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Inside Dentistry

April 2008, Volume 4, Issue 4
Published by AEGIS Communications

NYAS Hosts Medical-Dental Dialogue on Oral-Systemic Link

Spotlight on dentistry’s brightest happenings.

On January 18, a gathering of medical and dental dignitaries descended upon the New York Academy of Sciences (NYAS). With the Lower Manhattan skyline spread out beneath them and tributes to Charles Darwin surrounding them, they set forth upon a fittingly lofty task: to discuss the oral health–systemic health connection from both the medical and dental perspectives.

From basic science to clinical practice and policy: a medical-dental dialogue on the relationship between periodontal disease and systemic health evolved around the idea that physicians and dentists are rarely afforded an opportunity to discuss the oral-systemic link in an academic forum, according to David Albert, DDS. While important research is continually taking place on both sides, the communication of information and perspectives does not always occur with facility. "Today’s conference is a little bit about reattaching the head to the body," said Dr. Albert, associate professor of clinical dentistry at Columbia University School of Dental Medicine, as he welcomed the audience and participants and gave an overview of the day’s proceedings. The effects of oral conditions on cardiac disease, pregnancy outcomes, and renal disease would be examined in a trio of scientific sessions, each featuring a physician and a dentist and concluding with a formal discussion using an electronic system to generate real-time responses from the audience. Following the scientific sessions, the discussion would turn to policy and communication within the healthcare community. "I think by connecting policy and clinical research we will have an interesting forum that has not really been presented in other areas."

"The genesis of this meeting today was five years ago at the first meeting of the National Periodontal Disease Coalition," said Robert Klaus, president and CEO of Oral Health America. "Here we have combined physicians, surgeons, dentists, academics, and practitioners, to discuss the idea—and it’s a rather revolutionary idea still in some quarters—that oral health is total health. There’s a lot of talk in this political climate of change. We’re about change here today, and it’s going to be substantial change. This is the alpha point; this is the break-off point, the beginning." Borrowing from Yeats, he concluded: ‘Now and in time to be [all things] are changed, changed utterly: a terrible beauty is born."

ESTABLISHING THE SCIENCE

The first scientific session featured a discussion by Steven Shea, MD, professor of medicine and epidemiology at Columbia University College of Physicians and Surgeons, on periodontal infections and atherosclerotic vascular disease. His presentation reviewed data from the Multi-Ethnic Study of Atherosclerosis, focusing on risk factors for subclinical cardiovascular disease, including obesity and coronary calcium scores on computed tomography.

Complementing Dr. Shea’s work was Maurizio Tonetti, DMD, PhD, who presented on behalf of the European Research Group on Periodontology. Dr. Tonetti discussed lessons from interventional studies regarding periodontal disease and risk for atherosclerotic vascular disease, including his own groundbreaking research published last year in The New England Journal of Medicine. That study showed that intensive treatment of patients with severe periodontitis resulted in an acute systemic inflammation, followed by an improvement in both oral health and endothelial function at 6 months—a landmark in establishing the importance of oral health to systemic health.

The second session shifted the focus to pregnancy outcomes. Robert Goldenberg, MD, professor of obstetrics and gynecology at Drexel University College of Medicine, discussed preterm birth and peri-odontal disease. He hypothesized that the link between the two might involve "the contribution of periodontal disease to systemic inflammation in the mother, with the increase in inflammation from several sources precipitating preterm labor or membrane rupture."

Dr. Goldenberg was followed by Brian Michalowicz, DDS, who presented on intervention studies, particularly his Obstetrics and Periodontal Therapy (OPT) Trial, to determine if treatment of periodontitis is associated with reduced risk for adverse pregnancy outcomes. Dr. Michalowicz, associate professor of periodontology at the University of Minnesota School of Dentistry, reported that the OPT Trial found treatment was safe and effective, but it did not demonstrate a statistically significant improvement in pregnancy outcomes, although, he noted, there was a trend toward improvement.

The third session turned to less-charted waters, presenting data on periodontal infections and renal disease—a relatively novel field of investigation. Jai Radhakrishnan, MD, a nephrologist at Columbia University College of Physicians and Surgeons, explained the pathobiology of kidney disease, laying the groundwork for Dr. Steven Offenbacher’s talk on the plausibility of and emerging evidence for a link between periodontal infection and renal disease. Dr. Offenbacher, professor and director of the Center for Oral and Systemic Diseases at the University of North Carolina School of Dentistry, cited findings from the NHANES III and ARIC studies, among others, indicating an association between periodontal disease, renal insufficiency, and kidney failure. "These findings provide the impetus for larger studies, including interventional trials, to determine whether periodontitis is a risk factor for renal impairment and whether treatment may reduce cardiovascular disease mortality among end-stage renal disease patients," Dr. Offenbacher concluded.

FROM THEORY TO PRACTICE

Following the scientific presentations, which illuminated the need for increased congress between oral and systemic physicians, the discourse turned to policy and education and a discussion of "current and future mechanisms to improve communication, collaboration, and education regarding these interlinking fields of healthcare." The moderator, Burton Edelstein, DDS, professor of dental medicine at Columbia University School of Dental Medicine, put it succinctly: "Having heard the science, we now turn to a group of people who are involved in answering the ‘so what’ questions, which are: What are the implications for the putative and apparently persuasive oral-systemic association? Who should know what, when, and how, and what should they do about it?" Participants in this session included: Michael Glick, DMD, professor of oral medicine at Arizona School of Dentistry and Oral Health and editor-in-chief of The Journal of the American Dental Association; Richard Valachovic, DMD, executive director of the American Dental Education Association; David Krol, MD, chair of the Department of Pediatrics at the University of Toledo College of Medicine; and Sherry Glied, PhD, professor and chair of the Department of Health Policy and Management at Columbia University’s Mailman School of Public Health.

Dr. Glick discussed the role of dentists in providing for their patients’ overall health. He cited the need for an elaboration of communication between all healthcare providers, touching on some areas such as salivary diagnostics, blood pressure screening, and even screening for socioeconomic status (a known risk factor for cardiovascular and other diseases), where dentists could take an active role in pinpointing potential problems and referring their patients to the proper specialists.

Drs. Valachovic and Krol discussed the lack of educational integration between dental and medical schools. "We are at a crossroads," Dr. Valachovic said, echoing Dr. Glick’s remarks on the necessity for dentists to play a more active role in screening patients for systemic disease. Dr. Krol presented the pediatrician’s perspective, commenting on the overwhelming lack of oral health components to the medical school curricula. In the same way that dentists would do well to become alert to their patients’ systemic conditions, so must physicians—particularly pediatricians—gain "the knowledge, comfort, and skill sets to become competent providers of oral health guidance, preventive strategies, and appropriate referral. Therefore, oral health must be a component of the medical education curriculum."

Dr. Glied moved the conversation out of the realm of education and addressed the practical issues involved in integrating the "disparate systems" of medicine and dentistry in terms of financing dental services—the crux, as she sees it, of any practical hope for wholesale change. "There are lots of people who are not getting dental care. That’s strongly correlated with income, it’s particularly true among low-income people, and that’s a concern in light of the systemic effect, because if we look at who suffers from the systemic diseases that we’re talking about, that is the same population that isn’t getting a lot of dental care," she said. "Many people who have heart disease or who are pregnant do not go to the dentist in a given year. So there is clear need to bring the systems together.

"We need a holistic vision of medical care," she continued. "We want to expand it to include dental health." Making an analogy based on a model integrating mental health and systemic health, she proposed four scenarios for dental and medical systems to operate in synchronicity. The first two, a model of organizational integration co-locating medical and dental providers, and a model of primary care-based integration, were rejected based on logistical issues ranging from physical space to coding incompatibilities to referral issues. The third model is a disease-management model. "It’s a third-party, generally an insurer or a specialized disease-management company, who actually coordinates care. All providers feed their information to a central administrative person, and that person connects with the patients and tells them what they need to do." Dr. Glied indicated that Medicare is in the midst of a demonstration project, but "the jury is out" on whether this model can be successful.

The final model is a model in which insurers adjust the coinsurance for related services to give incentives to patients to change their behavior in accordance with what’s needed given their medical condition. As with the third model, "the information flows to a third party, the insurer, and that person is actually interacting with the patient. It’s not a collaboration among disciplines; it’s a collaboration through a third party.

"From a health economist perspective, moral hazard [the risk that people will abuse their coverage through overuse] is limited because people don’t like going to the dentist. We can give them insurance for free and they still won’t go. So expanding dental insurance will not set off an avalanche of use, and it’s really hard to spend a huge amount of money on dental care. You could spend a million dollars on medical care, and that would be really hard to do in the dental world."

Integrating dental and medical insurance is economically feasible "in the sense that both forms of insurance exist and the moral hazard risk is not serious and the mental health model tells us that integrated plans are possible in other kinds of insurance, so there are ways to deal with the distinct provider pool. So there is the potential to do the kind of integration that works through insurers, where it’s not doctors and dentists talking to each other, it’s doctors and dentists talking to insurers."

She noted that such a model has already been enacted by Aetna Insurance, adding, "My sense is that if we’re going to move forward with some type of integration, it’s going to build off this kind of financial model because that’s the thing that’s most likely to work, at least in the short run.

"But you have to be really careful before you go down this road," she cautioned. "It’s really dangerous to follow the idea that the reason you want to integrate, the reason you want to provide dental insurance, is that it’s going to save money on the medical or because it’s going to do something good on the medical side. You have to keep in your mind that dental care is valuable because oral health is valuable in and of itself. If better oral health also gives you better treatment of heart disease, that’s a bonus. Don’t think of it as the main reason to enhance access to oral health."

CONCLUSION

Among the goals set forth prior to this symposium were to increase awareness of the link between oral and systemic health; to increase appreciation of the need for improved communication between medical and dental practitioners; and to discuss the need for policy change in dental and medical education. A survey of the 162 attendees revealed that these goals were met quite well (average satisfaction score, 4.4 out of 5). Medical schools and medical practitioners are recognizing the importance of oral health to overall health—a message the dental community has been trumpeting since Surgeon General Satcher's report in 2000.

Said Dr. Ira Lamster, DDS, MMSc, dean and professor of dental medicine at Columbia University College of Dental Medicine, "With the identification of links between oral infection and certain systemic diseases, there is a need to explore other related issues, including communication of research findings to physicians and other healthcare workers, and how to appropriately convey this information to patients. In sum, this research has emphasized the need for dentists to become active participants in the management of patients with a variety of systemic disorders and diseases."

A gathering such as the NYAS symposium, in which medical and dental schools united to promulgate information on oral and systemic health, can only be perceived as a stride toward this integration of specialties that is becoming necessary to foster the best, most complete care for patients.

Proceedings from the symposium will be published in the Annals of the New York Academy of Sciences. Additional coverage, including audio and PowerPoint presentations, is available in the eBriefings section of the Academy's Web site. Visit www.nyas.org for more information.

From Basic Science to Clinical Practice and Policy: A Medical-Dental Dialogue on the Relationship Between Periodontal Disease and Systemic Health, was jointly sponsored by Columbia University College of Dental Medicine, Columbia University College of Physicians and Surgeons, The New York Academy of Sciences, and the National Periodontal Disease Coalition. The sponsors gratefully acknowledge Aetna Dental, Colgate Oral Pharmaceuticals, Johnson and Johnson Oral Health Care Products, Oral Health America, and OraPharma, Inc, for their generous educational grants. Continuing medical and dental education credits for participants were provided through Columbia University College of Physicians and Surgeons and Columbia University School of Dental Medicine, respectively.

Participants

David Albert, DDS, MPH
Associate Professor of Clinical Dentistry and Clinical Health Policy and Management Director, Section of Socialand Behavioral Sciences
Columbia University College of Dental Medicine
New York, New York
Session Co-Chair

Burton Edelstein, DDS, MPH
Professor of Dental Medicine and Clinical Health Policy and Management
Chair, Section of Social and Behavioral Sciences
Columbia University College of Dental Medicine
New York, New York
Session Co-Chair

Michael Glick, DMD
Professor of Oral Medicine
Arizona School of Dentistry and Oral Health
Mesa, Arizona
The Role of Dental Professionals in the Diagnosis and Management of Patients with Systemic Diseases

Sherry Glied, PhD
Professor and Chair
Department of Health Policy and Management
Mailman School of Public Health
Columbia University
New York, New York
Clinical Practice in Medicine and Dentistry: Can Disparate Systemsbe Integrated?

Robert Goldenberg, MD
Professor of Obstetrics and Gynecology
Drexel University College of Medicine
Philadelphia, Pennsylvania
Preterm Birth and Periodontal Disease

Robert Klaus, PhD
President and CEO
Oral Health America: National Periodontal Disease Coalition
Chicago, Illinois
Session Co-Chair

David Krol, MD, MPH
Associate Professor and Chair
Department of Pediatrics
University of Toledo College of Medicine
Toledo, Ohio
Medical Education: Integrating Oral Health into the Curriculum

Abhijit Kshirsagar, MD, MPH
Research Assistant Professor
Division of Nephrology and Hypertension
University of North Carolina School of Medicine
Chapel Hill, North Carolina
Session Chair

Ira Lamster, DDS, MMSc
Dean and Professor of Dental Medicine
Columbia University College of
Dental Medicine
New York, New York
Session Chair

Bryan Michalowicz, DDS, MS
Associate Professor
Division of Periodontology
University of Minnesota School of Dentistry
Minneapolis, Minnesota
Periodontal Infections and Pregnancy Complications: Lessons from Intervention Studies

Steven Offenbacher, DDS,PhD, MMSc
Professor and Director
Center for Oral and Systemic Health
University of North Carolina School of Dentistry
Chapel Hill, North Carolina
Periodontal Infections and Renal Disease: Plausibility and Emerging Evidence

Panos Papapanou, DDS, PhD
Professor of Dental Medicine
Chair, Section of Oral and Diagnostic Sciences
Director, Division of Periodontics
Columbia University School of Dental Medicine
New York, New York
Session Chair

Jai Radhkrishnan, MD, MS
Assistant Professor of Clinical Medicine
Columbia University College of Physicians and Surgeons
New York, New York
Pathobiology of Kidney Disease

Steven Shea, MD
Professor of Medicine and Epidemiology
Columbia University College of Physicians and Surgeons
New York, New York
Risk Factors for AtheroscleroticVascular Disease

Maurizio Tonetti, DMD, PhD, MMSc
Executive Director
European Research Group on Periodontology
Genova, Italy
Periodontal Infections and Risk for Atherosclerotic Vascular Disease: Lessons from Intervention Studies

Richard Valachovic, DMD, MPH
Executive Director
American Dental Education Association
Washington, DC
Dentistry at the Crossroads: Is it Time to More Closely Integrate Medical and Dental Education and Practice?