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hygiene tribuneDental Tribune Middle East & Africa Edition | March-April 2015 9B < Page 8B > Page 10B for thousands of years.62 Glycyr- rhizin is 50 times sweeter than sucrose. It retains, when sapid, a singular liquorice flavour. The liquorice sweetness has a slow- er onset than sugar and lingers. Unlike artificial sweeteners like aspartame, saccharine, and cy- clamates, it contains no sulfur molecule.63 For the treatment of bronchial asthma, the root of liquorice (Glycyrrhiza glabra) has been used as a traditional medicine in the East and West. Licochalcone A is the predominant, character- istic chalcone in liquorice root which might be involved in the pathogenesis of virus-exacerbat- ed asthma.64 Liquorice is used as a flavorant in a variety of edibles, medi- cine, and tobacco, and is often innocently consumed in vast amounts without any regard or only with vague concepts of side effects. When imbibed, liquo- rice acts like hyperaldosteron- ism which presents with typical symptoms including high blood pressure, low blood potassium, muscle pain and weakness.65 Liquorice may induce hyperten- sion62 because excessive licorice consumption can precipitate a severe hypertensive event through activation of renal min- eralocorticoid receptors.66 Besides the hypertension prob- lem, liquorice can stain the tongue and teeth. Glycyrrhyzin by itself does not stain teeth, but when combined with dark food dyes, tobacco and/or cur- ries, liquorice is associated with stains. Tooth staining from black liquorice is known, but the tooth staining derives mainly from added dyes to liquorice confections and from liquoric- eflavoured tobacco. Liquorice sweets are generally health promoting, pleasurable to eat, and in moderation on their own rarely stain teeth. Accumulation of extracellular polysaccharides from microbial activity contrib- utes to biofilm formation and bacterial plaques. This allows for a tacky gummy surface of muco-polysaccharides to stick to stagnant areas on teeth, and with adherent chromogenic bacteria, liquorice tobacco prod- ucts discolour teeth and accel- erate adjacent gingival break- down. Quitting the tobacco habit with safe stain removal through scaling and polishing from teeth is feasible.67 Heavy tobacco dental staining can be noticed from pipe smok- ingwithLiquoriceasanadditive. It contributes to increased to- bacco staining, especially when included in aromatic pipe tobac- cos; the dental stain is directly proportional to the amount and frequency of the pipe smoking. Not only is the palatal and lin- gual side of teeth prone to ac- cumulating dark tobacco stain but also the mucosa undergoes specific changes. Gingival re- cession, alveolar bone loss, and periodontal pockets result from the deleterious effect of the to- bacco smoke. Combined with chewing tobac- co, liquorice additives enhance and prolong the flavour of the chewing tobacco experience, and consequently damage from longer contact time onto the gingiva, seeming to derive more from tobacco contents rather than just liquorice. Adjacent re- cession, cervical dentinal stain- ing, and thickening with hyper- keratosis of mucosa are seen.74 Frequently liquorice is mixed with dark caramel and food colorings which leave a surface brownish/black tongue stain. This tongue stain is water solu- ble and usually disappears after a few hours.74 Health care workers, including all in the dental team, discover- ing new hypertension patients, or noting a history of taking diu- retics, should always enquire about consumption or use of any liquorice containing product.67 Unduly stained teeth, a stained tongue or other oro-dental signs of intraoral chewing tobacco abuse combined with elevated blood pressures, should alert dentists to the possibility of mor- bidity arising from liquorice tox- icity or abuse.74 5 - Curry Curry powder is commonly used spice in many countries of the world. This spice can stain teeth and, if inhaled, it could lead to health problems. Hypersensitivi- ty pneumonitis (HP) is a group of immunologically mediated lung diseases caused by the inhala- tion of environmental agents (organic dusts from vegetable or animal products), in susceptible individuals.68 S Ando reported a case of a man who had worked in a factory that produced curry sauce for 13 years and developed a non- specific interstitial pneumonia (NSIP) with bronchiolar lesions associated with curry powder and ground pepper.69 6 - Portobello Mushrooms Mushrooms are valuable sourc- es of vitamins such as retinol, thiamine, riboflavin, pyridoxine, and niacin. Portobello has the highest riboflavin and niacin contents.70 These items are won- derful additions to the entree, but they are also known to stain and discolor teeth. 7 - Mouthwashes that contain Chlorhexidine or Cetylpyri- dinium chloride: a - Chlorhexidine: Chlorhexidine anti-plaque mouthrinses (CHX) remained for a long time as the gold stand- ard for mouthrinses but stain- ing side effects can be seen with this formulation. The tongue is stained a dark blue-gray color but it is not permanent and will fade over time after CHX use is stopped. As for teeth, the stain would have to be polished off by the dentist or hygienist. Caustic burns of the lips, mouth and tongue have been seen in patients who use mouthwashes containing alcohol and chlo- rhexidine.71 A study showed that CHX mouthrinse was more effective in controlling plaque and gin- givitis than chlorhexidine con- taining toothpaste but caused greatest deposition of extrinsic stains. Supragingival calculus deposition was least in triclosan NaF+ group followed by CHX + triclosan + NaF + ZnCl(2) and CHX. More than half of the sub- jects reported adverse events duringtheexperimentalphase.72 Thus,although chlorhexidine di- gluconate (CHX) is currently the most effective mouthwash for reducing plaque and gingivitis, one of its side effects is extrinsic tooth staining. Interestingly, oxy- genating agents may reduce this staining. A review done by Van Maanen-Schakel NW, searched the literature for data concern- ing the inhibiting effect of an ox- ygenating agent (OA) on CHX- induced tooth staining. There was moderate evidence that a combination of CHX and an OA reduces tooth staining without interfering with plaque growth inhibition.73 Most of the search into stain for- mation has been carried out on chlorhexidine, although there are other antiseptics which cause staining to a lesser extent and the mechanism proposed could be applicable to stain- ing found with polyvalent met- als. The characteristic staining of the tongue and teeth noted by Flotra74 is not peculiar to chlorhexidine, it has been re- ported in other cationic antisep- tics,75 an essential oil/phenolic mouthrinse76 and following prolonged use of delmopinol mouthrinses.Thereisgreatindi- vidual variation in the degree of staining from person to person, this makes explanation more difficult as it may be caused by intrinsic factors, differences in extrinsic factors or both .Berk suggested that the protein and carbohydrate in the acquired pellicle could undergo a series of condensation and polymerisa- Conservative Care and Treatment of TMJ Dysfunction in Dental Patients By Shivani Sarsthi, Physical Therapist (TMJ Specialist) E ach year, the number of reported cases of TMJ dysfunction patients in- creases. Whether the cause is from stress, trauma to the jaw, post-dental procedures, or other factors, the number of TMJ suf- ferers is growing. TMJ dysfunc- tion is defined as a term cover- ing pain and dysfunction of the muscles of mastication and the temporomandibular joints. The symptomatic picture of a TMJ patient does vary signifi- cantly, but often includes: mus- cle, joint, and facial pain, diffi- culty with chewing, joint sounds, headaches and tinnitus. Recent studies show that more females than males suffer from TMJ symptoms, most of which, are in their childbearing years. The conventional methods used to treat TMJ dysfunction include: Botox to relax specific muscle groups (masseters), or- thodontics (braces, retainers, mouth guards), and in some cases, surgery. There exist options in the field of physical therapy for patients looking for an alternative health approach. Specialized treatment using soft tissue release and joint mobilization, alone, has had a profound affect on the re- lief of symptoms from a number of TMJ sufferers. Application of intra-oral technique to release the lateral pterygoid and myo- fascial release to the anterior neck component are two exam- ples of treatment goals. Both techniques help to relieve pres- sure on the jaw caused by hyper- toned muscle groups. There is a demand placed on oral surgeons and dentists, to address TMJ related com- plaints, specifically after oral surgery, and dental procedures in which the jaw is open and overstretched (beyond normal range), for a long period of time. A patient may experience trau- ma to the jaw due to an over- stretch injury or invasive dental procedure that has indirectly impacted the jaw. The effects of manual, soft tissue work has had positive effects on majority of patients and serve for a non- invasive treatment option. This Shivani Sarsthi, Physical Therapist / TMJ Specialist Breath and Health Alternative Medical Center 1080 Al Wasl Road Umm Suqeim 2, Jumeirah, Dubai www.breathandhealth.net email: shivani.sarsthi@gmail.com t: 055 307 9405 Contact Information further benefits the patient with help of pain management and restoration, optimal and func- tional range of motion of the TMJ. Current research shows a link between stress and the TMJ. Specific triggers such as alcohol intake and smoking, for exam- ple, have an effect on sleep qual- ity, and therefore, may promote bruxism at night. Bruxism, is a neurologic, sleep movement disorder characterized by grind- ing or clenching of the teeth in our sleep. This disorder is very damaging to the teeth and the jaw joints, and also causes fa- tigue and pain to the facial mus- cles. Lifestyle changes and sleep hygiene techniques are rein- forced by the physical therapist, tion reactions leading to discol- ourationof the acquired pellicle. Chlorhexidine may accelerate formation of the acquired pelli- cle and also catalyze steps in the Maillard reaction.2 The results of a recent study demonstrated that regular use of CPH and chlorhexidine mouthrinses resulted in extrin- sic stain accumulation after six weeks, with increased accu- mulation after 12 weeks versus brushing alone.77 Polyvinylpyrrolidone (PVP) (a polymer used as a synthetic blood plasma substitute and in the cosmetic, drug, and food- processing industries) was shown in vitro to reduce chlo- rhexidine induced, dietary stain- ing without affecting the uptake of the antiseptic to the test sub- strate. A study in vivo aimed to determine whether PVP affected plaque and dietary staining by a low concentration chlorhex- idine rinse. Tooth stain areas were comparable for placebo, 0.03% and 0.06% chlorhexidine rinses, but significantly reduced with the PVP/chlorhexidine rinses compared to the 0.06% chlorhexidine rinse. Tooth stain intensity was significantly in- creased with 0.06% chlorhex- idine rinses compared to pla- cebo and chlorhexidine/PVP rinses. PVP, at the concentra- tions tested, reduced the stain propensity of a 0.06% chlorhex- idine rinse but at the expense of some loss of plaque inhibition.78 Addy et al wanted to determine whether a co-polymer anti- adhesive agent would prevent staining by a low concentra- tion chlorhexidine solution. Ad- ditionally, the possibility that an essential oil/phenolic rinse product may cause staining. Tooth and tongue staining was significantly increased with 0.2% chlorhexidine compared to the essential oil/phenolic rinse which in turn was signifi- to help maintain optimal TMJ functioning and help manage pain and discomfort. Treatment and management of TMJ is a joint effort between pa- tients, the dental and profession- als and can be effectively treated through specialized physical therapy modalities. t: 0553079405