Internet-Based Prevention
Monitoring toothbrushing
Background.—Apps are able to instantly transport us to
a site where we can learn more, spend money, play games,
or link up with others. The public loves them, as evidenced
by the download of 102 billion apps in 2013. Although most
(91%) were free, they generated $26 billion. Now innovative
app developers have targeted personal hygiene with an
Internet-connected toothbrush.
How It Works.—Manual brushes are increasingly being
replaced with electronic products that achieve the same
goal. However, the Kolibree toothbrush, developed by
the French firm Kolibree, includes a sensor that detects
how much plaque is being removed during brushing. It
also records brushing activity so users can see if they are
achieving consistent cleaning. The brush then relays the in-
formation to a smartphone app. The tooth brush is ex-
pected to be available worldwide in the latter part of
Oral Medicine
Care before, during, and after radiation therapy
Background.—The adverse effects of radiation therapy
(RT) in the oral cavity are targeted at cells that are rapidly
dividing or otherwise less capable of repairing damage.
These include cells of the mucous membranes, underlying
soft tissue, tooth, periosteum, bone, glands, and vascula-
ture. Xerostomia, dysgeusia, mucositis, altered normal
flora, radiation caries, reduced mouth opening, and osteor-
adionecrosis of the jaw (ORN) can develop as a result of RT-
caused damage. Management of oral health is particularly
important for patients with head and neck cancers
(HNCs) because oral complications are common during
and after RT. Most are unavoidable, but some are prevent-
able. The management of the dental needs of patients
who have undergone or will undergo RT was discussed.
Before Radiotherapy.—A multidisciplinary team
(MDT) is essential in assessing, diagnosing, and managing
HNC patients. Such a team should at least include a dental
practitioner with experience in HNC; specialists in restora-
tion and rehabilitation plus health practitioners to educate
and teach preventive dental care should be part of any
expanded dental team.
32 Dental Abstracts
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2014. Its price will range from $99 to $200, depending on
the model selected. The app is free.
Clinical Significance.—We use apps on our
smartphones to connect us to the world, but
this one connects to how well we brush our
teeth. We have yet to see how accurate the
sensor is, how it well it works, and whether it
improves the toothbrushing efforts of patients.
Horseman RE: Internet toothbrushing. J Calif Dent Assoc 42:353-
354, 2014
Reprints available from Publications Specialist Andrea LaMattina;
e-mail: andrea.lamattina@cda.org
The patient first goes through a thorough assessment
and receives preventive advice and needed extractions
and fillings from a general dentist. Final oral rehabilitation
is considered from the beginning of treatment, so a
specialist prosthodontist should be included. The assess-
ment is based on the patient’s diagnosis, prognosis, pro-
posed treatment, patient factors, and pre-existing oral
health. Unrestorable teeth and those with gross periodon-
titis are removed with as little trauma as possible and min-
imal flap surgery. It should be noted that inconsistent
evidence surrounds the association between pre-RT extrac-
tions and the development of ORN. Sufficient healing time
before RT should be allowed, which is usually 10 days to 3
weeks. After the assessment, checkups are scheduled every
3 months, and the patient is instructed in daily fluoride and
bicarbonate rinses, with restorations placed as needed.
During the patient’s full medical and dental history, fac-
tors that may increase the risk of oral complications are
noted, along with risk factor modification—such as smok-
ing and alcohol cessation. The patient should also be eval-
uated for motivation and whether he or she can manage
expected dental hygiene regimens. If motivation is a prob-
lem, further appointments with an experienced hygienist
may help prevent complications. The patient’s oral exami-
nation should include radiographs as indicated, and a
detailed tooth-by-tooth assessment is recorded. Patients
who use dentures should be advised to discontinue their
use until after treatment is completed. The dentures should
also be checked to ensure they fit well and will not cause
ulceration.
Considerations specific to restorations pre-RT
include paying special attention to avoid using patient
time for extensive treatments. Scaling, prophylaxis,
and fluoride applications should be done and simple
restorations carried out. Alternatively, provisional resto-
rations using glass ionomer cements can be done. HNC
patients may suffer trauma to the irradiated soft tissues
if there are sharp cusps or restorations, so these should
be eliminated through smoothing or repair. Impressions
can be taken for study models and the fabrication of soft
mouth guards or medication carrying trays during
treatment.
During Radiotherapy.—The major concerns during RT
are mucositis, oropharyngeal candidiasis, xerostomia, and
emergencies. Up to 80% of HNC patients develop oral mu-
cositis (OM) after 7 to 10 days of treatment that lasts for
several months, usually manifesting as atrophy, swelling,
erythema, ulceration, and pseudomembrane formation.
These are often accompanied by colonization with
gram-negative organisms and candida organisms. Patients
experience pain and functional difficulties and may
require a nasogastric tube or percutaneous endoscopic
gastrostomy (PEG) feeding. The tissues most often
affected are the soft palate, hypopharynx, floor of the
mouth, cheeks, tongue, and lips. OM can be prevented
or treated through frequent tooth brushing with a soft,
regularly changed toothbrush, regular flossing, oral
rinses, adequate hydration, and avoidance of oral irri-
tants. Symptoms may be managed by tooth mousse,
topical barrier gels, and benzydamine. Aloe vera gels
and honey products may offer some patients comfort.
Dental-protective stents may prevent scattering of radia-
tion in patients with metal fillings, which can produce
OM. Analgesia for pain and consultation with a dietitian
to assess oral intake are also advised.
Oropharyngeal candidiasis (OPC) often occurs after
head and neck RT and can be a significant cause of
morbidity and decreased quality of life. Usually the tongue,
oral cavity, and labial commissure are affected. Symptoms
can include burning pain, difficulty swallowing, dysgeusia,
and halitosis. Local therapy is the treatment of choice un-
less the case is severe, suspected to include disseminated
candidiasis, in a high-risk patient, or has not responded to
local methods. Regular dental hygiene, saliva substitutes,
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and cessation of smoking and alcohol can prevent OPC.
Topical miconazole, fluconazole, or nystatin can be helpful
for local therapy, with oral fluconazole used for systemic
treatment.
Xerostomia is manifest as hyposalivation and increased
salivary viscosity. Functional issues related to xerostomia
can affect speech, taste, chewing, and swallowing. Oral in-
fections are also more likely, as are dental caries, in pa-
tients with xerostomia. Tumor location and technique
used to deliver RT along with dose are linked to the
incidence of xerostomia, but even small doses can cause
glandular destruction. Newer techniques such as
intensity-modulated RT (IMRT) avoid large doses to the
parotids and protect function. Management of xerosto-
mia includes good oral hygiene, salivary substitutes,
and sialogogues.
Should a dental emergency develop during TR, the radi-
ation oncologist should be contacted and the problem
described. Acute toothache may be managed using stan-
dard restorative or endodontic techniques. Difficulties
may arise with OM, general discomfort, and limited ability
to open the mouth. Extractions should be performed
with minimal trauma by a specialist.
After Radiotherapy.—Chemical and microbial
changes in the oral cavity after RT create a cariogenic
environment in which dental deterioration is common.
Radiation caries can affect even those teeth not irradiated
and can progress to full dental loss in 3 years. The inci-
dence of caries is related to radiation dose. The sites
affected are the labial surfaces of the cervical, cuspal,
and incisor areas. Prevention is the best approach and in-
cludes using fluoride in medication carrier trays at least
once a day. Dental hygiene measures and xerostomia
management also help to prevent caries. Rinses should
be either nonacidic fluoride preparations or bicarbonate
preparations. Brushing and flossing should be gentle
and thorough.
If restorations are planned after therapy, the clinician
should be aware that the process may be complicated
by limited access because of trismus or scarring and
poor moisture control caused by marginal gingivitis.
There is also an altered dental substrate and a hostile
oral environment. None of the currently available restor-
ative materials offer ideal properties to manage this situa-
tion, but conventional glass ionomer cements (GICs) offer
simple bonding procedures and chemical adhesion plus
fluoride release and reuptake, which may prevent re-
current caries. Resin-modified GICs (RMGICs) offer
improved structural and marginal integrity, similar rates
for recurrent caries, and greater resistance to acid
erosion. GICs are the material of choice for restorations
after RT.
Volume 60  Issue 1  2015 33
 Endodontic treatment is preferred to extraction in radi-
ation fields where caries involves the pulp. Root canal ther-
apy can be complicated by trismus and poor access. Cutting
access cavities through the labial or incisal aspects or de-
coronating grossly carious teeth offers a compromise.
Crown and bridgework is generally avoided because the
margins will be susceptible to recurrent caries. Simple indi-
rect restorations are acceptable in patients who are
compliant and have a stable dentition. For these it is impor-
tant to keep margins supragingival and use a hygienic
design. Removable prostheses are generally contraindicated
unless they are necessary for esthetics or function. Patients
must be counseled about the risks of these prostheses and
strongly encouraged to practice impeccable oral hygiene.
Dentures that are tissue borne also risk trauma and ORN,
so careful clinical technique should be combined with pa-
tient education and frequent recall. Denture provision is
traditionally delayed for 12 months after completing RT so
the area can heal and ridge remodeling can be completed.
Recent evidence indicates it may be possible to insert den-
tures within 6 months with results similar to those achieved
when denture placement is delayed 1 year.
ORN is typically a late serious complication after RT
in which irradiated bone is exposed and undergoes ne-
crosis. Preventive measures to avoid the need for dental
interventions have lowered the rates of ORN signifi-
cantly over the past several decades. However, extrac-
tion of teeth may become necessary, and this should
be accomplished with minimal trauma by an experi-
enced clinician. Prophylactic antibiotics, platelet-rich
plasma (PRP), and steroids have no consistent evidence
supporting their use in reducing ORN rates. It is recom-
mended that the general dental practitioner consider
endodontic treatment first and undertake extractions
only when needed. Safe extraction of teeth is possible
if they are out of the field or in fields receiving less
Infective endocarditis prophylaxis
Background.—Over a century ago it was suggested that
the oral cavity could be the source of organisms that might
produce bacteremia and ultimately focal infection. Focal
infection of oral origin could theoretically affect any organ
in the body, but infective endocarditis (IE) is considered
the most important possible infection because it is so preva-
lent and carries a high morbidity and mortality. The incidence
of IE varies from country to country, and the oral cavity is sus-
pected to be the source of the infective agent in 14% to 20%
of cases. Currently the evidence for a relationship between
distant site infections and bacteremia secondary to dental
34 Dental Abstracts
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than 50 Gy; the socket is closed primarily. The oral
and maxillofacial surgeon should perform care for teeth
in fields receiving greater than 50 Gy of radiation.
The use of hyperbaric oxygen (HBO) for ORN manage-
ment is under investigation. More research is also
needed before pentoxyfylline and tocopherol can be
recommended.
Follow-Up and Discharge.—A head and neck cancer
multidisciplinary team conducts follow-up for HNC pa-
tients, with discharge to the community dentist once the
patient successfully completes treatment and has no active
complications. Follow-up evaluations are scheduled at
3-month intervals, with the entire team kept abreast of all
developments.
Clinical Significance.—Preventive care is the
ideal approach to patients scheduled for RT
because of cancer of the head and neck.
Although few adjunctive therapies are sup-
ported by strong evidence, several are available.
Further research is needed in particular to
determine the correct approach to pre-RT ex-
tractions and the use of hyperbaric oxygen
and various pharmacologic treatments.
Beech N, Robinson S, Porceddu S, et al: Dental management of pa-
tients irradiated for head and neck cancer. Austral Dent J 59:20-28,
2014
Reprints available from N Beech, Oral and Maxillofacial Surgery
Dept, Royal Brisbane and Women’s Hospitals, Herston QLD 4006;
e-mail: nicholas.beech@uqconnect.edu.au
procedures is weak and has not demonstrated a causal rela-
tionship. However, researchers have recommended using
prophylactic measures, specifically antibiotics, to prevent
bacteremia subsequent to dental interventions. More
recently these recommendations have been questioned.
Antibiotic Prophylaxis Recommendations.—The rec-
ommendations for antibiotic prophylaxis (AP) have been
based on the potential for infection involving a medical de-
vice or condition. The American Heart Association (AHA)
formulated guidelines for AP before surgical procedures to