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Infectious conditions/ diseases are caught by the infected person from someone or something.
They are caused by micro-organisms [micro- can only see with a microscope, organism- living thing] or microbes for short. Micro- organisms capable of producing disease are called pathogens.
There are 4 types of organism that cause diseases, Bacteria, Viruses, Fungi and Protozoa.
Only the first 3 concern us in the mouth.
Protozoa are tiny amoeba like organisms that cause things like amoebic dysentery.
There is another type of infectious ‘thing’ called a Prion, this is not strictly speaking an organism but an infectious protein capable of causing disease. Prions cause CJD/ Creutzfeldt-Jakob disease otherwise known as ‘mad cow disease’ and other rare diseases, more of which no doubt will be discovered.
Bacteria.
We have lots of bacteria in our mouths [and all over our bodies] naturally, some are good, some are helpful and some given the right conditions cause disease.
They come in lots of different shapes, for example:- cocci- little bobbles, streptococci- lines of little bobbles, staphylococci- clumps of little bobbles, spirochaetes- spirally ones a bit like fuselli pasta and bacilli- little rod shaped ones of various shapes and sizes.
Some bacteria produce pus.
Some produce gasses which smell.
Some need oxygen to survive- aerobic bacteria and some can survive at very low levels of oxygen- anaerobic bacteria.
Your immune system is there to get rid of these bacteria but should the infection be very severe or you be immune suppressed or vulnerable in some other way you may need ANTIBIOTICS.
Antibiotics work on the bacteria, they don’t work on you.
Different antibiotics are needed for different bacteria and different types of bacteria.
Some bacteria cause specific diseases and some conditions are associated with lots of different bacteria.
Conditions in the mouth which are associated with bacteria are;-
• Caries/ tooth decay.
• Periodontal disease/ gum disease.
• Apical abscess [an abscess at the end of the root of your tooth caused by the nerve in your tooth dying from infection from severe tooth decay].
• Periodontal abscess [what your granny would call a gum boil], severe infection in the bottom of a deep periodontal pocket around a tooth caused by gum disease.
• Syphilitic Ulcers this is a particular shape of ulcer [snail track] associated with the sexually transmitted disease Syphilis caused by the bacteria Treponema pallidum.
• Periocoronitis- infection around a partially erupted tooth such as a wisdom tooth.
Most infections in the mouth can be treated by what is known as ‘local measures’. Antibiotics should only be used as a last resort when all else has failed. As you no doubt know there is an increasing worldwide problem with the development of antibiotic resistant organisms due to over prescription of antibiotics in the past.
Viruses.
These are much smaller micro-organisms than bacteria and can only be seen with a very powerful microscope called an electron microscope. Viruses are a protein capsule which gets inside a cell in our body, the capsule contains all the information/ chemicals it needs to reproduce itself inside the call it has taken over. Every type of virus has a different shape and a different protein capsule.
Most common viral infections will last 7-14 days and our immune systems will deal with it.
They are treated by;-
• Rest.
• Lots of fluids.
• Analgesics [pain killers].
• Antipyretics [take your temperature down]. The drug used for this is Paracetamol.
• A viral infection in the mouth is often relieved by an antimicrobial mouthwash.
• Viruses are treated if necessary with ANTIVIRAL AGENTS.
Dentally related Viral infections are;-
• Herpes Simplex 1 [above the belt]. This starts as a primary infection called Primary Herpetic Gingivo Stomatitis. It usually occurs in babies or young children, the mouth is covered in lots of little painfull blisters. The virus then stays living in one of your big nerves for ever. This nerve is the Trigeminal nerve in your face and when you are run down, tired, ill, exposed to too much sunlight, have immune problems it re-emerges as a secondary infection- Herpes Labalis more commonly known as a cold sore which is highly infectious. If you do get a cold sore it is very important that you try not to touch it as you will spread it around your face and even into your eye. It is also very important that you do not kiss anyone anywhere!
• Herpes Simplex 2 [below the belt]. This is genital herpes which is transferable to the mouth.
• Varicella Zoster. This is the virus that causes Chicken Pox. This also may stay in a nerve branch forever and re-emerge in adult hood as Herpes Zoster or Shingles. The person will get one sided [unilateral] rash and ulceration along the path of the infected nerve. In the mouth and face this will be the sensory Trigeminal nerve. As anyone will tell you this is a horrible condition to have and often the person is left with lasting Neuralgia [continuous burning pain] afterwards. It is especially dangerous if it affects the eye and such patients should be referred to an ophthalmologist.
• HPV- Human Papilloma Virus, this is dealt with in more detail in the previous chapter on Oral Cancer.
• HIV/ Aids.
• Glandular Fever- This is caused by the Epstein-Barr virus. The person has painful swollen lymph glands all over the body including the neck.
• Mumps- This is caused by the Paramyxovirus where usually both Parotid salivary glands [in front of your ears] swell up.
• Hand, Foot and Mouth disease. This is caused by the Coxsakievirus. This is a fairly common infection in children where the patient gets painful blistering in the mouth, on the palms of the hands and the soles of the feet.
None of these are particularly nice things to have and more difficult to cure than other infections as there are very few antiviral agents. Thankfully there are more and more vaccinations being developed to combat them.
Fungi.
These are plant like organisms and tend to live on the surface of the body not within it. Most oral infections are caused by Candida usually Candida albicans.
Candida lives on us normally but sometimes it gets out of hand and makes a nuisance of itself.
Predisposing factors to Oral Candidosis [oral thrush] are;-
• Patient on antibiotics.
• Patient on steroids either systemic or inhaled [very important to rinse your mouth out after you have used your steroid asthma inhaler].
• Patient on immunosuppressants.
• Patient immunosuppressed.
• Patient anaemic.
• Endocrine disorders [endocrine glands produce hormones] such as Diabetes.
• Salivary glands not working properly [Hypofunction].
• Very young people and very old people [extremes of age].
Candida infection is often due to the fact that the patient has an underlying medical condition which is why it is known as ‘the disease of the diseased’.
Conditions in the mouth caused by Candida;-
• Thrush- usually seen as a white layer that rubs off with underlying red sore patches.
• Denture sore mouth- which is rarely sore, just looks like it is. People get this under dentures and orthodontic braces [appliances] that cover the roof of the mouth. It will follow the pattern of the denture or the appliance and is caused by poor cleaning of the denture or the brace leading to colonisation of Candida underneath it and in the case of dentures not taking them out at night.
• Angular cheilitis- this is where the patient gets inflamed and cracked skin at the corners of the mouth. It sometimes is a mixed infection with staphylococcal bacteria. It is often seen in patients with candida under their denture, deficiency anaemias, eating disorders, eczema, Chrons disease, immune deficiencies and very worn dentures.
TO SUM UP.
Eat a proper balanced diet with plenty of fruit and veg.
Get enough sleep.
Keep your immune system healthy.
Practice good oral hygiene and go to the dentist regularly.
Antibiotics treat bacteria.
Anti-viral agents treat viruses.
Anti-fungal agents treat fungi.
The condition must be diagnosed by a suitably qualified person so the correct agent may be used on the organism concerned!

Oral Cancer is a vast subject and of course subject to lots of ongoing research.

There are several very good websites with lots of useful information on them so I am just going to explain a few things and then I am going to point you in the right direction.

Types of cancer.

The first thing to say is there are hundreds of different types of cancers it is not one disease it’s an overall blanket term. So when someone says lung cancer or breast cancer that just tells you where it is not what type it is.

So tumour just means growth, in fact strictly speaking it means swelling [Latin]. Not all growths/ tumours are cancer. Tumours can be caused by all sorts of things; – infections, cysts, new growths, all sorts. A new growth is called a neoplasm.

There are 2 types of neoplasm benign and malignant.

Benign neoplasms just grow, now obviously you could have a benign neoplasm some were where it would be unsightly, or get in the way, or press on other organs and cause trouble but on the whole they just grow.

Malignant neoplasms do 2 things; – they invade and they metastasize. Imagine it like this, in its very simplest form- they put down little feelers [cancer like a crab] into the surrounding tissues and the ends of those little feelers break off, get into your blood or lymph vessels are carried around your body to other places where they form secondary cancers [metastases]. The lymphatic system is an organ system, part of the circulatory and immune systems, draining fluid back into your blood system via lymph nodes. It’s a good idea to check your lymph nodes every month or so, an excellent guide to doing this is provided by The Wessex Cancer Trust at www.wessexcancer.org.uk .

Why do we get cancers?

This is a very simple explanation, it is far more complex than this but this will do for now.

All our cells contain DNA [deoxyribonucleic acid], this contains our genetic information and is a sort of instruction manual/ blueprint for each of our cells. Sometimes this DNA gets damaged somehow. In a normal cell the damage gets repaired or your cell dies off but in in a malignant cell this doesn’t happen, the blueprint in your DNA gets altered and the damaged altered cells carry on growing as if they have a mind of their own. This alteration in your genes is called a mutation. You have to have quite a lot of changes to the information in your DNA in a cell for it to become cancerous.

Mutations can be caused by lots of things;-

The luck of the draw [which means we don’t know what the cause is yet but hopefully we will] – for some reason a cell spontaneously mutates.

Genetic- inherited from our parents.

Risk factors- these are things like smoking, drinking to excess, exposure to too much radiation or UV light. Continuous exposure to these risk factors leads to genetic mutations.

The mouth is the most common site for cancer in the head and neck region.

Mouth [Oral] Cancers].

Different types of cells can form cancers but the majority 9/10 in the mouth are called oral squamous cell carcinomas or OSCC for short. These arise in cells called keratinocytes in the skin [oral mucosa] inside your mouth.

The commonest places to have cancer in the mouth are; – the lips [usually the lower lip], the sides of your tongue [lateral border], the floor of your mouth, the base of the tongue [where it starts right at the back] and the tonsils.

Facts and figures and websites.

The Oral Health Foundation www.dentalhealth.org published ‘the first comprehensive review into mouth cancer’ ‘The State of Mouth Cancer 2018/2019 UK Report’. This report is excellent, very readable and understandable and can be downloaded.

Look it up yourself but here are a few facts and figures from it;-

New cases in the UK have now reached 8,302 per year.

Cases have increases by 49% in the last 10 years and by 135% in the last 20 years.

56% are on the tongue and the tonsils.

In 2018 2722 UK citizens died from oral cancer.

The 10 year survival rate is under 60%.

78% of cases are in over 55 year olds but increasing in younger age groups.

17% that’s 1 in 6 are due to smoking.

1/3^rd are due to excess alcohol, drinking over 10 units per week increases your risk by 81%.

Smoking and drinking more than the recommended units of alcohol gives you a 30x increased risk than if you just did one of them!

HPV [human papilloma virus] no 16 and 18 is linked to 73% of oral pharyngeal cancers and 1 in 10 of cancers in the mouth [more about this later].

I also suggest you visit http://www.mouthcancer.org  which has 2 very good sections;

‘How to spot mouth cancer’ from which you can also download mouth cancer signs and symptoms, self-examination and a list of risk factors all as PDFs, you could print them and put them up at work!

‘Mouth cancer risk factors’ which explains risk factors in more detail.

Other useful websites are;-

www.mouthcancerfoundation.org very good website, has lots of good information about HPV and also a community forum and support groups for people who have been affected by oral cancer themselves or their loved ones.

www.nhs.uk  a few facts and figures from this are oral cancer is the 6^th most common cancer in the world, 1 in 50 of all cancers in the UK, 12.5% ie 1 in 8 in younger people.

www.oralcancerfoundation.org an American website go to the section ‘Understanding Oral Cancer’ this has a lot of info on HPV and a lot of pictures of things to look for.

www.macmillon.org.uk as ever an excellent source of information and support.

www.wcrf-uk.org the world cancer research fund which has more statistics.

www.cancerresearchuk.org brilliant as ever.

Pharyngeal cancers.

Your pharynx is the pipe that goes from the back of your nose, past the back of your mouth and your voice box [larynx] at the top of your trachea [your wind pipe], it also includes the top part of your oesophagus the bit your food goes down. The bit behind your nose is called your nasopharynx, the bit at the back of your mouth is called your oropharynx and the bottom bit is called your laryngopharynx or hypopharynx. Oral cancers and pharyngeal cancers are termed collectively as Oropharyngeal cancers and have the same risk factors.

Risk Factors.

The causes of cancer are a combination of the wrong genes, external factors [such as exposure to radiation, UV light, workplace chemicals] and lifestyle.

LIFESTYLE ACCOUNTS FOR 75%.

A cancer risk factor is something which increases your chances of developing cancer. Things which increase DNA mutations increase your risk of developing cancer. Some risk factors you can’t do anything about such as your age, ethnicity and sex but others you can and these are known as modifiable risk factors. There are things in your lifestyle which you either do or don’t do which increase your chance of developing cancer.

What are the main risk factors for Oral Cancer?

Smoking and other tobacco usage;- snuff, chewing tobacco, water pipes, 2^nd hand smoke, snuz. Tobacco contains over 60 carcinogens [cancer causing chemicals]. The stronger the tobacco you use, the longer you smoke for, and the greater the amount- the greater the risk.

Drinking more than the recommended units especially if you smoke. The more you drink and the greater the number of years the greater the risk.

Betel nut chewing [usually as Paan/ quid with areca nut and slaked lime]

Diet low in fresh fruit and veg.

Sunlight [for lip cancer].

HPV infection.

These are the main life style risk factors but there are others including Marijuana and Khat use.

Mouthwashes containing alcohol are thought to pose no risk unless used to excess, though you might want to choose an alcohol free one if you have a choice. Poor oral hygiene is probably a greater risk.

Beneficial factors.

Well obviously the reverse of above.

Doing your best to keep a healthy immune system and if you are immune suppressed for reasons such as being HIV +ve or having received chemotherapy, keeping your mouth clean and healthy.

Infections due to poor oral hygiene, periodontal [gum disease], chronic oral candida [thrush] and oral viral infections link very strongly with oral cancer see next section.

Infections.

A pathogen is a disease causing microorganism [micro- can only be seen with a microscope] [organism- living thing].

There are 5 [that we know of] types of organism that cause disease;- Bacteria, Viruses, Fungi, Prions [ such as those causing CJD] and Protozoa [ such as those causing amoebic dysentery]. The first 3 are the ones that concern us.

Bacteria.

Poor oral hygiene leads to caries [tooth decay] and gum disease [periodontal disease]. Periodontal disease has been shown to increase the risk for oral cancer. Some specific bacteria found in the mouth can metabolise alcohol to acetaldehyde which is a carcinogen [cancer causing chemical]. There may be other bacteria associated oral cancer which we have yet to be sure of.

Viruses.

There are various viruses implicated in different oropharyngeal cancers but the one that is most concerning is HPV [human papilloma virus].

There are more than 100 different types of HPV some produce warts on the skin, mouth and genitals.

They are the most commonly shared sexual infections.

The risk factors for HPV infection include;-

Having sex at an early age.

Multiple sexual partners.

Risky sexual behaviour with unknown partners.

Lack of condom use.

One of the problems with the advent of the pill is the increase in the incidence of sexually transmitted disease; – syphilis, gonorrhoea, chlamydia, HIV, HPV. Sex is just how these type of organisms get from one person to another. Picking up a sexually transmitted disease [STD] is not shameful, if you suspect you might have a problem the sooner you get help and advice the better for you and for future sexual partners. You might like to visit this website www.sh24.org.uk [sexual health 24 hours a day] it has lots of useful advice and self-testing kits by post or/and go to see your doctor.

Most sexually active adults will have been affected with high risk HPV at some stage. Most people 90% will clear it from their system. Only a small number of people with HPV will go on to develop oropharyngeal cancer. Numbers 16 and 18 are the ones most implicated in oropharyngeal cancer, other numbers are implicated in other types of cancer; – all cervical cancers and a high number of cancers of the anus, penis, vagina and vulva.

Risk factors for HPV related oropharyngeal cancer are;-

More than 26 lifetime sexual partners.

6 or more oral sexual partners.

Sex at a young age.

Fungi.

Candida albicans is the common yeast [a type of fungi] in the mouth. There are other types of candida some of which produce nasty compounds and some can also convert alcohol to acetaldehyde. Candida likes to live on the back of your tongue, make sure you clean your tongue on a regular basis. Candida will always be there, it lives on us normally, just don’t want it getting out of hand!

What are the things to look for with oral cancer?

Red and/or white patches in the mouth.

Ulcers which don’t heal within 3 weeks.

Lumps or bumps which appear for no good reason.

There are obviously lots of red patches, white patches, ulcers, lumps and bumps which are not at all something to be worried about. As a rough rule of thumb if the cause is traumatic [you have damaged yourself in some way] or infective, it will go away or at least start to look a lot better within 7-10 days. Add another week on for luck, if it’s still there after 3 weeks go and see your dentist or your GP. The dentist’s field of expertise is the mouth, they are highly trained to spot signs of oral cancer AT AN EARLY STAGE and other worrying things. It is mandatory for your dentist to keep their training in oral cancer up to date in order to stay on the dental register [ kept by the General Dental Council GDC] and be allowed to practice.

There are a range of conditions which are known as PMDs [potentially malignant disorders]. This means essentially that they are OK in themselves but they have the potential to turn into something nastier at a later date, which doesn’t necessarily mean they will but they should be kept a close eye on by your dentist. Lichen planus is probably the most common one which you may have heard of [affects 2% of the population in the UK]. Your dentist will spot these.

Remember this;-

Go to your dentist regularly at the very least every 2 years preferably every year for the health of your teeth, for the health of your gums and for the health of your mouth in general. This applies even if you have full dentures.

Eat sensibly, drink in moderation, don’t smoke and practice safe sex.

If you find anything suspicious, however trivial go and see your dentist they won’t mind.

The earlier something is found, the less invasive the treatment, the better the outcome for the patient and the better your chances of survival.

PREVENTION IS BETTER, SIMPLER, CHEAPER AND LESS PAINFUL THAN CURE! 

Ulcer is a descriptive term and means ‘a hole in your skin’.

There are actually 40 different types of mouth ulcer and the ‘history’ starts to give the clinician a clue as to what type they are. The history as you say in the medical profession is the ‘story’ in the patients words how long you’ve had something, what makes it better, what makes it worse etc followed by the answer to various questions your health professional might ask you.

An ulcer is as if you got a pair of eyebrow tweezers and pulled a good deep chunk off the top layer of your skin. There are various conditions where the very thin superficial layer thins, sloughs off, atrophys or appears to be eroded but an ulcer goes down deeper through the top layer of epithelium [skin with no tough keratin and very few layers such as you find in your mouth] and down to the layer below which is called the lamina propria. The lamina propria has little nerve endings in it, that and superficial infection is why ulcers can be so sore and as we all know are made even sorer by eating things such as spicy foods and citrus.

Causes of ulcers.

Systemic [whole body] diseases which cause ulcers of various sizes and characteristics. These range from; – immunological diseases, various infectious diseases [such as syphilis, chicken pox, HIV and herpes], some disorders in your gastrointestinal tract [stomach and intestines][such as Crohns disease, Coeliac disease and Ulcerative colitis], some skin diseases and some blood disorders [anaemia, leukaemia].

Oral cancer can also present as an ulcer [see chapter on oral cancer].

Drugs a patient may be on can cause ulcers.

All of the above are very rare the vast majority of ulcers are caused by either local damage or are apthous ulcers.

Local Damage/ Traumatic Ulcers are causes by things such as;-

Trauma from a broken tooth rubbing a hole, a brace that is rubbing on your cheek, ill-fitting dentures, accidentally biting yourself etc.

Burns from food especially things like melted cheese on pizza, hot coffee, hot toffee, chips straight out of the fryer, soup that’s just been heated in a microwave. Be careful with microwaves as they heat unevenly which is why you should stir everything after heating and never give a baby a bottle of milk that has been warmed in the microwave without stirring and temperature testing first. Much better to use a bottle warmer.

Aspirin also causes burns if held on the site of a sore tooth. Painkillers act on your brain, not on the spot. People tend to use other painkillers now a days but aspirin burns were common in the past. Aspirin is acetylsalicylic acid and so will cause a chemical burn.

With all of the above, remove the cause and it will go away. If it doesn’t within about 3 weeks, go and see your dentist/ GP.

Apthous Ulcers.

These are the sort of ulcers we all get. Nowadays they are technically called Recurrent apthous stomatitis or RAS for short.

Very common affects about 20% of the population in the UK.

It’s not thought that they are infectious.

Usually starts in childhood or adolescence.

It’s never really been decided exactly what causes them but we do know that in about 1/3^rd of cases it seems to run in families and we do know that they are stress linked typically occurring when changing schools, sitting exams, family break up, domestic problems, moving house etc.

Sometimes it will be deficiencies such as iron, vit B12 and folic acid.

Sodium laurel sulphate is a foaming detergent used in tooth paste which can cause ulcers in some people so it’s worth switching to another brand to see if that helps.

With women it’s sometimes linked to your cycle.

Food allergies are sometimes the culprit, a common one is cinnamon found hidden in a lot of processed foods and ready meals.

They come in 3 main types; – Minor [little ones], Major [big ones] and Herpetiform [lots of little pin head sized ones and nothing to do with Herpes infection, the term is descriptive].

There is no real cure. They usually heal spontaneously in about 7-10 days though the big ones can take up to 6 weeks. If you get the odd one that’s manageable but if you get them a lot and they make your life a misery go and see your dentist, there are various anti-inflammatory and steroid preparations that can help.

Smokers who stop will sometimes get ulcers or get worse ulcers if they already have them. This will settle down. Please don’t start again.

General Management;-

Good oral hygiene.

Plenty of fruit and veg, 5 a day, preferably 7 if not more.

Change toothpaste to one without sodium laurel sulphate.

Cut out cinnamon.

Keep your iron levels up.

A mouthwash with Chlorhexidine [Corsodyl] or Triclosan once a day might help.

Get enough sleep.

Reduce the stress in your life [what idiot said that? But it has been said to me on more than one occasion by people who should know better].

NB- This is very serious.

If you have an ulcer which doesn’t go away within a normal length of time and you have removed all the normal causes please go and see your dentist it could be cancer.

If you have lots of episodes of mouth ulcers and you have them on your genitals and possibly eye problems as well, especially if you are of Eastern Mediterranean, Arabic, Jewish, Chinese, Japanese or Korean descent go to your doctor or your dentist. This could be a condition called Bechet’s  Syndrome [should have a cedilla under the ‘c’ he was Turkish] which is very rare but can be life threatening.

Any ulcers out of the ordinary should be investigated as they could possibly be linked to other serious conditions. Go and see your GP or your dentist, they not necessarily trained to be experts in everything, what they are trained to be is SUSPICIOUS.

 

 

 

 

 

Bad breath is also known as Oral Malodour or Halitosis [this last term according to QI is a made up word and I’ve never liked it but made up or not it is widely used so I have included it].

Common causes.

Food- the most obvious which we all know about, eating certain foods; – garlic, spices, onions, cabbage, brussel sprouts, cheese and onion crisps etc. This is obviously easy to manage by avoiding such foods in certain social situations.

‘Morning breath’- most people have breath that is ‘less than fresh’ first thing in the morning, thankfully the only people around at the time are our nearest and dearest who are, hopefully, forgiving until we have brushed our teeth. This is usually caused by reduced salivary flow during the night washing away bacteria, old dead cells etc and will be exacerbated by mouth breathing while asleep which I think most people probably do judging by the number of patients who complain to me about their partners snoring. Saliva flow will be further reduced by other factors which cause a dry mouth; – alcohol, smoking, certain drugs etc [see chapter 11].

Less common causes.

1- Infection in your mouth [oral sepsis].

• Tooth decay [caries] caused by poor oral hygiene.
• Gum disease [periodontal disease] caused by poor oral hygiene.
• Infection around an erupting wisdom tooth [periocoronitis].
• Infected extraction sockets.
• Ulcers [next chapter].
• Some other mouth [oral] infections- come to those in a later chapter.
• Bacteria and fungi on the back of your tongue.
• Food trapping around;- ledges on fillings, bridges and implants not cleaned correctly, very misaligned teeth etc.
• Dentures not cleaned thoroughly, regularly and disinfected on a regular basis.

Rotting bits of food smell just like something you have left in the back of the fridge too long and some bacteria give of nasty gasses as they metabolise. The bacteria most implicated in this are Gram-negative anaerobes of various types. Anaerobe bacteria survive in the absence of oxygen so are found in the bottom of periodontal pockets [see chapter 5], under gum flaps on erupting wisdom teeth and in extraction sockets that have not been kept clean according to ‘post-operative instructions’. The smell that you will most recognise is that of ‘volatile sulphur compounds [VSCs]’ ie rotten eggs.

2- Dry mouth. [see chapter 11].

3- Smoking, alcohol and some drugs.

4- Respiratory [breathing system]/ ENT problems;- infection in nasal passages, tonsillitis, sinusitis, lower respiratory tract infections.

5- Diseases in the rest of your body [Systemic diseases], some of which are;-

• Diabetes- when the patient becomes ketotic and the breath smells of acetone [pear drops, nail varnish remover].
• Stomach and intestines [Gastro-intestinal].
• Liver [hepatic] failure.
• Kidney [renal] failure.
• Lung [pulmonary] disease.
• Other metabolic disorders.

These causes are rare but obviously very important and need to be thoroughly investigated.

If you can get a willing partner or friend to help you, try and decide if the smell is coming from your nose, your mouth or both.

As a rough rule of thumb if it’s coming from your mouth it is likely to be infection of one sort or another in your mouth or your throat. If it’s coming from your nose it’s probably your sinuses or your nasal [nose] passages. If it’s coming from both it’s probably due to systemic [whole body] disease.

Little kids quiet often shove things up their noses;- beads, little nuts, peas seem to be a particular favorite, tiny lego, your pills- don’t leave them lying around etc. This leads to infection and malodour.

What to do.

• Avoid foods that make your breath smell; – onions, garlic, spices etc in a situation when you want to have fresh breath.
• Avoid habits that worsen breath; – alcohol and tobacco.
• Thorough oral hygiene as in chapters 6, 7 and 8. When you have that down to a fine art a mouthwash may help but ask your dentist which one first.
• Visit your dentist. He or she will identify any dental problems and together you can solve and treat those.
• Eat a good breakfast and regular meals. See the ‘eat well plate’, don’t forget your 5 a day. Make it 7 if you can, more if poss. interestingly pineapple contains an enzyme which helps clean your mouth.
• Brush your teeth after meals.
• Brush your tongue before going to bed. You can use a manual toothbrush, your electric toothbrush but not too fiercely, a teaspoon with the bowl facing down, or a tongue scraper. I never find these much use myself though some peoples swear by them. They are of very little help if you are a person who has a big furrow up the middle of their tongue. If you do have a furrow clean it thoroughly with a toothbrush, it’s like a little micro climate for bugs. You need to clean your tongue as far back as you can get to, as most of the bugs live ‘over the hill’. When you start looking at your tongue in detail don’t be alarmed if you see what looks like a ‘V’ of Darlic’s heads across the back of your tongue, this is normal anatomy these are your Circum Valate papillae.
• Keep your mouth as moist as possible 1.5 litres of water a day for a woman, 2 litres for a man. Use sugar free gum [xylitol containing] after a meal.
• Your dentist may recommend one of the new ’fresh breath’ products.
• If you have dentures, clean them very thoroughly at the end of the day, clean or at least rinse them after every meal, leave them out at night so you don’t get bacteria breeding under them. Ask your dentist for advice as to an overnight soak.

When you have seen your dentist for any treatment required together with an ongoing plan of action [care plan] and you have followed the above advice to the letter, if the problem appears to be no better your dentist will refer you to a specialist in Oral Medicine for their opinion. The specialist will probably also liaise with ENT and a physician to rule out other systemic causes.

If this is you please seek help, start with the ordinary things you can do yourself then go and see your dentist. A lot of patients who come to me for the first time have put off coming for a long time because they are embarrassed about their breath and the state of their mouths. Please don’t be, we are here to help.

There is nothing that saps your confidence more than feeling that your breath smells, that other people are avoiding getting to close to you or that you need to cover your mouth when talking. It makes you nervous in social situations meaning you either avoid them altogether or are constantly on edge.

Please seek help, the solution may be very simple and will make a big difference to your life.

The dental profession is here to help, we have seen it all before, you won’t be the first and you won’t be the last!

Please take my advice and good luck.

 

 

 

 

Saliva is one of those things in life that you never really appreciate ‘till it’s not there anymore.

Saliva has a function [the human body doesn’t usually waste its resources on producing things that have no use] and is essential to oral health.

These are its functions;-

Lubrication, you need it to talk and eat comfortably, It lubricates your food to make it easier to swallow and coats your teeth and the skin inside your mouth [oral mucosa] with a protective layer.

Taste, as some of your food needs to partially dissolve in saliva in order for you to be able to taste it.

Immunity, it contains antibodies and other anti microbials to help you fight infection and disease.

Digestion, it has enzymes in it [alpha amylase often called ptyalin] so it starts digesting your food [the carbohydrate] as it embarks on its journey from one end to the other and cleans up the bits a little.

Mineralisation, helps remineralise the outside of your teeth.

Buffering the acid in your food and drink back to neutral to stop it dissolving the enamel of your teeth.

Saliva is truly magical stuff!

Where does it come from?

It is not made anywhere else in the body.

You have 3 pairs of major salivary glands [one on either side]-

Parotid in front of your ears these are what swells up when you get mumps,

Submandibular in the floor of your mouth near the angle of your jaw [where your jaw turns a right angle below your ears].

Sublingual underneath your tongue.

Then on your lips, soft palate and dotted all over the inside of your mouth you have lots of little minor salivary glands [a bit like the sebaceous glands in your hair].

All these glands big and little together produce a combination of serous [watery] and mucous [thicker] saliva depending on what type of secretory calls they have in them and what type of saliva is needed in that particular place.

These salivary glands are called exocrine glands. So a gland, any gland in your body, makes whatever it makes and then it either discharges it straight into your blood system [endocrine glands] to carry it to where it’s needed [for example cells in your pancreas discharging insulin] or as in the case of salivary glands it has a bit of pipe work, a duct, to carry it to where it’s needed.

Your mouth is like a little sluice, you are constantly producing saliva which washes stuff down your throat- old dead cells, bits of food etc. It is constantly cleaning your mouth and helping to keep it healthy. If you are not producing enough your mouth will become unhealthy.

DRY MOUTH.

The real name for this condition is Xerostomia.

All of us suffer from a dry mouth occasionally- taking exams, got to make a speech, difficult customer, job interview etc. This is normal, but some people [and indeed all of us as we get older] will have dry mouths for other reasons.

Lack of saliva depending on the severity can make life very difficult for the sufferer, causing difficulty in eating, swallowing and talking comfortably, unpleasant and altered taste sensation and if oral hygiene is not diligent, rampant tooth decay [caries] with eventual tooth loss.

Main causes of dry mouth.

Uncommon causes.

Blockage in a major salivary duct. Stones can form in salivary ducts just like in your kidneys [though not made of the same stuff] they are called sialiths. Even rarer, a growth in a major gland will cause it not to function properly.

There are also some auto immune type diseases which cause the salivary glands to stop working. The most well-known of these is Sjogren’s syndrome where the salivary glands and the tear [lacrimal] glands stop working.

Patients who have had radiotherapy to the head and neck region for cancer will have malfunctioning salivary glands.

Patients with these problems are special cases and require tailor made management.

Commonest causes-

1 Advancing years.

2 Drugs.

Advancing years– as we all get older our salivary glands like other bits of us become a little less efficient!  Approximately 30% of people over 65 suffer from a dry mouth.

Drugs– as we are all living longer many of us are on drugs for various things [polypharmacy]. Many of the drugs for the commonest things also cause a dry mouth. They include- antihypertensives [high blood pressure], antihistamines, some antidepressants and many more.

A dry mouth is difficult to quantify. Some patients are unaware of a problem and some appear to have sufficient saliva but constantly feel their mouths are dry.

There is a way of measuring it called the Challacombe scale [invented by Prof Challacombe, professor of Oral Medicine at King‘s College Hospital London]. This looks for various things in the mouth and depending on how many of them present, puts the patient into 1 of 3 management categories.

The beauty of this scale is that anyone can use it, it’s very simple and straight forward, doesn’t require any specialised medical or dental knowledge, any health professional or member of the public can use it.

Most people fall into category 1.

THIS IS THE MANAGEMENT;-

Scrupulous oral hygiene [how did you guess].

Reduce/ remove as far as possible any sugar in the diet.

Rinse the mouth with water after eating.

Use an alcohol free fluoride rinse after lunch for one minute [ask your dentist which one which one].

Drink at least 8 glasses of fluid a day of which no more than ½ should be tea or coffee as they are diuretics. Sip water throughout the day and keep a glass at your bedside at night.

Always drink water with meals, eat slowly and eat ‘wet’ or moistened foods;- Soup , melon , grapes, casseroles, yoghurt, salad dressing etc

Chew sugar free chewing gum after a meal [containing xylitol towards the front of the list of ingredients] or a little cube of hard cheese [if you haven’t got high cholesterol]. These both stimulate salivary flow and cheese also tops up the calcium on the outside of your teeth.

You can look up the Challacombe scale yourself-

If you type The Challacombe Scale in to google or similar it will give you hopefully top of the list fgdpscotland.org.uk [Federation of General Dental Practioners in Scotland] and you can download a printable copy of the scale. If you look a bit further down the list you will find the link to the relevant entry in Wikipedia which gives you further information.

Things that will make the dryness worse are;-

Alcohol.

Drugs as mentioned.

Smoking.

Caffeine in coffee, tea and some soft drinks such as colas.

Mouth breathing, keep your lips moist by using a lip salve.

Hot dry environments, sleep with your windows open, perhaps a humidifier in your bedroom, even a wet towel sitting on top of your radiator when its on in in cooler months will help.

A bit of a dry mouth is manageable by yourself using the above information. However if it is a real problem it is very important that you seek professional advice. The above is just a rough overview. There are lots of medical causes of dry mouth and as with all medical problems the diagnosis is the most important thing. Go and see your dentist and your GP.