Applying research findings to patient care

Feb. 1, 2012
Our current understanding of oral-systemic associations has its roots in the focal infection theory that became popular ...

By Richard H. Nagelberg, DDS

Our current understanding of oral-systemic associations has its roots in the focal infection theory that became popular in the late 1800s and early 1900s. Connecting systemic disease to oral infection was the reason for the exceedingly high number of tooth extractions that occurred early in the 20th century. The theory was largely abandoned for many decades until research revealed some trends indicating connections between the mouth and body.

On a clinical level, it is now possible to meld research findings with new technologies, allowing us the potential to simultaneously enhance the oral and systemic health of our patients. Applying well-designed, peer-reviewed research evidence to our patient care protocols can help us provide optimal care. Exceeding the standard of care by practicing with a wellness philosophy rather than an end-stage disease model constitutes optimal care. An example of this approach to disease management is as follows.

A 2009 study in the journal Therapeutic Advances in Cardiovascular Disease by Pesonen et al. concluded that chronic infection by bacteria, including the periodontal pathogen Aggregatibacter actinomycetemcomitans (Aa), is associated with atherosclerosis and coronary obstruction. A 2010 study in the Journal of Hypertension by Desvarieux et al. provided evidence of a direct relationship between periodontal pathogens and hypertension, a major risk factor for cardiovascular disease.

It is important to recognize that these research findings indicate the effects of periodontal pathogens on systemic health, independent of periodontal disease. Salivary diagnostic technologies provide highly valuable information that can be coupled with research results. Bacterial DNA test results impact the oral and general health of the patient ( If the test results indicate the presence of Aa, the patient’s health history and family history should be reviewed, followed by a detailed discussion regarding the prevalence of cardiovascular diseases among the patient’s relatives. A periodontal patient with high levels of Aa and a significant personal or family history of atherosclerosis, heart attacks, and strokes should be strongly encouraged to be monitored regularly by his or her primary care physician, internist, cardiologist, etc. The patient should be given a copy of the bacterial DNA test results so the information can be conveyed to the physician. The patient’s physician may not be aware of this type of research, nor the existence of salivary diagnostic technologies.

A large body of research has indicated the impact of periodontal disease on systemic conditions such as diabetes and cardiovascular diseases, among others. In a 2011 study in Diabetologia by Preshaw et al., the authors state that the risk of cardiorenal mortality is three times higher in diabetic people with severe periodontitis than diabetic individuals without severe periodontitis. Another 2011 study in the Journal of the American College of Cardiology by Fifer et al. found direct evidence for an association between periodontal disease and atherosclerotic inflammation. There are salivary diagnostic tests for genetic predisposition to periodontal disease. This would be powerful information for patients who are predisposed to diabetes or cardiovascular diseases. The critical need to address periodontal disease for the oral and general health of our patients, including those with diabetes and cardiovascular diseases, is obvious. The effect of the care we provide beyond the oral cavity is substantiated by decades of research. Carefully selecting the conclusions from credible studies and incorporating them into our treatment plans constitutes optimal care.

The real value of dental and medical research is to advance our understanding of disease processes. The research itself, however, does nothing to improve the lives of our patients. Incorporating research findings and new technologies into patient care protocols is how we accomplish this. Failing to do so denies our patients the benefits of optimal care. Just 30 years ago, mouth-body connections were not a common part of discussions among health-care professionals and the lay public as they are today. Further research will not disprove the existence of oral-systemic associations since that would indicate that the oral cavity is separate from the rest of the body, with its own independent systems. Every organ, tissue type, and cell is connected to the body as a whole.

With the benefit of hindsight, the old focal infection theory was apparently ahead of its time. It was just waiting for research to catch up.

DR. RICHARD NAGELBERG 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 protected].

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