Dental care in the pharmacy

An Overview Of Some Of The More Common Dental Problems That Present At The Pharmacy Counter

Dentists recommend that people have a cleaning and check-up every six months. Depending on a patient’s specific oral health needs, they may recommend a dental visit more often than that. However, many people visit their dentist far less frequently for many reasons, including financial reasons, lack of time and fear of the dentist, among others.

When patients visit a pharmacy with dental problems, the pharmacist is in an ideal position to encourage people to visit their dentist every six months, as prevention is better than cure. In this article, I discuss just a few of the more common dental problems pharmacists encounter in their practice.

PART 1: GINGIVITIS (GUM DISEASE)

Gingivitis is more commonly called ‘gum disease’ (also known as periodontal disease) and is caused by a build-up of bacteria in the gums. It causes gum irritation, red swollen gums, and bleeding. Gingivitis can be mild, and many are not aware they have the condition and only get treatment when it is too late, ie, gum and dental damage are evident. Gingivitis is generally not painful but if not treated early, it will result in more serious gum disease (periodontitis), which can cause tooth loss. Gum problems can begin in adolescent years and continue into adulthood.

Periodontitis and general poor oral health can have a detrimental effect on overall health. Periodontal disease is associated with more risk of heart attack, stroke, and lung disease. In women, it is linked to premature birth or low birthweight babies. It is not fully understood if periodontal disease is a cause of any of these conditions or why people with periodontal disease have higher incidences of these health problems. Poor oral hygiene is the main cause of gingivitis, as it increases formation of plaque. Plaque is a ‘furry’ coating that forms on the tooth; it can be colourless or sometimes a pale-yellow colour.

Plaque is a sticky film of bacteria that forms on teeth due to starches and sugars reacting with bacteria found in the mouth. Plaque requires removal daily (via brushing and flossing), as it re-forms quickly again within 24 hours after last removal. If not removed, the bacteria in plaque forms acid, which damages enamel and causes tooth decay and when under gums on the tooth’s root, can lead to bone damage and eventual tooth-loosening and loss. Whilst poor oral hygiene is the most common cause of gingivitis, other factors that increase risk include smoking, being diabetic, increasing age, dry mouth, hormonal changes (due to pregnancy, menstrual cycle or taking the contraceptive pill), poor diet, substance misuse and poorly-fitting dentures.

SYMPTOMS

Healthy gums will be firm and a pale pink colour. Signs of gingivitis include soft, puffy, tender, dark red and easybleeding gums (may be red or pink colour on the toothbrush or floss). Other signs include swollen gums, receding gums, and bad breath. A dental appointment is important if some of these symptoms are noticed; a dentist can quickly diagnose gingivitis and advise on the right course of action. Prompt treatment will clear gingivitis symptoms and prevent development of more serious gum disease and tooth loss. Treatment requires professional care through the dentist, followed by improved regular oral hygiene practice at home.

WHAT A DENTIST WILL DO

After checking teeth, the dentist (or dental hygienist) will thoroughly clean to remove all plaque and tartar. Dentists remove plaque and tartar using a procedure called scaling. Scaling may be temporarily uncomfortable, especially as gums are sensitive (which is often the case with gingivitis) or if there is excessive plaque and tartar buildup. The dentist may fix crowns or fillings (dental restorations) that make brushing and flossing in certain areas difficult. Teeth that are misaligned, crowns that are poorlyfitting, bridges or fillings can irritate gums and prevent removal of plaque in certain areas by flossing and brushing, so the dentist may need to fix some of these issues. The dentist will advise on effective brushing and flossing techniques at home.

SELF-HELP

Gingivitis will clear-up with a thorough professional cleaning by a dentist or hygienist, and if the person then practices good oral hygiene by brushing and flossing. There are steps a person can take to prevent and reverse gingivitis. These include regular professional dental cleanings (generally recommended as every six months). A soft toothbrush is best if there are gum problems and aim to replace it every three or four months to ensure maximum cleaning capacity. Consider the use of an electric toothbrush, as it may be better for removal of plaque and tartar. It is important to brush teeth twice-daily or better again, after every meal or snack. Floss at least once-daily (this is where many people fail, and it is very important). Use an antiseptic mouthwash if a dentist advises. A thorough cleaning using a toothbrush and floss will take three-to-five minutes if done properly.

PART 2: DRY MOUTH

Dry mouth (medically known as xerostomia) is due to a reduction in saliva produced by salivary glands. Dry mouth is often a sideeffect of medication and less frequently, is caused by a condition that damages or blocks salivary glands. Dry mouth can vary from being a slight nuisance, to having a major effect on general and dental health. It affects appetite and taste, hence reducing ability to enjoy food and reducing nutrition. Saliva has many roles, including aiding digestion and enhancing our ability to taste food and allow easier swallowing. Saliva prevents tooth decay by neutralising acids caused by bacteria, preventing growth of bacteria and washing away food pieces.

CAUSES

Medicines Many medicines, including many over the counter medicines, can cause dry mouth. Medicines with an anti-cholinergic effect are a common culprit. These include tricyclic antidepressants and older antipsychotic drugs, drugs used for neuropathy (ie, gabapentin), benzodiazepines, some antihistamines (especially the ones that cause drowsiness), decongestants and analgesics, as well as muscle relaxants.

Ageing

The ageing process does not cause dry mouth, but older people have increased likelihood of conditions that cause dry mouth, as well as increased likelihood to be taking medicines that cause dry mouth.

Cancer treatment

Both chemotherapy and radiation therapy change the quality of saliva and can reduce the amount and quality of saliva produced. Radiation treatment of the head and neck area is especially known to damage salivary glands, thus reducing saliva. This may be reversible after treatment but in some cases, it may cause permanent damage and hence ongoing dry mouth.

Nerve damage

A head or neck injury or surgery that results in nerve damage to the head or neck can lead to dry mouth.

Other health conditions

Dry mouth can be a result of some health conditions, including Sjogren’s syndrome (an autoimmune disease which is a relation of arthritis and causes enlarged salivary glands, dry mouth, and dry eyes) and HIV/AIDS. Stroke and Alzheimer’s disease can make a person perceive they have dry mouth, despite normal functioning of the salivary glands. Snoring and breathing with an open mouth (while sleeping) can also contribute to dry mouth.

Smoking

Smoking can cause and exacerbate symptoms of dry mouth.

Symptoms

While dry mouth is a nuisance, it is the symptoms and problems caused by dry mouth that have the major impact on people’s lives. When not enough saliva is being produced, problems caused will include dryness of the mouth or throat; thick and stringy saliva; bad breath; changed taste sensations (or inability to taste flavours properly); problems with chewing; swallowing and speech problems; increased tooth decay and gum irritation and gum disease; and problems wearing dentures, including friction and pain. Reduced saliva also leads to more oral problems, including increased plaque, tooth decay and gum disease, mouth sores, fungal infection (candida) in the mouth, coated (discoloured) tongue, cracked lips, and sores or skin splits occurring at the corners of the mouth. All these problems can lead to poor nutrition due to reduced ability to chew and swallow.

TREATMENT

Input can be from a doctor, dentist, or pharmacist to advise on the condition. Initially, an examination of the mouth, review of medical history and details of medicines being taken (including over-the-counter medicines) will be required to rule out and determine possible causes. Depending on the causes of dry mouth, a GP may need to change medicines that can cause dry mouth. In most cases, there are alternative options that will not cause dry mouth. In some cases, it may not be possible to change the medicines causing the dry mouth, as there may not be suitable alternatives and the benefits may outweigh the risks.

MOUTH MOISTURISING PRODUCTS

Options include mouth rinses, artificial saliva or moisturisers that lubricate the mouth. For severe dry mouth, options include prescription medication that works by stimulating saliva. Options include pilocarpine or cevimeline that stimulate saliva production. There are over-the-counter saliva substitutes available from pharmacies, including the Xerostom, Bioxtra and Biotene ranges of products. These brands come in the likes of gels, mouthwashes, toothpaste and chewing gums and have been shown in studies to increase saliva flow by up to 200 per cent and shown to relieve pain associated with dry mouth and improve taste and flavours. These products not just lubricate the mouth, but also stimulate saliva flow.

OTHER TIPS

Sip water or sugar-free drinks regularly to moisten the mouth and drink water during meals, as it will help make chewing and swallowing easier. Use sugar-free chewing gum or suck sugar-free hard sweets. Bear in mind, however, that xylitol is often a sugar substitute in sugar-free products, and it can bring on diarrhoea and cramps if taken in large amounts. Aim to breathe through the nose, not the mouth. Treatment for snoring may be recommended, as snoring causes breathing through the mouth during the night. A room humidifier may also help, as it will add moisture to the air while sleeping. Regular moisturisation of the lips will soothe dry or cracked areas. Because of increased risk of dental problems, regular check-ups with a dentist are recommended.

WHAT TO AVOID?

Avoid substances that can exacerbate dry mouth, including caffeine and alcohol (these can cause dryness and irritation); avoid mouthwashes containing alcohol; avoid salty and dry food; stop smoking; and patients can discuss with their GP or pharmacist regarding medicines to avoid, including over-the-counter medicines that can cause dry mouth (such as antihistamines and decongestants).

PART 3: HALITOSIS (BAD BREATH)

Up to 50 per cent (22-to-50 per cent) of the population suffer from bad breath and approximately half of these experience a severe problem leading to personal and social discomfort and social embarrassment. The ‘mouth air’ of those suffering from more severe halitosis is tainted with compounds, including hydrogen sulphide, methyl mercaptan and organic acids, leading to foulsmelling air.

AETIOLOGY

The source of the bad odour is located within the oral cavity in approximately 90 per cent of cases of halitosis, meaning only a small percentage of cases are due to nonoral causes, such a serious underlying medical condition which warrants immediate referral to a doctor, ie, diabetes. The tongue is recognised as the biggest source of bad breath and is considered the main cause in up to 90 per cent of cases by some experts, so other causes like gingivitis are considered a cause in only a fraction of cases compared to tongue hygiene. Oral micro-organisms most likely to cause halitosis are gram-negative bacteria species, which include the likes of treponema denticola, porphyromonas gingivalis, prevotella intermedia, bacteroides loescheii, enterobacteriaceae, centipeda periodontii and fusobacterium nucleatum (this oral bacteria list is not exhaustive).

COMMON CAUSES ?

• Failing to brush teeth twice daily. ?
• Improper cleaning of dentures. ?
• Bad breath in morning.
• This affects most people and dry mouth is the most common cause. ?
• Alcohol: Alcohol causes dehydration and less saliva production, leading to bad breath. ?
• Smoking: This is often called ‘smokers’ breath’, which is a stale smell caused by the scent of cigarette smoke lingering in the mouth and the chemicals from cigarette smoke mixing with saliva. ?
• Certain foods and drinks, such as onion and garlic or coffee and acidic fizzy drinks. ?
• Infection (more below).

MORE SPECIFIC CAUSES ?

• Tongue bacteria: Considered one of the main causes of bad breath. It can be caused by catarrh from the back of the throat and nasal area. It is more often caused by a general build-up of oral bacteria due to poor dental hygiene. Brushing the tongue with toothpaste (especially if coated) can help. A tongue-scraper or cleaner may be used in more severe tongue coating. Despite the tongue being considered the biggest factor in halitosis, simple general oral hygiene measures described, such a regular teeth brushing, flossing, and staying well hydrated, will minimise build-up of bacteria in all areas of the mouth, including the tongue (not just the gums and teeth). ?
• Gum disease (gingivitis): Due to poor oral hygiene. Bacteria in plaque cause a bad odour. ?
• Tooth decay: Like the bacteria that cause food to break down (creating plaque) and causing gingivitis, the bacteria trapped in a decaying tooth can emit a foul smell. ?
• Trapped food: Food getting caught between the teeth getting broken down by bacteria. ?
• Dry mouth: Poor saliva flow means food debris is less likely to get washed away. Described above. ?
• Acid reflux from the stomach: These acids have a sour odour causing bad breath. ?
• Diabetes: Diabetics are more prone to high blood sugar levels, meaning higher glucose levels in saliva, which promotes oral bacteria growth (glucose is a food source for bacteria), leading to more dental plaque. Well-controlled diabetes and good oral hygiene reduce this risk in diabetes. ?
• Chest infection: Phlegm or mucus infected with bacteria or viruses that can have a smell. ?
• Other infections: Tonsil, throat, and sinus infections: Bacteria/viruses involved can emit a foul smell. ?
• Other chronic conditions: Certain lung conditions, kidney and liver disease, chronic irritation of the stomach and oesophagus, and autoimmune disorders like Sjogren’s disease can cause halitosis.

DIAGNOSIS IN SEVERE CASES

It is rare that someone must get diagnosed with halitosis, as they will be aware of it themselves or those close to them will make them aware of it, and the steps described in this article will ease symptoms in most cases. Specific diagnostic tools are only used in rare cases where halitosis is so severe and persistent despite simple and well-recognised steps, including improved dental hygiene and improving diet. In this situation, three methods for measuring halitosis are:

1. Organoleptic measurement.
2. Gas chromatography.
3. Sulphide monitoring. Organoleptic measurement has shortcomings, but is the gold standard method to assess severe halitosis.

INTERVENTIONS TO STOP BAD BREATH

Improving oral hygiene is the numberone step to improving bad breath. Some of the other interventions described below, in addition to the usual oral hygiene interventions like regular brushing and flossing, may be considered if bad breath persists despite good oral hygiene. ?

• Regular brushing: Brushing teeth morning and night with fluoride and antimicrobial toothpaste. Do not rinse the mouth out with water straight away after brushing, as this will rinse away the fluoride and antimicrobial benefits of brushing in the minutes after brushing. ?
• Dental flossing: Should be done daily using the proper technique. ?
• Regular dental check-ups: A dental check-up with a dentist once a year and cleaning with dental hygienist every six months. ?

• Probiotics: This is less proven, but some research in Japan found that consuming sugar-free yogurt with probiotic bacteria twice a day for six weeks reduced bad breath by reducing levels of odour-producing sulphide compounds. One Japanese study found that eating yogurt with the probiotic strains of streptococci and lactobacilli bacteria has the best effect. ?
• Avoid crash diets: Apart from the many other negative effects of crash diets, a low-carbohydrate diet breaks fat into ketones to create ketosis. These ketones accumulate in urine and saliva and can cause bad breath. The effect of ketones in the mouth is a metallic taste in the mouth and a smell that is described as sweet, fruity or like the smell of nail polish remover. Drinking plenty of water will dilute the concentration of ketones, thus reducing bad breath from ketones.

References upon request Disclaimer: Brands mentioned are meant as examples only and not meant as preference to other brands.