Common Dental Problems in Malaysia

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Dental plaque also plays a role in gum disease
Dental plaque also plays a role in gum disease

“I love to eat an apple after a meal, just to cleanse my teeth —they always look polished afterwards” Catherine Zeta-Jones

What Else Can Go Wrong with My Mouth and Teeth if I Am Not Careful with My Diet or Home Care?

We have already discussed dental plaque and its role in tooth decay. It is important to remember that tooth decay is an infection of the tooth which, if allowed to proceed untreated, will usually result in the death of the tooth and formation of a dental abscess. These bacteria and their toxic products may also possibly spread to other organ systems thereafter through the circulatory system. 

In historical times or under more primitive conditions, an untreated toothache could and has killed someone. 

An example: a woman in Kuantan began to feel ill and was admitted  to the local hospital. Tests were run. Scans were made. Yet her condition continued to deteriorate, much to the consternation of the doctors treating her. They were completely stumped. Finally, someone got the bright idea of checking her teeth. X-rays were taken and an abscessed tooth, which was not hurting her at all, was identified. The tooth was treated and her health returned to normal. She returned to a normal life.

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It is important to remember that when doctors look in a patient’s mouth, the first thing they typically notice is the tongue and tonsils. It is a rare doctor, indeed, who can recognize any but the most obvious dental diseases.

Dental plaque also plays a role in gum disease. Each tooth is suspended in its socket by a network of fibers. These suspensory fibers are embedded at one end in the cementum covering the root of the tooth, and the other end in the bone of the socket wall. There are also blood vessels and nerve fibers running through this suspensory ligament (the periodontal ligament). 

This ligament at the oral end begins with the fibers attached to the tooth from the gum tissue which form a cuff of tissue (sulcus) surrounding each tooth. In good health, this cuff should be no more than 3-4 mm deep from the crest of the gum tissue to the depth of the cuff. If dental plaque is allowed to accumulate and mature within the sulcus, the toxic/acidic by-products of the bacterial inhabitants of the plaque begin to attack the attachment of the gum tissue to the tooth and the bone underlying it in such a way that the attachment begins to migrate down the root with or without accompanying loss of height of the gum tissue around the tooth. 

If the gum tissue around the tooth begins to look red and puffy and bleeds easily when brushed or flossed, but the bone is not yet involved, the condition is termed "gingivitis", an infection of the gum tissue. 
If the gum tissue around the tooth begins to look red and puffy and bleeds easily when brushed or flossed, but the bone is not yet involved, the condition is termed “gingivitis”, an infection of the gum tissue. 

A periodontal (peri – around, dontal – tooth) pocket develops over time greater in depth than the healthy 3-4mm. Once the depth of the pocket surpasses 5mm, it is no longer physically possible for a person to get into the pocket effectively to clean it and certain pathogenic changes begin to occur. 

The bacterial population in the pocket begins to change and become more virulent if the process is not arrested by the dental professional. With increased virulence, the tissue attachment and surrounding bone begin to deteriorate more rapidly.

If the gum tissue around the tooth begins to look red and puffy and bleeds easily when brushed or flossed, but the bone is not yet involved, the condition is termed “gingivitis”, an infection of the gum tissue. 

Gingivitis is a condition which is completely reversible if immediate steps are taken to thoroughly clean the teeth and then establish regular daily brushing and flossing routines. 

Patients in this condition may or may not feel any pain but will notice bleeding of the gums in certain areas when brushing and flossing. It may take as much as two weeks of diligent home care after first seeing a dental professional to return the gum tissue to normal health: pink, knife-edged tissue, firm and not bleeding. If the process is not interrupted and allowed to continue, and the bone underneath the infected gum tissue becomes involved (sulcus depths ›5mm), the condition is termed “periodontitis” or periodontal disease.

This periodontal disease can be acute (rapid onset), or chronic (develops over a long period of time), moderate, or severe. Besides inadequate oral  hygiene, this condition is also greatly affected by your heredity. 

If your parents lost their teeth early in life and needed dentures as a result, then there is a good chance that you may have a greater risk of developing the condition than the average person. That does not mean you are doomed to the same fate, only that you must devote more attention than the average person to diet and oral hygiene to avoid the same outcome. 

Periodontal disease, on the other hand, once diagnosed, is a genetic susceptibility to a condition that will need to be monitored and carefully managed by both you and your dental team for the rest of your life if you wish to keep your teeth. No one is ever "cured" of periodontal disease.
Periodontal disease, on the other hand, once diagnosed, is a genetic susceptibility to a condition that will need to be monitored and carefully managed by both you and your dental team for the rest of your life if you wish to keep your teeth. No one is ever “cured” of periodontal disease.

Your first indication that something like this may be happening (if you have been avoiding the dentist for some time) might be a bad taste in the mouth or chronic bad breath. Again, at this point it must be stressed that you must seek regular professional care (on average, at least every six months) to avoid allowing things to get out of hand. It is supremely important to remember that pain is not a good indicator of need; contrarily, lack of pain does not mean there are no problems present!

Furthermore, Periodontal Disease is not a disease in the sense that a cold or flu is a disease. With a cold or flu, you contract it, suffer through the symptoms, then the disease passes and the you are cured, that particular strain of bug never to return. 

Periodontal disease, on the other hand, once diagnosed, is a genetic susceptibility to a condition that will need to be monitored and carefully managed by both you and your dental team for the rest of your life if you wish to keep your teeth. No one is ever “cured” of periodontal disease.

Untreated periodontal disease can have wide ranging effects on your overall health and other organ systems as well. More and more evidence is being found that shows a link between periodontal disease and heart disease, stroke, diabetes, and poor pregnancy outcomes, just to name a few. 

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In one sense, the mouth is the gateway to your body’s overall health.  Another very self-destructive habit that may occur in a person’s mouth is teeth grinding (Bruxism) or clenching. This habit may be triggered by excess stress, or bite misalignments (malocclusion: disharmonious contacts between upper and lower teeth). 

Bruxism requires intervention if a person is to avoid wearing the teeth away to a fraction of their original length or creating notches (abfractions) in the gum line areas of the teeth.

Very often the patient is totally unaware that bruxing or clenching is going on. It usually happens during sleep and is diagnosed at a dental checkup by a professional looking for such damage or a sleeping partner reporting the noisy event. 

If caused by malocclusion, Bruxism needs to be corrected by the dentist selectively adjusting the patient’s bite. It may take more than one visit to get everything functioning properly, but the bite will eventually settle in properly. 

One major concern is that if Bruxism continues after the adjustment, the malocclusion may redevelop. At this point in time, just following the adjustment, it would be a great time to have a night guard fabricated. 

Teeth are designed to take the forces of chewing along their long axes (vertical forces). When a person grinds his teeth in his sleep, he applies horizontal forces to the teeth, alternately applying compressive and tensile forces to the necks of the involved teeth. If the supporting bone is not strong, these forces may result in a loosening of the tooth in its socket (like alternately pushing and pulling on a fencepost). 

If the supporting bone is stronger than the tooth, then the tooth structure may deteriorate at the weakest point, that is, at the neck of the tooth just at the gum line, either cheek side or tongue side of the tooth. This is a mechanical process rather than a result of tooth decay and is termed an “Abfraction” 

If the supporting bone is stronger than the tooth, then the tooth structure may deteriorate at the weakest point, that is, at the neck of the tooth just at the gum line, either cheek side or tongue side of the tooth. This is a mechanical process rather than a result of tooth decay and is termed an "Abfraction" 
If the supporting bone is stronger than the tooth, then the tooth structure may deteriorate at the weakest point, that is, at the neck of the tooth just at the gum line, either cheek side or tongue side of the tooth. This is a mechanical process rather than a result of tooth decay and is termed an “Abfraction” 

On the inside of the lower arch, this buttressing may take the form of one or more rounded bumps called “Tori “- singular: “Torus”. Tori, continue to grow slowly throughout life and may also form in the midline of the palate creating problems for denture wearers and the proper fit of their prostheses.

Abfractions are often confused with “Abrasion”. Whereas, Abfractions have relatively sharp edges and are distinct notches in the necks of the teeth, Abrasions are relatively smooth concavities in the gingival (gum line) or middle thirds of a tooth caused by an aggressive horizontal brushing technique with a toothbrush that is too hard or a paste which is too abrasive (Any soft, rounded-end, nylon bristle tooth brush or dentifrice displaying a symbol indicating acceptance by the Malaysian Dental Association are acceptable for good home care). Typically, Abrasion is found on canines and premolars.

Teeth Abrasion

“Attrition” is excessive tooth wear on incisal or occlusal surfaces of the teeth. It results, in time with teeth that appear much shorter than they should be. It can be the result of Bruxism or a diet which has a great deal of grit in it. Bruxism was discussed above. 

A gritty diet is generally found in more primitive cultures where stone ground grains are consumed as a dietary staple. An additional interesting example of attrition involves a story revolving around the plains Indians in the early days of this country. Part of the work the women would do was chewing on buffalo hides to make them pliable enough to use as coverings for their homes and to make clothing. 

Also, the women would grind their corn using stones which would result in gritty meal, and therefore gritty bread. Both of these activities contributed to accelerated attrition of the teeth. When their teeth were abraded to the point where they could no longer work or eat properly, they would often starve

"Attrition" is excessive tooth wear on incisal or occlusal surfaces of the teeth.
“Attrition” is excessive tooth wear on incisal or occlusal surfaces of the teeth.

Not to be overlooked, “Root Canal” is a term that sends shivers down the backs of many people. It is greatly overrated by those who do not know the procedure. Essentially, it is only a filling only deeper. 

Rather than just removing decay and restoring a tooth, the entire pulp and its contents are removed, the tooth innards are cleansed and shaped, and an inert rubbery filling material called “gutta percha” is placed in the canal spaces formerly occupied by pulp tissue. Think of a rubber cork in a glass bottle if you will as an analogy. Undergoing root canal (Endodontic Therapy) is no worse than getting a tooth filled. 

Also, if one wonders why it is that the body cannot deal with a tooth infection all by itself with its immune system, just remember that the white blood cells that the body uses to fight infection have to travel through blood vessels to reach the infection site.

They cannot move into a tooth’s root system without a healthy system of blood vessels to transport them. The closest they can get to an abscessed tooth is the perimeter of the abscess outside the tooth’s roots. The necrotic contents of the tooth will remain a continuing irritant feeding the abscess around the roots until the abscess is dealt with by the dentist one way or another.

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If an individual has decay in a tooth that is allowed to enlarge to the point where it invades the pulp, many possible outcomes may ensue. No matter the symptoms, the pulp will die. If it dies rapidly, faster than the body’s immune system can accommodate the physiologic changes, than a toothache will occur. 

The classic presentation of a patient in this condition is one in which the patient comes into the office with a cup of ice water and takes a sip of the water every few seconds. Cold is the only thing that will relieve this pain. 

If the tooth is not attended to immediately, the infection may spread outside the apex of the tooth into the surrounding bone causing pain or cellulitis (classic swelling of the face associated with a tooth ache). Dentists refer to this situation as a “hot tooth” and it may be very difficult to achieve sufficient anesthesia to treat the tooth until a patient has been placed on antibiotics for a few days first. 

Why? The acidic nature of the break-down products of a necrotic pulp make it difficult for the anesthetic solution to work properly on the nerves in the immediate area. A dental anesthetic must be both water soluble (break into ions) to pass through the tissue fluid to reach the nerve site and then reassemble into its original form (which is fat soluble) to pass through the fatty nerve sheathe to interrupt nerve transmission of pain impulses. 

The acidic nature of the abscess makes reassembly of the ions into the original anesthetic much more difficult, thus preventing sufficient anesthetic from entering the nerves in the immediate area. 

Being on an appropriate antibiotic for a period of three or four days helps reduce the acidity in the area, returning the area’s chemistry to a more normal state so that the anesthetic may do its job properly. 

Usually, a dentist will also prescribe some form of pain medication to cover the first few days after starting to take the antibiotic to help ease the patient’s discomfort until the antibiotic can kick in. 

Once the antibiotic has had several days to work, it alone will be sufficient to deal with the pain. This does not mean that the problem is solved. If the tooth is not treated with a root canal to be saved, it must be removed, as the pain will surely return with a vengeance if nothing is done.

Why do teeth die after an injury? Consider what happens when you injure any other part of your body. At first the area may not feel anything at all – like going into shock. Then you may or may not feel pain. Next comes swelling of the damaged area. 

But wait! The tissue inside the tooth is encased in an inflexible casing made up of dentin, cementum, and enamel. If the tissue swells enough it may put sufficient pressure on the blood vessels to stop the blood supply to the rest of the cells that make up the pulp tissue. 

If that happens for a long enough period of time, the cells will begin to die for lack of oxygen, food supply, and waste product removal.

Other than unchecked decay, the tooth may be injured as a result of an accident or by excessive bruxism. At one extreme the pulp may be exposed and the need for a root canal would be obvious. 

At the other extreme the tooth may be merely display an increased sensitivity to pressure applied to the chewing surface of the tooth. If there is enough remaining tooth structure, the tooth may be treated with a root canal, a subsequent crown and be saved. If too much tooth structure is Damaged, the tooth will have to be removed. 

Sometimes the process of pulp death occurs so slowly that the patient is completely unaware that a problem exists.
Sometimes the process of pulp death occurs so slowly that the patient is completely unaware that a problem exists.

Sometimes the process of pulp death occurs so slowly that the patient is completely unaware that a problem exists. The body’s immune system is able to accommodate the changes the tooth goes through if it happens at a pace the body can keep up with. 

In such instances, the only way to diagnose a problem that exists is with a full mouth series of x-rays wherein the dentist can view the entirety of the tooth in its socket along with the surrounding bone. Any substantial increase in the width of the periodontal ligament space near the apex of the roots would tend to indicate such a problem. 

Further examination of the tooth in question with a device called a “pulp tester” would then be in order, along with exposure to heat, cold, and sensitivity to percussion (tapping on the tooth).  A non-responsive tooth most likely indicates death of the pulp, 

Referred pain is always a possibility that must be considered when a patient comes in complaining about a tooth that shouldn’t be hurting, but is seemingly the source of discomfort . 

One last common event that is frequently seen in a population is the cracked tooth. Whereas a tooth requiring a root canal generally responds to a stimulus that produces pain that lasts longer than five minutes and often is a dull throbbing type of pain that slowly dissipates (unless the tooth is a “hot tooth” as previously described, whose pain seems to be originating from the center of Hell and is pretty constant). 

A cracked tooth, by contrast produces a very sharp pain that goes away when the biting pressure is eased. What is happening is that an upper tooth is engaging a lower tooth and contact forces the cusps (points) on the affected tooth to try and move laterally in opposite directions, stretching  the crack. 

If the crack is fairly shallow, a crown is in order to hold all the parts of the affected tooth together. If the crack has propagated more deeply and engaged the pulp, a root canal must be done first before a crown can be placed. 

If, however, the crack extends below the pulp and into one or more of the tooth’s roots, the tooth cannot be treated with a root canal and must be removed. In such a case, a root canal would be a waste of money since the tooth will eventually fail due to leakage and bacterial invasion through the crack. 

There are also genetic abnormalities that can affect a person’s teeth. Just to mention a few: Enamelogenesis Imperfecta occurs when there is an overall malfunction in the production of dental enamel in early development. 

The teeth erupt normally but the enamel covering of the teeth is soft and wears off easily. Dentinogenisis Imperfecta is another example of genetic disturbance that causes the dentin to be improperly formed resulting in “soft teeth” which, like Enamelogenesis Imperfect are easily decayed and lost. 

Gemination or twinning of teeth produces one tooth from two developmental buds that fuse together while growing. Supernumerary Teeth are extra teeth that occur during development (typically in the third molar areas, premolars, or between the central incisors) and Congenitally Missing Teeth are teeth which never form at all. Mulberry Molars are malformed molars of a typical shape which usually occur in a child whose mother had syphilis while she was pregnant.

There are many other oral conditions and diseases of the mouth. I would encourage the reader interested in pursuing other pathologies to do a “Google” search and see the wide variety of conditions which could affect an individual under the appropriate conditions. They’re far too numerous to mention here. 

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