The Relationship of Oral and Systemic Health

Question 1

Oral health affects…
Oral pain is linked to…

Answer 1

Oral wellness affects:

• Obtaining a job
• Confidence
• Enjoyment

Oral pain is linked to:

• Poor school performance in children
• Work loss in adults to care for themselves and their children
• Difficulty chewing and inadequate nutrition

Question 2

Prevalence

Answer 2

• Dental caries is the most common chronic disease of childhood
• 1 in 5 children aged 5-11 years have at least one untreated decayed tooth
• Periodontitis (deep gum disease) affects almost 50% of U.S. adults
• 50,000 oral cancers are diagnosed annually
• 9,700 deaths annually in U.S. (1.1 hrly)

Question 3

Consequences of poor oral health

Answer 3

Oral pain can cause:
* poor school/work performance
* difficulty chewing leading to inadequate nutrition
* costly ED visits

Dental decay and tooth loss can cause:
* aesthetic and self-image issues
* feeling worthless, unhappy, shy
* costly restorations
* systemic complications

Question 4

Mrs. Smith is diabetic, so you perform an oral examination at this visit and advise her to see a dental care provider regularly. What is the probable mechanism connecting periodontal disease with diabetes mellitus?

• Diabetics with chronically high blood sugar levels have high salivary sugar levels that promote tooth decay in the same way eating foods high in sugar content cause tooth decay.
• The bacterial and host response in periodontitis releases inflammatory chemical mediators into the bloodstream that have distant effects.
• Patients with elevated blood sugars have high levels of oral bacteria that lead to increased rates of decay.
• The medications prescribed to treat diabetes mellitus cause dry mouth, which in turn promotes dental decay.

Answer 4

The bacterial and host response in periodontitis releases inflammatory chemical mediators into the bloodstream that have distant effects.

Question 5

Mrs. Smith takes multiple medications each day to treat her hypertension, depression, asthma, and allergies. Today you review her medication list, which includes hydrochlorothiazide, citalopram, intranasal fluticasone, albuterol, and loratadine.

Which oral complication is common to all the medications Mrs. Smith takes?

• Cancer of the tongue
• Taste alteration
• Oral candidiasis (thrush)
• Xerostomia

Answer 5

Xerostomia, or dry mouth, is a common oral condition commonly associated with use of diuretics, antihistamines, anti-depressants and nasal steroids. Reduced salivary flow impedes pH normalization after eating and produces an oral environment favoring periodontal disease and dental caries. Patients on these medications should be educated about the importance of good oral hygiene, increased water drinking (not sugary beverages), using sugar-free gum or mints to stimulate saliva production, and avoiding frequent carbohydrate snacks. Salivary substitutes can be prescribed if symptoms persist despite increased fluid intake and saliva stimulation.

Question 6

interaction between nutrition and oral health

Answer 6

• Frequent ingestion of sugary snacks and beverages contributes to obesity, and to dental caries
• Poor dentition, dental pain, and chewing problems due to missing teeth interfere with eating
• Children, patients with special healthcare needs, and older adults are more at risk and have few reserves when nutritionally deprived

Question 7

Oral risks of:
* tobacco use
* alcohol use
* substance use

Answer 7

People with tobacco use disorder are at higher risk of:
* Oral cancer
* Periodontal disease

People with alcohol use disorder may develop:
* Oral cancer (synergistic with tobacco)
* Poor hygiene and resultant caries or periodontal disease

People with other substance use disorders are at higher risk of:
* Dental caries due to dry mouth from substances
* Tooth loss and dental pain from inability to provide self-care or access dental treatment

Question 8

define iatrogenic

Answer 8

Iatrogenic is the term for adverse effects caused by diagnostic and therapeutic interventions.

Question 9

Normal job of saliva + effect of xerostomia

Answer 9

• Saliva rinses the mouth and cleans the teeth between meals, neutralizing acids produced by bacteria and allowing the teeth to remineralize.
• Decreased saliva flow results in dry mouth (xerostomia), which promotes caries and periodontal disease.

Question 10

common meds which cause xerostomia

Answer 10

• steroids
• anti-histamines
• diuretics
• anti-HTNs
• opioids
• anti-depressants

SODDAA

Question 11

adverse intra oral effects of:
* Phenytoin/CCB
* IV Bisphosphonates
* Chemo/Rad
* Steroids

Answer 11

• Phenytoin/CCBs: gingival hyperplasia
• IV Bisphos: osteonecrosis
• Chem/Rad: stomatitis and mucositis
• Steroids: candidiasis

Question 12

caregiver/pt limitations

Answer 12

• Dental care is not always a high priority and may not be given the attention it deserves by patients, caregivers and health care providers.
• Caregivers may be overwhelmed with care needs and deemphasize oral care without realizing its importance to overall health.
• Financial limitations may force patients to choose between systemic and oral health care and basic necessities.
• Oral hygiene and dental care can be physically or behaviorally challenging for those with conditions such as Parkinson’s, arthritis, autism, Down Syndrome, and many others.

Question 13

healthcare provider challenges

Answer 13

• May forget to ask about oral health when other problems compete for attention.
• Oral health prompts are often not incorporated into the electronic medical record.
• May be unsure when or where to refer in the community - especially for elderly with Medicare, patients with special needs, young children, and pregnant women.
• Limited training: Oral health training in health professional schools is steadily increasing, but health providers may be unsure of correct questions to ask or how to perform a proper exam.

Question 14

complications of untreated oral bacterial infections

Answer 14

• intraoral abscess
• sinusitis
• cellulitis (facial/periorbital)
• bacteremia, sepsis
• airway compromise

Question 15

aspriation pneumonia as a complication of oral infections

Answer 15

• Aspiration of oral bacteria is associated with pneumonia, particularly in bedridden and hospitalized patients.
• Eighty-three percent of patients who develop nosocomial pneumonias are mechanically ventilated.
• Oral care interventions led to a 90% reduction in ventilator associated pneumonia in adult ICUs.

Question 16

what causes inflammation in the mouth?

Answer 16

• Dental plaque is a polymicrobial biofilm that may contain 500 different species of bacteria.
• Some bacteria, particularly anaerobes, produce toxins that damage gum tissue.
• Neutrophils are white blood cells recruited to attack the bacteria. When there is gum damage, the immune system sends in macrophages to clean up cellular debris and dead and dying neutrophils.
• The macrophages secrete inflammatory mediators such as fatty acids, interleukin 1, and tumor necrosis factor that can circulate beyond the oral cavity.
• This inflammatory cascade and systemic spread of pro-inflammatory mediators is being studied to explain the observed link between oral disease and a wide range of systemic diseases.

Question 17

Link between inflammation, systemic disease, and oral health

Answer 17

• Inflammation constitutes a major mechanism for the observed link between oral disease, specifically periodontitis, and systemic diseases, although direct cause-and-effect is difficult to establish.
• Strong evidence exists for a causal link between periodontal disease and diabetes.

Emerging evidence for links with other conditions including:
* Obesity
* Coronary artery disease
* Metabolic syndrome
* Pregnancy outcomes/Preterm labor
* Oral health after menopause
* Rheumatoid Arthritis

Question 18

Obestity/DM and oral health

Answer 18

The oral-systemic link between obesity and oral disease is intimately tied up with diabetes in a “three-way street.”

• Fat tissue is a metabolically-active organ that produces tumor necrosis factor alpha (TNF α) and interleukin 6.
• These cytokines promote bone breakdown and inflammation, processes that both potentiate periodontal disease.
• TNF α also causes insulin resistance that predisposes to Type 2 diabetes.
• Poor glycemic control is associated with periodontal disease.
• Periodontal disease then leads to worsening glycemic control, creating a vicious cycle.

DM & Glycemic Control
* Poor glycemic control is associated with a threefold increased risk of having periodontitis in diabetics versus controls.
* Diabetics with good glycemic control have no significant increased risk of periodontal disease.
* Chronic infection (like periodontal disease) worsens glucose control
* Treatment of periodontal disease results in a 10–20% improvement in glycemic control.

Question 19

Heart Disease & Oral Health

Answer 19

Periodontal disease is associated with coronary artery disease and cerebrovascular disease, though the impact is unclear.

• Studies support an association between periodontitis and atherosclerotic vascular disease, but not a causative relationship.
• Inflammatory cytokines implicated in atherogenesis are also produced in periodontitis.
• Treatment of periodontal disease has not been shown to reduce cardiovascular risk.

Question 20

Adverse Pregnancy Outcomes

Answer 20

Numerous studies associate periodontitis with preterm birth (PTB) and low birth weight (LBW):

• Association between periodontitis and PTB and LBW is biologically plausible.
• Treatment did not change outcomes in three large U.S. based NIH funded randomized controlled trials.

However:
* Periodontal treatment is safe in pregnancy
* Treatment improved periodontitis and women felt better
* Question remains if treatment of periodontitis before pregnancy would make a difference

Question 21

Menopause & Oral Health

Answer 21

Oral health is an important part of counseling for peri- and postmenopausal women.

• Incidence of periodontitis increases after menopause.
• Hormone replacement therapy appears to be protective.
• Primary care clinicians should counsel peri- and postmenopausal women about maintaining good oral hygiene.

Question 22

Rheumatoid Arthritis & Oral Health

Answer 22

There is an association between periodontitis and the development of RA in patients who are susceptible.

Aggregatibacter actinomycetemcomitans can contribute to periodontitis by producing a toxin that can trigger hypercitrullination in neutrophils.

• Hypercitrullination can trigger the formation of autoantibodies.
• Treatment of periodontal disease in patients with RA has led to reductions in some markers of disease activity in RA patients (ESR, TNF-α titers, and disease activity scores).

Question 23

Infectious Diseases and Oral Health

Answer 23

HIV related oral diseases include:
* Candidiasis (thrush)
* Oral hairy leukoplakia
* Kaposi sarcoma
* Periodontal disease
* Ulcerative conditions (herpes virus and aphthous ulcers)
* A careful oral exam should be part of every HIV+ patient visit

Human papilloma virus (HPV) is on the rise, as are cancers associated with HPV.
* 25% of oral cancers and 66% of oropharyngeal cancers are related to HPV 16.

Question 24

Tooth Loss & All Cause Mortality

Answer 24

• Loss of a large number of teeth negatively affects overall health and is an important public health issue.
• Loss of all natural teeth (complete edentulism) prior to age 65 is associated with 1.5 times increased risk of death from all causes.
• Statistics were based on 41,000 adults over 16 years of age and study controlled for socioeconomic status (OR 1.5 - 95% CI 1.3-1.7)

Question 25

You would like to start a fluoride varnish program in your office since your state Medicaid program now reimburses for this service. Your team members are concerned about introducing an additional procedure into already busy well child visits. You have recently learned about the importance of oral health to overall health and would like to present data to your team members about the importance of promoting good oral health.

Which of the following statements is true?
* Dental caries is five times more common than asthma in children.
* Oral cancer is the fourth most prevalent cancer in adults.
* Children are more likely to lack medical insurance compared with dental insurance.
* All of the above

Answer 25

Dental caries is five times more common than asthma in children.

Question 26

The conversation with your team then turns to what oral health services your practice should offer. One of your team members points out that many oral problems are already managed in the office. Your office manager is confused and thought oral health was exclusively the domain of dentists.

Which of the following are routine oral health related scenarios that primary care providers should feel comfortable addressing?
* Managing anticoagulation before, during and after dental procedures in collaboration with a dentist
* Initially evaluating oral trauma
* Managing the oral effects of common medications
* Consulting with dentists about the need for antibiotic prophylaxis before a dental procedure
* All of the above

Answer 26

all of the above

Question 27

Your varnish program proves to be successful. After 3 months your team decides to expand their scope of involvement in the promotion of oral health.

With a minimal amount of continuing education, clinicians in your office could play all of the following roles EXCEPT:
* Advocate for community water fluoridation and fluoride varnish programs
* Develop closer relationships with local dentists to improve the effectiveness of referrals
* Extract teeth in the office
* Apply fluoride varnish
* Have posters promoting oral hygiene and teeth injury prevention in every exam room

Answer 27

Extract teeth in the office

Question 28

Oral Health Promotion

Answer 28

The medical home is an ideal place for oral health screening and guidance to occur. The Smiles for Life courses on oral examination, infant oral health, adult oral health, women’s oral health, caries risk assessment, and geriatric oral health cover the following topics in detail:

Screen for disease and risk:
* History, risk assessment, and examination

Provide anticipatory guidance regarding
* Caries
* Oral health maintenance
* Early referral
* Fluoride

Question 29

Medical Monitoring and Management

Answer 29

Medical Offices are ideal sites to:
* Monitor conditions such as diabetes, which affect both oral and systemic health directly and also indirectly via the medications used in treatment.
* Evaluate and initially manage oral emergencies.
* Apply fluoride varnish for prevention of caries, particularly in locations where dental services are not available.

Question 30

role of PCP in resource poor areas

Answer 30

Screen, Advise, Advocate
* Many areas lack dental providers, creating an additional reason for primary care providers to address oral health. The medical home is the dental home until primary care clinicians can help patients find appropriate dental care.

PCPs should:
* Counsel patients on oral health promotion
* Screen for oral disease and facilitate appropriate referrals
* Focus on prenatal oral health and develop fluoride varnish programs for infants and children
* Collaborate with schools, Head Start, and health providers promoting oral health in the community
* Consider further training to learn skills such as anesthetic blocks, biopsies, and incision and drainage (if access is not available)
* Know your local resources, such as dental providers who accept Medicaid and Federally Qualified Healthcare Centers (FQHCs) that offer dental services.

Question 31

Collaboration w/ Dental Professionals and Advocacy

Answer 31

Get to know your local dental health professionals and develop relationships that promote collaboration. Common areas of collaboration include:
* Referrals for routine and emergency care
* Pain management
* Medically complicated patients
* Anticoagulation
* Antibiotic prophylaxis

Health care professionals can be powerful advocates for oral health in patients and communities. Promote the following:
* Improved access to care
* Prevention of oral disease
* Community water fluoridation
* Safety and injury prevention

In addition, clinicians should be aware of the following issues and support improvements at both the local and systems levels.
* Many patients who have private health insurance lack dental insurance—be sure to ask
* Medicaid may cover dental care, but relatively few dentists accept Medicaid insurance.
* Free care clinics increase access, but have limitations including poor continuity.
* Rural areas often face dental health professional shortages.
* There continues to be a nationwide shortage of dentists comfortable treating children under age three.

Question 32

Virginia is a 65-year-old woman who visits her community health clinic for a routine check-up. She has a history of Type 2 diabetes, obesity, hyperlipidemia, and hypertension. The health care team understands the importance of a team-based, collaborative approach to monitor her oral health and systemic health conditions.

What should the primary health care team do to maintain a climate of mutual respect?
* Promote the interests of dentists at the center of interprofessional oral health care delivery.
* Allow dentists to disclose private and confidential dental information without the patient’s authorization.
* Value the dentist’s expertise and contributions in managing oral and systemic health conditions.
* Prevent the dentist from raising ethical dilemmas concerning general health care.

Answer 32

Value the dentist’s expertise and contributions in managing oral and systemic health conditions

Question 33

While you are conducting an oral health history to assess Virginia’s oral health status, she reports that she brushes her teeth twice a day and that her gums bleed occasionally. She does not use dental floss. She also states that her last dental visit was “several years ago” and has not returned due to a lack of dental insurance.

As a primary care clinician, how would you appropriately assess and address this patient’s oral and systemic health care needs?
* Avoid explaining the roles of the dentist and social worker on the team.
* Foster an independent relationship between the patient and the social worker.
* Develop strategies to meet the patient’s oral health care needs independently from the social worker and dentist.
* Recognize your limitations in oral health knowledge and skills.

Answer 33

Recognize your limitations.

Question 34

When you examine Virginia’s mouth, you notice that she has a loose tooth and her gums are red and swollen. You explain to Virginia the importance of good oral health in relation to managing her diabetes and counsel on improved hygiene, including regular brushing and flossing. The nurse shows Virginia proper brushing and flossing techniques. You recommend that she see a dentist as soon as possible. Because you work in a community health center (CHC) with co-located dental facilities, you ask that an appointment be arranged with the dentist when Virginia is finished with your visit. Because she does not have dental insurance, she will meet with the social worker as well to discuss the cost of the dental visit and potential opportunities to cover some of those costs.

How would you communicate with Virginia and other health care providers in a way that supports a patient-centered team approach to oral and systemic health care?
* Communicate health information to the patient using discipline-specific terminology.
* Withhold sharing different ideas and opinions to the social worker.
* Ensure common understanding of health information, treatment plans and care decisions between the patient, social worker and dentist.
* Delay providing instructive feedback to the social worker about his teamwork.

Answer 34

Ensure common understanding of health information, treatment plans and care decisions between the patient, social worker and dentist.

Question 35

Working with multi-disciplinary teams

Answer 35

Professional is a broad term that includes individuals with the knowledge and/or skills to contribute to the physical, mental and social well-being of a community.

• Collaborative practice in health-care occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, and communities to deliver the highest quality of care across settings.
• Practice includes both clinical and non-clinical health-related work, such as diagnosis, treatment, surveillance, health communications, management and sanitation engineering.
• Interprofessional education occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.
• Oral health provides a natural opportunity for collaborative practice given the relationship of oral health to systemic health and the need for multiple provider types to ensure good oral health.

Create a Health “Team”
* Reach out to medical or dental colleagues to get to know them better.
* Discuss how to best communicate.
* Help the patient find the right team.
* Ideally, walk the patient to meet the staff and make an appointment
* Otherwise, introduce them via a website or brochure and help them make an appointment
* Teach one another. For example, a dental team member could attend a diabetes or prenatal group visit and discuss oral health or perform triage exams

Question 36

Benefits of collaborative practice

Answer 36

Collaborative practice can improve:
* Access to and coordination of health services
* Health outcomes for people with chronic disease
* Patient care and safety

Collaborative practice can decrease:
* Total patient complications
* Hospital admissions and length of hospital stay
* Tension and conflict among caregivers
* Staff turnover
* Clinical error rates and mortality rates
* Redundant medical testing and associated costs