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In February 2004, the Ameri-

can Heart Association an-

nounced research findings

from Finland that evaluated 256

cardiac patients with similar demo-

graphic characteristics. Researchers

found in this patient population that

Winter

The Impact of PeriodontalDisease on Major SystemicConditions

From Our Officeto Yours...

Cross-sectional studies of verylarge groups have long indicated arelationship between periodontitisand cardiovascular disease, stroke,diabetes and chronic pulmonarydisease.

Studies support the hypothesesthat disease-causing bacteria asso-ciated with periodontal infectionsand the endotoxins released by thesemicroorganisms enter the circulatorysystem and contribute to diseaseentities which are manifested inother parts of the body, such as theheart or brain.

This current issue of ThePerioDontaLetter reviews themost current information on thepossible connection betweenperiodontal disease and majorsystemic disease.

As always, we welcome yourcomments and suggestions andlook forward to working with you aswe explain to our patients the needto control periodontal disease fortheir general health.

a poor oral health diagnosis is a

strong predictor of heart disease.

The principal author, Dr. Sokja

Janket of the University School of

Dental Medicine and Harvard

University School of Public Health,

suggests that dentists advise patients

Figure 1. This illustrationshows howbacteria mayenter thebloodstreamand attractplatelets.

(Illustration courtesy ofthe Oral Health Letter,The Chronicle of Oraland Systemic HealthInformation for thePublic through the StateUniversity of New York atBuffalo)

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300, Philadelphia, PA 19102 (215) 735-3660

The Brown

I. Stephen Brown, D.D.S., Periodontics & Implant Dentistry

small band of researchers began tosuspect that other disease processes,specifically inflammation, was themajor contributing factor in the sec-ond type of patient. Peter Libby andothers proposed that an overactiveimmune system was attacking theplaques that accumulate in almostevery adult's heart, causing them torupture and spew their contents in theform of heart-stopping clots.

In female patients, cholesterollevels may not be as predictive of car-diovascular risk as C- reactive protein.Newly-developing protocols forassessing cardiac risk and stroke pre-vention call for tests highly specific ofCRP levels, in addition to lipid pro-files. Risk assessment utilizing CRPis particularly important for womenwith diabetes. Women in this catego-ry have an eight times greater risk forcardiovascular disease, and womenwho smoke and use contraceptives arethree to five times more likely toexperience a cardiovascular event.

with poor oral health to seek cardiacexaminations, even if they do notexhibit symptoms of heart disease.Researchers are actively working todevelop an understanding of the under-lying factors contributing to this unusu-ally high correlation between peri-odontal disease and systemic diseases.

Scientists also theorize that bacte-ria contributing to periodontal diseasealso activate white blood cells induc-ing a systemic inflammatory andimmune response that may contributeto cardiovascular disease and stroke.

The most widely studied pro-inflammatory molecule associatedwith this reaction is C-reactive protein(CRP). Another pro-inflammatorycytokine, Interleukin-6, may producea similar systemic response. CRP,which is elevated dramatically duringacute inflammation, augments theimmune response to certain antigens,activates complement, and increasesthe production of monocytic, inflam-matory tissue factors.

Studies by D’Autio, Matilla etal and Craig et al indicate peri-odontitis may increase the inflam-matory burden and increase car-diovascular risk based on the con-centration of serum CRP.

Recently, researchers have alsonoted a stronger relationship betweenstroke, periodontitis and CRP. Beckand Offenbacher noted in a 2002review that bleeding sites and pock-et depths might be a better reflec-tion of systemic risk than measure-ments of attachment or bone loss.This may explain why studieswhich only measured radiographicchanges and indices of attachmentloss often fail to accurately reflectthe impact of periodontal disease onsystemic conditions.

For every heart attack patient withhigh cholesterol and plaque-cloggedblood vessels in the previously refer-enced studies, there is one with lowcholesterol and apparently whistle-clean arteries. In the mid-1980s, a

Figures 2 and 3. It is easy to be deceived by the clinical appearance of gingival tissues which mayappear healthy on the surface, but which may have deep pockets which always have subgingivalinfection. These two photos show bleeding on probing indicating inflammation and current infection.

PerioDontaLetter, Winter

Studies by Andriankaja, Genco etal conclude the association betweenperiodontal disease and the risk ofmyocardial infarction is strong andindependent of smoking in youngindividuals. In older individuals, theyfound the association weaker and alsothat smoking appears to play a moreimportant predictive role.

Recent studies published in the NewEngland Journal of Medicine indicatethat standard antibiotics do not work forthe secondary prevention of heart dis-ease. Yet evidence that infection is astimulus for athero-thrombosis contin-ues to mount. An editorial writer for thejournal recommended that we beginanew to investigate this association.

Pockets which patients cannotkeep clean on a daily basis almostassuredly have inflammation at thebase of defects. At this time, it seemsprudent that pocket reduction/elimi-nation treatment is still the appropri-ate course of action not only for these

patients’ dental health but for theirsystemic health as well.

Periodontal Diseaseand Diabetes

In 2003, the National Institute of

Dental and Craniofacial Research

reported that people with noninsulin-

dependent diabetes mellitus (Type 2)

are three times more likely to develop

periodontal disease than nondiabetic

individuals.

It is reasonable to assume that the

risk is greater in insulin-dependent

Type 1 diabetics. Susceptibility toperiodontal disease is one of themost common sequelae of diabetes.The many oral health complications

associated with uncontrolled diabetes

include, but are not limited to, gin-

givitis, periodontal disease, salivary

gland dysfunction, increased suscepti-

bility to bacterial, viral and fungal

infections, caries, periapical abscess-es, loss of teeth, loss of taste, andburning mouth syndrome.

Studies have demonstrated thatnon-compliant patients with Type 1diabetes who do not maintain rigorouscontrol of their diabetes, experiencemore extensive and severe periodontaldisease than patients who maintain rig-orous diabetic control. One studyshowed periodontal disease is six timesmore likely to occur in people with dia-betes than in people without diabetes.

Grossi et al and Saremi et al foundthat effective treatment of periodontaldisease in diabetics reduces hyper-glycemia and insulin requirements,improves glycemic control and pre-vents, delays or reduces the severityof diabetic complications such as dia-betic retinopathy.

As a result of this compellingevidence, they instituted a pro-gram of diagnosis and treatmentof periodontal disease into the

Figure 4. After scaling, root planing andantimicrobial therapy, the gingival tissuesappear clinically healthy.

Figure 5. However, flap reflection in an areawith pockets greater than 5mm in depth revealssignificant reverse osseous architecture withintrabony defects.

routine treatment regimen fordiabetics.

Many authorities believe the hostresponse to periodontal pathogensincreases insulin resistance. Withinthe past two years research has begunto point towards a correlation betweenthe severity of periodontal inflamma-tion, pocket depths and glycemic con-trol. The most prevalent theory sug-gests that the severity of inflammationcombined with the large surface areaof the pocket wall increases systemi-cally disseminated molecules whichinduce inflammation.

Periodontal Disease andRespiratory Infections

Studies of the relationshipbetween periodontal disease and res-piratory infections by Scannapieco etal reveal that periodontal disease mayincrease a person's risk for chronicobstructive pulmonary disease(COPD). Other data by Scannapiecouncovered a correlation between theamount of periodontal disease andvital lung capacity. They also demon-strated that patients with periodontaldisease experience twice as many res-piratory infections as healthy patients.

The periodontal and respiratoryhealth of 13,792 patients was ana-lyzed. The study demonstrated thatpatients with periodontal disease,

defined by individuals exhibiting amean loss of attachment (MAL)greater than 3mm., were found to havenearly a one-and-a-half times greaterrisk of COPD. A distinct trend wasalso noted revealing that lung functionapparently diminished with increasedattachment loss. This suggests thatperiodontal disease activity may con-tribute to the progression of COPD.

It appears that aspiration of oralpharyngeal flora brings respiratorypathogens into the tracheobronchialtract allowing respiratory pathogensto colonize the oral and pharyngealtissues which, in turn, causes pneu-monia. Comprehensive periodontaltreatment and enhanced oral hygienereduced pneumonia and death two tofive fold. More research and clinicaltrials are necessary to determine ifperiodontal therapy reduces the inci-dence of pulmonary infections inpatients with COPD.

We recommend a risk profile aspart of a diagnostic workup whichcan be used to develop risk modifi-cation strategies to be incorporatedinto a periodontal treatment plan.The risk profile should include age,gender, hormone replacement thera-py, smoking habits, and medicalconditions including diabetes melli-tus. Other important indices shouldinclude pocket depths and bleedingon probing.

The periodontal status of patientsshould be closely monitored andpatients with high risk for heart dis-ease, especially women, should beaggressively treated with periodontaltherapy. Monitoring of individualsites during maintenance and activecare for these sites as they are discov-ered may help control elevation ofinflammation in the body.

Periodontal Diseaseand Preterm LowBirth Weight Babies

US researchers have concludedthere is a link between periodontaldisease and preterm delivery low birthweight babies in women over 25.Preterm delivery is defined as a gesta-tion period of less than 36 weeks, anddelivery weight less than 2400 grams(5.2 lbs.) is considered to be low birthweight. The jury is still out on themagnitude of the link between peri-odontal disease and preterm deliveryand/or low birth weight babies.However, strong link or not, it is com-mon sense to provide pregnantpatients with thorough dental hygieneand periodontal care before, during,and after the pregnancy.

We hope this review of the possi-ble connection between local inflam-matory disease and major systemic dis-ease better helps you explain to yourpatients the need to control periodontaldisease for their general well-being.

We invite you to call us to discussindividual patients or to provide you withwritten information regardingthe perio-systemic connection. PDL tm

“I believe that, some time in the future, leading cardiologists willwonder in retrospect, how information so needed by their patientscould have been overlooked or neglected for so long.”

Charles C. Bass, MD, American Heart Journal

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300, Philadelphia, PA 19102 (215) 735-3660