J Am Board Fam Med: first published as 10.3122/jabfm.2010.03.090023 on 7 May 2010. Downloaded from CLINICAL REVIEW Recognition and Management of Common Acute Conditions of the Oral Cavity Resulting From Tooth Decay, Periodontal Disease, and Trauma: An Update for the Family Physician Paul C. Edwards, MSc, DDS, and Preetha Kanjirath, BDS, MDS This article presents an overview of common and/or significant diseases of the oral cavity that the family physician is likely to encounter, with an emphasis on pathogenesis, recognition, complications, and management. Topics reviewed include the sequelae of dental caries, periodontal disease, and trauma. Prevention and early intervention strategies are emphasized. Recent updates and practical issues for the family physician are highlighted. (J Am Board Fam Med 2010;23:285–294.) Keywords: Dental Decay, Otolaryngology, Periodontal Diseases The oral cavity is a distinctive region of the body fibrous connective tissue attachment (periodontal that, as a result of being exposed to the harsh oral ligament). Finally, a central pulp complex that is environment, is subject to a distinctive set of con- composed of neurovascular and loose, fibrous con- ditions and diseases, many of which are unique to nective tissue. copyright. this area. Furthermore, the effect of disease in the Dental caries, or tooth decay, is one of the most oral cavity can have significant impact on the over- prevalent chronic diseases affecting modern soci- all health of the individual. ety. These are also known colloquially as cavities, reflecting the cavitation that occurs in more ad- Dental Caries and Tooth Pain vanced lesions. Once viewed as a disease of children The teeth are 32 highly specialized hard tissue units (Figure 1), it seems that, because a greater percent- that each consist of 3 functional units. First, the age of the adult population are retaining their http://www.jabfm.org/ visible crown portion, which is exposed to the oral teeth, adults are now developing new carious le- environment and is composed of an outer layer of sions at the same incidence rate as children.1 inorganic, heavily mineralized tissue (enamel) over- Among some methamphetamine abusers, a pattern lying a somewhat softer collagen-containing calci- of rampant carious destruction is noted, a condition fied substance (dentin) that resembles bone in its termed “meth mouth”2 (Figure 2). There is also an ratio of organic to inorganic composition. Sec- exponential increase in risk of developing caries on 28 September 2021 by guest. Protected ondly, the root portion, which anchors the tooth to among patients who take multiple medications that the surrounding alveolar bone by means of a dense, predispose to xerostomia. Among the aging popu- lation, caries are commonly seen on the root sur- face of the teeth, where the gums have receded This article was externally peer reviewed. Submitted 3 February 2009; revised 30 November 2009; (Figure 3). accepted 4 December 2009. Caries develop through a complex interaction in From the Department of Periodontics and Oral Medicine, Faculty of Dentistry, University of Michigan, Ann Arbor. which transmissible cariogenic oral microflora, pri- Funding: none. marily Streptococcus mutans and lactobacilli, metab- Conflict of interest: none declared. Corresponding author: Paul C. Edwards, MSc, DDS, De- olize fermentable dietary carbohydrates, resulting partment of Periodontics and Oral Medicine, Faculty of in lactic acid production.3 The resultant drop in pH Dentistry, University of Michigan, 1011 N University Ave- nue, Ann Arbor, MI 48109-1078 (E-mail: paulce@ at the tooth surface results in dissolution of the umich.edu.) mineral component of the enamel. This process is doi: 10.3122/jabfm.2010.03.090023 Common Acute Conditions of the Oral Cavity 285 J Am Board Fam Med: first published as 10.3122/jabfm.2010.03.090023 on 7 May 2010. Downloaded from Figure 1. Rampant caries in a child. (Photograph Figure 3. Root caries may be difficult to detect courtesy of Dr. Ana Veira.) clinically because they are frequently hidden by the gingiva. (Photograph courtesy of Dr. Eduardo Bresciani.) a dynamic one, in which demineralization is coun- tered by remineralization through the buffering 4 capacity of the saliva. Progression of caries results the center of the tooth through small-diameter when the rate of demineralization exceeds the dentinal tubules. When caries penetrate through remineralization rate. Clinically, caries start in the the full thickness of the enamel to reach the under- deep pits on the biting surfaces of the posterior lying dentin, patients will typically exhibit momen- teeth or on the smooth surfaces of the teeth (Figure tary tooth pain on exposure to cold and/or osmotic copyright. 4). Although often visible to the naked eye as a soft agents such as sugar. This process, termed reversible area of surface cavitation, ranging from white (re- pulpitis, is not an acute emergency and can typically flecting early demineralization) to brown or black be treated by conservative mechanical removal of in color, the caries process can also occur beneath the decay and placement of a dental restoration (a an intact layer of surface enamel or between 2 “filling”) to replace the lost tooth structure, pro- adjacent teeth, making early visual recognition ex- vided that this treatment is initiated in a reasonable tremely difficult without the assistance of radio- time frame (typically several weeks). A similar type graphs (Figure 5). of pain can be elicited in patients who have gingival http://www.jabfm.org/ Although the caries process in the heavily min- eralized enamel layer of the tooth is primarily a physicochemical process, the underlying dentin is Figure 4. Caries commonly start in the deep grooves connected to the highly innervated pulp tissue at (pits and fissures) located on the biting surface of the molar teeth. In this case, a small surface opening Figure 2. Rampant caries in a methamphetamine user. hides extensive subsurface decay. (Photograph courtesy of Dr. Eduardo Bresciani.) on 28 September 2021 by guest. Protected 286 JABFM May–June 2010 Vol. 23 No. 3 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2010.03.090023 on 7 May 2010. Downloaded from Figure 5. This radiograph shows interproximal carious matory agents (eg, ibuprofen 600 to 800 mg every lesions that would have been difficult to detect by 4 to 6 hours) may be beneficial in cases of mild to clinical examination alone. moderate pain, in more severe cases acetamino- phen-narcotic combinations (eg, Tylenol #3, Per- cocet, or Vicodin) are typically required. Although antibiotics are often inappropriately prescribed, they are not indicated at this stage. Instead, it is important to refer the patient to a dental provider. Definitive treatment involves either surgical extrac- tion of the involved tooth or, if the decision is made to try to preserve the tooth, mechanical extirpation of the pulpal tissue (a pulpectomy; the first step in root canal treatment). Eventually, if untreated, pulpal necrosis will de- velop as a result of prolonged inflammation within the confined space of the pulp cavity. This condi- tion, termed acute apical periodontitis, is character- recession, resulting from either excessively rough ized by severe pain located to the affected tooth. tooth brushing habits or as a result of periodontal The pain is aggravated by pressure (eg, touch or disease. The exposed root surface, especially when biting). As with irreversible pulpitis, treatment in- coupled with toothbrush-related removal of the volves prompt root canal therapy or extraction of protective cementum, results in momentary tooth the tooth. Because the pain is the result of necrotic pain on exposure to cold and/or osmotic agents pulp tissue and not an infectious process, antibiotic such as sugar. The degree of sensitivity can be therapy is not indicated.5,6 However, in the pres- reduced by instructing the patient to change their ence of underlying medical conditions that com- copyright. brushing technique and use less force while brush- promise host resistance, such as poorly controlled ing, incorporating a vertical brushing stroke instead diabetes or among patients taking high-dose corti- of a “back and forth” horizontal brushing motion, costeroids, antibiotic therapy, as described below coupled with long-term use of specially formulated for an acute apical abscess, should be considered. toothpaste for “sensitive” teeth. These toothpastes In many cases, depending on the host’s immune contain salts such as potassium nitrate or potassium response, bacterial load, and virulence, inflamma- oxalate that seal the exposed dentinal tubules tion may spread beyond the apical area of the tooth, http://www.jabfm.org/ and/or modulate nerve transmission. Dentist-ap- resulting in an acute apical abscess. This is evident plied agents such as fluoride varnishes and thin clinically by the presence of an intraoral swelling, layers of bonded resin can provide more rapid res- typically located within the buccal vestibule apical olution of symptoms. to the tooth root. This situation is ideally managed If caries go untreated, severe dental pain that by a dentist through removal of the tooth or extir- either persists after removal of the inciting stimulus pation of the necrotic pulp tissue and/or incision or occurs spontaneously will typically result. This and drainage of any fluctuant abscess. If immediate on 28 September 2021 by guest. Protected condition, termed irreversible pulpitis, results in se- dental management cannot be arranged, empirical vere pain that may last for hours or days if un- broad-spectrum antibiotic coverage should be con- treated. Patients with irreversible pulpitis will typ- sidered, especially if the patient has any underlying ically present on an urgent basis in acute distress medical conditions that could reduce bacterial re- with minimal physical reserves after being unable sistance (eg, diabetes, inability to sleep because of to obtain any relief for an extended period of time.