Dental disease delays surgery in a significant percentage of patients because dental and medical providers work in isolation without proper communication, particularly affecting cardiothoracic surgery, obstetric, and cancer patients. Integrating dental teams into the broader medical care team through improved communication, shared electronic records, and collaborative treatment planning can prevent surgical delays and improve patient outcomes.
Between 21% and 48% of cardiothoracic surgery patients require dental treatment before surgery, with roughly 21% failing dental clearance entirely.
The U.S. experiences approximately 5,300 dental-related emergency department visits daily, with about 5% resulting in hospital admissions.
Dental disease contributes to systemic complications including elevated diabetes markers, cardiovascular disease exacerbation, preterm labor, and infection risk in vulnerable populations.
Solutions include direct doctor-to-doctor communication, shared patient information, salivary diagnostics, and dental teams functioning as active members of the medical care team.
Dental disease routinely complicates the care of medical and surgical patients, yet dental and medical providers continue to work largely in isolation from one another. Drawing on hospital-based practice, this article examines where that separation harms patients, including patients undergoing cardiothoracic surgery, obstetric patients, and patients with head and neck cancer. It outlines practical steps dental teams can take to function as full members of the patient’s care team.
According to the U.S. Centers for Disease Control and Prevention, the U.S. has nearly 2 million emergency department visits each year for dental-related conditions, roughly 5,300 a day, and about 5% of them result in hospital admissions.
According to research published by the U.S. National Institutes of Health, between 21% and 48% of cardiothoracic surgery patients require dental treatment for active dental disease before surgery. Nearly all of these patients present with moderate periodontitis, and almost half require oral surgery. Roughly 21% fail dental clearance and must undergo extractions or other dental treatment before surgery can proceed.
Too often the dental and medical teams treating a patient remain siloed, and the lack of communication between them is a significant source of risk to the patient.
Barriers to integrated care
CommunicationDr. Anna K. McGuire.
In the U.S., dental education is separate from every aspect of medical education, and that separation has created a barrier, with dentistry on one side and all of medicine on the other.
Information about a shared patient does not pass easily between providers. Within medicine, various service lines readily share consults, treatments, test results, and outcomes through electronic medical records such as Epic and secure messaging such as Epic’s Haiku, and providers function as a “team.” Because dental providers sit outside that team, patients often downplay information their dental providers give them.
Dental providers themselves (dentists, hygienists, and assistants) also frequently downplay their role in the patient’s systemic medical care, describing their work as “just a cleaning” or “just a filling” and often saying that “no one dies from a tooth.”
Although most dental offices record vital signs at an initial appointment, many do little more than chart them. Patients should be told why these measurements matter at a dental appointment, and the findings should be shared with the primary care physician (PCP) and other providers, because the dental team often sees the patient more frequently than any other healthcare provider.
Socioeconomic factors and dental anxiety
Socioeconomic factors are often cited as a barrier to treatment, with lack of dental insurance and limited access to care blamed for preventing patients from becoming dentally optimized before medical intervention. These factors are real, but they are only part of the picture.
Many hospitalized patients with the conditions discussed here have private dental insurance or the financial means to pay for dental care, yet they cite severe anxiety as the reason they have not completed treatment, even after receiving an examination and diagnosis of their oral condition.
Self-pay patients, who paid a nominal fee for an examination and radiographs or used a “coupon” for a free first visit, often fail to return because of anxiety, sticker shock, or being overwhelmed by the amount of treatment they require.
Their condition then compounds, and medical treatment is frequently delayed because they also fail to return to their specialist or PCP. Dental offices must insist on follow-up for unfinished treatment plans, just as specialists follow up to protect the patient’s medical outcome. Persistent follow-up from both sides keeps patients from falling through the cracks.
Dental disease as systemic disease
Dental caries
Carious lesions are open wounds. Patients experience symptoms that cause discomfort but are placated when the symptoms subside with the ebb and flow of the disease process. This delays treatment and allows decay to progress toward the pulp or destroy a significant amount of tooth structure.
A “simple” dental cavity can also raise a diabetic patient’s A1C, leaving the patient’s PCP or endocrinologist searching for the cause of the elevation and chasing it with medication. Because no shared standard of care has been established between the medical and dental worlds, information does not reach every provider who needs it.
Gingivitis and periodontal disease
Gingivitis and periodontal disease, at any stage or grade, involve chronic inflammation of the gingiva. Read that again: Chronic inflammation. That inflammation provokes an immune response with implications for, and correlations with, multiple other disease processes.
Correlation does not imply causation, but chronic inflammation sets the stage for exacerbation of cardiovascular disease, diabetes, autoimmune diseases, respiratory diseases, and cancer. Bacteria associated with various periodontal states have been found throughout the body, participating in end-organ disease and in conditions such as compartment syndrome.
Patient populations at risk
Obstetric patients
Patients who have not seen a dentist for some time before conceiving may present with plaque and calculus buildup and chronic gingival inflammation, which pregnancy hormones can exacerbate.
Dental caries can progress quickly when patients are ill-advised to avoid dental care during pregnancy, or when a provider refuses to treat a pregnant patient, regarding pregnancy as a “disease” the provider is ill-prepared to treat.
The obstetric community has extensively studied the relationship between gingivitis, periodontal disease, and preterm labor and delivery. In addition, untreated decay can spread rapidly to the pulp and cause infection, placing the patient at risk of transmitting infection to the fetus and of preterm labor and delivery, with resulting admissions to the neonatal intensive care unit.
Cardiac patients
Patients requiring mitral valve repair, transcatheter aortic valve replacement, or coronary artery bypass grafting commonly require dental clearance. Historically, these patients were predominantly older. In recent years, the demographic has shifted: Drug use has pushed the age down, but the age of patients undergoing these procedures has also declined overall, independent of drug dependence.
Presurgical dental care is ideal, particularly when dental infections are present. Keeping a patient on antibiotics from before surgery through recovery is poor antimicrobial stewardship and can compromise the patient in the future.
After surgery, the patient enters a vulnerable phase of cardiac recovery, with a high risk of readmission because of an adverse event or failure. Patients are also often placed on anticoagulant therapy postoperatively, which further complicates any significant oral surgery or endodontic treatment not completed before cardiothoracic surgery.
Maintaining a patient on antibiotic therapy indefinitely is unrealistic; patients have difficulty following prescription instructions for a short course, let alone an open-ended one. Preventing multidrug resistance should remain front of mind.
Head and neck cancer patients
Great care must be taken with patients newly diagnosed with head and neck cancer, many of whom will undergo surgery along with radiation and chemotherapy. As dental practitioners, we take a conservative approach to preserve as much of the dentition as possible, and patients frequently request this to maintain their self-esteem, masticatory function, and overall well-being. Treatment plans must be reviewed thoroughly with the patient, the patient’s family and the entire care team.
Even with a well-designed plan for meticulous hygiene, cancer treatment can ravage the salivary glands or erode the patient’s motivation to maintain basic hygiene, let alone additional measures. The result can be severe xerostomia, heavy biofilm accumulation, periodontal disease, and rampant caries that can lead to dental abscesses.
This is a difficult situation because the risk of osteoradionecrosis following an extraction after radiation therapy is significant. Alternatives to extraction, such as endodontic treatment with decoronation, can have less-than-ideal outcomes. Hyperbaric oxygen treatment does not reliably prevent osteoradionecrosis.
Discussion
Much of my practice consists of patients from these populations, referred to me as the “last” effort for dental care. These patients and their medical teams are often exasperated by the lack of continuity of care. Much of the problem stems from providers’ inability to communicate with one another.
Dentistry is part of the medical team. Dental providers should conduct themselves accordingly and should not hesitate to pick up the phone and speak doctor to doctor.
Most physicians and surgeons do not fully understand what our treatment involves. A case in point is the physician who, as a patient, asks for a “regular cleaning,” as though he or she were a Formula One car coming into the pit for a tire change.
Neither profession is above the other; we share the same goal: the well-being and positive outcomes of our mutual patients. I cannot overstate the need for communication and colleague education on both sides.
Referrals from hospital service lines represent late-stage dental intervention. I urge dental teams to become active members of the medical team in preventing the systemic progression of disease. Consistent oral hygiene -- beginning in childhood and continuing through adolescence, adulthood, and old age -- is the only way to gain control over the dental factors that contribute to complications in cardiothoracic surgery and to maintain healthy dentition.
Educating patients and their families is essential, because dental literacy is low among patients and caregivers, just as dental providers’ confidence in engaging with the broader care team is low. A positive outcome for the patient is the ultimate goal of the entire team.
Salivary diagnostics
Dental teams should use modern tools to better address the relationship between oral and systemic health. One of the newest is salivary testing.
One commercially available system, Oral Genome, uses rapid saliva testing through an AI-powered app that measures and analyzes seven specific oral biomarkers within 15 minutes. The results are intended to help the dental team assess the bacteria responsible for periodontal disease; chronic inflammation; salivary pH; the buffering capacity of natural saliva; nitric oxide, which offers a window into local circulation and cardiovascular health; glucose levels, which give insight into metabolic health and diabetes management; and salivary proteins, which serve as the patient’s first immune barrier.
In much the same way that a complete blood count with differential gives physicians a broad view of the body’s current state, salivary testing may offer the dental team a comparable overview of the oral cavity. Clinicians may wish to consider incorporating salivary diagnostics into comprehensive and new patient examinations, giving the provider additional information to share with the patient and the broader care team as we develop a treatment plan that supports the patient’s overall medical health. Further research will help define the role of these tools in routine practice.
Editor's note: The author reports no financial relationship with Oral Genome or any other company named in this article. References are available upon request.
Dr. Anna K. McGuire is a general dentist with nearly 30 years’ experience who maintains a hospital-based surgical practice at Miami Valley Hospital in Dayton, OH. She treats admitted patients from cardiothoracic surgery, neurosurgery, trauma, obstetrics, and the emergency department. A Tufts University School of Dental Medicine graduate, she completed a general practice residency at Miami Valley, where she served as chief resident. She is also a partner and senior dentist at Stonecreek Dental Centerville.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
Dr. Anna K. McGuire.
Dr. Anna K. McGuire.
