Download Primary Care Management of Oral Health in Patients with Diabetes

Primary Care Management
of Oral Health in
Patients with Diabetes
Goals for this Session
• Show why oral health is a priority for primary
care’s diabetes management.
• Review key structures of the mouth and the
disease processes that affect them.
• Outline a set of primary care actions shown to
be effective in protecting and improving oral
health and overall health.
• Introduce a framework for incorporating oral
health actions into primary care practice.
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Oral Health Fits in Primary Care
• Preventable infectious disease.
• Common problem.
• Serious health impact.
• Patient and family behavior (self-care) is key.
• Early recognition and treatment reduces
the impact.
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Oral Health As a
Key Element of
Diabetes Management
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Oral Health: Part of Diabetes Care
• Diabetes undermines oral health; poor oral
health accelerates diabetes.
• Positive feedback loop drives both
disease processes.
• Interventions to preserve oral health
are effective:
• Meticulous attention to medication side effects.
• Diet.
• Oral hygiene.
• Coordination of referrals for dental care as needed.
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Periodontal Disease and Diabetes
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Periodontal Treatment Reduces
Medical Costs for People with Chronic
Conditions
Lower Annual Medical Costs
Reduced Hospital Admissions
$1,090
21.2%
(10.7%)
$2,840
$2,433
(40.2%)
28.6%
(73.7%)
$5,681
39.4%
(40.9%)
Diabetes
Stroke
Heart Disease
Pregnancy
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Oral Health Delivery Framework
Five actions primary care teams can take to protect and promote their
patients’ oral health. Within the scope of practice for primary care; possible
to implement in diverse practice settings.
Preventive interventions:
Fluoride therapy; dietary counseling to protect teeth and gums;
oral hygiene training; therapy for substance use; medication
changes to address dry mouth.
Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care.
Seattle, WA: Qualis Health; June 2015
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Primary Care’s Role in Oral Health
The Oral Health Screening
Assessment: Ask and Look
Decide and Act
• Identify risk factors:
•
•
•
•
Adjust medication list.
Fluoride for caries risk.
Printed education material.
Coaching.
• Identify signs of disease:
• Referral to dentistry.
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Oral Health Screening in Primary Care
Risk Assessment
Identifying high-risk patients:
• Tobacco use
• No recent dental care
• Poor oral hygiene
• High dietary sugar content
• Frequent snacking
• Inadequate fluoride
• Meds affecting saliva
Treatment: Reduce risk
Case Finding
Detecting signs of disease:
• Gums
• Gingival inflammation
• Periodontitis
• Teeth
• Loose teeth
• Erosion
• Caries
Treatment: Referral
and in-clinic therapy
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Oral Structures and
Oral Disease
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The Healthy Mouth
Photo: UKCD, Robert Henry DMD, MPH
•
•
•
•
•
Saliva
Teeth
Gums
Oral mucosa
Tongue
Photo: UKCD, Robert Henry DMD, MPH
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The Primary Threat Is Bacterial
Infection
Teeth and/or gums
Bacteria
UKCD, Robert Henry DMD, MPH
Substrate:
carbohydrate
Over time
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Saliva
• Secretion: Autonomic
nerve stimulation
• Components:
• Antimicrobial proteins
• High calcium concentration
• Role:
• Physical barrier, lubrication, and cleansing
• pH buffer for acid: food, bacteria, and
gastric reflux
• Remineralization
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The Salivary Glands
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Saliva Repairs Enamel
• Demineralization:
• Acid dissolves enamel.
• pH drops with eating and drinking (except
water).
• Stimulation of bacterial growth by sugar.
• Acid in food and beverages.
• Remineralization:
• Saliva restores pH balance and remineralizes
enamel between meals/snacks.
• Time is required for remineralization.
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Saliva: The Protective Balance
Protective Factors
Saliva
Peptides (defensins)
Oral hygiene
Prudent diet
Fluoride
No Caries
Pathologic Factors
Acid-producing bacteria
e.g., Strep mutans
Frequent carbohydrates
Reduced saliva
Caries
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Remineralization Takes Time
Regular Meals
Regular Meals
Plus Frequent
Snacks
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Medications Causing Oral Dryness
•
•
•
•
•
•
•
•
•
Diuretics
Antihistamines
Antipsychotics
Antidepressants
ADD medications
Anti-anxiety medications
Anticholinergics
Proton pump inhibitors
Many others
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Drugs that Cause Oral Dryness
Caffeine
Alcohol
Amphetamines
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Assessing for Oral Dryness
• Ask
• Dry mouth.
• Not enough saliva.
• Look
•
•
•
•
Dry-appearing mucosa and tongue.
Enlargement of the parotid glands.
Tongue blade sticking to oral mucosa.
Lack of saliva pooling under the tongue.
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Loss of Protective Saliva
• Patient’s experience:
• Mouth feels dry
• Difficulty:
• Swallowing
• Tasting food
• Speaking
Photo: Dr. Bea Gandara, Univ. of WA
• Untreated leads to infection:
•
•
•
•
Tooth decay
Periodontal disease
Angular cheilitis
Yeast infection of the tongue
Photo: Dr. Bea Gandara, Univ. of WA
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Consequences of Dry Mouth
Dry mucosa
Tooth loss
Root caries
Gum recession
Photo: Dr. Bea Gandara, Univ. of WA
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Managing Patients with Dry Mouth
Avoid:
• Medications causing oral dryness.
• Alcohol, caffeine, and tobacco.
• Sugary drinks and snacks.
Suggest:
• Frequent sips of water.
• Sugar-free products with xylitol.
• Saliva substitutes and stimulants.
Saliva
substitutes
Saliva
stimulants
Sugar-free
gum and mints
Prevent infection:
• Daily oral hygiene.
• Protect teeth with fluoride.
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Oral Dryness Leads to Caries
• Plaque deposits build up on teeth.
• Dietary acid and acid-producing bacteria
erode enamel.
• Caries-producing bacteria invade enamel.
• Progression to dentin causes deep decay.
• Progression to pulp causes tooth death:
• Need for expensive root canal therapy and
crown to save tooth, or
• Tooth loss.
• Bacteria spread to other teeth.
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What is Plaque?
• Initially a film, which turns into hard deposit
on the teeth.
• Protein precipitate from saliva, food, and bacteria
adheres to teeth.
• Calcium deposits from saliva turn it into calculus.
• Substrate for bacterial growth.
• A place acid and bacteria have prolonged
contact with enamel and roots.
• Barrier to protective effects of saliva.
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Anatomy of a Tooth
Periodontal
ligaments
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Tooth Decay Progression
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Assessing for Caries
• Ask
• Do you experience tooth pain or bleeding gums when
you eat or brush your teeth?
• Has anyone in the immediate family (including a
caregiver) had tooth decay, or lost a tooth from tooth
decay, in the past year?
• Look
• White discoloration of the enamel.
• Dark discoloration of enamel or root.
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The Spectrum of Caries
Root
caries
Early
caries
Advanced
caries
Plaque setting
the stage for
caries
Photo: Dr. Bea Gandara, Univ. of WA
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Actions to Prevent Tooth Decay
Remove bacteria daily.
• Brush twice daily for two minutes
with fluoridated toothpaste.
• Floss daily, preferably at night.
Limit sugar, and sweet, sticky, or
sugary foods and drinks.
Fluoride Toothpaste
• Use xylitol (a natural sweetener).
• Rinse with water after meals.
Use fluoride.
• Use fluoridated toothpaste.
• Drink fluoridated water.
• Apply fluoride varnish.
Regular dental care.
Fluoride Varnish
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The Impact of Fluoride
• Inhibits bacterial metabolism and limits pH drop
associated with eating and drinking.
• Makes enamel and dentin more resistant to
demineralization and dissolution in acid.
• Enhances remineralization by attracting calcium
to demineralized enamel.
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Periodontal Disease
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The Pathway to Periodontal Disease and
Tooth Loss
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Early Periodontal Disease
Gingivitis
Redness
Bleeding
Puffiness
Photo: Dr. Bea Gandara, Univ. of WA
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Advanced Periodontal Disease
• Gum retraction
• Bone loss
• Spaces between teeth
• Loose teeth
• Tooth loss
Gum puffiness
masking spaces
between teeth and
bone loss
Gum
recession
Photo: Dr. Bea Gandara, Univ. of WA
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Periodontitis Accelerators
• Poor oral hygiene
• Medication side effects
• Malnutrition
• Eating disorders
• Alcohol
• Tobacco
• Chemical dependency
• Hormonal effects of pregnancy
• Diabetes
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Assessing for Periodontal Disease
• Ask:
• Find out if patient experiences tooth pain or bleeding
gums when eating or brushing.
• Look:
• Gum inflammation, bleeding, gum recession.
• Root exposure.
• Decide/Act:
• Refer to dentist for intensive treatment.
• Address the accelerators.
• Apply fluoride to protect roots.
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Case 1
• A 50-year-old man presents for his diabetes
check.
• He has had diabetes for five years. He
acknowledges pain while eating, says his gums
bleed while brushing, and he drinks two martinis
every evening.
• His last visit to a dentist was two years ago.
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Case 2
• A 55-year-old patient with diabetes presents for
routine monitoring, and during her visit she
reports pain while eating.
• You’ve had trouble getting her glycemic control
into the target range because she consumes a
lot of sugar daily.
• She admits that it has been three years since
she last saw a dentist.
• During her exam, you see visible decay on
several teeth. She also has mild gum
inflammation.
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Group Discussion
• Who will ask the questions that give you
this information?
• Who will look in the mouth and look for
the key findings?
• Who will order preventive actions?
• Who will deliver preventive actions?
• How will you set up the referral?
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Addressing Oral Health for
Diabetes in an Already Busy
Primary Care Practice
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Building Oral Health into the Process
• Structure visits and use the entire team to
ensure oral health isn’t overlooked.
• Use health IT to organize information so
that risk factors are easily identifiable and
education interventions are automated.
• Share the care among team members and
let the clinician focus on the reason for the
visit.
• Used structured referrals to dentistry.
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Teamwork to Share the Care
• Identify target
population patients
before visit.
• Ask about
symptoms while
rooming patient.
• Set up orders for
the clinician to sign.
• Arrange for oral
health protocol at
the end of the visit.
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Prevention Through Counseling
Most important topics:
• Oral hygiene best practices:
• Brush twice daily for two minutes with
fluoride toothpaste.
• Floss at least once daily.
• Diet:
• Reduce sugar and carbohydrates, rinse with water.
• Allow sufficient intervals between snacks.
• Recognize dry mouth as a sign of trouble:
• Teach patients to ask about medication side effects.
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Prevention Through Counseling
Technique depends on team resources:
• Synergy with general health messages:
• Teach-back
• Motivational interviewing
• Patient education:
• Handouts
• Videos
• Peer support
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Summary
• Caries is a chronic infection caused by sugar
in the diet.
• Periodontal disease is accelerated by diabetes;
diabetes is negatively impacted by
periodontal disease.
• Can be prevented with interventions:
• Effective oral hygiene
• Avoidance of sugar
• Fluoride
• The Oral Health Delivery Framework, including
referrals, fits into the primary care workflow.
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Source: Developed by Qualis Health for the Washington Dental
Service Foundation “Oral Health Preventive Services in Primary Care
Project.” 1st ed. Seattle, WA. November 2014.
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About the Oral Health Integration in Primary Care Project
The Organized, Evidence-Based Care Supplement: Oral Health Integration joins the Safety Net Medical Home Initiative Implementation
Guide Series.
The goal of the Oral Health Integration in Primary Care Project was to prepare primary care teams to address oral health and to
improve referrals to dentistry through the development and testing of a framework and toolset. The project was administered by
Qualis Health and built upon the learnings from 19 field-testing sites in Washington, Oregon, Kansas, Missouri, and Massachusetts,
who received implementation support from their primary care association. The Organized, Evidence-Based Care Supplement: Oral
Health Integration built upon the Oral Health Delivery Framework published in Oral Health: An Essential Component of Primary Care,
and was informed by the field-testing sites’ work, experiences, and feedback. Field-testing sites in Kansas, Massachusetts, and Oregon
also received technical assistance from their state’s primary care association.
The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on Oral Health, a
consortium of funders and health professionals who share a vision that dental disease can be eradicated, and funded by the
DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation.
For more information about the project sponsors and funders, refer to:
• National Interprofessional Initiative on Oral Health: www.niioh.org.
• DentaQuest Foundation: www.dentaquestfoundation.org.
• REACH Healthcare Foundation: www.reachhealth.org.
• Washington Dental Service Foundation: www.deltadentalwa.com/foundation.
The guide has been added to a series published by the Safety Net Medical Home Initiative, which was sponsored by The Commonwealth Fund,
supported by local and regional foundations, and administered by Qualis Health in partnership with the MacColl Center for Health Care Innovation.
For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org.
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