Therapeutic Guidelines Oral and Dental update

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Hi, and welcome to the Australian Prescriber podcast on Therapeutic Guidelines: Oral and Dental. For this podcast, I have the pleasure of welcoming Dr Lee Fong. Lee, like myself, is a GP, not a dentist, so I reckon Lee today we'll be doing more of a chat amongst peers more than necessarily a super-duper expert. How does that sound to you?

That sounds fantastic because I'm not a super-duper expert, but I'm back for a second round. So I think we've had a conversation about oral and dental things in the past. And as before, I've got dentistry in my lineage. My dad is a dentist.

That's right. And you passed the first test, which is why we invited you back for the second. And in fact, Lee, it's a very special occasion for Australian Prescriber because I believe this is the 200th AP podcast. So we thought we would get you as our special guest on for number 200. You don't win any sort of prize, but you can be doubly honoured to be here.

Thank you for having me on for the 200th episode, and congratulations to the whole AP team.

Thank you very much on their behalf.

So Oral and Dental, we are going to be talking about it as a health practitioner who's not dentally qualified, although no doubt some of those will be listening to the podcast as well. I do read this striking statistic that the average tooth loss for Australians over 65, and I've still got a few years to go but not too many, is more than 13 teeth lost. So we only start with, I believe it's 32 if my maths is correct. So that's pretty severe for older Australians.

It certainly is, and like you, I actually did a quick tooth count, ran my tongue around the inside of my mouth and I came up with 28, but that's because my wisdom teeth are missing in action. So I think you're right, 32 it is.

32 it is. I'm a Collingwood supporter. Occasionally people remind me that we are meant to have fewer teeth than most other supporters. Happily, I have a very good relationship with my dentist.

What I really want to spend a fair bit of time talking about is prevention based on that fact that we want people to keep their teeth. Dentists are of course wonderful, and technology is advancing every year in terms of tooth implants and crowns and fillings that last. But in the end, what we're really after is prevention, and no better people to do that than GPs who know all about prevention being better than cure. Let's run through a few preventive steps which a GP can take and in fact should take, either when it comes up opportunistically or at annual health checks. What are some of the big-ticket items, Lee?

Well, there's the usual one that we know of which is trying to reduce the amount of sugar that we have in our diet. In particular, avoiding sticky forms, not just sugary things but in sticky forms because they hang around more. They stick to your teeth. The more they stick to your teeth, the more likely you're going to get chewed up by the bacteria in our biofilm. And then you have the acid byproducts that lead to the demineralisation of the tooth structure.

That's a story I certainly repeat to patients a lot, perhaps not using some of the more technical terms, but the concept that if you eat the sticky stuff, that's the chocolate, sweet biscuits, toffees, that sort of thing, and bits of it stay on your teeth, that's where the bacteria get into your teeth and gum. So that's a good narrative to talk about.

And then of course we talk about tooth brushing as well as we've always done, and regular dental reviews, which of course guided partly by the person's willingness to go to the dentist, the affordability of a dental service, and perhaps fear, in some cases, of the dentist. We might get into that a little bit more later on when we talk about special groups.

What else have we got along the prevention lines?

Besides sugary foods, another thing to remember is the sugary drinks, but in particular, sugary, acidic drinks, soft drinks, which of course are acidic in and of themselves. And I'm not saying that people shouldn't have soft drinks at all, but if you are, then think about essentially minimising contact with your teeth. So for example, maybe you don't sit there with a can of soft drink slowly sipping it over the course of a couple of hours, and/or use a straw to minimise, again, contact with your teeth.

Yeah, okay. Thank you. We of course are very familiar with the risk factors for oral cancer. We've got tobacco, alcohol, which we talk about all the time anyway, so we won't go any more into that. I think betel nuts, those red nuts that people do spit out sometimes, not so common in Australia, but a particular risk as well.

Yes, indeed.

And then tell us about anything else we can do, Lee.

So we are a nation of sports enthusiasts, and so trauma from sports activities is absolutely an issue. So just to recommend the use of mouthguards. Really kids from the point when they start playing contact sports, then a mouthguard is an important thing. You can get ones that are just over the counter at the chemist or you can get customised ones made by a dentist. Customised ones, more comfortable but of course there's more expense associated with that. In either case, a mouthguard definitely is recommended.

Wonderful. I also noticed there's a link in the guidelines to examination of the older patient, looking at opportunistic, preventative oral health for older people. So listeners can check that out.

Talking about a couple of specific populations, I think older people is one of them. Children, you've partly mentioned with sport, and of course encouraging them to learn to brush their teeth with an adult supervising it a lot early on. And then teaching them ways to do it by themselves, particularly with electric toothbrushes, I think is quite effective. There's a couple of other groups. So there's a section on palliative care needs, Aboriginal and Torres Strait Islander people, and there's quite an expanded section on pregnancy. Talk me through any particular oral risks during pregnancy.

So when people are pregnant, then there's an increased risk associated, particularly with dental caries in the first instance. When you're pregnant, you tend to be hungry. When you're hungry, you tend to snack more. And so that tends to promote that acidic environment. Vomiting in early pregnancy can definitely be an issue, and then reflux can happen later on in pregnancy.

So an interesting and specific bit of advice that is given in the context of vomiting is that patients should avoid brushing for about 60 minutes. It's really to limit trauma to the enamel that's softened by the acid. And in the meantime in that 60 minutes, rinse with water and then actually apply a fluoride toothpaste, but just using your finger instead of a brush. So there's some very specific advice there, which I have to admit I wasn't aware of.

With fluoride, of course, I am mindful that just last week, a council in Northern Queensland just voted to take fluoride out of the water, which I think is obviously a terrible decision, but I guess there's that public health advocacy too for GPs in rural areas to really push to stop that happening. Unfortunately, it didn't work in this instance. Any other particular things relevant to pregnancy?

So there's a few conditions that are more prevalent. So gingivitis, periodontitis is more common in pregnancy. I was surprised to hear that the prevalence of those hormonally driven conditions can hit as high as 94%. So the numbers are 40 to 94%.

Yeah, right.

They usually resolve after delivery, but can be a particular problem if there was pre-existing periodontitis. There's a thing called a pregnancy epulis or granuloma that can bleed quite readily. Again, I think mostly they resolve themselves, but sometimes they do need a removal.

The other tip is that it is a really good idea to get a dental checkup if you're planning on becoming pregnant, so that if there's anything that needs to be done, get it done beforehand.

The other thing to think about is that, well, if that didn't happen and then something dental does crop up, then whilst you can engage in any emergency dental treatment whilst you're pregnant, at any stage of the pregnancy, generally speaking, if you have a choice, the best time to do it is in the second trimester. In the first trimester, if you're feeling nauseated and you've got an exaggerated gag reflex, that does make dental work particularly challenging. And avoiding the third trimester in the context of the inferior vena cava type issues and having to prop people up on their sides and all that sort of stuff. And reflux as well.

Yeah. Often the second trimester is that happy window period for a few things, isn't it? So oral health might be one of those. I have certainly had a lot of patients where it's an issue of fear of the dentist or not wanting to go or in people where they have lots and lots of life problems, so either on the spectrum or cognitive disability. And we tend to forget about oral health because there's so much else to do and it doesn't seem to rank in the top things that we should be doing about the health. But I was really pleased to see that this new update has a significant new section on oral and dental health in people with cognitive disability.

That's a really important point to make. So that's a really valuable addition, and I think it does tie in in some ways quite closely to looking at oral health in the older population. And I think when you are particularly looking at patients who are in a nursing home, in residential aged care, then dental problems can often get forgotten a bit. And it's really important to remember dental causes, for example of pain. Someone who has delirium, it may not be super obvious that the dentition is the cause of the problem and to remember to look for that when there is a change in someone's behaviour.

But again, if we're talking about things from a preventive perspective, it's about screening. So those are 2 really important populations with screening. It's important for people in residential aged care and people with disabilities. And there's actually a really good video that's linked that shows how really anybody, particularly people who have got some medical background, can do a relatively simple and straightforward dental screen for people in these high-risk populations.

Thank you, Lee. And just for those dental students and dentists listening in and oral hygienists, et cetera, that section also does cover particular techniques of communication, keeping people calm and reassuring them if they do have cognitive disability or perhaps dementia in the older age groups.

Moving on to oral mucosal diseases now, Lee, there was an update there and looking at red flags for oral cancer. Now, some of those flags would be familiar to most GPs because we deal with lots of skin cancer all around the body. Any particular tips there?

If we talk about red flags for oral cancer, and there's some that probably we know of or would seem relatively intuitive. So for example, if you've got an ulcer that's hanging around for more than a couple of weeks, there's a pigmented lesion on the oral mucosa, red, white, mixed red and white, where there's changes that look suspicious. So that could be induration, ulceration with rolled margins, fixation to underlying tissues, and also that if a lesion is in a high-risk site. And so the obvious question then is, well, what's a high-risk site of the mouth? And it turns out that is the lateral aspects of the tongue and the floor of the mouth.

Lovely. Lateral tongue and floor of the mouth, be particularly aware. Most of the other things would be similar red flags for skin cancers, which we are much more familiar with looking at.

And then there is a section, we won't go into it in any detail, but talking about non-malignant conditions that require specialist referral, talking about pigmented lesions, oral syphilis. And I know that syphilis is re-emerging. Having worked in remote communities, I'm reasonably familiar with it, but a lot of city GPs not so much but more so in the last couple of years unfortunately. And there's also a bunch of photographs which help aid recognition of various viral diseases, so hand, foot and mouth, and herpes simplex and zoster and herpangina, which are great.

We might talk about acute infections, always a biggie and it's something GPs deal with a lot. Someone comes in with tooth pain and it's pulsing and keeping them awake at night. Generally the guidelines divide that into 2 parts. One is if they're likely to be able to access dental treatment and drainage within 24 hours, and then if not so soon. Can you talk us through the first case there if they can get to the dentist later that day or the next morning?

Yeah. So for a dental infection where it's thought that you can get to it pretty quick and that it can be promptly drained, then the thing to remember there is that you're probably not going to get anaerobes in terms of a predominant cause of underlying the problem. So if it's non-severe and it's localised, it's less than 24 hours, then just get the drainage done. Don't need antibiotic therapy. If it's thought to be still non-severe but antibiotics are thought to be required because the infection is spreading, then in the absence of those or less dominance of anaerobes, then penicillin should do the job. That's under 24 hours.

And then it mentions cefalexin and clindamycin as alternatives for allergies. In the second case there where dental procedure is likely to be delayed, the person's unlikely to be able to get there, what happens in that case?

In that case, then using a broader spectrum therapy because of that concern about penicillin-resistant anaerobes. So there we're looking at, say, penicillin plus metronidazole or Augmentin, amoxicillin plus clavulanic acid.

Thank you, Lee. And moving on to patients with medical conditions, there's been updated guidelines in the latest Oral and Dental Therapeutic Guidelines on assessing bleeding risk. There's a flowchart there which helps the dentists identify the likelihood of bleeding risk and then how to manage people taking antithrombotic drugs before a dental procedure. That's probably of particular interest to the dentists who then can check with their GP or medical specialist depending on the circumstance if they're doing a procedure. And then it talks about kidney failure, which as people live longer and longer, it's increasingly seen, I think, in general practice. What are the main risks with kidney failure as they relate to dentistry?

There's a few dot points to consider here. So looking at the risk of bleeding because of anticoagulant therapy, anticoagulant therapy that the patient might be in for haemodialysis, that there's risk of infection in the context of uraemia and poor nutrition. Reduced drug clearance of course, so you might need to adjust some doses for drugs. And if it comes down to the wire and we're looking at kidney transplant, there should be a dental assessment before you push in that direction to identify what do you need, what teeth need treatment before the patient ends up on immunosuppressive therapy. And also looking at what might be needed in terms of risk of medication-related osteonecrosis of the jaw.

Lastly, I think time for one more, Lee, obstructive sleep apnoea. The mainstay of treatment is usually CPAP [continuous positive airway pressure] along with a few lifestyle things. Talk us through the place of oral appliances.

So I have to admit, this was something that I just found fascinating because as you just said, as a GP, I think obstructive sleep apnoea, the thing that pops to mind is weight loss and CPAP, and it's like straight onto a CPAP machine. That's it. End of the story. One plus one equals 2, that's where you go. But there is something called a mandibular advancement appliance. Kind of looks like a mouth guard, but what it does, it sort of fits over the upper and lower teeth and it pushes the lower jaw forward by 8 to 10 mm or so. So your lower teeth end up in front of your upper teeth. And the thing that I found surprising is that for patients with mild to moderate obstructive sleep apnoea, the efficacy of these devices is comparable to CPAP, but of course it's a lot cheaper and a lot more portable. So that's just, I thought, a really interesting tip about obstructive sleep apnoea.

Yeah, wonderful. And certainly worth considering for those who don't like the CPAP or are on the milder end of the spectrum and prefer something much simpler, or perhaps their partner prefers something much simpler as well.

Lee Fong, that's all we have time for. Congratulations on being a special guest for the 200th podcast, and thanks for running us through the Therapeutic Guidelines: Oral and Dental update.

Thank you very much. Lovely to be here. And again, congratulations to the team.

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My guest's views are their own and don't represent Australian Prescriber, and my views are certainly all mine.