Section 4 - Management of diagnosed conditions

1. What is dental caries and periodontal disease? ^1,4–6

• The two main oral conditions experienced by most Australians
• Dental caries (decay) results from destruction of tooth tissue:
  • begins with acids originating from plaque bacteria metabolising carbohydrate (from sugary foods and drinks)
  • in the presence of acid, calcium and phosphate ions that make up the tooth surface, diffuse out of the tooth enamel (demineralisation)
  • tooth enamel eventually breaks down to form a hole or cavity
• Saliva plays an important role in the remineralisation (repair) of the tooth surface
• The risk of dental caries increases with certain chronic conditions, medicines, diets and behaviours that cause a dry mouth
• Periodontal (gum) disease is chronic inflammation of the gums and structures that support the teeth:
  • caused by plaque bacteria resulting in deep gum inflammation
  • progresses slowly and is often painless
  • the teeth loosen and may eventually be lost
  • bacteria can collect in the space that attaches the tooth to the jaw leading to permanent bone loss
• These oral conditions impact other chronic conditions e.g. diabetes and heart disease

2. Diagnosis of dental caries and periodontal disease ^2,3,6

• Identification is a simple case of gaining a brief history and examining the mouth
• Dental caries are identified by:
  • early white or frosty non-cavitated lesions
  • brown (active) or black (inactive) cavities or structural damage
  • pain and sensitivity
  • bad breath or a bad taste in the mouth
  • dental x-rays
• Periodontal disease is identified by:
  • gums that spontaneously bleed or bleed during brushing
  • painful, tender, inflamed, swollen or receding gums
  • bad breath or a bad taste in the mouth
  • sensitive, loose or lost teeth

3. Management of dental caries or periodontal disease ^1–8

• Management goals are to promote and maintain optimal oral health by:
  • practising good oral hygiene:
    • Smoking cessation
    • brushing and flossing twice daily with fluoride containing toothpastes
    • wearing a mouthguard when playing contact sports
  • healthy dietary intake:
    • breastfeeding
    • choosing healthy snacks like fruit, cheese and vegetables
    • limiting sugary foods and drinks
    • drink plenty of tap water
    • avoiding alcohol
  • seeking regular dental visits:
    • arrange for children to have a dental assessment by 2 years of age. See Oral health (child)

1. Support patient self-management ^1–3
   • Support the patient with lifestyle modification with particular focus on Smoking cessation and Alcohol reduction
   • Provide dental caries and periodontal disease resources. See Resource 1.
   • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
2. Social-emotional support
   • See Social-emotional wellbeing
3. Diet and nutrition ^1–5
   • Frequent exposure to dietary sugars and acids is the primary cause of dental caries
   • Sticky foods e.g. dried fruit and lollies are a higher risk for decay than foods easily washed away e.g. cheese and fruit
   • Frequent snacking increases tooth surface exposure to acids
   • Less snacking reduces acid exposure and increases remineralisation time
   • Avoid sugary and diet soft drinks, sports and energy drinks and juice
   • If bottlefeeding, only use breastmilk, infant formula or water in the bottle
   • Continuous breast or formula feeding in children > 12 months can cause decay
   • During interrupted sleep avoid sipping drinks, other than water
   • Avoid chewing or sucking acidic vitamin tablets
   • Encourage a healthy well balanced diet. See Diet and nutrition
4. Fluorides and fluoride varnish ^6,9,10
   • Water fluoridation is the most efficient and well established method for reducing dental caries in a community. In communities where there is no fluoridated drinking water:
     • provide advice about alternate fluoride sources e.g. mouth rinses, high fluoride toothpastes, fluoride varnish
     • advocate on behalf of their community for water supplies to be fluoridated. See Resource 3.
     • promote healthy oral hygiene behaviours
   • Fluoride varnish:
     • is applied by dental practitioners and those authorised to do so. See Table 1.
     • is used to prevent dental caries in those at risk e.g. those in rural and remote locations
     • releases fluoride over 24 hours to increase calcium fluoride reserves and long term fluoride release
     • can be applied to individual teeth or spot application to localised areas
   • Fluoride supplements (tablets or drops) are not recommended for use in Australia as a public health measure

5. Smoking cessation ^1–8,11
   • Smoking:
     • reduces blood oxygen supply to gums and increases risk of periodontal disease
     • increases rates of bad breath (halitosis), tooth staining and loss and acute ulcerative gingivitis than those who don’t smoke
     • is a significant risk factor for oral cancers
   • Refer patient to a smoking cessation program. See Smoking cessation
6. Toothpastes and gels ^1–6
   • Encourage brushing with toothpaste or gel as they:
     • provide a source of fluoride and promote remineralisation of the tooth surface
     • can reduce tooth sensitivity
     • reduce the build up of acid producing bacteria and plaque
     • assist in tooth surface stain removal
   • From the age that teeth first erupt to 18 months of age:
     • teeth should be cleaned without toothpaste by a responsible adult
     • in areas with unfluoridated water supplies, teeth should be cleaned twice a day with a pea-sized amount of low fluoride toothpaste 400 to 550ppm (0.4 to 0.55 mg/g) by a responsible adult
   • Between 18 months and 5 years of age:
     • teeth should be cleaned twice a day with a pea-sized amount of low fluoride children’s toothpaste by or under the supervision of a responsible adult
     • when finished children should spit out. Do not rinse or swallow
     • children should avoid licking or eating toothpaste
   • For over 6 years of age:
     • teeth should be cleaned twice a day or more with standard fluoride 1000ppm (1mg/g) toothpaste
     • when finished spit out. Do not rinse or swallow
   • Children should not dispense toothpaste without supervision
   • Keep toothpaste out of reach of young children
7. Toothbrush and denture brush ^2,4,6
   • Electric toothbrushes are a superior plaque removal tool and useful where a persons manual dexterity is limited
   • Grip, head size, shape and bristle flexibility are matched to individual needs
   • Effectiveness depends on technique and physical ability of the individual
   • Hard brushes and abrasive toothpastes can result in tooth wear, ulcerations and gum recession
   • Replace toothbrushes after 3–4 months or sooner if bristles become frayed
8. Interdental cleaning ^2,4,6
   • Toothbrushes do not remove plaque from between teeth
   • Use dental floss, ribbon or tape to effectively remove plaque from between teeth
   • Pre-threaded flossing tools and interdental brushes are available and useful where there is significant spacing between the teeth
9. Reduce a dry mouth (xerostomia) ^2,3,6–8,11
   • Saliva is the bodys natural defence against tooth decay that:
     • clears food debris and bacteria from around teeth
     • neutralises harmful acids produced by plaque, foods and drinks
     • protects the soft tissues of the mouth
     • prevents fungal infections
     • acts as a vehicle for minerals such as fluoride, calcium and phosphate to help strengthen tooth enamel
   • Saliva flow is reduced with:
     • smoking cigarettes and drinking alcohol or caffeinated beverages
     • snoring or breathing through the mouth
     • dehydration from fever, vomiting, diarrhoea, exercise or low fluid intake
     • Depression and Anxiety disorders
     • increasing age
     • Diabetes, Dementia and Stroke and transient ischaemic attack
     • many medicines e.g. methylphenidate for the treatment of ADHD, antidepressants, antihistamines, decongestants and antihypertensives
     • chemotherapy and radiotherapy
   • Actions to improve saliva production to assist with tooth remineralisation and relieve a dry mouth include:
     • chewing sugar-free gum
     • using ‘saliva substitutes’ (available from pharmacies)
     • taking frequent sips of water
     • avoiding lollies and soft drinks
     • Smoking cessation and Alcohol reduction
     • limiting caffeinated drinks e.g. tea, coffee, sports and soft drinks
     • using gravies and sauces to make food softer and easier to chew and swallow
10. Mouth rinses ^2,6,9
    • Agents in mouth rinses may be effective in reducing plaque and gingivitis
    • Fluoride containing mouth rinses have caries-inhibiting effects and should only be prescribed by a dental practitioner
    • Avoid mouth rinses containing alcohol

4. Medicines for dental caries or periodontal disease

1. Antibiotic prophylaxis ^12,13
   • Is only required to prevent infective endocarditis before some dental procedures (see below) in patients with:
     • Rheumatic heart disease
     • prosthetic cardiac valve and material used for repair
     • previous infective endocarditis
     • congenital heart disease (under certain circumstances)
   • Anticoagulants may need to be ceased prior to dental procedures
2. Dental procedures requiring antibiotic prophylaxis ^13,14
   • Unless otherwise determined between the dentist and specialist, the only dental procedures requiring antibiotic prophylaxis involving:
     • extraction
     • implant placement
     • biopsy
     • removal of soft tissue or bone
     • subgingival scaling and root planing
     • replanting avulsed teeth

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Healthy Teeth For Life–Fact Sheets and Dental prevention and promotion information
2. The NHMRC Public Statement on Water fluoridation and human health in Australia and fluoride information
3. Queensland Government Quitline