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Interdisciplinary Oral Health

Adapted from ICC 2008May 2008

Mark Deutchman MD Terry Batliner DDS Rich Call DDS Brad Potter DDS MS John D. McDowell, DDS, MS John D. McDowell, DDS, MS

Lonnie Johnson DDS David Gaspar MD Bonnie Jortberg PhDLonnie Johnson DDS David Gaspar MD Bonnie Jortberg PhDKatherine Anderson MD Robin Michaels PhD Inis Bardella MD Katherine Anderson MD Robin Michaels PhD Inis Bardella MD

Kent Voorhees MD Colleen Conry MD Frank deGruy MDKent Voorhees MD Colleen Conry MD Frank deGruy MD40 Dental Students Ruthie Wilson Mark Osvirk

Delta Dental Frontier FoundationSociety of Teachers of Family Medicine Group on Oral Health

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Objectives

Developing your understanding of the importance of oral health to systemic health

Recognize oral lesions

Developing your skills to perform the oral/head/neck examination

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Major information source :

Smiles for LifeA National Oral Health

Curriculum for Family MedicineSTFM Group on Oral Health

Module 1The Relationship of Oral to Systemic

Health

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Why is oral health important?

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Prevalence of Oral Disease

Severe gum disease affects 19% of adults aged 25-44

30,000 oral cancers diagnosed annually; 8000 die

Dental caries most common chronic disease of childhood 5 times more common than asthma 50% in low income children- up to 70% in

Native Americans

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Consequences of Untreated Oral Disease Pain, infection, tooth loss Impaired chewing & nutrition Systemic complications ER visits, hospitalizations,

surgeries Extensive and costly dental

treatments (OR $5,000+) Missed school and work

52 million school hours lost/yr

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Prevention in both medical and dental

homes Caries resistance Water fluoridation Fluoridated toothpaste Fluoride topical application Sealants

Gum disease prevention Brushing Flossing Regular dental visits

Oral cancer prevention Smoking cessation Alcohol

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Colorado’s realities

• In April 2000, nearly one-third of Coloradocounties lacked access to dental services for low incomeand at-risk (Medicaid, CHP+, Medicare)populations.

• 9 Colorado counties have NO LICENSEDDENTIST at all.

• Only 11% of Colorado’s dentists participate inMedicaid’s Dental Program. 40% of Coloradocounties (25) do not have a dentist that acceptsMedicaid.

• Only 19 of the 182 counties in the three statearea of Colorado, South Dakota and NorthDakota have any pediatric dentists.

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The Disconnect Most patients have a medical home; many fewer

have dental home Children are 2.5 times more likely to lack dental

coverage than medical coverage Dentists per capita declining Few pediatric dentists >90% of physicians think oral health should be

addressed at well visits, yet… Surveys of physicians

• > 50% had little or no oral health training• Only 9% could answer 4 simple questions correctly• Averaged <2 hours of oral health training

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Oral Health

Dental Home

Systemic Health

Medical Home

Oral and systemic health are linked so care should be too

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Systemic conditions with oral manifestations

Poor glucose control in diabetics oral candidiasis and periodontal disease

Immunosuppression due to illness or chemotherapy periodontal disease

Dry mouth from illness or medications periodontal disease Sjogren’s syndrome Rheumatologic disorders

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Oral effects of medications

Candidiasis from inhaled or oral steroids

Xerostomia from diuretics, anticholinergics, antihistamines and many antihypertensives

Gingival hyperplasia from phenytoin

Ulcerative stomatitis from methotrexate

Mucositis from chemotherapy or radiation treatment

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Oral and systemic conditions that appear

linked Adverse pregnancy outcome Preterm labor Preterm delivery

Atherosclerosis (Coronary heart disease and stroke) Obesity Osteoporosis also affects alveolar bone Potential mechanisms:

Bacteremia from infected gums (evidence: oral bacteria in atherscloerotic plaque)

Inflammatory mediators leak into bloodstream

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Oral Anatomy

1. Tongue2. Palatine tonsil3. Tonsillar pillar4. Tonsillar pillar5. Uvula6. Palate (soft and

hard)7. Posterior wall of

pharynx8. Teeth

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Anatomy of a Tooth

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Primary Dentition

8 incisors + 4 canines + 8 molars = 20 by age 3

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Primary Tooth Eruption

Newborn 6 -12 months

Age 1 Age 3

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Adult Dentition

8 incisors + 4 canine + 8 premolars + 12 molars = 32 Teeth

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Lesion recognition

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Bony Torus of palate

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Torus of mandible

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Mucocele

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Gingival hyperplasia

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Hairy tongue

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Erythema migrans

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Aphthous stomatitis

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Denture sores

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Pyogenic granuloma

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Candidiasis

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Herpes labialis

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Angular chelitis

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Periodontal disease

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Caries: Etiology Triad

Oral bacteria (Mutans Strep) break down dietary sugars into acids which eat away the tooth

Teeth

Sugars

Caries

Bacteria

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White SpotsWhite spots indicate

acids have demineralized enamel

First clinical signs of caries

White spots place a child at high risk for developing cavities

Indication for dental referral

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Early Caries

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Moderate Caries

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Severe Caries

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Leukoplakia

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Lichen planus

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Erosive lichen planus

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Squamous cancer - tongue

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Cancer

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Cancer

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Cancer

sites

51Squamous cell carcinoma of lateral tongue

52Squamous cell carcinoma of palatal gingiva

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Leukemic infliltrates

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Adult Oral Examination

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Oral/head/neck exam checklist

Wash hands Greet the patient Confirm supplies: light, gloves, mouth mirror, tongue blade, gauze pad Inspect the face and neck for obvious lesions, masses, nodes Palpate the TM joint Palpate the neck for nodes and masses Anterior triangle, Posterior triangle, Submandibular, Supraclavicular and infraclavicular areas Put on gloves for intraoral examination View and palpate the buccal mucosa including sulci Inspect gingival tissues Inspect teeth Inspect palate Inspect tonsillar pillars Inspect tongue: top, lateral edges, under-surface. Use gauze pad to grasp

tip of tongue when examining lateral edges. Palpate floor of mouth Explain exam findings to patient Discard gloves

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Inspect/palpate face/neck

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Inspect lips

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Labial mucosa - upper

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Labial mucosa - lower

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Right buccal mucosa

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Left buccal mucosa

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Gingiva

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Dorsum of tongue

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Tongue left margin

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Tongue right margin

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Ventral tongue

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Floor of mouth

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Hard palate

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Oropharynx

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Palpate floor of mouth

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Child Oral Exam (Knee to Knee)

1: Child is held facing caregiverin a straddle position

2: Child leans back onto examiner while caregiver holds child’s hands

3: Provider performs exam while caregiver holds child’s hands and legs

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Oral/head/neck exam checklist

Wash hands Greet the patient Confirm supplies: light, gloves, mouth mirror, tongue blade, gauze pad Inspect the face and neck for obvious lesions, masses, nodes Palpate the TM joint Palpate the neck for nodes and masses Anterior triangle, Posterior triangle, Submandibular, Supraclavicular and infraclavicular areas Put on gloves for intraoral examination View and palpate the buccal mucosa including sulci Inspect gingival tissues Inspect teeth Inspect palate Inspect tonsillar pillars Inspect tongue: top, lateral edges, under-surface. Use gauze pad to grasp

tip of tongue when examining lateral edges. Palpate floor of mouth Explain exam findings to patient Discard gloves