1. 1 Interdisciplinary Oral Health Adapted from ICC 2008 May 2008 Mark Deutchman MD Terry Batliner DDS John D. McDowell, DDS, MS Rich Call DDS Brad Potter DDS MS John D. McDowell, DDS, MS Lonnie Johnson DDS David Gaspar MD Bonnie Jortberg PhD Katherine Anderson MD Robin Michaels PhD Inis Bardella MD Kent Voorhees MD Colleen Conry MD Frank deGruy MD 40 Dental Students Ruthie Wilson Mark Osvirk Delta Dental Frontier Foundation Society of Teachers of Family Medicine Group on Oral Health

2. 2 Objectives  Developing your understanding of the importance of oral health to systemic health  Recognize oral lesions  Developing your skills to perform the oral/head/neck examination

3. 3 Major information source : Smiles for Life A National Oral Health Curriculum for Family Medicine STFM Group on Oral Health Module 1 The Relationship of Oral to Systemic Health

4. 4 Why is oral health important?

5. 5 Prevalence of Oral Disease  Severe gum disease affects 19% of adults aged 25-44  30,000 oral cancers diagnosed annually; 8000 die  Dental caries most common chronic disease of childhood  5 times more common than asthma  50% in low income children- up to 70% in Native Americans

6. 6 Consequences of Untreated Oral Disease  Pain, infection, tooth loss  Impaired chewing & nutrition  Systemic complications  ER visits, hospitalizations, surgeries  Extensive and costly dental treatments (OR $5,000+)  Missed school and work  52 million school hours lost/yr

7. 7 Prevention in both medical and dental homes  Caries resistance  Water fluoridation  Fluoridated toothpaste  Fluoride topical application  Sealants  Gum disease prevention  Brushing  Flossing  Regular dental visits  Oral cancer prevention  Smoking cessation  Alcohol

8. 8 Colorado’s realities In April 2000, nearly one-third of Colorado counties lacked access to dental services for low income and at-risk (Medicaid, CHP+, Medicare) populations. 9 Colorado counties have NO LICENSED DENTIST at all. Only 11% of Colorado’s dentists participate in Medicaid’s Dental Program. 40% of Colorado counties (25) do not have a dentist that accepts Medicaid. Only 19 of the 182 counties in the three state area of Colorado, South Dakota and North Dakota have any pediatric dentists.

9. 9 The Disconnect  Most patients have a medical home; many fewer have dental home  Children are 2.5 times more likely to lack dental coverage than medical coverage  Dentists per capita declining  Few pediatric dentists  >90% of physicians think oral health should be addressed at well visits, yet…  Surveys of physicians > 50% had little or no oral health training Only 9% could answer 4 simple questions correctly Averaged <2 hours of oral health training

10. 10 Oral Health Dental Home Systemic Health Medical Home Oral and systemic health are linked so care should be too

11. 11 Systemic conditions with oral manifestations  Poor glucose control in diabetics  oral candidiasis and periodontal disease  Immunosuppression due to illness or chemotherapy  periodontal disease  Dry mouth from illness or medications  periodontal disease  Sjogren’s syndrome  Rheumatologic disorders

12. 12 Oral effects of medications  Candidiasis from inhaled or oral steroids  Xerostomia from diuretics, anticholinergics, antihistamines and many antihypertensives  Gingival hyperplasia from phenytoin  Ulcerative stomatitis from methotrexate  Mucositis from chemotherapy or radiation treatment

13. 13 Oral and systemic conditions that appear linked  Adverse pregnancy outcome  Preterm labor  Preterm delivery  Atherosclerosis (Coronary heart disease and stroke)  Obesity  Osteoporosis also affects alveolar bone  Potential mechanisms:  Bacteremia from infected gums (evidence: oral bacteria in atherscloerotic plaque)  Inflammatory mediators leak into bloodstream

14. 14 Oral Anatomy 1. Tongue 2. Palatine tonsil 3. Tonsillar pillar 4. Tonsillar pillar 5. Uvula 6. Palate (soft and hard) 7. Posterior wall of pharynx 8. Teeth

15. 15 Anatomy of a Tooth

16. 16 Primary Dentition 8 incisors + 4 canines + 8 molars = 20 by age 3

17. 17 Primary Tooth Eruption Newborn6 -12 months Age 1Age 3

18. 18 Adult Dentition 8 incisors + 4 canine + 8 premolars + 12 molars = 32 Teeth

19. 19 Lesion recognition

20. 20 Squamous cell carcinoma of lower lip

21. 21 Bony Torus of palate

22. 22 Torus of mandible

23. 23 Mucocele

24. 24 Gingival hyperplasia

25. 25 Hairy tongue

26. 26 Erythema migrans

27. 27 Aphthous stomatitis

28. 28 Denture sores

29. 29 Pyogenic granuloma

30. 30 Candidiasis

31. 31 Herpes labialis

32. 32 Angular chelitis

33. 33 Periodontal disease

34. 34

35. 35 Caries: Etiology Triad Oral bacteria (Mutans Strep) break down dietary sugars into acids which eat away the tooth Teeth Sugars Caries Bacteria

36. 36 White Spots  White spots indicate acids have demineralized enamel  First clinical signs of caries  White spots place a child at high risk for developing cavities  Indication for dental referral

37. 37 Early Caries

38. 38 Moderate Caries

39. 39 Severe Caries

40. 40 Leukoplakia

41. 41 Lichen planus

42. 42 Erosive lichen planus

43. 43

44. 44

45. 45

46. 46

47. 47 Squamous cancer - tongue

48. 48 Cancer

49. 49 Cancer

50. 50 Cancer sites

51. 51 Squamous cell carcinoma of lateral tongue

52. 52 Squamous cell carcinoma of palatal gingiva

53. 53 Leukemic infliltrates

54. 54 Adult Oral Examination

55. 55 Oral/head/neck exam checklist  Wash hands  Greet the patient  Confirm supplies: light, gloves, mouth mirror, tongue blade, gauze pad  Inspect the face and neck for obvious lesions, masses, nodes  Palpate the TM joint  Palpate the neck for nodes and masses  Anterior triangle, Posterior triangle, Submandibular,  Supraclavicular and infraclavicular areas  Put on gloves for intraoral examination  View and palpate the buccal mucosa including sulci  Inspect gingival tissues  Inspect teeth  Inspect palate  Inspect tonsillar pillars  Inspect tongue: top, lateral edges, under-surface. Use gauze pad to grasp tip of tongue when examining lateral edges.  Palpate floor of mouth  Explain exam findings to patient  Discard gloves

56. 56 Inspect/palpate face/neck

57. 57 Inspect lips

58. 58 Labial mucosa - upper

59. 59 Labial mucosa - lower

60. 60 Right buccal mucosa

61. 61 Left buccal mucosa

62. 62 Gingiva

63. 63 Dorsum of tongue

64. 64 Tongue left margin

65. 65 Tongue right margin

66. 66 Ventral tongue

67. 67 Floor of mouth

68. 68 Hard palate

69. 69 Oropharynx

70. 70 Palpate floor of mouth

71. 71 Child Oral Exam ( Knee to Knee) 1: Child is held facing caregiver in a straddle position 2: Child leans back onto examiner while caregiver holds child’s hands 3: Provider performs exam while caregiver holds child’s hands and legs

72. 72 Oral/head/neck exam checklist  Wash hands  Greet the patient  Confirm supplies: light, gloves, mouth mirror, tongue blade, gauze pad  Inspect the face and neck for obvious lesions, masses, nodes  Palpate the TM joint  Palpate the neck for nodes and masses  Anterior triangle, Posterior triangle, Submandibular,  Supraclavicular and infraclavicular areas  Put on gloves for intraoral examination  View and palpate the buccal mucosa including sulci  Inspect gingival tissues  Inspect teeth  Inspect palate  Inspect tonsillar pillars  Inspect tongue: top, lateral edges, under-surface. Use gauze pad to grasp tip of tongue when examining lateral edges.  Palpate floor of mouth  Explain exam findings to patient  Discard gloves