Sunday, December 23, 2012

Human hands 'evolved for fighting'

Human hands may have built the Taj Mahal and adorned the ceiling of the Sistine Chapel with glorious art, but researchers have found they evolved – not just for manual dexterity - but primarily for fighting.
Compared with apes, humans have shorter palms and fingers and longer, stronger, flexible thumbs - features that have been long thought to have evolved so our ancestors could make and use tools, a new study has found.

For a University of Utah study, men whacked punching bags, suggesting human hands evolved not only for the manual dexterity needed to use tools, play a violin or paint a work of art, but so men could make fists and fight.
"The role aggression has played in our evolution has not been adequately appreciated," said University of Utah biology Professor David Carrier, senior author of the study.
"There are people who do not like this idea, but it is clear that compared with other mammals, great apes are a relatively aggressive group, with lots of fighting and violence, and that includes us," Carrier said.
"We are the poster children for violence". Humans have debated for centuries "about whether we are, by nature, aggressive animals," he added.
As our ancestors evolved, "an individual who could strike with a clenched fist could hit harder without injuring themselves, so they were better able to fight for mates and thus more likely to reproduce," he said.
Fights also were for food, water, land and shelter to support a family, and "over pride, reputation and for revenge," he added.
"If a fist posture does provide a performance advantage for punching, the proportions of our hands also may have evolved in response to selection for fighting ability, in addition to selection for dexterity," Carrier says.
Carrier and co-author Michael H Morgan conducted their study to identify any performance advantages a human fist may provide during fighting.
The first experiment involved 10 male students and non-students – ages 22 to 50 and all of them with boxing or martial arts experience – hit a punching bag as hard as they could.
Surprisingly, the peak force was the same, whether the bag was punched with a fist or slapped with an open hand.
"Because you have higher pressure when hitting with a fist, you are more likely to cause injury" to tissue, bones, teeth, eyes and the jaw, Carrier said.
The second and third experiments tested the hypothesis that a fist provides buttressing to protect the hand during punching.
"Because the experiments show the proportions of the human hand provide a performance advantage when striking with a fist, we suggest that the proportions of our hands resulted, in part, from selection to improve fighting performance," Carrier said.

Sunday, December 02, 2012

Drugs Used in Dentistry

There are a number of different drugs your dentist may prescribe, depending on your condition. Some medications are prescribed to fight certain oral diseases, to prevent or treat infections, or to control pain and relieve anxiety.
Here you will find a description of the most commonly used drugs in dental care. The dose of the drugs and instructions on how to take them will differ from patient to patient, depending on what the drug is being used for, patient's age, weight, and other considerations.
Even though your dentist will provide information to you about any medication he or she may give to you, make sure you fully understand the reasons for taking a medication and inform your dentist of any health conditions you may have.
Drugs to Control Pain and Anxiety
Local anesthesia, general anesthesia, nitrous oxide, or intravenous sedation is commonly used in dental procedures to help control pain and anxiety. Other pain relievers include prescription or nonprescription anti-inflammatory drugs, acetaminophen (Tylenol), and anesthetics.

Corticosteroids are anti-inflammatory drugs that are used to relieve the discomfort and redness of mouth and gum problems. Corticosteroids are available by prescription only and are available as pastes under such brand names as Kenalog in Orabase, Orabase-HCA, Oracort, and Oralone.
Your dentist may recommend a nonprescription anti-inflammatory drug -- such as Motrin -- to relieve mild pain and/or swelling caused by dental appliances, toothaches, and fevers. Tylenol may also be given.
Note: Unless directed by your dentist, never give infants and children aspirin.

Dental anesthetics are used in the mouth to relieve pain or irritation caused by many conditions, including toothache, teething, and sores in or around the mouth (such as cold sores, canker sores, and fever blisters). Also, some of these medicines are used to relieve pain or irritation caused by dentures or other dental appliances, including braces.
Anesthetics are available either by prescription or over-the-counter and come in many dosage forms including aerosol spray, dental paste, gel, lozenges, ointments, and solutions. Dental anesthetics are contained in such brand name products as Ambesol, Chloraseptic, Orajel, and Xylocaine.
Note: The FDA has issued a warning to consumers about the use of benzocaine, the main ingredient in over-the-counter liquids and gels used to reduce teething pain in very young children. Benzocaine is associated with a rare but serious condition called methemoglobinemia, which greatly reduces the amount of oxygen carried through the bloodstream. The FDA says benzocaine products should not be given to children younger than age 2 unless under the supervision of a health care professional.
Also, because the elderly are particularly sensitive to the effects of many local anesthetics, they should not use more than directed by the package label or the dentist. Anesthetics used for toothache pain should not be used for a prolonged period of time; they are prescribed for temporary pain relief until the toothache can be treated. Denture wearers using anesthetics to relieve pain from a new denture should see their dentist to determine if an adjustment to the appliance is needed to prevent more soreness.

Chlorhexidine is an antibiotic drug used to control plaque and gingivitis in the mouth or in periodontal pockets (the space between your gum and tooth). The medication is available as a mouth rinse and as a gelatin-filled chip that is placed in the deep gum pockets next to your teeth after root planing. The drug in the gelatin-filled chip is released slowly over about seven days. Dental products containing this antibacterial are marketed under various prescription-only brand names, such as Peridex, PerioChip, and PerioGard, as well as other over-the-counter trade names.
Note: Chlorhexidine may cause an increase in tartar on your teeth. It may also cause staining of the tooth, tooth filling, and dentures or other mouth appliances. Brushing with a tartar-control toothpaste and flossing your teeth daily may help reduce this tartar build-up and staining. In addition, you should visit your dentist at least every six months to have your teeth cleaned and your gums examined. Be sure to tell your dentist if you have ever had any unusual or allergic reaction to this medicine or to skin disinfectants containing chlorhexidine.

Your dentist may recommend the use of an over-the-counter antiseptic mouth rinse product to reduce plaque and gingivitis and kill the germs that cause bad breath.
Drugs Used to Treat Periodontal Disease
The doxycycline periodontal system (marketed as Atridox) contains the antibiotic doxycycline and is used to help treat periodontal disease. Doxycycline works by preventing the growth of bacteria. Doxycycline periodontal system is placed by your dentist into deep gum pockets next to your teeth and dissolves naturally over seven days.
Note: Tell your dentist if you have ever had any unusual or allergic reaction to doxycycline or to other tetracyclines. Use of doxycycline periodontal system is not recommended during the last half of pregnancy or in infants and children up to 8 years of age because the product may cause permanent discoloration of teeth and slow down bone growth. Use of doxycycline periodontal system is not recommended, if breastfeeding, since doxycycline passes into breast milk. This class of drugs also may decrease the effectiveness of estrogen-containing birth control pills, increasing the chance of unwanted pregnancy.

Fluoride is a drug used to prevent tooth decay. It is available on a nonprescription basis in many toothpastes. It is absorbed by teeth and helps strengthen teeth to resist acid and block the cavity-forming action of bacteria. As a varnish or a mouth rinse, fluoride helps reduce tooth sensitivity. Prescription-strength fluoride is available as a liquid, tablet, and chewable tablet to take by mouth. It usually is taken once daily. It is prescribed for children and adults whose homes have water that is not fluoridated (has not had fluoride added to water).
Note: Before taking fluoride, be sure to tell your dentist if you are allergic to fluoride, tartrazine (a yellow dye in some processed foods and drugs), or any other drugs. Do not take calcium, magnesium, or iron supplements while taking fluoride without checking with your dentist. Tell your dentist if you are on a low-sodium or sodium-free diet. Do not eat or drink dairy products one hour before or one hour after taking fluoride. Fluoride can cause staining of the teeth.

Pilocarpine, marketed as Salagan, may be prescribed by your dentist if you have been diagnosed with dry mouth. The drug stimulates saliva production.
Other Antibiotics
  • Tetracyclines (the class of drugs including demeclocycline, doxycycline, minocycline, oxytetracycline, and tetracycline) and the drug triclosan (marketed as Irgasan DP300) are also used in dentistry. These medications may be used either in combination with surgery and other therapies, or alone, to reduce or temporarily eliminate bacteria associated with periodontal disease, to suppress the destruction of the tooth's attachment to the bone or to reduce the pain and irritation of canker sores. Dental antibiotics come in a variety of forms including gels, thread-like fibers, microspheres (tiny round particles), and mouth rinses.
  • Antifungals are prescribed to treat oral thrush. The goal of treatment is to stop the spread of the Candida fungus. Antifungal medicines are available in tablets, lozenges, or liquids that are usually "swished" around in your mouth before being swallowed.

Some Dental and Periodontal Diseases

This is a broad topic and does not form part of the routine training of medical staff, so it is usually best dealt with by a dental general practitioner. However, current NHS dentistry provision is increasingly patchy, so such problems are presenting to medical primary care and emergency departments more frequently. In this record, you will find basic information on the presentation and initial management of dental and periodontal disease as well as notes on systemic conditions that affect the teeth and gums.
You may also want to refer to the separate articles Problems in the Mouth and Oral Ulceration.

  • Local causes - this usually arises as a result of irritation of the nerve supplying the affected tooth. This can be due to a number of local problems, including inflammation of the pulp (pulpitis), infection and, most commonly, decay. Gum disease, grinding teeth (bruxism), tooth trauma and an abnormal bite are also causes. In babies and young children, consider the growth of unerupted teeth.
  • Systemic causes - systemic problems should also be borne in mind. Think of temporomandibular joint, sinus or ear infections and tension in the facial muscles which can cause discomfort that resembles a toothache (these are often accompanied by a headache). Angina should also be considered in your list of differentials.
  • Management - once you are sure that this is a local problem, it is appropriate to refer to a dental practitioner. Whilst waiting to be seen, advise patients to take regular oral analgesia (non-steroidal anti-inflammatory drugs (NSAIDs) are a good starting point) and some patients find that application of a cool compress on the cheek overlying the affected tooth helps.

  •  Nature of the problem - dentine is protected by a hard layer of enamel but if this is broken then caries follows. This can result from trauma or inadequacy of the enamel; the most common cause of breakdown of enamel is by lactic acid that is formed by bacteria when sugars are left in contact with the teeth. Risk factors are therefore a diet high in sugars and poor dental hygiene. Dental caries (or decay) is a common problem in all industrialised and in many developing countries. In the UK, a survey found that 40% of 5 year-olds had experienced some dental caries,[1] with Scottish preschool children experiencing some of the highest rates of dental caries in Europe.[2]
  • Treatment - destroyed structures of the tooth do not regenerate so treatment is aimed at preventing further decay. Decayed material is removed by drilling and a substance is used to fill the tooth. Many different materials are now available, including silver amalgam, gold and high-strength composite resin. Crowns are used if decay is extensive and there is limited tooth structure which may cause weakened teeth. The decayed or weakened area is removed and repaired and a covering jacket or crown is fitted over the remainder of the tooth. Crowns are often made of gold, porcelain or porcelain fused to metal. If the nerve root dies a root canal filling may be required.
  • Prevention - attention to diet and regular tooth brushing are the main preventative strategies. There is a wealth of material concerning dietary factors, particularly in young children. In summary:[2]
    • Human breast milk and unmodified cow's milk are not cariogenic, unlike infant formula milk (theoretically, soya infant formula milk is the worst offender).
    • Drinks containing free sugars (including natural fruit juices) are cariogenic and shouldn't be given in a bottle.
    • Foods and confectionary containing free sugars should be minimised and restricted to meal times.
    • Cheese may actively protect against caries and is a good high-energy source for toddlers.
    • Sugar substitutes are better for teeth than free sugars although beware of salt content and additives used to make the food as appealing.
    Brushing (supervised in young children) removes both sugar and organisms, and antiseptic mouthwashes may be beneficial too. 

Fluoridation There has been a lot of research into the fluoridation of products and its protective effects against dental caries. For example, fluoridation of toothpastes, mouth rinses, gels and tooth varnishes has been common practice for several decades, resulting in beneficial effects where these products have been used appropriately.[1] Previous research over some 50 years has shown that adding fluoride to water supplies can reduce decay by 40-60%.[3] 1 part per million is required and, in those areas where there is fluoridation of water, children aged under 7 should use lower fluoride toothpaste. The fluoridation of water, however, remains politically controversial and there are organised campaign groups both 'for'[4] and 'against'.[5] No more than 10% of the country receive fluoride in their water. The favoured areas are mostly in the north-east of England and the Midlands. In 2004 health ministers were still insistent that fluoridisation of water supplies is a matter for local decision and this remains the case to date. It is the responsibility of strategic health authorities to bring pressure upon local water boards. Fluoridation of milk and salt has also been examined as a possible approach although the effectiveness of such measures is yet to be proven. It is worth noting that fluoride supplements taken by a pregnant woman have no beneficial effects on the child's teeth.[2]

Numerous other areas of research are being explored for the prevention of dental caries, including the development of various fillings, antibacterial agents and fissure sealants.[6]

  • Nature of the problem - this is a collection of pus in the tooth or within the surrounding structures. It most commonly originates in the centre (pulp) of the tooth - a periapical or dentoalveolar abscess. A periodontal abscess originates in the tissue surrounding the tooth. Their pathophysiology and management are different but, in the context of primary care, they can be treated as the same entity.
  • Presentation - a dental abscess presents with worsening pain (hours to days) which may radiate to the ipsilateral ear, jaw and neck. There may be a bad taste in the mouth, fever ± malaise and trismus (inability to open the mouth). It is more likely to occur where there are risk factors for dental caries (see 'Dental caries' above) and a history of previous dental procedures. Other risk factors include diabetes, immunocompromise, smoking and drug-induced gum disorders. Look for facial swelling, regional lymphadenopathy, altered tooth appearance and gum swelling. Alternative diagnoses to consider include:
  • Management in primary care - the patient needs to be seen by a dental practitioner. In the interim, pain can be managed with regular analgesics such as NSAIDs (advise ibuprofen or naproxen in patients at risk of cardiovascular adverse events[7]). Advise the patient to consume cool, soft food and to avoid very hot or cold foods and drinks. Patients should avoid flossing the affected tooth. Consider antibiotics only in the absence of immediate attention by a dental practitioner and if:
    • The infection appears to be severe (fever, lymphadenopathy, cellulitis, diffuse swelling).
    • Patients are at risk of developing complications (eg people who are immunocompromised or diabetic or have valvular heart disease).
    Suitable antibiotics include amoxicillin or metronidazole for 5 days or a course of amoxicillin 3 g repeated after 8 hours may be offered for adults. Avoid repeat prescriptions and changing antibiotics - these patients should be managed by dental practitioners.
Wisdom teeth and their problems
Impacted wisdom teeth should not be removed unless they have associated significant dental or other oral disease. Conditions warranting removal of impacted wisdom teeth include:[8]
  • Unrestorable caries.
  • Non-treatable pulpal and/or periapical pathology.
  • Cellulitis, abscess and osteomyelitis.
  • Internal/external resorption of the tooth or adjacent teeth.
  • Fracture of the tooth.
  • Disease of the tooth follicle (ectomesenchymal tissue surrounding the developing tooth germ) including cyst/tumour.
  • Tooth/teeth impeding surgery or reconstructive jaw surgery.
  • When a tooth is involved in, or within the field of, tumour resection.

A post-extraction bleeding tooth socket should be treated by using a wad of wet gauze placed over the socket and the patient should be advised to bite down and arrest the haemorrhage through pressure; any medications that promote bleeding should be considered for temporary discontinuation and the patient should seek dental advice if the symptoms do not settle, as suturing may be necessary.
  • Tooth loss: permanent dentition - traumatic tooth loss should be managed in adults and children with permanent teeth, initially, by trying to replace the tooth in the socket. If this is not possible, store the tooth in milk or the patient's own saliva. Attendance at a dental clinic as soon as possible (within 24 hours) gives a chance of replacing the avulsed tooth successfully.
  • Tooth loss: primary dentition - in children with 'milk teeth', replacement of the tooth is not advised due to the danger of damaging the underlying permanent tooth. Store the avulsed tooth in saliva or milk and get the patient to attend a dental practitioner as soon as possible. A five-day course of antibiotics is recommended in this situation.[9]
  • Dental concussion - the tooth is said to be concussed when there is damage to the supporting tissues without abnormal loosening or displacement of the tooth. Pulp necrosis may ensue (seen as the tooth going dark). This should be managed by a dental practitioner. Where the tooth is left as it is (common where a primary tooth is involved), the key thing is to advise parents to look out for swelling of the gum around the tooth; this may be an early manifestation of inflammation ± infection.
  • Problems with fillings and crowns - these can be affected by external trauma (eg a fall). This is likely to be associated with more extensive injury - or by more minor trauma, eg biting on a hard fragment of food. It is best to get the tooth checked out by a dental practitioner, as loosening or chipping of the filling results in pain in the short-term and risk of further dental caries later on.

The word periodontal literally means 'around the tooth'. Periodontal disease is most commonly a chronic bacterial infection that affects the gums and bone supporting the teeth. If left untreated it can lead to loss of teeth.
Worrying symptoms and signs of periodontal disease warranting urgent referral to an appropriate specialist.
  • Rapid progression of symptoms - see 'Aggressive periodontitis', below.
  • Unexplained tooth mobility for more than three weeks.
  • Unexplained swelling or ulceration of the oral mucosa, lasting for more than 3 weeks - malignancy needs to be ruled out.
  • Other suspicions of malignancy: unexplained painful, swollen and bleeding, red or red and white patches on the oral mucosa and unexplained tooth mobility lasting more than 3 weeks.
  • Risk factors for malignancy include increasing age (>45 years old), heavy drinking or smoking as well as other use of tobacco (eg chewing).

If a lesion in the oral cavity cannot be diagnosed definitively as benign, follow up for six weeks and, if resolution does not occur, refer urgently to a specialist.

Non-urgent referral to a dentist should be considered for:
  • People who cannot use a toothbrush or dental floss.
  • Gingivitis not responding to the usual oral hygiene measures.
  • Periodontitis.
  • Unexplained red and white patches (including suspected lichen planus) or the oral mucosa where there is no swelling, bleeding or pain.

Gingivitis refers to inflammation of the gum of any cause. However, it is most often associated with plaque.
What is plaque? This is the soft, sticky bacterial deposit that readily forms on exposed surfaces of teeth. It is easily removed by brushing and flossing. It calcifies over time, forming tartar (or a calculus) which can only be removed by a dentist or dental hygienist with special instruments. Plaque results in a local inflammatory reaction, gingivitis.
Gingivitis is the mildest form of a spectrum disease and it can progress to periodontal disease.
  • Presentation - in plaque-associated gingivitis, the gums become red, swell and bleed easily. There is usually little or no discomfort. The most important risk factors for this disease are:
    • Ineffective oral hygiene
    • Cigarette smoking
    • Diabetes mellitus
    Older individuals as well as immunocompromised patients are also at risk. It is extremely common, with some degree of the disease occurring in up to 90% of the adult population in the UK. It is estimated to affect a little over 40% of UK teenagers too.
  • Other causes of bleeding gums:
  • Management - this condition should be managed by a dentist. However, in the interim, advise good oral hygiene (see 'Oral healthcare', below) and use of antiseptic mouthwashes (eg chlorhexidine or hexetidine). This is also an opportunity to address the issue of smoking cessation as this also contributes to periodontal disease.

This is a condition caused by primary infection with the herpes simplex virus, often by contact with someone who has cold sores. It predominantly (but not exclusively) affects toddlers and young children and is characterised by an acute onset of fever, malaise, pain and ulceration of both gingiva and oral mucosa. It may be managed with aciclovir (first episode and child presenting within 3 days of onset on symptoms)[11] or conservatively with simple analgesia and (not aspirin). The episode should fully resolve over about 14 days.

Herpetic gingivostomatitis is common in patients being treated for cancer and a Cochrane review found that aciclovir is effective both for the treatment and prevention of this condition.[12]

Also known as Vincent's gingivitis or trench mouth, this is a progressive, painful, acute bacterial infection of the gums. The bacteria involved tend to be those already present in the mouth and it is predominantly associated with anaerobic flora. Although it is not thought to be infectious, it may occur in epidemic form, especially in institutions (eg prisons).
  • Presentation - sudden onset, acutely painful, bleeding gums, excess salivation and ulceration, swelling and sloughing off of dead tissue. There may be difficulty in swallowing or talking and some report a metallic taste in the mouth. Occasionally, it is accompanied by severe halitosis. Risk factors include immunocompromise, malnutrition, smoking, stress and ineffective oral hygiene.
  • Management - these patient should be referred to dentists urgently for immediate treatment and management. Whilst they wait to see the dentist, patients should be prescribed metronidazole or amoxicillin for 3 days, paracetamol or ibuprofen for pain relief and chlorhexidine (0.12% or 0.2%) mouthwash or hydrogen peroxide 6% mouthwash. They should carry on brushing their teeth if possible, using a soft toothbrush.
  • Prognosis - if left untreated, it can spread to involve all the gingiva and spread into the bone, forming intraosseous craters (necrotising ulcerative periodontitis). If inadequately treated, it may lead to recurrent ulcerative gingivitis for many years with halitosis, gingival bleeding and recession of the gums. Inadequate treatment can also rarely lead to noma (rapidly spreading gangrene of the lips and cheeks) - more likely in malnourished or immunocompromised individuals.

Untreated gingivitis can advance to periodontitis which is an inflammation of the periodontal ligament (which attaches the tooth to the bone) and bone. Toxins produced by the bacteria in plaque irritate the gums and stimulate a chronic inflammatory response in which the tissues and bone that support the teeth are broken down and destroyed. There have been suggestions that periodontal disease might be a risk factor for cardiovascular disease and pulmonary infection and that its presence in pregnant women may cause them to have low birthweight or premature babies.[13][14] However, the evidence is conflicting and further studies are awaited.[15][16] One Indian study has found an association between periodontal disease in pregnancy and the development of pre-eclampsia.[17] A Cochrane review has found some evidence that treating periodontal disease may improve glycaemic control in diabetic patients.[18]
  • Presentation - this condition is frequently asymptomatic but, occasionally, the patient may complain of one or more of:
    • Pain (which may or may not be caused by an associated periodontal abscess).
    • Halitosis or a foul taste in the mouth.
    • Recession and associated root sensitivity.
    • Drifting/loosening of teeth causing difficulty in eating.
    Up to 30% of the population may be genetically susceptible to periodontal disease but a number of other factors (see 'Gingivitis', above) also increase risk. Look for bleeding, pus and debris expressible from gingival pockets, loosening or drifting of teeth (there may eventually be tooth loss) and the presence of a periodontal abscess.
  • Management - this is the same as for gingivitis. Ultimately, patients should be seen by a dentist.
  • Prognosis - untreated, periodontal disease can lead to permanent damage to the periodontal ligament and alveolar bone. There may be recurrent gum abscesses or detachment of the gum from the tooth with the formation of periodontal pockets. Progressive deepening of periodontal pockets and recession of the gums can lead to drifting and loosening of the teeth, with loss of multiple teeth.

A severe form of periodontists (formerly known as early-onset periodontists) occurs in patients (usually under the age of 35) who are otherwise clinically healthy. It tends to be associated with Actinobacillus actinomycetemcomitans. There is rapid loss of dental attachments with loss and destruction of bone. Familial aggregation may suggest a genetic predisposition or a poor family tradition of attention to dental hygiene.
Periodontal surgery
In the early stages of periodontal disease, attention to dental hygiene will suffice. Eating less refined carbohydrate and stopping smoking will also help. Scaling and root planing will also help but surgery may be necessary.
There are 4 types of periodontal surgery:
  • Pocket reduction surgery - folds back the gum tissue and removes the bacteria before securing the tissue into place. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where bacteria are sequestered. This allows the gum tissue to reattach to healthy bone.
  • Regenerative procedures - these fold back the gum tissue and remove the bacteria. Membranes, bone grafts or tissue-stimulating proteins can be used to encourage the ability to regenerate bone and tissue.
  • Crown lengthening - is a procedure to remove excess gum and bone tissue to reshape and expose more of the natural tooth. This can be done to one tooth, to even the gum line, or to several teeth to expose a natural, broad smile. It is a restorative or cosmetic dental procedure. If the tooth is decayed or broken below the gum line, or has insufficient tooth structure for a restoration, it can be extracted and a bridge can be used.
  • Soft tissue grafts - stop further dental problems and gum recession and improve the aesthetics of the gum line. Soft tissue grafts can be used to cover roots or develop gum tissue where absent due to excessive gingival recession. Gum tissue from the palate or another donor source covers the exposed root. This can be done for one tooth or several teeth to even the gum line and reduce sensitivity. A soft tissue graft can reduce further recession and bone loss. In some cases, it can cover exposed roots to protect them from decay. This may reduce tooth sensitivity and improve the aesthetics of the smile.

Prevention of gingivitis and periodontal disease requires good oral hygiene (see 'Oral healthcare', below), possible use of antimicrobial mouthwashes and the regular review of a dentist.[19] This is particularly true in diabetics who are more likely to develop infections of the gum and periodontal disease. Other risk factors include puberty and pregnancy as well as bruxism (clenching and grinding of teeth) which can put stress on the structures around the teeth and loosen them. Smoking is also a significant factor in the development and progression of periodontal disease; this is another opportunity to think about stopping smoking.
  • Gastrointestinal disease - the mouth is the first part of the alimentary canal and so, in theory at least, history and examination of the gastrointestinal tract should start with the mouth. Think of this when considering Crohn's disease for example.
  • Non-gastrointestinal systemic disease - conversely, when looking at lesions in the mouth, bear in mind that there could be a systemic explanation, eg mouth ulcers caused by leukaemia, pemphigus or systemic lupus erythematosus.
  • Secondary problems affecting the mouth - the problem you are looking at in the mouth may actually be a secondary problem such as due to insufficient saliva (which is both lubricating and antibacterial, being a good source of immunoglobulin A (IgA)). Disease of both teeth and gums is more common if saliva flow is impaired. This may occur in Sj√∂gren's syndrome, where irradiation to treat cancer may have damaged the glands, in dehydration or when anticholinergic drugs are used.
  • Congenital problems - it could be that the problem occurred before you met the patient: all women are screened for syphilis at booking for pregnancy and so congenital syphilis is now very rare in Western societies. One feature is wide-spread peg-shaped teeth called Hutchinson's teeth.
  • Childhood problems - developing teeth are also affected by the use of tetracycline which discolours teeth. Profound neonatal jaundice may also stain teeth. Poor intake of calcium in the very early years of life can lead to poor calcification of permanent dentition. Gastrointestinal malabsorption may be to blame but, if a child has cow's milk intolerance and animal milk is replaced by soya milk, this will contain insufficient calcium.
  • Iatrogenic problems - finally, drugs may affect both adults and children; for example, phenytoin which can lead to hyperplasia of the gums.
Therefore, when a patient presents with dental or periodontal problems, take a full history (including medical and drug history), consider gastrointestinal causes, systemic causes and iatrogenic causes and, once you are satisfied that these do not apply and the problem is related purely to the teeth or gums, refer the patient on to a dental practitioner.

The most important factors for the prevention of both dental and periodontal disease are a good diet with a minimum of sugar, and attention to oral hygiene.[20][21] But what do we mean when advising 'good oral hygiene'? Below is a synopsis of the current advice about basic oral healthcare.

  • Brush teeth twice a day.
  • Floss teeth three times a week.
  • Visit a dental practitioner or dental hygienist regularly.
Intervals between visits vary depending on the condition of the teeth and any treatment received. However, in the absence of specific conditions needing particular treatment, the National Institute for Health and Clinical Excellence (NICE) suggests intervals no shorter than 3 months and no longer than 12 months (in those under 18 years old) or 24 months in those over 18 years old.[22]

Regular checks by dentists include scaling of teeth (if required) and the identification and early treatment of caries if it occurs. However, there is a severe shortage of dentists in many parts of the country. Dental health of the population has improved in the last 30 years but this has stagnated in recent years.[23] Much attention is paid to the dental health of children but in old people who still have some teeth it is a problem that is aggravated by regression of gums, reshaping of the mandible and a tendency for saliva volume to diminish.[24]

Older people, institutionalised patients, patients with mental health problems and individuals with a learning disability may face particular challenges in managing their oral health. Problems may be experienced due to:
  • Barriers in accessing adequate oral care due to lack of perceived need, inability by the individual to express need and a lack of ability to self-care.
  • Fear and anxieties, which are also significant contributors to poor access to oral care providers.
  • The knowledge and skills of carers may be inadequate.
  • Concurrent illness may take priority and oral healthcare takes a back seat.
Detailed guidance for these specific patient groups are more within the remit of dental practitioners. However, documents outlining these recommendations are included in the further reading section - integrated care pathways are used and there will be an overlap of the services provided to the individual (and these may include the general practitioner).

The first link provided in the Internet and further reading section below can be used to find a local NHS dentist: names, locations and opening hours are provided. It also provides information regarding charges and a number of helpful links to related websites.
This logo signifies that the product has been approved by the British Dental Health Foundation and is a useful guide as to the quality of the item.
  • Relief of toothache:
    • Papyrus records detail Egyptian remedies such as stone powder, ocher (iron ore) and honey. Other civilizations developed plant remedies, including cloves, pepper, cinnamon, poppy seeds, ginger, copal (resin from trees), mint and tobacco.
  • Removal of the tooth and substitution with artificial replacement:
    • Extraction was practised by the Egyptians and in ancient Greece. Hippocratic literature devoted many paragraphs to dental care and included a numbering system for teeth.
    • In Roman times the Etruscans of central Italy made crowns and bridges, gold bands holding cadaver or calf teeth, or artificial teeth made from ivory or bone, though these soon rotted.
    • This skill was largely lost until the 1800s, Elizabeth I using cloth to fill the holes in her mouth to improve her appearance in public.
    • A French pharmacist Duchateau, with dentist Dubois de Chemant, designed the first hard-baked, rot-proof porcelain dentures in 1774 and the Englishman Claudius Ash invented an improved porcelain tooth around 1837.
    • With Charles Goodyear's discovery of vulcanised rubber in 1839 (a cheap, easily worked, mouldable base for false teeth) and Horace Wells' discovery of nitrous oxide for painless teeth extraction in 1844, dentures became popular.
  • Removal of decay and restoration:
    • The oldest filling is >2,000 years old, being a piece of bronze wire inserted into the root canal of a Nabetan warrior in Egypt, believed to prevent 'tooth worms' being thought as the cause of decay well into the Middle Ages.
    • In the Middle Ages resins, waxes and gums were used as fillings, with lead and gold introduced shortly after.
    • The Frenchman Pierre Fauchard is considered the father of modern dentistry, developing an improved drill in 1728. He favoured tin foil or lead cylinders for fillings.
    • US dentist Robert Arthur developed the cohesive gold foil method in 1855.
    • Amalgam (silver, or its alloys, combined with mercury) was developed by the Frenchman Auguste Taveau in 1816, with fears of leaky fillings and the effect of mercury on health surfacing quickly. These were not assuaged until the work of Chicago dentist G V Black in 1895 who standardised both cavity preparation and amalgam manufacture.
  • Prevention:
    • In ancient India and China medical writings recommended a toothbrush made from a frayed twig, and both tongue scrapers and toothpicks were in use.
    • An American dentist trained his office assistant as a dental hygienist in 1906 and set up the first hygienist course in 1913 in Bridgeport, Connecticut. This led to the first dental public health programme.

The author is grateful to Dr D J Ward for his additions in the historical section.
Further reading & references
  1. Marinho VCC, Higgins JPT, Logan S, Sheiham A.; Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD002782. DOI: 10.1002/14651858.CD002782.
  2. Prevention and management of dental decay in the pre-school child, Scottish Intercollegiate Guidelines Network - SIGN (2005)
  3. FAQs: fluoridation, British Dental Health Foundation
  4. British Fluoridation Society; Action group promoting the benefits of fluoride
  5. All Party Parliamentary Group Against Fluoridation; Action group against fluoridation
  6. NHS Evidence; 2010 Oral Health Annual Evidence Update - Dental Caries
  7. Dental abscess, Clinical Knowledge Summaries (January 2008)
  8. Wisdom teeth removal; NICE Technology appraisal, 2003; Summary of advice
  9. Blinkhorn AS, Mackie IC; My child's just knocked out a front tooth. BMJ. 1996 Mar 2;312(7030):526.
  10. Gingivitis and periodontitis - plaque-associated, Clinical Knowledge Summaries (2007)
  11. Amir J, Harel L, Smetana Z, et al; Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ. 1997 Jun 21;314(7097):1800-3. [abstract]
  12. Glenny AM, Fernandez Mauleffinch LM, Pavitt S, et al; Interventions for the prevention and treatment of herpes simplex virus in Cochrane Database Syst Rev. 2009 Jan 21;(1):CD006706. [abstract]
  13. Jeffcoat MK, Geurs NC, Reddy MS, et al; Periodontal infection and preterm birth: results of a prospective study. J Am Dent Assoc. 2001 Jul;132(7):875-80. [abstract]
  14. Lopez NJ, Smith PC, Gutierrez J; Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol. 2002 Aug;73(8):911-24. [abstract]
  15. Moore S, Ide M, Coward PY, et al; A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J. 2004 Sep 11;197(5):251-8; discussion 247. [abstract]
  16. Oliveira AM, de Oliveira PA, Cota LO, et al; Periodontal therapy and risk for adverse pregnancy outcomes. Clin Oral Investig. 2010 May 22. [abstract]
  17. Shetty M, Shetty PK, Ramesh A, et al; Periodontal disease in pregnancy is a risk factor for preeclampsia. Acta Obstet Gynecol Scand. 2010 May;89(5):718-21. [abstract]
  18. Simpson TC, Needleman I, Wild SH, et al; Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database Syst Rev. 2010 May 12;5:CD004714. [abstract]
  19. Coventry J, Griffiths G, Scully C, et al; ABC of oral health: periodontal disease. BMJ. 2000 Jul 1;321(7252):36-9.
  20. Harris R, Nicoll AD, Adair PM, et al; Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004 Mar;21(1 Suppl):71-85. [abstract]
  21. Sanders TA; Diet and general health: dietary counselling. Caries Res. 2004;38 Suppl 1:3-8. [abstract]
  22. Dental recall - Recall interval between routine dental examinations, NICE (2004)
  23. Pitts NB, Boyles J, Nugent ZJ, et al; The dental caries experience of 14-year-old children in England and Wales. Surveys co-ordinated by the British Association for the Study of Community Dentistry in 2002/2003. Community Dent Health. 2004 Mar;21(1):45-57. [abstract]
  24. Atkinson JC, Grisius M, Massey W; Salivary hypofunction and xerostomia: diagnosis and treatment. Dent Clin North Am. 2005 Apr;49(2):309-26. [abstract]

Original Author: Dr Olivia Scott

Current Version: Dr Laurence Knott

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.         

[ Collected from this website ]

Important Ways to Take Care of Your Teeth

Duh. You’ve only been hearing that since you were too small to really understand what it meant, but the importance of daily brushing and flossing can not be overstressed. Even as adults who should know better, we often skip flossing because it’s too painful, time-consuming, or boring.
Why are brushing and flossing so critical to your health? Every day, bacteria grow in our mouths. During the day, saliva washes away much of it, but at night it happily multiplies in the warm, moist environment. At night, you produce less saliva, so the bacteria are less likely to be washed away. The more bacteria you allow to settle on to your teeth and gums, the more likely you are to develop cavities (which is why those bacteria are so often called “cavity bugs” by your friendly dentist), halitosis (bad breath), and gum disease.
Brushing twice a day for two minutes at a time – in the morning and before bed – is a way of removing the bacteria and keeping your mouth cleaner. Use a soft manual toothbrush or electric brush and gently scrub your teeth and gums in a circular motion, being careful to get all the way back to your back teeth
Flossing is just as necessary as brushing. Your toothbrush can remove bacteria and plaque from the outside surfaces of your teeth, but most cavities start as food decays between your teeth, and abscesses, other infections, and gum disease can be triggered by these unattended cavities. Flossing daily in the evening scrapes out bits of food that would otherwise feed the bacteria in your mouth. If you haven’t flossed in a while, your gums might bleed a little, but after a couple of days of gentle flossing, your gums will toughen up.
There are a variety of flosses available, as well, and you can pick exactly the type you like best and that feels good in your mouth. Not only can you choose from the old-fashioned waxed and unwaxed flosses, you can also select a dental tape, which is like a flat ribbon – perfect for sliding between close-set teeth – or single use flossing gadgets where the floss is already tightly attached to a Y-shaped handle, allowing you to easily maneuver the floss one-handed through your mouth. Floss also comes covered in mint to keep your breath smelling bright and fresh. It only takes about 30 seconds to efficiently floss your teeth by sliding the floss side to side and up and down along each of the inner edges between your teeth. Again, don’t miss the back edges of your wisdom teeth. Wisdom teeth are often overlooked and under-flossed, and the neglect makes them prime candidates for decay and infection.

Fruits and vegetables in their whole form – with skin on, if appropriate – provide vitamins, minerals, and other nutrients vital to your body’s overall health. Crunching on apples and carrots also keeps your teeth in top form, as long as the apples and carrots aren’t also sticking around between your teeth at night. Eating deep, leafy greens such as kale, chard, and spinach also provide calcium, which is essential for bone mass. Bone mass and exercise help your teeth in a way we’ll talk about in just a moment.

You know you should stay away from sweets, as sugar is bacteria’s favorite fuel and it doesn’t do your body any good whatsoever. Since it’s nearly impossible to abstain completely, extra brushing after eating sugary foods can help you get fewer cavities.

It may be surprising that exercise can benefit your teeth and gums, but research has shown that exercise increases bone mass. When you begin to suffer from osteoporosis, or a gradual loss of bone density that causes bones to become porous and more fragile, your body will steal calcium, phosphorous, and other minerals from your mouth and jaw in order to maintain the support structure of your skeleton. You might notice that your gums are receding and bleeding during brushing. Your jaw can also become severely weakened.
Exercise and a diet that includes lots of the necessary nutrients – like calcium and phosphorous – that support proper bone density will also keep your mouth happy. Make sure you also get a good dose of Vitamin D, which you can either take in through sunlight or with supplements.

Visiting your dentist every six months for checkups should be a no-brainer, but getting wayward teeth into shape by visiting an orthodontist in Manhattan, Oceanside, or Duluth – wherever you happen to live – is also important. Teeth that grow in crookedly can be teeth that become unhealthy. Not only will the proper methods of straightening or correcting dental abnormalities help you love your smile, it will be easier to keep your teeth clean and healthy. Psychologically, if you love your smile, you are also more likely to be vigilant in keeping it white and bright.
Aside from crooked teeth, an orthodontist can help you solve other problems, such as tooth grinding and TMJ, both of which damage your teeth and jaw over time.
Tooth health doesn’t just affect your mouth. It affects your entire body. Keeping your teeth and gums happy also means you are less prone to other illnesses and infections, and keeping your body happy and healthy means your mouth is less susceptible to disease.

6. Brushing:

 I get a lot of questions about dental hygiene and health, and for good reason. Dental records of our paleolithic ancestors show a fairly low incidence of caries when compared to modern teeth. Exceptions exist, but the general trends suggest that Grok had better teeth than the average contemporary human. Of course, when cavities struck back then, they hit hard and got really ugly, because there were no dentists, drills, or x-rays to fix the problem, but most never got to that point. Also, the adoption of agriculture is generally associated with the emergence of poor dental health, so much so that many researchers use the appearance of dental caries in a population as strong evidence for the presence of farming. Maize/corn is particularly bad, as is wheat, but the same relationship may not hold true for rice agriculture in Asian records.
Okay – let’s take a look at a couple common questions I get about dental health:

Mark, this morning as a dental assistant was making my head buzz and my gums hurt with some sort of ultrasonic tooth cleaner, I thought, “what can Grok teach us about tooth care?” Something tells me Grok did not brush his teeth–did he do anything to take care of himself in that way? And if he survived just fine, what does that tell us about “conventional wisdom” that says we should adopt a routine, and buy a medicine cabinet full of stuff to take care of our teeth? I certainly don’t mean to convey that tooth care is bad–but rather am just thinking about what we can learn from the past to harmonize the present.
Thanks for reading this, and thank you for your dedication to better health!
Hey Mark! I’ve recently taken an interest in making my oral regimen more Primal. I’ve read up on a lot of the more natural toothpastes and toothpaste alternatives but I’m undecided. What have you and your wife found to be the safest and most effective way to keep your cavities at bay?? Thanks!
Before resorting to anything reactive, whether it be brushing with homemade toothpaste, dousing your oral cavity with anti-bacterial mouthwash, bypassing the teeth altogether with an IV nutrient feed, or using a dental dam to chew, those seeking excellent dental health should establish a strong dietary foundation of the minerals, micronutrients, and other cofactors that play major roles in the maintenance of teeth.


7. The Vitamin D/A/K2 Connection

You’ve probably heard about how this holy trinity of micronutrients works together to promote proper bone and tooth mineralization, which means putting calcium and other minerals where they belong (bones, teeth) instead of where they don’t (arteries, dental calculus/plaque). Both Stephan Guyenet and Chris Masterjohn have written extensively about the synergistic interplay between the three nutritional factors, so I’ll keep this brief. Get adequate midday sun or take vitamin D supplements; eat grass-fed butter, hard cheeses, and organs (especially goose liver, apparently), or supplement with vitamin K2; get plenty of vitamin A from liver, egg yolks, and other animal products.


8. Grain Avoidance

I probably don’t have to tell you to avoid grains, but for any newcomers who might be reading: ditch the grains, beans, and other legumes that contain high levels of phytic acid, which is known to bind to and prevent absorption of minerals critical for dental health. Nuts also contain phytic acid, but we tend not to eat as many nuts as grains or legumes due to the caloric load. It’s a lot easier to eat two cups of whole wheat than it is to eat two cups of almonds. If you do eat nuts on a regular basis, consider soaking and/or sprouting them to reduce phytic acid content.


9. Nutrient Intake

It’s not enough to consume the holy mineralization trio and avoid excessive amounts of mineral-binding phytic acid; you also need the raw building blocks. That means getting plenty of minerals in your diet. Leafy greens, grass-fed meat, organs, nuts, roots, and tubers are all good Primal sources of calcium, phosphorous, magnesium, and other vital micronutrients – vital for general and dental health – so eat plenty of them.


10. Hate the Toothbrush? Use a Chewstick

There are numerous examples of traditional cultures using chewing sticks from trees with medicinal or antimicrobial properties, like the neem in India, the miswak/arak in Africa, the Mid East, and Asia, or the tea tree, which I mentioned in a previous post. Here’s an example of a Masai “toothbrush” – it’s a whittled-down branch from a (perhaps medicinal) tree with the end frayed and the fibers splayed out to permit interdental entry. If you don’t have access to a miswak, neem, or tea tree, you can find chew sticks online quite easily. Toothpicks or floss will also work pretty well as a physical deterrent, albeit without any medicinal qualities.
There isn’t a ton of head-to-head research on the subject, but one study from 2003 found that miswak chewing sticks removed more plaque and resulted in better gingival health than toothbrushes. The caveat is that chew stick users had to be instructed in the proper use of the implements, whereas toothbrushes are fairly straightforward (not to mention most of us have grown up using them, so we’re well-versed in toothbrushing). It’s notable that chew sticks do not require toothpaste, and they appear to be just as, if not more, effective than toothbrushes. Longer history of use, too. You just have to know how to use it. Miswak appears to be the most studied, so you’ll probably want to use that variety.


11. Toothpaste

 If you’re gonna use a toothbrush, do you need the paste? If so, is Crest/Colgate/insert-mainstream-paste-here good, or should you go with an herbal/alternative/insert-paste-available-at-Whole-Foods-here instead?
Toothpaste use increases abrasion during brushing, while water alone produces less abrasive force. Interestingly, the same study revealed that softer toothbrushes actually cause as much abrasion (and sometimes more) than stiffer toothbrushes. While increased abrasive forces seem like they’d reduce more plaque, that doesn’t seem to be the case. A recent study found that the brushing is the important part, not the paste. In fact, brushing without paste was more effective at removing plaque than brushing with paste.
An herbal toothpaste made from herbs and plants traditionally used to treat oral disease in India was superior to a placebo toothpaste in the treatment of gingival bleeding and oral hygiene. Another study compared herbal toothpastes to conventional fluoride-containing toothpastes in the treatment of established gingivitis and found that both were equally effective.
In another study, a baking soda toothpaste beat an antimicrobial non-baking soda toothpaste in plaque removal and tooth maintenance. Most studies, in fact, show that baking soda is more effective at plaque removal than toothpastes without baking soda. It’s pretty common among older folks to just use straight baking soda to brush, and this seems to be an effective tactic.
If you’ve got all the nutritional and environmental cofactors under control, I don’t think obsessive dental hygiene beyond daily brushing (remember, even if the bristly toothbrush is a recent invention, cleaning our teeth with sticks or picking at them with fingernails is tradition), some toothpicking/flossing, regular dental visits, and/or maybe some chew sticking is necessary. It doesn’t even seem like toothpaste is necessary for good oral health. That said, I do use it – perhaps because I’ve just become conditioned to, or maybe because I need the artificially fresh feeling it provides – but I also don’t feel the pressing need to brush on schedule. I just don’t develop a ton of plaque if I go a bit longer than normal without brushing, nor do I get bad breath. And as anyone who’s been married for more than ten years will tell you, the wife will definitely let you know if things go awry in that area. If you want a cheap toothpaste that isn’t overly sweet, baking soda should do the trick.