Twenty years ago, psychologist Daniel J. Simons created the now-classic “gorilla experiment” video. When he asked viewers to count the number of times a group of people passed a basketball back and forth, half the viewers failed to notice the actor in a gorilla suit strolling through the scene. He demonstrated how, by concentrating on specific tasks, we become blind to things that would otherwise draw our attention.
Our approach to reducing risk of cardiovascular disease (heart attack, stroke and renal failure) focuses — for good reasons — on aspirin, blood pressure, cholesterol and smoking. But there is a gorilla strolling through the scene that we’re not seeing: periodontal disease. An emerging body of evidence points to periodontal disease as a significant risk factor for cardiovascular disease.
Medical clinicians have traditionally ignored periodontal disease, partly due to focusing on other tasks and partly because, like the gorilla in the video, we didn’t expect it to be there. But we ignore it at our peril. In the world of whole-person population health and value-based payment, we’re missing an opportunity — literally right under our noses — to improve cardiovascular outcomes and prevent avoidable cost.
Recent research offers compelling evidence:
- Inflammation caused by chronic infection in periodontal tissue produces an array of circulating peptides. This results in low-grade inflammation of the peripheral vasculature that accelerates a restructuring of the endothelium in a way that we recognize as small-vessel atherosclerosis.
- The risk of stroke rises with the severity of periodontal disease with an average hazard ratio similar to that of hypertension.
- People who receive regular dental care for their periodontal disease have a reduction in risk similar to a 10-point decrease in systolic blood pressure.
Medical doctors consider periodontal disease to be in the realm of dentistry, and it is true that dentists and dental hygienists are the ones with the knowledge, skills and tools to perform the procedures used to treat it. However, the current dental delivery system is not prepared to address this cardiovascular risk factor.
- 40% of all adults have periodontal disease. That number rises to 60% in economically disadvantaged populations.
- Those at highest risk for cardiovascular disease, including many in disadvantaged populations, lack access to dental care.
- Dentists treating periodontal disease tend to concentrate on saving teeth; they don’t usually aim to decrease cardiovascular risk by reducing inflammation to the lowest level possible.
Because it straddles the historic professional divide between medicine and dentistry, a preventive, whole-person, population health approach to periodontal disease requires interventions that bridge the divide. The most successful models have both dental and medical professionals on the same clinical staff. However, models for much tighter integration of dental professionals into medical teams are appearing in FQHCs and staff model HMOs.
Comagine Health has been a leader in understanding, designing, testing and measuring the impact of the components of oral health integration in these settings from both the medical and dental perspectives.
2015-2017: Developed the Oral Health Delivery Framework
We identified a handful of simple, highly effective actions that primary care practices could take to improve and maintain their patients’ oral health and developed the Oral Health Delivery Framework. Testing in delivery systems across the U.S. showed that providers were able to incorporate the framework into their workflow.
2017-2018: Created an Oral Health Status Measurement Process
In collaboration with Arcora Foundation, we created a method for measuring the oral health status of populations, making it easy for dentists at an FQHC to enter diagnosis codes describing oral disease severity — rather than simply documenting procedure codes for reimbursement. Not only did we show a steady increase in documentation of oral disease severity, we were able to report on severity distribution in defined patient populations.
2019 and Beyond: Implement Medical-Dental Interventions
Comagine Health is now developing integrated medical-dental interventions to identify strategies capable of producing measurable improvements in periodontal health in high-risk populations.
- Primary care teams leverage their experience managing populations with chronic disease to assure that every patient in a high-risk population has an active relationship with a dental home, has their medication list reviewed to minimize periodontal side effects, and understands basic oral hygiene.
- Dental teams work with their primary care colleagues to assure that members of the high-risk population are monitored regularly and that periodontal disease severity is documented at each visit. Dentists also use a standard stepped-care protocol to treat periodontal disease with a goal of reducing periodontal inflammation to a minimum.
- Population reporting tracks the number and percentage of people in the target population:
- With a dental home
- With a dental visit within six months that includes assessment and documentation of periodontal disease severity
- Achieving the clinical goal
This basic structure and the accompanying process and outcome metrics provide a framework for evaluating the effectiveness of medical-dental collaborative interventions in improving periodontal disease management, as well as for measuring the clinical and financial impact of those interventions. Just as we can widen our focus to see a gorilla sauntering through a basketball game, we can widen our approach to reducing cardiovascular disease. Bridging the divide between medicine and dentistry with a collaborative model is showing promising signs of improving both patient and financial outcomes.