Tooth and Periodontal Disease
Adults have 32 permanent teeth, including the incisors, canines, premolars, and molars. As shown in Figure 1, the crown of a tooth rises above the gingiva, and the root is the portion embedded in alveolar bone. The periodontal ligament suspends a tooth and its roots in the bone and is made up of collagen fibers. The major component of teeth is a bone-like substance called dentin. Inside the tooth lies the pulp, containing blood vessels and nerves. The crown is covered by enamel and the roots are covered by cementum.
(Enlarge Image)
Figure 1.
Tooth anatomy.
Diseases of the teeth are frequently identified by clinical inspection of the oral cavity and by x-ray examination. Common radiographs include periapical views to identify the crown and root, bite-wing radiographs to examine the interproximal spaces, occlusal views to image large segments of the dental arch, and panoramic views to identify both dental arches and their supporting structures. Periapical, bite-wing, and occlusal radiographs are intraoral films made by placing film inside the patient's mouth and directing the x-ray beam through the area to be imaged. Panoramic radiographs, which are extraoral films requiring special equipment to obtain, are frequently used since they can display the entire maxillomandibular region on a single film.
Dental caries, or injury and destruction of the calcified structures of the teeth by Streptococcus species and other bacteria, continue to be extremely prevalent in the United States. Although less than 15% of US adults are free of caries, the absolute number of caries per individual during the past 50 years has declined. This is due in part to preventive measures such as water fluoridation and the use of toothpaste, supplements, and mouth rinses that contain fluoride.
Caries may occur on smooth tooth surfaces, chewing surfaces, and most commonly in pits and fissures (Fig 2). To prevent caries in the pits and grooves of occlusal surfaces of posterior teeth, dental sealants have been developed. These materials modify the resistance of teeth to caries by coating the occlusal grooves with an adherent material such as a plastic resin. Dental sealants are currently indicated for newly erupted teeth with significant pits and fissures or for patients with significant previous occlusal caries. Once dental caries occur, they are treated by removal of the affected tissue and replacement with a restorative material such as silver amalgam, gold, or composite. The primary goal, however, is prevention of caries through dietary modification, limitation of sucrose-containing food, use of fluoride supplements, and antibacterial measures such as daily personal oral hygiene and regular professional cleanings.
(Enlarge Image)
Figure 2.
Location of pit and fissures on tooth surfaces.
During office visits with patients of all ages, physicians are advised to counsel regular visits to a dental care provider and daily flossing and brushing. However, in 1997, only 64.9% of the US population aged 2 and older had a dental visit within the preceding 12 months. One barrier is cost, since more than half of all expenditures for dental care are out-of-pocket. This is especially true for elderly patients, since cleanings, fillings, extractions, and denture preparation are not covered by Medicare. A broader range of services are available under Medicaid, but benefits and eligibility may vary. A survey by the American Dental Association in 1995 found the average fee for an oral examination with x-rays was $83, crown placement $550, and dentures $705 per arch.
Although cost may be an important factor, compliance with screening recommendations is also suboptimal, even when dental care is available at no monetary cost to the patient. In one study, which evaluated patients eligible for dental care within the VA system, only 62% reported a dental visit within the past year. By 1987, 100 million Americans had dental insurance. Although this should improve access, almost one third of persons in this group have not had a dental visit within the past year.
Since significant numbers of persons in the United States have not had recent dental care, it is important for physicians to be aware of several groups of patients who may be at increased risk for dental caries and require further counseling and intervention. Patients with physical handicaps or neurologic, psychiatric, or arthritic conditions may be less able to provide self-care. Substances such as tobacco and alcohol and contact with acid due to recurrent vomiting or gastroesophageal reflux disease may cause erosion and subsequent injury to teeth. Xerostomia may predispose patients to caries. This condition affects patients with Sjögren's disease or those who use medications that cause xerostomia, including antidepressants, antihypertensives, antipsychotics, duiretics, and antihistamines. Patients receiving radiation therapy for head and neck cancer are at risk for salivary gland dysfunction. Appropriate considerations in these individuals include increased frequency of mechanical plaque removal, use of a modified toothbrush, use of chlorhexidine mouthwashes, and topical fluoride prophylaxis.
If dental caries are not properly recognized and treated, complications may occur. Spread of infection from the hard tissues of the teeth to the pulp results in reversible or irreversible pulpitis. Reversible pulpitis is manifested as transient pain in response to thermal stimuli. Analgesics, avoidance of extreme temperature stimulation, and dental referral for therapy are appropriate. If the infection progresses, irreversible pulpitis may occur. This is evidenced by persistent, often throbbing pain, which may be worsened by heat and relieved by cold. Pulp removal by root canal or tooth extraction is usually required. The root canal process involves removal of infected tissue, cleansing of the area, and filling of the canal with an inert material. After root canal treatments, coronal restoration with a crown is often required to prevent tooth fracture or carious recurrence.
In some cases, the inflammation and infection of the pulp may extend beyond the tooth to the periapical tissues of the periodontal ligament. This is suggested by exquisite pain on chewing, touch or percussion of the teeth, and usually requires pain medication in addition to local therapy. If fever, lymphadenopathy, tooth mobility, or edema of the soft tissues is also present, a periapical abscess may have developed, and antibiotics and incision and drainage are needed.
The presence of a periapical abscess is an indication for rapid intervention to avoid complications such as cellulitis, bacteremia, and spread to adjacent tissues of the head and neck. One such example is Ludwig's angina, a medical emergency resulting from seeding of the submandibular space by an infection arising in the second or third lower molars. The patient may have had a recent dental procedure, and presents with pain, fever, drooling, dysphagia, and dyspnea. Cellulitis of the neck, tongue elevation and soft-tissue swelling may be observed on physical examination. Airway management, antibiotics to cover oral pathogens, and surgical drainage are the mainstays of therapy.
Because physicians frequently encounter patients with dental complaints, familiarity with the initial management of these conditions is important. Issues that may arise include the appropriate use of antibiotics and the indications for immediate dental referral. Antibiotics may be unnecessarily prescribed in up to 30% of cases, which may increase costs and risk of side effects. Since the primary management of acute dental conditions is mechanical, antibiotics should be reserved for the treatment of an established infection, such as a periapical abscess, or for periprocedural prophylaxis against bacterial endocarditis. When needed, penicillin and its derivatives, erythromycin, clindamycin, and metronidazole are appropriate adjuncts to definitive dental treatement. In contrast, pulpitis or tooth pain, the most frequent dental complaint, is treated by removing affected pulpal tissue, and antibiotics are not indicated.
In addition to the use of antibiotics, physicians should be aware of the indications for acute dental referral, or need for care within 24 hours. As summarized by Dunne, indications include (1) severe, acute pain that cannot be relieved by removal of thermal stimuli or analgesics; (2) trauma, especially if teeth have been avulsed; (3) orofacial swelling that is new or enlarging; (4) bleeding that cannot be stopped; and (5) fever due to dental infection.
Diseases of the Teeth
Adults have 32 permanent teeth, including the incisors, canines, premolars, and molars. As shown in Figure 1, the crown of a tooth rises above the gingiva, and the root is the portion embedded in alveolar bone. The periodontal ligament suspends a tooth and its roots in the bone and is made up of collagen fibers. The major component of teeth is a bone-like substance called dentin. Inside the tooth lies the pulp, containing blood vessels and nerves. The crown is covered by enamel and the roots are covered by cementum.
(Enlarge Image)
Figure 1.
Tooth anatomy.
Diseases of the teeth are frequently identified by clinical inspection of the oral cavity and by x-ray examination. Common radiographs include periapical views to identify the crown and root, bite-wing radiographs to examine the interproximal spaces, occlusal views to image large segments of the dental arch, and panoramic views to identify both dental arches and their supporting structures. Periapical, bite-wing, and occlusal radiographs are intraoral films made by placing film inside the patient's mouth and directing the x-ray beam through the area to be imaged. Panoramic radiographs, which are extraoral films requiring special equipment to obtain, are frequently used since they can display the entire maxillomandibular region on a single film.
Dental caries, or injury and destruction of the calcified structures of the teeth by Streptococcus species and other bacteria, continue to be extremely prevalent in the United States. Although less than 15% of US adults are free of caries, the absolute number of caries per individual during the past 50 years has declined. This is due in part to preventive measures such as water fluoridation and the use of toothpaste, supplements, and mouth rinses that contain fluoride.
Caries may occur on smooth tooth surfaces, chewing surfaces, and most commonly in pits and fissures (Fig 2). To prevent caries in the pits and grooves of occlusal surfaces of posterior teeth, dental sealants have been developed. These materials modify the resistance of teeth to caries by coating the occlusal grooves with an adherent material such as a plastic resin. Dental sealants are currently indicated for newly erupted teeth with significant pits and fissures or for patients with significant previous occlusal caries. Once dental caries occur, they are treated by removal of the affected tissue and replacement with a restorative material such as silver amalgam, gold, or composite. The primary goal, however, is prevention of caries through dietary modification, limitation of sucrose-containing food, use of fluoride supplements, and antibacterial measures such as daily personal oral hygiene and regular professional cleanings.
(Enlarge Image)
Figure 2.
Location of pit and fissures on tooth surfaces.
During office visits with patients of all ages, physicians are advised to counsel regular visits to a dental care provider and daily flossing and brushing. However, in 1997, only 64.9% of the US population aged 2 and older had a dental visit within the preceding 12 months. One barrier is cost, since more than half of all expenditures for dental care are out-of-pocket. This is especially true for elderly patients, since cleanings, fillings, extractions, and denture preparation are not covered by Medicare. A broader range of services are available under Medicaid, but benefits and eligibility may vary. A survey by the American Dental Association in 1995 found the average fee for an oral examination with x-rays was $83, crown placement $550, and dentures $705 per arch.
Although cost may be an important factor, compliance with screening recommendations is also suboptimal, even when dental care is available at no monetary cost to the patient. In one study, which evaluated patients eligible for dental care within the VA system, only 62% reported a dental visit within the past year. By 1987, 100 million Americans had dental insurance. Although this should improve access, almost one third of persons in this group have not had a dental visit within the past year.
Since significant numbers of persons in the United States have not had recent dental care, it is important for physicians to be aware of several groups of patients who may be at increased risk for dental caries and require further counseling and intervention. Patients with physical handicaps or neurologic, psychiatric, or arthritic conditions may be less able to provide self-care. Substances such as tobacco and alcohol and contact with acid due to recurrent vomiting or gastroesophageal reflux disease may cause erosion and subsequent injury to teeth. Xerostomia may predispose patients to caries. This condition affects patients with Sjögren's disease or those who use medications that cause xerostomia, including antidepressants, antihypertensives, antipsychotics, duiretics, and antihistamines. Patients receiving radiation therapy for head and neck cancer are at risk for salivary gland dysfunction. Appropriate considerations in these individuals include increased frequency of mechanical plaque removal, use of a modified toothbrush, use of chlorhexidine mouthwashes, and topical fluoride prophylaxis.
If dental caries are not properly recognized and treated, complications may occur. Spread of infection from the hard tissues of the teeth to the pulp results in reversible or irreversible pulpitis. Reversible pulpitis is manifested as transient pain in response to thermal stimuli. Analgesics, avoidance of extreme temperature stimulation, and dental referral for therapy are appropriate. If the infection progresses, irreversible pulpitis may occur. This is evidenced by persistent, often throbbing pain, which may be worsened by heat and relieved by cold. Pulp removal by root canal or tooth extraction is usually required. The root canal process involves removal of infected tissue, cleansing of the area, and filling of the canal with an inert material. After root canal treatments, coronal restoration with a crown is often required to prevent tooth fracture or carious recurrence.
In some cases, the inflammation and infection of the pulp may extend beyond the tooth to the periapical tissues of the periodontal ligament. This is suggested by exquisite pain on chewing, touch or percussion of the teeth, and usually requires pain medication in addition to local therapy. If fever, lymphadenopathy, tooth mobility, or edema of the soft tissues is also present, a periapical abscess may have developed, and antibiotics and incision and drainage are needed.
The presence of a periapical abscess is an indication for rapid intervention to avoid complications such as cellulitis, bacteremia, and spread to adjacent tissues of the head and neck. One such example is Ludwig's angina, a medical emergency resulting from seeding of the submandibular space by an infection arising in the second or third lower molars. The patient may have had a recent dental procedure, and presents with pain, fever, drooling, dysphagia, and dyspnea. Cellulitis of the neck, tongue elevation and soft-tissue swelling may be observed on physical examination. Airway management, antibiotics to cover oral pathogens, and surgical drainage are the mainstays of therapy.
Because physicians frequently encounter patients with dental complaints, familiarity with the initial management of these conditions is important. Issues that may arise include the appropriate use of antibiotics and the indications for immediate dental referral. Antibiotics may be unnecessarily prescribed in up to 30% of cases, which may increase costs and risk of side effects. Since the primary management of acute dental conditions is mechanical, antibiotics should be reserved for the treatment of an established infection, such as a periapical abscess, or for periprocedural prophylaxis against bacterial endocarditis. When needed, penicillin and its derivatives, erythromycin, clindamycin, and metronidazole are appropriate adjuncts to definitive dental treatement. In contrast, pulpitis or tooth pain, the most frequent dental complaint, is treated by removing affected pulpal tissue, and antibiotics are not indicated.
In addition to the use of antibiotics, physicians should be aware of the indications for acute dental referral, or need for care within 24 hours. As summarized by Dunne, indications include (1) severe, acute pain that cannot be relieved by removal of thermal stimuli or analgesics; (2) trauma, especially if teeth have been avulsed; (3) orofacial swelling that is new or enlarging; (4) bleeding that cannot be stopped; and (5) fever due to dental infection.
Source...