CHAPTER 3 They also provide protection against microbial Although this measure has not been fully ORAL DISEASES, INFECTIONS AND infections and environmental insults. implemented, the results have been dramatic. The craniofacial tissues also provide a useful Dental caries began to decline in the 1950s CRANIOFACIAL DISORDERS among children who grew up in fluoridated (6 CE Hours) means to understanding organs and systems in less accessible parts of the body. The salivary cities, and by the late 1970s, decline in decay Learning objectives glands are a model of other exocrine glands, and was evident for many Americans. The application !! Explain new research and findings regarding an analysis of saliva can provide telltale clues of of science to improve diagnostic, treatment and the connection between oral health and health. overall health or disease. The jawbones and their prevention strategies has saved billions of dollars !! Learn about the six major dental diseases. joints function like other musculoskeletal parts. per year in the nation’s annual health bill. Even !! Discuss the connection between heart The nervous system apparatus underlying facial more significant, the result is that far fewer disease, diabetes and oral infections. pain has its counterpart in nerves elsewhere in the people are edentulous (toothless) today than a !! Review some effective disease preventative body. A thorough oral examination can detect signs generation ago. measures. of nutritional deficiencies as well as a number of The theme of prevention gained momentum as !! Learn about craniofacial disorders. systemic diseases, including microbial infections, pioneering investigators and practitioners in the !! List factors affecting future dental health immune disorders, injuries and some cancers. 1950s and 1960s showed that not only dental care practices. Indeed, the phrase the mouth is a mirror has been caries but also periodontal diseases are bacterial Introduction used to illustrate the wealth of information that can infections. The researchers demonstrated that the be derived from examining oral tissues. infections could be prevented by increasing host The realization that oral health can have a resistance to disease and reducing or eliminating significant impact on the overall health and well- New research is pointing to associations between the suspected microbial pathogens in the oral being of the nation’s population has become a chronic oral infections and heart and lung cavity. The applications of research discoveries major issue in the world of science and research. diseases, stroke and low-birth-weight, premature have resulted in continuing improvements in the Realizing the gains that have been made in disease births. Associations between oral health of Americans, new approaches to the prevention, while acknowledging that there are and diabetes have long been noted. Scientific prevention and treatment of dental diseases, and populations that suffer disproportionately from reports assess these associations and explore the growth of the science. oral health problems, the purpose of this course mechanisms that might explain the oral-systemic is to help “define, describe and evaluate the disease connections. The significant role that scientists, dentists, interaction between oral health and health and The broadened meaning of oral health parallels dental hygienists and other health professionals well-being [quality of life], through the life span in the broadened meaning of health. In 1948, have played in the prevention of oral disease and the context of changes in society.” Key elements the World Health Organization expanded the disability leads to a third theme of this course: to be addressed are the determinants of health and definition of health to mean “a complete state safe and effective disease prevention measures disease, with a primary focus on prevention and of physical, mental and social well-being, and exist that everyone can adopt to improve oral “producing health” rather than “restoring health”; not just the absence of infirmity.” It follows that health and prevent disease. These measures a description of the burden of oral diseases and oral health must also include well-being. Just as include daily procedures and disorders in the nation; and the evidence for we now understand that nature and nurture are other lifestyle behaviors, community programs actions to improve oral health to be taken across inextricably linked, and mind and body are both such as community water fluoridation and the life span. expressions of our human biology, so, too, we tobacco cessation programs, and provider-based must recognize that oral health and general health interventions such as the placement of dental Oral health are inseparable. We ignore signs and symptoms sealants and examinations for common oral and The mouth includes not only the teeth and the of oral disease and dysfunction to our detriment. pharyngeal cancers. (gingiva) and their supporting tissues, but Consequently, a second element of the course is General health risk factors, such as tobacco also the hard and soft , the mucosal lining that oral health is integral to general health. You use and poor dietary practices, also affect of the mouth and , the , the , the cannot be healthy without oral health. Oral health oral and craniofacial health. The evidence for salivary glands, the chewing muscles, and the and general health should not be interpreted an association between tobacco use and oral upper and lower jaws. Equally important are the as separate entities. Oral health is a critical diseases has been clearly delineated in almost branches of the nervous, immune and vascular component of health and must be included in every surgeon general’s report on tobacco since systems that animate, protect and nourish the the provision of health care and the design of 1964, and the oral effects of nutrition and diet oral tissues, as well as provide connections to community programs. are presented in the surgeon general’s report on the brain and the rest of the body. The genetic nutrition (1988). All the dental professions can patterning of development in utero further reveals The wider meanings of oral and health in no play a role in reducing the burden of disease in the intimate relationship of the oral tissues to the way diminish the relevance and importance of America by calling attention to these and other developing brain and to the tissues of the face and the two leading dental diseases, caries and the risk factors and suggesting appropriate actions. head that surround the mouth, structures whose periodontal diseases. They remain common and location is captured in the word craniofacial. widespread, affecting nearly everyone at some Clearly, promoting health and preventing diseases point in the life span. What has changed is what are concepts the American people have taken A key element to discuss is that oral health means we can do about them. to heart. As a nation, we hope to eliminate much more than healthy teeth. It means being disparities in health and prevent oral diseases, free of chronic oral-facial pain conditions, oral Researchers in the 1930s discovered that people cancer, birth defects, AIDS and other devastating and pharyngeal (throat) cancers, oral soft tissue living in communities with naturally fluoridated infections; mental illness and suicide; and the lesions, birth defects such as cleft and palate, water supplies had fewer dental caries than chronic diseases of aging. To live well into old and scores of other diseases and disorders that people drinking unfluoridated water. But not until age free of pain and infirmity and with a high affect the oral, dental and craniofacial tissues, the end of World War II were the investigators quality of life is the American dream. collectively known as the craniofacial complex. able to design and implement the community These are tissues whose functions we often take clinical trials that confirmed their observations Scientists today take that dream seriously in for granted, yet they represent the very essence and launch a better approach to the problem of researching the intricacies of the craniofacial of our humanity. They allow us to speak and dental caries: prevention. Soon after, adjusting complex. They are using an ever-growing array of smile; sigh and kiss; smell, taste, touch, chew and the fluoride content of community water supplies sophisticated analytic tools and imaging systems swallow; cry out in pain; and convey a world of was pursued as an important public health to study normal function and diagnose disease. feelings and emotions through facial expressions. measure to prevent dental caries. They are completing the mapping and sequencing Page 26 Elite of human, animal, microbial and plant genomes, medical status. Although common dental diseases with regard to mastication and dental occlusion. the better to understand the complexities of human are preventable, not all members of society are As a test of this sensibility, a human hair placed development, aging and pathological processes. informed about or able to avail themselves of between the tips of the fingers will rarely be They are growing cell lines, synthesizing molecules appropriate oral-health-promoting measures. sufficient to stimulate the nerve endings, but the and using a new generation of biomaterials to Similarly, not all health providers may be aware same hair placed between the lips or incisors will revolutionize tissue repair and regeneration. of the services needed to improve oral health. In instantly be felt. More than ever before, they are working in addition, oral health care is not fully integrated Pain and thermal sensitivity in the teeth are multidisciplinary teams to bring new knowledge into many care programs. Social, economic transmitted through nerve endings in the pulp. and expertise to the goal of understanding complex and cultural factors and changing population Because the pulp is in a narrow canal composed human diseases and disorders. demographics affect how health services are of connective tissue, blood vessels and nerves delivered and used, and how people care for and surrounded by hard tissue, any infection or Oral diseases and disorders in and of themselves. Reducing disparities requires wide- inflammation that would normally cause tissue themselves affect health and well-being ranging approaches that target populations at to swell creates pressure on the pulpal nerves. throughout life. highest risk for specific oral diseases and involves That pressure, along with bacterial or immune The burden of oral problems is extensive and may improving access to existing care. One approach system products that stimulate the nerve endings, be particularly severe in vulnerable populations. includes making dental insurance more available produces the severe pain of pulpal infections. It includes the common dental diseases and other to Americans. Public coverage for dental care is oral infections such as cold sores and candidiasis minimal for adults, and programs for children Neuroscientists have long studied oral-facial pain, that can occur at any stage of life, as well as birth have not reached the many eligible beneficiaries. not only because of its importance in oral disease, defects in infancy and the chronic facial pain but also because it provides an accessible model of The mouth reflects general health and well- pain elsewhere in the body. These investigations conditions and oral cancers seen in later years. being. The mouth is a readily accessible and Many of these conditions and their treatments have greatly enriched our understanding of visible part of the body and provides health care the basic mechanisms of pain perception and may undermine self-image and self-esteem, providers and individuals with a window on discourage normal social interaction, cause other modulation. They have helped delineate the their general health status. As the gateway of complex pathways and multiple transmitters that health problems, and lead to chronic stress and the body, the mouth senses and responds to the depression as well as incur great financial cost. convey pain signals to the brain and spinal cord, external world and at the same time reflects what as well as the mechanisms and molecules that can They may also interfere with vital functions such is happening deep inside the body. The mouth may as breathing, food selection, eating, swallowing modulate and inhibit nociceptive input. These show signs of nutritional deficiencies and serve as studies have also exploited new brain-imaging and speaking and with activities of daily living an early warning system for diseases such as HIV such as work, school and family interactions. techniques to confirm the wide distribution of infection and other immune system problems. The pain pathways and relay centers in the cerebral Safe and effective measures exist to prevent mouth can also show signs of general infection hemispheres and cerebellum. the most common dental diseases – dental and stress. As the number of substances that can be caries and periodontal diseases. Community reliably measured in saliva increases, it may well This research has generated new approaches water fluoridation is safe and effective in become the diagnostic fluid of choice, enabling to the control of acute and chronic pain. These preventing dental caries in both children and the diagnosis of specific disease as well as the approaches include the use of nonsteroidal, adults. Water fluoridation benefits all residents measurement of the concentration of a variety of anti-inflammatory drugs and long-acting local served by community water supplies regardless drugs, hormones and other molecules of interest. anesthetics for acute oral and dental pain, and the of their social or economic status. Professional Cells and fluids in the mouth may also be used for use of more potent drugs, drug combinations and and individual measures, including the use genetic analysis to help uncover risks for disease other kinds of therapies to treat chronic pain. of fluoride mouth rinses, gels, dentifrices and and predict outcomes of medical treatments. Researchers have emphasized the importance of dietary supplements and the application of dental Oral diseases and conditions are associated adequate pain control in patients with chronic sealants, are additional means of preventing with other health problems. Oral infections can pain conditions. dental caries. can be prevented by be the source of systemic infections in people Otherwise, the constant barrage of signals can good personal oral hygiene practices, including with weakened immune systems, and oral signs effect long-term changes in the brain that actually brushing and flossing. and symptoms often are part of a general health worsen the pain (producing hyperalgesia) condition. Associations between chronic oral Lifestyle behaviors that affect general and cause normally nonpainful stimuli to infections and other health problems, including be perceived as painful (a condition called health such as tobacco use, excessive diabetes, heart disease, and adverse pregnancy allodynia). Unrelieved chronic pain may also alcohol use and poor dietary choices outcomes, have also been reported. Ongoing suppress the immune system. affect oral and craniofacial health as well. research may uncover mechanisms that strengthen These individual behaviors are associated with the current findings and explain these relationships. Recently, investigators discovered a link between increased risk for craniofacial birth defects, oral certain taste sensations, pain and temperature. and pharyngeal cancers, periodontal disease, Touch, temperature and pain Their findings indicate that capsaicin, the dental caries and candidiasis, among other oral The mouth also contains large numbers of ingredient that makes hot peppers taste hot, binds health problems. Opportunities exist to expand nerve endings, similar to those found elsewhere to a receptor on the surface of nociceptors that the oral disease prevention and health promotion in the body, that are sensitive to touch also responds to noxious heat. The researchers knowledge and practices of the public through (mechanoreceptors), hot and cold temperatures have cloned the gene for the capsaicin receptor community programs and in health care settings. (thermoreceptors) and pain (nociceptors). The (called vanilloid receptor 1); they believe it is All health care providers can play a role in dense concentration of these receptors in the involved in several chronic pain conditions, promoting healthy lifestyles by incorporating facial skin, joints, muscle and oral soft tissues, especially those where inflammation plays a role, tobacco cessation programs, nutritional relayed to an image of the body mapped onto such as viral and diabetic neuropathy, rheumatoid counseling and other health promotion efforts the sensory cortex of the brain, accounts for arthritis and oral mucositis pain caused by cancer into their practices. the finesse with which we can discriminate the chemotherapy or radiation. qualities and precise location of these sensations. There are profound and consequential oral There is evidence that the prevalence of a In particular, the periodontal ligament, which health disparities within the U.S. population. number of pain conditions varies by gender anchors the teeth in the jaws, is a tactilely Disparities for various oral conditions may and that men and women respond differently sensitive tissue providing important feedback relate to income, age, sex, race or ethnicity, or to different analgesic drugs. These findings Elite Page 27 have prompted studies aimed at determining , viruses, parasites, fungi. Thus infectious characteristics of food (e.g., stickiness), and whether there are sex differences in pain anatomy diseases, notably dental caries and periodontal timing of food intake also play a role. and neurochemistry and whether (and how) diseases, predominate among the ills that can The essential role of bacteria in caries initiation nociception is affected by sex hormones. compromise oral health. Injuries take their toll was established in landmark experiments in the as well, with the face and head particularly 1950s. Investigators observed that germ-free Speech vulnerable to sports injuries, motor vehicle animals fed high-sugar diets remained caries- Human speech and language are the faculties that crashes, violence and abuse. Less common but free until the introduction of mutans streptococci most distinguish us from other higher primates; very serious are oral and pharyngeal cancers, (a particular group of bacterial strains having a they are also the links that bind people together in with a five-year survival rate of hardly better number of common characteristics and which diverse social groups and cultures. than 50 percent. Birth defects and developmental adhere tightly to the tooth). Later experiments Central to speech are laryngeal mechanisms disorders frequently affect the craniofacial demonstrated the transmissibility of the involving the vocal cords. Equally critical are the complex. These appear most commonly as bacteria from mother to litter and from caries- respiratory system, the and the nasal and isolated cases of cleft lip or palate, but clefting infected to uninfected cage-mates. Species of oral cavities. The tongue is the most important or other craniofacial defects can also be part Lactobacillus, Actinomyces and other acid- structure of the peripheral speech mechanisms, of complex hereditary diseases or syndromes. producing streptococci within the plaque may working in conjunction with the lips, teeth and Additionally, acute and chronic pain can affect also contribute to the process. palate to produce a rich repertoire of sounds. the oral-facial region, particularly in and around the temporomandibular (jaw) joint, and accounts If the caries infection in enamel goes unchecked, Abnormalities in oral structures, from missing for a disproportionate amount of all types of pain the acid dissolution can advance to form a cavity or malformed teeth and malocclusion to cleft lip that drive individuals to seek health care. that can extend through the dentin (the component and palate, can seriously affect articulation. The of the tooth located under the enamel) to the pulp movements of speech are orchestrated by brain Many systemic diseases such as diabetes, arthritis, tissue, which is rich in nerves and blood vessels. centers that coordinate the muscles of mastication, osteoporosis and AIDS as well as therapies The resulting toothache can be severe and often facial expression and jaw movements. for systemic diseases can directly or indirectly is accompanied by sensitivity to temperature and compromise oral tissues. The World Health Hearing impairments can also affect speech. To sweets. Treatment requires endodontic (root canal) Organization’s International Classification of therapy. If untreated, the pulp infection can lead learn to speak, children must be able to hear others Diseases and Stomatology currently lists more than and monitor the feedback from their own voices. to abscess, destruction of bone, and spread of the 120 specific diseases, distributed in 10 or more infection via the bloodstream. Congenital deafness and the serious hearing defects classes that have manifestations in the oral cavity. associated with some craniofacial syndromes can Dental caries can occur at any age after teeth severely compromise speech acquisition. Dental and periodontal infections erupt. Particularly damaging forms can begin The most common oral diseases are dental caries early, when developing primary teeth are The oral cavity and the periodontal diseases. Individuals are especially vulnerable. This type of dental caries The mouth is the gateway to the body, performing vulnerable to dental caries throughout life, with is called early childhood caries (ECC). Some dozens of functions that place high demands 85 percent of adults aged 18 and older affected. six out of 10 children in the United States have on its unique hard and soft tissues. The point of Periodontal diseases are most often seen in one or more decayed or filled primary teeth entry is the lips, which open into the oral cavity. maturity, with the majority of adults experiencing by age 5. ECC may occur in children who The cheeks form the sides of the cavity, and the some signs and symptoms by the mid-30s. are given pacifying bottles of juice, milk or roof is formed by the palate, which separates Certain rare forms of periodontal disease affect formula to drink during the day or overnight. the mouth from the nose above and the pharynx young people. The major oral health success The sugar contents pool around the upper front (throat) behind. The anterior palate is hard, story of the past half century is that both caries teeth, mix with cariogenic bacteria and give rise formed by underlying bone, and serves as a and periodontal diseases can be prevented by to rapidly progressing destruction. Other risk shield against trauma to the face and head. The a combination of individual, professional, and factors for ECC include arrested development posterior palate is soft, composed of muscles community measures. of , chronic illness, altered salivary and connective tissue that blend into the walls composition and volume (resulting from the of the pharynx. Hanging from the rear of the Dental caries use of certain medications or malnourishment), is the uvula, a mass of muscle and The word caries derives from the Latin for mouth breathing and blockage of saliva flow in a connective tissue. Under the tongue is the floor rotten, and many cultures early on posited a tooth bottle-fed infant. of the mouth, composed primarily of muscle and worm as the cause of this rottenness. By the 20th Although there have been continuing reductions salivary glands. The paired tonsils and adenoids, century, caries came to describe the condition in dental caries in permanent teeth among children important components of the immune system, of having holes in the teeth – cavities. This and adolescents over the past few decades, caries lie at the sides of the palate and within the description, although not incorrect, is misleading. prevalence in the primary dentition may have nasopharynx, respectively. In actuality, a cavity is a late manifestation of a stabilized or increased slightly in some population The pharynx opens into channels leading either bacterial infection. groups. Reductions in caries in permanent teeth also to the lungs for respiration or the esophagus for The bacteria colonizing the mouth are known as have been proportionately greater on the smooth further digestion and passage to the stomach. the oral flora. They form a complex community surfaces rather than on the pit-and-fissure surfaces This is a point of vulnerability: Should food or that adheres to tooth surfaces in a gelatinous characteristic of chewing surfaces. The gingival some other obstruction lodge in the airway, it mat, or biofilm, commonly called . tissues tend to recede over time, exposing the tooth could lead to death by asphyxiation. A cariogenic biofilm at a single tooth site may root to cariogenic bacteria that can cause root caries. Externally, the oral cavity is bounded by the contain one-half billion bacteria, of which species An important risk factor for root caries in older maxilla (the upper jaw bone), attached to the of mutans streptococci are critical components. people is the use of medications that inhibit salivary flow, leading to dry mouth (xerostomia). cranium, and the mandible (the lower jaw), These bacteria are able to ferment sugars and attached to the temporal bone of the skull by the other carbohydrates to form lactic and other Saliva contains components that can directly temporomandibular joint. acids. Repeated cycles of acid generation can attack cariogenic bacteria, and it is also rich in result in the microscopic dissolution of minerals calcium and phosphates that help to remineralize Oral invaders in tooth enamel and the formation of an opaque tooth enamel. Demineralization of enamel As the gateway to the body, the mouth is white or brown spot under the enamel surface. occurs when pH levels fall as a result of acid challenged by a constant barrage of invaders – Frequency of carbohydrate consumption, physical production by bacteria. It can be reversed Page 28 Elite at early stages if the local environment can Even the most protective genetic endowment □□ Taking medications that cause dry mouth. counteract acid production, restoring pH to and developmental milieu are unlikely to confer □□ Bridges that no longer fit properly. neutral levels. Remineralization can occur resistance to decay in the absence of positive □□ Female hormonal changes, such as with through the replacement of lost mineral (calcium personal behaviors. These include sound dietary pregnancy or the use of oral contraceptives. and phosphates) from the stores in saliva. habits and good oral hygiene, including the use of Fluoride in saliva and dental plaque and the fluorides, and seeking professional care. There are Prevention buffering capacity of saliva also contribute to indications, however, that some destructive oral Daily oral hygiene measures to prevent this process. Indeed, it is now believed that habits are on the rise, such as the use of smokeless periodontal disease include: fluoride exerts its chief caries-preventive effect (spit) tobacco products by teenage boys. Although ■■ Brushing properly on a regular basis (at least by facilitating remineralization. Several studies the chief concern here lies in the long-term risk for twice daily), with the patient attempting to have demonstrated that remineralization results oral cancers, spit tobacco that contains high levels direct the bristles underneath the in an increase in tooth hardness and mineral of sugar is also associated with increased levels of gumline, to help disrupt the bacterial growth content, rendering the tooth surface more decay of both and root surfaces. and formation of subgingival plaque. resistant to subsequent acid attack. Overt caries ■■ Flossing daily and using interdental brushes lesions develop when there is insufficient time for Periodontal diseases (if there is a sufficiently large space between remineralization between periods of acidogenesis Like dental caries, the periodontal diseases are teeth), as well as cleaning behind the last or when the saliva production is compromised. infections caused by bacteria in the biofilm tooth, the third molar, in each quarter. Over 400 medications list dry mouth as a (dental plaque) that forms on oral surfaces. The ■■ Using an antiseptic . side effect, notably some antidepressants, basic division in the periodontal diseases is gluconate based mouthwash antipsychotics, antihistamines, decongestants, between gingivitis, which affects the gums, and in combination with careful oral hygiene may antihypertensives, diuretics and anti-Parkinsonian periodontitis, which may involve all of the soft cure gingivitis, although they cannot reverse drugs. The effects of xerostomia may be tissue and bone supporting the teeth. Gingivitis any attachment loss due to periodontitis. particularly severe in cancer patients receiving and milder forms of periodontitis are common ■■ Using a “soft” toothbrush to prevent damage radiation to the head or neck because the rays can in adults. The percentage of individuals with to tooth enamel and sensitive gums. destroy tissue rather than simply moderate to severe periodontitis, in which the ■■ Using periodontal trays to maintain dentist- inhibiting salivary secretion. destruction of supporting tissue can cause the prescribed medications at the source of the tooth to loosen and fall out, increases with age. disease. The use of trays allows the medication The professional application of dental sealants to stay in place long enough to penetrate the (plastic films coated onto the chewing surfaces Signs and symptoms biofilms where the bacteria are found. of teeth) is an important caries-preventive In the early stages, periodontitis has very few ■■ Regular dental check-ups and professional measure that complements the use of fluorides. symptoms, and in many individuals the disease teeth cleaning as required. Dental check-ups The films prevent decay from developing in the has progressed significantly before they seek serve to monitor the person’s oral hygiene pits and fissures of teeth, channels that are often treatment. Symptoms may include the following: methods and levels of attachment around inaccessible to brushing and where fluoride may ■■ Redness or bleeding of gums while brushing teeth, identify any early signs of periodontitis, be less effective. teeth, using or biting into hard and monitor response to treatment. The rate of caries progression through enamel food (such as apples) (though this may Typically dental hygienists (or dentists) use is relatively slow and may be slower in patients occur even in gingivitis, where there is no special instruments to clean (debride) teeth below who have received regular fluoride treatment or attachment loss). the gumline and disrupt any plaque growing who consume fluoridated water. Because a large ■■ Gum swelling that recurs. below the gumline. This is a standard treatment percentage of enamel lesions remain unchanged ■■ Halitosis, or bad breath, and a persistent to prevent any further progress of established over periods of three to four years, and because metallic taste in the mouth. periodontitis. Studies show that after such a progression rates through dentin are comparably ■■ , resulting in apparent professional cleaning (periodontal ), slow, the application of infection control and lengthening of teeth. (This may also be bacteria and plaque tend to grow back to pre- monitoring procedures to assess caries risk status, caused by heavy-handed brushing or with a cleaning levels after about three to four months. lesion activity status, evidence of lesion arrest stiff toothbrush.) Hence, in theory, cleanings every three to four and evidence of lesion remineralization over ■■ Deep pockets between the teeth and the months might be expected to also prevent the extended periods of time is recommended. gums (pockets are sites where the attachment initial onset of periodontitis. However, analysis has been gradually destroyed by collagen- Experts believe that the earlier mutans of published research has reported little evidence destroying enzymes, known as collagenases). streptococci are acquired in infancy, the higher either to support this or the intervals at which ■■ Loose teeth, in the later stages (though this the caries risk. Most studies indicate that infants this should occur. Instead, it is advocated that may occur for other reasons as well). are infected before their first birthday, around the interval between dental check-ups should be ■■ Patients should realize that the gingival the time the first incisors emerge. However, one determined specifically for each patient between inflammation and bone destruction are largely study found the median age of acquisition to every three to 24 months. be 26 months, coinciding with the emergence painless. Hence, people may wrongly assume Nonetheless, the continued stabilization of a of the primary molars. DNA fingerprinting has that painless bleeding after teeth cleaning is patient’s periodontal state depends largely, if not demonstrated that the source of transmission is insignificant, although this may be a symptom primarily, on the patient’s oral hygiene at home usually the mother. of progressing periodontitis in that patient. ■■ Certain factors increase the risk for as well as on the go. Without daily oral hygiene, It is not clear why some individuals are more periodontal disease: periodontal disease will not be overcome, susceptible and others more resistant to □□ Smoking. especially if the patient has a history of extensive caries. Genetic differences in the structure and □□ Diabetes. periodontal disease. biochemistry of enamel proteins and crystals □□ Poor oral hygiene. A contributing cause may be low selenium in as well as variations in the quality and quantity □□ Stress. the diet: “Results showed that selenium has the of saliva and in immune defense mechanisms □□ Heredity. strongest association with gum disease, with low are among the factors under study. Analysis of □□ Crooked teeth. levels increasing the risk by 13-fold.” mutans streptococci genomes may also shed light, □□ Underlying immunodeficiencies – indicating which species are particularly virulent e.g., AIDS. The cornerstone of successful periodontal and which genes contribute to that virulence. □□ Fillings that have become defective. treatment starts with establishing excellent oral

Elite Page 29 hygiene. This includes twice daily brushing with advanced periodontitis, surgically treated cases periodontal disease with rapid loss of attachment daily flossing. Also the use of an interdental often have less further breakdown over time (more than 2 mm/year). Eighty percent will brush (called a proxi-brush) is helpful if space and when coupled with a regular post-treatment suffer from moderate loss (1-2 mm/year), and the between the teeth allows. Persons with dexterity maintenance regimen are successful in nearly remaining 10 percent will not suffer any loss. problems such as arthritis may find oral hygiene halting tooth loss in nearly 85 percent of patients. to be difficult and may require more frequent Alternative treatments professional care and the use of a powered Maintenance Periodontitis has an inescapable relationship toothbrush. Persons with periodontitis must Once successful periodontal treatment has with subgingival (tartar). The first step realize that it is a chronic inflammatory disease been completed, with or without surgery, an in any procedure is to eliminate calculus under and a lifelong regimen of excellent hygiene and ongoing regimen of “periodontal maintenance” the gumline, as it houses destructive anaerobic professional maintenance care with a dentist/ is required. This involves regular checkups and bacteria that consume bone, gum and hygienist or periodontist is required to maintain detailed cleanings every three months to prevent (connective tissue) for food. repopulation of periodontitis-causing bacteria, affected teeth. Most alternative “at-home” gum disease treatments and to closely monitor affected teeth so that involve injecting antimicrobial solutions, such Initial therapy early treatment can be rendered if disease recurs. as , into periodontal pockets Removal of bacterial plaque and calculus is Usually periodontal disease exists due to poor via slender applicators or oral irrigators. This necessary to establish periodontal health. The plaque control, so if the brushing techniques are process disrupts anaerobic bacteria colonies and is first step in the treatment of periodontitis involves not modified, a periodontal recurrence is probable. effective at reducing infections and inflammation nonsurgical cleaning below the gumline with when used daily. There are any number of potions a procedure called scaling and debridement. Assessment and prognosis and elixirs that are commercially available which In the past, root planing was used (removal Dentists and dental hygienists “measure” are functionally equivalent to hydrogen peroxide; of cemental layer as well as calculus). This periodontal disease using a device called a but at substantially higher cost. These treatments, procedure involves use of specialized curettes . This is a thin “measuring however, do not address calculus formations and to mechanically remove plaque and calculus stick” that is gently placed into the space between are therefore short-lived, as anaerobic bacteria from below the gumline, and may require the gums and the teeth and slipped below the colonies quickly regenerate in and around calculus. multiple visits and local anesthesia to adequately gumline. If the probe can slip more than 3 complete. In addition to initial scaling and root millimetres length below the gumline, the patient In a new field of study, calculus formations are planing, it may also be necessary to adjust the is said to have a “gingival pocket” around that addressed on a more fundamental level. At the occlusion (bite) to prevent excessive force on tooth. This is somewhat of a misnomer, as any heart of the formation of subgingival calculus, teeth with reduced bone support. Also it may be depth is in essence a pocket, which in turn is growing plaque formations starve out the lowest necessary to complete any other dental needs defined by its depth, i.e., a 2 mm pocket or a 6 members of the community, which calcify into such as replacement of rough, plaque retentive mm pocket. However, it is generally accepted calcium phosphate salts of the same shape and restorations, closure of open contacts between that pockets are self-cleansable (at home, by the size of the original, organic bacilli. Calcium teeth and any other requirements diagnosed at the patient, with a toothbrush) if they are 3 mm or phosphate salts (unlike calcium phosphate; the initial evaluation. less in depth. This is important because if there primary component in teeth) are ionic and adhere is a pocket which is deeper than 3 mm around to tooth surfaces via electrostatic attraction. Re-evaluation the tooth, at-home care will not be sufficient to Smaller, free floating calcium phosphate salt Multiple clinical studies have shown that cleanse the pocket, and professional care should particles are equally attracted to the same areas, nonsurgical is usually be sought. When the pocket depths reach 6 and 7 as are additional calcified bacteria, growing successful in periodontal pocket depths no greater mm in depth, the hand instruments and cavitrons calculus formations as unorganized, yet strong, than 4-5mm. It is necessary for the dentist or used by the dental professionals may not reach “brick and mortar” matrices. The microscopic hygienist to perform a re-evaluation four to six deeply enough into the pocket to clean out the voids in calculus formations house new anaerobic weeks after the initial scaling and root planing to bacterial plaque that cause gingival inflammation. bacteria, as does the top “diseased layer.” determine whether the treatment was successful In such a situation the bone or the gums around in reducing pocket depths and eliminating that tooth should be surgically altered or it will inflammation. It has been found that pocket depths always have inflammation, which will likely which remain after initial therapy of greater than result in more bone loss around that tooth. An 5-6 mm with bleeding upon probing are indicative additional way to stop the inflammation would be of continued active disease and will very likely for the patient to receive subgingival antibiotics show further bone loss over time. This is especially (such as minocycline) or undergo some form true in molar tooth sites where furcations (areas of gingival surgery to access the depths of the between the roots) have been exposed. pockets and perhaps even change the pocket depths so that they become 3 mm or less in depth Periodontal surgery and can once again be properly cleaned by the If nonsurgical therapy is found to have been patient at home with his or her toothbrush. unsuccessful in managing signs of disease If a patient has 7 mm or deeper pockets activity, periodontal surgery may be needed to around the teeth, then he or she would likely stop progressive bone loss and regenerate lost risk eventual tooth loss over the years. If this bone where possible. There are many surgical periodontal condition is not identified and the Because the root cause of subgingival calculus approaches used in treatment of advanced patient remains unaware of the progressive nature development is ionic attraction, it was periodontitis, including , of the disease then, years later, they may be hypothesized that the introduction of oppositely osseous surgery, guided tissue regeneration and surprised that some teeth will gradually become charged particles around the formations might . The goal of periodontal surgery loose and may need to be extracted, sometimes chelate calcium phosphate salt components away is access for definitive calculus removal and due to a severe infection or even pain. from the matrix, thus actually reducing the size of surgical management of bony irregularities subgingival calculus formations. that have resulted from the disease process According to the Sri Lankan Tea Labourer study, to reduce pockets as much as possible. Long- in the absence of any oral hygiene activity, To accomplish this, a sequestering agent solution term studies have shown that in moderate to approximately 10 percent will suffer from severe comprised partly of sodium tripolyphosphate

Page 30 Elite (STPP) and sodium fluoride (charge-1) was tested requires surgical removal of the excess tissue latest generation of probes finds evidence of both on a patient with burnished and new subgingival followed by appropriate personal and professional continuous and multiple-burst patterns of loss in calculus at a depth of 6 mm. The patient oral health care. different patients and at different times. delivered the solution using an oral irrigator, A form of gingivitis common 50 years ago but Most researchers agree that periodontitis results once a day for 60 days. The results of this test relatively rare today is acute necrotizing ulcerative from a mixed infection but that a particular were the successful elimination of all calculus gingivitis, also known as Vincent’s infection group of gram-negative bacteria are key to the formations studied. This test was conducted using or trench mouth. This aggressive infection is process and markedly increase in the subgingival a subgingival endoscopic camera (perioscope) by characterized by destruction of the gingiva plaque. The bacteria most frequently cited are an independent periodontist. between the teeth, spontaneous bleeding, pain , , This alternative treatment keeps subgingival calculus and oral odor. People under extreme stress have Bacteroides forsythus, , at bay, in concert with traditional periodontal an increased susceptibility. Spirochetes and other and Actinobacillus actinomycetemcomitans. treatments. In this way, periodontitis may be bacteria have been found in the connective tissue Their role in disease initiation and progression controlled by the patient, with complete restoration of of those affected. An association between smoking is determined in part by their “virulence dental health being a collaborative effort between the and this type of gingivitis is well recognized and factors.” These include the ability to colonize patient and the dental professional. was demonstrated as early as 1946. This condition subgingival plaque, generate products that can has been seen in some HIV-positive patients. directly injure tissues, and elicit an inflammatory Gingivitis Treatment requires a combination of professional or immune response. The potentially noxious Gingivitis is an inflammation of the gums periodontal treatment and antibacterial therapy bacterial products include hydrogen sulfide, characterized by a change in color from normal pink along with professional smoking cessation polyamines, the fatty acids butyrate and to red, with swelling, bleeding and often sensitivity assistance as appropriate. propionate, lipopolysaccharide (also known and tenderness. These changes result from an as endotoxin), and a number of destructive accumulation of biofilm along the gingival margins Adult periodontitis enzymes. The interaction of this arsenal with and the immune system’s inflammatory response The most common form of adult periodontitis is the host response is at the core of periodontal to the release of destructive bacterial products. described as general and moderately progressing; pathology, (Socransky and Haffajee 1991, 1992). The early changes of gingivitis are reversible with a second form is described as rapidly progressing Sequencing of the genomes of several key thorough toothbrushing and flossing to reduce and severe, and is often resistant to treatment. periodontal pathogens is under way and should plaque. Without adequate oral hygiene, however, The moderately progressive adult form is provide further insight into these pathogens as these early changes can become more severe, with characterized by a gradual loss of attachment well as catalyze new treatment approaches. infiltration of inflammatory cells and establishment of the periodontal ligament to the gingiva and This drawing shows a dentist using a probe to of a chronic infection. Biofilm on tooth surfaces bone along with loss of the supporting bone. check for inflammatory pockets. opposite the openings of the salivary glands often It is most often accompanied by gingivitis. mineralizes to form calculus or tartar, which is It is not necessarily preceded by gingivitis, covered by unmineralized biofilm – a combination but the gingivitis-related biofilm often seeds that can exacerbate local inflammatory responses. A the subgingival plaque. The destruction of gingival infection may persist for months or years, periodontal ligament and bone results in the yet never progress to periodontitis. formation of a pocket between the tooth and adjacent tissues, which harbors subgingival Gingival inflammation does not appear until the plaque. The calculus formed in the pocket by biofilm changes from one composed largely of inflammatory fluids and minerals in adjacent gram-positive streptococci (which can live with tissues is especially damaging. or without oxygen) to one containing gram- negative anaerobes (which cannot live in the The severity of periodontal disease is determined presence of oxygen). Numerous attempts have through a series of measurements, including the been made to pinpoint which microorganisms in extent of gingival inflammation and bleeding, the supragingival (above the gumline) plaque are the probing depth of the pocket to the point of the culprits in gingivitis. Frequently mentioned resistance, the of the organisms include , periodontal ligament measured from a fixed Veillonella parvula, and species of Campylobacter point on the tooth (usually the cemento-enamel and Treponema. But as Ranney (1989) notes, junction), and the loss of adjacent alveolar bone Delicate balances “The complexity of the results defies any attempt as measured by x-ray. Severity is determined by Neutrophils (a type of white blood cell) and to define a discrete group clearly and consistently the rate of disease progression over time and the antibodies are the major immune defenses associated with gingivitis.” response of the tissues to treatment. against bacterial attack. Neutrophils move to the site of infection, where they engulf bacteria Gingival inflammation may be influenced by Adult periodontitis often begins in adolescence and elaborate antibacterial agents and enzymes steroid hormones, occurring as puberty gingivitis, but is usually not clinically significant until the to destroy bacteria. Although stimulation of pregnancy gingivitis, and gingivitis associated with mid-30s. Prevalence and severity increase but the immune system to attack the offending birth control medication or steroid therapy. The do not accelerate with age. One view proposes bacteria is generally protective, immune hyper- presence of steroid hormones in tissues adjacent that destruction occurs at a specific site during responsiveness and hypersensitivity can be to biofilm apparently encourages the growth a defined period, after which the disease goes counterproductive, leading to the destruction of certain bacteria and triggers an exaggerated into remission. The current view is that the of healthy tissue. Nevertheless, the neutrophil/ response to biofilm accumulation. Again, thorough disease process may not be continuous but rather antibody axis is critical for full protection against oral hygiene can control this response. progresses in random bursts in which short periodontal diseases. periods of breakdown of periodontal ligament Certain prescription drugs can also lead to gingival and bone alternate with periods of quiescence. Also important is the release of certain potent overgrowth and inflammation. These include These episodes occur randomly over time and at molecules called cytokines and prostaglandins, the antiepileptic drug phenytoin (Dilantin); random sites in the mouth. Part of the difficulty especially prostaglandin E2 (PGE2) which can cyclosporin, used for immunosuppressive therapy in determining the pattern of progression reflects contribute to tissue destruction. Cytokines are in transplant patients; and various calcium channel variation in the sensitivity of the instruments used proteins secreted by immune cells that help blockers used in heart disease. Treatment often to measure the loss of soft tissue and bone. The regulate immune responses and also affect bone, Elite Page 31 epithelial and connective tissues. Most prominent patients with diabetes mellitus, both type 1 to 100 percent of diseased sites in these patients, in periodontal diseases are interleukin 1 (IL-1), and type 2, are more susceptible to periodontal but is absent or appears in very low frequency in tumor necrosis factor alpha (TNF-gamma) and diseases. Measures such as the gingival index, healthy or minimally diseased sites. It is possible interferon gamma (IFN-gamma). These cytokines pocket depth and loss of attachment are more that the bacteria are transmitted among family mediate the processes of bone resorption and severe if the diabetic patients are smokers. The members through oral contacts such as kissing or connective tissue destruction. likelihood of periodontal disease increases sharing utensils, because the same bacterial strain markedly when diabetes is poorly controlled. appears in affected family members. However, Susceptibility and resistance In contrast, periodontal diseases respond well evidence of a neutrophil defect argues for a PGE2 may play a central role in the tissue to therapy and can be managed successfully genetic component. Another organism frequently destruction that occurs in periodontal diseases. in patients with well-controlled diabetes. Such associated with LJP is ochracea. Levels of PGE2 in periodontal tissue are low therapy can result in improvements in the diabetic Neither of these bacteria dominate in the or undetectable in health, increase in gingivitis, condition itself. There is some evidence that generalized adult form of the disease, where and rise significantly in periodontitis. Now there osteoporosis may be a risk factor for periodontal Porphyromonas gingivalis is considered of is increasing evidence that the level of PGE2 disease. More clinical attachment loss and greatest significance. produced in response to bacterial challenge edentulousness have been reported in osteoporotic Prepubertal periodontitis is rare and can be (especially by endotoxin) can be used as a than in nonosteoporotic women. Two studies in either general or localized. The generalized form measure of susceptibility. 1996 showed that estrogen replacement therapy in begins with the eruption of the primary teeth and Presumably, the level of PGE2 production is postmenopausal women not only gives protection proceeds to involve the permanent teeth. There subject to genetic influence. Studies of identical against osteoporosis, but also results in fewer teeth is severe inflammation, rapid bone loss, tooth and fraternal twins, either reared together or lost to periodontal disease. mobility and tooth loss. The localized form of the apart, provide evidence that genetic factors may The less common rapidly progressive form of disease is less aggressive, affecting only some indeed influence susceptibility or resistance adult periodontitis typically affects people in primary teeth. The infection involves many of the to the common adult form of periodontitis. their early 20s and 30s. It is characterized by organisms associated with periodontitis, but the Recently, a commercial test for a genetic marker severe gingival inflammation and rapid loss of mix may differ somewhat, with Actinobacillus of susceptibility has been introduced. The marker connective tissue and bone. Many patients have actinomycetemcomitans, Prevotella intermedia, is associated with increased production of a an inherent defect in neutrophil response to Eikenella corrodens and several species particular form of interleukin 1-beta (IL-1-beta) infection. Several systemic diseases have been of Capnocytophaga implicated. Defects in when stimulated by periodontopathic bacteria. In associated with this form of periodontal disease, neutrophil function noted in both forms of the 1996, it was found that nonsmoking adults who including type 1 diabetes, Down syndrome, may explain why patients are highly susceptible are positive for the marker are 6 to 19 times more Papillon-Lefevre syndrome, Chediak-Higashi to other infections as well. likely to develop severe periodontitis. syndrome and HIV infection. Specific bacteria Selected mucosal infections and conditions Susceptibility to adult periodontitis has also been associated with rapidly progressive disease Like the skin, the mucosal lining of the mouth explored in relation to a variety of behavioral and include Porphyromonas gingivalis, Prevotella serves to protect the body from injury. This lining demographic variables as well as to the presence intermedia, Eikenella corrodens, and Wolinella is itself subject to a variety of infections and of other diseases. One of the strongest behavioral recta. Most recently, mutations in the cathepsin conditions, ranging from benign canker sores to associations is with tobacco use. The risk of alveolar C gene have been associated with the Papillon- often fatal cancers. bone loss for heavy smokers is seven times greater Lefevre syndrome and how the defect can result than for those who have not smoked. Cigarette in periodontal disease. Oral candidiasis smoking also may impair the normal host response Refractory periodontitis Chronic hyperplastic candidiasis is a red or in neutralizing infection, resulting in the destruction Refractory periodontitis is not a specific form white lesion that may be flat or slightly elevated of healthy periodontal tissues adjacent to the site of of disease, but refers to cases in which patients and may adhere to soft or hard tissue surfaces, infection. Smokers also have decreased levels of continue to exhibit progressive disease at including dental appliances. It is caused by salivary and serum immunoglobulins to Prevotella multiple sites despite aggressive mechanical species of Candida, especially Candida albicans, intermedia and Fusobacterium nucleatum and therapy to remove biofilm and calculus, along the most common fungal pathogen isolated from depressed numbers of helper T cells as well. Finally, with the use of antibiotics. Refractory sites the oral cavity. Normally, the fungi are present smoking alters the cells that engulf and dispose exhibit elevated levels of a number of different in relatively low numbers in up to 65 percent of bacteria – neutrophils and other phagocytes – bacteria, with the dominant species different of healthy children and adults and cause no affecting their ability to clear pathogens. in different subjects. It is not known whether harm. Problems arise when there is a change Epidemiologic studies have found that such variations in pathogenicity of the bacteria, defects in oral homeostatis – the normal balance of additional factors as increasing age, infrequent in the subject’s defense systems, or combinations protective mechanisms and resident oral flora dental visits, low education level, low income, of these factors are responsible for the refractory that maintain the health of the oral cavity, so that comorbidities and inclusion in certain racial or nature of the disease. The adoption of new defense mechanisms are compromised. Under ethnic populations are associated with increased diagnostic technology to detect predominant these circumstances, the fungal organisms can prevalence of periodontitis. It is important that bacterial species, followed by selective antibiotic overgrow to cause disease. A primary disruption epidemiologic studies also take into consideration treatment, may help resolve infection and disease in homeostasis occurs with the use of antibiotics the fact that tobacco use, oral hygiene, professional in these patients. and corticosteroids, which can markedly change prophylaxis, and routine dental care are correlated the composition of the oral flora. to socioeconomic status, as are race and ethnicity. Early-onset periodontitis Deficiencies in the immune and endocrine Sex is another factor. Males tend to have higher The forms of periodontitis occurring in systems are also important. Indeed, the diagnosis levels of periodontal diseases, presumably because adolescents and young adults generally involve of candidiasis in an otherwise seemingly of a history of greater tobacco use and differences defects in neutrophil function. Localized juvenile healthy young adult may be the first sign of HIV in personal care and frequency of dental visits. periodontitis (LJP) mainly affects the first molar infection. Other causes of candidiasis include However, female hormones may play a protective and incisor teeth of teenagers and young adults, cancer chemotherapy or radiotherapy to the head role (as they do in protecting against osteoporosis). with rapid destruction of bone but almost no and neck, xerostomia resulting from radiation to telltale signs of inflammation and very little Certain systemic diseases heighten susceptibility. the head and neck, medications, chronic mucosal supragingival plaque or calculus. Actinobacillus Epidemiological studies have confirmed that irritation, certain blood diseases and other actinomycetemcomitans has been isolated at 90 Page 32 Elite systemic conditions. Also, tobacco use has been in the bloodstream, in about 10 days. However, The ulcers appear in crops of 10 to 100 at a identified as a cofactor. herpes viruses are notorious for their ability to time, concentrating in the back of the mouth and lasting for seven to 14 days. Candidiasis often causes symptoms of burning and avoid immune detection by taking refuge in the soreness as well as sensitivity to acidic and spicy nervous system, where they can remain latent foods. Patients may complain of a foul taste in for years. In oral herpes, the virus commonly the mouth. However, it can also be asymptomatic. migrates to the nearby trigeminal ganglion, the Genomic analysis of the Candida albicans genome cluster of nerve cells whose fibers branch out to is helping investigators identify numerous genes the face and mouth. In about 20 to 40 percent that code for virulence factors, including enzymes of people who are virus-positive, the virus may that can facilitate adhesion to and penetration of reactivate, with infectious virus particles moving mucous membranes. At the same time, researchers to the oral cavity to cause recurrent disease. are exploring novel gene technologies to increase The usual site of a recurrent lesion is on or near production of a family of native salivary proteins, the lips. Recurrences are rarely severe, and the histatins that have known anticandidal and lesions heal in seven to 10 days without scarring. other antimicrobial effects. The recurrences may be provoked by a wide This picture shows a canker sore in the mouth The most common form of oral candidiasis is range of stimuli, including sunlight, mechanical on the upper lip. denture stomatitis. It occurs when tissues are trauma and mild fevers such as occur with a cold. RAU can begin in childhood, but the peak period traumatized by continued wearing of ill-fitting Emotional factors may play a role as well. for onset is the second decade. About 50 percent or inadequately cleaned dental appliances and is Oral human papillomavirus infections of close relatives of patients with RAU also have described as chronic erythematous candidiasis. There are more than 100 recognized strains of the condition, and a high correlation of RAU has Another form, candidal angular cheilosis, occurs oral human papillomavirus (HPV), a member of been noted in identical but not fraternal twins. in the folds at the angles of the mouth and is the papovavirus family, implicated in a variety of Associations have been found between RAU and closely associated with denture sore mouth. oral lesions. Most common are papillomas (warts) specific genetic markers. Other common forms of Candida infection are found on or around the lips and in the mouth. HPV pseudomembranous candidiasis (thrush), which RAU has also been associated with is found in 80 percent of these oral squamous may affect any of the mucosal surfaces, and acute hypersensitivities to some foods, food dyes and papillomas. The virus has also been identified in erythematous candidiasis, a red and markedly food preservatives. Nutritional deficiencies – 30 to 40 percent of oral squamous cell carcinomas painful variant commonly seen in AIDS patients. especially in iron, folic acid, various B vitamins and has been implicated in cervical cancer as well. or combinations thereof – have also been In most cases, Candida infection can be Whether a cancer or nonmalignant wart develops reported, and improvements noted with suitable controlled with antifungal medications used may depend on which virus is present or on which dietary supplements. locally or systemically. Control is difficult, viral genes are activated. however, in patients with immune dysfunction, The two factors that have been found to have the Oral warts are most often found in children, as in AIDS, or other chronic debilitating diseases. strongest association with RAU are immunologic probably as a result of chewing warts on the Often the organisms become resistant to standard abnormality, possibly involving autoimmunity hands. In adults, sexual transmission from the therapy, and aggressive approaches are necessary. and trauma. anogenital region can occur. The spread of oral candidiasis to the esophagus Volunteers with and without a history of RAU In general, viral warts spontaneously regress after or lungs can be life-threatening and is one of the were studied for their reaction to the trauma of a one or two years. The immune system normally criteria used to define frank AIDS. needle prick to the inner cheek tissue. No ulcers keeps HPV infections under control, as evidenced developed in non-RAU subjects, but nearly half Herpes simplex virus infections by the increased prevalence of HPV-associated of those prone to canker sores had a recurrence. In any given year, about a half-million Americans lesions in HIV-infected patients and others with will experience their first encounter with the herpes immunodeficiency. RAU also can occur in a number of systemic simplex virus type 1 (HSV-1), the cause of cold diseases, including HIV infection, ulcerative sores. That first encounter usually occurs in the Recurrent aphthous ulcers or canker sores colitis, Crohn’s disease and Behçet’s disease. In oral region and may be so mild as to go unnoticed. Recurrent aphthous ulcers (RAU), also referred to general, people who are immunocompromised But in some people, particularly young children as recurrent aphthous stomatitis, is the technical are more susceptible to RAU, as are people with and young adults, infection may take the form of term for canker sores, the most common and a variety of blood diseases. primary herpetic stomatitis, with symptoms of generally mild oral mucosal disease. Between RAU itself does not give rise to other illnesses malaise, muscle aches, sore throat and enlarged and 5 and 25 percent of the general population is but is uncomfortable. Symptomatic treatment tender lymph nodes before the appearance of the affected, with higher numbers in selected groups, includes topical analgesics, antibacterial rinses, familiar cold sore blisters. These blisters usually such as health professional students. The disease topical corticosteroids and a new prescription show up on the lips, but any of the mucosal surfaces takes three clinical forms: RAU minor, RAU major medication that reduces pain and healing time. can be affected. Bright-red ulcerated areas and and herpetiform RAU. The minor form accounts marked gingivitis may also be seen. for 70 to 87 percent of cases. The sores are small, Developmental disorders discrete, shallow ulcers surrounded by a red halo Herpes viruses also cause genital infections, which The importance of the face as the bearer of identity, appearing at the front of the mouth or the tongue. are transmitted sexually. Both HSV-1 and HSV-2 character, intelligence and beauty is universal. The ulcers, which usually last up to two weeks, have been found in oral and genital infections, Craniofacial birth defects, which can include such are painful and may make eating or speaking with HSV-1 predominating in oral areas and manifestations as cleft lip or palate, eyes too closely difficult. About half of RAU patients experience HSV-2 in genital areas. Herpes viruses have also or widely spaced, deformed ears, eyes mismatched recurrences every one to three months; as many as been implicated as cofactors in the development of in color and facial asymmetries, can be devastating 30 percent report continuous recurrences. oral cancers. Crowded living conditions can result to the parents and child affected. Surgery, dental in greater contact with infected individuals, which RAU major accounts for 7 to 20 percent of cases care, psychological counseling and rehabilitation aids in transmission of HSV. and usually appears as one to 10 larger coalescent may help to ameliorate the problems but often at ulcers at a time, which can persist for weeks or great cost and over many years. Normally, the immune system mounts a months. Herpetiform RAU has been reported successful attack on the viruses, with symptoms Although each developmental craniofacial as occurring in 7 to 10 percent of RAU cases. abating by the time neutralizing antibodies appear disease or syndrome is relatively rare, the Elite Page 33 number of children affected worldwide is in of candidate genes, including MSX1, RAR, an chromosome 22 (22q11). Further characterization the millions. In addition, craniofacial defects X-linked locus and the genes for TGF-beta-3 of this chromosomal deletion region will provide form a substantial component of many other and TGF-alpha. The pattern of inheritance in information on the specific gene(s) affected and its developmental birth defects, largely because they cleft lip/palate and cleft palate suggests that function in craniofacial development. occur very early in gestation, when many of the between 2 and 20 genes may be involved, with The thymus defects severely compromise cellular same genes that orchestrate the development of one gene representing a major component in the immunity, depriving the body of thymus-derived the brain, head, face and mouth are also directing development of the cleft. One of the common T cells and paving the way for severe infectious the development of the limbs and many vital syndromic forms of cleft lip/palate, the Van der disease. Inadequate or missing parathyroid internal organs, such as the heart, lungs and liver. Woude syndrome, is caused by an autosomal glands cause severe hypocalcemia (low blood dominant form of inheritance at a locus on By about the third week after fertilization, the calcium levels) and seizures. The great vessel chromosome 1. Future molecular genetic studies three germ layers of the embryo – the ectoderm, abnormalities alter cardiac output and lead to will be needed to provide the information endoderm and mesoderm – have formed, as well compromised circulation to heart tissues. necessary for prenatal diagnosis, calculation of as the first of four sets of paired swellings – the risk, and potential gene therapy. branchial arches – that appear at the sides of Cranial bone and dental anomalies the head end of the embryo. Some craniofacial Defects in the timing of developmental events The Treacher Collins syndrome – defects result from failure of the arches to can cause premature fusion of cranial bones. complete their morphogenetic development. mandibulofacial dysostosis Impairments of tooth development can result Other craniofacial defects are the result of Children with the Treacher Collins syndrome from interruptions of the developmental sequence the abnormal differentiation of cells derived have downward-sloping eyelids; depressed at several different stages. from the ectoderm and endoderm or from cheekbones; a large fishlike mouth; deformed ectomesenchyme cells, which originate in a part ears with conductive deafness; a small, receding chin and lower jaw; a highly arched or cleft of the ectoderm (the neural crest), in interaction with future connective tissue (the mesenchyme). palate; and severe dental malocclusion. These defects result from defective cranial neural crest Craniofacial anomalies caused by cell differentiation, migration and proliferation. Consequently, the first branchial arch structures altered branchial arch morphogenesis are deficient, and all derivative craniofacial Cleft lip/palate and cleft palate components are affected. The most common of all craniofacial anomalies The underdeveloped facial structures can and among the most common of all birth defects, contribute to airway blockage and repeated are clefts of the lip with or without cleft palate upper respiratory infections, either of which and cleft palate alone; these occur at a rate of 1 to can be fatal. The faulty development of the 2 out of 1,000 births, resulting in more than 8,000 ears leads to a conductive deafness. The severe affected newborns every year. Cleft lip/palate and facial deformities exacerbate the psychological cleft palate are distinct conditions with different difficulties these youngsters face. patterns of inheritance and embryological origins. The male to female ratio of cleft lip/palate is 2 Investigators have identified the gene involved to 1; the ratio for cleft palate alone is just the in an autosomal dominant form of the syndrome. This picture is of a child with a facial reverse, 1 to 2. The function of the gene is not yet known, but its deformity caused by a cleft lip/palate. identity will provide opportunities for prenatal These anomalies result from the failure of diagnosis, gene therapy and further understanding Craniosynostoses the first branchial arches to complete fusion of craniofacial development. processes. Clefting can occur independently or as Some craniofacial anomalies are associated with so-called master genes that orchestrate a program part of a larger syndrome that may include mental The Pierre Robin syndrome retardation and defects of the heart and other by which the embryo assumes its basic shape. Deficient development of the first-branchial-arch- Craniosynostosis, which occurs in approximately organs. Not all cases of clefting are inherited; a derived mandibular portion results in the lower number of teratogens (environmental agents that 1 out of 3,000 births, is one such anomaly. It jaw being set far back in relation to the forehead. results in the premature fusion of the cranial can cause birth defects) have been implicated, As a result, the tongue is set back and may obstruct as well as defects in essential nutrients such sutures, a dangerous condition that puts pressure the posterior airway, compromising respiration on the developing brain. A number of diseases as folic acid. Smoking by the mother during and, in severe cases, leading to inadequate aeration pregnancy also increases the risk. It is becoming and syndromes, including Crouzon’s, Apert’s and failure to thrive. The infant is also at risk for Boston-type craniosynostosis, Pfeiffer’s and increasingly evident that most diseases and the development of cor pulmonale, an enlargement disorders, not just craniofacial anomalies, result Saethre-Chotzen, share this anomaly, but differ of the right ventricle of the heart that occurs in other features, which can include structural from interactions involving multiple genes and secondarily to a chronic lung condition. Cleft environmental factors. defects such as webbing of the hands and feet palate may be another consequence. as well as mental retardation. Boston-type Infants with clefts have difficulty with vital oral craniosynostosis has been linked to MSX2, one of The DiGeorge/Velocardiofacial syndrome functions such as feeding, breathing, speaking and the master genes. Several of the other syndromes The primary defect in the DiGeorge syndrome swallowing. They are also susceptible to repeated involve point mutations at one or another locus results from altered development of the fourth respiratory infections. As these children grow, they in genes that code for fibroblast growth factor branchial arch and the third and fourth pharyngeal must cope with the social consequences of a facial receptors (FGFR 1, 2 and 3). Collectively, these pouches. Deficiencies affecting the thymus, deformity, delayed and altered speech, frequent genes are associated with cell regulation, either parathyroid glands and the great vessels that derive illness and repeated surgeries that may persist through mediating growth factor effects or by from these structures result. The facial features through late adolescence. serving as transcription factors. are subtle and include a squared-off nasal tip, Current molecular epidemiology investigations small mouth and widely spaced eyes. Similar have examined both syndromic and Hereditary hypodontia or anodontia facial features, along with heart defects, are seen Conditions of underdeveloped teeth (hypodontia) nonsyndromic (isolated) cleft lip/palate and cleft in the velocardiofacial syndrome. Both syndromes palate. Linkage studies have identified a number or their complete absence (anodontia) have been are associated with deletions on the long arm of correlated with specific genes, such as MSX1 and Page 34 Elite LEF1. The complete absence of teeth alters the painful and dangerous because of the constant risk have been categorized as “intentional” and bony development of the mandible and maxilla. that the bullae will become infected. “unintentional.” People identified as being at risk for certain injuries, as well as the causes of those Amelogenesis imperfecta and Craniofacial manifestations of single-gene injuries, can be targeted for appropriate prevention dentinogenesis imperfecta defects strategies. Such an approach is broadly applicable Amelogenesis imperfecta and dentinogenesis In many craniofacial defects, mutations within to sports, falls and motor vehicle injuries imperfecta are linked to defects in structural a single gene manifest as complex syndromes (unintentional) as well as to injuries caused by genes that code for proteins essential to the with varied organ and limb defects as well as abusive and violent behaviors (intentional). development of tooth enamel (amelogenesis facial anomalies. Injuries are a major public health problem, imperfecta) or dentin (dentinogenesis outranking cancer and heart disease as a leading Ectodermal dysplasias imperfecta). The teeth are weak and extremely cause of death in some age groups of the sensitive to temperature and pressure. The The ectodermal dysplasias (EDs) are a family population. Cranial injuries in particular are a ordinary forces of chewing are painful and can of hereditary diseases first observed by Charles leading cause of mortality. Oral-facial injuries lead to further wear and pain. Darwin over a century ago. They involve defects can bring disfigurement and dysfunction, greatly in two or more tissues derived from the ectoderm The enamel matrix genes include tuftelin, diminishing the quality of life and contributing to – skin, hair, teeth, nails and sweat glands. ameloblastin, and amelogenin; researchers have social and economic burdens. The ectodermal structures fail to differentiate begun to link mutations in these genes with properly owing to altered epithelial-mesenchymal The leading causes of oral and craniofacial amelogenesis imperfecta. Similarly, genes labeled signaling. A gene, EDA, at an X-linked locus injuries are sports, violence, falls and motor DSP and DPP have been characterized for dentin has been linked to the syndrome, and ongoing vehicle collisions. Oral cavity injuries may also matrix and are associated with the inheritance of research is aimed at determining the function be caused by foreign objects in food. dentinogenesis imperfecta. of the gene and the molecular mechanism of the syndromes. More recently, investigators Sports Craniofacial defects secondary to other have discovered genes linked to autosomal Craniofacial sports injuries occur not only in developmental disorders (i.e., non-sex-linked) forms of ED, displaying contact sports, but also in individual activities A number of genetic diseases occur in which both dominant and recessive inheritance. Oral such as bicycling, skating, and gymnastics, craniofacial defects are secondary to a more manifestations of the ectodermal dysplasias are especially on trampolines. Each sport predisposes generalized structural defect. associated with the teeth. Alterations in tooth its participants to a specific array of extrinsic development can include hypodontia, anodontia risk factors. These include physical contact, and conically shaped teeth. projectiles such as balls and pucks, and the quality of the playing field and equipment. The Waardenburg syndrome In contact sports the absence of protective The Waardenburg syndrome equipment such as headguards and mouthguards has been subdivided into is a major risk factor. In a recent survey of several types. All involve a school-aged children in organized sports, football variety of abnormalities in the was the only sport in which the majority of position and appearance of the participants used mouthguards and headgear. nose and eyes, with pigment There are intrinsic risk factors as well, relating to changes that may cause one characteristics of the individual participant. These eye to differ in color from include age, sex, injury history, body size, aerobic the other. Other signs include fitness and muscle strength, central motor control, deafness, a mildly protruding This picture shows Treacher Collins Syndrome and general mental ability. jaw, cleft lip and palate, and skeletal deformities. patients with jaw deformity. The syndrome is inherited in an autosomal Falls Osteogenesis imperfecta dominant manner with complete penetrance and Falls are a major cause of trauma to teeth, variable expression. Specific genes associated Inherited mutations of collagen genes lead to a primarily to incisors. Unlike bone fractures, with this syndrome are members of the number of “brittle bone” diseases characterized fractures of the crowns of the teeth do not heal or homeobox family that regulate the transcription by defects in mineralized tissues that form from repair, and affected teeth often have an uncertain of other genes: Waardenburg type 1 with PAX3; a collagen-rich matrix. Osteogenesis imperfecta prognosis. Problems may develop later due to Waardenburg type 2 with MITF, 3q14.1; and presents a spectrum of deficiencies that includes damage to the pulp. Waardenburg type 3 with PAX3, 2q35. fragile bones, clear or blue sclera, deafness, loose Motor vehicle collisions ligaments, and painful dentinogenesis imperfecta- Cleidocranial dysplasia like changes in the teeth. The effects of motor vehicle collisions may range The inheritance of a regulatory gene defect in from minor and reversible effects to long-term Epidermolysis bullosa – recessive cleidocranial dysplasia leads to features that include medical, surgical and rehabilitative consequences. delayed tooth eruption, supernumerary teeth, Post-traumatic headaches and chronic oral-facial dystrophic type altered or missing collarbones, short stature and The gene defect in epidermolysis bullosa – pain can occur. Neuromuscular and glandular possible failure of cranial suture closure. The exact damage may cause short- or long-term problems recessive dystrophic type – manifests as blisters or mechanism of the associated gene, CBFA1, located bullae that appear shortly after birth on skin areas with chewing, swallowing and tearing or result in on chromosome 6, has not been determined but facial tics or paralysis. following minor trauma. Mutations in keratin genes appears to be essential for bone development. that contribute to the epithelial cell cytoskeleton Violence have been correlated with this condition. Injury The family is the single most frequent locus of The oral manifestations include both mucosal bullae The common perception is that injuries are random violence in Western society. Domestic violence and altered teeth. Altered teeth with hypoplastic occurrences that are unpredictable and hence includes child abuse, spousal and elder abuse, enamel develop and exhibit an increased unpreventable. In actuality, experts in the field and abuse of the disabled. Child abuse is of susceptibility to caries. Oral bullae develop from make the point that there are no basic scientific particular concern to the oral health community even the slightest mucosal trauma. The condition is distinctions between injury and disease. Injuries because 65 percent of cases involve head and Elite Page 35 oral-facial trauma and dentists are required to in the blood characteristic of an autoimmune encountered of these oral facial neuralgias is tic report suspected cases of child abuse. In the disorder, a labial (minor) salivary gland biopsy, douloureux, or trigeminal neuralgia, a disease young child, head injury is the most common and a series of eye tests to measure flow rate and of unknown etiology affecting one, two or all cause of death. tissue characteristics. Confirmatory tests include three branches of the trigeminal nerve. The pain an evaluation of salivary flow and chemistry. is highly intense and of a stabbing nature, and Psychological trauma from abuse can result lasts for a few seconds. This transient attack in sleep disturbances, eating disorders, Patients with Sjögren’s syndrome are at some risk may be repeated every few minutes or several developmental growth failure in young of developing diseases such as non-Hodgkin’s hours. There may be no precipitating factor, or children and nervous habits such as lip and lymphoma; clinical data indicate that such it may occur in response to a gentle touch or fingernail biting and thumb sucking. Effects lymphomas develop in 5 percent of patients with a breeze wafting across the face – a condition may also include chronic underachievement in Sjögren’s syndrome. experts call allodynia, the feeling of pain in school and poor peer relationships. In abusive Histological examination shows that immune response to a normally nonpainful stimulus. On families, physical neglect is commonplace, with cells infiltrate the glands and cluster around the other occasions, there may be a specific trigger inadequate provision of basic needs, including secretory elements, resulting in a breakdown zone. Although spontaneous remission for weeks medical and oral health care. of the normal structure of the gland. The or months may occur, it is rarely permanent. mechanisms by which this occurs involve Selected chronic pain conditions Given the unknown, unpredictable nature of tic immune-cell-mediated inflammation and Oral, dental or craniofacial signs and symptoms douloureux, it is not surprising that fear of pain stimulation of the salivary gland cells themselves play a critical role in autoimmune disorders comes to dominate these patients’ lives, as they to produce tissue-destructive molecules such such as Sjögren’s syndrome and in a number of avoid doing anything that might trigger an attack. as cytokines. Another hypothesis is that a viral chronic and disabling pain conditions. infection of the glands may trigger the immune Trigeminal neuralgia generally occurs in later life, but also occurs in younger individuals Sjögren’s syndrome response that leads to autoimmunity, whereas genetic or regulatory alterations might lead to affected by multiple sclerosis, where it is Sjögren’s syndrome is one of several autoimmune abnormalities in apoptosis. assumed to be associated with lesions (multiple disorders in which the body’s own cells and sclerosis “plaques”) in the brain stem. Medical tissues are mistakenly targeted for destruction In addition to saliva substitutes and artificial treatment depends largely on the use of a by the immune system. Like other autoimmune tears, some medications, such as pilocarpine drug that has become a virtual specific, the conditions, Sjögren’s syndrome is more prevalent and cevimeline, are prescribed to increase antiepileptic drug carbamazepine. For those among women. The ratio of females to males salivary flow from the residual healthy gland patients with no consequential adverse effects, it affected is 9 to 1, with symptoms usually tissue, again providing symptomatic relief can control the disease. An alternative for chronic developing in middle age. There are an estimated only. The problems that develop in the other sufferers is the surgical removal of a small vein or 1 million to 2 million individuals in the United organ systems are also treated symptomatically. artery that may be exerting pressure on the nerve States with Sjögren’s syndrome. At advanced stages, steroids are employed root or the selective destruction of the nerve intermittently to alleviate problems. The disease occurs in two forms. Primary fibers themselves using chemical or electrical methods. In many cases, these procedures can Sjögren’s involves the salivary and lacrimal (tear) Acute and chronic oral-facial pain glands. In secondary Sjögren’s the glandular produce complete relief from pain. Since the 19th century when two dentists, Horace involvement is accompanied by the development Wells and Frederick Morton, demonstrated the of a connective tissue or collagen disease, most Temporomandibular disorders analgesic powers of nitrous oxide and ether, oral often rheumatoid arthritis, lupus erythematosis, Various etiological factors, including trauma, health investigators have been recognized leaders scleroderma or biliary cirrhosis. can give rise to pain and dysfunction in the in the field of pain management worldwide. Their temporomandibular joint and surrounding The glandular involvement causes a marked analyses of the cells, pathways and molecules muscles, conditions collectively called reduction in fluid secretion, resulting in involved in the transmission and modulation of pain temporomandibular disorders (TMDs). The pain xerostomia and xerophthalmia (dry eyes). have given rise to a growing variety of medications, may be localized or radiate to the teeth, head, The constant oral dryness causes difficulty in often combined with other approaches, that can ears, neck, and shoulders. Abnormal grating, speaking, chewing and swallowing; the dry eyes control acute and chronic pain. Pain researchers clicking or crackling sounds, known as crepitus, often itch and feel gritty. There is no cure for today stress that chronic pain can become a in the joint often accompany localized pain. Pain Sjögren’s, and patients often carry eyedrops and disease in itself, causing long-term detrimental is also found in response to clinical palpation water bottles or saliva substitutes in an attempt changes in the nervous system. These changes of the affected structures. TMDs are common, to provide symptomatic relief. Clinically, the may affect resistance to other diseases as well as occurring in as many as 10 million Americans. reduction in salivary flow changes the bacterial effectively destroy quality of life. Most people have Although surveys indicate that both sexes are flora, which, in addition to the reduction in experienced acute pain involving teeth and the oral affected, the majority of individuals seeking salivary protective components, increases the tissues at one time or another. treatment are women of childbearing age, a risk of caries and candidiasis. Recent studies phenomenon suggesting that hormonal influences have indicated that there is a reduction in Atypical facial pain should be investigated. masticatory function and an increased prevalence Atypical facial pain is characterized by a continuous of periodontal disease. In advanced stages, the dull ache on one or both sides, most frequently in Several factors can contribute to the onset or salivary glands may swell because of obstruction the region of the maxilla (the upper jaw). The pain exacerbation of TMD symptoms. These factors and infection or lymphatic infiltration. In tends to be episodic and is aggravated by fatigue, include: both forms of the disease, other systems may worry or emotional upset. It is often accompanied ■■ Certain developmental anomalies. eventually become affected. Nasal, laryngeal by pain elsewhere in the body and depression. Once ■■ Injury to the jaw from accidents or abuse. and vaginal dryness may occur, as well as a dental cause can be ruled out, pain resolution ■■ Oral habits that greatly stress the joint and abnormalities in internal organs. depends on the successful use of antidepressants, musculature, such as tooth grinding (bruxism). psychotherapy or both. ■■ Jaw manifestations of systemic diseases such Diagnosis is difficult in the early stages, and as fibromyalgia and arthritic diseases; and women often report that it took many years Tic douloureux some irreversible treatments for initial signs and consultations with many specialists before The oral-facial region is also subject to pain and symptoms. they received the correct diagnosis. Diagnosis that can be paroxysmal or continuous along a involves demonstration of specific antibodies The multiplicity of factors that may cause or distinct nerve distribution. The most frequently contribute to TMDs has unfortunately led to Page 36 Elite a multiplicity of treatments. Most of these involving an interplay among genetic, and the extent, severity and management of treatments have not been tested in randomized environmental and behavioral factors. some of these lesions may reflect nuances due to controlled clinical trials. During the 1970s and ■■ Many inherited and congenital conditions variation in the underlying systemic condition. 1980s, many individuals underwent surgery that affect the craniofacial complex, often resulting For example, the and proved unsuccessful in many cases. in disfigurement and impairments that may necrotizing ulcerative periodontitis sometimes seen in HIV infection have been difficult to resolve Leading investigators have proposed standardized involve many body organs and systems and with routine dental curettage and prophylaxis. research diagnostic criteria to clarify the kinds affect millions of children worldwide. of pathology that can give rise to TMDs and to ■■ Tobacco use, excessive alcohol use and The appearance of soft or hard tissue classify the most common forms of TMDs. Such inappropriate dietary practices contribute to pigmentation is associated with a number of criteria could be used in designing clinical trials many diseases and disorders. In particular, diseases and treatments. Malignant melanoma and could ultimately lead to better diagnostics, tobacco use is a risk factor for oral cavity can appear in the mouth as brown or black flat or treatments and prevention. and pharyngeal cancers, periodontal raised spots. Kaposi’s sarcoma can appear as a diseases, candidiasis and dental caries, flat or raised pigmented lesion. Addison’s disease The criteria use two dimensions or axes: among other diseases. causes blotches or spots of bluish-black or dark ■■ Axis I delineates various forms of joint or ■■ Some chronic diseases, such as Sjögren’s brown pigmentation to occur early in the disease. muscle pathology. syndrome, present with primary oral symptoms. Congenital discrete brown or black patches (nevi) ■■ Axis II explores pain-related disability and ■■ Oral-facial pain conditions are common and can appear in any part of the mouth. Pigmentation psychological status. often have complex etiologies. of the tooth crowns may be seen in children with The approach requires detailed clinical The range of oral, dental and craniofacial diseases cystic fibrosis and porphyria and those exposed to examinations and patient histories. and conditions that take a toll on the U.S. during tooth development. population is extensive. This course provides The oral tissues can also reflect nutritional status A mirror, a model and a better highlights of diseases and conditions affecting understanding of diseases and disorders and exposure to risk factors such as tobacco. The Americans using available national and state data tongue appears smooth in pernicious anemia. Studying the diseases and disorders that affect to describe the burden of disease in the United Group B vitamin deficiency is associated with craniofacial tissues can provide scientists with States. There is no single measure of oral health oral mucositis and ulcers, glossitis, and burning models of systemic pathology. Because some or the burden of oral diseases and conditions, just sensations of the tongue. Scurvy, caused by craniofacial tissues, such as bones, mucosa, as there is no single measure of overall health or severe vitamin C deficiency, is associated with muscles, joints and nerve endings, have overall disease. The relationship of oral health to gingival swelling, bleeding, ulceration and counterparts in other parts of the body and these the use of dental services is described. tooth loosening. Lack of vitamin D in utero or tissues are often more accessible to research However, the effects of health care visits and of infancy impairs tooth development. Enamel analysis than deeper-lying tissues, researchers specific services rendered need further study. hypoplasia may result from high levels of studying craniofacial tissues can gain valuable fluoride or from disturbances in calcium and insights into how cancer develops, the role of Physical signs and symptoms of disease phosphate metabolism, which can occur in inflammation in infection and pain, the effects of and risk factors hypoparathyroidism, gastroenteritis, and celiac diet and smoking, the consequences of depressed A number of signs and symptoms of disease, disease. The mouth also can reflect the effects of immunity and the changes that can arise from a lifestyle behaviors and exposure to toxins tobacco use, perhaps providing the only visible mutated gene. can be detected in or around the craniofacial evidence of its adverse effects. Other craniofacial tissues, teeth, gingiva, tongue, complex. Pathogens entering the mouth may salivary glands and the organs of taste and proliferate locally with oral and pharyngeal Oral manifestations of HIV infection and smell, are unique to the craniofacial complex. signs and symptoms; other pathogens may enter of osteoporosis Study of the diseases affecting these tissues the bloodstream directly or through lymphatic The mouth can serve as an early warning system, has revealed a wealth of information about channels and cause generalized disease. Oral diagnostic of systemic infectious disease and their special nature as well as the molecules signs suspected to be indications of systemic predictive of its progression, such as with HIV and mechanisms that normally operate for the illness may be confirmed by the presence of rash, infection. In the case where oral cells and tissues protection, maintenance and repair of all the oral, fever, headache, malaise, enlarged lymph nodes have counterparts in other parts of the body, oral dental and craniofacial tissues. When factors or lesions elsewhere on the body. changes may indicate a common pathological perturb these nurturing elements, the oral health process. During routine oral examinations and Swollen parotid glands are a cardinal sign scale can tip toward disease. When those factors perhaps in future screening tests, radiographic or of infection with the mumps virus and can stem from systemic diseases or disorders, the magnetic resonance imaging of oral bone may be also be seen in individuals with Sjögren’s mouth can sometimes mirror the body’s ill health. diagnostic of early osteoporotic changes in the syndrome and HIV. The salivary glands are Similarly underscoring the connection between skeleton. The following sections provide details. also frequently involved in tuberculosis and oral and general health are studies suggesting histoplasmosis infections. Oral signs of infectious that poor dental health, mainly due to chronic HIV infection mononucleosis, caused by Epstein-Barr virus, dental infections, may heighten the risk for both The progressive destruction of the body’s immune include sore throat, gingival bleeding and cardiovascular disease and stroke independently system by HIV leads to a number of oral lesions, multiple pinpoint-sized hemorrhagic spots of factors such as social class and established such as oral candidiasis and oral hairy leukoplakia, (pettechiae) on the . There can be a cardiovascular risk factors. that have been used not only in diagnosis but also large overlap in the clinical appearance of oral in determining specific stages of HIV infection. manifestations of various diseases with different Infection and disorder highlights Oral candidiasis is rarely seen in previously etiologies, and the clinical diagnosis often ■■ Microbial infections, including those caused healthy young adults who have not received prior involves ancillary procedures, which may include by bacteria, viruses and fungi, are the primary medical therapy such as cancer chemotherapy laboratory tests, diagnostic imaging and biopsy. cause of the most prevalent oral diseases. or treatment with other immunosuppressive Examples include dental caries, periodontal Oral tissues may also reflect immune deficiency. drugs. It was associated with AIDS as early as diseases, herpes labialis and candidiasis. For example, nearly all HIV-infected individuals 1981 in the first report of the syndrome and was ■■ The etiology and pathogenesis of diseases develop oral lesions at some time during their frequently noted among otherwise asymptomatic and disorders affecting the craniofacial illness. Other immunosuppressed individuals may HIV-positive populations. Oral candidiasis may structures are multifactorial and complex, have the same lesions. However, the presentation be the first sign of HIV infection and often occurs

Elite Page 37 as part of the initial phase of infection, the acute therapeutic progress and determining outcomes bacteremia. However, these distant infections have HIV syndrome. It tends to increase in prevalence of treatment. Key issues in the development of a been seen more often in high-risk patients such as with progression of HIV infection when CD4 new generation of saliva diagnostics include their those who are immunocompromised. lymphocyte counts fall. It also appears to be the selectivity, sensitivity, response time, dynamic Oral bacteria have several mechanisms by most common oral manifestation in pediatric HIV range (values of interest), representative sampling which they invade mucosal tissues, perhaps infection and has been demonstrated to proceed to and, perhaps most important, their reliability or contributing to their ability to cause bacteremias. esophageal candidiasis, a sign of overt AIDS. Both stability as well as their ability to assess multiple For example, oral bacteria and their products the pseudomembranous and the erythematous substances simultaneously. may invade the periodontal tissues directly. forms of candidiasis appear to be important For the clinician, the mouth and face provide Actinobacillus actinomycetemcomitans has been predictors of progression of HIV infection. ready access to physical signs and symptoms found in gingival connective tissue in patients Like oral candidiasis, oral hairy leukoplakia of local and generalized disease and risk factor with localized juvenile periodontitis. Invasion in HIV-positive persons heralds more rapid exposure. These signs and symptoms augment of tissue by Porphyromonas gingivalis has also progression to AIDS. Oral hairy leukoplakia is other clinical features of underlying conditions. been described in vivo and in vitro. Although oral an oral lesion first reported in the early days of Comprehensive care of the patient requires bacteria can enter the blood through injured or the AIDS epidemic. Since its discovery, hairy knowledge of these signs and symptoms, their role ulcerated tissue, bacterial invasion of periodontal leukoplakia has been found in HIV-negative in the clinical spectrum of general diseases and tissues represents another possible mechanism. persons with other forms of immunosuppression, conditions, and their appropriate management. In the immunocompetent individual, bacteremia such as organ or bone marrow recipients and Oral biomarkers and surrogate measures are also originating from the oral cavity is usually those on long-term steroid therapy and less being explored as means of early diagnosis. With transient and harmless. However, if the frequently among immunocompetent persons. further development and refinement, oral-based individual’s immune system is compromised, diagnostics such as salivary tests can become Osteoporosis, a degenerative disease the normally harmless oral bacteria may pose widely used and acceptable tools for individuals, characterized by the loss of bone mineral and a significant risk. The morbidity and mortality health care professionals, researchers and associated structural changes, has long been associated with oral foci of infections are hard community programs. The continued refinement of suspected as a risk factor for oral bone loss. to assess. This is due to the formidable task of imaging techniques also has the potential of using In addition, measures of oral bone loss have tracking the source of an infection unless the oral imaging to identify early signs of skeletal been proposed as potential screening tests for responsible pathogen is indigenous to a specific bone degeneration. osteoporosis. Osteoporosis affects over 20 anatomic location. million people in the United States, most of The mouth as a portal of entry for infection Viridans group streptococci (VGS) have a whom are women, and results in nearly 2 million More than 500 bacterial strains have been low degree of virulence but can be associated fractures per year. The disease is more prevalent identified in dental biofilm, and more than 150 with morbidity and mortality under certain in white and Asian American women than in bacterial strains have been isolated from dental circumstances. Increased pathogenicity of black women. Oral bone loss has been reported to pulp infections. More recently, 37 unique and Streptococcus viridans is most prominent in be more prevalent in women than in men. previously unknown strains of bacteria were individuals with neutropenia (low blood counts of circulating white blood cells called neutrophils) Oral-fluid-based diagnostics: The example identified in dental plaque (biofilm). Most oral lesions are opportunistic infections – that is, and has been associated with a toxic-shock-like of saliva they are caused by microorganisms commonly syndrome (TSLS) or viridans streptococcal The diagnostic value of salivary secretions found in the mouth, but normally kept in check shock syndrome (VSSS), as well as with adult to detect systemic diseases has long been by the body’s defense mechanisms. These respiratory distress syndrome (ARDS). recognized, and oral fluids and tissues (buccal microorganisms can induce extensive localized cells) are increasingly being used to diagnose a Although a high degree of morbidity is associated infections that compromise general well-being in wide range of conditions. Saliva- and oral-based with viridans streptococcal bacteremia, a low and of themselves. diagnostics use readily available samples and incidence of mortality has been reported. do not require invasive procedures. Researchers However, they also may spread to other parts of Several studies have shown that under adverse have detected antibodies in saliva that are the body if normal barriers are breached. The circumstances, oral flora and oral infections are directed against viral pathogens such as human oral mucosa is one such barrier that provides associated with increased incidence of morbidity. immunodeficiency virus and hepatitis A virus or critical defense against pathogens and other Reduction of oral foci of infection decreases B virus. Saliva is being used to detect antibodies, challenges. Salivary secretions are a second systemic complications, specifically in severely drugs, hormones, and environmental toxins. The major line of defense. Damage to the oral neutropenic patients undergoing chemotherapy. simplest tests are those that detect the presence mucosa from mechanical trauma, infection or In addition, hospital stays for patients with oral or absence of a substance in the saliva, such salivary dysfunction with resulting derangements mucositis undergoing autologous bone marrow as various drugs. Greater technical challenges in lubricatory and antimicrobial functions of transplants were longer than for those without are presented for tests that will be used for saliva as a result of chemotherapy, radiation and oral mucositis. therapeutic monitoring since accurate levels of medications causing hyposalivation, allows a Other cohorts identified at increased risk for a substance and/or its metabolites are needed. In portal of entry for invading pathogens. systemic complications due to oral bacteria these instances the saliva/plasma concentration include hospitalized patients unable to perform ratio must be determined experimentally. Most Oral infections and bacteremia adequate oral hygiene, those receiving saliva- recently, oral fluids have been used as a source of Oral microorganisms and cytotoxic byproducts reducing medications and those taking antibiotics microbial or host DNA. associated with local infections can enter the that alter the oral flora. A positive dental plaque bloodstream or lymphatic system and cause damage Saliva has the potential of replacing blood, the culture for aerobic pathogens was significantly or potentiate an inappropriate immune response associated with the development of hospital- current standard for testing many diseases and elsewhere in the body. Dissemination of oral conditions (e.g., diabetes, infectious disease, acquired pneumonia and bacteremia in a study of bacteria into the bloodstream (bacteremia) can occur individuals in an intensive care unit. Parkinson’s disease, alcoholic cirrhosis, after most invasive dental procedures, including Sjögren’s syndrome and cystic fibrosis tooth extractions, endodontic therapy, periodontal In addition, several case reports have been sarcoidosis). Important goals for the future are surgery and scaling and root planing. Even routine published implicating indigenous oral flora in the development of new diagnostic tests for early oral hygiene procedures such as daily toothbrushing, the development of brain abscesses. This serious disease detection, defining individual patient subgingival irrigation and flossing may cause condition is associated with a mortality rate of risk of adverse response to drugs, monitoring Page 38 Elite almost 20 percent, and full recovery in only can result via reactivation of a latent virus or differences also exist. For example, in contrast to slightly more than 50 percent of all patients. a newly acquired virus. The severity of the chemotherapy-associated lesions, radiation damage These data are based on single case reports and infection, including fatal outcome, depends on is anatomically site-specific; toxicity is localized to most probably represent rare events. However, the degree of immunocompromise. irradiated tissue volumes. The degree of damage they provide additional examples that point to the depends on treatment-regimen-related factors, potential pathogenicity of the normal oral flora Radiation therapy including the type of radiation used, the total dose during special adverse circumstances. Radiation therapy disrupts cell division in healthy administered, the fractionation, and field size. Thus, tissue as well as in tumors and also affects the research involving both cohorts of cancer patients Oral infections as a result of therapy normal structure and function of craniofacial remains essential to enhancing patient management. tissues, including the oral mucosa, salivary Development of new technologies to prevent Chemotherapy glands and bone. Oral-facial complications are cancer-therapy-induced oral mucositis could Oral mucositis can be a major dose-limiting common after radiation therapy to the head substantially reduce the risk for oral and problem during chemotherapy with some and neck. The most frequent, and often the systemic infections, oral pain and the number anticancer drugs, such as 5-fluorouracil, most distressing, complication is mucositis, but of hospital days. Improvement in quality of life methotrexate, and doxorubicin. It is estimated adverse reactions can affect all oral-facial tissues. that approximately 400,000 patients undergoing and reduction in health costs are also likely and cancer therapy each year will develop oral Radiation can cause irreversible damage to the desirable outcomes. salivary glands, resulting in dramatic increases complications (NIH 1990). Infection of The new technologies could also provide a setting in dental caries. Oral mucosal alterations may ulcerated mucous membranes often occurs after in which novel classes of chemotherapeutic become portals for invasion by pathogens, which chemotherapy, especially since patients are usually drugs, used at increased doses, could be may be life-threatening to immunosuppressed immunocompromised. Bacterial, fungal, and viral implemented. These advances in turn could lead or bone-marrow-suppressed patients. A less causes of mucositis have been identified. to enhanced cancer patient survival and lengthen common but very serious adverse consequence is the duration of disease remission. The mechanism by which cancer-chemotherapy- destruction of bone cells and bone death, called induced mucositis occurs is likely associated with osteoradionecrosis (ORN). ORN can result in Pharmaceuticals the rapid rate of turnover of oral epithelial cells. infection of the bone and soft tissue and can In addition, other components likely include A number of medications used to treat systemic require surgery to excise the dead tissue, which diseases can cause oral complications, ranging upregulation of pro-inflammatory cytokines can in turn leave the face badly disfigured as well and metabolic by-products of colonizing oral from xerostomic effects to alterations in the surface as functionally impaired. The likelihood of ORN is structure of the enamel or mucosa. More than microflora. Chemotherapy alters the integrity of increased with trauma to the bone, including that the mucosa and contributes to acute and chronic 400 over-the-counter and prescription drugs have caused by tooth extraction. The risk is especially xerostomic side effects. These include tricyclic changes in oral tissue and physiologic processes. marked when the trauma occurs near the time The ulcerated mucosa is susceptible to infection antidepressants, antihistamines and diuretics. The of radiation. Management includes elimination dimensions and impact of these side effects vary by microbial flora that normally inhabit the oral of acute or potential dental and periodontal foci cavity, as well as by exogenous organisms, and depending on the response of the individual patient of disease, increased patient participation in and the duration of medication use. exacerbates the existing mucositis. Further, oral hygiene, use of oral topical fluorides for these microflora can disseminate systemically. caries prevention and use of antiviral, antifungal Staining of the teeth or mucosa is associated with Compromised salivary function can further or antimicrobial therapy for management of a variety of drugs, including tranquilizers, oral elevate risk for systemic infection of oral origin. infections associated with mucositis. contraceptives and antimalarials. The antibiotic Both indigenous oral flora and hospital-acquired tetracycline can cause enamel hypoplasia when pathogens have been associated with bacteremias Combined cancer therapies taken by the mother during pregnancy and and systemic infection. Changes in infection profiles Rapid developments have occurred in the use of by children during tooth development. The in myelosuppressed (immunosuppressed) cancer blood cell growth factors for treatment of various antimicrobial mouthrinse agent chlorhexidine also patients tend to occur in cyclic fashion over many conditions, including the anemia of end-stage renal can stain the teeth, but this staining is external and years. This evolving epidemiology is caused by disease, the neutropenia occurring with cancer care can be removed by dental prophylaxis. multiple factors including use of antibiotics. Gram- and the bone marrow toxicity and mucositis that Other drugs have been associated with gingival positive organisms including viridans streptococci can follow aggressive chemotherapy or radiation overgrowth, including cyclosporin, which has been and enterococci are currently associated with therapy. Researchers have found that topical used as an immunosuppressant in the United States systemic infection of oral origin in myelosuppressed application of transforming growth factor beta since 1984 to prevent rejection of transplanted cancer patients. In addition, gram-negative (TGF-B) in the hamster model of oral mucositis organs and bone marrow. This drug has also been pathogens including P. aeruginosa, Neisseria spp. significantly reduced basal cell proliferation and used in other countries for treatment of type 2 and Escherichia coli remain of concern. reduced the severity of mucositis associated with diabetes, rheumatoid arthritis, psoriasis, multiple 5-fluorouracil treatment. Cancer patients undergoing bone marrow sclerosis, malaria, sarcoidosis and several other radiation who have chronic periodontal disease Other growth factors considered for use in diseases with an immunological basis. Other may also develop acute periodontal infections reducing mucositis include granulocyte- drugs that cause gingival overgrowth include with systemic complications. The extensive monocyte colony-stimulating factor and calcium ion channel blocking agents used in the ulceration of gingival granulocyte colony-stimulating factor. Bone treatment of angina pectoris and postmyocardial associated with periodontal disease is not directly morphogenetic proteins are also in development syndrome, such as nifedipine and verapamil, and observable clinically, yet may represent a source for alleviating the toxicity and mucositis that phenytoin (sodium 5,5-phenylhydantoin), used in for disseminated infection by an extensive array follow chemotherapy and radiation therapy. Other the treatment of epilepsy and also for management of organisms. Inflammatory signs may be masked approaches to reducing mucositis and adverse of other neurological disorders. Treatment often due to the underlying bone marrow suppression. oral effects of chemotherapy and radiation consists of using an alternate drug, although this therapy include fractionating the dose of radiation is not always possible. Conservative periodontal Viruses are also associated with clinically and combining chemotherapy with growth factors therapy can reduce the inflammatory component of important oral disease in patients receiving or with less toxic oncostatic agents. enlargement, but surgery is often required. Drugs chemotherapy. Infections caused by herpes that cause systemic bone marrow suppression, Although the oral mucositis occurring in simplex virus, varicella-zoster virus and Epstein- oral mucosal injury or salivary compromise chemotherapy and in head and neck radiation Barr virus typically result from reactivation of a collectively promote the risk for clinical infection. latent virus, whereas cytomegalovirus infections patients shares many characteristics, distinct Elite Page 39 In addition, antibiotics and concurrent steroid Oral infections and respiratory disease protective factors in saliva. Infection with HIV therapy often alter oral flora, thereby creating an Pathogens in the oral cavity can also gain provides a case in point. environment for fungal overgrowth. In high-risk access to the airway, sometimes with serious Early in the 1980s, when AIDS was first cancer patients, fungal infection can cause severe consequences. In adults, bacterial pneumonias identified in the United States, concern was morbidity and even death. are strongly associated with aspiration of bacteria expressed about casual (i.e., nonsexual) into the lower respiratory tract, which is normally transmission of HIV. Detailed household studies Infective endocarditis sterile. Common respiratory pathogens such did not demonstrate transmission of HIV, even The purported connection between oral infection as Streptococcus pneumoniae, Streptococcus when family members shared eating utensils and a specific heart disease, infective endocarditis, pyogenes, Mycoplasma pneumoniae and and with an HIV-affected member. has a long history. Endocarditis is caused by Haemophilus influenzae can colonize the Similarly, surveillance data collected over time bacteria that adhere to damaged or otherwise oropharynx and the lower airway. In addition, oral showed no evidence of casual transmission. receptive surfaces of the tissue that lines heart bacteria including A. actinomycetemcomitans, valves (the endocardium). Dental and other surgical Actinomyces israelii, Capnocytophaga spp., Only one nonoccupational episode of HIV procedures may predispose susceptible patients Eikenella corrodens, Prevotella intermedia and transmission has been attributed to blood- to infective endocarditis by inducing bacteremias. Streptococcus constellatus can be aspirated into contaminated saliva; this incident involved intimate However, bacteremias from oral infections that the lower airways. kissing between sexual partners. There have been occur frequently during normal daily activities, a few cases of HIV transmission from performing Chronic obstructive pulmonary disease, coincidental even with chewing food, toothbrushing oral sex on a person infected with HIV, and it is also characterized by obstruction of airflow due to and flossing, contribute more substantially to the possible to become infected with HIV by receiving chronic bronchitis or emphysema and by recurrent risk of infective endocarditis. Oral organisms are oral sex. In the San Francisco Options Study of episodes of respiratory infection, has been common etiologic agents of infective endocarditis. men who have sex with men identified within 12 associated with poor oral health status. Although For example, strains of S. sanguis, as well as months of HIV seroconversion, oral transmission oral bacteria, including periodontal pathogens, gram-negative oral bacteria including Haemophilus represented 7.8 percent of primary HIV infections. have the potential for causing respiratory aphrophilus, A. actinomycetemcomitans, Rothenberg et al. (1998) reviewed epidemiologic infections, the frequency and nature of such E. corrodens, Capnocytophaga spp., and studies and reports of 38 cases of oral transmission infections are not known and merit further study. Fusobacterium nucleatum, have been associated of HIV in the literature. They concluded that although oral-genital contact may be less efficient with bacterial endocarditis. Oral transmission of infections than needle-sharing or anal intercourse for the Infective endocarditis occurs with different Besides being a portal of entry for infections, transmission of HIV, its increased use by men who incubation periods, which differ in causative the mouth is an important source of potentially have sex with men and in crack cocaine smokers bacteria and signs and symptoms. For example, pathogenic organisms and is often the vehicle by may increase its contribution to HIV transmission Staphylococcus aureus endocarditis may have a which infection is delivered to the bodies of others. over time. Several studies provide evidence that rapid onset and fatal course if it affects the left Microorganisms were not discovered in the mouth when the oral environment is compromised, the side of the heart. With a more indolent course, until the 17th century, when van Leewenhoek mouth can be a potential site of transmission of patients may often be unaware of infection and examined dental plaque using a microscope he infectious microbes. Data suggest that there is a may experience fever, night chills, myalgia had constructed. In 1884, Koch demonstrated positive association between the presence of oral and arthralgia for a considerable period of time that tuberculosis could be transmitted by airborne lesions resulting from crack cocaine use, receptive before diagnosis. The infection is often curable if droplets from the mouth and respiratory tract. oral intercourse and HIV transmission. A case diagnosed and treated early. Since that time, we have learned that many report has documented the passage of HIV from a common respiratory infections, such as influenza, The classic risk factors for endocarditis include partner who is HIV-positive to one who is HIV- the common cold, pneumonia and tuberculosis, cardiac valve disorders (valvulopathies) that negative in the presence of periodontal disease but can be transmitted from oral secretions. Before include rheumatic and congenital heart disease, in the absence of other risk factors. Because the the development of effective vaccines, orally complex cyanotic heart disease in children, and type, duration and frequency of oral contact in past transmitted diseases such as chickenpox, measles, mitral valve prolapse with regurgitation. Recent studies may not have been specified, the risk could mumps, polio and diphtheria were a major source studies indicate that the use of certain diet drugs be somewhat higher for oral transmission of HIV of morbidity and mortality in childhood. Viral (fenfluramine and dexfenfluramine) has induced than previously reported. The risk might also vary diseases such as hepatitis B, herpes labialis, acute cardiac valvulopathy, which may in some cases depending on factors such as viral load, infectious herpetic gingivostomatitis, cytomegalovirus and be transient. Among at-risk persons, bacteremias dose, area of exposure and presence or absence infectious mononucleosis may also originate from are more likely to occur in those with periodontal of oral lesions. Additional studies are needed to oral contact. disease. However, the oral pathogens causing evaluate the risk of oral-genital transmission of periodontitis have only rarely been shown to Disease-causing microorganisms can be spread HIV; some are under way. cause endocarditis. by direct contact (with saliva or blood from Other sexually transmitted diseases (STDs) the mouth) or indirect contact (with saliva- or Prevention of infective endocarditis from oral can occur through oral contact. For example, blood-contaminated surfaces, including hands or bacteria depends on limiting the entry and pharyngeal infection with Chlamydia trachomatis lips), droplet infection (from coughing, sneezing dissemination of bacteria through the bloodstream has been found in 3 to 6 percent of men and or even normal speech), or by aerosolized and lymphatic circulation. Antibiotic prophylaxis women attending STD clinics. Most infections organisms. These organisms can be inhaled, for dental procedures that are likely to provoke are asymptomatic. Another common sexually ingested or taken in through mucous membranes bacteremia has historically been recommended. transmitted infection, herpes simplex virus, in the eyes, nose or mouth or through breaks in A recent study, however, suggests that receiving commonly infects the pharynx and is seen in 20 the skin. A number of diseases can be spread via dental treatment does not significantly increase percent of patients with primary genital herpes. oral sexual contact, including gonorrhea, syphilis, the risk of infective endocarditis, even in patients The painless chancre of primary syphilis can be trichomoniasis, chlamydia and mononucleosis. with valvular abnormalities. Further research is found in the oral cavity; however, there are no necessary to determine whether some heart or As mentioned earlier, the oral mucosa and saliva data on the prevalence of this site of infection valvular conditions or certain dental procedures, provide significant defense against disease for Treponema pallidum. Among persons with such as surgery or scaling, would require coverage transmission. Epidemiological and animal gonorrhea, pharyngeal infection occurs in 3 to 7 with pre-procedural antibiotics and others would studies are providing evidence, however, that percent of heterosexual men, 10 to 20 percent of be precluded. the oral cavity may be the site for transmission heterosexual women and 10 to 25 percent of men of serious systemic infections despite the who have sex with men. Gonococcal infection Page 40 Elite can cause acute pharyngitis, but is usually alterations in connective tissue metabolism, Diabetes type not specified asymptomatic. The transmission of pharyngeal altered host immunological and inflammatory The final set of reports on the association gonorrhea to sex partners had been thought to be response, altered subgingival microflora and between diabetes and periodontal diseases rare. However, in one study, 17 of 66 men who hereditary patterns. Studies were classified by consists of seven cross-sectional studies in which had sex with men who had urethral gonorrhea type of diabetes and age of study population. the type of diabetes was not specified and was reported insertive oral sex as their only risk factor not easily determined from other information in the past two months. Type 1 diabetes provided. Four of the seven studies included Ten reports focused principally on children and The role of the mouth as a portal of entry for only adults. In the other three studies, subjects adolescents with type 1 diabetes, comparing them infection presents ever-new challenges for ranged in age from childhood to older adulthood. with groups of similar ages without diabetes. All study. Although oral tissues and fluids normally All seven studies found subjects with diabetes to but one of the studies reported greater prevalence, provide significant barriers and protection against have increased prevalence, extent, and severity of extent or severity of at least one measure or index microbial infections, at times these infections periodontal disease. of periodontal disease (e.g., gingival inflammation, can not only cause local disease but also, under Diabetes is a risk factor for the occurrence and probing pocket depth, loss of periodontal certain circumstances, can disseminate to cause prevalence of periodontal diseases. Although there attachment or radiographic evidence of alveolar infections in other parts of the body. The control is insufficient evidence of a causal association, bone loss) among subjects with diabetes, even of existing oral infections is clearly of intrinsic the findings of greater prevalence, severity, or though these investigations were conducted in a importance and a necessary precaution to prevent extent of at least one manifestation of periodontal variety of countries across several continents. systemic complications. disease in individuals with diabetes is remarkably Another set of studies on the relationship between consistent in the overwhelming majority of Associations among oral infections type 1 diabetes and periodontal disease included studies. Furthermore, there are no studies with and diabetes, heart disease/stroke and subjects with and without diabetes between the superior design features in the literature to refute adverse pregnancy outcomes ages of 15 and 35. All six studies reported greater this assessment. The studies were conducted in Recent studies have reported associations prevalence, extent or severity of at least one distinctly different settings, with subjects from between oral infections, primarily periodontal measure or index of periodontal disease. A third different ethnic populations and of different ages, infections, and diabetes, heart disease and stroke, set of studies conducted in Scandinavia looked at and with a variety of measures of periodontal and adverse pregnancy outcomes, but sufficient the relationship between periodontal disease and status. This inevitable variation in methodology evidence does not yet exist to conclude that one type 1 diabetes (or diabetes reported as requiring and study populations limits the possibility that leads to the other. This section characterizes the insulin therapy without specification of diabetes the same biases apply in all the studies. There is nature of these associations by describing the type) in adults between 20 and 70 years old. Three a need for further research using stronger designs quality of the evidence supporting the reports. of the four studies were cross-sectional, and one that also control for confounding variables such as Both observational and experimental studies were was a treatment follow-up study. All four studies socioeconomic status. accepted as admissible evidence. Where there reported greater prevalence, extent or severity of at are operative mechanisms proposed that support least one measure of periodontal disease. Glycemic control an association between oral infectious agents Several lines of evidence support the plausibility and the systemic conditions in question, they are Type 2 diabetes that periodontal infections contribute to problems introduced at the outset. There are fewer reports on the relationship with glycemic control, thus compromising the between type 2 diabetes and periodontal disease, health of diabetic patients. It has been reported The periodontal disease-diabetes connection particularly where type 2 diabetes is explicitly that the chronic release of tumor necrosis factor There is growing acceptance that diabetes identified or discernible from the ages of alpha (TNF-alpha) and other cytokines such as is associated with increased occurrence and subjects. Seven studies limited to subjects with those associated with periodontitis interferes progression of periodontitis, so much so type 2 diabetes included a comparison group with the action of insulin and leads to metabolic that periodontitis has been called the “sixth without diabetes. Two of these studies included alterations. Other studies have noted relationships complication of diabetes.” The risk is independent only adult subjects; the remaining five were between insulin resistance and active inflammatory of whether the diabetes is type 1 or type 2. Type large population-based studies of diabetes and connective tissue diseases, other clinical diseases, 1 diabetes is the condition in which the pancreas periodontal disease in Pima Indians, a group with acute infections and periodontal disease. the highest known prevalence of type 2 diabetes produces little or no insulin. It usually begins The body of literature concerning the relationship in the world. The Pima Indian studies included in childhood or adolescence. In type 2 diabetes, between periodontal infection and impaired subjects aged 5 years and older or 15 and older. secretion and utilization of insulin are impaired; glycemic control is varied in the strength, All seven studies reported greater prevalence, onset is typically after age 30. Together, these quantity, breadth and consistency of evidence extent or severity of periodontal disease among two types of diabetes affect an estimated 15.7 presented. The preliminary evidence, while subjects with diabetes for at least one measure of million people in the United States and represent encouraging, does not support a clear-cut periodontal disease. Three of these studies were the seventh leading cause of death. The goal of conclusion that treating periodontal infection longitudinal and showed that the progression diabetic care is to lower blood glucose levels can contribute to management of glycemic of periodontal disease was greater in diabetes to recommended levels. Some investigators control in type 1 or type 2 diabetes. Only studies patients than in individuals without diabetes. have reported a two-way connection between using systemic antibiotic treatment affected diabetes and periodontal disease, proposing that In addition to finding significant differences in glycemic control favorably. The results suggest not only are diabetic patients more susceptible various measures of periodontal status between that infections other than periodontitis may to periodontal disease, but also the presence of subjects with and without type 2 diabetes, a be implicated or that intensive treatment of periodontal disease affects glycemic control. number of these reports also provide estimates periodontal infections with systemic antibiotics of association and risk. Using periodontal is necessary to affect glycemic control favorably. Effects of diabetes on periodontitis attachment loss as the measure estimated that Further rigorous controlled studies in diverse prevalence and severity people with type 2 diabetes were 2.8 times more populations are warranted. Several reviews have described candidate likely to have destructive periodontal disease. mechanisms to explain why individuals When they used radiographic bone loss as the The oral infection, heart disease and with diabetes may be more susceptible to measure and controlled for other important stroke connection periodontitis. These include vascular changes, covariates, the estimate rose to 3.4. During the past decade, infectious agents have alterations in gingival crevicular fluid, become recognized as causes of systemic

Elite Page 41 diseases, without fever or other traditional signs needed to determine the extent to which these released during an acid challenge, resulting in of infection. Helicobacter pylori is associated associations are causal or coincidental. a more acid-resistant enamel surface structure. with peptic ulcers and, along with Chlamydia Fluoride also has been shown to inhibit the pneumoniae and cytomegalovirus, is now Prevention and control of dental caries process of glycolysis by which fermentable thought to be associated with increased risk for Although many caries prevention strategies, carbohydrates are metabolized by cariogenic cardiovascular disease as well as malignancies notably community water fluoridation and use of bacteria to produce acid. All these effects occur (Wu et al. 2000). Studies investigating the a fluoride-containing dentifrice, benefit adults and after the tooth erupts, while it is functioning in relationship between oral and dental infections children alike, most of our understanding of the the mouth, enabling fluoride to prevent caries and the risk for cardiovascular disease suggest effectiveness of these strategies comes from the over a lifetime in both children and adults. study of children, during a life stage when caries that there is potential for oral microorganisms, The first use of fluoride for caries prevention was incidence is high. Caries prevention programs such as periodontopathic bacteria, and their in 1945 in the United States and Canada, when have been designed and evaluated for children effects to be linked with heart disease. the fluoride concentration was adjusted in the and have used a variety of fluoride and dental drinking water supplying four communities. This Mechanisms of action sealant strategies applied separately and together. public health approach followed a long period of Infectious agents are thought to affect the Because these strategies are complementary, their epidemiologic studies of the effects of naturally risk of heart disease through several possible use in combination has the potential of virtually occurring fluoride in drinking water. mechanisms. Bacteria or viruses originating in eliminating dental caries in all children. tissues such as the lungs or oral mucosa may The success of the community water fluoridation However, dental caries is a problem for all ages. directly infect blood vessel walls. Such infection trials in reducing dental caries led to the Although direct evidence of caries preventive may be largely asymptomatic, but may cause local development of other important fluoride-containing strategies in adults is limited, the evidence that vascular inflammation and injury, which would products, such as dietary supplements and, most does exist is consistent with expected effects contribute to the development of lipid-rich plaques notably, fluoride-containing dentifrices, in the early based on experience with children. The Centers and atherosclerosis. Bacteria or viruses may also 1960s. Fluoride-containing gels, solutions, pastes for Disease Control and Prevention (CDC) interact with white blood cells or platelets, both of and varnishes were also developed for topical use, recently convened an expert work group to which integrate into the developing atherosclerotic either applied by professionals or self-applied at develop recommendations for modalities to plaque. Cells of the blood vessel wall and white home or in other settings. All of these products prevent and control dental caries based on a blood cells and platelets can release prostaglandins were tested for safety and effectiveness in reducing review of publications selected by the work group (especially PGE2), interleukins (especially IL-1), caries. Products designed for professional use and other experts. thromboxane B2 (TBX2) and tumor necrosis generally have higher concentrations and are used factor alpha (TNF-alpha). Bacterial products in the Fluoride at less frequent intervals than those designed for self-application. blood may also stimulate liver production of other Fluoride reduces the incidence of dental caries pro-inflammatory or pro-coagulant molecules such and slows or reverses the progression of existing Controlled clinical trials from the 1940s as C-reactive protein and fibrinogen. lesions (i.e., helps prevent cavities). Today, through the 1970s documented the benefits Microbes may also stimulate expression of all Americans are exposed to fluoride to some of professionally applied fluoride in reducing tissue factor, which would activate coagulation. degree, and there is little doubt that widespread dental caries, and several excellent reviews are During the process of coagulation, platelets use of fluoride has been a major factor in available. Professional application of fluoride would become trapped in the growing clot or the overall decline in recent decades in the is inherently more expensive than self-applied thrombus. Microthrombus formation is one of the prevalence and severity of dental caries in the methods, so the use of such an approach for key factors in the development of atherosclerotic United States and other economically developed groups and individuals at low risk of dental caries plaques. As atherosclerotic plaques enlarge, the countries. Fluoride is the ionic form of the is unlikely to be cost-effective. For patients at lumen of the coronary blood vessels narrows and element fluorine, the 13th most abundant element high risk of dental caries, however, professionally the blood supply to the heart muscle becomes in the crust of the Earth. Because of its high applied fluoride is still considered cost-effective. reduced. A frank heart attack or myocardial affinity for calcium, fluoride is mainly associated It is not clear whether fluoride varnishes and infarction results when a larger part of the with calcified tissues (i.e., bones and teeth). The gels would be most efficiently used in clinical coronary artery lumen becomes occluded. Failing ability of fluoride to inhibit, and even reverse, programs targeting groups at high risk of dental to receive enough blood, the heart muscle dies, the initiation and progression of dental caries is caries or whether they should be reserved for resulting in an infarct. well known. Fluoride’s mechanisms of action individual high-risk patients. ■■ The oral cavity is a portal of entry as well as include incorporation of fluoride into enamel The U.S. Preventive Services Task Force and the site of disease for microbial infections pre-eruptively, inhibition of demineralization, the Canadian Task Force on Periodic Health that affect general health status. enhancement of remineralization and inhibition Examination affirm that there is strong evidence ■■ The oral cavity and its functions can be of bacterial activity in dental plaque. to support the major methods for providing adversely affected by many pharmaceuticals A variety of theories regarding fluoride’s fluoride to prevent dental caries. and other therapies commonly used in mechanisms of action account for the range treating systemic conditions. The safety of fluoride is well documented and of fluoride products available. The initial has been reviewed comprehensively by several ■■ The oral complications of these therapies theory of action was based on the belief that can compromise patient compliance scientific and public health organizations incorporation of fluoride into the hydroxyapatite (Institute of Medicine (IOM) 1997, National with treatment. Individuals such as of developing tooth enamel in the pre-eruptive immunocompromised and hospitalized Research Council (NRC) 1993, Newbrun 1996, phase reduced the mineral’s solubility, thereby U.S. Department of Health and Human Services patients are at greater risk for general increasing enamel resistance. Because of the morbidity due to oral infections. (USDHHS) 1991, World Health Organization length of time the tooth is at risk of caries during (WHO) 1984). When used appropriately, fluoride ■■ Individuals with diabetes are at greater risk the post-eruptive phase, however, the topical for periodontal diseases. has been demonstrated to be both safe and effects of fluoride are considered to predominate. effective in preventing and controlling dental ■■ Animal and population-based studies These effects are based on fluoride’s role in have demonstrated an association between caries. The IOM (1997) classified fluoride as the aqueous phase around the tooth, both in a micronutrient, citing it, along with calcium, periodontal diseases and diabetes, saliva and in dental biofilm (plaque). Fluoride cardiovascular disease, stroke and adverse phosphorus, magnesium and vitamin D, as an in plaque contributes to the remineralization of important constituent in maintaining health. pregnancy outcomes. Further research is demineralized enamel when bound fluoride is

Page 42 Elite Appropriate use of fluoride products can in the control city, Muskegon, Mich. Dramatic to the pit-and-fissure surfaces of teeth. The minimize the potential for enamel fluorosis, a declines in dental caries among children in Grand material hardens within 60 seconds or so into broad term applied to certain visually detectable Rapids and three other cities conducting studies a thin, hard, protective coating. Sealants were changes in the opacity of tooth enamel associated shortly thereafter led to fluoridation in many introduced in the late 1960s and received the with areas of fluoride-related developmental other cities. In an extensive review of 95 studies American Dental Association Seal of Approval hypomineralization. There are also many conducted between 1945 and 1978 reported in 1976. Most of the dozen products approved developmental changes in enamel that are not the modal caries reduction following water by the ADA do not contain a therapeutic agent, fluoride-related. Most enamel fluorosis seen fluoridation to be between 40 and 50 percent for but work by providing a physical barrier that today is of the mildest form, which affects neither primary teeth and 50 and 60 percent for permanent prevents microorganisms and food particles from aesthetics nor dental function. Cosmetically teeth. Fluoridation also benefits middle-aged and collecting in the pits and fissures. First-generation objectionable enamel fluorosis can occur when older adults. Benefits to adults include reductions sealants used ultraviolet light to harden or “cure” young children ingest higher than optimal in both coronal and root caries. the material; improved second- and third- generation sealants cure by chemical or visible amounts of fluoride from any source while tooth These benefits are important because older light activation, respectively. enamel is forming (up to age 6). Its occurrence people typically experience gingival recession, appears to be most strongly associated with the which results in exposed root surfaces, which are Sealant placement requires meticulous attention total cumulative fluoride intake during the period susceptible to caries. In addition, tooth retention to technique, but they can be successfully of enamel development, but the condition’s in older U.S. cohorts has increased in recent provided in “field” settings using portable dental severity depends on the dose, duration and timing decades, so that the number of teeth at risk for equipment. To be most effective, sealants should of fluoride intake. Specific recommendations caries in older age groups is also increasing. be placed on teeth soon after they erupt, but they have been made to control fluoride intake by can be applied across a wide age range. Not only Finally, many medications used to treat chronic children during the years of tooth development. does the risk for caries continue across the life diseases common in aging have the side effect span, but an individual’s risk also can increase for Fluoridation of drinking water of diminished salivary flow, depriving teeth any number of reasons. Sealants are particularly For more than half a century, community water of the many protective factors in saliva. Other helpful for persons with medical conditions fluoridation has been the cornerstone of caries evidence of the benefits of fluoridation comes associated with higher caries rates, children prevention in the United States; indeed, CDC from studies of populations where fluoridation who have experienced extensive caries in their has recognized water fluoridation as one of has ceased. Examples in the United States, primary teeth, and children who already have the great public health achievements of the Germany and Scotland have shown that when incipient caries in a permanent molar tooth. 20th century. All water contains at least trace fluoridation is withdrawn and there are few other fluoride exposures, the prevalence of caries amounts of fluoride. Water fluoridation is the Efficacy increases. In Wick, Scotland, which began water controlled addition of a fluoride compound to a Initial clinical trials using a random half-mouth fluoridation in 1969 but stopped it in 1979, the public water supply to achieve a concentration design and first- or second-generation sealant caries prevalence in 5- to 6-year-olds with limited optimal for dental caries prevention. In the materials established their efficacy. Several exposure to other sources of fluoride increased 1940s, it was concluded that 1 ppm (part per comprehensive reviews and a meta-analysis of by 27 percent between 1979 and 1984. This was million) fluoride was the optimal concentration the amount of caries prevented testify to the despite a national decline in caries and increased for climates similar to that of the Chicago area; utility of these materials a systematic process availability of fluoride-containing dentifrices. this concentration would significantly reduce the to select and review studies of one-time sealant prevalence of dental caries with an acceptably placement on permanent teeth in subjects low prevalence of enamel fluorosis. Fluoride mouth rinses Several different formulations of fluoride unexposed to other preventive measures. Pooled Current U.S. Public Health Service (USPHS) mouthrinses are available, differing in the results from 17 studies meeting their selection recommendations for fluoride use include an amount of fluoride and suggested frequency of criteria found that second-generation sealants optimally adjusted concentration of fluoride use. Rinses with low fluoride concentrations reduced caries over 70 percent. in drinking water ranging from 0.7 to 1.2 (0.05 percent neutral sodium fluoride or 0.1 These early trials firmly established retention ppm, depending on the mean maximum daily percent stannous fluoride) are designed for daily as essential to preventing caries; a sealant is air temperature of the area. A lower fluoride use and are available over-the-counter. Higher- virtually 100 percent effective if it is fully concentration is recommended for communities concentration rinses (0.2 percent sodium fluoride) retained on the tooth. in warmer climates than cooler climates because are designed for weekly use and are available it is assumed that persons living in warmer only by prescription or in public programs. Effectiveness climates drink more tap water. Administrators of school-linked sealant programs Dental sealants and of school-based programs with either fixed Effectiveness The pits and fissures that characterize the biting clinics or portable equipment reported on their Numerous studies in naturally fluoridated surfaces of posterior teeth provide a haven experiences with these programs. These studies, areas preceded the field trials. There are no for food debris and decay-causing bacteria. using second-generation sealants, have shown randomized, double-blind, controlled trials of Not surprisingly, these sites are often the first effectiveness results comparable to those of water fluoridation because its community-wide and most frequent to be affected by decay in clinical trials, regardless of the physical delivery nature does not permit randomization of people children and adolescents. The width of most site or personnel used for sealant application. to study and control groups. Similar results have pits and fissures is narrower than a single Complete retention after approximately one year been derived from numerous well-conducted field toothbrush bristle, making cleaning of their varied from 83 to 94 percent. studies by various investigators on thousands deepest recesses almost impossible. According A Consensus Development Conference sponsored of subjects in different parts of the world. to national estimates, as much as 90 percent of by the National Institutes of Health concluded Conducting a study in which individuals are all dental caries in schoolchildren occurs in pits that “an extensive body of knowledge has firmly randomized to receive or not receive fluoridated and fissures. The teeth at highest risk by far are established the scientific basis for the use of water is unnecessary and is not feasible. permanent first and second molars. sealants.” The panel urged the development of In 1945, Grand Rapids, Mich., became the first Enamel bonding, a technology introduced in the educational materials to enhance public and city in the United States to fluoridate its water mid-1950s, led to the development of sealants. professional acceptance as well as third-party supply; the oral health of its schoolchildren was These are clear or opaque plastic resinous reimbursement. Consensus on the value of periodically compared with that of schoolchildren materials designed for professional application sealants is reflected by the inclusion of sealant Elite Page 43 objectives in Healthy People 2000 and Healthy diseases affecting the periodontal tissues. These knowledge about the teratogenic effects of People 2010. In addition, sealant placement efforts have met with some success, but they prescription drugs, such as the antiepileptic drug is supported in federally funded programs for tend to reach only those people who already use phenytoin and the retinoic acid drugs used to treat women and children, and sealants are covered dental services. Currently, there are no broad cystic acne. services in all state Medicaid programs. A community-based intervention programs that As information from developmental biology, workshop on guidelines for sealant use has address periodontal diseases. genetics and epidemiologic and clinical studies made recommendations for sealant use in both Gingivitis can be controlled with available accrues, dental care providers are better community and individual care programs. methods, and its control is the principal positioned to provide counseling. The public way to prevent periodontitis. However, the is best served by health promotion and disease Community dental sealant programs currently available methods are individually or prevention campaigns that communicate findings Several community-based public health initiatives professionally based and require conscientious about risk and protective factors in pregnancy. have arisen to promote sealant use among private oral hygiene practices and regular dental visits. practitioners and through community-based Although some schools instruct children in proper Prevention and control of intentional and programs. These activities include reaching methods of oral hygiene, no community methods, unintentional injury dentists through continuing education courses; other than programs designed to discourage Intentional and unintentional injuries are related directing large-scale promotional activities to tobacco use, are available for preventing gingivitis to behaviors and are thus amenable to prevention. consumers, community leaders and third-party or periodontitis in the general population. As studies of motor vehicle and sports injuries payers; and providing sealants directly to children have demonstrated, injuries are frequently due in school programs. Prevention and control of craniofacial to a sequence of predictable events, and a public Prevention and control of periodontal diseases birth defects health approach can be successful in injury Periodontal diseases, caused by specific bacteria The causes of craniofacial birth defects are often prevention and control. complex and multifactorial, the result of gene- in dental plaque, affect most adults at some point The interventions that have proved to be most environment interactions occurring from the time in their lives. The mildest and most common form effective in controlling injuries have been of conception to birth. Even when a mutation in of periodontal disease is gingivitis. Over time, passive; that is, they do not require the individual a single gene has been discovered as the cause of periodontitis, the more severe form of periodontal to participate. Examples include the use of a particular syndrome, there can be considerable disease, can lead to the destruction of the soft environmental controls such as vehicle and variation in susceptibility, with some infants tissue and bone that anchor the teeth into the jaw. roadway design, speed limits, passenger restraints showing little or no sign of a problem and others Lacking support, teeth can loosen and be lost. and airbags to prevent injuries from motor vehicle experiencing multiple organ defects. Periodontal diseases can be prevented and collisions. Passive measures such as these are controlled through an array of mechanical and The work to complete the mapping and sequencing more easily implemented at the state or federal chemical means. Conscientious oral hygiene of the human genome will undoubtedly shed light level. However, many preventive measures for and professional oral cleanings to reduce plaque on the hundreds of genes involved in craniofacial oral-facial injuries have been directed at the can reverse gingivitis. Methods for personal development and provide details on when and how individual and professional health service levels, oral hygiene include toothbrushing and flossing, they function in development. This knowledge rather than at the population at large. which may be augmented by over-the-counter and may in turn lead to gene therapies that restore or Craniofacial injuries prescription mouthrinses with antimicrobial action. “rescue” the function of a defective gene and thus prevent the anomaly. The principal causes of craniofacial injuries are motor vehicle collisions, falls, assaults Community programs to prevent gingivitis Craniofacial defects also may occur because the and sporting activities. Except in relation to With the confirmation of specific bacteria in susceptible embryo or fetus was exposed to an sports, injuries to the craniofacial region have dental plaque as the cause of gingivitis, public environmental teratogen, a diminished oxygen received little attention. These injuries are hardly health officials began to seek ways to educate supply or a deficit in an essential nutrient. An insignificant, however, and efforts to prevent the public about plaque control in community association may exist between low-birth-weight, them are gaining acceptance. For example, to settings, primarily in schools. These efforts have premature babies who may show other subtle increase public awareness of the importance of had equivocal results. Although knowledge craniofacial anomalies and mothers with chronic facial protection, the inaugural National Facial and attitudes were enhanced in demonstration oral infectious disease. programs, improvements in plaque levels and Protection Month was celebrated in April 2000. In addition, diets poor in folic acid increase gingivitis were short-lived in clinical trials. This national campaign, providing information to the risk of spina bifida and possibly clefting the media and the public, was sponsored by the Prevention of periodontitis syndromes. Clinical trials using vitamin American Association of Oral and Maxillofacial supplementation with varying levels of folic Tobacco use is a major risk factor for the Surgeons (AAOMS 2000). acid are under development to determine development and progression of periodontal Motor vehicle collisions are the leading cause whether they can lower the risk of clefts in diseases, and proven strategies aimed at reducing of death during the first three decades of life in high-risk pregnancies. Outcomes of clinical tobacco use should aid in the prevention of the United States and the leading cause of death trials of nutrient supplementation in pregnancy periodontitis. The following section on oral from injury over most of the life span. Data may lead to new nutritional guidelines and the and pharyngeal cancers includes a discussion from multiple sources indicate that craniofacial development of enriched food products, which of such intervention strategies. Until recently, injuries account for a substantial subset of these can form the basis for community-wide health most interest in controlling tobacco use reflected injuries annually. Even though it is likely that promotion and disease prevention programs. concerns about oral cancers. As appreciation passive measures enacted to reduce fatalities of the role of tobacco in the progression of Given the array of variables affecting prenatal have reduced nonfatal craniofacial injuries, no periodontal diseases and tooth loss increases, growth and development, the key to public health supporting data exist. attention to these oral health effects may increase programs aimed at preventing birth defects lies Various sources report the number of motorcycle- attention to tobacco cessation in primary primarily in health promotion and education and pedal-cycle-related craniofacial injuries. Data oral health care. Periodontitis can also be a campaigns. Individuals need to be made aware of from the National Electronic Injury Surveillance complication of poorly controlled diabetes. known risk and protective factors in pregnancy. System indicate that head injuries account for Such programs should emphasize the importance Some efforts have been directed at alerting dental 50 percent of all pedal-cycle-related injuries; of good nutrition, avoidance of tobacco and practitioners to the need to educate patients about of those, bicycle-related events accounted alcohol use, and prenatal care. Education includes Page 44 Elite for 19 percent of all facial injuries within the Because the topical benefits of fluoride have been Provider-based care study period. In similar studies, tricycle-related shown to be highly effective and daily exposure The range of conditions and diseases that affect incidents were found to be responsible for up to to small amounts of fluoride can reduce the the craniofacial complex is extensive and can 61 percent of injuries to the head, face or mouth. risk of dental caries in all age groups, experts provide clinicians with important indications Motorcycle injuries are a major source of fatal recommend that all persons drink water with about the patient’s general as well as oral health and nonfatal head trauma in the United States. an optimal fluoride concentration in addition status. Management of the oral health, general Helmet use reduces head and facial injuries to brushing daily with a fluoride dentifrice. health interface calls for interdisciplinary and among bicyclists and motorcyclists by up to 50 This combination provides a cost-effective coordinated care and an enhanced role for percent. Health promotion efforts have increased and easy way to prevent dental caries and is an primary care providers. Dentists, oncologists, acceptance at the community level for helmet use excellent example of the individual-community dermatologists, infectious disease specialists, by bicyclists; however, helmet use regulations vary partnership. For persons at low risk of dental hematologists, endocrinologists, plastic surgeons by state and with the public whim. Over a dozen caries, these two exposures to fluoride may be and rheumatologists are just a few of the states currently have bicycle helmet laws, and half the only ones necessary. For persons at moderate specialists who may be involved in the diagnosis of the states have motorcycle helmet laws. or high risk of dental caries, additional fluoride and management of conditions affecting the may be helpful and can come from daily use craniofacial complex. Many authors have described craniofacial of another fluoride product. These can include Dentists, their allied staff and medical and injuries related to sports. Information is usually mouth rinses, prescribed supplements and nursing personnel are in a unique position to obtained from community or regional surveys professionally applied topical fluoride products. of injuries or mouthguard use and effectiveness. incorporate new approaches for prevention, Craniofacial injuries sustained during sporting Daily hygiene and the prevention of diagnostic and treatment strategies in their practices. Advances in oral science are providing activities are a major source of nonfatal injury periodontal diseases the basis for a shift in emphasis from the and disability, possibly accounting for up to Toothbrushing and flossing also play a critical role one third of all sports injuries. The increasing repair and restoration of damaged tissues to in the prevention of periodontal diseases. Unlike earlier diagnoses, control of infections and participation of women in competitive sports dental caries prevention, prevention and control of means that young women should be alerted to remineralization and regeneration of lost tissues. gingivitis and periodontitis are achieved directly The application of risk-assessment strategies and the risks and advised of the need for additional through the mechanical removal and disruption protective gear as appropriate. interventions tailored to individuals and groups of dental plaque. Some dentifrices also contain is expanding with the increased understanding of Health professionals are in an ideal position to chemical therapeutics to control the formation of risk factors and the development of biomarkers provide up-to-date health information and care to tartar (calculus) and to reduce plaque formation that signal host resistance, susceptibility, and the their patients. They also have an opportunity to and gingival inflammation. Both manual and presence and progression of disease. enhance their knowledge and practices as well as electric toothbrushing are effective at removing increase their communication to patients about plaque and preventing gingivitis. The changing demographics of the U.S. population and a greater understanding of the the procedures they provide and the reasons for Interproximal (between the teeth) cleaning is these procedures. relationship between oral health and general also important in maintaining gingival health. In health are presenting new challenges. Making one short-term evaluation of adults, the addition clinical decisions for patients requires integrating Daily hygiene and dental caries prevention of flossing to the daily regimen of brushing The use of a fluoride-containing dentifrice is a range of interacting biological, psychological, resulted in an almost twofold reduction in social, cultural and environmental factors. In critical for dental caries prevention. Even more gingival inflammation. beneficial than the physical removal of plaque in order for disease to manifest, the etiologic toothbrushing is the delivery of a small amount of Because preventive measures in periodontics rely agent(s) must be present, the host must be fluoride to the tooth surfaces. Investigators have mainly on the removal of bacterial plaque and susceptible, the environment conducive and conducted numerous clinical trials on fluoride calculus, methods typically include personal oral sufficient time available for the factors to interact. dentifrices using rigorous designs and including hygiene measures combined with professional Early diagnosis and prompt treatment require randomized groups, double-blind designs and diagnostic and prophylactic measures (i.e., an understanding of the pathology and of the placebo controls. All together, these studies provide regular exam and cleaning). Periodic professional diagnostic, prevention and treatment modalities strong evidence that using a fluoride dentifrice is care for removal of plaque and calculus deposits available. As genetic information accumulates, effective. Fluoride dentifrices account for more has also been demonstrated to improve the clinical judgments will increasingly be informed than 90 percent of the market in the United States, periodontal health of participants. by knowledge of an individual’s genetic Canada and other developed countries. susceptibility or resistance to particular diseases Healthy lifestyles and disorders. The development of tailored A fluoride dentifrice is an effective means of There is more to the individual’s role in treatment plans will require incorporating reducing the prevalence of dental caries for all promoting oral health and hygiene than brushing all these factors together with input from persons. Although children’s teeth should be and flossing. Other behaviors that have an the patient’s health providers, taking into cleaned daily from the time they erupt, parents influence on oral health include use of tobacco consideration the patient’s interests and needs. and caregivers should consult a dentist or other and/or alcohol products, diet, oral habits such health care provider about the use of a fluoride as bruxing and clenching the teeth, and use of Changing approaches to selected diseases dentifrice for children under the age of 2. For helmets, mouthguards or other protective devices. children under 6, fluoride dentifrices should be and conditions used in small amounts to minimize swallowing Individuals can obtain credible information The science and technology base is providing of the product. Mild enamel fluorosis can result regarding oral health from various sources, new approaches to risk assessment, diagnosis, from excessive dentifrice use, because children including health care providers, professional prevention and treatment. Highlights of selected under 6 do not have adequate control of the organizations, government agencies and patient diseases and conditions follow. swallowing reflex or may intentionally swallow advocacy groups. Increasingly, the World Wide a flavored dentifrice. Experts recommend that for Web is a source for health care information. For Dental caries children under 6, the parent or caregiver should example, the National Oral Health Information Dental caries is caused by a transmissible supervise toothbrushing, apply a pea-sized amount Clearinghouse offers information on oral health, microbial infection that affects tooth mineral. (0.25 gram) of dentifrice to the toothbrush, and with an emphasis on special-care patients and A number of factors play a role in the initiation encourage the child to spit out the excess. their health care providers. and progression of the disease, including bacterial biofilm, specifically the presence of Elite Page 45 mutans streptococci and species of lactobacilli; soft to tactile probing and radiolucencies are used addition, fluoride-containing prophylactic pastes the frequency of simple sugars in the diet; the to detect the effects of this disease. The most are available for professional application. Clinical flow and composition of saliva; the availability common diagnostic approaches include visual judgment of risk factors determines the type and of fluoride; the structure of tooth mineral in a inspection, the use of an explorer (a probelike frequency of interventions needed. Although given individual; and oral hygiene behaviors. instrument) to determine the integrity of the there is general agreement on the overall Sound caries management takes all these factors tooth surface, the use of a light source to detect value of topical fluorides in reducing dental into account. Today there is the prospect that difference in reflectance across tooth structure caries, comparative clinical trials are needed clinicians will be able to balance protective and (transillumination) and radiographs. to determine which of the existing fluoride pathologic factors and work with the patient to The most basic diagnostic methods – visual alone formulations (acidulated phosphate fluoride, control disease. and visual examination with an explorer – have stannous fluoride, amino-fluoride or sodium limited sensitivity but excellent specificity. The fluoride) and which delivery system (gel, varnish, Risk assessment visual examination may be combined with a dentifrice or solution) are most efficacious. Reviews of caries risk prediction models radiographic series for the initial assessment. A second line of defense is through control of conclude that clinical variables, especially past Bite-wing radiographs are frequently used to the etiologic agent. Chemotherapeutic agents caries experience, are the best predictors of new diagnose interproximal caries (between teeth) and (including the antimicrobial mouthrinse agent caries experience. At the time of initial tooth for these surfaces provide excellent sensitivity chlorhexidine and fluoride) can be used to reduce eruption, the presence of mutans streptococci and specificity. Radiographic examination plaque. Dietary measures aimed at reducing appears to be the primary predictor of future allows examination of otherwise inaccessible the frequency and quantity of sugars and the caries. With continued tooth eruption, this areas. Specifically, the depth of a lesion and its substitution of sugars by sugar-free sweeteners variable disappears as a primary predictor and relationship to the pulp chamber can be evaluated may effectively starve the bacteria. is replaced by the status of the most recently for interproximal lesions. However, radiographs exposed or erupted tooth surface. For example, The process of tooth demineralization and re- are of little value in detecting caries on the the presence of carious lesions in the primary mineralization has received significant attention occlusal surfaces of the teeth. For these surfaces, incisors has been found to be the best predictor of over the past four decades. Investigators are a negative radiographic diagnosis does not imply caries in the later-erupting primary molars. studying the effectiveness of therapeutic agents lack of a carious lesion in enamel. for arresting carious lesions and remineralizing Despite recent declines, dental caries is a Precavitated carious lesions and caries in restored enamel in populations at high risk for dental prevalent disease, with some age and population teeth pose an additional diagnostic challenge. A caries. For example, a combined chlorhexidine- groups particularly vulnerable. A guide for review of the literature on the clinical diagnosis fluoride solution can enhance remineralization the identification of vulnerable patients and of precavitated carious lesions concluded of incipient lesions and arrest caries in patients the treatment of caries as an infectious disease that visual detection of these lesions has low who suffer from radiation-induced caries. The use developed by the American Dental Association sensitivity and moderate specificity. It is difficult of a twice-daily rinse with 0.05 percent sodium proposes questions to be considered at an initial with these lesions to determine whether there fluoride to prevent demineralization and induce examination. These questions, together with are no caries or whether only the enamel or remineralization in subjects with radiation-induced information gathered at recall examinations, outer layer of dentin is involved. Carious lesions hyposalivation has also been found to be effective. allow classification of child and adult patients forming around restorations are seen more into high-, moderate- and low-risk disease This study also addressed the effects of frequently at the approximal and cervical margins categories. This approach has been incorporated chlorhexidine use alone, which has been of these restorations. Distinctive color changes in a variety of caries risk assessment forms associated with tooth staining, alterations in around a restoration alone are not diagnostic adopted by some dental schools and managed taste and potential hypersensitivity reactions. of active caries. Currently, the progression of care programs. Studies are needed to determine It showed that the application of 40 percent carious lesions is the most definitive diagnostic the validity and reliability of such approaches for by weight chlorhexidine varnish every three parameter for disease activity. Progression can be different patient populations and practice settings. months enhanced remineralization of root determined over specific time intervals only by caries more than fluoride varnish, although both The use of tests to assess caries risk to professional assessment. treatments were associated with fewer filled root determine the activity status of preclinical surfaces than the control group after one year. A disease is becoming more widespread. A range Prevention chlorhexidine varnish has not yet been approved of diagnostic aids for caries activity testing are The primary prevention of dental caries starts in the United States, and large-scale, double- available. Microbial tests can detect the presence with adequate prenatal and perinatal nutrition blind, placebo-controlled clinical trials are not yet and quantify the levels of lactobacilli and mutans to ensure normal development of the teeth available to test the effects of specific regimens in streptococci. The development and use of these and supporting structures. It continues with relation to caries risk. tests are based on studies that have associated interventions aimed at preventing transmission these microbes individually and together with of cariogenic microbes from caregivers to Studies also are evaluating interventions to different types of carious lesion development. infants, and proceeds with specific strategies prevent mutans streptococci transmission. Measurements of plaque and salivary pH have employed across the life span. These approaches Findings from cross-sectional studies indicate been used to evaluate the oral environment include the provision of sufficient fluoride, the that infants are initially infected by their overall and to note the changes in pH that occur use of dental sealants, the adoption of healthy parents, specifically mothers, around the time after eating various foods. Salivary flow and behaviors, including avoiding unhealthy dietary the teeth erupt. A longitudinal study using DNA composition analyses add another dimension. practices and practicing appropriate oral hygiene, fingerprinting demonstrated that mothers were Decreased flow has been related to caries and the timely use of care services. Although the source of the bacteria in their infants and the susceptibility, as have increases in viscosity. many factors are brought to bear on the primary degree of matching to maternal strains was higher These factors warrant further study to determine prevention of dental caries, the combination of for female infants than for males. their sensitivity and specificity. fluoride in its multiple forms and dental sealants Based on a study of child-mother pairs (with the is the foundation. child initially at 1 year of age), the application of Diagnosis Fluoride is available in a variety of products that a 1.0 percent chlorhexidine rinse alternated with Clinical signs, patient-derived history and can be used by health professionals, individuals a 0.2 percent sodium fluoride gel to the mother’s radiographic images remain the primary means and public programs. Topical solutions and teeth (three times per day on two consecutive of dental caries diagnosis. Tooth surface pitting gels, mouth rinses and dentifrices are available days, twice per year for three years) delayed, and and cavitation, white and/or brown spots, areas for daily, weekly or as-prescribed frequency. In in some cases prevented, the colonization of their Page 46 Elite children’s teeth by mutans streptococci. Timing are not yet part of routine practice. However, they is involvement of the soft tissue and bone that of colonization has been shown to be correlated could potentially be used for close monitoring support the teeth. If untreated, periodontitis may with caries prevalence. In a longitudinal study of the lesions and for patient motivation. Laser progress and result in abscesses, mobile teeth and that followed children in four-month intervals treatments for soft tissue surgery have been used tooth loss. Periodontitis also may be associated from 15 months to 4 years of age, children in in recent years. Currently, in vitro with certain systemic diseases and conditions. who were infected earlier had a higher caries studies are under way for the application of lasers Gram-negative anaerobic bacteria in plaque are prevalence than those in whom the infection for hard tissues, specifically to prevent dental implicated as causative agents in periodontitis. was detected at later ages. Studies also have caries by altering tooth mineral and inhibiting However, host immune system factors, been aimed at reducing the levels of cariogenic progression of artificial caries-like lesions. specifically, a chronic inflammatory response, are bacteria in the infants themselves. Despite the best efforts of the individual and health now considered to be the primary determinants Work continues on the development of a caries care provider, caries may progress. Advances in of disease progression and outcome. The disease vaccine. One approach focuses on the production materials science over the last two decades have process is very similar across the different types and release of antibodies against cariogenic bacteria fortunately led to major improvements in dental of periodontal disease and involves interactions antigens. Specific antigens have been purified and restorative materials, resulting in a wide range of between infectious agents and their virulence synthesized. Another approach involves biological aesthetically pleasing, longer-lasting restorations factors and host defense mechanisms, operating replacement therapy, where nonpathogenic bacteria that can be placed with less trauma. Traditional within a context of environmental, acquired instilled in the mouth prevent pathogenic bacteria materials such as amalgam fillings and gold and genetic risk factors specific to a given from colonizing. Yet another approach employs crowns are now augmented by aesthetic materials, individual. Sufficient knowledge of demographic passive immunization in which antibodies, including bonded composite resins, porcelain and systemic risk factors and indicators has produced outside the body (in cultures, animals, fused to metal crowns and facings. been acquired to guide clinical decisions in eggs, or plants), are applied to the teeth and oral the management of periodontal diseases. The When teeth have been lost, the options for tissues to protect against disease. A recent study presence of pathogenic bacteria, poor oral rehabilitation include a range of prosthetic indicated that “plantibodies” painted on the teeth hygiene, tobacco smoking, diabetes mellitus and devices. Removable full and partial dentures and could prevent mutans streptococci colonization for pre-existing periodontal disease are some of the fixed bridges provide aesthetic and serviceable 120 days, the period of the experiment. factors that contribute to the likelihood of disease restorations for many patients. Still another presence, progression and treatment outcomes. option is the use of dental implants. These are Treatment used not only in patients who have lost teeth due A systematic identification of risk factors, indicators Prompt treatment of early carious lesions permits to caries and periodontal diseases, but also to and predictors has been proposed as the first step the preservation of tooth structure through restore form and function in patients treated for in diagnosing and managing periodontal diseases. conservative approaches. A 10-year study reported trauma, craniofacial cancers, hereditary tooth Clinicians can weigh the known risks for individual that caries did not progress under a dental sealant defects and other abnormalities. patients and devise treatment plans appropriate placed over cavitated lesions where the lesions to their risk category. These same factors and the were no more than halfway through the dentin. The evidence base for the survival of the outcomes of treatment can also be used to assess endosseous dental implants, an implant Materials that can bond to enamel and to dentin prognosis upon completion of therapy. Studies are that is placed directly into a tooth socket, is continue to be refined and improved. Glass under way to determine the feasibility and validity extensive and has been recently reviewed. The ionomer cements have contributed to materials that of assessing a complex of risk factors to predict predictability of endosseous dental implants in can bond to enamel and dentin, release fluoride states of periodontal health and disease. fully and partially edentulous patients has been and increase remineralization in adjacent teeth. clearly demonstrated in longitudinal studies. Most recently, putative genetic markers for These cements, together with polymeric resin Many implant designs and surfaces have shown susceptibility for oral disease have been composites and hybrids of these two materials, high success rates (often exceeding 95 percent studied. In particular, a specific genotype of the are now available for tooth restoration with other in good-quality bone and 85 percent in poorer- polymorphic IL-1 gene cluster has been shown materials. Based on the available materials and quality bone, such as the posterior maxilla). to be associated with severe periodontitis in emerging techniques, such as air and nonsmokers. IL-1-beta is of interest because the laser ablation, restoration procedures are more Rehabilitation of lost tooth structure or even the proinflammatory cytokines are key regulators of conservative than ever before. whole tooth itself may be revolutionized in the the host immune response to microbial infection next century, based on discoveries of the natural A proposed categorization of carious lesions for and extracellular matrix catabolism and bone repair and regeneration mechanisms the body the purpose of conservative management places resorption. Functionally, this polymorphism is uses. The new sciences of biomimetics and tissue lesions into three categories: lesions where no associated with high levels of IL-1 production, engineering combine engineering principles and treatment is advised, lesions where preventive and high levels of IL-1 have been associated with materials science with rapidly growing knowledge care is advised and lesions where restorative progressive periodontal breakdown. of the progenitor cells and molecules that give rise treatment is advised. This approach, using caries to specific tissues such as skin, bone, teeth and A consensus has been reached by a specialty as an infectious disease paradigm, resulted in cartilage. Already it is possible to generate new organization that all patients in general and specialty a marked reduction of operative procedures in cartilage and bone of a prescribed shape to replace care should be screened for periodontal disease. The Danish schoolchildren and has been proposed as tissue lost from injury or disease. Eventually, it may recommended approach is to apply the periodontal a means to preserve tooth structure and maximize be possible to use a patient’s own oral cells and cell screening and recording examination (PSR). appropriate care in the United States. products to generate new tooth enamel, dentin and Related screening tests include the community New imaging and laser technologies are cementum for the natural repair of carious lesions. periodontal index of treatment needs (CPITN) and emerging as tools for early diagnosis and the basic . prompt treatment of dental caries. For example, Periodontal diseases quantitative light-induced fluorescence is Periodontal diseases are caused by microbial Diagnosis showing promise for dental caries diagnosis. Two infections, and are plaque-related complex Most diagnostic tests for periodontal diseases rely different methods, the quantitative infrared laser diseases like dental caries, presenting as several on a physical examination to note any swelling, fluorescence method and electrical conductance clinical variants. The mildest form is gingivitis, redness, gingival bleeding or . measurements, are currently commercially characterized by inflammation of the gingiva with Periodontal probing, radiographs and microbiologic available. At present, these methods are being a marked loss of gingival collagenous material. and histological examinations of biopsied tissue used to augment conventional diagnostic tools but In a more advanced disease, periodontitis, there provide important additional information. These

Elite Page 47 tests indicate the presence, extent and severity of quiescent or actively progressing. The goal of must always be based on the individual needs of gingival and periodontal tissue destruction; they treatment is to determine whether the disease is the patient. Regardless of the approach selected, do not indicate the cause of disease or whether it is active in order to prevent further tissue loss. This maintenance is important to long-term success. entails professional plaque removal and careful quiescent or actively progressing. Systemic administration of antibiotics, including instruction of the patient on scrupulous self-care. Gingival inflammation may be assessed using the , 3 metronidazole, spiromycin a variety of methods, including bleeding on The concept of management of a patient’s risk and clindamycin, has been extensively studied probing and the use of indices such as the gingival factors as part of treatment is reasonably well and reviewed. The risk of generating antibiotic index to grade redness and bleeding. In adult documented for individuals who smoke and resistance in bacteria precludes the use of systemic periodontitis, the absence of inflammation is those who are diabetic and may be important agents in treating simple gingivitis. Similarly, associated with a lack of disease progression, but for other risk factors such as stress and low systemic antibiotics should not be used for the the presence of inflammation does not indicate dietary calcium. Several studies have shown that routine first-line treatment of common forms of inevitable progression to destruction. Longitudinal treatment of periodontal disease in smokers is adult periodontitis. The preponderance of evidence studies have also been conducted in patients who not as successful as in nonsmokers. Thus, the from well-controlled, randomized, blinded clinical participate in maintenance programs. management of smoking as a risk factor will trials indicates that the agents do not offer sufficient contribute to the success of periodontal therapy. benefit to overcome risks of either drug sensitivity The absence of gingival bleeding, especially at Furthermore, it appears that treatment of diabetic or the emergence of antibiotic-resistant pathogens. recall visits, has been shown to be a valid indicator patients with periodontal disease may require of gingival health in these patients. Measurement The situation is different in cases of aggressive more intense therapy since several studies have of probing depths (also termed pocket depths) is forms of periodontitis, such as early-onset, shown that antibiotic therapy is successful not an integral part of the periodontal examination. rapidly progressive or refractory periodontitis, only in reducing periodontal disease, but also in Longitudinal studies have shown that shallow which affect less than 10 percent of periodontitis reducing glycated hemoglobin. probing depths and minimal loss of attachment patients. Randomized, double-blind clinical trials are associated with lack of disease progression. Professional plaque removal typically employs as well as longitudinal assessments indicate that The mere presence of a pocket does not herald scaling and root planing, in which hardened the use of systemic antibiotics can slow disease progressive periodontitis at that site. deposits of plaque and other debris are removed progression in these patients. from the periodontal pocket and the tooth root Although teeth with moderate to deep probing To circumvent the problems of systemic surface is smoothed over. The effectiveness of depths are at higher risk for additional destruction, therapy, investigators have applied antimicrobial scaling and root planing has been demonstrated a single examination cannot determine the fate of agents directly into the pocket. Antimicrobials repeatedly in longitudinal, cohort and the tooth with certainty. Radiographs are used to incorporated into either resorbable and randomized clinical trials and was reviewed obtain a visual image of the bony support around a nonresorbable interpocket delivery systems by Cobb. Demonstrated benefits include tooth or . They are an essential tool have been studied in randomized, double-blind, decreased gingival inflammation, decreased in planning complexprosthetic reconstructions, controlled clinical trials and are now FDA- probing depth and facilitation of maintenance as well as a necessary diagnostic aid in assessing approved and on the market. When used as an of clinical attachment level. The evidence periodontal progression. adjunct to scaling and root planing, gains in indicates that similar results may be obtained clinical attachment level and decreases in probing with ultrasonic and sonic instruments as with Prevention depth and gingival bleeding were demonstrated. manual instruments. Regardless of the methods Because periodontal diseases are plaque- Because these delivery systems are relatively used, meticulous attention to detail is required to associated infections, prevention and new, there is a paucity of evidence addressing achieve optimal results. management of the early signs of these diseases their long-term effectiveness. depend on effective plaque control. This can Topical administration of antimicrobial agents For patients who have lost significant bone and/ be accomplished using both mechanical and contributes to the control of gingival inflammation. or connective tissue, there are a number of chemotherapeutic approaches. The prophylaxis Supragingival irrigation (e.g., applying a jet of regeneration procedures to facilitate the growth of performed in the dental office on periodontally water under pressure) may be used as an adjunct new periodontal ligament, cementum and alveolar healthy patients reduces plaque and removes to toothbrushing and has been shown to aid in bone over previously diseased root surfaces. The stains and calculus. How often patients should the reduction of gingival inflammation. However, evidence base for bone-grafting techniques using be recalled for such preventive procedures is no clear substantial long-term benefits for the either natural or synthetic bone materials has been based on an assessment of risk factors, such as treatment of periodontitis have been shown if reviewed by Garrett (1996). Natural bone grafts the patient’s age, oral hygiene, personal habits irrigation is applied subgingivally. Surgical therapy may use autografts, in which bone is transferred (e.g., smoking and diet) and a medical history is employed to provide access to root surfaces and from one site to another in the same patient; indicating a heightened risk of infection (such as bony defects for debridement and root planing. allografts, which use bone grafts from a human noted with diabetes or HIV infection). Surgery can facilitate regeneration, augment the donor; and xenografts, which use tissues from gingiva and promote root coverage. It is also Chemical plaque control has become an other species. Limited case-report evidence shows necessary in placing dental implants. important part of the clinician’s armamentarium that extraoral autogenous bone, such as hip grafts, and may be prescribed for patient care at home. Palcanis reviewed the evidence regarding surgical has high potential for bone growth. Extraoral Significant reductions in gingival inflammation therapy. The overall goal is to make plaque sites require a second surgical site, and in some have been demonstrated for chlorhexidine, control easier for the patient, thereby reducing cases fresh grafts may be associated with root co-polymer when used in conjunction disease progression. Many surgical techniques resorption. Case report evidence indicates bone fill with a fixed combination of essential oils and are available. Extensive randomized clinical trials exceeding 50 percent of the osseous defect may be stannous fluoride. The magnitude of gingival and longitudinal studies form the basis of the achieved. Controlled studies comparing grafted to inflammation reduction was greatest for evidence for the efficacy of these procedures. All nongrafted sites report significant improvements chlorhexidine. The evidence supporting these procedures decrease pocket depth, and, with the in clinical attachment levels and bone gain, but effects includes multiple randomized, double- exception of , all increase clinical the magnitude of gain is less than that indicated in blind controlled clinical trials. attachment level. A caveat to be noted, however, case reports. is that procedures designed to reduce probing Freeze-dried demineralized bone represents Treatment depth may increase gum recession, exposing one of the most frequently used and well- Once periodontal disease is established, the the root and possibly compromising aesthetics. studied bone graft materials in periodontics. resultant bone and connective tissue loss may be Thus, selection of a particular surgical procedure Freeze-dried demineralized bone is an allograft Page 48 Elite material, harvested, prepared and demineralized parents or potential parents on behavioral risk Pain relief may also improve function and can prior to grafting. The demineralization step is factors, especially tobacco and alcohol use, the be combined with adjunctive measures such as important because it retains the activity of bone teratogenic potential of certain prescription drugs the use of hot or cold compresses and behavioral morphogenetic proteins, compounds in the graft and the need for adequate nutrition in the perinatal treatments such as relaxation and imaging material found to be essential for new bone period is emphasized. A study performed in 1995, therapy to reduce muscle tension. The variety formation. Case reports and controlled clinical trials supplementation of the diet by multivitamins and of pain medications has greatly increased in have demonstrated the bone-forming potential of folic acid during the periconceptional period (i.e., recent years. They include aspirin and other such material, with some variability in the amount before, during and after conception) markedly nonsteroidal anti-inflammatory drugs, tricyclic of bone fill achieved. Because allografts are derived diminished the occurrence of cleft lip and palate antidepressants, new antiepileptic drugs, the from donor tissues, proper collection, handling and in a high-risk group. Unfortunately, only about 29 selective serotonin re-uptake inhibitors and the storage are essential to ensure viability and prevent percent of women of childbearing age consume more potent opiate family of drugs. contamination with viruses or other pathogens. recommended amounts of these essential nutrients. If the pain problem has recently developed, Alloplasts represent a class of synthetic The evidence associating moderate to severe providers can take steps to prevent the pain from resorbable or nonresorbable graft materials. periodontal disease in pregnant women with low- becoming chronic. This will entail a general When evaluated in controlled clinical trials, they weight preterm births warrants attention to the health assessment to determine whether there are demonstrated improvements in probing depth and importance of maintaining optimal oral health in co-morbidities, including other pain problems, attachment level. Histology, however, indicates pregnancy. The oral care clinician can contribute as well as patient questionnaires to provide that, in general, synthetic grafts act primarily as to birth defect prevention not only by treating information on how the pain problem is affecting space fillers, with little, if any, regeneration. oral disease, but also by providing educational overall health and well-being. The data collected messages to patients to promote the birth of Beginning in the 1980s, a number of investigators will record the extent to which the problem healthy, full-term babies. explored a procedure called guided tissue interferes with work, social interaction and sleep, regeneration. The idea was to employ either a whether the patient is experiencing mood changes Treatment resorbable or nonresorbable membrane at the and symptoms of depression, and what coping A number of birth defects may not be apparent diseased site that would selectively allow passage skills are manifest. Such patient profiles allow for at birth because they are not manifested of cells able to regenerate periodontal attachment more selective treatment tailored to the needs of until later in development. One example is apparatus and bone while prohibiting migration the individual patient. the ectodermal dysplasias (ED), disorders of nonregenerative cells such as fibroblasts. Patients in whom pain has become chronic and characterized by abnormalities of skin, hair, The evidence for the efficacy of guided tissue intractable may be referred to an established pain sweat glands and teeth. Dentists are essential in regeneration ranged from randomized controlled clinic for multidisciplinary treatment and may the management of care for children with these clinical trials to case reports. Although less also be alerted to patient organizations where disorders, who must be repeatedly fitted with evidence is available for resorbable membranes individuals with similar pain problems can find dentures throughout childhood. than for nonresorbable membranes, significant information and support. improvements in clinical attachment levels have More recently, clinical studies have demonstrated been shown compared to debridement alone. that fitting ectodermal dysplasia patients as young Temporomandibular disorders Most favorable results are reported for bone loss as 12 years old with dental implants not only is Among the common types of craniofacial pain between the roots of mandibular tooth defects effective, but also provides greater functional likely to be seen by oral care providers are (Class II furcations). Less favorable results were utility and satisfaction. As with other complex temporomandibular disorders, characterized reported in maxillary molar and Class III (through craniofacial anomalies, management by a by symptoms of pain and dysfunction in and and through) furcation defects (Garrett 1996). multidisciplinary team is the best approach, with around the temporomandibular joints or the experts able to advise on the various oral, skin masticatory muscles. Birth defects and sweat gland complications. Temporomandibular disorders may occur as a There are hundreds of genetic diseases and Mutations have recently been identified for result of injury, arthritis or fibromyalgia or for syndromes as well as congenital anomalies that several forms of ED, including the anhydrotic unknown reasons. Approaches used to obtain a affect the craniofacial, oral and dental tissues. form (absence of sweat glands). Ultimately, differential diagnosis of these conditions can range However, some craniofacial anomalies may be the development of genetic diagnostic tests can from a physical examination that may include spontaneous and manifest only at the time of birth. confirm the diagnosis in the child and permit palpation and measuring the mouth opening, to Rapidly advancing knowledge of the genetics of counseling of parents. the use of complex imaging and instrumentation, development and of mutations associated with including procedures such as arthroscopy. specific birth defects is aiding in the development Chronic craniofacial pain and Diagnosis of temporomandibular disorders is of screening tests for genetic disorders and sensorimotor conditions identifying high-risk individuals and families. based on the physical examination and a complete A variety of problems involving pain and other medical and dental history, including information A complete diagnosis of the craniofacial disorder sensorimotor abnormalities affect the craniofacial about hearing, speech and swallowing problems, may involve a multidisciplinary team of experts complex. These conditions can include burning as well as pain and dysfunction. This information in imaging, genetics and other areas. Similarly, mouth syndrome, trigeminal neuralgia, can be complemented by data from imaging and long-term management of the disorder, often various facial palsies, postherpetic neuralgia other diagnostic tests. Evaluation encompasses extending to adulthood, generally calls for a team affecting branches of the trigeminal nerve, examination of oral-facial tissues, musculature of specialists, including physicians and dentists, temporomandibular disorders, fibromyalgia and and neurological function. surgeons, nurses, rehabilitation experts, speech disorders of taste or olfaction. Some of these are pathologists, psychologists and social workers. infectious in origin (e.g., postherpetic neuralgia Particular attention is paid to measures of the Quality of life considerations, including social and some taste disorders); some are traumatic range of motion, mouth opening, existence of and psychological effects of birth defects such as (e.g., some cases of temporomandibular disorder); any parafunctional conditions (e.g., clenching, cleft lip and palate, are taken into account. and for others, the cause or causes are unknown. grinding), and the presence of joint or muscle Patients with facial palsies and trigeminal tenderness and cutaneous hyperalgesia. Features Prevention neuralgia are generally referred to neurologists for of the reliability studies on the examination Primary prevention involves minimizing exposure treatment. Disorders of taste and smell also require methods have been reviewed. Psychosocial to known teratogens, and genetic counseling neurological consultation as well as brain imaging assessments using validated instruments as appropriate. The importance of educating because they can be symptomatic of brain tumors. can determine the extent to which pain and Elite Page 49 dysfunction diminish the patient’s quality of life and “evidence-based nursing,” among others. The health care and may reflect changes in care and can suggest appropriate treatments. practice of evidence-based dentistry “incorporates provision and referral patterns. the judicious use of the best evidence available The evidence base for the efficacy of treatment Management of conditions such as oral and from systematic reviews, when possible, with modalities is severely limited and has pharyngeal cancers, cleft lip/palate, and chronic knowledge of patients’ preferences and clinicians’ resulted in a wide range of diagnostics and pain requires multidisciplinary teams. The experiences to make recommendations for the therapies. Treatments range from conservative promotion of oral health and the prevention of provision of the right care, for the right patient, and reversible approaches to joint surgical oral disease are at a turning point. A systematic and at the right time.” procedures. At present the evidence is insufficient approach to integrate the scientific findings into to warrant prophylactic intervention for The reliance on evidence using systematic reviews evidence-based assessments will provide clearer management of these disorders. of the literature has led to initiatives in the United guidance to all health care professions and the Currently available epidemiological evidence States, Canada and Europe to enhance the conduct public. To capitalize on the rapidly emerging suggests that temporomandibular disorders and use of systematic reviews. The Agency for science base, the active participation of a full range can frequently resolve over time and that Healthcare Research and Quality (AHRQ) created of dentists and additional health care providers conservative, reversible approaches are the 12 evidence-based practice centers in 1997 to with individuals in the community is needed. treatments of choice. Ideally, the practitioner and conduct systematic reviews and develop evidence References the patient should work together to develop a reports. The Cochrane Collaboration and the Centre American Surgeon General World Health Organization treatment plan that is evidence-based and patient- for Reviews and Dissemination at the University centered, taking into consideration all etiologic of York are examples of prominent activities in the factors, the level of pain and dysfunction the United Kingdom to support systematic reviews. patient is experiencing, and their impact on the The Cochrane Oral Health Review Group, one of patient’s quality of life. 50 specialty review groups within the Cochrane ORAL DISEASES, INFECTIONS Collaboration, has a number of systematic reviews AND CRANIOFACIAL DISORDERS completed or under way of interest to oral health Factors affecting future dental health Final Examination Questions practitioners. In Canada, considerable contributions care practices Select True or False for questions 1-5 to the field have been made by McMaster The last decades of the 20th century were and mark your answers on the Final University and the Canadian Coordinating Office witness to major improvements in the prevention, Examination sheet found on page 81 or for Health Technology Assessment. diagnosis and treatment of oral diseases, a trend complete your test online at that will continue to accelerate the paradigm shift In the United States, the National Institute www.elitecme.com. in the management of oral diseases from repair of Dental and Craniofacial Research joined of damaged tissues to the control of infections. efforts with AHRQ in 1999 to designate one of 1. The periodontal ligament, which anchors In addition, modification of risk factor exposures AHRQ’s Evidence-based Practice Centers to the teeth in the jaws, is a tactilely sensitive will result in improvements in health and in the conduct reviews on oral, dental and craniofacial tissue providing important feedback with management of disease. diseases and disorders. The work of this center regard to mastication and dental occlusion. should significantly strengthen the scientific A closer look into factors that will affect the base of knowledge related to the diagnosis and True False future of oral health care requires an overview management of oral, dental, and craniofacial of the current state of guidelines for oral care conditions. Examples of topics that will be and the status of evidence-based practice. The 2. The effects of xerostomia may be particularly reviewed include the management of dental approaches used to determine the evidence for severe in cancer patients receiving radiation caries and dental care of medically compromised practice and the development of guidelines for to the head or neck because the rays can patients, including patients with HIV disease. care are an emerging field of activity. Education destroy salivary gland tissue rather than simply inhibiting salivary secretion. in the health professions is already emphasizing Conclusion the importance of relying on randomized, During the past several decades, there have been True False controlled clinical trials, the gold standard for major improvements in the prevention, diagnosis judging the merits of proposed interventions, and treatment of oral diseases. Enhanced disease 3. Patients with diabetes mellitus are less wherever possible. prevention and health promotion will require the susceptible to periodontal diseases. participation of all health professions, especially in Evidence-based practice True False addressing common risk factors such as tobacco, During the 1990s, “evidence-based medicine” alcohol and inappropriate dietary practices. The emerged as both popular phraseology and field of diagnostic tests for oral diseases should 4. Current U.S. Public Health Service practice philosophy. The origins of evidence- continue to expand, enabling clinicians to analyze (USPHS) recommendations for fluoride use based medicine go back to mid-19th century Paris the risk of disease and disease progression include an optimally adjusted concentration and earlier, yet the approach is still a relatively for individual patients. Full assessment of the of fluoride in drinking water ranging from young discipline that is now rapidly evolving. strengths and weaknesses of new diagnostic tests 1.5 to 2.0 ppm, depending on the mean Evidence-based medicine has been defined as and evaluation of when they are best used will maximum daily air temperature of the area. the integration of “individual clinical expertise be key to proper interpretation of the results, with the best available external clinical evidence True False permitting tailored referrals and treatments. from systematic research” and with patients’ choices. The skills required include defining a Treatment options for individual patients are 5. Temporomandibular disorders may clinical problem, critically appraising the relevant increasing, including the recent efforts to occur as a result of injury, arthritis or literature, and deciding whether and how to understand and define early childhood caries fibromyalgia or for unknown reasons. integrate this information into practice (Evidence- and other periodontal infections. The increased True False Based Medicine Working Group 1992). knowledge of risk factors, the importance of monitoring disease progression and treatment Evidence-based medicine is neither a “cookbook” effects, and the ability to diagnose conditions nor an ivory tower approach. The philosophy and intervene earlier will necessitate increased is being adopted across a range of disciplines, involvement of all health professionals in oral leading to the terms “evidence-based dentistry” DMI06ODE13

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