Improving lives through collaboration
Barbara McClatchie, DDS, and Eric Goulder, MD, FACC, are not only a couple by marriage but also business partners who practice medical-dental collaboration. Back when the two were dating, McClatchie had heard Bradley Bale, MD, and Amy Doneen, DNP, ARNP, speak about their BaleDoneen Method of cardiovascular disease prevention, which encompasses dental care, at the founding meeting of the American Academy for Oral Systemic Health. This greatly improved her understanding of the oral-systemic link—an area of research in which the presence of pathogens associated with periodontal disease has been associated with an increased risk of other systemic inflammatory conditions. She suggested that Goulder participate in a BaleDoneen preceptorship, after which he transitioned from working in a hospital performing cardiac surgeries and placing stents to partnering with McClatchie to open The Heart Attack and Stroke Prevention Center of Central Ohio and Complete Health Dentistry of Columbus, the nation's first center with a cardiologist and a dentist providing care together under one roof.
When McClatchie speaks about her partnership with Goulder, she highlights their individual roles and emphasizes the successes of their collaborative approach. "To reduce inflammation, he has to look outside of his specialty regarding reasons for increased inflammatory markers, I have to use my testing and markers, and we have to treat our patients together," she says.
One of their many successful cases involved a man who presented with severe rheumatoid arthritis that had rendered him bedridden. "We performed all of our charting and diagnostics, including saliva testing, an inflammatory panel, a carotid intima-media thickness scan, and a cone-beam computed tomography (CBCT) scan. After gathering all of his markers, it became apparent that he was at high risk for a heart attack or stroke, so the dentist, the hygienist, and the cardiologist sat down together to customize his treatment plan," says McClatchie. "Although his high-sensitivity C-reactive protein was initially 35 mg/L (under 1 mg/L is considered normal), 2 weeks after beginning periodontal therapy, it was down to 26 mg/L, and 3 months later, it was down to 1.6 mg/L. Nothing was altered regarding his medical treatment; it was exclusively the dental treatment that improved his inflammatory panel. The pain in his hands and knees was dramatically reduced, he had increased energy, and he gained back 30 pounds. He rode his Harley to his later dental appointments."
McClatchie references a 2017 article published by Bale and colleagues regarding the contribution of high-risk periodontal pathogens to the pathogenesis of atherosclerosis.1 According to the article, studies indicate that the adverse cardiovascular effects from periodontal disease can be attributed to a few putative or high-risk bacteria: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, or Fusobacterium nucleatum.1 The article explains that there are three accepted essential elements in the pathogenesis of atherosclerosis—lipoprotein serum concentration, endothelial permeability, and binding of lipoproteins in the arterial intima—and that the evidence suggests that high-risk pathogens can influence this pathogenesis triad in an adverse manner.1
The Influence of Inflammation
Joseph R. Greenberg, DMD, a clinical professor of restorative dentistry at Temple University's Kornberg School of Dentistry with a private practice in Villanova, Pennsylvania, notes that inflammation has metabolic pathways that are common to periodontal disease, gingivitis, type 2 diabetes, and cardiovascular disease.2 "There's a new understanding that the resolution of inflammation is an active process, not a passive one involving the decay of inflammatory molecules as was previously believed," he says. "Even though it's a defense system of the body, too much inflammation can get out of control and is not good for us." Greenberg adds that many studies have established that periodontal disease and type 2 diabetes influence each other and that there is good evidence of reciprocal control.
In addition to diabetes, periodontal pathogens and/or periodontal bacterial virulence factors have been demonstrated to be present in areas associated with both cardiovascular disease and dementia/Alzheimer's disease says Maria L. Geisinger, DDS, MS, a professor and director of the Advanced Education Program in Periodontology at the University of Alabama at Birmingham. "In cases of cardiovascular disease, putative periodontal pathogens have been found within atherosclerotic plaques throughout the vasculature, but particularly engulfed in foam cells, which are activated macrophage cells," she notes. "Similarly, regarding dementia, P gingivalis and its virulence factors (eg, gingipains) have been found in the brain tissue and spinal fluid of patients suffering from Alzheimer's disease."
Association, not Causality
Speaking more directly to the mechanisms behind the oral-systemic link, Geisinger explains that in hospital-based nosocomial pneumonias, bacteria were found in the lungs that genetically matched the bacteria found in the oral cavities of the same patients. These relationships are predicated on the idea that in patients with oral inflammation, bacteria frequently enter the bloodstream during activities such as mastication and toothbrushing. In patients with higher levels of gingival inflammation, there is an even greater opportunity for oral bacteria to enter the bloodstream and do damage throughout the body. "It is important to remember that association is not causality, but patients with moderate to severe periodontitis are at a significantly increased risk of developing diabetes mellitus, rheumatoid arthritis, certain forms of cancer, hypertension, cardiovascular disease, cerebrovascular disease, erectile dysfunction, adverse pregnancy outcomes, dementias, and obesity," she says. "Periodontal disease has also been linked to higher rates of morbidity and mortality associated with end stage renal disease and osteoporosis."
Patient and Provider Education
Although the link between periodontal disease and associated systemic conditions has been publicized in professional journals and consumer media, Geisinger notes that, overall, patients have low levels of medical and dental knowledge and a low awareness of these interactions. She emphasizes that critical to increased awareness is enhanced interprofessional collaboration between medical specialists and physicians to facilitate conversations and referrals.
McClatchie agrees and adds that because medical and dental professionals "don't know what they don't know," it's incumbent upon physicians and dentists to keep abreast of current research. She suggests that such collaboration, which is currently outside the standard of care, may get more wind in its sails through concierge medicine, where patients will "start demanding more root cause medicine and dentistry, asking why something is happening versus just accepting a pill for it."
To help provide education, McClatchie and Goulder give each of their patients a copy of Bale and Doneen's book Beat the Heart Attack Gene: The Revolutionary Plan to Prevent Heart Disease, Stroke, and Diabetes.3 McClatchie, who notes that Bale and Doneen are coming out with another book that will tie in with Alzheimer's disease, continues to educate herself on the relationship between oral and systemic health and became certified in the ReCODE protocol developed by Dale Bredesen, MD, to aid in the reversal of cognitive decline. "If you're treating for cardiovascular disease, you're actually treating for cognitive decline as well," she says. "Research shows that P gingivalis, one of the high-risk bacteria, is directly related to the amyloid plaques found in the brains of Alzheimer's disease patients as well."
Health Literacy and Integration
According to Greenberg, increasing oral health literacy is especially critical in "at-risk" communities and among underserved populations. "We need to find ways to communicate using language that's friendlier to patients," he says. "It's going to require all of our healthcare partners to be successful in this. Dentistry represents maybe five percent of the healthcare dollars spent, so the field of medicine, the government, and the insurance companies need to help us out."
One possible solution, Greenberg suggests, is to create a business model in which "helping people in the inner cities generates positive revenue for providers and third-party payors, who can influence the government or have the dollars themselves to promote diet and nutrition." Schools can play their part as well, he says.
Greenberg points out a recent World Health Organization resolution that positions oral health as a part of overall global health and recommends its inclusion into universal health coverage. He also cites a June 15, 2021, Santa Fe Group webinar4 during which Edward Murphy, MBA, executive vice president, dental, of Life & Specialty Ventures, noted the results of a 5-year study conducted by the Mayo Clinic involving people with cardiovascular disease, type 2 diabetes, and periodontitis who had been seen under one roof by a group of healthcare providers that included dentists. "The savings on the health insurance side for those diagnosed with periodontitis and treated was 30 percent of their total healthcare dollars," Greenberg says.
In the first efforts in this direction, Greenberg notes that Medicare is considering adding dental coverage to pay for maintenance care and hygiene services and that the American Dental Association (ADA) is working on fair reimbursement for dentists for common services that may have to be provided more frequently to achieve high levels of periodontal health and low bleeding scores. "People with type 2 diabetes or cardiovascular disease should get coverage that includes prophylaxis three to four times a year," he adds.
"Studies have demonstrated that only 4 to 8 percent of US adults floss daily," says Geisinger. "However, daily interdental cleaning has been shown to reduce interdental plaque levels and gingival inflammation. Making that one change has even been associated with an extra 6 to 8 years of life expectancy for older adults."
For patients without periodontitis, routine prophylaxis appointments allow for the assessment of periodontal health, evaluation of home hygiene practices, performance of oral cancer screening, evaluation of the hard and soft tissues, and removal of oral plaque and calculus. "For patients diagnosed with periodontitis and receiving active treatment, more frequent appointments for monitoring, assessment, and cleanings may be necessary to prevent reinfection and reactivation of disease." says Geisinger. "For periodontitis patients, a 3-month interval is generally suggested because studies demonstrate that it takes approximately 9 to 11 weeks for dysbiotic bacterial biofilms to reestablish subgingivally after meticulous cleaning."
McClatchie's patients' prophylaxis appointments are personalized based on their health history, bacteria, and their ability to maintain their periodontal health between appointments, which occur every 6 months for younger, healthier patients and every 2 to 3 months for high-risk patients. In periodontal disease prevention and treatment, she personalizes care by assembling a patient's health history, completing a periodontal chart, and conducting saliva testing to ascertain the types of bacteria present, their levels, and best treatment options. McClatchie's treatment plans include the use of dental probiotics to address any bacterial imbalances that are causing inflammation as well as electric toothbrushes to better break up biofilms. "As a treatment or preventative maintenance program to keep infection under control, most of our heart attack, stroke prevention, and other high-risk patients are prescribed Perio Protect Perio Trays for at-home delivery of 1.7% hydrogen peroxide gel," she adds.
Greenberg notes that for proper disease prevention education, a patient needs to acquire sufficient oral health literacy through effective information transfer/coaching regarding which toothbrush to use and how to engage it in the mouth. He adds that collaborative efforts are especially significant in pediatrics, where good habits can be established early on. "I advise patients and teach them how to best control their biofilm with brushing, particularly with an electronic toothbrush, and with interproximal brushes," he says. "For an adult with gum recession, traditional flossing doesn't always engage all of the exposed surfaces. Patients also need to understand the correlation between their bleeding upon probing score and type 2 diabetes, cardiovascular disease, and certain cancers." Greenberg advises his patients with dental implants to have their teeth professionally cleaned four times a year due to the complex microbiology around implant sites and the physical difficulty of cleaning off the plaque/biofilm.
Sugar and Lifestyle Factors
Xylitol and other sugar substitutes can reduce the risk of developing dental caries and improve outcomes associated with low intraoral pH. According to McClatchie, because xylitol lowers Streptococcus mutans levels, it can reduce the incidence of caries among children and help older adults with dry mouth to avoid developing decay on their root surfaces.
"I'm a big believer in Xylitol products," says Greenberg, adding that he favors it in toothpaste. "Sugar consumption is one of the worst dietary habits promoting chronic disease. It's addictive and harmful not only to oral health but to general health. Studies in cities such as Philadelphia show that stores near elementary schools serve up high carbohydrate and high sugar food products and that sourcing lower calorie sweeteners like xylitol is difficult in poorer communities. Even when it's available, it's cost prohibitive to some."
Emerging data suggest that increased sugar consumption also has an impact on gingival inflammation. "Reducing sugar intake could have a beneficial effect on both caries and periodontal disease progression," says Geisinger. "Furthermore, antioxidant consumption and vitamin D/calcium supplementation have demonstrated beneficial effects on gingival health, and the use of polyunsaturated fatty acids, such as omega-3 fatty acids, and resolvins, such as those triggered by low-dose aspirin, may reduce markers of gingival inflammation in patients at risk of periodontal disease progression."
Zinc helps enhance dental health, as do natural microbial rinses, notes McClatchie, adding that cardiovascular health significantly relies on positive lifestyle choices, including a balanced, natural diet and limited processed foods. "With patients who smoke, we see increased bone loss as well as periodontal disease and heart disease," she says. "Oftentimes, their gums don't bleed because of the heat and effects of the smoking, and their periodontal disease is missed because they're not seen as bleeding. These patients don't heal as well. They don't have sufficient oxygen in their tissues."
Geisinger points out that tobacco consumption—including smoking and vaping—is the number one modifiable risk factor for periodontal disease and that its cessation significantly improves treatment outcomes.
Smoking and alcohol consumption dries out tissues, Greenberg notes, explaining that for older patients, xerostomia can lead to aggressive tooth decay that may result in accelerated tooth loss. Fluoridation of the water supply also is very important. "In Pennsylvania, only a little more than half of all of our communities have controlled water fluoridation," he says. "According to the ADA, that's 0.7 parts per million. It's easier to do now than ever before, but there are many different water companies in many different communities. Citizens need to raise their voices. Drinking bottled water may be convenient, but it's the fluoridated tap water, like we have in Philadelphia, that prevents tooth decay."
Diagnosing and Treating Periodontal Disease
"Regarding the diagnosis and treatment of periodontal disease, Stage I and Stage II periodontitis can, in most cases, be treated with nonsurgical therapy, whereas the more advanced stages (ie, Stage III and Stage IV) and the more rapidly progressing forms of the disease (ie, Grade C) often require more advanced therapy," says Geisinger. "This underscores the importance of accurate, early diagnosis to reduce patient morbidity and increase the likelihood of positive outcomes, including tooth retention, over time."
According to McClatchie, complete periodontal charting showing the depth of the gum pockets is an important diagnostic tool, as is saliva testing, because a patient isn't going to be able to remove the bacteria from anything deeper than 4 mm unless he or she has an electric toothbrush. "CBCT scans can help visualize signs of inflammation or infection, showing the roots of the teeth, the sinuses, and any polyps or cysts," says McClatchie. "In addition, the airway can be measured to ascertain if there is an increased chance of obstructive sleep apnea or sleep-disordered breathing." Calcification of the carotid artery could indicate the possibility of cardiovascular disease, so if it is detected during a CBCT examination, McClatchie sends the scans to a radiologist for a detailed report and recommends the patient to Goulder for a cardiovascular workup.
Diagnostic imaging can't tell the whole oral health story. "General dentists and dental hygienists should be performing bleeding assessments and doing some periodontal charting at every visit," says Greenberg. "For the hygienist to do the first pass in the mouth to determine the patient's bleeding upon probing score is very easy. Then the dentist can follow up. If the patient is new to the practice, the dentist should see him or her first and do complete periodontal charting." Greenberg notes that if you dig for pockets, anyone is going to bleed. "The bleeding on probing assessment should involve a gentle sweep. Depending on the number of teeth in the mouth, a score of eight or nine might be OK for maintenance, but numbers beyond that necessitate treatment." Although many periodontists are inclined toward the placement of dental implants, Greenberg prefers that teeth be saved whenever possible.
"In cases of destructive periodontal disease, the first consideration for treatment should always be the regeneration of lost tissues," says Geisinger "If predictable, bone substitutes, resorbable and/or nonresorbable membranes, adjunctive growth factors, and platelet concentrates/patient-derived blood products may all be used in guided tissue regeneration procedures to regenerate the lost periodontal tissues, including alveolar bone, cementum, and periodontal ligament." Lasers have also demonstrated utility as an adjunct to traditional periodontal therapies. "There is significant heterogeneity in the efficacy of different laser types and wavelengths that demonstrate a benefit in the treatment of periodontal disease," says Geisinger.
She emphasizes that periodontal and restorative care go hand-in-hand. "In some cases, restorative and/or orthodontic care can improve periodontal outcomes by reducing the plaque retentiveness of surfaces, closing open contacts, addressing occlusal trauma, and establishing posterior support and vertical dimension in patients with a significant loss of occlusal pairs," says Geisinger. "Conversely, the establishment of optimal periodontal health is necessary to ensure the stability of the dentition for restoration."
The COVID-19 Connection
The dental industry has long had experience in practicing transmission precautions against viruses, such as hepatitis and AIDS; however, dental practices were locked down during the height of the COVID-19 pandemic, which created a setback for some oral health issues. Although the full impact of COVID-19 on periodontal health remains to be seen, a relationship between the two conditions was observed. "Preliminary data suggest that individuals with moderate to severe periodontal disease demonstrated significantly more severe COVID-19 outcomes, including the need for ventilation and the occurrence of death, when compared with those without periodontal disease," says Geisinger. "The relative risk for COVID-19-related death in hospitalized individuals with periodontitis was 8.91 times higher than in those without periodontal disease. Emerging research has shown that the oral cavity is an initial target for COVID-19 infection due to the high rate of expression of angiotensin converting enzyme-2 (ACE-2) receptor, which facilitates the binding of SARS-CoV-2 spike proteins. Mucosal immunity may prove beneficial in enhancing vaccine-related immunity and decreasing nasopharyngeal viral load, thus reducing the spread of COVID-19."
Geisinger believes that the importance of oral healthcare outweighs the safety concerns that people had about visiting dentists during the height of the pandemic. Longitudinal data demonstrate that COVID-19 infection rates associated with the provision of dental care remain exceedingly low5,6 and further evidence suggests that dental care—particularly the treatment of acute disease and the reduction of chronic oral inflammatory disease—results in improvements in both oral and overall health that can have a significant impact on patients' quality and quantity of life.
A Growing Body of Evidence
Although it is still agreed that the research supporting the existence of the oral-systemic link demonstrates association, not causality, a growing body of evidence indicates that the treatment of periodontal disease can ameliorate the severity and/or symptoms of various diseases and conditions. Beyond the identification of shared inflammatory pathways and known periodontal pathogens in other diseased tissues of the body, the specific mechanisms linking periodontitis with the risk of other systemic inflammatory diseases are poorly understood. As additional research is conducted, oral healthcare providers need to remain informed of any developments and look for opportunities to increase collaboration with medical providers in order to better educate patients about prevention and develop evidence-based, multidisciplinary treatment modalities.
1. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2017;93(1098):215-220.
2. Van Dyke TE. Pro-resolving mediators in the regulation of periodontal disease. Mol Aspects Med. 2017;58:21-36.
3. Bale BF, Doneen AL, Cool LC. Beat the Heart Attack Gene: The Revolutionary Plan to Prevent Heart Disease, Stroke, and Diabetes. Wiley; 2014.
4. Hinde W, Irving K, Baenen B, et al. Learning from the convergence of medical and dental insurance: who's driving the change? The Santa Fe Group's Oral Health Integration Resource Center website. Published June 15, 2021. Accessed October 5, 2021.
5. Estrich CG, Mikkelsen M, Morrissey R, et al. Estimating COVID-19 prevalence and infection control practices among US dentists. J Am Dent Assoc. 2020;151(11):815-824.
6. Araujo MWB, Estrich CG, Mikkelsen M, et al. COVID-2019 among dentists in the United States: a 6-month longitudinal report of accumulative prevalence and incidence. J Am Dent Assoc. 2021;152(6):425-433.