1. Open Wide: Common Infectious Conditions We Overlook
What’s New in Medicine
September 2014
Russell Maier, MD

2. “You are not healthy without good oral health…”
David Satcher, MD, 16th Surgeon General
Oral Health in America: A Report of the Surgeon General
Dental care is the most common unmet health need
Oral disease can severely affect systemic health
Strong evidence shows clear links between oral health and respiratory disease2, cardiovascular disease3, and diabetes4.
Because oral health is linked to overall health, the effects of poor oral health are felt far beyond the mouth.
Primary Care interventions are evidence-based
Recommend oral health training for non-dental health professionals.
According to the Surgeon General's Report on oral health in 2000:
Dental care is the most common unmet health need.
Oral disease can severely affect systemic health.
Much oral disease is preventable or at least controllable.
Profound disparities in oral health and access to care exist for all ages.
USPSTF recommends fluoride varnish – B recommendation
1. Association between untreated dental caries and inappropriate use of ED. (Cohen et al., 2011; Davis et al., 2010)
2. Link between oral health and respiratory disease. (Scannapieco and Ho, 2001)
3. Link between oral health and cardiovascular disease. (Blaizot et al., 2009; Offenbacher et al., 2009; Scannapieco et al., 2003; Slavkin and Baum, 2000)
4. Link between oral health and diabetes. (Chávarry et al., 2009; Löe, 1993; Taylor, 2001; Teeuw et al., 2010)

3. Learning Objectives
Understand the prevalence and consequences of oral disease
Learn about the interrelationships between oral and systemic diseases
Identify risk and protective factors that influence oral health
Recognize caries and periodontal disease
Understand the importance of primary care providers addressing oral health
Understand how to interrupt and minimize oral diseases impacting children, pregnant women and people with diabetes
Childhood - USPSTF use of fluoride & UNC research on efficacy of screenings
Prenatal to interrupt disease process
Diabetic -periodontal infection
Routine management in medical office of abscesses

4. Prevalence Tooth Decay
Nearly 40% of kindergarteners in WA have tooth decay
Nearly 1 in 4 adults in the U.S. have untreated tooth decay
Periodontal Disease
47% of U.S. adults have some form of periodontal disease (> with age)
40% of pregnant women have some form periodontal disease
70% of adults 65+ have some form of periodontal disease
Photo: ICOHP
The following statistics speak to the prevalence of poor oral health:
Dental caries is the most common chronic disease of childhood.
It is five times more common than asthma.
It affects 50% of low-income children.
47% of U.S. adults have some form of periodontal disease.
70% of adults over 65 have gum disease
Severe gum disease affects 19% of adults aged 25–44.
There are 30,000 oral cancers diagnosed annually. 
Oral cancer causes 8,000 deaths a year.
Diagnosis is often late.
References US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America's children. Pediatrics Apr;105(4 Pt 2):
Prevalence of Periodontitis in Adults in the United States: 2009 and 2010 J DENT RES , first published on August 30, 2012
Prevalence of tooth decay: Sources
2010 Washington State Smile Survey
Adult stats:
Health, United States,
Perio dz source:
CDC study, cited here:
A study titled Prevalence of Periodontitis in Adults in the United States: 2009 and 2010 estimates that 47.2 percent, or 64.7 million American adults, have mild, moderate or severe periodontitis, the more advanced form of periodontal disease. In adults 65 and older, prevalence rates increase to 70.1 percent. This study is published in the Journal of Dental Research, the official publication of the International and American Associations for Dental Research.
Lieff S, Boggess KA, Murtha AP, Jared H, Madianos PN, Moss K, et al. The oral conditions and pregnancy study: periodontal status of a cohort of pregnant women. J Periodontol 2004;75:116–26. [PubMed] ⇦
Photo: Robert Henry, DMD, MPH

5. Periodontal Disease Systemic Diseases
People with serious gum disease are more likely to have a chronic condition
Periodontal disease—correlated with a variety of conditions with systemic implications
Cardiovascular disease, heart disease, respiratory infections, diabetes, HIV, adverse pregnancy outcomes
Systemic diseases can have an impact on oral health
Dementia
Chronic disease medications that cause xerostomia
(91% of patients with heart disease have periodontitis, compared with 66% of people with no heart disease1) That’s a difference of 25%, and the Bensley article cites a 1.4 fold increase
Oral Health: The Mouth Body Connection WebMD Feature. Joanne Barker. Reviewed by Steve Drescher, DDS 2012
Article Sources:
Sally J. Cram DDS, PC. Sally J. Cram DDS, PC. Bensley L. Preventing Chronic Disease, May 2011; vol 8: pp A50. National Institute of Dental and Craniofacial Research. Kim J. Odontology. September 2006; vol 94: pp Pamela McClain, DDS. Pamela McClain, DDS. National Institute of Diabetes and Digestive and Kidney Disorders. Diabetes Overview - National Diabetes Information Clearinghouse. American Academy of Periodontology. Ask a Periodontist: Frequently Asked Questions About Gum Disease. News release, American Dental Association. Research, Science and Therapy Committee of the American Academy of Periodontology. Journal of Periodontology. August 2005; vol 76: pp Martínez-Maestre MÁ. Climacteric. December 2010; vol 13: pp Centers for Disease Control and Prevention. Ortiz P. Journal of Periodontology. 2009;80(4): News Release, American Academy of Periodontology. News Release, American Dental Association.

6. Consequences for Patients’ Health
Oral diseases are largely preventable but untreated oral disease can lead to:
Pain that makes it difficult to work, learn in school, sleep, eat
Poor eating habits and nutrition
Reduced self-confidence and/or problems obtaining employment
Complications of chronic diseases like diabetes, heart disease, and stroke
Transmission of cariogenic bacteria from mothers to infants

7. Oral-systemic Connection
Periodontal treatment reduces medical costs for people with chronic conditions & pregnant women
Study Conducted by University of Pennsylvania, School of Dental Medicine for United Concordia Dental

8. Inflammatory Response

9. Oral Disease is Preventable Preventing and Interrupting Oral Disease
GOOD NEWS!
Oral Disease is Preventable
Preventing and Interrupting Oral Disease
* Key point is this is a disease where we (medical clinicians) can make a difference.

10. Preventing and Interrupting Tooth Decay

11. Tooth Decay Process: A Bacterial Infection
Bacteria Refined Carbohydrates = Acid
Acid Time (20 min) = Enamel Demineralization
& Risk for Decay
Slide 17: Tooth Decay—Process
Here is another way to understand the steps in getting tooth decay:
Germs + Refined Carbohydrates = Acid
Acid Attacks + Tooth = Decay
Untreated Decay  Infection, Abscess, Loss of Tooth
Decay begins with acids attacking the tooth enamel (the outer portion of the tooth).
Teeth can be kept healthy with daily oral hygiene, healthy diet, and the use of fluoride in drinking water, toothpaste, mouth rinses, and professionally-applied gel or varnish.
2. If decay progresses, it creates a cavity or hole in the tooth.
3. If a person has a cavity but doesn’t have the tooth repaired, and doesn’t change the conditions in the mouth, the decay will continue to destroy the tooth. That tooth may become infected or abscessed.
4. Untreated decay and/or an untreated abscess may result in a tooth needing to be removed (extracted).
In more serious cases, an untreated abscess can lead to serious widespread infection, often resulting in swelling of the face, and sometimes resulting in swelling of the brain or even death.
People who are in a weakened immune state may have difficulty recovering from a dental abscess.
Untreated Decay  Infection, Abscess, Loss of Tooth
OH Slides & Notes – Script

12. Tooth Decay Progression
Image from Istock.com

13. Early Decay: White Spots/Lines
Appearance
White spots and lines—first clinical signs of demineralized enamel
Begins along the gum line
Without intervention, lesions will progress to cavities that are initially yellow
Treatment
Fluoride varnish application to reverse or arrest lesions
Dietary and oral hygiene counseling
Dental referral
Appearance & Symptoms
White spots and lines are the first clinical signs of demineralized enamel
Typically begins at the gingival margin
If the disease process is not managed, lesions will progress to cavities that are initially yellow
Treatment
Immediate dental referral
Dietary and oral hygiene counseling
Topical fluoride to reverse or arrest lesions
Photos: Joanna Douglass, BDS, DDS

14. Tooth Decay, Abscessed Teeth, Facial Swelling
Abscesses
Slide 19: Tooth Decay
Photo 6 – Caries (Cavity, Tooth Decay)
When a tooth decays, its enamel surface breaks down and allows acids and bacteria to enter the softer areas inside the tooth. Usually, decay begins as a small whitish area that, if left untreated, grows and darkens. Decay often occurs between the teeth where food particles are more difficult to remove. How many areas of decay do you see on this photo? (At least 7.)
Photo 7 – Abscessed Teeth
In photo 7, untreated decay has allowed infection to enter the teeth and move into the teeth roots. Swelling on the gum above these teeth (arrows) indicates infection (abscess) from the teeth that is draining into the mouth.
Photo 8 – Facial Swelling from Abscess
If the infection isn’t treated, the person’s face may begin to swell as the infection spreads from the tooth to the surrounding area in the face or neck.
Widespread infection can make people extremely ill; this is a matter that needs immediate attention.
Often the dentist (or physician) will treat the infection with antibiotics first, then repair the tooth.
Treatment could include placing a filling or crown, root canal treatment (the nerve chamber is cleaned and sealed), or extraction (removal) of the tooth.
Abscessed
Teeth
Facial
Swelling
OH Slides & Notes – Script

15. Tooth Decay Process: Snacking & Sipping
It’s not just WHAT, but HOW, we eat & drink
Acid persists for minutes after sugar or carbohydrate ingestion
Acid leads to demineralization
Key message:
Frequency of sugar/carbohydrates
more significant than quantity
The process of demineralization and remineralization is dynamic.
ECC occurs when the scale tips more toward demineralization.
On the other hand, preventing ECC tips the scale more toward remineralization. 15

16. Diet and Dental Caries Eating Frequency Regular Meals
Plaque Level Acids
Regular Meals
The bottom graph shows the typical snacking child.
The steady source of sugar/carbs results in almost continual exposure of the teeth to acid.
This results in virtually no rest period for the enamel to remineralize.
Regular Meals Plus Frequent Snacks

17. Tooth Decay - Risk Factors
Prior decay and/or fillings
Existing white spot lesions
Frequent consumption of sugar & carbohydrate
Inadequate fluoride
Special health care needs
Physical disabilities and dementia
Medications that:
Decrease salivary flow (xerostomia)
Contain high levels of sucrose
Recurrent Caries
Risk Factors
High oral bacterial counts
Frequent consumption of sugar-containing foods
Inadequate fluoride exposure 
Low socioeconomic status
Xerostomia related to medications or disease
Physical disabilities and dementia
Make brushing and other oral hygiene more difficult
Existing restorations or appliances
Recurrent caries common at site of existing restorations
Treatment
Removal of decayed tooth structure and replacement with dental restorative material, usually composite (white) or amalgam (silver)
Root canal therapy or extraction of the tooth if decay has progressed into the pulp of the tooth
Extraction is not without consequences. It may result in spacing issues, drifting of the retained teeth, and malocclusion of the neighboring tooth
Prevention
Daily oral hygiene that includes fluoride toothpaste and flossing 
Regular professional dental care
Fluoride rinses, gels or varnishes for  high-risk patients, especially institutionalized elderly:
Fluoride rinse: Phos – Flur 0.044% (sodium fluoride and phosphate fluoride rinse) 10mL once daily after brushing
Fluoride gel: Gel Kam (0.4% stannous fluoride gel) cover toothbrush with gel and brush once daily
References Warren, J.J., Cowen, H.J., Watkins, C.M., Hands, J.S. Dental caries prevalence and dental care utilization among the very old. J Am Dent Assoc 2000; 131:
Guggenheimer, J., Moore, P.A. Xerostomia: etiology recognition and treatment. J Am Dent Assoc 2003, 134:61-69.
Saunders, R.H., Meyerowitz, C. Dental caries in older adults. Dent Clin North Am 2005, 49:
Tan, H.P., et al. A Randomized Trial on Root Caries Prevention in Elders. JDR 2010; 89(10);
Malocclusion of drifting teeth after extraction
Photos: UKCD

18. Caries Process: Ongoing Balance
Protective Factors
Saliva
Peptides (defensins)
Fluoride
Pathologic Factors
Acid-producing Bacteria
e.g. Strep mutans
Frequent carbohydrates
Reduced saliva
Trainer Note:
Not all cities have fluoridated water, so cannot assume in all settings. Refer to for more info.
The body is usually at homeostasis. Bone undergoes constant turnover. New cells are made for lining the gut. The tooth has a constant battle between the forces of good – fluoride, saliva, remineralization – and bad – carbohydrates, step mutans, no fluoride.
The visual message is that one can tip the balance one way or another – just as we can tip the balance in osteoporosis or diabetes with appropriate interventions and habits.
Caries
No Caries

19. Tooth Decay – Prevention Tips
Remove bacteria (plaque) every day
Brush twice daily with fluoridated toothpaste
Floss daily
Limit frequency of sweet, sticky, or sugary foods and drinks
Choose sugar substitutes, especially xylitol (a natural sweetener that reduces cavity-causing germs in the mouth)
Use fluoride
Toothpaste
Fluoridated water
Fluoride varnish, gel, or rinse
Slide 21: Tooth Decay - Prevention
If your toothbrush looks like this, it’s time to buy a new one!
Remove bacteria (plaque) every day
Brush, floss, and use other aids as needed
Limit sweet, sticky, or sugary foods and drinks (refer to prior discussion of snacks & acid attacks)
Choose sugar substitutes
The germs that cause tooth decay cannot use sugar substitutes to make acid, so these products help prevent decay.
Use moderation when eating “dietetic” candies sweetened with sugar substitutes. These sweeteners have a laxative effect and can create gastric distress or cause diarrhea.
Xylitol (another sugar substitute) not only prevents decay, but also can help teeth rebuild themselves (remineralization).
Name-brand products that contain xylitol:
Carefree Koolerz gum; some of the Trident gum varieties; some of the Tom’s of Maine toothpastes; Orajel toothpaste; Biotene rinses, toothpaste, gum (also used to relieve dry mouth);some of the Starbucks “after-coffee” mints or gum
Check ingredient labels; look for xylitol as first or second ingredient
For the greatest benefit, we need to chew the gum or eat the mints 3-5 times per day, for about 5 minutes, especially after meals and snacks. This amount will not create gastric distress for most people.
Fluoride Varnish
OH Slides & Notes – Script

20. Benefits of Fluoride Topical (main effect) Systemic
Inhibits tooth demineralization
Enhances remineralization
Inhibits bacterial metabolism
Systemic
Reduces enamel solubility
Promotes remineralization of enamel
NOTE: these images good for patients, but would be interesting to include image depicting ion exchange process. Investigate video from Intertalks (sp?) on T drive.
The use of fluoride, both through dietary and topical applications, has led to dramatic drops in caries rates.
How Does Fluoride Help Prevent Dental Caries?
Through topical mechanisms, the main effect, fluoride works by
Inhibiting tooth demineralization
Enhancing remineralization
Inhibiting bacterial metabolism
Through systemic mechanisms, the lesser effect, fluoride works by
Reducing enamel solubility through incorporation into its structure during tooth development
What are the primary sources of fluoride?
Systemic fluoride is obtained through:
Water fluoridation
Dietary fluoride supplements
Topical Fluoride is the most beneficial and is obtained through:
Fluoride toothpastes
Gels, foams, mouthwashes
Fluoride varnish
Photos: Joanna Douglass, BDS, DDS

21. Preventing and Interrupting Periodontal Disease

22. Gum Disease Gingivitis Periodontal Disease
Slide 11: Gum Problems - Photos
Photo 4 – Gingivitis
Gums are red and swollen and may bleed easily.
Brushing and flossing can help improve this condition, or professional care may be needed.
If plaque remains on the teeth, it hardens to form tartar or calculus, which irritates the gums. The tartar or calculus cannot be removed by brushing. Eventually, the gums detach and pull away (recede) along the length of the teeth.
Tartar on the teeth may need to be removed (by having the teeth cleaned) before the gingivitis will improve.
Photo 5 - Periodontal Disease
If the gingivitis is not treated or controlled, it can progress to a more serious condition, periodontal disease, where the bone holding the teeth in place is destroyed.
Eventually, the gums may pull away from their original position, exposing the roots of the teeth. This allows decay and infection into tooth roots and also into the bone that supports the teeth.
As the bone dissolves, the teeth will become loose.
The loose teeth may become so painful that eating becomes difficult and severe infections may develop.
The disease may be treatable or may require the teeth to be removed.
These teeth have been partially cleaned, but tartar deposits remain visible.
Gingivitis
Periodontal Disease
OH Slides & Notes – Script

23. Periodontal Disease
Image from

24. Risk Factors for Periodontitis
Lack of oral hygiene
Systemic diseases (e.g. diabetes)
Tobacco use
Poor nutrition
Dry mouth
Slide 10: Gum Problems
Diabetes and Smoking – Higher Risk for Periodontal Disease
People with uncontrolled diabetes may be more susceptible to gum problems, even without much plaque on the teeth. Blood sugar control is critical for keeping gum tissue healthy. Daily oral hygiene care is critical.
Smokers also are more likely to have periodontal disease.
Prevention: Plaque Removal, Professional Treatments
Daily plaque removal by brushing and flossing keeps gum tissue healthy.
Professional cleanings on a regular basis are also needed to keep gum tissues healthy.
OH Slides & Notes – Script

25. Periodontal Disease - Prevention
Clean teeth and gums
Brush twice a day
Floss daily
Avoid tobacco
Smoking and “smokeless” (chewing or spit tobacco)
Get routine dental care—including cleaning
Slide 12: Gum Problems - Prevention
Clean the teeth and gums daily
Caregiver prompts, assists, or performs the oral health care for consumers
If your consumer is able, s/he may need only a reminder to take care of oral health. However, you should still monitor self-care for quality.
The consumer’s service/care plan may indicate that you will need to perform the oral care for your consumer.
Brush, floss, other aids
The brush cleans the areas we can see: Tongue and cheek sides of the teeth, biting surfaces.
Floss cleans between the teeth where the brush can’t reach.
Toothpicks, specialized brushes or cleaners, or other products are available to help you clean if you have trouble using a brush or floss.
These will be discussed in more detail later.
Avoid tobacco products
Smoking increases the risk of developing gum problems.
Smokeless tobacco causes gingivitis, gum recession, bone loss, tooth decay.
Schedule routine dental care
Professional care is important in controlling gum problems.
OH Slides & Notes – Script

26. Periodontal Disease - Treatment
Oral health instruction—brushing & flossing
Dental office cleaning of the teeth
Deep scaling & root planing if needed
Anti-bacterial rinses
Surgery to correct gum problems
Ongoing periodontal treatment
Slide 13: Gum Problems - Treatment
This is general information to help you understand some of the treatments that your consumer may receive at the dental office.
Oral health instruction
Brushing, flossing, and using other aids help keep teeth and gums in good condition.
Thorough cleaning of the teeth
The dental hygienist or dentist can remove the calculus deposits to improve tissue health and to make home care easier.
Anti-bacterial rinses
The dentist may prescribe anti-bacterial rinses to control the plaque. It is important to follow the doctor’s instructions exactly.
Surgery to correct problems
Sometimes cleaning and home care are not enough to control the problems, and surgery may be needed to reshape the gum tissue or eliminate the deeper areas of infection.
Periodontitis
OH Slides & Notes – Script

27. Patients Who Benefit the Most from Improved Oral Health
Pregnant women
Children
Patients with diabetes or other chronic conditions
NOTE: These are priority populations who have particular needs, but important to point out that medical systems should address the oral health of all patients.

28. National Recommendations: Oral Health
AAP, AAFP, AAPD
Recommend children be screened by their first birthday (physician or dentist)
The AAP and AAPD recommend that providers refer the child to a pediatric dentist or a family dentist when the child’s first tooth erupts or by the child’s first birthday. This will ensure the early establishment of a dental home. However, this is not practical in the real world in which we provide care because of the lack of payment mechanisms for many children, and limited availability of general dentists willing to see children and pediatric dentists.
The take home message is that all children should be screened, and that can be done by primary care providers. If you identify high-risk children, or children under one year with active disease those kids deserve first shot at limited dental access, not that all kids need to see a dentist by age one
USPSTF recommends primary care clinicians apply Fluoride Varnish to primary teeth starting at first primary tooth eruption – B Recommendation

29. Children

30. Children: Cleaning Teeth
< 2 years
Clean gums with cloth
When teeth erupt, begin using soft toothbrush
Smear of fluoridated toothpaste
2x/day parent performs & supervises
2-6 years
Pea-sized amount of fluoridated toothpaste 2x/day
Parent performs & supervises
> Age 6 years
Brush with pea-sized amount of fluoridated toothpaste 2x/day
Begin flossing when teeth touch
Smear/rice-sized
Before age two
Pea-sized
When child can spit
Excessive ingestion of toothpaste can cause fluorosis which is a minor cosmetic problem, relative to losing teeth to caries. In rare situations, such as consuming a large portion of a family sized tube, systemic toxicity including electrolyte abnormalities can result in a medical emergency.
Guidelines
Use a small smear for children at increased risk for caries less than 2 years.
Apply a pea-sized amount of toothpaste for children 2 years and older regardless of caries risk status.
Most preschool children swallow most toothpaste placed on the brush. These guidelines take this into account and these amounts are safe to swallow but spitting out should always be encouraged..
Parents should keep toothpaste tubes out of reach of small children.
References Shulman JD, Wells LM. Acute fluoride toxicity from ingesting home-use dental products in children, birth to 6 years of age. J Public Health Dent 1997;57: Douglass JM, Douglass AB, Silk H . A Practical Guide to Infant Oral Health at the Well Child Visit. American Family Physician 2004;70: ,

31. Good Preventive Medicine for Obesity too!
Children: Diet
Birth – 1 Year
Hold infant for bottle and breast feeding
No bottle at bedtime/nap (water ok)
Introduce cup at 6 months
1 – 2 Years
Wean/discontinue bottle feeding months
2 Years plus
Choose fresh fruits, vegetables, whole grain snacks, sliced meat or cheese
Avoid constant use of Sippy cup
Avoid juice, energy or sports drinks (if used, at meal time only)
Limit sugary/high carbohydrate foods
Good Preventive Medicine for Obesity too!
Given the prevalence of obesity in our culture, there is little role for juice in nutrition for the majority of kids – it is just empty calories like soda pop.
Frequent questions about implementation arise, and these last few slides are topics we are discussing already with anticipatory guidance. Including oral health is simply adding the tag line, “…and not only will help your child grow and develop normally, but its good for her teeth, too!”

32. Pregnant Women

33. Why is Oral Health Care Important for Pregnant Women?
The bacteria that causes tooth decay is transmitted to infants after birth
Women are receptive to oral health messages during pregnancy
Promote mother’s positive role-modeling of oral health behaviors
Promote link between oral and systemic health
Periodontal disease is associated with pre-term births, pre-eclampsia, gestational diabetes
The benefits to the pregnant patient are many. First of all, oral disease is addressed. “The American Academy of Periodontology urges oral health care professionals to provide preventive services as early in pregnancy as possible and to provide treatment for acute infection or sources of sepsis irrespective of the stage of pregnancy.” (CAL) (J Periodontol 2004: 75(3): 495
If good oral health is promoted, this promotes good systemic health.
Care of the pregnant patient may strengthen attitudes towards importance of oral health and baby teeth; behaviors include ability to care for own and infant’s oral health and seek oral health care. Evidence exists that women are particularly receptive to information about caring for infants while they are pregnant. (ref?)
Anticipatory guidance has the potential to prevent Early Childhood Caries. (CAL)
Finally, once an infant is born, there is much less time to visit the dentists office! Additionally, some women may lose their dental coverage only a couple of months after the baby is born.
Gestational Diabetes:
Definition:
High blood glucose levels in pregnant women who have never had diabetes.
Clinical characteristics:
3-7 % of pregnancies; increasing with the obesity epidemic
Usually diagnosed at 28 weeks or later
Increased risk of excessive birth weight
Pregnant women who develop GDM are at greater risk for periodontal disease than women who do not
If periodontal disease occurs, control of GDM is more difficult
Pre-term births and Periodontitis:
Severe periodontitis leads to high levels of prostaglandins in the blood
High levels of prostaglandins are associated with early uterine contractions, early birth and low birth weight
Data to date shows that periodontal treatment during pregnancy:
Is safe for the mother and fetus and
Does not alter the rates of preterm birth or low birth weight
Pre-Eclampsia and Periodontitis:
Periodontal disease may be associated with pre-eclampsia (Boggess, 2003)
PGE2, IL-1 and TNF- levels from gingival crevicular fluid higher in women with preeclampsia (Oettinger-Barak, 2003)
“Oral pathogens have been found in placentas of women with preeclampsia, which imply a possible contribution of periopathogenic bacteria to the pathogenesis of this syndrome.” (Barak, 2007)

34. The Maternal-Child Linkage
Mothers/primary caregivers are the main source of the bacteria responsible for causing caries
How are the bacteria transmitted?
Via saliva contact such as tasting food, licking spoons or pacifiers
The more active the disease in mother’s mouth, the more likely the child is to acquire the bacteria early
If colonization is delayed until after two years of age, then children have less dental decay
Mothers are the primary source of Mutans Streptococci, the bacteria responsible for causing caries.
How Are Mutans Streptococci Transferred?
Mothers with high rates of caries pass their high oral bacterial load and dietary habits on to their babies early in life.
It is thought that transfer occurs via saliva contact such as tasting food, or licking spoons.
The higher the level of maternal bacteria the more likely the child is to acquire the bacteria.
If this colonization is delayed until after 2 years of age, then caries scores at age 4 years decreases.
Caregivers with high bacteria levels usually have:
A high frequency of sugar intake
Poor oral hygiene
High levels of decay
Fathers can theoretically pass on the bacteria, but in practice rarely do
 References US Department of Health and Human Services. Oral health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Ramos-Gomez et al. (2002). Bacterial, behavioral and environmental factors associated with early childhood caries. Journal of Clinical Pediatric Dentistry, 26(2): Douglass JM, LI Y, Tinanoff N. Systematic review of the association between mutans streptococci in primary caregivers and mutans streptococci and dental caries in their children. Pediatric Dentistry 2008, 30(5):

35. Dental Care is Safe Throughout Pregnancy
Preventive interventions
Diagnosis, including needed dental radiographs
Treatment of oral diseases, including periodontal treatment
Radiation exposure is extremely low during dental radiographs. Patients and their unborn children are generally at higher risk from the oral disease affecting the pregnancy than they are from radiation exposure.
Risks
Radiation exposure to the fetus from dental x-rays is so low that it cannot be measured by conventional techniques
4 bite wing radiographs results in a background radiation equivalency of 7 hours.
Procedures
Proper radiographic techniques can minimize radiation exposure.
X-ray as necessary to make diagnosis (i.e. root canal therapy, trauma, caries)
Limit exposure by :
Utilizing lead apron shielding (abdominal and thyroid)
Avoiding retakes when possible
Using rectangular collimation
Using the fastest available receptor (E/F speed film or digital)
Using a long cone to focus radiation only on mouth
References
Maillie HD, Gilda JE. Radiation induced cancer risk in radiographic cepahalometry. Oral Surg Oral Med Oral Pathol 1993;75:
Abbott P. Are dental radiographs safe? Aust Dent J. 2000;45:
Langlais RP, Langland OE. Risks from dental radiation in CDA J. 1995;May:33-39.
American Dental Association Council on Access, Prevention, and Interprofessional Relations (ADA). ADA oral health care series: Women's oral health issues. Chicago, IL: American Dental Association, 1995.
Oral Health Care During Pregnancy and Early Childhood Practice Guidelines. New York Public Health Department 2006.
Oral Health During Pregnancy and Early Childhood: Evidence Guidelines for Health Professionals. California Dental Association Foundation. February
NY State Practice Guidelines; CDA Foundation Evidence-based Guidelines
Photo: ICOHP

36. Barriers to Dental Care
Only 50% of pregnant woman with a dental problem visit a dentist
Why?
Pregnant women don’t know the importance of oral health before baby is born
Unfounded fears that dental treatment may harm their fetus
Dentists have been hesitant to treat due to:
Lack of guidelines
Liability concerns
Easier to wait
Important for Primary Care Providers to encourage dental visits during pregnancy
Dentists, medical clinicians, and patients need to be aware of the importance of oral health and the safety of treatments during pregnancy. Clinicians need to take time during first prenatal visits to ask about oral health, examine the mouth, and refer. Studies show that few medical clinicians advise pregnant patients to see the dentist.
Why Don't Pregnant Women Obtain Dental Care?
Lack of national prenatal oral health guidelines
Medical clinicians do not routinely refer patients for dental care
Many dentists are unsure of how to manage the pregnant patient
Care may be postponed until after pregnancy
Wide variation in opinion about use of local anesthetics, radiographs, and treatment in pregnancy
Fear of malpractice
Dentists may under-treat pregnant patients for fear of litigation.
Litigation review from 1945 to 2001 showed only one lawsuit which was a coincidental stillbirth found in favor of the physicians.
References
Hilgers KK, Douglass J, Mathieu GP. Adolescent pregnancy: a review of dental treatment guidelines. Pediatr Dent 2003;25(5): 459–467.
Gaffield, ML, Colley Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the Pregnancy Risk Assessment Monitoring System. Journal of the American Dental Association 2001;132(7): Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. Am J Public Health 2004;94(5):765–771
Al Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32(7):815–821
Pistorius J, Kraft J, Willershausen B. Dental treatment concepts for pregnant patients: results of a survey. Eur J Med Res 2003;8(6): 241–246
Lindow SW, Nixon C, Hill N, Pullan AM. The incidence of maternal dental treatment during pregnancy. J Obstet Gynaecol 1999;19(2): 130–131 Stefanac S, Nesbit S. Treatment planning in dentistry. St Louis, Mo.: Mosby 2001:92-94.

37. Patients with Diabetes

38. Diabetes
Untreated periodontal disease can lead to costly diabetes complications
Diabetes affects nearly ½ million adults in Washington
Improving an individual’s oral health may reduce diabetic complications, positively impacting overall health

39. Periodontal Disease & Diabetes
A Vicious Cycle
Patients with periodontal disease are twice as likely to develop diabetes
Poor glycemic control is associated with threefold increase of periodontal disease
Periodontal disease worsens glycemic control
Treatment of periodontal disease results in 10-20% improvement in glycemic control
References
Mealey, B. L., Periodontal disease and diabetes: A two-way street. J Am Dent Assoc 2006; 137: Demmer, R.T., Jacobs, D.R., Desvarieux, M. Periodontal disease and incident type 2 diabetes mellitus: Results from the first National Health and Nutrition Examination Survey and its epidemiologic follow up study. Diabetes Care 2008; 31(7): Moore, P.A., et al. Type 1 diabetes mellitus, xerostomia and salivary flow rates. Oral Surg Oral med Oral Pthol Oral Radiol Endod 2001; 92: Promsudth, A., et al. The effect of periodontal therapy on uncontrolled type 2 diabetes mellitus in older subjects. Oral Dis 2005; 11:293-8.

40. Patients with Diabetes: Management40
Tell patients that taking care of their oral health is an important part of managing their diabetes
Avoid
Alcohol, caffeine and tobacco products
Sugar-containing drinks and candies
Frequent snacking on foods high in sugar and carbohydrates
Suggest
Sugar-free gum and mints with xylitol
Prevent caries and periodontal disease
Daily oral hygiene
Protect teeth with fluoride—toothpaste (including prescription strength), rinse, fluoride varnish, fluoridated water
Prevent caries and periodontal disease by:
Maintaining meticulous oral hygiene
Using increased strength topical fluorides such as 1.1% sodium fluoride 40

41. Start Today! Address your patients’ oral health in routine checkups

42. WDS Foundation Can Provide
Oral health training for your care team
Assistance with developing the best approach for including oral health in visits and EHR
Coaching support and assisting with barriers that arise
Patient education materials
Assistance with dental referrals

43. Course Summary
Oral infections are among the most common untreated chronic infections
Oral health is the most common unmet health need in a variety of vulnerable populations
Caries, present throughout the life cycle, is preventable, reversible, and treatable
Periodontal disease increases the risk of Type 2 diabetes and the risk of diabetic and other chronic disease complications – yet is preventable
Primary care providers can have a major impact in improving the oral health of individuals and communities

44. Questions?

45. For More Information Resources Contact SmilesForLifeOralHealth.org
8 modules, AAFP & AAP Prescribed Credit, Additional resources
KidsOralHealth.org
Oral health tips for parents/caregivers
Provider oral health tools, training and resources
Contact
Russell Maier, MD
Glenn Puckett
Acknowledgements: Some content and photos for this presentation were drawn from the Smiles for Life curriculum as well as other Washington Dental Service Foundation trainings.