A physician should always examine the mouth and be able to recognize major oral disorders, particularly possible cancers. However, consultation with a dentist is needed to evaluate nonmalignant changes as well as patients with tooth problems. Likewise, patients with xerostomia or unexplained swelling or pain in the mouth, face, or neck require a dental consultation. Children with abnormal facies (who also may have dental malformations requiring correction) should be evaluated by a dentist. In FUO or a systemic infection of unknown cause, a dental disorder should be considered. A dental consultation is necessary before head and neck radiation therapy and is advisable before chemotherapy.

Clues suggesting systemic disease may be found in the mouth and adjacent structures (see Table 1: Approach to Dental and Oral Symptoms: Oral Findings in Systemic Disorders). A dentist should consult a physician when a systemic disorder is suspected, when the patient is taking certain drugs (eg, warfarin, bisphosphonates), and when a patient's ability to withstand general anesthesia or extensive oral surgery must be evaluated. Patients with certain heart valve abnormalities may require antibiotic prophylaxis to help prevent bacterial endocarditis before undergoing certain dental procedures (see Table 3: Endocarditis: Procedures Requiring Antimicrobial Endocarditis Prophylaxis and Table 4: Endocarditis: Recommended Endocarditis Prophylaxis During Oral-Dental, Respiratory Tract, or Esophageal Procedures*).

Table 1
Oral Findings in Systemic Disorders Oral Manifestation Possible Indication Candidiasis Diabetes, AIDS, other causes of immunosuppression (eg, agranulocytosis, neutropenia, leukemia, immunoglobulin defects, disorders of leukocyte function), antibiotic use Atrophic glossitis (a smooth tongue caused by atrophy of filiform papillae) Iron deficiency Painful atrophy of the oral mucosa and surface of the tongue, sometimes with aphthous ulcers Megaloblastic anemias Magenta tongue Vitamin B12 deficiency Darkly pigmented areas (if not a racial characteristic) Hemochromatosis, Addison's disease, Peutz-Jeghers syndrome, melanoma (rare, but may be seen on the palate), smoker's melanosis Linear, grayish discoloration (lead line) in the gingiva adjacent to teeth Lead, silver, or bismuth poisoning Violaceous patches Kaposi sarcoma, AIDS Keratotic lichenoid patches, sometimes with painful mucosal atrophy Graft-vs-host disease if in the mouth of an organtransplant recipient Reddish discoloration of the teeth Congenital erythropoietic porphyria High, arched soft palate Marfan syndrome Notched incisors, domed or mulberry molars Congenital syphilis Hairy leukoplakia (white, vertical folds on lateral border of tongue) HIV transforming to AIDS Red or reddish purple collections of oral telangiectases Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) Multiple impacted supernumerary teeth and osteomas Gardner's syndrome

Common dental disorders are discussed in Common Dental Disorders. Dental emergencies, including toothache, are discussed in Dental Emergencies.

Anatomy and Development

Teeth

The teeth are categorized as incisors, canines, premolars, and molars and conventionally are numbered beginning with the maxillary right 3rd molar (see Fig. 1: Approach to Dental and Oral Symptoms: Identifying the teeth.).

Fig. 1
Identifying the teeth. The numbering system shown is the one most commonly used in the US.

Each tooth has a crown and a root. The canines have the largest and strongest roots. An inner pulp contains blood vessels, lymphatics, and nerves, surrounded by the hard but porous dentin, a very hard enamel coating that covers the crown. The bonelike cementum is over the root, which, when healthy, is covered by gingiva (see Fig. 2: Approach to Dental and Oral Symptoms: Section of a canine tooth.). Twenty deciduous teeth normally begin appearing at close to age 6 mo and should all be in place by age 30 mo (see Table 1: Physical Growth and Development: Tooth Eruption Times). These teeth are followed by 32 permanent teeth that begin to appear by about age 6. The period from age 6 to 11 is called the mixed dentition stage, in which both deciduous and permanent teeth are present. Timing of tooth eruption is one indicator of skeletal age and may identify growth retardation or establish age for forensic purposes.

Fig. 2
Section of a canine tooth.

Supporting tissues

The gingiva surrounds the teeth at the base of their crowns. The alveolar ridges are trabecular bone containing sockets for the teeth. The periodontium consists of the tissues that support the teeth—the gingiva, epithelial attachment, connective tissue attachment, periodontal ligament, and alveolar bone. The mandible and maxilla support the alveolar ridges and house the teeth. Saliva from the salivary glands bathes and protects the teeth. The tongue directs food between the grinding surfaces and helps clean the teeth. The maxilla receives innervation from the maxillary nerve, the 2nd division of the trigeminal nerve (the 5th cranial nerve). The mandibular nerve, which is the 3rd and most inferior division of the trigeminal nerve, innervates the mandible.

In the elderly, or in some periodontal diseases, gingival recession exposes the dental root adjacent to the crown, making root caries common. If tooth destruction results and the tooth must be removed, the mechanical stimulation necessary for maintaining bone integrity ceases. Consequently, atrophy of the alveolar ridge (senile atrophy) begins when teeth are absent.

Gingival Recession

Mouth

Normally, keratinized epithelium occurs on the facial aspect of the lips, dorsum of the tongue, hard palate, and gingiva around the teeth. When healthy, the gingiva extends 5 to 7 mm from the tooth. Nonkeratinized mucosa occurs over alveolar bone further from the teeth, inside the lips and cheeks, on the sides and undersurface of the tongue, on the soft palate, and covering the floor of the mouth. The skin and mucosa of the lips are demarcated by the vermilion border.

The buccal mucosa, including the vestibule and nonkeratinized alveolar mucosa, is usually smooth, moist, and more red than pink (as compared to healthy gingiva). Innocuous entities in this region include linea alba (a thin white line, typically bilateral, on the level of the occlusal plane, where the cheek is bitten), Fordyce's granules (aberrant sebaceous glands appearing as < 1 mm light yellow spots that also may occur on the lips), and white sponge nevus (bilateral thick white folds over most of the buccal mucosa). Recognizing these avoids needless biopsy and apprehension. The orifices of the parotid (Stensen's) ducts are opposite the maxillary 1st molar on the inside of each cheek and should not be mistaken for an abnormality.

The dorsal surface of the tongue is covered with numerous whitish elevations called the filiform papillae. Interspersed among them are isolated reddish prominences called the fungiform papillae, occurring mostly on the anterior part of the tongue. The circumvallate papillae, numbering 8 to 12, are considerably larger and lie posteriorly in a V pattern. The circumvallate papillae do not project from the tongue but instead are surrounded by a trench. The foliate papillae appear as a series of parallel, slitlike folds on the lateral borders of the tongue, near the anterior pillars of the fauces. They vary in length and can easily be confused with malignant lesions, as may the foramen cecum, median rhomboid glossitis, and, rarely, a lingual thyroid nodule. Lingual tonsils are components of Waldeyer's ring, are at the back of the tongue, and should not be mistaken for lesions. If an apparent abnormality is bilateral, it is almost always a normal variant.

Innervation is supplied by the lingual nerves (branches of the 5th cranial nerves), for general sensory innervation, and the chorda tympani fibers (of the 7th cranial nerve), which innervate the taste buds of the anterior 2/3 of the tongue. Behind the circumvallate papillae, the glossopharyngeal nerves (9th cranial nerves) provide the sensations of touch and taste. The tongue has taste receptors for sweet, salty, sour, bitter, and umami (a savory taste triggered by natural glutamic acid and glutamates such as the flavoring agent monosodium glutamate). Although previously thought to be isolated to particular portions of the tongue, these receptors are now known to be distributed over the surface of the tongue. The hypoglossal nerves (12th cranial nerves) control movement of the tongue.

The major salivary glands are the paired parotid, submandibular, and sublingual glands. Most oral mucosal surfaces contain many minor mucus-secreting salivary glands. Anteriorly and near the midline on each side of the floor of the mouth are the openings of Wharton's ducts, which drain the ipsilateral submandibular and sublingual glands. The parotid glands drain into the cheeks via Stensen's ducts.

Evaluation

The first routine dental examination should take place by age 1 yr or when the first tooth erupts. Subsequent evaluations should take place at 6-mo intervals or whenever symptoms develop. Examination of the mouth is part of every general physical examination. Oral findings in many systemic diseases are unique, sometimes pathognomonic, and may be the first sign of disease. Oral cancer may be detected at an early stage.

History

Important dental symptoms include bleeding, pain, malocclusion, new growths, numbness or paresthesias, and chewing problems (which may lead to weight loss—see Table 2: Approach to Dental and Oral Symptoms: Some Oral Symptoms and Possible Causes). General information includes use of alcohol or tobacco (both major risk factors for head and neck cancer) and systemic symptoms, such as fever and weight loss.

Table 2
Some Oral Symptoms and Possible Causes Symptoms Causes Bleeding or pain with brushing (common) Acute necrotizing ulcerative gingivitis (rare) Bleeding diathesis* Gingivitis (most common) Leukemia* Ear pain, referred (fairly common) Inflamed gingival flap around a partly erupted mandibular 3rd molar (pericoronitis) Localized osteitis (dry socket) after lower molar extraction Face, head, or neck pain (uncommon, except with poorly fitting dental appliances or temporomandibular disorders) Eagle's syndrome† Infection Malocclusion Occult lesions with low-grade anaerobic infections spreading to the bone Poorly fitting dental appliances Spasm of the masticatory muscles Temporomandibular disorders Facial numbness or paresthesias (uncommon, except with stroke) Antrum or nasopharynx tumor Brain stem tumors Extraction of a mandibular molar causing damage to the inferior alveolar nerve‡ Multiple sclerosis Oral tumor (rare) Stroke Viral infection Masticatory fatigue (rare, except with poorly fitting dentures) Congenital muscular or neuromuscular disorder (in younger people) Myasthenia gravis (a cardinal symptom) Poorly occluding artificial dentures (in older people) Masticatory pain or jaw claudication (rare) Giant cell (temporal) arteritis Polymyalgia rheumatica Weight loss (fairly common) Poorly fitting dental appliances Stomatitis Temporomandibular disorder Too loose, too few, or painful teeth *May be indicated by easily induced gingival hemorrhaging. †Elongation of the styloid process or ossification of the stylohyoid ligament, causing pain when the head is turned. ‡May cause paresthesia of the lower lip.

Physical examination

A thorough inspection requires good illumination, a tongue blade, gloves, and a gauze pad. Complete or partial dentures are removed so that underlying soft tissues can be seen.

Most physicians use a head-mounted light. However, because the light cannot be precisely aligned on the axis of vision, it is difficult to avoid shadowing in narrow areas. Better illumination results with a head-mounted convex mirror; the physician looks through a hole in the center of the mirror, so the illumination is always on-axis. The head mirror reflects light from a source (any incandescent light) placed behind the patient and slightly to one side and requires practice to use effectively.

The examiner initially looks at the face for asymmetry, masses, and skin lesions. Slight facial asymmetry is universal, but more marked asymmetry may indicate an underlying disorder, either congenital or acquired (see Table 3: Approach to Dental and Oral Symptoms: Some Disorders of the Oral Region by Predominant Site of Involvement).

Teeth are inspected for shape, alignment, defects, mobility, color, and presence of adherent plaque, materia alba (dead bacteria, food debris, desquamated epithelial cells), and calculus (tartar).

Teeth are gently tapped with a tongue depressor or mirror handle to assess tenderness (percussion sensitivity). Tenderness to percussion suggests deep caries that has caused a necrotic pulp with periapical abscess or severe periodontal disease. Percussion sensitivity or pain on biting also can indicate an incomplete (green stick) fracture of a tooth. Percussion tenderness in multiple adjacent maxillary teeth may result from maxillary sinusitis. Tenderness to palpation around the apices of the teeth also may indicate an abscess.

Loose teeth usually indicate severe periodontal disease but can be caused by bruxism (clenching or grinding of teeth—see Approach to Dental and Oral Symptoms: Bruxism) or trauma that damages periodontal tissues. Rarely, teeth become loose when alveolar bone is eroded by an underlying mass (eg, ameloblastoma, eosinophilic granuloma). A tumor or systemic cause of alveolar bone loss (eg, diabetes mellitus, hyperparathyroidism, osteoporosis, Cushing's syndrome) is suspected when teeth are loose and heavy plaque and calculus are absent.

Calculus is mineralized bacterial plaque—a concretion of bacteria, food residue, saliva, and mucus with Ca and phosphate salts. After a tooth is cleaned, a mucopolysaccharide coating (pellicle) is deposited almost immediately. After about 24 h, bacterial colonization turns the pellicle into plaque. After about 72 h, the plaque starts calcifying, becoming calculus. When present, calculus is deposited most heavily on the lingual (inner, or tongue) surfaces of the mandibular anterior teeth near the submandibular and sublingual duct orifices (Wharton's ducts) and on the buccal (cheek) surfaces of the maxillary molars near the parotid duct orifices (Stensen's ducts).

Caries (tooth decay—see Common Dental Disorders: Caries) first appears as defects in the tooth enamel. Caries then appears as white spots, later becoming brown.

Attrition (wearing of biting surfaces) can result from chewing abrasive foods or tobacco or from the wear that accompanies aging, but it usually indicates bruxism. Another common cause is abrasion of a porcelain crown occluding against opposing enamel, because porcelain is considerably harder than enamel. Attrition makes chewing less effective and causes noncarious teeth to become painful when the eroding enamel exposes the underlying dentin. Dentin is sensitive to touch and to temperature changes. A dentist can desensitize such teeth or restore the dental anatomy by placing crowns or onlays over badly worn teeth. In minor cases of root sensitivity, the exposed root may be desensitized by fluoride application or dentin-bonding agents.

Deformed teeth may indicate a developmental or endocrine disorder. In Down syndrome, teeth are small. In congenital syphilis, the incisors may be small at the incisal third, causing a pegged or screwdriver shape with a notch in the center of the incisal edge (Hutchinson's incisors), and the 1st molar is small, with a small occlusal surface and roughened, lobulated, often hypoplastic enamel (mulberry molar). In ectodermal dysplasia, teeth are absent or conical, so that dentures are needed from childhood. Dentinogenesis imperfecta, an autosomal dominant disorder, causes abnormal dentin that is dull bluish brown and opalescent and does not cushion the overlying enamel adequately. Such teeth cannot withstand occlusal stresses and rapidly become worn. People with pituitary dwarfism or with congenital hypoparathyroidism have small dental roots; people with gigantism have large ones. Acromegaly causes excess cementum in the roots as well as enlargement of the jaws, so teeth may become widely spaced. Acromegaly also can cause an open bite to develop in adulthood. Congenitally narrow lateral incisors occur in the absence of systemic disease. The most commonly congenitally absent teeth are the 3rd molars, followed in frequency by the maxillary lateral incisors and 2nd mandibular premolars.

Defects in tooth color must be differentiated from the darkening or yellowing that is caused by food pigments, aging, and, most prominently, smoking. A tooth may appear gray because of pulpal necrosis, usually due to extensive caries penetrating the pulp or because of hemosiderin deposited in the dentin after trauma, with or without pulpal necrosis. Children's teeth darken appreciably and permanently after even short-term use of tetracyclines by the mother during the 2nd half of pregnancy or by the child during odontogenesis (tooth development), specifically calcification of the crowns, which lasts until age 9. Tetracyclines rarely cause permanent discoloration of fully formed teeth in adults. However, minocycline darkens bone, which can be seen in the mouth when the overlying gingiva and mucosa are thin. Affected teeth fluoresce with distinctive colors under ultraviolet light corresponding to the specific tetracycline taken. In congenital porphyria, both the deciduous and permanent teeth may have red or brownish discoloration but always fluoresce red from the pigment deposited in the dentin. Congenital hyperbilirubinemia causes a yellowish tooth discoloration. Teeth can be whitened (see Table 4: Approach to Dental and Oral Symptoms: Tooth Whitening Procedures).

Defects in tooth enamel may be caused by rickets, which results in a rough, irregular band in the enamel. Any prolonged febrile illness during odontogenesis can cause a permanent narrow zone of chalky, pitted enamel or simply white discoloration visible after the tooth erupts. Thus, the age at which the disease occurred and its duration can be estimated from the location and height of the band. Amelogenesis imperfecta, an autosomal dominant disease, causes severe enamel hypoplasia. Chronic vomiting and esophageal reflux can decalcify the dental crowns, primarily the lingual surfaces of the maxillary anterior teeth. Chronic snorting of cocaine can result in widespread decalcification of teeth, because the drug dissociates in saliva into a base and HCl. Chronic use of methamphetamines markedly increases dental caries (“meth mouth”).

Swimmers who spend a lot of time in overchlorinated pools may lose enamel from the outer facial/buccal side of the teeth, especially the maxillary incisors, canines, and 1st premolars. If Na carbonate has been added to the pool water to correct pH, then brown calculus develops but can be removed by a dental cleaning.

Fluorosis is mottled enamel that may develop in children who drink water containing > 1 ppm of fluoride during tooth development. Fluorosis depends on the amount of fluoride ingested. Enamel changes range from irregular whitish opaque areas to severe brown discoloration of the entire crown with a roughened surface. Such teeth are highly resistant to dental caries.

The lips are palpated. With the patient's mouth open, the buccal mucosa and vestibules are examined with a tongue blade; then the hard and soft palates, uvula, and oropharynx are viewed. The patient is asked to extend the tongue as far as possible, exposing the dorsum, and to move the extended tongue as far as possible to each side, so that its posterolateral surfaces can be seen. If a patient does not extend the tongue far enough to expose the circumvallate papillae, the examiner grasps the tip of the tongue with a gauze pad and extends it. Then the tongue is raised to view the ventral surface and the floor of the mouth. The teeth and gingiva are viewed. An abnormal distribution of keratinized or nonkeratinized oral mucosa demands attention. Keratinized tissue that occurs in normally nonkeratinized areas appears white. This abnormal condition, called leukoplakia, requires a biopsy because it may be cancerous or precancerous. More ominous, however, are thinned areas of mucosa. These red areas, called erythroplakia, if present for at least 2 wk, especially on the ventral tongue and floor of the mouth, suggest dysplasia, carcinoma in situ, or cancer.

With gloved hands, the examiner palpates the vestibules and the floor of the mouth, including the sublingual and submandibular glands. To make palpation more comfortable, the examiner asks the patient to relax the mouth, keeping it open just wide enough to allow access.

The temporomandibular joint (TMJ) is assessed by looking for jaw deviation on opening and by palpating the head of the condyle anterior to the external auditory meatus. Examiners then place their little fingers into the external ear canals with the pads of the fingertips lightly pushing anteriorly while patients open widely and close 3 times. Patients also should be able to comfortably open wide enough to fit 3 of their fingers vertically between the incisors (typically 4 to 5 cm). Trismus, the inability to open the mouth, may indicate temporomandibular disease (the most common cause), pericoronitis, scleroderma, arthritis, ankylosis of the TMJ, dislocation of the temporomandibular disk, tetanus, or peritonsillar abscess. Unusually wide opening suggests subluxation or type III Ehlers-Danlos syndrome.

Table 3
Some Disorders of the Oral Region by Predominant Site of Involvement Site Disorder or Lesion Description Lips Actinic atrophy Thin atrophic mucosa with erosive areas; predisposes to neoplasia   Angioedema Acute swelling   Angular cheilitis (cheilosis) Fissuring at corners of mouth, often with maceration   Cheilitis glandularis Enlarged, nodular labial glands with inflamed, dilated secretory ducts; sometimes everted, hypertrophic lips   Cheilitis granulomatosa Diffusely swollen lips, primarily the lower   Erythema multiforme Multiple bullae that rupture quickly, leaving hemorrhagic ulcers; includes Stevens-Johnson syndrome   Exfoliative cheilitis Chronic desquamation of superficial mucosal cells   Keratoacanthoma A benign, locally destructive epithelial tumor resembling squamous cell carcinoma; regresses spontaneously in about 6 mo   Peutz-Jeghers syndrome Brownish black melanin spots, with GI polyposis   Secondary herpes simplex (cold sore) Short-lived (< 10 days) vesicle followed by small painful ulcer at the vermillion border (common)   Verruca vulgaris (wart) Pebbly surface Buccal mucosa Aspirin burn Painful white area; when wiped off, exposes an inflamed area   Fordyce's granules Cream-colored macules about 1 mm in diameter; benign; aberrant sebaceous glands   Hand-foot-and-mouth disease Small ulcerated vesicles; coxsackievirus strain infection in young children; mild   Herpangina Vesicles in posterior of mouth   Irritation fibroma Smooth-surfaced, dome-shaped, sessile   Koplik's spots Tiny, grayish white macules with red margins near orifice of parotid duct; measles precursor   Linea alba Thin white line, typically bilateral, on the level of the occlusal plane; benign   Smokeless tobacco lesion White or gray corrugated; usually behind lower lip; tends toward cancer   Verrucous carcinoma Slow-growing, exophytic, usually well differentiated; at site of snuff application; metastasis unusual, occurs late   White sponge nevus Thick white folds over most of buccal mucosa except gingivae; benign Palate Infectious mononucleosis Petechiae at junction of hard and soft palate   Kaposi sarcoma Red to purple painless macules progressing to painful papules   Necrotizing sialometaplasia Large, rapidly developing ulcer, often painless; appears grossly malignant; heals spontaneously in 1–3 mo   Papillary inflammatory hyperplasia Red, spongy tissue, succeeded by fibrous tissue folds; velvety texture; benign; occurs under poorly fitting dentures   Pipe smoker's palate (nicotine stomatitis) Red punctate areas, are ducts of minor salivary glands, appearance is red spots surrounded by (often severe, usually benign) leukoplakia   Secondary herpes simplex Small papules quickly coalescing into series of ulcers (uncommon)   Torus palatinus Overgrowth of bone in midline; benign   Wegener's granulomatosis Lethal midline granuloma, with bone destruction, sequestration, and perforation Tongue and floor of mouth Ankyloglossia Tongue unable to protrude; speech difficulty   Benign lymphoepithelial cyst Yellowish nodule on ventral part of tongue or anterior floor of mouth   Benign migratory glossitis (geographic tongue, erythema migrans) Changing patterns of hyperkeratosis and erythema on dorsum and edges; desquamated filiform papillae in irregular circinate pattern, often with an inflamed center and a white or yellow border   Dermoid cyst Swelling in floor of mouth   Enlargement of tongue (macroglossia) Localized or generalized depending on how many teeth are missing; adjacent teeth may indent tongue; posterior enlargement associated with obstructive sleep apnea and snoring   Fissured (scrotal) tongue Deep furrows in lateral and dorsal areas   Glossitis Red, painful tongue; often secondary to another condition, allergic, or idiopathic   Hairy tongue Dark, elongated filiform papillae   Linea alba Thin white line on edges of tongue, usually bilateral   Lingual thyroid nodule Smooth-surfaced nodular mass of thyroid tissue follicles, on the far posterior dorsum of tongue, usually at the midline   Ludwig's angina Painful, tender swelling under the tongue; can compromise the airway by forcing the tongue superiorly and posteriorly   Median rhomboid glossitis Red (usually) patch in midline of tongue, without papillae; asymptomatic   Neurilemmoma Persistent swelling, sometimes at site of prior trauma; can be painful   Pernicious anemia Smooth, pale tongue, often with glossodynia or glossopyrosis   Ranula Large mucocele penetrating the mylohyoid muscle; may plunge deep into the neck; swollen floor of mouth   Thyroglossal duct cyst Midline swelling that moves upward when tongue protrudes   TB Ulcers on dorsum (firm), cervical adenopathy Salivary glands Benign lymphoepithelial lesion (Mikulicz's disease) Unilateral or bilateral enlargement of salivary glands; often with dry mouth and eyes   Sialadenitis Swelling, often painful; benign   Sialolithiasis Swelling (eg, of floor of mouth) that increases at mealtime or when offered a pickle   Sjögren's syndrome Systemic disease causing dry mucous membranes   Xerostomia Dry mouth; usually secondary to drugs Various Acute herpetic gingivostomatitis Widespread ulcerating vesicular lesions; always present on gingiva; other locations may be involved; usually in young children   Behçet's syndrome Multiple oral ulcers similar to those of aphthous stomatitis; also includes dry eyes   Cicatricial pemphigoid Bullae that rupture quickly, leaving ulcers; ocular lesions develop after oral lesions; found on alveolar mucosa and vestibules   Condyloma acuminatum Venereally transmitted wart forming cauliflower-like clumps   Dyskeratosis Occurs with erythroplakia (red), leukoplakia (white patch on mucous membrane that does not rub off), and mixed red and white lesions; precancerous   Hemangioma Purple to dark-red lesions, similar to port wine stain; benign   Hereditary hemorrhagic telangiectasia Localized dilated blood vessels   Lichen planus Lacy pattern (Wickham's striae), sometimes erosive; may become malignant; most common on buccal mucosa, lateral tongue   Lymphangioma Localized swelling or discoloration; benign; most common on tongue   Mucocele (mucous retention cyst) Soft nodule; if superficial, covered by thin epithelium; appears bluish; most common on lips and floor of mouth   Noma Small vesicle or ulcer that rapidly enlarges and becomes necrotic   Pemphigoid Small yellow or hemorrhagic tense bullae; may last several days before rupture; most common on vestibules and alveolar mucosa   Pemphigus Bullae that rupture quickly, leaving ulcers; can be fatal without treatment   Canker sores, recurrent aphthous stomatitis Small painful ulcers or large, painful scarring ulcers (two distinct conditions)   Syphilis Chancre (red papule rapidly developing into a painless ulcer with a serosanguineous crust), mucous patch, gumma

Table 4
Tooth Whitening Procedures Done By Ingredients Comments Dentist In office Concentrated hydrogen peroxide is applied to teeth, which is exposed to a light or laser Very effective Gingiva, skin, and eyes must be protected Patient At home 6% carbamide peroxide (becomes 3% hydrogen peroxide when applied) and a thickening agent containing copolymers of acrylic acid cross-linked with a polyalkenyl polyether are added to a custom-made tray Very effective Patient (OTC products) Commercial whitening strips Composed of carbamide peroxide Very effective Whitening toothpaste Usually contain carbamide or hydrogen peroxide Moderately effective Paint-on whitening Usually composed of titanium dioxide Not very effective

Testing

For a new patient or for someone who requires extensive care, the dentist takes a full mouth x-ray series. This series consists of 14 to 16 periapical films to show the roots and bone plus 4 bite-wing films to detect early caries between posterior teeth. Modern techniques reduce radiation exposure to a near-negligible level. Patients at high risk of caries (ie, those who have had caries detected during the clinical examination, have many restorations, or have recurrent caries on teeth previously restored) should undergo bite-wing x-rays every 12 mo. Otherwise, bite-wings are indicated every 2 to 3 yr. A panoramic x-ray can yield useful information about tooth development, cysts or tumors of the jaws, supernumerary or congenitally absent teeth, 3rd molar impaction, Eagle's syndrome (less frequently), and carotid plaques.

Geriatrics Essentials

With aging, resting salivary secretion diminishes and can be further diminished by drugs, although meal-stimulated salivary flow is usually adequate. The flattened cusps of worn teeth and weakness of the masticatory muscles may make chewing tiresome, impairing food intake. Loss of bone mass in the jaws (particularly the alveolar portion), dryness of the mouth, thinning of the oral mucosa, and impaired coordination of lip, cheek, and tongue movements may make denture retention difficult. The taste buds become less sensitive, so the elderly may add abundant seasonings, particularly salt (which is harmful for some), or they may desire very hot foods for more taste, sometimes burning the often atrophic oral mucosa. Gingival recession and xerostomia contribute to development of root caries. Despite these changes, improved dental hygiene has greatly decreased the prevalence of tooth loss, and most older people can expect to retain their teeth.

Poor oral health contributes to poor nutritional intake, which impairs general health. Dental disease (particularly periodontitis) is associated with a 2-fold increased risk of coronary artery disease. Edentulous patients cannot have periodontitis (because they do not have a periodontium), although periodontitis may have resulted in their tooth loss. Aspiration pneumonia in patients with periodontitis can involve anaerobic organisms and has a high mortality rate. Severe bacteremias secondary to acute or chronic dental infection may contribute to brain abscesses, cavernous sinus thrombosis, endocarditis, prosthetic joint infections, and unexplained fevers.

Dental Care of Patients With Systemic Disorders

Certain medical conditions (and their treatment) predispose patients to dental problems or affect dental care.

Hematologic disorders

People who have disorders that interfere with coagulation (eg, hemophilia, acute leukemia, thrombocytopenia) require medical consultation before undergoing dental procedures that might cause bleeding (eg, extraction, mandibular block). Hemophiliacs should have clotting factors given before, during, and after an extraction. Such oral surgery should be done in the hospital in consultation with a hematologist. All patients with bleeding disorders should maintain a lifelong routine of regular dental visits, which includes cleanings, fillings, topical fluoride, and preventative sealants, to avoid the need for extractions.

Cardiovascular disorders

After an MI, dental procedures should be avoided for 6 mo, if possible, to allow damaged myocardium to become less electrically labile. Patients with pulmonary or cardiac disease who require inhalation anesthesia for dental procedures should be hospitalized.

Endocarditis prophylaxis is required before dental procedures only in patients with

• Prosthetic cardiac valves
• Previous history of bacterial endocarditis
• Cyanotic congenital defects of the heart or great vessels (if unrepaired, if completely repaired during first 6 mo after surgery, or if repaired but with residual defects)
• Cardiac transplantation recipients with a valvulopathy

The heart is better protected against low-grade bacteremias, which occur in chronic dental conditions, when dental treatment is received (with prophylaxis) than when it is not received. Patients who are to undergo cardiac valve surgery or repair of congenital heart defects should have any necessary dental treatment completed before surgery.

Although probably of marginal benefit, antibiotic prophylaxis is sometimes recommended for patients with hemodialysis shunts and within 2 yr of receipt of a major prosthetic joint (hip, knee, shoulder, elbow). The organisms causing infections at these sites are almost invariably of dermal rather than oral origin.

Epinephrine and levonordefrin are added to local anesthetics to increase the duration of anesthesia. In some cardiovascular patients, excess amounts of these drugs cause arrhythmias, myocardial ischemia, or hypertension. Plain anesthetic can be used for procedures requiring < 45 min, but in longer procedures or where hemostasis is needed, up to 0.04 mg epinephrine (2 dental cartridges with 1:100,000 epinephrine) is considered safe. Generally, no healthy patient should receive > 0.2 mg epinephrine at any one appointment. Absolute contraindications to epinephrine (any dose) are uncontrolled hyperthyroidism; pheochromocytoma; BP > 200 mm Hg systolic or > 115 mm Hg diastolic; uncontrolled arrhythmias despite drug therapy; and unstable angina, MI, or stroke within 6 mo.

Some electrical dental equipment, such as an electrosurgical cautery, a pulp tester, or an ultrasonic scaler, can interfere with early-generation pacemakers.

Cancer

Extracting a tooth adjacent to a carcinoma of the gingiva, palate, or antrum facilitates invasion of the alveolus (tooth socket) by the tumor. Therefore, a tooth should be extracted only during the course of definitive treatment. In patients with leukemia or agranulocytosis, infection may follow an extraction despite the use of antibiotics.

Immunosuppression

People with impaired immunity are prone to severe mucosal and periodontal infections by fungi, herpes and other viruses, and, less commonly, bacteria. The infections may produce hemorrhage, delayed healing, or sepsis. Dysplastic or neoplastic oral lesions may develop after a few years of immunosuppression. People with AIDS may develop Kaposi's sarcoma, non-Hodgkin lymphoma, hairy leukoplakia, candidiasis, aphthous ulcers, or a rapidly progressive form of periodontal disease.

Endocrine disorders

Dental treatment may be complicated by the presence of some endocrine disorders. For example, people with hyperthyroidism may develop tachycardia and excessive anxiety as well as thyroid storm if given epinephrine. Insulin requirements may be reduced on elimination of oral infection in diabetics; insulin dose may require reduction when food intake is limited because of pain after oral surgery. In people with diabetes, hyperglycemia with resultant polyuria may lead to dehydration, resulting in decreased salivary flow (xerostomia), which, along with elevated salivary glucose levels, contributes to caries.

Patients receiving corticosteroids and those with adrenocortical insufficiency may require supplemental corticosteroids during major dental procedures. Patients with Cushing's syndrome or who are taking corticosteroids may have alveolar bone loss, delayed wound healing, and increased capillary fragility.

Neurologic disorders

Patients with seizures who require dental appliances should have nonremovable appliances that cannot be swallowed or aspirated. Patients unable to brush or floss effectively may use chlorhexidine 12% rinses in the morning and at bedtime.

Obstructive sleep apnea

Patients with obstructive sleep apnea who are unable to tolerate treatment with a positive airway pressure (CPAP, biPAP)) mask are sometimes treated with an intraoral device that expands the oropharynx. This treatment is not as effective as CPAP, but more patients tolerate using it.

Drugs

Certain drugs, such as corticosteroids, immunosuppressants, and antineoplastics, compromise healing and host defenses. When possible, dental procedures should not be done while these drugs are being given.

Some antineoplastics (eg, doxorubicin, 5-fluorouracil, bleomycin, dactinomycin, cytosine, arabinoside, methotrexate) cause stomatitis, which is worse in patients with preexisting periodontal disease. Before such drugs are prescribed, oral prophylaxis should be completed, and patients should be instructed in proper tooth brushing and flossing.

Drugs that interfere with clotting may need to be reduced or stopped before oral surgery. Patients taking aspirin, NSAIDs, or clopidogrel should stop doing so 4 days before undergoing dental surgery and can resume taking these drugs after bleeding stops. Warfarin should be stopped 2 to 3 days before oral surgery. PT is obtained; INR of 1.5 is considered safe for surgery. For people receiving hemodialysis, dental procedures should be done the day after dialysis, when heparinization has subsided.

Phenytoin and Ca channel blockers, particularly nifedipine, contribute to gingival hyperplasia; however, this hyperplasia is minimized with excellent oral hygiene and frequent oral prophylaxes (cleanings).

Bisphosphonates, primarily when given parenterally for treatment of bone cancer, and to a much lesser degree when used orally to prevent osteoporosis, can result in osteonecrosis after an extraction (see Osteonecrosis: Osteonecrosis of the Jaw).

Radiation therapy

(Caution: Extraction of teeth from irradiated tissues [particularly if the total dose was > 65 Gy, especially in the mandible] is commonly followed by osteoradionecrosis of the jaw. This is a catastrophic complication in which extraction sites break down, frequently sloughing bone and soft tissue.) Thus, if possible, patients should have any necessary dental treatment completed before undergoing radiation therapy of the head and neck region, with time allowed for healing. Teeth that may not survive should be extracted. Necessary sealants and topical fluoride should be applied. After radiation, extraction should be avoided, if possible, by using dental restorations and root canal treatment instead.

Head and neck radiation often damages salivary glands, causing xerostomia, which promotes caries. Patients must therefore practice lifelong good oral hygiene. A fluoride gel and fluoride mouth rinse should be used daily. Rinsing with 0.12% chlorhexidine for 30 to 60 sec, if tolerated, can be done in the morning and at bedtime. Viscous lidocaine may enable a patient with sensitive oral tissues to brush and floss the teeth and eat. A dentist must be seen at 3-, 4-, or 6-mo intervals, depending on findings at the last examination. Irradiated tissue under dentures is likely to break down, so dentures should be checked and adjusted whenever discomfort is noted. Early caries may also be reversed by Ca phosphopeptides and amorphous Ca phosphate, which can be applied by a dentist or prescribed to a patient for at-home use.

Patients who undergo radiation therapy may develop oral mucosal inflammation and diminished taste as well as trismus due to fibrosis of the masticatory muscles. Trismus may be minimized by such exercises as opening and closing the mouth widely 20 times 3 or 4 times/day. Extractions of teeth in irradiated bone should be avoided (because of possible osteoradionecrosis). Sometimes root canal therapy is done, and the tooth is ground down to the gum line. If extraction is required after radiation, 10 to 20 treatments in a hyperbaric O₂ chamber may forestall or prevent osteoradionecrosis.

Last full review/revision March 2009 by Robert B. Cohen, DMD