Tooth and Periodontal Disease: A Review for the Primary-Care Physician.

ABSTRACT: Dental diseases are widespread and are often underrecognized and treated. Caries and periodontal disease are common dental conditions that cause the majority of tooth loss. Although these conditions are preventable, many persons do not receive regular dental care and have acute problems when seen by their physician. Dental diseases frequently affect patients with multiple systemic disorders, including autoimmune disorders, diabetes, and human immunodeficiency virus (HIV) infection. The presence of dental disease may trigger inflammatory responses and have systemic consequences. Since dental disease affects almost all individuals, physicians should be able to recognize common conditions such as caries, periodontal disease, pulpitis, and dental abscess. In addition to initiating treatment and appropriate dental referrals, physicians should be familiar with the management of antibiotics and medications in the perioperative period. Another important role for physicians is to help reduce the societal and economic impact of these diseases through patient education and prevention.

COUNSELING PATIENTS during the periodic health examination about dental health and methods to reduce dental disease is recommended by the US Preventive Services Task Force. [1] In addition, inspection of the oral cavity is often expected by patients in ambulatory settings. [2] Adults at high risk for tooth decay, periodontal disease, and oral cancer are significantly more likely to visit a physician than a dentist and frequently go to emergency rooms, urgent care centers, and physicians' offices for treatment of acute dental conditions. [3,4] In these cases, the management of nontraumatic dental problems by physicians is often empiric and symptomatic, rather than diagnostic. [5,6] To help increase familiarity with these diseases and aid physicians in diagnosis, management, and prevention, we review common dental diseases that clinicians may encounter in outpatient practice.

DISEASES OF THE TEETH

Adults have 32 permanent teeth, including the incisors, canines, premolars, and molars. As shown in Figure 1, the crown of a tooth rises above the gingiva, and the root is the portion embedded in alveolar bone. The periodontal ligament suspends a tooth and its roots in the bone and is made up of collagen fibers. The major component of teeth is a bone-like substance called dentin. Inside the tooth lies the pulp, containing blood vessels and nerves. The crown is covered by enamel and the roots are covered by cementum.

Diseases of the teeth are frequently identified by clinical inspection of the oral cavity and by x-ray examination. Common radiographs include periapical views to identify the crown and root, bite-wing radiographs to examine the interproximal spaces, occlusal views to image large segments of the dental arch, and panoramic views to identify both dental arches and their supporting structures. [7] Periapical, bite-wing, and occlusal radiographs are intraoral films made by placing film inside the patient's mouth and directing the x-ray beam through the area to be imaged. [8] Panoramic radiographs, which are extraoral films requiring special equipment to obtain, are frequently used since they can display the entire maxillomandibular region on a single film. [9]

Caries may occur on smooth tooth surfaces, chewing surfaces, and most commonly in pits and fissures (Fig 2). To prevent caries in the pits and grooves of occlusal surfaces of posterior teeth, dental sealants have been developed. These materials modify the resistance of teeth to caries by coating the occlusal grooves with an adherent material such as a plastic resin. Dental sealants are currently indicated for newly erupted teeth with significant pits and fissures or for patients with significant previous occlusal caries. [12] Once dental caries occur, they are treated by removal of the affected tissue and replacement with a restorative material such as silver amalgam, gold, or composite. The primary goal, however, is prevention of caries through dietary modification, limitation of sucrose-containing food, use of fluoride supplements, and antibacterial measures such as daily personal oral hygiene and regular professional cleanings.

Dental caries, or injury and destruction of the calcified structures of the teeth by Streptococcus species and other bacteria, continue to be extremely prevalent in the United States. Although less than 15% of US adults are free of caries, the absolute number of caries per individual during the past 50 years has declined. [10] This is due in part to preventive measures such as water fluoridation and the use of toothpaste, supplements, and mouth rinses that contain fluoride.[4,11]

During office visits with patients of all ages, physicians are advised to counsel regular visits to a dental care provider and daily flossing and brushing. [1] However, in 1997, only 64.9% of the US population aged 2 and older had a dental visit within the preceding 12 months. [13] One barrier is cost, since more than half of all expenditures for dental care are out-of-pocket. [14] This is especially true for elderly patients, since cleanings, fillings, extractions, and denture preparation are not covered by Medicare. [15,16] A broader range of services are available under Medicaid, but benefits and eligibility may vary. A survey by the American Dental Association in 1995 found the average fee for an oral examination with x-rays was $83, crown placement $550, and dentures $705 per arch. [17]

Although cost may be an important factor, compliance with screening recommendations is also suboptimal, even when dental care is available at no monetary cost to the patient. In one study, which evaluated patients eligible for dental care within the VA system, only 62% reported a dental visit within the past year. [18] By 1987, 100 million Americans had dental insurance. [14] Although this should improve access, almost one third of persons in this group have not had a dental visit within the past year. [4]

Since significant numbers of persons in the United States have not had recent dental care, it is important for physicians to be aware of several groups of patients who may be at increased risk for dental caries and require further counseling and intervention. Patients with physical handicaps or neurologic, psychiatric, or arthritic conditions may be less able to provide self-care. Substances such as tobacco and alcohol and contact with acid due to recurrent vomiting or gastroesophageal reflux disease may cause erosion and subsequent injury to teeth. [19,20] Xerostomia may predispose patients to caries. This condition affects patients with Sjogren's disease or those who use medications that cause xerostomia, including antidepressants, antihypertensives, antipsychotics, duiretics, and antihistamines. [21,22] Patients receiving radiation therapy for head and neck cancer are at risk for salivary gland dysfunction. [23] Appropriate considerations in these individuals include increased frequency of mechanical plaq ue removal, use of a modified toothbrush, use of chlorhexidine mouthwashes, and topical fluoride prophylaxis. [24,25]

If dental caries are not properly recognized and treated, complications may occur. Spread of infection from the hard tissues of the teeth to the pulp results in reversible or irreversible pulpitis. [26] Reversible pulpitis is manifested as transient pain in response to thermal stimuli. Analgesics, avoidance of extreme temperature stimulation, and dental referral for therapy are appropriate. If the infection progresses, irreversible pulpitis may occur. This is evidenced by persistent, often throbbing pain, which may be worsened by heat and relieved by cold. [27] Pulp removal by root canal or tooth extraction is usually required. [28] The root canal process involves removal of infected tissue, cleansing of the area, and filling of the canal with an inert material. After root canal treatments, coronal restoration with a crown is often required to prevent tooth fracture or carious recurrence. [29,30]

In some cases, the inflammation and infection of the pulp may extend beyond the tooth to the periapical tissues of the periodontal ligament. [28] This is suggested by exquisite pain on chewing, touch or percussion of the teeth, and usually requires pain medication in addition to local therapy. If fever, lymphadenopathy, tooth mobility, or edema of the soft tissues is also present, a periapical abscess may have developed, and antibiotics and incision and drainage are needed. [27]

The presence of a periapical abscess is an indication for rapid intervention to avoid complications such as cellulitis, bacteremia, and spread to adjacent tissues of the head and neck. One such example is Ludwig's angina, a medical emergency resulting from seeding of the submandibular space by an infection arising in the second or third lower molars. The patient may have had a recent dental procedure, and presents with pain, fever, drooling, dysphagia, and dyspnea. Cellulitis of the neck, tongue elevation and soft-tissue swelling may be observed on physical examination. [31] Airway management, antibiotics to cover oral pathogens, and surgical drainage are the mainstays of therapy.

Because physicians frequently encounter patients with dental complaints, familiarity with the initial management of these conditions is important. Issues that may arise include the appropriate use of antibiotics and the indications for immediate dental referral. Antibiotics may be unnecessarily prescribed in up to 30% of cases, which may increase costs and risk of side effects. [32] Since the primary management of acute dental conditions is mechanical, antibiotics should be reserved for the treatment of an established infection, such as a periapical abscess, or for periprocedural prophylaxis against bacterial endocarditis. [33] When needed, penicillin and its derivatives, erythromycin, clindamycin, and metronidazole are appropriate adjuncts to definitive dental treatement. [32] In contrast, pulpitis or tooth pain, the most frequent dental complaint, is treated by removing affected pulpal tissue, and antibiotics are not indicated.

In addition to the use of antibiotics, physicians should be aware of the indications for acute dental referral, or need for care within 24 hours. As summarized by Dunne, [34] indications include (1) severe, acute pain that cannot be relieved by removal of thermal stimuli or analgesics; (2) trauma, especially if teeth have been avulsed; (3) orofacial swelling that is new or enlarging; (4) bleeding that cannot be stopped; and (5) fever due to dental infection.

PERIODONTAL DISEASE

The accumulation of bacterial plaque on teeth induces a host response resulting in soft-tissue destruction and tooth loss. Although periodontal disease is common, affecting 30% of young adults and more than 80% of persons over 65 years of age, most cases are asymptomatic. [35,36] This chronic and progressive condition begins as inflammation of the gingiva (gingivitis) and may spread to the periodontal ligament and alveolar bone (periodontitis). Gingivitis may be suggested on physical examination by a darkening of the gingiva from their normal pink to bright red due to increased vascularity. As the inflammatory process spreads from the gingiva to the supporting tissues, the attachment of the gingiva moves down the root of the tooth. When the space between the tooth and soft-tissues becomes greater than 3 mm deep it is referred to as a periodontal "pocket." Probing of this crevice to measure depth is important for the diagnosis and staging of periodontal disease. [37] Symptoms of periodontitis include pain, lo oseness of a tooth, and bleeding from the gums during brushing or eating. Approximately 7% to 15% of adults may have signs of severe periodontitis including attachment loss, formation of pockets, and bone loss on x-ray. [38]

Bacteria associated with periodontal disease include gram-negative organisms such as Porphyromonas gingivalis and anaerobes such as Actinobacillus actinomycetemcomitans and Bacteroides species. Deposits of grey-yellow bacterial plaque on the teeth in conjunction with erythema, edema, and bleeding of the gingiva are seen in gingivitis. In periodontitis, these symptoms and signs may be accompanied by halitosis and an unpleasant taste, but pain is not usually present. As the infectious and inflammatory process continues, the teeth may become loosened, and destruction of the periodontal ligament and supporting alveolar bone occurs. Spaces may develop between teeth, chewing may be difficult, and abscesses may occur. It is postulated that a nidus of infection such as a food particle or fragment of mineralized plaque (calculus) may become imbedded in a pocket and contribute to the development of a periodontal abscess (Fig 3) [39] Pocketing, gingival swelling, and bleeding on stimulation are present on clinical exam ination. [40] Treatment options include antibiotics that are active against oral flora, thorough irrigation, and consideration of incision and drainage. [39,40]

Prevention, early recognition, and treatment of periodontal disease are crucial to avoid the sequelae of inflammation and infection that lead to tooth loss. Local therapy to remove bacterial plaque and mineralized plaque or calculus includes regular dental visits, daily brushing and flossing of teeth, and the use of topical antibacterial rinses and mouthwashes that may help to prevent plaque accumulation. Surgical debridement of the infected tissues and reduction in pocket size may be necessary in severe cases.

Reducing the bacterial load has been the mainstay of treatment for periodontal disease, but new treatments are being investigated. One recent study with short-term follow-up suggested that estrogen supplementation in postmenopausal women can reduce the clinical signs of gingival inflammation and, slow the progression of periodontal disease. [41] Periostat (CollaGenex Pharmaceuticals, Newtown, Pa), a subantimicrobial dose of doxycycline that inhibits collagen destruction, was recently approved for adjunctive use in the treatment of periodontitis after clinical trials showed a reduction in disease in treated patients as compared with those given placebo. [42,43]

Several groups of patients are at high risk for periodontal disease and may require aggressive personal hygiene and frequent dental visits. Patients with HIV infection or leukemia may have rapidly progressive periodontitis, and those with inflammatory conditions such as rheumatoid arthritis and Crohn's disease may be severely affected. [44-46] Individuals with uncontrolled type I and type II diabetes mellitus have a higher incidence of periodontal disease, and once established, the disease progresses more rapidly than in nondiabetic patients. [37] Although not completely understood, this relationship between diabetes and periodontal disease most likely involves alterations in host defenses, microangiopathy, and compromised wound healing. [47] Pregnancy may exacerbate chronic gingivitis and cause proliferative responses in the soft-tissues that often regress after parturition. [48] Certain medications such as nifedipine, cyclosporine, and phenytoin are well described causes of gingival overgrowth and subseque nt inflammation and plaque accumulation (Fig 4). In these cases, discontinuance of the causative medication is appropriate. Resection of the hyperplastic tissue may be required in some instances for optimal control of plaque. [36] Chronic alcoholism can also predispose individuals to periodontal disease.

In addition to local complications, periodontal disease may have systemic consequences. Bacterial respiratory tract pathogens colonize dental plaque and are believed to contribute to pulmonary infections and exacerbations of chronic obstructive pulmonary disease through aspiration, generation of cytokines, and alterations in the antibacterial properties of saliva. [19] In patients in intensive care units, this colonization has been prospectively linked to the development of nosocomial pneumonia and bacteremia. [50] Further research is needed to determine whether improved oral health and a reduction in the presence of pathogenic oral bacteria can reduce the risk of respiratory tract infection in high-risk patients.

Recently, much attention has been given to the possible relationship between periodontitis and the development of atherosclerosis. This was postulated after showing that bacterial species such as Porphyromonas gingivalis can activate thrombotic pathways and that periodontal infections are associated with release of cytokines and other inflammatory mediators. [38,51-53] Although some studies have shown an increased risk of subclinical atherosclerosis and coronary artery disease in persons with periodontitis, treatment of periodontal disease has not yet been proven to reduce the incidence or severity of these conditions. [38,54]

EDENTULOUS PERSONS

An important predictor of health is the retention of natural teeth with age. In 1993, however, 33% of Americans over the age of 65 were edentulous, and only 16% of these persons visited a dentist. [55] Physicians may, therefore, play an important role in the oral health of edentulous persons.

The loss of natural teeth affects the ability to eat, speak, and chew, and may lead to costly restorative and rehabilitative care. Dental caries and periodontal disease cause the majority of tooth loss, though other causes include trauma and complications from treatment of oral cancer.[56] Disabilities that result from tooth loss may not be reversible, even with proper-fitting dentures. Tooth loss is considered largely preventable through education, personal hygiene, dental care, and community preventive measures, such as water fluoridation.

One option to replace lost teeth is the use of dental implants. These contain a titanium screw and are permanently osseointegrated into alveolar bone. Full dentures or single tooth units are then attached for cosmetic and functional purposes. Removable dentures made of acrylic resins are less expensive and are more commonly used. [57] The preparation of any prosthetic device may be complicated by anatomic considerations, comorbid illnesses, and medication side effects. Although stability and alignment of the prosthesis are important, dentures may be rejected by patients if they are uncomfortable or do not aid in function. [58] Once dentures are constructed, a denture brush and chemical immersion cleaners should be used regularly to avoid plaque accumulation. Annual dental visits are often recommended to assess fit and function. [59]

Persons with dentures frequently experience oropharyngeal pain, which may be due to denture-induced stomatitis, hypersensitivity to denture materials, or trauma from poorly fitting appliances. [60] Patients should be encouraged to remove dentures at night to avoid infections such as candidiasis, the major cause of denture stomatitis. Overuse of dentures may cause damage to mucosal structures and loss of underlying bone. These changes may alter the fit of dentures causing discomfort and difficulty chewing and may lead to mucosal ulceration and superinfection.

PERIOPERATIVE CONSIDERATIONS

Physicians may be asked to examine a patient in advance of a dental procedure and to advise on issues such as antibiotic prophylaxis and management of anticoagulation. Prophylactic antibiotics have been used for many years in patients with cardiac abnormalities to reduce the incidence of infective endocarditis after dental procedures. The link between dental treatment and infective endocarditis in patients with valvular disease has recently been challenged in a case-control study. [61] However, the current recommendation of the American Heart Association is to use prophylaxis for patients with high-risk cardiac conditions such as prosthetic heart valves and moderate-risk conditions such as valvular disease, ventricular septal defect, and mitral valve prolapse with regurgitation and/or thickened leaflets. [62] The presence of an atrial septal defect, coronary artery bypass graft, implanted defibrillator, or pacemaker does not require prophylaxis.

Single oral doses of amoxicillin, clindamycin, cephalexin, or azithromycin are appropriate for most dental procedures that require prophylaxis. [62] Prophylaxis against endocarditis is recommended for procedures such as dental extractions, periodontal surgery, and teeth cleaning (Table).

Antibiotic prophylaxis is not needed for dental procedures in persons with orthopedic pins, plates, and screws, and is needed only for those with total joint replacements in certain situations. According to the American Dental Association and the American Academy of Orthopaedic Surgeons, prophylactic antibiotics in patients with total joint replacements should be considered when (1) a high-risk procedure such as an extraction is planned, (2) the patient is within 2 years of joint replacement, (3) the patient has had previous prosthetic joint infections, or (4) the patient has diabetes or is otherwise immunocompromised. [63]

The nature of the planned procedure, the risk of bleeding, and the risk of thromboembolism during a period without anticoagulation should be considered when choosing a preoperative management strategy for patients receiving long-term anticoagulation. If it is necessary to normalize the INR before a procedure, removing warfarin 4 days before surgery with rapid reinstitution after surgery is often a safe option. [64] However, many dental procedures such as extractions, root canal filling, and abscess drainage can be done without discontinuing warfarin therapy, since the risk of uncontrollable bleeding is low in patients with therapeutic levels. [65,66]

The risk of death is estimated to be 1:200,000 to 1:400,000 during outpatient dental procedures in which general anesthesia is used and has been shown to be lower when local anesthetic alone is used. [67] Small studies have shown that even hihg-risk patients in the perimyocardial infarction period can undergo dental procedures safely. [68] Although it is rarely necessary to postpone dental procedures because of medical illness, it is prudent to optimize cardiac and pulmonary status and to delay elective procedures in patients with uncontrolled ischemia, congestive heart failure, and other high-risk conditions.

CONCLUSIONS

Dental disease has an enormous social and economic impact in the United States and is responsible for 189 million missed hours of work each year and expenditures of approximately $60 billion in 2000. [16,69] Many persons will not receive any oral health care except that received from a physician, and new research suggests that tooth and periodontal diseases may have important systemic consequences. Therefore, physicians have an important role in the management of these conditions by identifying dental and oral disease, encouraging proper dental hygiene, counseling on the effects of tobacco and alcohol, and initiating referrals to dental professionals as needed. The best treatment of tooth and periodontal disease remains prevention, and with further knowledge and experience, physicians may be able to help reduce the incidence and associated health care costs of these conditions.

From the Department of Medicine, Baylor College of Medicine, Houston, and the Department of Restorative Dentistry and Biomaterials, University of Texas-Houston Dental Branch.

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TABLE.

Dental Procedures and Prophylaxis Against Endocarditis [*]

Endocarditis Prophylaxis Recommended

Dental extraction

Periodontal procedures including surgery

Prophylactic cleaning of teeth or implants where bleeding is anticipated

Dental implant placement and reimplantation of avulsed teeth

Endodontic (root canal) instrumentation

Subgingival placement of antibiotic fibers or strips

Initial placement of orthodontic bands

Intraligamentary local anesthetic injections

Endocarditis Prophylaxis Not Recommended

Restorative dentistry--includes filling of cavities and tooth replacement--unless significant bleeding is anticipated

Nonintraligamentary local anesthetic injections

Taking of oral impressions

Fluoride treatments

Taking of oral radiographs

Placement of removable prosthodontic or orthodontic appliances or appliance adjustment

Postoperative suture removal

Intracanal endodontic treatment

Placement of rubber dams

(*.)Adapted from Dajani et al [62]

KEY POINTS

* Tooth and periodontal disease are preventable conditions that affect almost all individuals.

* Many persons in the United States do not receive regular dental care.

* Physicians are often called upon to manage acute dental conditions such as pulpitis and dental abscess.

* Dental and periodontal disease may have important systemic consequences.

* Published guidelines should be followed when using perioperative antibiotics in patients undergoing dental procedures.