How to Get Patients to Understand the Oral-Systemic Link. Photo courtesy of reineg/stock.adobe.com.
The chances are that many of the patients who sat in your chair this week had some form of gum disease. Many of those patients might also have an increased risk for developing—or already have—a systemic condition. However, it is likely your patients do not know that a link exists between these health factors, and it is up to you to explain it to them.
Gum disease is prevalent among many of your adult patients. In the study, “Prevalence of Periodontitis in Adults in the United States: 2009 and 2010,”1 the Centers for Disease Control and Prevention (CDC) estimates that around 65 million people have periodontal disease. Moreover, the CDC estimates that 47% of adults over 30 years old have the condition, as well as 70% of adults over the age of 65.
For over 20 years, the US surgeon general has recognized the link between periodontal disease and other systemic conditions such as cardiovascular health, stroke, and diabetes, in addition to an increased risk for adverse pregnancy outcomes.
Further research has continued to link these serious health conditions. Per the American Dental Association (ADA) the association is clear, and the data suggest 2 possible explanations2:
- Chronic inflammation in the oral cavity could increase bloodstream inflammatory markers that affect the patient’s immune response or increase the patient’s burden of inflammation.
- The oral cavity collects pathogenic bacteria that infiltrate the bloodstream and affect other parts of the body or systemic pathologies.
Furthermore, the ADA says that gum disease and other systemic conditions share common factors that increase the risk for disease, such as having a poor diet or smoking.
However, to date, no research has provided evidence of a causal link between gum disease and other systemic health conditions. Moreover, the ADA advises, no evidence indicates that if a person receives gum disease treatment it will prevent the onset or progression of these associ-ated conditions.2
Richard Nagelberg, DDS, a speaker and writer and clinical consultant for OraPharma, Inc, thinks it is essential to talk about this link with patients. Patients should understand that in addition to maintaining good health such as through smoking cessation, exercising, and eating well, it is also critical to manage your oral health through excellent home care. Not only will it save their teeth, he says, but it could have a much more significant effect on their health beyond the oral cavity.
“Hopefully that encourages them to be more meticulous about their home care and professional care because in all candor, that’s all that needs to happen,” Dr Nagelberg says.
Lori Hall, CDA, LDH, director of hygiene at Heartland Dental, says dental practitioners know that oral and systemic diseases are linked, but many times the patients do not. Therefore, talking to patients about how the whole body is connected and how oral health diseases can affect their overall health is vital for patient education.
“Patients need to understand that the connection exists. Things usually show up in your oral health before they appear in your body. For example, many times, people who have inflammation in the oral cavity are prediabetic, and we are seeing that in the dental practice way ahead of them having a test for diabetes or understanding that they have a pre-disposing factor,” Hall says.
Reducing inflammation is a vital point to communicate to patients. The primary connection between oral health and systemic conditions such as stroke, heart disease, rheumatoid arthritis, and others is inflammation, Dr Nagelberg explains. Therefore, addressing the inflammation surrounding periodontal disease and reducing bleeding upon probing and pocket depth are essential for managing gum disease.
However, patients need to understand that treating gum disease also reduces the overall inflammation in the body. Further, patients should know that their approach to oral health home care affects inflammation levels in the mouth.
“That should empower patients, and Heaven willing, it will inspire them to do what they need to do in their home care,” Dr Nagelberg says.
Dr Nagelberg has been having such conversations with patients for years. He says the revelation often is eye-opening to the patient.
“They look at me like I have 2 heads,” he notes.
Hall had similar reactions during her conversations, especially earlier in her career.
“I always had patients say they did not think they needed any treatment. So I always felt bad about that,” she says.
Nevertheless, Dr Nagelberg and Hall continue to have the conversation. Dr Nagelberg believes that no one will have periodontal disease if patients have proper home care habits and come in for office visits as recommended by their dental professionals. Over his 40 years of practice, he believes the most important thing he does for patients is present them with home care instructions. He wants all of his patients to get the maxi-mum benefits of home care.
“If I haven’t done that, I have accomplished nothing,” he states.
“As hygienists, we want to make sure we’re educating our patients about periodontal disease and [that] patients under-stand how important it is to treat it,” notes Hall, in agreement.
Tools and Techniques That Might Help With the Conversation
Hall thinks using intraoral cameras and visuals are an excellent tool for educating patients about what is going on in their mouths. Seeing is believing, she says.
“When we are talking specifically about periodontal disease,” she explains, “it is amazing to show patients a scan of their mouth and how this can show gum infection and periodontal disease that is often associated with malocclusion. Then [they realize that] their mouth is a window to their overall health.”
Dr Nagelberg uses a variety of techniques when working with patients. He also employs an old saying when instructing the team at his suburban Philadelphia private practice: Information tells and stories sell.
However, he explains that the dental professional is not “selling” dentistry to patients but educating them through stories about the oral-systemic link. In other words, statistics do not mean as much to people until they see how those statistics affect them personally.
“Patients want to know ‘What does it mean [for] me?’” Dr Nagelberg says.
Part of the education process, he continues, is showing patients through x-rays and intraoral camera images what is going on in their mouth to get them emotionally invested. Then he talks about the loss of their jawbone, knowing that those words are effective.
“We say, ‘This is what has happened in your mouth. We need to intervene and stop this process,’” Dr Nagelberg says, adding that once the patient sees the images, they are more receptive to his message.
Dr Nagelberg’s team also personalizes the home care recommendations. For example, one patient needs a power toothbrush, whereas another might need a rinse. Some patients might need to add a water flosser. Whatever you recommend, Dr Nagelberg suggests showing patients how to use the devices.
"Don’t have them take it home to figure out,” he advises.
Dr Nagelberg’s team also is diligent about providing positive feedback if the patient’s oral health has improved on a return visit. The staff first acknowledge the patient’s hard work and congratulate them on improving their health. Then the team follows up by complimenting patients for reducing inflammation in their whole body, not only their mouth.
Further, free tools are available that can help make periodontal health education easier for dental professionals. The MyPerioHealth patient education app for periodontal disease is an interactive tool designed to help patients understand the stage and grade of periodontal disease. While in the hygiene chair, the patient loads the app on their phone and the hygienist gives them the information to fill in the prompts. Then the app determines the staging and grading, similar to how the hygienist would determine those on paper.
MyPerioHealth is free and non-promotional, and Dr Nagelberg believes it could facilitate patient understanding about what is happening in their mouth and lead to improved case acceptance.
“This is the first time the patient is participating in the process,” he says of the app. “Up until now, patients have been passive. This app changes the model because the patient is part of the disease-discovering process.”
Hall would like more hygienists to talk about patients’ medical history and the connection between oral health and overall health. Heartland has a robust education process for hygienists that helps them develop these skills.
In their onboarding process, Heartland educates hygienists on the oral-systemic link and shares best practices on how to effectively communicate the information to the patient.
In addition, Hall says Heartland has quarterly “hygiene dinners” during which people talk about these topics and share different approaches on what works for them or what tools they use. Getting different perspectives can help dental profession-als break old habits or gain new ideas to add to their care process.
"We call them connect-to-collaborate meetings,” Hall says. “It’s really about sharing best practices and verbiage because that’s how we all learn.”
How to Improve Conversation Outcomes
Patient experience is an essential part of any dental practice. That includes how the team handles this oral-systemic conversation. Consistency and continuous improvement are key, Dr Nagelberg and Hall agree.
Dr Nagelberg recommends having team meetings to ensure everyone approaches the oral health and systemic health connection the same way. He also recommends going over the words to use with patients so that the team presents a consistent message.
For example, he suggests that when the hygienist brings in the doctor for the exam, they say, “[Patient name] has a diagnosis of periodontal disease.” Then the dentist and hygienist instruct the patient together on the patient’s ideal home care regimen.
“The patient then sees that every-one in the dental practice is on the same page,” Dr Nagelberg says.
Framing the conversation in terms of the patient is also essential. Dr Nagelberg cautions against diving too deep into the science of the connection because most patients will lose interest or tune out. Instead, focus on the effects of the disease, such as loss of teeth and bone and increased inflammation in the body, to appeal to the patient emotionally. Then give clear instructions on what the patient can do at home to reduce the potential for a systemic effect.
Research on this topic is ever evolving. To stay on top of it, Dr Nagelberg recommends having someone on the clinical staff study the latest research.
At a team meeting, that person can then explain it to the whole team. That way, everyone who interacts with patients has the most up-to-date information regarding the oral-systemic associations in their oral exams and patient interactions.
Dr Nagelberg also advises paying close attention to the family history on the intake forms, particularly any reports of family members with dentures, diabetes, Alzheimer disease, or a history of heart attacks. Patients with a family history of these conditions are at a higher risk for them, and they need to understand that. Moreover, Dr Nagelberg says this family history should drive the patients’ home care recommendations.
“Make the connection for patients between knocking down the bacteria so [their] mouth is healthier and [lowering] the level of inflammation in their body,” he says.
Hall points out that in addition to staying abreast of the most recent data on the oral-systemic connection, hygienists and other dental professionals should feel comfortable having this conversation with patients.
As health care providers with expertise in oral health, talking to patients about their gum disease, its connections to another condition, and what it says about inflammation in the body is part of the job and a crucial duty for their role in the practice.
“I’m not afraid to tell people about periodontal disease because I need them to understand how important this is to take care of and how it can affect their body,” Hall says.
Additionally, Hall thinks a renewed effort to have a dialogue with their patients’ medical professionals on this topic is essential.
As mutual health care providers, dental professionals should also share their information with the patients’ medical team. She also would like to see more communication between medical and dental insurance providers. Both collaborations would have excellent benefits to patients.
“We have an obligation to start partnering or establishing a partnership with medical doctors,” Hall says. “Sometimes patients come to the dentist and have not seen their medical doctor for years and vice versa. So to continue to connect the systemic link, we also, as professionals, must connect. That is super important.”
However, Dr Nagelberg believes that communicating about this area starts with the patient. This open communication emphasizes what the patient can do to prevent increased risk for gum disease and its associations with other systemic conditions.
“Everybody understands that smoking is bad for you. Everybody also knows that a high-fat diet and sedentary lifestyle are bad for their health and can impact their general health. But few people understand that another contributor to total body health is the mouth,” Dr Nagelberg explains. “So if we could impart this information to patients, it is going to be eye-opening for a lot of them. But it also facilitates the understanding that what they are doing for home and professional care can have much more impact, especially beyond the oral cavity.”
Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914 -920. doi:10.1177/00220345124573732.
Oral-systemic health. American Dental Associ-ation. September 23, 2019. Accessed January 3, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/oral-systemic-health