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!!

ok ,thanks ,that's very helpful .

yeah I really have been through all that

now I know you know dental provision is not good and joined up thinking is a pipe dream ,so though I've seen a dentist since my surgery I've had no advice . Perhaps he thought my teeth were ok .

Anyway I'll go with the chewing gum and Fluriguard .

Thanks again - you're doing a good thing here ,hope you don't get inundated .

MrsMorton you are saintly and wise.

looking forward to the gum disease / bleeding gums advice, both me and dh have this. dh says our dentist ( a nice person) said to brush very hard and bleeding is good. Is that so? Because he's still brushing hard and nothing seems to improve. And should we just buy Corsodyl?

Thanks for all this - marvellous idea.

Bonzo

Sooo, gums. My least favourite bit of dentistry but arguably the most important... you wouldn't put a roof on a burning house so they say, meaning unless the gums are healthy, it doesn't matter what you do to the tooth.

I'm not sure where to start so bear with me.

The teeth sit in a special type of bone called "alveolar bone", the sole purpose of this bone is to hold your teeth in. If there were no teeth, we would just have the jaw bone and this is why, if a tooth is removed, the bone will resorb as there is no longer any need for it. They are held in place by the periodontal ligament in a special sort of joint called a "gomphosis". On top of this you have the gum which sits around the tooth and seals off the tooth (and the mouth) from the bone.

The gum around the tooth creates a sort of cuff, usually about 1mm deep. This is called the gingival crevice, it constantly leaks fluid which is why placing fillings under the gum can be hard, it's impossible to stick stuff there as it's always a bit damp.

Over the course of the day or night, plaque bacteria (that live in the mouth constantly) sit in the gingival crevice and carry out their routine business of secreting bacterial toxins, multiplying and creating something called a biofilm. The effect of all of this on your gums is to cause "micro ulcers" in the gingival crevice. The gums become red and sore and they bleed when you brush (or eat etc) because the ulcers are being rubbed. This is gingivitis and it can form pretty quickly, within 24-48 hours.

The best remedy for gingivitis is a really good clean, with a toothbrush. This will remove the plaque from the gingival crevice and allow the gums to heal. Our default reaction when something is sore and bleeding though is to steer clear of it, this is completely the wrong thing to do with gingivitis, get amongst it with a really good clean and it will almost certainly resolve within 12-24 hours.

The reason mouthwash isn't especially effective is twofold. Firstly, imagine the gingival crevice as the line around a shoe, where the shoe joins the sole. If you walk around a muddy field and want to clean said who, just sloshing a bucket of water over it will probably make a little difference but it's not going to pass close inspection. The mud will have washed off the smooth bits but it's probably still stuck in the awkward bit between the shoe and the sole. You need to get n there with a brush and manually scrub away at any left over muddy bits.
The second reason is the biofilm , essentially this is where bacteria have one over on us. Biofilms are everywhere, notably in pipes and tubes. We use chemicals to try to get rid of them but a biofilm is an impenetrable mass of bacteria, protein and slime. Chemicals (like mouthwash) are entirely useless. The only thing that can remove a biofilm in the gingival crevice is manual cleaning. With a toothbrush.

If you brush effectively twice a day, your gums shouldn't bleed. If they do then you shouldn't just go and buy corsodyl, you should see the dentist who will hopefully send you to a hygienist because they are amazing at spotting what you're not doing and remedying it. They may be pricey but they are cheaper than new teeth!

More to come on gums, I'm just going to have my supper.

My wisdom tooth stinks but causes me no pain? Does it need to come out? If not how can I stop the smell

It's possible there is chronic "subclinical" infection. Have you asked your dentist about it? It's also possible it could be decaying...

I'm going to the dentist on Tuesday so will see them! Terrified of having it pulled

Jumping on here. Have had a week of dentist and hygienist, hasn't been bad considering the amount of time, but has piqued my interest in all things dental.

Thank you MrsMorton, you're truly a gem

Could you tell us the benefits of a water flosser vs manual dental floss, if there are any?

I'm not interested enough in either of them to tell you but I promise I will ask my hygienist on Monday and let you know what she says! I wasn't joking when I said I hate gums...

You're a star for this btw.

Is there any incentive to create work to do ie after a check up? Or is it more likely if a dentist says you need to get something done, they will only say it if you do? eg a filling.

So, once plaque has been on the teeth for a while (a few days, some papers say 12 days), it begins to mineralise. Saliva has lots of minerals in it and they sort of seed into the plaque to create a very hard structure called calculus (or tartar).

This calculus is so tightly bound to the teeth that it can't be cleaned off with a brush, it has to be either manually scraped off the teeth or cleaned off using ultrasonic energy. This is called scaling and is what the hygienist does thankfully. Calculus is entirely preventable by good oral hygiene methods, some teeth are more difficult to keep clean (if they are very crowded or rotated for example) and some people are "rapid calculus formers" which means they form this hard stuff more quickly than everyone else. Still, no one forms it in 24 hours though so brushing twice a day is fine.

Once the calculus has formed, it presents a porous and rough surface so bacteria find it easier to colonise as well as the fact that it has created a ledge on the tooth under which bacteria can hide. This can often be the beginning of more severe gum disease.

Gums become inflamed very quickly, they are sensitive souls. If this calculus forms and the bacteria are hanging around for long periods of time (months) the gums remain inflamed but the alveolar bone (that holds the teeth in) starts to resorb and we get "bone loss".

Bone loss is a normal physiological occurrence at a fairly slow rate, hence we become long in the tooth. Poor oral hygiene and the accumulation of plaque and calculus make it move a great deal more quickly.

Once the bone started to resorb, "pockets" will develop. This is where the attachment of the gum to the tooth has started to follow the bone but the top of the gum remains in place as it is inflamed. I've attached a picture hopefully.

We know that just normal brushing actually cleans below the gum line and will do so for about 4-5mm so that's not too bad. Once the pocket is deeper than that though, normal brushing can't clean it. The dreaded biofilm develops and things can get worse, more bone resorption and eventual loose teeth.

Once the teeth have reached this stage, management by a dentist/hygienist is crucial. The bone loss is generally not reversible but it can be stopped and loose teeth can become firm again.

marsha. An NHS contract is worth a fixed amount of money. Let's say the PCT pay dentist X £100,000 for providing Z units of care every year. If he provides too many units of care then he will be doing it for free (out of his own pocket). If he doesn't provide enough then the PCT want their money back.

It's up to the dentist to spread the care throughout the year but it is a very difficult line to walk! You can't tell how many people will need dentures or fillings every year. Some people will need 10 fillings- the dentist will get paid the same if they only need one so most dentists see it as swings and roundabouts, for every patient who needs ten, you may have one patient who needs a tiny filling that takes a few minutes.

I don't know any dentists who tout unnecessary work but I'm sure they exist.

Sorry, my NHS contract paragraph was meant to illustrate that it doesn't make masses of financial sense to find extra work as there will definitely be someone along soon who unquestionably needs the work doing!

Cool thanks. I was the one tiny filling person, but I'm glad there's no incentive. It's a very busy surgery by the looks of it in any case.

Thank you mrs Morton for such a great thread.

Can gingivitis be hereditary? My MIL drives me bonkers saying she has no control over it when I'm sure it's just good hygiene

Ah, well you must be doing something right then!

Also, just to clarify, the contract value includes everything, rent, salaries, equipment, insurance, materials. It's not just "pay". The patient contribution (£18.50 or £50.50 etc) is part of that contract value, not additional to it.

Just marking my place to read later

Periodontal disease (which is where you get the bone loss etc) does have some hereditary factors. Race also plays a significant role with afro caribbean men being particularly unfortunate. That said, without the bacteria and the biofilm... it wouldn't happen.

There are lots of risk factors including things like smoking, general health (diabetes especially), stress, hormone levels, hereditary factors and so on. The biggest factor is hygiene though.

ooh can you answer my question? i have a sore tooth that using sensodyne toothpaste numbs for a bit. the dentist just says keep an eye on it (it's a crown) but surely it must be something more?

Thank you :)

southeast that is truly a piece of string question! It's really impossible to say without lots more information.

Ultimately though, you are the "consumer". If you're happy with numbing it with sensodyne then that's relatively cheap and easy. If you are fed up of it and want something done then that is what you must ask for.

One of the primary ethical principles is "do no harm" and dental litigation is higher in the UK than anywhere else in the world, we are a risk averse profession and by not doing anything, maybe she feels she is less likely to do the wrong thing?

southeast that is truly a piece of string question! It's really impossible to say without lots more information.

Ultimately though, you are the "consumer". If you're happy with numbing it with sensodyne then that's relatively cheap and easy. If you are fed up of it and want something done then that is what you must ask for.

One of the primary ethical principles is "do no harm" and dental litigation is higher in the UK than anywhere else in the world, we are a risk averse profession and by not doing anything, maybe she feels she is less likely to do the wrong thing?

Great thread. Thanks MrsM.

I have a question if that's okay? The gum on one of my teeth seems to be getting lower (hope that makes sense!) What's causing this an d is there anything I can do about it? The tooth is slightly wobbly. Its a lower central incisor if that makes a difference.