Your dentist may recommend a treatment or procedure to restore or replace a tooth that has been lost or damaged or to improve the appearance, health and function of your teeth. Some of these procedures are straightforward, while others are more involved.

The information in this section has been provided to help you understand the different treatments and procedures available to keep your smile healthy.

• Bonding and Veneers – Bonding and veneers make your teeth look better by changing their colour, shape or spacing.
• Bridges and Dentures – Bridges and dentures are 2 ways to restore a badly damaged tooth or replace a lost tooth.
• Care After Minor Oral Surgery – After minor oral surgery, you may have pain, bleeding and swelling. This section offers some advice on dealing with these problems.
• Crowns – If your tooth is damaged but not lost, a crown (also called a cap) can be used to cover the damaged part of your tooth. A crown protects your tooth from further damage.
• Dental Implants – Dental implants are used to replace missing roots and support replacement teeth.
• Fillings – There are several different types of fillings that can be used to fill a cavity, but the final decision on which type of filling is placed in your mouth is yours alone.
• Orthodontics – Orthodontic treatment uses braces or other appliances to put gentle pressure on your teeth and eventually move them into the right position. They can either be fixed or removable.
• Root Canal Treatment – Root canal treatment is the process of removing the infected, injured or dead pulp from a tooth.
• Teeth whitening – Although teeth are not naturally meant to be completely white, many Canadians want a brighter smile. Responding to this desire, a wide range of “whitening” options has become available to consumers.

This information is intended for informational use only and does not replace the professional care of your dentist. Only your dentist has the skills, training and expertise to identify and address all your oral health care needs. If you have a question or concern about your oral health, please talk to your dentist.

 Source: Canadian Dental Association web-site

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Poor oral health can affect a person’s quality of life. Oral pain, missing teeth or oral infections can influence the way a person speaks, eats and socializes. These oral health problems can reduce a person’s quality of life by affecting their physical, mental and social well-being.

Oral disease, like any other disease, needs to be treated. A chronic infection, including one in the mouth, is a serious problem that should not be ignored. Yet bleeding or tender gums are often overlooked.

Research has shown there is an association between oral disease and other health problems such as diabetes, heart disease and stroke, respiratory illness in older adults, as well as pre-term and low-birth-weight babies. Although researchers are just beginning to understand this relationship, evidence shows that oral disease can aggravate other health problems and that keeping a healthy mouth is an important part of leading a healthy life.

Five Steps to Good Oral Health

As part of a healthy lifestyle and to help reduce the risk of oral disease, follow these 5 steps to good oral health.

1. See your dentist regularly

Regular dental exams and professional cleanings are the best way to prevent problems or to stop small problems from getting worse.

Your dentist will look for signs of oral disease. Oral diseases often go unnoticed and may lead to or be a sign of serious health problems in other parts of the body.

Only your dentist has the training, skill and expertise to diagnose and treat oral health diseases and to meet all your oral health care needs.

2. Keep your mouth clean

Brush your teeth and tongue at least twice a day with a soft-bristle toothbrush and fluoride toothpaste to remove plaque and bacteria that cause cavities and periodontal disease (gum disease).

Floss every day. If you don’t floss, you are missing more than a third of your tooth surface.

Your dentist may also recommend that you use a fluoride or antimicrobial mouthrinse to help prevent cavities or gum disease.

When choosing oral care products, look for the Canadian Dental Association (CDA) Seal of Recognition. Oral care products that have earned the Seal of Recognition have been reviewed by CDA and will effectively contribute to your oral health.

3. Eat, drink, but be wary

Healthy food is good for your general health and your oral health. The nutrients that come from healthy foods help you to fight cavities and gum disease.

Limit how much and how often you consume foods and beverages that contain sugar. Sugar is one of the main causes of dental problems.

Limit your consumption of foods and beverages that are high in acid. The acid may play a part in causing dental erosion.

4. Check your mouth regularly

Look for warning signs of periodontal disease (gum disease) such as red, shiny, puffy, sore or sensitive gums; bleeding when you brush or floss; or bad breath that won’t go away. Gum disease is one of the main reasons why adults lose their teeth.

Look for warning signs of oral cancer. The 3 most common sites for oral cancer are the sides and bottom of your tongue and the floor of your mouth. The warning signs include:

• bleeding that you can’t explain,
• open sores that don’t heal within 7 to 10 days,
• white or red patches,
• numbness or tingling,
• small lumps and thickening on the sides or bottom of your tongue, the floor or roof of your mouth, the inside of your cheeks or on your gums.

Look for warning signs of tooth decay. The possible warning signs include teeth that are sensitive to hot, cold, sweetness or pressure.

Report any of these warning signs to your dentist.

5. Avoid all tobacco products

Stained and missing teeth, infected gums and bad breath are just some of the ways smoking can affect your oral health. Besides ruining your smile, smoking can cause oral cancer, heart disease and a variety of other cancers, all of which can kill you.

All forms of tobacco are dangerous to your oral health and your overall health, not just cigarettes. Smokeless tobacco such as chewing tobacco, snuff and snus can cause mouth, tongue and lip cancer and can be more addictive than cigarettes.

If you use tobacco products, ask your dentist and your family doctor for advice on how to quit.

If you take care of your teeth and gums at home and visit your dentist regularly, your smile should last you a lifetime. You and your dentist are partners in keeping your oral health good for life.

Source:  http://www.cda-adc.ca/en/oral_health/cfyt/good_for_life/

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The CAP has adopted this position because long-term comparative clinical studies have not been completed on the efficacy of lasers in the treatment of periodontal disease.

In addition, claims that laser surgery causes less post-operative pain than traditional surgery have not been documented with controlled clinical trials and therefore remain unsubstantiated.

It is important to note that lasers have the potential to cause permanent thermal damage to bone and tooth root structure if used inappropriately.

The position of the CAP on laser treatment is similar to that of the American Academy of Periodontology as set out in “Lasers in Periodontics”, which may be reviewed in detail at http://www.perio.org/resources-products/pdf/lr-lasers.pdf.

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Serum 25-hydroxyvitamin D is the clinically useful marker of vitamin D status, and it is this form of vitamin D that is measured when a physician requests a “vitamin D test” for a patient. To achieve serum 25-hydroxyvitamin D levels of greater than 75 nmol/L, a vitamin D intake of at least 1,000 IU (25 ug) vitamin D per day would be required. Before we discuss the specifics of the relationship of vitamin D with periodontal health, it is prudent to provide some background about the current dietary recommendations for vitamin D.

Current recommendations for Vitamin D

For Canada and the United States, the current Dietary Reference Intake for vitamin D was released in 1997. The recommended level of vitamin D intake for men and women over age 30 are the following (6):

31-50 years 200 IU (5 ug)

51-70 years 400 IU (10 ug)

>70 years 600 IU (15 ug)

Not surprisingly, much new and important data have been published in the ensuing years since the release of these recommendations. Of note is the fact that much research includes diseases other than those where there is a well-established role of vitamin D in bone health. This demonstrates the potential wide-ranging biological effects of vitamin D. As a result, current dietary reference intakes for vitamin D are under review and it is anticipated that an updated recommendation will be released later this year. In the meantime, several health organizations have created specific recommendations for vitamin D intakes. The Canadian Cancer Society recommends 1,000 IU (25 ug) vitamin D per day for adults – especially during the winter months when endogenous production of vitamin D is negligible – for potential protection against cancer development.

Most recently, Osteoporosis Canada has developed guidelines that recommend daily vitamin D supplements of 400 IU (10 ug) to 1,000 IU (25 ug) for adults under age 50 without osteoporosis or conditions affecting vitamin D absorption.10 Osteoporosis Canada also recommends vitamin D supplements of between 800 IU (20 ug) to 2,000 IU (50 ug) vitamin D for men and women over age 5010. Notably, these are approximately 2 to 5 times higher than current dietary reference intakes for vitamin D.

Vitamin D and Periodontal Health

Vitamin D has been studied with respect to periodontal health because of known benefits to bone metabolism as well as anti-inflammatory activity involving T-cell homeostasis. Review of studies investigating the relationship between vitamin D intakes and periodontal health in adults suggest that vitamin D promotes periodontal health.

Using cross-sectional data from over 11,000 subjects that was collected as part of the National Health and Nutrition Examination Survey (known as NHANES III), investigators showed an inverse relationship between attachment loss and serum 25-hydroxyvitamin D (25(OH)D3) in men and women over age 50 but not among those under age 50. As noted by the authors, this finding may be explained by the fact that periodontal disease is more prevalent at older ages. Study subjects over 50 years of age had a fairly wide range of serum 25-hydroxyvitamin D levels, ranging from less than 40.2 nmol/L (n=554) through to individuals with levels greater than 85.6 nmol/L (n=449). Serum 25-hydroxyvitamin D levels of subjects were divided into quintiles, and thus individuals in the two highest quintiles had levels at approximately the level often advocated as having potential health benefits (i.e., serum 25-hydroxyvitamin D levels of 75 nmol/L). The authors also reported there was no relationship between bone mineral density (BMD) and attachment loss. This was a somewhat surprising finding as loss of BMD at the wrist, spine and hip are associated with a greater number of lost teeth due to loss of alveolar bone in the jaw. This finding also suggests that the potential immunomodulatory effects of vitamin D may be the predominant mechanism linking vitamin D with attachment loss.

Another study using the NHANES III data showed that subjects with the highest intakes of vitamin D were less likely to bleed on probing.

Male and female subjects ranged in age from 13 to over 90 years of age. Of note is the fact that all subjects in this analysis had never smoked, and this perhaps strengthens the findings as it could be postulated that higher serum 25-hydroxyvitamin D may have greater benefits among smokers due to compromised periodontium. The relationship was such that for every 30 nmol/L increase in serum 25-hydroxyvitamin D, there was a 10% lower odds for bleeding upon probing. Moreover, the association was linear over the range of serum vitamin D levels. The lowest and highest median quintile were 32.4 nmol/L and 99.6 nmol/L, respectively, with the highest mean quintile being even higher than the target vitamin D level of 75 nmol/L.

We would be remiss not to at least discuss briefly that dietary calcium levels may also be an important consideration when examining the relationship of vitamin D with periodontal health. The studies discussed so far measured calcium intakes, and unless calcium supplements were taken, most individuals had calcium intakes that were below recommended levels. For both men and women, calcium intakes should be 1,000 mg for age 31-50 years and 1200 mg for over age 50 years. One randomized controlled trial and a few cross-sectional studies have investigated both nutrients together in the context of periodontal health. The randomized controlled trial in healthy older individuals (over age 65 years) who received daily supplementation of calcium (500 mg) in combination with vitamin D (700 IU or 17.5 ug) showed a lower risk of tooth loss with no differences in probing depths at the end of 3 years.

This finding, combined with the studies investigating vitamin D alone, emphasize the importance of subjects meeting the recommended intake of calcium. A cross-sectional study showed that among patients with at least two interproximal sites with ≥3 mm clinical attachment loss, subjects who took vitamin D (≥400 IU or ≥10 ug per day) and calcium (≥1000 mg per day) supplements had better clinical status including shallower probing depths, fewer bleeding sites, lower gingival index values, fewer furcation involvements, less attachment loss, and less alveolar crest height loss. While a clinical benefit of supplementation was observed, the differences between groups were not statistically significant. It will be important to further study this relationship with a larger sample size and in randomized controlled trials.

The NHANES III data has also been used to examine if intake of dairy products relates to periodontal health as dairy foods represent a major dietary source of vitamin D as well as calcium.1 Over 12,000 individuals were included in this analysis and the prevalence of periodontitis was markedly lower for subject with the highest quintile of dairy intake compared to those consuming low amounts of dairy foods. Individuals were classified as having periodontitis if they had at least one site with an attachment loss of ≥3 mm and a probing depth of ≥4 mm. While findings to date suggest a positive role for vitamin D in periodontal health, randomized controlled trials, with a primary objective of determining optimal vitamin D levels for prevention of or attenuation of periodontal disease, are needed.

Improving Vitamin D Status: Food or Supplements?

As discussed earlier, it is believed that for optimal health, in general, serum 25-hydroxyvitamin levels should be 75 nmol/L or higher and that likely a diet containing a minimum of 1,000 IU (25 ug) vitamin D per day is required to achieve this level. Vitamin D is naturally present in only a few foods, namely fatty fish (1 serving contains approximately 350 IU or 8.75 ug) and eggs (1 egg contains approximately 30 IU or 0.75 ug vitamin D). Milk can be a major source as it is fortified with vitamin D. One glass of milk, regardless of fat content, contains 100 IU (2.5 ug) of vitamin D. Moreover, chocolate flavored milk beverage also contains 100 IU (2.5 ug) of vitamin D. So, if aiming for 1000 IU (25 ug) of vitamin D through dietary sources, many glasses of milk and multiple servings of fish need to be consumed each day. Thus, supplements are warranted to help achieve these levels of vitamin D.

Take-Home Points:

Higher serum 25-hydroxyvitamin D is associated with better periodontal health:

• Inverse relationship between serum 25-hydroxyvitamin D and attachment loss in men and women over age 50.
• Calcium may also facilitate better periodontal health – a combination of daily supplements of calcium (500 mg) and vitamin D (700 IU) is associated with lower risk of tooth loss.
• Higher intake of dairy products is associated with a lower risk of periodontitis.

Serum 25-hydroxyvitamin D, the accepted marked of vitamin D status, should be at least 75 nmol/L to promote optimal health, including periodontal health. To achieve such serum levels, vitamin D intakes of at least 1,000 IU (25 ug) are likely required.

Few foods contain significant quantities of vitamin D either naturally or through food fortification and thus vitamin D supplements are likely needed to achieve appropriate serum levels of 25-hydroxyvitamin D.

Although the evidence regarding the important role of vitamin D in prevention of a wide range of diseases is increasing, it is important to recognize that vitamin D is unlikely a panacea for health, and that you can get “too much of a good thing”. It is advised that individuals do not consume in excess of 2,000 IU (50 ug) of vitamin D per day.

Published by Oral Health & Dental Practice Management, October 2010

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• Visiting the Dentist Regularly – The regular checkup is important. Almost all oral diseases are asymptomatic in their early stages; including periodontitis, gingivitis, decay, and oral cancer. In addition, these problems are much easier and less expensive to fix when caught early.
• Updating Medical History with Dentist – Many medical conditions adversely impact your oral health both directly (diabetes, AIDS, Sjogren’s, etc.) and indirectly due to medications used (hypertension, heart disease, depression, cancer, etc.). Your dentist must be aware of all conditions and medications, even if it does not seem pertinent, to properly manage your treatment and prevention program.

• Reducing Frequency of Sugar Intake – The amount of sugars eaten throughout the day is not as important as the frequency of intake. This includes both simple sugars and starches. The mouth has a natural buffering capacity in the saliva which neutralizes the bacterial acids, thus minimizing decalcification of enamel. Frequent sugar doses overload this ability.

• Not Smoking – Smoking is just plain terrible for your mouth. Stained yellow to eth are the obvious problems, but the hidden damage is far more threatening. Smokers are much more likely to suffer oral cancer than non-smokers. Periodontal disease in smokers is more severe, progresses faster, and responds very poorly to treatment.

• Protecting Your Teeth – Dental protection includes the obvious, such as wearing mouth guards for sports. Less obvious ways to protect your teeth from trauma include always wearing a seatbelt, never using your teeth as tools, and wearing a night guard if bruxism is evident.

• Using Mouthwash – Mouthwashes and prescription rinses used twice daily help reduce gingivitis when accompanied by proper brushing and flossing.

• Brushing and Flossing – The simple act of proper daily hygiene will prevent the majority of dental troubles in most people.

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Patients particularly at risk include those with special needs and infants on long-term medications who have not yet established proper oral hygiene. The presence in the mouth of sweet syrupy medications can contribute to high rates of dental caries (such as those seen in early childhood caries). There are sugar substitutes that do not contribute to dental caries.

The Canadian Dental Association’s position is as follows:

1. Health care providers, especially physicians, dentists and pharmacists, should be made aware of the high sugar content of oral elixers, suspensions and chewable medications and should be advised to try to prescribe/dispense drugs utilizing sugar substitutes whenever possible.
2. The Pharmaceutical Manufacturers Association and Proprietary Drug Association should be made aware of the high risk of decay associated with prescription and over-thecounter drugs containing sugar and should be encouraged to employ sugar substitutes in medications.
3. Special needs patients and/or parents/caregivers of children should be advised of the increased risk of tooth decay associated with the chronic use of sugar-sweetened medications. They should also be counseled regarding oral hygiene and other preventive measures.
4. Labeling of medication should indicate sugar content to assist the choice of alternatives.
   High sugar content medications such as oral elixers, suspensions and chewable medications should include warnings regarding the increased risk of dental caries from chronic use on labels or/and in drug monographs.

Approved
CDA Board of Directors
February 2005

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The use of tobacco products is the leading cause of preventable death and disease in Canada
accounting for some 30,000 deaths annually. The Canadian Dental Association (CDA)
recognizes with deep concern the effects of the use of tobacco products on both general and oral
health.
Practising dentists see firsthand the initial signs of problems that arise when individuals use
tobacco products, including smokeless tobacco (also known as spit tobacco, snuff and chewing
tobacco). Dentists are concerned that tobacco products have been shown to contribute to oral
diseases, including oral cancer and periodontal diseases.
The following policy affirms the need to eliminate the use of all tobacco products in Canada and
establish a norm of non-smoking as a social attitude for Canadians.

1. CDA supports efforts to ban all advertising and promotion of tobacco products and other measures to limit or constrain use.
2. CDA urges that regulations prohibiting the sale of all tobacco products to minors be strictly enforced.
3. CDA encourages governments to develop educational programs aimed at smoking prevention among Canadians in general, but particularly in our school systems.
4. CDA urges dentists to set an example to the public by not using tobacco products.
5. CDA encourages dentists to place no smoking signs in their reception areas and declare their offices smoke-free environments.
6. CDA urges governments to encourage those engaged in the cultivation, production and sale of tobacco products to find alternative crops and to diversify into alternative activities.
7. CDA urges the prohibition of exporting tobacco and tobacco products, especially to Third World countries.
8. CDA urges that the health of non-smokers be protected by banning smoking in all public places, through provincial legislation and/or municipal bylaws, and specifically urges that smoking be banned in all workplaces, schools, health care facilities and public transport systems.
9. CDA encourages the eradication of the use of tobacco products. Studies indicate that dental counseling is effective in influencing patients to quit using tobacco. CDA urges dentists to inquire about their patients’ tobacco use and provide advice and encouragement to those patients interested in quitting.

Approved
CDA Board of Directors
February 2005

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Recent evidence presented in this report, primarily from epidemiological studies, now suggests that there may be an association between periodontitis and certain systemic disorders, notably cardiovascular disease (artherosclerosis, heart attacks and strokes) and complications of pregnancy (pre-term birth and low birthweight infants).

While a number of interactions have been identified, other reviewers suggest no or limited relationship. Therefore, additional research is needed to evaluate disease pathogenesis, relationships to the oral cavity and possible therapeutic interventions. Dentists and dental specialists are constantly looking for signs and symptoms of these diseases, which can be detected during regular oral health and physical examinations. The Canadian
Dental Association recognizes the Surgeon General’s report but recommends that further
emphasis should be placed on research and educating dentists, physicians, students, residents, other healthcare professionals and most importantly, patients regarding the importance of these possible relationships.

This report places oral health in the perspective of systemic health and suggests that the dental and medical professions need to develop even closer ties in the future.

Approved
CDA Board of Directors
February 2005

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