__________________________ Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition
PATIENTS WITH XEROSTOMIA Xerostomia is the subjective description of dry mouth, which can be caused by any number of events [62]. Dry mouth can be a transient reduction or loss of saliva as a result of salivary gland dysfunction. It places patients at a higher risk for car- ies because saliva contains buffers to neutralize acids in the mouth. Adequate saliva is important for several reasons. The presence of calcium and phosphate in the saliva aids in the remineralization of tooth surfaces [63]. Saliva also helps to naturally cleanse teeth, protects the oral mucosa from mechani- cal injury, facilitates chewing and swallowing, and inhibits bacterial growth [64; 65]. Saliva production can decrease with age [59; 66]. Moreover, some medications are commonly associated with xerostomia. More than 500 medications have reduced saliva as a side effect [62; 67]. The main medication classes associated with xerosto- mia include antidepressants, antihypertensives, antihistamines, antipsychotics, sedatives, anorexiants, antiparkinsonism agents, opioids, muscle relaxants, and diuretics [65]. Head and neck radiation therapy and the autoimmune disease Sjögren syndrome are other common causes of salivary gland dysfunc- tion that results in dry mouth [62; 68]. Remedies for reducing the effects of xerostomia vary, and recommendations should be patient specific. Depending on a patient’s age and cognitive ability, dental professionals should encourage them to chew sugar-free gum, use sugar-free candies, or sip water to reduce the exposure to sugars. The use of over-the-counter saliva substitutes for oral lubrication also helps to increase patients’ comfort. Prescription medications designed to stimulate saliva flow may also be recommended for patients who have undergone radiation treatment and for those with Sjögren syndrome. However, efficacy, side effects, and compliance must be weighed against the benefits of using these medications [67; 69]. Patients experiencing xerostomia need to demonstrate excellent oral hygiene and may benefit from fluoride and other caries prevention treatments such as the application of in-office fluoride varnish or in-office fluoride treatments [70].
Adolescents are forming habits that will be a foundation for their adult life. Healthy eating, limiting snacks and sugars, and good oral hygiene will be invaluable practices that will help protect their teeth from caries. OLDER ADULTS Older adults are at increased risk for caries as a result of gingival recession, reduced saliva flow, inadequate oral hygiene, physi- cal and sensory limitations, and cognitive limitations [57]. In the United States alone, the elderly population (i.e., those age 65 and older) will grow to 20% (72 million) by 2030 [57; 58]. Aging baby boomers who have retained more of their teeth and have undergone more complex dental procedures will have a greater exposure to dental caries and periodontal concerns, as well as greater expectations of their dental care providers [57; 59]. Many studies have found root surface caries to be most prevalent in the elderly population [60]. Ideal oral hygiene may be difficult to achieve, as manual dex- terity often becomes limited in elderly patients. The presence of partial dentures also complicates oral hygiene, as food and plaque frequently accumulate where the dentures rest against the natural tooth structure. Educating elderly patients who wear partial dentures, and their caregivers when applicable, concerning proper oral hygiene is essential to protect the teeth adjacent to partials from caries. Practices such as cleaning the mouth after meals with fluoridated toothpastes and rinses, removing partials when performing oral hygiene, removing partial dentures before going to bed, paying attention to dietary intake, and using prescription-strength fluoride gels or toothpastes should be encouraged in these patients [59; 61]. Elderly patients also consume an elevated amount of ferment- able carbohydrates and sugars, further increasing their caries risk. Missing teeth, poorly fitting prosthetics, and tooth mobil- ity due to periodontal disease may make eating fresh fruits, vegetables, and high-fiber foods difficult. To replace these items in their diet, elderly patients are more likely to consume breads, cakes, pies, and food replacement drinks, as these substances are easy to prepare and eat [59]. In addition, elderly patients may suck on hard candies and eat sugary snacks throughout the day to combat the symptoms of xerostomia. Special considerations need to be taken into account when recommending dietary changes to elderly patients. Food cost, level of difficulty of preparation, and ease of mastication are factors that must be taken into account when advising dietary changes. Replacing candies with a sugar-free variety, limiting snacks, and adding calcium-rich foods such as cheese to their diet are a few of the measures that older adults can take to reduce caries risk. The use of power toothbrushes and fluo- ride may also be helpful in reducing caries incidence in this population.
CARIES PREVENTION PRODUCTS AND PROCEDURES
FLUORIDE Fluoride has been used for more than 80 years to prevent dental caries [70]. Demineralization and remineralization are natural processes, as minerals are lost and returned to the tooth surface during the day [71]. Fluoride strengthens enamel, making it more resistant to the acids that promote demineralization and facilitate the development of carious lesions. It also enhances the remineralization of impaired
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