Dental Articles written by Dr. Ranjani
Third molars or Wisdom teeth as they are more commonly called are the last teeth to erupt in the mouth. They normally erupt between 17 and 25 years of age. While the eruption of other permanent teeth do not usually cause any problems, eruption of the wisdom teeth is usually accompanied by pain and swelling in the gums. In many cases, the tooth erupts without further ado; when the pain and swelling becomes a recurrent problem treatment is warranted.
These problems are more often seen in relation to erupting lower wisdom teeth. In such cases, an x-ray is taken of the offending tooth. If the tooth is in the normal position in the jaw(upright) with sufficient space for it to erupt just an excision of the overlying gum should be adequate. If on the other hand, the tooth is abnormally positioned or there is insufficient space in the jaw to accommodate it, an extraction is indicated. Such teeth are said to be "impacted", and their removal requires a minor surgical procedure, i.e. incision of the overlying gum, removal of the surrounding bone and extraction of the tooth. The incision is usually closed with two or more sutures.
While most cases of impacted wisdom teeth can be removed under local anesthesia in the dental clinic, teeth that are deeply placed in the jaw bone may require the same surgical procedure under general anesthesia. General anesthesia is also indicated when one or more wisdom teeth are impacted and require removal. This does away with repeated procedures with the attendant inconvenience. The common problem seen with the upper third molars is 'cheek bite'. Erupted but malposed upper wisdom teeth can irritate and excoriate the cheek mucosa in the adjacent region. Grinding the offending tooth can temporarily correct this, but the problem is likely to recur and chronic cheek bite can predispose to cancer. Therefore the best course of action is extraction of the offending tooth. A small percentage of the upper wisdom tooth can be impacted within the bone and may require surgical removal.
It is better to remove the upper wisdom tooth also if the lower wisdom tooth on the same side has been removed or vice versa. Wisdom teeth are usually non-functional and their removal does not detract from the normal masticatory function. Infact one may truly said to be wiser without the wisdom teeth!
The misconceptions which abound among the general public about dentistry needs to be cleared up. These wrong ideas prevent patients from seeking timely treatment thereby complicating simple dental problems.
- For instance patients hesitate to get their teeth extracted during the rainy season, thinking that this would affect their health. Teeth can be extracted if indicated in any sort of weather; the weather has no role to play in dental treatment.
- It is common belief that extraction of upper teeth can affect the brain or the eyes. This has no scientific basis; extraction of any tooth does not affect these organs.
- Some patients with cavities in the teeth are quite surprised at being told so; they claim that they do not eat sweets! sweets are not the sole cause for cavities; any food debris can cause decay if allowed to remain on the surfaces of the teeth. Even drinking milk can be responsible for cavities if the mouth is not rinsed after.
- Patients often don’t replace one or two teeth if lost, thinking that they have to wait till they lose all the teeth to replace them. Even single teeth can and should be replaced.
- Some patients do not want cavities in their children's milk teeth to be filled “as they are going to fall anyway”. It is advisable to fill such cavities to avoid premature loss of these and attendant problems to the permanent successors.
- Orthodontic treatment often requires extraction of one or more premolars; some parents are apprehensive about extraction of sound teeth. Such extractions do not affect the child's health and fears to the contrary are unfounded.
- Cleaning of teeth is thought by some to cause loosening of the teeth and to create gaps between them; such fears are not grounded in fact. Cleaning of the teeth is done by ultrasonic instruments, which dislodge deposits on the teeth. They do not and cannot damage the enamel or loosen teeth.
- A visit to the dentist is most often dictated by pain in a tooth; even if aware of a cavity in the tooth, the patient delays seeing a dentist till pain forces him to do so. Timely consultation with the dentist will save such patients a lot of pain and also give the dentist a chance to save the tooth.
The forementioned misconceptions are often stumbling blocks to effective conservative treatment. If these myths are exploded the time and expense involved in dental treatment can be considerably reduced.×
It is well known that foods rich in carbohydrates can cause decay of teeth and inadequate oral hygiene can result in gum diseases; but the fact that certain childhood habits can also be a cause for dental problems
This is one of the commonest oral habits during childhood. Thumb sucking till about six years of age does not cause much of a problem; persistence of this habit after eruption of the permanent upper incisors can result in protrusion of these teeth. Habit correcting appliances can prevent this from happening or indicator in cases of thumb sucking beyond the age of 6.
Breathing through the mouth while sleeping ( which is more common) and also while studying or watching TV can cause several changes in the facial Skelton of children.
The palate becomes high and arched; the face can get elongated and the teeth may protrude. This is called 'Adenoid facies' Such children need to be seen by an ENT surgeon to rule out the above; there after an appliance called an oral screen is given to encourage the child to breathe through the nose.
Pushing the tongue against the back of the front teeth while speaking causes the upper and lower front teeth to splay out; this results in a condition called open bite which is a challenge to correct. Yearly identification of this habit and correction by an appropriate appliance will avoid prolonged and difficult treatment later. In addition to the fore mentioned habits, nail biting and chewing of pencils/pens can also cause irregularity of the front teeth. Identifying the causative factor, elimination of the same and appliance treatment are required to correct the habits at an early age before they get reinforced and more difficult to correct once the child is older.
WHY DENTURES ?
The loss of a front tooth due to any reson usually has the patient visit the dentist to have it replaced immediately.but for most patients a loss of a molar tooth(grinder) does not install the same urgency to replace it.they feel no one will notice a missing back tooth!
While the primary function of front teeth are aesthetics and speech, that is not the case with the back teeth, Mastication is their primary function.
A person who has lost a molar or molars from one side of the jaw would tend to use the teeth of the opposite side for masticatory purposes,this can lead to
- Accelerated wear of the teeth on that side.
- The load on the temporomandibular joint(the joint between the lowr jaw and the skull- which is felt just in front of the ear) on that side is increased causing joint pain and associated joint problems like pain and clicking of the joint .many a time such patients may come to the clinic complaining of vague pain in the jaws,which can be directly attributted to the loss of the molar teeth.
- Incomplete mastication of food can often lead to digestive problems.
- The teeth adjacent to the lost teeth tend to tilt or drift into the gap.this creates spaces between these teeth and their immediate neighbours.these gaos act as food traps which can cause gum infection,decay of these teeth and bad breath.
- The teeth in the opposing jaw corresponding to the lost teeth to supraerupt (seeming to grow longer) thereby exposing their roots whioch can cause sencitivity to hot/cold,pain and loosening of these teeth.
- Loss of molars can cause unsightly hollows in the cheek.
The above mentioned points make replacements of lost molars imperative.loss of any back teeth barring the 3rd molar or the wisdom teeth should be replaced, at the earliest.
Replacement of of lost teeth can be by any one of the following methods:
- Removable dentures
- Fixed dentures
- Implant supported dentures
Removable dentures: are the simplest and the leat expensive.but they have to be removed twice a day and cleaned while brushing the natural teeth.
Fixed dentures: These take support from the teeth next to the missing teeth.thse teeeth are reduced in size and caps are fitted to these,to which are attached the teeth to be replaced.this is called a bridge.and this is held in place with the help of dental adhesives or cements.these bridges can be made of either cast metal or ceramic.ceramic bridges are more aesthetic than metal bridges.
Implant supported dentures: implants are titanium”root substitues” which are surgically embedded in the jaw bones in the region of the last teeth.artificial teeth made of ceramic are fitted on to these implants.
Teeth that are well aligned and regular make for an attractive smile and pleasing profile. Teeth that are protruding and irregular are not only unaesthetic but may be functionally deficient. Usually, irregular and crowed teeth are noticed when the milky teeth in the front of the jaws fall; the permanent successors being larger than the teeth that they replace, crowding results. In such cases it may be necessary to create space by removing the adjacent milk teeth. The successors of such extracted milk teeth can be accommodated when they erupt by extracting their adjacent milk teeth in turn. These extractions are termed serial extractions. This is usually done between 6 and 10 years of age.
In the permanent dentition, crowned teeth can be corrected by wearing fixed braces. This crowding of teeth is due to a discrepancy between the jaw size and size of the teeth. Large teeth in small jaws result in irregular, malaligned teeth. Small teeth in large jaws result in excessive spaces between teeth. In the former, it may be necessary to extract teeth to create space; it is usually the premolars that are extracted (one premolar in each quadrant of the jaws). This space is utilized to align the crowded teeth. In excessive spacing, extractions may not be necessary.
In both cases, an orthodontic appliance is fixed to the teeth, which moves the teeth to the desired position. The appliance cannot be removed till the treatment is complete, which may take 12-18months.After completion of the treatment, the appliance is removed; a removable appliance called a retainer should then be worn for further period of 6-12 months.
Fixed orthodontic appliance therapy is usually done after all the milk teeth have fallen i.e,11-12 years of age. With the recent advances in Orthodontics it is even possible to do orthodontic treatment in adults, well into their third and fourth decades.
Prevention and treatment
Dental decay or caries is one of the commonest dental diseases. Even though dental caries is a disease of childhood no age group is immune to it. Cavities are found more often in the moral teeth than in the front teeth. The grinding surfaces of the molars in both the milk and the permanent dentition contains pits and fissures(grooves). Food debris particularly from sticky substances like chocolates tend to remain in the grooves. Bacteria that are present in the mouth digest this food debris by releasing certain acids and enzymes which also dissolves the substance of the tooth causing cavities. These cavities in turn collect more food debris thereby paving the way for more bacterial action and deeper cavities result.
Most parents give their children a glass milk at bed time. More often that not the children are sleepy and skip the night time brushing after drinking milk. The milk forms a film on the teeth which is acted upon by bacteria causing decay.
Children who have been drinking milk from a feeding bottle well beyond the age of weaning have a peculiar form or decay called “rampant caries” or ”feeding bottle caries”. In such cases one finds all the upper teeth badly decayed and discoloured. Prevention being better than cure these basic precautions can reduce the incidence of decay.
- Brushing one's teeth twice a day with a good fluoridated tooth paste.
- Rinsing the moth with after every meal/snacks/drink.
- Bi-annual dental checkups.
- Topical fluoride application and pit and fissure sealent treatment for children.
- Timely weaning of children from feeding bottle.
Thr first signs of decay in a tooth are black dots or small holes. At this stage the tooth is usually painless and can be filled relatively easily. This is the ideal stage for treatment. If fillings are not done at this stage and cavities are allowed to get deeper, the tooth may become sensitive to hot/cold drinks and sweats. Filling now may require atwo stage treatment:a temporary filling which reduces the sensitivity and a permanent filling two weeks hence. Without treatment the cavity may deepen further and cause pain. At this stage a root canal treatment may be required to svae the tooth. In this context a bi-annual dental checkup assumes significance and cavities can be detected early and filled in the initial stage itself. Fillings can be done with either silver or tooth coloured materials. The tooth coloured fillings give a more aesthetic result. Prevention of dental caries in children takes the form of
1- Topical fluriode applications wherein formulations of fluoride are applied to the teeth.These makes the enamel of the teeth resistant to the decay causing chemicals released by the bacteria. This has to be repeated every six months.
2- Pit and fissure sealands are applied on the grinding surface of the molars. This flow into the pit and fissure on the surface of the molars and prevent food debris accumulation therby avoiding decay. Prevention of decay by these means and prompt detection and filling of cavities in teeth will go along way in retaining ones own teeth.
Causes and treatment
Discolouration of teeth, particularly the front teeth causes concern in once mind. It not only affects the smile but may even make the person reluctant to smile. Teeth may be discolored due to:
* Extrinsic causes
* Intrinsic causes
Extrinsic causes: Habits like pan/ betel net tobacco chewing, smoking and excessive intake of coffee and tea can result in stains on the surface of the teeth. Certain liquid iron preparations can also stain the teeth. These stains can easily be removed by ultrasonic cleaning of the teeth. But it should be borne in mind that resumptions of these habits can stain the teeth again.
(i) Ingestion of excessive fluoride (in drinking water) and certain drugs like tetracycline during the formative years of the teeth can affect enamel formation resulting in pitted and discoloured teeth.
(ii) Trauma to the front teeth can impair blood supply to the pulp of the teeth causing its death. This dead matter can leak to the substance of the tooth causing discolouration.
Intrinsic strains cannot be removed by ultrasonic cleaning. But with the recent advances in aesthetic dentistry it is quiet easy to rectify this problem. Removal of the stains can be done by the following methods:
1) Bleaching: This is the simplest form of treatment for discoloured teeth. A bleaching paste is applied on to the teeth and held in place by soft splints which fit over the teeth. The splint is kept in the mouth for about 20 minutes. Repeated applications over a few weeks are usually sufficient to remove the stains.
2) Ceramic veneers: Thin ceramic veneers can be stuck to the surfaces of the discoloured teeth, masking the discoloration. The veneers can be making in a number of shades to suit different clinical situations. Veneers are making in dental laboratory and the treatment needs two or three appointments.
3)Composite resins which are available in different shades can also be used to mask discoloured teeth. This is usually done as a single stage procedure.
4) Very severe cases of discolouration can be treated by fitting acrylic (Plastic) or ceramic caps to these teeth.
Missing permanent teeth cause aesthetic and functional problems. Till recently replacement of such missing teeth was done either by removable dentures or fixed bridges. Neither of these solutions is ideal and each has its own disadvantages.
Removable dentures can slip or cause difficulties in speech and in some cases cause ulceration of the mucosa. Fixed bridges take support from teeth adjacent to the missing teeth which need to be reduced in size to accept crowns. Since the bone in the area where the teeth are missing does not bear any load it may lead to disuse atrophy and bone loss results.
Recurrent decay, periodontal (gum) disease often cause failure of removable dentures and fixed bridges and may require replacement every few years. Now there is a solution to these problems in the form of dental implants. Instead of being supported by soft tissue of the jaw bone in the case of removable dentures or the neighbouring teeth in the case of bridges-implants are fixed directly to the jaw bone and the missing teeth are fixed on them.
Dental implants are make of titanium which has the property of fusing or attaching to bone ( a process called osteontegration) a fortuitous discovery made by Dr.Branemark in the 1950’s There are several types of dental implants and the most commonly used are root form implants. Dental implants may be used to replace single or multiple teeth or can even be used to replace the full complement of teeth.
The procedure is usually carried out in two stages. The first where the implant is placed in the jawbone and the second where the tooth is fixed to the implant. When the patient first comes in an x-ray is taken to assess the height of bone available and in cases where multiple dental implants are required a dental C.T. may be taken. If these show any deficiency in the bone height bone grafting and other bone augmentation surgery may be required before implants are placed.
Once it is established sufficient bone is present the dentist surgically places the implants in the required area in the jawbone. This is usually done under local anesthesia and as an outpatient procedure. After a waiting period of 4-8 weeks the patient is called back and the replacement teeth are fabricated and fixed to the implants. In cases where teeth have been recently extracted the patient may have to wait for few months for healing to be completed before implants can be placed. But if sufficient bone is present in the extracted region it may possible to place the implant immediately after the extraction.
Dental implants offer many benefits over removable dentures and fixed bridges.
- Implant dentures look natural and function like natural teeth.
- The dental implant is a life time replacement and is definitely more durable than dentures and brides.
- When compared to the removable dentures, which may be loose and make chewing and speaking difficult implant dentures are more stable as they are fixed to the jawbone. Moreover they need not be removed and washed unlike removable dentures.
- The insecurity that the conventional dentures wearers have about dentures slipping and clicking is totally eliminated by implant dentures.
- Most conventional dentures wearers complain about diminution of taste sensation and difficulty in speaking as the upper denture covers the whole palate. Since the implant dentures are fixed directly to the bone the palate is not covered. Therefore neither speech nor taste is affected.
- The inherent instability of conventional dentures forces most dentures wearers to opt for a limited diet. Implant dentures do not impose any such restrictions and the patient is free to eat whatever her or she desires.
- Conventional dentures have to be removed for cleaning and during bed time. This may make the patient feel and look older. Implant dentures, which need not be removed, will definitely add to the patient's self esteem and confidence.
Dental implants are now the treatment of choice to replace missing permanent teeth and as seen above offer the advantages of aesthetics and functionality closest to the natural teeth.×