The Mouth Body Connection: Oral Health and Systemic Health Connections

The Mouth Body Connection: Oral Health and Systemic Health Connections

The Mouth: An Open Pathway into the Body

A Window for Disease Manifestations Medication Induced Hyperplasia

Learning Objectives By the end of this seminar, participants will be able to: Discuss the prevalence and sequelae of oral disease Recognize the inter relationships between oral and systemic disease

The Big Picture You are not healthy without good oral health C. Everett Koop, MD Dental care: the most common unmet health need Oral disease can severely affect systemic health Profound disparities in oral health and access to care exist at all ages Much oral disease is preventable (or at least controllable) 5

Dental caries is the most common chronic disease of childhood 5 times more common than asthma Affects 50% of low income children Affects up to 70% of Native American children Periodontitis affects 19% of adults aged 25 44 Prevalence 6

30,000 oral cancers diagnosed annually 8000 die Diagnosis is often late Prevalence 7

Prevalence of Geriatric Oral Health Issues 50% of the elderly (age >65) perceive their dental health as poor or very poor 33% of the elderly had untreated cavities Low income elderly suffer more severe tooth loss than their wealthy counterparts

Prevalence of Geriatric Oral Health Issues Edentulism: affects 1/3 of those over age 65; 50% of those in nursing homes Periodontitis in 41% of the elderly

Physical, Economic and Social Consequences Mounting evidence of aggravating effects on systemic conditions Oral pain Poor school performance in children Work loss in adults Poor chewing and poor nutrition Costly emergency department visits Dental decay and tooth loss Aesthetics and self image Speech and language development Costly restoration Photos: Donald Greiner DDS MS, ICOHP 10

The Disconnect Children are 2.5 times more likely to lack dental coverage than medical coverage Only 43% of elderly visit the dentist Dentists per capita appear to be declining, especially those that accept Medicaid and see infants 11

The Disconnect More than 90% of physicians think oral health should be addressed at well visits, yet greater than 50% have little or no oral health training. Little communication and cooperation between medical and dental providers 12

So who should take care of a patient s oral health? Who is responsible for the patient s oral health?

Inter Relationships Between Oral and Systemic Health and Disease Oral Systemic

Mechanisms Behavioral Nutritional Iatrogenic Lack of priority Direct bacterial extension Inflammatory 15

Case #1 55 year old man has a sore on his tongue. He is a 25 pack year smoker and drinks daily. Photo: Ellen Eisenberg DMD 16

Behavioral Component Tobacco Lung and oral cancer Alcohol Liver disease Oral cancer Drug abuse Blood borne infections Poor hygiene ( meth mouth ) Who makes the diagnosis? Who does the counseling? Photos: Brad Neville DDS, James Cecil, DMD, MPH 17

Case #2 75 year old man is brought in by his family who are concerned about poor appetite and progressive weight loss despite his new dentures. Photos: Robert Henry DMD MPH 18

Nutritional Component Cariogenic diet in children and adults Obesity Poor dentition, mechanical issues and dental pain interfere with eating Children, special needs patients, and the elderly are particularly vulnerable Poor eating may result in malnutrition Elderly failure to thrive: think poor fit of dentures A lot of counseling for one office, one provider 19

Case #3 65 year old woman on multiple medications for depression and cardiovascular disease develops severe caries Photo: John McDowell DDS 20

Iatrogenic Component: Xerostomia Decreased saliva promotes caries and periodontal disease Many medications reduce salivary flow steroids antihistamines diuretics antihypertensives anticholinergics antidepressants Need for dental to address medications? Photo: John McDowell DDS 21

Iatrogenic: Other Gingival hyperplasia phenytoin Osteonecrosis IV bisphosphonates Stomatitis and mucositis cancer chemotherapy radiation therapy Candidiasis steroids Periodontal disease immunosuppressives Need for dental to address medications? Photo: Ellen Eisenberg DDS 22

Case #5 4 year old goes to bed with a toothache and awakens crying and feverish Photo: ICOHP 23

Direct Bacterial Extension Intraoral abscesses Sinusitis Facial cellulitis Periorbital cellulitis Bacteremia and its consequences Brain abscess Aspiration pneumonia Infections prompt medical and dental to interact! Photo: ICOHP 24

Case #6 52 year old woman with previously wellcontrolled type 2 diabetes has increasing hyperglycemia Photo: Efthimia Ioannidou, DDS MDS 25

The Role of Inflammation Macrophages Neutrophils Toxins Anaerobic bacteria in plaque Circulating inflammatory mediators 26

Diabetes Poor glycemic control is associated with a threefold increased risk of having periodontitis in diabetics vs 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 27

Coronary Heart Disease CHD and periodontitis are associated, but causation is not clear Inflammatory cytokines implicated in atherogenesis are also produced in periodontitis Systemic antibody response to periodontitis is associated with CHD Smoking is associated with both CHD and periodontitis 28

Pregnancy: Preterm Birth (PTB) and Low Birth Weight (LBW) Association between periodontitis and PTB and LBW is confirmed; however RCT studies of treatment show no change in outcome Periodontal treatment is safe in pregnancy: No bad prenatal outcomes in any studies Women felt better Need to study preconception interventions

National Institute of Dental and Craniofacial Research Scientists are using an ever growing array of sophisticated analytical tools and imaging systems to test and study normal function and diagnose disease through oral cells and fluids. New tests are constantly being developed to make oral tissues and fluids an increasingly accurate mirror of health and sickness.

How can medical and dental providers work together: Practical Solutions

Interdisciplinary Care Set up in same building and conduct meetings together (e.g. a community health center) Have a professional perform visiting consults (e.g. hygienist in MD office once a week) Conduct regular in services for others Create lists for proper referrals know who does what, what insurance they take, what patient populations they see, etc.

Work synergistically Support cross pollination of ideas: Dental supporting fluoride varnish done by medical providers Medical supporting dental doing oral cancer screens, blood pressure monitoring, nutrition advice More interprofessional health education in schools/residencies

Take Home Messages Oral and systemic health are interrelated Oral exams must be systematic and complete Certain groups are at particular risk for oral problems Medical providers can have a major impact on the oral health of individuals and communities

Oral Health, Systemic Health and Pharmacology Sandra Leal, PharmD, CDE Director of Clinical Pharmacy, El Rio Health Center

Summary Oral health coupled with systemic health are well understood to be foundations for improved health outcomes and quality of life for patients. This presentation will address the important opportunity to understand the linkage between oral and systemic health, as well as the value of medication review to improve common concerns for patients. Strategies for collaboration between dental providers, medical providers, and patients will be explored to identify and resolve common barriers to improve both oral and systemic health.

Assessment Questions 1. The following are common ways medication affect dental health: a.bleeding gums b.dry mouth c.bitter taste d.metallic taste e.all of the above 2. Herbal medication is not usually associated with oral health affects. a.true b.false

Objectives At the completion of this program, participants will be able to: Recognize the inter relationships between oral and systemic disease Highlight the role of the primary care clinician in promoting oral health Describe how medication can affect oral health Explain strategies for collaborating with the health care team to optimize medication use with oral health

Abnormal Bleeding Reduced blood clotting from aspirin and anticoagulants such as warfarin Medications that might contribute Aspirin Lessens ability for blood to clot Warfarin (Coumadin) Combination of anticoagulants Chemotherapy Kills normal cells in mouth Hormones Progesterone cause inflamed gum tissues due to the body's exaggerated reaction to the toxins produced from plaque

Taste Altering Medication Cardiovascular agents Chemotherapy Central nervous system stimulants NSAIDs Taste dysfunction can be caused by damage or alteration to any part of the nerve pathway from the taste buds Respiratory inhalants Smoking cessation products Nicotine skin patches

Enlarged Gum Tissue The exact mechanism of gingival hyperplastic reaction is unknown. Some theories include direct stimulatory effect on fibroblast proliferation and morphologic structures, poor oral hygiene, and direct effect on mast cells. Antiseizure medication such as phenytoin Immunosuppressants Calcium channel blockers SING MED J. 1988; 29: 498 503. Source: http://smj.sma.org.sg/2905/2905smj18.pdf

Estimated Prevalence of Drug Associated Gingival Enlargement According to the Most Frequently Reported Prevalence Rate J Periodontol 2004;75:1424 1431. Source: http://www.perio.org/resources products/pdf/45 gingivalenlarge.pdf

Dry Mouth Anticholinergic properties that generally cause decreased saliva production Antihistamines Decongestants Painkillers Blood pressure medications Muscle relaxants Drugs for urinary incontinence Antidepressants Parkinson s medication

Herbs that Cause Dry Mouth Ephedra (ma huang): appetite suppressant St. Johns Wort: antidepressant Valerian: insomnia

Oral Fungal Infections Balance upset of microorganisms in the mouth Oral inhalers for asthma Antibiotics Chemotherapy Steroids

Treatment of Side Effects Reduction in dosage of the drug or changing to alternative drugs may help

Disease and Exposures that Affect Sense and Taste

Conditions and Treatments that can Affect the Physiology of the Oral Cavity

Impact of Medication on Oral Health Many medications can have negative impact on oral health Medication review is key to addressing problems Include vitamins Minerals Herbal products Over the counter preparations

Collaboration Strategies Communication Review medical conditions Medication review at all care transition points Update list of medications at all appointments Educate providers and patients about possibility of drug related effects

Example of Collaborative Opportunities Explore opportunities to create affiliations between medical and dental providers Research Continuing education ie guideline updates Presentations Health promotion opportunities Committee work ie P&T

Patient Centered Medical Home (PCMH)