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The dental profession is undergoing a dramatic increase in its understanding of disease processes and mechanisms, including the interaction between oral and systemic diseases and conditions. Many of these advances are the result of new research techniques. The link between oral conditions, most notably periodontal diseases, and systemic events is accepted in the dental and medical professions. Ongoing research efforts will shed more light on these associations as well as the potential impact of periodontal therapy on the body.
The common thread between the mouth and body is inflammation. Periodontal disease is a bacterial infection resulting in a chronic inflammatory response. David L. Cochran, president of the AAP, indicates that the inflammatory mediators in periodontitis are the same ones that stimulate pathologic processes in blood vessels in coronary heart disease, rheumatoid arthritis, and pregnancy complications. With this level of commonality, disease linkages make perfect sense.
Among the most recent findings is further affirmation of the link between periodontitis and cardiovascular disease. Some studies, in fact, provide evidence that some perio pathogens are causative agents. A 2009 study (J Periodontal Res 2009 Sept.) found that the potent periodontal bacterium, P. gingivalis, contributed to the development of vascular inflammation and atherosclerosis, which are primary risk factors for cardiovascular events.
Another area of research concerns the potentially significant connection between periodontal disease and rheumatoid arthritis (RA). Many studies have shown an epidemiological association, frequently finding the two diseases in the same study subjects. Now, evidence of the biologic basis of the association is also being uncovered.
Recently published research (J Clin Perio 2009 Dec.) examined bacteria in subgingival plaque, serum, and synovial joint fluid by DNA analysis. The results demonstrated that all study subjects had perio pathogens in the synovial joint fluid. The authors concluded that perio pathogens could have a role in the etiology of RA.
Another study (Compend Contin Educ Dent 2009 May) indicated that chronic periodontal and joint inflammation share many common pathologic, cellular, and molecular features. The authors also stated that the mechanisms involved in the destruction of adjacent connective tissue are quite similar in the two diseases.
They found the perio pathogen P. gingivalis may serve to amplify autoimmune responses, ultimately initiating RA in genetically susceptible individuals. Finally, a 2009 interventional study (J Periodontol 2009 Apr.) found that nonsurgical periodontal treatment had a beneficial effect on RA’s signs and symptoms.
There does not appear to be a clear consensus at this time regarding the association between periodontal disease and adverse pregnancy events. Some recent studies indicate an increased frequency of preterm, low-birth-weight babies among pregnant women with periodontal disease, while other well-designed studies do not find this relationship.
A clinically prudent approach may be to actively educate women of childbearing age about the importance of periodontal health, and provide perio treatment for pregnant women, ideally between the 14th and 20th weeks of gestation. Obviously, periodontal disease prevention prior to pregnancy would be ideal.
The strongest perio systemic link is between periodontal disease and diabetes. When these two diseases are poorly controlled, they adversely affect each other. Diabetes is the number one systemic risk factor for periodontal disease, while uncontrolled perio disease worsens glycemic control by increasing insulin resistance.
Some recent studies indicate that providing perio treatment improves glycemic control. A 2010 review article (Diabetes Care 2010 Feb.) concluded that periodontal treatment improves glycemic control in type 2 diabetic individuals for at least three months.
Particularly interesting research is underway, investigating the potential to diagnose diabetes using gingival crevicular blood. This seems logical since high blood sugar is present everywhere, including the oral cavity. Chairside testing of gingival crevicular blood for sugar levels and diagnosing diabetes in a dental setting could be among the most impactful public health initiatives ever developed.
There is no doubt about the existence of oral-systemic connections. Continuing global research will indicate the strength of these associations and unravel the mechanisms involved.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on many topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].
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