Transcription
(click) - I am so honored to be here, and I congratulate Lucy and Jerry for hosting such a wonderful event. For all these years, every year I learn more and more. I have to admit, as a dentist, when I graduated, I really was not well-prepared to take care of people with intellectual disability or anything. I learned a lot of it through hard knocks, and I'm just gonna say mea culpa to all my patients before that I didn't know how to treat as well, and thank you for teaching me now. So, I am so honored to be here amongst you all. You guys are the heroes and the champions of special needs and care for special needs.
And I wanna know how many dentists are here. Any dentists? Okay, one, me. Okay, no-- (laughter) There's two or three. And then the first question is, why aren't they here? They're part of the team, right? All right, good. So, how many have heard me speak before? Okay, great, so I can't use some old jokes. All right, that's okay. (laughter) This is not gonna be about flossing and brushing, because that's proven that's not the key to everything. So what we're gonna go is go over some materials today. And hopefully give you some idea on what, I'm looking for the clicker. - Clicker? - Who's got the clicker? And give you some ideas to think and bring back home to yourself that will improve oral health. I'm gonna tell you some things, I'm gonna make you a little uncomfortable first, all right? Gonna wake up some of you who are kind of sleeping. Actually, you're in mindfulness yoga, right? That what you're doing? Okay, all right. So, nothing to disclose. I'm not paid representative anything.
A lotta the information I've learned is just through a lotta great people and experiences, particularly Special Olympics. And this revelation that dentistry and medicine, they're not independent. They're really together. And we need to start working better together. How many of you write prescriptions? Any of you? Okay, a lotta messages gonna be for you all too, as well. So what we're gonna do is talk a little bit about what we already know about, sorta highlight the fact about the disparity of care. And I have the privilege and pleasure to travel different countries and teach dentists how to take care of people with special needs. And I can tell you the challenges of getting dental care is not unique to here. Everywhere has a unique challenge. But there is light at the end of the tunnel. I always dedicate this to a young person. It's not my son. But to remind ourselves that the youth of today is our future of tomorrow. And we talk about dental disease as preventable disease. And yet for 200 years, we really haven't done very much about it. And we really neglected to take care of people with intellectual disability and special needs. So we really need to start focusing on what we can prevent. We're gonna come back to him in a bit.
I have a lot of information. It's like going to Costco and trying to fit everything in one basket. I just got a lotta things to unpack. So some of the things I'm not gonna read to you because it's already on my slide. So intellectual disability, we try to teach my dental students, my dental residents, the impact. At one time we thought, well, I'm not gonna see a lotta that in my practice. But actually you are, you're gonna see a lot of it. And at one time the disparity of care was, I think Elizabeth had mentioned before, way before in the '20s and '40s, the lifespan of someone with intellectual disability was very short. Why was that? Because most the health histories were WNL. We never looked. And we never thought about it. It wasn't until we started paying attention that they are people, they have diagnoses, they have diseases on top of things. So life expectancies increased only because we're starting to focus more on their health. And we started realizing that patients with special needs are not just patients with special needs. There are many multiple factors. Whether it's from intellectual disabilities or a combination thereof. Usually this talk that I give is about two hours, but I gotta squeeze it into 30 minutes, so I'm not gonna go through each one. But this is just to illustrate the complicated nature of this. Whatever we do to treat one thing, we affect something else.
So if developmental disability were this broad slide here, I usually ask my students, "Well how frequent do you think that is?" And usually a lot of 'em think, well, not that often. So I say, "Well, how many?" 'Bout 10 to 20% have some form of developmental disability, of which about one out of 44 have an intellectual disability. Matt Holder showed me this slide, and I said, "I'm stealing this one," because it sounds really good. Because it gives an idea in terms of the scope of what things are. Autism spectrum, that's one in 59. And autism, you know, it is more diagnosed. But if you went to New Jersey, you know, it's one in 39. Why do you think that is? Because the services are better there. So that's what's happening. In Iceland, they've got Down syndrome down to almost 0%. Why do you think that is? Yeah, they abort them early. And that's just wrong. That's just wrong, that's not a treatment. That's terrible. So the youth of today, the professional today need to know the injustice for the population. And it's part of our job to take care of things. We talked about cerebral palsy. In the scheme of things, my number that we have is one in three hundred and such. I think Hank had one in 280. But it's still fairly frequent. Down syndrome we have is one in 690. And then fetal alcohol syndrome we have is one in 2,000. And then fragile X, we have one in 3,000. So I try to impress upon my dental students and residents that we need to know more about this, and we need to teach you about it. So our goal here is to learn more about that, how it affects dentistry, and how it affects medicine. And all together, that's what it is.
So disparity of care in all populations, for all developmental disability, dental care is one of the number one unmet healthcare needs. Whether it's here or whether it's in Africa or Asia. For example, the average lifespan of someone with Down syndrome is 55 for a white person. But why is the lifespan for a average black person at 26? This is one of the studies that was done, Rick Rader had five years ago. The disparity of care is incredible. It's only because we're not paying attention. There was a confidential student study in United Kingdom eight years ago where a male with intellectual disability will die 13 and a half years earlier than someone without. And in a female, they will die 20 years earlier. I hope that makes all of us uncomfortable, but you probably already know this already, right? So we need to do something. We need to be the advocates, as someone had suggested yesterday, all right? But all patients, they all die of the same top diseases: cancers, diabetes, heart disease. And access to care is terrible. The general public believes, in a survey, that people with intellectual disability or developmental disability get better care than the average population. 10 years ago, when they did a study of dental school and medical school deans, they admittedly said that 52% of medical schools and 53% of dental school deans felt that their dental students were not competent in treating people with special needs. I know, kinda depressing right now.
Fortunately, recently, the American Dental Association has been embarrassed by the National Council on Disability for neglecting to take care of this population. And the Commission on Dental Accreditation has now changed their accreditation standards to increase the competency expectations of pre-doctoral students and post-doctoral student education. So now we will now have more education in dental schools, and more clinical experiences as well. So hopefully we will have a generation of doctors and dentists that will be able to not only see patients, but actually treat them as well. Wouldn't that be great? So we need to have this new wave of people embracing this idea and taking care of it. In post-doctoral education, the same thing's happening. More people are starting to be engaged and involved in being the people who take care of people with special needs. It's taken a long time to get there, but we're starting to get there. All right, so now to the doctors who are prescribing, and dentists as well. A reminder that every medication we prescribe has side effects. And sometimes we forget to monitor those. So a lotta the medication changes that we get are listed below.
The number one thing I wanted to remind everyone is the diagnostic overshadowing. Not only of the medical conditions, but the dental conditions as well. So most the time, with medical or dental overshadowing is we attribute the symptom to something other than the real cause. And we need to take a step back and then look at the whole evaluation. For instance, in this sorta circle, when a patient complains of something, often we think medication to change and help the behavior. But sometimes that's not the etiology. But when we give them medication, the behaviors decrease. So a lotta times we feel like, ah, we're onto something. The problem worsens, the patient has more problems, and the circle continues. So it keeps on going in the vicious circle. We need to stop and look. Many times you hear of people coming in, we take care of their dental needs, and all of a sudden the behaviors calm down. Amazing, right? Or maybe because they have GI problems, that's what it's been, and we've been masking it. So this diagnostic overshadowing is something we need to be wary of. New behaviors are sometimes just due to the diagnose itself, and it may not be just needing medication. It just may need a good look. With intellectual disability for our dental, everyone wants to do hospital dentistry, it seems like. And much of it is not necessary. Only 1.5% from our studies are truly profound. So in a diagram, all those in purple are those that can be seen in dental offices, but they're not. They're not. And it's not because their dentist aren't capable. They just don't feel comfortable. And it's our job to remind them that it's okay, they can go to courses and classes to learn how to do this.
And we talked about dental caries before. Pandemic disease. Every country has this, it's a huge problem. Lotta people are losing teeth prematurely, which is terrible. And it's multi-factorial. Last time I came and talked to you about this Caries Management by Risk Assessment. We don't have to lose teeth early. And it's not just for people with special needs. This is a process of understanding the cause and the effect, right? The cause and the effect. Because brushing and flossing, albeit good and hygienic, it's not gonna stop the cavity process. They're gonna keep doing that. So this young boy, this is his mouth. Do you think that he's not brushing or he's not flossing? No, he's brushing and he's flossing. Do you think mom and dad don't love him? No, of course not. His side effect is he has a condition called aplastic anemia, and he's taking a lot of medication. Poor young kid, child. I was referred to him because he needed to have a bone marrow transplant, but we had to extract a lotta these teeth. Those of you who are doing exams, you can help me a lot by just identifying a few things, and we're gonna talk about a few of these things. And by the time you're gonna be done, you're gonna be pretty good at it too.
This slide reminds me, this is risk factor, dental caries risk. When you're a baby, you have certain cavity risk factors. As you become older, as an adolescent, you have different cavity risk factors. As you get older and become geriatric, you have different risk factors. So just because you don't have cavities for 10 years doesn't mean you're not gonna get cavities later. So let me explain. This CAMBRA concept is not just for the medically compromised or those with developmental delays. It's for everyone who has teeth, okay? That's you out there right now, all right? So lemme tell you about a few things. This is not a new concept, it's been around for 20 years. But dentistry has been awfully behind in times. It's not about magic potions or powders, and it's not about all fluoride, albeit fluoride is okay and good in certain usages. But sometimes we get so passionate under myth that we think fluoride's terrible, it's a poison. And you have to tongue in cheek know that it's not the same type of the fluoride we're talking about. So doctors take diagnostic tests to get a baseline. What do the dentists do? Well, we check for periodontal pockets. We'll take x-rays, and we'll show you certain things. But that's all we do, really. But there are other more elaborate tests as well, that we can tell many things. Your predisposing factors, if you will, for dental disease, by checking for the health of your saliva and the health of your biofilm, all right? Let me talk a little bit more about it.
You cannot treat what you don't diagnose, or you can't even get an idea of the prognosis. If you do the same thing over and over again, you're gonna get the same thing. Often patients come to us and say, "I don't understand it. I brush three times a day and floss three times a day, but I get a cavity every couple of years. My husband," it's always the husband. "Never flosses and never brushes, and he never gets a cavity!" What's up with that, right? Sound semi-familiar? Everyone's looking at their spouse or whatever. So instead of the brushing and flossing only, you have to recognize risk factors. There's basically five major risk factors that contribute to dental disease. Ready? First one is saliva. Has 63% influence weather you get a cavity or not. Your diet, 55% influences, and that's mostly sugars. Bacteria, your natural bacteria in your mouth, in your biofilm, is 46 to 51% influence. And even genetics has an influence whether you get a cavity or not, almost 50%. The very last one 100% influences whether you get a cavity or not is the pH of your saliva or your biofilm, right? It's all basic chemistry. If I put a tooth in a jar of acid, it dissolves, right? Basic high school chemistry. The pH that's neutral is seven, right? Enamel will dissolve at a pH of 5.5. Your dentin and your root will dissolve at a pH of six. Right now, your saliva may or may not be neutral. When I drink coffee, this yummy coffee from Starbucks, that's a pH of two or three. So now my teeth are bathed in pH of three or two acidic. It's softening. But guess what? My saliva's gonna neutralize it, right? So hopefully it'll neutralize it quickly back to a seven. It's called a Stephan Curve. So when I drink it, it goes down and eventually goes back up. Someone who has medication that impairs the salivary function or the decrease of saliva do not neutralize the acids, and therefore your teeth get soft and you get a cavity. That is CAMBRA.
So recognizing your pattern, and you're not gonna see all these in your picture, but not only does some medications cause dry mouth, some will increase stomatitis, some will increase xerostomia and reflux or dental caries because of the sugars involved with it. So anyone who's prescribing anything, remind the patients, if their mouth is dry, they should rinse their mouth more frequently. And that can go to you as well, anyone with teeth. Prescription patterns, there's 25% more likelier to get a prescription, 300 more likely to continue that prescription. 46% of psychotropic drugs don't even have a corresponding psychiatric diagnosis. And 13% of anti-seizure drugs go to patients that don't even have seizures. So too many medications being prescribed. Lotta side effects that we see that can happen. These are data that we collect from Special Olympics throughout all the countries. Saliva is really really important. Someone said something about drooling, I think, earlier, you know? If you have saliva, you have to have the amount of quality and quantity of saliva. And I can tell, the very one thing is, all of you can be a quick dentist. If you see a patient or if you yourself, if your saliva is thick, ropy, bubbly, you have salivary impairment. You are an extreme caries risk. That means that you're not producing enough saliva, or the quality of saliva. Easily can be checked with a pH paper. And you might just be dehydrated. That might be all it is. Do you know how much saliva you produce in one day? Quite a bit. One to two liters. Do you drink one to two liters of water? - No. - No, right? And for a lot of patients whose caregiver take care of geriatric patient, and those who caregive for special needs patients, they don't get enough water. Why? 'Cause you have to go to the bathroom, right? So therefore, a lotta times they are dehydrated. So we know that bacteria's bad. We know diet affects things. A lot of it is sugar. Sugar feeds and drives the bacteria to form acids. Those acids eat away at teeth. And that's kind of important to note. So we wanna keep that off. Genetics, we talked about, was an influence. Dental disease affects or is associated with other problems, such as diabetes, cardiovascular problems, pregnancy outcomes, pneumonias, and other things. There's a certain connection. It's a balance to get a cavity. If you really wanna stop getting a cavity, your dentist needs to be watching for certain things. The risk factors, if you will. Almost like the risk factors you would think about for hypertension. You wanna look at the risk factors.
On the left hand side, white spot lesions, restorations within three years, enamel lesions, or cavities predispose that patient to cavities. In the middle, your bacteria, your absence of saliva, or destructive lifestyle habits, that is an influence. Like a teeter-totter. How you change the teeter-totter, unfortunately, it's off balance to one side, is to improve your saliva to make sure you have healthy quality saliva, dental sealants, antimicrobials, which is the rinsing of your mouth with antimicrobial materials, and then rebuild the tooth. Yeah, that's right, you can rebuild the tooth. Just like in chemistry, if things are leaching out, you can change the pH and your ions will change and go back the other way and get hard again. Effective lifestyle, and then a risk-based reassessment, meaning that you see the dentist more frequently and have him check it. So basically you have a hammer. When all you have are the hammer, everything is a what? Nail, right. In dentistry, our hammer is basically the sharp instrument that we go poking around, or we look for something and we drill and then we fill. What we should do is change. What are those two coins down there? That's right, it's a paradigm. So that paradigm-- (laughter) The paradigm is to not do that. The paradigm is say, "Hey, what's causing my teeth to soften, and what can I do to change it?" With that sharp instrument, as my teeth are softening, if I push into a soft spot, now bacteria goes in that hole and I get a cavity. Instead, the dentist should be drying the teeth and looking for surface texture. If it's a dull color when they dry it, that means demineralizing. But if I change the dynamics, it can re-harden. I can remineralize it. And I'm gonna give you the five ingredients it takes to remineralize the teeth in just a second, all right? So there's this form we call the CAMBRA form. It does everything that I showed with the teeter-totter to assess what are the risk factors. And then we look at the teeth and coloration from zero, on your far left, to six on the other side. And if it's a certain thing in the middle, it can tell us if it's worthy to remineralize. So if we have the five right ingredients, we can take something that's the starting of a cavity and stop it, right? Okay, so the new paradigm is prevention-based. It's to continue to evaluate things, take x-rays, and prevent it by basically using fluoride varnish to help make the tooth harder. But fluoride varnish won't work unless it has the four other ingredients. Yeah I know, I'm teasing you. So the five ingredients are coming up. Just a reminder of food. Okay, you think of acids, biofilm, and chemistry. So if you're gonna go swimming or if you have aquariums, you'll understand this concept quite well. So, that's a nice swimming pool. But if the pH drops a little bit, things grow, all right? The same thing with your mouth. And so, when the bad bacteria are on there too long, it will make good bacteria become acidogenic and turn acidic. So that's why that's not a good thing. So if you have a bad bacteria, you wanna kill off the bad bacteria to grow a good healthy environment. But you don't know what you don't test for. We have this meter, but actually NASA started using to test for bacteria activity of ATP. We're able to use that for plaque now to see the activity of bacteria in your mouth now. And so we use that as our metric. So the five things you need to do to grow teeth is to control the salivary pH, have a certain amount of proper fluoride, kill off the bad biofilm, and you need calcium, and you need phosphate. If you have those five ingredients, your teeth can get stronger. Isn't that great? But if only all you do is fluoride, that's not gonna help you.
I'm gonna go through a couple quick cases, because I've got four and a half more minutes. This is a miracle stuff now for dentistry. It's called silver diamine fluoride. The way it works is it's made with silver, which is a strong antimicrobial agent. So if you see a cavity, and physicians can do this as well, if you see a cavity and you dry it and you paint this on it, it stops the cavity. It kills it. Not only it kills it, the solvent's ammonia, then the fluoride remineralizes the tooth. It makes it hard again. It's magic. And you know, it's cheap, which is great. So here's some examples. The negative side effect is it kills the cavity and turns it dark, all right? That's the only one bad thing. But the tooth will get harder and you can put a filling on top and cover it if you want. So this is something that does not require someone to be numbed up for. How's that, right? Not very good. It's like, "You mean, you don't have to give me a shot?" Right on. So you just dry it, you wipe the silver diamine fluoride, it kills it, and it turns it dark. And then later on you can put a filling on it. You could actually put the filling on the same day, if you want. Or you can just put it on for those who are pre-cooperative. You can use it in this fashion, as under a sealant. And hyper-mineralize the tooth as well. Here's an example of a lotta cavities. And this was done probably in about 45 minutes. No anesthetic, and the patient was able to save their teeth. So here's a really dramatic case. It's called a Sjogren patient. Some of you know about that, it's an autoimmune disease. This person's a 17-year-old person. Walks around like this because the air hurts her so much. And there's not enough tooth structure to really crown. And she says, "I'm desperate, what can I do? Everyone wants me to take out all my teeth." We said, "Well, we can do silver diamine fluoride, but it's gonna turn things kinda dark." Everyone is so concerned how things will turn out dark. It did turn out dark. And then we put some filling material on top called glass ionomer. It's not a composite. Glass ionomer is the other thing I wanted to tell you about. It's a material that is fluoride-based and releases fluoride, but fights cavities. Because in a dry mouth, composites, or your tooth-colored materials, don't last. This is the only material that continues to release fluoride onto the tooth and strengthen the tooth, okay? So you don't have to be worried about that. There's a consent for that. I'm probably running out of time, right? I got two more minutes? I got one minute? - Two. - Two more minutes, okay.
So my thoughts are this. If we can desensitize our patients earlier, use some of this newer technology and newer materials to remineralize the teeth, and focus on their medication side effects about their dry mouth and control it, I think we got a chance, especially with the new practitioners in. So how do you control salivary pH? Simple. Glass of water, half a teaspoon of baking soda, mix it up, and rinse. That's a pH of eight and a half or nine already, okay? The recommendations are usually one to two teaspoons, but it's disgusting, I wouldn't do that to you. But you yourself, you the clinician, you try that. Half a teaspoon in water, rinse, spit. 'Specially at nighttime. So many of our patients have GERD. Gastric reflux. So many of our patients are mouth breathers. So many of our patients are wearing CPAPs. All these are contributing factors to dry mouth and extra early cavities, okay? So, what else can I say? You all understand about saliva and the importance of saliva, right? And you all know how to rinse. I think I've covered most everything I wanted to cover, okay? And so, quick slide
Right before. Oh gosh. (laughter) Too much, you guys. Half an hour, wow, okay.
Final cautions. MI paste, that is a paste, a child died about a year ago who was allergic to milk products. MI paste is the paste that has the calcium and phosphate. That's what you're missing in saliva.
Xylitol is very good. It's a substitute sugar, five carbon. It's very good to reduce cavities because it fakes out strep mutans and cannot process it, so you have less acids. Unfortunately, it's fatal to dogs. I don't know about cats. But dogs, it's not a good thing.
Chlorhexidine, that's an antimicrobial mouth rinse. If you're gonna use that, don't use fluoride for 45 minutes, because they bind with one another and neutralize it.
Lastly, Special Olympics has this saying, this motto. Let me win. But if I cannot win, let me be brave in the attempt. My motto for dentists is, let me treat. But if I cannot treat, let me be brave in the attempt. And I will leave you with Hippocrates: "Cure sometimes, treat often, comfort always."
Thank you very much for your time. (applause)