Irish Society for Disability in Oral Health

Annual Conference

Wet Mouths vs Dry Mouths

Maintaining the dentition in the dry mouth

18th June, 2010 Denise MacCarthy BDS, FDS RCS (Edin), MA, MDentSc

Senior Lecturer-Consultant in Restorative DentistrySchool of Dental Science, Trinity College, Dublin

Maintaining the dentition in the dry mouth

Causes of dry mouth & effects of salivary hypofunction on teeth and oral soft tissues

Baseline dental status of patients attending our clinic

Prevention as key strategy in the care of the dry mouth

Restoration of post radiation dental caries

Suggested protocol for maintainance of long-term oral health

Causes of dry mouth

Physiological Psychological Medications Systemic diseases or conditions Radiotherapy to the head & neck region Chemotherapy

How do we assess salivary hypofunction

Patient complaint – dryness, speech, eating, swallowing, sleeping

Appearance of mouth – tissue red & atrophic, sticky to touch, materia alba, candida

Saliva flow test – resting and stimulated

Normal Saliva Flow

Reduced Saliva Flow

Unstimulated 0.3 – 0.7 ml/min 0 – 0.2 ml/min

Stimulated 1 – 2 ml/min <0.4 ml/min

Saliva Flow Rates

Sensitive Teeth

4%

Difficulty Eating

4%Other13%

Dry Mouth79%

Mouth Problems Post Radiotherapy Patients Primary Complaint

Patient Preference in the Management of Radiation Induced Dry MouthPatient Preference in the Management of Radiation Induced Dry MouthMac Carthy and WaldronMac Carthy and Waldron

Post-radiation DENTAL CARIES

H&N Radiation Treatment

Effect on salivary glands - no saliva

Risk of caries

Dental extraction

Effect on bone – bone cells & blood flow

Risk of osteo-radio necrosis (ORN)

Limited mouth opening - trismus

• 5% - 38% prevalence

3 finger test

Wood sticks

Therabite

Profile of our Patients

Dublin Dental School & Hospital H&N Cancer Oral Care Clinic established in 1997

Patients by residence

Patients by residence

28%

8%

11%5%

48%

Dublin

Rest of Leinster

Munster

Connaught

Ulster

An audit of dental extractions in head and neck cancer patients undergoing radiation treatment. D MacCARTHY, A NiOGAIN*, M O’REGAN. J Dent Res 2004

Patients Referred 1997-2006 (Pre & Post Radiotherapy n=590 patients) D MacCARTHY 2007

0

20

40

60

80

100

120

140

160

180

200

1997-1998

1999-2000

2001-2002

2003-04 2005-06

3-D Column 1

Patient Age at Baseline (Pre Radiation n=709) D MacCARTHY 2007

0

5

10

15

20

25

30

35

% Subjects

< 24 years

25-34 years

35-44 years

45-54 years

55-64 years

65-74 year

75 + year

2%4%

8%

26%

32%

20%

Dental Hard Tissues D MacCARTHY 2007

0

5

10

15

20

25

30

35

40

45

0 1 to 10 11 to 20 21 +

Teeth Present

Prevention as key strategy in the care of the dry mouth post radiotherapy

Dental treatment planning

Retain teeth if possibleCompliance?

Dental Care Considerations

Dental extractions (10-14 days pre radiation)

Radiation stents Discuss the risk of osteo-radio necrosis Maintain mandibular movement

• Advise regarding dry mouth• Dietary advice and caries prevention

therapy• Oral hygiene instruction & scaling• Smoking cessation advice• Education, motivation & support

Dental Extractions Required at Baseline

D MacCARTHY 2007

0

10

20

30

40

50

60

0 1 to 10 11 to 20 21 +

% ExtractionsRequired

Radiation stent to spare healthy tissue

Dry Mouth - what do our patients find most useful?Patient Survey in Dublin Dental Hospital in 2005 (n=120) D MacCARTHY C WALDRON 2007

Water (99%) Sugar free gum (70%) BioXtra or Biotene gel (70%) Mouth Kote (30%)

Caries Prevention

Dietary

Oral hygiene

Stimulate Saliva

Replace

Chemical agents – mouthwashes & gels

10 minutes a day!

Oral Hygiene, Gingival & Periodontal Health

Oral Hygiene

Smoking Habits in Pre-radiotherapy Head and Neck Cancer Patients. MacCarthy D*, Glass GB, O’Regan M (2006)

0

5

10

15

20

25

30

% Patients

Never smoked

Quit longterm

Quit recently

Current smoker

27%22%

25%26%

Relationship between smoking and periodontal disease

0

5

10

15

20

25

30

35

40

45

50

Never Quit Recent Smoker

CPITN 0

CPITN 1

CPITN 2

CPITN 3

CPITN 4

Baseline periodontal status, oral hygiene and smoking habits in head and neck cancer patients. D MacCarthy, B Glass, M O’Regan. J Clin Perio Supp 7;Vol 33(abs 88) p 139: (2006).

Patient Education

Written information

Internet

Dental hygienist

But, prevention does not

always work predictably

in this patient group…

Restoration of post -

radiation dental caries

Mean proportions of selected bacteria from biofilms developing on root surfaces with and without caries (Bowden 1990)

Root Surface Caries

Bacterium Sound Initial (soft)

ACTIVE LESION

Advanced (hard)

INACTIVE LESION ??

Mutans streptococciStreptococcus sanguinisActinomyces naeslundiLactobacillusVeillonella

21912NDND

34111314

8481312

Management of Root Caries

Chemical therapy – fluoride & chlorhexidine

Recontouring of tooth to remove undermined tooth structure

Restoration of carious lesion

Chemical Therapy for Dental Caries

Increasing regular daily delivery of fluoride reduces root caries, irrespective

of the type of fluoride treatment

Evaluation of different fluoride treatments of initial root carious lesions in vivo. Fure & Lingstrom, Oral Health Prev Dent 2009

Fluoride has a beneficial effect on root caries. Richards, Oral Health Prev Dent 2009.

Restoration of Root Caries

Composite - microfil CompomerGlass Ionomer

Sandwich technique

Glass Ionomer Cements

Release fluoride Reabsorb from topically applied fluoride Controversial

Uptake and release of fluoride by saliva-coated glass ionomer cement. Amen, Buijs & tenCate 1996

Fluoride release / uptake from newer glass-ionomer cements used with the ART approach. Gao, Smales & Gale 2000

Fluoride release and uptake by glass-ionomers and related materials and its clinical effect. Forsten 1998.

Implants

Reduced saliva makes denture wear difficult Implants very useful in dry mouth to aid

retention of prostheses

Placement of implants into irradiated bone must be approached with caution – radiation dose above 40Gy, field including neck

Extractions post-radiation treatment Contact radiation oncologist field & dose Refer to oral surgeon

If not possible to extract, root canal treatment and sleeper may be best option

Dental Supportive Care for the Head and Neck Cancer Patient

Objective of dental treatment is to achieve oral health, comfort, function

Education : OHI, diet, fluoride use, jaw exercises and smoking/ alcohol cessation

Longterm Oral Care for the H&N Cancer PatientA parternership between GDP and Specialist

Early diagnosis and constant review Motivate patient to attend appointments Do not extract if tooth in radiation field or if history of

bisphosphonates Monitor for tumour recurrance and ORN OHI & scaling Dietary advice and fluoride/chlorhexidine therapy Smoking cessation advice and support Monitor for oral infection – caries, periodontal, candidal

Restore when necessary

Role of the TeamSupport, maintenance, intervention for oral health

Patient Reception staff Dental nurse Dental hygienist Dental technician Oral surgeon Prosthodontist Periodontist General dental practitioner Community dentist

Thank you for your attention