Dental Care for Primary Care (Gonzalez, 4/14/2021)

Great thanks and Happy Birthday to our Grand Rounds speaker this week, Gina Gonzalez, DDS for a comprehensive review of what primary care doctors should know about dental care: Oral Health for the Primary Care Provider. Dr. Gonzalez took us from the cradle to the grave (or crib to casket, so to speak) and motivated me to schedule a dental preventive visit ASAP! 

She reminded us that the mouth is an important part of the body, and when medical providers are seeing patients, we should definitely be examining their mouths, giving them preventive dental care recommendations, and screening for oral cancers. 

For those of you who missed it, a link to the video recording can be found HERE. For those of you who prefer the summary, here are my summary notes:

Tooth decay and periodontal disease are 100% preventable

• 92% of US adult have dental disease, 50% have gum disease, 5% of adults are edentulous
• 42% of US children have early childhood cavities (i.e. in baby teeth)
• Fluoride reduced decay by 50%

Pediatrics:

Prevention

• Cavities are an infectious disease! Strep mutans is the oral bacteria transmitted from adults' mouths to babies' mouths Pro tip: don't kiss babies on the mouth (you'll give them your bacteria)
• A baby's first visit to the dentist should be as soon as baby has its first tooth (parental education: how to care for the mouth, fluoride-- remember, in Sonoma County, we don't have fluoridated water, so parents need to use fluoride supplement or a fluoride containing toothpaste)
• To get a good look in a baby's mouth during your exam, try doing a knee-to-knee exam (see photo), in which the baby straddles parent and head is in examiner's lap 

  

  knee to knee dental exam position

  
  
• Kids should NOT use toothpaste unless they know to spit OR parents can put about 1/4 size of pea (can wipe away, is not harmful)
• Breastmilk (and formula ) both have a lot of carbs--> don't forget to wipe down baby's mouth after they feed
• Fruits and veggies that contain fluoride include: grapes, spinach, oatmeal and carrots
• Brush baby's teeth every day!
• Early childhood caries can be prevented: no fall asleep after nursing/bottle without wiping the teeth, only water in the bottle, clean
• No soda!

Pathology

• Rarely, infants are born with a neonatal tooth (often rudimentary root), which be easily extracted, particularly if they are making problems with breastfeeding
• Silver diamide fluoride is treatment for ECC (it may be ugly but STOPS the decay and avoids general anesthesia, capping, etc.)
• When a child is getting their adult teeth, two rows of teeth is normal, usually teeth come out on the own, don't worry!
• If a child's tooth comes out due to trauma, put the tooth back in child's mouth while you seek care; if you are worried they cannot safely do so, put the tooth in your own mouth (saliva is good for preserving the root). A third choice is to put it in milk (not water, which is dehydrating)
• In children, purulent abscess can form due to trauma or decay; if you see one, they critically need treatment 

Adults

Prevention

• Advise adults to floss their teeth before they brush: fluoride goes into cleaner space
• Power brushes can remove more plaque than traditional toothbrush
• Tongue hygiene brush is a good idea
• Drink water that is similar to pH of saliva (6.-7.6), bubbly water is acidic, saliva lubricates and bathes your teeth

Pathology

• Tooth decay is a result of poor hygiene, poor diet, genetics, prescription medications (e.g. SSRI, BP meds can cause a lot of dry mouth, leading to cervical decay--> add fluoride, brushing)
• soda is bad! 46gm sugar, very low pH
• Periodontitis is irreversible gum disease; it requires urgent and imperative tooth care
• As teeth decay and become abscess, infection can go through the bone, full of pus, hard to numb 
• As patients age, elders tend to drop out of routine care (transportation); don't forget to talk about how they are accessing dental care at well check visits
• Edentulism is a travesty! When teeth removed, you lose proprioception, start chewing funny, lose pressure to eat, get jaw collapse--> poor appetite, failure to thrive. Dental implants (with dentures attached) are superior!

Oral cancer screening is important and quick!

• grab a gauze, pull the tongue out!
• All you need: 2x2 gauze, tongue depressor and flashlight
• high risk locations for oral cancer: floor of the mouth, lateral borders of the tongue, junction of the hard and soft palate, and posterior oropharynx
• to do a cancer exam:
• look at skin of face, scaling, irregular and dark changes, particular attention to ear
• palpate back of neck, clavicular nodes, SCM, submandibular and sublingual glands
• eyes: Movement, melanoma, sclera
• look in nose
• look at vermillion border of mouth
• palpate bimanually to feel for anything fixed, parotid gland (tenderness occlusion), check joints (pops/clicks, jaw deviation)
  
• lateral border of tongue, floor of mouth, symmetry, gums/bones/teeth
• palpate inside mouth, junction of hard/soft palate
• look for symmetry!
• can be done in 3 minutes!
• oral cancer risks: tobacco, alcohol, vaping

Okay, now for a quiz: are these oral lesions benign or cancerous? Name these abnormalies (answers below)

A.

B.

C. 

D.

E.

F.

G.

H.

I.

J.

K.

A. black hairy tongue (benign) B. oral lichen planus C. Pyogenic granulomas (aka "pregnancy tumors") (benign) D. fordyce granules (benign) E. Geographic tongue (benign) F. Labial HSV G. Oral HPV H. Squamous cell cancer I. Squamous cell cancer  J. verrucous carcinoma K. precancerous lesion from snuff