Oral & Systemic Disease Research Archive

BELOW IS A PARTIAL LIST OF THE HUNDREDS OF PUBLISHED ARTICLES ON THE O/S CONNECTION

Live Oral Bacteria Found In Arterial Plaque University Florida News March 22 2005 Ann Progulske-Fox University of Florida College of Dentistry 

Periodontal Disease May Increase Risk of Stroke American Academy of Neurology 51st Annual Meeting Toronoto, Canada April 21 1999 Mithcell Elkind, MD, Columbia University, New York

Archived Article From Dentistry Today Magazine...Oral-Systemic Connection

Robert J. Schulhof , A.B, M.A. Math Statist.

The Oral Systemic Connection- the Facts, the Opportunities- Can your practice be in the Life Saving Business?

The Oral-Systemic Disease Connection is a revolutionary new opportunity for astute dental offices to change the character of their practices to a wellness model.  In this article the author presents an overview of the most recent research connecting periodontal disease with systemic diseases.  He also examines the paradigm shifts required in attitudes, diagnostics, in-office treatments, and home care for those dental practices that seek to effectively change the health of their patients.

A Major Turning Point For The Future of Dentistry

Most dental historians consider Donna Shalala’s Surgeon General’s report of May 2000 as the official kick off of the “Oral Systemic Connection”. 

“The terms oral health and general health should not be interpreted as separate entities. Oral health is integral to general health; this report provides important reminders that oral health means more than healthy teeth and that you cannot be healthy without oral health. Further, the report outlines existing safe and effective disease prevention measures that everyone can adopt to improve oral health and prevent disease.”

“Recently, research findings have pointed to possible associations between chronic oral infections and diabetes, heart and lung diseases, stroke, and low-birth-weight, premature births” (1)

Since that time an amazing amount of research has been forthcoming to improve our understanding of these “associations”, far too many to even list in an overview paper like this (footnote CDM’s website for listings). Of course the clinical practitioner is not so interested in statistical facts as much as guidance that will directly affect treatment decisions. The question of interest is “If I treat this patient’s periodontal disease, will it reduce their risk of systemic disease?”  After looking at the statistical research we now know that in the average practice the answer in hundreds of cases is a resounding “YES”.  

How Long Will This Take…and How Much Will It Cost?

This is question often asked of patients to their dentists or treatment coordinators regarding proposed treatment plans.  The same question should be ask of dentists and hygienists regarding the oral systemic disease connection.  It is time that we move beyond simple soft tissue disease management to a new higher standard of care.  How has the plethora of emerging research and statistical data affected the way you treat this serious health risk?  How many more lives of your patients will be needlessly at risk of secondary systemic disease infection as a result of periodontal infection and inferior decades-old treatment?

There is a tendency for many dental practitioners to want to evaluate new treatment methodology with their own primary research—observation analysis in their own practice.  Researching new effective treatments for periodontal disease and tracking the corresponding reductions in systemic diseases presents a problem--time.  For instance, the average adult has less than a 3% risk of having a heart attack in the next year.  A study to evaluate a specific treatment protocol would require a long-term study involving thousands of patients to determine a statistical advantage.   Even a study of pregnant women will require nine months to evaluate treatment effectiveness on the 10% incident rate of pre-term or low birth weight babies.  Your patients who are at risk do not have the luxury of waiting for addition research.

It has been 8.5 years since Donna Shalala’s statement on the importance of good oral health to total systemic health.  How has this research affected the way you practice dentistry?  Are you ready to take advantage of a new patient health-focused treatment program that can prolong life, prevent disease, and turn your hygiene department into a highly profitable wellness center?  The following information will help.

While there have been hundreds of articles written on Oral-Systemic Relationships, as a health scientist, I regard the following few as being landmarks worthy of special note: 

Pre-Term Birth

Periodontal disease has been shown to increase the risk of pre-term/ low-birth weight babies, and periodontal treatment has been shown to reduce the incidence of  PT/LBW.

·        In 2002 Periodontal Therapy May Reduce the Risk of Preterm Low Birth Weight in Women With Periodontal Disease: A randomized Controlled Trial.  Lopez showed a reduction in pre-term/low birth weight babies by 80% (from 10% untreated to 2% treated) by periodontal treatment prior to the second trimester of pregnancy. (2)

·        In 2005 Periodontal Therapy Reduces the Rate of Preterm Low Birth Weight in Women With Pregnancy-Associated Gingivitis , Lopez showed a 68% reduction of PT/LBW in this much more common group. (3)

Because of their younger age, true periodontal disease is much less common in pregnant women compared to pregnancy-associated gingivitis. However this latter article shows that good oral care is important for the majority of pregnant women.

Heart Disease

C Reactive Protein- This inflammation correlated risk factor for heart disease has been shown to increase with periodontal disease and to decrease with the treatment of periodontal disease.

·        In 2002  Comparison of C-Reactive Protein and Low-Density Lipoprotein Cholesterol Levels in the Prediction of First Cardiovascular Events, (4) Ridker showed in a study of 27,000 people that a substance produced by the liver in response to inflammation, C-Reactive Protein, is a better predictor of cardiac events than high Cholesterol.. This is significant for dentistry because:

·        In 2000 Elevation of systemic markers related to cardiovascular disease in peripheral blood of periodontitis patients. (5) Loos & Craandijk, showed that periodontal disease, being a chronic inflammation could significantly increase CRP, therefore increasing the risk of heart attack.

·        In 2004, Grossi at the University of Buffalo showed that treatment of periodontal patients with elevated CRP using Scaling & Root Planing along with topical antibiotics significantly reduced CRP, often to low risk levels. This research was later confirmed by DAiuto (6) and Iawamoto (7).

These results are of great practical importance because CRP can be tested in the dental office. We recommend testing before treatment helping the patient to evaluate their cardiac risk, and also after treatment to assess if risk has been measurably lowered due to periodontal treatment.

Endothelial Function/Vascular function- Rather than a risk factor like cholesterol or CRP, endothelial function is a direct measurement of the effectiveness of the circulatory system. This is now of great interest in dentistry because endothelial function can be measured directly in the dental office with a device called the EndoPAT2000 (Itamar Medical) (8) and treatment of periodontal disease has been shown to significantly improve endothelial function..

·        In 2007  Treatment of Periodontitis and Endothelial Function (9) Tonetti concluded, "This study showed that intensive treatment of periodontitis, a common potential source of low-grade inflammation, results in an improvement in endothelial function.. The endothelial function improvements at six months appeared to be in response to therapy. The improvements were significantly correlated with a reduction in the number of periodontal lesions (P=0.002) and with a reduction in gum bleeding scores (P=0.003). “The mechanism remains uncertain, they added, but may include direct effects from the gram-negative bacteria and their product invading periodontal tissue or indirectly acting as triggers for a systemic inflammatory response that harms the vascular walls.” 

Effect of Periodontal Treatment on Cost of Health Care

The real bottom line is also the financial “bottom line”. We have now arrived at the point where insurance companies see that treating periodontal disease is a medical necessity, and they are willing to pay for periodontal treatment.  Treating periodontal disease in cardiac patients, diabetics, and pregnant women can be a tremendous cost-saving measure for the insurance companies—it reduces their cost of major heart surgeries, long-term costs associated with diabetes treatment/dialysis, and post-natal intensive hospitalization costs. 

·        2006- Aetna And Columbia Announce Results From Study Showing Relationship Between Periodontal Treatment And A Reduction In The Overall Cost Of Care For Three Chronic Conditions – “The results of the study, which included approximately 145,000 Aetna members with continuous dental and medical coverage, indicate that periodontal care appears to have a positive effect on the cost of medical care, with earlier treatment resulting in lower medical costs for members with diabetes, coronary artery disease (CAD), and cerebrovascular disease (CVD) or stroke.”(10)

·        2006 – CIGNA Dental Turns Evidence into Action; Builds on Industry Leading Oral Health Integration Program to Launch New Initiatives for Diabetes and Cardiovascular Disease; Establishes Clinical Advisory Panel.  “Under the new programs, beginning July 1, 2006 CIGNA Dental members who are also enrolled in CIGNA HealthCare's disease management programs for diabetes and cardiac care may receive 100% reimbursement for out-of-pocket costs associated with periodontal scaling and root planing, and periodontal maintenance. The new initiatives expand upon the previously launched CIGNA Dental Oral Health Maternity Program(SM) (OHMP), which provides enhanced benefits during pregnancy for members with both CIGNA medical and dental coverage. The CIGNA Dental Oral Health Integration Programs are designed to help eliminate cost as a barrier to seeking appropriate treatment.” (11)    

Many Centers for Dental Medicine  practices are now routinely submitting charges for periodontal treatment to the patient’s health insurance, using the special Dental Writer insurance program and are actually being reimbursed!

Diabetes – It is well known that diabetics, because of their impaired immune systems, are twice as likely to get periodontal disease. the relationship also goes the other way- the periodontal bacteria make it more difficult to control blood sugar and increase the rate of diabetes. Additionally, it has been shown that periodontal disease greatly increases the complications of diabetes and increases  the mortality rate by a factor of 7 or more in the later years! The good news is that treating periodontal disease can significantly lower HbA1c- the definitive measure of blood sugar control.

·        2004 The Severity of Periodontal Disease is Associated with the Development of Glucose Intolerance in Non-diabetics: The Hisayama Study (12) “In the subgroup with normal glucose tolerance 10 years previously, subjects who subsequently developed impaired glucose tolerance were significantly more likely to have deep pockets. Deep pockets were closely related to current glucose tolerance status and the development of glucose intolerance.”

·        2005 Periodontal Disease Predicts Mortality in Diabetics- The results of a study published in the January issue of Diabetes Care suggest that periodontal disease is strongly predictive of mortality from ischemic heart disease and diabetic nephropathy in Pima Indians with type 2 diabetes. (13) “Those with severe periodontal disease had a 28.4 % death rate and those with no or little periodontal disease had a 3.7% death rate.”

·        2006- Periodontal Therapy May Help Diabetic Patients Improve Sugar Control- “Results of a new study support the hypothesis that periodontal therapy may improve metabolic control (lower HbA1c) in diabetic patients. The results suggest that periodontal therapy may reduce a diabetic patient’s HbA1c count by as much as 20 percent at three and six months following treatment. According to the American Diabetes Association, HbA1c provides patients with a picture of their average blood sugar changes in the past two to three months and gives them a good idea of how well their diabetes treatment plan is working. A healthy HbA1c count is between the ranges of 4.0 to 6.0. “We found that conventional treatment for chronic moderate generalized periodontitis, which included a simple, non-surgical procedure called Scaling and Root Planing (SRP) lowered the study group’s HbA1c count from 7.2 to 5.7,” (14)

The Oral Systemic Circle- What is cause? What is effect?

It would be wrong to oversimplify the cause-effect relationship between oral health and systemic health. Yes, it is true that periodontal disease can increase the rate of systemic disease, but it is also true that people tend to be generally either healthy or un-healthy and unhealthy people get more diabetes, heart disease, cancer … and periodontal disease.

·        2006- Obesity Is a Significant Predictor of Periodontal Disease. “The relationship between periodontal disease, obesity and insulin resistance was examined in the Third National Health and Nutrition Examination Survey (NHANES III). Researchers from University at Buffalo found that obesity is a significant predictor for periodontal disease, independent of age, gender, race, ethnicity, and smoking”. (15)

For this reason, after initial periodontal treatment it is important to counsel the patient on diet, exercise, smoking and other life style factors if treatment is going to be successful in the long term.

How many lives could you save?

The question isn’t of whether treating periodontal disease will save lives by reducing heart attacks and diabetes as well as other systemic diseases, but how many lives will be saved. . The average healthy patient has about a 10% chance of a heart attack in 10 years, depending on a number of risk factors.  Almost 30% of your adult patients will have some relationship to diabetes. 7% will have it and know it. 3% will have it and don’t know it, 20% are pre diabetic.

Here is an example of the impact that a dental practice might have as a Wellness Center If  the practice has 2000 active patients with an average age of 50 years and 50% have  bleeding and/or pockets>4mm ,then:

·        Prevent 20 heart attacks a year! About 25% of the patients with perio will have a CRP reading of 5 or greater. These people have 4 times the chance of a heart attack as healthy people. If you treat  these people and reduce their CRP to normal,  you will be saving about 20 heart attacks a year.

·        Save 40 people from becoming type 2 diabetes a year adding 8.2 years to their life expectancy. Of your 2000 patients 20%, or 400  have A1c scores between 6.0 and 6.9 meaning that if you didn’t intervene and stop their perio they would likely become diabetics in the next ten years. That’s 40 people that you could save from diabetes each year.

·        Discover 60 people who have diabetes now and don’t know it, adding years to their life. Yes 3%, that’s 60 of your existing patients have it now and don’t know it. Co management with their MD now can greatly increase their survival rate.

·        Save the lives of 4 type 2 diabetics a year. Odds are 200 of your patients have type 2 diabetes and 80% or 160 of those have periodontal disease. Treating their periodontal disease will stop about 2.5%, or  4 of those from dying each year, mainly from ischemic heart disease and kidney disease.

There are also some non-quantifiable life savings.

·        Discover Cancer through CRP testing– Cancer is an inflammatory disease and tends to raise CRP off the charts. Our offices have found people with very high CRP scores, referred them to their MD’s for assessment and find cancer that was undetected.  Early discovery of cancer will often be the difference for successful treatment or a terminal disease.

·        Discover Endothelial Dysfunction- We have all heard of people like newscaster Tim Russert who had their cholesterol under control with medication, checked out OK on their stress test and died suddenly of a heart attack. Every day people are subject to Atherosclerosis, Sudden Cardiac Death (2/3 Asymptomatic), Acute Coronary Syndrome, Plaque Rupture, Vasoconstriction, Reaction to Mental Triggers—and the thing that all these people had in common was endothelial dysfunction!  As a dentist with an EndoPAT 2000 you could be discovering patients who are in danger well before they need to see the cardiologist, and track their progress to health on your Wellness Program.

Making your practice into a Wellness Center

We routinely evaluate practice statistics from recall appointments, which show that while over 50% of the monthly recall patients have periodontal disease only about 10% are receiving treatment.  This is not considered a problem by patients who just feel that “my bleeding gums are normal”.  These patients would by highly motivated to accept care if they fully understood the risk to their health of that “little bit of bleeding.” Fully implementing periodontal treatment in the practice could more than double hygiene productivity and profitability by adding an additional $20,000 per month!

Additionally, by establishing an oral-systemic testing protocol in your practice as part of your “Wellness Assessment”, you would be discovering diabetics and pre-diabetics and people with impending heart attack risk weekly--actually making your practice the leading edge of preventative medicine in your area! Today, every dentist in town is the consummate “Cosmetic Dentist”. Why not be the leader in health in your area and build your own wellness center niche?

Finally you will discover the benefits of positioning your practice as a leader in the advanced treatments for periodontal disease.  Since periodontal disease and systemic disease are intimately related, it is vital to co-manage your periodontal patients with the other members of their health care team. This will create two- way referral relationships with other members of the medical profession and bring higher quality patients to your practice—patients that value their health and have been referred to you by their physician.

Like anything worthwhile there will be challenges including: management, diagnosis, treatment, and marketing.  We will deal with these issues in future articles.

Free Statistical Analysis of Your Practice

Centers for Dental Medicine, in conjunction with Florida Probe, offer a free statistical analysis of your hygiene program to determine your current treatment effectiveness, current hygiene production potential, and business model options.  For more information, phone 1-866-546-5444.

Bob Schulhof is  the CEO and founder of Diamond Age Systems and the Chief Scientist for Centers for Dental Medicine. , Bob received his Masters degree in Mathematical Statistics at UCLA. In 1964 and began his scientific career with Hughes Aircraft company and the Lunar Lander Program. He .began his career in dental research and management in 1969 and has contributed over 100 articles to the dental scientific and management literature.

Bob Schulhof  may be reached at bschulhof@qwest.net and at 866-546-5444 Ext.3.

For Information on becoming a Center for Dental Medicine phone the toll-free 1-866-546-5444-Ext. 1

     Robert J. Schulhof

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The Centers For Dental Medicine program offers a comprehensive program to help dental professionals implement  the newest and most advanced periodontal program.  The Centers for Dental Medicine program is the leader in educating and training dentists and their support staff regarding how to implement the latest new aspects regarding the Oral and Systemic Health Connection.  To date we have helped hundreds of dental professionals implement a higher standard of care in the treatment of oral infection. services.  

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