Bob: A Case Study in Intervention of Patients with/or at Risk for Cardiovascular Disease and Periodontal Disease

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Vivien Manning
5 years ago
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Bob: A Case Study in Intervention of Patients with/or at Risk for Cardiovascular Disease and Periodontal Disease Several recently published consensus opinions 1,2 concluded that oral healthcare

co-management of cardiometabolic diseases such as CVD. Another report 3 suggested that oral HCPs can play an important role in the primary prevention of CVD.

1 Bob: A Case Study in Intervention of Patients with/or at Risk for Cardiovascular Disease and Periodontal Disease Several recently published consensus opinions 1,2 concluded that oral healthcare providers (HCPs) have an important role to play in screening dental patients for cardiovascular disease (CVD), triaging them to the appropriate medical provider, and participating in the co-management of cardiometabolic diseases such as CVD. Another report 3 suggested that oral HCPs can play an important role in the primary prevention of CVD. Yet, regardless of how valuable this service would be, there are a number of unanswered questions about the viability of this model of care. For instance, since this is non-conventional in a dental setting, how do oral HCPs overcome the inertia of current practice/routines, and lack of education and training in this area of patient care? Other potential barriers include such things as limited appointment time, lack of resources, and unfamiliarity with how to collaborate/communicate with other healthcare disciplines. One question that arises is, Since screening and referral of at risk patients is perceived as not being directly related to dental procedures, how will oral HCPs be reimbursed for nondental-related activities? And, finally, will there be patient push back, in other words, will patients consent to oral HCPs screening for CVD? What about patients willingness to allow blood testing for CVD screening? These are only a few of the barriers to implementing progressive intervention of patients with/or at risk for CVD and periodontal disease. The following case study presents a 58 year old executive in commercial development, named Bob. At the end of the brief case description, you will be challenged to consider how to care for patients like Bob, and how to overcome the barriers associated with intervention of CVD in dental practice settings. Please note: the table at the end of the case study may help identify perceived barriers to progressive intervention of patients with/or at risk for CVD and periodontal disease. 1 Friedewald, et al Hein, et al Glick & Greenberg Page

2 Case Scenario For the past 5 years you have been practicing dental hygiene in a general dental practice (with multiple clinicians) that is established in an upper middle class, suburban community. The office attracts many patients who are professionals because it is well respected for cosmetic dentistry. Recently you have learned more about how periodontal disease may increase the risk for atherosclerosis-induced diseases such as CVD. On today s schedule is Bob, who has been a patient of record for close to 15 years. Bob is out of town for long periods of time, and the last time he visited the office was 8 years ago. At his last visit, the dentist developed a comprehensive treatment plan that included porcelain veneers of the maxillary anterior teeth, in addition to replacement of a number of failing crowns and other restorations. The periodontal record from his last visit of 8 years ago was very vague, and there was nothing in the progress notes to indicate the status of Bob s periodontal health at that time. Several notations in the progress notes indicated that gross debridement was performed on 2-3 visits over several years period of time. Bob has returned to the practice fully intending to move ahead with aesthetic dentistry. He was appointed for 60 minutes with you for a full mouth series of x-rays and periodontal evaluation, followed by a 60 minute appointment with the dentist for a comprehensive restorative examination. Although Bob was expecting to be examined, he was also expecting you to clean his teeth, and expressed disappointment that there was not time allocated on your schedule for this. Bob is 6 feet, 3 inches tall, and weighs 210 pounds. With the exception of repeated episodes of pneumonia over the last several years, Bob described his overall health as good. His father died of coronary heart disease. Bob has been smoking since he was in college, and reports smoking 1-1 ½ pks/day. The only medication that Bob takes is Mevacor (decreases elevated serum total and LDL-cholesterol) which was prescribed several months ago by his physician. Bob s chief complaint today is his cracked teeth. He is unhappy with the appearance of his smile, and asked you for advice on how to freshen his breathe. When you were probing, Bob said, My gums have always bled just a little. After the dentist completed his examination he asked the patient why he had been away for so long. Bob insisted that he was earnest about going forward with whatever it took to get my teeth fixed, and that money was no object. He also suggested that since he had a 2 month break before his next project, he wanted to start the veneers soon as possible. Recently you attended a continuing education course on the relationship between periodontal disease and CVD. You learned that there is compelling evidence that periodontal disease amplifies systemic inflammation and subsequently increases the risk for CVD. With the growing consensus that periodontal disease should be considered a modifiable risk factor for CVD and other atherosclerosis-induced diseases, and Bob s risk profile, you are convinced that something other than routine care is important. Although you are motivated to address Bob s needs and have the best intentions, the practice is very traditional and past attempts to integrate novel models of care or new treatment modalities, have been discouraged. Given your knowledge about the relationship between periodontal disease and CVD and Bob s risk profile, what next steps will you take with this patient? Bob s dental records follow below. 2 Page

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5 Discussion Questions: 1. Given the constraints of a traditional practice philosophy and other limitations, what treatment would you probably render in this case? 2. Assuming you could abandon office protocols and disregard limitations of traditional dental practice, what would be the best care you could provide for Bob? a. What factors place Bob at greater risk for heart disease and diabetes? (Cardiometabolic Risk) b. Beyond the significant amount of restorative dentistry that needs to be done, what else should be treatment planned for Bob? c. Is this a case that may need referral; if so, to whom? d. What are some of the key messages that are so important in educating Bob about periodontalsystemic risk? e. Would there be a reason to communicate with Bob s physician? f. What patient management issues might the business staff encounter with Bob? 3. What are the barriers to progressively intervening in cases like Bob, and other patients at risk for CVD in dental practice settings? 4. How can the barriers associated with intervention of CVD in this dental practice setting, or your current practice setting, be addressed and overcome? 5 Page

6 5. What types of intra- and interprofessional collaborations (e.g., collaboration with dental specialists, physicians, dieticians, or allied healthcare providers) would be beneficial in cases like Bob? 6. How can oral healthcare providers distinguish themselves as professionals in intervention of CVD and other atherosclerosis-induced diseases? 6 Page

7 Perceived Barriers to Progressive Intervention of Patients with/or at Risk for Cardiovascular Disease and Periodontal Disease in Dental Practice Settings Fear of upsetting or offending patient Fear of appearing judgmental of patient Lack of knowledge, education & training; lack of trained personnel Lack of patient acceptance of advice from an oral healthcare provider Patients may believe oral healthcare providers lack credibility in this area Concern intervention would be perceived as practicing outside the scope of dental/dental hygiene practice Frustration with potential patient noncompliance Unclear of what outcomes should be tracked, or how to monitor Not enough time in daily schedule Little to no reimbursement for service Lack of appropriate referral options Lack of patient educational materials No clear cost-benefit to practice Lack of interest in topic Language barrier Competing/more compelling considerations in patient care No coherent effort by schools, professional authorities educate and train students or practitioners about this model of care Lack of endorsement from professional associations or authorities Unclear how to collaborate/communicate with other disciplines Not sufficiently motivated to change; too hard to overcome inertia of current practice/routines Lack of evidence, clear correlation between periodontal-systemic links is lacking Don t believe that applying evidence will result in better outcomes No clear guidelines Do not know how to discuss these issues with patients, or how to start the conversation Lack of resources Cultural biases Fear of upsetting physician community and loosing potential source of referrals Not sure the presence of CVD, or risk for CVD will impact dental treatment decisions (treatment plans) Fear of contradicting advice that physicians may have given to patients Legal issues associated with failure to follow-up with patients and their physicians Other Other 7 Page

7 STEPS TO REDUCE HYGIENE CANCELLATIONS

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