oral cancer

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The facts about oral cancer (signs, symptoms and factors)
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Physical Risk factors (smoking, drinking, age and HPV)
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Epidemiology and mortality
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Leukoplakia and erythroplakia
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Cancer of the lip
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Tumors of the salivary glands
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Malignant melanoma
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Screening for oral cancer
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Visual exam
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Oral CDX
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Vizilit

Oral Cancer--The facts (and why that lump you noticed in the mirror this morning is probably NOT cancer!)
Oral and pharyngeal (throat) cancer represents about 3% to 5% of all forms of cancer. In 2006, 30,000 cases are expected to be diagnosed in the US, and 8000 are expected to die of the disease. If cancer of the larynx, which is quite similar to oral squamous cell cancer and has similar risk factors is includedl, an additional 14,000 diagnoses will be added to the 2006 total.

The five year survival rate for this type of cancer has remained at about 50% since the early 1960's. About half of the cases occur in persons over the age of 65.

Oral cancer attacks more men than women (male/female ratio = 2/1), and more blacks than whites (black/white ratio = 2/1). The survival rate is better for Caucasians (54%) than for Afro-Americans (34%). The most common sites of oral cancer are the floor of the mouth, the sides and undersurface of the tongue, the back of the throat, and the lips. Although it is not considered oral cancer in the strict sense, cancer of the larynx (the voice box) has a similar etiology (cause & origin) and causes approximately 2% of all forms of cancer. 90% of the victims of cancer of the larynx are males, and most are between 60 and 70 years old.

Indications that you may have developed oral or laryngial cancer

* A sore in the mouth that does not heal spontaneously within three weeks;
* A lump or thickening in the cheek;
* A white or red patch on the gums, tongue, or lining of the mouth;
* Soreness or a feeling that something is caught in the throat;
* Difficulty chewing or swallowing;
* Difficulty moving the jaw or tongue;
* Numbness of the tongue or other area of the mouth; or
* Swelling of the jaw that causes dentures to fit poorly or become uncomfortable.

The general characteristics of oral cancer

90% of all oral cancers are of a type called Squamous cell carcinoma, which means that they derive from squamous cells which are the type of cells that make up the pink mucosa that lines the mouth. Laryngeal cancer (cancer of the vocal cords) is also generally caused by squamous cell carcinoma, and is also associated with heavy smoking. Most oral cancers tend to happen on the floor of the mouth or the sides and undersurface of the tongue. They also tend to be relatively painless during their early development. The image to the right shows a rather advanced cancer on the side of the tongue. (Click the image to see a larger version, as well as some other rather scary examples of oral cancer.) Note the mottled white and red appearance of the growth. As you will see, this is an important characteristic of these cancers.

It is interesting to note that squamous cell carcinoma is NOT USUALLY one of the more virulent cancers, and yet it kills about half of those that get it. This is an important point since if it is diagnosed at a reasonably early stage (within the first year, or in some cases within the first two years--The earlier, of course, the better), it can generally be removed before it becomes locally invasive or spreads to other parts of the body and becomes a death dealing issue. Why would anyone let a problem like this progress until it is this large? (Click the image for more info on why this one got so big.) Why does does such a slow growing cancer have such a large mortality rate? (Mortality rate is the measure of the ratio of those who contract the disease to those who die from it. In the case of Squamous cell carcinoma, the mortality rate is about 50%, meaning that approximately half the people diagnosed with it will eventually die as a direct result of the cancer, or from complications associated with it.)

The physical factors that increase the risk of oral cancer

Since 90% of all oral cancers are of a type called Squamous Cell Carcinoma, when we speak of "risk factors" associated with oral cancer, we are talking about risk factors associated with this particular entity. These risk factors do not pertain to the other 10% of cancers which can occur in the oral cavity. This 10% are covered later on this page. There are four factors that appear to increase the risk of developing oral squamous cell carcinoma:

(1)Tobacco AND (2)alcohol--When indulged in together over a long period of time, heavy alcohol and tobacco use are the most potent physical factors contributing to the development of squamous cell carcinoma. Those who both smoke and drink heavily, have a 15 times greater risk of developing oral cancer than those that have neither habit.

* Tobacco is a known carcinogen, which means that it is known to damage cellular DNA. Damaged DNA can cause the cellular reproductive machinery to malfunction, which is the first step in the growth of malignant cellular masses (cancer).
* Alcohol is known to inhibit a gene that functions in response to DNA damage. This gene is responsible for initiating cell death in cells in which the the DNA is damaged.
* Thus the tobacco causes malignant mutations in the cellular DNA, while the alcohol inhibits the body's natural defense against malignancy.

(3)Age--The large majority of squamous cell carcinoma victims are over the age of 45. This probably relates to the tendency of the immune system to become less and less competent at recognizing and eliminating mutated cells that arise in the body from time to time. It may also be associated with the time it takes for the other three factors discussed in this section to have their damaging effects.

(4)HPV--The human papilloma virus. HPV is transferred from person to person by vigorous physical contact, especially oral sexual contact. The presence of HPV may be the major risk factor in the development of oral cancers in patients who are not heavy smokers and drinkers. HPV is covered in more detail under the lifestyle discussion below.

Factors relating to epidemiology and mortality in patients with oral and laryngeal cancers (Epidemiology is the study of how a disease spreads and who is likely to get it.)

Lifestyle issues:

Lifestyle issues are behavior patterns which are considered under the control of the individual. They are the most important factors in the mortality (death rate) and epidemiology (how the disease spreads, and who is likely to get sick) associated with oral and laryngeal squamous cell cancers. Patient lifestyle choices probably accounted for the development of the lesions seen in the images on this page, and also contributed to the fact that they grew so large before diagnosis.

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Heavy Drinking-- While alcohol is one of the major physical risk factors in the direct development of oral cancer, heavy drinking (the behavior) is associated with oral cancer's high mortality (death) rate. Heavy drinkers are much less likely to notice, let alone seek professional help for a painless growth under their tongues!
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Smoking-- Tobacco has a direct effect on the tissues that the smoke actually comes into contact with. This includes both the tissues of the mouth, and the tissues in the larynx (voice box). 75% of persons who develop oral squamous cell carcinoma are, or have been heavy smokers. It appears that the effects of tobacco are cumulative, so people who have been heavy smokers (or snuff dippers) for many years are more at risk for developing oral or laryngeal cancer than those who have only recently started.
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HPV-- When discussing HPV as it relates to oral cancer, the lifestyle issue here relates to sexual behavior. 25% of oral cancers appear in patients who have never smoked, and it is thought that human papilloma virus may be the carcinogenetic element involved in these cases. There are approximately 80 strains of the human papilloma virus. Many of the strains of HPV cause ordinary warts, the kind that develop on the hands and feet. Most strains of HPV are thought to be harmless, but two types, HPV16 and 18, have been shown to be the causative agents of cervical cancer (cancer affecting the epithelial cellular layer--the surface cells--surrounding the opening of the uterus) and are spread by sexual means. These strains of HPV have recently been implicated as a causative agents in oral squamous cell cancer as well. Since the virus itself is transmitted exclusively by vigorous physical contact, the implication is that oral/genital sexual contact (oral sex) may be the major means of transmission of the virus.
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Normal kissing does not seem to be implicated. Monogamous couples composed of persons who have never engaged in sex outside of their relationship are not at risk either.
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As the incidence of smoking has declined over the last 30 years in the USA, the incidence of promiscuous sexual contact has risen. Thus the expected benefit of fewer people smoking has been offset by the liability of more widespread infection with HPV. This means that the rate of oral cancer diagnosis in the US has remained constant over the last twenty years, instead of falling as might have been the expected with the decline in the number of smokers.

For more on the human papilloma virus, please see the website of the oral cancer foundation.

The implication here is that if you are under the age of 45, have not indulged for long periods of time in the combined habits of heavy drinking and smoking, and have not indulged in vigorous oral sexual activity with partners that are likely to be promiscuous, then the likelihood that the sore you found in your mouth this morning is probably not squamous cell cancer. Hopefully, this page should go a long way in setting your mind at ease. On the other hand, this is NO guarantee that the lesion is not dangerous. No website is a replacement for a visit to a dentist or physician who can deal with you personally!

The rule of thumb in assessing any soft tissue sore in the oral cavity is "if it is not gone in three weeks, see a dentist or physician and have it properly diagnosed"!

Age and its relationship to mortality and epidemiology in oral and laryngeal cancers

One of the most important factors associated with oral cancer is age. Even in a population of cigarette smoking drinkers, the vast majority who develop oral cancer tend to be over the age of 40. Half of all oral cancers arise in persons over the age of 65. Advanced age is probably the most important factor in the mortality associated with the development of any cancer. This is due to the fact that as a person ages, their immune system tends to become less efficient at recognizing and eliminating aberrant cellular growths which arise from time to time in people of all ages. Since about half of all cases of oral cancer, and most cases of laryngial cancer occur in patients over the age of 65, the advanced age of the cohort alone would account for a substantial portion of the death rate in these patients.



Painless Lesions contribute to the mortality rate ("Lesions" are abnormal growths, erosions or sores.)

The initial lesions of squamous cell carcinoma tend to be painless. The fact that they are painless makes them easily overlooked in the early stages. The lack of pain in early lesions combined with the tendency for this cancer to develop in heavy drinkers may be largely responsible for oral cancer's 50% mortality rate . These lesions start out as small white or red patches about 1 to 2 mm in diameter and progress toward larger lesions slowly. They will usually be noted by a patient when they are large enough to be felt during movements of the effected organ. They generally appear to be irregular sores with a white and red mottled center, surrounded by a red border. As the lesion enlarges, it may become more and more bound-down to the underlying tissues thus becoming less mobile. Pain and/or numbness generally develop later in the course of the lesion's growth.

Leukoplakia

Persons who smoke heavily or use smokeless tobacco such as snuff and chewing tobacco tend to get whitish patches called leukoplakia on the oral mucosa (the wet tissue lining the mouth) . The image on the right shows a fairly typical patch on the side of a man's tongue. The image to the left shows a similar patch on the floor of the mouth. These patches can happen anywhere in the oral cavity such as on the cheek mucosa, the roof of the mouth, or the back of the throat. The common denominator seems to be HEAVY use of cigarettes or prolonged contact of snuff or chewing tobacco with cheek tissue. Leukoplakia is not itself a form of cancer, but is considered pre-cancerous and should be biopsied (a procedure in which a tiny piece of tissue is sent out for microscopic examination) since about 20% are found to be pre-malignant . It is white, firm tissue and cannot be scraped off. It generally goes away when the stimulation of the tobacco stops, but with continued heavy tobacco use it can transform into squamous cell cancer. In order to picture what a cancer developing in these lesions would look like, imagine irregular red blotches developing inside the white leukoplakic plaque, and a large red border developing around the entire lesion! Erythroplakia (see image at right) is the term applied to red bloches which appear within areas of leukoplakia. Erythroplakia is considered to be more dangerous than leukoplakia alone. Click on the image to the left or the one to the imediate right to see these images enlarged, and other scary images of leukoplakia. Neither leukoplakia nor erythroplakia are contagious conditions.

The number one cancer of the head and neck is cancer of the larynx--the voice box--which is more susceptible to particulate carcinogens such as cigarette smoke and various forms of pollution than other tissues. The majority of patients who get cancer of the larynx are men between 60 and 70 years old who have a history of heavy smoking and generally heavy drinking. Women in the same category are also prone to squamous cell carcinoma.

Cancer of the lip

Cancers on the lips are a special case. They generally strike the lower lip and are more likely to happen after long, repeated episodes of exposure to the sun. Cancer of the lip is also squamous cell carcinoma and has the same clinical course as intraoral cancers. Going to the beach several times a summer is generally not a significant risk factor for cancer on the lip. Most people who get this form of cancer tend to be outdoor workers who labor all day in the sun for years on end. Perhaps because more people work indoors today than ever before, the incidence of cancer of the lip is decreasing.

What about the other 10% that are not squamous cell carcinoma?

The probability of developing any type of cancer increases with age! Chronic illness is another factor that increases the likelihood of developing these forms of cancer. There are, unfortunately, numerous types of cancer that can originate in various oral structures including bone, lymph nodes, salivary glands etc. These are not associated with known risk factors the way squamous cell cancer is associated with smoking, drinking and promiscuous oral sexual activity. There is some evidence that non squamous cell cancers of the oral cavity are related to precipitating factors such as exposure to the Epstein Barr virus (the virus responsible for mononucleosis which in some persons seems able to remain dormant in the body for a lifetime) as well as the human papillomavirus (HPV), and radiation treatments to the head and neck for cancer or acne (not diagnostic x-rays). Radiation was once a treatment modality for facial acne (back in the early 20th century) but is no longer used because of the obvious danger from large amounts of radiation. It is still used in the treatment of carcinomas and Sarcomas (two different classifications of malignancy) but is carefully aimed and metered to avoid side effects.

A minor salivary gland tumor tends to be a firm mass on one side of the palate (the roof of the mouth). They do not occur in the midline. If it is cancerous, it will remain enlarged and will not go away after two or three weeks. About 50% of these large persistent masses will prove to be malignant (cancer). But be aware that small salivary glands in the palatal mucosa do become infected occasionally. When this happens, they can become sore and slightly enlarged, but the problem is generally temporary and disappears without treatment within two weeks.

About 80% of all salivary gland tumors begin in the parotid glands. (A tumor is simply a mass. It is not necessarily cancerous.) The patient notes a swelling on the side of the face below and in front of the ear. This swelling does not get larger and smaller at different times of the day (as salivary gland infections do), but remains constant, or grows larger over time. 10%-15% of salivary gland tumors start in the submandibular glands causing a swelling on one side of the neck just under the jawline. These also remain enlarged over time. The rest develop in the sublingual gland, causing a similar swelling under the chin, or in one of the many minor salivary glands. Most tumors of the parotids are benign (noncancerous). Masses in the minor salivary glands (the smallest of salivary glands) are more frequently malignant (cancerous), however because there are so many more parotid gland tumors, a greater number of cancers are found in the parotid glands than any of the other salivary glands. (For a diagram of the major salivary glands, see my page on Dry Mouth.)

One of the most deadly forms of oral cancer is Malignant melanoma. Thankfully, it is very rare in the oral cavity. It begins as small black spot, generally smaller than a millimeter, and develops irregular borders as it grows larger (see image on the right). Melanoma can happen on any tissue in the mouth, particularly inside the lips, cheeks, undersurface of the tongue and on the hard palate. It is likely to be tan, dark brown or black, sometimes mixed with red or gray.

Melanoma occurring anywhere other than the mouth is generally considered to be fairly treatable. Unfortunately, due to the anatomy of the head and neck, oral melanoma is most often fatal.

Fortunately, most dark spots on oral tissue are likely to be amalgam tattoos discussed in more depth on the sores, lumps and bumps page. Amalgam tattoos happen after dental appointments, remain stable, do not grow larger over time, and are relatively circumscribed (without diffuse, irregular borders). They also tend to have a blue-gray color, unlike the dark brown or black seen in melanoma. They are most common on the gums, cheeks and floor of mouth immediately adjacent to teeth. Amalgam tattoos attain and maintain their maximum size shortly after the introduction of the amalgam into the tissue, while melanomas will grow and change shape over the course of a week or two.

How dentists screen for oral cancer

Although screening by your dentist is the best method of reducing the pain, suffering and mortality related to oral cancers, it is not altogether reassuring to know that differentiating early malignant and premalignant lesions from benign growths is quite difficult, even for experienced dental practitioners. Early stage oral cancers are asymptomatic and the clinical characteristics associated with malignancy such as pain, swelling, redness, enlargement, fixation (becoming bound down to underlying tissue) and deformation of the surrounding tissues generally do not develop until quite late in the clinical course of the disease.

Until recently, there were only two courses a dentist could take when he saw a suspicious early lesion. ("Lesions" are abnormal growths, erosions or sores.) The first, and most frequent course was waiting several weeks to see if the lesion progressed or regressed. If It went away, all was well, and the crisis was averted. If it got bigger, or if the lesion had been present for several weeks and was already of significant size on initial examination, then the dentist proceeded to the second course which is a sectional (knife) biopsy in which the patient is anesthetized and a piece of the lesion is surgically removed and sent to a laboratory in formalin for microscopic analysis. The microscopic examination of the tissue sample provides a definitive diagnosis upon which to base a treatment plan.

The difficulty with this protocol is that there is a high incidence of oral abnormalities which can be candidates for biopsy. It is claimed that between 5 and 15% of all new patients present with abnormal lesions in their mouths, however these include such lesions as aphthous, fibromas and many of the other obviously benign conditions explained on this page. No knowledgeable dentist would consider these to be candidates for biopsy. Even so, quite a few truly suspicious lesions do walk through our doors with only about 5% turning out to be cancer. Given these odds, it is impractical to immediately subject all these lesions to a potentially painful procedure like a surgical biopsy. Thus, using the older protocol, virtually everyone presenting with an early lesion was sent home to wait the obligatory two to three weeks to see if it progressed or not. While not a dangerous course of action, it still left any potential malignancy to progress for the entire waiting period plus whatever time it took to examine the biopsy tissue. It was not especially reassuring for either the dentist or the patient to know that if there was a cancerous lesion, it had to wait at least a month to be removed!
A better screening method has recently become available. It is called the Brush Biopsy (Oral CDx). This consists of placing a small, sterile, hard bristled brush over the lesion and twirling it around until part of surface of the lesion is abraded away. The procedure rakes up cellular material from the entire thickness of the surface of the lesion onto the brush. Although this procedure may irritate the area, (it should produce pinpoint bleeding areas) it does not generally require local anesthesia. The cellular material scraped up on the brush is smeared onto a glass slide, fixed with a chemical that comes with the kit, and dried. The glass slide is then placed into a plastic container and sent to a lab for computer scanning and further manual examination of suspicious cells. The makers of this biopsy kit claim 100% accuracy in identification of abnormal cellular components provided that the clinician was aggressive enough in obtaining a full thickness sample. The brush biopsy does NOT establish a definitive diagnosis. It does indicate the need for a surgical biopsy to establish the diagnosis.

The brush biopsy is not suitable for melanoma ( pigmented lesions) or lesions on the dry parts of the lips. It is generally reserved for use on lesions that show eroded or overgrown mucosal surfaces. Its principle use is for pre-cancerous lesions that will develop into squamous cell carcinoma. It is not useful for deeper lesions such salivary gland tumors.

Vizilite

Zila Pharmaceuticals has heavily marketed a light source which, when shined on oral mucosa is reputed to cause squamous cell carcinoma lesions to fluoresce, thus helping a trained clinician to spot them for early detection of oral cancer. This product is called Vizilite, and it is heavily marketed to dentists. It would be a great benefit for the early detection of oral cancer if......it actually worked as advertised.

In 2004, "the manufacturers of Vizilite applied to the ADA for the ADA Seal of Acceptance for their product. The official seal of acceptance is considered the ultimate in product recognition in terms of marketing a given product for use in dentistry in the United States. The Council on Scientific Affairs is charged with the review of all studies related to products requesting the seal. The companies are asked to submit all studies that support their claims. They are required to submit at least two credible clinical studies.

The usual requirement is that of two independent double blind clinical trials, each conducted at a separate site. In addition to the review of this data by the entire Council on Scientific Affairs, the studies are sent out to a number of outside reviewers. The conclusion on Vizilite was quite clear. Their submitted study data was extremely weak. All outside consultants were in agreement in not supporting the product for the seal. The Council was unanimous in not supporting the application." (Click here for the reference)

This light source has apparently been shown to be beneficial in the differentiation of cervical (uterine) squamous cell carcinoma. It appears, however, that the progression of the same cancer in the oral cavity is biologically different from the progression of cervical squamous cell carcinoma, and for this reason, it is of limited use in the oral cavity.

Therefore, the use of the Vizilite as a method of screening for oral cancer is probably more of an unnecessary expense than a benefit to either patients or the doctors using it.

Even so, the manufacturers of Vizilite continue to heavily market the product, and even advertise in the Journal of the American Dental Association. The presence of an ad in the Journal does not mean that the ADA endorses the product, any more than an ad on this website means that I endorse the product.

oral anatomy

Normal oral anatomy (click the appropriate structure above)
Tonsils
Should I have my child's tonsils removed?
Tonsiloliths
The throat (diagram)
The tongue and its associated bumps
Burning mouth/tongue syndrome (BMS)
Bald tongue (atrophic glossitis)
The floor of the mouth
The major and minor saliva glands
The facts about oral cancer (signs, symptoms and factors)
Leukoplakia and erythroplakia
Cancer of the lip
Tumors of the salivary glands
Malignant melanoma
Screening for oral cancer
Non cancerous lumps, bumps and abnormalities in the mouth
Tori and exostoses (hard bony tumors on the palate and gums)
Tongue abnormalities
Burning mouth/tongue syndrome (BMS)
Bald tongue (atrophic glossitis) (beefsteak tongue)
Lingual tonsils
Black or white hairy tongue
Geographic tongue
Enlarged Circumvallate papillae
Median Rhomboid Glossitis
Ankyloglossia (tongue tied)
Abnormalities of the gums
Gingivitis
Periodontitis
Trench Mouth (ANUG)
Pericoronitis
Parulus
Abnormalities of the lips and inside of the cheeks
Canker sores (aphthous)
Stenson's duct
Cold sores (herpes Labialis)
Angular cheilitis
Mucocele
Fordyce granules
Lichen Planus
Fibroma
Nicotinic Stomatitis (smokers palate)
Amalgam Tattoo
The oral manifestations of AIDS (HIV)


Have you ever wondered what that little thing that hangs down in the back of your throat is called? A glance at the diagram above will tell you it is called the Uvula. What's it for? It acts as a very effective valve that keeps food and drink from regurgitating up into the nasal cavity when eating or drinking (see diagram below). It vibrates while snoring, and when it is removed (usually in a procedure to reduce snoring) people seem to have minor problems immediately after the surgery with nasal regurgitation, especially when drinking carbonated beverages.

This problem goes away a few weeks after the surgery. The other structures, labeled clockwise around the diagram are as follows:

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The Labial Frenum is a little tag of tissue in the center of the upper and the lower lip that attaches the lip to the gums. It too is not especially useful, and sometimes causes orthodontic or periodontal problems if the attachment on the gums is too close to the teeth. If it becomes a problem, we usually simply cut it . This is most often done on children if the attachment of the frenum is too "high" and causes a diastema (space) between the adult teeth. The procedure is called a "frenectomy". An interesting thing to note is that a glancing blow to the face will generally rip this structure, and a ripped labial frenum, in combination with other "recurrent" bodily injuries is considered to be a legal indication of child abuse.


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The gingiva are what most people call the "gums". These are covered in more detail below.


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The roof of your mouth has two distinctive parts. The Hard Palate is the tough, leathery, non movable part of the roof of your mouth that is attached to the inside of your teeth and curves up to make the vault of your palate. The Soft Palate lies behind the hard palate and is closer to the back of your throat. You can feel the dividing line between the hard and soft palates with your tongue if you can draw it back that far. The Uvula is attached to the back of the soft palate. The Hamulii (singular hamulus) are hard little bumps in the corners of the soft palate just where the soft palate meets the very back of the tuberosities. If you press hard with the tip of the tongue to the inside and behind the gums behind the last top teeth, you may be able to feel them. They represent the tips of little projections from the base of your skull called the hamular processes of the palatine bone.


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The Maxillary Tuberosities are the tough, hard humps behind your top back teeth on both sides of the dental arch (note that both upper and lower teeth are arranged in "arches"). These humps have underlying bone and hard gum tissue covering them, and they are persistent, permanent parts of the mouth, even if all the upper teeth are extracted.


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Your Tonsils are at the border between your mouth and your throat. The Tonsils you can see at the corners of your throat are called the palatine tonsils. They are, in fact, only a part of a ring of tonsilar tissue that lines your entire throat. If you stick your tongue out really far, you can see some bumpy, pink (sometimes bluish) tissue toward the back on both sides. These are called the lingual tonsils. The lingual tonsils extend to the top (dorsal) surface of the tongue further back down your throat (see diagram below). Above the soft palate, about even with the palatine and lingual tonsils lie two similar masses of tissue called the Adenoids. These complete the tonsilar ring, so called because the palatine tonsils, lingual tonsils and adenoids form a complete ring of tonsilar tissue surrounding the throat. The tonsilar ring is composed of lymph nodes. Lymph nodes are a part of a separate "circulatory system" called the lymphatic system which acts like a drain to help keep the hydrostatic system of the body in balance. It keeps the various parts of your body from swelling up due to too much water pressure by allowing the water to redistribute itself. (In Tropical climates, the bite of certain mosquitoes can transfer a nasty little parasitic worm which lodges in the lymphatic system thereby blocking it and causing enormous swelling of various parts of the body. The condition is called "elephantiasis"--see image to the right) The lymph nodes (including the tonsils) act as a sort of filtration system to keep the fluids in the lymphatic vessels free of germs so that a localized infection does not spread to distant parts of the body through the lymphatic system.

Should I have my child's tonsils removed?
The thumbnail on the right (click on it to enlarge) shows typical palatine tonsils in a young child. (They shrink as we get older.) You can see that tonsils can take up quite a bit of room in the throat, and while they are not removed as casually today as they were earlier in the 20th century, their removal has certain advantages. They are a major factor in the constriction of the throat that causes snoring and obstructive sleep apnea, and when infected they can enlarge even more and add to the misery of a sore throat. When infected with Strep bacteria, numerous small yellowish-white plaques (white spots) appear all over them in the crevices (tonsilar crypts) that are visible over the surfaces of the tonsils seen in this image. These plaques are active colonies of the Streptococcus organism. Tonsils, like other lymph nodes, may enlarge during the course of viral and bacterial illnesses, and when this happens, constriction of the throat becomes more severe.

Of course the palatine tonsils do have physiological functions associated with the immune system. However they are fairly redundant (that is, there are a lot of other lymph nodes in the area which have the same function), and while some parents and politically inclined health organizations would sooner see their children lose their heads rather than their tonsils, no one ever seems to suffer any permanent adverse affects from their removal.

Conversely, their physical absence has a number of distinct advantages relating to less constriction of the airway and fewer complications from chronic infections. The major advantage of removing a child's tonsils is that the operation is much less painful for children than it is for full grown adults. If it becomes necessary to remove the tonsils during adulthood, the convalescence period is about two weeks of severe pain, especially upon swallowing. (Adults tend to lose a lot of weight. Children have fewer problems.)

Tonsiloliths (tonsil stones)

People with chronic sinusitis and post nasal drip may develop tonsiloliths, which are tiny, white, foul smelling stones which lodge in the tonsilar crypts. Sometimes a tonsolith can be pried out of the surface of the tonsil with a pencil or other small pointed instrument leaving what appears to be a little "hole" but is, in actuality, the tonsilar crypt in which it originally formed. Tonsiloliths sometimes give the feeling of something lodged in the throat. They can also contribute to bad breath. Some people have chronic problems with tonsiloliths. The only sure treatment for chronic tonsiloliths is removal of the tonsils. The operation is performed by an ear, nose and throat specialist (ENT) and is fairly simple and safe. As noted above, in adults the operation causes a very serious sore throat for two weeks post-op. Short of removing the tonsils, the bad breath can be treated with mouth rinses, and the condition itself may be lessened by gargling with Peridex® mouth wash which is available by prescription from your dentist or physician, and possibly by the use of decongestants to lessen the post nasal drip which is part of the cause of tonsiloliths.

Do you have Bad Breath?

Click here to learn about all the forms of bad breath, and how you can treat them


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The Retromolar Pad is similar to the maxillary tuberosities discussed above, except that it is behind the last lower molars, and it is not underlain by a corresponding hump of bone. Even so, it, like the tuberosity, is a persistent landmark and remains as a hump of tissue even if the lower teeth have all been extracted.


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The Vestibule is the curvature of the tissue where the lining of the inside of the lips (labial mucosa) or cheeks (buccal mucosa) meet the gingiva (the gums). If you run your tongue around the outside of the teeth and extend it as far as it will go down (or up) into the cheeks keeping it in contact with the gums, the tip is extended into the labial or buccal vestibule.


Place the cursor over the image to identify the various anatomic structures

The image above shows the actual anatomy of the gingiva, known commonly as the "gums". The lighter pink colored gum tissue is called the "attached gingiva" because it is firmly attached to the underlying bone. It has the same consistency as the gums overlying the hard palate discussed above. The darker pink tissue above it is called the unattached gingiva also called the Alveolar Mucosa. It is not firmly attached to the underlying bone. The junction between them is called the mucogingival junction. The small margin of tissue outlined in yellow on the lower diagram is called the free or marginal gingiva (sometimes called the free gingival margin), and it is the unattached, sleevelike portion of the gingiva that encircles the tooth to form the gingival sulcus.

The Vermillion border is the junction of the dry, pink part of the lip with the skin of the face. The labial (lip) vestibule is marked on the diagram. The Upper Labial Frenum is also visible.
The Throat

The illustration on the right shows what is called a sagittal section of the face and neck. Note the proximity of the back of the tongue, the soft palate and the epiglottis to the back of the throat. The area between these structures and the back of the throat represents the narrowest parts of the airway and it is the narrowness of the airway in these areas that are of chief concern in the treatment of snoring and obstructive sleep apnea. The throat is a dual purpose organ allowing both the function of breathing and of eating and drinking. Air goes down the trachea to the lungs and food and drink go down the esophagus into the stomach. A remarkable little organ called the epiglottis is the valve that determines into which tube the air or food flows. This organ closes over the trachea blocking it off when anything but air is flowing through the throat. It opens when the person is breathing. You do have conscious control of the epiglottis. You can get a sense of where it is by clearing your throat. During this process, the epiglottis obstructs the trachea (airway) while you are exhaling, blowing air past the partially closed valve.

The Tongue (and its associated "bumps")


The tongue is composed entirely of muscle and connective tissue covered with two types of mucosa (Mucosa is the pink "skin" in the mouth). The image on the left shows part of the lingual tonsil on the lateral (side) surface. The lingual tonsil is much larger than the portion shown here. It curves up and around the posterior top surface of the tongue too (see the graphic below). The ventral surface is the underside of the tongue and it is smooth and not involved with tasting food. The dorsal surface is on top and is covered with a thin, pink velvet carpet. The velvet is composed of tiny hair-like projections called "filiform papillae".



The filiform papillae are a bit like hair in that they keep growing throughout your life. The image on the left is a false color electron micrograph of the filiform papillae on a cat's tongue. Human filiform papillae are similar except they tend to be flatter and lie down instead of sticking up in little points (see the image of fungiform papilla below). Click on the image to see a larger version. In healthy people, the individual hairs are shed before they get too long, and the natural red color of the underlying tongue tissue shows through giving the top surface of the tongue a velvety pink appearance. In some disease conditions (mostly fever causing diseases), the hair does not shed easily and forms a white, or sometimes even a black "coat" on the dorsal surface of the tongue. The filiform papillae are naturally white, but are often stained brown or black by foods or by dry mouth. When the filiform papillae grow too long, they remain on the dorsum of the tongue like a thick mat. This condition is known as "white hairy tongue" or "black hairy tongue" (see images below). A white or black coating on the tongue is NOT necessarily associated with any particular disease condition. This overgrowth of "hair" is easily removed by scraping the surface of the tongue with a tongue scraper. The filiform papillae are not associated with the sense of taste. White and black hairy tongue are not contagious conditions. Click on either image below to see larger versions.



The floor of the mouth

The image to the right shows the undersurface of the tongue. The thin strip of tissue that runs vertically from the floor of the mouth to the undersurface of the tongue is called the lingual frenum. It tends to limit the movement of the tongue, and in some people, it is so short that it actually interferes with speaking. It is a simple matter to "snip" this chord under local anesthesia. It is most often done when a child is between 5 and 9 years old. The procedure is called a lingual frenectomy.

The "V" shaped hump of tissue in the floor of the mouth houses a series of saliva gland ducts. The two largest ducts are in the center just in front of the attachment of the lingual frenum and are called Wharton's Ducts. They empty the submaxillary saliva glands (also known as the submandibular salivary glands). These ducts can be quite active in some persons, and upon occasion, a "fountain" of saliva may erupt from them while the patient is talking causing one of those embarrassing moments. The Sublingual saliva glands glands empty through a series of tiny ducts in the tissue on either side of Wharton's ducts.

If you look carefully at this image, you will note some blue tinted tissue under the tongue and in the floor of the mouth. These represent the presence of superficial veins that run in this area, and they are called varicosities. Their presence is normal, becoming more and more prominent as the patient ages.



If you look at the surface of your tongue, you will notice many tiny bumps scattered in among the velvet along the edges of the dorsal surface. The bumps are another type of papilla called "fungiform papillae" (named in honor of their mushroom-like shape). These are small, slightly raised and slightly redder than the surrounding "velvet" filiform covered surface that surrounds them. Foliate papillae are a third type located on both sides of the tongue in a small area just above (dorsal to) the lingual tonsils on the lateral surface of the tongue. The fungiform and foliate papillae are associated with taste buds. These papillae tend to be specialized with respect to the type of taste buds they contain. The image above and to the right shows the areas on the tongue which contain the fungiform and foliate papillae with taste buds specialized to taste the four basic tastes. (Our sense of smell is intimately linked to our sense of taste, and it is in our nose that we taste everything besides salty, sweet, bitter, and sour.) Notice that on this little image the back of the dorsal surface of the tongue contains a series of large bumps. If you stick out your tongue, you can see them on your tongue too. These large bumps on the top surface of the back of the tongue are a fourth type of papilla called circumvallate papillae. They are located along the "circumvallate line" and contain taste buds that confer the sense of sour and bitter to the back of the tongue. They can actually be quite prominent and are often mistaken by patients for cancerous growths.
No, this child does not have Blue Tongue Disease! (There is no such thing--in humans anyways. Such a disease does exist, but it only affects cattle, goats, sheep and deer.) A few drops of blue food coloring were applied to demonstrate the general size and location of the (otherwise pink) fungiform papillae which are the little bumps scattered all over the top surface of the tongue. They are usually difficult to see unless an overgrowth of filiform papillae causes the ordinarily pink velvet of the tongue to turn white, in which case the fungiform papillae stand out as red dots.
This is a micrograph of a fungiform papilla (the large round structure in the center of the image) surrounded by hairlike filiform papillae, which in this case are "combed" down and are lying side by side.

Macroglossia (large tongue)

The tongue normally resides on the inside of the arch formed by the lower teeth. Most people's tongues fit neatly into this space, however, a minority of people have tongues which are a bit larger than the space available. This does not mean that the patient cannot actually fit their tongue into this space. The tongue is a very flexible organ, and can accommodate itself to the prevailing conditions easily. On the other hand, once fitted into the space, it relaxes and presses up against the teeth. This causes the tongue to fill up the space available. Tongues like this have scalloped edges like the one pictured to the left. The scallops reflect the shape of the teeth as well as the spaces between them. This condition is sometimes associated with burning around the edges of the tongue. Click the image to see why, and for larger images.

Fissured tongue (scrotal tongue)

Fissured tongue, also known as scrotal tongue is characterized by folds and fissures in the dorsal (top) surface of the tongue. The fissures are of variable depth and usually extend laterally from a median groove as is pictured in the thumbnail to the right. This condition does not cause any symptoms, unless food particles and debris lodge in the depths of the fissures causing a mild glossitis (inflammation of the tongue). It is considered to be a normal form of tongue anatomy. Click on the thumbnail to see a larger version.



(Many people who inquire about "bumps on the tongue" are worried about HIV and AIDS. Please click on the icon to the right to view a complete explanation of AIDS and its oral manifestations.)




Burning mouth syndrome (BMS) (also known as burning tongue syndrome)

A small percentage of older men and women (mostly women), generally at, or around the age of menopause develop a problem with chronic burning pain and phantom tastes in their mouths. It often centers on the tongue. The tongue itself looks perfectly normal. It just develops a burning sensation that progresses throughout the day. These patients may have seen numerous doctors to try to rid themselves of the annoying, and sometimes painful symptoms, but generally to no avail. The problem has been ignored for centuries because there seemed to be no physical reason for the symptoms, and because it was believed that it was a hysterical symptom brought on by emotional distress. In fact, the problem sometimes does respond to antidepressant drugs like Elavil.

Recent research has revealed a hypothesis which might explain BMS (Burning Mouth Syndrome). It involves actual damage of the seventh cranial nerve which supplies the taste buds in the anterior 2/3 of the tongue. This may be caused by either (or perhaps both) the change in hormonal balance due to menopause and/or a viral infection. The theory is that these persons have lost much of their ability to taste, even though many do not realize their loss since the brain is good at amplifying small signals. The loss of the function of the 7th nerve leaves the trigeminal nerve (which allows the tongue and mouth to experience pain sensation) in a position of dominance. This theory assumes a sort of balance between the two nerves, and if a patient suffers a loss of ability to taste because of damage to the 7th cranial nerve, then the brain exaggerates the impulses from both the trigeminal and the 7th cranial nerve causing a constant burning sensation because of exaggerated trigeminal sensitivity. In addition, due to exaggeration of impulses from the 7th cranial nerve, the brain begins to generate phantom taste sensations. This sort of taste hallucination is similar to the tactile "fat lip" sensation that a patient feels when the conduction of the trigeminal nerve is blocked by a shot of a local anesthetic to numb the lower teeth.

Sometimes people develop this problem due to a hypersensitivity to some toothpaste or oral rinse that they have recently begun using. The first line of defense is to change your toothpaste to a type with only fluoride (Tom's of Maine is a reasonable choice) and cut out mouth rinses. The type of toothpaste most often involved with this type of hypersensitivity are those containing pyrophosphates which are added to reduce the buildup of calculus (like Crest Complete or Colgate Total) Also try to determine if you have recently been taking a new medication whose introduction coincided with the onset of the symptoms. A simple change of medication could make the difference.

It was discovered, quite by accident, that patients suffering from epilepsy who also suffered BMS experienced relief from the symptoms of both of these ailments by the administration of the epilepsy drugs clonazepam (Klonopin) and gabapentin (Neurontin). Thus a small, once or twice a day oral dose of of one of these drugs has been found to relieve the symptoms of BMS in most patients. Alternatively, clonazepam may be dissolved in the mouth using 1/2 of a .5 mgm tablet twice a day. Another drug which has been found to be useful in treating BMS is Chlordiazepoxide (Librium) not to exceed 10 mgm three times per day.

Another treatment that may work (or at least reduce the symptoms) in about 1/2 of sufferers is capsaicin desensitization. Capsaicin is the ingredient in hot peppers that makes them hot. The regimen is dilution of one part Tabasco sauce in two or three parts water with the patient rinsing and expectorating (spitting out). This is done every 2-3 hours at first, and tapering off over a day or two to once or twice a day. Be careful. Some people are hypersensitive to capsaicin, so if the burning is too severe, stop immediately!

Bald tongue (Atrophic glossitis)

As people begin to reach their senior years, sometimes they notice that their tongue begins to burn when eating sharp tasting foods. A look in the mirror reveals a beefy red tongue lacking the filiform papillae which, in health, give the top (dorsal) surface of the tongue a normal, light pink, velvet appearance. The loss of the filiform papillae is known as atrophic glossitis, and it may be caused by several different factors. Click on the image for a larger view.

The first factor is nutrition. Atrophic glossitis is most often caused by a lack of B vitamins in the diet. The addition of daily doses of folic acid, niacin, vitamin B12, pyroxidine, riboflavin, and even Iron, all in the form of a simple daily multiple vitamin tablet may help to restore the tongue and relieve the burning on eating.

The second factor is an oral yeast infection known as thrush, also known as candadiasis. In older patients with weak immune function, the mouth acts as a good incubator for yeast cells. These accumulate under a denture and often cover the tongue leaving a white coating that is easily scraped off revealing red tissue underneath. This is easily treated with Mycelex troches, or a single Diflucan tablet. Both of these are anti-fungal medications.

The third factor is mechanical abrasion of the tongue against a rough dental appliance, or occasionally on the teeth themselves, producing a more localized, persistent area of smooth surface on the tongue. This is treated by building a new denture and repairing or removing rough, broken teeth. Sometimes it is as easy as scraping hardened dental calculus off the insides of the lower front teeth.


The Saliva glands

There are three pairs of major saliva glands. The Parotid glands are on the sides of the jaw just below and in front of the ears. They are the "pickle glands" that create that funny feeling on the sides of your face when you first taste something really sour. The reason you feel it is that the parotids are contracting, expressing a sudden burst of saliva into the mouth. The glands empty through tiny holes in little bumps on the inside of the cheeks. These bumps are called Stenson's ducts and you can feel them with the tip of your tongue on the cheeks on either side of your mouth beside the upper back molars. The sublingual and submaxillary (also called the submandibular) glands empty into the mouth through ducts under the tongue. For a more detailed diagram and explanation of the anatomy of the major salivary glands, click here.

Sometimes one of the ducts to a gland will become blocked, generally due to a calcium deposit called a sialolith, or a salivary stone. When this happens, the patient may notice a transient swelling in the face that comes whenever he eats, or thinks about food. The swelling corresponds to the time when the salivary gland is producing saliva. The sialolith causes the saliva to back up in the duct or in the gland itself. Ordinarily, saliva always flows from the gland into the mouth, and this keeps germs from the mouth from progressing up the duct into the gland. But when the flow of saliva is blocked, bacteria can now enter the duct. Infections of this nature are called retrograde infections because the lack of flow of body fluid in the normal direction allows the germs to flow backwards (retro) into the organ that produces it. This problem is treated by an oral surgeon who clears the duct or removes the stone, and administers antibiotics.

There are also about 600-1,000 minor salivary glands, which occur just under the mucosa (pink skin) all over the inside of the mouth, except on the top surface of the tongue. They are located beneath the lining of the lips, the undersurface of the tongue, the floor of the mouth, the hard and soft palate, inside the cheeks, nose, sinuses, and the larynx (voice box). These glands are susceptible to retrograde infections and blockages of the duct just like the major salivary glands. When this happens, the patient may notice a small reddish (inflamed) lump or bump, sometimes sore, sometimes not. These small lesions can happen anywhere on the smooth pink mucosa lining the lips, cheeks or undersurface of the tongue and floor of the mouth, as well as on the hard palate. Duct blockages often cause the swelling to take place at or around mealtime. The swelling generally subsides between meals.


If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, there are three other pages with images you may find useful. Start on this page.

Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions.

* Oral cancer
* Lumps, bumps and sores and discolorations
* Disease processes

The index on this page includes links to subjects covered on the cancer and lumps & bumps pages.




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tooth anatomy

The Crown

The crown of the tooth is that portion of the tooth that is covered with enamel. In most people, the crown lies nearly entirely exposed above the gum line. In children, the gingiva may partially cover the cervical (lower) part of the enamel.

Enamel

Enamel is the substance that covers the crown of the tooth. It is very hard and quite resistant to mechanical and chemical attack. Its purpose, of course, is to protect the tooth from the dangers posed to the teeth by the oral enviornment. In general, it is vulnerable only to acid attack from excess sugar (decay), generalized trauma such as a blow from a hard object, and serious bruxing with associated attrition. It is white, but somewhat translucent and allows the color of the underlying dentin to shine through to a certain extent which is why teeth look yellow. In the diagram to the left, the enamel is represented by the top layer on the tooth. Here it looks a bit like a neat haircut. The reason it is drawn that way is because the enamel is made up of microscopic enamel rods all of which run about parallel to each other and which project perpendicularly from the surface of the underlying dentin. When you are looking at a tooth in the mouth, you are seeing millions of these little enamel rods packed side by side, but you are seeing them end-on, as in the illustration on the right which is a reasonable representation of their cross section. They are packed together a bit like an Escher drawing.



The micrograph above on the left shows the rods in sagittal section, which means you are seeing them as if the tooth were cut like the tooth in the "haircut" image above. The image on the right shows the enamel rods end-on after etching the surface with acid. The acid treatment dissolves the internal parts of the enamel structure faster than the outer parts, so you are seeing only the outline of the rods. The actual rods are solid structures, but do not show up well in micrographs.

Each enamel rod is attached to the dentin underneath it. For this reason, cracks in the enamel (crazes) penetrate only as far as the dentin. This method of attachment makes it impossible for the enamel to separate from the tooth no matter how many crazes develop in its structure.

Dentin



Dentin is the hard, yellow bone-like material that underlies the enamel and surrounds the entire nerve. It composes the bulk of the tooth, and is sensitive to touch and other stimuli. In the image at the top of this page, the illustration shows thousands of tiny little lines that run approximately parallel to each other and perpendicular to the surface of the nerve space. These lines represent tiny tubes that run parallel to one another throughout the structure of the dentin. These are called dentinal tubules, and they originate from the inner surface of the nerve space and travel perpendicularly from their point of origin to the surface of the tooth terminating at the undersurface of the enamel, or the surface of the root itself in areas where it is not covered with enamel.

The tubules contain tiny projections of cells that line the inside of the nerve space. These cells are called odontoblasts, and they are actually the covering layer of the nerve itself. The projections of the odontoblasts into the dentinal tubules are not nerves. However, the odontoblasts connect with nerve axons in the dental pulp (nerve). Exposed dentin is sensitive to touch, air and other stimuli because these stimuli cause movement of the fluid in the odontoblast projections inside the tubules. This movement of fluid can be sensed by nerve endings in the dental pulp which anastomose (connect) with the odontoblasts. The image on the right above is an electron micrograph of actual dentinal tubules seen end-on.

The dental pulp (the nerve of the tooth)

What the lay public calls the nerve of a tooth is called the dental pulp by dentists. It is a complex organ composed of connective tissue, blood vessels, and nerve axons. It is pink and soft, and looks just like the lining of the mouth when it is removed during root canal procedures. Its original purpose during development is the formation the teeth themselves. In other words, the nerve of a tooth is a "generative" organ. The nerve starts out as a clump of specialized cells, and as we begin to grow, it slowly takes the shape of a tooth. The cells on the outside of the pulp begin to form the various hard structures , enamel and dentin, that we associate with the tooth itself. The tooth is formed from the outside toward the inside, with the dental pulp slowly replacing itself with tooth structure. While we are still young, the nerves in our teeth are relatively large, but they slowly shrink becoming more and more narrow throughout our lives. Once the tooth is fully formed, the nerve slows its formative functions, but it keeps building dentin in a process called dentinogenesis. During this slow growth phase of its life, the nerve serves mostly to keep the teeth hydrated and allows the dentin to retain a certain amount of elasticity. Thus, living dentin acts something like a shock absorber, preventing the teeth from fracturing. Whenever a nerve in a tooth dies, the tooth looses this shock absorber effect and is more prone to fracture. This is the reason that a tooth that has been endodonticly treated needs to be protected with a crown.

Root canals (endodontic treatment of the dental pulp)

A "root canal" is actually only a part of the dental pulp. It has all the same characteristics and functions as the rest of the dental pulp, except that it is located inside the root portion of the tooth and is thus rather thin and spindly. When we tell a patient that they need a "root canal", we are not talking about the anatomical structure itself. We are talking about a procedure. We really mean that the nerve is sick and must be removed in its entirety from the tooth, the empty space where it used to live cleaned and sterilized and finally sealed with a form of rubber called gutta percha or one of the newer materials designed for this purpose. The technical name for this procedure is "endodontic treatment". The root canal(s) in any given tooth start out just like the rest of the nerve, as a solid piece of soft tissue. Blood vessels and nerves enter through a hole at the tip of each root. The tip of the root is called the "apex", and the hole that allows the nerve tissue, with its accompanying blood vessels to enter the tooth is called the apical foramen. Of course, blood must traverse through the root canals in order to infuse the nerve. As we age, the root canals too replace themselves with more and more dentin until they become less tube like and more like a network of blood vessels and nerves running down approximately the center of the root. The image to the right shows some of the complex anatomy that the dentist is presented with when he must perform a root canal procedure to relieve pain and infection. In fact, the nerve anatomy can become even more complex as we age. As the canal becomes thinner and thinner, we say that it has become sclerosed. One can see that it could be quite difficult to remove ALL the dead tissue in the root canals if its internal anatomy has become more and more sclerosed and difficult to negotiate as the tooth ages or becomes sick. While it is important for the endodontist to remove as much dead nerve tissue as possible from the pulp chamber and root canals, the final line of defense against endodontic failure is to make sure that any remaining dead nerve tissue inside the tooth is properly sealed off at the apical foramen and any other openings in the root by properly fitted and placed sealing materials.

The cementum

Cementum is to the root of a tooth as enamel is to the crown. Cementum is a relatively soft bony tissue that covers the root surface in a thin layer. Its main function is to act as an attachment layer for the periodontal ligament which is a soft tissue sheath that acts as a cushion between the bony socket and the tooth itself. It is relatively soft and does not wear well against environmental assaults, so it abrades away rapidly whenever it is exposed to the oral environment because of recession. The image to the right shows the relationship of the enamel that covers the crown of a tooth, to the cementum that covers the root. Unless there is wear of the cementum due to recession, or attrition of the enamel due to bruxing or mechanical abrasion, the dentin is never exposed. The cementum meets the enamel in a line that surrounds the tooth. This line is called the cemento-enamel junction.

The apical foramen

The apical foramen is simply the hole in the tip of the root where the nerve and all its accompanying blood vessels must enter the tooth. Each root has a foramen at its tip and blood must both enter and exit the dental pulp from this point. The foramen is often not located at the very tip of the root, but may be offset one to three millimeters toward the crown of the tooth.

tooth anatomy

Note: This page is written for students planning a career medicine or in one of the dental fields. It contains more technical information than most people in the general public want to know. Click on the icon at the right to see a labeled diagram and text without the confusing terms.



The structures that support the teeth

Healthy teeth are, of course, embedded in bone. The bone is covered with gums, and the gums attach not only to the bone, but also to the tooth itself.


The gingiva

The gingiva is that portion of the gums that surrounds the teeth and lies above the level of the bone. The diagram to the right is a detail which shows the microscopic structure of this vital attachment of the gums to the tooth. The soft tissue is covered by an epithelial layer (red) called the oral epithelium. This attaches to the surface of the tooth on the dentin between one and three millimeters below the level of the crest of the gingiva. The part of the gingiva below the crest but above the attachment is called the free gingival margin. The potential space between the free gingival margin and the tooth (collapsed in life) is called the gingival sulcus. Just below the epithelial attachment lies a large number of connective tissue fibers (blue) called the gingivo-dental fibers. Some, which are not visible here actually circle the entire tooth and are called circular fibers. These fibers are responsible for securely attaching the gingiva to the tooth.

This attachment is responsible for separating the dirty oral environment from the totally clean environment inside the body. The gingival attachment is doubly important because it protects the underlying bone (alveolar crest) from becoming infected. Nature is especially protective of the bone because it is not highly vascularized and an infection in bone, especially in pre modern man's environment would have been a death-dealing event. An infection in bone is called osteomyelitis, and even today, with modern antibiotics, it is still quite a dangerous condition. Thus nature built in a simple mechanism to protect mammals from getting osteomyelitis as they aged and became more susceptible to oral infection. She programmed the bone to resorb (to be absorbed); to "get out of the way" before the infection reached it. This is the basis of periodontal disease---The loss of bone as a protective mechanism against a dangerous bone infection. Better the loss of the teeth than the premature loss of life!

The periodontal Ligament (PDL)

The periodontal ligament is just visible in the diagram immediately above. It is the soft tissue that lies between the tooth and its bony socket. As you can see, it is really just a continuation of the connective tissue associated with the gingivo-dental fibers, and if you look at the large diagram at the top of the page, you can see that it continues around the entire tooth. In a healthy situation, there is never a direct attachment between the bone and the tooth itself. Such a direct attachment, when it occurs in pathological situations, is called ankylosis.

The PDL is composed of fiberous connective tissue in which the fibers run approximately perpendicularly from the tooth surface to the bony socket. In any given area, a cross section looks like a tangled mass of nearly parallel fibers that attach at one end into the cementum overlying the root of the tooth, and at the other end, into the aveolar bone inside the socket.



The bone that supports the teeth is called alveolar bone. It's only purpose in life is to support the teeth, and if a tooth is extracted, the alveolar bone that originally supported it will eventually be resorbed by the body. The part of the alveolar bone that lines the socket is a thin layer of dense cortical bone called the lamina dura. The bone that underlies the lamina dura is cancellous bone (sometimes called medulary bone). Cancellous bone looks spongy and contains blood producing "organ" called bone marrow. In fact, all three of the features discussed in this section, the lamina dura, the periodontal ligament and the cancellous bone can be seen on any intraoral dental x-ray. In the x-ray seen on the left, follow the edge of any of the three teeth present from the top of the crown down into the bone. The dark line that separates the tooth from the bone represents the space where the periodontal ligament lives. The thin bright strip of bone directly beside the periodontal ligament space is the lamina dura. Under the lamina dura is the less bright cancellous bone. If you look carefully you can see the trabeculii --the tiny spicules of bone crisscrossing the cancellous bone that make it look spongy. These trabeculii separate the cancellous bone into tiny compartments which contain the blood producing marrow. These marrow spaces are seen in the colored image of the PDL above as bright "blobs".

reimplanted tooth

What if you or your child knocks out a front tooth?

Step by step instructions for patients and for dentists



The accidental loss of an adult tooth is a grave event and very tricky to treat. Even the best techniques sometimes fail to permanently save the tooth. As you read the rest of this page, bear in mind that there is a distinct possibility that you or your child may loose the tooth even though every step is religiously followed!

Instructions for the patient

Procedures for the dentist

If patient presents with tooth already reimplanted in socket

If patient presents with tooth in hand or improperly reimplanted

If tooth has open apex (blunderbuss)

If tooth has fully formed root (apex)

Splinting the tooth in position

Managing the tooth after the reimplantation


Instructions for the accident victim or parent

1. If the tooth is one of the four front baby teeth (deciduous teeth), there is NO NEED to reimplant it (ie do not replace it in the socket). Front baby teeth do not hold space for the adult teeth that will begin to erupt at age six, and the early loss of one of these teeth rarely causes harm to the adult dentition.

2. If the root of an adult tooth is broken, (especially if part of the root remains in the socket) reimplantation is not possible. Any attempt will fail. This means that the trip to the dentist, though necessary, may be put off until it is convenient. The only things a dentist can do under such circumstances it to prescribe antibiotics, and to place artificial bone in the socket for possible implant placement at a later date. The placement of artificial bone is a bit involved for an off hours emergency. The placement of artificial bone is generally best done under the auspices of an oral surgeon or a periodontist. These specialists have become the de-facto implantology specialists.

3. Any avulsed tooth must be reimplanted in the socket within 60 minutes if the reimplantation is to have a reasonable chance of working.

This may be done at the site of the accident by any adult including the patient himself provided the tooth is fairly clean and provided it slips back into the socket easily with light finger pressure. If the tooth goes back into its proper position so that the patient may bite down without pushing the tooth out of its normal alignment, then the process has been successful.

If the tooth is dirty, simply have the patient remove all dirt with their own saliva. Have the patient suck fairly hard on the tooth. Be sure that the patient spits out blood and debris after each sucking action. This removes dirt and will hopefully dislodge any clot that may have formed in the socket making it easier to reimplant the tooth.

You still must take the patient to a dentist, but the major emergency has been averted and there is less urgency associated with the emergency.

If the tooth cannot be replaced in the socket (for any reason), then there are three ways to transport the tooth to the dentist's office:

Have the patient remove dirt and debris by sucking on the tooth as above and then have the patient store the tooth in their own mouth in the pouch between the cheek and the top back teeth. Transport the patient to a dentist ASAP.

This is NOT advisable if the child is under the age of six since the child may swallow the tooth. If this is the case, proceed to the next two options.

Place the tooth is a cup of clean saline (salt water). You may make saline by placing one and a half teaspoons of salt in four cups of clean water. Tap water is acceptable, but bottled water may be cleaner if it is IMMEDIATELY available. The saline has the advantage of acting to clean off the tooth. Transport the tooth and patient to the dentist ASAP.

Place the tooth in a cup of fresh milk (any fat content). This has nearly the same advantages as saline. Transport the tooth and the patient to the dentist ASAP.

A commercial product is available for the storage of an avulsed tooth if you, or someone you know happens to have it in their medicine cabinet. The manufacturer states that the tooth may be reimplanted up to 24 hours after the avulsion if it is kept in this solution. It is called Save-A-Tooth, and can be ordered by clicking here.

Instructions for the dentist

1. If the tooth has been properly replaced in the socket at the site of the accident:

Do not extract the tooth to treat the root.

Clean the effected area with water spray, or chlorhexidine mouth rinse.

Verify proper alignment of the tooth by the following methods:

Have the patient bite down and verify that the tooth is not in traumatic occlusion and remains in acceptable alignment with neighboring teeth.

Take a periapical x-ray

if the tooth is in traumatic occlusion, remove the tooth from the socket and proceed to step 2 below.

Suture gingival lacerations

Splint the tooth with (preferably) a flexible splint. Have the patient bite into occlusion to eliminate traumatic bite prior to splinting. The splint will be kept on the tooth for 7 to 10 days.

prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation of tetanus immunization.

If the tooth has an open apex (blunderbuss) avoid doing a root canal unless an abscess develops or there is radiographic evidence of pulpal necrosis.

Proceed to the Post-emergency procedures.

2. If the tooth has not been replaced in the socket, or if it must be removed due to traumatic occlusion or misalignment:

If the tooth has an open apex (not fully formed root)

If the tooth has been out of its socket for much more than an hour, or especially, if the tooth has dried out during transportation, the reimplantation procedure is unlikely to be successful, and the patient or parents should be so informed. It is still permissible to attempt reimplantation since survival is always possible, even if unlikely. It is, however unlikely that the root will continue to form its apex and apexification will be necessary. There is also a very substantial chance that the root will experience external resorption or become ankylosed. The most reasonable course of action is to warn the parents of this outcome and to avoid the procedure altogether.

If the tooth has been out of its socket for an hour or less, and has been properly transported to the dental office, then the procedure has a better chance of working. This implies that the blunderbuss root will continue to form an apex and the tooth will continue to erupt normally after the reimplantation procedure.

Clean the effected tooth with water spray or saline.

Place the tooth in a solution of doxycycliine if available (Low concentration, about 1mgm per 20 cc of saline. Can be made on premises using 1/2 of a 100 mgm tablet finely crushed and added to about a liter of saline. In most situations, this step is not especially practical and may be omitted if it is not possible. At minimum, clean the tooth with copious saline solution. Do not use antiseptic solutions on tooth.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket. If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint. Have patient bite into occlusion to be certain that the position is correct before applying the splint. The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation of tetanus immunization.

Do not perform a root canal procedure unless a post op x-ray shows serious periapical involvement. The idea here is to allow the root apex to form normally. If the pulp dies at any point during treatment, then a root canal procedure with apexification will be necessary.



If the tooth has a fully formed root (apex)

If the tooth has been out of its socket for an hour or less, and it has been properly handled (as stated above in instructions for patients), the reimplantation procedure is the same as that shown above with the exception of the use of doxycycline rinse. The instructions are repeated below for clarity and completeness:

Clean the effected tooth with water spray or saline.

Clean the tooth with copious saline solution. Do not use antiseptic solutions on tooth.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket. If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint. Have patient bite into occlusion to be certain that the position is correct before applying the splint. The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation for tetanus immunization.

Proceed to post-emergency procedures.

If the tooth has been out of the socket for well over an hour, or if the tooth has been allowed to dry out during transport, the treatment differs from that above mostly because of changes that have taken place on the surface of the root. The following procedure is designed to minimize external root resorption during post operative healing.

Rinse off all debris from the tooth with copious water or saline.

Gently and quickly root plane the root of the tooth to remove necrotic periodontal ligament and any foreign debris that has dried onto the surface.

Immerse the tooth in a 2.4% Sodium Fluoride solution acidulated to pH 5.5 for 5 minutes. This item is rarely found in dental offices today. It has been replaced with various neutralized rinses, gels and foams of lesser concentration. In the absence of the stronger solution, a lesser concentration of fluoride may be used instead. The idea is to convert surface hydroxyapatite into fluoroapetite to reduce external resorption during healing. Keep the tooth in the fluoride solution for a minimum of five minutes; 20 minutes if possible. Wash off the fluoride solution afterwards with copious saline. Click here to see a clinical study recommending this procedure.

Irrigate the socket with saline and remove all coagulum.

Inspect the socket. If bone is displaced into the socket, move it back into position with a suitable instrument in order to allow proper insertion of the tooth.

If available, apply Emodogain® to the inside of the socket. This is a specialty item and is not likely to be found in the offices of most general dentists. It has been found to be helpful in experimental situations but no human studies have been carried out to prove its usefulness in reimplantation of avulsed teeth. If available, it may be useful, but certainly not essential.

Replace the tooth in the socket with minimal digital pressure.

Suture gingival lacerations.

Take a periapical x-ray to check root alignment.

Splint tooth in position with (preferably) a flexible splint. Have patient bite into occlusion to be certain that the position is correct before applying the splint. The splint will be kept in place for about one week.

Prescribe a suitable antibiotic (doxycycline is ideal).

Refer to physician for evaluation of tetanus immunization.

Proceed to post-emergency iprocedures.

3. Spilinting the tooth in position:

The ideal splint for avulsed teeth is a flexible splint. These are typically made using Gortex or other synthetic cloth or metallic mesh strips made for this purpose. Other types of flexible splint may involve bonded orthodontic brackets and thin orthodontic wire. Ideally, the splint should encompass several teeth on either side of the avulsed tooth. There are quite a few options depending on the comfort level of the practitioner. The recommendation for flexiblity involves theoretical considerations in the formation of the new periodontal ligament. However, since the splint is kept in place for no more than 7 to 10 days, the flexibility factor may be of little practical significance. This is my personal opinion. I'm sure others would argue the point vehemently.

The simplest type of splint involves nothing more than a fairly thick strip of light cured composite running across three teeth with the avulsed tooth in the middle. I have found that this works quite well. The procedure for upper incisors (the most commonly avulsed teeth) involves having the patient bite into occlusion and keeping his teeth in this position for the entire procedure. This stabilizes the tooth and guarantees that the tooth will not be in traumatic occlusion. The three teeth are pumiced and acid etched. Bond is applied and light cured. Finally a fairly thick layer of composite is layered over the buccal surfaces of three teeth. I try to keep it neat, but this is a functional repair and will be removed in a week, so I generally use a color that contrasts with the teeth in order to make removal easier. I do not spend much time forming it to look like a restoration.

In the case of lower incisors, I place the splint on the buccal surface if the occlusion permits. Otherwise, I place it lingually.

The splint is removed in about a week (10 days tops) and assessed for mobility. If the mobility is excessive, then reapply the splint for another several weeks. Otherwise, allow the tooth to function normally.

4. Post-emergency procedures (managing the tooth after reimplantation):

Root canal procedure should be initiated in 7-10 days unless the avulsed tooth has an open apex and the tooth was reimplanted under optimal conditions.

The splint should be removed in 7 to 10 days unless the radiograph shows serious bony involvement along the lateral edges of the root.

If the tooth has a closed apex, or if a tooth with an open apex has obviously abscessed or shown radiographic evidence of pulpal necrosis, begin the root canal procedure prior to removing the splint.

At this time, instrument the canal completely and place calcium hydroxide paste in the canal. Allow the paste to remain in the canal for approximately a month prior to obturation of the canal.

The root canal procedure may be completed when an intact lamina dura can be traced all the way around the root. In most cases this will happen within a month. If the lamina dura has not begun to form, or if external resorption is apparent on the radiograph, then the calcium hydroxide should remain in the canal. The status of the lamina dura should be checked one month post op and at three month intervals after that. At the time of the exam, the calcium hydroxide paste should be washed out and replaced with fresh paste.

HIV viron.

This schematic shows shows a graphic representation of the structure of an HIV viron. A viron is a single virus particle. The actual "active" chemical molecules are the two ribbonlike copies of RNA protected inside the green capsid core shell, along with two copies of a protein molecule (the black balls labeled "protease, polymerase, RNAse, integrase"). The protein molecules have several functions once the virus penetrates into the host T cell, the major one being to jumpstart the process of viron replication.



RNA is a mirror image of DNA, the material that genes are made from. Once inside the host T cell, the "black ball" protein goes to work making multiple copies of viral DNA out of the two strands of viral RNA. This process is called "reverse transcription" because it is the opposite of what usually happens in normal cells. Generally, normal DNA molecules (the natural genes of the body) code for multiple copies of mirror image RNA which then goes fourth into the cell body to make protein molecules useful to the cell.

Instead, this new viral DNA creates more viral RNA. The new copies of viral RNA now hijack the host cell's "ribosomes", which are little protein factories that construct protein according to the instructions encoded in the viral RNA. The new viral proteins are then organized into new virons which then escape the host cell taking with them an envelope of the host cell's own membrane as a protective envelope along with two copies of the newly manufactured RNA.

In the lower left of this electron micrograph you can see a new viron budding off the membrane of an infected T cell. If you look closely, you can also see that the cell membrane of the T cell is composed of two very thin parallel lines. These lines are actually two interlaced molecules of phospholipids (called a bilayer) which is the common construction of all cellular membrane structure. Note that when the viron buds off, it removes some of this host membrane structure for its own protection. Within each viron, now encapsulated in its own stolen cellular membrane, lives the capsid which is a virus manufactured protein sheathe which houses the core viral RNA.
The image to the right shows the structure of a natural cell membrane. It is composed of a pair of phospholipid chains which are arranged in such a way that the lipid portions face each other thereby avoiding contact with the aqueous (water based) surrounding medium. For a better understanding of this structure, click on the image.

In the schematic at the top of the page, the red envelope is actually the stolen cell membrane. The purple molecules lining it are a viral protein which stabilizes the membrane. The dumbbell shaped molecules projecting outward from the membrane are specially manufactured "sugar" molecules called glucopolysacharides which are responsible for recognizing the correct host cell membrane and then attaching to it so it can begin the process of entering another host cell.

HIV is in a broad category called "retroviruses" because it contains RNA as the infective molecule instead of DNA which is the stuff of other "normal" viruses. The prefix "retro" means "reverse" and is a reference to the reverse transcription mentioned above.

aids

If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, this page may be of use to you:
HOWEVER

Note that you do NOT have to have HIV to exhibit any of the pathology on this page. The images occur on this page because people with AIDS are more likely to be plagued with these disorders than people with intact immune systems.

First read this page,

Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions

(Note: the oral images on this page start here)

Normal oral anatomy
Lumps, bumps and sores and discolorations
Oral Cancer




Index

What's the difference between HIV and AIDS

How does HIV produce disease?

What is the origin of the HIV virus?

Epidemiology of AIDS in America

Infection and death rates in North America

AIDS and Race

A note on heterosexual transmission

Women are the key to limiting the epidemic

Infection and death rates

The association of HIV with other sexually transmitted diseases

The transmission of AIDS between dentists and patients (The Acer case in perspective)

A note on AIDS transmission in the third world

Africa

Latin America

China

The general diagnostic signs of AIDS

The Bangui definition of AIDS

Oral Signs of AIDS

AIDS related fungal infections

Oral Candidiasis (Thrush)

Angular Cheilitis (dry, cracked corners of the lips)

AIDS related viral infections

Hairy leukoplakia (a tongue symptom)

Herpes Zoster (Shingles)

Herpes Simplex (cold sore virus)

Primary Herpes Stomatitis

A note on Genital Herpes

Human Papillomavirus (HPV) (causes warts)

Tumors and growths (Neoplasms)

Kaposi's Sarcoma

Non Hodgkin's Lymphoma

Bacterial infections associated with AIDS

Acute Necrotizing Periodontitis

Acute Necrotizing Gingivitis

Acute Necrotizing Oral Stomatitis

Other indications of immune deficiency

Geographic tongue


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It's more complicated than you think. You can beat Halitosis, but first you have to understand it. Click here to go to a page on this site to learn everything there is to learn about Bad Breath.




What is the difference between HIV and AIDS?

HIV stands for Human Immunodeficiency Virus. In other words, HIV stands for the organism which attacks the human immune system causing damage which makes the patient more susceptible to other diseases. AIDS is an acronym for Acquired Immune Deficiency Syndrome. A syndrome is simply a grouping of symptoms which occur together. Whenever a doctor sees a particular grouping of symptoms, he can infer that the patient has a specific disease. For example, if you come into the office sneezing, with a runny nose and complain of aching muscles and a feeling of tiredness, then the doctor may assume you have a common cold caused by rhinovirus.

The symptoms you exhibit to the doctor make it possible for him to make a presumptive diagnosis without doing any blood tests. AIDS is a group of symptoms which, if seen to occur together, infer to the doctor that the patient may be suffering from the HIV virus. The symptoms of AIDS include many different disease entities, but the most common ones are included in the Bangui definition.

Not everyone infected with the virus develops AIDS, and not everyone with the signs and symptoms diagnostic of AIDS harbors the virus, especially in third world countries. At the present time, there is no cure for the virus (HIV), however the syndrome (AIDS) can be controlled with various combinations of medications.

How does HIV produce AIDS?

HIV attacks the immune system. Viruses in general are not quite "living" objects. They have no cellular apparatus of their own to metabolize food or to reproduce. They are "molecular parasites" which means that they are really just very active chemicals that must infect a living organism in order to take over the cellular components of the host (victim) for their own purposes. Since they are nothing more than very complex chemical molecules, they have very specific needs with regards to the type of host cells they can infect.

HIV infects a particular component of our immune system called the "T cells". T cells are a type of white blood cell (specifically, a type of lymphocyte) which is responsible for protecting our bodies from attack by foreign invaders such as other viruses, bacteria, yeast and various cancer cells which may arise in our bodies from time to time. It is the ultimate irony that HIV attacks and kills the very cells that are supposed to protect us from viral, as well as other types of infections. Since HIV kills off an important part of our immune system, an infected individual becomes vulnerable to common diseases which are generally not dangerous to people with intact immune systems. Thus infected young persons become vulnerable to diseases generally seen only in infants whose immune systems are not fully developed, or the very old, whose immune systems are in decline.

For example, a young healthy adult may have a chronic Herpes Simplex infection resulting in cold sores recurring on his or her lips once or twice a year. On the other hand, a person with a compromised immune system may get such a severe flare-up of herpes simplex that he could have it all over his entire mouth and even elsewhere, and need hospitalization to recover. Simple infections that other people can ignore while they heal become life threatening disasters for the AIDS patient.

For those interested in looking at an image of actual HIV virons (virus particles) with a schematic of the structure of the beast and a short discussion on how they infect a host and reproduce, then please click on the thumbnail image below.



What is the origin of the HIV virus?

The disease entity that later came to be known as AIDS seemed to pop out of nowhere about the year 1981. For the general public, awareness began as a series of rumors that gay men were getting sick with illnesses that were rarely seen in modern America, and almost never seen in young men. Many people, including some scientists and journalists attributed it to the gay lifestyle, since it seemed to be confined to that population. In 1982, the term "AIDS" was first used to describe the syndrome. It was not until 1984 when Dr. Robert Gallo claimed to have discovered the virus that it became widely known that AIDS was linked to a specific disease causing entity, and not simply to lifestyle issues. (In reality, the virus was first isolated at the Pasteur institute in France the year before, but the full implications of the discovery were not recognized at that time.) As the biological characteristics of the virus were discovered over the next few years, scientists noted its similarity to SIV (simian immunodeficiency virus). SIV was already a well known entity, and it began to be suspected that HIV was really a pre existing virus which made the jump from monkeys or apes to humans. A 2006 news article tells the story of some modern biological sleuthing and confirms that the virus has been traced to a colony of chimpanzees in Cameroon (on the west coast of Africa).

The first human known to be infected with HIV was a man from Kinshasa in the nearby country of Congo who had his blood stored in 1959 as part of a medical study, decades before scientists knew the AIDS virus existed.
Presumably, someone in rural Cameroon was bitten by a chimp or was cut while butchering one and became infected with the ape virus. That person passed it to someone else.


The epidemiology of AIDS in America (who has it, where it's been and where it's going)

Note: This section is filled with statistics. For the most recent CDC surveillance reports available click here. Avert.org digests these statistics and presents them in an easily understood format. Note that statistics on epidemiologic phenomena generally remain two years behind due to the methods of collection and the need to verify their accuracy. The most up to date statistics are currently for 2006.
The Centers for Disease Control and Prevention (CDC) is one of the 13 major operating components of the Department of Health and Human Services (HHS), which is the principal agency in the United States government for protecting the health and safety of all Americans and for providing essential human services, especially for those people who are least able to help themselves.


According to CDC figures there have been nearly a million cases of HIV diagnosed in the United States since 1981, the year when the first cases of what would eventually become known as AIDS were reported to the Center for Disease Control (CDC). It was not until 1984 that the virus was first isolated and determined to be the causative agent of the AIDS epidemic in the United States.

From the beginning of the AIDS epidemic in 1981 until the end of 1984, about 529,113 Americans died of their HIV infection. As of the 2004 statistics, 9,443 children under age 13 were infected and a little over half of those have died. From 1999 through 2004, the estimated number of AIDS cases decreased 68% among children. A 2005 article in the New York times notes:

In 1990, as many as 2,000 babies were born infected with H.I.V., the virus that causes AIDS; now, that number has been reduced to a bit more than 200 a year, according to health officials. In New York City, the center of the epidemic, there were 321 newborns infected with H.I.V. in 1990, the year the virus peaked among newborns in the city. In 2003, five babies were born with the virus.

The reason for the decline is probably due to aggressive implementation of Public Health Service guidelines including early intervention, education, and aggressive use of the drug AZT in pregnant women with HIV. From 2001 through 2004, the estimated number of HIV/AIDS cases has shown marginal increases among males but has decreased 15% among females. In 2004, males accounted for just over 80% of all HIV/AIDS cases since the beginning of the epidemic in 1981, while in 2004 males accounted for approximately 73% of all newly diagnosed cases.

Current yearly statistics from the CDC (the statistics are always 2 years behind)

Transmission category
Male adult or adolescent 2001 2002 2003 2004 2005
Male-to-male sexual contact 16,625 16,852 16,804 18,203 18,939
Male Injection drug use 5,171 4,379 4,177 3,828 5,806
Male-to-male sexual contact and injection drug use 1,525 1,431 1,398 1,372 2,190
Male Heterosexual contact 5,095 4,843 4,720 4,581 5,208
Other 214 183 179 161 287
Subtotal 28,630 27,689 27,279 28,143 32,430
Female adult or adolescent
Injection drug use 2,877 2,408 2,252 2,134 3,179
Heterosexual contact 9,192 8,709 8,248 8,102 8,278
Other 211 187 205 174 253
Subtotal 12,280 11,303 10,706 10,410 11710
Child(<13 yrs at diagnosis)
Perinatal 306 245 186 145 57
Other 54 44 18 32 1
Subtotal 360 288 204 177 58

Infection and death rates In North America



The chart above (current to 2004) shows a graphic representation of the number of HIV cases diagnosed (dark blue diamonds) versus the number of deaths (light blue squares) in the United States during each year of the epidemic. The statistics are taken from Avert.Org. The steep, nearly geometric rise in the number of new cases diagnosed each year until the early 1990's was alarming and caused quite a bit of hysteria at the time. The steep drop in newly reported cases during the rest of the decade confirmed that the epidemic was under control and was not about to depopulate the earth. (The figure for 1980 includes the estimate of all deaths from HIV prior to 1981 when the epidemic was first recognized.)

To place these figures in perspective, a little over a half million North Americans died of AIDS between 1960 and 2004. During the same period, more than 30 million North Americans died of cardiovascular related diseases and cancer. Today, AIDS kills about 16,000 individuals annually in the United states. Heart disease alone (not including other cardiovascular ailments) kills a little over 700,000 yearly, or over 38 times the number of AIDS related deaths. These figures do not diminish the tragedy of the AIDS epidemic. They serve, rather, to place it in context.

AIDS and Race in the US (Click this link for the statistics)
During the 1990s, the epidemic shifted steadily toward a growing proportion of AIDS cases among black people, Hispanics and women, and toward a decreasing proportion in MSM (men having sex with men), although this group remains the largest single exposure group. Blacks and Hispanics have been disproportionately affected since the early years of the epidemic. In absolute numbers, blacks have outnumbered whites in new AIDS diagnoses and deaths since 1996, and in the number of people living with AIDS since 1998. In 2003, blacks accounted for 50% of all HIV/AIDS cases diagnosed.

AIDS and Heterosexual transmission in the US (Click this link for the statistics)

The pie chart below shows the proportion of male to female HIV cases diagnosed in the US during 2004. The chart also shows the major routes of transmission. IDU stands for Intravenous Drug User, meaning that the virus was transferred by way of using dirty needles while injecting IV drugs. At a glance, one can see that in 2004, nearly three quarters of the patients diagnosed with HIV were males. Nearly half of all patients diagnosed with HIV were infected via male to male sexual intercourse. While only about one sixth of all males infected with HIV in 2004 were infected through heterosexual intercourse, nearly 80% of all women infected with HIV in 2004 were infected via heterosexual intercourse.



Comparing the pie chart above (for the cases diagnosed in 2004) with the bar chart on the right (showing cumulative cases since 1981), it is not difficult to see why men have outnumbered women by more than 3 to 1 over the course of the epidemic. The number of men having sex with men (MSM), along with the better than 3 to 1 ratio of male Intravenous Drug Users (IDU's) to female IDU's tends to skew the data toward a preponderance of men. (The 3 to 1 IDU figure is computed by adding the Male IDU and the MSM plus IDU figures). Click here for reference.




The multi dimensional bar chart above shows the trends of the major categories of transmission of all cases of AIDS/HIV diagnosed each year starting in 2001. For the actual statistics, click here, also reprinted on this page . All categories of modes of transmission have shown incremental decreases each year except for MSM (men having sex with men) which shows a fairly large jump for the year 2004 (about 1,400 more in 2004 than in 2003).

Normal vaginal sexual intercourse between a man and a woman is the most important means of transmitting HIV to women. One can see this by looking at the pie chart above. Surprisingly, however, it is a less important factor in the spread of the virus from women to men. Men are approximately one third less likely to contract the HIV virus from an infected woman than the reverse. Women are more prone to infection with the virus due to the nature of their anatomy and physiology than are men. This has implications for the spread of the disease in the western world. (Anal sex, on the other hand, exposes the participants, both male and female, to a higher risk of infection than a woman having vaginal sex due to the more easily abraded nature of the lining of the rectum and intestine, a higher probability of abrasions of the skin of the penis, and a higher probability of bacterial infections.)

Note: It is important to remember that statistics relating to the mode of transmission of HIV may be heavily influenced by the fact that they are entirely self reported by the patients themselves. It is very likely that the female to male statistic is actually much lower than reported (on the order of 1 to 8 rather than 1 to 2) due to the fact that many infected men are reluctant to admit that they contracted the virus via homosexual contact. See this article for more on the subject.

Women are the key to limiting the epidemic

One can easily see when considering the charts accompanying this article that women (in western nations), as a group, are less likely than men to acquire the HIV virus. This fact, in combination with the fact that a woman with the disease is less likely to pass it on to her male partners act to modify the spread of the disease in the heterosexual population. One could say that women in the US, Europe and other western countries, because of their relative freedom and their determination to exercise discretion in their choice of male sexual partners (women are also more likely to remain monogamous than are men), act as a "firebreak" on the spread of HIV in the non-IDU, heterosexual population. This is probably one of the most significant reasons why the AIDS epidemic did not spin out of control as was predicted in the popular media during the 1980's and 1990's. It has now become apparent to most people that predictions of a North American heterosexual holocaust have proven unfounded. As the epidemic has settled into maturity since 1997, it is also apparent that a majority of those afflicted remain in the "high risk" categories of Men who have Sex with Men (MSM), and Intravenous Drug Users (IDU) of both sexes.

Still, there is little doubt that heterosexual intercourse is the predominant mode of transmission for the HIV virus worldwide. For reasons explained below, the continent with most serious AIDS epidemic is Africa with an overall infection rate of 9% of the entire population and over one third of the population of some African nations infected with the virus.

A note on the association of HIV with other STD's

As the sexual revolution in the US and Europe began to overtake traditional sexual morality, it started to become obvious that there was an association between the increase in the prevalence of sexually transmitted diseases and the transmissibility of the HIV virus. This association is out of proportion to the actual prevalence of HIV versus the prevalence of the unrelated STD's. In other words, persons who were infected with diseases like syphilis, gonorrhea, Chlamydia and herpes type II were more likely to pass the HIV virus along to their sexual partners than persons infected with the HIV virus alone.

At first glance, this makes sense. The presence of these diseases produces genital ulcers which allow fluids containing HIV to be transmitted to or from either of the individuals engaged in sexual relations. However, the degree of transmissibility appears to go beyond the presence of genital ulcers suggesting that the mere presence of these diseases in persons also infected with HIV increases the likelihood of transmission of HIV. The exact mechanism for this synergistic effect is not yet apparent, however, it is clear that there is an increased incidence of viral shedding associated with coexisting STD infections. A report was published by researchers from the University of North Carolina School of Medicine in July 1997 about the results of their study in Malawi [1]. Briefly, they found that the semen of men infected by both HIV and other venereal diseases such as gonorrhea contains eight times as much HIV as that of patients infected by HIV alone. When HIV-infected men were given antibiotics to treat other STDs (Sexually Transmitted Diseases) the amount of HIV in their semen fell dramatically, reducing the chances of them infecting their partners. Click here for a well documented and very technical paper on this subject.

[1] Myron S Cohen .Sexually transmitted diseases enhance HIV transmission: No longer a hypothesis. The Lancet 1998 Volume 351, Issue (Supplement III) pages 5-7

You, your dentist and AIDS (The Acer case)

In September of 1990, Doctor David Acer, a dentist in a small town in Florida died of AIDS. Before his death he sent a letter to all of his patients, informing them of his health status and urging them to take an HIV test. Acer reassured them that he had always followed standard infection-control procedures. Altogether, five deaths have been blamed on the transfer of HIV from Doctor Acer to his patients.

Since that time, there have been no undisputed cases of HIV transfer from any dentist to any patient. In addition, there have been no documented instances of dental personnel contracting HIV from their patients.

In 2006, the CDC (A division of the National Institute of health) issued this statement regarding Dr Acer.
There has been only one instance of patients being infected by a health care worker in the United States; this involved HIV transmission from one infected dentist to six patients. Investigations have been completed involving more than 22,000 patients of 63 HIV-infected physicians, surgeons, and dentists, and no other cases of this type of transmission have been identified in the United States.


Even before the wide dissemination of "universal precautions", when dentists and hygienists did not routinely wear gloves or masks, neither they, nor their patients infected each other in spite the virtual certainty the virus was present in a percentage of both the patients and the dental personnel. Bear in mind that dental personnel all over the country frequently puncture their skin accidentally with dirty dental needles, handpiece burs and other sharp instruments. If there were a perceptible risk in transmitting the AIDS virus in the dental setting, there is no question that some dental personnel would have been occupationally infected by now!

Unfortunately, through 2002 (I am unable to find more recent statistics), the CDC did receive reports of 57 health care workers in the United States with documented, occupationally acquired HIV infection, of whom 25 have developed AIDS in the absence of other risk factors. This suggests that health care workers, (who cannot legally discover the HIV status of their patients) are at much greater risk of contracting the virus from a patient than any patient is of contracting the disease from a health care worker! However, 56 cases out of the millions of health care workers at risk still represents a miniscule percentage of the total health care population!

No one knows what were the circumstances leading to the transfer of HIV from one doctor to not one, but to five of his patients, but it is evident that those circumstances have never been reproduced during the years since Dr. Acer's death.

The conclusion that can be drawn from this is that HIV is a fragile organism that is not easily transmitted except by aggressive sexual activity with an infected person, by blood to blood contact as in massive large bore needle sticks, or when drug abusers share their needles and syringes. In 2003, the total number of HIV diagnoses attributed to "other (undetermined) causes" amounted to a little more than 1%.

Cleanliness in a dental office is, of course, important. Even if HIV transmission is unlikely, it is still possible to transfer other diseases such as Hepatitis B which is documented to be transferable between medical personnel and their patients. However, in view of the facts that have come to light over the last ten years, the initial hysteria surrounding the HIV status of physicians, dentists and other health care providers was quite unwarranted.

A note on the spread of AIDS in third world countries

It is very difficult for Americans to understand the huge cultural differences between western civilization and those cultures in which the term "civilization" does not have the same meaning as it does in Europe, Australia, North America and other first world nations. These differences permeate every aspect of the lives of the individuals in the various cultures, from everyday thought patterns to the manner in which they govern themselves. They manifest especially in the less formal aspects of peoples' lives such as their sexual practices and patterns of drug use, both of which may vary significantly from western cultural traditions.

Africa

In Sub Saharan Africa, the AIDS epidemic has a very different epidemiological profile than it does in the west. There, the scale of the problem dwarfs the prevalence of HIV in the rest of the world. In Sub Saharan Africa, over 25 million people are infected. Sixty-four percent of all HIV positive people worldwide and 76 percent of all women with the virus are in sub-Saharan Africa. There, nearly equal numbers of males and females are infected, while males outnumber females by nearly 3 to 1 in Western countries. The reasons for this are complex, and not always easy to ascertain because they involve personal and and in some cases taboo factors that people don't like to talk about to interviewers. People, when asked about their sex lives simply do not give honest answers.

Infection rates vary widely from country to country on the African continent due to the sometimes stark differences in the cultural affinities of the respective populations. Certainly, the social chaos in areas suffering the agonies of prolonged war, revolution and famine would lead to the wider dissemination of HIV as well as other endemic diseases. Prostitution and polygamy appear to be more widely practiced in some areas of the continent than they are in Western countries. Men are less likely to be circumcised in Sub-Sahara Africa. This increases the likelihood of inflammation and open sores around the head of the penis. These men are more likely to both contract HIV from, and to spread it to their heterosexual partners. In some parts of Sub-Saharan Africa, especially in countries located in the southern third of the continent, heterosexual anal intercourse is said to be a more widely practiced form of birth control than many people admit. (Scientific data on this is sketchy, however a study by researchers at the University of Tuebingen in Germany suggests that this is a major factor in the spread of HIV in southern Africa.) Because of the physical differences between anal and vaginal intercourse, this practice would tend to short circuit the North American female-to-male "firebreak" mentioned above.

The role of circumcision in the transmission of HIV
As was mentioned above, men are less likely to be circumcised in Sub-Sahara Africa. It has long been suspected that circumcision tends to reduce the likelihood of transmission of HIV to males. Now a study has confirmed this hypothesis.

"Removing the foreskin is thought to harden the glans (head) of the penis, making it less permeable to viruses. Research conducted in 2005 showed the transmission of HIV from women to men during sex was reduced by 60 per cent if the men were circumcised.

A study published last month calculated that if all men in sub-Saharan Africa were circumcised, it would prevent almost six million new cases of HIV infection and save three million lives over the next 20 years."

( The reference for this quote is now offline, but try these: 1, 2, 3, 4.)


In addition, there is an increased tendency toward viral shedding in persons with untreated syphilis, gonorrhea, chlamydia, herpes and other less well known STD's. The lack of proper diagnosis and treatment of these diseases in primitive social conditions increases the risk of spreading the HIV virus. In some sub Saharan countries, the rate of reported STD infection is ten times that reported in the US, and these statistics are based on a much lower standard of surveillance than is the case in western countries.

There is also a widespread belief in some areas of Africa that an infected male can be cured of HIV by having sex with a virgin. This erroneous belief is suspected of increasing the frequency of rape and the spread of the virus. Customs, beliefs and conditions such as these, along with an enormous number of historical, demographic, economic and cultural factors converge to increase the infection rate in Sub-Saharan Africa.

One African bright spot is Uganda. There, the epidemic has been nearly stopped by a campaign promoting abstinence.

"According to a U.S. Agency for International Development study, in Uganda "national HIV prevalence peaked at around 15 percent in 1991, and had fallen to five percent as of 2001. This dramatic decline in prevalence is unique worldwide."

In the mid-1980s, when it became clear that AIDS was on the rise in Uganda, President Yoweri Museveni adopted a program that, as Arthur Allen has written in The New Republic, "would become known as ABC, for Abstain, Be faithful or wear a Condom -- very much in order of emphasis."

According to a study of one Ugandan district, almost 60 percent of youths age 13-16 reported engaging in sexual activity in 1994, but by 2001, the number had plummeted to less than 5 percent. The USAID study reports that compared with men in other sub-Saharan African countries, Uganda males are "less likely to have ever had sex (in the 15-19-year-old range), more likely to be married and keep sex within marriage, and less likely to have multiple partners."

The effect on HIV rates has been nearly miraculous. Researcher Rand Stoneburner estimates that Uganda's approach has been almost as effective as an HIV vaccine. " (Rich Lowry Dec 6, 2002) (click here for the stats)

One should also note that there is some controversy about the reported incidence of HIV on the African continent. The diagnosis in most areas is based on the Bangui definition--- the complex of symptoms (AIDS) exhibited by the patient--- rather than by the serological (blood) test which is the definitive test used in Western countries. As discussed above, numerous diseases that are endemic in Africa may produce symptoms identical to those seen in actual HIV infection. As a result, there is a substantial chance that the reported incidence of HIV in Africa may be markedly overstated, although the controversy is in the degree and significance of the over reporting. There is, understandably, a great deal of anger when a loved relative or friend is reported as having died of AIDS when the family knows that person has never engaged in behaviors known to increase the risk of contracting the virus.

Latin America

Outside of Africa, many other third world countries have customs and practices that can appear just as exotic to American and European eyes. Upon visiting Honduras, I was surprised to learn from the Peace Corps volunteers working there that there are no laws limiting access to prescription drugs by persons without a prescription. Thus, people with no medical training can buy any prescription drug, along with needles and syringes to administer it without the intercession of a doctor. Illiterate peasants living in remote villages know that penicillin and other antibiotics can cure infections that used to be fatal, and they frequently pool their resources to buy a supply to administer to sick villagers. In order to save money, they often reuse needles and syringes. AIDS in Honduras and other Central and South American third world countries has begun to spread throughout the population as a result of this practice.

China

In china, the historical significance of opium and other narcotics is quite different than in the west. In the nineteenth century, the British and other western nations intentionally used opium as a means of opening up the otherwise insular Chinese culture to trade. (Internet search term; "opium wars" .) As a result of this historical fact, the use of narcotic drugs is widely established among the peasant population as a whole in spite of the draconian methods that the Chinese government uses to suppress them (Mao Tse-Tung threatened to execute them if they didn't give up the habit). In many poorer areas of China, large masses of the common people share needles and drug supplies thus spreading HIV very widely among the entire population (not just among isolated groups of drug abusers as in the US).

Even the public health establishment in China seems alien by western standards. The Chinese have been ruled by legalistic, bureaucratic regimes for over a thousand years. All bureaucracies (even in the US) tend to follow rigid, legalistic rules and guidelines which do not allow for swift, rational changes in procedure to cope with changing conditions (or even common sense circumstances). The incidence of HIV has exploded in China over the course of a single decade. The following quote is reprinted from The Times (of London).

SATURDAY AUGUST 11 2001:

The blood bank system made the spread of HIV almost inevitable. Freshly drawn blood was collected in huge pools for the extraction of plasma, used in pharmaceuticals. Later, the mixed up blood was pumped back into the veins of the donors to allow a quick return to the blood bank. One woman said: “There are hundreds of thousands of people with Aids. It is a supercancer. We are just waiting to die.”

An especially good article that elaborates on these and other aspects of Chinese bureaucratic rule and the AIDS epidemic can be read by clicking here.

The general signs and symptoms of AIDS

HIV generally makes its presence known in two separate stages. The first stage is called "Acute retroviral syndrome" and happens about two weeks after acquisition of the virus. These symptoms are similar to those seen in a severe case of the flu or Mononucleosis (fever, malaise, sore throat, headache, cough, diarrhea, vomiting etc). During this period, the virus is multiplying vigorously and a blood test will usually demonstrate the presence of HIV. In many people, this stage will resolve spontaneously within two to three weeks, and if the patient has simply toughed out the illness without seeing a physician, he may not realize that he actually is infected with HIV.

A long period (called a latency period) may elapse between this primary infection and the more serious secondary stage of the disease which has been labeled Acquired Immune Deficiency Syndrome, or AIDS for short. The latency period is generally between 5 and 15 years, with the majority of patients developing AIDS at about eight to ten years, and about one percent not developing AIDS at all. AIDS is characterized by secondary infections caused by organisms that take advantage of the patient's compromised immune response. It is generally a combination of these "opportunistic infections" and the direct effects of HIV (the virus itself) which cause the two classes of signs and symptoms characteristic of the later stages of the disease and discussed below.

The Bangui definition of AIDS (The classic definition of AIDS)

Major signs

Unexplained weight loss greater than 10% of body mass

Fever lasting longer than a month

Chronic diarrhea of longer than one month duration

Minor signs

Persistent coughing

Itchy dermatitis (red, itchy skin, often with tiny pustules--pruritic dermatitis)

Recurrent Shingles (painful skin eruptions over the skin on one part of the body caused by the chickenpox virus, Herpes zoster.)

Fungal infections of the mouth and throat in younger persons not otherwise likely to get this disease.

Chronic, severe, recurring Herpes Simplex (similar to shingles but not confined to one part of the body)

Lymphadenopathy (generalized swelling of the lymph nodes, especially those of the head and neck)

The Bangui definition assumes that the presence of two of the major signs accompanied by one or more of the minor signs is an indication of severe suppression of the immune system, and in the third world may lead to the presumptive diagnosis of AIDS. (There are actually about thirty signs of the disease, however those mentioned above are the most common.) The Bangui definition was the primary means of diagnosis for HIV in the US and other Western countries prior to the introduction of serological (blood) tests that prove the existence of the virus in the body. It is still used extensively in Africa to define AIDS and HIV, but it is no longer considered diagnostic in Western countries. Even given a presumptive diagnosis of AIDS based on the Bangui definition, the presence of HIV cannot be assumed. A blood test must confirm that the the virus is actually present.

In the United states, the appearance of any disease characteristic of a severe immune deficiency in an otherwise healthy, young person is reason enough for the diagnosing doctor to recommend an HIV blood test. The discussion that follows involves the sorts of signs that might elicit such a recommendation from your dentist.

The oral signs of AIDS

If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, this is one of four pages with images you may find useful. Read this page,
Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions

Normal oral anatomy
Lumps, bumps and sores and discolorations
Oral Cancer




Bear in mind throughout the following discussion that many of the disease entities shown here are not, in and of themselves, an indication of the presence of AIDS. A few of them are "pathognomonic" which means that the presence of that symptom is considered indicative of the syndrome and should prompt the diagnosing practitioner to recommend a blood test to detect the presence or absence of HIV. In such cases, this is clearly stated in the text. In NO instance is the presence of any of the following conditions, in the absence of such testing, diagnostic of the presence of HIV.

Fungal Infections

Candidiasis (Thrush)





Thrush is a common problem for infants since their immune systems are not yet fully developed. In healthy adults, however, it happens only rarely, and usually is an indication of a lowered immune response. Often it is due to illnesses other than AIDS such as general viral infections or stress related fatigue. It is characterized by creamy white, soft plaques that are easily scraped off the mucosa (the lining of the mouth) revealing a red, inflamed patch underneath. This type is seen in the picture to the right. It is easily treated with topical antibiotics like Nystatin.

The image to the left shows pharyngeal candidiasis. The pharynx is the throat, and pharyngeal candidiasis is an indication of the severe immune system depression characteristic of AIDS. This form of yeast infection was considered pathognomonic of AIDS until it was realized that persons who use inhaled steroid medications for the treatment of asthma are also prone to this sort of infection. (Once again, the presence of pathognomonic signs of a disease, --which means observable things that are frequently associated with a particular disease-- do not necessarily mean that the patient has that disease, but a blood test is strongly recommended in such cases.) Oral and pharyngeal candidiasis are not contagious.



Angular Cheilitis

Angular cheilitis is a very common fungal infection of the corners of the lips. It happens all the time to healthy people who tend to have moist lips, especially in the cold winter months. This condition is caused by a persistent fungal infection, and left untreated, tends to remain active for many months. It generally looks like a reddened, dry area at the corners of the lips. The severe, white, ulcerated variety shown to the left is more indicative of the type seen in AIDS. Even a severe case like this, by itself, does not indicate that the patient has AIDS. It is easily treated with Nystatin cream which is simply an antibiotic that kills the fungus. Angular cheilits is not contagious. click the image on the left to see more images of angular cheilitis.




Viral associated signs of HIV
Hairy Leukoplakia

Hairy leukoplakia is one of the most common HIV associated oral signs. It is a white, corrugated or "hairy" "coating" on the lateral borders of the tongue. Unlike Thrush, it is not easily scraped off. It is painless, but patients occasionally complain of its appearance and texture. It is caused by the body's reaction to the Epstein-Barr virus (responsible for Mononucleosis), and can be eliminated with a viral antibiotic like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®). This condition is rarely seen in patients not infected with HIV. However, some healthy patients may develop a "callous" on the lateral borders of the tongue due to the nervous habit of continually scraping the tongue over the teeth. This can lead to embarrassment if the dentist suggests an AIDS test to a person who believes such a suggestion is an insult! It is never meant as a value judgment. Hairy Leukoplakia is not contagious. click the image to see a larger version of this image and more information on hairy leukoplakia.


Herpes Zoster (Shingles)

Herpes Zoster (better known as shingles) is caused by the same virus that causes Chicken Pox. Herpes zoster "hides out" in a somatic nerve branch after the initial Chicken Pox infection (which usually happens in childhood), and flares up again later in life when the immune system begins to fail. Shingles is common in otherwise healthy elderly persons. It generally does not occur in younger people unless they are concurrently infected with the AIDS virus. The distribution of the rash on the body is the key to the diagnosis of shingles, and distinguishes the herpes zoster virus from other forms of herpes viruses. The distribution of the rash caused by herpes zoster in shingles is almost always on one side of the body, and is confined to the distribution of a single nerve root. The skin surface distribution of each spinal or cranial nerve is called a dermatome. The image on the left shows a rash which is confined to the dermatome defined by the third branch of the trigeminal nerve. It is outlined in blue to make it easier to see. Click the image to see larger images, as well as a great deal more on the concept of somatic dermatomes. Shingles infections are quite painful, and they generally go away after four or five weeks, but shingles may reoccur again at a later date. It frequently leaves those so afflicted with "postherpetic neuralgia" (PHN), which is severely sensitive skin, well after the infection.

Persons infected with HIV are prone to this disease if they have previously been infected with Chicken Pox. For people with AIDS, this condition can be severe and even life threatening. In the mouth, it is identified by its distribution. It is limited to one side of the affected organ. The image to the right shows the Herpes zoster virus infecting half of the upper posterior palate. It is easy to confuse Herpes zoster with Herpes simplex which may occur in the same distribution purely by chance. While the Herpes simplex virus is contagious, Shingles, surprisingly is not. Since a large percentage of the population already has been exposed to Chicken pox, most people harbor an immunity to Herpes zoster, and the probability that anyone will develop this disease depends more on the state of their immune system than on recent exposure to the virus.



Herpes Simplex (the "cold sore" or "fever blister" virus)
Herpes Simplex (type I) is the virus that causes cold sores in normal, healthy adults. The image at the right shows a typical cold sore, sometimes called a fever blister due to its propensity to appear when the patient has a cold or other febrile (fever causing) illness. This is another bug that, like Shingles, tends to "hang out" in a nerve root for the life of the patient after the initial infection, which often occurs in childhood. Once infected, the patient remains infected for life. However the virus remains dormant inside the nerve root most of the time until the patient suffers an illness or other problem which lowers his immune response. The virus takes advantage of the drop in immune response to flare up in the typical cold sore seen in this image. Click the image above for more on Herpes simplex.

This image is what the initial infection may look like when a child, or young adult is first infected with the Herpes Simplex virus. This is called "Primary Herpes stomatitis", and as you can see, it can look quite severe with blisters both inside and outside the mouth. ("Stomatitis" means inflammation of the entire mouth.) The patient is quite sick, but this primary infection will disappear after 10-14 days with rest and lots of fluids. In healthy people, this infection happens only once in a lifetime. The presence of the virus only becomes apparent in adulthood whenever a cold sore appears.

Whenever an adult appears in a clinic with a case of Primary Herpes Stomatitis, this infers a severely depressed immune response, and the dentist might consider referring the patient to a physician for diagnosis of an underlying disorder. Adults presenting with severe herpes stomatitis should consider being tested for HIV. It must be remembered, however, that a primary herpes stomatitis can happen at any time of life if the patient has never before had a cold sore. Click on the image to see larger views of this condition.



Patients with AIDS have immune systems much more depressed than normal people with a cold or the flu. AIDS victims may get not only recurrent cold sores, but recurrent (repeating) cases of full blown Herpes Stomatitis as well. Whenever an adult appears in a clinic with a case of Primary Herpes Stomatitis, this infers a severely depressed immune response, and the treating physician or dentist may suspect an undiagnosed HIV infection underlying the Herpes infection. New antibiotics like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) are effective in suppressing the Herpes.


Herpes simplex blisters can sometimes occur in the oral cavity on tissues not generally associated with cold sores. They always happen on tissue that is firmly bound down to underlying bone, such as the gums immediately around the teeth or on the roof of the mouth. As you can see, the appearance of this infection in the mouth can easily be confused with Herpes Zoster (shingles), especially if it occurs on only one side of the mouth. The viruses are closely related, and the blisters in the oral cavity can look identical.

The presence of this type of infection in the mouth does not indicate the presence of HIV, although this infection is more common in AIDS patients than in the non-HIV population. This can happen to anyone who harbors the Herpes Simplex virus. Left alone, provided the patient is not immunologically compromised, it disappears in 10 to 14 days and may be treated with acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) for quicker recovery. The herpes simplex virus is very contagious and if one person in a family develops a cold sore, then others in the family may develop one as well.

A Note on Genital Herpes

Herpes Simplex type I (HSV-1) prefers to infect the face and oral cavity. It is the virus most responsible for traditional cold sores and primary herpes stomatitis. There is, however a second variety of Herpes that prefers to infect the genital areas. Herpes Simplex Type II (HSV-2) is called "genital Herpes" because of its venereal (sexually transmitted) qualities. Both varieties produce similar lesions, the difference between them being their site specific preferences. Both establish latency (take up permanent residence) in nerve roots and once established, tend to cause occasional outbreaks with active lesions (sores) in areas of the body serviced by that particular nerve root. HSV-1 prefers to live in the trigeminal nerve root where it causes lesions in the oral cavity and on the face. HSV-2 takes up residence in the sacral ganglion at the base of the spine where it may cause genital lesions (see the dermatome chart on the Herpes zoster page).

Even though each type has site specific preferences, the viruses are genetically similar and can take up residence in nerve roots in other parts of the body, including in each other's territory. Outside of their own home territories, however, neither virus is especially virulent, and rarely cause recurrent outbreaks.

HSV-2 causes approximately 90% of all cases of genital herpes. Genital herpes caused by HSV-1 is generally much milder than that caused by HSV-2. HSV-1 is usually transferred to the genital area by direct oral/genital contact, although the virus is present in the saliva of infected individuals. Thus the use of saliva as a lubricant can, in fact, transfer HSV-1 to the genital area. HSV-1 is found in only about 10% of all cases of genital herpes, however most people infected with HSV-1 in the genital area have few, if any, outbreaks after the initial episode. HSV-2 prefers to live in this area and causes a much more virulent infection there.

On the other hand, HSV-1 causes almost all cases of oral and facial herpes. Oral herpes caused by HSV-2 almost never reoccurs, except in immunocompromised patients.

For more on this subject, visit this page.

Human Papillomavirus lesions (warts)

Warts are caused by a virus. In the oral cavity, they tend to be somewhat flatter than the type occurring on hands, but if they are dried with air, the tiny projections characteristic of regular warts become evident. The causitive agent is the Human Papillomavirus (HPV). These growths generally are not painful and can be ignored unless they interfere with appearance or function. Persons infected with HIV may develop very large, multiple warts. They may be removed using lasers, cautery or cold steel blades. The presence of oral warts is not in itself an indication of AIDS. HPV is contagious.

Neoplasms (tumors, or "growths")

Kaposi's Sarcoma (KS) (pronounced "cap-o-zeez")

Kaposi's Sarcoma is a tumor composed of numerous tiny blood vessels. It tends to be dark red or deep purple. It may be flat, or a swollen mass. These growths are not generally painful unless secondarily infected by another type of Herpes or bacteria. Thus good oral hygiene is important in the management of these tumors.

Kaposi's occurs most frequently on the skin, although tumors can occur in the gastrointestinal tract and mouth. In the oral cavity, the lesions occur mostly on the palate (the roof of the mouth). Although they are technically a form of cancer, there is evidence that they are, in fact the result of a secondary infection with Herpes virus type VIII. This virus is found in high concentration in the saliva of infected individuals and can cause Kaposi's Sarcoma only in patients with very compromised immune systems. Some recent research has shown that this virus is transferred through deep kissing.


Kaposi's tumors are seen almost exclusively in gay men with AIDS. The occurrence of one of these lesions anywhere on the body of a young man is indicative of the presence of HIV. Kaposi's is infrequent in women, even women with AIDS. It is also rare in men who have contracted AIDS via intravenous drug use. It is not known why women and heterosexual males with AIDS do not generally succumb to Kaposi's sarcoma, although there is probably an association between the gay lifestyle and the transfer of the herpes type 8 virus. These lesions occur as the initial manifestation of AIDS in approximately 11% of patients. Prior to the AIDS epidemic, they were seen (rarely) only on the lower extremities of elderly men.



Lymphoma (lymphatic cancer)


Non Hodgkin's Lymphoma (NHL) is a cancer that starts in a lymph node and spreads to other areas of the body through the lymphatic system and the blood vessels. Prior to the AIDS epidemic, NHL generally effected older individuals (average age 67), however the incidence of NHL has increased substantially in younger persons since the beginning of the AIDS epidemic. Lesions (abnormalities) like those in the image to the right, especially in a younger person, may be the first indication that a patient has HIV, although it is usually accompanied by a generalized lymphadenopathy (swelling of lymph nodes all over the body). A suppressed immune response is a strong factor in the development of NHL, however persons with no history of immunosuppression (or HIV) may contract the disease. There is some evidence that one or more secondary viruses may bear the responsibility for the actual disease, the Epstein-Barr (Mononucleosis) virus once again being a prime suspect. Treatment for this condition usually involves chemotherapy and Radiation therapy




Bacterial diseases associated with AIDS

Periodontal Disease
In order to understand how periodontal disease (gum disease) affects persons with AIDS, it will be helpful to read my explanation of regular periodontal disease, since the process in HIV infected people is the same (albeit more severe and much more rapidly progressing) as in otherwise healthy people. The treatment for HIV infected persons is also the same as the treatment for otherwise healthy persons with Periodontal disease, except that irrigation with Betadine (an Iodine solution) and more aggressive antibiotics are used.

In light of the fact that Gum Disease in HIV infected patients is so similar to the variety seen in the normal population, it is unlikely that a dentist would draw a parallel between the presence of this process and the presence of HIV until the condition presented itself like the picture below and to the right.






The image to the right shows a case of necrotizing ulcerative periodontitis. The difference between periodontitis and gingivitis is the degree of bony involvement and the depth of the pocketing. The white, red and bleedy area under the necks of the lower teeth is indicative of necrotizing (in the process of dying) tissue. While the process can be halted by aggressive intervention from a dentist and periodontal health maintained by good oral hygiene, the damage to the gums and bone is permanent. Periodontal disease is caused by poor oral hygiene and is not contagious.



Acute Necrotizing Ulcerative gingivitis (trench Mouth)
A less severe form of this condition found in the non HIV infected population (also seen in early stages of AIDS) is called Acute Necrotizing Ulcerative Gingivitis (ANUG), formerly called "Trench mouth". In ANUG, only the gingiva immediately surrounding the teeth becomes necrotic. ANUG is often found in people with poor oral hygiene who are either ill or under extreme physical or emotional stress. (It was named "trench mouth" because it was common in soldiers who fought in the trenches during world war I. These men were certainly under extreme physical and emotional stress, and had little opportunity to brush their teeth.)

ANUG, being a bacterial infection, is very easily treated by gentle cleaning of the teeth and irrigation of the affected gums with 3% hydrogen peroxide. The bacteria that take advantage of a patient's run-down condition tend to be anaerobic which means that they die in the presence of oxygen. Hydrogen peroxide liberates oxygen (hence the bubbles) when it is exposed to blood, and the oxygen acts as an antiseptic and speeds healing of the damaged gum tissue. The patient is sent home with a prescription for Penicillin and instructions on cleaning the teeth to prevent further problems. ANUG is not contagious.

Dentists today rarely see cases of ANUG, however the disease is making a comeback in communities in which there is a lot of drug addiction. It is especially prevalent in populations of methamphetamine addicts and is a part of the syndrome now known as Meth Mouth.



Acute Necrotizing Oral Stomatitis
This is a sight we never see except in a hospital setting. This man's mouth is being eaten alive by the same bacteria that his immune system would ordinarily have no problem keeping at bay if it were functioning normally. The difference between a dead body and a live one from the point of view of everyday environmental bacteria is a functioning immune system. AIDS attacks the immune system, and unless the disease and the bacteria can be kept at bay by modern drug therapy, the human body has no defense against parasitic bacteria and viruses.




Other indications of immune deficiency

Geographic tongue--This condition is characterized by the disappearance of the filiform papillae from irregular patches on the top surface of the tongue. Then, the patches "heal" up and reoccur on another part of the tongue at a later date. This process keeps going on and on over time, and one can see lesions in varying stages of healing over large expanses of the tongue. No one knows why some people get this condition. It is thought to be an oral form of psoriasis (a common skin condition). Patients who live with this problem frequently complain of pain on eating sharp foods. Serious outbreaks can be treated with topical application of steroid gels. Otherwise it is not treated. It is not a contagious condition. Recently, it has been noted that this condition may be seen more frequently in AIDS patients, however the presence of geographic tongue certainly does NOT mean that the patient has AIDS. The reason that it may be more prevalent in persons with HIV is that the immune system deficit seen in AIDS patients may lead to an increase in dermatological abnormalities such as unusual forms of psoriasis. Click the image on the right for a larger view.

Introduction of abfraction

Much of the information that follows was learned at a lecture given by Dr. Thomas C. Abrahamsen, DDS. I present it on my website in my own words using his outline. Unfortunately, Dr Abrahamsen would not allow me to use his images, but you can see them by clicking here. This is important information since most dentists see severe wear patterns on teeth, but do not know exactly how they occur. I have been amazed recently at how accurate the diagnoses can be when, upon seeing the various types of wear in a patient's mouth, I have questioned the patient about his or her particular habit. Since each habit has specific wear patterns, it becomes possible to ask such questions and possibly help the patient to prevent further serious damage to his or her teeth. As a public service, I am writing this series of dedicated pages on the subject, and I will eventually populate them with images of my own.
Unfortunately, outside of very early research by WD Miller in 1907, and by G Ganges in 1975, there are few other studies available to back up Dr Abrahamsen's conclusions, and the theory of Abfraction currently reigns supreme in explaining many non-carious lesions. I have no ax to grind and I have not completely abandoned the theory of abfraction, but common sense and my own experience has lead me to believe that Dr. Abrahamsen may, in fact, be correct in denying that bruxing is the reason for severe loss of tooth structure on buccal surfaces.

Since I have no means of doing research on this subject, I will appreciate any observations from dentists and hygienists who have taken the time to learn the information presented here and have applied it clinically.

References:

Abrahamsen TC, The worn dentition - Pathognomonic patterns of abrasion and erosion. International Dental Journal (2005) 55, 268-276

Miller W.D. 1907 : Experiments and observations on the wasting of tooth tissue variously designated as erosion, abrasion, chemical abrasion, denudation, etc. Dent Cosmos 49 vol.1,2,3(1907): 1-23,255-47

Sanges G, Traumatization of teeth and gingiva related to habitual tooth cleaning procedures J Clinical Perio 3 (1975): 95-103







If you have been in practice long enough, you will have run into something like this eventually. This is a 76 year old farmer who has fairly obviously been "grinding his teeth". In fact, you would be making a correct assumption. Note that the tooth wear is much worse anteriorly than it is in the posterior. As we will eventually see, this is diagnostic of abrasion from bruxism. But notice a few other less obvious things. You see no occlusal amalgam fillings in the posterior teeth. You see no plaque or redness around the gingiva. You see no active decay anywhere. Furthermore, the patient has no periodontal bone loss in spite of a serious bruxing habit. On the other hand, you do see a few buccal composite fillings along with severe buccal-cervical wear. We can conclude the following from these observations:
This patient has probably never used too much sugar. We conclude this by the lack of amalgam fillings in the intact molars and the occlusal of #4, the one "surviving" premolar.
The patient has had good oral hygiene for most of his life. We conclude this by the lack of periodontal disease, in spite of severe bruxing, and the current state of health of the gingiva and supporting structures.
On the other hand, something has caused cervical erosion on #s 4,5,6,11 and 12.
The theory of abfraction suggests that the cervical buccal lesions were caused by the biomechanical "bending" of the teeth due to severe bruxing forces. But look at the buccal composite on #6. Note that the filling seems to be raised above the surface of the enamel. Did abfraction cause this too?


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Note the pattern of cervical erosion seen in the image above. Was this caused by the process of abfraction, or is this toothbrush abrasion? And why is is so different than the image below which most dentists and hygienists would not hesitate to call toothbrush abrasion?



In the following pages, I hope to show that there are really five major causes of non carious tooth wear, and abfraction, if it is even a real factor, plays only a minor part

the theory of abfraction

Believe it or not, the theory of abfraction is not proven. Dentists began noticing eroded or notched areas (erosions) on teeth close to the gum line (the cervix of the tooth) as early as the early 1700's. The origin of these tooth defects remained a mystery for 150 years until a dentist named W.D. Miller did some research and published a paper in 1907 titled: Experiments and observations on the wasting of tooth tissue variously designated as erosion, abrasion, chemical abrasion, denudation, etc.

His conclusions were based on both observation and experiment. He concluded that these notch-like cervical erosions were caused by vigorous tooth brushing in combination with abrasive tooth powders.

Interestingly, GV Black, who is widely considered the father of modern dentistry disagreed with Miller, and even traveled to England to see his work. Black had to agree that many of Millers experimentally produced lesions looked like the erosions he had been studying, but remained skeptical. Black eventually published a paper, based on observation alone refuting Miller's conclusions. Unfortunately, Miller died before he could respond to Black's paper, and the origin of cervical erosions has remained controversial ever since.

In the early 1990's, a dentist named J. O. Grippo concluded that cervical erosions were the result of flexing of the teeth at the gum line due to heavy bruxing (grinding). This flexure resulted in damage to the enamel rods at the gum line resulting in their loosening and consequent flaking away of the tooth structure. He named this type of damage abfraction in a paper published in 1991 (Grippo JO. Abfractions: a new classificationof hard tissue lesions of teeth. J EsthetDent 1991; 3:14-19.)

Nearly all the research on the relationship of occlusal forces (bruxing) to cervical lesions shows that teeth do, indeed flex in the cervical region under bruxing loads, but none seems to cite actual damage caused by this deformation without an abrasive or erosive component applied as well. Nevertheless, the abfraction theory argues that bruxing forces alone can cause the erosion of the tooth structure on buccal surface, especially in the cervical region, that every dentist and hygienist is familiar with. It is postulated that abfraction is responsible for chronic sensitivity of the teeth to cold foods and liquids. This biomechanical theory implies that damage like that seen in the images below would be difficult to repair with bonded fillings because the repair would tend to pop off after a while due to the constant deformation of the tooth caused by bruxing.



Many dentists dispute the theory of abfraction, blaming this type of damage on what is commonly called "toothbrush abrasion". This harks back to the early work of W.D. Miller in 1917, however it has been confirmed by more recent studies by T.C. Abrahamsen which have shown that toothpaste (not the toothbrush) is abrasive enough to cause this type of damage if the patient is too aggressive in brushing the teeth in a very hard and vigorous "sawing" motion. Abrahamson suggests that the term "toothbrush abrasion" be replaced with the term "toothpaste abuse".

His studies using mechanical "tooth brushing" machines have shown that the toothbrush alone does not cause the type of tooth damage shown here, but the addition of toothpaste to the bristles does! (Toothbrushes without toothpaste do cause soft tissue damage and indeed, overly vigorous tooth brushing without toothpaste leads to gingival recession.) The current support for the theory of abfraction, as opposed to theory of toothbrush abrasion may be due, at least in small measure to the considerable influence of toothpaste manufacturers who actually did much of the original work showing the damage that toothpaste could do to teeth, but suppressed the results for obvious reasons.

Dental Thermal Hypersensitivity

Proponents of the theory of abfraction postulate that dental hypersensitivity to cold is due to abfractive removal of tooth structure at the cervix of the tooth due to bruxing. Opponents would argue that most dental thermal hypersensitivity is due to erosion of tooth structure because of toothpaste abuse.



The evidence against the theory of abfraction is as follows:

The theory of abfraction is based primarily on engineering analyses that demonstrate theoretical stress concentration at the cervical areas of teeth. While there are a number of studies linking occlusal forces to tooth flexure, few controlled studies exist that demonstrate the relationship between occlusal loading and abfraction lesions.

Most of the damage of this nature is to the buccal surfaces of the teeth, with little erosion to lingual surfaces. If flexure of the teeth were causing this problem, it seems likely that we would see equal damage to both buccal and lingual surfaces.

There is little or no evidence of these lesions in prehistoric skulls, even though the teeth show considerable occlusal (chewing surface) wear from mulling tough and fibrous foods. All the cervical erosions found in historic skulls seem to begin after the invention of tooth powders and toothbrushes in the 16th century.

The lesions tend to be much worse on the buccal surfaces of the premolars and the canines where patients are likely to place the most brushing force. It becomes progressively worse as one proceeds from the posterior teeth to the anteriors. Furthermore, the most affected teeth tend to be in buccal version. The teeth in which linguals are affected are mostly found mesial to an edentulous space (like the one shown in the image below).

The damage seems to stop at the gingival crest instead of at the crest of the bone, which is where the theory of abfraction suggests the flexure should be the worst. The gingiva heal daily protecting the root of the teeth from the toothbrush and toothpaste, and these lesions DO show a sharp delineation at the gingiva with a sloping finish in the coronal direction.

Not all persons with cervical lesions demonstrate occlusal wear, which would indicate a bruxing habit, and not all persons with severe bruxing occlusal wear exhibit cervical non carious lesions.

Frequently, the teeth in which there is ongoing erosion of buccal tooth structure have no opponent in the opposite arch. If it can be shown that the damage is ongoing, or that the damage began after the extraction of the opposing tooth, then bruxing cannot be a factor in producing it.

The theory of abfraction postulates that toothbrush abrasion works in combination with bruxing to create some fairly bizarre effects on teeth. The image on the right shows a tooth which has assumed the shape of a Coca Cola bottle. You are viewing the back of the tooth in a mirror. Click the image to enlarge it. The yellow arrow emphasizes the area of concern. On the enlarged image, you can see that the damage stops at the gum line, leaving a shelf of unaffected root about even with the level of the gums.
On the other hand, the fact that this tooth is the last in the arch makes it more vulnerable to abrasion by the toothpaste on toothbrush bristles, as it does not have another tooth behind it to "protect" it. Dentists who do not believe in the theory of abfraction argue that natural tooth structure is simply abraded away by overzealous tooth brushing. The image below shows a similar 270 degree lesion surrounding both central incisors. The lingual (tongue side) of the teeth are not affected as severely as the buccal (front) and interproximal (between the teeth) areas where vigorous brushing would most likely take place.
















Both of these images represent the type of cervical erosions under discussion. Those dentists who subscribe to the theory of abfraction believe that patients with these lesions are probably severe bruxers as well as "severe tooth brushers". Click on either image to see enlargements.

For those who believe in the theory of abfraction and wish to read more about it (with numerous images), you should see the site of Dr. Brian Palmer, and click on the three sections of his long presentation.

Terminology

The following pages contain information which will help dental practitioners of all types to diagnose the reasons for wear patterns on their patients' teeth. It is based nearly exclusively on the experience of Dr. Thomas C. Abrahamsen, D.D.S., M.S, F.A.C.P. who has been making these observations since about 1972. Dr Abrahamsen has published his findings in a well regarded paper; The worn Dentition--pathognomonic patterns of abrasion and erosion. This paper is available online in .pdf format (Adobe reader, which can be downloaded free). Since Dr Abrahamsen has refused to allow me to use his images, I would suggest that the earnest reader download the paper and refer to the figure numbers that I have placed in the following text. I will attempt to populate this piece with images of my own over the next few years. Interested practitioners are encouraged to send appropriate images if they find this information helpful (see the email button in the right shared border).


Terminology

Dr Abrahamson has come to believe on the basis of studies carried out by WD Miller in 1917 and G. Sanges in 1975 that the term toothbrush abrasion is inaccurate and should be discarded in favor of the following terms:

Toothbrush recession: Studies have shown that the toothbrush, regardless of the stiffness of the bristles or the way the ends are shaped does NOT cause abrasion of the tooth structure. The toothbrush itself DOES cause injury to the gingiva, with consequent recession, and the extent of this injury is dependent on the stiffness of the bristles and the way the bristles are shaped at the tip. The most damage to the gingiva is caused by stiff bristles which are shaped with rough, sharp edges. The least recession is caused by soft bristles with milled, rounded ends.
Toothpaste Abrasion: Although the toothbrush does not damage the teeth by itself in spite of aggressive brushing, the addition of abrasive, in the form of toothpaste DOES abrade away tooth structure, a bit like a ragwheel with pumice on it will abrade away the acrylic on a denture. The ragwheel, by itself does little to the surface of the acrylic, but the addition of pumice will abrade the surface quickly. Furthermore, the coarseness of the pumice does not effect the final outcome. Even flour of pumice will abrade the denture away as surely as coarse pumice, given enough time and pressure.
Toothpaste Abuse: This term means nearly the same thing as toothpaste abrasion, defined above, but it requires some further explanation. Toothpaste abuse does NOT mean using too much toothpaste on the brush. It means using toothpaste in conjunction with very aggressive, prolonged, frequent, and hard brushing using a wide, back and fourth, "sawing" motion with the brush. This is most frequently done by patients on the occlusal and buccal surfaces of the teeth, and less aggressively on the lingual surfaces. It's a very common problem and is often engaged in by patients who do not like the color of their teeth. They mistakenly believe that aggressive brushing with toothpaste will whiten them. Instead, they wear away the white enamel allowing more yellow from the underlying dentin to show through.
The following terms are defined in fairly standard fashion except for the concept of attrition which now has an expanded definition to include both abrasion and erosion:

Attrition: Attrition is now defined as the pathologic wear of teeth from abrasion and erosion. Everyone wears down their teeth in one way or another during a lifetime, and thus everyone suffers at least some attrition.
Abrasion: Abrasion is defined as the pathologic wear of teeth from mechanical rubbing; either on occlusal surfaces from bruxing or from the misuse of toothpaste on virtually any surface exposed to toothbrush bristles and toothpaste.
Erosion: Erosion is defined as the pathologic wear of teeth from a chemical-dissolving process such as those cases in which stomach acid is regurgitated into the mouth in bulimia, or Acid Reflux Disease (formerly known as GERD). Erosion also happens because of acidic solutions and foods kept in the mouth for prolonged periods.
One further term needs special attention, because it is a highly diagnostic finding:

Cupping or Cratering: This diagnostic finding is one of the most obvious and easily discernable characteristics of erosive and abrasive attrition. When the practitioner sees cupping on molar cusp tips, its characteristics will go a long way toward helping with the diagnosis.
Cupping happens on the cusp tips of molars and premolars and incisal edges of incisors and canines. Cupping on molars has less to do with bruxing than with erosion caused by acids, while cupping on anterior teeth is more likely due to bruxing in older patients.

Diagnostic Models:

Doctor Abrahamson correctly notes that the diagnosis of all forms of attrition are facilitated by the use of hand articulated diagnostic models. In fact, all erosive and abrasive tooth stigmata are more easily seen on well made stone models, and the ability to hand articulate them has the added benefit of making it possible to inspect the occlusion from the lingual to see if occlusal wear on maxillary teeth actually coincides with the occlusal wear on the mandibular teeth. Many practitioners assume that all occlusal wear is from bruxing, but are surprised to see that the wear facets on opposing teeth do not coincide.

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen

Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling
The following pages will examine each of these five causes of tooth wear and give the pathognomonic wear pattern associated with them. Images will follow in time, however in the meantime I refer you directly to the relevant figures in Dr. Abrahamsen's paper. I will give you the diagnostic features of each pattern of wear, as well as various questions you can ask the patient in order to confirm your diagnosis.

Bruxism

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling


It is important to remember that these causes rarely exist alone. You will find the stigmata from one major cause of tooth wear intermixed with one or more secondary causes. This page will examine the diagnostic features of bruxism. It follows closely the outline provided by Dr Abrahamsen.
Bruxism is defined as the grinding or rubbing together of the upper and lower teeth. It is caused by stress, and the other pathological effects of bruxing on the human body are discussed in my section on TMJ.


This page discusses only the wear caused by bruxism on the teeth.

Wear patterns on teeth caused by bruxism

Bruxing causes wear on occlusal and incisal surfaces of the teeth. The wear is always progressively greater from the posterior to the anterior. In other words, the more anterior the tooth, the greater the wear. The full size image can be seen on the first page of this series. However, even in this smaller image, one can see that the anterior teeth are much more worn than the posterior teeth. This is a very important point in the diagnosis of bruxing. The only exception to this rule is a patient with an anterior open bite.
Cupping or cratering on molar cusp tips is often present, but it is NOT due to bruxing. It is due to a secondary habit of toothpaste abuse since persons who brux are likely to be aggressive brushers. See figures 1 and 2 on Dr. Abrahamsen's paper.
Inspection of the teeth, or hand articulated stone models will show that the abraded areas on the maxillary teeth match abraded areas on mandibular teeth.
The type of patient who bruxes

Stress causes bruxing. Since EVERYONE suffers stress at certain points in their lives, it can be assumed that EVERYONE bruxes to one extent or another. However some people are more stressed than others and therefore suffer more bruxing wear than the "average" patient. If you make study models on any adult patient, you will find wear facets on premolars and anterior teeth at minimum.
Sleep apnea also causes night bruxing. Night bruxing can occur in the absence of sleep apnea, simply as a reaction to daytime stress, but obstructive sleep apnea produces severe night bruxing. Click here for more on obstructive sleep apnea.
Confirming your diagnosis of bruxing

You CANNOT ask your patient if he or she bruxes. They always deny the habit, and indeed, the habit is done almost entirely unconsciously.
The best method of confirming the diagnosis of bruxing is to take diagnostic study models and inspect the pattern of wear facets.
The least wear will be toward the posterior of the arch, and the most wear will be toward the anterior.
When the upper and lower models are hand articulated, you will find that they fit together well, and upper and lower wear facets will coincide.
See figures 3-6 on Dr. Abrahamsen's paper.
Treatment of bruxism

The treatment for bruxism is a traditional bruxing guard or a deprogrammer such as the NTI. These treatments work well provided that the patient gains relief from the painful symptoms of TMJ if he complies with the treatment. Unfortunately, treating bruxism in patients who have only tooth wear has not been successful in my hands since the patients cease wearing the appliance after strenuous efforts to comply.
Treating obstructive sleep apnea by referring the patient to the appropriate medical professional will generally reduce or eliminate night bruxing in patients with this problem.

Toothpaste Abuse

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling

The second most common cause of tooth wear is toothpaste abuse. As you may recall from the third page in this series, toothpaste abuse does NOT mean using too much toothpaste on the brush. It means using toothpaste in conjunction with very aggressive, prolonged, frequent, and hard brushing using a wide, back and fourth, "sawing" motion with the brush. This is most frequently done by patients on the occlusal and buccal surfaces of the teeth, and less aggressively on the lingual surfaces. This is a very common problem and is often engaged in by patients who do not like the color of their teeth and want to whiten them in the mistaken belief that aggressive use of the toothbrush/toothpaste will accomplish this.

Early research has shown that the toothbrush itself does not damage the teeth without additional abrasive, in spite of aggressive brushing. However, the addition of abrasive in the form of toothpaste DOES abrade away tooth structure. This is a bit like a lab ragwheel on a dental lathe. The ragwheel, by itself does little to the surface of the acrylic, but the addition of pumice will abrade the surface quickly. Furthermore, the coarseness of the pumice does not affect the final outcome. Even flour of pumice will abrade the denture away as surely as coarse pumice, given enough time and pressure.

The signs and symptoms of toothpaste abuse

Sandblasted teeth: The earliest sign of toothpaste abuse is the gradual elimination of the surface anatomy on the teeth, just as though the teeth have been sandblasted. See figures 7-10 on Dr Abrahamsen's paper for a great illustration of this phenomenon. This phenomenon is seen especially in younger adults who are very self conscious about the whiteness of their teeth.
Mandibular canines and premolars are the worst affected: The wear pattern is most pronounced on the cervical buccal surfaces of the mandibular premolars and canines, however the buccal surfaces of other teeth are often also affected. The reason that the damage from toothpaste abuse becomes worse the further anterior you go is because it is easier for the patient to be more aggressive with the toothbrush in the anterior regions.
Cupping or cratering on the mandibular molars is very common in cases of toothpaste abuse. In the image to the right, the cupping shows smooth, rounded enamel edges. The smoothness of the enamel around the craters is diagnostic of toothpaste abuse. Toothpaste on the brush is responsible for wearing the dentin below the level of the enamel and causing the smooth, rounded edges on the surrounding enamel.
Polished amalgams: Since very aggressive brushers are likely to brush the occlusal surfaces of their teeth, amalgam fillings may be highly polished.
Damage to the buccal tooth structure can be very severe: Until recently, I believed that abfraction was responsible for the damage seen in most of the images below. While biomechanical flexure of the teeth may be involved, I now believe that the major factor in producing these lesions is toothpaste abuse. (See also figures 11-14 on Dr Abrahamsen's paper)
Teeth that are very sensitive to cold. Often, patients who abuse toothpaste abrade away enough tooth structure at the cervix of their canines and premolars to cause serious tooth sensitivity. Overly agressive brushing is probably the major cause of tooth thermal hypersensitivity. Patients with this type of damage to their teeth also often complain of pain when eating or drinking sweet foods.






Confirming your diagnosis of toothpaste abuse

The damage from toothpaste abuse is worse on the buccal surfaces of the lower premolars and canines. There is often a stark difference between the damage on the right side of the dentition versus the left side due to the "handedness" of the patient.
Hand articulated diagnostic models show that upper and lower wear patterns do NOT coincide. It is very helpful to look at the occlusion from the lingual aspects to confirm this.
Ask the patient demonstrate their usual brushing technique. Give the patient a toothbrush (use their own if possible) and toothpaste and let the patient go to the sink to demonstrate. Stress that the technique they show you should be the same as the one they practice daily. You will be quite surprised to see how seriously aggressive they can be with their brush. Also, ask the patient how many times per day they practice this ritual. Quite often, they will tell you that they brush as often as they can in any given day.
Ask the patient if they like the color of their teeth!!! A vast majority of younger patients and middle age women exhibiting these lesions are dissatisfied with their tooth color, and they will tell you that they brush aggressively to make their teeth whiter.
The types of patients who damage their teeth with toothpaste abuse

Patients who dislike the color of their teeth and want to make them whiter. This applies to younger patients and women into late middle age. They will aggressively brush their teeth with the most abrasive toothpaste they can find, especially one that promises "whiter teeth". This habit becomes ingrained and continues even into older ages when the patient may care less about the color of their teeth.
Patients who learned aggressive horizontal brushing techniques when young and continue the habit throughout their lives. Childhood habits die hard! Children often begin brushing their teeth before developing the manual dexterity to anything more than horizontal strokes on the buccal surfaces.
Fearful patients. Many patients develop aggressive, horizontal tooth brushing techniques due to fear of retribution from their parents when they were children. Others are persons who are afraid of having to go to the dentist.
Treatment modalities for patients suffering the damage from toothpaste abuse

Offer to whiten the patient's teeth with bleaching techniques. In this instance, bleaching goes past cosmetic treatment into the realm of preventive treatment to prevent further serious damage to the teeth.
Repair the damage using standard treatment modalities. The patient should be made aware that composite restorations will not lighten along with their natural tooth structure, so sometimes it is wise to bleach before making this type of repair in order to match the color. Alternatively, the patient may wish to repair the damage with veneers (Lumineers work quite well), or crowns.
Council the patient about their tooth brushing technique, and explain the dangers of abrasives in toothpastes. Explain that aggressive brushing with toothpaste removes the white enamel from the surface of their teeth exposing the yellow color of the dentin underneath, causing their teeth to become even more yellow than they were before brushing. Suggest that the patient switch from using toothpaste to using mouthwashes such as Act which contains fluoride, or Listerine, which has been shown to kill plaque organisms.

regurgitation

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Bulimia
Acid Reflux Disease (GastroEsophageal Reflux Disease)
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling

Erosion of tooth structure means the dissolving of hard tooth structures, both enamel and dentin, due to frequent exposure of the teeth to acidic solutions. There are three major forms of erosive processes in the mouth. These are Regurgitation of stomach contents into the mouth, Soda Swishing, and Fruit Mulling. There are other unusual habits that can cause tooth erosion, but they are very patient specific and, taken as separate entities, are fairly rare.

Regurgitation of stomach contents into the mouth is the major cause of tooth wear from erosion, and as such, it constitutes the third major cause of non carious loss of tooth structure, after both forms of abrasion: Bruxism and Toothpaste Abuse.

There are two major conditions which cause regurgitation of stomach contents into the mouth. They are the eating disorder known as bulimia, and chronic acid reflux disease (ARD)

Bulimia

Bulimia is an eating disorder in which the patient (almost always female) wants to eat to satisfy hunger, but is afraid that she will get fat if she does. This leads to binge eating followed by intentionally vomiting the stomach contents in order to avoid gaining weight. These patients have a serious psychological disease which, once established, is essentially an addiction, and which is almost impossible to break without professional help.

Unfortunately, these patients almost NEVER admit to the habit, and when confronted, they will generally deny the habit, and may react by leaving your practice for good. To further complicate the issue, the dental stigmata of bulimia are permanent, unless repaired by a dentist, and remain with the patient forever, even if the patient has sought professional help to kick the habit. Often, an actively bulimic patient will lie about the status of their disease, saying that they have been "cured" and are no longer actively bulimic in order to get the treatment they came in for.

The best way to confront the patient is with extreme compassion. Most patients with bulimia know that they have a big problem and really want help. (Most bulimics are aware that their condition may lead to death--Which happens in about 6% of all cases.) Many large regional hospitals have eating disorder clinics, and it would be wise for each practitioner to know where the closest ones are located so a referral can be made.

Recognizing Bulimia--Wear patterns on the teeth

Loss of tooth structure is progressively worse toward the anterior teeth. This is because of the way the tongue is held in the mouth when the patient vomits. The vomitus is projected especially toward the palatal surfaces of the maxillary incisors with progressively less damage as you proceed posteriorly. As the palatal surfaces of the maxillary incisors erode, the incisal edges become more and more thin and translucent, eventually producing a knife-edge which is easily crazed and chipped. Note the image above. Nearly all of the palatal enamel has been dissolved by the acidic stomach contents which have been projected against the incisors. The canines are affected, but less so. This profile is pathognomonic of early bulimia.
Note especially in the image above that the loss of tooth structure is fairly even beginning at the free gingival margin. This is an important distinction which differentiates bulimics from heavy bruxers who may also have worn palatal enamel, but rarely as evenly distributed, or subsuming the entire palatal surface.
Please refer to figures 15-18 on Dr. Abrahamsen's paper to see stone models with these stigmata. Note that the amount of damage is worse toward the anterior and less toward the second molars. Also note that the upper teeth are much more heavily affected than the lowers.
Posterior teeth may be affected in long standing cases, but the maxillary posteriors will be more affected than the mandibular posteriors. Also, most of the damage to posterior maxillary teeth will be on the occlusal and palatal surfaces. Mandibular posteriors will be affected mostly on occlusals with minimal damage extending to the buccal surfaces due to the position of the tongue.
Mandibular anteriors are not affected, since they are protected from the acid by the position of the tongue during vomiting.
Cupping, or cratering is very common, especially on the maxillary posteriors. In the absence of bruxing or toothpaste abuse, the enamel edges of the cupping lesions are prone to be sharp, in contrast to those caused by toothpaste abrasion.
Silver and composite restorations may be elevated above the surface of the enamel in which they were placed. This is due to the dissolution of the enamel by the stomach acid as it speeds by the teeth.
Hand articulated study models will show that the occlusal wear on maxillary and mandibular arches do NOT coincide.
This type of wear frequently occurs in combination with abrasive attrition (bruxing and toothpaste abuse) but not generally with other forms of erosion ( soda swishing or fruit mulling).
For an excellent discussion of the dental effects of bulimia, see this page on the website of Dr. Jerry Bouquot

Acid Reflux Disease (Gastro-Esophageal Reflux Disease)

Chronic Acid Reflux Disease (ARD), also known as GastroEsophageal Reflux Disease (GERD) is a very common problem. It involves the unintentional regurgitation of stomach contents into the mouth, with immediate swallowing. The extent of the damage to the teeth depends on the frequency of the reflux, and the amount that enters the mouth before swallowing. Since the vomitus is generally not ejected from the mouth, the pattern of tooth erosion differs significantly from that of bulimia in which the vomitus is always ejected.

Recognizing ARD in the mouth

Loss of tooth structure is progressively worse toward the more posterior teeth. This is exactly the reverse of the erosive pattern in bulimia in which the damage is worse on anterior teeth.
The damage is principally to the palatal and occlusal surfaces of the maxillary molars.
The lower teeth, and the maxillary anteriors remain relatively less affected due to protection from the tongue when swallowing.
Silver and composite restorations in the affected teeth will be elevated above the surface of the enamel in which they were placed.
Hand articulated study models will show that the occlusal wear on opposing upper and lower teeth do NOT coincide.
Cupping, or cratering in maxillary molars is common

soda swishing

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling

Erosion of tooth structure means the dissolving of hard tooth structures, both enamel and dentin, due to frequent exposure of the teeth to acidic solutions. There are three major forms of erosive processes in the mouth. These are Regurgitation of stomach contents into the mouth, Soda Swishing, and Fruit Mulling. There are other unusual habits that can cause tooth erosion, but they are very patient specific and, taken as separate entities, are fairly rare.

Soda Swishing

I have been telling my patients for years that diet soda can't harm their teeth. If it has no sugar, it can't contribute to tooth decay. I was, of course correct about the decay, but I was not prepared for something I learned in a lecture by Dr. Thomas C. Abrahamsen. Having spent over 30 years studying erosion of tooth structure, Dr. Abrahamsen informed the hall about the phenomenon of "Coke Swishing".

Coke swishing is the habit of retaining each mouthful of CocaCola in the mouth for a few seconds and swishing it around between the teeth before swallowing. It turns out that it is not just Coke. It could be virtually any soda. Most of my patients who do this are using Mountain Dew. Thus, I will refer to this habit as "Soda Swishing"

All sodas, including diet soda contain three acids. Phosphoric acid is added to impart a tart flavor and to counteract the sweetness of the sugar or artificial sweeteners, and also as a preservative to prevent the growth of mold. Citric acid is added, especially to fruit flavored sodas to give a bit more of a zippy flavor. Carbonic acid is a byproduct of the carbonation process, but is the weakest of the three acids and is probably the least harmful to the teeth. (I'm happy to report that since beer only contains carbonic acid, it is much less harmful to the teeth--even when swished.)

When a patient drinks a diet soda without swishing it, it goes past the teeth quickly, and does very little damage to the teeth. But when a patient develops a soda swishing habit, then it it is held in the mouth for long enough to dissolve tooth structure.

The type of patient who swishes soda

Soda swishing almost always starts out when the patient is quite young, but continues into adulthood.
These patients swish the soda around in their mouths in order to remove the carbonation which hurts their throat.
These patients are NOT high volume soda consumers. One can can last a very long time.
Recognizing soda swishing erosion

Cupping or cratering is always present. This cupping has sharp enamel edges unless the patient is also a toothpaste abuser. Please see figures 19-22 on Dr. Abrahamsen's paper
The most cratering will be seen on the mandibular first molars because these are the first adult teeth to erupt and the habit is usually well established in early childhood (see image above). The most cratering will be seen on the lingual aspect of the mesiobuccal cusp of the lower first molar.
Mandibular molars are much more heavily affected than maxillary molars because gravity keeps the soda in contact with them.
Over the years, the posterior teeth become more worn than anterior teeth due to tongue position while swishing.
Silver amalgams in posterior teeth are elevated above the enamel surface because the acids in the soda dissolve the enamel around them.
This habit can be found in combination with bruxing and toothpaste abuse stigmata, but it is never seen with damage from regurgitation or fruit mulling.
The easiest way to confirm the diagnosis is to ask the patient if they swish the soda before swallowing it since most patients will freely admit to the habit.
Hand articulated plaster study models show that the worn occlusal surfaces on the lower teeth do not match wear on the opposing upper teeth.

fruit mulling

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling

Erosion of tooth structure means the dissolving of hard tooth structures, both enamel and dentin, due to frequent exposure of the teeth to acidic solutions. There are three major forms of erosive processes in the mouth. These are Regurgitation of stomach contents into the mouth, Soda Swishing, and Fruit Mulling. There are other unusual habits that can cause tooth erosion, but they are very patient specific and, taken as separate entities, are fairly rare.

Fruit mulling is the habit of "chewing" fruit pulp for prolonged periods before swallowing it. This habit causes loss of tooth structure due to a combination of erosion from the acidity of the fruit itself, as well as a modified form of abrasion from the constant rubbing together of the teeth over the fruit pulp during the mulling process.

The type of patient who mulls fruit

Fruit mullers are generally very health conscious.
They are frequently vegetarians.
They eat a high proportion of fruit in their diet, and tend to mull (chew) the fruit pulp for a prolonged period before swallowing it in order to savor the taste and feel of the fruit.
Due to their health consciousness, they rarely drink sodas or become bulemic. Thus these habits are almost never seen in combination with fruit mulling.
Also due to their health consciousness, these patients are likely to be aggressive tooth brushers, so the patterns of tooth wear seen in fruit mullers are often combined with those seen in toothpaste abuse.
Recognizing a fruit mulling habit

Please refer to Dr. Abrahamsen's paper, figs. 23 and 24
The posterior teeth are worn to a greater extent than the anterior teeth.
Maxillary and mandibular teeth are worn equally.
This is in opposition to soda swishing in which the lower posteriors are worn more than the maxillary teeth.
Cupping and cratering are always present and are a major factor in helping to diagnose this disorder.
With fruit mulling, the enamel edges surrounding the craters are worn smooth due to the abrasion of the fruit pulp (unless the edges are recently broken). This is in opposition to soda swishing in which the enamel edges are more prone to be sharp, unless the habit is combined with toothpaste abuse.
Silver amalgams may be elevated above the level of the enamel surfaces in which they were placed (see the upper image).
This symptom is seen in all forms of erosion as a result of acidic erosion of the enamel surrounding the fillings.
Hand articulated plaster models show that wear on the posterior maxillary and mandibular teeth match up perfectly.
This habit never occurs in combination with regurgitation or soda swishing.
These patients will admit to their fruit mulling habit.

occlusion

The most important factors that affect a patient's occlusion
The relationship of the upper and lower teeth
The components of the temperomandibular joint
The Neuromuscular system
Centric Relation versus centric occlusion
Centric Occlusion
Centric Relation
Discrepancies between centric occlusion and centric relation
Group function versus canine guidance
How a normal jaw opens and closes (the Gothic Arch)
Joint Derangements
The normal behavior of the articular disc
Internal joint derangements
Anterior disc displacement
The classification of joint derangements
Total Joint replacement surgery
Other TM Joint derangements
The muscles of mastication
The temporalis
The masseter and medial pterygoid
The lateral pterygoid
The Digastric muscle
The complex relationship between occlusion and facial appearance
My patient Popeye

In dentistry, the term occlusion refers to the way that the upper and lower teeth come together. Originally, the term "occlusion" meant just the way in which each individual tooth met with it's mate in the opposite arch. Thus courses in dental school that dealt with occlusion were most concerned with such concepts as which cusp of an upper molar occluded (came together) with which particular groove in the lower molar that it touched when the patient closed his teeth together.

Occlusion

Indeed, the very first course in occlusion that I took as a dental student involved exclusively such minutia as "The mesiobuccal cusp of the maxillary first molar occludes with the mesial buccal groove of the mandibular first molar...." and so on throughout the mouth. It is unknown whether anyone ever stayed awake throughout a full lecture period. This sorry state of dental education did not begin to change until the late 1970's or early 80's.

Fortunately for the dental students of the world, and especially fortunately for the dental patients of the world, the study of occlusion came into its own as research showed that in order for the upper and lower teeth to meet, the teeth had to be attached to something! And whatever it was that they were attached to had to have a mechanism that allowed them to come together. Much more research showed that the teeth were embedded in human jaws and that the jaws were attached to a joint in front of the ear. (Whoda thunk it?)

In fact, occlusion is one of the most important factors in dentistry because the success or failure of practically everything a dentist does in a patient's mouth depends upon its ability to operate within the boundaries of the patient's physiologic occlusion. Even a simple filling that changes the way a patient bites can cause untold agony for the patient. See my page on TMJ for a full rundown of the disease states that are associated with occlusal factors.

This page is concerned principally with an explanation of the relationship between the way the teeth come together, and the resulting configuration of the temperomandibular joint. It is of interest mostly to dental students, hygienists and assistants who want a simple, practical straightforward understanding of occlusion as it relates to their patient without having to deal with the technical minutia and professional infighting that has become the daily fare of the dentist or physician who wants to specialize in this field.

By the way

For a thorough understanding of glass and porcelain, Students and dental professionals should consult my five page course "Dental Ceramics for the beginner"


The three most important factors that affect a patient's occlusion:

1. The first factor is the minute relationship of the upper and lower teeth when they come together. This generally coincides with the most common definition of the patient's "bite", but also includes the specifics of which cusp on a specific tooth contacts which groove on the opposing tooth. It is also concerned with how the teeth contact during lateral excursions (The way that the upper and lower teeth contact during side to side movements of the lower jaw). This is discussed in detail below.

2. The second factor is the exact relationship of the components of the temperomandibular joint (the TMJ). (See the highlighted spot on the image of the skull at the top of this page to get your bearings before looking at the diagram at the right.) The TMJ is the ball and socket joint that allows the lower jaw to swing open and closed. The components of the TMJ are as follows :

The condyle: This is the "ball" in the joint. It is a part of the mandible (lower jaw), and is covered in a layer of cartilage which allows for smooth motion within the joint assembly. The condyle is the part of the lower jaw around which the lower teeth pivot. Click the image for a larger view.



The glenoid fossa: The fossa is the "socket", or depression in which the condyle sits. It is located in the temporal bone of the skull. The glenoid fossa is also covered with a layer of cartilage which allows smooth activity in the joint. The back of the fossa is steep bone, and the condyle of the mandible sits fairly snugly up against it and can move only slightly backwards from its normal position in the fossa. The front of the fossa is a more gentle slope of bone called the articular eminence. The eminence is also covered with cartilage. The condyle is able to "translate" forward over this eminence of bone and does so whenever the mouth is opened wide, moves side to side, or whenever the patient protrudes his jaw.



The articular disc: The articular disc is also called the meniscus. It is made of hyaline cartilage. The meniscus has an indentation on the bottom side to accommodate the head of the condyle. The articular disc is really part of a larger structure composed of the cartilage disc plus fibrous ligaments on either side and behind it. The ligament behind the meniscus is called the retrodiscal pad in deference to its function as a shock absorber for the condyle when the lower jaw is drawn back as far as it will go. These ligaments are all connected to the condyle only at their periphery so that there is a thin "potential" space filled with synovial fluid both above and below the articular disc. (A potential space is a collapsed space like the one between a rubber glove and a hand. It is present, but not immediately apparent, and it could potentially get wider if air or water were introduced under the glove.) The articular disc remains between the condyle and the fossa and acts as a shock absorber. The majority of physical derangements of the TM Joints involve damage to the articular disc and/or displacements of fragments of the articular disc.



The joint capsule is the covering of the TM joint. Think of it as a bag that contains the joint. It isolates the contents of the joint and allows free movement of the condyle and articular disk within a small "swimming pool" of synovial fluid. The capsule has lots of blood vessels and nerves as well as connective tissue. Inflammation of the capsule (capsulitis) is a factor in much of the pain from TMJ disorders. All major joints in the body are surrounded by a synovial capsule.

3.The third factor is the neuromuscular system: This involves the muscles of mastication which open and close the jaw, as well as the brain and the cranial nerves which give sensory and motor innervation to the muscles. The muscles of mastication are discussed later in this piece. The brain is important in the concept of occlusion because it is the source of both the voluntary muscular activity which operates the system, as well as unconscious habits such as bruxing (grinding and clenching) which can lead to some of the most serious disease states of occlusion. This subject is discussed in detail below.

Centric Relation vs. Centric Occlusion--How the position of the teeth determines the position of the components in the joints.

Centric occlusion is the term used to describe the position of the lower jaw when the teeth are fully occluded (together). This varies from person to person depending upon the number and position of teeth in each jaw. In the image of the skull at the top of this page, all 32 teeth are present and occluding (biting) in an absolutely normal class I relationship. This position can change throughout a person's life depending on such factors as the loss of teeth (with the consequent shifting of the teeth that takes place after teeth are removed), fractures of the jaw, orthodontic movement of the teeth to new positions, or the shifting of the teeth due to the constant pressures from bruxing (generally unconscious habits of grinding of clenching). When the teeth are fully occluded, the condyle is forced into a specific position within the glenoid fossa. Note that the term centric occlusion does not take joint configuration into account. A patient's centric occlusion may be physiologic, meaning that the joint is placed into a comfortable position, or pathologic, meaning that the joint is forced into an eccentric position which may produce organic joint dysfunction.

Centric Relation

In the image of the skull at the top of this page, the TMJ has been lightened to show the general anatomy. In this case, the condyle is approximately centered in the glenoid fossa. More specifically, the condyle is slightly closer to the top and the back of the glenoid fossa. This relaxed, centralized position of the condyle within the glenoid fossa is called centric relation. If the TM Joints are in a state of health, they tend to approximate this position whenever the teeth are slightly separated and the muscles of mastication are relaxed. Ideally, this position of the joints should also be approximated when the teeth are brought together into the patient's centric occlusion. The image on the right shows another dried skull with the teeth in centric occlusion and the joint in centric relation. Click on this image to see an enlargement. In life, the articular disc would be resting in the natural space between the condyle and the glenoid fossa without much pressure placed upon it. This is a normal, healthy situation, and in an ideal world, everyone would have a centric occlusion that would allow the condyle to remain in centric relation. It is considered the ideal joint configuration, and it is also the configuration that all dentists strive to produce in patients in which a new centric occlusion must be recreated from scratch.

Unfortunately, when a patient places his teeth together in centric occlusion, the condyles on either side of the jaw do not always line up within the glenoid fossa in centric relation. Even if the tooth-to-tooth position is a perfect class I centric occlusion as shown above, the condyle could be forced into abnormal positions within the fossa. It could (depending upon the growth patterns the patient has experienced throughout early life) actually be jammed up hard against the top of the glenoid fossa. Or it could be located considerably forward of the ideal position, with a consequent tendency toward sliding backwards up the articular eminence. It might be jammed hard against the fibrous connective tissue at the back of the articular disc at the back of the fossa. Situations like these often lead to pain in the joint with frequent headaches and referred pain that is perceived as earaches and neckaches. They also seem to lead to bruxing which further exacerbates the pain.

A discrepancy between centric occlusion and centric relation can also develop in later life if the patient loses teeth, is injured in an accident or has orthodontics in which not enough consideration was given to joint position in the finished case.

Does a discrepancy between centric occlusion and centric relation always cause trouble for the patient?

NO! Even a centric occlusion that causes serious misalignment of the TM joint may cause no noticeable joint dysfunction or pain. The reason that serious misalignment of the joints when the teeth are closed together may be of no significance is that there is no physiologic reason for the patient to keep their teeth together at all. When the teeth are nearly touching, but not occluded, healthy TM joints will automatically fall into a comfortable configuration approaching normal centric relation, even if forceful occlusion would ordinarily force them out of this position. Even while chewing food, the teeth rarely contact at all. (The next time you eat, take notice.) The only time during a normal day when the teeth come together for normal physiological processes is during swallowing, and even then, it is only necessary for light contact to take place on a relatively few teeth...UNLESS...the patient has a bruxing habit!

Bruxing is a nervous habit of grinding the teeth during prolonged periods during the day. To get an idea of the full extent of the pain and agony caused by bruxing habits, read my page on TMJ. If there is no bruxing habit, even seriously dysfunctional occlusions can remain perfectly physiologic and comfortable.

Group function versus canine guidance

When a person bruxes his or her teeth side to side, keeping the teeth in constant contact, the cusps of the upper and lower teeth slide over each other forcing the lower jaw to drop slightly as they approach a cusp-tip to cusp-tip relationship. The number of cusps that remain in contact during lateral excursions of the lower jaw vary from person to person.

Canine Guidance--In young persons with ideal occlusal relationships, the upper and lower teeth contact evenly throughout the entire dental arch when the teeth are fully together in that person's centric occlusion. However, as soon as he or she begins a lateral excursion, all the teeth (anterior and posterior alike) lose contact, except for the upper and lower canines on that side. In other words, the canines are situated and inclined in such a way that, while they allow full contact of all teeth in centric occlusion, they force the jaw to open as the upper and lower canines slide over each other. This disengages the cusps of all other teeth as the person begins to grind side to the side. (This phenomenon is called "cuspid rise" in deference to the fact that most articulators are hinged in such a way that the upper teeth move instead of the lower. This artificial way of mounting the models makes the upper canines appear to rise instead of the lower canines drop, which is what happens in a real mouth.) In fact, canine guidance is considered the most physiologic of all occlusal relationships because it protects the teeth from wear and tends to prevent bruxing in most persons who are likely to brux only occasionally. In the absence of chronic bruxing habits, this relationship often persists throughout life.

Group Function--On the other hand, if a person is a habitual bruxer, the combination of tooth movement and cuspal wear over a period of years reduces, and eventually eliminates the prominence of the canine prematurely. This causes more and more posterior tooth cusps to remain in contact over more and more of the excursive movements. The process continues until, eventually, all the cusps of the back teeth remain in contact throughout the entire lateral excursion. This "group functioning" of all the posterior teeth now replaces the original canine rise in causing the lower jaw to drop during excursions.

An occlusion in group function is more prone to perpetuate the bruxing habit leading to greater and greater wear on all teeth. Eventually, the occlusion is worn flat, eliminating any tendency of the lower jaw to drop at all during lateral excursions. In other words, all, or most of the teeth remain in contact throughout the entire lateral excursion, and fail to disclude, as they do in canine guided occlusions. This may cause extreme wearing of the anterior teeth as well as the posteriors. Tooth wear from bruxing is called attrition. Continual bruxing leading to continual wear of the teeth also changes the relationship of the patient's centric occlusion to their centric relation, causing a slow, continuing protrusion of the lower jaw bringing about more and more wear on the anterior teeth. Many dentists believe that by recreating a canine guided relationship they can stop a severe bruxing habit and save a dentition otherwise doomed to "death by attrition".

How a normal jaw opens and closes

When a person opens his mouth, the lower jaw swings at the TM Joint which is located just in front of the ear at about the level of the opening of the ear canal. Place your middle fingers lightly on this spot and you can feel the condyle as it moves within the joint space. As you begin to open your mouth, at first you can feel no movement of the joint. During this early part of jaw opening, the condyle is simply rotating within the glenoid fossa. But as you continue to open your mouth wider, you can begin to feel the head of the condyle move forward. This forward movement is called translation and it is a normal part of opening the jaw wide. During translation, the condyle is slipping forward and downward as it slides over the articular eminence. The movement of the lower jaw is traced out by the red line in the image to the right. As the lower jaw begins to swing open, a point on the surface of any lower tooth traces a smooth radius around the place in the glenoid fossa where the head of the condyle rotates. As the jaw opens further, the condyle begins a smooth translation down the slope of the articular eminence. This second opening component traces out a different radius around the changing position of the condyle.

The blue arrow traces out the path of the lower jaw on closing. Notice that the jaw traces out a smooth arc on closing without the complication of rotational and translational movement seen on opening. This is because the condyle begins and ends its closing path by smoothly sliding back up the articular eminence until it comes to rest in centric relation at the end of its closing cycle. The red "broken" arc combined with the smooth blue closing arc is often referred to in dentistry as the classic "gothic arch" due to its similarity with the architectural structure of the same name.

How the articular disc behaves during normal jaw opening?



Note the muscle labeled "lateral pterygoid" in the image on the left above. This muscle has fibers which attach separately to the front of the articular disc, with the majority attaching to the neck of the condyle. When they contract, both the articular disc and the condyle are pulled forward in unison in order to affect translation of the condyle. When the condyle translates down the incline of the articular eminence, the articular disc follows. The disc is in red and the ligaments that attach it to the bony structures are represented in bright yellow. Notice that the disc is not rigidly attached to the head of the condyle. It remains on top of the condyle, but moves into new positions throughout the translation process. The thinnest part of the disc always remains between the closest points of contact between the articular eminence and the the condyle.

The damaged TM Joint (internal joint derangement)

If a patient forcefully bruxes (grinds or clenches the teeth), the entire masticatory system is placed under great strain. The teeth can wear. The periodontium (gums and the bone that supports the teeth) may become inflamed, and in combination with poor hygiene, periodontal disease may result. The TMJ is always placed under stress during bruxing, even if centric occlusion coincides with centric relation. See my page on TMJ for a full listing of the problems associated with bruxing.

If there is a substantial discrepancy between centric relation and centric occlusion, bruxing can cause serious long term damage to the TM Joint. This may include stretching of the ligaments that keep the disc in place causing a progressive anterior displacement of the disk forward of the head of the condyle, perforation of the thin area of the disc, tearing of the disc, or outright fragmentation of the articular disc apparatus into several small pieces which may seriously interfere with opening and closing.

Anterior disc displacement (What causes popping and jaw displacement when opening and closing?)

The lateral pterygoid muscle is attached to the condyle and is responsible for drawing the jaw forward when the right and left joints are equally active. It is also responsible for shifting the jaw to the right or left when only one of the two joints are active. For example, contraction of the right lateral pterygoid shifts the lower jaw to the left. During unconscious grinding, the lateral pterygoid muscles are extremely active.

As noted above, some of the fibers of the lateral pterygoid muscle are attached separately and directly to the anterior of the articular disc. Over time, constant bruxing can cause the disc ligaments to stretch displacing the meniscus anteriorly. When this happens, popping noises can be heard when the patient opens the mouth.

The popping is due to the noise the condyle makes if it moves under the anteriorly displaced meniscus. The popping is also associated with deviations in the lateral (side to side) movement of the jaw so the patient no longer experiences smooth opening and closing jaw movements. As the condition progresses, the popping and jaw movement deviation may be experienced by the patient as the jaw closes as well.

Whenever the condyle pops under the firm, elastic, rubber-like meniscus, the condyle is displaced downward and the jaw is displaced to the opposite side of the face. These lateral (side to side) jaw deviations can become quite complex if the disks on both sides are anteriorly displaced or otherwise damaged since the popping and displacement on either side generally happen at different points in the jaw opening movement.

It is likely that pain will NOT be experienced during any of this popping and displacement activity since cartilaginous structures do not have nerve endings. When pain IS experienced, it is generally due to capsulitis which means inflammation of the synovial capsule. When pain is not experienced by the patient, the dentist will generally strive only to treat the bruxing habit in order to arrest the progressive nature of this disorder. If pain is experienced by the patient due to internal joint derangements, the dentist generally combines the bruxing treatment with NSAID's (non steroidal anti inflammatory drugs).

The classification of joint derangements

Type IA--popping in the TM Joints without pain: very common: said to affect as much as 50% of normal subjects.

Type IB--popping in the TM Joints associated with pain.

Type II-- similar to type IB but patient experiences occasional jaw locking with the inability of the jaw to open or close beyond a certain point. The lock is caused by the displaced maniscus blocking the path of the condyle during translation. Both types of lock can generally be reduced by the patient with little difficulty.

Closed lock--associated with the inability of the condyle to slide under the displaced meniscus when the patient tries to open the mouth beyond a certain point

Open lock-- associated with the inability of the condyle to slide back under the meniscus when trying to close the mouth.

Type III--a persistent lock, usually on trying to open. Since the patient cannot open the mouth beyond this point, there is no popping. This condition (unlike all type I and II derangements) requires aggressive therapy with reduction of the lock under anesthesia and physical therapy. If no improvement is seen in three weeks, surgery is generally indicated.

Serious derangements of the TM Joints are sometimes treated by total joint replacement. Click the image below to be directed to a page with images of the surgery as well as before and after images of the results.






Other TM Joint disorders

Torn meniscus--This condition results in free movement of the anterior fragment of the meniscus which usually moves ahead of the condyle during translation due to the action of the lateral pterygoid muscle. The effect of this is generally more serious displacement of the mandible during opening or closing, as well as a higher probability of locks. It may also be the cause of the type III persistent locking noted above. This type of injury also allows the cartilage of both the head of the condyle and the glenoid fossa to come into forceful contact without the shock absorbing benefits of an intact meniscus.

damage to the cartilaginous coverings of the condyle and glenoid fossa--This can lead to severe bone-to bone contact with consequent wear of the bone in both structures. This results in grinding noises in the joint (called crepitus) and results in severe arthritis and sometimes even a fusing of the bones (called ankylosis) of the joint.

The temperomandibular joint is like any other major joint in the body. It is susceptible to any disease that can affect any other joint in the body. Thus osteoarthritis is often found in the TMJ in older persons, although it is generally symptomless. This joint can suffer traumatic damage which can lead to joint derangements or painful inflammatory changes in the capsule. It can also suffer dislocations which can lead to stretched ligaments and a tendency to recurrent dislocation.

Dislocation of the TM Joint involves the displacement of the condyle anterior to the articular eminence. This generally implies severe stretching of the joint ligaments and is one of the more severe effects of parafunction. Once the condyle slides anterior to the articular eminence, reduction is quite difficult owing to the spasm in virtually all of the muscles of mastication. Spasm in the masseter, temporalis and medial pterygoid muscles causes them to apply extreme upward force on the condylar head while spasm in the lateral pterygoid applies massive anterior force. These forces lock the condyle into its anteriorly displaced position making self reduction nearly impossible. A health professional may reduce the dislocation by placing his/her thumbs well distal and lateral to the lower second molars on either side (taking extreme care to position the thumbs well out of the way of the occlusion to avoid injury to his or her own fingers) and the remaining fingers under the body of the mandible. The trick is to press down hard with the thumbs while rotating the body of the mandible up so that the patient's mandible pivots around the thumbs.

Once a patient dislocates one or both condyles, the ligaments remain stretched out for a long time making further dislocations all too easy. Patients will frequently "test" whether their jaws will dislocate again, and find that it happens without too much effort. Patients should be cautioned not to try to test their jaw. The ligaments need about a year or sometimes more to heal before they become reasonably resistant to dislocation, and each time a patient tests out their jaw, the ligaments are further injured and healing is delayed again. A soft diet and a bruxing appliance are probably the best recommendations.

The muscles of mastication

The teeth could not occlude or disclude without the five (paired) muscles of mastication that make it all possible. The relationship between centric occlusion and centric relation obviously influences the way the muscles behave (the way the patient moves them during the course of a normal day). It is very important to note, however, that the reverse is also true. The use of the muscles may, over time, heavily influence the relationship between centric occlusion and centric relation. Just as important, the growth patterns of the structures in the joint, the occlusion itself, and the shape and length of the muscles of mastication all influence each other while the child grows. A majority of the pain and headaches patients experience with temperomandibular dysfunctions (TMD) comes from muscle splinting (cramps) in these powerful muscles.

The Temporalis muscle
The temporalis is one of three muscles that close the jaw and clench the teeth. It's origin is from the periosteum (covering of the bone) of the temporal fossa. It forms a thick tendon which passes under the zygomatic arch and inserts into the the medial surface (the inside surface) and the anterior border of the coronoid process. The way the muscle is leveraged gives it a great amount of power, and splinting in the temporalis can cause serious headaches.




The Masseter and the Medial Pterygoid muscles
The image on the right is of the masseter muscle. The medial pterygoid muscle is leveraged in the same way as the masseter, only on the medial (inside) surface of the mandible.

The masseter has an origin on both the outside and inside of the zygomatic process of the maxilla and the zygomatic arch. The masseter inserts into a broad part of the lower jaw, along the lateral surface of the coronoid process, the ramus and the angle of the mandible. This is also a powerfully leveraged muscle, and overuse of this muscle can produce a "square jaw" appearance to the face.

The medial pterygoid muscle arises from the medial (inside) surfaces of the lateral pterygoid plate which is attached to the undersurface of the temporal bone. In lay terms, the attachment is on the undersurface of the skull just behind the last upper tooth. The fibers of the medial pterygoid are directed downward and backward, just like the masseter (pictured above), only on the inside of the mandible. The insertion of this muscle is to the inside of the lower border and angle of the mandible. Click on the thumbnail to the left to see a large cutaway diagram of the medial pterygoid.

The masseter and medial pterygoid act like a contractile "hammock" in which the lower jaw rests. These two muscles are more or less "twins", the masseter acting on the outside of the lower jaw and the medial pterygoid on the inside.




The lateral pterygoid muscle
The lateral pterygoid muscle is an incredibly important muscle. It is responsible for drawing the jaw forward when both the right and left muscles are equally active. It is also responsible for moving the lower jaw from side to side when the right or left lateral pterygoid is active separately. Contraction of the right lateral pterygoid muscle moves the jaw to the left, and contraction of the left draws the jaw to the right. It is also responsible, in combination with the digastric muscle for opening the lower jaw during the translation phase of opening.

The image to the right shows the lateral pterygoid muscle partially obscured by the coronoid process and part of the zygomatic arch. Click on the thumbnail below to see a large cutaway diagram of the lateral pterygoid muscle. It is actually shaped a bit like a partly unfolded fan. The wide end of the fan, it's origin, originates from a small, finlike projection under the skull called the lateral pterygoid plate. The narrow end of the fan inserts into the anterior surface of the coronoid process. Using your imagination, you can see how contraction of this muscle draws the condyle--(and the lower jaw) forward.

This muscle is composed of two parts. The upper belly inserts into the articular disk inside the TMJ (as noted above). The lower belly inserts into the neck of the condyle. The two bellies may work independently, but usually in concert to keep the articular disk always situated between the closest points of contact between the condyle and the glenoid fossa during both the rotational phase of jaw opening and the translational phase.

Overuse of the lateral pterygoid during bruxism--remember that the lateral pterygoid is responsible for lateral movements of the lower jaw--causes stretching of the ligaments that hold the articular disk in place over the head of the condyle. This in turn can cause the two heads of the lateral pterygoid to begin to function out of sync which causes even more stretching of the ligaments. This causes the articular disc too much latitude and allows the disc to displace anteriorly. This further exacerbates the asynchronization of the two heads which causes further anterior displacement...and so on until the disc becomes traumatized. The huge forces placed on the condyle by the masseter, temporalis and the medial pterygoid during bruxing will "mash" the articular disc if it is improperly situated between the condyle and the glenoid fossa.

Overuse of the lateral pterygoid also causes cramps in the muscle which manifests as an earache. If the lateral pterygoid is sore, pain can be stimulated by sticking the fingers in the ear and pressing forward on the tragus.


The Digastric Muscle

The digastric muscle is the muscle most responsible for opening the lower jaw (in combination with the coordinated contraction of the lateral pterygoid muscles). It is actually composed of two muscles connected in the middle by a strong tendon. The tendon loops under the hyoid bone which is the only bone in the human body not directly connected to at least one other bone by ligaments.

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The hyoid bone is supported in the neck at the level of the adams apple by a large number of strap-like muscles, all of which brace each other using the hyoid bone as an anchor point.



The front half of the digastric is called the anterior belly. The half of the digastric behind the hyoid bone is called the posterior belly. The tendon that joins the two bellies actually slides under the bottom of the hyoid bone. I have highlighted the tendon in yellow in the illustration above.
The digastric's relatively small bulk, and leveraging under a bone not directly connected to the rest of the skeleton makes it quite a weak muscle when compared with the tremendous upward pressure that can be exerted on the jaws by the combined force of the temporalis, masseter and medial pterygoid which oppose it. This accounts for the inability of a patient to open his mouth against spasms of any of the three closing muscles. The inability to open the mouth is a condition called trismus.

The digastric muscle is rarely involved in disorders of the TMJ or the muscular syndromes associated with bruxing. You do not get TMD by keeping your jaw open, which is the major function of the digastric. You contract these disorders by overusing the other muscles of mastication.




The complex interactions of the joint, the occlusion, the muscles and facial appearance.

In the discussion above, we examined the way in which a poor occlusion, overactivity in the muscles of mastication and the lack of canine guidance can cause anatomical changes in the temperomandibular joint as well as wear on the teeth themselves. This image shows how serious the wear on the teeth can be. Wear on the teeth caused by bruxing is called attrition. As the teeth wear down over time, the lower jaw tends to protrude more and more as well. Prolonged, forceful bruxing can also cause tooth movement, especially if teeth have been extracted in the arch.

Bruxing can, over the years, set up a viscous circle involving changes in the the shape and position of the teeth, which in turn cause changes in the muscles of the muscles of mastication. People who chew or grind their teeth much more on one side than the other will tend to take on an asymmetrical facial appearance. The muscles on the side of the face in which the hyperactivity takes place tend to become larger and more bulky, while the muscles on the underutilized side tend to become atrophied.

As the muscles change in strength and length, the teeth wear unevenly on both sides causing more and more shifting in the position of the jaw's centric relation which causes more and more pathological changes in the anatomy of the TM Joints, more bruxing and more muscle deformation.

Popeye--An interesting case of muscle/joint/occlusion interaction.
Early in my career, I had to try to build a complete set of dentures for an old gentleman from the "old country". He had had his dentures (the same pair) since the age of 16, and he was now 76. Needless to say, his dentures were very seriously worn.

As a denture ages, the teeth wear and the bony ridges that support the denture recede causing the space between the nose and the tip of the chin to collapse. As this process continues, the back teeth of the upper and lower dentures no longer make contact, and the patient is forced to protrude his lower jaw to get them to contact without dislodging the dentures from the ridges (gums). This can cause quite a bizarre facial appearance over time, and of course it seriously affects the patient's ability to function. The most common effect on the wearing of the denture itself is the fact that the lower front teeth now protrude out well in front of the upper front teeth, often causing a lot of wear on the buccal (outside) surfaces of the upper front denture teeth.

In my patient's case, the change in his centric occlusion brought about by the combination of denture wear and loss of ridge height caused not only this protrusion of the lower jaw, but a very pronounced shift of the lower jaw to the patient's right. This caused what would ordinarily be the midlines of his upper and lower edentulous ridges (toothless gums) to be offset nearly a half inch. In addition, his nose and his chin were so close together due to loss of vertical dimension that his mouth had turned into something of a wide slit that seemed to go from ear to ear. He looked like Popeye the sailor without the squinty eye. (Actually, he did smoke a pipe which had worn a large notch in the front teeth of the denture and may have contributed to the shift in the lower jaw to the right. The notch coincided with the area where the upper and lower teeth crossed over into crossbite.) In any case, the dentures fit perfectly together in this position.

NO PROBLEMO! I can fix this! So I thought--remember it was early in my career. So I built him a nice looking upper denture with a lower denture which occluded in a perfect centric occlusion that coincided with a normal centric relation. The patient couldn't wear it. His lower jaw kept protruding and shifting to the right, back into the position his old denture had forced it into. Nothing I did could correct this condition. So I rebuilt the denture several more times and ended up with a new version of his old denture, complete with notch in the front teeth. The patient was happy, but his wife was not impressed.

Here's what had happened. The slow deterioration of the denture and ridge height caused a corresponding change in the shape and length of the muscles of mastication on both sides of the face. Since the back teeth no longer made contact when the patient closed his teeth together, he began to protrude his lower jaw farther out to get them to occlude. This protrusion caused further discrepancies in the ability of the back denture teeth to make contact, so the patient began to shift his lower jaw to the right to chew properly. Over the years, the muscles of mastication changed in shape and length to accommodate this unusual bite. The change in shape in the muscles was permanent and could not be reversed by a new, properly built denture. Even when forced to bite in centric relation with my first attempt at a denture, he retained a lopsided appearance with the right side of his face larger than the left. I don't know what his joints looked like, but I suspect that there was some anatomical change there (ligament stretching and maybe even some minor bony changes) to accommodate the changed centric occlusion. This patient seemed to suffer no major joint signs or symptoms other than his pronounced tendency to shift to the right on closing. Go figure!


Engrams

Pain in the joint due to disk displacement or other inflammatory changes will cause the patient to develop muscular engrams. Engrams are unconsciously memorized programmed muscle movements that happen on opening or closing the jaws. Their original purpose for the patient is to avoid placing the joint or muscle in a position which provokes pain or spasm. Thus patients will sometimes unconsciously cause their lower jaws to deviate to the right or left during particular points when opening or closing the jaws. These movements are not caused by mechanical interferences inside the joint as discussed above. They are simply reflexive memories that translate into unconscious behavior. This behavior can be quite complex with the jaw deviating right and left in complex, but completely reproducible patterns each time the patient opens or closes his mouth. Furthermore, the engramic behavior persists well after the pain that originally stimulated them has vanished. Upon occasion, engrams must be unlearned to promote healing. This is done by practice sitting in front of a mirror trying to open or close without deviation, or exercises opening against resistance such as upward pressure placed against the chin by the heel of the hand.

extractions

Extractions



Due to the extent of the subject matter, the extraction page has been divided into 6 separate pages. This section can be read in its entirety simply by clicking the "next page" link at the bottom of each page.

Index

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Reasons to extract teeth
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Types of extractions
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simple extractions
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Complex extractions
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Impacted teeth
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Can an abscess kill you?
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Ludwig's angina
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Cavernous sinus thrombosis

Page 2

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Wisdom teeth
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Pericoronitis
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The relationship of the wisdom teeth to the sinuses
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At what age should wisdom teeth be extracted
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Amyloblastoma

Page 3

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What to do after an extraction

Page 4

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Complications after extraction
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Bleeding
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Infection
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Dry Socket
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Broken Jaw
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Sinus perforation
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Sequestrii (broken pieces of bone that come out of the socket after weeks after the extraction and are mistaken for pieces of tooth.)
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Retained roots (Pieces of tooth left in the bone after the extraction)

Page 4a

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Osteonecrosis (avascular necrosis of the jawbone)
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Osteoradio-necrosis
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Bisphosphonate related osteonecrosis of the jaw (BRONJ, or sometimes called BON) (from drugs like Actonel, Boniva and Fosamax)

Page 5

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Do all extracted teeth have to be replaced?

Page 6

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Can I pull my own tooth?

Why dentists extract teeth

Dentists extract teeth for many reasons, but by far, the most common is that the patient is in pain and wants to relieve the pain as quickly, permanently and as inexpensively as possible. This does not mean that there are not other ways of relieving the pain. But the other methods are likely to be more expensive or inconvenient. Other reasons are:



1.

The patient may choose extraction because the other alternatives are simply too expensive.
2.

The dentist may decide that the tooth is not repairable, or may be impractical to repair under the circumstances, and extraction is the best of a bunch of bad alternatives. This includes teeth that are decayed below the gum line, or teeth that have lost too much bone due to periodontal disease.
3.

Removal of the tooth may be a matter of health. This is the case in the decision to remove impacted wisdom teeth, teeth associated with cysts or tumors, or teeth that would otherwise compromise the patient's oral health if left in place. In some instances, an infected tooth can even bring a patient close to death by causing swelling that can stop breathing or initiating a brain abscess.
4.

Teeth are frequently removed because they are crowded and their removal would create a situation which could be repaired in their absence. Orthodontists request extractions to give them more room to move teeth around. Dentists sometimes remove crowded front teeth and replace them with bridges, removable partial dentures or implants.


This x-ray shows a dark crescent in the root toward the right side of the film. This is decay, and it has reached the nerve, which is labeled with the lower arrow. Decay in this position cannot be filled without touching and killing the nerve necessitating a root canal which is an expensive procedure. Furthermore, the tooth has severe bone loss from periodontal disease. Thus the most expedient thing to do was to extract it.


The tooth above was extracted because of gum disease. The dark material on the root is not decay. It is calculus (hardened plaque) which built up on the root because the bone has been reabsorbed by the body below that point. If the bone had been surrounding the root as it would in the healthy state, plaque could never have reached this far down on the root surface. This tooth was loose because, as the x-ray shows, only the very tip was held in place by bone. Click on the left-hand image above for more information about the root of a tooth extracted because of gum disease.

The types of extractions

1. Simple extractions

A Simple extraction is one in which the dentist can remove the tooth simply by loosening the gums around it, grasping the crown above the gum line with a plier-like forceps and then moving it side to side until it loosens from the bone. Teeth are normally held into the bone by a thin sheathe of soft tissue that separates it from the bone like a sock separates a foot from a shoe. This sheathe is called the periodontal ligament, and it is this structure which ultimately enables the dentist to remove the tooth. The key to simple extractions is to rock the tooth side to side slowly enlarging the socket in the bone while at the same time breaking the ligament which binds the tooth in the socket.

2. Complex (surgical) extractions

Unfortunately, not all extractions can be done by simply grasping the tooth with forceps and rocking it out. What if there is nothing left above the gum line to grasp? Or what if the crown breaks off leaving the roots still in the bone? These things can and do happen, and any dentist that extracts teeth will have to deal with them routinely. In these cases, it becomes necessary to surgically remove the tooth. This is frequently accomplished by prying the root out using a sharp instrument that can be forced between the root and the bone surrounding it. This technique is called "luxation". In the case of multiple rooted teeth, the roots are first separated so they can be removed individually. Unfortunately, not all roots or root fragments may be removed in this fashion. This means that the dentist must make an incision into the gums around the tooth and raise a flap of tissue exposing the tooth and its surrounding bone.

Sometimes, after the flap is raised, there is enough tooth exposed to grab and remove it as in a simple extraction (#1 above). Sometimes, the technique described above as luxation may successfully remove the tooth. If luxation fails, the dentist must take a handpiece (drill) and cut away some of the surrounding bone in order to gain a purchase on the tooth. After the tooth has been pried out of the artificially enlarged socket, the dentist then sutures (sews) the flap of tissue back in place so that healing can proceed normally.

3. Impacted teeth

When a tooth does not fully erupt into the mouth, but remains below the gums, it is said to be impacted. Impacted teeth can present special health problems for most patients, and they are generally removed to prevent future difficulties. The extraction of such teeth proceeds like the surgical extraction explained above with a few modifications. Sometimes, the only surgical procedure is the raising of the soft tissue flap. If after raising the flap, the extraction can proceed as a simple extraction, the tooth is said to be a "tissue impaction" because there was enough of the crown left above the bone to grab and extract with forceps.
But many times the crown is submerged below the level of the bone. The tooth may even be lying on its side under the bone which complicates the extraction further. In these cases, not only must the dentist remove surrounding bone in order to expose the tooth, but he must cut and break the tooth itself into sections so that each section can be removed separately. Teeth in this condition are said to be "bony impactions" and are further classified as vertical, horizontal or angular depending on the angle of the tooth under the bone.



Can an abscessed tooth kill you?

Ludwig's angina

A bacterial infection any place in the body causes a localized inflammatory reaction. Inflammation is characterized by four things: swelling, pain, heat and redness. An abscess is an inflammatory reaction surrounding a localized pocket of pus. When a localized inflammatory reaction happens in most areas of the body, it is not generally immediately life threatening, however when it happens in the lower jaw, the resulting swelling can place increasing amounts of pressure on the internal structures of the floor of the mouth, throat, and neck. This includes the trachea (windpipe). If the swelling becomes too severe, the trachea can become so severely constricted that the patient is unable to breathe, and may consequently die. Prior to 1942 when penicillin was first marketed (it was discovered in 1928, but not available to the public until 1942), this was a very common cause of death in persons of all ages. In 1836, a doctor named Wilhelm Frederick von Ludwig was the first to describe this condition as a scientific entity, and it was named Ludwig's angina in his honor. The term angina comes from the Greek word "ankhon", and means "strangling".

Cavernous Sinus Thrombosis

Upon occasion, especially in the case of an untreated abscess of an upper front tooth, the patient can get a brain abscess which can kill him. This brain infection is called cavernous sinus thrombosis. Click the image to the left to see my page explaining the mechanics of cavernous sinus thrombosis and its relationship to the "dangerous triangle".

extractions

Complications after extractions of teeth
Bleeding from the extraction socket
Infections
Dry socket
Broken jaw
Sinus perforation
Sequestrii
Retained root tips
Osteonecrosis of the jaw (bone-death at site of extractions)
Osteoradio-necrosis (Osteonecrosis related to radiation therapy)
Bisphosphonate related osteonecrosis of the jaw (BRONJ)

1. Bleeding

It is possible to bleed to death following the extraction of a tooth. But it almost never happens. All you have to do is follow directions #1 and #2 on the post-op instruction page and the bleeding will stop. The only patients that may still be in danger from excessive bleeding are those who are taking anticoagulant drugs (blood thinners) like Coumadin or Heparin for cardiovascular problems, or people with bleeding disorders like Hemophilia or related clotting cascade disorders . These patients should consult their physicians before having a tooth extracted. People taking aspirin and other non steroidal anti inflammatory drugs (NSAID's) like Advil or Aleve may experience prolonged bleeding times, but in my experience, these drugs have never presented a problem as long as the patient keeps the extraction site covered with gauze to stem the bleeding. The blood WILL clot eventually!

2. Infection

The mouth is alive with bacteria, especially in people with poor oral hygiene. Infection is a constant problem after extractions, and most dentists have developed a personal protocol on whether or not a particular patient needs preventive antibiotics. People who present at the office with swollen faces, teeth tender to light pressure, swollen gums or tongue, or bleeding and pus around a tooth are generally already infected. They should expect to be given prophylactic (preventive) antibiotics after an extraction.

Patients may develop infections after an extraction even if they were not infected before the extraction. This is a common complication and is due to the fact that that the mouth is teeming with bacteria and cannot be sterilized prior to the extraction. (They are NOT due to any error on the part of the dentist!) The first sign of an infection after an extraction is often renewed bleeding after 48 hours. The bleeding is not generally severe, but it is an indication that the patient should return to the dentist's office for evaluation and possibly a prescription for antibiotics. Other signs of infection include renewed swelling around the extraction site and surrounding parts of the face, as well as increased pain after 48 hours. Signs of infection two days after an extraction should be attended to as soon as possible. Click here to see how severe tooth related infections can become.

Some dentists will give a patient an antibiotic and send them home for several days to allow the infection to clear before attempting the extraction. The reason for this is because the local anesthesia does not work as well in acid environments and it may take a lot of shots to get the patient numb. However, if the dentist gives enough anesthesia, it is possible to extract a tooth under such circumstances. In general, I have never found that extraction of a tooth in the presence of an active infection has presented special problems as long as the patient takes the antibiotics prescribed faithfully.

It is NOT necessary to take antibiotics after every extraction. A simple extraction in a clean, uninfected mouth generally does not require prophylactic antibiotics.

Whenever the extraction requires the cutting of any tissue (see surgical and impacted extractions above), it is generally a good idea to give prophylactic antibiotics, and the patient SHOULD fill the prescription and take the drug faithfully, or he may suffer an extended convalescence.

3. Dry Sockets

A dry socket, while not potentially life threatening like bleeding or infections, is one of the most painful, common, debilitating and dreaded post extraction problems encountered in dentistry. Patients often state that they felt fine for a day or two after the extraction, but then the extraction site began to become painful. They may also say they have a bad taste in their mouth. Dry sockets are much more common following the extraction of lower teeth than they are after extraction of upper teeth. They can happen after even the simplest of extractions. If you get a dry socket, it is not (necessarily) your fault. Nor is it the fault of the dentist. They are a quirk of nature. You may THINK you are going to die. You won't!

Patients who are more likely to get a dry socket are those who smoke during the first 48 hours after the extraction, women on birth control pills, and persons who tend to constantly grind and clench their teeth (see my page on TMJ)

What is a dry socket?

A dry socket is a condition in which the blood clot that forms in the extraction site becomes detached from the walls of the socket, or dissolves away leaving the bare bone exposed to saliva and the foods you eat. The bone becomes inflamed due to bacteria and contaminants in the saliva, and this inflammation is persistent and painful. The socket begins to emanate a bad odor. The pain is "deep pain". That is, it comes from tissues buried deep in the body, and your brain has no experience of pain from these regions. When the brain receives pain signals through these unusual channels, it is unsure of the exact location of the pain, so it tells you that the pain is coming from areas on that side of your face and head that are far removed from the actual source. Pain like this is called referred pain. It seems to shoot up the side of the head, or makes your eye ache.

Can a dry socket be prevented?

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Studies have shown that in-office pre-operative and post-operative rinsing with 0.12% chlorhexidine (Peridex) reduces the incidence of dry sockets. It is a good idea for the patient to be given a prescription for a bottle of chlorhexidine to be used for rinsing three times a day for several days starting 24 hours after the extraction.
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Removing third molars within the ideal window of time when the roots are 1/2 to 2/3 developed, about age 17 for boys and 16 for girls, reduces the likelihood of dry socket.
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Treating the socket immediately post-operatively with a small amount of tetracycline on a piece of Gelfoam has been shown to reduce the likelihood of dry socket.
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Patient should maintain good oral hygiene and follow post-op instructions.

How are dry sockets treated?

Left alone, dry sockets will always heal. It may take a month or more, and the pain is persistent for the entire period of healing. Antibiotics are not useful in curing a dry socket, and the usual pain medications are not very effective. It is better to go back to the dentist who extracted the tooth and let him or her "pack" the socket. This is a procedure done (usually) without anesthesia even though it can be painful. It does not take too long, and the pain relief is almost complete, beginning a few minutes after the socket is packed. The first packing will provide relief for 12 to 24 hours. As you return to the dentist and the old packing is removed, the socket is washed out and a new packing is placed. Each succeeding packing debrides (cleans) the socket and renews the pain relief. A second packing may last 24 to 48 hours, and succeeding packings last longer still. Within three packings, or sometimes more depending on the severity of the dry socket, the wound begins to heal from the bottom up and can be left empty to heal without pain.

4. Broken Jaws

Yes, it does occasionally happen. The fracture of a lower jaw is unusual, principally because dentists who extract teeth routinely do not place great force on any instrument to remove a tooth. Teeth are generally "finessed out" with a minimum of pressure applied to the jaw through the surgical instruments. There are, however, some situations in which a dentist can look at the x-ray and see that the jawbone that surrounds the tooth is much more fragile than is usually the case, and will usually warn the patient that fracture of the jaw is a possibility. People are not like cars, every one identical. Everyone is unique and presents unique circumstances under which the dentist must labor. The chances that the removal of any given tooth will result in a fractured lower jaw run about the same for any dentist who attempts the extraction. That particular patient is usually more prone than other people to a broken jaw due to any traumatic incident such as a traffic accident or a blow to the jaw during a sporting event. Unfortunate, but true, and a fact of life for any dentist who extracts teeth.

5. Sinus perforation

The image to the right is a detail from a panoramic film. The roots of the upper back teeth are always in close approximation to the maxillary sinus. Since everyone is built differently, The roots of the teeth may actually appear to be inside the sinus. There is always a thin wall of bone between the root and the sinus, but is can be very thin indeed. Most of the time, the bone remains intact, but upon occasion, a piece of the bone separating the root from the sinus may break off and be removed with the tooth. This creates a direct connection between the sinus and the mouth! That means that you would be unable to suck on a straw, because air would rush into your mouth from your nose through the socket.

Sometimes a sinus perforation will go unnoticed by the dentist or the patient. If the perforation is small, the only symptom could be a nosebleed. If this happens, call the dentist so he can prescribe the proper drugs so that healing can proceed normally

When a sinus perforation occurs, the dentist will prescribe an antibiotic to prevent infection and a decongestant to keep the sinuses clear during healing. The patient bites on his gauze as is usual after any extraction, and a clot will form in the socket as usual. If nothing disturbs the clot, it will organize during healing and close the perforation. Dry sockets rarely happen after extraction of upper teeth unless the patient smokes.



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It is IMPERATIVE, however that the patient do NOTHING that could disturb the clot.
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Do not suck on anything for at least a week. This puts pressure on the clot and could dislodge it into the mouth.
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Do not smoke...the longer you wait the better. This will dissolve the clot, or could even suck it out of the socket.
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Do not blow up balloons or anything else. This puts pressure on the clot and could dislodge it into the sinus.
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Avoid sneezing. This explosive event will definitely dislodge the clot.

In the case of very large perforations, or in case the clot dislodges and a perforation between the sinus and the mouth remains after healing, It may be necessary to perform a further surgical procedure in order to draw a flap of gum tissue over the perforation to close it permanently.

6. Sequestrii (Broken bone fragments that come out weeks after the extraction, but are often mistaken for pieces of tooth.)

Extraction of a tooth requires that the bone surrounding it be expanded, or sometimes even fractured to allow the tooth to slip out of the socket. Most of the time, these fractures are of the type known as "greenstick" fractures which means they are only partial fractures immediately around the top of the socket leaving the bone fragments still attached to the main body of the bony structure beneath. In some instances, these greenstick fractures coalesce to release a bone fragment completely from the underlying bony structure. Even when this happens, the bone fragments tend to heal and reattach to the main body of the bone during healing.

In the oral cavity, however, the presence of oral bacteria, as well as noxious chemicals from the foods we eat and cigarettes we smoke can cause the healing to cease. This is what causes dry sockets. Bony fragments that do not heal properly often loose their blood supply and become "necrotic" (dead tissue). Thus, the body begins the process of ejecting them from the healing socket, a process known as sequestration. The process can be painful, and sometimes requires the dentist to reenter the socket to remove the sequestrum. When the sequestrum comes out on its own, the patient often mistakes this piece of bone for a piece of tooth that the dentist left in the socket.

Sequestrii are a normal complication of extractions. They are often unavoidable, and undetectable at the time of the extraction. They are not considered to be a mistake the dentist made. Once the sequestrum is gone, the healing resumes, the pain subsides and all is well.

7. Retained roots (Pieces of tooth left in the bone by the dentist)

A large majority of teeth are removed in one piece when they are extracted by the dentist. However, many do break leaving one or more fragments of varying size in the bone. Most of the time, these root fragments are easily "luxated" using a sharp instrument which is forced down between the root and the surrounding bone. On rare occasions, the root fragment may be too firmly attached to the bone (ankylosis), at too odd an angle, or too close to a vital structure like the sinuses or mandibular nerve to remove in this manner. In most instances, it is NOT essential to remove every root fragment that is left in the bone!! Retained root tips will generally simply heal in place and never cause a problem to the patient after healing. When confronted with this situation the dentist must weigh the relative benefits of removal of the root tip versus the complications that the removal will cause the patient. Often, the removal of the offending root fragment necessitates quite a bit of drilling of bone and heavy duty prying, not to mention quite a bit of time. This always results in a much greater degree of pain for the patient during healing. It also increases the likelihood of a dry socket, which is a painful result that most people would rather do without. On the other hand, leaving the root tip in place causes no further difficulties to the patient most of the time.

8. Osteonecrosis of the jawbone

Osteonecrosis of the jawbone (ONJ) is a disease resulting from the temporary or permanent loss of the blood supply to the bone. Without a blood supply, the bone dies (the term "osteo" means "bone"; the term "necrosis" means "death"). When this happens, the dead bone becomes exposed to the oral environment. Exposed necrotic bone is not an uncommon complication after extractions of teeth, even in healthy patients who have never had radiation therapy or bisphphonate drug therapy. Simple cases involve only the bone immediately surrounding the extraction socket, and usually, the necrotic bone will heal over spontaneously with time. Unfortunately, more serious cases of ONJ happen to people who are taking bisphosphonates for osteoporosis or as part of a chemotherapeutic regime for some forms of cancer. Serious ONJ also happens to patients who have had radiation therapy to the head or neck for the treatment of cancers. Since the subject is so complex, I have given this subject its own page.

extractions

Osteonecrosis of the jawbone (ONJ) is a disease resulting from the temporary or permanent loss of the blood supply to the bone. Without a blood supply, the bone dies (the term "osteo" means "bone"; the term "necrosis" means "death"). When this happens, the dead bone becomes exposed to the oral environment. Exposed necrotic bone is not an uncommon complication after extractions of teeth, even in healthy patients who have never had radiation therapy or bisphphonate drug therapy. Simple cases involve only the bone immediately surrounding the extraction socket, and usually, the necrotic bone will heal over spontaneously with time.

Serious ONJ is extremely rare in dentistry, and it tends to happen only to patients who have known predisposing factors such as radiation therapy for cancers of the head and neck or IV bisphosphonate drug therapy for metastasizing cancers or osteoporosis. Osteonecrosis of the jaw generally happens in susceptible patients after a dental extraction or periodontal osseous surgery. It may also happen after a fall or an auto accident in which the jawbone is broken. It can even happen under an ill fitting denture. The presence of exposed necrotic bone in the oral cavity may cause the patient pain, but surprisingly, it is often asymptomatic, possibly because the necrotic bone acts like a dressing over the vital bone and allows healing to take place underneath it.

There is no specific treatment for osteonecrosis of the jaw other than treatments aimed at preventing infection and controlling pain if present. More advanced cases may require conservative debridement of necrotic bone. Many cases of osteonecrosis will heal over time. Some (very few) never heal.

Other terms for osteonecrosis are avascular necrosis, aseptic necrosis and ischemic bone necrosis. There are two named types of osteonecrosis in dentistry: Osteoradio-necrosis (radiation associated bone death), and Bisphosphonate Related OsteoNecrosis of the Jaw (BRONJ).

Osteoradio-necrosis is the name given to necrosis of a portion of the jawbone in a patient who has received extensive radiation therapy for the treatment of cancers in the head and neck. Radiation affects rapidly growing cells, and the cells in the endothelial lining of blood vessels are especially vulnerable to damage from large amounts of radiation. High doses of radiation result in a cumulative progressive endarteritis (inflammation of the inner lining of the arteries) which eventually leads to the destruction of the smaller arteries in the bone. Dense bone, like that found in the lower jaw is not especially well vascularized to begin with, and therapeutic amounts of radiation (far in excess of the radiation used to take normal diagnostic dental x-rays) reduces the blood flow further making normal healing of the bone difficult.

Patients who have had extensive cancer related radiation therapy to their head or neck should be sure to tell their dentist about this and avoid having teeth extracted. This often means doing root canals on teeth that are otherwise hopelessly decayed and non restorable. Patients who have had this type of radiation therapy should be especially careful to avoid excessive sugar intake and be meticulous about their oral hygiene.

Osteoradio-necrosis is NOT associated with diagnostic x-rays like the ones your dentist takes periodically to examine your teeth.

Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ)

Bisphosphonates are therapeutic agents used to treat diseases that feature bone fragility. These diseases include osteoporosis, Paget's disease of bone, multiple myeloma and certain cancers in which metastases are a feature, especially breast cancer. Bisphosphonates inhibit osteoclast activity thus inhibiting the resorption of bone. This will make the bone more dense, but also less vascularized and less able to remodel after injuries.

Necrotic bone exposed to the oral environment for at least eight weeks in a patient that has been treated with any of the bisphosphonates is called Bisphosphonate Related OsteoNecrosis of the Jaw, or BRONJ for short. Some authorities refer to it as BON which stands for Bisphosphonate OsteoNecrosis. BRONJ can be a complication after extractions, periodontal surgery involving bone recontouring or facial trauma from any source. It can also occur spontaneously in susceptible patients. BRONJ can occur in the upper or lower jaw, however the incidence in the lower jaw is twice as high as in the upper. BRONJ may also follow less traumatic injuries such as chronic denture sores.

There is no specific treatment for Bisphosphonate Related OsteoNecrosis of the Jaw other than treatments aimed at preventing infection and controlling pain if present. More advanced cases may require conservative debridement of necrotic bone. I am unable to find any reference to patients actually dying as a direct result of BRONJ, although patients being treated with IV bisphosphonates for metastasizing cancers or multiple myeloma may die of an accumulation of the side effects of their treatment modalities which may include very serious BRONJ. In patients taking low doses of oral bisphosphonates for osteoporosis (such as Actonel, Boniva, or Fosamax), spontaneous healing is actually quite a frequent occurrence.

Oral bisphosphonates

Most people are familiar with the names of several of the oral drugs used to treat osteoporosis, since the companies that manufacture them do a lot of advertising.
Brand Name

Manufacturer
Generic Name
Actonel Procter & Gamble Pharmaceuticals risedronate
Boniva Roche Laboratories ibandronate
Fosamax Merck & Co. alendronate
Fosamax Plus D Merck & Co. alendronate
Skelid Sanofi Pharmaceuticals tiludronate
Didronel Procter & Gamble Pharmaceuticals etidronate

Patients taking oral bisphosphonates such as the ones listed above, have a very low risk of developing BRONJ. These patients seem to have less severe manifestations of necrosis which respond more readily to stage specific treatment regimens. Dentists should inform patients that they have a small chance of contracting osteonecrosis, however dentoalveolar surgery does not appear to be contraindicated in this group. The actual incidence of BRONJ in the total population of patients who take oral bisphosphonates is approximately 0.7 cases per 100,000 patients per year. The risk of BRONJ is especially low if the patient has been taking the bisphosphonate for less than three years and has no other complicating factors. These complicating factors include:

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Diabetes
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Concurrent steroid use
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Smoking
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Poor oral hygiene, especially in patients with periodontal disease
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Therapeutic head and neck radiation
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The concurrent administration of other chemotherapeutic agents.

Question: Does the risk for BRONJ decrease if the patient stops taking the oral bisphosphonate for several months before having their extraction?

Answer: There is no hard data proving that there is a benefit to halting oral bisphosphonate medication, even for several months prior to the surgical procedure. Evidence suggests that the drug remains in the bony structure more or less permanently. The half life of bisphosphonates in bone is about 10 years. Even so, drug holidays are still recommended for patients who have been taking their drug for over three years.

The rule of thumb seems to be that no delay in surgery is necessary for patients who have been taking oral bisphosphonates for less than three years unless they have one or more of the above complicating factors. If the patient has been taking bisphosphonates for more than three years or has complicating factors, a three month drug holiday is advised prior to surgery with the holiday extending until bony healing is complete (usually about three months post-op). Click here for the reference.

Question: Does the length of time a patient has been taking an oral bisphosphonate affect the probability that the patient will contract BRONJ?

Answer: Yes! The general consensus is that the probability of contracting bisphosphonate related osteonecrosis of the jaw as a result of dental osseous surgeries during the first three years of oral drug therapy is substantially less than for those patients who have been taking the drug for more than three years. Patients and dentists should strive to produce a state of oral health during the first three years of bisphosphonate therapy to reduce the likelihood of BRONJ later.

Question: Is a patient taking oral bisphosphonates likely to develop BRONJ after implant placement?

Answer: Implants have been known to fail in patients taking oral bisphosphonates. However studies of patients on oral bisphosphonates receiving implants indicate a very low risk of either implant loss or BRONJ following implant placement, especially if the patient has been taking the drug for less than three years.

IV bisphosphonates

While patients taking oral bisphosphonates show a very low risk of BRONJ, patients taking IV (injection) bisphosphonates are at significant risk of developing BRONJ after extractions or other surgical interventions involving the manipulation of bone (incidence is 0.8-12%). IV bisphosphonates are generally used as part of a chemotherapeutic regimen for the treatment of cancer. The most commonly used IV bisphosphonates are:
Brand Name Manufacturer Generic Name
Aredia Novartis pamidronate
Zometa Novartis zolendronic acid
Bonefos Schering AG clodronate

Any patient who has been treated with IV bisphosphonates should follow these guidelines:

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Avoid extractions unless the teeth are very mobile.
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Choose root canals rather than extractions whenever possible.
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Have extremely good oral hygiene and regular dental care.
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Be especially careful to keep your dentures in good repair to avoid chronic sore spots. Patients are advised to have relines every 2 years and get new dentures every five to seven years. (Click here to see why.)
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Before the prescription of bisphosphonates for bone disease the patient should be made dentally fit so that the need for subsequent dental extractions is minimized.

Staging and treatment for ONJ patients Click here for the reference.

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Stage 1: Exposed/necrotic bone in patients who are asymptomatic and have no evidence of infection.
o

Treatment of stage 1: These patients benefit from the use of oral antimicrobial rinses, such as chlorhexidine 0.12%. No surgical treatment is indicated. Patients who present with Stage 1 disease have done well with this type of conservative treatment.
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Stage 2: Exposed/necrotic bone in patients with pain and clinical evidence of infection.
o

Treatment of stage 2: These patients benefit from the use of oral antimicrobial rinses (chlorhexidine) in combination with antibiotic therapy. Penicillin is the drug of choice, with clindamycin used if the patient is allergic to penicillin.
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Stage 3: Exposed/necrotic bone in patients with pain, infection, and one or more of the following: pathologic fracture, extra-oral fistula, or osteolysis extending to the inferior border.
o

Treatment of stage 3: These patients typically have pain that impacts the quality of life. Surgical debridement/resection in combination with antibacterial mouth rinses (chlorhexidine) and antibiotic therapy may offer long-term palliation with resolution of acute infection and pain.

extractions

Do ALL extracted teeth HAVE to be replaced?

The short answer is NO! The removal of any tooth has consequences, some of which are important enough to cause you to seriously consider replacing that tooth with a removable or fixed alternative. If it's one of your top front teeth, then esthetic considerations will probably cause you to want to replace it. But even then, if you don't care about how you look, leaving the space will not kill you. The x-ray below shows what happens to the adjacent teeth if a first molar is extracted when a patient is very young. There IS tilting of the teeth and a small collapse of the occlusion, but it is not especially obvious when you look at the teeth in the mouth.

I am going to guess that at least a third of my adult patients have lost back teeth in the past and have never had them replaced. A vast majority suffer no major problems eating, speaking or esthetically (The way they look). On the other hand, a few, especially some women, tend to develop the joint problems, headaches, neck aches or ear aches typical of TMJ. If they use a lot of sugar, they are more prone to ectopic decay (explained below). In addition, many of these people who later want to repair the damage caused by the loss of the tooth find that repair is much more expensive because of the movement in the adjacent and opposing teeth.

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The removal of any tooth will always cause destabilization of the remaining teeth and over a period of years, every tooth in your mouth will move in response to its loss, at least a little. The amount of movement depends upon several factors:
o

Your age: The younger you are when the tooth is removed, the more quickly and severely the rest of your teeth will move in response.
o

The position of the tooth in the mouth: The loss of any back tooth (the canine tooth and behind) will have a greater effect on the movement of the remaining teeth than the loss of a front tooth. The removal of the last tooth in the arch will not effect the position of any tooth in front of it. It may, however allow hypereruption ("extrusion") of the tooth above or below the missing tooth if that tooth does not make contact with a tooth in the opposite arch. Finally, the majority of the movement in the remaining teeth happens on the same side as the missing tooth. Teeth on the oposite side of the dental arch are effected, but not nearly as much.
o

Bruxing (grinding or clenching the teeth): If you brux your teeth, then the movement is more severe and happens more quickly than if you do not brux.

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The image to the right shows the effect of the removal of a lower first molar.

Note that the tooth behind the space has leaned forward into the space vacated by the extracted first molar. This movement tilts the biting surface of that tooth downward and therefore allows the tooth directly above the space (the top first molar) to begin to extrude down. Because of the way this tooth is shaped, the downward movement of the top first molar opens up some space between itself and the teeth on either side of it. This newly created space allows the adjacent teeth to move and tilt as well causing a discrepancy in the curvature of the arch form. The image on the left shows a fairly typical situation in which a upper first molar was removed, probably before the age of twelve. The upper second molar has tilted forward closing the space vacated by the extracted first molar. At the same time, the misaligned biting surface on the second molar has caused a similar discrepancy in the position of the lower second molar. Less apparent in this image is the decrease in "vertical dimension" (the space between the top and the bottom jaws) on that side. This produces a misalignment in the position of the ball joint of the lower jaw leading, in some cases to TemporoMandibular dysfunction.

The early loss of back teeth has five consequences:


1.

It stimulates bruxing which leads to TMJ.


2.

It tends to "collapse the occlusion" ( decreases the vertical dimension) which means that the Jaw on that side must close a bit further in order to get the teeth to touch. This pushes the ball joint of the jaw further into its socket causing injury to structures within the joint.


3.

The tilted angles of the biting surfaces means that biting forces are no longer parallel with the long axis of the tooth (straight up and down the root of the tooth. This puts extra pressure on the bone which supports the tooth and tends to cause loss of the bone. This is a localized form of gum disease that over a period of years may ultimately lead to the loss of the tilted teeth.



4.

The tilted and extruded position of the teeth place the contacts between these teeth and the adjacent teeth in unusual positions. The contact between the teeth is the place where decay is most likely to occur because it is a place where plaque tends to build up. Decay in unusual positions on the teeth is called "ectopic caries", and it is generally quite difficult to repair without striking the nerve. When this happens, it becomes necessary either to extract the tooth or to perform a root canal procedure in order to avoid a toothache.


5.

It makes it more difficult and expensive to replace the missing tooth later due to the poor position of the surrounding and opposing teeth.


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Note that the loss of a back tooth, even if there are more teeth behind the space, does not always lead to the leaning and extrusion of the remaining teeth. If all of the teeth adjacent to the extracted tooth, as well as all teeth in the opposite arch make firm, stable contact with teeth in the opposing arch, and as long as at least half of the occlusal table (the top, chewing surface) is in stable contact with teeth in the opposing arch, then there is little likelihood of major tooth movement. This is especially true if the patient does not tend to have bruxing (grinding and clenching) habits.

extractions

Can I pull my own tooth?

Don't laugh. People really do try! In general, the answer to this question is NO! There are only two situations when it is even possible for a person to extract his/her own tooth.

1.

The first situation is a loose baby tooth, and even then it is usually a good idea to check on the general age when that particular baby tooth is supposed to get loose. (This coincides with the general time when the adult tooth will erupt.) If you try to pull a "loose" baby tooth and it turns out that it is only abscessed, then you could have a real disaster on your hands to include a very sick and unhappy child. (See explanation beside the image below.)
2.

The second situation is when an older patient has had severe gum disease for a long time (most of these people are well over the age of 45), and the tooth is is extremely loose (very wobbly) because the gum disease has caused the loss of almost all of the bone that used to surround the tooth. In the latter case, even touching the tooth can be extremely painful and attempting to yank on it will be much worse (not to mention bloody). Even then, if you misjudge the amount of bone remaining around the tip of the root, you may only succeed in breaking the top off the tooth.

Just because a tooth feels loose, it doesn't mean that it will be easy to pull out with a pair of pliers. The image to the right shows an x-ray of two teeth, one of which has an abscess. The gray frothy material that surrounds the roots of the teeth is the patient's jawbone. The top of the bone is denoted by the blue arrows. If a tooth has an abscess like the one on the molar, it may not only be painful to touch, but it may be be slightly mobile (loose). The looseness is caused by the swelling of the ligament that surrounds the root of the tooth. (The ligament is like a very sheer sock. The inside of the sock is attached to the root of the tooth, and the outside of the sock is attached to the bone.) You can see that the length of the roots that are embedded in the bone is very great, and even if the tooth feels a bit wobbly, it is not likely to pull out of the bone, even if you give a great, fast yank. The top is more likely to break off leaving the roots (and the abscess) still in place, and you will end up having to go to the dentist anyways in order to have them removed surgically. (Note: Dentists don't actually "pull" teeth out. They rock the tooth slowly side to side until the bone surrounding it expands and the ligament breaks allowing it to slide out. Click here for more on how dentists remove teeth.)

Finally, if you attempt to remove the tooth and fail in the attempt, the infection that has caused all the pain is likely to spread and cause a massive problem that could put you in the hospital.

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reline

After a new denture has been inserted, it ought to retain in the mouth quite nicely due to the fact that the shape of the inside of the denture base conforms closely to the shape of the gums. (Please note that good retention (suction) of the denture does not necessarily mean that the same denture is stable. For a good explanation of the difference between these two characteristics please click here.)


Unfortunately, the longer you wear the denture, the more your gums change underneath it, and the looser it gets. In order to restore the retentive qualities of the denture, and to prevent the production of flabby gum tissue under it, you should have the denture professionally relined at least every two years.

There are actually three types of denture relines: Hard, Soft and Temporary.

Hard reline

This is the kind of reline that should be done on all full dentures every two years. The dentist removes some of the plastic from the inside of the denture, and then fills the denture with a soft material (think of soft putty) which, when replaced in the mouth, conforms to the contours of the tissues, and then hardens to a rubbery consistency. When the denture is removed, the denture now contains an accurate impression of the shape of the gums. The denture is sent to the lab, and the impression material is replaced with pink, hard acrylic in exactly the same shape as the original impression material. When returned, the denture now conforms to the contours of your mouth and should make maximum contact with the tissues producing maximum suction. In our office, the impression is scheduled for first thing in the morning. The patient goes home without the denture, but returns later the same day (usually early afternoon) for the insert (fitting appointment).

Soft reline

Occasionally, a patient finds that he cannot wear the denture because his gums are too tender, and he keeps getting sore spots. In cases where the patient is unable to wear ordinary dentures because of tender gums, the denture can be relined with a material that remains somewhat pliable for a year or two before it needs replacement. The consistency of this material can range from waxy to hard rubber, and is generally less likely to give the patient sore spots than ordinary pink acrylic.

Unfortunately, by the time that a patient resorts to a soft reline material to make the denture wearable, it usually means that factors other than simple sore spots are partly to blame for the difficulties that the patient is experiencing wearing the dentures. These could include an overbuilt denture or a resorbed ridge which is so unstable that the patient must keep constant force on the teeth to keep them in place. Both of these conditions can be corrected, sometimes with less expensive simple surgery or sometimes with much more expensive implant retained dentures.

Temporary relines (Therapeutic relines)

Frequently, by the time a patient with an old denture finally shows up at the dentist's office looking for a new denture, the dentures have not been serviced for such a long time that the gums are in terrible condition. They may be red, swollen and quite misshapen. Relining the old denture, or building a new one using impressions taken while the gums are in such poor condition would lead to a denture that would simply perpetuate the problem with the new appliance.

When faced with situations like this, a dentist will frequently resort to a temporary, or palliative (medicated) reline material to allow the inflammation to subside. This reline makes the denture fit much more tightly, and is usually soft and pliable. It will not last more than a few months, but the patient wears it for a few weeks until the gums return to a more normal state. After this happens, then the patient is ready for his new denture or hard reline.

Cleaning your dentures

It is not wise not wear your dentures all day long without giving your gums at least two hours per day to recuperate. If you do, it causes rapid loss of the underlying bony support and its replacement with soft flabby tissue which causes your denture to become unstable. (This is a serious issue and you should read about it here.) Leaving them out overnight is the best plan.

You also need to clean and deodorize your dentures at least once a day to avoid serious denture breath (ask the grandkids). Leaving your dentures out overnight and getting into a routine of denture hygiene is the best plan. You can soak them in a commercial denture cleaner, but you can really do a better job and keep them fresher by following these directions:

Brush the dentures thoroughly with a soft brush and plain dish detergent. Never use toothpaste or an abrasive powder. Denture teeth are made out of multiple layers of different colored acrylic to make them look more natural, and scrubbing them with abrasive powders like Comet or Babbo or using hard abrasive brushes will remove layers of the plastic making them look dead and eventually turning them into flat blocks of plastic. Plain dish detergent will work as well as any other cleaner.

Soak them overnight in a dilute solution of laundry bleach. A tablespoon of bleach in 6-8 ounces of water is more than strong enough to remove stains, disinfect and thoroughly deodorize them. Just rinse them off in the morning with copious water before inserting them in your mouth. If you keep them in a covered container, you only need to change the solution once a week. You will be quite surprised at how much better they smell throughout the day.

mini implants

In order to better understand how mini implants work, it will be helpful to read about the history and current status of standard dental implants. Mini implants have been in use since about 1970 (click here to see a case actually placed in 1970), but were not considered "permanent" implanted devices until April 1999 when they were cleared by the Food and Drug Administration.

The term "permanent" is not accurate concerning any medical or dental device, since nothing in medicine or dentistry can be guaranteed to last forever. The term "long term" is more accurate and truthful when referring to any dental appliance.

Since the FDA approved the MDI mini implant as a long term method of denture stabilization, mini implants have become increasingly popular among dentists. They are also used for supporting crowns in situations in which there is not enough room for a standard implant. The cost of a mini dental implant is generally on the order of one quarter to one third the cost of a standard dental rootform implant. (Note: MDI mini implants have also been accepted for transitional and long term use by Health Canada in Ottawa 11/9/04.)

Mini implants are 1.8 mm in diameter and come in 4 lengths. The length chosen by the surgeon is determined by the amount of bone available to retain the implant, as well as an assessment of the density of the bone. Very dense cortical bone may be better served with a shorter implant. Generally, four mini implants are placed in the anterior portion of the lower jaw. A second type of mini implant is called a Max and is 1.6 mm in diameter. Max's come in three lengths and are generally used in cases in which the bone density is low. This is most generally the case in the stabilization of upper dentures.

Unlike standard implants, mini implants allow immediate loading. This means that the patient walks out of the office on the day of surgery with a lower denture which is not only solidly stable, but can be used to eat immediately. Mini implants can often (not always) be placed in the lower jaw without cutting an incision in the gums. in other words, they can often be placed right through the gums directly into the underlying bone. Most of the time, the only anesthetic necessary is an injection directly over the position in the gums where each implant is to be placed. The old lower denture can then be retrofitted over the newly placed implants, and the patient can use the denture immediately without waiting for the three to six months necessary for a standard implant to integrate. Furthermore, because the implants are about the size of a standard wooden toothpick (they are made out of a titanium alloy), patients who have been told that there is not enough bone to accommodate standard implants can generally be fitted with minis. The entire procedure (placing the implants and retrofitting the old denture so that it is supported by the newly placed minis) takes about 90 minutes. It is generally painless, and produces very minimal post operative discomfort.

Patients can be fitted with these implants and begin using the newly stabilized denture immediately because these implants do not require months of waiting time to integrate. The implants are "screwed" firmly into the bone so integration is immediate (although further integration on a microscopic level has been shown to take place for months after the initial placement of the implant. Finally, since the procedure generally involves no major incisions, there are very few contra-indications to the surgery.

The decision about the need for making an incision before placing mini implants, and the subsequent need for sutures (stitches) after the implants are placed is made on a case by case basis. The major factor is the shape of the remaining bony ridge as determined by x-ray.
If a patient has been without lower front teeth for a very long time (decades), the bone at the top of the ridge may be quite sharp. Consequently, the pilot drill used to prepare the bone to receive the implant may slip off the top of the ridge when the hole is started.

To avoid this problem and to allow the implant to integrate into bone along its maximum length, the dentist makes an incision along the ridge, from about where the canine tooth used to be on one side to the canine position on the other side. This allows the dentist to visualize the bone, and to flatten the sharp ridge slightly in order to drill the pilot holes in precise positions.

The use of an incision does NOT preclude the immediate loading of the implants after the procedure, and the patient leaves the office wearing their denture.


The only medical conditions that absolutely preclude the placement of these implants are the following:

Uncontrolled diabetes
A history of radiation treatment to the jaws (generally for cancer)--this does not include diagnostic x-rays

Immuno-suppressed patient

Substance abuse

Factors which place the prognosis for these implants in doubt include the following: Note that these factors do not necessarily preclude the use of mini implant retained dentures. However patients who exhibit these traits are more likely to suffer complications and possible failure of one or more of the implants.

Heavy smoking and/or drinking

Sjorgren's syndrome

Alzheimer's disease (these patients may be unable to insert and remove the dentures after the implants are placed)

People who clench their teeth.

Young persons who are still growing

Even people with heart disease, high blood pressure, or other serious medical conditions usually have no difficulties retaining mini implants. Old age is NOT a factor! Persons taking anticoagulants like coumadin and wafarin need to stop taking their medication several days before the procedure only if the dentist determines that an incision will be necessary in order to place the implants. The surgery is very short (about 90 minutes) and very little bleeding occurs. Furthermore, there is generally very little post operative discomfort. Tylenol, Advil, or Aleve for the first twelve hours after surgery are often sufficient. If an incision is used, the dentist may prescribe a narcotic for the first twelve hours after the surgery. If no incision is used, many people require no pain medication at all.

Patients on immunosuppressive therapies such as methotrexate for rheumatoid arthritis may be successful with mini implants if the dose of the immunosuppressant is low, and the patient is able to take a drug holiday for at least a week before the implants are inserted and a week afterwards. Always check with your physician before doing this.

Oral bisphosphonates (for osteoporosis or Pagets disease of bone--drugs like Actonel, Boniva and Fosamax) are not considered a contraindication for implants. While implants have been known to fail in patients taking oral bisphosphonates, studies indicate a very low risk of either implant loss or BRONJ (Bisphonate Related OsteoNecrosis of the Jaw) following implant placement. This is especially true if the patient has been taking the drug for less than three years and has no other complicating factors. If the patient has been taking their bisphosphonate for more than three years, some authorities recommend a two to three month drug holiday before the implants are placed, extending to about a month post-op.

What is involved?

The first visit is a general "meet and greet" during which the doctor gets the necessary information from the patient and explains to the patient what to expect. In some offices, this visit is a free consult. At a subsequent visit, the dentist will generally take two x-rays; a panorex and a lateral jaw film to assess the amount of bone available, and to determine which size implant is appropriate for the case. Many offices will charge for the x-rays, but apply the fee to the final cost of the case when it is completed. In a very few instances, we find cases in which the amount or quality of bone is not suitable even for mini implants. The old denture is assessed for suitability to receive housings with o-rings. These housings remain permanently in the denture and will engage the implants. If the denture is not suitable to receive housings, or the patient has decided to have a new one made after the implants are placed, the dentist will simply reline the old denture with soft reline material. The soft reline material engages the denture nearly as well as the housings, but should be changed every six months. If the patient is a suitable candidate, he/she is given all the information necessary in order to decide if he/she really wants to go through with the procedure, and then the patient is asked to sign an informed consent document.

The surgery

The following describes the most common type of mini implant surgery; one in which the ridge is reasonably wide and no incision is needed. note that all implants are placed in the anterior of the ridge, about where the six front teeth used to be located. Mini implants cannot be placed along the back part of the ridge where the molars used to be because in those locations, there is a large nerve trunk which might be injured if an implant was placed there.

On the day of Surgery, the dentist will determine the correct position for each of (generally) four implants and then marks the position for each on the ridge with an indelible marker. Anesthesia is injected into the gums directly over the spots he/she made on the gums. Then the dentist begins to drill right through the gums into the bone using a 1.1 mm pilot drill in a slow speed handpiece.



After drilling the pilot hole, The dentist then begins the procedure for inserting the implant through the gums into the drilled hole. He begins by carefully aligning the implant with the original pilot hole and slowly twisting it with a finger wrench until the resistance becomes too great to continue easily. Then the dentist switches to a thumb wrench. The thumb wrench is slowly twisted until the implant is fully seated with the ball and about 1.5 mm of the shank remaining above the gums. (In the images here, a special retraction device retracts the tongue, lips and cheek so the field is kept clear and dry.)



If too much resistance to twisting the implant is met, the dentist may switch to using a specially designed ratchet wrench to finish the insertion.



The finished case looks like the images below. This is the same case viewed head on, and again, from above, using a mirror. These images were taken immediately post op. Note the lack of bleeding.



The post operative x-ray of this case looks like the image below. Note that the implants do not necessarily have to be perfectly parallel to one another.



Retrofitting the lower denture.

In order to retrofit the denture so that it snaps onto the newly placed implants, the old denture is modified so that there is a hollow in the underside corresponding to the general position of the implants.





At this point, there are two ways to engage the implants in the denture. The first way is simply to fill the hollow in the base of the denture with a soft reline material. This material engages the implants fairly firmly, but allows some movement. It transmits less biting force to the implants and may be the best solution in cases in which patients smoke or clench their teeth, or in which there are other factors that may interfere with the final integration of the implants.
The soft reline material must be replaced periodically, but the procedure is easy and relatively inexpensive. Some dentists prefer using this method on all their patients for the first three to six months after initial placement of the implants to allow the best environment for healing, before proceeding to the long term option which is placing housings with o-rings in the denture for a more positive snap fit (see below).

The implants and the retrofit are generally billed separately, so the total cost to the patient of the soft reline option is considerably less than the total cost with permanent housings in the denture. Some patients prefer to continue indefinitely with a series of soft relines rather than placing housings since the soft material is very comfortable against the gums and new relines once or twice a year will keep the denture base so well adapted to the gums that food rarely ever gets under the denture.




The second way to retain the denture over the implants is to place a specially designed housing with a rubber o-ring over each implant. The dentist may use this option on the day of surgery when the implants are first placed, or he/she may remove the soft reline material that was placed at the time of surgery and place the housings in the denture at a later date. These housings will be transferred to the hollow that was made in the bottom of the denture in the step immediately above.



At this point, the dentist tries the denture into the mouth to see if it fits over the implants with their housings without interfering with the original fit of the denture. He keeps grinding out the hollow in the denture until the lower denture fits over the implants without changing the bite of the lower denture teeth against the upper denture. When he is satisfied that the upper and lower dentures meet in the mouth in the same relationship as they did before surgery without touching any of the implants, the dentist fills the hollow in the bottom of the denture with self curing (hard) plastic and fits the lower denture back over the implants with their housings. The patient is instructed to bite down on the dentures while the plastic pick-up material sets. Once the pickup plastic is set and finished, the lower denture looks like the image below. At this point the lower denture should snap into position over the implants.



A note about the quality of the existing denture

If the dentures are old and do not occlude (fit together) properly, it is very often advisable to have at least the lower denture either remade, relined or rebased prior to the placement of the implants. A rebase is the complete replacement of the pink plastic base of the denture with new plastic. This makes perfect sense because a firmly retained lower denture that does not fit properly with the upper denture will dislodge it and make the upper denture unwearable. Furthermore, if the lower denture has been repeatedly repaired, or the teeth keep falling out, then the modifications necessary to allow the same lower denture to engage the implants will weaken it further and make it even more prone to breakage in the future. If the dentures are much over seven years old, the patient should consider having a new set made either prior to the placement of the implants, or shortly thereafter.

Frequently asked questions

Q. How long do mini implants last?A. No one can guarantee how long any implant will last since so many of the factors that determine the longevity of these devices are patient specific. Some minis done in the mid 1970's are still in function. Mini implants have been in common usage only since about the year 2000, after approval for long term use by the FDA. The vast majority of MDI minis placed since that time are still functioning well. A small percentage of implants will fail for various reasons. A failed mini implant is easily removed, and healing is generally complete. Another implant can usually be placed adjacent to the site of the failed implant immediately, or after waiting for three months, directly into the position formerly occupied by the failed implant.


The series of x-rays above shows the forerunner to the current version of the MDI mini implant. This one was placed in the lower jaw to replace a missing lower incisor in 1970. At the time it was placed, the dentist was not sure if the implant would stand on its own, so the implant tooth was splinted to the tooth next to it to stabilize it just in case the implant failed. As you can see, the opposite happened. The tooth that was supposed to stabilize it was eventually lost to gum disease, but the mini implant survived quite nicely. The last film on the right was taken in 1989 and shows that the implant has more bony support than the remaining natural tooth to the left. (That tooth has a root canal, and a second (tiny) mini implant was placed beside the original mini.) To learn more about reading dental x-rays, click here.




Q. I have heard of cases in which an implant will break while the dentist is inserting it. What happens then?

A. Upon rare occasions, a mini implant will break while the dentist is placing it. Considerable force is placed on the implant during the process of insertion. This is considered a "normal" complication, and since the implant is made of titanium and will actively integrate with the bone, there is no good reason to retrieve the broken piece. Most dentists simply remove any of the broken implant that remains above the boneline and then proceed to place another implant adjacent to the broken one.

Q. What if the patient smokes or drinks heavily?

A. Patients who smoke are MUCH more likely to experience implant failure. Smoking seems to affect the circulation of blood which is, of course, a factor in healing. Heavy drinking and other substance abuse negatively affects a patient's nutrition and general health. Some high functioning alcoholics have been successful with dental implants, but substance abuse is generally a contra-indication for placing any type of implant.

Q. Why does clenching or grinding on a denture increase the likelihood of implant failure?

A. Unlike natural teeth, implants are solidly attached to the bone without an intervening ligament. This means that implants do not have a natural "shock absorber" to reduce the effect of the constant forces that grinding and clenching will transmit to them. Clenching and grinding can place literally tons of pressure on the bone/implant interface. Bone is not well vascularized (ie. it does not have a lot of blood vessels to nourish and heal it in case of injury). The constant "shocks" experienced at the bone/implant interface due to clenching and grinding cause micro fractures and crushing of bone at the interface and these will subsequently cause the body to recognize the implant as a foreign invader. Thus the body mounts an inflammatory response, which means that it begins to replace the bone surrounding the implant with soft tissue containing lots of blood vessels in order to "reject" the implant.

People who habitually grind or clench their teeth may still be able to retain implants, but they would do better to avoid the housings with the o-rings, and remain with the soft reline option mentioned above.

Q. My mother is nearly 90 but still quite bright and active. She is frustrated because she can't eat with her lower denture. Are mini implants a good alternative for her, or is she too old?

A. Age or physical condition are not usually factors regarding the success of mini implants. Your mother is probably a candidate for minis. The short surgery, low cost and minimal post-op discomfort, as well as the ability to function against the new implants immediately, make this form of therapy ideal even for seniors with numerous physical ailments. The only common age related factors that may interfere with these cases are dementia and severe osteoporosis. Severe osteoporosis may affect the bone density and reduce the likelihood that the implants will be successfully retained. Dementia makes it difficult or impossible for the patient to cooperate during surgery, and may make it difficult for the patient to insert or remove the denture after surgery.

Q. Can a mini implant fracture or break while I am eating?

A. MDI minis are made of a special alloy of titanium (Ti6A14Va) rather than the CP titanium used in conventional implants. The use of this alloy has virtually eliminated the likelihood of fracture of these implants during normal functioning. The clinical trials of these implants prove that they can take a lot of abuse before fracturing.

Q. How can I find a doctor who will place mini implants and retrofit my denture?

A. The Imtec corporation which manufactures the MDI mini implant system and all related instruments for their placement also offers seminars, courses and mini residencies to dentists who wish to become involved with this service. The company keeps a list of doctors who have had official education in the process. You can find a doctor (the database is worldwide) by going to their site, clicking on your language, and clicking on the link "Locate a doctor" which is located in the second toolbar near the top of the page. Use the "advanced search" option to enter your state or city

full dentures

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Should I have my teeth pulled and get full dentures?
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I make quite a few full dentures. I do this mostly in cases where people come in with an old one that needs to be replaced. There are also cases in which people present with teeth in such bad condition that there is literally no other affordable alternative. However, many young people come to my office with numerous teeth that have what they believe are nonrepairable cavities, or they may not like the appearance of their teeth because they are crooked. They expect the denture will be a simple way to correct all their problems.


Many of these people have avoided going to the dentist because they are afraid of what the dentist will think, or afraid of what will happen to them once they get there. Let me make four things very clear.

1. We see people with very bad teeth ALL THE TIME. At least half of all our patients come to the dentist the first time only because they are in so much pain that they can't stand it anymore! They become good dental patients only because of their first few bad toothaches. You are not alone in having this problem!

2. Your fear of the pain is WAY out of proportion to the actual pain you will feel when we work on you. Do you remember how big your dad and mom looked to you when you were a child? When you finally grew up, they didn't look so big anymore. Your memory of the pain involved in seeing a dentist is like that too. Once you actually see it with grown up eyes, it doesn't look so big and bad anymore. Many of our very best regular patients started out just like you. They sometimes come in just to say hi even when they don't have a problem because the staff is friendly, and the atmosphere makes them feel comfortable.

3. Full dentures are a last resort! If you are used to having even diseased or ugly teeth, you cannot even imagine how disappointed you may be with full dentures. Dentures are, in fact, a sort of myth made of plastic! (Read on and you will see why.) I've been making them since 1978. I've seen it all!

4. You do not naturally lose your teeth when you get old. This is a picture of a 73 year old man who simply brushed daily and used toothpicks to clean between his teeth all his life. He didn't eat much sugar except when he was very young (which accounts for the one visible filling you see on the upper left back tooth). With a little care, anyone can keep their teeth all their life!

Click here to read an exchange of emails between me and a patient who got a denture and found she could not wear it. These situations happen all the time and can be downright tragic.

Things you mother never told you--(about her false teeth)!

1. Having full dentures is like having fake hands. They may look like real hands, but try holding a pen to write your name with them. False teeth are not real teeth. People with them can barely chew their food, You can put just 15% of the pressure on false teeth as you normally use to chew your food, before they lose the suction that keeps the top one in your mouth. The lower ones have no suction at all and they just sit there by virtue of their own weight, and the ability of the tongue to help them stay put. Many people find lower dentures so cumbersome that even if the top ones are reasonably successful, they do not wear the lowers except when they go out in public.

2. As soon as the natural teeth are removed, the face begins to age rapidly. When new dentures are inserted for the first time, your facial appearance remains the same...at first .... But as soon as you walk out the door, the bone that held your original natural teeth begins the process of resorbtion (disappearing) which begins the process of collapsing your facial appearance.

Note: It is helpful to see the severe bone loss that can eventually happen after the teeth are extracted. Compare the panoramic x-ray of a normal mouth (seen on the x-ray page ) with that of a person who has been without teeth (edentulous) for a number of years (on the implant page) and notice the amount of bone that nature can remove if the teeth are extracted at an early age.

Dentures accelerate the aging process of your face because the distance between your nose and your chin begins to decrease as soon as the natural teeth are extracted. The bone that used to hold your top natural teeth begins to retreat up toward your nose, and the bone that held the lower natural teeth "goes south", allowing both the top and bottom false teeth to ride with them in the same directions. Within a few months, your face ages several years. As a result, the denture teeth eventually begin to disappear under your lips while the lips themselves begin to flatten out. This process continues for the rest of your life.






The image on the left above shows the facial appearance of a 48 year old woman who had her teeth removed at the age of 28. Unfortunately, she kept her same denture the full 20 years. This allowed the distance between her nose and her chin to collapse (this distance is called the vertical dimension). Note the flattening or "sinking" of the lips. As the lips flatten, they begin to develop little vertical wrinkles called ragades, or perioral Lines (marked in blue on the diagram on the right). The diagonal lines marked in yellow are called the labiomental folds. These tend to become more pronounced as the lips, no longer supported by lower teeth and gums collapse inward, and the vertical dimension diminishes. The lips begin to blend into the labiomental folds bringing about the illusion that the lips are a great deal longer from right to left than they really are. The combination of sunken lips and pronounced labiomental fold give the mouth the appearance of a horizontal slit rather than the full lipped appearance of a person with natural teeth. In some people, the diagonal lines from the corner of the nose to the corners of the lips, called the nasolabial folds (marked in red) become much more pronounced after the loss of the teeth adding to the appearance of rapid aging.

The edentulous (toothless) woman shown above is 48 years old. Compare her with this 53 year old woman who has retained all her natural teeth. The fullness of the lips and the lack of ragades are due to the steady presence of the natural teeth throughout her life. The nasolabial folds become apparent mostly when she smiles. The Labiomental folds are not apparent, due to the presence of the lower teeth (and their supporting structures) which support the lower lip to keep it from sinking inward. While this patient is chronologically older than the patient above, she looks physically younger because she kept her natural teeth.

3. A denture is NOT forever. As dentists, we can help prevent some of the facial aging if (and only if) you return every 2 years for a reline, and every 5 to 7 years to get new dentures. If you don't wait too long, we can usually build new dentures with "longer teeth" (actually extra pink plastic that replaces the gums). We can also place the teeth somewhat further forward to fill out your lips a bit. However if you wait too long, the muscles that let you chew your food begin to shorten to accommodate the reduced space between your nose and chin (vertical dimension), and you will not be able to tolerate the increase in length of the teeth that would be necessary to restore your original vertical dimension. This is nature talking, not the dentist who will do his best to accommodate your wishes.



A denture worn too long can really do damage to the facial appearance. Long term wear of an old denture can force huge changes in the muscles of the face which affect not only facial appearance, but functional changes in the way the patient uses the jaws. Click here to read about my patient Popeye. His story comes at the end of a page written primarily for dentists, dental students and other dental professionals. The rest of the page is full of technical data on occlusion, the study of the relationship between the position of the teeth, the muscles of mastication and the corresponding position of the jaw joints. But for readers with endurance, it will provide some insight into the secret lives of dentists and just how complex the profession really is.

4. Dentures must be relined every two years. This means that new plastic must be added to the inside of your existing denture in order to fill spaces between the denture and the gums left vacant by the receding bone. Relines do NOT restore vertical dimension, but they do keep the denture tight and stable. If you fail to reline the denture the consequences are not good.

As the bone recedes and more and more space becomes vacant inside the denture, most people will begin wearing stiff denture adhesives to maintain the dentures in their mouths. They tend not to notice that the teeth move around more and more while chewing food. When a denture retains suction, but beings to move around over the bony ridge that supports it, we say the denture has good RETENTION, but lacks STABILITY. When the hard denture base is in close approximation to the bone that supports it, the denture has maximum stability, but as the distance increases, no matter what type of goo you put under it, the teeth become less and less stable and are much more easily dislodged by chewing food.

People tend to get used to this, and they plan to get new dentures--someday--when the problem becomes so serious that they can not eat properly. But if they have waited more than two years to reline the denture, something unfortunate happens to the tissue that supports the denture. Nature begins to build more gums between the bone and the denture to take up the slack. At first this sounds good, but the gum tissue that nature builds after the real teeth are gone is soft and flabby. It's like a layer of Jell-O. Yes, Jell-O will stick to a wall--it has great retention, but it won't support any weight (it has no stability). Likewise, the flabby new gum tissue that forms because of an ill fitting denture will not support a stable denture. (The image to the right shows an example of a very common form of flabby, redundant tissue that forms under an ill fitting denture. It looks like little pebbles on the roof of the mouth. This type of overgrowth is called papillary hyperplasia. It is permanent until it is surgically removed. Of more practical importance to the denture's stability are the thick layers of flabby tissue that form over the U shaped bony ridge, which is the area most responsible for supporting the denture during chewing.)

When we try to build a new denture over this flabby tissue, it will have the same stability problems as the old one unless the patient goes to an oral surgeon to have it removed before the new denture is made.

If you need to use more than a touch of denture adhesive to retain your denture, then you need a reline. I have seen some very odd things used to take up extra space inside an old denture. Some patients use layers of tissue paper. One patient actually presented to their dental office with a neatly trimmed slice of bologna as a makeshift "denture liner". Using anything other than denture adhesive is a bad idea because the denture breath gets pretty ripe!

5. If you are a "gagger" (and have avoided seeing dentists to avoid gagging), you can be sure that the new denture will cause you to gag too. Probably the saddest group of people we see in this profession are those people who hate dentists because they tend to gag when anyone (including a dentist) puts something in their mouths. These people have it in the back of their mind that they can just wait until their teeth get so bad that a dentist will just put them to sleep, remove the teeth and they will wake up with false teeth and live happily ever after.

Actually, the first part of the dream can come true. It is expensive, but you can get your teeth pulled under general anesthesia and have an immediate denture inserted. It's the "happily ever after" that doesn't pan out. Gaggers tend to go toothless a lot because the presence of the denture in their mouths makes them feel like throwing up all the time. They avoid eating at other people's houses, and will wear their dentures only when absolutely necessary. The only hope these people have is if they can afford full mouth implants.

What are the affordable alternatives to having all the teeth removed?

1. Missing and hopeless teeth can be replaced without extracting the good teeth. They can be replaced using Removable partial dentures. Partial dentures are much more comfortable and stable than full dentures. They do not have to cover the entire roof of your mouth for stability because they are held in by the remaining natural teeth. Even the presence of a few natural teeth remaining on either side of the dental arch can make it possible to wear a partial denture instead of full dentures. The presence of any number of real teeth can reduce (though not completely eliminate) the accelerated aging process associated with full dentures.



This man has only 4 teeth, but his all-plastic partial is as stable as a rock! The clasps are made of plastic and are visible under my fingers.


2. Even if you are unhappy with the appearance of your front teeth, it is possible to replace only the front ones with a partial denture. If you have two front teeth that are very crooked, it is possible to remove only these and replace them with a partial or bridge and avoid removing all the other teeth.

Having said this, there are always people who really DO need to have all their teeth extracted and have dentures made. These include people with all their teeth so badly decayed that they would all require root canals and crowns which can become extremely expensive, and not every patient can afford this. They include people with terminal gum disease which has caused the teeth to become loose or to change their positions so badly that repair again becomes too expensive, or likely to fail after a short while. They also include people who have been to dentists for years trying to save their teeth, but have finally given up and are just plain tired of all the bother their teeth have caused them. No matter who you are, they are your teeth, and you have a right to have them removed if you have ultimately made up your mind to do so. If this applies to you, I have prepared an entire page on the different types of dentures, and the steps involved in making them.



Click here to read an exchange of emails between me and a patient who got a denture and found she could not wear it. These situations happen all the time and can be downright tragic.



The different types of full dentures

bleaching

Does bleaching really work?

Exactly what gets bleached?

Is Bleaching the teeth safe?

Tooth Sensitivity

What Bleaching can NOT do.

The different forms of tooth bleaching and their effectiveness

Whitening toothpastes

High concentration bleach in custom made trays

Crest White Strips

In Office Bleaching

Use of Lights and lasers

How we make custom bleaching trays

Are Over-The-Counter bleaching kits effective?

Why did dentists resist bleaching for such a long time?

Does bleaching the teeth really work? In a word, YES! It has been done in one form or another for the last 100 years, and it has proven itself to be safe and effective. The current popularity of the bleaching process goes back only about 10 years, catching on with the public fairly quickly, and with dentists much more slowly over that time. The reasons that dentists have been less quick to endorse the process are very interesting, and not what you would expect. I will cover this aspect later in this piece, but first, you need to know a bit more about the process itself.

Exactly what gets bleached during the bleaching process?

The diagram to the right shows the internal structure of a natural tooth. The layer you can see directly in the mouth is the enamel layer which is the only portion of the tooth that should lie above the gums. The natural color of enamel is white, but it is translucent and the color of the other structures that underlie it tend to show through. The material immediately under the enamel is called dentin. It's normal color is yellow, but its structure is porous, and materials from the nerve can permeate it causing it to darken to a brownish yellow as we get older. The color we see when we look at a tooth in the mouth is a composite of the colors of the enamel which may permanently stain as we get older, and the underlying dentin which darkens over the years due to its close association with the underlying nerve.

This is the reason that simply brushing the teeth will not prevent the teeth from becoming darker yellow as we get older. You can brush all day, but you will not be able to brush away the natural internal color scheme.

Enter bleach! Root canal treated teeth tend to be dark because the dead nerve which prompted the root canal treatment turns a chocolate brown and permeates the surrounding dentin before the dead material is removed during the root canal procedure. It was discovered about 100 years ago that these teeth could be lightened up substantially by temporarily sealing up a cotton pellet soaked with oxalic acid inside the access hole in the crown of the root canal treated tooth. The cotton pellet was removed after several days and the access was sealed with a filling. Hydrogen peroxide may have been used to lighten teeth as early as 1884. In 1917, the process was speeded up using hydrogen peroxide and a heat lamp. This is still the basic procedure used in some offices today.

Later, it was discovered that even dark vital teeth (teeth with live nerves) could be bleached by soaking the tooth in 30% hydrogen peroxide. This stuff is 10 times more concentrated than the type you can buy in the drugstore, and in order to use it safely, the dentist had to isolate the dark tooth with a rubber dam. The peroxide could penetrate through the enamel into the dentin and bleach out the dark color.

Finally, about 20 years ago, it was discovered that a 10-percent carbamide peroxide solution could be applied to the teeth safely without fear of burning or otherwise damaging the mouth, or poisoning the patient. This dilute solution of peroxide, if kept in contact with the teeth long enough bleached the teeth to a brighter color. The longer the contact, the brighter the teeth got (up to a point.....sooner or later, there's no color left to bleach out.).

Is bleaching safe?

Most dentists now offer bleaching as an esthetic treatment for their patients. The American Dental Association has published the following statement:

"Dentist-prescribed, home-applied bleaching made by a reputable manufacturer and used under the supervision of a dentist in a relatively short-term treatment duration is safe and recognized as most effective in lightening the color of teeth. Bleaching materials that have received the ADA Seal of Acceptance are recommended.

Mild thermal sensitivity [sensitivity to cold] is a common side effect associated with most in-office and dentist-prescribed home bleaching methods. However, no long term irreversible tissue effects have been demonstrated in relevant clinical studies."

Peer reviewed studies have found no irreversible side effects from bleaching with 10 % carbamide peroxide.

Tooth Sensitivity

Bleaching solutions do cause your teeth to become temporarily sensitive. In order to permanently bleach the teeth, the solution must penetrate through the enamel to reach the underlying dentin. (Click here to see a schematic diagram of the anatomy inside a tooth.) The dentin contains microscopic tubules which allow the flow of cellular fluids between the living nerve in the center of the tooth and the outer layer of enamel. This is the reason that the teeth become sensitive. It would be logical to assume that this process can't be too good for the health of the nerve, however, over the course of the years that these bleaching products have been used, no ill effects have been reported. The sensitivity goes away within a few days of terminating the bleaching treatments, and the nerves in the teeth suffer no permanent damage. The sensitivity, while temporary, in rare cases may be severe and has been known to force some patients to terminate the bleaching treatment early.

What bleaching can't do

Bleaching will not bleach out the black, brown or white color imparted to teeth due to decay. Teeth should be repaired before bleaching is performed.

Bleaching will not bleach out darkness imparted to teeth by old amalgam fillings. Removing the old metal filling and replacing it with a new composite will usually accomplish this, but if the tarnish has penetrated deeply into the tooth structure, the tooth may remain permanently discolored.

Bleaching will not generally improve the appearance of fluorosis if the patient grew up in a part of the country (before the 1960's) that had a high concentration of fluoride in the drinking water. This problem is also prevalent in patients who "ate" a lot of fluoride toothpaste when they were toddlers.

Bleaching is ineffective in reducing the irregular gray horizontal lines seen on patients with tetracycline stain in their tooth structure. Tetracycline stain is seen primarily in older patients who received tetracycline to treat ear infections when they were infants and toddlers. Physicians in those days did not know that this drug would incorporate itself into the developing teeth of children causing this deformity.

The different forms of dental bleaching

Whitening toothpastes: These are over-the-counter preparations that have a low concentration of carbamide peroxide. These toothpastes will work to brighten your teeth if you are a very good brusher, brush many times a day, and have a lot of patience. In the years since these toothpastes have been on the market, I have seen only one person who achieved real results using whitening toothpaste only. They are very useful, however in maintaining the whitening achieved by using trays and strips.



Bleach releasing disposable strips (Crest Strips): These are strips of plastic designed so that they will adhere to the teeth. They are applied and worn for several hours like the trays described above. The carbamide concentration in home bleaching strips is only 7% to 14% while professionally prescribed take-home bleaches come in either 22% or 32%. Thus it takes a lot longer to get the same results using over the counter bleaching strips than it does using professionally prescribed bleaching solutions in trays. The main advantages to the strips is that no impressions need to be taken to make trays, and the strips do not apply pressure to the teeth which may increase the sensitivity of the bleaching process. A number of my patients have tried them. Some have had good results. Others have had little or no improvement. The major problems I have heard about with the strips is that they do not adhere very well to lower teeth, and they are too short to bleach all the upper teeth that show when the patient smiles.



Professionally supervised take-home bleaching with custom made trays: This type of system is available only through your dentist. The bleaching material can only be bought with a prescription and must be applied using the custom trays that the dentist or his hygienist makes for you. The agent is carbamide peroxide and it comes in concentrations between 10% to 35% with 15% being the most popular for professional take-home bleaching. Because of the high concentration of the agent, and the close approximation with the teeth made possible by the trays, this system produces very good results in anywhere from several hours to several weeks of regular use. A drop of agent is placed in each tooth indent and the trays are placed in the mouth for 30 minutes to an hour maximum. The carbamide peroxide penetrates the enamel into the dentin and effectively bleaches the teeth.

Post-bleaching tooth sensitivity is a frequent complaint, but it is transient and generally lasts no more than 24 hours. The use of high fluoride concentration toothpaste (5000 ppm) such as that found in the prescription toothpaste PreviDent used prior to, and throughout bleaching effectively reduces the sensitivity. Alternatively, the use of a 5000 ppm fluoride gel for 5 minutes in the bleaching trays after each bleaching session can also reduced sensitivity. The patient can also use amorphous calcium phosphate products (MI paste by GC America) either in the trays for 3 minutes, or as a dentifrice twice daily.

Professionally supervised at-home treatment has the highest dentist satisfaction rate of all bleaching methods offered with 94% being either very satisfied or satisfied with the results.



In-office bleaching (Power bleaching): Some offices offer a quick start bleaching procedure in which a concentrated peroxide gel is placed on the teeth and allowed to remain in place while "activated" with a light source. Treatments like this tend to be faster, but they require a lot of chair time which means that they are likely to be expensive. Prior to the introduction of at-home tray-bleaching techniques, this was the only form of bleaching offered to the public. The tray method can achieve the same or better results, (albeit over a greater length of time) with the added benefit of total patient control of the degree of bleaching desired. They can use the trays as long as they want, and keep them around for touch-ups later.



A note on Light or laser bleaching: In-office bleaching systems use a gel made with a 35% solution of hydrogen peroxide rather than the carbamide peroxide used with trays or strips in the take-home systems. The hydrogen peroxide gel is much stronger than the carbamide peroxide solutions used in take-home systems, and it must be applied by dental staff because of the potential to harm it could do to other oral tissues surrounding the teeth. These strong hydrogen peroxide solutions offer very effective tooth bleaching in about two hours on their own, however most dentists speed up the process by using a heat or light source to liberate more oxygen from the gel faster than would happen without the light or heat source. Manufacturers of these solutions have managed to cut the time down to about one hour, or in some cases even to a half hour if the light or heat source is used to accelerate the process. On the other hand, retail light bleaching kits that come with a flashlight-like device that illuminates the tray (sold on TV, and recently in big-box merchandise stores) are no more effective at whitening the teeth than using the low concentration bleach that is sold with them without the light. They are simply gimmicks. Stick with the Crest White Strips or go to a dentist for the real thing.

How we make bleaching trays in the office

The first step in bleaching involves a thorough examination, X-rays and cleaning. Bleaching diseased teeth is like painting a rusted out old car. The owner walks away thinking he has a new car, but finds out soon that he is no better off than before. It is not ethical for a dentist to perform an esthetic procedure like bleaching in the presence of curable disease!

It is important to be aware that fillings, including white fillings in the front teeth do not whiten with bleach. Therefore, if you have any composite fillings in your front teeth, they may have to be replaced after the bleaching process since the shade of these fillings was chosen to match the teeth as they were before bleaching. In practice, this is not always necessary.

The second step is taking impressions of the upper and lower teeth so models can be made to fabricate the bleaching trays. The major problem with impressions is that people who gag may have a difficult time. The key to having impressions taken is to be sure to breath only through your nose. If you breath through your mouth during this procedure, you will have gagging problems. I usually tell my patients to practice by opening their mouths wide, and humming, being sure that all the sound is coming out of their nose. When performing this feat, the back of the tongue blocks off the throat, and since the impression material cannot go any further down the throat than that, the gagging reflex is suppressed. (This is really the same thing that happens when you are chewing food which is why gaggers generally have no problems eating. You will notice that when chewing food, you can hum at the same time.)

Finally, you get your trays and the bleaching kit, and go home and begin the process. The instructions vary slightly according to the type and manufacturer of the bleaching kit, but you generally wear the trays anywhere from several hours several times a day, to overnight for as long as you want to keep the process up.

Are "over-the-counter" bleaching methods as good as the kind you get from the dentist?

The results you can expect from all of the over-the-counter methods are never as good as you can get with prescription dental bleaching methods. The reason for this is that the dentist can provide prescription strength bleach and custom bleaching trays that fit your teeth tightly and keep the bleach in undiluted contact with the teeth for long periods of time. Neither bleaching strips nor the stock trays provided in the over-the-counter bleaching systems have either of these advantages.

The advantage to the availability of the dental bleaching agents through sources such as the home shopping network is that once you finish a prescription bleaching regime, your custom trays remain in your possession indefinitely, and touchups, or continued bleaching can be done using the prescription custom trays and the relatively less expensive bleaching agents available from commercial sources.

The retail light bleaching kits that come with a flashlight-like device that illuminates the tray (sold on TV, and recently in big-box merchandise stores) are no more effective at whitening the teeth than using the low concentration bleach that is sold with them without the light. Click here to see why.

So why did it take dentists so long to come around?

In order to answer this question, it is helpful to begin by reading my page on the Nature of dental practices. In fact, most dentists are not just out to make a fast buck. If that were the case, there would have been no hesitation in the acceptance of bleaching by individual dentists.

A substantial majority of general dentists are what I call the "dentists in the trenches". Although we all do esthetic work, the majority of our time is spent alleviating pain, curing infections, saving bombed out teeth, teaching oral hygiene and generally making our patients feel better about their mouths, and themselves. You could say that we are really physicians who specialize in the mouth.

For me, and I suspect for a lot of the other older guys who have been practicing dentistry in the trenches for so many years, it was hard to work bleaching into our concept of what dentistry means. We see dentistry as a branch of health care, but bleaching teeth seems to fall more under the rubric of cosmetology. It seems more akin to dying your hair, or applying fingernail polish. Thus, when it first became apparent that there was a market for whitening teeth, many of us were reluctant to integrate it into our concept of the meaning of what we do for a living. "Teeth are supposed to be off-white, and they are supposed to get darker with age. It's normal!" And normality is what health is all about.

What changed my mind was my hygienist, Jen. She is, in fact, an esthetician who specializes in skin care. That's what she did before she became a hygienist. (Note that teeth are "dermal" structures, so she's really still in her field.) She really really wanted to bleach teeth. So I bought the kits and let her have at it. The first thing that struck me was how well it worked. I had no problems telling who had bleached their teeth and who hadn't. The second thing that absolutely amazed me was the sheer number of patients who wanted to have it done. People who I had been treating for years and who it never occurred to me would want to bleach their teeth were showing up with teeth that fluoresced in the dark. And they were very very happy.

So I realized that bleaching does fit into the general concept of health.....mental health! When a person looks in a mirror and likes what he sees, he feels better all over.

bonding

Direct Bonding

Indirect bonding (Traditional veneers)

Lumineers® (Extreme makeover teeth)-Usually require no shots




Direct Bonding

The two images to the left above are an example of "direct" dental bonding done at our office. These restorations are known as veneers. In order to accomplish this form of "instant orthodontics", tooth colored composite filling material was "bonded" to the front surfaces of the natural teeth and then carved using a handpiece (high speed drill), and slow speed polishing instruments to sculpt more esthetic (pleasant appearing) teeth in a better position.

Direct veneers are very thin coats of filling material placed on teeth, which are sometimes altered (prepared) beforehand, and sometimes not. The above teeth were not prepared, and the veneers were placed without giving shots. The image on the right is the completed case finished with a "Flipper" which is the least expensive way to replace missing teeth. If the patient had chosen a more expensive flexible partial denture instead, the clasp would not have been so visible. This is a fairly inexpensive way to take a bad situation and turn it around.

Below are before and after images of 2 less complex cases of "instant orthodontics" through direct bonding. In these cases composite filling material was applied to three teeth (the two central incisors and the lateral incisor to the right in both cases). The top case was done about eight years ago and looks essentially the same today as when the veneers were first applied. The bottom case was done in the summer of 2001. The lower case demonstrates the difficulty in placing wide veneers on short teeth since the finished result shows teeth which are a bit wide and somewhat blocky. In spite of this, the patient was pleased to be rid of her spaces.







The term "bonding" is a misnomer. It applies to a process, and not the product. Bonding is the process of applying a dilute acid to the enamel of a tooth to produce a frosted surface which looks microscopically like a series of mountains and valleys. This microscopic roughness is then filled with a liquid plastic which, when hardened, mechanically adheres onto the surface of the tooth and allows the further bonding of a glass filled composite filling material. (See my page on dental materials for more than you probably want to know about the technical aspects of bonding fillings to teeth.) This composite can be shaped into the form of a tooth, as I have done in the example above. Direct bonding is an artistic endeavor on the part of the dentist. No laboratory is involved in the production of the final product. The two images to the right show the replacement of old composite fillings with new ones. Even though this type of work is bonded, they still are billed as simple fillings and are paid for by most dental insurance companies while the bonded veneers shown above are considered cosmetic and are generally not covered by insurance.





















The image at the right shows a patient with crooked canine teeth (eye teeth) which are twisted, making them look like fangs. The left central tooth has had a root canal and has darkened. This patient seldom smiled because of the appearance of his teeth.

The image to the right shows the patient's smile one hour later. Composite was bonded to the inside of the canine teeth to close the space between the canines and the lateral teeth. This gives the "fangs" the appearance of being straight. The darkened central incisor was shaved back slightly and composite was bonded over the front to hide the dark color. This entire procedure was done without getting the patient numb.

The images below show how a filling may be bonded inside a tooth. Bonding a filling (even a silver filling can be bonded) tends to make it waterproof. It also prevents the filling from being dislodged in cases where an unbonded filling might not stay in place. Once again, this is an example of direct dental bonding. To see the complex history of this tooth, click on the image on the right below.



Composite filling materials are actually quite complex, and there are quite a few different kinds. For a better understanding of the chemical and physical makeup of composites, as well as a technical explanation of the different types, please click on the dental material button below:



Indirect dental bonding (Traditional veneers)

The following procedure applies to traditional bonded porcelain veneers. For a discussion of the newest type of veneer which can be done without preparing, or "drilling down" the tooth, and hence without shots, click here.


In indirect bonding, the artwork is done by a lab technician on a lab bench, and bonded onto the tooth by the dentist. The dentist usually prepares the teeth with the handpiece so that the space where the lab manufactured porcelain veneers (or filling in the case of back teeth) will be cemented will allow the insertion of the finished piece without interferences. That means that the dentist must cut the preparations so that there is a clear "path of withdrawal" with no interfering undercuts. When the dentist is finished preparing the teeth, he or she takes an impression which is poured with plaster to create an exact replica of the prepared tooth which is sent to the lab for fabrication of the appliance

These steps are a form of artwork all by themselves and can be quite demanding. Between the additional laboratory fees for the prefabricated restoration and the time it takes to prepare the teeth, this form of dentistry is quite a bit more expensive than the direct restorations described above (on the order of 5 or more times as expensive).

Tooth prepared for veneer
Inserted veneer






These graphics are reprinted with permission from Ivoclar Viadent, a company that manufactures IPS Empress®, A porcelain system used by dental laboratories to fabricate all-porcelain crowns and veneers.

The image above on the left shows the dentist making .6 mm depth cuts in the enamel of the tooth. He or she uses a special bur that automatically produces the cuts to the proper depth. A medium grit diamond bur is used next to reduce the remainder of the surface to the the same depth. After preparation, an impression is taken and sent to the lab for fabrication of the porcelain veneers.





Prepared stubby teeth
veneers inserted




Veneers direct from lab



The three images above show a case in which the patient's teeth did not show when she spoke because they were simply too short. She had a space (diastema) between the central teeth, and the edges were chipped and irregular. The image to the left shows the teeth after they were prepared to receive the veneers. Note the shoulder prepared around the edges (margins) of each tooth. This is done to allow the technician who will fabricate the veneers to place a sufficient bulk of porcelain for strength and color. (The porcelain is somewhat translucent, and if it is too thin, and the tooth structure over which the veneer will be placed is too discolored, which is often the case, the underlying discoloration may not be completely masked by the veneer.)

The image on the top left shows a tiny piece of string placed just under the gums around each tooth. This is kept in place temporarily to retract the gums away from the margins of the preparations so the impression will be completely clear and the technician will know exactly where to end the porcelain. The string was removed after taking the impression, and the patient went home with the teeth in exactly the condition you see them in above. (No temporary veneers were placed.) This is possible because the amount of tooth structure removed is small enough that a layer of enamel is left over the sensitive parts of the tooth, the preps are not very noticeable by anyone other than the patient herself, and we usually expect the finished porcelain to be returned within six working days, so the patient will not remain in this condition for very long.

The teeth were, in fact lengthened about one and a half millimeters, but the real magic was accomplished by making the veneers extra thick. This trick tends to push the lip out slightly, making it a bit fuller. It also does not allow the lip to drape as low over the teeth as it did without the extra bulk thus giving the appearance of even longer teeth when the patient's lip is at rest. The effect is not only startling, but sometimes disconcerting at first because the patient may feel that the teeth "stick out too far". Within a few days, the patient gets used to the new feel of their teeth.

For a thorough understanding of glass and porcelain, Students and dental professionals should consult my five page course "Dental Ceramics for the beginner"


So what's the difference between direct and indirect restorations besides cost?

In point of fact, both direct and indirect bonded restorations may look identical when they are first done. The difference is that the indirect variety are generally made out of porcelain. Porcelain is harder and more durable than directly placed composites and in general will not wear over time. It remains shiny indefinitely. The surface of direct composite veneers will wear over time and lose their shine.

Direct composite veneers frequently finish down to a knife edge margin in places around the periphery, at least in some areas, and these very thin areas may "curl" and separate after about three to five years leaving tiny areas of brown stain here and there. These defects can usually be repaired, but since indirect porcelain veneers never have knife edge finishes, and have super hard surfaces, no stain or reduction of the shine ever takes place. In addition, indirect porcelain fillings in back teeth have the advantage of not wearing down over time.

Indirect porcelain veneers are more brittle than direct composite restorations, and are somewhat more likely to fracture after taking a sharp blow from a hard object such as a coffee mug, or chewing down on something unexpectedly hard in food. However the newer porcelains are on the order of 12 times stronger than the older standard porcelains that were used only a few years ago, and breakage is now fairly rare. If you can afford indirect dentistry, then porcelain is the way to go. This is the Cadillac in dentistry while the direct composites are the station wagons.

While most general dentists will do composite fillings in any teeth, not all of them will do direct composite veneers preferring indirect porcelain veneers instead. The reason for this is that not all dentists are able to produce the artwork involved in bonding direct veneers quickly enough to turn a profit. If you think about it, it makes sense. There are thousands of dentists all around the country, and every one has different strengths and weaknesses. In the production of services, time is money, and some dentists would need to spend too much time trying to get the contours and color just right. If they offered this service, they would have to charge such high fees that the price of porcelain would become increasingly competitive. To understand how this works, click here.

Indirect Bonding--Lumineers® Indirect bonding without shots.

The newest form of esthetic dentistry involves bonding ultra-thin porcelain veneers, generally without anesthetic, to unprepared or lightly prepared teeth. This has been made possible because of a new innovation in dental materials. LUMINEERS BY CERINATE is a cosmetic solution for permanently stained, chipped, discolored and misaligned teeth. It may even be used to revitalize old crowns and bridgework. LUMINEERS are a porcelain veneer that can be made as thin as a contact lens and are placed over existing teeth, most of the time without requiring the removal of sensitive tooth structure (unlike traditional veneers discussed above).

The technology used to fabricate this product involves pressing porcelain particles into veneers about one third of a millimeter thin. It is something of a breakthrough because it is difficult to prepare a veneer this thin with the strength and masking properties necessary to restore broken, misaligned and discolored teeth.

The advantages to this type of esthetic restoration are as follows:

Since in most situations, Lamineers require little or no modifications to the underlying teeth themselves, they can be done from start to finish without shots most of the time.
Most cases return from the lab within 7 to 10 working days, so the patient can expect to receive his or her veneers within two weeks of the impression appointment.
Since the veneer is bonded entirely to tooth enamel, the bond is very strong (the strongest bond in all of dentistry) and the restorations are clinically proven to last for a minimum of 20 years.
Lumineer veneers are proprietary which means that the veneers are built only by certified lab technicians. This is no small consideration since the dentist cannot "cheap out" by using a discount lab where technicians are not as well versed in the art. Denmat must maintain high standards or risk damaging the reputation of the product. The work that comes back is always very good.
The disadvantages of Lumineers are as follows:

The Teeth that will receive the lumineers and the gums that surround them should be in reasonable condition. There can be no active decay in the teeth, and any fillings present must be in fairly good condition prior to doing the veneers. With a seriously damaged tooth that has been extensively repaired with composite, it is often best to place an all-porcelain crown on it instead of a veneer. Crowns cover the entire surface of the tooth and protect it from further decay.
Oral hygiene must be good before the veneers can be done. If the hygiene is poor, then the gums may recede away from the margin of the veneers making the result less than optimum. Also, bleeding gums will interfere with the bonding process and often causes a line of discoloration under the porcelain at the gum line.
What can be accomplished with Lumineers?

Discolored teeth



The above teeth show severe tetracycline stain. Note that The veneers not only mask the original color of the teeth, but are used to make the teeth appear longer as well. In this case, eight upper teeth were veneered as well as eight lower teeth. It is often necessary to place veneers on more than just the front six teeth because otherwise, the "smile" would not be wide enough. The veneers may be ordered in varying degrees of opacity. In this case, relatively opaque veneers were chosen to mask out the unattractive color of the underlying tooth structure.

Unattractively arranged teeth



These teeth were crooked, as well as yellow and discolored. Veneers were used to lengthen, straighten and whiten the teeth. In this case the smile was wide enough to require the veneering of 8 teeth. It is often financially more feasible to veneer only the four front teeth, but it would then be unwise to make the veneers much brighter than the color of the existing canine teeth. Four bright veneers would look "fake" next to the natural color of the canine (eye) teeth.

This brings up the question of how many teeth to veneer. The most ideal smile is created by placing veneers on 8 to10 top teeth (from second premolar on one side to second premolar on the other side) If the decision is made not to brighten the smile, or otherwise to alter the shape or form of the arch (the dental arch is shown in the diagram below), it may be sufficient to veneer as few as two (see "closing spaces" below) or four incisors.



Closing spaces



In this case, only three teeth were veneered in order to close the spaces between them (the two central teeth and the patient's left lateral incisor). This patient whitened his otherwise yellow teeth with bleaching trays prior to the application of the veneers.

Hollywood smiles--Making a reasonably good smile perfect



In this case, this patient had relatively nice looking teeth to begin with. However, she spent a lot of time in public and wanted a perfect smile. In her case, ten veneers were placed (second premolar to second premolar). This sort of dentistry is becoming more and more common as the general affluence of the average American increases and dental awareness spreads because of mass communication, and entertainment shows such as Extreme Makeover. Note, however, that unlike the veneers done on the program Extreme makeover, Lumineers require little or no tooth modification, and almost never require shots to make the patient numb.

periodontal flow

Several dentists have written to me asking exactly how I handle periodontal patient flow in my own office. The following routine is practiced as a matter of routine by the hygienists in my practice and represents a fairly healthy and up-to-date method of patient periodontal triage and treatment.

Patients are broken down into six groups according to their initial periodontal diagnosis when entering the practice for routine dental treatment. Each diagnosis is handled in a different way. Since the treatment regimen for each diagnosis is always the same, the hygienists can tell the patient exactly what the steps are and how much the total periodontal treatment plan will cost.

Since any periodontal case must be well documented, all patients who fall into any periodontal classification except the first one (the periodontally "clean" patient) must have a full series of radiographs and a periodontal probing on the first visit. In the case of "gingivitis" (debridement patients), the periodontal probing is deferred to a second visit, along with the oral examination and treatment plan.



1. The periodontally healthy patient

A vast majority of your patients will fall into this category. These patients present with 1-3 mm sulcus depth, minimal calculus and minimal bleeding on probing. Their periodontal treatment consists of an initial prophylaxis and scheduled regular recall prophys:

First visit
Exam (0150)

x-rays

FMX (0210)--Patients over the age of 30 and any patient with extensive dental work, extensive caries or extensive missing teeth.

4 horizontal BWX (0274) --Patients 12-30 with selective periapicals if there are individual teeth with suspected periapical pathology.

4 horizontal BWX (0274) and a panorex ( )--Patients under 30 with unerupted wisdom teeth, congenitally missing teeth or other suspected pathology.

2 horizontal BWX (0274)--Patients under 12 without erupted 2nd molars.


Prophylaxis (1110)

Recall visits

Recall Exam (0120)

Appropriate BWX once a year

Recall prophy (1110)

2. Healthy patients with minor isolated pockets

These patients present in a state of reasonable periodontal health, but with minor isolated pocketing and bleeding that probably will require further periodontal treatment. This includes patients with overall good periodontal health, but having one or two specific areas in which the pockets will require enough deep scaling to need anesthesia.

First visit

Exam (0150)

FMX (0210)

pocket probing

Prophy (1110)-- only if the site specific needs are minimal. In this case, the third visit would be skipped.

Second Visit

Localized scale and root planing 1-3 teeth/area(4342) -- billed per site

Isolated Arestin (4381) -- billed per site

Third visit--Only if no prophy was performed at first visit.

Fine scale Prophy (1110)--Short visit to complete the prophy in the areas unscaled in the second visit.



3. The "Gingivitis" patient (The full mouth debridement patient)

"Gingivitis" is a misnomer, but stands as a diagnosis acceptable to insurance companies. These patients present with 1-4 mm pockets, extensive calculus and/or serious bleeding and pain on probing. These conditions make it very difficult get accurate probing depths, and hide the true long term classification of the patient's periodontal condition.

"Gingivitis" patients do not receive a standard prophy or billable oral examination at their first visit, although the overall condition and any serious problems should be noted and treated immediately if necessary. There are two reasons for deferring the examination until a later visit.

Insurance companies will not approve an examination on the same visit as a full mouth debridement.
It is difficult to assess the true periodontal condition until some healing has taken place.
In reality, many patients with more serious periodontal disease will initially be classified as gingivitis patients if probing is difficult or impossible due to heavy calculus, bleeding or pain on probing. Two to three weeks after a debridement, oral examination becomes much easier, and classification of the patient's periodontal condition becomes more accurate.

First visit

FMX (0210)

Pocket probing

Full Mouth Debridement (FMD) (4355)

Second visit

Exam (0150)

Pocket probing

Evaluate for root planing and appoint for appropriate root planing appointments.

Fine scale (1110) -- Only if the the periodontal condition has improved. In this case, the patient is reclassified as a periodontally healthy patient and placed on a regular recall schedule.

4. Early periodontitis

Patients in this category present with numerous 4-5 mm pocketing and bleeding on probing. These patients may require a full mouth debridement on their first visit, after which they will enter immediately upon their root planing visits. Many patients in this category do not have enough calculus to justify a FMD, in which case the following regimen is followed.

First visit

Exam (0150) or Comprehensive perio exam (0180)

FMX (0210)

Spend the time explaining to the patient why they need special (and more expensive) periodontal treatment with anesthesia at subsequent visits. The appoint for two visits of root planing.

Second visit

2 quads of scaling and root planing (4341) billed per quadrant

Arestin placement (4381) billed per site maximum 3 sites per quad

Third visit

2 quads of scaling and root planing (4341) billed per quadrant

Arestin placement (4381) billed per site maximum 3 sites per quad

Fourth visit (2 - 3 weeks later--no charge)

Post-op check and prophy touch-up. At this visit, the patient is evaluated as to outcome of the treatment. Early periodontal disease often clears quite well if the patient is willing to spend the time cleaning interproximally (I recommend Stimudents). If the condition heals to a state of health, future recalls may be regular prophys (1110) twice a year. If not, the patient may require a higher frequency schedule of perio maintenance recalls (4910)

5. Moderate Periodontitis

Patients in this category present with numerous 5-7 mm pockets and moderate to severe bleeding on probing. These patients may require a full mouth debridement on their first visit, after which they will enter immediately upon their root planing visits. Many patients in this category do not have enough calculus to justify a FMD, in which case the following regimen is followed.

First visit

Exam (0150) or Comprehensive perio exam (0180)

FMX (0210)

Spend the time explaining to the patient why they need special (and more expensive) periodontal treatment with anesthesia at subsequent visits. The appoint for four visits of root planing.

Visits 2, 3, 4 and 5

Because of the depth of the pockets and the wide expanse of root surface above the periodontal attachment, any given quadrant will require more time to thoroughly root plane. Trying to do more than one quad at a time on these patients will tax the resources of both the patient and the hygienist.

1 quad of scaling and root planing (4341) billed per quadrant

Arestin placement (4381) billed per site maximum 3 sites per quad

Recall visit in 3 months, and at 3 or 4 month intervals after the first recall depending on the outcome of the initial treatment.

Exam and perio maintenance cleaning (4910) -- This is a combined fee, including both the exam and the "perio prophy". The patient should be made aware that his or her bill for future cleanings will be higher than that charged for a regular prophy due to the wider expanse of tooth structure that must be scaled.

Vertical BWX (0274) once a year at perio maintenance recalls

6. Severe Periodontitis

Patients in this category present with numerous pockets of 7 mm and greater, severe bleeding on probing and 2+ or higher mobility.

When patients in this condition want desperately to keep their natural teeth, we do not attempt to treat their periodontal condition in our own office. These patients receive the following:

Exam

FMX

Referal to a periodontist.

More frequently, these patients choose a treatment plan that includes keeping the teeth with a good prognosis, extracting the teeth with the poorest prognosis, replacement of the missing teeth with implants or removable prosthetics, and referral to a periodontist for treatment of their periodontal condition

meth mouth

The image above represents what is commonly referred to as Meth mouth. The first thing that strikes you is the tooth decay, but if you look carefully, you can see a lot more going on. Note the red, swollen, irregular borders of the gums, and the yellowish white plaque which coats the teeth where they meet the gums. Meth mouth is really about more than rampant tooth decay. It is a lifestyle issue.

The general public associates meth mouth with people who are addicted to methamphetamines. Let me assure you that the syndrome called meth mouth is NOT always associated with an addiction to methamphetamine, or with any other drug for that matter. Long before the widespread use of amphetamines, the condition you are looking at occurred in people who lived under conditions of prolonged stress, poor nutrition, poor oral hygiene, and high sugar intake.

In the mid 1970's, during a dental school externship, I had occasion to work in an emergency room in an impoverished part of one of the exurbs of Boston. Most of the time, when I saw cases like this, the patient was a young woman, often a single mother living on welfare. Others were prostitutes. Some were cocaine or heroine addicts. Methamphetamine was not a popular drug at that time, so it was rarely a contributor to their problems. These women would come to the emergency room because of very sore gums which made it difficult to eat. They also had a high fever, waves of nausea and very bad breath. The decay in their teeth was a secondary concern, and was an ongoing problem for them, but it did not constitute the reason for their visit to the emergency room.

The pain in their gums, their fever and their inability to function was caused by a condition known as Acute Necrotizing Ulcerative Gingivitis (or ANUG for short). You can see a localized area of ANUG in this detail from the image at the top of the page. Notice the redness, swelling and erosion of the gum margins in this area. This is what an acute infection of the gums looks like. Even touching this area with a cotton swab is painful. I can bring you the image, but I cannot convey the odor. Notice the mounds of bacterial plaque coating the roots of the teeth. Oral bacteria (plaque) can actually eat a living body. ANUG happens only to persons who neglect their oral hygiene and who's immune system has been compromised by prolonged stress, malnutrition or other chronic diseases such as HIV.

The treatment for this condition is actually fairly easy. We just clean around the teeth with hydrogen peroxide on a cotton swab and give the patient a prescription for penicillin (or clindamycin if they are allergic to penicillin). The infection clears up in a few days, and while the gums never regain their old scalloped appearance, they do heal and maintain their health with a later professional cleaning and improved oral hygiene. In persons who do not seek treatment, the condition may eventually clear spontaneously, only to reappear again at a later date.

Why do some non-addicts have this type of problem while others do not?

What is important is not so much the appearance or treatment of rampant tooth decay and ANUG, but what caused these problems in the first place. You don't have to be a meth addict to have a mouth that looks like this! These women were living in impoverished conditions. They were frequently subject to abuse by boyfriends or pimps. Some were addicted to heroine or cocaine (methamphetamine was not as common in those days as it is today). They rarely brushed their teeth. They also tended to ignore their nutrition, their diet consisting mostly of soda and sweet snack foods. The reasons that any person, including non-addicts, may have mouths that look like this are as follows:

Gum infection

High stress and bad nutrition tend to suppress the immune system which is responsible for fighting off the germs that live in the mouth. The bacteria in plaque (the soft paste that accumulates on the teeth at the gum line) get the upper hand in these people and begin to dissolve (rot) the gums. When bacteria attack living tissue, the condition is called an infection. ANUG is simply an acute infection.

Tooth decay

The very high sugar content in the diets of these patients, along with poor oral hygiene allows the bacteria in plaque to create acids which dissolve their teeth, especially around the gum line where the concentration of plaque is the highest. This is what causes the rampant tooth decay.

Broken teeth

High stress lifestyles also cause people to grind their teeth as a way of relieving the stress. This is called Bruxing and is covered on my pages covering dental headaches (TMJ). Severe bruxing increases the severity of the damage to the teeth caused by decay, and in addition it causes the already weakened teeth to break.

All this, and we haven't even discussed methamphetamines.

How Meth mouth got its name

The condition in the image at the top of this page got the name Meth Mouth sometime toward the end of 2004 or early 2005 when it became a major problem for the corrections personnel responsible for processing new inmates in city jail populations. (Jail is where prisoners are incarcerated before sentencing.) Prior to this time, rampant tooth decay was not uncommon in these populations, but authorities began to notice a sudden sharp increase. Furthermore, before this time, the combination of rampant caries and ANUG in persons arrested for violent crimes was less common. Since the overt illness caused by ANUG necessitated a trip to the emergency room, or, at minimum, in-house treatment prior to incarceration, the recent increase in arrests of persons with this combination of oral issues prompted city officials to look for the cause of the problem. It was not too long before they discovered that most of the prisoners presenting with the combination of rampant decay and ANUG were methamphetamine addicts.

What was especially unusual was the fact that ANUG was now occurring in conjunction with the violent behavior that caused the arrest in the first place. ANUG makes the patient quite ill. Most people who feel sick don't want to be overly active----unless they are high on meth. Methamphetamine makes people forget that they are sick. It also promotes the violent and otherwise screwy behavior that leads to arrest. Now that methamphetamine was becoming the drug of choice for both male and female criminals as well as prostitutes, these changes in behavior caused a sudden increase in arrests of persons suffering from the combination of acute gum disease and serious tooth decay.

For most practitioners, the main characteristic of note was the tremendous increase in tooth decay occurring since the meth epidemic began, not to mention the increase in violent and self destructive behavior. ANUG, being a less common feature, took a back seat, and most commentators barely mention it when discussing meth mouth. It must be remembered, however that acute gum infections are very much a part of the meth mouth syndrome.

While addiction to other drugs reduce the quality of life, and can be associated with the same oral manifestations as meth, methamphetamine appears to be especially virulent in this respect.

The signs and symptoms of Meth mouth

In medicine, the term "signs" means those things that the doctor or other people can see, feel, hear or smell, while the term "symptoms" refers to things the patient can sense and are not necessarily apparent to the doctor or other people. In other words, signs are objective, while symptoms are subjective. Some of the signs of meth mouth are visible in the photograph above, while others are not visible in the image. The objective signs include:

Rampant tooth decay, especially around the gum line

Recurrent ANUG. This may resolve itself without treatment, but will generally return again later. This may happen over and over again.

Broken teeth. Pictured to the right, broken teeth frequently happen due to the weakening of the tooth because of the decay at the gum line and between the teeth.

Attrition of the teeth. This means wear of the enamel of the teeth due to constant grinding.

Seriously bad breath. This becomes worse during periods of ANUG, but remains a problem, usually due to poor hygiene and dry mouth.

Abscessed teeth. This happens when the decay kills the nerve in the tooth.

The subjective symptoms the patient experiences include the following:

Serious tooth pain. From abscesses and acute nerve pain due to decay.

Pain in the gums when eating. This happens especially during acute periods of ANUG.

Fever, malaise, nausea. These symptoms happen due to acute infections like tooth abscess and ANUG.

Headaches, neck aches, jaw aches. These symptoms relate to severe bruxing (grinding and clenching) of the teeth.

How does meth cause these signs and symptoms?

Methamphetamines are in a class of drugs which are termed "central nervous system stimulants". This places them in the same class as cocaine, PCP, ecstasy and other drugs which cause people to feel more awake and stimulated. The difference is that Meth is like these other drugs on steroids! Methamphetamines cause the following effects on the human body:

Destructive lifestyle. Methamphetamine, popularly shortened to meth and also nicknamed "ice" or "Speed", is addictive. In other words it produces an initial pleasurable effect, followed by a rebound unpleasant effect. It starts with an "up" and is followed by an unpleasant "down" which can be avoided by taking more of the drug. The longer the "up" is maintained, the worse the "down" feels, and the harder the addict will seek the drug to maintain the high. The harder the addict seeks the drug, the less attention he/she pays to his/her other bodily needs. Addicts stop caring for themselves, neglecting oral and personal hygiene, and they stop eating the foods that normal people crave and substitute soda and candy. They even go for days at a time without sleep.

Poor oral hygiene leads to periodontal disease interspersed with acute gum infections (ANUG). It also leaves masses of plaque around the gum line and between the teeth. Plaque is made of almost pure bacteria.

Sugary foods and drinks cause the mass of plaque to become acidic causing tooth decay. Whenever the patient eats or drinks sugared foods, this leads to the massive (rampant) decay (caries) you see in the image at the top of the page.

The substitution of sugar for nutritious foods affects the immune system, reducing the addict's resistance to various diseases including chronic gum disease and ANUG.

The lack of sleep also helps to further weaken the addicts immune system.

In the end, the association of the addict with other addicts brings about not only an addiction to the drug, but also an addiction to the lifestyle itself. Lifestyles involve not just the drug, but the friends the addict makes, the types of amusements he enjoys, the foods he eats, and even the level of abuse and violence that the individual comes to expect in his or her life. (Yes, people do become addicted to physical abuse, and even fall in love with their abusers!) Most addicts find that breaking the addiction to the drug is much easier than breaking the addiction to the lifestyle. This is the reason that so many addicts who kick their drug habit eventually go back to the old habits and become addicted to the drug again. Meth is not the only drug that can cause people to loose interest in living, but it appears to be more likely than other drugs to do it.



The image above shows what can happen to a person who becomes addicted to methamphetamine. The difference between the before and after shots is less than three years. While this essay dwells on what meth can do to the inside of the mouth, one should always bear in mind that meth mouth is only a part of the overall story.



The physiologic effects of the drug. Methamphetamine is a psychostimulant and sympathomimetic drug. It works on the brain and triggers a cascading release of norepinephrine, dopamine and serotonin. These are all neurotransmitters which help the neurons (brain cells) to pass electrical signals to each other. It causes euphoria and excitement, and also an increase in focus, increased mental alertness, and the elimination of fatigue, as well as a decrease in appetite. The effects are something like those of adrenalin (epinephrine), the fight or flight hormone. It causes a number of physiological effects which relate to meth mouth:

Excessive sweating and diarrhea. Both of these effects bring about dehydration and cause the addict to have a ferocious thirst. This leads him or her to drink excessive amounts of fluid, most of which turns out to be soda and other sugared soft drinks.

Loss of appetite. The body craves energy, and in view of the ferocious thirst mentioned above, the addict will generally turn to sugary soft drinks to compensate for the reduction in calories generated by the destruction of the appetite.

Dry mouth. This is ultimately due to the excessive sweating and diarrhea. Unfortunately, the dry mouth has serious consequences for the addict. The lack of saliva and dry conditions in the mouth cause a shift in the bacterial flora (the mix of germ species in the mouth) toward bacteria that produce more acid from the sugar consumed in the ubiquitous soft drinks the addict is likely to consume. This causes the decay to advance much faster than would otherwise happen in a patient without a dry mouth.

Muscular hyperactivity. This is due to the increased mental alertness and excitement caused by the cascading release of the neurotransmitters mentioned above. This causes bruxing (grinding) and clenching of the teeth. These habits in turn cause the following problems:

Broken teeth. The constant grinding and clenching place a great deal of pressure on the decay weakened teeth and cause them to break.

Attrition. The constant movement of the jaws as the teeth slide over each other causes serious wear on the teeth that have not already broken.

Headaches, earaches and jaw aches. This is serious pain caused by the overuse of the muscles that close the jaws. It is similar to having a cramp in your leg, only the way the chewing muscles are leveraged causes the pain to be constant. Click here for more on dental headaches.

Joint damage. The joint in question is the temperomandibular joint (the TMJ) which is the joint that allows you to open and close your jaw. Over time the joint deteriorates due to the constant pressure. Click here for more on joint dysfunction.



Can my Meth Mouth be treated?

The answer to this question depends very much on you!

If you are still hooked, or are actively engaged in an addictive lifestyle:

NO! Chances are that as an active addict, you will fail in any attempt to treat your oral condition. Persons who are actively taking the drug or are still involved in the culture of addicts are unlikely to change the destructive lifestyle that caused the problem in the first place. Addicts are generally unable to maintain their oral hygiene or place restrictions on their sugar use. Unless they can control these aspects of their lives, all attempts to repair the damage are destined to failure. Addicts who kick the drug habit but maintain the lifestyle associated with it are likely to relapse and become addicted again.



If you can successfully kick both the habit and the lifestyle:

YES! It is possible to treat Meth Mouth if you have truly decided to re-enter society. This means both kicking the drug habit and having enough self respect to follow through with your treatment! This entire website is dedicated to explaining how dentists repair situations like yours. Go to my index page and then click on the "Start Here" button. Caution! Here are the hard realities:

You MUST make and keep all your dental appointments. No dentist will maintain you as a patient if you don't. Addicts find this to be a major stumbling block.

You must maintain your oral hygiene and limit the amount of sugar you use, or all your dental work will rot out again.

Basic dentistry is available through state Medicaid providers, but for any of the more advanced treatments, you will have to seek out a private dentist. This costs money, and you will need to be gainfully employed or have some other means of making payments. No private dentist will treat you if you refuse to pay your bills.

The key is personal responsibility! If you are willing to take responsibility for the repair your ravaged mouth, you are on the road to the repair of your whole life.



Does Methamphetamine cause the rampant decay by itself?
There is speculation about the possibility that methamphetamine (the drug itself), directly produces the rampant decay seen in meth mouth. When in aqueous solution, it is somewhat caustic by itself. Several studies have shown that methamphetamine does lower saliva PH for a number of hours after the drug is ingested. (Click here to see one.)



I do not believe that low saliva PH or the the chemical causticity of methamphetamine contribute significantly to the decay. Note the distribution of the caries as shown in the image above. The decay tends to begin around the gingival margin (the gum line) and between the teeth. This suggests that the decay is associated with areas where plaque accumulates. Plaque causes this type of tooth decay when it becomes acidified as a result of frequent contact with sugar.

Low salivary ph caused by ingestion of methamphetamine would be more likely to cause hypocalcification over entire enamel surfaces (a bit like bulimia) rather than being limited to the distribution actually observed. Furthermore, I know of no research that has shown that plaque organisms produce excess acid in response to the presence of methamphetamine, or that corrosive levels of methamphetamine tend to accumulate in the plaque.

The pharmacologic activity of the drug produces dry mouth syndrome --lower saliva output. Dry mouth syndrome means increased decay as a result of a shift in the oral bacterial balance toward species that produce higher acid output when exposed to sugar. Considering the large amounts sugary soft drinks that addicts are prone to drink to satisfy their thirst, as well as the lifestyle that most addicts live, it is more likely that the drug's direct corrosive effect, and its effect on salivary PH are probably overwhelmed by the well documented destruction produced by the combination of poor oral hygiene, dry mouth, copious amounts of liquid sugar and bruxing.

P.S. Here is another image of what Meth can do to a human mouth. This one is from the site of the American Dental Society. I present it here to show the extent of neglect that the drug can produce: In the image above, the patient has brushed his own teeth. This shows the general condition of the teeth in the average addict.

instant orthodonticts

The image on the left above shows the appearance of a patient's front teeth two weeks after I had attempted to repair the right central incisor for the third time in three years. The tooth was repaired in composite, using a pin in order to help stabilize the restoration. The reason that this patient kept breaking it was the tooth's rather prominent position, since in addition to being tilted severely to the patient's right, it projected considerably in front of the adjacent teeth.

This made it very prone to traumatic injury. The patient plays contact sports, and even though he wore a sports mouth guard, the lack of support from adjacent teeth made this tooth especially prone to breakage, right through the flexible silicone rubber of the guard.



This incisal image shows just how crowded the dentition was. It also shows how prominent the broken tooth was when the patient presented in my office. The dark spot is the remains of the now broken pin that was originally used to stabilize the restoration. Also, please note the severe crookedness of the teeth adjacent to the broken tooth.



I had been seeing this person since he was a child, and had originally urged the parents to consider orthodontics (braces), but at that time the family was unable to afford it. By the time of this accident the patient was reaching adulthood, and he did not want to go through the years in braces that orthodontics would entail at this time of life. Therefore, a decision was made to simply extract the offending tooth and repair the smile using a prosthetic device, which means a false tooth.

As you can see from the incisal view above, simply extracting the most crooked tooth without altering the shape of the adjacent teeth would leave very little room for a false tooth. Putting a tiny false tooth in the space vacated by the original would have created a very poor result. Thus the treatment plan included placing crowns on both adjacent teeth to make them smaller. This would allow for more room which can be divided up more equitably. In addition, this option has the added benefit of creating retainers for a three unit fixed (non removable) bridge which can be built to straighten the adjacent teeth as well as adding a false tooth to replace the broken one.



The right lateral incisor and the left central incisor were prepared as abutments for a three unit bridge. Note that the teeth were prepared prior to the extraction of the crooked central incisor. The reason for this was to avoid water and air spray from contaminating a fresh extraction site causing a possible infection. After the preparation of the abutment teeth, the right central incisor was extracted, and a lab processed temporary three unit bridge was placed over the abutments and the extraction site.



The above image was taken immediately upon placement of the prefabricated laboratory processed plastic temporary three unit bridge. The notch between the patient's right canine and right lateral incisor is there to allow space for the crooked lower canine on that side. Closing that notch would have caused the lower canine to hit the plastic of the temporary bridge, and would not allow the patient to fully close his mouth. The irregular appearance of the gums around the temporary is due to the fact that the crooked natural tooth was just extracted from this site. The temporary will be worn for about six weeks to allow the extraction site to heal and the gum tissue to remodel.



About six weeks after the temporary bridge was placed, the patient returned to the clinic, the temporary was removed, and the preparations were refined. The six weeks represents the time needed to allow the socket to heal and the gums to remodel. Refining the preparations means essentially cutting the preparation margins back beneath the gum line so that they will be hidden when the final appliance is inserted. At this time, an impression was taken and sent to the laboratory for fabrication of the final restoration.



Three weeks later, the lab sent back the finished bridge. This restoration is made of Lava, the 3M-ESPE version of a zirconium ceramic framework overlain with esthetic porcelain. The zirconium framework provides tremendous strength without compromising the translucent esthetics necessary to approximate the appearance of natural teeth.



The finished case, pictured above was cemented in place with a resin modified glass ionomer cement. The result is quite good, even though some compromises have been made in the final shape of each individual unit to allow for proper sizing of the individual teeth.









The above image shows a patient who was missing his right lateral incisor with the two central incisors bucked in. As a result, the right canine and left lateral incisor look like fangs. This, along with the serious discoloration of the natural teeth kept the patient from smiling. The solution in this case was to do five crowns to include the four anterior teeth, but also the patient's right first premolar (the one with the visible amalgam filling). The trick in this case was to create the illusion that the premolar was actually the patient's right canine. The canine was built to look like a slightly enlarged lateral incisor, the left lateral was built to be more prominent, and the central incisors were rebuilt to be straight. The left first bicuspid remains in its natural condition and now becomes the patient's left canine. The result is seen in the image below. This gives the patient a much wider and brighter smile in addition to straight teeth.

nice teeth

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Why do some people have such nice teeth?


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What are nice teeth?
Awful looking teeth can become nice teeth
How teeth are built
The five major factors which effect the health of the teeth
Sugar
Oral Hygiene
Clenching and grinding (bruxing) the teeth
Dry Mouth
Habits which can seriously wear away tooth structure
Abrasion
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing
Fruit Mulling


Sometimes nice teeth are in the eye of the beholder. The photo above shows teeth that look truly nice. The problem is, that the patient was in my office because she HATED her teeth. What you see in this picture is a woman with natural lower teeth and a full upper denture. In other words, she had NO upper teeth at all. She was seeing me because this was her third denture in two years, and she could not successfully wear any of them. They made her gag, would not stay in her mouth, and made her gums sore! These are, in fact, NOT "nice teeth".


Actually, nice teeth are not always straight. They are not always pearly white. They sometimes have fillings, and sometimes, some of the teeth may even be missing. One thing that nice teeth have in common is that they are HEALTHY! If the teeth and supporting structures (Periodontium--i.e. gums) are in a state of good health, all other defects are easily and usually quite affordably corrected.

Crooked teeth can be straightened with orthodontics (braces) or sometimes, bonding. Discolored teeth can be bleached, or bonded. Deformed teeth can be repaired inexpensively with tooth colored fillings or (more expensively) with crowns or veneers. Missing teeth can be replaced with removable partial dentures, bridges or implants.

The teeth on the left below may look awful, but within a single forty minute appointment, the two middle teeth were repaired to look like the ones on the right. This is ORDINARY dentistry. The results may not be perfect, but they surpassed the patient's expectations. These are just plain fillings, not crowns or anything especially expensive. You will note that the two central teeth are not the exact same width. These teeth were originally overlapped and crooked, but since they were so badly decayed, I took the liberty of straightening them at the expense of making one slightly wider than the other. It didn't take me any extra time or energy to do this, so it cost the patient nothing over the cost of the two fillings. This is after only one appointment. After five or six appointments, the patient's whole mouth will contain nothing but "nice teeth"!





In other words, once the teeth are in a state of health, all their deficiencies can be overcome by the purchase of dental services which, even in the absence of dental insurance, are quite affordable by anyone, especially if the treatments are performed over the course of a year. When the teeth and gums are in a state of good health, any money spent replacing missing teeth or placing bonded veneers on discolored or malformed teeth is money well spent.



The image on the right shows how serious decay can be. You may be surprised to learn that this case is actually quite repairable. It is a case in progress. Click on the image and on the linked page, you will learn just how the case was treatment planned and treated.



Can teeth with fillings, crowns or root canals cause other systemic diseases such as fibromyalgia, scleroderma, multiple sclerosis, lupus, Chronic fatigue or various autoimmune diseases?
Click here to find out







Teeth and supporting structures.. Anatomy


Dental professionals and students of dental technologies who want a more detailed understanding of the anatomy of the teeth and their supporting structures may wish to proceed to the two pages I have written and illustrated especially for them. Click the icon on the right.



The image on the right is a schematic of a tooth as it sits in the gums. The tooth consists of a crown (which is that part of the tooth that is visible above the gums), and the root(s) (7). In a state of health the roots are surrounded by the gingiva (4), and the bone (5). Deep inside of the tooth is the nerve (3) (also called the dental pulp) which is composed of soft tissue like that in your finger tip. It contains blood vessels and connective tissue as well as nerve tissue. (For more on the structure of nerves as they relate to the teeth, click here.) The nerve is surrounded by a yellow, bony substance called dentin (2). The dentin contains millions of parallel microscopic tubules which hold tiny projections of living nerve tissue. The dentin is covered above the gum line by a hard white shell called enamel (1). The enamel acts like armor, protecting the sensitive dentin underneath. If the integrity of the enamel is breached by decay or traumatic injury, the dentinal tubules become exposed to the air and caustic chemical attack. This causes movement of fluid in the dentinal tubules and is the reason that broken or decayed teeth are sensitive when touched or dried out. If the decay actually penetrates to the level of the nerve itself, then the nerve becomes inflamed and becomes extremely sensitive or painful even if there is no immediate stimulus. For more information on the anatomy of the oral cavity, click on the diagram or here to visit my page on oral/dental anatomy.

Notice that the gingiva (4) not only covers the bone, but also narrows down to a very thin soft tissue sheath which attaches to and surrounds the entire root of the tooth, separating it from the surrounding bone like a sock separates a foot from its shoe. This thin soft tissue sheath is called the periodontal ligament (6) and is an extremely important part of the structure of the dental apparatus. It acts as both a biological barrier separating the germ filled oral cavity from the sterile bone and blood supply underneath, as well as a shock absorber allowing a small amount of movement of the tooth in response to forces from above.



The whole tooth

The image to the right shows an extracted tooth. The roots and the crown are clearly visible. The inside of the tooth is made of dentin (2 in diagram above). The roots are actually covered with a thin layer of yellow, bony material called cementum (8). The crown is covered with white, translucent enamel (1). Teeth in your mouth look yellow because the yellow dentin underneath shows through the white translucent enamel. The place where the enamel ends and the roots begin is clearly demarcated on this diagram. This line is called the CementoEnamel junction (CEJ).




Meth mouth
What happens to your teeth when you are a serious addict?


The 5 major factors that effect the health of the teeth

There are five major factors which effect the health of your teeth. Each is explained in the numbered sections below:

Sugar

Oral hygiene

Grinding and clenching the teeth (bruxing)

Dry mouth

Habits that cause severe tooth wear

Just about everyone is born with strong, healthy teeth! I mean it! You may think you have soft teeth or bad gums, but you don't! You just have some bad habits that have lead you to have difficulty with your teeth. These habits cause the disease processes which make make your teeth look and feel bad. Correct these habits and the problems stop in their tracks. Once the disease processes stop, then you can begin the process of repairing the damage that has occurred, and you can have not only healthy teeth, but "Nice Teeth" too.

1. SUGAR.....causes decay!



Click on the image to see the disposition of this case

Believe it or not, even if you never brushed your teeth, you would never get a single cavity if there were no sugar in your diet. No sugar, No decay....period! Even if you NEVER brushed your teeth! (If you want proof of this, go to a museum of natural history sometime and look at the skeletons of ancient humans. You will find their teeth quite worn, and some may be missing from gum disease, but you will see NO cavities! These people did not have dentists, and they did not brush their teeth, but they had limited access to concentrated sugar which is the reason that they had no tooth decay.)

This does not mean that sugar is evil. If you eat sugars only with meals, it does relatively little harm. 95% of all cavities are caused by specific sugar habits which people usually develop during adolescence or early adulthood as a result of a change in lifestyle. Suppose you get a job in an office where everyone gathers around a soda machine during breaks. You begin drinking soda, canned juice or sweetened ice tea, at first as a social habit, then because you get used to it. The sugar is metabolized by the germs in your mouth and turns to a dilute acid which decalcifies the enamel and dentin and causes decay. The more you drink, the more decay you get. For a more thorough discussion of this phenomenon and the specific sugar habits that may be involved, click here.

Q. But even diet soda contains acid from the carbonation (carbonic acid) as well as citric acid and even other forms of acid added to enhance the flavor. Why is it that diet soda doesn't cause decay??

A. All the non sugar related acids in soda (including diet soda) are so soluble in water that they are washed off the teeth almost immediately before they can cause much decalcification of the tooth structure. On the other hand, the sugar in regular soda is very sticky and remains on the teeth for a long time. In addition, the bacteria in plaque use sugar as a raw material to create dextrans which is the viscous sticky stuff that makes plaque adhere to the teeth. The dextrans have the property of absorbing more sugar which is turned into acid by the plaque bacteria causing the plaque to remain acidic for twenty minutes or more after each exposure to sugar.

2. Oral hygiene---Failure to clean your teeth thoroughly at least once a day!



The soft sticky white stuff that builds up on the necks of your teeth is not food debris. It is made of germs that accumulate in a sticky mass called plaque. Plaque is very toxic because it is a mass of living organisms which produce (along with acid made when you eat sugar) collagenase and endotoxins which tend to eat away at the gums, the periodontal ligament and the underlying bone that supports the teeth. This disease process is known as gum disease, or periodontal disease. This disease is painless, but does cause bleeding of the gums which may be the only indication that you have periodontitis . Eventually, it causes the loss of so much supporting bone, that the teeth become mobile and painful to touch. In general, when teeth lose so much bone that they become mobile, they must be extracted.







The images above illustrate a real case of periodontal disease that presented in my office. The two central teeth had become mobile and painful and were removed as part of the patient's treatment plan. By the end of the treatment plan, the remaining teeth were free from disease and the missing teeth were replaced with a removable partial denture. For a discussion of this case and the meaning of the colored, extracted tooth in the bottom image, click here.



This process can be stopped where it is at any time simply by removing the plaque from ALL surfaces of the teeth, but the bone, once lost, never comes back. In order to arrest the disease (which can go on painlessly for many years with bleeding as the only outward sign that you have it), you must brush and clean between the teeth at least once a day. It is difficult to convince people how easy it is to clean between the teeth. Dental floss is considered the gold standard, but I have found that toothpicks (Stimudents or similar aids bought in a drug store) work exceptionally well and are very easy to use, especially because they can be manipulated with one hand.



Do you have bad breath?

It's more complicated than you think. You can beat Halitosis, but first you have to understand it. Click here to go to a page on this site to learn everything there is to learn about Bad Breath.


3. Clenching or grinding your teeth. (bruxing)

Of all the self inflicted problems people face on a daily basis, the most pervasive and misunderstood is the habit of grinding or clenching the teeth. Grinding of the teeth with side to side motion is known as bruxing. You DO clench and brux your teeth. Everyone does at one time or another, particularly when under stress or in deep concentration. These habits are almost entirely unconscious. No one realizes that they do it until it is pointed out to them. You may do it while working on your computer, while driving your car, while vacuuming the rug, while concentrating on a problem, or when you are mad at your spouse or the kids. In addition, you may be doing it while you sleep. For most people, the problems associated with bruxing are temporary and minor, but if you are one of the many people who does it to excess, it is probably one of the most self destructive habits in existence. It causes headaches, jaw aches, ear aches, stiff neck and is frequently associated with other stress related pain. For a more complete discussion of Bruxing and its associated woes, see my page on TMJ.

In addition, clenching and bruxing contributes to almost everything else that can go wrong with your teeth:



*Bruxing and clenching contribute to the severity of decay.
The constant pressure of your teeth against each other places enormous forces on your fillings and other man made repairs that dentists have done in your mouth. This pressure on these rigid structures tends to cause tiny stress fractures in the teeth where they meet the filling or crown. These tiny cracks allow leakage of sugar and germs under the margins of the restorations and extend the decay into these areas where it can damage the tooth structures without being disturbed by toothbrushes or the detersive action of foods. Note that if you are not using sugar, these tiny cracks are of little clinical importance. We say that the grinding and clenching are codestructive and accelerates and intensifies the damage done by sugar.

*Bruxing and clenching contribute to Periodontal disease.
The constant pressure of the teeth against each other causes the teeth to rock back and forth in their sockets. This effects the blood supply to the periodontal ligament and lowers the ability of the structures that support the teeth to resist the advance of the plaque organisms in the sulcus that surrounds the tooth. This accelerates the bone loss seen in periodontal disease. Note that if the teeth are kept clean by brushing and flossing, the movement of the teeth within the socket is of little clinical significance. We say that the grinding and clenching are codestructive and accelerates the damage done in periodontal disease by plaque.

*Bruxing and clenching cause sensitive teeth.
Generalized sensitivity of the teeth to cold foods is a very common symptom of clenching and grinding the teeth. Grinding and clenching is probably the second most common reason for sensitive teeth after toothpaste abuse. The reason for this phenomenon is not yet understood. It may involve the pressure placed on the dentinal tubules by the stretching of the periodontal ligament. More or less constant problems with tooth sensitivity imply toothpaste abuse, while if the sensitivity is more episodic (comes and goes) the sensitivity probably corresponds to times when you are under stress and likely to be bruxing.

The most frequent cause of sensitive teeth is "toothpaste abuse"! If you suffer from overly sensitive teeth you should read this link.

*Bruxing and clenching are the major causes of phantom tooth pain.
Grinding on one tooth in particular can cause that tooth to be painful and very sensitive to cold. This problem can mimic a severe toothache and is frequently misdiagnosed as inflammation of the dental pulp (nerve) prompting an unnecessary root canal.

*Bruxing and clenching can cause teeth to develop invisible cracks.

These cracks can cause severe pain when pressure is applied to the cracked tooth. This problem is called cracked tooth syndrome.

*Bruxing and clenching can destroy even the best dental work.
Early failure of fillings, crowns, implants and almost anything manmade is frequently caused by grinding and clenching the teeth.



To learn more about the effects of bruxing, please see my page on TMJ.


Grinding and clenching are difficult to stop since the habits are unconscious and frequently happen during sleep. They can often be controlled with a bruxing guard, which is a horseshoe shaped plastic wafer made to fit over the biting surfaces of (usually) the top teeth. The guard has a flat lower biting surface and prevents the lower teeth from locking together with the upper teeth thus reducing the forces that can be placed upon the ligaments that hold the teeth in the bone. For a more thorough discussion of this phenomenon, please see my page on TMJ.

4. Dry mouth

Dry mouth (xerostomia) effects the health of teeth mostly in elderly patients and drug addicts. This is because both of these populations use drugs which depress the production of natural saliva. The elderly are also prone to disease states that cause dry mouth. For those especially interested in learning the causes and treatments for dry mouth syndrome, please see my dedicated page on xerostomia.

A number of conditions and drugs tend to cause chronic dry mouth. They include the normal ageing process, Sjorgren's syndrome, and numerous prescription and non prescription drugs such as antihistamines and decongestants (used for colds), numerous psychiatric drugs including Lithium and Thorazine and drugs used to produce drowsiness and assist in falling asleep. Numerous illegal recreational drugs such as those mentioned here also cause dry mouth.

Plaque is composed of a range of species of bacteria, and the relative number of each species of plaque organisms is highly dependent on the exact chemical and physical composition of the saliva in the mouth. Dry mouth causes a drastic change in the composition of the plaque reducing the populations of some species and increasing the populations of others. Unfortunately, this shift in floral composition tends to cause an overgrowth of organisms which produce acidic waste products, especially when sugar is abundant. Of course, the acid in plaque is the actual agent that produces tooth decay. This generally means that people with chronically dry mouths tend to get rampant decay in their teeth.

Compounding this problem is the natural tendency of persons who suffer from dry mouth to sip sweet drinks and suck on hard candy all day. The combination of dry mouth plus copious amounts of sugar throughout the day causes serious decay in these people, especially the elderly. This combination of dry mouth and excessive sugar usage causing rampant decay is called "dry mouth syndrome"

The greatest advance in dentistry concerning dry mouth syndrome has been the discovery that hard candies and chewing gum sweetened with xylitol instead of sugar can actually inhibit tooth decay. Since the presence of sweet things in the mouth can help promote the production of saliva, sucking on hard candies artificially sweetened with xylitol can be a real lifesaver for these people.

5. Habits that cause serious wear of the teeth (attrition)



Much of the information that follows was learned at a lecture given by Dr. Thomas C. Abrahamsen, DDS. I present it on my website in my own words. Unfortunately, Dr Abrahamsen would not allow me to use his images, but you can see them by clicking here. This is important information since most dentists see severe wear patterns on teeth, but do not know exactly how it occurs. I have been amazed recently at how accurate the diagnoses can be when, upon seeing the various types of wear in a patient's mouth I questioned the patient about his or her particular habit. As a public service, I am writing a series of dedicated pages on this subject, and I will eventually populate them with images of my own.

There are five specific habits which cause serious tooth wear not connected with tooth decay. They are discussed in depth in a new eight page course geared for dental professionals: Recognizing tooth wear.

The five habits fall under two broad categories; Habits that cause abrasion of tooth structure, and those that cause erosion. Pathological tooth wear from abrasion and/or erosion is called attrition.

Abrasion is the mechanical removal of tooth structure due to rubbing of the teeth, either over each other (bruxism) or with toothpaste on a brush (toothpaste abuse).

Erosion is defined as the chemical dissolving of tooth structure with acidic solutions. Each type of habit leaves wear patterns on the teeth which are unique to the habit, and diagnosis of the habit can be made by careful inspection of plaster models of the teeth.

Abrasion
Bruxism--This is the habit of grinding of the lower teeth against the upper teeth when not eating. This causes wear on the chewing surfaces of both top and bottom teeth. Bruxing is mostly a reaction to life stresses, and since everyone becomes stressed at numerous points in their lives, EVERYONE bruxes, at least occasionally. But some persons (Type A personalities?) carry the stress so far that they cause massive damage to the teeth.
Toothpaste abuse--Interestingly, a number of studies in the literature have demonstrated that toothpaste is more abrasive than the toothbrush , regardless of the hardness of the bristles. It is the toothpaste, and not the toothbrush that causes toothbrush abrasion.
I know that this is heresy from the viewpoint of hygienists and most dentists, however research in this area goes back to 1917. (Miller WD. Experiments and observations on the wasting of tooth tissue variously designated as erosion, abrasion, chemical abrasion, denudation, etc. Dent Cosmos 1907;XLIX(1):1–23; XLIX(2):109–24; XLIX(3):225–47.) Recent studies done by Thomas C. Abrahamsen, DDS have shown that modern toothbrushes without toothpaste do not create cervical lesions, while the same toothbrushes using toothpaste do.

If this assertion is true, then most of the cervical lesions that dentists and hygienists have been calling "toothbrush abrasion" are in fact caused by toothpaste abuse. This still means that the patient is being too aggressive with his or her toothbrush, however, it is not the toothbrush that causes the damage, but the abrasives in the toothpaste. In order to avoid this type of problem, patients who like to vigorously "scrub" their teeth may wish to use mouthwash instead of toothpaste on their brush, and learn to use a more correct method of brushing the teeth. Good choices of mouthwash would be a fluoride containing mouthwash such as Act®, or Listerine® which has been shown to kill plaque organisms.

Toothpaste is not really necessary in order to thoroughly clean the teeth. Most dentists, when cornered, will admit that toothpaste serves more of an esthetic purpose than a practical one, adding a bit of a zippy taste to the tooth brushing process, but not much to the process of removing plaque. The abrasive in toothpaste will help to remove serious stain from drinking large amounts of coffee or tee, but it will not remove the yellowness from your teeth since the yellow color comes from the dentin which is UNDER the outer layer of the enamel. Overbrushing with toothpaste will make your teeth even yellower.



Sensitive teeth

Toothpaste abuse is probably the most frequent cause of tooth hypersensitivity. By overbrushing with abrasive toothpastes in order to try to make your teeth brighter, you are removing much of the tooth structure around the necks of your teeth that used to protect the nerves from cold sensitivity. Only a dentist can repair the damage already done, but you can prevent further damage to the teeth by brushing your teeth with mouthwash instead of using abrasive toothpastes.




Erosion--The chemical dissolution of tooth structure.
Regurgitation--This classification of non-carious loss of tooth structure includes Bulimia (an eating disorder involving binge eating followed by vomiting to avoid weight gain) and GERD (Gastro-Esophogeal Reflux Disease), now commonly called ARD (Acid Reflux Disease). This type of erosion of tooth structure is caused by frequent vomiting (in the case of bulimia) and regurgitation of stomach contents into the mouth with subsequent swallowing (in the case of ARD). Each of these disorders creates a different pattern of tooth erosion and can be differentiated by looking at plaster models of the teeth.
Soda-Swishing--Carbonated sodas contain three acids: citric acid, phosphoric acid and carbonic acid. If the soda contains sugar, then it will contribute to the production of decay, but diet sodas will not. Ordinarily the acids in sodas pass by the teeth too quickly to cause much tooth erosion, however if a patient develops the habit of "swishing" the soda around in his or her mouth before swallowing it (in order to remove the carbonation which may hurt their throat), then the acids in the soda (diet or regular) will, over time, cause considerable erosion to the enamel on the teeth. This damage is habit specific and can be diagnosed by looking at plaster models of the teeth.
Fruit mulling--This habit, commonly engaged in by health conscious patients (often vegetarians) is a combination of bruxism and acid erosion caused by fruit which is kept in the mouth and "mulled" for considerable time before it is swallowed.
All of the above habits can cause serious damage to the tooth structure, and may eventually necessitate extensive restoration of the dentition.

oral hygiene

Five minutes once a day can keep your teeth intact the rest of your life


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Do you have Bad Breath?

If so, this is the most important page on this site, because it is where you begin to learn how to control it properly. However, there are other sources of bad breath.

After learning the basic of oral hygiene, Click here to learn about all the forms of bad breath, and how you can treat them




In order to understand WHY you need to clean your teeth carefully once a day, it is important that you eventually refer to the following links on the diseases you are preventing. You can reach age 45 with a mouth full of loose, decayed teeth, or you can keep your teeth the rest of your life. The difference is 5 minutes a day in the bathroom and a small shift in your daily sugar intake.


It is difficult to be a successful person in today's world if you fear opening your mouth wide enough to let people see your teeth. Please click on the icons below to learn about the dangers of NOT spending that five minutes a day!




Periodontal disease
Tooth decay


Gum disease and tooth decay are invisible and largely painless when they first start, but the final outcome is always the loss of your teeth. By the time that any given area of the mouth becomes affected, the problem becomes so painful that you will be driven into a dentist's office even if you have vowed never to enter one in your life. At that point, you will either lose the offending tooth or teeth, or require expensive procedures to save them. It is infinitely easier to prevent the problems in the first place than it is to treat the problems caused by ignorance and neglect.

Once a day???

Yes! It has been well established that if a person cleans his or her teeth thoroughly (including between the teeth) once every twenty four hours, he can prevent periodontal disease. (Once a day will reduce the incidence of decay, but in the presence of the chronic sugar habits, even brushing four or five times a day will not prevent all decay. The best way to prevent decay is to reduce the number of times per day that sugar crosses your teeth.) I encourage patients to brush twice a day, in the morning upon getting up and in the evening before going to bed. I suggest that they use floss or Stimudents once a day. I like to do it at bedtime because doing the most thorough cleaning at that time reduces my "morning breath". It makes no difference what time of day you choose to clean between your teeth.

(Speaking of morning breath, Arm & Hammer has developed a new toothpaste called "PM" which I have been using for a while, and it really does seem to reduce morning breath if used before bed. Unfortunately, it tastes rather like baking soda, and for that reason failed as a marketable product. You can, however, create your own version of the same thing by dipping your toothpaste coated toothbrush into a teaspoon of baking soda and then brushing as described below. just ignore the taste, and if you brush thoroughly, you'll wake up in the morning without morning breath.)

By the way, plaque, the stuff you are brushing away is made of nearly 100% living germs. For some interesting pictures and a good description of plaque, click on the icon to the right. When you see it up close, you will know why you need to brush and floss!


And it's incredibly easy!!!

The Bass technique. The correct way to brush your teeth
The key to brushing the teeth is:

1. Always use a soft brush...A soft brush will clean much better than a hard or medium one because some of the bristles will bend at heights of contour and others will remain straight reaching down into the sulcus that surrounds the teeth. It is in this sulcus that Periodontal disease begins when plaque (made of germs) is allowed to accumulate here. The point is to always aim to remove the plaque from the sulcus around each tooth.



2. hold the brush so the bristles point at an angle (45 degrees) into the sulcus as pictured here. Use short, vibrating, back and forth strokes. The tips of the bristles don't even have to move. The point is that each change of direction (each "vibration") forces the bristles further into the sulcus and as much as possible between the teeth . Vibrate the bristles in one brush position for a few seconds, then move one tooth foreword and do it again, advancing around the "arch" of first the outside of your upper teeth, then around the inside as pictured here. Once you finish the bottom proceed to the top teeth beginning on the top left working around the outside of the teeth to the top right outside, then do the insides of the top teeth from the right inside to the left inside. The entire procedure should take about two or three minutes spending 30 or 40 seconds on each surface of each arch. after thoroughly brushing the insides and the outsides of the teeth, the job is one half finished. Now you must clean between your teeth.
A Bit of attention needs to be paid to the canine teeth (the eye teeth), especially in the upper arch. Because this tooth lies at the junction of the back teeth and the front teeth, it tends to be fairly prominent. Bearing down too hard directly on this tooth with the toothbrush sometimes can injure the gums, or even wear a notch in the tooth at the level of the gum line. It is generally best to brush the back half of the canine teeth while brushing the back teeth, then "turn the corner" and brush the front half once you change the angle of the toothbrush to brush the front teeth. By brushing each half of the tooth separately, you avoid injury to the gums and wear of the tooth.








What type of toothpaste is best?

Prior to the discovery of the benefits of Fluoride, toothpaste was just a form of perfume that induced people to brush their teeth. It had no real benefit over and above its esthetic value. But with the discovery that low concentrations of fluoride could actually reduce the incidence of decay, toothpaste gained importance as a vehicle for delivering the benefits of a true medication. Since that time, new additives have been discovered which allow the toothpaste to deliver new benefits to the teeth. Among these additives are disinfectants which actually kill the germs in plaque, and can deliver a germicidal effect for hours after brushing. Another one (pyrophosphates) helps prevent the buildup of calculus, which is the hardened material the hygienist has to scrape off when you have your teeth cleaned. Both Proctor and Gamble, and Palmolive have toothpastes that contain all three additives. They are Colgate Total and Crest Complete. Other brands contain whiteners to help bleach the teeth. No matter which toothpaste you use, the largest single benefit of brushing the teeth is still the value of mechanically removing plaque. A toothbrush with NO toothpaste does this as well as one with toothpaste!

A word of caution!! Very vigorous brushing with toothpaste on the brush will, over time cause extensive wear on the teeth. This type of damage can be avoided by using the Bass technique described above with a "wiggle-jiggle" motion (very short strokes). Real damage to the teeth is caused by vigorous "sawing" over the teeth using commercial toothpaste. Surprisingly, the brush without the toothpaste does NOT cause tooth wear. Since it is the toothbrush, and not the toothpaste that actually cleans the teeth, you can do as good a job brushing with less long term damage to the teeth if you dip the brush in mouthwash instead of using toothpaste. Click on the image to see more images of "toothpaste abuse".

Sensitive teeth

Toothpaste abuse is probably the most frequent cause of tooth hypersensitivity. By overbrushing with abrasive toothpastes in order to try to make your teeth brighter, you are removing much of the tooth structure around the necks of your teeth that used to protect the nerves from cold sensitivity. Only a dentist can repair the damage already done, but you can prevent further damage to the teeth by brushing your teeth with fluoride containing mouthwash (Act) instead of using abrasive toothpastes.


Cleaning between the teeth (just another couple of minutes)

If you do not clean between your teeth once a day, I guarantee that you will still get periodontal disease by the time you are in your forties. You will be especially prone to the bone loss that is the final symptom of gum disease if you neglect to clean between your teeth and you grind or clench your teeth (bruxism).

There are two commonly used ways to clean between the teeth. The first way is Flossing the teeth. While flossing is considered the gold standard of interproximal cleaning methods, I have discovered through very hard experience that people really do not like to do it, and even if they begin flossing regularly, they tend to do it less and less over time. The second way to clean between your teeth is with thin toothpicks similar to the Stimudents demonstrated below . I have found that these toothpicks have two great advantages over floss. First, they are very easy to use (you can use them one-handed and can use them anywhere including on the way to work in your car). Second, if used properly, they clean as well as, or even better than floss. I have seen people with severely inflamed gums (moderate to severe periodontitis) literally stop their disease cold within two weeks using Stimudents regularly! I will cover both methods below. No matter which one you use, you will be assured that you will be the only little old man or woman in the rest home who isn't trading her dentures with the other little old ladies (they really do this) because you will have the real thing!

Flossing




I have found that it is easier to use waxed floss than unwaxed. It does not slip between the fingers as easily as unwaxed floss, but it does slip between the teeth more easily and doesn't fray as much. You can use one of the new Teflon varieties like Glide. These slip between the teeth easily and don't fray as easily as unwaxed floss either, but I have found that that is too slippery for me to hold. It makes no difference which kind you use. They all clean the teeth equally well. Actually, baby yarn works great!

Tear off a piece of floss about two feet long (it's cheap), and wind it around your middle fingers as pictured in the top left image above. That way you have your two index fingers and two thumbs free to manipulate the floss between the teeth. Using two index fingers, two thumbs, or one index finger and one thumb, practice by beginning on the front teeth where the access is easy. Using any combination of fingers and thumbs, whichever combination is the easiest, slip the floss between two front teeth as pictured in the image on the top right above. Wrap the floss into a "C" around one of the teeth as pictured in the lower left image, and pull the floss up and down against the tooth. Notice that the floss actually appears to go under the gums. It is simply going into the sulcus that surrounds the tooth, and that's where you want to clean the most. Cleaning in an up and down motion reaches the bottom of the sulcus and actually removes plaque. Sawing the floss back and fourth does not, and it may actually wear grooves in the teeth. After drawing the floss up and down on the back tooth, bend it into the reverse "C" and do the same to the surface of the next tooth facing the one you just cleaned. Thus, for each space you enter between teeth, you have two separate teeth to clean.

It may take a while to complete the process all the way around your mouth the first time you do it, because the manual dexterity is a learning process, and for the first week or so, it will seem clumsy if you are not used to it. On the other hand, if you persist, you get good at it and it takes less and less time to complete the process, until you are down to less than a minute for the whole mouth. As time goes on, the constant pressure of the floss against the teeth actually causes the contact between the teeth to lighten, and getting the floss into each contact gets easier too.

If the floss frays or breaks between two teeth, it probably means that you have a cavity in one or both of the teeth, or that a filling has an overhanging margin and should be replaced. Persist, and the bleeding stops after a week or so, and your bad breath will begin to disappear.

Using toothpicks (Stimudents)



Stimudents are simply a very thin wooden toothpick made of orangewood. You can buy them in many drug stores (especially CVS and Walgreens) or super markets. They work just as well as floss to clean between your teeth. (They can be hard to find, but you can call Johnson & Johnson at 800-526-3967. Wait until the automatic answering system gives you a choice to go to the oral health section. Once there you can speak to a representative who can tell you all the stores in your area where they are sold.) Simply break one off (see the middle image above), wet the end by sucking on it, and begin cleaning between each of your teeth just as you would use a toothpick at a restaurant. Notice that the Stimudents have a wedge shaped cross section (see the image at the right). The flat edge is placed closest to the gums while the point is pointing toward the edges of the teeth .The Stimudents are pushed as far between the teeth as they will go (see the rightmost image in the grouping of three above). You can reach the furthest spaces back in your mouth as I am doing here. At first, you will experience some bleeding and some discomfort because the plaque bacteria have caused a chronic infection in the gums, and like any infected tissue, it hurts when it is touched. However the pain and bleeding subsides within a week or two after you start using them.

These little sticks are worth their weight in gold, because they have worked so well to cure so many of my more motivated patients' chronic periodontal disease. Since they are disposable, the patient does not have to be near running water to use them. They frequently use them while commuting to work or watching television. It feels great to use them, especially after the disease clears up, and once patients notice that the bleeding has stopped and their teeth are no longer mobile, they feel good about themselves.

Doctor's BrushPicks are a cleaning aid similar to Stimudents, and are used in the same way. They are double ended, one end being a toothpick and the other a tiny plastic brush which also fits between the teeth (see image below). BrushPicks have a number of advantages. They are made of plastic and are more durable than Stimudents. They are much thinner and stiffer than Stimudents which makes them fit between teeth that are very close together. They come in a dispenser which makes them easier to dispense than Stimudents. There are three sizes of dispenser; 60, 120 and 250. All of the dispensers are small enough to fit in your pocket or purse. Finally, they can be found in most large drug stores (specifically, Walgreens and CVS). They can also be ordered by clicking here.







Other tooth cleaning aids

Pointed rubber tips are used in much the same way as the Stimudents above. They are especially easy to use since they come on a handle which makes access to the spaces between the teeth even easier than Stimudents. They are made out of a fairly soft rubber, and therefore are comfortable to use. I prefer Stimudents because the grain in the wood adds a roughness which is more likely to remove plaque than the smooth surface of the rubber tip.

Mouthwashes used to be almost exclusively perfume for the mouth. They didn't do much more than cover up the bad odors of the disease processes. But fairly recently, some mouthwashes have been introduced which contain medicaments which do more than cover up odor. Some are designed to deliver fluoride to the teeth. Fluoride has proven to combine chemically with the teeth to create a thin layer of fluoroapetite which is resistant to acid attack and helps to reduce the decay caused by the sugar habits. The old eucalyptus formula of Listerine mouthwash has proven actually to reduce the number of bacteria in plaque and helps fight periodontal disease when used in combination with toothbrush and floss or toothpick.
The newer forms of electric toothbrush are quite effective in removing plaque if the bristles are held at a 45 degree angle to the teeth and gums as noted above. They force a two minute brushing time and supply a super fast vibratory motion, a slower version of which is noted in the above description of the Bass technique.

The little "Y" shaped implement on the lower left is a floss holder for people who have trouble gaining the dexterity needed to manipulate floss between the back teeth. The other alternative for these people is, of course, Stimudents.

The handle to the right of the floss holder is a "Proxabrush". The brush itself is the tiny extension at the top pointing to the left. It is a tiny brush made to be used between the teeth in the same way the Stimudents are. They are very effective aids and are a staple in the treatment of severe periodontal disease. They are excellent for cleaning between the teeth if the spaces are large enough to accommodate the brush. The only problem is that the brushes wear out and must be replaced fairly often, and since they are reusable (unlike Stimudents) the patient must be near running water to wash them off during and after use.

The three long strap like objects to the right of the Proxabrush are tongue scrapers. These have serrated edges and are very flexible. They come in three stiffnesses. They are bent into a "C" shape, and the middle of the "C" is placed as far back on the surface of the tongue as possible and then scraped forward over the surface of the tongue. Your tongue has a feltlike surface. The feltlike material is actually composed of tiny "hairs" which naturally break off (exfoliate) when they get too long. Under some circumstances, this hair does not exfoliate properly and the tongue gets a white (or sometimes black depending on your diet) "coat" on it. This coat may catch food odor and cause bad breath. These tongue scrapers help to "shave" the tongue to eliminate the hairy coat.

Halitosis

Bad breath plagues just about everyone at one time or another. People snicker about it, but bad breath can be a devastating social disability. More than a few people have been denied employment, failed in business and relegated to low social status because of it. There are four areas from which bad mouth odors originate. Before you can begin to treat your specific problem, you must be able to diagnose it. For this purpose, I have provided an entire page on the diagnosis and treatment of bad breath.

child dentistry

Index of this page

When should I first bring my child to the dentist?

Should the parent accompany the child into the operatory?

Should my child see a children's dentist?

Why fill baby teeth?

Baby tooth eruption schedule

Adult tooth eruption schedule

How to interpret a child's x-ray

Why does my child grind her teeth at night?

What if the baby tooth does not fall out on its own?

Thumb sucking habits

Will my child need braces?

The ugly duckling stage

Space maintainers

Why does my child keep getting cavities?

Children's oral hygiene

At what age should a child begin to brush?

Should a child floss?

Is there a difference between the shape of baby teeth and adult teeth?

Baby tooth pulpotomy versus an adult tooth pulp cap

What is a Stainless Steel Crown?

Which baby teeth need stainless steel crowns?

Can Stainless steel crowns be used on adult teeth?

fluoride

fluorosis

Fluoride and adults

What are topical sealants?

How are sealants done?

How long do sealants last?

Success depends on the child's cooperation

What teeth are sealed?

What is the oldest a patient can be to have her teeth sealed?

What is a frenum, and why does the doctor want to clip it?



When should I first bring my child to the dentist?

The American Academy of Pediatric Dentisty suggests that a child first be seen by a dentist when the first baby tooth erupts, or by the age of one year. At this visit, the parent holds the child on his or her knee while the dentist sits facing the parent knee to knee. While the child will not yet have all of his or her baby teeth in place by the age of one, a visual inspection allows the dentist to assess for the beginning of early childhood decay (nursing bottle caries) and to council the parents on any obvious problems that appear to be developing. It also creates a record for the child and the parents. Most childhood falls that result in injuries to the teeth happen between the ages of two and three, while the child is learning to coordinate his movements. In an emergency, parents are very glad to have the telephone number of a sympathetic doctor who already knows their baby.


Having said this, it is very rare to find a general dentist who will do an actual procedure, like a filling or an extraction on a child under the age of three. If it is absolutely necessary to do a procedure on a very young child, the general dentist usually refers to a pedodontist (a children't dentist) who can sedate him or her, or an oral surgeon who can "sleep" the child.

Should the parent accompany the child into the operatory

The answer we learned in dental school was NO!! Children always behave better without the parent in sight.



The real answer to this question is: It depends entirely on the child (and the parents).

I have found that in a majority of cases, children do perfectly well with parents in the operatory. It is the minority of cases that are the most difficult, and the ones in which the parents are best asked to leave for the waiting room.

The behavior of children in the dental setting depends largely on the child's trust in an authority figure and his or her willingness to surrender control over his own body, even at the expense of minor pain, to an adult he does not know. Trust is a quality learned at home, on the playground and at school. Children who have learned that adults trusted by their parents are adults to be trusted by them are more likely to have better experiences at the office than those who have learned to distrust adults in general. Children who have been trained to expe