Medicine has been great at creating body silos over the years. The most obvious example is the disconnect between physical health and mental health. Physical health providers often find it very difficult to get information about their patients’ mental condition from their patients’ mental health providers, and mental health providers rarely connect with physical health providers to really understand the total health picture of the person they are treating. Vision, mostly treated by optometrists, is rarely integrated into general medical care and, increasingly, our feet are carved out to podiatrists practicing in a one-off fashion.
I could go on and on about body carve-outs, but won’t as what I want to talk about today is oral health. Unless you get a mouth cancer of some sort, oral health pretty much belongs to the dentists and the dentists are not really connected to (or considered by most doctors to be a part of) your medical care.
The dentist at a medical home conference
I must confess I didn’t start thinking about this until I attended the National Medical Home Summit West (NMHSW) in San Francisco on September 21, 2011. Raymond Carter, who puts on this conference, had brilliantly included a dentist, Martin Lieberman, DDS from Washington state, as one of the speakers. Dr. Lieberman introduced the audience to the concept of Medical-Dental Integration and advocated for having dentists be part of the Medical Home.
Now, we all know whenever something gets “hot” in medicine (and Patient-Centered Medical Homes (PCMH) are hot right now), everyone tries to reframe what they do to be a part of the hot new thing. A number of years ago, when primary care was first getting a lot of attention, specialists including OB-GYNs and emergency physicians were proclaiming themselves primary care doctors. Ok, so now the dentists want to capture some of the PCMH glow? Could be, but I also believe that Dr. Lieberman is on to something by raising the issue of the impact (sometimes bidirectional) of oral and systemic health.
Here is an example: Periodontitis is a chronic infectious disease of the gums. Untreated, it can lead to receding gums, loose teeth, and loss of teeth. Two studies (one by Mealy BL and Oates TW and the other by Taylor GW and Borgnakke WS) have shown that periodontal disease impacts glycemic control of diabetics. A recent meta-analysis of controlled studies, published in Diabetes Care by Wijnand J. Teeuw DDS and colleagues, suggests that treatment of periodontal disease appears to improve glycemic control by ~0.4% in Type 2 diabetic patients for at least 3 months. One study the authors reviewed showed that there is a difference in response to treatment depending on whether the patient had evidence of systemic inflammation as measured by C-reactive protein (CRP). Hemoglobin A1c levels decreased significantly in the group of patients that had decreased levels of CRP post-periodontal disease treatment compared to those whose CRP levels remained unchanged.
Dr. Lieberman also said at the Medical Home conference that “researchers estimate that as many as 18% of the 250,000 premature low-weight infants born in the United States each year may be attributed to infectious oral disease.” He did not provide a reference, so I went to PubMed to look for one. Although there are a number of research papers that address the topic and purport to show an association between periodontal disease and adverse birth outcomes, none of the large reviews of the literature state definitively that periodontal disease causes premature delivery or low birth weight. Nor could I find a definitive review that showed that treatment of periodontal disease prevents these problems. That being said, the possibility of a link has not been ruled out because of issues related to study design (variations in diagnosis severity, treatment, control groups, etc) of the reviewed papers.
Other obvious examples of the interplay of oral and general health are oral manifestations of HIV, the link between dental infections and heart valve infections, and the impact of significant tooth loss on nutritional status. There are even studies that link oral health behaviors to poor self-image.
Dr. Lieberman described co-locating a dentist in a Medical Home as one way of putting the mouth back in the body. But it isn’t the only way. Primary Care Physicians (PCPs) could simply make dental health a routine part of the comprehensive annual exam. (Yes, I know. If PCPs do everything we ask of them, they would have to work 18 hours/day as shown in Tom Bodenheimer, MD‘s presentation’s 8th slide at NMHSW). But some of this stuff could be handled by questionnaires and/or other members of the healthcare team. The point is recognizing and making clear to patients the interplay between dental health and general health.
When was the last time your doctor talked to you about the state of your teeth? Or encouraged you to see a dentist? Or inquired whether you had ever been told you had gum disease? If this is happening routinely where you get care, let me know.
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