Kyle Isaacs, BHS, RDHEP
Do you get frustrated when patients are not as healthy as you’d like—when they come back three, four, or six months later, only for you to find a lot of biofilm, calculus, inflammation, and bleeding? You’ve dug deep into your bag of tricks, recommending in-office fluoride treatments, xylitol, electric toothbrushes, dry mouth products, prescription fluoride, and antimicrobial mouth rinses. You have drawn on motivational interviewing to help elicit behavioral changes. Still, many patients have not conquered their oral health challenges.
Now imagine a patient who has special needs and all of the factors that can exacerbate disease (e.g., issues with compliance, dexterity, muscle contractions, cooperation, medications, age, money, diet, limited or no access to dental care, the need for independence, etc.). Many people with special needs live in long-term care facilities, are unable to access preventive dental care, or are reliant on others for activities of daily living, or ADLs.
I am lucky to have had the opportunity to go to long-term care facilities and private residences to provide preventive oral health services for people with special needs. I have encountered considerable unmet oral health needs, which are typically due to lack of understanding and access-to-care issues. One of the largest special needs populations is the elderly; the majority of the patients I see are in this group.
As people age, they are more likely to have difficulty taking care of some of their most basic needs. In 2000, 13 million people used paid long-term care services; as baby boomers age, it is estimated that this number will more than double to 27 million utilizing these services by 2050.1 This number does not take into account the many more who will be living on their own or with a partner of a similar age, many of whom will have trouble with ADLs and many of whom will be diagnosed with dementia. If we don’t do something soon to deal with the oral health needs of this growing population, poor oral health will result in poor health outcomes, poor self-esteem, increased health-care costs, and poor quality of life.
If we are to help those who are unable to care for themselves, we need to change current practice acts, allow dental hygienists in each facility, and use the most effective products for biofilm control. I know how important this is because I have been taking care of residents in facilities, in their homes, and at adult day-care services. Over the past four years, I have seen the ravages of what happens when people are no longer able to care for themselves. Imagine you have a patient with special needs who is unable to understand or remember instructions or who is unable to perform oral hygiene. These patients are reliant on us and especially their daily caregivers to either clean their teeth for them, cue them to do it, or stay with them while they brush their teeth.
The majority of older people take multiple medications, and many suffer from chronic disease and from xerostomia. I have observed caregivers hand my dementia patients toothbrushes, tell them to brush, and then leave the room. How thorough can patients be if they cannot even remember what they did or said a few seconds earlier? I know that if I can get their caregivers to brush their teeth or at least use products that help remove biofilm and prevent its adherence, then I will be the first one to do so.
We have probably all made recommendations for our patients to use rinses, gels, and toothpastes containing detergents, fluoride, antimicrobials, abrasives, and other additives, hoping that they will get and stay healthy. Does being sold mean products are safe? Will everyone use them wisely? Are they effective? In the case of toothpaste, maybe we just think products are safe and effective when they have been around for a long time. Because there are so many products on the market, it is our responsibility to stay current with the science to help our patients make informed decisions about what is best for their oral health.
A study looking at the use of over-the-counter mouthwashes found that regular use of certain products might have detrimental outcomes.2 The 945 study participants were overweight or obese and aged 40–65 without diabetes or prediabetes at the beginning of the study. They were surveyed about their mouthwash habits; those who used a mouthwash two or more times per day had a 55% higher chance of being prediabetic or being diagnosed with diabetes during the three years of the study, compared to participants who did not use a mouthwash.2 The authors concluded that using a mouthwash two or more times a day kills good and bad bacteria; good bacteria are needed to form nitric oxide, which helps regulate insulin and control blood sugar.2–4
Although more studies are needed to look at the consequences of altering oral bacteria, it is imperative that we use our critical thinking skills to help our patients make informed choices about which products are best for them and that we do not just recommend the same rinses and pastes for everyone. I have seen countless patients who rinse with something to help with gingivitis or periodontitis or who brush with a toothpaste for the same reasons, thinking it will solve all their problems—but often, they have made their decisions to purchase and use the products based on commercials. Wouldn’t they be significantly better off if they made these decisions based on recommendations from their dental professionals?
My perspective on Livionex dental gel
I have found one alternative to the detergents, chemicals, and antimicrobial ingredients found in toothpaste. Livionex dental gel is a product that not only removes the biofilm, but also prevents it from adhering to the tooth surface.5 This product uses activated edathamil which has been shown to chelate the calcium out of biofilm.6 Normally, biofilm matures and pulls calcium from the saliva and the tooth surface. When there is calcium in the biofilm, it is much easier for the biofilm to attach to the tooth surface by increasing the secretion of exopolysaccharides (glucans), thus increasing the sticky nature of the biofilm.5 Reducing the calcium in the biofilm disperses and removes biofilm and decreases its ability to stick to the tooth surface.5
A small randomized, double-blind clinical study with eight subjects compared Livionex dental gel to a toothpaste with triclosan for 28 days of brushing twice a day.7 Researchers wanted to compare biofilm, inflammation, bleeding upon probing, and pocket depths between the two dentifrices. Results demonstrated significantly better biofilm removal, decreased gingival inflammation, and better probing depths with Livionex.7
A randomized double-blind crossover clinical study with 22 subjects compared Livionex gel to a toothpaste with triclosan.6 The researchers collected data on inflammation, bleeding, and biofilm. No other oral hygiene regimens, such as mouth rinses or gum, were allowed. At the end of the study, the Livionex group had less inflammation and 45% less biofilm.6
Another great aspect of this gel is that there are no abrasives in it, as it does not need them for biofilm removal. This is especially important for people who have recession and exposed root surfaces, for whom the combination of brushing and abrasives would increase the likelihood of both sensitivity and increased caries.
As people age, their mucosae thin, and they are likely to require medications that may increase the possibility of hyposalivation—a bad combination for tender and sensitive oral tissues. Most toothpastes have fluoride in them to help with remineralization, but Livionex dental gel does not.8 Even without fluoride, the dental gel can aid remineralization because of the free calcium.
In another study, the dental gel was compared to a control toothpaste that contained fluoride. After an acid challenge, there was no difference between the two dentifrices in signs of erosion to the enamel surfaces.8 Because the gel does not contain abrasives, detergents (e.g., sodium lauryl sulfate), or antimicrobials, it is gentler and more easily tolerated by my patients, and it improves their oral health.5
My own results
I provided samples of Livionex tooth gel to the caregivers of three of my dementia patients and instructed them to use the gel on my patients one to two times a day. All three patients live in memory-care facilities and are completely dependent on others for oral care or for cueing to perform oral care. Since I left the samples, one has been unavailable for reevaluation, one is scheduled for a later date, and I have reevaluated the third. I will share my results from the third patient.
I began seeing my patient in 2017, and as with most of my patients who reside in long-term care facilities, there was a lot of food and biofilm on her teeth, especially interproximally and along the cervicals. In April 2018, I performed a full periodontal charting, and I started my patient on Livionex dental gel once a day and on Enamelon treatment gel once a day. Because of dry mouth and caries issues, I wanted her to use a product with fluoride and one that had calcium and phosphate. I saw her again in May. At that time, I only looked at her gingival health. My thoughts at that time were, “Wow, her tissue is so much pinker, there is less plaque, and I know there is less bleeding!”
On June 5, I was able to confirm these results with a new periodontal charting. Here are the results: In April there were 33 sites that had bleeding on probing, and in June, there were only 18. In June, there were 41 sites where the pocket depth had decreased by 1 mm and seven sites where it had increased by 1 mm. Of the sites where there were increases in pocket depth, five were on the palatal or lingual aspects, and one was on the buccal of No. 10. This patient is brushing her own teeth. For those of you who have not seen firsthand, I can tell you that in long-term care facilities, care providers are not generally comfortable providing oral care. They don’t usually watch people clean their teeth, and even if they did, most caregivers do not understand what constitutes thorough brushing and interdental cleaning. The only change made with my patient was introducing Livionex gel once a day.
The many benefits of this dental gel make it a great choice for anyone but especially for those who are unable to care for themselves. It is our responsibility to understand the science and help our patients decide what products are the safest and most effective for their oral health needs. I am excited to have another option for my patients that is safe and has this unprecedented effect on dental plaque. Keeping up with the latest innovations and not relying on what we have always done is imperative. It is easy to get left behind, and when we do, our patients suffer.
References
1. Long-term care statistics. The American Association for Long-term Care Insurance website. http://www.aaltci.org/long-term-care-insurance/learning-center/long-term-care-statistics.php.
2. Whiteman H. Could mouthwash be putting you at risk for diabetes? Medical News Today website. https://www.medicalnewstoday.com/articles/320199.php. Published November 28, 2017.
3. Joshipura KJ, Muñoz-Torres FJ, Morou-Bermudez E, Patel RP. Over-the-counter mouthwash use and risk of pre-diabetes/diabetes. Nitric Oxide. 2017;71:14-20. doi:10.1016/j.niox.2017.09.004.
4. Anbarani QG, Ho J, Vu TH, et al. A double-blinded, randomized study evaluating the in vivo effects of a novel dental gel on enamel surface microstructure and microhardness. J Clin Dent. 2017;28(3):49-55.
5. Jacobsen PL. The evolution of plaque removal. RDH magazine website. http://www.rdhmag.com/articles/print/volume-34/issue-12/features/the-evolution-of-plaque-removal.html. Published December 18, 2014.
6. Nayudu A, Lam T, Ho J, et al. Plaque removal and gingival health after use of a novel dental gel: A clinical study. Dentistry (Sunnyvale). 2016;6(10):396.
7. Ralston D, Carrasco R, Jacobsen PL, Wink C. 2014. Comparison of plaque removal capabilities between two dentifrices. J Oral Hyg Health. 2014;2:157. doi: 10.4172/2332-0702.1000157.
8. Lam T, Ho J, Anbarani AG, Liaw LH, Takesh T, Wilder-Smith P. Effects of a novel dental gel on enamel surface recovery from acid challenge. Dentistry (Sunnyvale). 2016;6(10):397. doi:10.4172/2161-1122.1000397.
Kyle Isaacs, BHS, RDHEP, is an expanded-practice dental hygienist working in a variety of settings. She is passionate about serving the under-served, mentoring other dental hygienists, and volunteering. She is an American Dental Hygienists’ Association member and serves on the board of the Oregon Dental Hygienists’ Association. She is a recipient of the 2017 Sunstar/RDH Award of Distinction and the 2018 Hu-Friedy/ADHA Master Clinician Award. She can be reached at [email protected] or milestwosmiles.com.
