Maxillofacial Surgery in the Immunocompromised Host

1. Maxillofacial Surgery in the Immunocompromised Host Frederick Mars Untalan MD Baguio General Hospital & Medical Center

3. MAXILLOFACIAL SURGERY Dentoalveolar surgery (surgery to remove impacted teeth, difficult tooth extractions, extractions on medically compromised patients, bone grafting or preprosthetic surgery to provide better anatomy for the placement of implants, dentures, or other dental prostheses) Diagnosis and treatment of benign pathology (cysts, tumors etc. Diagnosis and treatment (ablative and reconstructive surgery, microsurgery) of malignant pathology (oral & head and neck cancer.) Diagnosis and treatment of cutaneous malignancy (skin cancer), lip reconstruction Diagnosis and treatment of congenital craniofacial malformations such as cleft lip and palate and cranial vault malformations such as craniosynostosis, (craniofacial surgery) Diagnosis and treatment of chronic facial pain disorders Diagnosis and treatment of temporomandibular joint (TMJ) disorders Diagnosis and treatment of dysgnathia (incorrect bite), and orthognathic (literally "straight bite") reconstructive surgery orthognathic surgery maxillomandibular advancement surgical correction of facial asymmetry. Diagnosis and treatment of soft and hard tissue trauma of the oral and maxillofacial region (jaw fractures, cheek bone fractures, nasal fractures, LeFort fracture, skull fractures and eye socket fractures). Splint and surgical treatment of sleep apnea, maxillomandibular advancement genioplasty (in conjunction with sleep labs or physicians) Surgery to insert osseointegrated (bone fused) dental implants and Maxillofacial implants for attaching craniofacial prostheses and bone anchored hearing aids Cosmetic surgery limited to the head and neck: (rhytidectomy/facelift, browlift, blepharoplasty/Asian blepharoplasty, otoplasty, rhinoplasty, septoplasty, cheek augmentation, chin augmentation, genioplastyoculoplastics, neckliposuction, lip enhancement, injectable cosmetic treatments, botox, chemical peel etc.) surgery Orthognathic surgery Critical Care issues Mouth Infections tumors trauma Craniofacial malformation aestheticsurgery TMJ Sleep medicine & surgery

4. MAXILLOFACIAL SURGERY

5. Oral mucosal disease: a decade of new entities, aetiologies and associations. New patterns of oral mucosal disease and indeed new disorders have been emerging over the past decade. Although infection with human immunodeficiency viruses (HIV) is having the most profound impact, there are also major changes in oral health and the standard of health care required, because of other new disorders and medical care. The increase in tissue transplantation, with the concomitant use of immunosuppression is resulting in a range of oral problems. Other iatrogenic oral diseases likely to increase include ulcers associated with cytotoxic chemotherapy; lichenoid eruptions related to drugs and restorative materials; and a multiplicity of other complications. Dilemmas are presented by some new disorders such as orofacialgranulomatosis. No less are the difficulties presented by the now obvious heterogeneous nature of oral subepithelialvesiculobullous disorders. Finally, there are, even in these days of social medicine and antimicrobial availability, new infectious diseases emerging. Continued increases in population mobility; continued sexual promiscuity; and the development of new drugs are all likely to act to increase the spectrum of oral disorders seen. Scully C, Porter SR. Int Dent J. 1994 Feb;44(1):33-43.Centre for the Study of Oral Disease, University Department of Oral Medicine, Surgery and Pathology, Bristol Dental Hospital and School, UK. “…with the concomitant use of immunosuppression … resulting in a range of oral problems.” “…even in these days of social medicine and antimicrobial availability, new infectious diseases are emerging.”

6. MAXILLOFACIAL SURGERY

7. OBJECTIVES To define the role of maxillofacial surgery in the immuno-compromised host To be aware of maxillofacial disorders in the immuno-compromised host & their management options

9. Immunocompromised Host A human or animal whose immunologic mechanism is deficient immunodeficiency disorder or other disease result of the administration of immunosuppressive drugs or radiation.

10. Immunocompromised Host A human or animal whose immunologic mechanism is deficient immunodeficiency disorder or other disease result of the administration of immunosuppressive drugs or radiation.

11. Systemic problems due to a local infection

12. Oral health status of immunocompromised children Objectives: (1) To determine the type and frequency of orofacial manifestations in HIV perinatally infected children. (2) To describe the incidence and prognostic implications of these orofacial manifestations (3) To examine caries rates, periodontal status and eruption patterns among these immunocompromised children. Methods: This is a retrospective-cohort study of 47 perinatally HIV-infected children seen at the Children's Hospital of Oakland, California, AIDS Clinical Trials Group site and at UCSF. All HIV-positive children seen in 1992 and 1993 at Children's Hospital in Oakland were eligible for the study. 34 of these CHO children were infected perinatally in 1980 or later. At the University of California San Francisco, 70 perinatally HIV-exposed children and 20 control children were followed prospectively from January 1986 through January 1993; of these 70 children, 13 (19%) were determined to be HIV-infected. The records of those 13 children were reviewed from birth until time of last visit (or of death). Results: Ninety-two percent of the 47 study children had at least one oral manifestation, most commonly pseudomembranouscandidiasis (81%) or parotid enlargement (26%). We found that the incidence of oral manifestations was 30% to 60% within six months of birth. These children displayed an unusually high prevalence of drug-induced and early childhood caries. Tooth eruption did not appear to occur significantly later than expected. Conclusions: Orofacial manifestations are common in pediatric HIV infection and can be manageable. These manifestations were found to be possible markers and predictors of progression in HIV infection. Primary care of these patients should include a careful oral examination at regular intervals and early intervention. Ramos-Gomez FJ, Petru A, Hilton JF, Canchola AJ, Wara D, Dorenbaum A, Greenspan JS; International Conference on AIDS. Int Conf AIDS. 1996 Jul 7-12; 11: 299 (abstract no. Th.B.4276). Children's Hospital Oakland and University of California, San Francisco, CA, USA. Orofacial manifestations are common in pediatric HIV infection and can be manageable.

13. Immunosuppression and oral health Head and neck lesions have been encountered in more than 40% of patients with immunosuppression due to a variety of conditions. The most common clinical manifestation of immunosuppression is chronic dry mouth. This condition can be either a direct result of an autoimmune disease, like Sjögren’s syndrome, or the result of suppression of the immune system by drugs, such as those used to prevent rejection of transplants. Sjögren’s syndrome is the second most common rheumatic autoimmune disease that is often first diagnosed due to an oral symptom. Mouth dryness lasting more than three months, dental decay, fungal infections, oral ulceration and swelling of salivary glands are common oral signs of the disease. A study comparing Sjögren’s patients to control subjects showed that they saw their dentists about twice as often, experienced about three times more dental disease and expended about three times more in treatment costs.3 There is some evidence indicating that Sjögren’s patients have more severe markers for periodontal disease, such as bleeding on probing and clinical attachment loss. HIV is another autoimmune condition with many oral complications. Studies have documented an increase in the incidence of oral yeast infections, xerostomia, oral hairy leukoplakia, melanotichyperpigmentation, angular cheilitis and gingival erythema.Commonly reported neoplasms in HIV patients include Kaposi’s sarcoma and non- Hodgkin’s lymphoma. The first recognized manifestations of HIV can often be the oral symptoms associated with dry mouth or fungal infections. Organ, bone marrow and stem cell transplants have also been associated with oral conditions. Immunosuppressive drugs taken to prevent the reject of transplants can result in xerostomia, oral mucositis and gingival overgrowth. These patients require a higher degree of oral care prior to transplantation in order to eliminate sources of infection and a more intense maintenance after transplantation to prevent further medical and dental complications. Delta Dental of Wisconsin The most common clinical manifestation of immunosuppression is chronic dry mouth Immunosuppressive drugs taken to prevent the reject of transplants can result in xerostomia, oral mucositis and gingival overgrowth.

14. Systemic Diseases Caused by Oral Infection Recently, it has been recognized that oral infection, especially periodontitis, may affect the course and pathogenesis ofa number of systemic diseases, such as cardiovascular disease,bacterial pneumonia, diabetes mellitus, and low birth weight.The purpose of this review is to evaluate the current status oforal infections, especially periodontitis, as a causal factorfor systemic diseases. Three mechanisms or pathways linking oralinfections to secondary systemic effects have been proposed: (i)metastatic spread of infection from the oral cavity as a resultof transient bacteremia, (ii) metastatic injury from the effectsof circulating oral microbial toxins, and (iii) metastatic inflammationcaused by immunological injury induced by oral microorganisms.Periodontitis as a major oral infection may affect the host'ssusceptibility to systemic disease in three ways: by shared riskfactors; subgingivalbiofilms acting as reservoirs of gram-negativebacteria; and the periodontium acting as a reservoir of inflammatorymediators. Proposed evidence and mechanisms of the above odontogenicsystemic diseases aregiven. Xiaojing Li,1,* Kristin M. Kolltveit,1 Leif Tronstad,2 and Ingar Olsen1Department of Oral Biology1 and Department of Endodontics,2 Faculty of Dentistry, University of Oslo, Oslo, Norway Clinical Microbiology Reviews, October 2000, p. 547-558, Vol. 13, No. 40893-8512/00 “…periodontitis, may affect the course and pathogenesis ofa number of systemic diseases, such as cardiovascular disease,bacterial pneumonia, diabetes mellitus, and low birth weight.”

15. The diabetic dental patient. DM is such a common disease in the United States that virtually every dentist encounters patients with known or undiagnosed diabetes. The dentist should be alert for both general and oral signs and symptoms suggestive of uncontrolled or poorly controlled DM, and laboratory or interoffice screening tests should be a part of dental practice. Under no circumstances, however, should the dentist attempt to diagnose the disease. Patients with suggestive symptoms or with abnormal blood glucose levels identified by screening tests should be referred to a physician for diagnosis and any treatment necessary. Uncontrolled DM may be associated with increased frequency and severity of oral infections, including periodontal disease and dental caries. In some diabetic patients, susceptibility to oral disease may continue despite establishment of effective metabolic control. Dental treatment can safely be performed on the controlled diabetic patient, but some adjustment of office protocol and of antihyperglycemic drug administration may occasionally be necessary. Finally, the dental treatment team must always be alert for signs and symptoms of developing diabetic emergencies and be prepared to provide treatment as necessary. Rees TD. Dent Clin North Am. 1994 Jul;38(3):447-63.Department of Periodontics, Baylor College of Dentistry, Dallas, Texas. dental treatment team must always be alert for signs and symptoms of developing diabetic emergencies and be prepared to provide treatment as necessary.

16. ORAL HEALTH, ATHEROSCLEROSIS, AND CARDIOVASCULAR DISEASE During the last two decades, there has been an increasing interestin the impact of oral health on atherosclerosis and subsequentcardiovascular disease (CVD). The advent of the inflammationparadigm in coronary pathogenesis stimulated research in chronicinfections caused by a variety of micro-organisms—suchas Chlamydia pneumoniae, Helicobacter pylori, and cytomegalovirus—aswell as dental pathogens, since these chronic infections arethought to be involved in the etiopathogenesis of CVD by releasingcytokines and other pro-inflammatory mediators (e.g., C-reactiveprotein [CRP], tumor necrosis factor [TNF-]) that may initiatea cascade of biochemical reactions and cause endothelial damageand facilitate cholesterol plaque attachment. Yet, due to themulti-factorial nature of dental infection and CVD, confirminga causal association is difficult, and the published resultsare conflicting. The main deficit in the majority of these studieshas been the inadequate control of numerous confounding factors,leading to an overestimation and the imprecise measurement ofthe predictor or overadjustment of the confounding variables,resulting in underestimation of the risks. A meta-analysis ofprospective and retrospective follow-up studies has shown thatperiodontal disease may increase the risk of CVD by approximately20% (95% confidence interval [CI], 1.08–1.32). Similarly,the reported risk ratio between periodontal disease and strokeis even stronger, varying from 2.85 (CI 1.78–4.56) to1.74 (CI 1.08–2.81). The association between peripheralvascular disease and oral health parameters has been exploredin only two studies, and the resultant relative risks amongindividuals with periodontitis were 1.41 (CI 1.12–1.77)and 2.27 (CI 1.32–3.90), respectively. Overall, it appearsthat periodontal disease may indeed contribute to the pathogenesisof cardiovascular disease, although the statistical effect sizeis small. Jukka H. Meurman1,*, Mariano Sanz2 and Sok-Ja Janket3,41 Institute of Dentistry, University of Helsinki, and Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, PB 41, FIN-00014 Helsinki, Finland; 2 Faculty of Odontology, Complutense University, Ciudad Universitaria, E-28040 Madrid, Spain; and 3 Boston University Goldman School of Dental Medicine and 4 Harvard School of Public Health, Boston, MA 02215-1204, USA; “…periodontal disease may indeed contribute to the pathogenesisof cardiovascular disease…”

19. Salivary Yeasts, Saliva, and Oral Mucosa in the Elderly Yeasts are commensals in the oral cavity and may not cause diseaseunless there are predisposing host factors, such as other disease,or when medication is being taken. The elderly are at increasedrisk of yeast infection. In this paper, prevalence of salivaryyeasts in a group of 368 inhabitants of Helsinki aged 76, 81,and 86 years is reported. Salivary yeasts were counted by theOricult-N® dip-slide method, salivary secretion rate andbuffering capacity were measured, type of dentition was noted,and signs of yeast infection and the occurrence of subjectivesymptoms were determined. There was no growth of yeasts in 25% of the subjects. From oneto 20 colonies/slide were observed in 21%, 21-50 colonies in21%, and over 50 colonies (a high count) in 33%. Subjects withlow salivary flow rates and low buffering capacities had significantlyhigher yeast counts than did subjects with normal salivary flowrates and buffering capacities. High yeast counts were foundin 19% of subjects with natural teeth. The corresponding percentagesin those wearing partial or complete dentures were 32 and 41,respectively. High salivary yeast counts were associated withoral mucosal lesions but not with subjective complaints of oralsymptoms. T.O. NarhiDepartment of Prosthetic Dentistry A. AinamoDepartment of Prosthetic Dentistry J.H. MeurmanCariology, Institute of Dentistry, University of Helsinki, Mannerheimintie 172, 00300 Helsinki, Finland . The elderly are at increasedrisk of yeast infection.

20. Oral sources of septicaemia in patients with malignancies This article reviews papers dealing with oral infections of adult septicaemia patients, searched from MEDLINE, Current Contents and Core Biomedical Collection databases from January 1966 to November 1996. Case reports were excluded. The systematic review of literature revealed that our knowledge of the topic is mostly based on very small patient material. There are no multicentre studies on the effects of various oral health treatment modes on the prevention of septicaemia of oral origin. The number of controlled and comparative studies on the efficacy of the different treatment protocols of oral infections is also small. Current recommendations in this respect are mainly empirical and not evidence based. Clinical practice guidelines are therefore urgently needed. Nevertheless, close co-operation between oncological and oral health units is emphasised because many studies have shown that the oral cavity is indeed an important source of bacteraemia. Life-threatening infections may follow if maintenance of oral health is neglected during anticancer therapy and if potential oral infection foci are left untreated before immunosuppressive therapy. J.H. Meurman1, , S. Pyrhönen2, L. Teerenhovi2 and C. Lindqvist1, 31Institute of Dentistry, University of Helsinki, Finland2Department of Oncology, Helsinki University, Central Hospital, Helsinki, Finland3Department of Oral and Maxillofacial Surgery, Helsinki University, Central Hospital, Helsinki, FinlandReceived 21 February 1997; revised 21 April 1997. Available online 25 February 1998. Oral OncologyVolume 33, Issue 6, November 1997, Pages 389-397 Life-threatening infections may follow if maintenance of oral health is neglected during anticancer therapy and if potential oral infection foci are left untreated before immunosuppressive therapy.

21. Oral health status, oral microflora, and non-surgical periodontal treatment of renal transplant patients receiving cyclosporin A and FK506 OBJECTIVES: To determine the oral health status, oral microflora and the effect of non-surgical periodontal treatment on gingival overgrowth of renal allograft recipients receiving either cyclosporin A (CsA) or FK506 (Tacrolimus) as an immunosuppressant. MATERIALS AND METHODS: A total of 47 patients receiving CsA (mean age 43.1 years) and 10 receiving FK506 (mean age 40.1 years) were included in the study. Stone casts were taken for measurement of gingival overgrowth. An oral rinse technique was used to investigate the prevalence of yeasts, and aerobic and facultatively anaerobic Gram-negative rods (AGNR). RESULTS: The CsA and FK506 patients exhibited a Gingival Overgrowth Index (GOI) of 45.2%, and 25.1%, respectively (p < 0.05). The CsA patients had a GOI of 15.2% after one year of non-surgical periodontal treatment. The difference between pre- and postoperative gingival overgrowth indices was significant (p < 0.0001). Candida albicans and Klebsiellapneumoniae were the most notable yeast and AGRN found. CONCLUSIONS: Renal transplant patients, being immunocompromised, constitute a high-risk group for gingival overgrowth. However, the FK506 regime appeared to ameliorate this effect, compared with CsA. Non-surgical periodontal treatment was effective in reducing established gingival overgrowth in both CsA and FK506 patients (p < 0.05). Adequate pre- and post-transplant oral health care is recommended, for these patients, irrespective of the drug regime. Chu FC, Tsang PC, Chan AW, Leung WK, Samaranayake LP, Chan TM. Ann R AustralasColl Dent Surg. 2000 Oct;15:286-91.Faculty of Dentistry, University of Hong Kong, Hong Kong. Renal transplant patients, being immunocompromised, constitute a high-risk group for gingival overgrowth

23. oral cavity of the new-born The baby’s mouth does not contain bacteria becomes colonized with bacteria such as Streptococcus salivarius. appearance of the teeth during the first year colonization by Streptococcus mutans and Streptococcus sanguis (dental surface and gingiva) anaerobic species - gingival crevice area Bacteroides and spirochetes (puberty)

24. Oral microbiology diverse microflora dental caries periodontal disease. Bacteria occupy the ecological niche tooth surface and gingival epithelium. host defense system

25. Treponemadenticola Fusospirochetes periodontal disease Treponemadenticola considered as one of the main etiological bacteria of periodontitis. Jobin M-C et al. (2008). "The Molecular Biology of the Survival and Virulence of Treponemadenticola". Molecular Oral Microbiology. Caister Academic Press. ISBN 978-1-904455-24-0 Spirochetes and fusi-form bacilli (normal flora in the mouth) bleeding in the oral cavity, the bacteria can cause infection Acute necrotizing ulcerative gingivitis (ANUG) Vincent angina with a membrane covering the throat area

26. Veillonella Porphyromonasgingivalis Gram-negative oral anaerobe strongly associated chronic adult periodontitis. Duncan M J (2008). "The Molecular Biology of Porphyromonasgingivalis". Molecular Oral Microbiology. Caister Academic Press. ISBN 978-1-904455-24-0. Veillonella (gram-negative anaerobic cocci). thrives in the acidic environment of caries thought to slow the development of dental caries converts the acidic products of other species to less acidic products.

27. Aggregatibacteractinomycetemcomitans Lactobacillus associated with dental caries although these bacteria are normally symbiotic in humans and are found in the gut flora. oral pathogen due to its virulence factors, localized aggressive periodontitis in young adolescents it can cause bone loss

28. http://www.lymphomalife.net/

29. CDC Guidelines for Preventing Health-Care-Associated Pneumonia Level IA/IB recommendations all currently done in SICU Educate/Involve staff in infection prevention Sterilize equipment Change vent circuits/humidifiers only when visibly contaminated. Drain condensate away from patient Wash hands/change gloves between patient contact and after contamination Use sterile fluids only for humidification and medication administration Pneumococcal vaccine for pts at high risk

30. Other potential interventions based on CDC guidelines EndotrachealTubes with Continuous Subglottic Suctioning- CATEGORY II: Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale Oral Care Protocols- UNRESOLVED Chlorhexidinegluconate (CHG) for cardiothoracic patient populations- CATEGORY II

31. Attitudes & procedures for oral care Oral care is a very high priority(90.8%) Patients comfort is more important than oral care Nurses fear dislodgement of the endotracheal tube Cleaning the oral cavity is an unpleasant task (42.5%) The oral cavity is difficult to clean (62.3%) Inconsistently documented Munro, C. & Grap, M. (2004). American Journal of Critical Care, 13(1),25-33 & Binkley et al., (2004) American Journal of Infection Control, 32(3), 161-169.

32. Chemical interventions to reduce plaque done twice a day Listerine vs 0.12% chlorhexidinegluconate (CHG) vspovidine iodine vs water CHG vslisterinevs stannous fluoride CHG spray or swab vs “routine” swab CHG mouth rinse vs “standard” oral care CHG performed better in all studies DeRiso et al. (1996) Chest, 109(6), 1556-1561 & Fourrier, et al. (1998). Critical Care Medicine, 26(2), 301-308 & Genuit et al. (2001). Surg Infect, 2(1), 5-18 & Houston, et al. (2002). American Journal of Critical Care, 11(6), 567-570 & Fourrier, F. (2005). Critical Care Medicine, 33(8), 1728-1735.

34. Nutrition and oral health in Africa Poverty, low birth weight, low life expectation at birth, widespread malnutrition, numerous endemic infections, little or no access to safe water, poor oral hygiene, deplorable environmental sanitation and political instability among other problems, characterise the lives of many Africans, particularly in sub-Saharan Africa. In African countries undergoing rapid urbanisation, health problems associated with undernutrition and overnutrition coexist, and these result from lifestyle changes which promote physical inactivity, increased consumption of fats and refined carbohydrates, as well as abuse of tobacco and alcohol. Thus, in several African countries, inflammatory oral diseases (e.g. periodontal diseases, acute necrotising gingivitis, noma) resulting from inappropriate interactions between microorganisms and the malnourished, immunocompromised host, have continued to pose serious health problems. There are suggestions of increasing incidence of squamous cell carcinoma, probably related to increased use of alcohol and tobacco, which elicit nutrient deficiencies and oxidative stress. Additionally, there is an increase in caries prevalence particularly in the poor urban areas. The latter is related not only to increased availability of refined sugars, but also to limited access to the caries preventive effects of fluorides. Good dietary practices through judicious combination of available foods should therefore feature prominently in the promotion of optimal oral health in Africa. ENWONWU Cyril O. ; PHILLIPS Reshma S. ; IBRAHIM Christine D. ; DANFILLO Ishaku S. ; International dental journal ISSN 0020-6539 2004, vol. 54, no6, pp. 344-351, SUP Poverty, low birth weight, low life expectation at birth, widespread malnutrition, numerous endemic infections, little or no access to safe water, poor oral hygiene, deplorable environmental sanitation and political instability among other problems… Good dietary practices through judicious combination of available foods should therefore feature prominently in the promotion of optimal oral health

35. Chlorhexidine prophylaxis for chemotherapy-and radiotherapy-induced stomatitis: A randomized double-blind trial Patients receiving cytotoxicantineoplastic therapy often have treatment-associated stomatitis. A 0.12% chlorhexidinedigluconatemouthrinse was evaluated (15 ml, three times a day) in a prospective, double-blind randomized trial as prophylaxis against cytotoxic therapy-induced damage to oral soft tissues. Seventy subjects, forty inpatients receiving high-dose chemotherapy and thirty outpatients receiving high-dose head and neck radiation therapy, were evaluated. Chlorhexidinemouthrinse significantly reduced the incidence of oral mucositis in the chemotherapy group on day 14 (p < 0.02) and at 1 week follow-up on day 28 (p < 0.002). Mucositis in the patients undergoing chemotherapy who received chlorhexidine also resolved more rapidly. Mucositis severity was significantly less compared to the control chemotherapy group on day 14 (p < 0.03), day 21 (p < 0.04), and on 1 week follow-up (p < 0.02). Concomitant trends in the reduction in oral streptococci and yeast were noted in the chemotherapy group receiving chlorhexidinemouthrinse. Although no differences were observed in oral mucositis between the control and chlorhexidine groups of patients undergoing high-dose radiotherapy, similar reductions of oral microflora to those seen in the chemotherapy population were also noted for patients undergoing radiation therapy who received chlorhexidine. Although generally not significant, some increase in gram-negative bacilli was noted in the chlorhexidine-treated patients in both the chemotherapy and radiotherapy groups, but there was no correlation with increased systemic infection. Prophylactic chlorhexidinemouthrinse reduces oral mucositis and microbial burden in patients with cancer undergoing intensive chemotherapy. Gerald A. Ferretti DDS, MS, a, , Ted P. RaybouldDMDb, Albert T. Brown PhDc, John S. Macdonald MDd, Martha Greenwood MDe, Yosh Maruyama MDf, John GeilMDg, Thomas T. Lillich MS, PhDh and Robert C. Ash MDiOral Surgery, Oral Medicine, Oral PathologyVolume 69, Issue 3, March 1990, Pages 331-338 Prophylactic chlorhexidinemouthrinse reduces oral mucositis and microbial burden in patients with cancer undergoing intensive chemotherapy.

36. Update on general health risk of periodontal disease OBJECTIVES: To review the potential of periodontal infections to cause nonoral diseases. Therapeutic recommendations are provided to help patients and dental practitioners prevent systemic complications from periodontal infections. FINDINGS: Systemic diseases from oral bacteria are mostly caused by transient bacteraemias, which can occur spontaneously from dental foci of infection, from mastication, brushing, flossing or other daily manipulations, or from dental treatments. Examples of systemic infections that may involve oral microorganisms include infective endocarditis, aspiration pneumonia, HIV-related disseminated candidiasis and cancrumoris, septicaemia associated with cancer chemotherapy and radiotherapy, necrotisingfaciitis and various other life-threatening infections. Inflamed gingiva constitutes a significant reservoir for herpes viruses, which have the potential to cause serious systemic diseases in immunocompromised patients. Periodontal disease may also aggravate chronic insulin insensitivity and thus interfere with glycaemic control in diabetic patients. Controversy surrounds the involvement of periodontal infections in coronary heart disease. CONCLUSIONS: Cumulative evidence suggests that periodontal disease can be an important cause of morbidity and mortality of various systemic diseases, especially in individuals exhibiting compromised host defence. Maintaining a healthy dentition and periodontium by means of daily oral hygiene practice and regular professional care is the most effective way of preventing systemic diseases from oral infections. Slots J. Int Dent J. 2003;53 Suppl 3:200-7.University of Southern California, School of Dentistry, Los Angeles 90089-0641, USA. jslots@usc.edu Cumulative evidence suggests that periodontal disease can be an important cause of morbidity and mortality of various systemic diseases, especially in individuals exhibiting compromised host defence. Maintaining a healthy dentition and periodontium by means of daily oral hygiene practice and regular professional care is the most effective way of preventing systemic diseases from oral infections.

37. The role of oral microorganisms in cancer therapy It has been assumed that the principal changes that occur in the oral flora during cancer therapy are yeast and gram-positive coccal proliferation. Recent studies have shown that treatment with topical antifungals or disinfectants has failed to relieve such complications as irradiation mucositis that occur during anticancer therapy. Thus, many of the oral lesions observed during treatment are not due to candidiasis or streptococcal infection. It has been shown that anticancer therapy impairs or reduces the carriage defense of the oropharynx and is accompanied by colonization and proliferation of gram-negative bacilli. It is argued that if oral infectious complications are to be prevented during anticancer therapy, then the selective elimination of gram-negative bacilli may be indicated. Martin MV, van Saene HK. CurrOpin Dent. 1992 Sep;2:81-4.University of Liverpool Recent studies have shown that treatment with topical antifungals or disinfectants has failed to relieve such complications as irradiation mucositis that occur during anticancer therapy. “…if oral infectious complications are to be prevented during anticancer therapy, then the selective elimination of gram-negative bacilli may be indicated.”

38. Management of oral mucositis in patients who have cancer Oral mucositis is a clinically important and sometimes dose-limiting complication of cancer therapy. Mucositis lesions can be painful, affect nutrition and quality of life, and have a significant economic impact. The pathogenesis of oral mucositis is multifactorial and complex. This review discusses the morbidity, economic impact, pathogenesis and clinical course of mucositis. Current clinical management of oral mucositis is largely focused on palliative measures such as pain management, nutritional support and maintenance of good oral hygiene. However, several promising therapeutic agents are in various stages of clinical development for the management of oral mucositis. These agents are discussed in the context of recently updated evidence-based clinical management guidelines Lalla RV, Sonis ST, Peterson DE. Dent Clin North Am. 2008 Jan;52(1):61-77, viii.Division of Oral Medicine, Department of Oral Health and Diagnostic Sciences, University of Connecticut Health Center MC 1605, 263 Farmington Avenue, Farmington, CT 06030, USA. lalla@nso2.uchc.edu Current clinical management of oral mucositis is largely focused on palliative measures such as pain management, nutritional support and maintenance of good oral hygiene.

39. Radiotherapy-induced mandibular bone complications The mandible is among the bones most frequently affected by irradiation. The most severe post-radiation injury of the mandible is osteoradionecrosis (ORN). Conflicting data have been reported on the incidence of this complication, its aetiology and management. The incidence of mandibular ORN in head and neck cancer patients managed with radical or postoperative irradiation, has varied widely in the literature from 0.4% to 56%. The interpretation of data derived from particular series are difficult due to the different scoring methods and classification systems used for the evaluation of post-radiation bone damage. Although ORN occurs typically in the first three years after radiotherapy, patients probably remain at indefinite risk. The diagnosis of ORN is principally based on the clinical picture of chronically exposed bone. Radiological symptoms include decreased bone density with fractures, cortical destruction and loss of spongiosatrabeculation. Numerous factors that may be associated with the risk of ORN include treatment-related variables (for example, total radiotherapy dose, biologically effective dose, photon energy, brachytherapy dose rate, combination of external beam irradiation and interstitial brachytherapy, field size, fraction size, volume of the mandible irradiated with a high dose), patient-related variables (like deep parodontitis, pre-irradiation bone surgery, bad oral hygiene, alcohol and tobacco abuse, bone inflammation, dental extraction after radiotherapy) and tumour-related factors (tumour size or stage, proximity of the tumour to bone, anatomic tumour site). Primary management of post-radiation bone lesions include conservative modalities such as saline irrigations, antibiotics during infectious episodes, topically applied antiseptics, gentle sequestrectomy and removal of visibly loosened bone elements as well as treatment with hyperbaric oxygen (HBO). Surgery is reserved for persistent ORN and includes radical resection of the lesion(sequestrectomy, hemimandibulectomy etc.) with reconstruction. In recent years the introduction of preventive oral hygiene measures and meticulous dental evaluations before and after irradiation, improvement in radiotherapy techniques and the development of reliable diagnostic and therapeutic procedures have resulted in a decreased incidence of ORN. Nevertheless, given the severe impact of ORN on patient quality of life, research should be continued to further ameliorate this problem. Jereczek-Fossa BA, Orecchia R. Cancer Treat Rev. 2002 Feb;28(1):65-74.Division of Radiotherapy, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy. barbara.fossa@ieo.it

40. Leukaemia in children. Part II--Dental care of the leukaemic child, including management of oral side effects of cancer treatment The treatment of a leukaemic child requires a multidisciplinary approach. The dental team should provide interceptive and preventive measures prior to the commencement of therapy whenever possible. During therapy, preventive and palliative measures are essential. Once remission is achieved, the child continues to have increased dental needs due to the effects of treatment. These needs may include an increased caries rate, dental maldevelopment, and secondary malignancy. Ayers KM, Colquhoun AN. N Z Dent J. 2000 Dec;96(426):141-6.Department of Oral Health, School of Dentistry, University of Otago, PO Box 647, Dunedin. The treatment of a leukaemic child requires a multidisciplinary approach. The dental team should provide interceptive and preventive measures

41. Radiation treatment breaks and ulcerative mucositis in head and neck cancer. Unplanned radiation treatment breaks and prolongation of the radiation treatment time are associated with lower survival and locoregional control rates when radiotherapy or concurrent chemoradiotherapy is used in the curative treatment of head and neck cancer. Treatment of head and neck cancer is intense, involving high-dose, continuous radiotherapy, and often adding chemotherapy to radiotherapy. As the intensity of treatment regimens has escalated in recent years, clinical outcomes generally have improved. However, more intensive therapy also increases the incidence of treatment-related toxicities, particularly those impacting the mucosal lining of the oral cavity, pharynx, and cervical esophagus, and results in varying degrees of ulcerative mucositis. Ulcerative mucositis is a root cause of unscheduled radiation treatment breaks, which prolongs the total radiation treatment time. Alterations in radiotherapy and chemotherapy, including the use of continuous (i.e., 7 days/week) radiotherapy to ensure constant negative proliferative pressure, may improve efficacy outcomes. However, these approaches also increase the incidence of ulcerative mucositis, thereby increasing the incidence of unplanned radiation treatment breaks. Conversely, the reduction of ulcerative mucositis to minimize unplanned breaks in radiotherapy may enhance not only tolerability, but also efficacy outcomes. Several strategies to prevent ulcerative mucositis in radiotherapy for head and neck cancer have been evaluated, but none have demonstrated strong efficacy. Continued investigation is needed to identify superior radiation treatment regimens, technology, and supportive care that reduce unplanned radiation treatment breaks with the goal of improving clinical outcomes in head and neck cancer. Russo G, Haddad R, Posner M, MachtayM.Oncologist. 2008 Aug;13(8):886-98. Epub 2008 Aug 13. Department of Radiation Oncology, Jefferson Medical College, Philadelphia, Pennsylvania 19107-5097, USA. Several strategies to prevent ulcerative mucositis in radiotherapy for head and neck cancer have been evaluated, but none have demonstrated strong efficacy.

42. Managing the oral sequelae of cancer therapy Patients undergoing systemic chemotherapy and/or head and neck radiotherapy frequently experience treatment side effects. Oral complications are among the most common problems associated with these therapies. These sequelae include mucositis, oral hemorrhage, infection, and xerostomia (dry mouth). Occasionally, oral complications are so severe that the cancer treatment must be reduced or even terminated. By providing comprehensive care, nurses work to help prevent, identify, and manage these oral sequelae, and thus maximize quality of life. Limiting the effects of oral sequelae increases patient adherence to treatment protocols, improves the quality of life, and increases the odds of long-term survival. Sadler GR, Stoudt A, Fullerton JT, Oberle-Edwards LK, Nguyen Q, Epstein JB. MedsurgNurs. 2003 Feb;12(1):28-36.University of California, San Diego School of Medicine, San Diego, CA, USA. Oral complications are among the most common problems associated with these therapies

43. Side effects of radiotherapy in oral cavity: diagnosis, prevention and treatment guidelines To avoid, or at least to reduce complications in patients who require head and neck radiotherapy, adequate oral cavity treatment is necessary before the therapy. Recent management guidelines speak of possibilities of preventing osteoradionecrosis with hyperbaric oxygen, using long-wave ultrasound in stimulating osteoblasts growth, and surgical transfer of submandibular salivary glands to submental area with 99% effectiveness in preventing xerostomia, besides traditional therapy. Preventive measures are naturally the best choice, since late complications treatment is not needed as often, and should draw special attention of physicians and patients. Since wide a spectrum of preventive and curative measures is required, the need exists for standard teams to look after the patients during and after radiotherapy, and which should include, besides radiotherapist, oral or maxillofacial surgeon in cooperation with oral medicine specialist. Badzek S, Tomas I, Krajina I, Pućo K, Kelović VL, Krajina Z, Plestina S. LijecVjesn. 2009 Nov-Dec;131(11-12):324-7.Klinika zaonkologijuMedicinskogfakulteta, KBC Zagreb. sbadzek@kbc-zagreb.hr “Since wide a spectrum of preventive and curative measures is required, the need exists for standard teams to look after the patients during and after radiotherapy…”

44. Manifestations and treatment of xerostomia and associated oral effects secondary to head and neck radiation therapy Xerostomia is one of the most common side effects of head and neck radiation therapy. Other oral effects are mucositis and radiation caries. Because xerostomia resulting from radiation therapy may be of a more permanent nature than xerostomia resulting from other causes, treatment is typically more extensive. Numerous regimens treat symptoms of xerostomia and associated caries and mucositis. Among them is the daily application of a fluoride gel, recommended to prevent or minimize dental caries. For patients with severe, chronic xerostomia who have some residual salivary tissue, the use of a sialagogue can promote an increased flow of saliva and treat the symptoms. Garg AK, Malo M.J Am Dent Assoc. 1997 Aug;128(8):1128-33.Univesity of Miami School of Medicine, Fla. 33015, USA. “..the daily application of a fluoride gel, recommended to prevent or minimize dental caries..” “..chronic xerostomia who have some residual salivary tissue, the use of a sialagogue..”

45. Preventive oral and dental care in radiotherapy patients An overview is presented of the preventive measures that can be taken with regard to the various side effects of radiotherapy of the head-and-neck region. Xerostomia, mucositis, radiation caries, trismus and osteoradionecrosis are to some extent preventable. Visch LL. Ned TijdschrTandheelkd. 1994 May;101(5):204-8.Afdeling TandheelkundigeOncologie, Dr. Daniël den Hoed Kliniek, postbus 5201, 3008 AE Rotterdam. “Xerostomia, mucositis, radiation caries, trismus and osteoradionecrosis are to some extent preventable.”

46. An efficacious oral health care protocol for immunocompromised patients A twice-weekly oral and perioral examination was provided to 120 patients receiving antineoplastic therapy. Sixty patients were monitored while following the traditional hospital oral care protocol (chlorhexidine, hydrogen peroxide, sodium bicarbonate, thymol glycol, benzocainemouthrinse, and nystatin). The mouth care protocol was then changed (experimental protocol = chlorhexidine, benzocaine lozenges, amphotericin B lozenges), and patients were monitored until the sample size matched that of the hospital mouth care regime. There was a statistically significant reduction in oral complications upon introduction and maintenance of the experimental protocol. Solomon CS, Shaikh AB, Arendorf TM. Spec Care Dentist. 1995 Nov-Dec;15(6):228-33.Department of Oral Medicine and Periodontics, Faculty of Dentistry, University of the Western Cape, South Africa. the traditional hospital oral care protocol chlorhexidine, hydrogen peroxide, sodium bicarbonate, thymol glycol, benzocainemouthrinse, and nystatin experimental protocol chlorhexidine, benzocaine lozenges, amphotericin B lozenges

47. Vaccination against oral infections Dental caries and periodontitis have an infectious etiology and immunization has been proposed as a means of controlling them. However, the approaches vary according to the nature of the bacteria involved and the mechanisms of pathogenesis for these two very different diseases. In the case of dental caries, proteins involved in colonization of teeth by Streptococcus mutans can produce antibodies that inhibit the cariogenic process. Periodontal vaccines are less well developed, but some antigenic targets have been identified. Hajishengallis G and Russell M W (2008). "Molecular Approaches to Vaccination against Oral Infections". Molecular Oral Microbiology. Caister Academic Press. ISBN 978-1-904455-24-0. Periodontal vaccines are less well developed, but some antigenic targets have been identified.

48. Comparative Microbial Analysis of Oral Antiseptics STUDY OBJECTIVE: To evaluate the in vitro antiseptic properties of Sage Antiseptic Oral Rinse, Cepacol mouthwash/gargle and Biotene mouthwash. TEST DESIGN: Three antiseptic products were tested in vitro against Streptococcus mutans (ATCC #25175), Actinomycesviscosus (ATCC #19246) and Candida albicans (ATCC #18804). The study was conducted according to the FDA Tentative Final Monograph for Oral Antiseptic Drug Products (Federal Register Vol. 59, No. 27, February 9, 1994, Section 356.90). RESULTS: Sage's Antiseptic Oral Rinse and Cepacol mouthwash/gargle passed the testing as defined in the Tentative Final Monograph for Oral Antiseptic Drug Products. Biotene mouthwash did not meet the acceptance criteria as defined in the FDA Tentative Final Monograph for Oral Antiseptic Drug Products. Both the Sage Antiseptic Oral Rinse and the Cepacol mouthwash/gargle reduced the number of bacteria per ml by at least three log10 while the Biotene mouthwash had little or no effect in microbial reduction. Sage Antiseptic Oral Rinse, Cepacol mouthwash/gargle and Biotene mouthwash. Both the Sage Antiseptic Oral Rinse and the Cepacol mouthwash/gargle reduced the number of bacteria per ml by at least three log10 while the Biotene mouthwash had little or no effect in microbial reduction. Author: Russell Nisengard, DDS, PhD, Distinguished Teaching Professor, Periodontics and Microbiology, Department of Periodontics and Endodontics, School of Dental Medicine, State University of New York at Buffalo.

49. Macroscopic and microscopic study of tissue response to oral antiseptics and its influence on carcinigenesis Studies have related the action of alcohol on the oral mucosa as a promoter of carcinogenesis, once most oral antiseptics contain alcohol. Its utilization for mouthrinses from 30 to 60 seconds, as indicated on the labels, yields a longer-lasting topical action when compared to the intake of alcoholic beverages. This study aimed at conducting a macroscopic and microscopic analysis of the tissue response of tongue mucosa of hamsters to daily topical applications of antiseptics (Anapyon, Listerine, Oral B) during 13 and 20 weeks, following the methodology for carcinogenesis investigation developed by the Discipline of Pathology of Bauru Dental School, University of São Paulo. After sacrificing the animals, their tongues were removed and fixed on 10% formalin. Macroscopic examination did not reveal significant alterations, and the specimens were processed by routine histotechnical procedures for HE staining. Three serial sections of each tongue were evaluated, and characteristics related to epithelial hyperkeratinization, atrophy, hyperplasia and dysplasia were organized in tables. Despite the observation for moderate dysplasia in one case in the Anapyon 20 week group, the further results were very similar to the control group (saline solution), eliminating the need of comparative statistical tests. By means of such methodology for testing the carcinogenesis-initiating action, it was concluded that oral antiseptics are unable to trigger the development of neoplasms. Camila Lopes CardosoI; RenataFalchete do PradoII; LuísAntônio de AssisTaveiraIIIIUndergraduate student, Department of Stomatology, Bauru Dental School, USP, Bauru, São Paulo, Brazil IIDDS, MSc, Graduate Student in Oral Pathology, Department of Stomatology, Bauru Dental School, USP, Bauru, São Paulo, Brazil IIIPhD, Associate Professor, Department of Stomatology, Bauru Dental School, USP, Bauru, São Paulo, Brazil “…oral antiseptics are unable to trigger the development of neoplasms.”

50. Assess respiratory status throughout procedure Assess mouth Gather supplies Brush teeth 1-2 minutes Rinse toothpaste from mouth and suction Apply CHG to mouth surfaces Suction excess CHG Reassess mouth

51. Rinse brush with tap water and place on dry paper towel and allow to air dry in kidney basin Document procedure in Emtek and CHG in MAR

52. Some recommendations Antiseptic Tooth & Gum Tonic antimicrobial, oral rinse natural herbs and essential oils that have been used for centuries to maintain healthy tissue. botanical agents have been combined into a stimulating formula with ingredients that include: vegetable glycerin, extracts of Echinacea, pure essential oils of peppermint, red thyme, eucalyptus globulus and lavender. no alcohol, colored dyes, artificial chemicals, flavorings, preservatives, or sweeteners in this product. Tooth & Gum Paste a unique toothpaste with the natural herbs and essentials oils found in the mouth rinse. It does not have any fluoride or sodium lauryl sulfate (a common foaming agent). From the internet, various sources

53. Some recommendations Tooth & Gum Spritz Tooth & Gum Spritz is a non aerosol, mouth spray that will freshen your breath for hours. Under-The-Gum Irrigant Under-The-Gum Irrigant is a potent antimicrobial formula used for more serious periodontal situations with the use of a Water Pik at home. From the internet, various sources

54. To much information can build fear & anxiety. But too much information will set you free.

56. Maxillofacial Surgery in the Immunocompromised Host Frederick Mars Untalan MD Baguio General Hospital & Medical Center

57. Thank you

59. Impact of oral health on general health Is oral health linked to overall health? Oral health has several effects on overall health. Several systemic diseases, on the other hand, can be manifested in the mouth. Taking care of oral hygiene does not only promote oral health, but also overall health. Poor mouth care may weaken the balance of care in various diseases, such as cardiovascular diseases, diabetes, rheumatoid arthritis and many chronic diseases. Careful oral hygiene and regular checkup visits are the foundation of preventive care. When are antibiotics necessary before treatment? When there are untreated bacterial colonies in the mouth, bacteria also spread to other parts of the body through the bloodstream. Dental care procedures that involve puncturing the mucosa in particular may cause bacteremia, the presence of bacteria in the blood. Bacteremia can cause problems to people with heart diseases, such as a congenital heart defect, heart valve disorder, artificial valve or a history of endocarditis, an infection of the heart's inner lining. In order to prevent the spreading of bacteria into the bloodstream, antibiotics are administered before the procedure. Medication is also necessary in situations where the body's own defenses function poorly or have been suppressed by medications. Antibiotic prophylaxis is required by diabetics with poorly controlled diabetes, organ transplant patients, people with severe rheumatism and people who have recently undergone joint replacement surgery. When is taking care of oral hygiene particularly important? Heart diseasesCardiovascular diseases and oral health are known to be linked. Poor oral health may even promote atherosclerosis (buildup of plaque inside the arteries) and increase the risk of myocardial infarction. Taking care of oral hygiene is vital to people with heart disease and in preventing heart disease. Oral infections must be treated without delay to stop them from spreading. Antibiotics before a procedure are particularly recommended for people with a congenital heart defect, heart valve disorder, artificial valve or history of endocarditis. DiabetesGood oral hygiene is particularly important also in diabetes. The better one's oral health, the better diabetes control and vice versa. Gum diseases are often more common in people with diabetes. When the flow of saliva is reduced, teeth are also more prone to decay. Effective home care and frequent checkups keep both oral infections and diabetes under control. Antibiotics are necessary if diabetes is poorly under control. Organ transplant patients Organ transplant patients' defense system functions poorly due to heavy medication. The patient's mouth must be completely healthy before and after organ transplantation. All infections of dental origin are potentially fatal when the body's own defense system is suppressed. Organ transplant patients require antibiotic prophylaxis before treatment in many cases. Rheumatoid arthritis Treatment for rheumatoid arthritis also involves immunosuppressant medications. In addition, people with rheumatoid arthritis often suffer from reduced flow of saliva. Their teeth are prone to dental decay due to dry mouth. In order to prevent oral infections from spreading to the joints, particular attention should be paid to keeping the teeth clean. It is a good idea to visit the dentist several times a year. Taking care of oral hygiene rigorously is also important in other chronic diseases. Particular attention should be paid to oral health during pregnancy, too.

60. CHLORHEXIDINE oral rinse (Peridex®, Periogard®) is used to treat gingivitis. Bacteria that grow on your teeth between brushings cause gingivitis. Chlorhexidine destroys this bacteria. Chlorhexidine oral rinse will help to decrease gum bleeding and redness and swelling of your gums. Chlorhexidine oral rinse will not prevent plaque or tartar from forming on your teeth. Proper toothbrushing and flossing are still needed. Treatment with chlorhexidine oral rinse usually begins immediately after a dental cleaning.What should I tell my health care provider before I take this medicine? They need to know if you have any of the following conditions:• an unusual or allergic reaction to chlorhexidine, especially skin antiseptics• other gum or dental problems• front tooth fillings, dentures or other mouth appliances, especially those having rough surfacesHow should I take this medication? Chlorhexidine oral rinse should be used immediately after brushing and flossing. Rinse all toothpaste completely from your mouth. The cap on the original container may be used to measure the 15ml (1 tablespoonful) dose. Fill the cap to the "fill line." If you do not have the cap, ask your pharmacist or other healthcare professional for a device to measure the dose. Swish 15 ml chlorhexidine oral rinse in your mouth for 30 seconds. Do not swallow the medicine. Use the medicine full strength; do not mix with water before using. Do not eat or drink for several hours after using the oral rinse as this may decrease the effect of the medicine. Your dose and daily use may be different from these directions. Follow the directions from your dentist or other healthcare professional.Contact your pediatrician or health care professional regarding the use of this medicine in children. Special care may be needed.What if I miss a dose? If you miss a dose of this medicine, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and start back on your regular schedule. Do not use double doses.What drug(s) may interact with chlorhexidine oral rinse? Very little chlorhexidine is taken-up by your body. The oral rinse should not interact with any other medications you are taking.Tell your prescriber or other health care professional about all other medicines you are taking including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffiene or alcohol, if you smoke or if you use illegal drugs. These may effect the way your medicine works. Check before stopping or starting any of your medications.What should I watch for while taking chlorhexidine oral rinse? Visit your dentist every 6 months for dental cleanings and to check on your progress.Chlorhexidine oral rinse may have a bitter aftertaste. Do not rinse your mouth after using chlorhexidine oral rinse because that will increase the bitter taste. Also, rinsing will decrease the effect of the chlorhexidine.Chlorhexidine oral rinse may change the way food tastes to you. This effect may last up to 4 hours after using the rinse. Usually this effect becomes less noticeable as you continue using the rinse. Your taste should return to normal after stopping the use of chlorhexidine.Chlorhexidine oral rinse may increase tartar build-up and stain your teeth, dentures or fillings. Brush with a tartar control toothpaste and floss daily to help decrease the amount of tartar build-up and staining. It is important to visit your dentist at least every 6 months to have your teeth cleaned.What side effects may I notice from using chlorhexidine oral rinse? Side effects that you should report to your prescriber or other health care professional as soon as possible:• shortness of breath• rash• hives• itching• swelling of tongue or throatSide effects that usually do not require medical attention (report to your prescriber or other health care professional if they continue or are bothersome):Rare or uncommon:• swollen glands on side of face or neck• mouth irritation• tongue irritationMore common:• increased tartar build-up• changes in taste or a metallic taste• staining of teeth, fillings, dentures or other mouth appliancesWhere can I keep my medication? Keep the medicine out of reach from children. If child accidentally drinks chlorhexidine oral solution, get medical attention right away. Small children may have nausea and vomiting and signs of drunkenness.Store away from direct light and heat.Keep from freezing.Do not keep or use the medicine after the expiration date on the bottle.

61. mouthwash a medicated liquid used for cleaning the oral cavity and treating mucous membranes of the mouth. Many over-the-counter mouthwashes contain alcohol, which may contribute to surface softening and increased wear of dental resins and composite materials. mouthwash,n a mouth rinse possessing cleansing, germicidal, or palliative properties. Only some are approved by the ADA for treatment of gingivitis. mouthwash, alcohol in,n a key ingredient in commercial oral rinses; helps oil-based ingredients blend into product. Typically constitutes from 15% to 30% of the solution. Serves to decrease surface tension while increasing the rinse's astringent properties. May be drying to the oral mucosa. mouthwash, deodorants in,n a number of active ingredients including chlorophyll; added to oral rinses to decrease unpleasant smells that are the result of unbrushed teeth. mouthwash, flavoring agents in,n an additive in oral rinses designed to enhance the product's taste. Agents are typically derived from aromatic waters and essential oils. mouthwash, sodium benzoate,n a solution used prior to brushing teeth for the purpose of freshening the mouth. Long-term studies have not proved this to be effective in reducing gingivitis.

63. The Normal Bacterial Flora of Humans Beneficial Effects of the Normal FloraThe effects of the normal flora are inferred by microbiologists from experimental comparisons between "germ-free" animals (which are not colonized by any microbes) and conventional animals (which are colonized with a typical normal flora). Briefly, some of the characteristics of a germ-free animals that are thought to be due to lack of exposure to a normal flora are: 1. vitamin deficiencies, especially vitamin K and vitamin B122. increased susceptibility to infectious disease3. poorly developed immune system, especially in the gastrointestinal tract4. lack of "natural antibody" or natural immunity to bacterial infectionBecause these conditions in germ-free mice and hamsters do not occur in conventional animals, or are alleviated by introduction of a bacterial flora (at the appropriate time of development), it is tempting to conclude that the human normal flora make similar contributions to human nutrition, health and development. The overall beneficial effects of microbes are summarized below.1. The normal flora synthesize and excrete vitamins in excess of their own needs, which can be absorbed as nutrients by their host. For example, in humans, enteric bacteria secrete Vitamin K and Vitamin B12, and lactic acid bacteria produce certain B-vitamins. Germ-free animals may be deficient in Vitamin K to the extent that it is necessary to supplement their diets.2. The normal flora prevent colonization by pathogens by competing for attachment sites or for essential nutrients. This is thought to be their most important beneficial effect, which has been demonstrated in the oral cavity, the intestine, the skin, and the vaginal epithelium. In some experiments, germ-free animals can be infected by 10 Salmonella bacteria, while the infectious dose for conventional animals is near 106 cells.3. The normal flora may antagonize other bacteria through the production of substances which inhibit or kill nonindigenous species. The intestinal bacteria produce a variety of substances ranging from relatively nonspecific fatty acids and peroxides to highly specific bacteriocins, which inhibit or kill other bacteria. 4. The normal flora stimulate the development of certain tissues, i.e., the caecum and certain lymphatic tissues (Peyer's patches) in the GI tract. The caecum of germ-free animals is enlarged, thin-walled, and fluid-filled, compared to that organ in conventional animals. Also, based on the ability to undergo immunological stimulation, the intestinal lymphatic tissues of germ-free animals are poorly-developed compared to conventional animals.5. The normal flora stimulate the production of natural antibodies. Since the normal flora behave as antigens in an animal, they induce an immunological response, in particular, an antibody-mediated immune (AMI) response. Low levels of antibodies produced against components of the normal flora are known to cross react with certain related pathogens, and thereby prevent infection or invasion. Antibodies produced against antigenic components of the normal flora are sometimes referred to as "natural" antibodies, and such antibodies are lacking in germ-free animals. Harmful Effects of the Normal Flora

64. The Normal Bacterial Flora of Humans Harmful effects of the normal flora, some of which are observed in studies with germ-free animals, can be put in the following categories. All but the last two are fairly insignificant. 1. Bacterial synergism between a member of the normal flora and a potential pathogen. This means that one organism is helping another to grow or survive. There are examples of a member of the normal flora supplying a vitamin or some other growth factor that a pathogen needs in order to grow. This is called cross-feeding between microbes. Another example of synergism occurs during treatment of "staph-protected infections" when a penicillin-resistant staphylococcus that is a component of the normal flora shares its drug resistance with pathogens that are otherwise susceptible to the drug.2. Competition for nutrients Bacteria in the gastrointestinal tract must absorb some of the host's nutrients for their own needs. However, in general, they transform them into other metabolisable compounds, but some nutrient(s) may be lost to the host. Germ-free animals are known to grow more rapidly and efficiently than conventional animals. One explanation for incorporating antibiotics into the food of swine, cows and poultry is that the animal grows faster and can therefore be marketed earlier. Unfortunately, this practice contributes to the development and spread of bacterial antibiotic resistance within the farm animals, as well as humans. 3. Induction of a low grade toxemia Minute amounts of bacterial toxins (e.g. endotoxin) may be found in the circulation. Of course, it is these small amounts of bacterial antigen that stimulate the formation of natural antibodies.4. The normal flora may be agents of disease. Members of the normal flora may cause endogenous disease if they reach a site or tissue where they cannot be restricted or tolerated by the host defenses. Many of the normal flora are potential pathogens, and if they gain access to a compromised tissue from which they can invade, disease may result. 5. Transfer to susceptible hosts Some pathogens of humans that are members of the normal flora may also rely on their host for transfer to other individuals where they can produce disease. This includes the pathogens that colonize the upper respiratory tract such as Neisseriameningitidis, Streptococcus pneumoniae, Haemophilusinfluenzae and Staphylococcus aureus, and potential pathogens such as E. coli, Salmonella or Clostridium in the gastrointestinal tract.

65. Biofilm formation

66. Mechanical removal of plaque Foam sponges or toothettes most widely used method by nurses Toothettes not effective in plaque removal Toothbrushes remove plaque better than toothettes but are rarely used in critically ill Not consistently performed Hixson, S et al, (1998). Advanced Practice in Acute and Critical Care, 9(1) & Harris, J. & Miller, T. (2000). Critical Care Nurse, 20(1), 51-68 & Pearson, L. (2002). Journal of Advanced Nursing, 39(5), 480-489.

67. Commercially Available Oral Care Products