Transcript Primary Care Management of Oral Health in Children and Adolescents

Primary Care Management
of Oral Health in Children
and Adolescents
Goals for this Session
• Show why oral health is a priority for primary
care’s treatment of children and adolescents.
• 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 action 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
the Treatment of Children
and Adolescents
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Preventing Caries in Childhood
Goal:
• Reduce loss of permanent teeth.
• Develop effective oral health behaviors to protect
children from dental disease in adulthood.
• Reduce number of dental procedures for children done
under general anesthesia.
Strategy: Screening in Primary Care
• Risk factor recognition and modification:
• Risk reduction: Dietary coaching and oral hygiene.
• Maternal oral health.
• Fluoride.
• Case finding:
• Referral to dentistry.
• Care coordination.
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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:
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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
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Maternal/family caries
No recent dental care
Poor oral hygiene
High dietary sugar content
Frequent snacking
Inadequate fluoride
Meds affecting saliva
Adolescent tobacco and
drug use
Case Finding
Detecting signs of disease:
• Teeth
• White chalk marks
• Early caries
• Advanced caries
Treatment: Referral
Treatment: Reduce risk
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Oral Structures and Oral
Disease
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The Healthy Mouth
• Saliva
• Teeth
Photo Credit: AAP
• Gums
• Oral mucosa
• Tongue
UKCD, Robert Henry DMD, MPH
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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
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Diuretics
Antihistamines
Antipsychotics
Antidepressants
ADD medications
Anti-anxiety medications
Anticholinergics
Proton pump inhibitors
Many others
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Assessing for Oral Dryness
• Ask
• Dry mouth.
• Not enough saliva.
• Look
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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:
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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 dry mouth.
• Alcohol, caffeine, and tobacco.
• Sugary drinks and snacks.
Suggest:
• Frequent sips of water.
• Sugar-free products with xylitol.
• Saliva substitutes and stimulants.
Prevent infection:
• Daily oral hygiene.
Saliva
substitutes
Saliva
stimulants
Sugar-free
gum and mints
• Protect teeth with fluoride.
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Dry Mouth 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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Baby Teeth—Permanent Teeth
• Baby teeth role in oral
cavity development.
• Shared tooth germ cells.
• Baby teeth guide
permanent teeth growth.
• Baby teeth role in chewing
and speech development.
• Cariogenic bacteria spread
to permanent teeth.
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Anatomy of a Tooth
Periodontal
ligaments
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Tooth Decay Progression
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Identifying and Reducing Risk of
Caries in Children
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Where Does the Sugar Come From?
• Mostly from food.
• Sugary drinks.
• Bottles at nap and
bedtime with anything
other than water.
• For older children,
candy and other
sweets.
• Carbohydrates.
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How Much Sugar Is in Kids’ Drinks?
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Assessing Risk from Sugar
Ask About:
• Exposure to sugar in sippy cups, bottles,
pastries, candy, energy drinks, etc.
• Time between snacks for enamel to recover.
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Where Do the Bacteria Come From?
• Mostly from mom and
other family members.
• Spread is unavoidable.
• The main bacteria are:
• Streptococcus mutans.
Photo Credit: Simone D’Amore
• The focus is on oral
hygiene for the entire
family, especially
mother.
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Assessing the Risk of Bacteria
Ask:
• Has anyone in the immediate family (including
a caregiver) had tooth decay, or lost a tooth
from tooth decay, in the past year?
• Has the child had a cavity in the past year?
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Interventions to Reduce Risk
• Fluoride
• Fluoridated water
• Fluoride supplementation
• Fluoride varnish
• Fluoridated toothpaste
• USPSTF: All commercial plans must cover
• Diet change for the whole family
• Oral hygiene for the whole family
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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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Fluoride Varnish
• Can be
applied in
primary care.
• Reimbursed
by Medicaid in
most states.
• Effective for
three months.
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Federal Recommendations
• 2014 USPSTF:
• Every child should receive fluoride varnish every
3–6 months from age 6 months to 6 years.
• All children living in communities with < 0.6 ppm
fluoride in drinking water should receive supplements.
• Water fluoridation goal is 0.7 ppm.
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Oral Hygiene
• Introduce brushing with first
tooth appearance.
• Infants:
• Brush twice daily with
parental supervision.
• Use small amounts of
fluoride toothpaste.
• For older kids and adults:
• Brush twice daily for two
minutes with fluoride
toothpaste.
• Floss at least once daily.
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Diet
• Limit bottle content to milk, formula, tap water.
• Strictly limit sweet drinks to natural fruit juice.
• Ensure there are at least two hours between
meals/snacks.
• Teach healthy diet choices:
• Limit snacks to fresh fruits and vegetables.
• Limit sugar content at meals.
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Screening for Caries in Children
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Look for Caries in Enamel
Photo: AAP
Photo: Bre Holt, MPH
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Look for Deep Caries
Photo Credit: Dr. Johanna Douglass
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Act: Positive Screen Means Referral
• Treatment of caries requires dental evaluation.
• The job of primary care is to ensure that
someone who screens positive is referred to a
specialist able to:
• Properly assess the disease.
• Develop an appropriate treatment plan.
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Case 1
1-year-old female comes in for a well-child exam.
• This little girl has a 3 ½-year-old brother, who
has had multiple cavities treated by the family
dentist, and her mother had a root canal for a
dental abscess last month.
• She has not seen a dentist.
• She has a juice-filled sippy cup, and her mom
has a super-sized soft drink.
• Her mouth appears normal.
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Case 2
A 14-year-old male comes in for a well exam.
• He has been on Adderall for the past two years
for presumed attention deficit disorder.
• This young man drinks Red Bull one to two
times a week and has tried both beer and wine
with his friends. He has several friends who
smoke, although he has not tried cigarettes.
• He has not seen a dentist in the past year.
• He has extensive plaque and several teeth
showing signs suggestive of caries.
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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
Pediatrics 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.
• Can be prevented with interventions targeting
the whole family:
• 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 Massachusetts League of
Community Health Centers “Clinical Connections: Quality Improvement
Leading to Clinical Integration Project.” Supported by the DentaQuest
Foundation. 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. 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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