Tuesday, October 23, 2012

JoAnn Snider RDH, BSDH: Oral Care for Sjogren's Syndrome Patients

WaterPic found here. Read on to see why I'm going to consider tossing my floss and using this instead. 

Laura C. Strom, MS, LMFT, LPCC AND sjoggie recently had an opportunity to exchange correspondence with dental hygienist JoAnn Snider, and she generously forwarded it to me. I'm paying it forward and passing it along to y'all. Because this was lengthy correspondence and contains a great deal of excellent information, I am going to break it down into two posts, the first on oral care.

Thank you Laura and JoAnn!

JoAnn Snider,  RDH, BSDH; Sjögren' s Advocate; patient, Speaker, and Author spoke at the Sjogren's Syndrome Foundation conference in La Jolla, CA on 4/21/12. This from Ms. Snider: "As always, if something I write or say can be used to help other Sjogren's patients, I authorize anyone to reprint anything or pass it along."

Oral Care for Sjogren's Syndrome Patients presented by JoAnn Snider, RDH BSDH 

1.  Plaque control is #1
A.  Power up! 
      Any power toothbrush is better than hand brushing. 
          A hand brush requires 300 grams/cm2  (centimeter squared) to remove plaque.
            Most power brushes only need 150 grams/cm2.
          A Sonicare only requires 80 grams/cm2.
          Less pressure means less abrasion to exposed tooth surfaces and gum tissues.
     B.  Special toothpastes or rinses—Biotene PBF
Reduces the ability of the bacteria to stick to your tooth and each other.  Using either one twice a day can average a 91% reduction in plaque and mineral build up.
C.   Reach Gum Care floss or a Water Flosser:
Not every patient can manage dental floss.  Studies at USC show that a Water Flosser (formerly known as Water Pik) can be twice as effective as string floss and it’s a whole lot easier to use.  I use mine before brushing to remove food and plaque, and then brush with the Biotene PBF Toothpaste with its 12 hour plaque fighting enzyme complex for the maximum benefit.  Aim the water just above the gum line for best results.  It’s actually the splash that removes plaque just under the gum line where it starts and flushes it out.

2.  Stay well hydrated
When I was first diagnosed, it seems as if I could drink water all day and still feel dry.   Dry Mouth is the second most common symptoms of Sjogren’s.  Dr. Troy Daniels and Dr. Ava Wu warn against too frequent sipping of water because it can actually make your mouth drier by rinsing out the protective components.  In order to make saliva, you do need adequate fluid intake.  Some experts recommend at least 5 glasses of water per day to replace what is lost during the day.   In hot weather, increase your intake.  Watery foods, soups, juices and other non-caffeinated drinks can also count as part of your needed water for the day.  For caffeinated drinks, only half the total volume counts because of the inefficiency of processing the caffeine.

3.  Replace lost protection:
Stimulated saliva has more minerals than the ambient saliva.  Chewing gum, SF candies, even brushing the insides of your cheeks and lips with a sonic toothbrush can increase salivary output for up to 90 minutes.   Sugar-free doesn’t always mean problem free. 
Choose gums and candies where mannitol is not the primary sweetener.  At a dental conference last year I heard about a dentist who lost an upper molar after sucking on peppermint sugar-free Life-Savers with mannitol.  Some bacteria can metabolize that sugar alcohol much like actual sugar so be careful.
Some products also contain minerals and enzymes which may help to maintain a healthier oral environment.  Some products are primarily slick while others, like Biotene, provide minerals and enzymes to help replace missing components. 

4.  Avoid sugary or acidic food as much as possible
Use a straw!  
Rinse with water for at least 30 seconds to help dilute acids and rinse out sugars. 

5.  Strengthen exposed tooth surfaces
Fluoride-- There is a shift happening in the world of fluoride and in some circles the new standard of care is fluoride varnish instead of traditional fluoride treatments.  These varnishes are painted on the tooth every 3-6 months, depending on the product, and may help stop a pattern of recurring decay between checkups.  The custom trays are great, but for a very dry patient, there may not be enough ambient minerals to effect the rebuilding necessary to prevent further damage. 

MI Paste--MI Paste is concentrated minerals in a mild flavor that has an excellent record of rebuilding tooth surfaces.  The Plus version with fluoride offers a 5:3:1 ratio which is the most effective combination of Calcium, phosphorous and fluoride. The Recaldent™ is a bio-available form of Calcium that maximizes the uptake and can even help rebuild white spots where plaque has begun to break down the tooth.  MI Paste may be dispensed through the dental office, but is also available through dental suppliers or several online sources, including Ebay,  A SSF support group may be able to order it by the case with the support of a local dentist according to a regional manager on the West Coast. 

6.  Alter Oral Chemistry
A.  Xylitol  Some patient can’t tolerate fluoride well, so Xylitol may be a good alternative in their decay prevention program.  I use 6-10 grams of Xylitol per day because of my severe allergies to the food coloring or corn sweeteners in most fluoride products.  Xylitol comes in a sugar like form, in gum, compressed tablets and in some candies.  I prefer the compressed tablets because of the extended exposure time.  The Xylitol from the gum is released in as little as 5 minutes of chewing. 

B.  CHX rinse
Choose alcohol free for less burning on your tongue.  At the conference they recommended one week per every three month period.  Swish it twice a day for 30-60 seconds for best results.  This helps to reduce the number of  bacteria that can cause a problem.
Wait 2 hours before using anything else. 
Repeat as directed by your dentist. 

7.  Improve salivary function—Systemic Medication
If chewing gum doesn’t create much saliva, you might be a candidate for a saliva stimulator, sialogogue.
“Many researchers believe that stimulating the salivary glands using products like Salagen and Evoxac may be protective and preserve secretory functions…there is no convincing clinical evidence to prove that…”  but “…. I recommend that patients begin these agents when they have dryness symptoms or any signs of changed salivary function.”       Dr. Philip Fox  January 2003, The Moisture Seekers, p. 8
{Former NIH Sjogren’s Clinic Director and long-time SSF Board member}
 ·       Take after meals (or with food) to minimize side effects.
·       Start with a low dose:  5mg Salagen (generic = pilocarpine) or 15mg Evoxac (generic, not available yet = cevimeline) at two meals and gradually build up to the full dose over a period of several weeks as tolerated.
·       Allow a minimum of 10 – 12 weeks for best results.
·       Learn about the side effects – that first rush of spit that may be perceived as nausea is really your glands actually work; sweating, etc.
·       If one doesn’t work, try the other.

 Don’t let dry mouth get you down!  Even if you have had problems in the past, with some of the new products you can take control and develop your own program for successful dry mouth management.


Tomorrow, I'll post Ms. Snider's excellent sample letter to your dental professionals, and an oral care product list.

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