Dental Education Hub

Category: Clinical Dentistry

  • Excessive salivation: An easy and instant guide

    Excessive salivation: An easy and instant guide

    Excessive salivation is an uncommon complaint as compared to other complaints that are associated with salivary glands such as dry mouth, salivary gland obstruction, and bacterial infections, and inflammation. Excessive salivation can be a transient or a chronic problem depending on the etiology. In the medical and dental literature, the terms that are used to describe excessive salivation is sialorrhoea, hypersalivation, and ptyalism. The patients with excessive saliva usually present with the complaint of difficulty in swallowing and dribbling of the saliva.

    Causes of Excessive Saliva

    The excessive salivation is either due to increase formation of saliva by the salivary glands or due to a decrease in the clearance of saliva from the oral cavity due to compromised swallowing reflex. When the symptoms of excessive salivation are due to reduce clearance of saliva from the oral cavity it is referred to as false hypersalivation or false sialorrhoea.

    Therefore, the causes of excessive salivation are broadly classified into two types:

    1. Hypersecretion
    2. Neuromuscular dysfunction or compromised swallowing

    Hypersecretion

    The hypersecretion of saliva is also referred to as true sialorrhoea. Numerous factors that may produce excess saliva such as wearing of an intraoral dental prosthesis or device such as dentures, orthodontic retainers or other orthodontic appliance for the first time, infected or ulcerated lesions of the oral cavity, early pregnancy, teething, drugs such as pilocarpine, mercury poisoning, and rabies.

    Neuromuscular dysfunction or compromised swallowing

    The salivary secretion is optimal but there is a problem in clearance or swallowing of saliva. This is also referred to as false sialorrhoea. Factors that produce neuromuscular dysfunction are carcinoma of the oral cavity, cerebral palsy, Parkinson’s disease, and cancerous or non-cancerous obstructions within the pharynx or esophagus. One of the physiological reasons that are sometimes misinterpreted by the parents as excessive salivation is in infants due to their developing swallowing reflex that results in the drooling of saliva.   

    Diagnosis of Excessive Saliva

    The diagnosis of excessive salivation is usually based on the patient’s past medical history and intraoral examination. Sometimes confirmation of the excessive salivation is required.  Excessive salivary secretion can be confirmed with a test called sialometry which demonstrates the salivary flow per minute. 

    Management of Excessive Saliva

    For the management of any disease including excessive salivation it is important to address or eliminate the causative factor. Treatment of excessive salivation is also according to the underlying cause.  Anticholinergic drugs are sometimes prescribed to suppress the salivary flow but these drugs may produce the symptoms of dry mouth and results in other complications such as dental caries and microbial infections.

    In rare cases, through surgery, the opening of the major salivary ducts is redirected into the pharynx. Reassurance and patient and patient’s attendant education is important for every patient especially those with false sialorrhoea such as in infants.   

    Excessive Saliva

  • Dry mouth: Simple, informative, and evidence-based guide

    Dry mouth: Simple, informative, and evidence-based guide

    Have you ever felt the dryness of mouth during the period of anxiety or stress for example during the period of your school examination? Dry mouth is also referred in the medical literature as xerostomia. Xerostomia is the most common salivary gland problem. It is estimated that dry mouth affects one in four individuals at some point in their life.
    Dry mouth makes daily functions difficult such as speaking, eating, and swallowing.

    Clinical features of Dry Mouth

    There is dryness of oral tissues and soreness. The changes in the mucosa of the tongue are more prominent and characterized by the presence of red and atrophic appearance with prominent lobules and fissures on the surface of the tongue. Their loss of protective function that is associated with salivary flow leads to dental caries, fungal infections, and ascending bacterial sialadenitis. Patients with reduced salivary flow also report difficulty in speaking, mastication, swallowing, and difficulty in controlling dentures.

    Causes of Dry Mouth

    Medications are among the most common cause of dry mouth. Medications that cause dry mouth are anticholinergic drugs, tricyclic antidepressants, antihistamines, antihypertensive agents, cytotoxic drugs, and diuretics.
    Radiation therapy uses to treat the head and neck cancers results in irreversible damage to the salivary glands. Systemic diseases and syndromes such as diabetes, acquired immune deficiency syndrome, ectodermal dysplasia, and Sjögren syndrome are associated with varying degrees of oral dryness. Dehydration because of high temperature and humidity or because of the use of diuretics also produces dry mouth. Psychogenic state, anxiety, and depression cause dry mouth due to an increase in sympathetic activity. In some patients, during the anxious state, there is abundant or excess saliva but the patient complains of dry mouth. Certain physiological states also produce dry mouth such as pregnancy.

    Complications associated with Xerostomia

    Due to reducing the salivary flow a plethora of adverse effects and complications develop in the dry mouth patients. These complications include more susceptibility to microbial infections such as dental caries, fungal infections, ascending bacterial infection and inflammation of the salivary gland, and halitosis or bad breath due to reduce the clearance of food by the saliva and increase microbial growth in the oral cavity.

    Diagnosis of dry mouth

    The diagnosis of dry mouth is based on the history of the patient and intraoral examination. Sialometry is performed to measure the salivary flow rate. The normal salivary flow rate is 0.1 ml/min. The salivary gland biopsy is performed to diagnose salivary gland neoplasia and Sjögren syndrome.

    Treatment of Dry mouth

    The dry mouth treatment is according to the cause and there no single management plan for patients with dry mouth. The following paragraphs will only outline the general management of a patient with dry mouth.
    The dose of the drugs that produce xerostomia should be modified or some alternative drug should be used. The change in dosage of the drug or any alternative drug should be used in consultation with the patient general medical practitioner. The alcohol and tobacco should be avoided as they worsen the symptoms of xerostomia and also injurious to health. The chewing gums stimulate the salivary flow but the sorbitol containing chewing gums should be used as these are less cariogenic as compared to sucrose-containing chewing gums. The cholinergic drugs such as pilocarpine are prescribed to stimulate the saliva formation. These drugs are also referred to as sialogogues or the salivary gland stimulants but these drugs are only effective when there is residual healthy salivary tissue. Partial relief may be obtained by the administration of artificial saliva especially after radiation therapy. These artificial salivary substitutes are available over the counter. These available salivary substitutes lack the protective proteins that are present in the natural saliva.
    In patients with dry mouth, the maintenance of Oral hygiene is essential to prevent dental decay and other bacterial and fungal infections. For maintenance of oral hygiene products with strong flavors and with alcohol should be avoided as these products may further irritate the oral mucous membrane. Similarly, sugar-containing products should be avoided as these products increase the susceptibility of dry mouth patients to dental caries.

    Home remedies for dry mouth

    Dry foods should be avoided as these worsen the symptoms of xerostomia. Water can be sipped throughout the day. Protect the lips with a lubricant such as petroleum jelly. Avoid hot and humid environments and consider placing a humidifier in the office or at home. Avoid caffeine-containing drinks that contain caffeine because of its diuretic effect. It is also important to avoid over the counter medications such as antihistamines as they worsen the symptoms of existing xerostomia.

    Dry Mouth| Dry Mouth Causes and Management

  • The Comprehensive Dental Exam for New Patients

    The Comprehensive Dental Exam for New Patients

    Before beginning the comprehensive dental examination of a new patient. The dentist or the dental care professional (dental hygienist) should introduce him/herself to the patient and the patient attendant.  This is the initial and the most important step and should be considered as a part of the new patient dental examination protocol.

    Patient History

    In the new patient dental examination protocol, the first and the essential step is patient history. A comprehensive patient history helps in the diagnosis of dental disease and also in the subsequent management of the dental condition. A comprehensive patient history also builds a connection with the patient and that helps in the diagnosis and formulation of the best treatment plan for the patient.

    The comprehensive dental examination begins with recording the main concern of the patient or in other words the reason for attending the dental clinic. Sometimes patients have more than one presenting complains, in that case, try to establish and record the main concern of the patient. The presenting complaints of the patient ideally should be recorded in the patient’s own words.

    For a new patient dental examination, the previous dental history should also be recorded as it tells about the previous occurrence or history of the same problem, patient last dental visits and treatments performed, a pattern of dental attendance of the patient and in the past how frequently the patient has changed the general dental practitioners and the reasons of frequently changing the dental practitioners and general attitude of the patient towards the dental care.

    In a new patient dental examination protocol, the comprehensive knowledge of the patient medical history is paramount importance as it may have a major impact on the treatment planning of the patient. The patient medical history should be recorded on a dental chart either paper or computerized record before starting the dental examination of a new patient. Sometime the elderly patients and those with language barriers may need the help of an interpreter to discuss their presenting complaint and medical history. It is an important responsibility to keep the records of the patients updated including the medical history that should be updated at regular intervals before the commencement of the dental examination.  These records not only help in the management of the patient but are also helpful in forensic dentistry and forensic medicine experts in case of the mass disaster for the identification of an individual or criminal investigation.

    In the medical history, the patient should be asked about heart problems, blood pressure, bleeding disorders, history of asthma, current medications, and allergy to medicines, for example, penicillin allergy. It is also important to ask about diseases such as diabetes and epilepsy to manage these patients well in the dental practice. It is also of paramount importance to ask the patient about communicable diseases as well such as hepatitis B and C, and HIV infection. It is also important to ask the female patients of the childbearing age about pregnancy. The contact details of the patient general medical practitioner are important to confirm the medical history of the patient or for any further discussion or expert medical opinion.

    In a comprehensive dental exam, it is important to gather the patient social history. The social history of the patient includes questions that tell about the factors that influence dental disease in the past and also give some prediction about the future. The social history of the patient includes marital status, patient occupation, number of dependents, habits, smoking, and alcohol consumption.

    Comprehensive Dental Examination

    After the history, the next step is the clinical dental examination. Before starting dental examination always reassure the patient especially the children and the anxious patients.  The comprehensive dental examination is divided into two components extraoral examination and intraoral examination. The extraoral examination includes the patient’s general appearance of the patient, swelling in the head and neck region, lip competency, the examination of the temporomandibular joint, an examination of the muscle of mastication, and palpation of lymph nodes.

    The intraoral examination is performed using the basic intraoral examination instruments that comprise of mouth mirror, explorer, and tweezer.  Begin the intraoral examination with the area of the presenting complaint as this makes the patient more comfortable with the dental professional and increases the patient confidence. After carefully examining the area of presenting complain of the patient examine the other areas of the oral cavity systematically. For example, observe the condition of the soft tissues like gingiva, buccal, lingual, and labial sulci, the floor of the mouth, palate, and retromolar areas. Record the presence of any abnormal appearance, swelling, or sinuses.  For the dentition record the number of teeth present, missing, and unerupted teeth. Also, record the general state of the dentition and oral hygiene status. Teeth that are restored and those with caries should also be recorded.  In the case of dentures, their age and condition and soft tissues under the dentures should be examined and recorded. Tooth surface loss other than caries for example due to erosion, attrition, and abrasion should be recorded. The periodontal condition should also be recorded. A brief evaluation of occlusion should be performed at this step and it includes, the path of mandibular closure, any premature contacts, over erupted teeth, intercuspal relationship, overjet, and overbite.

    DIAGNOSIS

    After history and a comprehensive dental examination, a provisional diagnosis is made. However, this provisional diagnosis can only be confirmed after some special tests and investigations. The investigations in the dental clinical settings usually include dental radiographs, photographs, pulp vitality testing (chemical or thermal stimuli), study models for the analysis of occlusion, histological examination, and blood tests. For a single patient, either one of these or multiple investigations is performed.

    From the patient history examination and investigations, a definitive diagnosis will be reached. The definitive diagnosis should be recorded in the patient chart. In patients with multiple dental complaints, there may be more than one definitive diagnosis, for example, dental caries and periodontal disease.

    Treatment Planning and Patient Management

    The treatment planning should focus initially on relieving the patient presenting complain that is usually pain.  After providing emergency treatment the next step is the preventive advice as this is important to prevent any future dental disease.  Necessary periodontal treatment and treatment of carious teeth other than the main complaint should be done. In the later stages, more advanced treatment procedures can be performed such as endodontics, crowns, bridges, partial dentures, and dental implants.

    When the treatment is complete it is important to emphasize recall visits. The frequency of the recall visits is dependent on the future dental disease risk status determined by the dentist.

    It is usually asked how long does a dental exam take. The average time it takes for a dental care professional to perform a comprehensive dental examination on a patient is about 30 to 45 minutes.

    However, it may take longer than usual in several circumstances like severe or complex dental problems, type of dental practice especially when the dental examination is performed by the student at a teaching site, and welfare sites where patients are treated in large numbers free of cost or on subsided rates.

    Factors that affect treatment planning

    Numerous factors can affect the treatment planning and these factors should be considered while performing a comprehensive dental examination. Some of the key factors that affect treatment planning are:

    Multiple underlying medical conditions.

    • Highly anxious and non-cooperative patients.
    • Patients who are unable to maintain oral hygiene.
    • Patients who are unable to adhere to the treatment and follow up appointments.
    • In areas where there is limited availability of the dentists, dental care professionals, and specialists.

    Treatment planning is also dependent on patient affordability. Even when the dental treatment payments are made by the third party. There are sometimes limited treatment procedures that are covered.

  • What is Dry Socket: A Comprehensive Exploration

    What is Dry Socket: A Comprehensive Exploration

    Dry socket is one of the complications that occur after tooth extraction. A dry socket in the literature is also known as ‘fibrinolytic alveolitis’ or ‘focal alveolar osteitis’ there is delayed healing in the dry socket due to the fibrinolytic activity within the tooth extraction socket. This fibrinolytic activity results in intense pain and exposure of the alveolar bone due to the non-healing of the socket.

    Signs and Symptoms of Dry Socket

    The following signs and symptoms are indicative that the patient is suffering from a dry socket.

    • In a dry socket, the postsurgical pain increases on the third to the fifth day after tooth removal.
    • The pain intensity in a dry socket is moderate to severe that has throbbing nature and pain is not relieved by the medications (analgesics and antibiotics).
    • The pain of the dry socket is localized but occasionally pain radiates to the auricular region. There is no swelling or signs of infection such as swelling, fever, and redness.
    • There is some degree of trismus but it is usually a result of surgical trauma during dental extraction and not as a result of dry socket.
    • The intra-oral clinical examination demonstrates that the extraction socket is empty with complete or partial loss of blood clot. The bone of the alveolar socket is sometimes partially visible because of the loss of blood clot.
    • The area of the tooth extraction socket has a bad smell filled with debris and the patient also complains about bad taste.

     Associated Risk factors for Dry Socket

    The cause of alveolar osteitis or dry socket is not fully understood. The dry socket occurs in 1-3% of all dental extractions. The incidence of dry socket is associated with several local and systemic factors such as

    • Tooth extraction during active infection.
    • Extraction of the mandibular teeth especially mandibular molars.
    • Wisdom tooth extraction especially mandibular third molars that are surgically extracted.
    • History of traumatic extraction in which there is the removal of bone and trauma to soft tissues.
    • Cancer patients who have undergone radiotherapy recently.
    • Female patients currently on oral contraceptives.
    • Tobacco consumers who are using any form of tobacco like cigarettes, smokeless tobacco, and Electronic cigarettes.
    • History of soft tissue inflammation around partially erupted or impacted wisdom teeth.
    • History vigorous rinsing post-extraction or not followed post-extraction instructions properly.
    • Poor oral hygiene maintenance.
    • Active Periodontal diseases such as periodontitis or acute necrotizing ulcerative gingivitis.
    • Local bone diseases or sclerosis such as Paget’s disease, cemento-osseous dysplasia, and osteopetrosis which reduces the blood supply required for the formation of a blood clot.
    • Excessive use of local anesthesia the vasoconstrictor in the local anesthesia prevents the formation of a blood clot.
    • Patients with a previous history of dry socket are also at high risk of developing dry socket after tooth extraction in the future.

    Dry socket is usually diagnosed with a history of pain and clinical examination only and usually, no investigations such as x-rays are required unless retained root fragments or fracture of the alveolar bone is suspected. 

    Treatment of Dry Socket

    The management of the patient presenting with the dry socket is straight forward and consists of the following steps. The home remedies for dry socket treatment should be avoided and the patient should consult the operating dentist or any qualified dental practitioner for management of dry socket.  

    1. Reassure the patient that this is not a serious condition or complication of tooth extraction and the pain is not due to the extraction of the wrong tooth or due to remnants or roots of a tooth. The pain and the resulting discomfort will subside within a few hours and the socket will completely heal in the next few weeks.
    2. Irrigate the extraction socket under gentle pressure with the help of a sterile syringe under local anesthesia. The best choice for irrigation is sterile normal saline or with a chlorohexidine solution (0.12%). The excessive irrigation solution should be removed with gentle suction.
    3. The extraction socket should not be curetted as it will further escalate the pain and will cause discomfort to the patient. Gently remove the debris that is not removed after the irrigation of the socket.
    4. After removal of excess irrigation solution and removal of debris, the medicated dressing should be placed but not pushed inside the socket as packing of the socket with medicated dressing may further delay the healing process.
    5. The medicated dressings placed as part of the treatment of dry socket usually consists of the following ingredients: Eugenol, topical anesthetic such as benzocaine and a carrying vehicle. The medicated dressings are commercially available with different brand names such as Alvogyl. The patient usually feels better within ten minutes after the placement of the medicated dressing.
    6. The majority of the patients feel pain relief only with one dressing and very few of them require multiple follow up appointments and dressings. The frequent changing of medicated dressings may also delay healing of the extraction socket and therefore unnecessary follow-up appointments must be avoided.  The tooth extraction site will heal normally but slower than usual within a week.
    7. Antibiotics are not suggested as part of the management of dry socket. However, the non-steroidal anti-inflammatory drugs (analgesics) can be prescribed but with the local measures that are described earlier.

    Prevention of Dry Socket

    The incidence or likelihood of dry socket can be minimized by adhering to the following general guidelines. 

    1. Use of surgical techniques that cause minimal trauma to the tissues such as atraumatic dental surgery with clean soft tissue incisions.
    2. The optimal level of sterilization of the dental instruments and the implementation of strict infection control measures during dental extraction.
    3. Ask the patient to rinse the oral cavity with Chlorhexidine or another oral antiseptic agent before dental extraction.
    4. Strict adherence to the post-extraction instructions or guidelines.
    5. Maintaining proper oral hygiene.
    6. Abstaining from smoking and any form of tobacco.

    If the pain of dry socket fails to resolve after several follow up appointments. It may indicative of some other conditions that are needed to be addressed such as small bone sequestra that are left after tooth extraction, retained tooth or root fragments, osteomyelitis, pre-existing pathology in the adjacent tooth, surgical trauma or damage to the adjacent tooth during dental extraction, dislocation of the mandible, fractured bone and osteonecrosis.  

  • Tooth Extraction Aftercare: An Ultimate Guide

    Tooth Extraction Aftercare: An Ultimate Guide

    Exodontia or Tooth extraction

    The tooth extraction or exodontia refers to the removal of tooth or tooth roots with minimum pain, discomfort and trauma to the patient.

    The tooth extraction or exodontia is performed because of one of the following reasons.

    • Grossly decade or infected tooth because of dental caries
    • Pulpitis (Inflammation of the dental pulp)
    • Periapical inflammation of the periodontal tissues
    • Abscess because of periapical inflammation and pericoronitis (inflammation of soft tissues around partially erupted tooth)
    • Cracked or Fractured tooth
    • Tooth associated with numerous pathologies such as tumors, cysts, and fracture of bones of the jaw
    • Grossly displaced, Impacted tooth and supernumerary tooth
    • Part of the orthodontic treatment plan
    • Retained deciduous tooth

    Post Extraction care

    The post tooth extraction care instructions add less than ten minutes to the patient appointment time but these instructions are of paramount importance as these tooth extraction aftercare instructions minimize the negative sequelae of tooth extraction and resulting patient discomfort. These post-extraction instructions also reduce the overhead costs that are associated with the removal of a tooth.

    The following are the evidence-based guidelines for post tooth extraction care of the extraction site. These post-extraction instructions not only apply to the normally extracted tooth but the same also applies to surgical extractions including wisdom tooth extractions.

     Following these guidelines as mentioned reduce the post-extraction costs but also fasten the healing process after tooth removal.

    Haemorrhage Control

    Bite firmly on moistened gauze placed on the tooth extraction site. The gauze is placed to control the bleeding from the tooth extraction site. Bite firmly on the gauze pack for at least 20 to 25 minutes and avoid chewing the gauze or opening the mouth.

    It is normal for the tooth extraction site to ooze slightly up to 24 hours after tooth removal.

    Spitting and Rinsing

    Avoid rinsing with water or any other medicated solution or spitting saliva for 24 hours post-extraction as it may dislodge the newly formed clot and trigger bleeding from the extraction site.

    After twenty-four hours rinse the mouth with a glass of warm saline water for a three to four times a day for a week.

    Food and Drinks

    Do not eat any food immediately after tooth removal as the tooth extraction area is under the effect of local anesthesia and there is a chance of injury to oral soft tissues. Avoid hot food, fluids, carbonated drinks, and hard food. Instead, choose a cool, soft and liquid diet with high calorie and fluids. The soft diet keeps the tooth extraction area comfortable by preventing trauma and bleeding from the tooth extraction site and hasten the healing process.

    For two to three days after tooth removal chew the food from the opposite side of the dental arch.  The patient should be advised to avoid using a straw while drinking as this creates negative intraoral pressure that may dislodge the newly form clot and results in bleeding from the tooth extraction site.

    Smoking

    Those who smoke should avoid smoking for at least 24 hours post-extraction. As tobacco smoke and nicotine interfere with the formation of clots and delay the process of wound healing at the tooth extraction site.

    Medications

    To avoid pain and discomfort after tooth removal take the medicines as prescribed and do not modify the drug dose, add other drugs or stop using the medication. Do not locally apply any medication at the tooth extraction site for pain relief or rapid healing as it may cause harm to the soft tissues.

    The initial or first dose of medication short be taken earlier post-extraction this prevents discomfort before the effect of local anesthesia disappears. These medications are for the relief of the post-extraction pain but also reduces inflammation and swelling.

    Oral Hygiene Maintenance

    As part of post-extraction care, the mouth should be kept clean as possible as this reduces the microbial load, reduces food particles and dead cells and helps in healing of the tooth extraction site. After tooth extraction, the brushing of the teeth that are away from the tooth extraction site can be performed as usual. Brushing of teeth adjacent to the tooth extraction site should be avoided after tooth extraction to prevent pain and bleeding from the tooth extraction site. Resume the normal tooth brushing routine, use of floss and mouthwash 2 to 3 days post-extraction.

    After 24 hours of tooth extraction gently rinse the mouth with a warm saline rinse or any other rinse recommended by the doctor. The water should be warm and not hot to prevent burn or damage to the tissues. Rinse the oral cavity with the warm saline for at least three times a day especially after meals for one week.

    Rest

    The strenuous exercise or work should be avoided for 12 hours post-extraction because strenuous work or exercise may result in increased bleeding from the extraction site. Keep your head in a slightly upright position on the pillow.  

    Post extraction follow up

    The patient should visit the dentist within 1 week or as advised after tooth extraction to check the progress of the healing of the tooth socket. Besides, if the sutures were placed after tooth extraction they will be removed from the tooth extraction site during this follow up appointment.    

    It is advisable to give the patients written post-extraction care instructions in addition to the verbal instructions.  These written post tooth extraction instructions should also contain the operating dentist or dental practice telephone number and email address. So the patient may contact in case of any concern or query.

    Tooth Extraction AfterCare

    Tooth Extraction AfterCare