Well beyond the oral-systemic curve
The associations between the mouth and the body are being incorporated into dental and medical practice with increasing frequency.
By Richard H. Nagelberg, DDS
The associations between the mouth and the body are being incorporated into dental and medical practice with increasing frequency. Public awareness of the impact of oral disease on general health is currently very high. It is an exciting time in the dental profession, and the benefits to our patients are increasing virtually every day. A particularly dramatic example of this approach to patient care is occurring right now.
A medical colleague of mine, Dr. Charles Whitney, is treating a patient named Barbara, who presented for care in December 2011. The patient’s daughter was concerned about her mother’s apparent memory loss, and set up the appointment with Dr. Whitney.
Barbara is an 81-year-old edentulous woman in good health, who had experienced considerable memory loss compared to previous testing. The pattern of memory loss was atypical for Alzheimer’s disease. MRI supported the diagnosis of vascular dementia. Vascular dementia is the second most common type of dementia after Alzheimer’s disease. It occurs as a result of an interrupted blood supply to the brain caused by countless small asymptomatic vascular events.
Blood tests revealed cholesterol levels within normal limits. Barbara has well-controlled blood pressure, absence of insulin resistance, and she is a nonsmoker. The only blood parameter that was not consistent with health was the level of the inflammatory marker LpPlac2 (Plac2). LpPlac2 is an FDA-approved blood test for determining the risk for ischemic stroke. Levels above 200nG/mL are associated with an increased risk for stroke. Barbara’s LpPlac2 level was 309nG/mL. Typical causes of elevated levels of Plac2 include insulin resistance, other underlying inflammatory diseases, and sleep apnea. Barbara did not have insulin resistance, she has no other inflammatory conditions, and she does not have sleep apnea. Other causes of elevated Plac2 levels are high-risk oral bacteria.
Salivary diagnostic testing performed by the doctor revealed the presence of elevated levels of Aa and Pg. These are highly pathogenic bacteria capable of causing aggressive forms of periodontal disease. Research has shown that both bacteria are associated with atherosclerosis and arterial obstruction, as well as increased risk of vascular events such as heart attacks and strokes. Since Barbara is completely edentulous and wears upper and lower full dentures, the treatment plan consisted of full-mouth disinfection with chlorhexidine and systemic antibiotics. To complete full-mouth disinfection, the patient swabbed her mouth thoroughly with chlorhexidine-soaked gauze, and then gargled to disinfect the tonsillar region twice daily for eight days. The treatment objective was to normalize the Plac2 level, halt the disease process, and improve cognitive function. The only alternative treatment plan would have been to increase the dosage of daily aspirin and prescribe Aricept, which is not indicated for vascular dementia.
If Barbara were not edentulous, periodontal therapy would be undertaken. It is noteworthy that the etiology of this case of vascular dementia is not periodontitis, which cannot occur in edentulous individuals, but rather, the periodontal pathogens themselves. The outcome of treatment is still to be determined as of this writing. Barbara will have salivary diagnostic retesting, and her Plac2 level reexamined in approximately three months.
This approach to a case of vascular dementia is not typical at this point. It does demonstrate what is possible when the treating physician is aware of the impact of periodontal disease and perio pathogens and incorporates the knowledge into his or her patient care approach. Among the most important takeaways from this example is what form treatment would have taken without this information. It would likely have been limited to supportive care and increasing the patient’s aspirin dose.
Barbara’s outcome is still indeterminate, but now she has a fighting chance for improved Plac2 levels, ceasing the disease process, and improved cognitive function. The treatment is noninvasive and carries little or no risk of side effects, and it has no identifiable risk of worsening the disease process.
This is indeed an exceptionally exciting time to be in the dental profession. Among our responsibilities is the need to disseminate information in a responsible manner to our medical colleagues to increase awareness of the oral contribution to general health. We need to use this information not only for our patients, but also for our family members and ourselves. There was a time in the dental profession when dentists were essentially mechanics or tooth carpenters. That time is gone.
RICHARD NAGELBERG, DDS, has practiced general dentistry in suburban Philadelphia for more than 29 years. He is a speaker, advisory board member, consultant, key opinion leader for several dental companies and organizations, and lecturer on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at email@example.com.
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