Open Wide: Common Infectious

Conditions We Overlook

What’s New in MedicineSeptember 2014

Russell Maier, MD

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“You are not healthy without good oral health…”

Oral Health in America: A Report of the Surgeon General• Dental care is the most common unmet health need• Oral disease can severely affect systemic health

David Satcher, MD, 16th Surgeon General

• Strong evidence shows clear links between oral health and respiratory disease2, cardiovascular disease3, and diabetes4.

• Because oral health is linked to overall health, the effects of poor oral health are felt far beyond the mouth.

• Primary Care interventions are evidence-based

• Recommend oral health training for non-dental health professionals.

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Learning Objectives• Understand the prevalence and consequences of oral disease

• Learn about the interrelationships between oral and systemic diseases

• Identify risk and protective factors that influence oral health

• Recognize caries and periodontal disease

• Understand the importance of primary care providers addressing oral health

• Understand how to interrupt and minimize oral diseases impacting children, pregnant women and people with diabetes

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Prevalence

Tooth Decay• Nearly 40% of kindergarteners in WA have

tooth decay • Nearly 1 in 4 adults in the U.S. have

untreated tooth decay

Periodontal Disease

• 47% of U.S. adults have some form of periodontal disease (> with age)

• 40% of pregnant women have some form periodontal disease

• 70% of adults 65+ have some form of periodontal disease

Photo: Robert Henry, DMD, MPH

Photo: ICOHP

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Periodontal Disease Systemic Diseases

• People with serious gum disease are more likely to have a chronic condition

• Periodontal disease—correlated with a variety of conditions with systemic implications– Cardiovascular disease, heart disease, respiratory infections,

diabetes, HIV, adverse pregnancy outcomes

• Systemic diseases can have an impact on oral health– Dementia– Chronic disease medications that cause xerostomia

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Consequences for Patients’ HealthOral diseases are largely preventable but untreated oral disease can lead to:

• Pain that makes it difficult to work, learn inschool, sleep, eat

• Poor eating habits and nutrition

• Reduced self-confidence and/or problems obtaining employment

• Complications of chronic diseases like diabetes, heart disease, and stroke

• Transmission of cariogenic bacteria from mothers to infants

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Oral-systemic ConnectionPeriodontal treatment reduces medical costs for people with chronic conditions & pregnant women

Study Conducted by University of Pennsylvania, School of Dental Medicine for United Concordia Dental 2005-2009

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Inflammatory Response

INFLAMMATION

DIABETES

CARDIOVASCULAR

NEUROLOGICALDISEASES

CANCER

AUTOIMMUNEDISEASES

PULMONARY DISEASES PERIODONTAL

DISEASE

ARTHRITIS

Presentation Title | Section | 9

Preventing and Interrupting Oral Disease

GOOD NEWS! Oral Disease is Preventable

Presentation Title | Section | 10

Preventing and Interrupting Tooth Decay

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Tooth Decay Process: A Bacterial Infection

Bacteria + Refined Carbohydrates = Acid

Acid + Time (20 min) = Enamel Demineralization & Risk for Decay

Untreated Decay Infection, Abscess, Loss of Tooth

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Early Decay: White Spots/Lines

Appearance • White spots and lines—first clinical

signs of demineralized enamel • Begins along the gum line• Without intervention, lesions will

progress to cavities that are initially yellow

Treatment • Fluoride varnish application to

reverse or arrest lesions • Dietary and oral hygiene

counseling• Dental referral Photos: Joanna Douglass, BDS, DDS

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Tooth Decay, Abscessed Teeth, Facial Swelling

Abscesses

Tooth Decay

Facial Swelling

AbscessedTeeth

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Tooth Decay Process: Snacking & Sipping

• It’s not just WHAT, but HOW, we eat & drink– Acid persists for 20-40 minutes after sugar or

carbohydrate ingestion– Acid leads to demineralization

• Key message:– Frequency of sugar/carbohydrates

more significant than quantity

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Diet and Dental Caries

Regular Meals

Regular Meals Plus Frequent Snacks

Plaque Level Acids

Eating Frequency

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Tooth Decay - Risk Factors• Prior decay and/or fillings

• Existing white spot lesions

• Frequent consumption of sugar & carbohydrate

• Inadequate fluoride

• Special health care needs

• Physical disabilities and dementia

• Medications that:

– Decrease salivary flow (xerostomia)

– Contain high levels of sucrose

  Photos: UKCD

Recurrent Caries

Malocclusion of drifting teeth after extraction

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Caries Process: Ongoing Balance

Protective FactorsSalivaPeptides (defensins)Fluoride

Pathologic FactorsAcid-producing Bacteria e.g. Strep mutans

Frequent carbohydratesReduced saliva

No Caries Caries

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Tooth Decay – Prevention Tips Remove bacteria (plaque) every day• Brush twice daily with fluoridated

toothpaste• Floss dailyLimit frequency of sweet, sticky, or sugary foods and drinks • Choose sugar substitutes,

especially xylitol (a natural sweetener that reduces cavity-causing germs in the mouth)

Use fluoride • Toothpaste• Fluoridated water• Fluoride varnish, gel, or rinse

Fluoride Varnish

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Benefits of Fluoride

• Topical (main effect)– Inhibits tooth

demineralization– Enhances remineralization– Inhibits bacterial

metabolism

• Systemic – Reduces enamel solubility– Promotes remineralization

of enamelPhotos: Joanna Douglass, BDS, DDS

Presentation Title | Section | 21

Preventing and Interrupting Periodontal Disease

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Gum Disease

Gingivitis Periodontal Disease

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Periodontal Disease

Image from www.periotherapy.com

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Risk Factors for Periodontitis

• Lack of oral hygiene• Systemic diseases (e.g. diabetes) • Tobacco use• Poor nutrition• Dry mouth

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Periodontal Disease - Prevention

• Clean teeth and gums– Brush twice a day– Floss daily

• Avoid tobacco– Smoking and “smokeless” (chewing or spit

tobacco)

• Get routine dental care—including cleaning

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Periodontal Disease - Treatment

• Oral health instruction—brushing & flossing

• Dental office cleaning of the teeth

• Deep scaling & root planing if needed

• Anti-bacterial rinses• Surgery to correct gum

problems• Ongoing periodontal

treatment Periodontitis

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Patients Who Benefit the Most from Improved Oral Health

• Pregnant women• Children • Patients with diabetes or

other chronic conditions

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National Recommendations: Oral Health

AAP, AAFP, AAPDRecommend children be screened by their first birthday (physician or dentist)

USPSTF recommends primary care clinicians apply Fluoride Varnish to primary teeth starting at first primary tooth eruption – B Recommendation

Presentation Title | Section | 29

Children

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Children: Cleaning Teeth< 2 years

Clean gums with cloth When teeth erupt, begin using

soft toothbrush Smear of fluoridated toothpaste 2x/day parent performs &

supervises

2-6 years Pea-sized amount of fluoridated

toothpaste 2x/day Parent performs & supervises

> Age 6 years Brush with pea-sized amount of

fluoridated toothpaste 2x/day Begin flossing when teeth touch

Pea-sized

When child can spit

Smear/rice-sized

Before age two

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Children: Diet• Birth – 1 Year

– Hold infant for bottle and breast feeding– No bottle at bedtime/nap (water ok)– Introduce cup at 6 months

• 1 – 2 Years– Wean/discontinue bottle feeding 12-18 months

• 2 Years plus– Choose fresh fruits, vegetables, whole grain snacks, sliced meat

or cheese– Avoid constant use of Sippy cup– Avoid juice, energy or sports drinks (if used, at meal time only)– Limit sugary/high carbohydrate foods

Good Preventive Medicine for Obesity too!

Presentation Title | Section | 32

Pregnant Women

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Why is Oral Health Care Important for Pregnant Women? The bacteria that causes tooth decay is

transmitted to infants after birth

Women are receptive to oral health messages during pregnancy

Promote mother’s positive role-modeling of oral health behaviors

Promote link between oral and systemic health

Periodontal disease is associated with pre-term births, pre-eclampsia, gestational diabetes

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The Maternal-Child Linkage

Mothers/primary caregivers are the main source of the bacteria responsible for causing caries

How are the bacteria transmitted?

• Via saliva contact such as tasting food, licking spoons or pacifiers

• The more active the disease in mother’s mouth, the more likely the child is to acquire the bacteria early

• If colonization is delayed until after two years of age, then children have less dental decay

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Dental Care is Safe Throughout Pregnancy

• Preventive interventions

• Diagnosis, including needed dental radiographs

• Treatment of oral diseases,including periodontal treatment

Photo: ICOHPNY State Practice Guidelines; CDA Foundation Evidence-based Guidelines

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Barriers to Dental CareOnly 50% of pregnant woman with a dental problem visit a dentist

Why? • Pregnant women don’t know the importance of oral health

before baby is born• Unfounded fears that dental treatment may harm their fetus• Dentists have been hesitant to treat due to:

– Lack of guidelines– Liability concerns– Easier to wait

Important for Primary Care Providers to encourage dental visits during pregnancy

Presentation Title | Section | 37

Patients with Diabetes

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Diabetes

• Untreated periodontal disease can lead to costly diabetes complications

• Diabetes affects nearly ½ million adults in Washington

• Improving an individual’s oral health may reduce diabetic complications, positively impacting overall health

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Periodontal Disease & Diabetes

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Patients with Diabetes: Management

Tell patients that taking care of their oral health is an important part of managing their diabetes

Avoid• Alcohol, caffeine and tobacco products• Sugar-containing drinks and candies• Frequent snacking on foods high in sugar and carbohydrates

Suggest• Sugar-free gum and mints with xylitol

Prevent caries and periodontal disease• Daily oral hygiene

• Protect teeth with fluoride—toothpaste (including prescription strength),

rinse, fluoride varnish, fluoridated water

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Presentation Title | Section | 41

Start Today!Address your patients’ oral health in routine checkups

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WDS Foundation Can Provide

• Oral health training for your care team

• Assistance with developing the best approach for including oral health in visits and EHR

• Coaching support and assisting with barriers that arise

• Patient education materials

• Assistance with dental referrals

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Course Summary

• Oral infections are among the most common untreated chronic infections

• Oral health is the most common unmet health need in a variety of vulnerable populations

• Caries, present throughout the life cycle, is preventable, reversible, and treatable

• Periodontal disease increases the risk of Type 2 diabetes and the risk of diabetic and other chronic disease complications – yet is preventable

• Primary care providers can have a major impact in improving the oral health of individuals and communities

Presentation Title | Section | 44

Questions?

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For More InformationResources• SmilesForLifeOralHealth.org

– 8 modules, AAFP & AAP Prescribed Credit, Additional resources• KidsOralHealth.org

– Oral health tips for parents/caregivers– Provider oral health tools, training and resources

ContactRussell Maier, MD

russell.maier@chcw.org

509-574-6126

Glenn Puckett

gpuckett@deltadentalwa.com

206-528-5328

Acknowledgements: Some content and photos for this presentation were drawn from the Smiles for Life curriculum as well as other Washington Dental Service Foundation trainings.