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Medical-perio: the golden age of dentistry as a health and longevity service

March 22, 2010
Why should any dentist care about the oral-systemic connection and seek to work more closely with physicians? Drs. James McAnally and Neil Gottehrer point out that as the causes of death are eliminated, the potential for longevity increases.
By Dr. James McAnally and Dr. Neil Gottehrer
Why should any dentist care about the oral-systemic connection and seek to work more closely with physicians? Simply put, major causes of death are eliminated, and as a result the potential for longevity increases. According to the latest CDC records from 2006, the top 10 leading causes of death by disease were:

1. Heart disease: 631,636
2. Cancer: 559,888
3. Stroke (cerebrovascular diseases): 137,119
4. Chronic lower respiratory diseases: 124,583
5. Accidents (unintentional injuries): 121,599
6. Diabetes: 72,449
7. Alzheimer's disease: 72,432
8. Influenza and pneumonia: 56,326
9. Nephritis, nephrotic syndrome, and nephrosis: 45,344
10. Septicemia: 34,234

Four of the top 10 causes of death (in bold) have inflammatory components, and all four have reported links to dental disease based in science.

There is also evidence that a percentage of pneumonia cases resulting in death can be attributed to aspirated oral bacteria from an infected periodontium.

Even more vividly, the February 2010 issue of Obstetrics and Gynecology contains a report by researchers at the Department of Periodontics at Cincinnati’s Case Western Reserve University School of Dental Medicine reporting the first documented link between a mother with pregnancy-associated gum disease to the death of her fetus. Doctors found the exact same strain of bacteria from the 35-year-old California woman’s infected gums in her stillborn baby.

Unfortunately, the linkage between gingival health and general health isn’t new, nor is new information circulating within the profession and lay press.

Spend a few minutes searching any major public database of trade magazines, scientific literature, or popular press such as ProQuest and multiple authorial fingers will point at this connection starting in the mid to late 1990s.

While professional organizations have mouthed the importance of such data and links, few have taken concrete steps or formulated real action steps solidifying the “what to be done” side of the equation for the practitioner. Ask the leader of any major dental trade organization, what is the best way to coordinate better relationships between physicians and dentists to deal with the matter and get disease treated, and one is likely to get a mouth full of words with little practical application.

The bottom line is as more evidence accumulates, it is becoming clear that part of the equation to keep the general population much healthier and living longer involves every dentist who diagnoses or treats a patient who has teeth or has been restored with dental implants.

Additionally, if one happens to be a male dentist who practices more than three days a week in a sitting position, there is an automatic increase in risk for heart attack, and thus personally most dentists should be very interested in this subject from one’s own health standpoint.

Linkage grows between heart and mouth

Cardiovascular disease (CVD) and periodontal disease are among the most prevalent conditions affecting adults today.

Up to 80 million (one of every three) adults have cardiac disease. 38.2 million are under the age of 60. Periodontal disease affects as many as 75% of adults in the United States.

Recent clinical studies confirm a strong connection between the two diseases. Desvarieux, et al. in 2005, studied the relationship between periodontal bacteria and atherosclerosis (increased carotid artery intima-media thickness; i.e., narrowing of the artery leading to ischemia and “heart attacks”). He found that periodontal infections can contribute to CVD morbidity (death) and that the chronic oral (periodontal) infection can be a possible mechanism causing CVD.

In April 2009, Piconi, et al., published a study showing that treatment of periodontal disease resulted in improvement in atherosclerosis and reduced narrowing of the carotid artery (intima-media thickness). In laymen’s terms, treat the gum problems and even those already with heart disease can see improvements.

The results clearly indicated a strict association existing between periodontal disease and atherosclerosis, suggesting that periodontal disease is an independent risk factor for the development of atherosclerosis and is a significant predisposition for the disease!

Why screening and why ‘risk assessment?’

Based on this data, every adult patient should be assumed to have had or presently has some form of active gingivitis and or periodontitis.

While the traditional examination for periodontal disease remains a six point probing on each tooth, it is possible to simplify the screening exam to determine if the patient has active disease and requires treatment. This greatly expands the number of patients who can be screened via referral or via marketing efforts to bring awareness to the importance of disease treatment.

The most important reason to simplify the screening is that it dramatically increases the understanding for the physician who is not trained to diagnose or treat periodontal disease. With understanding comes a recommendation by the physician on what to do. For the patient, it means the physician being vocal about treatment and the patient following through with the recommended treatment with their dentist.

The traditional reason for evaluation for treatment is to treat active disease and retain as many teeth as possible (i.e., prevent tooth loss). That was the pre-linking of major diseases to dental health. With the introduction of clinical studies that confirm that periodontal disease is a major potential risk for cardiac disease, the new rationale for a simple screening exam, based on the new science, is to perform a Medical-Periodontal Risk Assessment.

This assessment is a basic screening exam for periodontal disease, which may place the patient at risk for cardiac disease — thus, the designation as a “risk assessment” instead of a complete periodontal evaluation for active disease. One such risk assessment tool has been made available to physicians and dentists in a free guide written by Dr. Neil Gottehrer, which is available by contacting ChaseHealthAdvance, a division of JPMorgan Chase.

Why develop a system such as the Healthy Heart Dental Program?

As a profession, we’ve failed to learn how to interact with our physician colleagues in ways that work. While many physicians (and far more dentists) and patients are aware of the information — scientific and lay — moving through the population, many are not aware of what to do and of dentistry’s role in the equation.

Thus, a systematic approach to screening and communication with the physician’s office is a must in order for more patients to have the dental side of risk removed from the health equation. Without letting local physicians (and patients as a result) know that you have a vital piece of the answer ready for them in your practice via certain ways of communicating and certain actions on the doctor and hygiene team’s part, the disease linkage remains little more than theory seen in literature.

While patients may not always seek out care that is beneficial to them, physicians have an obligation to recommend appropriate treatment to patients that may better their long-term health, even if that means recommending treatment by the dentist.

Whether we are nearing what Malcolm Gladwell documents as “the tipping point,” where physicians will actively seek out dentists who understand their role in helping the physician’s patient, can be debated. What isn’t debatable is the fact that when the local dentist takes action in the right fashion, more patients are treated, which is good for everyone — the patient, the physician’s practice, and the dentist’s practice.

Additionally, very good news is that as more clinical studies provide strong evidence for physicians, who are more evidence-based than most dentists, they make changes in their practices based on the science.

Finally, if physicians order a blood test, they are now obligated to follow through with making recommendations to the patient including that he/she gets the proper periodontal and restorative dentistry completed.

Eventually this will be an ethical obligation for all dentists. For those who see the opportunity, now is the time to collaborate with the physicians in your community, help your existing patients reduce their disease risk with conservative, nonsurgical periodontal care, and help the patients you receive by referral from the physician with their periodontal and restorative dental needs.

Instead of waiting for physicians to seek out the dentist, the astute dentist is putting him/herself in front of multiple physicians as the local expert, telling physicians what to do related to helping their patients.

By making local physicians aware of the evidence and aware of the fact that you are the local expert, you will help more patients, do something much bigger than just “fixing teeth” ... and finally, as a result, grow your practice.

Getting the word out that you’re the local expert
‘If you don’t ask, you don’t get.’ — Dr. James R. McAnallyWhy create physician referral marketing and expert status?With any form of marketing in dentistry, the first step is getting your message in front of the patient. This occurs either via internal marketing to your existing patients asking them for referrals or via external marketing (Internet, newsprint, radio, TV, direct mail, etc.). In most markets, external marketing as a dentist means competing with many other dentists to have the best message and the best sales process after attracting attention. Effective “problem-solution”-based external marketing to the consumer/patient is very effective and routinely generates patients needing a particular service in any market regardless of how crowded the local market or how competitive the local dentist feels the market is. Specialists in dentistry, up until recently, enjoyed a near monopoly-like referral system in which the general dentist referred difficult or complex cases to the specialist to handle. This meant the specialist usually avoided external marketing and had little concern for such. Those days are over but the concept of referral marketing is still a powerful one under new circumstances.Tools designed with the physician in mind allow for the creation of a physician (family practice and cardiologist) dental referral network. Essentially, this is akin to creating a new service market in a local area that few if any dentists understand or are taking advantage of. It’s open to generalists and specialists as no one has ownership other than he (or she) who shows up first.Physician referrals and creation of expert status in a local environment with the oral-body inflammatory connection comes about by multiple planned mechanisms. The end result of building a referral network is an increase of patients who wish to reduce their cardiac disease risk who will be referred and/or seek out the expert directly. Some patients will simply need help with simple periodontal problems, but many will also need restorative and/or implant dentistry. In other words, a lot of dentistry comes along with those needing help regaining periodontal health.The path to expert status includes: your existing patients, the patients of your patient’s physicians, other physicians in the community, the physician’s staff, creation of an Healthy Heart Emissary in your practice (usually a hygienist), and Healthy Heart Screening Days.Ultimately, this means hundreds (if not thousands over many years) of referrals both for treatment of perio and which in a fair number of cases leads to restorative treatment (crowns, implants, etc.). You take care of the dental needs; the physician manages the medical needs. The result? Healthier patients and potentially patients with longer life spans.To receive more information about systems to promote your practice as the local oral-inflammatory expert and how to stimulate medical-perio referrals, contact Big Case Marketing at (206) 601-6754 or go to
Dr. James McAnally is the CEO of Big Case Marketing and vice president of Dental Idea Lab, global leaders in providing turn-key advertising and case acceptance training for the specialist or generalist with advanced clinical training who seeks complex case patients needing implant and reconstructive dentistry and in providing physician referral medical-perio programs. Based in Seattle, Wash., and Boston, Mass., his firm’s doctor clients are on three continents and the trademarked sales system taught to dentists is distributed worldwide. His clients often refer to him as the “Warren Buffet of dental marketing and sales” and the “Walter Hailey for the 21st Century.” Dr. McAnally’s articles and e-mail tips are distributed to more than 30,000 doctors in 56 countries in venues such as the Profitable Dentist, Inside Dentistry, Dental Economics,,,, and Dentistry Today. His latest book, “The Gloves-Off Guide to the Biggest Marketing Secrets in Reconstructive Dentistry” was published in 2008. To find out more visit,,, or e-mail [email protected].Dr. Neil Gottehrer is a board-certified periodontologist, practicing clinician, and assistant clinical professor of oral biology at Stonybrook School of Dental Medicine. He’s published and lectured nationally and internationally and is currently the president of the Institute of Advanced Oral and Physical Health in Havertown, Pa. Recently, Chase Health Advance, the health-care financing arm of JP Morgan Chase, published a free resource guide by Dr. Gottehrer titled, “Evaluation and Management of the Oral-Body Inflammatory Connection.” Dr. Gottehrer co-authored this guide with renowned cardiologist Dr. Marvin Slepian. Dr. Gottehrer is considered the leading authority on the science surrounding this oral-body inflammatory connection and with the clinical application of the evolving role dental inflammation plays in increasing the risks for and of the exacerbation of serious systemic health issues.