The relationship between oral health and systemic health has been well documented. Poor oral health has been associated with diabetes, coronary artery disease, and metabolic syndrome.1–5 The exact mechanisms are not truly understood but seem to be related to chronic inflammation. To support this relationship, researchers have connected inflammation of the gingival tissues, either with or without periodontal disease, to adverse outcomes in pregnancy, such as premature birth and low birthweight infants.6 Inadequate oral health negatively impacts quality of life and mortality as well.7
Despite the importance of oral health, a lack of access to dental care in the United States is a significant health problem. An estimated 130 million adults and children lack dental care coverage, and 30% of the population is unable to obtain basic dental services.8,9 In a seminal report on oral health, the Surgeon General provided extensive detail on the extent of dental disease in the U.S. population and declared dental caries in children a “silent epidemic.”10
Nurse practitioners (NPs) are in a prime position to improve the oral health of their patients and to address these health disparities. Two Institute of Medicine reports advocated the use of nondental health professionals to improve oral health through assessments, patient education, and preventive care within the context of primary care settings.11,12 The purpose of this article is to provide NPs with concrete information regarding caries risk assessment for children and adults, chemical therapy to prevent progression of the dental caries process, and appropriate patient education to prevent caries.
Glossary of select oral health terms
Many NPs are unfamiliar with common dental and oral disease terms. This is most likely due to a lack of oral health education in graduate curricula. This is not a problem unique to NPs, as oral health information is nearly nonexistent in graduate nondental programs.13,14 NPs may find the following terms and explanations helpful.
Anatomy of a tooth. An excellent picture of the inside of a tooth is available at www.allthingsstemcell.com/tag/mesenchymal/. The outside of the tooth, the part visible during oral exams, is composed of enamel. Enamel may become yellow with age because of chronic staining and also because enamel becomes thinner with age; the darker dentin becomes visible through the thinning enamel. Dentin is a calcified tissue that is denser than bone. Dentin forms below the enamel. While normally yellow, it can present as gray to black.15 Dentin protects the innermost part of the tooth, the pulp. The pulp contains nerves, blood vessels, and connective tissue all contained within the pulp chamber in the center of the tooth structure.16 The blood vessels and nerves exit the tooth via canals that extend into the roots, or apex, of the tooth. The tooth is anchored by a tissue called cementum, which covers the dentin under the gingival tissue.17 Cementum attaches to the periodontal ligament, which in turns attaches to the alveolar bone lining the upper and lower jaws.
Dental plaque is a collection of microorganisms that form a biofilm and adhere to tooth surfaces, although it can also form on dentures.18,19 In healthy mouths, the microorganisms forming dental plaque exist in a homeostatic state, much like the microflora found in the gastrointestinal tract. In individuals who consume high quantities of simple sugars, the presence of fermentable sugar encourages the growth of streptococcus mutans and lactobacilli in the plaque. These bacteria create acid as they metabolize the simple sugars in the oral cavity.18 The acid production can erode tooth enamel and cause pits and grooves in the enamel, known as dental caries. Dental plaque can also harbor other pathogens, such as those associated with pneumonia.20
Caries are cavitations in tooth enamel as a result of acid produced by bacteria interacting with carbohydrates. In small children, cavities usually occur initially in the upper incisors because these teeth erupt the earliest and are not protected by saliva.21 In older adults, caries are more likely to form around earlier restorations or on the roots of teeth because of gingival recession.22
Gingivitis. The part of the gum that abuts teeth is the gingiva. When oral hygiene is insufficient, dental plaque accumulates in the gingival margin creating an inflammatory lesion in the gingiva known as gingivitis.23 Gingivitis is a sign that periodontal disease is a risk; gingivitis does not actually become periodontal disease. Inflammation of the gingiva, however, causes the vasculature in and around the teeth to dilate and proliferate. This provides better opportunities for bacteria to access systemic circulation.24
Periodontitis is the destruction of periodontal fibers and alveolar bone, which ultimately leads to tooth loss. The extent of periodontitis is affected by the amount of bacteria in the oral cavity, the composition of these bacteria in the plaque, the existence of comorbid illnesses such as diabetes, and lifestyle factors, such as tobacco and alcohol use.23 Chronic periodontitis, like gingivitis, causes the vasculature in and around the teeth to dilate and proliferate and then provides additional routes for bacteria to invade the systemic circulation.24
Persons at risk for poor oral health
The populations with high rates of dental disease and problems accessing dental care include, but are not limited to, rural, low-income, minority, developmentally disabled, older adults, institutionalized populations, as well as pregnant women and homeless individuals.12 Rural populations, which tend to have higher poverty rates and longer travel distances as key barriers to oral healthcare, have lower utilization of care and higher rates of dental disease.25 Black patients are at the highest risk of periodontitis, tooth loss, gingivitis, abscesses, xerostomia, and soft tissue lesions because this population has the highest incidence of diabetes relative to any other racial or ethnic group.26 Twice as many Hispanic children are likely to have untreated dental caries compared with non-Hispanic White children. Mexican children are less likely to have ever visited a dentist compared with Puerto Rican, Central, and South American, Cuban, and other Hispanics.27
Furthermore, the growing older adult population in the United States poses many challenges to oral health, even more significant in light of a study, which found 58.3% of American Indian older adults were totally edentulous.28 Dependent individuals in institutional settings, a growing segment of the U.S. population, are rarely served by the traditional dental care system and present a number of unique challenges including comorbidities or special needs, which dental professionals are often unprepared to deal with.29
Early childhood caries (ECC) is an infectious and chronic disease that results in tooth destruction in children up to age 5.21 ECC affects up to 50% of children in low socioeconomic communities.21 Dental caries is not a condition affecting only children but ultimately impacts over 95% of all adults at some point in their life.30 Destructive periodontal disease is similarly progressive, affecting 52% of adults over age 60.31 Periodontal disease is associated with respiratory and cardiovascular disease.32,33 Dental diseases are preventable, yet, when left unchecked, can progress to cause tooth destruction, pain, infection, and, in some cases, death.34,35
NPs are particularly well suited to deliver preventive dental care. Patients often seek help for dental problems within the medical system where NPs provide primary care, health promotion, and disease prevention.36,37 NPs are poised to provide interventions to improve oral health from instructing patients on proper oral hygiene techniques, to applying fluoride varnishes and prescribing fluoride gels.34
Caries Management by Risk Assessment
NPs can play a major role in regards to areas of caries risk assessment and the provision of chemical therapy to prevent the progression of the dental caries process, coupled with referral to dentists for any necessary restorative work, such as fillings. One such proposed paradigm is Caries Management by Risk Assessment (CAMBRA). CAMBRA is the result of dental research scientists translating their findings into evidence-based tools for clinical practice.38,39 The CAMBRA protocol was pioneered at UCSF School of Dentistry.40–42 “CAMBRA provides an evidence-based methodology to assess caries disease indicators and risk factors on an individual basis. Results are the basis for an individualized treatment plan, which include behavioral, chemical, and minimally-invasive restorative procedures that are most appropriate for the individual patient.”43 Implementing this protocol for dental practitioners requires a paradigm shift in the practitioners' management of dental disease–moving away from a restorative mindset toward a focus on risk-based, patient-centered disease management.
CAMBRA is a philosophy rather than a proprietary, step-by-step system.43 The therapeutic products available are continually being improved so that specific protocols will need to be generic and capable of continual update without changing the basic premises. CAMBRA uses a simple caries risk assessment tool to determine whether a patient is at low, moderate, high, or extreme risk. (See Caries risk assessment form: Age 6 to adulthood and Caries risk assessment tool up to age 5.) The risk level determines the therapy, with additional intensity and additional products being added as the risk increases. The chemical therapy is then used by the patient at the same time as any necessary restorative work is being done. The aim is to bring every patient to low risk and to maintain the health of their teeth indefinitely via simple chemical therapy.41,42,44
Dental Caries Mechanism as a basis for CAMBRA–The caries balance
As discussed earlier, acid-producing bacteria that are incorporated into the biofilm (plaque) on the teeth produce acid when they ferment carbohydrates. This acid travels into the tooth and dissolves the mineral component of enamel or dentin. If this process is not reversed, a cavity results.45 The body has a complex defense mechanism against caries progression that relies upon saliva and its many components. There are proteins and lipids in saliva that protect the tooth and, most important, calcium and phosphate that replace lost mineral from the tooth and repair early lesions by remineralization.
Dental caries is a multifactorial disease that is best understood as a balance between pathologic factors and preventive factors.45,46 The pathologic factors are caries-inducing bacteria that produce acid by fermenting carbohydrates (numerous species involved), frequent (numerous times per day) ingestion of fermentable carbohydrates, and salivary dysfunction caused systemically or by therapy, such as radiation or hyposalivatory medications. The protective factors include adequate salivary function and amount, remineralization of partially dissolved tooth mineral, requiring fluoride, calcium/phosphate, and extrinsic antibacterial therapy, such as chlorhexidine, sodium hypochlorite, and others in development. The basic idea of CAMBRA is to assess the risk, using the caries balance idea as a basis, to then alter the risk and provide stability into the future. The more the pathologic factors outweigh the protective factors, the higher the risk of caries. In other words, therapy requires lowering the bacterial challenge while increasing the effect of the protective factors in order to enhance remineralization. This guiding principle underpins chemical therapy and is right in the realm of the NP's activity.41,42
The simple steps for the CAMBRA approach for patients ages 6 years through adult are as follows:
- Obtain a medical and dental history to determine several of the risk factors and disease indicators, such as hyposalivatory medications and prior dental restorations.
- Perform a clinical exam to identify carious lesions, which range from precavitated demineralization to open cavities. Early demineralization appears as enamel defects, such as white lines near the gingival margins.21 As the enamel is eroded by bacterial acid, yellow spots can appear as the underlying dentin is exposed. Cavitations appear as pits, which can enlarge and open directly onto the dentin so that teeth appear to have dark centers.21 Excellent pictures of demineralization and caries can be found in the Smiles for Life Curriculum available atwww.smilesforlifeoralhealth.com (located in modules two and three).
- Complete the caries risk assessment form using items from 1 and 2 above plus additional questions.42 The form was recently validated in a retrospective study of over 12,000 patients.47 Using the form, NPs can identify disease indicators, pathologic risk factors, and preventive factors and determine the level of caries risk: low, moderate, high, or extreme.
- Determine a treatment plan, including chemical therapy, based upon the caries risk level.
- Provide the patient with written instructions, dispense products, and use motivational interviewing to improve adherence.48
- Refer to general or pediatric dentist for necessary restorative work.
- Plan follow-up, recall, and new risk assessment according to the level of risk. High-risk patients should be recalled after about 4 months.
Therapeutic Agents by Caries Risk Level (ages 6 years through adult)41,49:
- Low risk: Two times (or more) daily brushing with an over-the-counter fluoride-containing toothpaste.
- Moderate risk: Advise the patient to brush at least twice daily with an over-the-counter fluoride-containing toothpaste. In addition, prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for one 7-day period each month. For the remaining 3 weeks, have the patient rinse twice daily with over-the-counter sodium fluoride products containing 0.05% sodium fluoride after brushing. This regimen should be repeated monthly for 6 months, and the patient should be reevaluated after that period for caries risk improvement.
- High risk: Apply fluoride varnish at the initial visit, and every visit thereafter, until risk status is reduced. An excellent video demonstrating the correct application of fluoride varnish is available at www.smilesforlifeoralhealth.com. Prescribe chlorhexidine gluconate mouthrinse, 10 mL daily for 1 week monthly, to be repeated every month. Prescribe 5,000 ppm fluoride toothpaste to be used twice daily. Instruct the patient to brush first prior to using the mouthrinse. Have the patient return to the clinic in 4 months for a reevaluation of caries risk.
- Extreme risk: This category is high risk plus salivary dysfunction (hyposalivation). Follow the same protocol for high-risk patients, and instruct patients to sip from a water bottle with one teaspoon of baking soda added for pH control.
Chlorhexidine gluconate rinse can discolor teeth if used without brushing.20,50 Exposed dentin will become discolored first followed by the enamel.51 Restorative surfaces, such as ceramic crowns, can also become discolored.51 Discoloration is usually detected in patients who undergo periodontal surgery and cannot brush due to sutures or concerns over tissue disruption. Because this protocol involves using the chlorhexidine rinse for a 1-week period (monthly), and tooth brushing is not suspended, the risk of discoloration is negated. Products containing essential oils (such as menthol, thymol, and eucalyptol) and antistaining ingredients may be alternatively prescribed.51,52
The application of fluoride varnish is a safe practice. The amount of varnish used is extremely small, and accidental ingestion during the application process does not create any risks from fluoride overdose.21 Dental fluorosis is a potential adverse reaction from the use of fluoride-containing products. Dental fluorosis is the alteration of tooth enamel that ranges from nearly indiscernible fine, white, lacy webs or pits to pronounced roughened surfaces.53 Dental fluorosis results from overingestion of fluoride while the enamel is being formed below the gingival surface. It can only occur in children 8 years of age or younger. Dental fluorosis can be prevented by using pea-sized amounts of fluoridated toothpaste (discussed below); adult supervision to prevent ingestion of fluoride-containing products by children younger than 6 years of age; and avoidance of fluoride rinses in children under the age of 6.53
Caries prevention: Oral hygiene
The majority of oral health problems can be controlled with simple oral hygiene education, especially when the risk level has been lowered as described above. Unfortunately, simple oral hygiene will not control dental caries in moderate- and high-risk individuals, necessitating the protocols discussed above.
NPs can educate parents about the importance of caries prevention, which should begin as soon as any teeth appear. Teeth should be gently cleansed, as soon as they erupt in babies, after eating via a soft cloth or soft pediatric toothbrush.21 Placing babies to bed with bottles and sippy cups that include juice, honey, milk, or sweetened beverages should be avoided completely. If necessary, the bottles and sippy cups should contain only water. Sweet drinks, such as soda and sweetened fruit drinks, should be avoided—not only because of the development of caries, but for health reasons. Parents should encourage the consumption of fresh fruits in lieu of fruit juices.
Brushing and flossing are important skills to instill in small children and to reinforce throughout the life span. Soft toothbrushes are preferable in order to prevent inadvertent enamel abrasions. Young children should be supervised by parents until around age 6, using smaller amounts of toothpaste on the brush (a smear for babies and a pea-sized amount for toddlers).21,44 Alcohol-free fluoride rinses should also be encouraged after age 6. Flossing does not have to involve string floss. Proximal or interdental brushes are viable alternatives. These brushes can be single-use disposables, which look like plastic toothpicks with spiral brushes. Multiple-use brushes look like standard toothbrushes with a spiral brush on the end. The spiral brush is placed between the teeth to remove debris. The parent can use the interdental brush initially, teaching the child to use it until he or she becomes more adept.
Oral hygiene remains important throughout adulthood. The use of proximal brushes can be suggested to adults as well, who may find them easier to use than traditional string floss. Some adults prefer floss heads, which can be mounted onto toothbrush handles. Individuals with cognitive limitations, such as those with dementia or with delayed intellectual development, may find tooth brushing and flossing scary. One researcher found that persons with dementia who resisted mouth care were reacting out of fear and perceived threat to their bodily integrity.54,55 Mouth care fear can be overcome in these individuals through a variety of simple strategies. For example, having the caregiver brush his or her teeth alongside the individual with cognitive limitations may reduce care-resistant behaviors. Other techniques include the use of pantomime, gestures, and distractions.54
Implications for practice
NPs' scope of practice and reimbursement capacity for different services varies by state and across funding sources.56 As primary care providers, NPs can provide oral health screening, oral health education, and oral healthcare referrals. (See Patient handout for caries.) Providing these services is not a legal scope of practice question but rather a question of training, standards of care, and reimbursement. Nursing education does not often provide training on oral health as a core component of overall healthcare or best practices in techniques for oral healthcare assessments. There is an acknowledged need to increase primary healthcare providers' knowledge of the etiology of caries, particularly in relation to infants, children, and also in the context of adults or patients with multiple comorbidities.57
The dental reimbursement system has traditionally been separate from medical care reimbursement, creating an additional barrier for NPs to bring these services into their practices. Increasingly, preventive oral health interventions such as fluoride varnish, oral exams or screenings, anticipatory guidance, or oral health risk assessment (such as CAMBRA) are being provided by nondental healthcare providers in hopes that early intervention can prevent future disease.58 In 2009, 40 states allowed medical primary care providers, including NPs, to receive reimbursement from Medicaid for providing preventive oral healthcare services.58 The requirements for reimbursement vary by state; some states require services to be provided together, and others require a certification course in risk assessment, intervention, education, and referral in order to qualify.58 Changing reimbursement mechanisms are also increasing the potential for more oral health services to be provided as part of primary care.59
Putting it all together: The NYU Nursing-Dental Model Exemplar
New York University provides a creative example of how previously disparate disciplines came together to address oral healthcare and related interdisciplinary teaching, research, and practice. In 2005, New York University's College of Nursing and College of Dentistry formed one academic unit in order to create new synergies in research, teaching, and practice. The Nursing and Dentistry faculty collaborated on papers related to the workforce, oral health education and practice advances, and ways the two disciplines could come together to screen for diabetes, human immunodeficiency virus, hypertension, and chronic diseases, which may have previously been overlooked during the dental encounter.60–68 From the perspective of the nursing faculty, oral health assessment had been underappreciated in the discipline as a critical way of addressing the oral-systemic connection and the essential nature of oral health assessment to help identify early symptoms that might indicate cardiac disease or cancer, for example.69
An innovative practice model was developed in which the college of nursing created a faculty practice that was colocated in the dental school where over 325,000 patient visits are completed annually. With over 1,800 patient visits a day, the Dental and Nursing faculty agreed that they would offer each patient, as appropriate, the opportunity to be seen by an NP during their dental visit. This activity has spawned a great deal of enthusiasm in the faculty and the patients whom they serve. Clearly, these are creative, synergistic, and valuable opportunities.
Promoting oral health
NPs can promote the systemic health of their patients by addressing oral health. One contribution NPs can make is in the area of caries risk assessment and management. This is an area that NPs may not feel comfortable addressing. There are many resources available that NPs can access:
- The American Association of Pediatricians provides a set of oral health tools for use by anyone with pediatric patients: www2.aap.org/commpeds/dochs/oralhealth/PracticeTools.html.
- The American Academy of Pediatrics Oral health Section tracks reimbursement for oral health activities, including the application of fluoride varnish: http://www2.aap.org/commpeds/dochs/oralhealth/State.html.
The Smiles for Life Curriculum is comprised of eight modules that explore oral health issues among the life span. Clinicians can register to receive free continuing-education credit associated with each module at: www.smilesforlifeoralhealth.com.
A 30-minute video that demonstrates methods to provide mouth care to individuals with dementia who resist care can be accessed via the Portals of Geriatric Online Education (www.pogoe.org). The video is titled Oral Hygiene & Care-Resistant Behaviors: Making a Difference. In order to locate and view the video, users must register (at no charge) and type the product identifier 20998 in the search box.
Patient handout for caries
HOW TOOTH DECAY HAPPENS (to be given to each patient)
Tooth decay is caused by certain types of bacteria (mutans streptococci and lactobacilli) that live in your mouth. When they attach themselves to the teeth and multiply in dental plaque, they can do damage. The bacteria feed on what you eat, especially sugars (including fruit sugars) and cooked starch (bread, potatoes, rice, pasta, and the like). Within just a few minutes after you eat or drink, the bacteria begin producing acids as by-products of digestion. Those acids can penetrate into the hard substance of the tooth and dissolve some of the minerals (calcium and phosphate). If the acid attacks are infrequent and of short duration, your saliva can help to repair the damage by neutralizing the acids and supplying minerals and fluoride that can replace those lost from the tooth. However, if: 1) your mouth is dry, 2) you have many of these bacteria, or 3) you snack frequently, then the tooth mineral lost by attacks of acids is too great, and cannot be repaired. This is the start of tooth decay and leads to cavities.
CONTROLLING TOOTH DECAY
Diet: Reducing the number of sugary and starchy foods, snacks, drinks, or candies can help reduce the development of tooth decay. That does not mean you can never eat these types of foods, but you should limit their consumption particularly when eaten between main meals. A good rule is three meals per day and no more than three snacks per day.
Fluorides: Fluorides help to make the tooth more resistant to being dissolved by the bacterial acids. Fluorides are available from a variety of sources, such as drinking water, toothpaste, over-the-counter rinses, and products prescribed by your dentist such as brush-on gels or high-fluoride toothpastes used at home, or gels, foams, and varnishes applied in the dental office. Daily use is very important to help protect against the acid attacks.
Plaque removal: Removing the plaque from your teeth on a daily basis is helpful in controlling tooth decay. Plaque can be difficult to remove from some parts of your mouth especially between the teeth and in grooves on the biting surfaces of back teeth. If you have an appliance such as an orthodontic retainer or partial denture, remove it before brushing your teeth. Brush all surfaces of the appliance also.
Saliva: Saliva is critical for controlling tooth decay. It neutralizes acids, and provides minerals and proteins that protect the teeth. If you cannot brush after a meal or snack, you can chew some sugar-free gum. This will stimulate the flow of saliva to help neutralize acids and bring lost minerals back to the teeth. Sugar-free candy or mints could also be used, but some of these contain acids themselves. These acids will not cause tooth decay, but they can slowly dissolve the enamel surface directly over time (a process called erosion). Some sugar-free gums are designed to help fight tooth decay and are particularly useful if you have a dry mouth (many medications can cause a dry mouth). Some gums contain baking soda that neutralizes the acids produced by the bacteria in plaque.
Gum that contains xylitol as its first listed ingredient is the gum of choice. If you have a dry mouth, you could also fill a drinking bottle with water and add a couple teaspoons of baking soda for each 8 oz of water and swish and spit with it frequently throughout the day. Toothpastes containing baking soda are also available by several companies.
Antibacterial mouth rinses: Rinses that your dentist can prescribe are able to reduce the numbers of bacteria that cause tooth decay and can be useful in patients at high risk for tooth decay.
Sealants: Sealants are plastic or glass ionomer coatings bonded to the biting surfaces of back teeth to protect the deep grooves from decay. In some people the grooves on the surfaces of the teeth are too narrow and deep to clean with a toothbrush, so they may decay in spite of your best efforts. Sealants are an excellent preventive measure used for children and young adults at risk for this type of decay. They do not last forever and should be inspected once a year and replaced if needed.
Featherstone JD, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35(10):703–713. Reprinted with permission from the Journal of the California Dental Association.
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