Case 2 – Jenny’s smooth teeth

Body in health

• What does each layer of the teeth consist of?

• How is the tooth anchored in place?

The tooth is anchored in place by the periodontium, which consists of the bone, periodontal
ligament and the cementum
• What is the normal external appearance of the teeth?

• What factors in the diet can affect erosion?

Body in disease

• What causes the teeth to be worn down?

Non-Carious Tooth Tissue Loss:
Erosion – NCTTL caused by acidic/chemical components
Abrasion – NCTTL caused by mechanical forces other than occluding/masticatory
forces e.g. aggressive tooth brushing, parafunctional habits
Attrition – NCTTL caused by tooth-to-tooth contact
Abrfraction – NCTTL around the gingival margin caused by the forces of the teeth
during mastication
• What is the appearance of worn-down teeth?
o Lingual/palatal cupping
o Dentine showing through under the enamel
o Worn down incisal edge/cusps
o Smooth glassy appearance of the enamel
• What is the highest pH that enamel starts to erode?
This describes the change in dental plaque pH, when acidogenic bacteria break down the
sugars in the mouth causing a decrease in oral pH – the results are presented in a graphical
format. This provides information to a person’s oral hygiene and how susceptible they are to
getting cavities. A pH of 5.5 is the critical point (the highest pH) at which demineralisation
will take place. In cavities the pH stays lower (more acidic) for longer.

• What is the difference between erosion and dental decay?

Caries
Bacterial acids
Due to refined sugars and poor oral hygiene
Prevented by change of diet and
improvement of oral hygiene
Can lead to more severe problems (e.g.
pulpitis, abscesses, tooth extraction)
Erosion
Non-bacterial acids
Due to intrinsic or extrinsic acids
Prevented by change of medication, diet or
treating eating disorder
May lead to tooth sensitivity, weaker more
brittle teeth

• What is heart burn?

 A condition where some of the stomach acids are forced into the oesophagus, and
sometimes into the mouth.
Long term heart burn can lead to:
o Oesophagitis, which can include erosions and ulcers in the epithelial lining of the
oesophagus
o Barrett’s Oesophagus, this is a abnormal changes in the lining. It develops in some
people who have long-term heart burn, and it is a risk factor for cancer in the
oesophagus
o Strictures, the damaged lining becomes scarred and this leads to the narrowing of
the oesophagus.
• What causes chipping on the incisal tips?
• What is dental decay?
• What are the signs and symptoms?
o Early enamel caries – this is demineralisation that is localised to the enamel allow,
and can be reversed with high fluoride application. Clinically it appears as white
chalky spots on the enamel.
o Caries into the dentine – this is when the acid from the bacteria complete breaks
down the enamel and enters into the dentine. The dentine is soft, brown and sticky
o Pulpitis – the dental caries as passed the enamel and dentin and reached the pulp.
The pulp becomes inflamed and causes the patient pain. This can eventually lead to
periapical abscess if left untreated
• Plaque – what is plaque, what does it consist of, what is the difference between calculus
and plaque?

Plaque: this is a clear, sticky biofilm that forms around the teeth – bacteria adhere to the
tooth by the acquired pellicle layer, from there they proliferate and form colonies where
they attach to each other. Bacteria that secrete enzymes that forms acids as by-products –
therefore irritating the gums or demineralising the enamel and causing inflammation/tooth
decay. Mechanical disruption is essential to remove this biofilm (i.e. flossing and tooth
brushing). Plaque is
Lactobacilli (caries)
Streptococcus Mutans (caries)
Actinomyces (caries)
Porphyromonas gingivalis (gum disease)
Aggregatibacter Actinomycetemcomitans (gum disease)
Prevotella intermedia (gum disease)

Calculus: if the plaque is not removed by regular tooth brushing, then this could harden to
become calculus – this mineralised substance contains both calcium and phosphate salts,
which can eventually become a form of hydroxyapatite. This is mineralised, and therefore
cannot be removed by regular tooth brushing; only a dental professional can remove this
during oral cleaning. Calculus is more porous, so bacteria are more adherent and more
staining occurs.
 • How do eating disorders affect oral health?

Procedures and treatments

• How do the different types of antacids work?

o Alginates – antacids that contain alginates create a foam barrier on top of the
stomach contents and protect the oesophagus
o Stomach acid neutralisers – these temporarily neutralise the gastric acid. However if
they are taken long term, it may lead to acid rebound. This is where the symptoms
return more intense than before medication
o Stomach acid blockers – these provide long-term relief but not immediately. They
act directly on the cells of the stomach to reduce the amount of acid produced.
However Proton blockers like omeprazole have oral side effects like dry mouth
• What are the side effects of antacids?
o Proton blockers like omeprazole have oral side effects like dry mouth
o Some antacids can interact with other medication. Increasing or decreasing the
effectivity
o For some stomach neutralisers, if taken long term, may lead to acid rebound. This is
where the symptoms return more intense than before medication
• What is the use of diet sheets and how are they assessed?
Diet sheets ask the patient to record the daily food and drinks they eat (including snacks) –
as well as any medication taken - over the course of three days, with a measurement, time
food was eaten along with it. It is used to look for any foods with high sugar and/or acidity
content (e.g. sweets, soft drinks, etc.). It is used to check for caries risk assessment, so a
treatment plan can be organised.

• What is the contact between the dentist and the GP?

• How does fluoride affect the teeth?

Fluoride is a substance that inhibits demineralisation of enamel and enhances
remineralisation. It replaces the calcium in the hydroxyapatite crystals of the enamel, this
increases the critical pH. This means this type of enamel will require a pH of 4.5 or below to
be demineralised.

It inhibits bacterial production of acid that breaks down enamel; it also decreases the ability
for bacteria to adhere to the tooth surface. Fluoride affects the enzyme in bacteria that
breaks down the sugar and creates acid as a by-product. However with too much fluoride (in
children developing their teeth), also known as fluorosis, the teeth can become more brittle
and will break off easily.