Systemic Diseases and Dental Treatment: Talking With Your Patients

Now, more than ever, patients are hearing about the “mouth-body” connections between systemic disease and oral disease. Dentists and physicians have known for years that illnesses and conditions of the mouth, gums, and teeth are directly related to illnesses and conditions in the rest of the body. Research is now providing ample evidence to back this up.
Dental treatment for the management of oral disease is finally being recognized as a vital cog in the “total-body health” machine. How can we talk to our patients about the im­portance of dental treatment to their general health? What might we highlight as a means to support our recommendations for our patients’ care? How can we approach the topic so that our patients say “yes” to what they really need?

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FIVE TALKING TIPS
Inflammation Is the Connection
Most patients understand the concept of infection and how the body may become infected (germs). Many also understand the basics of inflammation. For example, if you hit your thumb with a hammer, it will usually become red, swell, and get hot (symptoms of inflammation); and it will also most likely hurt. Talking to patients about the relationships between inflammation/infection, oral diseases, and general health can be key to their understanding of the importance of dental treatment. Discuss the fact that studies show that bacterial infection and tissue inflammation are important causative factors in periodontal disease. Bacterial by-products and inflammation in the body can also be major factors in the development of diseases such as diabetes, heart disease, stroke, and other serious problems. Therefore, inflammation appears to be a significant link between systemic disease and oral disease.1
The literature defines inflammation as the first response of the immune system to injury, infection, or irritation. When an infection occurs, a series of automatic reactions begins which are designed to protect the body as a whole. Blood vessels dilate around the site of an infection, causing redness and heat. Blood vessels may also constrict some distance away from the site, causing swelling, pressure, and pain on nerve endings. All of this blood vessel activity causes white blood cells to move to the affected area, surrounding bacteria and preventing their spread. Therefore, the purpose of inflammation can be explained as a method of isolating and eliminating infection.
The entire body may be affected by the process of inflammation, leaving a patient feeling feverish, achy, or tired. However, patients may be surprised to know that it is possible to have an infection and an inflammatory response occurring, without any general systemic symptoms at all. If the cause of the inflammation goes away, the situation may resolve. If the cause of the inflammation does not go away or becomes worse; harm may occur to organs, blood vessels, the heart, and even joints and nerves. Therefore, since periodontal disease can trigger a systemic (or whole body) inflammatory response if the disease is not controlled, the body can be damaged.

Periodontal Disease: What is It? What Can it Do?
According to the ADA, approximately 70% of the population has some form of periodontal disease, making it one of the most widespread health issues in the United States. We need to help patients understand how this disease can affect them personally. After discussing the fact that periodontal disease is caused by bacteria growing around the teeth, and the subsequent inflammatory response that occurs; it is natural to provide details of periodontal disease symptoms in patient-friendly terminology. Explain to them that the combination of a bacterial infection and inflammatory reaction can result in the destruction of the tissue and bone around teeth. This in turn can cause loose teeth, exposed roots, bad breath, sensitivity, bleeding, swelling, and pain. Patients need to know that it is a major factor in tooth loss. If the foundation is faulty, the building will fall. They also need to know that periodontal disease may exist in the absence of overt symptoms.

Periodontal Infection, Inflammation, and General Health Problems
Even if a patient seems unconcerned about tooth loss, bad breath, sensitivity, bleeding, and pain, he/she may be concerned about how the bacteria implicated in periodontal disease is related to the bacteria found in heart disease. According to a study published in the Journal of Periodontology,2 periodontal pockets may become infected by a specific type of bacteria, and/or combinations of certain types of bacteria, that are related to the development of acute coronary syndrome (ACS). (According to the American Heart Association, ACS is an “...umbrella term used to cover any group of clinical symptoms compatible with acute myocardial ischemia…[which is] chest pain due to insufficient blood supply to the heart muscle that results from coronary artery disease.”) The bacteria that were identified from the study as present in both periodontitis and ACS are Treponema denticola, Tannerella forsythia, and Streptococcus spp. According to Stefan Renvert, DDS, PhD, Department of Health Sciences, Kristianstad University, “This might be one of several explanations as to why elevated bacteria and the combination of specific pathogens in periodontal pockets can be linked to a history of ACS. The amount of periodontal bacteria results in an inflammatory response that elevates white blood cell counts and C-reactive protein (CRP) levels, which has also been linked in past studies to heart disease.”3 What might this mean for patients? Those who receive periodontal examinations, necessary treatment, and subsequent adequate home care, might be able to reduce their incidence of ACS.
Heart disease is not the only condition linked to periodontal disease. Diabetes and preterm, low-birthweight babies have been shown to be related to periodontal disease. In the October 2003 issue of the Journal of the American Dental Association,4 a study revealed that when diabetic patients’ periodontal infections were treated, they experienced a “marked improvement” in their ability to manage blood sugar. In 2006, the Journal of Periodontology2 reported that insulin resistance leading to diabetes was higher in persons with periodontal disease. Therefore, controlling a patient’s periodontal disease might help control a patient’s diabetes.
Additionally, a certain protein, CRP, has been shown to be present in periodontal disease and heart disease, and has also been implicated as having an impact on premature births. In 2003, a Journal of Periodontology5 study followed 366 women with advanced gum disease. Those who received treatment in the form of scaling and root planing in the second trimester showed an 84% reduction in premature births!4

Dental Treatment Can Reduce/Eliminate Periodontal Disease, Thus Reducing the Risks of Many General Health Disorders

We have already discussed the fact that the bacteria that cause periodontal disease do not confine themselves to the mouth, but can travel throughout the body. As the inflammatory system attempts to “fight off” these bacteria, the inflammatory response may become widespread. Susceptible organs, arteries, and tissues can be damaged. If the bacteria and inflammation in the mouth are not controlled, as in the case of chronic periodontal disease, the body can never shut down the inflammatory system in the rest of the body. Why? The cause of the inflammatory response (the bacteria and inflammation in the mouth) never goes away. Therefore, patients need to know that if they are diagnosed with periodontal disease, it is in their best interests to accept treatment.
Treatment may be in the form of root planing and scaling of the teeth, medicines or prescriptions, and/or surgical interventions by a dentist. Patients need to understand that when diseased tissues and bacteria are removed from teeth, gums and bone, infection and inflammation can be reduced or eliminated. With the burden of infection reduced, the body’s immune system can promote a general healing process. Be careful that patients understand that controlling the health of the mouth cannot totally prevent any risk of general health problems. Health issues have many components; for example, being overweight, smoking, family history, diet, exercise, and the effect of medications all have an impact. However, by maintaining a healthy mouth and reducing oral inflammation, a patient may be able to live life as a generally healthier person.6

Discuss Fees and Insurance While Emphasizing the Long-Term Benefits of Treatment
A few insurers are beginning to acknowledge the connection between a person’s oral health and their general physical wellness. While dental (“tooth” related treatments) are still often payable only by dental plans, a few carriers have begun to cover some services under their medical plans. For example, a few carriers stipulate that if a pregnant woman is covered by both the medical and dental programs provided by their company, she will be entitled to 3 rather than 2 adult prophylaxis-D1110 procedures that year. As evidence mounts as to the mouth/body connection in certain diseases, it is possible that eventually more carriers will recognize periodontal services as payable under medical contracts. Until that happens, dental plans are still the primary source of coverage for periodontal treatment; although in most cases, that coverage is quite limited.
In an effort to control plan costs, and because so many people need periodontal services, most contracts contain payment restrictions. This means that for most patients, a good portion of the cost of any periodontal treatment will be their responsibility. Because of this, giving the patient a written fee estimate prior to the commencement of treatment is a must.

CONCLUSION
It is important for patients to take ownership of their health and the responsibilities that they have in maintaining good oral and systemic health. In order to be able to do this, patients need to understand their oral health conditions; understand and accept the dentist’s treatment plan; understand and accept their role in home care and follow-up treatment; and acknowledge and accept the total fee that will be charged.


References

 

  1. Beck JD, Offenbacher S. Relationships among clinical measures of periodontal disease and their associations with systemic markers. Ann Periodontol. 2002;7:79-89.
  2. Renvert S, Pettersson T, Ohlsson O, et al. Bacterial profile and burden of periodontal infection in subjects with a diagnosis of acute coronary syndrome. J Periodontol. 2006;77: 1110-1119.
  3. American Academy of Periodontology. New study supports findings that periodontal bacteria may be linked to heart disease [news release]. July 18, 2006. http://www.perio.org /consumer/heart-disease.htm. Accessed April 10, 2009.
  4. Robertson C, Drexler AJ, Vernillo AT. Update on diabetes diagnosis and management. J Am Dent Assoc. 2003;134: 16S-23S.
  5. Jeffcoat MK. Hauth JC, Geurs NC, et al. Periodontal disease and preterm birth: results of a pilot intervention study. J Periodontol. 2003;74:1214-1218.
  6. Tekavec C. Your Mouth Can Make You Sick. Pueblo, CO: Stepping Stones to Success; 2007.

Ms. Tekavec is the author of the Dental Insurance Coding Handbook with all current ADA codes, as well as the designer of a dental chart, endorsed by the Colorado Dental Association and others. She is also the author of a series of patient brochures explaining various dental procedures. Ms. Tekavec practices as a dental hygienist and is the president of Stepping Stones to Success. She has appeared at all major US dental meetings and has been listed in Dentistry Today’s Leaders in Dental Consulting for 10 years. She can be reached at (800) 548-2164 or via her Web site at steppingstonestosuccess.com.

 

Disclosure: Ms. Tekavec is the author of Your Mouth Can Make You Sick.



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