[Good oral care deserves to be better integrated into primary care]. / Goede mondzorg verdient een betere integratie in de eerstelijnszorg.

Oral and general health are inextricable. In primary care, the fields of care by general practioners, youth healthcare, healthcare for older people and oral care are all distinctly separated. Healthcare professionals are increasingly confronted with the complexity and increase in Noncommunicable diseases (NCD's) and an aging population. The aetiology of NCD's in primary care concern the professional fields of all healthcare professionals mentioned, meaning that lifestyle-related risks might be prevented more effectively through collaboration. In primary care, the number of medically compromised people is on the rise and healthcare professionals encounter each other's patients, whose risks remain invisible to them. Through collaboration such problems could be faced more effectively. Better integration of oral care into primary care can also contribute to the quality of care and safety of care receivers, and reduce further inequality. In order to better design this integration with the help of innovation, more practicebased research and implementation is needed.

[Medicaments and oral healthcare. Medicaments potentially inducing angioedema and/or urticaria]. / Serie: Medicamenten en mondzorg. Medicamenten die angio-oedeem en/of urticaria kunnen induceren.

Angioedema stems from increased vasodilation and vascular permeability, resulting in extravasation of fluid. Hereditary and acquired types of angioedema can be distinguished, with 3 and 4 subtypes, respectively. Groups of medicaments potentially inducing angioedema are, among others: ACE inhibitors, angiotensin II receptor blockers, dipeptidyl peptidase-4 inhibitors, thrombocyte aggregation inhibitors and immunosuppressive agents. Urticaria is characterised by red, slightly raised swellings, usually associated with a strong itching sensation and can be subdivided in an acute and a chronic type. Mast cells in the uppermost layer of the skin or the mucous membranes release a lot of histamine, increasing the dilation and permeability of blood capillaries, resulting in extravasation of fluid. Medicaments potentially inducing urticaria are, among others, the following groups: analgesics, anaesthetics, antibiotics, antidepressants, antihistamines, antihypertensives, antifungals, corticosteroids, H2 blockers, cancer medicaments, muscle relaxants, thrombocyte aggregation inhibitors and vaccines. Medical history and being alert when administering and prescribing anaesthetics, analgesics and antibiotics are very important in the prevention or treatment of angioedema and/or urticaria.

[Facial angioedema following pharmacotherapy with an ACE inhibitor]. / Angio-oedeem in het aangezicht na medicatie met een ACE-remmer.

A 56-year-old women suddenly had a swelling on her right cheek and on the right side of her upper lip, for which she decided to first visit her family physician and subsequently her family dentist. During the past two years, she was treated for an ovarian carcinoma by an oncologist. Recently, she was using the antihypertensive ACE inhibitor enalapril, prescribed by her family physician. Consultation between her family dentist, family physician and oncologist led to the diagnosis angioedema as an adverse effect of enalapril. The family physician replaced enalapril by the angiotensin II receptor blocker losartan. Subsequently, the swelling disappeared within two days. This angioedema type occurs most frequently in the head and neck area. Oropharyngeal, tongue and laryngeal oedema are very dangerous because they may cause airway obstruction. Today, a live-threatening or fatal condition is mostly prevented as a result of better vigilance of dentists and physicians. Nevertheless, such a condition will still occur occasionally.

[The objective oral health of Parkinson's disease patients]. / De objectieve mondgezondheid van personen met de ziekte van Parkinson.

In this article, the results of a research project on the objective oral health of Parkinson's disease patients, related to the duration and the progression of the disease, are reported. Participants were 74 patients with Parkinson's disease and 74 control persons. All participants were orally examined. Dentate Parkinson's disease patients had statistically significantly more teeth with carious lesions, more tooth root remnants, and more biofilm and food particles when compared to dentate control persons. Within the group of dentate Parkinson's disease patients, the number of teeth with restorations as well as the number of mobile teeth were positively related to the duration of the disease. Additionally, in this group the number of teeth with carious lesions, the number of teeth with restorations, and the number of tooth root remnants were positively related to the progression of the disease. Parkinson's disease patients need daily oral hygiene care support, particularly in advanced stages of the disease.

[Medicaments and oral healthcare. Hyperpigmentation of oral soft tissues due to afamelanotide]. / Serie: Medicamenten en mondzorg. Hyperpigmentatie van de orale slijmvliezen door afamelanotide.

The medicament afamelanotide is an analogue of endogenous ?-melanocyte-stimulating hormone. It promotes cutaneous pigmentation, providing protection from sunlight. In dermatology, afamelanotide seems to establish therapeutic results for polymorphic light eruption, solar urticaria, erythropoietic protoporphyria, Hailey-Hailey disease, vitiligo and acne vulgaris. Afamelanotide is available for non-medical use to realise quick and easy skin tanning. Adverse effects of afamelanotide mentioned in the scientific literature are development and aggravation of melanocytic naevi, degeneration of melanocytic naevi to melanomas, melanonychia, systemic toxicity, rhabdomyolysis, posterior reversible encephalopathy syndrome, priapism and hyperpigmentation of oral soft tissues. Furthermore, numerous adverse effects of afamelanotide have been reported to the Netherlands pharmacovigilance centre LAREB as well as numerous adverse effects due to overdosage of afamelanotide to the National Poisons Information Centre. Dentists should be alert to hyperpigmentation of oral soft tissues due to afamelanotide.

[The subjective oral health of Parkinson's disease patients]. / De subjectieve mondgezondheid van mensen met de ziekte van Parkinson.

This article comprises a report on a research project on the subjective oral health of Parkinson's disease patients, related to the duration and the progression of the disease. Participants were 74 patients with Parkinson's disease and a 74-person control group. All participants were interviewed about educational level, smoking habits, length of time since the last oral health consultation, number of oral health consultations during the previous 5 years, daily oral care, type of toothbrush used, chewing problems, biting problems, loss of taste, burning mouth, xerostomia, halitosis, remaining food particles, painful and bleeding gums, tooth mobility, toothache and tooth sensitivity. More patients with Parkinson's disease than people in the control group reported daily oral care support and had chewing problems, biting problems, loss of taste, tooth mobility and xerostomia. Among the patients with Parkinson's disease, the prevalence of chewing problems was related to the duration as well as the progression of the disease. Furthermore, a relation was demonstrated between the progression of the disease on the one hand and biting problems and daily oral care support on the other.

[The need for gerodontology in education and research]. / De noodzaak van gerodontologie in onderwijs en onderzoek.

The realisation that oral care for elder patients is very desirable and also necessary is only a few decades old. The earliest research was carried out in 1978. In the Netherlands and Flanders, research on oral care for the elderly began a few years later: the first doctoral degree in the field of gerodontology was awarded at the University of Nijmegen in 1989, after which more followed. In 2005, the BENECOMO was established, a Belgian-Dutch consortium in which geriatric dentists and specialists in healthcare for the elderly cooperate closely in research. A consequence of the cooperation has been, among other things, that gerodontology is now a broad professional field, which takes into consideration the importance of biomedical, psychological and social factors and a multidisciplinary approach, aiming at prevention.

[Caries explosion following bariatric surgery]. / Cariësexplosie na bariatrische chirurgie.

In a general dental practice, attention was drawn to a patient by numerous deep carious cavities following bariatric surgery. In the research literature, indications can be found for a negative influence of bariatric surgery on oral health. Risk factors for caries, such as the number of cariogenic bacteria in saliva, inadequate quantity and quality of saliva, gastrooesophageal reflux and vomiting may be become more pronounced. Additionally, dietary habits will change due to the altered anatomy of the gastro-intestinal tract. Negative effects of bariatric surgery on periodontal tissue have also been found. However, it is conceivable that patients who are overweight already have poorer oral health prior to bariatric surgery,due to lifestyle and dietary habits, than comparable people who are not overweight. Health education programmes prior to and following bariatric surgery seem to have a positive effect on oral health. Initiating more research into oral health related to bariatric surgery is recommended.

[Early oral symptoms of Parkinson's disease]. / Vroege orale symptomen van de ziekte van Parkinson.

A family dentist established that the oral self-care of a 58-year-old man was suddenly inadequate. The dental hygienist who had been recruited subsequently noticed that the dexterity of the man was inadequate. The man's general medical practitioner referred him to a neurologist, who diagnosed Parkinson's disease. Due to this problematic situation, the man was off the family dentist's radar for approximately 1 year. Thereafter, a course of intensive support for his oral health behaviour was initiated. Given the progressivity of Parkinson's disease, it makes sense to aim at an oral health plan resistant to the patient's life course. The family dentist should be aware of his continuing responsibility to provide care and supervision until such time when informal and professional domiciliary care are no longer satisfactory or achievable and admission to a care facility is unavoidable. Only then can the family dentist hand over his responsibility to the geriatric dentist allied to that specific care facility.

[Series: Medicaments and oral healthcare. Medicaments and addictive substances, potentially inducing or ameliorating bruxism]. / Serie: Medicamenten en mondzorg. Medicamenten en verslavende middelen die potentieel bruxisme induceren of dempen.

Bruxism is described as a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. This article provides an inventory of medications registered in the Netherlands and of addictive substances reported to potentially induce or aggravate bruxism as an adverse effect, and of medications registered in the Netherlands reported to potentially ameliorate existing bruxism. Groups of medications known as having the potential adverse effect of bruxism are amphetamines, anticonvulsants and selective serotonin reuptake inhibitors. Separate medicaments found in the scientific literature, having this potential are aripiprazole, atomoxetine, duloxetine, flecainide, ketotifen and methadone. Addictive substances with bruxism as potential adverse effect are alcohol, heroin, methamphetamine, methylenedioxymethamphetamine, nicotine and piperazines. Medications with the potential to ameliorate existing bruxism are botulinum toxin A, bromocriptine, buspirone, clonazepam, clonidine, gabapentin and levodopa.

[Possible treatment options for Parkinson's disease]. / Behandelingsmogelijkheden voor de ziekte van Parkinson.

Possible treatment options for Parkinson's disease consist of medications for motor symptoms as well as non-motor symptoms, such as cognitive decline, depression, hallucinations and delusions, constipation, and drooling. A number of these medications are in the experimental stage. In addition, physical activity and exercise can favourably influence the motor as well as the non-motor symptoms. Speech and dysphagia therapy are available, whereas cognitive behavioural therapy can control depressionand anxiety. Deep brain stimulation is the only surgical treatment currently used. Potential future surgical treatments are gene therapy, (stem) cell therapy, and the application of growth factors. Worldwide, research projects are being carried out in order to be able to control the disease. Once in a while surprising discoveries are made. Whether cure and/or prevention are possible remains to be seen.

[Medicaments and oral healthcare. Mechanisms of interaction between medicaments]. / Serie: Medicamenten en mondzorg. Mechanismen van interacties van medicamenten.

Interactions between medicaments or between a medicament and another product used by the patient may result in a medicamentbecoming inactive or in an increase in the side effects. By proper historytaking, a dentist will often know which medicaments a patient uses and can take this into account in prescribing a medicament. Self-care medications and specific foods are often not spontaneously reported by a patient but can still interact with a medicament prescribed. A dentist should be aware of the interactions a prescribed medicament can have with other medicaments and products used by the patient. Therefore dentists have to ask directly about such medicaments and products, and record them in the patients' file.

[Parkinson's disease: pathogenesis, aetiology, symptoms, diagnostics, and its course]. / Ziekte van Parkinson: pathogenese, etiologie, symptomen, diagnostiek en beloop.

Parkinson's disease is a slowly progressive neurodegenerative disorder characterised by motor symptoms, which are accompanied or often even preceded by non-motor symptoms. Pathologically, the disease is characterised by neural degeneration in specific brain regions, including the dopaminergic neurons of the pars compacta of the substantia nigra. At the molecular level, mitochondrial dysfunction, oxidative stress, altered protein handling, and reactive microgliosis contribute to the neural degeneration. Advanced age is a significant risk factor. Men are more often affected by the disease than women. Environmental, life-style and genetic factors are potential aetiological factors. The disease is primarily diagnosed on the basis of clinical features. In clinically uncertain cases, magnetic resonance imaging and dopamine transporter single-photon emission computer tomography can provide additional information. Patients usually die due to comorbidity. Parkinson's disease has also several negative influences on the orofacial system.

[Medicaments and oral healthcare. Proliferation of the gingiva]. / Serie: Medicamenten en mondzorg. Proliferatie van de gingiva.

Adverse effects of medications and self care products on the gingiva can be divided into inflammation, intrinsic discolouration, irritation, trauma, cytotoxicity, lichenoid reaction, and proliferation. This article deals with the last-mentioned type of adverse effects; the other 6 have been discussed in a previous article. Proliferation of the gingiva as an adverse effect of medications has been reported for anticonvulsants, calcineurin inhibitors, calcium channel blockers and isotretinoin. With regard to the anticonvulsants that have been registered in the Netherlands, proliferation of the gingiva is predominantly induced by phenytoin, but also by carbamazepine, ethosuximide, phenobarbital, gabapentin, levetiracetam, primidone and valproic acid. All calcineurin inhibitors registered in the Netherlands may induce the adverse effect. This is also the case for nearly all calcium channel blockers, but particularly for dihydropyridines. Presumably, proliferation of the gingiva may be prevented or reduced in a number of ways. The most important one is good oral hygiene. Furthermore, proteins and cells that play an important role [in the process of gingival proliferation] have been discovered and there are medications that have the potential to eliminate these proteins and cells.

[Iatrogenic, intrinsic irritation of the oral mucosa]. / Iatrogene, intrinsieke irritatie van het mondslijmvlies.

The behaviour of a 78-year-old, edentulous female resident of a care home, suffering from dementia indicated to her care providers that she was experiencing oral pain. At the left (pre)molar region of the mandibular residual alveolar ridge, an irritated, red-coloured, sharply restricted mucosal area was seen, extending in width from the buccal to the lingual border of the ridge. Eventually it was identified as mucosal irritation, apparently due to hydroxylapatite cones that had previously been inserted to augment the residual alveolar ridge. Preservation and augmentation of an edentulous part of an alveolar ridge or of a fully edentulous alveolar ridge are both possible using alveolar implants and/or several surgical procedures. In the current case, such previous treatment was not known to have taken place. Consequently, the dentist was not able to provide treatment immediately. This case illustrates the need for general dental practitioners to keep an eye on their older patients and to provide all relevant information when the oral health care provision is taken over by another dentist.

[Medicaments and oral healthcare. Adverse effects of medicines and self care products on the gingiva]. / Serie: Medicamenten en mondzorg. Bijwerkingen van medicamenten en zelfzorgmiddelen op de gingiva.

Medications and self care products may have adverse effects on the gingiva. These adverse effects can be divided into inflammation, intrinsic discolouration, irritation, trauma, cytotoxicity, lichenoid reaction, and proliferation. This article deals with the first 6 types of adverse effects mentioned: a subsequent article will deal with the last type mentioned. Since contraceptives were introduced, there have been indications that they cause or promote gingivitis, but with the current contraceptives this adverse effect is rarely seen. Intrinsic discolouration of the gingiva has been reported when using Staloral®, minocycline, contraceptives and hydroxychloroquine. Irritation and trauma of the gingiva are seen when self care products containing carbamide peroxide or hydrogen peroxide are used for external tooth whitening, or which have analgesic potential, such as acetylsalicylic acid and hydrogen peroxide or oral rinses containing alcohol. Several cytostatics may induce apoptosis of keratinocytes in the gingiva. Oral rinses with antibacterial ingredients have cytotoxic potential. Lichenoid reactions have been reported due to the use of several (groups of) medications.

[Medicaments and oral healthcare 6. Oral side effects of -medications commonly used by older people]. / Serie: Medicamenten en mondzorg 6. Orale bijwerkingen van door ouderen veelgebruikte medicamenten.

In the coming decades the western world will experience a double ageing of its population; there will be an increase in both the number of older people and the average age. The increase in life expectancy will also mean more and more older people who suffer from multiple systemic diseases that are treated with medications. At this moment, 45% of those over 65 use 5 or more medications and 20% of those over 75 use as many as 10 or more. The more medications used, the greater the risk of side effects and therefore oral side effects, like symptoms of dry mouth or the development of candidiasis, angioedema, gingival hyperplasia, lichenoid reaction of the oral mucosa, dysgeusia, halitosis and osteonecrosis. Considering the wide range of oral side effects, it is important for dentists to be well aware of the medications being used by older patients as well as having a thorough knowledge of their oral side effects.

[Medicaments and oral healthcare 5. Adverse effects of -medications and over-the-counter drugs on teeth]. / Serie: Medicamenten en mondzorg 5. Bijwerkingen van medicamenten en zelfzorg­middelen op gebitselementen.

Intrinsic tooth discoloration may occur as an adverse effect of fluoride and tetracyclines. Extrinsic tooth discoloration may occur as superficial staining or as discoloration of the superficial pellicle and/or biofilm due to chlorhexidine, liquid iron salts, essential oils, some antibiotics and stannous fluoride. Inhibition of orthodontic tooth movement has been reported due to the use of prostaglandin synthetase inhibitors. If medications or over-the-counter drugs induce hyposalivation or contain much sucrose, caries may develop. Erosion may occur if the acidity of medications or over-the-counter drugs is excessive. Attrition is a well-known adverse effect of serotonin reuptake inhibitors, antiparkinson agents, and antipsychotics. Congenital dysplasia is observed following childhood treatment with cytostatic drugs. External cervical root resorption is an adverse effect of internal teeth-whitening products. Prenatal exposure to antiepileptic drugs and childhood treatment with cytostatic drugs may cause dental agenesis. Antiseptic drugs applied for external teeth-whitening and toothpastes with additional ingredients to prevent extrinsic discoloration and creation of calculus, may cause tooth hypersensitivity.

[Preventive dentistry 6. Prevention of caries in frail older people]. / Preventieve tandheelkunde 6. Preventie van cariës bij kwetsbare ouderen.

Many older people have a bad oral health, with (root) caries a prevalent cause. Alarming results of research projects raise the question whether sufficient preventive measures are being taken to prevent the development and progress of (root) caries in frail older people. A review of the recent literature revealed that in frail older people and physically or cognitively impaired adults, daily use of a 5,000 ppm fluoride toothpaste and quarterly application of chlorhexidine or sodium fluoride can decrease by half the risk of root caries. In the Netherlands, toothpaste containing 5,000 ppm fluoride is not (yet) on the market. At the present time, only the advice brochure 'Prevention of root caries' is available. Another measure to prevent deterioration of oral health among frail older people is paying attention to frail older people who do not visit their dentist on a regular basis due to physical limitations and care dependency. When this is the case, it is necessary to intensify professional oral healthcare with instructions to personal caregivers and professional care providers in order to fight (root) caries.

[Medicaments and oral healthcare 4. Pharmacotherapy in (frail and care dependent) older people]. / Medicamenten en mondzorg 4. Medicatie bij (kwetsbare en zorgafhankelijke) ouderen.

Polypharmacy is the consequence of multimorbidity. Both phenomena may cause functional limitations and/or frailty and/or care dependency in older people. In the human body, a medicament undergoes at least 3 important actions: absorption, distribution and elimination. These actions may proceed aberrantly in older people. Following interaction with receptors, a medicament triggers a chain reaction in the human body. The receptors and each link of the chain reaction may be subject to changes due to diseases as well as ageing. This, particularly, is the case with regard to medications directed towards the central nervous system and the cardiovascular system. Furthermore, interactions may occur between various medications mutually and between medications on the one hand and on the other hand food and water intake, self-medication with herbs, and diseases. Moreover, older people usually experience more adverse effects of medications when compared to younger people. This is due to altered body actions and reactions, polypharmacy and the many possible interactions. In older people, utilisation and intake of medications often give rise to problems that can be divided into medicament-related, patient-related, care- and care provider-related and other problems.