ED5 - Oral Health (Caplan 2011-12)

7/29/2019 ED5 - Oral Health (Caplan 2011-12)

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Oral Diseases: The Basics

Dr. Dan Caplan

Department of Preventive and Community DentistryCollege of Dentistry

University of Iowa

Introduction for M3 Course

November 12, 2012

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Dental Caries

Gingivitis and Periodontal Disease

Oral Cancer and Soft Tissue Lesions

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Dental Caries


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Caries: dynamic process of demineralization of dental

hard tissues by products of bacterial metabolism,

alternating with periods of remineralization

Harris and Christen. Primary preventive dentistry. Norwalk, CT, 1995.

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How to Prevent Multifactorial Diseases?

More sugar faster, deeper drops in pH

More plaque faster, deeper drops in pH

More frequent exposures to sugarmore time at low pH

bacteria

income

fluoride

education

saliva

sugar

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Gingivitis and Periodontal Disease


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Color Texture Shape Bleeding

Gingivitis

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10

2. Gingival epithelium migrates

along root surface, forms pocket

1. Periodontal ligament destroyed

3. Alveolar bone resorbs

4. Tooth becomes loose

Periodontal Disease


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oralhygiene

hormonal

changes

diabetes

stress

dental

visits

educationdiabetes

immune

deficiencies

smoking

income

race

How to Prevent Multifactorial Diseases?

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Lip Cancer

Lesion due to

smokeless

tobacco

Leukoplakia

Oral Cancer Lesions

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Oral Candidiasis Oral Hairy Leukoplakia

Kaposis

Sarcoma

HIV-Related Soft Tissue Lesions

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Rebecca Slayton, DDS, PhD

Department of Pediatric DentistryUniversity of Iowa

Oral Health Basics for

Medical Students


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Understand primary and permanent tooth

anatomy and timing of eruption

Understand the dental caries process

Be familiar with fluoride varnish and its

application

Recognize infections of odontogenic origin

Objectives


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Tooth Anatomy

Crown = portion visible above gumline; enamel outside

Root = portion of tooth in the bony socket (alveolus)

Dentin= yellowish-tan, contains microtubules thatconnect to the pulp

Pulp = neurovascular structures necessary for toothviability

Periodontal ligament = anchors tooth to alveolarbone


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Cross-section of a Tooth
http://bmj.com/content/vol320/issue7250/images/large/oralch01.f1.jpeg


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Enamel

Dentin

Pulp

Bone


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Names of Teeth

Refer to tooth:

By primary or permanent

By name and quadrant

eg, primary lower left lateral incisor


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Primary Tooth Development

and Eruption

Tooth development begins at 4-6 weeks

gestation Mineralization at 14 weeks gestation

First primary tooth erupts about 6 mo

(variable) Lower central incisors usually first

Refer if no teeth by 18 mo


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There are 20 primary teeth

Right Left


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Healthy Primary Dentition


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Panoramic Radiograph


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Permanent teeth

First permanent tooth to erupt is usually either lowercentral incisor or lower 1st (6 year) molar

Enamel on permanent teeth may appear more yellowthan on primary teeth

Permanent incisors have mamelons (little bumps) onincisal edges that wear smooth over time

Last to erupt are third molars (wisdom teeth) at about17-21 years of age


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Mixed Dentition Phase

Both primary and permanent teeth are

present

From about 6 yrs (first permanent tooth) until12-13 yrs (last primary tooth shed)

Ugly duckling phase

permanent teeth look large next to baby teeth transient malpositioning may occur


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Mixed Dentition


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Right Left


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Healthy Permanent Dentition


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caries is a multifactorial infectious disease

contributing factors include Streptococcus

mutans, salivary pH, diet, oral hygiene,fluoride and the presence of susceptibletooth surfaces

there is strong evidence that host geneticfactors confer susceptibility or resistanceto this disease

Caries is the disease process, cavities are

the consequence of the disease

DENTAL CARIES


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Consequences of Dental Caries

Dental caries (tooth decay) is the single most common chronicchildhood disease5 times more common than asthma and 7times more common than hay fever.

More than 51 million school hours are lost each year to

dental-related illness. Poor children suffer nearly 12 timesmore restricted-activity days than children from higher-income families. Pain and suffering due to untreated diseasescan lead to problems in eating, speaking, and attending tolearning.

Oral Health in America: A Report of the Surgeon General, 2001


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Tooth

Microflora

Carbohydratediet

Time

Genetics

Dental

Caries

Fluoride


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Demineralization/Remineralization


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Early Childhood Caries

Presence of 1 or more decayed, missing or

filled tooth surface in any primary tooth in a

child less than 71 months (5 yrs 11 mo)

Previously known as baby bottle tooth

decay, nursing caries, bottle rot


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White spot lesion Cavity

Smooth Surface Caries


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Pit and Fissure Caries


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Microbiology of Dental Caries

Oral microflora - hundreds of bacteria species

(over 700)

Cariogenic bacteria must:

Contribute to the environment by producing

organic acids (acidogenic)

Be able to withstand/proliferate in acidic

environment (aciduric)


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Microbiology of Dental Caries

Three (known) cariogenic bacteria

mutans streptococci (MS)

S. mutans, S. sobrinus, S. sanguinis, S. salivarius, S. milleri

lactobacilli L. acidophilus, L. casei

actinomyces

Oral bacteria are transmitted from the mother or

caregiver to the infant through activities that sharesaliva


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Oral bacteria transmitted from mother or

primary caregiver

Adhesion transiently to gingival tissues

Colonization occurs once teeth erupt

Plaque on teeth is a biofilm with thousands of

bacterial colonies

Adhesion/Colonization


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The age at which a child becomes colonized

with the cariogenic bacterial group, mutans

streptococci, is a critical factor for caries risk

Therefore, goal is to delay or prevent

transmission

Caries risk and MS


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Break or Dr. Levy?


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Who is at risk?

Caries is unevenly distributed - a small

percentage of children demonstrate the

majority of carious tooth surfaces.Approximately 20% of children have 80% of

decay


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Prevention by definition must start early

Prevention or delay of ECC could be

accomplished by prolonging the time which

the child remains free of cariogenic bacteria

Once disease is present it is too late for

prevention

Caries Prevention


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Prevention requires early risk assessment

What factors contribute to risk?

When should we assess caries risk?

Caries Risk Assessment


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AAPD Caries Risk Assessment Forms www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.p

df

AAP Oral Health Risk Assessment Tool http://www2.aap.org/oralhealth/RiskAssessmentTool.html

Caries Risk Assessment Tools
http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdfhttp://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdfhttp://www2.aap.org/oralhealth/RiskAssessmentTool.htmlhttp://www2.aap.org/oralhealth/RiskAssessmentTool.htmlhttp://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdfhttp://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf


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www.aap.org/oralhealth


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Risk Factors


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Risk Factors


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Protective Factors


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Clinical Findings

High Risk


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Previous Caries Experience

Best and most consistent predictor of futurecaries

Active decay and/or fillings and stainlesssteel crowns


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Family History of Caries

There is strong evidence

from twin studies that

there is a genetic

component to cariessusceptibility and

resistance


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Early assessment

First visit by first birthday

Medical and dental collaboration

Increased awareness Community involvement

Education/empowerment

Maternal oral health

Delay and/or reduce transmission of oral bacteria

Keys to Prevention


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Early intervention

Remineralization fluoride varnish, fluoride toothpaste,

fluoridated water

Diet healthy snacks, reduce refined carbohydrate foods

and beverages

Oral hygiene supervised brushing 2 times daily with

fluoridated toothpaste

Disrupt biofilm, deliver fluoride

Keys to Prevention


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Break or Dr. Levy?


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Fluoride Varnish

First introduced in Germany in 1964

Over 40 years of clinical study

Majority of studies have exhibited a 25-45

percent reduction in dental caries

Reduction in occlusal as well as smooth

surface caries


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Fluoride Varnish

Introduced to United States in 1991

FDA approval as a cavity liner

5% NaF (2.26% F ion)

Fluoride ingestion lower than with gels

Available through Dental Supply Houses


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Fluoride Varnish Technique

Dry teeth with 2x2 gauze

Paint varnish on teeth with brush

Varnish will set on contact with saliva

Instruct parent not to brush off until the

following day


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In all but 4 states, Medicaid will reimburse

physicians for fluoride varnish application with

or without oral health education

Fluoride Varnish


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Fluoride Varnish


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Effective preventive agent

When combined with oral health education

has been shown to reduce caries incidence in

young children

Recommended frequency of application

every 3-6 months in children at high risk for

caries

Fluoride Varnish


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Odontogenic (Dental) infection

Dental caries

Pain occurs when dentin and pulp

involved

Infection may progress thru alveolar bone

to form fistula and periapical abscess

May result in localized or systemic

infection


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Periapical abscess

Commonly called agumboil

May spread to fascial spaceswith facial swelling, airwaycompromise

Treatment for periapicalabscess: if fluctuant - can incise and

drain

If not fluctuant, useantibiotics/analgesics astemporizing measures


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ALWAYS refer for dental care ASAP

Definitive dental treatment needed to

eliminate source of infection and prevent

recurrence root canal or

extraction

Periapical abscess


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Etiology may be from prior trauma, fromdental caries or periodontal infection

Single or multiple teeth

Localized pain and/or swelling

Facial swelling/cellulitis

Systemic manifestations fever, malaise

Dental Infection


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Abscessed Primary Teeth

Treat by extraction orby removing affected

pulp tissue and

restoring tooth Similar to root canal

treatment but

generally limited to

crown of the tooth

Antibiotics not

indicated for localized

infection unless


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Acute Odontogenic Infections

The acute dental abscess is polymicrobial facultative anaerobes, (viridans group streptococci and the

Streptococcus anginosus group)

strict anaerobes (anaerobic cocci, Prevotella and

Fusobacterium species) New sampling techniques have identified others such

as:

Atopobium (Gram-positive strictly anaerobic coccobacilli),

Anaerobic Gram-positive rods (Bulleidia extructa,Cryptobacterium curtum, Eubacterium sulci,

Mogibacterium timidum and Mogibacterium vescum)


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Acute Odontogenic Infection

Identify source of infection

Remove if a primary tooth

May require incision and

drainage

Systemic antibiotics indicated

May require admission to

hospital and IV antibiotics

Treatment of Acute Odontogenic


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Antibiotics should only be used in cases of systemicinvolvement

Exception may be in cases where dental care is not immediatelyavailable

Pen VK is antimicrobial of first choice Amoxicillin covers majority of microbes, tastes better and

may have better compliance

Clindamycin for patients who are allergic to Penicillinor when admitted for IV antibiotics, Incision and

drainage Duration should be for 72 hours after all symptoms are

gone (usually 7-10 days)

Treatment of Acute Odontogenic

Infections


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Antibiotics for dental infections

For significant facial

cellulitis, may requirehospitalization and IV

antibiotics


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Facial Cellulitis Permanent Teeth

Refer to Oral Surgeon or Pediatric Dentist to:

Determine source of infection

Perform incision and drainage

Debride pulp tissue or extract tooth Prescribe antibiotics

May require hospitalization and IV antibiotics

Refer to General Dentist, Endodontist or PediatricDentist to perform restoration, root canal treatment

or extract

d f


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Odontogenic Infections

The overall mean total cost to treat patientsadmitted with odontogenic facial cellulitis was

$4138 2376

Deamonte Driver adolescent in Maryland

who died from a dental abscess that spread to

his brain had hospital costs over $250,000

k


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The mouth and teeth are part of the body

Poor oral health = poor overall health

Prevention starts early

Delay maternal transmission of oral bacteria

First visit by first birthday

Limit amount and frequency of cariogenic foods

and beverages

Take Home Messages


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Resources

American Academy of Pediatrics Section onOral Health http://www2.aap.org/oralhealth/

American Academy of Pediatrics Caries RiskAssessment Tool http://www2.aap.org/oralhealth/RiskAssessmentTool.html

American Academy of Pediatric DentistryGuidelines www.aapd.org Smiles for Life curriculum

www.Smilesforlifeoralhealth.org
http://www2.aap.org/oralhealth/http://www2.aap.org/oralhealth/RiskAssessmentTool.htmlhttp://www.aapd.org/http://www.smilesforlifeoralhealth.org/http://www.smilesforlifeoralhealth.org/http://www.aapd.org/http://www2.aap.org/oralhealth/RiskAssessmentTool.htmlhttp://www2.aap.org/oralhealth/

Documents

ED5 - Oral Health (Caplan 2011-12)