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Oral Systemic Health and the Big Three by Jamie Toop, DDS and Tom von Sydow

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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.
It has been 20 years since this report was published and dental schools have stepped up to lead in the areas of oral systemic health and interprofessional collaboration. The New York University College of Dentistry was one of the leaders in promoting interprofessional collaboration by forming an alliance with the university's College of Nursing in 2005 for cross-discipline, team-based education and training.

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.



Reducing the cost of care
The drive to cross-train and collaborate throughout the entire spectrum of health care is not just an academic exercise. There is mounting evidence that the cost reduction to the health-care system achieved by treating periodontal disease could be enormous. The table above shows that this may be an opportunity to save more than $250 billion. And this data is just focused on the three main drivers of health-care spending (diabetes, heart disease, and stroke).

When examining other conditions that have been associated with periodontal disease, including pre-term, low-birth-weight infants, Alzheimer's disease, and erectile dysfunction, among others, the association of systemic disease and periodontal disease is ever mounting. Leading the way in this research are private insurance companies as well as government agencies. They are quickly concluding the health-care economy will benefit by incorporating oral health into the treatment plans of all patients to promote whole body health.

However, we must acknowledge that some disagree with this data and point to other bodies of research that suggest treatment of periodontal disease has no effect on the outcome of these major systemic disease states. The purpose of this article is not to perform an entire audit of all available data. In our opinion, looking at the entire spectrum of work, we feel confident that patient outcomes are affected in a positive way by proactively addressing oral-health issues.

As the system moves from volume to value, and reimbursement models move toward outcomes versus activities, the momentum of this integration will accelerate. Those on the forefront will not only reap the rewards financially, but more importantly, their patients will lead healthier, happier lives.

Tips for taking action
As dentists, the one thing we can do is take action. There are five simple steps we can follow on Monday morning to increase our knowledge and action in this quickly evolving space.

1. Seek out information.
First and foremost, we can educate ourselves. The volume of information readily available is vast. One great place to start is to read the book, Beat the Heart Attack Gene (B. Bale, MD and A. Doneen, DNP, ARNP, 2014) and watch the documentary, Say Ahh (G. Kadi, 2015). These are excellent resources to provide a solid foundation on the science and outcomes achieved by addressing periodontal disease. In addition, we can better understand the economic benefits of taking action by looking at available data on the potential financial impact to the system.

2. Empower the whole team.
As a next step, we can sit down with the hygienists and team members in our practices to have a discussion around the diagnosis and treatment of periodontal disease.

Our team should also have a solid understanding of the big three as well as the other chronic conditions that have been linked to periodontal disease. A clinical protocol should be in place, and it is critical that the entire team is contributing and feels empowered to make a difference.

3. Reach out to local medical care providers.
We can also reach out to the local primary-care providers in our proximity to start a dialogue and share information with them. Some of us already know medical doctors in the area whom we can connect with, or we can try to find those who are willing to engage and take action. This will help identify like-minded clinicians to whom we can start cross-referrals.

4. Create a plan.
In order to see the best outcomes from our efforts, we need a plan in place.

Nothing is likely to happen until we have created a realistic plan—focused on the patient—which all players can execute. We may need to analyze the current health history gathered from the patients in our practice and determine if modifications might help us gain a better understanding of their overall health situation.

We can also develop or leverage existing educational tools to help inform patients of the associations between oral health and chronic conditions.

5. Commit to taking action.
As oral health-care providers, we have the ability to take action and commit to the movement. There is only one type of doctor who is licensed to diagnose and treat periodontal disease, and that is the dentist.

As the evidence connecting oral health to systemic conditions continues to mount, external forces are going to move the management of periodontal disease forward. We have the opportunity to lead the way.

Dr. Jamie Toop graduated from Loma Linda University School of Dentistry in 2010. She now lives in Las Vegas, Nevada, where she is the owner dentist of Rocksprings Dental Group, a practice supported by Pacific Dental Services. She serves as a faculty member of the PDS Institute as a subject matter expert for the oral systemic link.



Tom von Sydow is the vice president of Strategy & Platform Development for Surgical Services at Pacific Dental Services. He is also leading programs to promote oral systemic health in PDS-supported practices.


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