Oral-systemics 2016

Sept. 22, 2016
Richard H. Nagelberg, DDS, studies what the literature has to say about the oral-systemic connection between periodontal disease and other systemic diseases.

Richard H. Nagelberg, DDS

In dentistry, the debate about the existence of various associations between the mouth and the body is over, except perhaps for a very small number of skeptical holdouts. But what about the medical community? Is there a consensus regarding the oral-systemic interconnections? Some medical journals provide insight into the level of acceptance among our physician colleagues. The three examples noted below are all from peer-reviewed medical journals.

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"Recognizing the periodontal health status of patients is critical, as the severity of the periodontal disease correlates with the risk level of developing [atherosclerosis]. ... There is evidence that proper periodontal treatment reduces systemic inflammation levels and there exists a relationship between inflammation and atherogenesis."1

"Nowadays, periodontal disease can also be considered another cardiovascular risk factor. It involves inflammatory, immunological and humoral activities, which induce the production of proinflammatory cytokines and the destruction of the [gingival] epithelium. This allows the entry of endotoxins and exotoxins in the bloodstream, which may contribute to atherogenesis and thromboembolic events. There is also direct invasion of the vessel wall by oral pathogens, triggering an inflammatory response that produces endothelial dysfunction."2

"Epidemiological, biological and clinical links between periodontal and cardiovascular diseases are now well established."3

The first statement calls physicians to action, specifically to recognize the periodontal health status of their patients as an identifiable risk factor for the development of atherosclerosis. The second statement covers both mechanisms of the oral-systemic interconnections, including the contribution of periodontal disease to the total inflammatory burden and the direct effects of periodontal pathogens on the vasculature. The third statement is elegantly simple and self-explanatory. It comes from the highly regarded journal Atherosclerosis, the subtitle of which is "International Journal for Research and Investigation on Atherosclerosis and Related Diseases."

Anecdotal evidence of attempts by dentists to establish a relationship with patients' physicians is largely disappointing. Physicians' nonresponsiveness to invitations to meet, attend seminars, respond to streams of information about specific patients, and requests to co-manage patients occurs more often than not. This is unfortunate, because co-managing patients will become the norm as salivary diagnostics in virtually all aspects of health care becomes the standard of care. This can be illustrated by the following research concerning periodontal pathogens and rheumatoid arthritis (RA).

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"Converging and reproducible evidence now makes a clear case for the role of specific periodontal infective pathogens in initiating, amplifying and perpetuating rheumatoid arthritis. The unique enzymatic properties of the periodontal pathogen Porphyromonas gingivalis (P. gingivalis) and its contribution to the burden of citrullinated peptides is now well established. The impact of localized infection such as periodontitis in shaping specific anti-citrullinated peptide immune responses highlights a key area for treatment, prevention and risk assessment in rheumatoid arthritis."4

The body of research linking P. gingivalis to rheumatoid arthritis evolved quickly, leading to the above statement that indicates a now well-established relationship. A physician in possession of this information would likely not have a clue how to proceed in terms of identifying, managing, and monitoring the presence of P. gingivalis. Individuals with RA or a family history of RA should have salivary bacterial testing completed using a laboratory such as OralDNA Labs (Eden Prairie, Minnesota). The testing should be undertaken regardless of the patient's periodontal status since the relationship involves the bacteria P. gingivalis, not periodontal disease.

If the patient has periodontal disease, it should be appropriately treated to complete resolution with retesting three months post-op. Individuals with P. gingivalis identified in the bacterial test report, with or without periodontal disease, should be instructed in whole-mouth disinfection, including a power toothbrush, tongue scraper, interdental brushes and floss, and an antimicrobial rinse. Retesting should be completed in three months.

Incorporation of mouth-body research findings into daily dental practice should be occurring currently in routine dental practice. We'll just have to wait for our medical colleagues to catch up.

READ DR. NAGELBERG'S "MAKING THE ORAL-SYSTEMIC CONNECTION" BLOG ON DENTISTRYIQ

References

1. Nguyen CM, Kim JW, Quan VH, Nguyen BH, Tran SD. Periodontal associations in cardiovascular diseases: The latest evidence and understanding. J Oral Biol Craniofac Res. 2015;5(3):203-6. doi: 10.1016/j.jobcr.2015.06.008.

2. Macedo Paizan ML, Vilela-Martin JF. Is there an association between periodontitis and hypertension? Curr Cardiol Rev. 2014;10(4):355-61.

3. Rangé H, Labreuche J, Louedec L, et al. Periodontal bacteria in human carotid atherothrombosis as a potential trigger for neutrophil activation. Atherosclerosis. 2014;236(2):448--55. doi: 10.1016/j.atherosclerosis.2014.07.034.

4. Leech MT, Bartold PM. The association between rheumatoid arthritis and periodontitis. Best Pract Res Clin Rheumatol. 2015;29(2):189-201. doi: 10.1016/j.berh.2015.03.001.

Richard H. 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. He lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact Dr. Nagelberg at [email protected].

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