Seediscussions,stats,andauthorprofilesforthispublicationat:https://www.researchgate.net/publication/12042701

Dentaldamage,sequelae,andprevention

ArticleinWesternJournalofMedicine·May2001

Source:PubMed

CITATIONS

9

READS

79

3authors,including:

CrispianScully

UniversityCollegeLondon

1,373PUBLICATIONS25,687CITATIONS

SEEPROFILE

Allin-textreferencesunderlinedinbluearelinkedtopublicationsonResearchGate,

lettingyouaccessandreadthemimmediately.

Availablefrom:CrispianScully

Retrievedon:16October2016

ToolboxDental damage, sequelae,and preventionRuth Holt, Graham Roberts, Crispian Scully, Eastman Dental Institute for Oral Health Care Sciences, UniversityCollege London, University of London, 256, Gray’s Inn Road, London WC1X 8LD UKCorrespondence to: Dr Scully, c.scully@eastman.ucl.ac.uk

Competing interests: None declared

This article was published in BMJ 2000;320:1717-1719. This article is the second in a series adapted from TheABC of Oral Health, edited by Crispian Scully and published by the BMJ Publishing Group in November 2000.

TOOTH DAMAGETeeth may be damaged by dental caries,trauma, erosion, attrition, and abrasion orlost through periodontal disease.

DISEASECaries and inflammatory periodontal diseaseare the most prevalent oral diseases, and bothresult from the activity of dental bacterialplaque. Plaque is a complex biofilm that con-tains various microorganisms and formsmainly on teeth and particularly betweenthem, along the gingival margin, and in fis-sures and pits (figure 1). This biofilm adheresby a variety of mechanisms. If plaque is notremoved regularly, the flora evolve, andplaque may calcify, forming calculus (tartar)(figure 2).

Fermentation of sucrose and other non-milk extrinsic sugars to lactic and other acidscauses tooth decalcification and, with prote-olysis, results in caries (decay)(figure 3). Themain organism involved in this process isStreptococcus mutans.

Caries is seen less commonly because ofthe protective effect of fluoride, but it is stillprevalent in disadvantaged and deprivedpeople, especially in preschool-aged children.

Accumulation of plaque and a change inthe microflora may also cause gingival inflam-mation (gingivitis). Gingivitis may progressto damage the periodontal membrane(chronic periodontitis) and lead to tooth loss.

OTHER DAMAGETraumaTrauma is common in sport, road accidents,violence, and epilepsy. It occurs mainly inmen and boys and usually affects the maxil-lary incisors.

Tooth erosionThis problem is increasingly common withgreater consumption of carbonated and fruitdrinks and, occasionally, from gastric regur-gitation or repeated vomiting (as in bulimia,alcoholism, and gastroesophageal reflux)(figure 4). Typically, the effect is little morethan a loss of normal enamel contour. Whenerosion is severe, dentine or pulp may bedamaged.

Tooth wearAttrition, wearing of the biting (occlusal) sur-faces, is usually caused by tooth grinding(bruxism) or the consumption of an abrasivediet. Abrasion, wearing at the tooth cervicalmargin, is mainly caused by brushing with ahard brush or abrasive dentifrice. It can leadto exposure of dentine and, therefore, tem-perature sensitivity. Desensitizing toothpastesare available, but professional dental care maybe needed.

SEQUELAEMost dental pain occurs as a result of caries.Initially, caries presents as a painless whitespot (decalcification of the enamel, whichmay be reversible), followed by cavitation andbrownish discoloration. Once caries reachesthe dentine (figure 5), pain may result fromthermal stimulation or from sweet or sour

Summary points

• Caries and periodontal disease are themain oral diseases, and dental bacterialplaque underlies these diseases

• Although caries in enamel is painless,caries in dentine may be associated withpain on exposure to heat, cold, or sweetmaterial

• Caries in dentine left untreated mayprogress to pulpitis, which leadsinevitably to pulp necrosis. Pulp necrosisoften leads to dental abscess

• Sucrose and refined carbohydrates arethe main causes of caries. Frequency ofexposure is more important than thetotal amount consumed

• Most oral antiseptics have only transienteffects

• Chlorhexidine, triclosan, and someessential oils have proven antiplaqueactivity

Figure 1 Accumulation of dental plaque close togingival margins and around the contact areas of teeth(top). Same teeth after brushing (bottom).

The first article in this series is available on our website

288 wjm Volume 174 April 2001 www.ewjm.com

food or drink. Pain may also occur whendentine is exposed by trauma, erosion, orabrasion; this subsides within seconds of re-moving the stimulus. Pain may be poorly lo-calized, often only to within 2 or 3 teeth ofthe affected tooth. The tooth should be re-stored (filled).

Untreated caries can progress through thedentine to the pulp, which becomes inflamed(pulpitis). Within the rigid confines of thepulp chamber, this inflammation producessevere persistent pain (toothache). Necrosis ofthe pulp eventually occurs. Inflammation canthen spread around the tooth apex (periapicalperiodontitis), eventually forming an abscess,granuloma, or cyst.

PREVENTIONDiet and lifestyleSugars, particularly nonmilk sugars in itemsother than fresh fruits and vegetables, are themajor dietary causes of caries. Frequency ofintake is more important than the amountconsumed.

Dietary advice should start with recom-mending appropriate infant feeding andweaning practice. Only milk and watershould be given in feeding bottles and con-sumption of other drinks should be confinedto main meals. Children should be intro-duced to a cup at about 6 months of age andshould have ceased using bottles by about 1year. Weaning foods should be free of or verylow in sugars other than those present in freshmilk and raw fruits or vegetables.

For older children and adults, snack foodsand drinks should be free of sugars. Becauseof the risk of erosion as well as of caries, fre-quent consumption of carbonated and coladrinks should be discouraged. Fruit juices canalso cause tooth erosion. Water and milk arethe preferred options for children.

Saliva buffers may counter plaque acids.Therefore, chewing sugar-free gum or cheeseafter meals may be of value. Fresh fruit andvegetables can also confer some protectionagainst oral cancer. Other habits, principallysmoking or chewing tobacco, may contributeto periodontal disease and oral malignancy.Some chewed products contain sugars thatmay predispose to caries.

FluoridesFluorides protect against caries by inhibitingmineral loss, promoting remineralization ofdecalcified enamel, and reducing formationof plaque acids. Water fluoridation is consid-ered the most effective, safe, and equitablemeans to prevent caries; it can reduce theprevalence of caries by about one-half.

Where the water supply contains less than700 µg per liter of fluoride (0.7 ppm), chil-dren older than 6 months who are at highrisk of caries may be given daily fluoridesupplements as drops or tablets (see table).However, many toothpastes contain fluoride,and it is probably use of these products thathas led to the decline in caries in many coun-tries. Children younger than 6 years may in-gest toothpaste. To reduce the risk of fluoro-sis (excess fluoride in developing teeth),

children should use only a pea-sized amountof toothpaste, and their brushing should besupervised.

Fluoride rinses or gels are useful mainlyfor patients with special needs or those athigh risk of caries, such as people with drymouths.

Fissure sealantsPlastic coatings placed by a dental profes-sional in the pits and fissures of the perma-nent teeth can help reduce caries.

Oral hygieneGood oral hygiene can prevent periodontaldisease and oral malodor (halitosis). Themost important means of maintaining oralhygiene is using a toothbrush. Many types oftoothbrush are available, and most are effec-tive at removing plaque. Electric brushes maybe useful for individuals with poor manualdexterity. Tooth brushing at least twice dailyusing a fluoride toothpaste and a small-headed brush with medium-hard bristles willhelp to reduce caries.

Recommended fluoride dietary supplementation for cariesprophylaxis in high-risk children in relation to waterfluoride content and age

Fluoridein watersupply(ppm)*

Age of child

<6mos

6mos-3 yrs

3-6yrs >6 yrs

<0.3 0 250 500 1mg/day. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0.3-0.7 0 0 250 500. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

>0.7 0 0 0 0

*Local district dental officer, or equivalent, or water companyshould be able to supply this information.

Figure 3 Extensive caries in an adolescent with poororal hygiene. Upper left central incisor and lower rightfirst premolar show obvious caries with large discoloredcavities.

Figure 4 Extreme example of tooth erosion in apatient after repeated gastric regurgitation

Figure 2 Calculus formed by calcification of plaque(top). Same teeth after calculus removed by scaling(bottom) (magnification × 1/1.2). Calculus cannot beremoved by tooth brushing.

. . . . . . . . . . . . . . . . . . . . . .

Toolbox

Volume 174 April 2001 wjm 289www.ewjm.com

Tooth brushing, however, removes plaqueonly from smooth dental surfaces and notfrom the depths of contact areas, pits, andfissures. Effective interdental plaque removalrequires regular flossing. (Some flosses alsocontain fluoride.)

Toothpastes containing triclosan (such asColgate Total) and chlorhexidine (Corsodyl)have antiplaque activity and have been shownto protect against periodontitis without ad-verse reactions. Products containing phos-phates and phosphonates may help to pre-vent calculus, but some have producedadverse reactions. Many “luxury” toothpastesclaim a tooth-whitening effect, but few havesupporting evidence; distinguishing the re-sults of increased diligence in brushing from agenuine whitening effect of the paste is notstraightforward.

Overly enthusiastic brushing or use of anabrasive toothpaste can cause abrasion; silica-based toothpastes are less abrasive than thosewith calcium carbonate or aluminum trihy-drate bases.

The use of mouthwashes is an area of

contention. Many are advertised heavily, andalthough legal constraints ensure that theclaims are never untrue, the impressiongained may be overly optimistic. Manymouthwashes have only a transient antisepticactivity, some can be harmful by causing mu-cosal reactions, and these products can bedangerous to children who may ingest them.Most effective antiplaque mouthwashes haveprolonged retention on oral surfaces by ad-

sorption then slow desorption with contin-ued antiplaque activity.

Chlorhexidine helps control plaque andperiodontal disease but binds tannins,thereby causing dental staining if the userdrinks coffee, tea, or red wine. Such stainingcan be removed by dental professionals. Lis-terine, which achieves its antiplaque effectfrom essential oils, does not stain teeth, but itcontains alcohol. Triclosan also has an anti-plaque effect.

Vaccination against oral diseaseAcceptable, reliably successful vaccinesagainst caries or periodontal disease are notavailable.

Mouth protectionSoft plastic mouth guards, or occlusal splints,may be needed to prevent damage fromtrauma, as in sports injuries or bruxism. Forpatients with acid reflux, bulimia, or alcohol-ism, use of antacids or acid-reducing agentsmay help to reduce tooth erosion.

Acknowledgment: Crispian Scully thanks RosemaryToy, general practitioner, Rickmansworth, Hertford-shire, England, for her advice.

Authors: Ruth Holt is senior lecturer, Graham Roberts isprofessor of pediatric dentistry, and Crispian Scully isdean at the Eastman Dental Institute for Oral HealthCare Sciences, University College London, University ofLondon (www.eastman.ucl.ac.uk)

.............................................................................

Further reading

Murray JJ, ed. Prevention of Oral Disease. Oxford:Oxford University Press; 1996.

Ohrn R, Enzell K, Angmar-Mansson B. Oral status of81 subjects with eating disorders. Eur J Oral Sci1999;107:157-163.

Scully C, Flint S, Porter SR. Oral Diseases. London:Martin Dunitz; 1996.

Scully C, Welbury R. A Colour Atlas of Oral Diseases inChildren and Adolescents. London: Mosby Wolfe; 1994.

Tomar SL, Winn DM. Chewing tobacco use anddental caries among US men. J Am Dent Assoc1999;130:1601-1610.

Watt R, Sheiham A. Inequalities in oral health: a reviewof the evidence and recommendations for action. Br DentJ 1999;187:6-12.

Four Main Ways to MaintainOral Health

Diet• Reduce consumption and, especially,frequency of intake of food and drinkcontaining sugar

• Consume food and drink containingsugar only as part of a meal; snacks anddrinks between meals should be free ofsugars

• Avoid frequent consumption of acidicdrinks

Tooth cleansing

• Brush teeth thoroughly twice daily anduse a fluoride toothpaste; brushingalone does not prevent caries

• Remove plaque regularly to preventperiodontal disease

• See a dental health professional forother aids to plaque removal

Fluoridation

• Request local water company to supplywater with optimum fluoride level. Waterfluoridation is a safe, equitable, andhighly effective public health measure

• Consider use of fluoride supplements forchildren at high risk and living in areaswithout water fluoridation

Visiting a dentist

• Have an oral examination every year

• Schedule more frequent examinations ifat special risk from oral disease, such asthose with hyposalivation or for whomoral disease may be a particular risk tohealth, such as patients with heartdisease

Modified from The Scientific Basis of Dental Health Education;Health Education Authority, 1996

Figure 5 Caries in dentine. Initially, a brown spot withsurrounding white area (second molar) is the onlyoutward sign of a large cavity extending into thedentine (top). If untreated, the decay extends to thepulp (red central area, bottom).

. . . . . . . . . . . . . . . . . . . . . .

Toolbox

290 wjm Volume 174 April 2001 www.ewjm.com