A new level of care

March 21, 2012

There are an overwhelming number of studies showing that your oral health is related to your body’s overall health. If your mouth isn’t healthy, you may be twice as likely to die from a heart attack, three times as likely to die from a stroke and even four to seven times more likely to die if you have diabetes. Additionally, you may be 63% more likely to develop pancreatic cancer, one of the deadliest forms of cancer. Clearly oral health (or lack thereof) has life and death consequences.

There are an overwhelming number of studies showing that your oral health is related to your body’s overall health. If your mouth isn’t healthy, you may be twice as likely to die from a heart attack, three times as likely to die from a stroke and even four to seven times more likely to die if you have diabetes. Additionally, you may be 63% more likely to develop pancreatic cancer, one of the deadliest forms of cancer. Clearly oral health (or lack thereof) has life and death consequences.

I could go on, however, knowing all of this you would think dentists and physicians would want to work closely with one another for the best chances of keeping our patients alive. Now is that actually happening for most of you out there in the real world? Probably not. But here’s some good news. The times are drastically changing for the better with the addition of new medical tests performed in the dental offices and used to communicate with the physicians in a language they understand. 

C-Reactive Protein Test

From a few drops of blood obtained from a finger nick, a quantitative hs-CRP determination, with clinical accuracy, can be obtained. These test results can help determine a patient’s risk for a number of adverse health conditions related to periodontal disease.These medical tests help bridge the gap between the two professions.

The long-held and outdated perception of dentistry is finally climbing out of the hole where we have been considered second-class doctors. We are now leading the charge of the oral-systemic connection, and that is putting our profession in a very important position to enhance everything physicians are trying to accomplish for their patients.

Physicians cannot give a person a “clean bill of health”-nor can people even consider themselves healthy-if their mouths aren’t healthy. Physicians will have to, and hopefully will want to, listen to the information we present. To ignore us could be malpractice. It is time for dentists to make the first step toward working closely together with physicians, and in-office medical tests can help us do exactly that. The following simple screening tests are available now and many pioneering.

C-reactive protein

Many researchers and clinicians think inflammation is more harmful to the cardiovascular system than established risk factors such as high LDL cholesterol. The link between inflammation and heart disease helps explain why almost half of all people who develop heart disease do not have any of the well-known risk factors for the disease, other than high levels of inflammation. C-reactive protein (CRP) is a protein made by our immune system, and a test for it serves as a barometer of our body’s overall level of inflammation. Parade Magazine medical editor Dr. Mark Liponis called CRP the best “crystal ball” of health ever devised in a single blood test. Elevated levels have been shown to precede and predict heart attack, stroke, colon cancer, diabetes, high blood pressure, Alzheimer’s disease, aneurysms, sudden cardiac death, abnormal heart rhythms like atrial fibrillation and even macular degeneration, a leading cause of blindness.

With periodontal disease being the most common inflammatory process of the body, it makes sense to test patients for CRP, identify its level and work to reduce the inflammatory contribution of gum disease in the cascade of processes that put our health at risk.

This test, available from Healthy Heart Dentistry (healthyheartdentistry.com), requires a couple drops of blood dabbed on a card that is sealed and mailed to the lab. The level of measured CRP remains fairly stable over days to weeks. Make sure you are using a high-sensitivity C-reactive protein test that detects even the lowest levels of inflammation. The ideal range for CRP is less than 0.7 mg/dl. Moderate risk is between 1.0 and 3.0 mg/dl and high risk is 3.0 mg/dl and up.

Studies have shown improving periodontal disease can reduce CRP levels. By performing this simple test you can now communicate with the patient’s physician whenever you diagnose periodontal disease and testing shows an increased risk CRP level. The physician will appreciate the opportunity to follow up with the patient and knowing the patient is undergoing periodontal therapy to get the source of infection and inflammation under control.

 

Blood sugar/Hemoglobin A1c (HbA1c)

Crises, what crises? Well, maybe you noticed there is a diabetic crisis in our country right now as 23 million Americans have diabetes and 6 million don’t even know it. Another 60 million may have pre-diabetes. Periodontal disease triggers blood sugar instability by impairing the ability of insulin to maintain normal levels of blood sugar. This can cause someone to become diabetic or make a diabetic’s current condition worse. A complication of helping to control diabetes by clearing up periodontal disease is that diabetes itself is a major cause of periodontal disease. People with diabetes are twice as likely as people without it to have periodontal disease.

With periodontal disease and diabetes reinforcing each other and creating a cycle of illness, screening for diabetes in the dental office makes sense. Patients with HbA1c’s of 8% or higher should be informed they need to see their physician. Both clinicians should work together to bring that level down (7% or less is the goal). The physician may require a specific meal plan, more physical activity, as well as prescription diabetes medicines. The dentist should work diligently to reduce the oral infection with a thorough periodontal care program.

The test, also available from Healthy Heart Dentistry, requires the same protocol as the C-reactive protein screening, and gives you a picture of the patient’s glucose control over the last three months. For non-diabetics, the usual reading is 3.5-5.5%, and diabetic patients want to keep their HbA1c levels at 7% or lower to have a better chance of preventing or delaying diabetic-related problems with the eyes, kidneys and nerves.

Saliva pH

Salivary acidity should be a great concern of all dentists. Not only can acidic saliva cause tooth erosion and decay, it also gives an indication that the overall pH balance of your body is not right. Most all of the serious degenerative diseases like cancer, heart disease, arthritis, osteoporosis and others are connected to excess acidity in the body. An ideal saliva pH is around 7.4, and a saliva pH of 6.4 is 10 times more acidic.

This simple and safe test, that is available from a number of sources including Micro Essential Laboratory (microessentiallab.com), requires putting clean saliva on pH paper and comparing the resultant color to the accompanying chart. Usually acidic pH is a nutritional issue, and to increase it a patient needs to consume more alkaline foods such as fruits, vegetables and whole grains, while steering clear of the acidic foods that are so commonplace in the American diet like fried foods, coffee, soda, alcohol, sugar and processed flour.

Periodontal pathogens

There are many types of bacteria that are involved in periodontal disease, and a few of them are much worse than the others. Some specific pathogens cannot be effectively removed with scaling and root planing. They may require antimicrobials and systemic antibiotics to gain control. We now can perform a biofilm assessment with a periodontal pathogen test that allows us to determine the amount of bacteria, the types of bacteria and if therapy has made a difference in their presence.

These are, once again, simple tests either requiring placing paper points in crevicular fluid such as with the micro-IDENT® Plus from Hain Diagnostics (hain-diagnostics.com) or collecting a 30-second saliva rinse sample such as the MyPerioPath® exam from OralDNA Labs (oraldna.com). When you know the bacteria present, you then have justification for customized treatment instead of automatically placing your patients on the same antibiotic regimen time and time again. Appropriate home care systems also can be recommended.

Genetic periodontal risk

What if you are genetically predisposed to be more susceptible to developing periodontal disease? Well it certainly isn’t fair, but it could be a reality for your patients. One-third of the population has the positive gene Interleukin-1 (IL-1), which is a major player in the expression of inflammation and bone destruction. These people show an increased bleeding-on-probing prevalence, and studies indicate they have a genetically determined hyper-inflammatory response that is expressed in the clinical response of the periodontal tissues.

When all of the studies are looked at together, it becomes clear that IL-1 promotes the destruction of the periodontium. The resultant inflammation is a primary contributor to atherosclerosis, diabetes, pregnancy complications and many more illnesses.

The My PerioID® PST® test from OralDNA requires a 30 second saliva rinse sample. Once the genetic periodontal risk is identified, there is no need to retake this particular test ever again because your genetic risk has been established. These patients have a 3-7 times greater risk for severe periodontal disease and may require more aggressive periodontal treatment.

 

HPV oral cancer risk

The human papilloma virus (HPV) infection has been established as an important risk factor for oropharyngeal cancers. Alcohol and tobacco had previously been considered the biggest risk factors for oral, head and neck cancers. Now it appears that there will be more HPV-related cancers in the next 10 years due in large part to changes in sexual behaviors. This is cause for alarm in the medical world and should be all the more important in the dental community, especially because we now have the opportunity to screen for this virus with a simple saliva gargle and swish test.

Patients who are HPV+ need to be identified as early as possible in their lives to increase their chances of survival. They should be tested regularly for any sign of oral and pharyngeal lesions. You will want to include a referral to the ENT for a laryngoscope exam of the entire oral pharyngeal tract to identify any lesions (as soon as possible) that may require biopsy.

Earlier this year, OralDNA introduced a new OraRisk® HPV risk assessment that tests for 77 known HPV viruses. Some are high risk and some are low risk. The test report breaks it down and makes recommendations for followup exams. Dentists can be the first practitioners in the medical world to screen for oral HPV.

HIV screening test

This may seem like the biggest stretch for dentists, yet HIV infections can show their first signs in the mouth. If we are screening for HPV, it makes perfect sense to also test for HIV, especially because it may take up to 10 years before the HIV virus progresses to AIDS. Once again, the dentist is in a position to potentially save and extend lives.

The OraQuick ADVANCE® Rapid HIV-1/2 Antibody Test from OraSure Technologies (orasure.com) can be done completely inside the office. All the test requires is oral swabbing under the lips, and the results are produced in just 20 minutes. A positive result is not a confirmed diagnosis, but it is a strong reason to refer the patient to a primary care physician for a test of confirmation. I’m quite certain many dentists will avoid this test because of the remote chance of having to give someone bad news, but try looking at it this way: The sooner the HIV virus is detected, the greater the chance of survival. Because of early detection and miraculous medical advances, HIV+ people are leading longer and more comfortable lives these days.

Leading our profession

The days of dentistry being a distant cousin to medicine are thankfully falling by the wayside. Conversations between dentist and physician are now more common, and lab reports from the tests I’ve mentioned are helping dentists speak to physicians in the language they understand. As we move forward with medical testing in our offices, we bring a whole new level of health awareness to our patients. Additionally, our improving communications and partnerships with physicians raise the bar of health benefits for our patients even higher.