02 - PA 614 2023 Introduction to Oral Health Chillura.pptx
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Introduction to Oral Health FCM I 2023 PA 614 Christopher Chillura, MSPAS, PA-C Learning Objectives • To be familiar with the anatomy and nomenclature of teeth and periodontia • To understand the progression of periodontal disease • To provide helpful patient care instructions for oral health • Gi...
Introduction to Oral Health FCM I 2023 PA 614 Christopher Chillura, MSPAS, PA-C Learning Objectives • To be familiar with the anatomy and nomenclature of teeth and periodontia • To understand the progression of periodontal disease • To provide helpful patient care instructions for oral health • Gingivitis • Periodontal Disease • Pericoronitis Dental Anatomy & Nomenclature Adults Dental Anatomic Surfaces Facial : The part of the tooth that faces the opening of the mouth. This surface is visible when someone smiles. This is a general term applicable to all the teeth. Labial : The facial surface of the incisors and canines. Buccal : The facial surface of the premolars and molars. Oral : The part of the tooth that faces the tongue or palate. This is a general term applicable to all the teeth. Lingual : Toward the tongue; the oral surface of the mandibular teeth. Palatal : Toward the palate; the oral surface of the maxillary teeth. • Approximal/interproximal : The contacting surfaces between two adjacent teeth. • Mesial : The interproximal surface facing anteriorly or closest to the midline. • Distal : The interproximal surface facing posteriorly or away from the midline. • Occlusal : Biting or chewing surface of the premolars and molars. • Incisal : Biting or chewing surface of the incisors and canines. • Apical : Toward the tip of the root of the tooth. • Coronal : Toward the crown or the biting surface of the tooth. Primary/Baby Dental Anatomy Pulp: neurovascular supply of tooth, nutrient delivery Dentin: majority of tooth, cushions during mastication Enamel: yellow- grey/white translucent surface, protectant Crown: covered in enamel Root: surrounded by cementum, anchored by periodontal ligament Periodontium Dental attachment apparatus Gingival subunit: gingival tissue and junctional epithelium Periodontal subunit: periodontal ligament, the alveolar bone, and the cementum of the root of the tooth Gingival sulcus: space between the gingiva tissue and the tooth Gingival Subunit Mucobuccal Fold • Area of mucosa where the attached gingiva gives rise to the looser buccal mucosa Eruption • Typically symmetric • Mandibular central incisors are the first primary teeth to erupt, usually between 6 and 10 months of age • Teething symptoms: cranky, chew on objects, excessive drooling, fever, diarrhea • Teething management: chilled rings or teething devices • Permanent teeth eruption: usually begin to erupt at six years of age. Central incisors and first molars are the first permanent teeth to erupt, followed sequentially by the lateral incisors, canines, first premolars, second premolars, second molars, and third molars • If tooth eruption is delayed ≥6 months beyond the normal range for a particular tooth or if there is asymmetric tooth eruption of ≥6 months, evaluation for causes other than normal variation may be warranted Permanent Eruption The Gum Disease Progression Gingivitis • Inflammation of mucosal epithelial tissue surrounding the cervical portion of the teeth and the alveolar processes • Etiology: • Drug-induced, hormonal, nutritional, infectious, plaque-induced, trauma • Acute vs chronic • Most common: chronic form induced by plaque • Pathogenesis: • Plaque build up 2/2 inadequate oral hygiene • Inflammation starts 4-5 days after plaque formation (destruction of collagen, deposition of neutrophils, fibrin, lymphocytes) • Progression→pockets form between gingiva and teeth→gingiva separates from tooth→ pockets deepen • Periodontal ligaments break down and destruction of the local alveolar bone→teeth loosen and eventually fall out Plaque Induced Gingivitis • Dental plaque (bacterial biofilm): dense, non-mineralized, complex mass of bacterial colonies living in a gel-like intermicrobial matrix that forms around the gingival margin (gum line), both supra- and subgingivally • Accumulation within 24 hours without regular removal • Exopolysaccharide that surrounds & protects it from antibiotic/drug penetration • Mechanical debridement is the only effective way to remove plaque • Plaque buildup may be caused by dental restorations that are ill-fitting Plaque Induced Gingivitis • Calculus ("tartar"): mineralized plaque • Calculus promotes retention of bacterial biofilm and must be removed to promote resolution of inflammation • Cannot be removed by toothbrushing, flossing, or polishing-requires intervention by a dentist or dental hygienist Gingivitis Risk Factors • Poor oral hygiene!! • Use of tobacco or ethanol is thought to be a risk factor • Immune incompetence is observed more frequently in HIV-infected children • Diabetes mellitus • Certain medications • Hormonal effects, with exacerbation of disease activity during puberty, menstruation, and pregnancy Drug Induced Gingivitis • Extensive! • Gingival bleeding may occur with the use of anticoagulants and fibrinolytic agents • Phenytoin, oral contraceptive agents, and calcium channel blockers may cause gingival hyperplasia • Gingivitis has been observed with use of protease inhibitors (eg, saquinavir, ritonavir), vitamin A and analogues, danazol, pentamidine, misoprostol, methotrexate, and gold compounds • Gingivostomatitis has been observed in exposure to arsenic, gold, bismuth, mercury, nickel, sulfur dioxide, lead, thallium, zinc, methyl violet, and topical chlorhexidine Gingivitis Epidemiology • Children aged 3-11 years: 9-17% • At puberty, prevalence rises to 70-90% • In recent years, periodontal disease has slowly decreased among adult Americans • Chronic periodontitis is still the most prevalent chronic inflammatory condition in the elderly • Gingivitis is slightly more prevalent in males than in females Gingivitis Presentation • Bleeding when brushing, flossing, chewing (more w/hard foods) • Minimal physical findings aside from local findings at the dental-gingival margins • Gingival pockets may be detected with a periodontal probe • Mild bleeding from the gum margins may occur with any manipulation Gingivitis Work Up • Lab studies not helpful for diagnosis- clinical • Imaging: not helpful until periodontitis Gingivitis Treatment/Consult Proper oral hygiene (including brushing and flossing) should be stressed Referral to a dentist or periodontist General measures • Remove irritating factors such as plaque, calculus, and faulty dentures • Use a warm saline rinse Gingivitis Prevention • Regular oral hygiene • Power brush • Interdental brushes is the best prevention • Daily flossing in addition to brushing will reduce plaque and bacterial counts • Rinsing with chlorhexidine • NSAIDs have been shown to speed the resolution of inflammation when teeth are being cleaned and scaled to remove plaque. • In the future, antibiotics also may be used to treat simple chronic gingivitis, but no current evidence exists to justify this practice Gingivitis Complications • Not a direct significant threat to the health of a healthy individual, but it can contribute to illness and cause local and systemic complications • Most common complication of chronic gingivitis is progression to periodontal disease and tooth loss • Odontogenic abscesses by allowing a route of bacterial invasion into the periodontal space from the gingival pocket • Osteomyelitis of alveolar bone may arise but is uncommon • Any dental procedures involving manipulation that causes bleeding may result in endocarditis Gingivitis Associations • Coronary artery disease (CAD) and cerebrovascular disease/ischemic stroke • Elevated levels of chronic inflammation (eg, C-reactive protein) • Increased risk of myocardial infarction (MI) • Periodontal disease in pregnancy has been associated with an increase in preterm birth and adverse pregnancy outcomes • • • • Preterm birth Fetal growth restriction/low birthweight Pre-eclampsia Gestational diabetes Gingivitis Prognosis • Untreated chronic gingivitis leads to periodontal disease, eventually resulting in tooth loss • After an initial cleaning and scaling in its early stages, gingivitis usually is reversible with good dental hygiene • The usual course is acute, relapsing, intermittent, and chronic • Gingivitis generally responds well to appropriate treatment Periodontitis • Gingival inflammation with loss of supportive connective tissues: • Alveolar bone • Loss of attachment of periodontal ligament to the cementum • Clinical findings: increased probing depth, bleeding on probing, and tooth mobility • Bone loss is seen on radiographs • Progression of the disease will cause increased mobility and eventual tooth loss • Systemic disease may result from pathogenic bacterial strains included among the >500 bacterial species harbored in periodontal pockets • 5-15% of the population in the US suffers from severe generalized periodontitis Periodontitis Treatment • Debridement of subgingival biofilm and calculus by a periodontist, general dentist, or dental hygienist • Improved oral hygiene: brushing two times daily, flossing or interdental cleaning • Adjunctive therapies: • Topical doxycycline, minocycline or chlorhexidine • Amoxicillin or metronidazole for severe cases • Low dose of doxycycline (20 mg) may be taken twice a day for up to nine months Pericoronitis • Acute localized infection caused by food particles and microorganisms trapped under the gum flaps • Involves the wisdom teeth in adolescents and adults, and occurs during the eruption of the permanent teeth in children • Symptoms: pain and limitation of movement on opening the jaw, discomfort on mastication and swallowing, and facial swelling • Signs: • • • • • Pericoronal tissues are erythematous and swollen Pressure can often express an exudate from under the infected flap Masticator spaces are often involved→trismus Localized painful lymphadenopathy Halitosis Pericoronitis Treatment • Gentle irrigation warm water • Antiseptic solution • NSAIDs/Analgesia • Oral/IV antibiotics • Incision & drainage (I&D) • Flap resection • Dental extraction Enamel Erosion Increased Acid • Sugary Diet: Soda Fruit juice Flavored water Sugary snacks Starchy snacks Citrus fruits • Dry mouth • Acid reflux • Taking acidic medicines such as aspirin or antihistamines • Low-salivary flow • Genetics • Bruxism, or grinding of the teeth Panel A: Dental caries, pulpal infection, and periapical abscess. Panel B: Periodontal infection with destruction of supporting structures. Panel C: Pericoronal infection. Gingivitis
