by Shirley Gutkowski, RDH, BSDH
Keeping up with the slew of new weapons against decay is a demanding yet ultimately exciting challenge for hygienists.
Adjunctive therapies are remedies that help us get desired results in the therapeutic treatment of dental diseases, specifically periodontal disease and dental caries. Some adjuncts are used for bacterial colony disruption, colony size reduction, and colony demographic redistricting, while others help with detection.
Many of new therapies that fight dental disease have advanced during the last decade. Herbal remedies and nutritional counseling are among the most controversial of these new treatments. Most hygienists are not up-to-date in their knowledge of nutrition as it relates to infectious dental disease. Herbal remedies, on the other hand, are unregulated by the government. The public has no way of knowing if herbal remedies contain what their labels claim. Most herbal products are touted as "natural;" however, natural doesn't equal safe. "Natural" is a broad term that can encompass everything from dirt to dandelion leaves.
Weak regulatory standards are not the only drawback to recommending herbals. While manufacturers profess that their herbal remedies are safe, medicine is having quite a time with the some of the side effects of herbs. The complications that can occur from these nonmedications when combined with surgeries, conservative therapies, and prescription medications can be troublesome. For instance, gingko and garlic can increase bleeding, while St. Johns Wort can diminish the effectiveness of oral contraceptives. Encourage patients to let all providers know the kinds of "safe and natural" herbal remedies they take on a regular basis.
Let's now examine the adjuncts that can treat caries. I said treat caries - as in hygienists treating decay. Surgical removal of decayed enamel and placing a material to fill the void rebuilds the biologic shape of the tooth. But restorations don't stop or treat the condition. Decay as a condition can recur throughout the mouth.
During the last few years, there has been a slow movement toward trying to rebuild incipient enamel breakdown. The doctors who were comfortable waiting on incipient decay were suddenly regaining a little respect from the "Watch it do what?" crowd. An article in the July 2000 JADA by Dr. John D. B. Featherstone mapped out a program for remineralization from the incipient decay stage. The protocol involves CHX and fluoride. Another article in the same journal by G.H. Hildebrant and B.S. Sparks advised using Xylitol for the same goal. Clearly, watching areas of early decay is not enough. Patients must actively participate. They have two choices: returning to the dental office for daily treatments, or managing the treatments at home.
The friendly neighborhood drug store is full of adjuncts available for home use. Toothbrushes, our first line of defense, are innumerable. Regardless of color, shape, or means of motion, it is up to the user to reap the full benefit of a toothbrush. The polished bristles still have to touch all the parts of all the teeth to remove the caustic bacteria.
Alarm from bleeding and at the bright red toothbrush bristles can stop even the most attentive patient from twice-daily brushing. This becomes a two-fold problem. The bacteria are still there, and there is no fluoride distributed on vulnerable tooth surfaces. The CDC calls toothpaste the most effective way to administer topical fluoride other than public water supplies. Black-bristled toothbrushes, made by TESS, and black floss made by POH, are an obvious solution for patients who are alarmed at the sight of blood. For information on these products, visit www.tess corp.com, and www. oralhealthproducts.com.
On another shelf in the store are toothpastes with fluoride. These products take up shelf after shelf with their diverse colors, flavors, ingredients, and price ranges. Fluoride is the main reason to purchase any toothpaste. Toothpaste is an excellent medium for delivering this indispensable agent to teeth. But the essential information most consumers are unaware of is how to use fluoride toothpaste effectively. A stripe of paste the full length of the brush is a waste.
Fluoride works best in low doses over an extended period. Overdosing a brush delivers a high concentration of fluoride over a short period of time. After topical use of fluoride, salivary fluoride concentration increases, which prolongs the effect. Rinsing excessive toothpaste is necessary to decrease ingestion; however, rinsing also reduces the amount of time of exposure. The proper use of fluoride toothpaste, according to the CDC, is to use a smaller amount - about the size of a pearl. Brush to distribute the paste and expectorate the excess. This method leaves a small amount that continues working on the teeth. This increases the duration of fluoride content of saliva as well, converting the high concentration/low duration to a low concentration/high duration. Fluoride use also is one of the cornerstones of remineralization.
Fluoride lozenges are another excellent means to deliver fluoride optimally. Lozi-Flur lozenges deliver fluoride over 10 minutes. They taste good and increase the saliva's fluoride content for 30 minutes or longer if xerostomia is an issue. Some dental personnel are concerned with the potential for swallowing the fluoride, which is understandable. However, toxicity is not an issue at this dosage. Fluoride not incorporated into the enamel is excreted.
For some reason, this wonderful product is not widely publicized. Many journal articles mention fluoride lozenges as an excellent delivery mechanism. The taste is mild, the results are outstanding, and the cost is low. Fluoride lozenges should be distributed through dental offices. The lozenges come in quantities that are not dangerous to children, even if the entire package is consumed. The only trick to using this fluoride delivery system is ensuring that patients don't chew it. For more information, go to www.dreirpharmaceuti cals.com.
As a treatment adjunct, fluoride varnish fits the bill nicely. According the CDC guidelines on fluoride published in August 2001, fluoride varnish can be safely used off label for caries control. The mantra "low concentration/high duration" is also true of fluoride varnish. It lasts for hours until it is brushed off. Fluoride varnish applied onto the occlusal surface of erupting molars, including under the operculum, has been noted in the pits and fissures six months later. Fluoride, up until now, was an adjunct that was thought to work mainly on the smooth surface of teeth. However, varnish offers a measure of protection when applied to the occlusal surface of erupting teeth as well. Readers can obtain more information at www.colgateprofessional.com.
A patient suffering from a high incidence of decay will benefit greatly from a prescription of chlorhexidine in conjunction with fluoride therapy. According to the Featherstone article, rinsing with chlorhexidine twice a day for three weeks on a quarterly regimen will rearrange the oral flora to one that is populated by fewer virulent bacteria. The body, in a sense, will have a break from its fight against entropy. When the entire family is suffering from recurrent caries, it is wise to treat them all to break the cycle of reinfection. Small family members benefit from chlorhexidine applied with a cotton swab.
Technology is the latest rage for floss. Glide floss, made of GortexTM, has been popular for some time. Manufacturers are also coating floss with fluoride and Xylitol. Floss comes in different colors (including black), flavors, and with different applicators to make it easier to use. Our goal as oral health care providers is to encourage our patients to floss; however, it is their formidable task to figure out which one to use! For more information, check these web sites: www.xylifloss.com, www. glidefloss.com, and www.ada.org /prof/prac/sealcons/con-cat1.asp? category=Floss.
Patients who find regular floss difficult to use can benefit from the power flossers available today. They remove plaque, decrease bleeding, and, most importantly, unmotivated patients will use them. Imagine the smile on the face of your favorite patient with fingers as thick as sausages when you hand him a power flosser with a handle the circumference of a hammer handle instead of a toothpick! Check out www.waterpik.com for more information.
Sealants are the most superior preventive adjunct available today. A properly placed sealant is an indis-pensable tool in caries control. The most noticeable change in sealant material is color. Any hygienist who places a sealant knows the difficulty of an uncooperative, super-salivating wiggle bug. With only two hands available, the benefit of a sealant with contrasting color is much more than a cute feat of chemistry. The 3M ESPE pink sealant is obvious to the clinician before curing. It turns opaque white after exposure to UV light. The microfine tip that comes with the 3M ESPE sealant makes it easy to apply just enough material in the perilous grooves. This tip avoids over filling the pits and fissures, which results in less waste. It's not easy to stay abreast of the new techniques and technologies, and it's impossible to get everything in one article. But the last decade has seen extraordinary advancements in oral care. For both the new hygienist and seasoned hygienist, keeping up is nearly a full time job.
pensable tool in caries control. The most noticeable change in sealant material is color. Any hygienist who places a sealant knows the difficulty of an uncooperative, super-salivating wiggle bug. With only two hands available, the benefit of a sealant with contrasting color is much more than a cute feat of chemistry. The 3M ESPE pink sealant is obvious to the clinician before curing. It turns opaque white after exposure to UV light. The microfine tip that comes with the 3M ESPE sealant makes it easy to apply just enough material in the perilous grooves. This tip avoids over filling the pits and fissures, which results in less waste.
It's not easy to stay abreast of the new techniques and technologies, and it's impossible to get everything in one article. But the last decade has seen extraordinary advancements in oral care. For both the new hygienist and seasoned hygienist, keeping up is nearly a full time job.
The candy aisle
When the equilibrium between bacteria and saliva becomes upset, decay occurs. The candy aisle is one of the most unlikely places to find products that will help decrease the chances of decay. Savvy hygienists know that chewing gum will dislodge food particles and increase saliva, which re-establishes the equilibrium. Saliva not only buffers the acids produced by the bacteria, but also has all the elements necessary to rebuild damaged enamel. Chewing gum with Xylitol can remineralize teeth and upset the cariogenic oral flora.Xylitol is a preferred sugar for Strep mutans. However, when excreted as a waste product it is not acidic and therefore does not lower the pH of the mouth. This is good news on two fronts:
- The environment is no longer friendly to acidophilic bacteria.
- There is no acid to dissolve the enamel.
New mothers with tooth decay can lower their own caries risk as well as their children's by using Xylitol. For more information, check the Web sites www.xylitolworks.com and www.xylitolinfo.com.
Another ingredient available in the candy aisle is derived from milk and not only doesn't promote decay, but has been proven to remineralize enamel twice as quickly as sugar-free confections without it. The ingredient is Recaldent and it is in certain products in the Trident line of gum and mints. Dosage is one serving four times per day. RecaldentTM is derived from the casein in milk. It is safe for individuals suffering from lactose intolerance, but should not be used by those with milk allergies. Check www.tridentgum. com for more information.
What can we do as dental therapists for our patients who suffer from decay, other than educating them on the value of shopping in the candy lane? How about fluoridated water? Rinsing or drinking tap water frequently during the day is a pretty good resource. The benefit comes from the topical topical effects, rather than any systemic value.
High-tect data
Historically, a sharp explorer was the best way to detect decay on the occlusal anatomy of posterior teeth. If the explorer stuck, decay was present. Practitioners became aware later that the explorer sometimes stuck because the fissure was just wide enough to allow the sharpened point to penetrate a microscopic measure - it was stuck, but was not a real indicator of decay.Research also has shown us that decay can be transmitted from one tooth to another. A sharp explorer can introduce Strep mutans from one tooth into the fissure of a caries-free tooth. Tools that measure the density of the enamel, like the DIAGNOdent by KaVo, eliminates such archaic methods of caries detection.
The DIAGNOdent provides clinicians with a numerical reading of enamel density. A reading over a certain number gives the practitioner the quantitative information needed to surgically remove the damaged enamel and restore the tooth's biological contours.
Practitioners can use the information to make the decision to use a sealant or a biological restoration. This adjunct relays quality information useful for saving enamel, not just for padding production numbers.
An article by Karen Kaiser, RDH, in the August 2002 issue of RDH, explores caries detection in-depth.
Shirkey Gutkowski, RDH, BSDH, has been a full-time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Corss Link publications. She can be contacted by email at [email protected].
