In the age of collaborative care, providers are crossing disciplinary lines to rewrite the rules of heart disease prevention.
by Rachel O’Connor, PA-S and Jonathan B. Levine, DMD
Healthcare is a field that is dynamic by nature, required to evolve with society in order to meet its ever-changing needs. In the past decade, healthcare has seen a dramatic shift toward new core values of provider solidarity and interdisciplinary collaboration. In modern healthcare facilities, the classic doctor and nurse team has been modified to include healthcare professionals of a wide range of disciplinary backgrounds, working in tandem to meet each patient’s individual needs. This model, known as patient-centered collaborative care, places a tremendous emphasis on the ideas that healthcare is a team effort, and that patients receive the best care when the collective power of seemingly polar disciplines is harnessed and channeled.
One of the great benefits of a collaborative approach to healthcare is the increased awareness and communication that is taking place between medicine and dentistry. More clinicians are now recognizing the importance of considering the human body as a whole, rather than a sum of parts to be treated in isolation from one another. For far too long, the separation of dentistry from other branches of medicine has caused many to relegate oral health as a low priority issue, while placing the emphasis of care on the rest of the body.
It’s easy to take the divide between dentistry and medicine for granted, considering it has been that way since anyone alive today can remember. But when you think about it, it seems odd that a component of our healthcare is blatantly separate from the rest of medicine. Dental records are kept apart from medical records, dental insurance is harder to obtain than medical insurance, and emergency rooms are ill-equipped to address the growing number of dental emergencies they are faced with each year. The reason for the separation stems back to 1840 at the college of medicine at the University of Maryland in Baltimore. As the story goes, a group of dentists approached the physicians at the college of medicine about adding dental instruction to the curriculum. The physicians rejected the idea, initiating the divide between the two fields. Since then, efforts to integrate the two professions have been unsuccessful, largely due to dentists’ fear of losing professional autonomy as a consequence of joining the medical community.
The precedent may have stuck, but separating dentistry from overall health makes even less sense today than it did in 1840. Each system of the body is interconnected with the others in a delicate balance which must be maintained for optimal health. Poor health in one area of the body is bound to cause problems in another, and since the mouth is a part of that system, it shouldn’t come as a surprise that poor oral health can lead to dire systemic consequences. The era of collaborative care has given rise to an exciting, much-needed frontier of medicine: oral-systemic medicine, or the approach to care that considers both oral and systemic components of wellness.
Pioneers of oral-systemic medicine are working to foster a collaborative relationship between medical and dental professionals through open communication between the disciplines. The goal is to change the way providers and patients think about health. Rather than addressing each medical problem individually as it arises, the new approach to medicine is about preventing disease proactively by maintaining a state of continuous systemic wellness via interdisciplinary collaboration.
Researchers have been aware for several decades of an association between cardiovascular disease, the leading cause of death in the U.S., and the widespread oral health condition, periodontal disease. Periodontal disease (or periodontitis) is a chronic inflammatory disease of the gums caused by bacterial infection which affects nearly half of all American adults. Gingivitis, the mildest form of the disease, is marked by swollen gums that bleed easily. If not addressed, gingivitis can advance to more severe stages of periodontal disease which threaten the tissues and bones that support teeth. In advanced periodontal disease, gums recede away from the teeth, creating “pockets” that become infected, and eventually, tooth loss can result.
In 1989, two Scandinavian researchers found higher levels of oral disease in patients who had recently suffered a heart attack. Since then, numerous others have recorded similar nebulous parallels between oral and cardiovascular disease states. In a number of studies, the oral bacteria responsible for periodontal disease have been identified in atherosclerotic plaques in the arteries of periodontal disease patients. In 2013, infectious disease epidemiologist Dr. Moise Desvarieux published a benchmark study in the Journal of the American Heart Association, which demonstrated that reduction of periodontal disease is related to a decreased rate of progression of carotid artery atherosclerosis.
Even so, substantial evidence that periodontal disease causes cardiovascular disease has been difficult to pinpoint, especially since the two diseases share many risk factors, including cigarette smoking, age and diabetes. In a 2012 statement by the American Heart Association, the organization expressed that while the then current research supported an association between periodontal disease and atherosclerosis, it failed to provide evidence of a causative relationship.
In November 2016, a peer-reviewed literature review by Bradley Bale, MD and Amy Doneen, DNP, ARNP was published in the British Medical Journal which compiled and deconstructed the research to date on the role of periodontal pathogens in the development of atherosclerosis. Bale and Doneen are among the most influential names in cardiology and founders of the renowned BaleDoneen method for preventing cardiovascular events. The duo received acclaim from the scientific community in late 2016 for their role in publicizing the oral-systemic linked through their evidence-based conclusion that periodontal disease is not simply a risk factor for, but a contributing cause of, heart disease. Their groundbreaking publication cites evidence of the ways that periodontal disease due to high risk pathogens can cause systemic inflammation and promote each of the pathologic mechanisms necessary for the development of atherosclerosis. The condition has been shown to promote increased serum lipoprotein concentration, endothelial permeability, and lipoprotein binding in intima, each of which are crucial components of atherosclerosis progression. However, atherosclerosis is a complex disease process and periodontal disease is one of many causes. Not every person who possesses periodontal disease will develop atherosclerosis, nor will patients unaffected by periodontal disease necessarily be free of atherosclerosis. Additionally, periodontal disease may not be necessary for the development of atherosclerosis.
Now that this preventable and treatable cause of cardiovascular disease has been identified, clinicians have a responsibility to include oral disease management in heart disease prevention plans in order to effectively reduce their patients’ risk. The latest BaleDoneen publication calls attention to the lack of an effective and reliable strategy for periodontal disease reduction within the dental community. The periodontal therapies used in most dental offices today are costly, inconvenient, and only marginally effective. Additionally, most options are associated with harmful side effects. Locally-administered antibiotics are a common treatment option which place patients at risk for the development antibiotic resistance and the creation of ‘superbugs.’ The dental community is faced with a unique opportunity to take on a monumental role in the fight against heart disease by establishing a failsafe method that improves gum health (and therefore, overall health) in a way that is effective, efficient, and convenient. Once such a plaque control solution has been developed, it has the potential to significantly reduce the impact of cardiovascular disease.
Although most systems of medicine and dentistry operate exclusively, there is growing evidence demonstrating the shortfalls in cost and quality when having separate systems treating the same patients. Health insurance companies and the American Dental Association have shown reduced medical costs for people with diabetes, cerebrovascular stroke, and coronary disease who receive on-going oral health care. A barrier to providing a dental and health care delivery model includes the separation of dental and medical insurance. Although we have an increasing number of seniors, including the baby-boomers, it is surprising to note dental benefits are not included in Medicare. In a study funded by Pacific Dental Services, Avalere Health estimated the benefit on Medicare Program spending from treatment of periodontal disease. The article found an estimated savings of 63.5 Billion over a period from 2016 to 2025. With new payment arrangements covering oral health services, we can promote better overall health, cut costs, and encourage integration.
In an effort to improve and bridge the gap, some progress has been made to develop integrated systems. Organizations such as the Federally Qualified Health Centers, which provide comprehensive care regardless of one’s health insurance status, have taken the lead by combining dental services into their health centers. Co-location is only the first step, as collaboration between the two professionals is needed to fully integrate oral and systemic care delivery. In early 2016, Harvard School of Dental Medicine launched an initiative to improve collaboration by joining students from Northeastern University’s Nurse Practitioner program into Harvard’s Dental Teaching Clinics. In the clinic, DMD and NP students are being trained alongside to tackle the oral and systemic health needs of patients. Although there has been some progress in overcoming the barrier to integration, continued advancements in initiatives and policy changes are necessary to ultimately lead to system-wide transformations.
It is often at the crossroads between disciplines that innovation is born and discoveries are made. We are at an exciting crossroads in medicine. Thanks to the BaleDoneen study and continued research in the field of oral-systemic medicine, more and more clinicians are recognizing the need for unity in healthcare. Medical and dental professionals, equipped with a body of knowledge unbeknownst to past generations, have the ability to make major strides towards eliminating heart disease together. Through open dialogue between medicine and dentistry, patient education, and a clinical culture that embraces oral-systemic health awareness, more deaths can be prevented and more patients inspired to lead healthier lives. This discussion marks an important milestone in medicine, and should providers be willing to take the leap, this may very well be only the beginning.