Oral Disease - NHS Education for Scotland Portal ms... · Web viewSigns and symptoms may be pain,...
Transcript of Oral Disease - NHS Education for Scotland Portal ms... · Web viewSigns and symptoms may be pain,...
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