What is thumbsucking?

Babies have a natural desire to suck. Thumbsucking is a common way babies seem to comfort themselves. Thumbsucking usually begins by 3 months of age.

A child usually sucks his thumb when he is tired, bored, sick, or upset or when he is not using his hands to play. A child may suck a finger(s) or fist instead of a thumb. Sometimes a security object, such as a blanket, may become part of the thumbsucking habit.

What is the cause?

An infant’s desire to suck on the breast or bottle is a drive that is essential for survival. More than 80% of babies do some extra sucking when they are not hungry. With ultrasound many babies even can be seen sucking in the uterus. Thumbsucking also appears to help a child comfort herself and often increases when breast or bottle feedings decrease. It does not mean that a child is insecure or has emotional problems.

How long does it last?

The sucking need is strongest during the first 6 months of a child’s life. In a study by Dr. T. Berry Brazelton, only 6% of thumbsucking babies continued the habit past 1 year of age and only 3% continued beyond the age of 2 years. A more recent study, however, found that 15% of 4-year-olds still sucked their thumbs. Those children who continue sucking their thumbs after the age of 4 often have become involved in a power struggle in their early years with a parent who tried to stop their thumbsucking. Occasionally, the thumbsucking simply persists as a bad habit.

The American Dental Association advises that a child can probably suck his thumb until he is 4 or 5 years old without damaging his teeth or jawline. However, thumbsucking must be stopped before a child’s permanent teeth come in (at age 6 or 7) because it can lead to an overbite (buck teeth). Another reason to encourage children to give up the habit before they enter school is to prevent the teasing they would otherwise receive.

By adolescence, most normal children abandon thumbsucking because of peer pressure.

How can I help my child overcome thumbsucking?

1. If your child is less than 5 years old, distract your child or ignore the thumbsucking. Thumbsucking should be considered normal before the age of 4 years and usually ignored, especially when your child is tired, sick, or stressed. Help your child overcome any stressful situations. However, if the thumbsucking occurs when your child is bored and he is over 1 year old, try to distract him. Give him something to do with his hands without mentioning your concern about the thumbsucking. Occasionally praise your child for not thumbsucking. Until your child is old enough for you to reason with, any pressure you apply to stop thumbsucking will only lead to resistance and lack of cooperation.
2. After 5 years of age, help your child give up thumbsucking during the day. Most 5-year-olds have reached the age of reasoning and are developmentally ready to cooperate with their parents and work on a bad habit. They must have an understanding of cause and effect relationships, the ability to discriminate between right and wrong, and the capacity to practice some degree of self-control and self-denial. First get your child’s commitment to giving up thumbsucking by showing her what thumbsucking is doing to her teeth and body. Show her the gap between her upper and lower teeth with a mirror. Have her look at the wrinkled rough skin (callus) on her thumb. Discuss the unhealthy aspects of placing the thumb in the mouth when there are germs or dirt on it. Appeal to her sense of pride. At this point most children will agree that they would like to stop thumbsucking. If your child expresses the desire to stop, the next step is careful planning. Young children may become frustrated easily and want to stop trying. To help succeed, parents will want to be available for the first difficult days and focus on keeping the child distracted from the sucking behavior by planning some activities to occupy the child’s hands such as drawing, craft projects, puzzles, and games. If the hands are busy they won’t be going in the mouth. Because most children with sucking habits are unaware of the activity, it will be important to use some sort of reminder on the thumb. Character Band-Aids work well for daytime, but children generally need assistance placing the bandage comfortably on the top part of the thumb. However, it is important that it is the child’s choice to wear the reminder and not to be enforced by parents. Introduce the reminder as a special helper to let the child know when the thumb is trying to sneak in the mouth. Limit television watching for the first couple of weeks and avoid other situations that stimulate the sucking habit. Older children may also want an outlet for dealing with the urge to suck their thumb. You can suggest doing something else with her thumb, such as holding her thumb inside a closed fist for 10 seconds or twirling her thumbs. Although self-reminders are the most effective, parent reminders may occasionally be helpful if the child approves. Ask your child if it will be all right if you remind her when she forgets. Do this gently with comments such as “Guess what?” and put an arm around your child as she remembers that she has been sucking on her thumb again.
3. At the same time, help your child give up thumbsucking during sleep. Most children depend heavily on the sucking activity to relax and fall asleep at naptime and bedtime. The sleeping habit is the strongest part of the behavior and it takes the longest to eliminate. It will be important to address the sleeptime sucking at the same time you are working on the daytime habit to minimize frustration and enhance success. Parents will also want to plan to be available at bedtime for the first week to help the child adjust to falling asleep without sucking. Your child can be told that the sleeptime thumbsucking is not his fault, because “that old thumb just sneaks in and he doesn’t even know it because he is sleeping.” He will need a powerful reminder, one that covers the entire hand. A long cotton tube sock is the most effective reminder. A glove or puppet sock are other options. Help your child look upon this method as a clever and a fun idea rather than any kind of penalty. Again, parents should assist with putting on the bedtime reminders but not enforce cooperation. It is important to remember that parents cannot eliminate the habit for their child. The habit belongs to the child and the child must willingly cooperate and accept responsibility if the habit is to be eliminated.
4. Incentives Praise your child whenever you notice she is not sucking her thumb in situations where she previously did. This will build her self confidence. Give her a star on her chart and a reward (such as a dime, a snack, or an extra story) at the end of any day during which she did not suck her thumb at all).
5. Consult with a thumbsucking expert if these techniques are not successful. When the permanent teeth come in, thumbsucking carries the danger of causing an overbite. Eventually an overbite will require orthodontic braces, which are expensive. An expert on thumbsucking is called a certified oral myologist (CMO). They are trained to help children stop their sucking habits quickly using motivational programs. Ask your doctor about CMOs or call The International Association of Orofacial Myology at 303-765-4395.
6. What to avoid The following techniques are generally not helpful and may prolong the thumbsucking habit because the child looks upon them as punishment:
   • Dental appliances: This is usually a reminder bar that is placed in the upper part of the mouth.
   • Elastic wrap or splints: Placing these around the elbow to keep it from bending often causes some discomfort. It can also cause temporary blueness, swelling, and numbness of the arm in the morning.
   • Bitter-tasting medicines applied to the thumbnail: If the parent applies this medicine without the child’s permission, the child will usually just wash it off or switch to another finger. Only if your child wants to use it as a reminder it may be helpful.

How can I prevent thumbsucking?

If your baby needs to suck a lot, try to interest him in a pacifier instead of his thumb when he needs to be comforted, but is not hungry. However, avoid overusing it. Unlike thumbsucking, pacifier use can be controlled as your child grows older because you can take away the pacifier. If they are older than 1 year, children who use pacifiers do not switch to sucking their thumbs when they give up the pacifier. Children are always able to give up their pacifiers by age 4 or 5 years.

Thumbsucking lasting beyond age 5 can usually be prevented if you avoid pulling your child’s thumb out of his mouth at any age. Also, don’t comment in your child’s presence about your dissatisfaction with the habit. Scolding, slapping the hand, or other punishments will only make your child dig in his heels about thumbsucking. If you can wait, your child will usually give up the thumbsucking naturally. If you turn the issue into a showdown, you will lose, since the thumb belongs to your child.

When should I call my child’s healthcare provider?

Call during office hours if:

• Your child is over 4 years old and sucks her thumb constantly.
• Your child is over 5 years old and doesn’t stop when peers tease her.
• Your child is over 6 years old and sucks her thumb at any time.
• Your child’s teacher has expressed concern about thumbsucking in class.
• Your child also has emotional problems.
• The permanent teeth appear to be crooked.
• The thumbsucking does not improve after trying this approach.
• You have other concerns or questions.

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What is a mouth guard?

A mouth guard is a protective device that fits inside the mouth to protect the teeth. The most common type of mouth guard fits around the top teeth. The bottom teeth are protected when the mouth guard overlaps them. Some mouth guards fit both top and bottom teeth.

Mouth guards are available in sporting good stores and come in several sizes. Many mouth guards can be custom-fitted by boiling them and biting into the mouth guard or by pouring a gel into the mouth guard that solidifies when you bite into it. A mouth guard may also be custom-made by your dentist.

Why wear a mouth guard?

Your teeth are important. Mouth guards should always be worn in contact sports such as football, lacrosse, hockey, and rugby. It is recommended that they be worn in other sports such as basketball. A mouth guard not only protects your teeth but acts as a shock absorber during head contact. Mouth guards may lower your risk of getting a concussion.

Definition

Temporomandibular joint disorders (TMJ disorders) are problems or symptoms of the joints that connect your lower jaw to your skull.

See also: Facial pain

Alternative Names

TMD; Temporomandibular joint disorders

Causes

There are two matching temporomandibular joints — one on each side of your head, located just in front of your ears. The abbreviation “TMJ” literally refers to the joint but is often used to mean any disorders or symptoms of this region.

Many TMJ-related symptoms are caused by the effects of physical and emotional stress on the structures around the joint. These structures include:

• Cartilage disk at the joint
• Muscles of the jaw, face, and neck
• Nearby ligaments, blood vessels, and nerves
• Teeth

For example, daily stress can lead you to clench and grind your teeth, both during the day and at night while you sleep. Clenching means you tightly clamp your top and bottom teeth together, especially the back teeth. The stressful force of clenching causes pressure on the muscles, tissues, and other structures around your jaw.

Many people who clench also grind their teeth. Grinding is when you slide your teeth over each other, generally in a sideways, back-and-forth movement. This action may wear down your teeth and can be noisy enough at night to bother sleeping partners.

Poor posture can also be an important factor in TMJ. For example, holding the head forward while looking at a computer all day strains the muscles of the face and neck.

Other factors that might make TMJ symptoms worse are stress, poor diet, and lack of sleep.

All of these stresses can result in “trigger points” — contracted muscles and pinched nerves in your jaw, head, and neck. Trigger points can refer pain to other areas, causing a headache, earache, or toothache.

Other possible causes of TMJ-related symptoms include arthritis, fractures, dislocations, and structural problems present since birth.

Symptoms

• Biting or chewing difficulty or discomfort
• Clicking sound while chewing or opening the mouth
• Dull, aching pain in the face
• Earache
• Grating sensation while chewing
• Headache
• Jaw pain or tenderness of the jaw
• Reduced ability to open or close the mouth

Exams and Tests

TMJ pain and symptoms may need to be checked by more than one medical specialist, such as your primary care provider, a dentist, or an ear, nose, and throat (ENT) doctor, depending on your symptoms. Some dentists specialize in TMJ diagnosis and treatment.

A thorough examination may involve:

• A dental examination to show if you have poor bite alignment
• An MRI of the jaw area
• Feeling the joint and connecting muscles for tenderness
• Pressing around the head for areas that are sensitive or painful
• Sliding the teeth from side to side
• Watching, feeling, and listening to the jaw open and shut
• X-rays to show abnormalities

In some cases, the results of the physical exam may appear normal.

Treatment

Simple, gentle therapies are usually recommended first. If those don’t work, mouth guards and more aggressive treatments may be considered. Surgery is generally a last resort. Fortunately, there are many steps you can take at home long before that point.

Try massaging the various muscles that may be involved. Probe all of the muscles of the face, shoulders, and back of the neck. (Avoid the area around the throat.) Press on the muscles to identify extremely painful points. Massage the painful spot with hard, slow, short strokes. Do this several times a day until the muscle is no longer painful when pressed.

To massage the masseter muscles on each side of your jaw, place your thumb inside your mouth and squeeze the thick muscle in your cheek (toward the back of your mouth) with your fingers. To get at the harder-to-reach jaw muscles inside your mouth, use your index finger to probe for tender areas behind the teeth, and use the finger to massage these spots.

Other home-care therapies, such as moist heat or cold packs on the face, vitamin supplements, or biofeedback are useful for some people. Exercising several times each week may help you relax, strengthen your body, increase flexibility, and increase your ability to handle pain.

Read as much as you can, as opinion varies widely on how to treat TMJ disorders. Get several doctor’s opinions. The good news is that most people eventually find something that helps.

MOUTH GUARDS

Mouth guards, also called splints or appliances, have been used since the 1930’s to treat teeth grinding, clenching, and TMJ disorders. Many people have found them to be useful, but the benefits vary widely. The guard may lose its effectiveness over time, or when you stop wearing it. Other people may feel worse pain when they wear one.

There are different types of splints. Some fit over the top teeth, while others fit over the bottom teeth. They may be designed to keep your jaw in a more relaxed position, prevent clenching, or provide some other function. If one type doesn’t work, another may.

For example, a new type of splint is called the NTI-tss. It fits over just a couple of top, front teeth. The idea is to keep all of your back teeth completely separated, under the theory that most clenching is done by these back teeth. With the NTI splint, the only contact is between the tiny splint and one bottom front tooth.

MORE AGGRESSIVE TREATMENT

Be cautious about any non-reversible treatment method that permanently alters your bite. However, if a mouth guard doesn’t work, your dentist may recommend orthodontics to help re-align your teeth.

Reconstructive surgery of the jaw is rarely required. In fact, studies have shown that the results are often worse than before surgery.

Muscle relaxant medications may help. Nonsteroidal anti-inflammatory medications (NSAIDs) help reduce swelling (inflammation) in the jaw stemming from arthritis or other causes.

Support Groups

For additional information, two excellent books are Taking Control of TMJ by Robert Uppgaard and The Trigger Point Therapy Workbook by Clair Davies.

Outlook (Prognosis)

Most cases can be successfully treated, although at first it may be difficult to diagnose the problem and find an effective solution. Some cases of pain go away on their own without treatment. TMJ-related pain may return again in the future. If the cause is nighttime clenching, treatment can be very tricky because it is a sleeping behavior that is hard to control.

Mouth splints are a common treatment approach for teeth grinding. While some splints may silence the grinding by providing a flat, even surface, they may not be as effective at reducing pain or stopping clenching. Splints may be effective in the short-term but could become less effective over time. Splints can also cause changes in your bite.

Possible Complications

• Chronic face pain
• Chronic headaches

When to Contact a Medical Professional

See your health care provider right away if you are having trouble eating or opening your mouth. Keep in mind that a wide variety of possible conditions can cause TMJ symptoms, from arthritis to whiplash injuries. Experts who are specially trained in facial pain can help diagnose and treat TMJ.

TMJ problems do not fall clearly into one medical area. There are a wide variety of treatment approaches. If you are interested in a massage-based approach, look for a massage or physical therapist trained in trigger point therapy, neuromuscular therapy (NMT), clinical massage, or pain relief, especially for TMJ pain.

Dentists who specialize in evaluating and treating TMJ disorders will typically perform x-ray exams and may use a kinesiograph or EMG (electromyography). They may give you a mouth guard. Surgery is now considered a last resort by most TMJ experts.

Prevention

Many of the home-care steps to treat TMJ problems can prevent such problems in the first place:

• Avoid eating hard foods and chewing gum.
• Drink plenty of water every day and get plenty of sleep.
• Learn relaxation techniques to reduce overall stress and muscle tension.
• Maintain good posture, especially if you work all day at a computer. Pause often to change position, rest your hands and arms, and relieve stressed muscles.
• Use safety measures to reduce the risk of fractures and dislocations.

References

American Dental Association. TMD/TMJ (temporomandibular disorders). Available at: http://www.ada.org/public/topics/tmd_tmj.asp.

Lobbezoo F. Topical review: new insights into the pathology and diagnosis of disorders of the temporomandibular joint. J Orofac Pain. 2004; 18(3): 181-191.

Simons DC, Travell JG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. Upper Half of the Body. 2nd Ed. Atlanta, GA: Emory University;1998.
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Definition

Face pain may be dull and throbbing or an intense, stabbing discomfort in one or both sides of the face or forehead.

Considerations

Pain that starts in the face may be caused by a nerve disorder, an injury, or an infection in a structure of the face. Face pain may also begin elsewhere in the body.

Sometimes face pain occurs for no known reason.

Causes

• Abscessed tooth (continuous throbbing pain on one side of the lower face aggravated by eating or touching)
• Cluster headache
• Herpes zoster (shingles) or herpes simplex (cold sores) infection
• Injury to the face
• Migraine
• Myofascial pain syndrome
• Sinusitis or sinus infection (dull pain and tenderness around the eyes and cheekbones that worsens when bending forward)
• Tic douloureux
• Temporomandibular joint dysfunction syndrome

Home Care

Follow the treatment prescribed for the cause of the pain.

Painkillers may provide temporary relief. If the pain is severe or persistent, call your primary health care provider or dentist.

When to Contact a Medical Professional

• Face pain is accompanied by chest, shoulder, neck, or arm pain. This could mean a heart attack. Call your local emergency number (such as 911).
• Pain is throbbing, worse on one side of the face, and aggravated by eating. Call a dentist.
• Pain is persistent, unexplained, or accompanied by other unexplained symptoms. Call your primary health care provider.

What to Expect at Your Office Visit

In emergency situations (such as a possible heart attack), you will first be stabilized. Then, the health care provider will take a medical history and perform a physical examination. For tooth problems, expect a referral to a dentist or orthodontist.

You may be asked the following questions:

• What part of your face is in pain?
• Is the pain on both sides?
• If the pain is only on one side, which side is it on?
• Is the pain over a sinus (forehead, cheekbones)?
• Did the pain begin suddenly?
• Is face pain occurring repeatedly (is it recurrent)?
• How long have the episodes of face pain lasted (for how many months)?
• How long does each episode of pain last (how many seconds)?
• Is the pain worse when speaking, chewing, or swallowing?
• Does the pain develop when touching a specific part of the face (trigger point)?
• Did face pain occur before the start of a brain or nervous system problem (weakness, speech loss)?
• What other symptoms do you have?

Diagnostic tests that may be performed include:

• Dental x-rays (if a tooth problem is suspected)
• ECG (if heart problems are suspected)
• Tonometry (if glaucoma is suspected)
• X-rays of the sinuses

Neurological tests will be performed if nerve damage is suspected.

References

Siccoli MM, Bassetti CL, Sándor PS. Facial pain: clinical differential diagnosis. The Lancet Neurol. 2006;5:257-267.

Silberstein SD, Young WB. Headache and facial pain. In: Goetz CG, ed. Textbook of Clinical Neurology. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 53.

Cutrer FM, Moskowitz MA. Headaches and other head pain. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 421.
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Definition

All adults should visit their health care provider from time to time, even if they are healthy. The purpose of these visits is to:

• Screen for diseases
• Assess risk of future medical problems
• Encourage a healthy lifestyle
• Update vaccinations
• Maintain a relationship with a doctor in case of an illness

Alternative Names

How often you need a physical exam; Health maintenance visit

Information

Even if you feel fine, it is still important to see your health care provider regularly to check for potential problems. Most people who have high blood pressure don’t even know it. The only way to find out is to have your blood pressure checked regularly. Likewise, high blood sugar and high cholesterol levels often do not produce any symptoms until the disease becomes advanced.

There are specific times when you should see your health care provider. Age-specific guidelines are as follows:

AGE 18-39

• Blood pressure screening:
  • Have your blood pressure checked every 2 years unless it is 120-139/80-89 Hg or higher. Then have it checked every year.
  • Watch for blood pressure screenings in your area. Ask your health care provider if you can stop in to have your blood pressure checked. Check your blood pressure using the automated machines at local grocery stores and pharmacies.
  • If the top number (systolic number) is greater than 130 or the bottom number (diastolic number) is greater than 85, call your doctor.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be monitored more closely.
• Cholesterol screening:
  • Men over age 34 should be checked every 5 years.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be monitored more closely.
• Dental exam:
  • Go to the dentist every year for an exam and cleaning.
• Eye exam:
  • If you have vision problems, have an eye exam every 2 years.
• Immunizations:
  • After age 19, you should have a tetanus-diphtheria and acellular pertussis (TdAP) vaccine as one of your tetanus-diphtheria vaccines one time. You should have a tetanus-diphtheria booster every 10 years.
  • Your doctor may recommend other immunizations if you are at high risk for certain conditions such as pneumonia.
• Men: Testicular exam:
  • Men should do a monthly testicular self-exam.
  • If you are not sure what you should be looking for, contact your health care provider for instruction.
• Physical exam:
  • You should have two physical exams in your 20s.
  • During the first exam, ask to have your cholesterol checked. Other blood tests are not necessary for healthy young people.
  • Your height and weight should be checked at every exam.
• Women: Breast self-exam:
  • Women may do a monthly breast self-exam.
  • Women should contact their health care provider immediately if they notice a change in their breasts, whether or not they do breast self-exams.
  • A complete breast exam should be done by a health care provider every 3 years for women age 20-40.
• Women: Pelvic exam and Pap smear:
  • Women should have a pelvic exam and Pap smear every 1-2 years to check for cervical cancer, depending on the technique.
  • Screening should start within 3 years after first having vaginal intercourse or by age 21.
  • If you are over age 30 or your Pap smears have been negative for 3 years in a row, your doctor may tell you that you only need a Pap smear every 2-3 years.
  • Women who have had a total hysterectomy (uterus and cervix removed) may choose not to have Pap smears.
  • Women who are sexually active should be screened for chlamydia infection. This can be done during a pelvic exam.

AGE 40-65

• Blood pressure screening:
  • Have your blood pressure checked every 2 years unless it is 120-139/80-89 Hg or higher. Then have it checked every year.
  • Watch for blood pressure screenings in your area. Ask your health care provider if you can stop in to have your blood pressure checked. Check your blood pressure using the automated machines at local grocery stores and pharmacies.
  • If the top number (systolic number) is greater than 130 or the bottom number (diastolic number) is greater than 85, call your doctor.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be monitored more closely.
• Cholesterol screening:
  • Men over age 34 should be checked every 5 years.
  • Women over age 44 should be checked every 5 years.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be monitored more closely.
• Colon cancer screening: People between the ages of 50 and 80 should be screened for colorectal cancer. African-Americans need to start screening at age 45. This may involve:
  • A stool test done every year.
  • Flexible sigmoidoscopy every 5 years along with a stool guaiac test.
  • Colonoscopy every 10 years.
  • Double-contrast barium enema.
  • Computed tomographic colonography (virtual colonoscopy).
  • People with risk factors for colon cancer such as long-standing ulcerative colitis, personal or family history of colorectal cancer, or history of large colorectal adenomas may need a colonoscopy more often.
• Dental exam:
  • Go to the dentist every year for an exam and cleaning.
• Eye exam:
  • If you have vision problems, continue to have an eye exam every 2 years.
  • Everyone (with or without eye problems) should begin to have regular eye exams every 2 years after age 40.
  • Once you turn 45, make sure that you have tonometry done to check for glaucoma.
• Immunizations:
  • You should receive a flu vaccine every year after age 50.
  • Ask your doctor if you should get a vaccine to reduce your risk of pneumonia.
  • You should have a tetanus-diphtheria booster vaccination every 10 years.
  • A shingles or herpes zoster vaccination may be given once after age 60.
• Physical exam:
  • Have a physical exam every 1-5 years.
  • Your height, weight, and body mass index (BMI) should be checked at each exam.
  • Routine diagnostic tests are not recommended.
• Men: Prostate exam:
  • Most men age 50 or older should discuss screening for prostate cancer with their health care provider. African-American men and those with a family history of prostate cancer should start at age 45.
  • Screening tests may include the PSA blood test and a digital rectal examination.
• Women: Breast exams:
  • Women may do a monthly breast self-exam.
  • Women should contact their doctor immediately if they notice a change in their breasts, whether or not they do self exams.
  • A complete breast exam should be done by a health care provider every year.
• Women: Mammograms:
  • Women over the age of 40 should have a mammogram done every 1-2 years depending on risk factors to check for breast cancer.
• Women: Osteoporosis screening:
  • All postmenopausal women with fractures should have a bone density test (DEXA scan).
  • Women under 65 who have risk factors for osteoporosis should be screened.
• Men: Osteoporosis screening:
  • All men ages 50-70 with risk factors for osteoporosis should discuss screening with their doctor.
• Women: Pelvic exam and Pap smear:
  • Women should have a yearly pelvic exam and Pap smear done to check for cervical cancer and other disorders.
  • If your Pap smears have been normal for 3 years in a row, your doctor may tell you that you only need a Pap smear to every 2-3 years.
  • Women who have had a total hysterectomy (uterus and cervix removed) may choose not to have Pap smears.
  • Women who are sexually active should be screened for chlamydia infection. This can be done during a pelvic exam.

AGE 65 AND OLDER

• Abdominal aortic aneurysm screening:
  • Men between ages 65 – 75 who have smoked should have an ultrasound done once to screen for abdominal aortic aneurysms.
  • Others should discuss such screening with their health care provider.
• Blood pressure screening:
  • Have your blood pressure checked every year.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be watched more closely.
• Cholesterol screening:
  • If your cholesterol level is normal, have it rechecked every 3-5 years.
  • If you have diabetes, heart disease, kidney problems, or certain other conditions, you may need to be monitored more closely.
• Colon cancer screening: One of the following screening tests should be done:
  • A stool test every year
  • Flexible sigmoidoscopy every 5 years along with a stool guaiac test
  • Colonoscopy every 10 years
  • Computed tomographic colonography (virtual colonoscopy)

Note: Patients with risk factors for colon cancer, including long-standing ulcerative colitis, personal or family history of colorectal cancer, or history of large colorectal adenomas may need a colonoscopy more often.

• Dental exam:
  • Go to the dentist every year.
• Eye exam:
  • Have an eye exam every 2 years.
  • Make sure your health care provider checks for glaucoma.
• Hearing test:
  • Have your hearing tested every year.
• Immunizations:
  • If you are over 65, get a pneumococcal vaccine if you have never had before, or if you received one more than 5 years before your turned 65.
  • Get a flu shot every year.
  • Get a tetanus -diphtheria booster every 10 years.
  • A shingles or herpes zoster vaccination may be given once after age 60.
• Men: Prostate exam:
  • All men should discuss prostate cancer screening with their health care provider.
  • Screening may involves a PSA test or digital rectal exam.
• Physical exam:
  • Have a yearly physical exam.
  • With each exam, you should have your height and weight checked.
  • Routine diagnostic tests are not recommended unless your doctor finds a problem.
• Women: Breast exams:
  • Women may do a monthly breast self-exam.
  • Women should contact their doctor immediately if they notice a change in their breasts, whether or not they do self exams.
  • A complete breast exam should be done by a health care provider every year.
• Women: Mammograms:
  • Women should have a mammogram done every 1-2 years depending on risk factors to check for breast cancer.
• Women: Osteoporosis screening:
  • All women should have a bone density test (DEXA scan).
  • Ask your doctor about the proper calcium intake and exercise needed to help prevent osteoporosis.
• Men: Osteoporosis screening:
  • All men over age 70 should have a bone density test (DEXA scan).
• Women: Pelvic exam and Pap smear:
  • Women should have a yearly pelvic exam and Pap smear done to check for cervical cancer and other disorders.
  • If your Pap smears have been negative for 3 years in a row, your doctor may tell you that you only need a Pap smear to every 2 – 3 years.
  • Women who have had a total hysterectomy (uterus or cervix removed) may choose not to have Pap smears.
  • If you are over 70 and your Pap smear has been normal for 10 years, or if your test results have been normal for 3 years in a row, you may choose not to have any more Pap smears.

References

U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm. Rockville, MD: Agency for Healthcare Research and Quality; February 2005.

U.S. Preventive Services Task Force. Screening for Chlamydial Infection. Rockville, MD: Agency for Healthcare Research and Quality; June 2007.

Smith RA, Cokkinides V, Brawley OW. Cancer Screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin. 2008;58(3):161-79. Epub 2008 Apr 28.

Gaziano JM, Manson JE, Ridker PM. Primary and secondary prevention of coronary heart disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, PA; Saunders Elsevier; 2007: chap 45.

American Diabetes Assocation. Standards of medical care in diabetes — 2008. Diabetes Care. 2008;31(suppl 1):S12-54.

National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Feb. 2008. Accessed Feb. 22, 2008.
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Alternative Names

Tartar and plaque on teeth; Calculus

Information

You should get specific instructions from your dentist or hygienist on how to correctly brush and floss. But in general, recommendations for preventing and removing tartar or plaque on your teeth include:

• Brush at least twice a day with a brush that is not too large for your mouth and that has soft, rounded bristles. The brush should let you reach every surface in your mouth easily, and the toothpaste should contain fluoride.
• Floss gently at least twice a day. This is important to prevent gum disease.
• See your dentist or oral hygienist every 6 months for a thorough teeth cleaning and oral examination.

Dental sealants are a means of protecting teeth from decay by sealing over healthy pits, fissures, and grooves in the teeth. Well-balanced meals are also recommended for maintaining healthy teeth and gums.

For more information, see: Oral hygiene

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Definition

Geographic tongue is a map-like appearance of your tongue due to irregular patches on its surface.

Alternative Names

Patches on the tongue; Tongue – patchy; Benign migratory glossitis; Glossitis – benign migratory

Causes

The specific cause of geographic tongue is unknown, although vitamin B deficiency may be involved. Other causes may include irritation from hot or spicy foods, or alcohol. The condition appears to be less common in those who smoke.

The pattern on the surface of the tongue may change very rapidly. This pattern changes occur when there is a loss of the tiny finger-like projections, called papillae, on the tongue’s surface. This makes areas of the tongue flat. These areas are said to be “denuded.” Denuded areas may persist for more than a month.

Symptoms

• Map-like appearance to the surface of the tongue
• Smooth, beefy red patches and lesions on the tongue
• Patches that change location from day to day
• Soreness and burning pain (in some cases)

Exams and Tests

Your doctor will usually diagnose this condition based on an examination of your tongue. Tests are usually not necessary.

Treatment

There is no treatment.

Outlook (Prognosis)

Geographic tongue is a harmless condition, but it can be persistent and uncomfortable.

When to Contact a Medical Professional

Call your doctor if the symptoms last longer than 10 days. Seek immediate medical help if:

• The tongue is severely swollen
• Breathing trouble occurs
• There are problems with speaking, chewing, or swallowing

Prevention

Avoid irritating your tongue with hot or spicy food or alcohol if you are prone to this condition.

References

Goldman L, Ausiello D. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: WB Saunders; 2004:2428.

Shulman JD. Prevalence and risk factors associated with geographic tongue among US adults. Oral Dis. Jul 2006; 12(4): 381-6.
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Definition

Tongue problems include pain, swelling, or a change in how the tongue looks.

Alternative Names

Dark tongue; Burning tongue syndrome

Considerations

The tongue is mainly composed of muscles. It is covered with a mucous membrane. Small bumps (papillae) cover the upper surface of the tongue. Between the papillae are the taste buds, which allow you to taste. The tongue moves food to help you chew and swallow.

The tongue also helps you form words.

There are many different reasons for changes in the tongue’s function and appearance.

DIFFICULTY MOVING THE TONGUE

Tongue movement problems are most often caused by nerve damage. However, problems moving the tongue may also be caused by ankyloglossia, a disorder where the band of tissue that attaches the tongue to the floor of the mouth is too short. Tongue movement disorders may result in speech difficulties or difficulty moving food during chewing and swallowing.

TASTE ABNORMALITIES

Taste problems can be caused by damage to the taste buds, nerve problems, side effects of medications, an infection, or other condition. The tongue normally senses sweet, salty, sour, and bitter tastes. Other “tastes” are actually a function of the sense of smell.

ENLARGEMENT OF THE TONGUE

Tongue swelling occurs with Down syndrome, acromegaly, myxedema, amyloidosis, rhabdomyoma, and other disorders. The tongue may get wider in persons who have no teeth and do not wear dentures.

COLOR CHANGES

Color changes may occur with inflammation of the tongue (glossitis). Papillae are lost, causing the tongue to appear smooth. Geographic tongue is a patchy form of glossitis where the location of inflammation and appearance change from day to day.

HAIRY TONGUE

Hairy tongue is a harmless condition in which the tongue looks hairy or furry. Its appearance can be worrisome. The disorder usually goes away with antibiotics.

BLACK TONGUE

Sometimes the upper surface of the tongue turns black or brown in color. This is an unsightly condition but not harmful.

PAIN IN THE TONGUE

This may occur with glossitis and geographic tongue. Tongue pain may also occur in with diabetic neuropathy, oral cancer, mouth ulcers, and leukoplakia.

After menopause, some women have a sudden feeling that their tongue has been burned. This is called burning tongue syndrome or idiopathic glossopyrosis. There is no specific treatment for burning tongue syndrome.

Causes

Minor infections or irritations are the most common cause of tongue soreness. Injury, such as biting the tongue, can cause painful sores. Heavy smoking will irritate the tongue and make it painful.

A viral ulcer, also called a canker sore, commonly appears on the tongue (or anywhere in the mouth) for no apparent reason. Some doctors believe that these ulcers are linked to emotional stress or fatigue, although this has not been proven.

Possible causes of tongue pain include:

• Anemia
• Cancer
• Dentures that irritate the tongue
• Oral herpes (ulcers)
• Neuralgia
• Referred pain from teeth and gums
• Referred pain from the heart

Possible causes of tongue tremor:

• Neurological disorder
• Overactive thyroid

Possible causes of white tongue:

• Local irritation
• Smoking and alcohol use

Possible causes of smooth tongue:

• Anemia
• Vitamin B-12 deficiency

Possible causes of red (ranging from pink to magenta) tongue:

• Folic acid and vitamin B-12 deficiency
• Pellagra
• Pernicious anemia
• Plummer-Vinson syndrome
• Sprue

Possible causes of tongue swelling:

• Acromegaly
• Allergic reaction to food or medicine
• Amyloidosis
• Angioedema
• Beckwith syndrome
• Cancer of the tongue
• Congenital micrognathia
• Down syndrome
• Hypothyroidism
• Infection
• Leukemia
• Lymphangioma
• Neurofibromatosis
• Pellagra
• Pernicious anemia
• Strep infection
• Tumor of the pituitary gland

Possible causes of a hairy tongue:

• AIDS
• Antibiotic therapy
• Drinking coffee
• Dyes in drugs and food
• Chronic medical conditions
• Overuse of mouthwashes containing oxidizing or astringent agents.
• Radiation of the head and neck
• Tobacco use

Possible cause of grooves in the tongue:

• Birth defect — normally occurs in 10% of population

Home Care

Practice good oral hygiene for hairy tongue and black tongue. Be sure to eat a well-balanced diet.

Canker sores are caused by viruses and can’t be cured by treatment. They must heal on their own.

See your dentist if you have a tongue problem caused by dentures.

Antihistamines can help relieve a swollen tongue caused by allergies. You should avoid the food or drug that causes the tongue swelling.

When to Contact a Medical Professional

Make an appointment with your doctor if your tongue problem persists.

What to Expect at Your Office Visit

The doctor will perform a physical examination, look closely at the tongue, and ask question such as:

• When did you first notice the problem?
• Have you had similar symptoms before?
• Do you have pain, swelling, breathing problems, or difficulty swallowing?
• Do you have a tongue tremor?
• What makes the problem worse? (Eating, drinking, swallowing, talking)
• Do you wear dentures?
• What have you tried that helps?
• Are there problems with the teeth, gums, lips, or throat?
• Does the tongue bleed?
• Do you have a rash or fever?
• Do you have allergies?
• Are there problems with speaking or moving the tongue?
• Have you noticed changes in taste?
• What medications do you take?
• Do you smoke cigarettes, cigars, or a pipe?
• Do you use alcohol excessively?

Blood tests may be done to confirm specific disorders, particularly systemic causes of tongue disorders. Biopsy of tongue lesions may be needed in some cases.

Treatment depends on the cause of the tongue problem.

• If nerve damage has causes a tongue movement problem, the underlying condition must be treated. Therapy may be needed to improve speech and swallowing ability.
• Ankyloglossia may not require treatment unless you have speech or swallowing difficulties. Surgery to release the tongue can relieve the problem.
• Medicine may be prescribed for mouth ulcers, leukoplakia, oral cancer, and other mouth sores.
• Anti-inflammatory medicines may be prescribed for glossititis and geographic tongue.

This list is not all inclusive. For more details, see the specific disorder.

References

Rakel P, ed. Conn’s Current Therapy 2006. 58th ed. Philadelphia, Pa: WB Saunders; 2005:1038.

McKenna JK. Dermatologic drug reactions. Immunol Allergy Clin North Am. Aug 2004; 24(3): 399-423, vi.

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Definition

Toothpaste is a product used to clean teeth. This article discusses the effects of swallowing a lot of toothpaste.

This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.

Poisonous Ingredient

• Sodium fluoride
• Triclosan

Where Found

• Various toothpastes

Symptoms

Swallowing a large amount of regular toothpaste may cause stomach pain and possible intestinal blockage.

These additional symptoms may occur when swallowing a large amount of toothpaste containing fluoride:

• Convulsions
• Diarrhea
• Difficulty breathing
• Drooling
• Heart attack
• Salty or soapy taste in the mouth
• Slow heart rate
• Shock
• Tremors
• Vomiting
• Weakness

Home Care

Do NOT make a person throw up unless told to do so by poison control or a health care professional. Seek immediate medical help.

If the product was swallowed, immediately give the person water or milk, unless instructed otherwise by a health care provider. Do NOT give water or milk if the patient is having symptoms (such as vomiting, convulsions, or a decreased level of alertness) that make it hard to swallow.

Before Calling Emergency

Determine the following information:

• The patient’s age, weight, and condition
• The name of the product (as well as the ingredients and strength, if known)
• The time it was swallowed
• The amount swallowed

Poison Control

The National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.

This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.

Take the container with you to the hospital, if possible.

See: Poison control center – emergency number

What to Expect at the Emergency Room

People who swallow regular (nonfluoride) toothpaste may not need to be seen in the emergency room.

Those who swallow a lot of fluoride toothpaste (more than one tube) may need to go to the emergency room.

At the emergency room, the health care provider will measure and monitor the patient’s vital signs, including temperature, pulse, breathing rate, and blood pressure. The patient may receive:

• Calcium — medicine (antidote) to reverse the effect of the poison
• Endoscopy — camera down the throat to see burns to the esophagus and the stomach
• Fluids by IV
• Medicines to treat symptoms
• Tube through the mouth into the stomach to wash out the stomach (gastric lavage)

Outlook (Prognosis)

Patients who swallow a very large amount of fluoride toothpaste and survive 48 hours usually recover. See also: Fluoride overdose

Most nonfluoride (regular) toothpastes are relatively nontoxic (nonpoisonous). Recovery is very likely.

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Definition

A gum biopsy is a surgery in which a small piece of gingival (gum) tissue is removed for examination.

Alternative Names

Biopsy – gingiva (gums)

Why the Test is Performed

This test is done to determine the cause of abnormal gum tissue.

How the Test is Performed

A painkiller is sprayed into the mouth in the area of the abnormal gum tissue. In some cases, a numbing shot may be used. A small piece of the gum tissue that appears abnormal is removed and checked for problems in the laboratory.

How to Prepare for the Test

There is no special preparation, although you may be told not to eat for a few hours before the biopsy.

How the Test Will Feel

The topical anesthetic should numb the area during the procedure, although some tugging or pressure may be felt. If there is bleeding, the blood vessels may be sealed off with an electric current or laser. This is called electrocauterization. After the numbness wears off, the area may be sore for a few days.

Risks

• Bleeding from the biopsy site
• Infection of the gums
• Soreness

Considerations

Avoid brushing the biopsy area for 1 week.

Normal Results

This test is only performed when there is an abnormality.

What Abnormal Results Mean

• Thrombotic thrombocytopenic purpura (TTP)
• Amyloid
• Oral cancer (for example, squamous cell carcinoma)
• Noncancerous mouth sores (the specific cause can be determined in many cases)

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