Periodontology 2000, Vol. 74, 2017, 194–199 © 2017 John Wiley & Sons A/S.
amp; Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
The place of periodontal
examination and referral in
general medicine
S A M U E L C H A N , G R A H A M M. P A S T E R N A K & M A L C O L M J. W E S T
The separation of medicine and dentistry is a peculiar
historical artifact resulting in medicine being preoc-
cupied with various systems of the body and dentistry
being focused on disease and injury of the teeth, jaw
and mouth. The professional boundaries are dutifully
respected but the distinction has resulted in a poverty
of cooperation, greatly inhibiting the synergistic
potential. Nature, of course, does not discern
between our synthetic categories, and diseases have
little regard for the boundaries of our respective
professions. Chronic kidney disease, cardiovascular
disease, endocrine disorders and peripheral vascular
disease are a few of the myriad of illnesses that can
produce both medical and dental complications. The
ubiquity of such chronic diseases, and the enormous
financial and social burden they yield, demands that
medicine and dentistry coordinate their efforts to
achieve a more comprehensive delivery of care.
Background
Much like medicine, dental care can be accessed
through private or public insurance schemes depend-
ing on the health policies of a country. For example,
in Australia, the insurance system is based on an indi-
vidual purchasing insurance that covers an agreed
percentage of the cost of visiting a private dentist.
Individuals accessing basic dental care receive regular
check-ups and tooth cleaning from a dentist. Individ-
uals may choose not to visit a dentist, yet unknow-
ingly have gingivitis because this condition is largely
asymptomatic (17). Unfortunately, when ignored,
gingivitis can progress to periodontitis. Periodontal
diseases are pervasive and in 2010 were the fifth most
prevalent health issue among Australians (9).
194
PERIODONTOLOGY 2000
Although a periodontist can treat those patients who
present to them, the systemic consequences of a peri-
odontal infection may often go unrecognized. Indeed,
periodontal infections are considered a risk factor for
cardiovascular disease (8).
Periodontal effect on vascular
health
A major contributing factor to cardiovascular dis-
ease is atherosclerosis, a process in which narrowing
of the arteries occurs as a result of subendothelial
deposition of fibrous plaques with a concurrent
population of reactive immune cells inside the ves-
sel wall. Some of these plaques are prone to rup-
ture, leading to occlusive thrombi. Factors
contributing to the formation and stability of pla-
ques, such as hypertension, dyslipidemia and type
II diabetes mellitus, should be identified and con-
trolled by both nonpharmacological and pharmaco-
logical means, in order to lower the overall risk of
developing an acute coronary syndrome, stroke or
other atherosclerotic-related events. An ever-
increasing number of studies show a positive associ-
ation between chronic oral infections, including
periodontal diseases, and cardiovascular disease (5,
6, 8). Periodontitis represents a potential source of
inflammation, and during the formation of peri-
odontal pockets, inflammatory cell infiltrates (in-
cluding macrophages, neutrophils and lymphocytes)
are recruited into the periodontal lesion where they
secrete proinflammatory mediators (11, 24).
Although bacteremia may occur following almost
all types of dental manipulations, bacteremia associ-
ated with periodontal disease is more sustained and

has considerable consequences (28). The DNA of
periodontal bacteria has been detected in carotid
arterial plaques, coronary arterial plaques, intralumi-
nal thrombi, atherosclerotic vessel plaques and pri-
mary varicose veins (21). Additionally, the levels of
inflammatory mediators, including C-reactive pro-
tein, fibrinogen, cytokines and leukocytes, are ele-
vated (36). These mediators then negatively influence
the stability of the plaque. The importance of this
relationship is illustrated by the fact that periodontal
disease predisposes to 25–50% higher prevalence of
cardiovascular disease (5) and a five-fold increase in
cardiovascular disease-related mortality (7) when
the necessary periodontal management was not
provided. Periodontal pocketing is associated with
central arterial stiffness, a marker of presymptomatic
arterial dysfunction, in Indigenous Australians (23).
Fortunately, it has been shown that intensive
periodontal treatment is associated with improved
long-term endothelial function (40) as well as modest
reductions in the level of systemic C-reactive
protein (13).
Patients with significant peripheral vascular disease
requiring leg, foot or arm amputation often require
dental review before surgery. These patients are often
predisposed to bacteremia given their immunocom-
promised state and hence bacteria may flourish in
their oral mucosa. A clinical example to illustrate this
is that of a 54-year-old man who underwent a leg
amputation secondary to a nonhealing arterial ulcer
from poorly controlled diabetes. He experienced per-
sistent bacteremia after surgery and, following a thor-
ough septic screen, the source of the infection was
suspected to be the oral mucosa. The patient died a
few months postoperatively. Subsequent detailed his-
tory and examination revealed that the patient had
never received any form of dental care in his life. If
the patient had had his teeth evaluated, bacteremia
may not have occurred.
Hypertension is a highly prevalent condition and a
major contributor to cardiovascular morbidity.
Although periodontal disease and hypertension
would be expected to be unrelated, research on alter-
nate risk factors for cardiovascular disease indicates
otherwise (42). An association between high diastolic
blood pressure and the presence of periodontal pock-
ets exists (14), and the systolic blood pressure of
patients with periodontal disease is significantly
higher than that of patients with no periodontal dis-
ease (12). Importantly, intensive periodontal treat-
ment reduces systolic blood pressure and improves
lipid profiles more than standard therapy (12). As a
result of these associations, screening for
Periodontal examination and referral in general medicine
hypertension at periodontal clinics is an important
consideration for all dentists.
Bacteremia from periodontitis is well known to be
the primary cause of infective endocarditis, a condi-
tion in which bacteria, most commonly Staphylococcus
aureus, seed onto a heart valve, most commonly the
mitral valve, as seen in Fig. 1. Patients who have had
heart-valve surgery are particularly at risk of infective
endocarditis, which has a mortality of approximately
80% at 5 years (30). In 2007, the American Heart Asso-
ciation recommended careful dental evaluation and
treatment before any cardiac surgery (44). Periodonti-
tis should be treated before surgery as such treatment
reduces the risk of endocarditis after valve replace-
ment (30). However, because of the progression of
valvular disease, it is not always reasonable to delay
valve-replacement surgery. Additionally, manage-
ment after valve replacement, which includes antico-
agulation and artificial ventilation, can increase the
risk of hemorrhage from extractions and make it diffi-
cult to maintain oral hygiene, respectively (44). Thus,
it is important to appreciate the overlap between car-
diovascular disease management and periodontal
management in improving the health outcomes and
prognosis of our patients.
The following stresses the importance of dental
evaluation before valvular surgery: a 58-year-old
woman experienced mitral valve endocarditis causing
severe left ventricular systolic dysfunction to 25%,
which subsequently resulted in her death 3 months
later. A septic screen was uninformative. The source
of the infection was probably poor oral hygiene. If the
patient had had her teeth evaluated, a better outcome
may have eventuated. Conversely, good outcomes
have been reported in patients who have had a thor-
ough dental review before surgery. The onus should
be on both the hospital and the patient to adhere to
advice given and to ensure that health-care systems
Fig. 1. Gross pathology of bacterial endocarditis involving
the mitral valve. Photograph provided by Dr Edwin
Ewing Jr.
195
Chan et al.
have the checks and balances in place for patients
before they undergo surgery.
Periodontal health and systemic
correlates
The impact of poor periodontal health and the
release of inflammatory mediators are not restricted
to the cardiovascular and cerebrovascular systems.
Periodontal infections influence the initiation and
progression of chronic obstructive pulmonary disease
and respiratory infections, such as pneumonia (37).
Oral interventions can reduce the incidence of hospi-
tal-acquired pneumonia by up to 40% (37). Obstetric
prognosis is also influenced by the health of the
periodontium. Periodontal diseases have also been
associated with preterm birth and low birth weight
(27, 35).
By 2025, an estimated 6.3% of the world’s popula-
tion will have type II diabetes mellitus (15). Prolonged
hyperglycemia, measured empirically as glycated
hemoglobin, results in numerous macrovascular,
microvascular and oral-health complications, such as
periodontitis (10). Periodontitis has a negative effect
on glycemic control (41). Patients with periodontitis
have been found to be at increased risk of being in a
dysmetabolic state, characterized by decreased serum
levels of high-density lipoprotein, raised levels of low-
density lipoprotein and mild insulin resistance (33).
Additionally, diabetic patients with increasingly sev-
ere periodontitis have more complications than do
diabetic patients with mild or no periodontitis (39).
Of interest then is the finding that treatment of peri-
odontitis has been shown to improve glycemic con-
trol in type 2 diabetes mellitus (20). This suggests that
referrals to periodontists do not have to wait for gly-
cemic control to be established; rather, referral to
periodontists should begin immediately. It has been
shown that an inflammatory state is correlated with
insulin resistance and thus type 2 diabetes mellitus
(16). The possibility of a causal relationship is illus-
trated by the presence of a dose–response relation-
ship between the periodontal inflamed surface area
and glycated hemoglobin (32). Reducing the peri-
odontal inflamed surface area of a diabetic patient
may reduce glycated hemoglobin by up to 1 percent-
age point, thereby reducing their individual risk of
cardiovascular disease mortality by up to 25% (4).
Additionally, nonsurgical periodontal therapy can
improve metabolic control in patients with diabetes
(29).
196
Regardless of the degree to which periodontitis
impacts glycemic control or poor glycemic control
affects oral health, measures that safeguard oral
health or modify risk factors need to continue to be
part of regular care in patients with type II diabetes.
While the dental profession recognizes the relation-
ship between periodontal disease and diabetes melli-
tus, the level of awareness by the medical profession
is not as apparent (25). Awareness that glycemic con-
trol is associated with improved periodontal status
should grow. It should be suggested that dentists and
periodontists who treat diabetic patients with peri-
odontal disease should monitor serum glucose as
part of good patient care. This is important consider-
ing that some patients are seen by dentists more
often, and on a more regular interval, than they are
seen by their physician (25).
The need for consistent glucose monitoring of dia-
betic patients can be demonstrated by the following
case. A 50-year-old obese lady had recurring foot
infections and cellulitis on her right leg for 2 years
secondary to poor glycemic control. She was persis-
tently bacteremic, and viridans streptococci were pre-
sent in blood cultures 2 months before her death. A
septic screen did not reveal the source; however, this
was thought to be her mouth. If previous evaluation
of, or intervention on, her oral health had been
carried out, she may not have developed sepsis.
Although additional studies have questioned the
actual causal nature between various systemic dis-
eases and periodontal health, the overwhelming
wealth of publications highlighting the interrelated-
ness not only warrants further research but also an
active effort by periodontists and doctors alike to
implement a program that streamlines the referral
process and increases the level of interdisciplinary
management and communication.
Chronic kidney disease affecting
oral health
In addition to the above, chronic disease and its lack
of management can negatively affect oral health.
Pathological changes in the oral cavity are more com-
mon in patients with chronic kidney disease as a
result of both complications and treatment (1, 18, 34).
This includes increased incidence of periodontal dis-
ease in patients with hyperuricemia, as well as those
on dialysis and receiving kidney transplants (1). Iwa-
saki et al. (22) showed that periodontal disease leads
to decreased kidney function in the elderly. The

treatment protocols for chronic kidney disease, as
well as for other chronic illnesses, involve complex
pharmacological regimes. Several classes of pharma-
ceutical drugs, such as immunosuppressants (includ-
ing corticosteroids, cyclosporine and tacrolimus),
cause xerostomia and mucosal inflammation and
thus could promote poor oral health and pathology
(1). A proper examination of the oral cavity in patients
with renal disease is an invaluable aid and can pre-
vent complications that occur as a result of either
renal disease or the therapy used to treat it (38).
To depict this situation clinically, a 58-year-old
renal transplant patient died from bacteremia
8 months postoperatively, the source probably stem-
ming from his oral mucosa, perhaps secondary to
immunosuppressive therapy. This patient was not
adherent to follow up given to him by physicians,
which may also have contributed to his death. Den-
tal review of all transplant patients, or those on
immunosuppressive therapy, is therefore para-
mount.
Burden of chronic disease
Oral health is a neglected area of global health and
has traditionally been registered as low on the radar
of national policy makers, as poor oral health gener-
ally affects morbidity more than it affects mortality
(26). There has been increasing scientific interest
regarding the interactions between oral health and
systemic disease. As a result, in 2007, the World
Health Organization advocated the integration of
health policies regarding oral and general health
(43). Additionally, the European Union and the USA
have emphasized the importance of oral health on
overall general health. Despite the awareness regard-
ing the impact of oral health and the increasing
attention within public policy, there are barriers pre-
venting access to both basic and specialist dental
care.
There is an epidemic of chronic disease, which has
had a tremendous strain on health-care budgets. Fig-
ure 1 presents the yearly direct health-care cost, in
the USA, of three chronic diseases (heart disease and
stroke, diabetes and end-stage renal disease) that are
influenced by periodontal health. With $3 out of every
$4 spent on chronic diseases, such as cardiovascular
disease and type II diabetes mellitus (3), active man-
agement of risk factors that contribute to the
advancement of chronic diseases will help this bur-
den. The adverse effect of dental health on systemic
diseases has been demonstrated. If more resources
Periodontal examination and referral in general medicine
were directed toward improving community oral
health, the incidence and associated expenditure of
these diseases would be reduced.
Barriers to access
There are numerous factors that influence the fre-
quency with which individuals access dental ser-
vices, let alone specialist care. The affordability of
dental care and the economic hardships associated
with its use presents one of the main barriers to care
(9). The insurance system also determines the fre-
quency with which individuals access dental care.
Those with increasing levels of private coverage are
more likely to visit a dentist and this, unsurprisingly,
influences overall dental health. Furthermore, age is
strongly associated with the interval between visits
to dentists, despite having an increase risk of peri-
odontitis (9). The uninsured and the elderly should
therefore be the target in any policy that aims to
improve the provision of dental care in the commu-
nity.
Advice to physicians
Periodontitis and systemic diseases share numerous
risk factors, such as age, gender, socio-economic sta-
tus, income, level of education, ethnicity, smoking
and alcohol intake, highlighting the interrelatedness
of management. Physicians should be aware of the
oral-health correlates of systemic disease, recognize
risk factors and refer accordingly. This information
could be reinforced in continuing medical education
modules, both for surgical and for physician trainees,
as well as be implemented into the medical and den-
tal student curriculum.
Before referral, the doctor and the dentist should
inform the patient why there is reason to be con-
cerned and the importance of managing risk factors.
The doctor and the dentist should provide a letter of
referral for the patient outlining the medical and den-
tal history, respectively. The dentist should outline
the list of procedures carried out, their impression of
prognosis, as well as whether there is a requirement
for follow-up appointments. Regarding the in-patient
setting, most medical departments with sub-acute
wards hold regular multidisciplinary team meetings.
One possible suggestion would be to include a peri-
odontist. Given the difficulty in organizing specialist
schedules, the importance of an electronic health
record is highlighted here.
197
Chan et al.
Conclusion
The fields of dentistry and medicine are intercon-
nected and complementary to each other. Recogniz-
ing diseases that influence either profession is
beneficial to all parties involved. Specifically, peri-
odontal diseases are a treatable, and therefore a mod-
ifiable, risk factor for systemic diseases, especially
atherosclerotic disease, which has a high prevalence
and economic burden. There is a lack of awareness of
the importance of dental health to overall general
medical health, and vice versa, not only within the
medical and dental communities, but also with policy
makers and the community in general. To provide
patients with the optimal level of care, physicians
need to continue to refer to dental professionals as
they do with other medical specialties. With the ever-
shrinking budget of health care and the negative
impact of periodontal disease on chronic disease,
oral-preventative programs embedded into general
medicine are the next logical step in the ongoing his-
tory of medicine and dentistry.
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