Open Wide:
Common Infectious
Conditions We Overlook
What’s New in Medicine
September 2014
Russell Maier, MD
“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.
2
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
3
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
Photo: ICOHP
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
4
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
5
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, 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
6
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
7
Inflammatory Response
DIABETES
CANCER
AUTOIMMUNE
DISEASES
CARDIOVASCULAR
INFLAMMATION
PULMONARY
DISEASES
8
PERIODONTAL
DISEASE
NEUROLOGICAL
DISEASES
ARTHRITIS
GOOD NEWS!
Oral Disease is Preventable
Preventing and Interrupting
Oral Disease
Presentation Title | Section | 9
Preventing and Interrupting
Tooth Decay
Presentation Title | Section | 10
Tooth Decay Process: A Bacterial Infection
Bacteria
Acid
+
Refined Carbohydrates =
+
Time (20 min) =
Acid
Enamel Demineralization
& Risk for Decay
Untreated Decay  Infection, Abscess, Loss of Tooth
11
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
14
Facial
Swelling
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
Recurrent Caries
• Special health care needs
• Physical disabilities and dementia
• Medications that:
– Decrease salivary flow (xerostomia)
– Contain high levels of sucrose
Malocclusion of drifting
teeth after extraction
Photos: UKCD
17
Caries Process: Ongoing Balance
Protective Factors
Saliva
Peptides (defensins)
Fluoride
No Caries
18
Pathologic Factors
Acid-producing Bacteria
e.g. Strep mutans
Frequent carbohydrates
Reduced saliva
Caries
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
19
Fluoride Varnish
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
Presentation Title | Section | 21
Gum Disease
Gingivitis
22
Periodontal Disease
Periodontal Disease
Image from www.periotherapy.com
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Risk Factors for Periodontitis
•
•
•
•
•
24
Lack of oral hygiene
Systemic diseases (e.g. diabetes)
Tobacco use
Poor nutrition
Dry mouth
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
26
Periodontitis
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
Presentation Title | Section | 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
30
Smear/rice-sized
Pea-sized
Before age two
When child can spit
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
Presentation Title | Section | 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 preterm 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
NY State Practice Guidelines; CDA Foundation Evidence-based Guidelines
35
Photo: ICOHP
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
Presentation Title | Section | 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
40
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
•
•
40
Daily oral hygiene
Protect teeth with fluoride—toothpaste (including prescription strength),
rinse, fluoride varnish, fluoridated water
Start Today!
Address your patients’ oral
health in routine checkups
Presentation Title | Section | 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
•
•
•
•
43
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
Questions?
Presentation Title | Section | 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
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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.