Dental Care and Mouth Conditions Flashcards
Teething
pathophys
how many complete permanent teeth do adults have?
- Around 6 months lower central incisors erupt first
- Continue to 2-3 years of age
- 5-6 start to fall out
32 teeth
- 4 incisors
- 2 canines
- 4 premolars
- 6 molars in each arch
Teething
symptoms
2/3 of children experience
- gingival irritation (87%)
- irritability (68%) and drooling (56%)
- a decrease in appetite for solid food
- an increase in thirst
- a mild increase in body temperature (up to 37.7°C)
- loose stools
- ear rubbing and nasal congestion
Symptoms may appear up to 4 days prior to tooth eruption and resolve 3 days post eruption
Teething
Non-pharm
- chew and bite on a frozen face cloth or coolted teether
- rubbing with back of cold spoon
- avoid long term contact with very cold items
- teething biscuits not recommended (sugar) and amber necklaces lack evidence
Teething
Pharm
- Oral analgesics (e.g., acetaminophen or ibuprofen) can be used
Dental Care
when to brush teeth?
when to see dentists
Brush teeth after every meal and at bedtime (with toothpaste)
- soft bristles, replace every 3 months
- powered toothbrushes are better
- See Dentist/Dental Hygienist q 6 months
- The Canadian Dental Association recommends dental assessments for infants within 6 months of the first tooth erupting and at least by the age of 1 year
Dental Care
Dentifrices (toothpaste) functions (4)
- minimize plaque and tartar
- strengthen enamel with dluoride
- remove stains
- freshens mouth
- look for Canadian Dental Association seal
mouthwashes suggested as an adjunct
Chlorhexidine is common prescription dispensed used once or twice daily
can cause staining, discoloration, taste disturbances
Dental Care
Fluoride function?
what happens with excess intake (4)
- Locally reduces demineralization and promoting remineralization of early caries
- children < 3 rice sized amount, 3-6, pea- sized amount
- Most toothpastes contain 0.243%
- excess leads to Gastric distress, headache, weakness, can cause skeletal fluorosis (joint pain)
Aphthous Ulcers/Canker sores
describe (1)
greater freq in who?
inflammatory, non-infectious lesions
- Can be painful, leading to difficulties eating, speaking, and swallowing
- 50% of indiv have recurrences
- Greater frequency of occurrence in those aged <40, female sex, family history, and higher socioeconomic class
- freq and severity decreases with age
Aphthous Ulcers/Canker sores
pathophys (1)
unknown cause, multifactorial
potential risk factors: local trauma, stress, allergies, genetic, systemic disease, hormone change, preservatives, NSAIDs, nutritional deficiencies, foods (chocolate, coffee, strawberries, tomatoes, citrus)
Aphthous Ulcers/Canker sores
Minor aphthae (70-87%)
- describe characteristics
- location
- Single or multiple (1-5) lesions with whitish-grey pseudomebraneous centers,
erythromatous halos, and defined, raised margins - Commonly <1cm in size
- Found on lips, cheeks, under the tongue, floor of mouth, or soft palate
- Localized discomfort may precede appearance of lesion(s)
- Usually heal spontaneously within 7-10 days without scarring
Aphthous Ulcers/Canker sores
Major aphthae (7-20%)
- describe characteristics
- location
- Similar in appearance to minor aphthae, but are more severe, numerous (1-10), and larger in size (>1cm).
- Can be found on the salivary glands and throat (and therefore make swallowing
difficult) - Common in patients infected with HIV
- Can persist for weeks or months and often scar
Aphthous Ulcers/Canker sores
Herpetiform aphthae (5-10%)
- describe characteristics
- location
- Multiple clusters of pinpoint ulcers that may coalesce into a widespread, irregular
lesion (2-3mm in diameter but 10-100 in number) - Usually heal in 7-30 days and may scar
- More common in women and have a later age of onset
Aphthous Ulcers/Canker sores
Other conditions with similar presentation (name a few)
Fever, vesicles, lesions elsewhere on the body, or other systemic symptoms (e.g., diarrhea) may indicate \_\_\_\_\_\_\_?
- infections, GI disease (Crohn’s), autoimmune (lupus), vit deficiencies (iron, folate, B-vitamins), cancer/pre-cancerous lesions (white thickened patches on the oral mucosa may indicate pre-cancerous lesions associated with tobacco use)
non-oral issue from other conditions
Aphthous Ulcers/Canker sores
Red Flags
size, duration, number
- Pain is debilitating Ulcer size > 1 cm Duration > 14 days > 5 ulcers present Multiple clusters that are coalescing Reoccurring history (6-12 times/year) of ulcers that last > 14 days and scar Systemic symptoms present Ulcers on gums or hard palate Immunocompromised (e.g. HIV) Ulcers and blisters present on other parts of the body (e.g. skin, eye, genitalia)
Aphthous Ulcers/Canker sores
Goals of Therapy (5)
- Control local pain Reduce duration of ulcers Restore normal oral function Ensure adequate food and fluid intake Decrease frequency and severity of recurrences
Aphthous Ulcers/Canker sores
Non-pharm treatment (4)
Avoid foods which cause pain
- e.g. hard or salty foods
Address sources of oral trauma
- e.g., use soft toothbrushes, fit dentures properly
Maintain regular daily oral hygiene
Cleanse mouth with salt and water
- Dissolve ½ to 1 teaspoonful of table salt in 250mL warm water. Rinse / swish after each meal.
Aphthous Ulcers/Canker sores
pharm treatment (3 types)
(first 3)
Protectants
- Hydroxypropyl cellulose or carboxymethyl cellulose patches placed over lesions may provide pain relief and protection during healing
Local anaesthetics
- Benzocaine or lidocaine applied with a finger or cotton swab QID (or more often) provides temporary pain relief
- Should be used cautiously or avoided in children <2 due to risk choking and increased absorption leading to methemoglobinemia.
Systemic therapy (OTC or prescription)
- Aside from acetaminophen for pain relief, reserve for severe cases, or those due to underlying conditions
- Colchicine, montelukast, dapsone, infliximab, thalidomide
Aphthous Ulcers/Canker sores
pharm prescription treatment (3 types)
(the last 3)
topical agents are considered first-line therapy
Topical anti-inflammatories / steroids
- e.g., triamcinolone 0.1% (Oracort®)
- Intended for pain relief, not prevention, better efficacy if started early
- Dab on area, do not rub
- No food/drink 30 minutes after application
- Adverse effects: oral candidiasis (look for white patches = candidiasis)
- Good option for APA prescribing
-Dexamethasone ointment
(May show faster healing of ulcer, may need to be compounded)
Topical anaesthetics
Benzydamine 0.15% rinse
Swish and gargle q3h prn – do not swallow!
Topical antibiotics / mouthwashes (compounded)
e.g., tetracycline 5%, minocycline 2%, penicillin G
Reduces pain, ulcer size, and duration of episodes
Used QID for 10 days, Retain in mouth for ~1-2 minutes then spit out
Adverse effects: oral candidiasis, sore throat, stained teeth, bacterial resistance
Aphthous Ulcers/Canker sores
Common OTC Products
OTC
Kank-A® (benzocaine 20%)
Orajel® (benzocaine 10-20%)
Amosan Cleanser® (sodium perborate)
Aphthous Ulcers/Canker sores
Prevention (name 3)
- Avoid local trauma (e.g., biting)
Reduce emotional stress (e.g., relaxation)
Address nutritional deficiencies
Calcium, vitamin C, iron, zinc, folic acid and vitamins B1, B2, B6 and B12
Identify and eliminate foods that cause hypersensitivity (e.g., citrus fruits or sodium lauryl sulfate in toothpastes)
Identify and manage drug-induced causes (e.g.,
NSAIDs, beta-blockers, ACE-inhibitors, opioids)
Treat underlying systemic disease
Aphthous Ulcers/Canker sores
Monitoring
F/U
- when to f/u and refer
- monitor for pain healing daily to every 3 days
- f/u 7-14 days
- > 14 days refer
Halitosis
Classification (3)
- Genuine – malodor is truly present
- Pseudohalitosis – odor is of concern to the patient, but is not perceived by others
- Halitophobia – despite treatments for halitosis and or lack of physical or social evidence for malodor, the patient believes halitosis is present
latter 2 psychological component
Halitosis
Pathophys (3 causes)
Halitosis
- Putrefactive process – the decomposition of organic matter by microorganisms, especially at the back of the tongue
- the transition of gram (+) bacteria to anaerobic gram (-) bacteria that are proteolytic that overproduce volatile sulfur compounds (VSCs) - disease or malfunction of oral tissues
- gingivitis, dental abscess - Extraoral pathologic halitosis may originate from sources other than the mouth
- e.g., nose or digestive tract
Halitosis
risk factors
- Use of systemic antibiotics or antibacterial mouthwashes can cause overgrowth of anaerobic bacteria/fungi
- decreased salivation
- reduced carb intake, body breaks down fat and protein leading to fruity breaht
- xerostomia
Halitosis
pt assessment (3)
- obtain full medical and dental history (oral practices)
- obtain lifestyle history (foods consumed, etc)
- assess temporal relationships (after waking, after eating)
Halitosis
Goals of therapy (5)
Identify and resolve causes
Eliminate or minimize signs and symptoms
Encourage safe and effective oral hygiene
Prevent recurrences and complications
Improve self-confidence and quality of life
Halitosis
Management – Non-Pharm (3)
Maintain good oral hygiene practices
Use a soft-bristled toothbrush BID (especially on the back of the tongue) and floss daily
Treat periodontal diseases, Avoid over-cleaning
Increase salivary flow
e.g., ensure adequate water intake, chew sugarless gum, eat fibrous vegetables like celery
Avoid potential causes
e.g., foods known to cause malodor, alcohol, tobacco,
caffeine
Halitosis
Management – Pharm
Mouthwashes
- mask odor, anseptic
- temporary benefit
- swished deeply gardled before bedtime
- xerotstomia pdts
Halitosis
Common OTC/Rx (3)
2 OTC, 1 Rx
Listerine® products
- Contain eucalyptol, menthol, zinc fluoride, etc.
Crest® or Cepacol® products
- Contain cetylpyridinium (may reduce bad breath within 2 weeks)
Chlorhexidine 0.12% (Rx)
- Has antibacterial properties, but should not be used for longer than 1 week at a time
Halitosis
NHPs (5)
many in gum Chlorophyll Parsley Menthol Mint Mangosteen little evidence
Halitosis
Monitoring - when improved?
F/U - how many days
- improvement in 1 week
- monitor for side fx with mouth washes for stains
- F/U 7 days
Xerostomia
what is it?
- technically subjective
- salivary hypofunction, but also can be normal
- common in women, 1 in 5 adults
- more in older individuals
Xerostomia
pathophys
what kind of conditions can lead to this?
Not a disease itself, but rather a manifestation secondary to a medical condition, drug, or radiation treatment.
Examples include:
Autoimmune diseases (e. ., Sjögren syndrome)
Endocrine disorders (e.g., diabetes)
Genetic conditions (e.g., cystic fibrosis)
Neurologic and psychiatric disorders (e.g., Parkinson’s)
Viral infections (e.g., HIV, mumps)
Miscellaneous (e.g., dehydration, bone marrow transplant)
*Medications (e.g., anticholinergics, antihistamines,
benzodiazepines, NSAIDs, etc., etc.)
Xerostomia
Symptoms (5)
Dental caries (cavities) Difficulty eating dry foods Lipstick adheres to front teeth Saliva appears stringy or foamy Swollen oral mucosa due to overgrowth of Candia albicans
Xerostomia
Complications (3)
Decreased ability to chew / swallow
Avoidance of foods
Decreased nutritional status
Inhibition of taste
Impaired ability or willingness to speak
Oral / dental infections
Increased dental caries
Tooth losses
Discomfort wearing dentures
Xerostomia
Pt assessment
- drugs or diseases
- eating difficulties
- timing (during day or night)
- day: hypofunction
- night: sleep apnea, nasal congestion
Xerostomia
what is chronic atrophic candidiasis
what to do in this case?
REFER
- Symptoms of regional or generalized mucosal pain, often described as “burning”
- Inability to eat acidic or spicy foods, leading them to make changes in their diet
- Cheilitis, seen as “cracks” in the corners of the mouth
Xerostomia
Goals of therapy (2)
- Relieve symptoms and improve mouth comfort
- Prevent complications
Xerostomia
Management – Non-Pharm (3)
- dental care (avoid sugary or acidic foods)
- stimulate salivary flow (gum, candies with alcohol based sugars)
- water consumption (frequent sips of water, suck on ice chips
- petroleum jelly for lips
Xerostomia
Management – Pharm (1)
Saliva substitutes
Replace moisture and lubricate the mouth
Mimic saliva but do not stimulate production
Due to swallowing, product is easily washed away
i.e., not a permanent solution and does not decrease risk of complications
Little evidence for one product over another
All contain hydroxymethylcellulose or
carboxymethylcellulose, electrolytes, and flavorings
Xerostomia
Common OTC (recognize only)
Moi-Stir® spray or swabs
Mouth Kote® has yerba santa
OraMoist® patches that dissolve in 2-4 hours
Oral Balance® gel
Biotene® toothpaste, mouthwash, gel, spray
Moisture is available as a spray or swabs and contains electrolytes
Yerba santa thins out saliva
Oral moist patch is composed of synthetic polymers
Patch inside of cheeks or hard palate and dissolves over a period of 2-4 hours
Oral balance gel is a moisturized containing a synthetic polymer for pt with dry mouth secondary to radiation
More relief to pts with severe xerostomia
1 hour of day and 4 hr of night relief
Pilocarpine drops in water (1-2%) - without side effects
Xerostomia
Rx (3)
MOA
Sialogogues - promotes secretion of saliva
Salagen® - pilocarpine
MOA: a cholinergic agonist that stimulates exocrine glands
Onset/duration: 1 hour / 3-5 hours
Adverse effects: dizziness, headache, hyperhydrosis, skin flushing, tachycardia, taste perversion
Anethole trithione
MOA: stimulates the parasympathetic nervous system to increase acetylcholine production
Efficacy not fully established
Adverse effects: diarrhea, urine discoloration
Fluoride
Applied to prevent dental caries. Commonly administered by dental health professional, but also available as toothpastes and mouthwashes used BID
e.g., Clinpro 5000®
Xerostomia
Monitoring and F/U
- improvement time?
- time for f/u?
- improve in 1 week
- give diff suggestion if not working and then refer
- f/u 7 days
