Practice of Drs. Carter, Pieroni & Williams
1325 Travis Blvd., Suite D
Fairfield, CA 94533
707-427- 2222
Dental Health
Bad breath can be acute or chronic depending on the underlying cause. It may indicate the need to clean the teeth and mouth more often, tooth or gum disease, or intestinal disorders.
Possible Cause/Risks Include:
Bacteria in mouth, diabetes, drugs, gum disease, heavy metal accumulation, infection, liver disease, not eating, poor diet, poor dental hygiene, smoking, sulfur, stress, and tooth decay.
Helpful Lifestyle Changes:
Brush and floss teeth regularly. Clean and replace your toothbrush regularly. Avoid mouthwashes with flavorings, dyes, and alcohol.
Avoid stress and seek out ways to relax and resolve stressful conditions in your life. Get sufficient sunlight, exercise, and sleep.
Helpful Dietary Changes:
Avoid spicy foods and those that leave residues or get stuck in the teeth (alcohol, cheese, meat, sweets). Go on a cleansing or r aw food fast to detox your body. Chew parsley after meals, it is very rich in chlorophyll, a natural mouthwash.
May be linked to frequent vomiting or gastroesophageal reflux, less than normal amounts of saliva, medications containing sugar, or special diets that require prolonged bottle feeding or snacking. When oral hygiene is poor, the teeth are at increased risk for caries.
Counsel the parent/caregiver on daily oral hygiene to include frequent rinsing with plain water and use of a fluoride-containing toothpaste or mouth rinse. Explain the need for supervising children to avoid swallowing fluoride. Refer to an oral health care provider and/or gastroenterologist for prevention and treatment. Prescribe sugarless medications when available.
The dentist, periodontist, or dental hygienist removes the plaque through a deep-cleaning method called scaling and root planing. Scaling means scraping off the tartar from above and below the gum line. Root planing gets rid of rough spots on the tooth root where the germs gather, and helps remove bacteria that contribute to the disease
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Medications
Medications may be used with treatment that includes scaling and root planing, but they cannot always take the place of surgery. Depending on the severity of gum disease, the dentist or periodontist may still suggest surgical treatment. Long-term studies will be needed to determine whether using medications reduces the need for surgery and whether they are effective over a long period of time. Here are some medications that are currently used:
Prescription antimicrobial mouthrinse
A prescription mouth rinse containing an anti microbial called chlorhexidine
To control bacteria when treating gingivitis and after gum surgery
It's used like a regular mouthwash.
Antiseptic "chip"
A tiny piece of gelatin filled with the medicine chlorhexidine
To control bacteria and reduce the size of periodontal pockets
After root planing, it's placed in the pockets where the medicine is slowly released over time.
Antibiotic gel
A gel that contains the antibiotic doxycycline
To control bacteria and reduce the size of periodontal pockets
The periodontist puts it in the pockets after scaling and root planing. The antibiotic is released slowly over a period of about seven days.
Antibiotic micro-spheres
Tiny, round particles that contain the antibiotic minocycline
To control bacteria and reduce the size of periodontal pockets
The periodontist puts the micro-spheres into the pockets after scaling and root planing. The particles release minocycline slowly over time.
Enzyme suppressant
A low dose of the medication doxycycline that keeps destructive enzymes in check
To hold back the body's enzyme response -- If not controlled, certain enzymes can break down gum tissue
This medication is in pill form. It is used in combination with scaling and root planing.
Surgery
Flap Surgery. Surgery might be necessary if inflammation and deep pockets remain following treatment with deep cleaning and medications. A periodontist may perform flap surgery to remove tartar deposits in deep pockets or to reduce the periodontal pocket and make it easier for the patient, dentist, and hygienist to keep the area clean. This common surgery involves lifting back the gums and removing the tartar. The gums are then sutured back in place so that the tissue fits snugly around the tooth again.
Bone and Tissue Grafts.
In addition to flap surgery, your periodontist may suggest bone or tissue grafts. Grafting is a way to replace or encourage new growth of bone or gum tissue destroyed by periodontitis. A technique that can be used with bone grafting is called guided tissue regeneration, in which a small piece of mesh-like fabric is inserted between the bone and gum tissue. This keeps the gum tissue from growing into the area where the bone should be, allowing the bone and connective tissue to regrow.
Since each case is different, it is not possible to predict with certainty which grafts will be successful over the long-term. Treatment results depend on many things, including severity of the disease, ability to maintain oral hygiene at home, and certain risk factors, such as smoking, which may lower the chances of success. Ask your periodontist what the level of success might be in your particular case.
Getting a Second Opinion About Treatment
When considering any extensive dental or medical treatment options, you should think about getting a second opinion. To find a dentist or periodontist for a second opinion, call your local dental society. They can provide you with names of practitioners in your area. Additionally, dental schools may sometimes be able to offer a second opinion. Call the dental school in your area to find out whether it offers this service.
Can periodontal disease cause health problems beyond the mouth?
Maybe. But so far the research is inconclusive. Studies are ongoing to try to determine whether there is a cause-and-effect relationship between periodontal disease and:
- an increased risk of heart attack or stroke,
- an increased risk of delivering pre term, low birth weight babies,
- difficulty controlling blood sugar levels in people with diabetes.
In the meantime, it's a fact that controlling periodontal disease can save your teeth -- a very good reason to take care of your teeth and gums.
Diabetes can cause serious problems in your mouth. You can do something about it.
If you have diabetes, make sure you take care of your mouth. People with diabetes are at risk for mouth infections, especially periodontal (gum) disease. Periodontal disease can damage the gum and bone that hold your teeth in place and may lead to painful chewing problems. Some people with serious gum disease lose their teeth. Periodontal disease may also make it hard to control your blood glucose (blood sugar).
Other problems diabetes can cause are dry mouth and a fungal infection called thrush. Dry mouth happens when you do not have enough saliva—the fluid that keeps your mouth wet. Diabetes may also cause the glucose level in your saliva to increase. Together, these problems may lead to thrush, which causes painful white patches in your mouth.
You can keep your teeth and gums healthy. By controlling your blood glucose, brushing and flossing everyday, and visiting a dentist regularly, you can help prevent periodontal disease. If your diabetes is not under control, you are more likely to develop problems in your mouth.
Take steps to keep your mouth healthy. Call your dentist when you notice a problem.
If you have diabetes, follow these steps:
- Control your blood glucose.
- Brush and floss every day.
- Visit your dentist regularly. Be sure to tell your dentist that you have diabetes.
- Tell your dentist if your dentures (false teeth) do not fit right, or if your gums are sore.
- Quit smoking. Smoking makes gum disease worse. Your physician or dentist can help you quit.
Take time to check your mouth regularly for any problems. Sometimes people notice that their gums bleed when they brush and floss. Others notice dryness, soreness, white patches, or a bad taste in the mouth. All of these are reasons to visit your dentist.
Remember, good blood glucose control can help prevent mouth problems.
What do I need to know about dry mouth?
Everyone has a dry mouth once in a while--if they are nervous, upset or under stress.
But if you have a dry mouth all or most of the time, it can be uncomfortable and can lead to serious health problems.
Dry mouth...
- can cause difficulties in tasting, chewing, swallowing, and speaking
- can increase your chance of developing dental decay and other infections in the mouth
- can be a sign of certain diseases and conditions
- can be caused by certain medications or medical treatments
Dry mouth is not a normal part of aging. So if you think you have dry mouth, see your dentist or physician--there are things you can do to get relief.
What is dry mouth?
Dry mouth is the condition of not having enough saliva, or spit, to keep your mouth wet.
Symptoms include:
- a sticky, dry feeling in the mouth
- trouble chewing, swallowing, tasting, or speaking
- a burning feeling in the mouth
- a dry feeling in the throat
- cracked lips
- a dry, tough tongue
- mouth sores
- an infection in the mouth
Why is saliva so important?
Saliva does more than keep the mouth wet.
- It helps digest food
- It protects teeth from decay
- It prevents infection by controlling bacteria and fungi in the mouth
- It makes it possible for you to chew and swallow
Without enough saliva you can develop tooth decay or other infections in the mouth. You also might not get the nutrients you need if you cannot chew and swallow certain foods.
What causes dry mouth?
People get dry mouth when the glands in the mouth that make saliva are not working properly. Because of this, there might not be enough saliva to keep your mouth wet. There are several reasons why these glands (called salivary glands) might not work right.
- Side effects of some medicines. More than 400 medicines can cause the salivary glands to make less saliva. Medicines for high blood pressure and depression often cause dry mouth.
- Disease. Some diseases affect the salivary glands. Sjogren's Syndrome, HIV/AIDS, diabetes, and Parkinson's disease can all cause dry mouth.
- Radiation therapy. The salivary glands can be damaged if they are exposed to radiation during cancer treatment.
- Chemotherapy. Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry.
- Nerve damage. Injury to the head or neck can damage the nerves that tell salivary glands to make saliva.
What can be done about dry mouth?
Dry mouth treatment will depend on what is causing the problem. If you think you have dry mouth, see your dentist or physician. He or she can try to determine what is causing your dry mouth.
- If your dry mouth is caused by medicine, your physician might change your medicine or adjust the dosage.
- If your salivary glands are not working right but can still produce some saliva, your physician or dentist might give you a medicine that helps the glands work better.
- Your physician or dentist might suggest that you use artificial saliva to keep your mouth wet.
What can I do?
- Sip water or sugarless drinks often.
- Avoid drinks with caffeine, such as coffee, tea, and some sodas. Caffeine can dry out the mouth.
- Sip water or a sugarless drink during meals. This will make chewing and swallowing easier. It may also improve the taste of food.
- Chew sugarless gum or suck on sugarless hard candy to stimulate saliva flow; citrus, cinnamon or mint-flavored candies are good choices.
- Don't use tobacco or alcohol. They dry out the mouth.
- Be aware that spicy or salty foods may cause pain in a dry mouth.
- Use a humidifier at night.
Tips for keeping your teeth healthy
Remember, if you have dry mouth, you need to be extra careful to keep your teeth healthy. Make sure you:
- Gently brush your teeth at least twice a day.
- Floss your teeth every day.
- Use toothpaste with fluoride in it. Most toothpastes sold at grocery and drug stores have fluoride in them.
- Avoid sticky, sugary foods. If you do eat them, brush immediately afterwards.
- Visit your dentist for a check-up at least twice a year. Your dentist might give you a special fluoride solution that you can rinse with to help keep your teeth healthy.
It started as an observation, that soon took the shape of an idea. It ended, five decades later, as a scientific revolution that shot dentistry into the forefront of preventive medicine. This is the story of how dental science discovered-and ultimately proved to the world-that fluoride, a mineral found in rocks and soil, prevents tooth decay. Although dental caries remains a public health worry, it is no longer the unbridled problem it once was, thanks to fluoride.
The longer plaque and tartar are on teeth, the more harmful they become. The bacteria cause inflammation of the gums that is called "gingivitis." In gingivitis, the gums become red, swollen and can bleed easily. Gingivitis is a mild form of gum disease that can usually be reversed with daily brushing and flossing, and regular cleaning by a dentist or dental hygienist. This form of gum disease does not include any loss of bone and tissue that hold teeth in place.
When gingivitis is not treated, it can advance to "periodontitis" (which means "inflammation around the tooth.") In periodontitis, gums pull away from the teeth and form "pockets" that are infected. The body's immune system fights the bacteria as the plaque spreads and grows below the gum line. Bacterial toxins and the body's enzymes fighting the infection actually start to break down the bone and connective tissue that hold teeth in place. If not treated, the bones, gums, and connective tissue that support the teeth are destroyed. The teeth may eventually become loose and have to be removed.
Risk Factors
- Smoking. Need another reason to quit smoking? Smoking is one of the most significant risk factors associated with the development of periodontitis. Additionally, smoking can lower the chances of success of some treatments.
- Hormonal changes in girls/women. These changes can make gums more sensitive and make it easier for gingivitis to develop.
- Diabetes. People with diabetes are at higher risk for developing infections, including periodontal disease.
- Stress. Research shows that stress can make it more difficult for our bodies to fight infection, including periodontal disease.
- Medications. Some drugs, such as antidepressants and some heart medicines, can affect oral health because they lessen the flow of saliva. (Saliva has a protective effect on teeth and gums.)
- Illnesses. Diseases like cancer or AIDS and their treatments can also affect the health of gums.
- Genetic susceptibility. Some people are more prone to severe periodontal disease than others.
Who gets periodontal disease?
People usually don't show signs of gum disease until they are in their 30s or 40s. Men are more likely to have periodontal disease than women. Although teenagers rarely develop periodontitis, they can develop gingivitis, the milder form of gum disease. Most commonly, gum disease develops when plaque is allowed to build up along and under the gum line.
What can I do to prevent gum disease?
Here are some things you can do to prevent periodontal diseases:
- Brush your teeth twice a day (with a fluoride toothpaste)
- Floss every day
- Visit the dentist routinely for a check-up and professional cleaning
- Eat a well balanced diet
- Don't use tobacco products
How do I know if I have periodontal disease?
Symptoms are often not noticeable until the disease is advanced. They include:
- Bad breath that won't go away
- Red or swollen gums
- Tender or bleeding gums
- Painful chewing
- Loose teeth
- Sensitive teeth
Any of these symptoms may signal a serious problem, which should be checked by a dentist. At your dental visit:
- The dentist will ask about your medical history to identify underlying conditions or risk factors (such as smoking) that may contribute to periodontal disease.
- The dentist or hygienist will examine your gums and note any signs of inflammation.
- The dentist or hygienist will use a tiny ruler called a 'probe' to check for periodontal pockets and to measure any pockets. In a healthy mouth, the depth of these pockets is usually between 1 and 3 millimeters.
- The dentist or hygienist may take an x-ray to see whether there is any bone loss.
- The dentist may refer you to a periodontist, a specialist who treats gum diseases.
How is periodontal disease treated?
The main goal of treatment is to control the infection. The number and types of treatment will vary, depending on the extent of the gum disease. Any type of treatment requires that the patient keep up good daily care at home. Additionally, modifying certain behaviors, such as quitting tobacco use, might also be suggested as a way to improve treatment outcome.
This information is for people who have mouth (oral) problems related to HIV infection. It explains the most common oral problems linked to HIV and shows what they look like. It also describes where in the mouth they occur and how they are treated.
They are common
Oral problems are very common in people with HIV. More than a third of people living with HIV have oral conditions that arise because of their weakened immune system. And even though combination antiretroviral therapy has made some oral problems less common, others are occurring more often with this type of treatment.
They can be painful, annoying, and lead to other problems
You may be told that oral problems are minor compared to other things you have to deal with. But you know that they can cause discomfort and embarrassment and really affect how you feel about yourself. Oral problems can also lead to trouble with eating. If mouth pain or tenderness makes it difficult to chew and swallow, or if you can not taste food as well as you used to, you may not eat enough. And, your doctor may tell you to eat more than normal so your body has enough energy to deal with HIV.
They can be treated
The most common oral problems linked with HIV can be treated. So talk with your doctor or dentist about what treatment might work for you.
Remember, with the right treatment, your mouth can feel better. And that's an important step toward living well, not just longer, with HIV.
Treatment:
Red sores
Aphthous (AF-thus) ulcers. Also known as Canker Sores
Red sores that might also have a yellow-gray film on top. They are usually on the moveable parts of the mouth such as the tongue or inside of the cheeks and lips.
Painful: Yes
Contagious: No
Mild cases – Over-the-counter cream or prescription mouthwash that contains corticosteroids; More severe cases – corticosteroids in a pill form
Herpes (HER-peez) A viral infection
Red sores usually on the roof of the mouth. They are sometimes on the outside of the lips, where they are called fever blisters.
Painful: Sometimes
Contagious: Yes
Prescription pill can reduce healing time and frequency of outbreaks.
White hairlike growth
Hairy Leukoplakia (Loo-ko-PLAY-key-uh) caused by the Epstein-Barr virus White patches that do not wipe away; sometimes very thick and “hairlike.” Usually appear on the side of the tongue or sometimes inside the cheeks and lower lip.
Painful: Not usually
Contagious: No
Mild cases – not usually required; More severe cases – a prescription pill that may reduce severity of symptoms. In some severe cases, a pain reliever might also be required.
White creamy or bumpy patches
like cottage cheese Candidiasis (CAN-di-dye-uh-sis), a fungal (yeast) infection – Also known as thrush white or yellowish patches (or can sometimes be red). If wiped away, there will be redness or bleeding underneath. They can appear anywhere in the mouth.
Painful: Sometimes, a burning feeling
Contagious: No
Mild cases – prescription antifungal lozenge or mouthwash; More severe cases – prescription antifungal pills.
Warts
Small, white, gray, or pinkish rough bumps that look like cauliflower. They can appear inside the lips and on other parts of the mouth.
Painful: Not usually
Contagious: Possibly
Inside the mouth – a doctor can remove them surgically or use “cryosurgery” – a way of freezing them off; On the lips – a prescription cream that will wear away the wart. Warts can return after treatment.
Dry mouth
Dry mouth happens when you do not have enough saliva, or spit, to keep your mouth wet. Saliva helps you chew and digest food, protects teeth from decay, and prevents infections by controlling bacteria and fungi in the mouth. Without enough saliva you could develop tooth decay or other infections and might have trouble chewing and swallowing. Your mouth might also feel sticky, dry and have a burning feeling. And you may have cracked, chapped lips.
To help with a dry mouth, try these things:
- Sip water or sugarless drinks often
- Chew sugarless gum or suck on sugarless hard candy
- Avoid tobacco
- Avoid alcohol
- Avoid salty foods
- Use a humidifier at night
Talk to your doctor or dentist about prescribing artificial saliva, which may help keep your mouth moist.
TMD
You may have read articles in newspapers and magazines about "TMD" -- temporomandibular (jaw) disorders, also called "TMJ syndrome." Perhaps you have even felt pain sometimes in your jaw area, or maybe your dentist or physician has told you that you have TMD.
If you have questions about TMD, you are not alone. Researchers, too, are looking for answers to what causes TMD, what are the best treatments, and how can we prevent these disorders.
TMD is not just one disorder, but a group of conditions, often painful, that affect the jaw joint (temporomandibular joint, or TMJ) and the muscles that control chewing. Although we don't know how many people actually have TMD, the disorders appear to affect about twice as many women as men.
The good news is that for most people, pain in the area of the jaw joint or muscles is not a signal that a serious problem is developing. Generally, discomfort from TMD is occasional and temporary, often occurring in cycles. The pain eventually goes away with little or no treatment. Only a small percentage of people with TMD pain develop significant, long-term symptoms.
Each year in the North America, about 29,000 people learn they have cancer of the oral cavity (the mouth and lips) or the oropharynx (the part of the throat at the back of the mouth).
This National Cancer Institute (NCI) booklet (NIH Publication No. 03-1574) has important information to help people with oral cancer and their family and friends better understand this disease. It discusses possible causes, symptoms, diagnosis, and treatment of the disease. It also has information about rehabilitation and about sources of support to help patients cope with oral cancer.
Scientists are studying oral cancer to learn more about this disease, and doctors are exploring new ways to treat it. This research keeps increasing our knowledge about oral cancer.
Understanding Cancer
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.
Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.
Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.
Tumors can be benign or malignant:
Benign tumors are not cancer:
- Benign tumors are rarely life-threatening.
- Generally, benign tumors can be removed, and they usually do not grow back.
- Cells from benign tumors do not invade the tissues around them.
- Cells from benign tumors do not spread to other parts of the body.
Malignant tumors are cancer:
- Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
- Malignant tumors often can be removed, but sometimes they grow back.
- Cells from malignant tumors can invade and damage nearby tissues and organs.
- Cells from malignant tumors can spread to other parts of the body. The cells spread by breaking away from the original cancer (primary tumor) and entering the bloodstream or lymphatic system. They invade other organs, forming new tumors and damaging these organs. The spread of cancer is called metastasis.
Oral Cancer: Who's at Risk?
Doctors cannot always explain why one person develops oral cancer and another does not. However, we do know that this disease is not contagious. You cannot "catch" oral cancer from another person.
Research has shown that people with certain risk factors are more likely than others to develop oral cancer. A risk factor is anything that increases your chance of developing a disease.
The following are risk factors for oral cancer:
- Tobacco: Tobacco use accounts for most oral cancers. Smoking cigarettes, cigars, or pipes; using chewing tobacco; and dipping snuff are all linked to oral cancer. The use of other tobacco products (such as bidis and kreteks) may also increase the risk of oral cancer. Heavy smokers who use tobacco for a long time are most at risk. The risk is even higher for tobacco users who drink alcohol heavily. In fact, three out of four oral cancers occur in people who use alcohol, tobacco, or both alcohol and tobacco.
- Alcohol: People who drink alcohol are more likely to develop oral cancer than people who don't drink. The risk increases with the amount of alcohol that a person consumes. The risk increases even more if the person both drinks alcohol and uses tobacco.
- Sun: Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun's harmful rays. The risk of cancer of the lip increases if the person also smokes.
- A personal history of head and neck cancer: People who have had head and neck cancer are at increased risk of developing another primary head and neck cancer. Smoking increases this risk.
Quitting tobacco reduces the risk of oral cancer. Also, quitting reduces the chance that a person with oral cancer will get a second cancer in the head and neck region. People who stop smoking can also reduce their risk of cancer of the lung, larynx, mouth, pancreas, bladder, and esophagus. There are many resources to help smokers quit:
- The Cancer Information Service at 1-800-4-CANCER can talk with callers about ways to quit smoking and about groups that offer help to smokers who want to quit. Groups offer counseling in person or by telephone.
- Also, your doctor or dentist can help you find a local smoking cessation program.
- Your doctor can tell you about medicine (bupropion) or about nicotine replacement therapy, which comes as a patch, gum, lozenges, nasal spray, or inhaler.
- The "National Cancer Institute Information Resources" section has information about the Federal Government's smoking cessation Web site, http://www.smokefree.gov.
Some studies suggest that not eating enough fruits and vegetables may increase the chance of getting oral cancer. Scientists also are studying whether infections with certain viruses (such as the human papillomavirus) are linked to oral cancer.
If you think you may be at risk, you should discuss this concern with your doctor or dentist. You may want to ask about an appropriate schedule for checkups. Your health care team will probably tell you that not using tobacco and limiting your use of alcohol are the most important things you can do to prevent oral cancers. Also, if you spend a lot of time in the sun, using a lip balm that contains sunscreen and wearing a hat with a brim will help protect your lips.
People used to think that as you got older you naturally lost your teeth. We now know that’s not true. By following easy steps for keeping your teeth and gums –healthy plus seeing your dentist regularly—you can have your teeth for a lifetime!
Plaque: What is it?
Plaque is made up of invisible masses of harmful germs that live in the mouth and stick to the teeth. Some types of plaque cause tooth decay. Other types of plaque cause gum disease. Red, puffy or bleeding gums can be the first signs of gum disease. If gum disease is not treated, the tissues holding the teeth in place are destroyed and the teeth are eventually lost. Dental plaque is difficult to see unless it’s stained, You can stain plaque by chewing red “disclosing tablets,” found at grocery stores and drug stores, or by using a cotton swab to smear green food coloring on your teeth. The red or green color left on the teeth will show you where there is still plaque—and where you have to brush again to remove it. Stain and examine your teeth regularly to make sure you are removing all plaque. Ask your dentist or dental hygienist if your plaque removal techniques are o.k.
Floss Use floss to remove germs and food particles between teeth. Rinse.
Brush Teeth Use any tooth brushing method that is comfortable, but do not scrub hard back and forth. Small circular motions and short back and forth motions work well. Rinse. To prevent decay, it’s what’s on the toothbrush that counts. Use fluoride toothpaste. Fluoride is what protects teeth from decay.
Brush the tongue for a fresh feeling! Rinse again. Remember: Food residues, especially sweets, provide nutrients for the germs that cause tooth decay, as well as those that cause gum disease. That’s why it is important to remove all food residues, as well as plaque, from teeth. Remove plaque at least once a day—twice a day is better. If you brush and floss once daily, do it before going to bed.
Wisdom teeth, also known as third molars are the last teeth to erupt. This occurs usually between the ages of 17 and 25. There remains a great deal of controversy regarding whether or not these teeth need to be removed. It is generally suggested that teeth that remain completely buried or un-erupted in a normal position are unlikely to cause harm. However, if these impacted teeth are in an abnormal position (a dentist can show you this on an x-ray), their potential for harm should be assessed.
