Dental disorders

Tooth decay (dental caries) is the progressive destruction of dental tissue following the compromise of the enamel due to chronic exposure to oral bacterial acids (e.g., lactic acid produced by S. mutans). Manifestations include tooth pain and bad breath. Diagnosis is often made on the basis of tooth appearance (e.g., enamel breakdown, discoloration) and x-ray (increased radiolucency). Treatment depends on the size of the lesion and mainly includes caries excavation and restoration of the dental surface. A dental abscess is a collection of pus in the pulp of a tooth that can spread to local or regional structures. Causes include dental caries, trauma, and failed dental root canal treatment. Clinical features include severe pain, dysphagia, and possibly facial erythema, fever, and/or lymphadenopathy. On inspection, the surrounding gingiva is often erythematous and swollen. Treatment includes antibiotics, abscess drainage, and, if necessary, removal of the infected tooth. Malocclusion is any deviation from ideal tooth positioning that leads to irregular contact between the upper and lower teeth when the jaw is closed. While usually asymptomatic, malocclusion can cause symptoms (e.g., discomfort when chewing) in pronounced cases. Management includes correction of tooth deviation and jaw positioning with orthodontic treatment (e.g., braces). Dental injuries include dental avulsion, dental subluxation, and dental fracture. Dental avulsion is the complete displacement of a tooth from its socket due to trauma. Management includes manual replantation of the permanent tooth into its socket, followed by urgent splinting. Dental subluxation is the partial detachment of a tooth from its socket and usually does not require active treatment. Dental fracture is a partial or complete interruption in the continuity of tooth due to trauma. Treatment depends on the extent of injury and involves sealing and, in cases of root fracture, splinting.

• Definition: the progressive destruction of dental tissue following the compromise of the enamel due to chronic exposure to oral bacterial acids
• Epidemiology
  • Prevalence of untreated dental caries
    • Children 5–19 years: 13.2%
    • Adults 20–64 years: ∼ 24%
• Etiology
  • Pathogens: Streptococcus mutans, S. mitis, Actinomyces, S. mutans, Lactobacillus
  • Risk factors
    • Presence of specific microorganisms in dental plaque (e.g., S. mutans, Lactobacillus)
    • Host factors include:
      • Poor oral hygiene
      • High-sugar diet
      • Sjogren syndrome
• Pathophysiology: oral bacteria metabolize carbohydrates → acid production (e.g., lactic acid) → demineralization of tooth enamel
• Clinical features
  • Tooth pain
  • Possibly bad breath
• Diagnostics
  • Inspection of the oral cavity with a mouth mirror: change in enamel (e.g., enamel breakdown, surface discoloration)
  • The teeth can be probed with dental instruments to check for soft areas
  • Bitewing radiography: carious lesions appear radiolucent
• Differential diagnosis
  • Dental fluorosis
  • Dental hypomineralization
  • Dental hypoplasia
• Treatment: depends on the size/extent of the lesion
  • Very small lesion in which remineralization is still possible: application of fluoride gel, varnishes, pit, and/or fissure sealant usually suffices
  • Lesions that involve hard tissues but do not involve the pulp: caries excavation and restoration of the dental surface
  • Lesions that involve both enamel and dentin in proximity to the pulp: indirect pulp capping
  • Lesions that involve enamel, dentin, and pulp: root canal treatment, followed by extracoronal restoration
• Complications: mostly caused by inflammation of the pulp
  • Apical periodontitis
  • Periapical abscess
  • Periostitis, osteomyelitis
• Prevention
  • Proper oral hygiene
  • Use of toothpaste supplemented with fluoride

Reference:^[1][2]

• Definition: a collection of pus in the pulp of a tooth that can spread to regional structures (oral, cervical, facial) as well as local ones (gums, alveolar bone)
• Etiology
  • Dental caries
  • Poor oral hygiene
  • Trauma
  • Failed dental root canal treatment
• Pathophysiology: damage to enamel → oropharyngeal bacteria enter tooth cavity → infection within the pulp cavity grows → infection spreads down through root canal and into mandible/maxilla
• Types
  • Periapical abscess
    • Most common type
    • Tooth decay or trauma → bacterial infection in the soft pulp of the tooth → pus collects at the apex of the dental root
    • Pus collects in surrounding tissue and may appear at the gum line
  • Periodontal abscess
    • Second most common type
    • Can be caused by periodontitis or impaction of foreign objects (e.g., food, dental floss) → bacterial infection deep in the periodontal pocket → pus collects between the teeth and gums
    • Swelling and erythema of the surrounding mucosa
    • The affected tooth may be mobile.
• Clinical features
  • Severe pain, can generally be elicited with palpation
  • Dysphagia
  • Possibly facial erythema, fever, and/or lymphadenopathy
  • Rarely: trismus
  • In severe cases: dyspnea or airway compromise due to swelling and pus collection in neck structures
• Diagnostics
  • Oral inspection
    • Affected tooth may be discolored and/or show enamel breaks.
    • Surrounded gingiva is often erythematous and swollen
  • Laboratory studies: CBC (may show leukocytosis, neutrophilia)
  • Imaging: x-ray, CT, or MRI of the head and neck
    • To assess possible ascending bacterial infection to the sinus cavities or the neck
    • May show subcutaneous air (sign of necrosis) and/or deviation of the trachea
• Differential diagnosis
  • Gingival abscess
  • Langerhans cells histiocytosis
  • Osteomyelitis
  • Peritonsillar abscess
  • Vertical root fracture
• Treatment
  • Antibiotic treatment: penicillin PLUS cephalosporin with or without metronidazole
  • Abscess drainage
  • Pain management
  • Removal of the affected tooth, if necessary
• Complications
  • Abscess descending into the deep neck space
  • Abscess ascending to intracranial sinuses → cavernous sinus thromboses
  • Sepsis

Reference:^[3][4]

• Definition: any deviation from ideal tooth positioning that leads to irregular contact between the upper and lower teeth when the jaw is closed
• Types: The most common forms are anterior crowding, vertical overbite, and sagittal overjet. ^[5]
• Clinical features
  • Usually asymptomatic
  • In severe cases: discomfort when biting or chewing, frequent biting of cheeks or tongue, speech problems
• Management: : correction of deviated teeth and jaw positions through orthodontic treatment (e.g., braces) to achieve proper occlusion
• Prognosis: Whether orthodontic correction of dental alignment has a positive effect on dental health is still subject to debate. ^[6]

Dental avulsion

• Definition: the complete displacement of a tooth from its socket secondary to trauma. Dental avulsion is a dental emergency.
• Management
  • Manual replantation of the permanent tooth into the socket as soon as possible by the first capable person, followed by urgent referral to a dentist for splinting
    • The tooth should be handled by the crown to avoid injury to the periodontal ligament (PDL).
    • Any debris should be removed by rinsing the tooth with tap water or saline prior to replantation.
    • Do not scrub or sterilize the tooth as these procedures damage the PDL.
  • In case replantation is not possible, the tooth should be kept in a dental preservation culture medium, cold milk, or saliva.
  • Antibiotic prophylaxis

Dental subluxation

• Definition: the partial dislodging of a tooth from its socket
• Management
  • Serial dental radiographs to assess for evidence of a root fracture
  • Active treatment is not required.
  • Close follow up should be carried out to assess for complications (e.g., pulpal damage)

Dental fracture

• Definition: a partial or complete interruption in the continuity of a tooth secondary to trauma
• Management
  • Infractions (cracking): manage with sealing
  • Crown fractures
    • Complicated (dental pulp is exposed): manage with pulp therapy
    • Uncomplicated (dental pulp is not exposed): tooth fragment replantation or tooth edge smoothening
  • Root fractures: managed with dental splinting