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Veteran Oral Health and Medical-Dental Integration

Family Medicine Training

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Content Overview

Section 1: Burden of oral disease among veterans
Section 2: Impacts on veteran overall health: oral-systemic health considerations
Section 3: Military subpopulations and access to dental care
Section 4: Trauma-informed care considerations
Section 5: Identification and management of dental problems in primary care setting
Section 6: Policy and advocacy

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Section 1: Burden of oral disease among veterans

Objective

Examine the prevalence of oral disease among the US veteran population

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Dental caries (cavities)

Refers to both the disease and resulting lesion

Tooth-adherent cariogenic bacteria (primarily S. mutans) metabolizes sugars and produces acid, which demineralizes tooth structure¹

56% of veterans had above-average caries experience, compared with 37% of nonveterans²

The clinical term for cavities is “dental caries”, which refers both to an infectious disease and the resulting lesion on a tooth. Caries are primarily caused by the bacteria Streptococcus mutans, which is often found in the oral cavity. S. mutans adheres to tooth structure, metabolizing sugars and producing acid. If untreated, this demineralizes tooth structure and eventually leads to cavitations of the teeth.

This image on this page demonstrates the clinical and corresponding radiographic appearance of dental caries. There are different classification systems, but they’re based on the extent of caries and proximity to the neurovascular bundle, or pulp, inside the tooth.

Dental caries is highly prevalent. National data from the Centers for Disease Control consistently demonstrates that nearly 90% of adults between the ages of 18-64 have had dental caries; and 1 in 4 adults have untreated cavities.

However, veterans experience an even higher burden of dental caries. In a recent survey, significantly more veterans (56%) compared with nonveterans (37%) were more likely to have above-average caries experience, assessed through Decayed, Missing, Filled Teeth (DMFT) scores.

References:

1. https://www.ncbi.nlm.nih.gov/books/NBK551699/

2. https://www.carequest.org/system/files/CareQuest_Institute_Veteran-Oral-Health.pdf

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Periodontal (gum) disease

Inflammation and infection of the oral tissues holding the teeth in place¹
Leading cause of tooth loss in adults
42% of veterans reported having gum problems or bone loss around their teeth (periodontal disease) compared with 27% of nonveterans²

https://cdeworld.com/courses/4389-periodontal-diseases-and-the-dental-assistant

Pessoa L, Galvão V, Ferreira C, Santos Neto L. Periodontal infection in adult-onset Still's disease patient: clinical and haematological considerations. BMJ Case Rep. 2011 Apr 26;2011:bcr0220113803. doi: 10.1136/bcr.02.2011.3803. PMID: 22696669;

Periodontal disease, commonly referred to as gum disease, is defined as an infection of the tissues holding the teeth in place. A hallmark of the disease is chronic inflammation. Gingivitis (inflammation localized to the soft tissue) precedes periodontal disease; once the inflammation progresses to destruction of both soft and hard tissues, an individual is diagnosed with periodontal disease.

Periodontal disease is the leading cause of tooth loss in adults, and more veterans report having periodontal disease compared with non-veterans.

The photo demonstrates a common clinical presentation of periodontal disease. Besides significant calculus build up and gingival recession, the gums are very inflamed, and the teeth have likely started changing position due to severe supporting bone loss.

References:

https://www.nidcr.nih.gov/health-info/gum-disease
https://www.carequest.org/system/files/CareQuest_Institute_Veteran-Oral-Health.pdf

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Perceived oral health status and unmet dental needs

41% of veterans self-described their oral health as either fair or poor¹
12% of all veterans (~2.5 million)were unable to visit a dentist in the past year despite having a dental need²

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Provider-assessed urgency of dental needs

After an oral health examination, 37% of veterans (~8 million) received a recommendation to see a dentist urgently or at their earliest convenience to address an acute dental need

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Key takeaway:

Compared with non-veterans, veterans face an increased burden of dental disease, including dental caries and periodontal disease.

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Section 2: Impacts on veteran overall health: oral-systemic health considerations

Objectives

Describe the common mechanism underlying the relationship between oral health and systemic diseases
Identify common medical and behavioral health conditions among veterans and their dental manifestations

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Summary of current evidence on associations between oral and systemic disease

Diagram from Sung Choi, PhD; presentation on “Evaluating the cost and health benefits of integrated care” at Oral Health in the Commonwealth, April 30, 2024.

This diagram illustrates a summary of the current evidence on associations between oral and systemic diseases. An especially robust body of research supports the link between periodontal disease and a wide range of systemic conditions, demonstrated by the pink links in the diagram.

Dental caries has specifically been associated with both blood disorders and mental disorders. Tooth loss has been associated with mental disorders, adverse pregnancy outcomes, cancer, neurodegenerative diseases, and cardiovascular diseases. Endodontic conditions (referring to the infection of the nerve of a tooth), have been linked with systemic inflammation.

Reference:

Diagram material adapted from the following: Botelho J, Mascarenhas P, Viana J, Proença L, Orlandi M, Leira Y, Chambrone L, Mendes JJ, Machado V. An umbrella review of the evidence linking oral health and systemic noncommunicable diseases. Nat Commun. 2022 Dec 9;13(1):7614. doi: 10.1038/s41467-022-35337-8. PMID: 36494387; PMCID: PMC9734115.

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Underlying mechanism: inflammatory response

Hajishengallis G, Chavakis T. Local and systemic mechanisms linking periodontal disease and inflammatory comorbidities. Nat Rev Immunol. 2021 Jul;21(7):426-440. doi: 10.1038/s41577-020-00488-6. Epub 2021 Jan 28. PMID: 33510490; PMCID: PMC7841384.

Most evidence linking oral and systemic health centers on the underlying mechanism of the activation of inflammatory mediators, which can have clinical effects on certain organs and particular medical conditions arising in each organ system.

The VA released an evidence brief specifically on Detection and Treatment of Dental Problems on Chronic Disease Outcomes, which concluded that “Periodontal disease may trigger an inflammatory response in the body that leads to high blood pressure, vascular inflammation, and/or atherosclerosis; these processes then contribute to the etiology and severity of certain chronic diseases. Bacteria in the oral cavity may also be inhaled into the lower respiratory tract, leading to exacerbations of chronic obstructive pulmonary disease (COPD).”

Reference:

1. https://www.hsrd.research.va.gov/publications/esp/preventive-dental.cfm

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Mediators of the oral-systemic health connection

Predisposing and precipitating factors¹

Genetic factors
Medications – i.e. anticholinergics, immunomodulators
Altered host response
Environmental factors – i.e. stress

Unmet social needs also underlie this relationship

Kapila YL. Oral health's inextricable connection to systemic health: Special populations bring to bear multimodal relationships and factors connecting periodontal disease to systemic diseases and conditions. Periodontol 2000. 2021 Oct;87(1):11-16. doi: 10.1111/prd.12398. PMID: 34463994; PMCID: PMC8457130.

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Evidence from VA: chronic conditions and oral health

Chronic condition	Impact of periodontal treatment¹
Type 2 diabetes	“Likely improves measures of chronic disease severity and inflammation (eg, HbA1c², fasting blood glucose, total cholesterol, CRP) with only minor adverse events in the short term (3-4 months )”
Cardiovascular disease	“Likely improves measures of inflammation (eg, TNF-α, IL-6 and CRP) at 3 months”
Chronic obstructive pulmonary disease (COPD)	“May improve lung function and reduce the frequency of exacerbations at 1 and 2 years compared to no treatment”

This table summarizes findings from the VA evidence brief on the impacts of periodontal treatment on three types of chronic conditions: type 2 diabetes, cardiovascular disease, and COPD.

Periodontal treatment is most frequently performed by general dentists and dental hygienists. Advanced cases are managed by periodontists, who are dentists who’ve completed a three-year residency in periodontics. Most common treatment includes non-surgical periodontal therapy, which is called ”scaling and root planning” and is commonly referred to as a “deep cleaning”. This procedure is usually done by quadrant of the mouth under local anesthesia and involves manipulation of gingival tissues to remove subgingival calculus (tartar) and debris. Depending on the patient’s diagnosis and extent of disease, the scaling and root planning treatment can take between 2-4 dental visits. In cases where the periodontal disease is severe, surgical approaches may be taken.

Though this research, the VA concluded that periodontal treatment is linked to short-term positive effects (ranging from 3-4 months) for both diabetes and cardiovascular disease; the impact on COPD was longer-lasting (1-2 years). Patients with periodontal disease should be seen by their dental provider for periodontal treatment 3-4 times per year, so if an individual has consistent access to dental care, these effects should persist.

References:

https://www.hsrd.research.va.gov/publications/esp/preventive-dental.cfm
Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis. Diabetes Care. 2010 Feb;33(2):421-7. doi: 10.2337/dc09-1378. PMID: 20103557; PMCID: PMC2809296

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Behavioral health

Those who serve are more likely to experience “invisible wounds” of behavioral health conditions¹, including the following:

Post-traumatic stress disorder (PTSD)
Depression
Substance Use Disorder (SUD)

Air Force Wounded Warrior Project. Invisible Wounds Initiative.

https://www.woundedwarrior.af.mil/Airmen-Veterans/Invisible-Wounds-Initiative/

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Oral consequences of PTSD¹

Bruxism and associated symptoms
Tooth sensitivity and/oral pain lacking clinically-observable cause
Xerostomia
Periodontitis and gingivitis
Dental caries
Tooth loss
Dysphagia

BMJ Best Practice. Bruxism.

https://bestpractice.bmj.com/topics/en-us/708

It’s important for clinicians to recognize how dental treatment involves many potentially triggering events for PTSD, such as auditory and visual stimuli and confining positions. We will discuss this in more detail in Section 4, which focuses on trauma-informed care.

PTSD often manifests in consequences observed in the oral cavity, including:

Bruxism and associated symptoms (observed wear on teeth, gingival recession, muscle spasms, temporomandibular disorder (TMD))
Tooth sensitivity and/oral pain lacking a clinically-observable cause
Xerostomia
Periodontitis and gingivitis
Dental caries
Tooth loss
Dysphagia

The clinical photo illustrates a common presentation of bruxism, which can progress to expose the dentin after the enamel is worn through. This can cause sensitivity. Eventually, the patient may wear through the dentin, which can expose the pulp (neurovascular bundle) of the tooth. This photo also demonstrates significant gum recession, which can worsen with bruxism; this may also cause sensitivity as the cementum of the tooth roots are exposed.

References:

1. https://cdha.org/Portals/CDHA/PDF/CE%20Exams/Treatment%20Considerations%20for.pdf?ver=FEgdW9h8_97g0FDdq4moyw%3D%3D

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Behavioral health: Depression

Prevalence is highest among active duty and older veterans, and this is a significant risk factor for oral diseases¹

May demotivate individuals to maintain home oral hygiene (brushing and flossing) and contribute to habits negatively impacting oral health²

Dietary changes
Substance use
Dental anxiety
Lack of motivation

Xerostomia is common side effect of antidepressants³

Dimensions of Dental Hygiene.

https://dimensionsofdentalhygiene.com/new-study-finds-link-between-poor-oral-health-severity-covid-19/

The prevalence of depression is highest among active duty and older veterans. This is a significant risk factor for oral diseases¹, often demotivating individuals to maintain home oral hygiene (brushing and flossing) and contribute to habits negatively impacting oral health²

Those habits include dietary changes such as the consumption of more sugary foods and beverages; substance use, including alcohol use, smoking and recreational drugs; dental anxiety; and lack of motivation to maintain dental visits.

Additionally, xerostomia is a frequent side effect of antidepressants, especially SSRIs, SNRIs, and atypical antidepressants. Xerostomia is a main factor in causing dental disease, especially caries.

References:

https://academic.oup.com/milmed/article/186/1-2/e149/5917414
https://newsroom.tricare.mil/News/TRICARE-News/Article/3642618/mental-health-is-health-depression-and-oral-health
https://pubmed.ncbi.nlm.nih.gov/29274375/

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Depression and dental implants

Implications on dental implants

Link between use of antidepressants and dental implant failure
Systemic and behavioral changes can lead to increased risk of peri-implantitis and implant failure

Heitz-Mayfield, L. Peri-implant mucositis and peri-implantitis: key features and differences. Br Dent J 236, 791–794 (2024). https://doi.org/10.1038/s41415-024-7402-z

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Tobacco, alcohol, and substance use disorder

There is an association between deployment and initiation of smoking, binge drinking, and drug use.¹

Disproportionately high use of smokeless tobacco compared with nonmilitary population²

Among veterans presenting for first-time care within the VHA system, close to 11% meet criteria for an SUD diagnosis.

This group also often experience co-occurring mental health conditions including PTSD, depression, and anxiety.³

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Bidirectional relationship between SUD and oral health

Cuberos, M., Chatah, E.M., Baquerizo, H.Z. et al. Dental management of patients with substance use disorder. Clin Dent Rev 4, 14 (2020). https://doi.org/10.1007/s41894-020-00078-8

SUD 🡪 oral health	Oral health 🡪 SUD
Cannabis 🡪 oral cancer, xerostomia, periodontitis	Exacerbate contributing factors
Crack cocaine 🡪 soft tissue lesions	Frequency of opioid prescribing
Methamphetamine 🡪 rampant caries, bruxism, xerostomia	“May improve lung function and reduce the frequency of exacerbations at 1 and 2 years compared to no treatment”
Opioids 🡪 caries, tooth loss
SUD medications (including buprenorphine and methadone) 🡪 xerostomia, caries

There is a bidirectional relationship between Substance Use Disorder and oral health status.

The clinical photos demonstrate destructive impacts of SUD on an individual’s dentition.

SUD impacts oral health in multiple ways. Cannabis use increases risk of oral cancer, xerostomia, and periodontitis. Smoking crack cocaine results in intraoral soft tissue lesions. Methamphetamine is associated with rampant dental caries, bruxism, excessive tooth wear, and xerostomia. Opioid use is associated with dental caries and tooth loss. Finally, medications for SUD (including buprenorphine and methadone) increase risk of xerostomia and dental caries. The FDA even issued a warning about this, as individuals with no significant dental history experienced serious dental problems including cavities, oral infections, and tooth loss. This likely occurs as buprenorphine medicines dissolved in the mouth, which creates a prolonged, highly acidic, intraoral environment.

Additionally, oral health affects SUD. Oral pain can exacerbate factors contributing to SUD. And although there is more judicious prescribing of opioids by dentists now, historically, there was a relatively high frequency of opioid prescriptions by dentists, often after surgical procedures such as wisdom teeth extractions.

�References:

https://www.thenationalcouncil.org/resources/oral-health-mental-health-substance-use-treatment-toolkit/
https://www.fda.gov/safety/medical-product-safety-information/buprenorphine-drug-safety-communication-fda-warns-about-dental-problems-buprenorphine-medicines
https://pmc.ncbi.nlm.nih.gov/articles/PMC9856241/

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Key takeaways:

An ever-increasing body of evidence demonstrates associations between oral and systemic diseases, which are often linked by inflammatory responses
Veteran-specific research illustrates how treatment of periodontal disease has important implications on chronic conditions including diabetes, cardiovascular disease, and COPD
Those serving are more likely to experience “invisible wounds” of behavioral health conditions, which are associated with risk factors contributing to poor oral health and have substantial implications on dental care delivery

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Section 3: Military subpopulations and access to dental care

Objectives

Examine how the Department of Defense (DoD) evaluates oral health in determining deployability
Describe key differences how members of the military access dental care

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Department of Defense (DoD) Oral Health and Readiness and Classification System¹

Despite the system, about 1 in 10 deployable individuals experience a dental emergency annually

	Class 1	Class 2	Class 3
Description	Current dental exam; no treatment needs	Current dental exam; no urgent treatment needs	Dental caries likely to be an emergency, acute TMD, chronic oral infections or pathology
Deployability	Yes	Yes	No

Oral health has long been a consideration for military service. Even in the American Civil War, recruitment criteria included the ability for an individual to bite open a packet of gunpowder. The Department of Defense (DoD) first implemented its Oral Health and Readiness and Classification System in the 1980s, and it’s been periodically updated. Both Class 1 (current dental examination with no treatment needs) and Class 2 (current dental examination with no urgent treatment needs) meet established criteria for dental readiness.

Conditions consistent with nondeployability (Class 3) include dental caries likely to present as an emergency within the next year, acute temporomandibular disorder (TMD), and chronic oral infections or pathology.

However, even with this system, about 1 in 10 deployable individuals experience a dental emergency annually.

Reference:

1. Leiendecker T. The Department of Defense oral health and readiness classification system. Mil Med. 2008 Jan;173(1 Suppl):1-2. doi: 10.7205/milmed.173.supplement_1.1. PMID: 18283737.

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Recruits

Often coming from communities where their oral health was not addressed

96% had dental conditions requiring treatment
Majority were nondeployable due to Class 3 dental conditions
60% of recruits did not have a past-year dental examination

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Active-Duty

Demographics¹

84% are men
31% identify as a racial minority
80% have a high school diploma and/or some college experience

8% hold a Bachelor’s degree or higher

Reserve and National Guard members do not receive active-duty dental care benefits²
Active duty service members receive access to oral healthcare, which ends upon separation from the military³

84% of active duty military members are men. 31% identify as a racial minority (per the Office of Management and Budget, “Hispanic is not considered a minority race status”). 80% have a high school diploma and/or some college experience; only 8% hold a Bachelor’s degree or higher

Reserve and National Guard members do not receive active-duty dental care benefits, even though they are held to the same deployment and readiness standards as active duty personnel. Only active duty service members receive access to oral healthcare, which ends upon separation from the military. This care is usually provided at military dental clinics but may be completed at a civilian dentist if the care can’t be completed at a military dental treatment facility

References:

1. https://download.militaryonesource.mil/12038/MOS/Reports/2017-demographics-report.pdf

2. https://www.baldwin.senate.gov/imo/media/doc/dental_care_for_our_troops_one_pager.pdf

3. https://www.tricare.mil/CoveredServices/Dental/ADDental

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Eligibility and receipt of VA dental care

Due to strict eligibility criteria, only 15% of veterans enrolled in the VA for health care services qualify to receive dental care through the Veterans Health Administration (VHA)

“For example, veterans with a service-connected dental disability, such as a combat injury to the head/neck, or those who are considered 100 percent disabled as a result of service, are eligible for full dental care.”¹

Of those eligible, only 34% utilize VA dental care²

Barriers for eligible veterans seeking dental care include geographic location and ability to access care at a VA facility, lengthy wait times, limited number of providers, and competing priorities.
Modifiable barriers for eligible veterans: lack of awareness on eligibility and a lack of support navigating VA health care system.

References:

1. https://dental.nyu.edu/globalreach/veterans-oral-health-initiative.html

2. https://aidph.org/wp-content/uploads/2024/04/Compendium_VOH_BestPracticesFINAL.pdf

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Population subgroups disproportionately impacted by oral disease

Unmet social needs¹

Dental care impacts outcomes in the VA Homeless Veterans Dental Program²

Older adults³

64% of older community-dwelling male veterans in the VA Dental Longitudinal Study (VA DLS) were in need of dental care

LGBTQIA+ veterans⁴

Experience poorer health-related outcomes

Certain veteran populations face even more dental disease, including those with unmet social needs, including unstable housing and lack of transportation. VA research through the Homeless Veterans Dental Program found that dental care positively impacts program outcomes including completion of the program, employment, financial stability and permanent housing status. And among veterans who had experienced homelessness, veterans who received dental care were more likely to demonstrate improvements in perceived overall health, oral health, and self-esteem.

Additionally, older adults disproportionately face barriers to oral health care and report unmet needs for dental care. Over 6 in 10 older adult veterans residing in the community were clinically determined to be in need of dental care.

Veterans identifying as LGBTQIA+ experience poorer health-related outcomes.

References:

https://www.carequest.org/system/files/CareQuest_Institute_Veteran-Oral-Health.pdf
https://www.va.gov/homeless/dental.asp

3. https://pubmed.ncbi.nlm.nih.gov/12028262/

4. https://www.rand.org/pubs/research_reports/RRA1363-9.html

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Key takeaways:

Many military members have significant dental conditions preventing deployment
Comprehensive dental coverage is only provided widely among Active Duty members; a very small proportion of veterans are eligible to receive dental care through the VHA, and a smaller number actually receive that care

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Section 4: Trauma-informed care considerations

Objectives

Identify how trauma may be expressed by patients in clinical encounters
Identify key principles of trauma-informed care
Recognize actionable strategies that providers can implement to provide trauma-informed care in a dental setting

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Concepts of trauma¹

87% of veterans reported exposure to at least 1 potentially traumatic event (PTE)¹

U.S. Substance Abuse and Mental Health Services Administration

87% of veterans reported exposure to at least 1 potentially traumatic event (PTE)

These are the three main concepts of trauma, defined by the Substance Abuse and Mental Health Services Administration. They demonstrate significant variation across individuals.

Events refer to either the actual or extreme threat of physical or psychological harm; these can be either single or multiple occurrence(s). Next, there is wide variation in how the event is experienced; different experiences may be traumatic for one individual but not for another. Finally, effects can be either felt immediately or delayed and may last for the short- or long-term.

Reference:

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC9040390/

2. https://library.samhsa.gov/product/samhsas-concept-trauma-and-guidance-trauma-informed-approach/sma14-4884 (Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.)

https://www.samhsa.gov/mental-health/trauma-violence/trauma-informed-approaches-programs

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How trauma is expressed by patients¹

Exhibiting habits and behaviors of avoidance

Frequently missed or postponed appointments
Delays in care until condition worsens
Reluctance to discuss health problems
Confusion or poor memory
Challenges adhering to treatment

Hypersensitivity reactions

Guarding
Varying perceptions of and experiences with pain

Trauma may be expressed in patients through a variety of ways, including exhibiting habits and behaviors of avoidance:

Frequently missed or postponed appointments

Delays in care until condition worsens

Reluctance to discuss health problems

Confusion or poor memory

Challenges adhering to treatment

Trauma can also be expressed through hypersensitivity reactions.

Guarding reactions include limited mouth opening, or tongue thrusting to prevent anything from entering the mouth, keeping the hands near the mouth, and turning the head away from the provider.

Varying perceptions of and experiences with pain, such as an exaggerated response to the dental air-water syringe.

This connects to how we as providers can frontload information to minimize harm in the office (i.e. explain what you are going to do before you do it - Ex: “I’m going to move the chair back now...I’m going to start the handpiece, it’s a bit loud, etc.”

Reference:

1. https://www.carequest.org/education/webinars/trauma-informed-care-creating-psychologically-safe-environment-dental-setting?check_logged_in=1

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Post-traumatic stress disorder (PTSD)

Prevalence of PTSD among veterans estimated at 8%

Shutterstock Image

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Principles of Trauma-Informed Care (TIC)

Safety
Trustworthiness and transparency
Peer support
Collaboration and mutuality
Empowerment, voice, and choice (consent)
Cultural, historical, and gender issues

U.S. Substance Abuse and Mental Health Services Administration

The following are underlying principles of trauma-informed care:

Safety

Trustworthiness and transparency

Peer support

Collaboration and mutuality

Empowerment, voice, and choice, which is about consent.

Cultural, historical, and gender issues

Many of these points coincide with the “show, tell, do” treatment strategy and letting patients know what you are going to do before you do it and asking if they have questions. Perhaps letting them know how something might feel or taste and what to expect.

Reference:

1. https://library.samhsa.gov/product/samhsas-concept-trauma-and-guidance-trauma-informed-approach/sma14-4884 (Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.)

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Trauma-informed care: steps

“Meet client needs in a safe, collaborative, and compassionate manner.”
Prevent treatment practices that retraumatize people with histories of trauma who are seeking help or receiving services
Build on the strengths and resilience of clients in the context of their environments and communities
Endorse trauma-informed principles in agencies through support, consultation, and supervision of staff.”

Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 1, Trauma-Informed Care: A Sociocultural Perspective. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207195/

�

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Trauma and the dental setting¹

History of trauma has been associated with increased dental anxiety
Common triggers in dental office

Reclining dental chair
Placing patient bib around their neck
Close positioning of dental team members
Difficulty speaking and communicating
Contact in head and neck region

Adobe Stock Image

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Examples of implementing TIC in dental offices

Diagram from Aniela Brown, MSW and Mana Mozaffarian, DMD; “Trauma-Informed Care: Creating a Psychologically Safe Environment in the Dental Setting. CareQuest Institute for Oral Health. Webinar, January 23, 2025.

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Examples of implementing TIC in dental offices

Care delivery changes^1,2

Staff training

Trauma-informed and motivational interviewing training
Avoiding shaming
Validate fears and phobia in dentistry

Create a safe environment

Provide consistency in providers whenever possible

Provide autonomy

Offer minimally invasive procedures
Practice “stop”

Practice accommodations

Practice Tell-Show-Do techniques and use explanatory model
Schedule and promote a culture of 5-minute stretches and movements to prevent physical injury
Breaks to take a breath and reground if needed
Avoid loud and sudden sounds
Remind the patient they can stop treatment anytime

Establish a mental health care coordination protocol including care coordination and follow-ups with referrals

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Key takeaway:

Dental settings and procedures have significant potential to trigger traumatic responses, and it’s important for health care professionals to understand and implement key principles of trauma-informed care

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Section 5: Identification and management of dental problems in primary care setting

Objectives

Discuss and implement strategies to identify common oral health problems in primary care visits
Identify when in-office treatment and/or referrals are indicated for dental problems

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Temporomandibular disorders (TMD)¹

Umbrella term that refers to pain or dysfunction from the temporomandibular joint (TMJ) and associated masticatory muscles
Symptoms

Pressure, tension, soreness in the bilateral preauricular and masseter areas, typically mild – moderate intensity
Pain may be sharp with chewing or opening wide
Difficulty opening the mouth or intermittent locking of the jaw
Teeth sensitivity without an identifiable dental problem

May present with associated symptoms of

New or increased frequency of tension type headaches or migraines
Earaches or tinnitus
Pain extending behind eyes, or through the shoulder, neck, or back

Typically caused by overuse of joint and muscles due to grinding/clenching but can also be due to trauma or a systemic inflammatory arthritis

https://mynjdentist.com/conditions/tmj-disorders/

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Temporomandibular disorders (TMD)¹

Initial recommendations

Home care with heat packs and gentle massage
Softer diet (“if it hurts, don’t eat it”)
Voltaren gel applied to skin of jaw up to QID PRN
NSAIDs for short-term pain management

Naproxen 220 – 500 mg BID for 10 – 14 days

For persistent pain

Consider referral to physical therapy for TMJ
Consider muscle relaxants QHS PRN to reduce clenching

cyclobenzaprine 5 – 10 mg QHS PRN
methocarbamol 500 – 1500 mg QHS PRN

Consider referral to oral surgery or orofacial pain specialist

https://mynjdentist.com/conditions/tmj-disorders/

Generally, conservative management is recommended, including gentle massage and applying heat packs, maintain a softer diet, and applying Voltaren gel. NSAIDs are not indicated for long-term management; instead, they may be used intermittently in combination with a longer-term approach including muscle relaxants to reduce clenching.

Night guards are helpful in some cases, especially if the symptoms seem associated with the patient clenching or grinding their teeth. However, OTC night guards (often sold at drug stores) tend to be made from soft materials and may actually worsen symptoms; custom-fabricated nightguards made by the patient’s dentist may help.

For long-term management, refer to an oral medicine specialist, who has additional training to diagnose and treat conditions like TMD. There are few of these specialists, but many dental schools often have one.

Reference:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7998670/

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Dental caries

In-office fluoride and/or silver diamine fluoride (SDF application)
Smiles for Life SDF course:

Fukuoka, Brooke MO. Clinical Use of Silver Diamine Fluoride. Decisions in Dentistry. February 2018;4(2):30-32,35-36.

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Assessing need for emergency or urgent care¹

Dental emergencies

Potentially life-threatening

Potential for airway compromise
Uncontrolled bleeding

Urgent dental care

Examples: severe dental pain, pericoronitis, required dental treatment prior to critical medical procedures, biopsy of abnormal tissue

American Dental Association

For acute and emergent issues, such as severe dental caries or an abscess, the most important action by the PCP is an efficient referral to a dental provider.

Unless the patient is experiencing a true dental emergency or has no other access to a dental provider, avoid referring to the ER, unless you know that the ER has an on-call dentist or oral surgeon. Care provided in ER settings is often limited to antibiotics and pain medications, and this often triggers a cycle of patients returning to the ER again for their unmet dental problem.

Dental emergencies are potentially life-threatening, such as cellulitis with intraoral or extraoral swelling that could potentially compromise the airway, trauma involving facial bones possibly compromising airway, and uncontrolled bleeding.

Urgent dental care “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments”.

Non-urgent care includes restorative dentistry and extractions for asymptomatic teeth.

Reference:

1. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/coronavirus/covid-19-practice-resources/ada_covid19_dental_emergency_dds.pdf

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Acute and emergent issues: pain management

If the pulp is already infected, then medications will only have a temporary effect
Key patient questions:

When did pain begin?
Does anything improve it?
Is the pain “spontaneous”?

In-office clinical tests:

Percussion - tapping on the tooth to test periodontal ligament inflammation (indicates degenerating pulp)
Palpation - palpating gingiva around apex of tooth to assess for tenderness (signs of abscess/cellulitis)

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Acute and emergent issues: pain management

American Dental Association

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Acute and emergent issues: pain management

American Dental Association

If NSAIDs are contraindicated or pain control is inadequate, then there are clinical guidelines on alternatives. Generally, prescribing opioids for acute dental pain is not recommended. In the CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain, they report nonopioid therapies to be at least at least as effective as opioids for many common types of acute pain, including dental pain and pain related to a simple dental extraction. If opioids are prescribed, the clinician should discuss risks and benefits and consider precautions including checking the prescription drug monitoring program database and offering naloxone.

Reference:

1. https://www.cdc.gov/overdose-prevention/hcp/clinical-care/dental-pain-care.html#:~:text=Offer%20naloxone%20when%20prescribing%20opioids,are%20present%20(Recommendation%2012).

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Prescribing antibiotics

American Dental Association evidence-based clinical practice guidelines¹
Pathway for individuals without immediate access to definitive dental treatment

American Dental Association

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Community resources for referrals

Safety net settings: dental and dental hygiene schools and FQHCs for reduced and/or sliding payment scales
Veteran-specific¹

Qualification information:

VA dental clinic directory:

Nonprofit connecting vets with dentists:

Free annual event:

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Primary care practice changes

Establish a system to (1) identify veterans and (2) ask about oral health needs

“Do you or a family member have a history of military service?”

Establish protocols for management and referral of dental problems in primary care settings
Motivational interviewing
Effectively conduct intraoral cancer screenings¹

For primary care providers, there are several actionable practice changes to facilitate medical dental-integration:

Establish a system to (1) identify veterans and (2) ask about oral health needs

Many providers’ erroneously assume that military members and veterans receive health and dental care through other health systems and are not likely to be seen in our practices. In obtaining patient social history, most do not value the importance of asking about a history of military service and its impact on a patient’s health in general.

To identify these individuals, you can ask the question “Do you or a family member have a history of military service?” Generally, it’s a good idea to phrase the question this way instead of asking “Are you a veteran?” There are a number of reasons former service members do not consider themselves veterans or they do not meet the requirements to be legally termed a veteran.

�

Motivational interviewing ultimately encouraging veterans to seek dental care, with additional support addressing modifiable barriers to care

Establish protocols for management and referral of dental problems in primary care settings

Effectively conduct intraoral cancer screenings

Smiles for Life has a fantastic resource on conducting an intraoral examination. Screening for oral cancer only takes a few minutes and informs clinicians on how to examine high-risk sites for oral cancer, including the tongue, buccal mucosa, palate, and floor of mouth. This may be especially impactful for high-risk patients, including those who use alcohol or tobacco.

Reference:

1. https://www.smilesforlifeoralhealth.org/courses/the-oral-examination/

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Key takeaway:

Primary care providers should be able to identify significant dental problems and facilitate management, usually through a deliberate, appropriate referral.

For more information, these specific Smiles for Life courses are a good starting point for physicians to increase knowledge:

Relationship of Oral and Systemic Health

Oral Examination

Adult Oral Health

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Section 6: Policy and advocacy

Objective

Summarize systems-level issues prohibiting person-centered, comprehensive oral health care for veterans
Identify policy levers internal and external to your organization

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Systems-level issues prohibiting veteran dental care

Lack of data illustrating the scope of the problem and impacts beyond the oral cavity
Access to dental care is generally limited to active-duty service members and a small subset of veterans

15% of veterans are eligible

Only 34% of those eligible utilize VA dental care

Many veterans experience co-occurring medical conditions and unmet social needs impacting their oral health

First, data on veteran oral health is relatively limited. If more comprehensive information was available on unmet dental needs among veterans and subsequent impacts on oral health and quality of life, this would inform both the public and policymakers about this important unmet need.

Secondly, as reviewed earlier, only a proportion of the US military receives dental care, which is infrequently continued after active duty. Reserve and National Guard members do not receive dental care benefits. Only 15% of veterans enrolled in the VA for health care services qualify to receive dental care through the Veterans Health Administration (VHA), generally with a 100 percent service-connected disability. Of those 15%, only only 34% utilize VA dental care.

Finally, an approach of medical-dental integration is critical to provide holistic, person-centered medical care to veterans. As it currently stands, there are multiple divisions between the medical and dental care delivery and insurance systems.

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Policy levers

Individual and organizational

Individual awareness of dental problems and broader impacts of oral disease
Availability of training through program/clinic

State and national

State oral health coalitions and taskforces
National

Oral Health Progress and Equity Network (OPEN)
Association of State and Territorial Dental Directors (ASTDD)
Community Catalyst
AAFP

There are multiple levels of impacts of changes. Generally, starting at an individual level by increasing your awareness of dental problems and knowledge of impacts of untreated dental disease is a good starting point. Within your organization or workplace, make sure your program is providing training opportunities to support this work.

For changes on a broader scale, it’s important to be aware of existing organizations and individuals to partner with. Each state has an individual oral health coalition and taskforce, and participation of primary care providers is greatly appreciated. Other national organizations focusing on oral health equity include the Oral Health Progress and Equity Network, Association fo State and Territorial Dental Directors, and Community Catalyst. Finally, AAFP is well-connected with resources for impacting legislation, including partnerships with lobbyists.

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Future Questions/Comments

Elizabeth Alpert, DDS, MPH�elizabeth_alpert@hsdm.harvard.edu

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Acknowledgment of Funding

This important work is made possible through the generous support of the CareQuest Institute for Oral Health, Inc.

Learn more about their commitment to advancing oral health: https://www.carequest.org/

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Acknowledgments: Project Advisors and Reviewers

Maya Bass, MD, MA, Program Director, Cooper Family Medicine Residency/Cooper Medical School of Rowan University
Roxanne Bavarian, DMD, DMSc - Instructor | Oral and Maxillofacial Surgery, Harvard School of Dental Medicine
Alec S. Eidelman, DMD, MPH, MMedEd, Lecturer, Oral Health Policy & Epidemiology – Harvard School of Dental Medicine
Britt Gayle, MD, MedStar Health
Janet F. Hale PhD, RN, FNP, Professor Emeritus, Tan Chingfen Graduate School of Nursing, Univ of Massachusetts Medical School
Robert Motley, MD, MHCDS, Vice Chair, Community Medicine and Ellen M. & Dale W. Garber Professor in Family Medicine, Thomas Jefferson University
Hugh Silk, MD, MPH, Professor, Dept. of Family Medicine and Community Health, Univ of Massachusetts Medical School
Robert Smethers, RDH, MSDH, Dental Hygiene Assistant Professor, Forsyth School of Dental Hygiene, Massachusetts College of Pharmacy and Health Sciences
Lisa Thompson DMD, Program Director, Geriatric Dentistry, Harvard School of Dental Medicine