The Oral Systemic Connection

The oral cavity plays an important role in the overall health of the body.

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Oral Systemic Connection




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Oral cavity plays an important role in the overall health of the body


It has been reported that 3 out of every 4 Americans have signs of mild periodontal disease or gingivitis. Almost 30% show signs of the more severe disease, chronic periodontitis. We now have reason to believe that the health of your teeth and gums may have a significant effect on the overall health of your body. Recent scientific literature suggests a strong relationship between oral disease and other systemic diseases and medical conditions.
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According to numerous studies, there are three ways oral disease may affect your overall health. First, bacteria from your gums enter the saliva. From the saliva it may adhere to water droplets within the air you inhale each time you breathe. These bacteria laden water droplets may be aspirated into the lungs, potentially causing pulmonary infection and pneumonia. This can be very troublesome for the elderly or those who may suffer from generalized weakened immunity, associated with chronic obstructive pulmonary disease (COPD).Inflammatory mediators found in inflamed gums called “cytokines” can also enter your saliva. As they too are aspirated into the lungs, they have pro-inflammatory effects on the lower airway, which can contribute to further pulmonary complications. 



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Secondly, bacteria associated with periodontal disease can enter the body’s circulatory system through the gums (periodontium) around teeth and travel to all parts of the body. As the oral bacteria travels, it may cause secondary infections or it may contribute to the disease process in other tissues and organ systems. Finally, inflammation associated with periodontal disease may stimulate a second systemic inflammatory response within the body and contribute to or complicate other disease entities that may have an inflammatory origin such as, cardiovascular disease, diabetes, orthopedic implant failure and kidney disease. Whatever the route oral bacterial may influence, it is in every patient’s best interest to maintain their mouth in an optimum state of health.


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The goal of many studies being conducted at universities and research centers throughout the world is to understand just how oral bacteria affect overall health. As these studies are published, health care professionals will begin to better understand the underlying biological mechanisms that are responsible for this oral systemic connection.
A new paradigm between dentistry and medicine is now developing regarding patient care. As the oral systemic connection is more clearly understood, dentists who are trained in diagnosing oral and periodontal disease will play a greater role in the overall health of their patients. Many times, the first signs of unnatural systemic health conditions reveal themselves in changes within the oral cavity. Medical histories should be carefully reviewed when “at risk” patients are identified. A comprehensive Periodontal Risk Evaluation should be performed and results should be sent to the patient’s treating physician(s). 
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The oral cavity plays an important role in the overall health of the body. Physicians will play a more active role in the oral systemic connection. They will screen at risk patients for the common signs of periodontal disease, which include bleeding gums, swollen gums, pus, shifting teeth, chronic bad breath and family history of periodontal disease. When appropriate, they will refer them to dentists and Periodontists who are uniquely qualified to evaluate and treat their patient’s oral conditions. This new era of interdisciplinary dental/medical cooperation will undoubtedly result in improved patient health, as well as an improvement in overall patient longevity.

Pulmonary Oral Heart Connection

Oral bacteria will naturally accumulate around your teeth and gums. However, when these bacteria increase to abnormal levels, signs of gum disease may become evident. About 75% of all Americans show signs of mild gum disease (periodontal disease) and gingivitis. Almost 30% show signs of the more significant disease, chronic periodontitis.

Bacteria from gum disease can easily get into the saliva. From the saliva, it may adhere to tiny water droplets that you inhale as you breathe. A mouth that has an abundance of bacteria will more easily infect the lungs. For those patients who have a compromised immune system or chronic obstructive pulmonary disease (COPD), this can be very dangerous.

Elderly patients in nursing homes, who have lost mental motivation, and much of their ability to clean their teeth properly, have high levels of oral bacteria. This makes them particularly prone to oral bacteria induced pneumonia. The oral bacteria levels in the elderly may also increase due to the lack of salivary flow often seen with age and certain medications.



Pulmonologists should routinely ask patients if they have signs of periodontal disease. If bleeding gums (the most common sign of periodontal disease) are reported, the patient immediately should be referred to a periodontist or dentist trained in the diagnosis and treatment of periodontal disease. Although early treatment may be very beneficial to preventing secondary pneumonia, good oral maintenance and prevention should be the goal.

Patients who have compromised pulmonary function should have a comprehensive Periodontal Risk Evaluation. They must also maintain a frequent professional hygiene schedule with their periodontist or dentist. At the very least, proper oral hygiene will diminish the potential bacterial load to the lungs.

Oral Heart Connection



Recent studies have shown that there is a very strong association between gum disease (periodontal disease) and cardiovascular disease (including, heart attacks and strokes). This website will shed light on the nature, progression and treatment of periodontal disease and it’s possible connection to the circulatory system pathology (atherosclerosis, atheroma formation and infectious endocarditis). Recent research reports will continually be added to our list of references.








 

Quick Facts

1. Heart disease kills more people than all forms of cancer and AIDS combined.
2. Approximately 1 million people die from cardiovascular disease, (CVD) annually.
3. More than 2600 people die from CVD each day, one every 34 seconds.
4. At least 70 million Americans have some form of CVD.
5. More than 500,000 people annually have a stroke, one every 45 seconds.
6. Periodontal disease is associated with a significant increase in risk of CVD.
7. More than 75% of Americans have moderate to advanced periodontal disease.
8. Periodontal disease is treatable and often curable.

Of the sudden deaths relating to CVD, more than 50% had no previous signs of the disease!




If you have gum disease (also known as periodontal disease) during normal chewing or teeth brushing, bacteria can enter the bloodstream and travel to other parts of the body. It is important to understand how this bacteria can affect your heart and circulatory system.

Bacteria found in infected gum tissue around teeth during periodontal disease breaks down the epithelial barrier between the gums and the underlying connective tissue. Once this occurs, a series of inflammatory reactions take place which allow chemical mediators of inflammation, antigens and bacteria to enter the blood stream. In the bloodstream, bacteria and inflammatory mediators are carried to other parts of the circulatory system where they contribute to the formation of cardiovascular disease.

Cardiovascular disease begins with the weakening of arterial walls. As they weaken, inflammatory mediators and fatty deposits enter forming “atheromas” within the vessel wall. When atheromas grow, they are covered by a thin fibrous covering. When this covering ruptures, it leaves a roughened surface where blood platelets can stick, forming a clot.

If the clot becomes unstable, it may break off and travel down stream where it may ultimately lodge in smaller vessels. Since no blood flow can go beyond the clogged vessel, the tissue the blood was supplying dies. If this scenario occurs in the heart, it is called a myocardial infarction (commonly referred to as a heart attack). If it occurs in the brain, it is called a stroke.



When unstable atheromas rupture and cause clots that block arterial blood supply to the brain, the brain tissue beyond the clot dies causing a stroke.





Sometimes, bacteria from the mouth enters the bloodstream and travels to the heart where it attaches to the heart valves or muscle tissue. This condition is known as infectious endocarditis.

Fetus Oral Health Connection

Pre-term, Low Weight Babies

Pre-term delivery (births occurring prior to 37 weeks gestation) and low birth weight are among the adverse pregnancy outcomes that represent a significant public health concern. According to the March of Dimes, 1 in every 13 babies born in the United States is born with low birth weight. Since birth weight is one of the most important factors in the growth, development and survival of an infant, this rate is substantial. Low birth weight is defined as less than 5 pounds, 8 ounces at birth. Modern day science and medicine has increased the survival rate of these babies significantly. However, adverse pregnancy outcomes are the leading cause of neonatal death, long-term neurodevelopmental disturbances and other serious complications.

Graph Oral Systemic

Could the health of a mother’s mouth affect the outcome of her pregnancy?

The cause of pre-term, low birth weight babies (PTLBW) is not truly known. Scientific evidence identifies many associated risk factors, which include a multiples pregnancy, uterus or cervix abnormalities, mother’s chronic health issues, smoking while pregnant, drugs and alcohol, insufficient prenatal care, low socioeconomic factors, maternal age (under 18 or over 35), and maternal or fetal infection (including the systemic inflammation resulting from infection).

Gum disease (periodontitis) is a chronic infection of the gums surrounding the teeth, which in recent years is being linked with contributing to systemic infection. The association between gum disease and pre-term, low weight babies has been observed for many years. Although the exact association is still being reviewed by researchers around the world, there seems to be an agreement that good oral health is increasingly important to women of child bearing age.

Some scientific research suggests that the bacteria around teeth that are affected by periodontal (gum) disease produce toxins which enter the blood stream, cross the placenta, and interfere with growth and development of the developing fetus. While this is happening, other substances are being produced which may enhance the trigger mechanism for early delivery of the fetus. Yet other studies indicate that it is the body’s immune system, which responds to the circulating chronic oral bacteria and its endotoxin by-products with systemic inflammation that contributes to pre-term, low weight babies. Based on these theories, periodontal disease (particularly in the advanced stage) may be an independent risk factor to PTLBW outcomes.

Babies and Oral Health

Will treating Periodontal Disease During Pregnancy Decrease the Incidence of Adverse Pregnancy Outcome?

At this time, there are some research conclusions that demonstrate a significant reduction in the rate of PTLBW, as well as those that show no improvement in the risk outcome. There is, however, a biological plausibility that untreated periodontal disease may increase the risk of PTLBW babies. Several larger studies are currently in progress to further examine this possibility.

Oral Health Recommendations

Maintaining good oral hygiene, both at home and with a professional, in conjunction with annual periodontal probing visits with a dental professional, is the best proactive approach.

For women who are experiencing loose or shifting teeth, have a family history of periodontal disease, who have chronic bad breath or bleeding gums, a comprehensive Periodontal Risk Evaluation is recommended. This exam should be performed by a periodontist or dentist trained in the diagnosis and treatment of periodontal disease. This examination should include the review of current, full mouth x-rays (if pregnant, check with your obstetrician prior to x-rays) to determine the degree of possible periodontal bone loss.

Many factors can contribute to PTB. Gum disease is one factor easily eliminated as a cause of PTB. Therefore, it should be monitored closely, and treated immediately if detected prior to becoming pregnant and during pregnancy. During pregnancy, treatment of periodontal disease, usually in the 2nd trimester, can be provided safely to improve the oral health of the mother.

Diabetes

One of the most interesting relationships in the oral systemic connection is the newly emerging two-way relationship between periodontal disease (periodontitis) and diabetes. For years it’s been apparent that diabetes exacerbates periodontal disease. What’s relatively new is the belief that periodontal disease may have an influence on diabetes. Diabetes is a metabolic disease characterized by insulin resistance or lack of secretion. Diabetics suffer from higher than normal blood sugar levels called hyperglycemia. Over time, this condition can cause permanent damage to the eyes, kidneys, blood vessels and nervous system.

As diabetes progresses, so does the likelihood of developing and/or worsening of chronic periodontitis. Researchers are currently studying the possibility that uncontrolled periodontal disease may interfere with glucose regulation in the body. This makes the diabetic condition worse by interfering with glucose metabolism, which in turn could increase the chance of other serious medical complications.

A growing body of scientific literature suggests a bi-directional relationship. Although the exact nature of this relationship is not clear, both healthcare professionals and patients should be aware of and address this concern.

It is not unusual to see very swollen gums, loose and/or shifting teeth and/or a bad taste in the diabetic condition. When gums are inflamed, local inflammatory mediators known as “cytokines” enter the blood stream and cause a negative effect on glucose regulation. By treating underlying periodontal disease, glucose regulation has a much better chance of returning to a more normal state. Home care in the diabetic patient should be meticulous to avoid making the situation worse. Additionally, the diabetic patient should see their hygienist or a periodontist every 3 months for professional maintenance of the more difficult areas of the mouth.

Medical management of the diabetic patient by a physician should include asking patients if they have signs of loose or shifting teeth, bleeding gums, chronic bad breath and/or a family history of periodontal disease. If the answer is “yes”, the patient should be referred to a periodontist or dentist trained in periodontal diagnosis and treatment. Early intervention in a diabetic patient is extremely important for managing both their oral and systemic health.

An estimated 20.8 million individuals in the United States have diabetes. Over six million diabetics are undiagnosed.

American Diabetes Association Warning Signs of Diabetes

Type 1 Diabetes: insulin dependent. - Frequent Urination - Unusual thirst - Extreme hunger - Unusual weight loss - Extreme fatigue - Irritability   Type 2 Diabetes: manageable with diet, exercise and medication, if applicable. - Any of the type 1 symptoms - Frequent infections - Blurred vision - Cuts/bruises that are slow to heal - Tingling/numbness in the extremities - Recurring skin, gum or bladder infections

Note: Individuals with type 2 diabetes frequently do not have any symptoms.

If you suspect that you or anyone in your care may have diabetes, promptly check it out with a physician.

Identifying Gum Disease

Periodontal disease (gum disease), is a bacterial infection of the tissue surrounding the teeth; causing localized and systemic inflammation. It may be accompanied locally by loss of supporting tissue and bone. The cause of periodontal disease is a bacterial film known as plaque. As plaque accumulates, the normal bacteria located around teeth begin to change into more virulent and pathogenic bacteria. It is these species of pathogenic bacteria that are responsible for the ensuing infection and destruction of surrounding bone.

Periodontal disease is usually diagnosed by measuring bone loss visible on x-rays and “pocket depth” with a periodontal probe around teeth, which is indicative of the amount of surrounding bone and attachment loss. It is these findings along with visible inflammation and bleeding upon probing that lead to a periodontal disease diagnosis.

Periodontal disease may occur as gingivitis (inflammation of the soft tissues only) or periodontitis (infection of the soft tissue and supporting bone). As periodontitis progresses, it destroys the support of the teeth and initiates a local and systemic inflammatory response. It is this secondary inflammatory response and circulating bacteria that is suspect in the:


-Pathogenesis of cardiovascular and cerebrovascular disease
-Complications with glycemic control and associated pathologies
-Orthopedic implant failure due to oral bacteria induced infection
-Complications with pulmonary disease
-Contribution to pre-term, low weight babies

Periodontitis can exist as mild, moderate or severe. As the severity of periodontitis increases, so does its suspected contribution to the conditions mentioned above.
Periodontal disease can progress into advanced forms resulting in loose teeth and eventually loss of teeth.

Periodontal disease is usually diagnosed by measuring bone loss visible on x-rays and “pocket depth” with a periodontal probe around teeth, which is indicative of the amount of surrounding bone and attachment loss. It is these findings along with visible inflammation and bleeding upon probing that lead to a periodontal disease diagnosis.

Quick Facts
Signs and Symptoms of Periodontal Disease


1. Bleeding gums
2. Sore or swollen gums
3. Loose teeth
4. Gum recession
5. Chronic bad breadth
6. Pus around teeth
7. Pain upon chewing
8. Recent bite change
9. Spaces between teeth
10 Food accumulation in gums

If you have one or more of these symptoms, you may have periodontal disease.



Now that we know what periodontal disease is and that it may have a strong association with cardiovascular disease, pre-term/low weight babies, diabetes, orthopedic implant failure, and pulmonary disease, here is what we can do about it....

Preventing and Treating Gum (Periodontal) Disease

Preventing and Treating Gum (Periodontal) Disease


The specific bacteria responsible for causing periodontal disease includes:
p. gingivalis, p. intermedia, f. nucleatum, t. forsythensis, t. denticola, a. actinomycetemcomitans


Associations between periodontal disease and diabetes, cardiovascular disease, stroke, pulmonary disease and pregnancy complications are currently being studied. Although the exact causal relationships between oral bacteria and various diseases have not yet been determined, the weight of the evidence thus far supports a plausible correlation. More scientific research is needed. However, the elimination and/or maintenance of gum disease may prove to be an important factor to overall health.

Maintaining good oral health goes beyond brushing teeth a couple of times a day, daily flossing and the use of a good mouthwash. Even by being scrupulous with at home hygiene, over time, bio film (plaque) will adhere to teeth and harden. The plaque will form in hard to reach areas, creating pockets where bacteria can grow, requiring a professional cleaning. It is the excess accumulation of bacteria that causes the local periodontal tissue to become inflamed (gingivitis). If left untreated, gingivitis will progress to a more chronic condition, periodontitis (periodontal disease). When inflammation is present, oral bacteria and its byproducts, called endotoxins, can enter the general blood circulation. It is the body’s secondary inflammatory response to these circulating bacteria that is implicated in the complication of many medical conditions and diseases. The goal of periodontal treatment is to remove inflammation-causing bacteria from the mouth, thereby preserving tooth health and decreasing overall systemic inflammation.

Behavioral and biological risk factors also play a role in the progression of periodontal disease. These include:

Smoking or chewing tobacco
Stress Family history of periodontal disease
Ill fitting fillings, crooked teeth, food impaction areas
Medications
Other systemic diseases

Treatment Methods


Depending on the severity of the periodontal disease, the treatment will vary. For mild disease, scaling and root planing is recommended, along with creating new oral hygiene habits to eliminate its recurrence. It is important to follow through with the follow-up evaluation to confirm the status of your oral health. If the disease is more moderate, then scaling and root planing and improved oral hygiene habits may be accompanied by the administration of local and/or systemic antibiotics, as well as more frequent scheduled hygiene appointments to help manage the disease. If this is not sufficient, surgical intervention may be necessary to remove diseased tissue, eliminate pocket depth or regenerate lost supporting tissue. When periodontal disease is advanced, treatment options may change again. In addition to the treatment recommendations of moderate periodontal disease, more aggressive periodontal surgery and/or tooth removal may be necessary.

Your Next Steps

Your next step will be to have a Periodontal Risk Evaluation by a periodontist or dentist who is highly qualified to diagnose and treat periodontal disease. During your evaluation, your medical history will be carefully reviewed. Your blood pressure will be noted. Full mouth x-rays will be examined for radiographic signs of periodontal disease destruction. Most importantly, each tooth will be evaluated for:

Attachment loss
Bleeding upon probing
Pocket depth
Recession
The presence of pus
Mobility
Occlusion (bite relationship)
Adequacy of existing restorations

These results will be noted on a periodontal chart. This information, along with the other factors will lead to a specific diagnosis of periodontal disease. If periodontal inflammatory disease is present, a course of recommended treatment will be established. Additionally, the prognosis and recommendations for maintenance will be established. The results of your Periodontal Risk Evaluation will be sent to your physician(s) to become part of your medical record.

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