Why the RDH is a critical member of the health-care team
Dental hygienists are a vital link in the multi-disciplinary team addressing heart disease
Dental hygienists are a vital link in the multi-disciplinary team addressing heart disease
BYAmy L. Doneen, DNP, ARNP, Alice E. Dupler, JD, APRN-BC, Eqs,andNeva L. Crogan, PhD, ARNP, FAAN
Registered dental hygienists have the knowledge, skill, and professional education linking oral health and vascular health. Oral health has a direct impact on the vascular system, with periodontal and endodonic disease directly associated with vascular disease development, heart attack and ischemic stroke risk (Lockhart, 2012). The complexity of vascular disease (atherosclerosis) requires an inclusive approach to care, including the oral health-care specialist.
Cardiovascular disease (CVD) remains the leading cause of death and disability in developed countries, creating a catastrophic financial strain on our current health-care system. Understanding the multi-factorial risk profile of this disease, it becomes clear that a multi-disciplinary team is necessary to achieve optimal wellness. Registered dental hygienists are vital partners in care with the medical team. This article will discuss why this relationship is important and how this partnership can be supported and nurtured.
The current health care paradigm targets end-stage disease, treating the disease after it becomes evident. Currently, six hundred billion dollars are spent annually to treat vascular disease in this fashion (waiting until someone has had a heart attack or ischemic stroke) (Go, 2014). It is estimated to increase to more than three trillion dollars annually by the year 2030. One-third of all cardiovascular deaths occur in individuals less than 75 years of age (Roger, 2012). Fifty percent of annual major coronary events are recidivistic and of these, 50% are fatal (Briffa, 2013).
Additional articles to consider reading
- Barriers to oral-systemic practice
- Stop premedicating! ADA review examines treatment of patients with prosthetic joints
- Where Oral Meets Systemic
These rates of vascular events and healthcare expenditures are not sustainable. Rather than waiting for an event to identify who is at risk, assessment of a client's inflammatory response and disease can be conducted to prevent CVD. Implementation of this assessment contributed to vascular disease regression in a family practice setting; the oral/systemic connection is a core component of a client's plan of care (Feng, 2014).
Risk factors associated with the development of vascular disease can be effectively managed in the traditional medical setting. These include factors contributing to hypertension, hyperlipidemia, insulin resistance, type 2 diabetes, and lifestyle issues, including obesity, lack of exercise, poor dietary habits, and nicotine exposure (Cook, 2012). Some causative factors go beyond a standard family practice and are equally assaultive to the vascular system. These important risk factors include periodontal disease (Humphrey, 2008), endodontic disease (Friedlander, 2007), and sleep apnea (Jelic, 2010). Using a team approach to create an optimal environment of health for the patient allows for the inclusion of oral health experts, including registered dental hygienists.
Advanced gum disease affects 47.2% of adults; all adults aged 30 years and older have some form of periodontal disease (CDC, 2013). Periodontal disease increases with age; more than 70 percent of adults 65 years and older have periodontal disease. The highest risk groups are men who live below the poverty level (65.4%), do not have a high school education (66.9%), and who currently smoke (64.2%) (2013).
Appreciating the significance of periodontal disease, it is important to also appreciate that the pulse of dental health care in the United States is shifting. Insurance coverage is a major driver of utilization of dental care (Wall, 2012). Age and poverty level have historically impacted access to dental care. Government funding of programs targeting childhood dental health, resulted in an increase in service utilization from 1997 to 2010. The opposite is true in non-elderly adults, where utilization of dental services decreased. The most rapid decline occurred in those in the lowest income group. Significantly, the highest risk group for cardiovascular events is non-elderly adults between the ages of 55-64 years (Go, 2014).
Most recently, Steele and colleagues recruited over 6,000 people age 21 and older from a wide variety of socio-economic backgrounds (2014). The aim of the study was to determine which factors led to poor dental health. Interestingly, many of the same risk factors for poor oral health were consistent with higher cardiovascular risk. They included increasing age, poor economic status, lack of insurance coverage, lack of access to care, and smoking (Steele, 2014). The Centers for Disease Control and Prevention (2014) cited an increase in periodontal health for certain ethnic groups including non-Hispanic blacks, Hispanics, American Indians, and Alaska Natives. The CDC reported that those with these demographics also have the highest rates of type 2 diabetes and cardiovascular disease (2014).
The RDH role in health care
The American Dental Hygienists' Association (2010) acknowledged that hygienists are an integral part of the health-care team. Specifically, dental hygienists are experts in disease prevention given they conduct assessments of dental hygiene, determine appropriate dental hygiene interventions, and, based on their clinical judgment, plan, implement, and evaluate the dental hygiene component of the overall treatment plan. Dental hygienists work in partnership with other health-care providers to promote optimal oral health to the public (2010).
With this definition in place, dental hygienists have taken the role as key partners in cardiovascular disease prevention.
To fully appreciate the oral/systemic connection as it relates to vascular wellness, it is necessary to understand health from the perspective of the arteries and the mouth. Arterial health (or cardiovascular wellness) is:
• A state for which atherosclerosis is absent
• There is no inflammation, and primary prevention can be effective
• If atherosclerosis is present in the arterial system, inflammation is present, and secondary or tertiary prevention may be required.
Optimal oral health, as it relates to vascular wellness, is an oral environment that lacks inflammation. When inflamed, oral pathogens can invade the vascular system and create the opportunity for an unstable atherosclerotic disease state. There are many conditions that cause vascular inflammation. Oral bacteria resulting from periodontal disease) is one of those conditions.
Based on an extensive review of the literature, the United States Preventative Services Task Force (USPSTF) (2014) identified periodontal disease as an independent risk factor for coronary heart disease (CHD). This determination was based on the work of several scholars. Humphrey and colleagues (2009) evaluated systemic reviews, prospective studies, and expert opinion papers completed from 1966 to 2008. Their work included studies conducted from 5 to 21 years in duration. They concluded that periodontal disease was a risk factor and an independent marker for CHD. The researchers also noted that periodontal disease was a risk factor independent of traditional CHD risk factors, including socioeconomic status (2009). This was supported by the USPSTF in 2010 when they recommended identification and treatment of periodontal disease to prevent CHD in eligible patients.
The American Heart Association (AHA) later performed a review of more than 530 peer reviewed, medical, and dental publications (Lockart, 2012). Researchers concluded that periodontal disease was associated with CHD. Notably, they determined that based on the rigor of the science, this finding could greatly improve health outcomes (2012).
The language spoken between the medical and dental community in regards to CVD must be one of mutual recognition. In the medical community, laboratory data is utilized to reveal hidden causes of vascular inflammation. Blood and urine tests are utilized to evaluate the effectiveness of treatment, lifestyle, and pharmaceutical interventions on the artery wall. They provide confidence to know that the patient is safe. Likewise, health-care providers can rely on technology to identify asymptomatic atherosclerosis and follow the disease over time.
Networking to prevent CVD
The Bale/Doneen Method assesses for vascular disease risk using a disease/inflammatory approach to risk assessment. This method has been proven to effectively regress atherosclerosis. Dental hygienists and health-care providers can assess client inflammation in the vascular system and determine if oral pathogens are driving the risk. (Feng, 2014). Ultimately, the hope is to treat the disease, preventing the end-stage result of a heart attack or ischemic stroke. If the patient feels the disease, a rupture or an erosion would have resulted in a thrombotic event. Optimal CV wellness and optimal oral health is tied together by a lack of inflammatory burden.
How to communicate? Knowing that periodontal disease and endodontic pathogen burden are one of the critical root causes of this inflammatory disease, dental hygienists are essential in prevention of CVD. Health-care providers assess for gingiva inflammation in the medical office. However, Wilder and colleagues (2014) noted that of 625 cardiologists, only 20% reported having received oral health in their professional education, while 80% reported not receiving any oral health education in their formal schooling. They concluded that an increase in interprofessional education and practice including registered dental hygienists, physicians, dentists, and nurse practitioners would have the greatest impact on awareness and implementation of strategies to improve oral health and possibly heart health (Wilder, 2014).
Speaking a common language also means that the dental team should participate in laboratory testing to determine pathogen burden objectively; subsequently, the language between providers can be objective and understood. Laboratory reports become a point of mutual understanding of what the hygienist is treating and what the health care team is hoping to accomplish. Both can positively impact vascular stability. Laboratory data provides an objective, common language between specialties. Goals of treatment can be determined and follow-up care can be mutually monitored and anticipated.
Research opportunities - As clinicians and scientists, it is imperative that dental hygienists and health-care providers track their clinical findings so that collaborative ambulatory data can be published. This allows for sharing information with a scholarly approach to learning. Ambulatory or real-life data is a critical step in the scientific process. Using evidence-based research as the backdrop, applying the science to practice and tracking the data, generates the opportunity to learn and discuss findings that can be disseminated between the medical and dental communities. Simple Excel data sets can be gathered, comparing oral pathogen burden with perio-probing charts and laboratory data for vascular inflammation. These numbers can be tracked and recorded, becoming part of medical and dental records for the patient.
Patient education tools can be generated together and disseminated between offices, creating a fluency of involvement between the medical and dental teams. This inclusive approach to care will surely enhance the health and wellness of the patient. Because the health-care model and the registered dental hygienist model of care both focus on patient education, this creates the perfect pairing of dissemination of health and wellness information.
Exciting opportunity to build relationships - Atherosclerotic vascular disease is a multi-faceted inflammatory condition. Oral health is a critical component for vascular health. Dental hygienists are specialists who contribute to heart health and prevention of CVD. They impact care provided in family practice, cardiology, sleep medicine, endocrinology, psychology, nutrition, exercise science, and life coaching.
Inflammation driven by oral health is equally significant with other inflammatory causative factors such as insulin resistance, sleep apnea, dyslipidemia, and hypertension. We ask for a partnership with our dental hygiene colleagues to join in the fight against the devastating effects of cardiovascular disease. As a medical/dental team, optimal wellness can be achieved in each of our patients. RDH
Amy L. Doneen, ARNP, is an international leader and lecturer in preventing heart attacks, stroke, and diabetes. She has lectured in Rome, Italy, Helsinki, Finland, and Madrid, Spain as well as hundreds of keynote lectures to dental and medical groups across the United States. She is a co-founder of the Bale/Doneen Method, and the co-principle lecturer and researcher for this method of CVD Prevention. She is the owner and medical director of the Heart Attack and Stroke Prevention Center in Spokane, Wash. Her research on CVD prevention has been published in several peer reviewed medical, nursing, and dental journals. She is a member of the American Heart Association, American Stroke Association, American Diabetic Association, Society of Atherosclerotic Imaging and Prevention, and an inaugural member of the American Academy of Oral/Systemic Health.
1. CDC (2014) Online accessed 11/17/2014. http://www.cdc.gov/OralHealth/periodontal_disease
2. Cook N, Paynter N, Eaton C, Manson J, Martin L, Robinson J. (2012). Comparison of the Framingham and Reynolds risk scores for health initiatives. Circulation. 125(14):1748-56.
3. Feng D, Esperat C, Doneen A, Bale B, Song H, Green A. (2014). Eight-year outcomes of a program for early prevention of cardiovascular events. A growth curve analysis. Journal of Cardiovascular Nursing
4. Friedlander AH, Cohen SN. (2007). Panoramic radiographic atheromas portend adverse vascular events. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(6):830-5.
Go A, Mozaffarian D, Roger V, Benjamin E, Berry J, Blaha M. (2014). Heart disease and stroke statistics - 2014 update: A report from the American Heart Association. Circulation. 129(3):e28-e292.
5. Humphrey L, Rongwei F, Buckley D, Freeman M, & Helfand, M. (2008). Periodontal disease and coronary heart disease incidence: A systemic review and meta-analysis. Journal of Intern Medicine. 23(12):2079-2086.
6. Jelic S, Lederer DJ, Adams T, Padeletti M, Colombo PC, Factor PH. (2010) Vascular inflammation in obesity and sleep apnea. Circulation,121(8):1014-21.
7. Lockhart P, Bolger A, Papapanou P, Osinbowale O, Trevisan M, Levison M, Taubert, Newburger J¸Gornik H, Gewitz, M, Wilson W, Smith J, Baddour L. (2012). Periodontal disease and atherosclerotic vascular disease: Does the evidence support an independent association? A scientific statement from the American Heart Association. Circulation published online April 18, 2012. http://circ.ahajournals.org/content/early/2012/04/18
8. Standards for clinical dental hygiene practice, Chicago, Ill. American Dental Hygienists' Association 2008.
9. Steele J, Shen J, Tsakos G, Fuller E. (2014). The interplay between socioeconomic inequalities and clinical oral health. Journal of Dental Research. DOI:10.1177/0022034514553978. USPSTF (2014) Online accessed 11/16/2014. http://www.uspreventativeservicetastkforce.org/uspstf/grades.htm.
10. Wall T. (2012). Recent trends in the utilization of dental care in the United States. Journal of Dental Education. 76(8); 1020-1027.
11. Wilder R. (2014). North Carolina Cardiologists' Knowledge, Opinions and Practice Behaviors Regarding the Relationship between Periodontal Disease and Cardiovascular Disease. Journal of Dental Hygiene. 88(5): 275-284.