Addressing perio-systemic links

May 20, 2014
There is a variety of ways to bring the impact of the mouth on the body to daily patient care. It starts by understanding the two mechanisms currently understood to be in play.

By Richard H. Nagelberg, DDS

There is a variety of ways to bring the impact of the mouth on the body to daily patient care. It starts by understanding the two mechanisms currently understood to be in play. One is the contribution of periodontal disease to the total inflammatory burden. All sources of inflammation from everywhere in the body are contributors. Moderate to severe periodontal disease is a big source of chronic inflammation; the bad kind. Think about an ingrown toenail, which has the surface area of the gingiva around one to two teeth. An individual with moderate to severe gum disease has many multiples of this surface area contributing to the total inflammatory burden. The second mechanism is the direct effects of certain bacteria to vascular disease, particularly the development of atherosclerosis (ASVD). Aa, Pg, and Fn have been implicated in the development of atherosclerotic plaques. In the case of Fusobacterium nucleatum (Fn), it is now considered a facilitator of ASVD by breaking the junctions between endothelial cells, allowing the bacteria and anything smaller to migrate into the artery wall.

One of the most powerful ways to impact patient care is by identifying the specific bacteria for patients with periodontal disease. If any of the bacteria noted above are present in a perio patient, a reexamination of the patient's health and family history should be undertaken including dialogue with the patient. If there is prevalence of cardiovascular disease, periodontal disease, or rheumatoid arthritis, among others, the periodontal disease must be treated to complete resolution followed by a bacterial post-test. If a periodontally healthy patient's health or family history reveals the same disease entities, identifying the bacteria they harbor should also be undertaken due to the direct bacterial effect, even though periodontal therapy will not be necessary.

Significant reduction in the population of the bacteria can be achieved by an aggressive approach to biofilm control. This would include a power toothbrush, interproximal brushes, floss, picks, etc., and an antibacterial mouth rinse. Other items that should be considered include probiotics, antioxidants, devices such as AirFloss or Waterpik, which can be used with a variety of irrigants, tongue cleaner, and sodium hypochlorite. Antibiotics should be used cautiously, and only after mechanical methods have been exhausted. Even then the risk-to-benefit ratio may not be favorable. Repeating the bacterial test to determine if the endpoint has been achieved should be undertaken approximately three months later.

Diabetic individuals are a class unto themselves. The impact of periodontal disease on people with diabetes is beyond debate. Controlling gum disease is critical for these patients because the infectious and inflammatory properties of periodontitis increase insulin resistance (IR), worsening hyperglycemia. Hyperglycemia has its own constellation of medical complications that are life threatening and life changing; however, the elevated levels of insulin that accompany IR cause arterial damage. IR is the biggest root cause of atherosclerosis. Getting periodontal disease under control is of paramount importance. Sometimes this is accomplished in the general dental setting; sometimes it needs to be managed by a periodontist. Frequent monitoring should also be undertaken. Diabetic individuals with periodontal disease should have perio maintenance at least every three months, and in some cases every one to two months. Every patient is different. In the absence of periodontal disease, recare intervals of less than six months should be decided on a case-by-case basis. It is doubtful that the physicians who are managing patients with diabetes are aware of the oral contribution to glycemic control. The primary responsibility for controlling this confounder lies with those of us in the dental profession.

Patient education is perhaps the most important aspect of bringing the research findings to our patients. Many patients have heard something about the relationship between the mouth and the body. Providing information such as, "Pristine gingival health constitutes vascular disease prevention" in terms the patient understands is very powerful. Helping patients understand the primary importance of reducing the bacterial population on a daily basis is another easily understood concept. Keep in mind that we are trying to decouple the infectious and inflammatory aspects of periodontal disease.

It is always first and foremost about our patients and their total health, not just their oral health.

Richard Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations, and he lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].

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