Dental Chronicles

[Mrsmorton]

I have noticed a number all of the dental related questions on MN get repeated once a month or so; this may be entirely unwelcome but what I intend to do is to make a series of detailed posts answering the most common questions so that I can signpost posters to an answer. Often they disappear in chat and then resurface.

I am a dentist (that's no secret on here) but I have no way of proving my qualifications and neither do I feel the need to. I hope that this will be of some assistance to someone at some point!!

[Mrsmorton]

When should my child see the dentist?

Opinion on this varies between dentists, HVs and other dentists.

It's a good idea to get children used to the dentist and the environment so that it doesn't become a "thing" when they grow up. This means attending with mum or dad (or GPs or CM) for routine check ups, even when the child is not having a check up themselves.

Doing things like getting the child to open their mouth for people who aren't their routine carers is a good way of preparing them for the dentist having a look. Friends and relatives visiting the house are great audiences for this.

It's ideal for a child to be seeing the dentist for "teeth counting" from about 2.5-3 years of age. Advanced decay can often be found in 4 year olds so it's really important to identify it quickly and put preventative measures into place to prevent things worsening. Also, if a child is used to opening their mouth, it's much more likely that if they do have problem, it can be easily looked at and maybe even treated without the need to go under a GA.

[Mrsmorton]

Toothpaste.

The key ingredient in toothpaste is Fluoride. Rafts and rafts of high quality evidence exist to back this up. What is important is that it spends time in contact with the tooth.
I analogise this to my patients as like putting sunscreen on. You wouldn't put sunscreen on and then vigorously wash it off with an expensive shower gel. Toothpaste is the same so to brush your teeth and then swill for however long with overpriced and under effective mouthwash is no good at all.
Spit don't rinse is the mantra.

This is especially important at night when the mouth dries and the protective saliva can't get rid of the bacteria so well. Spit don't rinse. You will get used to it. The fluoride has a topical effect on the tooth once the tooth has erupted (sort of like hair conditioner).

Fluoride and calcium are used in the production of tooth enamel when the teeth are forming so essentially, diet, illness and medication before the age of about 7 can affect the development of teeth. After the age of 7, no matter what antibiotics you have or how many times you get pregnant, that calcium and fluoride is not affected by medication, illness or pregnancy. It is only affected by diet, acid (and trauma).

Tooth decay.

The only thing that causes tooth decay is fermentable carbohydrates, e.g. sugar. This is digested by the bacteria that live on the teeth and attacks the enamel. Some enamel doesn't form properly and isn't as resistant to this attack and some saliva is better than others but still, without the sugar, the decay simply wouldn't happen.

After eating something with sugar in, your mouth becomes very acidic and your teeth start to become vulnerable. Your saliva removes the acid after approximately 45min (depending on the individual) and the teeth are fine.

If sugar is kept to meal times (three times a day) then the mouth is only acidic for maximum of three hours. This is not sufficient to cause decay. If sugar is eaten more frequently then the mouth is continuously acidic and the teeth are constantly vulnerable, leading to decay and fillings or toothache.

Removing the bacteria with good brushing can reduce decay but we can never get rid of all of the bacteria so reducing the frequency of sugar is key to prevention.

Some of my patients have additional dietary needs and we can work with them to provide additional fluoride based products that can be used during the day as well as xylitol and other preventive measures to reduce the chance of decay. This seems to work well.

Other patients have sensory issues which mean toothbrushing is very challenging, again we have medicaments, tips and tricks to surmount this, including the use of non foaming toothpastes, swabs rather than brushes and gels.

[DenturesMightBeTheWayToGo]

Hello? Am I allowed to post you a question? Thank you.

[Mrsmorton]

Yes of course. I'm just writing a post about toothache...

[DenturesMightBeTheWayToGo]

Thank you...
Hello Mrsmorton. As you are a dentist I'd like to ask your advice. I had a fixed top brace (at my normal private dentist surgery but with their orthodontist). Complete vanity on my part (a little bit of overlapping with front 4 teeth). My dentist and hygenist said it was a good idea - although unnecessary. So I saw the brace man. All well. Was on for over a year. Once off within 2 months I had 2 wobbly top teeth - one so wobbly that it was bleeding and almost ready to fall out. So wobbly infact, that I now have to wear a plastic retainer all the time or they will fall out, the fixed brace has been re-fitted on the outside of my top teeth (I have new plastic retainers to fit over the top), but keeps breaking and doesn't 'hold' the wobbly teeth properly. My proper dentist keeps saying I have gum disease - but I didn't before the fixed brace.
So, I now keep having to pay dentist for appointments for 'gum disease' that I never previously had - the treatment is painful - and expensive. And, although paid a fixed price for the original brace (£2,000 for the duration with no extras, included all appointments etc), am now having to pay the orthodontist for every extra appointment and all the extra brace fitting and retainers.
I am miserable, have 2 wobbly teeth, and my teeth are not straight like promised. I have to think about what I am eating. Top teeth are so important when eating!
I wish I'd been happy with my wonky teeth. I am over 40. Not had a filling for about 20 years. My teeth are looked after! Do I go to another dentist for a second opinion - not so much about the wonky/wobbly teeth, but more about the sudden gum disease? I feel they are covering themselves - giving me gum disease gives them an excuse? Could I be wrong? Thank you and apologies it's so long.

[Mrsmorton]

I will pm you shortly, that sounds like a complex issue.

[AnnieMorel]

Really useful, MrsM.

Yes, can we ask questions?

[Mrsmorton]

Yes, fire away.

[Mrsmorton]

Toothache.

I do a lot of NHS OOH sessions. The provision is pretty poor and it's threatening to get worse. The three most common diagnoses I make are Pulpitis, periodontitis and pericoronitis.

Pulpitis is, I think, the worst dental pain a person can be in. There are two sorts but the most common sort is what I will talk about here.
It is characterised by constant, dull throbbing pain, exacerbated by heat and laying down and relieved only slightly by painkillers, cold water and elevating the head.

The tooth is made of three layers, the hard and insensitive enamel, the softer and sensitive dentine, and inside is a nerve and blood vessels, what is called the pulp. The nerve helps us to feel temperature with our teeth but it is not the blood supply to the tooth, it just lives inside there like a crab inside its shell.

Pulpitis is caused by a deep cavity in the tooth (either filled or unfilled) which has touched or gone close to the pulp. When we fill a tooth, sometimes the decay will go close to the pulp and we usually try to avoid going into the pulp "chamber" which is where the nerve and blood vessels live. The pulp becomes inflamed, sometimes only for a short while and then it settles, sometimes it doesn't settle and it tries to swell (like anything that's inflamed does) and it begins to die (becomes necrotic, sort of rotting). Heat makes it worse as it's inflamed and hot already, cold helps because it cools the inflamed nerve.

The standard MN answer to toothache is antibiotics but the problem with pulpitis is that the blood supply to the tooth isn't working properly (which is why painkillers don't work), and there is often no actual infection (just inflammation). What needs to be done is to remove the top of the pulp chamber (by drilling out the filling or decay) and get rid of the dead or dying nerve. We then put some antibacterial paste inside the tooth and a temporary filling.

What follows then is either a root canal treatment or an extraction based on your preference and the prognosis of the tooth. Pulpitis is often not visible on x rays. It can also be caused by trauma affecting the blood supply to the tooth and by cracks within the tooth allowing bacteria to penetrate through the dentine into the nerve.

When a tooth has spent a long long time dying, it often skips this stage and causes an abscess, these are much less common but involve a frank infection around the tooth which can often be seen on an x ray. The best treatment of these is either to open the tooth by drilling out the filling or decay, or to remove the tooth all together. Sometimes swelling makes this difficult so antibiotics are used to control this before treatment is done...

[AnnieMorel]

I need an implant

My dentist charges £2500.

However I saw a Groupon offer for an implant centre in Harley St that does them for £1195, iirc. From their website, it all looks good - well qualified dentists with loads of implant experience and good reviews (not surprising!) and a fully inclusive package including aftercare.

My cousin is friends with her dentist and he did her implant recently for 'cost', meaning it only cost her £300, so my £2500 seems relatively obscene in comparison!

I don't feel particularly obliged to use my dentist as the cost is so high and he wouldn't be doing it anyway - it would be done by the oral surgeon that goes in.

Anyway - would you warn against these clinics that offer cheaper implants?

[Mrsmorton]

An implant at cost is more than £300. Just the actual time (surgery rent) and raw materials would be more than that so I would take that with a pinch of salt tbh. It may be true but I am highly suspicious.

Harley Street is not a qualification, it is an address- like may prestigious London medical addresses, the actual provision of care can be below average.

I have nurses working for me who have worked briefly at Harley St clinics and left because they wouldn't compromise their standards. There is a reason they are cheaper, it may be because they do so many, they can get bulk discounts but I remain to be convinced.

What qualifications does the Harley Street dentist have? Implant specialist is not a bone fide specialty btw. If I was having an implant placed I would look for a specialist (on the GDC register) in oral surgery or restorative dentistry. I think some periodontists do implants as well but I can't remember seeing any recently.

[Mrsmorton]

Oh, and ethical dentists don't sell their wares on discount websites, it just doesn't happen.

can you tell I have issues with these charlatans

[AnnieMorel]

Thanks! You have confirmed some of my doubts.

This is the place.

2 of them are 'master implantologists', is that a qualification?

[Mrsmorton]

Not in the UK.

[Mrsmorton]

Pericoronitis is the posh word for wisdom teeth infections. Lots of myths surround wisdom teeth!!

I have had all of mine taken out (done whilst I was a dental student) under local anaesthetic but by an oral surgeon as the lower two were impacted.

Wisdom teeth, third molars or 8's as they are known usually erupt between 18-23years, they often arrive later but not usually earlier. They are the last tooth in the arch (although some people have 9's!) and are the most commonly congenitally missing tooth. They start to develop in the jaw at around 9-10years

In the olden days, when our diet consisted of bread with stones in, and there was no dental care available to people, by the time we got to the age of 20, we had almost certainly lost one or more of our other molars and the wisdom teeth would have space to erupt, thus helping us chew our food for another 15 years or so.

Now, most people retain their molar teeth, perhaps due to the availability of dental care (perhaps!) or better education and a more refined diet. All through your teens, your Wisdom teeth are brewing around in the jaw bone and when (as is their destiny) the time arrives for them to erupt, there isn't enough room for them to fully grow through.

When they cant erupt, this is called impaction. Wisdom teeth can be impacted into bone, soft tissue or tooth, or a combination of these three. If it's impacted into bone, this means a bit of jaw bone at the back is covering the tooth (or part of it) thus preventing eruption. This is usually associated with soft tissue impaction-the annoying flappy bit of gum over the tooth that is called "operculum". If the tooth is impacted into tooth, this usually means it is pushing into the back of the second molar or tooth 7.

When teeth erupt normally, the "epithelium" of your gum seals the tooth off, this means the bacteria in your mouth cannot get down the root of the tooth. If the wisdom tooth is partially erupted, part of the tooth may be poking through the gum. This means the gum isnt sealed off corectly and bacteria can flood around the rest of the tooth-think of the erupted bit of tooth as the tip of the iceberg.
It is impossible to stop the bacteria getting around the tooth like that, although keeping things as clean as possible will definitely help, and antibiotics are a brilliant treatment. Because the infection is living without Oxygen, it is termed anaerobic and metronidazole is a great treatment for anaerobic infections. You must never ever drink alcohol whilst taking Metronidazole though. It has an antabuse effect (google it) and will make you poorly poorly!

Just to make matters even more exciting, there is a nerve in your jaw called the Inferior Dental Nerve (sometimes Inferior Alveolar Nerve) that supplies sensation to your lip. Add to that the Lingual Nerve (which comes from the same branch of the trigeminal nerve as the ID nerve) which runs along the inside of your jawbone and supplies sensation to your tongue. The roots of your wisdom teeth can often lie very close or even wrap round, your ID nerve. The lingual nerve is basically between your wisdom tooth and your tongue (but tucked into the skin there!).

This all makes for a very complicated procedure if the wisdom tooth needs extraction. There's not much room back there!

The position and orientation of the tooth, along with the position of the ID nerve (which can be seen on an x-ray) and patient factors such as nervousness, mouth opening, support available etc etc, are things that your dentist will take into account when deciding whether or not she shoudl take the tooth out or refer you to hospital.

Sometimes, a large part of the problem can be caused by the top wisdom tooth (these normally erupt ok, maybe a little bit outside towards your cheek) chewing on the operculum (the flappy bit of gum). This can be really painful and simply taking the top one out can relieve the problems enormously. Taking top wisdom teeth out is easy peasy in 99.9% of cases and if this will fix you, it's much much better to have this done than to get the bottom ones done if they don't need to be done.

When it comes to extracting the bottom ones, it's something all dentists (certainly in the UK) are trained to do. It's something we try to avoid in General Practice though-it's not a great practice builder, unless you have an oral surgeon on site. I always think if I do it, my patients will think I'm horrid, I'd much rather they came back to me and said "that oral surgeon is horrid" and I can give them sympathy!

Aside from the issues with the nerves that I mentioned earlier, one issue with wisdom teeth (and the thing that makes them sore afterwards) is bone removal. The bone that is covering the tooth and quite possibly a significant amount more will need removing. This takes a while to heal and is painful afterwards. Also remember that you'll have your mouth open for quite some time so that will be sore in the morning too.

Having said that, I'm delighted to have had mine out, the bad taste I had from them having chronic infection has gone, I can open my mouth wider than before and I don't get ear ache anymore. Perfect.

There are pretty strict guidelines that must be met before you can have your wisdom teeth taken out, unfortunately you can't have it done prophylactically so even if I know that a patient will have problems, I can't send him to have his 8's out until he has been to see me with acute problems twice in any 12 months, there is gross decay in the 8 or it is causing decay in the 7 (tooth in front), it is involved in an area that is being operated on for cancer, it needs to be taken out to repair a fracture or there is a cyst or abscess.

(I wrote this for a different website a few years ago)

[GrannyGoggles]

Mrsmorton are you willing to PM? I would be v grateful for impartial input and insight in to an ongoing issue

[Mrsmorton]

Yes no problem at all but I'm going to bed now so I'll look at it tomorrow

[gingeroots]

Great thread Mrsmorton . You should get a grant for it .Seriously .

Ok here's my shameful question ,no criticism please .

Following an oesphagectomy I've developed a boiled sweet habit . I have to wean myself off this . While I'm doing so what can I do to reduce damage to my teeth ? Brush after sucking a sweet ? Use Flourigard mouthwash ?

I also have a very dry mouth 24 hours a day .

TIA

[GaryShitpeas]

Ooh u have questions !!

I have a missing tooth right at the back, would you recommend an implant? As it really bothers me but I'm scared of the cost tbh. And the pain.

And also do you believe in the benefits of oil pulling (in terms of teeth whiteness and gum health) as I've been doing it a year or so and I'm sure there's a difference! (Could just be wishful thinking tho!)

[Mrsmorton]

ginger Id recommend sugar free sweets! Xylitol has great anti cavity properties.

You can get artificial saliva, have you spoken to your dentist about it at all? Chewing gum and fluoriguard are also your friends.

[Mrsmorton]

gary no, I wouldn't recommend implants for back teeth. No real benefit for cost in my opinion.

Oil pulling is, IMO pointless. If you did the same with water you would achieve the same results.
If you've a spare 20 min or whatever to use on your oral health, get flossing!!

I'm working on a gum disease post next, any other hot topics anyone would like?

[Gobbolinothewitchscat]

mrsmorton - this is fantastic. My DH is a dentist and for what it is worth! thinks you are doing a great service setting all of this stuff out so clearly and helpfully.

he also agrees with you re: out of hours provision

[gingeroots]

Thanks MrsM .

Expain about the Floriguard and chewing gum ? When to use ?

I can't tolerate sugar free stuff ,surgery has affected my digestive system ,cut vagus nerve ,removed half of stomach ,repositioned what remains to form new oesphagus . Digestion all confused ,get severe cramps with sugar free stuff .

Shall ask about artificial saliva .

[gingeroots]

Is it really better to use electric toothbrushes ? Not really possible to achieve same effect with manual ?

Is it ok to brush teeth frequently in day ? Or is it bad for enamel ?

[Mrsmorton]

You can brush just as well with a manual brush it's just most of them are too big and most of us are too lazy.
ginger read what I posted about saliva, it neutralises the bacteria that produce the stuff that attacks teeth. Chewing gum stimulates saliva production (if you can produce any) so shortens the amount of time that teeth are under attack for.

Fluoriguard helps to remineralise teeth that have been affected by the acid (from sugar/bacteria) so using it midway between brushing is helpful especially if your saliva rate is low.

Tbh, if you've been thru all of that, I'd expect you to be seeing someone to help your teeth. If your dentist doesn't help or doesn't know, ask for a referral to oral medicine. Especially to help with saliva.