Februari 21, 2017
hello, i'm norman swan.welcome to this program on oral health. we're coming to you across australia through the rural health educationfoundation's satellite network. tooth decay and gum disease -dental caries, periodontitis - are two of the most prevalentand preventable illnesses in australia. about 50,000 australiansend up in hospital each year for dental conditionsthat could have been prevented, not to mention the hundredsof thousands of people disabled by their teeth problems -
unable to eat properly, malnourishedand everything else that goes with it. we'll look at what these diseases are,how they develop and what can be done to prevent them. we'll also focus on specialcircumstances faced by people living in rural and remote areas, where the dental-workforce shortageis particularly acute. therefore, it's you the generalpractitioner who's got to cope. there are a number of useful resourcesavailable on the rural health educationfoundation's website:
let me introduce our panel. marc tennant is director of the centrefor rural and remote oral health at the university of western australiain perth. - welcome, marc.- thank you, norman. bruce simmons is a dentist who's beenworking in government dental services, one of the few. let's hope it's a growing number. - more than 30 years, is that right?- that's true. in alice springs. welcome, bruce.
thank you. debra parke-bryant is a dental therapistand dental hygienist from mildura in victoria. welcome, debra. angela masoe is the oral health programscoordinator for the greater southern areahealth service in queanbeyan, nsw. welcome. last and certainly not leastis elizabeth dodd, a rural doctorand amateur dentist par excellence
based in griffith, new south wales. - welcome, elizabeth.- hi. you're looking uncomfortablewith that title i just gave you. many dental storiesfrom years in general practice? not from dental practice. norman: in general practice, sorry. but from years doing workin remote australia in places like cloncurry. my definition of remote is where youfill in for the dentist and for the vet.
norman: and fill in for the teethas well, perhaps. what dental procedureshave you had to do as a gp? i've done an extraction on someone who had actually broken a toothon a rib bone. i seem to remember you had to work outwith the figure of 8 movement, and all sorts of movements,for different teeth, to get them out. no, the worst problemwas getting a decent anaesthesia. so you could work it outwhile they were numb. what does a dental hygienistactually do, debra?
a dental hygienist will diagnose,under the supervision of a dentist, gum disease,and can treat patients of any age. we do non-surgical treatmentof gum disease - scaling and cleaning. and generally the oral hygienist,i consider the most important part, teaches patientshow to look after their mouth and take care of themselves,making sure they keep healthy - diabetes and understanding the problemsthat make gum disease worse and the connection betweengum disease and other health issues.
for example, dry mouth can be an issue.those sorts of things. we need to educate patients how bestto manage their dental situation. a holistic dentist is a personwho treats the whole tooth, and you treat the whole mouth. we're looking after the gum part.the dentist is looking after... glad to see the whole person features. angela,what does a dental therapist do? a dental therapist treats childrenfrom 0 until they turn 18, prominently in a public system,but we can now work in private practice.
norman: it varies from state to statein australia? it's different, yeah. we can do examinations,diagnose and treat, for example, do restorations,extractions of primary teeth. if you're competent,you can take out permanent teeth. norman: how do we knowif you're competent? we have all the site practiceunder the guidelines of the dental act. is there anything you can't do? we refer surgicalsand orthodontic treatment.
we concentrate on the prevention sideof the business. norman: things like fissure sealants. fissure sealants, oral-health promotionin communities, et cetera. how much does it vary across australia,what a dental therapist can do? there's only actthat is a little bit different, in that they can't take outpermanent teeth. marc: there are some other variations. it's a really problematic situation. but an important one, because it's oneanswer to the dental-workforce problem,
particularly in rural australia. absolutely. what we'll seeunder the new coag activities about unification of qualificationsaround the country will flow over into dental therapistsand dental hygienists, and we'll see some sensible situations. we've got situations wheredental therapists working on the border between victoria and new south wales have to do different thingsten minutes apart.
they're not allowed to do somethingten minutes from another place. norman: even though they're trained? trained,and competent in one jurisdiction. in another jurisdiction,they say, 'you can't do that.' what dictates that, the powerof the australian dental association? no, dental is under state acts. we actually need to get coordinationbetween state acts to do that, and that is a very long journey. give me a sense, as a consumer,of comfort.
surgical,if you need a general anaesthetic, you'll bailto a general-practitioner dentist. but what can the dentist dothat you can't in terms of scope of practice,competency and so on? a lot more. norman: you've got to say that,otherwise bruce will beat you up. we can do a pulpotomy - the coronal partof the tooth, we can remove that. but we can't do a root-canal treatmenton a permanent tooth, is a classic example of what therapistscan do and can't do.
if we expose the nerveof a permanent tooth, we will refer that to a dental officerfor root-canal treatment. or... norman: what about bridges? definitely not. no fixed bridges or crowns, fixed crowns or things. it's really not very much practisedin children's dentistry anyway, but it's not partof the therapist's training. that's the key thing, is,what training have therapists received.
norman:you can put in a nerve block? yes. and we can take impressionsfor mouthguards and take an impression for a dentistto do an appliance for them. but we won't do the appliancefor the client, but we can take the impressionof the mouth. where you're going, norman, is,with a crisis in our workforce like in all health professionsat the moment, the opportunity to extend, to reshape what dental therapistsand dental hygienists are doing
are certainly there, and are agenda items to fixsome of the crisis we're facing. may as well talk about it nowsince we're talking about it. what are the dimensionsof the problem... elizabeth, how many dentistshave you got in griffith? - six.- that's not bad. no, they're looking after 60,000 people. one thing you should say,it may be a long-term solution, but in the short-term,there aren't many hygienists around.
there's only been a couple of trainingschools around for long in australia. therapist numbershave been allowed to run down up until the last few years. it's not as thoughthere's an instant solution. they're waiting for work. debra: and like the dental force,we're ageing. - we're not going to be here forever.norman: no, no, no. so for the time being, presumably you face the problem
that public dentistry is inaccessible -huge waiting lists. it is inaccessible,unless you're under the age of 18. just to give you an idea, norman, in the year 2000,we were training less dentists - sorry i'm... - less dentists than we wereat the end of world war ii, in absolute numbers,forget the population. we'd got to a crazy situation. the same situation happenedwith therapy,
and hygiene is relatively smallin numbers. we got to a situation wherewe were licking the iceberg on the poop deck of the titanic. finally we decided to actuallydo something. we've now increased numbersin the existing five dental schools... - ..and therapy schools.norman: there are new schools as well. we've opened up four new onesin australia, three of which are locatedin rural and regional australia. how long before you see the effects?it's a five-, six-year program?
the other thing, just on quality,before we get on to... we're going to get on to the meat here -caries and periodontitis. don't go away. on quality,dentists don't do a residency year. they don't do a registration year. any medical graduate watching knowsthat they were qualified for nothing when they walked out of medical school. you'd have to assumethat the average dental student has done one crown or two crownsas part of their training,
so what are they qualified for,and how good are australian dentists if they're not doinga registration year? the first thing to say is, because we at schools knowwe don't have a registration year, it means the training they haveduring their five years is differentto what a medical student has. in fact, it's a real bonus. a final-year dental studenthas to treat a cohort of patients. mathematically, we knowthey're equivalent to about half
of an employed dentistas a dental student. it's almost like a registration yearin final year? absolutely. what you can do thenis place these students in locations under supervision,and get care happening. norman: is it the samewith dental therapists in training? we do two weeks out in the fieldwith the bachelor. now, it's a bachelor of oral health. norman: how do you getyour in-practice training to know you're competentafter you've graduated?
during our training course, we're working in dental hospitalsin a clinic setting. we're under supervisionin a clinic setting during our training. marc: very different to medicine. the majority of new dentist graduates go looking for supportive practicesto begin with. norman: they don't want to be treated as slave labourin their first job? - they want a mentor.- they do, exactly.
we might come back to workforce issues,but let's get down to business. for the gps watching,you'll have to deal with some of this and look in people's mouths,as you are, i'm sure, as we speak. marc, what's caries? caries is one of the two majorconditions that is dentistry, really - caries and periodontal disease. caries is a condition of the destructionof tooth substance. most of us think of teeth like pieces ofconcrete embedded in our mouths. they're not actually like that.
the surface of a tooth and your salivaare in a balanced ionic environment. the ions in your toothcan actually move out into your saliva. norman:it's like your bones - dynamic. it's a dynamic environment. the beginnings of dental decay is a situation where the environmentis tipped towards the ions moving out. the surface of your toothstarts to be demineralised. with that demineralisation, you startto see the tooth surface become white. norman: let's go through that process.here's a graphic illustration of it.
what tips that balanceis the environment in the tooth, what you've created -bacteria, carbohydrate, plaque. marc: sugar and acid. fundamentally, it's the acid processthat bacteria make from sugars that drives the ions outof the tooth surface into the saliva. you start to acidically eat awaythe tooth surface. from there, you get bacterial infection. the bacteria then drives the cyclefaster and faster and faster. debra, where do cariogenic bacteriacome from?
my understanding isthat a baby is born with a clean mouth. these bacteria, basically, yes. we can get themfrom our family members. basically,we're born with a sterile mouth, but we get these bacteriafrom all sorts of sources - family, particularly. we get the bacteriasitting on the teeth. they're then fed by the fermentablecarbohydrates in our diet. even a very young child,if they're having fruit juices -
lots of sugar in those -will sit in the plaque. the bacteria will work on them.acid is the by-product. it drives the ph down,we get that ionic exchange. it's the acid environmentthat's the toxic thing. what if you have a hot cupof orange juice? i'm told that's toxic. that would make it worse, obviously. norman: drinking an acid drinkcan make it worse? yes. it reduces the ph,makes the mouth more acid. that's where we get the ionic exchange.we're losing the surface of the tooth.
people have focused in the paston trying to get rid of bacteria, or trying to prevent those bacteriagetting in. has there been any luck with that -vaccines, things like that? vaccines have been tried for... since i was born, i think, there's beenwork on vaccines for dental decay. the reality is,it's a complex mix of bacteria that gives the environment this effect. vaccines are targeted at a singlebacteria or cluster of bacteria, so vaccines haven't workedfor dental decay.
the reality is, because we nowunderstand this balance, we can look to other mechanisms. let's come to that in a moment,in terms of intervention. i want to look at risk factorsin the overall pattern. if you look at the pattern, and predominantly we're talking aboutdental caries, the pattern over the last 20, 30 yearsin australia, what's been happening? we've had, not everywhere,but we've had significant fluoridation. the reality is fluoride is listed inthe top-ten public-health initiatives
in the last hundred years. it's been an astonishingly effectivepublic-health measure. historically, we believed fluoridewas embedded in a tooth from the insideas we developed our teeth. so systemically absorbed, comes throughthe bloodstream through the pulp... built into the tooth. the reality,we know that's not the case. we understand now, it's the exposureof the tooth's surface to fluoride that's the effective part.
norman:what does fluoride actually do? fluoride modifiesthe hydroxyapatite crystals within the surface of the tooth, andby modifying the molecular structure, makes it more resistant to acid. norman: it toughens the tooth?- toughens against acid, that's all. fluoride has been an astonishing event. just to give a ballpark idea,in the mid-'60s, a 12-year-old would have 12 holes.12 for 12. today in australia,the average 12-year-old
has something around one hole. that's the sort of effect overa 40-year period you're talking about. nowadays, we see dental decayin a small subset of the population. 70% of australian 12-year-oldshave no decay at all. no holes. they eat sugar. they've got none at all, that 70%. what are the factors that determinenot having decay at all, apart from genetic -some people just don't get decay? clearly, fluoride exposure.got to make that clear.
not all australians are exposedto topical fluoride on their teeth. fluoride critics say,it's not been fluoride in the water, it's been fluoride toothpaste, 'causeit came along around the same time. fluoride toothpaste made the difference,not fluoridation. there are some very strong argumentsabout that. queensland is a beautiful test modelof that. it hasn't had fluoridated water, butthe average 12-year-old in queensland... they've got higher dmfts -decayed, missing, filled teeth - than, say, sydney has.
brisbane's got higher than sydney. but it's not 12 for 12, it's about 2. so it's double. so it is higher... - but at a lower level.- at a much lower level. the effect of fluoridated toothpastehas without doubt been a strong driver. they've probably got fluoridefrom other sources as well - processed food and so on. that plus toothpastehas made a big difference.
what are the risk factorsfor being in the 30%, apart from not livingin a fluoridated area? the core measure in thatis socio-economics. when we look aroundto find groups of people who have high dental disease, low socio-economic peoplehave higher caries for kids. you look through all the factorsin low socio-economics about diet, about health maintenance. norman: go on, debra?
we know thatin non-fluoridated areas... for example, i'm from mildura.we have a non-fluoridated water supply. children have 36% greater chanceof having tooth decay, or the decay experience is 36% higher. we know childrenare about three times more likely to require general anaestheticfor dental treatment. melbourne water supply, and generallythe capital cities apart from brisbane, most of the country was fluoridatedin the late '60s, early '70s. this is where marc was talking aboutthe significant drop in dental decay.
i see it daily -quite significant levels of decay not just isolatedto the lower socio-economic groups, but generally across the board,and fluoride will make a big difference. i remember a paediatric dentistin new south wales showing statistics where she doesn't do manydental clearances on children in sydney, but she's got a busy listin coffs harbour, which at that time wasn't fluoridated,with the most awful mouths. recently, i saw a preschool groupthat came through our practice for an orientation visit and a talkabout tooth brushing and diet.
of the 18 children in one group,11 needed urgent dental treatment. that was seen only with a mirrorwhen they hopped on the chair. eight of those children, i estimate,required a general anaesthetic. two already had abscesses and two children had already hadgeneral anaesthetics. there's been an uptick recentlyin dental decay epidemiologically. what's the cause? is it bottled water - people aren'tdrinking fluoridated water anymore? the upswing in dental decay -lots of clinicians are seeing it.
the epidemiological evidenceis still not strong. we're still there. the upswing is from oneto at most, two, let's say. it's not like we're going backto the mid-'60s. the reason for a possible upswing,all sorts of factors about diet. bottled water could possibly be one. the actual studywas around tank water, then bottled waterwas a subsequent bit of that study. but we should be clear herethat we're not isolationists. if a kid is swapping coca-colafor bottled water,
then in diabetes termsand all the other health benefits of swapping to water, let's just do it. let's not agonise over whether or notthere's fluoride in it. bruce,take us through some photographs of the progression from demineralisationthrough to plaque so we know what we're looking at. bruce: that's a fairly young person,probably in their teens. they're all permanent teeth,no baby teeth. that means at least 11 years old,maybe 12.
if you look at the upper teeth,the obvious ones, you can see the gum margins are redand slightly inflamed, which is indicativeof there having been plaque - bacterial growth around the gums. underneath that, you can seea white halo around the gum margins. on the two front, central incisors,you can see a couple of brown spots. the white halosare areas of decalcification. a combination of sugar and plaquehas produced acid. norman: so if a gp sees this,
what should elizabeth be sayingto her patient, given that there's a shortageof dentists and gps using that opportunityfor secondary prevention? a couple of take-home messagesdefinitely are - brush your teeth twice a daywith a fluoride toothpaste. most toothpastes have fluoride in them. fluoride is what's going to give youmajor protection, using fluoride toothpaste twice a day. norman: low-fluoride versus highif it's a child, or go for full-blown?
it's only up to six years. - foot to the floor on that?- yup. - angela, show us how it's done.- ok. i also want to add to that conversation that in that case,i'd definitely be advising the patient to go for the high-fluoride toothpaste,5000 plus. i'm not promoting colgate, it's mainly that they're the onlycompany producing this one. so this toothpaste,depending on the case...
norman: early on in the course? that case, i definitely would. you're going to teachyour practice nurse or the gp to do this because nobody else is around to do itat the moment. how much toothpastedo you put on the brush? pea-sized toothpaste. before you go any further,let's just stop here for a moment. should i have flossed before i brush? i would rather that you stabilisethat decalcification problem first.
norman: don't worry about flossing?- no. i won't kick-start the client offon a flossing program. what about washing your mouth out? you might floss,and the mirror becomes spattered. i'm sorry - you're not eating, i hope. then you wash your teeth. you wash your mouth outand still more food particles come out. you've been told thatyour retained carbohydrate is what rots your mouthduring the night,
particularly whenyou've got no saliva left. don't forget we're in a droughtin australia, so save the water. only a small mouthful, rinse and spit. - before you wash your teeth?- before you brush. the last thing on your teethhas got to be the toothpaste? that's correct. norman: ok, got it. let's go. if it's a battery-driven toothbrush, we need to make sure it'salong the gum line, all around there.
run the battery-driven toothbrush. if it's a manual one, flex that muscle,and do nice circles, making sure we're cleaning the gumsas well as the teeth all the way around. don't forget inside next to that tongue. calculus, or tartar, tends to settleall around these bottom teeth. norman: hard or soft? soft. - soft bristles?- soft-bristled toothbrushes.
this is good for adults as well. norman: so, a circular movementon the gums? bruce: tooth and gums.- tooth and gums. debra: i recommend children's toothpastefor my adult patients. small head, soft bristles,easy to get to the back of your mouth. norman: the toothbrush?- yes. i'm a medium-pressure sort of person. i've watched people brush in such a waythat they haven't removed the plaque. isn't it the casewith some electric toothbrushes,
you see people with traumatised teeth because they've been going at ittoo hard? people can do it with a manual brush. manual brushes,particularly medium or hard. so electric toothbrushis just a steady move round, making sure the gums are there,but not a zip round? - correct.- occlusal surface and inside surface. you don't wash out at the end,just spit it out? debra: rinse, like, two minutes.
i really do believeit's all in the brushing. it's not about the timing,it's about making sure that every single tooth in the mouthis brushed properly. could i be controversial, and say that evidence isit's the fluoride in the toothpaste that is reducing tooth decay? the toothbrush is the mechanism bywhich you put toothpaste in your mouth and spread it around. if you swill it round and tryto get the fluoride into the plaque,
that is your primarytooth-decay defence. protecting your gums -brush your teeth to remove plaque. your brush is helping your gums. this is why we're talking the 5000. the fluoride and the toothpasteis the primary prevention. let's go to our next photograph,which is of plaque. take us through that, bruce. how would you know that that's plaque? do you have x-ray vision as a dentist?
bruce: we have very bright lights. even with my 60-year-old eyes,i could see it in a dental chair, but i don't think i can see it here. norman: it's presumptive,with the swollen gums? marc: exactly. if you look roundthose lower incisors, you can see that they look bulky and redand sticking out, and don't look normal. often, clinicians like us,when we walk down the street, we look at people's mouthsand don't see the plaque,
we see those gumsand know they've got plaque. debra: probably the patient noticesthey bleed when they brush. their natural reactionis to avoid the area - if it bleeds when i brush it,i'm not going to brush it again. marc: and the answer is the reverse. how critical is plaque to dental caries, debra? to dental caries, it may not be as importantto remove all the plaque.
it's more importantto get the fluoride there. but for gum disease, it's vitallyimportant to remove the plaque. we'll come to gum disease in a minute. plaque is the gluethat holds the bacteria on? plaque is the carbohydrateand the bacterial load. that's what it is. its relationship to dental caries is that it produces the acidthat dissolves the tooth substance. the plaque isthe bacterial and carbohydrate load.
but removing itdoesn't necessarily do the job? it doesn't do the job completely,but breaking it up is important. most tooth decayoccurs between the teeth, which used to be an argumentfor flossing, and in the pits and groovesof the back teeth. evidence suggestsyou can't remove plaque, particularly from pits and fissures. the toothbrushdoesn't go down into those narrow areas. between the teeth is a similar argument.
again, and i found it controversialat the time, but the boffins will tell us thatremoval of plaque with a toothbrush won't have any major effect. norman: because the problemis the bacteria, what you're eating. the plaque might be there,but the plaque is harmless. debra: it has an effect on our gums. let's go to the next photograph. this is where we've put in a reveal of how much plaque wason that previous slide - quite a lot.
bruce: it's a disclosing solutionthat discloses young plaque as pink and older plaque - at least 24 hoursand probably later - in purple. it's got a special double feature. that shows where plaque has beenaccumulating for a long period. it might be on areas whereyou've been concentrating. norman:debra, when you get your pick out and flick off the scale on teeth,is that just cosmetic? no, that's plaque that's beenleft undisturbed that mineralises and becomes hard.
it can't be removed easilyby the patient. it's just too hard. that last slideshows where that plaque accumulates. it primarily accumulatesalong the gum line. we're very good at brushing our teeth, not particularly good atcleaning along the gum line. when we're removing plaque,to help maintain gum health, we need to get along the gum line. we've seen demineralisation,the first slide, which is probably the next slideafter plaque.
now let's have a look atdental caries full-blown. talk us through this shot, bruce. bruce: the lower incisor teeth,the lower front teeth, there's a load of numbers there. i think they're indicatingvarious things. number 2 shows decalcification,which is early caries. norman:decalcification of this set of teeth? bruce: that's right. 4 is interestingbecause it's got quite a black cavity,
which looks pretty ugly, but black caries indicatesthere's been remineralisation, which is not a bad thing. the other teeth going further roundseem to have, above the black margin... norman: i don't know much aboutdentistry, but it doesn't look good. it looks bad.so that gets us... talk to me about fissure sealingand the role of that. is that the same thingas fluoride application or is that a different story?
fissure seals is a clinical,prevention procedure. it initially started off for preventionof decay in permanent teeth in high-risk children, when they'resealing the deciduous molars. it's basically what it says -sealing out decay. the product that we're usingat the moment, it's a glass ionomer. it has slow-release fluoride. like marc said, we're putting fluoride back intothe saliva, or the oral environment. every time you brush your teeth,if you have an acidic oral environment,
the fluoride can be combined. norman: it works with it?- yeah. norman: what's the varnish we're seeing? marc: there's an interesting story aboutfissure sealants that adds to that. fissure sealants - you put themin the fissure of newly erupted teeth. lots of them actually fall out. but we actually know thateven when they fall out, because they've hada slow-release fluoride into that risk area, the fissure,
those teeth are protected even afterthe fissure sealant has dropped out. so fissure sealants are actuallya very positive, constructive way of protecting high-risk parts. how do you apply it? is it complicated? no, very easy. this is how we explain itto the young ones. we shampoo with the poly... marc: etch.- yeah, etch. then we dry the tooth, then we flow the glass ionomerinto the grooves,
or the valleys, of the tooth. so this is high-risk young peoplewith their permanent teeth? angela: yeah.bruce: individual risk. particularly with aboriginal children,a lot of teeth are hypoplastic. they're poorly formeddue to childhood illnesses and the like. any tooth that looks like that,straight to it with a fissure sealant. it's more than a fissure sealant. someone saidit's a mountain and valley sealant. you cover the toothwith a protective layer
and hope that will reducethe likelihood of decay. let's talk about the special needsof aboriginal communities, which you have expertise on. how does the story we've told so fardiffer for aboriginaland torres strait islander communities? i'm talking primarilyabout the northern territory and truly remote areas. tooth brushing, althoughwe've tried hard over many years to get that established at home,hasn't happened.
any tooth brushing generallyoccurs in school and the like, which we try and do. caries rates are very high. they're particularly highin young children. they're quite highin the permanent dentition as well. get me back to the point you're asking. the circumstances which are differentfrom what we've been saying. it's a question of severityand prevalence. two key messages
which we would usually applyin a private practice would be, brush your teeth twice a daywith a fluoride toothpaste and reduce the sugar and sweet intake. both of those are extraordinarilydifficult to address in communities. so you're tending to run towardsschool tooth-brushing programs, preschool tooth-brushing programs. the other part of that slide whichwe've gone past had fluoride varnish. we've been doing researchin the northern territory, painting fluoride varnish six-monthlyon children aged 18 months to 4 years.
norman:is that easier than fissure sealing? bruce: it is. the major advantage is, it doesn't have to be done by a dentistor therapist. norman:an aboriginal health worker can do it? or a doctor or nurse. you could be doing it,and i would recommend it, six-monthly from 18 months through to 16 yearsor whenever, really, because other areas of prevention areso difficult to control at this point. aboriginal peopleare massively over-represented
in the extent of and prevalenceand incidence of dental decay. for example, some western australiandata which is equivalent in queensland, three times more likely to end up witha general anaesthesia for dental decay in infantsand primary-age kids. that's even when access to servicesto get them referred to the tertiary service is not there. it's an enormous problem. let me take the lucky 12-year-oldwho's got no caries. when they're 70, will they have caries?
what's the natural history? the natural history depends onthe cohort we're talking about, and our young people, we don't reallyknow what they'll be like at 70. in general, as marc was saying,as cohorts have been ageing and the fluoride peoplehave been coming through - even we 60-year-oldshave benefited from that - caries rates have been much less. the national surveyof adult oral health demonstrated that for people over 35, there was only 5%who hadn't had caries.
in fact, on average, people are getting4 or 5 decayed teeth every 20 years. so people are stillgetting decayed teeth. saliva. my understanding is,saliva is really important. dry mouth, bad for the teeth. saliva's very important,'cause it buffers the oral environment, helps clean, clearance for all the food, like you said earlier on about rinsing. also, it acts like a reservoirfor all the fluoride, calcium phosphates, et cetera,so it's healing.
medications would bea significant cause of low saliva load. we issue a lot of medicationswhich reduce saliva. we've been issuing lotsof antidepressants. old people get anticholinergics, particularly to help themwith dribbly bladders or dementia. antihistamines will be in full usethis month because spring is here in the south. they're all going to dry the mouth. dry mouth is a decimating process.
in three months, you can haveevery tooth in a person's mouth breaking down towards gum linethrough dry mouth. we've got a picture of somebody's mouthafter salivary dysfunction. that's presumably something likeautoimmune disease that can cause that. marc: any process that driesthe mouth puts you at high risk, be it a good game of footballor whatever. dry mouth puts you at risk. norman: angela, chewing gumis a good thing for saliva?
chewing gum stimulates the saliva glandsto produce more saliva, and that's a natural defence. norman:chewing gum that's calcium-enriched is supposed to be good,or is that just marketing? - sugar-free gum.- no, it actually is. sorry, bruce.it's an australian invention. basically, it's a neat part of whey -curds and whey, the whey of milk - that can tip the balance backtowards the tooth. it has ccpa in it, this stuffthat can drive ions back into a tooth
and actually regenerate someof those early lesions. and you've got somesaliva-assist products. there's three on the marketthat we know of. i'm not promoting any of them. it's just so people are aware thatthere's aid and help out there for those with dry mouths. they're lubricants. that pink one is the same stuffthat's in the chewing gum? no, this is the same productfor dry mouth.
but like marc was saying,there is tooth mousse. there's one new on the market. i'm not promoting again,but it's the one that is available. it has fluoride plus the casein,or the phosphopeptides. going back to chewing gum,any chewing gum will do the job. some will do it better. angela: sugar-free.- thank you for that correction. 'if a mother refuses fluoride tablets inan area with no fluoride in the water, can the mother usefull-strength toothpaste,
neutral-fluoride mouthwash daily, and will these be enoughto prevent caries?' debra? the issue of fluoridationis a public-health issue. fluoride tablets by the way are not partof the fluoride regime and recommendations anymore. we were talking earlier about fluoridenot being as effective taken systemically. that's part of that argument. so fluoride tabletsare not recommended anymore.
water fluoridation is seen as beingthe most effective form of fluoridation. if somebody didn't want to havefluoridated water, they could drink bottled waterif they wish, and they could useordinary fluoride toothpaste to get fluoride from that source. norman: so fluoride tabletsare off the menu? they're not on the recommendationanymore, no. is there any cancer concern? another question is people asking -these questions are from a pharmacist -
about whether there's a cancer concernwith oral fluoride. this very question came uponly yesterday in mildura. we had the information session - the state governmentis proceeding with fluoridationof the mildura water supply, and those very questions came up. research has done comparisonswith queensland, who are non-fluoridated,and with states that are fluoridated. there's no significant differencefor all of those.
generally, the concerns that are raised,the osteosarcomas, there are a number of those concernsthat are raised. probably the primary concernfor most people is that the water supplyis being fluoridated sometimes against the wishesof the individual. you've got to look atpublic-health issues - whether the benefits to the greatermajority of the population overweighs the objectionsof the individual. there's some really nicecochrane review work
and systematic meta-analysisaround the issues of cancer and the pros and cons of fluoride. all that international work says that there's no real dataaround cancer effects and fluoride. elizabeth, what's your commonestprescription for osteoporosis? it's bisphosphonates. we've got a questionabout osteonecrosis of the jaw. - have you ever seen a case?- no. have either of you two dentistsseen a case?
we've had one in alice springs,one case. it's certainly concerning whenit happens, and it draws attention. but overall, the message is that it's... marc could probably explain this better. it's a pretty rare event still. for anybody who's not heard about it, we're talking about somebodywho's on bisphosphonates, has a dental procedure and the tootheither dies or doesn't heal properly. - the bone.- the bone in the jaw.
it can be mild or severedepending on that. so it's much rarer than the media,like me, might have promoted it? marc: to some extent. early work was done on patients who had very high-dose bisphosphonatesfor cancer and things. the low-dose, osteoporosis story,there's still... norman:it's different if you've got myeloma. it's a great opportunityfor gps to ask patients, have you had a regular dental check?what's your dental health like?
what's your periodontal health like? is the recommendationfor someone like elizabeth, before she starts somebody on fosamax,to send them to the dentist? that is the therapeutic guidelinebefore starting. the question from this pharmacist is,does clindamycin help? she says she's seen dentists using it. debra: is that for...- for the treatment of osteonecrosis. i'm not aware of those. don't know the answer to that.
any effects of salbutamol or ventolinon the teeth? dry mouth. debra: and issues that surround that. yeah, dry mouth. is there anything betterin terms of anti-asthmatic medication, or you've just got to live with it? you've got to use your preventerregularly. focus on topical corticosteroids? yes.
might help your periodontal diseaseas well. i'll keep going through these,'cause lots of good questions. 'i've read about a product calleddentist in a box that people can keep at home and use if they lose a fillingor break a tooth, as an emergency.' i reviewed the dentist in a boxfor remote use. norman: this isn't about dead dentists. this is about first aid, is it? it is very much basic first aid.
it is primarily for middle-class peoplewho, a filling falls out or something. it's not designedfor use in acute situations. something to stuff in the toothuntil you see the dentist? bruce: you've got a sharp edgeor something like that. it's ok, but not definitive? yeah, for particular use. another question -'i've read that xylitol causes the cells of the plaque bugsto explode and die, and thus helps prevent caries.is this a myth?'
- sounds like a myth to me.norman: that's chewing gum? yes. oh, i couldn't say. it's probably more the chewing andsaliva doing it rather than the xylitol. i would say about extras... i offer it as an alternative to parents if they're looking for something niceto give their children. they can at least chew chewing gum. teachers may not like it, but it's something sweet,and does them no harm dentally.
a rural general practitionerfrom victoria writes, 'i've got a patient with bulimia. how does this conditionaffect the teeth, and what are the bestmanagement strategies?' my understanding is, this is a major issue in rehabilitatingyoung women, particularly. we see teeth severely eroded,particularly on the surface underneath, when they're purging. norman: it's hydrochloric acidfrom the stomach?
the acid effect can almost wearthe teeth down to nothing. the problem is,when you've got a patient who's bulimic, they're resistant to putting anythingin their mouth, so treating it is very difficult. they don't want to put anythingin their mouths at all. marc, what's the storyfrom your point of view? oh, i... 100% agree. it's the same story. all we're doing is dissolving teethwith acid.
debra: what's most important... traditionally, wine-tasters have beenknown to wear their teeth out. they used to brush their teethafter every session, and that's the last thing you want to do if you've got a lot of acidin your mouth, is brush your teeth, at least for a whileafter you've had that acid, because you're leavinga lot of decalcified enamel. mildura is wine-taster's-teeth central. you're putting varnishesand things like that, but not brushing.
the wine-tasting, have a break, then have a piece of cheese,'cause there's casein in the cheese. the swedish treatment,the mandometer treatment for anorexia nervosa and bulimia,involves major dental reconstruction so these kids feelthey can be rehabilitated. a rural midwife has sent in a fax - 'some pregnant patients report theirteeth seem to fall apart when pregnant. what dental precautions are neededin this period?' i would recommend tooth brushing,keeping the gums healthy,
fluoride toothpasteand look at... the old story of -the baby stole my calcium, we don't believe that story anymore. the realities aroundthe hormonal processes of pregnancy modify the way you react to the bacteriain your mouth. that can significantly increasegum disease. that's the worry. women become much more awareof their own health at that time. they're much more health-consciousduring pregnancy. norman: it's a changeable moment.
seek dental treatment, and find out, ok, i've got two teeththat need to be removed. it's not the result of the pregnancy, rather the attention to healthat that particular time. we will get on to case studiesin a moment, but i want to talk aboutperiodontal disease first. doctor, my teeth are okbut my gums need to come out. periodontal disease is the other oneof the big two. the realityaround periodontal disease...
what's the differencebetween gingivitis, which we saw in those pictures,and periodontal disease? quite a big difference. gingivitis has an effecton the peripheral margins of the gums of your teeth. we know that nearly 100% of teenagershave gingivitis. probably all of us on this panelhave some gingivitis in our mouths at the moment. not a destructive condition.
a separate conditioncalled periodontitis is an extremely destructive condition. that condition destroys the ligamentthat holds your teeth. if you're the gp looking in the mouthand you see red, swollen gums, how do you know whether it's gingivitisversus periodontitis? to be honest, it doesn't matter. i would automatically assumeit's periodontitis, because that's a better assumptionto make. norman:does that change the management?
not really. the managementis fundamentally the same. the management is aroundthe bacteria, the plaque - back to that story again. the difference in this conditionfrom caries is, the bacteria is stimulatingan inflammatory reaction. it's the cytokine reaction. norman: essentially,it's an exaggerated reaction? that ends up destroying the ligamentstructure that holds your teeth. as you can see in the lower frame here,
the old wives' story about growinglong in the tooth is periodontitis. the ligament is destroyedand the gums, the periodontium, moves further up the tooth,in upper teeth, obviously, therefore the tooth looks longer. - it is actually a one-way ticket.norman: treatment doesn't work? treatment cannot reconstructthat ligament. norman: can you stop it?- we can stop it, yes. norman: doing what? bruce: can i jump in and say
that although plaqueis part of the issue, smoking and diabetes in particular... and perhaps some geneticpredisposition... basically, some people get it.it's about one in every five. there was a paper in jamafrom new zealand a few weeks ago which suggested smoking -tobacco and cannabis - and diabetes. plaque wasn't a strong risk factor, atleast for people in their 30s and 40s. clinically,i'm pretty persuaded of that position. i see a lot of aboriginal men,in particular, who smoke
and have got bad periodontal conditions. diabetes, as you know,is very prominent in aboriginal people, and consequent poor periodontalcondition is very noticeable. in that practical way, i would say thatthat's their underlying problem. debra, show us your wallies. ok. this is a lovely set of teeth. we've got some periodontal disease and we get the inflammatory response,a host response -
inflammation from the bacteriathat sit below the gum line. and we get bone loss, bone destruction. eventually the tooth comes loose. this is when patientsoften attend a doctor. they'll say,'my teeth don't feel right.' the teeth may actually movefrom loss of supporting tissues, the bonecaused by the periodontal disease. treatment for this is to remove thecalculus that sits below the gum line, make the tooth clean again.
norman: can you make a loose tooth tightagain? it can tighten up,but we can't restore the lost tissue. we can't restore the lost bone. sometimes patients maintain teethin functional use, and are still functional even thoughthere's some degree of mobility. but we can get the diseaseinto remission. we cannot cure the damage, but wecan stop the disease from progressing. norman: and you're ona scrambled-egg diet forever more. if your teeth are loose, yes.
norman: anything else to show uson your attractive model? we can see calculus, or tartar,build-up. norman:hold it more square to the camera. progressing down the tooth. we can see significant bone loss. that tooth would eventuallybecome loose. that's when the tooth is lost. so the old saying the bushie out therewho pulled his teeth out with pliers... - he was periodontal.- ..he probably had...
..significant gum disease. we wouldn't easily remove our teethotherwise. one of the problems withperiodontal disease and tooth decay is that symptoms appearlate in the disease process. people can have significant destructionof periodontal ligament and loss of bone... norman: by the time they get to you? ..affecting their function,and it needn't have happened. and they needn't have hadsignificant symptoms beforehand.
not necessarily had any pain,and no significant bleeding, particularly in smokers. smokers don't get a lot of bleedingfrom their gums, even in very advanced periodontitis. a question has come inabout tetracycline, a non anti-bacterial effecton periodontitis. is that true? yeah. historically, for some particularkinds of periodontal disease, they've used short-termtetracycline treatment as its anti-bacterial mechanism.
but that's only short-term. you can't do that for the chroniccondition of normal periodontitis. however,there have been some reports now that modificationsto cytokine processes involved can actually happen with tetracyclines. we've already spoken about pregnancy,angela. what is the story with pregnancy? it used to be saidthat if the mother had caries, that somehow prejudiced the baby'sunborn teeth. is that true?
i think that's going backto the bacteria transfer. norman: a postnatal phenomenonrather than in-utero? we don't want to promote thattoo much. we're saying, if the mothercan look after her oral health, that knowledge and skill to look afterher family will flow on to her baby, the good practices that she's gained. that's crucial,to begin as soon as she... another question that's just come inthis moment about vomiting in pregnancy -hyperemesis,
and tooth problems. again, because of the acidityof their purging, it is most importantnot to brush straightaway. rinse their mouthto neutralise the environment. as i understand it,some women find it very difficult to even put a toothbrush in their mouthearly in the stages of pregnancy. chlorhexidine is a reasonablealternative to brushing for a period of time,maybe a month or two. knocking off the bacteria,unless they become resistant.
a question ongastro-oesophageal reflux. is that a cause of dental destruction? do things like proton-pump inhibitorsthat reduce the acid help? certainly... we're going through a suiteof conditions which are really - acid entering the mouth.so, yes is the answer. but there is a treatment for that acid, which isgetting a proton-pump inhibitor or... anything that raises the ph back upis a winner. norman: there's no randomised trial?- no.
can i go back to the pregnancy story? there's interesting work coming out around improving the periodontal healthof the mother and its relationship to then reducinglow pre-term birth weight. this is the whole inflammationand periodontitis story? the whole inflammation story,which is really interesting. the data is not solid yet. it's the samewith coronary heart disease - it would just be shared risk factors
rather than the periodontal diseasecausing it. let's go to one of our case studies. your patient, elizabeth. jane brings her two-year-old daughter sally to see you. jane has just begun brushing sally's teeth. she's noticed her upper front teeth have changed colour.
there doesn't seem to be any pain, and she's on a healthy diet. when you ask her about her diet, she says she's a great sleeper. she goes to bed each night with a bottle of juice for the past year. mother's idea of a healthy diet and mineare obviously a little different. i don't think this child should begoing to bed with anything in its mouth. we can't just say, give ita drink of water, send it to bed.
we can negotiate, and tryand reduce the strength of this juice until it gets downto a reasonable amount. it would of course be far preferableif she gave her a drink of milk and sent her to bed. - with nothing?- with nothing in her mouth. but the thing is that at this stage, we've got early damage to the teeth, and we might be ableto save these teeth. what's the trickfor examining the mouth here, angela?
we're actually rolling out a programacross new south wales, where we're working in partnershipswith child and family nurses. we're rolling it into someof the private practices. we're working and gettingthe child and family nurses to identify spots like jane's daughter. exactly like - lift the lip. norman: so, the mother holds the... liz is the mum. norman:is elizabeth the doctor or the mother?
- she's the mum.- i'm the mother? there you are. ok, let's change roles. norman: i'm confused now.is elizabeth the mother? no, she's going to be the doctor,'cause we're giving her the training. ok. so, just check it. norman: lying in that position -nestled in your lap. - pull back with it.- oh, yes. in my lap,and the child is lying in liz's lap. norman:invading each other's personal space
for the sake of the child. how old can you go up towith that technique? up to 18 months to 2 years, depending on the child's comfort, because their comfort and securityis very important. norman:let's have a look at the picture. here's a picture ofthe lift-the-lip technique in the lap, baring the lip like this. let's have a look at teeththat might look a bit like sally's,
and what that looks like. marc: it's quite interesting, actually. it's very interesting. we expect thisto not be a major problem. i can tell you about western australia. 80% of the populationhas fluoridated water. we have a great school dental service,all these things. still, the fifth most common cause of a primary school-aged kidto go to hospital
is dental decay. so early-childhood studiesis a really significant problem. and intervenable.let's have a look at the mouth. angela, maybe you talk us through this. ecc stands for early-childhood caries? angela: early-childhood caries. the white, frosty linein the bottom picture - you can see the white, frosty linenext to the gum line - that is the initial-decay process.
that is reversible. norman: so, yellowing teeth?- yellowing teeth. the white line is where the plaque... norman: what we saw earlier,where you get this in more relief. angela: yeah. bruce: the caries hasn't gone into the hole there as yet in any of those early stages. norman: if you don't do anything,this is what it could look like:
angela: that's correct. we're trying to get the childand family nurses to identify these and refer them all. norman: what's the intervention? increase fluoride tooth brushing, contact with a fluoride toothpaste and start teaching the parentto change the diet, especially not putting baby to bedwith a bottle and making sure that there's only waterin the bottle, if they use a bottle.
but we're encouraging... is this child a candidatefor fissure sealing? if they will be compliant in the chair,then yeah, it's a high-risk. - not the photo we just saw.angela: too young. debra: that's a candidatefor general anaesthetic and extraction. if they had caries in the front teeth,you might consider fissure sealing. i think it's important to talkto parents about how things happen. we shouldn't jump to conclusionsabout how things happen. we should have a discussion around,
what do they think has caused the holes,and are they important to them. try to get some ownershipof the problem by the family, rather than just tell peoplewhat's good for them. and in aboriginal communities, harness the local communityand health workers? - yes, indeed.- debra, you wanted to say? a lot of parents assume that childrendon't need to start dental visits until they're five or six,going to school. ideally, we start as young as possible.
we were talking about parentsand allied health workers looking at children's teethand identifying those that are at risk. parents can certainly start bringingtheir children for first dental visits as early as 18 months. norman: assuming they can affordprivate dental care. yes, that's the situation.but there's a school dental service. is there evidence that dental check-upsmake a difference? it allows us to identify childrenthat are at risk, talk to parents. norman:that's not the question i asked.
- can i jump in?- you can. that national surveyabout oral health demonstrated that adults across the board, the people who are by farthe most dentally healthy... that could be because they're wealthier, of a higher socioeconomic classand brushing their teeth more. well, no. it demonstrated they had quite a historyof decay, as we pointed out before, but that decay had been well managed,
so it hadn't led to tooth lossand tooth destruction. norman: it's complicatedmaking the call on this. i'll give you the other sideof the story from your homeland, from england,that... wash your mouth out.i'm from scotland. marc: sorry, from scotland. ..that people who went to the dentistregularly ended up with full dentures faster thanpeople who didn't go to the dentist. so the question about thatis not simple.
norman:so it's not so much the dentist, it's what the dentistor dental therapist does and the intervention that occurs. it's the expectation of boththe patients and the profession, and that has changed. basically most australianswant to keep their teeth and most dentists and therapistsand hygienists have been taught to do all they can to keep them. the old days have disappeared,but not entirely.
i'm thinking of public dental services,where there's a lack of resources. people come in with bad teeth,and the solution is to take them out, but less so in private practice. the other interesting thing is,in a way, australia's school dental serviceshave been an experiment in extending that -come back every six months. most services have grown outto 12 to 18 months in parallel with fluoride and things, and the reality is, there hasn't beena dramatic going backwards
with those changes in time. it's a complicated question. let's go to young adults.we're taking a life-span approach. we started with pregnancy, toa young child, a toddler, a preschooler. now let's go to charlie,who's 24 years old. it's your monday-morning surgery, elizabeth, and charlie presents to you with a swollen left side of his face. he says that he got hit in the jaw
in the pub on friday night and today, his face is too sore to go to work. he's got swelling over his left jaw, which is warm to touch. he can open his mouth, but only about a centimetre. you also see he's got a pretty rotten mouth underneath that. what are you going to do, doctor?
we managed to organise him an x-ray. norman: that shows a fracture, andone of his teeth seems to be gone too, and probably an abscess. my big concern is actually his abscess, because he's technically gota compound fracture. that means he's now on a long tripoff somewhere. from where i am,that's 250km minimum one way to get that fixed,in a very wealthy area of australia. and...
if he's actually in central australia,if he's aboriginal, he might have heart diseaserelated to previous rheumatic fever. he may have had septicaemia, and quite serious problemscan ensue from this. so i'm going to look at covering himwith antibiotics to cover aerobes and anaerobes and see about getting himoff to someone to fix it. after the jaw is fixed, bruce,what do you do about his teeth? well, there's a whole loadof different factors in that.
first of all,assuming he can get to see me. for a lot of people, that would probablybe quite a challenge. access is a problem. there may not be a dental service.he may not be able to afford it. it sounds as if he's got somevery bad teeth. and... if he's able to cometo the public dental service, by the sound of those teeth,odds are he would have some teeth out. really?because conservation is so expensive? and takes time. there's such a bigline-up of people wanting care...
only the rich can afford conservation? that was what i was saying earlier, yes. what about this new medicare item,debra? the teen dental plan is quite specific. it's a preventive treatment plan. there are a limited number of itemsthat we can use here. we can do an examination.examination is required. we can actually tell the patient,do they need restorations or not. we can take x-rays for them.we can do a scale and clean.
we apply fissure seals,fluoride treatments. but it doesn't include actual treatment. most of these patientsare health care card holders. for example, i'm in a private practice.they come and have an examination. we go through oral-hygiene instruction, telling them what they need to doto take care of their mouth, but if they can't afford treatment and need to go to a publicdental clinic for treatment, there may be a lag timebetween diagnosis and then treatment,
if they can access that treatmentat all. but fluoride could perhapsstabilise their decline? we can help them with that part of it,and we can probably... ..yes, reduce the chanceof that progressing on any further. but often, these children,they're teens, they've been on high-sugar drinks,they drink a lot of coca-cola. that's the age group. they may have extensive workneeding to be done. if there's a long waiting listat the public clinic,
it may end up treatment for painand extractions. norman: we're creating a demandthat's not necessarily being met. absolutely.it's an interesting policy position. bear in mind that dental servicesare run by the state - the different jurisdictions,state and territory governments - whereas the medicare teen dental programis a commonwealth program. so the commonwealthare driving up the treatment problem in the state sector. what if this wasn't a broken jaw,
but at the pub,he'd knocked out his tooth? take us through the process. try to get that tooth back inas quickly as possible, is the answer,preferably a tooth with a clean root. also, holding it by the crownof the tooth, not the root of the tooth. keep the root of the toothas clean as possible, and get it back in the mouthas soon as possible. norman:transport it in milk if you can. bruce: right. if you can't do that,put it into milk.
norman:if, as a gp, you put it back in, they hold it intill you can get it splinted? bruce: yep. the dentist in a boxhas some aluminium foil, or you could use chewing gum. something to hold it in. but the best thing is to get the personto hold it if they're able. i don't fancy the aluminium foil if you've got an amalgam fillingon the top.
you'd be creating some electricity. let's move on to our next stagein our lifespan, to jim. jim is a diabetic man in his 50s who attends to see you, elizabeth,for a check-up. he reports that his gums have beenbleeding a lot lately, although he's got no pain. he says he's excellent withdental hygiene, brushes once a day, uses a mouthwash, but it's not madeany difference to the bleeding. my job here is to look at his diabetes
and consider very carefully his diet, because what he's eating is obviouslynot what's best for his teeth. so if possible, we really should betalking to the dietician as well here, because we need much better controlof his sugars and we need a different choice of foods that are causing less damageto his teeth. marc, is there evidence that bettercontrol of diabetes helps periodontitis? this is what we assume he's got. absolutely yes.
diabetes, everyone knowsaffects capillaries, retinas, et cetera. it affects capillariesin the periodontal ligament as well. by damaging those capillaries, you get a driver of thatperiodontal-disease effect. so, yes. let's go on to our next stage in life. emma, who is 65, and has come to see you, elizabeth, for her senior's health check. she's got some incisors, and you,
being an excellent gp, look inside her mouth, as everybody who has watched this program will do from now on. they seem to be loose. she's got some carious teeth, which have needed dental attention for many years, and a lot of missing teeth.
she said she saw a dentist last year because she thought it would be easier to have them all whipped out. the dentist wasn't keen to do this - difficult to arrange a general anaesthetic. what do you think? i think she's got a different view onwhat an older person's mouth looks like. half the people of her agedon't have any teeth at all,
and to her it's quite a normal thingto choose taking out all the teeth as a choice for an end-of-life wayto have your mouth. what actually happens depends on whether she has insurance coverfor dentistry or not. if she can't affordto see a private dentist, they're going to rot awayuntil she finally gets an appointment. some more are going to fall out. eventually, the public dental servicewill remove the last of them. if she's got private care,she has some option
of getting some of them fixed. but it's a thing whereshe's got a different view of what her mouth should be like. we haven't seen a picture, but do you think on the face of itshe's got a restorable mouth? i'm a little bit concernedabout the loose lower teeth. very often, what happens with people who have got quite severedental problems is we end up taking out all the upper teethand putting in an upper denture,
which is reasonably manageable. most people manage an upper denture. full lower denturesare much more difficult to manage, so we often try and doa half-stage removal. that may be somethingyou could perhaps propose. it sounds really radical. if she had money, is it worth tryingto restore those teeth? as you said,we haven't seen the photos. you'd want to take some x-raysand make a general analysis.
she's already saidshe wants the teeth out, but that could be a reflectionof the total cost of the treatment or the difficulty of getting into see a dentist or the fact she hates the drilland the needles, because she's asked for a ga. there's a whole lot of factors. the practical thing is, she may bea candidate for a full-mouth clearance? a lot of people a generation agohad full-mouth clearances, and somehow have managedto get through life
and have accepted them pretty well. but round about this age or older, they start rattling aroundinside your gums, because it can get quite hardto manage those dentures. you get atrophy. the dentures? it's possible. people seem to be able to manage. most people with dentures keepwearing them, from my experience.
often the bottom denturegets forgotten about, ultimately, and people just wear the top one. perhaps only when visitors are around. but they like to have somethingin their mouth. it's going to get really trickyas we age as a population. we're just on the beginningof this slope. as a profession, we haven't graspedwhat we're facing here. within 10 or 15 years' time, it's notgoing to be 50% of the population without any teeth, it's going to besomething like only 10%.
we're going to have all these peoplewith crowns, bridges, implants. we're going to havecomplicated mouths in elderly people. the journey over the next ten years is going to be arounddeveloping an understanding of what geriatric dentistry needs to be,and we've got a way to go. let's assume she's got money,and she's 85, with loose dentures. my understanding is that you can takea cheaper option than dental implants, which are implantsthat anchor the dentures which can be quite effective.
marc: yes, you can. there's a number of that going on. the impact of residential care,if she was in a home? angela: difficult. daily care. we really need to form a partnershipwith the residential carers, and train them up on howto do home care for these residents - removing dentures, cleaning them. if they've got teeth,keep them clean as a routine. norman: it's a pretty toxic environmentfor teeth, isn't it?
debra: it's very difficult. we're talking about patientswith low saliva outflow because they're onnumerous medications. residential care, nurses are geared todealing with dentures a lot easier than they are to dealingwith patients who have their teeth. norman: so there's pressureto go down the clearance line? patients with dementia, it can bedifficult to take care of their teeth. there hasn't been that pressure. taking teeth outis becoming more and more rare,
but it's somethingthat needs to be thought about. another question - 'is there anythingwe can do to help people on medications like calcium-channel blockersor anti-epileptics that get gum overgrowth?' sometimes they have surgery and reduce the gumthat's overgrown the teeth. otherwise, maintaining good oral hygieneis the only place we can go. i have a number of special-needspatients who have gone down that path. eventually we've gone to surgeryto remove some of the overgrowth
so we can maintainreasonable oral hygiene. norman: marc?- absolutely. the overgrowth is an over-reactionto the bacterial load. so driving down the - keep these teethsuperclean is a winning solution. our next case study is marie, aged 24,mother of a three-year-old daughter. she goes to a pharmacist asking for something to relieve the pain of toothache. she's referred to a dentist,
but since there's a long waiting list, she's goes to see you, elizabeth. you've got a busy night. you see very poor oral hygiene. you find out that marie is on a methadone program. marie says, she's heard that methadone rots your teeth. doctor? methadone is not actuallythe rotter of the teeth.
but on a methadone program,you're served methadone syrup. methadone syrup is traditionallymixed with orange juice. it's then drunk under supervision. there's just your methadone,your orange juice, and you've left acid in your mouth. then the methadone has gota side effect of drying out the mouth, reducing the saliva,so we've got less saliva. then the underlying problemthat she's on the methadone program is always associated witha chaotic lifestyle
and an inability to be organised. norman: the last thing on their mind is fluoride toothpastemorning and night. you've got a program,haven't you, angela? it's called great whites. we've worked in partnership with drug and alcoholand support-case managers. when the program kicked off, we wereonly expecting 10 clients out of 100. 96 clients out of 100have accessed oral-health care.
norman: shows you the significanceof the problem. the other significant thingis that out of this 100, we had 25 children, and the children of these clientshad low decay rate, which was brilliant. because of the caring programprovided, they're very aspiring. they felt that they couldkeep their appointments, come for oral-health care. it's been quite a successful program. this program,with the workforce issues,
is managed bya retired volunteer dentist. that's another group of peoplethat we're not accessing. there's another group who we'vealluded to, without time to go into, who have special needs. most important for this group, we're nottrying to get the fluoride toothpaste. well, we are giving them fluoride, but our key message is, after the dose,rinse their mouths with water. if we can get that going... norman: elizabeth,what do you think is the role of the gp
in oral health in the country? it's important to rememberthat it's part of the whole patient. we look inside the mouthsof many young children 'cause they've gotupper respiratory-tract infections, and we're looking at tonsils. we don't look often enoughinside the mouths of adults. we need to be doing this,and looking for those early signs to remind peopleabout their oral health, and that if they can take better careof what's there,
we might be able to manageuntil we get more dental therapists, hygienists and dentists on track. that's a good final message. angela,what's your take-home message? as health professionals, we needto advocate for water fluoridation. and get that toothbrush and brush. norman: with fluoride toothpaste.- fluoride toothpaste. norman: don't worry about flossing, make sure toothpasteis the last thing that hits the mouth. - keep it simple.norman: debra?
i would say to every parent, lookin your child's mouth every single day. if you see something thatdoesn't look right, doesn't brush off, get it seen to. deal with itwhile it's in the early stages. find out what's going on,see what we can do. norman: bruce? i've agreed with all the suggestionsso far. i've only got one other,and that is to take an active interest in encouraging moredental professionals into your area.
professionals as a whole need to seethemselves as a professional group. unless they're working together to geta good regional representation together, the region may well be running down. norman:so, be a bit collegiate. marc? my only addition to the fluoride,fluoride, fluoride toothpaste story... norman: is a bit of fluoride?- a bit of fluoride toothpaste. the messages we are talking aboutare no different to the messages of the diabetes programs,cardiovascular programs. they're all about diet,improved general health.
norman: stop smoking.- all those things. they're the same messages. thank you all very much indeed. i hope you've got a lot from tonight'smouth... tonight's program! we mouthed on about oral health. if you're interested inobtaining more information about issues raised in this program, there are a number of resourcesavailable don't forget to complete and send in
your evaluation forms,and please register for cpd points by completing the attendance sheet. our thanksto the department of health and ageing for making the program possible. above all, thanks to you for taking timeto attend and ask questions. i'm norman swan. bye for now. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�
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