We are entering an era
of medical awareness
and understanding in
which all health care
providers need to
shoulder the
responsibility for a
patient’s medical
health.
That oral infections may have an impact on systemic health is not a new concept. More than 2,000 years ago, Hippocrates suggested that arthritis could be cured by the removal of infected teeth. The notion that a focus of infection in the mouth could affect other parts of the body was a very fashionable hypothesis in the late 1800s and the early 1900s and was known as the “focal infection theory.” Teeth were extracted under the pretext of curing a myriad of different diseases and conditions as farfetched as anemia, insomnia, phobias, polio and even stupidity. Most of the rationales for this choice of treatment were based on what were, at that time, plausible medical theories that were perpetuated until accepted as facts.
Although the focal infection theory fell out of vogue during the 1920s and 1930s, there is a renewed interest in the effect of oral infections on the development and exacerbation of systemic diseases. Particularly, the association between periodontal disease and general health has been elucidated and discussed both in the professional literature and the lay press.
This connection has popularized the terms “oral-systemic” and “periodontal medicine.”
How do we position oral health within systemic health? Is it a matter of identifying oral infections that may cause or exacerbate systemic illness, or identifying how oral treatment modalities affect systemic conditions and how treatment of systemic illness affects oral health, or using oral tissues and fluids to identify systemic conditions, or involving oral health care providers in screening for systemic conditions? All of these questions have been discussed in the dental and medical literature and are, to a certain extent, equally valid.
Numerous chronic medical conditions are caused by or associated with infectious diseases. The more familiar are liver disease, caused by hepatitis viruses; peptic ulcer, caused by Heliobacter pyloris; or cervical cancer, which is associated with a human papilloma virus infection. Periodontal disease is a chronic infectious disease that has been postulated to affect other chronic conditions through various pathways, including the generation of inflammatory mediators, by direct effect of bacterial colonization, or as a result of toxins produced by periodontal pathogens. Thousands of articles have discussed periodontal disease and its association with heart disease, stroke, pneumonia, preterm births, low-birth weight babies, osteopenia, osteoporosis and diabetes mellitus. Several decades ago, it was recognized that oral infections had a significant impact on morbidity and mortality of medically compromised patients, such as those with cancer or those undergoing chemotherapy. Elimination of oral infections before initiating radiation therapy, chemotherapy or various cardiac conditions today is the standard of care in most medical institutions in the United States. These circumstances are not chronic in nature, and timely interventions many times can prevent and even eliminate significant complications.
Treatment of oral infections and mucosal lesions with medications ranging from topical analgesics and antibiotics to systemic glucocorticoids may affect bleeding tendencies, general bacterial resistance, liver functions, glycemic control and more. There is no doubt that the effect of management for oral conditions is not limited to the oral cavity. Furthermore, the effects of epinephrine and the use of dental radiographs have been implicated in causing adverse events in specific patient populations. However, interventions for systemic conditions also may have a dramatic impact on oral health. Xerostomia can be induced by hundreds of medications, gingival overgrowth can be stimulated by different classes of medications, the development of osteonecrosis of the jaws recently has been associated with specific drugs, and oral ulcerations secondary to radiation and chemotherapy are very common.
Diagnoses of Sjogren’s syndrome and leukemia can be supported by oral biopsies. The use of oral fluids as diagnostic modality is a burgeoning field that is providing, for the first time, an alternative to traditional serology. Salivary samples today are used for such varied tasks as making a diagnosis of an infectious disease to serving a marker for blood alcohol levels. Future use for oral fluid diagnostics is almost unlimited, including testing for cancers and many other systemic conditions.
Neurological problems affecting oral functions, development of infections such as oral candidiasis, pain in the jaws secondary to cardiovascular disease or even metastatic cancers are only a few examples of conditions that may manifest initially in the oral cavity. As oral care providers, we are experts in distinguishing between normal and abnormal oral conditions. This is the easy part. Another responsibility is to provide the care necessary to maintain optimal oral health for patients with complex medical conditions. This can be challenging but is necessary for more and more patients surviving and living with increasingly more multifaceted health problems. But should we go further and try to screen for and monitor systemic conditions that do not directly affect the mouth or the provision of dental treatment?
Oral care providers traditionally treat patients who perceive themselves as healthy. This puts us in an advantageous position to discover diseases that have yet to display significant adverse clinical manifestations. Exhibiting shortness of breath during normal physical activities, fatigue, orthopnea, swollen ankles, frequent urination, heat intolerance and inadvertent weight changes may be signs that develop over time and, therefore, may not immediately cause a patient to seek medical advice. Yet, all of these signs and symptoms suggest the presence of potentially severe systemic conditions. Should oral care providers screen patients for common medical conditions? Should dentists start to check patients’ blood pressure, cholesterol and plasma glucose to screen for heart disease and diabetes mellitus? We are not going to do it to diagnose or treat a systemic disease, but early detection undoubtedly will result in a better medical outcome. Is this part of our responsibilities as health care providers?
It is critical to understand the limitations of reports linking oral and systemic conditions and to look at them from the perspective of the role of oral health care providers in the overall health of our patients. We are entering an era of medical awareness and understanding in which all health care providers need to shoulder the responsibility for a patient’s med cal health.
the field
We have defined and redefined where the boundaries lie for oral health care providers in the field of medicine. It is clear that the mouth is an integral part of the body, that oral infections have systemic implications, that treatment of oral and systemic conditions has a reciprocal impact, that we have the potential to screen and monitor medical diseases and conditions, and that we provide care for patients who have chronic and sometimes complex illnesses. Patients will be better served if we initiate a dialogue with our physician colleagues, that is not limited to oral infection-systemic interactions. A successful partnership should embrace the full potential impact we can have on health by looking at the more expanded concept of an oral-medical connection.
of medical awareness
and understanding in
which all health care
providers need to
shoulder the
responsibility for a
patient’s medical
health.
That oral infections may have an impact on systemic health is not a new concept. More than 2,000 years ago, Hippocrates suggested that arthritis could be cured by the removal of infected teeth. The notion that a focus of infection in the mouth could affect other parts of the body was a very fashionable hypothesis in the late 1800s and the early 1900s and was known as the “focal infection theory.” Teeth were extracted under the pretext of curing a myriad of different diseases and conditions as farfetched as anemia, insomnia, phobias, polio and even stupidity. Most of the rationales for this choice of treatment were based on what were, at that time, plausible medical theories that were perpetuated until accepted as facts.
Although the focal infection theory fell out of vogue during the 1920s and 1930s, there is a renewed interest in the effect of oral infections on the development and exacerbation of systemic diseases. Particularly, the association between periodontal disease and general health has been elucidated and discussed both in the professional literature and the lay press.
This connection has popularized the terms “oral-systemic” and “periodontal medicine.”
How do we position oral health within systemic health? Is it a matter of identifying oral infections that may cause or exacerbate systemic illness, or identifying how oral treatment modalities affect systemic conditions and how treatment of systemic illness affects oral health, or using oral tissues and fluids to identify systemic conditions, or involving oral health care providers in screening for systemic conditions? All of these questions have been discussed in the dental and medical literature and are, to a certain extent, equally valid.
Numerous chronic medical conditions are caused by or associated with infectious diseases. The more familiar are liver disease, caused by hepatitis viruses; peptic ulcer, caused by Heliobacter pyloris; or cervical cancer, which is associated with a human papilloma virus infection. Periodontal disease is a chronic infectious disease that has been postulated to affect other chronic conditions through various pathways, including the generation of inflammatory mediators, by direct effect of bacterial colonization, or as a result of toxins produced by periodontal pathogens. Thousands of articles have discussed periodontal disease and its association with heart disease, stroke, pneumonia, preterm births, low-birth weight babies, osteopenia, osteoporosis and diabetes mellitus. Several decades ago, it was recognized that oral infections had a significant impact on morbidity and mortality of medically compromised patients, such as those with cancer or those undergoing chemotherapy. Elimination of oral infections before initiating radiation therapy, chemotherapy or various cardiac conditions today is the standard of care in most medical institutions in the United States. These circumstances are not chronic in nature, and timely interventions many times can prevent and even eliminate significant complications.
Treatment of oral infections and mucosal lesions with medications ranging from topical analgesics and antibiotics to systemic glucocorticoids may affect bleeding tendencies, general bacterial resistance, liver functions, glycemic control and more. There is no doubt that the effect of management for oral conditions is not limited to the oral cavity. Furthermore, the effects of epinephrine and the use of dental radiographs have been implicated in causing adverse events in specific patient populations. However, interventions for systemic conditions also may have a dramatic impact on oral health. Xerostomia can be induced by hundreds of medications, gingival overgrowth can be stimulated by different classes of medications, the development of osteonecrosis of the jaws recently has been associated with specific drugs, and oral ulcerations secondary to radiation and chemotherapy are very common.
Diagnoses of Sjogren’s syndrome and leukemia can be supported by oral biopsies. The use of oral fluids as diagnostic modality is a burgeoning field that is providing, for the first time, an alternative to traditional serology. Salivary samples today are used for such varied tasks as making a diagnosis of an infectious disease to serving a marker for blood alcohol levels. Future use for oral fluid diagnostics is almost unlimited, including testing for cancers and many other systemic conditions.
Neurological problems affecting oral functions, development of infections such as oral candidiasis, pain in the jaws secondary to cardiovascular disease or even metastatic cancers are only a few examples of conditions that may manifest initially in the oral cavity. As oral care providers, we are experts in distinguishing between normal and abnormal oral conditions. This is the easy part. Another responsibility is to provide the care necessary to maintain optimal oral health for patients with complex medical conditions. This can be challenging but is necessary for more and more patients surviving and living with increasingly more multifaceted health problems. But should we go further and try to screen for and monitor systemic conditions that do not directly affect the mouth or the provision of dental treatment?
Oral care providers traditionally treat patients who perceive themselves as healthy. This puts us in an advantageous position to discover diseases that have yet to display significant adverse clinical manifestations. Exhibiting shortness of breath during normal physical activities, fatigue, orthopnea, swollen ankles, frequent urination, heat intolerance and inadvertent weight changes may be signs that develop over time and, therefore, may not immediately cause a patient to seek medical advice. Yet, all of these signs and symptoms suggest the presence of potentially severe systemic conditions. Should oral care providers screen patients for common medical conditions? Should dentists start to check patients’ blood pressure, cholesterol and plasma glucose to screen for heart disease and diabetes mellitus? We are not going to do it to diagnose or treat a systemic disease, but early detection undoubtedly will result in a better medical outcome. Is this part of our responsibilities as health care providers?
It is critical to understand the limitations of reports linking oral and systemic conditions and to look at them from the perspective of the role of oral health care providers in the overall health of our patients. We are entering an era of medical awareness and understanding in which all health care providers need to shoulder the responsibility for a patient’s med cal health.
the field
We have defined and redefined where the boundaries lie for oral health care providers in the field of medicine. It is clear that the mouth is an integral part of the body, that oral infections have systemic implications, that treatment of oral and systemic conditions has a reciprocal impact, that we have the potential to screen and monitor medical diseases and conditions, and that we provide care for patients who have chronic and sometimes complex illnesses. Patients will be better served if we initiate a dialogue with our physician colleagues, that is not limited to oral infection-systemic interactions. A successful partnership should embrace the full potential impact we can have on health by looking at the more expanded concept of an oral-medical connection.
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