Tooth Disorders

Tooth Disorders

To maintain healthy teeth, a person must remove plaque daily with a toothbrush and dental floss. Also, to reduce the risk of tooth decay, a person should limit the amount of sugar consumed. Fortunately, fluoridated water helps reduce this risk.

Limiting both tobacco and alcohol use keeps the mouth and teeth healthy, too. Tobacco - whether it’s smoked, chewed, or dipped - makes gum disease worse. Tobacco, alcohol, and especially the combination of alcohol and tobacco cause mouth cancer.

Cavities
Cavities (dental caries) are decayed areas in the teeth, the result of a process that gradually dissolves a tooth’s hard outer surface (enamel) and progresses toward the interior.

Along with the common cold and gum disease, cavities are among the most common human afflictions. If cavities are not properly treated by a dentist, they continue growing. Ultimately, an untreated cavity can lead to tooth loss.

Cause
For tooth decay to develop, a tooth must be susceptible, acid-producing bacteria must be present, and food must be available for the bacteria to thrive. A susceptible tooth is one that has relatively little fluoride or has pronounced pits, grooves, or fissures that retain plaque (the collection of bacteria that accumulates on teeth). Although the mouth contains large numbers of bacteria, only certain types cause decay. The most common decay-causing bacterium is Streptococcus mutans.

Decay develops differently, depending on its location in the tooth. Smooth surface decay, the most preventable and reversible type, grows the slowest. In smooth surface decay, a cavity begins as a white spot where bacteria are dissolving the calcium of the enamel. Smooth surface decay between the teeth usually begins between ages 20 and 30.

Pit and fissure decay, which usually starts during the teen years in the permanent teeth, forms in the narrow grooves on the chewing surface and the cheek side of the back teeth; this decay progresses rapidly. Many people can not adequately clean these cavity-prone areas because the grooves are narrower than the bristles of a toothbrush.

Root decay begins on the bone-like tissue covering the root surface (cementum) that has been exposed by receding gums, usually in people past middle age. This type of decay often results from difficulty cleaning the root areas and from a diet high in sugar. Root decay can be the most difficult type to prevent.

Decay in the enamel, the hard outer layer of the tooth, progresses slowly. After penetrating into the second layer of the tooth-the somewhat softer, less resistant dentin-decay spreads more rapidly and moves toward the pulp, the inner-most part of the tooth, which contains the nerves and blood supply. Although a cavity may take two or three years to penetrate the enamel, it can travel from the dentin to the pulp - a much greater distance - in as little as a year. Thus, root decay that starts in the dentin can destroy a lot of tooth structure in a short time.

Symptoms
Not all tooth pain is caused by cavities. Toothaches may result from roots that are exposed but not decayed, excessively forceful chewing, or fractured teeth. Sinus congestion can make the upper teeth sensitive.

Usually, a cavity in the enamel causes no pain; the pain starts when the decay reaches the dentin. A person may feel pain only when drinking something cold or eating candy. This indicates that the pulp is still healthy. If the cavity is treated at this stage, the dentist can usually save the tooth, and most likely no further pain or chewing difficulties will develop.

A cavity that gets close to or actually reaches the pulp causes irreversible damage. Pain lingers even after a stimulus (cold water, for example) is removed. The tooth may even hurt without stimulation (spontaneous toothache).

When bacteria enter the pulp and the pulp dies, the pain may stop temporarily. But in a short time (hours to days), the tooth becomes sensitive when the person bites or when the tongue or a finger presses on it because inflammation and infection spread out just beyond the end of the root, causing an abscess (a collection of pus). Pus accumulating around the tooth tends to push it out of its socket. Biting pushes it back in place, causing extreme pain. Pus can continue to accumulate and cause swelling in the adjacent gum or can spread more broadly through the jaw (cellulitis) and drain into the mouth or even through the skin near the jaw.

Diagnosis and Prevention
If a cavity is treated before it starts to hurt, the chance of damage to the pulp is reduced, and more of the tooth structure is saved. To detect cavities early, a dentist inquires about pain, ex-amines the teeth, probes the teeth with dental instruments to test for sensitivity and softness, and may take X-rays. A person should have a dental examination every six months, though every examination will not include X-rays. Depending on the dentist’s assessment of a person’s teeth, X-rays may be taken anywhere from every 12 to 36 months.

Five General Strategies are Key to Preventing Cavities:

  1. Good oral hygiene
  2. Proper diet
  3. Fluoride
  4. Sealants
  5. And antibacterial therapy

Oral Hygiene
Good oral hygiene, which involves brushing before or after breakfast and before bedtime and flossing daily to remove plaque, can effectively control smooth surface decay. Brushing prevents cavities from forming on the sides of the teeth, and flossing gets between the teeth where a brush can’t reach. Food debris can be cleaned from beneath the gum margin and from the surfaces facing the lips, cheeks, tongue, and palate with a rubber-tipped gingival stimulator.

For a person with normal manual dexterity, proper brushing takes only about three minutes. Initially, plaque is quite soft, and removing it with a soft-bristled toothbrush and dental floss at least once every 24 hours makes decay unlikely. Once plaque becomes calcified, a process that begins after about 24 hours, removing it becomes more difficult.

Diet
Although all carbohydrates can cause tooth decay to some degree, the biggest culprits are sugars. All simple sugars have the same effect on the teeth, including table sugar (sucrose) and the sugars in honey (levulose and dextrose), fruits (fructose), and milk (lactose). Whenever sugar comes in contact with plaque, Streptococcus mutans bacteria in the plaque produce acid for about 20 minutes. The amount of sugar eaten is irrelevant - the amount of time the sugar stays in contact with the teeth is the important issue. Thus, sipping a sugary soft drink over an hour is more damaging than eating a candy bar in five minutes, even though the candy bar contains more sugar.

A person who tends to develop cavities should eat sweet snacks less often. Rinsing the mouth after eating a snack removes some of the sugar; brushing the teeth is more effective. Drinking artificially sweetened soft drinks also helps, though diet colas contain acid that can promote tooth decay. Drinking tea or coffee without sugar also can help people avoid cavities, particularly on exposed root surfaces.

Fluoride
Fluoride can make the teeth, particularly the enamel, more resistant to the acid that helps cause cavities. Fluoride taken internally is particularly effective while the teeth are growing and hardening - until about age 11. Water fluoridation is the most efficient way to supply children with fluoride, and over half of the United States population now has drinking water with enough fluoride to reduce tooth decay. However, if a water supply has too much fluoride, the teeth can become spotted or discoloured. If a child’s water supply does not have enough fluoride, a doctor or dentist can prescribe sodium fluoride drops or tablets. A dentist may apply fluoride directly to the teeth of a person of any age who is prone to tooth decay. Toothpaste containing fluoride is also beneficial.

Sealants
Sealants may be used to protect hard-to-reach grooves on the back teeth. After thoroughly cleaning the area to be sealed, a dentist conditions the enamel and places a liquid plastic in and over the grooves of the teeth. When the liquid hardens, it forms such an effective barrier that any bacteria inside a groove stop producing acid because food can no longer reach them. A sealant lasts fairly long-about 90 per cent remain after 1 year and 60 per cent after 10 years - but may occasionally need repair or replacement.

Antibacterial Therapy
Some people have especially active, decay-causing bacteria in their mouth. A parent may pass these bacteria to a child, presumably by kissing. The bacteria flourish in the child’s mouth after the first teeth come in and can then cause cavities. So a tendency toward tooth decay that runs in families does not necessarily reflect poor oral hygiene or bad eating habits.

For people who are very prone to decay, anti-bacterial therapy may be needed. The dentist first removes decayed areas and seals all pits and fissures in the teeth. Then the dentist prescribes a powerful mouth rinse (chlorhexidine) for several weeks to kill off the bacteria in any remaining plaque. The hope is that less harmful bacteria will replace the cavity-causing bacteria. To keep bacteria under control, the person may use daily home fluoride rinses and chew gum containing xylitol.

Treatment
If decay is halted before it reaches the dentin, the enamel can repair itself, and the white spot on the tooth disappears. Once decay reaches the dentin, the decayed part of the tooth must be removed and replaced with a filling (restoration). Treating the decay at an early stage helps maintain the strength of the tooth and limits the chance of damage to the pulp.

Fillings
Fillings are made of various materials and may be put inside the tooth or around it. Silver amalgam is most commonly used for fillings in back teeth, where strength is important and the silver colour is relatively inconspicuous. Silver amalgam is relatively inexpensive and lasts an average of 14 years. Gold fillings (inlays) are more expensive, and at least two dental visits are required; however, they are stronger and can be used in very large cavities.

Composite resins and porcelain fillings are used in the front teeth, where silver would be conspicuous. Increasingly, these fillings are also being used in back teeth. Although they have the advantage of being the colour of the teeth, they are more expensive than silver amalgam and may not last as long, particularly in the back teeth, which must take the full force of chewing.

Glass ionomer, a tooth-coloured filling, is formulated to release fluoride once in place, a benefit for people prone to decay at the gum line. Glass ionomer is also used to restore areas damaged by overzealous brushing.

Root Canal Treatment and Tooth Extraction
When decay advances far enough to permanently harm the pulp, the only way to eliminate the pain is to remove the pulp by root canal (endodontic) treatment or tooth extraction. Back teeth that have had root canal treatment are best protected by a crown, which replaces the entire chewing surface. The restoration method for front teeth that have had root canal treatment depends on the amount of tooth that remains.

Rarely, fever, headache, and swelling of the jaw, floor of the mouth, or throat may develop a week or two after root canal treatment. If such complications develop, the person should be examined by a dentist or doctor.

If the tooth is extracted, it should be replaced as soon as possible. Otherwise, neighboring teeth may change position and alter the person’s bite. The replacement may be a bridge -a fixed partial denture in which teeth on either side of the missing tooth are covered with caps - or a removable denture. Also, implants may be used to replace missing teeth.

A crown is a restoration that fits over a tooth. Getting a properly shaped crown usually takes two visits to the dentist, though sometimes it takes several visits. On the first visit, the dentist prepares the tooth by tapering it slightly, takes an impression of the prepared tooth, and puts a temporary crown on it. A permanent crown is then fashioned in a dental prosthetics laboratory, using the impression. On the next visit, the temporary crown is removed, and the permanent crown is cemented onto the prepared tooth.

Usually, crowns are made of an alloy of gold or another metal. Porcelain can be used to mask the color of the metal. Crowns also may be made entirely of porcelain, but it is harder and more abrasive than tooth enamel and may cause wear on the opposing tooth. Also, crowns made entirely of porcelain or similar material have a slightly greater tendency to break than those made of metal.

Pulpitis
Pulpitis is painful inflammation of the tooth pulp, the innermost part of the tooth that contains the nerves and blood supply.

Causes
The most common cause of pulpitis is tooth decay; the second most common cause is injury. Because the pulp is encased in the unyielding walls of the tooth, it has no room to swell when it becomes inflamed. It can only increase the pressure inside the tooth. Mild inflammation, if relieved, may not damage the tooth permanently. Severe inflammation kills the pulp. Increased pressure may push the pulp out through the end of the root where it can injure the jawbone and surrounding tissues.

Symptoms and Diagnosis
Pulpitis causes intense tooth pain. To determine if the pulp is healthy enough to save, a dentist can perform certain tests. For example, a dentist can apply a cold stimulus. If the resulting pain from the stimulus stops within a few seconds after the cold stimulus is removed, the pulp is still healthy. The dentist can save it by removing the decayed part of the tooth and putting in a filling. However, if pain persists after the cold stimulus is removed or if pain occurs spontaneously, the pulp is not healthy enough to save.

A dentist may also use an electric pulp tester, which indicates whether the pulp is alive but not whether it’s healthy. If the person feels the small electrical charge delivered to the tooth, the pulp is alive. Sensitivity to tapping on a tooth often means that inflammation has spread to the surrounding tissue and bone. X-rays can confirm tooth decay and show whether spreading inflammation has caused bone loss around the root of the tooth.

Treatment
The inflammation stops when the cause is treated. When pulpitis is detected early, a temporary filling containing a sedative can eliminate the pain. This filling can be left in place for six to eight weeks and then replaced with a permanent filling. Sometimes a permanent filling can be put in immediately:

When pulp damage is extensive and can not be reversed, the only way a dentist can stop the pain is by removing the pulp, using root canal treatment or tooth extraction.

Periapical Abscess
A periapical abscess is a collection of pus, usually from an infection, that has spread from a tooth to the surrounding tissues.

Cause
The body attacks infection with large numbers of white blood cells; pus is the accumulation of these white blood cells and dead tissue. Usually, pus from a tooth infection drains into the gums first, so the gums swell near the root of the tooth. Depending on the location of the tooth, the pus may then drain to the skin, mouth, throat, or skull.

Treatment
A dentist treats an abscess or cellulitis by eliminating the infection and draining the pus, which requires oral surgery or root canal treatment. Dentists often prescribe antibiotics to help eliminate the infection, but removing the diseased pulp and draining the pus are more important.

Additional Resource:
NOAH (New York Online Access to Health) : Tooth Disorders and Problems

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