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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.
6
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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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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
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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.pdf7/29/2019 ED5 - Oral Health (Caplan 2011-12)
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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/