A telltale sweet tooth

Dr Sinthia Bosnic-Anticevich

Today, she comes in to fill her prescription for atenolol.

She is happy and cheerful as ever, all is going well and off she goes. But just as she is about to leave, she remembers that she has forgotten to buy her favourite lollies.

You remember that she only just came into the pharmacy a couple of days ago to get the lollies.

You comment on Mrs Auditore’s obvious love of sweets, and she responds that it is not her love of sweets that makes her buy so many, but rather the fact that without them she has great trouble with a dry mouth. She always has a lolly in her bag.

You know that Mrs Auditore has hypertension and diabetes and begin to wonder whether there might be a problem here.

You decided that it is important to ask her about the following issues:
• Does she have any other symptoms?
• How long has she had xerostomia (dry mouth)?
• Has she had any problems with her teeth or gums lately (tooth loss or dental caries/decay)?
• When was the last time she saw her dentist?
• Has she been experiencing any mouth or face pain?

Xerostomia (dry mouth) is a risk factor for poor oral health, i.e. dental caries (decay) and periodontal (gum) disease.

Xerostomia occurs due to a lack of saliva, either from disease, age or use of certain medications including antidepressants, antipsychotics, urinary antispasmodics, diuretics and beta blockers.

Oral health problems can include ill-fitting dentures, number of teeth present, deep caries and periodontal disease or other infections.

All of these can result in pain and discomfort and can interfere with proper eating.

Oral health assessment tends to be based on tooth loss and the presence of dental caries.

The prevalence of oral diseases increases with age. Although there is controversy over whether the physiological and pathological changes that occur in oral disease are due to the aging process itself or due to disease, medications or environmental changes (Locker, 2000), risk factors for poor oral health in the elderly include race, socio-economic status, systemic illness, dentition status, medications, oral cancer, periodontal (gum) disease and dental caries.

Periodontal (gum) disease is a chronic and serious infection of the tissue around the tooth, that, if left untreated, can lead to tooth loss. It has been shown to be associated with cardiovascular disease, diabetes mellitus and respiratory infections (Desvarieux et al 2005, Shanies and Hein, 2006). 

Periodontal disease also includes gingivitis and periodontitis.

Risk factors for periodontal disease include smoking/tobacco use, genetics (up to 30 per cent of the population may be genetically susceptible to gum disease), stress, hormonal changes (e.g. associated with oestrogen), medications, clenching or grinding of teeth, diabetes, autoimmune disease and poor nutrition.

Other oral health issues for the elderly
Specific issues for the elderly also include access to dental care for a variety of different reasons.

Mrs Auditore might be having trouble getting access to her dentist. Low economic status and potential to have dental insurance, social isolation, residence in a long-term care institution, transportation limitations or complex medical conditions may all prevent the elderly from obtaining regular dental care.

Limited access to dental care poses problems in terms of controlling the risk factors for poor oral health, and identification and treatment of problems as they arise.

Mrs Auditore’s response
She doesn’t have any other symptoms but has had a dry mouth for ages. She is not exactly sure how long – maybe a couple of years.

She doesn’t wear dentures and does not have any mouth or facial pain.
But neither has she been been to visit her dentist for a couple of years. She was supposed to ring up to make an appointment after her last visit, but keeps forgetting.

Up until now she hadn’t realised it had been a couple of years since her last visit.

Your assessment and recommendations
As a health care professional who regularly interacts with Mrs Auditore, you realise that there are several things that you can recommend to this patient.

Mrs Auditore has several risk factors for poor dental health: diabetes, beta blocker use, xerostomia, age.
Based on her medical history of hypertension and diabetes, and her clarification of your questions, you suspect that the cause of her dry mouth is the particular beta blocker she is taking.

This is probably a problem that can quite easily be solved with her GP who can help her by considering an alternative beta blocker – one which is less likely to give her a dry mouth. Therefore you suggest that she goes to see her GP about this.

You also recommend that she makes that appointment to see her dentist.
In the meantime, there is a lot more that you can do for her. You decide to give her some advice.

Lollies
With regards to her consumption of lollies, Mrs Auditore’s favourites, of course, are not the sugar-free ones.

You explain that eating foods with high sugar content regularly, such as those associated with her habit of regularly “snacking” on lollies, is associated with an increased risk of tooth decay, as it provides the bacteria on the teeth with a constant supply on which to fester, ultimately leading to tooth decay.

You therefore suggest sugar-free lollies, if she really wants lollies, but also offer her other suggestions for her dry mouth.

Dry mouth
In addition to seeing her GP about her current medication and other options, there are options to help relieve her dry mouth which include oral gels, sprays, rinses, toothpaste or chewing gum or OTC saliva substitutes.

Tooth brushing
Although the dentist will apply fluoride gel to Mrs Auditore’s teeth, tooth brushing on a daily basis is an essential part of maintaining good oral health.

Soft-bristled tooth-brushes are recommended rather then medium- or hard-bristled brushes, because they are less abrasive on the gums and tooth structure.

Electric toothbrushes are just as effective as manual brushes and if Mrs Auditore has difficulty using a toothbrush, perhaps she should consider this as an option. Mrs Auditore should always use toothpaste with fluoride to prevent tooth decay, and should floss her teeth regularly.

Once again, if she has difficulty with this, electric interdental cleaners are available. In addition, adjunctive fluoride rinses or gels are recommended to patients who are prone to tooth decay.

Mouthwashes
If Mrs Auditore is to use a mouthwash, she should not use one with alcohol as it can lead to dry gums and cause her more discomfort.
 
Review
Looking after Mrs Auditore’s teeth is just as important as taking her medications and managing health as best she can; it’s something that needs to be done regularly. Mrs Auditore should make sure she doesn’t forget about going to her dentist on a regular basis.

References are available on request.

Dr Sinthia Bosnic-Anticevich is a senior lecturer in the faculty of pharmacy at the University of Sydney.