Promotion Of Remineralization And Reversal Of The Demineralization Process

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The early carious lesion can be reversed by the remineralization process. The use of fluoride is critical for the process of remineralization. The action of fluoride is considered to be topical, promoting remineralization and inhibiting demineralization of teeth. Additionally, it may inhibit plaque bacteria. There are many brands and types of topical fluorides available that can be professionally or self-applied. For those at lowest risk, a 0.05% sodium fluoride rinse (ACT rinse, Fuoriguard, Carifree Maintenance Rinse) is available over the counter and may be used for 1 to 2 minutes daily. Higher-level fluoride rinses, gels, and dentifrices are available by prescription. 1.23% acidulated phosphate gel (many brands) is not very well tolerated by those who have severe salivary gland dysfunction because of mucosal sensitivity. The author usually prescribes a 1.1% neutral sodium fluoride dentifrice (Prevident 5000, Control Rx Multi 1.1% NaF dentifrice with xylitol) or gel. The neutral gel can be applied in a custom tray for 5 to 10 minutes once daily and seems to be tolerated well by those who

Sjogren Wound

Fig.1. 48-year-old male previously diagnosed with SS. Unstimulated whole salivary flow rate is reduced at less than 0.1 mL/min. The stimulated parotid salivary flow rate is on the low side of normal. Incipient caries or white spot demineralized lesions are noted on the cervical area of the maxlilary and mandibular cuspids, bicuspids and molars (arrows only indicate mandibular lesions). The teeth were treated with 5% sodium fluoride varnish. The patient will initiate a daily regimen of 1.5% NaF dentifrice, except when using a chlorhexidine rinse for 1 week out of a month, and will chew gum or apply a paste with recaldent to deliver calcium and phosphate to the tooth surface. The patient was counseled on diet and management of intraoral pH. He elected to continue to use water as his wetting agent of choice and not to use a muscarinic agonist to stimulate salivary flow.

Fig.1. 48-year-old male previously diagnosed with SS. Unstimulated whole salivary flow rate is reduced at less than 0.1 mL/min. The stimulated parotid salivary flow rate is on the low side of normal. Incipient caries or white spot demineralized lesions are noted on the cervical area of the maxlilary and mandibular cuspids, bicuspids and molars (arrows only indicate mandibular lesions). The teeth were treated with 5% sodium fluoride varnish. The patient will initiate a daily regimen of 1.5% NaF dentifrice, except when using a chlorhexidine rinse for 1 week out of a month, and will chew gum or apply a paste with recaldent to deliver calcium and phosphate to the tooth surface. The patient was counseled on diet and management of intraoral pH. He elected to continue to use water as his wetting agent of choice and not to use a muscarinic agonist to stimulate salivary flow.

have sensitive mucosa. For greater compliance, the neutral fluoride can be prescribed as a toothpaste/toothpaste, where application can be done simultaneous with tooth brushing. After application of the fluoride, the interproximal dental areas should be flossed to deliver the medicament to these generally inaccessible areas. 5% sodium fluoride varnish (Duraphat, Durafluor, Cavity Shield) or 0.1% difluorsilane varnish (Fluor Protector, Ivoclar, Viadent) may be applied professionally two to four times per year to the most caries- susceptible areas of the mouth (exposed root surfaces, around crown margins, and at incisal edges). This product is US Food and Drug Administration (FDA)-approved as an anticaries agent for children. This product allows extended release of the active ingredient with no measurable systemic levels, and it may be applied directly to potential problem areas of the tooth.

Salivary calcium and phosphate interacts with the available salivary fluoride to enhance the remineralization process. Sialochemistry studies show that patients who have SS may have decreased salivary phosphate levels with no change in calcium levels.26 Remineralizing agents that deliver calcium and phosphate to the tooth surface are becoming available in the United States. Prospec MI paste uses Recaldent, a milk-derived protein to deliver calcium and phosphate. This product can be applied professionally with a prophy cup, in a tray, or be used at home under professional supervision. Recaldent chewing gum may be used two to six times daily. Short-term studies have shown that temporarily increasing calcium and phosphate levels in saliva may be beneficial in helping those who have salivary dysfunction to more efficiently use fluoride. There is no consensus, however, on how often or how much calcium phosphate should be delivered for maximum effectiveness,15 and there have been no clinical trails specifically testing the effectiveness of these newer remineralizing agents in patients who have salivary dysfunction.

Minimally invasive dentistry (MID) is a concept that the profession has been shifting toward in the past decade.27-29 This shift has been facilitated by the development of new technologies and materials. The goal of this philosophy is to conserve healthy tooth structure and to realize that permanent restorations usually will need replacement in the future and that there is a restoration cycle that can lead to larger and larger restorations, tooth fracture, endodontic treatment, and eventually extraction of the tooth. Theoretically, this restoration cycle can be accelerated for individuals who have salivary dysfunction. The goal of MID is to interrupt and slow this restoration cycle. Consequently, dental caries is treated like an infectious disease, and strategies to prevent the decay process may be initiated. Newly developed dental materials allow the dentist to place smaller, conservative restorations to preserve existing tooth structure and to repair existing restorations with fluoride-releasing materials rather than to replace it with something slightly larger. Subgingival margins are difficult to clean, most susceptible to recurrent decay, and least accessible to cleansing and remineral-ization/antimicrobial strategies. Subgingival margins on a restoration are placed below the gum line and are not always avoidable in the interest of aesthetics. Supragingival, above the gum line, margins are preferred. If necessary, full coverage crowns should not be placed unless caries activity is controlled.

Increasing the amount of saliva in the mouth may be achieved in those individuals who have functioning salivary glands by means of the use of sugar-free hard candies or lozenges (Salive), sugar-free chewing gum, or by the use of a muscarinic agonist. A xylitol- containing gum or candy may have additional clinical benefit (Xylichew, Spry, TheraGum,). Pilocarpine tablets, Cevimeline capsules, or Bethanachol may be prescribed to increase saliva production. These medications are contraindicated in those who are pregnant or have a history of uncontrolled asthma, gastrointestinal ulcer, acute iritis or narrow angle glaucoma, and they may not be suitable for those who have unstable cardiovascular disease. Some individuals decide to discontinue the prescribed muscarinic agonist because of intolerable adverse effects, including sweating. In these cases, it is possible to titrate the medication (ie, pilocarpine, by cutting the 5 mg or 7.5 mg pill to a final dose of 2.5 to 3.75 mg three times daily, or dissolving one half capsule of cevimeline in 1 tablespoon of water) to maximize the sensation of increased saliva while minimizing systemic adverse effects. A single paper noted that cevimeline is highly soluble in water and suggested that a very short topical effect could be obtained by means of a rinse-and-spit regimen, avoiding systemic absorption of the medication.30 Other individuals benefit by switching to an alternative medication (ie, bethanechol or pilocarpine or cevimeline).31

Artificial salivas are available and are primarily palliative. Some of these products will have additives aimed at stimulating saliva or providing beneficial proteins, enzymes, or ions. Some patients depend on these products extensively. Others find these products not to their taste, and prefer water as a wetting agent. In any case, patients are advised to try different products to determine if there is one that they like. These products are useful to get very dry patients through difficult periods (telephone conversations, going to sleep, and social interactions). Patients are advised to make sure the artificial saliva is applied to the hard palate, buccal mucosa, and inner lips.32

Oral Infections in patients who have salivary dysfunction tend to be primarily mucosal erythematous fungal infections, or less frequently infection of the salivary glands. Clinically, this type of fungal presents as generalized or localized patchy areas of erythema on the tongue, buccal mucosa, palate, lips, and corners of the lips. The erythema almost invariably is associated with the sensation of burning and sensitivity to spicy/acidic foods. If the infection is on the tongue, depapillation (bald tongue) may be observed. With treatment, the burning sensation, depapillation of tongue, and taste alterations will resolve. If the burning sensation does not resolve with treatment, and there is an absence erythema at the site, then the presence of burning mouth syndrome33 should be considered. The treatment of choice for an oral fungal infection in the author's clinic is topical Nystatin Vaginal tablets (105 units/tablet), because there is no fermentable carbohydrate in the carrier. The patient is instructed to suck on the tablet three to four times a day for 7 to 10 days. For those who have severe salivary dysfunction, small sips of water may be necessary to facilitate dissolution of the tablet. Most antifungal preparations for oral use contain sugar to increase palatability. If a sugar-containing oral preparation is used, the patient should be informed to not use the medication immediately before bed without a thorough tooth brushing. A systemic medication may be used, but there is some concern that that the salivary level of the medication may not be sufficient in those who have the most severe salivary dysfunction.34 Thus, the patient should be informed that if there is not significant resolution in 7 to 10 days with the systemic medication, he or she will be switched to a topical oral antifungal. A fungal infection of the lip is treated with either a nystatin creme or nystatin creme with triamcinolone acetonide (ie, Mycolog II). The presence of a denture adds complexity to the treatment process, as it will need to be treated also. The denture may be soaked overnight in 0.2% chlorhexidine or a dilute bleach solution. Please note that chlorhexidine and nystatin should not be used together, as chlorhexidine-nystatin complexes may be formed, inactivating both compounds.35 The patient may sprinkle a fine layer of nystatin powder for oral suspension onto moistened surface of the wet denture and wear through the day. The patient should be instructed regarding the possibility of cross-contamination with lipsticks and toothbrushes.

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