Relationship Between Oral Health and Systemic Disease - American ...

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Figure 2: Connection between periodontal disease and atherosclerosisFrom: Dave S, Batista EL Jr, Van Dyke TE: Cardiovascular disease and periodontal diseases:commonality and causation. Compend Cont Educ Dent. 2004; 25(7) (Suppl 1):26-37.valis can induce platelet aggregation, a component of atheromaand thrombus formation. 19 This suggests a possible invasion ofatheromas by oral pathogens as well as a possible contributionto their development. However, causality has yet to be established.Animal model studies investigating the relationshipbetween CVD and periodontal disease have demonstrated thatclinically induced oral infection with P. gingivalis will increaseatheroma size and elevate CRP levels. 20 More recently, a studyof humans reported a positive independent association betweencarotid intima-media thickness (IMT) and bacterial burdenincluding P. gingivalis, Actinobacillus actinomycetemcomitans,Treponema denticola, and Tannerella forsythensis. 21 Figure 2represents the proposed connection between periodontal diseaseand atherosclerosis.It is also thought that an autoimmune response may beinvolved in the development of atherosclerosis. Most humanshave immune reactions against microbial heat-shock protein 60(HSP60). Antibodies against bacterial versions of this proteinmay cross-react with human HSP60, causing an autoimmuneresponse and stimulating athersosclerosis. 4Diabetes mellitus is another systemic condition with oralinflammatory connections. One of the major complications ofdiabetes is periodontitis. 22 While diabetes increases the probabilityof developing periodontal disease 22-24 , periodontitis alsoincreases the risk of poor glycemic control in people with diabeteswhen compared to those individuals with diabetes withoutperiodontitis. 25 Fortunately, periodontal treatment canimprove glycemic control by reducingthe bacterial burden and theinflammatory response. 26-28There are several biologicalmechanisms proposed to explain theincreased incidence and severity ofperiodontal disease in individualswith diabetes. Diabetes tends toincrease susceptibility to infection—including oral infection—and thedisease itself decreases the effectivenessof cells that kill bacteria.Another explanation is thatinflammation is enhanced in thosewith diabetes. Research has demonstratedelevated levels of inflammatorymediators in the gingival crevicularfluid of periodontal pockets of poorlycontrolled patients with diabetes ascompared to those without diabetesor those with diabetes who are wellcontrolled. These patients had significantperiodontal destruction with anequivalent bacterial challenge. 24,29,30 Inparticular, the proinflammatorycytokine, TNF-α, plays a major rolein this process. TNF-α has a significantrole in insulin resistance, the primarycause of type 2 diabetes. It isproduced in large quantities by fat cells. Periodontitis has alsobeen associated with increased levels of TNF-α. Elevated levels ofTNF-α may lead to greater bone loss by killing cells that repairdamaged connective tissue or bone and may exacerbate insulinresistance and worsen glycemic control. 31-33It has also been hypothesized that diabetes interferes withthe capacity to form new bone after periodontal diseases havecaused bone resorption. Graves, et al., studied genetically diabeticmice with type 2 diabetes and nondiabetic littermates byinjecting them with P. gingivalis. The death of osteoblasts wasmeasured, and results indicated that there was a higher andmore prolonged rate of osteoblast cell death in the diabeticgroup. It was concluded that the capacity to repair a bonydefect by producing new bone would be severely limited whenosteoblasts died prematurely. Yet further study is needed in thisarea to refine this concept. 34As with CVD and diabetes mellitus, there is a relationshipbetween oral infection and respiratory disease. In particular,chronic obstructive pulmonary disease (COPD) and pneumoniahave been associated with poor oral health. 35-38 It is likelythat oral biofilm serves as a reservoir of infection for respiratorybacteria. Specifically, Pseudomonas aeruginosa, Staphylococcusaureus, and enteric bacteria that has been shown to colonize theteeth of patients admitted to hospitals or long-term care facilities.These bacteria may be released into saliva and then aspiratedinto the lower airway causing infection. 4 Another vehicle bywhich bacteria from the oral cavity can be introduced into therespiratory system is intubation.4 access—special supplemental issue—april 2006
Inflammatory mediators, such ascytokines produced by the periodontium,may be another mechanism bywhich respiratory disease are associatedwith oral health. These mediators presentin inflamed gingival tissues enter thegingival crevicular fluid and then thesaliva. Once aspirated, these mediatorscan have proinflammatory effects in thelower airway.Further, studies have demonstratedthat periodontal diseases have beenshown to increase the risk of adversepregnancy outcomes such as prematurebirth and low birth weight. 39-41 Uterinecontractions are stimulated by oxytocin,which is produced by the hypothalamus,and by prostaglandins produced by theplacenta. This process normally occursin the third trimester and leads to birth.However, chronic infection can stimulatethe inflammatory process, whichleads to elevated amniotic levels ofprostaglandins, TNF-α, and IL-1 andIL-6. These mediators then lead to prematurerupture of membranes andpreterm labor. Other work has suggestedthat periodontal pathogens may travelfrom the gingival sulcus to the placentaand stimulate preterm birth. Specifically, Han and colleaguesfound that periodontal bacteria, including Fusobacteriumnucleatum, entered the bloodstream from the oral cavity anddirectly affected the birth process. 42 A summary of the biologicalmechanisms by which gingival inflammation effects systemichealth appears in Figure 3.Translating Science to PracticeAs often occurs, research provides many answers anddrives more questions. Despite the knowledge obtainedthrough science, it is incumbent upon clinical practitioners totranslate the evidence into practical use. What does the aboveinformation mean for clinical practice? Does it offer opportunitiesfor changing dental hygiene interventions? How can weuse this information to answer patients’ questions when theyinquire about CRP levels, or ask if their periodontal conditionwill give them heart disease? Are we better prepared to addresstheir question when they say they read two conflicting articlesabout oral and systemic health in the same issue of Reader’sDigest, Prevention magazine, or Every Woman and wonderwhich one is accurate?Understanding the association between oral health andsystemic health does provide opportunities for oral hygiene cliniciansto reframe their protocols. The process begins by practicingoral medicine. First, comprehensive medical assessmentis needed for each patient. A review of systems and vital signsFigure 3: Model to explain oral inflammation-systemic disease associationFrom: Scannapieco, FA: Periodontal inflammation: from gingivitis to systemic disease?Compend Cont Educ Dent. 2004; 25(7) (Suppl1): 16-24.evaluation should be part of that assessment process. Duringthese assessments, identifying risk factors for specific systemicdiseases is important, including age (over 40 years), hypertension,dyslipidemia, smoking, obesity/overweight, CVD, diabetesor symptoms of diabetes and women who are pregnantand have poor oral hygiene.Comprehensive oral assessmentis equally important. Thismay include thorough head andneck examination, radiographs(if clinically indicated), periodontalprobing, bacterialmonitoring of periodontal andcarious pathogens, genetic testingfor periodontal disease orother diagnostic tools that seemappropriate to each individualneed.Understanding theassociation betweenoral health andsystemic health doesprovide opportunitiesfor oral hygieneclinicians to reframetheir protocols.As these assessments are being performed, risk factors fororal and systemic diseases are being noted and explained to thepatient. It is essential that the patient understand that the purposeof these assessments is to prevent problems from occurringor treat them as readily as possible. Patients are well acquaintedwith the idea that physicians prefer to treat a stroke or aheart attack before it occurs by identifying possible risk factorsand trying to reduce them. They are used to attending a medicalappointment and having certain assessments performed.They are even used to requesting certain tests or proceduresbased on their own education and experience. Thus, it is timespecial supplemental issue—april 2006—access 5
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