Relationship Between Oral Health and Systemic Disease - American ...

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that we incorporate these approaches into dental and dentalhygiene practice. Our patients need to become accustomed tothe same comprehensive assessment process. Clinicians canthen put together a picture for the patient that incorporates oraland systemic risk factor findings, and discuss how their chronicgingivitis or periodontitis condition may place them at riskfor CVD, poor glycemic control or an adverse pregnancy outcome.Once risks have been identified, those that can be modifiedare incorporated into the dental hygiene treatment plan andpatient education process. Just as a physician will recommend apatient lose weight or prescribe an antihypertensive agent, thedental hygiene therapist may make recommendations for thepatient to begin a smoking cessation program, use specific preventiveoral care products, monitor their blood sugar regularly orcomplete a nutrition counseling program, in addition to havingdebridement of plaque biofilm and calculus. Certainly, patientswill view the dental hygiene appointment as more than a “cleaning”if greater emphasis is placed on the patient’s total health, riskfactor assessment and risk factor modification.In addition, once risk factors have been identified andappropriate treatmentplanned, it is important tobe prepared to answer questionsabout medicationsand products that have antiinflammatoryand/or antibacterialproperties. Forexample, in the past decade,several engineered therapeuticproteins and antibodieshave been generatedand are either currently inuse or in the late stages of clinical trials. Patients may be familiarwith:• Etanercept (Embrel ® ), which binds TNF-α and preventsit from engaging its inflammatory functions• Recombinant Protein C, which helps the body dissolvesmall clots triggered during inflammation• Infliximab (Remicade), a monoclonal antibody thatbinds to TNF-α, and has been used to treat autoimmuneinflammatory diseases such as rheumatoid arthritis andCrohn’s diseaseWhile these drugs are being used to treat systemic diseases,it is possible that they could be used to treat inflammation relatedto gingivitis and periodontal disease. Other engineered proteinsunder development may also be used to treat these oralinfections. 43Another anti-inflammatory medication that has beenshown to be effective for the treatment of periodontitis is lowdosedoxycycline hyclate (Periostat). Periostat inhibits the collagenaseactivity by neutrophils, thus preventing the degradationof connective tissue and bone loss. Therefore, it is beneficial aspart of host modulation therapy. It is administered twice dailyat a dosage of 20 mg. Periostat is an antibiotic; however, thedose is too low to produce antibacterial effects. Studies haveJust as a physician will recommend a patient lose weight orprescribe an antihypertensive agent, the dental hygienetherapist may make recommendations for the patient tobegin a smoking cessation program, use specific preventiveoral care products, monitor their blood sugar regularly orcomplete a nutrition counseling program, in addition tohaving debridement of plaque biofilm and calculus.demonstrated that Periostat improves the effectiveness of routinescaling and root planing and that the progression of periodontitisis decreased. 43Optimal preventive education programs should includediscussion of twice-daily brushing, flossing and use of achemotherapeutic mouth rinse to reduce bacterial plaque andsusceptibility to gingivitis. 44 Products recommended should bethose that have been well-researched and demonstrated safetyand efficacy. For example, Peridex ® and Listerine ® AntisepticMouthrinse are the only two chemotherapeutic mouth rinsesthat have been approved by the American Dental AssociationCouncil on Scientific Affairs. Their effectiveness has been wellestablished. Similarly, a dentifrice containing triclosan/copolymer(Colgate Total ® Toothpaste) has been shown to be effective inreducing plaque and gingivitis, controlling bacterial infectionand preventing or slowing the progression of periodontal disease.45 In addition, triclosan has been shown to possess potentanti-inflammatory properties. In vitro studies have demonstratedthat triclosan has inhibited IL-1 stimulated prostaglandinproduction in human gingival fibroblast cells, inhibited theproduction of IL-1 by fibroblasts stimulated with TNF-α andhas inhibited the productionof collagenases byhuman bone cells andfibroblasts stimulated withIL-1 and TNF-α. 46,47 Theantibacterial and antiinflammatoryproperties oftriclosan are reasons to recommendColgate Total ®toothpaste both for patientswith periodontal diseases aswell as for those whose systemichealth has been compromised.ConclusionResearch suggests that there is an interrelationship betweenoral infection, inflammation and systemic health. Patients, dentalhygienists, dentists, dental specialists and other health careproviders should be aware of the consistent relationshipsbetween oral inflammation and systemic diseases. They shouldvalue the need to modify assessment, prevention, and treatmentprotocols to improve the oral health as well as total health of thepatients they treat in the office each day.Take Advantage of the Opportunity toEarn CE PointsBased on the information presented in Inflammation: TheRelationship Between Oral Health and Systemic Disease,you can earn 2 CE points by visiting www.adha.org andselecting “Continuing Ed” on the left-hand navigational bar.Then simply click on ADHA Continuing Education Coursesand select this course.6 access—special supplemental issue—april 2006
A Case in PointMrs. White, a 45-year-old Hispanic female, presents toyour practice for an initial dental hygiene appointment.She is new to the area, but reports that she faithfully haddental and dental hygiene care every six months. Mrs.White’s medical history is significant for the following:• Myopia for which she wears corrective lenses• Borderline hypertension—no medications prescribed• Prediabetes—diet and exercise recommendationsmade by nurse practitioner• Overweight—diet and exercise recommendationsmade by nurse practitioner, advised to lose 20pounds• Smokes 1/2 pack of cigarettes daily for over 20yearsOral history is significant for the following:• Generalized gingivitis with moderate plaque presenton lingual surfaces of mandibular premolar andmolar teeth and supragingival calculus and plaquenoted on the lingual surfaces of mandibular incisors• No evidence of current or recurrent decay, previoushistory of decay with occlusal restorations presenton all first molars, and a crown on tooth #31• Presence of nicotine stomatitisMrs. White reports that she has been advised previouslyto quit smoking and has attempted to do so on threeoccasions without success. She states that she was toldthat she had gingivitis by her previous dentist and dentalhygienist, but that it was not serious and that she shouldbrush and floss more. Mrs. White admits that she does notfloss regularly, but brushes twice daily with a manual toothbrush.Given this information about Mrs. White, take amoment and imagine her sitting in the operatory. She isready for her appointment. What is your next step? Do youneed more information or are you ready to proceed withtreatment? Have you mentally picked up your cureteagerly anticipating removing the debris from themandibular region? If your answer is “Yes, let’s get started,”read this paper again. Mrs. White does not need theplaque and calculus removed yet nearly as much as sheneeds to know about her risk factors for oral and systemichealth. Mrs. White needs you to take time out to reviewyour findings from assessments and speak frankly with herabout her health status. This is the perfect moment to discusssymptoms of diabetes that Mrs. White may not realizeshe has, to educate her about the links between smoking,hypertension, diabetes and CVD. Mrs. White is 45, overweightand Hispanic, placing her at greater risk for convertingfrom prediabetes to diabetes. Nevertheless, withsome effort, she can avoid that step through a concertedeffort of diet and exercise. She may not realize that amodest weight loss will benefit her greatly in terms ofimproved general health. In addition, now is when you canbegin discussing the link between her oral health and generalhealth. The presence of chronic gingivitis coupled withprediabetes and borderline hypertension places Mrs.Whiteat risk for further health issues. Also, she presents with nicotinestomatitis, another reason to incorporate smoking cessationas part of your education discussion and treatmentplan. Mrs. Whitehas known shehas gingivitis, admitsshe does notfloss regularly, butdoes brush daily.What recommendationswould youmake to help improveher oralIn the course of reviewing thisinformation, it is possible to see howthe traditional dental hygieneappointment can be reframed. That45-minute “cleaning” just does not fitthe profile of needs for Mrs. White.home care regimen? Would you switch her to a poweredtoothbrush, have her use a mouth rinse, recommendColage Total ®toothpaste? How often would you want tosee Mrs. White for follow-up?In the course of reviewing this information, it is possibleto see how the traditional dental hygiene appointmentcan be reframed. That 45-minute “cleaning” just does notfit the profile of needs for Mrs. White. She deserves aschedule that allows for assessment and education, treatmentand education, and re-evaluation and education. Isall this necessary for a simple case of gingivitis? Perhapsthe real question we should be asking is, do we ever seesimple cases of gingivitis? What have we been missing bynot allowing adequate time to perform comprehensiveassessment and risk factor analysis?This case and the questions posed provide the dentalhygiene reader an opportunity to reflect on the prospectof incorporating oral medicine into dental hygiene practice.Continually reviewing the literature related to oral andsystemic health – and discerning relevant components –will enable dental hygienists to refine practice and continueto provide quality care to their patients.special supplemental issue—april 2006—access 7
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