AHEAD OF THE CURVE

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					      Raising the Bar




      AHEAD OF THE CURVE
       Frank Formica, DDS
       Bowie, MD




                             P
                                     atients in his community near Baltimore and Annapolis consider Dr. Frank Formica
                                     the authority in technical dentistry, including temporomandibular joint disturbances.
                                     Formica is also respected for providing excellent restorative dentistry and periodontal
                              treatment. Much has changed during his 40-year career, but Formica acknowledges that
                              implementing periodontal medicine is not new; he has been applying credible research
                              findings related to the systemic effects of periodontal
                              disease into his clinical protocols for many years.
                                                                                           This column is dedicated to
                                                                                           clinicians, educators, and
                              Formica believes dentistry is a specialized field of
                                                                                           researchers at the forefront of
       medicine, and that dentists must be aware of new findings in medicine as
                                                                                           oral-systemic medicine. To
       these findings may directly relate to treatment. He cites articles published
                                                                                           call them early adopters is an
       during the past 10 years in both dental and medical journals as being
                                                                                           understatement. Professionals
       pivotal in convincing him to start talking with periodontal patients about
                                                                                           who are ahead of the curve
       their increased risk for cardiovascular diseases (CVD). Formica discusses
                                                                                           read the research and look
       this research with patients — specifically that heart attacks may be caused
                                                                                           for appropriate, innovative
       from infections such as periodontal disease.
                                                                                           opportunities to transfer the
                                                                                           research to private practices or
       “As a dentist with the knowledge that one of the most common infections
                                                                                           academic settings. Pursuits for
       of mankind is periodontal disease, I started to order a high sensitivity c-
                                                                                           excellence fuel their purposes,
       reactive protein (hsCRP) test on patients with the disease,” Formica said.
                                                                                           plans, and searches for better
       HsCRP is a blood test used to identify candidates who are at greater risk for
                                                                                           ways to take care of patients
       an acute coronary event. Concerned about the role of chronic periodontal
                                                                                           and motivate students. To those
       infection in increasing patients’ risk for CVD, Formica has ordered hsCRP
                                                                                           ahead of the curve, PennWell
       testing on many of his patients during the past five years. He shares the
                                                                                           says, “Well done.”
       results with physicians, who have been helpful and willing to consult on the
       medical aspects of treatment.
                                                                                           Stories welcome: To contribute
                                                                                           stories about other clinicians,
       “A patient related to me that after having had a heart attack, he asked
                                                                                           educators, and researchers at
       his physician why the attack occurred,” Formica said. “The physician was
                                                                                           the forefront of oral-systemic
       unable to provide a clear explanation to this patient because he had no
                                                                                           medicine, please e-mail
       classic risk factors for cardiovascular disease. When the patient presented
                                                                                           Casey Hein, Chief Editor, at
       to my practice, we diagnosed him with chronic periodontitis. His physician
                                                                                           caseyh@pennwell.com.
       was elated that a risk factor for CVD had been identified and treated.”

                                                                                          A complimentary copy of this
       “In another case, a long-term patient with periodontal disease who refused
                                                                                          article may be downloaded
       treatment despite repeated warning of dangers of untreated periodontal
                                                                                          in Adobe Acrobat at www.the
       disease, suffered a heart attack. The progress notes recorded over the
                                                                                          systemiclink.com
       years document the diagnosis of periodontal disease and subsequent



       50                         GRAND ROUNDS     IN   ORAL-SYSTEMIC MEDICINE     •   F EBRUARY 2006     •   V O L . 1 , N O. 1




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                                                                                                                 Ahead of the curve


       recommendations for treatment. The last entry was, ‘This        Richter communicates with patients’ physicians
       patient will have a heart attack,’ and six months later he      (endocrinologists, cardiologists, rheumatologists,
       suffered his first episode of myocardial infarction.”           obstetricians, and internists) to discuss specific
                                                                       cases and growing evidence to support periodontal
       Formica was asked what he thinks is the most needed             systemic links. In addition, Richter is diligent about
       change in educating dentists and physicians. The                monitoring clinical endpoints that give him the
       most important change he would make in achieving                information to more accurately refer to medical
       interdisciplinary education would be to add a course in         specialists those patients who do not respond
       internal medicine for dental students and a course in oral      favorably to periodontal treatment.
       medicine for medical students so physicians would have
       the diagnostic knowledge necessary to refer to dentists         Richter and Kilmeade promote smoking cessation
       those patients at risk for oral diseases and conditions.        by providing relevant literature and recommending
                                                                       specific smoking cessation counselors. They have
       When asked what he thought researchers will have                identified many patients who were at risk for
       discovered about the relationship between the oral cavity       diabetes and who later were confirmed diabetics
       and the whole body in 20 years, Formica said, “The mouth        upon evaluation by their physicians. Some patients
       mirrors what is happening in the body, and it can be an         credit early intervention of their diabetes to Richter
       entry point for infections. The treatment of periodontal        and Kilmeade.
       disease must be both local and systemic” (F. Formica,
       written communication, Nov 2005).                               Richter and Kilmeade have organized round table
                                                                       discussions with members of the medical community.
       Jonathan Richter, DDS                                           The intent is to share ideas on mutual patient care
       Lauren Kilmeade, RDH                                            and foster collaborative relationships.
       Great Neck, NY
                                                                       When asked how members of the medical community



                              D
                                      r. Jonathan Richter and          have reacted to their progressive diagnostic and
                                      Lauren Kilmeade share a          treatment philosophies, Richter said, “Initially the
                                      vision for building a practice   medical community thought we were using the
                              totally dedicated to comprehensive       HbA1C to diagnose. When they realized how we were
                              periodontal      medicine.      Their    utilizing the data to manage and treat our patients
                              dedication was jump started in part      comprehensively and to refer them to the proper
                              by the death of Kilmeade’s 59-year-      physicians, they seemed to embrace the concept” (J.
                              old father, who died from heart          Richter, written communication, Nov 2005).
                              disease and diabetes in 2001.
                                                                       Kilmeade and Richter cite the lack of support from
       At the heart of their comprehensive wellness model is           organized dentistry and medicine as a hurdle to the
       Kilmeade teaching patients how oral health affects overall      implementation of oral-systemic medicine, but that
       systemic health. They credit dental assistants — one of         doesn’t seem to have slowed them down.
       whom is a licensed practical nurse — and members of
       the business staff for their knowledge of oral-systemic         When asked what patients say about this kind of
       medicine and their ability to reinforce patient education.      comprehensive care, Kilmeade said, “Our patients
                                                                       choose us for their dental care because they are
       Clinical protocols in Richter’s office include monitoring       confident they are receiving comprehensive quality
       blood pressure at all recare appointments, using                care that is customized to their individual needs. They
       glucometers to monitor diabetic patients’ blood sugar           indeed participate in helping us help them. Once the
       before procedures, and using chairside HbA1c analyzers to       oral/systemic concept is presented and applied to
       screen patients for undiagnosed diabetes and to determine       their personal health, they are converted into true
       whether periodontal treatment was effective in reducing         believers, taking their oral health to heart as much
       patients’ glycosylated hemoglobin.                              as we do” (L. Kilmeade, written communication, Nov
                                                                       2005).



      GRAND ROUNDS     IN   ORAL-SYSTEMIC MEDICINE      •   F EBRUARY 2006    •   V O L . 1 , N O. 1                        51



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