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Dental Pathology

What causes bad breath (halitosis) and ways to fix it!

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Oral Thrush

Halitosis, or bad breath, can have a number of causes. One of the biggest and most common of these is oral thrush as a result of a fungal infection. Candida Albicans can cause a large white, yellow, or brownish patch on the tongue. This typically forms when saliva flow is low, there is increased mouth breathing, insufficient oral hygiene, smoking, or in cases of reduced immunity.

Saliva is not only important to flush away bacteria from the teeth and gums, but also fungal pathogens from the tongue. Low saliva flow is called Xerostomia. When this occurs pathogens are allowed to accumulate and settle in on the tongue resulting in oral thrush.

Xerostomia can be caused by dehydration, most medications, caffeine and alcohol consumption, smoking, advancing age, and Sjogren’s syndrome (an auto-immune condition of the salivary glands that commonly presents with other auto-immune conditions.)

To improve xerostomia drink plenty of water, switch medications (where possible), reduce caffeine and alcohol intake, and quit smoking. There are also certain aides you can purchase that can stimulate saliva flow delivered in mouthwashes, toothpastes, and gels.

Mouth breathing may be due to sinus congestion, so if there are issues here it is advisable to investigate these with your GP or an Ear Nose and Throat Surgeon. Nasal sprays can be useful for periods of heavier congestion.

In addition to improving your saliva, brushing your tongue every time you brush your teeth will help clear this fungal accumulation. Using your toothbrush is fine, however, since a soft or ultrasoft toothbrush is the preferred brush for your teeth, it is best to use a tongue scraper. You can also use fungal lozenges and gels that your dentist can prescribe for you, though these tend to have a somewhat limited effect.

Whenever you notice any abnormal patches on your tongue or elsewhere in your mouth, ensure you see your dentist to investigate. Though oral thrush is the most common cause, this could be due to other conditions which will need further treatment.

Gum Disease

When halitosis is particularly mentionable by your peers, it could be due to gum disease, either severe gingivitis or periodontitis. Both will present with red, bleeding gums, particularly when brushing and flossing. Without intervention, gum disease is likely to worsen over time and can lead to wobbly teeth and early tooth loss.

To prevent gum disease ensure you are brushing for two minutes, twice a day, brushing your gums gently but thoroughly. Floss at least once a day. Don’t be scared if you see any bleeding. Bleeding means there is bacteria and it’s the bacteria inflaming your gums. Remove the bacteria and the gums should improve.

Ensure any issues with the gums are assessed by a dentist. Once severe periodontitis sets in the damage is often irreversible. Bad breath from gum disease generally responds very quickly to treatment.

Reflux

Reflux can occur with a weak oesophageal sphincter (GORD), related to your diet and quantity of food eaten, stomach ulcers, or from other issues from the stomach or gastrointestinal tract. When halitosis is caused by reflux you’ll likely experience multiple periods of an acidic taste occurring in your mouth. You may also present with a higher amount of tooth wear. Drinking plenty of water and eating smaller portions may help. Also avoid acidic and carbonated beverages. If simple changes to your diet doesn’t improve your reflux it is best to investigate with your GP.

Tonsil Stones

Small white/yellow calcifications may develop within your tonsils which are generally shed from time to time. Tonsil stones are more likely to occur with dehydration and regular alcohol and caffeine intake. Most of the time these will be shed and swallowed without you realising, though someone smelling your breath at the time may detect something a bit stale. Unless you suffer any symptoms tonsil stones aren’t usually too much of a concern. Simply drink plenty of water and few, if any, tonsil stones will develop. If you notice a fair number of these shedding, or have sore, enlarged tonsils without signs of an infection, have your tonsils examined by your dentist or GP.

Tooth Decay and Abscesses

When bad breath is a result of tooth decay or abscesses within the mouth, you’ll likely be aware of the issues. For tooth decay to be severe enough to cause halitosis you’ll be able to feel the size of the holes easily with your tongue. Abscesses will usually be quite painful. There may be pus leaking giving a foul taste and cellulitis, swelling around the cheeks and jaws. See your dentist immediately if you show any of these conditions. Cellulitis is of particular concern, as swellings arising from infected teeth could also block airways in severe cases.

Lesions Within the Mouth

Sores, cuts and ulcers could also lead to bad breath. In cases of extracted teeth, food can occasionally get caught here and will cause a smell. Keep any lesions clean with salt water rinses and ensure you do not pick at the area. Picking at sores will remove the healing factors in place and delay healing. If any sore persist after two weeks without improvement or worsening smells see you dentist immediately as this could indicate an infection or some other chronic condition.

Lesions that do not resolve in time or come and go, that are painful or bleed, should always be assessed by your dentist. Some of these could be auto-immune related or, in rare cases, carry carcinogenic properties. Early identification and management is vital in these cases.

Severe toothache. Tooth pain from pulpal infection.

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Toothaches are a major source of dental pain. Tooth pain can originate from a number of sources. From exposed dentine to leaky fillings, traumatic pressure, hypersensitivity from grinding or abrasive brushing, or referred pain from gums or nearby sinuses. Generally the most severe toothaches arise within the pulps, or “nerves”, of the teeth. This is commonly called pulpal pain or “nerve pain”.

How does pulpal pain, or “nerve pain”, occur in a tooth?

A toothache that can be described as an 8 to an 11 out of 10 would usually be caused by pulpal pain. It will likely be hot and cold sensitive, worsened with pressure, and give a severe ache. The primary source of this tooth pain is pulpal infection.

The first stage of tooth infection is when bacteria breaks down the outer layer of the tooth. To achieve this, bacteria needs to be well established on the tooth surface and given access to carbohydrates to metabolise. Bacteria quickly forms into a soft white layer called plaque. The longer it is left undisturbed, the greater the decay potential. If one little spot of plaque is left for more than 24 hours and given access to carbohydrates, particularly sugars, then tooth decay can occur. Once decay reaches inside the tooth it is unlikely to stop without intervention.

Enamel forms the outermost layer of the tooth. This is the strongest part of the tooth and most resistant to the decaying effects of bacteria. The longer bacteria has to work on this area the more likely decay may penetrate this layer and cause a cavity.
The yellow layer of the tooth is dentine. This structure is less dense and bacteria and decay can break this area down much quicker. To stop this process a filling is needed. If nothing is done the decay will keep extending.
The dental pulp or “nerve” of the tooth. This layer is a nutrient rich area filled with blood vessels and small nerves. When bacteria reaches here it spreads quickly. Inflammation results, crushing the nerves inside. This is how severe toothaches arise.
Bacteria quickly moves through the pulp to the base of the tooth roots and into the bloodstream. An abscess may form in this area and bacteria can spread into nearby tissues causing cellulitis.

Early tooth decay, or tooth infection, can be treated with fillings. The decay is removed by a dentist and the lost tooth structure is restored using composite resin, a white tooth coloured material, in most cases. If left untreated this decay will usually extend until it reaches the interior of the tooth – the pulp. The pulp is a nutrient rich area that feeds the tooth blood and nerves, it is what makes the tooth alive. Imagine bone marrow but for teeth. Unfortunately, it is so nutrient rich that as soon as bacteria reaches here it spreads and multiplies almost instantly. The infected tooth becomes an infected pulp and severe tooth pain, or pulpal pain, results.

Why is pulpal pain so bad?

The nutrient-rich, lush area of the pulp becomes the perfect breeding ground for bacteria. It spreads quickly, releasing nasty toxins into the bloodstream. The body detects the bacteria has invaded areas it shouldn’t be and mounts a defence to try to destroy the bacteria. When there is an immune response, inflammation occurs. However the pulp is encased by hard tooth walls and doesn’t allow for swelling. So pressure builds up within the pulp, full of tiny nerves which essentially become crushed. That’s when we experience severe toothaches.

Does pulpal pain go away on its own?

Treating a toothache can seem scary, expensive, and possibly even more painful, so you may be tempted just to let things play out. This is not a good idea.

The type of bacteria that invades the pulp is bacteria our body is usually good at destroying, however that tight area inside the tooth is very hard to reach. Larger white blood cells can’t access the pulp very well and the immune system isn’t capable of clearing out the bacteria on its own. This means the infection cannot be cleared without professional intervention.

If you’re lucky, an equilibrium could be achieved where bacteria is cleaned from the body as it leaks from the tooth and the pain may lessen. These states are usually only temporary however and a large bacterial load is likely to resurface in the future. You’ll also always have a source of bacteria entering your bloodstream potentially causing other health effects. If the bacterial load becomes more severe then you could also develop cellulitis, swelling within the nearby tissues. The swollen areas become very tender and may even extend further back to your airways, restricting airflow.

Treatments for pulpal pain

 

Antibiotics

If you’re in a lot of pain, there’s a fair amount of swelling, or you’re just too scared to see the dentist right away, a course of antibiotics can help to clear the infection from the nearby tissues. This is only a very temporary solution however. Antibiotics, like the immune system, is not able to properly access the pulps of teeth and cannot remove the bacteria inside. It will reduce the amount of bacteria just around the tooth and reduce inflammation, so it will help with the pain. But soon after the antibiotics are finished the bacteria will spread again and the pain is likely to return.

The best way to permanently remove the bacteria is to remove the source, which is the tooth pulp. This can be achieved either through a root canal treatment or tooth extraction.

Root canal treatment

In most cases your dentist will recommend root canal treatment when they determine you have an infected pulp. This process involves removing all the decay and cleaning inside the tooth. The pulp is completely removed, and the area is shaped and then filled to prevent any bacteria from returning. It usually consists of three sessions which needs to be performed with high care. Any left-over bacteria could lead to long term failure. It has a success rate of 90% over a ten year period. Once completed the tooth will be essentially “dead”, but the bacteria will be removed and the tooth can be kept. Healing will be able to occur and the tooth will not be a source of bacteria to the body anymore.

Tooth extraction

If the cost of root canal treatment is too high, or the tooth is too compromised to have a successful outcome, the tooth can be extracted instead. With the tooth removed the source of the bacteria will be too and the bacteria that entered the nearby tissues can usually be cleared by the immune system quickly. The obvious down-side to this option is that a space is left where the tooth was. Sometimes this can be tolerated if it is a back tooth, though there will be less area to chew with. A front tooth can be unsightly and tooth replacement options will usually be recommended. Dentures, implants or bridges can provide options to replace missing teeth.

For more information on root canal treatments, dental extractions, or tooth replacement options, click on the link below.

How to prevent bleeding gums

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At times when brushing or flossing you may notice some bleeding, it could be a little bit, or it could be a lot. The gums can get swollen, tender and red, a condition called gingivitis.

The cause all comes back to bacteria.

Bacteria releases chemicals that are detected by your body where your immune system tries to fight it off. But the more that builds up, the harder it is for your body to clear it away. Your first line of defense is your saliva, then immune complexes are released from the blood stream in an attempt to reach the bacteria on your teeth. However, once bacteria builds up a thick layer called plaque, it is protected from our body’s defenses. The immune system keeps trying to penetrate into that thicker plaque and as more chemicals are released from bacteria, so too are more chemicals released by the immune system. The result is inflammation: red and bleeding gums.

The solution? Remove the bacteria, aka: plaque.

Plaque is a thick layer of bacteria that has its own defenses from being removed so things like mouthwashes and antibiotics are not that effective at targeting deep into it. That means physical removal is the most effective method. This involves brushing two minutes twice a day and flossing at least once a day. Don’t be scared of the bleeding, go gently but thoroughly. Once you’re consistently removing that plaque the bleeding will subside shortly after.

Still bleeding even with thorough brushing and flossing?

Other factors such as calculus (a hard substance that builds up on teeth over time), or poor margins on restorations can lead to areas not properly cleaned. A visit to the dentist to perform a thorough and at times, deep clean, may be warranted. They can also check to see if any of your fillings are defective which may need to be replaced. Other health conditions can also lead to bleeding gums, such as pregnancy (pregnancy gingivitis), uncontrolled Diabetes, certain medications, or other oral pathology. Looking after your health and removal of the bacteria should still resolve your gums. If your gum disease is more severe it may have progressed to periodontitis, which occurs when gingivitis has been untreated for a long time. Periodontitis requires further intervention with a dental professional.

It is recommended to have regular check ups and cleans every 6-12 months. Most health funds will cover two a year so it’s good to be vigilant and take full advantage of this.

End message:

Don’t be afraid of bleeding gums, it just means you need to brush and floss more thoroughly (but gently). And don’t forget your dental maintenance appointments!

What is TMD (Temporomandibular Joint Disorder)?

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Temporomandibular disorder, or TMD, describes a range of issues arising from in and around the temporomandibular joint (TMJ). These involve: night-time grinding or clenching; tooth wear and cracks in teeth; clicking or pain when opening and closing the lower jaw; pain resulting from long periods of mouth opening; or limited capacity for mouth opening. The causes of these symptoms usually have many factors involved.

So where do we start? Firstly, your general dentist will assess your symptoms and possible causes of TMD, then will tailor your treatment accordingly.

The temporomandibular joints (TMJ) provide the pivot points for the lower jaw’s range of movement. This joint can suffer damage over time from disc displacement (clicking or locking), arthritic wear, or other pathological issues.
The masseters are the main muscles of mastication involved in chewing. If these become overworked they can become hypertrophic (enlarged), may become tender, and lead to further grinding and clenching.
Wear tends to occur on the chewing surfaces of teeth over time due to excessive grinding. The small lower incisors shows the most wear but wear will also be occurring on all the teeth. In severe cases, the wear can be quite significant and lead to shorter teeth and reducing the vertical dimension of your bite.
The necks of teeth can also suffer abfraction, which is wear that leads to concavities here and exposes dentine. The exposed dentine can be quite sensitive and since this part of the tooth is less dense, further wear or decay is likely to develop here.
A major muscle of mastication that stretches out laterally here is called the temporalis. If increased tension is experienced here, headaches are commonly experienced.
Those who suffer TMD may find that their jaws fatigue quickly after holding there mouths open for a short period of time. This is generally because of the overworked muscles of mastication that work in the opposite direction to close the jaw.
Congestion in the nasal sinuses may lead to increased mouth breathing and this can increase the likelihood of congestive sleep apnoea. It is important to search for any issues that be contributing to TMD when selecting a treatment protocol.

Causes of TMD

Congestive sleep apnoea: occurs as a result of your tongue rolling back in your mouth at night, blocking your airways. Grinding and clenching may occur as an attempt to wake yourself up at night. Specialised splints or C-PAP machines can be useful in treating this condition.

Crooked teeth have been occasionally associated with TMD, though usually when there are more significant bite problems. Teeth straightening, at times with jaw repositioning surgery, may help to reset your bite into a more harmonious position.

Anxiety, stress, and personality quirks may just lead some people to grind without any other clearly defined cause.

What are the treatment options?

Splints

If sleep apnoea and bite discrepancies don’t seem to play a large role we usually start with a splint. This is a clear plastic mouthguard you wear on your top teeth at night. These are specially fitted for your teeth so they don’t fall out easily and provide an even bite with a free range of movement. These will not stop your grinding or clenching, but it will help to reduce it and ease forces. The plastic material acts as a buffer between your teeth and protects them from wear and cracks. The splint can look bulky at first, but after a couple of weeks most people adapt fairly well. For our splints, we use a hard firm material on the outside and a gel layer on the inside fitting surface. These are generally reported as far more comfortable than the standard plain hard splint design.

Splints are specially moulded to your teeth to ensure they will stay on all night snugly.
At Smile Design Dental we use a gel internal layer to ensure comfort.
Hard plastic outer layer will keep the splint’s stability and absorb the wear from nocturnal grinding. The bite will be fairly even to ensure forces are well distributed and avoiding any locking from the joints.

Muscle Relaxant Injectables

Muscle relaxant injectables provide an alternative to those who find a splint still too bulky. These can be injected into the overworked, enlarged chewing muscles. The masseters, bands of thick muscle at the back of your jaws, are usually injected first and reviewed 4-6 weeks later. The muscles will lose some strength so that they will naturally release when clenched, easing tightness. The temporalis, a band over the temple and stretching laterally across the skull, may also require injecting. The injectables typically last 4-6 months and can be seen to slim the jawline giving a nice aesthetic side effect.

Injectables into the masseter muscles will reduce strength and bulk. Allowing the jaw to open with less resistance and will reduce capacity to clench tightly for long periods. Reducing the bulk can help to slim the jawline.
A thin wide band of muscle over the temporals is the temporalis. When these muscles are overworked there is an increased tendency for headaches. Muscle relaxant injectables may be added here along with the masseters may be warranted in some cases.

Other treatments

Physiotherapy can also be used as an adjunct to the prior treatment methods. This will f on improving range of motion and decreasing tension. If your TMD is a little more complicated you may require a more specialised splint, anti-inflammatory or anti-anxiety medications. If there are physiological changes to the joints then surgery may be required. Arthritis or other changes can occur when TMD has been present for a long time without adequate intervention. These can be difficult to treat and may only provide a small improvement, therefore early management of TMD is critical.

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