The traditional model of medicine treats the body as individual systems and organs. This “dis-integrated” model of medical care also frequently excludes the oral cavity. Some examples we are all too familiar with: a physician or an endocrinologist overlooks the mouth when considering a disease-management program for a diabetic patient; a patient suffering from chronic lung disease (COPD) has little advice from his/her medical team about managing his/her dental plaque and; a stroke survivor goes unaware that his/her oral health will likely deteriorate to cause further inflammation and risks for another adverse medical event.
Moreover, in these cases where patients with multiple chronic conditions (MCC) are told to “see their dentist” by the medical team, a trip to the dentist happens all too infrequently. Either the patient has no dentist, or is anxious about going to the dentist because of the large co-pay on dental work, because of dental costs for those without insurance, and because of perceived pain and trauma and difficulty of getting to and from the dental practice.
The cost of “dis-integrating” oral care from medical care is significant and growing. The evidence from intervention studies (those where changes to oral health are monitored for subsequent changes in overall health) now shows that poor oral health is not only an independent risk factor for MCC but can aggravate chronic conditions. For example, it is becoming clear that reduced inflammation of the gums can stabilize glycemic control amongst Type 2 diabetics (Chart 1). It is also clear that improved oral hygiene (both above and below the gum line) can slow the decline of lung capacity of COPD patients, as well as reduce exacerbations for these patients. 1
Where: GC = control group without SRP and GT = treated group with SRP at baseline
*results at at p<0.05
Source: Mauri-Obradors E, et al. 2018. Benefits of non-surgical periodontal treatment in patients with type 2 diabetes mellitus and chronic periodontitis: a randomized controlled trial. J Clin Periodontol., 45 (3) March: 345-353
So, as the population ages and MCC grows, a critical question is: can our community afford to continue with this separation of dental care from medical care? Put another way: is the separation of the mouth from the body a sensible, evidence-based approach to managing the health of rapidly growing numbers of older Canadians?
The Origins of Poor Oral Health
Poor oral health, as indicated by chronic periodontitis and/or (recurrent) caries emerges when the microbial biofilm has a change in the balance of microorganisms. The color, texture and consistency of gum tissue changes from a pink, firm, stippled look to red, spongy and smooth, indicating infection and inflammation. In terms of the hard tissues, root caries often emerges quickly and repetitively in patients with MCC. Both pathologies arise when the mix of bacteria shifts from being symbiotic or commensal with the host to being dysbiotic. Disease promoting bacteria dominate the biofilm and cause poor oral health.
Oral dysbiosis emerges most commonly with advancing age and the onset of MCC. Many times, it is “the chicken or the egg” scenario when it comes to diabetes, which came first – diabetes or periodontal disease. Chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) are also common diseases where oral dysbiosis is a contributing factor, not to mention the emerging connections between poor oral health with heart disease and Alzheimer’s.
What It Means to Manage the Primary Cause of Poor Oral Health
What might work for managing oral dysbiosis cost-effectively and if this condition can be managed, what are its implications for the conduct of hygiene services? Will it help to overcome the separation of dental care from medical care which limits our role in Canadian communities as they age.
These are complex but vital questions that are presently under investigation by several Canadian organizations such as Sinai Health System (Toronto) and my practice of independent dental hygiene called the Gleam Smile Centre in Hamilton.
For years, my practice has served MCC patients with Prevora (DIN 02046245). Prevora is a high strength, sustained-release topical antiseptic coating applied to the hard tissues and the gingival margin. It works by re-adjusting the composition of the plaque on the teeth, at the gum line and in the gingival crevice. Prevora shifts this mix of bacteria from dysbiotic to symbiotic. And when this happens, almost universally the patients experience better oral health, and often remark they feel better too.
The consequences of Prevora’s pronounced treatment effect have become increasingly apparent over time. Gleam’s original focus for Prevora on preventing root caries, has expanded to include the prevention of inflammation in the mouth and most recently, the delivery of oral health consultation and care to diabetic patients in the setting of a group medical practice.
In this journey, we have learned that by getting patients healthier the patient becomes very loyal, very willing to pay for services, and indeed, very willing to give testimonials.
We should not be surprised about this response by the Prevora patient. Any treatment which manages both caries and periodontal disease at the same time is clearly cost-effective to those with and without insurance. Any treatment which minimizes discomfort and pain has merit. Lastly, a treatment which manages a threat to overall health becomes a priority; after all, we know how informed the patients have become about the linkages between the mouth and their overall health.
Baby Steps Towards Integrated Care
Most recently, Gleam is participating with a Toronto family medical practice in a pilot study to improve the oral health of Type 2 diabetic patients using mobile hygiene with Prevora. This practice has several diabetic patients daily. Many of these patients have a dental plan or are regular visitors to a dentist yet few if any, have a dental focus on managing oral dysbiosis or even understand the importance of doing so.
The pilot study is designed to evaluate three endpoints: first, how best to integrate hygiene into the patient’s regular visit to the medical practice; second, how best to engage the patient to participate in managing oral dysbiosis as part of their diabetes program, and; third, what effect has improved oral hygiene on glycemic control (e.g. AIC levels) for these patients.
In this pilot study, Gleam is providing a short consultation with the diabetic patient about oral dysbiosis and diabetes, about the Prevora treatment plan, and about its costs and convenience. Our consultation is upon referral by the family doctor and is tracked by the medical clinic in the electronic medical record of the patient. In this manner, our hygiene service has been integrated into the patient pathway.
Trials and Tribulations –Then a Breakthrough?:
Change in any profession or industry is difficult and slow, but in healthcare and dental care, it can be glacial. We are rooted in our procedures, in our silos and by our insurance systems.
But change we must when considering the emerging science and studies showing the linkages between oral health and overall health (Chart 1), when we are compelled to treat an aging population with co-morbidities which include poor oral health, and when we can show that by integrating our services with those of the physician, we can improve our practice and the health of our patients.
Ten years ago, Gleam opened its doors and offered a range of conventional hygiene services. Today, we are practicing much differently and even in new venues. One reason for our change is our ability to manage the cause of poor oral health, with an affordable, topical antiseptic procedure. This ability has made better management of MCC patients a possibility, even in a medical practice. Gleam believes we could be on the cusp of a breakthrough for independent hygiene.
- Zhou, X et al. 2014. Effects of periodontal treatment on lung function and exacerbation frequency in patients with chronic obstructive pulmonary disease and chronic periodontitis: a 2 year pilot randomized controlled trial. J Clin Periodontol, 4: 41(6), 564-572
About the Author
Julie DiNardo, RDH graduated in 1987 and working independently since 2008, Julie has a well established private practice, the Gleam Smile Centre, in Hamilton Ontario. Focusing on the wellbeing of her community, she was the recipient of the Community Service Award in 2016 for her advocacy efforts towards better oral health. Julie is past president of the Business Executives Organization and continues to be on their board of directors. As a founding member of the American Association for Oral Systemic Health, Julie has been able to bring forward the message of better oral health for improved patient care.