Dr. Damon Adams, Dentistry Today’s editor-in-chief, posed the following written questions to Drs. Neil Gottehrer, Jack L. Martin, and Daniel Casullo. All the authors met to collectively answer and compile their responses to each question.
There has been a great deal of attention paid by the consumer to reducing and/or controlling medical risk. How is this starting to affect dentists in the care of their patients?
There are an increasing number of consumers who have read about the possible risks associated with dental and periodontal disease. Information has suggested the possibility of serious potential medical risk for the patient who has periodontal disease. Consumers are beginning to become very concerned about this risk. Since the medical risk can often be reduced with timely identification and successful treatment of the dental disease, dentists are now making the periodontal exam a routine part of their initial patient examination. In response to all of the media attention to this risk connection, more dentists are insisting that their patients have a periodontal exam before any dental treatment begins.
Dentists are beginning to understand that patients are very appreciative of a dentist who is concerned about their overall physical health. The first question these dentists should ask of their patients is how concerned they are about their physical health. Since the most common response is “very concerned,” the dentist then asks if they are interested in finding out if their dental condition may pose a risk to their health. Because patients are concerned about this and interested in learning more about their present dental condition, dentists are finding it easier for their patients to accept periodontal treatment recommendations. Dentists who are not paying attention to this increased patient awareness may find it more difficult to get patients to accept treatment because patients want to be treated by dentists who are contemporary in their outlook and up-to-date on the latest information regarding dental/physical health.
In September 2010, the US Centers for Disease Control and Prevention, Division of Oral Health completed a National Health and Nutrition Examination Survey (NHANES), published in the Journal of Dental Research, which found gum disease to be a significant public health concern. NHANES has historically been the main source for determining the status of periodontal disease in the US adult population. Comprehensive periodontal exams were conducted on more than 450 adult patients over the age of 35 years. The prevalence rates were compared against previous NHANES studies, which only used a partial mouth periodontal exam. The previous studies had shown prevalence of gingivitis and periodontitis as high as 56% in adults. The present study found that the original methodology may have understated the disease prevalence by up to 50%! These figures could easily be interpreted to represent periodontal disease as the most common disease present in the body today and possibly even of epidemic proportions. With estimates of current care being as low as 5%, dentists must become more interested in addressing this problem and treating the disease.
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| Figure. Stat-Ck PRA documentation record used for periodontal risk assessment at initial visit. |
With increasing attention being paid to the association between cardiac disease/stroke and periodontal disease, how can dentists positively impact this known connection?
With the common pathway in the progression of these diseases being chronic inflammation, the dentist is becoming a disease management specialist. Reducing inflammation in the mouth can easily help manage disease.
The use of topical drugs and systemic drugs has been proven to successfully reduce the severity of the disease. Site-specific antibiotics have been documented to reduce and destroy bacteria by direct contact. Topically placed minocycline (Arestin), when placed in selected periodontal pockets, works well. Oral medication taken in low dosages (such as subantimicrobial dosage doxycycline in 20 mg tablets, taken twice a day orally) has been proven to suppress enzymes known to break down periodontal tissue, thus supporting alveolar bone and the promotion of healing in the periodontal pocket. This medication also suppresses marker enzymes identified to be active in cardiac disease, such as C-reactive protein (CRP). Therefore, it has been surmised that both diseases may be impacted just by actively treating periodontal disease. This can help with diabetes control and lipid metabolism and has been documented in clinical studies to improve endothelial function and to reduce the severity of atherosclerosis. Additionally, the dentist can identify patients who are at risk for cardiovascular disease (CVD), and encourage them to seek medical care for aggressive risk factor intervention as well as screening for early detection of already established (but unrecognized) CVD.
A major resource impacting this association is the periodontist. Too often the periodontist is considered “just a surgeon.” Periodontists should play an active role in team management of the patient, as they routinely benefit all parties involved. They are helpful to the family dentist/dental hygienist, assisting in confirming clinical diagnoses, implementing a more effective nonsurgical management program where needed, treatment planning the more difficult cases for permanent tooth replacement, and providing regenerative care when required.
Periodontists can also motivate a patient to take advantage of his/her dentist’s expertise. Too often, they are not asked to do this and are thus underutilized. A team approach, resulting in a healthier patient, is also advantageous to the physician and cardiologist. This increased attention can motivate physicians to become partners, especially when the dentist refers patients to them for cardiac risk assessment. After a few referrals, they often refer patients who need critical dental care because they realize that patients actually can benefit physically, especially if they are unable to do anything more for them.
By treating and then encouraging the maintenance of oral health, using the latest and most current home hygiene devices, including a power tooth brush and Water Pik (now referred to as the Water Flosser), which removes 99.9% of plaque from treated areas in seconds, the dentist can help reduce risk and impact of this connection by recommending regular twice a day use of these devices. The Water Pik Water Flosser removes harmful bacteria deep between the teeth and below the gingival margin, where traditional brushing and flossing can’t reach. By insisting that the patient use this optimal combination of pulsation and pressure to clean where traditional brushing and flossing are unable to reach, inflammation of the gums is reduced and health improved.
What recent research has been done to verify the oral-body-inflammatory connection with cardiac disease?
Numerous studies have demonstrated an association between oral disease and CVD. A recent meta-analysis has demonstrated that periodontal disease is an independent marker beyond traditional cardiovascular risk factors. A dental and periodontal status and risk for progression of carotid atherosclerosis was done in Vienna in 2006. It concluded that dental status, oral hygiene, and particularly tooth loss were associated with the degree of carotid stenosis and predicted future progression of the disease. It was also one of the first studies to show that edentulous patients had a significantly increased risk for disease progression as compared with patients with teeth. Extrapolating from these findings makes a strong case for replacing missing teeth with permanent dental implants.
As early as 2004, periodontitis was studied as a risk factor for ischemic stroke. Patients with periodontal disease had a 4.3 times higher risk of cerebral ischemia than subjects with little or no periodontitis. Gingivitis as well as bone loss was independently associated with the risk of cerebral ischemia.
A Swedish study completed in 2010 analyzed the number of teeth as a predictor of cardiovascular mortality in a group of 7,674 subjects, followed for 12 years. The study results presented, for the first time, a relationship between number of teeth and CVD. There was a sevenfold increased risk for mortality from cardiovascular heart disease in subjects with less than 10 teeth, compared to those with more than 25 teeth.
A more recent study in 2010 has discovered how bacteria in the mouth that results in tooth decay can also cause blood clots. It was hypothesized that poor dental hygiene can lead to bleeding gums, providing bacteria with an escape route into the blood stream, where they can initiate blood clots leading to heart disease. Streptococcus bacteria normally live in the oral biofilm, causing tooth decay and gum disease. When they enter the bloodstream through the bleeding gum, they produce a protein that binds together platelets from the blood in a clot, resulting in thrombosis.
Are physicians/cardiologists really aware of how dental care can reduce some of these serious risks?
In general, physicians and cardiologists are still not actively aware of how dental treatment can reduce this risk. It is, unfortunately, our job to make them aware. By referring patients to physicians or guest speaking to small groups of physicians, the dentist can make a small impact. But the truth is that all the media coverage has helped, mainly by making the physicians’ patients aware and then the patients mention it to them. It is interesting to note that, although early trials of antiobiotics in clinical dosages to treat CVD had failed, these trials were of short-term duration; trying to impact a chronic condition and focused on CVD as a potential direct infection rather than an exaggerated host response to an inflammatory stimulus. As a result, they often addressed the wrong pathogens.
Then, in 2004, a group of cardiologists in New York studied the clinical and biochemical results of the matrixmetalloproteinase (MMP) inhibition with a subantimicrobial 20 mg dosage of doxycycline (the same drug used in managing periodontal disease) to prevent acute coronary syndromes in a pilot trial. They described vulnerable plaque which demonstrated intense inflammation, secreted MMPs that degrade the fibrous cap over cholesterol plaque and ultimately lead to rupture. They used the same dosage as used in periodontal management, theorizing that it would reduce inflammation and possibly prevent coronary plaque rupture events. It reduced enzyme activity by 50%, and appeared to exert potentially beneficial effects on inflammation, promoting cardiac plaque stability. Based upon these results, physicians may be able to help improve a patient’s periodontal condition if they are prescribing subantimicrobial dosages of doxycycline.
We often ask physicians to do blood studies to evaluate the high sensitivity CRP levels as well as hemoglobin A1C prior to periodontal treatment. We want to determine if the periodontal disease has resulted in systemic changes affecting disease. They are also asked to retest after periodontal active treatment has been concluded to see if there has been an improvement. After a few patients’ results come back as improved, they become believers. It increases the physician/cardiologist awareness of how the dentist can possibly help in reducing serious risks, in those patients where these blood levels are routinely seen elevated.
It is also important for a patient to see in-office, third party verification of how dental care can reduce these serious risks. There are office patient education video programs, of short duration of one to 2 minutes, which illustrate the connections and provide third party verification of the serious need for dental/periodontal treatment. The best example of such a program, which is portable and can be viewed on a laptop computer, is the CAESY Educational Program produced by Patterson Dental. Patients who have viewed the oral body inflammatory connection video have commented that they wish they had this confirming information earlier in their dental care and request immediate periodontal management and go back to their physicians with the information.
Have any statement positions been made by the cardiologists regarding care from the dentist related to systemic disease?
The cardiologists in the American Journal of Cardiology, July 2009 edition, pages 59 to 68, have published a consensus, repeated in the Journal of Periodontology, July 2009 edition, pages 1,021 to 1,032, that says that periodontitis has a direct relation to atherosclerotic disease. No causal relation is determined, but there is indirect evidence of moderate association of periodontal disease to coronary heart disease. There was strong association with stroke and evidence accumulating for a potential cardiovascular protective benefit from periodontal therapy. This was a landmark paper and the first consensus of opinion between the 2 professions.
What research has been done to verify that periodontal treatment can impact/reduce cardiac risk?
There are still no studies which show direct reduction of clinical endpoints for CVD with periodontal treatment. Reduction of blood marker levels of high sensitivity CRP and hemoglobin A1C suggest that there can be an impact. Additional studies need to be done with double blinds to verify that periodontal treatment does have impact on cardiac risk.
Currently, are there any good screening tests for periodontal risk assessment that the physician can request?
The physician can request that the dentist perform the Stat-Ck Periodontal Risk Assessment (Figure). Developed in 2002, all teeth are examined with the periodontal probe circumferentially, with the patient’s status graded A to F. It replaces the Periodontal Screening and Recording as a screening test, with actual results recorded rather that a recommendation for further evaluation. Unlike the traditional 6-point probing, this format is easily understood by patients, allowing them a simple way of understanding their periodontal status. It explains the result, with suggestions for treatment for each category, as well as recommendations for removal of hopeless teeth and placement of immediate crowns for caries control (such as with the CEREC [Sirona] or E4D [D4D] in-office systems), placement of antibacterial crowns (such as Captek [Precious Chemicals Company] to help control bacterial accumulation, and immediate placement of dental implants (such as HG System [Hiossen]), where teeth must be removed and replaced the same day. In the future, probing may be replaced with ultrasound tests, which may be a more accurate assessment of pocket depth as well as clinical condition, and may be able to be done in the physician’s as well as the dentist’s office where an immediate assessment is required.
While there is no verified direct causal connection between periodontal disease and a heart attack/stroke, is there a connection between the causal mechanisms of these 2 conditions?
One can easily speculate that both conditions can be the result of an exaggerated host response to inflammatory stimuli. Clinical studies have shown for each disease that there is a strong connection with chronic inflammation, and coincidentally, both diseases have produced elevated levels of MMPs as well as CRP. Treatment of periodontal disease has reduced elevated levels of these markers which can lead one to suspect a connection, although unconfirmed, between both diseases. Many epidemiologic studies profiling heart attack/stroke patients show overwhelming levels of periodontal disease, a possible contributing etiologic factor. Periodontal disease, seen frequently in the cardiac patient, may one day be declared a contributing factor to cardiac disease, as is smoking and obesity nowadays.
What dental procedures, past or present, could be done to reduce the possible risk of cardiac disease?
Since CRP has been shown to be a risk predictor for CVD, periodontal treatment which reduces these levels is very beneficial. Immediately placed dental implants, after extractions in patients with end-stage periodontics suggest by studies done, that there is a significant decrease in CRP. The studies showed that dental implant placement does not change the lowered CRP level during a 12-month period. By reducing these protein levels and replacing missing teeth, dental implants can possibly now be considered a possible way of reducing the risk of cardiac disease.
Placement of antibacterial crowns in areas of high concentrations of bacteria could possibly reduce risk. The only material in this category now is Captek, which has been documented to reduce more than 70% of the bacteria present in a pocket surrounding this crown, without any formal periodontal treatment.
Reduction of inflammation by clinical instrumentation (traditional scaling and root planing) is still one of the best methods for reducing pocket depth and gaining reattachment of the gingival tissue to the tooth. It must be repeated every 3 months to maintain an optimally healthy mouth, but it is one of the best ways to reduce the possible risk of cardiac disease. This can now be done painlessly, using topically applied analgesics (such as Oraqix [DENTSPLY Pharmaceutical]).
Use of the new EMS Air-Flow with the Perio-Flow nozzle has been documented to completely remove the bacterial biofilm from below the gum, in a single visit, painlessly and equally efficient as scaling and root planing, in approximately half the time. If enzymes produced by these bacteria contribute to cardiac risk, then using this unit in initial nonsurgical treatment and on a regular basis quarterly can help to reduce this risk. Obviously, as discussed previously, use of a power toothbrush and a Water Flosser twice daily, which has likewise been documented to remove 99% of the subgingival bacteria, may help reduce risk for cardiac disease.
How can dentists stay up-to-date on current/new restorative procedures that will help improve dental health, while possibly reducing some of the serious medical risks that were discussed here? Why do you feel that this is so important to their practices and patients?
Dentists must dedicate a portion of their professional time to continuing education, as well as getting subscription to and the reading of contemporary journals which focus on product development relative to disease management. We must now consider ourselves “disease management specialists,” which describes what we are trained to do. By keeping up to date with product development, we will be able to improve our skills as “disease management specialists” and help our patients directly or indirectly to control disease which can threaten their health. Practices in the future will thrive and prosper, focusing on disease management. Patients, who cannot avoid hearing this “new” information on the oral body inflammatory connection, will seek out these contemporary management practices because they show that they care about their patients’ complete health and they know what’s going on in the latest developments in health.
How do you see the future of dental care in light of all this new information and technologies that are being developed? Is there a new symbiotic relationship developing between dentists and physicians in helping their patients maintain overall physical health?
The future of dental care will be maintaining physical health. The dentist will actively contribute to a patient’s health as a disease management specialist. Treatment will not be different, just more comprehensive. There will be systemic testing, use of new drugs, and use of newer materials as they are developed. Missing teeth will be replaced with dental implants, knowing the critical need for this now with all the new study data being published. Cardiac disease, increased with loss of teeth, may be reduced with permanent replacement with dental implants. Physicians will receive Stat-Ck Periodontal Risk Management Assessments that give them an review of their patients’ dental condition. This assessment will become a standard part of the dental office software management programs and maintained as part of the permanent patient record. The assessment should be repeated at every quarterly periodontal maintenance visit, with the results being forwarded to the family physician. The physician routinely receives reports of their patients’ condition from the specialist. Now that the dentist is the “disease management specialist,” the physician will expect and look forward to receiving these periodic updates. In fact, now many practices use a periodontal probe for isolated exams at every office visit. This further establishes for patients the importance of these evaluations and ongoing observation of their condition.
The physicians will need to work closely with experienced dentists who can assess risk, joining together in the management of disease. The ultimate reward will be healthier patients, motivated to maintain good periodontal/oral health for medical/physical benefits, as well as the dental/aesthetic benefit.
Dr. Gottehrer has been in practice in suburban Philadelphia, Pa for more than 30 years, focusing his practice on cosmetics, implant dentistry, and periodontics. He is a graduate of the University of Maryland Dental School, received his postgraduate periodontal training at the University of Pennsylvania, and is a board-certified periodontist. He teaches the senior elective course in periodontics at the University of Maryland Dental School. He has published and lectured internationally, and is currently the president of the Institute of Advanced Oral and Physical Health in Havertown, Pa. He is the recent recipient of the The William J. Geis Memorial Award from the American Dental Education Association-Gies Foundation. He can be reached at (610) 449-9500 or via e-mail at dr.neilg@verizon.net.
Disclosure: Dr. Gottehrer reports no conflicts of interest.
Dr. Martin graduated the Columbia University School of Medicine in 1975. His postgraduate training included resident in surgery, New York University Medical Center (New York, NY); Intern in medicine and resident in medicine, Mary Imogene Bassett Hospital (Cooperstown, NY); and Fellow in cardiology at the Hospital of the University of Pennsylvania (Philadelphia, Pa). He is board certified by the American Board of Cardiovascular Diseases and American Board of Internal Medicine, with subspecialties in cardiovascular diseases and interventional cardiology. He is an associate professor of clinical medicine at Thomas Jefferson University, in Philadelphia. He has been on the faculty at both University of Pennsylvania School of Medicine and Temple University School of Medicine. Previously, he served as chief of interventional cardiology for Main Line Health and chief of the division of cardiovascular diseases at Bryn Mawr Hospital (Bryn Mawr, Pa). He is presently the chief of cardiovascular disease at the Northeast Methodist Hospital in San Antonio, Texas. He can be reached via e-mail at martinj@mlhs.org.
Disclosure: Dr. Martin reports no conflicts of interest.
Dr. Casullo is in private practice in Center City, Philadelphia, Pa, as well as a clinical associate professor at the University of Pennsylvania School of Dental Medicine (Philadelphia). He earned his DMD from Tufts University School of Dental Medicine (Boston, Mass). He was awarded postdoctoral certificates in both periodontics and fixed prosthesis, and also served as director of the DMD general practice program and the general practice residency (GPR) program, at the University of Pennsylvania School of Dental Medicine. He served on the ADA Commission for Accreditation for GPR. He co-authored a widely used textbook, The Dental Specialties in General Practice, and contributed to numerous other textbooks. He can be reached at dpcasullo@hotmail.com.
Disclosure: Dr. Casullo reports no conflicts of interest.
