by Jamie Toop, DDS and Tom von Sydow
The big three
The connection between oral health and systemic conditions is now widely recognized by both medical and dental practitioners. The inflammation and bacteria associated with periodontal disease have been linked to six out of the seven leading causes of death in the United States, including heart disease, stroke, diabetes, cancer, chronic lower respiratory disease, and Alzheimer's disease.
As dental health-care providers, we should understand how oral health plays a role in whole-body health. Here, we will focus on what we're calling the "big three," which are the top three oral-systemic associations that dental practitioners should be most comfortable talking about with patients: heart disease, stroke and diabetes.
When a patient presents one or more chronic oral-disease states, such as periodontal disease or an endodontic abscess, inflammation is occurring in that patient's body in response to a bacterial assault. The patient's body responds with localized inflammation, which can become chronic if the assault continues. This is where the inflammatory cascade begins, which can lead to inflammatory diseases that cause the body to constantly fight infection within itself. There is likely a tipping point where the inflammation in the body reaches a certain threshold that can contribute to the development of, or exacerbation of, chronic diseases such as heart attack, stroke and diabetes.
Heart disease and stroke connection
The growing body of scientific evidence points to a close relationship between periodontal disease and many other inflammatory diseases. We asked Dr. Thomas W. Nabors, cofounder of OralDNA Labs, about the association between heart disease, stroke, and oral health.
He said, "There is excellent peer- reviewed literature [showing] that the same pathogenic bacteria that are causally related to periodontal disease are also uniquely linked to coronary artery disease, atherosclerosis, hypertension, and increased risk for heart attack and stroke."
These inflammatory diseases develop at a greater rate once the body reaches that hypothetical inflammation tipping point.
Dr. Charles Whitney, a leading advocate of oral systemic health and wellness, and owner of Revolutionary Health Services in Washington Crossing, Pennsylvania, stated that there is Level A evidence associating cardiovascular disease and periodontal disease.
In fact, Circulation, the journal of the American Heart Association, published a study that assessed thrombi in 101 heart-attack events. The researchers concluded that as many as half were likely triggered by bacteremia that were either periodontal or endodontic in origin (Pessi, et al., 2013).
Although further evidence is needed to establish a cause-and-effect relationship between periodontal disease and heart disease or stroke, research continues to support a strong association.
The pathogens leading to infection in the oral cavity can differ, and the associated inflammatory response may also differ. Since studies have shown the presence of oral bacteria in the thrombi of patients who suffered a heart attack, this may suggest that certain levels of some endodontic or periodontal pathogens can contribute to heart disease.
As more evidence is found, it may be beneficial for dental health-care providers to administer a simple salivary test to measure the volume of oral bacteria that may be associated with both periodontal disease and coronary artery disease or stroke. Whitney likens this to gasoline and matchsticks.
"Risk factors are the gasoline that fills the engine of disease in arterial walls, and the triggers are the matchsticks that explode the tank and cause events like heart attacks and strokes," he said. "Bacteremia of oral pathogens is clearly a very important matchstick that needs to be eliminated."
When we eliminate periodontal disease (the matchstick) and associated bacteremia through diagnosis and treatment with scaling and root planing, followed by three-month follow-up periodontal maintenance cleanings, we see a decline in hospital visits and an increase in health-care savings. Last year, dental insurer United Concordia demonstrated that in-office periodontal therapy is a useful tool to help in protecting against heart disease and stroke (United Concordia, 2014).
Diabetes connection
Type 2 diabetes is another inflammatory disease that is seen more commonly in patients with periodontal disease. The American Academy of Oral Systemic Health (AAOSH) estimates that 93 percent of people with periodontal disease are at risk for diabetes.
It further estimates that patients with both periodontal disease and diabetes have an increased risk for premature death by 400 percent to 700 percent (AAOSH.com). Inflammation is the matchstick catalyst that ignites the bodily response that causes people to become resistant to insulin, the hallmark of prediabetes and Type 2 diabetes.
By screening patients, oral health-care providers can play an integral part in identifying patients at risk for diabetes and prediabetes. It is estimated that up to 27.8 percent of the American population has undiagnosed diabetes (CDC, 2014).
Dr. Nabors noted study findings showing that by counting the number of periodontal pockets that are greater than 5mm, looking for missing teeth, and requesting an HbA1c test, prediabetes or Type 2 diabetes can be predicted 92 percent of the time (Lalla, et al., 2011).
With the overwhelming evidence connecting periodontal disease to systemic health, dentists now have the capability to do more in determining risk of chronic diseases. With these conditions accounting for three of the top seven leading causes of death in the United States, it is more important than ever to truly integrate dentistry and medicine.
Action at the university level
Academic institutions are playing a significant role in supporting the integration of dentistry and medicine. In 1995, the Institute of Medicine (IOM) published the report, Dental Education at the Crossroads: Challenges and Change, which proposed four recommendations to promote oral health:
- integration of dentistry with medicine and the health-care system on all levels: research, education, and patient care
- support from dental schools in educating students on all models of clinical practice
- commitment of dental schools in improving dental education and contributing research, technology transfer, and public-health service
- collaboration among the dental community in influencing alternative models of education, practice, and performance assessment for dental professionals.
Leaders at the university believe that interprofessional care will help improve care coordination and patient outcomes, produce cost savings, and reinforce the link between oral health and systemic conditions.
In 2009, the national education associations of dentistry, nursing, pharmacy, osteopathic medicine, and public health came together to form an Interprofessional Education Collaborative (IPEC) focused on the promotion of interprofessional education. These organizations are working together to guide advancements in curriculum across many health professions to include interprofessional learning experiences.
In 2011, IPEC published the report, Core Competencies for Interprofessional Collaborative Practice, to serve as a framework for educators to adopt best practices in preparing their students for team-based care in their future workplace through interactive, cross-disciplinary learning. The goal is to reduce the fragmentation of various health professions and prepare students for a collaborative practice environment when they enter the workplace.
In 2012, the U.S. Department of Health and Human Services, Health Resources and Services Administration, formed the National Center for Interprofessional Practice and Education. This organization works in cooperation with multiple partners, including the University of Minnesota. Its focus is on collecting and analyzing data, developing resources, and providing unbiased leadership to inform health-care professionals and academic institutions around the country on the effectiveness of interprofessional practice and education to improve health outcomes and reduce health-care costs.
Many dental schools are adopting interprofessional education (IPE) programs and looking at ways to incorporate cross-disciplinary learning and hands-on, team-based training for students. Universities are forming partnerships among the various health science programs within their framework, including the schools of dentistry, medicine, nursing, and pharmacy. The integration of IPE at each university can range from cross-disciplinary courses in the first and/or second year to interprofessional teams working together in rotations at community-based health-care facilities, or providing team-based care in the dental school's clinic during the third and fourth year.
Several grants have funded interprofessional training between the nurse practitioner and dental programs at major universities, including NYU, the University at Buffalo, and the University of Louisville. As nurse practitioners and dental students collaborate in delivering comprehensive care during their education, it will be a more natural transition for them to continue to collaborate in the workplace.
In April 2015, Harvard School of Dental Medicine announced its initiative to "transform dentistry by removing the distinction between oral and systemic health." In this new educational model, DMD students join medical students to study clinical medicine, then pursue further interdisciplinary clinical science education. - See more at: http://www.dentaltown.com/Dentaltown/Article.aspx?i=405&aid=5668#sthash.IajqHj9d.dpuf
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