By Christine Taxin

A steady flow of information is coming to light about the role of the mouth as it relates to systemic disease. While research is still unfolding, studies are showing that oral disease can both contribute to and/or be a sign of systemic disease. There has been a call to action recently for dental and medical providers to work together in treating patients, recognizing risk factors and referring patients across specialties when necessary.

However, the application of this practice is still in infancy. Many dental professionals are not aware of all the possible systemic issues influenced by oral disease. Similarly, they are not always confident in recommending patients with oral disease to seek medical risk assessment for things such as heart disease, diabetes, or respiratory issues. On the other hand, many physicians still feel it is not within their specialty to treat issues in the oral cavity, and therefore do not consider checking for oral disease.

Research suggests the management of oral disease can reduce the risk for systemic disease, and vice versa. Therefore, there is a need for a comprehensive risk assessment that can be used across disciplines in order to make timely referrals. There is also great need for both types of providers to prioritize working to educate themselves and their teams about risks of the mouth and body.

Periodontal Disease: Why it matters

According to the American Academy of Periodontology, Periodontal Disease (PD) occurs when:

Plaque spread[s] and grow[s] below the gum line. Toxins produced by the bacteria in plaque irritate the gums. The toxins stimulate a chronic inflammatory response in which the body in essence turns on itself, and the tissues and bone that support the teeth are broken down and destroyed. Gums separate from the teeth, forming pockets that become infected. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Eventually, teeth can become loose and may have to be removed.(1)

The inflamed and lacerated gums of patients with PD allow toxins from the infection into the blood stream. The mouth becomes the entry point for the infection to pass into the rest of the body, leading to higher risk for a multitude of systemic issues like heart disease, stroke and diabetes. What has recently become known is that periodontal disease and systemic disease when coupled, compound effects one on another. If one of the diseases goes untreated it makes it more difficult to treat the other. This further demonstrates it is in the best interest of both the doctor and dentist to watch for early warning signs of disease typically outside of their respective practice.

The good news of this synergistic relationship however, is if one (systemic or periodontal) disease is caught in its early stages it gives doctors and patients an early warning the other may not be far behind.

It is imperative for physicians to know the signs and symptoms of PD and assess patients accordingly. If risk factors are present then a referral should be made to a periodontist for treatment. By treating the disease of the mouth doctors can impact their success with the treatment of systemic disease. Unfortunately as many as 1/3 of the population did not visit the dentist last year,(2), so physicians are essential to catching PD in its early stages.

Disease indicators include:

• Gums that bleed during and after tooth brushing
• Red, swollen, or tender gums
• Persistent bad breath or bad taste in the mouth
• Receding gums
• Formation of deep pockets between teeth and gums
• Loose or shifting teeth
• Changes in the way teeth fit together upon biting down, or in the fit of partial dentures.

Risk factors to look for include:

• Smoking
• Family History
• Diabetes
• Overweight(3)
• Decreased Immune Response
• Medications (Calcium Channel Blockers, Dilantin)
• Alcohol use

Systemic disease: It matters too

According to Consumer Reports: Gum disease and diabetes counteract with yin-yang synergy; because diabetes can affect circulation, it can restrict blood flow to the gums, making a person more susceptible to gum disease. Research suggests that treating periodontal disease can improve blood-sugar control. In fact some insurance companies already offer patients with diabetes extended coverage for periodontal treatments.

While recognizing periodontal issues are critical to physician’s work, systemic risk factors that could be catalyzed by, or lead to oral disease need to be assessed by dental teams regularly. Gathering a basic health history and taking a blood pressure reading may not be enough. The American Academy of Periodontology(4) offers some insight into a more complex set of data points dental wellness teams need to assess in order to truly gauge their patient’s health and overall risk:

• Osteoporosis — Researchers have suggested that a link between osteoporosis and bone loss in the jaw. Studies suggest that osteoporosis may lead to tooth loss because the density of the bone that supports the teeth may be decreased, which means the teeth no longer have a solid foundation.
• Respiratory disease — Research has found that bacteria that grow in the oral cavity can be aspirated into the lungs to cause respiratory diseases such as pneumonia, especially in people with periodontal disease.
• Cancer — Researchers found that men with gum disease were 49% more likely to develop kidney cancer, 54% more likely to develop pancreatic cancer, and 30% more likely to develop blood cancers.
• Diabetes — People with diabetes are more likely to have periodontal disease than people without diabetes, probably because people with diabetes are more susceptible to contracting infections. In fact, periodontal disease is often considered a complication of diabetes. Those people who don't have their diabetes under control are especially at risk. Research has suggested that the relationship between diabetes and periodontal disease goes both ways - periodontal disease may make it more difficult for people who have diabetes to control their blood sugar. Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts people with diabetes at increased risk for diabetic complications
• Heart disease — Several studies have shown that periodontal disease is associated with heart disease. While a cause-and-effect relationship has not yet been proven, research has indicated that periodontal disease increases the risk of heart disease. Scientists believe that inflammation caused by periodontal disease may be responsible for the association. Periodontal disease can also exacerbate existing heart conditions. Patients at risk for infective endocarditis may require antibiotics prior to dental procedures. Your periodontist and cardiologist will be able to determine if your heart condition requires use of antibiotics prior to dental procedures.
• Stroke — Additional studies have pointed to a relationship between periodontal disease and stroke. In one study that looked at the causal relationship of oral infection as a risk factor for stroke, people diagnosed with acute cerebrovascular ischemia were found more likely to have an oral infection when compared to those in the control group.

While the list provided by the American Academy of Periodontology is exhaustive enough, the potential impact the health of the oral cavity has remains unknown. There have also been reports of connection between PD and colon cancer, complications with orthopedic implants,(5) and premature or stillbirth(6)(7).

• Preterm birth/stillborn birth — PD places pregnant women at greater risk for preterm birth than alcohol consumption or smoking. This underscores the importance of offering dental screening to women who are pregnant or contemplating pregnancy and the need for physicians who provide obstetric care to be aware of the possible connection between poor dental health and poor pregnancy outcomes.
• Colon cancer — An infection from a common type of mouth bacteria can contribute to colorectal cancer. The bacteria, called Fusobacterium nucleatum, can attach to colon cells and trigger a sequence of changes that can lead to colon cancer.
• Orthopedic implants — Joint prosthesis infections that originate from oral bacteria may lead to failure of the prosthesis, resulting in the need for additional surgery. Dental evaluations and clearance prior to replacement surgery may minimize the potential risk of infection due to bacteria originating from the mouth.

What is a sure thing is that doctors and dentists must combine efforts to treat the body as the interconnected and unified organism it is, instead of divided between mouth and body.

Connecting the body through risk assessment

There is a common methodology of practice between physicians and dentists that can make early intervention and treatment of oral-systemic issues successful: risk assessment. Both practices already use risk assessment, so a tool that speaks cross-discipline is a simple yet effective solution. With assessment of risk the providers can refer the patient to a specialist for further testing or treatment. Cooperative diagnosis requires both communities to be knowledgeable regarding the oral-systemic link and actively engaged with one another during the treatment process. Links2Success has developed a comprehensive Dental Wellness Risk Assessment Form to enable dental and medical professionals to carry out the task of risk assessment and referral. Each item can be assessed by the provider or self-reported by the patient. If medical risk is identified that could lead to or be affected by oral disease, the doctor can refer the patient to the appropriate dental team. If the dental team assesses risk, they can refer to the appropriate medical provider with documentation of assessment. While a shared risk assessment form is not the ultimate answer, it is a necessary first step.

For more information on cooperative risk assessment and diagnoses go to www.links2success.biz or call Christine Taxin at (914) 303-6464 Ext 704.

Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company Ms. Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York.  With over 25 years’ experience as a practice management professional she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for Maimonides Hospital.

References

1. http://www.perio.org/consumer/types-gum-disease.html
2. http://usatoday30.usatoday.com/news/health/2009-03-10-dental-skip_N.htm
3.  …researchers found that the prevalence of periodontal disease among obese young adults (aged 18–34 years) was 76 percent higher than that among normal weight young adults. (http://www.jada-plus.com/content/134/7/826.3.short?related-urls=yes&legid=jada;134/7/826-b)
4. http://www.perio.org/consumer/other-diseases
5. http://www.oralsystemicevaluationcenter.com/oral-systemic-connection.htm
6. http://www.perio.org/consumer/women.htm
7. http://www.hindawi.com/journals/jp/2010/293439/