This Guidelines summary of the Oral Health Foundation’s A–Z of oral health information has been produced to provide background information on a number of common oral health conditions, and to assist community pharmacy teams in providing advice to patients and members of the public on managing their oral health.
This summary only includes information relevant to the community pharmacy setting. For further information, refer to the Oral Health Foundation website.
Reflecting on Your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
Definition and Causes
- Bad breath (halitosis) is a common problem and there are many causes
- Persistent bad breath is usually caused by odorous gases released by the bacteria that coat the teeth, gums, and tongue
- Other causes include food caught between the teeth and on the tongue; strong foods (such as garlic, coffee, and onions); dry mouth; infections in the throat, nose or lungs; sinusitis, bronchitis; diabetes; liver or kidney problems; and smoking
- Bad breath or a bad taste in the mouth can be a sign of gum disease.
Advice for Keeping Breath Fresh
- Advise people to:
- get rid of any gum disease and keep the mouth clean and fresh
- keep a diary of foods and medicines and discuss with a dentist
- brush teeth and gums last thing at night and at least one other time during the day, with a fluoride toothpaste
- brush the tongue as well, or use a tongue scraper
- cut down on frequency of sugary food and drink consumption
- visit the dental team regularly, as often as they recommend
- clean in between the teeth with interdental brushes or floss (or other products) at least once a day—brushing alone only cleans up to about 60% of the surface of the teeth
- use a mouthwash—some contain antibacterial agents that could kill the bacteria that make the breath smell unpleasant; however, if bad breath continues, visit the dental team to make sure that the mouthwash is not covering up a more serious underlying problem. Chlorhexidine mouthwashes can cause tooth staining if used for a long time
- chew sugar-free gum—it helps the mouth produce saliva and stops it drying out
- clean dentures thoroughly.
Burning Mouth Syndrome
Definition and Causes
- Burning mouth syndrome (BMS) is a hot feeling or sensation that can affect the tongue, lips, palate, or areas all over the mouth. BMS is a neuropathic pain and is sometimes called glossodynia
- No one knows exactly what causes BMS. In some cases, it may have more than one cause. Possible causes include:
- dry mouth
- acid reflux
- nutritional deficiencies (for example iron, vitamin B12, or folic acid)
- thyroid problems
- hormone changes
- stress, anxiety, or depression
- problems with the immune system
- damage to the nerves controlling taste or pain
- a reaction to certain types of toothpastes or mouthwashes
- badly fitting dentures or being allergic to the materials used to make dentures
- Anyone can have BMS, but it is more common during the menopause.
Advice on Managing Burning Mouth Syndrome
- People with BMS should see their dental team for a check-up to determine the cause as treatments can vary
- Symptoms can be eased at home by:
- sipping water often
- sucking on crushed ice
- chewing sugar-free gum—this helps produce more saliva, which helps to stop the mouth getting dry
- avoiding things that irritate the mouth, such as hot and spicy foods, mouthwashes that contain alcohol, or acidic fruits and juices
- avoiding tobacco and alcohol products.
Caring for Teeth and Gums
Advice to Help People Keep Their Mouths Clean and Healthy
- Brush teeth for 2 minutes, last thing at night and at least one other time during the day, using fluoride toothpaste
- Spit toothpaste out after brushing and do not rinse
- Use a toothbrush with a small- to medium-sized head
- Use a toothbrush with soft to medium, multi-tufted, round-ended nylon bristles
- Consider using a power toothbrush
- Use small, circular movements to clean teeth
- Change toothbrushes regularly, and at least every 3 months
- Clean between teeth every day using interdental brushes or dental floss
- Have sugary drinks and foods less often
- Visit the dental team regularly, as often as they recommend.
Child Oral Health
- First teeth usually start to appear when a child is around 6 months old. All 20 baby (also called primary or deciduous) teeth should appear by the age of 30 months
- The first adult (permanent) molars will appear at about 6 years of age, before the first primary teeth start to fall out at about age 6–7
- All permanent teeth should be in place by the age of 14, except the ‘wisdom’ teeth. These may appear any time between 18 and 25 years of age.
Oral Healthcare for Children
- Cleaning a child’s teeth should be part of the daily hygiene routine—if possible, just before the child goes to bed and at least one other time during the day
- All children up to 3 years old should use a smear of toothpaste with a fluoride level of at least 1000 parts per million (ppm). After 3 years old, they should use a pea-sized amount of toothpaste that contains 1350–1500 ppm
- It is important to supervise a child’s brushing until they are at least 7 years old
- Children should use a small-headed toothbrush with soft, nylon bristles, suitable for their age. Using a power toothbrush, suitable for the age of the child, can help to make brushing fun and make sure the child brushes for the correct amount of time
- The main cause of tooth decay and dental erosion is not only the amount of sugar or acid in the diet, but how often it is eaten or drunk, so it is important to only consume sugary and acidic foods at mealtimes.
Dental Decay and Erosion
Causes of Dental Decay
- Dental decay happens when the enamel and dentine of a tooth become softened by acid attack after eating or drinking anything containing sugars. Over time, the acid makes a cavity in the tooth. The acid attacks can last for an hour after eating or drinking, before the natural salts in saliva cause the enamel to remineralise and harden again
- It’s not just sugars that are harmful: other types of carbohydrate foods and drinks react with plaque and form acids. (These are the ‘fermentable’ carbohydrates: for example, ‘hidden sugars’ in processed food, natural sugars like those in fruit and cooked starches.)
- Having sugary or acidic snacks and drinks between meals can increase the risk of decay, because teeth come under constant attack and do not have time to recover.
Recognising Dental Decay
- In the early stages of dental decay there are no symptoms, but the dental team may be able to spot a cavity in its early stages
- Once the cavity has reached the dentine, the tooth may become sensitive. As the decay gets near the dental pulp people may suffer from toothache. If the toothache is brought on by hot or sweet foods this may last for only a few seconds. As the decay gets closer to the dental pulp the pain may last longer and people may need to take painkillers—paracetamol or ibuprofen—to control the pain
- Toothache is a sign to visit the dental team straight away.
Definition and Causes of Dental Erosion
- Erosion is the loss of tooth enamel caused by acid attack
- After eating or drinking anything acidic, tooth enamel becomes softer for a short while, and loses some of its mineral content. Saliva will slowly cancel out this acidity. However, if this acid attack happens too often, the mouth does not have a chance to repair itself and tiny bits of enamel can be brushed away. When the enamel is worn away, the dentine underneath is exposed, which may lead to pain and sensitivity.
Preventing Dental Erosion
- There are a number of things people can do to prevent dental erosion:
- only consume acidic food and drinks, and fizzy drinks, at mealtimes. This will reduce the number of acid attacks on the teeth
- drink quickly, without holding the drink in the mouth or ‘swishing’ it around the mouth. Or use a straw to help drinks go to the back of the mouth and avoid long contact with the teeth
- finish a meal with cheese or milk as this will help cancel out the acid
- chew sugar-free gum after eating. This will help produce more saliva to help cancel out the acids that form in the mouth after eating
- wait for at least one hour after eating or drinking anything acidic before brushing the teeth. This gives the teeth time to build up their mineral content again
- brush teeth last thing at night and at least one other time during the day, with fluoride toothpaste. Use a small-headed brush with medium to soft bristles
- spit out after brushing and do not rinse, so that the fluoride stays on the teeth longer
- as well as using a fluoride toothpaste, the dental team may suggest a fluoride-containing mouthwash and a fluoride varnish applied at least every 6 months. They may also prescribe a toothpaste with more fluoride in it.
Offering Advice to People With Dentures
- It is important to treat dentures like treat natural teeth, keeping them as clean as possible to avoid further tooth loss, inflamed gums or bacterial and fungal infections. They should be cleaned thoroughly at least once a day and after eating if needed
- Dentures may break if dropped. To avoid this, advise people to always clean dentures over a bowl of water or a folded towel
- Advise people to brush and soak their dentures every day using a non-abrasive denture cleaner, not toothpaste. Then soak in a denture-cleaning solution
- if there is a build-up of stains or scale, advise the person to have the dentures cleaned by the dental team
- it is important not to use any type of bleaching product to clean dentures. Advise the person not to use very hot water to soak dentures
- some people have sensitive gums and may need a softer lining made for their dentures. Some products can damage the lining. Some cleaning products can also damage metal dentures
- advise people not to keep dentures in overnight unless there are specific reasons to do so
- Denture stomatitis (thrush) is caused by a yeast or fungus called candida. If untreated, the condition can cause soreness in the mouth and may lead to poorly fitting dentures in the future
- Dentures are custom-made to fit the mouth and shouldn’t need a denture fixative. However, some people prefer to use a fixative to give them extra confidence or if their dentures start to become loose before they have them replaced. A poorly fitting denture may cause irritation and sores
- Even with full dentures, people still need to take good care of their mouth. Every morning and evening, the wearer should brush the gums, tongue, and the roof of the mouth with a soft brush. This removes plaque and helps the blood circulation in the mouth.
Definition and Causes
- Dry mouth (xerostomia) is a condition that affects the flow of saliva, causing the mouth to feel dry
- The most obvious symptom is a dry mouth. Other symptoms include:
- saliva feels thick and sticky, making it difficult to speak or swallow
- a ‘prickly’ or burning sensation in the mouth and sensitivity to certain foods
- the mouth can become sore and there is a higher risk of tooth decay and gum disease
- in some cases, the mouth can also become red and shiny
- these symptoms don’t necessarily mean that a person has dry mouth but it may be best to talk to the dental team or doctor about it
- Dry mouth can be a symptom of many different problems and can happen with age. Quite often it is a side effect of medication—especially heart, blood pressure, and depression medications. Dry mouth can also be caused by medical treatments such as radiotherapy, or surgery to the head or neck
- In some cases, dry mouth can be a direct result of a medical condition (for example diabetes, lupus, Sjogren’s syndrome, and blocked salivary glands)
- Women who are going through the menopause may suffer from dry mouth. Women taking hormone replacement therapy may also find they suffer from dry mouth
- Dry mouth can cause problems as saliva helps to cancel out the acid that attacks teeth, and is a very important part of dental health. Some people find that they have problems with swallowing when their saliva flow is affected. Having less saliva can also affect the taste of food and makes it harder to eat drier foods. Sometimes it can affect speech and it makes people more likely to have bad breath.
Symptom Relief and Advice
- There are a number of products designed to help the mouth stay moist and comfortable. These are usually gels or sprays. Some have extra ingredients that may help prevent tooth and gum problems. There are also special products to help with day-to-day oral hygiene (for example toothpastes and mouth rinses)
- Due to the higher risk of tooth decay and gum disease with dry mouth, it is important to visit the dental team regularly
- To relieve the symptoms of dry mouth, some people find that sipping water, or sucking sugar-free sweets, helps in the short term. Chewing sugar-free gum can also help as it encourages the mouth to make saliva. Rinses, gels, pastes, and lozenges are also recommended
- It is important to use a fluoride toothpaste containing at least 1350–1500 ppm of fluoride. A ‘total care’ toothpaste may be best as these contain antibacterial agents and other ingredients to control the build-up of plaque. Some products contain sodium lauryl sulphate, and some people with dry mouth find this can irritate the mouth and make the condition worse.
Definition and Causes
- Gum disease is described as swelling, soreness, or infection of the tissues supporting the teeth. There are two main forms of gum disease: gingivitis and periodontal disease.
- gingivitis means ‘inflammation of the gums’. This is when the gums around the teeth become very red and swollen. Often the swollen gums bleed when they are brushed during cleaning
- long-standing gingivitis can turn into periodontal disease. There are a number of types of periodontal disease and they all affect the tissues supporting the teeth. As the disease gets worse the bone anchoring the teeth in the jaw is lost, making the teeth loose. If this is not treated, the teeth may eventually fall out
- Most people suffer from some form of gum disease, and it is a major cause of tooth loss in adults. However, the disease develops very slowly in most people, and it can be slowed down to a rate that should allow people to keep most of their teeth for life
- All gum disease is caused by plaque. Plaque is a film of bacteria that forms on the surface of the teeth every day. Many of the bacteria in plaque are completely harmless, but there are some that have been shown to be the main cause of gum disease
- Smoking can also make gum disease worse.
Gum Disease Prevention and Treatment
- To prevent and treat gum disease, all plaque should be removed from the teeth every day by brushing and cleaning in between the teeth with interdental brushes or floss
- The first sign is blood on the toothbrush or in the toothpaste spat out after cleaning the teeth. Gums may also bleed whilst eating, leaving a bad taste in the mouth. Breath may also become unpleasant. The first thing to do is visit the dental team for a thorough check-up.
Gum Health and Overall Health
- Infections in the mouth can be linked with problems in other parts of the body. Problems that may be caused or made worse by poor dental health include:
- heart disease
- giving birth to a premature or low-birth-weight baby
- respiratory disease
- Medical costs for patients with diabetes, cardiovascular disease, or strokes, and for pregnant women, can be significantly less if their gum disease is treated thoroughly
- A recent study has shown that people who stay fit and healthy are 40% less likely to develop tooth-threatening gum infections that could lead to gum disease.
Definition and Causes
- Lichen planus is a long-lasting disease, which can affect the mouth and sometimes other areas of the body. Oral lichen planus usually happens from middle age onwards, and more women get it than men
- Lichen planus shows in many different ways. The most common signs are white patches on the lining of the mouth (usually the cheeks, tongue, and gums). These don’t usually hurt, but sometimes there can be redness, ulcers or, very rarely, blistering as well as the white patches. If so, it may be painful to eat hot or spicy foods
- The appearance and symptoms of oral lichen planus can be like those of some other disorders, so a biopsy is usually needed to be sure about the diagnosis
- The cause of lichen planus in most patients is unknown. It may be a sign of a slight weakness in the body’s immune system, but patients with lichen planus don’t usually have any other problems. Occasionally it can be caused by a reaction to medicines such as some painkillers, diabetic treatments, drugs for high blood pressure, beta-blockers, gold, or penicillamine
- Oral lichen planus does not seem to be caused by an infection, and isn’t genetic
- Emotional stress, spicy food, or citrus fruits can often cause the symptoms to get worse.
Treatment for Lichen Planus
- Usually, oral lichen planus only needs to be treated when there are painful symptoms. Sometimes patients with white patches that are not painful complain of a slight roughness of the lining of the mouth. But this usually does not need any treatment
- When oral lichen planus does need treating, it is usually treated with corticosteroid cream on the area. Some areas may need other treatments, such as immunosuppressants applied to the area. Very rarely people might need to take an oral corticosteroid or some other, similar, oral medications.
Definition and Causes
- Ulcers are painful sores that appear inside the mouth. They are usually red or yellow.
- Usually a single mouth ulcer is due to damage caused by biting the cheek or tongue, or by sharp teeth, brushing, or poorly fitting dentures. These ulcers are called ‘traumatic’ ulcers. If there are a number of mouth ulcers, and they keep coming back, this is called ‘recurrent aphthous stomatitis’
- Less common causes of mouth ulcer include:
- herpes simplex in children and some adults
- other less common viral and bacterial infections, but this is rare
- anaemia and occasionally by other blood disorders, and some skin or gastrointestinal diseases
- sometimes mouth ulcers are the only sign of an underlying disease
- cancer of the mouth can first appear as a mouth ulcer. The ulcers caused by mouth cancer are usually single and last a long time without any obvious nearby cause (for example a sharp tooth). Any ulcer that lasts longer than 3 weeks should be looked at by a dentist. Ulcers caused by cancer usually appear on or under the tongue, but may occasionally appear somewhere else in the mouth. Cancer of the mouth is usually linked to heavy smoking and drinking. Doing both together greatly increases the risk.
Reducing the Risk of Mouth Ulcers
- The risk of mouth ulcers may be reduced by:
- keeping the mouth as clean and healthy as possible
- using high-quality toothbrushes (to reduce the risk of damage to the mouth)
- eating a good diet which is rich in vitamins A, C, and E, and include foods such as fresh fruit and vegetables (to lessen the risk of mouth cancer)
- regularly visiting the dentist.
Oral Care Products
Toothbrushes and Toothpastes
- It is usually recommended that adults use a toothbrush with a small- to medium-sized head with multi-tufted, soft to medium filaments (bristles). These filaments should be round ended and made from nylon
- Power toothbrushes with rotating and oscillating heads have been proven to be the most effective
- There are toothpastes which can help to remove staining
- There are several toothpastes that contain ‘desensitising agents’ to help reduce the pain of sensitive teeth
- There are specialist ‘enamel formula’ toothpastes people can use if they feel that their diet is high in acid and they think that they may be at risk of acid erosion
- There are several ‘natural’ toothpastes that contain special mineral salts and plant extracts. They are made of only natural ingredients and flavouring. However, sometimes these toothpastes do not contain fluoride
- Total care toothpastes contain a number of ingredients such as antibacterial agents, ingredients that help control plaque and prevent gum disease, fluoride to help prevent tooth decay, and flavours that help to freshen the breath. They may also contain whitening or tartar-control ingredients.
Interdental Cleaning Products
- Interdental brushes are for cleaning the small gaps between the teeth. These can be on long or short handles for easier use and are generally colour coded for the different-sized gaps
- There are several different types of dental floss or tape, including mint-flavoured, wax-coated and ones containing fluoride. Many people prefer tape to floss, as it is wider and can be gentler on the gums. Floss ‘harps’ have the floss attached to a handle, which may make the floss easier to use
- These are another way of cleaning in between the teeth using a high-pressure jet of water. Some people with bridges and implants find them particularly useful.
- Many people use a mouthwash as part of their daily oral health routine. Some mouthwashes contain an antibacterial ingredient to help reduce plaque and prevent gum disease. Mouthwashes may contain fluoride to help prevent decay, and all will help to freshen the breath and wash away bits of food
- Some mouthwashes, especially ones containing chlorhexidine, are particularly effective at treating gum infections. They are also very effective at treating other mouth problems, such as those following a tooth extraction or when a wisdom tooth is coming through. They can cause staining, although this can be easily removed by the dental team.
Other Oral Care Products
- After brushing and cleaning people can use a disclosing tablet or solution to dye any plaque that hasn’t been removed. This can help to show any places they are missing when brushing
- Denture fixatives are products that help to stick or hold a denture in place and to stop it moving around and causing irritation and sores. Fixatives can come in different forms, including creams, powders, and strips
- For bad breath, in the short term people can use mouth rinses, sugar-free gum, and sugar-free mints. Many of the bacteria causing bad breath live on the tongue, so brushing the tongue or using a tongue scraper will also help
- There are a number of products designed to provide moisture and comfort for dry mouth. These include rinses, toothpastes, gels, and sprays. People also get lozenges and chewing gums for when they are out and about
- ‘Oral’ probiotics may help to keep up the balance between the friendly bacteria in the mouth and the harmful bacteria, which can cause plaque build-up, gum disease, and bad breath.
Definition and Causes
- The part of the tooth we can see has a layer of enamel that protects the softer dentine underneath. If the dentine is exposed, a tooth can become sensitive. This usually happens where the tooth and the gum meet and the enamel layer is much thinner
- People are more likely to feel the sensitivity when drinking or eating something cold, from cold air catching the teeth, and sometimes with hot foods or drinks. Some people have sensitivity when they have sweet or acidic food and drinks. The pain can come and go, with some times being worse than others.
Prevention and Treatment
- People should see the dentist if they have tried treating their sensitive teeth for a few weeks and have had no improvement
- There are many brands of toothpaste on the market made to help ease the pain of sensitive teeth. These toothpastes can take anything from a few days to several weeks to take effect
- To prevent sensitive teeth, people should be advised to:
- brush teeth last thing at night and at least one other time during the day, with fluoride toothpaste containing at least 1350 ppm of fluoride
- consider using toothpaste specially designed for sensitive teeth
- use small, circular movements with a soft-to medium-bristled brush
- try to avoid brushing teeth from side to side
- change toothbrushes every 2–3 months, or sooner if worn
- don’t brush straight after eating as some foods and drinks can soften tooth enamel; leave at least an hour before brushing
- have sugary foods, and fizzy and acidic drinks, less often. Try to have them just at mealtimes
- visit the dental team regularly, as often as they recommend.