Dental Decay (Caries)
Bacteria cause demineralization, cavitation
• Can attack teeth thru life span
• Some types are more common in older people:
Recurrent caries: decay at the interface of a dental restoration (e.g., filling or crown) and tooth
• Root caries
• Both recurrent/ root caries are asymptomatic-may become advanced before discovery= destruction of much or all of the tooth
Patient-level risk factors for suboptimal transitions
Low education (<high school)
Limited ADL support
Poor self-management skills
Living alone
Poor health perception
Prior hospitalizations/long stays
Low income or homelessness
Age, ≥5 multimorbidities (e.g., depression, cardiovascular disease, diabetes, cancer, substance abuse)
System-level risk factors
High hospital admission communities
Lack of discharge education
Poor communication across settings
Failure to implement follow-up plans
What defines an optimal transition of care?
Coordinated, timely, and safe movement of patients across settings, with accurate information transfer, patient empowerment, and continuity of care. Goal: reduce 30- and 90-day readmissions
Contains care coordination, discharge planning and disease or case management
Key components of optimal transitions:
Accurate, timely transfer of information
Patient empowerment for their preferences
Comprehensive assessment of patient & caregiver needs
Comprehensive Med review & mgmt
logistical arrangement to execute transition (home health, oxygen, PT, social work)
Discharge planning starts at admission
Coordination with medical & community resources
Follow-up after discharge
Barriers to safe transitions
Diverse patient needs
lack of provider education/feedback (no discharge summary/poor knowledge of post-acute settings)
communication difficulties w/colleague at time of transition
time/resource constraints (no reimbursement in US system)
What is the CCTP (Community-Based Care Transitions Program (CCTP) / Policy Approach)
Federally funded program (2011) to improve transitions of Medicare patients; shown dec 30-day rehospitalizations.
CMS transitional care management codes (99495): in 2013
Within 2 business days post-discharge: contact patient (phone, email, in-person)
Moderate complexity medical decision-making
Face-to-face visit within 14 days. Home with family support and home with home healthcare = reimbursed by Medicare
Transitional care mgmt payment codes allow ambulatory care provider to bill for services they perform to assist with transitions of care in the first 30d of d/c from inpt setting
Medicare post-discharge destination coverage:
Home health services: nursing, PT, OT, speech, social work, aides
Requires OA receiving home health be homebound
Custodial care (Alf/nursing home)
Covers snf up to 100 days oost hospital stay for skilled needs (IV tx, artificial nutrition/hydration, wound/ostomy care, rehab)
Acute rehab: must tolerate 3 hrs/day therapy- for OA w/substantial and considerable rehab need/potential
Long-term acute care: for prolonged care needs (long term ventilation, IV nutrition, complex wound care, multiple IV meds)
Inpt hospice
Discharge medication instructions:
Indication for each med, stop dates, tapering schedule, CLEAR behavior triggers for PRN psych meds
Reconcile pre-admission & new medications preadmit med that have been stopped, dosage of cont’d meds that changed
Meds added during hospital stay as PRN/ppx (analgesics/ppi/laxative) can be tapered/discontinued
Key info to communicate to next clinician:
Direct communication of: Critical but pending study results, goals of care (pt preferences & adv directives)
family/caregiver dynamics,
Brief discharge summary suffices:
Hospital course summary w/care provided and important test results,
problems/diagnoses list,
functional & cognitive status at BL/discharge
Reconciled med list, allergies, follow-ups appt, test results still outstanding
contact info for discharge clinician
Risk factors for dental decay
Poor oral hygiene: d/t impaired visual acuity, no manual dexterity, limited upper extremity flexibility; or diminished salivary flow
-frequent sticky, starchy, sugary foods (esp at night)
- infrequent dental visits d/t diminished sensitivity, permanent or removable artificial teeth & limited lifetime exposure to fluoride
Examples of evidence-based programs:
Project RED: Education, discharge planning, med reconciliation, PCP communication dec 30-day ED visits & hospitalizations
GRACE Initiative: Home-based NP + social worker care = dec hospital & nursing home admissions
peridontal disease
Periodontitis is worse in patients with poorly controlled diabetes, and may impair diabetic control
-linked epidemiologically and immunologically to peripheral vascular disease, CVD, CAD to the circulating C reactive proteins
-the same pathogens causing periodontitis to be aspirated into the lungs to cause pneumonia
what organism causes periodontitis?
Plaque or Porphyromonas gingivalis
salivary function in aging
the major salivary glands undergo regressive histologic changes with aging
-by old age, healthy glands are more susceptible to factors that impede function such as dehydration or drug-induced hypofunction
Erythroplakia
Redness or mix of red/white patch of tissue/lesions in the oral cavity that cannot be associated with inflammation
-biopsy immediately!
Account on 93% of cellular atypia
Leukoplakia
thickened, white, pre-malignant leathery-looking spots on the inside of the mouth that can develop into oral cancer
<10% become malignant
-monitor closely, biopsy if increasing in size or not gone in 14 days (2 wks)
Demographics of Squamous Cell Carcinoma of the mouth
Oral cancer incidence rates are higher for White males than for Hispanic and Black males. The incidence of oral cancer increases with age.
epidemiology of oral squamous cell carcinoma
most frequent malignancies worldwide, accounts for 90% of all oral cavity cancers.
Multiple risk factors associated,
smoking, alcohol intake,
infection, sun exposure, poor oral hygiene, chronic irritability, and genetic disorders.
