The Brain-Mouth Connection

How Good Oral Health Can Improve Mental Health

Jessamin Cipollina, MA

Mental health plays a significant role in oral health. People struggling with mental health issues such as anxiety and depression may be at higher risk of developing oral health problems like tooth erosion, cavities and gum disease. There are gaps in oral healthcare needs for individuals who struggle with mental health, including overall lack of awareness of the “brain-mouth connection” and the importance of promoting oral health among patients with mental health issues. Findings from evidence-based studies reveal that those with mental health problems are more likely to be affected by poor oral health and underutilize oral health services.^1-5 Those struggling with mental illness are often affected by the social determinants of health that limit access to regular dental care. Side effects of medications that are used to treat mental health problems, including antipsychotics, antidepressants and mood stabilizers, are associated with a higher risk for xerostomia, tooth decay, oral infections, periodontal disease, oral pain and tooth loss.^1,3-5 Dental and medical health care providers can collaborate on best practices for managing and preventing the many oral health problems that are associated with mental health issues.

In the US, 45 million people are living with some form of mental illness that negatively impacts their day-to-day life, including their oral health.⁶ Isolation and financial hardships that many experienced as a result of the COVID-19 pandemic deeply affected mental health status across the globe.^5-7 Closure of dental offices in the first year of the pandemic exacerbated oral health issues and prolonged treatment. Even with dental offices reopening and safety precautions in place, many who experience dental anxiety or anhedonia and lack of motivation related to depression are not likely to schedule a dental cleaning. Many who lost their jobs during the pandemic remain uninsured and unable to afford dental care out of pocket. Additionally, people who struggle with their mental health may feel insecure about their poor oral health due to lack of home oral hygiene and, as a result, are reluctant to see their dentist.^1,3,5,7 Dental care may not be easily accessible for those with mental health issues, but health care professionals in psychiatric, pharmaceutical and primary care settings have an opportunity to promote the importance of oral health care with their patients.

Mental illness is multifaceted and complicated to manage, and the many forms of mental health issues out there include numerous symptoms and treatments that can lead to increased risk for oral health problems. People with psychiatric disorders are at risk for oral health problems due to side effects of medications and neglect of their oral hygiene. For all mental health conditions, early detection, prevention and treatment of oral health problems is essential to improving patients’ overall health and quality of life.^2,5,7

Stress. Any level of stress can have physical effects on the body. Stress affects the immune system, sleep, eating, and personal hygiene. People who are experiencing stress may also grind or clench their teeth (bruxism) periodically during the day and when sleeping, which can cause mouth pain, gum recession and tooth fractures. The COVID-19 pandemic significantly increased incidence of cracked teeth due to stress related to personal, social and financial hardships.^2,5

Mood Disorders. Mood disorders, such as bipolar disorder, often cause over-brushing that may damage gums and cause dental abrasions and mucosal or gingival lacerations. Bipolar patients treated with lithium and/or anti-psychotics experience higher rates of xerostomia and stomatitis. Those who are treated with mood stabilizers are at increased risk for gingival hyperplasia and periodontal disease.⁵

Sleep. Lack of sleep can impair immune system functioning which can lead to increased risk of harmful inflammation and infection throughout the body, particularly in the vulnerable oral cavity. Difficulty sleeping is associated with increased risk for periodontitis and tooth decay. Lack of sleep can lead to poor nutritional choices, such as increased intake of coffee and snacking on food high in sugar and carbs throughout the day. Lack of sleep can also be due to stress or bruxism.^5,8

Anxiety. Many people experience dental anxiety and dental phobias and, as a result, will neglect home oral health care and/or avoid going to the dentist. Additionally, medications that treat generalized anxiety disorders can cause dry mouth (xerostomia) which can lead to tooth decay. People who struggle with anxiety often experience bruxism and temporomandibular joint disorders (TMJ) that cause oral pain.^1,5

Obsessive-Compulsive Disorders (OCD). For people with OCD, brushing and flossing can be turned into repetitive, compulsive habits. Over-brushing and flossing can cause enamel erosion and tooth sensitivity.⁵

Depression. People who struggle with depression often neglect various aspects of their self-care. They do not feel motivated to carry out day-to-day hygiene practices and this lack of motivation can contribute to poor food and nutrition choices and poor oral hygiene. Depression is also associated with higher abuse of alcohol, caffeine, and tobacco, which may cause tooth erosion and decay.^3-5

Substance Use/Abuse. Use of substances is a common coping mechanism among those struggling with mental health problems, such as depression, anxiety, mood disorders and others. In addition to being a standalone issue, substance abuse is rampant among those struggling with mental illness. Abused substances include those that are prescribed (e.g. opioids), illicit (e.g. cocaine, methamphetamine) and legal (e.g. alcohol), and all of these contribute to oral health problems such as xerostomia, tooth decay, tooth loss, bruxism, periodontitis and mucosal lacerations.⁵

Trauma. Traumatic experiences can stay with a person for their entire life. Those with significant physical and mental trauma histories may experience dental anxiety and phobias, trauma triggers, when faced with situations that include health professionals working at close proximity to their mouth and using dental instruments in the mouth. People who have experienced trauma are more likely to avoid dental care. Careful consideration and small steps need to be taken in preparing patients for what will happen during their dental visit.^1,3,5

Eating Disorders. Disordered eating behaviors such as vomiting and restricting food can cause oral health problems. Acids from vomiting make patients with eating disorders more susceptible to tooth decay and enamel erosion. Those who under-eat or restrict food may not receive enough iron and/or calcium, as well as have a weakened immune system, which can predispose them to tooth decay and oral infections.⁵

Psychotic Disorders. Schizophrenia spectrum and other psychotic disorders increase risk for serious health problems, like metabolic syndrome, that increases risk for periodontal disease. Individuals who suffer from a psychotic disorder often demonstrate poor motivation related to personal care and hygiene, and often avoid dental and other necessary health care due to delusions, paranoia and/or trauma.⁵

Dental and medical professionals have a unique opportunity to collaborate by educating patients and their caregivers, students and other health care providers about the importance of good oral care in improving health outcomes for those with mental health problems. An interprofessional approach for improving mental health and oral health can include dentists, primary care physi­cians, nurse practitioners, nurses, psychiatrists, physician assistants, pharmacists, nutritionists, community health workers and social workers, among others. All health professionals have the opportunity to encourage their patients who struggle with mental illness to adopt good home oral care practices like brushing and flossing teeth regularly, along with other home health habits like reducing sugar intake, exercising, smoking cessation, and reducing or eliminating substance use. 

When making referrals or recommending care, it is important to think about the barriers that many people experience in accessing both mental health and dental care services. Those without health insurance may not be able to afford regular health care services and check-ups. Dental disease is concentrated among populations with low socioeconomic status, and many people must make difficult financial choices when seeking dental care. It is the role of health professionals to assess, diagnose, manage oral health problems within their scope of practice and refer their patients appropriately. Many patients with mental illness may have a dental benefit through Medicaid and public insurance. However, insurance coverage does not guarantee access to needed services. We call on health professionals everywhere to collaborate and engage with one another across oral health and mental health care settings to effectively improve the mental, oral and overall health and well-being of this population!

References:

1. All 4 Oral Health. The Mind-Body Connection: How Mental Health Can Impact Oral Health. March 6, 2015: OHNEP. Accessed May 30, 2022. https://all4oralhealth.wordpress.com/2015/03/06/the-mind-body-connection-how-mental-health-can-impact-oral-health/

2. CareQuest Institute for Oral Health. The Connection Between Oral Health and Mental Health. 2022: Research Brief. Accessed May 30, 2022. https://www.carequest.org/resource-library/connection-between-oral-health-and-mental-health

3. Tiwari T, Kelly A, Randall CL, Tranby E, Franstve-Hawley J. Association between mental health and oral health status and care utilization. Front Oral Health. 2022;2:732882. doi:10.3389/froh.2021.732882.

4. Pitułaj A, Kiejna A, Dominiak M. Negative synergy of mental disorders and oral diseases versus general health. Dental and Medical Problems. 2019;56(2):197-201. doi:10.17219/dmp/105253.

5. National Council for Mental Wellbeing. Oral Health, Mental Health and Substance Use Treatment: A Framework for Increased Coordination and Integration. 2022. Accessed May 25, 2022. https://www.thenationalcouncil.org/wp-content/uploads/2021/09/NC_CoE_OralhealthMentalHealthSubstanceUseChallenges_Toolkit.pdf?daf=375ateTbd56.

6. World Health Organization. COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide. March 2, 2022: Press Release. Accessed May 30, 2022. https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide

7. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057. doi:10.15585/mmwr.mm6932a1

8. Alhassani AA, Al-Zahrani MS. Is inadequate sleep a potential risk factor for periodontitis? PLoS One.2020;15(6):e0234487. doi:10.1371/journal.pone.0234487.

Improving HPV Vaccine Confidence: An Interprofessional Challenge

Jessamin Cipollina, MA

April is Oral Cancer Awareness Month, an opportunity for educators, practitioners and advocates alike to promote awareness of oral and oropharyngeal cancers (OPC) and the importance of regular oral cancer screenings. In the US, human papillomavirus (HPV) is the not only the most common sexually transmitted infection, but it is one of the most difficult viruses to identify and diagnose. Studies have shown that most sexually active people experience a mild to severe HPV infection at some point in their life. The CDC estimates that over 42 million Americans are currently living with HPV and approximately another 13 million become newly infected each year.¹ Approximately 10% of men and 3.6% of women have oral HPV, and other types of HPV transmission are known to be equally widespread in both men and women.¹

There are 200 types of HPV, 40 of which are sexually transmitted and at least 9 that are linked to cancer (see HPV’s Impact on Mouth).² For many people with strong immune systems, the infection clears on its own. Most oral HPV lesions are benign, and may persist or reoccur. However, even with a strong immune system, untreated HPV infection in any part of the body can lead to cancer. Findings from studies that have explored HPV-associated OPC call for improved health literacy around HPV and oral cancer screenings in dental and medical settings to reduce oral cancer rates.^3-6

OPC traditionally are thought to be caused primarily by tobacco and alcohol use, but studies show that about 70% of cancers of the oropharynx are linked to HPV.⁷ As tobacco use and alcohol abuse have reportedly declined in the US over the past 20 years, rates HPV infection and HPV-associated cancers have steadily increased. A report from the CDC declared that the most common HPV-associated cancer in the United States is oropharyngeal squamous cell carcinoma (SCC), including those cancers on the tongue, tonsils, mouth and throat.⁸

Interprofessional collaboration and management of patients with HPV-related OPC is essential for providing effective whole-person care, including strategies for health promotion, symptom management, and self-management. Medical and dental professionals are well-positioned to assess OPC risk with their patients and emphasize the importance of preventing oral cancer. The good news is that we have an effective HPV vaccine, the only confirmed cancer preventive intervention.⁹

Health professionals – nurses, nurse practitioners, midwives, dental hygienists, physician assistants and more – are well-positioned to partner with families to improve HPV vaccine confidence. The vaccine can be administered to patients as young as 9 years of age, and up to age 45.⁹ For those adults who did not receive the vaccine as teenagers, it is not too late. Health professionals need to query adult primary care and dental patients about whether or not they have received the HPV vaccine.

A positive strategy for approaching parents of preteens and adolescents, as well as adults, about the HPV vaccine is to emphasize its value in preventing cancer. Medical and dental teams can contribute to reducing oral cancer rates and the severity of HPV-associated oral cancer by collaborating to perform oral cancer screenings and include oral health assessments as a “best practice”. Promotion of HPV vaccine administration has great potential to reduce HPV-associated cancers across the US (see Rising Rates of HPV-Associated Oropharyngeal Cancers).

A recent article in the Journal of Dental Education challenges health professionals to collaborate in preventing HPV-associated OPC and interprofessionally managing OPC when it occurs.⁶ Although vaccine administration is a common and widespread practice in primary care settings, including HPV vaccine health literacy and administration in dental offices would expand the reach of HPV vaccine administration to vulnerable populations.⁶ As of March 2022, new CDT code categories include codes for the administration of the HPV vaccine. Providing interprofessional education experiences in dentistry and other health professions at the academic level, including nursing, pharmacy and medical education, has the potential to improve all health care professionals’ knowledge of HPV and oral cancer so that they are well-prepared to provide health literacy and administer the HPV vaccine with confidence.

A critical facet of promoting HPV vaccine administration is building vaccine confidence. All health professionals have the capacity to be community leaders and build public trust in all vaccines, particularly the HPV vaccine. Providing health literacy about the HPV vaccine as a cancer prevention method is the best way to combat misinformation and educate families and communities about the importance of vaccines. Findings from numerous studies reveal that a recommendation from a trusted health care provider is key to parents’ decision to have their children vaccinated.^3-6 To effectively reduce rates of HPV and HPV-associated cancers, all health care professionals need to be well-versed about HPV and OPC to provide accurate information about the vaccine and emphasize its capacity to prevent cancers with a high mortality rate (see The Need for the Needle).

We call on dental and medical professionals to provide patients of all ages with HPV vaccine and OPC information. Interprofessional communication and collaboration is vital to improving health outcomes. Faculty can play an important role by using HPV-associated OPC as a valuable interprofessional clinical exemplar in simulations or clinical experiences. Students across health professions can partner in promoting HPV vaccine confidence to decrease multiple forms of HPV-associated cancer across the US. 

1. Centers for Disease Control and Prevention. HPV Infection. Accessed April 12, 2022. https://www.cdc.gov/hpv/parents/about-hpv.html
2. Centers for Disease Control and Prevention. Chapter 5: Human Papillomavirus. Accessed April 12, 2022. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt05-hpv.html
3. Arora S, Ramachandra SS, Squier C. Knowledge about human papillomavirus (HPV) related oral cancers among oral health professionals in university setting–A cross sectional study. J Oral Biol Craniofacial Res. 2018;8(1):35-39. doi: 10.1016/J.JOBCR.2017.12.002
4. Lechner M, Vassie C, Kavasogullari C, et al. A cross-sectional survey of awareness of human papillomavirus-associated oropharyngeal cancers among general practitioners in the UK. BMJ Open. 2018;8(7):e023339. doi:10.1136/bmjopen-2018-023339
5. Stull C, Freese R, Sarvas E. Parent perceptions of dental care providers’ role in human papillomavirus prevention and vaccine advocacy. J Dent Am Assoc. 2020;151(8):560-567. doi: 10.1016/j.adaj.2020.05.004.
6. Haber J, Hartnett E, Feldman L, Cipollina J. Making the case for interprofessional education and practice collaboration to address rising rates of HPV-associated oropharyngeal cancers. J Dent Educ. 2021;1-4. doi: 10.1002/jdd.12752.
7. Centers for Disease Control and Prevention. HPV and Oropharyngeal Cancer. Accessed April 12, 2022. https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm
8. Mulcahy N. CDC: Top HPV-Associated Cancer Is Now Oropharyngeal. MedScape, 2018. Accessed April 12, 2022. http://www.medscape.com/viewarticle/901122
9. FDA expands Gardasil 9 approval for head and neck cancer prevention. Healio. Accessed April 12, 2022. https://www.healio.com/news/hematology-oncology/20200615/fda-expands-gardasil-9-approval-for-head-and-neck-cancer-prevention

Sweet Salvation

Linking Diabetic Health and Oral Care

Jessamin Cipollina, MA

Diabetes is the 7^th leading cause of death in the US, with 1.4 million Americans diagnosed every year.^1,2 Of the 34 million adults in the US currently living with type 2 diabetes (T2D), 8.5 million are unaware of their condition.¹ Another 88 million adults are prediabetic, and 22% will develop T2D within 5 years if left untreated.³ Rates of diabetes are highest among American Indians/Alaskan Natives, non-Hispanic blacks and Hispanics, as well as among those from low-income backgrounds.¹ Many people are aware of the risk factors for diabetes – high blood pressure, being overweight, poor diet and family history of diabetes – but few think about the connection between diabetes and oral health.

Diabetes and oral conditions, like periodontal disease, are both inflammation-based, immune-related disorders that share a bi-directional relationship. Poor blood sugar control increases the risk for gum problems, while periodontal disease may cause blood sugar to rise. The body’s natural inflammatory response to bacteria and plaque in the mouth atttacks the gum tissue and supporting tooth structures, increasing risk for periodontal disease and other severe oral health problems like tooth loss.⁴

But, many people with diabetes do not know that they are at high risk for these oral health problems. People who are at risk for diabetes or who are diabetic may experience more difficulty in keeping their mouth healthy and preventing serious oral health problems. Additionally, people who are unaware of their diabetes or who have poorly controlled diabetes are at three times the risk of developing periodontal disease, leading to severe oral infection.⁴

In addition to oral health problems, there are other well-known complications of diabetes, including nerve damage, blindness, kidney failure, and heart disease. Preventive oral health interventions are essential to decreasing risk for these debilitating complications that greatly reduce quality of life and overall health and well-being of those with diabetes. 

A key component of diabetes care is oral care. Regular dental visits, along with good oral hygiene, are particularly important in preventing and treating periodontal disease and preventing severe oral problems common in people with diabetes such as tooth decay and tooth loss. Research findings reveal that diabetic patients with treated periodontal disease maintain better glycemic control.^4,5 Good oral care, like toothbrushing twice per day and flossing once per day, and regular dental cleanings are essential to reducing risk for diabetes-related complications.⁶

Unfortunately, many individuals with diabetes often experience barriers in accessing regular dental care. Medicaid and other low-cost insurance plans do not cover dental care, leaving patients to pay for costly out-of-pocket dental care. Those that cannot afford it, often forgo dental check-ups, so that oral problems remain untreated and can become more severe over time.^4,5

Primary care nurses, nurse practitioners, midwives, physicians, physician assistants, pharmacists, and other health care professionals are well-positioned to promote oral health literacy that helps patients who are pre-diabetic or diabetic integrate consistent oral hygiene habits as a part of their daily self-care routine. Providers need to ask about oral health issues as part of the health history and look for symptoms and signs of oral disease by using the HEENOT approach that includes an intra- and extra-oral exam.⁷ Common oral complaints that may be reported to clinicians include bleeding and/or pain during brushing and flossing, tooth sensitivity, bad breath or a bad taste in the mouth that won’t go away, loose teeth, and pain when chewing. In the oral exam, providers may see red or swollen gums and gum recession, and the patient may have a history of periodontal abscesses. Any oral health issues need to be documented in the electronic health record (EHR), and providers need to make a dental referral if the patient does not already have a dental home. 

Collaboration among primary and dental care team members is essential in caring for patients with diabetes. Motivational interviewing can be used to promote healthy lifestyle changes, such as establishing a nutritional diet and exercise plan, and engaging patients in managing their oral and overall health. Vaccine education and administration (e.g. COVID, flu, pneumonia, shingles) is imperative to protecting overall health and prevent these serious illnesses in patients with diabetes. Primary and dental care professionals can communicate with one another in providing their patients with person-centered care.

The connections between diabetes and oral health are not new and have been established for many years! There is a wealth of evidence-based research and resources for health professionals and patients about the oral-systemic health of those living with diabetes. Faculty and educators need to incorporate oral health into their curricula with nursing and other health professions students to promote oral health integration in clinical practice.^8,9 Whether in the dental chair, a primary care office, or an acute care setting, remember the connections between oral health and diabetes. We challenge all clinicians, dental and medical, who care for patients with diabetes to engage them in taking charge of their diabetic oral and overall health!

References:

1. American Diabetes Association. Statistics About Diabetes. 2021. https://www.diabetes.org/resources/statistics/statistics-about-diabetes
2. Centers for Disease Control and Prevention. Type 2 Diabetes. 2021. https://www.cdc.gov/diabetes/basics/type2.html
3. Centers for Disease Control and Prevention. Prevalence of Prediabetes Among Adults. 2020. https://www.cdc.gov/diabetes/data/statistics-report/prevalence-of-prediabetes.html
4. Darling-Fisher C, Borgnakke W, Haber J. Oral health and diabetes. American Nurse Today, 2017;12(8):22–25. https://www.americannursetoday.com/ana-journal-august-2017/
5. Darling-Fisher C, Kanjirath PP, Peters MC, Borgnakke W. Oral health: An untapped resource in managing glycemic control in diabetes and promoting overall health. The Journal for Nurse Practitioners, 2015;11(9):889-896. DOI: 10.1016/j.nurpra.2015.08.001
6. Centers for Disease Control and Prevention. Take Charge of Your Diabetes: Healthy Teeth. 2021. https://www.cdc.gov/diabetes/library/factsheets/diabetes-and-healthy-teeth.html
7. Haber J, Hartnett E, Hallas D, et al. Putting the mouth back in the head: HEENT to HEENOT. American Journal of Public Health, 2015;105(3):437-441. DOI: 10.2105/AJPH.2014.302495
8. Faculty Tool Kits. Oral Health Nursing Education and Practice (OHNEP). http://ohnep.org/faculty-toolkit
9. Oral Health and Diabetes Patient Care. Oral Health Nursing Education and Practice (OHNEP). http://ohnep.org/sites/ohnep/files/oral-health-and-diabetes.pdf

The Need for the Needle

Building Vaccine Confidence

Jessamin Cipollina, MA

Building vaccine confidence is a success challenge for health professionals and community leaders. As trusted professionals, they have the opportunity to influence groups that are more likely to be hesitant to receive vaccines. Building trust about vaccine safety is essential to improving vaccination rates and improving global public health. Nurses, nurse practitioners, midwives, dentists, pharmacists, physicians and physician assistants are among the many health professionals that are well-positioned to foster vaccine confidence in their patients using health literacy to correct misinformation and educate families and communities about the value of vaccines. The COVID-19 and human papillomavirus (HPV) vaccines illustrate the importance of promoting vaccine confidence.

The COVID-19 pandemic has brought to light the impact of vaccine hesitancy and the reasons many people are reluctant to receive any and all vaccines. Vaccine hesitancy refers to those who refuse vaccines despite evidence about safety and availability of vaccines. The We Can Do This campaign launched by the Biden administration aims to dispel myths and misinformation about the COVID-19 vaccine to encourage communities across the US to get vaccinated.¹ Public health campaigns help combat misinformation, thereby improving health literacy and building confidence in individuals to get themselves and their families vaccinated to protect them from potentially fatal infections like COVID-19. Initiatives like the We Can Do This campaign include efforts to spread information and positive messaging about the COVID-19 vaccine through a network of trusted messengers in communities and health care settings, as well as through television ads and across social media platforms.

The momentum behind promoting the COVID-19 vaccine provides an advocacy framework for the HPV vaccine. HPV is responsible for over 34,000 cancer diagnoses every year in the US.² Like the COVID vaccine, hesitancy around the HPV vaccine is due to many misconceptions about its safety and social implications. Gardasil 9, the HPV vaccine, has been around for over 15 years; research findings support its safety and effectiveness in preventing HPV and reducing risk for oral cancer. Gardasil 9 prevents 90% of HPV-associated oral, cervical, anal and penile cancers.³ In 2020, the FDA approved Gardasil 9 as an HPV vaccine for prevention of oropharyngeal and head and neck cancers, making it the only cancer prevention vaccine. The Gardasil 9 vaccine is approved for administration to children as young as age 9 and adults up to age 45.³ Despite scientific evidence about its effectiveness, only about half of US teens are fully vaccinated.² Widespread parental misinformation about its side effects and the erroneous belief that this vaccine promotes sexual behavior among youth contribute to vaccine hesitancy.

Findings from several studies of vaccine hesitancy and parents’ attitudes about the HPV vaccine show that a recommendation from a trusted healthcare provider is the strongest predictor of parents’ decision to have their child receive the vaccine.^4-6 A recent study from Pediatrics examined HPV vaccine hesitancy among parents using data from the 2021-2018 National Immunization Survey (NIS). Their findings revealed that vaccine hesitancy had increased from 2012-2018 for parents of young girls and boys, and this was largely due to concerns about the safety of the vaccine.⁴ A similar study from Lancet, based on NIS data, found that 58% of parents had no intent on having their children vaccinated, citing safety concerns and lack of a provider recommendation as reasons for not having their children vaccinated or completing the HPV vaccine dosage series.⁵

A standard of care for all health care professionals is to provide anticipatory guidance to improve health literacy about vaccines. There is a growing national movement to expand the dental profession’s role in vaccine advocacy and administration. Dental teams have many opportunities to provide information about HPV and the safety of the HPV vaccine to parents of their young patients. Along with HPV vaccine education and recommendation for young patients, dentists perform oral cancer screenings on their adult patients. Early detection of oral HPV infection and cancer has great potential to reduce the spread of HPV as well as the onset of severe HPV-related oral cancers.⁶

Although oral cancer screenings have long been designated to the dental team, medical teams including trusted primary care providers, physicians, physician assistants, pharmacists, nurses, nurse practitioners and community health workers (CHW), need to be knowledgeable about HPV and its oral-systemic links. Management of HPV necessitates interprofessional collaboration across the entire health care team to best address the needs of patients of all ages. Reducing HPV infection and cancer rates requires dental and medical professionals to become well-versed about the importance of the HPV vaccine and provide HPV and oral cancer education resources to their patients and communities. Enhancing the role of all clinicians in providing HPV health literacy beyond the pediatrician’s office is imperative to combating vaccine hesitancy and building vaccine confidence.⁶

Despite documented progress and success of numerous 20^th century life-saving vaccines in eradicating public health crises, vaccine hesitancy has rapidly infiltrated communities worldwide.⁷ The explosion of social media and communication technology have provided a platform for spreading misinformation about both the COVID-19 and HPV vaccines, having a negative impact on vaccine confidence. Vaccine hesitancy is a global population health equity problem that demands health professionals provide health literacy and vaccine recommendations to their patients that instill vaccine confidence and trust in health care system.⁷ The CDC has numerous resources for  clinical teams to use for building HPV vaccine confidence in patients and communities.^8,9 The following diagram provides a model for steps that clinical teams can take to improve confidence in the HPV and other vaccines.

References:

1. Johnson D. VP Kamala Harris, HHS open drive to inspire Americans to take COVID-19 vaccine. Published April 1, 2021. Accessed October 25, 2021.  https://www.upi.com/Top_News/US/2021/04/01/hhs-covid-vaccines-campaign/6031617291181/

2.  HPV and oropharyngeal cancer. Centers for Disease Control and Prevention. 2020. Updated September 3, 2020. Accessed October 25, 2021. https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm

3. Mehra S. FDA expands Gardasil 9 approval for head and neck cancer prevention. Published June 15, 2020. Accessed October 25, 2021. https://www.healio.com/news/hematology-oncology/20200615/fda-expands-gardasil-9-approval-for-head-and-neck-cancer-prevention

4. Sonawane K, Zhu Y, Lin Y et al. HPV vaccine recommendations and parental intent. Pediatrics, 2021:147(3). doi: 10.1542/peds.2020-026286.

5. Sonawane K, Zhu Y, Montealegre JR et al. Parental intent to initiate and complete the human papillomavirus vaccine series in the USA: a nationwide, cross-sectional survey. Lancet, 2020;5(9):484-492. doi: 10.1016/S2468-2667(20)30139-0

6. Haber J, Hartnett E, Feldman LM, Cipollina JE. Making the case for interprofessional education and practice collaboration to address rising rates of HPV-associated oropharyngeal cancers. J Dent Educ, 2021 Aug 4. doi: 10.1002/jdd.12752. Epub ahead of print.

7. Badur S, Ota M, Öztürk S, Adegbola R, Dutta A. Vaccine confidence: the keys to restoring trust. Hum Vaccin Immunother, 2020;16(5):1007-1017. doi:10.1080/21645515.2020.1740559

8. Talking to Parents About Infant Vaccines. Centers for Disease Control and Prevention. Updated July 1, 2019. Accessed October 25, 2021. https://www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf

9. Top 10 Tips for HPV Vaccination Success: Attain and Maintain High HPV Vaccination Rates. Centers for Disease Control and Prevention. Updated April 7, 2017. Accessed October 25, 2021. https://www.cdc.gov/hpv/hcp/2-dose/top-10-vaxsuccess.html

The Race to Health Equity

Oral Health Disparities Persist Among Racial & Ethnic Minorities 

Jessamin E. Cipollina, M.A.

Health service access, affordability, and use varies for all Americans. Promotion of health equity across the health care landscape requires elimination of disparities in access to care, as these disparities impact individuals’ abilities to receive affordable, comprehensive and quality care. Regular primary care visits and preventive care are under-utilized by racial/ethnic minority groups, due to a long history of discrimination. Racial inequity throughout the health care system is well-documented in the literature, and research shows how racial/ethnic minority groups are impacted by multiple social determinants of health. Despite being integral to promoting overall health outcomes, oral health is a frequently forgotten component of overall health. Due to access barriers, such as lack of dental insurance or low socioeconomic status, there are significant oral health disparities among U.S. racial/ethnic minority populations.

Studies have found that people from racial/ethnic minority groups are less likely to have health insurance than their White counterparts. Implementation of the Affordable Care Act (ACA) in 2010 led to significant gains in health coverage over the past decade, yet substantial discrepancies remain for racial/ethnic minorities. As of 2018, 12% of Black adults, 19% of Hispanic adults, and 22% of American Indian and Alaskan Natives are uninsured, compared to only 8% of White adults.¹ Individuals belonging to a racial/ethnic minority group are less likely to seek medical help and preventive care for serious chronic health problems – heart disease, diabetes, and cancer, to name a few – and are more likely to have poor health outcomes and higher mortality rates.^2-4 The high costs of health care, combined with an extensive history of racial stereotyping, coupled with experiences that have built mistrust, prevent racial/ethnic minority individuals from achieving better health outcomes within their communities.

Dental care is not included as an essential benefit in many commercial health plans. The ACA does include oral health as an essential benefit for children only, not for adults and older adults. The CHIP program covers dental care in all 50 states for children insured by Medicaid, but only 35 states have an adult Medicaid dental benefit.⁵ According to the ADA Health Policy Institute, the most common reason for delaying or not pursuing dental care is cost as many individuals and families cannot afford out-of-pocket care costs.⁶ Moreover, there are a limited number of dental practices that will accept Medicaid-insured patients, making access and availability a crucial issue.⁶ Finally, a high proportion of racial/ethnic minority individuals live in communities without fluoridated water and schools that have fluoride varnish and sealants programs, which are shown to be highly effective in preventing oral health problems.⁷

Prominent health inequities persist in oral health care within racial/ethnic minority groups, which are also associated with lower socioeconomic status and high rates of poverty. In the US, people are unable to afford regular preventive dental care, and many vulnerable communities lack access to transportation to appointments or lack fluoridated water.^3,8 As a result, we see oral health disparities across the lifespan among racial/ethnic groups. In U.S. children aged 2-5, 33% of Mexican American and 28% of Black children have had cavities in their primary teeth, compared to 18% of White children.⁸ Black and Mexican American U.S. adults are twice as likely to have untreated caries than their White counterparts, and older non-Hispanic Black and Mexican American adults have 2 to 3 times the rate of untreated cavities as older White adults.⁸ Periodontal disease is most common among Black and Mexican American adults; a study using data from the 2009-2014 National Health and Nutrition Examination Survey and found that the highest rates of moderate-severe periodontitis were in Black (42%) and Mexican American (46.4%) adults, while white adults had the lowest rate at 31%.⁹ Oral cancer, which affects about 54,000 Americans every year,¹⁰ shows a 41% survival rate for Black men, more than 20% lower than White men.⁹

Despite strong evidence that oral care and overall care are connected, dental care continues to be treated as a silo component of health care, separate from other health care professions. Interprofessional health education may be the answer to solving this dilemma! Think about how we can expand current interprofessional initiatives that bring dental, nursing, medical and other health professions together for classroom, simulation, and “live” clinical experiences to learn from, with, and about each other while learning about oral health and its links to overall health, as well as the related social determinants of health. Think about the oral health contributions that can be made by clinicians in primary care settings; think about the contributions the dental team can make to improving overall health. This perspective is particularly important when providing primary care or dental care for racially and culturally diverse patients especially those with disabilities, without dental insurance, or difficulty accessing affordable dental care.

Expanding a diverse health professions workforce is crucial to promoting oral health and primary care utilization among racial/ethnic minority Americans. Presently, approximately 20% of the nursing workforce (RNs, NPs, and MWs),¹¹ 20% of physicians,¹² 10% of dentists are from racial/ethnic minority backgrounds.¹³ Practitioners from racial/ethnic minority backgrounds are best equipped to work in those communities that align with their background, as they can lend their own experiences to providing culturally-competent care and improve trust of health professions among racial/ethnic minority groups. Decades of racial bias and discrimination in health care settings, and resulting mistrust, are major factors contributing to low health care utilization and poor health outcomes in racial/ethnic minority populations.^2-4,14 Increasing the number of racially/culturally diverse health care professions students and clinicians can contribute greatly to expanding health care access and satisfying health care experiences for individuals and families from underserved communities and improve health care perceptions and trust among Americans from racial/ethnic minority communities.

The COVID-19 pandemic has underscored the physical, financial and sociopolitical barriers that disadvantaged populations face in accessing regular oral care and treatment. COVID-19 has exacerbated the impact of the social determinants of health; financial strain, transportation limitations and general distrust of the health care system have prevented many Americans from visiting their dentists. Oral care education, practice and policy initiatives need to incorporate the social determinants of health in understanding how to best treat vulnerable patients. Racial/ethnic minority identity often overlaps with several social determinants that impact health outcomes, namely low socioeconomic status.^2,3,14 Oral health curricula, simulation and clinical experiences should incorporate social determinants of health in patient interactions by addressing economic disadvantages, insurance complications, experiences of discrimination and environmental barriers to care among vulnerable populations. Interprofessional education experiences are crucial to promoting quality integrated health care that speaks to a wide spectrum of care interventions for racial/ethnic minority patients. Oral health literacy products that address common oral-systemic complications can be disseminated to minority and disadvantaged communities to improve oral health and overall health outcomes. The responsibility falls on health care teams that include oral care professionals to engage with their communities and encourage health care utilization to reduce oral health and overall health disparities and to build a better health future for racial/ethnic minority Americans across the lifespan.

1. Artiga S, Orgera K, Damico A. Changes in health coverage by race and ethnicity since the ACA, 2010-2018. Kaiser Family Foundation. Published March 5, 2020. Accessed February 23, 2021. At: https://www.kff.org/racial-equity-and-health-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/
2. Manuel JI. Racial/ethnic and gender disparities in health care use and access. Health Serv Res, 2017;53(3):1407-1429. doi: 10.1111/1475-6773.12705.
3. Egede LE. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med, 2006;21(6):667-669. doi: 10.1111/j.1525-1497.2006.0512.x.
4. Frakt, A. Bad medicine: the harm that comes from racism. The New York Times. Published January 13, 2020. Updated July 8, 2020. Accessed February 23, 2021. At: https://www.nytimes.com/2020/01/13/upshot/bad-medicine-the-harm-that-comes-from-racism.html
5. American Dental Association, Health Policy Institute. Dental benefits and Medicaid. Accessed February 23, 2021. At: https://www.ada.org/en/science-research/health-policy-institute/dental-statistics/dental-benefits-and-medicaid
6. Yarbrough C, Nasseh K. Vujicic M. Why adults forgo dental care: evidence from a new national survey. American Dental Association Health Policy Insitute. Published November 2014. Accessed February 23, 2021. At: https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx
7. Griffin S, Naavaal S, Scherrer C, et al. School-based dental sealant programs prevent cavities and are cost-effective. Health Affairs, 2016;35(12). doi: 10.1377/hlthaff.2016.0839.
8. Centers for Disease Control and Prevention. Disparities in oral health. Updated February 5, 2021. Accessed February 23, 2021. At: https://www.cdc.gov/oralhealth/oral_health_disparities/index.htm
9. Eke PI, Thornton-Evans GO, Wei L, et al. Periodontitis in US adults: national health and nutrition examination survey 2009-2014. J Am Dent Assoc, 2018;149(7):576-588. doi: 10.1016/j.adaj.2018.04.023.
10. The Oral Cancer Foundation. Oral cancer facts. Accessed February 23, 2021. At: https://oralcancerfoundation.org/facts/
11. Rosseter R. Enhancing diversity in the workforce. American Association of Colleges of Nursing. Updated April 1, 2019. Accessed February 23, 2021. At: https://www.aacnnursing.org/News-Information/Fact-Sheets/Enhancing-Diversity
12. Association of American Medical Colleges. Diversity in medicine: facts and figures 2019. Accessed February 23, 2021. At: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
13. Peterson, B. How diversity in the dental profession could mean better care for minorities. Chicago Crusader. Published June 3, 2019. Accessed February 23, 2021. At: https://chicagocrusader.com/how-diversity-in-the-dental-profession-could-mean-better-care-for-minorities/
14. Healthy People 2030. Discrimination. Accessed February 23, 2021. At: https://health.gov/healthypeople/objectives-and-data/social-determinants-health/literature-summaries/discrimination

Good Eating: Linking Oral Health and Nutrition in Older Adults

Jessamin E. Cipollina, MA

Older adults often struggle with maintaining proper nutrition, which can lead to many adverse health outcomes. Chronic health problems contribute to changes in appetite, taste and smell, which contribute to decreased food intake and lack of motivation to cook and prepare food. Trouble chewing related to ill-fitting dentures and loose or missing teeth, as well as oral pain from tooth decay, abscesses or xerostomia, also make it difficult to enjoy eating. The COVID-19 pandemic has exacerbated many of the challenges older adults already face including, but not limited to: food shopping, enjoying meals with friends, or have food preparation help from a home aide, who may be at risk for spreading the virus. It is clear to see that for older adults, nutrition, oral health and COVID-19 are inextricably linked!

The important relationship between oral health and nutrition for older adults is minimized in our health culture, but a healthy mouth and teeth are vital to the idea that nutrition contributes to a healthy body. The majority of adults 65 and older have one or more chronic conditions, many of which have an oral-systemic connection. There is a great need for more awareness about the links between inflammation, infection and the chronic conditions that have related to oral health problems that can affect a person’s nutritional status and overall health. Chronic conditions, including diabetes, cancer, heart disease and depression, impact older adults’ ability to maintain both proper oral hygiene and nutrition Older adults are at risk for oral infections related to tooth decay, gum disease and tooth loss, all of which make chewing and swallowing difficult.^1-3 Poor oral hygiene is a prominent and harmful barrier to getting adequate nutrition.

There are many physiological and metabolic changes in aging that put older adults at risk for nutrient deficiencies. Day-to-day activity and energy needs decline significantly, along with muscle mass, senses and overall ability to absorb nutrients. These declines can be associated with a total lack of appetite, along with inspiration to cook and eat healthful food.² Behavioral and mental health issues are often neglected in health care across the lifespan, especially the connections between behavioral, oral and nutritional health.^1,4-7 Older adults are particularly susceptible to feelings of hopelessness and loneliness due to losing their partners, friends and family in old age. The grief or loss that this group experiences related to illness and death of friends and family is often related to or can lead to depression, addiction and substance abuse. As a result, the symptoms that older adults experience impact their ability and motivation to shop for food and eat alone or in the company of others as these activities become less interesting.^5-7 Similarly, oral health issues like tooth loss or poor dentition can greatly affect older adults’ self-esteem, making them reluctant to socialize due to their appearance. Social support from family, friends and the community are greatly important in improving older adults’ quality of life, and positive mental health is a hugely important factor in promoting positive health outcomes in this age group.^4-7

When thinking about nutrition and oral health with this age group, the social determinants of health (SDOH) need to be considered. Age-related changes associated with oral health impede ability to eat and drink. Those older adults who experience economic disadvantages, lack of insurance, and are in racial/ethnic minority communities are shown to have the most oral health complications. Those older individuals with disabilities or who are homebound or institutionalized are also at increased risk for poor oral health, especially in the midst of a global pandemic where access to care is limited for this age group.^2-3 Food insecurity is common among older adults in the US: approximately 5 million adults over 60 rely on SNAP benefits, and households with older adults have only $125 per month for their food budget.⁸ Food insecurity, being on a fixed income, and other related social and environmental factors are often overlooked in the health care system. Due to the COVID-19 pandemic, vital food delivery service programs have been halted and older adults may no longer receiving regular hot meals. With a limited budget and necessary social distancing precautions, access to healthy food is greatly restricted for this age group. Without the motivation and financing to buy, cook and eat healthy foods, older adults’ poor nutrition can lead to serious physical health complications.^2,4

Promoting accessible, affordable and available oral health care is a responsibility that falls on the entire health care system. This age group has complex care needs that benefit from an interprofessional team of health care professionals to effectively address nutritional, oral health and overall health issues. Connecting students and clinicians across the health professions to provide effective whole-person care is a must, yet dentists and nutritionists are often left out of this team! Interactive classroom, simulation, case study, and live clinical experiences provide opportunities for interprofessional teams of students and clinicians who collaborate to develop management plans that address the spectrum of physical, behavioral, dental, nutritional, and social support interventions needed by this complex patient population.^9-10 Oral health and nutrition education can also be integrated by faculty using web-based curricula integration tools that weave nutrition, oral health and overall health and interprofessional competencies. These types of experiences prepare students to promote interprofessional teamwork and care in clinical practice, providing comprehensive whole-person care to their patients.^9-10 Health professions educators, students, and clinicians are equally responsible for promoting another important intervention, health literacy, to educate patients and providers alike about the links between oral health, nutrition, and overall health. Oral health and nutrition are inseparable key components of older adults’ health and play a vital role in influencing their ability to eat and get the nutrients they need to thrive.

1. The Gerontological Society of America. Oral Health: An Essential Element of Healthy Aging. 2017. Retrieved from https://www.geron.org/images/gsa/documents/gsa2017oralhealthwhitepaper.pdf. 
2. The Gerontological Society of America. What’s Hot: A Newsletter of the Gerontological Society of America. 2020. At: https://www.geron.org/images/gsa/documents/whatshotnutritionoralhealth.pdf. 
3. CDC. Oral Health for Older Americans. CDC, 2020. https://www.cdc.gov/oralhealth/basics/adult-oral-health/adult_older.htm. Accessed August 14, 2018.
4. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of oral disease among older adults and implications for public health priorities. Am J Public Health. 2012;102(3):411-418. doi:10.2105/AJPH.2011.300362
5. Chen Y, Feeley TH. Social support, social strain, loneliness, and well-being among older adults. J Soc Pers Relat. 2014;31(2):141-161. doi:10.1177/0265407513488728
6. Rouxel P, Heilmann A, Demakakos P, Aida J, Tsakos G, Watt RG. Oral health-related quality of life and loneliness among older adults. Eur J Ageing. 2017;14(2):101-109. doi:10.1007/s10433-016-0392-1
7. Cipollina JE. Eating, Chatting and Laughing: Oral Health Improves Social Support and Quality of Life of Older Adults. 2020. At: https://all4oralhealth.wordpress.com/2018/08/21/eating-chatting-and-laughing-oral-health-improves-social-support-and-quality-of-life-of-older-adults/
8. National Council on Aging. SNAP and Senior Hunger Facts. At: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/senior-hunger-facts/
9. Haber, J., Hartnett, E., Cipollina, J., Allen, K., Crowe, R., Roitman, J., Feldman, L., Fletcher, J., & Ng, G. Attaining Interprofessional Competencies by Connecting Oral Health to Overall Health. Journal of Dental Education. Published in Early View. doi: 10.1002/jdd.12490
10. Greenberg SA, Hartnet E, Berkowitz GS et al. Senior oral health: A community-based interprofessional educational experience for nursing and dental students. 2020, Journal of Gerontological Nursing;46(8):37-45. doi: 10.3928/00989134-20200527-03

It’s Back to School for Everyone: Promoting Children’s Oral Health in a Pandemic

Jessamin E. Cipollina, M.A.

Thanks to the COVID-19 pandemic, students have missed out on in-person learning since early spring when the virus shut down pre-K to PhD programs in academic institutions across the globe. Faculty were left scrambling to find ways to connect with their students while isolated in their homes. Administrators were challenged to stayed up to date with ever-changing information about the coronavirus and how to provide essential education to rapidly growing young minds. Parents were tasked with guiding their children through a new system of online learning by setting up their young children with the technology and materials they might otherwise have access to in their school.

As schools across the US launch a new academic year, we see a variety of learning modalities – socially distant and masked in-person classroom learning, at-home virtual lessons, or a complex combination of the two. Administrators, faculty and parents alike have been working tirelessly to develop effective curricula that takes into account many limitations that come with keeping everyone safe and healthy.

How can we as health professionals provide guidance and support to schools and families about keeping their loved ones safe as we begin the new school year? We can make an important contribution to keeping children healthy, from birth through adulthood, by encouraging them to take care of their mouths.

The mouth is the gateway to the rest of the body, and it is especially important to take care of teeth, tongue and gums. A recent study in the UK examined the connection between oral health and COVID-19 infection. The study found a significant association between high bacterial load in the oral cavity and severe COVID-19 infections. Good oral hygiene plays an important role in keeping teeth and gums healthy, and preventing harmful oral bacterial infections including tooth decay and periodontal disease.

Oral health is linked to overall health at all ages. Children should be encouraged to take charge of their oral health from a young age. Parents need to guide their children’s oral hygiene activities until they are able to do so on their own, just as they would with learning to tie their shoes. It is important for children to maintain a good oral hygiene routine day and night, and a regular brushing routine, along with healthy nutrition, is essential to promote their health now and as they move into young adulthood. You can learn more about oral health care at home from our previous blog Oral Health Home Habits for Healthy and Happy Smiles.

Efforts to reduce the transmission of germs among younger students are especially important given the current climate. Teachers and parents are at the forefront of enforcing healthy habits and classroom policies for minimizing the spread of illness. Wearing a mask, sanitizing hands,  maintaining social distance and asking children to not touch their face are simple public health strategies that decrease risk of spreading and contracting COVID-19. The graphic below illustrates methods for minimizing the spread of germs at snack and lunch times.

Source: http://www.teachergoals.org

It truly takes a village to ensure our children are equipped with the physical, mental and emotional tools they need to thrive in a pandemic environment. The past six months have tested the power of families, educators and communities to rapidly adjust our daily routines in the face of a glowering pandemic. Educators and parents alike continue to do what they do best: provide a supportive and engaging learning environment for our children, whether at school or at home. We must overcome the logistical, social and financial challenges to promote the oral and overall health and well-being of our children as we strive to resolve the COVID-19 pandemic.

Oral Health Home Habits for Healthy and Happy Smiles

Jessamin E. Cipollina, M.A.

In a matter of weeks, our world has been turned upside down due to the present coronavirus (COVID-19) pandemic. The Centers for Disease Control and Prevention (CDC) and other national and global health organizations are promoting hygiene practices to prevent transmission of the virus. Schools, universities, and colleges have moved to remote instruction; non-essential employees are working from home to implement social distancing practices so people can better protect themselves and their loved ones and prevent the spread of COVID-19. Health care professionals across the globe are working tirelessly and fearlessly to treat the hundreds of thousands of patients with this life threatening infection. With over 800,000 reported cases and counting, it is all hands on deck for health care workers as hospitals overflow and medical supplies remain scarce worldwide.

Given such sudden and drastic changes to our everyday routine, it is common for folks to neglect  basic daily health practices. As you know, oral health shares many links to other health problems, especially chronic conditions. Diabetes, cardiovascular disease, kidney disease, respiratory conditions like pneumonia and conditions where people are immunocompromised, like those with cancer, organ transplants, and auto-immune diseases, are among those for whom daily oral hygiene is especially important to prevent oral disease. If you or a loved one experiences an oral health issue that requires immediate attention, the ADA recommends contacting your dentist instead of going to the ER, as hospitals and frontline health professionals are overwhelmed with caring for patients affected by COVID-19.

OHNEP always has and will continue to advocate for all health professionals to integrate oral health in their primary, acute, home, or long term care setting or practice to reduce the burden of oral disease on overall health. So to keep your message simple; please remind your patients to:

Brush…

• Brush teeth, tongue and gums with a clean, soft-bristled toothbrush
• Replace toothbrushes every three to four months
• Use fluoride toothpastes to help prevent against tooth decay

Floss…

• Floss at least once per day
• Floss all teeth, and all spaces
• Consider investing in a power air or water flosser if you are unable to visit your dentist for a regularly scheduled cleaning

Rinse…

• Rinse mouth to prevent harmful build-up of plaque and tartar
• Rinse with warm water after meals
• Rinse with antibacterial mouthwash

Right now, many of us feel isolated and powerless with the looming uncertainty of what implications the current pandemic will have for our world. One health practice that each of us can be in charge of is our oral hygiene! If there is anything that we can be in control of in such an out-of-control world, it is our own health. Before we can support others, we need to look after ourselves, and practicing good oral hygiene is one simple and effective way to practice self-care every day.

 

 

Sources:

Burger, D. ADA recommending dentists postpone elective procedures. American Dental Association. Published March 16, 2020. https://www.ada.org/en/publications/ada-news/2020-archive/march/ada-recommending-dentists-postpone-elective-procedures.

Businesswire. DentalPlans.com Provides Tips for At-Home Dental Hygiene. Published March 24, 2020. https://www.businesswire.com/news/home/20200324005050/en/.

Intimate Partner Violence Shocks the Head and Mind

Jessamin E. Cipollina, M.A.

Intimate Partner Violence (IPV) is defined as any physical and sexual violence, stalking, or psychological harm by a current or former partner.¹ The CDC identifies IPV as a “serious, preventable public health problem” that affects millions of people in the U.S. every year and can result in many negative health consequences including anxiety, substance abuse, and traumatic brain injury.^1,2 Recent statistics show that about 1 in 4 women and 1 in 10 men have experienced some form of IPV in their lifetime, many of whom report experiences before the age of 18.¹ IPV affects both men and women at any age and can result in lifelong emotional, physical and fiscal trauma to survivors and their families, not to mention the lasting oral health consequences  that can severely impact overall health and quality of life.

According to a report from the Health Resources and Services Administration (HRSA), approximately 75% of injuries from IPV occur around the head, neck and mouth.² This can result in serious injuries to the mouth and teeth. Ongoing physical abuse from a partner such as slapping or hitting across the face can lead to serious head trauma and brain injury, including broken jaw, facial and mouth lacerations, loosening of teeth and traumatic evulsion of teeth. ² Primary care physicians, nurse practitioners, midwives, nurses, physician assistants, dentists and dental hygienists are a few of many clinicians who are well-positioned to identify signs of IPV and take initial action to address abuse. But clinicians and staff may not be aware of what to look for in patients or what questions to include in screening protocol.^2,3

Examples of Clinical Signs of IPV

Obvious

• Broken teeth
• Fractured jaw
• Cuts
• Facial bruising
• Bite marks
• Bruises on neck
• Wrist, arm or ankle strains
• Patches of missing hair

Subtle

• Headaches
• Depression
• Fatigue
• Lack of eye contact
• ER trips for vague reasons
• Self-inflicted cuts
• Hidden cuts
• Passive interaction
• Eating disorders

The findings of recent studies demonstrate a need for IPV competencies to be integrated in oral health care and increased self-efficacy among all health professions in IPV screening. IPV screenings and know-how are especially important in primary care practice, urgent care and ER settings that are frequented by men and women who have sustained injuries from physical abuse. Several studies report that many health professionals, particularly dentists and dental assistants, do not receive education or training in identifying and approaching IPV in their offices. As such, continuing education in identifying signs of abuse is warranted.^2,3 These findings also reveal some reluctance among oral health professionals to screen due to lack of expertise in detecting IPV. They recommend promoting adoption of IPV screenings in dental offices.^2,3 Mandatory reporting of abuse is required in many states, but practitioners may not be equipped with adequate resources to report abuse as well as refer their patients to safe services if they are in imminent danger.

HRSA’s Strategy to Address Intimate Partner Violence includes four Priorities for addressing and raising awareness of IPV in clinical settings. This initiative aims to increase IPV knowledge within the health care workforce and increase access to IPV-informed health services, with the ultimate goal of earlier intervention and prevention of IPV.^2,3 In addition to the primary care workforce, HRSA purports that practitioners and office staff also are perfectly poised to recognize both obvious and subtle indicators of IPV and should be aware of screening questions and methods that can be used with patients to assess their safety.^2,3

Sample Screening Questions

• “Since your last visit, I see that you have two broken teeth. How did that happen?”
• “I notice you have a bruise on your jaw. How did that happen?”
• “You seem upset/distracted today. Is there anything you would like to talk about with me?”
• “You mentioned that things have been stressful at home. Can you tell me more about what has been going on?”

HRSA also describes several trauma-informed practices that can be adopted by health professionals and staff to make their clinic a safe space, as well as “activating” clinic environments to promote IPV education and practices.^2,3

Trauma-Informed Practices for Health Professionals

• Schedule longer appointments to get a patient acclimated to procedures in mouth
• Provide a consultation room in the dental offices to further engage with patient
• Identify a “quiet room” in the dental office where procedures can be done
• Ask assessment questions using an open-ended and non-judgmental manner that encourage patient disclosure
• Allocate a portion of the visit to just involve your patient, excluding visitors
• Provide interpreters for your patients
• Offer patients immediate and private access to an advocate in person or over the phone
• Develop a list of referral resources at the ready for patients that need immediate attention
• Familiarize yourself with the IPV reporting requirements in your state
• LISTEN to your patients
• Evaluate your attitudes and beliefs about IPV
• Decide that you aren’t here to diagnose or treat IPV, but to create an opportunity for patients to share these and other experiences that may impact their overall health

There is a compelling need to integrate IPV competencies into oral health clinical education and practice! This clinical issue exemplifies the importance of interprofessional education and practice that includes collaboration between and among clinicians from different professions to effectively address IPV as a population health problem. It is the responsibility of health care professionals to ensure that their clinical setting has safe spaces and that productive, thoughtful conversations about IPV and related trauma topics can take place. IPV is one of many national public health concerns that can have irrevocable effects on oral health and overall health. Studies demonstrate that practitioners need to make progress in acquiring the competencies and resources necessary to identify signs of IPV and address them in clinical practice settings.

Resources for Patients and Practitioners

National Domestic Violence Hotline
thehotline.org
1-800-799-SAFE (1-800-799-7233)
Provides information on identifying domestic abuse, 24-hour helpline and online live chat for immediate support and referrals

Safe Horizon
safehorizon.org
1-800-621-HOPE (1-800-621-4673)
Advocacy organization with 24-hour helpline and online live chat, including resources for safety and support

National Coalition Against Domestic Violence (NCADV)
ncadv.org
Provides resources for domestic violence victims and their families to find immediate aid and plan for a safe future

 

 

¹Centers for Disease Control and Prevention (CDC). Intimate Partner Violence. Retrieved from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html

²Health Resources and Services Administration, Office of Women’s Health. The HRSA Strategy to Address Intimate Partner Violence. Rockville, Maryland: 2017.

³Health Resources and Services Administration, Office of Women’s Health, Office of Planning, Analysis and Evaluation, & Bureau of Primary Health Care. Lunch and Learn: Intimate Partner Violence and Oral Health. Presentation. April 4, 2018.

⁴Harris CM, Boyd L, Rainchuso L et al. Oral health care providers’ knowledge and attitudes about intimate partner violence. J Dent Hyg. 2016;90(5);283-96. https://www.ncbi.nlm.nih.gov/pubmed/29118181.

⁵Lemich SA, Freudenthal JJ, Neill K et al. Dental hygienists’ readiness to screen for intimate partner violence in the state of Texas. J Dent Hyg. 2018;92(3);47-55. https://www.ncbi.nlm.nih.gov/pubmed/29976793

⁶Parish CL, Pereya MR, Abel SN et al. Intimate partner violence screening in the dental setting: results of a nationally representative survey. J Am Dent Assoc. 2018;149(2);112-21. https://www.ncbi.nlm.nih.gov/pubmed/29389334

Why You Should Take A Powder on Brushing with Charcoal

Jessamin E. Cipollina, M.A.

Charcoal has become a recognized active ingredient over the past couple of years, finding its way onto our restaurant menus and into our makeup bags. Spend any amount of time online and you will find ads from so-called “health gurus” and social media influencers sporting messy black smiles to promote the health benefits of brushing with charcoal. Beauty product manufacturers, celebrities and social media platforms are highly influential in promoting activated charcoal to not only brighten teeth, but also ingest as part of a cleansing “detox” regimen. Although charcoal appears to be a “proven” cure-all for our teeth and bodies, there is insufficient evidence that using charcoal products provide any significant health benefits. With new health and beauty crazes on the rise, health professionals and researchers are now responsible for keeping checks and balances on whether these fads are helpful or hurtful.

Activated charcoal is known for its ability to bind to organic matter, and producers of charcoal toothpaste claim that it is able to bind to plaque and other bacteria in the mouth to effectively clean teeth and remove staining. Many manufacturers claim that activated charcoal is a natural product that has been used for centuries to cleanse the body inside and out. With roots in ancient Greece, charcoal and ash composites were reportedly used to clean teeth and freshen breath.¹ Charcoal is also well known for its detoxifying effects; activated charcoal can prevent poisonous substances and chemicals from being absorbed into the bloodstream, and thus is now sold as a “detox” additive for food and drinks. These are unfounded claims with no scientific evidence backing them up. There also are many other reasons to be wary of using charcoal tooth whitening products beyond the unknown.²

Many medical experts agree that although charcoal toothpastes may be effective in removing stains, there is no evidence of any significant whitening effects. In fact, long-term use of charcoal products on teeth can wear down tooth enamel due to their abrasive nature and further expose dentin in teeth making them look yellower than whiter. Prolonged use can also irritate gums and increase tooth sensitivity. Most charcoal toothpastes also do not contain fluoride, proven to keep teeth and gums healthy and protect against decay.^1-3

A recent article from the British Dental Journal provides an in-depth review of current knowledge surrounding charcoal toothpastes and powders, and how the risks of using such products could outweigh the benefits.¹ The authors argue that there is very little evidence supporting manufacturers’ claims that charcoal can whiten teeth and improve oral health. Rather, there is sufficient evidence that charcoal dentifrices may ultimately cause more harm than good. In addition to charcoal toothpastes not containing fluoride, potentially abrading dentin, irritating gums and increasing tooth sensitivity, the authors cite another potential risk of charcoal as a carcinogen. It is possible that long-term use of charcoal products could have dire outcomes.^1,2 Overall, there is simply not enough evidence to support that charcoal promotes oral health and hygiene, as the proposed risks appear to offset the wildly under-researched “benefits”.

Activated charcoal products are promoted as handy tooth-whitening tools among other over-the-counter tooth whitening gels and films. Although these regimens are considered safe, consumers should at the very least be aware of potential risks and common side effects of tooth whitening. Both tooth whitening and bleaching products contain chemicals that lighten tooth color. As might be expected from using chemicals, increased tooth sensitivity and gum irritation are common and often to a mild degree. More serious side effects, particularly from repeated or prolonged use of whitening regimens, include enamel softening, tooth roughness, and demineralization, along with increased susceptibility to dehydration.⁴ It is important to point out that white teeth are not necessarily a sign of healthy teeth; maintaining good oral hygiene by brushing twice daily for two minutes with a fluoride toothpaste, daily flossing, and regular dental check-ups is ultimately the best way to guarantee a healthy and happy smile.

 

Sources:

¹Greenwall LH, Greenwall-Cohen J, Wilson NHF. Charcoal-containing dentifrices. Br Dent J. 2019;226(9);697-700. https://www.nature.com/articles/s41415-019-0232-8. Accessed January 7, 2019.

²Santos-Longhurst A. Charcoal toothpaste for teeth whitening: the pros and cons. Healthline. https://www.healthline.com/health/dental-and-oral-health/charcoal-toothpaste. Updated June 18, 2019. Accessed January 7, 2019.

³Vyas K. The truth about activated charcoal. Interesting Engineering. https://interestingengineering.com/the-truth-about-activated-charcoal. Published September 13, 2019. Accessed January 7, 2019.

⁴Carey CM. Tooth-whitening: what we now know. J Evid Based Dent Pract. 20114;14(Suppl);70-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058574/. Accessed January 7, 2019.