Oral health, good nutrition and overall health among the elderly
The ability to eat nutritious foods is of key importance to staying healthy in old age.
Yet according to the National Institutes of Health, millions of American seniors suffer from untreated decay, missing teeth and other oral conditions. These problems make it more difficult for elders to eat right. Oral impairments such as missing teeth have been associated with poorer nutritional status in elders, as reflected in the reduced intake of vitamins, calcium, dietary fiber and protein, studies have found.
Diabetes, hypertension, dyslipidemia, or a combination of these chronic conditions affect a vast majority of older Americans the Institute of Medicine has observed. The serious impact of all of these problems can be mitigated with dietary changes. Poor oral health can present a barrier to such options.
“Quality of life clearly suffers when individuals are forced to limit food choices and the foods chosen do not provide optimal nutrition,” noted then-Surgeon General David Satcher in his landmark 2000 Oral Health in America report.
Dentures can help, but they do not serve as full replacements for lost natural teeth, concluded Satcher. “Clinical research has demonstrated a general reduction in chewing function as the number of missing teeth increases, even when dentures are worn.”
Atraumatic restorative treatment
Developed by a Dutch dentist working in third-world settings, Atraumatic Restorative Treatment is an alternative, minimally-invasive approach to treating tooth decay.
Hand instruments are used to remove the soft, demineralized area of the tooth, a method that requires no drill or anesthesia. A fluoride-releasing glass ionomer cement is then applied to the tooth using a syringe or brush. Research has shown the effectiveness of the technique in stabilizing decayed teeth and preventing the progression of decay. Since its development more than two decades ago, the treatment, which can be particularly useful in caring for young, elderly or anxious patients, has been adopted for use in countries around the world.
A variation of the method, called Interim Therapeutic Restoration (ITR) is now being employed in California by specially-trained dental hygienists working in public health settings.
The battle over midlevel providers
More than 49 million Americans are living in areas with a shortage of oral health care providers. It would take nearly 10,000 additional dental practitioners to meet the current needs, according to the calculations of the U.S. Department of Health and Human Services Health Resources and Services Administration, which are based upon a population-to-practitioner ratio of 3,000:1. The shortage of dental providers disproportionately affects people living in poor and rural areas. Millions more lack dental insurance or other means of paying for care. Some say the answer may lie in a less highly-trained and less-expensive care provider called the dental therapist.
Advocates for the model compare the dental therapist to a nurse practitioner. These so-called midlevel providers work under the general, not direct, supervision of dentists, bringing care to isolated or underserved communities. They receive two years of intensive technical training and provide a range of services including preventive and restorative procedures and simple extractions.
The dental therapist model got its start in the 1920’s in New Zealand and is now well-established in many developed countries including the U.K., Australia and the Netherlands.
On tribal lands in Alaska, dental therapists began offering care in 2005 as part of a longstanding federally authorized program that trains residents of Alaska Native tribal villages to provide basic care to their neighbors. In 2009, Minnesota became the first U.S. state to approve a law allowing such midlevel dental workers to practice. Pilot programs sponsored by the federal government and community-based drives funded by the W.K. Kellogg Foundation are targeted at exploring the use of such providers in additional states.
The model has been supported by many public health and grassroots organizations, who cite research indicating the quality of care provided over many years in many countries. But dental therapists have been strongly opposed by the American Dental Association and several other dental specialty groups. The organizations assert that dental therapists are not qualified to perform procedures considered irreversible or “surgical” such as drilling or extracting teeth.
Centers for Medicare and Medicaid (CMS) Oral Health Initiative (OHI)
Oral health advocates often observe that tooth decay is the most common chronic childhood disease, more common than asthma. Poor children, who often lack access to preventive dental care, bear a disproportionate burden of this disease.
The CMS Oral Health Initiative, launched in April 2011, sets a goal of significantly increasing preventive dental services provided to poor children covered by Medicaid. While Medicaid entitles child beneficiaries to dental care, less than 41 percent of Medicaid children received preventive dental services nationwide in 2011, with rates varying widely within individual states.
The CMS Oral Health Initiative sets a goal that all states increase the use of preventive dental services by Medicaid children by 10 percentage points within five years, with interim annual improvement goals of 2 percent. Each state has its own baseline and goal. Nationally, the program aims to see that 52 percent of young Medicaid beneficiaries receive a dental service during fiscal year 2015.
Commission on Dental Accreditation (CODA)
Often referred to by its acronym, CODA, the agency has the responsibility of accrediting dental and dental-related education programs in the United States.
In its work, the commission develops standards for dental educational programs and makes accreditation decisions about individual programs related to predoctoral and postdoctoral dental education, advanced areas of study such as dental anesthesiology, as well as recognized specialties including dental hygiene, dental assisting and dental laboratory technology.
In February 2015, CODA voted to adopt training standards for dental therapy education programs nationwide. The measure, which came in the wake of urging by the Federal Trade Commission, opens the way for accredited dental institutions to train the auxiliaries.
The Chicago-based commission was established in 1975, replacing an earlier group, the American Dental Association’s Council on Dental Education. The change was part of an effort to give the broader community of dental health providers a voice in decisions and policies related to dental accreditation and education.
Today, CODA’s 30-member board of commissioners includes members drawn from professional dental organizations representing dentists, hygienists, dental assistants, dental specialties, dental laboratories, educators, dental students as well as four public representatives. The group meets twice a year.
Community water fluoridation
Early in the 20th century, dentists working in areas with high levels of naturally-occurring fluoride in water observed patients with mottled tooth enamel, a condition now known as fluorosis, seemed to be less susceptible to cavities. By the 1930s, scientists in the newly established dental hygiene unit of the the National Institute of Health began comparing the prevalence of fluorosis with data on caries prevalence among children in 26 states and noted a strong inverse relation between the two. The relationship was borne out in a study of 21 cities in Colorado, Illinois, Indiana, and Ohio. Researchers concluded that tooth decay among children was lower in cities with more fluoride in their community water supplies.
“At concentrations greater than 1.0 ppm (parts per million,) this association began to level off. At 1.0 ppm, the prevalence of dental fluorosis was low and mostly very mild,” notes a history of these studies provided by the U.S. Centers for Disease Control and Prevention.
The hypothesis that dental caries could be prevented by adjusting the level of fluoride in community water supplies was then field tested in four pairs of cities. “After conducting sequential cross-sectional surveys in these communities over 13-15 years, caries was reduced 50 percent to 70 percent among children in the communities with fluoridated water,” the CDC history notes.
In 1962, a recommended optimum range of fluoride concentration was set at 0.7 to 1.2 parts per million (or 0.7 to 1.2 milligrams per liter.) based on epidemiological studies into water consumption patterns and disease rates across climates and regions.
In 2006, an analysis by the National Research Council concluded that the standard was too high to protect against adverse health effects including dental fluorisis and the potential risk for bone fractures and skeletal fluorisis, a rare condition in the United States.
In 2011, the U.S. Department of Health and Human Services and U.S. Department of Environmental Protection proposed the recommended level of fluoride in drinking water be set at the lowest end of the optimal range, noting the fact that Americans are now getting fluoride from a variety of sources that did not exist in the early days of community fluoridation, including gels, mouth rinses, tablets, and drops.
While groups including the Fluoride Action Network insist that fluoride is dangerous at any level, public health officials including the U.S. Surgeon General cite voluminous research fluoride’s safety and effectiveness in preventing tooth decay. Currently, 72 percent of the U.S. population has access to fluoridated public water systems.
Dental amalgam – a mixture of metals including silver, tin, copper and zinc that are bound together by mercury – has been used for more than 150 years by dentists to restore decayed teeth. Dental amalgam is regulated as a medical device by the U.S. Food and Drug Administration (FDA). In a final rule issued in 2009, the agency determined that while the material releases low levels of mercury vapor it is safe for use in most patients over the age of six.
Health officials say however, that dental amalgam poses serious health risks when it enters the environment and the food chain by way of wastewater discharged from dental offices. Combined with bacteria, mercury can form into methylmercury, a neurotoxin. Exposure can occur when people eat fish containing methylmercury.
A federal rule that was announced in the last days of the Obama Administration would have required dentists to install equipment designed to capture mercury and other metals contained amalgam waste for safe disposal and recycling. The unpublished rule was withdrawn by the Environmental Protection Agency in compliance with a memorandum issued by President Donald Trump. In a February 2017 lawsuit, the Natural Resources Defense Council sought to reinstate the rule.
Americans who have dental benefits are more likely to go to the dentist, take their children to the dentist, obtain preventive and restorative care and enjoy better oral health, research has found. The uninsured are about two-thirds as likely as people with insurance to have visited the dentist within the last year, according to the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality.
An estimated 5.3 million children who lack benefits are expected to gain them through the Patient Protection and Affordable Care Act (ACA) in 2014. Some will get dental coverage through state Medicaid expansion. Others will get benefits through health insurance exchanges created by states under the ACA. Pediatric oral coverage will be offered to anyone puchasing insurance on these exchanges, though whether families are required to buy the coverage is up to the individual states.
The ACA does not address the need for adult dental benefits. Under Medicaid, adult dental benefits vary from state to state and often offer only very limited coverage. Medicare, the federal insurance program for the elderly does not include coverage for routine dental care.
About 98 percent of dental benefits are provided through employer or other private and public group programs, according to the NADP. Public group programs include Medicaid and TriCare, which provides coverage for the military.
Dental coverage is generally not integrated into medical insurance but instead is sold as a separate policy. In America, the majority of dental policies today are offered through dental preferred provider organizations or DPPOs. Dental health maintenance organizations or DHMOs, indemnity and discount plans also offer coverage.
Dental emergency department visits
Each year, more than a million Americans arrive in hospital emergency departments (EDs) seeking help with dental problems. But EDs are tremendously expensive and ineffective sources of dental care, research has shown.
Between 2008 and 2010 alone, more than 4 million patients with dental conditions turned to hospital EDs. The visits cost $2.7 billion, according to a study by the American Dental Association. A total of 101 of the patients died in the emergency rooms.
Most EDs are not staffed or equipped to provide dental care. The vast majority of patients do not receive procedures during their visits that would address their problem. Many instead are offered prescription medications for pain and infection. With routine professional and home care, most of the dental conditions that bring patients to EDs could be prevented or addressed in less costly and more effective ways.
The lack of insurance or other means to pay for care, geographical isolation, poor diet and poor oral hygiene all contribute to the oral conditions that drive people to hospitals, experts say. The lack of dentists who accept Medicaid has also been identified as a barrier, particularly in urban areas, where the vast majority of dental emergency department visits occur.
Dental sealants are thin plastic coatings that are professionally applied to childrens’ permanent molars (back teeth) to protect them against decay. The plastic sealing material protects the deep narrow pits and fissures often found on the chewing surfaces of those teeth from food deposits and decay-causing bacteria.
Sealants are recommended for first permanent molars, which erupt at about 6 years of age, and the second permanent molars which appear when children are about 12.
The quick, noninvasive procedure has been shown by studies to reduce the incidence of tooth decay by more than 60 percent according to the U.S. Centers for Disease Control and Prevention. In recognition of the preventive power of sealants, public health officials and advocates stress the importance of establishing school-based sealant programs in poor communities where children might lack private dental care.
A dental therapist is a licensed oral health professional working as part of a dental team to offer basic preventive and restorative treatment.
Dr. Frank Catalanotto, a pediatric dentist and professor at the University of Florida, explains how dental therapists can help dentists serve Medicaid patients and how two rural Kansas dentists are leading the effort to authorize them in that state.
Dental therapists, sometimes known as dental nurses, first came into use in New Zealand in 1921 and are now working in more than 50 countries and territories around the world.
The first American dental therapists began working in Alaska Native villages in 2005. The Alaskan therapists, called DHATs or dental health aide therapists, are required to have high school degrees and undergo more than two years of technical training in a narrow range of skills including dental restorations and simple extractions. Working under the general supervision of dentists, DHATS provide access to care to more than 40,000 Alaska Natives, many of them living in remote and isolated areas.
In 2009, the Minnesota State legislature authorized the licensing of two categories of dental therapists: dental therapists and advanced dental therapists. Both types are required to practice in settings that serve poor and under-served people. Both types also work with collaborating dentists, although advanced dental therapists are allowed to practice without supervision.
Variations on the dental therapist model are being explored in a number of other states as a way of expanding care to patients who are poor, lack private insurance or who live in isolated areas.
Advocates of dental therapists say the model has a long history of effectiveness worldwide.
However, the model is strongly opposed by the American Dental Association which maintains that only dentists should perform surgical procedures such as restorations and extractions.
Licensed dental hygienists in the United States typically care for patients under the direct supervision of dentists. But in many states, this arrangement is gradually changing. Hygienists increasingly see a role for themselves in working more independently, particularly in public health settings such as schools and nursing homes where they can help address the need for basic preventive services such as oral health assessments and education, tooth cleanings, fluoride treatments and sealants.
To gain the freedom to work outside the direct supervision of dentists, national and state hygienists’ groups are pushing to modify state laws and dental practice acts. Now 37 states termed “direct access” states by the American Dental Hygienists’ Association allow hygienists to provide care in at least one practice setting to patients who have not first been seen by a dentist. In some states, the latitude afforded hygienists is fairly limited but in others, such as California, a hygienist with an advanced license can work under the remote supervision of a dentist to offer a variety of services including interim therapeutic tooth restorations.
Minnesota and Maine have passed legislation allowing hygienists with advanced training to offer an expanded range of services as mid-level dental providers. Now a dozen other states are also weighing hygiene-based mid-level provider models. Such measures are often met with strong resistance from organized dentistry whose leaders, in many states, firmly insist that dental auxiliaries should work under the direct supervision of dentists.
Preventing oral disease is much cheaper than treating it, public health officials stress. Effective intervention methods are known.
Extensive research has shown that fluoride works in a variety of systemic and topical ways to reduce the risk of dental decay (caries) in children and adults.
Since the 1940’s, communities across the United States have been supplementing naturally-occurring fluoride in their water supplies to provide a level considered adequate to promote oral health, particularly among children. The U.S. Department of Health and Human Services’ recommended optimal level of 0.7 milligrams per liter has been set to prevent tooth decay while minimizing the chance of ill effects such as dental fluorosis and skeletal deformities that may be caused by the consumption of fluoride at excess levels.
Currently, an estimated 64 percent of the population (more than 72 percent of people served by public water systems) have access to optimally fluoridated water according to the Centers for Disease Control and Prevention.
However, people in some communities distrust tap water and may substitute bottled water, which may not be fluoridated. And in some places, community fluoridation programs have been resisted and even reversed by activists who portray them as forced medication or as a violation of personal liberty.
Fluoride toothpaste is recommended for both children and adults. Professionally applied fluoride varnishes have been shown effective in preventing caries in both deciduous (baby) teeth and permanent (adult) teeth. Dental sealants, which are thin plastic resin coatings, professionally applied to the chewing surfaces of the molars (back teeth) are also effective. Yet poor children, who are at higher risk of disease, are less likely to get them.
Oral health literacy, the ability to obtain, process and understand the basic information needed to make appropriate oral health decisions, is also seen as key to prevention of disease. Beyond basic reading, writing and communication skills, oral health literacy also addresses the individual’s ability to obtain needed services and perform self-care.
These skills may be taken for granted in wealthier communities with ready access to information and services, but is of crucial importance in poorer places, where residents are at higher risk of disease and have less knowledge about how to fight it.
Early childhood caries
Early Childhood Caries (ECC) is a common chronic bacterial infection that causes severe tooth decay. Research shows it can begin to develop in infancy, even before the first teeth erupt. Data from national surveys show ECC is highly prevalent and often untreated among children under three years of age.
The disease was formerly known as nursing bottle caries or baby bottle tooth decay, but a growing understanding has led researchers to conclude that the development of ECC is not consistently associated with poor feeding habits. ECC is now understood as an infectious disease with a number of contributing causes, including the transmission of disease-causing bacteria, often from caregiver to child.
Prevention efforts now focus on identifying children at high risk for ECC while they are still infants and providing family education, instruction in careful home brushing with fluoridated toothpaste and professional fluoride varnish treatments.
While, on the whole, Americans have been keeping their natural teeth until later in life, nearly 23 percent of people 65 or older in the United States are edentulous, meaning they have lost all their teeth.
The study found that 32 percent of non-Hispanic black adults aged 65 and over are edentulous compared with non-Hispanic white adults (22 percent.) Only 16 percent of Mexican-American adults have lost all their teeth. Complete tooth loss is more than twice as high for older adults living below
100 percent of the poverty level (37 percent) compared with those living at 200 percent of the poverty level or higher (16 percent). See a chart illustrating these rates.
Edentulism can impact self-esteem and the ability to speak, as well as the ability to eat healthy foods. Even when wearing dentures, people without teeth experience difficulties eating foods, including many fruits and vegetables. They often must chew food longer than people who still have their natural teeth, factors that have been found to negatively impact food selection and nutritional status.
Endocarditis and Oral Infections
Endocarditis is an infection of the inner lining of the heart chambers and valves. It can occur if bacteria, fungi or other germs enter the blood stream (a process called bacteremia) and attach themselves to damaged areas inside the heart.
A group of bacteria known as Viridans streptococci, which are often found in the mouth, are a common cause of endocarditis.
Endocarditis, which can result in stroke or even death, most often occurs in people with preexisting heart disease, damaged or artificial heart valves, or implanted medical devices in the heart or blood vessels.
Patients who are at risk of endocarditis may be advised to take antibiotics before undergoing invasive dental procedures because oral bacteria from infections of the teeth and gums can enter the blood stream during such procedures.
When oral infections are present, even daily activities such as chewing and toothbrushing can result in bacteremia. Maintaining good oral health appears to help lower the risk of bacteremia and subsequent endocarditis.
First aid for an avulsed tooth
While stressing the importance of wearing protective gear, including a mouthguard for sports, accidents still happen. Experts urge parents, teachers, coaches and student athletes to know what to do in the case of a dental emergency.
A primary (baby tooth) that has been knocked out should not be replanted. But quick action should be taken to try to save a permanent adult avulsed tooth.
2. Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
3. If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try to encourage the patient / parent to replant the tooth. Bite on a handkerchief to hold it in position.
4. If this is not possible, place the tooth in a suitable storage medium, e.g. a glass of milk or a special storage media for avulsed teeth if available…The tooth can also be transported in the mouth, keeping it between the molars and the inside of the cheek. If the patient is very young, he/she could swallow the tooth- therefore it is advisable to get the patient to spit in a container and place the tooth in it. Avoid storage in water!
5. Seek emergency dental treatment immediately.
First dental visit
It is recommended that a child has his first dental visit as soon as his first tooth erupts, or by his first birthday, whichever comes first. Sometimes described as a “well baby checkup” for the teeth, it’s a time for the dentist to assess the child for caries risk and check for signs of tooth decay or other problems. It is also an opportunity for the provider to talk with parents about proper diet and home care. The dentist may demonstrate how to gently clean the baby’s teeth using a soft brush or cloth with water. This early visit is also a chance to ask about habits such as thumbsucking, and caution against feeding practices such as putting the baby to bed with a bottle of milk, formula or juice that could lead to tooth decay. The provider may also apply fluoride varnish to newly-erupted teeth. Some dentists prefer, with very young children to do a lap exam, sitting knee to knee with the parent and cradling the child’s head on the lap.
The primary teeth, also known as “baby teeth” or deciduous teeth, often begin to appear when the child is about six months old. Most kids have their full set of 20 primary teeth by the time they are three. These teeth begin to fall out at about the age of six. But in the meantime they play an essential role in the child’s development, helping him chew and speak and maintaining space for the coming permanent teeth.
Fluoride varnish, a lacquer containing fluoride, has been found by studies to be effective in reducing and preventing tooth decay on primary and permanent teeth.
It is generally applied by a health care professional using a small brush and it works by increasing the concentration of fluoride in the outer surfaces of the teeth.
Contact with saliva causes the varnish to harden, where it provides a high concentration of fluoride to remain in contact with the tooth enamel.
The dose of fluoride helps to slow the process of demineralization that can lead to tooth decay.
In 2014, the U.S. Preventive Services Task Force issued a recommendation that primary care clinicians apply fluoride varnish to the teeth of all infants and children, beginning with the eruption of the primary teeth.
“Three out of four preschool-age children ages 5 years and younger do not visit a dentist, but most see a primary care clinician,” said task force chair and physician Michael LeFevre. “This means that primary care clinicians can play an important complementary role in helping dentists keep children’s teeth healthy.”
Global Burden of Disease study
Tooth decay, gum disease and other oral problems impact an estimated 3.9 billion people worldwide.
Untreated tooth decay in permanent teeth has been identified as the most common of 291 diseases systematically compared for worldwide impact by the Global Burden of Disease Study, funded by the Bill and Melinda Gates Foundation. The problem affects an estimated 2.4 billion people worldwide, according to a March 2015 systematic review and analysis authored by researchers using GBD resources.
Untreated decay in deciduous (baby) teeth, the tenth most prevalent condition in the GBD study, impacts 621 million children globally.
Severe gum disease, or periodontitis, which leads to tooth loss and which has possible links with a range of other illnesses, is also extremely prevalent, currently affecting more than 11 percent of the world’s population, according to GBD- based research.
The World Health Organization has identified oral disease as an international concern and has set goals for addressing serious care shortages and deep health disparities found in countries and regions around the globe.
An ounce of prevention is worth a pound of cure and nowhere is that more true than with oral health.
While saliva has anti-bacterial and buffering properties that help keep the teeth clean, oral health professionals continually stress the importance of twice-daily brushing, using a soft-bristle brush and fluoride toothpaste.
They also recommend daily flossing as a way of cleaning areas between the teeth and beneath the gum line where the brush does not reach.
The mechanical actions of brushing and flossing disrupt the buildup of bacterial plaque that can cause decay and gum disease.
The fluoride in the toothpaste helps inhibit bacterial activity and remineralize the tooth enamel.
A Cochrane systematic review found that powered toothbrushes with rotating and oscillating heads removed more plaque and reduced gum disease more effectively than manual tooth brushes.
Babies’ teeth should be cleaned from the time they erupt, but parents are advised to consult their physician before using fluoridated toothpaste on children under two. Parents also need to supervise preschoolers who brush their own teeth, making sure they use only a small amount of toothpaste and do not swallow it.
National Health and Nutrition Examination Survey (NHANES)
The acronym “NHANES” comes up constantly as you read research papers or government reports about oral health in America, or listen to experts talk about the topic.
That is because the National Health and Nutrition Examination Survey is the main source of oral health information in the country. The survey, really a series of ongoing surveys, is unique in that it combines interviews and physical examinations of a nationally representative sample of about 5,000 people each year.
NHANES health interviews, which are conducted in respondents’ homes, include demographic, socioeconomic, dietary and health-related questions.
The physical examinations gather detailed medical, dental, and physiological measurements, as well as the results of laboratory tests. Health measurements are collected in specially designed and equipped mobile units, which travel to locations throughout the country. For NHANES oral health assessments, trained health technologists using dental lights and disposable mirrors conduct open-mouth examinations of respondents, documenting each decayed, restored and sealed tooth. Examiners also check for the presence or absence of specific oral conditions.
The findings result in a mother lode of data for government and academic researchers who are focused upon understanding aspects of the oral health status of Americans.
Rapid tooth decay, or “meth mouth,” is one of the many devastating consequences of methamphetamine, or meth, addiction.
Researchers are still trying to understand this condition, which they say is unique to meth addiction.
The chemical composition of this potent drug, manufactured from ingredients including anhydrous ammonia, red phosphorus, lithium and pseudoephedrine, is highly acidic. Smoking or snorting the drug is likely to lower the pH level within the mouth, they say, making the tooth enamel more vulnerable to demineralization and decay. But intravenous meth users may also develop “meth mouth.”
A common side effect of methamphetamine use - xerostomia, or dry mouth – is also known to put oral health at risk by depriving the teeth of the buffering and cleansing properties normally offered by the saliva. Cravings for high-sugar drinks, tooth grinding and poor oral hygiene – all problems that often accompany addiction to the drug – are also risk factors for tooth decay.
The progress of “meth mouth” varies among individuals. In extreme cases, the teeth of users are reduced to crumbling and blackened stumps.
Opioids in dentistry
Amid growing awareness of America’s epidemic of opiod addiction, oral health providers are being urged to examine their prescribing practices.
Dentists are among the leading prescribers of opioid pain medications, research has found. The prescriptions often are written for patients who have undergone surgical tooth extractions.
Public health and dental leaders are urging dentists to become more cautious about prescribing opiods and to consider alternatives such as nonsteroidal medications and acetaminophen in helping patients cope with pain following dental procedures.
U.S. Surgeon General Vivek Murthy has included dentists in his appeal to health care providers to help fight the epidemic. Murthy has stressed that addiction can begin with a routine prescription. American Dental Association president Carol Gomez Summerhays has urged dentists to review their prescribing practices and talk with patients about the safe handling and use of medications. She has also appealed to dentists to consult databases maintained by state-run prescription monitoring programs to help identify “doctor-shopping patients” whose prescription histories may reveal drug-seeking behavior.
Of the more than 79 million prescriptions written for opiod analgesics in 2009, dentists were the third most frequent prescribers, according to a study, published in the Journal of the American Medical Association.
Federal data reflected in the National Prescription Audit offered somewhat different findings for a more recent year. It concluded that dentists were the fifth most frequent prescribers in 2012, behind family practitioners, internists, general practitioners and surgeons.
Oral and Pharyngeal Cancers
Each year in the United States, oral and pharyngeal cancers claim more than 8,000 lives. More than 30,000 new cases of cancer of the mouth and throat are diagnosed, according to the Centers for Disease Control and Prevention.
These cancers take a disproportionate toll upon minorities and they are deadly, with a five-year survival rate of only about 50 percent.
Early detection is key, stresses the CDC which offers the following warning signs.
a mouth sore that fails to heal or that bleeds easily
a white or red patch in the mouth that will not go away
a lump, thickening or soreness in the mouth, throat, or tongue
difficulty chewing or swallowing food
Tobacco use and heavy drinking both put people at heightened risk of oral cancer and a decrease in smoking in recent years has helped reduce oral cancers, researchers say.
But at the same time, rates of base-of-tongue and tonsillar cancers have been rising. Studies attribute the increase to a growing incidence of human papillomavirus-associated cancers.
HPV can cause normal cells in infected skin turn abnormal. Yet it is still unclear whether having HPV alone is sufficient to cause oropharyngeal cancers, or if other factors (such as smoking or chewing tobacco) interact with HPV to cause these cancers. About 7 percent of Americans have HPV, but only 1 percent have the type of HPV found in oropharyngeal cancers (HPV type 16.) according to the CDC.
Oral health refers to a state of wellbeing that addresses the wellbeing of the entire mouth.
In addition to the teeth, the mouth is home to the gums (gingiva) and their supporting tissues, the hard and soft palate, the tongue, the lips, the upper and lower jaw, chewing muscles, salivary glands, and the oral mucosa (the mucous membranes that line the oral cavity.)
Branches of the nervous, immune and vascular systems located in the mouth activate, defend and nourish the oral tissues and connect them with the brain and the rest of the body.
It is often stated that oral health is bound to overall health and these systems provide essential links.
Infections that start in the mouth can travel to the brain and other parts of the body.
The associations of periodontal disease and diabetes, periodontal disease and cardiovascular disease, and periodontal disease and pregnancy outcomes have been studied intensely for more than a decade. Periodontal (gum) disease is a recognized complication of diabetes.
An addition, a number of diseases and health problems reveal themselves in oral conditions; oral lesions can be the first sign of HIV infection; a type of sexually transmitted human papillomavirus, HP-16, has been shown to cause oral cancer. Dry mouth (xerostemia) can be a symptom of the common autoimmune disorder Sjogren’s syndrome.
The microorganisms that inhabit the human mouth are sometimes referred to collectively as the human oral microbiome. Scientists estimate that there are likely to be between 500 and 700 common species of oral bacteria inhabiting the oral cavity. Distinct subsets of these bacteria are found in the different microbial habitats provided by the teeth, tongue, gums, cheeks and hard and soft palates, as well as in contiguous areas of the throat and sinuses, nasal passages and lungs.
The Human Microbiome Project, supported by the National Institutes of Health, has a goal of isolating and naming all the major organisms that comprise the oral biome in order to better understand their relationships with one another as well as their impact upon oral and systemic health and disease.
The human oral biome is being studied as part of the larger Human Microbiome Project. This focus on the body’s ecology reflects a growing recognition that interactions of groups of organisms rather than single pathogens are responsible for many diseases.
Tooth decay, for example, can occur after acid-loving bacteria such as mutans streptococci and lactobacilli gain dominance over acid-sensitive species inhabiting the plaque or biofilm covering the enamel of a tooth.
Orofacial clefts are among the most common of all birth defects. They include clefts of the lip, clefts of the palate (the roof of the mouth), and clefts affecting both the lip and the palate.
In a cleft lip, the tissue that forms the lip does not join completely, leaving a small slit or a larger gap that may extend up into the nose. In a cleft palate, the tissue that forms the roof of the mouth does not join completely.
While the causes of orofacial clefts are still being studied, genetic factors, together with environmental exposures, the mother’s diet and medication use all may play a role. Women who smoke while pregnant, or who have been diagnosed with diabetes before pregnancy are at higher risk of having a baby with an orofacial cleft, research has shown.
Each year, an estimated 2,651 babies in the United States are born with a cleft palate and 4,437 babies are born with a cleft lip with or without a cleft palate, according to The Centers for Disease Control and Prevention (CDC.)
Surgery to repair the cleft and correct the appearance and function of the mouth is recommended when the child is still very young. The child may also need specialized dental and orthodontic care as well as other types of therapy.
Perinatal oral health care
Untreated oral disease can compromise the health of both mother and child.
Women with high levels of the decay-causing bacteria mutans streptococci (MS) are likely to infect their young children, passing along the burdens of tooth decay to a new generation, evidence shows.
While adult dental benefits are optional under Medicaid, some states cover dental benefits during pregnancy while others are adopting strategies to extend dental benefits to pregnant and new mothers out of a growing recognition of the importance of perinatal oral health care.
The association between periodontal (gum) disease and birth outcomes has also received a great deal of attention. A causal connection has not yet been established, but continues to be explored.
Preventing tooth decay in young children
Young children are far more likely to be seen by doctors and nurses than by dentists. These nondental health providers can play an important role in helping to fight tooth decay, according to a set of recommendations issued in May 2014 by the U.S. Preventive Services Task Force (USPSTF).
The recommendations focus on the importance of access to fluoride.
For children whose water supply lacks fluoride, the USPSTF recommends that primary care clinicians prescribe oral fluoride supplements in the form of drops, tablets or lozenges starting at age 6 months.
The USPSTF also recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting when the first primary tooth erupts.
The USPSTF also weighed the value of regular dental screenings performed by nondental professionals on young children but found that current evidence is insufficient to balance the potential benefits and harms of such exams for children from birth to age 5. The mission of the USPSTF is to promote health by offering evidence-based recommendations on clinical preventive and counseling services, screenings and medicines.
Racial and ethnic diversity in America’s dental workforce
Dentistry remains a largely white profession in the United States, even as the nation’s population grows increasingly diverse.
More than three quarters of America’s dentists are white according to federal employment data. Meanwhile, minority dentists remain rare and vastly outnumbered in the profession and in their communities.
While more than 12 percent of America’s population is black, fewer than four percent of America’s dentists are black, the Institute of Medicine (IOM) observed in a 2011 survey of the the country’s dental system, Advancing Oral Health in America.
And while Hispanics comprise more than 16 percent of the country’s population, Hispanic dentists represent only 5.36 percent of active dentists, a white paper by the Hispanic Dental Association concluded in a 2013 report.
Asian Americans are the only minority to be more than proportionately represented among the nation’s dentists. While comprising less than 4 percent of the population, they represented nearly 9 percent of American dentists, according to the IOM.
Diversity among health professionals improves access to care in underserved and minority communities and minority providers put patients at ease and provide culturally sensitive services. Minority dental students are more likely than their white peers to aspire to serve minority patients, the IOM observed.
Transmission can occur through direct contact with blood, oral fluids, or other body materials; indirect contact with contaminated instruments, equipment or surfaces; contact by way of the spattering of infected droplets due to the coughing, sneezing or talking; and inhalation of airborne microorganisms.
Infection through any of these routes requires that all of the following conditions, known as a chain of infection be present, according to the CDC:
“a pathogenic organism of sufficient virulence and in adequate numbers to cause disease;
a reservoir or source that allows the pathogen to survive and multiply (e.g., blood);
a mode of transmission from the source to the host;
a portal of entry through which the pathogen can enter the host; and
a susceptible host (i.e., one who is not immune).”
To prevent disease transmission, the CDC points out, infection-control strategies must interrupt at least one link in the chain.
The concept of universal precautions evolved to protect dental patients and workers from bloodborne pathogens through the careful handling of sharp instruments, adherence to correct sterilization procedures, the use of rubber dams, protective garments and meticulous handwashing.
In 1996, the CDC expanded the set of practices and redefined them as standard precautions. These are designed to protect patients and health care workers from both bloodborne pathogens and microorganisms spread via other body fluids, excretions and secretions, broken skin and mucous membranes. Yet, the CDC notes: “saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions.”
Routine dental benefits are missing from Medicare
Since Medicare’s creation in 1965, routine dental benefits, along with hearing and vision coverage, have been missing from the federal health care program that covers 55 million elderly and disabled Americans.
“Medicare is an acute care system, focusing on treating people and curing their diseases, not taking care of all the routine things that come with age,” observed former Los Angeles Times reporter Bob Rosenblatt, who hosts the Help With Aging website and blogs regularly about Medicare.
As a result, dental, hearing and vision services are seldom covered unless they can be shown to be directly related to the medical treatment of an underlying disease.
In the case of dental care, Medicare will pay only for a very narrow range of services that are considered integral parts of covered medical procedures, such as the reconstruction of a jaw damaged by accident or disease, or dental extractions done in preparation for radiation treatment of the jaw. In some cases, Medicare will pay for oral exams but not treatment, preceding kidney transplantation or heart valve replacement.
As American age, advocacy groups have begun to organize efforts to expand Medicare to include comprehensive dental vision and hearing benefits. One group, Oral Health America, estimates that roughly 70 percent of Americans aged 65 or older have no dental benefits of any kind. But at the same time, some in congress have voiced concerns about increased spending on Medicare.
Saliva, the watery fluid produced by the salivary glands, serves many vital functions. It moistens food and makes it easy to swallow and contains an enzyme which aids in the digestion of starch. Just as importantly, the flow of saliva in the mouth protects the teeth and oral tissues from disease. It is rich in components that can attack decay-causing bacteria, as well as calcium and phosphates that aid in the remineralization of tooth enamel. The lack of saliva, a condition known as xerostomia, is a side effect of many medications. It can make the teeth more vulnerable to decay.
Salivaomics, defined as the study of biologic molecules contained in saliva, is a growing field. Saliva is rich in proteins and other substances that are increasingly seen as useful in the screening and diagnoses of oral and systemic diseases. Salivary screening tests for HIV and human papillomavirus are already in use and researchers foresee a day when saliva may be used to detect the presence of various cancers, heart disease, diabetes, periodontal disease and other conditions.
An appreciation of the diagnostic value of saliva has contributed to the growth of the field of research known as salivaomics.
Saliva, the fluid secreted by the salivary glands, contains substances including proteins and bacteria that can serve as markers for a variety of diseases and conditions. While saliva contains many of the molecules found in blood serum, it is easier and cheaper to collect than blood. Salivary screening tests are already available for viral infections including HIV and human papillomavirus. Diagnostic tests for oral and systemic conditions are not as far along, but progress is being made.
Recent research has suggested that two bacteria found in saliva may serve as biomarkers for pancreatic cancer. At the National Institute of Dental and Craniofacial Health, clinical investigators are studying salivary proteins to gain a better understanding of a condition known as graft versus host disease. And a team from the University of California, Los Angeles is investigating the use of saliva technology to detect mutated genes linked to cancers of the neck and throat. At the 2016 meeting of the American Association for the Advancement of Science, the leader of the UCLA team, David T. Wong, a prominent salivaomics researcher, predicted that in the future, saliva-based tests will offer a simple way for health care providers to non-invasively screen patients for a variety of cancers. A device Wong and his team developed which detects biomarkers for a specific type of lung cancer in a drop of saliva is beginning to be clinically tested on patients in China.
The use of saliva in chairside screening tests may one day lead to the closer integration of dentistry and larger health care system, according to Wong and other experts.
School nutrition is important to oral health
Since 2004, public school districts that participate in federal school lunch and breakfast programs have been mandated to establish wellness policies that promote student health. Under these policies, districts are required to adopt nutritional guidelines for all foods and drinks that are available in schools during the school day. These policies were reinforced by the Healthy Hunger Free Kids Act of 2010 which gave the U.S. Department of Agriculture the authority to set nutritional standards for all foods regularly sold in schools during the school day.
As part of the effort to improve school nutrition and model healthy eating habits, many school districts have banned junk food and soft drinks from school vending machines. These efforts, while stirring some controversy, can be seen as representing important steps toward helping ensure better oral health and overall health among students, according to the Association of State and Territorial Dental Directors (ASTDD). The group estimates that American children consume, on average, six cans of soda, containing about 60 teaspoons of added sugar, each week. The consumption of sodas and junk food contributes to poor nutrition and chronic health problems including obesity and dental caries, the disease that causes tooth decay.
“While there has been progress in reducing dental caries over the past 25 to 30 years, it remains a serious problem,” the ASTDD has noted. “In addition to poverty, race, ethnicity and geography, poor nutritional intake and the availability of unhealthy eating choices contribute to the presence of dental caries among school aged children.” The group supports the inclusion of oral health lessons in school nutrition curricula.
Dental caries is among the most common chronic childhood diseases, according to the U.S. Department of Health and Human Services. About one in five children aged 5 to 11 have at least one untreated decayed tooth.
Silver Diamine Fluoride
For years, dentists around the world have used silver diamine fluoride (SDF) to treat tooth decay. Now interest in using the compound as an alternative to drilling and filling teeth is growing in the United States.
In the fight against decay-causing bacteria, some researchers call the agent, silver diamine fluoride, a “silver-fluoride bullet.”
Silver has long been recognized for its antimicrobial properties and fluoride, the ionic form of the element fluorine has been shown to inhibit tooth decay. While some U.S. experts stress that more research is needed, evidence suggests that SDF is not only effective in halting the bacteria-driven decay process but in preventing the development of new caries. The material is cheap and can be easily painted onto the affected tooth.
It has been found to help control tooth pain as well. In 2014, the U.S. Food and Drug Administration (FDA) approved the use of the agent for the treatment of tooth sensitivity in adults.
A handful of U.S. dentists also are using SDF off-label to treat cavities. Clinical trials may eventually pave the way for an FDA application on the use of SDF for the treatment of tooth decay in the United States.
State dental boards
State dental boards are the agencies in charge of licensing and regulating the dental profession under the dental practice acts established by each of the states.
Under a state’s professional licensing process, the board determines whether applicants seeking licensure as dentists and dental auxiliaries meet state standards for education, training, competency and character. State boards also consider complaints against license holders and may take disciplinary action against those found to have violated the state’s dental practice act. They set and define standards that distinguish safe from dangerous practices and may serve as watchdogs for activities interpreted as unlicensed practice. Board members are often licensed dentists and hygienists.
The American Association of Dental Boards has created this mapcontaining links to contact information for each state dental board. The association also maintains links to individual state dental practice acts.
The teeth-whitening debate
Food, drink, tobacco, aging and other factors can stain the teeth. Dental whitening, which involves applying peroxide-containing preparations to the teeth in order to lighten stains on the surfaces, enamel and dentin layers. has grown into a multibillion dollar business in recent years.
Many dentists offer teeth-whitening services, Do-it-yourself teeth-whitening kits are also available in pharmacies. In some states, retail salons and mall kiosks also offer teeth-whitening. The retail providers maintain the services are safe and that they have a right to provide them.
But in a number of cases, dental organizations are fighting the retail providers, arguing they are practicing dentistry without a license and putting customers at risk.
According to the Institute of Justice, a nonprofit libertarian law firm, state dental boards have taken steps to shut down retail teeth whitening businesses in at least 25 states.
Since 2005, at least 14 states have changed their laws and regulations and now ban all but licensed dentists, hygienists and assistants from performing teeth-whitening procedures, according to the Institute for Justice.
On October 14, 2014, the U.S. Supreme Court heard oral arguments in a case involving teeth-whitening. In North Carolina State Board of Dental Examiners v Federal Trade Commission, the FTC took the side of the retail teeth-whitening shops, holding that the state dental board “illegally thwarted competition by working to bar non-dentist providers of teeth-whitening goods and services from selling their products to consumers.”
Temporomandibular Joint Disorder (TMJD, also known as TMD)
This painful condition is believed to affect between five and 12 percent of all Americans, yet it has no standard definition.
The temporomandibular joints located on both sides of the head allow for the movement of the mandible (the lower jaw) for chewing and speaking. TMJD is measured by the presence of various types of pain in the joint and muscle as well as sounds caused by the joint, facial pain and difficulty with chewing and moving the lower jaw.
People suffering from TMJD may experience chronic tenderness in one or both of the joints, swelling or painful muscle spasms. The pain may be localized or radiate from the joint to the head, ears teeth, neck and shoulders.
TMJD is more common among young people than older ones, and is at least twice as prevalent among women as men. Women taking estrogen supplements or oral contraceptives are more likely to seek treatment for TMJD.
A number of factors including trauma, jaw clenching, tooth grinding (bruxism), developmental anomalies and the manifestations of systemic diseases such as fibromyalgia and arthritis can contribute to the onset or exacerbate the pain associated with TMJD.
The variety of factors that may cause or aggravate TMJD have led to a variety of treatments, but some of them have not been adequately tested for effectiveness. More research is needed for a better understanding of this disorder.
How tooth decay works
Tooth decay is the manifestation of a disease known as dental caries, a name taken from the Latin word for rotten.
The mouth has its own delicate ecosystem. Even healthy teeth are covered in a gelatinous biofilm also known as plaque that is made up of complex and sensitive microbial communities.
The consumption of carbohydrates, particularly sugars, can upset the balance within the biofilm, giving rise to caries-causing bacteria, predominantly Streptococcus mutans. When S mutans ferments sugar, acid is generated that can de-mineralize tooth surfaces.
Saliva provides some protection. It contains anti-microbial components that fight pathogens as well as mineral salts such as calcium that can help re-mineralize the teeth. Fluoride in the saliva has been shown to enhance the re-mineralization process.
But when acid is generated with such frequency that re-mineralization can’t keep up (think of between-meal snacks of candy or soda) caries lesions, or cavities, result.
The unmet need for dental care
Nearly 30 million poor children are entitled to dental benefits through Medicaid’s child health component, known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. A majority do not obtain the care they need, however, due to a variety of factors. Poor families frequently confront barriers to obtaining care. They often experience transience, lack of transportation, disruptions to mail and telephone service, and inability to take off from work to get children to appointments.
In addition, a low level of oral health literacy may keep parents from recognizing the need for care and in negotiating the challenges of finding professional care and supervising home care.
Adding to the challenges, is the shortage of dentists serving poor communities. A vast majority of American dentists work in private practice settings, located in more affluent areas. Only 20 percent of the nation’s practicing dentists provide care to Medicaid patients, according to the U.S. Department of Human Services Health Resources and Services Administration.
Many dentists complain of Medicaid’s low reimbursement rates and administrative burdens. While some providers also say that Medicaid patients are more likely to miss appointments, other providers say this issue can be addressed with proper case management.
Poor adults are not entitled to dental care under Medicaid. Adult dental benefits are considered optional and vary from state to state. They are vulnerable to cuts during economic downturns.
Safety-net clinics located in Federally Qualified Health Centers, community health centers, dental schools and state and local health departments offer care to seven or eight million Americans, far short of the estimated 80 to 100 million Americans who need it, according to the Institute of Medicine in its report Advancing Oral Health In America.
Free weekend clinics such as those organized by nonprofits such as the Remote Area Medical Foundation and Mission of Mercy draw crowds of people in need of care. But even many of the providers who volunteer acknowledge that charity care cannot fix the system.
Virtual Dental Home
Virtual Dental Home is an innovative model of dental care now being piloted in California. The project deploys new technology and dental auxiliaries to bring services to needy children in Head Start centers and schools.
The system is designed to extend the current dental workforce to reach underserved areas while addressing the financial, transportation, language and cultural barriers many poor families face in accessing the traditional office-based dental care system.
Under the system, dental hygienists, equipped with small portable dental chairs, laptop computers, digital cameras and handheld x-ray machines set up temporary clinics at schools and other educational settings. Working under the general supervision of an off-site dentist, they provide diagnostic, preventive and early-intervention services. Children with more extensive needs are referred to the dental office for care.
Saliva moistens the mouth and makes food easier to swallow. It also protects the mouth from disease. The lack of saliva, a condition known as xerostomia, or dry mouth, makes the teeth and oral tissues more vulnerable to decay and other infections.
Dry mouth occurs when the salivary glands are not working properly. Diseases including diabetes, HIV/AIDs and Sjögren's Syndrome can cause xerostomia. Dry mouth is also a common side effect of more than 400 medicines, including pharmaceuticals often prescribed for high blood pressure and depression. Radiation treatments, chemotherapy and nerve damage can also impact the production of saliva.
Xerostomia is a common condition, particularly among the elderly. If diagnosed, a healthy care provider can take steps to alleviate the problem by adjusting or changing the medication that may be causing it or recommending the use of artificial saliva.
There are also home health habits that can help address the symptoms of xerostomia. These include the frequent sipping of water or sugarless drinks, the use of sugarless gum and sugarless candy to stimulate saliva flow; and regular brushing and flossing to keep the teeth and gums clean.