Editorials
Fighting the Silent Epidemic of Poor Oral Health
See related articles on pages 501 and 509.
In 2000, Surgeon General David Satcher, M.D., Ph.D., called poor oral health in America a "silent epidemic." He emphasized that oral health is not just about healthy teeth but is integral to general health, and pointed out that safe, effective measures exist for preventing the most common dental diseases-dental caries and periodontal diseases.1 In this issue of American Family Physician, Gonsalves and colleagues discuss the most common oral lesions that physicians encounter and note that differentiating benign from worrisome lesions, and providing appropriate risk-factor counseling, is crucial to the achievement of national oral health goals.2,3
Since the Surgeon General's report, oral health has moved to the forefront of many prevention initiatives. Children's oral health is a particularly important part of this effort. There is now consensus among leading national professional health organizations that the earlier a child receives preventive oral health services, the lesser his or her risk of developing dental disease. The American Academy of Pediatric Dentistry recommendations published in 2000 stated that infants should have an initial oral evaluation within six months of the eruption of the first primary tooth but by no later than one year of age.4 In 2003, the American Academy of Pediatrics joined the dental community by advocating that a dental home be identified for all at-risk infants by one year of age.5 The basis of these policies is that dental caries is an infectious and thus preventable disease.
Early childhood caries, a particularly severe pattern of dental disease affecting infants and toddlers, results in pain, oral dysfunction, and low self-esteem, and often necessitates costly rehabilitation in a hospital setting. Children at risk of developing early childhood caries include those with special health care needs; those with mothers who have a history of multiple caries; those who have a high sugar intake, sleep with a bottle, or have milk in their mouths over a prolonged period; and those whose families are of low socioeconomic status. However, the disease can be prevented by oral risk assessments, anticipatory guidance, and preventive oral health interventions.6
Family physicians are in a unique position to champion oral health and reduce disparities in this area because of their provision of care to children and adults, and especially to childbearing women. Dental interventions aimed at women who are pregnant, such as referral for dental cleaning and education about dental hygiene, can reduce the risks of prematurity and low birth weight.7
In spite of national recommendations, many children have limited access to dental professionals. For every child without health insurance, there are three who lack dental insurance, and the number of dentally uninsured Americans totals more than 100 million.8 Three out of four dentists do not treat patients with Medicaid insurance; many more do not treat those who are uninsured.9 However, during the first few years of life, children visit clinics for well-child examinations and immunizations. These visits are an ideal time to provide screening, anticipatory guidance, and appropriate needs-based referrals so that dentists, who are in more limited supply, can provide the definitive care to those who most need it.
At well-child examinations, health care professionals should "lift the lip" to check for early signs of caries on the top front teeth. Medical charts, whether electronic or paper-based, should have a section to check off when the oral health assessment has been performed as part of a physical examination. Anticipatory guidance should be offered on appropriate feeding and sucking habits, nutrition, weaning, and care of the teeth, including wiping the erupting teeth with gauze or a soft cloth. Health education in this period should include information about the role of primary teeth to dispel myths that "baby teeth" are not important. All education should stress the infectious nature of the disease and be provided in a culturally and linguistically appropriate manner.
The biggest barrier faced by the primary care community in implementing these strategies is time. To help with this, clinics can develop risk assessment tools that would indicate which children and their families need more guidance on this issue. Because of the infectious nature of the disease, children who have siblings with early childhood caries would be obvious candidates.
Collaboration must be built among all disciplines to address this epidemic. In San Diego, Calif., tobacco settlement money was used to create a manual on accessing dental resources for primary care professionals who care for children. Health care professionals should advocate for increased state and federal funds for oral health programs, support community-based oral health education programs, promote water fluoridation projects, and support programs to increase the number of, and payments to, dentists willing to serve low-income families.
The traditional model of oral health care by a solo-practice dentist is not sufficient to combat the silent epidemic of early childhood caries. The preventable nature of tooth decay must be addressed through screening, assessment, and anticipatory guidance at the primary care level. This approach can build collaboration between primary care and dentistry, and can help eliminate oral health disparities.
editor's note: The Society of Teachers of Family Medicine Group on Oral Health has developed a comprehensive curricular resource to assist students, residents, and practicing physicians in enhancing their skills at diagnosis, management, and prevention of common child and adult oral problems. It includes five annotated PowerPoint modules addressing children and adults, pregnant patients, and dental trauma. Also available are patient education materials, pocket cards, handheld computer programs, resources for further learning, and an implementation guide. All materials can be downloaded at http://www.stfm.org/oralhealth. Oral health resources are also available at the Association of Clinicians for the Underserved Web site, http://www.clinicians.org.
Address correspondence to Lois Wessel, R.N., M.S., C.F.N.P., at lwessel@clinicians.org. Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
2. Gonsalves WC, Chi AC, Neville BW. Common oral lesions. Part I: Superficial mucosal lesions. Am Fam Physician 2007;75:501-7.
3. Gonsalves WC, Chi AC, Neville BW. Common oral lesions. Part II. Masses and neoplasia. Am Fam Physician 2007;75:509-12.
4. Sanchez OM, Childers NK. Anticipatory guidance in infant oral health: rationale and recommendations. Am Fam Physician 2000;61:115-24.
5. Hale KJ, for the American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003;111(5 pt 1):1113-6.
6. Finn E, Wolpin S. Dental disease in infants and toddlers: a transdisciplinary health concern and approach. Zero to Three 2005;25:28-33.
7. Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: a randomized controlled trial. J Periodontol 2002;73:911-24.
8. Wessel LA, Wolpin S, Sheen J. Early childhood caries. Rural Roads 2005;2:12-7.
9. Sinkford JC, Reinhardt JW. Dentistry and oral health. In: Satcher D, Pamies RJ, eds. Multicultural Medicine and Health Disparities. New York, N.Y.: McGraw-Hill, 2006:309-10.
Guidelines for Treating Adults with Acute Cough
See related article on page 515.
Simasek and Blandino review the literature on the treatment of the common cold in this issue of American Family Physician.1 The authors conclude that the ability to make confident and specific treatment recommendations is limited because of flaws in the evidence.
The American College of Chest Physicians (ACCP) recently published evidence-based guidelines for diagnosing and treating acute cough (less than three weeks in duration), subacute cough (three to eight weeks in duration), and chronic cough (more than eight weeks in duration) in adults and chronic cough in children.2 This editorial highlights key recommendations for treating adult patients with acute cough (Table 13). Figure 12 is an algorithm for the management of acute cough.
Management of Acute Cough
Figure 1. Algorithm for the management of acute cough in patients 15 years or older. (COPD = chronic obstructive pulmonary disease.)
Adapted with permission from diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):1S-292S. Available online at http://www.chestjournal.org/cgi/content/full/129/1_suppl/1S.
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table 1 Summary of Recommendations for Managing Acute Cough in Adults |
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It should be established that the cough has been present for less than three weeks. |
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It should be determined whether the cough is likely caused by a potentially life-threatening or non-life-threatening condition. |
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The differential diagnosis of acute cough should be considered. |
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When cough is caused by the common cold, older antihistamine/decongestant medications and the nonsteroidal anti-inflammatory drug naproxen (Naprosyn, Aleve) are likely to be helpful; newer nonsedating antihistamines and over-the-counter combination cough medications are not likely to be helpful; antibiotics are not indicated. |
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Acute bronchitis should not be diagnosed until the common cold, asthma, and an acute exacerbation of chronic bronchitis related to cigarette smoking or other environmental irritants have been ruled out. |
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In the context of a common cold syndrome, if the cough worsens (a biphasic course) or does not steadily improve after the first week, another cause of cough for which antibiotics may be beneficial should be considered. |
| Information from reference 3. |
Because studies have inconsistently targeted the multiple cardinal symptoms of the common cold (e.g., rhinorrhea, nasal congestion, postnasal discharge, throat clearing, cough), the evidence on how to best treat any one symptom is not strong. Therefore, the Duke Center for Clinical Health Policy Research (which conducted an evidence-based review of the literature for the ACCP guideline committee) limited its review to cough.4 Clinically, there are several reasons why it makes sense to target cough caused by the common cold: the common cold, which is the most prevalent condition in humans, is accompanied by cough in up to 83 percent of persons5; the common cold is the most prevalent cause of acute cough6; and cough is the most common complaint seen by primary care physicians in the ambulatory setting in the United States,7 probably because cough adversely affects health-related quality of life.6
Although acute cough from the common cold is usually transient and minor, it may be life threatening when caused by a more serious condition (e.g., congestive heart failure, pneumonia, pulmonary embolism). Therefore, the first step in managing an acute cough is to clinically determine whether it is caused by a potentially serious illness or one of a variety of non-life-threatening conditions (e.g., upper respiratory infection, bronchitis, mild asthma).
Because the common cold is the predominant cause of acute cough, it is useful to review the definition of the common cold and stress the importance of identifying acute nasal symptoms. The common cold is a minor, acute respiratory illness characterized by symptoms and signs usually related to the nasal passages with or without fever, lacrimation, throat irritation, hoarseness, and cough. Because the definitions of the common cold and acute bronchitis are similar,8 an acute bronchitis diagnosis should not be made unless the common cold has been ruled out.8 Other causes also should be ruled out before diagnosing acute bronchitis because it is often overdiagnosed, leading to more antibiotic prescriptions.
Acute bronchitis may imply a bacterial cause, making it more likely that antibiotics will be used. When acute bronchitis is diagnosed, antibiotics are prescribed in 65 to 80 percent of patients,9 and extended-spectrum antibiotics are prescribed in more than 50 percent of older patients.10 Moreover, many patients think that antibiotics are more important for recovery from acute bronchitis (44 percent of patients) than colds (11 percent of patients).11 Asthma and acute exacerbation of chronic bronchitis related to smoking or other irritants also should be ruled out before making an acute bronchitis diagnosis because they commonly present as acute cough-phlegm syndromes8; 30 to 65 percent of patients with these conditions have been misdiagnosed as having acute bronchitis.12-14
By using the most rigorous and current methods to develop its evidence-based clinical practice guideline for acute cough, the ACCP guideline committee made diagnostic and treatment recommendations based on two components: (1) the quality of the evidence, which was rated according to study design and strength of the modalities used; and (2) the net benefit of the recommendation based on the estimated benefit to the specific patient population (the net benefit represents an assessment of the balance between benefits and harms).4 Using this process, the committee's recommendations are stronger than Simasek and Blandino's,1 who based their recommendations on Cochrane reviews.
The committee strongly recommends that patients with acute cough from the common cold receive a first-generation antihistamine/decongestant or the nonsteroidal anti-inflammatory drug naproxen (Naprosyn, Aleve) unless there is a contraindication (e.g., glaucoma, benign prostatic hypertrophy, hypertension, renal failure, gastrointestinal bleeding, congestive heart failure).15 They also strongly recommend that newer-generation, nonsedating antihistamines should not be used because they are ineffective.15 The committee does not recommend over-the-counter combination cold medications, except for those that contain older antihistamine/decongestant ingredients, until they are proved effective in randomized controlled trials.16 A meta-analysis has called into question whether the presumed increased sedation effect of first-generation antihistamines compared with newer nonsedating antihistamines is substantiated by objective data and if it is clinically relevant.17
Antibiotics are rarely effective for acute cough and are not indicated for acute cough from the common cold, acute bronchitis, asthma, mild exacerbations of chronic bronchitis related to smoking, or environmental irritants. On the other hand, antibiotics are likely to be effective for conditions such as pneumonia, upper airway cough syndrome from bacterial sinusitis, and Bordetella pertussis infection in the lower respiratory tract (whooping cough), if given early in the illness, and for exacerbations of bronchiectasis and severe chronic bronchitis in current or previous smokers with severe airflow obstruction.2
A history, physical examination, and selected diagnostic testing can help physicians accurately diagnose patients who will likely benefit from antibiotics. For example, cough will be at its worst during the first few days of a common cold when it is caused by an uncomplicated viral infection and will gradually and progressively improve over the next week or two.5 If the cough worsens (a biphasic course) or does not steadily improve after the first week, another cause for the cough for which an antibiotic may be beneficial (e.g., bacterial sinusitis, whooping cough) should be considered.18
editor's note: Dr. Irwin served as chair of the committee for the Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines.
Address correspondence to Richard S. Irwin, M.D., at irwinr@ummhc.org. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Simasek M, Blandino DA. Treatment of the common cold. Am Fam Physician 2007;75:515-21.
2. Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):1S-292S.
3. Irwin RS, Baumann MH, Bolser DC, Boulet LP, Braman SS, Brightling CE, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):1S-23S.
4. McCrory DC, Lewis SZ. Methodology and grading of the evidence for the diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):28S-32S.
5. Curley FJ, Irwin RS, Pratter MR, Stivers DH, Doern GV, Vernaglia PA, et al. Cough and the common cold. Am Rev Respir Dis 1988;138:305-11.
6. French CT, Fletcher KE, Irwin RS. A comparison of gender differences in health-related quality of life in acute and chronic coughers. Chest 2005;127:1991-8.
7. National Center for Health Statistics. National ambulatory medical care survey: 1998 summary. Accessed December 13, 2006, at: http://www.cdc.gov/nchs/products/pubs/pubd/ad/311-320/ad315.htm.
8. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):95S-103S.
9. Linder JA, Sim I. Antibiotic treatment of acute bronchitis in smokers: a systematic review. J Gen Intern Med 2002;17:230-4.
10. Steinman MA, Sauaia A, Maselli JH, Houck PM, Gonzales R. Office evaluation and treatment of elderly patients with acute bronchitis. J Am Geriatr Soc 2004;52:875-9.
11. Gonzales R, Wilson A, Crane LA, Barrett PH Jr. What's in a name? Public knowledge, attitudes, and experiences with antibiotic use for acute bronchitis. Am J Med 2000;108:83-5.
12. Thiadens HA, Postma DS, de Bock GH, Huysman DA, van Houwelingen HC, Springer MP. Asthma in adult patients presenting with symptoms of acute bronchitis in general practice. Scand J Prim Health Care 2000;18:188-92.
13. Jonsson JS, Gislason T, Gislason D, Sigurdsson JA. Acute bronchitis and clinical outcome three years later. BMJ 1998;317:1433.
14. Hallett JS, Jacobs RL. Recurrent acute bronchitis: the association with undiagnosed bronchial asthma. Ann Allergy 1985;55:568-70.
15. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):72S-4S.
16. Bolser DC. Cough suppressant and pharmacologic protussive therapy. Chest 2006;129(1 suppl):238S-49S.
17. Bender BG, Berning S, Dudden R, Milgrom H, Tran ZV. Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a meta-analysis. J Allergy Clin Immunol 2003;111:770-6.
18. Braman SS. Postinfectious cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 suppl):138S-46S.
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