The OHNEP Interprofessional Oral Health Faculty Toolkit

Adult-Gerontology Nurse Practitioner Program

CURRICULUM INTEGRATION OF INTERPROFESSIONAL ORAL HEALTH CORE COMPETENCIES:

• Adult-Gerontology Health Assessment • Adult-Gerontology Health Promotion • Adult-GerontologyPrimary Care • Resources

The Oral Health Nursing Education and Practice (OHNEP) program has developed an Interprofessional Oral Health Faculty Tool Kit to S! provide you with user friendly curriculum templates and teaching-learning resources to use when integrating oral health and its links to ! overall health in your Adult-Gerontology Nurse Practitioner program.

! Oral health and its relation to overall health has been identified as an important population health issue. Healthy People 2020 (2011), the IOM Reports, Advancing Oral Health in America (2011) and Building Workforce Capacity in Oral Health (2011), as well as the IPEC Competencies ! (2011), challenged HRSA to develop interprofessional oral health core competencies for primary care providers. Publication of the report, ! Integrating Oral Health in Primary Care Practice (2014), reflects those interprofessional oral health competencies that can be used by Adult- Gerontology Nurse Practitioners for faculty development, curriculum integration and establishment of “best practices” in clinical settings. ! The HRSA interprofessional oral health core competencies, the IPEC competencies and the NONPF core competencies provide the framework for the curriculum templates and resources. Exciting teaching-learning strategies that take students from Exposure to Immersion to Competence can begin in the classroom, link to simulated or live clinical experiences and involve community-based service learning, advocacy and policy initiatives as venues you can readily use to integrate oral health into your existing primary care curriculum. The Adult- Gerontology Nurse Practitioner curriculum template illustrates how oral health can be integrated into health promotion, health assessment and clinical management courses.

The Smiles for Life interprofessional oral health curriculum provides a robust web-based resource for you to use that articulates with the oral health curriculum template for each course. A good place to begin oral health integration is by transitioning the HEENT component of the history and physical exam to the HEENOT approach. In that way, you and your students will NOT forget about including oral health in patients encounters.

Research evidence continues to reveal an integral relationship between oral and systemic health. Chronic diseases managed by Adult Gerontology Nurse Practitioners, such as diabetes, Celiac and HIV, are but a few of the health problems that have oral manifestations that can be treated or referred to our dental colleagues. It is important for nurse practitioners on the frontline of primary care to have the oral health competencies necessary to recognize both normal and abnormal oral conditions and provide patients with education, prevention, diagnosis, treatment and referral as needed.

We encourage you and your students to explore the resources in the templates as you “weave” oral health and its links to overall health into your Adult-Gerontology Nurse Practitioner program. If you need additional technical assistance, please feel free to contact us at [email protected]

A-GNP Curriculum Integration of Interprofessional Oral Health Competencies in Health Assessment

ADULT - 1) EXPOSURE: INTRODUCTION 2) IMMERSION: DEVELOPMENT 3) COMPETENCE: ENTRY-TO-PRACTICE GERONTOLOGY HEALTH KNOWLEDGE: ORAL EXAM SKILL/BEHAVIOR ASSESSMENT SKILL/BEHAVIOR Goal: Understand the oral exam Goal: Describe best practices in dental caries Goal: Demonstrate integration of HEENOT management across the lifespan competency in physical exam of adult in clinical • Complete Smiles for Life Module #7 experience IPEC Competencies: • Submit SFL Certificate of Completion Read: Values and Ethics, • CAMBRA: Best Practices in Dental Roles and • Complete SFL Quiz for Module #7 • Read Responsibilities Caries Management (Hurlbutt, 2011) (Appendix 1) • Adult Caries Risk Assessment Tool Putting the Mouth Back in the Head: HEENT to Interprofessional HEENOT (Haber et al, 2015) Communication, CAMBRA for patients over age 6 E (Appendix 7) S • Perform oral examination of adult in clinical Teams & Teamwork N U experience, identifying any oral abnormalities T M R M Y A T SKILL/BEHAVIOR L KNOWLEDGE: ORAL CARE OF ADULT SKILL/BEHAVIOR I E Goal: Understand issues in oral care of adults Goal: Demonstrate integration of HEENOT in V Goal: Demonstrate integration of HEENOT HRSA Oral Health V oral health history, risk assessment and E competency in health history of adult in Competencies: E • Complete Smiles for Life Modules #1, 3, 5 physical exam of adults during simulation clinical experience Oral Health Risk L lab A Assessment, Oral • Submit SFL Certificates of Completion • Identify oral pathologies in adult S Health Evaluation, A • Complete SFL Quizzes for Modules #1, 3, 5 S • Perform appropriate oral health history of Oral Health Preventive photographs (Appendix 8) S (Appendix 2, 3, 4) E adult, including frequency of sugar/ Intervention, S • Present electronic health record of adult S tobacco/alcohol intake Communication E • Download SFL Adult Oral Health Pocket with oral health included in history, risk S and Education S Card (Appendix 5) for use in clinical setting assessment, exam and plan (HEENOT) M S E M N E T PARTNERSHIP & COLLABORATIVE PRACTICE FOR & COLLABORATIVE PARTNERSHIP

N KNOWLEDGE: ORAL CARE OF OLDER ADULT T Goal: Understand issues in oral care of older SKILL/BEHAVIOR NONPF Competencies: adults Goal: Demonstrate integration of HEENOT in SKILL/BEHAVIOR Delivers evidence- based • Complete Smiles for Life Module #8 oral health history, risk assessment and Goal: Demonstrate integration of HEENOT practice for patients • Submit SFL Certificate of Completion physical exam of older adults during simulation throughout lifespan; lab competency in oral health assessments of Accurately documents • Complete SFL Module #8 Quiz (Appendix 6) older adult in clinical experience relevant comrehensive • Complete: • Identify oral pathologies in geriatric and problem-focused • NICHE, OHNEP, & HIGN Geriatric health histories; Performs photographs (Appendix 9) • Perform oral health history, physical Oral Health Webinar Series (NICHE exam and complete risk

and accurately OUTCOMES HEALTH OF CIENT/PATIENT OPTIMIZATION 2014) • Present electronic health record of older assessment of older adult, with documents partinent, adult with oral health included in history, comprehensive and accurate documentation of oral INTER-PROFESSIONAL • APTR Oral Health Learning Module risk assessment, exam and plan (HEENOT) focused physical, mental Part 4: Older Adults health assessment findings health and cognitive assessment • Read: Our Current Geriatric Population (Douglass & Jimenez, 2014) CONSTRUCTS © Oral Health Nursing Education and Practice (OHNEP) APPENDIX 1 Adult-Gerontology Health Assessment

Smiles for Life Module 7 Quiz: Oral Examination

S! 1. What constitutes a tooth’s outer layer? 5. Oral cancer is most common in which area 8. When examining a 9 month old child’s mouth, what is a reason for an early referral to A. Enamel of the mouth? ! a dentist? B. Dentin A. Hard palate A. The child has only 4 incisors ! C. Pulp B. Surface of tongue C. Inside of cheek B. Developmental tooth defects are present ! C. No molars have erupted 2. What is a full complement of adult teeth? D. Posterolateral tongue D. No canine teeth have erupted ! A. 26 E. Counting less than 20 teeth ! B. 28 6. When performing the “knee-to-knee” oral exam on a young child, in what position C. 30 9. You are performing an oral exam on your D. 32 should the child start? 21 year old patient who has been using A. Facing the examiner smokeless tobacco for 4 years. What part of 3. A caregiver asks you how many teeth B. Standing up this patient’s oral cavity is especially her 3 year old child should have. What C. Sitting on the exam table important for you to examine? would you respond? D. Facing the caregiver A. The sun-exposed areas of the patient’s cheeks A. 20 B. The inner aspect of the patient’s lips and cheeks B. 22 7. Which of the following is NOT needed by a C. Any discoloration or pitting of the patient’s teeth C. 24 primary care clinician to conduct a thorough D. Any plaque build-up along the patient’s gum line D. 28 oral exam? E. The patient’s posterior pharynx A. An exam light to illuminate key 4. At what age do teeth typically features in the mouth 10. A complete oral examination includes each begin to erupt in children? B. Tongue depressors to lift the lip of the following EXCEPT: A. 3-9 months and retract the cheek A. Temporomandibular joint (TMJ) exam B. 9-15 months C. A mouth mirror to view lingual surfaces of B. Cervical node exam C. 15-21 months teeth C. Palpation of the floor of the mouth D. 21-27 months D. Dental explorer D. Sinus exam E. Gauze pads to grasp the tongue E. Exam of the skin around the mouth

(Clark et al, 2010) APPENDIX 2 Adult-Gerontology Health Assessment

Smiles for Life Module 1 Quiz: The Relationship of Oral to Systemic Health S! 1. What is the most common chronic 5. What can a primary care clinician do to 8. Which of the following infections ! disease of childhood? promote oral health? is NOT potentially caused by direct A. Asthma A. Collaborate with dental and other health extension from a dental source? ! B. Seasonal allergies professionals A. Otitis media ! C. Dental caries B. Apply dental sealants B. Sinusitis D. Cefuroxime C. Prescribe oral fluoride supplements to every C. Brain abscess ! patient D. Facial cellulitis ! 2. What is a consequence of untreated D. Apply fluoride varnish to the teeth of all dental caries? adults 9. What is the suggested common A. Osteonecrosis of alveolar bone pathway linking chronic periodontitis 6. Which of these classes of medications and conditions such as diabetes, B. Gingival hyperplasia is NOT generally associated with C. Oral mucositis coronary artery disease and adverse decreased salivary flow? pregnancy outcomes? D. Tooth fractures A. Antihistamines A. Direct bacterial extension B. Antibiotics B. Poor nutrition 3.Which condition is associated with C. Corticosteroids C. Circulating antibodies periodontal disease? D. Anticholinergics D. Inflammation A. Asthma E. Diuretics B. Preterm labor 10. Which of the following is NOT a C. Sinusitis 7. A patient undergoing chemotherapy for mechanism for inter-relationships D. Hypothyroidism cancer is at risk for which of these oral between oral and systemic disease? 4. Which of the following medications is complications due to the effects of A. Behavioral linked to gingival hyperplasia? chemotherapy? B. Iatrogenic A. Phenytoin A. Osteonecrosis of alveolar bone C. Neurologic B. Amoxicillin B. Gingival hyperplasia D. Inflamatory C. Digoxin C. Oral mucositis D. Coumadin D. Tooth fractures (Clark et al, 2010) APPENDIX 3 Adult-Gerontology Health Assessment

Smiles for Life Module 3 Quiz: Adult Oral Health 1. Which dental procedure does NOT require 5. Risk factors for adult caries may include all 8. Whichof the following statements, S! prophylaxis for individuals at high risk the following except: concerning xerostomia or dry mouth, is ! of bacterial endocarditis? A. Low socioeconomic status not true? A. Dental extractions B. Existing tooth restoration A. Xerostomia is caused by a decrease in ! B. Periodontal procedures C. Decreased salivary flow the production of saliva ! C. Post-operative suture removal D. A vegetarian diet B. Xerostomia can cause a burning sensation, D. Prophylactic cleaning of teeth if E. Physical disabilities change in taste, and difficulty swallowing ! bleeding is anticipated C. Medications can contribute to xerostomia E. Re-implantation of avulsed teeth 6. Which of the following patients requires D. Xerostomia can increase the development of ! bacterial endocarditis antibiotic prophylaxis? caries 2. Periodontal disease can be clinically A. A 26 year old woman with mitral valve E. Xerostomia is rarely a problem for patients distinguished from gingivitis in which of prolapse undergoing routine teeth cleaning wearing complete dentures the following ways? with no anticipated bleeding. A. Inflammation of the gums B. A 64 year old man with a prosthetic mitral 9. Which of the following has been B. White discoloration of the permanent valve who is undergoing a tooth extraction. implicated in the development of recurrent teeth C. A 16 year old boy with a ventricular septal aphthous ulcers? C. Enlarged pockets at the gum base defect completely repaired in infancy who A. Trauma D. Gingival hypertrophy requires extraction of an impacted wisdom B. Vitamin C deficiency C. Sickle Cell Anemia 3. Which of the following is NOT a common tooth. site for oral cancers? D. A 32 year old man who had bacterial D. Herpes simplex virus infection A. Tongue endocarditis 5 years ago who B. Floor of mouth isundergoing orthodontic appliance 10. Which of the following factors is C. Hard palate adjustment. NOT involved in the development of D. Lower lip “Meth Mouth”: 7. Which of the following is not a normal A. Poor oral hygiene 4. Which of the following is most likely to lead age-related tooth change? B. Increased carbohydrate to poorer oral health in the elderly? A. Gingival recession consumption A. Alzheimer’s dementia B. Root caries C. Nighttime mouth breathing B. Coronary artery disease C. Yellowing of teeth D. Teeth grinding C. Hypothyroidism D. Wearing away of teeth with exposed E. Xerostomia D. All of the above dentin (Clark et al, 2010) APPENDIX 4 Adult-Gerontology Health Assessment

Smiles for Life Module 5 Quiz: Oral Health In Pregnancy S! 1. Which of the following is a C. Dental treatment should only be done during the 8. If a pregnant woman has an oral FALSE statement? second trimester for comfort and safety reasons abscess in the first trimester, what ! A. Gingivitis is very common in pregnancy D. Dental treatment can be done during should she do regarding its B. Periodontitis is associated with preterm birth any trimester treatment? ! C. Treatment of periodontitis in pregnancy A. Take antibiotics and pain medication decreases the risk of preterm birth 5. What guidance should you give a pregnant only and wait until her second trimester ! patient about having dental x-rays during her D. Deep root scaling to improve periodontitis to see the dentist is safe during pregnancy pregnancy? ! A. Dental x-rays should be avoided during B. Avoid x-rays for further diagnosis ! 2. Which of the following is a TRUE statement: pregnancy C. Have the tooth treated or extracted A. Mothers with caries pass their genetic B. Dental x-ray should be limited to only one under local anesthesia immediately predisposition for caries on to their babies film per pregnancy D. Delay definitive treatment B. Mother with caries pass caries-causing C. Dental x-rays should be taken as until after delivering her bacteria to their babies in utero necessary to reach a full diagnosis baby C. Mother with caries pass caries-causing bacteria D. Dental x-rays are rarely needed during 9. Amalgam restorations placed during to their infants early in life via saliva pregnancy pregnancy can lead to which negative transmission outcome in the fetus? D. All of the above 6. What oral health guidance should you give a pregnant patient? A. Birth defects 3. A pregnancy granuloma: A. Brush twice daily with fluoridated toothpaste B. Neurologic sequelae A. Has malignant potential and should be biopsied B. Use chlorhexidene mouthwash three times per C. Spontaneous abortions B. Should be excised during pregnancy even if day D. None of the above asymptomatic to avoid complications C. Avoid sugary drinks and snacks between meals C. Can be observed D. Take fluoride dietary supplements 10. What could pregnant women do D. Is not likely to recur if excised E. A and C only after vomiting to reduce the risk of 4. A pregnant patient asks you for guidance enamel erosion? about having dental treatment during her 7. All of the following conditions can cause worsening gingivitis EXCEPT: A. Swish with baking soda and water pregnancy. What would you say? B. Vigorously brush her teeth A. Dental treatment should only be done A. Onset of puberty during the second and third trimester B. Monthly menses C. Immediately take a dose of a proton B. Dental treatment should only be done C. Menopause pump inhibitor during the third trimester because D. Use of oral contraceptives D. Immediately take 3-4 antacid tablets organogenesis is complete E. Pregnancy (Clark et al, 2010) APPENDIX 5 Adult-Gerontology Health Assessment

Smiles for Life Adult Oral Health Pocket Card Side 1 S! Other Oral Disease Risk Factors ANTIBIOTIC PROPHYLAXIS GUIDELINES FOR Planned Procedure ! Tobacco and alcohol use (cancers) ORAL PROCEDURES** Prophylaxis recommended for highest risk patients for: Family history of oral cancers All dental procedures that involve manipulation of Lack of mouth guard use for sports At Risk Medical Conditions ! gingival tissue or the periapical region of teeth or Methamphetamine use (erosions) Highest Risk Acquired valvular dysfunction perforation of the oral mucosa Bulimia (erosions) ! Prosthetic cardiac valves Significant GERD (erosions) Prophylaxis NOT recommended for: Previous bacterial endocarditis ! Congenital heart disease (CHD) Local anesthetic injections through non-infected tissue Screening Oral Exam Removable appliance placement Observation - Unrepaired cyanotic CHD Oral radiographs ! Remove all dentures and appliances - Completely repaired congenital heart defect during the first 6 months after the procedure Orthodontic appliance adjustment Teeth and oral hygiene - Repaired CHD with residual defects Shedding of primary teeth Palate and gums Cardiac transplantation recipients who develop Bleeding from trauma to the lips and oral mucosa Buccal mucosa cardiac valvulopathy Floor of mouth & tongue Lower Risk - No longer prophylaxed Antibiotic choices (lateral borders & undersurface) Acquired valvular dysfunction Standard prophylaxis (give 1 dose only orally 30 – 60

Posterior pharynx Hypertrophic cardiomyopathy minutes before procedure): Palpation Mitral valve prolapse with audible regurgitation Amoxicillin: Adults: 2.0 g; children: 50 mg/kg Floor of mouth Isolated secundum atrial septal defect Unable to take oral medication (give 1 dose only 30 – 60 Neck Previous coronary artery bypass grafting minutes before procedure): Record Physiologic, functional, or innocent murmurs Ampicillin: Adults: 2.0 g; children 50 mg/kg; IM or IV Signs of caries Cefazolin or Ceftriaxone: Adults: 1.0 g; children 50 Previous Kawasaki disease w/o valve dysfunction - White spots, brown spots, pits mg/kg; IM or IV Cardiac pacemaker or implanted defibrillator Signs of periodontal disease Allergic to penicillin (give orally 1 dose only 30 – 60 Prophylaxis also recommended for patients with the - Poor oral hygiene (presence of plaque) minutes before procedure): following implanted medical devices: - Erythematous or receded gums Clindamycin: Adults: 600 mg; children: 20 mg/kg - Loose teeth Total joint replacement Cephalexin: Adults: 2.0 g; children; 50 mg/kg - In place less than 2 years Signs of other oral disease (caution if hypersensitivity to penicillin) - Immunocompromised patient - Soft tissues lesions Azithromycin or clarithromycin: Adults: 500 mg; - Previous prosthetic joint infection - Tooth erosion children: 15 mg/kg Vascular grafts in place less than 6 months **IMPORTANT NOTICE: Refer to dentist: Arteriovenous shunt for hemodialysis The “Antibiotic Prophylaxis Guidelines” above are All adults for 6 month check ups Neurosurgical shunts based on the latest recommendations by the American All adults with signs of caries, periodontal Indwelling catheters Heart Association (updated 2007). It is advised to disease or suspicious oral lesions. consult the American Heart Association website for more details and for any updates: www.heart.org

(Silk, Douglass & Douglass, 2011) APPENDIX 5 Adult-Gerontology Health Assessment

Smiles for Life Adult Oral Health Pocket Card Side 2 S!

! ANTICOAGULATION GUIDELINES FOR ORAL Management PROCEDURES Discontinue meds or move to morning dosing Cessation of anticoagulation or anti-platelet agents Avoid sugar containing foods and drinks ADULT ORAL HEALTH POCKET CARD ! carries a risk of thromboembolic event Xylitol mints, sugar-free gum Hugh Silk MD, Alan Douglass MD, Joanna Douglass BDS Cleanings, fillings, and simple extractions can be Rx brush on topical fluoride gel Smiles for Life Oral Health Curriculum ! www.smilesforlifeoralhealth.org October 2011 performed without interrupting anticoagulation Rx saliva substitutes Bleeding can be controlled with local agents, e.g. Regular dental visits higher risk for caries Creation of this product was funded by: National Interprofessional Initiative on Oral Health ! surgical (oxidized cellulose polymer), tranexamic acid or epsilon amino caproic acid mouthwash (discuss Denture Care and Problems The information contained in this card should not substitute for ! with dentist/oral surgeon) Care consultation with an oral health expert. Patients that are at high risk for thromboembolic Soak in water or denture cleaner overnight PRIMARY CARE events that need to undergo oral procedures that are Rinse with water after every meal hih ris or bleedin can be anaed ith “bride Brush daily with soft brush and denture cleaner Prevention of Caries & Periodontal Disease therapy” usin enoxaparin ovenox andor heparin Problems Eliminate sweet snacks/drinks between meals days before the procedure Problems with chewing, cheek biting, speech, Brush twice daily with fluoridated toothpaste Communication with dentist/oral surgeon is vital cracked corners of mouth = poorly fitting dentures Floss daily Regular dental visits every 6 months Erythematous candidiasis under dentures Regular oral exam at annual medical exam GERIATRIC ORAL HEALTH - Nystatin rinse 3x daily, ointment under denture

- Soak denture in chlorhexidine or nystatin Xerostomia Caries Risk Factors Signs Presence of cavities or multiple fillings Gingival recession Need to sip water or suck candies to talk PERMANENT TOOTH CHART: Xerostomia (medications, disease) Needs fluids to form food bolus when eating Poor oral hygiene Oral burning/soreness and altered taste Poor access to dental care No pooling of saliva in floor of mouth Low socio-economic and/or education status Tongue fissured Inadequate fluoride High frequency foods/drinks/medications with sugar Etiology Special health care needs (oral health often overlooked) Primary disease (Sjogrens/RA/salivary tumor) Presence of partial dentures or other appliances

Medications anticholinergics, antidepressants, Periodontal Disease Risk Factors antipsychotics, diuretics, antihypertensives, sedatives, Poor oral hygiene including lack of flossing antihistamines, inhalers Tobacco use Diabetes and/or Osteoporosis Family history of periodontal disease Medications (anticonvulsants, methotrexate, Ca++ channel blockers may cause gingival hyperplasia)

(Silk, Douglass & Douglass, 2011) APPENDIX 6 Adult-Gerontology Health Assessment

Smiles for Life Module 8 Quiz: Geriatric Oral Health (part I) S! 1. What is the most common site 4. Which statement is true regarding 6. What is the most significant reason why complete tooth loss ! for caries in the elderly? dental prostheses? has declined in the US from 50% to 18% in the last 60 years? ! A. Site of a previous restoration A. Implants are commonly placed in a A. Increased use of dental insurance in the elderly (filling) jaw to replace teeth lost due to severe B. Increased use of bottled and filtered water products among adults ! B. On a root that is exposed due to osteoporosis C. Addition of fluoride to most community water systems gingival recession B. Dentures should be removed and D. Increased use of multiple prescription medications in the elderly ! C. On coronal surface of tooth cleaned daily ! D. On the buccal surface of molars C. Bridges should be removed daily to facilitate cleaning of teeth 7. While performing an oral exam on a 72 year old patient, you 2. Which of the following is an D. A partial denture is permanently fixed observe the finding in the photograph. How should you manage absolute contraindication for to adjacent teeth and therefore does this finding? placing dental implants? not need to be removed to perform a A. Refer the patient to an oral surgeon for immediate biopsy of A. Diabetes mellitus that is complete oral assessment probable oral cancer controlled B. Schedule the patient to return in 2 weeks to reassess the lesion. B. Root caries in the teeth that are to 5. HPV influenced oral cancers have If the lesion is still present, you should then refer the patient for be replaced which of the following biopsy C. Use of IV bisphosphonates characteristics? C. Treat the patient with an antifungal solution and reassess in 2 D. Use of medication known to cause A. Account for the rise in oral cancers in weeks xerostamia younger individuals , age 40-64 D. Document this finding as sublingual varicosities that are normal in this age group and require no further evaluation 3. What is the adverse intraoral B. Are usually seen in the anterior

effect with which calcium channel portion of the mouth, especially the blockers are most associated buccal mucosa or the lip with? C. Epidemiologically related to exposure A. Stomatitis to HPV 18 B. Thrush D. Less likely to be associated with oral C. Gingival hyperplasia cancer than other sexually transmitted infections such as syphilis D. Osteonecrosis of mandible and gonorrhea (Clark et al, 2010) APPENDIX 6 Adult-Gerontology Health Assessment

Smiles for Life Module 8 Quiz: Geriatric Oral Health (part II) S! 8. Which of the following statements is true 10. Elderly with poor oral hygiene, missing teeth 11. Which of the following is an regarding the oral health of elderly patients with and dental pain are at risk for worsening oral appropriate use of fluoride in older ! dementia? health due to which of the following nutritional adults? ! A. Aging alone is the major contributor to poor oral factors? A. Topical fluoride treatments for health of older individuals with dementia A. Lack of foods rich in vitamins such as vitamin C exposed roots ! B. Medications used to treat hypertension, and beta carotene B. Oral fluoride supplementation for ! depression and behavioral disturbances seen in B. Compensating for taste alteration due to patients with multiple carious lesions this population have little effect on their oral prescribed medication with soft, sugared foods C. Oral fluoride supplementation for ! health such as ice cream, pudding and white bread patients with multiple carious lesions C. Since this population struggles with Activities of which can lead to caries in remaining teeth D. Topical fluoride for gingival Daily Living (ADLs), they are at high risk for poor C. Use of mints or sweetened beverages to relieve hyperplasia caused by phenytoin oral health unless caregivers assist with oral care dry mouth therapy D. Reminding these individuals to brush their teeth D. All of the above E. Topical fluoride as a routine each day is adequate to achieve and maintain preventive measure in patients with good oral health excellent oral care (no caries or periodontal disease) 9. After a hip fracture, a 76 year old woman is admitted to a long-term care facility for rehabilitation. While examining her mouth shortly thereafter, you see the condition in the photograph. What is the most likely cause of what you see? A. The patient developed cellulitis of her palate during her recent hospital stay B. The patient’s palate was damaged during intubation for anesthesia C. The patient’s dentures were improperly cleaned while she was in the hospital D. The patient probably has an oral cancer (Clark et al, 2010) APPENDIX 1-6 Adult-Gerontology Health Assessment

Smiles for Life Answer Key S! ! ! Module 1: Module 3: Module 5: Module 7: Module 8: ! 1. C 1. C 1. C 1. A 1. A ! 2. A 2. C 2. C 2. D 2. C ! 3. B 3. C 3. C 3. A 3. C 4. A 4. A 4. D 4. B 4. B 5. A 5. D 5. C 5. D 5. A 6. B 6. B 6. E 6. D 6. C 7. C 7. B 7. C 7. D 7. D 8. A 8. E 8. C 8. B 8. C 9. D 9. A 9. D 9. B 9. C 10. C 10. C 10. A 10. D 10. D 11. A

(Clark et al, 2010) APPENDIX 7 Adult-Gerontology Health Assessment

American Dental Association Caries Risk Assessment Form (Ages >6) S! ! ! ! ! !

www.ada.org/~/media/ADA/Public Programs/Files/topics_caries_educational_over6.ashx APPENDIX 8 Adult-Gerontology Health Assessment Adult Oral Health Checklist

S! Please check as you identify each item: ! Strep throat (A) ! Periodontal disease (B) ! Black hairy tongue (C) ! Herpetic lesion (D) ! Gingival recession (E) Canker sore (F) Angular cheilitis (G) x! Tori madibularis (H) x!

Images from: CDC public health images library Gujral, D. M., Bhattacharyya, S., Hargreaves, P., & Middleton, G. W. (2008). Periodontal disease in a patient receiving Bevacizumab: a case report. Journal of medical case reports, 2(1), 47. Jain, A., & Kabi, D. (2013). Severe periodontitis associated with chronic kidney disease. Journal of Indian Society of Periodontology, 17(1), 128. Jeong, J. S., Lee, J. Y., Kim, M. K., & Yoon, T. Y. (2011). Black hairy tongue associated with erlotinib treatment in a patient with advanced lung cancer. Annals of dermatology, 23(4), 526-528. Khuller, N. (2009). Coverage of gingival recession using tunnel connective tissue graft technique. Journal of Indian Society of Periodontology, 13(2), 101. Kwon, K. H., Lee, D. G., Koo, S. H., Jo, M. S., Shin, H., & Seul, J. H. (2012). Usefulness of vy advancement flap for defects after skin tumor excision. Archives of plastic surgery, 39(6), 619-625. Lee, K. H., Lee, J. H., & Lee, H. J. (2013). Concurrence of Torus Mandibularis with Multiple Buccal Exostoses. Archives of plastic surgery, 40(4), 466-468. tori madibularis APPENDIX 8 Adult-Gerontology Health Assessment Adult Oral Health Answer Key

S! Answers A! ! Strep throat (A) ! Periodontal disease (B) ! Black hairy tongue (C) Herpetic lesion (D) ! B! C! ! Gingival recession (E) Canker sore (F) Angular cheiltis (G) E! F! x! Tori madibularis (H) D x! C! F!

Images from: G! CDC public health images library Gujral, D. M., Bhattacharyya, S., Hargreaves, P., & Middleton, G. W. (2008). Periodontal disease in a patient receiving Bevacizumab: a case report. Journal of medical case reports, 2(1), 47. Jain, A., & Kabi, D. (2013). Severe periodontitis associated with chronic kidney disease. Journal of Indian Society of Periodontology, 17(1), 128. Jeong, J. S., Lee, J. Y., Kim, M. K., & Yoon, T. Y. (2011). Black hairy tongue associated with erlotinib treatment in a patient with advanced lung cancer. Annals of dermatology, 23(4), 526-528. Khuller, N. (2009). Coverage of gingival recession using tunnel connective tissue graft technique. Journal of Indian Society of Periodontology, 13(2), 101. Kwon, K. H., Lee, D. G., Koo, S. H., Jo, M. S., Shin, H., & Seul, J. H. (2012). Usefulness of vy advancement flap for defects after skin tumor excision. Archives of plastic surgery, 39(6), 619-625. Lee, K. H., Lee, J. H., & Lee, H. J. (2013). Concurrence of Torus Mandibularis with Multiple Buccal Exostoses. Archives of plastic surgery, 40(4), 466-468. APPENDIX 9 Adult-Gerontology Health Assessment

Geriatric Oral Health Checklist S! Please check as you identify each item: ! ! Melanoma (A) ! Candidiasis (B) ! Denture sores (C) ! Denture Stomatitis (D)

! APPENDIX 9 Adult-Gerontology Health Assessment

Geriatric Oral Health Answer Key S! Answers ! A! B! ! Melanoma (A) ! Candidiasis (B) ! Denture sores (C) ! Denture Stomatitis (D)

Images from: CDC Public Health Images Library Clark M.B., Douglass A.B., Maier R., Deutchman M., Douglass J.M., Gonsalves W., Silk H., Tysinger J.W., Wrightson A.S., & Quinonez R. (2010). Smiles for life: a national oral health curriculum. 3rd Edition. Society of Teachers of Family Medicine. Retrieved from smilesforlifeoralhealth.com ! A-GNP Curriculum Integration of Interprofessional Oral Health Competencies in Health Promotion

ADULT- 1) EXPOSURE: INTRODUCTION 2) IMMERSION: DEVELOPMENT 3) COMPETENCE: ENTRY-TO-PRACTICE GERONTOLOGY HEALTH KNOWLEDGE: ORAL HEALTH EDUCATION SKILL/BEHAVIOR SKILL/BEHAVIOR PROMOTION Goal: Understand oral disease and the role that Goal: Critically evaluate current oral health Goal: Advocate for oral public health within your nurses can play in oral care research in the media community

IPEC Competencies: Read • Find news story on oral health and • Identify oral health advocacy organization Values and Ethics, evaluate its accuracy by searching in your state, access your state’s resource Roles and • The Primary Care Visit: What Else Could be Happening? (Fulmer & Cabrera, evidence-based literature page and identify oral health issues in your Responsibilities • Post copies of media piece and Interprofessional 2012) community Communication, • Evaluating and Managing Dental supporting/refuting literature on • Join US National Oral Health Alliance and

E Teams & Teamwork Complaints in Primary and Urgent Care Discussion Board and lead discussion S participate in Open Forum Discussion Board N in class U T (Idzik and Krauss, 2013) on oral health issues in your community M R M Y A SKILL/BEHAVIOR KNOWLEDGE: ORAL HEALTH MAINTENANCE SKILL/BEHAVIOR T L Goal: Understand importance of maintaining I Goal: Advocate for smoking cessation in Goal: Develop primary care oral health smoking adults E oral health throughout the lifespan V HRSA Oral Health V literacy program for adults E Competencies: E Read: • Engage smoking adults in evidence-based Oral Health Risk L • Maintaining Oral Health Across the Life • Plan with dental students: A Assessment, Oral smoking cessation program Span (Jablonski et al, 2014) • Evidenced-based primary S Health Evaluation, A S • Implement evidence-based cancer screening Oral Health Preventive • Surgeon General’s Fact Sheets care oral health literacy S program for adults E program in smoking adults Intervention, S • Promoting Smoking Cessation (Larzelere & S Communication E • Evidence-based oral S and Education S Williams, 2012) cancer screening M S • Help Your Patients Quit brochure (ADA) program for smoking E M (Appendix 1) adults N E T PARTNERSHIP & COLLABORATIVE PRACTICE FOR & COLLABORATIVE PARTNERSHIP

N T NONPF Competencies:: KNOWLEDGE: ORAL-SYSTEMIC CONNECTION SKILL/BEHAVIOR SKILL/BEHAVIOR Implements health promotion, Goal: Understand relationship between oral and Goal: Develop primary care oral health Goal: Identify Medicaid and sliding scale dental health maintenance, health systemic health literacy program for older adults clinics protection and disease prevention initiatives that are age, gender, culture and • Read • Read Develop list of dental providers in the area to health status appropriate; Uses Systemic Diseases and Oral Health Tooth Loss and its Association with whom you can refer patients who accept pharmacologic and non- (Tavares et al, 2014) Dietary Intake and Diet Quality in Medicaid or sliding scale pharmacologic management American Adults (Zhu & Hollis, 2014) OUTCOMES HEALTH OF CIENT/PATIENT OPTIMIZATION strategies to ameliorate • Following health literacy principles, physical and behavioral develop evidence-based nutrition INTER-PROFESSIONAL symptoms in individuals who and oral health education program have psychiatric/substance misuse disorders with dental students for older adults CONSTRUCTS © Oral Health Nursing Education and Practice (OHNEP) APPENDIX 1 Adult-Gerontology Health Promotion Help Your Patients Quit (ADA) (part I)

S! Tobacco&Cessa*on& ! ! ! ! ! APPENDIX 1 Adult-Gerontology Health Promotion Help Your Patients Quit (ADA) (part II)

S! ! Pharmacotherapy& ! ! ! ! A-GNP Curriculum Integration of Interprofessional Oral Health Competencies in Primary Care

ADULT- 1) EXPOSURE: INTRODUCTION 2) IMMERSION: DEVELOPMENT 3) COMPETENCE: ENTRY-TO-PRACTICE GERONTOLOGY PRIMARY CARE KNOWLEDGE: ADULT WITH CHRONIC DISEASE SKILL/BEHAVIOR COLLABORATIVE CASE STUDY Goal: Recognize oral health manifestations of Goal: Provide comprehensive health maintenance Goal: Collaborate interprofessionally on adult chronic diseases in adults services to adults with chronic diseases chronic disease case with oral health needs • Read: • Oral Manifestations of GERD IPEC Competencies: • Review: • A-GNP and dental students to collaborate (Ranjitkar et al, 2012) Values and Ethics, • SFL modules 1, 3, 7, 8 on developing a management plan for adult with Celiac Disease (Appendix 5) Roles and • Adult and geriatric oral health • Oral Hygiene Status of Individuals Responsibilities photographs (Appendix 1, 2) with CVD (Shetty et al, 2012) • A-GNP and dental students to present one Interprofessional • Develop care for either patient and include article from list (Appendix 6) on Celiac Communication, • Read

E Disease in adults and report findings on Teams & Teamwork The association between celiac disease, HEENOT in history, risk assessment, exam and S N U oral health T dental enamel defects and apthous ulcers in plan a United States cohort (Cheng et al, 2010) M R M Y SKILL/BEHAVIOR A KNOWLEDGE: ADULT WITH INFECTIOUS Goal: Identify oral manifestations of infectious diseases in T COLLABORATIVE CASE STUDY L DISEASE I adults Goal: Collaborate interprofessionally on E Goal: Recognize oral health manifestations of V adult infectious disease case with oral HRSA Oral Health V • Read: E health needs Competencies: E STIs in adults • A Case of Oral Plasmablastic Lymphoma (Medel & Oral Health Risk L A Assessment, Oral Hamao-Sakamoto, 2014) S • A-GNP and dental students to collaborate on Health Evaluation, Read A • Oral Manifestations of Secondary Syphilis in the Elderly S developing a management plan for adult with Oral Health Preventive S • Oral Manifestations of Sexually Transmitted E Intervention, S Infections (DePaola, 2013) (Minicucci et al, 2013) S STI and oral health needs (Appendix 7) Communication E • Oral Syphilis: A Series of 5 Cases (Hertel et al, 2013) S and Education • HPV and Oropharyngeal Cancer (CDC 2013) • A-GNP, dental and medical students to S M collaborate caring for adults with infectious S • Statement on HPV and Squamous Cell • Choose one STI, post photo of oral manifestations on E M Cancers of the Oropharynx (ADA) discussion board and lead discussion in class on its oral N diseases in adult dental clinic E manifestations: Strep, Thrush, HIV, Syphilis, HPV, gonorrhea T PARTNERSHIP & COLLABORATIVE PRACTICE FOR & COLLABORATIVE PARTNERSHIP

N T KNOWLEDGE: OLDER ADULT PRIMARY CARE SKILL/BEHAVIOR COLLABORATIVE CASE STUDY NONPF Competencies: Goal: Recognize oral health needs of older Collaborates with individual, Goal: Provide comprehensive health Goal: Collaborate interprofessionally on family, caregivers in development adults maintenance services to older adults geriatric case with cognitive decline and oral of educational interventions health needs appropriate to complex acute, Read: Collaborate together on Discussion critical and chronically-ill patient’s • Reducing care-resistant behaviors during Board on: • Read needs, values, developmental and govnitive level andh ealth oral hygiene in persons with dementia • Cardiovascular case study Opportunities for Nursing-Dental (Jablonski et al, 2011) (Appendix 3) Collaboration: Addressing Oral Health literacy; Implements health OUTCOMES HEALTH OF CIENT/PATIENT OPTIMIZATION promotion, health maintenance, • Ensuring Oral Health for Older Individuals • Diabetes case study (Appendix 4) Needs Among the Elderly (Coleman, protection and disease with Intellectual and Development 2005) INTER-PROFESSIONAL prevention that are age, gender, Disabilities (Waldman & Perlman, 2012) • A-GNP and dental students to collaborate culture and health status on developing a management plan for appropriate case studies of older adults with cognitive CONSTRUCTS decline and oral health needs © Oral Health Nursing Education and Practice (OHNEP) APPENDIX 1 Adult- Gerontology Primary Care Adult Oral Health Checklist S! E! ! Strep throat (A) ! Periodontal disease (B) ! Black hairy tongue (C) D ! Herpetic lesion (D) ! Gingival recession (E) Canker sore (F) A! Angular cheiltis (G) x! Tori madibularis (H) x! C! F! H!

G! B! Images from: CDC public health images library Gujral, D. M., Bhattacharyya, S., Hargreaves, P., & Middleton, G. W. (2008). Periodontal disease in a patient receiving Bevacizumab: a case report. Journal of medical case reports, 2(1), 47. Jain, A., & Kabi, D. (2013). Severe periodontitis associated with chronic kidney disease. Journal of Indian Society of Periodontology, 17(1), 128. Jeong, J. S., Lee, J. Y., Kim, M. K., & Yoon, T. Y. (2011). Black hairy tongue associated with erlotinib treatment in a patient with advanced lung cancer. Annals of dermatology, 23(4), 526-528. Khuller, N. (2009). Coverage of gingival recession using tunnel connective tissue graft technique. Journal of Indian Society of Periodontology, 13(2), 101. Kwon, K. H., Lee, D. G., Koo, S. H., Jo, M. S., Shin, H., & Seul, J. H. (2012). Usefulness of vy advancement flap for defects after skin tumor excision. Archives of plastic surgery, 39(6), 619-625. Lee, K. H., Lee, J. H., & Lee, H. J. (2013). Concurrence of Torus Mandibularis with Multiple Buccal Exostoses. Archives of plastic surgery, 40(4), 466-468. APPENDIX 2 Adult-Gerontology Primary Care

Geriatric Oral Health Checklist S! ! ! Melanoma (A) A! ! Candidiasis (B) ! Denture sores (C) ! Denture Stomatitis (D) C!

B! D!

Images from CDC Public Health Images Library Clark M.B., Douglass A.B., Maier R., Deutchman M., Douglass J.M., Gonsalves W., Silk H., Tysinger J.W., Wrightson A.S., & Quinonez R. (2010). Smiles for life: a national oral health curriculum. 3rd Edition. Society of Teachers of Family Medicine. Retrieved from smilesforlifeoralhealth.com ! APPENDIX 3 Adult-Gerontology Primary Care Cardiovascular Disease Case Study S! ! ! ! Design an oral exam and treatment plan for a 61 year old man with a prosthetic ! mitral valve who will undergo deep cleaning of his gingival and gingival pockets. ! What are your treatment plans if this patient is allergic to PCN? APPENDIX 4 Adult-Gerontology Primary Care Diabetes Case Study S! A 65 year old Hispanic male Mr. M. was referred by the ! Dental clinic because of early evidence of periodontal • Oral Health History ! disease. The patient has family history of Type 2 ! Diabetes (T2D) and history of caring for his diabetic • Physical Health Exam ! grandfather for many years. He described himself as an ! expert in diabetes because of the years of caring for his ailing diabetic grandfather. During the health history, he • Oral-Systemic Risk Assessment complained of symptoms of hyperglycemia: fatigue, thirst, and weight loss. On physical exam, his blood • Action Plan pressure was 160/95, BMI of 31, random blood sugar of 332 mg/dl, and HgbA1c > 13%. He was diagnosed • Preventive Interventions with T2D and obesity. He was started on Metformin twice a day, he was counseled on diet and physical activity. The patient was referred back to dentistry for • Interventions continued periodontal care in light of his new diagnosis of T2D. • Collaboration

What is the follow-up nursing primary care action plan for Mr. M.? • Referrals What are the 3 months follow-up outcomes? ! ! !! APPENDIX 5 Adult-Gerontology Primary Care Celiac Disease Case Study S! A 39-year-old woman presents with symptoms of diarrhea, nausea, flatulence, colic, ! difficulty with falling asleep, lack of appetite and a weight loss of 20lbs in the last two ! years. ! ! She also complains of the appearance of lesions in the mouth, particularly on the ! tongue.

She has had frequent dental problems over the years, including dental caries and root canals.

What else would you like to know? What is your differential? What tests will you order? What is your diagnosis? What treatment will you prescribe? Where do you refer patient? What is your follow-up?

da Silva et al. (2008). Oral manifestations of celiac disease. A case report and review of the literature. ! APPENDIX 6 Adult-Gerontology Primary Care Celiac Disease Reference List S! ! Admou, B., Essaadouni, L., Krati, K., Zaher, K., Sbihi, M., Chabaa, L., . . . Alaoui-Yazidi, A. (2012). Atypical celiac disease: from ! recognizing to managing.Gastroenterol Res Pract, 2012, 637187. doi: 10.1155/2012/637187 ! Campisi, G., Di Liberto, C., Iacono, G., Compilato, D., Di Prima, L., Calvino, F., . . . Carroccio, A. (2007). Oral pathology in ! untreated coeliac [corrected] disease. Aliment Pharmacol Ther, 26(11-12), 1529-1536. doi: 10.1111/j. ! 1365-2036.2007.03535.x

Cheng, J., Malahias, T., Brar, P., Minaya, M. T., & Green, P. H. (2010). The association between celiac disease, dental enamel defects, and aphthous ulcers in a United States cohort. J Clin Gastroenterol, 44(3), 191-194. doi: 10.1097/MCG. 0b013e3181ac9942

Rashid, M., Zarkadas, M., Anca, A., & Limeback, H. (2011b). Oral manifestations of celiac disease: a clinical guide for dentists.J Can Dent Assoc, 77, b39. PMID: 21507289

APPENDIX 7 Adult-Gerontology Primary Care STI Case Study

S! Chief Complaint: 35 yo female Lisa presents to clinic complaining of hoarseness of voice, sores in mouth ! Current Health Status: ! Lisa has no other health problems. ! ! Medications: None ! Sexual History: multiple partners, intermittent condom use Physical Exam: Alert, oriented, 35yo old female. HEENOT – Eyes, Ears, nose and dentition normal. Scattered papillomas on tongue and pharynx Abdomen – soft, nontender MS – nl Gyn – No visible lesions – cervical studies pending Neuro – nl

What else would you like to know? What is your differential? What tests will you order? What is your diagnosis? What treatment will you prescribe? Where do you refer patient? What is your follow-up? RESOURCES

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