Richard H. Nagelberg, DDS
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The interconnected nature of periodontal disease, cardiovascular disease (CVD), and diabetes is supported by such a large volume of research that it cannot be ignored. It must be incorporated into our diagnostic/treatment protocols as dental professionals.
Atherosclerosis is an inflammatory disease and the primary driver for cardiovascular events. The development of lipid plaques in the walls of arteries is the result of damage to the endothelial lining of the blood vessel. Inflammation from all sources, particularly chronic inflammation, contribute to atherosclerosis.
In addition to C-reactive protein (CRP) levels, other markers also reveal the strength of the associations between periodontal and heart diseases. PLAC-2 is an independent marker for coronary endothelial dysfunction and, in fact, the only FDA-cleared blood test to determine risk for ischemic stroke associated with atherosclerosis. Elevated PLAC-2 levels are significantly associated with coronary heart disease (CHD) as shown in a 2010 Lancet study. The Mayo Clinic Heart Study found that PLAC-2 levels predicted first major cardiovascular events, and other studies revealed these levels also mark secondary cardiovascular event risk.
CRP is a noncausative marker of CVD. PLAC-2 is a player — not just a marker — and is a target of therapy. Separate studies in the American Journal of Cardiology have shown multiple mechanisms of the association between periodontal disease and CVD. One study found that periodontal disease is associated with elevated PLAC-2 levels; another found that periodontal disease is directly linked to atherosclerotic inflammation.
Still other research has shown that the concentration of perio pathogens, independent of a clinical diagnosis of periodontal disease, is directly linked to hypertension. Sufficient evidence exists to support the association of periodontal disease with the development of vascular diseases.
Many studies have demonstrated the bidirectional relationship between periodontal disease and diabetes. A 2011 study published in Pediatric Diabetes journal concluded that periodontal damage is associated with impaired beta cell function and metabolic syndrome components in type 2 diabetes.
Another 2011 study in the Journal of Clinical Periodontology demonstrated that nonsurgical periodontal therapy improved glycemic control in type 2 diabetics. A recent study in the Journal of the Canadian Dental Association concluded that the chronic inflammatory state in periodontitis contributes to the overall low-grade inflammation that occurs in diabetes, which in turn aggravates insulin resistance.
The relationship between periodontal disease and diabetes is accepted by the American Diabetes Association. The hallmark of diabetes is glycemic control, and one of the primary causes of hyperglycemia is insulin resistance. The biggest root cause of atherosclerosis is insulin resistance. The interconnected nature of periodontal disease, CVD, and diabetes is grounded in a very large body of research.
Many studies that provide evidence of a connection between periodontal disease and systemic conditions indicate that additional research needs to be completed to affirm their findings. As dental providers, we have the ability and responsibility to decide when the evidence is sufficient to implement the research findings into our treatment protocols.
A large body of research has demonstrated several mechanisms at play, including the effect of the total inflammatory burden from all sources — whether from periodontal disease, an ingrown toenail, or anything in between — on systemic diseases and conditions, and the direct effects of perio pathogens on hypertension and atherosclerosis development. Developments in medical research provide other lines of evidence, such as the current understanding of atherosclerosis as an inflammatory rather than a lipid-driven disease.
Connecting the dots of disease relationships is not a difficult exercise. Periodontitis has significant infectious and chronic inflammatory components. Chronic inflammation is a primary causative agent in CVD. Chronic inflammation increases insulin resistance, which worsens glycemic control. Insulin resistance is the biggest root cause of atherosclerosis and atherosclerosis is the kickoff event for heart attacks and strokes. Round and round it goes.
The consensus in the medical and dental professions is that there is a relationship between periodontal and systemic diseases. It is appropriate at this time to take a “guilty until proven innocent” approach to the interconnected nature of periodontal disease, CVD, and diabetes since we are treating people, not just mouths, and impacting their health beyond the oral cavity.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, key opinion leader for several dental companies and organizations, and lecturer on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].