438 Oral care

Exam 3

Describe tooth anatomy

Crown - for mastication and chewing

Neck - In gumline

Root - support and attach tooth to surrounding tissues

Gum - gingiva

Enamel

Symptoms of caries

No initial symptoms, but a progressive lesion on tooth

• Sensitive to stimuli (heat, cold, sweetness, chewing)

• Continuous pain + difficulty chewing if lesion invades dental pulp

• Can progress to abscess and tooth loss

Caries etiology

Carbohydrates in diet

Oral bacteria

Host resistance alterations (orthodontic appliances, xerostomia, medications, radiation therapy, tobacco product use, alcohol use, immune system dysregulation)

Do not self-treat caries/when to refer

Symptoms of toothache, visualized lesion, entire tooth discoloration, bleed/swelling/reddened gums, persistent mouth odor despite use of fluoride toothpaste

Goals of therapy caries

Prevent or control dental plaque

Difference between plaque and calculus

Plaque - fresh/soft deposit removed by teeth brushing

Calculus - harder form of plaque removed by professional cleaning

Gingivitis symptoms

Inflamed gingiva, may progress to periodontal disease

Gingivitis etiology

Accumulation of supragingivial (above gingiva) bacterial plaque

Medications (calcium channel blockers, cyclosporine, phenytoin)

Reduced saliva flow (anticholinergics, antidepressants)

Tobacco

Pregnancy (hormones, connective tissue changes)

When to refer gingivitis

Swollen gums

Gums that bleed with brushing or flossing

Receding gums

Darker red gums

Goals of therapy gingivitis

Prevent calculus formation, remove and control supragingivial plaque

Dietary non-pharm options for caries and gingivitis

Avoid highly cariogenic (caries-causing) foods

• 15% or more sugar

• Sticks to teeth

• Can remain in mouth after being chewed

Drink adequate water

Non-pharm options for plaque removal

Chewing sugarless gum x 20 min after a meal

Brushing & flossing (adults & children older than 5 years, electric or non)

Dental floss: at least once daily (no difference w wax)

Irrigating devices-removes minimal amount of plaque; supplement to brushing & flossing

Non-pharm options for caries and gingivitis prevention

Activated charcoal (novelty)

Probiotics - possible benefit for gingivitis prevention

Vitamin D - adequate vit D during pregnancy can reduce caries in children

Xylitol (sugar alcohol in sugarless gums) - no stat benefit

OTC treatment options for chemical plaque management + follow up

Fluoride, dentifrices (toothpastes), mouthrinses

Follow up with professional dental cleanings every 6 months

Toothpaste use in adults

Size of pea, BID

Soft toothbrush, change every 3-4 months

Use fluoride-containing toothpaste

Hold at 45° angle

Floss daily

Toothpaste use in children

Start brushing when teeth erupt with fluoride toothpaste

Younger than 3 - size of rice grain; older - pea size

Supervise and have parental education

Don’t use too much fluoride (flescks/stripes/brown spots on teeth, enamel pits)

Pharmacologic methods of prevention of caries and gingivitis

Dentifrices and ingredients

Dentrifrices for prevention of caries and gingivitis

Act directly on oral bacteria or disrupt plaque components to aid in mechanical removal by removing plaque/stains, reducing mouth odors, enhancing physical appearance

Ingredients in dentrifices

Abrasive (removes particles and superficial stains)

Humectant (moistening agent)

Sweetener, flavor

Surfactant (foaming and particle removal)

Binder/thickener (holds all ingredients together)

Anticaries activity agent

Dentrifrice abrasive categories

Low abrasion: 10-25% silica abreasives

Mild abrasion: baking soda

High abrasion: 40-50% (dicalcium phosphate, calcium pyrophosphate, calcium carbonate, alumina trihydrate)

Fluoride anticaries agent

Sodium fluoride & sodium monofluorophosphate - remineralize, strengthen weakened enamel, reduce gingivitis and sensitivity

Stannous fluoride - above + adds protective layer over teeth to prevent plaque, slight staining if use continuously for 2-3 months, removed at professional cleaning

Significance of fluoride

Fluoride is necessary, otherwise oral hygiene fails to reduce cavity incidence

Whitening dentrifices ingredients

NOT tooth-bleaching products

Baking soda, titanium dioxide, aluminum oxide +citrate salt + papain, peroxides

Chemotherapeutic agents that can be combined with whitening dentrifrice

Fluoride, potassium nitrate, stanous flouride, metal salts, essential oils, hydrogen peroxide, sodium bicarbonate

Plaque control mouthrinses ingredients + MOA

Aromatic oils: antibacterial, local anesthesia

Anticrobials: bactericidal activity

Phenol: local anesthetic, antiseptic, bactericidal activity

Mouthrinse adverse effects + cautions

AE - occasional burning, irritation of oral mucosa; maycause sloughing of oral epithelium

C - mouth ulcers or irritation, keep away from children, alcohol content issues (poisoning, oral cancer)

Mouthrinse use

Use 1-2 tbsp, 1-2x daily

Most effective before brushing except if it contains fluoride

Don’t eat/drink 30 mins after

Supervise under 12 yrs

Plaque control with gum

Increased saliva flow and mechanical removal of debris

Chew after eating, sugarless gum only

Halitosis symptoms

Bad breath caused by volatile sulfur compounds

Systemic and oral causes of halitosis

Systemic

• Medications: TCAs, first-gen antihistamines, oxybutynin, meclizine, Parkinson’s meds

• Kidney/liver failure

• Cancer

• Ketosis

Oral

• Poor hygiene

• Xerostomia

• Foods/beverages

• Garlic or onions

• tobacco

To not self-treat halitosis

Medical conditions associated with halitosis, persistent halitosis despite good oral hygiene

Mechanical and chemical halitosis prevention

Mechanical

• Tongue brushing

Chemical

• Zinc salts (reduce receptor binding for VSCs)

• Chlorine dioxide (breaks disulfide bonds, oxidizes VSC precursors)

Oral pain causes

Exposure of dentin, injury to mouth or lips or with RAS or herpes simplex labialis, nerve pain of face, facial herpes zoster, cluster headaches

Dentin/tooth hypersensitivity

Develops due to exposure dentin and dentin tubules opening to oral cavity and tooth pulp

Oral pain symptoms

Short and stabbing/sharp

Chemical/physical stimulus to dentin reaches open tubule, tubule fluid flow increased → nerve stimulation → pain

Pain from hot, cold, sweet, sour liquids; hot or cold air on teeth

Do not self-treat for oral pain

Toothache

Mouth soreness associated with dentures

Fever or swelling

Loose teeth

Bleeding gums

Broken teeth

Severe tooth pain started or worsened by hot, cold, or chewing

Trauma to the mouth

Goals of therapy for oral pain

Repair damaged tooth surface via appropriate toothpaste

Correct inappropriate toothbrushing technique

Non-pharm options for oral pain

Stop triggers (acidic foods, aggressive toothbrushing)

Avoid toothbrushing within 30-60 min of acidic foods/drinks

Correctly brushing teeth with fluoride toothpaste

OTC treatments for oral pain

Standard toothpaste withfluoride

Desensitizing toothpaste (potassium nitrate 5% + fluoride, arginine 8% + calcium carbonate)

Follow up for oral pain

Standard toothpaste with fluoride & soft bristled brush

• Continue if resolution after 7 days

14 days of desensitization toothpaste

• If resolved, switch to regular strength fluoride toothpaste

• Otherwise, refer

Potassium nitrate 5% + fluoride MOA + indication

Depolarizes nerves in tubules & pulp to block perception of stimuli;

seals exposed dentin

For hypersensitivity

Potassium nitrate 5% + fluoride PD

Onset 2 weeks

Duration of use and beyond

Potassium nitrate 5% + fluoride SE + DI

No SE

DI with sodim or stannous fluoride: calcium in foods/supplements

Potassium nitrate 5% + fluoride avoid, pregnancy, lactation

Avoid high abrasion toothpastes, whitening toothpastes

No concern in pregnancy or lactation

Potassium nitrate 5% + fluoride dosing

Brush with 1 inch strip BID

Arginine 8% + calcium carbonate MOA and indication

Depolarizes nerves in tubules & pulp to block perception of stimuli

For tooth sensitivity

Arginine 8% + calcium carbonate PD

Onset is 2 weeks

Duration of use and beyond

Arginine 8% + calcium carbonate SE + DI + avoid

No SE or DI

Avoid using fluoride toothpaste at same time

Arginine 8% + calcium carbonate dosing

Brush with 1 inch strip BID for an entire 2 weeks

Recurrent aphthous stomatitis (RAS)

Canker sore or aphthous ulcer

RAS etiology

Unknown for most patients

Triggers: stress, local trauma, food allergy/gluten sensitivity, hormonal

changes, genetic predisposition

• Systemic diseases (e.g. SLE, allergies, IBD, nutritional deficiencies, HIV)

RAS signs and symptoms

Epithelial, circular ulcer on nonketatinized, movable mouth surfaces

• Last 5 to 14 days, 0.5 to 2 cm

Do not self-treat RAS

If underlying cause

• Lesions present 14 days or more

• Frequent recurrence

• Sx of systemic illness

• Self-care ineffective

Goals of therapy for RAS

Relieve pain & irritation

2. Heal lesions

3. Be able to eat/drink & do usual oral care

4. Prevent secondary infection

5. Prevent recurrence

Non pharm options for RAS

Correct any diagnosed nutritional deficiencies

• Avoid food allergy triggers

• Avoid spicy/acidic foods if active lesions

• Avoid textured foods that can irritate lesions

Apply ice to lesions x 10 minutes; max 20 minutes in an hour

DIY salt water rinses (table salt in tap water, swish then spit)

OTC treatment options for RAS

Topical

1. Oral debriding & wound

cleansing agents

2. topical oral anesthetics

3. topical oral protectants

4. oral rinses

• Systemic : analgesics

Follow up for RAS

7 days of treatment or 14

days since lesion/s first

appeared

• Side effects of topicals: see

medical provider

Oral debriding and wound cleansing agents

Carbamide peroxide 10% to 15% in

anhydrous glycerin

• Hydrogen peroxide 3% (DIY)

• Sodium perborate monohydrate

• Sodium bicarbonate (DIY)

•

Oral debriding and wound cleansing agents MOA + use

Release of molecular oxygen

Use up to 4x daily for 7 days

Oral debriding and wound cleansing agents SE + avoid

Mouth tissue irritation

• Short-term tooth hypersensitivity

• Black hairy tongue

Avoid toothpastes containing sodium lauryl sulfate

Dosage/administration of carbamide peroxide 10% to 15% in anhydrous glycerin

Drops of carbamide peroxide

or hydrogen peroxide applied

x 1 min

• Rinse: carbamide peroxide

drops on tongue, mix with

saliva, swish x 1 min

Dosage/administration of hydrogen peroxide 3% (DIY)

50:50 mix of hydrogen

peroxide 3% & water: swish x

1 min

Dosage/administration of sodium perborate monohydrate

Sodium perborate

monohydrate powder:

dissolve in 1 oz water & use

right away

Dosage/administration of sodium bicarbonate (DIY)

Thick paste, expectorate

Topical anesthetics for RAS

*Benzocaine 5% to 20%

• *Butacaine sulfate 0.05% to 0.1%

• *Dyclonine 0.05% to 0.1%

Topical oral protectants and rinses for RAS

Barrier protectants protect, decrease frition, and provide temporary relief

• Coat ulcers with topical oral protectants (denture adhesive, dissolvable patch, dissolves after 8-12 hrs)

Rinses like Listerine or saline rinse (1-3 tsp salt in 4-8 oz warm tap water)

Minor oral mucosal injury/irritation etiology

Dental procedures

• Accidental injury: biting tongue/cheek, abrasion from sharp foods

DNST minor oral mucosal injury/irritation

Same as tooth hypersensitivity

Goals of therapy Minor oral mucosal injury/irritation

Control discomfort, aid healing, prevent secondary bacterial infection

Nonpharm therapy for Minor oral mucosal injury/irritation

Sodium bicarbonate

• Baking soda ½ to 1 tsp in 4 oz water; swish x 1 minute then expectorate; discard extra; fresh each time

• Saline rinse

• MOA: debride, clean wound, stimulate health

• Salt 1 to 3 tsp in 4 to 8 oz warm water

• Ice x 10 minutes (max 20 min in an hour)

Pharmacotherapy of Minor oral mucosal injury/irritation

Same as RAS:

1. Topical analgesics and anesthetics

2. Oral protectants

3. Oral debriding/wound cleansing

• Astringents: tissue contraction, stop secretions

When to refer for Minor oral mucosal injury/irritation

Sx persist after 7 days treatment or 10 days of initial injury

 Sx gets worse during treatment

 Sx of infection develop (fever, redness, swelling)

Causes of herpes simplex labialis (HSL)

HSV-1, HSV-2, CMV, Epstein-barr virus, infected for life

Symptoms of HSL

Prodrome - burning, itching tingling, numbness

Visual - small, red papules of fluid-filled vesicles, inflamed border, crust on top of mature lesion

Spontaneous healing over 10 days

When to refer HSL

• lesions present more than 14 days

• increased outbreak frequency

• symptoms of infection (fever, swollen glands, rash)

• no prior cold sore

goals of therapy HSL

relieve pain and irritation, prevent secondary infection, prevent spread of lesions

non-pharm options for HSL

keep lesions clean

handwashing

avoid sharing utensils, drinking vessels

moisturize involved skin (petroleum jelly w clean finger)

avoid triggers that slow healing (stress, local trauma, wind/sun, fatigue)

facial/lip sunscreen if sun is trigger

tea tree oil, lysine, lemon balm

OTC treatment options for HSL

topical skin protectants

external analgesics/anesthetics

docosanol 10%

follow up recommendations for HSL

14 days

docosanol 10% cream MOA

inhibits fusion of virus to cell membrane, prevents viral infection

docosanol 10% cream indication

reduce duration and severity of HSL symptoms

docosanol 10% cream PD

decreases time to heal by ~1 day

docosanol 10% cream SE

none

docosanol 10% cream DI

none

docosanol 10% cream avoid

placing aspirin tablet on lesions, hydrocortisone, astringents, zinc sulfate

docosanol 10% cream dosing

apply 5x/day starting in prodrome until lesion healed, max 10 days

xerostoma

dry mouth

xerostoma etiologies

health conditions: sjogrens, diabetes mellitus, depression , crohn’s disease

radiation therapy

medications: 1st gen antihistamines, decongestants, diuretics, TCAs, antipsychotics, sedatives

excessive alcohol consumption

tobacco use

excessive caffeine use

mouth-breathing

xerostoma symptoms

dry mouth (less than 1.5 L saliva in 24 hrs)

difficulty talking, swallowing

mouth sores

haliotosis

altered taste, loss of appetite

tooth hypersensitivity

overtime: caries

when to refer xerostoma

tooth erosion, decay

candidiasis (fungal infection), gingivitis

decreased denture-wearing time

mouth soreness due to dentures

fever or swelling

loose/broken teeth

severe tooth pain worsened by hot,cold, chewing

mouth trauma

sjogren syndrome

non-pharm options for xerostome

avoid triggers (tobacco, caffeine, alcohol, hot spice)

adjust or change causative meds if possible

limit sugary food/acidic food intake

chew gum with sugar alcohol (xylitol)

increase water consumption

cool mist humidifier in home

very soft bristled toothbrushes

OTC treatment for xerostoma

artificial saliva products (sprays, gels, gums, toothpastes)*

follow up recommendation for xerostoma

re-evaluate after 5-7 days of therapy

artificial saliva MOA

mimics natural saliva, replacement, not cure

artificial saliva indication

dry mouth

artificial saliva PD

onset minutes

duration few hours

artificial saliva se

hypersensitivity if preservatives

artificial saliva di

none

artificial saliva avoid

sodium-based products if low-salt diet, can decrease effectiveness

artificial saliva dosing

depends on product

gel: ½ inch of gel on tongue, spread throughout mouth

minimum frequency: after meals, at bedtime