Tues 20 May 2003
Dr Peter Foltyn (Dentist, St Vincent's Hospital)
Main speaker Dr Peter Foltyn (Dentist, St Vincent's Hospital). Chaired by Dr Richard Hallinan who gave several amusing anecdotes from his father who is a retired dentist.
Dr Hallinan began by reminding us how much a smile is worth at a job interview as well as the draw backs of bad breath and poor nutrition which are so common in dependency cases. He invited the large audience (of over 40) to benefit from Dr Foltyn's 20 year experience in treating such patients in his practice at Darlinghurst, Sydney.
Dr Foltyn gave us all a timely reminder of the importance of good dental care and the pitfalls of a number of factors countering dental hygiene. He dealt with a number of important issues for patients with drug and alcohol problems including xerostomia (dry mouth). When the salivary mechanism is inhibited there is a break-down of the normal manner of diluting and removing debris resulting in a lower pH and an acidic environment for the teeth. This allows penetration of the enamel, especially at the gingival margins where it is thinnest and where is joins the dentine. Thus for patients who are taking antidepressants, anti-cholinergics and for some patients on methadone there is a need to counter dry mouth. The use of 'swish and rinse' at the time of medication (and at other times during the day and night) can be very effective in protecting the teeth. Chewing gum can stimulate salivation and sugar-free gums are now available.
Regular brushing after each meal, however, is still the mainstay of treatment/prevention. We were told that a medium brush with small, angled head is best and that much modern tooth paste is either unnecessary and in some cases may cause irritation to already delicate buccal surfaces. This, we were told, was largely due to the foaming agent used in virtually all proprietary brands available in supermarkets. Sodium laurel sulfate has been shown to increase irritation in some people but there are only two current brands available (largely at chemist shops) which omit the use of this chemical. The other agents common to most tooth pastes are an abrasive agent as well as a detergent. It may be that brushing with just water is as effective and less irritating to some people than when using some pastes. We were told that while some electric tooth brushes have certain advantages, they are not necessary for optimal dental care.
Another common cause of xerostomia in the hospital setting is head and neck radiotherapy. It can be so devastating for the teeth that occasionally extractions are recommended before radiation starts since healing is often so protracted afterwards. Also, infections can set in, including one type of osteomyelitis which is almost untreatable.
We were shown some shocking technicolour anatomy-atlas-type dental soft-porn to demonstrate these matters. Once getting over the initial shock of close-up dental views we then looked at projections of sequential Xrays of dentition in various states of dissolution (literally). Some were in AIDS cases, others nutritional deficiencies, radiation stomatitis and cancer cases, including Kaposi's sarcoma.
Plaque was discussed at length, as well as the various ways of dealing with it. It was pointed out that in some cases plaque can extend under the gingival margins, requiring tooled removal by the dental surgeon. Other exposed areas were dealt with and we were reminded about individual brushing, tooth by tooth on the three surfaces, lingual, buccal and interfacial. Gentle but purposive brushing to engage the gingival margin was stressed. Minor bleeding in inflamed areas is to be expected for a time but continued bleeding should always be examined by the dentist. Flossing to clean the inter-dental surfaces should also be done regularly. Three times yearly check-ups in patients at increased risk was also stressed.
Topical fluoride should be applied in such high-risk individuals and the dental fluoride 'tray' is the most effective way. It is like a mouth guard which should be smeared with fluoride paste/gel and inserted for ten minutes before retiring. Dr Foltyn said that dentists will apply the same thing for a fee, but to do it oneself regularly is more appropriate for most of our patients. It would appear that fluoride can be effective even in late stage dental wear and tear.
We were advised to tell our patients with poor dentition to avoid strong mouth washes with alcohol bases such as Listerine. A water based mouth wash with antiseptic is more appropriate and less likely to cause irritation. Chemists can advise on the types.
The methadone 'syrup' marketed in Australia still contains sorbitol which is a sugar. Although it is not actively absorbed and is safe for diabetics, as a sugar it is still a fuel for oral bacteria and alcohol with other constituents are not likely to help dental hygiene. The sugar-free 'solution' Biodone should probably be our 'first line' product and the 'syrup' mainly used for those sensitive patients who are unable to tolerate the pure medicine. But importantly, Dr Foltyn says that this must not give any false sense of dental security as xerostomia will occur to the same degree with both products.
The use of buprenorphine may also cause dental problems although one would hope to a lesser degree than oral methadone syrup. We need to watch carefully with this new medication and advise regular dental check-ups.
There are many other issues which had to be left to another session and there was lively discussion on this pressing issue. We need to examine better analgesia during and after dental surgery in dependency patients. Antibiotics in those with heart murmurs, prosthetic joints, etc need to be addressed. Putting more resources into high risk cases should be a public health priority as good teeth can improve self confidence, job prospects and even romance!
Dr Foltyn can be contacted for more information. He can send email copies of the excellent hand-out for dental recommendations in xerostomia (dry mouth) as well as the grizzly photographs. He requests that you place "Concord Seminar" in the title. firstname.lastname@example.org
Sheridan J, Aggleton M, Carson T. Dental health and access to dental treatment: a comparison of drug users and non-drug users attending community pharmacies. British Dental Journal (2001) 191:453-457
Byrne AJ. Methadone and oral hygiene. Australian Dental Journal. 1996 41;1:61