Oral Health Update Lydia Elliott, DNP, FNP-BC

Transcription

1 Oral Health Update Lydia Elliott, DNP, FNP-BC 2017 NPSS Asheville, NC

2 Objectives Value the importance of the oral assessment as an integral part of the physical exam Appreciate the oral systemic link and the adverse effects of various systemic diseases/conditions on the oral cavity Recognize the effects of pharmacologic agents on the oral cavity Describe a comprehensive oral assessment Identify preventive and interventional oral care strategies for infants, children, and adults NCNA 2017 NPSS

3 National Health & Nutrition Examination Survey, What percentage of older adults had dental caries in permanent teeth? A. Less than 50% B. 70% C. 80% D. Greater than 90%

4 National Health & Nutrition Examination Survey, What percentage of adults had no loss of permanent teeth? A. Less than 50% B. 70% C. 80% D. Greater than 90%

5 National Health & Nutrition Examination Survey, How prevalent was complete tooth loss (edentulism) among older adults? A. 5-10% B % C % D. Greater than 20%

6 National Health & Nutrition Examination Survey, What percentage of adults had dental caries in permanent teeth? A. Less than 50% B. 70% C. 80% D. Greater than 90%

7 What about the pediatric population? Dental caries is the most chronic childhood disease in the US Age of first dental caries is getting younger -Caries can develop as early as 10 months of age Prevalence of tooth decay in preschoolers is rising -By age 3, 25% of children enrolled in WIC have caries

8 Identified Disparities in Oral Health Children Older adults Compromised immune system Disabled Living in institutional settings Less education Lower income No insurance or public insurance

9 Does ethnicity make a difference? Populations at greater risk for oral problems include: African Americans Latino Access is a MAJOR obstacle

10 Why is oral health important? The health of the mouth affects the health of the body Oral Systemic Link One mouth can be home to more than 6 billion bacteria

11 Healthy People 2020 Goal: Prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to preventive services and dental care.

12 How do we reach the 2020 goal? HRSA (2012) -Developed the Integration of Oral Health into Primary Care Practice (IOHPCP) initiative -In 2016, awarded $156 million to Health Centers across US to expand oral health services IOM (2011) -Advancing Oral Health in America and Improving Access for Oral Health for the Vulnerable and Underserved

13 How do we reach the 2020 goal? CDC Working to advance health promotion and dental disease prevention activities -Leads national surveys and data analyses -Developed guidelines for infection control in dental practice settings (2003) -Initiated state-based Oral Disease Prevention Program (FY 2001) -Developed guidelines for fluoride use (2001)

14 How do we reach the 2020 goal? It is going to take a paradigm shift in how oral health is approached Integration of Oral Health & Primary Care Everyone needs to paddle in the same direction

15 Anatomy of a Tooth

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17 Primary (Deciduous) Teeth Gold = Incisors Green = Canine (cuspids) Blue = Molars

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19 Mastication & Neuronal Activity Chewing process is considered positive feedback to stimulate neuronal activity of the brain

20 Potential Effects of Poor Oral Health Naorungroj et al. (2013) found multiple tooth loss and gingival bleeding to be significantly associated with... lower cognitive status

21 Potential Effects of Poor Oral Health Poor glycemic control CAD Adverse pregnancy outcomes Peptic ulcer disease Stroke Dementia Respiratory ailments Rheumatoid arthritis Other considerations: joint replacement, prosthetic valves

22 Guidelines for Antibiotics Before Dental Procedures Patients with the following conditions should still take antibiotics prior to dental procedures: Prosthetic heart valves History of having had infectious endocarditis Certain specific, serious congenital heart conditions Cardiac transplant who develops a problem in a heart valve

23 Oral Health & A1c Hyperglycemia Gum Disease Elevated A1c Poorly controlled T2DM + severe periodontal disease doubles risk of ESRD and triples risk of cardiorenal mortality

24 Oral Health & A1C Routine nonsurgical periodontal therapy decreases A1c about 0.4% in persons with T2DM and periodontitis Now, that is something to smile about!

25 Oral Care Tips for Young Children Infant Before teeth erupt, clean mouth daily with wet soft wash cloth First dental visit should occur before age 1 or within 6 months of first tooth eruption Average age of 1 st dental visit in US is 4 years old

26 Oral Care Tips for Young Children Infant -Bottle restricted to breast milk or formula -Wean from bottle by age 1 -Avoid dipping pacifier in anything sweet Child -Once teeth erupt, brush 2x/day with fluoridated tooth paste -Fluoride varnish recommended for all children through age 5 -Fluoride supplements recommended if water source is well water

27 Oral Care Tips for Older Children Mouth guards during sports Floss twice a day to remove bacteria -Require assistance until age 10 yo Brush twice a day for 2 minutes covering all surfaces -Require assistance until age 6 to 10 yo Avoid sticky sugary food i.e., taffy

28 Erosion in Primary Dentition of 6-year-old girl Shortening of crown height and visible pulp as a consequence of high intake of acidic drinks

29 Oral Care Tips for Adults Regular brushing and flossing Regular dental visits -every 6 months Limit alcohol and tobacco use Brush and rinse dentures after each meal, remove at night, and sanitize regularly

30 Denture Stomatitis

31 My dentures don t fit 31% of adults > 75 yo have lost all natural teeth Dentures should be remade every 5 to 7 years due to natural remodeling of bone/tissues that changes fit, bite, and position Dentures will need to be adjusted within first 6 to 12 months after teeth extraction Gagging can result from dentures extending into sensitive areas Cheilitis can be caused by loose fitting dentures

32 Angular Cheilitis

33 My mouth hurts Potential causes of mouth/tooth pain include: Bruxism Dental caries Gum abscess Apthous Ulcer Maxillary sinusitis TMJ problem Acute necrotizing ulcerative gingivitis Poorly fitting dentures

34 Risk Factors for Gingival Inflammation Hormonal fluctuations -puberty, pregnancy, menopause Diabetes Poor dietary choices Salivary changes

35 Gingivitis

36 Periodontal Disease Look for the 4 Es -Exposure to tooth necks at gum line -Edema -Erythema -Exudate from gums, lesions, or abscesses

37 Risk Factors for Periodontal Disease Smoking Diabetes Poor oral hygiene Stress Heredity Crooked teeth Underlying immunodeficiencies Fillings that become defective Taking medication that causes dry mouth Bridges that no longer fit properly Female hormonal changes

38 Early Periodontitis

39 Advanced Periodontitis

40 Risk Factors for Caries Children -Poor maternal/primary caregiver oral health -Continual bottle/sippy cup use Children & Adults -Inadequate exposure to fluorides -Frequent snacking -High sugar foods -Special healthcare needs

41 Caries/Cavities

42 Abscessed Tooth

43 Dry Socket BCP users may be at higher risk

44 Effects of Medications Bisphosphonates Dilantin Antihistamines Decongestants Diuretics Antihypertensives Antidepressants

45 Recommendations Regarding Bisphosphonates Dental exam before drug is started and regular exams thereafter Avoid invasive dental tx while on drug -routine fillings and cleanings OK Related to possible link with osteonecrosis of the jaw

46 Gingival Enlargement

47 Xerostomia

48 Role of Primary Care Providers Perform oral risk assessment -begin at age 4 to 6 months Application of dental fluoride varnishes -recommended through age 5 -may bill for this service Oral health assessments for school-age children -now required by many states as part of annual PE Provide education

49 Role of Primary Care Providers Update patient history questionnaire: "Do you see blood in the sink when you brush, floss your teeth, or see your hygienist? Do you have a h/o periodontal disease? Have you had a dental exam in the last 6 months? Include name of dentist in medical record Provide comprehensive oral assessments and evaluations Interprofessional collaboration (Refer if needed) -let s fix the oral-systemic gap between medicine and dentistry

50 AAP Formal Oral Risk Assessment Tool Tool assesses: -caries risk factors -protective factors -clinical findings RED FLAGS: Mother/primary caregiver had active decay in last 12 months Clinical finding of white spots/decalcifications, decay, or fillings

51 Decalcifications (White Spots)

52 Oral Health Exam HEENT HEENOT (Put the mouth back in the head) The O (oral cavity) includes: Gums Teeth Mucosal surfaces Salivary glands Soft and hard palate Tongue

53 Documentation

54 Primary Dentition upper right upper left A B C D E F G H I J T S R Q P O N M L K lower right lower left

55 How do PCPs prepare for a new role? Self-education -Refer to next slide on Resources for Providers Support legislative issues Interprofessional collaboration Know your community resources

56 Resources for Providers American Academy of General Dentistry me/alpha/1 American Academy of Periodontology American Dental Association

57 Resources for Providers Oral Health: Periodontal Disease disease/index.htm Oral Health Risk Assessment Tool (for children) assessmenttool.pdf Smiles for Life

58 Fun Fact Toothbrush was invented in 1498 in China Over 500 Years Ago Nylon bristled toothbrush was introduced in 1938

59 Toothbrush Tips Change every 3 months Change after recovery from illness Use soft bristles Brush at 45 degree angle to gums Rinse with hot water before & after brushing Air dry upright and not touching each other Close toilet lid before flushing No swapping Consider electric toothbrush if dexterity problems

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61 References Darling-Fisher, C. S., Kanjirath, P. P., Peters, M. C., & Borgnakke, W. S. (2015). Oral health: An untapped resource in managing glycemic control in diabetes and promoting overall health. Journal for Nurse Practitioners, 11(9), Drexel University College of Medicine. (n.d.). Gender and ethnic medicine project: Oral health. Retrieved from Health/default.htm Dye, B. A., Thornton-Evans, G., Xianfen, L., & Lafolla, T. J. (2015). Dental caries and tooth loss in adults in the United States, NCHS Data Brief, 197, 1-5. Hyattsville, MD: National Center for Health Statistics.

62 References Erickson, L. E., (2016). The mouth-body connection. Journal of the American Society on Aging, 40(3), Heavey, E. (2014, March). Oral health in primary care. Nursing 2014, 44(3), Naorungroj, S. et al. (2013). Cross-sectional associations of oral health measures with cognitive function in late middle-aged adults: A community-based study. Journal of the American Dental Association, 144,

63 References Ren, Y.F. (2011). Dental erosion: Etiology, diagnosis, and prevention. Academy of Dental Therapeutics & Stomatology. Retrieved from US Dept. of Health & Human Services. (2014). Integration of Oral Health and Primary Care Practice. Retrieved from lhealth/primarycare/integrationoforalhealth.pdf Zhu, J., Li. X., Zhu, F., Chen, L., Zhang, C.,... Jin, L. (2015). Multiple tooth loss is associated with vascular cognitive impairment in subjects with acute ischemic stroke. Journal of Periodontal Research, 50,

64 Lydia Elliott, DNP, FNP-BC Assistant Professor Western Carolina University Office: NPSS ASHEVILLE, NC