I have become a reluctant blogger. :-/ There is such need for the services of advanced dental hygiene clinicians, it is hard to 'pick a lane' or topic to write about services we can perform. However, today I found this article "Why Little Teeth Matter, written in Dimensions of Dental Hygiene, a journal for dental hygiene professionals, I thought was relevant and understandable, even if you are not a dental hygienist.
To make a long story short, if you have little ones, ask your dentist if he or she will be your baby's Dental Home. A Dental Home is just what it sounds like, a place where you can take your small child for dental care, if needed. When would that be?
Sometimes your dentist does not want to be your baby's dental home. That is understandable. Some dental offices are not 'child friendly'. They may refer you to a pediatric dentist. Ask your pediatrician if he or she can be a dental home until your child can be seen by the dentist. Some pediatricians and their staff members are trained to provide visual oral health screenings, provide oral hygiene instruction, and place fluoride varnish to prevent tooth decay.
In the early stages of life, children need dental disease prevention. I started this post with the title "Caries prevention starts by protecting the first tooth". As soon as your baby's first tooth comes in, you should begin caring for it, keeping it clean, strengthening it with fluoride, and learning how to keep it and all next 19 primary (baby) teeth that come in healthy and cavity free. Yes. it can be done. Cavities are not inevitable. Our goal, as oral health providers, is to help your child never get a cavity.
Call an RDHAP. He or she may be able to come to your home to provide this education and preventive care. An RDHAP is a dental hygienist licensed to work outside the traditional dental practice, caring for the oral health of patients unable to get dental hygiene care in the traditional office setting. Look on our "I Need an RDHAP" map for an RDHAP near you.
Aging comes with many challenges. Among them is maintaining good oral health. It seems that when we are young there is an emphasis on daily brushing with fluoridated toothpaste and consuming less sugar to reduce the risk of tooth decay. However, as we age, both of these decay preventive strategies seem to be put on the back burner. Why is this?
Below is an overview of the common reasons tooth decay or caries increases as we age. They include:
Skimping on professional dental and dental hygiene care
Upon retirement, if you were lucky enough to have dental insurance prior to retiring, this benefit often gets dropped from retirement insurance coverage. Private dental insurance is available, but is notoriously pricey. As a dental hygienist in private practice, I have seem many patients who previously made regular preventive visits to the dentist, then start stretching them out and put off needed restorative care after retirement. Further, when our budgets get tight, professional dental care tends to get sidelined. It should not. Oral health is linked to general health. Maintaining a regular routine of preventive dental and dental hygiene care is as important as regular visits to the MD.
Many medications have the side effect of reduced saliva or the feeling of a dry mouth, called xerostomia. Medications that commonly cause dry mouth include antihistamines, antidepressants, muscle relaxants, diuretics, and decongestants, to name a few. Other processes that can contribute to the reduced saliva flow include Sjogren's Disease, salivary gland dysfunction, cancer treatment, normal aging, and even snoring and mouth breathing. Why is this important to know?
Saliva plays an important role in maintaining our oral health. Saliva contains many minerals that assist in digestion. It keeps the mouth moist to assist chewing and swallowing. Saliva has antibacterial qualities, helping to keep our oral tissues healthy. Minerals in the saliva are key to maintaining a neutral pH in the mouth. If the pH becomes too acidic, minerals are pulled from the tooth in order to neutralize the pH. If the saliva is too acidic for an extended period of time, mineral loss (called demineraliziation) will outpace minerals being redeposited (remineralization), leading to tooth decay. There are, however, many ways to reduce the effects of a dry mouth. Dry mouth can be difficult to treat and there is often no cure. An oral health professional can help patients learn to manage dry mouth and maintain a more neutral saliva pH.
We all know what we should eat and drink to reduce the risk of tooth decay - fresh fruits and vegetables, complex carbohydrates, unsweetened beverages and limit the processed sugar. Why don't we do that as we age? Several reasons come to mind. However, those elderly who seem to have the most cariogenic (cavity causing) diets are those who are bed or home bound, living in assisted living situations and not in control of their own diets, as well as those on limited incomes.
Those of us who have the choice and ability to choose healthy foods can still make poor choices. It is those who lack that ability who need the help of oral health care professionals to guide them to clean their teeth better and make better choices when possible.
Decreased ability to manage optimal oral self care
As we age, we need to change the way we brush and clean our teeth. The brushing technique we learned as children needs to be adapted to adult teeth and gums. Good oral self care is challenging for the healthy individual (how many of us love to floss?), and it takes time (two minutes brushing your teeth sounds like a long time). Becoming forgetful, possibly unable to stand and concentrate on our oral hygiene for 2-3 minutes, or having arthritic issues that make managing a toothbrush and dental floss difficult can create a situation where oral health begins to suffer.
Tooth decay along the gumline is the most challenging to treat and prevent. Abfraction is the breaking down of the tooth at the gumline for reasons unknown. We do know that the root surface is much softer than the enamel, so the patient who grew up with generally healthy teeth can become very prone to tooth decay on the root surfaces. The best advise from oral health care professionals is to have the roots checked regularly. The RDHAP can provide preventive care and place small temporary restorations that may slow down or stop the progress of decay until the patient can see his or her dentist..
So now what?
Tooth decay can happen very fast if the issues I have described converge. A visit to the dentist or dental hygienist is important to help identify any dental or oral hygiene issues a patient is having. These professionals can help guide the patient and/or caregiver to create new routines and strategies to help protect the oral health of the patients.
If you or your loved one is elderly and challenged to get to a traditional dental office, we have a solution. The RDHAP is a private practicing dental hygienist who can come to your home and help you maintain your oral health. Go to the Map to find an RDHAP in your area.
Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. JADA. 2007. Accessed at https://jada.ada.org/article/S0002-8177(14)62738-0/fulltext
I am a dental hygienist. I have practiced clinically for more than 40 years. If I have seen this scenario once, I have seen it hundreds of times. A patient who has been seen for several years comes in for routine dental hygiene care (cleaning appointment). Unfortunately, this appointment we find tooth decay starting under crowns, on molars, in areas the patients normally keeps very clean.
The dental hygienist and dentist need to be detectives in order to help the patient stop the decay. Removing the decay and placing a filling or crown is NOT the answer. Of course, this is important, but we need to know the cause and how to prevent more decay.
If we look at the four things necessary to put your teeth at risk for tooth decay, we begin by asking the patient questions with this list in mind. There are four (4) components that have to be in place to get a cavity.
Lets investigate these one at a time.
Tooth: The crown of our teeth (the part we see) is composed of enamel. Enamel is the hardest material in the body. The acids, however, can breach that hard surface, causing a hole or cavity. Unfortunately, most adults have some periodontal disease, that results in bone loss and exposed root surfaces. Root surfaces are softer than enamel and more easily decayed. This is the area most older people develop tooth decay.
The best ways we have learned to protect the tooth from tooth decay are to:
Bacteria: Even patients who take excellent care of their teeth can get cavities on their root surfaces. The bacteria are probably not the main culprit.
A lack of saliva can create an acidic environment in the mouth, as well. Many medications we can result in xerostomia or dry mouth. A change or addition in medication, an illness, change in diet can all affect your oral health.
Your dentist or dental hygienist should always update your medical history, including changes such as those mentioned. Sometimes it is a change we think is small or inconsequential that makes the difference.
Sugar/Fermentable Carbohydrates: As we investigate how our older adults are taking in sugar and fermentable carbohydrates, we commonly find them sneaking into their diets in small by catastrophic forms. Consider sugars in these forms (The American Dental Association has a very thorough list):
What are some healthy alternatives? Glad you asked.
Time: Remember that 20 minute time frame the bacteria need to start creating the acids? It is hard to change habits, but little alterations can help. Are you sipping on your beverage or candy because your mouth is dry? Are you sipping on a beverage during the day as you work? Try these strategies:
Dry mouth, a common side effect of many medications, reduces the amount of saliva in the mouth. Saliva keeps the pH of our mouth neutral. Saliva contains minerals that help remineralize the tooth. Without it, the pH becomes more acidic and minerals are leached from the tooth in order to try to neutralize the oral environment. Ask your physician if you have a lot of trouble with dry mouth. Together you may be able to find an alternative medication.
The short answer is yes. If you have active caries lesions (cavities), they are filled with bacteria. First, you need to get the bacteria removed and the cavity filled. Then you have to change your habits in order to make your mouth uninhabitable for the cavity 'causing' bacteria. But, let's go back further.
The long answer to the question is much more complex. Like most other diseases humans are prone to, a lot of things have to happen for it to manifest itself. This is a story of prevention.
Tooth decay is the result of a preventable disease called dental caries. The result of untreated dental caries is a caries lesion or cavity. You read it correctly. This disease is preventable. The bacteria responsible for reeking most of the havoc of this disease are transmissible. You were not born with these bacteria in your mouth. They are passed on to use by loving parents, grandparents, siblings, or even fellow toddlers in the playroom.
There are four (4) components that have to be in place to get a cavity.
Let's address these one at a time.
Host/Tooth: Rarely are people born with weak teeth. Oh, there are diseases that causes weak teeth with defective or no enamel, but they are rare. Our teeth normally erupt healthy. It is the first 18-24 months in the mouth, when our immune systems are developing, that they become compromised if parents are not vigilant. To keep the newly erupting teeth healthy, the rule of thumb is to always wipe them with a clean wash cloth or use a small tooth brush after you feed the baby. Infant formula and breast milk contain sugars essential for growth, but not so good if left on their little teeth too long (20 minutes). Never put a baby to bed with a bottle that contains anything but water, since they are bathing their teeth in sugar, creating the perfect environment for tooth decay to start.
Bacteria: We all have them. Most are good and important to our digestion and general health. The bacteria that 'cause' tooth decay, however, are not among the good guys. The rule of thumb here is to avoid sharing saliva, where many of the bacteria live, with your infant or toddler. How does that happen? Sharing food, toys, and toothbrushes; pre-chewing food (yup, people do that). Never clean a pacifier with your saliva. In otherwise, reduce the chance of infecting your baby with caries causing bacteria. Of course all of this may be OK if you or the other people loving on your baby are at low risk for dental caries. A few bad bacteria may get transmitted to your child, but we can keep them from growing in numbers by performing good regular oral hygiene. Read on.
Food (sugars and fermentable carbohydrates): Our bodies need carbohydrates to function properly, but the recommendations are to eat complex carbohydrates in the form of fresh fruits, vegetables, and legumes. In American culture, it is almost impossible to avoid the fermentable carbohydrates, though. We should all learn to curb them for lots of reasons, but that is for another blog post ;-). The rule of thumb here is to choose beverages that have no sugar (water), and snack on complex carbohydrates, such as fruit, vegetables, nuts. There are snacks that we can choose that actually have tooth-protective properties (white cheese, almonds, for example).
Time: So what does time have to do with all this? The bacteria that 'cause' tooth decay need about 20 minutes of exposure time to turn your cookie, cracker, or juice into an acid. It is actually the acid that causes the decay. The bacteria are really just the acid factories. If we look back on what we have read so far, the fewer bacteria (acid factories) you have in your mouth, the longer it is going to take to produce enough acid to cause a cavity. The less of their favorite foods the bacteria have to eat, the longer it will take to produce enough acid to cause cavities. The rule of thumb is to (1) avoid snacking, (2) remove the carbohydrates from your mouth (brush/floss/rinse) after snacking, and (3) minimize acidic beverages between meals.
Wow! That was a lot of information. My recommendation or RULE OF THUMB is to take baby steps. This post is basically about how to reduce the risk of ever developing tooth decay. It starts with protecting infants. Start small, wherever you think you have the best chance of success. Don't worry if you fail. We all fail now and then. I hate to even call it failing. It is part of learning. Just forget it, and keep trying.
I have gone through how to prevent or reduce the risk of developing dental caries. So what if you already have it? What if you are grandparent or relative and the new baby in your family is kissable? What can you do? Stay tuned for Can I Stop Getting Cavities: Part 2.
Clark MB, Slayton RL. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics. 2014;134:626-633 http://pediatrics.aappublications.org/content/pediatrics/134/3/626.full.pdf Accessed January 11, 2019
Featherstone JDB, Crystal YO, Chaffee BW, Shan L, Ramos-Gomez FJ. An Updated CAMBRA Caries Risk Assessment Tool for Ages 0-5 Years. CDA J. 2019;47(1):37-47. https://www.cda.org/Portals/0/journal/journal_012019.pdf. Accessed January 5, 2019
Nursing homes get some bad press. Just the name commonly conjures up a vision of someplace we do not want to be. Be they good, bad, or otherwise, our notions of nursing homes can always be improved if we take the time to visit those confined to these facilities and help out the staff when we are visiting our loved ones. There are some things, due to the fact that we are not skilled nursing professionals, we cannot attend to, but these hard working caregivers may be really happy to have us add some TLC and smiles to what can be an otherwise stressful day.
So where does oral health care come in here? It does not need to be said that the nursing home staff work very hard for their clients. What we, as oral healthcare workers tend to forget, is that they are medically trained and not dentally trained. It can be very foreign and uncomfortable for some of these workers to place their hands in their patient's mouths and perform excellent oral hygiene. We need to make sure this is being done, however. As most of us know, the mouth is attached to the body. Not only is it part of the body, it is the beginning of the digestive tract, the place where all sustenance generally enters the body. It is important in talking, smiling, eating, drinking, and swallowing. Anyone with a mouth probably knows a clean mouth makes you feel better.
I just read a Cochrane Library systematic review about research that has been done on nursing home patients and their oral health. The review of four studies concluded that there may be less incidence of aspiration pneumonia, but not enough good research has been done to draw a direct line from improving daily oral care and fewer pneumonia deaths.
Aspiration pneumonia is caused by aspirating food, fluids, saliva, or mucous and can make patients very ill and even cause death. Dental hygienists have long subscribed to the theory that the better the oral health is, the less chance of developing aspiration pneumonia. Patients who are trying to recover from any of a variety of illnesses are more prone to pneumonia as they lay in bed. We have all coughed when food or saliva 'goes down the wrong pipe". Those who are ill sometimes either may not feel it, or lack the reflexes to stop the stuff that doesn't belong there from drifting down the wind pipe into their lungs. The goal of good, daily plaque removal is to reduce the bad bacteria, fungi, etc., from accumulating in the oral cavity, so there are fewer "bad actors" or pathogens available to cause disease.
Though the research is still out on whether or not performing oral hygiene daily on patients in nursing homes, I can only believe that it helps and the smiles I get from patients after I have cleaned their teeth is evidence they feel better. We have to take our victories for these patients where we can get them. Ask any RDHAP. We believe we can make a difference and reduce the incidence of aspiration pneumonia.
If you are having questions about what to look for when visiting your loved ones in a care facility, or would like an RDHAP to look in on a particular patient, please go to the map on I Need and RDHAP to find a practitioner near you who can help you and your family care for everyone's oral health.