by Richard H. Nagelberg, DDS
Our knowledge of the processes involved in the development and progression of periodontal disease is quite advanced at this time. Further research will certainly bring us closer to a more complete understanding of the disease. We know enough at this time, however, about periodontal disease, vascular disease, and diabetes to act on the relationships among them. A good way to begin providing care beyond the oral cavity is to identify the risk elements, precursors, and indicators of periodontal disease, vascular disease, and diabetes for each individual patient, and then educate, refer, and provide treatment where necessary.
We are well aware of the primary risk elements for periodontal disease, including heredity, smoking, diabetes, nutrition, xerostomia, faulty dental restorations, stress, poor oral hygiene, hormonal variations, immunocompromise, connective tissue diseases, previous history of periodontal disease, and occlusal disease. Two of the most important risk elements are diabetes and smoking. The number of risk elements identified for each patient increases disease likelihood, speed of onset, severity, etc., in an exponential manner rather than an additive manner. A patient with one risk factor has a greater likelihood of periodontal disease resolution than the patient who smokes, is an uncontrolled diabetic with dry mouth, and has a high stress level. The most important risk elements are the specific causative bacteria responsible for each patient's case of periodontal disease. Salivary testing is a requirement for providing optimal care beyond the oral cavity. Research has demonstrated abundantly the impact of periodontal disease and the impact of the perio pathogens themselves on vascular disease.
If we are to truly provide care for our patients -- not just their mouths -- then we need to understand the risk elements for cardiovascular disease. Some of the more unique risk factors for cardiovascular disease include elements that may not demonstrate a cause and effect relationship but rather an associated risk. Brad Bale, MD, and Amy Doneen, MSN, ARNP, (www.baledoneenmethod.com) call them red flags. Red flags include elevated cholesterol; elevated blood sugar; tobacco and nicotine use in any form, including cigarettes, chewing, dipping, patch, and secondhand smoke; psychosocial issues such as anxiety, depression, or work/home stress; diabetes; metabolic syndrome; history of gestational diabetes or preeclampsia; high blood pressure; abdominal obesity; sleep problems, including obstructive sleep apnea (OSA) and/or restless leg syndrome; age, including men over 40 and women over 50 years old; periodontal disease; bleeding or receding gums; erectile dysfunction; rheumatoid arthritis; lupus; psoriasis; migraine headaches; history of breast cancer; lead exposure; hypothyroidism; insulin resistance; gout; nonalcoholic fatty liver disease; polycystic ovarian syndrome (PCOS); brothers of women with PCOS; hirsutism; oligomenorrhea (changes in menstrual cycles); osteoporosis; history (in men) of low testosterone levels; and Hispanic or African American descent.
Bale and Doneen further recommend expanding our family history forms to include heart disease (stents, bypass surgery, congestive heart failure) or heart attacks; aneurysm, especially abdominal or intracranial; diabetes; hypertension; high cholesterol; metabolic syndrome; obesity; stroke (CVA) and mini strokes (TIA); vascular dementia (or memory changes later in life); autoimmune disorders such as rheumatoid arthritis, lupus, and psoriasis; men with sisters who have PCOS; and parents or siblings with dentures or periodontal disease or bleeding gums. It is worth noting that many of the same items are included in red flags, which are about the patient in the chair. Family history elevates the risk of an event or condition occurring in the patient.
We can think of patient assessment in the dental setting as a multistage risk evaluation. Risk assessment does not necessarily have to occur in a linear fashion, such that the risk elements for periodontal disease are evaluated first, followed by red flags and family history review. Periodontally healthy patients still need to have their red flags and family history evaluated and documented. There are certainly patients with pristine gingival health who have strong personal or family histories of hypertension, high cholesterol, heart attacks, psoriasis, etc.
The dental and medical professions have operated on an end-stage disease model far too long, in which action is not taken until disease manifests. Transitioning to a wellness model, in which the risk elements are managed prior to disease development, will allow us to care for our patients -- not just their oral cavities.
Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and 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 protected].
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