Your Mouth

Development of the Deciduous Dentition baby teeth starts months before a baby is born.

Two Major Causes of Tooth Loss

• Decay (caries)
  Major cause of tooth loss under the age of 25.
  A destructive process caused by the bacteria in plaque which act on sugar to form acid. Enamel and dentin are destroyed, causing cavitation of the tooth. 
• Decay that is not treated will advance through the tooth layers into the pulp, which contains the nerves and blood vessels. Intense pain may result, with no relief until the pulp is removed (root canal treatment), or the tooth is removed (extraction). 
• Regular dental care is the only treatment for tooth decay. Enamel that has been destroyed does not grow back. The decay must be removed, and the cavity filled.

  Periodontal (Gum) Disease

  • Major cause of tooth loss over the age of 25.
  • often called Pyorrhea
  • Irritants in plaque cause inflammation of the tooth's supporting structures. Later, calculus may also collect in the spaces between the gum and lower part of the tooth's crown, making cleansing more difficult, and thereby enhancing the spread of the disease.
  • If left untreated the irritants in plaque may continue to attack until the tissue and bone which support the affected teeth are destroyed.
  • Seemingly healthy teeth may be lost and others weakened.
  • Treatment may include:
    1) development of a good oral hygiene program;
    2) cleaning by a dentist or hygienist (since calculus can only be removed by a dental professional);
    3) if severe enough may necessitate antibiotic therapy and/or periodontal (gum) surgery
    

  Plaque A soft, sticky deposit on teeth which contains harmful bacteria. This film of material is constantly forming on your teeth and is the primary cause of tooth Decay and Periodontal disease, the two major causes of tooth loss.  When sugar in the foods you eat combines with the bacteria in plaque, acid is formed, which decays, or destroys tooth structure.  Periodontal (gum) disease is caused by irritants in plaque. Later, plaque may become mineralized to form a hard substance, which adheres to teeth, known as calculus (tartar). Calculus is important because it accentuates the destruction by making cleansing of the teeth and gums more difficult. Infected and decayed teeth can be the source of other infections throughout the body, while decayed or missing teeth can interfere with the proper chewing of food. This may lead to nutritional deficiencies or to disorders of digestion.

Periodontal (gum) disease

Gingivitis The irritation caused by bacterial plaque that has accumulated in the mouth is the primary cause of periodontal disease. In this first stage of periodontal disease called Gingivitis, inflamed and bleeding gums may be present. Later, the plaque may become mineralized to form a hard deposit known as calculus, or tartar, which accentuates the destruction by making cleansing more difficult.	Periodontitis As the disease progresses, calculus and plaque continue to build up. Deep pockets form between the teeth and gums which fill up with pus and bacteria. The destruction of bone which supports the teeth begins in this stage called Periodontitis.
	Advanced Periodontitis In Advanced Periodontitis, the tissue around the teeth withdraws further, while bone destruction worsens. Eventually the lining of the tooth socket (the periodontal ligament) and most of the tooth's bony support will be lost. Seemingly healthy teeth may be lost and others weakened. Periodontal disease can be successfully treated through prompt thorough attention which will include a strict oral hygiene program and may necessitate minor periodontal surgery.

Dental Specialties

Prevention and Corrective Procedures

Dental Examinations:
Except in the case of an emergency, the first dental appointment is spent conducting a thorough examination. A complete health history, visual inspection of the mouth tissues and teeth, necessary x-rays, and diagnostic models when required, are all part of a complete dental examination. The findings derived from the above procedures will help the dentist diagnose your mouth's present condition, and recommend proper treatment. Once the appropriate services have been determined, the discussion of fees and financial arrangements can be more easily accomplished.

Regular check ups, usually at 6 month intervals, are then important if decay and other dental problems are to be controlled and prevented. When you see your dentist at regular intervals, he can:

• Find and treat decay and other dental diseases early while damage is minimal and corrective procedures are usually less expensive.
• Give instructions on brushing, flossing, diet and fluoride use.
• Apply fluoride or pit and fissure sealants which will help prevent decay.
• Periodically clean your teeth to remove stains and tartar.

Children should have their first dental examination around age 2, before all of the deciduous (baby) teeth are present in the mouth. This is important because dental problems may start very early, and the deciduous teeth are essential for the proper development of your child. Deciduous teeth:

preserve space for the correct alignment of the permanent teeth which will develop later.

 are needed for the development of proper speech patterns.
are needed for appearance and chewing.

Nutrition:
Please remember that it is you who is in charge of your day to day physical, mental and dental health. Of course, a properly balanced diet is one of the most important factors governing your health. A diet with large amounts of sugar may possibly cause health problems. In addition, each time you eat, the sugars in your foods combine with the acid producing bacteria in plaque to promote tooth decay or periodontal disease. Remember, the frequency of eating sugar-rich foods, along with the time the sugar remains in the mouth, and the physical form of the food are also important factors which affect the rate of decay. For your continued good health, eat selected foods that have high nutritional values, and eliminate sugary snacks that contribute to dental problems.

Fluoride:
The use of fluoride, whether dietary (ingested internally in water, drops or tablets), or topical (applied to the tooth surfaces in gels, mouth rinses and tooth pastes), may contribute to a significant reduction of dental decay. It combines with the tooth enamel to strengthen it, and make it more resistant to decay.

Since it appears that the greatest benefit of dietary fluoride use is derived during the period of tooth development, a child should receive adequate fluoride from infancy until at least 12 to 14 years of age. By this time, all the teeth but the wisdom teeth would be fully developed.

Fluoride use should be supervised by a dentist or physician to make sure proper concentrations are taken. At this time, the accepted concentration of fluoride in water is 1 p.p.m. (part per million). If this level is not met, appropriate dietary supplements may be prescribed.

The effectiveness of fluoride use will vary from child to child due to differences in habits, heredity, diet and oral hygiene practices.

Brushing and Flossing

Tooth decay and periodontal (gum) disease start with plaque that remains on teeth for 24 hours or more.  Therefore, you should thoroughly clean your teeth at least once a day. It is also advisable to brush after eating whenever you can, especially after sweet snacks.  Cleaning your teeth just before you go to bed is always a good idea.

Brushing

Space Maintenance

Space Maintainers:

Figure A  Notice how the space was closed after the early loss of a deciduous tooth. There is not room for the succeeding permanent tooth to erupt into its normal position.

While children, like adults, need their deciduous (baby) teeth for chewing, appearance, and speaking, they also need a full set of healthy teeth to hold space in their jaws for the permanent teeth. Yes, it is true that these "baby" teeth will eventually be lost, but neglect may cause serious dental problems that would impair the proper development of your child's mouth.

If a deciduous tooth is lost too early, the teeth on either side may drift into the empty space thereby eliminating the necessary room for the succeeding permanent tooth to erupt into its proper position. This problem could cause a malocclusion (crooked teeth), and may contribute to decay and periodontal disease. Your dentist may recommend inserting a space maintainer when one or more deciduous teeth have been lost prematurely.

B and C (shown on the left) are just two typical lower space maintainers of which there are many variations.

Figure B  Unilateral Space Maintainer used when one or two baby teeth have been lost on one side.	Figure C  Lingual Arch Space Maintainer used when several teeth on each side of the arch have been lost. In this case, the front six teeth (light blue) and the six year molars are present, but the baby teeth in-between have been lost.

Partial Dentures

Removable appliances that replace one or more missing teeth. They receive support when under force from the tissues (teeth and gums) underlying the partial, and are kept in position by clasps (metal arms that grasp supporting teeth) and rests (metal tabs that lie on the teeth, keeping the partial from being pushed into the gums). The partial denture, although the restoration of choice in many situations, is not as strong nor does it function as well as the original teeth, and does not have the solid anchorage of a fixed bridge. 

Advantages of a Partial Denture:
1) Restores the "natural balance" of the teeth in the mouth, but not to the degree that a bridge would.
2)Can often be used where there is not sufficient anchorage for a fixed bridge.
3)Generally, the initial expense is less than bridge work, but over the years it may not fair as well. Due to decay, breakage, loss, or replacement of the appliance as conditions in the mouth change, the total expense may be much more.
4) Only minor tooth adjustment.
5) Usually can be added to if another tooth in the mouth is lost.

Disadvantages of a Partial Denture:
1) Is often not as kind to the mouth tissues as bridge work. If it is not kept absolutely clean, and properly fitted, many dental problems may result.
2)Usually covers a much larger area in the mouth than a fixed bridge. Therefore it may feel bulky and unnatural.
3)Since it is removable and easily collects food, it must be taken out of the mouth often for cleaning, and may be lost.

These are simply two of a great variety of upper and lower partial dentures. Every partial denture is designed and created to fit, and fulfill the needs of each dental patient.

Full Dentures

Removable appliances that are necessary when all the natural teeth are destroyed and lost. They are completely supported by the soft tissue and underlying bone.

It is very unfortunate when all the teeth are lost, since even well constructed dentures are never as effective as the natural teeth.

Choice of procedures:
Immediate or After Healing

Immediate denture: The denture is constructed before the natural teeth are extracted, and inserted in the mouth at the time those teeth are removed. This procedure has advantages that include:
1) no humiliating toothless period while healing;
2) the denture acts as a protective covering while the mouth heals;
3) repositioning the denture teeth to make them look natural is less difficult, and
4) natural appearance is more easily maintained.
The disadvantages of additional expense and time may outweigh the advantages. More appointments are necessary to watch the progress of healing, and relining or denture duplication is often necessary due to the uneven shrinkage of the mouth.

After healing: Upon removal of the remaining teeth, the mouth is allowed to heal from six weeks to several months before the denture is made. The greatest advantage of this method is obviously the fact that the mouth will be healed, to a large degree, before the patient must get use to wearing the new denture.

Success of the denture as a replacement for the natural teeth : Involves many factors, some of which are: 1) patient's attitude must be willing to make the denture work for him; 2) amount of support after healing (size of the dental ridge); 3) amount of tissue change that takes place after the denture is inserted; 4) patient's general health, and 5) proper maintenance.

Remember: The mouth was not intended to bear the stress of artificial teeth, therefore, until the tissue gets conditioned, one should expect some irritation (sore spots) and discomfort. The greatest changes will take place in the first six months. During this time, the dentures must be altered to meet these changes. If the denture becomes loose, due to shrinkage of the dental ridge, a Reline may be necessary: that is refitting the denture to the changing ridge by adding acrylic (material the denture is constructed of) to the inside of the denture. There are two types:

Laboratory Reline: A new impression of the dental ridge will be made inside the denture and sent to the laboratory where they will process the acrylic. This type of reline is generally thought to be more expensive but lasts longer than the chairside reline.

Chairside or Office Reline: This type of reline usually takes 30-45 minutes and is accomplished in the office by adding the acrylic to the inside of the denture in a soft consistency, and then conforming it to the ridge directly in the mouth. When it hardens (12-15 minutes) the denture will be trimmed of excess, polished, and returned so that the patient may leave the office with his denture.

The idea that a denture can remain permanently satisfactory is a mistaken one. Due to the inevitable shrinkage of bone, and .individual problems, no dentist can truly guarantee a superior permanent fit. As changes in the mouth arise, the dentures must be altered to correct these conditions. Further, since these changes are natural and occur at different times in various individuals, the necessary alterations are generally not part of the original charge any more than the repair and maintenance is part of the original cost of a new car.

Types of Malocclusions:

Class I Considered normal occlusion In normal occlusion, the upper teeth bite slightly ahead of the lowers.

Class II In Class II Malocclusion, the upper teeth bite greatly ahead of the lower teeth. May show characteristics of “buck teeth” and “receding jaw”

Class III In Class II Malocclusion, the upper front teeth bite behind the lower teeth. May show a characteristic “prominent or bulldog jaw”

Answers to Some Commonly Asked Dental Questions - I

Why are X-rays (Radiographs) necessary?
X-rays are probably the most valuable diagnostic tool available to the dentist. They enable the dentist to discover problems which a visual examination can not. A few specific examples follow:

Although the safety of dental x-rays has been often questioned, the American Dental Association says that when dental x-rays are made with modern equipment and techniques, the patient has little reason to be concerned about safety.

Answers to Some Commonly Asked Dental Questions - II

How many baby and permanent teeth does a person normally get?
The deciduous dentition (baby teeth) is comprised of 20 teeth all of which should be erupted around the age of 3 years old.

The permanent dentition numbers 32 teeth which includes 4 wisdom teeth.

What about tooth coloration?
Generally the deciduous dentition is milk white, and therefore often much lighter in shade than the permanent dentition. As people age, it is often observed that the permanent teeth become darker and more brittle. Stains, both internal and on the surface, along with decay, restorations, nonvital (dead) nerves, etc. can alter the natural shading of teeth {when the nerve of a tooth dies it becomes very dark). This shading is transmitted through the dentin and enamel layers, giving the tooth a characteristic dark appearance. 

Will the positioning of the baby teeth give you a clue as to the development of the permanent dentition, and in particular a possible developing malocclusion?
It is usually much better if the baby teeth have spaces between them which will allow adequate room for the larger developing permanent teeth. This is not to say however, that a normally aligned deciduous dentition without spacing will give way to a malocclusion. When a child's baby teeth are crowded, this definitely suggests that there may be a future problem. Such a situation bears close watching.

Types of malocclusions vary greatly from simple (one or more teeth out of alignment or rotated) to complex (i.e., abnormally sized dental arches). There are many situations that may cause a malocclusion such as: abnormally sized or shaped teeth; abnormally sized arches; decay; premature tooth loss; habits; accident; abnormal number of teeth; teeth erupted in an improper position, etc. To be well informed of possible problems, parents should have children's teeth examined routinely while the dentition is developing.

What type of toothbrush should I use?
Most dentists recommend a brush with soft, end-rounded bristles, a flat brushing surface, and a straight handle. Soft bristles are less likely to injure gum tissues, while the head of the brush should be small enough to reach every tooth. Children, of course, need smaller brushes than adults. Ask your dentist to prescribe the toothbrush suited for your needs.

What toothpaste should we use?
A fluoride toothpaste is generally recommended, especially for children, where it may prevent 25 - 30% of a child's decay. Other toothpastes can make brushing pleasant and leave your mouth feeling fresh, but may not give you protection against future decay. Your best protection is to check for the American Dental Association Council on Dental Therapeutics' seal of acceptance.

 Do mouthwashes help prevent decay or periodontal (gum) disease?
Most mouthwashes are designed to temporarily freshen your breath or sweeten your mouth. They do not remove plaque and cannot prevent decay or periodontal disease. Recently, however, fluoride mouth rinses have been introduced. These products will reduce the incidence of dental decay when used routinely. Again, one should look for the seal of the American Dental Association's Council on Dental Therapeutics.

What is an Anesthetic?
An anesthetic is an agent used to create a loss of bodily sensation. There are three types used in dentistry:

Topical- sprayed or brushed onto the tissue to numb (freeze) it. This type penetrates only a few millimeters and has short action. Therefore it cannot be used for major restorative procedures. It is generally used to numb the tissue prior to the injection of a local anesthetic.

 Local Anesthetic- is injected into the tissue to numb the teeth, bone and surrounding tissues. This type is generally given for most dental procedures.

 General Anesthetic - is given in several forms, but renders the recipient unconscious. This is the type one would get in a hospital when having surgery.

 Does it mean that you are into the nerve when a tooth that is being drilled on experiences pain?

No. Enamel has very little or no pain response, but the underlying dentin layer when stimulated by thermal changes, drilling, etc., does elicit a sensitive response. Depending on the age and condition of the teeth, the elicited response may vary greatly from tooth to tooth and person to person. Obviously then, one can see that when the drill penetrates the enamel layer and enters the dentin, the patient may feel sensitivity within the tooth, but the work being done may be neither deep nor near the nerve.

 Why do my front (white) fillings get darker?
Because of the particular composition of the resin filling materials, which are rather grainy in nature, they tend to take on stain quite easily. To lessen this problem it is suggested to have your dentist polish all white fillings, that you practice good oral hygiene, and try to eliminate substances that stain your teeth. Several of the worst offenders are coffee, tea and tobacco. For permanent stains, ask your dentist about bonding and other procedures.

Why do my gums often bleed, especially when brushing?
Several possible situations may give rise to bleeding gums, but by far the most common cause is periodontal disease. In the early stages of the disease, irritants in the plaque cause the gums to become inflamed, engorged with blood, and bleed easily. Later, calculus (tartar) may form around the necks of the teeth, making cleansing more difficult. If this becomes a noticeable problem, then one should seek dental treatment. Often, regular professional cleanings and a reinforced home oral hygiene program will be enough to substantially contain the disease.

You tell me I have periodontal disease, then why haven't I noticed any discomfort or pain?
Periodontal disease is usually a very slowly progressing disorder that infects the supporting structures of teeth, namely the gum tissue, periodontal ligament, and bone. It may take many years for the disease to completely manifest itself. Ordinarily there is little discomfort until the later stages when the teeth become loose, showing much exposed root surface and the surrounding tissues are severely infected and atrophied. Perhaps the greatest reason for so many people becoming victims of the disease is that they cannot actually see or feel the underlying bone being destroyed.

Is it possible to feel ill from an infected tooth?
Yes. When a tooth becomes severely infected it is possible for this infection to travel throughout the body causing a variety of effects, (i.e., headaches, earaches, elevated temperatures, inflammations generally in the head and neck region, nauseousness, etc.). If you are inflicted with an ailment that you feel may be initiated by an infected tooth, you should receive dental attention immediately.

Why is it often necessary to remove Impacted wisdom teeth?
Any tooth, not just wisdom teeth, may be impacted if the tooth moves in the wrong direction or is blocked from reaching its normal position in the mouth (see page 24). Although no one can always predict which impacted teeth will cause a problem, most of them eventually need to be removed. Typical reasons for impacted tooth removal include: infection of the surrounding gum tissue that can spread throughout the body; decay; disruption of other teeth's growth and position; cyst formation at the crown of the impacted tooth which may cause damage to the surrounding teeth as well as to the surrounding bone, and "referred pain." That is pain in other areas (i.e., eyes, ears, neck, throat, etc.). Because unexpected complications often occur at the most inconvenient times, and older people generally do not recover as quickly from surgery as a younger person, dentists usually recommend that most impacted teeth be removed at the earliest possible age.