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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. 2 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. 3 Oral Health As a Key Element of Diabetes Management 4 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. 5 Periodontal Disease and Diabetes 6 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 7 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 8 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. 9 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 10 Oral Structures and Oral Disease 11 The Healthy Mouth Photo: UKCD, Robert Henry DMD, MPH • • • • • Saliva Teeth Gums Oral mucosa Tongue Photo: UKCD, Robert Henry DMD, MPH 12 The Primary Threat Is Bacterial Infection Teeth and/or gums Bacteria UKCD, Robert Henry DMD, MPH Substrate: carbohydrate Over time 13 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 14 The Salivary Glands 15 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. 16 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 17 Remineralization Takes Time Regular Meals Regular Meals Plus Frequent Snacks 18 Medications Causing Oral Dryness • • • • • • • • • Diuretics Antihistamines Antipsychotics Antidepressants ADD medications Anti-anxiety medications Anticholinergics Proton pump inhibitors Many others 19 Drugs that Cause Oral Dryness Caffeine Alcohol Amphetamines 20 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. 21 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 22 Consequences of Dry Mouth Dry mucosa Tooth loss Root caries Gum recession Photo: Dr. Bea Gandara, Univ. of WA 23 24 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. 24 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. 25 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. 26 Anatomy of a Tooth Periodontal ligaments 27 Tooth Decay Progression 28 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. 29 The Spectrum of Caries Root caries Early caries Advanced caries Plaque setting the stage for caries Photo: Dr. Bea Gandara, Univ. of WA 30 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 31 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. 32 Periodontal Disease 33 The Pathway to Periodontal Disease and Tooth Loss 34 Early Periodontal Disease Gingivitis Redness Bleeding Puffiness Photo: Dr. Bea Gandara, Univ. of WA 35 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 36 Periodontitis Accelerators • Poor oral hygiene • Medication side effects • Malnutrition • Eating disorders • Alcohol • Tobacco • Chemical dependency • Hormonal effects of pregnancy • Diabetes 37 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. 38 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. 39 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. 40 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? 41 Addressing Oral Health for Diabetes in an Already Busy Primary Care Practice 42 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. 43 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. 44 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. 45 Prevention Through Counseling Technique depends on team resources: • Synergy with general health messages: • Teach-back • Motivational interviewing • Patient education: • Handouts • Videos • Peer support 46 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. 47 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. 48 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. 49