Dental Disease

Gum disease (periodontal disease) is an inflammation in the gums, bone, and tissues that surround and support the teeth. Gum disease is most likely to affect adults over 30, although anyone is at risk. In the United States , about 66% of young adults, 80% of middle-aged people, and 90% of people older than 65 have some form of gum disease.

Healthy Gums

The form and severity of gum disease may vary depending on how gum tissues react to plaque and bacteria. It can affect all or part of the gums.

Early-stage gum disease (gingivitis) causes red, swollen gums that bleed easily when brushed. Because gingivitis usually doesn’t cause pain, many people mistakenly delay treatment. With care it can be reversed. See illustrations of a cross section of a tooth with gingivitis and of teeth and gums affected by gingivitis.

Advanced gum disease (periodontitis) develops if the disease progresses, and affects more than the gums. The gums pull away from the teeth, leaving deep pockets where plaque can grow and do further damage. Periodontitis can progress until the bones that support the teeth are damaged. Teeth may become loose, fall out, or require removal (extraction). See illustrations of a cross section of a tooth with periodontitis and of teeth and gums affected by periodontitis.

What causes gum disease?

  • Gum disease is caused primarily by the growth of bacteria on the teeth and gums. The bacteria produce gum-irritating chemicals and form plaque on the teeth. The plaque causes a hard mineral buildup (calculus or tartar) to develop on the teeth.
  • Cigarette smoking and use of smokeless tobacco products may also cause gum disease.
  • Some people may inherit a tendency toward developing gum disease.
  • Some gum disease may occur because of other diseases or medications.  

What are the symptoms of gum disease?

Healthy gums are pink and firm, fit snugly around the teeth, and do not bleed easily. Symptoms of early-stage gum disease (gingivitis) are red or swollen gums that may be tender and bleed easily when brushed or flossed. Gingivitis seldom causes pain.

Symptoms of gum disease (periodontitis) may include:

  • Gums that bleed during brushing.
  • Persistent bad breath that won’t go away with proper dental care.
  • Gums that pull away from the teeth.
  • Pus coming from the gums.
  • Pus between the teeth and gums.
  • A change in how your teeth fit together when you bite.
  • Loose teeth or teeth that fall out.
  • Red, swollen, or tender gums.
  • Pus between the teeth and gums.

Diagnosing Gum Disease  

Gum disease is diagnosed during a dental examination by your dentist, who will look for: Bleeding gums. Hard mineral deposits (calculus or tartar) above and below the gum line. Areas where your gums are pulling away from your teeth, or receding down the root of the tooth. Pockets that have formed between your teeth and gums. The dentist or dental hygienist may take X-rays of your teeth to look for bone damage and other problems.  

Treating Gum Disease

Treatment for gum disease includes:

  • Improved brushing and flossing, for mild gum disease.
  • Antibiotics for an infection.
  • Regular removal of hard mineral deposits (calculus or tartar) by means of root planing and scaling.
  • Surgery, for severe gum disease.


Preventing Gum Disease

Gum disease usually can be prevented by:

  • Brushing your teeth in the morning, after meals and snacks, and before bed.
  • Flossing once a day.
  • Visiting your dentist for regular checkups and teeth cleaning.
  • Quitting tobacco use.


Periodontitis occurs when the inflammation of the gums progresses into the deeper underlying structures and bone. In the most common form of periodontitis, plaque (and sometimes calculus) is found below the gumline. The gums may feel irritated, appear bright red, and bleed easily. The ligaments holding the tooth in its socket break down and the gums pull away from the teeth, resulting in a periodontal pocket or space between the tooth and gum. The periodontal pocket deepens and fills with more bacteria. Supportive ligaments and bone start to show damage.

Moderate periodontal disease: notice the accumulation of calculus around the gumline. The gums are red, swollen and tender.

Calculus and plaque do not have to be evident to the naked eye for periodontal disease to be present. You need regular examinations performed by your oral health professional to assess your periodontal health and determine if periodontal disease is active in your mouth.

After non-surgical periodontal therapy (i.e. scaling). The gums have been restored to health. Notice the gums have receded, exposing the root of the tooth. This is due to the irreversible bone loss as a result of previous periodontal disease. This can lead to tooth sensitivity.


When periodontitis progresses to the advanced stage, the gums severely recede (pull away from the tooth ); pockets deepen and may be filled with pus.

There may be swelling around the root and you may experience sensitivity to hot or cold or feel pain when brushing your teeth. This is due to the severely receding gums exposing the root surface.

As bone loss increases, your teeth may lose so much support that they need to be removed to preserve the overall health of your mouth.

Adult gum disease is usually not painful. It can progress slowly. You may not even be aware of it until the advanced stages, when the tooth is in danger of being lost. Check your gums thoroughly and regularly. It is also important to go for regular checkups (at an interval schedule determined through collaboration with your oral health professional, based on your own personal needs). Your dental hygienist can detect the early stages of gum disease, when it is the easiest to treat.

Advanced periodontal disease: further progression of periodontitis with major loss of bone support. The teeth may lose so much support that they may be loose

Trench Mouth/Gingivitis

Trench Mouth is a severe gum infection — earned its name because of its prevalence among soldiers on the front lines during World War I. Although it’s less common today, trench mouth still affects thousands of young adults between the ages of 15 and 35. The disease is also known by other names, including Vincent’s stomatitis and acute necrotizing ulcerative gingivitis.

Although the exact cause isn’t well understood, trench mouth seems to develop when factors such as poor oral hygiene, tobacco use and stress disrupt the balance between “good” and “bad” bacteria in your mouth. People whose immune systems are severely compromised by conditions such as HIV/AIDS are particularly at risk.

Trench mouth begins as a bacterial infection that causes inflamed, bleeding gums, but eventually, large ulcers may form on your gums and between your teeth. These are often extremely painful and can cause bad breath and a foul taste in your mouth.  

When it’s not treated, the infection can spread to the inside of your cheeks, your lips or your jawbone, where it can damage or destroy vital tissues. Fortunately, regular brushing and flossing, professional tooth cleaning, and antibiotic therapy can usually clear up the infection. And continuing to practice good oral hygiene can help prevent future problems.


“Toothache” usually refers to pain around the teeth or jaws. In most instances, toothaches are caused by tooth or jaw problems, such as a dental cavity, a cracked tooth, an exposed tooth root, gum disease, disease of the jaw joint (temporo- mandibular joint), or spasms of the muscles used for chewing. The severity of a toothache can range from chronic and mild to sharp and excruciating. The pain may be aggravated by chewing or by cold or heat. A thorough oral examination, which includes dental x-rays, can help determine the cause, whether the toothache is coming from a tooth or jaw problem.

Sometimes, a toothache may be caused by a problem not originating from a tooth or the jaw. Pain around the teeth and the jaws can be symptoms of diseases of the heart (such as angina or heart attack), ears (such as inner or external ear infections), and sinuses (air passages of the cheek bones). For example, the pain of angina (inadequate supply of oxygenated blood to the heart muscle because of narrowing of the arteries to the heart) is usually located in the chest or the arm. However, in some patients with angina, a toothache or jaw pain are the only symptoms of their heart problem. Infections and diseases of the ears and sinuses can also cause pain around the teeth and jaws. Therefore, evaluations by both dentists and doctors are sometimes necessary to diagnose medical illnesses causing “toothache.”

Dental Causes of Toothache

Common dental causes of toothache include dental cavities, dental abscess, gum disease, irritation of the tooth root, cracked tooth syndrome, temporomandibular disease, impaction, and eruption.

Dental Cavities

The most common cause of a toothache is a dental cavity. Dental cavities (caries) are holes in the two outer layers of a tooth called the enamel and the dentin. The enamel is the outermost white hard surface and the dentin is the yellow layer just beneath the enamel. Both layers serve to protect the inner living tooth tissue called the pulp, where blood vessels and nerves reside. Certain bacteria in the mouth convert simple sugars into acid. The acid softens and (along with saliva) dissolves the enamel and dentin, creating cavities. Small shallow cavities may not cause pain and may be unnoticed by the patient. The larger deeper cavities can collect food debris. The inner living pulp of the affected tooth can become irritated by bacterial toxins or by foods that are cold, hot, sour, or sweet-causing toothache. Toothache from these larger cavities is the most common reason for visits to dentists.

Treatment of a small and shallow cavity usually involves a dental filling. Treatment of a larger cavity involves an onlay or crown. Treatment of a cavity that has penetrated and injured the pulp requires either a root canal procedure or extraction of the affected tooth. Injury to the pulp can lead to death of pulp tissue, resulting in tooth infection (dental abscess). The treatment of an infected tooth is either removal of the tooth or a root canal procedure. The root canal procedure involves removing the dying pulp tissue (thus avoiding or removing tooth infection) and replacing it with an inert material. The procedure is used in an attempt to save the dying tooth from extraction.

Gum Disease

The second most common cause of toothache is gum disease. Gum disease refers to inflammation of the soft tissue (gingiva) and abnormal loss of bone that surrounds the teeth and holds them in place. Gum disease is caused by toxins secreted by bacteria in “plaque” that accumulate over time along the gum line. This plaque is a mixture of food, saliva, and bacteria. Early symptoms of gum disease include gum bleeding without pain. Pain is a symptom of more advanced gum disease as the loss of bone around the teeth leads to the formation of gum pockets. Bacteria in these pockets cause gum infection, swelling, pain, and further bone destruction. Advanced gum disease can cause loss of otherwise healthy teeth.

Treatment of early gum disease involves oral hygiene and removal of bacterial plaque. Moderate to advanced gum disease usually requires a thorough cleaning of the teeth and teeth roots called “root planing” and “subgingival curettage.” Root planing is the removal of plaque and tartar (hardened plaque) from exposed teeth roots while subgingival curettage refers to the removal of the surface of the inflamed layer of gum tissue. Both of these procedures are usually performed under local anesthesia and may be accompanied by the use of oral antibiotics to overcome gum infection or abscess. Follow-up treatment may include various types of gum surgeries. In advanced gum disease with significant bone destruction and loosening of teeth, teeth splinting or teeth extractions may be necessary.

Cracked Tooth Syndrome

“Cracked Tooth Syndrome” refers to toothache caused by a broken tooth (tooth fracture) without associated cavity or advanced gum disease. Biting on the area of tooth fracture can cause severe sharp pains. These fractures are usually due to chewing or biting hard objects such as hard candies, pencils, nuts, etc. Sometimes, the fracture can be seen by painting a special dye on the cracked tooth. Treatment usually involves protecting the tooth with a full-coverage gold or porcelain-fused-to-metal crown. However, if placing a crown does not relieve pain symptoms, a root canal procedure may be necessary.

Tooth Root Sensitivities

Chronic gum disease also contributes to toothache due to root sensitivities. The roots are the lower 2/3 of the teeth that are normally buried in bone. The bacterial toxins dissolve the bone around the roots and cause the gum and the bone to recede, exposing the roots. The exposed roots can become sensitive to cold, hot, and sour foods because they are no longer protected by healthy gum and bone. The sensitivities may be so severe that the patient avoids any cold or sour foods.

Early stages of root exposure can be treated with topical fluoride gels applied by the dentist or with special toothpastes (such as Sensodyne or Denquel) which contain fluorides and other minerals. These minerals are absorbed by the surface layer of the roots to make the roots stronger and less sensitive to the oral environment. If the root exposure causes injury and death of the inner living pulp tissue of the tooth, then a root canal procedure or tooth extraction may be necessary.

Temporo-Mandibular Joint Syndrome

Diseases of the temporo-mandibular joint(s) can cause pain, usually in front of one or both ears. The TMJ hinges the lower jaw (mandible) to the skull. Pain in the temporo-mandibular joint(s) can be caused by acute trauma (such as a blow to the face), inflammatory or degenerative arthritis, or by the mandible being pushed back towards the ears whenever the patient chews or swallows. Sometimes, muscles around the TMJ used for chewing can go into spasm, causing head and neck pain and difficulty opening mouth normally. These muscle spasms are aggravated by chewing or by life “stress,” which cause the patients to clench their teeth and further tighten these muscles. Temporary muscle spasms can also be caused by dental injections that are used to deliver local anesthetic for dental work or by the trauma of extracting impacted wisdom teeth.

Treatment of temporo-mandibular joint pain usually involves oral anti-inflammatory medicines like ibuprofen (Motrin) or naproxen (Naprosyn). Other measures include warm moist compresses to relax the joint areas, regular aerobic exercise to reduce stress, eating soft foods that do not require much chewing, and/or repositioning the mandible forward with a TMJ dental splint.

Repositioning the mandible forward with a splint relieves pressure on the nerves and blood vessels of the TMJ, and relieves pain. The splint changes the position of how the upper and lower teeth meet. To maintain this new position, the TMJ splint needs to be worn all the time, including mealtimes, indefinitely. In patients who do not wish to wear the splint indefinitely, alternative measures to maintain the new position include placing full-coverage crowns on all of the back teeth (bicuspids and molars) or by using dental braces.

Eruption & Impaction

Impacted (teeth pressing together) or erupting (tooth growing out or “cutting”) molar teeth (the large teeth in the back of the jaw) can cause pain. As the molar teeth erupt, the nearby tissues can become inflamed and swollen. Impacted teeth can require pain medication, antibiotics, and surgical removal. This most commonly occurs with impacted molar (wisdom) teeth.

The most common cause of a toothache is a dental cavity.
The second most common cause of toothache is gum disease.
A toothache can be caused by a problem that does not originate from a tooth or the jaw.

Dental cavities (caries) are holes in the two outer layers of a tooth called the enamel and the dentin. The enamel is the outermost white hard surface and the dentin is the yellow layer just beneath enamel. Both layers serve to protect the inner living tooth tissue called the pulp, where blood vessels and nerves reside. Dental cavities are common, affecting over 90% of the population. Small cavities may not cause pain, and may be unnoticed by the patient. The larger cavities can collect food, and the inner pulp of the affected tooth can become irritated by bacterial toxins, foods that are cold, hot, sour, or sweet-causing toothache. Toothache from these larger cavities is the number one reason for visits to dentists.

Cavity Causes

Cavity-causing bacteria in the mouth consume simple sugars, converting them into acid plaque. Acid plaque is different from the periodontal plaque that causes “Gum Disease.” The acid plaque produced by these bacteria cause the hard inorganic layers of the enamel and dentin to soften. The softened layers are then dissolved by saliva, leaving a hole (cavity) in the tooth. Unless filled by a dentist, the cavity can continue to erode and damage the inner pulp of the tooth. Damage to the pulp can lead to pulp death, infection and tooth abscess. Therefore, pulp damage will necessitate either tooth extraction or a root canal procedure where the dying pulp is removed and replaced with an inert material.

The enamel on baby teeth are immature and porous. It takes seven years for the porous, chalky enamel to be replaced by more mature, dense, hard, shiny enamel. Therefore children are more prone to cavities than adults.

Cavity-causing bacteria are difficult to eradicate because they are very similar to the other harmless bacteria that live in the oral cavity. The many cavity-causing bacteria include: Lactobacillus acidophilus bacteria reside in the pits and fissures of the chewing (occlusal) surfaces of teeth. These bacteria can cause rampant tooth decay in young children ages 3-12, causing cavities in both baby teeth and the first permanent molars that erupt around age 6.

Six species of streptococcus bacteria attack the smooth surfaces on the sides of the teeth. These sides are usually touching adjacent teeth, and cavities arising on these sides can be difficult to detect visually. These cavities are best detected by the use of x-rays.

Odontomyces viscoses bacteria live on the back of the tongue and attack exposed cementum. Cementum is the hard outer layer of the tooth root (the bottom two thirds of tooth that is normally buried in dental bone). In older patients and in patients with gum disease, the tooth root and cementum become exposed and vulnerable to attack by these bacteria.

Preventing Cavities

The number of cavities can be reduced by proper nutrition, good oral hygiene, fewer snacks in between meals, the use of oral or topical fluorides, and topical sealants.

Nutritional counseling – consuming less simple sugar (sucrose or table sugar) will reduce the number of acid- producing bacteria in the mouth. Adequate dietary calcium, phosphorous, vitamins A, D, and C promote healthy and strong enamel formation.

Eating fewer snacks in between meals – every snack is followed by an “acid attack” on the teeth. Therefore, snacking all day causes the teeth to be bathed in acid continuously. Fewer snacks and eating desserts only with meals help to reduce the number of “acid attacks” on teeth.

Home oral hygiene – brushing your teeth frequently helps reduce acid plaque damage to enamel, while frequent flossing removes the acid plaque from the smooth surfaces between teeth. If one cannot brush and floss immediately after a meal, he/she should try chewing self-cleaning foods at the end of the meal. These include apples and celery that are crunchy and help sweep away food debris and plaque. Chewing sugarless gum for a few minutes at the end of a meal can also help.

Filling Cavities

Before a dentist can fill a cavity, it must be thoroughly cleaned by hand instruments and mechanical rotary instruments, called handpieces. The clean cavity is then filled with either dental amalgam, composite material, gold, or porcelain to restore the tooth to its original shape and size.

The most economical, time-honored material is the silver filling (also known as dental amalgam). It is composed of silver, tin, traces of metallic mercury, and other compounds. Dental amalgam has been used safely in dentistry for nearly 150 years. While some people have raised concerns over the health effect of mercury in the dental amalgam, the actual amount of metallic mercury in dental amalgam is less than the mercury found in seafood or polluted air. Swedish and American scientists could find no correlation between having new silver fillings and changes in the levels of mercury in the blood or urine. The American Dental Association still supports dental amalgam as a safe and effective filling material, especially for the cavities on the chewing surfaces of back teeth (bicuspids and molars). The amalgam can be a health problem if the patient has a true allergy to mercury (true allergy to mercury is rare, and the condition must be ascertained by a physician).

A new filling material that is increasing in popularity is porcelain. Even though it is almost as expensive as gold, the color of porcelain filling can be matched to the natural tooth color. Two appointments are necessary to perform the porcelain filling. During the first appointment, the dentist cleans the cavity and takes an impression of the tooth. A dental laboratory then creates a stone model of the tooth and fabricates the porcelain filling from the tooth model. The porcelain filling is then cemented or “bonded” onto the tooth during a second appointment with the dentist.

Gold is an excellent material for filling teeth. It has good wear compatibility to the enamel of opposing and adjacent teeth. Gold adapts very well to the edges of a cavity and is totally inert or nontoxic. However gold is expensive, is unsightly in color, and is technically challenging to use. Therefore, gold fillings are rarely performed anymore.

An alternative to amalgam is the use of composites. Composites are plastic resins mixed with quartz fillers or other hard minerals for strength. Composites are widely used to fill cavities in the front teeth because they come in various shades that match the natural tooth color. However they are less suitable for cavities in the back teeth because they are softer than amalgam and more prone to wear down and chip with chewing. If the composites are inadequately “cured” with the special composite light, leakage of bacteria and saliva can occur under the filling. Such leakage causes tooth sensitivity to cold and sweets. Leakage also causes the decay process to recur under and around the composite filling, causing subsequent fracture of the tooth.



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