October 24, 2011

Physicians’ Role in Oral Health
By Jaimie Lazare
For The Record
Vol. 23 No. 19 P. 24

Maintaining healthy teeth and gums is essential to older patients’ general health and quality of life.

Oral health has assumed prominence as a public health issue because of the influence the condition of a patient’s mouth exerts on his or her general wellness. Poor oral health leads to problems such as tooth decay, tooth loss, and pain that will likely affect a patient’s quality of life.

Tooth loss was once thought to be a normal part of aging. However, this perspective has changed due to the fluoridation of community drinking water, improved dental hygiene, and dental technological advancements.1 These improvements have resulted in a decline in the number of edentulous elders. But with increased tooth retention, elders are at risk for problems such as dental caries and periodontal infections.2

According to the Administration on Aging, there were more than 39 million people aged 65 and older living in the United States in 2009. By 2030, the elder population is expected to surpass 72 million. Unfortunately, there aren’t enough physicians trained to care for older patients and even fewer trained geriatric dentists.3 Physicians and other providers who care for aging adults need to expand their vigilance regarding patient health to encompass oral and dental health concerns.

Providers with geriatric specialties are in short supply, which is unlikely to change anytime soon. “Geriatricians certainly have the special skill set in taking care of older people, but there are not enough of us,” says Sharon Brangman, MD, immediate past president of the American Geriatrics Society, a professor of medicine and division chief of geriatrics at SUNY Upstate Medical University, and medical director for Hearth Management’s Senior Living Communities in Syracuse, N.Y.

Many elders don’t have access to dental care due to a lack of dental insurance. However, older patients tend to visit their physicians more often than they do dentists, and it’s been reported that patients who maintain regular visits with their primary care physicians have greater access to preventive dental care.4

Additionally, older patients frequently fail to obtain proper dental care due to financial concerns, the dread of dental procedures, or a general lack of access to dental professionals. As a result, geriatricians and other primary care providers should include oral/dental evaluations as part of elders’ routine care.

Medicare/Medicaid Shortcomings
Many retiring baby boomers may be surprised to discover they no longer have dental insurance. “I think that it comes so much as a part of our benefits package that they [boomers] just assume that when they retire it comes as part of Medicare. I think that it’s going to be a bit of an educational event. I don’t think people even think about it until all of a sudden they don’t have it,” says Sarah J. Crane, MD, an assistant professor of primary care internal medicine and geriatrics at the Mayo Clinic Graduate School of Medicine in Rochester, Minn., adding that it’s not clear whether they’ve grasped the fact that dental benefits aren’t continuing into their retirement.

Medicare does not cover routine dental care, and less than 20% of elders aged 75 and older have private dental coverage.3 Medicaid provides an optional adult dental care plan; however, it fails to meet the minimum standards of care in several states. And to further complicate matters, Medicaid’s reimbursement rates fall well below provider fees; as a result, many dentists will not treat Medicaid patients.3

Wanda C. Gonsalves, MD, associate dean for resident inclusion and diversity education, an associate professor in the department of family medicine at the Medical University of South Carolina, and medical director of the physician assistant program, says people seek out pain treatment from mainstream physicians when they don’t have dental insurance because they’re more likely to have medical homes than dental homes.

“I’ve seen patients come in for oral pain, and it’ll be something like an aphthous ulcer which is causing their pain. When it’s an acute dental problem and they don’t have dental insurance, they’ll present to the emergency department,” she explains.

Playing a Role in Oral Health
While surveys indicate that 90% of physicians favor incorporating oral health interventions into wellness visits, 40% of physicians report having received no training in oral health.4 “There’s a vast lack of familiarity among physicians with anything having to do with oral health, and that’s true in our training and education just as much as it is in our practical day-to-day knowledge,” Crane says. “One of the examples we give is of a fever of unknown origin that got all sorts of workup because it never occurred to the physician team that it might be a dental issue.”

Kevin T. Hendler, DDS, FASGD, FICD, a diplomate of the American Board of Special Care Dentistry, assistant professor of geriatrics at Emory University School of Medicine in Atlanta, and director of geriatric dentistry at the Ina T. Allen Dental Center, recalls a situation in which a patient’s routine blood work revealed elevated white blood cells indicating an infection. The medical fellow treating the patient remembered what she learned during her rotation in the dental clinic, and it turned out the patient had a bad abscess in his mouth.

Building an awareness of common oral problems and the risk factors for older patients’ dental issues is important because when physicians know what to look for, they can make proper referrals. “If you know how to do an oral exam, it doesn’t take a lot of time to concentrate on the mouth. It’s a part of the entire body and you should consider doing a good oral exam, especially in those with risk factors such as smoking and drinking,” Gonsalves says.

Hendler suggests physicians ask their patients when they last visited a dentist and whether they’re experiencing any dental problems. Hendler notes physicians should also consider the medications they prescribe because some of them may cause dry mouth, which results in other dental problems.

Physicians should discuss with their patients the importance of preventive measures aimed at maintaining good oral hygiene, such as fluoride toothpaste and varnish, electric toothbrushes, and flossing. It’s important to stress the effectiveness of fluoride for the prevention of tooth decay because a survey released in January by the Centers for Disease Control and Prevention revealed that while most adults were aware of fluoride’s efficacy in preventing tooth decay in children, they didn’t realize its preventive effects in adults.

Common Oral Culprits
Elders experience a decline in the number of blood vessels coming into a tooth and hardness of tooth enamel, resulting in reduced sensitivity that decreases a patient’s response to tooth decay or trauma.1 “There is also a decline in innervation within the tooth, leading to less symptoms associated with dental caries or dental abscess formation and thus less care-seeking behaviors,” explains Douglas B. Berkey, DMD, MPH, MS, a professor in the department of applied dentistry at the University of Colorado School of Dental Medicine, dental director of Total Longterm Care of Colorado, and codirector at the University of Colorado Center on Aging.

While dental caries can affect people at any age, elders are at a greater risk of root caries because of periodontitis and receding gums, which increase the risk of the systemic entry of cariogenic bacteria such as Streptococcus mutans and Lactobacillus. And the buildup of plaque on teeth along the margins of the gums causes gingivitis, leading to inflammation of the gums that will appear red and swollen and bleed readily upon gentle brushing.1

“Physicians could also look for clinical disease indicators such as red, swollen, or bleeding gums; gums that are receding; missing teeth; teeth that are sensitive or loose; or gingival abscess because those things, I think, are [not only] important dentally but important medically as well,” Berkey says.

Older adult tooth loss may occur due to periodontitis that results from inflammation of the gums causing periodontal ligament detachment, increasing the space around teeth. With an increase in the pocket space around teeth resulting from gingival recession and poor oral hygiene, the teeth become loose and ultimately fall out.1 And there is evidence suggesting periodontal disease is linked to other health problems, such as diabetes, cardiovascular disease, pneumonia, rheumatologic diseases, and wound healing.1 Gonsalves notes that the evidence is strongest in the connection between periodontal disease and diabetes.

“When you have chronic inflammation in your mouth, there is a connection with inflammation and other parts of the body. And when it’s inside blood vessels, especially the ones leading to the heart or the brain, it can result in increased heart attacks or strokes,” Brangman says. “We also know that people who have high bacterial infections in their mouth could have high rates of endocarditis. We certainly don’t want a lot of bacteria hanging out in the mouth because you’re more likely to aspirate it and get pneumonia. So teeth that are infected or gums that are infected can lead to systemic illness.”

“Xerostomia, or dry mouth because of decreased salivary flow, can worsen the underlying problems of poor oral hygiene. Saliva has a protective antibacterial and antifungal effect, so if you have dry mouth and poor oral hygiene, then you’re increasing the risk of dental caries and periodontal disease, which is an inflammatory response,” Gonsalves says. To induce salivary flow, artificial salivary substitutes or sugar-free candy can be helpful, she suggests.

“The side effects of certain medications, especially anticholinergic medications, tend to cause dry mouth. Saliva is very important for easing swallowing, so people with dry mouth may have trouble eating food and are more likely to choke,” says Brangman. “Certainly another thing that we see is changes in taste and that can happen also due to medications. Doctors need to know what medications are more likely to interfere with taste and smell.”

Berkey also notes that an oral cancer examination is appropriate within the medical setting. If physicians notice suspicious oral problems such as white or red patches, sores that don’t heal, masses or lumps, or difficulty swallowing or speaking, then an appropriate referral to a specialist is essential.

The National Institute of Dental and Craniofacial Research reports that oral cancer survival rates have improved, and 60% of these patients have a five-year survival rate, which increases with early detection. Hendler says the late detection of oral cancers may be due to a lack of routine screening and patients’ fears of being diagnosed, especially if they become aware of a growth or a sore in the mouth.

Quality-of-Life Concerns
Depression is a big problem in older patients and for those living in a nursing facility or a retirement community, eating is a social venture. If older patients are embarrassed about how their teeth look or because it takes them a long time to eat, then they’re likely to stay in their rooms, resulting in social isolation and possibly leading to depression, Hendler says.

Crane notes that there are also accessibility concerns for elder patients when it comes to getting healthful foods. For these patients, physicians need to be aware of oral care issues because they relate to both medical concerns and quality-of-life parameters, such as nutrition. “I think often we just say, ‘Go find a dentist’ without properly appreciating the barriers to that statement. We don’t always have the expertise about resources that are available, as limited as they may be, to assist that patient in resolving that concern,” Crane says.

“Older people without teeth or with poorly fitting dentures may not be able to maintain their weight, and weight loss in an older person is very significant. So there’s a direct connection between an oral issue and how it impacts the whole patient,” Brangman says. “As a person gets older, especially if they have some degree of cognitive problems, they may not remember some of the cues that are needed to swallow safely. And if they don’t have teeth or properly fitting dentures, they may not be able to chew food thoroughly and then they’re at risk for choking.”

Bridging the Gap
Medical and dental communities are making strides in improving oral health. Last November in Washington, D.C., the American Dental Association hosted a two-day conference, during which Berkey, Crane, and Hendler were speakers, as a collaborative effort among multidisciplinary healthcare professionals to provide recommendations that could serve to improve dental care for older adults.

Berkey suggests that providing better dental care for older patients will involve establishing a broader community among healthcare providers, including policymakers and researchers, and having everybody work together for better care and advocacy. “Because the mouth is not as much as before seen as a separate part of the body, we’re starting to actually see some very viable associations between general health and oral health. By treating the mouth we treat the whole body,” he says.

Gonsalves helped develop a program in 2005 called Smiles for Life. It’s a comprehensive program that was created for family medicine residency programs and more recently has been crafted into a broader curriculum to improve the knowledge base for all primary care clinicians, including nurse practitioners and physician assistants.

“If you talk about the concept of coordinated care, which is all the talk these days, it’s impossible to discuss coordinating care for all of the patient’s multiple problems without talking about all of them and that includes their teeth,” Crane says.

— Jaimie Lazare is a freelance writer based in Brooklyn, N.Y.

Oral Health Tips for Elder Patients
Approximately 250 million older adults experience the loss of natural teeth. And even though dental advancements have improved tooth retention in elders, people over the age of 65 lose an average of 13 teeth (including wisdom teeth), and 26% have no remaining teeth.

The dental concerns of elder patients cover a range of oral health problems such as root decay and periodontal disease. Promoting good oral hygiene can help geriatric patients with natural teeth or dentures safeguard their oral health between dental visits with the following practical tips:

• Suggest that patients with limited use of their hands (eg, rheumatoid arthritis) try adapting their toothbrushes by inserting the toothbrush handle into a rubber ball or sponge hair curler. They can also lengthen toothbrush handles with a piece of wood or plastic such as a ruler.

• Recommend electric toothbrushes for patients with dexterity problems who cannot use a manual toothbrush. Studies have shown that electric brushes efficiently remove plaque and aid in gum stimulation.

• Promote daily brushing and flossing to protect against root and tooth decay.

• Recommend that patients with partial or full dentures use a soft toothbrush or denture-cleaning brush along with a commercially prepared denture powder or paste, hand soap, or baking soda. Dentures should be brushed inside and outside and rinsed with cool water.

• Remind patients to brush partial dentures, their remaining natural teeth and gums, and especially the teeth supporting a partial denture.

— Source: American Dental Hygienists’ Association

 

References
1. Gonsalves WC, Wrightson AS, Henry RG. Common oral conditions in older persons. Am Fam Physic. 2008;78(7):845-852.

2. Shenkin J, Baum B. Oral health and the role of the geriatrician. J Am Geriatr Soc. 2001;49(2):229-230.

3. Oral Health America. A state of decay: The oral health of older americans. 2003:1-8. Available at: http://www.oralhealthamerica.org/pdf/StateofDecayFinal.pdf

4. Douglass A, Maier R. Promoting oral health: The family physician’s role. Am Fam Physic. 2008;78(7):814-815.