Time to integrate oral health screening into medicine? A survey of primary care providers of older adults and an evidence-based rationale for integration

Current scientific evidence for why periodontitis should be included in diabetes management

This Perspective provides a brief summary of the scientific evidence for the two-way links between periodontal diseases and hyperglycemia (diabetes mellitus [DM] and pre-DM). It delivers in a nutshell current scientific evidence for manifestations of hyperglycemia on periodontal health status and effects of periodontal diseases on blood glucose levels and in turn incidence, progression, and complications of diabetes. Of outmost importance is presentation of scientific evidence for the potential of routine periodontal treatment to lower blood glucose levels, providing a novel, economical tool in DM management. Non-surgical periodontal treatment ("deep cleaning") can be provided by dental hygienists or dentists in general dental offices, although severe cases should be referred to specialists. Such therapy can decrease the costs of DM care and other health care costs for people with DM. The great importance of a healthy oral cavity free of infection and subsequent inflammation - especially periodontitis that if untreated will cause loosening and eventually loss of affected teeth - has largely gone unnoticed by the medical community as the health care curricula are largely void of content regarding the bi-directional links between oral health and systemic health, despite elevation of blood glucose levels being an integral part of the general systemic inflammation response. The importance of keeping disease-free, natural teeth for proper biting and chewing, smiling, self-esteem, and pain avoidance cannot be overestimated. Medical and dental professionals are strongly encouraged to collaborate in patient-centered care for their mutual patients with - or at risk for - hyperglycemia.

Antibodies against Periodontal Microorganisms and Cognition in Older Adults

INTRODUCTION

Markers of poor oral health are associated with impaired cognition and higher risk of Alzheimer disease (AD) and thus may help predict AD.

OBJECTIVES

The aim of this study was to evaluate the cross-sectional association between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and cognition in middle-aged and older adults.

METHODS

The study population consisted of participants of the third National Health and Nutrition Examination Survey (NHANES III) (1988 to 1994), who were 60 y and older, among whom cognition and IgG antibodies against 19 periodontal microorganisms were measured (N = 5,162).

RESULTS

In multivariable quantile regression analyses, the Orange-Red (Prevotella melaninogenica, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis) and Yellow-Orange (Staphylococcus intermedius, Streptococcus oralis, Streptococcus mutans, Fusobacterium nucleatum, Peptostreptococcus micros, Capnocytophaga ochracea) cluster scores were negatively associated with cognition. A 1-unit higher cluster score for the Orange-Red cluster was associated on average with a lower cognitive score (β for 30th quantile = -0.2640; 95% confidence interval [CI], -0.3431 to -0.1848). Similarly, a 1-unit higher score for the Yellow-Orange cluster was associated with a lower cognitive score (β for 30th quantile = -0.2445; 95% CI, -0.3517 to -0.1372).

CONCLUSION

Groups of IgG antibodies against periodontal microorganisms were associated with lower cognition among free living adults 60 years and older, who were previously undiagnosed with cognitive impairment. Though poor oral health precedes the development of dementia and AD, oral health information is currently not used, to our knowledge, to predict dementia or AD risk. Combining our findings with current algorithms may improve risk prediction for dementia and AD.

KNOWLEDGE TRANSLATION STATEMENT

IgG antibodies against periodontal microorganisms were associated with lower cognition among adults 60 years and older previously undiagnosed with cognitive impairment. Periodontal disease may predict cognition among older adults.

Partnering for Integrated Care: A Learning Collaborative for Primary Care and Oral Health Teams

PURPOSE

The Teaming and Integrating for Smiles and Health (TISH) Learning Collaborative was developed to help health care organizations accelerate progress in integrating delivery of oral and primary care. By providing expert support and a structure for testing change, the project aimed to improve the early detection of hypertension in the dental setting and of gingivitis in the primary care setting, and to increase the rate of bidirectional referrals between oral and primary care partners. We report its outcomes.

METHODS

A total of 17 primary and oral health care teams were recruited to participate in biweekly virtual calls over 3 months. Participants tested changes to their models of care through Plan-Do-Study-Act cycles between calls. Sites tracked the percentages of patients screened and referred, completed the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) and Interprofessional Assessment questionnaires, and provided qualitative feedback and updates in storyboard presentations.

RESULTS

On average, with implementation of the TISH Learning Collaborative, sites displayed a nonrandom improvement in the percentages of patients screened for hypertension, referred for hypertension, referred to primary care, and referred for gingivitis. Gingivitis screening and referral to oral health care were not markedly improved. Qualitative responses indicated that teams made progress in screening and referral workflows, improved communication between medical and dental partners, and furthered understanding of the connection between primary care and oral care among staff and patients.

CONCLUSIONS

The TISH project is evidence that a virtual Learning Collaborative is an accessible and productive avenue to improve interprofessional education, further primary care and oral partnerships, and achieve practical progress in integrated care.

Healthy Food, Healthy Teeth: A Formative Study to Assess Knowledge of Foods for Oral Health in Children and Adults

Eating patterns characterised by low intakes of processed carbohydrates and higher intakes of fat- and Vitamin D-rich foods are associated with protection against dental caries. The aim of this formative study was to evaluate the extent to which the knowledge of children and adults of foods for oral health reflects dietary guideline advice, and the evidence base for foods associated with increased and decreased caries burdens. Using a novel card-sorting task, the participants categorised foods according to their knowledge of each food for oral health. There were no differences between children and adults in the categorisation of fresh, minimally processed foods. Fish, chicken, and red meat were categorised as healthy by significantly fewer children than adults. High-sugar foods were correctly characterised as unhealthy by nearly all participants. More children categorised breakfast cereals as healthy than adults. There were no statistically significant differences between children and adults for the categorisation of brown or wholegrain breads categorised as healthy. The alignment of the participants’ beliefs with dietary guideline recommendations suggests education through health promotion initiatives is successful in achieving knowledge acquisition in children and adults. However, recommendations to increase the intake of refined carbohydrates inadvertently advocate foods associated with increased caries burdens.

Referral Patterns in Oral Medicine: A Retrospective Analysis of an Oral Medicine University Center in Southern Italy

Referral of a patient from one healthcare provider to another is an important part of the medical practice. The aim of this study was to analyze the referral process to the Oral Medicine Unit in a university-based tertiary center in Southern Italy. A chart review of new referrals to the Oral Medicine Unit during a 24-month period was conducted. The following data were recorded: demographic characteristics, medical history, number of physicians seen prior to Oral Medicine assessment, referral source, diagnostic procedures ordered by referrals, reason for referral, site of lesion/condition, final diagnosis. Then, the rates of correct identification for health-care professionals and the appropriateness of the reference diagnosis based on the disease were calculated with descriptive statistic indicators. There were 583 new first consultations. A total of 62.9% of patients were referred by general dental practitioners, 27.4% by physicians, and 9.7% did not have a referral. The most common diseases for referral were immune-mediated diseases (39.6%) and oro-facial pain disorders (25.2%). Only 28.5% of patients had a correct provisional diagnosis. The results of this study show the need to implement curricula in the field of oral medicine among dentistry and medical students, and to support the continuing education among healthcare providers to reduce diagnostic delay for oral diseases.