Aging, Systemic Disease and Oral Health: Implications for Women Worldwide (Part II)
Course Number: 330
Final Thoughts and Home Care Recommendations
The preceding sections of this course have highlighted research related to women and stroke, rheumatoid arthritis and depression. Women have shown disproportionate outcomes from medical conditions in measures of prevention, diagnosis, prevalence, incidence as well as response to treatments. Their culture, education, and most importantly access to care have placed female populations worldwide at potential risk for adverse disease outcomes.
Oral risk assessments, screening, education, referrals and treatment planning are essential components necessary for comprehensive oral healthcare; providing oral healthcare professionals the opportunity to identify early stages of disease, determine patient acceptance, and tailor oral care recommendations based on need. The oral healthcare professional can directly influence the patients’ oral health status, educate them about systemic relationships linked to oral health concerns, and help them embrace whole body health.
Educational materials for patient information and videos are available from numerous organizations. The American Dental Association (ADA) and the American Dental Hygienists’ Association (ADHA) have online patient information (www.ada.org) and www.dentalcare.com provides the latest up-to-date customized patient education available for print in 6 languages.
Home care regimens including specialized products to improve gingival and periodontal health are particularly significant when treating these patients. Oral healthcare professionals should consider the complex needs reported in relationships to prevalence when recommending home care products for these conditions.
Products to enhance mechanical plaque removal are fundamental to a good oral hygiene regimen. The oscillating-rotating power toothbrush technology has demonstrated increased efficacy in plaque removal over manual brushes.120,121 Also tools exist that offer compliance-enhancing features such as timers, multiple brushing modes, and visual pressure sensor indicators which help motivate patients to brush with good technique. According to the Cochrane Database of Systematic Reviews 2010, “brushes with a rotation oscillation action reduced plaque and gingivitis more than those with a side-to-side action in the (4-12 weeks).” The systematic review further detailed 398 studies compared power technologies to each other, and 17 trials including 1369 subjects meeting selection criteria were evaluated. Seven studies compared the rotating oscillation action and side-to-side (sonic action) technologies. The outcome stated in the Cochrane review provides evidence that when independent, highly regarded third parties evaluate performance, the oscillating-rotating power toothbrush technology was consistently top ranked.122
Flossing and interproximal aides are additional home care methods necessary to mechanically remove plaque; each removing plaque biofilm below the gingival margin along with the interproximal regions. Patients have opportunities to select from numerous interproximal brushes, varieties of floss, floss picks, floss holders and oral irrigators allowing ease and compliance in accomplishing necessary interdental care.
Recently a small study was presented that compared the effectiveness of an oral irrigator (water flosser) and interdental brush on bleeding indices and gingival abrasion. The oral irrigator was shown to be significantly more effective than the interdental brush for improving gingival health in this clinical study.132
In addition to toothbrushes and oral irrigators, there are also interdental brushes. As an adjunct to brushing, the interdental brushes were shown to remove more dental plaque than brushing alone.133 All three studies in this systematic review that compared interdental brushes as an adjunct to brushing showed a significant difference in favor of the use of interdental brushes for plaque removal. The majority of the studies showed a positive significant difference on the plaque index when using interdental brushes compared with floss. No differences were found for the gingival or bleeding indices. Meta-analysis showed superiority of the interdental brush to floss with respect to plaque removal.133
Chemotherapeutic dentifrices and rinses help inhibit plaque biofilm and are important home care products that should be recommended based on individual patient needs. Dentifrices, containing active ingredients such as stannous fluoride or triclosan are used to inhibit plaque regrowth between brushings, reduce gingival inflammation and bleeding. A significant difference between the two ingredients found in over-the-counter dentifrices is that only stannous fluoride additionally offers protection from sensitivity123,124 as well as caries and gingival health benefits.108 When recommending a stannous fluoride dentifrice, it is important the product contain stabilized stannous fluoride (Crest® PRO-HEALTH™), which provides greater product efficacy than unstabilized formulations.126,127 An advanced regimen including (Crest® PRO-HEALTH® Clinical Gum Protection™), a dentifrice demonstrating reduced gingival inflammation, bleeding and plaque along with daily use from an oscillating-rotating toothbrush and floss provides strong evidence that it is beneficial in addressing the necessary components for optimum gingival health.128 Parodontax™ contains 0.454% stannous fluoride formulation kills bacteria and reduces carbohydrate metabolism, inhibiting bacterial growth and loosening the structural integrity of the biofilm. Additionally, sustained bacterial actions have been demonstrated by stannous fluoride containing dentifrices with hexametaphosphate. Other stannous fluoride formulas exist with similar benefits (Colgate Total SF).134
Whether rinses are prescription or over-the-counter versions, they can serve as effective and successful adjuncts to patients’ daily hygiene routines. Chlorhexidine rinses have been viewed as the gold standard due to their substantivity and efficacy (and now it is available in an alcohol-free formula); however, these rinses are limited to a short-term use due to some extrinsic staining and patient compliance concerns. Over-the-counter options include chemotherapeutic rinses with cetylpyridinium chloride (CPC), a broad-spectrum antimicrobial agent available in an alcohol-free formula. Alcohol-free formulas are recognized as providing pleasurable rinsing experiences; especially ideal for those patients already experiencing xerostomia and/or oral manifestations induced from medications, necessary for treating a myriad of medical conditions. Essential oils rinses are also over-the-counter, and may or may not contain alcohol. While alcohol in oral rinses are not harmful, there are some that prefer alcohol-free formulations. It is important to know that research findings have indicated CPC and essential oils rinses when formulated properly have demonstrated significant and comparable reductions in plaque and gingivitis.129,130 In-office or take-home fluoride products are available to treat those patients requiring additional fluoride assistance, such as the aging population experiencing an increased rate of root caries. It has been estimated that about one-fifth of the aging patients report xerostomia, increasing their risk for plaque, gingivitis, and caries, due to a lower oral pH.131 Various forms of specialized rinses, dentifrices, liquid moisturizers, salivary stimulants, sugar-free chewing gum are marketed to assist with symptoms and protect against xerostomic conditions.
Each day oral health care professionals are challenged to provide the best treatment and home care recommendations to assist patients in achieving optimal oral health. Resources currently available with valid and credible research findings can assist oral health care professionals to better understand the oral-systemic relationships challenging worldwide populations. Aging and sex/gender-specific concerns represent unique health concerns requiring specialized care and awareness. As we better understand this plethora of information before us, we will continue to address the ever challenging needs facing our patients, recommend the latest evidence-based technology, and we too will evolve just as the research unfolds additional oral discoveries and causal relationships in the systemic diseases impacting our oral health and whole body wellness.