The concept that oral health is a part of overall health has never been truer than it is today. Much has been written about the impact of the oral condition and what it means to the well-being of the individual since the landmark 2000 statement, “Oral Health in America: A Report of the Surgeon General.” Whether it be cardiovascular disease, diabetes, premature birth weight, or oral carcinoma, it is very apparent that how individuals take care of their oral health can have a great impact on the rest of their body.
Today, much of the dental educational experience revolves around individual risk assessment, critical thinking, and the interventions that go along with these results. This may be newly developing in dental schools, but risk assessment and its results have been used in medicine for quite some time.
Goldman, Caldera, Nussbaum, and their colleagues published “Multifactorial index of cardiac risk in noncardiac surgical procedures” in the New England Journal of Medicine in 1977. The Cardiac Risk Index was used to determine an individual’s risk for perioperative complications following surgery based on multiple risks that were presented, such as the type of surgery to be performed, age, and comorbidities. It has subsequently been revised and is now known as the Revised Cardiac Risk Index.
The assessment of an individual’s risk in developing disease could assist providers in developing personalized plans for their patients. For example, an individual with a low risk for developing periodontal disease could have a personalized oral hygiene plan that would be entirely different than an individual with a high risk.
The risk is calculated based upon the data points accumulated from the patient interview, past medical history, familial and psychosocial history, diagnostic results, comprehensive examination, and, potentially, the genome. The same could be said of caries risk, with the resulting personalized plan including interval and types of preventive therapies such as three-month recalls instead of six months and types of fluoride supplements and applications.
Potential for Oral Cancer
One of the most important risk assessments that has the potential of being overlooked in the oral health evaluation is the assessment of the risk of developing oral cancer. According to the American Cancer Society’s most recent 2017 estimates, almost 50,000 people will be diagnosed with oral cavity or oropharyngeal cancer this year, with about 9,700 of those resulting in death. That’s more than one death every hour. It’s almost twice as likely to be seen in men as in women, but it is equally common in blacks and whites.
There has been progress in reducing this number, but more can be done through early detection, risk assessment, and behavior modification. Aaron Yancoskie, DDS, associate professor of dental medicine and the director of oral and maxillofacial pathology at the Touro College of Dental Medicine and Westchester Medical Center, considers this assessment incredibly important in improving quality of life and reducing deaths.
“Oral cancer accounts for 5% of cancer related deaths in the United States,” said Yancoskie. “It is a tragedy that may be prevented through appropriate risk assessment and behavior modification as well as detection of early lesions by thorough clinical examination and timely intervention.”
In the June 2011 Journal of Oral and Maxillofacial Surgery article, “Oral Cancer: Risk Factors and Molecular Pathogenesis,” Hari Ram, BDS, MDS, and his coauthors note that the chemical risk factors of tobacco and alcohol use are codified, but many other risks such as biological factors, dietary deficiencies, and viruses are also implicated.
Other Systemic Issues
Although we know that an understanding of the risks and modifying behaviors does not eliminate risks completely, these facts indicate more than ever that the routine visit to your oral healthcare provider can result in improved oral health, overall wellbeing, and potential lifesaving outcomes.
In addition to the oral health risk assessments of caries, periodontal disease, and oral carcinoma, which are associated with the comprehensive intra-oral head and neck examination, are those overall health related issues that can alert the primary care oral health provider to screen for other health related issues. Screening for items such as hypertension, cardiovascular disease, obesity, diabetes, and viral diseases can lead to medical linkages.
A prime example is diabetes. According to the American Academy of Oral Medicine, about 23 million Americans suffer from diabetes, while the American Diabetes Association estimates there are an additional 7.2 million who do not know they have the disease. Primary care screenings of this group of undiagnosed patients within the dental office could have a marked impact on the morbidities of the disease.
Oral markers along with a comprehensive medical, familial, and psychosocial history could lead to appropriate screening within the dental office and yield preliminary results to create direct medical linkages to care. This paradigm is all for the ultimate benefit of the patient for their overall health and oral health care. The same could be said for screening patients for HIV, hepatitis C, and cardiovascular disease, and the list will grow with the advent of better and less invasive screening tests, including salivary analysis.
The Touro College of Dental Medicine, the first dental school to open in New York in almost 50 years, is developing a curriculum and clinical experience that will completely incorporate risk assessment and primary care screening. The assessment of all comprehensive care patients will include the risk assessments of caries, periodontal disease, oral cancer, tobacco usage, and nutrition and grow to include primary care screening when indicated of diabetes, hypertension, cardiovascular disease, HIV, hepatitis, and obesity. These assessments and screenings will lead to the development of personalized care, direct primary medical care linkages, and inter-professional care, which will ultimately lead to better health outcomes, all for the betterment of our patient population.
Although it was evident in 2000 with the statement of then Surgeon General David Satcher, MD, PhD, “that the mouth reflects general health and well-being,” it is even more evident through current research today and most important that it be part of what we teach.
Dr. Myers graduated with a DDS and a certificate in pediatric dentistry from the Columbia University College of Dental Medicine. He also completed a fellowship at the Albert Einstein College of Medicine. He was appointed dean of the Touro College of Dental Medicine at New York Medical College in July 2017 after serving as senior associate Dean for academic and administrative affairs, where he was responsible for the academic curriculum including its development, management, and integration, and faculty affairs. He can be reached at email@example.com.