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First class dental | Issue 2. Spring ’19
April 1, 2019
How your Dental Appointment Can Improve Your health
Many patients are on medication such as Zometa, Fosamax, Boniva, or Actonel to help treat and prevent osteoporosis. While these medications provide many benefits, they can also lead to side effects which affect your oral health. Healthcare providers and patients need to be aware of the signs, symptoms, and latest information regarding Medication-related Osteonecrosis of the Jaw (MRONJ).
Dental Guidelines for Patients Who Have or are at Risk for Medication-Related Osteonecrosis of the Jaw (MRONJ)
Medication-related osteonecrosis of the jaw (MRONJ) is a condition in the mouth characterized by areas of necrotic maxillary and/or mandibular bone that is often associated with soft tissue infection and pain. MRONJ can be seen in patients receiving antiresorptive or antiangiogenic agents for cancer, osteoporosis, and metabolic and developmental bone diseases...
Patients should be evaluated by a dentist prior to initiation of antiresorptive or antiangiogenic therapy according to the guidelines below. All invasive dental procedures that involve manipulation of bone should be completed at least 4-8 weeks (or longer if clinically feasible) prior to initiation of therapy. Update (within one year) radiographs sufficient to rule out dental disease (e.g., caries and periodontal disease) and evaluate previously endodontically treated teeth and third molars • Dental treatment plan the patient • Extract teeth that are non-restorable or with poor long-term prognosis (including root tips) • Complete all restorative dentistry, endodontic therapy, and periodontal therapy as appropriate depending on the clinical circumstances • Place the patient on regular follow-up schedule.
Frequently Asked Questions (FAQs)
• Which dental procedures are safe to perform in patients at risk for or with MRONJ? Any procedure that does not involve manipulation of the bone may be safely performed. These generally include delivering local anesthesia, scaling and prophylaxis, placing restorations including crowns and fixed prostheses, fabricating dentures and conventional root canal therapy.
• Which dental procedures should be avoided in patients at risk for or with MRONJ? Any invasive elective procedure that involves manipulating the bone should be avoided if possible but if performed, should be followed by two weeks of antibiotic coverage as noted above. This includes periodontal surgery (e.g., crown-lengthening and bone grafting), endodontic surgery (e.g., apicoectomy), and placement of dental implants (see section below). In addition, orthodontic treatment outcomes may be negatively affected in patients with a history of bisphosphonate use. ● Should patients at risk for, or with MRONJ be prescribed antibiotics prior to dental treatment? There is no need to prescribe antibiotics for dental prophylaxis, routine caries control or other noninvasive procedures. However, antibiotic therapy is indicated for any dental procedure involving manipulation of the bone (e.g., extraction) and should be administered for two weeks following the dental procedure or until the overlying mucosa has healed. ● Is a drug holiday indicated for patients at risk for, or with MRONJ prior to invasive dental procedures? There is insufficient evidence to support a drug holiday prior to invasive dental procedures. Some experts suggest possible benefit of a two-month drug holiday in patients who have taken oral bisphosphonates for more than four years. Ultimately the patient’s need for antiresorptive therapy should supersede drug holiday considerations and the decision should be made by the oncology team or other physician. At this time, there is no consensus regarding a drug holiday for patients on denosumab. Similarly, no recommendation pertaining to a drug holiday can be made for antiangiogenic agents due to lack of data. In these cases, best clinical judgment should be used taking into consideration the patient’s disease status and consultation with the oncology team. – ● Can patients at risk for, or with MRONJ, receive dental implants? Although the incidence of dental implant failure is unknown in cancer patients with exposure to antiresorptive and antiangiogenic agents, implant placement is generally not recommended, especially in patients with established MRONJ. Dental implants may be placed with caution in patients with osteoporosis at risk for MRONJ because MRONJ occurs infrequently in these patients. Patients should be carefully counseled and radiographs of the patients should be examined for evidence of bone changes as noted above. ● Should patients at risk for, or with MRONJ receive any adjunctive therapies prior to invasive dental procedures? There is insufficient high-quality evidence to support or refute the use of adjunctive therapies such as hyperbaric oxygen, pentoxifylline and tocopherol, low-level laser, ozone, teriparatide, bone morphogenic proteins and platelet-rich plasma prior to dental procedures.
What is the link between Sleep and Alzheimer’s Disease?
The body needs sleep to be healthy. Sleep is the time the body recovers and repairs itself. Scientist have discovered another important function of sleep and that is when the glymphatic system works to wash the brain of harmful proteins and toxins. The accumulation of toxic proteins such as beta amyloid and tau in the brain are associated with Alzheimer’s disease, researchers have speculated… that impairment of the glymphatic system due to disrupted sleep could be a driver of the disease.
Screening for sleep related disorders (SRD) such as insomnia, snoring, frequent awakenings, and sleep apnea is critical to understanding your risks. There are easy and non-invasive ways to screen. Many believe if they have an sleep issue CPAP is their only option, however there are many choices patients can have to lead a healthier life.
Dry mouth, or xerostomia, refers to a condition in which the salivary glands in your mouth don’t make enough saliva to keep your mouth wet. Dry mouth is often due to the side effect of certain medications or aging issues or as a result of radiation therapy for cancer. Less often, dry mouth may be caused by a condition that directly affects the salivary glands.
It May Be What You’re Taking
More than 400 types of medicine can cause dry mouth, including over-the-counter drugs for allergies and cold symptoms. Prescription drugs for high blood pressure, overactive bladder, and mental health problems can also cause it. Radiation can damage salivary glands, and chemotherapy can cause saliva to thicken and make your mouth feel dry...
Smoking Can Make It Worse
There are plenty of reasons to quit smoking, and having dry mouth is one of them. Smoking doesn’t cause dry mouth. But smoking cigarettes or cigars, or using pipes or other tobacco products, even smokeless ones, can aggravate it.
Saliva preservation: If salivary content is low, one must do as much as possible to keep the oral tissues as moist as possible and limit the things that can dry the mouth out. Those experiencing dry mouth should try to breathe through their nose as much as possible, and limit mouth breathing.
Avoiding caffeine, alcohol, and tobacco is very important. Using a humidifier to introduce more moisture to a room or at bedside can be helpful, especially while sleeping. Don’t use OTC antihistamines or decongestants, as they can dry the mouth out as well.
Saliva substitution: There are many home remedies to help replace the moisture that saliva provides to the mouth. These include drinking water more frequently throughout the day, especially while eating. Sucking ice chips throughout the day will help the mouth remain as moist as possible. A mouthwash can be helpful, but it can also be harmful. When selecting a mouthwash, the person must choose a product that doesn’t contain alcohol, such as Biotene, for alcohol-based products will only cause further mouth dryness. Closys mouthwash can be extremely beneficial due to its absence of alcohol and excellent germ-killing properties. Artificial OTC saliva substitutes and oral lubricants containing glycerin will provide help during eating and speaking. They won’t cure xerostomia, but will provide some relief. Moisturizing the lips with a balm or Vaseline can also be helpful.
Saliva stimulation: Chewing gum can help stimulate salivary flow, but it is important to remember not to use gum or candies that have sugar in them or the person will be placed at greater risk for developing cavities. Sugar-free lemon drops, lozenges, or other hard candies can also help stimulate the salivary glands. Other remedies include medications that help increase salivary flow such as pilocarpine (Salagen) and cevimeline (Evoxac). These prescription medications are to be avoided by people with asthma or glaucoma.
Prevention of caries and Candida infection: Cavities, gingivitis, periodontal disease, and fungal infections are common complications of dry mouth. A dry oral environment makes plaque control more difficult, so meticulous oral care and hygiene becomes essential in preventing rampant caries, gingivitis, and periodontal disease. The affected individual should incorporate a low-sugar diet and begin daily use of fluoride treatments and antimicrobial rinses to combat the effects oral dryness has on the teeth and oral tissues. Prescription toothpastes that contain more fluoride, calcium, and phosphate will help protect and remineralize teeth where necessary. Frequent visits to the dentist are necessary to help manage these complications. Since people with dry mouth often develop fungal infections such as thrush (oral candidiasis), they may require topical antifungal treatment such as rinses and dissolving tablets. Dentures often harbor fungal infections, so they should be soaked daily in chlorhexidine or 1% bleach.
Congrats to Dr. Cohen for passing his Board Certification Exam in Dental Sleep Medicine!
Board certification through the Academy of Clinical Sleep Disorder Disciplines (ACSDD) demonstrates extensive clinical knowledge an experience in providing oral appliance therapy to treat snoring and sleep apnea. It demonstrates that Dr. Cohen has the technical skill, in-depth knowledge and professional judgment to provide sleep medicine treatments.
Happy to welcome Christine Jones-Kerper
Meet Christine: Certified Dental Assistant
Christine join our dental family in 2019. She enjoys working with us because she gets to be part of a team that takes pride in their work and educates their patients. Every day, she comes in and does her best to serve her patients. She is also an emergency medical technician... She and her husband are the proud parents of two children, Breanna and Connor, and three grandchildren, Arabella, Ryleigh and Madalein. Her favorite hobby is off-roading in her jeep.
Obscure Dental Fact:
Vermont Law states, if you’re a woman and you want to get false teeth, you’re going to have to ask your husband for a written letter of permission. Now that’s just insanely crazy.
April 6th 2019 our office was proud to Support the American Foundation for Suicide Prevention’s (AFSP) at Lower Morelands “Out of Darkness Walk”
Because we need to change the culture.
Depression, bipolar, anxiety disorder, and other mental health conditions will affect 1 in 4 of us during our lives, and yet too often these illnesses go untreated. In the United States alone someone attempts suicide every minute...
Because students can save lives.
Students are a force for change. Be a part of this walk and join thousands of students across the country to raise money for the American Foundation for Suicide Prevention.
Because we can prevent suicide.
Together we can bring mental health conditions like depression and anxiety out of the darkness and put a stop to this loss of life.
Walk to support a friend, a loved one, or yourself. We all have a reason to walk, and each reason connects us.
Check out the AFSP website! https://afsp.org/
Dry Mouth (Xerostomia) Medical Author: Steven B. Horne, DDS
Not all sleep is equal when it comes to cleaning the brain
Date: February 27, 2019 Source: University of Rochester Medical Center
Dana-Farber Cancer Center: Oral Medicine and Oncology