Dental and oral health.pdf

Dental and oral health Learning objec2ves - Condi'ons concerning the hard 'ssues of the oral cavity (teeth, bones). - Condi'ons concerning the so; 'ssues of the oral cavity (everything aside from the teeth and bones). - Issues concerning pa'ents with no teeth (paediatrics and geriat...

Dental and oral health Learning objec2ves - Condi'ons concerning the hard 'ssues of the oral cavity (teeth, bones). - Condi'ons concerning the so; 'ssues of the oral cavity (everything aside from the teeth and bones). - Issues concerning pa'ents with no teeth (paediatrics and geriatrics). - Items found in the oral health sec'on of community pharmacies. Broadly what’s dealt with in pharmacy prac2ce. - Why people come to pharmacy and not den'st? à it’s free and more friendly. Hard 2ssues – what can go wrong? - Caries - Teeth fractures (cracked teeth) - Periodon''s - Alveolar ostei's (dry socket) - MRONJ – medica'on related osteonecrosis of the jaw. - General sensi'vity. The hard 2ssues of the oral cavity Dental caries – what, when, why, how - What? o Holes in teeth, also known as cavity/cavi'es. - When? o As soon as teeth erupt (can be in the primary den''on i.e. baby teeth or permanent den''on i.e. adult teeth) - Why? o When dental plaque adheres to the surface of teeth (and is not removed for a substan'al period of 'me), bacteria (predominantly streptococcus mutans) adhere to the plaque and produce an acid which demineralises the tooth structure. Interplay between bacteria, sucrose, saliva and 'me. - Prevalence o Around 1 in 4 (24%) Australian children aged 6–14 had dental caries in their permanent teeth, o Around 1 in 10 (11%) had at least one permanent tooth with untreated decay Effect of Dental Caries & Treatment - Painful à causes sensi'vity, pain and in some cases severe pain. - Untreated may lead to tooth loss (extrac'on) which has broader consequences (poor mas'ca'on, speech, dysphagia, ongoing problems with nutri'on). - Untreated may infect the pulp chamber leading to a spreading infec'on with some'mes fatal consequences e.g. Ludwig’s angina, cavernous sinus thrombosis. How are caries treated? - Requires a den'st – tooth may be restored; root canal treatment may be necessary or extrac'on. - Supply of analgesics to temporize un'l pa'ent sees a den'st. Paracetamol (4g max) and Ibuprofen (2.4g max). Generally, 1TDS of each. - At face, there’s no valve in vein, therefore the infec'on can move freely. Fractured teeth/cracked tooth syndrome. - Pa'ents present with vague symptoms – poorly localised, episodic, pain on chewing/bi'ng. - Fractures of teeth are the third most common cause of tooth loss in industrialised countries. - Generally, pa'ents don’t know their teeth are fractured. (Teeth can s'll be intact. - Supply of analgesics to temporize un2l pa2ent sees a den2st. Paracetamol (4g max) and Ibuprofen (2.4g max). Generally, 1TDS of each. - Periodon22s – what, when, why, How - What? o Inflamma'on of the ligaments aaaching the tooth to bone leading to bone loss around the teeth. - When? o Takes 'me to advance to level of bone loss – begins as gingivi's and progresses when le; untreated. - Why? o Foreign body stuck to teeth à bacterial aaachment à localised inflamma'on (cytokines, matrix metalloproteinases) à leading to bone loss. - Have rela'on to type 2 diabetes. If the pa'ent got diagnosed with type 2 diabetes, you should recommend the pa'ent to go checked on their teeth. Effect of Periodon22s & Treatment - Painful à causes sensi'vity, pain and in some cases severe pain. - Untreated may lead to tooth loss (extrac2on) which has broader consequences (poor mas'ca'on, speech, dysphagia, ongoing problems with nutri'on). - The propor'on of adults with moderate or severe periodon''s increased with age, ranging from 12% in 15–34 year olds, 33% in 35–54 year olds, 51% in 55–74 year olds and 69% in those aged 75 years and over in 2017–18 (AIHW 03/2021). - Bidirec2onal rela2onship with type 2 diabetes – the presence of one makes the other worse. - Treatment? o ‘Deep cleaning’ is performed to remove plaque and calculus from beneath the gums. o Pa2ents will present in pain and some2mes with mobile “wobbly” teeth. Supply analgesics as well as chlorhexidine mouthwash TDS for 2 weeks + referral to den2st. Gingivi2s - Inflamma'on of the gums can be generalised or localised. - The precursor to periodon''s - Can be treated with improved oral hygiene and professional dental prophylaxis (scale and clean) - Advise pa2ents to brush twice daily as well as CHX mouthwash (e.g. Savacol) for 2 weeks. Alveolar ostei2s (Dry Socket) - What? o Localised painful inflamma'on of the bone surrounding extrac'on socket following premature loss/breakdown of the blood clot. NB: Only can occur following a tooth extrac'on. - When? o Complicates approximately 5% of extrac'ons. - Why? o Pathogenesis is poorly understood. Mostly secondary to smoking, excessive spiing. Pa'ents who have T2D, take the OCP, female, older age likely to experience this. - Treatment? o Self-limi'ng, analgesics and saline/CHX irriga'on. o Supply of analgesics to temporize un'l pa'ent sees a den'st. Paracetamol (4g max) and Ibuprofen (2.4g max). Generally, 1TDS of each. MRONJ – Medica2on Related Osteonecrosis of the jaw. - What? o Exposed bone in the maxilla or mandible that has been present for more than 8 weeks following a tooth extrac'on. - When? o In pa'ents who are taking bisphosphonates, an'-resorp've or an'-angiogenic medica'on. - Incidence o 1% in cancer pa'ents and 0.1% in pa'ents with metabolic bone disease. - Why? o Inhibi'on of osteoclas'c bone resorp'on and remodelling. o Exis'ng inflamma'on and infec'on from teeth that were removed. o Inhibi'on of angiogenesis (forma'on of new blood vessels) - Treatment o Relevance? Counsel pa'ents prior to star'ng an'-resorp've and an'angiogenic medica'on and advise them to see their den'st. MRONJ – Medica2ons to be aware of in a community pharmacy sebng. - You will mostly see the medica'ons listed below (used in the treatment of osteoporosis). These are the main medica2ons of concern regarding poten2ally causing MRONJ. o Bisphosphonates: § Alendronate § Risedronate § Zoledronic acid o Monoclonal an2body § Denosumab Sensi2ve Teeth - When? à Nonspecific - Why? à Could be many reasons – untreated decay, recent dental work, generalized sensi'vity. - Counselling à Refer to a den'st for further inves'ga'on + advise use of sensi've toothpaste. Summary Hard 2ssue - From pharmacist perspec've, can provide analgesics along with other medicaments to temporize the situa'on. - Den'st referral will lead to fixing the source of the problem and may involve a prescrip'on. Sod 2ssues à what can go wrong? - Ulcers (intra-oral/extra-oral). - Cold sores - Infec'ons – bacterial, viral, fungal. - Dry mouth Ulcers - What? o Full thickness loss below the basal layer of epithelium i.e. you are exposing the underlying connec've 'ssue (very vascular, ample nerve innerva'on and thus painful). - When & why? o 1. Trauma'c o 2. Haematological o 3. Immunological o 4. Gastrointes'nal o 5. Vasculi'c/Ischaemic o 6. Neoplas'c o 7. Infec've o 8. Drug reac'ons Trauma2c ulcers - How? o Trauma'c ulcera'ons are common and can be associated with: § Ea'ng rough, sharp, hot foods. § Sharp broken teeth or dental restora'ons. § Toothbrushing. § Chemical burns à follows along tooth whitening. - Treatment o Salt-water mouthwash o Benzdyamine 1% gel (adult and child 6 years or older) topically to ulcer 2-3 hourly as necessary o Commonly pa'ents present in pain for oral ulcera'ons – need to provide analgesic support + counselling. Ensure to advise that ulcers should not last for longer than 2 weeks (epithelial turnover 'me) Infec2ve ulcers - Ulcers secondary to a bacterial, viral or fungal infec'on. Common examples secondary to VIRAL infec2on: - Herpangina o Viral illness in children causing painful ulcers in the mouth. O;en in the back of the throat and roof of the mouth o Other symptoms are headache, fever, decreased appe'te, neck pain. o Treatment includes managing pyrexia, symptoma2c relief for ulcers (also men2on a bland diet – cold milk, ice cream, avoid spicy foods) - Hand, foot and mouth disease (HFMD) o Very similar oral presenta'on and considera'ons. o Accompanied by small oval blisters on palms and soles of feet (generally not itchy cf. chickenpox). o Relevance? Provide symptoma2c relief and reassurance i.e. self limi2ng and generally resolves within 2 weeks. Paracetamol and/or ibuprofen + anaesthe2c containing mouthwash or gel (Cepacaine, SM-33, Difflam mouth gel) - Cold Sores (Herpes Simplex Labialis) - What? o Recurrent oral mucocutaneous herpes simplex virus (HSV) infec'on follows latent ac'va'on of the virus. - Where? o Lesions usually occur on the lips but can also occur on the intraoral mucosa or other areas of the skin. - When? o Lesions usually preceded by the prodromal stage, las'ng several hours to days, which features pain, burning, 'ngling or itching. Recurrences are usually mild and infrequent. Frequency can be minimized with sun protec'on. - Fungal Infec2ons - What? o Candida species are a commensal organism of the oral cavity. Oral candidiasis is an opportunis'c infec'on that is uncommon in healthy individuals. - Why? o o Hygiene is important. Common Fungal Infec2ons Fungal Infec2ons - Referral is necessary (either den'st or GP). Intra-oral white lesions may be much more sinister and require further inves'ga'on. - The white thing can be removed à if it’s not removed? à problem à can be cancer. Dry Mouth - What? o May be the subjec've sensa'on (xerostomia) or there may be a pathological problem (salivary hypofunc'on). The laaer being an objec've reduc'on in the quan'ty and quality of saliva. - Why? o Dehydra'on o Alcohol o Anxiety o Mouth breathing o Drugs (generally the “an'” drugs – an'cholinergics, an'histamines, an'hypertensives, an'depressants, an'psycho'cs as well as opioids, inhaled bronchodilators) Chronic dry mouth may: - Contribute to tooth decay, periodontal disease, oral candidiasis, difficulty retaining dentures, difficulty chewing, swallowing, speech and altered sense of taste. Relevance? - Counsel about the possibility of this happening where relevant, any alterna've medica'ons? - Ensure adequate hydra'on, drinking water regularly. - Products that s'mulate saliva, such as lozenges, chewing gum. - Ar'ficial salivary products e.g. Biotene. - Referral to determine cause! Edentulous Pa2ents – Paediatrics & Geriatrics - Teething o Tooth erup'on generally accompanied by pain, swelling, drooling, irritability. - Treatment o Teething gels should not be used because of the lack of evidence of efficacy and the poten2al for harm. o Cold cucumbers. o Teething rings. o Rubbing the gums with a clean finger Denture concerns - Loose dentures - Irrita'ng dentures (sharp, large, uncomfortable) - Poten'al causes: o May have been made incorrectly, old, broken, underlying pathology causing mucosal changes. - Dirty dentures - Relevance? o Can offer polydent (or other) products – self use adhesive products as well as denture cleaners. Common Prescrip2ons What else is in the oral health sec2on? - Dental floss - Interdental brushes - Toothbrushes - Mouthwash e.g. Listerine – limited use, o;en if ever, not required. - Neutrafluor – prescribed for pa'ents who have a high caries risk - Oral-eze – contains a local anaesthe'c. - Denture related products - Salivary subs'tu'ons