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- Local causes – this usually arises as a result of irritation of the nerve supplying the affected tooth. This can be due to a number of local problems, including inflammation of the pulp (pulpitis), infection and, most commonly, decay. Gum disease, grinding teeth (bruxism), tooth trauma and an abnormal bite are also causes. In babies and young children, consider the growth of unerupted teeth.
- Systemic causes – systemic problems should also be borne in mind. Think of temporomandibular joint, sinus or ear infections and tension in the facial muscles which can cause discomfort which resembles a toothache (these are often accompanied by a headache). Angina should also be considered in your list of differentials.
- Management – once you are sure that this is a local problem, it is appropriate to refer to a dental practitioner. Whilst waiting to be seen, advise patients to take regular oral analgesia (non-steroidal anti-inflammatory drugs (NSAIDs) are a good starting point) and some patients find that application of a cool compress on the cheek overlying the affected tooth helps.
- Nature of the problem – dentine is protected by a hard layer of enamel but if this is broken then caries follows. This can result from trauma or inadequacy of the enamel; the most common cause of breakdown of enamel is by lactic acid that is formed by bacteria when sugars are left in contact with the teeth. Risk factors are therefore a diet high in sugars and poor dental hygiene. Dental caries (or decay) is a common problem in all industrialised and in many developing countries. In the UK, a survey found that 40% of 5-year-olds had experienced some dental caries. Scottish pre-school children experienced some of the highest rates of dental caries in Europe.
- Treatment – destroyed structures of the tooth do not regenerate so treatment is aimed at preventing further decay. Decayed material is removed by drilling and a substance is used to fill the tooth. Many different materials are now available, including silver amalgam, gold and high-strength composite resin. Crowns are used if decay is extensive and there is limited tooth structure which may cause weakened teeth. The decayed or weakened area is removed and repaired and a covering jacket or crown is fitted over the remainder of the tooth. Crowns are often made of gold, porcelain or porcelain fused to metal. If the nerve root dies, a root canal filling may be required.
- Prevention – attention to diet and regular tooth brushing are the main preventative strategies. There is a wealth of material concerning dietary factors, particularly in young children. In summary:
- Human breast milk and unmodified cow’s milk are not cariogenic, unlike infant formula milk (theoretically, soya infant formula milk is the worst offender).
- Drinks containing free sugars (including natural fruit juices) are cariogenic and shouldn’t be given in a bottle.
- Foods and confectionary containing free sugars should be minimised and restricted to meal times.
- Cheese may actively protect against caries and is a good high-energy source for toddlers.
- Sugar substitutes are better than free sugars for teeth, although beware of salt content and additives used to make the food as appealing.
Brushing (supervised in young children) removes both sugar and organisms, and antiseptic mouthwashes may be beneficial too.
There has been a lot of research into the fluoridation of products and its protective effects against dental caries. For example, fluoridation of toothpastes, mouth rinses, gels and tooth varnishes has been common practice for several decades, resulting in beneficial effects where these products have been used appropriately.
Previous research over some 50 years has shown that adding fluoride to water supplies can reduce decay by 40-60%. 1 part per million is required and, in those areas where there is fluoridation of water, children aged under 7 should use lower-fluoride toothpaste. The fluoridation of water, however, remains politically controversial and there are organised campaign groups both ‘for’ and ‘against’.No more than 10% of the country receive fluoride in their water. The favoured areas are mostly in the north-east of England and the Midlands. In 2004 health ministers were still insistent that fluoridisation of water supplies is a matter for local decision and this remains the case to date. It is the responsibility of strategic health authorities to bring pressure upon local water boards. Fluoridation of milk and salt has also been examined as a possible approach, although the effectiveness of such measures is yet to be proven. It is worth noting that fluoride supplements taken by a pregnant woman have no beneficial effects on the child’s teeth.
Numerous other areas of research are being explored for the prevention of dental caries, including the development of various fillings, antibacterial agents and fissure sealants.
- Nature of the problem – this is a collection of pus in the tooth or within the surrounding structures. It most commonly originates in the centre (pulp) of the tooth – a periapical or dentoalveolar abscess. A periodontal abscess originates in the tissue surrounding the tooth. Their pathophysiology and management are different but, in the context of primary care, they can be treated as the same entity.
- Presentation – a dental abscess presents with worsening pain (hours to days) which may radiate to the ipsilateral ear, jaw and neck. There may be a bad taste in the mouth, fever ± malaise and trismus (inability to open the mouth). It is more likely to occur where there are risk factors for dental caries (see ‘Dental caries’ above) and a history of previous dental procedures. Other risk factors include diabetes, immunocompromise, smoking and drug-induced gum disorders. Look for facial swelling, regional lymphadenopathy, altered tooth appearance and gum swelling. Alternative diagnoses to consider include:
- Infections such as mumps, sinusitis, acute otitis media and facial cellulitis.
- Salivary gland disorders such as a stone, infection (parotitis) or dehydration/dry mouth.
- Intraoral or salivary gland neoplasm.
- Management in primary care – the patient needs to be seen by a dental practitioner. In the interim, pain can be managed with regular analgesics such as NSAIDs (advise ibuprofen or naproxen in patients at risk of cardiovascular adverse events). Advise the patient to consume cool, soft food and to avoid very hot or cold foods and drinks. Patients should avoid flossing the affected tooth. Consider antibiotics only in the absence of immediate attention by a dental practitioner and if:
- The infection appears to be severe (fever, lymphadenopathy, cellulitis, diffuse swelling).
- Patients are at risk of developing complications (eg, people who are immunocompromised or have diabetes or valvular heart disease).
Suitable antibiotics include amoxicillin or metronidazole for five days or a course of amoxicillin 3 g repeated after eight hours may be offered for adults. Avoid repeat prescriptions and changing antibiotics – these patients should be managed by dental practitioners.
Wisdom teeth and their problems
Impacted wisdom teeth should not be removed unless they have associated significant dental or other oral disease. Conditions warranting removal of impacted wisdom teeth include:
- Unrestorable caries.
- Non-treatable pulpal and/or periapical pathology.
- Cellulitis, abscess and osteomyelitis.
- Internal/external resorption of the tooth or adjacent teeth.
- Fracture of the tooth.
- Disease of the tooth follicle (ectomesenchymal tissue surrounding the developing tooth germ) including cyst/tumour.
- Tooth/teeth impeding surgery or reconstructive jaw surgery.
- When a tooth is involved in, or within the field of, tumour resection.
A post-extraction bleeding tooth socket should be treated by using a wad of wet gauze placed over the socket and the patient should be advised to bite down and arrest the haemorrhage through pressure; any medications that promote bleeding should be considered for temporary discontinuation and the patient should seek dental advice if the symptoms do not settle, as suturing may be necessary.
- Tooth loss: permanent dentition – traumatic tooth loss should be managed in adults and children with permanent teeth, initially, by trying to replace the tooth in the socket. If this is not possible, store the tooth in milk or the patient’s own saliva. Attendance at a dental clinic as soon as possible (within 24 hours) gives a chance of replacing the avulsed tooth successfully.
- Tooth loss: primary dentition – in children with ‘milk teeth’, replacement of the tooth is not advised due to the danger of damaging the underlying permanent tooth. Store the avulsed tooth in saliva or milk and get the patient to attend a dental practitioner as soon as possible. A five-day course of antibiotics is recommended in this situation.
- Dental concussion – the tooth is said to be concussed when there is damage to the supporting tissues without abnormal loosening or displacement of the tooth. Pulp necrosis may ensue (seen as the tooth going dark). This should be managed by a dental practitioner. Where the tooth is left as it is (common where a primary tooth is involved), the key thing is to advise parents to look out for swelling of the gum around the tooth; this may be an early manifestation of inflammation ± infection.
- Problems with fillings and crowns – these can be affected by external trauma (eg, a fall). This is likely to be associated with more extensive injury – or by more minor trauma – eg, biting on a hard fragment of food. It is best to get the tooth checked out by a dental practitioner, as loosening or chipping of the filling results in pain in the short-term and risk of further dental caries later on.
The word periodontal literally means ‘around the tooth’. Periodontal disease is most commonly a chronic bacterial infection which affects the gums and bone supporting the teeth. If left untreated it can lead to loss of teeth.
Worrying symptoms and signs of periodontal disease warranting urgent referral to an appropriate specialist
- Rapid progression of symptoms – see ‘Aggressive periodontitis’, below.
- Unexplained tooth mobility for more than three weeks.
- Unexplained swelling or ulceration on the oral mucosa, lasting for more than three weeks – malignancy needs to be ruled out.
- Other suspicions of malignancy: unexplained painful, swollen and bleeding, red or red and white patches on the oral mucosa and unexplained tooth mobility lasting more than three weeks.
- Risk factors for malignancy include increasing age (>45 years old), heavy drinking or smoking as well as other use of tobacco (eg, chewing).
If a lesion in the oral cavity cannot be diagnosed definitively as benign, follow up for six weeks and, if resolution does not occur, refer urgently to a specialist.
This should be considered for:
- People who cannot use a toothbrush or dental floss.
- Gingivitis not responding to the usual oral hygiene measures.
- Unexplained red and white patches (including suspected lichen planus) or the oral mucosa where there is no swelling, bleeding or pain.
Gingivitis refers to inflammation of the gum of any cause. However, it is most often associated with plaque.
Plaque is the soft, sticky bacterial deposit that readily forms on exposed surfaces of teeth. It is easily removed by brushing and flossing. It calcifies over time, forming tartar (calculus) which can only be removed by a dentist or dental hygienist using special instruments. Plaque results in a local inflammatory reaction, gingivitis.
Gingivitis is the mildest form of a spectrum disease and can progress to periodontal disease.
- Presentation – in plaque-associated gingivitis, the gums become red, swell and bleed easily. There is usually little or no discomfort. The most important risk factors for this disease are:
- Ineffective oral hygiene
- Cigarette smoking
- Diabetes mellitus
Older individuals as well as immunocompromised patients are also at risk. It is extremely common, with some degree of the disease occurring in up to 90% of the adult population in the UK. It is estimated to affect a little over 40% of UK teenagers too.
- Other causes of bleeding gums:
- Platelet disorders
- Vitamin C deficiency
- Vascular conditions
- HIV infection
- Management – this condition should be managed by a dentist. However, in the interim, advise good oral hygiene (see ‘Oral healthcare’, below) and use of antiseptic mouthwashes (eg, chlorhexidine or hexetidine). This is also an opportunity to address the issue of smoking cessation, as this also contributes to periodontal disease.
This is a condition caused by primary infection with the herpes simplex virus, often by contact with someone who has cold sores. It predominantly (but not exclusively) affects toddlers and young children and is characterised by an acute onset of fever, malaise, pain and ulceration of both gingiva and oral mucosa. It may be managed with aciclovir For a first episode and the child presenting within three days of onset of the symptoms, it may be managed with aciclovir. Or, it may be managed conservatively with simple analgesia (not aspirin). The episode should fully resolve over about 14 days.
Herpetic gingivostomatitis is common in patients being treated for cancer and a Cochrane review found that aciclovir is effective both for the treatment and prevention of this condition.
Acute necrotising gingivitis
Also known as Vincent’s gingivitis or trench mouth, this is a progressive, painful, acute bacterial infection of the gums. The bacteria involved tend to be those already present in the mouth and it is predominantly associated with anaerobic flora. Although it is not thought to be infectious, it may occur in epidemic form, especially in institutions (eg, prisons).
- Presentation – sudden onset, acutely painful, bleeding gums, excess salivation and ulceration, swelling and sloughing off of dead tissue. There may be difficulty in swallowing or talking and some report a metallic taste in the mouth. Occasionally, it is accompanied by severe halitosis. Risk factors include immunocompromise, malnutrition, smoking, stress and ineffective oral hygiene.
- Management – these patients should be referred to dentists urgently for immediate treatment and management. Whilst they wait to see the dentist, patients should be prescribed metronidazole or amoxicillin for three days, paracetamol or ibuprofen for pain relief and chlorhexidine (0.12% or 0.2%) mouthwash or hydrogen peroxide 6% mouthwash. They should carry on brushing their teeth if possible, using a soft toothbrush.
- Prognosis – if left untreated, it can spread to involve all the gingiva and spread into the bone, forming intraosseous craters (necrotising ulcerative periodontitis). If inadequately treated, it may lead to recurrent ulcerative gingivitis for many years with halitosis, gingival bleeding and recession of the gums. Inadequate treatment can also (rarely) lead to noma (rapidly spreading gangrene of the lips and cheeks) – more likely in malnourished or immunocompromised individuals.
Untreated gingivitis can advance to periodontitis which is an inflammation of the periodontal ligament (which attaches the tooth to the bone) and bone. Toxins produced by the bacteria in plaque irritate the gums and stimulate a chronic inflammatory response in which the tissues and bone that support the teeth are broken down and destroyed. There have been suggestions that periodontal disease might be a risk factor for cardiovascular disease and pulmonary infection and that its presence in pregnant women may cause them to have low birth weight or premature babies. However, the evidence is conflicting and further studies are awaited. One Indian study has found an association between periodontal disease in pregnancy and the development of pre-eclampsia. A Cochrane review has found some evidence that treating periodontal disease may improve glycaemic control in people with diabetes.
- Presentation – this condition is frequently asymptomatic but, occasionally, the patient may complain of one or more of:
- Pain (which may or may not be caused by an associated periodontal abscess).
- Halitosis or a foul taste in the mouth.
- Recession and associated root sensitivity.
- Drifting/loosening of teeth causing difficulty in eating.
Up to 30% of the population may be genetically susceptible to periodontal disease but a number of other factors (see ‘Gingivitis’, above) also increase risk. Look for bleeding, pus and debris expressible from gingival pockets, loosening or drifting of teeth (there may eventually be tooth loss) and the presence of a periodontal abscess.
- Management – this is the same as for gingivitis. Ultimately, patients should be seen by a dentist.
- Prognosis – untreated, periodontal disease can lead to permanent damage to the periodontal ligament and alveolar bone. There may be recurrent gum abscesses or detachment of the gum from the tooth with the formation of periodontal pockets. Progressive deepening of periodontal pockets and recession of the gums can lead to drifting and loosening of the teeth, with loss of multiple teeth.
A severe form of periodontitis (formerly known as early-onset periodontitis) occurs in patients (usually under the age of 35) who are otherwise clinically healthy. It tends to be associated with Actinobacillus actinomycetemcomitans. There is rapid loss of dental attachments with loss and destruction of bone. Familial aggregation may suggest a genetic predisposition or a poor family tradition of attention to dental hygiene.
In the early stages of periodontal disease, attention to dental hygiene will suffice. Eating less refined carbohydrate and stopping smoking will also help. Scaling and root planing will also help but surgery may be necessary.
There are four types of periodontal surgery:
- Pocket reduction surgery – folds back the gum tissue and removes the bacteria before securing the tissue into place. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where bacteria are sequestered. This allows the gum tissue to reattach to healthy bone.
- Regenerative procedures – these fold back the gum tissue and remove the bacteria. Membranes, bone grafts or tissue-stimulating proteins can be used to encourage the ability to regenerate bone and tissue.
- Crown lengthening – is a procedure to remove excess gum and bone tissue to reshape and expose more of the natural tooth. This can be done to one tooth, to even the gum line, or to several teeth to expose a natural, broad smile. It is a restorative or cosmetic dental procedure. If the tooth is decayed or broken below the gum line, or has insufficient tooth structure for a restoration, it can be extracted and a bridge can be used.
- Soft tissue grafts – stop further dental problems and gum recession and improve the aesthetics of the gum line. Soft tissue grafts can be used to cover roots or develop gum tissue where absent due to excessive gingival recession. Gum tissue from the palate or another donor source covers the exposed root. This can be done for one tooth or several teeth to even the gum line and reduce sensitivity. A soft tissue graft can reduce further recession and bone loss. In some cases, it can cover exposed roots to protect them from decay. This may reduce tooth sensitivity and improve the aesthetics of the smile.
Prevention of periodontal disease
Prevention of gingivitis and periodontal disease requires good oral hygiene (see ‘Oral healthcare’, below), possible use of antimicrobial mouthwashes and the regular review of a dentist. This is particularly true in those with diabetes who are more likely to develop infections of the gum and periodontal disease. Other risk factors include puberty and pregnancy as well as bruxism (clenching and grinding of teeth) which can put stress on the structures around the teeth and loosen them. Smoking is also a significant factor in the development and progression of periodontal disease; this is another opportunity to think about stopping smoking.
Systemic diseases affecting the teeth and gingiva
- Gastrointestinal disease – the mouth is the first part of the alimentary canal and so, in theory at least, history and examination of the gastrointestinal tract should start with the mouth. Think of this when considering Crohn’s disease, for example.
- Non-gastrointestinal systemic disease – conversely, when looking at lesions in the mouth, bear in mind that there could be a systemic explanation – eg, mouth ulcers caused by leukaemia, pemphigusor systemic lupus erythematosus.
- Secondary problems affecting the mouth – the problem you are looking at in the mouth may actually be a secondary problem such as due to insufficient saliva (which is both lubricating and antibacterial, being a good source of immunoglobulin A (IgA)). Disease of both teeth and gums is more common if saliva flow is impaired. This may occur in Sjögren’s syndrome, where irradiation to treat cancer may have damaged the glands, in dehydration or when anticholinergic drugs are used.
- Congenital problems – it could be that the problem occurred before you met the patient: all women are screened for syphilis at booking for pregnancy and so congenital syphilis is now very rare in Western societies. One feature is widespread peg-shaped teeth called Hutchinson’s teeth.
- Childhood problems – developing teeth are also affected by the use of tetracycline which discolours teeth. Profound neonatal jaundice may also stain teeth. Poor intake of calcium in the very early years of life can lead to poor calcification of permanent dentition. Gastrointestinal malabsorption may be to blame but, if a child has cow’s milk intolerance and animal milk is replaced by soya milk, this will contain insufficient calcium.
- Iatrogenic problems – finally, drugs may affect both adults and children; for example, phenytoin can lead to hyperplasia of the gums.
Therefore, when a patient presents with dental or periodontal problems, take a full history (including medical and drug history), consider gastrointestinal causes, systemic causes and iatrogenic causes and, once you are satisfied that these do not apply and the problem is related purely to the teeth or gums, refer the patient on to a dental practitioner.
The most important factors for the prevention of both dental and periodontal disease are a good diet with a minimum of sugar, and attention to oral hygiene. However, what is meant when advising ‘good oral hygiene’? Below is a synopsis of the current advice about basic oral healthcare.
Basic oral healthcare
- Brush teeth twice a day.
- Floss teeth three times a week.
- Visit a dental practitioner or dental hygienist regularly.
Intervals between visits vary depending on the condition of the teeth and any treatment received. However, in the absence of specific conditions needing particular treatment, the National Institute for Health and Care Excellence (NICE) suggests intervals no shorter than three months and no longer than 12 months (in those under 18 years old) or 24 months in those over 18 years old.
Regular checks by dentists include scaling of teeth (if required) and the identification and early treatment of caries if it occurs. However, there is a severe shortage of dentists in many parts of the country. Dental health of the population has improved in a period of 30 years but this has stagnated in recent years. Much attention is paid to the dental health of children but in old people who still have some teeth it is a problem that is aggravated by regression of gums, reshaping of the mandible and a tendency for saliva volume to diminish.
Oral care for people with special needs
Older people, institutionalised patients, patients with mental health problems and individuals with a learning disability may face particular challenges in managing their oral health. Problems may be experienced due to:
- Barriers in accessing adequate oral care due to lack of perceived need, inability by the individual to express need and a lack of ability to self-care.
- Fear and anxieties, which are also significant contributors to poor access to oral care providers.
- The knowledge and skills of carers may be inadequate.
- Concurrent illness may take priority and oral healthcare takes a back seat.
Detailed guidance for these specific patient groups are more within the remit of dental practitioners. However, documents outlining these recommendations are included in the ‘Further reading & references’ section – integrated care pathways are used and there will be an overlap of the services provided to the individual (and these may include the general practitioner).