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