Kelly Tanner Williams, RDH, MS, CDA

Manager, Professional Education South East

Kelly.Tanner-Williams@philips.com

Kelly Tanner Williams, RDH, MSDH, CDA has been active in all aspects of

the dental hygiene profession. She has served as a mentor, clinician, con-

sultant, researcher, and also as a dental hygiene educator and clinical

director. Kelly has served as past president of the Virginia Dental Hygien-

ists’ Association and also as Chair of the ADHA Council for Public Rela-

tions. She has been recognized for her outstanding leadership within health

care and university settings, and is a recipient of the ADHA and Johnson &

Johnson Award for Excellence. Williams is currently working towards her

Ph.D. in Organizational Leadership from Regent University.

Kelly manages the South East region for Philips Oral Healthcare and presents a variety of educational programs nationwide.

Objectives:

Incorporate oral pathology screenings/exams at every

recare visit

Customize a treatment plan based on the patient’s

individual level of caries risk

Exemplify a pathway to wellness with education about

the inflammatory process

Implement resources and tools for routine comprehen-

sive patient screenings

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Resources:

Canadian Dental Hygienists Association www.cdha.ca

American Dental Hygienists Association www.adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf

Philips CARE—Online risk evaluator tool www.philipsoralhealthcare.com/CARE

In Pursuit of Health

CARE to Take the Journey

Paradigm Shift in Dentistry: Treatment Prevention Risk Assessment (Pre-1970’s) (1970’s—2005) (Today)

Standard of Care

Canadian Dental Hygiene Process:

Assessment—What is happening?

Planning—What needs to happen?

Implementation—What will we do?

Evaluation—What are the outcomes

American Dental Hygienists Association Standards for Clinical DH Practice:

Assessment—Collection, analysis and documentation

Dental Hygiene Diagnosis—Analysis of data, critical decision making skills

Planning—establish goals/outcomes based on patient’s needs, expectations, values and current scientific evidence; integrate within overall dental treatment plan

Implementation—delivery of DH services w/minimal risk and optimal oral health

Evaluation—ongoing review and documentation of DH care outcomes

Documentation—complete, accurate recordings of patient information and care

Oral & Systemic Risk Factors

Age, Race, Gender

Lifestyle

Diet

Habits

Health

Customized Assessment Risk Evaluator

Interactive portal created by leading dental experts

Comprehensive assessments for caries, periodontal diseases, oral pathology

Quickly determines patient’s risk

Assists in developing customized treatment plans based on patient’s needs

© 2015 Philips Oral Healthcare

Tanning Devices Family History Moles Weak Immune

RISK ASSESSMENT: ORAL PATHOLOGY 2013 Statistics 5-Year Relative Survival Rates

36, 000 in the US

6,850 Will Die as a Result

50% Five-Year Survival Rate

Signs & Symptoms

Difficulty chewing/swallowing

Difficulty moving jaw/tongue

Sore, irritation or lump

White/red patch

Swelling

Unilateral ear pain

Numbness

8-Point Examination for Oral Cancer Screening

Protective Factors Dental Care Oral Self-Exam Limit Sun Exposure Healthy Diet Eliminate Tobacco

Calculate Louisa’s Risk

51 years young New patient Last exam 16 mos Alcohol recovery last 4 years Former smoker last 4 years Poor nutrition Musician educator Wants whiter teeth

Melanoma Risk Factors Symptoms

Fair Complexion Sunshine High Altitude Sunburn History

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Resources:

Achatz, G. (2011). Life, on the Line. New York, NY: Penguin Group.

American Cancer Society www.cancer.org

Oral Cancer Foundation www.oralcancerfoundation.org

Centers for Disease Control and Prevention www.cdc.gov

National Institute of Dental and Craniofacial Research www.nidcr.nih.gov

Silverman S Jr, Shillitoe EJ. Etiology and predis-posing factors. In: Silverman S Jr,ed. Oral cancer. 3rd ed. Atlanta , Ga : American Cancer Society, 1990:7-30

Hein C, Kunselman B, Frese P. Preliminary find-ings of consumer-clients perceptions of dental hygienists scope of practice/Qualifications and the level of care being rendered. American Dental Hygienists’ Association Annual Session. June 2006

Gurenlian J. The role of the dental hygienist in oral cancer screening, education and manage-ment. The Inside Summit on Oral Cancer Discov-ery and Management 2007;3(2):21-2.

© 2015 Philips Oral Healthcare 2

Louisa’s Oral Exam Possible bruxism Palpable lymph node-Left Cervical abrasion w/occas sens Interproximal biofilm 60% Coated tongue 1mm x 4mm, irregular white

patch-Left buccal mucosa, asymptomatic

RISK ASSESSMENT: DENTAL CARIES An Epidemic Disease

Oldest/Most Widespread Disease

Affects More Than Other Chronic Infectious Diseases

Nearly 1/3 of US Adults Untreated Tooth Decay New Caries Pathogen

Scardovia Wiggsiae

Associated w/Severe Early Childhood Caries

Thrives in Acidic Conditions

Caries Risk Assessment Codes 2014

D0601 = Low Risk

D0602 = Moderate Risk

D0603 = High Risk

Caries Risk Factors

Tooth

Saliva

Flora

Substrate Transmissible Pathogens

Children Infected: Mother, Caregiver, Siblings

Soft Tissues Colonize Prior to Tooth Eruption

Early Infection=Increased Caries Later

Other Risks to Consider

Frequent Tobacco Use

Acid Reflux

Protective Factors

Homecare Technology

Chlorhexidine

Sealants

Chlorhexidine—Molecules adhere to and damage bacterial surface, osmotic imbalance and

the precipitation of cytoplasm ensue and result in cell death.

Sealants—Occlusal surfaces account for 12.5% of tooth surface BUT experience more than

50% of all decay.

At-Home Fluoride

SnF—Stannous Fluoride

NaF—Neutral Sodium Fluoride

APF—Acidulated Phosphate Fluoride

© 2015 Philips Oral Healthcare

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Resources:

Centers for Disease Control and Prevention www.cdc.gov C. R. Tanner, J. M. J. Mathney, R. L. Kent, Jr., N. I. Chalmers, C. V. Hughes, C. Y. Loo,7 N. Pradhan, E. Kanasi, J. Hwang, M. A. Dahlan, E. Papadopolou, and F. E. De-whirst. (Apr. 2011). Cultivable Anaerobic Microbiota of Severe Early Childhood Caries. J. Clinical Microbiology, p. 1464–1474 Vol. 49, No. 4. Harris et al. (2004) Prevention in Clinical Oral Health Care. David P. Capelli, Connie Chenevert Mobley. Capelli DP, Mobley CC. (2008). Prevention in Clinical Oral Health Care. Maryland Heights, MO: Mosby Elsevier. V. Kim Kutsch, DMD, Robert J. Bowers. (2012). Balance. A Guide for Managing Dental Caries for Patients and Practi-tioners. Tamarac, FL: Llumina Press. A.K.L. Wan, W.K. Seow, et al. (2001). Oral colonization of S. mutans in Six-month-old Predentate Infants. J.Dent Res. 80:2060-2065. A.K.L. Wan, W.K. Seow, et al. (2003). A Longitudinal Study of Streptococcus Mutans Colonization in Infants after Tooth Eruption. J.Dent Res. 82:504-508. R.J. Berkowitz, H.V. Jordan and G. White. (1975). The early establishment of S. mutans in the mouths of infants. Archs. Oral Biol. 20:171-174. R.J. Berkowitz and H.V. Jordan. (1975). Similarity of bac-teriocins of S. mutans from mother and infant. Archs. Oral Biol. 20:725-730. S. Alalusua, O.V. Renkonen. (1983). Transmission of specfic strains confirmed by DNA matching S. mutans establishment and dental caries experience in children. Scand. J. Dent Res. 91:453-457. McDonnell, Gerald and A. Denver Russell. (1999). Antisep-

tics and Disinfectants: Activity, Action and Resistance. Clin-

ical Microbiology Reviews 12.1: 147-79.

3

Lifestyle/Habits

Income

Socioeconomic

Education

Diabetes

Bulimia

Head/Neck Radiation

Fluoride

Xylitol

Calcium Phosphate

Salivary Flow

New Fluoride Codes 2013

1203—Child 1204—Adult 1206 = Varnish Only 1206.1-Kids 1206.2-Adults 1208 = Any other FL Delivery

Xylitol

Cannot be Metabolized by S. mutans

At-Home Use: 6-8 grams

Inhibits Growth of S. mutans in Biofilm

FDA Approved Calcium Phosphate

Calcium Phosphate

Amorphous Calcium Phosphate

Calcium Sodium Phosphosilicate

TriCalcium Phosphate

Other Options

pH Neutralization: sprays, rinses, lozenges, and baking soda/water

Sodium Hypochlorite Rinse

Calculate Brody’s Risk

9 years young

4th grade

College Educated Parents

ADD

No Siblings

Crowded Teeth

Heavy Biofilm RISK ASSESSMENT: PERIODONTAL DISEASES

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Resources:

Jenson et al. (2007). Clinical Protocols for Caries Management by Risk Assessment. CDA Journal. 35(10): 714-723.

Fontana M, Wolff M. (2011). Translating the

Caries Management Paradigm Into Practice:

Challenges and Opportunities. CDA Journal. 39

(10) 702-708.

Rachel Wall, Inspired Hygiene http://www.youtube.com/watch?feature=player_embedded&v=AbVdFdJ7GEM

© 2015 Philips Oral Healthcare 4

Brody’s Oral Exam Arrives 10 min late for 30 min appt Parents monitor 2 min brushing/evening Forego BWX today Return in 2 wks for exam & BWX Several small white spot lesions w/

bleeding Recare appts since age 3 Mother is receptive to recommendations

but fails to follow through

The American Academy of Periodontology recommends that every patient receive a com-prehensive periodontal evaluation on an annual basis. Periodontal Infection Chronic—20-25% Adults Worldwide Aggressive—Rare, Severe, Rapidly Progressing

AAP Risk Factors for Perio Diseases

Age Smoking/Tobacco Genetics Stress

Theory of Inflammation

Diabetes: An Inflammatory Disease?

Inability to Produce Insulin

Decreased Immune Function

Inflammatory Mediators Release

Hyperglycemia

Hemoglobin A1c (HbA1c)

Test measuring % of glucose attached to red blood cells

Indicates blood sugar levels from previous 2-3 months

© 2015 Philips Oral Healthcare

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Resources:

Bouchard P ., et al. (2006) Risk Assessment for severe clinical assessment loss in an adult popu-lation. J Periodontal; 77: 479-489.

Hermes CR, Baumhardt SG, Rösing CK. (2013). Occurrence of aggressive periodontitis in patients at a dental school in southern Brazil. Acta Odon-tol Latinoam;26(2):84-8-abstract.

Iain, L. et al. (2013). Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Disea-ses.. J Peridontal;84.

Parakevas S, Huizinga JD, Loos BG. (2008) A systematic review and meta-analyses on C-reactive protein in relationship to periodontitis. J Clin Periodontal; 35:277-290.

Page RC, Schroeder HE. (1976). Pathogenesis of

inflammatory periodontal disease. A summary of

current work. Lab Invest;34:235–249.

Southerland, Janet H., George W. Taylor, and Steven Offenbacher. (2005). Diabetes and perio-dontal infection: making the connection. Clinical Diabetes 23.4: 171-178. Policicchio, Piero. (2014). Diabetes and Perio-dontitis: A Two Way Relationship. RESEARCH & REVIEWS: Journal of Dental Sciences. 2.1: 37-42.

5

Medications Clenching/Grinding Other Systemic Diseases Poor Nutrition/Obesity

Global Epidemic: 346M

Type 1 and Type 2

Most Significant Systemic Risk Factor for Periodontal Diseases

Two-Way, Direct and Dose Dependent Relationship

Obesity and Inflammation

Inflammatory Disease

Visceral Abdominal Fat Cells Produce Cytokines

Triggers Inflammatory Process

Smoking

Increased Risk for Perio Diseases

Most Significant Risk Factor for Development/Progression of PDs

Current Smokers 4x> Periodontitis

Nutrition-Poor nutrition exacerbates periodontal diseases

Vitamin C-promotes wound healing, regulates health of periodontal ligament, helps with bone formation by depositing calcium phosphate crystals

Vitamin D-aids in Calcium absorption, helps to form and maintain strong bones.

Calcium-absorption is key. Common foods for calcium: Bok Choy, Almonds, White Beans, Broccoli, Peas, Brussels Sprouts, Collard Greens, Spinach, Turnip Greens, Edamame, Tofu and Sesame Seeds.

Genetics

AgP/IL-1B-Gene Responsible for 3x Increase in IL-1 Production

IL-1A/IL-1B Association with Chronic Periodontitis

Emerging—Polymorphisms in the IL1, IL6, IL10, VDR, CD14 Genes May Be Associat-ed with Chronic Periodontitis Susceptibility in Certain Populations

Possible Contributing Factors—Limited Research

Bruxism

Medications

Stress

Rheumatoid Arthritis

Pregnancy & Periodontal Diseases

Hormonal changes increase risk for perio diseases

Pregnant patients may have increase risk for PLBW delivery

Perio diseases could prompt adverse pregnancy outcomes via systemic infections and inflammatory methods

Protective Factors Periodontal Diseases

Healthy Diet

Professionally Delivered Dental Care

Biofilm Control: Daily Brushing, Interproximal Cleaning

Antimicrobial Delivery

Oral-Strain Probiotics

Periodontal Procedure Codes 2014

D4921—Gingival Irrigation per Quad

D4342—SRP 1-3 Teeth/Quad

D4910—Perio Maintenance

D5994—Periodontal Medicament Carrier

Laboratory Processed

© 2015 Philips Oral Healthcare

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Resources:

J. Lim, A. Iyer, L. Liu, J. Y. Suen, R.-J. Lohman, V. Seow, M.-K. Yau, L. Brown, D. P. Fairlie. (2013) Diet-induced obesity, adipose inflammation, and metabolic dysfunction correlating with PAR2 expression are attenuated by PAR2 antagonism. FASEB J 27:4757-4767. Tilg, Herbert, and Alexander R. Moschen. (2006). Adipo-cytokines: mediators linking adipose tissue, inflammation and immunity. Nature Reviews Immunology 6.10: 772-783. Nishida M et al. (2000). Dietary vitamin C and the risk for periodontal disease. J Periodontal; 71: 1215-1223. Hildebolt CF. (2005). Effect of vitamin D and calcium on periodontitis. J Periodontal; 76:1576-1587. Bali et al. (2012). Genetics and Aggressive Periodontal Disease: An Update Review. www.johcd.org;6(2). Korman et al. (1997). The interleukin-1 genotype as a sever-ity factor in adult periodontal disease. J Clin Periodontal; 24:72-77 Schaefer et al. (2013). Validation of reported genetic risk factors for periodontitis in a large scale replication study. J Clin Periodontology; 40:563-572. Stabholz et al. (2000). Genetic and environmental risk fac-tors for chronic periodontitis and aggressive periodontitis. Periodontology, Vol 53, 2010, 138-153. Akcali, A. (2013). Periodontal diseases and stress: a brief

review. Journal of Oral Rehabilitation; 40: 60-68.

Branschofsky et al. (2011). Secondary trauma from occlu-

sion and periodontitis. Quintessence Int. Jun; 42(6);515-22

Brusca et al. (2010). The impact of oral contraceptives on

women’s periodontal health and the subgingival occurrence

of aggressive periodontopathogens and Candida species. J

Periodontol. Jul:81 (7): 1010-8

Ciando, SG. (1996). Medications as Risk Factors for Perio-

dontal Disease. Journal of Periodontology. Vol.67, No. 10s,

Pages 1055-1059.

Liden et al. (2013). Periodontal systemic associa-

tions:review of the evidence. J Periodontal; 84 (4 Suppl) S8-

S19. 6

Systemic Antibiotics—Specific to Periodontal Pathogen Testing

Porphyromonas gingivalis

Tannerella forsythensis (Bacteroides forsythus)

Treponema denticola Systematic Reviews:

2003—Haffajee, Socransky & Gunsolley

Clinical improvements in attachment level change

2011—Lexzczynska et al

Low doses of doxycycline can modulate host pro-inflammatory agents

Oral-Strain Probiotics

Calculate Rolland’s Risk

65 years young

Retired Contractor

Last Prophy 2+ Years

History of Tobacco

Diet Inadequate

Full Dentition

Generalized Bone Loss

© 2015 Philips Oral Healthcare

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Resources:

Leszczynska et al. (2011). Periodontal pharma-

cotherapy – an updated review. Advances in Med-

ical Sciences; 56: 123-131.

Bonifait, Chandad and Grenier. (2009). Probiotics

for Oral Health: Myth or Reality? JCDA; Vol.

75, No. 8: 585-590.

7

Rolland’s Oral Exam Several small brown, non-elevated spots 3mm x

3mm Scar-Right side of chin Full natural dentition Bleeding upon probing 12 pockets>5mm Several furca No mobility 10% Horizontal bone loss Vertical bones loss in several areas Plaque biofilms are evident approx. 90% Soft tissue exam is unremarkable