PREVENTATIVE TREATMENT AND MAINTAINING ORAL HEALTH

Darshini Ramasubbu explains how those with an intellectual disability can prevent dental decay

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Prevention is the focus for all patients, regardless of any disability present. The best way to thwart disease is to be aware of its causes and how to avoid or minimise them. As regards the mouth, the two main problems which afflict patients are dental decay and gum disease.

Dental decay is caused by oral bacteria, which ingest sugar and produce an acid-containing by-product which then breaks down the minerals in teeth. The more frequently sugar features in the diet, the more the teeth are subsequently exposed to this acid.

It is unrealistic to cut sugar from the diet altogether, but reducing snacking, particularly of sugary foods, and consuming an alkaline substance such as cheese after such foods, can reduce the risks of tooth decay. Sometimes sugary snacks can be used an rewards for good behaviour or as incentives and it is important to avoid this, or to break the habit if it is already in place

Dry mouth and medicines that cause dry mouth can lead to more rapid decay because saliva plays several roles in decay reduction. It is important that if you feel your mouth is dry, or you notice it in someone you care for, to seek a professional opinion to determine the cause, and to minimise the damage it can cause to the teeth. For people who have conditions or medications that cause dry mouth, saliva substitutes or alternatives (such as frequent sipping of water or sucking sugar-free sweets to stimulate increased saliva) can be effective.

Fluoride has an important role in counteracting demineralisation and repairing damage caused by acid, and it is therefore vital in strengthening teeth. It has been found that the effect that fluoride exerts on erupted teeth is mainly topical, meaning the more it is in actual contact with the teeth (rather than being ingested), the greater its reparative role. In Ireland, over 70% of the population receive water that is fluoridated, so that every time we consume a glass of tap water, we are benefiting our teeth by helping to re-mineralise them. Other sources of fluoride include toothpaste, mouthwashes and varnishes.

Ideally, teeth should be brushed morning and night, for approximately 3 minutes, with a toothpaste containing at least 1000 ppm (parts per million) of fluoride. (Playing a song while brushing can ensure brushing for sufficient time. There are specially-designed brushing videos for various ages, available online (e.g. on YouTube). For patients who are at higher risk of decay, high-fluoride toothpastes (e.g. Duraphat) can be obtained under prescription from the dentist. These toothpastes contain more fluoride, which can have a greater effect on weakened teeth, though care needs to taken as ingestion can lead to health problems.

Fluoride mouth rinses are recommended for daily use in non water-fluoridated areas, and they can also be used after meals to reduce the damage caused by acid. Mouth rinses can be an excellent and easy way to deliver fluoride to the teeth and they can be easily incorporated into school routine. Decanting into smaller, travel-size bottles can be a good way of ensuring daily use, particularly for after meals. Fluoride varnishes applied in the dental clinic have also been shown to be very effective in lowering the rate of tooth decay and they can form an important cornerstone of preventative care, especially for those who would struggle with brushing or mouth rinsing.

Gum disease, or periodontal disease, is very common in Ireland, particularly among older people. This is caused by oral bacteria which subsequently cause gum inflammation, and can cause gums to recede. Gum disease can lead to teeth loosening and early tooth loss. It can also significantly impact on the appearance of the teeth, with the darker, yellower root of the tooth becoming exposed as the gum recedes. The position of the teeth can also change as they become looser.
Good brushing technique and adequate time spent brushing and flossing are essential for the removal of plaque, particularly from the junction where the tooth meets the gum, where plaque can be seen to visibly accumulate.

Antimicrobial mouthwashes or varnishes containing chlorohexidine (such as Corsydol or Kin) can help to prevent and combat gum disease. These adjuncts can prevent the formation of plaque in the mouth, and are best used 1-2 times per week after brushing, as frequent use can lead to staining of teeth.

Patients with conditions such as diabetes or Down Syndrome have accompanying immune defects which lead to increased risk of developing periodontal disease. They should therefore be seen regularly for screening and monitoring any existing or developing periodontal problems. Some medications, such as those commonly taken for epilepsy, can lead to gums appearing swollen, or ‘gingival hyperplasia’. If this occurs, it is important to seek professional advice on management.

Smoking is also a contributing factor to gum disease; it can disguise the severity of gum disease because smokers gums tend to show inflammation and bleed less than non-smokers with similar levels of gum disease. All patients should be discouraged from smoking due to its many harmful effects on the body, and relations to cancers in the mouth, throat and lungs.

Malocclusion or misaligned teeth can also impact those with intellectual disability. Some conditions such as Down Syndrome can predispose to missing teeth and difference in jaw size. The necessity for orthodontic treatment, and the ability to cope with it, must be determined on a case-by-case basis—as always, the health of the teeth is the priority. Braces can lead to increased risk of decay and gum problems if rigorous oral hygiene and limited sugar intake are not maintained.

One of the key features of preventative dentistry is to anticipate problems and to identify them as early as possible, so that minimal treatment is required. This is particularly important when patients have intellectual disability, as treatment may be traumatic and difficult for them, and dental phobia is very common universally.

Regular examination, every six months or annually, is recommended in the NICE (National Institutes of Clinical Excellence) guidelines. This enables any problems to be seen early and treated quickly and effectively, hopefully before the need for more serious or invasive treatment arises. This, coupled with optimum home care, leads to healthy teeth and gums, and happier patients, carers, parents and dentists.

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