Dental Health for Adults: A guide to protecting your teeth and gums

| April 4, 2007

Dental Health for Adults: A guide to protecting your teeth and gums

Crunching into a crisp apple, flashing an appreciative smile, and even pronouncing your name all depend on good dental health. Strong, healthy teeth support everyday activities like these. But mouth diseases and the tooth loss that may follow can interfere with these important activities and make you feel less confident about your appearance.

The impact of oral disease can extend far beyond the mouth. Research has unveiled potential links between chronic gum infection and conditions as serious as diabetes, stroke, cancer, heart disease, and pregnancy complications. Not only might these ailments provoke oral health problems, but there's evidence that dental problems such as gum disease can contribute to bodily illness.

Fortunately, the landscape of dental health has changed dramatically over the past century. As recently as a generation ago, most people lost their teeth within their lifetime. In 2007, the majority of middle-aged people can expect to keep most of their natural teeth for the rest of their lives. And there's more good news: Children have fewer cavities than in the past.

This transformation in the oral health of Americans reflects a greater understanding of the causes and prevention of dental disease. Just after World War II, fluoride was added to drinking water, leading to a dramatic drop in tooth decay among children. A couple of decades later, researchers discovered that gum disease as well as tooth decay was caused by bacterial infection. Suddenly, the two major causes of tooth loss could be countered by attacking bacteria in the mouth using the basic oral hygiene techniques of brushing and flossing. In 2007, scientists are researching methods to prevent tooth decay and gum disease in hopes of making tooth loss as rare as polio and measles.

While prevention remains the key to a healthy smile, the science of dental treatment continues to advance. Thanks to evolving materials and techniques, dentists are more successful than ever before at reversing the disease process and preserving, repairing, and replacing teeth. This report will introduce you to developments like smart fillings that can help prevent cavities and methods for placing dental implants.

It also sifts through the hype surrounding certain dental products and procedures. Can chewing xylitol gum protect against tooth decay? Are silver fillings and fluoridation safe? Which toothbrush really works best? You'll find the answers to these questions below.

Your mouth: The basics

Your mouth plays a vital role in a variety of processes from breaking food into small particles so it can be swallowed and digested to enabling verbal communication to serving as a first line of defense for the body by preventing microbes and other harmful agents from entering your system. Learning a little about the structure of your mouth will help you maintain the best possible oral health.

Your teeth

Your first teeth called primary, deciduous, temporary, or baby teeth form in the gums before birth and begin erupting at about six months. The complete set of 20 temporary teeth is usually in place by age two or three. These teeth serve several important functions. First, they allow an infant to begin eating solid foods and to develop speech. They also act as placeholders, enabling the permanent teeth to align correctly as they grow in.

Beginning at about age 6 and continuing until age 12 or 13, the baby teeth fall out and are replaced by their permanent counterparts, plus an additional eight teeth. Four more teeth, often called the wisdom teeth, usually emerge between ages 17 and 21, completing the adult set of 32 teeth.

You have several different types of teeth, including incisors, canines, bicuspids, and molars (see Figure 1). The variety in tooth shapes reflects the range of foods in the human diet. The set of teeth supported by your lower jaw is called the inferior dental arch, while the set of teeth supported by the upper jaw is the superior dental arch.

Your teeth are surprisingly strong. The incisors can exert 3050 pounds of pressure, and the molars can bear down with more than 200 pounds of force.

Figure 1: Your teeth and their functions

Your teeth and their functions

The adult mouth has three types of teeth.

Incisors: eight teeth in the middle front of the jaw (four upper and four lower) that have straight sharp edges shaped for cutting food.
Canines: four larger teeth, also called cuspids or eyeteeth, with sharp points designed for ripping or tearing.
Bicuspids and molars: the remaining teeth 8 bicuspids (sometimes called premolars) and 812 molars, which have broad, flat surfaces with small mounds for grinding food.

Beyond your teeth

Several other important oral structures enable the teeth to do their job.

Oral mucosa. This is the soft pinkish-to-purplish tissue covering the inside of the mouth. Its primary function is to prevent irritants and infectious agents from entering the body. A fibrous protein called keratin makes most of the surfaces of the oral mucosa more resistant to injury.

Gums. Gum tissue (gingiva), a specialized portion of the oral mucosa, connects to each tooth at the neck and extends over the root and supporting bone. In a healthy mouth, the root remains entirely out of sight below the gum line. The gum tissue attaches securely to the underlying structures except at the upper edge, where it forms a tiny flap about 1.5 millimeters wide, at the margin of the tooth and gum. The V-shaped hollow under this flap is called the sulcus. It's easy for food and bacteria to get trapped in this pocket. This can lead to inflammation and eventually to periodontal disease, also called gum disease. Because gum tissue contains no keratin, it's particularly vulnerable to infection from bacteria that collect in the sulcus.

Bones and jaw. The five bones that make up the mouth include the powerful, horseshoe-shaped lower jaw (the mandible); the two bones of the upper jaw (the maxilla); and the two bones that form the roof of the mouth (the palate). The way in which your upper and lower teeth come together when you close your mouth is called your bite, or occlusion. For you to chew effectively, your teeth must mesh correctly.

Tongue. This muscular structure manipulates food in your mouth, bringing it into contact with the teeth and moving it into the throat. Your tongue is also essential for clear speech. Taste buds on the tongue enhance the pleasure of eating.

Salivary glands. Three pairs of glands release saliva into the mouth. There are two types of saliva: a watery substance that clears food and dead cells from the lining of the mouth, and a thicker secretion that binds chewed food into a ball so it can be swallowed. Saliva serves many purposes. It helps cleanse food and bacteria from the teeth, protects the mucosa from irritants and toxins that enter the mouth, and prevents the membranes from drying out. Saliva forms a protective film on the teeth, and its slightly alkaline pH helps neutralize acids (from food, drink, bacteria, or the digestive process) that could erode tooth enamel. It also contains compounds that destroy or prevent the growth of certain microbes, especially fungi. In addition, it contains calcium and phosphorous, which help regenerate tooth enamel that's been damaged by decay. Adding fluoride to the saliva, by way of toothpaste, drinking water, or mouth rinses, amplifies these healing effects. An insufficient flow of saliva which can be caused by medications, irradiation, or certain diseases greatly increases your risk for tooth decay.

Healthy mouth, healthy body

The health of your mouth and your overall well-being may be more closely linked than you realize. Some of the same lifestyle choices that can keep your body in tip-top shape also help keep your teeth and gums healthy. For example, limiting sweets and avoiding tobacco are good for both your oral and general health.

The connection extends beyond lifestyle choices. Medications used to treat various illnesses can affect your oral health. Plus, certain illnesses may make you more prone to dental problems, while some dental problems may make you more vulnerable to particular illnesses. Understanding the connection between your oral health and the well-being of your body will help you take good care of both.

Eat right

Bacteria need a steady supply of carbohydrates, especially sugary foods. A large and continuous source of sugar allows the bacterial population to multiply and produce enough acid to dissolve tooth enamel faster than the body can rebuild it. The rise in dental cavities tracks closely with the widespread availability of inexpensive refined sugar beginning in the 18th century.

Both how much sugar you eat and when you eat it can affect your risk for cavities. Foods such as these increase your chances of getting cavities:

Foods with sugar content of more than 15%20%.
Sticky sweets such as honey, molasses, chewy candy, or raisins. These stay on the teeth longer than other sugars.
Slowly dissolving sugars. Slow-melting hard candies expose your teeth to sugar for a longer period of time compared with foods that are eaten quickly.
Sweets eaten alone. The saliva you secrete when you eat a meal may rinse away sugars.
Sweets eaten before bedtime. Unless you brush afterward, the sugar will remain undisturbed on the teeth until the next morning.
Starch and sugar combinations. Cookies, cakes, and other sweet baked goods are likely to cause decay.

Making positive food choices can be just as important as avoiding damaging items. Some foods, such as aged cheese and peanuts, actually lower the likelihood of decay by cutting the acidity of your saliva. Dairy products are high in natural sugar (in the form of lactose), but they also contain a protein that prevents bacteria from sticking to your teeth. In addition, dairy products are a natural source of calcium, an important nutrient for maintaining the strength of your teeth and bones. Insufficient calcium intake also contributes to periodontal disease.

Other nutrients you need for optimum oral health include

vitamin D for building and maintaining bone
folate, ascorbic acid, iron, and zinc to replenish the lining of the gums, especially in the pockets next to the teeth
protein and vitamins A and C to produce the connective tissue that supports the teeth.

Don't smoke

Tobacco is as devastating to your oral health as it is to the rest of your body. Not only does tobacco use cause such annoyances as tooth staining, tartar buildup, and bad breath, but tobacco users also risk developing tooth decay, severe gum disease, and mouth and throat cancers.

More than 30,000 new cases of oral cancer will be diagnosed among Americans in 2007, and approximately 7,400 people will die from the disease. The American Cancer Society reports that smokers are six times more likely to develop this disease than nonsmokers, and 90% of people with oral cancers use tobacco. Chewing tobacco is no less dangerous than smoking it; "smokeless" tobacco contains at least 30 carcinogens and can increase your cancer risk by four to six times. And because it contains high levels of sugar, it can promote decay.

Smokers are also at greater risk for gum disease. A 1994 study led by researchers at the State University of New York at Buffalo found that smokers were seven times more likely to develop periodontal disease than nonsmokers. The good news is that 10 years after quitting, former smokers are no more likely than nonsmokers to show signs of gum disease.

Medications and oral health

Hundreds of prescription medications have the potential to cause oral side effects. The most common side effect is dry mouth, which can be brought on by more than 400 different drugs. Dry mouth raises the risk of tooth decay and gum disease. Other common oral side effects include the overgrowth of yeast or other microbes, mouth sores, growth of excessive gum tissue, changes in taste, and staining of teeth. For example, tetracycline can stain teeth when it's taken in early childhood. The oral effects of medications are a particular problem for older adults, because they tend to take the most medication.

Table 1 lists some of the medications that can cause oral side effects. If you experience any of these effects, consult your doctor.

Table 1: Common oral side effects of medications
Side effect	Medications
Dry mouth	Tricyclic antidepressants, antihistamines, diuretics, anti-anxiety drugs, anticonvulsants, barbiturates, decongestants, muscle relaxants, bronchodilators, narcotic painkillers, and many others
Staining of teeth	Tranquilizers, oral contraceptives, antimalarial drugs, tetracycline (taken in early childhood when the teeth are developing), chlorhexidine
Overgrowth of gum tissue	Cyclosporine, calcium-channel blockers, antiseizure medication
Oral yeast infection (thrush)	Combinations of antibiotics and steroid drugs
Death of bone tissue	Bisphosphonates used intravenously in cancer treatment and, less frequently, oral bisphosphonates for osteoporosis prevention and treatment

Oral health and other diseases

Journal of the National Cancer Institute Some of the most intriguing oral health research is attempting to connect the dots between diseases of the mouth and other illnesses. For example, a 2007 study published in the reported that gum disease may increase the risk of developing pancreatic cancer. So far it's unclear how periodontal disease might contribute to pancreatic cancer and no definite cause-and-effect relationship has been proven, but the findings are intriguing and will no doubt spur further research.

Links between other health conditions and gum disease have been studied in greater depth. Under particular scrutiny is how periodontal disease may relate to diabetes, heart disease, and pregnancy complications.

Taking care of your teeth at home

When it comes to tooth loss, the primary culprits are decay and periodontal disease. Tooth decay, the gradual breakdown of the tooth's enamel and interior tissue, can cause cavities and, eventually, the death of the tooth (see "Tooth decay and cavities"). Periodontal disease, on the other hand, attacks the gum tissue, ligaments, and bone that support the teeth (see "Gum disease"). Both of these conditions result from the uncontrolled growth of bacteria in the mouth.

Streptococcus mutans At any time, the number of microbes living in your mouth exceeds the human population of earth. Although most of these microbes are harmless, some bacterial species in particular are responsible for tooth decay. The decay-causing bacteria mix with saliva to form a sticky film, called plaque, that adheres to the surface of your teeth. The bacteria consume sugar from food residue in the mouth and excrete lactic acid, which becomes part of the plaque layer. If plaque isn't removed, the acid dissolves the tooth's enamel and inflames the gum tissue.

The plaque that forms on easily accessible surfaces can be dislodged with natural chewing and tongue movements. However, hard-to-reach places such as between the teeth, in the furrows of the molars, and at the edges of the gums around the teeth are likely spots for plaque to build up and disease to develop.

Most people can keep bacteria in check with a relatively simple regimen of home care. Some individuals, however, have less natural resistance to oral bacteria. For these people, decay or gum disease may appear or advance despite their best efforts at hygiene. If your dentist suspects this is your problem, he or she may test your susceptibility to bacteria and tailor your oral care accordingly.

Brushing

The cornerstone of any good oral hygiene program is regular brushing. To prevent the chain of events that occurs when bacteria accumulate, you must remove plaque from the surfaces of your teeth at least once every 24 hours. It's best, though, to brush at least twice daily once after you eat breakfast in the morning and then again in the evening before you go to sleep. To keep your brushing regimen effective, replace your toothbrush when the bristles splay out of line, generally about once every three months.

Flossing

No matter how thoroughly you brush your teeth, it's impossible to reach the plaque and food debris that lodge between teeth and under the gum line. Using dental floss every time you brush not only makes your teeth cleaner, it also stimulates gums, polishes tooth surfaces, prevents buildup of plaque, and reduces gum bleeding. And flossing can help you prevent gum disease.

How many people heed the message that flossing is important for good dental health? According to a 2005 survey sponsored by the American Dental Association, nearly 52% of adults said they flossed at least once a day, while 32% floss less than daily and 16% never floss.

Flossing is simple, and synthetic fibers make it easier to floss between closely spaced teeth. Flavored flosses make the experience tastier, too. In addition, a variety of other products are available to help clean between teeth and under the gum line. For a look at some of these options, see Table 3. Your dentist or hygienist can advise you on which one is right for you.

Table 3: Types of dental floss and cleaning devices
Product	Description	Considerations
Unwaxed floss	Thin nylon yarn composed of 35 strands twisted together for strength.	Can be inserted between closely spaced teeth, but more likely to break or fray than the waxed variety.
Waxed floss	Basic dental floss coated with a light layer of wax.	More resistant to breaking than unwaxed floss. Wax may make it harder to use in tight spaces.
Polytetrafluoro-ethylene floss	Floss made from the same synthetic fiber used for high-tech rain gear (Gore-Tex). One brand is Glide.	Strong fibers resist breaking and fraying. Slippery surface slides easily between closely spaced teeth.
Dental tape (waxed or unwaxed)	Broader and flatter than traditional floss.	More effective than traditional floss for cleaning between teeth that are not tightly spaced.
Super Floss	Yarnlike fabric with stiffer portions on either end.	Stiff ends can be guided through dental work such as implants, braces, or bridges. Individual threads include unwaxed portions for normal flossing.
Floss threader	Needle-type device through which floss is threaded.	"Needle" allows floss to be pushed through spaces in dental work. Similar to Super Floss.
Floss holder	Y-shaped plastic tool that holds a length of floss between two prongs.	Can make flossing easier for people who have trouble manipulating the floss or fitting their fingers into their mouth.
Toothpick	Common pointed cleaning tool made from wood, ivory, or metal.	Useful for cleaning around gums and between teeth. Use toothpicks made out of a material, such as wood, that is softer than the tooth. Moisten before using. Take care not to press too hard on gums.
Toothpick holder	Device to hold a toothpick at the correct angle for cleaning.	Useful for cleaning gum line, gingival pockets, concave tooth surfaces, exposed roots, and areas around fixed bridges. Can be used to apply medications to gum areas.
Tip stimulator	Cone-shaped rubber nub found at the end of many toothbrushes or mounted on a handle of its own.	Useful for massaging gums, freeing trapped food, and dislodging plaque.
Wedge stimulator	Triangular plastic or wooden tool.	Especially useful for removing plaque and reducing inflammation in areas where the gum tissue between the teeth is missing. Moisten wooden stimulators before use and discard when the wood starts to splinter.
Interproximal brushes and swabs	Small spiral brushes or swabs that are pushed in and out of gaps between widely separated teeth or around braces or prosthetic devices.	Brush should be slightly larger than the space being cleaned. Brushes with special plastic-coated stems are available to avoid scratching implant abutments (see "Dental implants").
End-tufted brushes	Plastic handle with toothbrush-type bristles on either end.	Useful for cleaning hard-to-reach areas on the gum line such as the margins of crowns and the insides of the lower back teeth. Used with a paintbrush-style motion.
Irrigation devices	Motorized units that send a steady or pulsating stream of water or mouth rinse through a detachable nozzle to a targeted area of the mouth.	Good for flushing out accumulated debris from braces, bridges and other restorations, and deep gum pockets. However, irrigation does not completely remove plaque.

Using mouth rinses

If you walk down the dental care aisle of your local supermarket or pharmacy, you'll find a dizzying array of mouthwashes, plaque-removing rinses, fluoride treatments, and similar products. Do you need one?

Most rinses can effectively freshen your mouth and curb bad breath for up to three hours. However, their success in preventing tooth decay, gum inflammation, and periodontal disease is limited. Rinses can't substitute for regular dental examinations and proper home care. Most dentists believe that a regimen of brushing with a fluoride toothpaste, flossing, and getting routine cleanings and exams is sufficient for fighting tooth decay and gum disease. In some cases, though, a rinse may be helpful, and your dentist might recommend using one.

If you would like to try a rinse, how do you choose one? First, it helps to know that mouth rinses fall into two basic categories: cosmetic and therapeutic.

Beating bad breath

At best, bad breath's an embarrassment. At worst, it can be a sign of serious disease. In extreme cases, bad breath (also called halitosis) can cause a person to live in isolation. Many factors can cause bad breath; here are some of the most common offenders.

Oral hygiene problems. About 90% of bad breath originates with oral bacteria. Food debris that collects in the mouth can rot if it's not removed promptly. In addition to brushing and flossing your teeth daily, brush your tongue every day to keep breath smelling fresh. The area at the far back of the tongue is particularly important, because this is where as much as 80% of odor-causing bacteria congregate. Food particles that collect on poorly fitting or unclean dentures can also cause odor.

Dental problems. There's strong evidence that the same bacteria that cause halitosis also produce gum disease. When plaque collects under the gums, the bacteria in it release foul-smelling sulfur compounds that irritate and eventually destroy the gum tissue and supporting structures. Flossing daily to remove plaque from the gum pockets around the teeth can combat this problem.

Diet. Certain foods have long been linked to breath odor. For example, cabbage produces foul-smelling gases during digestion that are released when you belch. Although garlic is another well-known source of bad breath, it was not until 1999 that scientists explained why its scent is so persistent. A study at the Minneapolis Veterans Affairs Medical Center discovered that when you digest garlic, it releases a specific sulfur compound. This compound progresses unaltered into your bloodstream, and you may exhale it from your lungs up to three hours later. Similarly, alcohol travels unchanged through the digestive system and exits through the respiratory system. Ironically, a lack of food can also affect your breath. Extreme dieting causes changes in the body's metabolism that result in a fruity scent on the breath.

Infection and chronic disease. Helicobacter pylori, H. pylori Kidney failure, liver disease, diabetes, and respiratory tract infections (such as sinusitis and tonsillitis) can cause breath odor. In addition, research in 2007 points to a link between halitosis and a stomach-dwelling bacterium that causes ulcers and other stomach problems. A 1998 Italian study of 58 people who complained of both stomach problems and halitosis showed that bad breath disappeared when was successfully treated. In cases where the stomach bacteria persisted, mouth odor remained, even when the individuals used an antiseptic mouth rinse.

Dry mouth (xerostomia). Too little moisture in the mouth allows dead cells and bacteria to accumulate on your tongue and teeth. This is also the cause of "morning breath."

Tobacco. Smoking and chewing tobacco lend an unpleasant scent to your breath. Tobacco use also contributes to other odor-causing maladies, such as dry mouth and gum disease.

Working with your dentist

Even if you follow a diligent home care routine, regular checkups with a dental professional are still a must. Your dentist can watch for early signs of decay, gum disease, oral cancer, or other dental problems and take appropriate action. In addition, professional cleaning rids your teeth of calcified plaque, called calculus or tartar, that can build up in hard-to-reach places. Finally, your dentist can spot clues that oral problems are actually symptoms of other diseases in the body.

The dental checkup

For most people, two checkups per year are sufficient. But if you have special problems or if you're at high risk for conditions such as periodontal disease, your dentist may recommend that you come in as frequently as every three months. A routine visit will include a professional cleaning, an exam, and possibly x-rays. Your dentist should also discuss your health history, asking about your past dental problems, allergies, medication use, drug reactions, recent illnesses, and chronic diseases.

During the cleaning, the dentist or hygienist will use a scaler (a small metal instrument with a bladelike end) to scrape off tartar above and below the gum line. Or he or she may use an ultrasonic vibrating device to shake loose plaque and tartar, and then rinse it away with a stream of water. The dentist or hygienist will then polish the teeth with a lightly abrasive paste and finish up with a flossing. The now-smooth tooth surfaces make it more difficult for plaque to accumulate before the next cleaning.

After your teeth are clean, your dentist will examine them for signs of decay, using a metal probe and a small mirror with an angled handle. He or she will also check for gum swelling and redness and measure the depth of the gingival pockets. Swelling, redness, and deep pockets are all signs of gum disease. Your dentist will test how your upper and lower teeth come together and will look for evidence of tooth grinding or problems with the temporomandibular joint (which connects the lower jaw to the skull). He or she should also examine your neck, lymph glands, palate, and the soft tissues of your mouth (cheeks, tongue, lips, and floor of the mouth) for signs of infection or oral cancer, especially if you are age 35 or older. Because early detection of oral cancer is important, if you're unsure whether your dentist screens you regularly for this disease, ask him or her to do so at each exam. You may also want to perform a monthly self-exam, particularly if you are at high risk.

In the course of dental work, your dentist may inadvertently touch the soft palate at the back of your throat, evoking your gag reflex. This often happens when your dentist positions x-ray films or takes tooth impressions. Fear often exacerbates the gag mechanism, so much so that some people retch at even the smallest touch to their palate. Needless to say, this causes problems for both the patient and the dentist. If you have a sensitive gag reflex, you may find that certain techniques such as hypnosis, acupressure, or acupuncture can help you relax.

X-rays

Virtually everyone who visits the dentist will have x-rays taken at some point. Dental x-rays involve passing electromagnetic radiation through the jaw to produce images of the structures inside. On an x-ray image, teeth, bones, fillings, and restorations appear lighter than the background, because they block more of the radiation than the surrounding soft tissue. Decayed areas or abscesses in the bone around teeth appear darker than healthy teeth, because the damaged teeth contain less radiation-blocking material.

X-rays are valuable in uncovering problems in places that aren't readily visible to the eye. X-ray images can reveal cavities inside and between the teeth, wisdom teeth that have failed to erupt, and bone deterioration below the gum line.

An added bonus of x-rays

Journal of the American Dental Association Wide-angle x-rays, called panoramic x-rays, may provide early warning of an impending stroke. Calcium deposits in the carotid arteries (the vessels that supply blood to the brain) show up on this kind of x-ray. These deposits sometimes break free of the artery walls and travel to the brain, where they can lodge in a smaller vessel, obstruct blood flow, and trigger a stroke. A November 2000 article reported that data from this kind of x-ray were valuable in uncovering life-threatening blockages and spurring treatment.

Dealing with dental anxiety

For some people the fear of visiting the dentist outweighs the pain of a toothache. If you're afraid of going to the dentist, you're not alone. About 8%15% of Americans avoid regular treatment solely for this reason. But refusing to visit the dentist out of fear has a paradoxical effect. Procrastination almost invariably leads to more advanced oral health problems and lengthier, more complex procedures.

Most adults who suffer from dental anxiety can trace their fears back to unpleasant childhood experiences. Fortunately, improvements in techniques, medications, and equipment over the past 30 years mean that even the most skittish patients can be assured that their visits now will be more comfortable than those of their youth.

Medications for pain and anxiety

Many medications can relieve dental pain and anxiety. These can be used individually, in combination, or along with relaxation techniques.

Local anesthetics. Dentists use a thin needle to inject these pain control medications at the site of the procedure. In most cases, the medication takes effect within a few minutes and deadens pain for about three hours. Lidocaine (Xylocaine) and mepivacaine (Carbocaine, Isocaine, and Polocaine) have replaced procaine (Novocaine) as the most commonly used drug. Many dentists prefer to use one of these drugs along with a small amount of epinephrine, which constricts the blood vessels and keeps the painkiller working longer. However, this mixture is not an option for people with high blood pressure or other forms of cardiovascular disease.

Topical anesthetics. These can ease the sting of an injection or minimize the discomfort of cleanings and minor gum treatments. Topical preparations typically come in the form of a numbing gel or spray, which your dentist applies to the gums a couple of minutes before beginning work. Some dentists are now using a small adhesive strip that sticks to your gum and releases the painkiller into the tissue.

Anti-anxiety drugs. Your dentist can offer you diazepam (Valium) or a similar drug to calm your nerves before a dental procedure. You'll need to arrive for the appointment about an hour ahead of time if you choose this option. You should also arrange for someone else to drive you home.

Conscious sedation. This approach dulls your awareness without inhibiting body functions such as breathing and swallowing. Drugs of this type usually are used to quell anxiety, but they can be combined with other drugs to reduce pain. One of the most common choices is nitrous oxide, sometimes called "laughing gas." You inhale it through a mask in a mixture with oxygen. Nitrous oxide produces a sense of relaxation that begins almost immediately and ends when you stop breathing it. It has very few side effects and is safe for most people. For lengthy dental procedures, though, drugs administered intravenously may work better. Your dentist will mix a sedative or anti-anxiety medication with a narcotic and sometimes a barbiturate drug. Only specially trained and certified dentists are qualified to offer this type of sedation.

General anesthesia. With this form of sedation, you are unconscious and unable to breathe or swallow independently. General anesthesia is usually reserved for surgical procedures on the mouth or jaw. It's also used for people whose dental anxiety is so overwhelming that it makes routine care otherwise impossible, and for individuals with mental or physical disabilities that interfere with treatment. Although safe for most people, general anesthesia carries more risks than other forms of sedation. Only professionals trained in anesthesiology can administer it.

Mending molar? Tender tooth? Raw root? How you can ease post-treatment pain

Today's sophisticated anesthesia techniques mean that you can count on a virtually pain-free stint in the dental chair. After a procedure, though, your mouth will still need anywhere from a few hours to a few days to get back to normal. Here are some things you can do to ease your discomfort:

Reduce swelling by applying ice wrapped in a damp cloth to the affected area.
Relieve soreness following gum treatments by rinsing with a mild solution of salt or baking soda.
Take over-the-counter pain medication such as acetaminophen or ibuprofen. (Aspirin shouldn't be used after surgical procedures.) Your dentist can prescribe stronger medication following procedures that are likely to cause more intense pain, such as extractions, implant placements, and root canal therapy.

Alternative therapies for anxiety

For some people, anxiety triggered by the sight of the dental chair, nervousness at the sound of the drill, or fear of gagging or choking can loom as large as concerns about pain. Hypnosis, guided imagery, relaxation exercises, and counseling can ease anxiety and fear. For people who don't have dental anxiety but can't tolerate pain medication, these approaches can also help with pain control. In either case, you should discuss your concerns with your dentist.

A few of the most popular techniques are briefly described here. To learn more about these techniques, you may want to enroll in a stress management program or mind/body program, or check your library or bookstore for books on stress management techniques.

Plaque diseases

The two most common oral diseases tooth decay and periodontal disease originate in plaque, the sticky bacteria-laden film that collects on your teeth between brushings. Although both of these problems can ultimately lead to tooth loss, there are important differences. First, tooth decay and gum disease are caused by different species of oral bacteria. In addition, tooth decay attacks teeth themselves; periodontal disease affects the gum tissues and surrounding structures.

There's hardly an adult alive who doesn't show signs of one or both of these conditions. Indeed, tooth decay is second only to the common cold as the world's most prevalent ailment, and as many as half of Americans age 30 or older show signs of periodontal disease.

Tooth decay and cavities

Although many people believe that the terms "tooth decay" and "cavity" are synonymous, they are not. Tooth decay (also known as dental caries) originates when bacteria produce acid that destroys the surface of the teeth. The decay process is gradual. When decay advances to the point where a hole forms in the enamel, this is called a cavity. Initially this hole may be microscopic. If left untreated, however, the decay can penetrate through the enamel layer and into the softer tissue below.

Figure 3: The ravages of tooth decay

The ravages of tooth decay

Tooth decay often progresses gradually, but when left untreated it can have devastating effects. Decay begins with the development of plaque, which consists of bacteria. These bacteria can dissolve the enamel of the tooth, boring a hole known as a cavity (A). At this point the damage is limited to the enamel and dentin, but as decay progresses, the damage can extend to the pulp. The pulp becomes infected and swollen; this is known as pulpitis (B). The swelling may cut off the blood supply, which can cause the pulp to die. If the infection spreads to the root, it can create an inflamed pocket called an abscess (C). Not only are abscesses quite painful, but if the infection enters the bloodstream, the problem can become life-threatening.

Gum disease

Gum disease is the primary culprit in adult tooth loss. Without rigorous dental hygiene, plaque formation spirals into disease and, eventually, the destruction of the teeth and surrounding structures.

As with cavities, periodontal disease is caused by bacteria in the mouth. But the bacteria that cause cavities need oxygen to survive, while the bacteria that attack the gums prefer an oxygen-free environment. The effects of periodontal disease range from mild redness and swelling of the gum tissue (gingivitis) to complete destruction of the tooth's bony support structure (advanced periodontitis).

Pulp diseases

The life or death of a tooth depends on the health of the pulp. This network of nerves, blood vessels, and tissues occupies a hollow central chamber that extends from the crown of the tooth to its roots. The branch of dentistry that specializes in preventing and treating pulp problems is called endodontics.

The pulp nourishes the surrounding dentin via specialized cells called odontoblasts. These cells also relay sensory information, which is why injury or damage near the pulp evokes pain.

Types of pulp damage

The pulp can be damaged in a number of ways. Among the most common are undetected tooth decay and advanced periodontal disease. Abrasion and erosion can also wear away the tooth's hard outer layers, leaving the pulp vulnerable. The pulp may inadvertently be injured when your dentist grinds a tooth in preparation for a deep filling or restoration. And of course pulp trauma occurs when a tooth is broken or knocked out.

Pulp damage is categorized as either reversible or irreversible. Its consequences can range from mild tooth sensitivity to complete nerve death of the tooth or even infection of the surrounding tissues. Symptoms vary according to the extent of the damage and can include pain, fever, prolonged sensitivity to hot or cold, swelling or tenderness of the gums, and cracked or discolored teeth.

Diagnosing pulp disease

The description you give of your symptoms will form the basis of your dentist's diagnosis. The severity, nature, duration, and location of the pain all offer clues about the extent of pulp damage. Your dentist will look for visual clues, such as cracked or discolored teeth and changes in the gum tissue. Your dentist may also try exposing the tooth to stimuli such as heat, cold, or a light electrical current. A response indicates the nerve is still alive.

Your dentist may inject a local anesthetic at the base of the tooth in question. If the pain goes away, that shows the tooth was the right one. If the pain persists, the dentist will repeat the injection at the base of the next tooth and will continue until the diseased tooth is identified.

Although x-rays can shed light on the interior structure of the tooth, they cannot reveal whether the pulp is healthy. Pulpitis must be very advanced before bone degeneration shows up on the film.

Treating pulp disease

Once pulp disease is discovered, your dentist will try to stop the spread of infection and, if possible, save the tooth. The type of intervention depends on the extent of the disease.

Know the warning signs of dental infection

Infections in and around the teeth can be caused by advanced decay or periodontal disease, or they may be a complication from oral surgery or tooth extraction. Because an infection can spread to the gum and mouth tissues as well as other parts of your head and neck, seek help at the earliest signs of a problem.

Call your dentist immediately if you have

pain, heat, and swelling in the area
fever
foul odor and pus.

Get emergency attention if you have

difficulty speaking or swallowing
swelling of the tongue or under the tongue.

When a tooth needs to be pulled

Despite the best efforts of you and your dentist, there are times when a tooth is so decayed or damaged that the only remedy is extracting it. You may also need to have fragile, diseased, or impacted teeth removed before a prosthesis can be fitted.

While your general dentist may perform simple extractions, he or she may refer you to an oral surgeon for more complicated ones. For a simple extraction, your dentist injects a local anesthetic into the gum and loosens the tooth with hand instruments, such as pliers and short levers. Once the dentist has loosened the tooth sufficiently, he or she pulls it out in one piece.

For teeth that cannot be removed in a single piece, local or general anesthesia can be used, depending on your preference and that of your dentist. If the tooth is impacted, your dentist may have to cut the gum and bone to reveal the tooth. Then he or she breaks the tooth into pieces, removes it from the gum, and stitches the wound shut.

Your mouth will need a few days to heal from the trauma of the extraction. Here are some things you can do to ease your discomfort and help the process along:

Expect a small amount of bleeding.
Avoid activities that could dislodge the clot where the tooth was removed. These include smoking, drinking through a straw, or rinsing your mouth vigorously.
Apply a cold cloth or ice pack to your face to reduce swelling.
Avoid brushing and flossing the area that is healing. Brush and floss normally in the rest of your mouth.
Take pain medication as directed by your dentist.

Dental 911: Dealing with emergencies

Table 5: Tips for handling common dental emergencies
Problem	Do	Don't	Professional care
Toothache	Take an over-the-counter pain reliever. Apply ice to the area. Rinse your mouth with warm water. Remove food particles between teeth with dental floss.	Don't use heat. Don't place an aspirin or other pain reliever directly on the tooth or gum. Don't eat very hot, cold, sweet, or spicy foods.	Call your dentist for advice. Have the tooth examined as soon as possible.
Broken tooth	Gather the broken pieces and rinse your mouth with warm water. Take an over-the-counter pain reliever. Place dental wax or chewing gum over sharp edges to prevent damage to mouth tissues.	Don't eat hard foods.	Call your dentist immediately for breaks that involve the dentin or pulp. Call dentist as soon as possible for crown or enamel-only fractures.
Knocked-out tooth	Pick up tooth by the crown, not the root. Rinse off blood or dirt with milk, or cold running water if milk isn't available. Reinsert the tooth into the socket if possible and hold it in place by pressing gently with your finger or by biting a clean cloth. If reinsertion isn't possible, place the tooth in a container of milk. Or, as a last resort, wrap it in a damp cloth.	Don't touch or scrub the root.	Get to the dentist immediately. Teeth that are replanted in the mouth within 30 minutes of the injury have the best chances for survival.
Broken or lost filling or crown	Save the filling or crown, and bring it to your dentist. Apply dental wax to any sharp edges to protect mouth tissues. Use denture adhesive to temporarily reattach a crown until you get to the dentist.	Don't try to replace the filling yourself. Don't eat very hot or cold foods.	Make an appointment as soon as possible.
Bleeding from cuts in the mouth or after a tooth extraction	Use clean gauze to apply pressure to the area for five minutes. If bleeding continues, press a moistened tea bag against the cut for five minutes.	Don't rinse your mouth.	Call your dentist if you are unable to stop the bleeding. Go to the hospital emergency room if you can't reach your dentist and bleeding is significant.
Mouth sores	Rinse with warm salt water. Apply a piece of ice or a paste made from baking soda and water to the sore for a few minutes. Use over-the-counter anesthetics (Orajel, etc.) for temporary relief.	Don't put aspirin on the sore. Don't use steroid creams. Don't take antibiotics unless they are prescribed for this problem. Don't use hot packs.	If the problem doesn't clear up in a week, see your dentist, as this may be a sign of a more serious problem.
Broken dental appliances	Save all the pieces and bring them to your dentist. Cover protrusions with dental wax to prevent irritation to mouth tissues. Remove the denture until you can get to the dentist.	Don't try to glue pieces back together yourself. Don't try to bend the wire clasps of a partial denture back into place. Don't wrap pieces in tissue, which can be thrown away by mistake.	See your dentist as soon as possible.

Tooth replacements: Bridges, dentures, and implants

Tooth loss can have a profound effect on your health and well-being. Even though diseases leading to tooth loss are largely preventable, 45% of Americans age 65 and over have lost six or more teeth, and 20% have lost all of their natural teeth due to decay or gum disease. Research shows that it takes 20 well-placed teeth to preserve your normal chewing function. As the number of teeth decreases, the quality of a person's diet drops. Missing teeth can also make speaking difficult and can make you self-conscious about your appearance. In addition, an empty space in the dental arch destabilizes the teeth that remain. The consequences can be tooth shifting, bone loss, and bite problems.

Although nothing can truly take the place of healthy natural teeth, several replacement options are available. They can improve your functioning and your appearance, as well as help you preserve surrounding teeth.

Fixed prostheses (crowns and bridges)

There are many different kinds of fixed prostheses. Typically, a single crown is used to restore one damaged tooth, while a bridge can be substituted for one or more missing teeth.

Removable prostheses (dentures)

In certain situations, removable prostheses (either partial or full dentures) may be the best option for regaining at least some level of oral functioning. However, they are usually the treatment of last resort because they can be uncomfortable. If they aren't made properly and checked regularly, they may accelerate bone loss in the jaws.

There are several risks associated with full dentures. Once all the teeth are gone, the supporting alveolar bone reabsorbs into the body. The pressure from the dentures often hastens this process. As the bone disappears, the position of the dentures shifts, causing the teeth to meet unevenly and making chewing difficult. In addition, the dentures exert considerable pressure on underlying nerves, which are now unprotected. This can make chewing extremely painful. Even partial dentures can stress the alveolar bone. Partial dentures and overdentures may also lead to irritation and sores in the mouth. In addition, bacteria can collect around the dentures, increasing the risk for oral infections and root decay in any remaining teeth.

Dental implants

The ideal dental prosthesis would be a replacement system that looks and functions like natural teeth, is durable, does not damage existing structures, and doesn't cause unwanted side effects. Many dentists are optimistic that the latest generation of implant technology will fulfill these goals.

An implant starts with a titanium metal screw that is surgically inserted into the alveolar bone of the upper or lower jaw where a natural tooth has been lost. The screw acts as a substitute for a natural tooth root, forming the base for a replacement. A dentist can place implants alone or in combination. They can serve as individual replacement teeth or as abutments for fixed bridges, or as anchors for full or partial removable dentures.

Implants had been used for decades with mixed success. The materials and techniques were less than ideal until a breakthrough occurred in the late 1960s, when researchers explored the use of titanium. They discovered that bone would grow directly into the surface of a titanium implant and create a bond so firm that the implant could not be dislodged. This osseointegration was something that didn't happen with implants made of other materials. These devices became known as osseointegrated implants.

Are you too old for braces?

Ideally, human teeth would line up as neatly as the keys on a piano. Unfortunately, many people must contend with crooked teeth, crowded smiles, or poorly aligned bites. These problems raise more than cosmetic concerns. Crowded or overlapping teeth can be difficult to clean, making tooth decay and gum disease more likely. Teeth that don't come together properly when you close your jaws a problem called malocclusion, or "bad bite" can cause chewing and swallowing problems. Poor tooth alignment can also make it difficult to pronounce certain sounds and can put excessive stress on the chewing muscles, causing facial pain.

While childhood is the ideal time to make changes in the positioning of the teeth, more adults are opting for orthodontic treatment and coming away with excellent results. The American Association of Orthodontists notes that one in five orthodontic patients is over age 18.

If you're considering orthodontic treatment to correct longstanding cosmetic or bite problems or to remedy the effects of tooth loss, keep a few things in mind. Because the bones of adults have stopped growing, some structural changes cannot be accomplished without surgery. Also, the entire process may take longer for you than for a child or adolescent. While the time it takes to straighten teeth varies from person to person, on average, treatment lasts about two years. If you are undergoing orthodontic treatment, you may also need to see a periodontist as well as your general dentist and orthodontist to ensure that the treatment is not complicated by bone loss resulting from gum disease.

Cosmetic dentistry

Along with your eyes, your smile is the first thing a person notices when meeting you. So, when you hesitate to smile because of broken, discolored, or poorly spaced teeth, you may be sending an unintended negative message. But many people are finding they don't have to hide their teeth any longer. With the advent of different materials and treatments, a better smile is now within reach for millions of adults.

Teeth whitening

According to the Academy of General Dentistry, tooth whitening is a $600 million industry that is growing by 15%20% each year. In addition to the whitening procedures performed under the supervision of a dentist, drugstore and supermarket aisles overflow with whitening remedies.

Whitening products fall into two main categories: those that contain peroxide, which actually changes the natural color of the tooth, and others, such as whitening toothpastes, that remove surface stains using polishing or chemical agents and mild abrasives. Because whitening toothpastes don't change the color of teeth, their effects are more subtle than bleaches. This section focuses on products containing peroxide.

Bleaching, or whitening of the teeth using peroxides, is available both through your dentist and in several types of over-the-counter products. The American Dental Association recommends you consult with your dentist before using a bleaching product, even an over-the-counter one. That's because bleaching can be uncomfortable for people with sensitive teeth or an exposed root. Also, because most products only bleach natural teeth, if you have tooth-colored fillings, crowns, veneers, or dentures, bleaching may leave some areas whiter than others. In addition, your dentist can evaluate whether bleaching is right for your teeth, since different kinds of discoloration respond differently to whitening.

Most bleaching is not permanent, so keeping your teeth pearly white means repeating the bleaching process regularly. How long a bleaching treatment lasts depends upon which method you choose (see Table 6) and on how well you take care of your teeth, whether you smoke, and what you eat and drink.

Table 6: Common over-the-counter teeth-whitening kits
Product	How it is used	How often it is used	Main active whitening ingredient	How long manufacturer claims effects last
Rembrandt Whitening Pen	Apply gel to teeth	Once per night for 14 days	Hydrogen peroxide	Up to 6 months
Crest Night Effects Whitening Gel	Paint gel on teeth	Once per night for 14 days	Sodium carbonate peroxide	Up to 6 months
Crest Whitestrips	Apply strips to teeth	Twice per day for 30 minutes each; repeat for 7, 10, or 14 days depending on type of kit	Hydrogen peroxide	12 months
Rembrandt Whitening Strips	Apply strips to teeth	Once per day for 30 minutes; repeat for 5 days	Hydrogen peroxide	Up to 6 months
Klear Action Whitening Light system	Rinse teeth; paint on gel; shine activating light on teeth	1020 applications (under 5 minutes each)	Urea peroxide	Up to 6 months

Bonding

Bonding involves applying a tooth-colored composite resin to the surface of the teeth to correct chips, cracks, or tooth spacing, or to get rid of stubborn stains. First, your dentist treats your teeth with acid to make them more receptive to the resin. Next, he or she applies a thin coat of the bonding material to the tooth and hardens it using a light or a chemical solution. Additional coats of resin can be applied to fill gaps and lengthen teeth. Finally, the dentist polishes the tooth. The whole procedure can be accomplished in one visit. The cost of bonding depends on the size and complexity of the site being repaired.

Veneers

Veneers also alter the tooth's color, shape, and surface. They can be used to cover stained or chipped teeth, camouflage gaps and spaces, and make crooked teeth appear straighter without orthodontic treatment. These thin shells are prefabricated in a laboratory based on an impression your dentist makes of your mouth. Veneers can be formed out of porcelain, acrylic, or composite resin. Porcelain generally provides the best looking and longest lasting veneer.

Installing a veneer takes two appointments. On the first visit, your dentist will pare down the enamel so the added thickness of the veneer does not affect your bite. Next, he or she makes a mold of your teeth, which is used to craft the veneer in a dental laboratory. On your next visit, the dentist etches the surface of the enamel and attaches the veneer using a thin coat of composite resin.

Veneers are subject to chipping, but you can count on them lasting up to 10 years if you avoid activities that are likely to break them, including biting hard objects and chewing ice. Veneers cost between $1,000 and $1,300 per tooth.

Tooth reshaping

Minor imperfections in tooth length, contour, and shape can be remedied by removing small amounts of enamel from the surface and sides of the tooth. Your dentist can also correct signs of wear and tear, such as chips, grooves, and ground-down edges. Recontouring is often done in conjunction with bonding. Some people experience tooth sensitivity for a brief period after the procedure. Individuals with thin enamel are not good candidates for this technique. The process can cost between $200 and $400 per tooth.

Crown lengthening

Sometimes teeth appear "too short" because there is excessive gum tissue around their bases. This problem can be corrected with a type of minor gum surgery called gingivectomy. The crown of the tooth is made to appear longer by trimming or reshaping the gum and bone to expose more of the tooth enamel. The gum line can also be trimmed to produce a more even appearance. The procedure also has therapeutic uses. A dentist may need to remove gum tissue before repairing a tooth that is broken or decayed below the gum line or installing a crown or bridge.

Glossary

abscess: Pus-filled pocket surrounded by inflamed tissue.

abutment: Tooth or implant to which a fixed prosthesis is anchored.

alveolar bone: Part of the jawbone that supports the teeth.

bonding: Application of composite resin to the surface of a tooth to change its shape or color, or to attach something to the tooth.

cavity: Hole in the tooth caused by advanced decay.

cementum: Layer of tooth material that covers the root.

crown: Part of the tooth that is visible above the gum line. Also refers to a type of restoration that covers the crown of the tooth.

demineralization: Process by which bacteria destroy tooth enamel.

dental caries: See tooth decay.

dental implant: Metal post inserted into the alveolar bone to support an artificial tooth or other prosthesis.

dentin: Layer of hardened tooth tissue under the enamel and around the pulp.

denture: Removable set of artificial teeth.

enamel: Hard outside layer of tooth material.

fluoride: Naturally occurring mineral that helps prevent tooth decay. It is a common additive to toothpaste and mouth rinses and is present in many community water sources.

gingiva: See gums.

gingivitis: Inflammation of the gums.

gum disease: See periodontal disease.

gums: Form of oral tissue that covers the roots of teeth and surrounding bone. Also called the gingiva.

halitosis: Bad breath.

impacted tooth: Tooth that can't emerge normally because of an obstruction or overcrowded teeth.

occlusion: Way in which biting surfaces of upper and lower teeth come together. Also called bite.

oral mucosa: Layer of soft pinkish tissue that lines the interior of the mouth.

osseointegration: Process in which bone heals around an implant to create a stable anchor.

palate: Tissues that make up the roof of the mouth.

periodontal disease: Diseases including gingivitis and periodontitis that attack the gum tissue and the structures supporting the teeth. Also called gum disease.

periodontitis: Advanced stage of gum disease that attacks the teeth's supporting structures.

plaque: Sticky, bacteria-laden material that builds up on teeth.

pulp: Tissue containing nerves and blood vessels that fills the chamber at the center of the tooth.

remineralization: Rebuilding of enamel structure from mineral components of saliva.

restoration: Replacement of all or a portion of tooth structure with metal, plastic, or ceramic material.

root: Portion of the tooth below the gum line.

root canal: Channel in the root of the tooth that contains the pulp.

root canal therapy: Procedure in which diseased pulp tissue is removed from the pulp chamber and root canal and the area is sealed off.

sealant: Liquid plastic coating applied to biting surfaces of teeth to protect them from decay.

Streptococcus mutans: Bacterial species responsible for dental caries.

sulcus: V-shaped hollow at the margin of the tooth and gum.

tartar: Hardened layer of plaque that builds up on teeth. Also called calculus.

tooth decay: Infectious disease that attacks the teeth. Also called dental caries.

Resources

Organizations

Academy of General Dentistry www.agd.org 211 E. Chicago Ave., Suite 900 Chicago, IL 60611 888-243-3368 (toll free)

This organization of general dentists provides patient education materials on a range of dentistry and oral health topics. It also offers a directory of member dentists, organized by location, on the Web site and by phone at (877-292-9327; toll free). You may post questions to the Smileline online message board, and a member will respond within a few hours.

American Dental Association (ADA) www.ada.org 211 E. Chicago Ave. Chicago, IL 60611 312-440-2500

The ADA offers many services for dental consumers. The Web site includes an oral health information section that covers the spectrum of dental concerns and a list of general dentists and dental specialists by location. In addition, the ADA maintains a database of all oral health products that have received the ADA Seal of Acceptance.

National Oral Health Information Clearinghouse www.nidcr.nih.gov/HealthInformation/ 1 NOHIC Way Bethesda, MD 20892 301-402-7364

A service of the National Institute of Dental and Craniofacial Research (part of the National Institutes of Health), the clearinghouse provides information and resources about oral disease, including specialized information for individuals whose oral health may suffer because of cancer treatment, chronic disease (such as diabetes), or physical or mental limitations.

Books

The Columbia University School of Dental and Oral Surgery's Guide to Family Dental Care Rebecca W. Smith and the Faculty of the Columbia University School of Dental and Oral Surgery (W.W. Norton & Company, 1997, 446 pages)

This extensive reference provides descriptions of dental problems and practices. The book covers all the major types of specialty care and includes a chronology of appropriate oral health treatment for all stages of life.

A Consumer's Guide to Dentistry Gordon J. Christensen, D.D.S. (Mosby, 2002, 214 pages)

This easy-to-read reference provides practical advice on the complete range of common dental problems and procedures. Step-by-step explanations, accompanied by color photographs, include a description of each problem, symptoms to look for, and advantages and disadvantages of the treatment alternatives.

Review Date: 2007-04-01

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