Medical and Dental Factions Converge Toward Agreement on Oral?Systemic Associations
Allison M. DiMatteo, BA, MPS
The opinions and interests of members of the dental and medical communities have converged. There is increasing agreement among both factions of health care that associations exist between oral disease and systemic health. Although the specific nature of the relationships is still being explored through numerous investigations, the traditional medical community is acknowledging current evidence that patients are not truly healthy unless they also have good oral health.
Respected literature among the medical profession is increasingly publishing research findings that demonstrate a connection between diseases of the oral cavity and chronic conditions affecting the rest of the body. Organizations such as the American Medical Association (AMA) and the American Dental Association (ADA) have partnered to educate the media and the masses about the relationships between oral and systemic health. Most noticeably since the beginning of this year, health care insurance companies are taking steps to promote recognition among their respective members that oral health is essential to overall well-being.
As a result, a greater emphasis is being placed on collaborative case management between dentists and physicians for patients who have diabetes and/or cerebrovascular disease, among other conditions, or are pregnant. Oral health for such patients is increasingly being monitored as rigorously as their “medical” condition, and this research-based trend is only likely to continue. And, more and more educational opportunities for medical and dental professionals, as well as the public, are being encouraged to foster and maintain common knowledge about disease processes that affect the entire human biologic system—mouth and body.
THE COLLABORATIVE AMA/ADA BRIEFING
In the first event of its kind, medical and dental professionals shared their ongoing research into the connections between oral and systemic health in February during a media briefing jointly sponsored by the AMA and the ADA, with support from the Colgate-Palmolive Company. According to one of the meeting’s renowned speakers, Louis F. Rose, DDS, MD, from Drexel University College of Medicine and the University of Pennsylvania School of Dental Medicine, the collaborative effort was successful in terms of the support, recognition, and attention it garnered.
“The more interest researchers receive from industry, the better these types of opportunities will be,” Rose says. “We need to continue developing courses for professionals, and there also needs to be more credible, current, and accurate information about oral-systemic connections shared with the public.”
Attention was given during the briefing to infectious periodontitis and the need for enhanced communication between dentists and physicians. In particular, Robert J. Genco, DDS, PhD, from the State University of New York at Buffalo (SUNY Buffalo), explained that periodontal infections can travel into the neck and chest, as well as lodge in the lungs, brain, or heart. Rose emphasized periodontal inflammation as the sixth complication of diabetes and the need for physicians and dentists to work together to care for the overall health of diabetic patients. Additionally, the fact that progressing periodontal disease during pregnancy causes greater risk of preterm delivery was discussed by Steven Offenbacher, DDS, PhD, MMSc, from the University of North Carolina School of Dentistry.a
Other well-known researchers included Elizabeth Krall Kaye, PhD, MPH, from Boston University, who explained that cigarette smoking nearly doubles the risk for needing endodontic (ie, root canal) treatment. Mo™se Desvarieux, MD, MPH, PhD, from the Department of Epidemiology at Columbia University’s Mailman School of Public Health and the recipient of a Chair of Excellence from the French Institut National de la Santé et de la Recherche Médicale to conduct international studies on oral and cardiovascular health, elaborated on the current understanding of the connection between oral infections and cardiovascular disease.a
RECOGNIZING THE RESEARCH
Contributing to the convergence of attention and agreement among dental and medical communities are the research findings themselves, explains Rose. The research available today is of a much better quality than in years past, and there’s more of it, he says.
“There never really was definitive research until about 1995,” Rose observes. “The medical community was interested, and now there is better research—definitive research—regarding associa- tions between oral disease and diabetes, cardiovascular disease, and preterm low birth-weight babies.”
According to Desvarieux, what is developing among the dental and medical communities is an understanding that the oral environment is not separate from the rest of the body. The main question that remains to be answered through research is, “What does the relationship that people find between oral health and systemic health mean?”
“There is no doubt that numerous studies, in varied populations, have consistently found some type of relationship,” Desvarieux says. “Is it just something that occurs by chance because there are common risk factors, or is the relationship truly a contribution of oral health to systemic health? This is what’s being explored through ongoing research.”
Such research includes a recent study published in the Archives of Internal Medicine demonstrating that patients with periodontitis, particularly infections causing a high concentration of pathogens in the blood, are at greater risk of coronary heart disease (CHD).b In particular, the researchers examined 789 subjects (ie, 263 patients with angiographically confirmed, stable CHD and 526 population-based, age- and sex-matched controls with no history of CHD) and analyzed subgingival biofilm samples. The results of the multivariable analysis—which considered other potential risk factors—showed a statistically significant association between high levels of periodontal pathogens and the presence of CHD.b Reuters took note of the study and, shortly after it was published, took the news to the general public when it ran the research findings as a news bureau wire story by Reuters Health.
By necessity and responsibility to those who purchase and benefit from coverage, health care insurance companies are paying attention to—if not also contributing to—the growing body of available research on the oral-systemic link. For example, Delta Dental Plan of Minnesota® conducted a symposium in March in conjunction with the 35th annual meeting of the American and International Associations for Dental Research (AADR/IADR) entitled “The Latest in Understanding the Dental-Medical Connection.” During the symposium, leading experts from across the United States—including Genco, Offenbacher, Dr. George W. Taylor from the University of Michigan, Dr. James Beck from the University of North Carolina School of Dentistry, and Dr. Frank Scannapieco from SUNY Buffalo—presented the current status of research on the relationship between oral disease and major medical conditions (eg, cardiovascular disease, stroke, respiratory illness, diabetes, and pregnancy).
And insurance companies are sharing what’s known with their members and the public, also. When Blue Cross and Blue Shield of Minnesota® announced in March that it joined forces with Delta Dental Plan of Minnesota to introduce a combined medical/dental plan for the individual marketplace, a joint statement mentioned research into the connection between oral health and medical conditions.c But, more specifically, it stated that taking a proactive approach to oral health may have a positive impact on overall health.c
EARLIER PERIODONTAL CARE LEADS TO LOWER MEDICAL CARE COSTS
It might have a positive impact on overall health care costs, too. Aetna® announced in March the results of a 2-year retrospective study it conducted with Columbia University College of Dental Medicine. The study, which examined claim data from approximately 145,000 Aetna members participating in PPO plans with continuous dental and medical coverage, found a positive relationship between periodontal treatment and a reduction in the overall cost of care for three chronic medical conditions.d
“We thought that analyzing our sizable database, which integrates dental and medical information, could potentially validate some cost relationships as a parallel to what we have seen in the clinical research,” explains Mary Lee Conicella, DMD, the national director of clinical operations for Aetna. “The overall data from our study did show that earlier treatment of periodontal disease resulted in lower overall health care costs.”
The study specifically indicated that periodontal care appears to have a positive effect on the cost of medical care, with earlier treatment resulting in lower medical costs for members with diabetes, coronary artery disease, and cerebrovascular disease (CVD) or stroke. In addition, the actual cost of medical care for patients with diabetes and coronary artery disease was found to be lower if they received periodontal care in the first year of the study.d
APPLYING RESEARCH TO POLICY DECISIONS
When considering policies and coverage, insurance companies do take the research into account by performing systematic reviews of the literature, collaborating with colleagues in academia, and/or conducting their own data gathering and evidence producing assessments. High on the list of what constitutes best evidence are clinical, randomized trials.
“When Delta Dental Plan of Minnesota conducted its symposium, we brought together top dental researchers so that we could determine exactly what the state of the science is for each of the major dental-medical associations,” notes Sheila Riggs, DDS, DMSc, president and chief executive officer of Delta Dental Plan of Minnesota. “We believe it is our corporate responsibility to continually monitor the most recent scientific studies to ensure our groups and members have access to appropriate dental benefits based on solid scientific research.”
As a result of insurance company-initiated research, as well as the academic oral-systemic studies, medical and dental insurance providers are considering ways to keep their members healthier. Whether it’s through special “packaging” of benefits or changing the manner in which existing benefits are marketed or promoted, the convergence of awareness among researchers and policy makers is affording greater attention to the importance of oral care.
“We [researchers] are not at the stage where we can make any treatment recommendations for patients based on cardiovascular risks,” Desvarieux cautions. “Clearly, however, it would be difficult for anybody to be opposed to patients receiving good oral care.”
According to Conicella, once periodontal disease is treated—regardless of the cost (ie, relatively low for conservative scaling and root planing treatment; higher for advanced cases of periodontal disease that require surgery)—the cost to maintain a member’s periodontal health is very low long term. Since Aetna’s recent study suggests that periodontal treatment has a positive impact on medical costs, she says that over time, the costs associated with treating periodontal disease will become insignificant.
Consider, for example, the costs associated with preterm, low birth-weight babies. According to Carl Gong, DMD, the dental officer for Blue Cross of California (WellPoint), the cost to the medical system of a preterm, low birth-weight baby is at least $200,000 to $400,000; these babies are also medically compromised for at least the first few years of their lives, if not longer, requiring medical care at significant costs.
“There is definitive research showing that prenatal patients who receive appropriate periodontal treatments have a significant decrease in preterm, low birth-weight babies,” Gong explains. “When you balance the costs for caring for a preterm infant with the costs for periodontal treatment—which is between $400 and $500—the cost benefit to providing periodontal care to pregnant patients is overwhelming.”
Additionally, as the associations between oral health and systemic health become more clearly defined, the manner in which health care professionals manage patient care may become more inclusive and disease management-oriented. In the ideal world, all patients with medical insurance would also have dental coverage, Gong says. This would enable them to have access to dental care, especially when appropriate.
“What I envision is that we will create overall disease management programs, similar to what we have now on the medical side for diabetes,” Gong says. “So, where there is a correlation between oral health and medical conditions, we would create a disease management program in which we identify those patients with the condition and ensure that they receive the necessary preventive and periodontal treatments.”
EDUCATING DENTISTS & PHYSICIANS
The nature and mechanisms of the associations—as well as whether or not there is a cause and effect relationship—are still unfolding. Therefore, researchers like Desvarieux encourage dentists and physicians not to get ahead of themselves.
“A number of studies are in place to really determine what is better for the patient in terms of oral disease and systemic health, including the INVEST study funded by the NIDCR,” Desvarieux notes. “We still need to determine the mechanisms of the relationships, as well as their implications for prevention and treatment.”
As they wait in anticipation, many dentists and physicians alike are encouraged by what’s taking place within their respective professional communities in recognition of what the current body of evidence suggests.
“We have much better education about oral infections in dental schools and continuing education courses, so we have much more astute clinicians,” believes Rose. “Now, almost for the first time, we also have dentists and physicians communicating about the dental and medical status of patients, so there’s an improvement in the continuity and quality of care provided. The patient can benefit tremendously from this.”
However, Rose suggests that more education is needed in a joint medical/ dental format so that dentists can educate physicians and visa versa about specific disorders. It’s fine to say that periodontal disease may be a contributing factor to heart disease or stroke, but when a patient asks how this happens, dentists and physicians need to know more in order to explain more, he says.
“The depth of knowledge needs to be enhanced on both sides,” Rose believes. “Dentists and hygienists need to understand medical disorders, and dentists on staff at hospitals need to provide some education to the physicians there.”
As opinions from the medical and dental sides of health care continue to converge toward agreement that there are known associations between oral disease and systemic health, oral treatments and the insurance coverage for them may take center stage in the future. What’s more, according to Riggs, the whole perception of the role of dentists and hygienists—as well as the primary care team—could change.
“That’s exciting, because if the research shows a positive relationship between oral health and systemic health, then we’ll basically be looking at changing how dentistry and medicine are practiced,” says Riggs. “We are all going to have to put aside our current processes and embrace change, depending on what the current and ongoing research shows.”
But regardless of what the research may tell us, the public is starting to demand simplification and an almost unification of health care, notes Derek Bridges, president of dental and vision for Blue Cross of California (WellPoint), which offers members both traditional medical and dental coverage. He says that consumers generally want someone [ie, insurance providers] to take care of all of their health care needs, not necessarily one part of it.
According to Desvarieux, medical and dental practitioners are already beginning to develop an automatic reflex to seek advice from other professional colleagues, whether diabetologists, cardiologists, periodontists, etc, when caring for medically compromised patients. In this regard, he sees the convergence of interest regarding associations between oral disease and systemic health as a welcome development that can ultimately enhance overall patient care.
b Spahr A, Klein E, Khuseyinova N, et al. Periodontal infections and coronary heart disease: role of periodontal bacteria and importance of total pathogen burden in the coronary event and periodontal disease (CORODONT) study. Arch Intern Med. March 13, 2006; 166(5): 554-559.