Wednesday, October 31, 2012

It's Blowing in the Wind

Anything that I had thought about posting today seems trite and just irrelevant in the wake of hurricane Sandy. 

Watch a real-time animated version of this map here. 

Check out this wind map, found here, to watch a live version of the speed and direction of the wind patterns in the United States. Mesmerizing. I wish I would have found this site on Monday. 

My thoughts and prayers are with this storm's victims....

Tuesday, October 30, 2012

Good Questions from Great Readers

Today's post is yet another installment in the Answer. That. Question! show.

Since these questions were posted publicly on my blog, I'm assuming that the questioners would be OK with me writing a post that includes them. If that's not the case, please let me know and I'll modify the post.

I thought today's questions deserve a less silly format, so just for today I'm going to abandon the studio audience, the voice-over disclaimer guy, and the APPLAUSE sign. Although if y'all feel prompted to clap, please feel free to do so.

I can't imagine why anyone would.

So. Question number one comes from Cindy:

Q: "Your entry from October 26th 2012 was very helpful. Would you be able to do an entry for dry eyes, too?"
A: The October 26th post was titled Oral Care Products as Recommended by a Dental Hygienist. I'm glad that you found it useful. Actually, the information from that post was very generously shared by Laura Strom, MS, LMFT, LPCC and JoAnn Snider, RDH BSDH, so I can't take any credit for that impressive list. I would love to be able to provide a list for dry eye products, so if anyone out there has a professional contact person that would be willing to collaborate with me in creating one, let me know!

Question number two:

Q: Heidi asks, "How are you doing this week post the infusion?"
A: I'm slowly recovering my energy levels and am right about where I expected to be at this point based on my experiences following my first cycle of rituximab. I was able to go for a little drive-wherever-we-want-to vacation last week and managed that surprisingly well. Thanks for asking!

Question number three:

Q: This from Cynthiane: "......Jump forward to fall of 2010 and I start having the strangest symptoms. Dry mouth. Tongue sticking to the roof of my mouth and having to peel it off in the mornings when I got up. Not being able to chew food without a drink of water. The sides of my face were swollen, my lymph nodes were all swollen in my neck and under my arms. So, now the doctor says I have Sjogren's, which I had never heard of. Then, BAM!, test comes back I have Hashimoto's. Last winter I start noticing my hands are funny colors and I can't hold anything cold. Doctor says I have Raynaud's. Then my hands get nodules on the joints, both hands, then my feet, too. Pain is miserable. No great surprise here, Rheumatoid Arthritis has come to join the great autoimmune party going on inside my body.
Throw in some glucose intolerance and some GERD and that completes the picture. I'm wondering if you have any advice or ideas? I don't suppose there is anything I can do to keep further illnesses at bay? Thanks! Sign me TIRED of feeling TIRED."
A: Oh, girl. First of all, know that all of us here know exactly what you mean when you identify yourself as "TIRED of feeling TIRED", and that we completely empathize with your situation. We have all been where you are and it's not fun. So here's a virtual group hug from me and everyone else on Reasonably Well. As far as advice or ideas, I think that one of the most important thing that a sjoggie can do is to become his/her own advocate in his/her health care. You can do that in several ways, the first being to become as educated and informed about your disease as possible. There's lots of great resources out there; check my sidebar for links to Sjogren's related information sources such as The Sjogren's Forum, The Sjogren's Syndrome Foundation, and The American Autoimmune Related Disease Association. It's also important for you to connect with others that are dealing with autoimmune disease. Sometimes we feel so isolated since many health care providers aren't familiar with the diagosis and treatment of autoimmune disease such as Sjogren's.  I'm glad that you have found Reasonably Well, but there are several other great sjoggie blogs out there. Check my side bar under the LINKS section. (If anyone has read sjoggie blogs that aren't listed there, please send the links to me and I'll be sure to add them to my list.) Additionally, I have found an incredible amount of support from members of the Sjogren's World Forum, which is a very active message board with a fantastic group of moderators. Check it out. The questions asked there are ones that I and others have wondered about many times, and the answers that are given from others very useful.

About my sidebar items: If you are viewing Reasonably Well via a mobile reader, like your cell phone, my sidebar does not appear. To see the list of links, you can do one of two things: scroll to the bottom of the page and click "View web version", or read Reasonably Well on a computer.

Well. Alrighty then. Cut to commercial -- this episode is OVER. See y'all tomorrow.

Monday, October 29, 2012

Diagnostic Saliva

Image found here, which is a fascinating comparison of saliva beading to inkjet printing. 

Thanks to Annie for sending me a link to this story found here:
"In a special supplement to the Journal of the American Dental Association, Dr. David Wong, the associate dean of research at the UCLA School of Dentistry, details the latest progress in the field of 'salivaomics' — the study of the genes, proteins, DNA and RNA contained in saliva — and how dentists may be able to use salivaomics to not only diagnose diseases in their early stages, but also monitor the progress of treatment and predict the possibility of recurrence..." Continue reading here
Interesting. Using saliva constituents to diagnose not only oral/salivary gland problems, but to potentially also diagnose and monitor other body-wide significant diseases? Brilliant.

You can read Dr. Wong's full paper entitled Salivaomics and published in the October 2012 issue of JADA here.

Dr. Wong has also written an excellent article on the same topic which appeared in Dimensions of Dental Hygiene, here.
"Imagine the benefits of being able to monitor health status, disease onset and progression, and treatment outcomes through noninvasive means. Salivary diagnostics could turn this possibility into a reality. A national initiative promoted by the National Institute of Dental and Craniofacial Research (NIDCR) has created a roadmap to turn saliva diagnostics into a clinical reality. Oral fluid is a perfect medium in the exploration of health and in disease surveillance. The clinical applications and opportunities are enormous." 

Sunday, October 28, 2012

Sealed With A...............

Yesterday, after posting my elephant seal pictures, I received lots of cautionary emails that all went something like this:

ARE YOU CRAZY, WOMAN?! You shouldn't have been on the beach with elephant seals! Those things are DANGEROUS! And it's not good for THEM when you get so close, either!

Excellent points, guys. You're right -- nobody should get close to wild seals. And I'm glad that y'all were concerned for my safety. However....

Here's how this interesting photo shoot actually went.

John and I were meandering our way north on California Highway 1, enjoying the leisurely drive. Awhile after we passed the Hearst mansion, I noticed several cars in a parking lot next to the beach. I pointed this out to John and he obligingly pulled over as I dug around in all the junk piled on Goldie's back seat and grabbed my camera.

The beach area was fenced and lined with walking paths and informational signs.

Cool! It's an interpretive site for elephant seals! I exclaimed.

John and I walked along the path, reading the signs and peering over the fence hoping to see one or two seals.

 See? Safe behind the fence. And that's where I stayed, cross my heart and hope to die. 

I see one! I see one! I shouted, and zoomed in using the telephoto lens on my camera. Click click click click click..... Love that thing.

Awwww! He's so cuuuuuuttttteeeee! Wish there were more.....

John laughed and pointed to the southern edge of the beach. "Look over there, Babe."

What? All I see over there is lots of hunks of driftwood, I commented as I brought my camera up and zoomed in on what I thought was beach debris.....

....then gasped with surprise when I realized that the beach was strewn with zillions of blubbery SEALS.

Wowsers! I zoomed and snapped to my heart's content, thinking that I just couldn't wait to download these pictures and get a closer look at them. I spotted a cluster of five critters snuggled in against each other. What a cozy looking scene! How My heart melted. Awwwwwwwwww........ I zoomed and snapped some more.

Afterwards, we hopped into Goldie and made our way up the coast. Later that evening after we checked into our hotel, I grabbed the cables and eagerly downloaded that day's worth of photos. Look, John! Check these out! I grabbed John and pulled him over to my laptop, then clicked over to the pictures that I had expected to be the best of the bunch -- the ones of the snuggling stackful of seals. I frowned and examined the picture more closely.

Wait.....was that.....was that SEAL SNOT?! We burst into laughter. Because, after cropping the picture and zooming in even more.......

Oh, brother. 

......we determined that, yes. Yes, indeed. I had a fabulous picture of piles of snotty seals. Actually, I had oodles of pictures of this particular goobery gang.


It was a good thing that I took zillions of pictures of this....herd....or whatever you call an enormous group of seals. Because there were luckily several other photos of seals with much cleaner noses.

I think tidy seal schnozzles are much more attractive than snotty ones, wouldn't you agree?

 This little guy was my favorite. 

At some point, the mucous-y group must have somehow cleaned up their act, (and I think I really don't want to know how a seal blows his/her nose) because after anxiously scanning all bazillion of the photos, I did find this keeper:

So. To summarize: Julia -- safely behind the fence. Seals -- Snotty and on the other side of the fence.

And now you know the rest of the story.

Saturday, October 27, 2012

We've Been Galavanting

Yep. I took all of these pictures this week. Love my telephoto lens, betcha those elephant seals would be been cranky if I would have gotten close. Not that I would have tried. They all had fish breath. 

I'll explain tomorrow. 

Friday, October 26, 2012

Oral Care Products as Recommended by a Dental Hygienist

Image found here.

As promised, here's a list of oral care products as recommended by JoAnn JoAnn Snider,  RDH, BSDH.

Thank you for this extensive list, Ms. Snider!

Product suggestions with key ingredients, manufacturer and contact info, and in some cases, where to buy for the best pricing.  

Some of the products have money-saving coupons available at their website so be sure and check first.  Online sources also may have special deals so check around:; are two such suppliers.  I have no financial interest in any site or product in this guide, although Oasis rinse (at the item a GSK product) and Diiachi have provided support for speaking at a prior dental hygiene conference and my trip to Philadelphia last year to be interviewed on camera for Evoxac.

Note:  Some mint flavors are quite strong and may be unsuitable for patients with a super dry mouth.  These are indicated by the M++ for strong mint, M+ for medium, and M for mild.

Bad breath:
Transient relief:
Sugar-free gum or candies (avoid Mannitol if at all possible) –Mint varies by product
Listerine breath strips or spray (M++ Mint or cinnamon)
Specialty products made for bad breath management:
Breath-Rx {M+} – Gum, toothpaste, or rinse; []
Clo-SYS {M} –Toothpaste;  Rinse  (add flavor or not; it’s your choice); Spray; Gum {M+}
Buffering Agents--OTC’s:
MI Paste (available through dental suppliers or online) – Use every 3-4 hours as directed.
                Assorted mild fruit, vanilla or very mild mint.  []
MI Paste Plus:  minerals and fluoride; use twice a day;   Assorted mild fruit, vanilla or very mild mint.
Nuvora Salese:  Xylitol, pH buffering; Peppermint M+++, Spearmint M+, and Lemon
[ or 1-877-530-9811]
*Special pricing for orders through a dental office
Sodium bicarbonate rinses: 

Buffering Agents by Prescription:
CariFree Rinse {M+}:  Xylitol, Sodium Fluoride, pH buffered with baking soda []
Numoisyn (see Dry Mouth Lozenges by Prescription only)
NeutraSal :  Buffers acids for normal pH with calcium phosphate; promotes remineralization;
Note: Each prescription comes with a Sjögren’s  support kit with Omega-3 supplement for dry mouth and dry eyes, and Xylitol gum.
                 [ or 1-866-963-8881]

Dry Mouth Gels:  OTC’s
MedActive Oral relief gel:  Spilanthes Extract, Xylitol;
Oral Balance:  minerals, enzyme complex;  []; coupons:  []
Oragel:  glycerine, sucralose, sorbitol, proprietary antioxidants; unflavored []

Dry Mouth lozenges: OTC’s
MedActive Oral Relief Lozenge: Xylitol, fruit flavors [ or 1-866-887-4867]
OraMoist:  Xylitol, enzymes and mild citrus flavor [ or 1-800-448-1448]
Salese from Nuvora; Mild lemon or Wintergreen [ or 1-877-530-9811]
*Special pricing for orders through a dental office
Thayer’s Dry Mouth lozenges:  Slippery Elm, Apple pectin, lemon flavor, Sorbitol []
Thayer’s Slippery Elm lozenges:  Cherry, Tangerine, and unflavored []
Theramints:  compressed Xylitol, Mint or Fruit[3M ESPE;] available through dental suppliers at a discount or online]

Dry Mouth lozenges: Prescription only
Numoisyn:  Tablets contain sorbitol and malic acid to stimulate normal salivation; sugar free and buffered with calcium to protect teeth; []

Dry Mouth Liquid:  Prescription only
Numoisyn Liquid:  Linseed extract; similar viscosity to that of natural saliva; can be used in conjunction with chlorhexidine without impairing the antibacterial effects ; extended relief;  []

Dry Mouth Rinse:  OTC’s
Biotene:  Minerals and natural enzymes for reduced inflammation; mild mint flavor []
Biotene PBF:  Extended action with special enzyme complex to reduce plaque and mineral deposits by up to 91%; green label; available at most drug and grocery stores []
Oasis:  Glycerine
MedActive Oral Relief Rinse:  Orange Crème and Ruby Raspberry flavors; Spilanthes Extract; Xylitol;

**Other alcohol-free oral rinses in mild flavors:
Tom’s of Maine “Cleansing” rinse:  Spearmint (M) []

Dry Mouth Sprays:  OTC’s
MedActive:  Xylitol, Orange Crème, Ruby Raspberry, Butterscoth, Vanillamint, Lemonade;
available online from multiple sources []
Oral Balance Spray:  minerals, enzymes; carried by most drug stores and large retailers
Rain:  Xylitol, Aloe Vera, glycerin; available online and many health food stores []
Thayer’s Dry Mouth Spray:  Xylitol, glycerine; lemon or peppermint []

Dry Mouth Toothpaste:  See “Toothpaste”

Floss that is soft and gentle to gum tissues:
Reach Gentle Gum Care
Reach CleanPaste dental floss

Fluoride, brush-on:  By prescription
Clinpro 5000 Plus toothpaste; 1.1% NaF, Vanilla-Mint is very mild and well tolerated. [3M ESPE]
PreviDent® 5000 Booster (1.1% Sodium Fluoride) M+
PreviDent® 5000 Plus toothpaste or gel;  1.1% NaF, Fruitastic; preferred to mint by many patients
PreviDent® 5000 Dry Mouth – Mint (M++) (Try Enamel Protect instead!)
PreviDent® 5000 Enamel Protect:  Milder flavor  (M)   
  More information on Colgate®  fluorides:  []
ProDentRx 5000; cool mint, berry fresh, and citrus splash. [Zila]

Fluoride for custom trays:  OTC
Gel-Kam .4% stannous fluoride, Fruit & Berry flavor

Fluoride for custom trays:    By Prescription
Denti-Care 1.1% neutral sodium fluoride gel
Denti-Pro Gel (1.1% Neutral Sodium Fluoride)
Omni .4% Stannous Fluoride, 12106N Natural Flavor
Prevident gel:  Mint (M+), Fruitastic;

Fluoride Rinses: OTC
ACT Restoring rinse or ACT Total Care:  alcohol-free;  []
ACT Dry mouth rinse:  Fluoride, Botanicals to soothe dry mouth;  alcohol-free; dye-free []
   Use alcohol-free ACT  twice a day if decay-free.
Phos-Flur from Colgate:  Mint; Kid flavors, Grape and Bubble Gum are alcohol-free; []
Tom’s of Maine (Kid’s) “Juicy-Mint” (alcohol-free and dye-free);  glycerin, sodium fluoride; []

Fluoride Rinses:  By Prescription
CariFree .05% NaF with Xylitol—complete care system []
CaviRinse .02% NaF, weekly rinse [3M ESPE]
ProDentRx .63% SnF in Cool Mint, Berry and Citrus [Zila]

Fluoride Varnish:  By Prescription
  All go on white and are reapplied 3-4 times a year for best results except as noted.
Cavity Shield [3M ESPE] Bubblegum; Sodium fluoride; Ideal for Primary teeth or sensitive folks
Duraflor Halo [Medicom}, Mint, Berry, Bubblegum;
EnamelPro w/ACP [Premier]; Bubblegum, Strawberry;
MI Paste Varnish [GC America]; Strawberry; goes on white; bioactive Recaldent and minerals included; ideal for dry    mouth where adequate minerals may not be present;  []**New, January, 2012
Prevident; Raspberry; Clear; Colgate; 2-3/year
Vanish; [Omni 3M ESPE ] Cherry, Melon, Mint; goes on Clear; 2-3/year.
UltraThin; Melon or mint (M+); goes on Clear; WaterPik;
Reduce bioburden:   OTC’s
Xylitol (where it is the primary ingredient in gum or candies)—See Xylitol listing

Reduce bioburden:   By Prescription
Alcohol-free Chlorhexidine Gluconate Oral Rinse USP, 0.12% from GUM®
--New SSF recommendation:  Twice a day for 1 week every three months in at risk patients. (4/20/2012)

Toothbrushes, battery powered with replaceable heads and batteries:
Oral B: Oral B/Braun; 8000 strokes/minute; oscillating head reduces gum trauma. Requires approximately 180 grams/cm2 to remove plaque
Sonic Spin-Brush [Arm & Hammer, 16,000 strokes/minute; replace head every 3 months]
Spin-Brush [Arm & Hammer, 6000 strokes/minutes; replace head every 3 months] Both require 180 grams/cm2 to remove plaque
Sonicare (basic unit with 31,321 strokes/minute); replacement heads are pricey compared to the Flexcare heads
Requires 80 grams/cm2 to remove plaque

Toothbrush, electronic/rechargeable:
Flexcare Electronic toothbrush: with or without the ultraviolet light sanitizer unit; least expensive heads of any Sonicare
31,321 strokes/minutes; requires 80 grams/cm2 to remove plaque
Oral B Triumph—Round head; oscillates; must dissolve out old toothpaste residue for best results
31,000 strokes/minute; requires 180 grams/cm2 to remove plaque
Sensonic from WaterPik (no indication on pressure required)

Toothpaste for Dry Mouth:
Biotene Regular—blue label; improves inflammation; enzymes and minerals []           
Biotene PBF – green label; 12 hour anti-plaque enzyme complex []
Tom’s of Maine:   Mild flavors well tolerated:  Silly Strawberry or Orange-Mango for kids []

Toothpaste for sensitive teeth:
Biotene Sensitive: Mild mint, Xylitol, enzymes and minerals []
Pronamel  Isoactive:  Mint; better than Sensodyne for mildness []
Tom’s of Maine Toothpaste for Sensitive Teeth:  Mint (M+)

Toothpaste for patients with frequent canker sores: 
Biotene or Biotene PBF
Rembrandt Canker Sore formula SLS-free formula
Tom’s of Maine “Clean and Gentle” SLS-free formula

Toothpaste for patients sensitive to Fluoride:
Tom’s of Maine Fluoride-free in Silly Strawberry []
Tom’s of Maine Fluoride-free Anti-Plaque and Whitening:  Mint []

“Water Flosser”
WP-100 (smaller footprint on your counter top; more tips to choose from); WP-60 (basic model)
WP-300 Small travel size in carrying case; WP-260  Children’s version (which I use for traveling)
WP-360, WP-450 Cordless or rechargeable hand held units
NEW**Shower Floss (coming soon)—cradle attaches to shower head; rechargeable.

Xylitol Products:
Compressed Tablets:
  Spry:  Assorted flavors,
  Theramints, 3M ESPE:  Fruit, Mint (M) []
  Xylimints:  Lemon; Licorice; Chocolate; Peppermint M+. etc.; Made in Finland;  Distributed by Tundra Trading Company, Glendale, CA  800-505-3895 and available online or at a number of retailers.)
   XylitolUSA:   Assorted flavors; Made in USA;  []
   Xyloburst:  Strawberry, Lemon and Mint []
Gum –  Chewing longer than 10 minutes does not provide additional benefits.
   Biotene:  Xylitol, minerals, bacteriocidal enzyme, mild mint. []
   MighTeaFlow:  Green tea, Xylitol, Glycerine []**new product; highly rated at the SSF conference!
   Spry:  Xylitol, mint or fruit flavors []
   Theragum:  – no longer available for sale even though it’s listed in the SSF product guide
   XyliChew:  Assorted flavors including Licorice; .8 grams Xylitol per piece; Made in Finland; Distributed by Tundra     Trading Company, Glendale, CA  800-505-3895 and available online or at a number of retailers.)
   Xyloburst:  Spearmint, Peppermint, Green Tea, Cinnamon and Fruit []
   XylitolUSA: Assorted flavors; Made in USA;  []
  Salese [] – Lemon, Spearmint; Xylitol delivery; Peppermint (M+++)

Prescription information for Medical and Dental Professionals:

Oral Candida:

Dr. Fred Vivino’s treatment for oral Candida:
Treatments- *Fluconazole (Diflucan®) 100mg daily for 14 - 21 days
Clotrimazole (Mycelex®) vaginal troches 5x/day x 21 days
*Other oral troches and Nystatin rinse has excessive amount of sugar contraindicated in dry mouth patients.

Angular chelitis from Candida alone:
OTC: Miconazole cream; Clotrimazole cream
Prescription: Nystantin, or Ketioconazole cream

Angular chelitis from mixed infection: Candida and Staph. Aureas
Topical Miconazole Nitrate 2%;
 Hydrocortisone 1%-Iodoquinol 1% topical cream

CariFree:  866-928-4445 | – Call or email for details please!
This protocol fits into the CAMBRA program with pH testing and preventive products. (more information and recent studies)

Rx:  Evoxac 30mg
Disp:  90 (for 1 month)
Sig:  1 capsule three times a day, preferably with meals
Refills:  12

Rx:  Numoisyn Liquid
Disp:  300 mL per bottle.
Sig:  Shake bottle well. Take 2 mL (about 1/2 teaspoon) of Numoisyn Liquid and rinse
around in the mouth before swallowing. Use as needed.
Refill:  12

Rx:  Numoisyn Tablets
Disp:  300
Sig: Dissolve 1 by mouth as needed for dry mouth several times a day
Refill:  12

Rx:  NeutraSal®
Sig:   2-10 times per day or as needed for dryness from Sjogren’s Syndrome
Dissolve in 1 oz tap, distilled or bottled water; Use immediately after the solution appears clear or nearly clear. Swish half for 30 seconds and spit out; repeat with the second half and spit out.
Disp:  10 boxes of 30
Refill:  4 times
**Ask about their “No Patient Left Behind” program to cover patient co-pay or one month free for patients without insurance coverage.  1-866-963-8881

Laura Strom clarified this list:
"I believe Evoxac became a generic about 3 weeks ago. Also Biotene was bought by a larger company and discontinued about 2 months ago."

Thursday, October 25, 2012

It's Still Alive......

The seriously informative post promised for today just isn't happening, people. For a variety of reasons, one being that I am forced to use my phone app yet again.

In the meantime, here's a question for y'all.

Remember these? Anyone remember what they're called? Anyone want to hazard a guess what happened when I opened up a box of my daughter's stuff and it TALKED after a zillion years of being stuffed in a dresser drawer?
Yeah. It did. And yeah, I DID.

Wednesday, October 24, 2012

A Dental Hygienist's Letter to her Personal Dental Care Team

Xylitol and Green Tea gum found here

As promised, here's part two of the excellent information provided by JoAnn Snider RDH, BSDH; Sjögren' s Advocate; patient, Speaker, and Author. This is a copy of the letter that she composed when dealing with new dental care providers.

I especially appreciated the section in which she emphasizes the fact that even those sjoggies conscientiously performing meticulous care of their teeth can have dental problems. How many of us have been given THE LECTURE about proper oral care after a dental exam?

Feel free to edit this letter for your own use since Ms. Snider has generously added this to her email: "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."
Dear Dental Team, 
I am a dental hygienist with Primary Sjögren's Syndrome. There is no lecture that can convey the frustration and discomfort of a Sjogren’s-dry mouth, but it is a very common symptom for Sjogren’s patients. Normal flavors can burn or sting. We know that enamel breaks down when the pH drops to 5.5, but exposed root surfaces may demineralize at 6.5. The pH of plaque is only 2.5, so it’s no wonder that Sjögren's patients can get into trouble so easily. 
Patients can do everything right, and still may not have the right results. The new CariFree kit or GC America’s Saliva Check kit or even pH paper can be valuable tools in your office to help determine which patients are the most at risk from acidic saliva or extremely low volume.  Any very dry patient needs to be on an aggressive prevention program to maintain their teeth. This letter is a summary of the steps that are working for me and my patients with severe dry mouth.  
According to Dr. Troy Daniels and Dr. Ava Wu, of the SICCA Sjögren’s study at UC San Francisco, sipping water too frequently can actually dry out the mouth so ask your patients not to overdo it. I’ve seen patients who literally had their teeth turn to chalk and break off at the gum line in as little as three months with too frequent sips of water. The fine line between enough and too much is difficult to determine, so suggest sipping water to help with swallowing, eating, and counteracting what I call “Velcro Throat,” and then an oral moisturizer like Oral Balance, or sugar-free gum after drinking water to replace minerals and enzymes that were rinsed away. We don’t use water to moisturize dry hands, so it makes sense that water won’t be as good as saliva for our mouth either. 
Prescribe and construct custom fluoride trays for patients who have uncontrolled decay. According to the SSF Handbook, they should be worn for five minutes a day until the patient has at least one year of decay-free exams. I’ve listed several mild or unflavored fluoride gels to use with the custom trays on the enclosed product sheets.  
For some a fluoride varnish may be superior to the trays.  Fluoride varnishes are being reinvented with new white or clear products that are well accepted and effective when fluoride trays are not working well. The patient can expect 3 - 6 months of decay prevention from each application.  We have seen a dramatic improvement in cases where fluoride trays didn’t seem to be working.  MI Paste’s new varnish contains not only the necessary fluoride but the bio-active Recaldent to provide essential minerals for optimal benefit in your dry mouth patient.  
If your patient has acidic saliva or severe dry mouth, MI paste has excellent buffering capabilities, with a half-life of three hours to help restore oral pH and protect teeth. Applying a pea-sized dose every 3-4 hours will reduce acid damage and may restore white spot lesions. For longer action, a bleaching or fluoride tray can be placed over the teeth to hold the MI Paste in place longer. Dispensing it through the office makes it easier for patients to comply. It is available from most dental suppliers.  There are also several other choices available for pH buffering like Cariostat and NeutraSal, mineral solutions, or even a baking soda rinse several times a day. 
More frequent hygiene visits and a little encouragement may also very helpful.  When I speak to patient groups, they report that they receive blame and recriminations most often.  They can do everything right and still not get the right results until we find the correct balance of treatment and maintenance products to manage their decay problems. 
If your patient has normal saliva, just not enough, have them increase saliva production by sucking on sugar-free candies, cough drops or chewing sugar-free gum several times a day. I keep some sugar-free cough drops in my drawer and give out samples to patients to remind them to avoid hidden sugars. Stimulated saliva contains more minerals to neutralize acids and to provide for tooth repair.   
Products with Xylitol provide additional benefits by interfering with the metabolism of Strep. mutans group which makes them less sticky, and by reduces the overall bio-burden. Xylitol is added to several brands of gum but can also be purchased with higher concentrations from 3M ESPE, or from the Spry. A therapeutic dose is 6 – 10 grams a day.  Patients should be instructed to start out slowly when adding Xilitol since it can have a laxative effect in excess.  Studies show the compressed tablets provide the most benefit, but other products can be very useful as well.  Nuvora’s Salese is just one of the Xylitol delivery systems.  The Xylitol green tea gum was a big hit at a recent national Sjogren’s Syndrome Foudation meeting both for it’s good flavor and the restoration of a more normal “feeling”.  
Any battery operated toothbrushes may give additional efficiency on gum line plaque for patients who can’t afford the expense of the electronic brushes. Power toothbrushes provide more strokes per minute which also increases the patient’s effectiveness, and require less pressure against the side of the tooth which can reduce tooth sensitivity and abrasion.  Sonicare is the least abrasive of those available.  Bump up the patient’s home care program. I use the new Flexcare from Philips and add another 30 seconds at the end to brush my palate and the inside of my lips. This stimulates increased salivary output for up to 90 minutes, and a significant increase in the mucin and proline-rich glycoproteins that provide the relief from dryness that we crave.   
Soft floss like Reach Gentle Gum Care may be more comfortable than regular floss, and can remove more crevicular plaque than waxy floss. For non-flossers, Water Pik studies show that their oral irrigator is two times more effective than string flossing. If your patient is only willing to make one change, a new WaterPik Water Flosser is gentle and more effective than anything else. Aim the stream at the tooth near the gum line for best results.  I use my Water Flosser before brushing to maximize the effects of my special Biotene PBF toothpaste. 
Recommend oral moisturizers to help with the dryness symptoms and increase acid control. In general the rinses provide transient relief, the gels last longer and give more relief for the money.  Prescription Numoisyn liquid is also good for night time use. 
Consider prescribing a sialogogue, like Pilocarpine (Salagen) or Cimeviline (Evoxac.) According to Dr. Phil Fox, former Director of the NIH Sjogren’s clinic and Past-Chairman of the SSF Board, “the jury is still out on whether these drugs can improve the function of the remaining salivary glands, but the benefits of increased output is significant and reduces overall risk of decay.”  Pilocarpine has a half-life of 1-2 hours, while Evoxac’s is 4-6 hours.  I’ve been using Evoxac since it was first introducted over 10 years ago.  Before prescribing Evoxac, check with the patient’s physician to rule out any contraindications, like uncontrolled asthma or some types of glaucoma.  Request samples to dispense in your office by clicking the “Request samples” at or call  1-877-437-7763 for more information. 
Using a thin ultrasonic tip on a lower setting to de-plaque your Sjögren's or other dry mouth patient reduces gum trauma and increases patient comfort. I love the oscillating prophy angles too. Because they don’t rotate, they don’t scuff gums and can’t overheat the tooth. I also keep several low-abrasion mild non-mint prophy paste flavors on hand for dry mouth patients who are sensitive to mint. 
To reduce the overall bio-burden, treatment with a non-alcohol Chlorhexadine rinse one week every three months may be helpful according to the latest recommendation from Sjögren's Syndrome Foundation.  Avoid the alcohol version since alcohol is drying.  Even as a hygienist, I couldn’t stick with Peridex for the whole week because it was too painful to use.  
When you treat any dry mouth patient, you may wish to ask if they have any other symptoms like joint or muscle pain, dry eyes, or  unexplained fatigue or systemic involvement that could be indicative of Sjögren's  Syndrome.  Obvious oral symptoms include no pooled saliva, red fissured or cobblestone tongue surface, frequent oral yeast infections which present with burning and redness, or rampant decay even with good oral hygiene.  Getting a patient diagnosed and treated sooner may reduce the overall severity of their disease.  
Check out the Sjögren's Syndrome Foundation website [] for more information on dry mouth including free Dry Mouth brochures for your office. I am a professional member and enjoy their quarterly professional journal that has great articles by experts in Sjogren’s research.
Recommend joining the Sjögren's Syndrome Foundation to your Sjogren’s patients.  The Moisture Seekers, a monthly newsletter, is full of articles on living with this disease, and helpful hints for improving quality of life issues written by experts and patients. To find out more about the SSF go to their website or call them at 1-800-475-6473. 
Sincerely yours,

JoAnn Snider,  RDH, BSDH; Sjögren' s Advocate; patient, Speaker and Author
Interesting. I didn't realize the degree of usefulness for Xylitol containing products.

Tomorrow's post will cover JoAnn's oral care product list.

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.