Oral Disease



Oral Disease

Abnormality of structure or function, or both, in the oral cavity

Erosion

• The loss of tooth structure due to chemical wearing by acids not of bacterial origin.

• Erosion is found initially in the enamel and, if unchecked, may proceed to the underlying dentine.

• Erosion is commonly linked to excessive consumption of soft drinks such as fruit drinks, fruit juices and carbonated drinks such as colas and sports drinks.

• Citric acids and fruit acids have erosive qualities.

• Other possible sources of erosive acids are from frequent sucking of lemon juice, exposure to chlorinated swimming pool water, and gastric reflux.

• Saliva has a buffering agent that tries to dilute the acids. People with xerostomia may suffer from erosion as there is no buffering action.

• No universal index for erosion which means it is difficult to monitor it’s progress

General health impact

• Signs of tooth destruction from erosion are a common characteristic in the mouths of people with bulimia since vomiting results in exposure of the oral cavity to gastric acids.

• Patients with gastric reflux often show signs of erosion.

• Patients with xerostomia are at higher risk of erosion due to the lack of protective properties of saliva.

• Pregnancy, alcoholism, obesity and motion sickness can be high risk factors

Impact on oral health

• As erosion progresses to dentine, the patient may experience pain or sensitivity

• Changes in appearance

• Issues with mastication in severe cases

Prevention

• Reduce the consumption of acidic foods and drinks

• Milk and cheese after consumption may be beneficial

• The practice of swishing/ frequent sipping of acidic drinks discouraged

• Drink through a straw and place well back in the mouth

• Avoid tooth brushing following consumption for 1 hour

• Fluoride application

• De-sensitising materials and toothpastes

• Where gastric regurgitation is the cause patient should consult GP

• Severe cases may require restorations to reconstruct lost tooth tissue

Abrasion

• The loss of tooth structure by mechanical forces by an object. An example of this would be abrasive toothbrushing.

• If the wear extends past the enamel, abrasion can quickly destroy the softer dentin and cementum structures.

• Possible sources of this wearing of tooth are toothbrushes, toothpicks, floss, and any dental appliance frequently set in and removed from the mouth.

• The teeth most commonly affected are premolars buccally and canines labially.

Attrition

• A condition caused by bruxism

• Bruxism is grinding or clenching teeth (mechanical force). This usually occurs during sleep and can cause jaw pain and headaches.

• Attrition initially wears away the enamel and, if unchecked, may proceed to the underlying dentine.

• Habits such as clenching and clicking the teeth together nervously, place greater amounts of forces on opposing teeth and begin to cause wear patterns.

• As expected, wear usually begins on the incisal or occlusal surfaces and creates a flat appearance.

• Due to this wear, cusps, pits and fissures are destroyed which means there are no stagnation areas for plaque to adhere to. Reduction in caries risk.

Abfraction

• The loss of cervical hard tissue due to occlusal overloading. Cervical restorations may de-bond due to these forces.

Ulcer

• Breach of mucous membrane

• The raw base of an ulcer is often painful and bleeds

• Herpes can cause ulceration on gingivae called herpetic gingivitis

• Necrotising Ulcerative Gingivitis (NUG) presents with ulcers that cause necrosis of the interdental papillae

Traumatic ulcer

• An ulcer caused by injury

• Usually a single ulcer that will heal within 7-14 days

• Caused by irritation, biting skin, excessive tooth brushing, sharp edges to fillings

Apthous ulcer

• An ulcer that usually appears as a result of stress, certain foods or deficiencies in iron, vitamins and folic acid

• It is a common condition and has no cure.

Cleft palate and lip (cleft fissure or opening)

Lip (harelip)

• Congenital condition

• Defect in along the normal lines of fusion of the lip tissues

• Usually associated with cleft palate

• Surgery usually occurs at 3 months old to repair the cleft

Palate

• Lack of fusion along the normal developmental lines of the palate.

• Can be partial or complete

• Gives rise to feeding, dental and speech problems.

• Treated by oral surgery or orthodontics.

• Surgery usually carried out at 6-12 months old

• A cleft lip/palate affects appearance, eating and may result in long term dental treatment

Glossitis

• Inflammation/infection of the tongue

• Characterised by dark red colour, loss of papillae, smooth appearance, sore and tender

• Colour will be fiery red if caused by deficiency of B vitamins.

• Patient may experience difficulty with chewing, swallowing, or speaking.

• Can be caused by bacterial or viral infections (including oral herpes simplex).

• Poor hydration and low saliva in the mouth may allow bacteria to grow more readily.

• Can also be caused by mechanical irritation or injury from burns, rough edges of teeth or dental appliances, or other trauma

• Exposure to irritants such as tobacco, alcohol, hot foods, or spices.

• Allergic reaction to toothpaste, mouthwash, breath fresheners, dyes in sweets, plastic in dentures or retainers, or certain blood-pressure medications

• A painful tongue may be an indication of several underlying serious medical conditions and nearly always merits assessment by a doctor or dentist.

Geographic tongue

• Characterised by smooth, red patches on the upper aspect of the tongue. This is said to resemble a map

• Loss of papillae will occur

• While it is not common for the condition to cause pain, it may cause a burning or stinging sensation, especially after contact with certain foods, such as spicy or citrus foods.

• Chemicals, such as mouth washes and teeth whiteners, can also aggravate the condition.

• Geographic tongue may also cause numbness.

• Its cause is uncertain, though tends to run in families and is associated with several different genes.

• Geographic tongue is more commonly found in people who are affected by environmental sensitivity, such as allergies, eczema, and asthma.

• Some think that it may be linked to stress or diets high in sugar or processed foods. Females are affected 3 times more than males.

Hairy tongue

• Harmless condition caused by a fungus which grows on the top surface of the tongue

• Papillae grow in length on the dorsum of tongue

• Forms a thick matted brown or black layer

• Usually due to smoking or anti biotic therapy, radiotherapy or HIV. Affects the elderly more

Fungal Conditions

Candida albicans is the fungi responsible for oral fungal conditions and is generally found in denture wearing or immuno-compromised patients.

• Angular Chelitis - Inflammation at the angles of the lips, often on both sides. Signs are erythema, fissures or ulceration

• Denture Stomatitis - Inflammation under denture due to the prosthesis remaining in place at all times or xerostomia. Signs are redness in the shape of the denture and possible angular chelitis

• Thrush - Red, raw sore patches remain when white coating is removed. Signs - thick, white patches on the tongue, cheeks, lips and palate.

General Health Impact

• Difficult to control fungal growth in immuno-compromised patients

• Xerostomia due to drugs and medical conditions

• Difficulty in treating some patients as anti fungal drugs are not always comaptible with drugs taken for medical conditions (Warfarin)

• Asthma sufferers are prone due to steroid use

• Young babies prone to thrush

Prevention

• Remove appliance at night and keep in water (dentures only)

• Brush appliance with soft toothbrush (no toothpaste as it is abrasive)

• Clean appliance after meals

• Place in a mild hypochlorite solution once a week for 20 minutes

• Brush soft tissues with a soft toothbrush twice a day

• Clean existing teeth as per caries prevention

• Asthma sufferers should rinse their mouths with water after inhaler use

Gerodontology

Effects of Aging on soft tissues

• Their cheeks may sag from loss of muscle tone- may cause angular chelitis

• The tongue may lose some of its papillae- diminished taste.

• Oral soft tissues become thinner, are less hydrated and elastic

• More susceptible to infection, and require a longer time to heal.

Effects of Aging on teeth

• It becomes thinner and more brittle.

• Undermining caries

• Changes in the pulp make the tooth less sensitive and diminished blood flow slows healing.

• Facial height may be diminished due to loss or wear of teeth

Osteoporosis can affect the mouth

• The bone becomes more brittle and less dense.

• Edentulous bony ridges become atrophic (decrease in size) and dentures may need to be modified to compensate. 

Anodontia

• Absence of all or some teeth

• Tends to be hereditary

Hypodontia

• Partial Anodontia - Absence of six or less teeth

• Commonly affects the lateral incisors, 2nd premolars and 3rd molars

Hyperdontia

• Tooth of abnormal form in addition to normal number of teeth

• Supernummery teeth such as 4th molars (9’s)

• Mesiodens – supernummery tooth, usually malformed and lying in the midline of the maxilla.

Macrodontia

• Abnormally large teeth

Microdontia

• Teeth abnormally small

• Usually associated with congenital heart disease or downs syndrome.

• Especially in maxillary lateral incisors and the 3rd permanent molars

Hypoplasia

• Under development of organ tissue

• Enamel hypoplasia can be caused by fluorosis and antibiotic therapy in childhood

• Defective formation of dentine due to illness such as measles or starvation

Hyperplasia

• Overdevelopment of organ tissue - Increased production of cells

• Can be caused due to hormone disturbances, pregnancy, leukaemia or can be hereditary.

• Gingival hyperplasia can be treated by carrying out a gingivectomy.

Xerostomia

• Dry mouth caused by reduced or absent saliva flow

• Several diseases, treatments, and medications can cause xerostomia. It can also be exacerbated by smoking or drinking alcohol.

• Xerostomia can cause difficulty in speech and eating.

• It also leads to halitosis and a rise in the number of cavities, as the protective effect of saliva's remineralizing the enamel is no longer present.

• May be a sign of an underlying disease, such as Sjögren's syndrome, poorly controlled diabetes

• Other causes of insufficient saliva production include anxiety, dehydration, chemotherapy, and radiation therapy.

• Xerostomia is a common side-effect of various medications including some antidepressants

Treatment

• Find cause and remove if possible

• Pay particular attention to oral hygiene

• Sipping of sugar free fluids frequently and chewing xylitol chewing gum

• Artificial saliva’s (not suitable for vegetarians and some religious groups)

• Lip balm/ Vaseline may prevent the lips drying/cracking

• Drinking 8-10 glasses of water a day

Prevention

• Cease smoking

• Reduce alcohol intake

• Regular dental checkups for early diagnosis

• Good oral hygiene techniques

Facial Pain

Trigeminal neuralgia

• Severe stabbing pain

• Pain may be felt in the ear, eye, lips, nose, scalp, forehead, cheeks, teeth, or jaw and side of the face.

• Originates from the trigeminal nerve

• No evident cause

• Usually treated with an anticonvulsant drug – carbamazepine

Atypical (idiopathic) facial pain

• Persistent facial pain with no apparent cause

• Often associated with anxiety or depression

• usually located in the region of the maxilla

• Usually described as dull, aching pain

• Sometimes the pain may seem to be located in a tooth that has been previously extracted, or associated with a previous surgical procedure.

Sinusitis – see anatomy relevant to dentistry notes

Staining

Staining of the teeth may be either extrinsic (on the tooth surface) or intrinsic (within the tooth structure)

Intrinsic Stain can be caused by:

• Pulp necrosis

• Hypoplastic enamel –defect in the enamel

• Tetracycline ingestion during tooth formation

• Fluorosis

• Dental caries or restorations

• Systemic upset during tooth formation

Extrinsic Staining

• These result from the pigmentation of the usually colourless salivary pellicle and may be removed by polishing the teeth.

• They can be divided into metallic and non-metallic stains.

Metallic Stains

• Various metals are capable of staining the teeth should they come in contact with them

• Examples are the brown / black stain of mercury

• Medicines that contain iron can cause a black iron sulphate stain

Non Metallic Stains

• These are very common and various types have been described below:

Black Stain

• Usually seen as a thin black / dark brown line adjacent to and following the contour of the gingival margin.

• It is often firmly attached and is more common in children and its cause is unknown

Tobacco Stains

• The most common stain observed in patients it varies in colour from light brown to black and occurs on the lingual and palatal aspects of teeth

Yellow Stain

• This is a generalised dull yellow staining of the tooth which results from discolouration of dental plaque by dyes in foodstuffs

Chlorhexidine Stain

• An important disadvantage of using chlorhexidine to control plaque is the unsightly black staining which often occurs

Osteonecrosis

• Death of bone

• The development of lesions is most frequent after invasive dental procedures, such as extractions, but is also known to occur spontaneously.

• Osteoradionecrosis – necrosis of bone following radiation therapy due to reduced blood supply.

• Bisphosphonate-related osteonecrosis - Bisphosphonates are used to prevent the loss of bone mass. Cancer patients may take them to protect bones and reduce raised calcium levels in blood. They work by inhibiting osteoclasts (bone destroying cells). Taking any bisphosphonate may cause osteonecrosis of the jaw. The jaw has a high turnover of bone and bisphosphonates accumulate here. This may reduce bone turnover and blood supply which may lead to death of the bone. This is discussed in oral disease

• Signs and symptoms may be pain, inflammation of the surrounding soft tissue, secondary infection or drainage may or may not be present.

• Lesions are more common on the mandible than the maxilla.

Cancer

• Uncontrolled growth of a group of cells

• Squamous cell carcinoma most common oral cancer making up to 90% of oral cancers.

• Squamous cells are located in the outer surface of the skin, nearer the surface. Can grow at speed and can spread to other organs.

• Malignancy is a word used to characterise a population of cells that grow and divide without respect to boundaries

• Benign is a word used to describe cells that are self limiting in their growth and do not invade other tissues. If left untreated, they can become malignant.

Lip cancer

• Commonly caused by exposure to sunlight

• Considered oral cancer but behaves more like skin cancer

Basal cell carcinoma

• Is the most common skin cancer.

• Affects the deeper layer of the outer skin cells.

• Never spreads to other organs and treatment less invasive.

• Rarely a threat to life

Causes of cancer

• Smoking

• Tobacco

• 50 times more likely to acquire cancer if both are taken together in excess

• Human papilloma virus (HPV) becoming a more common cause of cancer

• Viral and fungal infections

• Diet and nutrition

• Physical: heat or mechanical trauma

• Immune deficiency such as transplant patients

• Genetics

Signs and Symptoms

• Common sites for abnormalities are the side or under tongue, floor of mouth, inside the cheeks, lower lip, throat or gingivae

• Under tongue is most important

• Ulcers that do not heal within 10 days should be considered a concern

• The ulcer may have a punched out appearance with rounded rogue edges

• Cauliflower appearance lesions

• Lump, swelling or neck mass

• Trigeminal numbness, but this is also a sign for Multiple Sclerosis

• Mobile teeth

• White patches

• Red patches. These are most concerning in comparison to white patches.

• Speckled appearance (red and white)

Potentially malignant conditions (pre cancerous)

These are conditions that can become cancer:

• Lichen planus is an inflammatory reaction that presents as a rash or white patch

• Hyperplastic candidosis is a hard and fixed tongue

• Oral submucous fibrosis which is inflammation, thickening and hardening of the mucosa. Opening of the jaw will be restricted. Caused by chewing tobacco

• Leukoplakia is a white thickening caused primarily by tobacco

• Erythroplakia presents as a red velvet area. This can’t really be diagnosed as anything else and is much more concerning than white patches. Often linked to tobacco use.

• Syphilis. Syphilitic tumours are usually found on the dorsum of the tongue

Common misdiagnosis

• Leukoplakia. This can also be caused by cheek biting or thrush

• Geographic tongue

• Amalgam tattoo

• Lichen planus

• Inflamed tonsils

Treatment

Oncology is a branch of medicine concerned with the treatment and diagnosis of tumours

• Early detection is a huge factor in success of treatment

• The aim of treatment is to remove disease, restore function, aesthetics and quality of life. Not just to keep the patient alive.

• The target from referral to the end of treatment is 62 days

• GDP’s may be asked to undertake pre treatment procedures at short notice.

• Use of OPG, CT scan, PET scan, MR to detect cancer

• The most high risk patient is the 40 year old male smoker and drinker

Radiotherapy

There are 2 types of radiotherapy

1. Curative. This damages DNA using ionising radiation.

2. Palliative which is used to alleviate symptoms

• Perspex mask constructed to minimise dose to other areas

• Generally done over 6 weeks for 5 days a week. Sessions usually last 5-30 minutes

• Side effects can be fatigue, loss of taste, xerostomia, tanning, hair loss, erythema (reddening), sweating and radiation caries

• Long term side effects can be a stiff neck, Trismus, permanent hair loss and an increased risk of malignancy

Chemotherapy

• Drugs used to divides cells and damages DNA

• Used before during or after radiotherapy

• The drugs are toxic to kidneys, can cause tinnitus, hearing loss and dermatitis

• Problem with the drugs is that they can divide normal cells. This may cause problems with the digestive system lining, loss of hair, irritability, loss of apatite, skin and hair problems.

Surgery

• Removal of disease

• Lost tissue can be replaced by ‘flaps’ taken from fibula, abdomen, radial, arteries.

Rehabilitation

• Aim to reconstruct and duplicate form and function

• Improve aesthetics

• Sensory organs - all head

• After treatment the patient may have altered anatomy, speech problems, trismus, impaired chewing and swallowing and nutrition problems.

• Rehabilitation should consider the psychological impact on the patient. While there lives may be saved, they be in danger of becoming reclusive. Patients sometimes expect they will go back to normal function. The quality of life only good if patient feels it is

• It should also consider the physiological impact the treatment has had. Can the patient swallow and speak?

• Part of rehabilitation will include rebuilding the dentition using implants, dentures or obturation

• Speech therapy may be necessary to allow the patient to do simple things like speak on phone or order a paper.

• Patient monitored at regular intervals

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