Smile therapy

Eternal vigilance is not only the price of liberty; it’s the price of a healthy mouth. Unchecked dental caries and periodontal disease – the dastardly duo more commonly known as tooth decay and gum disease – can lead to excruciating pain, tooth loss, social embarrassment and poor general health, including heart disease, stroke and pneumonia. Periodontal disease is even thought to be the origin of infections causing joint replacement failure. A recent Harvard School of Public Health study suggests it is also a risk factor for pancreatic cancer. That’s why it’s so important to recognize that tooth decay and gum disease are preventable. You can keep them at bay with twice daily brushing and flossing, along with regular visits to a dentist.

“Every study shows you’re better off with your natural teeth,” says Dr. Chris Wyatt, assistant professor at the University of British Columbia’s faculty of dentistry. He’s also director of the geriatric dentistry program at UBC, which provides dental care for 2,000 residents of long-term care facilities. Ironically, he’s a prosthodontist dealing with the consequences of tooth decay and gum disease using crowns, bridges, veneers, dentures or dental implants to replace missing teeth. But he acknowledges, “Whatever we do as dentists is second best.”

Overzealous cleaning can make gums bleed, but if careful brushing around the cuff of a tooth with a soft brush turns the bristles red, the problem may be gingivitis. This inflammation of the gums can be treated. Ignored, it can progress to periodontal disease, an infection of the structures that hold teeth in place. This is not a reversible condition and will usually need to be treated by a gum specialist called a periodontist.

A healthy mouth has a normal flora – an array of bacteria living in balance. They synthesize some vitamins, have an immune function and tend to keep other potentially harmful bacteria at bay.

Plaque, a whitish, jelly-like coating contains bacteria and their by-products. If not brushed or flossed off within 24 hours, it hardens to calculus (tartar), a breeding ground for damaging germs. This has to be scraped off by a dental professional. Streptococcus mutans and Lactobacillus are two villains implicated in dental caries. Thriving on a sugary diet, they produce acids that attack tooth enamel.

The hazards of a dry mouth
Saliva protects teeth by washing away food debris and bacteria and neutralizing damaging acids. Aging, smoking and drugs such as antihistamines, antidepressants and high blood pressure medications can reduce the normal volume of saliva (about three pints daily). Diseases such as diabetes and Parkinson’s as well as chemotherapy and radiation treatment for cancer can have similar outcomes. Without enough saliva, bacteria accumulate and the result is a sharp rise in tooth decay and gum disease. Dry mouth, called xerostomia, also makes wearing dentures painful.

The onset of cognitive or physical disorders often means personal dental care declines. “That’s when we start to see this rampant increase in disease,” Wyatt says. “In an older adult, most of it is root decay.”

People living in long-term care facilities tend to have a high incidence of oral disease and consequently lose weight, suffer pain and sleep poorly. Caregivers may not have time or training to adequately help with dental hygiene. If it’s difficult to get a resident to a dentist’s office or if dental professionals are reluctant to provide service in the long-term care setting, periods between regular checkups may be too long.

The fact is everyone needs to see a dentist regularly, even people who have no teeth. Oral cancer rates rise with age, and constant rubbing from dentures can cause tumours. Changes in denture fit can indicate bone loss, possibly from osteoporosis or the lack of stimulation of the bone that occurs with natural teeth.

Wyatt discourages the use of so-called natural toothpaste and recommends fluoride toothpaste, which helps remineralize tooth enamel. “It helps fight tooth decay. We know it works,” he says.

Fluoride whether in municipal water supplies or in toothpaste, has been a huge factor in the improvement of dental health since the Second World War. Other positive influences on oral health include growing income, greater access to dental insurance and, in Canada, more dentists per capita.

Statistics Canada reports that in 1990 48 per cent of people 65 and older had no teeth; by 2003 that percentage had dropped to 30 per cent, with nine per cent of them doing without dentures. (The World Health Organization considers people who have lost all their teeth chronically disabled.) Not surprisingly, low economic status appears to be linked to complete tooth loss.

“Some people don’t do very well with dentures,” Wyatt points out. For those who can afford it, dental implants are a comfortable and secure option. These titanium “roots” can be used to replace one or several teeth or act as anchors for upper or lower plates. Upper plates then don’t need to cover the palate, minimizing interference with taste and smell sensation; partial bridges can be fastened to implants, leaving adjacent teeth intact. As it heals, bone tissue eventually grows around the implant, locking it in place. In turn, this artificial root stimulates and maintains bone mass.

Developed in Europe more than 40 years ago, dental implants have been performing reliably in North America for 25 years, Wyatt says. “The success rate of implants is very high. It’s a fairly predictable procedure.” He notes that age is not a factor in dental implants, as long as the person is healthy and capable of dealing with the surgical procedure.

Implant surgery usually requires only local anesthetic. After an incision is made in the gum, a special drill creates a precise opening where the titanium fixture is inserted. Some systems require further surgery and placement of a healing cap, followed later by attachment of the new tooth. Other systems include the healing cap on the titanium implant, eliminating the extra surgery. A recent innovation uses computed tomography (CT) to plan the surgery for the appropriate anchor sites for four or five implants that will hold a full upper denture. Some patients can be fitted with their new teeth at this time, although they must be careful to eat soft food until complete healing has occurred.