Integrating Oral Health and Medical Care

1. Integrating Oral Health and Medical Care Jacqueline A. Tallman, RDH, MPA Dental Director Health Disparities Collaborative National Network for Oral Health Access Michigan Primary Care Association jtallman@mpca.net

2. Introduction • Overview and Impact of Oral Diseases • Disparities in Oral Health Care • Relationship Between Oral Health and Systemic Diseases • Oral Health and the Diabetes Collaborative • Oral Health Resources • Questions and Discussion

3. Oral Health • More than teeth and gums! • Also includes supporting tissues, hard and soft palate, mucosal lining of the mouth and throat, tongue, lips, salivary glands, chewing muscles, and upper and lower jaws Oral Health in America: A Report of the Surgeon General

4. Oral Health . . . these tissues allow us to speak and smile; sigh and kiss; smell, taste, touch, chew, and swallow; cry out in pain; and convey a world of feelings and emotions through facial expressions  The essence of our humanity!! Oral Health in America: A Report of the Surgeon General

5. Oral Diseases • Progressive and cumulative – become more complex over time • Dental caries (tooth decay) is the single most common chronic childhood disease – 5 times more common than asthma and 7 times more common than hay fever Oral Health in America: A Report of the Surgeon General

6. Oral Diseases • Over 50 percent of 5- to 9-year-old children have at least one cavity or filling, and that proportion increases to 78 percent among 17-year-olds. • These are improvements compared to a generation ago! Oral Health in America: A Report of the Surgeon General

7. Oral Diseases • Poor children suffer twice as much dental caries as their more affluent peers, and their disease is more likely to be untreated. Oral Health in America: A Report of the Surgeon General

8. Dentally Uninsured • Uninsured children are 2.5 times less likely than insured children to receive dental care and are 3 times more likely to need it! • For every child without medical insurance, there are at least 2.6 children without dental insurance. Oral Health in America: A Report of the Surgeon General

9. Vulnerable Populations • Those who suffer the worst oral health are found among the poor of all ages, with poor children and poor older Americans particularly vulnerable • Members of racial and ethnic minority groups experience a disproportionate level of oral health problems Oral Health in America: A Report of the Surgeon General

10. Why the disparities? • There are many factors that influence vulnerability to oral disease • Socioeconomic factors • Lack of resources to pay for care • Inability to take time away from work • Lack of transportation • Physical disability or other illness that limits access • Lack of understanding and awareness of the importance of oral health Oral Health in America: A Report of the Surgeon General

11. Why the disparities? • Cultural values influence oral health and well-being and can play an important role in care utilization practices and in perpetuating acceptable oral health and facial norms. Oral Health in America: A Report of the Surgeon General

12. Oral health is integral to general health Oral Health in America: A Report of the Surgeon General 2000 http://www.nidcr.nih.gov/sgr/oralhealth.htm

13. “You cannot be healthy without oral health”

14. Demonstrated relationships between oral health and systemic diseases • Diabetes • Cardiovascular Disease • Adverse Pregnancy Outcomes

15. Cardiovascular Disease and Oral Health • Association has been demonstrated between periodontal disease and cardiovascular disease and research continues to determine the extent to which the association is causal or coincidental • Two theories: Bacterial and C Reactive Protein

16. Cardiovascular Disease and Oral Health Gum disease may harm the heart, too http://www.heartcenteronline.com/myheartdr/home/research-detail.cfm?reutersid=3018 Theory: the Porphyromonas gingivalis bacterium can actually migrate from the mouth to the heart and cause inflammation in arteries that promotes atherosclerosis

17. C Reactive Protein C Reactive Protein Test http://www.heartcenteronline.com/myheartdr/common/articles.cfm?ARTID=376 CRP is an inflammatory marker — a substance that the body releases in response to inflammation. High levels of CRP in the blood mean that there is inflammation somewhere in the body.

18. C Reactive Protein The researchers theorize that people living with a chronic infection such as gum disease may produce higher levels of C Reactive Protein, which could place them at higher risk of heart attack.

19. C Reactive Protein Another reference: The New England Journal of Medicine Volume 347:1557-1565 November 14, 2002 Number 20 Comparison of C-Reactive Protein and Low-Density Lipoprotein Cholesterol Levels in the Prediction of First Cardiovascular Events Paul M. Ridker, M.D., Nader Rifai, Ph.D., Lynda Rose, M.S., Julie E. Buring, Sc.D., and Nancy R. Cook, Sc.D. http://content.nejm.org/cgi/content/short/347/20/1557

20. Perinatal Health Preterm Birth Preterm birth, resulting in babies born too little and too soon, is a major cause of morbidity today. Evidence indicates that infections can be major risk factors in preterm birth.  Case-control studies point to an association between periodontal infection and increased rates of

21. Perinatal Health preterm birth. This article summarizes evidence to date, and the strategies the ongoing intervention studies are using to answer the fundamental clinical question:  can periodontal therapy reduce the risk of preterm birth? http://www.dentalcare.com/soap/ce111pc/pg01.htm This is part of a P& G mini course on the relationship between oral health, pregnancy, and postmenopausal osteoporosis.

22. Perinatal Health Improving Women's Health and Perinatal Outcomes: Snapshot of the Impact of Oral Diseases Fact sheet containing a number of frequently asked questions pertaining to women's oral health, access to oral health services, and potential strategies to improve the oral health status of women. Available online: http://www.jhsph.edu/wchpc/pub/oralfacts.pdf Source: http://www.ask.hrsa.gov/detail.cfm?id=MCH00012

23. Other systemic links • Many systemic diseases and conditions have oral manifestations – may be the initial sign of clinical disease • Pharmaceuticals and other therapies commonly used in treating systemic conditions can cause oral complications Oral Health in America: A Report of the Surgeon General

24. Diabetes and Periodontal Disease • Effective treatment of periodontal infection and reduction of periodontal inflammation is associated with a reduction in glucose blood levels.  http://www.perio.org/resources-products/pdf/4-diabetes.pdf

25. Diabetes and Periodontal Disease • Persons with diabetes are at greater risk for periodontal diseases • There is now some thought that untreated periodontal disease in persons predisposed to diabetes makes them more likely to develop the disease

26. Oral Health Resources PERIODONTAL DISEASE TREATMENT PROTOCOL FOR INDIVIDUALS WITH TYPE 2 DIABETES MELLITUS Indian Health Service Dental Program Fred B. Skrepcinski, DMD, MPH Email jtallman@mpca.net for electronic copy

27. Diabetes and Periodontal Disease – Education Resources Diabetes and Oral Health Internet Resources - direct links to websites with provider and patient education resources - Available on the Diabetes Virtual Office (Under Tools/Resources, then Miscellaneous). Includes: Periodontal Complications of Diabetes This power point presentation has color slides and script ready to download and use for staff in-service training. It was developed from the NIDCR slide series that is no longer available.

28. On the way to the throat and between the ears! Check the teeth and oral tissues!

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30. http://oralhealth.dent.umich.edu/VODI/html/index.html Click on dental caries or periodontal disease, then screening, and then demo for short videos on how to screen in a medical setting. Also check out the Signs & Symptoms section for further information.

31. What Works? • Hearing from their medical provider that they need to see the dentist! • Hearing from their medical provider that their oral health affects their diabetes and their general health! • Repeated messages if necessary • Same day quick initial visit to dental – easier to come back if they have had that initial meeting! • Escorted by medical staff to dental to make appointment • Established referral system that all staff know and use – may take several PDSA cycles to develop! • Tracking referrals – will be available electronically in PECS 3.0!!!

32. Sample Referral Form • WESTSIDE COMMUNITY HEALTH SERVICES • MEDICAL/ DENTAL DIABETES REFERRAL • Patient name: ______________________________________ Date of birth:________________ • Last First • Medical Account Number: ________________________ • Do you have a dentist? YES NO • Have you seen a dentist in the last year? YES NO • For routine exam and cleaning? YES NO • For emergency care or pain relief? YES NO • 3..Do you have loose or painful teeth? YES NO • 4 .Do your gums bleed when you brush or floss? YES NO • 5. Do you have bad breath? YES NO • Type Diabetes 1 2 • HbA1c= • Allergy to Doxycycline Yes No • REFERRING PHYSICIAN:_________________________________ Date:_________________ • **FORWARD/FAX THIS FORM TO SUE TESSIER AT WESTSIDE DENTAL. • FAX #: (651) 602-7518 • ---------------------------------------------------------------------------------------------------------------------

33. Sample Referral Response Form • DENTAL COMPLETE THIS SECTION: • 1. Periodontal Status: I. Gingivitis • II. Early Periodontitis • III. Moderate Periodontitis • IV. Advanced Periodontitis • 2. Dental Treatment needs: • Yes • No • 3. Treatment Completed : • Yes • No • DENTIST NAME: __________________________________ Date___________ • **DENTIST PLEASE RETURN FORM TO PHYSICIAN

34. Collaborative Resources • Dental Listserv • Dental Resources on Virtual Office • Dental Director to contact with questions • Dental Breakouts at Learning Sessions and Phase 2 Summits • Mechanism to share forms and education tools

35. Dental Listserv Includes persons from Phase 1 and Phase 2 and others who have expressed interest in the collaborative dental initiative. The purpose is to share information, ask questions, and keep the communication open between the face to face meetings! Not just for dental providers!!

36. Dental Listserv If you have not received the initial communications and would like to join, please send an email to jtallman@mpca.net and request that your name be added.

37. Diabetes Virtual Office A virtual office for the Diabetes Collaborative has been established and has the Oral Health and Diabetes Web Resources document posted for your use. (Under Tools/Resources, then Miscellaneous.) This includes several pages of websites for patient education materials, some in multiple languages; provider in-service training; periodontal references; Other resource materials will be added as they become available. Check with your data specialist if you are not signed on!

38. Colgate Diabetes Program • If you are a member of the AADE (American Association of Diabetes Educators), you can register to receive Colgate samples every month by calling 1-800-840-3000. When prompted for a PIN number, press O for the operator. They will take it from there! • They also have a dental education sheet for persons with diabetes.

39. Free Oral Care Kit for Public Health Centers Colgate is offering “Oral Health . . . from Pregnancy through the Toddler Years” to health centers at no cost through this order form or by emailing bsbf@jmheducation.com. The kit has oral health messages covering the periods of pregnancy, 0-6 months, 6-18 months, and 18-24 months. They are available in English and Spanish.

40. Free Bright Smiles, Bright Futures Kits for Kindergarten Classes If your schools have not already signed up for their free dental kits, this will provide them the information to do so. These are also available in English and Spanish. Kits are sent to the schools. For more information, call 800-375-7576

41. The Interface Between Medicine and Dentistry in Meeting the Oral Health Needs of Young Children This document is part of the Children’s Dental Health Project that has been a great resource of information through their patient education sheets, CDHP News *Bytes, and website http://www.cdhp.org. An electronic version of this document is available on their website.

42. Questions?