How it affects how dental hygienists offer treatment
by Sonya L. Prater, RDH, BS, FACE
My six year old recently started kindergarten. He is the youngest of three boys, full of energy and is too smart for his own good. Nothing seems to slow him down and he truly lives life to the fullest. As children, we never anticipate all the life experiences that lie ahead. I don’t ever remember a moment where I was afraid of what illness or tragedy would befall me, like many of you, I’m sure. On August 31, 2011, Venus Williams went public with her battle against a debilitating disease. She too was once invincible, full of energy, and quite successful as a tennis player. Recently diagnosed with Sjoren’s syndrome, Venus faced the reality that her body simply could not perform in one of the most prestigious tennis tournaments in the country, the U.S. Open.
In a recent interview with a colleague of ours, I realized that she too had never anticipated what tragedy would
JoAnn Snider, RDH
For those of us who don’t know, Sjogren’s syndrome is a chronic autoimmune disease where there is an overproduction of B lymphocytes (one of two types of white blood cells). This saturation of white blood cells clog and damage moisture-producing glands all over the body. Although dry eyes and xerostomia are trademark symptoms of Sjogren’s, this disease can cause dysfunction of organs, such as kidneys, lungs, liver and pancreas, and the central nervous system. Extreme fatigue, as well as muscle and joint pain, are also characteristic of this disease. Unfortunately, according to the National Center for Biotechnology Information, these patients are at a much higher risk (44 times higher) for developing lymphomas.
Sjogren’s syndrome can be classified as primary or secondary. Almost half the time, this disease occurs alone and is referred to as primary Sjogren’s. When occurring with another connective tissue disorder, such as rheumatoid arthritis, lupus, or scleroderma, it is referred to as secondary Sjo..gren’s.
Diagnosis is not easy; it often mimics other diseases and can take, on average, seven years to diagnose. Dr. Henrik Sjo..gren first identified the disease in 1933. It is neither racially nor ethnically biased. However, nine out of 10 victims are women.
As dental hygienists, we play an active role in the health of our patients. JoAnn’s passion as a patient and especially as a clinician is raising the awareness of Sjogren’s syndrome and working cooperatively with physicians to help get a proper diagnosis and treatment. There are many times I desperately wish that I knew what could be wrong with my patient. Realizing that in some small way I can help raise the quality of life for an individual is very rewarding.
Dental hygienists are passionate people. We are purposeful in everything we do, believe in the services we provide, and have a strong desire to help others. By raising the awareness and learning more about diseases that we can help recognize as well as treat (oral symptoms anyway), we can increase the quality of life in hundreds of patients. Since JoAnn’s diagnosis 13 years ago, she has aided in the diagnoses of 12 people with Sjogren’s syndrome. Without her awareness and definitely her personal experiences, those people could still be wondering what was wrong with them.
One hurdle we face is that our patients tend to give us only half the story when it comes to their health. They often feel the body’s health is unrelated to their dental health. When you know the questions to ask and signs to look for, you begin to get more answers. Hopefully, as you read along, you will be able to incorporate this information into practice almost immediately.
If you are not already familiar with the signs and symptoms related to Sjo..gren’s syndrome, reading this article and doing a little research on your own will give you a better understanding of what to look for while treating your patients. In our profession, you don’t have to look far to find people who suffer with xerostomia. Along with dry mouth comes mouth sores, an inflamed and cracked tongue, an increased caries rate, difficulty swallowing, breathing, chewing, and speaking, sloughing palate, sensitive roots, sore gums, dry eyes, unexplained joint and muscle pain, fatigue, interrupted sleep, and an overall lack of energy.
JoAnn has worked hard in increasing the awareness of this disease by speaking to different groups, doing volunteer work, and referring patients back to their primary physicians to be tested for Sjogren’s along with a letter from the dentist (it’s really from JoAnn but the doctors seem to accept it better coming from another “doctor”), and a resource sheet about the disease.
When it comes to treating the oral symptoms of this disease, we need to be keenly aware of a few things. Mint flavors, alcohol, and highly acidic products will only aggravate the symptoms of a dry, irritated, and inflamed mouth. JoAnn has an advantage over most of us. She is not only a dental hygienist but also a Sjo..gren’s patient. She firmly believes in an aggressive prevention program. Her recommendations may vary a little depending on the person’s symptoms, but for most, a combination of the following products are standard recommendations:
- Sonicare - Use the gentle cycle, especially in the case of recession with exposed roots
- Water Flosser
- Xylitol – six to 10 grams each day (Theramints from 3M)
- MI Paste/MI Paste Plus (all flavors are fairly mild)
- Oral moisturizing discs – slowly dissolves over a period of time
- Biotene products – toothpaste, mouth rinse, Oral Balance gel
- ACT for dry mouth (in mild cases)
- Fluoride varnish every three months (fruity flavors)
- Custom fluoride trays for home use — for active decay, with a natural flavor gel (twice a day for five minutes for the first month and once daily after that)
- Medoral dry mouth spray – can be found online in a variety of flavors
Some prescription medications can bring some relief as well. Drinking water and using products that moisten the mouth just are not enough with some patients. Artificial saliva substitutes include Numoisyn, Caphosol, Salivart, and NeutraSal.
JoAnn takes the prescription medication Evoxac (www.evoxac.com) as part of her dry mouth management program. This medication is indicated for the treatment of symptoms of dry mouth in patients with Sjo..gren’s. Evoxac stimulates more saliva production, which reduces the severity of her symptoms, and has improved not only the quantity of saliva, but also the quality. JoAnn relies on Evoxac’s six-hour half-life to provide continued relief throughout the day.
As with many medications, however, there are some contraindications to taking Evoxac; uncontrolled asthma and glaucoma to name a few. So when recommending this to patients, JoAnn refers them to their physicians first to make sure it will be safe to add to their daily regimens.
When asked how this diagnosis has changed her life, one of JoAnn’s responses was that she spends much more time on her teeth than she used to. She also brushes her palate and cheeks in order to stimulate minor salivary glands. This simple suggestion can offer your patients up to 90 minutes of extra salivary production. Most of us are unable to relate to our patients in this way. Personally, my only experience with xerostomia is when I take antihistamines, which is only a few times during winter season. That duration of time doesn’t even compare to the longevity and severity of the symptoms a Sjo..gren’s patient will experience.
In an effort to minimize patient discomfort during dental visits, keep in mind the technology that is available. An ultrasonic scaler with an ultrathin tip is the instrument of choice with patients who have sensitive roots and sore gums. This will not disrupt the immune system when used on low power and will be gentler on the gingival tissues. You can debride more quickly and effectively than hand scaling, adding moisture at the same time. Your patients will greatly appreciate your attention to details.
In addition to all of the products that are available to help treat xerostomia, there are a few helpful tips that JoAnn offers as well. Because Sjogren’s sufferers have difficulty with dryness, as mentioned earlier, it also affects chewing, swallowing, and speaking, and gives you the feeling of “Velcro throat.” Velcro throat is described as the feeling of each side of the throat being stuck together and not even being able to breathe.
Drinking water not only moistens the mouth but it also keeps you hydrated. Reducing the amount of sodas and increasing water intake is very important. On a side note, caffeine and sugar cause a massive depletion of minerals; the more you drink, the quicker you experience dehydration. For every can of soda consumed, the amount of oxygen in the blood is reduced by 25% for up to three hours. Our bodies need oxygen to live and function properly. Imagine the effect on the body after three to four sodas each day. It’s no wonder why some people have no energy.
Hydration also affects the amount of moisture that can be released from the salivary glands, thus increasing the level of comfort for the oral and pharyngeal tissues. Not having enough salivary flow decreases the level of digestion that occurs in the mouth and can disrupt other bodily functions. It’s like setting up a game of dominos. When one falls, they all fall. Keep in mind, however, that sipping water too frequently can actually make dry mouth worse by rinsing out the protection and minerals. After drinking water, JoAnn will then use some sort of saliva stimulation or moisturizer to replace the minerals that may have been rinsed out.
Although life has thrown a curveball to JoAnn, little gets her down. She may slow a bit but she continues on her journey to inform the general public as well as professional organizations of what Sjogren’s syndrome is all about. As dental hygienists, she wants us to be empowered to recognize the symptoms, educate and treat the patients, and refer them back to their medical doctors for further evaluation.
Helpful resources related to this disease are can be found on www.sjogrens.org. Printed materials and other resources are available for your office. Become a member and sign up for the Moisture Seekers newsletter for updated information and helpful tips. Do yourself a favor and get educated about this disease. Your patients will thank you for it. RDH
Sonya Prater, RDH, BS, FACE, graduated from Western Kentucky University and has been in private practice for over 16 years. She has held eight state licenses and remains in active status in South Carolina and Georgia. She is currently practicing in Savannah, Ga., in a very progressive, customer service-driven dental office that specializes in highly complex and reconstructive TMD cases.
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