Richard H. Nagelberg, DDS
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It is now well established that periodontal disease increases the risk for systemic diseases and conditions. The strength of the various oral-systemic connections varies. The link between periodontal disease and pregnancy is still under investigation, as is the relationship with rheumatoid arthritis, among others. The evidence at this point, however, is sufficient to be considered complete regarding the interconnections between periodontal disease, atherosclerosis, cardiovascular diseases, and diabetes. These associations can briefly be described as follows: Diabetes is the No. 1 systemic risk factor for periodontal disease; periodontal disease worsens glycemic control by increasing insulin resistance; insulin resistance is the biggest cause of atherosclerosis; and atherosclerosis is the primary driver of cardiovascular diseases. Each of these relationships has been demonstrated by a large body of research.
Two mechanisms of these associations have been revealed to this point. One is the effect of the total inflammatory burden on atherosclerosis, cardiovascular diseases, and diabetes. Chronic inflammation from all sources, including the oral cavity, increases the risk for the diseases noted. The other mechanism is the result of direct effects of the periodontal pathogens, independent of the inflammatory response.
Studies have shown that atherosclerosis is a chronic inflammatory response of arterial endothelial cells, rather than a lipid-driven disease. Lipid accumulation in the arterial wall follows inflammation of the endothelium. Periodontal disease was shown in a 2011 study by Fifer et al. to be directly linked to atherosclerotic inflammation. Other studies have shown evidence of a direct relationship between periodontal pathogens and the development of hypertension, which is a significant risk factor for cardiovascular diseases. Further research has demonstrated a significantly increased risk of heart attack for perio patients with high levels of the perio pathogen Porphyromonas gingivalis.
With these mechanisms in mind, prevention of periodontal disease development and suppression of the perio pathogens will minimize the risk for systemic events in addition to maintaining and improving oral health. This is the essence of the wellness model, rather than the end-stage disease model of health care. If we can prevent periodontal disease from developing in the first place and keep the population of perio pathogens in the oral cavity to minimal levels, we will have then successfully reduced the oral contribution to systemic disease risk.
As dental professionals, we have a wide array of biofilm control devices available to us, including power toothbrushes such as the Philips Sonicare, antimicrobial mouthrinses, and interdental devices such as the Proxabrush, among others. Entirely new categories of biofilm-reducing devices are now available, which will further enable us to assist our patients with their home-care efforts. Philips has developed a product called the AirFloss. It has a tip that is easily placed between teeth. A reservoir holds water or mouthwash. Activation of the unit provides a brief, high-velocity microburst of air and fluid that effectively removes interdental biofilm. It is quick and easy and can be used around the entire mouth in less than one minute. The AirFloss is indicated for patients who are not flossing optimally.
Another exciting innovation is the development and availability of oral probiotics by Oragenics, a biopharmaceutical company. Dr. Jeffrey Hillman, one of the founders of Oragenics, identified strains of bacteria that are not pathogenic and incorporated them into an oral probiotic mint called EvoraPlus. Three naturally occurring strains of Streptococcus bacteria are incorporated onto the mint in a freeze-dried form. The mints are available without a prescription and are taken daily. The probiotic bacteria compete for binding sites and nutrients with cariogenic bacteria. They also reduce the population of perio pathogens by releasing hydrogen peroxide as a metabolic byproduct. Significant reduction in Streptococcus mutans and periodontal pathogen populations occur with daily use of EvoraPlus.
The wellness model is the future of health care. In effect, there is a shift from sick care to health care. The effect of periodontal disease beyond the oral cavity needs to be addressed daily by dental professionals. With existing technologies and biofilm-control products — along with exciting new products such as AirFloss and the oral probiotic EvoraPlus — we can shift from treating disease to promoting health and disease prevention, enhancing the care we offer our patients. After all, it is all about the patient — first, foremost, and always.
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].