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  • Good morning. Thank you for inviting me to speak at this meeting
  • My own main area of interest is the post radiotherapy patient and I would like to focus on this patient group today
  • The saliva flow test can be simply done clinically getting the patient to drool saliva into a cup over a 5 minute period. Stimulated saliva flow is assessed similarly whilst patient chews wax, gum or a piece of rubber dam
  • Saliva is important for lubrication, remineralisation of teeth and clearance of debris from the mouth
  • Normal jaw opening is 40 – 50mm (3 fingers) This may be reduced following radiotherapy due to fibrosis Future impact on restorative dentistry and oral care
  • Four main centres in Cork, Galway, Belfast and Dublin. 75% of our patients are from Dublin and Leinster
  • The following tables relate to a mixed group of pre and post radiotherapy patients. Since the clinic was established the numbers have increased so that we now see the majority of H&N cnacer patients in Ireland. This is due to the increased referrals for dental assessment as this is now part of “BEST PRACTICE” in cancer care.
  • Main age group is 35-70. Many younger patients.
  • This group of patients is mainly DENTATE – 70% have more than 11 teeth teeth. 60% have 1-10 carious teeth. Root caries does not seem to be a major problem at baseline.
  • The most urgent dental decision pre-radiation is which teeth should be extracted or retained Easy in case 1, but what to do in case 2 Compliance??? How do we assess which patient will look after their teeth in the future, who will get sick, depressed, or have personal problems following their cancer treatment OH, SMOKING, ATTENDANCE, SOCIAL, PAST HISTORY Every patient wants to keep their teeth and promises to take good care
  • Keep radiation away from healthy tissue
  • All of the patients in this slide were pre radiotherapy at baseline. 50% of patients were current or recently past smokers. 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).
  • Oral hygiene instruction Dietary advice Daily use of fluoride therapy Management of dry mouth Jaw stretching exercises Smoking & alcohol cessation advice
  • d_mc_carthy_maintaining_the_dentition_in_the_dry_mouth.ppt

    1. 1. Irish Society for Disability in Oral Health Annual Conference Wet Mouths vs Dry Mouths Maintaining the dentition in the dry mouth 18th June, 2010 <ul><li>Denise MacCarthy BDS, FDS RCS (Edin), MA, MDentSc </li></ul><ul><li>Senior Lecturer-Consultant in Restorative Dentistry </li></ul><ul><li>School of Dental Science, Trinity College, Dublin </li></ul>
    2. 2. Maintaining the dentition in the dry mouth <ul><li>Causes of dry mouth & effects of salivary hypofunction on teeth and oral soft tissues </li></ul><ul><li>Baseline dental status of patients attending our clinic </li></ul><ul><li>Prevention as key strategy in the care of the dry mouth </li></ul><ul><li>Restoration of post radiation dental caries </li></ul><ul><li>Suggested protocol for maintainance of long-term oral health </li></ul>
    3. 3. Causes of dry mouth <ul><li>Physiological </li></ul><ul><li>Psychological </li></ul><ul><li>Medications </li></ul><ul><li>Systemic diseases or conditions </li></ul><ul><li>Radiotherapy to the head & neck region </li></ul><ul><li>Chemotherapy </li></ul>
    4. 4. How do we assess salivary hypofunction <ul><li>Patient complaint – dryness, speech, eating, swallowing, sleeping </li></ul><ul><li>Appearance of mouth – tissue red & atrophic, sticky to touch, materia alba, candida </li></ul><ul><li>Saliva flow test – resting and stimulated </li></ul>
    5. 5. Saliva Flow Rates 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
    6. 6. Mouth Problems Post Radiotherapy Patients Primary Complaint Patient Preference in the Management of Radiation Induced Dry Mouth Mac Carthy and Waldron
    7. 7. Post-radiation DENTAL CARIES
    8. 8. 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)
    9. 9. Limited mouth opening - trismus <ul><li>3 finger test </li></ul><ul><li>Wood sticks </li></ul><ul><li>Therabite </li></ul><ul><li>5% - 38% prevalence </li></ul>
    10. 10. Profile of our Patients <ul><li>Dublin Dental School & Hospital </li></ul><ul><li>H&N Cancer Oral Care Clinic established in 1997 </li></ul>
    11. 11. Patients by residence An audit of dental extractions in head and neck cancer patients undergoing radiation treatment. D Mac CARTHY, A N i OGAIN*, M O’REGAN. J Dent Res 2004
    12. 12. Patients Referred 1997-2006 (Pre & Post Radiotherapy n=590 patients) D Mac CARTHY 2007
    13. 13. Patient Age at Baseline (Pre Radiation n=709) D Mac CARTHY 2007
    14. 14. Dental Hard Tissues D Mac CARTHY 2007
    15. 15. <ul><li>Prevention as key strategy in the care of the dry mouth post radiotherapy </li></ul>
    16. 16. Dental treatment planning <ul><li>Retain teeth if possible </li></ul><ul><li>Compliance? </li></ul>
    17. 17. Dental Care Considerations <ul><li>Dental extractions (10-14 days pre radiation) </li></ul><ul><li>Radiation stents </li></ul><ul><li>Discuss the risk of osteo-radio necrosis </li></ul><ul><li>Maintain mandibular movement </li></ul><ul><li>Advise regarding dry mouth </li></ul><ul><li>Dietary advice and caries prevention therapy </li></ul><ul><li>Oral hygiene instruction & scaling </li></ul><ul><li>Smoking cessation advice </li></ul><ul><li>Education, motivation & support </li></ul>
    18. 18. Dental Extractions Required at Baseline D Mac CARTHY 2007
    19. 19. Radiation stent to spare healthy tissue
    20. 20. Dry Mouth - what do our patients find most useful? Patient Survey in Dublin Dental Hospital in 2005 (n=120) D Mac CARTHY C WALDRON 2007 <ul><li>Water (99%) </li></ul><ul><li>Sugar free gum (70%) </li></ul><ul><li>BioXtra or Biotene gel (70%) </li></ul><ul><li>Mouth Kote (30%) </li></ul>
    21. 21. Caries Prevention <ul><li>Dietary </li></ul><ul><li>Oral hygiene </li></ul><ul><li>Stimulate </li></ul><ul><li>Saliva </li></ul><ul><li>Replace </li></ul><ul><li>Chemical agents – mouthwashes & gels </li></ul>
    22. 22. 10 minutes a day!
    23. 23. Oral Hygiene, Gingival & Periodontal Health
    24. 24. Oral Hygiene
    25. 25. Smoking Habits in Pre-radiotherapy Head and Neck Cancer Patients. MacCarthy D*, Glass GB, O’Regan M (2006)
    26. 26. Relationship between smoking and periodontal disease 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).
    27. 27. Patient Education <ul><li>Written information </li></ul><ul><li>Internet </li></ul><ul><li>Dental hygienist </li></ul>
    28. 28. <ul><li>But, prevention does not </li></ul><ul><li>always work predictably </li></ul><ul><li>in this patient group… </li></ul>Restoration of post - radiation dental caries
    29. 29. 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 streptococci Streptococcus sanguinis Actinomyces naeslundi Lactobacillus Veillonella 2 19 12 ND ND 34 11 13 1 4 8 48 13 1 2
    30. 30. Management of Root Caries <ul><li>Chemical therapy – fluoride & chlorhexidine </li></ul><ul><li>Recontouring of tooth to remove undermined tooth structure </li></ul><ul><li>Restoration of carious lesion </li></ul>
    31. 31. Chemical Therapy for Dental Caries <ul><li>Increasing regular daily delivery of fluoride reduces root caries, irrespective of the type of fluoride treatment </li></ul><ul><li>Evaluation of different fluoride treatments of initial root carious lesions in vivo. Fure & Lingstrom, Oral Health Prev Dent 2009 </li></ul><ul><li>Fluoride has a beneficial effect on root caries. Richards, Oral Health Prev Dent 2009. </li></ul>
    32. 32. Restoration of Root Caries <ul><li>Composite - microfil </li></ul><ul><li>Compomer </li></ul><ul><li>Glass Ionomer </li></ul><ul><li>Sandwich technique </li></ul>
    33. 33. Glass Ionomer Cements <ul><li>Release fluoride </li></ul><ul><li>Reabsorb from topically applied fluoride </li></ul><ul><li>Controversial </li></ul><ul><li>Uptake and release of fluoride by saliva-coated glass ionomer cement. </li></ul><ul><li>Amen, Buijs & tenCate 1996 </li></ul><ul><li>Fluoride release / uptake from newer glass-ionomer cements used with the </li></ul><ul><li>ART approach. Gao, Smales & Gale 2000 </li></ul><ul><li>Fluoride release and uptake by glass-ionomers and related materials and its </li></ul><ul><li>clinical effect. Forsten 1998. </li></ul>
    34. 34. Implants <ul><li>Reduced saliva makes denture wear difficult </li></ul><ul><li>Implants very useful in dry mouth to aid retention of prostheses </li></ul><ul><li>Placement of implants into irradiated bone must be approached with caution – radiation dose above 40Gy, field including neck </li></ul>
    35. 35. Extractions post-radiation treatment <ul><li>Contact radiation oncologist field & dose </li></ul><ul><li>Refer to oral surgeon </li></ul><ul><li>If not possible to extract, root canal treatment and sleeper may be best option </li></ul>
    36. 36. 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
    37. 37. Longterm Oral Care for the H&N Cancer Patient A parternership between GDP and Specialist <ul><li>Early diagnosis and constant review </li></ul><ul><li>Motivate patient to attend appointments </li></ul><ul><li>Do not extract if tooth in radiation field or if history of bisphosphonates </li></ul><ul><li>Monitor for tumour recurrance and ORN </li></ul><ul><li>OHI & scaling </li></ul><ul><li>Dietary advice and fluoride/chlorhexidine therapy </li></ul><ul><li>Smoking cessation advice and support </li></ul><ul><li>Monitor for oral infection – caries, periodontal, candidal </li></ul><ul><li>Restore when necessary </li></ul>
    38. 38. Role of the Team Support, maintenance, intervention for oral health <ul><li>Patient </li></ul><ul><li>Reception staff </li></ul><ul><li>Dental nurse </li></ul><ul><li>Dental hygienist </li></ul><ul><li>Dental technician </li></ul><ul><li>Oral surgeon </li></ul><ul><li>Prosthodontist </li></ul><ul><li>Periodontist </li></ul><ul><li>General dental practitioner </li></ul><ul><li>Community dentist </li></ul>
    39. 39. Thank you for your attention