Category Archives: Oral Surgery, Oral Pathology & Oral Medicine

Bleeding Gums During Pregnancy



Pregnancy Gingivitis


  • What is Gingivitis?
  • What is Pregnancy Gingivitis?
  • Causes of Gum Disease in Pregnancy
  • Symptoms of Pregnancy Gingivitis
  • Complications of Pregnancy Gingivitis
  • Treating Gingivitis in Pregnancy
  • Prevention

Some ladies may feel that their gums are uncomfortable than usual during pregnancy. Their gums are sore or tender, or if they bleed when brushing or flossing, they may have a condition called pregnancy gingivitis. Pregnancy gingivitis is a very common occurrence during pregnancy however; if it is not treated it can lead to complications with their pregnancy. If you are pregnant and notice any of the symptoms of pregnancy gingivitis it is important that you visit with your dentist in order to get appropriate treatment.

Pregnancy gingivitis is an hyperplastic reaction to microbial plaque. Elevated estrogen or progesterone levels resulting from hormonal shifts enhance tissue vascularity, which permits an exaggerated inflammatory reaction to plaque.

What is Gingivitis?

Gingivitis is more commonly referred to as gum disease, and it will affect over 90% of Americans at some point in their lives. Caused by the sticky plaque that accumulates on our teeth and gums, it can leave your gums swollen and tender, and even cause them to bleed. Gingivitis can also make brushing and flossing extremely painful. Gingivitis is one of the earliest stages of a more severe type of gum disease, called periodontal disease. Untreated gum diseases will progress into periodontal disease, which can cause irreversible damage to your gums and teeth. (More info on gingivitis)

What is Pregnancy Gingivitis?

Pregnancy gingivitis is simply gingivitis that occurs during pregnancy. More than 50% of all pregnant women experience some form of pregnancy gingivitis. Though gingivitis disease is annoying, it is usually harmless, unless it is left untreated. Pregnancy gingivitis is an hyperplastic reaction to microbial plaque. Elevated estrogen or progesterone levels resulting from hormonal shifts enhance tissue vascularity, which permits an exaggerated inflammatory reaction to plaque.  Pregnancy gingivitis produces fiery red, swollen and tender marginal gingiva and compressible and swollen interdental papilla. If pregnancy gingivitis progresses to periodontal disease, it can increase your risk of going into preterm labor.

Causes of Gum Disease in Pregnancy

There are a number of causes of gum disease in pregnancy. One such reason is increased blood flow. During pregnancy, your blood flow actually increases by between 30% and 50%. This is to ensure that your baby is provided with the appropriate nutrients to grow and develop. Unfortunately, this increased blood flow can also cause you gums to swell and become very tender. It may even cause your gums to bleed, leaving them at increased risk for gingivitis.

The rise in your hormones can also play a role in you developing pregnancy gingivitis. These higher levels of hormones leave your gums and teeth more sensitive to the bacteria that hide in plaque. This is one reason why gingivitis is so common in pregnancy.

Morning sickness may also play a small role in contributing to pregnancy gingivitis. Many women find that they can no longer stand the smell or taste of toothpaste, making it difficult to maintain good oral hygiene. Increased vomiting during pregnancy can also take its toll on your gums. Vomit contains stomach acid which can eat away at your gums and teeth, making your mouth very sensitive.

Symptoms of Pregnancy Gingivitis

There are a few symptoms of gum disease to keep an eye out for. If you notice any of these symptoms, it is important to seek treatment as soon as possible.

  • tender, swollen gums
  • red or purple-red gums
  • gums that look shiny
  • bleeding gums after brushing or flossing
  • persistent bad breath
  • a bad taste in the mouth that won’t go away
  • mouth sores

Complications of Pregnancy Gingivitis

Generally speaking, pregnancy gingivitis is nothing to worry about. However, if your gingivitis is left untreated it could cause potential health problems for both you and your baby.

Sometimes, gum disease can cause sores to form on your gums. These sores are often called pregnancy tumors. These tumors can grow up to three-quarters of an inch in size and may cause discomfort or even pain. If ruptured, pregnancy tumors can become infected. Most tumors can be easily removed though, before they cause any complications.

It is important to take pregnancy gingivitis seriously because, if untreated, it will lead to periodontal disease. Periodontal gum disease is an advanced form of gingivitis that attacks the bones and tissues supporting the teeth. This disease can cause permanent damage to your mouth, and can cause you to lose both your gums and teeth. Periodontal disease has also been linked to a higher risk of premature birth – in fact, women with periodontal disease are seven times more likely to give birth prematurely.

Treating Gingivitis in Pregnancy

There are no cures for gum disease although its damage can sometimes be reversed or halted. All pregnant women should receive at least two thorough dental cleanings during pregnancy. This should help to reduce your chances of developing pregnancy gingivitis or periodontal disease.

If you already have gingivitis, the best gum disease treatment is to have a complete cleaning at your dentist’s office. Your dentist will scale your teeth using a variety of instruments. This will remove excess plaque from your teeth and around your gum line. Serious gingivitis may also require root planning, a process during which the roots of your teeth are cleaned of plaque completely.


As always, the best treatment for gingivitis is prevention. Maintaining a good oral hygiene routine will ensure that you have healthy gums and teeth for a long time to come. Try following these tips:

  • brush twice a day for at least five minutes
  • use a soft bristle brush – this will prevent you from irritating your gums
  • floss once a day or use an anti-bacterial mouthwash to get rid of plaque from between your teeth
  • avoid eating large amounts of refined sugar – this will cut down on plaque and tartar buildup
  • visit your dentist regularly

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Treatments of gum disease:


Dental Caries (Tooth Decay)


  • What is Tooth Decay?
  • How Will I Know if I Have a Cavity?
  • How Do Dentists Detect Cavities?
  • Are Some People at More Risk for Developing Cavities?
  • How Can I Prevent Cavities?
  • What should I do if I have tooth decay?

What is Tooth Decay?

Dental cavities are an infection caused by a combination of carbohydrate-containing foods and bacteria that live in our mouths. The bacteria are contained in a film that continuously forms on and around our teeth. We call this film plaque. Although there are many different types of bacteria in our mouths, only a few are associated with cavities. Some of the most common include Streptococcus mutans, Lactobacillus casei and acidophilus, and Actinomyces naeslundii.


When these bacteria find carbohydrates, they eat them and produce acid. The exposure to acid causes the pH on the tooth surface to drop. Before eating, the pH in the mouth is about 6.2 to 7.0, slightly more acidic than water. As “sugary foods” and other carbohydrates are eaten, the pH drops. At a pH of 5.2 to 5.5 or below, the acid begins to dissolve the hard enamel that forms the outer coating of our teeth.

As the cavity progresses, it invades the softer dentin directly beneath the enamel, and encroaches on the nerve and blood supply of the tooth contained within the pulp.

Cavities attack the teeth in three ways:
1. Pit & Fissure
2. Smooth surface
3. Root surface

The first is through the pits and fissures, which are grooves that are visible on the top biting surfaces of the back teeth (molars and premolars). The pits and fissures are thin areas of enamel that contain recesses that can trap food and plaque to form a cavity. The cavity starts from a small point of attack, and spreads widely to invade the underlying dentin.

Decays formed at the the pits and fissures and spread to the whole biting surface of the teeth

The second route of acid attack is from a smooth surface, which is between, or on the front or back of teeth. In a smooth-surface cavity, the acid must travel through the entire thickness of the enamel. The area of attack is generally wide, and comes to a point or converges as it enters the deeper layers of the tooth.

At the smooth surface area, decay started in-between of the teeth
The third is the attack started at the root surface of the tooth after it was exposed to the oral cavity. The root is usually exposed due gum recession as a result of periodontitis (gum disease)
Decay at the root surface of the teeth


Recipe for tooth decay formation?


How Will I Know if I Have a Cavity?

The large majority of cavities are completely painless. This is because the outer enamel has no nerves. It is only when the cavity enters the underlying dentin that the cavity may begin to feel sensitive (Teeth sensitive). The most common cavity symptoms are an increased sensation to cold, sweet foods or beverages. A cavity is often responsible for a broken tooth. The cavity weakens the tooth, especially when it forms under a tooth filling or a tooth cusp, and can easily cause a fracture when biting down.
Sensitive Teeth

Patients are sometimes taken off guard when they learn that they have a few cavities but they don’t have any symptoms. It is far better to treat a small cavity than to wait until they have symptoms; such as pain. By the time there are symptoms, the cavity may have spread to infect the dental pulp, necessitating a root canal procedure or a tooth extraction to eliminate the infection. Always remember that most dental problems are insidious — that is, they sneak up on you. Regular dental exams, at least twice a year, will greatly reduce the likelihood that a dental cavity will go undetected and spread, causing toothache pain and infecting the dental pulp.

The decay has spread into dental pulp causing pain

How Do Dentists Detect Cavities?

Cavities are detected a number of ways. The most common are clinical (hands-on) and radiographic (X-ray) examinations. During a clinical exam, the dentist uses a handheld instrument called an explorer to probe the tooth surface for cavities. If the explorer “catches,” it means the instrument has found a weak, acid damaged part of the tooth — a dental cavity. Dentists can also use a visual examination to detect cavities. Teeth that are discolored (usually brown or black), can sometimes indicate a dental cavity.
Regular dental examination is important to prevent tooth decay
Bite-wing radiograph is good to detect interproximal (in-between) caries

Dental X-rays, especially check-up or bitewing X-rays, are very useful in finding cavities that are wedged between teeth, or under the gum line. These “hidden” cavities are difficult or impossible to detect visually or with the explorer. In some cases, none of these methods are adequate, and a dentist must use a special disclosing solution to diagnose a suspicious area on a tooth.

Are Some People at More Risk for Developing Cavities?

People who have reduced saliva flow due to diseases such a Sjogren Syndrome; dysfunction of their salivary glands; have undergone chemotherapy or radiation; and who smoke are more likely to develop cavities. Saliva is important in fighting cavities because it can rinse away plaque and food debris, and help neutralize acid. People who have limited manual dexterity and have difficulty removing plaque from their teeth may also have a higher risk of forming cavities. Some people have naturally lower oral pH, which makes them more likely to have cavities.

How Can I Prevent Cavities?

The easiest way to prevent cavities is by brushing your teeth and removing plaque at least three times a day, especially after eating and before bed. Flossing at least once a day is important to remove plaque between your teeth. You should brush with a soft-bristled toothbrush, and angle the bristles about 45 degrees toward the gum line. Brush for about the length of one song on the radio (three minutes). It’s a good idea to ask your dentist or hygienist to help you with proper brushing methods.

Blushing and Flossing teeth are to do it daily to stop caries

Reducing the amount and frequency of eating sugary foods can reduce the risk of forming cavities. If you are going to drink a can of sweetened soda, for instance, it is better to drink it in one sitting, than sip it throughout the day. Better yet, drink it through a straw in one sitting, to bypass the teeth altogether. Getting to the dentist at least twice a year is critical for examinations and professional dental cleanings.

Reduce high sugar food can reduce dental cavity significantly

To reduce the incidence of cavities, use toothpaste and mouthwash that contains fluoride. Fluoride is a compound that is added to most tap water supplies, toothpastes, and mouth rinses to reduce cavities. Fluoride becomes incorporated into our teeth as they develop and makes them more resistant to decay. After our teeth are formed, fluoride can reverse the progress of early cavities, and sometimes prevent the need for corrective dental treatments.

Mouthwash with fluoride

The recent drop in the number of cavities is largely due to the addition of fluoride to our drinking water. Mass water fluoridation is the most cost-effective measure available to reduce the incidence of tooth decay. The Environmental Protection Agency has determined that the acceptable tap water concentration for fluoride is 0.7 to 1.2 parts per million.

A dental procedure called sealants can also help reduce cavities on the top and sides of back teeth (occlusal, buccal and lingual surfaces). A sealant is a white resin material that blankets the tooth, protecting the vulnerable pits and fissures of the tooth. Sealants are routinely placed on children’s teeth to prevent cavities on their newly developing molars. The use of sealants to prevent cavities is also a cost-effective way to reduce the incidence of cavities on adults as well. Sealants are generally not used on teeth that already have fillings.

Fissure Sealant

People who have a dry mouth are at risk for developing cavities, and can have their dentist prescribe artificial saliva and mouth moisturizers, as well as recommend chewing sugarless gum to stimulate saliva production. Finally, an antiseptic mouthwash containing chlorhexidine gluconate such as Chlohexxa or Oradex can also be useful in killing bacteria associated with dental caries.

What should I do if I have tooth decay?

You should go the to dental clinic as soon as possible. Early or small decay is easily to treat. Usually a small filling will do. However if it is large cavity, then a larger filling is required provided there is no pain. In cases where the tooth is painful (eg. pain on biting, disturb sleep), then root canal treatment or extraction is required to stop the infection.

Small filling
Filling can be silver (amalgam) or white (composite).

Large Filling
Usually required
Comparison within big and small filling:

Small Filling                           vs.       Large filling

  • Less pain during filling                More pain (because lager & deeper cavity)
  • More aesthetic                             Less aesthetic
  • More lasting and durable             Less durable
  • Cheaper                                       More expensive (more filling material)

Or tooth capping of is a procedure to created back function, aesthetic as well as protection to a severely damaged tooth. It is usually made of porcelain fused with metal or a full porcelain material. Crown is durable and more lasting compared to a large filling.


Root canal treatment (RCT)
RCT is required when infection from caries has spread to the pulp of a tooth. The tooth is usually painful on chewing and sometimes disturb sleep. The purpose of this treatment  is to preserve the tooth by removing the dead and infected pulp leaving the tooth bacteria free.

After RCT, the tooth can be restored with filling or a corwn. If there is a lot of tooth structure loss, the tooth should be protected with a crown.

Root Canal Treatment

Tooth extraction in another way to stop infection. However, this method is commenced  if patient don’t want to keep the tooth anymore. Patient have to understand the consequent of removing the tooth

Root canal treatment              vs.        Tooth extraction

  • Tooth preserved                             Tooth removed
  • Difficult (esp molar tooth)              Simple & fast
  • Expensive                                       Cheaper than RCT
  • Few visits                                       One visit
  • Lesser problems in future              More problems in future
Tooth Extraction

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Impacted Wisdom Teeth


  • What is wisdom teeth?
  • Impacted Wisdom Teeth
  • Signs and Symptoms of Impacted Wisdom Tooth
  • Consequence of impacted wisdom teeth
  • Treatment Options
  • Indication of Wisdom teeth Extraction
  • Surgery or Not Surgery?
  • Surgical Removal of Wisdom Tooth
  • For Anxiety Patient…
  • What Do I Need to Do During Recovery?
  • Complication of Wisdom Tooth Surgery

What is wisdom teeth?

They are the last molar (or third molar) that usually erupt at the age of 18 to 25 years old (and sometimes older). The eruption of the tooth may cause pain in some of the cases. There are usually 4 wisdom teeth in each person. However, in some cases not every tooth will erupt into the oral cavity.

Impacted Wisdom Teeth

When a wisdom tooth cannot erupted properly either it tilt to the front or back or half-way jammed it is consider as impacted. The impaction cause severe pain especially when the tooth is erupting. This prevents the patient from open his mouth wide or eat properly. Sometimes it interferes with his daily activities. Impaction of wisdom tooth also will cause food trap easily (between the second last molar and wisdom teeth) which will result in decay at the second molar.

Impacted wisdom teeth can be divided into one of several categories. Mesioangular impaction is the most common form (44%), and means the tooth is angled forward, towards the front of the mouth. Vertical impaction (38%) occurs when the formed tooth does not erupt fully through the gum line. Distoangular impaction (6%) means the tooth is angled backward, towards the rear of the mouth. And finally, Horizontal impaction (3%) is the least common form, which occurs when the tooth is angled fully ninety degrees sideways, growing into the roots of the second molar.

Impacted wisdom teeth may also be categorized on whether they are still completely encased in the jawbone. If it is completely encased in the jawbone, it is a bony impaction. If the wisdom tooth has erupted out of the jawbone but not through the gumline, it is called a soft tissue impaction. Sometimes the wisdom tooth fails to erupt completely through the gum bed and the gum at the back of the wisdom tooth extends over the biting surface, forming a soft tissue flap or lid around the tooth called an operculum. Teeth covered by an operculum can be difficult to clean with a toothbrush.

Signs and Symptoms of Impacted Wisdom Tooth

Usually impacted wisdom teeth are presented with:

Gum Swelling
Cheek swelling
  • pain (may disturb sleep and may extend to the back, neck and head)
  • unable to open the mouth big due to pain
  • infection of the gum around the wisdom tooth
  • swelling on the gum
  • swelling on the cheek of the affected side
  • fever

Consequence of impacted wisdom teeth

Impacted wisdom tooth can lead to:

  1. Acute gum infection or pericoronitis that happens around the wisdom tooth (Most common).
  2. Infection on the pulp or pulpitis in the wisdom teeth due to decay
  3. Infection on the pulp or pulpitis in the second molar due to prolong food trap that causes dental caries.
  4. Infection on the bone or osteomylitis which occur if infection spread into the bone.
  5. Infection around the facial tissue or cellulitis. This happens when the infection spread into the soft tissue around the facial region (Below).

    Facial cellulitis
  6. Gum abcess – if pus present  in the gum or facial abcess if it’s in the face region
  7. Gum problem or periodontitis around wisdom tooth and second molar.

Treatment Options

1. Leave it – If the symptoms are very mild, usually with some mouth rinse and the pain will subside. However, sometimes the pain may come back due to re-infection.

2. Take antibiotic and pain killer – Again the symptoms will subside however re-infection still can occur.


3. Incisional and Drainage – Removing of the pus accumulated either in the gum or facial region then followed by removing of the wisdom tooth.

4. Operculectomy – Removing the gum that cover the wisdom tooth for easy cleaning. However, sometimes the gum might grow back and infection can re-occur

Operculectomy procedure

5. Extraction – Removing the wisdom tooth (surgery or without surgery)


6. Root canal treatment – On the second molar if the pulp is infected and the wisdom tooth required to be removed.

Indication of Wisdom teeth Extraction

Wisdom teeth are extracted for two general reasons: either the wisdom teeth have already become impacted, or the wisdom teeth could potentially become problematic if not extracted. Potential problems caused by the presence of properly grown-in wisdom teeth include infections caused by food particles easily trapped in the jaw area behind the wisdom teeth where regular brushing and flossing is difficult and ineffective. Such infections may be frequent, and cause considerable pain and medical danger.

According to NICE (The National Institute for Clinical Excellence – UK), the routine practice of prophylactic removal of pathology-free impacted third molar should be discontinued. Third molar should be removed if there is evidence of pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulitis, abcess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumour resection.


The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.

Surgery or Not Surgery?

When a wisdom tooth erupts vertically just like the second molar and the access is easily, then extraction of the tooth will be straight forward case. Usually the surgeon will loosen the tooth and grip the tooth with a forceps to remove it.

Horizontal impaction of wisdom tooth

However, most of the impacted wisdom tooth is embedded in the bone, tilted either forward or backward. Sometimes the tooth is in a horizontal position instead of vertical. This will make extraction with forceps impossible. Therefore, surgery is required.

Surgical Removal of Wisdom Tooth

Usually done by a oral surgeon (Specialist) or an experience dentist and it should be done in a sterile manner. After injections are given, a small cut will be made on the gum to expose the wisdom tooth and bone surrounding it. Then some bone  near to the tooth will be removed to allow instrument to engage with the tooth. Next, the tooth will be sectioned into half or more and the fragment of tooth will be removed.

After the whole tooth was removed completely, the socket will be cleaned and the surgeon will inspect the wound to make it is clean and bleeding stop. Finally, the gum will be held together by stitches and the patient will be allowed to go home with gauze, pain killer and antibiotic. Usually the whole process takes about an hour or less.

For Anxiety Patient…

If in a case of an anxious patient come for wisdom tooth surgery, usually, we will prescribe some medication of reduce anxiety before the surgery or patient will have to inhale nitrous oxide during the procedure so that he/she will feel relax and calm all the time during surgery. If the patient is extremely phobia of surgery, then he can opt for surgery done under general anaesthesia which required hospitalization.

What Do I Need to Do During Recovery?

After your wisdom teeth are removed you may experience some swelling and mild discomfort, which are normal symptoms and are part of the healing process. Here is what to expect after the procedure.

1) The First 24 Hours:

Bleeding: This may occur for several hours after your wisdom teeth are removed. To control it, place a piece of clean moist gauze or moistened tea bag over the empty tooth socket and bite down firmly. This needs to be done for about 45 minutes. You should avoid rinsing, spitting or sucking actions for 24 hours after your wisdom teeth are removed. For example, don’t drink beverages through straws or smoke, and avoid hot liquids (such as soup or tea). You should also avoid carbonated and alcoholic drinks. These activities can cause the clot to dislodge, which will cause dry socket.

Facial Swelling: This can occur where the wisdom tooth was extracted. You can apply a cold compress to ease the swelling and pain. Cold compress(ice packs) should be used 20 minutes on 20 minutes off. Repeat as necessary during this first 24-hour period. Avoid taking aspirin, ibuprofen (e.g. Motrin, Advil, etc.) if you have a stomach ulcer.

Pain: Medications such as Mefenamic Acid (Ponstan) or Etoricoxib (Arcoxia) can be taken to manage your pain. We may prescribe more potent pain relievers, such as narcotics, if necessary.

Antibiotics: Antibiotics may be prescribed post-treatment and should be taken until you have finished the prescription.

Food: Avoid hot liquids and alcoholic beverages for at least 24 hours. When the extraction is more difficult, you will need to consume a soft or liquid diet for at least 24 hours after removal of your wisdom teeth.

Brush your Teeth: You need to continue to brush your teeth, but avoid the teeth adjacent to the extracted tooth during the first 24 hours. On day two, you can resume the gentle brushing of your teeth. However, do not use commercial mouth rinses because these can irritate the area of extraction.

2) After 24 Hours:

Facial Swelling: Facial Swelling in the area of your wisdom tooth extraction needs to be man aged with heat after the first 24 hours of ice. Use a moist warm towel and apply it to the area on a 20-minute on, 20-minute off schedule. Repeat as necessary.

Rinse Your Mouth with Warm Salt Water: Use 1/2 teaspoon of salt in a cup of warm water after before bed and after meals. Do not use commercial mouth rinses.

Complete Healing: This will not occur for a few weeks to a few months following the removal of your wisdom teeth. However, usually within the first week or two, you will feel reasonably comfortable because enough healing has taken place. We will explain what to expect regarding your healing process.

Complication of Wisdom Tooth Surgery

1) The usual problem the patient will experience after surgery

  1. Pain on surgical site
  2. Limited mouth opening
  3. Swelling around the cheek
  4. Bruise over the cheek (not usual)

2) Complication (Rare!!)

  1. Infection on surgical site (Higher risk for smoker and diabetic patient)
  2. Lower jaw fracture (Will only happens in very thin jaw or a rough surgery)
  3. Bleeding (Can be from arteries which usually can be controlled with compression)
  4. Injury to nerve (Damage to the nerve will happens when the wisdom tooth is very near to the nerve and the event of removing it cause injury to the nerve. This will result in numbness on the lower lipand usually it takes 6-12 months to recover.)


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