(Medically) Complicated Thursday, June 9, 2016 9:30 Am-12:30 Pm

CE Course Handout

It's (Medically) Complicated

Thursday, June 9, 2016 9:30 a.m.-12:30 p.m.

Welcome! It’s (Medically) Complicated!

Thursday, June 9, 2016 It's (Medically) Complicated ADHA CLL Annual Session, Pittsburgh, PA

Thomas A. Viola, R.Ph, C.C.P. [email protected] Lillian J. Caperila, RDH, BSDH, M.Ed. [email protected]

Program Objectives Program Objectives Pharmacology Hygiene Plan

• Review the prominent disease states found in the • Discuss the changing paradigm in caries prevention medically-complex patient utilizing risk assessments and consideration with • Distinguish between the states of xerostomia and complex polypharmacy patients hyposalivation • Select effective fluoride therapy using calcium & • Recognize the protective functions of saliva and its phosphate in professional and take-home care. role in prevention • Integrate critical thinking skills and implement • Explain and compare disease-induced and medication-induced xerostomia effective patient care strategies considering the most common chronic diseases.

Case Study Case Study

• 57 year-old male • Patient is diabetic and was a • Last recare visit May 2012 former smoker • Generalized advanced • Statins to control cholesterol chronic periodontal • LDL (148); HDL (56) disease • Rx dietary changes • Significant medical history: • Reduced high fructose and • BP is 140/88 carbohydrates • Monitors glucose level • Began walking 3-4 times week for 1-2 miles each day

Radiographic survey • Present and missing teeth • Pathology: caries, lesions, restored teeth, tori, root exposure etc… • Periodontal exam: • Probing 6 sites, mobility, recession, furcation involvement, occlusal assessment… • Gingival description • Active bleeding, exudate • Sensitivity, pain • Salivary flow

Patient Education Plan Clinical Phenotype:

Discuss and document… 1. Medical & dental information 2. Oral examination & radiographs • Nutrition assessment • Lifestyle patterns What is missing here in your • Patient’s at-home oral care diagnosis and treatment plan?

Pathogenic burden?

Salivary Diagnostic Tests: • PerioPath® test • MyPerioProgress ® report

• Scaling & root planing therapy • Antimicrobial mouthrinses • Host modifying medicaments: – Low dose doxycycline hyclate (Periostat™) – Site specific antibiotic (Arestin™, Atridox™)

Salivary Diagnostics: How it is changing our approach to diagnosis, risk assessment, and treatment of periodontal disease. Bader H & Arndt H. Ineedceonline: PennWell® publication Feb 2013-Jan 2016. 13 CAMBRA: Caries Management By Risk Assessment

CAMBRA: CAMBRA: General Health Factors Clinical Risk Factors:

Dental Hygiene Treatment Plan: CAMBRA: updated risks . Recent hospitalization and reason? . General observation of patient’s appearance, gait • Removable partial dentures and cognitive capabilities • History of extensive prosthodontic or restorative therapy . Take vital signs and record/w date • Over 60 years of age . List names of drugs/herbal supplements • Smoking . Record the daily dosage and frequency (compliance?) • Infectious contact . Research the drug list: . side effects . interactions that may alter treatment outcomes Roberts, D. Maragliano, R. Chapman R. Put the Plan into Action, Dimensions of Dental Hygiene, June 2011 © 2014 Viola & Caperila - All Rights Reserved 18 Dental-Specific Pharmacology, Interactions, Drug interaction & oral conditions and Clinical References

Apps available for mobile devices

Dental-Specific Pharmacology, Interactions, www.AADMD.org/resources/additionalresources and Clinical References

Today’s Review of Disease States Economic Burden

• Cardiovascular disease • Diabetes • The mean annual spending on adult dental care peaks • Respiratory (COPD) between the ages of 55 to 64 del Aguila et al, 2002 • GERD  dental caries account for about half of this spending • Alzheimer's • Parkinson’s • Americans spent an estimated $108 billion on dental • Chemotherapy & Head and services in 2010 Neck Radiation Patients • Projected increase to $180 billion by 2020. Truffer et al 2010

Cardiovascular Disease

. The function of the cardiovascular system is to supply oxygen via the blood to all areas of the body.

. This is accomplished through the contraction of CARDIOVASCULAR DISEASE the heart and actions of the blood vessels.

Cardiovascular Disease Hypertension

Goal of Treatment Drugs Employed . Cardiovascular disease refers to disease of the Reduce plasma volume Diuretics heart and blood vessels that result in this failure. Dilate blood vessels ACEI’s, ARB’s, CCB’s, • Hypertension Alpha-1 Blockers • Coronary Artery Disease Reduce cardiac output • Cardiac Arrhythmia (via SANS) Beta-1 Blockers, • Congestive Heart Failure clonidine

Coronary Artery Disease Congestive Heart Failure

Goal of Treatment Drugs Employed Goal of Treatment Drugs Employed Reduce plasma volume Diuretics Increase coronary artery flow Nitrates, CCB’s Dilate blood vessels ACEI’s, ARB’s, CCB’s Reduce oxygen demand Beta-1 Blockers Reduce contraction rate Beta-1 Blockers Inhibit progression of disease Antihyperlipidemic Agents Increase cardiac contractility Digoxin Prevent thromboembolism Antithromboembolic Agents Prevent thromboembolism Antithromboembolic Agents

Total Cholesterol • The benefit of using epinephrine to achieve profound anesthesia may outweigh the risk in patients with – Under 200 Desirable controlled cardiovascular disease. – 200-239 Borderline high – 240 and above High • Pain-induced stress leads to the release of endogenous epinephrine.

• This may exacerbate cardiovascular disease.

Classification of Cholesterol levels Classification of Cholesterol levels

LDL Cholesterol HDL Cholesterol • Less than 100 Optimal! • Under 40 Low • 100-129 Near-optimal • Over 60 High • 130-159 Borderline high *Optimal HDL should be >50 for women • 160-189 High Triglycerides • 190 and above Very high • Under 150 Optimal • 150-199 Borderline high • 200 and above High

Dental Hygiene: Cardiovascular Dental Hygiene: Cardiovascular

Observation during examination: • Face, arms or legs: numbness or weakness mainly on one When is best time to schedule this patient? side of body • Brain: confusion, trouble speaking, dizziness, loss of balance, What should be in your office emergency kit? bad headaches At visit – Ask if experienced an MI in past 30 days? • Eyes: trouble seeing from one or both • Stomach: throwing up or urge to

• Legs/Body: feeling tired and trouble walking

http://www.dentistryiq.com/articles/2013/06/heart-disease-and-stroke-update.html http://www.dentistryiq.com/articles/2013/06/heart-disease-and-stroke-update.html 35 36 Emergency Protocol* Patients with risk factors for coronary heart disease and experience “chest pain” Dental Hygiene: Cardiovascular

1. Take & record vital signs (BP over 180/110 Therapeutic Treatment: contraindicated for treatment that day) • Pain management pre-treatment 2. Administer 0.4mg tab of nitroglycerin sublingually or • 1-2 metered dose of spray (0.3 - 0.6mg) Mechanical removal of biofilm, pathogens 3. Provide Oxygen – flow rate 4 liters/min. to 6 • Altering immune response with selective antibiotics liters/min. via nasal cannula • Treating hypersensitivity – topical fluoride varnish 4. If pain doesn’t subside in 3 minutes, repeat dose of nitroglycerin 5-15 minutes 5. Chest pain that persists after 3 doses is most likely an Take-home agents: MI • Antimicrobial dentifrice/rinses 6. Pain persists – administer a 325 mg uncoated aspirin • Supplemental fluoride & calcium/phosphate products and CALL 911 7. Record all events in patient’s record • Power toothbrush, dental floss, proximal brushes

Dental Hygiene: Cardiovascular Dental Hygiene: Cardiovascular Treating hypersensitivity: root exposure “dry mouth symptoms”

 Avoid use of petroleum jelly on lips = causes dehydration Rx: cocoa butter  Avoid lemon glycerin swabs or crushing pills in fruit jam to assist in swallowing = dental caries risk  If hydrogen peroxide mouthrinse used - must be diluted to neutralize acidity

Dental Hygiene: Cardiovascular Take-home products

DIABETES

• Agents used to Treat NIDDM – Stimulate insulin production • glipizide (Glucotrol, XL) • repaglinide (Prandin) A disease of insulin resistance! – Reduce cellular insulin resistance • metformin (Glucophage) • rosiglitazone (Avandia) • pioglitazone (Actos)

Diabetes Diabetes

• Agents used to Treat NIDDM • Agents used to Treat NIDDM – Inhibit breakdown of ingested carbohydrates – Inhibit the breakdown of incretin hormones • acarbose (Precose) • sitagliptin (Januvia)

• saxagliptin (Onglyza) – Mimic the action of incretin hormones • Prolongs the stimulation of insulin production • linagliptin (Tradjenta) –exenatide (Byetta) –liraglutide (Victoza) • alogliptin (Nesina)

Diabetes Diabetes

• Insulin – Mechanism of action • Replacement of endogenous insulin Short Intermediate Long Acting Acting Acting – Adverse effects .Humulin R .Humulin N .Humulin U .Insulin aspart (Novolog) .Humulin L .Insulin detemir (Levemir) • Hypoglycemia, weight gain .Insulin lispro (Humalog) .Humulin 70/30 .Insulin glargine .Insulin glulisine (Apidra) .Humalog Mix (Lantus)** – Patient care considerations 75/25 **discard 28 days after 1st use • Treat hypoglycemia with glucagon, glucose

– Look carefully at oral cancer screening for: – Medical, Dental and Risk Assessments • Dry mouth, gingival inflammation, poor healing of oral tissues, thrush (thrives on high glucose level) and burning of – Determine Type of Diabetes and A1C test results mouth or tongue – Emergency kit: glucose gel or tablet OR orange juice – New Diabetes PPOD Tool Kit for collaborative care – Listen – allow patient to tell their stories since many of these “Working Together to Manage Diabetes. A Toolkit for diseases have “silent symptoms” when undiagnosed Pharmacy, Podiatry, Optometry and Dentistry (PPOD)” – Feel – be empathetic to gain their trust and compliance *Available through the National Diabetes Education Program http://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-dental-professionals.pdf

Diabetes: Dental Hygiene Care

• Confirm appointment: • remind to eat meal • check glucose level • Dietary review: Balanced meals to include high • Scheduling in late morning nutrients and reduce intake of after meal high sugar drinks and alcohol. (glucose high/insulin activity is • Home care lower) • Antimicrobials, stannous fluoride treatment gel RESPIRATORY • Pain management for • Maintenance – 2-3 months invasive procedures

Respiratory Respiratory • Chronic Obstructive Pulmonary Disease (COPD) • Asthma • Irreversible airway obstruction • Reversible airway obstruction, inflammation • Types • Reduction in expiratory airflow • Emphysema • Precipitated by • Alveolar destruction, enlargement • allergens, pollution, exercise, stress • Airway collapse • local anesthetics containing sulfites • Chronic Bronchitis • Symptoms • Chronic inflammation of airways • shortness of breath, wheezing • Excessive sputum production

http://www.ncbi.nlm.nih.gov/pubmedhealth/?term=COPD

Respiratory Respiratory

• Beta-2 Agonists – Mechanism of action • Beta-2 Agonists • Stimulate beta-2 adrenergic receptors – Adverse effects – Relax bronchial smooth muscle • May also stimulate cardiac beta-1 receptors

– Uses/Types • Short-acting beta-2 agonists (albuterol) – Patient care considerations – Treatment of acute asthmatic attacks • Xerostomia • Have short-acting beta-2 agonist inhaler • Long-acting beta-2 agonists (salmeterol) available during appointment – Treatment of chronic asthma attacks

Respiratory Respiratory

• Cholinergic Antagonists – Mechanism of action • Cholinergic Antagonists (continued) • Block pulmonary cholinergic receptors – Adverse effects – Relax bronchial smooth muscle • Nausea • Cough – Uses • Chronic management of COPD – Patient care considerations – Types • May produce xerostomia, altered taste • tiotropium (Spiriva)

Respiratory Respiratory

• Inhaled Corticosteroids • Inhaled Corticosteroids (continued) – Mechanism of action – Adverse effects • Reduce airway inflammation • Less than orally administered agents • Hoarse voice – Uses • Cough • Treatment of chronic asthma, COPD – Patient care considerations – Types • Xerostomia • fluticasone (Flovent) • Oral candidiasis and fungal pharyngitis • budesonide (Pulmicort)

• INHALERS accessible during care Patient management during procedures: • CAMBRA: focus on salivary function and adverse • Patient should be upright effects of medications during procedures • Inhaler or oxygen should be • NaF Varnish applied – post-prophy available • Home self-care: • Assess and note salivary flow • SnF2 Gel (970ppm) delivering ACP • Instrumentation: • Xylitol products • Hand instrumentation • Saliva stimulants, hydrate • Avoid sprays and aerosols • Avoid alcohol-based products • Ultrasonic scaler & prophyjet

Xylitol (Diabetes, Respiratory)

To promote anti-cariogenic effects: 6-10 GRAMS /day is key! Gum/mints 5-6 per day for 5 minutes each

PEPTIC ULCER DISEASE (GERD): GASTROESOPHAGEAL REFLUX DISEASE

Peptic Ulcer Disease (PUD) Peptic Ulcer Disease (PUD)

– Breakdown in the prostaglandin-based protective lining of the stomach –Treatment • Lifestyle changes – Leads to: • Erosion • Decrease acid production • Ulceration • Perforation • Coat and protect stomach lining

• Eradicate H.Pylori – Related to the presence of Helicobacter pylori (H. Pylori) • Dental considerations –Use COX inhibitors with caution

. Stomach contents “reflux” into esophagus – Treatment • Lifestyle changes . Burning in the middle of the chest (heartburn)‏ –Change in diet –Elevation of head in sleeping position . Leads to esophageal tissue damage • Decrease acid production . Related to position of stomach and cardiac sphincter • Dental considerations Hiatal hernia –Semi-supine dental chair position –Use COX inhibitors with caution

Treatment of PUD/GERD Treatment of PUD/GERD

• Histamine-2 Receptor Antagonists • Histamine-2 Receptor Antagonists – Mechanism of action – Adverse effects • Block histamine-2 receptors in stomach wall • Headache, dizziness • Decrease gastric acid production • GI upset

– Types – Patient care considerations • cimetidine (Tagamet) • Halitosis • famotidine (Pepcid) • Drug interactions at liver microsomal • ranitidine (Zantac) enzymes

Treatment of PUD/GERD Treatment of PUD/GERD

• Proton-Pump Inhibitors (continued) • Proton-Pump Inhibitors – Adverse effects – Mechanism of action • Headache • Inhibit “proton pump” in stomach wall • GI upset

– Types – Patient care considerations • esomeprazole (Nexium) • Halitosis, xerostomia, taste alteration • lansoprazole (Prevacid) • Drug interactions at liver microsomal • rabeprazole (Aciphex) enzymes • omeprazole (Prilosec) –clopidogrel (Plavix)

© 2014 Viola & Caperila - All Rights Reserved 71 © 2014 Viola & Caperila - All Rights Reserved 72 GERD complicated with acids GERD complicated with acids Sipping acidic drinks and eating fruit frequently

Images courtesy of A. Papas DMD – Tufts University Oral Medicine

GERD & Sjögren's syndrome Dental Hygiene: GERD CAMBRA: “extreme high risk for dental caries” • Dietary, pH neutralization • Reduce or eliminate acidic fluids/ frequency • Past history experience with fluoride? • 4-6 months recare based on dental history Preventive therapy: (Office) NaF Varnish delivering CA/P ions (Home) SnF2 Treatment Gel w/ACP and Images courtesy of A. Papas DMD – Tufts University Oral Medicine Bicarbonates for neutralization of saliva

Brushing technique: changing toothbrushes pH & low abrasive choices

Alzheimer’s disease is neurodegenerative disorder characterized by the loss of memory, language, visiospatial skills, problem-solving ability and abstract reasoning. It is also frequently associated with behavioral abnormalities. ALZHEIMER’S DISEASE

Alzheimer’s Disease Alzheimer’s Disease

The cause of Alzheimer's disease is unknown but it Patients with Alzheimer's disease have a greater appears to involve the loss of cortical and incidence of xerostomia, oral lesions, candidiasis, cholinergic neurons. Deposits of beta-amyloid periodontal disease, and root caries. In addition, plaques initiate inflammation, neurofibrillary tangles these patients often sustain oral injuries from falls and oxidative damage that result in a decrease of as well as lacerations of the tongue, and cheeks neurotransmitters necessary for normal cognition, (as a result of impaired mastication) and are at an memory and behavior. increased risk for aspiration pneumonia (due to dysphagia).

Alzheimer’s Disease Alzheimer’s Disease

. NMDA receptor antagonists –Mechanism of action . Cholinesterase inhibitors • Decrease overstimulation of NMDA receptors –Mechanism of action

–Increase acetylcholine activity –Types

• memantine (Namenda) –Types

• donepezil (Aricept) –Patient care considerations

• May result in agitation, dizziness and poor –Patient care considerations coordination • Increased incidence of cardiac abnormalities • Possible hypersalivation

Continued… 1. Memory life that disrupts 4. Confusion with time & 7. Misplacing things and losing daily life place ability to retrace steps 2. Challenges in planning or 5. Trouble understanding 8. Decreased or poor judgment solving problems visual images and spatial 9. Withdrawal from work or 3. Difficulty completing relationships social activities familiar tasks at home, at 6. New problems with 10. Changes in mood and work or at leisure words in speaking and personality writing

Hygiene Care Plan Self-care products

CAMBRA conducted with family member Typically: high risk for either or both dental caries & periodontal disease • Plaque assessment is critical to guide care • At home therapies decided based on patient’s abilities – Antimicrobial rinses and treatment gel for home use to minimize oral disease progression • Supervised dietary schedules • Printed materials for home guidance • Simplest interproximal aids

Parkinson’s Disease

Parkinson's disease is associated with the degeneration and loss of dopamine-producing neurons in the nigrostriatal portion of the brain, as well as the formation of destructive lesions and loss of function in the limbic, motor, and autonomic PARKINSON’S DISEASE systems

Parkinson’s disease is characterized by the The associated neuromuscular and cognitive presence of Lewy bodies; structures that are deficits result in an inability to perform and maintain strongly correlated with neuron degeneration and adequate general and oral hygiene, enhancing the are considered a diagnostic marker for the disease. progression of dental disease, impairing home care regimens and encumbering-office dental treatments.

Parkinson’s Disease Parkinson’s Disease

. Dopaminergic Agents – Mechanism of action • Increase dopamine activity . Dopaminergic Agents –Adverse reactions –Types • Dizziness • Dopaminergic agents • Sedation – levodopa/carbidopa • Hallucinations • Dopamine agonists – Mirapex, Requip • Anticholinergic Agents –Patient care considerations – benztropine • Acute dystonia of tongue, jaw and neck

Dental Hygiene – Parkinson’s Dental Hygiene: Parkinson’s

CAMBRA: xerostomia likely related to meds 3 - 4 month re-care schedules: • Patient should be well-rested for appointments – Adequate time – alleviate stress • Use of a chairside assistant is recommended • May have more difficulty with detailed plaque control aids & – Morning appointments if better rested & alert memory of instructions – Review proper dietary suggestions that reduce • Discuss frequent re-care intervals to monitor prevention strategies plaque and soft food accumulation • Fluoride varnish for maximum protection (3-4x yearly) – Reduce stress with multiple visits • Alcohol-free antimicrobial rinses – Interactive home care technique • Stabilized SnF2 gel with technology to deliver ACP, co- polymers for moisturizing and Spilanthes for mild flavor enhancement

CANCER – RADIATION THERAPY

Chemotherapy/Radiation Chemotherapy/Radiation

Many cancer patients and their families are unaware While chemotherapy is designed to be toxic to that cancer treatments may affect the oral tissues cancer cells, unfortunately, it may also be toxic and that visiting their dentist is an important part of normal, rapidly dividing cells, such as those of the the overall treatment. Cancer treatments affect gastrointestinal tract and hair follicles. dental treatment planning, prioritization, and timing.

Chemotherapy/Radiation Chemotherapy/Radiation

However, the mouth is also a prime target for the Oral complications common to both chemotherapy and radiation include oral mucositis and infection. adverse effects of chemotherapy. This leads to an Oral complications specific to chemotherapy include array of oral complications as a result of neurotoxicity and bleeding. chemotherapy. Oral complications specific to radiation therapy Necessary dental treatment and proper oral include salivary gland dysfunction, radiation caries, hygiene prior to, during, and after cancer osteoradionecrosis, tissue necrosis, and trismus. treatments can reduce the incidence and severity of oral complications.

Finally, oral complications not related to CAMBRA – “extreme high risk for caries & adverse oral effects” chemotherapy or radiation include osteonecrosis of *Coordinate with Oncology/Radiation team the jaw (associated with the use of bisphosphonates • Scheduling: and other medications). While not as severe, other • Prophylaxis 2-3 weeks prior to oncology therapy complications, such as dysphagia, dysgeusia and • NaF Varnish/ACP every 4-6 weeks throughout care head and neck pain can lead to secondary • Emphasize importance in biofilm control at home complications, such as dehydration and malnutrition. • Rx: morning & evening application of preventive treatment SnF2 gel without water rinsing • Rx: products to treat mucositis or ulcerations if needed

Radiation Patients Young Radiation Patient 106 Case study with and without fluoride therapies

May 28, 2008 Oct 22, 2008 Sept 23, 2009 Images courtesy of A. Papas, Tufts University Boston MA Generalized Post 5 months of radiation Fluoride therapy improves Demineralization occurs therapy compromises tooth or halts the with adequate home care structure demineralization process

Effects of radiation vs. demineralization patterns

XEROSTOMIA

Prevalence of Xerostomia Is it Xerostomia?

• • It is estimated that approximately 10% of the general Is it “xerostomia” or “hyposalivation”? population is affected by xerostomia. • Xerostomia (subjective perception) • Self-reported sensation of a “dry mouth” • Prevalence of xerostomia varies by age group • Oral dryness • Increases to 25% over age 65 • Constant need for mouth moisture

Prevalence of xerostomia varies by presence of systemic • Especially dry during sleep/upon awakening diseases and medications • Sleep interruptions • Increases to over 50% in LTC facilities • Must keep liquids at bedside

Is it Xerostomia? Is it Xerostomia?

• Self-reported sensation of a “dry mouth” • Hyposalivation (salivary gland dysfunction) – Altered sensations » Burning sensation • Clinically measured decrease in quantity

» “Feels like sand in my mouth” • Change in quality of saliva (“ropey”)

–Altered behavior • Palpation of glands reveals enlargement and tenderness » Need to drink water all day long » Need to suck candy • Attempts to “milk” the glands produce little or no secretion » Need to chew gum checking stimulated salivary flow

• Physical changes in appearance of oral mucosa and soft tissues • What is “normal” for saliva flow? –Dry, pale or red • Resting whole saliva –Signs of atrophy • Normal flow is about 0.3 to 0.4ml per minute

• Physical changes in appearance of tongue • Reflexive response to various stimuli –Fissured, inflamed • Mechanical (chewing and speaking) –Loss of papillae • Chemical (taste and smell) –Multiple caries on tooth surfaces

Complications of Xerostomia Complications of Xerostomia

• Xerostomia results in a functional decrease in • This functional decrease in quantity and quality the quantity and quality of saliva of saliva leads to oral complications • Loss of protective mucins • Increased susceptibility to caries • Dry, fragile oral mucosa • Cervical, interproximal, buccal and other “unexpected” surfaces involved • Loss of antimicrobial defenses • Imbalance of microbial ecosystem • Increased susceptibility to periodontal disease or exacerbation of existing disease

Complications of Xerostomia Sjogren's patient who stopped Rx prevention after 5 years

. Increased susceptibility to opportunistic infection Candidiasis 5 Years caries-free despite insufficient salivary production Viral infections And on preventive fluoride protocol

. Increased susceptibility to trauma of tissues 1/8/09 . Increased difficulty in wearing dental appliances and Several months after discontinuing prostheses preventive regimen

11/20/08 Case from Tufts University Oral Medicine

Immune Diseases Disease-Induced Xerostomia Extreme high risk • Medically complex patients are most at risk for disease-induced xerostomia. • 9:1 ratio of women to men • 1-4 million individuals affected in • Multiple organ system diseases and illnesses USA contribute to the development of xerostomia • Typical diagnosed patient is peri- menopausal or postmenopausal female • Multiple organ system diseases and illnesses • Documented pediatric cases exist exacerbate the complications of xerostomia

Disease-Induced Xerostomia Disease-Induced Xerostomia

• Cardiovascular disease – Gastrointestinal disease • Hypertension • Acid reflux • Stroke – • Congestive heart failure Erosion –Damage to nerves, salivary glands • Respiratory disease • Asthma and COPD – Diabetes mellitus • Mouth-breathing • Neuropathy • Sleep apnea • Polyphagia, polydipsia, polyuria

Disease-Induced Xerostomia Oral Complications of Xerostomia

Cancer: • High dose chemotherapy • Radiation therapy of head and neck CNS: • Parkinson’s Disease • Alzheimer’s Disease • Anxiety • Depression • Psychoses

Xerogenic Medications Popular drugs causing xerstomia • Antispasmodics • Bronchodilators DRUG BRAND NAME CONDITION • Antiemetics • Decongestants Albuterol Proventil, Ventolin Respiratory problems • Antihistamines • Antiparkinsonian Agents Atorvastatin Lipitor High cholesterol

• Antihypertensives • Psychotherapeutic Agents Diazepam Valium Anxiety

Diphenhydramine Benadryl Allergies • Anti-acne Agents • Antianxiety Agents Hydrochlorothiazide Esidrix, HCTZ High blood pressure • NSAIA’s • Antidepressants Hydrocodone Lorcet, Lortab, Vicodin Pain (narcotic) • Muscle relaxants • Anticonvulsants Metformin Fortamet, Glucophage Diabetes

• Opioid analgesics • Antineoplastic Agents Phenobarbital Luminal Anxiety

Non-Pharmacologic Treatment Non-Pharmacologic Treatment

• Non-pharmacologic treatment includes • Non-pharmacologic treatment includes maintaining and increasing hydration. changes in eating and drinking behavior. • Frequent hydration and ice chips • Difficult for patients with diabetes/HTN • Avoid carbonated and sports drinks (acidic)

• Sugar free candy and gum without citrus • Avoid caffeine (increased urination) flavors (acidic) • Xylitol proven activity against S. mutans • Avoid foods high in sodium

• Use humidifier during sleep, use lip balm • Avoid irritants • (spicy foods, alcohol, tobacco)

Pharmacologic Treatment Pharmacologic Treatment

Pharmacologic treatment includes agents to stimulate or simulate saliva and minimize oral and – Ora Moist Dry Mouth Patch non-oral complications. • Adheres to roof of mouth or buccal mucosa

• Salivary stimulants • Extended release (2 to 4 hours)

• Saliva substitutes • Sugar and alcohol free (contains xylitol)

• Fluorides • Contains naturally-occurring enzymes • Calcium & Phosphate additives

ACP CPP-ACP CSPS TCP Amorphous Calcium Casein Phosphopeptide Calcium Sodium Beta Tri-calcium Phosphate Amorphous Calcium Phosphosilicate Phosphate Phosphate (Functionalized TCP) ADA license (Recaldent®) (Novamin®) Mechanism of Specialized salt Casein binds to Silica binds Ca/P Blended beta Action compounds tooth surface until until sodium tricalcium No defined structure pH is lowered/ elevates pH to phosphate is or crystalline structure acidic challenge free CA/P ions insoluble Survey Access Code Highly reactive frees ions crystalline form

Solubility and Rapid delivery Becomes soluble Becomes soluble Low to moderate Bioavailability Highly soluble & only during lowered when sodium rate of solubility Bioavailable pH/acidity elevates and 04CLL93-2726 Greater Fluor uptake buffers pH

Professional • Enamel Pro: • MI Paste* NUPRO VANISH F varnish Products Pro-paste delivers ACP MI Paste Plus NuSolutions Prophy with TCP NaF Varnish & Gel/ACP MI Varnish paste It's (Medically) Complicated ENAMELON/ACP (all w/Recaldent) Clinpro 950 •Day White/Nite White GSK Sensodyne Clinpro 5000 & Relief /ACP * Tooth Mousse only Repair & Protect • Arm & Hammer available International Complete Care /ACP 134

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Special Thanks

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