Integrating dental and medical care for the chronic bulimia nervosa patient: a case report

Excessive tooth erosion and resulting sensitivity and esthetic concerns are well-documented problems in patients with eating disorders. Several techniques for restoring lost tooth structure have been reported in the literature. However, the potential significant role of dental care in the comprehensive treatment of the chronically bulimic patient has received little attention. Integration and coordination of dental treatment with medicopsycho-social therapy of the bulimic patient may enhance the patient's success in combating this complex disorder. The key to proper dental management is a definitive approach to data collection and close coordination among all health care personnel providing primary health care therapy. A specific dental approach model is recommended in this report of a patient with a 15-year history of bulimia.     

Management of the oral sequelae of cancer therapy

Oral cancer and the oral sequelae of treatment for oral and other malignancies can significantly affect a patient's oral and systemic health, as well as have a profound impact on quality of life. Compromised oral health prior to, during, and following cancer therapy can affect treatment outcomes. Increasingly, dental professionals in the community are being called upon to provide care for these individuals. Radiation therapy is routinely used for tumors of the head and neck, delivering a concentrated radiation dose to the tumor, but also to the immediately surrounding tissue. Oral complications are related to the site radiated and the total radiation dose. Cancer chemotherapy is provided as a primary treatment for some cancers and as an adjunctive modality for other cancers. The goal is to eradicate the rapidly growing cells of the tumor, but chemotherapy is often toxic to other cells that rapidly divide normally including the oral mucosa. The use of combined chemotherapy and radiation is now considered standard for most locally advanced tumors of the head and neck. The toxicities of this combined therapy are essentially the same as with radiation alone, but develop more rapidly and are typically more severe when they reach maximum level. The most common oral sequelae of cancer treatment are: xerostomia, the sensation of a dry mouth as a result of damage to the salivary glands and/or medication; mucositis, the inflammation and ulceration of the oral mucosa; and infection as a result of the loss of mucosal integrity. Management of oral health during cancer therapy includes identifying at-risk patients, patient education, appropriate pretreatment interventions, and timely management of complications. Appropriate preventive and therapeutic measures will help minimize the risk of oral and associated systemic complications, improve treatment outcomes, and improve the patient's quality of life.     

Developing lifetime relationships with patients: strategies to improve patient care and build your practice

AIM: The purpose of this article is to describe three strategies to build a thriving, patient-centered practice and promote oral health throughout a patient's lifetime. BACKGROUND: Compared to previous decades, more dental patients are "shopping around" for dental care and changing dental practices. This trend is due to factors such as acceptance of dental insurance, more comprehensive service offerings by other dentists, and effective marketing campaigns by other dental offices. FINDINGS: Delivering customer service exceeding patient expectations ("WOW" service), advocating patient education, and developing customized home care regimens will help lead to long-term patient retention and promote optimal patient care. DISCUSSION: A dental team making relationship-building a priority conveys respect for their patients' time and well-being. Once trust has been established patients are more likely to be receptive to oral health education and become more compliant with home care regimens. Since a patient's oral health status will likely change over time, it's important to make education and customized treatment planning an integral part of each visit. CONCLUSIONS: By demonstrating a strong commitment to customer service, education, and home care, patients recognize the care providers in a dental practice are interested in their well-being rather than simply treating problems. CLINICAL SIGNIFICANCE: If patients recognize a dental practice is focused on prevention and at-home oral health care, they are more likely to partner with that practice for a lifetime of excellent oral health care.     

Dietary and nutritional needs of patients after therapy for head and neck cancer

BackgroundThe number of cancer survivors in the general population is increasing. Oral and dental status affects patients' quality of life and oral function, which, in turn, may affect nutritional intake and general health. The authors review the importance of oral health and the role of the oral health care provider in supporting dietary intake and providing nutritional guidance.MethodsThe authors provide a brief review of oral complications of therapy and nutritional guidelines for patients with head and neck cancer.ResultsOral adverse effects of head and neck cancer treatment include salivary gland dysfunction, taste change, orofacial pain and mucosal sensitivity, oral infection, tissue defects and necrosis, trismus and fibrosis, progressive dental and periodontal disease, and problems with prosthesis function.ConclusionsManaging oral adverse effects of treatment may have an impact on dietary and nutritional intake, as well as on quality of life. Dietary modifications may be needed because of the patient's oral function and may include modification of food texture and flavor, as well as the use of dietary supplements.Clinical ImplicationsAs part of the patient's health care team, dental care professionals should be aware of the oral adverse effects of cancer therapy, as well as their role in recognizing and treating the resulting oral conditions. In addition, they should provide guidance to patients to support their oral dietary and nutritional intake.     

Sensory and motor deficits in the elderly: impact on oral health

Hearing, vision, orthopedic, and speech disorders are the most common impairments in the elderly. Older adults experience other sensory impairments such as olfactory and gustatory dysfunction, as well as oral motor problems including difficulty with mastication, speech, and swallowing. These disorders can directly affect oral health and can impair dental treatment. Therefore, it is imperative that dental health practitioners be cognizant of these conditions and aware of the impact these conditions and their treatments can have on oral health and function. Dental professionals may need to use different communication techniques for patients with vision or hearing losses. Accommodations in the dental office and by dental professionals will help older patients who have sensory and/or motor impairments to preserve their oral health and function and receive dental treatments in a safe and efficacious manner. This paper reviews the most common causes of sensory and motor impairments and their implications for oral health care with treatment modification guidelines for the older patient.     

Desensitization of the gag reflex in an adult with cerebral palsy: a case report

Severe oral hypersensltlvlty and averslve oral behaviors present a significant barrier to dental treatment and compromise oral health status. Although several authors have addressed the reduction of oral hypersensltlvlty and averslve behaviors (such as gagging, retching, and vomit-Ing) In the otherwise well dental patient, treatment for patients with severe disability has not been explored. The successful management of oral hypersensltlvlty and averslve behavior can have significant health benefits. These can be described van outcomes paradigm as physical and social benefits for the patient, psychological benefits for the patient, carer, and practitioner, and organizational benefits for the Institutions providing dental care and medical management. This paper summarizes the management of a severely disabled patient whose averslve behaviors were eliminated with non-Invasive therapy techniques. Oral hygiene was facilitated and health benefits were Identified across a number of domains following successful multi-disciplinary management.     

The Oral Health Information Suite (OHIS): its use in the management of periodontal disease

Health care costs continue to increase at a rapid rate. Dental costs alone have risen from $31.5 billion in 1990 to $70.3 billion in 2002, outpacing inflation by 160 percent. Payers for health care services have no means to evaluate the value of these large expenditures. Quantified information is not available regarding a patient's condition prior to and after treatment nor on the probability of future disease. The absence of this information prevents dentists from responding effectively to challenges by payers and patients, and specifically prevents dentists from effectively influencing the quality of periodontal care. We have developed a user-friendly Internet-based technology that quantifies risk for periodontitis and periodontal disease severity and extent and generates recommended treatments and interventions. A caries risk assessment tool has also been developed, and an oral cancer assessment tool is being developed. This technology, designated the Oral Health Information Suite (OHIS), provides quantitative information to the clinician and patient as an aid to diagnosis and to facilitate individual, needs-based treatment planning. OHIS enables successful application of the wellness model of oral health care, which may be expected to result in more uniform and accurate clinical decision making, improved oral health, reduction in the need for complex periodontal therapy, reduction in oral health care costs, and improved clinician productivity and income. It also will permit patients to become more involved in their oral health care, payers to quantify and predict their health care expenditures, dentists to experience an increase in trust and respect, and periodontists to be more properly consulted regarding periodontal care.     

The dental patient with asthma. An update and oral health considerations

OVERVIEW: Asthma is a serious global health problem that has steadily increased in prevalence during the past two decades. New classification and treatment guidelines have been published, and dental providers need to be aware of these changes. LITERATURE REVIEWED: The authors searched textbooks and MEDLINE, looking for the most updated medical information on asthma, as well as for previous publications on treatment of asthmatic patients in a dental setting. RESULTS: More than 9,000 articles on asthma were published in English between 1997 and 2000. From 1960 until 2000, approximately 40 articles specifically addressed asthma and dental care. The authors reviewed more than 300 articles from the medical literature and all articles after 1980 that directly focused on oral health issues for importance and relevance. CONCLUSIONS: Recent information regarding the etiology, pathogenesis and treatment of asthma had not been adequately addressed in the dental literature. Dental care of asthmatic patients may necessitate considerations beyond what has previously been published in the dental literature. CLINICAL IMPLICATIONS: In the treatment of asthma, as with treatment of most medical conditions, oral health care providers play a role that is important in terms of both the patient's overall health and the systemic condition's effect on oral health. This article provides dentists with a timely update on asthma and the relationship between asthma and oral health, and it offers suggestions for safe and appropriate dental care.     

Compliance with fluoride gel use in irradiated patients

Patients who undergo radiation therapy that includes the salivary glands frequently experience severe xerostomia. The standard of care for these patients who have natural teeth has become daily application of fluoride by means of custom-fabricated carriers. The purpose of this study was to determine patient compliance with fluoride gel application using carriers.
Using a structured verbal questionnaire, we interviewed 76 patients who had completed radiation therapy for head and neck cancer. Thirty of these patients were seen regularly in the dental clinic of the Cancer Agency (group 1); the remaining 46 were not seen on a regular basis (group 2).
Overall, 43% of patients reported using fluoride gel regularly (once a day). In group 1, 67% of patients used fluoride regularly, as did 28% of patients in group 2 (p = 0.001). There were no significant differences between the groups in frequency of toothbrushing and use of dental floss. Compliance with the use of fluoride in carriers was not associated with differences in other oral care measures in the two groups, which suggests that fluoride application in carriers achieves limited compliance in relation to daily oral health care measures. Regular follow-up of patients after radiation therapy is needed to assess their need for, and compliance with, daily fluoride application.     

Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare

Cigarette smoking increases the risk of developing several systemic conditions including cancer, cardiovascular and pulmonary diseases. Cigarette smoking is also detrimental to oral health as it increases the incidence and severity of oral cancer, periodontal diseases and peri‐implantitis, as well as impacting negatively on the dental patients' response to therapy. Therefore, consideration of smoking behavior and recommendation of smoking cessation are important parts of dental treatment planning. However, cigarettes are no longer the most popular form of tobacco use among adolescents in the United States and globally. In recent years, tobacco smoking using a waterpipe (“hookah,” “shisha”) and use of electronic cigarettes (ECIGs) has increased significantly. Thus, dental clinicians likely will treat more patients who are waterpipe and/or ECIG users. Yet, the literature on the health effects of waterpipe and ECIGs use is sparse. Both waterpipe and ECIGs deliver the dependence‐producing drug nicotine. Waterpipe tobacco smoking has been associated with periodontitis, dry socket, premalignant lesions, and oral and esophageal cancer. The health effects of long‐term ECIG use are unknown. The purpose of this review is to inform healthcare professionals about waterpipes and ECIGs, highlight emerging evidence on the biological effects of these increasingly popular tobacco products, and introduce perspectives for dental patient management and future research.     

Adult hemopoietic stem cell transplantation

BACKGROUND: Hemopoietic stem cell transplantation, or HSCT, is an important tool in modern cancer treatment. Refinement of transplantation techniques and supportive care has resulted in increased posttransplantation survival rates. Dental care is a key supportive element in both pretransplantation and posttransplantation care of this patient population. METHODS: The authors provide an overview of HSCT transplantation, emphasizing the oral complications and required supportive dental care. CONCLUSIONS: It is critical that transplantation candidates undergo dental screenings and be treated adequately before transplantation, that their care be closely managed during the transplantation process, and that they be given dental support as soon as their recovery permits. Dentists should consult with the patient's oncologist or primary health provider to identify the appropriate timing and intensity of dental support. CLINICAL IMPLICATIONS: Because of improved transplantation survival rates, more patients may seek supportive outpatient dental care after transplantation, which requires special management considerations. Dental professionals need to be knowledgeable about modern HSCT.     

The role of dentistry in palliative care of the head and neck cancer patient

Although palliative care for the terminally ill is based on a multidimensional philosophy to provide whole-person comfort care while maintaining optimal function, it does not usually include dentistry in its team approach. Dentists can have a significant role in the care of these patients by providing total, active comfort care of the oral cavity. The function of the oral cavity is essential to the patient's ability to thrive. Therefore, alleviation of pain and prevention of infection in the oral cavity should be a priority in providing total, active comfort for the patient. The oral problems experienced by the hospice head and neck patient clearly affect the quality of his or her remaining life. Through routine assessments and interventions by a dentist on the palliative care team (Figure 4), comfort care for the patient may be improved by the maintenance of oral hygiene and procedures to hydrate the oral mucosa. In addition, routine dental assessments may identify dental disease and facilitate dental interventions for caries, periodontal disease, oral mucosal problems or prosthetic needs. Attention to such detail may reduce not only the microbial load of the mouth but the risk for pain and oral infection as well. This multidisciplinary approach to palliative care, including a dentist, may reduce the oral debilities that influence the patient's ability to speak, eat or swallow. Not only does maintenance of oral health have impact on the quality of life, which is already challenged by the disease, but it also aids in the ability of patients to thrive for whatever precious time is left to them.     

Under the Influence: Informing Oral Health Care Providers About Substance Abuse

Treating the drug addicted dental patient is different than treating the non-addicted patient due to differences related to the emotional/behavioral/personality issues of the addict, the addict's often poor general health and poor nutrition, ongoing problems of oral hygiene and the effects of drugs on the oral mucosa, gingiva and dentitionBackgroundOral health care providers need to be aware of the emerging trends in substance abuse, able to recognize patient's addicted to drugs and to be knowledgeable about the effects of substance abuse to provide the most efficacious treatment to avoid the consequences of contraindicated dental procedures and therapy. This article defines the scope of the problem of drug abuse and provides an overview of commonly abused substances and their effects on health and oral health.MethodsA review of the literature combined with the authors' extensive experience in the substance abuse field explains parameters of oral health care treatment of the drug addicted individual for patient and provider safety.ConclusionsThe drug culture has evolved and the drug user is different. Oral health care providers need to realize that any patient may be an addict in order to identify them, provide appropriate oral care and direct them, if they desire, toward appropriate treatment.     

The pregnant and breast-feeding patient.

The pregnant or breast-feeding patient presents a number of unique management problems for oral health care providers. Clinicians are responsible for providing safe and effective care for the mother, while also considering the safety of the fetus or newborn. They must consider the effects of medications, which may be distributed from the maternal plasma through the placenta to the fetus, or to breast milk, exposing the nursing infant to potentially dangerous concentrations. In addition, a number of maternal oral changes, requiring the attention of oral health care providers, may be observed as a consequence of the multiple physiologic changes associated with pregnancy. In view of the dual responsibility that oral health care providers face in treating the pregnant or breast-feeding patient, understanding the physiology of pregnancy, fetal development, potential oral complications of pregnancy, and the effects that dental intervention may have on the woman, her fetus, or her neonate are imperative.     

Current practice in dental oncology in the U.K

The clinical management of cancer patients, particularly where it affects the head and neck, may result in short- and long-term complications. Specialist management of the dental sequelae of cancer is often recognized nowadays by the term'Dental Oncology' Members of the dental team play a vital role in preventing and promptly managing such complications and all dental professionals should have a sound understanding and knowledge of the oral implications of cancer therapy and their management, and the contribution of this to the patient's quality of life. CLINICAL RELEVANCE: This article offers the dental team an overview of the impact of cancer therapy and strategies for preventing and managing the oral side-effects of cancer therapy prior to, during, and beyond cancer treatment.     

Patient dental values and their relationship to oral health status, dentist perceptions and quality of care

In this study, 1287 patients completed a questionnaire assessing knowledge of home care procedures, adherence to home care instructions, obstacles presented to the dentist in delivering care, and ability to pay for optimal care. Ninety-seven dentists that provided treatment for these patients completed a parallel questionnaire. Measures of oral health and the quality of restorative care were based on clinical examinations. It was found that though patient values and dental perceptions were associated, dentist perceptions did not closely match patient dental values. Analysis of variance indicated that patient dental values were related positively to both oral health measures and the quality of restorations. Patient-reported compliance with home care recommendations showed the strongest relationship to both oral health and quality of restorations.     

Rheumatoid arthritis: a review and suggested dental care considerations.

BACKGROUND: Rheumatoid arthritis, or RA, is a chronic multisystem disease of presumed autoimmune etiology. It is estimated that arthritis and other rheumatic conditions affect 42.7 million Americans. Medical complications due to RA and its treatment may affect the provision of oral health care. METHODS: The authors undertook an extensive review of the English literature relating to RA and dental care. They used primarily MEDLINE searches, which included such key words as "rheumatoid arthritis" and "dental care" and subsequent appropriate subheadings. While the MEDLINE search spanned the years from 1975 to the present, the most recent literature was prioritized. Appropriate medical and dental textbooks were also used. The authors extrapolated information from selected texts based on its relevance to dentistry, oral health and the role of the dental provider in the overall treatment of RA patients. RESULTS: The authors reviewed nearly 200 articles and seven textbooks. Their determination of the texts' relevance to oral health care was based on content, significance, quality, journal in which articles were published and year of publication. Major features of RA--including its diagnosis, pathophysiology, clinical features and medical treatment--were identified, as well as complications due to treatment modalities and various related oral manifestations and conditions. CONCLUSIONS: Medical complications due to RA and its treatment can affect oral health care. Oral health care providers need to recognize and identify modifications of dental care based on the medical status of patients with RA. Furthermore, oral health care providers play an important role in the overall care of these patients as it release to early recognition, as well as control of the disease. CLINICAL IMPLICATIONS: In most patients with RA, the condition will necessitate few or no changes in routine dental care. However, considerations include the patient's ability to maintain adequate oral hygiene, xerostomia and its related complications, the patient's susceptibility to infections, impaired hemostasis, and untoward drug actions and interactions. Patients with RA may require antibiotic prophylaxis owing to joint replacement and/or immune suppression, glucocorticosteroid replacement therapy and modifications in oral hygiene procedures. Intra- and extraoral conditions such as ulcerations, gingival overgrowth, disease-associated periodontitis and temporomandibular pathology also need to be recognized.     

Impact of improved dental services on the frequency of oral complications of cancer therapy for patients with non-head-and-neck malignancies

An earlier study by our group reported a frequency of about 40% for oral problems associated with cancer therapy for patients with non-head-and-neck malignancies. Since then, we have instituted a variety of preventive and treatment protocols aimed at the aggressive management of the mouth in patients being treated for malignant disease. In the present study we evaluated the frequency and nature of oral problems associated with cancer treatment in 495 patients treated for non-head-and-neck malignancies between 1978 and 1986. Our analysis indicates that the frequency of oral problems in the study population was 10.5%, compared to 38.7% in 1978. The specific nature and distribution of oral problems by diagnosis, by patient's age, and by type were remarkably consistent. Our results suggest that early and aggressive dental intervention in standardized protocols reduces the frequency of oral problems associated with cancer therapy.