The objective of PerioFrogz is to help dental professionals stay current with on-going research; facilitate integration of research findings into daily practice, ultimately elevating the level of patient care.
“Interactions between chronic renal disease and periodontal disease”
Source: Oral Dis. 2008 Jan;14(1):1-7.
Author By: Craig RG
Summary of research:
- Number of people with End Stage Renal Disease (ESRD) is increasing
- Atherosclerotic complications including stroke and heart attack are the primary causes of death in the ESRD population.
- Periodontal disease may be a treatable source of systemic inflammation.
Results and Conclusions
- Cardiovascular diseases including heart attack, cardiac arrest, cardiac arrhythmia and stroke are the primary causes of death for ESRD patients.
- Mortality is highly associated with increased inflammatory burden.
- Periodontal disease contributes to systemic inflammation.
- The periodontal status of chronic renal disease patients needs to be carefully monitored.
Key take-away
- ESRD patients receiving renal replacement therapy including hemodialysis, peritoneal dialysis or kidney transplants will comprise an increasing segment of dental patient populations.
- The contribution of periodontal disease to the inflammatory burden makes it imperative to diagnose, treat and educate patients in the ESRD population about the critical importance of biofilm control and professional care, since their mortality is highly associated with inflammation.
Implementation strategies:
I have been repeatedly asked over the last several months about the economy and it’s affect on dentistry. I work with many practices on site that are doing very well. These practices are from a variety of economic and geographic areas; however the one thing they have in common is that they market on a regular basis not only to the public, but to other professionals in their communities.
Consider this, as budgets become less flexible; patients are even more concerned about staying healthy. The healthier they stay, the lower their medical expenses and costs of prescriptions. This is an even bigger consideration for patients who are already at risk. When we work with our local health care providers we create reciprocal referrals. Medical practitioners want to know who in their dental community is up to date and being proactive with cooperative case management.
We must involve the medical practitioners in our treatment planning and case management when it comes to high risk patients such as those suffering with ESRD. Doesn’t it make sense for us to reach out and request the assistance of those medical professionals treating these types of patients on a regular basis? With that in mind, the following action plan will assist you as you reach out to your medical community to increase the health and wellness of your patients using dentistry as a vehicle to do so!
Before you start on your Action Plan, you should know what your end point goals are. Clearly write them out. Here are a few to choose from to get you started.
Possible Goals:
- Inform practitioners of relevant, impactful research.
- Cultivate relationships within the medical community.
- Increase referrals from the medical community.
- Identify our practice as one dedicated to understanding and incorporating research into clinical practice.
- Notify practitioners of our commitment to cooperative case management.
Sample Action Plan:
Please note – you will need to customize your action plan to meet your goals. Be sure to set target dates for the completion of each task and identify the team members who are responsible for each task. When several team members are involved in one task, it is a good idea to have a task or project manager, someone who is the point person.
- Complete an internet search for all area physicians and institutions that are involved in the treatment of chronic renal disease. In addition to medical facilities, consider dieticians & nutritionists.
- Organize your list geographically, possibly by zip code. Divide your community into four sections, as needed, depending upon the size of your community. (For more rural areas this step may not be needed, however in concentrated city areas you may choose to limit your geographic radius.)
- Now that you know the number of providers in each section of your community you can determine how you will go about delivering the information.
- Choose your venue. This step will need to be customized according to your goals and your resources. Here are three suggestions. (Please do not limit your creativity. Get your team members involved and brain storm ideas.)
- Inform practitioners about the research in a written format, ie.PerioFrogz pdf titled Summary of Research – ESRD on this website. Include a cover letter informing practitioners of your commitment to patient care through cooperative patient management. Include business cards or referral cards.
- Invite practitioners to a ‘meet and learn’ (afternoon or evening). Distribute copies of the information listed above and provide a short PowerPoint presentation or talk, 10 or 15 minutes or so detailing how you handle new patients, the level of care provided through your hygiene department as well as the variety of technologies you have in your office to enhance patient care. Discuss patient co-management strategies.
- Produce a newsletter exclusively for the medical community informing them of the research. Use the same data listed in the first bullet.
- Now that you have determined your venue, break the project down into steps and set up a time line that involves the entire team. Divided the tasks among the team members (including the Doctor) so there is not a burden for any one person.
When the Team works together, the team reaps the rewards and ultimately it is your patients who will benefit from your efforts to increase awareness of the mouth body connection within your community. Most of all create some excitement and positive energy around this project and realize how much your community at large will benefit from your efforts.
To download a PDF file of the "Summary of Research Chronic Renal Disease and Periodontal Disease" CLICK HERE
“Maternal oral health in pregnancy”
Source: Obstet Gynecol. 2008 Apr;111(4):976-86
Author By: Boggess KA
Summary of research:
Periodontal disease affects up to 40% of reproductive-aged women.
Maternal oral flora is one of the greatest predictors of child’s oral flora.
Periodontal infection is associated with adverse pregnancy outcomes.
Key take-away
Effective preventive techniques and successful treatment measures to reduce caries and periodontal disease exist within the dental profession, yet these conditions remain quite prevalent.
Reproductive-aged women or women who are pregnant provide an opportunity for education regarding their oral health and that of their unborn child.
Risk assessment, diagnosis, prognosis and treatment planning to treat both caries and periodontal disease in this group of individuals, when appropriate, is not optional.
Implementation strategies:
The clinician must understand the critical importance of meticulous oral hygiene and professional care before (for those planning a family) or during pregnancy. This is also critical after pregnancy, especially during the first 30 months of the infant’s life when transmission of pathogens from parent to child has the greatest probability.
Due to the transmissible nature of these diseases, once periodontal disease or caries infection is identified in the pregnant or reproductive-aged woman, the spouse should also be screened and treated when appropriate.
Proactive conversations with individuals who may be affected by this research should be the intention of every clinician who has opportunity to be involved in patient care. (see the following example)
Scenario One:
A male patient (Nick) comes in for his routine preventive appointment and proudly tells you that he and his wife (Katie) are expecting their first child. Previous chart notes indicate the presence of moderate bleeding upon probing and during the prophy. You have not seen his wife since she has become pregnant.
Clinician: “Nick, that’s great news, congratulations! I am so please for you and Katie. I know Dr. Williams will be happy for you too. Before I get started with your hygiene visit today, I’d like to share some research that will be of particular interest to you now that you are a father to be. We now know that periodontal disease progression during pregnancy can increase the risk for adverse outcomes like pre-term, low birth weight infants. Have you heard anything about this? We also understand that the bacteria that cause both gum disease and tooth decay are transmissible from spouse to spouse and parent to child. If the parents, especially mom, have these bacteria the child will most likely have them as well. So, today, I am going to do some very careful screenings for you to be sure you do not have any disease activity present that might be transferred to Katie. Either way, it will be very important for Katie to be screened as soon as possible as well. Do you have any questions for me before I get started?”
Nick: “What happens if I do have a problem? What do we do about it?”
Clinician: “That’s a great question. There are several ways we can treat both gum disease and tooth decay. There are also some preventive things you and Katie can do during and after her pregnancy. Let me go ahead and do your screenings and then you and I and Dr. Williams can decide how best to proceed based on your results.”
Scenario Two:
A female patient (Shirley) comes in for her routine prophy and during the health history update and risk assessment she informs you she has already undergone the preliminary steps and is beginning in-vitro fertilization in a few weeks. She comments on how stressful this whole process has been not only financially but emotionally. Her previous chart notes have no indication of periodontal disease or caries infection.
Clinician: “Well Shirley, even though you have had some stress, this is a very exciting time for you. Today, included with your hygiene visit I will be providing you with several screenings, the most important one for you, considering your upcoming in-vitro procedure, will be the periodontal screening. Are you aware of the research linking periodontal or gum disease with pre-term low birth rates in infants? The studies show that about 40% of women in child bearing years are affected. If you don’t have any questions, I’ll get started and share the results with you as I go along.“
Shirley: “I haven’t heard about this. I already have my appointments scheduled and the time off work arranged. I’m not sure I can make changes.”
Clinician: “Shirley, please don’t be concerned just yet. With your history I’m not expecting there to be any problems. Let me collect the data and then Dr. Williams will be in to do an exam and diagnosis. You’re in good hands and we’ll take great care of you.”
Scenario Three:
A young woman, mid twenties, comes into the dental office for a routine exam and checkup. There are no risk factors and no concerns where her health and family history are concerned. After the screenings it is discovered that the patient (Betty) has several areas of decay, some demineralization and bleeding gums with scattered 4mm pockets and a few isolated 5mm areas.
Clinician: “Betty, as you saw during your screenings you do have some decay and gum disease. Let me reassure you these issues are easily treated and we can help you. I do want to share some important information with you before we talk about your treatment options. Ongoing research is showing a link to premature infant births in those women who experience periodontal disease progression during pregnancy. Therefore, I need to ask, are you planning to start a family any time soon
Note: Regardless of how Betty responds, the clinician should take this opportunity to provide education and supporting data (brochures, handouts). Even if Betty is not planning a family anytime soon, she may one day. In all likelihood, she has friends or family members in a similar age group that she might share this information with.
“Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease.”
Source: Circulation 2008 Apr1;117(13):1688-74
Authors: Dietrich T, Jimenez M, Krall Kaye EA, Vokonas PS, Garcia RI
Summary of research:
• Recognize the relationship between periodontitis and coronary heart disease (CHD), (angina, myocardial infarction or fatal CHD) in men.
• Significant association between periodontitis and CHD among men <60 years of age independent of diabetes, blood pressure, smoking, cholesterol etc.
• No such association found among men > 60 years of age.
Results and conclusions:
• Chronic periodontitis is associated with incidence of coronary heart disease among younger men (<60), independent of established cardiovascular risk factors.
Key take-away
• Male patients with chronic periodontal disease who are below the age of 60 have a higher risk of angina, heart attack or fatal coronary heart disease compared to men over the age of 60.
Implementation strategies:
• During routine risk assessment with all male patients under the age of 60 the clinician should make a statement (see sample below) regarding this research and comment about the importance of ongoing periodontal evaluation at each dental hygiene appointment.
Scenario One:
The patient (Albert) is in the office today for a new patient appointment. Albert is a 47 year old computer specialist in good health. Albert reports that his last dental visit was about 2.5 years ago and at that time he was told he had some problems with his gums. He did not follow through with treatment at that time. Albert is recently married and moved to your community. When asked if his gums bleed, Albert reports yes – almost everyday.
Clinician: “Albert, before I begin your exam today, which includes a periodontal evaluation, I would like to share a piece of research with you from the medical journal ‘Circulation’. This research suggests that men in your age group with chronic periodontal disease were found to have a significant risk for coronary heart disease. While I can’t be sure you will be affected, I treat all my patients with the same standard of care. Once I have completed your exam and screenings, you and I and the Doctor will discuss any treatment you may need. I am very glad you have chosen our practice. You are in good hands; we will take great care of you.”
Albert: “I had no idea there was a connection at all, let alone at my age. It sounds to me like I could be at risk because my gums bleed.”
Clinician: “Past research has supported the connection, but this study looked specifically at age groups most affected. Since this research is more recent, we are taking a very proactive stand. Dr. Brown is very committed to not only your dental health but your general health and wellness. Once we have completed the exams, we will review any treatment suggestions Dr. Brown has for you. Shall we go ahead and get started?”
Please note: Since we know that Albert is a computer specialist, he is most likely quite analytical which is why we can confidently make a reference to the medical journal.
Scenario Two:
The patient (William, 55 years old) is in the office today for a periodontal maintenance visit. He has been on a 12 week interval and has been in disease remission for about 9 mos. Today, following his screenings and exam, it is noted that William has several areas of moderate bleeding and no increase in pocket depths.
Clinician: “William, now that I have completed your periodontal evaluation let’s talk about what you saw going on in your mouth. I am concerned about these areas that have started to bleed again, how about you? Let me make a couple of recommendations. You will need some additional periodontal therapy and for you this is quite important. Recently the medical research indicates an increased risk for CHD in men who are <60 and have chronic periodontal disease. You fit both of those categories; however, you have been in remission for about 12 months which is very much in your favor. Can you tell me what has changed? Why do you think your gums have started to bleed again?
William: “I just got out of my home care routine. After going on vacation to Hawaii, I got out of the habit.”
Clinician: “I understand William, it happens to the best of us. So here is what I suggest you do: today’s visit can become a periodontal therapy appointment to get started with your treatment and I suggest you return for 1-3 additional appointments of periodontal therapy. Step up that home care and let’s work together to reverse the infection and get you back into remission. Keep in mind that your periodontal disease may put you at greater risk for CHD. Would you like me to proceed? At this point I need to have Dr. Brown come in and give you a diagnosis. You have made a good choice to turn this around as soon as possible.”
Scenario Three:
The patient, (Bruce) has been on a 6 mos. recall for (prophy only) about the last 2 years in spite of the fact he has been repeatedly told his bleeding gums are a problem. Bruce is one of those patients who only will do what his insurance will cover in full. After his periodontal charting today you sit him upright and begin your discussion.
Clinician: “Bruce, I am concerned about what you saw in your mouth today. What do you think?
Bruce: “I think my gums have always bled. Why is it such a big deal now?”
Clinician: “I know we talk about this every time you come in and Doctor has indicated the need for periodontal therapy in the past. Today more than ever this is a big deal because there is some important medical research that has found a strong association between CHD and periodontal disease in men under the age of 60. The fascinating thing is that the risk is independent of risk factors we all are aware of such as smoking, diabetes, high cholesterol, high blood pressure and others. The only qualifiers are age and periodontal disease and you have both. It is more important than even I previously understood, to have the periodontal treatment that Dr. Brown has recommended. What would you like to do Bruce?”
Family History of Diabetes + Perio Disease May Indicate Undiagnosed Diabetic Patient. Refer to MD
Diabetes in the dental office: using NHANES III* to estimate the probability of undiagnosed disease
Source: J Periodontal Res. 2007 Dec;42(6):559-65
Borrell LN, Kunzel C, Lamster I, Lalla E.
Department of Epidemiology, Columbia University College of Dental Medicine, Mailman School of Public Health, Columbia University, New York, NY
Summary of research:
• One third of diabetes cases remain undiagnosed.
• 60% of Americans see a dentist at least once per year.
• Dental professionals can screen patients for undiagnosed diabetes.
Results and conclusions:
• Periodontal patients with a family history of diabetes, hypertension and high cholesterol bear a probability of 27-53% of having undiagnosed diabetes.
• Dental office could provide an important opportunity to identify individuals unaware of their diabetic status.
Key take-away
• It is critical to have a thoroughly completed and reviewed health history, including family history of any type of diabetes.
• Dental providers should consider referring patients with a family history of diabetes and refractory periodontal disease to their physician for diabetic screening.
Implementation strategies:
• Incorporate a simple diabetes screening for patients with a family history of diabetes, hypertension, high cholesterol, and periodontal disease. **
• Identify and screen patients who are slow to heal after periodontal therapy or any dental surgical procedure.
• Involve the team in the development and use of the verbal skills to present this screening to those patients of concern.
“Mrs. Smith, as you know Dr. Williams’ first concern is always for his patients and their overall health and wellness. With your family history of diabetes and your current health concerns coupled with your slow healing and recurrent periodontal infection, Doctor has asked me to assist you with a simple **diabetes screening questionnaire. It only takes a minute or two to complete. Doctor Williams will evaluate your responses and recommend a consultation with your physician if necessary.”
*NHANES III, the Third National Health and Nutrition Examination Survey is a database collected from 34,000 persons by the CDC, 1988-1994. It was designed to obtain nationally representative information on the health and nutritional status of the U.S. population.
**Use the companion Defeat Diabetes Screening Questionnaire attached.
To download a PDF file of the Defeat Diabetes Screening Test shown below CLICK HERE