Related Terms
- Acquired immunodeficiency syndrome, AIDS, aphthous stomatitis, calculus, cancer, candida esophagitus, candidiasis, canker sore, cavities, chemotherapy, cold sore, dental caries, denture aid, erythroplakia, gingivitis, gingival bleeding, hairy leukoplakia, halitosis, hemorrhage, herpes simplex, herpes virus, HIV, human immunodeficiency syndrome, jaw clenching, leukoplakia, mucositis, oral cancer, oral leukoplakia, oral thrush, osteomyelitis, periodontitis, phenytoin-induced gingival hyperplasia, plaque, pregnancy-related gingivitis, stomatitis, Streptococus mutans, teething, tooth clenching, xerostomia.
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Background
- Dental health refers to the care of the mouth, which includes the teeth and gums. Taking good care of dental health can help prevent disease in the mouth and throughout the body.
- The health of the mouth can be an indicator of the individual’s overall health. Many serious diseases, such as diabetes, human immunodeficiency syndrome (HIV), and some eating disorders (such as bulimia), show their first signs as symptoms in the mouth, such as oral thrush (an overgrowth of yeast in the mouth). It is for these reasons that healthcare professionals recommend complete, yearly oral exams.
- Dental problems include dental cavities, gum diseases (such as gingivitis and periodontitis), canker sores (aphthous stomatitis), mucositis, fungal infections, oral leukoplakia, and oral cancer. The most common oral health problems are cavities and gum disease (including gingivitis and periodontitis).
- Most adults show signs of gum disease during their lifetime. According to the Centers for Disease Control (CDC), gum disease affects about 14% of adults aged 45-54 years.
- Signs and symptoms of soft tissue diseases such as cold sores are common in adults and affect about 19% of those aged 25-44 years.
- For every adult 19 years or older without medical insurance, there are three without dental insurance. Dental insurance is important, as the cost of dental procedures keep many individuals from seeking dental care, leading to problems such as tooth decay and gingivitis.
- Approximately 70% of adults in the United States reported visiting a dentist in the past 12 months. Those with incomes at or above the poverty level are much more likely to report a visit to a dentist in the past 12 months than those with lower incomes.
- During the past several decades, the percentage of older adults in the United States who have retained their natural teeth has increased steadily due to advances in dental healthcare.
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Signs and symptoms
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Dental caries: The main symptom of dental caries is pain. Often the pain appears after the damage to the tooth has already begun. The type and intensity of the pain varies, depending on the level of decay. An acute (immediate), brief pain indicates the start of caries. Generally, it is triggered by a specific event, such as eating something hot or cold. The deeper the decay, the more intense the pain. The pain from tooth decay can be dull or throbbing. When the caries reach the dental pulp, the pain becomes continuous and piercing. Other symptoms associated with caries include: the presence of a small pit, or hole, in the tooth; food deposits between teeth; sensitivity to hot and cold food and beverages; bad breath (halitosis); bitter taste in the mouth; swelling of the gums; and facial swelling with enlarged glands in the neck.
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Gum disease: Symptoms are often not noticeable until the disease is advanced. Gum disease progresses in stages. Early symptoms of gum disease include bleeding gums when flossing or brushing the teeth, gum tenderness, redness, or puffiness. If plaque from teeth and gums is not removed by good daily dental care, over time it will harden into a crust called calculus or tartar. Once tartar forms, it starts to destroy gum tissue, causing gums to bleed and pull away from the teeth, known as periodontitis. With periodontitis, gums become weakened and form pockets around the base of teeth. Bacteria pool in these pockets, causing further destruction of the gums. As periodontitis spreads, it damages deeper gum tissue and can eventually spread to areas of the jawbone that support the teeth. This can cause teeth to become loose and fall out.
- Symptoms include: bad breath (halitosis); red or swollen gums; tender or bleeding gums; painful chewing; loose teeth; and sensitive teeth.
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Canker sores: The following are the most common symptoms of canker sores (aphthous stomatitis): ulcers in the mouth, usually inside the lips, on the cheeks, or on the tongue; ulcers that are covered with a yellow layer and have a red base; lesions that usually heal in seven to 14 days; and lesions that tend to recur. In most cases fever is not present.
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Leukoplakia: Leukoplakia can have various appearances, but typically first appears as flat, gray or gray-white sores (plaques) – usually on the gums or on the insides of the cheeks and sometimes on the tongue. Over weeks or months, leukoplakia can develop into patches with white color, thick, rough, or wrinkled texture and a hardened surface. Sometimes, individuals may also have raised red lesions (erythroplakia), which are more likely to show precancerous changes.
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Oral cancer: Oral cancer often starts as a tiny, unnoticed white or red spot or sore anywhere in the mouth. Other signs include: a sore that bleeds easily or does not heal; a color change of the oral tissues; a lump, thickening, rough spot, crust, or small eroded area; pain, tenderness, or numbness anywhere in the mouth or on the lips; problems chewing, swallowing, speaking, or moving the jaw or tongue; or a change in the way the teeth fit together.
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Oral thrush: Oral thrush symptoms are usually easy to spot and include: white or yellow spots in the mouth, particularly on the tongue and the inside of the cheeks; raised areas in the mouth that bleed and become sore if scraped; a burning sensation in the throat; and difficulty chewing and swallowing.
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Mucositis: Mucositis due to chemotherapy typically begins three to five days after the start of therapy, peaks at seven to 10 days, and slowly subsides over the next week. Mucositis due to radiation usually appears toward the end of the second week of treatment, plateaus during the fourth week of radiation, and may persist for two to three weeks after treatment is over. Symptoms include redness, pain, and ulceration.
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Diagnosis
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Dental caries: Dental caries should be diagnosed and managed by a dentist. Dentists use visual inspection to determine if dental caries or tooth decay is present. Large dental caries are often apparent to the naked eye, but smaller lesions can be difficult to identify. Dental radiographs, or X-rays, may show dental caries before they are otherwise visible, particularly in the case of caries between tooth surfaces.
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Gum disease: A dentist will ask about the individual’s medical history to identify underlying conditions or risk factors (such as smoking) that may contribute to gum disease. The dentist or hygienist will examine the gums and note any signs of inflammation. The dentist or hygienist will use a tiny ruler called a ‘probe’ to check for periodontal pockets and to measure any pockets. In a healthy mouth, the depth of these pockets is usually between one and three millimeters. An x-ray may also be taken to see whether there is any bone loss. The dentist may refer the individual to a periodontist, a specialist who treats gum diseases.
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Canker sores: Canker sores, or aphthous stomatitis, are usually diagnosed based on a complete history and physical examination of the individual. The lesions are unique and usually allow for a diagnosis simply on physical examination. In addition, a doctor or dentist may order the following tests to help confirm the diagnosis and rule out other causes for the ulcers: blood tests; cultures of the lesions to determine if a virus or bacteria is present; and a biopsy of the lesion – taking a small piece of tissue from the lesion and examining it microscopically. Herpes simplex sores (cold sores) look like canker sores, but usually a dentist or doctor can diagnose canker sores by their shape and size. Cold sores also cause a lot of pain for a sore that is quite small. A doctor may test for low levels of folic acid or vitamin B12 in the blood if sores keep returning.
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Leukoplakia: Most often, a dentist diagnoses leukoplakia by examining the patches in the mouth and ruling out other possible causes for symptoms. To help ensure that no early signs of cancer exist, a dentist may remove a tissue sample (biopsy) for analysis. This can involve either removing the entire lesion (excisional biopsy), or a portion of the lesion, removing cells from the leukoplakic patches with a small, spinning brush (oral brush biopsy). The tissue is then analyzed in a laboratory using a highly specialized imaging system that allows a pathologist to detect a single abnormal cell among hundreds of thousands of healthy cells. A negative report means no abnormal cells are present. If the report is positive, a dentist is likely to perform another biopsy by removing a small tissue sample and sending it to a laboratory for analysis.
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Oral thrush: Diagnosis of oral thrush is usually made through observation by a dentist or doctor or through laboratory sample to determine if a yeast infection is present. Lab tests will look for signs of yeast (Candida) infection.
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Mucositis: Diagnosis of mucositis is based on the symptoms you have and the appearance of the tissues of the mouth following chemotherapy, bone marrow transplants, or radiotherapy. The appearance will be of red burn-like sores or ulcers throughout the mouth. Mucositis from chemotherapy usually begins four to five days after treatment is started, reaches its peak at seven to 10 days, and slowly goes away over the next five to seven days unless there are complications such as infection. Mucositis associated with radiotherapy usually appears at the end of the second week of treatment and may last for six to eight weeks.
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Others: A dentist will exam the oral cavity for signs of bruxism (the clenching or grinding of the teeth). Excessive clenching and grinding of the teeth can wear down tooth enamel, exposing the tooth to decay. Bruxism may lead to temporomandibular joint problems (TMJ). TMJ causes pain as a result of inflammation of the temporomandibular joint, which connects the jaw to the lower skull.
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Complications
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Dental caries: Complications of dental caries include pain and tooth loss. Gum disease may also develop in severe dental caries.
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Gum disease: Complications of gum disease include: recurrence of periodontitis; tooth abscess; infection or abscess of the soft tissue (facial cellulitis); infection of the jaw bones (osteomyelitis); trench mouth (a painful infection of the gums); loose teeth or tooth loss; and tooth flaring or shifting.
- Gum disease may increase the risk of heart attack or stroke due to dangerous bacteria found in the mouth. Chronic (long-term) gum infections can lead to chronic inflammation and increased levels of C-reactive protein (CRP) in the blood. High levels of CRP have been linked to an increase in cardiovascular diseases, such as heart attacks.
- Research has found an association between chronic gum disease and premature delivery. One well-known study reported that compared to mothers with healthy gums, pregnant women with chronic gum disease were four to seven times more likely to deliver prematurely.
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Canker sores: Complications of canker sores can include fever, swollen glands, and fatigue. Sores that keep coming back can indicate that important vitamins may be low, especially folic acid or vitamin B12.
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Leukoplakia: Leukoplakia usually does not cause permanent damage to tissues in the mouth and frequently goes away once the irritating factors, such as smoking, are removed. Some patches may become inflamed, however, causing ongoing discomfort.
- Oral cancer is the most serious complication of leukoplakia. A majority of oral cancers form in the vicinity of leukoplakic patches, and the patches themselves may show cancerous changes. Hairy leukoplakia, on the other hand, isn’t painful and isn’t likely to lead to cancer. But it may indicate the presence of HIV infection or AIDS.
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Oral thrush: When severe, thrush can spread into the throat and down the esophagus. Known as candida esophagitus, this condition can make it especially difficult to chew and swallow, and can increase the risk for malnutrition and further illness.
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Mucositis: The consequences of mucositis can be mild (needing little treatment) to severe (possibly resulting in fatal complications). Severe complications of mucositis include hypovolemia (decreased blood volume), electrolyte abnormalities (such as sodium and potassium imbalances), and malnutrition.
- Other complications from mucositis may include taste loss, nausea, pain, vomiting, diarrhea, and a sore or dry mouth. These factors may make eating difficult. Weight loss may occur.
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Treatment
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Dental caries: A tooth that has been destroyed cannot regenerate. However, using appropriate treatment, the progression of cavities can be stopped. The goal of treatment of dental caries is to preserve the tooth and prevent complications, such as pain and gum disease.
- A dentist will remove decayed tooth material by drilling and replacing with a restorative material (called a filling) such as silver alloy, gold, porcelain, or composite resin. Anesthetics are usually used, such as novocaine. Nitrous oxide (laughing gas) may also be used. Pain medications, such as ibuprofen (Motrin®, Advil®), or opiates, such as codeine (Tylenol #3®), may be prescribed when needed. For those individuals who fear dental work, sedation with anti-anxiety agents, such as alprazolam (Xanax®) may be used. It is advisable in these individuals to have someone to drive them to and from the dentist due to the drowsiness caused by the anti-anxiety drug. Antibiotics, such as ampicillin, may be prescribed for any infection or the prevention of an infection.
- Crowns are used if decay is extensive and there is limited tooth structure, which may cause weakened teeth. Large fillings and weak teeth increase the risk of the tooth breaking. The decayed or weakened area is removed and repaired using a covering jacket or “cap” (crown) fitted over the remainder of the tooth. Crowns are often made of gold, porcelain, or porcelain fused to metal.
- A root canal is recommended if the nerve in a tooth dies from decay or from a traumatic blow. The center of the tooth, including the nerve and blood vessel tissue (pulp), is removed along with decayed portions of the tooth. The roots are filled with a sealing material. The tooth is filled and a crown may be placed over the tooth if needed.
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Gum disease: The goal of treatment for gum disease is to thoroughly clean the pockets of bacteria around the gums and to prevent more damage. Many individuals with gum disease can be successfully treated with noninvasive therapies, such as scaling. If pockets between the gums and teeth are 5 millimeters or less in depth, the individual is a good candidate for scaling and root planning, sometimes in conjunction with antibiotic therapy. If the individual consistently practices good oral hygiene at home, this may be the only treatment necessary.
- Scaling removes tartar and bacteria from tooth surfaces and beneath the gums. Scaling may be performed using instruments or an ultrasonic device. Root planning smoothes the root surfaces, discouraging further accumulation of tartar. In addition to these procedures, a periodontist may prescribe antibiotics, such as doxycycline (Periostat®) or penicillin (V-cillin K®), to help control bacterial infection.
- Some dentists, for example, recommend antibiotic mouth rinses, such as chlorhexidene (Peridex® or PerioChip®). Others may insert threads and gels containing antibiotics into the space between the teeth and gums or into pockets after deep cleaning. These products appear to lower bacteria levels and may help prevent future problems.
- However, in advanced periodontitis, where the depth of the pockets between the gums and teeth is more than 5 millimeters, gum tissue may not respond to non-surgical treatments. Surgery may be required in these cases. Deep pockets may need to be opened and cleaned. Loose teeth may need to be supported. Extraction (removal) of a tooth may be necessary for advanced periodontitis so destruction does not spread to adjacent teeth.
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Canker sores: Canker sores usually heal by themselves in 14 days without any treatment. Various treatments are only useful to relieve the pain of the sores. People with canker sores can rinse their mouth with salt water. Salt water has antibacterial properties and may aid in healing the canker sore. Avoiding hot and spicy foods also helps to minimize pain. Pain relievers used for canker sores include viscous lidocaine (Xylocaine viscous®), an anesthetic that can be applied to the sore or used to rinse the mouth to numb the pain. However, although it relieves pain, it may interfere with an individual’s sense of taste. Benzydamine mouthwash (Difflam®) can provide temporary relief from the pain of canker sores, but it does not speed up healing. Silver nitrate can also be applied to the sore to relieve pain. Severe canker sores may be treated with corticosteroid medications, such as dexamethasone (Decadron®) in a mouth rinse or prednisone (Deltasone®) taken as tablets. A doctor may give those with chronic (long-term) problems with canker sores vitamin B12, iron, or folate for nutrient deficiencies.
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Leukoplakia: The usual treatment for leukoplakia is to remove the source of the irritation. For most people, quitting smoking or eliminating alcohol consumption clears the condition. When this is not effective or if the lesions show early signs of cancer, a dentist may choose to remove leukoplakic patches using a scalpel, a laser, or an extremely cold probe that freezes and destroys cancer cells (cryoprobe). These procedures are performed using anesthetics to numb any pain or discomfort. Recurrences of leukoplakia are frequent, so healthcare professionals recommend yearly checkups.
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Oral thrush: It is essential to get treatment for thrush if there are any signs of the illness, such as white patches on the tongue. Oral thrush can persist for months, becoming extremely painful. A healthcare provider can prescribe medicated treatments to help restore the balance of yeast in the body. Prescription treatment generally involves taking a course of oral antifungal tablets, such as fluconazole (Diflucan®). Other drugs include nystatin (Nystatin® oral suspension), amphotericin (Fungilin® lozenges), or miconazole (Daktarin® oral gel).
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Mucositis: Treatment of mucositis is mainly supportive, helping to alleviate redness and pain. Oral hygiene is the mainstay of treatment; individuals are encouraged to clean their mouth every four hours and at bedtime, more often if the mucositis becomes worse. Water-soluble jellies can be used to lubricate the mouth. Salt mouthwash can soothe the pain and keep food particles clear so as to avoid infection. Individuals are also encouraged to drink plenty of liquids, at least three liters a day, and avoid alcohol. Citrus fruits, alcohol, and foods that are hot are all known to aggravate mucositis lesions. Medicinal mouthwashes may be used such as chlorhexidine (Peridex®) and viscous lidocaine (Xylocaine viscous®) for the relief of pain. Palifermin (Kepivance®), is a human KGF (keratinocyte growth factor) that has been shown to enhance epithelial cell proliferation, differentiation, and migration. Experimental therapies have been reported, including the use of cytokines and other modifiers of inflammation (such as interleukin-1 and tissue growth factor-beta3), amino acid supplementation (such as glutamine), vitamins (vitamins E, A, and C), colony-stimulating factors, cryotherapy (freezing), and laser therapy. Symptomatic relief of the pain of oral mucositis is provided by barrier protection agents such as Gelclair®. This viscous oral gel can be diluted and used as an oral rinse. The film-forming agents within Gelclair® coat the oral mucosa shielding ulcerated tissues and protecting exposed nerve endings.
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Integrative therapies
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Good scientific evidence:
- Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today, it is widely used throughout the world and is one of the main pillars of Chinese medicine. Results of acupuncture in postoperative dental pain have been promising and supported by numerous studies. More research is needed to better clarify the use of acupuncture for dental procedures.
- Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
- Bloodroot: Bloodroot (Sanguinaria canadensis) has traditionally been associated with antimicrobial activity. Sanguinarine, a constituent of bloodroot, has been used as a toothpaste or mouth rinse ingredient for plaque and gingivitis. The results of these studies are mixed, and additional study is needed in this area.
- Avoid in individuals with a known allergy or hypersensitivity to bloodroot (Sanguinaria canadensis) or its constituents. Sanguinarine-containing oral products should be avoided in those with oral lesions (wounds in the mouth), as sanguinarine may irritate or cause oral lesions. Traditionally, bloodroot was used to stimulate menstruation, and should therefore not be used during pregnancy. Bloodroot is not recommended in breastfeeding women due to a lack of available scientific evidence.
- Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil very high in gamma-linolenic acid (GLA). Preliminary evidence suggests that borage has anti-inflammatory effects that may make it beneficial in treating periodontitis (gum disease) and gingivitis. Additional research is needed.
- Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil’s GLA. Avoid if breastfeeding.
- Clove: Clove essential oil is commonly used as a dental pain reliever. Early studies have found that a homemade clove gel may be as effective as benzocaine 20% gel. Clove oil combined with zinc oxide paste may be effective for dry socket (inflammation after tooth extraction).
- Avoid if allergic to clove, eugenol, or some licorice products or tobacco (clove cigarette) products. Use cautiously if allergic to Balsam of Peru. Avoid with a history of seizures, stroke, or liver damage. Use cautiously if taking medications that treat diabetes. Use cautiously with diabetes, low blood sugar levels, bleeding problems, or impotence. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks.
- Hypnotherapy, hypnosis: Several promising studies in adults and children report that anxiety related to dentist visits can be reduced with the use of hypnotherapy. Benefits for dental anxiety may be long-standing (measured at up to three years). However, some research reports that hypnosis may be less effective for this use than group therapy or systematic desensitization therapy.
- Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
- Probiotics: Probiotics are beneficial bacteria (sometimes referred to as “friendly germs”) that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut (harmful bacteria and yeasts) under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be consumed as capsules, tablets, beverages, powders, yogurts, and other foods. Short-term consumption of probiotic-containing cheese may be effective for dental caries. There is also evidence that the probiotic Lactobacillus rhamnosus GG, when added to milk, may help reduce dental carries in young children.
- Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency. Probiotics may cause diarrhea in sensitive individuals, leading to dehydration. Dehydration may be serious in infants and small children, so careful use of probiotics in these individuals is recommended by healthcare professionals.
- Rhubarb: Pyralvex® has been used for decades as a salve for gingivitis and the oral mucosa; Parodium® was introduced more recently as a similar treatment. Their active components both include rhubarb (Rheum palmatum) extract. The results from several clinical studies investigating Pyralvex® and Parodium® indicate that these combination treatments may be beneficial in treating gingivitis. However, additional study is needed in this area.
- Avoid in individuals with a known allergy or hypersensitivity to rhubarb or its constituents. Anaphylaxis and rash have been reported. Rhubarb is not recommended in pregnant or breastfeeding women due to a lack of available scientific research. In theory, rhubarb may have uterine stimulant effects. Due to anthraquinone alkaloids, which are potentially mutagenic and genotoxic, rhubarb may be risky during breastfeeding. In case reports, rhubarb has also caused neonatal jaundice. Pregnant women considering taking rhubarb should consult with a qualified healthcare professional, including a pharmacist, to check for interactions.
- TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat dental pain, as an alternative or addition to pain medications. Therapy sessions may last from minutes to hours.Several small randomized controlled trials in adults and children report pain reduction or reduced need for pain medications during dental procedures with the use of various TENS techniques. These studies provide promising preliminary evidence but do not include clear descriptions of design or results. Therefore, better research is necessary.
- Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
- Zinc: A few studies have reported significant reduction in plaque accumulation following treatment with zinc rinses and dentifrices. Preliminary research suggests that zinc citrate dentifrice may reduce the severity and occurrence of calculus formation. However, more well-designed studies are needed to confirm the effectiveness of zinc for plaque and gingivitis. More research may help to determine zinc’s potential efficacy in other dental applications as well.
- Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
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Unclear or conflicting scientific evidence:
- Acacia: Available data shows promising results for use of acacia for plaque; however further studies are warranted.
- Acacia is generally considered safe when taken in the amounts typically found in foods. Avoid if allergic to acacia, pollen or any members of the Fabaceae or Leguminosae family. Use cautiously if taking amoxicillin or iron. Use cautiously with gastrointestinal disorders, respiratory disorders or pink eye. Acacia may prevent the body from absorbing drugs, and tannins from acacia may increase the risk of certain cancers. Avoid if pregnant or breastfeeding.
- Arginine: Some research suggests that ibuprofen-arginate (Spedifen®) may reduce pain after dental surgery faster or more effectively than ibuprofen (e.g., Motrin® or Advil®) alone. More research is needed to better determine the effectiveness of this therapy for dental pain.
- Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
- Betel nut: Toothpaste containing betel nut was once used due to the belief that betel nut could protect against tooth decay while strengthening gums, but now this use has been discontinued. Results from poorly described retrospective analyses suggest that betel nut chewing may serve a protective role against the development of dental caries. In vitro data suggest anti-microbial effects of betel nut, which may play a role. However, due to the known toxicity associated with acute or chronic betel use, and the availability of other therapies with demonstrated efficacy against the development of dental caries, the risks of betel nut use likely outweigh the potential benefits.
- Betel nut cannot be considered safe for human use by mouth. This is due to toxic effects associated with short or long-term chewing or eating of betel nut. Avoid if allergic to betel nut or other plants of the Palmaceae family. Avoid if pregnant or breastfeeding.
- Black tea: Black tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Black tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. There is limited study of black tea as a mouthwash for dental cavity prevention. It is not clear if this is a beneficial therapy.
- Black tea contains caffeine, so those individuals who should not ingest caffeine should use decaffeinated black tea products. Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances or insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism and irritability.
- Bloodroot: Preliminary study has not suggested benefit of sanguinarine, a component of bloodroot, for periodontal disease, although results are mixed. Additional study is needed.
- Avoid in individuals with a known allergy or hypersensitivity to bloodroot (Sanguinaria canadensis) or its constituents. Sanguinarine-containing oral products should be avoided in those with oral lesions (wounds in the mouth), as sanguinarine may irritate or cause oral lesions. Traditionally, bloodroot was used to stimulate menstruation, and should therefore not be used during pregnancy. Bloodroot is not recommended in breastfeeding women due to a lack of available scientific evidence.
- Chitosan: Evidence suggests that chitosan has antibacterial properties and may reduce dental plaque. More evidence is needed.
- Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.
- Coenzyme Q10: Preliminary human studies suggest possible benefits of CoQ10 taken by mouth or placed on the skin or gums in the treatment of periodontitis. Better research is needed before a conclusion can be drawn.
- Allergy associated with CoQ10 supplements has not been documented in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with use of anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin), or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.
- Copper: Copper has been used for its antibacterial properties, including as an oral rinse for dental plaque. Preliminary study suggests that rinsing with a 1.1mM copper solution may be effective in plaque reduction. Further research is required before recommendations can be made.
- Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson’s disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The United States Recommended Dietary Allowance (RDA) is 1,000?g for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1300?g for nursing women.
- Cranberry: Because of its activity against some bacteria, cranberry (Vaccinium macrocarpon) juice has been proposed as helpful for mouth care, including dental plaque. However, many commercial cranberry juice products are high in sugar, and may not be suitable for this purpose. There is currently not enough research in this area to make a conclusion.
- Avoid if allergic to cranberries, blueberries or other plants of the Vaccinium species. Sweetened cranberry juice can affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.
- Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Eucalyptol is used as an ingredient in some mouthwash and dental preparations, as the oil may possess antimicrobial properties. Listerine® mouth rinse is a combination of essential oils (eucalyptol, menthol, thymol, methyl salicylate), which has been shown to be efficacious for the reduction of dental plaque and gingivitis. Although studies on combination mouthwashes show effectiveness (such as Listerine®), it is not clear if eucalyptus oil by itself is effective or safe for this purpose.
- Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria. Avoid if pregnant or breastfeeding. A strain of bacteria found on eucalyptus may cause infection. Toxicity has been reported with oral and inhaled use.
- Folate: Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Early evidence shows that applying folic acid topically may inhibit phenytoin-induced gingival hyperplasia (overgrowth of gum tissue) secondary to phenytoin therapy. Oral folic acid supplementation has not been proven to be beneficial. More research is needed in this area. Based on preliminary data, applying folic acid topically may improve pregnancy-related gingivitis. Well-designed clinical trials are needed to confirm these results.
- Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
- Green tea: Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. There is limited study of tea as a gargle (mouthwash) for dental caries prevention. It is not clear if this is a beneficial therapy for this indication. Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.
- Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis mellifera) from the nectar of flowers. Currently, there is limited study showing a small benefit in the use of honey in the treatment of gingival plaque and gingivitis. Further study is needed.
- Avoid if allergic or hypersensitive to honey, pollen, celery or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
- Iodine: Povidone-iodine mouthwash has been suggested to reduce mouth flora in the setting of periodontitis or around oral surgery. At this time, evidence for use of iodine for periodonitis or gingivitis is not conclusive.
- Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
- Licorice: Further studies are needed prior to recommending for or against the use of glycyrrhizin in dental hygiene.
- Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid licorice with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or if taking diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
- Lycopene: There is some evidence that lycopene, administered systemically, may be an effective treatment for gingivitis. Further studies are needed to support these early findings and to examine lycopene in combination with other gingivitis treatments.
- Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.
- Magnet therapy: Limited available study indicates that incorporation of dental magnets into dentures may be useful for patients with limited ability to tolerate or control removable dentures. Further research is needed to confirm the effectiveness of magnets as a denture aid.
- Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
- Mastic: Mastic is the resin of Pistacia lentiscus, a shrub of the sumac family (Anacardiaceae) found in the Mediterranean regions of France, Spain, Portugal, Greece, Turkey, and Africa. Mastic has reported antibacterial activity against Helicobacter pylori in vitro. Therefore, mastic gum may reduce the amount of dental plaque. However, more research is needed in this area, including studies comparing mastic gum to other forms of oral hygiene.
- Avoid in individuals with a known allergy or hypersensitivity to mastic, or members of the Anacardiaceae family, such as pistachio, terebinth, Chinese pistache, and Schinus terebinthifolius (Brazilian pepper). Well-designed studies evaluating the effects of mastic ingestion beyond four weeks are currently lacking. Therefore, the long-term use of mastic cannot be recommended. Use cautiously with gastric or duodenal ulcer or if taking ACE inhibitors. Avoid if pregnant or breastfeeding.
- Neem: Neem (Azadirachta indica) has a long history of use in India. Neem has been found to have anti-plaque properties and antimicrobial activity against oral pathogens. Comparisons of neem to the prescription drug chlorhexidine have reported significant results. Additional study is needed to confirm the effectiveness of neem for dental plaque.
- Avoid in individuals with a known allergy or hypersensitivity to neem (Azadirachta indica) or members of the Meliaceae family. Use cautiously with liver disease. Avoid in children and infants. Avoid if pregnant or breastfeeding.
- Phenylalanine: D-phenylalanine enhanced the effect of acupuncture as anesthesia during extraction of teeth. For use of D-phenylalanine as an adjunct to acupuncture for dental anesthesia, the therapeutic rationale was the hypothetical possibility that D-phenylalanine may enhance, or prolong the duration of endorphins. Additional research is needed to confirm these results.
- Use cautiously in patients taking monoamine oxidase inhibitors (MAOIs) or in those with hypertension, anxiety disorders, psychiatric disorders, sleep disorders, or Parkinson’s disease or tardive dyskinesia. Avoid in patients with hypersensitivity to phenylalanine or with phenylketonuria (PKU).
- Pomegranate: Extracts from pomegranate fruits may be beneficial in treatment of dental conditions such as dental plaque and periodontitis. Additional studies are warranted.
- Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.
- Propolis: Propolis is a natural resin created by bees, used in the construction of hives. Propolis is produced from the buds of conifer and poplar trees, in combination with beeswax and other bee secretions. There is preliminary evidence that propolis may reduce dental pain, for example with the use of a propolis gel. Early studies also suggest that using a propolis mouthwash may reduce dental plaque formation, reduce bacteria in the mouth, relieve dental pain and gum inflammation (periodontitis), be useful as a sealant after root canal surgery, and help heal dental wounds. Early study using a gel prepared with propolis and caffeic acid phenethyl ester (CAPE) applied to the gums found that the gel provided comfort and was accepted by subjects. Although there has been promising research, particularly in the area of plaque reduction, most studies have been small, low quality, and not fully convincing. Better studies are needed before a recommendation can be made.
- Patients should avoid propolis who have had an allergic/hypersensitivity reaction to propolis, Populus nigra L. (black poplar), poplar bud, bee stings/bee products (including honey), or Balsam of Peru. There are multiple reports of swelling, fluid collection, redness, burning, eczema, swelling, fever, and other allergic reactions with repeated use of propolis on the skin. Severe allergic reactions have been reported. Use cautiously with asthma or gastrointestinal disorders. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.
- Pycnogenol®: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica), which is grown in coastal south-west France. Chewing gum containing Pycnogenol® is reported to minimize gingival bleeding and plaque formation. Pyconogenol® has also been added to toothpaste for antioxidant effects. Further research is needed to confirm these results.
- Avoid if allergic/hypersensitive to Pycnogenol®, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.
- Stinging nettle: Limited available study has examined the effect of a mouthwash containing nettle on plaque and gingivitis in healthy adults, and did not find any benefit. Further studies are required before a conclusion can be made.
- Avoid if allergic or hypersensitive to nettle, the Urticaceae family or any ingredient of nettle products. Use cautiously with diabetes, bleeding disorders, low sodium levels in the blood, or in the elderly. Use cautiously with diuretics and anti-inflammatory drugs. Avoid if pregnant or breastfeeding.
- Tea tree oil: Tea tree oil is obtained by steam distillation of the leaves of Melaleuca alternifolia. Tea tree oil is purported to have antiseptic properties, and has been used traditionally to prevent and treat infections. Study results on the effects of tea tree oil mouthwash on dental plaque and gingivitis are mixed. Further research is needed before a conclusion can be drawn.
- Avoid if allergic or hypersensitive to tea tree oil (Melaleuca alternifolia), any of its constituents, balsam of Peru, benzoin, colophony (rosin) tinctures, eucalyptol, or other members of the Myrtle (Myrtaceae) family. Avoid taking tea tree oil by mouth. Avoid if taking antineoplastic agents. Use tea tree oil applied to the skin cautiously in patients with previous tea tree oil use. Avoid if pregnant or breastfeeding.
- Thyme: Thyme (Thymus vulgaris) has been used medicinally for thousands of years. One of thyme’s main constituents, thymol, has antibacterial effects. Thymol is included as one of several ingredients in antiseptic mouthwashes such as Listerine®. Clinical studies have reported efficacy of Listerine® in decreasing dental plaque formation and gingivitis, although human evidence for thymol alone is limited.
- Avoid in individuals with a known allergy or hypersensitivity to members of the Lamiaceae (mint) family or to any component of thyme, or to rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury, or in atopic patients, due to multiple reports of contact dermatitis. Use cautiously in patients with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously in patients with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.
- Vitamin C: Vitamin C (ascorbic acid) is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits such as oranges. In preliminary study, a reduced amount of calculus, visible plaque, and bleeding gum sites was observed after the use of vitamin C chewing gum. Further research is needed to better determine the effectiveness of vitamin C for dental plaque.
- Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.
- Vitamin D: Oral bone and tooth loss are correlated with bone loss at non-oral sites. Research suggests that intake levels of calcium and vitamin D aimed at preventing osteoporosis may have a beneficial effect on tooth retention.
- Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.
- Yarrow: Based on laboratory study, yarrow water extract showed antibacterial effects on Staphylococcusaureus. However, human study using a combination formula (including yarrow, juniper, and nettle) found no effect on gingivitis or dental plaque inhibition. Additional human study is needed.
- Avoid in individuals with a known allergy or hypersensitivity to yarrow (Achillea millefolium), its constituents, or members of the Compositae/Asteraceae family. Use cautiously with photosensitivity. Avoid if pregnant or breastfeeding as yarrow has traditionally been used as an abortifacient (induces abortion), emmenagogue (induces menstruation), contraceptive, and for stimulating uterine contractions.
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Author information
- This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).
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Bibliography
- American Academy of Family Physicians. .
- Academy of General Dentistry. .
- American Dental Association. .
- Centers for Disease Control and Prevention. .
- Dye BA, Thornton-Evans G. A brief history of national surveillance efforts for periodontal disease in the United States. J Periodontol. 2007 Jul;78(7 Suppl):1373-9.
- Heijnsbroek M, Paraskevas S, Van der Weijden GA. Fluoride interventions for root caries: a review. Oral Health Prev Dent. 2007;5(2):145-52.
- Naidoo S, Myburgh N. Nutrition, oral health and the young child. Matern Child Nutr. 2007 Oct;3(4):312-21.
- National Institute of Dental and Craniofacial Research. .
- Natural Standard: The Authority on Integrative Medicine. .
- Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet. 2007 Jan 6;369(9555):51-9.
- Worthington H, Clarkson J, Eden O. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000978.
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Prevention and self-management
- Management of dental problems begins at home. Taking care of the teeth and gums is very important.
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Brushing and flossing: Thorough tooth brushing and flossing to reduce dental plaque can prevent dental caries and gum disease. Healthcare professionals recommend drinking fluoridated water and using a fluoride toothpaste. Fluoride’s protection against tooth decay works at all ages.
- Brushing the teeth after each meal and snack is recommended. Brushing after meals helps remove any food particles from the teeth. Food particles lodged in the teeth may lead to dental caries. Also, a soft toothbrush is best. Turn the bristles against the gum line and brush gently. Use small, circular motions. Brush the front, back, and top of each tooth.
- Using dental floss at least once a day is recommended. Flossing helps prevent the buildup of plaque on the teeth. Plaque can harden and grow under the gums and cause problems. Using a sawing motion, gently bring the floss between the teeth, scraping from bottom to top several times.
- Mouthwashes can also be helpful to remove dental plaque.
- Keep dentures clean and comfortable.
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Limit tobacco use: In addition to the general health risks posed by tobacco, smokers have four times the risk of developing gum disease compared to non-smokers. Tobacco use in any form, such as cigarettes, pipes, and smokeless (chewing) tobacco, increases the risk for gum disease, oral and throat cancers, and oral fungal infection (candidiasis). Chewing tobacco containing sugar increases the risk of tooth decay.
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Limit alcohol use: Heavy use of alcohol is also a risk factor for oral and throat cancers. When used alone, alcohol and tobacco are risk factors for oral cancers, but when used in combination, the effects of alcohol and tobacco are even greater.
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Diet modification: Adults and children should avoid snacks full of sugars and starches as well as limit the number of snacks eaten throughout the day. The recommended five-a-day helping of fiber-rich fruits and vegetables stimulates salivary flow to aid in decreasing tooth decay.
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Regular dental checkups: It is recommended by healthcare professionals to visit the dentist regularly, preferably every six months for cleaning. Check-ups can detect early signs of oral health problems and can lead to treatments that will prevent further damage, and in some cases, reverse the problem. Professional tooth cleaning (prophylaxis) is also important for preventing oral problems, especially when self-care is difficult.
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Other: If medications produce a dry mouth, drinking plenty of water, chewing sugarless gum, and avoiding tobacco and alcohol can be helpful in reducing the problem.
- Have an oral health check-up before beginning cancer treatment. Radiation to the head or neck and/or chemotherapy may cause problems for the teeth and gums. Treating existing oral health problems before cancer therapy may help prevent or limit oral complications or tissue damage.
- It is recommended by healthcare professionals to call a dentist right away if there are problems with the teeth, gums, and oral cavity.
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Common dental problems, causes, and risk factors
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Dental caries: Dental caries is an infectious disease that damages the structures of teeth. Tooth decay or cavities are consequences of caries. All individuals are at risk for getting cavities throughout their lifetime. By the time most people are adults, 85% of people will have had a cavity. Cavities are caused by the bacteria Streptococcus mutans, which can attach themselves to hard surfaces like the enamel that covers the teeth. If the bacteria are not removed, they multiply and grow in number until a colony forms. More bacteria of different types attach to the colony already growing on the tooth enamel. Proteins that are present in the saliva (spit) also mix in and the bacteria colony becomes a whitish film on the tooth. This film, called dental plaque, damages and decays the teeth and causes cavities.
- Plaque begins to accumulate on teeth within 20 minutes after eating (the time when most bacterial activity occurs). If this plaque is not removed thoroughly and routinely, tooth decay will not only begin, but flourish. The acids in plaque dissolve the enamel surface of the tooth and create holes in the tooth (cavities). Cavities are usually painless until they grow very large inside the tooth and destroy the nerve and blood vessels in the tooth. If left untreated, a tooth abscess (pus enclosed in the tissues of the jaw bone at the tip of an infected tooth) can develop. Untreated tooth decay also destroys the internal structures of the tooth (pulp) and ultimately causes the loss of the tooth. Pulp refers to the softest part of the tooth that lies in its root and extends all of the way to the top part of the tooth (the crown). The pulp contains the blood vessels, the nerves, and connective tissue inside a tooth and provides the tooth’s blood and nutrients.
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Gum disease: Gum diseases include gingivitis and periodontitis. Gingivitis is inflammation of the gums that causes the gums to bleed and swell. Gum diseases are more often seen as people age, with most people showing signs of them by their mid-30s. Gingivitis is caused by infection or plaque around the teeth and is a common cause of tooth loss after age 35. The most common type of gum disease is gingivitis.
- Periodontitis is a more serious type of gum disease. Periodontitis is a dental disorder that results from progression of gingivitis, involving inflammation and infection of the ligaments and bones that support the teeth. Plaque, formed from bacteria, hardens into calculus (tartar) when left on the teeth. As plaque and calculus continue to build up, the gums begin to pull away, or recede, from the teeth, and pockets form between the teeth and gums. As the gums recede, more bone and the periodontal ligament are damaged. Teeth – even healthy teeth – may become loose and need to be extracted.
- Gum diseases such as gingivitis and periodontitis can be caused by numerous factors, including: smoking/tobacco use; genetics – up to 30% of the population may be genetically susceptible to gum disease; pregnancy, puberty, and menopause (hormonal changes can make individuals more susceptible to gum diseases); stress; medications, such as oral contraceptives, the anti-seizure drug phenytoin (Dilantin®), the immune system drug cyclosporin (Sandimmune®), and some heart medicines including nifedipine (Procardia®); clenching or grinding the teeth – clenching or grinding the teeth can put excess force on the supporting tissues of the teeth and could speed up the rate at which these periodontal tissues are destroyed; diabetes – diabetes makes the individual more susceptible to developing infections, including gum diseases; poor nutrition – vitamin deficiencies can impair the immune system, leading to periodontitis; and disease such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and cancer can impair immunity and lead to gum diseases.
- It has been estimated that 50%-75% of women experience gingivitis during pregnancy. Pregnancy-related gingivitis is caused by increased hormone levels and is most common between the second and eighth month of pregnancy. The increased hormones result in more overall fluid retention throughout the body, which can cause swollen, red, and tender gums. Hormonal changes in pregnancy have also been found to reduce resistance to infection in gum tissue and to promote growth of certain bacteria and plaque (particularly increased levels of progesterone), which causes inflammation. Swelling and tenderness in the gums may be severe and cause bleeding. Untreated gingivitis may lead to periodontitis. Research has found an association between chronic gum disease and premature delivery. One well-known study reported that compared to mothers with healthy gums, pregnant women with chronic gum disease were four to seven times more likely to deliver prematurely. Experts suggest that pregnancy gingivitis can be prevented by proper oral hygiene both prior to and during pregnancy, including brushing at least twice a day (with a fluoride-containing toothpaste), flossing once a day, using an antimicrobial mouth rinse, and regularly scheduled professional dental cleanings. Following delivery, gums usually return to normal. If symptoms such as bleeding, sensitivity, swelling, and irritation persist after delivery or get worse, it is advised to contact a dentist.
- Phenytoin-induced gingival hyperplasia is an enlargement of the gums. The gums can grow along the sides of, or over the teeth. Phenytoin (Dilantin®) causes gingival hyperplasia in approximately 50% of those who take it within two weeks to three months after initiation of therapy. This may progress to the point that the teeth are virtually submerged. Phenytoin is commonly used for seizure control.
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Canker sores: Canker sores, also known as aphthous stomatitis or mouth ulcers, are common, but mostly harmless, sores. Stomatitis means inflammation of the mouth. Canker sores appear as ulcers (an eroded area of the oral cavity, marked by tissue disintegration) that are white or gray with a red border inside the mouth. They occur in women more often than men, often during menstrual periods. The reason why they appear is unknown but some experts believe that problems with the immune system, the body system that fights disease, bacteria, or viruses, may be involved. Fatigue, stress, or allergies can increase the chances of getting a canker sore. Canker sores tend to heal by themselves in one to three weeks. If an individual gets a large sore (larger than 1 centimeter), it may need to be treated. Canker sores are vulnerable to infection by bacteria in the mouth.
- Canker sores are usually seen in children and adolescents from the ages of 10 – 19 years. For about one-third of the children affected, lesions continue to reappear for years after the initial outbreak. These ulcers are not contagious and cannot be spread from one child to another.
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Oral thrush: Oral thrush is a fungal or yeast infection (candidiasis) in the mouth caused by an overgrowth of Candida albicans. Oral thrush appears as red or white lesions, flat or slightly raised, in the mouth. When severe, this fungus can spread down the esophagus, making chewing and swallowing very painful. They are common among denture wearers and occur most often in those who are very young, in the elderly, or in those who have a problem with their immune system, such as in cancer and HIV/AIDS patients. Individuals who have dry mouth syndrome (xerostomia) and those taking antibiotics may also get oral yeast infections. These yeast infections can be prevented with good oral hygiene, such as cleaning dentures appropriately and brushing the teeth.
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Oral leukoplakia: Oral leukoplakia is a condition in which thickened, white patches form on the gums, on the inside of the cheeks, and sometimes on the tongue. The cause of leukoplakia is unknown, but it is considered to result from chronic irritation. Tobacco, either smoked or chewed, is the main cause, but irritation can also come from other sources, such as long-term alcohol use.
- Leukoplakia is the most common of all chronic mouth lesions. Although anyone can develop leukoplakia, it’s most common in older men. People with compromised immune systems sometimes develop an unusual form of the disorder called hairy leukoplakia. Hairy leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with human immunodeficiency virus (HIV), have acquired immunodeficiency syndrome (AIDS), or AIDS-related complex. Hairy leukoplakia consists of corrugated, fuzzy, hence the name “hairy,” white patches on the lateral borders of the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus
- In general, leukoplakia is not painful, but the patches may be sensitive when the individual touches them or eats spicy foods. Although the disorder usually is not dangerous, a small percentage of leukoplakic patches show early signs of cancer. Many cancers of the mouth occur next to areas of leukoplakia. For that reason, it is best to see a dentist if there are unusual changes in the mouth lasting longer than a week.
- The cause of leukoplakia is unknown. Many possible causes have been linked to leukoplakia, including tobacco, long-term alcohol use, and other chronic irritants. Tobacco use appears to be responsible for most cases of leukoplakia. The majority of individuals who develop leukoplakia are smokers, and most leukoplakic patches either improve or disappear within a year after stopping smoking. Chewing tobacco and snuff also play a key role. As many as three out of four regular users of “smokeless tobacco” products eventually develop leukoplakia where they hold the tobacco against their cheeks. Other factors contributing to leukoplakia include the fungus Candida albicans, which causes oral thrush, and human papillomavirus (HPV), the virus that causes genital warts.
- Oral cancer is the most advanced stage of leukoplakia. Oral cancer most often occurs in people over the age of 40. It is often found at late stages when it is harder to treat. This is because oral cancer is not usually painful so individuals may not recognize the problem early. Also, many people do not visit their dentists often enough to find the cancer early. The most common sites of oral cancer are on the tongue, lips, and floor of the mouth. Use of tobacco, especially with alcohol, is the main cause for these cancers.
- Chemotherapy or radiation treatments to the head and neck can cause dry mouth, tooth decay, painful mouth sores, leukoplakia, and cracked, peeling lips.
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Mucositis: Mucositis, or stomatitis, is inflammation of the mucous membranes lining the digestive tract from the mouth on down to the anus. Mucositis is a common side effect of chemotherapy and of radiotherapy that involves any part of the digestive tract. Mucositis affects the rapidly dividing mucosal cells lining the mouth, throat, stomach, and intestines. These cells normally have a short life span. Chemotherapy or radiation therapy can destroy the cells quickly and they are not replaced right away. Destruction of mucosal cells in the oral cavity leads to ulcers or sores. Mucositis is painful, can interfere with eating, and may require pain medication for a week or two until the tissues recover.
- Mucositis is also the primary cause of pain for patients undergoing bone marrow transplants due to chemotherapy and/or radiation therapies. Good mouth care is essential. Infection calls for prompt antibiotic treatment.
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The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.
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