July 1, 2014
by Adriana Gonzalez, RDH
Oral care providers must provide effective oral hygiene and prevention programs to their Medically Compromised Patients. These programs represent a rather varied and complex range of options, both in materials and regimens. The following is a general overview of a comprehensive range of tools, products and resources that support this group of patients, providing them with an improved oral environment that contributes to a healthier life.
WHO IS THE MEDICALLY COMPROMISED PATIENT?
As a result of advances in hygiene, nutrition, and medical science, we save more lives and live longer. Medical contributions have allowed damaged heart valves to be surgically replaced and occluded coronary arteries to be opened, revascularized, or replaced. Failed organs (liver, kidney, and heart) are transplanted. Cancer research has resulted in great advancements in cancer treatments, allowing people to live a longer healthier life. New medications have enhanced our quality of life; we can now control, among many other conditions, diabetes mellitus, hypertension and congestive heart failure.
All of these are wonderful medical advancements, but they are sometimes accompanied by side effects. For example, there are many diseases, medical treatments, and more than 500 medications that can cause xerostomia as a side effect, including 63 percent of the 200 most commonly prescribed drugs: tricyclic antidepressants, antipsychotics, atropinics, beta blockers and antihistamines.
Once xerostomia presents, its effects begin to manifest themselves in the oral cavity, compromising the patient’s oral health. One or more of the following clinical observations may be encountered: halitosis, mucositis, oral lesions, oral candida, rampant caries, and gum disease (Fig. 1).
Many clinical patients fall into the medically compromised patient category. How can the practitioner adjust current clinical treatment to serve these patients’ specific needs?
ORAL HEALTH TREATMENT PLANNING FOR THE MEDICALLY COMPROMISED PATIENT
There are three pillars in the foundation of an effective oral hygiene and prevention program for the medically compromised patient. The ideal oral health treatment plan includes:
1.An increase of saliva quality and salivary flow,
2.A daily disruption of the pathogenic biofilm, and
3.An increased protection and remineralization of tooth surfaces (Fig. 2).
1. Increase the quality of the saliva and salivary flow
Saliva has a direct link to balanced oral health. A commonality in medically compromised patients is that they experience xerostomia as a result of their illness or as a side effect of treatment or medication. The dry mouth creates an ideal environment for pathogenic microorganisms to develop, live, and multiply, further complicating the patients’ health by increasing the risk of stroke, heart attack, hypertension, bacterial pneumonia, immune deficiency, and other inflammatory disease. There is now clear evidence of direct links between periodontal disease and systemic health (Fig. 3).1-5
There are prescribed (Drug Identification Number) saliva stimulants and parasympathetics such as Pilocarpine, Bethanechol, Anethol Trithione, Sialor, medications that are beneficial to patients whose salivary glands are intact. This is NOT the case for patients who have undergone radiotherapy and may have compromised salivary glands. It is important to consider that these patients are often prescribed one or more medications during and after radiotherapy treatment, and thus both drug interactions and adverse side effects must be taken into consideration (Fig. 4).6
There are also non-prescription saliva stimulants available, with some approved by Health Canada (Natural Product Number) as saliva stimulating. X-PUR 100% xylitol gums/mints (Oral Science, Brossard QC) for daytime saliva stimulation and XyliMelts (Oral Science, Brossard QC) for nighttime saliva stimulation are indicated when dry mouth worsens. These unique products contain xylitol as a medicinal ingredient. Scientific data increasingly supports a regimen of xylitol-sweetened gum or lozenges as being very efficient in stimulating saliva. The action mechanisms are as follows: the perception of sweetness obtained from consuming xylitol stimulates the nervous system to produce saliva7-9 without providing cariogenic sugars that oral bacteria can consume (Fig. 5).
In addition to its value as a saliva stimulant, xylitol offers other benefits for the medically compromised patient:10,11
•Increased saliva pH
•Has antibacterial properties
•Low glycemic index, ideal for diabetics
2. Disrupt the pathogenic biofilm daily
With a decrease of salivary flow, there is an increase in pathogenic biofilm (Fig. 6). More pathogenic biofilm means more oral inflammation, which, in turn, links directly with inflammatory disease: gum disease, bone loss, tooth loss and caries. Biofilm removal and control is an essential part of the oral health treatment plan. In addition to regular dental hygiene visits and regular brushing, interdental biofilm removal is a must. Interproximal brushes are user friendly and have a higher compliance rate when compared to dental floss.12,13
Curaprox has developed an innovative chairside system that measures interdental spaces with a color-calibrated probe that corresponds to specific interproximal brush head sizes. This offers the dental team and the patient an effective and atraumatic means for removing interdental pa
thogenic biofilm. Dedicating time to chairside Oral Hygiene Instruction is a great opportunity to involve patients in their home care plan and to improve their commitment (Fig. 7).
3. Increase tooth surface protection and remineralization
In the medically compromised patient’s oral environment, natural remineralization and protection is often inadequate because there is a lack of free salivary calcium and phosphate ions due to the decreased salivary production and flow. Remineralization therapy and prevention has evolved from topical fluoride applications to a number of other approaches: anti-microbial therapies, oral hygiene instruction, diet recommendations, sugar substitutes, toothpastes and mouthrinses.14-16 The dental team is in the best position to determine which therapy or combination of therapies is best suited for their patients.
An example of an in-office treatment is the application of 5% NaF remineralizing varnish. This can be applied every one to six months depending on the severity of the patient’s clinical needs.
An example of a home care regimen is 1.1 % NaF gel applied in trays (five minutes/day), and/or the use of 0.2 % NaF rinse (daily) in combination with the topical application of CPP-ACPF (MI paste GC America, Alsip IL) or the daily use of X-PUR-REMIN toothpaste (Oral Science, Brossard QC). X-PUR-REMIN contains the innovative nano-particle medical hydroxyapatite (mHAP), which is virtually the same as the naturally occurring hydroxyapatite in teeth. mHAP helps to repair and protect the patient’s enamel and dentin, as it also provides an efficient anti-microbial effect.17 It is important to customize an Oral Health Treatment Plan to individual patient needs (Fig. 8).
IMPLEMENTING THE ORAL HEALTH TREATMENT PLAN
1. Diagnosis of the oral health problem
a.Thorough review of medical history and medications
b.Determine the patient’s oral pH
c.Assess the salivary flow and determine if it is low
d. Identify biofilm build up
e.Identify oral lesions
f. Conduct a caries assessment
2. In office treatment
b.Apply in-office fluoride treatment
c.Tailor OHI after removal of biofilm
d.Measure interdental spaces
e.Recommend saliva stimulating therapies
f.Recommend remineralizing therapies
g.Recommend oral hygiene appointment frequency
3. Home care treatment
a.Increase salivary flow with 100% xylitol gums and mints during the day and xylitol time releasing pastilles at night
b. Remove biofilm mechanically every day with a toothbrush and interdental brushes
c.Brush with an antimicrobial and remineralizing toothpaste
d.Apply fluoride by gel or rinse as prescribed by the dentist based on needs
4. Follow up care
a.Review recommended Oral Health Treatment Plan for efficacy at every appointment
b.Assess compliance to home care plan
c.Make necessary adjustments
Evidence suggests that the next decade will bring a significant increase in the medically compromised population. Knowledge about a wide range of medical conditions, prescription medications and their side effects is important; having a reliable up to date, comprehensive source for treatment protocols is vital.18,19 There are now very effective tools, products, and resources to support medically compromised patients for the purpose of making their lives better, healthier, and longer. It is the dental team’s responsibility to provide the patient-resource knowledge link to improve oral and systemic health. OH
Adriana Gonzalez is a Registered Dental Hygienist with over 17 years of experience.
Disclaimer: Aside from being a clinical Dental Hygienist, Adriana has held the position of Clinical/Hygiene Program Manager for Altima Dental Canada for over 5 yers, and is currently the Compromised Oral Health Specialist for Oral Science Canada with her focus being in the medical area. Adriana is also the co-facilitator for the ITop, Individually Taught Oral Prophylaxis, course. Adriana can be reached at firstname.lastname@example.org.
Oral Health welcomes this original article.
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