Pink Tooth – by Dr. Richard Simpson, DMD​

Dr. Richard Simpson, DMD image captured with TelScope Oral Telehealth System The Problem The mother of a 10 year old girl was concerned about a “pink tooth”. There was no report of pain or other concerns. Diagnosis The first image, captured with TelScope Telehealth System, reveals an emerging upper left permanent tooth (first premolar), with the primary (“baby”) tooth still present. The primary molar has a pink color to it because it has resorbed internally as the permanent tooth moved into position, and the underlying gum tissue is showing through. This situation is not uncommon, but can be evaluated by a dentist through a teledentistry examination and appropriate questioning to determine if any treatment is indicated. In this case, the baby tooth was loose and can be allowed to be lost naturally if no other problems develop. The parent was informed that an extraction of the primary tooth may be required if it is still present in several weeks. Gingivitis Due To Poor Brushing Habits Around Loose Teeth The second image, marked using the TelScope app, highlights the red gum margins of other teeth in this area. This inflammation is called gingivitis, and is commonly seen in children with a loose tooth because they are often hesitant to brush the area near that tooth. The child should be supervised when brushing and encouraged to gently but thoroughly brush at the gumline twice per day as normal. The gingivitis will heal with improved hygiene.  Dr. Richard Simpson, DMD Dr. Richard is a board certified pediatric dentist in private practice. His achievements include:• Diplomate in the American Board of Pediatric Dentistry• Fellow in the American College of Dentists• Fellow in the International College of Dentists• Fellow in the American Academy of Pediatric Dentistry• Advisory Board Member of The TeleDentists• Advisory Board Member of Holland Healthcare Dr. Richard’s experience and active interests include telehealth, child advocacy, health disparities, policy, and advancing improved medical-dental access to care. Dr. Richard is also a veteran with 15 years of military service.​

Facial Swelling Caused by Dental Infection – by Dr. Richard Simpson, DMD​

Dr. Richard Simpson, DMD image captured with TelScope Oral Telehealth System The Problem A 5-year-old male was seen in a medical emergi-care center with a chief complaint from the parent of pain and “his face is swollen”. He was also febrile (showing symptoms of a fever). The patient was diagnosed with a rapidly developing facial cellulitis (infection spreading into the soft tissues of the face), of probable dental origin. The child was given a shot of Rocephin, and was prescribed an oral antibiotic and an over-the-counter pain medication. The patient was then given a dental referral for further evaluation and treatment.Note: Untreated facial cellulitis from a dental infection can lead to multiple systemic health complications, blindness, difficulty breathing, and in rare cases, death. Diagnosis Upon dental exam, the facial swelling had resolved in response to the antibiotics. This intraoral image reveals the swelling was now localized and associated with an upper left second primary (“baby”) molar that had a large cavity (dental caries) present. This presentation and diagnosis is considered urgent, and treatment should be rendered as soon as possible. The tooth will require extraction (removal). A discussion of the recommendation for a space maintainer should take place. Inter-Professional Collaboration For Ideal Patient Care This case is an excellent example of how healthcare providers, equipped with a  in their facility, are able to triage a patient and obtain a teledentistry consult for an initial diagnosis and treatment plan, followed by a referral for appropriate treatment. This inter-professional collaboration through telehealth capabilities leads to effective and efficient health care, and can reduce appointment numbers, time, and exposure to others during these times of COVID-19.   Dr. Richard Simpson, DMD Dr. Richard is a board certified pediatric dentist in private practice. His achievements include:• Diplomate in the American Board of Pediatric Dentistry• Fellow in the American College of Dentists• Fellow in the International College of Dentists• Fellow in the American Academy of Pediatric Dentistry• Advisory Board Member of The TeleDentists• Advisory Board Member of Holland Healthcare Dr. Richard’s experience and active interests include telehealth, child advocacy, health disparities, policy, and advancing improved medical-dental access to care. Dr. Richard is also a veteran with 15 years of military service.

Chipped Tooth as a Sign of a Cavity – by Dr. Richard Simpson, DMD​

Dr. Richard Simpson, DMD image captured with TelScope Oral Telehealth System The Problem A 6-year-old male reported to the dental office with his mother, who stated she noticed “a chipped tooth”. There was no current pain reported. However, after questioning, it was confirmed that the patient had experienced oral pain for “a few days” several weeks earlier, but it went away. Diagnosis Clinical exam and an x-ray confirmed the patient had a large cavity (dental caries) in the lower right first primary molar. The second photograph, marked using the TelScope App, shows a fistula that developed as a result of a previous tooth abscess. This allowed the infection to eventually drain, which resolved the patient’s original pain. The nerve of the tooth is no longer vital (alive). This is a non-urgent diagnosis, but treatment is indicated. The treatment consists of extraction of the primary tooth, as well as a recommendation for a space maintainer to be placed on the second molar to hold eruption space for the replacement tooth, which usually emerges at age ten to eleven. Failure to remove the tooth could lead to multiple complications to include further fracturing of the tooth, space loss, shifting of teeth, recurrence of the infection, or damage to the underlying permanent tooth. Interesting Fact Tooth decay can be categorized by the type of tooth surface and the location on the tooth in which it develops. This cavity developed between the teeth and was originally much smaller. An x-ray taken at a routine dental exam can identify this type of cavity before it is visible in the mouth. Early diagnosis is important, because dental decay in primary teeth (“baby teeth”) typically increases in size four to six times faster than in permanent teeth.  Dr. Richard Simpson, DMD Dr. Richard is a board certified pediatric dentist in private practice. His achievements include:• Diplomate in the American Board of Pediatric Dentistry• Fellow in the American College of Dentists• Fellow in the International College of Dentists• Fellow in the American Academy of Pediatric Dentistry• Advisory Board Member of The TeleDentists• Advisory Board Member of Holland Healthcare Dr. Richard’s experience and active interests include telehealth, child advocacy, health disparities, policy, and advancing improved medical-dental access to care. Dr. Richard is also a veteran with 15 years of military service.​

Identifying an Oral Lesion – by Dr. Richard Simpson, DMD​

Dr. Richard Simpson, DMD image captured with TelScope Oral Telehealth System The Problem A 6-year-old female patient was seen for a routine Well Child exam by her pediatrician. The doctor noted a “swelling” on her lower lip, and the mother reported that it had been present for 4 weeks. The physician recommended a teledentistry evaluation with a dentist and referred her. DIAGNOSIS The “swelling” in question appeared as a raised, 4mm x 3mm soft tissue lesion with a broad base and normal color. It is located in the midline of the lower lip inside of the wet-dry line. The lesion did not change in size since it first appeared, and was not painful. The diagnosis is a mucocele. A mucocele is a harmless fluid-filled retention “cyst” that most commonly results from the rupture of a minor salivary gland. Hundreds of salivary glands are located under the surface of the lip and other areas of the oral mucosa to maintain moisture. If a mucocele does not disappear after 4-6 weeks, it should be removed by a dentist or an oral surgeon, as it can interfere with normal function and often lead to the development of chronic biting or sucking habits and scar tissue, especially in children. This is an excellent example of how an oral lesion or area of concern could be pre-screened by a healthcare provider, photographed using the TelScope Oral Telehealth System, and transmitted to a dentist for a teledentistry consult prior to scheduling an appointment.  Dr. Richard Simpson, DMD Dr. Richard is a board certified pediatric dentist in private practice. His achievements include:• Diplomate in the American Board of Pediatric Dentistry• Fellow in the American College of Dentists• Fellow in the International College of Dentists• Fellow in the American Academy of Pediatric Dentistry• Advisory Board Member of The TeleDentists• Advisory Board Member of Holland Healthcare Dr. Richard’s experience and active interests include telehealth, child advocacy, health disparities, policy, and advancing improved medical-dental access to care. Dr. Richard is also a veteran with 15 years of military service.​

What does my Neck have to do with my Jaw and Orofacial Pain?​

Julia Worrall And Miranda Weindling There is a well-established link between jaw pain, neck pain and stiffness––in fact; one study found that neck pain played a part in Temporomandibular disorder (TMD) . This is perhaps unsurprising, as, in the human body, nothing occurs in isolation. This article gives you a deeper insight into the anatomical links between the neck, jaw, and orofacial region in general, and how an issue in one can affect the other. Having this insight offers you a different approach to managing your TMD. The Connection Between TMD and the Neck TMD is a general term for conditions that affect the jaw. The broadness of this term encapsulates all the various conditions that can occur in this region. When you start to understand the complexity of the jaw, it becomes more apparent why pinpointing an exact cause for your TMD can be so challenging. An even broader term than TMD, but one which captures its co-occurring symptoms and possible causes, is orofacial pain. It covers all issues stemming from, or somehow related to, the mouth and jaw, including headaches, neck, musculoskeletal, and neuropathological issues. It is a helpful term as it encourages this wider perspective on TMD, for both causes and symptoms. So why is the neck such a critical area to examine when it comes to TMD? The previous  mentioned found an 82% correlation between jaw dysfunction and neck disability. When you consider that  depends on muscle activation and joint action in both the jaw and neck, the connection between a dysfunctional jaw and limitations in the neck start to seem more obvious. Let’s take a closer look at this area of the body, to understand why: The Anatomy of the Jaw  Bones and Joint: You have two jaw joints, one on each side of the head. This joint is called (TMJ), and simply by breaking its name down, you can learn a lot about it. The TMJ connects two bones of the : the temporal bone, located underneath your temples and extending around the lower sides of the skull; and the mandible, the lower jaw bone. The TMJ itself is located roughly in front of your ears, between a bony projection called the condylar process on the mandible, and a socket of the temporal bone called the mandibular fossa. The mandible, the only bone in the skull that can move, and is surprisingly mobile! Test the movements of your jaw––not only can you open and close it, but, to smaller degrees, side-to-side and forward and back, all enabled by both the , and its surrounding muscles. TMD can arise from  within the actual TMJ, such as , inflammation or arthritis. However, let’s focus on the soft tissues surrounding it because when it comes to neck pain, it is the muscles and connective tissues that are important. Muscles: If your TMD doesn’t stem from the TMJ, then it will be considered as myofascial, relating to  surrounding the joint. Muscle tenderness is a key symptom of TMD, and there are several possible causes. Like all muscles, it is possible to build up excess tension, by clenching the jaw, or overuse. Certain medical conditions, such as fibromyalgia and other , which result in chronic myofascial pain, are possibly partly due to TMD. The joints,  in the jaw work together to provide stability and movement. If you clench your teeth and place your hands on the sides of the face, you will feel two muscles of the jaw engage: the temporalis, located over your temples, and the bulging around your jaw is the masseter. There are two more significant muscles, which are smaller and deeper, the medial and lateral pterygoids. The  attaches to the disc in the TMJ and is related to disc displacement. As muscles work in combination, improper functioning in one tends to affect the others. If your TMD is myofascial, it is important to treat not just isolated muscles, but the surrounding tissues too. It may be impossible to tell which group of muscles is causing your TMD, but effective treatment can provide widespread relief. What does this have to do with my Neck? If you experience tenderness and tension in your jaw muscles, then evaluate the neck muscles too, particularly the , at the front and sides of the neck, and the , at the back of the neck. As mentioned earlier, the muscles of the jaw and neck work together to enable movement of the jaw, but they also share another soft-tissue connection: fascia. The  surrounds the muscles of the jaw.  is a film-like connective tissue that encases the muscles, other tissues and organs. Although fascia relates to different anatomical regions, it is a connected network that runs through the body. If we experience tightness or an injury in one area of the body, it can affect other areas via the fascial network. As the fascia of the neck extends to the jaw muscles, it indicates how interdependent these areas are, and the significance of treating them together. It is not only the soft tissues of the neck that can lead to TMD. A neurological cause, linked to a region in the lower brain stem called the , can cause symptoms from the cervical spine to be referred to the jaw. It is also possible for a  to cause pain in the jaw. Treatment When seeking treatment for TMD, it is advisable to have not just the jaw, but the entire orofacial region, and the neck and back, assessed. Poor posture, in  and , can affect the muscles and soft tissues, ultimately impacting the jaw. Consequently, physiotherapy, or soft tissue manipulation, can provide great relief if you experience TMD––and will likely indicate that your neck has been affecting your jaw (or vice versa). Physiotherapists can be highly effective at working with TMD patients, but unfortunately,  seem to be aware of this. At , we can connect you with practitioners––from dentists to physiotherapists and more––who understand the physiological relationships in the body that can lead to TMD and help you find relief.  Julia WorrallRN Julia Worrall is a Registered Nurse with decades of experience in acute care. Noticing that early intervention is lacking when it comes to head, neck, and jaw pain, Julia determined to bridge the knowledge gap between multidisciplinary providers and ensure that patients receive appropriate care to avoid delayed recovery, chronic pain, and polypharmacy scenarios. Julia is a published author and highly sought after international lecturer.​

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