By Richard H. Nagelberg, DDS
Edentulous individuals do not have to worry about oral-systemic interconnections: fact or fiction? Since there are no teeth, periodontal disease cannot possibly develop; therefore oral-systemic links cannot develop by that mechanism. There are, however, the direct effects of periodontal pathogens on the vasculature. But without teeth and the subgingival environment around them, can anaerobic bacteria exist and thrive in the mouth? As determined by bacterial DNA analysis through salivary diagnostics, they can and do, including the most pathogenic species such as Aa and Pg. Anaerobic environments exist on the tissue side of full dentures, in the tonsillar region, and on the posterior dorsum of the tongue, especially when there is postnasal drip. If an edentulous patient has other risk factors or a family history of cardiovascular disease, salivary bacterial analysis should be undertaken and the patient should be practicing a meticulous antibacterial home-care regimen. Edentulousness does not necessarily exclude an individual from being concerned about the effects of oral bacteria on his or her arteries. Even in the absence of teeth, home care needs to be practiced as if the patient's life depends on it.
A significant piece of information about any patient, most notably a new patient, can be determined after looking in the mouth for five seconds; and it is the most important piece of information. Wherever a patient is on the spectrum of gingival health - from perfect health to fulminating periodontitis or anywhere in between - is a direct reflection of his or her home care. If the patient's gingiva could not be healthier, he or she is knocking down the bacterial load sufficiently for the immune system to have the upper hand. The home care needs no modification, and the patient has both mechanisms of oral-systemic links under control. These patients have, in fact, eliminated two risk factors for cardiovascular disease and diabetes, among others.
Patients with any level of periodontal disease, including and perhaps most importantly, gingivitis, need to be doing something different at home. In these patients, the bacterial load is higher than their immune systems can handle, and disease occurs, which we can see after a very brief look in their mouths. The gingival health of anyone is a direct reflection of the effectiveness of his or her home-care efforts. The reason why gingivitis patients may be the most important to intercept is because failure to do so may lead to periodontitis, which they will have forever. Patients whose home care is less than ideal need to ramp up their efforts as if their lives depend on it.
As dental professionals, we habitually think of periodontal pathogens as existing only in the oral cavity, which is certainly where they originate. They do not, however, stay in the mouth. Every time we eat and brush, some bacteria get into the bloodstream. The body has an enormous ability to defend itself and does so successfully every moment of every day, including against this bacteremia occurring on a daily basis. In an individual with periodontitis, the ability of the bacteria to get into the circulation is multiplied due to the higher bacterial counts and the ulcerated gingival epithelium.
It would be advantageous for clinicians and patients to think about live bacteria and their endotoxins traveling around the body, potentially taking up residence in arterial walls, including coronary and cerebral arteries. If we can refocus our thoughts about where these periodontal pathogens operate, beyond the oral cavity, perhaps we can communicate the urgency to knock them down as much as possible to our patients.
All the procedures we complete for our patients are important to enhance their health and appearance. None is more important than home-care instructions. It may seem mundane and dogmatic, but it is the best way we currently have to manage periodontal disease, bacteria, and their influences around the body.
If a physician could eliminate significant risk factors for cardiovascular events as simply and inexpensively as tooth brushing, flossing, and rinsing, it would be all over the media in the same way as the discovery that Tums increased calcium levels.
Advise all patients to practice home care like their lives depend on it, because they do.
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].