The oral-systemic connection

The oral-systemic connections are accepted at this point by both the medical and dental professions.

Richard H. Nagelberg, DDS

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The oral-systemic connections are accepted at this point by both the medical and dental professions. The strength of the links is still under investigation. It is important to understand that there is not a single connection, but rather links for a variety of organ systems and disease entities. Currently, some associations are better established than others, and there are also varying degrees of acceptance of these links among health-care professionals, including dentists and dental hygienists.

Some connections are well-established, such as respiratory infections derived from inhaled oral pathogens. The association between periodontal disease and diabetes is also well-established, with a large body of evidence demonstrating the two-way relationship between them.

The increased incidence of periodontal disease in poorly controlled diabetic individuals has been sufficiently demonstrated to be accepted as fact. Poor glycemic control due to an increase in insulin resistance from the infectious and inflammatory components of periodontal disease has also been abundantly researched and demonstrated. The American Diabetes Association recognized this association in 2008.

The connection between periodontal disease and adverse pregnancy events has had its ups and downs. There was a fairly large body of evidence indicating an increased risk for preterm, low-birth-weight infants among women with periodontal disease in the early studies. Other studies have failed to show this relationship. A recent piece of published research is quite interesting.

The investigators looked at the effect of SRP on the rate of preterm birth (PTB), with a control group receiving only home-care instructions. They found no significant difference between the incidence of PTB in the control and treatment groups. They did find, however, that within the treatment group a strong relationship existed between successful periodontal treatment and full-term birth, and that patients who were refractory to periodontal treatment were significantly more likely to have a preterm baby [Jeffcoat M, Parry S, et al. BJOG. Jan. 2011; 118(2):250-256].

Consensus cannot be drawn from one piece of research, but these results are thought-provoking. Making the distinction between the effects of successful vs. unsuccessful periodontal treatment on PTB may prove to be more accurate. Obviously, further research needs to be done.

The relationship between periodontal disease and cardiovascular (cv) disease is another link with a significant amount of research demonstrating a strong relationship between them. Recent studies have shown a number of different mechanisms by which an association may exist. It is well-established that periodontal disease causes an increase in the level of CRP and Lp-PLA-2, which are significant markers of cardiovascular disease.

Other studies have demonstrated a positive relationship between the oral bacterial burden and hypertension. DNA studies have shown the presence of oral bacteria in coronary blood vessel walls. There is a large body of work suggesting this relationship exists. Another piece of the puzzle is the overall commonality of the inflammatory response. Research has shown the same inflammatory mediators are released in response to periodontal disease, rheumatoid arthritis, cv disease, and adverse pregnancy events.

The mere thought process around the oral-systemic connections implies that the oral cavity is, to some extent, separate from the rest of the body. There is no concept of ophthalmic-systemic links, kidney-systemic links, cardio-systemic links, or podiatric-systemic links. There are just oral-systemic links. The oral cavity is just another part of the body, as are the eyes, kidney, heart, feet, and so on.

When a podiatrist is treating a diabetic patient for a foot or ankle infection, he or she understands that resolving the infection will also positively impact blood sugar control. Perhaps we need to think of the oral cavity as just another part of the body.

The oral-systemic dots are well-connected at this point, but the evidence is not bulletproof yet. As dental professionals, we have the freedom to evaluate the research from many sources and decide for ourselves how to utilize the information. It is fortunate that treating every periodontal patient with any level of periodontal disease for the health of the oral cavity is substantially the same protocol for addressing the increased risk for systemic events; fortunate for clinicians and most importantly for the patient.

Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. In-office consultations are available. Contact him at gr82th@aol.com.

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