Prevention.txt

Dentists are oral health doctors; promote health, prevent oral diseases.

• Treat individuals
• diagnose disease and treat patients
• Prosthodontics, endodontics, orthodontics
• Biological sciences guided by need of patients
• research environment is: chairside

• deal with populations
• disease prevention of communities and health promotion
• sample specialties: Epidemiology, occupaitonal health, environmental health, nutrition
• study major threats to/needs of the health of a general population.
• Research environment: in the field 

• applied to entire population (accessible)
• cost effective
• safe

• •Endocarditis
• •Cardiovascular disease
• •Pregnancy and birth
• •Diabetes
• •HIV/AIDS
• •Osteoporosis

there is a lack of awareness of the importance of oral health among the public; and

there is a marked disparity between racial and socioeconomic groups in relation to oral health and overall health issues.

general health

poor diet

a US governernment project, Healthy People provides science-based, 10-year national objectives for improving the health of all Americans.

Goals to : Encourage collaborations across communities and sectors.Empower individuals toward making informed health decisions.Measure the impact of prevention activities.

• 17
• •Access to Preventive Services
• •Oral Health Interventions
• •Monitoring, Surveillance Systems
• •Public Health Infrastructure
• •Clinical recommendations
• •Community Interventions
• •Consumer Information
• •Elderly-Reduce rate of dentures, have good healthy teeth that they can eat with– rate has gone down- the one initiative they are happy about the progress
• •Children-sealants

• Centers for Disease Control and Prevention
• member of US Dept of Health and humand services
• oral health budget is $14.4 M
• TX receies btwn $235K to 355K per yr
• SCHIP is Texas Children's Health Insurance Program covering about 732K children.

• 3 dental schools
• 21 hygiene schools
• 78% of TX public drinking water is fluoridated
• YES.

• 1. Aging of the population
•       It will be different to manage an older population
•       how will retirees pay for care?
• 2. Modification of disease patterns
• 3. Changes in oral health coverage policies

• World Health Organization
• It promotes and supports global health policies (including oral health promotion and disease prevention)

targets to help school children, youth and elderly

it is a good physical (safe) and educational environment where kids have access to adequate safe water and nutrition.

• The sum total of human behavior or
• social characteristics peculiar to a specific group and passed from generation to generation or from one to another within the group.

 the natural belief that one’s native country, culture, language, and modes of behavior are superior to all others.

•People who are ethnocentric use their own culture as the standard of excellence against which people from other cultures are judged. 

• •common but erroneous behavior assuming that people possess certain characteristics or traits because they are members of a particular group. 
• •Stereotypical behavior can be unlearned.

•Race – one of three classifications (White, Black, Mongoloid) of human beings based on physical characteristics, such as skin color, stature, eye color, hair color and texture, facial characteristics and general body characteristics, all of which are hereditary.

ethnos is greek for NATION, and refers to people with common ancestry and culture.

• the unique cultural and social heritage and traditions of groups that reflect distinct customs, language and social values.
• •Ethnic groups share common factors such as language, dialect, nationality, music, folklore, religious beliefs, food preferences, geographical location, and a sense of uniqueness.•Examples of ethnic groups:  Hispanic, Japanese, Polish, Haitian.

• •The differences in race, language, ethnicity, values systems, religion, and local cultures that make up various groups in a community also account for the diversity.
• •It is also called multiculturalism.

• A process by which members of an ethnic minority group lose cultural characteristics that distinguish them from the dominant cultural group or take on the cultural characteristics of another group.
• Minority groups are “absorbed” into
• an established, larger community.

• •Melting Pot– old theory of cultural assimilation. 
• •People from other countries come to the US
• and assimilate into the mainstream white Anglo-Saxon Protestant culture. 
• •Gave up their own cultural identity in
• favor of the predominant culture of the society in which they found themselves. 
• •Thought to result in a blended culture with
• liberty, equality and justice for all.

• •Salad Bowl– current theory of cultural assimilation.•Recognizes cultural diversity as separate
• and unique components that remain heterogeneous within society.
• •Recognizes that culture influences the
• health status, beliefs and behaviors of individuals and that healthcare providers must be prepared to accommodate these differences. 

• •Goals, rights and needs of each person are considered important.
• •Individual has a right to stand up for himself/herself.
• •Individuals take risks independent of the group
• •Feel comfortable revealing their feelings only to people whom they know well.
• •More likely to hide emotions from outsiders.

• Collectivist •Concerns of the group are more important than those of the individual.
• •Group identity is emphasized.
• •Harmony among the members of the group is prized.
• •Assertive behavior seems rude and insensitive.
• •All risk is shared.
• •Discouragement of any negative emotions that might upset people in the group BUT frank about expressing negative emotion to outsiders.

• INDIVIDUALISM: Value is placed on self determination.
• -Shows initiative and works independently.
• -“I’ll make up my own mind.”
• -“The self-made man/woman.”
• COLLECTIVISM-Identifies with and works well with groups.
• Protection in exchange for loyalty and compliance.
• Emphasis is on the group identity.

• Use language primarily to express thoughts, feelings and ideas as clearly and logically as possible.
• Look for the meaning of a statement in the words that were used to express it.
• “Say what you mean and mean what you say.”
• Value being direct and literal. Gets right to the point.
• May be viewed as insensitive and blunt.
• Grow impatient with “beating around the bush.”
• North Americans use low context language.

• Value language as a way to maintain social harmony.
• The listener or the interpreter of the message is expected to “read between the lines,” to accurately infer the implicit intent of the message.
• discover meaning from the context the nonverbal behavior of the speaker (posture, tone of voice), the history of the relationship, and the general social rules that govern interaction between people.
• Value harmony - speak in an indirect way to avoid threatening another person’s “face” (to avoid giving offense).
• Use roundabout expressions. Example: In Japan, rather than saying “No,” a person may say “Let me think about it for a while.”
• High context language is used in Asia and the Middle East.
• If a patient says ‘let me think about that’ instead of ‘I cant afford that treatment right now.’

• Elaborate
• Use language that is much more rich and expressive than most people who speak English.
• Use strong assertions and exaggerations that don’t sound normal to English speakers.
• Can lead to misunderstandings between people from different backgrounds.
• Example: Arabic. If you just say “No” they will think you mean “Yes.” To really say “No,” you have to say it several times and add “By God” or “I swear to God.”
• Succinct
• Most extreme in cultures where silence is valued, such as Native American.

• Formal - not so much a matter of using correct grammar as of defining social position.
• Example: Korean - there are special vocabularies for different sexes, levels of social status and different social occasions.
• Asia and Africa
• Informal - casual friendliness, even to strangers.
• U.S., Canada, Australia, Scandinavia

• The ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural and linguistic needs.
• To become culturally competent, the health care provider must be aware of the impact of social and cultural factors on health beliefs and behaviors.
• Increases access to care for all patient populations.
• Attracts new patients to your practice.

• Epidemiologist
• Research on Hepatitis B being easily transferred from mothers to infants during childbirth
• Randomized blind controlled trial to test efficacy of
• Hepatitis B vaccine in a high risk group
• Helped persuade world health officials to
• include a vaccine for the virus in
• its global recommendations for immunizations

• “Systematic differences in health status that occur among population groups”
• “Differences in health between socially defined groups assumed to be correctable”
• A central goal of population health policy
• Priority setting

• it appears access to care, affording food and education increases life
• may be due to random variation or chance, but this demonstrates social disparities

• US population is so diverse
• no one size fits all solution
• approaches need to be tailored and targeted to individual, community and socio-environmental factors to have positive impact

There is no single solution that will fix the system, which currently leaves tens of millions of Americans without dental care.

• ACTION:
• 1. Several states would benefit from a stronger emphasis on oral health promotion in young children
• 2. Disparities from a young age suggest the need for better engagement of early childhood professionals in oral health promotion.

Advocate!!! - not only restorative, but we want to promote oral health.

A: Early Childhood. One question is “have you had any carries experienced in the past three years? This is b/c if they have, they’ll have more bacteria in their oral cavity from the earlier carriers.

• Surveys
• Epidemiological data
• Identifying patterns of diseases

Disease, Missing, Filled, Treated survey (oldest and most used index in dentistry when studying populations).

• The studies showed positive impact of fluoridation in alaska.
• Lack of water fluoridation and soda consumption (pH) were associated with dental caries severity- did not matter if the child brushed
• No other risk factor, including infrequent brushing or lack of dental floss use, was associated with dental caries severity

• Health of Houston 2010
• Areas of high disadvantage also have the highest level of fair/poor health
• Biggest reason for being uninsured: 1. I couldn't afford it 2. due to where I work I’m ineligible
• 50% of adults had no dental insurance last year. Another 8% had it only part of last year (as opposed to medical where only 34% do not have it)

• Improving quality of life for all Americans
• reducing health disparities

• 1. Increase the proportion of adults who received information from a dentist or dental hygienist focusing on reducing tobacco usage or smoking cessation.
• 2. Increase the proportion of patients that receive oral health services at Federally Qualified Health Centers each year.

• Dental medicare coverage for the elderly is really bad right now
• Healthy people 2010 must measure their results
• Moved away from target of preventing caries in 2-8 year olds
• Did great on objectives of decreasing adolescent caries and decreasing tooth loss in adults aged 35-44

100 million

Children…Poor children have Medicaid Access but few providers make it challenging

49 Million

• Financial barriers
• Cultural barriers
• Structural barriers

• Receives CDC funding to promote growth of school-based and school-linked dental sealant programs
• Monitor and expansion of community water fluoridation program
• Oral health program are in use
• Dental homes…?

• Compared to the national average:
• Texas had lower proportions of children with teeth in excellent or very good condition
• Texas had higher prevalence of caries experience, including untreated decay, among six-to-eight-year-old children
• No difference was noted at the highest socio-economic status level

• Increase awareness of the importance of oral health to overall health and well-being (example).
• Increase acceptance and adoption of effective preventive interventions (examples).
• Reduce disparities in access to effective preventive and dental treatment services.

• National Institute of Dental and Craniofacial Research
• National Institutes of Health (NIH)
• GOAL FOUR: Apply rigorous, multidisciplinary research approaches to eliminate disparities in oral, dental and craniofacial health.
• Goal FOUR works based on 4 objectives: identification of the problem; Support research; provide information to target audience and monitor the oral health status

• Office of the Surgeon General
• First oral health report, published in 2000 (David Satcher, Surgeon General)
• Interactions between oral health and general health and well-being
• DISCUSSED HOW Water fluoridation – one of the 10 top health advances of the 20th century
• Woke people up about oral health connection to systemic health

• Action 1. Change perceptions of oral health.
• Action 2. Overcome barriers by replicating effective programs and proven efforts.
• Action 3. Build the science base and accelerate science transfer.
• Action 4. Increase oral health workforce diversity, capacity, and flexibility.
• Action 5. Increase collaborations.

• The impact of oral disease disproportionately affected disadvantaged groups
• Females and minorities experiencing higher rates of tooth loss than males or whites
• Adequate oral health have the potential to address the major goal established by US Healthy People 2020
• Remarkable progress has been made in improving oral health and addressing oral health disparities

440,000/y in US, 5M/y globally

False: smoking deaths outnumber AIDS+alcohol+drugs+accidents+fire related deaths

20%

85-100%

Smoking Prevalence has been consistently higher among blacks than whites, while Hispanics have lower smoking rates

TRUE

chronic relapsing

Ten attempts

Our job is to help improve the success rate for quitting and in fact good treatments are available which can raise the success 7-8 times. But we are far from having the ideal treatment, yet.

• A.     Nicotine addiction
• B.     Social behavior
• C.     Genetic susceptibility
• D.     Psycho-social susceptibility
• E.      Knowledge and ability to process it
• F.      Advertising/marketing
• G.     Social environment
• H.     Laws, especially “environmental” rules
• (Clean indoor air laws, Bars in California, etc….)

• The Five A’s
• Ask if they smoke
• Advice to quit
• Assess motivation x change
• Assist if willing to
• Arrange for follow-up

• 1. pre-contemplation
• 2. Contemplation
• 3. Determination
• 4. Action (can skip straight to relapse)
• 5. Maintenance
• then either (6.1) Permanent Exit, or (6.2) Relapse back to step 2 or 3.

• Express Empathy
• Develop discrepancy
• Roll with Resistance
• Support Self Efficacy

• Start Bupropion-SR or Chantix 1-2 w. before quit date
• Fix a quite date (Most Important). Remove all tobacco products the night before quit date.
• Follow-up on that date or next day. Provide Nicotine Patch, Nasal or Mouth Inhaler, Gum
• Identify/Educate a support person (best if ex-smoker)
• Educate about the high risk for relapse & and how to cope with it: “don’t quit quitting”.

The concept of reward: Humans, as well as other organisms engage in behaviors that are rewarding; the pleasurable feelings provide positive reinforcement so that the behavior is repeated. There are natural rewards as well as artificial rewards, such as drugs.

Natural rewards such as FOOD, WATER, SEX and NURTURING allow the organism to feel pleasure when eating, drinking, procreating and being nurtured. Such pleasurable feelings reinforce the behavior so that it will be repeated. Each of these behaviors is required for the survival of the species. Remember, there is a pathway in the brain that is responsible for rewarding behaviors.

Certain parts of the brain govern specific functions. Such as the sensory, motor and visual cortex. The cerebellum for coordination and the hippocampus for memory. Nerve cells or neurons connect one area to another via pathways to send and integrate information. The distances that neurons extend can be short or long. For example: the reward pathway

the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex. The VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine which is released in the nucleus accumbens and in the prefrontal cortex. This pathway is activated by a rewarding stimulus. [Note: the pathway shown here is not the only pathway activated by rewards, other structures are involved too, but only this part of the pathway is shown for simplicity.]

NA and VTA, the PC is the decision maker: the connection between NA VTA and PC is used in addiction.

TRUE

• in 2018, 5Million
• in 2028, 7Million
• in 2038, over 9Million

Elderly constitute 13% of US population and 31% of healthcare costs.

• Life expectancy is greater for women of all ages & Women outlive men 7-8 years
• Number about 37 million by 2030.

• Nearly twice as many teeth are projected to be at risk for dental disease in 2030 as were in 1972.
• More primary oral health and preventive services will be required.
• Periodontal and prosthodontic needs will increase.

• the elderly seeking dental services throughout their lives.
• More will retain their teeth.
• Incidence of edentulism is declining in age 65+

False, the number of geriatric pop will far exceed the number of dentists willing...

• Circulatory
• Cardiovascular
• Cerebral
• Mental Disorders
• Diabetes
• Cancer
• Respiratory
• Musculoskeletal

• High blood pressure – 73million
• Coronary heart disease – 18 million
• Stroke – 6.5 million
• Heart failure – 6 million
• Angina pectoris – 8 million reduces risk by 1/3rd
• Peripheral Vascular Disease (PVD)
• Deep Vein Thrombosis (DVT)

False, Women are at a greater risk of circulatory disease after age 65.

2 times as likely

80 Million people have some form of CVD

estimated 75%

CVD can be affected by moderate to severe periodontitis; they should receive evaluation and possible treatment for disease state and prevention. we should work in collaboration with physicians to reduce inflammation.

Stroke is the third leading cause of death (7%) causing 160,000 deaths/year

African American Women

• Risk Factors
• Chronic hypertension
• Atherosclerosis
• Smoking
• Tobacco use
• Heart disease
• Diabetes
• Inactivity
• Elevated cholesterol & lipids *Alcohol Use
• Obesity

• Loss of Motor control and coordination
• Dysphagia (difficulty swallowing)
• Dysarthria (speech disorder)
• Decrease in muscle tone of affected side
• Cognitive deficits such as confusion
• Visual disturbances or perceptions
• Communication deficits (word-finding)
• Changes in the facial muscles, movement or sensory problems due to dysphasia or numbness.
• [… so, Dentures may no longer fit →discomfort, pain]
• Reduced fluid intake → dry mouth may result
• Reduced ability to chew or swallow→ poor nutrition→ poor health
• Oxygen therapy → dry mouth
• Medications → dry mouth is a side effect of 85% of drugs, some contain sugar=decay
• Food remains in mouth → needs total oral care assistance

1 in 4

• (they break down collagen) They are are enzymes that break the peptide bonds in collagen.
• They assist in destroying extracellular structures in pathogenesis of bacteria such as Clostridium. They are an exotoxin (a virulence factor) and help to facilitate the spread of gas gangrene. They normally target the connective tissue in muscle cells and other body organs.

Periodontal disease results in higher pro- inflammatory cytikine TNF-alpha that causes insulin resistance.

• * Anxiety
• * ASD (Acute Stress Disorder)
• * Agoraphobia/Social Phobia/Simple Phobia * OCD (Obsessive Compulsive Disorder)
• * PTSD (Post Traumatic Stress Disorder)
• * GAD (General Anxiety Disorder)
• * Childhood disorders
• * Tourette’s
• * Mood - Major Depression and Bipolar Disorder (Manic/Depressive)
• * Psychotic
• * Personality Disorders – schizoid, narcissistic, schizoaffective (combo)
• * Schizophrenia – delusions/hallucinations
• * Substance Related – work, sex, gambling, caffeine, nicotine, food, eating, drugs, alcohol

• *Over brushing
• *Picking at teeth
• *May do no oral care
• *May not accept treatment
• *May upset your office
• *Lot of the meds cause side effects – xerostomia
• *Dyskinesia and dystonia - abnormal movements (dentures are difficult)
• *Behavior is unusual

• *Rapidly failing memory
• *Disorientation
• *Confusion
• *Difficulty expressing thoughts
• *Paranoid suspicion about her family and the hospital staff

5.1 million

• * they may be or become Uncooperative
• * try to set Morning appointments
• * Sedation is an option
• * Focus on preventive
• *Acknowledge caregiver
• *Decide what is maintainable

• *geriatric Depression Scale
• *Clock Drawing Test
• *Mini-mental state exam
• *CAGE testing for substance abuse

• * Mucositis (and xerostomia)
• * Candidiasis

• * URI -upper reps. infect. do not treat
• * Upright positioning
• * Avoid rubber dam in severe cases
• * Pulse oximetry (if pulse ox <91%, use low flow 2-3L/min)
• * Avoid Nitrous oxide/oxygen in severe cases
• * Avoid barbiturates, narcotics, antihistamines, and anticholinergics
• * Steroid supplementation ???
• * Drug interactions with COPD medication

• * Avoid precipitating factors
• * Bring inhaler for each appointment
• * Avoid ASA, NSAIDs, barbiturates, and narcotics
• * Drug interactions -asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine)
• * Steroid supplementation ???
• * For sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended

• Arthritis
• Osteoarthritis
• Rheumatoid
• Gout
• over 100 others

CRP=C-Reactive Protein

Conclusions (based on data derived from self-reported health conditions) conclude that there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheu. arthritis and vice versa.

• Observe brushing – can the person maneuver toothbrush
• *Toothbrush modifications – check finger grasp
• *Arthritis medication – implications for treatmentespecially if they will have pain after appointment
• *AB coverage if joint replacement – more prevalent
• *Do better for afternoon appointment – will be more comfortable

• Assess each category of chronic condition
• *Know effects for body and mouth
• *Learn treatments and medications given
• *Elderly are not dependable reporters of status, past disease, medications
• *Collaborate with other health care professionals to know your patient’s past history

• What genetic, biomedical, behavioral, and social factors are crucial to maintaining health and functional capacities in the later years?”
• They Examined longitudinally a large cohort of independent elders on several physical, cognitive, emotional, and social parameters.

Common predictors have emerged, such as remaining active physically and cognitively, maintaining social contacts, and avoiding disease.

• Neglect, Illness, Finances *Periodontal Disease
• Caries
• Tooth Loss
• Education, Restoration, Rehabilitation, Repeat Cycle

• If facility accepts Medicaid patients, must abide by federal regulations
• Facility must offer dental services
• Nurse will examine mouth
• (if federal funds received) MDS form Sections L & M pertain to oral
• Must provide for oral needs (toothbrush etc)

• Finances
• Transportation
• Health
• Priority

• Cardiovascular Disease
• Cerebrovascular Disease
• Mental Disorders
• Depression
• Cognitive Disorders
• Dementia
• Diabetes
• Respiratory Disorders
• Arthritis

• Increased Susceptibility to Surface Infection (Candidiasis)
• Increased Susceptibility to Caries and Periodontal Disease
• Altered Taste Sensation
• Increased Injury to Oral Soft Tissues
• Increased Abrasion / Erosion of Teeth
• Burning Discomfort
• Halitosis

It is a fungal infection of the mouth (increased susceptibility to surface infection due to xerostomia

TRUE (will be 20% (70 million) in the population, and hispanics will be 16%)

• Cultural issues?
• Speak English?
• Gender issues? Marital status?
• Ratio of men to women
• Men more than likely will be married * Emotional well being
• Availability of caregivers
• Income of widows