Putting patient co-management into practice

Oct. 1, 2011
It’s hard to imagine a scenario in which dental and medical professionals would disagree with the enhanced benefit of a cooperative approach ...

by Richard H. Nagelberg, DDS

For more on this topic, go to www.dentaleconomics.com and search using the following key words: periodontal disease, oral-systemic, cardiovascular disease, diabetes, patient co-management, wellness, Richard H. Nagelberg, DDS.

It’s hard to imagine a scenario in which dental and medical professionals would disagree with the enhanced benefit of a cooperative approach to patient care. This can be accomplished in several ways, including communication, referrals, and updates regarding health status. In some circumstances, dental and medical professionals can devise a way to work together in real terms to alert patients to their risks for cardiovascular disease. This type of cooperative approach to disease identification occurred recently in the Philadelphia area.

I partnered with Charles Whitney, MD, after discovering that we both had attended an advanced cardiac training course given by Brad Bale, MD, Amy Doneen, MSN, ARNP, and Tom Nabors, DDS. One of the main premises of the Bale Doneen Nabors Method is that the currently accepted clinical guidelines for addressing atherosclerosis, cardiovascular disease, and diabetes are not best practices. They are standard of care — not optimal care.

Dr. Bale’s recommendations go well beyond the accepted guidelines in an effort to provide optimal care. For example, a stress test can give a false sense of reassurance regarding cardiovascular health. The prime example of this is the journalist Tim Russert. Several weeks after successfully passing a stress test, he died suddenly of a heart attack.

Among many other recommendations in the Bale Doneen Nabors course is advanced screening of the carotid arteries for the presence of arterial wall thickening. The test is called carotid intima media thickness ultrasound examination, or CIMT. It is different from traditional Doppler ultrasound.

CIMT can detect arterial wall thickening at a very early stage, providing an opportunity to address it before an event such as a heart attack or stroke occurs. It also indicates whether the treatment of a patient with known disease is working. This is truly a wellness approach to disease.

Both Dr. Whitney and I collaborated on this initiative to provide CIMT testing in my dental office. The test is painless, noninvasive, requires no disrobing, and takes five to 10 minutes. Test results that reveal carotid artery wall thickening beyond that which is age-appropriate establish a diagnosis of atherosclerosis. CIMT is also the only test that can detect soft plaque, which is particularly susceptible to rupturing and thus initiating a cardiovascular event.

Why was this testing undertaken in a dental setting on dental patients? Because periodontal disease and periodontal pathogens are major contributors to atherosclerosis and have a significant association with diabetes. Also, genotype positive individuals may be at increased risk for coronary disease.

There are cases in which periodontal disease and/or virulent perio pathogens are the only identifiable risk factors for cardiovascular disease. Perio pathogen and genotype identification are determined by salivary diagnostic testing (OralDNALabs.com).

Patients who participated in the testing responded very favorably and expressed appreciation for the opportunity to gain insight into their cardiovascular health.

The results were very revealing, and in some cases quite unexpected. The latter group included a man in his mid-40s who was substantially overweight, and by his own admission had an unhealthy diet and sedentary lifestyle. His CIMT test results indicated a cardiovascular age of someone eight years younger.

In other words, his carotid arteries were devoid of any thickening, a finding that was surprising and counterintuitive. Dr. Whitney’s interpretation of the patient’s results included the significant contribution of the patient’s family history.

Another CIMT test participant was a 56-year-old woman who had chest pain and cardiac stenting four months prior to the test. Her results revealed very dangerous soft plaque and considerable thickening of her carotid artery walls and a cardiovascular age of 71.

It is possible that if she had the CIMT test and diagnosis of atherosclerosis prior to her episode of chest pain and stent placement, medical treatment rather than surgical intervention would have been possible.

Other test participants had some artery wall thickening that they will now convey to their physicians, allowing the situation to be addressed before a heart attack or stroke occurs.

In the future, this type of testing and co-management of patients will hopefully be widely available. The unique opportunity to collaborate with a physician in a novel way was very gratifying professionally. Most important, however, was the tremendous impact on the patients who participated. Let’s not forget that it is always about our patients.

Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 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 protected].

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