Chapter 14: Hygiene-Related Oral Disorders Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Chapter 14:Chapter 14:

Hygiene-Related Oral DisordersHygiene-Related Oral Disorders

Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

22Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

Chapter 14 OutlineChapter 14 Outline

Hygiene-Related Oral DisordersHygiene-Related Oral Disorders Dental cariesDental caries

• PreventionPrevention

GingivitisGingivitis• PreventionPrevention

Tooth hypersensitivityTooth hypersensitivity• PathophysiologyPathophysiology

• TreatmentTreatment


Hygiene-Related Oral DisordersHygiene-Related Oral Disorders

Haveles (p. 174)Haveles (p. 174) Oral disorders are among the most prevalent Oral disorders are among the most prevalent

diseases in American societydiseases in American society Dental disorders result in 7 million days of lost Dental disorders result in 7 million days of lost

work each yearwork each year 50% of Americans require oral health care or 50% of Americans require oral health care or

treatment, and almost 80% have some form of treatment, and almost 80% have some form of periodontal diseaseperiodontal disease

68% of children ages 12 to 17 have experienced 68% of children ages 12 to 17 have experienced tooth decaytooth decay


Dental CariesDental Caries

Haveles (pp.Haveles (pp. 174-175) 174-175) Approximately 20% of the general population Approximately 20% of the general population

has experienced dental carieshas experienced dental caries Dental caries in children has decreased over the Dental caries in children has decreased over the

past decadespast decades The decrease is attributed to fluoridation of public The decrease is attributed to fluoridation of public

water supplies, dentifrices, and mouth rinses, not water supplies, dentifrices, and mouth rinses, not improved oral hygieneimproved oral hygiene

cont’d…cont’d…


Dental CariesDental Caries

Dental caries is considered to be an infectious Dental caries is considered to be an infectious disease that affects the calcified tissue of the disease that affects the calcified tissue of the teethteeth Plaque bacteria generate acid from dietary Plaque bacteria generate acid from dietary

carbohydrates, causing acid demineralization of carbohydrates, causing acid demineralization of tooth enameltooth enamel

Carious lesions start slowly on the enamel Carious lesions start slowly on the enamel surface and initially do not produce clinical surface and initially do not produce clinical symptomssymptoms Once demineralization progresses to dentin, the Once demineralization progresses to dentin, the

destruction proceeds at a much faster pace destruction proceeds at a much faster pace


PreventionPrevention

Haveles (p. 175)Haveles (p. 175) Good dental plaque control is the key to Good dental plaque control is the key to

preventing dental cariespreventing dental caries Reducing the amount and frequency of refined Reducing the amount and frequency of refined

carbohydrates, plaque removal, and fluoride use carbohydrates, plaque removal, and fluoride use can reduce the incidence of dental cariescan reduce the incidence of dental caries

Antiplaque products aid in the mechanical removal Antiplaque products aid in the mechanical removal of plaque and slow or inhibit its buildup on teethof plaque and slow or inhibit its buildup on teeth




Two methods are available to remove plaque Two methods are available to remove plaque from the teeth: mechanical and chemical from the teeth: mechanical and chemical managementmanagement Mechanical methods include brushing and flossingMechanical methods include brushing and flossing Chemical methods include specific drug products Chemical methods include specific drug products

to prevent or remove plaque buildupto prevent or remove plaque buildup


Nonpharmacologic TherapiesNonpharmacologic Therapies

Haveles (p. 175) (Box 14-1)Haveles (p. 175) (Box 14-1) Dietary measuresDietary measures One of the easiest ways to prevent caries is One of the easiest ways to prevent caries is

to avoid highly cariogenic foodsto avoid highly cariogenic foods Foods with higher water content, those that Foods with higher water content, those that

stimulate salivary flow, and foods high in protein stimulate salivary flow, and foods high in protein are less cariogenicare less cariogenic

Proteins in dairy products raise pH levels and can Proteins in dairy products raise pH levels and can inhibit bacterial growthinhibit bacterial growth



Nonpharmacologic TherapiesNonpharmacologic Therapies

Haveles (pp. 175-176) (Boxes 14-2, 14-3)Haveles (pp. 175-176) (Boxes 14-2, 14-3) Mechanical measuresMechanical measures

Toothbrushes, floss, oral irrigating devices, and Toothbrushes, floss, oral irrigating devices, and specialty aids are the primary types of plaque specialty aids are the primary types of plaque removal devicesremoval devices

ToothbrushesToothbrushes• Both manual and electric toothbrushes are available for Both manual and electric toothbrushes are available for

plaque removalplaque removal• The proper frequency and method of brushing vary from The proper frequency and method of brushing vary from

patient to patientpatient to patient Dental flossDental floss

• Interdental plaque removal can help decrease the Interdental plaque removal can help decrease the incidence of proximal caries, gingival inflammation, and incidence of proximal caries, gingival inflammation, and periodontal pocketingperiodontal pocketing


Pharmacologic TherapiesPharmacologic Therapies

Haveles (pp. 175-179)Haveles (pp. 175-179) Pharmacologic management of plaque and Pharmacologic management of plaque and

calculus enhances mechanical removal by calculus enhances mechanical removal by either acting directly on plaque bacteria or by either acting directly on plaque bacteria or by disrupting plaque so that it can be removed disrupting plaque so that it can be removed mechanicallymechanically FluorideFluoride XylitolXylitol ChlorhexidineChlorhexidine


FluorideFluoride

Haveles (pp. 176-179) (Box 14-1)Haveles (pp. 176-179) (Box 14-1) The most commonly used agent to reduce The most commonly used agent to reduce

inflammation and remineralize decalcified inflammation and remineralize decalcified areasareas The type and amount of fluoride that a person The type and amount of fluoride that a person

receives depends on his or her risk for developing receives depends on his or her risk for developing cariescaries• Those with a low risk only require fluoridated dentifricesThose with a low risk only require fluoridated dentifrices

• Patients considered to have a moderate-to-high risk for Patients considered to have a moderate-to-high risk for caries benefit from professionally applied fluoride productscaries benefit from professionally applied fluoride products



FluorideFluoride

Haveles (p. 176)Haveles (p. 176) Mechanism of actionMechanism of action

Fluoride is thought to work by two different meansFluoride is thought to work by two different means• Once incorporated into developing teeth, fluoride Once incorporated into developing teeth, fluoride

systemically reduces the solubility of dental enamel by systemically reduces the solubility of dental enamel by enhancing the development of fluoridated hydroxyapatiteenhancing the development of fluoridated hydroxyapatite

• The second action is thought to occur on the individual The second action is thought to occur on the individual microorganisms in biofilmmicroorganisms in biofilm

Topically applied stannous fluoride (SnF) inhibits bacterial Topically applied stannous fluoride (SnF) inhibits bacterial enzyme systems and alters the acid production that would enzyme systems and alters the acid production that would result in demineralization of tooth structureresult in demineralization of tooth structure



FluorideFluoride

ToxicityToxicity Nausea and vomiting have been reported in Nausea and vomiting have been reported in

children who have swallowed some of their children who have swallowed some of their fluoride treatmentfluoride treatment

Both acute and chronic toxicity can occurBoth acute and chronic toxicity can occur• Acute toxicity is a result of overdose and is a medical Acute toxicity is a result of overdose and is a medical

emergencyemergency

• Chronic toxicity occurs over time and is treated with Chronic toxicity occurs over time and is treated with medical managementmedical management



FluorideFluoride Acute toxicity occurs with a single overdose of Acute toxicity occurs with a single overdose of

fluoridefluoride Signs and symptoms include nausea, vomiting, Signs and symptoms include nausea, vomiting,

diarrhea, intestinal cramping, profuse salivation, black diarrhea, intestinal cramping, profuse salivation, black stools, progressive hypotension, and cardiac stools, progressive hypotension, and cardiac abnormalitiesabnormalities• Death can occur as the result of cardiovascular and respiratory Death can occur as the result of cardiovascular and respiratory

collapse collapse

Immediate treatment is necessary and includes inducing Immediate treatment is necessary and includes inducing vomiting and binding fluoride in the gastrointestinal (GI) vomiting and binding fluoride in the gastrointestinal (GI) tract to prevent systemic absorptiontract to prevent systemic absorption



FluorideFluoride

Haveles (p. 176) Haveles (p. 176) Chronic toxicityChronic toxicity

Dental fluorosis or mottled tooth enamel is the most Dental fluorosis or mottled tooth enamel is the most common sign of chronic fluoride toxicity during tooth common sign of chronic fluoride toxicity during tooth developmentdevelopment• Color changes in enamel are a result of hypomineralization of Color changes in enamel are a result of hypomineralization of

tooth enameltooth enamel

Children who drink water with at least 1 ppm of fluoride Children who drink water with at least 1 ppm of fluoride and ingest fluoride supplements are at risk for and ingest fluoride supplements are at risk for developing chronic toxicitydeveloping chronic toxicity• Treatment is esthetic and includes bleaching and restorationsTreatment is esthetic and includes bleaching and restorations



FluorideFluoride

Haveles (pp. 177-179)Haveles (pp. 177-179) Fluoride preparationsFluoride preparations

Can be divided into those applied by the dental Can be divided into those applied by the dental hygienist and those applied by the patienthygienist and those applied by the patient• Professionally applied fluoride topical agents are sodium Professionally applied fluoride topical agents are sodium

fluoride (NaF) and acidulated phosphate fluoride (APF)fluoride (NaF) and acidulated phosphate fluoride (APF)

• Patient-applied products include dentifrices, gels, and Patient-applied products include dentifrices, gels, and rinsesrinses



FluorideFluoride

Haveles (pp. 177-178)Haveles (pp. 177-178) Professionally applied fluoride topical agentsProfessionally applied fluoride topical agents

Both NaF and APF are equally efficacious in Both NaF and APF are equally efficacious in preventing cariespreventing caries• NaF is recommended when restorations are present NaF is recommended when restorations are present

because of the damage caused by acidsbecause of the damage caused by acids

• Experts recommend that fluoride products remain in Experts recommend that fluoride products remain in place for 4 minutesplace for 4 minutes

• The ionic exchange lasts for about 30 minutesThe ionic exchange lasts for about 30 minutes

• Topical fluoride applications only last for approximately 5 Topical fluoride applications only last for approximately 5 to 8 weeksto 8 weeks



FluorideFluoride Haveles (p. 177) (Figs. 14-2, 14-3; Table 14-2)Haveles (p. 177) (Figs. 14-2, 14-3; Table 14-2)

Annual 4-minutes in-office topical fluoride Annual 4-minutes in-office topical fluoride applications reduce tooth decay in permanent teeth applications reduce tooth decay in permanent teeth of children living in nonfluoridated areas by 26%of children living in nonfluoridated areas by 26% Clinicians have not proved that 1-minute in-office Clinicians have not proved that 1-minute in-office

applications are as effective as the 4-minute applicationsapplications are as effective as the 4-minute applications The concentrations of fluoride products variesThe concentrations of fluoride products varies

Products with higher fluoride concentrations are Products with higher fluoride concentrations are recommended for patients with widespread decay or at recommended for patients with widespread decay or at increased risk for cariesincreased risk for caries



FluorideFluoride Haveles (p. 178)Haveles (p. 178)

Summary of professionally applied topical agentsSummary of professionally applied topical agents Topical NaF: available as a viscous gel or foam and is Topical NaF: available as a viscous gel or foam and is

stable in 2% solution—ideal for porcelain or composite stable in 2% solution—ideal for porcelain or composite restorations or sealantsrestorations or sealants

APF 1.23%: acidic pH of 3.5; increasing the acidity of APF 1.23%: acidic pH of 3.5; increasing the acidity of the fluoride increases the uptake of fluoride by tooth the fluoride increases the uptake of fluoride by tooth enamelenamel

SnF: available in a two-part rinse; not endorsed by the SnF: available in a two-part rinse; not endorsed by the American Dental Association (ADA)American Dental Association (ADA)

NaF varnish: available for use in the United States as a NaF varnish: available for use in the United States as a dentin-desensitizing agent and as a cavity linerdentin-desensitizing agent and as a cavity liner



FluorideFluoride

Haveles (pp. 177-180) (Figs. 14-4, 14-5; Tables Haveles (pp. 177-180) (Figs. 14-4, 14-5; Tables 14-2, 14-3, 14-4)14-2, 14-3, 14-4)

Patient-applied topical fluoride preparationsPatient-applied topical fluoride preparations Dentifrices: nearly 98% of all dentifrices or Dentifrices: nearly 98% of all dentifrices or

toothpastes available in the United States contain toothpastes available in the United States contain some form of fluoridesome form of fluoride

Gels: prescription gels that the patient applies at Gels: prescription gels that the patient applies at homehome

Rinses: indicated as an adjunct to proper flossing Rinses: indicated as an adjunct to proper flossing and brushing with a fluoride dentifriceand brushing with a fluoride dentifrice



FluorideFluoride

Haveles (pp. 179-180)Haveles (pp. 179-180) RinsesRinses

Mouth rinses are generally safe when used as Mouth rinses are generally safe when used as directeddirected

These products should be kept out of the reach of These products should be kept out of the reach of childrenchildren• The alcohol content in mouth rinses ranges from 0% to The alcohol content in mouth rinses ranges from 0% to

27%, with most products containing 14% to 27% alcohol27%, with most products containing 14% to 27% alcohol Children’s products also contain fluorideChildren’s products also contain fluoride


XylitolXylitol

Haveles (pp. 179-180) (Box 14-6)Haveles (pp. 179-180) (Box 14-6) Xylitol is a natural product that looks and tastes Xylitol is a natural product that looks and tastes

like sucrose but is not fermented by cariogenic like sucrose but is not fermented by cariogenic bacteriabacteria Xylitol has been found to:Xylitol has been found to:

• Reduce levels of Reduce levels of Streptococcus mutansStreptococcus mutans in plaque and saliva in plaque and saliva

• Inhibit the attachment of biofilm to teethInhibit the attachment of biofilm to teeth

• Prevent the transmission of oral bacteria from mother to childPrevent the transmission of oral bacteria from mother to child

Several clinical trials have demonstrated the beneficial Several clinical trials have demonstrated the beneficial effects of chewing xylitol-based gumeffects of chewing xylitol-based gum


ChlorhexidineChlorhexidine

Haveles (pp. 179, 181) (Fig. 14-6)Haveles (pp. 179, 181) (Fig. 14-6) Chlorhexidine gluconate 0.2% is a bis-Chlorhexidine gluconate 0.2% is a bis-

biguanide local antiinfective used to kill biguanide local antiinfective used to kill S. S. mutans mutans bacteria and reduce the harmful bacteria and reduce the harmful effects of biofilmeffects of biofilm Chlorhexidine mouth rinse, 10 ml/day for 2 weeks Chlorhexidine mouth rinse, 10 ml/day for 2 weeks

every 2 to 3 months, is effective in reducing the every 2 to 3 months, is effective in reducing the incidence of cariesincidence of caries


GingivitisGingivitis

Haveles (pp. 179-181) Haveles (pp. 179-181) The result of the accumulation of supragingival The result of the accumulation of supragingival

bacterial plaquebacterial plaque Untreated chronic gingivitis can lead to periodontitis Untreated chronic gingivitis can lead to periodontitis



Haveles (p. 180)Haveles (p. 180) Prevention of gingivitis depends on calculus Prevention of gingivitis depends on calculus

prevention and plaque controlprevention and plaque control Many of the same products used to prevent caries Many of the same products used to prevent caries

are also used to prevent gingivitisare also used to prevent gingivitis Antigingivitis ingredients in dentifrices, mouth Antigingivitis ingredients in dentifrices, mouth

rinses, and other plaque removal products include rinses, and other plaque removal products include SnF, triclosan, cetylpyridinium chloride, and SnF, triclosan, cetylpyridinium chloride, and stabilized SnFstabilized SnF




Haveles (pp. 180-181)Haveles (pp. 180-181) Brushing and flossing are the first line of Brushing and flossing are the first line of

defense in preventing and treating gingivitisdefense in preventing and treating gingivitis ChlorhexidineChlorhexidine Essential oilsEssential oils TriclosanTriclosan


Chlorhexidine Chlorhexidine

Haveles (p. 180)Haveles (p. 180) Active against both gram-positive and gram-Active against both gram-positive and gram-

negative bacteria and has some antifungal negative bacteria and has some antifungal activityactivity Binds to the bacterial cell membrane and increases Binds to the bacterial cell membrane and increases

its permeability, which results in cell deathits permeability, which results in cell death Not used prophylactically but is used as an Not used prophylactically but is used as an

adjunct therapy for up to 6 months in persons adjunct therapy for up to 6 months in persons with periodontal diseasewith periodontal disease The most common adverse effects include tooth The most common adverse effects include tooth

and mucosal staining, bitter taste, taste alteration, and mucosal staining, bitter taste, taste alteration, increased calculus formation, and mucosal irritationincreased calculus formation, and mucosal irritation


Essential OilsEssential Oils

Haveles (p. 181)Haveles (p. 181) The antigingivitis mouth rinse that contains The antigingivitis mouth rinse that contains

thymol, menthol, and eucalyptol has been thymol, menthol, and eucalyptol has been shown to reduce gingivitis and plaqueshown to reduce gingivitis and plaque In a recent clinical trial, an essential oil mouth In a recent clinical trial, an essential oil mouth

rinse plus brushing and flossing was found to be rinse plus brushing and flossing was found to be effective in reducing interproximal bleedingeffective in reducing interproximal bleeding


TriclosanTriclosan

Haveles (p. 181)Haveles (p. 181) A natural substance that has antibacterial A natural substance that has antibacterial

efficacy that reduces plaque and gingivitisefficacy that reduces plaque and gingivitis Research has shown that triclosan is more Research has shown that triclosan is more

effective than fluoridated products in reducing effective than fluoridated products in reducing gingivitisgingivitis

No side effects reported and safe to useNo side effects reported and safe to use


Tooth HypersensitivityTooth Hypersensitivity

Haveles (pp. 181-182)Haveles (pp. 181-182) Tooth hypersensitivity (dentinal hyperalgesia Tooth hypersensitivity (dentinal hyperalgesia

[DH]) is characterized by a short, sharp pain that [DH]) is characterized by a short, sharp pain that comes from exposed dentin in response to comes from exposed dentin in response to thermal, chemical, or physical stimuli that cannot thermal, chemical, or physical stimuli that cannot be attributed to any other type of dental defect or be attributed to any other type of dental defect or disease disease Severe attrition and gingival recession as a result of Severe attrition and gingival recession as a result of

abrasions, erosions, abfraction, and abnormal tooth abrasions, erosions, abfraction, and abnormal tooth development can lead to tooth hypersensitivitydevelopment can lead to tooth hypersensitivity

Tooth bleaching can increase the risk for sensitivityTooth bleaching can increase the risk for sensitivity


PathophysiologyPathophysiology

Haveles (p. 181) (Fig. 14-7)Haveles (p. 181) (Fig. 14-7) Two processes are necessary for the Two processes are necessary for the

development of DHdevelopment of DH Dentin must become exposed through the loss of Dentin must become exposed through the loss of

gingival recession or enamel, and the dentin tubules gingival recession or enamel, and the dentin tubules must be open to the oral cavity and the pulpmust be open to the oral cavity and the pulp

When heat, cold, pressure, or acid touches exposed When heat, cold, pressure, or acid touches exposed dentin or reaches an open tubule, fluid flow in the dentin or reaches an open tubule, fluid flow in the dentinal tubule increases, causing increased dentinal tubule increases, causing increased stimulation of the nerves and resulting in painstimulation of the nerves and resulting in pain



PathophysiologyPathophysiology

Dental erosion is a result of both intrinsic and Dental erosion is a result of both intrinsic and extrinsic acidextrinsic acid Extrinsic sources of acid include medication, Extrinsic sources of acid include medication,

foods, and drinkfoods, and drink The most common cause of intrinsic acid The most common cause of intrinsic acid

production is gastric refluxproduction is gastric reflux


TreatmentTreatment Haveles (p. 181)Haveles (p. 181)

Treatment goals are to alter the damage of the Treatment goals are to alter the damage of the tooth surface using the appropriate dentifrice tooth surface using the appropriate dentifrice and to stop abrasive toothbrushing practices and to stop abrasive toothbrushing practices Choice of therapeutic agent should be based on Choice of therapeutic agent should be based on

effectiveness, caries risk, amount of tooth structure effectiveness, caries risk, amount of tooth structure present, patient acceptance, cost, and estheticspresent, patient acceptance, cost, and esthetics

Desensitizing agents seal the dentin tubules and Desensitizing agents seal the dentin tubules and prevent irritants from stimulating the nerves when prevent irritants from stimulating the nerves when topically applied to the dentintopically applied to the dentin


At-Home TherapiesAt-Home Therapies

Haveles (pp. 181-182) (Fig. 14-8; Table 14-5)Haveles (pp. 181-182) (Fig. 14-8; Table 14-5) The most common therapy for at-home use is The most common therapy for at-home use is

desensitizing toothpastedesensitizing toothpaste The vast majority of desensitizing toothpastes The vast majority of desensitizing toothpastes

contain 5% potassium nitratecontain 5% potassium nitrate Potassium nitrate ions are thought to diffuse along Potassium nitrate ions are thought to diffuse along

dentin tubules and decrease the excitability of dentin tubules and decrease the excitability of intradental nerves by altering their membrane intradental nerves by altering their membrane potential and decreasing repolarization potential and decreasing repolarization


In-Office TherapiesIn-Office Therapies Haveles (pp. 181-182) (Fig. 14-9)Haveles (pp. 181-182) (Fig. 14-9)

Professionally applied products include fluorides, Professionally applied products include fluorides, potassium oxalate, and adhesives and resinspotassium oxalate, and adhesives and resins Their effects are temporary because they do not Their effects are temporary because they do not

adhere to the dentin surfaceadhere to the dentin surface• Fluorides: NaF is thought to work by the formulation of Fluorides: NaF is thought to work by the formulation of

insoluble calcium fluoride within the dentin tubulesinsoluble calcium fluoride within the dentin tubules

• Oxalates: oxalate products reduce dentin permeability and Oxalates: oxalate products reduce dentin permeability and occlude the tubulesocclude the tubules

• Adhesives and resins: provide longer-lasting desensitizationAdhesives and resins: provide longer-lasting desensitization Include cavity varnishes, bonding agents, and restorative resin Include cavity varnishes, bonding agents, and restorative resin

materialsmaterials

Chapter 14: Hygiene-Related Oral Disorders Copyright © 2011, 2007 Mosby, Inc., an affiliate of Elsevier. All rights reserved.

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