TAKE-HOME POINTS
■ Primary care PAs are strategically placed to provide preventive oral health interventions for all populations.
■ Incorporating preventive oral health practices within primary care is cost-effective and benefits patients in all aspects of health.
■ Disparities exist in all patient populations, with noteworthy examples in the pediatric and geriatric populations.
■ Specific guidelines for pregnant females are lacking. Care for pregnant females with oral health disease requires a collaborative approach with community dental experts.
WHO SHOULD READ THIS?
Physician assistants who provide primary care in all communities.
WHY IS THIS IMPORTANT?
The US Surgeon General issued a special report in 2000 identifying the need to improve oral health care in the United States. The report highlighted the widespread nature of preventable oral health problems and the presence of disparities among all populations.1 Given the insufficient number of dental providers and limited patient access to dental health care, PAs in primary care may have the opportunity to provide cost-effective preventive oral health interventions.2
Disparities exist in almost all patient populations. Furthermore, the prevalence of oral disease is correlated with age, socioeconomic status, and access to care. The literature has also documented a correlation between oral and systemic illnesses, which emphasizes the need for primary care clinicians to adopt oral health preventive measures.3 This correlation is perhaps related to new literature which describes dental caries as a multifactorial process, linking infectious, environmental, and behavioral factors. Streptococcus mutans has been identified as the causative organism in dental caries. This bacterial species metabolizes carbohydrates to acid, which subsequently leads to dental decay. Oral fluoride intake, through either the community water supply or supplementation, reduces the susceptibility of teeth to acid.4
WHAT ARE THE CURRENT RECOMMENDATIONS?
Although prenatal care should include an assessment of oral health, specific guidelines for pregnant females are lacking.5 When pregnant females experience an oral health complaint, only about half follow up for evaluation.5 Gingivitis is the most common oral health disease in pregnant females, with a prevalence approaching 75%, and severe disease is linked with preterm labor and adverse pregnancy outcomes.4,5
Additionally, the mother's oral health has been identified as vital to the overall health of the mother herself, the developing fetus, and the neonate. Vertical transmission of S mutans infection from mother to child can occur, and xylitol gum may be used in pregnancy and postpartum to reduce transmission.5,6
The American Academy of Pediatrics recommends the first dental visit by age 6 months.7 However, the number of dental practitioners is insufficient to deliver the recommended care, with few dentists participating in public dental programs and only 3% specializing in pediatrics.7,8 Given that children and adults are more likely to have medical than dental insurance, primary care providers are ideal providers of preventive oral health care.9
Additionally, the United States Preventive Services Task Force (USPSTF) recommends that primary care providers prescribe oral fluoride supplementation for children older than 6 months where the water supply is deficient.10 PAs should adhere to community safety recommendations in order to protect against dental fluorosis, damage to the tooth enamel secondary to long-term exposure to fluoridated water, toothpaste, mouthwash, or supplementation. According to the US Department of Health and Human Services, the prevalence of dental fluorosis among adolescents has increased from 23% in 1986 to 41% in 1999-2004. The overall prevalence among people aged 6 to 49 years remains low, however, at 23%.11
WHAT'S NEW?
Primary care PAs are encouraged to incorporate oral health history and physical examination techniques into health promotion visits. Collaboration between medical and dental providers has led to tools that document the state of oral health, professional practice guidelines, and a Web-based oral health continuing medical education (CME) curriculum for primary care providers called Smiles for Life.12
In an effort to improve access, 38 states reimburse primary care providers for preventive oral health care services, including the application of fluoride varnish.12 Yet according to the most recent data, caregivers sought dental care for only 34% of the 26% of children with public dental insurance,8 and most caregivers do not seek dental care until children reach 3 years old.4 These data support the existing challenges in terms of access to dental care.
WHAT ELSE IS IMPORTANT TO KNOW?
Dental caries are the most common disease in adults and children
13 and the most common chronic disease in children; in fact, dental caries are five times more common than asthma.
4 The overall prevalence of caries among children has increased from 24% in 1988-2004 to 28% in 1999-2004. Children with severe dental disease may have pain, decreased nutritional intake, increased school absenteeism, and overall decreased quality of life.
8,14
The correlation between tobacco and alcohol use and squamous cell carcinoma of the oropharynx is well-documented. Approximately 75% of all oral cancers are attributed to tobacco and/or alcohol use, and most are asymptomatic squamous cell cancers.15 Recent pediatric literature also correlates environmental exposure to tobacco with S mutans colonization,4 which highlights the importance of anticipatory guidance, preventive care, and routine screening.
A number of common medications may lead to xerostomia, or dry mouth secondary to decreased saliva production. Saliva lubricates the oral cavity and protects against decay. Xerostomia is a common age-related change and is associated with the use of various medications (Table 1). Alternative drugs should be considered in patients with xerostomia and/or with existing oral disease.15 JAAPA
This article was written by CSAC chair Alison C. Essary, MHPE, PA-C. Contributors included the other members and staff of CSAC 2010-2011: Gilbert A. Boissonneault, PhD, PA-C; Anthony E. Brenneman, MPAS, PA-C; Marie-Michèle Léger, MPH, PA-C; Mark F. McKinnon, PA-C; Thomas Moreau, PA-C, MS; and Folusho E. Ogunfiditimi, PA-C. The manuscript was edited by Sarah Zarbock, PA-C.
REFERENCES
1. Jacques PF, Snow C, Dowdle M, et al. Oral health curricula in physician assistant programs: a survey of physician assistant program directors. J Physician Assist Educ. 2010;21(2):22-30.
2. Danielsen R, Dillenberg J, Bay C. Oral health competencies for physician assistants and nurse practitioners. J Physician Assist Educ. 2006;17(4):12-16.
3. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician. 2010;82(11):1381-1388.
4. Douglass JM, Douglass AB, Silk HJ. A practical guide to infant oral health. Am Fam Physician. 2004;70(11):2113-2220, 2121-2122.
5. Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. Am Fam Physician. 2008;77(8):1139-1144.
6. Sanchez OM, Childers NK. Anticipatory guidance in infant oral health: rationale and recommendations. Am Fam
Physician. 2000;61(1):115-120,123-124.
7. Mouradian WE, Schaad DC, Kim S, et al. Addressing disparities in children's oral health: a dental-medical partnership to train family practice residents. J Dental Ed. 2003;67(8):886-895.
8. Cantrell C. Engaging primary care medical providers in children's oral health. National Academy for State Health Policy Web site. September 2009. www.nashp.org/node/1153. Accessed April 4, 2011.
9. Mouradian WE, Reeves A, Kim S, et al. An oral health curriculum for medical students at the University of Washington. Acad Med. 2005;80(5):434-442.
10. US Preventive Services Task Force. Prevention of dental caries in preschool children: recommendations and rationale. 2004. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm. Accessed April 4, 2011.
11. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. NCHS data brief, no 53. Hyattsville, MD: National Center for Health Statistics; 2010.
12. Douglass AB, Maier R, Deutchman M, et al. Smiles for Life: A National Oral Health Curriculum. 3rd ed. Society of Teachers of Family Medicine. 2010. http://www.smilesforlifeoralhealth.org. Accessed April 4, 2011.
13. Nguyen DH, Martin JT. Common dental infections in the primary care setting. Am Fam Physician. 2008;77(5):
797-802,806.
14. Riter D, Maier R, Grossman DC. Delivering preventive oral health services in pediatric primary care: a case study. Health Affairs. 2008;27(6):1728-1732.
15. Gonsalves WC, Wrightson AS, Henry RG. Common oral conditions in older persons. Am Fam Physician. 2008;78(7):
845-852.
From the AAPA Committee on Diversity
As the Clinical Watch illustrates, oral health disparities span all patient populations. The article identifies several cost-effective opportunities for PAs to address these disparities at the primary care level. The best target audience may be pregnant females.
Routine and acute prenatal encounters provide the opportunity to address oral health for the expectant mother and constitute important preventive measures for the newborn. These principles may be reinforced during well-baby visits, potentially improving compliance. Advising patients of their health plan dental care entitlements may begin to address the fact that only 34% of children with public dental insurance actually sought care.8 As federal and state government agencies seek ways to cut entitlement costs, PAs should anticipate decreased funding for public dental insurance and expect that fewer dentists will be willing to participate in the plan.
The disparities in oral health illustrated in this Clinical Watch present another example of how PAs can make a difference for their patients with a few minutes spent on patient education. Furthermore, the time spent to review public dental insurance entitlements may provide primary care practices with an opportunity to improve quality of care for their patients and, potentially, a new source of revenue during challenging economic times.8