Questions :

26. GUIDELINES ON RADIATION SAFETY IN DENTISTRY

Contributed by:

Engineering Services Division Ministry of Health

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Questions :

24. Wanna be a Dentist?

Contributed by:

By Dr. Chai Wen Lin

Senior Lecturer, Department of General Dental Practice and Oral & Maxillofacial Imaging, Faculty of Dentistry, University of Malaya.

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It is common that when thinking of a profession in Health Services, the job as a Medical Doctor will first come into minds. Actually, this is due to lack of information about dentistry as a profession which in fact is very close to Medical Profession. This article should enlighten prospective students, parents, teachers and others who are interested in taking Dentistry as a career.

What does a Dentist do?

In the clinic, dentists see patients with various problems which may range from routine dental check up to severe toothache. When patients suffered from severe toothache, dentists will be able to relieve the pain instantly. They remove decay, fill cavities, examine x-rays, treat children’s teeth, straighten teeth, and repair fractured teeth. They also perform corrective surgery on gums and supporting bones to treat gum diseases. Dentists extract teeth and make models and measurements for dentures to replace missing teeth. They provide instruction on diet, brushing, flossing, use of fluorides, and other aspects of dental care, as well.

Most people may think dentists only look at just teeth and mouths. In actual fact, dentists always interact with people of all ages, cultures and personalities. For example, when a child is anxious, good dentist uses different approach of communication skill to manage this situation. They educate their patients, as well as the general public, on how to achieve oral health and prevent disease.

The job is different from that of a Medical GPs as dentists use a variety of dental materials, equipment, including x-ray machines, drills, and instruments such as mouth mirrors, probes, forceps, brushes, and scalpels. The skills of handling the equipments and materials were acquired during their undergraduate training. Dentists are artists as well as scientists. In order to brighten one tooth or realign an entire jaw, dentists use artist’s esthetic sense to help their patients look their best. They improve patients’ appearance by using a wide variety of cosmetic dental procedures. In other word, one who has good hand skill will be very suitable for this career.

If you think of being a medical doctor because of your strong urge of providing services to those needed, like sick, handicapped, poor individuals, dentists are actually providing similar services. They are mostly conscientious, civic-minded individuals. For example, an Oral Surgeon treats oral cancer patients, motor-vehicle accident cases who have injury on their faces.

Training

You will need to complete a five-year degree programme in one of the three public dental schools or two of the upcoming private dental schools in Malaysia. Upon completion of your training you will be awarded a BDS (Bachelor of Dental Surgery) or the equivalent of DDS (Doctorate of Dental Surgery).

Studies begin with classroom instruction and laboratory work in basic sciences, including anatomy, microbiology, biochemistry, and physiology. Startin in the 3rd year, students treat patients, usually in dental clinics, under the supervision of lecturers.

Dentistry requires diagnostic ability and manual skills. Dentists should have good visual memory, excellent judgment of space and shape, a high degree of manual dexterity, and scientific ability. Good common sense, self-discipline, and communication skills are helpful for success in managing patients in the clinics.

Job prospect

Presently there are about 2300 practicing dentists in Malaysia, with approximately in more than half in the private practice. The dentist to the population ratio stands at 1:10,451, highlighting the need to train more dentists for the country.

There are many areas that you can explore after obtaining basic degree. One can specialized in different field such as orthodontics, in which one specialized to straighten teeth, or oral surgery whereby one specialized in performing surgery to treat lesions like cysts, tumors, etc. in oral cavities.

Dentists need to balance their personal and professional lives to meet their individual needs and desires. For example, people who like to be involved in teaching and research can become academicians in universities. Ministry of Defense and Ministry of Health also have posts for those who really like to stay in government services. Dentistry allows you to be your own boss, when one decides to set up his own private practice.

Working Conditions

Currently you have to join “compulsory service” for three (3) years upon graduation whereby you will provide your service to the Ministry of Health. Works include general dentistry, dental public health and training at a hospital whereby you will go on call to attend to emergencies like dentoalveolar fractures, wound/cut to the oral cavity and its surrounding structures and jaw fractures. Your initial income will be within the bracket of RM 2000.

After 3 years of compulsory service you may decide to continue working for the government or become your own boss. Self-employed dentists in private practice tend to earn more than do salaried dentists. The capital to start a dental clinic is high as most of the equipments are imported from overseas but in due time, your income subsequently will increase to several thousand ringgit. Earnings vary according to number of years in practice, location, hours worked, and specialty. Most dentists work 5 or 6 days a week. Some work evenings and weekends to meet their patients’ needs. Initially, dentists may work more hours as they want to establish their practice. Experienced dentists often work fewer hours. A considerable number continue in part-time practice well beyond the usual retirement age.

Most Malaysian private dentists are “solo practitioner,” meaning they own their own businesses and work alone or with a small staff. Some dentists have partners, and a few work for other dentists as associate dentists. Dentists in private practice oversee a variety of administrative tasks, including bookkeeping, and buying equipment and supplies. They may employ and supervise dental surgery assistants, dental laboratory technician and receptionists. Like other business owners, these dentists must provide their own health insurance, life insurance, and retirement benefits.

Specialisation

You may also pursue an area of specialization of interest to become a specialist. The training in an area of specialization usually requires up to four (4) years, in order to be qualified as a consultant in the Ministry of Health of Malaysia. The following are areas of sub-specialization in dentistry: public health, operative/conservative dentistry, endodontics, oral pathology, oral medicine, oral surgery, orthodontics, paediatric dentistry, dental forensic, periodontics and fix and removable prosthodontics, and lastly oral and maxillofacial radiology.

Orthodontists straighten teeth by applying pressure to the teeth with braces or retainers. The oral and maxillofacial surgeons, operate on the mouth and jaws. Paediatric dentists’ work focuses on dentistry for children where as the periodontists treat gums and bones supporting the teeth. Prosthodontists are dentists who specialize in replacing missing teeth with permanent fixtures, such as crowns and bridges, or removable fixtures, such as dentures. Endodontists are dentists who look into the fine canal of teeth to perform root canal therapy. Public health dentists’ work includes promoting good dental health and preventing dental diseases within the community. They work mostly in the Ministry of Health or one of the teaching dental schools in the country. Oral pathologists are dentists who specialize in studying oral diseases where as oral and maxillofacial radiologists diagnose diseases in the head and neck through the use of imaging technologies. There is currently only two oral and maxillofacial radiologist in the country. Last but not the least, forensic dentist, as the name suggests, deals with forensic matter with regards to the teeth and face.

Expenses and Financial Assistance

A major concern of any potential dental student’s family is cost. Though a dental education may be expensive, it is within the reach of people from all economic backgrounds.

Financial assistance in the form of loans and scholarships are readily available from a variety of sources One excellent source is the Jabatan Perkhidmatan Awam scholarship. Others include a scholarship from the Ministry of Defence, various foundations like the Kuok Foundation and the Malaysian Dental Association Foundation. Besides, study loans are readily offered by various local banks in the country. Since loans are available, the financial support required from parents may not amount to more than help with living expenses for the dental student.

For all parents, talk to your son or daughter about a dental career. By helping him or her decide, you’ll provide the foundation for a future of satisfaction and success. We look forward to you becoming part of this prestigious profession.

Questions :

23. DO YOU HAVE DRY MOUTH?

Contributed by:

Associate Professor Dr. Ngeow Wei Cheong

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia.

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Introduction

Dry mouth or scientifically called xerostomia, is the term used to describe the condition whereby the amount of saliva that bathes the mouth is reduced. It is rather common for the general public to experience some degree of dry mouth as a result of various underlying causes. Among the causes are radiotherapy (common in Malaysian patients suffering from head and neck carcinoma, whereby radiotherapy may be the adjunct or only mode of treatment), Sjogren’s syndrome and as a complication of prolonged intake of medication. To certain extent, ageing also results in dry mouth, albeit in milder form. Assessment of the severity of dry mouth can be done in some dental hospital using Xerostomia Inventory (XI).1,2 The mean Xerostomia Inventory score in a normal population is about 17; scores above this figure indicate the degree of severity of xerostomia.

Dry mouth is a very uncomfortable condition and a common oral complaint for which patients may seek relief from the general dental practitioners. Remedies for xerostomia usually are palliative. This article reviews the different causes and options available for treating dry mouth.

I. RADIOTHERAPY

Dry mouth is a frequent complication for patients who undergo radiotherapy to the head and neck region. A common group of patients seen in Malaysia are those suffering from nasopharyngeal carcinoma (NPC), which unfortunately shows a high prevalence among the Chinese due to their genetic origin. In the process of treating NPC, both parotid glands are also irradiated. The effect of radiotherapy on the salivary glands can be very rapid. It had been shown that the resting flow of parotid saliva was significantly reduced to half after only 14 hours of exposure to 2 gray (Gy) of radiation.3 A gray (Gy) is a unit used to quantify the amount of radiation one is exposed to. Besides, any residual saliva tends to be thick and viscous and so loses its ability to lubricate and cleanse.4 Dry mouth is a chronic condition in these groups of people and is irreversible especially in elderly persons. In younger people, there may be an improvement in the quality and quantity of the saliva due to stimulation of the residual salivary glands.5

II. SJOGREN’S SYNDROME

Sjogren’s syndrome is caused by autoimmune inflammatory exocinopathy, in another word, it is a disease where one’s body immune system attacks it’s own body. Its incidence in Malaysian is unknown, but mainly affects middle-aged or elderly women.6 Its clinical features include:6

1. dry eyes (keratoconjunctivitis sicca)
2. Salivary and lacrimal glands swelling
3. Dry mouth (Xerostomia)

There is no connective tissue disease in primary (as listed above), but present in secondary Sjogren’s syndrome, typically rheumatoid arthritis or primary biliary cirrhosis.6

Dry mouth in Sjogren’s syndrome predisposes to depapillated lobulated tongue and candidosis. The sore tongue is lobulated (not merely fissured) in quilt-like fashion and is often diffusely erythematosus as a result of candidosis.6 Diagnosis of Sjogren’s syndrome is confirmed by performing a biopsy of the minor salivary glands of the mouth. In essence, a few small salivary glands that are hidden under the lip are cut up and examined under the microscope.

III. PHARMACOTHERAPY

It is a well-known fact that the administration of medications for various diseases has been associated with dry mouth and burning mouth syndrome. The chances of getting xerostomia increase with age and number of medications taken. Please note that in most cases, dry mouth is only noted with prolonged use of the medicine concern. Below are some of the commonly prescribed medicines that have been proven to cause xerostomia. They are listed in alphabetical order of ease of identification. The bracket on the back of the name of medicine is its purpose for prescription.

• Albuterol (Brochodilator)
• Alprazolam (Antianxiety)
• Amiloride (Diuretic)
• Amitriptyline (Antidepressant)
• Amoxapine (Antidepressant)
• Astemizole (Antihistamine)
• Atropine (Antichonergic/antispasmodic)
• Baclofen (Muscle relaxant)
• Belladonna alkaloids (Antichonergic/antispasmodic)
• Benztropine mesylate (AntiParkinsonian)
• Biperiden (AntiParkinsonian)
• Brompheniramine (Antihistamine)
• Brompheniramine with phenylpropanolamine (Antihistamine)
• Bupropion (Antidepressant)
• Captopril (Antihypertensive)
• Carbamazepine (Anticonvulsant)
• Carbidopa with levodopa(AntiParkinsonian)
• Carvediol (Antihypertensive)
• Chlordiazepoxide (Antianxiety)
• Chlordiazepoxide with clinidium (Antichonergic/antispasmodic)
• Chlorothiazide (Diuretic)
• Clomipramine (Antidepressant)
• Clonidine (Antihypertensive)
• Clorpheniramine (Antihistamine)
• Chlorpromazine(Anti-Psychotic)
• Chlorthalidone (Diuretic)
• Clozapine (Anti-Psychotic)
• Cyclizine (Antinauseant)
• Cyclobenzaprine (Muscle relaxant)
• Desipramine (Antidepressant)
• Diazepam (Antianxiety)
• Dicyclomine (Antichonergic/antispasmodic)
• Diethylpropion (Anorexiant)
• Difenoxin with atropine (Antidiarrheal)
• Diflunisal (Antiinflammatory analgesic)
• Diphenhydramine (Antihistamine)
• Diphenoxylate with atropine (Antidiarrheal)
• Dyphenhydramine (Antinauseant)
• Doxepin (Antidepressant)
• Felbamate (Anticonvulsant)
• Fenfluramine (Anorexiant)
• Fenoprofen (Antiinflammatory analgesic)
• Flurazepam (sedative)
• Fluoxetine (Antidepressant)
• Fluvoxamine (Antidepressant)
• Furosemide (Diuretic)
• Gabapentin (Anticonvulsant)
• Guanabenz (Antihypertensive)
• Guanethidine (Antihypertensive)
• Halazepam (Antianxiety)
• Haloperidol (Anti-Psychotic)
• Hydrochlorothiazide (Diuretic)
• Hydroxyzine (Antianxiety)
• Hyoscyamine (Antichonergic/antispasmodic)
• Hyoscyamine with atropine, phenobarbitol & scopolamine (Antichonergic/antispasmodic)

• Ibuprofen (Antiinflammatory analgesic)
• Imipramine (Antidepressant)
• Iptropium (Bronchodilator)
• Isoproterenol (Bronchodilator)
• Isotretinoin (Antiacne)
• Lamotrignine (Anticonvulsant)
• Levodopa (AntiParkinsonian)
• Lithium (Anti-Psychotic)
• Loperamide (Antidiarrheal)
• Loratidine (Antihistamine)
• Lorazepam (Antianxiety)
• Mazindol (Anorexiant)
• Meclizine (Antinauseant)
• Mepoeridine (Narcotic analgesic)
• Meprobamate (Antianxiety)
• Methantheline (Antichonergic/antispasmodic)
• Methscopolamine (Antichonergic/antispasmodic)
• Morphine (Narcotic Analgesic)
• Naproxen (Antiinflammatory analgesic)
• Orphenadrine (Muscle relaxant)
• Oxazepam (Antianxiety)
• Oxybutynin (Antichonergic/antispasmodic)
• Oxyphencyclimine (Antichonergic/antispasmodic
• Phendimetrazine (Anorexiant)
• Phentermine (Anorexiant)
• Phenylpropanolamine with chlorpheniramine (Decongestant)
• Pimozide (Anti-Psychotic)
• Piroxicam (Antiinflammatory analgesic)
• Prazepam (Antianxiety)
• Prazosin (Antihypertensive)
• Prochlorperazine (Anti-Psychotic)
• Promazine (Anti-Psychotic)
• Prometazine (Antihistamine)
• Propantheline (Antichonergic/antispasmodic)
• Pseudoephedrine (Decongestant)
• Reserpine (Antihypertensive)
• Scopolamine (Antichonergic/antispasmodic)
• Temazepam (sedative)
• Terfenadine (Antihistamine)
• Thioridazine (Anti-Psychotic)
• Thiothixene (Anti-Psychotic)
• Triamterene and hydrochlorothiazide (Diuretic)
• Triazolam (sedative)
• Trifluoperazine (Anti-Psychotic)
• Trihexyphenidyl (AntiParkinsonian)
• Tripelennamine (Antihistamine)
• Triprolidine with pseudoephedrine (Antihistamine)

TREATMENT OF DRY MOUTH

The treatment for dry mouth is essentially palliative, irregardless of the origin. The only one exception is for drug-induced dry mouth, whereby it may be treated by changing to different formulations where possible and practical. Consultation with the general medical practitioners is often required. The only good news for patients is that drug-induced is mild when compared to those caused by radiotherapy. Dry mouth of connective tissue disorder e.g. Sjogren’s syndrome is not very common in Malaysia.

When residual secretory capacity is present, either in the major or minor salivary glands, it is advisable to stimulate the salivary glands by mechanical or gustatory stimuli regularly. For mechanical stimulation, glandular massage can be applied.

Sugarless chewing gum can be useful in providing gustatory stimulation.7 Xylitol chewing gum is advocated because of its ability to reduce Streptococcus mutans counts in plaque and saliva, and at the same time helps in remineralisation of early caries lesions.8 One such product available in the market now is the sugarless chewing gum by Biotene® and Wrigley’s ®.

Alternatively, salivary flow can be stimulated by the use of cholinergic pharmaceutical preparations, such as pilocarpine or cevimeline.9 These drugs will need a medical prescription. Please consult your medical practitioner for advice.

Patients can also be given palliative oral care in the form of saliva substitutes and special mouthwashes for dry mouth e.g. Biotene®. Different types of saliva substitutes are now commercially available, containing different polymers as thickening agents, e.g. carboxymethylcellulose, polyacrylic acid, and xanthan gum.9 Study in Western population has found that mucin-based preparations may be better accepted to carboxymethylcellulose formulations10. Some patients, especially Malaysian patients find frequent sips of cold water or ice chips to be equally effective.11 Salivary substitutes or mouthwashes are useful to keep the mucosa moist, mobile and free from debris. In addition, nocturnal oral dryness can be alleviated by spraying the oral surfaces with water, or by applying a small amount of children’s dentifrice on the dental smooth surfaces. However, water is a poor lubricant. Please consult your dentist or pharmacist regarding these products.

CONCLUSION

Dry mouth is common problem seen in the general dental practice. Where there is residual salivary glands that are still functioning, stimulation could be done via massaging, use of sugarless chewing gums and prescription of systemic sialogogues. Alternatively, saliva substitute and specially formulated mouth rinse may be given to provide symptomatic relief.

*Disclaimer: The list of drugs causing dry mouth provided here are based on informations available from the manufacturers. Readers are advised to consult your medical doctor to verify this possible association.

REFERENCES

1. Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: a multi-item approach to measuring dry mouth. Community Dent Health 1998; 16: 12-7.
2. Thomson WM, Williams SM. Further testing of the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89;46-50.
3. Shannon IL, Trodahl JN, Starcke EN. Radiosensitivity of the human parotid gland. Proc Soc Exp Biol Med 1978; 157: 50.
4. Joyston-Bechal S. Management of oral complications following radiotherapy. Dent Update 1992; 19: 232-4, 236-8.
5. Carl W. Oral and dental care of patients receiving radiation therapy for tumours in and around the oral cavity. In: Carl W, Sako K eds. Cancer and the oral cavity. Chicago, Illinois: Quintessence Publishing Company, 1986; 167-83.
6. Scully C, Cawson RA. Colour Guide Oral Medicine. Edinburgh: Churchill Livingstone, 1988.
7. Mealey BL, Semba SE, Hallmon WW. The head and neck radiotherapy patient: Part 2 – Management of oral complications. Compendium 1994; 15: 442-56.
8. Toors FA. Chewing gum and dental health. Literature review. Rev Belge Med Dent 1992; 47(3): 67-92.
9. Nieuw Amerongen AV, Veerman EC. Current therapies for xerostomia and salivary gland hypofunction associated with cancer therapies. Support Care Cancer 2003; 11: 226-31.
10. Duxbury AJ, Thakker NS, Wastell DG. A double-blind cross-over trial of a mucin-containing artificial saliva. Br Dent J 1989; 166: 115-20.
11. McClure D, Barker G, Barker B, Feil P. Oral management of the cancer patient, part II: Oral complications of radiation therapy. Compendium 1987; 8(2):88: 90-2.

Questions :

22. Understanding dental infection

Contributed by:

Assoc. Prof. Dr. Ngeow Wei Cheong

BDS, FFDRCSI, FDSRCS, AM Department of Oral and Maxillofacial Surgery Faculty of Dentistry University of Malaya 50603 Kuala Lumpur Malaysia.

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Introduction

Dental infection is one of the most common infections in the world. The good news is that tooth decay, which in actual fact is an infection on the tooth structure is normally localise and restorable. Another common infection in the mouth are gingivitis and periodontitis. They are in fact gum disease, with gingivitis being milder and periodontitis being more severe. Occasionally dental infection from the tooth and gum spread to the surrounding and/or distant tissue. Dental infections can present as abscesses, sinus tracts or severe cellulitis involving the superficial spaces, masticator spaces, floor of the mouth spaces or deep neck spaces. This write-up reviews the local spread of dental infection namely, periapical abscess and sinus tract formations. The spread of infection to the maxillary sinus is briefly discussed.

Periapical abscess

The spread of caries in a tooth, if not arrested, will result in infection of the pulpal tissue and eventual pulpal necrosis i.e. the tooth dies off. This necrosed tissue may collect at the around the root of the tooth concerned. Inflammatory process will occur as the body responses to this collection. In essence the body tries to cure and protect oneself from the bad effect of this infection. However, in normal circumstances, the body usually is not able to wall-off the infection. Hence, there would be accumulation of acute inflammatory cells at the tip of a dead tooth. This is termed a periapical abscess by the dentist. Periapical abscess may arise as the initial periapical pathosis or from an acute exacerbation of a chronic periapical inflammatory lesion (phoenix abscess). It has to be reminded that the infection can happen in any part of the root i.e. not necessarily at the tip of the root.

Abscesses usually consists of a sea of polymorphonuclear leukocytes (aka white blood cells) often intermixed with inflammatory exudate, cellular debris, necrotic material, bacterial colonies or histiocytes. Periapical abscess has been classified into acute and chronic types, but it has been suggested that this is a misnomer since both types represent acute inflammatory reactions. Some dentists prefer to designate periapical abscesses as either symptomatic or asymptomatic based on their clinical presentations. Periapical abscesses become symptomatic when the purulent material accumulates within the alveolus. The initial stages produce tenderness of the affected tooth that is often relieved by direct application of pressure. With time, the pain becomes worse and the tooth will become very sensitive to percussion. Extrusion and swelling either around the tooth, at the labial sulcus or occasionally the lingual or palatal area may be noted.

The abscess may not be detected radiographically. If an radiograph (x-ray) is taken, dentists may only see a thickened peri-radicular periodontal ligament, an ill-defined radiolucency, or both depending on the time lapse between the onset of infection and time the radiograph is taken. Radiolucency (dark shadow in radiograph) is a sign that something may be wrong in the jawbones. It normally tell us that some bone has been lost, hence the dark shadow seen in radiograph. (Note: Bone and any hard tissue look opaque/white in radiograph). Radiolucency may not be appreciable in radiograph when there is not enough time for significant bone destruction. Phoenix abscess, however, will demonstrate the outline of the original chronic lesion with or without an associated ill-defined bone loss.

Most dental abscesses perforate bucally i.e. going away from the oral cavity toward the face because the bone is thinner on the buccal surface. Conversely, infections associated with maxillary lateral incisors, the palatal roots of maxillary molars and mandibular second and third molars typically drain through the lingual cortical plate.

With progression, the abscess may extend to the path of least resistance, away from the tooth. The purulence may extend through the medullary spaces away from the apical area, resulting in osteomyelitis, or it may perforate the cortex and channelised though the soft tissue or spread either diffusely through the overlying soft tissue as cellulitis, or to adjacent and/or distant potential tissue spaces. Fortunately, most dental abscess remained localised around the tooth concerned.

Sinus tracts

If the abscess finds its way through the oral mucosa, a sinus tract is formed. The pressure in the swelling may be relieved and if a chronic path of drainage is achieved, the abscess becomes asymptomatic. At the distal opening of an intraoral sinus tract, there is often a mass of subacutely inflamed granulation tissue known as a parulis (gum boil).

If it channelised through the skin, a cutaneous sinus tract may be formed. A cutaneous sinus that discharges on the skin of the face and neck is called scientifically a “cervicofacial sinus”. Among the commonly dental-caused cervicofacial sinus are those related to apical pathology around mandibular anterior teeth. This type of cervicofacial sinus has been described as “median mental sinus”. Other sites of extra-oral drainage of dental infection are the cheek, canine space, nasolabial fold, nose, upper lip and even the inner canthus of the eye.

Cervicofacial sinus can clinically simulate skin infection (carbuncle), sebaceous cysts, basal cell epithelioma, basal cell carcinoma (a type of skin cancer) or even squamous cell carcinoma (a type of skin cancer). Thus, many cases have been documented of patients receiving multiple biopsies and surgical excisions, multiple antibiotic regimens or radiotherapy without success because of misdiagnosis. The sinus tract continues to pour out discharges as the primary dental cause was never correctly diagnosed and treated. There was even a case that was correctly diagnosed only after 32 years.

Most patients are unaware of any associated dental problem, hence delaying the correct diagnosis of the cervicofacial lesion with its primary odontogenic origin. Only 50% of patients with cervicofacial odontogenic sinus tracts have a history of toothache. Otherwise, the involved area is usually asymptomatic and the patient generally healthy. Hence, anybody with an infection on the face that never heals may need dental check-up to rule out possible dental cause.

Spread of infection to the maxillary sinus

It is generally accepted that dental infections can cause sinusitis or more precisely maxillary sinusitis. Selden referred to such a manifestation as the endo-antral syndrome (EAS). This is a pathological condition resulting from the spread of infection from the root canal apices near the maxillary sinus into both the antral and periapical tissues. The degree of sinus involvement is related to the proximity of the involved apex to the sinus. Reported frequencies of sinusitis of dental origin vary considerably, between 4.6 and 47.0%.

Treatment

Treatment for periapical abscesses consists of drainage and elimination of the source of infection. Normally incision and drainage can be performed under local anaesthesia by any dentists. The pus should be sent for culture and sensitivity. Open drainage of the tooth shall be done if there is intention to retain it, otherwise it may be extracted. If extraction is to be done, normally extraction is done a day or two after the patient is prescribed antibiotics and analgesics. Of course dentist must use their personal judgement, as, if the patient is in severe pain but the dentist is still able to numb the region involved, then extraction there and then would be the best treatment. Dentists may consider giving prophylactic antibiotics 1 hour prior to dental extraction with pus present. Persistent parulis may need to be excised surgically.

Treatment for sinus tracts involves confirming the source of infection. This can be done by the dentist by inserting a soft gutta percha point and appropriate radiographs taken. Once the source is found, it can either be treated by endodontic therapy or exodontia. Surgical apicectomy may be needed for recurrent persistant sinus that does not respond to endodontic therapy.

Treatment for maxillary sinusitis consists of elimination of the source of infection. Open drainage followed by root canal therapy of the tooth shall be done if there is intention to retain it, otherwise it may be extracted. If extraction is to be done, it is suggested that this is done a day or two after the patient is prescribed antibiotics and analgesics. Patients may need a course of antibiotics until the sinusitis has resolved.

Note: The information provided in this article is meant to be used as general guidelines. It is best to consult your dentist if you suspect that you have dental infection.

References

1. Oral and Maxillofacial Pathology. Neville, Damm, Allen & Bouquot. W.B. Saunders: Philadelphia, 1995.
2. Ong ST, Ngeow WC. Median mental sinus in twins. Dental Update. May 1999; 26(4): 163-5.
3. Mitchell DA. A bizarre facial sinus. Dental Update 1994;21:303-4.
4. Malik SA, Bailey BMW. Cervicofacial sinuses. Br J Oral Maxillofac Surg 1984;221:178-88.
5. Bailey H. Median Mental sinus. Br Dent J. 1956;66:289-92.
6. Bernick SM, Jensen JR. Chronic draining extraoral fistula of 32 years duration. J Oral Maxillofac Surg 1969;27:790-4.
7. Ngeow WC. The use of gutta-percha point to locate the origin of facial sinus. Med J Malaysia 1997;52:181-2.
8. Selden H S. The endo-antral syndrome: an endodontic complication. J Am Dent Assoc, 1989; 119(3):397-8,401-2.
9. Matilla K. Roentgenological investigations into the relation between periapical lesions and conditions of the mucous membrane of the maxillary sinuses. Acta Odontol Scandinavica, 1965; 23:77-91.
10. Melen I, Lindahl, Andreasson L, Rundcrantz H. Chronic maxillary sinusitis. Definition, diagnosis and relation to dental infections and nasal polyposis. Acta Otolaryngologica (Stock), 1986;101(3-4):320-7.

Questions :

21. A THOUSAND MILLION SMILES

Contributed by:

Dr. Wong Foot Meow

BDS, FDSRCPS, FICD, AM Oral Surgeon

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100 Watt Smile

Happiness in life is being able to keep smiling and eat well. The first thing that people notice about you is your smile. If your smile is regarded as a curve that sets everything straight, imagine what miles of smiles can do. Only a healthy smile with bright sparking teeth and fresh breath can be termed the 100 watt smile. So how do you go about flashing a 100 watt smile? The first step is to consult a dentist who will analyse your problem and suggest the appropriate smile management plan.

Problems

Many dental problems can compromise a beautiful smile. Among the problems routinely identified in a smile analysis that would adversely affect your smile include :-

1. Bad breath.
2. Teeth which are not of one colour.
3. Uneven front teeth which may be crooked, protruding or overlapping.
4. Staining of teeth with white or brown stains.
5. Rough, non matching and discoloured anterior fillings.
6. Diseased unhealthy gums and gum recession.
7. Worn down and / or fractured teeth.

How to improve your smile

Depending on the problem or combination of problems, teeth may be improved by repairing, straightening, reshaping and whitening (bleaching) essentially aesthetic dentistry restores decaying, broken or defective teeth to improve your smile. Your friendly dentist may use any of the following or a combination to make your smile sparkle, but most importantly you must practise total oral hygiene.

1. Fresh breath.
2. Composite resin bonding and cosmetic contouring.
3. Bleaching.
4. Laminate veneers.
5. Porcelain bonded crowns.
6. Bridges.
7. Orthodontics (Braces).

Fresh Breath

Principal causes of bad breath is the release of two main gases : methymercaptan and hydrogen sulphide. Keeping bad breath at bay is really quite simple i.e. by brushing your teeth and gum but more importantly the tongue.

Composite Resin Bonding

Composite resins are tooth coloured filling materials which can be bonded on the tooth surface roughened by acid etching. The dentist can custom shape and contour the tooth with the appropriate shade (colour) of bonded composite resin giving the exquisite aesthetic appearance and beautiful smile. It is a quick, painless and inexpensive method of improving your smile but has a short life expectancy of 3 -5 years requiring frequent repair or replacement.

Bleaching

Bleaching is an effective method of lightening the teeth. People request for teeth whitening for many reasons. There are many causes of teeth discolouration. The commoner causes include extrinsic stains ( coffee, tea or tobacco ). Tetracycline ( antibiotic ) stains, non vital or root treated teeth and yellowing of aging teeth.

Age related discolouration begins from inside the tooth and is reflected out through the enamel. Bleaching must always be done in consultation and under the supervision of the dentist. Two bleaching techniques are recommended.

1. In-office type version using concentrated bleaching gel.
2. At home dentist – supervised version using less diluted bleaching gel.

The custom-made plastic mouthguard is filled with bleaching gel (normally carbornide peroxide which turns into hydrogen peroxide) and placed over the teeth. The bleach will slowly penetrate the enamel spitting up your teeth like it does your laundry whites.

The end result is teeth that sparkles a few shades lighter than when you first started. This usually last for a few years. Rebleaching may then be necessary.

Laminated Veneers

Usually made of porcelain, these thin plastics shells or they are “false fronts” (like false fingernails) which are bonded to the enamel of the front teeth. Laminate can make teeth discolouration, contour teeth and reduce create even, straight and aesthetic looking teeth.

Porcelain Bonded Crowns

A crown is a cap or cover replacing that portion of the tooth exposed in the mouth. Crowns are aesthetically designed to look and feel like real teeth. Badly fractured, discoloured or uneven teeth may be repaired or reshaped if desired. All porcelain crowns e.g.. Dicor resemble real teeth and look very natural.

Orthodontics

Braces are utilized by the orthodontist to straighten teeth, close gaps and improve smiles. Nowadays tooth coloured braces using porcelain brackets are socially acceptable as they are not so noticeable.

Conclusions

With all the advances outlined earlier there is no excuse for not having an attractive smile. An attractive smile can exude the warmth and self confidence that you want to convey. Happiness in life is also able to keep smiling and eat well. In addition, in order to maintain your smiles, remember to : * Visit your dentist once a year.

• Brush your teeth at least twice a day (minimum of 3 minutes per session)
• Floss daily
• Eat a well proper balanced diet with plenty of fruits and vegetables.

Questions :

20. Looking After Your Child’s Teeth: When Do You Start?

Contributed by:

Dr. Roslan Saub

Department of Community Dentistry, University of Malaya Kuala Lumpur

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Do you have a child? If you do, I’m sure you would want your child to be healthy. wouldn’t you? It is your responsibility to look after your child’s health. This should also include their oral health because it is part of total health. Often, many parents ignore their children’s oral health. If your child has a toothache, for instance, it will not only disturb your child’s daily activities but also yours as well. Your child couldn’t sleep, couldn’t eat well and will be crying all day and night. Why wait until they have these problems? Why can’t you prevent it from happening. Dental caries and gingivitis are two most common oral diseases in children. They can easily be prevented if you can inculcate in them good oral hygiene habit and dietary practice.

Why healthy teeth are important?

Human beings need to eat in order to stay alive. Food that we take need to be broken up into smaller pieces to enable our digestive system to absorb all its nutrients We need teeth to do this. If food have not been chewed well, there is a possibility that your child will suffer from constipation and perhaps malnourishment.

Children are in the process of development; physically, psychologically and socially. Proper eating is important to ensure that they are getting all the nutrients necessary for growth. Besides that they need teeth to speak properly. Healthy teeth are also important in the development of self- image. In addition primary teeth (baby teeth) are important to ensure that permanent teeth erupt into their correct position. Hence it is important to maintain good dentition, both primary and permanent throughout life.

When do teeth develop?

There are two sets of teeth in life. The baby teeth are the first set of teeth, which will then be replaced by the permanent teeth. Baby teeth begin to grow during the early stages of pregnancy. The first teeth will appear in the mouth from the age of 6 months and by 3 years old all 20 baby teeth are in place The permanent teeth starts to erupt at 6 years old and by 12 years old all baby teeth have been replaced by permanent ones. A child is in a mix dentition state between the age of 6 and 12 years old.

When do teeth develop?

Dental care of the child should begin as soon as pregnancy starts. This is because, as mentioned earlier, the development of baby teeth begin in the first trimester of pregnancy and continues until the teeth appear. Therefore to ensure normal development of the teeth, mothers should take good diet. Vitamin supplements such as calcium and vitamin D will benefit the baby’s developing primary teeth. Taking drugs such as tetracycline should be avoided during pregnancy to avoid permanent discoloration of the baby teeth.

Oral care for infant should starts at birth. The infant’s oral cavity has to be cleaned using a clean cloth by wiping all around the month. By doing so, it will avoid infection of the soft tissue. Breast feeding is encouraged among mothers. It increases mother-infant bonding and gives the child contentment, security and protection. However prolonged on-demand breast feeding, especially at night can cause detrimental effect to the milk teeth due to the lactose in breast milk which has been shown to produce lactic acid when fermented. When the mother is unable or unwilling to breast feed, and bottle feeding is used, make sure that you do not add sweeteners to the milk. Babies should not be allowed to sleep with a propped bottle or given reservoir comforters. It in advisable to wean off the bottle by the age of I year to avoid inevitable rampant caries.

Diet, especially sugary food, is one of the factors that cause dental caries. A study in Klang found that the total amount of sugar intake among the 12 years old school children was estimated at 72 grams per day per person or 26 kilograms per year per person which is much higher than recommended sugar intake that is 15 kilograms per year per person. They also found that the amount of sugar intake was higher at home than at school. Hence it is important for the parents to instil good dietary habits among their children as young as possible. Children should he given satisfying well-balanced meals so that they do not need to supplement them with snack food or drinks in between. If your child wants to eat between meals, avoid giving them sweet and sticky foods, you can always replace them with fruits, milk nuts, savoury biscuits, and low calories drinks which are safe snacks.

Start brushing your child’s teeth as soon as they appear. However children below 10 years old who does not have the skill to clean his teeth properly, need help from you, the parents. Parents play a primary role in cleaning their child’s teeth until their children are able to brush their teeth effectively by themselves. The very young child ( 6 months – 6 years ) must have his teeth brushed by the parents at least once a day especially before putting them to bed. This may be best achieved by sitting your baby on your knees and using a small toothbrush with soft bristles. At first use only water, but as the baby gets used to having his teeth cleaned, a small amount of fluoride toothpaste can be used. However it must be used with caution. Studies have shown that children at the age of 5 years old tend to swallow toothpaste and hence the amount placed on the brush each time much be carefully limited, generally to a pea-size quantity. Train your child to spit after brushing. To make brushing for you and the baby much easier, let the baby play with the brush and he will learn how it feels in his mouth. This will not only help in developing the brushing skills but also will help in developing the motor skill of your child. However supervision from an adult is necessary.

As the child gets older he will start to attempt this oral hygiene himself but will still need the additional help and supervision of an adult until he has developed the skill. The habit of brushing teeth should he made part of daily routine.

Once your child has teeth, you should take the initiative to make an appointment to see a dentist. It is advisable to bring your child to dental clinic as early as possible. This will help your child to become familiarized with the set-up of the dental clinic and to detect early dental diseases. Moreover it also helps in reducing fear towards dentist which is very common among young children. As a Malay proverb said “Kalau melentur buluh, biarlah dari rebungnya”. It means that if we want to train people, start them early in life. So in maintaining good oral health for life it should be started from the womb and continued throughout life. Hence preferable health behaviour such as good oral hygiene practices and healthy diet should be instilled as early as possible.

Questions :

19. Promoting Oral Health : Individual and Collective Responsibilities

Contributed by:

Professor Dr. Ishak Bin. Abdul Razak

Department of Community Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur

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Every year the Malaysian Government spends a considerable amount of money in meeting the oral health needs of the Malaysian public. About 18 million Ringgit was spent in 1975. By 1996, this amount had increased by 33 folds. This does not take into consideration the out-of-pocket expenses incurred in obtaining actual treatment in the private sector as well as other related expenses incurred in seeking care. Does more money spent on oral health means better oral health status?

Data on oral health status of 5 year-old pre-school children in 1995 indicate that 87% of these children had experienced tooth decay with an average of 6 deciduous (milk) teeth being affected. Among 12 year-old children, 70% were found to have experienced dental decay in 1988 which was a slight improvement from 78% in 1970. The mean number of decayed teeth among these children had also declined from 3.7 to 2.4 within this period. Current data suggests that on average less than 2 teeth are decayed. Among adults, the proportion of the population who suffered from the ravages of tooth decay has remained somewhat stagnant at about 95% in 1974 and 1990. The latter survey also found that the rate of edentulousness (total tooth loss) starts to rise from the age of 35 onwards. Nine out of ten adults showed some evidence of gum diseases. In 1993/94, about 1.5% of adults aged 25 years and above in Malaysia were found to have oral cancers or precancers with the prevalence increasing with increasing age.

So inspite of the large amount of money spent on oral care, it would appear that the oral health status of the Malaysian public has not shown significant improvement. While the dental services has been effective in meeting the treatment needs after the onset of disease, it has little influence in promoting a healthy lifestyle. It should be noted that the major oral diseases namely dental decay. gum diseases and oral cancers are actually diseases of lifestyle. For as long as unhealthy habits remain unchanged, oral diseases will occur or recur to the extent that it will drain the existing resources to treat them. What then can the public do as an individual and collectively as members of society in order to maintain and promote oral health in order to reduce the disease burden. Health preserved by way of life is far superior to health restored by treatment of disease.

There are three ways to achieve this:

• adopt healthy life practices.
• use wisely available oral health services.
• make decisions both collectively and individually to improve the community’s oral health and environment.

Adopt healthy life practices

Control sugar intake both in amount as well as frequency. Sugar not only contributes to tooth decay but also to the occurrence of diabetes, heart disease and obesity. Restrict consuming food or drinks containing sugar only to mealtimes. Beware of hidden sugars in food because it is often used as a flavouring as well as a preservative agent. Make it a habit to read food labels.

Use fluoridated toothpaste. The most effective measure to overcome tooth decay on an individual basis other than sugar restriction is to use fluoridated toothpaste. Use only a pea sized amount of toothpaste. For young children, brushing should be supervised to prevent swallowing of excessive toothpaste.

Regular and thorough tooth cleaning is the only way to maintain the health of the gums. Brush effectively twice a day especially before bedtime and use dental floss to remove food debris and bacteria in between teeth.

Avoid smoking and alcohol consumption and refrain from betel quid chewing. Smoking not only causes oral cancer, gum diseases, mouth odour and nicotine stain but more importantly it also causes lung cancers and heart diseases. A dose-response relationship between tobacco smoking and oral cancer has been demonstrated. Tobacco chewing is also hazardous to oral health because very often the tobacco is kept in a particular site in the mouth for long period of time with deleterious local effects leading to the development of oral cancers. Alcohol consumption is also an important independent risk factor. There is evidence that the combined effects of smoking and alcohol consumption is greater than the sum of the risks from exposure to either on its own.

Pay greater attention to your children’s teeth even though these may by deciduous (milk) teeth. Inculcate healthy habits early in life so that it will remain the norm.

Use wisely available oral health services

is it the dentist at least once a year to enable the dentist to undertake preventive measure before the onset of disease or to detect oral diseases at an earlier stage to ensure better prognosis in treatment. Preventing disease is a better option than treatment. However when treatment is required, choose the treatment options that will have the least oral health impact on function and aesthetics. A natural tooth that requires filling is better than having it extracted and having it replaced by a denture. So try and save the tooth whenever circumstances permit.

Collective actions

What can you do collectively as members of society in order to prevent oral diseases and enhance oral health. In other words what can you do to make the healthier choice the easier choice or to make the unhealthy choice more difficult.

Insist on fluoridation. Water fluoridation has been found to be the most cost effective means of reducing dental decay. It has been proven conclusively in bringing about a 50% reduction in dental decay, although effect is slightly reduced with the declining trend in dental decay. It is estimated that this benefit only cost 20 sen per capita per year.

Health cannot be achieved by the health sector alone. You have a role either as an individual or collectively as members of society in adopting healthy life practices and in ensuring that the healthy choice remains the easier choice.

Questions :

18. Eating Your Way To Good Dental Health Associate

Contributed by:

Professor Dr. Nasruddin Jaafar

Department of Community Dentistry, University of Malaya, Kuala Lumpur

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Your dietary habit is one of the most important influences on dental health. But it is impossible to look at dental health alone in total isolation from your general health. While this article will suggest ways how yon can maintain good oral health through tooth-friendly dietary habits, you must remember that you must balance it with moderation. For example if you are trying to reduce or give up sugar totally, you must ensure that you are not eating more fatty and salty snacks as replacement.

The general guideline suggested by nutrition experts should be observed. Among them is to ensure a daily balanced diet consisting of roughly 60% carbohydrates (whole wheat bread, rice, cereals, potatoes), 20% proteins (milk, meats, soya bean, nuts, legumes) and 20% fats. The food pyramid suggested by the Ministry of Health in the healthy lifestyle campaign should be the reference point for most Malaysians.

As far as dental health is concerned, sugar has been identified as one of the main problems. Although all sugars, whether natural or “artificially refined”, are capable of being turned into acids by plaque bacteria, the evidence suggest that sugars in fresh fruits (intrinsic sugars) are not of dental concern. Similarly, although lactose (milk sugar) can produce pH drops is lab-experiments, the milk fat offers some protective effect against caries so it is not a dental public health problem. The main culprit causing rampant caries has been narrowed down to non-milk extrinsic (NME) sugars. These NME sugars include sucrose, fructose, glucose and maltose.

The recommended daily dietary allowance for NME sugar by respected nutritional authorities, including the WHO and COMA of the UK, is quite specific. The policy is directed at decreasing dietary sugars to improve not only dental but general health as well. Of the 60% daily carbohydrate intake, it is recommended only 10% should come from free sugars or non-milk extrinsic (NME) sugar. The rest should come from complex carbohydrates and fresh food products especially fruits and vegetables.

Practically, the NME sugar allowance can be translated into a daily intake of 10 -12 teaspoonfuls of free sugars per day or around 20 kg per person per year so ensure good general and dental health. Unfortunately, most canned foods and drinks contain very high sugar preparations. For example a can of fizzy soft drinks typically contain 7-9 teaspoonfuls of NME sugars – almost reaching your daily recommended health allowance of 10 -12 teaspoonfuls per day.

The lower limit is zero NME sugar intake. But most Malaysians would find this difficult. Since the Malaysian per capita sugar intake is currently around 38 kg per person per year, you should perhaps start to have your current NME sugar intake to reach the 20 kg per person per year target. Eventually, your personal target should be towards zero NME sugar intake.

For dental health, the local effect of diet is much more important after the tooth has erupted in the mouth than the systemic effect before it erupts. The only important dietary trace element with proves pre- and post-eruptive caries preventive effect, shown in a large number of studies, is fluoride. Present evidence show that among the total dietary factors, NME sugar exerts the most significant effect.

What this imply is that eating lots of calcium-rich foods, vitamin D and phosphorus when your teeth are still forming (in the womb, infants, toddlers and early childhood) will help your teeth to be well formed before it erupts. But it does not make much difference in preventing dental caries when most teeth have already erupted if you are a teenager or adult. Controlling NME sugar is much more effective to prevent dental decay than increasing your vitamins, minerals or calcium intake, once all your teeth have erupted.

There are a number of ways how dietary sugars can influence dental decay. Studies have shown that not all people eating the same amount of sugar will get the same amount of caries. You can in fact modify your eating habit to reduce the risk of getting caries, especially if you really cannot avoid sweet foods.

First, foods differ in their ability to stimulate salivary flow. Generally, a lot of salivary flow is good for teeth. That is why some studies show that eating sugary foods at-meal times (when salivary flow is maximum) is less damaging to teeth, than in-between meals or before going to bed. A four-year study investigating the role of sugar is dental decay found that very high sugar consumption did not cause much caries if it is takes up to four times a day at-meal times and none between-meals. But of course we know now that a high sugar intake is not good for general health. Chewing gums has been advocated as good-for- teeth because of their ability to stimulate salivary flow. Of course, sugar-free gums should be your preferred choice.

Second, the frequency of sugar challenge (how often) per day is generally more damaging to teeth than the quantity (amount) of sugar taken. This is because the pH drop in plaque occurs within 3-7 minutes of a sugar challenge and only rises to the normal safe level around 40 minutes later. That means each time you take a sugary food (of drink) the micro-damage to your teeth (called de-mineralization) starts almost immediately. If the sugary snack is continuous such as taking regular sips of a sugared drink over a long period of time while watching your favourite TV programme, the damage is worst than if you had finished the drink in 2 or 3 big gulps. The acidic pH stays as the dangerous level for hours on end before being neutralized by your saliva.

A few studies have shows that there is another way to encourage the pH level to rise faster after a sugary challenge. As stated earlier, chewing gum after taking a sugary food will stimulate saliva, which will neutralize the acids. Other foods which have the same effect are savoury ones like cheese, nuts, crisps and our local keropok. Thus you could order your food intake to start off with sweet sugary ones and finish off with savoury ones so that the risk of damage is reduced. If you like your tea of coffee to be sweet, you can still do so by using alternative sweeteners which are non-cariogenic. But plain water is still best for health.

If you are looking after young children – stop giving them sugar-containing sweets. There are alternative sugar-free sweets, which are safe for teeth and taste just as rice. Never put sugared drinks or fruit juices in bottle reservoir feeders. Remember the longer the time of continuous contact between sugar, plaque and tooth – the more severe the damage. Saliva is greatly reduced just as your child is dosing off to sleep.

Increasing the consumption of fresh fruits will indirectly decrease the need for NME sugars as snacks. Furthermore, the fibre, vitamins and overall nutritional content of fresh fruits is much, much better. Thus you end up with much healthier diet. So in conclusion, you have to view your eating habits not just from the dental perspective but from your overall health. While you can reduce the risk of getting caries by modifying your sugar eating habits as suggested, for the sake of your health, it is always better to cut down the calories- laden, nutrient-deficient NME sugars. Moderation is the key to health. So keep trying.