Highlights

New Research

• A new study published in July 2008 found a definite connection between smoking in the first trimester of pregnancy and an increased risk of having a baby with cleft lip (a split lip that has not closed during development).
• A 2008 analysis of 106 past studies found that smoking clearly increases the risk of colorectal cancer. The connection was stronger for rectal cancer than for colon cancer.
• Research published in February 2008 found that smokers were more at risk of developing aggressive colon polyps, which are considered precursors to colon cancer.

Medication Warning

• Chantix is a pill designed to help people stop smoking. In February 2008 the Food and Drug Administration (FDA) required that a new warning to be added to the Chantix prescribing information. The warning concerns serious mental health problems that may occur with this medication, including thoughts of suicide or actual suicide attempts.

Risk Factors

• Neglected children, or children with absentee parents, are four times as likely to abuse drugs, drink, and smoke as children living with parents who were regularly present and who offered a structured lifestyle.
• People who have not graduated from high school or received their General Education Development (GED) certificate tend to have higher smoking rates than those who attended college.
• Men and women with mental disorders are 50% more likely to smoke than those without such illness.
• The rate of smoking is highest in the Midwest and South and lowest in the Northeast and West.

Introduction

Nearly 20% of adults in the United States smoke, according to a 2008 report by the U.S. Centers for Disease Control and Prevention (CDC). More than 77% of them smoke every day. Smoking had steadily declined among adults in recent years; though the trend has stalled between 2004 and 2006, according to the latest CDC report there was a 1% drop in smoking prevalence among U.S. adults in 2007.

The addictive effects of tobacco have been well documented. Tobacco is considered to be a mood and behavior altering substance that is psychoactive and abusable. Tobacco is believed to be as potentially addictive as alcohol, cocaine, and morphine. Tobacco and its various components increase the risk of cancer (especially in the lung, mouth, larynx, esophagus, bladder, kidney, colon, pancreas, and cervix), heart attacks, strokes, and chronic lung disease.

Smoking in Childhood and Adolescence

The younger children start smoking, the more likely they will smoke as adults. Smoking is often rapidly addictive. According to the American Cancer Society, the earlier you start smoking, the more likely you are to develop long-term nicotine addiction.

In the past, advertising was responsible for encouraging some teens to smoke. New regulations have made it much more difficult for advertisers to promote smoking to young people. However, scenes that show people smoking, often in a positive light, are still common in movies and television shows. This may be a major influence on the attitude toward smoking in children and adolescents.

To prevent children from smoking, parents should not smoke, and they should tell their child that they disapprove of smoking. Studies have shown that schoolchildren who believed that both their parents strongly disapproved of smoking were less than half as likely to smoke as those kids whose parents did not show as much disapproval towards smoking.

Children whose parents closely monitor their television and music-listening habits are less likely to drink, use drugs, and smoke cigarettes.

Neglected children, or children with absentee parents, are four times as likely to abuse drugs, drink, and smoke as children living with parents who were regularly present and who offered a structured lifestyle.

Doctors can have a major effect on young people. However, in one survey, less than half of teenagers had ever been asked by their doctors if they smoked, or were counseled not to smoke, even though most teen smokers said they would admit to it if asked.

Gender, Age, and Ethnicity

While the number of adults over 65 who smoke is lower than those in other age groups, older adults usually have smoked for a long time (about 40 years) and tend to be heavier smokers, according to the American Lung Association. Because of this, older smokers are more likely to have smoking-related illnesses.

Caucasian students (under age 18) are more likely to smoke than Hispanics and African-Americans. In 2007, the rate of smoking was highest among American Indians and Alaskan natives. Hispanics and Asians had the lowest rates.

Geography

In general, the rate of smoking is highest in the Midwest and South and lowest in the Northeast and West. Utah has the lowest rate of smoking in the United States.

Educational Level

A major U.S. government study reported that people who have not graduated from high school or received their General Education Development (GED) certificate tend to have higher smoking rates than those who attended college.

Higher rates of cigarette smoking have been reported among adults who have earned a GED and those with a 9 – 11 grade education. The lowest rates are seen among those with advanced college degrees.

Psychological Factors

People with low self-esteem and adolescents with behavioral problems have a higher risk for smoking. Men and women with mental disorders are 50% more likely to smoke than those without such illness. For example, depression and schizophrenia are known risk factors for smoking. Both may actually have biological effects that are responsible for this higher risk.

Smoking Among Persons with Disabilities

Smoking is much more common among persons with disabilities than those without emotional, mental, or physical limitations. A 2007 Centers for Disease Control study found that the rate of smoking is nearly 50% higher among persons with disabilities. The CDC survey included those with mental illness and drug and alcohol addictions in the disabled group.

Genetic Factors

Evidence now strongly supports the idea that genes play a role in a person’s dependence on nicotine. Researchers are now targeting specific genes that may be responsible for nicotine dependence. So far, research has been shown that there is a common genetic vulnerability to both nicotine and alcohol dependence.

Economic Factors

Some studies suggest that the cheaper it is to buy cigarettes and smoke, the more widespread smoking will be. For example, states that have low taxes on cigarettes have a high proportion of smokers. Making it more expensive to smoke may reduce the number of smokers.

Nicotine Addiction

Nicotine is the chemical in cigarettes that makes them addictive. Higher levels of nicotine in a cigarette can make it harder to quit smoking. A report by the Massachusetts Department of Health found that the amount of nicotine in cigarettes has steadily increased over the last 6 years. (Massachusetts is one of several states that require tobacco manufacturers to submit yearly reports regarding cigarettes.) Higher nicotine levels were found in all cigarette categories, including “light” brands.

Some researchers feel nicotine is as addictive as heroin. In fact, nicotine has actions similar to heroin and cocaine, and the chemical affects the same area of the brain.

Depending on the amount taken in, nicotine can act as either a stimulant or a sedative. Cigarette smoking has definite immediate positive effects. For example, it can:

• Boost mood and relieve minor depression
• Suppress little fits of anger
• Enhance concentration and short-term memory
• Produce a modest sense of well-being

Most smokers have a special fondness for the first cigarette of the day because of the way brain cells respond to the day’s first nicotine rush. Nicotine, particularly taken in the first few cigarettes of the day, increases the activity of dopamine, a chemical in the brain that elicits pleasurable sensations, a feeling similar to getting a reward.

Over the course of a day, however, the nerve cells become desensitized to nicotine. Smoking becomes less pleasurable, and smokers may be likely to increase their intake to get their “reward.” A smoker develops tolerance to these effects very quickly and requires increasingly higher levels of nicotine.

Smokeless Tobacco

Smokeless tobacco, also called spit tobacco, includes chewing tobacco (dip and chew), tobacco powder (snuff), as well as flavored tobacco lozenges. These products also contain nicotine.

Smokeless tobacco products allow tobacco to be absorbed by the digestive system or through mucous membranes. Smokeless tobacco contains at least 28 cancer-causing substances, and is not a safe substitute for smoking cigarettes or cigars. According to the National Institutes of Health, chewing on an average-size piece of chewing tobacco for 30 minutes can deliver as much nicotine as smoking three cigarettes.

Although research is inconsistent, some evidence suggests that smokeless tobacco produces an increase in the risk of oral cancer, gingivitis, and tooth loss. A recent review of existing literature found that while the risk of cancer in people using smokeless tobacco is lower than that of smokers, it is still higher than that of people who do not use tobacco at all.

Health Risks

Smoking — even just a few cigarettes a day — has been linked to many serious health risks. Some are listed below.

Effects on the Lungs

According to the American Lung Association, smoking is directly responsible for about 90% of the deaths due to lung cancer. Smoking is also responsible for the majority of deaths due to chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.

Cardiovascular Effects

All forms of tobacco raise the risk of heart attacks. Smoking, chewing tobacco, and being exposed to secondhand smoke greatly increase the risk of a heart attack. In some cases, the risk of heart problems in people who smoke or are exposed to smoke may be three times greater. The risk of a heart attack among those who stopped smoking may slowly decrease over time.

Effects on Male Fertility and Erectile Dysfunction

Smoking can harm a man’s sexuality and fertility. Heavy smoking is frequently cited as a contributory factor in erectile dysfunction because it decreases the amount of blood flowing into the penis.

Smoking impairs sperm motility, reduces sperm lifespan, and may cause genetic changes that can affect a man’s offspring. One trial found that men or women who smoke have lower success rates with fertility treatments. An earlier study reported that men who smoke also have lower sex drives and less frequent sex.

Effects on Female Infertility, Pregnancy, and Childbirth

Studies have linked cigarette smoking to many reproductive problems. Continuing to smoke during pregnancy may also cause health problems in the baby.

Negative effects of smoking on female fertility include:

• Greater risk for infertility. Women at greatest risk for fertility problems are those who smoke one or more packs a day and who started smoking before age 18.
• Earlier menopause. Women who smoke tend to start menopause at an earlier age than nonsmokers, perhaps because toxins in cigarette smoke damage eggs.
• Pregnancy complications. Women who smoke have a greater risk for ectopic pregnancy and miscarriage.

Effects on the Unborn Child. Smoking during pregnancy increases the risk for stillbirth, prematurity, and low birth weight in their babies. Women who smoke during pregnancy have lower levels of folate, a B vitamin that is important for preventing birth defects.

Children of mothers who smoke during pregnancy may also be at increased risk for obesity and diabetes.

A new study published in July 2008 found a definite connection between smoking in the first trimester of pregnancy and an increased risk of having a baby with cleft lip (a split lip that has not closed during the fetus’ development).

Some women have particular genes that may make them especially likely to deliver low birth weight infants if they smoke, although newborns of all female smokers have a greater risk for low weight. The good news is that women who stop smoking before becoming pregnant, or even during the first trimester, reduce the risk for a low birth weight baby to that of women who never smoked.

Women who want to become pregnant should make every attempt to stop smoking, and should use smoking cessation aids before they try to conceive. After birth, if new mothers cannot quit, they should at least be sure not to smoke in the same room as their infant.

Effects on Bones and Joints

Smoking has many harmful effects on bones and joints:

• Smoking can slow the process that adds calcium to bones, making them stronger. Women who smoke are at high risk for loss of bone density and osteoporosis.

• Postmenopausal women who smoke have a significantly greater risk for hip fracture than those who do not.
• Men who smoke may have more severe symptoms of knee arthritis, according to a study published in the Annals of Rheumatic Disease.
• Smokers are more apt to develop degenerative disorders and injuries in the spine.
• Smokers have more trouble recovering from surgeries.
• Smokers whose jobs involve lifting heavy objects are more likely to develop low back pain than nonsmokers.

Smoking and Diabetes

Smoking may increase the risk of developing diabetes or glucose intolerance, a condition that precedes diabetes.

Smoking and the Gastrointestinal Tract

Smoking increases acid production in the stomach. It also reduces blood flow and production of compounds that protect the stomach lining.

Inflammatory Bowel Disease. Smoking has mixed effects on inflammatory bowel disease, the collective term for ulcerative colitis and Crohn’s disease. Smokers have been shown to have lower than average rates of ulcerative colitis, but higher than average rates of Crohn’s disease. Smokers with Crohn’s disease who stop smoking are said to have less severe symptoms.

Colorectal cancer. Smoking clearly increases the risk of colorectal cancer and aggressive adenomatous colon polyps, which are considered precursors to colon cancer. The connection is stronger for rectal cancer than for colon cancer.

Hepatitis and Cirrhosis. Smoking is linked to increased liver scarring (cirrhosis) caused by either excessive drinking or chronic hepatitis B or C viruses.

Smoking and Thyroid Disease

Cyanide, a chemical found in tobacco smoke, interferes with thyroid hormone production. Smoking triples the risk for developing thyroid disease, particularly hyperthyroidism and hypothyroidism. Women smokers with subclinical hypothyroidism (a symptom-free condition in which the thyroid gland is mildly underactive) have a higher risk for developing full-blown hypothyroidism than their nonsmoking peers. Smoking has also been linked to goiter, a swelling of the thyroid that occurs in people who do not get enough iodine.

Smoking and Surgical Recovery

Smokers are at increased risk for heart and circulatory problems and delayed wound healing after surgery. In one study, patients who were able to cut down or quit smoking 6 – 8 weeks prior to knee or hip replacement surgery were much less likely to suffer complications.

Smoking and Age-Related Disorders

The following age-related conditions are thought to occur at higher rates in smokers than nonsmokers:

• Cataracts. Quitting smoking reduces your chances of needing cataract surgery in the future, although not to the level seen with nonsmokers.

• Age-related macular degeneration (AMD). AMD is a leading cause of blindness in older people. Symptoms of macular degeneration include a loss of central vision, which makes it difficult to read.
• Gum disease and tooth loss. A government study found that more than half of the cases of severe gum disease in adults in the United States may be due to cigarette smoking.
• Wrinkles. Studies confirm that smokers are nearly five times more likely to develop more and deeper wrinkles as they age compared to nonsmokers.
• Baldness and premature gray hair. Certain chemicals in smoke break down in hair cells, which leads to hair damage.
• Hearing loss, particularly high-frequency hearing loss.
• Incontinence.

Secondhand Smoke

Secondhand smoke is produced by a burning cigarette or other tobacco product. An estimated 4 million children a year get sick from being around secondhand smoke. Parental smoking has been shown to affect the lungs of infants as early as the first 2 – 10 weeks of life, and such abnormal lung function could persist throughout life.

Exposure to secondhand smoke in the home increases the risk for asthma and asthma-related emergency room visits in children who have existing asthma.

Parental smoking is believed to increase the risk for lower respiratory tract infections (such as bronchitis or pneumonia) by 50%. Environmental exposure to smoke is thought to be responsible for 150,000 – 300,000 such cases every year.

Smoking Bans

More and more households in the United States are banning smoking. The U.S. Centers for Disease Control and Prevention (CDC) reports that 75% of households now forbid smoking at any time or place in the home.

Smoking bans have spread across the country. By December 2007, at least 25 states and the District of Columbia have passed some type of law banning smoking in almost all public places and workplaces, including restaurants and bars. The date an individual state’s ban takes effect varies greatly; some do not take effect until 2009.

Quitting Smoking

It’s never too late to quit smoking. According to the American Cancer Society, about half of all smokers who keep smoking will die from a smoking-related disease. Quitting has immediate health benefits.

According to the National Institutes of Health, about 40% of smokers who want to quit make a serious attempt to do so each year, but fewer than 5% actually succeed. A June 2006 report published by the NIH says that the available smoking cessation products and therapies are greatly underused. If more smokers asked for or were offered such help, the agency says quit rates could double or triple.

Some people have certain genes that make quitting easier. Researchers at Duke University have identified more than 200 genes that distinguish those who have successfully quit smoking. It is the first time such genes have been identified. The findings could lead to new smoking cessation therapies that target a person’s specific genetic makeup.

Methods of quitting smoking include counseling and support groups, nicotine patches, gums, lozenges, and sprays, smoking cessation pills, and slowly cutting back on the number of cigarettes smoked (incremental reduction).

Nicotine Replacement Therapy

Nicotine replacement therapy involves the use of products that provide low doses of nicotine that do not contain the contaminants found in smoke. The goal of therapy is to relieve cravings for nicotine and ease the symptoms of withdrawal.

In general, nicotine replacement therapy benefits moderate-to-heavy smokers the most. However, it does appear somewhat helpful for light smokers (people who smoke fewer than 15 cigarettes a day).

Nicotine Patches. Nicotine patches deliver nicotine through the skin. This is called transdermal nicotine delivery. It is effective in reducing symptoms during withdrawal. Nicotine patches are available over the counter.

Patches may work in different ways:

• Step-Down Approach. Patches that use this method include NicoDerm CQ. The patches come in three strengths (21, 14, and 7 mg). You use the strongest dose first and reduce it gradually over a period of 8 – 10 weeks. A 21 mg patch is about equal to 15 cigarettes. A heavy smoker may need to wear two patches at first.
• Single-Step Approach. The single-step patch (Nicotrol) can be taken off after 16 hours and replaced 8 hours later. It can be used for only 6 weeks.

Patches are applied and used in similar ways:

• A single patch is worn each day and replaced after 24 hours.
• To avoid skin irritation it is applied to different hairless locations above the waist and below the neck each day.
• People can wear the patches for 24 hours, but some have reported odd dreams and have disliked the sensation of the patch during the night. People who wear the patch all the time, however, have fewer withdrawal symptoms and slightly better abstinence rates than those who take it off at night.
• Patches should be stored and discarded safely, particularly in homes with small children. Small children have been poisoned and gotten sick from wearing, chewing, or sucking on nicotine patches. There have been no reports of death from children who have been poisoned.
• The FDA recommends using the patches for 3 – 5 months, although some studies suggest that using them for 8 weeks achieves the maximum benefits.

Children should not come in contact with the patches, even while the smoker is wearing them. If the child has worn the patch, the affected skin should be washed right away. Urgent medical care may be required if the child has eaten nicotine or worn a patch for a prolonged time.

Nicotine Gum. Nicotine gum (Nicorette) is available over the counter and has helped many people quit. Some prefer it to the patch because they can control the nicotine dosage, and chewing satisfies the oral urge associated with smoking.

Tips for using the gum:

• If you are just starting to quit, chew 1 – 2 pieces each hour. A smoker should not chew more than 20 pieces a day.
• The goal is to stop using the gum by 6 months, but about 3% of people continue to use it long after they have quit smoking.
• The gum must be chewed slowly until it develops a peppery taste. It is then tucked between the gum and cheek where it is stored so that the nicotine can be absorbed.
• Coffee, tea, soft drinks, and acidic beverages may interfere with nicotine absorption, so people should wait at least 15 minutes after drinking before chewing a piece of gum.

Some people prefer other methods or cannot use the gum for the following reasons:

• They find the taste of the gum unpleasant.
• Side effects specific to the gum may include upset stomach, mouth ulcers, hiccups, and throat irritation.
• They are embarrassed by chewing gum.
• They wear dentures.

Long-term dependence may be a problem with the gum. Although such dependence is probably safer than smoking, research is needed to confirm this, and experts recommend people chew gum for no more than 6 months.

The Nicotine Inhaler. The nicotine inhaler resembles a plastic cigarette holder. It comes with a number of nicotine cartridges, which are inserted into the inhaler and “puffed” for about 20 minutes, up to 16 times a day. The dose is gradually decreased. It requires a prescription in the United States. Several studies have reported that the inhaler triples abstinence rates (between 17 – 28%) compared with placebo (6 – 9%) after 6 months. It has some specific advantages over other nicotine replacement products:

• The inhaler provides varying doses of nicotine on demand (as opposed to continuously with the patch or the gum) and is relatively fast-acting. Blood nicotine levels peak about 20 minutes after using the inhaler, comparable to the gum and faster than the 2 – 4 hours seen with the patch.
• It satisfies oral urges.
• Most of the nicotine vapor is delivered in the mouth, not into the lung airways (although some people experience mouth or throat irritation and cough).

Using a combination of the inhaler and the patch may be particularly effective.

The Nicotine Nasal Spray. The nasal spray satisfies immediate cravings by providing doses of nicotine rapidly and thus may play a useful role in conjunction with slower-acting nicotine replacement therapies. (Nicotine levels peak within 5 – 10 minutes after administering the spray). The spray can irritate the nose, eyes, and throat, so it may not be suitable for those with allergies or sinus infections. Most people, however, can tolerate the side effects, which usually go away within the first few days.

Nicotine Lozenge. A nicotine lozenge (Commit) is available over the counter. It is made from pressed tobacco and comes in two strengths for heavier or lighter smokers..Side effects included heartburn, hiccups, nausea, headaches, and cough. The Commit lozenge also contains phenylalanine, a chemical that certain people may need to avoid.

Facts about Nicotine Replacement Therapy:

• Not cheating on the very first day of nicotine-replacement use increases the chance of quitting permanently by tenfold.
• The more cigarettes a patient smokes, the higher the dose of nicotine replacement that may be required at the start.
• Adding a counseling program may boost the effect of any nicotine replacement program.
• Do not smoke while using nicotine replacement. It can cause nicotine to build up to toxic levels.
• Nicotine replacement helps prevent weight gain while it is being used, but people are still at higher risk for gaining weight when they stop all nicotine.

Side Effects. Side effects of any nicotine replacement product may include headaches, nausea, and other gastrointestinal problems. People often experience sleeplessness in the first few days, particularly with the patch, but the insomnia usually passes. Patients using very high doses are more likely to have symptoms. Reducing the dose can prevent them.

Special Concerns for Specific Individuals. There has been some concern that the patch might be harmful for people with heart or circulatory disease, but studies are finding that it poses no danger for these individuals. In fact, it may help reduce angina attacks brought on by exercise. However, unhealthy cholesterol levels (lower HDL levels) caused by smoking remain abnormal with use of the nicotine patch. HDL levels improve when all nicotine is stopped.

Nicotine replacement may not be completely safe in pregnant women, although it has been used successfully in this group without ill effect. There is an increase in heart rates in unborn children of women who use the patch as compared with those who smoke.

Keep all nicotine products away from children. Nicotine is a poison. All nicotine products should be kept safely away from small children. A parent should call a physician or a poison control center immediately if a child has been exposed to a nicotine replacement product, even for a short duration. Parents should also call the doctor if a small child has been exposed to a nicotine product and has any symptoms, including stomach upset, irritability, headaches, a rash, or fatigue.

Warnings Against Long-Term Use. No one should use nicotine replacement therapies as a long-term substitute for smoking. Any nicotine replacement therapy should be temporary. In one study, use of nicotine gum for more than a year was associated with insulin resistance, an abnormality that occurs in diabetes. Some studies have now suggested that nicotine itself may have properties that increase the risk for cancer, independent of carcinogenic chemicals in smoke. More studies are needed.

Smoking Cessation Pills

Antidepressants. The tricyclic antidepressant nortriptyline (Pamelor, Aventyl) may help reduce nicotine action. Quit rates with either of these medicines are as high as 30%. Long-term abstinent rates are more than twice those of placebo. Most other antidepressants, including fluoxetine (Prozac), have no additional benefits for smokers.

Nortriptyline has been specifically studied for helping smokers. It is best to start taking the medication 10 – 28 days before your intended quit date. Studies have reported quit rates of 14 – 24%. Side effects of nortriptyline include dry mouth and changes in taste. It should be noted that in rare cases, tricyclics can have serious side effects, and overdose can be deadly. Tricyclics may pose a danger for some patients with certain types of heart disease.

Bupropion (Zyban, Wellbutrin) is a type of antidepressant that is also an FDA-approved product for smoking cessation. It differs from most other antidepressants because it increases the effects of dopamine, the brain chemical that appears to play a strong role in nicotine addiction. Using Zyban along with nicotine replacement therapy may help you better control cigarette smoking cravings. Zyban does not contain nicotine. In most cases, Zyban is started a week or two before quitting, and must be taken for 7 – 12 weeks. The usual maintenance dose is 150 mg tablet twice a day. No single dose should be higher than 150 mg.

Side effects of bupropion include gastrointestinal problems, headaches, insomnia, dry mouth, and irritation. In very rare cases, seizures have occurred, although usually in people who exceeded the recommended dose or who already had risk factors for seizures.

Varenicline. A newer drug called varenicline (Chantix) may significantly reduce cigarette cravings and may work better than Zyban. The FDA approved Chantix as a smoking cessation aid in May 2006. It is for use in cigarette smokers age 18 and older. It should not be combined with nicotine replacement therapy.

Warning about Chantix: As of February 2008, the FDA instructed that Chantix carry a warning regarding serious mental health side effects that may occur while using the medication, or immediately after stopping it. These uncommon but potentially serious side effects include “changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior.” People taking Chantix, as well as their family members, should be aware of these potential dangers and report any symptoms to their doctor immediately.

Behavioral Methods and Counseling

Everyone who quits should aim to quit completely. Most people who return to smoking “cheat” in the first few weeks. Quitting completely is essential to regain good health and reverse bad effects caused by smoking. Reducing smoking, even by half, does not eliminate the risk for cancer and other health problems. Although smokers take in less smoke and nicotine, the body is still unable to heal itself from the ongoing intake of toxins. It should also be noted that changing to low-tar cigarettes is not a solution. In fact, smokers of these cigarettes tend to inhale deeper, perhaps even increasing health risks.

Create a List

Write down 10 reasons to quit. In addition to health reasons, the list might include having better smelling hair, clothes, and breath; having fewer wrinkles; enjoying the taste of food; and saving money. Read the list often during the quitting process to help stay motivated.

Decide on a Specific Quit Date

Some people find it helpful to choose a particular date to quit when little or no stress is anticipated for at least the first 3 days. Women affected by PMS should avoid quitting right before getting their period. It may help to write out a quit contract, putting the date on paper, and getting a friend to sign it. Discard all smoking paraphernalia on the eve before the quit date, and make plans to stay busy on the day itself, and especially at night, when the urge to smoke will be high.

Make an Oath

Take an extreme oath. For example, “If I smoke one more cigarette my dog will die.” Although this seems absurd, some people, even well-educated individuals, who have failed all other methods have reported that they quit completely and successfully after taking such an oath.

Let the Body and Mind Heal During Withdrawal

• Retreat from the world when cravings become overwhelming. Take naps, warm baths or showers, meditate, or read novels.
• Help your body get rid of nicotine. Drink plenty of water; eat fresh fruits, vegetables, whole grains, and fiber-rich foods. Carrots, apples, and celery are good munching foods.
• When cravings occur, hold your breath as long as possible or take a few deep rhythmic breaths.
• Use meditation or relaxation and deep breathing exercises. In fact, taking deep breaths when the urge to smoke occurs is a good stopgap measure.

Get Family and Friends Involved

• Tell all your friends and family that you’ve already quit, so you’ll be embarrassed if they catch you smoking.
• Pay a family member or friend if they catch you smoking. The amount should be large enough ($5 – 20) to be a deterrent, but not so large as to be ridiculous.
• If your partner or friend smokes, try persuading them to quit or, at the very least, not to smoke around you and others.

Exercise

Studies continue to show that smokers who exercise can greatly increase their ability to quit smoking while reducing their risk for weight gain. Move the muscles when cravings occur. Dance, run, walk, jump up and down, stretch, do push-ups. Yoga is an excellent exercise program for quitting. Older people and anyone with health problems should consult their health care provider before starting such a program.

Maintain a Healthy Diet

• Eat plenty of fresh, crunchy fruits and vegetables. This is also a useful way of satisfying oral cravings without adding many calories.
• Drink plenty of water and healthy beverages.
• Moderate intake of coffee or tea may be helpful in preventing weight gain. and may also have antidepressant properties. Avoid caffeine in the evening, however, since sleep disturbances can be a problem during withdrawal.

Change Daily Habits

• Change your daily schedule, particularly eating times, as much as possible. Eat at different times or eat many small meals instead of three large ones. Sit in a different chair or even a different room.
• If you smoke after eating, find other ways to end a meal. Play a tape or CD, eat a piece of fruit, get up and make a phone call, or take a walk (a good distraction that burns calories as well). For example, if you normally have a cigarette with coffee, drink tea instead or use a different cup.
• Substitute oral habits by eating celery, chewing sugarless gum, sucking on a cinnamon stick, or carrying worry beads.
• Go to public places and restaurants where smoking is prohibited or restricted.
• Set short-term quitting goals and reward yourself when they are met.
• Every day put the money normally spent on cigarettes in a jar and buy something pleasurable at the end of a predetermined period of time.
• Find activities that focus the hands and mind but are not taxing or fattening: Computer games, solitaire, knitting, sewing, whittling, and crossword puzzles.

About 4% of smokers who quit without any outside help succeed. Nevertheless, most people try to quit alone, and many have reported activities that can help the process of withdrawal. The primary obstacle in trying to quit alone is making the behavioral changes necessary to eliminate the habits associated with smoking. Excellent books, tapes, and manuals are available and are strongly recommended to help people who want to quit without other assistance.

Smokers who use outside help have the best record for quitting, with success rates of 25 – 35%. Those who are counseled in addition to using nicotine replacement and Zyban have the best chance. Brochures, audio tapes, and other self-help materials are often ineffective when used alone, but may be helpful in conjunction with a counseling program.

Types of Behavioral Approaches

Problem Solving or Coping Strategies. Smokers more likely to quit smoking when they learn thinking (cognitive) and behavioral techniques for breaking the link between certain cues and smoking, stress management techniques, and ways to handle the symptoms of withdrawal and the urge to relapse. The more intense the counseling program, the better. Smokers should look for programs that offer the following:

• Session lengths of 20 – 30 minutes
• Four to seven sessions
• A 2-week program
• Additional 2 weeks or more of follow-up contact

The Staged Approach. The intent of the staged approach is to plan quitting interventions customized for each individual rather than imposing some general method for quitting. The approach takes the smoker through six stages with behavioral interventions at each point:

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination

Most studies of this approach, however, were weak, and better research is needed on its benefits.

People who follow this approach do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal — if you tried quitting in the past and didn’t stick with it, don’t consider yourself a failure. Just try again.

Stage 1: Pre-Contemplation.

People at this stage have no plans or desire to stop smoking. They aren’t even considering quitting. People at this stage are generally unaware of the specific benefits that quitting can bring. Or, they may simply have “failed” in the past and have given up. There’s no point in talking about how to start a cessation program at this stage. Instead, it is important to think about how quitting will help you feel better, have more confidence, or live longer. The benefits must be identified before a person will consider quitting. If you are at this stage, a good activity is to ask several friends or family members why they quit.

Stage 2: Contemplation.

A person at this stage is thinking, “I think I should probably quit, but I need help getting started.” People at this stage know that quitting is good for them, but it seems like a daunting task or they don’t think they can pull it off. Some may have tried and failed in the past. It’s important for people at this stage to consider some of the truths and falsehoods of quitting. If you are at this stage, write down (brainstorm) all your potential roadblocks — the things that you believe make quitting difficult — and learn strategies for overcoming or side-stepping those hurdles. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. The goal is to identify the roadblocks and ways to overcome these hurdles, and make a commitment to quitting.

Stage 3: Preparation.

Smokers at this stage are ready to quit. The goal of this stage is to create a specific action plan that takes all factors into account, so that quitting is successful. People at this stage need to know what methods work and what support exists to help them. If you are at this stage, you should consider some backup plans — what to do when the urge to smoke hits you.

Stage 4: Action!

People at this stage have just quit. This stage is where the most behavioral change occurs. It requires significant commitment and energy. If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. Having a fellow smoker quit with you can be a huge support as you both get through this stage.

Stage 5: Maintenance.

People at this stage have been smoke-free at least 6 months. The goal now is to prevent relapse. If you are at this stage, continue to be wary of roadblocks and keep reminding yourself of the benefits you have gained. Think about what you have found most enjoyable about being smoke-free.

Alternative Methods for Quitting

Hypnosis. Although rigorous studies are lacking, some people report successful cessation from smoking when hypnosis is given in individual sessions. The process is effective only if you trust the therapist and can feel completely at ease in the vulnerable and passive state necessary for hypnotic suggestion.

During a typical session, the hypnotherapist will use various techniques (such as imagery, silent counting) to put you in a relaxed state.

When you are very relaxed, but not asleep, the hypnotherapist quietly suggests motivations for not smoking. The hypnotherapist should also reinforce a positive self-image while you are in deep relaxation. This helps many people avoid the depression that accompanies withdrawal.

The sessions usually take about 1 hour.

You should be taught methods of self-hypnosis to use at home, and follow-up once to reinforce what you’ve learned.

Acupuncture and Acupressure. The acupuncture technique for quitting smoking usually uses very tiny curved staples inserted into three different points around the edge of the ear. The procedure is painless. You will be told to press each staple in a certain order for a few seconds whenever the craving for a cigarette occurs. The acupuncturist may also use acupuncture points elsewhere on the body. There are no side effects except for some soreness if the acupuncture staple is pressed too hard.

A related technique called acupressure involves simply pressing select points on the body when a craving hits. Some studies have reported good quit rates with acupuncture, but few rigorous studies have been conducted using this approach.

Public Health Efforts and Social Pressure (Denormalization)

Denormalization is the idea that smoking is no longer normal. This concept of denormalization is best instituted by laws and local regulations making smoking inaccessible in public places, raising prices, and putting stricter limitations on cigarette advertising.

Increasing taxes on cigarettes may be one of the most important methods for reducing smoking in the population, particularly in younger people.

Evidence suggests that banning smoking in work and public places may be leading to a higher quit rate than in places where smoking is permitted.

Denormalization can also work on a personal level. A British study showed that when one spouse makes healthy changes, including quitting smoking, the other one follows. In couples where smoking continues, it usually continues in both.

Symptoms of Withdrawal

After you quit smoking, you with have some withdrawal symptoms. Such symptoms generally peak in intensity 3 -5 days after you quit, and usually disappear after 2 weeks, although some may persist for several months.

The symptoms of withdrawal include both physical and mental difficulties.

Physical Symptoms.

• Tingling in the hands and fe
  

Definition

Various types of sores can appear anywhere within the mouth, including the inner cheeks, gums, tongue, lips, or palate.

Alternative Names

Aphthous stomatitis

Causes

Most mouth sores are cold sores (also called fever blisters), canker sores, or other irritation caused by:

• Biting your cheek, tongue, or lip
• Chewing tobacco
• Braces
• A sharp or broken tooth or poorly fitting dentures
• Burning your mouth from hot food or drinks

Cold sores are caused by herpes simplex virus and are very contagious. Usually, you have tenderness, tingling, or burning before the actual sore appears. Herpes sores begin as blisters and then crust over.

The herpes virus can reside in your body for years, appearing as a mouth sore only when something provokes it. Such circumstances may include another illness, especially if there is a fever, stress, hormonal changes (such as menstruation), and sun exposure.

Canker sores are NOT contagious and can appear as a single pale or yellow ulcer with a red outer ring, or as a cluster of such lesions. The cause of canker sores is not entirely clear, but may be related to:

• A virus
• A temporary weakness in your immune system (for example, from cold or flu)
• Hormonal changes
• Mechanical irritation
• Stress
• Low levels of vitamin B12 or folate

For unknown reasons, women seem to get canker sores more often than men. This may be related to hormonal changes.

Less commonly, mouth sores can be a sign of an underlying illness, tumor, or reaction to a medication. Such potential illnesses can be grouped into several broad categories:

• Infection (such as hand-foot-mouth syndrome)
• Autoimmune diseases (including lupus)
• Bleeding disorders
• Malignancy (cancer)
• Immunosuppression (that is, when your immune system is weakened — for example, if you have AIDS or are receiving medication after a transplant).

Drugs that might cause mouth sores include chemotherapeutic agents for cancer, aspirin, barbiturates (used for insomnia), gold (used for rheumatoid arthritis), penicillin, phenytoin (used for seizures), streptomycin, or sulfonamides.

Home Care

Mouth sores generally last 10 to 14 days, even if you don’t do anything. They sometimes last up to 6 weeks. The following steps can make you feel better:

• Gargle with cool water or eat popsicles. This is particularly helpful if you have a mouth burn.
• Avoid hot beverages and foods, spicy and salty foods, and citrus.
• Take pain relievers like acetaminophen.

For canker sores:

• Rinse with salt water.
• Apply a thin paste of baking soda and water.
• Mix 1 part hydrogen peroxide with 1 part water and apply this mixture to the lesions using a cotton swab.
• For more severe cases, treatments include fluocinonide gel (Lidex) or chlorhexidine gluconate (Periden) mouthwash.

Nonprescription preparations, like Orabase, can protect a sore inside the lip and on the gums. Blistex or Campho-Phenique may provide some relief of canker sores and fever blisters, especially if applied when the sore initially appears.

Additional steps that may help cold sores or fever blisters:

• Apply ice to the lesion.
• Take L-lysine tablets.

Anti-viral medications for herpes lesions of the mouth may be recommended by your doctor. Some experts feel that they shorten the time that the blisters are present, while others claim that these drugs make no difference.

When to Contact a Medical Professional

Call your doctor if:

• The sore begins soon after you start a new medication
• You have large white patches on the roof of your mouth or your tongue (this may be thrush or another type of lesion)
• Your mouth sore lasts longer than 2 weeks
• You are immunocompromised (for example, from HIV or cancer)
• You have other symptoms like fever, skin rash, drooling, or difficulty swallowing

What to Expect at Your Office Visit

Your doctor will perform a physical examination, focusing on your mouth and tongue. Medical history questions may include the following:

• Are the sores on your lips, gums, tongue, lining of your cheeks, or elsewhere?
• Are the sores open ulcers?
• Are there large, white patches on the roof of the mouth or on your tongue?
• How long have you had the mouth sores? More than 2 weeks?
• Have you ever had sores of this type before?
• What medications do you take?
• Do you have other symptoms like fever, sore throat, or breath odor?

Treatment may depend on the underlying cause of the mouth sore.

A topical anesthetic (applied to a localized area of the skin) such as lidocaine or xylocaine may be used to relieve pain (but should be avoided in children).

An antifungal medication may be prescribed for oral thrush (a yeast infection).

An antiviral medication may be prescribed for herpes lesions (although, some feel that this does not shorten the length of time that the lesions are present)

Antibiotics may be prescribed for severe or persistent canker sores.

Prevention

You can reduce your chance of getting common mouth sores by:

• Reducing stress and practicing relaxation techniques like yoga or meditation
• Avoiding very hot foods or beverages

You can avoid mechanical irritation by:

• Visiting your dentist right away if you have a sharp or broken tooth or misfitting dentures
• Chewing slowly
• Using a soft-bristle toothbrush

If you seem to get canker sores often, talk to your doctor about taking folate and vitamin B12 to prevent outbreaks.

If you get cold sores often, taking L-lysine tablets or increasing lysine in your diet (found in fish, chicken, eggs, and potatoes) may reduce outbreaks. DO NOT use L-lysine if you have high cholesterol, heart disease, or high triglycerides.

To prevent the spread of herpes sores, do not kiss or have oral sex with someone with a cold sore or fever blister. Do not participate in these activities when you have an active cold sore. Do not share razors, lip balm, toothbrushes, or lipsticks.

To prevent cancerous mouth lesions:

• Do not smoke or use tobacco.
• Limit alcohol to 2 drinks per day.
• Wear a wide-brimmed hat to shade your lips. Wear a lip balm with SPF 15 at all times.

References

Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 5th ed. London, UK: Churchill Livingstone, Inc; 2000.

Yeung-Yue KA. Herpes simplex viruses 1 and 2. Dermatol Clin. 2002; 20(2): 249-266.

MacDonald J. Canker sore remedies: baking soda. CMAJ. 2002; 166(7): 884.

Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75(4):501-7.

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Fluoride overdose

Definition

Fluoride is a chemical commonly used to prevent tooth decay. Fluoride overdose occurs when someone accidentally or intentionally takes more than the normal or recommended amount of this substance.

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.

See also: Fluoride in diet

Poisonous Ingredient

• Fluoride

Where Found

Fluoride is found in many over-the-counter and prescription products, including:

• Certain mouthwashes and toothpastes
• Certain vitamins (Tri-Vi-Flor, Poly-Vi-Flor, Vi-Daylin F)
• Fluoridated water
• Sodium fluoride liquid and tablets

Fluoride may also be found in other household items, including

• Etching cream
• Roach powders

Note: This list may not be all inclusive.

Symptoms

• Abdominal pain
• Abnormal taste (salty or soapy taste)
• Convulsions
• Diarrhea
• Drooling
• Headache
• Heart attack
• Irregular heartbeat
• Nausea
• Shallow breathing
• Slow heartbeart
• Tremors
• Vomiting
• Weakness

Before Calling Emergency

Determine the following information:

• Patient’s age, weight, and condition (for example, is the person awake or alert?)
• Name of the product (ingredients and strengths, if known)
• Time it was swallowed
• Amount swallowed

However, DO NOT delay calling for help if this information is not immediately available.

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.

See: Poison control center – emergency number

What to Expect 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. Symptoms will be treated as appropriate. The patient may receive:

• Calcium or milk
• Methods or medicines to cause vomiting
• Tube through the mouth into the stomach to wash out the stomach (gastric lavage)

Outlook (Prognosis)

How well a patient does depends on the amount of poison swallowed and how quickly treatment was received. The faster a patient gets medical help, the better the chance for recovery.

References

Meier K. Fluoride. Poisoning and Drug Overdose. In: Olson K, Anderson I, eds. California Poison Control System. McGraw-Hill; 2003: pp.200-201.

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fluoride overdose

Definition

Swollen gums are abnormally enlarged, bulging, or protruding.

Alternative Names

Swollen gums; Gingival swelling

Considerations

Gum swelling is quite common and may involve one or many of the triangular-shaped bits of gum between nearby teeth. These sections are called papillae.

Occasionally, the gums swell significantly, blocking the teeth completely.

Causes

• Gingivitis
• Infection by a virus or fungus
• Malnutrition
• Poorly fitting dentures
• Pregnancy
• Sensitivity to toothpaste or mouthwash
• Scurvy
• Side effect of a drug such as Dilantin or phenobarbital

Home Care

Improve your nutrition if it is poor.

Avoid gum irritants such as commercial mouthwashes, alcohol, and tobacco. Change your toothpaste brand and avoid using mouthwashes if your swollen gums are caused by sensitivity to toothpaste or mouthwash.

Use good oral hygiene. See a periodontist or dentist at least every 6 months.

If your swollen gums are caused by a reaction to a drug, talk to your doctor about using a different type of medication. Never change medications without first talking to your doctor.

When to Contact a Medical Professional

• Swelling is severe, persistent, or is accompanied by other unexplained symptoms
• Discomfort is associated with swelling

What to Expect at Your Office Visit

The dentist will examine your mouth, teeth, and gums. You will be asked questions about your medical history and symptoms, such as:

• Quality
  • Do your gums bleed?
• Time pattern
  • Did the swelling begin recently?
  • Are they always swollen?
  • Does the amount of swelling change?
  • Does it only occur occasionally?
  • Have you had gum problems before?
• Oral hygiene habits
  • How often do you brush?
  • How often do you floss?
  • How hard of a toothbrush is used?
  • How vigorously do you brush?
  • What are other habits (use of toothpicks or other)?
  • When was the last time you had the teeth professionally cleaned (at the dentist)?
• Eating habits
  • Have you changed your diet?
  • Do you eat adequate amounts of fruits and vegetables?
  • Do you take supplemental vitamins?
• Other
  • What medications do you take?
  • Are you pregnant?
  • Have you changed mouthwash or toothpaste recently?
  • What other symptoms do you have? For example, breath odor, sore throat, pain.

Tests may include blood studies such as a CBC or blood differential.

The patient will be taught proper mouth and gum care.

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Definition

Bleeding gums can be a sign that you are at risk for, or already have, gum disease. However, persistent gum bleeding may be due to serious medical conditions such as leukemia and bleeding and platelet disorders.

Alternative Names

Gums – bleeding

Considerations

It is important to follow the instructions from your dentist in order to maintain healthy gums. Improper brushing and flossing technique may actually irritate or traumatize the gum tissue.

Causes

Bleeding gums are mainly due to inadequate plaque removal from the teeth at the gum line. This will lead to a condition called gingivitis, or inflamed gums.

If plaque is not removed through regular brushing and dental appointments, it will harden into what is known as tartar. Ultimately, this will lead to increased bleeding and a more advanced form of gum and jawbone disease known as periodontitis.

Other causes of bleeding gums include:

• Any bleeding disorder
• Brushing too hard
• Hormonal changes during pregnancy
• Idiopathic thrombocytopenic purpura
• Ill-fitting dentures
• Improper flossing
• Infection, which can be either tooth- or gum-related
• Leukemia
• Scurvy
• Use of blood thinners
• Vitamin K deficiency

Home Care

Visit the dentist at least once every 6 months for plaque removal. Follow your dentist’s home care instructions.

You should brush your teeth gently with a soft-bristle toothbrush after every meal. The dentist may recommend rinsing with salt water or hydrogen peroxide and water. Avoid using commercial, alcohol-containing mouthwashes, which aggravate the problem.

Flossing teeth twice a day can prevent plaque from building up. Avoiding snacking between meals and reducing carbohydrates can also help. Follow a balanced, healthy diet.

Other tips:

• Avoid the use of tobacco, which aggravates bleeding gums.
• Control gum bleeding by applying pressure directly on the gums with a gauze pad soaked in ice water.
• If you have been diagnosed with a vitamin deficiency, take recommended vitamin supplements.
• Avoid aspirin unless your health care provider has recommended that you take it.
• If side effects of medication are irritating, ask your doctor to recommend another medication. Never change your medication without consulting your doctor.
• Use an oral irrigation device on the low setting to massage the gums.
• See your dentist if your dentures do not fit correctly or if they are causing sore spots in your gums.

When to Contact a Medical Professional

Consult your health care provider if:

• The bleeding is severe or long term (chronic)
• Your gums continue to bleed even after treatment
• You have other unexplained symptoms with the bleeding

What to Expect at Your Office Visit

Your dentist will examine your teeth and gums, and ask questions such as:

• Are the gums bleeding a large amount?
• Did the bleeding begin recently?
• Do the gums bleed frequently or only occasionally?
• Have you had gum problems before?
• How often do you brush?
• How often do you floss?
• Do you use a soft- or hard-bristle toothbrush?
• How vigorously do you brush?
• What other home care aids do you use (toothpicks or other)?
• When was the last time you had your teeth cleaned at the dentist?
• Have you changed your diet?
• Do you eat adequate amounts of fruits and vegetables?
• Do you take supplemental vitamins?
• Do you have a high carbohydrate diet (pasta)?
• What medications do you take? Do you take seizures medicines, blood thinners (such as Coumadin, heparin), or aspirin?
• Are you pregnant?
• Have you changed mouthwash or toothpaste recently?
• What other symptoms do you have? (for example, sore throat)

Diagnostic tests that may be performed include:

• Blood studies such as a CBC or blood differential
• X-rays of the teeth and jawbone

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Definition

Breath odor is the scent of the air you breathe out of your mouth. Unpleasant, distinctive, or offensive breath odor is commonly called bad breath.

Alternative Names

Bad breath; Halitosis

Considerations

Some disorders will produce specific, characteristic odors to the breath.

A fruity odor to the breath occurs as the body attempts to get rid of excess acetone through the breathing. This is a sign of ketoacidosis, which may occur in diabetes. It is a potentially life-threatening condition.

Breath that smells like feces can occur with prolonged vomiting, especially when there is a bowel obstruction. It may also occur temporarily if a person has a tube placed through the nose or mouth to the stomach to drain the stomach contents (nasogastric tube) in place.

The breath may have an ammonia-like odor (also described as urine-like or “fishy”) in people with chronic kidney failure.

Causes

If previously normal breath turns into halitosis, causes could include:

• Abscessed tooth
• Alcoholism
• Cavities
• Dentures
• Drugs
  • Paraldehyde
  • Triamterene and inhaled anesthetics
  • Insulin – injection
• Food or beverages consumed (such as cabbage, garlic, raw onions, or coffee)
• Foreign body in the nose (usually in children)
  • Often (but not always) there is a white, yellowish, or bloody discharge from one nostril
• Gum disease (gingivitis, gingivostomatitis)
• Impacted tooth
• Lung infection
• Poor dental hygiene
• Sinusitis
• Throat infection
• Tobacco smoking
• Vitamin supplements (especially in large doses)

Diseases that may be associated with breath odor (not presented in order of likelihood — some are extremely unlikely):

• Acute necrotizing ulcerative gingivitis
• Acute necrotizing ulcerative mucositis
• Acute renal failure
• Bowel obstruction (can cause breath to smell like feces)
• Bronchiectasis
• Chronic renal failure (can cause breath to smell like ammonia)
• Diabetes (fruity or sweet chemical smell with ketoacidosis)
• Esophageal cancer
• Gastric carcinoma
• Gastrojejunocolic fistula (fruity-smelling breath)
• Hepatic encephalopathy
• Diabetic ketoacidosis
• Lung abscess
• Ozena, or atrophic rhinitis
• Periodontal disease
• Pharyngitis
• Zenker’s diverticulum

Home Care

Use proper dental hygiene (especially flossing), and remember that mouthwashes are not effective in treating the underlying problem.

Fresh parsley or a strong mint are often effective ways to fight temporary bad breath. Avoid smoking. Otherwise, follow prescribed therapy to treat the underlying cause.

When to Contact a Medical Professional

• Breath odor persists and there is not an obvious cause (such as smoking or eating odor-causing foods).
• You have breath odor and signs of a respiratory infection, such as fever, cough, or face pain with discharge from the nose

What to Expect at Your Office Visit

Your doctor will take a medical history and perform a physical examination.

You may be asked the following medical history questions:

• Is there a specific odor?
• Is there a fishy smell?
• Does the breath smell like ammonia or urine?
• Does the breath smell like fruit or is there a sweet-chemical smell?
• Does the breath smell like feces?
• Does the breath smell like alcohol?
• Have you recently eaten a spicy meal, garlic, cabbage, or other “odorous” food?
• Do you take vitamin supplements?
• Do you smoke?
• Does good oral hygiene improve the odor?
• What home care measures have you tried? How effective are they?
• Is there a recent sore throat, sinus infection, tooth abscess, or other illness?
• What other symptoms do you have?

The physical examination will include a thorough examination of the mouth and the nose. A throat culture may be taken if you have a sore throat or mouth sores.

In rare cases, diagnostic tests that may be performed include:

• Blood tests to screen for diabetes or kidney failure
• Endoscopy (EGD)
• X-ray of the abdomen
• X-ray of the chest

Antibiotics may be prescribed for some conditions. For an object in the nose, the doctor will use an instrument to remove it.

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Information

When putting an infant to bed:

• Make the nighttime routine consistent and pleasant.
• Give the last nighttime feeding shortly before putting the baby to bed. Never put the baby to bed with a bottle, as it can cause tooth decay. (See: Baby bottle tooth decay)
• Spend quiet time with your child by rocking, walking, or simple cuddling.
• Put the child in bed before he is deeply asleep. This will teach your child to go to sleep on his own.
• Your baby may cry when you lay him in his bed, because he fears being away from you. This is called separation anxiety. Simply go in, speak in a calm voice, and rub the baby’s back or head. Do not remove the baby out of the bed. Once he has calmed down, leave the room. Your child will soon learn that you are simply in another room.
• If your baby awakens in the night for feeding, do not turn on the lights. Keep the room dark and quiet. Use night lights , if needed. Keep the feeding as brief and boring as possible. Do not entertain the baby. When the baby has been fed, burped and calmed, return him to bed. If you maintain this routine, your baby will become used to it and go to sleep on his own.
• Sleeping with a baby younger than 12 months of age may increase the risk of sudden infant death syndrome (SIDS).

When dealing with an older child:

• Make the nighttime routine pleasant and predictable.
• Keep activities such as taking a bath, brushing teeth, reading stories, saying prayers, and so forth in the same order every night.
• Before you turn out the light, ask if the child needs anything else.
• Establish a rule that the child cannot leave the bedroom.
• Ignore verbal requests after the child has gone to bed.
• If your child starts screaming, shut the door to his bedroom and say, “I’m sorry, but I have to shut your door. I will open it when you are quiet.” If your child comes out of his room, avoid lecturing him. Using good eye contact, tell the child that you will open the door again when the child is in bed. If the child says he is in bed, open the door.
• If your child tries to climb into your bed at night, unless he is afraid, return him to his bed as soon as you discover his presence. Avoid lectures or sweet conversation. If your child simply cannot sleep, tell him he may read or look at books in his room, but he is not to disturb other people in the family.
• Praise your child for appropriate bedtime behavior.

Remember that bedtime habits can be disrupted by changes or stresses such as moving to a new home or gaining a new brother or sister. It may take time to reestablish previous bedtime practices.

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Definition

Toothache is pain in or around a tooth.

Alternative Names

Pain – tooth or teeth

Considerations

A toothache is generally the result of dental cavities (tooth decay) or sometimes an infection. Tooth decay is often caused by poor dental hygiene, although the tendency to get tooth decay is partly inherited.

Sometimes, pain that’s felt in the tooth is actually due to pain in other parts of the body. This is called referred pain or radiating pain. For example, an earache may sometimes cause tooth pain.

Causes

• Abscessed tooth
• Earache
• Injury to the jaw or mouth
• Heart attack (can include jaw pain, neck pain, or toothache)
• Sinusitis
• Tooth decay

Home Care

Over-the-counter pain medications may be used while waiting to see the dentist or primary health care provider.

For toothaches caused by a tooth abscess, the dentist may recommend antibiotic therapy and other treatments, like root canal.

To prevent tooth decay, use good oral hygiene. A low sugar diet is recommended along with regular flossing, brushing with fluoride toothpaste, and regular professional cleaning. Sealants and fluoride applications by the dentist are important for preventing tooth decay.

When to Contact a Medical Professional

Seek medical care if:

• You have a severe toothache
• You have a toothache that lasts longer than a day or two
• You have fever, earache, or pain upon opening the mouth wide

Note: The dentist is an appropriate person to see for most causes of toothaches. However, if the problem is referred pain from another location, you may need to see your primary health care provider.

What to Expect at Your Office Visit

The dentist will examine you. The physical examination may include an examination of the mouth, teeth, gums, tongue, throat, ears, nose, and neck. You may need dental x-rays. The dentist may recommend other tests, depending on the suspected cause.

The dentist will ask questions about your medical history and symptoms, including:

• When did the pain start?
• How severe is the pain?
• Where is the pain located?
  • Does it involve the jaw or ears?
  • Does it radiate to other parts of the body, such as the neck, shoulder, or arm?
• What makes it worse?
  • Is it worse after cold foods or liquids?
  • Is it worse after sweet foods or liquids?
  • Is it worse after chewing?
  • Is it worse after drinking?
  • Is it worse when you touch the area?
  • Is it worse after physical exertion?
• Does the pain wake you up at night?
• What makes it better?
  • Is it better after you use medications? (Which ones?)
  • Is it better after you use a heating pad?
  • Is it better after you rest?
• What other symptoms do you have?
  • Fever ?
  • Nausea?
  • Sweating?
  • Indigestion?
  • Chest pain?
  • Bleeding?
• What medications do you take?
• Have you been injured?
• When was the last dental checkup?
• Have you had previous dental problems?

Treatment may involve fillings, tooth removal, or a root canal, if the problem is severe. If there is a fever or swelling of the jaw, an antibiotic will usually be prescribed.
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Charcot-Marie-Tooth disease

Definition

Charcot-Marie-Tooth disease is a group of disorders that affect the peripheral nerves, the nerves running from outside the brain and spine.

Alternative Names

Progressive neuropathic (peroneal) muscular atrophy; Hereditary peroneal nerve dysfunction; Neuropathy – peroneal (hereditary); Hereditary motor and sensory neuropathy

Causes

Charcot-Marie-Tooth is one of the most common inherited nerve-related disorders. Defects in at least 14 genes cause different forms of this disease.

The disease involves damage to the covering (myelin sheath) around nerve fibers. In some, the disease causes destruction of the myelin sheath. In others, the central (axon) portion of the nerve cell wears away.

Nerves that stimulate movement (the motor nerves) are most severely affected. The nerves in the legs are affected first and most severely.

Symptoms

Symptoms usually begin between mid-childhood and early adulthood. They may include:

• Foot drop (inability to hold foot horizontal)
• Foot deformity (very high arch to feet)
• Loss of lower leg muscle, which leads to skinny calves
• Numbness in the foot or leg
• “Slapping” gait (feet hit the floor hard when walking)
• Weakness of the hips, legs, or feet

Later, similar symptoms may appear in the arms and hands, which may include a claw-like hand deformity.

Exams and Tests

A physical exam may show thickened nerve bundles under the skin of the legs. The stretch reflexes in the legs are absent. There is loss of muscle control and atrophy in the foot or leg. Lifting up the foot and toe-out movements will be difficult.

A muscle biopsy or nerve biopsy may confirm the diagnosis. Nerve conduction tests are often done to tell the difference between different forms of the disorder.

Genetic testing is available for most forms of the disease.

Treatment

There is no known cure. Orthopedic surgery or equipment (such as braces or orthopedic shoes) may make it easier to walk.

Physical and occupational therapy may help maintain muscle strength and improve independent functioning.

Outlook (Prognosis)

Charcot-Marie-Tooth disease slowly gets worse. Some parts of the body may become numb, and pain can range from mild to severe. Eventually the disease may cause disability.

Possible Complications

• Progressive inability to walk
• Progressive weakness
• Injury to areas of the body that have decreased sensation

When to Contact a Medical Professional

Call for an appointment with your health care provider if there is persistent weakness or decreased sensation in the feet or legs.

Prevention

Genetic counseling and testing is advised if there is a strong family history of the disorder.

Charcot-Marie-Tooth disease