ORAL HEALTH CARE Part 2
CE credit To obtain two (2) hours continuing education credit for participating in this two-part series on "OTC Product Counseling: Oral Health Care" Write to: APhA, Education Services 2215 Constitution Ave., NW, Washington, DC 20037 Request: Form 1987 -CE-03 Complete and return Form 1987-CE-03 to APhA for grading. A certificate will be awarded upon achieving a passing grade of 70% or better.
Note: There is only ONE assessment instrument to complete to obtain the two (2) hours of CE credit available for the two-part series. Fee: A $2.50 handling fee for APhA members (non-member fee is $12.50) for grading the assessment instrument and for issuing the certificate should accompany the returned completed form. The American Pharmaceu tical Association is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education. APhA provider number: 680-202-87-04.
the University of Wisconsin, Madison; Nelson is adjunct assistant professor of clinical pharmacy, Philadelphia College of Pharmacy and Science. "OTC Product Counseling: Oral Health Care" is a two-part self-study continuing education series for pharmacists, developed by the American Pharmaceutical Association, and based on presentations made by McGregor and Nelson at the 1986 APhAAnnual Meeting in San Francisco for the program, "OTC Product Counseling- Oral Health Care," which was supported by an educational grant from W arner-Lambert Company. This program is the second of a two-part series that covers the role of the pharmacist in oral health care. The first module provided pharmacists with an understanding of the oral cavity and the teeth, diseases of the oral cavity, and the oral health care market. This second module provides guidelines for pharmacists' intervention and treatment .
The authors of this two-part series are Thomas D. McGregor, MS, and Linda A. Nelson, PharmD. McGregor is adjunct assistant professor of pharmacy at
Objectives: Upon successful completion of both modules, pharmacists will be able to: 1. Understand the application of basic dental concepts in the differential diagnosis of oral disease; 2. Interpret the scientific oral health care literature and apply this information to pharmacy practice; 3. Evaluate oral health care products and counsel patients in their appropriate selection and use; 4. Recognize oral manifestations that mandate referral to dentists.
harmacists have a crucial role to play in promoting oral health care. Patients themselves compel this role--they question pharmacists constantly about toothpaste, toothbrushes, denture repair kits, dental floss, and dental rinses. They also query them about tooth abrasion, gingival recession, tooth stain, toothaches, abscesses, gum sores, denture sores, and canker sores. But the first step in getting started in oral health care is to establish some contact with the local practitioners in the area. The pharmacist can use phone contacts with these practitioners to find out the dentist's preferences in regard to product items such as mouthwashes and toothpaste. These should be the items that are stocked in the pharmacy. To promote collegiality with local dental practitioners, pharmacists can sponsor interdisciplinary events with these professionals.
Also useful in becoming comfortable in talking about oral health matters are continuing education courses in topics related to this general subject. Finally, pharmacists can create an oral hygiene center within the pharmacy. This means keeping all of the products useful in promoting oral health together, as well as becoming familiar with these products. When the pharmacist sees a patient browsing in this area, he can use that as his cue to help the patient select among the available products. For preventive dental care, the cornerstone remains the toothbrush. (The correct method of brushing is outlined in Table 1.) Even if the dentist or dental hygienist has already told the patient how to brush, it's useful to reinforce their instructions at this point. Brushing is the primary means of eliminating plaque from the inner, outer, and biting surfaces
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Table I- Brushing Technique
a Tooth rush es should be d isca rded every 3 onths; they w ear out in this inte rval. Soft too h r shes, with polished bristles, are f b l. There is no difference between a soft rush in efficiency of p la que removal, n har soft rush is much less like ly to injure the n gums. The tooth rush should be shap ed and sized so as to rmit the patient to reach ev e ry tooth in the mou th, a nd individuals w ho tend to activate their g g e fle x with a brush may do better with a sm 11er, child's toothbrush. Power toothbrushes a e e fective; they remove plaque as e ffectively as manual b rushing- but not more e ffectively. The other cornerstone of preventive technique is flossing . The best method for flossing is explained in Table 2. Patients should know that there is no diffe re nce between waxed and un ax floss, in terms of their ability to remove plaque from between the teeth . Ho w ever, some people find the waxed floss easier to u se , since it has less tendency to divide into fib e rs. Po 'en s need to be repeatedly urged to floss; this is a skill at requires some p rac tice. They need 0 be careful, in floSSing, not to damage the soft tissue of the gingiva. Many p eople, for ins ance, have a tendency to snap the floss be een the eeth. They should be e ncouraged to use a sawing motion instead, because snapping can injure so f issues. Patients just beginning to 58
Place the head of the toothbrush beside the teeth, with the bristle tips at a 45°angle.
Move the brush back and forth using short strokes in a gentle scrubbing motion.
Brush all surfaces of each tooth.
Brush the inside surfaces of the upper and lower teeth by tilting the brush vertically and using "up and down" strokes.
Brush the tongue to freshen breath.
Table 2-Flossing Technique •
Break off about 18 inches of floss, and wind most around the middle finger of one hand, and the remainder around the middlle finger of the opposite hand.
Hold floss tightly between thumb and forefinger, with about 1 inch between them.
Use sawing motion to guide floss between teeth.
Atthegumline, curve the floss into a "C" shape and guide it into the space between the gum and the tooth. Gently scrape side of tooth and proceed to the next tooth.
Repeat on the other teeth.
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floss need to know that bleeding and sore gums can occur during the first week. When the plaque has been broken up, and the bacteria removed, these symptoms should disappear. If they do not, the patient should see the dentist for further professional care. Concerning fluoride mouth rinses, patients need to be told that the rinse needs to be held in the mouth for 30 to 60 seconds, and swished . around. Patients should not swallow the rinse. In addition, the patient should not eat or drink anything for 30 minutes after use of the mouth rinse, thereby giving increased .contact time for the rinse's active ingredients, and making them more effective. By FDA ruling, rinses cannot contain more than 118 mg of fluoride per bottle or per container; this prevents accidental overdose or fluoride toxicity.
Oral Hygiene Products Oral hygiene aids such as disclosing tablets or solutions can provide tremendous reinforcement for patients. Patients should be toldto follow their usual dental care routine; then chew the tablet, spit out the residue, and rinse the mouth. Where the red color remains on the teeth, plaque is still present. The intensity of the color tells how much plaque is present. Oral irrigating devices use a spray of water to remove food and debris. However, they are not able to remove plaque very effectively, and so cannot replace brushing. Pharmacists should also ascertain that patients who purchase these devices do not have advanced periodontal disease, or any condition that may pr-edispose them to a risk of bacteremia. These include cardiac valve diseases or joint replacement. There are some caveats about denture products. First, patients should be told that denture cleansers are appropriate 'for their dentures, while household cleansers are not (these agents destroy dentures). Denture cleansers need to be used once a day; the patient should avoid using.too much force while applying the cleanser and rinse thoroughly before reinserting the denture into the mouth. Patients should use only a thin layer of powder or paste denture adhesive, and cleanse the surfaces of the denture twice daily, to remove old paste or powder. A poorly fitted denture requires professional attention. Use of denture reliners or repair kits should be strongly discouraged, but if the patient must fix his dentures in an emergency, these are preferable to a household glue, which dissolves denture material.
Chronic Problems Gingivitis, when still marginal, can often be diagnosed by the patient's complaint that his gums bleed excessively when he brushes his teeth. If the -gums are red and swollen, that's
another sign. If the disease progresses to periodontitis, the gums will have detached from the teeth, and pus may accum ulate in the pocket that has formed. Loose teeth are also signs of severe periodontitis. All of these signs necessitate referral to a dentist. The etiology of gingivitis is poor oral hygiene, which permits plaque to develop on the teeth under the gumline. Pharmacists need to remind their patients that effective brushing and flossing, in conjunctionwith professional care by a dentist, can prevent this disease and its complications. OTal candidiasis (thrush) is another oral disease that pharmacists may ,encounter. It is caused by an infection with a yeast (Candida), usually in a compromised host; it may also appear as a side effect of treatment with some drugs. These agents include steroids and antineoplastic agents; patients with diabetes are also at risk.
In counseling patients who have received metered-dose inhalers of steroid sprays, pharmacists should note that the patients are particularly at risk for developing thrush (oral candidiasis), since they are introducing 'steroids into the oral cavity. Therefore, these patients need to be reminded to rinse their mouth thoroughly after they use the spray in order to prevent this disease. Thrush presents as white, curd-like plaques, on a reddish base, that can be easily scraped off the oral mucosa. Good oral hygiene helps with this disorder, but cure requires prescription medication. Halitosis, in the main, is a social problem and mouth rinses may help. But if the bad breath is particularly bad, or especially persistent, some significant pathology may be involved. Approximately 90% of these causative disorders reside in the oral cavity. They include: • Poor oral ,hygiene; • Dental ,plaque; • 'C aries; • Gingival disease; • Stomatitis; and • Oral carcinoma. Therefore, any patient who complains of severe or lingering halitosis should see a dentist for a thorough evaluation. If a patient comes into the pharmacy
i i goa mou h sore, and he p harmacist he is 62 years old and a h eavy user of Cl es n alcohoL he sore m ay indicate a ry se 'ous con i ion-oral ca rcinoma . Th usu I resen ion of oral carcinoma is a poi less lesion hat is usually red o r red/white. Fi y percen of these lesions are located on the on ue; 16% on the floor of the mouth; and 34% o e ingival mucosa, palate , o r the buccal ucosa . Al hou h oral carcinoma can be fataL it is r Ie if i is detected early. The efore, pharma cists ca n help in the process of ly e tection, fi rst, by keeping a high index of sus icion for this disease in any patient with is f ctors for t is disease in his m e dical history. Smoking an excessive drinking are the two most impo ant of th se factors. Second, pharmacists n to are of the self-examination technique us to check for th is dise ase , and then t ch it to thei r patients (see Table 3). Ph r cists Iso need to be aware of which dugs in a tient's regime n may b e responsible for (or con tri u te to) complaints in the oral cavity (see 'J(
In helping patients maintain scrupulous oral he Ith care, pharmacists have a particularly import n t role to play by re inforcing what the e tist an denta l hygienist say to their patients. They can also perform a highly useful triage functio in considering patie nts' d e ntal com lai ts and urging the m to visit a dentist, if w rr nt , or recommend ing the appropriate r ucts if symptomatic relie f is all that is in ic t . Finally, pharmacists should watch for any rug si e e ffects that may manifest th s Ives in the oral cavity.
Table 3--Self-Examination for Oral Carcinoma • P lpate both sides of neck and jaw.
• 0 s rve li s-check a ll surfaces-note ch nges in color or consiste ncy. •
xamine gums with lips pulle d away- touch g ms to check for unusual lumps.
• Pull cheek away from teeth using thumb and fo efinge -observe and palpate for anything nusual . • Sick out tongue and grasp it with a gauze square-pull tongue to the rig ht and left while o serving and touching to detect anything abnormal . • Touch ongue to the roof of the mouth- repeat proced u as before. •
Say "ah" 0 vie he back of the mouth- use forefinger 0 feel the entire area (including roof of he mou ).
Table 4--Side Effects of Drugs Xerostomia An ticholinergics Antip arkinson agents Anticonvulsants An tihistamines Antidepressants Diuretics Hypnotics Narcotics Tranquilizers Phenothiazines Sympathomimetics Pigmentation (hard or soft tissues) Tetracycline Heavy metals Fluoride Antimalarials Liquid iron products Hematologic Hemorrhage (warfarin)
Leukopenia An tineoplastic agents Barbiturates Carbamazepine Chloramphenicol Gold salts Phenylbutazone Phenytoin Quinine Sulfonamides Thrombocytopenia Allopurinol Antineoplastic agents Carbamazepine Chloramphenicol Cimetidine Gold salts Heparin Penicillin Phenylbutazone Quinidine Quinine Sulfonamides Thiazide diuretics Gingival enlargement Phenytoin Aspirin bum Tardive dyskinesia Mucositis secondary to chemotherapy/radiation Allergic reactions
American Pharmacy Vol. NS27, No.4, April 1987/g04