The emerging body of knowledge within oral-systemic science and the changing nature of the healthcare environment are having a dramatic impact on the practice of dentistry. In the coming years (or even months) dental professionals will be required to play a larger role in collaborative healthcare management teams, as community practice continues its transition to an inter-professional care model.
Current estimates indicate that 75% of the North American population has some form of periodontal disease with approximately 15% demonstrating severe disease. These untreated oral infections have systemic effects.
The microorganisms and their associated endotoxins generate a localized host-mediated tissue destructive immune response that spills over into the circulation in the form of bacteremia and endotoxemia. This creates a “systemic exposure” and significantly increases the level of whole body inflammation. Years of elevated systemic inflammation have destructive effects on target tissues and organ systems throughout the body.
Recent data indicates that gingivitis may be as damaging as periodontitis with regard to elevating the systemic inflammatory burden and that these changes are reversible with periodontal treatment.
Inflammatory Driven Diseases & Conditions
The emerging base of evidence supports interrelationships between periodontal disease and adverse pregnancy outcomes. There is also a base of evidence of inflammatory driven disease states & conditions such as diabetes, atherosclerosis-induced diseases (cardiovascular and stroke), rheumatoid arthritis, renal disease, dementia, and respiratory disease.
Within this context, it is imperative that the dental profession be prepared to advocate strongly for preventive oral health throughout the lifespan, especially in children and older adults.Considering the various aspects of the “periodontal-systemic connection” that have been linked to development and/or exacerbation of systemic diseases, maintaining optimal periodontal health may do more to reduce healthcare expenditures throughout the lifespan than any other public health measure.
Cardiovascular disease and diabetes represent two of the most common chronic inflammatory diseases that could be significantly influenced by more aggressive oral care. For example, with regard to cardiovascular disease, the role of infection and inflammation in the initiation and progression of atherosclerosis is widely accepted. Systemic inflammatory markers are elevated years prior to the first myocardial infarction, highly predictive of recurrent infarctions, and up to 50% of individuals with cardiovascular disease do not have any traditional risk factors.
Within the context of all the factors that contribute to elevated systemic inflammatory burden, periodontitis represents a preventable, treatable, and modifiable risk factor.
With regard to diabetes, inflammatory process may play a greater role in the long-term progression of type I than in its onset. Additionally, increases in inflammatory markers are detected in healthy individuals who later develop type II, suggesting that inflammation precedes impaired glucose tolerance and insulin resistance.
Periodontitis has been linked to elevations of diabetic markers (serum glucose and glycated hemoglobin) and treatment of periodontitis has been shown to reduce these markers. In recent population-based studies, periodontitis has also been linked to pre-diabetes and insulin resistance raising the possibility that periodontitis may actually cause diabetes in otherwise healthy individuals. Again, periodontal disease represents a preventable, treatable, modifiable risk factor for elevated systemic inflammation.
An Inter-Professional Care Model
There is now enough evidence, from enough different perspectives, to support a “periodontal-systemic relationship” and to base patient management approaches on paradigms that include comprehensive inter-professional care.
In the future, comprehensive care models will most likely involve dental and medical professionals working together with other health professionals to assess and manage periodontitis and systemic disease. Thus, it is the responsibility of all health professionals to reduce oral infection and effective health policy must focus on reduction of risk factors for systemic inflammation. Even modest changes in risk can produce significant changes in disease burden.
The dental team can actively participate in redefining the approach to patient care, where inter-professional interactions emphasize linked health problems that interact synergistically to cause excess burden of disease. The epidemic of obesity, diabetes, cardiovascular disease, metabolic syndrome, and periodontal disease must be viewed with regard to the risk factors that bind them together. Chronic inflammatory diseases & conditions represent an interrelated cluster of maladies linked through systemic inflammatory burden. This mandates the inclusion of oral health and oral care in public health approaches to overall risk reduction for systemic inflammation.
These prevention approaches must target aggressive health promotion and risk reduction strategies in childhood, adolescence, and adulthood. This includes multidirectional screening and referral for undetected diabetes, cardiovascular disease, and periodontal disease. Educational, research, and case management teams should consist of the dentist & dental hygienist, physician, nurse, nutritionist, and pharmacist at a minimum. These inter-professional teams should emphasize:
- Comprehensive patient education and management
- Multidirectional screening & referral
- Collaborative reinforcement of health & wellness messages
- Public education forums & screenings for systemic conditions & periodontal disease
- Communication & awareness strategies for professionals, government, and news media.
All dental professionals should be aware of the “periodontal-systemic connection.”
They should also stress the importance of regular periodontal maintenance to their patients, as well as other health professionals. Optimum management of patients within the “periodontal area” of a dental practice is critically important, not only for the success and longevity of any restorative procedures that may follow, but also for overall health and wellness.
It is likely that preventive oral health will pay huge dividends as the population ages with regard to reducing potential systemic complications, especially those associated with chronic inflammatory diseases & conditions.
Want to learn more? Consider attending our course, "The Total Wellness Dental Practice."