Patti DiGangi, RDH, BS, believes dentistry is no longer just about fixing teeth. Dentistry is oral medÂicine. Her work helps dental professionals embrace the opportunities and understand the metrics that accurate insurance coding provides. The ADA recognized her expertise by inviting her to write a chapter in its CDT 2017 Companion book and again for its CDT 2018 Companion. She is the author of the DentalCodeology series of easy-to-read, bite-size books. Her latest book, "Teledentistry: Pathway to Pathology" was co-written with Cindy Purdy, RDH, BS. She can be reached at firstname.lastname@example.org.
THE SET-UP “As the evidence mounts in the area of oral-systemic links, the dental profession will need to become more involved in sorting out the relevant clinical information and determine what is appropriate for dental practice. In this article, Patti DiGangi explores an interesting theory.” -Dr. Peter Cabrera, Team Lead
“As the evidence mounts in the area of oral-systemic links, the dental profession will need to become more involved in sorting out the relevant clinical information and determine what is appropriate for dental practice. In this article, Patti DiGangi explores an interesting theory.” -Dr. Peter Cabrera, Team Lead
The first decade of this century gave the dental profession a massive amount of research, articles and continuing education programs about the oral-systemic link. Yet has this knowledge changed the way most dentists practice day-to-day? The changes have been slow, but the good news is all it takes is a few simple steps for dental professionals to immediately incorporate up-to-date oral-systemic information into their practices.
What the research shows
In July 2009, the American Journal of Cardiology and the Journal of Periodontology simultaneously published an Editor’s Consensus Paper on Periodontitis and Atherosclerotic Cardiovascular Disease (available at perio.org)1. This consensus paper clearly shows the evidence supporting inflammation as the oral-systemic connection. This document not only provides health professionals with a better understanding of the links between CVD and periodontitis, it also assists in reducing the risk factors. There are numerous non-oral risk factors strongly associated with an increased risk for periodontitis as well as disease severity, such as being overweight/obese. This non-oral risk factor is recognized as a major problem in the United States for both adults and children.
The role obesity plays
Is obesity an oral bacteria disease? This fascinating question was the basis of research The Forsyth Institute published in the June 2009 Journal of Dental Research.2 Dr. J. Max Goodson, senior author of the study, said, “There has been a world-wide explosion of obesity, with many contributing factors. However, the inflammatory nature of the disease is also recognized. This led me to question potential unknown contributing causes of obesity. Could it be an epidemic involving an infectious agent?”
This study demonstrates that the salivary bacterial composition of overweight women differs from non-overweight women. The data suggests that the bacterial species could serve as a biologic indicator of developing an overweight condition. These results will lead to future research on whether oral bacteria may participate in the pathology that leads to obesity.
Previous studies show how fat adds to the overall inflammatory burden and is an important risk factor to consider.1,6,7 Metabolic syndrome is a group of risk factors that occur together and increases the risk for coronary artery disease, stroke, type 2 diabetes and other diseases related to plaque buildup in artery walls. Risk factors include being overweight/obese, lack of physical activity and genetics. Metabolic syndrome affects more than 50 million Americans.5
Recognizing metabolic syndrome
There are five conditions that signal a patient may have metabolic syndrome. Patients can develop any one risk factor by itself, but they tend to occur together. Patients who demonstrate at least three of these risk factors should be diagnosed with metabolic syndrome.
It’s important to note that drug therapy is an alternate indicator for four of the five criteria. When you review a patient’s medication history, look for medications developed to manage high triglycerides, reduced HDL cholesterol, high blood pressure and elevated glucose levels. This is key to recognizing metabolic syndrome. Waist circumference and body mass index (BMI) also are important criteria. At the clinical level, individual patients with metabolic syndrome should be recognized so their multiple risk factors can be addressed and reduced.
Think about the many patients in your practice who qualify as high risk for metabolic syndrome, heart disease, type 2 diabetes and periodontal disease. Each one of these risk factors may become a volatile multi-directional component in the inflammatory cascade.
The importance of vital signs
On the medical side, taking a patient’s vital signs is taught as the bread and butter of patient assessment, and is something typically done at the beginning of every appointment. In addition to blood pressure, temperature, respiratory rate, and pulse, routine weight measurements are fundamental. Such measurements may indicate the person is overweight, underweight, or is retaining fluids (edema). Assessments for diet management and medication dosages are calculated based on these data.
Dentists and dental hygienists are taught and required to take vital signs, yet this important step is sometimes skipped or only completed for particular situations. Healthcare is moving into a time that goes beyond just taking vital signs to more individualized assessments. Moving forward, dental professionals must first take a step back to our basic education. Taking a brief moment to evaluate health/medication histories and record basic vital signs at every appointment can make a significant impact on our patients’ total health and well being.
The time is now
Each practice and practitioner is different. For some reading this article, the obesity link might be a new concept, and the thought of bringing a scale and tape measure into the dental practice might seem a bit unconventional. Before that step is taken, further research and study might be necessary. For others, adding waist circumference and weight measurements might be something they can see happening in their dental practice in the future. Wherever you are, now is the time to take steps to change clinical practice and incorporate up-to-date knowledge of the oral-systemic link.
1. Friedewald VE, Kornman KS, Beck JD, Genco R, Goldfine A, Libby P, Offenbacher S, Ridker PM, Van Dyke TE, Roberts WC; American Journal of Cardiology. “The American Journal of Cardiology and Journal of Periodontology editors’ consensus: periodontitis and atherosclerotic cardiovascular disease.” J Periodontal. 2009 Jul;80(7):1021-32. 2. Goodson, J.M., Groppo, D., Halem, S., Carpino, E. “Is Obesity an Oral Bacterial Disease?” Journal of Dental Research, Online July 8, 2009 88: 519-523. Retrieved 10/19/09 3. Is Obesity An Oral Bacterial Disease? ScienceDaily July 9, 2009. Retrieved 12/30/09 4. Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, Fruchart JC, James WP, Loria CM, Smith SC Jr; “Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.” Circulation. 2009 Oct 20;120(16):1640-5. Epub 2009 Oct 5. 5. Grundy, S., Cleeman, J., Daniels, S., Donato, K., Eckel, R., Franklin, B., Gordon, D., Krauss, R., Savage, P., Smith, S., Spertus, J. and Costa, F. “Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement: Executive Summary” Circulation, Oct 2005; 112: e285 - e290 6. Cell Press (2009, April 13). Fat-derived Inflammatory Factor May Explain Diseases That Come With Obesity. ScienceDaily. Retrieved 12/29/09 7. Mazurek, T, Zhang, L., Zalewski, A., Mannion, J., Diehl, J., Arafat, H., Sarov-Blat, l., O’Brien, s., Keiper, E., Johnson, A., Martin, J., Goldstein, B., and Shi, Y. ‘Human Epicardial Adipose Tissue Is a Source of Inflammatory Mediators.’ Circulation 108: 2460-2466; published online before print as doi:10.1161/01.CIR.0000099542.57313.C5 Retrieved 12/29/09 8. “How Obesity Policies are Failing in America” July 2009 Trust for America’s Health. www.healthyamericans.org Retrieved 12/31/09