Family physicians focus on preventive care to help people get well, stay well and avoid potential complications at every stage of life. Comprehensive oral health preventive medicine for older adults is essential and should include: Assessment, education, and referrals for older adults. Visits to the dentist may not be part of the older patient’s routine care due to the lack of dental benefits, exacerbated by low income, disability, mobility, and racial and ethnic disparities. The medical provider may offer the only oral health evaluation an older adult receives. The mouth reflects general health and well-being. This article reiterates general health risk factors common to many diseases, such as tobacco use and poor dietary practices, which also affect oral and craniofacial health. Oral health means more than healthy teeth and the absence of disease. It involves the ability of individuals to carry out essential functions such as eating and speaking, as well as to contribute fully to society.

Access to dental services is especially difficult for those most vulnerable; this is particularly true for low-income, older adults. Barriers to dental services for the adult over the age of 65 are complex, among the most prominent are a general decline in health, the ability to access oral healthcare services, transportation, lack of knowledge, and a lack of dental insurance. Medicare does not include any routine dental services. To add dental to the Medicare benefit there needs to be a legislative change to the Social Security Act. As a result of Section 1962 (a)(12) of the Social Security Act, beneficiaries are not entitled to Medicare dental coverage, particularly in the case of routine checkups, dental cleanings, cavity fillings, tooth extractions, and dentures. This exclusion from Medicare was not determined by the value or necessity of dental care, but rather by the type of service being provided and anatomical structure involved.

It appears to be more important for the older adult with limited access to dental services and multiple morbidities to use preventive oral health home care, including education for family caregivers on an oral health care plan to prevent disease. This may include special holders for toothbrushes to accommodate adults with arthritis, recommendations for electric toothbrushes, three sided toothbrushes, special holders for flossing, and fluoride. Many older adults have had crowns, bridges, and other restorations they want to maintain along with their natural teeth. Fluoride can save the teeth and any prior investment in dental care by preventing decay.

Maintaining a healthy mouth may be more complex for the older adult due to chronic disease issues. When the physician is treating and monitoring the patient the healthcare professionals in the practice could assist with appropriate recommendations. Many older adults experience poor oral health associated with multiple chronic health conditions such as periodontitis which has been found to be linked with diabetes, and heart disease. More recently, many chronic aging conditions are under study for determining an association with poor oral health. Medications patients are prescribed may cause xerostomia reducing the buffering effects of saliva. Many older adults have inadequate knowledge about oral-systemic health factors especially lower income, rural and less educated older adults. A flyer with more information for the older adult patient and the systemic connection of oral health and overall health accompanies this newsletter.

As research continues more will be known about the association of poor oral health with overall health. Duke University did a study on the association between dementia and number of teeth. While the Duke University researchers can’t say there’s enough evidence to say one causes the other, there appears to be a link between the number of teeth and periodontal disease with the risk of cognitive decline or dementia. Researchers reviewed 56 studies published between 1993 and 2013 and found evidence suggesting older people with cognitive impairment, such as dementia, are more likely to have oral health problems. The researchers do suggest more research is needed, but this is another possible link to oral health. As more research is done, the association between overall health and oral health may continue to demonstrate the significance of good oral health in all populations.

Nutritional intake for the older adult is an important concern for physicians. Literature has documented edentulism, tooth aches, and poorly fitting dentures cause individuals to forgo nutritious food choices such as fruit and vegetables due to an inability to chew properly. Older adults who suffer from edentulism are known to modify their dietary practices to match their new mastication abilities and tolerance levels. Reduced consumption of essential nutrients and fiber deprive older adults of nutritional health benefits, rendering them more vulnerable to disease. While advancing age impairs the sense of taste, diseases, medications, and dentures can also contribute to this sensory loss. It is important to have a discussion with the older patient about any dietary changes due to oral discomfort. The physician may prevent any nutritional insufficiencies before they occur. Family physicians can help the patient understand the importance of good oral health and refer to dentists for routine care.

What do you know about Georgia’s Regional Perinatal Centers? They can be a vital resource for primary care providers and family physicians providing care to pregnant women. Currently there are six Regional Perinatal Centers (RPC) located across the State of Georgia. The map and links to the centers are below. These are specially qualified hospitals designated to provide the most advanced care for high-risk mothers and infants.

Regional Perinatal Centers provide a number of services including the following:

• Comprehensive perinatal health care for pregnant women, their fetuses and infants of all risk categories
• Medical consultation
• Assistance with transport/transfers of high-risk mothers and infants
• Outreach education to providers and staff of hospitals within each specific region

Albany  Phoebe Putney Memorial  Albany, Georgia 31701  Columbus  Midtown Medical Center  Columbus, GA 31901  Atlanta  Grady Health System  Atlanta, GA 30303 ·  Macon  Navicent Health  Macon, GA 31201  Augusta  Georgia Regents University  Augusta, GA 30912  Savannah  Memorial University Medical Center  Savannah, GA 31404

Through a partnership with the Georgia Department of Public Health, GAFP offered two webinars in May on Developmental Screening and Severe Combined Immunodeficiency. Both webinars were recorded and are now available to view on the GAFP website at www.gafp.org/education/webinars/. You can see objectives and speaker information for each webinar below!

Dear Georgia Physician,

As most of you are already aware, the Centers for Disease Control and Prevention (CDC) has issued a travel alert for people traveling to countries where Zika virus transmission is ongoing. I want to urgently emphasize that all pregnant women should be screened for travel history to Zika-affected areas since Zika virus infection during pregnancy may lead to poor outcomes. Zika virus infections have been confirmed in infants with microcephaly and in the current outbreak in Brazil, a marked increase in the number of infants born with microcephaly has been reported.

Health care providers should ask all pregnant women about recent travel. Pregnant women with a history of travel to an area with Zika virus transmission and who report two or more symptoms consistent with Zika virus disease (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) during or within 2 weeks of travel, or who have ultrasound findings of fetal microcephaly orintracranial calcifications, should be tested for Zika virus infection.

There is no commercially available test for Zika virus.Patients meeting these criteria should immediately be reported to DPH at 1-866-PUB-HLTH (866-782-4584). DPH will facilitate laboratory testing, and provide information about appropriate clinical samples,interpretation of test results, and next steps.

Pregnant women in any trimester should consider postponing travel to the areas where Zika virus transmission is ongoing. Women trying to become pregnant should consult with their healthcare provider before traveling to these areas and strictly follow steps to prevent mosquito bites during the trip.

Brazilian health authorities report more than 3,500microcephaly cases in Brazil between October 2015 and January 2016. Some of the affected infants have had a severe type of microcephaly and some have died. Studies are under way to investigate the association of Zika virus infection and microcephaly.

Zika virus is transmitted to people primarily through the bite of an infected Aedes species mosquito. About one in five people infected with Zika virus will develop symptoms, which include fever, rash, joint pain,and conjunctivitis (pink eye). Other commonly reported symptoms include myalgia, headache, and pain behind the eyes. The illness is usually mild with symptoms lasting from several days to a week. Severe disease requiring hospitalization is uncommon and deaths are very rare.

No specific antiviral treatment is available for Zika virus disease. Treatment is generally supportive and can include rest, fluids,and use of analgesics and antipyretics. Because of similar geographic distribution and symptoms, patients with suspected Zika virus infections also should be evaluated and managed for possible dengue or chikungunya virus infection. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)should be avoided until dengue can be ruled out to reduce the risk of hemorrhage. People infected with Zika, chikungunya, or dengue virus should be protected from further mosquito exposure during the first few days of illness to prevent other mosquitoes from becoming infected and reduce the risk of local transmission.

Several cases of travel-associated Zika virus infection have been confirmed recently in the United States in Florida, Texas, Illinois,and Hawaii. In each case, the infected individual traveled outside of the country and tested positive once they got home.

As we work together to prevent the spread of Zika virus, I urge you to be alert to patients, especially pregnant women, who present with symptoms of Zika virus infection and have travel history to places where Zika virus has been reported. For more information on Zika virus and the guidelines for pregnant women, click here.

Very truly yours,

Brenda Fitzgerald, M.D.

Commissioner

Additional resources: http://www.cdc.gov/zika/

http://www.cdc.gov/zika/pregnancy/index.htm

http://www.cdc.gov/zika/hc–providers/index.html

Oral health is an essential and integral component of a person’s health throughout his or her life¹ especially for school-aged children. Poor oral health and untreated infections can negatively impact the quality of life for school-aged children. Both the National Institute of Dental and Craniofacial Research and the National Education Association cite research showing American children miss 52 million hours of school each year due to oral health issues.

Strengthening the primary care delivery system, and investing in oral health disease prevention in the medical practice can contribute to improving the overall health of children, especially very young children. According to the 1999-2004 National and Nutritional Examination Survey (NHANES), approximately 42% of children ages 2 to 11 years have dental decay in their primary teeth. After decreasing from the early 1970s to the mid-1990s, the prevalence of dental decay in children has been increasing, particularly in young children ages 2 to 5 years.²

Dental decay is an infectious disease caused by a disruption in the normal balance of oral bacteria and overgrowth of cariogenic organisms (primarily Streptococcus mutans, S. sobinus, and lactobacilli) as a consequence of a diet high in carbohydrates and sugar.  Late stage interventions waste healthcare dollars and introduce significant risk to young patients requiring extensive, restorative, dental treatment, which often requires sedation in a hospital setting. To make a difference in the health of school-aged children it will take the disciplines of both the primary care providers and dental teams to reduce the burden of oral disease.

Developing a coordinated oral health care effort in Georgia between medical providers and dental providers can make a difference. The vast majority of infants and young children in Georgia see their primary care provider on a routine basis for well child care visits and immunizations. Thus, offering fluoride varnish to high risk children without access to a dental home through their medical providers can help to prevent and arrest dental decay. Evidenced-based studies indicate oral health prevention is cost-effective and saves children from pain and lost days of school.

In Georgia’s rural areas, and some urban areas, access to a dental practice often has significant barriers for children and adults.  We know oral health prevention works, but many of Georgia’s citizens with low oral health literacy lack the preventive services and proper oral home care habits to prevent diseases.  Poor oral health status exists in vulnerable populations, including diverse social and cultural backgrounds, low economic status, and low levels of education.

Many of the habits that contribute to higher levels of oral disease can be changed with support and education from medical and dental providers. While a dental practice provides an ideal dental home, when a dentist is not available the pediatric/family medical provider can fulfill the oral health care needs of their patients from a preventive approach until a dentist can be accessed and a dental home can be established. The members of the Georgia Academy of Family Physicians (GAFP) serve Medicare and Medicaid patients and could best reach these populations with oral health education and preventive fluoride varnish services for children.  Medicaid will also reimburse the fluoride varnish services provided for children.

Significant barriers to oral health services not only affect children, but adults as well. The Institute of Medicine (IOM) July 2011 report,Improving Access to Oral Health Care for Vulnerable and Underserved Populations, states that millions of Americans are not receiving dental care because of “persistent and systemic” barriers that disproportionately affect children, seniors, minorities, and other vulnerable populations.³ While cavities are the most common chronic disease for children and teenagers, older adults are at a higher risk of losing their teeth as they age. ²

Here are a few risk factors to consider when determining a patient’s need for anticipatory guidance, home care education, and fluoride varnish:

• Having decay is a risk factor for getting more decay. For example,  if a mother/caregiver has decay, more than likely the child will have decay; if a child’s siblings have had decay then the child has a higher risk for decay; and if a child has had decay in the past, then they will have a higher risk for more decay.
• Children in Women, Infants, and Children Supplemental Nutrition Program (WIC), Head Start, or Medicaid are at higher risk than are children in the general population due to lower income levels.
• Tooth location:

• For teens and adults: Decay most frequently occurs in the back teeth due to grooves and pits where plaque and food particles are most likely to collect.  View the back teeth for breaks in the enamel requiring restoration (cavitation) during a screening and assist the patient in getting an earlier referral before emergency services are needed.  Plaque and food debris in the grooves of back teeth suggests oral home care education is needed along with a referral to a dental home.

• For younger children, pre-school age, most decay begins on the top front teeth, right at the gum or gingival line.  It begins as a white decalcified area, progresses to brown, cavitates to small holes, and eventually breaks down the tooth.  If fluoride varnish is placed on the teeth in the earliest stage, the white decalcified state, and homecare instructions are given and followed, progression of the disease can be arrested, and often times reversed.

• For patients of all ages, recommend that the family monitor:

• Certain foods and drinks: Foods that cling to teeth for a long time, such as milk, ice cream, honey, table sugar, soda, raisins and other dried fruit, and sweetened desserts (dietary counseling)

• Frequent snacking or sipping: Steady snacks, sipping sweetened beverages, and sipping cups filled with fluids other than water can contribute to oral deterioration due to the constant acid exposure (dietary counseling).

• Timing and frequency of brushing: Teeth should be brushed soon after eating and drinking (oral hygiene instruction).

• Fluoride: Fluoride is a naturally occurring mineral that helps protect against cavities and can even reverse the earliest stages of tooth decay. Georgia has achieved recognition for community water fluoridation, with almost 97% of the population using community water receiving the benefits of fluoridation.  Many people with access to good tap water with fluoride, consume sweetened beverages and sports drinks instead of drinking tap water. If a patient can’t brush during the day – instruct them to swish with fluoridated water and swallow at night (preventive strategies and dietary).

• Dry mouth: Lack of saliva due to certain medications can reduce the buffering effect of saliva and natural protection against the acid manufactured by decay-producing bacteria. To counteract dry mouth, patients can use a fluoridated toothpaste and drink and swish with water often (education on pharmaceutical use).

• Gastroesophageal reflux disease (GERD) can erode teeth and contribute to significant tooth damage. Patients can use medication to control their acid reflux and its effects on their teeth (preventive services and prescriptions).

Fluoride Varnish for Infants and Children

• Why the recommendation for the first dental visit at age 1 year?  Fluoride varnish can reduce the primary maternal dental flora in the infant’s mouth (mother’s or caregiver’s transmission of bacteria to infant’s mouth), during eruption of the primary dentition. A multi-faceted approach includes ensuring the woman gets referred for dental services pre-, during, and post pregnancy and that the infant receives his or her oral health exam at age one.

• What is it? Most fluoride varnishes are lacquers containing 5% sodium fluoride in a pine plant resin base. Fluoride varnish provides a highly concentrated, temporary dose of fluoride to the tooth surface. The varnish holds fluoride close to the surface of the tooth for a longer period of time compared to other concentrated fluoride products.  Unlike the low-dose fluorides available over the counter, such as fluoride toothpaste, highly concentrated fluoride products, like fluoride varnish, must be applied by a healthcare professional in Georgia.

• How does it work? The fluoride varnish becomes concentrated in the outer enamel surfaces when applied after teeth erupt into the mouth. Dental plaque and saliva act as fluoride reservoirs to enhance the remineralization process. In addition, fluorides interfere with the decay-causing bacteria colonizing on teeth and reduce their acid production; thus, slowing demineralization.⁴ 

• How long does it stay on the teeth? The fluoride hardens on the tooth as soon as it comes into contact with saliva, allowing the high concentration of fluoride to be in contact with tooth enamel for an extended period of time, about one to seven days.

• Is it easy to apply? Varnish application is quick and easy. Inadvertent ingestion is also less likely, making it helpful for application with infants, toddlers, developmentally disabled individuals, or people with severe gag reflexes.

• The recommendations: The CDC (2001) and ADA (2006) recommend at least biannual application, at six-month intervals, to control dental decay in primary and permanent teeth for moderate, or high, risk children.

Several studies have shown that fluoride varnish is efficacious in reducing decay in the primary teeth of high-risk children. Varnish placement is quick and easy. Medicaid will reimburse medical practitioners for the oral health education and fluoride varnish application. Single dose fluoride varnish application packets make placement easy and efficient. By offering patients oral health guidance and fluoride varnish you can help your patients have a healthier smile.

Contact:  Carol Smith, RDH MSHA

Director of Oral Health

Georgia Department of Public Health

404-657-3138

Carol.smith@dph.ga.gov

References

1. S. Department of Health and Human Services. (2000). Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Retrieved from http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/hck1ocv.@www.surgeon.fullrpt.pdf

2. Barker, L. Dye, B., , Lewis, B. Smith, V. Tan, S., , Thornton-Evans G, et al. (2007). 1988-1994 and 1999-2004). Trends in oral health status: United Sates 1988-1994 and 1999-2004Vital Health Stat 11, (248), 1-92.

3. Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011 July 13). Retrieved from www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx

4. Fluoride Varnish: an Evidence-Based Approach Research Brief. (2007). Retrieved from http://www.kdheks.gov/ohi/download/Flvarnishpaper.pdf