Oral Health with a Focus on Disabilities June

Oral Health with a Focus on Disabilities June

Oral Health with a Focus on Disabilities June Sadowsky, DDS, MPH Associate Professor, Dentist Geriatrician The University of Texas Health Science Center at Houston School of Dentistry General Practice and Dental Public Health 1 Dr. June Sadowsky Dr. June Sadowsky was a member of the HRSA funded Houston Geriatric Education Center when this presentation was developed. Dr. Sadowsky has presented this work to interprofessional audiences. Please credit her for the work she provided in the development and updating of this presentation.

2 Funded By This project was funded by a grant from the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. The grant was initially funded in 2007 with renewed funding for five years beginning in 2010. (Grant #UB4HP19058). The grant was successfully completed in June, 2015. Learning Objectives Successful completion will allow the student to: Gain knowledge of the risk factors associated with oral health and disabilities Perceive the oral manifestations of systemic

disease Be aware of the diseases and oral management Understand some interventions to assist older adults 4 School of Dentistry 7500 Cambridge, Houston, Texas 77054 5 Major Risk Factors

Periodontal disease Caries Socio-behavioral factors Environmental factors Health status UT Health 2002 6 A Risk Factor for Cardiovascular Disease Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic 7 Diseases. JPeriodontal. 1998 Jul;69(7)841-50. and Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. ChenYW etal ,J Clin Periodontol, 2009 Oct;36(10):830-5.

Other Risk Factors Medications which reduce saliva flow Smoking Diabetes Cancer Microsoft Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000 Volume 62, Issue 1, pages 5994, June 2013 8 Link Between Heart Disease and Gum Disease Inflammation is a major risk factor for heart disease, and periodontal disease may increase the inflammation level throughout the body. Since several studies have shown that

patients with periodontal disease have an increased risk for cardiovascular disease, cardiologists and periodontists developed clinical recommendations and will now see joining forces to help patients. British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81 showed that there was an unexpected correlation between dental disease and systemic disease (stroke, heart disease, diabetes). A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists, And The Journal Of Periodontology (JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol July 2009. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of 9 Periodontal Therapy on General Health American Journal of Preventive Medicine Volume 47, Issue 2, Pages 166174, August 2014 Caries Risk 85% had coronal and/or root caries

> 75% were taking medications with hyposalivary side effects Lack of fluoride in oral environment Saliva very acidic Caries Activity And Associated Risk Factors In Elderly Hospitalized Population 15-months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58 Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463. 10 Environmental Factors Societal healthcare

Cultural values Education Health promotion Lifestyle choices Stress Workrelated environment Fluoridated water Sugar consumption Alcohol use 11 Environmental Factors Mortality (length of life) 50% Morbidity (quality of life) 50%

Tobacco use Diet and exercise Health Outcomes Health Behaviors 30% Clinical Care 20% Health Factors Social and economic factors -40% Alcohol use Sexual Activity

Access to Care Quality of Care Education Employment Family and Social Support Income Physical Environment 10% Policies and Programs University of Wisconsin Population Health Institute Model 2012 Community Safety Environmental Quality

Built Environment 12 Socio-Behavioral Risk Factors Human biology Vulnerability Health care organization Public policy changes Lifestyle Develop personal skills to deal with life Recreation Use fluoride products Environment Create more support for elderly

Income inequality Google.com/images 1974, Marc Lalonde 13 The common risk factor approach (adapted from Petersen, 2003) Petersen PE, Sociobehavioural risk factors in dental caries international perspectives, Community Dentistry and Oral Epidemiology Volume 33, Issue 4, pages 274279, August 2005 14 Health Status Tobacco Alcohol

Diet well balanced Decrease sugar intake Increase fruit and vegetable Vitamin D deficiency Fluoride use and plaque removal per day Regular dental checkups Microsoft.com twice 15 Caries Management By Risk Assessment Education Caries

Risk Assessment Treatment Plan Caries Free http://ncpresby.pbworks.com/f/dental%2016.jpg Chronic Diseases Heart disease Stroke Cancer Chronic respiratory diseases

Diabetes Microsoft.com REPRESENT 60% OF DEATHS [email protected] 17 Manifestations of Systemic Disease 18 GI Disease Oral manifestations Crohns disease Ulcerative colitis

Noncaseating granulomas Areas of hemorrhage and ulceration Aphthous ulcers and chelitis Lip, mucosal swelling Cobblestone-like gingiva Mucosal tags Angular chelitis Decreased saliva production and malabsorption may lead to dental caries

GERD Mouth pH 5.5 Erosion Sensitivity Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohns Disease N Engl J Med. June 1 200; 342(22):1644 Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 19 26, No.8 (August 1981) Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol .Apr Chronic Liver Disease Liver Dysfunction

Coagulation/Vitamin K deficiency Gingival bleeding (in the absence of inflammation) Microsoft.com Petechiae Jaundice (bilirubin in submucosa of soft palate) Hepatitis - lichen planus, xerostomia, sialadenitis, erosive lesions ALD or Cirrhosis Cruz-Pamplona M, Margaix-Muoz M, Gracia Sarrin-Prez MG.Dental considerations in patients with 20 liver disease. J Clin Exp Dent.2011;3(2):e127-34. CD Johnson Chronic Kidney Disease Presence of kidney damage or decreased kidney function Chronic NSAID use

Oral symptoms Ammonia like taste and smell (urea in saliva) and frost on skin Stomatitis Gingivitis Parotitis Xerostomia Decreased salivary flow Google.com/images Atrophic glossitis Thirst Little JW. Dental management of the medically compromised patient. 2013 Elsevier/Mosby, St. Lous Mo. Cruz-Pamplona M, Margaix-Muoz M, Gracia Sarrin-Prez MG.Dental considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34. 21 Anemia

Occult Blood Loss Iron deficiency Anemia Chronic inflammation B-12 Deficiency (Pernicious Anemia) Gastrectomy Folate Deficiency Oral Manifestations Pale gums Glossitis (folate and Vitamin B-12 deficiency) Angular stomatitis (candida infection) Pica (desire to consume unusual substances, such as ice or dirt) Spivak JL. Anemia In The Elderly: Time For New Blood In Old Vessels?. Arch Intern Med. Oct 24 2005;165(19):2187-9. 22

Connective Tissue Disorders Sjogrens Syndrome 90% females over 50 Sicca syndrome dry eyes and mouth Xerostomia Atrophy of papillae of tongue produces a cobblestone effect Increased incidence of candida infection Dental caries Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302. Klasser GD, Balasubramaniam R Epsein J,Topical review-connective tissue diseases: orofacial manifestations including pain. 23

J Orofac Pain .2007 Summer;21(3):171-84. Pulmonary Conditions COPD 90% caused by smoking Air pollution Irreversible damage to the airways Restricts movement Cough and breathlessness Soft palate irritation from inhaler use Dry mucous membranes Wegeners granulomatosis Necrotizing vasculitis Maclay JD, Rabinovich RA, MacNee Update in chronic obstructive pulmonaryenlargement

disease 2008. Am J Respir Crit Care Ulceration andW.hyperplastic gingival Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398 24 Diabetes Affects approximately one in four Americans age 60 and older The number of adults age 75+ with 1 million in 2000 to more than 4 million in 2050

23.1% of patients 60+ OR one of every 4.2 patients you see over the age of 60! 5.7 million are undiagnosed 82% of diabetic patients with severe periodontal disease have experienced one or more Major cardiovascular Cerebrovascular Peripheral vascular events Compared to only 21% of diabetics without periodontal disease

Centers for Disease Control and Prevention. Public health and aging: trends in agingUnited States and worldwide. MMWR 2003;52(06):101-106 Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol 2006 Aug;77(8):1289-130 http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages 25 Diabetes Uncontrolled diabetics exhibit higher levels of collagenase that can degrade periodontal tissues(Ryan 2003, Salvi 1997) Periodontal disease results in higher proinflammatory cytikine TNF- that causes insulin resistance(Grossi 1998) Diabetic patients who have full-mouth disinfections every three months showed significant reductions in their HbA1c serum levels (blood glucose) (Lang 2008) 26

Arthritis Leading cause of disability Affects 8 million Severely limits ability to perform Activities of Daily Living (ADLs) Loss of Range of Motion Stiffness

Joint Deformity Overweight, Fatigue Unexplained fever May affect TMJ (temporomandibular joint) Rutger Persson G. Rheumatoid arthritis and periodontitis: inflammatory and infectious connections: review of the literature. J Oral Microbiol 2012; 4:10. 27 Arthritis Osteoarthritis common Joint Pain, Rheumatoid - + RF in tenderness and blood

inflammation Gout Uric acid CRP=C-Reactive Beer, sardines, organ meats Protein in blood serum produced in the liver during acute inflammation or infection Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:1025 Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914920. 28 Arthritis and Periodontal Disease Patients referred for periodontal treatment

prevalence of self-reported rheumatoid arthritis was 3.95% Significantly higher than that seen in patients not referred for periodontal treatment (0.66%) that reported in the general population (1%). Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011; 38:9981006 29 Arthritis and Periodontal Disease Of those referred patients with rheumatoid arthritis, 62.5% advanced forms of periodontal disease self-reported prevalence of cardiovascular disease and diabetes mellitus

Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk 30 of rheumatoid arthritis. J Rheumatol 2010; 37:18001804 Arthritis and Periodontal Disease Conclusions: there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheumatoid arthritis and vice versa. Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000 Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:18001804 31 Osteoporosis

People with osteoporosis are much more likely to lose their teeth due to bone loss in the jaw. Good homecare is even more important to help prevent tooth loss. Osteoporosis Treatment Bone-replacing cells in bone are suppressed and if an extraction, bone may not heal. Mattson JS1, Cerutis DR, Parrish LC.Osteoporosis: a review and its dental implications. Compend Contin Educ Dent. 2002 Nov;23(11):1001-4 Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Sep;100(3):349-56. 32

Oral Manifestation of Viral Diseases Herpes Zoster (Shingles) Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007 33 Oral Manifestation of Viral Diseases Human papillomavirus Squamous cell papilloma and verruca vulgaris Human immunodeficiency virus Plantar warts on hands Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Curr Opin Dent

1991;1:384-97. Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007 34 Head and Neck Cancer Incidence oral and pharyngeal cancer in 2012 in the US 40,250 new cases (28,540 in men and 11,710 in women) Estimated Deaths in 2012 7,850 people (5,440 men and 2,410 women) Careful monitoring of the oral cavity with strict application of preventive measures

Lower radiation doses or intensity-modulated radiotherapy (IMRT) Use of shielding Reduction in the use of toxic drugs Improved oral instructions and expectations Completion of dental treatment before beginning cancer care benefits the patient greatly http://www.cancer.org/acs/groups/cid/documents/webcontent/003128-pdf.pdf 35 Drug Induced Oral Manifestations Apthous stomatitis Canker sores Lichen Planus ACE inhibitors Beta-blockers

NSAIDs Diuretics hydroxychloroquine Gingival Enlargement (hyperplasia) Phenytoin Ca+ Channel Blockers Cyclosporine Dry Mouth/Xerostomia (hyposalivation) Single most adverse effect Anticholinergic effect Alters taste Difficulty eating , swallowing Treatment

Increased hydration Artificial saliva Procholinergic agents Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C Virus And Lichen Planus: A Case Control Study Of 340 Patients. J Am Acad Dermatol, Nov 1999;4195):787-9 Abdollahi M, Radfar M; A review of drug induced manifestations, J Contemp Dent Prac, 2003(2)1:10-31 36 Dry Mouth CD Johnson 37 Drug Induced Oral Manifestations Stevens-Johnson

Syndrome 3 weeks after meds Rash to purpuric macules 50 % oral Sulfonamides Penicillin Phenytoin Phylbutazone Drug -induced Neutropenia Ulcers on gingiva

Fungal Infections Radiation Chemotherapeutics Immunosuppressives Bologna JL, Jorizzo, JL, Papini, RP, Dermatology. Spain: Mosby 2003 38 Candidiasis 39 Diseases and Oral Management

40 Disease and Oral Management Alzheimers/dementia Dental Management Of Patients With Alzheimer's Disease And Other Dementias (Ronald L Ettinger July 2000volume 17, Issue 1pages Xxi, 164) Alzheimer's Disease And Dental Management (Hmeyra Kocaelli Etal Oral Surg, Oral Med, Oral Path, Oral Rad and Endo Vol 93 5, May 2002, Pages 521-524) Stroke Movement disorders Parkinsons Oral Health and Peripheral Arterial Disease. Hung HC, Circulation. 2003; 107: 11521157 Oral care for patients with cardiovascular disease and stroke (Louis F. Rose LF, Etal. J Am Dent Assoc, Vol 133, No suppl1, 37S-44S. 2002) Cant do ADLs

41 Disease and Oral Management Continued growth of population over 65 Globally oral health is poor in elderly Prevention is not emphasized Those in dependent situations have few oral caregivers More people are keeping their teeth longer means more teeth at risk World Wide Public Health Of Elderly - Improving The Oral Health Of Older People: The Approach Of The WHO Global Oral Health Programme Poul Erik Petersen, Tatsuo Community Dentistry And Oral Epidemiology Volume 33, Issue 2, Pages 8192, April 2005 42

Disease and Oral Management Long term care Patient consent issues Seventy percent of patients in long-term care facilities had unacceptable levels of oral hygiene (Kiyak et al. 1987, McIntyre et al. 1986) lack of knowledge about oral care Homebound Hospice Oral Cancer patients Majority elders Kiyak HA. An explanatory model of older persons use of dental services: implications for health policy. Med Care 1987;25:93652. MacEntee MI, Weiss R, Waxler-Morrison NE, Morrison BJ. Factors influencing oral health in long term care facilities. Community Dent Oral Epidemiol 1987;15: 3146. 43

Other Barriers to Dental Care Access Transportation Housing Live in abandoned car Legal VA Benefit Alien status 44 Interventions to Assist Older Adults

45 Management Options Education Entities caring for seniors Students and faculty to retain patients Linkage to Community Resources Transportation Mental Health Living Caregiving Outreach to Seniors concerning dental needs 46 Management Options Education

Caregiver training video designed for nursing homes, assisted living facilities, and individuals. Make a donation of one to a facility near you. 47 Dental Management Make all offices elder friendly Literacy alert Bigger print Language easy to understand

Educate caregivers Alter toothbrushes Forms for daily documentation of oral care Mobile/portable dental teams 48 References

Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic Diseases J. Periodontal. 1998 Jul;69(7)841-50 ChenYW etal . Association between periodontitis and anti-cardiolipin antibodies in Buerger disease. J Clin Periodontol, 2009 Oct;36(10):830-5. Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000 Volume 62, Issue 1, pages 5994, June 2013 A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The Online Versions Of Two Leading Publications, The American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists, And The Journal Of Periodontology (JOP), The Official Publication Of The American Academy Or Periodontology (AAP). J Periodontol July 2009 Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of Periodontal Therapy on General Health American Journal of Preventive Medicine Volume 47, Issue 2, Pages 166174, August 2014 British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81

Caries Activity And Associated Risk Factors In Elderly Hospitalized Population 15-months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58 Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463. 49 References

University of Wisconsin Population Health Institute Model 2012 1974, Marc Lalonde [email protected] Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohns Disease N Engl J Med. June 1 200; 342(22):1644 Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 26, No.8 (August 1981) Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol .Apr 2007;21(4):241-4 Bagan JV, Aguirre JM etal; Oral lichen planus and chronic liver disease: A clinical and morphometric study of the oral lesions in relation to transaminase elevation; Oral Surgery, Oral Medicine, Oral Pathology Volume 78, Issue 3, September 1994, Pages 337342 Cruz-Pamplona M, Margaix-Muoz M, Gracia Sarrin-Prez MG.Dental considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34. Little JW. Dental management of the medically compromised patient. 2013 Elsevier/Mosby, St. Lous Mo.

Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302. Klasser GD, Balasubramaniam R Epsein J, Topical review-connective tissue diseases: orofacial manifestations including pain. J Orofac Pain. 2007 Summer;21(3):171-84. 50 References

Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398 Centers for Disease Control and Prevention. Public health and aging: trends in agingUnited States and worldwide. MMWR 2003;52(06):101-106 Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol 2006 Aug;77(8):1289-130 http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages The influence of diabetes on periodontal disease, Ryan ME, Carnu O, Kamer A. JADA, Vol. 34, (10): 34S-40S. Salvi G, Yalda B, Collins J, et al. Inflammatory mediator response as a potential risk marker for periodontal diseases in insulin dependent diabetes mellitus patients. J Periodontol 1997;68(2):127:35. Grossi SG, Genco RJ: Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 3:5161, 1998 Lang NP, Tan WC, Krahenmann MA, Zwahlen M. A systematic review of the effects of fullmouth debridement with and without antiseptics in patients with chronic periodontitis. J Clin Periodontol. 2008 Sep;35(8 Suppl):8-21.

51 References Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:1025 Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental Res 2012; 91:914920. Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid arthritis: results from the First National Health and

Nutrition Examination Survey and its epidemiological follow-up study. J Clin Periodontol 2011; 38:9981006 Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000 Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:18001804 Mattson JS, Cerutis DR, Parrish LC. Osteoporosis: a review and its dental implications. Compend Contin Educ Dent. 2002 Nov;23(11):1001-4 Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Sep;100(3):349-56. Zachariasen RD, Oral manifestations of menopause. Compendium, 1993, 14(12):1584, 1586-91 52 Questions June M. Sadowsky, DDS, MPH 713-500-4064 [email protected]

Images HoustonGEC would like to thank: Microsoft images Google.com images UTHEALTH School of Dentistry New Patient Information UTHealth School of Dentistry 713-486-4000 53

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