July/Aug 2014, Volume 35, Issue 7
Published by AEGIS Communications
Oral Health Experts: The Evolving Realm of Dentistry
Oral healthcare is expanding to include a variety of ancillary therapies that require increased interaction between dental and medical professionals. Areas such as dental oncology, dental sleep medicine, and sleep prosthodontics—along with a greater understanding of the oral/systemic link—are prompting dentists to integrate further into the healthcare community.
Like all medical professions, dentistry is continuously evolving. Advancements in technology, materials, and techniques can improve efficiency and quality of care rendered to patients; and while none would argue that such progress is essential for the growth and development of the dental profession, dentistry is changing in other ways as well. What were once seen as specialized niches of interest on the periphery of dentistry are becoming more commonplace within the realm of oral healthcare. Many of these ancillary areas span the common ground between dentistry and medicine and require close interaction between the dental and medical teams. As offices integrate more specialized care to expand the scope of practiced dentistry, patients will benefit from the expertise of the dental professional in oral-related healthcare matters.
Dental oncology is a focus of dentistry dedicated to meeting the unique dental and oral healthcare needs that arise as a result of cancer therapy.1 Although the world of oncological medicine has seen great advances over the past few decades, many of the modern treatment modalities used to fight cancer still wreak havoc on oral homeostasis. Oral side effects associated with oncology care are often painful and present a significant risk for systemic infection at a time when the patient may be immunosuppressed. As a specialized area of oral medicine that is often seen as bridging the gap between dentistry and medicine, dental oncology is devoted to improving the oral health, systemic health, and quality of life of people battling cancer.
Sometimes dental oncology care falls squarely within the scope of dentistry; something as basic and fundamental as reducing the intraoral bacterial load by removing plaque and calculus prior to cancer treatment has been shown to diminish the incidence and severity of oral complications associated with cancer care. At other times, however, proper dental oncology care requires a thorough understanding of the effects of chemotherapy and head and neck radiation in order to develop a treatment plan that is timed appropriately to assure the patient’s safety before, during, and after cancer treatment. Management of complicated oral side effects specific to cancer therapy such as oral mucositis, xerostomia, oral pain, infections, and osteonecrosis—whether related to head and neck radiation or intravenous bisphosphonate therapy—are part of dental oncology care.1 Sometimes a patient undergoing treatment for cancer presents with comorbidities, all of which must be taken into consideration when evaluating and planning treatment for the individual.
In addition, some of the pharmacological and physiological effects of common cancer therapies limit treatment in the oral cavity; therefore, timing of dental oncology procedures is often critical to ensure the safety of the patient at various points along the cancer journey. Thus, treatment planning in dental oncology is often complex and requires open communication with physicians and nurses to coordinate care and give and receive clearances; nonetheless, the personal and professional rewards of the dentist or hygienist who incorporates dental oncology care into the practice are great.
Dental Sleep Medicine
Dental sleep medicine, also known as sleep dentistry, is an area of dentistry that focuses on the management of sleep-related breathing disorders, including snoring and obstructive sleep apnea, through the use of oral appliance therapy and/or upper airway surgery. Patients experiencing sleep apnea may simply snore loudly, or can actually stop breathing for short periods of time—sometimes up to hundreds of times per night. The result can be excessive daytime sleepiness, morning headaches, irritability, depression, decreased sex drive, and impaired concentration. Untreated, sleep-related breathing disorders can lead to hypertension, stroke, heart attack, and even sudden death during sleep.2
Because the first line of treatment is often an oral appliance, many dentists have become interested in this field and have expanded their practices to include dental sleep medicine as a service. The appliance, which is worn only at night, prevents closure of the airway by either depressing the tongue or repositioning the mandible. Like many other areas that were once on the outskirts of dentistry, dental sleep medicine requires close interaction with the medical community. In this case, since sleep apnea is a medical condition, a physician must diagnose the sleep disorder and recommend treatment. Once diagnosed, the patient then works closely with the dentist, who assists in the selection and fitting of the oral appliance and provides long-term follow-up care.
Recently, a new area of dentistry has emerged focusing not on the impact of an oral appliance on the airway as dental sleep medicine does, but rather on the airway itself and the impact that the airway has on the stomatognathic system. This area, known as sleep prosthodontics, serves to answer questions such as why malocclusions are developed, why myofacial pain symptoms are observed, and why dentitions become worn.3
Solutions in sleep prosthodontics are often interdisciplinary and entail a wide range of options including orthodontics, oral mycology, nutrition and diet counseling, orthognathics, continuous positive pressure airway (CPAP), mandibular advancing appliances (MAA), and otolaryngologic surgeries.3 The argument for treatment is strong in that, in children, snoring independent of obstructive sleep apnea may cause neurocognitive dysfunction and impaired daytime performance and increase the risk for social problems, poor academic performance, decreased attention, and anxiety/depression issues. Sleep disordered breathing may create craniofacial changes that further exacerbate the respiratory difficulty. Early intervention is, therefore, preferred to prevent worsening of the craniofacial problem. Such intervention may involve removal of the tonsils and adenoids or more complex treatment including other disciplines of dentistry and medicine as noted above.
Children are not the only patients who may benefit from sleep prosthodontics. In adults, sleep fragmentation may be a causative factor in the exacerbation of chronic myofacial pain. Understanding the impact that the airway and sleep have on the cause and interpretation of myofacial pain may help produce more effective treatment modalities to improve quality of life for these patients.4
The Oral/Systemic Link
Many dental offices have begun to embrace the concept that the mouth and teeth do not exist independent of the rest of the body. Today, a clearer picture of how oral health and systemic health are intertwined is coming into focus. Emerging science has shown the impact that chronic inflammation, such as that seen in untreated periodontal disease, can have on systemic health. More understanding is being gained regarding reactive oxygen species and their possible role in oral and systemic health. The importance of the oral/systemic link is further substantiated by evidence of relationships like that of human papilloma virus (HPV) and oropharyngeal cancer, diabetes mellitus and periodontitis, oral mucositis and graft-versus-host disease in a world where cellular and organ transplants are increasingly commonplace, and the oral effects of autoimmune diseases such as Sjögren’s syndrome and rheumatoid arthritis, just to name a few. The modern dental office can be a medical triage center where undiagnosed hypertension or diabetes are identified and referred—for example, to a physician for treatment; to a nutrition or diet consultation center where antioxidant screening is done to ensure the tools are in place for a beneficial systemic response to reactive oxygen species and free radicals; to a screening facility for oral and head and neck cancer; or to a convenient location for the assessment of caries risk or HPV infection through chairside diagnostic testing.5
Just a few years ago, many procedures were not considered to be dental services. Today, more and more offices across the country are realizing the impact they can and should have on the health and wellness of their patients.
As the field of dentistry continues to evolve from a profession of teeth and gum specialists to one of oral health experts who understand the correlation and impact that oral health has on systemic health—and vice versa—practitioners should be prepared to embrace their expanding roles in the healthcare community.
ABOUT THE AUTHOR
Dennis M. Abbott, DDS
Private Practice, Garland, Texas
Founder and CEO, Dental Oncology Professionals, Garland, Texas; Dental Oncologist, Baylor Charles A. Sammons Cancer Center, Dallas, Texas
1. Abbott DM. Dental oncology: caring for individuals battling cancer. Inside Dentistry. 2013;9(2):68-72.
2. American Academy of Dental Sleep Medicine Web site. http://www.aadsm.org. Accessed March 2, 2014.
3. Rouse JS. Sleep prosthodontics: a new vision for dentistry. Inside Dentistry. 2013:9(7):60-76.
4. Rouse JS. Sleep prosthodontics: analyzing myofacial pain: a new paradigm for examining temporomandibular disorder. Inside Dentistry. 2013;9(12):35-39.
5. The American Academy for Oral Systemic Health Web site. http://www.aaosh.org. Accessed March 2, 2014.
Sleep Prosthodontics: A New Vision for Dentistry
Head and Neck Skin Cancer: Dentists’ Responsibility in Early Detection
Advancing Wellness in the Dental Office Through Use of Screening and Diagnostic Technology