Integrating Oral
Health and Medical
Care
Jacqueline A. Tallman, RDH, MPA
Dental Director
Health Disparities Collaborative
National Network for Oral Health Access
Michigan Primary Care Association
jtallman@mpca.net
Introduction
 Overview and Impact of Oral Diseases
 Disparities in Oral Health Care
 Relationship Between Oral Health and Systemic
Diseases
 Oral Health and the Diabetes Collaborative
 Oral Health Resources
 Questions and Discussion
Oral Health
 More than teeth and gums!
 Also includes supporting tissues, hard and
soft palate, mucosal lining of the mouth and
throat, tongue, lips, salivary glands,
chewing muscles, and upper and lower jaws
Oral Health in America: A Report of the Surgeon
General
Oral Health
. . . these tissues allow us to speak and
smile; sigh and kiss; smell, taste, touch,
chew, and swallow; cry out in pain; and
convey a world of feelings and emotions
through facial expressions
 The essence of our humanity!!
Oral Health in America: A Report of the Surgeon
General
Oral Diseases
 Progressive and cumulative – become
more complex over time
 Dental caries (tooth decay) is the
single most common chronic childhood
disease – 5 times more common than
asthma and 7 times more common
than hay fever
Oral Health in America: A Report of the Surgeon
General
Oral Diseases
 Over 50 percent of 5- to 9-year-old
children have at least one cavity or filling,
and that proportion increases to 78
percent among 17-year-olds.

These are improvements compared to a
generation ago!
Oral Health in America: A Report of the Surgeon
General
Oral Diseases
 Poor children suffer twice as much dental
caries as their more affluent peers, and
their disease is more likely to be
untreated.
Oral Health in America: A Report of the Surgeon
General
Dentally Uninsured
 Uninsured children are 2.5 times less likely than
insured children to receive dental care and are 3
times more likely to need it!
 For every child without medical insurance, there
are at least 2.6 children without dental insurance.
Oral Health in America: A Report of the Surgeon
General
Vulnerable Populations
 Those who suffer the worst oral health are found
among the poor of all ages, with poor children and
poor older Americans particularly vulnerable
 Members of racial and ethnic minority groups
experience a disproportionate level of oral health
problems
Oral Health in America: A Report of the Surgeon
General
Why the disparities?
 There are many factors that influence
vulnerability to oral disease

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Socioeconomic factors
 Lack of resources to pay for care
 Inability to take time away from work
 Lack of transportation
 Physical disability or other illness that limits
access
Lack of understanding and awareness of the
importance of oral health
Oral Health in America: A Report of the Surgeon
General
Why the disparities?

Cultural values influence oral health and
well-being and can play an important role in
care utilization practices and in
perpetuating acceptable oral health and
facial norms.
Oral Health in America: A Report of the Surgeon
General
Oral health is
integral to general
health
Oral Health in America: A Report of
the Surgeon General
2000
http://www.nidcr.nih.gov/sgr/oralhealth.htm
“You cannot be
healthy without oral
health”
Demonstrated relationships between
oral health and systemic diseases
 Diabetes
 Cardiovascular Disease
 Adverse Pregnancy Outcomes
Cardiovascular Disease
and Oral Health
 Association has been demonstrated between
periodontal disease and cardiovascular disease and
research continues to determine the extent to
which the association is causal or coincidental
 Two theories: Bacterial and C Reactive Protein
Cardiovascular Disease
and Oral Health
Gum disease may harm the heart, too
http://www.heartcenteronline.com/myheartdr/home/rese
arch-detail.cfm?reutersid=3018
Theory: the Porphyromonas gingivalis bacterium can
actually migrate from the mouth to the heart and
cause inflammation in arteries that promotes
atherosclerosis
C Reactive Protein
C Reactive Protein Test
http://www.heartcenteronline.com/myheartdr/common/ar
ticles.cfm?ARTID=376
CRP is an inflammatory marker — a substance that
the body releases in response to inflammation.
High levels of CRP in the blood mean that there is
inflammation somewhere in the body.
C Reactive Protein
The researchers theorize that people living
with a chronic infection such as gum
disease may produce higher levels of C
Reactive Protein, which could place them at
higher risk of heart attack.
C Reactive Protein
Another reference:
The New England Journal of Medicine
Volume 347:1557-1565 November 14, 2002 Number 20
Comparison of C-Reactive Protein and Low-Density
Lipoprotein Cholesterol Levels in the Prediction of First
Cardiovascular Events
Paul M. Ridker, M.D., Nader Rifai, Ph.D., Lynda Rose, M.S., Julie
E. Buring, Sc.D., and Nancy R. Cook, Sc.D.
http://content.nejm.org/cgi/content/short/347/20/1557
Perinatal Health
Preterm Birth
Preterm birth, resulting in babies born too little and
too soon, is a major cause of morbidity today.
Evidence indicates that infections can be major
risk factors in preterm birth. Case-control
studies point to an association between
periodontal infection and increased rates of
Perinatal Health
preterm birth. This article summarizes evidence
to date, and the strategies the ongoing
intervention studies are using to answer the
fundamental clinical question: can periodontal
therapy reduce the risk of preterm birth?
http://www.dentalcare.com/soap/ce111pc/pg01.htm
This is part of a P& G mini course on the relationship between
oral health, pregnancy, and postmenopausal osteoporosis.
Perinatal Health
Improving Women's Health and Perinatal
Outcomes: Snapshot of the Impact of Oral
Diseases
Fact sheet containing a number of frequently
asked questions pertaining to women's oral health,
access to oral health services, and potential
strategies to improve the oral health status of
women.
Available online:
http://www.jhsph.edu/wchpc/pub/oralfacts.pdf
Source:
http://www.ask.hrsa.gov/detail.cfm?id=MCH00012
Other systemic links
 Many systemic diseases and conditions
have oral manifestations – may be the
initial sign of clinical disease
 Pharmaceuticals and other therapies
commonly used in treating systemic
conditions can cause oral complications
Oral Health in America: A Report of the Surgeon
General
Diabetes and Periodontal Disease
 Effective treatment of periodontal
infection and reduction of periodontal
inflammation is associated with a
reduction in glucose blood levels.
http://www.perio.org/resourcesproducts/pdf/4-diabetes.pdf
Diabetes and Periodontal Disease
 Persons with diabetes are at greater risk
for periodontal diseases
 There is now some thought that untreated
periodontal disease in persons predisposed
to diabetes makes them more likely to
develop the disease
Oral Health Resources
PERIODONTAL DISEASE TREATMENT
PROTOCOL FOR INDIVIDUALS WITH
TYPE 2 DIABETES MELLITUS
Indian Health Service
Dental Program
Fred B. Skrepcinski, DMD, MPH
Email jtallman@mpca.net for electronic copy
Diabetes and Periodontal Disease –
Education Resources
Diabetes and Oral Health Internet Resources direct links to websites with provider and patient
education resources - Available on the Diabetes
Virtual Office (Under Tools/Resources, then
Miscellaneous).
Includes:
Periodontal Complications of Diabetes
This power point presentation has color slides and
script ready to download and use for staff inservice training. It was developed from the
NIDCR slide series that is no longer available.
On the way to the throat and
between the ears!
Check
the
teeth
and
oral
tissues!
http://oralhealth.dent.umich.edu/VODI/
html/index.html Click on dental caries or
periodontal disease, then screening, and
then demo for short videos on how to screen
in a medical setting. Also check out the
Signs & Symptoms section for further
information.
What Works?
 Hearing from their medical provider that they need to
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see the dentist!
Hearing from their medical provider that their oral
health affects their diabetes and their general health!
Repeated messages if necessary
Same day quick initial visit to dental – easier to come
back if they have had that initial meeting!
Escorted by medical staff to dental to make
appointment
Established referral system that all staff know and
use – may take several PDSA cycles to develop!
Tracking referrals – will be available electronically in
PECS 3.0!!!
Sample Referral Form
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WESTSIDE COMMUNITY HEALTH SERVICES
MEDICAL/ DENTAL DIABETES REFERRAL
Patient name: ______________________________________ Date of birth:________________
Last
First

Medical Account Number: ________________________

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Do you have a dentist?
Have you seen a dentist in the last year?
For routine exam and cleaning?
For emergency care or pain relief?
3..Do you have loose or painful teeth?
4 .Do your gums bleed when you brush or floss?
5. Do you have bad breath?



Type Diabetes
1
HbA1c=
Allergy to Doxycycline

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
REFERRING PHYSICIAN:_________________________________ Date:_________________
**FORWARD/FAX THIS FORM TO SUE TESSIER AT WESTSIDE DENTAL.
FAX #: (651) 602-7518
---------------------------------------------------------------------------------------------------------------------
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
2
Yes
No
Sample Referral Response Form
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DENTAL COMPLETE THIS SECTION:
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1. Periodontal Status:
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No
3. Treatment Completed :
Yes
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DENTIST NAME: __________________________________ Date___________
**DENTIST PLEASE RETURN FORM TO PHYSICIAN
I. Gingivitis
II. Early Periodontitis
III. Moderate Periodontitis
IV. Advanced Periodontitis
2. Dental Treatment needs:
Yes
No
Collaborative Resources
 Dental Listserv
 Dental Resources on Virtual Office
 Dental Director to contact with
questions
 Dental Breakouts at Learning
Sessions and Phase 2 Summits
 Mechanism to share forms and
education tools
Dental Listserv
Includes persons from Phase 1 and Phase 2
and others who have expressed interest in
the collaborative dental initiative.
The purpose is to share information, ask
questions, and keep the communication
open between the face to face meetings!
Not just for dental providers!!
Dental Listserv
If you have not received the initial
communications and would like to join,
please send an email to jtallman@mpca.net
and request that your name be added.
Diabetes Virtual Office
A virtual office for the Diabetes Collaborative has
been established and has the Oral Health and
Diabetes Web Resources document posted for
your use. (Under Tools/Resources, then
Miscellaneous.) This includes several pages of
websites for patient education materials, some in
multiple languages; provider in-service training;
periodontal references;
Other resource materials will be added as they
become available.
Check with your data specialist if you are not signed
on!
Colgate Diabetes Program
 If you are a member of the AADE
(American Association of Diabetes
Educators), you can register to receive
Colgate samples every month by calling 1800-840-3000. When prompted for a PIN
number, press O for the operator. They
will take it from there!
 They also have a dental education sheet
for persons with diabetes.
Free Oral Care Kit for Public
Health Centers
Colgate is offering “Oral Health . . . from
Pregnancy through the Toddler Years” to
health centers at no cost through this
order form or by emailing
bsbf@jmheducation.com. The kit has oral
health messages covering the periods of
pregnancy, 0-6 months, 6-18 months, and
18-24 months. They are available in English
and Spanish.
Free Bright Smiles, Bright Futures
Kits for Kindergarten Classes
If your schools have not already signed up
for their free dental kits, this will provide
them the information to do so. These are
also available in English and Spanish.
Kits are sent to the schools. For more
information, call 800-375-7576
The Interface Between Medicine and
Dentistry in Meeting the Oral Health
Needs of Young Children
This document is part of the Children’s
Dental Health Project that has been a
great resource of information through
their patient education sheets, CDHP News
*Bytes, and website http://www.cdhp.org.
An electronic version of this document is
available on their website.
Questions?