--- module: 057-02 language: en chapter: 57 title: "Oral and Dental Disease, Salivary Function, and Maxillofacial Warning Signs" module_title: "Oral ecology, odontogenic infection, mucosal diagnosis, and medically complex dental care" source_sha256: e7b294e1a2bd774956108144f000add17bb08b01f04bb4a1d84c7db3c73fdefd --- # Oral ecology, infection, mucosa, and complex care ## The mouth as a vulnerable interface ### Cavitated enamel cannot repair ### Pulp lies in a rigid chamber ### Infection tracks to orbit, neck, mediastinum, airway ### Localise pain by structure and urgency ## Saliva and caries ecology ### Saliva is an active protective fluid #### Bicarbonate buffers, calcium and phosphate remineralise #### Immunoglobulin, lysozyme, lactoferrin limit organisms ### Subjective dryness precedes measured flow loss ### Caries is a biofilm-mediated ecological disease #### Frequent sugar selects acid-tolerant organisms #### Each exposure adds an acidic interval #### Sipped sweet drink worse than same with meal ### Cavitation forms a sheltered niche #### Restoration needed, fluoride cannot rebuild ## Pulpitis and antibiotic stewardship ### Inflammation inside non-compliant dentine ### Brief resolving pain: reversible ### Spontaneous, nocturnal, lingering pain: irreversible ### Necrosis may ease pain as infection spreads ### Percussion tenderness: ligament inflammation ### Antibiotics penetrate necrotic pulp poorly #### Repeated courses mask symptoms, breed resistance ### Culture only for severe, immune, failed, unusual ### Discharge with return signs and dental date ## Deep-space spread and Ludwig angina ### Spread follows muscle attachments and fascia #### Maxillary: canine space, sinus, orbit #### Mandibular molars: sublingual, submandibular, masticator ### Trismus signals masticator or deep space ### Red flags need surgical and airway assessment #### Not another outpatient antibiotic course ### Ludwig angina: bilateral cellulitis #### Firm floor pushes tongue up and back #### Stridor and desaturation are late #### Sedation or supine can cause obstruction ### Airway planning precedes imaging ## Periodontal disease ### Starts with plaque at gingival margin ### Gingivitis confined to soft tissue, reversible ### Dysregulated inflammation destroys ligament and bone ### Smoking masks bleeding, accelerates destruction ### Diabetes and inflammation worsen each other ### Remove biofilm and calculus, clean interdentally ## Examination and ulcer diagnosis ### Lesions hide under tongue and dentures #### Remove dentures, palpate bimanually ### Traumatic ulcers heal once irritant removed ### Aphthae on non-keratinised mucosa ### Recurrent herpes on keratinised attached mucosa ### Persistent or indurated ulcer needs urgent biopsy ## Cancer, mucositis, and white lesions ### Carcinoma risk not excluded without exposure #### Invades muscle, jaw, nerves, lymphatics #### Biopsy diagnoses, imaging stages ### Mucositis severe in neutropenia despite mild look #### Gentle hygiene, rinses, analgesia, nutrition #### Check platelets and immunity before procedures ### Wipe test for white lesions #### Candidal pseudomembrane wipes off, leaves erythema #### Keratosis and leukoplakia cannot be removed ### Rinse after inhaled steroids, remove dentures ## Dry mouth and salivary obstruction ### Review drugs, radiation, Sjogren, graft disease ### Water, sugar-free chewing, substitutes, fluoride ### Acidic sweets worsen erosion and caries ### Sjogren gland swelling raises lymphoma concern ### Stone or stricture causes meal-related swelling #### Long duct, mucous mineral-rich saliva ### Facial weakness with parotid mass warns malignancy ## Trauma, extraction bleeding, and jaw pain ### Avulsed tooth loses ligament viability as it dries #### Replant or store in suitable medium #### Primary teeth damage developing successor ### Local measures control extraction bleeding #### Anticoagulants not stopped reflexively ### Dry socket: clot loss, exposed bone ### Clicking alone needs no imaging or bite change ### Neuralgia versus giant-cell arteritis ## Medically complex care ### Remove infection before radiation or chemotherapy ### Radiation raises caries and osteoradionecrosis risk ### Pregnancy rarely precludes needed treatment ### Antiresorptive osteonecrosis: dose, infection, extraction #### Preserve teeth, do not avoid care indefinitely #### Stopping drug decided with prescriber ### Endocarditis prophylaxis for highest-risk hearts #### Daily hygiene reduces repeated bacteraemia