Oral disease

Lesson objectives
• Recognise the benefits of a healthy mouth
• Dental plaque and signs of inflammation
• How dental caries form and contributory factors
• Periodontal disease – and identify risk factors
• Recognise the appearance of oral cancer the different types and causes.
• Non-carious tooth surface loss
 Inflammation and Infection

Infection = invasion and multiplication of a pathogen within the body.

• Multiplication and Infection: Pathogens multiply and begin to disrupt the
natural balance of the oral microbiota. This disruption can lead to various
infections, including: gingivitis, periodontitis, oral thrush, cold sores.

Inflammation = body’s protective response against injury or infection

 Types of inflammation

Inflammation is classified into 2 types:

Heat
Acute inflammation is the immediate response to the irritation and lasts
from a few hours to few days.
Loss of
Chronic inflammation will result if the stimulus is not removed for a long Swelling
period of time (months or years). function

In some cases, the host's immune system successfully eliminates the

pathogen, leading to the resolution of the infection. However, certain
pathogens can evade complete eradication, leading to chronic
infections that persist in the body for extended periods. Pain Redness
What causes inflammation in the mouth?

Bacterial plaque (dental plaque biofilm)

It is a combination of bacteria and food debris adhered to the

tooth surface.
Plaque is soft initially and can be removed by brushing. If not, it
sets hard in time.
Definition: a thin, transparent, protein-containing, soft and sticky
film (Page 354)

How can we remove dental plaque?

 What causes inflammation in the mouth?

Dental calculus:
Soft plaque hardens in 48 hours (if not removed) and turns into
dental calculus
Forms above the gum line (supragingival) and below (subgingival)

How can we remove dental calculus?

 Stagnation areas

• Since those areas cannot be easily accessed

by the bristles of the toothbrush, bacteria
remains shielded and hidden.

➢ Gingival margin
➢ Interproximal areas
➢ Edges of dental restorations
➢ Pits and Fissures
➢ Exposed root surfaces
 Types of sugars pg. 355

Intrinsic sugars Extrinsic sugars

Found naturally in fruits and
vegetables
Sometimes occur naturally - milk sugar - lactose
Free sugars
Honey, natural syrups and natural fruit juices, fruit smoothie (released sugars)
Added artificially during food processing, added by the patient to the drinks
Refined sugars- sucrose and glucose

Added: Sugars added during food preparation, cooking, or by manufacturers during the processing of
foods and beverages.
Naturally Present: Sugars that naturally occur in honey, syrups (like maple syrup or agave syrup), fruit
juices, and fruit concentrates. While these sugars are naturally occurring, they are still considered free
sugars because they are extracted from the whole fruit and lack the fibre content that helps mitigate the
impact of sugar intake.

Harmless Lactose- harmless

Hidden sugars, free sugars or added sugars - the most damaging
 The importance of diet in caries
prevention

Cariogenic foods are those that contribute significantly to

the development of dental cavities (caries) or tooth decay.
These foods contain high amounts of sugars, particularly
sucrose, glucose, and fructose, which act as fuel for bacteria
in the mouth.

Non-cariogenic alternative sugars are sweeteners that are

less likely to contribute to tooth decay or cavities compared
to traditional sugars.

▪ Page 358-359- table with all sugars.

 The important role of saliva

▪ Saliva maintains the mouth at a neutral level, being neither acidic

nor alkaline.
▪ The neutral level maintained by saliva is pH7.
▪ As soon as we eat, the pH drops in 5.5 and the environment becomes
acidic
▪ If we do not eat from that moment, the mouth will come back to pH 7
in 20-120 minutes. The saliva helps in this process and cleanses the
mouth. This is called neutralisation.
▪ Components: water, inorganic ions and minerals, digestive
enzymes, antibodies, leucocytes.
 Controlling the frequency of
sugar intake

• Frequency - the more often sugars are

consumed, the more likely to develop dental
caries.
• We use Stephen’s Curve graphic to show
how teeth are affected by the uncontrolled
frequency of sugar intake

• https://jamiethedentist.com/dental-caries-
decay/stephan-curve/
Dental caries

What causes dental caries?

1. Dental plaque biofilm
2. Sugar
3. Frequency of sugar intake

Bacteria causing dental caries: pg. 354

1. Streptococcus mutans
2. Streptococcus sanguis
3. Some Lactobacilli
Dental caries

• decay or carious lesion;

• The enamel starts to get demineralised (dissolved) by the
action of bacteria (naturally present in the mouth) eating the
food debris and the sugars.
• The bacteria will produce acid
• The enamel will get dissolved by this acid
The progression of dental caries

• This new carious lesion will show as a white spot lesion.

• At this stage the patient will feel no pain or discomfort as the enamel
does not contain any nerves or blood vessels.

• The enamel can try to repair itself where attacked → these areas of
repair often appear as brown lesions on the teeth.

• An important feature of the enamel → it can re-mineralise

 If the cavity is not treated…

• Further, the caries will enter the dentine and will spread more rapidly
because of its hollow structure made of tubules.

• This undermines the enamel, and when biting, bits of tooth can chip
or break away, leaving a hole in the tooth structure called a cavity.

• Odontoblast cells will react by laying down secondary dentine in an

attempt to protect the nerve.
 Reaching the nerve

The pulp tissue will become irritated and inflamed → Pulpitis

The dentist can remove the caries, place a filling and restore
the tooth. The inflammation will be gone → reversible
pulpitis.
If the caries reaches the nerve chamber and the nerve is
exposed= Irreversible pulpitis

The pulp once exposed will die and from here problems arise
if no treatment is sought.
Alveolar abscess

❖ When irreversible pulpitis is not treated → The pulp or the nerve will
eventually die once exposed.
❖ A necrotic pulp leads to → ALVEOLAR ABSCESS
❖ What procedures can be done at this stage?
Conclusion
Risk groups of patients

• People with poor oral hygiene.

• People with high sugar and acidic diets.
• People who suffer from Xerostomia (dry
mouth)
 Non-carious tooth surface loss
Erosion Abrasion Attrition Abfraction

Due to acid such as fizzy Occurs when patients scrub Loss of enamel because of caused by bending forces
drinks, acidic fruits or a their teeth using excessive bruxism → grinding the teeth applied to a single standing
medical condition (acid reflux) force or abrasive tooth paste. (stress related) tooth.
Loss of tooth in the cervical
Overbrushing region
(usually premolars)
PERIODONTAL
DISEASE
 What is periodontal disease?

• Destruction of the supportive structures of the tooth, which

are → gingivae, periodontal ligament, alveolar bone.

Periodontal disease is a bacterial infection

Actinomyces, Prophyromonas gingivalis…. (237)

• Does not affect the teeth themselves, but the surrounding

tissues
• No sugars are involved in periodontal disease
 Factors involved in periodontal disease

• Dental plaque biofilm

• The plaque micro-organisms will produce toxins which will irritate the gums further and
even more.
• The plaque eventually turns into calculus and as it hardens

Bacteria in dental caries- acid

Bacteria in periodontal disease – toxins
Gingivitis- clinical features

▪ When healthy, the gingival crevice is not deeper than 3 mm.

▪ On examination, the clinician might notice that the patients
gingivae are swollen, reddened, and bleed when gently
probed.
▪ This swelling, may give rise to what are known as ‘false
pockets’

▪ False pockets - These pockets can give the illusion of deeper

gum pockets during a dental examination but are primarily
due to swelling, inflammation, or enlargement of the gum
tissue rather than actual loss of attachment between the
gums and teeth.
 Healthy Gingiva Unhealthy Gingiva

➢ Pale, pink in colour ➢ Red

➢ Firmly attached around the tooth ➢ Puffy and swollen

➢Gingival crevice depth 0-3mm ➢ Loose around neck of tooth

➢ No bleeding on probing ➢ Bleeding on probing

➢No swelling ➢ Halitosis (bad breath)

Periodontitis

▪ If gingivitis is not treated → the toxins will begin to soak

deeper and aggravate the condition.
▪ They will eventually destroy the periodontal ligament → a
True Pocket forms.
▪ True pocket- area of bone loss
• As more bone is lost the tooth begins to loosen.
• The end results in loss of the tooth.
Factors that can aggravate
periodontal disease
✓ Smoking. (smoking cessation advice)
✓ Diabetes, AIDS, Leukaemia (resistance to infection is poor)
✓ Vitamin C deficiency, stress

✓ Epilepsy treated with Phenytoin.

✓ Treatment with drugs such as Ciclosporin (used to fight cancers)
or Nifedipine (to reduce high blood pressure) – cause severe non-
inflammatory enlargement of the gums – gingival hyperplasia
 Other periodontal conditions

• Subacute pericoronitis= inflammation of the operculum (flap

of gum sitting on a partially erupted tooth).
• Usually, wisdom teeth are affected by this condition.
• Best antibiotics for anaerobic bacteria = Metronidazole
 Other periodontal conditions

Acute herpetic gingivitis - This condition is caused by an

initial infection with herpes simplex virus and is usually
seen in infants and children. (blisters and ulcers)

This viral infection is characterized by painful sores,

inflammation of the gums (gingivitis), and small blisters or
ulcers on the mucous membranes inside the mouth, lips, throat,
and sometimes the gums.
Other periodontal conditions

▪ Acute necrotising ulcerative gingivitis (ANUG)-an

acute gingivitis characterised by pain, necrotic
gingivae and halitosis.

Poor oral hygiene, stress, compromised immune function,

smoking, malnutrition, or other systemic conditions can
predispose someone to ANUG. Additionally, the condition
may occur suddenly and progress rapidly, necessitating
immediate dental attention
 Periodontal abscess

An acute lateral periodontal abscess is a localized collection of pus located

at the side of a tooth, within the periodontal tissues. It's a severe and
painful condition that arises due to an infection involving the periodontal
pocket and supporting structures around a tooth.

This infection is commonly associated with advanced periodontal disease,

where bacteria penetrate deep into the periodontal pockets, causing
inflammation and subsequent abscess formation.
Treatment typically involves drainage of the abscess to release the
accumulated pus and alleviate pain. This may be accompanied by scaling
and root planning, a deep cleaning procedure to remove bacterial plaque
and calculus from the root surfaces. Antibiotics might also be prescribed in
severe cases to control the infection and prevent its spread.
Oral Cancer

• 90% of OC affect the soft tissues initially, mostly the sides of the
tongue.
• Oral cancer appears as an ulcer without obvious cause, painless and
without resolving within 3 weeks.
• Type of skin cancer - squamous cell carcinoma(SCC)
• Lesions: leukoplakia or erythroplakia
 Oral Cancer Risk Factors

• Tobacco: The greatest risk factor for oral cancer is tobacco.

• Alcohol: Oral cancers are about 6 times more common in drinkers than in non-drinkers.
• Diet: Refined sugars, oils and carbohydrates and dairy products have been shown to increase risk
for oral cancer.
• Excessive Exposure to Sunlight: Excessive and unprotected exposure to sunlight and other
sources of ultraviolet radiation (UV) like tanning beds is linked with cancer in the lip area.
• Genetics- some people are genetically predisposed to SCC
Useful You Tube links:
▪ Dental caries explained- https://www.youtube.com/watch?v=3zL4Hou1P-c
▪ Periodontitis explained- https://www.youtube.com/watch?v=B35jRf4EKPA

Levison’s textbook: chapter 11

Q&A book: chapter 9