_____________________________________ Caries-Prone Patients: Prevention, Assessment, and Intervention
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. 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].
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 tooth surfaces [72]. Erupted teeth accrue the most benefit from fluoride when its salivary concentration is incorporated into the biofilm that adheres to the teeth [72]. Although it is a bit controversial, water fluoridation is one method of achieving these conditions [70; 72]. Approximately 72.7 of U.S. com- munities have fluoridated water as of 2020 [55]. Bottled water does not contain enough fluoride to prevent dental caries, so patients who drink only bottled water must be educated about the benefits of the topical fluoride found in toothpaste, oral rinses, and prescription-strength fluoride supplements [70; 73]. Parents of young children should be aware that multiple forms of fluoride ingestion can lead to fluorosis, that is, detectable changes in the tooth surface that can discolor the tooth but that do not adversely affect tooth strength [72]. Fluoridated water, toothpastes, and mouth rinses are advis- able for the general population and especially for caries-prone patients because the use of a fluoride mouth rinse in conjunc- tion with the use of a fluoridated toothpaste enhances enamel fluoridation and remineralization [72]. The use of prescription- strength fluoride toothpaste (1.1% neutral sodium fluoride) may be advantageous to and is usually well tolerated by patients consuming caries-promoting foods, orthodontic patients, patients with xerostomia, and those demonstrating substan- dard oral hygiene [72]. In-office fluoride treatments may help patients reduce dental caries. Treatments come in a variety of forms, including foams, gels, rinses, and varnishes. The application of 5% sodium fluoride varnish twice a year on the primary and permanent teeth of children ages 6 months through 15 years is beneficial in preventing caries in this age group as well as for the per- manent teeth of adult patients [10; 70]. The use of in-office professionally applied fluoride gel or foam at 3- to 12-month intervals provides the most preventive benefit for those do not consume fluoridated water and/or whose at-home oral hygiene is substandard [74].
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