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Maintaining oral health across the life span Abstract: Oral health is directly related to systemic health, yet many Americans have limited to no access to dental health professionals. Nurse practitioners are in an excellent position to fill this void by providing caries risk assessments, chemical therapy to prevent progression of caries, and appropriate patient education to prevent caries. By Rita Jablonski, PhD, CRNP, FAAN; Elizabeth Mertz, PhD, MA; John D.B. Featherstone, MSc, PhD; and Terry Fulmer, PhD, RN, FAAN
he relationship between oral health and systemic health has been well documented. Poor oral health has been associated with diabetes, coronary artery disease, and metabolic syndrome.1-5 The exact mechanisms are not truly understood but seem to be related to chronic inflammation. To support this relationship, researchers have connected inflammation of the gingival tissues, either with or without periodontal disease, to adverse outcomes in pregnancy, such as premature birth and low birthweight infants.6 Inadequate oral health negatively impacts quality of life and mortality as well.7 Despite the importance of oral health, a lack of access to dental care in the United States is a significant health
T
problem. An estimated 130 million adults and children lack dental care coverage, and 30% of the population is unable to obtain basic dental services.8,9 In a seminal report on oral health, the Surgeon General provided extensive detail on the extent of dental disease in the U.S. population and declared dental caries in children a “silent epidemic.”10 Nurse practitioners (NPs) are in a prime position to improve the oral health of their patients and to address these health disparities. Two Institute of Medicine reports advocated the use of nondental health professionals to improve oral health through assessments, patient education, and preventive care within the context of primary care settings.11,12 The purpose of this article is to provide NPs with
Keywords: caries, oral health, primary care
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Maintaining oral health across the life span
concrete information regarding caries risk assessment for children and adults, chemical therapy to prevent progression of the dental caries process, and appropriate patient education to prevent caries. ■ Glossary of select oral health terms Many NPs are unfamiliar with common dental and oral disease terms. This is most likely due to a lack of oral health education in graduate curricula. This is not a problem unique to NPs, as oral health information is nearly nonexistent in graduate nondental programs.13,14 NPs may find the following terms and explanations helpful. Anatomy of a tooth. An excellent picture of the inside of a tooth is available at www.allthingsstemcell.com/tag/ mesenchymal/. The outside of the tooth, the part visible during oral exams, is composed of enamel. Enamel may become yellow with age because of chronic staining and also because enamel becomes thinner with age; the darker dentin becomes visible through the thinning enamel. Dentin is a calcified tissue that is denser than bone. Dentin forms below the enamel. While normally yellow, it can present as gray to black.15 Dentin protects the innermost part of the tooth, the pulp. The pulp contains nerves, blood vessels, and connective tissue all contained within the pulp chamber in the center of the tooth structure.16 The blood vessels and nerves exit the tooth via canals that extend into the roots, or apex, of the tooth. The tooth is anchored by a tissue called cementum, which covers the dentin under the gingival tissue.17 Cementum attaches to the periodontal ligament, which in turns attaches to the alveolar bone lining the upper and lower jaws. Dental plaque is a collection of microorganisms that form a biofilm and adhere to tooth surfaces, although it can also form on dentures.18,19 In healthy mouths, the microorganisms forming dental plaque exist in a homeostatic state, much like the microflora found in the gastrointestinal tract. In individuals who consume high quantities of simple sug-
Caries are cavitations in tooth enamel as a result of acid produced by bacteria interacting with carbohydrates. In small children, cavities usually occur initially in the upper incisors because these teeth erupt the earliest and are not protected by saliva.21 In older adults, caries are more likely to form around earlier restorations or on the roots of teeth because of gingival recession.22 Gingivitis. The part of the gum that abuts teeth is the gingiva. When oral hygiene is insufficient, dental plaque accumulates in the gingival margin creating an inflammatory lesion in the gingiva known as gingivitis.23 Gingivitis is a sign that periodontal disease is a risk; gingivitis does not actually become periodontal disease. Inflammation of the gingiva, however, causes the vasculature in and around the teeth to dilate and proliferate. This provides better opportunities for bacteria to access systemic circulation.24 Periodontitis is the destruction of periodontal fibers and alveolar bone, which ultimately leads to tooth loss. The extent of periodontitis is affected by the amount of bacteria in the oral cavity, the composition of these bacteria in the plaque, the existence of comorbid illnesses such as diabetes, and lifestyle factors, such as tobacco and alcohol use.23 Chronic periodontitis, like gingivitis, causes the vasculature in and around the teeth to dilate and proliferate and then provides additional routes for bacteria to invade the systemic circulation.24
■ Persons at risk for poor oral health The populations with high rates of dental disease and problems accessing dental care include, but are not limited to, rural, low-income, minority, developmentally disabled, older adults, institutionalized populations, as well as pregnant women and homeless individuals.12 Rural populations, which tend to have higher poverty rates and longer travel distances as key barriers to oral healthcare, have lower utilization of care and higher rates of dental disease.25 Black patients are at the highest risk of periodontitis, tooth loss, gingivitis, abscesses, xerostomia, and soft tissue lesions Poor oral health has been associated because this population has the highest with diabetes, coronary artery disease, incidence of diabetes relative to any and metabolic syndrome. other racial or ethnic group.26 Twice as many Hispanic children are likely to have untreated dental caries compared with non-Hispanic White children. Mexican children are ars, the presence of fermentable sugar encourages the growth less likely to have ever visited a dentist compared with Puerof streptococcus mutans and lactobacilli in the plaque. These to Rican, Central, and South American, Cuban, and other bacteria create acid as they metabolize the simple sugars in Hispanics.27 the oral cavity.18 The acid production can erode tooth enamel and cause pits and grooves in the enamel, known as denFurthermore, the growing older adult population in the tal caries. Dental plaque can also harbor other pathogens, United States poses many challenges to oral health, even such as those associated with pneumonia.20 more significant in light of a study, which found 58.3% of
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Maintaining oral health across the life span
American Indian older adults were totally edentulous.28 are continually being improved so that specific protocols Dependent individuals in institutional settings, a growing will need to be generic and capable of continual update segment of the U.S. population, are rarely served by the without changing the basic premises. cambra uses a traditional dental care system and present a number of simple caries risk assessment tool to determine whether unique challenges including comorbidities or special needs, a patient is at low, moderate, high, or extreme risk. (See which dental professionals are often unprepared to deal Caries risk assessment form: Age 6 to adulthood and Caries with.29 risk assessment tool up to age 5.) The risk level determines the therapy, with additional intensity and additional Early childhood caries (ECC) is an infectious and products being added as the risk increases. The chemical chronic disease that results in tooth destruction in children therapy is then used by the patient at the same time as up to age 5.21 ECC affects up to 50% of children in low socioeconomic communities.21 Dental caries is not a condition affecting only children but ultimately impacts over NPs play a major role in caries risk 95% of all adults at some point in their assessment and chemical therapy to life.30 Destructive periodontal disease prevent the progression of the dental caries. is similarly progressive, affecting 52% of adults over age 60.31 Periodontal disease is associated with respiratory and any necessary restorative work is being done. The aim is cardiovascular disease.32,33 Dental diseases are preventable, to bring every patient to low risk and to maintain the yet, when left unchecked, can progress to cause tooth dehealth of their teeth indefinitely via simple chemical struction, pain, infection, and, in some cases, death.34,35 therapy.41,42,44 NPs are particularly well suited to deliver preventive dental care. Patients often seek help for dental problems Dental Caries Mechanism as a basis for cambra–The within the medical system where NPs provide primary care, caries balance health promotion, and disease prevention.36,37 NPs are poised As discussed earlier, acid-producing bacteria that are incorporated into the biofilm (plaque) on the teeth produce to provide interventions to improve oral health from inacid when they ferment carbohydrates. This acid travels into structing patients on proper oral hygiene techniques, to the tooth and dissolves the mineral component of enamel applying fluoride varnishes and prescribing fluoride gels.34 or dentin. If this process is not reversed, a cavity results.45 The body has a complex defense mechanism against caries ■ Caries Management by Risk Assessment progression that relies upon saliva and its many compoNPs can play a major role in regards to areas of caries risk nents. There are proteins and lipids in saliva that protect the assessment and the provision of chemical therapy to prevent tooth and, most important, calcium and phosphate that the progression of the dental caries process, coupled with replace lost mineral from the tooth and repair early lesions referral to dentists for any necessary restorative work, such by remineralization. as fillings. One such proposed paradigm is Caries ManageDental caries is a multifactorial disease that is best ment by Risk Assessment (cambra). cambra is the result understood as a balance between pathologic factors and of dental research scientists translating their findings into preventive factors.45,46 The pathologic factors are cariesevidence-based tools for clinical practice.38,39 The cambra 40-42 protocol was pioneered at UCSF School of Dentistry. inducing bacteria that produce acid by fermenting carbohydrates (numerous species involved), frequent (numerous “cambra provides an evidence-based methodology to assess times per day) ingestion of fermentable carbohydrates, and caries disease indicators and risk factors on an individual salivary dysfunction caused systemically or by therapy, such basis. Results are the basis for an individualized treatment as radiation or hyposalivatory medications. The protective plan, which include behavioral, chemical, and minimallyfactors include adequate salivary function and amount, invasive restorative procedures that are most appropriate remineralization of partially dissolved tooth mineral, refor the individual patient.”43 Implementing this protocol quiring fluoride, calcium/phosphate, and extrinsic antibacfor dental practitioners requires a paradigm shift in the terial therapy, such as chlorhexidine, sodium hypochlorite, practitioners’ management of dental disease–moving away and others in development. The basic idea of cambra is to from a restorative mindset toward a focus on risk-based, assess the risk, using the caries balance idea as a basis, to patient-centered disease management. then alter the risk and provide stability into the future. The cambra is a philosophy rather than a proprietary, more the pathologic factors outweigh the protective factors, step-by-step system.43 The therapeutic products available www.tnpj.com
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Maintaining oral health across the life span
Caries risk assessment form: Age 6 to adulthood Patient name:______________________________________ Assessment date:____________
Chart #:______________________________________
Date:________
Is this (please circle) baseline or recall
Disease indicators (any one YES signifies likely “high risk” and to do a bacteria test**)
YES = CIRCLE
Cavities/radiograph to dentin
YES
Approximal enamel lesions (E1, E2) (by radiograph)
YES
White spots on smooth surfaces (Eo)
YES
Restorations last 3 years
YES
YES = CIRCLE
Risk factors (biological predisposing factors)
YES
MS and LB both medium or high (by culture**)
YES
Visible heavy plaque on teeth
YES
Frequent snack (>3x daily between meals)
YES
Deep pits and fissures
YES
Recreational drug use
YES
Inadequate saliva flow by observation or measurement (**If measured note the flow rate below)
YES
Saliva-reducing factors (medications/radiation/systemic)
YES
Exposed roots
YES
Orthodontic appliances
YES
YES = CIRCLE
Protective factors Lives/work/school fluoridated community
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouthrinse (0.05% NaF) daily
YES
Fluoride toothpaste daily (5,000 ppm F)
YES
Fluoride varnish in last 6 months
YES
Office F topical in last 6 months
YES
Chlorhexidine prescribed/used 1 week each of last 6 months
YES
Xylitol gum/lozenges 4x daily last 6 months
YES
Calcium and phosphate paste during last 6 months
YES
Adequate saliva flow (>1 mL/min stimulated)
YES
**Bacteria/saliva test results: MS:
LB:
Flow rate:
mL/min. Date:
Visualize caries balance (Use circled indicators/factors above) (Extreme risk = high risk + severe xerostomia) Caries risk assessment (circle): Extreme high
Moderate
Low
From: Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-713. Reprinted with permission from the Journal of the California Dental Association.
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Maintaining oral health across the life span
Caries risk assessment tool up to age 5 Patient name:________________________________________
I.D. # ______________ Age ___________
Date_____________
Initial/baseline exam date______________________________Recall/POE date_____________ Respond to each question in sections 1, 2, 3, and 4 with a check mark in the yes or no column
Yes
No
Notes
1. Caries risk indicators–Parent interview** (a) Mother or primary caregiver has had active dental decay in the last 12 months (b) Child has recent dental restorations (see 5b below) (c) Parent and/or caregiver has low SES (socioeconomic status) and/or low health literacy (d) Child has developmental problems (e) No dental home/episodic dental care 2. Caries risk factors (biological)–Parent interview** (a) Child has frequent (greater than three times daily) between-meal snacks of sugars/ cooked starch/sugared beverages (b) Child has saliva-reducing factors present, including: 1. medications (for example, some for asthma or hyperactivity) 2. medical (cancer treatment) or genetic factors (c) Child continually uses bottle–contains fluids other than water (d) Child sleeps with a bottle, or nurses on demand 3. Protective factors (nonbiological)–Parent interview (a) Mother/caregiver decay-free last 3 years (b) Child has a dental home and regular dental care 4. Protective factors (biological)–Parent interview (a) Child lives in a fluoridated community or takes fluoride supplements by slowly dissolving or as chewable tablets (b) Child’s teeth are cleaned with fluoridated toothpaste (pea size) daily (c) Mother/caregiver chews/sucks xylitol chewing gum/lozenges 2-4x daily 5. Caries risk indicators/factors–Clinical exam of child** (a) Obvious white spots, decalcifications, or obvious decay present on the child’s teeth (b) Restorations placed in the last 2 years in/on child’s teeth (c) Plaque is obvious on the child’s teeth and/or gums bleed easily (d) Child has dental or orthodontic appliances present, fixed, or removable: (for example, braces, space maintainers, obturators) (e) Risk factor: Visually inadequate saliva flow–Dry mouth **If yes to any one of 1(a), 1(b), 5(a), or 5(b) or any two in categories 1, 2, 5, consider performing bacterial culture on mother or caregiver and child. Use this as a baseline to follow results of antibacterial intervention.
Parent/ caregiver Date:
Child Date:
Low
High
(a) Mutans streptococci (Indicate bacterial level: High, Medium, Low) (b) Lactobacillus species (Indicate bacterial level: High, Medium, Low) Child’s overall caries risk status: (CIRCLE) Recommendations given: yes______ no: ________
Date given:______________ or
Moderate
Date follow up:_______
Reprinted from: Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, Featherstone JD. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc. 2007;35(10):689-702. Reprinted with permission from the Journal of the California Dental Association.
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Maintaining oral health across the life span
daily with an over-the-counter fluoride-containing toothpaste. In addition, prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for one 7-day period each month. For the remaining 3 weeks, have the patient rinse twice daily with over-the-counter sodium fluoride products containing 0.05% sodium fluoride after brushing. This regimen should be repeated monthly for 6 months, and the patient should be reevaluated after that period for caries risk improvement. 3. High risk: Apply fluoride varnish at the initial visit, and every visit thereafter, until risk status is reduced. An excellent video demonstrating the correct application of fluoride varnish is available at www.smilesforlifeoralhealth.com. Prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for 1 week monthly, to be repeated every month. Prescribe 5,000 ppm fluoride toothpaste to be used twice daily. Instruct the patient to brush first prior to using the mouthrinse. Have the patient return to the clinic in 4 months for a reevaluation of caries risk. 4. Extreme risk: This category is high risk plus salivary dysfunction (hyposalivation). Follow the same protocol for high-risk patients, and instruct patients to sip from a water bottle with one teaspoon of baking soda added for pH control. Chlorhexidine gluconate rinse can discolor teeth if used without brushing.20,50 Exposed dentin will become discolored first followed by the enamel.51 Restorative surfaces, such as ceramic crowns, can also become discolored.51 Discoloration is usually detected in patients who undergo periodontal surgery and cannot brush due to sutures or concerns over tissue disruption. Because this protocol involves using the chlorhexidine rinse for a 1-week period (monthly), and Dental caries is a multifactorial disease tooth brushing is not suspended, the that is best understood as a balance between risk of discoloration is negated. Prodpathologic factors and preventive factors. ucts containing essential oils (such as menthol, thymol, and eucalyptol) and antistaining ingredients may be alter51,52 natively prescribed. • Provide the patient with written instructions, dispense products, and use motivational interviewing to improve The application of fluoride varnish is a safe practice. adherence.48 The amount of varnish used is extremely small, and accidental ingestion during the application process does • Refer to general or pediatric dentist for necessary restornot create any risks from fluoride overdose. 21 Dental ative work. • Plan follow-up, recall, and new risk assessment according fluorosis is a potential adverse reaction from the use of to the level of risk. High-risk patients should be recalled fluoride-containing products. Dental fluorosis is the after about 4 months. alteration of tooth enamel that ranges from nearly indisTherapeutic Agents by Caries Risk Level (ages 6 years cernible fine, white, lacy webs or pits to pronounced through adult)41,49: roughened surfaces. 53 Dental fluorosis results from 1. Low risk: Two times (or more) daily brushing with an overingestion of fluoride while the enamel is being formed over-the-counter fluoride-containing toothpaste. below the gingival surface. It can only occur in children 8 2. Moderate risk: Advise the patient to brush at least twice years of age or younger. Dental fluorosis can be prevented the higher the risk of caries. In other words, therapy requires lowering the bacterial challenge while increasing the effect of the protective factors in order to enhance remineralization. This guiding principle underpins chemical therapy and is right in the realm of the NP’s activity.41,42 The simple steps for the cambra approach for patients ages 6 years through adult are as follows: • Obtain a medical and dental history to determine several of the risk factors and disease indicators, such as hyposalivatory medications and prior dental restorations. • Perform a clinical exam to identify carious lesions, which range from precavitated demineralization to open cavities. Early demineralization appears as enamel defects, such as white lines near the gingival margins.21 As the enamel is eroded by bacterial acid, yellow spots can appear as the underlying dentin is exposed. Cavitations appear as pits, which can enlarge and open directly onto the dentin so that teeth appear to have dark centers.21 Excellent pictures of demineralization and caries can be found in the Smiles for Life Curriculum available at www.smilesforlifeoral health.com (located in modules two and three). • Complete the caries risk assessment form using items from 1 and 2 above plus additional questions.42 The form was recently validated in a retrospective study of over 12,000 patients.47 Using the form, NPs can identify disease indicators, pathologic risk factors, and preventive factors and determine the level of caries risk: low, moderate, high, or extreme. • Determine a treatment plan, including chemical therapy, based upon the caries risk level.
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by using pea-sized amounts of fluoridated toothpaste (discussed below); adult supervision to prevent ingestion of fluoride-containing products by children younger than 6 years of age; and avoidance of fluoride rinses in children under the age of 6.53
and flossing scary. One researcher found that persons with dementia who resisted mouth care were reacting out of fear and perceived threat to their bodily integrity.54,55 Mouth care fear can be overcome in these individuals through a variety of simple strategies. For example, having the caregiver brush his or her teeth alongside the individual with cognitive limitations may reduce care-resistant behaviors. Other techniques include the use of pantomime, gestures, and distractions.54
■ Caries prevention: Oral hygiene The majority of oral health problems can be controlled with simple oral hygiene education, especially when the risk level has been lowered as described above. Unfortunately, simple oral hygiene will not control dental caries in ■ Implications for practice moderate- and high-risk individuals, necessitating the NPs’ scope of practice and reimbursement capacity for protocols discussed above. different services varies by state and across funding sources.56 NPs can educate parents about the importance of caries As primary care providers, NPs can provide oral health prevention, which should begin as soon as any teeth appear. screening, oral health education, and oral healthcare referTeeth should be gently cleansed, as soon as they erupt in rals. (See Patient handout for caries.) Providing these services babies, after eating via a soft cloth or soft pediatric toothbrush.21 Placing baPersons with dementia who resisted mouth bies to bed with bottles and sippy cups that include juice, honey, milk, or care were reacting out of fear and perceived sweetened beverages should be avoided threat to their bodily integrity. completely. If necessary, the bottles and sippy cups should contain only water. Sweet drinks, such as soda and sweetened fruit drinks, should be avoided—not only because of is not a legal scope of practice question but rather a question the development of caries, but for health reasons. Parents of training, standards of care, and reimbursement. Nursing should encourage the consumption of fresh fruits in lieu of education does not often provide training on oral health as fruit juices. a core component of overall healthcare or best practices in Brushing and flossing are important skills to instill in techniques for oral healthcare assessments. There is an small children and to reinforce throughout the life span. acknowledged need to increase primary healthcare providSoft toothbrushes are preferable in order to prevent ers’ knowledge of the etiology of caries, particularly in inadvertent enamel abrasions. Young children should be relation to infants, children, and also in the context of adults supervised by parents until around age 6, using smaller or patients with multiple comorbidities.57 amounts of toothpaste on the brush (a smear for babies and The dental reimbursement system has traditionally a pea-sized amount for toddlers).21,44 Alcohol-free fluoride been separate from medical care reimbursement, creating an additional barrier for NPs to bring these services into rinses should also be encouraged after age 6. Flossing does their practices. Increasingly, preventive oral health intervennot have to involve string floss. Proximal or interdental tions such as fluoride varnish, oral exams or screenings, brushes are viable alternatives. These brushes can be singleanticipatory guidance, or oral health risk assessment (such use disposables, which look like plastic toothpicks with as cambra) are being provided by nondental healthcare spiral brushes. Multiple-use brushes look like standard providers in hopes that early intervention can prevent futoothbrushes with a spiral brush on the end. The spiral ture disease.58 In 2009, 40 states allowed medical primary brush is placed between the teeth to remove debris. The parent can use the interdental brush initially, teaching the care providers, including NPs, to receive reimbursement child to use it until he or she becomes more adept. from Medicaid for providing preventive oral healthcare Oral hygiene remains important throughout adultservices.58 The requirements for reimbursement vary by hood. The use of proximal brushes can be suggested to state; some states require services to be provided together, adults as well, who may find them easier to use than tradiand others require a certification course in risk assessment, tional string floss. Some adults prefer floss heads, which intervention, education, and referral in order to qualify.58 can be mounted onto toothbrush handles. Individuals with Changing reimbursement mechanisms are also increasing cognitive limitations, such as those with dementia or with the potential for more oral health services to be provided delayed intellectual development, may find tooth brushing as part of primary care.59 www.tnpj.com
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Maintaining oral health across the life span
■ Putting it all together: The NYU Nursing-Dental Model Exemplar New York University provides a creative example of how previously disparate disciplines came together to address oral healthcare and related interdisciplinary teaching, research, and practice. In 2005, New York University’s College of Nursing and College of Dentistry formed one
academic unit in order to create new synergies in research, teaching, and practice. The Nursing and Dentistry faculty collaborated on papers related to the workforce, oral health education and practice advances, and ways the two disciplines could come together to screen for diabetes, human immunodeficiency virus, hypertension, and chronic diseases, which may have previously been
Patient handout for caries HOW TOOTH DECAY HAPPENS (to be given to each patient) Tooth decay is caused by certain types of bacteria (mutans streptococci and lactobacilli) that live in your mouth. When they attach themselves to the teeth and multiply in dental plaque, they can do damage. The bacteria feed on what you eat, especially sugars (including fruit sugars) and cooked starch (bread, potatoes, rice, pasta, and the like). Within just a few minutes after you eat or drink, the bacteria begin producing acids as by-products of digestion. Those acids can penetrate into the hard substance of the tooth and dissolve some of the minerals (calcium and phosphate). If the acid attacks are infrequent and of short duration, your saliva can help to repair the damage by neutralizing the acids and supplying minerals and fluoride that can replace those lost from the tooth. However, if: 1) your mouth is dry, 2) you have many of these bacteria, or 3) you snack frequently, then the tooth mineral lost by attacks of acids is too great, and cannot be repaired. This is the start of tooth decay and leads to cavities. CONTROLLING TOOTH DECAY Diet: Reducing the number of sugary and starchy foods, snacks, drinks, or candies can help reduce the development of tooth decay. That does not mean you can never eat these types of foods, but you should limit their consumption particularly when eaten between main meals. A good rule is three meals per day and no more than three snacks per day. Fluorides: Fluorides help to make the tooth more resistant to being dissolved by the bacterial acids. Fluorides are available from a variety of sources, such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist such as brush-on gels or high-fluoride toothpastes used at home, or gels, foams, and varnishes applied in the dental office. Daily use is very important to help protect against the acid attacks.
Plaque removal: Removing the plaque from your teeth on a daily basis is helpful in controlling tooth decay. Plaque can be difficult to remove from some parts of your mouth especially between the teeth and in grooves on the biting surfaces of back teeth. If you have an appliance such as an orthodontic retainer or partial denture, remove it before brushing your teeth. Brush all surfaces of the appliance also. Saliva: Saliva is critical for controlling tooth decay. It neutralizes acids, and provides minerals and proteins that protect the teeth. If you cannot brush after a meal or snack, you can chew some sugar-free gum. This will stimulate the flow of saliva to help neutralize acids and bring lost minerals back to the teeth. Sugar-free candy or mints could also be used, but some of these contain acids themselves. These acids will not cause tooth decay, but they can slowly dissolve the enamel surface directly over time (a process called erosion). Some sugar-free gums are designed to help fight tooth decay and are particularly useful if you have a dry mouth (many medications can cause a dry mouth). Some gums contain baking soda that neutralizes the acids produced by the bacteria in plaque. Gum that contains xylitol as its first listed ingredient is the gum of choice. If you have a dry mouth, you could also fill a drinking bottle with water and add a couple teaspoons of baking soda for each 8 oz of water and swish and spit with it frequently throughout the day. Toothpastes containing baking soda are also available by several companies. Antibacterial mouth rinses: Rinses that your dentist can prescribe are able to reduce the numbers of bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay. Sealants: Sealants are plastic or glass ionomer coatings bonded to the biting surfaces of back teeth to protect the deep grooves from decay. In some people the grooves on the surfaces of the teeth are too narrow and deep to clean with a toothbrush, so they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for children and young adults at risk for this type of decay. They do not last forever and should be inspected once a year and replaced if needed.
Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10): 703-713. Reprinted with permission from the Journal of the California Dental Association.
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Maintaining oral health across the life span
overlooked during the dental encounter.60-68 From the perspective of the nursing faculty, oral health assessment had been underappreciated in the discipline as a critical way of addressing the oral-systemic connection and the essential nature of oral health assessment to help identify early symptoms that might indicate cardiac disease or cancer, for example.69 An innovative practice model was developed in which the college of nursing created a faculty practice that was colocated in the dental school where over 325,000 patient visits are completed annually. With over 1,800 patient visits a day, the Dental and Nursing faculty agreed that they would offer each patient, as appropriate, the opportunity to be seen by an NP during their dental visit. This activity has spawned a great deal of enthusiasm in the faculty and the patients whom they serve. Clearly, these are creative, synergistic, and valuable opportunities. ■ Promoting oral health NPs can promote the systemic health of their patients by addressing oral health. One contribution NPs can make is in the area of caries risk assessment and management. This is an area that NPs may not feel comfortable addressing. There are many resources available that NPs can access: • The American Association of Pediatricians provides a set of oral health tools for use by anyone with pediatric patients: www2.aap.org/commpeds/dochs/oralhealth/ PracticeTools.html. • The American Academy of Pediatrics Oral health Section tracks reimbursement for oral health activities, including the application of fluoride varnish: http://www2.aap.org/ commpeds/dochs/oralhealth/State.html. The Smiles for Life Curriculum is comprised of eight modules that explore oral health issues among the life span. Clinicians can register to receive free continuingeducation credit associated with each module at: www. smilesforlifeoralhealth.com. A 30-minute video that demonstrates methods to provide mouth care to individuals with dementia who resist care can be accessed via the Portals of Geriatric Online Education (www.pogoe.org). The video is titled Oral Hygiene & Care-Resistant Behaviors: Making a Difference. In order to locate and view the video, users must register (at no charge) and type the product identifier 20998 in the search box.
3. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis. Diabetes Care. 2010;33(2):421-427. 4. Kurihara N, Inoue Y, Iwai T, et al. Oral bacteria are a possible risk factor for valvular incompetence in primary varicose veins. Eur J Vasc Endovasc Surg. 2007;34(1):102-106. 5. Tremblay M, Gaudet D, Brisson D. Metabolic syndrome and oral markers of cardiometabolic risk. J Can Dent Assoc. 2011;77:b125. 6. Han YW. Oral health and adverse pregnancy outcomes—what’s next? Journal of Dental Research. 2011;90(3):289-293. 7. Padilha DM, Hilgert JB, Hugo FN, Bós AJ, Ferrucci L. Number of teeth and mortality risk in the Baltimore Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci. 2008;63(7):739-744. 8. Brown LJ. Adequacy of Current and Future Dental Workforce: Theory and Analysis. Chicago: American Dental Association; 2005. 9. Manski R, Brown L. Dental Coverage of Adults Ages 21-64, United States, 1997 and 2007. Statistical Brief 295. Rockville, MD: Agency for Healthcare Research and Quality; 2010. 10. 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; 2000. 11. Institute of Medicine. Advancing Oral Health in America. Washington, DC: The National Academies Press; 2011. 12. Institute of Medicine. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Washington, DC: National Academies Press; 2011. 13. Hein C, Schönwetter DJ, Iacopino AM. Inclusion of oral-systemic health in predoctoral/undergraduate curricula of pharmacy, nursing, and medical schools around the world: a preliminary study. J Dent Educ. 2011;75(9):11871199. 14. Nursing NCo. NYUCN Launches Oral Health Nursing Education Program. 2011. http://www.nyu.edu/about/news-publications/news/2011/04/26/nyucnlaunches-oral-health-nursing-education-and-practice-program.html. 15. Watson S. Dentin. Health: Dental Care; 2010. http://dentistry.about.com/od/ termsanddefinitions/g/dentin.htm. 16. Watson S. Tooth Pulp. Health: Dental Care; 2009. http://dentistry.about.com/ od/dentaltermsp/g/pulp.htm. 17. Healthnews.Org. Cementum. http://www.dentalfind.com/info/cementum. 18. Marsh PD. Dental plaque as a biofilm and a microbial community— implications for health and disease. BMC Oral Health. 2006;6(suppl 1):S14. 19. Felton D, Cooper L, Duqum I, et al. Evidence-based guidelines for the care and maintenance of complete dentures: a publication of the American College of Prosthodontists. J Am Dent Assoc. 2011;142(suppl 1):1S-20S. 20. Hutchins K, Karras G, Erwin J, Sullivan KL. Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control. 2009;37(7):590-597. 21. Clark MB, Douglass AB, Maier R, et al. Smiles for Life: A National Oral Health Curriculum. 2010. 3rd:www.smilesforlifeoralhealth.com. 22. Shay K, Ship JA. The importance of oral health in the older patient. J Am Geriatr Soc. 1995;43(12):1414-1422. 23. Gjermo PE, Grytten J. Cost-effectiveness of various treatment modalities for adult chronic periodontitis. Periodontol 2000. 2009;51:269-275. 24. Tomás I, Diz P, Tobías A, Scully C, Donos N. Periodontal health status and bacteraemia from daily oral activities: systematic review/meta-analysis. J Clin Periodontol. 2012;39(3):213-228. 25. Skillman SM, Doescher MP, Mouradian WE, Brunson DK. The challenge to delivering oral health services in rural America. J Public Health Dent. 2010;70(suppl 1):S49-S57. 26. Tomar SL, Lester A. Dental and other health care visits among U.S. adults with diabetes. Diabetes Care. 2000;23(10):1505-1510.
REFERENCES 1. Bakhshandeh S, Murtomaa H, Mofid R, Vehkalahti MM, Suomalainen K. Periodontal treatment needs of diabetic adults. J Clin Periodontol. 2007;34(1):53-57. 2. Borrell LN, Joseph SP. Periodontal treatment may control glycemic status among diabetic patients. J Evid Based Dent Pract. 2011;11(2):92-94.
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27. Ramos-Gomez F, Cruz GD, Watson MR, Canto MT, Boneta AE. Latino oral health: a research agenda toward eliminating oral health disparities. J Am Dent Assoc. 2005;136(9):1231-1240. 28. Phipps KR, Reifel N, Bothwell E. The oral health status, treatment needs, and dental utilization patterns of Native American elders. J Public Health Dent. 1991;51(4):228-233.
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Maintaining oral health across the life span
29. Glassman P, Subar P. Creating and maintaining oral health for dependent people in institutional settings. J Public Health Dent. 2010;70(suppl 1):S40-S48. 30. Dye BA, Tan S, Smith V, et al. Trends in Oral Heath Status: United States, 19881994 and 1999-2004. Hyattsville, MD: National Center for Health Statistics, United States Department of Health and Human Services; 2007. 31. NIDCR/CDC Dental OaCDRC. Oral Health, U.S. 2002 Annual Report: Section 3: Periodontal Disease. 2002. http://drc.hhs.gov/report/3_2.htm. 32. Blaizot A, Vergnes JN, Nuwwareh S, Amar J, Sixou M. Periodontal diseases and cardiovascular events: meta-analysis of observational studies. Int Dent J. 2009;59(4):197-209. 33. Scannapieco FA, Ho AW. Potential associations between chronic respiratory disease and periodontal disease: analysis of National Health and Nutrition Examination Survey III. J Periodontol. 2001;72(1):50-56. 34. Institute of Medicine. Advancing Oral Health In America. Washington, DC: National Academies Press; 2011. 35. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 2000. 36. Bureau of Labor Statistics. Occupational Outlook Handbook, 2010-2011 Edition: Registered Nurses. 2010. http://www.bls.gov/oco/ocos083.htm. 37. Moeller JF, Chen H, Manski RJ. Investing in preventive dental care for the Medicare population: a preliminary analysis. Am J Public Health. 2010;100(11):2262-2269. 38. Pitts N. Understanding the jigsaw of evidence-based dentistry. 3. Implementation of research findings in clinical practice. Evid Based Dent. 2004;5(3):60-64. 39. Pitts N. Understanding the jigsaw of evidence-based dentistry. 2. Dissemination of research results. Evid Based Dent. 2004;5(2):33-35. 40. Featherstone JD, White JM, Hoover CI, et al. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res. 2012;46(2):118-129. 41. Jenson L, Budenz AW, Featherstone JD, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. J Calif Dent Assoc. 2007;35(10):714-723. 42. Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-707, 710-713.
54. Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist. 2011;31(3):77-87. 55. Jablonski RA, Therrien B, Kolanowski A. No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice. Res Theory Nurs Pract. 2011;25(3):163-175. 56. Christian S, Dower C, O’Neil EH. Overview of Nurse Practitioner Scopes of Practice in the United States—Discussion. San Francisco, CA: UCSF Center for the Health Professions; 2007. 57. Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract. 2009;21(1):1-10. 58. Cantrell C. Engaging Primary Care Medical Providers in Children’s Oral Health. Washington, DC: National Academy for State Health Policy; 2009. 59. Pew Children’s Dental Campaign. Reimbursing Physicians for Fluoride Varnish: A Cost-Effective Solution to Improving Access. Washington, DC: The Pew Center on the States; 2009. 60. Spielman AI, Fulmer T, Eisenberg ES, Alfano MC. Dentistry, nursing, and medicine: a comparison of core competencies. J Dent Educ. 2005;69(11):12571271. 61. Russell SL, Mayberry LJ. Pregnancy and oral health: a review and recommendations to reduce gaps in practice and research. MCN Am J Matern Child Nurs. 2008;33(1):32-37. 62. Yost J, Li Y. Promoting oral health from birth through childhood: prevention of early childhood caries. MCN Am J Matern Child Nurs. 2008;33(1):17-23. 63. Dasanayake AP, Gennaro S, Hendricks-Muñoz KD, Chhun N. Maternal periodontal disease, pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs. 2008;33(1):45-49. 64. Gennaro S, Naidoo S, Berthold P. Oral health & HIV/AIDS. MCN Am J Matern Child Nurs. 2008;33(1):50-57. 65. Clemmens DA, Kerr AR. Improving oral health in women: nurses’ call to action. MCN Am J Matern Child Nurs. 2008;33(1):10-16. 66. VanDevanter N, Dorsen CG, Messeri P, Shelley D, Person A. Oral health care and smoking cessation practices of interprofessional home care providers for their patients with HIV. J Interprof Care. 2012;26(4):339-340.
43. Young D, Ricks CS, Featherstone JD, et al. Changing the face and practice of dentistry: a 10-year plan. J Calif Dent Assoc. 2011;39(10):746-751.
67. Hutchinson MK, VanDevanter N, Phelan J, et al. Feasibility of implementing rapid oral fluid HIV testing in an urban University Dental Clinic: a qualitative study. BMC Oral Health. 2012;12:11.
44. Ramos-Gomez FJ, Crystal YO, Ng MW, Crall JJ, Featherstone JD. Pediatric dental care: prevention and management protocols based on caries risk assessment. J Calif Dent Assoc. 2010;38(10):746-761.
68. Strauss SM, Tuthill J, Singh G, et al. A novel intraoral diabetes screening approach in periodontal patients: results of a pilot study. J Periodontol. 2012;83(6):699-706.
45. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7):887-899.
69. Fulmer T, Cabrera P. The primary care visit: what else could be happening? Nurs Res Pract. 2012;2012:720506.
46. Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent. 2006;28(2):128-132; discussion 192-128. 47. Doméjean S, White JM, Featherstone JD. Validation of the CDA CAMBRA caries risk assessment—a six-year retrospective study. J Calif Dent Assoc. 2011;39(10):709-715. 48. Peltier B, Weinstein P, Fredekind R. Risky business: influencing people to change. J Calif Dent Assoc. 2007;35(11):794-798. 49. Spolsky VW, Black BP, Jenson L. Products—old, new, and emerging. J Calif Dent Assoc. 2007;35(10):724-737. 50. Gil-Montoya JA, de Mello AL, Cardenas CB, Lopez IG. Oral health protocol for the dependent institutionalized elderly. Geriatr Nurs. 2006;27(2):95-101.
Rita Jablonski is an associate professor at the University of Alabama at Birmingham, School of Nursing, Birmingham, Ala.
Elizabeth Mertz is an assistant professor at the University of California, San Francisco, Calif.
John D.B. Featherstone is a dean and professor at the University of California, School of Dentistry, San Francisco, Calif.
51. Hofer D, Meier A, Sener B, Guggenheim B, Attin T, Schmidlin PR. Biofilm reduction and staining potential of a 0.05% chlorhexidine rinse containing essential oils. Int J Dent Hyg. 2011;9(1):60-67.
Terry Fulmer is a dean and professor at Bouvé College of Health Sciences and professor of Public Policy and Urban Affairs at Northeastern University, Boston, Mass.
52. Duss C, Lang NP, Cosyn J, Persson GR. A randomized, controlled clinical trial on the clinical, microbiological, and staining effects of a novel 0.05% chlorhexidine/herbal extract and a 0.1% chlorhexidine mouthrinse adjunct to periodontal surgery. J Clin Periodontol. 2010;37(11):988-997.
The authors have disclosed that they have no financial relationships related to this article.
53. Centers for Disease Control and Prevention. Dental Fluorosis. 2012. http:// www.cdc.gov/fluoridation/safety/dental_fluorosis.htm.
DOI-10.1097/01.NPR.0000446872.76779.56
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Maintaining oral health across the life span Abstract: Oral health is directly related to systemic health, yet many Americans have limited to no access to dental health professionals. Nurse practitioners are in an excellent position to fill this void by providing caries risk assessments, chemical therapy to prevent progression of caries, and appropriate patient education to prevent caries. By Rita Jablonski, PhD, CRNP, FAAN; Elizabeth Mertz, PhD, MA; John D.B. Featherstone, MSc, PhD; and Terry Fulmer, PhD, RN, FAAN
he relationship between oral health and systemic health has been well documented. Poor oral health has been associated with diabetes, coronary artery disease, and metabolic syndrome.1-5 The exact mechanisms are not truly understood but seem to be related to chronic inflammation. To support this relationship, researchers have connected inflammation of the gingival tissues, either with or without periodontal disease, to adverse outcomes in pregnancy, such as premature birth and low birthweight infants.6 Inadequate oral health negatively impacts quality of life and mortality as well.7 Despite the importance of oral health, a lack of access to dental care in the United States is a significant health
T
problem. An estimated 130 million adults and children lack dental care coverage, and 30% of the population is unable to obtain basic dental services.8,9 In a seminal report on oral health, the Surgeon General provided extensive detail on the extent of dental disease in the U.S. population and declared dental caries in children a “silent epidemic.”10 Nurse practitioners (NPs) are in a prime position to improve the oral health of their patients and to address these health disparities. Two Institute of Medicine reports advocated the use of nondental health professionals to improve oral health through assessments, patient education, and preventive care within the context of primary care settings.11,12 The purpose of this article is to provide NPs with
Keywords: caries, oral health, primary care
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Maintaining oral health across the life span
concrete information regarding caries risk assessment for children and adults, chemical therapy to prevent progression of the dental caries process, and appropriate patient education to prevent caries. ■ Glossary of select oral health terms Many NPs are unfamiliar with common dental and oral disease terms. This is most likely due to a lack of oral health education in graduate curricula. This is not a problem unique to NPs, as oral health information is nearly nonexistent in graduate nondental programs.13,14 NPs may find the following terms and explanations helpful. Anatomy of a tooth. An excellent picture of the inside of a tooth is available at www.allthingsstemcell.com/tag/ mesenchymal/. The outside of the tooth, the part visible during oral exams, is composed of enamel. Enamel may become yellow with age because of chronic staining and also because enamel becomes thinner with age; the darker dentin becomes visible through the thinning enamel. Dentin is a calcified tissue that is denser than bone. Dentin forms below the enamel. While normally yellow, it can present as gray to black.15 Dentin protects the innermost part of the tooth, the pulp. The pulp contains nerves, blood vessels, and connective tissue all contained within the pulp chamber in the center of the tooth structure.16 The blood vessels and nerves exit the tooth via canals that extend into the roots, or apex, of the tooth. The tooth is anchored by a tissue called cementum, which covers the dentin under the gingival tissue.17 Cementum attaches to the periodontal ligament, which in turns attaches to the alveolar bone lining the upper and lower jaws. Dental plaque is a collection of microorganisms that form a biofilm and adhere to tooth surfaces, although it can also form on dentures.18,19 In healthy mouths, the microorganisms forming dental plaque exist in a homeostatic state, much like the microflora found in the gastrointestinal tract. In individuals who consume high quantities of simple sug-
Caries are cavitations in tooth enamel as a result of acid produced by bacteria interacting with carbohydrates. In small children, cavities usually occur initially in the upper incisors because these teeth erupt the earliest and are not protected by saliva.21 In older adults, caries are more likely to form around earlier restorations or on the roots of teeth because of gingival recession.22 Gingivitis. The part of the gum that abuts teeth is the gingiva. When oral hygiene is insufficient, dental plaque accumulates in the gingival margin creating an inflammatory lesion in the gingiva known as gingivitis.23 Gingivitis is a sign that periodontal disease is a risk; gingivitis does not actually become periodontal disease. Inflammation of the gingiva, however, causes the vasculature in and around the teeth to dilate and proliferate. This provides better opportunities for bacteria to access systemic circulation.24 Periodontitis is the destruction of periodontal fibers and alveolar bone, which ultimately leads to tooth loss. The extent of periodontitis is affected by the amount of bacteria in the oral cavity, the composition of these bacteria in the plaque, the existence of comorbid illnesses such as diabetes, and lifestyle factors, such as tobacco and alcohol use.23 Chronic periodontitis, like gingivitis, causes the vasculature in and around the teeth to dilate and proliferate and then provides additional routes for bacteria to invade the systemic circulation.24
■ Persons at risk for poor oral health The populations with high rates of dental disease and problems accessing dental care include, but are not limited to, rural, low-income, minority, developmentally disabled, older adults, institutionalized populations, as well as pregnant women and homeless individuals.12 Rural populations, which tend to have higher poverty rates and longer travel distances as key barriers to oral healthcare, have lower utilization of care and higher rates of dental disease.25 Black patients are at the highest risk of periodontitis, tooth loss, gingivitis, abscesses, xerostomia, and soft tissue lesions Poor oral health has been associated because this population has the highest with diabetes, coronary artery disease, incidence of diabetes relative to any and metabolic syndrome. other racial or ethnic group.26 Twice as many Hispanic children are likely to have untreated dental caries compared with non-Hispanic White children. Mexican children are ars, the presence of fermentable sugar encourages the growth less likely to have ever visited a dentist compared with Puerof streptococcus mutans and lactobacilli in the plaque. These to Rican, Central, and South American, Cuban, and other bacteria create acid as they metabolize the simple sugars in Hispanics.27 the oral cavity.18 The acid production can erode tooth enamel and cause pits and grooves in the enamel, known as denFurthermore, the growing older adult population in the tal caries. Dental plaque can also harbor other pathogens, United States poses many challenges to oral health, even such as those associated with pneumonia.20 more significant in light of a study, which found 58.3% of
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Maintaining oral health across the life span
American Indian older adults were totally edentulous.28 are continually being improved so that specific protocols Dependent individuals in institutional settings, a growing will need to be generic and capable of continual update segment of the U.S. population, are rarely served by the without changing the basic premises. cambra uses a traditional dental care system and present a number of simple caries risk assessment tool to determine whether unique challenges including comorbidities or special needs, a patient is at low, moderate, high, or extreme risk. (See which dental professionals are often unprepared to deal Caries risk assessment form: Age 6 to adulthood and Caries with.29 risk assessment tool up to age 5.) The risk level determines the therapy, with additional intensity and additional Early childhood caries (ECC) is an infectious and products being added as the risk increases. The chemical chronic disease that results in tooth destruction in children therapy is then used by the patient at the same time as up to age 5.21 ECC affects up to 50% of children in low socioeconomic communities.21 Dental caries is not a condition affecting only children but ultimately impacts over NPs play a major role in caries risk 95% of all adults at some point in their assessment and chemical therapy to life.30 Destructive periodontal disease prevent the progression of the dental caries. is similarly progressive, affecting 52% of adults over age 60.31 Periodontal disease is associated with respiratory and any necessary restorative work is being done. The aim is cardiovascular disease.32,33 Dental diseases are preventable, to bring every patient to low risk and to maintain the yet, when left unchecked, can progress to cause tooth dehealth of their teeth indefinitely via simple chemical struction, pain, infection, and, in some cases, death.34,35 therapy.41,42,44 NPs are particularly well suited to deliver preventive dental care. Patients often seek help for dental problems Dental Caries Mechanism as a basis for cambra–The within the medical system where NPs provide primary care, caries balance health promotion, and disease prevention.36,37 NPs are poised As discussed earlier, acid-producing bacteria that are incorporated into the biofilm (plaque) on the teeth produce to provide interventions to improve oral health from inacid when they ferment carbohydrates. This acid travels into structing patients on proper oral hygiene techniques, to the tooth and dissolves the mineral component of enamel applying fluoride varnishes and prescribing fluoride gels.34 or dentin. If this process is not reversed, a cavity results.45 The body has a complex defense mechanism against caries ■ Caries Management by Risk Assessment progression that relies upon saliva and its many compoNPs can play a major role in regards to areas of caries risk nents. There are proteins and lipids in saliva that protect the assessment and the provision of chemical therapy to prevent tooth and, most important, calcium and phosphate that the progression of the dental caries process, coupled with replace lost mineral from the tooth and repair early lesions referral to dentists for any necessary restorative work, such by remineralization. as fillings. One such proposed paradigm is Caries ManageDental caries is a multifactorial disease that is best ment by Risk Assessment (cambra). cambra is the result understood as a balance between pathologic factors and of dental research scientists translating their findings into preventive factors.45,46 The pathologic factors are cariesevidence-based tools for clinical practice.38,39 The cambra 40-42 protocol was pioneered at UCSF School of Dentistry. inducing bacteria that produce acid by fermenting carbohydrates (numerous species involved), frequent (numerous “cambra provides an evidence-based methodology to assess times per day) ingestion of fermentable carbohydrates, and caries disease indicators and risk factors on an individual salivary dysfunction caused systemically or by therapy, such basis. Results are the basis for an individualized treatment as radiation or hyposalivatory medications. The protective plan, which include behavioral, chemical, and minimallyfactors include adequate salivary function and amount, invasive restorative procedures that are most appropriate remineralization of partially dissolved tooth mineral, refor the individual patient.”43 Implementing this protocol quiring fluoride, calcium/phosphate, and extrinsic antibacfor dental practitioners requires a paradigm shift in the terial therapy, such as chlorhexidine, sodium hypochlorite, practitioners’ management of dental disease–moving away and others in development. The basic idea of cambra is to from a restorative mindset toward a focus on risk-based, assess the risk, using the caries balance idea as a basis, to patient-centered disease management. then alter the risk and provide stability into the future. The cambra is a philosophy rather than a proprietary, more the pathologic factors outweigh the protective factors, step-by-step system.43 The therapeutic products available www.tnpj.com
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Maintaining oral health across the life span
Caries risk assessment form: Age 6 to adulthood Patient name:______________________________________ Assessment date:____________
Chart #:______________________________________
Date:________
Is this (please circle) baseline or recall
Disease indicators (any one YES signifies likely “high risk” and to do a bacteria test**)
YES = CIRCLE
Cavities/radiograph to dentin
YES
Approximal enamel lesions (E1, E2) (by radiograph)
YES
White spots on smooth surfaces (Eo)
YES
Restorations last 3 years
YES
YES = CIRCLE
Risk factors (biological predisposing factors)
YES
MS and LB both medium or high (by culture**)
YES
Visible heavy plaque on teeth
YES
Frequent snack (>3x daily between meals)
YES
Deep pits and fissures
YES
Recreational drug use
YES
Inadequate saliva flow by observation or measurement (**If measured note the flow rate below)
YES
Saliva-reducing factors (medications/radiation/systemic)
YES
Exposed roots
YES
Orthodontic appliances
YES
YES = CIRCLE
Protective factors Lives/work/school fluoridated community
YES
Fluoride toothpaste at least once daily
YES
Fluoride toothpaste at least 2x daily
YES
Fluoride mouthrinse (0.05% NaF) daily
YES
Fluoride toothpaste daily (5,000 ppm F)
YES
Fluoride varnish in last 6 months
YES
Office F topical in last 6 months
YES
Chlorhexidine prescribed/used 1 week each of last 6 months
YES
Xylitol gum/lozenges 4x daily last 6 months
YES
Calcium and phosphate paste during last 6 months
YES
Adequate saliva flow (>1 mL/min stimulated)
YES
**Bacteria/saliva test results: MS:
LB:
Flow rate:
mL/min. Date:
Visualize caries balance (Use circled indicators/factors above) (Extreme risk = high risk + severe xerostomia) Caries risk assessment (circle): Extreme high
Moderate
Low
From: Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703-713. Reprinted with permission from the Journal of the California Dental Association.
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Maintaining oral health across the life span
Caries risk assessment tool up to age 5 Patient name:________________________________________
I.D. # ______________ Age ___________
Date_____________
Initial/baseline exam date______________________________Recall/POE date_____________ Respond to each question in sections 1, 2, 3, and 4 with a check mark in the yes or no column
Yes
No
Notes
1. Caries risk indicators–Parent interview** (a) Mother or primary caregiver has had active dental decay in the last 12 months (b) Child has recent dental restorations (see 5b below) (c) Parent and/or caregiver has low SES (socioeconomic status) and/or low health literacy (d) Child has developmental problems (e) No dental home/episodic dental care 2. Caries risk factors (biological)–Parent interview** (a) Child has frequent (greater than three times daily) between-meal snacks of sugars/ cooked starch/sugared beverages (b) Child has saliva-reducing factors present, including: 1. medications (for example, some for asthma or hyperactivity) 2. medical (cancer treatment) or genetic factors (c) Child continually uses bottle–contains fluids other than water (d) Child sleeps with a bottle, or nurses on demand 3. Protective factors (nonbiological)–Parent interview (a) Mother/caregiver decay-free last 3 years (b) Child has a dental home and regular dental care 4. Protective factors (biological)–Parent interview (a) Child lives in a fluoridated community or takes fluoride supplements by slowly dissolving or as chewable tablets (b) Child’s teeth are cleaned with fluoridated toothpaste (pea size) daily (c) Mother/caregiver chews/sucks xylitol chewing gum/lozenges 2-4x daily 5. Caries risk indicators/factors–Clinical exam of child** (a) Obvious white spots, decalcifications, or obvious decay present on the child’s teeth (b) Restorations placed in the last 2 years in/on child’s teeth (c) Plaque is obvious on the child’s teeth and/or gums bleed easily (d) Child has dental or orthodontic appliances present, fixed, or removable: (for example, braces, space maintainers, obturators) (e) Risk factor: Visually inadequate saliva flow–Dry mouth **If yes to any one of 1(a), 1(b), 5(a), or 5(b) or any two in categories 1, 2, 5, consider performing bacterial culture on mother or caregiver and child. Use this as a baseline to follow results of antibacterial intervention.
Parent/ caregiver Date:
Child Date:
Low
High
(a) Mutans streptococci (Indicate bacterial level: High, Medium, Low) (b) Lactobacillus species (Indicate bacterial level: High, Medium, Low) Child’s overall caries risk status: (CIRCLE) Recommendations given: yes______ no: ________
Date given:______________ or
Moderate
Date follow up:_______
Reprinted from: Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, Featherstone JD. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc. 2007;35(10):689-702. Reprinted with permission from the Journal of the California Dental Association.
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Maintaining oral health across the life span
daily with an over-the-counter fluoride-containing toothpaste. In addition, prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for one 7-day period each month. For the remaining 3 weeks, have the patient rinse twice daily with over-the-counter sodium fluoride products containing 0.05% sodium fluoride after brushing. This regimen should be repeated monthly for 6 months, and the patient should be reevaluated after that period for caries risk improvement. 3. High risk: Apply fluoride varnish at the initial visit, and every visit thereafter, until risk status is reduced. An excellent video demonstrating the correct application of fluoride varnish is available at www.smilesforlifeoralhealth.com. Prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for 1 week monthly, to be repeated every month. Prescribe 5,000 ppm fluoride toothpaste to be used twice daily. Instruct the patient to brush first prior to using the mouthrinse. Have the patient return to the clinic in 4 months for a reevaluation of caries risk. 4. Extreme risk: This category is high risk plus salivary dysfunction (hyposalivation). Follow the same protocol for high-risk patients, and instruct patients to sip from a water bottle with one teaspoon of baking soda added for pH control. Chlorhexidine gluconate rinse can discolor teeth if used without brushing.20,50 Exposed dentin will become discolored first followed by the enamel.51 Restorative surfaces, such as ceramic crowns, can also become discolored.51 Discoloration is usually detected in patients who undergo periodontal surgery and cannot brush due to sutures or concerns over tissue disruption. Because this protocol involves using the chlorhexidine rinse for a 1-week period (monthly), and Dental caries is a multifactorial disease tooth brushing is not suspended, the that is best understood as a balance between risk of discoloration is negated. Prodpathologic factors and preventive factors. ucts containing essential oils (such as menthol, thymol, and eucalyptol) and antistaining ingredients may be alter51,52 natively prescribed. • Provide the patient with written instructions, dispense products, and use motivational interviewing to improve The application of fluoride varnish is a safe practice. adherence.48 The amount of varnish used is extremely small, and accidental ingestion during the application process does • Refer to general or pediatric dentist for necessary restornot create any risks from fluoride overdose. 21 Dental ative work. • Plan follow-up, recall, and new risk assessment according fluorosis is a potential adverse reaction from the use of to the level of risk. High-risk patients should be recalled fluoride-containing products. Dental fluorosis is the after about 4 months. alteration of tooth enamel that ranges from nearly indisTherapeutic Agents by Caries Risk Level (ages 6 years cernible fine, white, lacy webs or pits to pronounced through adult)41,49: roughened surfaces. 53 Dental fluorosis results from 1. Low risk: Two times (or more) daily brushing with an overingestion of fluoride while the enamel is being formed over-the-counter fluoride-containing toothpaste. below the gingival surface. It can only occur in children 8 2. Moderate risk: Advise the patient to brush at least twice years of age or younger. Dental fluorosis can be prevented the higher the risk of caries. In other words, therapy requires lowering the bacterial challenge while increasing the effect of the protective factors in order to enhance remineralization. This guiding principle underpins chemical therapy and is right in the realm of the NP’s activity.41,42 The simple steps for the cambra approach for patients ages 6 years through adult are as follows: • Obtain a medical and dental history to determine several of the risk factors and disease indicators, such as hyposalivatory medications and prior dental restorations. • Perform a clinical exam to identify carious lesions, which range from precavitated demineralization to open cavities. Early demineralization appears as enamel defects, such as white lines near the gingival margins.21 As the enamel is eroded by bacterial acid, yellow spots can appear as the underlying dentin is exposed. Cavitations appear as pits, which can enlarge and open directly onto the dentin so that teeth appear to have dark centers.21 Excellent pictures of demineralization and caries can be found in the Smiles for Life Curriculum available at www.smilesforlifeoral health.com (located in modules two and three). • Complete the caries risk assessment form using items from 1 and 2 above plus additional questions.42 The form was recently validated in a retrospective study of over 12,000 patients.47 Using the form, NPs can identify disease indicators, pathologic risk factors, and preventive factors and determine the level of caries risk: low, moderate, high, or extreme. • Determine a treatment plan, including chemical therapy, based upon the caries risk level.
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Maintaining oral health across the life span
by using pea-sized amounts of fluoridated toothpaste (discussed below); adult supervision to prevent ingestion of fluoride-containing products by children younger than 6 years of age; and avoidance of fluoride rinses in children under the age of 6.53
and flossing scary. One researcher found that persons with dementia who resisted mouth care were reacting out of fear and perceived threat to their bodily integrity.54,55 Mouth care fear can be overcome in these individuals through a variety of simple strategies. For example, having the caregiver brush his or her teeth alongside the individual with cognitive limitations may reduce care-resistant behaviors. Other techniques include the use of pantomime, gestures, and distractions.54
■ Caries prevention: Oral hygiene The majority of oral health problems can be controlled with simple oral hygiene education, especially when the risk level has been lowered as described above. Unfortunately, simple oral hygiene will not control dental caries in ■ Implications for practice moderate- and high-risk individuals, necessitating the NPs’ scope of practice and reimbursement capacity for protocols discussed above. different services varies by state and across funding sources.56 NPs can educate parents about the importance of caries As primary care providers, NPs can provide oral health prevention, which should begin as soon as any teeth appear. screening, oral health education, and oral healthcare referTeeth should be gently cleansed, as soon as they erupt in rals. (See Patient handout for caries.) Providing these services babies, after eating via a soft cloth or soft pediatric toothbrush.21 Placing baPersons with dementia who resisted mouth bies to bed with bottles and sippy cups that include juice, honey, milk, or care were reacting out of fear and perceived sweetened beverages should be avoided threat to their bodily integrity. completely. If necessary, the bottles and sippy cups should contain only water. Sweet drinks, such as soda and sweetened fruit drinks, should be avoided—not only because of is not a legal scope of practice question but rather a question the development of caries, but for health reasons. Parents of training, standards of care, and reimbursement. Nursing should encourage the consumption of fresh fruits in lieu of education does not often provide training on oral health as fruit juices. a core component of overall healthcare or best practices in Brushing and flossing are important skills to instill in techniques for oral healthcare assessments. There is an small children and to reinforce throughout the life span. acknowledged need to increase primary healthcare providSoft toothbrushes are preferable in order to prevent ers’ knowledge of the etiology of caries, particularly in inadvertent enamel abrasions. Young children should be relation to infants, children, and also in the context of adults supervised by parents until around age 6, using smaller or patients with multiple comorbidities.57 amounts of toothpaste on the brush (a smear for babies and The dental reimbursement system has traditionally a pea-sized amount for toddlers).21,44 Alcohol-free fluoride been separate from medical care reimbursement, creating an additional barrier for NPs to bring these services into rinses should also be encouraged after age 6. Flossing does their practices. Increasingly, preventive oral health intervennot have to involve string floss. Proximal or interdental tions such as fluoride varnish, oral exams or screenings, brushes are viable alternatives. These brushes can be singleanticipatory guidance, or oral health risk assessment (such use disposables, which look like plastic toothpicks with as cambra) are being provided by nondental healthcare spiral brushes. Multiple-use brushes look like standard providers in hopes that early intervention can prevent futoothbrushes with a spiral brush on the end. The spiral ture disease.58 In 2009, 40 states allowed medical primary brush is placed between the teeth to remove debris. The parent can use the interdental brush initially, teaching the care providers, including NPs, to receive reimbursement child to use it until he or she becomes more adept. from Medicaid for providing preventive oral healthcare Oral hygiene remains important throughout adultservices.58 The requirements for reimbursement vary by hood. The use of proximal brushes can be suggested to state; some states require services to be provided together, adults as well, who may find them easier to use than tradiand others require a certification course in risk assessment, tional string floss. Some adults prefer floss heads, which intervention, education, and referral in order to qualify.58 can be mounted onto toothbrush handles. Individuals with Changing reimbursement mechanisms are also increasing cognitive limitations, such as those with dementia or with the potential for more oral health services to be provided delayed intellectual development, may find tooth brushing as part of primary care.59 www.tnpj.com
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Maintaining oral health across the life span
■ Putting it all together: The NYU Nursing-Dental Model Exemplar New York University provides a creative example of how previously disparate disciplines came together to address oral healthcare and related interdisciplinary teaching, research, and practice. In 2005, New York University’s College of Nursing and College of Dentistry formed one
academic unit in order to create new synergies in research, teaching, and practice. The Nursing and Dentistry faculty collaborated on papers related to the workforce, oral health education and practice advances, and ways the two disciplines could come together to screen for diabetes, human immunodeficiency virus, hypertension, and chronic diseases, which may have previously been
Patient handout for caries HOW TOOTH DECAY HAPPENS (to be given to each patient) Tooth decay is caused by certain types of bacteria (mutans streptococci and lactobacilli) that live in your mouth. When they attach themselves to the teeth and multiply in dental plaque, they can do damage. The bacteria feed on what you eat, especially sugars (including fruit sugars) and cooked starch (bread, potatoes, rice, pasta, and the like). Within just a few minutes after you eat or drink, the bacteria begin producing acids as by-products of digestion. Those acids can penetrate into the hard substance of the tooth and dissolve some of the minerals (calcium and phosphate). If the acid attacks are infrequent and of short duration, your saliva can help to repair the damage by neutralizing the acids and supplying minerals and fluoride that can replace those lost from the tooth. However, if: 1) your mouth is dry, 2) you have many of these bacteria, or 3) you snack frequently, then the tooth mineral lost by attacks of acids is too great, and cannot be repaired. This is the start of tooth decay and leads to cavities. CONTROLLING TOOTH DECAY Diet: Reducing the number of sugary and starchy foods, snacks, drinks, or candies can help reduce the development of tooth decay. That does not mean you can never eat these types of foods, but you should limit their consumption particularly when eaten between main meals. A good rule is three meals per day and no more than three snacks per day. Fluorides: Fluorides help to make the tooth more resistant to being dissolved by the bacterial acids. Fluorides are available from a variety of sources, such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist such as brush-on gels or high-fluoride toothpastes used at home, or gels, foams, and varnishes applied in the dental office. Daily use is very important to help protect against the acid attacks.
Plaque removal: Removing the plaque from your teeth on a daily basis is helpful in controlling tooth decay. Plaque can be difficult to remove from some parts of your mouth especially between the teeth and in grooves on the biting surfaces of back teeth. If you have an appliance such as an orthodontic retainer or partial denture, remove it before brushing your teeth. Brush all surfaces of the appliance also. Saliva: Saliva is critical for controlling tooth decay. It neutralizes acids, and provides minerals and proteins that protect the teeth. If you cannot brush after a meal or snack, you can chew some sugar-free gum. This will stimulate the flow of saliva to help neutralize acids and bring lost minerals back to the teeth. Sugar-free candy or mints could also be used, but some of these contain acids themselves. These acids will not cause tooth decay, but they can slowly dissolve the enamel surface directly over time (a process called erosion). Some sugar-free gums are designed to help fight tooth decay and are particularly useful if you have a dry mouth (many medications can cause a dry mouth). Some gums contain baking soda that neutralizes the acids produced by the bacteria in plaque. Gum that contains xylitol as its first listed ingredient is the gum of choice. If you have a dry mouth, you could also fill a drinking bottle with water and add a couple teaspoons of baking soda for each 8 oz of water and swish and spit with it frequently throughout the day. Toothpastes containing baking soda are also available by several companies. Antibacterial mouth rinses: Rinses that your dentist can prescribe are able to reduce the numbers of bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay. Sealants: Sealants are plastic or glass ionomer coatings bonded to the biting surfaces of back teeth to protect the deep grooves from decay. In some people the grooves on the surfaces of the teeth are too narrow and deep to clean with a toothbrush, so they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for children and young adults at risk for this type of decay. They do not last forever and should be inspected once a year and replaced if needed.
Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10): 703-713. Reprinted with permission from the Journal of the California Dental Association.
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overlooked during the dental encounter.60-68 From the perspective of the nursing faculty, oral health assessment had been underappreciated in the discipline as a critical way of addressing the oral-systemic connection and the essential nature of oral health assessment to help identify early symptoms that might indicate cardiac disease or cancer, for example.69 An innovative practice model was developed in which the college of nursing created a faculty practice that was colocated in the dental school where over 325,000 patient visits are completed annually. With over 1,800 patient visits a day, the Dental and Nursing faculty agreed that they would offer each patient, as appropriate, the opportunity to be seen by an NP during their dental visit. This activity has spawned a great deal of enthusiasm in the faculty and the patients whom they serve. Clearly, these are creative, synergistic, and valuable opportunities. ■ Promoting oral health NPs can promote the systemic health of their patients by addressing oral health. One contribution NPs can make is in the area of caries risk assessment and management. This is an area that NPs may not feel comfortable addressing. There are many resources available that NPs can access: • The American Association of Pediatricians provides a set of oral health tools for use by anyone with pediatric patients: www2.aap.org/commpeds/dochs/oralhealth/ PracticeTools.html. • The American Academy of Pediatrics Oral health Section tracks reimbursement for oral health activities, including the application of fluoride varnish: http://www2.aap.org/ commpeds/dochs/oralhealth/State.html. The Smiles for Life Curriculum is comprised of eight modules that explore oral health issues among the life span. Clinicians can register to receive free continuingeducation credit associated with each module at: www. smilesforlifeoralhealth.com. A 30-minute video that demonstrates methods to provide mouth care to individuals with dementia who resist care can be accessed via the Portals of Geriatric Online Education (www.pogoe.org). The video is titled Oral Hygiene & Care-Resistant Behaviors: Making a Difference. In order to locate and view the video, users must register (at no charge) and type the product identifier 20998 in the search box.
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Rita Jablonski is an associate professor at the University of Alabama at Birmingham, School of Nursing, Birmingham, Ala.
Elizabeth Mertz is an assistant professor at the University of California, San Francisco, Calif.
John D.B. Featherstone is a dean and professor at the University of California, School of Dentistry, San Francisco, Calif.
51. Hofer D, Meier A, Sener B, Guggenheim B, Attin T, Schmidlin PR. Biofilm reduction and staining potential of a 0.05% chlorhexidine rinse containing essential oils. Int J Dent Hyg. 2011;9(1):60-67.
Terry Fulmer is a dean and professor at Bouvé College of Health Sciences and professor of Public Policy and Urban Affairs at Northeastern University, Boston, Mass.
52. Duss C, Lang NP, Cosyn J, Persson GR. A randomized, controlled clinical trial on the clinical, microbiological, and staining effects of a novel 0.05% chlorhexidine/herbal extract and a 0.1% chlorhexidine mouthrinse adjunct to periodontal surgery. J Clin Periodontol. 2010;37(11):988-997.
The authors have disclosed that they have no financial relationships related to this article.
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DOI-10.1097/01.NPR.0000446872.76779.56
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