Presentation on theme: "Open Wide: Common Infectious Conditions We Overlook"— Presentation transcript:
1 Open Wide: Common Infectious Conditions We Overlook What’s New in MedicineSeptember 2014Russell Maier, MD
2 “You are not healthy without good oral health…” David Satcher, MD, 16th Surgeon GeneralOral Health in America: A Report of the Surgeon GeneralDental care is the most common unmet health needOral disease can severely affect systemic healthStrong 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-basedRecommend oral health training for non-dental health professionals.According to the Surgeon General's Report on oral health in 2000:Dental care is the most common unmet health need.Oral disease can severely affect systemic health.Much oral disease is preventable or at least controllable.Profound disparities in oral health and access to care exist for all ages.USPSTF recommends fluoride varnish – B recommendation1. Association between untreated dental caries and inappropriate use of ED. (Cohen et al., 2011; Davis et al., 2010)2. Link between oral health and respiratory disease. (Scannapieco and Ho, 2001)3. Link between oral health and cardiovascular disease. (Blaizot et al., 2009; Offenbacher et al., 2009; Scannapieco et al., 2003; Slavkin and Baum, 2000)4. Link between oral health and diabetes. (Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010)
3 Learning ObjectivesUnderstand the prevalence and consequences of oral diseaseLearn about the interrelationships between oral and systemic diseasesIdentify risk and protective factors that influence oral healthRecognize caries and periodontal diseaseUnderstand the importance of primary care providers addressing oral healthUnderstand how to interrupt and minimize oral diseases impacting children, pregnant women and people with diabetesChildhood - USPSTF use of fluoride & UNC research on efficacy of screeningsPrenatal to interrupt disease processDiabetic -periodontal infectionRoutine management in medical office of abscesses
4 Prevalence Tooth Decay Nearly 40% of kindergarteners in WA have tooth decayNearly 1 in 4 adults in the U.S. have untreated tooth decayPeriodontal Disease47% of U.S. adults have some form of periodontal disease (> with age)40% of pregnant women have some form periodontal disease70% of adults 65+ have some form of periodontal diseasePhoto: ICOHPThe following statistics speak to the prevalence of poor oral health:Dental caries is the most common chronic disease of childhood.It is five times more common than asthma.It affects 50% of low-income children.47% of U.S. adults have some form of periodontal disease.70% of adults over 65 have gum diseaseSevere gum disease affects 19% of adults aged 25–44.There are 30,000 oral cancers diagnosed annually. Oral cancer causes 8,000 deaths a year.Diagnosis is often late.References US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America's children. Pediatrics Apr;105(4 Pt 2):Prevalence of Periodontitis in Adults in the United States: 2009 and 2010 J DENT RES , first published on August 30, 2012Prevalence of tooth decay: Sources2010 Washington State Smile SurveyAdult stats:Health, United States, 2012Perio dz source:CDC study, cited here:A study titled Prevalence of Periodontitis in Adults in the United States: 2009 and 2010 estimates that 47.2 percent, or 64.7 million American adults, have mild, moderate or severe periodontitis, the more advanced form of periodontal disease. In adults 65 and older, prevalence rates increase to 70.1 percent. This study is published in the Journal of Dental Research, the official publication of the International and American Associations for Dental Research.Lieff S, Boggess KA, Murtha AP, Jared H, Madianos PN, Moss K, et al. The oral conditions and pregnancy study: periodontal status of a cohort of pregnant women. J Periodontol 2004;75:116–26. [PubMed] ⇦Photo: Robert Henry, DMD, MPH
5 Periodontal Disease Systemic Diseases People with serious gum disease are more likely to have a chronic conditionPeriodontal disease—correlated with a variety of conditions with systemic implicationsCardiovascular disease, heart disease, respiratory infections, diabetes, HIV, adverse pregnancy outcomesSystemic diseases can have an impact on oral healthDementiaChronic disease medications that cause xerostomia(91% of patients with heart disease have periodontitis, compared with 66% of people with no heart disease1) That’s a difference of 25%, and the Bensley article cites a 1.4 fold increaseOral Health: The Mouth Body Connection WebMD Feature. Joanne Barker. Reviewed by Steve Drescher, DDS 2012Article Sources:Sally J. Cram DDS, PC. Sally J. Cram DDS, PC. Bensley L. Preventing Chronic Disease, May 2011; vol 8: pp A50. National Institute of Dental and Craniofacial Research. Kim J. Odontology. September 2006; vol 94: pp Pamela McClain, DDS. Pamela McClain, DDS. National Institute of Diabetes and Digestive and Kidney Disorders. Diabetes Overview - National Diabetes Information Clearinghouse. American Academy of Periodontology. Ask a Periodontist: Frequently Asked Questions About Gum Disease. News release, American Dental Association. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of Periodontology. August 2005; vol 76: pp Martínez-Maestre MÁ. Climacteric. December 2010; vol 13: pp Centers for Disease Control and Prevention. Ortiz P. Journal of Periodontology. 2009;80(4): News Release, American Academy of Periodontology. News Release, American Dental Association.
6 Consequences for Patients’ Health Oral diseases are largely preventable but untreated oral disease can lead to:Pain that makes it difficult to work, learn in school, sleep, eatPoor eating habits and nutritionReduced self-confidence and/or problems obtaining employmentComplications of chronic diseases like diabetes, heart disease, and strokeTransmission of cariogenic bacteria from mothers to infants
7 Oral-systemic Connection Periodontal treatment reduces medical costs for people with chronic conditions & pregnant womenStudy Conducted by University of Pennsylvania, School of Dental Medicine for United Concordia Dental
9 Oral Disease is Preventable Preventing and Interrupting Oral Disease GOOD NEWS!Oral Disease is PreventablePreventing and Interrupting Oral Disease* Key point is this is a disease where we (medical clinicians) can make a difference.
11 Tooth Decay Process: A Bacterial Infection Bacteria Refined Carbohydrates = AcidAcid Time (20 min) = Enamel Demineralization& Risk for DecaySlide 17: Tooth Decay—ProcessHere is another way to understand the steps in getting tooth decay:Germs + Refined Carbohydrates = AcidAcid Attacks + Tooth = DecayUntreated Decay Infection, Abscess, Loss of ToothDecay begins with acids attacking the tooth enamel (the outer portion of the tooth).Teeth can be kept healthy with daily oral hygiene, healthy diet, and the use of fluoride in drinking water, toothpaste, mouth rinses, and professionally-applied gel or varnish.2. If decay progresses, it creates a cavity or hole in the tooth.3. If a person has a cavity but doesn’t have the tooth repaired, and doesn’t change the conditions in the mouth, the decay will continue to destroy the tooth. That tooth may become infected or abscessed.4. Untreated decay and/or an untreated abscess may result in a tooth needing to be removed (extracted).In more serious cases, an untreated abscess can lead to serious widespread infection, often resulting in swelling of the face, and sometimes resulting in swelling of the brain or even death.People who are in a weakened immune state may have difficulty recovering from a dental abscess.Untreated Decay Infection, Abscess, Loss of ToothOH Slides & Notes – Script
13 Early Decay: White Spots/Lines AppearanceWhite spots and lines—first clinical signs of demineralized enamelBegins along the gum lineWithout intervention, lesions will progress to cavities that are initially yellowTreatmentFluoride varnish application to reverse or arrest lesionsDietary and oral hygiene counselingDental referralAppearance & SymptomsWhite spots and lines are the first clinical signs of demineralized enamelTypically begins at the gingival marginIf the disease process is not managed, lesions will progress to cavities that are initially yellowTreatmentImmediate dental referralDietary and oral hygiene counselingTopical fluoride to reverse or arrest lesionsPhotos: Joanna Douglass, BDS, DDS
14 Tooth Decay, Abscessed Teeth, Facial Swelling AbscessesSlide 19: Tooth DecayPhoto 6 – Caries (Cavity, Tooth Decay)When a tooth decays, its enamel surface breaks down and allows acids and bacteria to enter the softer areas inside the tooth. Usually, decay begins as a small whitish area that, if left untreated, grows and darkens. Decay often occurs between the teeth where food particles are more difficult to remove. How many areas of decay do you see on this photo? (At least 7.)Photo 7 – Abscessed TeethIn photo 7, untreated decay has allowed infection to enter the teeth and move into the teeth roots. Swelling on the gum above these teeth (arrows) indicates infection (abscess) from the teeth that is draining into the mouth.Photo 8 – Facial Swelling from AbscessIf the infection isn’t treated, the person’s face may begin to swell as the infection spreads from the tooth to the surrounding area in the face or neck.Widespread infection can make people extremely ill; this is a matter that needs immediate attention.Often the dentist (or physician) will treat the infection with antibiotics first, then repair the tooth.Treatment could include placing a filling or crown, root canal treatment (the nerve chamber is cleaned and sealed), or extraction (removal) of the tooth.AbscessedTeethFacialSwellingOH Slides & Notes – Script
15 Tooth Decay Process: Snacking & Sipping It’s not just WHAT, but HOW, we eat & drinkAcid persists for minutes after sugar or carbohydrate ingestionAcid leads to demineralizationKey message:Frequency of sugar/carbohydratesmore significant than quantityThe process of demineralization and remineralization is dynamic.ECC occurs when the scale tips more toward demineralization.On the other hand, preventing ECC tips the scale more toward remineralization.15
16 Diet and Dental Caries Eating Frequency Regular Meals Plaque Level AcidsRegular MealsThe bottom graph shows the typical snacking child.The steady source of sugar/carbs results in almost continual exposure of the teeth to acid.This results in virtually no rest period for the enamel to remineralize.Regular Meals Plus Frequent Snacks
17 Tooth Decay - Risk Factors Prior decay and/or fillingsExisting white spot lesionsFrequent consumption of sugar & carbohydrateInadequate fluorideSpecial health care needsPhysical disabilities and dementiaMedications that:Decrease salivary flow (xerostomia)Contain high levels of sucroseRecurrent CariesRisk FactorsHigh oral bacterial countsFrequent consumption of sugar-containing foodsInadequate fluoride exposure Low socioeconomic statusXerostomia related to medications or diseasePhysical disabilities and dementiaMake brushing and other oral hygiene more difficultExisting restorations or appliancesRecurrent caries common at site of existing restorationsTreatmentRemoval of decayed tooth structure and replacement with dental restorative material, usually composite (white) or amalgam (silver)Root canal therapy or extraction of the tooth if decay has progressed into the pulp of the toothExtraction is not without consequences. It may result in spacing issues, drifting of the retained teeth, and malocclusion of the neighboring toothPreventionDaily oral hygiene that includes fluoride toothpaste and flossing Regular professional dental careFluoride rinses, gels or varnishes for high-risk patients, especially institutionalized elderly:Fluoride rinse: Phos – Flur 0.044% (sodium fluoride and phosphate fluoride rinse) 10mL once daily after brushingFluoride gel: Gel Kam (0.4% stannous fluoride gel) cover toothbrush with gel and brush once dailyReferences Warren, J.J., Cowen, H.J., Watkins, C.M., Hands, J.S. Dental caries prevalence and dental care utilization among the very old. J Am Dent Assoc 2000; 131:Guggenheimer, J., Moore, P.A. Xerostomia: etiology recognition and treatment. J Am Dent Assoc 2003, 134:61-69.Saunders, R.H., Meyerowitz, C. Dental caries in older adults. Dent Clin North Am 2005, 49:Tan, H.P., et al. A Randomized Trial on Root Caries Prevention in Elders. JDR 2010; 89(10);Malocclusion of drifting teeth after extractionPhotos: UKCD
18 Caries Process: Ongoing Balance Protective FactorsSalivaPeptides (defensins)FluoridePathologic FactorsAcid-producing Bacteriae.g. Strep mutansFrequent carbohydratesReduced salivaTrainer Note:Not all cities have fluoridated water, so cannot assume in all settings. Refer to for more info.The body is usually at homeostasis. Bone undergoes constant turnover. New cells are made for lining the gut. The tooth has a constant battle between the forces of good – fluoride, saliva, remineralization – and bad – carbohydrates, step mutans, no fluoride.The visual message is that one can tip the balance one way or another – just as we can tip the balance in osteoporosis or diabetes with appropriate interventions and habits.CariesNo Caries
19 Tooth Decay – Prevention Tips Remove bacteria (plaque) every dayBrush twice daily with fluoridated toothpasteFloss dailyLimit frequency of sweet, sticky, or sugary foods and drinksChoose sugar substitutes, especially xylitol (a natural sweetener that reduces cavity-causing germs in the mouth)Use fluorideToothpasteFluoridated waterFluoride varnish, gel, or rinseSlide 21: Tooth Decay - PreventionIf your toothbrush looks like this, it’s time to buy a new one!Remove bacteria (plaque) every dayBrush, floss, and use other aids as neededLimit sweet, sticky, or sugary foods and drinks (refer to prior discussion of snacks & acid attacks)Choose sugar substitutesThe germs that cause tooth decay cannot use sugar substitutes to make acid, so these products help prevent decay.Use moderation when eating “dietetic” candies sweetened with sugar substitutes. These sweeteners have a laxative effect and can create gastric distress or cause diarrhea.Xylitol (another sugar substitute) not only prevents decay, but also can help teeth rebuild themselves (remineralization).Name-brand products that contain xylitol:Carefree Koolerz gum; some of the Trident gum varieties; some of the Tom’s of Maine toothpastes; Orajel toothpaste; Biotene rinses, toothpaste, gum (also used to relieve dry mouth);some of the Starbucks “after-coffee” mints or gumCheck ingredient labels; look for xylitol as first or second ingredientFor the greatest benefit, we need to chew the gum or eat the mints 3-5 times per day, for about 5 minutes, especially after meals and snacks. This amount will not create gastric distress for most people.Fluoride VarnishOH Slides & Notes – Script
20 Benefits of Fluoride Topical (main effect) Systemic Inhibits tooth demineralizationEnhances remineralizationInhibits bacterial metabolismSystemicReduces enamel solubilityPromotes remineralization of enamelNOTE: these images good for patients, but would be interesting to include image depicting ion exchange process. Investigate video from Intertalks (sp?) on T drive.The use of fluoride, both through dietary and topical applications, has led to dramatic drops in caries rates.How Does Fluoride Help Prevent Dental Caries?Through topical mechanisms, the main effect, fluoride works byInhibiting tooth demineralizationEnhancing remineralizationInhibiting bacterial metabolismThrough systemic mechanisms, the lesser effect, fluoride works byReducing enamel solubility through incorporation into its structure during tooth developmentWhat are the primary sources of fluoride?Systemic fluoride is obtained through:Water fluoridationDietary fluoride supplementsTopical Fluoride is the most beneficial and is obtained through:Fluoride toothpastesGels, foams, mouthwashesFluoride varnishPhotos: Joanna Douglass, BDS, DDS
21 Preventing and Interrupting Periodontal Disease
22 Gum Disease Gingivitis Periodontal Disease Slide 11: Gum Problems - PhotosPhoto 4 – GingivitisGums are red and swollen and may bleed easily.Brushing and flossing can help improve this condition, or professional care may be needed.If plaque remains on the teeth, it hardens to form tartar or calculus, which irritates the gums. The tartar or calculus cannot be removed by brushing. Eventually, the gums detach and pull away (recede) along the length of the teeth.Tartar on the teeth may need to be removed (by having the teeth cleaned) before the gingivitis will improve.Photo 5 - Periodontal DiseaseIf the gingivitis is not treated or controlled, it can progress to a more serious condition, periodontal disease, where the bone holding the teeth in place is destroyed.Eventually, the gums may pull away from their original position, exposing the roots of the teeth. This allows decay and infection into tooth roots and also into the bone that supports the teeth.As the bone dissolves, the teeth will become loose.The loose teeth may become so painful that eating becomes difficult and severe infections may develop.The disease may be treatable or may require the teeth to be removed.These teeth have been partially cleaned, but tartar deposits remain visible.GingivitisPeriodontal DiseaseOH Slides & Notes – Script
24 Risk Factors for Periodontitis Lack of oral hygieneSystemic diseases (e.g. diabetes)Tobacco usePoor nutritionDry mouthSlide 10: Gum ProblemsDiabetes and Smoking – Higher Risk for Periodontal DiseasePeople with uncontrolled diabetes may be more susceptible to gum problems, even without much plaque on the teeth. Blood sugar control is critical for keeping gum tissue healthy. Daily oral hygiene care is critical.Smokers also are more likely to have periodontal disease.Prevention: Plaque Removal, Professional TreatmentsDaily plaque removal by brushing and flossing keeps gum tissue healthy.Professional cleanings on a regular basis are also needed to keep gum tissues healthy.OH Slides & Notes – Script
25 Periodontal Disease - Prevention Clean teeth and gumsBrush twice a dayFloss dailyAvoid tobaccoSmoking and “smokeless” (chewing or spit tobacco)Get routine dental care—including cleaningSlide 12: Gum Problems - PreventionClean the teeth and gums dailyCaregiver prompts, assists, or performs the oral health care for consumersIf your consumer is able, s/he may need only a reminder to take care of oral health. However, you should still monitor self-care for quality.The consumer’s service/care plan may indicate that you will need to perform the oral care for your consumer.Brush, floss, other aidsThe brush cleans the areas we can see: Tongue and cheek sides of the teeth, biting surfaces.Floss cleans between the teeth where the brush can’t reach.Toothpicks, specialized brushes or cleaners, or other products are available to help you clean if you have trouble using a brush or floss.These will be discussed in more detail later.Avoid tobacco productsSmoking increases the risk of developing gum problems.Smokeless tobacco causes gingivitis, gum recession, bone loss, tooth decay.Schedule routine dental careProfessional care is important in controlling gum problems.OH Slides & Notes – Script
26 Periodontal Disease - Treatment Oral health instruction—brushing & flossingDental office cleaning of the teethDeep scaling & root planing if neededAnti-bacterial rinsesSurgery to correct gum problemsOngoing periodontal treatmentSlide 13: Gum Problems - TreatmentThis is general information to help you understand some of the treatments that your consumer may receive at the dental office.Oral health instructionBrushing, flossing, and using other aids help keep teeth and gums in good condition.Thorough cleaning of the teethThe dental hygienist or dentist can remove the calculus deposits to improve tissue health and to make home care easier.Anti-bacterial rinsesThe dentist may prescribe anti-bacterial rinses to control the plaque. It is important to follow the doctor’s instructions exactly.Surgery to correct problemsSometimes cleaning and home care are not enough to control the problems, and surgery may be needed to reshape the gum tissue or eliminate the deeper areas of infection.PeriodontitisOH Slides & Notes – Script
27 Patients Who Benefit the Most from Improved Oral Health Pregnant womenChildrenPatients with diabetes or other chronic conditionsNOTE: These are priority populations who have particular needs, but important to point out that medical systems should address the oral health of all patients.
28 National Recommendations: Oral Health AAP, AAFP, AAPDRecommend children be screened by their first birthday (physician or dentist)The AAP and AAPD recommend that providers refer the child to a pediatric dentist or a family dentist when the child’s first tooth erupts or by the child’s first birthday. This will ensure the early establishment of a dental home. However, this is not practical in the real world in which we provide care because of the lack of payment mechanisms for many children, and limited availability of general dentists willing to see children and pediatric dentists.The take home message is that all children should be screened, and that can be done by primary care providers. If you identify high-risk children, or children under one year with active disease those kids deserve first shot at limited dental access, not that all kids need to see a dentist by age oneUSPSTF recommends primary care clinicians apply Fluoride Varnish to primary teeth starting at first primary tooth eruption – B Recommendation
30 Children: Cleaning Teeth < 2 yearsClean gums with clothWhen teeth erupt, begin using soft toothbrushSmear of fluoridated toothpaste2x/day parent performs & supervises2-6 yearsPea-sized amount of fluoridated toothpaste 2x/dayParent performs & supervises> Age 6 yearsBrush with pea-sized amount of fluoridated toothpaste 2x/dayBegin flossing when teeth touchSmear/rice-sizedBefore age twoPea-sizedWhen child can spitExcessive ingestion of toothpaste can cause fluorosis which is a minor cosmetic problem, relative to losing teeth to caries. In rare situations, such as consuming a large portion of a family sized tube, systemic toxicity including electrolyte abnormalities can result in a medical emergency.GuidelinesUse a small smear for children at increased risk for caries less than 2 years.Apply a pea-sized amount of toothpaste for children 2 years and older regardless of caries risk status.Most preschool children swallow most toothpaste placed on the brush. These guidelines take this into account and these amounts are safe to swallow but spitting out should always be encouraged..Parents should keep toothpaste tubes out of reach of small children.References Shulman JD, Wells LM. Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. J Public Health Dent 1997;57: Douglass JM, Douglass AB, Silk H . A Practical Guide to Infant Oral Health at the Well Child Visit. American Family Physician 2004;70: ,
31 Good Preventive Medicine for Obesity too! Children: DietBirth – 1 YearHold infant for bottle and breast feedingNo bottle at bedtime/nap (water ok)Introduce cup at 6 months1 – 2 YearsWean/discontinue bottle feeding months2 Years plusChoose fresh fruits, vegetables, whole grain snacks, sliced meat or cheeseAvoid constant use of Sippy cupAvoid juice, energy or sports drinks (if used, at meal time only)Limit sugary/high carbohydrate foodsGood Preventive Medicine for Obesity too!Given the prevalence of obesity in our culture, there is little role for juice in nutrition for the majority of kids – it is just empty calories like soda pop.Frequent questions about implementation arise, and these last few slides are topics we are discussing already with anticipatory guidance. Including oral health is simply adding the tag line, “…and not only will help your child grow and develop normally, but its good for her teeth, too!”
33 Why is Oral Health Care Important for Pregnant Women? The bacteria that causes tooth decay is transmitted to infants after birthWomen are receptive to oral health messages during pregnancyPromote mother’s positive role-modeling of oral health behaviorsPromote link between oral and systemic healthPeriodontal disease is associated with pre-term births, pre-eclampsia, gestational diabetesThe benefits to the pregnant patient are many. First of all, oral disease is addressed. “The American Academy of Periodontology urges oral health care professionals to provide preventive services as early in pregnancy as possible and to provide treatment for acute infection or sources of sepsis irrespective of the stage of pregnancy.” (CAL) (J Periodontol 2004: 75(3): 495If good oral health is promoted, this promotes good systemic health.Care of the pregnant patient may strengthen attitudes towards importance of oral health and baby teeth; behaviors include ability to care for own and infant’s oral health and seek oral health care. Evidence exists that women are particularly receptive to information about caring for infants while they are pregnant. (ref?)Anticipatory guidance has the potential to prevent Early Childhood Caries. (CAL)Finally, once an infant is born, there is much less time to visit the dentists office! Additionally, some women may lose their dental coverage only a couple of months after the baby is born.Gestational Diabetes:Definition:High blood glucose levels in pregnant women who have never had diabetes.Clinical characteristics:3-7 % of pregnancies; increasing with the obesity epidemicUsually diagnosed at 28 weeks or laterIncreased risk of excessive birth weightPregnant women who develop GDM are at greater risk for periodontal disease than women who do notIf periodontal disease occurs, control of GDM is more difficultPre-term births and Periodontitis:Severe periodontitis leads to high levels of prostaglandins in the bloodHigh levels of prostaglandins are associated with early uterine contractions, early birth and low birth weightData to date shows that periodontal treatment during pregnancy:Is safe for the mother and fetus andDoes not alter the rates of preterm birth or low birth weightPre-Eclampsia and Periodontitis:Periodontal disease may be associated with pre-eclampsia (Boggess, 2003)PGE2, IL-1 and TNF- levels from gingival crevicular fluid higher in women with preeclampsia (Oettinger-Barak, 2003)“Oral pathogens have been found in placentas of women with preeclampsia, which imply a possible contribution of periopathogenic bacteria to the pathogenesis of this syndrome.” (Barak, 2007)
34 The Maternal-Child Linkage Mothers/primary caregivers are the main source of the bacteria responsible for causing cariesHow are the bacteria transmitted?Via saliva contact such as tasting food, licking spoons or pacifiersThe more active the disease in mother’s mouth, the more likely the child is to acquire the bacteria earlyIf colonization is delayed until after two years of age, then children have less dental decayMothers are the primary source of Mutans Streptococci, the bacteria responsible for causing caries.How Are Mutans Streptococci Transferred?Mothers with high rates of caries pass their high oral bacterial load and dietary habits on to their babies early in life.It is thought that transfer occurs via saliva contact such as tasting food, or licking spoons.The higher the level of maternal bacteria the more likely the child is to acquire the bacteria.If this colonization is delayed until after 2 years of age, then caries scores at age 4 years decreases.Caregivers with high bacteria levels usually have:A high frequency of sugar intakePoor oral hygieneHigh levels of decayFathers can theoretically pass on the bacteria, but in practice rarely do References US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Ramos-Gomez et al. (2002). Bacterial, behavioral and environmental factors associated with early childhood caries. Journal of Clinical Pediatric Dentistry, 26(2): Douglass JM, LI Y, Tinanoff N. Systematic review of the association between mutans streptococci in primary caregivers and mutans streptococci and dental caries in their children. Pediatric Dentistry 2008, 30(5):
35 Dental Care is Safe Throughout Pregnancy Preventive interventionsDiagnosis, including needed dental radiographsTreatment of oral diseases, including periodontal treatmentRadiation exposure is extremely low during dental radiographs. Patients and their unborn children are generally at higher risk from the oral disease affecting the pregnancy than they are from radiation exposure.RisksRadiation exposure to the fetus from dental x-rays is so low that it cannot be measured by conventional techniques4 bite wing radiographs results in a background radiation equivalency of 7 hours.ProceduresProper radiographic techniques can minimize radiation exposure.X-ray as necessary to make diagnosis (i.e. root canal therapy, trauma, caries)Limit exposure by :Utilizing lead apron shielding (abdominal and thyroid)Avoiding retakes when possibleUsing rectangular collimationUsing the fastest available receptor (E/F speed film or digital)Using a long cone to focus radiation only on mouthReferencesMaillie HD, Gilda JE. Radiation induced cancer risk in radiographic cepahalometry. Oral Surg Oral Med Oral Pathol 1993;75:Abbott P. Are dental radiographs safe? Aust Dent J. 2000;45:Langlais RP, Langland OE. Risks from dental radiation in CDA J. 1995;May:33-39.American Dental Association Council on Access, Prevention, and Interprofessional Relations (ADA). ADA oral health care series: Women's oral health issues. Chicago, IL: American Dental Association, 1995.Oral Health Care During Pregnancy and Early Childhood Practice Guidelines. New York Public Health Department 2006.Oral Health During Pregnancy and Early Childhood: Evidence Guidelines for Health Professionals. California Dental Association Foundation. FebruaryNY State Practice Guidelines; CDA Foundation Evidence-based GuidelinesPhoto: ICOHP
36 Barriers to Dental Care Only 50% of pregnant woman with a dental problem visit a dentistWhy?Pregnant women don’t know the importance of oral health before baby is bornUnfounded fears that dental treatment may harm their fetusDentists have been hesitant to treat due to:Lack of guidelinesLiability concernsEasier to waitImportant for Primary Care Providers to encourage dental visits during pregnancyDentists, medical clinicians, and patients need to be aware of the importance of oral health and the safety of treatments during pregnancy. Clinicians need to take time during first prenatal visits to ask about oral health, examine the mouth, and refer. Studies show that few medical clinicians advise pregnant patients to see the dentist.Why Don't Pregnant Women Obtain Dental Care?Lack of national prenatal oral health guidelinesMedical clinicians do not routinely refer patients for dental careMany dentists are unsure of how to manage the pregnant patientCare may be postponed until after pregnancyWide variation in opinion about use of local anesthetics, radiographs, and treatment in pregnancyFear of malpracticeDentists may under-treat pregnant patients for fear of litigation.Litigation review from 1945 to 2001 showed only one lawsuit which was a coincidental stillbirth found in favor of the physicians.ReferencesHilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: a review of dental treatment guidelines. Pediatr Dent 2003;25(5): 459–467.Gaffield, ML, Colley Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the Pregnancy Risk Assessment Monitoring System. Journal of the American Dental Association 2001;132(7): Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. Am J Public Health 2004;94(5):765–771Al Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32(7):815–821Pistorius J, Kraft J, Willershausen B. Dental treatment concepts for pregnant patients: results of a survey. Eur J Med Res 2003;8(6): 241–246Lindow SW, Nixon C, Hill N, Pullan AM. The incidence of maternal dental treatment during pregnancy. J Obstet Gynaecol 1999;19(2): 130–131 Stefanac S, Nesbit S. Treatment planning in dentistry. St Louis, Mo.: Mosby 2001:92-94.
38 DiabetesUntreated periodontal disease can lead to costly diabetes complicationsDiabetes affects nearly ½ million adults in WashingtonImproving an individual’s oral health may reduce diabetic complications, positively impacting overall health
39 Periodontal Disease & Diabetes A Vicious CyclePatients with periodontal disease are twice as likely to develop diabetesPoor glycemic control is associated with threefold increase of periodontal diseasePeriodontal disease worsens glycemic controlTreatment of periodontal disease results in 10-20% improvement in glycemic controlReferencesMealey, B. L., Periodontal disease and diabetes: A two-way street. J Am Dent Assoc 2006; 137: Demmer, R.T., Jacobs, D.R., Desvarieux, M. Periodontal disease and incident type 2 diabetes mellitus: Results from the first National Health and Nutrition Examination Survey and its epidemiologic follow up study. Diabetes Care 2008; 31(7): Moore, P.A., et al. Type 1 diabetes mellitus, xerostomia and salivary flow rates. Oral Surg Oral med Oral Pthol Oral Radiol Endod 2001; 92: Promsudth, A., et al. The effect of periodontal therapy on uncontrolled type 2 diabetes mellitus in older subjects. Oral Dis 2005; 11:293-8.
40 Patients with Diabetes: Management 40Tell patients that taking care of their oral health is an important part of managing their diabetesAvoidAlcohol, caffeine and tobacco productsSugar-containing drinks and candiesFrequent snacking on foods high in sugar and carbohydratesSuggestSugar-free gum and mints with xylitolPrevent caries and periodontal diseaseDaily oral hygieneProtect teeth with fluoride—toothpaste (including prescription strength), rinse, fluoride varnish, fluoridated waterPrevent caries and periodontal disease by:Maintaining meticulous oral hygieneUsing increased strength topical fluorides such as 1.1% sodium fluoride40
41 Start Today! Address your patients’ oral health in routine checkups
42 WDS Foundation Can Provide Oral health training for your care teamAssistance with developing the best approach for including oral health in visits and EHRCoaching support and assisting with barriers that arisePatient education materialsAssistance with dental referrals
43 Course SummaryOral infections are among the most common untreated chronic infectionsOral health is the most common unmet health need in a variety of vulnerable populationsCaries, present throughout the life cycle, is preventable, reversible, and treatablePeriodontal disease increases the risk of Type 2 diabetes and the risk of diabetic and other chronic disease complications – yet is preventablePrimary care providers can have a major impact in improving the oral health of individuals and communities
45 For More Information Resources Contact SmilesForLifeOralHealth.org 8 modules, AAFP & AAP Prescribed Credit, Additional resourcesKidsOralHealth.orgOral health tips for parents/caregiversProvider oral health tools, training and resourcesContactRussell Maier, MDGlenn PuckettAcknowledgements: Some content and photos for this presentation were drawn from the Smiles for Life curriculum as well as other Washington Dental Service Foundation trainings.