Oral Ulcers

Oral ulceration is probably the most common oral mucosal disease seen. It can potentially be the most serious too. There are many causes and one must make careful history and examination to help diagnosis.

Antibiotic use is rarely indicated. A corticosteroid cream application may help but if the ulcer does not heal in 2-3 week’s time, refer immediately for dental assessment. Human   and

Animal Bites Oral Burns

A common chemical burn seen in adults is caused by putting aspirin® in the buccal sulcus to relieve headache. Treatment is to treat cause of headache and don’t put aspirin® in the buccal sulcus!

Burnt mucosa heals itself quite quickly.

Chemical burns in children are usually due to ingestion of caustic liquids. Regular saline mouthwash should be done.

In severe burns, admit case for IV fluids and antibiotics (usually penicillin). Periodic follow-up is needed to check for scarring and adhesions.

Sedatives for Dental Procedures

To be used in anxious patients such as those who are phobic to needles, or in children.

Use diazepam 5-30mg 0.5-1 hour before procedure. This can also be given in divided doses such as 5mg nocte, 5mg in the morning and 5mg at 0.5-1 hour before dental procedure.

In children, diazepam 2mg (or according to age), is given either orally, IMI or PR at 0.5-1 hour before the procedure

OR

Midazolam 0.1mg/kg orally, SC, IMI or IV

TOOTH AVULSION

One of the commonest sequelae of facial trauma is tooth avulsion, exfoliation or articulation. Salient features

•        History of fall, interpersonal violence, sports injury, assault or accident.

•        Children are more common.

•        Central incisors and developing teeth are more frequently avulsed.

•        Patient presents extreme pain with a bleeding socket, clot in the socket and a raw wound with or without Lip & Labial mucosa injury.

Treatment

Immediately refer to a dentist. Best result is observed if tooth is reimplanted within 5-20 minutes.  Fixation of implanted tooth with periodontal wiring, arch bar wiring or composite resin; fixation period 6 to 8 weeks; root canal treatment done after reimplantation only (to avoid desiccation of periodontal ligament).

Interim storage

Best method is to place back the tooth in the socket immediately. Other storage media are saliva, milk (placed in ice since this minimizes the adverse effects on the periodontal ligament) and saline.

Pharmacological treatment

Cap. amoxycillin 250-500 mg 3 times a day for 5 days Or Tab. ciprofloxacin 250- 500 mg twice a day for 5 days.

Tab. diclofenac Potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times for 3-5 days.

DENTAL CARIES

This is a multifactorial infectious disease of hard tissues of teeth characterized by demineralization of inorganic and destruction of organic part of the tooth. (Enamel & Dentin)

Salient features

•        Usually asymptomatic in early stages.

•        Patient presents with tooth sensitivity and tooth ache only on cold & sweet intakes which may disappear on removal of stimuli.

Treatment

•        Examine for stage of caries and treat accordingly.

•        Careful assessment of oral cavity for presence of any white/ brown or black spot.

Non-pharmacological treatment

•        In non-cavitated lesion and low risk patient with good oral hygiene practices, no treatment is given.

•        In cavitated lesion, restoration is done. Pharmacological treatment

·       Patients with caries is likely to progress (in high risk patient) pit and fissure sealant.

•        Mouth wash with 0.2% chlorhexidine twice a day.

•        Advise fluorinated toothpaste or fluorinated mouthwashes.

Assessment of response to therapy

•        For caries active patient - follow up visit every 3 months and to check the progression of white / brown or black spot on the teeth.

•        For normal patients - follow up every 6 months to 1 year to check the development of the white spot cavitation.

Patient education/prevention

•        For caries active/high risk patient preferably.

•        Diet control and avoidance of sugar containing food.

•        Frequent ingestion of food containing sucrose should be substituted by sugar free foods.

•        Oral hygiene: (a) brushing of teeth twice a day (b) flossing (c) thorough rinsing after every meal.

•        Fluoride application using Topical 2% sodium fluoride (by dentist) 4 applications at weekly intervals at the age of 3, 7, 11 and 13 years.

•        0.05% sodium fluoride daily rinse (should not be swallowed).

•        0.2% sodium fluoride supervised weekly rinse in school (age of children

>7 years) only if these children have been identified as caries active patients.

DENTAL ABSCESS

Patient presents with pain and swelling. The most common types of dental abscesses are periapical abscess and lateral periodontal abscess.

I.  PERIAPICAL ABSCESS

Salient features

•            Presence of caries or trauma. Severe throbbing pain, disturbed sleep

•            Tooth is tender to touch & extruded from socket. Tooth may be mobile and associated with localized or diffuse swelling.

Immediate treatment

•            To give antibiotics as given below and refer to a dentist.

Pharmacological treatment

•            Cap. amoxycillin 250 -500 mg 3 times a day for 5 days. Or Tab. Ciprofloxacin 250-500 mg two times a day for 5 days.

•            Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times a day for 3-5

•            days.

Surgical treatment

•            Drainage of pus by entering the pulp chamber (pulpectomy) & relieve occlusion.

•            If fluctuant swelling of soft tissue is present drain by incision.

•            Extraction or root canal treatment should be done when acute symptoms subside.

•            Spread of infection should be closely observed to prevent complications like Ludwig's angina or osteomyelitis.

Patient education

•            Maintenance of oral hygiene.

•            Control of diabetes mellitus, if present.

•            No hot fomentation over the skin.

II.  LATERAL PERIDONTAL ABSCESS

Salient features

•            Same as in acute periapical abscess, often associated with bad taste.

•            Tooth is usually mobile and tender on percussion, associated with localized or diffuse swelling of the adjacent periodontium.

•            Vitality test usually positive if no associated pulpal problem.

•            Radiograph shows vertical or horizontal bone loss in relation to the tooth.

•​

Pharmacological treatment

•            Cap. amoxycillin 250-500 mg 3 times a day for 5 days.

•            Tab. metronidazole 400 mg 3 times a day for 5 days.

•            Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times/day for 3-5 days.

Surgical treatment

•            Debridement of pocket and drainage of pus and irrigation with chlorhexidine.

•            Spread of infection to be closely observed to prevent complications like Ludwig's angina.

Patient education

•            Maintenance of oral hygiene.

•            No hot fomentation over the skin.

•            Control of diabetes mellitus if present.

ADULT TYPE PERIODONTITIS

Most common dental disease of the gums & periodontium. Salient features

•            Swollen gums, bleeding from gums either spontaneously or while brushing.

•            Pain on eating something hard, difficulty in chewing food, dull pain in the gums, pus discharge from gum on pressing, loosening of teeth, recession of gums.

•            There is slowly progressive destruction of periodontitum, loss of periodontal attachment and presence of periodontal pocket.

•            Bad breath (Halitosis), sensitivity to hot & Cold intakes

Non-pharmacological treatment

•            Refer to a dentist for oral prophylaxis in form of thorough scaling and root planning.

•            Advise brushing twice daily once after breakfast and once after dinner with super soft tooth brush for at least 3 minutes.

Pharmacological treatment Local therapy

•            Advise antiplaque toothpast containing antibiotics.

•            Gel metronidazole to be massaged on the gums twice daily.

•            Rinsing with 0.2% chlorhexidine mouthwash twice daily which is effective after scaling.

Systemic therapy

•            In adults, Cap. tetracycline 250 mg 4 times a day for 5-7 days.

•            In very deep pockets: Combination of drugs i.e., Tab. ciprofloxacin 500 mg twice daily & Tab. tinidazole 300 mg twice daily for 5-7 days.

•            Recheck the depth of periodontal pockets, if it persists, refer to dentist for further management.

JUVENILE PERIODONTITIS

It is characterized by rapid destruction of periodontal tissues. Salient features

•            Common in the age group of 13-25 years.

•            Mobility in incisors and molars, spacing in upper incisors, distolabial migration of upper incisors, arc shaped bone loss extending from distal surface of second premolar to mesial surface of second molar.

Pharmacological treatment

•            Cap. tetracycline 250 mg 4 times a day for 14 days.

Surgical treatment

•            Extraction of badly involved teeth. Refer the patient to periodontist for further periodontical management at the earlies

•            Patient education

•            Proper brushing twice daily with super soft tooth brush.

INFLAMMATORY GINGIVAL ENLARGEMENTS

The gingival enlargement can be acute which is very painful or they can be chronic which may be painless. There are many causes for gingival enlargements. Before giving treatment, etiological factor must be evaluated.

Salient features

•            Acute enlargements may be localized or generalized, very painful, deep red in color, soft friable with shiny surface.

•            Chronic type may be localized or generalized, often painless and slowly progressive.

Pharmacological treatment

•            Tab. ciprofloxacin 500 mg 2 times a day for 3-5 days.

•            Tab. diclofenac potassium 50 mg b.d. or Tab. ibuprofen 400 mg 3 times a day for 3-5 days.

•            Rinsing with 0.2% chlorhexidine mouthwash twice daily.

•            Refer to a periodontist for surgical management and drainage of pus.

Patient education

•                     Proper brushing twice daily with super soft tooth brush.

DENTAL FLUOROSIS

Salient features

•                     Mainly seen in patients who are drinking fluorinated water (> 3PPM) during tooth development time.

•            White chalky/ brown spots on crowns of teeth

•            Brownish discoloration on enamel mainly, involves anterior teeth & first molars

Treatment

•            Oral hygiene maintainance as patients are more caries susceptible

•            Bleaching of teeth (Whitening of teeth)

•            Veneers or laminates for better esthetics

TRIGEMINAL NEURALGIA

It is sudden, sharp, severe or short duration, like electric shock like pain. Salient features

•            Presence of trigger zones involving trigeminal nerve areas

•            Unilateral sharp, shooting, lancinating type of pain may provoke on touch, washing face, shaving, on cold wind exposure.

•            Pain will be in recurrent bouts of attacks, may persist for second to minute

Treatment

•            Diagnostic dose of carbamazepine given to establish diagnosis

•            Evaluation of any primary lesion in brain by MRI

•            Tab. carbamazepine 200 mg. t.d.s as per intensity & frequency of pain & attacks.

•            Refer to Dentists for further evaluation & treatment.

ORAL CANCER (HABIT RELATED DISEASE)

Oral cancer is most common and associated with smoking and tobacco containing habit. Adults are more commonly involved. Salient features

•            Long standing (> 2 weeks) non-healing chronic ulcer in oral cavity.

•            Bleeding & non painful ulcer or growth

•            Regional lymphadenopathy, mobility or exfoliation of teeth.

•            Decreased appetite, reduced weight, Poor Oral Hygiene, history of tobacco habit since long time. Altered speech, difficulty in opening of mouth (Trismus)

Treatment

•            Refer to Oncologist after thorough clinical and histopathological examination.

•            Advice symptomatic treatment if required.

ORAL SUBMUCUS FIBROSIS (OSMF)

Salient features

•            Most common disease related with tobacco, lime and Betelnut

•            Gradually reduced mouth opening (Trismus)

•            Blanching (White opaque) oral mucosa

•            Recurrent ulcers & burning sensations on taking spicy food.

•            Change of voice, difficulty in deglutition.

•            Poor oral hygiene with gingivitis & periodontitis

•            Small shrunken uvula and decreased mobility of soft palate

Treatment

•            Quit habit as soon as possible, mouth opening exercises (physical exercises)

•            Oral Hygiene prophylaxis

•            Local medicaments in form of steroids

CYST OR TUMOR OF JAW

Salient features

•            Facial asymmetry, Non tender swelling or growth, Paresthesia of jaw

•            Displacement of teeth, improper occlusion

•            May be having discharge, Discoloration of teeth, Absence of teeth in arch

Treatment

Refer to oral maxilla facial surgeon for bone fractures

GENERAL MEASURES FOR GOOD ORAL HYGIENE

Select the right quality of tooth brush which should be short, soft and have uniformly trimmed bristles. Change the brush at least after every 3 months

Brush teeth at least twice a day for 2-3 minutes particularly at night before going to sleep. Use right technique of teeth brushing. Never use force while brushing. Use flossing at least once a day.

Avoid too much sugar and aerated drinks.

Avoid eating in between meals, if cannot be avoided rinse your mouth or preferably brush your teeth. Do not ingest or swallow fluorinated toothpaste while brushing.

Ensure regular dental checkup at 6 monthly interval.

ANTIBIOTIC PROPHYLAXIS IN DENTAL PROCEDURE

If patient is in the high or moderate risk groups, then antibiotic prophylaxis is recommended for the following dental procedures:

Dental extractions.

Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance.

Dental implant placement and reimplantation of avulsed teeth. Endodontic (root canal) instrumentation or surgery only beyond the apex. Sub gingival placement of antibiotic fibers or strips.

Prophylactic cleaning of teeth or implants where bleeding is anticipated. Antibiotic prophylaxis not recommended for the following dental procedures Restorative dentistry (operative and prosthodontic) with or without retraction cord. Local anesthetic injections (nonintraligamentary).

Intracanal endodontic treatment; postplacement and buildup.

Placement of rubber dams, postoperative suture removal, taking of oral impressions, and fluoride treatments.

Placement of removable prosthodontic or orthodontic appliances and orthodontic appliance adjustment.

Taking of oral radiographs. Shedding of primary teeth.

Management of potentially premalignant oral epithelial lesions

oral premalignant lesion is defined as any lesion or condition of the oral mucosa that has the potential for malignant transformation. A new term potentially premalignant oral epithelial lesions (PPOELs) has recently been used as a broad term to define both histologic and clinical lesions that have malignant potential

This encompasses a number of oral lesions, such as

·       leukoplakia

·       erythroplakia

·       erythroleukoplakia

·       lichen planus

·       oral submucous fibrosis (OSF)

·       oral dysplasia

DETECTION AND DIAGNOSIS

To date, there have been no reliable and validated in vivo chairside adjuncts that have sufficient sensitivity and specificity to be more superior than clinical examination and tissue biopsy

Adjunctive aids include:

·       photodynamic detection- including autofluorescence

·       vital staining (toluidine blue, Lugol’s iodine),

·       and brush cytology.

TREATMENT PPOELs

can be managed conservatively by observation alone.

Surgical excision is the invasive management of choice for this group of lesions- include

·       traditional excision,

·       cryosurgery,

·       and carbon dioxide (CO2) laser ablation.

Nonsurgical treatment

falls into the category of chemoprevention or observation.

·       Chemoprevention is the use of naturally or synthetically fabricated compounds designed to halt malignant transformation of PPOELs.

·       they may cause regression or eradication of PPOELs and increase the threshold of malignant transformation.

·       It uses the same concept of field cancerization but for treatment purposes