A Dental Hygienist's Letter to her Personal Dental Care Team

Xylitol and Green Tea gum found here. 

As promised, here's part two of the excellent information provided by JoAnn Snider RDH, BSDH; Sjögren' s Advocate; patient, Speaker, and Author. This is a copy of the letter that she composed when dealing with new dental care providers.

I especially appreciated the section in which she emphasizes the fact that even those sjoggies conscientiously performing meticulous care of their teeth can have dental problems. How many of us have been given THE LECTURE about proper oral care after a dental exam?

Feel free to edit this letter for your own use since Ms. Snider has generously added this to her email: "As always, if something I write or say can be used to help other Sjogren's patients, I authorize anyone to reprint anything or pass it along."

Dear Dental Team, 

I am a dental hygienist with Primary Sjögren's Syndrome. There is no lecture that can convey the frustration and discomfort of a Sjogren’s-dry mouth, but it is a very common symptom for Sjogren’s patients. Normal flavors can burn or sting. We know that enamel breaks down when the pH drops to 5.5, but exposed root surfaces may demineralize at 6.5. The pH of plaque is only 2.5, so it’s no wonder that Sjögren's patients can get into trouble so easily. 

Patients can do everything right, and still may not have the right results. The new CariFree kit or GC America’s Saliva Check kit or even pH paper can be valuable tools in your office to help determine which patients are the most at risk from acidic saliva or extremely low volume.  Any very dry patient needs to be on an aggressive prevention program to maintain their teeth. This letter is a summary of the steps that are working for me and my patients with severe dry mouth.  

According to Dr. Troy Daniels and Dr. Ava Wu, of the SICCA Sjögren’s study at UC San Francisco, sipping water too frequently can actually dry out the mouth so ask your patients not to overdo it. I’ve seen patients who literally had their teeth turn to chalk and break off at the gum line in as little as three months with too frequent sips of water. The fine line between enough and too much is difficult to determine, so suggest sipping water to help with swallowing, eating, and counteracting what I call “Velcro Throat,” and then an oral moisturizer like Oral Balance, or sugar-free gum after drinking water to replace minerals and enzymes that were rinsed away. We don’t use water to moisturize dry hands, so it makes sense that water won’t be as good as saliva for our mouth either. 

Prescribe and construct custom fluoride trays for patients who have uncontrolled decay. According to the SSF Handbook, they should be worn for five minutes a day until the patient has at least one year of decay-free exams. I’ve listed several mild or unflavored fluoride gels to use with the custom trays on the enclosed product sheets.  

For some a fluoride varnish may be superior to the trays.  Fluoride varnishes are being reinvented with new white or clear products that are well accepted and effective when fluoride trays are not working well. The patient can expect 3 - 6 months of decay prevention from each application.  We have seen a dramatic improvement in cases where fluoride trays didn’t seem to be working.  MI Paste’s new varnish contains not only the necessary fluoride but the bio-active Recaldent to provide essential minerals for optimal benefit in your dry mouth patient.  

If your patient has acidic saliva or severe dry mouth, MI paste has excellent buffering capabilities, with a half-life of three hours to help restore oral pH and protect teeth. Applying a pea-sized dose every 3-4 hours will reduce acid damage and may restore white spot lesions. For longer action, a bleaching or fluoride tray can be placed over the teeth to hold the MI Paste in place longer. Dispensing it through the office makes it easier for patients to comply. It is available from most dental suppliers.  There are also several other choices available for pH buffering like Cariostat and NeutraSal, mineral solutions, or even a baking soda rinse several times a day. 

More frequent hygiene visits and a little encouragement may also very helpful.  When I speak to patient groups, they report that they receive blame and recriminations most often.  They can do everything right and still not get the right results until we find the correct balance of treatment and maintenance products to manage their decay problems. 

If your patient has normal saliva, just not enough, have them increase saliva production by sucking on sugar-free candies, cough drops or chewing sugar-free gum several times a day. I keep some sugar-free cough drops in my drawer and give out samples to patients to remind them to avoid hidden sugars. Stimulated saliva contains more minerals to neutralize acids and to provide for tooth repair.   

Products with Xylitol provide additional benefits by interfering with the metabolism of Strep. mutans group which makes them less sticky, and by reduces the overall bio-burden. Xylitol is added to several brands of gum but can also be purchased with higher concentrations from 3M ESPE, or from the Spry. A therapeutic dose is 6 – 10 grams a day.  Patients should be instructed to start out slowly when adding Xilitol since it can have a laxative effect in excess.  Studies show the compressed tablets provide the most benefit, but other products can be very useful as well.  Nuvora’s Salese is just one of the Xylitol delivery systems.  The Xylitol green tea gum was a big hit at a recent national Sjogren’s Syndrome Foudation meeting both for it’s good flavor and the restoration of a more normal “feeling”.  

Any battery operated toothbrushes may give additional efficiency on gum line plaque for patients who can’t afford the expense of the electronic brushes. Power toothbrushes provide more strokes per minute which also increases the patient’s effectiveness, and require less pressure against the side of the tooth which can reduce tooth sensitivity and abrasion.  Sonicare is the least abrasive of those available.  Bump up the patient’s home care program. I use the new Flexcare from Philips and add another 30 seconds at the end to brush my palate and the inside of my lips. This stimulates increased salivary output for up to 90 minutes, and a significant increase in the mucin and proline-rich glycoproteins that provide the relief from dryness that we crave.   

Soft floss like Reach Gentle Gum Care may be more comfortable than regular floss, and can remove more crevicular plaque than waxy floss. For non-flossers, Water Pik studies show that their oral irrigator is two times more effective than string flossing. If your patient is only willing to make one change, a new WaterPik Water Flosser is gentle and more effective than anything else. Aim the stream at the tooth near the gum line for best results.  I use my Water Flosser before brushing to maximize the effects of my special Biotene PBF toothpaste. 

Recommend oral moisturizers to help with the dryness symptoms and increase acid control. In general the rinses provide transient relief, the gels last longer and give more relief for the money.  Prescription Numoisyn liquid is also good for night time use. 

Consider prescribing a sialogogue, like Pilocarpine (Salagen) or Cimeviline (Evoxac.) According to Dr. Phil Fox, former Director of the NIH Sjogren’s clinic and Past-Chairman of the SSF Board, “the jury is still out on whether these drugs can improve the function of the remaining salivary glands, but the benefits of increased output is significant and reduces overall risk of decay.”  Pilocarpine has a half-life of 1-2 hours, while Evoxac’s is 4-6 hours.  I’ve been using Evoxac since it was first introducted over 10 years ago.  Before prescribing Evoxac, check with the patient’s physician to rule out any contraindications, like uncontrolled asthma or some types of glaucoma.  Request samples to dispense in your office by clicking the “Request samples” at  http://www.evoxac.com/hcp/ or call  1-877-437-7763 for more information. 

Using a thin ultrasonic tip on a lower setting to de-plaque your Sjögren's or other dry mouth patient reduces gum trauma and increases patient comfort. I love the oscillating prophy angles too. Because they don’t rotate, they don’t scuff gums and can’t overheat the tooth. I also keep several low-abrasion mild non-mint prophy paste flavors on hand for dry mouth patients who are sensitive to mint. 

To reduce the overall bio-burden, treatment with a non-alcohol Chlorhexadine rinse one week every three months may be helpful according to the latest recommendation from Sjögren's Syndrome Foundation.  Avoid the alcohol version since alcohol is drying.  Even as a hygienist, I couldn’t stick with Peridex for the whole week because it was too painful to use.  

When you treat any dry mouth patient, you may wish to ask if they have any other symptoms like joint or muscle pain, dry eyes, or  unexplained fatigue or systemic involvement that could be indicative of Sjögren's  Syndrome.  Obvious oral symptoms include no pooled saliva, red fissured or cobblestone tongue surface, frequent oral yeast infections which present with burning and redness, or rampant decay even with good oral hygiene.  Getting a patient diagnosed and treated sooner may reduce the overall severity of their disease.  

Check out the Sjögren's Syndrome Foundation website [www.sjogrens.org] for more information on dry mouth including free Dry Mouth brochures for your office. I am a professional member and enjoy their quarterly professional journal that has great articles by experts in Sjogren’s research.
Recommend joining the Sjögren's Syndrome Foundation to your Sjogren’s patients.  The Moisture Seekers, a monthly newsletter, is full of articles on living with this disease, and helpful hints for improving quality of life issues written by experts and patients. To find out more about the SSF go to their website or call them at 1-800-475-6473. 

Sincerely yours,

JoAnn Snider,  RDH, BSDH; Sjögren' s Advocate; patient, Speaker and Author

Interesting. I didn't realize the degree of usefulness for Xylitol containing products.

Tomorrow's post will cover JoAnn's oral care product list.