The convergence of dental and medical care
As dental professionals, we focus our efforts on improving the lives of our patients every day we spend time at the chair. The dental profession is experiencing an explosion of knowledge, technology, diagnostic tools, and treatment options in a compressed time period.
Richard H. Nagelberg, DDS
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As dental professionals, we focus our efforts on improving the lives of our patients every day we spend time at the chair. The dental profession is experiencing an explosion of knowledge, technology, diagnostic tools, and treatment options in a compressed time period. Practicing on the leading edge of antiquity – drill and fill with amalgam and cast metal partial dentures – will likely have a place in dentistry going forward; however, it is definitely not the future of our profession.
The convergence of dental and medical care is underway. Our patients will be the beneficiaries of this trend. For too long, we have provided dental care in a bubble, practicing – to a large degree – apart from other health-care providers. Even when we consulted with our medical colleagues, it was to find out if premedication was necessary, get clearance for treatment of a medically compromised patient, or find out the HbA1c level of a diabetic individual, rather than providing true patient comanagement.
We have made diagnoses and provided treatments without the benefit of tests, reports, metrics, and other information that predict the likelihood of disease development and progression, as well as favorable treatment outcomes. We have practiced in this manner not due to negligence, but because of the limitations of tools that were available to us. This manner of addressing the clinical challenges we face is changing rapidly. Embracing new diagnostic tests and incorporating the information they provide in our treatment plans can only enhance the level of care we provide for our patients.
Today, laboratories that quickly, easily, and affordably provide dental practices with detailed reports on the type and quantity of bacteria responsible for an individual patient's periodontal disease are currently available. Also at our disposal are chairside-administered blood tests for C-reactive protein (CRP), glucose levels, and HbA1c levels, among others.
Healthy Heart Dentistry (www.healthyheartdentistry.com) is a laboratory that provides blood testing kits for dental offices through its Web site. A finger nick is used to collect two to three drops of blood onto a specially designed filter paper blotter.
The sample is sent to the laboratory for analysis, and a report is generated in about five days. Before this service was available to the dental profession, the patient had to be referred to his or her physician's office, which caused considerable delay.
Knowing the specific bacteria and blood parameters in play gives us better insight into the biological profile of our patients, enhancing treatment planning and outcomes. For example, if we have a perio patient with a family history of diabetes – with virulent periodontal pathogens such as Actinobacillus actinomycetemcomitans (A. a.) or Porphyromonas gingivalis (P. g.) causing the periodontal disease – and blood tests reveal an A1c level of 8.5%, there is an increased likelihood that more aggressive therapy will be required, including referral to a specialist for treatment. Refractory disease may occur in this patient and should be planned for in advance.
Another patient may have a family history of cardiovascular disease, a high CRP level of 8mg/L, and moderate to advanced periodontal disease. We need to be careful when evaluating CRP levels, since many behaviors and conditions can elevate CRP levels, including smoking, hypertension, diabetes, and rheumatoid arthritis, among others. Knowing the CRP level can, however, provide useful information.
Perio patients with high CRP levels and a family history of heart disease and stroke may have an increased risk of a cardiovascular event; thus a physician referral should be considered.
Finally, a patient with medium- to low-risk periodontal pathogens and blood tests within normal limits may not necessarily respond favorably to the treatment we provide. In this case, further testing with a salivary test for genetic predisposition to periodontal disease (www.oraldna.com) may be indicated, along with low-dose doxycycline. Repeated scaling with the use of Arestin and/or systemic antibiotics may also be necessary to achieve healing.
The convergence of dentistry and medicine is long overdue. In the dental profession, we finally have blood and bacterial tests that give us a truer picture of the biological events that have resulted in the 5+ mm pockets we see in our patients today. Factoring the test results in with risk factor identification and management will enhance the level of care we provide for patients, which is what it is always about.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. In-office consultations are available. Contact him at firstname.lastname@example.org.