Open Wide: Common Infectious Conditions W e Overlook

1. Open Wide: Common Infectious Conditions We Overlook What’s New in Medicine September 2014 Russell Maier, MD

2. “You are not healthy without good oral health…” David Satcher, MD, 16th Surgeon General 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 • 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.

3. 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

4. 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: ICOHP Photo: Robert Henry, DMD, MPH

5. 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

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 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

7. Oral-systemic Connection Periodontal 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

8. Inflammatory Response

9. GOOD NEWS! Oral Disease is Preventable Preventing and Interrupting Oral Disease

10. Preventing and Interrupting Tooth Decay

11. Acid + Time (20 min) = Enamel Demineralization & Risk for Decay Tooth Decay Process: A Bacterial Infection Bacteria + Refined Carbohydrates = Acid Untreated Decay  Infection, Abscess, Loss of Tooth

12. 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

13. Tooth Decay, Abscessed Teeth, Facial Swelling Tooth Decay Abscesses Abscessed Teeth Facial Swelling

14. 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

15. Eating Frequency Diet and Dental Caries Plaque Level Acids Regular Meals Regular Meals Plus Frequent Snacks

16. 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 Recurrent Caries Malocclusion of drifting teeth after extraction Photos: UKCD

17. Caries Process: Ongoing Balance Protective Factors Saliva Peptides (defensins) Fluoride Pathologic Factors Acid-producing Bacteria e.g. Strep mutans Frequent carbohydrates Reduced saliva Caries No Caries

18. Tooth Decay – Prevention Tips Remove bacteria (plaque) every day • Brush twice daily with fluoridated toothpaste • Floss daily Limit 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

19. Benefits of Fluoride • Topical (main effect) • Inhibits tooth demineralization • Enhances remineralization • Inhibits bacterial metabolism • Systemic • Reduces enamel solubility • Promotes remineralization of enamel Photos: Joanna Douglass, BDS, DDS

20. Preventing and Interrupting Periodontal Disease

21. Gum Disease Gingivitis Periodontal Disease

22. Periodontal Disease Image from www.periotherapy.com

23. Risk Factors for Periodontitis • Lack of oral hygiene • Systemic diseases (e.g. diabetes) • Tobacco use • Poor nutrition • Dry mouth

24. 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

25. 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

26. Patients Who Benefit the Most from Improved Oral Health • Pregnant women • Children • Patients with diabetes or other chronic conditions

27. National Recommendations: Oral Health AAP, AAFP, AAPD Recommend 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

28. Children

29. 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

30. 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!

31. Pregnant Women

32. 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

33. 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

34. Dental Care is Safe Throughout Pregnancy • Preventive interventions • Diagnosis, including needed dental radiographs • Treatment of oral diseases,including periodontal treatment Photo: ICOHP NY State Practice Guidelines; CDA Foundation Evidence-based Guidelines

35. Barriers to Dental Care Only 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

36. Patients with Diabetes

37. 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

38. Periodontal Disease & Diabetes

39. Patients with Diabetes: Management 40 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

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

41. 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

42. 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

43. Questions?

44. For More Information Resources • 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 Contact Russell 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.