Dental Health Informational Articles
Written By Dr. Birnbaum
What follows is for information purposes only. Your individual circumstances are unique and may vary from the text below.
Written by Ronald Birnbaum DDS and updated June 2009
Cosmetic topics
Human teeth start their development at a very young age. The quality of the development of the tooth - and its ultimate performance and longevity - can be influenced by events that occurred during your childhood, particularly at that period in time the tooth was being created. By the time the tooth has erupted into the mouth, a different set of factors take over that can influence the longevity of the tooth.
Teeth start from scratch as groups of cells that grow at specific points in the jaw. These cells can have their performance disrupted by certain events that take place while they are busy at work.
One of the most common factors that disrupt the cells are medications- usually antibiotics, that you were given as a child at particular points in time. Other common factors are vitamin deficiency or excess, sickness and trauma. Even the mineral composition of the water you were fed has a strong influence on the teeth at all times, teeth need sufficient- but not too much- calcium and fluoride circulating in your blood so they may form with correct strength. Therefore whether you grew up drinking reservoir water, ground well water or premium bottled spring water makes a huge difference in how your teeth are today.
Problems arising from developmental events may be seen in your teeth today as: weakened or malformed enamel, discolorations in the tooth (any color), growth in unusual directions and an increased susceptibility to attack by the bacteria that cause tooth decay.
Cavities are formed by certain bacteria that make a home in and around the teeth. Bacteria that are known to cause tooth decay feed off the food you put in your mouth and love sugar. Even if you maintain a low-sugar diet, certain foods high in carbohydrates will provide enough nourishment to the bacteria. Therefore keep your mouth as clean as possible by brushing twice a day and using dental floss daily, in order to minimize the food source available to the bacteria. These bacteria also prefer an acidic environment, therefore even sugar-free soda, containing "citric acid" is not good for you.
The use of a fluoride rinse may also help because fluoride can "stun" some bacteria and simultaneously deposit minerals on the surface of the teeth to make the tooth more resistant to attack. Once a tooth has grown into the mouth, only good oral hygiene, the use of a fluoride rinse and a proper diet can mitigate the factors that cause cavities.
Unfortunately, in today's high-stress lifestyle of fast food, sugar-packed coffees available on every corner and caustic diet-sodas, our teeth are under as much attack as ever before. We are even seeing an increase in the amount of tooth decay, a disturbing reverse in gains made over the past 30 years. In addition, many communities are choosing to halt water fluoridation as a cost-cutting measure. In just a few years from now, those communities will be seeing an increase in the amount of tooth decay as a result of their decision.
By reading this article, I hope you will become more educated about the main points of tooth decay.
Cavities
1. Pit and fissure type of cavity
All teeth start their lifetime carrying naturally developed grooves, fissures and "pits" that occur in humans with regularity and in well mapped locations on the surface of teeth. If the formation of these sites has been successful and of good quality, those areas are naturally sealed and can be highly resistant to decay. However, in many- most people in fact, these grooves, fissures and pits, especially where they are most numerous- on the back teeth, can have areas deficient from their formation. These sites present as naturally-formed cracks where food can enter from the moment the tooth is born. These holes are only microns wide and invisible at first.
Due to the narrowness of the opening, your toothbrush bristle is usually too wide to reach inside the hole to clean. Over months and years, the bacteria in the mouth can find a home in these holes and live comfortably, well fed by the food you provide them. The byproducts of these bacteria are acidic and cause a breakdown of the adjacent enamel, starting a "cavity" and proceeding to create a bigger hole than what was originally there. A well developed tooth can present some resistance to the attack, but any area that suffered during tooth development is going to be less resistant and the cavity will progress faster.
These "pit and fissure" cavities represent the most common type of cavities. Most people will have at least some susceptible areas. A high sugar diet feeds the bacteria more, drastically speeding the development of a cavity, and once again, your toothbrush bristle cannot reach inside to clean while all this is going on. In most respects, there is nothing you can do to prevent the decay from occurring, other than (1). maintain a diet low in sugar to slow bacterial activity, (2). maintain overall good oral hygiene to minimize bacterial colonization, (3). use of a fluoride rinse and (4). hope your teeth are well formed and resistant enough to attack.
Pit and fissure cavities are most often found by poking the surface of the tooth with a pointed instrument to detect the presence of a hole. If the instrument finds a hole, it will get "stuck" to a certain extent. Usually there will also be some discoloration around the opening, a clue to its presence, but this is not always the case. This makes the detection of these cavities relatively easy, but also a hit-and-miss experience, as one cannot judge the extent of the decay merely by the outside appearance. Sometimes a large and dangerous cavity is present but its surface appearance is innocuous or even undetectable and the patient (and dentist) unaware of any problem until it is too late.
Once a hole is detected it must be cleaned out of its bacteria to put a stop to the decay and the hole filled to restore strength to the tooth. If the bacteria have progressed deeply, the nerve of the tooth may have been affected by the bacteria as well, requiring additional cleaning of the infected nerve called a "root canal". Luckily, this occurs only in the deepest of cavities, and usually there will have been warning signs, such as a sensitivity to extreme temperatures or to sweet foods, so that the patient can tell the dentist long beforehand that something is afoot. From the earliest start of a cavity to needing a root canal usually takes two to three years of progression at minimum in most people.
Most pit and fissure cavities are found and treated in persons between the ages of 20 - 30 since these types of cavities are present or susceptible to development immediately after the tooth has erupted into the mouth and gain speed during active teenage or college years, especially if the person has a diet high in sugar and does not take ideal care of themselves. However, these cavities will still occur at any age and as the teeth wear down or chip, newly susceptible areas will present themselves.
The placement of a "coating" or sealant over susceptible areas immediately upon tooth eruption can successfully seal the opening of pits and fissures, thereby keeping bacteria out, but it needs to be placed as early as possible before sufficient bacterial colonization occurs. Most insurance companies recognize this and will willingly support paying for sealants, but not beyond the age of 16, as by then a colonization has been established.
Luckily, in 2009, treatment for most pit and fissure cavities has become markedly easier and more cost-effective as recent developments in dental materials have greatly simplified the procedures involved and eliminated the need for the unsightly "metal" fillings. We can now use tooth colored filling materials almost exclusively and with great success in safety and reliability, sometimes without the need for any injection except in the case of the deepest of cavities.
2. Interproximal (in-between teeth) type of cavity
This type occurs in-between teeth on the smoothened surfaces. No pit or fissure needs to be present so their development is not dependent on the pre-existing anatomy of the tooth.
Because of their location, most of the time they cannot be seen except with a radiograph (x-ray). When the dentist views the radiograph, the in-between areas of the teeth become visible and the cavity can be detected by looking at places known to be susceptible.
These cavities occur mainly if food has been allowed to get stuck between the teeth or if sugar has been carried in-between the teeth frequently. Therefore, a low-sugar diet goes a long way to reducing their formation, but most important is to keep the in-between areas clean with dental floss on a daily basis. Flossing is extremely important in their prevention. The use of a fluoride rinse also helps by strengthening tooth enamel.
These cavities are about as common as the pit and fissure type. However, unlike the former, the interproximal cavity is more preventable. So if your oral hygiene habits are good, chances are you can slow or prevent the progression of these cavities. However, they are more difficult to detect since we have to depend on the quality of the diagnostic equipment to show them, so by the time they become visible, they have usually attained a certain size that requires immediate attention.
If allowed to progress, the tooth will break down quickly and the nerve can become painful, requiring a "root canal".
Treatment for interproximal cavities in 2009 can be done with tooth colored filling materials yet almost always requires the use of an injection to numb the tooth.
3. Other types of cavities
Fillings are rarely going to last for a lifetime. As you go through life, you will wear down your teeth and your fillings will wear also. Even a well done filling can chip and get decay at any roughened edges once a bacterial trap occurs, requiring the removal of the filling and the cleaning out of any recurrent decay. Sometimes, decay around a filling starts at some hard to find corner and goes dangerously unnoticed as it buries underneath the filling. At some point the filling, once it has lost its footing - can "fall out" or worse- the decay makes a path straight for the nerve, necessitating a "root canal", yet all looks fine and dandy from the surface- except maybe for a tiny opening at the edge of the filling that allowed bacteria to enter. Any sensitivity to temperature or sweet, or food getting trapped around a filling are clues leading to its discovery. Any filling where breakdown at its edge is suspected needs to be considered for removal and inspection.
Gum recession, areas damaged by trauma, certain health problems and other factors unique to an individual can also lead to tooth decay. The information is above is only generalized and explains the cavities that occur in most people, most commonly.
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TOOTH WHITENING (BLEACHING)
Tooth whitening is used to remove stains that have built up over years of exposure to dark foods such as coffee, tea, red wine, ketchup, meats and from the tobacco in cigarettes. The staining collects in the outermost layer of your teeth called the enamel. By removing stains from the enamel, teeth can brighten to levels not seen since your youth!
Tooth whitening is done one of two ways:
1. Fabrication of customized trays to fit your teeth with nightly use of a bleaching gel for 1 to 2 weeks.
2. In-office "one hour laser" whitening using Zoom (also called Britesmile)
The fabrication of bleaching trays requires the making of an impression of your teeth in the office. The impression is sent to a laboratory that makes clear flexible plastic trays that have the shape of your teeth to fit them perfectly. A bleaching gel containing carbamide peroxide at 10-15% is squirted in small amounts into each tray and inserted in the mouth. You sleep with the trays for a few days and the longer you use it, the whiter the teeth will get. Most people will use it for 1 - 2 weeks the first time around to get to their desired color. If you have extra gel left over you can store it for future "touch up" of just a few days of use. This method is very reliable and the results get better the longer you use it. I generally supply Ultradent Opalescence to my patients as the bleaching gel.
The in office treatment using Zoom requires a single visit of about 1 1/2 hours. Your gums and teeth are isolated and an extremely powerful gel of 35% carbamide peroxide is applied on the teeth. The blue Zoom lamp ("laser") is directed at the teeth and after about one hour the procedure is stopped. The ultra-high strength of the gel combined with the use of the lamp creates a fast bleaching result.
Which method is better for you?
If you are the type of person who wants to maintain total control over the final result, go for the tray whitening. The longer you use it, the better it gets.
If you are a very busy person and don't want anything to do with this and just want to "walk in and walk out" with a brighter smile then do the Zoom treatment. Especially if you have a special occasion coming up and do not have enough time to do tray whitening before the event.
Is it effective?
The tray whitening offers you a great opportunity to get fantastic results. It takes longer and requires more effort, but the gel penetrates deeper and for a longer duration for a durable result. The longer you use it the better it gets. The trays will fit most people for 2-5 years so you can touch up on your own at any time just days before a special occasion.
The Zoom whitening is more of a "shock" whitening treatment. The result is usually great but because the procedure lasts for only 1 hour, the gel cannot penetrate as deeply as it could with the slower tray process. Because of this, sometimes the result is not as bright as with the trays. In addition, the color may regress within six months to one year.
Ideally one could do the Zoom treatment and then have trays made for the best possible results but it is more costly since you end up having both procedures.
Give a call to discuss with Dr. Birnbaum which treatment may be better for you.
Whitening trays with a gel syringe
Tray inserted onto top teeth - the customized trays fit the shape of
your teeth
Keep in mind that any tooth fillings and crowns in your mouth do not respond to tooth whitening.
Store-bought whitening products such as strips, gels and toothpastes do not work because the concentration of the ingredient is very weak. In addition, because the weak product must be used for a much longer period of time, it becomes harmful to gums and causes sores and sore throat as it spills out of its generic holder. By reading the ingredients, I have found that some contain chemistry that is directly harmful to teeth and overall health (i.e. silica, alcohol). These are heavily advertised but unregulated products so buyer beware!
Many patients are unhappy with the appearance of their teeth. Typically, the color, shape or position of their teeth is unappealing. Sometimes there is a chip on one edge or teeth are different in size or there are large spaces in between. Whatever your case may be, you don’t have to be a Broadway star or a top model to desire a beautiful smile. There are options available to you to help you improve your appearance- and bonding is one of them.
The term “bonding” refers to how tooth-colored filling materials adhere to your teeth. These state-of-the-art materials are literally bonded to your teeth wherever we want them to be. The materials come in a range of colors and it is possible to shape them to look like whatever we want.
As you can guess, using bonding to fix chipped teeth and close gaps between teeth is ideal. If you have a front tooth smaller than its neighbors, I can sculpt layers of bonding material to give it the dimensions we want and harmonize it with its neighbors. The same thing goes for discolored spots on teeth- just cover them up!
Similarly, great results are achieved by covering the front teeth with a porcelain veneer. A veneer is a thin custom-made porcelain layer that is glued to the front of the tooth. The advantage of a porcelain veneer is that it gives a smooth, shiny, translucent finish that appears virtually indistinguishable from natural tooth enamel. Since they are a step up from ordinary bonding material, porcelain veneers cost more, but the results are truly fabulous!
If you are not happy with some aspect of your smile and want to explore your options, feel free to discuss this with Dr. Birnbaum.
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Regular Cleanings Can Protect your Health - An Update on Gum Disease
A definitive connection has been found between the health of your gums and your risk of being affected by heart disease, stroke, diabetes and pancreatic cancer The plaque that accumulates in your mouth contains bacteria successfully linked to playing a part in these diseases. Simply put, the more of this bacteria you have, the more you may be at risk. That is why it is more important than ever to reduce the amount of bacteria in your mouth by brushing your teeth and using dental floss daily and having your teeth and gums cleaned regularly.
A proper gum hygiene program consists of brushing your teeth at least twice a day (morning and evening) and using dental floss as frequently as possible.
If your gums bleed routinely or if you sense bad breath, then most likely plaque has accumulated at high levels and it is important to have your teeth cleaned.
Heart Disease and Stroke
We’ve known this for many years already, yet study after study continues to confirm and strengthen the fact that the very same bacteria that start out in your teeth and gums, will travel by the bloodstream to other parts of the body. One of their primary targets is within the blood vessels themselves, where they settle in and contribute to the formation of plaques that block the flow of blood, leading to heart attacks and stroke.
Diabetes
More recently, these same bacteria have been shown to activate pathways in the body that contribute to the acquisition of diabetes. Persons with poorly controlled diabetes are afflicted with weakened gums and are more likely to suffer from tooth loss as the teeth literally lose their support. Once again, the bacteria in the gums are the main cause of the infections that lead to this problem.
Pancreatic Cancer
This link was found in 2008 and studies are still ongoing.
So the message is clear. Neglecting to take care of your oral health could have consequences on your body’s overall well being. Dr. Birnbaum wants to help you stay as healthy as you can. Be sure to brush and floss regularly and have regular cleanings as prescribed.
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Written by Dr. Ronald Birnbaum
One of the most common types of damage that occurs in the mouth is called Toothbrush Abrasion. I see it in about 8 out of 10 people. Toothbrush abrasion is an innocuous problem stemming from a bad habit that can lead to receded gums, sensitive teeth, holes cut into teeth, strange esthetics and tooth loss.
Introduction
For starters, take your toothbrush and move it back and forth along your skin. If you rub it like this enough times in the same area and with enough pressure, you will cause your skin to turn red and it may hurt. If you kept up this pace, your brush may eventually cause damage to your skin, cause a little bleeding, and hurt a lot. Now, please don’t try this for real, but you get the idea.
Fortunately, brushing the skin is not something most of us do, even though the outer skin is a tough layer of protection and will stand up pretty well against a toothbrush.
However, brushing the teeth is a daily exercise that all of us must do. When you take your toothbrush and carry it to the mouth, it is going to meet two things: something very hard (your teeth) and other things very soft (your gums, your tongue, etc.).
The enamel of teeth is the hardest substance in the human body, almost like rock, and very hard to break or otherwise do damage to. Enamel in adult teeth has years to form, which partly explains where this strength comes from. Enamel makes up the outermost layer of teeth when you look in the mirror.
Teeth are encircled by a fragile, thin, easy to damage layer of skin called the gums. Their most fragile spot than at that junction where the teeth meet the pink of the gums (called the gumline). It is at this point that toothbrush abrasion comes into the picture, because this is precisely the area in your mouth that is most vulnerable to damage from brushing one’s teeth too hard, leading to what is called toothbrush abrasion.
The Causes of Toothbrush Abrasion
We all brush our teeth every day. The goal of brushing is to remove food particles from around the teeth to render them clean and our breath feeling fresh. Food usually collects in the form of “plaque”, which is that whitish material that likes to hang around the gumline. So when you take your toothbrush, you are carrying it around the teeth, but often also against the gumline and maybe a little bit higher onto the gums themselves. So you brush and you brush and you brush and you’re done, great.
However, if you put too much force on the toothbrush as you go around, your gums don’t like it (remember the skin example). Keeping in mind that the gums are very fragile and weak, they really can’t stand up to this excessive force for too long. What happens over time is that the gums will actually recede- (in protest?) and you will have given yourself a receded gumline.
Gum Recession from Toothbrush Abrasion
Gum recession caused by toothbrushing is not the same thing gum disease, which is caused by bacteria and infection. This recession is caused by you. You have brushed too hard, too frequently, with too much force, too much on the gums, for too long, and now it is too late, your gum has disappeared. Maybe you pushed too hard because you were stressed or not paying attention. No matter what the reason, once the gum is gone, it is gone and it “‘aint ever gonna grow back”. You have receded gums and- you’re (gasp!) only 25, or 30 or 35 or whatever and you thought all your life that gum recession was only a problem for “old people”. As you can see, if the cause of the recession is toothbrushing, it can occur at any age, young and old.
Sensitivity in The Teeth
If a recession of the gumline has occurred, most people will first take notice of a sensitivity when something cold or sweet touches the side of the affected tooth while eating, drinking or breathing air. Sometimes also a pain occurs during toothbrushing as the bristles move across the side of the tooth. Why is this related?
As the gumline recedes due to excessive toothbrushing forces, it begins to expose a part of the tooth which is normally kept covered up by the gums. This part of the tooth is called the dentin, which is where the nerve endings are. As a result of the dentin being exposed, the nerve endings contained within also become exposed and the result is the sensitivity to cold, sweet or touching of the area.
The dentin is a layer underneath the enamel, but as you go down into the root of the tooth, the enamel slowly gets thinner and thinner until it stops about 1/3 of the way down. This is where the underlying dentin starts to show through and takes it the rest of the way down the root to the tip of the tooth. Where the enamel has stopped and the dentin takes over is called the dentin-enamel junction, which usually happens to be just below the gumline. If the gumline has receded, however, this junction becomes exposed and the dentin sensitivity becomes apparent.
If the gumline recession is minor, de-sensitizing materials can be placed over the exposed dentin to seal the nerve endings and make the patient comfortable. One popular material is potassium nitrate, contained in “sensitivity” toothpastes. Upon using a toothpaste containing it, it blocks the nerve endings, but it takes two weeks for enough to build up to give a noticeable result. Indeed if the person stops using the product, the material goes away and they are sensitive again. The other downside is that the toothpaste itself may not be what is needed in the rest of the mouth (maybe the person needs a tartar control toothpaste, or an anti-gingivitis formula), so it means a lot of toothpaste in the house. Finally, the overzealous person will attempt to brush the sensitivity toothpaste into the tooth vigorously, causing further gumline recession and worsening the problem.
A better solution is a desensitizing solution that is applied in the dental office directly to exposed sensitive dentin areas only. The chemical is then sealed into place, completely blocking the nerve endings. It is invisible, works instantly, offers long-lasting protection and is cheaper than buying tube after tube of special toothpaste.
Holes cut into teeth
As the gumline recedes and the dentin is exposed, not only does sensitivity become a problem, but the dentin itself can be literally cut away by the toothbrush if a bad forceful brushing technique is continued to be used.
The dentin is softer compared to enamel. While toothbrushing cannot easily cause harm to enamel, the dentin however, is quite easily damaged. Once a receded gumline has exposed enough dentin, the toothbrush can easily start to cut a hole into the tooth at this point. After a months of abuse, the hole will have grown to resemble a notch.
A smaller notch, if caught early, may not need any treatment other than desensitizer to keep the patient comfortable from the exposed dentin. However, a deeper notch will always require treatment to fill in the notch.
If the notch is left exposed, food and bacteria become trapped in hidden corners and this will lead to tooth decay (a cavity). Decay that occurs in the dentin notch will quickly eat away and destroy the tooth, resulting in pain and more complicated treatment like a root canal becoming necessary.
To treat a deeper notch, the treatment consists of a filling, usually of tooth-colored filling material applied directly to the notch to fill it in. This not only gives the tooth its correct contour back, but it covers up all exposed dentin, shutting off any sensitivity. This is a very common treatment.
Tooth Loss
A deeper notch, sometimes cutting as much as halfway into the tooth like a lumberjack saws a tree before it is about to be felled, will eventually weaken the tooth so much that just like the tree, the tooth will break, cracking out of the mouth when the person bites hard.
Yet even continued brushing too hard, with continuing recession of the gumline without necessarily any notching, will cause more and more of the tooth to be exposed. As the gum shrinks towards the tip of the root, the tooth loses support from the gums. Eventually the tooth may get loose and fall out due to simply not having enough gum around it to hold it up.
Esthetics due to Toothbrush Abrasion
Patients often ask why there is a yellow part of the tooth at the gumline. That is the dentin, it is always yellow. If the patient has brushed too hard and gumline has receded due to toothbrush abrasion, more of the dentin will be exposed, causing a “yellow teeth” esthetic problem. Sometimes tooth-colored filling material can be placed as a “patch” to cover up the yellow areas.
Treatment for Toothbrush abrasion
First and foremost is to stop the bad brushing habit. Keep brushing, but do so with a soft toothbrush, a light touch and with an up and down motion against the teeth to minimize destruction. It doesn’t matter if the toothbrush is manual or electric, both types can cause the same problem.
Since the gum doesn’t grow back, as long as the patient is comfortable, without sensitivity or deep notches, it can be left like that.
Some patients with high esthetic requirements opt to have plastic surgery on the gums to reposition the gums back into place or to cut out gum from another part of the mouth in order to cover up the teeth where the gumline has receded.
Information contained is generalized. Sensitivity of any kind may be an indicator of more a serious dental and/or overall health condition. This advice is not intended to be self-diagnostic nor may it be relevant to your particular condition and cannot be used to replace a dental examination.
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If you are missing or about to be missing one tooth or more, dental implants offer a modern solution for the replacement of missing teeth. A dental implant is a screw that is placed into the bone in the area you are missing the tooth. Over a few months, the bone grows around the screw and tightens it into place. A false tooth is then attached on top. The procedure requires no drilling on natural teeth. The best part is that they look and feel like natural teeth.
The implant screw is made of titanium. When implants were invented about thirty years ago, scientists experimented with different metals. The main factor was that the metal used in the implant had to be "accepted" by the body and not rejected. They found that titanium was accepted whereas some other metals weren't. Over the next ten or fifteen years, different designs were tried so that today, virtually all dental implants have the same basic design (see the photo at left).
A
hole is made in the area where the tooth/teeth is/are
missing. The implant is screwed into the hole and left to sit. Bone will grow around the implant to
tighten it into place over a few months. Implants placed in the top jaw need six months to attach
to the bone and implants placed in the lower jaw need
four months. After that, the false tooth can be attached on top and the whole thing
is done.
As you can see, the titanium screws are about as large as the tooth they are meant to replace.
Just about everybody who is missing teeth can have implants. The success rate of dental implants is above 95%. There are only certain situations where it is more challenging to place implants, this is usually where the patient has been missing the teeth for a long time and the bone in that area has shrunk so that there is no longer enough bone to put the implant into. People who smoke are also not good candidates because the bone and gum healing is compromised by smoke.
The fee for placing a implant is spread out over several months due to the multi-step nature of the procedure. Initially there is a "surgical" fee for when the implant is placed, then four to six months later, the tooth is put onto place and a separate "restorative" fee is charged at that point. Many insurance plans offer at least some coverage towards implants which helps reduce the cost. Feel free to discuss your needs with Dr. Birnbaum.
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Important Information about Oral and Pharyngeal Cancer
Oral and pharyngeal cancers are some of the most deadly and disfiguring of all cancers. They can affect almost anywhere in the oral cavity. Early detection is key to saving lives. No one is immune. For decades, it is well established that mainly persons who smoke and drink alcohol are at higher risk for being diagnosed with oral cancer than those who do not. However, in recent years, in response to an increasing incidence of oral cancer among people who did not otherwise smoke or drink, a disturbing link was discovered to a virus called human papilloma virus (HPV) that was causing additional cases of oral cancer. HPV is a sexually transmitted virus. Studies are ongoing but the signs of oral cancer are well known. At each examination appointment Dr. Birnbaum evaluates his patients for signs of oral, head and neck cancers.
If you smoke and drink alcohol, you are at higher risk for oral cancer. If you are sexually active and have been diagnosed with having HPV you may also be at risk.
Additional information should be obtained from the website of the Centers for Disease Control, please follow this link.
Update November 2011: Dr. Birnbaum is investigating the feasibility of offering testing for HPV(-16 variant) which has been implicated in the current pandemic of oral cancers.