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					  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 Dentistry
   School 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
         Saliva Flow Rates


               Normal Saliva      Reduced Saliva
                  Flow                Flow


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


Stimulated      1 – 2 ml/min        <0.4 ml/min
Mouth Problems Post Radiotherapy
Patients Primary Complaint
              Difficulty
               Eating           Other
                 4%              13%



         Sensitive
          Teeth
            4%
                                             Dry Mouth
                                                79%




  Patient Preference in the Management of Radiation Induced Dry Mouth
  Mac Carthy and Waldron
Post-radiation DENTAL CARIES
H&N Radiation Treatment

Effect on salivary               Effect on bone – bone
glands - no saliva                cells & blood flow



                                     Risk of osteo-radio
Risk of caries
                                      necrosis (ORN)

                 Dental extraction
 Limited mouth opening - trismus


 3 finger test


 Wood sticks     • 5% - 38% prevalence


 Therabite
Profile of our Patients




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

                                                  Patients by residence


                                                5%
                                         11%

                                                                          Dublin
                                       8%                                 Rest of Leinster
                                                              48%
                                                                          Munster
                                                                          Connaught
                                                                          Ulster
                                         28%




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


    200
    180
    160
    140
    120
    100
     80                                             3-D Column 1
     60
     40
     20
      0
          1997-   1999-   2001-   2003-04 2005-06
           1998    2000    2002
     Patient Age at Baseline
     (Pre Radiation n=709)
     D MacCARTHY 2007


35

30

25                                         < 24 years
                                           25-34 years
20                             32%         35-44 years
15                                         45-54 years
                         26%         20%
                                           55-64 years
10                                         65-74 year
                    8%                     75 + year
5
               4%
0         2%
                      % Subjects
Dental Hard Tissues
 D MacCARTHY 2007
45
40
35
30
25
20                                       Teeth Present

15
10
5
0
      0      1 to 10   11 to 20   21 +
Prevention as key
strategy in the care
 of the dry mouth
 post radiotherapy
Dental treatment planning




   Retain teeth if possible
   Compliance?
  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




  60

  50

  40

  30                                           % Extractions
                                               Required
  20

  10

   0
         0         1 to 10   11 to 20   21 +
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)


30

25

20
                                           Never smoked
15                                         Quit longterm
         27%                     26%
                         25%               Quit recently
                 22%
10                                         Current smoker

5

0
                  % Patients
        Relationship between smoking and
        periodontal disease
   50
   45
   40
   35
                                                                                  CPITN 0
   30
                                                                                  CPITN 1
   25
                                                                                  CPITN 2
   20
                                                                                  CPITN 3
   15                                                                             CPITN 4
   10
    5
    0
           Never             Quit           Recent          Smoker

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)   Advanced (hard)

                                     ACTIVE            INACTIVE
                                     LESION            LESION ??

Mutans streptococci         2            34                    8
Streptococcus sanguinis    19            11                   48
Actinomyces naeslundi      12            13                   13
Lactobacillus              ND            1                     1
Veillonella                ND            4                     2
   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
    Compomer
    Glass 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 Patient
A 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 Team
Support, 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