Integrating Oral Health Care into Systemic Disease Management

Integrating Oral Health Care into Systemic Disease Management. Image credit: © freshidea – stock.adobe.com

The term oral-systemic health is just a long way to say what it really is: Health. The mouth and the rest of the body are intrinsically linked—a fact that often goes overlooked. Dentistry and medicine continue to march forward on parallel paths that have historically not overlapped, leaving health care siloed into care for the body and the mouth, much to the detriment of overall health.

“Oral-systemic health is probably the most critical missing link in healthcare today,” says Sam Shamardi, DMD, diplomate of the American Board of Periodontology and Implant Surgery. “So many major medical health issues are directly linked to the mouth (and more specifically, to periodontal disease). Having a greater awareness of this within the medical community and greater population would create a seismic shift in overall patient care.”

Many dentists, doctors, and organizations like the American Association for Oral-Systemic Health (AAOSH) want to shift this paradigm. Oral health care is critical to overall healthcare due to the many associations between oral inflammation and systemic disease. However, the traditional mindset (for both patients and clinicians) has been that medical and dental specialties stay in their lanes. Dentists do teeth, and doctors do everything else.

“There isn’t cohesiveness between medicine and dentistry,” says Parul Dua Makkar, DDS, FACD. “Medical insurance and dental insurance are separate, so patients—and some practitioners—subconsciously feel like healthcare and oral health care are different. Groups like the AAOSH are bringing together masterminds of different professions in medicine and dentistry and combining them to make these associations.”

Why Oral-Systemic Health Matters

Oral health conditions such as periodontal disease have been linked with numerous health conditions, including heart disease, stroke, cancer, Alzheimer’s, respiratory disease, and more. Oral inflammation, bacterial contamination, and soft-tissue issues are all factors that can affect systemic health. This association with systemic conditions makes oral healthcare critical to health in general.

“The mouth is the gateway to overall health,” says Ellie Campbell, DO, MS, FAAOSH, secretary of AAOSH. “If you don't have proper nutrition and diet, your body cannot fight back. If you have bad oral health, infections, or periodontal disease, that’s all passing through the same bloodstream that goes to your heart and lungs and affects those organs. It’s all interconnected.”

In addition to associations between periodontal disease and oral infection with overall health, the physical structure of our mouths and jaws greatly affects the health of the rest of the body.

“Pathogenic oral bacteria affects so many areas of total health,” says Mike Milligan, DMD, a founding member and board member of AAOSH. “In addition, the structure, posture, and function of our mouths affect the quality of our airways, the way we breathe, how well we breathe and sleep, the oxygen and carbon dioxide levels in our blood, and our overall health.”

Where Oral Health is Being Integrated into Care

For Dr Campbell, learning about oral-systemic health was necessary to improve patient care in her integrative family medicine practice. She had an elderly patient whose blood pressure and cholesterol were managed with medication but was otherwise healthy. Despite this apparent good health, the woman suffered a stroke. Unfortunately, hemorrhagic transformation complications developed, and the woman ended up passing away.

Dr Campbell was troubled by the case. Where had conventional medicine failed and what had caused the stroke when the woman was presumably healthy? She began researching to determine what triggered the event, ultimately learning about the link between periodontal disease, inflammation, and stroke.

“I learned the woman had been complaining of a toothache in the weeks before her stroke,” Dr Campbell says. “Now I understand that I have leading indicators and bloodwork that I can do that can tell me months and years in advance that this patient has an inflammation problem, that their arteries are inflamed, and likely, depending on which markers, it's either a periodontal or endodontic problem.”

Since Dr Campbell began identifying sources of inflammation and the associated underlying root causes in her patients 7 years ago, she hasn’t had any patients suffer heart attacks or strokes.

“Every day we’re hearing about more and more comorbidities,” she says. “This is where I wanted to take steps to eliminate this potential link for my patients.”

Unfortunately, Dr Campbell says, she hasn’t seen an emphasis on this link in many fields outside of integrative medical doctors or biological/holistic dentists. While dentists and doctors are beginning to cross the aisle, the integration is nowhere near where it needs to be.

“The American Dental Association and the American Heart Association both have initiatives on oral-systemic health,” she explains “But I feel like it's mostly just talk at this point; I don’t think it’s been translated into action. There's always an implementation gap whenever there's a new initiative. And I hope that in 2024 and 2025, we'll see more and more doctors become enlightened as they hear these stories.”

Salivary diagnostics

Despite the slow adoption, tests, and diagnostics that can identify problem markers are entering the field. These indicators can alert clinicians to issues in both oral and systemic health.

“When people start taking a comprehensive approach, it will shift the mindset away from medicine and dentistry being separate,” Dr Dua Makkar says. “By having open conversations and getting more patients involved in their care, you can help them understand how the two are linked. The holistic approach, where we are doing salivary testing and associating that with a dental exam is where people will start to integrate, and more and more will happen over time.”

This saliva testing is one method that is beginning to close the gap between dental and medical healthcare. Through salivary diagnostics, the antibodies, cytokines, enzymes, and antimicrobials in saliva and blood can help identify underlying pathogens that can cause periodontal disease. These biomarkers can isolate potentially problematic bacteria that could be early indicators of disease, giving time to stave off larger problems before they start. As the availability of in-office salivary diagnostic testing increases, dentists and doctors can easily integrate saliva testing into their routine practice.

Unfortunately, while salivary testing is becoming more accessible in dental practices, that isn’t always the case for patients: insurance often stands in the way. While it may not be overly expensive, the lack of insurance coverage still presents a financial hurdle for many patients.

“The problem right now is that salivary diagnostics that look for oral bacteria are often not covered by insurance,” Dr Campbell says. “So, it takes a motivated, interested patient with enough discretionary income to prioritize their dental and medical health and make the necessary sacrifices to cover those tests.”

BaleDoneen Method

Another comprehensive approach to oral-systemic health is the BaleDoneen Method. This method integrates tests (such as bloodwork), oral assessments for periodontal disease, and lifestyle/diet evaluations to assess a patient’s overall risk for cardiovascular disease.

“More health care practitioners are becoming aware of the effect of periodontal and apical pathogenic oral bacteria on overall health,” Dr Milligan says. “I have worked with several physicians trained in the BaleDoneen Method of prevention of heart attack, stroke, and dementia, who have an incredible record of preventing these debilitating events. They say they cannot get the results they do without help from a dentist who is aware of and trained in detecting and minimizing the pathogenic periodontal and apical oral bacteria.”

This approach provides a more well-rounded approach to both oral and cardiovascular health. By emphasizing preventative care, periodontal issues can be avoided long before they progress to arterial disease. The BaleDoneen Method is also a critical education tool for patients to help them understand the links between oral and overall health—and that dentists aren’t only examining your teeth but are looking at interconnected systems.

“The mindset needs to shift away from thinking of dentists as cavity hunters,” Dr Dua Makkar says. “When we talk to patients, we need to explain we aren’t just checking for cavities, we’re looking at overall health. I’m taking X-rays because I’m checking for abnormalities. I’m checking your airway, looking for nodes, and screening for oral cancer. Patients don’t know this because it hasn’t been talked about.”

Getting patients to understand these links also opens doors for dentists to educate patients on the importance of nutrition, sleep, and other healthy habits that may typically be associated with body health.

“Some dentists help their patients with lifestyle choices like nutrition, exercise, posture, breathing, and healthy sleep,” Dr Milligan says. “The vast majority of physicians and dentists today are not educated and trained in these areas, but progress is being made, and hopefully many more will become educated and trained. The overall health of our patients will greatly benefit.”

Reaching across the aisle

Historically, dentists and physicians have, for the most part, stayed in their respective silos. They treat what they know best, excluding other aspects of the patient’s overall health.

“No one can know everything, so health care providers focus on different areas of interest to them,” Dr Milligan says. “But for maximum overall health for the patient, understanding how oral and overall health interact is extremely important.”

While this is critical in overall oral-systemic health care, it also comes into play in day-to-day treatment. Some patients have conditions that make dental cleanings a risk. For example, it has been recommended that patients with mitral valve prolapses take antibiotics every time they go to the dentist to avoid releasing bacteria into the bloodstream. Many dentists were unsure of what prophylactics and aftercare these patients required. If doctors and dentists communicated better about medical conditions, it would mitigate these concerns.

“When a patient gets an echocardiogram, they don't put whether or not the patient needs antibiotics before dental care at the bottom of the report,” Dr Campbell says. “If you get a knee replacement, there’s no report that says they need to be on prophylactic antibiotics at dental cleaning. If this information was included on discharge paperwork, the patient and the dentist would be educated and could make decisions accordingly. And that’s the sort of interprofessional collaboration we need.”

From a medical standpoint, this communication is just as critical. Many patients don’t get cleared before they go for surgery, leaving surgeons in the dark. Dr Dua Makkar says this could be as simple as noting whether the patient has missing teeth before intubation, or if they have metal fillings before undergoing radiation for oral cancer treatment. Sharing this information between doctors and dentists would form partnerships that not only benefit patient care but also make clinicians’ lives a lot easier.

This transition is beginning, as surgeons and dentists learn more about oral-systemic connections. Dentists are requiring signoffs from surgeons before cleanings, and surgeons are requesting a clean dental bill of health before surgeries.

“I do see more orthopedic surgeons who require a letter of oral health from the patient’s dentist before doing joint replacement surgery,” Dr Milligan says. “I see sleep physicians and dentists collaborating to help patients with UARS and obstructive sleep apnea (OSA). Continuing and growing this is critical. Over time more physicians and dentists are learning about the oral-systemic connections and implementing it in their overall patient care. This process has been slow, but I think it is improving.”

In addition to communication between doctors and dentists, Dr Dua Makkar believes clinicians across the board should be better versed in oral cancer and its potential connections with other systemic cancers. Since different types of cancers can metastasize to the oral cavity, dentists need to know a patient’s medical and cancer history so that the dentist can be vigilant about it. The correlations between systemic and oral cancer are not a one-dimensional story, so multi-dimensional approaches must be taken. To address this, educational opportunities such as the Dua Good Job symposium have been created.

“We want to bring together the different facets of medicine and dentistry and how they correlate to oral cancer,” Dr Dua Makkar says. “We look at oral-systemic links, treatment protocols, screening, psychological and nutritional impacts—a comprehensive approach to cancer that clinicians across both fields should know.

The Future of Oral-Systemic Health

While oral health has slowly been introduced into systemic disease management, there is still a long way to go. In addition to dental and medical clinicians collaborating more openly, education and communication need to improve.

“It’s time we begin taking periodontal health far more seriously as a population and medical/dental community,” Dr Shamardi says. “No other area of health care right now can make a bigger impact! Clear communication and teamwork between the medical and dental fields on a high level along with our academic institutions are key to improving integration.”

Before communication is facilitated, clinicians need to be educated about its importance. Integrating oral-systemic health education into medical, dental, and hygiene schools would provide clinicians across the fields with valuable information before they enter the workforce.

“I think a foundation of oral-systemic education should be at every level,” Dr Campbell says. “This starts with the next generation, but I think we all need to participate. Oral-systemic education should be part of the requirements to maintain our licensures.”

Education is critically important because it trickles down to patients. If practitioners don’t understand the importance of oral-systemic health, patients won’t either. And if patients don’t appreciate the connections between oral and overall health, systemic approaches won’t evolve.

“Education of the physicians, dentists, and all healthcare personnel needs to be much better on how the mouth affects the body and vice-versa, as well as the diagnostics and most effective treatment methods,” Dr Milligan says. “The healthcare personnel must understand and believe it and be competent in the diagnosis and treatment before the patient will accept the diagnosis and treatment. Communication with the patient also needs to improve.”

This communication must continue outside of the practice. Dr Shamardi believes that the message won’t make a sufficient impact if patients only hear it from their providers. “We need less bureaucracy and more action,” he says. “There needs to be a major national push to make this topic more of a priority. Cancer and Alzheimer’s receive far more attention than oral health. The irony is that they too are directly linked to periodontal disease!”

Dr Campbell agrees.

“We just need to get the word out,” Dr Campbell says. “We need to start this at the grassroots level and get the information in the hands of consumers. Heart attacks are optional, strokes are stoppable, and dialysis is not your destiny. And all those conditions share something in common: The oral health component. We now have leading indicators, and those things can be preventable. But no cardiovascular prevention program is complete without a medical provider, a dentist, and a hygienist on the team.”