Periodontal disease is a chronic inflammatory condition of the gum and surrounding tissue and is the major cause of about 70% of adult tooth loss. It affects three out of four people in their adult lives.
Research shows a correlation between gum disease (chronic periodontal disease) and the patient’s general health. Areas currently linked are cardiovascular disease, e.g., stroke and heart attacks, lung problems, diabetes and premature birth. Possible links to chronic periodontal disease have also been suggested for both rheumatism and stress.
This disease results from exposure of the periodontium, and here we mean soft tissue, bone, cementum and dentine tissue, to a myriad of harmful bacteria. About six billion bacteria inhabit the mouth. However, a symbiosis exists between them, and generally they do no harm. That balance can easily be disturbed, and any shift in the microbial population might lead to an attack on the periodontium. We human beings are very fortunate that many of our oral tissues have a barrier that prohibits these bacteria from penetrating the mucosa.
There are many ways the body produces this barrier. Some of it is physical, as seen in many oral cavity cells that contain the so-called Odland body (discovered by Dr. Odland). This body can produce a material that seals the cell surface like a shield against bacteria as well as harmful substances like alcohol.
The defence could also be immunological; for example, a high oxidation-reduction level that could act as a barrier. Plaque can influence whether the periodontal disease is acute or chronic, depending on what kind of bacteria is colonizing it.
DIABETES AND PERIODONTAL DISEASE:
About 10% of Canadians are affected by either type 1 or type 2 diabetes. By 2010, up to 3 million Canadians will be afflicted by diabetes mellitus.
Diabetes mellitus is an endocrine disease characterized by hyperglycaemia due to defective secretion of insulin. Research now shows that the relation between diabetes and periodontal disease is reciprocal. An individual with diabetes can see that his periodontal disease progresses more rapidly due to poorly controlled diabetes, and the opposite is also true.
Recent reports have shown that if a diabetic person treats his periodontal disease, this shows a positive effect on the glycaemia control. Generally, diabetic patients experience diminished salivary flow, burning mouth or tongue, and dry mouth (xerostomia), causing an increase in caries.
Uncontrolled diabetic cases show deterioration of their gum disease, including recession. The complications of diabetes in the system are even more ominous. These could include retinopathy, which might lead to blindness, or peripheral neuropathy, leading to loss of sensations in the limbs or burning sensations referred to as neuropathic pain.
Diabetes is known to contribute to delayed wound healing, and this is also relevant to periodontal disease. Treatment of periodontally challenged diabetic people is on two levels. One is to control the diabetes, and the other is to control the oral hygiene.
In my opinion, the ninth-month visit to the dentist is not acceptable, because these diabetic patients need more frequent monitoring. One must develop a program depending on how compliant the patient is, and then decide on two or three visits per year for maintenance with continuous observation.
RESPIRATORY DISEASE AND PERIODONTAL DISEASE:
Pneumonia, an inflammation of the lung, can be caused by bacterial infection, viral infection or fungal colonization of the respiratory tract, along with a deficient immune system. One of the most common causes of pneumonia is aspiration of the pathogens into the lower airways. Healthy people also tend to aspirate these microorganisms, but they have good immunological defense. Once that defense mechanism is decreased, it is easy for oral microorganisms to attack the lung tissue (parenchyma).
Many studies show that chronic obstructive pulmonary disease (COPD) can be exacerbated by periodontal disease. Several studies have shown that respiratory bacteria colonize the teeth of patients in intensive care units. The same could be said for people in nursing homes, who show a high rate of teeth harbouring respiratory pathogens and a high incidence of pneumonia.
The role played by the dentist here is to reduce the amount of oropharyngeal bacteria attached to teeth, and therefore to reduce the amount of harmful bacteria which can be aspirated into the lung. In addition to meticulous oral hygiene and periodontal treatment, the use of chlorohexidine has been suggested to reduce harmful bacteria.
CARDIOVASCULAR DISEASE AND PERIODONTAL DISEASE:
Often, a patient will be amazed when told that gum disease can lead to heart attacks or stroke. It is very hard for some patients to see the correlation; however, many statistical studies indicate this connection. Some studies hypothesize that periodontal microorganisms tend to produce toxins, which can induce inflammation and plaque (that is, vascular plaque), which can obstruct the cerebral vessel, leading to a stroke.
Any dental procedure that causes bleeding is well known to result in a shower of oral bacteria entering the general circulation. In a patient with an abnormal or artificial heart valve, the bacteria can stick to the valve and colonize it, rendering it leaky and dysfunctional.
Now, a team of scientists reports that it may have found a possible marker. As published online in the journal Stroke, researchers found in a large, racially mixed group of adults that the more teeth a person has lost, the more likely he or she is to have both advanced periodontal infections and potentially clogging plaques in the carotid artery, the vessel that feeds the brain. Many researchers have shown the association among cardiovascular disease, atherosclerosis, myocardial infarction and periodontal disease. C-reactive protein (CRP) is one of the acute phase proteins that increase during systemic inflammation. Testing CRP levels in the blood may be a new way to assess cardiovascular disease risk. A high-sensitivity assay for CRP test is now widely available. Testing the level of CRP is routine in the United States to assess cardiovascular disease. The higher the CRP level, the higher the chances that a person will get a stroke or cardiovascular disease.
Studies done at the University of Buffalo showed that patients infected with bacteria that cause periodontal disease had high levels of CRP.
It now has been proven that periodontal disease bacteria are able to induce CRP and fibrinogen, which are independent risk factors for cardiovascular disease.
The treatment here, obviously, is to have meticulous oral hygiene and to cut down on any factor promoting inflammation arising from the oral cavity and periodontal tissue. A consultation with the physician for patients with preexisting cardiac problems or a strong family history of cardiovascular disease will also be important.
PERIODONTAL DISEASE AND PREMATURE BIRTH:
Women with gum disease may run a greater risk of delivering a premature baby of low birth weight. The question of whether there is a correlation between premature birth and gum disease is interesting. Most of the studies are epidemiological in nature, i.e., a direct cause and effect has not been proven. I don’t think this point is relevant, because we have a good example of the devastating effect of smoking on many organs, and most of those studies are also epidemiological.
In the case of periodontal disease, one hypothesis is that the disease releases bacterial toxins called lip-polysaccharides and tumour necrosis factor alpha, which may interfere with fetal development. Another hypothesis is that periodontal disease might increase the level of circulating prostaglandin E2, a normal molecule which helps to initiate labour by stimulating cervix dilation and uterine contractions.
A periodontal maintenance visit during pregnancy is very important. The treating dentist should avoid certain medications during the first trimester, since this is the period when foetal organs are being formed.
The second trimester is the safest. The third trimester is also safe; however, the clinician should be aware of the pressure of the uterus on many abdominal organs, including the inferior vena cava, which might lead to postural hypertension if the patient is left lying on her back for long.
GUM DISEASE AND FINANCIAL STRESS:
A study done by Dr. Robert Genco at the University of Buffalo showed that high levels of stress, including financial stress and poor coping abilities, increase twofold the likelihood of developing periodontal (gum) disease. However, people who deal with their financial strain in an active and practical way (problem-focused) rather than with avoidance techniques (emotionfocused) had no more risk of severe periodontal disease than those without money problems.
How stress affects periodontal disease is not known, but I will speculate that stress affects the pituitary gland and the hypothalamus in the brain, and in turn, this stimulates the adrenal glands to release stress hormones. These hormones can decrease or modify the immune system, and hence increase gum disease activity.
GUM DISEASE AND ARTHRITIS:
In an Australian study of 130 people, the 65 people who had rheumatoid arthritis were more than twice as likely to have gum disease (with moderate to severe jawbone loss) than the control subjects. In addition, they averaged 11.6 missing teeth, compared to 6.7 in the control group. One can argue the case by saying that people who have arthritis have limited movement, and therefore they are prone to poor oral hygiene. However, the Australian researchers indicate that the control group had the same amount of plaque as those with rheumatoid arthritis. This means that those with rheumatoid arthritis had another factor that induced the arthritis, and it could be the periodontal disease.
OBESTITY AND GUM DISEASE:
A recent study published by Dr. Mohammed S. Al-Zahari from the University of Case Western in Cleveland indicates that gum disease is very common in obese patients, and it’s much more common in obese young adults because of their bad habits of eating. This epidemiological study was published in the Journal of Periodontology.
Current knowledge and continuing research into the relationship between periodontal disease and the other systems of the body are of utmost importance in improving dental and general health.
By Dr. K.A.Galil., DDS, D. Oral. Surg., PhD, FAGD, FADI, Cert. Periodontist Adj. Professor of Periodontics, University of Western Ontario, Faculty of Medicine and Dentistry