Time to Act: Young Adults, Periodontal Disease, and Blood Pressure Oral Health America Webinar Series November 12, 2018
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2018
CE Credit Available
2018
ABOUT ORAL HEALTH AMERICA America’s leading national oral health nonprofit focused on the nation’s oral and overall health for 63 years, with particular emphasis on children and youth, older adults and Americans whose voices are not wellrepresented in oral healthcare conversations. OHA employs strategic partnerships and communications to connect the dots between oral and overall health
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Young Adults, Periodontal Disease, and Blood Pressure
TIME TO ACT Thomas D. Schwieterman MD, MBA VP Clinical Affairs, Midmark Corporation
Meet “Dr. Tom” Dr. Thomas D. Schwieterman is vice president of clinical affairs and chief medical officer for Midmark Corporation. He leads the company’s focus on innovative technology and new approaches that enrich experiences between caregivers and their patients at the point of care. Dr. Tom practiced family medicine for 12 years before joining the team at Midmark. He is board certified and continues to practice medicine.
Young Adults, Periodontal Disease, and Blood Pressure
TIME TO ACT Thomas D. Schwieterman MD, MBA VP Clinical Affairs, Midmark Corporation
Learning Objectives 1. Describe at least two key changes made in the American
Academy of Pediatrics 2017 revised blood pressure guidelines for adolescents.
2. Name two reasons dentists should ask about an adolescent patient's medical history of hypertension.
3. Name two reasons dentists should check blood pressure in adolescent patients.
4. Identify three things that could cause an inaccurate reading when measuring blood pressure in adolescent patients.
DENTISTRY AND MEDICINE
Dentistry: a demanding branch of Medicine “In 1840, dentistry focused on the fundamentals- extracting
decayed teeth and plugging activities. Today, dentists use sophisticated methods for prevention, diagnosis and treatment. We implant teeth, pinpoint oral cancers, use 3-D imaging to reshape the jaw‌ we have also discovered much more about the intimate connection between oral health and overall health� R. Bruce Donoff, Dean of the Harvard School of Dental Medicine
RECONNECTING Dentistry and Medicine •
Harvard: Initiative to Integrate Oral Health and Medicine
• Harvard and Cambridge Health: Oral Physician Program
• Harvard and Northeastern: Nurse Practitioner and Dentist Model for Primary Care
• Kaiser Permanente: Integrated MedicalDental Practice
• Organizations: Dentaquest, Santa Fe Group, Oral Health America
• Department of Health and Human Services:
2016 Report, first of five goals is to “integrate oral health and primary care”
Oral Cavity: gateway to the body‌.
....also the gateway to improving outcomes in managing chronic disease
Collaboration: to prevent chronic disease
Tomorrow
Today
Physicians refer at-risk patients for therapeutic dental care
Dentists refer at-risk patients for therapeutic medical care
BOTH collaborate to a common goal of health and wellness and prevention of downstream chronic disease
Dentists: front line for adolescent care No Pri mary Care Phys i ci an Vi s i t Pri mary Ca re Phys i ci an Non-Genera l Checkup Vi s i t Pri mary Ca re Phys i ci an Genera l Checkup Vi s i t 100% 90% 80% 49% 70% 60% 50% 40% 19% 30% 20% 32% 10% 0% M
16
47%
18% 35% F
53%
20%
48%
18%
53%
21%
27%
26%
M
F
M
F
18
25%
27% 31%
44% 69%
70%
34%
17
40%
42%
14% 16% M
19
35%
75%
59%
27% 15% 16%
F
M
20
29%
13% 12%
F
M
26% 15% F
21
Adolescents are less likely to seek medical care the older they get.... if they do, most visits are not for a 'check up’. Source: https://www.ada.org/~/media/ADA/Science%20and%20Res earch/HPI/Files/HPIgraphic_1117_2.pdf?la=en
Source: modified from https://www.academicpedsjnl.net/article/S1876-2859(18)30007-X/pdf
Blood Pressure: the common ground • Blood pressure has become a
foundation for attacking the chronic disease burden
-
Impact of blood pressure is increasing
• Blood pressure is one of the more
important physiologic attributes to be monitored before any invasive procedure is to be undertaken
-
Including in the operatory and oral surgery suite Source: https://www.cdc.gov/bloodpressure/youth.htm
Blood Pressure: the common ground • Research continues to validate
that blood pressure abnormalities in children and adolescents establish a dangerous foundation for future chronic disease.
Source: https://www.cdc.gov/bloodpressure/youth.htm
Blood Pressure: adolescents at risk You are seeing―and perhaps missing―cases of hypertension among young adults and children in your practice.
10%
15%
of children under 13 years of age have hypertension or elevated blood pressure
of children between 9 and 12 years of age have hypertension or elevated blood pressure
1.3 MILLION
children between 9 and 12 years of age have hypertension or elevated blood pressure Source: https://www.cdc.gov/bloodpressure/youth.htm
Dentist Visits: better blood pressure readings • Medical visits - obtaining baseline blood pressure can be challenging -
Often for sickness and acute problems Fever causes vasodilation and temporary decrease in blood pressure Pain causes sympathetic nerve stimulation and temporary increase in blood pressure Usually associated with high anxiety level; “white coat syndrome”
• Dentists often in a better position to obtain true baseline blood pressure -
Rarely fever or pain at dental regular check-ups Patient is usually “healthy” Pain and fever are controlled prior to restorative procedure Anxiety remains
Blood Pressure: perhaps the single most important nonbehavioral problem contributing to the development of chronic disease
86% of the US $2.7 trillion in annual healthcare expenditures are from chronic disease
Source: www.cdc.gov/chronicdisease/about/costs/
Chronic Diseases: modifiable risk factors and cost Disease
Modifiable Risk Factor
Cost
Heart Disease and Stroke
HTN*, Lifestyle (Tobacco), Cholesterol, Diabetes
$190 Billion
Cancer
Lifestyle
$154 Billion
Diabetes
Lifestyle, BMI
$245 Billion
Obesity
Lifestyle, BMI
$147 Billion
Arthritis
Lifestyle, BMI
$140 Billion
Dementia
? : Lifestyle, HTN, Cholesterol $159-215 Billion
Lifestyle: nutrition, activity, tobacco, alcohol, stress, sleep and emotional well-being
*HTN alone is estimated at $69.9 Billion
Source: National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)
Source: Heidenreich, P. A., et al. "Interdisciplinary Council on Quality of Care and Outcomes Research.(2011). Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association."Â Circulation123.8: 933-944.
Chronic Diseases: modifiable DENTAL factors Disease
Modifiable Risk Factor
Modifiable Dental Factors
Heart Disease and Stroke
HTN*, Lifestyle (Tobacco), Cholesterol, Diabetes
Periodontal Disease
Cancer
Lifestyle
Periodontal Disease
Diabetes
Lifestyle, BMI
Periodontal Disease, Sugary Food – Caries
Obesity
Lifestyle, BMI
Sugary Food – Caries
Arthritis
Lifestyle, BMI
Periodontal Disease
Dementia
? : Lifestyle, HTN, Cholesterol
Periodontal Disease
Lifestyle: nutrition, activity, tobacco, alcohol, stress, sleep and emotional well-being Source: National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) https://www.perio.org/consumer/gum-disease-and-other-diseases https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495574/ https://www.alzheimers.net/gum-disease-could-lead-to-the-development-of-alzheimers/
*HTN alone is estimated at $69.9 Billion Source: Heidenreich, P. A., et al. "Interdisciplinary Council on Quality of Care and Outcomes Research.(2011). Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association." Circulation123.8: 933-944.
Periodontal Disease and Puberty Epidemiologic and immunologic data:
• Irreversible tissue damage from periodontal disease begins in late adolescence* • Adolescents have a higher prevalence of gingivitis than younger children or adults -
Increase in sex hormones affects the composition of the subgingival microflora * Circulating sex hormones may alter capillary permeability and increase fluid accumulation in gingival tissues Inflammatory gingivitis considered transient as the body accommodates the ongoing presence of sex hormones*
*Source: http://www.aapd.org/media/policies_guidelines/g_adoleshealth.pdf
Periodontal Disease: contributes to hypertension • Chronic inflammation contributes to hypertension • Inflammation is the root cause of the issue - Inflammation leads to stimulation of stress systems – cortisol and the sympathetic nervous system
- Oxidative stress from inflammation leads to endothelial dysfunction (and thus development of vascular disease)
SPRINT Study showed that reducing blood pressure significantly lowered adverse chronic events
S.P.R.I.N.T. Systolic PRessure INtervention Trial • Hypothesis - Lowering systolic blood pressure goal to < 120 mmHg will reduce clinical events beyond < 140 mmHg
• Huge Trial -
102 clinical sites, nearly 10,000 participants Participants; age 50 years with systolic BP of 130-180 mmHg
• Results - Lowering systolic blood pressure to a target of 120 mmHg resulted in significantly LOWER rates of fatal and nonfatal cardiovascular events and deaths from any cause.
-
25% lower relative risk overall and even higher reductions (about 40%) from heart-related problems
S.P.R.I.N.T. Systolic PRessure INtervention Trial Protocol formed the basis for what is now called the SPRINT Protocol â&#x20AC;˘
New requirements for taking proper blood pressure measurements - Preparation - Positioning - Methodology - Averaging
SPRINT Protocol: preparation and positioning Automated BP measurement with an averaging feature
Patient not talking Ensure patientâ&#x20AC;&#x2122;s back is supported
Cuff placed on bare arm Arm supported at heart level by Patient Support Rails Plus
Legs uncrossed and feet flat on the floor
SPRINT Protocol: methodology and averaging “…The preferred method is the automated device as it offers reduced potential for observer biases and decreased demand on staff in terms of training and effort in data collection” Average of 3 blood pressure measurements after a period of rest
- Used to reduce effects of single variation in blood pressures - Improves accuracy and precision
Blood Pressure: lower disease burden
In 2017, the American Heart Association and the American College of Cardiology released a whole new set of guidelines for management of blood pressure disorders â&#x20AC;&#x201C; first in decades
American Heart Association and American Diabetes Association created a partnership in July 2018
New numbers are based on expert review of thousands of clinical studies
Recommendations are clinically significant, will increase the number of US citizens diagnosed as hypertensive by 10â&#x20AC;&#x2122;s of millions
Evidence was convincing that lower threshold would reduce cardiovascular events by double digits
Blood Pressure Categories Blood Pressure Category
Systolic mmHg
Diastolic mmHg
(Upper umber)
(Lower umber)
Normal
Less than 120
and
Less than 80
Elevated
120-129
and
Less than 80
High BP (Hypertension) Stage 1
130-139
and
80-89
High BP (Hypertension) Stage 2
140 or higher
or
90 or higher
Hypertensive Crisis
Higher than 180
and/or
Higher than 120
(Consult your doctor immediately)
Source: American Heart Association
In the operatory • Patient in a relaxed position with feet and back supported, after emptying bladder
• Allow the patient to rest quietly for 3 minutes • Avoid talking and use of phones • Use an automated device – with averaging if possible
• Allow the machine to do the pressure with patient alone for a few minutes
• Record the blood pressure readings in the patient’s medical chart
• Provide the patient with a copy of their
blood pressure readings, with instructions if applicable
Operatory Know your risks
Time to act is NOW • Periodontal disease is a leading indicator of chronic disease
• Dentists are uniquely positioned to impact overall health of our population
• Collaboration to ensure patient overall health and wellness
Dentistry: “A demanding branch of medicine” The 1867 mission --“...to develop and foster a community of global leaders, dedicated to improving human health by integrating dentistry and medicine at the forefront of education, research, and patient care.”
Source: https://www.statnews.com/2017/07/17/dentistry-medicine-division/
Questions?
Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes. • Write your questions in your control panel on the upper right hand of your screen. • Submit questions at any time.
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Thank you.
CE Credit Available
2018
Contact Information Thomas D. Schwieterman, M.D. Vice President, Clinical Affairs and Chief Medical Officer Midmark Corporation tschwieterman@midmark.com Tina Montgomery Director of Programs Oral Health America Tina.montgomery@oha-chi.org
2018
THANK YOU! Letâ&#x20AC;&#x2122;s improve the oral and overall health of all Americans together.
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