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Ever-strengthening evidence linking oral and systemic diseases is providing today’s dental hygienists with the capability of doing more than simply cleaning teeth. The dental community must leave behind the limited image of the dentist as the senior member of the oral hygiene “police,” with the hygienists the loyal foot soldiers in the war against plaque. Instead, it is time to embrace the concept of the dentist and dental hygienist as important members of the healthcare team who are needed to help patients achieve better oral and overall health.
Chronic diseases, including cardiovascular disease, stroke, diabetes, and certain cancers, are responsible for seven out of every 10 deaths in the United States and account for the vast majority of health spending.1 Cardiovascular disease and stroke, diabetes, and cancer are among the leading causes of death in the United States.2 There is general agreement in medicine that a persistently elevated level of systemic inflammation is likely to be involved in the development and progression of multiple chronic diseases. There is also growing evidence that the mouth contributes to the systemic burden of inflammation when chronic inflammatory periodontal disease (CIPD), also called adult periodontitis, persists. The hematogenous dissemination of bacterial, bacterial by-products, and the inflammatory mediators released in the local inflammatory reaction to pathologic biofilm accumulation on tooth surfaces can participate in the pathogenesis of chronic diseases.3 CIPD is linked with cardiovascular disease, stroke, diabetes, certain cancers, and other diseases.4
CIPD begins when an accumulation of bacterial biofilm on tooth and soft-tissue surfaces initiates many host immunoinflammatory processes involved in bacterial clearance. This host-mediated inflammatory response also results in clinically significant connective tissue and bone destruction.5 Bacterial accumulations on the teeth are essential to the initiation and progression of periodontitis. Adequate patient and professional control of toothborne biofilms can reduce the destruction of periodontal tissues and lessen the systemic inflammatory burden.6,7
Thus, regular screening for evidence of periodontal inflammation and then treatment intended to result in the most rapid resolution of local inflammation has long been the focus of the typical dental maintenance visit. The goal has been to keep CIPD at bay and prolong the functional life of teeth. However, the link between oral and systemic inflammation means that adequate periodontal attention over the lifespan of a patient can potentially pay dividends to that patient’s oral and overall health. Today’s dental hygienist can play a significant role in helping patients manage their overall health. To do so, hygienists must alter their approach and their message to patients.
Risk Management
Inflammatory-based systemic diseases and CIPD can be adversely affected by environmental, genetic, and acquired risk factors. World Health Organization first proposed what is termed the Common Risk Factor Approach (CRFA) in an attempt to integrate oral health into a broader health promotion. The CRFA was based on the understanding that CIPD shares modifiable behavioral risk factors with many of the chronic diseases that place a significant burden on healthcare worldwide.8,9
The well-accepted modifiable risk factors for CIPD, which are common to cardiovascular disease, stroke, cancer, and diabetes, include tobacco use, obesity, hyperglycemia, and poor diet. Management of the more significant inflammatory disease risk factors has long been the goal of public health efforts. Sustained changes in the typical destructive lifestyle factors such as tobacco cessation, weight loss, and normalization of blood glucose requires regular and ongoing recognition, reinforcement, and professional advice. The dental office may provide the best available opportunity for the general population to make meaningful changes in their lifestyle choices.
Medicine has long struggled with getting patients to remain compliant with ongoing regular visits needed to manage chronic diseases.10 In contrast, dentistry has successfully incorporated regular and ongoing office visits into its model of delivery of care. For many people, regular visits to the dental office are simply a way of life. In 2014, 83% of children and 62% of adults had a dental visit.11 The dental hygienist is well positioned to regularly screen patients for these common risk factors. The routine maintenance visit, when properly structured, can afford dental hygienists the opportunity to provide healthy lifestyle education and motivation to assist patients in smoking cessation, blood sugar control, weight reduction, and following a healthy diet. The typical recall appointment can be made to be more of an overall health check-up rather than just a beauty visit.
As such, it seems prudent to restructure the typical dental hygiene visit to include screening for and assistance in the management of the risk factors common to periodontal and other systemic diseases. Prevention and improved control of the chronic diseases is certainly more efficient than waiting until these problems progress further and require significant expenditures to manage as full-blown diseases. Dental professionals have the opportunity, and perhaps even the responsibility, to develop revised dental maintenance visit protocols to include regular screening for obesity, tobacco use, and diabetes. This article will detail a strategy for incorporating routine screening for obesity and abnormal blood sugar levels into the typical hygiene visit. Because tobacco use counseling is not new to dental professionals it will not be reviewed here.
Obesity
Obesity is now recognized as a significant risk factor for CIPD.12 When people are overweight, adipocytes increase their systemic output of destructive inflammatory mediators. The inflammatory mediators of adipocyte origin are believed to play a pivotal role in the development of the chronic diseases associated with obesity. The mechanisms by which obesity increases the risk for CIPD have been well established.13 The inflammatory mediators of adipocyte origin mimic the inflammatory mediators released in the localized host response to toothborne biofilm. Patients who are over their ideal weight already have levels of the inflammatory mediators sufficient to enhance the periodontal destructive process. In the presence of local biofilm, patients over their ideal weight are more likely to develop CIPD, which may be more difficult to manage.
Evidence is emerging that obesity can adversely affect periodontal therapeutic outcomes.14 Certainly, for oral and overall health benefits, screening patients for obesity should be part of a dental evaluation. Even potentially more important, evidence is starting to emerge that suggests that, like with many of the systemic diseases associated with CIPD, there may be a two-way relationship between obesity and CIPD.15 The levels of leptin, a hormone involved in appetite control, may be affected by periodontal inflammation. As such, it may be harder for patients who are overweight to manage their hunger and lose weight.
Thus, screening patients for obesity in the dental office can help dental hygienists gauge their patients’ risk for CIPD and help them better manage their overall chronic disease risk. Body mass index (BMI) is an efficient screening tool for obesity. BMI is calculated by dividing the body weight (in pounds) by the height (in inches) squared (BMI = weight/height2) (Table 1).
While useful as a general screening tool, BMI has limitations. BMI is a surrogate measure of body fatness because it is a measure of excess weight rather than excess body fat. Factors such as age, sex, ethnicity, and muscle mass can influence the relationship between BMI and body fat. Also, BMI does not distinguish between excess fat, muscle, or bone mass, nor does it provide any indication of the distribution of fat among individuals.16
Having patients self-report their height and weight (while not always reliable) would provide the dental professional an opportunity to determine a BMI score for the patient. A more objective result could be obtained if patients’ height and weight were recorded at the dental maintenance visit. Because obesity is acknowledged as a multiple-risk-factor syndrome for overall and oral health, risk assessment in the dental office on a regular basis, including the evaluation of BMI, is encouraged.17
Patients whose BMI is scored as overweight or obese should be advised that they are at increased risk for chronic diseases, including cardiovascular and cerebrovascular disease, diabetes, and certain cancers. They are also at increased risk for CIPD. If CIPD develops and is not successfully treated, inflammation of oral origin can further add to their chronic disease risk. These patients should also be screened for factors linked to obesity, including diet, exercise, sleep apnea, and stress. They should be advised of the identified lifestyle changes aimed at reducing their excessive weight. Finally, clinicians should consult with the patient’s medical provider to develop a plan in which dental and medical providers can co-manage the patient’s health.
Screening for abnormal weight may be of particular benefit to children. Children who are overweight are at an increased risk of becoming obese as adults. Routine weight screening of pediatric patients and early intervention through education and referral can reduce the risk for chronic diseases in adulthood.17 Evidence suggests that obesity in adults14 and in children18 may adversely affect the outcome of certain dental therapies. Thus, in addition to assisting patients achieve wellness in the dental office, screening for obesity can also be used to determine the need for more aggressive therapy. Empirically, it seems reasonable to treat patients who are overweight or obese more aggressively due to their increased risk for developing CIPD.
Diabetes
Evidence is clear that periodontal inflammation can adversely affect blood sugar control and resolution of oral inflammation has the potential to improve blood sugar control.19 The two-way relationship between diabetes and CIPD suggests that while a visit to the dental office may not be the first option for a patient with diabetes, it certainly should be the second. Ongoing surveillance for and successful treatment of CIPD can be an important part of diabetes management. Third-party payers are realizing the reduced overall healthcare costs when CIPD is eliminated in patients with diabetes.20 The cost savings available with early diagnosis of diabetes or prediabetes has also been demonstrated. Successful management of many of the chronic diseases of aging, like diabetes, require regular professional oversight. The well-established maintenance model of dentistry lends itself to ongoing management of chronic diseases. Screening for elevated blood sugar in the dental setting for diagnostic or maintenance purposes is being investigated as an effective method of reducing the healthcare costs of managing diabetes.21
While various laboratory values can be obtained to analyze a patient’s blood sugar level, the A1c blood test (also called hemoglobin A1c, HbA1c, or glycohemoglobin test) lends itself nicely to the dental office. The test requires no fasting or other special preparation.22 A drop of blood from a simple finger stick can be analyzed quickly in the dental office. A1c is based on the tendency for sugar in the blood to bind with protein. One of the most readily available proteins is hemoglobin, which is found in red blood cells. The amount of hemoglobin with sugar bound to it in a known quantity of blood can be measured and then extrapolated to determine the overall level of sugar in the blood. In the body, red blood cells typically live for about 3 months. Thus, the A1C test reflects the average of a person’s blood glucose levels over the past 3 months. The A1C test result is reported as a percentage. The higher the percentage, the higher a person’s blood glucose levels have been. The diagnostic categories associated with differing A1c levels are as follows: Normal = A1c level below 5.7%; Prediabetes = A1c level 5.7% to 6.4%; Diabetes = A1c level 6.5% or above.22
While originally proposed as a mechanism to help patients with diabetes control their disease, HbA1c is now being promoted internationally as a general screening tool to identify patients with prediabetes or previously undiagnosed diabetes.23
Successful management of diabetes requires ongoing blood sugar monitoring. Sadly, many patients with diabetes do not receive adequate maintenance care through their medical visits.24 From a public health perspective, for patients who adhere to regular maintenance dental visits, improved blood sugar monitoring is possible via A1c screening in the dental office. With CIPD being a recognized complication of diabetes, it is estimated that up to 27.8% of patients presenting to the dental office have undiagnosed diabetes or prediabetes.25
Due to the prevalence of diabetes and the toll it takes on public healthcare costs, the American Diabetes Association recently suggested guidelines for type II diabetes and prediabetes screening in asymptomatic adults.26 Screening should be performed in adults of any age who are overweight or obese, and who have one or more diabetes risk factor (Table 2). With CIPD being a recognized complication of diabetes, it seems reasonable to screen every patient presenting to the dental office with evidence of CIPD. Testing should begin at age 45 and, if the test is normal, repeated at least every 3 years.
Thus, either in-office A1c testing or referral to a medical professional for blood sugar screening should be considered for dental patients who already have a diagnosis of diabetes, and for undiagnosed patients who present with signs and symptoms of CIPD (Table 3).
Changing the Message
It seems reasonable and prudent for dental hygienists to play a greater role in co-managing the risk factors (eg, tobacco, obesity, hyperglycemia) that are common to both periodontal and associated systemic diseases. Screening for and assisting medicine in managing abnormalities in these other sources of systemic inflammation are an important part of systemic disease management and should be part of CIPD management. Embracing an expanded view of the benefits of regular dental care affords dentistry the opportunity to define a new message that can impact both patient and practice success.
Unfortunately, presently the concluding message when discussing links between oral and overall health is centered only on improved oral hygiene. The long-standing mantra of dentistry, “brush and floss or else,” has not motivated the throngs of patients with unmet dental needs to have those needs professionally addressed. Thus, it seems the message has failed to get through and needs to change. While the importance of patient-driven daily hygiene cannot be overstated, clinicians and patients must realize that even improved daily hygiene will have little, if any, effect on reducing existing subgingival periodontal inflammation. Daily hygiene is not therapy for subgingival inflammation that already exists; rather, it is part of a strategy for preserving oral health once it has been achieved.
Dentists and hygienists can emphasize several points when discussing oral-systemic links with patients. First, they should stress that inflammation is at the root of many chronic diseases of aging. Second, the mouth can be a significant source of systemic inflammation if CIPD persists. And, third, it is thus important to partner with a dental professional for life to eliminate any periodontal inflammation and then keep it at bay. Doing so can improve the patient’s oral and overall health.
Individually, this message can be presented in the context of the specific systemic condition that is associated with CIPD. For example, tobacco-using patients presenting for dental evaluation certainly should be advised that tobacco use increases their risk for CIPD. They should also be advised that the inflammatory burden imparted by CIPD can increase their risk for heart disease. Because their tobacco habit itself is a potential risk factor for cardiovascular disease, tobacco-using patients should be alerted that: (1) they are already at risk for cardiovascular disease; (2) they are at increased risk for CIPD; (3) if CIPD is not adequately managed, the persistence of CIPD can raise their cardiovascular risk even further; and (4) it is therefore important that they consider tobacco cessation. Furthermore, they should be advised to partner with a dental professional, especially if their tobacco habit continues, to eliminate periodontal inflammation and keep it at bay over their lifetime. Doing so should be part of their cardiovascular disease risk management.
A customized message beyond the basic “brush and floss” may provoke patients to put more urgency into their oral care. Presenting dental care in the framework of overall health not only offers opportunities to better motivate patients, it also allows dental healthcare providers to potentially improve their patients’ overall health. Increasingly, the maintenance-oriented model of dentistry, although long focused only on the care of tissues in the oral region, is being evaluated in public health efforts as at least a partial solution to the problems of systemic disease management.
Dental healthcare providers should modify their patient-visit routines to incorporate screening for the risk factors common to periodontal and systemic diseases. Co-management with medical professionals of the common risk factors represents a timely opportunity for dentistry to expand its available services it provides to patients. As the economics of healthcare continue to constrict, patients often view dentistry as less of a priority relative to medicine. Expanding the role of dentistry can only strengthen the dental industry’s position as a legitimate player on the healthcare stage.
Conclusion
Dentistry can and should do more than exhort patients to adhere to a daily oral hygiene routine. Besides being told to brush and floss, patients should also know that risk-factors management during dental visits can help them better achieve overall wellness. Rather than simply helping patients to keep their teeth, the new goal of dental therapy should be to assist patients in achieving wellness by having dentists co-manage the risk factors that link oral and systemic diseases, help their patients achieve a functional and esthetic dentition that can be maintained relatively inflammation-free, and then support them in doing so over their lifespan. Embracing an innovative approach and new message can help dentistry assume its rightful position as an integral part of the provision of overall healthcare.
Disclosures
The author had no disclosures to report.
References
1. Centers for Disease Control and Prevention. Chronic Disease Overview. https://www.cdc.gov/chronicdisease/overview/index.htm. Updated June 28, 2017. Accessed June 29, 2017.
2. Centers for Disease Control and Prevention. Leading Causes of Death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Updated March 17, 2017. Accessed June 29, 2017.
3. Tomás I, Diz P, Tobías A, et al. Periodontal health status and bacteraemia from daily oral activities: systematic review/meta-analysis. J Clin Periodontol. 2012;39(3):213-228.
4. Nagpal R, Yamashiro Y, Izumi Y. The two-way association of periodontal infection with systemic disorders: an overview. Mediators Inflamm. 2015;2015:793898. doi: 10.1155/2015/793898.
5. Kornman KS, Page RC, Tonetti MS. The host response to the microbial challenge in periodontitis: assembling the players. Periodontol 2000. 1997;14:33-53.
6. Vidal F, Figueredo CM, Cordovil I, Fischer RG. Periodontal therapy reduces plasma levels of interleukin-6, C-reactive protein, and fibrinogen in patients with severe periodontitis and refractory arterial hypertension. J Periodontol. 2009;80(5):786-791.
7. Torumtay G, Kırzıoğlu FY, Öztürk Tonguç M, et al. Effects of periodontal treatment on inflammation and oxidative stress markers in patients with metabolic syndrome. J Periodontal Res. 2016;51(4):489-498.
8. Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol. 2000;28(6):399-406.
9. Tonetti MS, Jepsen S, Jin L, Otomo-Corgel J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: a call for global action. J Clin Periodontol. 2017;44(5):456-462.
10. García-Pérez LE, Álvarez M, Dilla T, et al. Adherence to therapies in patients with type 2 diabetes. Diabetes Ther. 2013;4(2):175-194.
11. Centers for Disease Control and Prevention. Oral and Dental Health. http://www.cdc.gov/nchs/fastats/dental.htm. Updated May 3, 2017. Accessed June 29, 2017.
12. Keller A, Rohde JF, Raymond K, Heitmann BL. Association between periodontal disease and overweight and obesity: a systematic review. J Periodontol. 2015;86(6):766-776.
13. Genco RJ, Grossi SG, Ho A, et al. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. J Periodontol. 2005;76(11 suppl):2075-2084.
14. Gerber FA, Sahrmann P, Schmidlin OA, et al. Influence of obesity on the outcome of non-surgical periodontal therapy - a systematic review. BMC Oral Health. 2016;16(1):90.
15. Khorsand A, Bayani M, Yaghobee S, et al. Evaluation of salivary leptin levels in healthy subjects and patients with advanced periodontitis. J Dent (Tehran). 2016;13(1):1-9.
16. Centers for Disease Control and Prevention. Body Mass Index: Considerations for Practitioners. US Dept of Health and Human Services. https://www.cdc.gov/obesity/downloads/bmiforpactitioners.pdf. Accessed June 29, 2017.
17. Hague AL, Touger-Decker R. Weighing in on weight screening in the dental office: practical approaches. J Am Dent Assoc. 2008;139(7):934-938.
18. Saloom HF, Papageorgiou SN, Carpenter GH, Cobourne MT. Impact of obesity on orthodontic tooth movement in adolescents: a prospective clinical cohort study. J Dent Res. 2017;96(5):547-554 .
19. D’Aiuto F, Gable D, Syed Z, et al. Evidence summary: the relationship between oral diseases and diabetes. Br Dent J. 2017;222(12):944-948.
20. Nasseh K, Vujicic M, Glick M. The relationship between periodontal interventions and healthcare costs and utilization. Evidence from an integrated dental, medical, and pharmacy commercial claims database. Health Econ. 2017;26(4):519-527.
21. Herman WH, Taylor GW, Jacobson JJ, et al. Screening for prediabetes and type 2 diabetes in dental offices. J Public Health Dent. 2015;75(3):175-182.
22. National Institute of Diabetes and Digestive and Kidney Diseases. The A1c Test and Diabetes. https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis/a1c-test. Updated September 2014. Accessed June 30, 2017.
23. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32(7):1327-1334.
24. Prestes M, Gayarre MA, Elgart JF, et al. Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme. Acta Diabetol. 2017. doi: 10.1007/s00592-017-1016-8.
25. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014. www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed June 30, 2017.
26. American Diabetes Association. Standards of medical care in diabetes–2014. Diabetes Care. 2014;37(suppl 1):S14-S80.
About the Author
Tim Donley, DDS
Private Practice and International Lecturer
Bowling Green, Kentucky
