The Mouth Body Connection: Oral Health and Systemic Health - - PowerPoint PPT Presentation

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
• f oral

disease

• Recognize the inter‐relationships between oral

and systemic disease

5

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)

6

Prevalence

• 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

7

Prevalence

• 30,000 oral cancers

diagnosed annually

• 8000 die
• Diagnosis

is often late

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

Photos: Donald Greiner DDS MS, ICOHP

10

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

11

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

12

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

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

15

Mechanisms

• Behavioral
• Nutritional
• Iatrogenic
• Lack of priority
• Direct bacterial extension
• Inflammatory

Photo: Ellen Eisenberg DMD

16

Case #1

55 year‐old man has a “sore”

• n his tongue.

He is a 25 pack‐year smoker and drinks daily.

Photos: Brad Neville DDS, James Cecil, DMD, MPH 17

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: Robert Henry DMD MPH

18

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.

19

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

Photo: John McDowell DDS

20

Case #3

65 year old woman on multiple medications for depression and cardiovascular disease develops severe caries

Photo: John McDowell DDS

21

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: Ellen Eisenberg DDS

22

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?

23

Case #5

4 year old goes to bed with a toothache and awakens crying and feverish…

Photo: ICOHP

24

Direct Bacterial Extension

• Intraoral abscesses
• Sinusitis
• Facial cellulitis
• Periorbital cellulitis
• Bacteremia and its consequences
• Brain abscess
• Aspiration pneumonia

Photo: ICOHP

Infections prompt medical and dental to interact!

Photo: Efthimia Ioannidou, DDS MDS

25

Case #6

52 year old woman with previously well‐ controlled type 2 diabetes has increasing hyperglycemia

26

The Role of Inflammation

Toxins Neutrophils Macrophages Anaerobic bacteria in plaque

Circulating inflammatory mediators

27

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

28

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

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
• ral tissues and fluids an increasingly accurate mirror
• f 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

• pportunity to understand the linkage between
• ral 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
• Respiratory inhalants
• Smoking‐cessation products
• Nicotine skin patches

Taste dysfunction can be caused by damage or alteration to any part of the nerve pathway from the taste buds

Enlarged Gum Tissue

• Antiseizure medication such as phenytoin
• Immunosuppressants
• Calcium channel blockers

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.

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

• Antihistamines
• Decongestants
• Painkillers
• Blood pressure medications
• Muscle relaxants
• Drugs for urinary incontinence
• Antidepressants
• Parkinson’s medication

Anticholinergic properties that generally cause decreased saliva production

Herbs that Cause Dry Mouth

• Ephedra (ma huang): appetite suppressant
• St. Johns Wort: antidepressant
• Valerian: insomnia

Oral Fungal Infections

• Oral inhalers for asthma
• Antibiotics
• Chemotherapy
• Steroids

Balance upset of microorganisms in the mouth

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
• n 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)