CHICAGO—April 18, 2012—The American Academy of Periodontology (AAP) supports the American Heart Association’s (AHA) scientific statement “Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association?” recently published in Circulation. The statement concludes that observational studies to date support an association between periodontal disease and cardiovascular disease, independent of shared risk factors. The AHA’s statement confirms the conclusions of the statements published by the AAP and the American Journal of Cardiology in 2009 and the U.S. Preventive Services Task Force in 2008.
While current research does not yet provide evidence of a causal relationship between the two diseases, scientists have identified biologic factors, such as chronic inflammation, that independently link periodontal disease to the development or progression of cardiovascular disease in some patients.
The lack of causal evidence should not diminish concern about the impact of periodontal status on cardiovascular health. According to Pamela McClain, DDS, president of the American Academy of Periodontology and a practicing periodontist in Aurora, Colorado, “Periodontal disease and cardiovascular disease are both complex, multi-factorial diseases that develop over time. It may be overly simplistic to expect a direct causal link. The relationship between the diseases is more likely to be mediated by numerous other factors, mechanisms, and circumstances that we have yet to uncover. However, as the AHA statement points out, the association is real and independent of shared risk factors. Patients and healthcare providers should not ignore the increased risk of heart disease associated with gum disease just because we do not have all the answers yet.”
The AAP believes additional long-term interventional studies are needed to better understand the specific nature of the relationship between periodontal disease and cardiovascular disease. Patients’ periodontal status should also be added to future longitudinal studies of cardiovascular disease. The AAP hopes that the American Heart Association’s statement brings attention to the association between the two diseases and the need for additional research in this area.
Dr. McClain encourages physicians and dentists to communicate the association between cardiovascular disease and periodontal disease to patients. “It is not as simple as telling a patient that brushing and flossing will ward off a heart attack,” says Dr. McClain. “Patients should be aware that by maintaining periodontal health, they are helping to reduce harmful inflammation in the body, which has been shown to reduce the risk of cardiovascular disease.”
Patients should expect to receive a comprehensive periodontal evaluation from their dental professional at least once a year, adds Dr. McClain. This includes a detailed examination of the teeth and gums, and an assessment of risk factors such as smoking, age, and overall health status. In addition, patients diagnosed with periodontal disease should be sure to inform their general health care provider and/or cardiologist to encourage better integration of their care.
“There is no compelling evidence to support that treating periodontal disease will reduce cardiovascular disease at this time,” says Dr. McClain, “but we do know that periodontal care will improve your oral health status, reduce systemic inflammation, and might be good for your heart as well.”
Studies have shown that smoking can impair the body’s ability to heal itself immediately after surgery; but, this most recent study also showed that when a patient has periodontal plastic surgery, smoking can damage the ability of that procedure to stay intact over a long period of time.
“People who smoke and have had some sort of periodontal plastic surgery should be aware of the negative side effects of smoking. It can be costly to have to repeat a surgery because the desirable outcomes might have been undone by smoking,” explained Dr. Preston D. Miller, DDS, and AAP president. “Therefore, it is important patients and doctors agree to a smoking cessation program prior to any periodontal surgery. This will help a patient’s chance of achieving optimal results.”
A recent study by Sharma and Shamsuddin published in the January 2011 issue of the Journal of Periodontology suggests a possible link between upper respiratory diseases—including pneumonia, acute bronchitis, and chronic obstructive pulmonary disease (COPD)—and periodontal disease. Typically occurring when bacteria are inhaled into the lungs, the bacteria that cause periodontal disease also can be inhaled into the respiratory tract and increase the risk of infection.
The study examined 200 people, 100 who had been hospitalized with a respiratory infection and 100 who were healthy. The study results demonstrated that those who were part of the healthy group had better periodontal health, while the periodontal health of those with respiratory illnesses was worse.
Several studies have suggested a link between periodontal disease and other inflammatory diseases, such as cardiovascular disease and diabetes. However, there is not a lot known about how periodontal disease can impact respiratory health. Considering that respiratory infections, including chronic obstructive pulmonary disease (COPD) and pneumonia, can be severely debilitating and are a major cause of death in the United States, research into how periodontal health and respiratory health are potentially connected is imperative.
The significance of this research study is that it provides further evidence of the perio-systemic link by demonstrating that the incidence of pathogens in the periodontium may play a role in the progression of non-oral disease. These findings suggest that the presence of bacteria associated with periodontal disease, such as Porphyromonas gingivalis, may increase a patient’s risk of developing or exacerbating respiratory infections. The occurrence of these oral pathogens, and the resulting supragingival plaque accumulation, periodontal pockets, and—I would argue—the inflammatory response diminishes the host defense, thereby increasing subjects’ risk for developing a respiratory infection.
Poor periodontal health, therefore, may be viewed as a risk factor for respiratory disease. But as the researchers note, other factors may come into play as well. Additional research is needed in this area to better understand how periodontal disease and respiratory disease are related.
This study places a lot of emphasis on the role of bacterial pathogens in the progression of both periodontal disease and respiratory disease. While the presence of bacteria is a determinant of disease, it is often the inflammatory response to bacteria that is essential in the initiation and progression of disease states.
Individuals may be genetically predetermined to respond differently to a challenge, such as bacteria, and therefore their level of disease may be different. It seems that while an in-depth discussion of inflammation was missing in this study, there was speculation that periodontal pathogens not only are responsible for respiratory tract infection, but also that these pathogens may affect the local defense mechanisms of the region to increase these patients’ risk for respiratory disease.
Both periodontal disease and respiratory disease are often classified as inflammatory conditions, so it may be possible that inflammation may be a factor in the link between the two. Obviously, more research is required to illustrate this and better understand if and how the inflammatory response to periodontal bacteria leads to the development or aggravation of respiratory infections.
Periodontal disease is a chronic, inflammatory disease that can impact overall health, and therefore, we must treat our patients accordingly. This means conducting a comprehensive periodontal evaluation on an annual basis to ensure that periodontal disease is caught early and an appropriate treatment plan can be established. The dental team must work together to ensure that each patient receives a yearly comprehensive examination, including intraoral, extraoral, and occlusal evaluations; a thorough assessment of plaque, calculus, and gingival inflammation; probing of at least six sites per tooth; assessment and documentation of recession and attachment loss around teeth; radiographic evaluation of bone loss; and an assessment of patient-associated risk factors such as age, smoking, and the presence of other chronic, systemic conditions associated with systemic inflammatory burden.
Newswise — Sex hormones may be the biological reason why men are at greater risk than women for destructive periodontitis, an infection of the gums, according to researchers at the University of Maryland Dental School.
To establish better management and risk assessment models for periodontal disease, Harlan Shiau, DDS, DMedSc, assistant professor, and Mark Reynolds, DDS, PhD, MA, professor at the Dental School, have published the first comprehensive review of gender differences in the development and progression of the destructive periodontal disease.
In a review paper in the Journal of Periodontology, the authors examine evidence for a biologic basis for a sexual dimorphism, or the differences in susceptibility, to periodontal disease between men and women. They conclude that sex steroids exert effects on multiple ways on the immune system regulation of inflammation. They also conclude that the root of the difference may be genetic.
“Differential gene regulation, particularly in sex steroid-responsive genes, could likely play a part in the observed sexual dimorphism of destructive periodontal disease,” said Shiau.
“Differential gene regulation, particularly in sex steroid-responsive genes, could likely play a part in the observed sexual dimorphism of destructive periodontal disease,” said Shiau.
“We think it is a plausible explanation,” he added. The observation of men “having worse gum disease than women” was generally accepted by dental clinicians previously, says Shiau, “but we wondered if the traditional explanations were adequate. This study provides health care professionals with important comparative data for estimating gender-related differences in risk for destructive periodontal disease.”
Prior to the current review paper, the researchers conducted a systematic review of published population studies on the prevalence of periodontal disease. In their analysis they established that men, indeed, have a greater prevalence of periodontal disease than women globally.
Shiau and Reynolds explored potential biologic explanations by drawing from the extensive body of literature in autoimmune disease research, where there also exists sexual dimorphism in disease prevalence.
“Also, we considered the competing hypothesis that the environment explains the dimorphism, such as the observation that men have worse oral hygiene and compliance than women. However, there exist population studies, which control for potential co-variants, like these, and have still yielded significant gender effects.” Shiau explains.
“The innate immune response plays a considerable role in the pathogenesis of periodontal disease. The literature seems to indicate that a heightened innate immune response in men compared to women, as well as potential differences in regulation of amplification and termination of inflammation, provide a sound biologic basis for sex differences in periodontal disease progression,” says Shiau.
A smile is one of the most universally recognizable facial expressions, helping to depict an individual’s happiness, confidence, attractiveness, sociability and sincerity. According to a study published in the Journal of Periodontology (JOP), the official publication of the American Academy of Periodontology (AAP), a smile may also help convey healthy teeth and gums. Researchers found evidence that periodontal, or gum, disease may negatively affect an individual’s smiling patterns and deter someone from displaying positive emotions through a smile.
The study, conducted at the University of Michigan, evaluated the smiling patterns of 21 periodontal patients while viewing a segment of a comedy program. At predetermined measurement points throughout the segment, the researchers assessed three dimensions of each patient’s smile: the horizontal width of the mouth in millimeters, the open width of the mouth in millimeters, and the number of teeth shown. In addition, the researchers also noted the number of times the patient covered his or her mouth while watching the segment. Individual perceptions of how the patient’s quality of life is affected by oral health were also considered. The data were then evaluated along with a clinical exam of the patient’s periodontal health.
“Since periodontal disease is prevalent in such a large number of adults, we sought to investigate if the disease affects a person’s smiling behavior,” said study author Dr. Marita R. Inglehart. “Smiling plays a significant and essential role in overall well-being. Previous findings suggest that smiling can affect social interactions, self-confidence and can influence how people perceive one another.”
The study findings indicated that periodontal disease can certainly impact how a person smiles. The more symptoms of gum disease found in a patient’s mouth, such as periodontal pockets between four to six millimeters deep or loose, moving teeth, the more likely the patient was to cover his or her mouth when smiling or to limit how widely the mouth opened during the smile. In addition, the more gum recession seen in the patient, the fewer teeth he or she showed when smiling. The way patients perceived their quality of life as a result of their oral health was also significantly correlated with the number of teeth affected by periodontal disease.
“It is already widely known that periodontal disease is connected to systemic health,” said Dr. Susan Karabin, DDS, President of the AAP. “These results help demonstrate that periodontal disease may affect more than just overall health. It can also impact actual quality of life, making caring for one’s teeth and gums all the more important.”
Stress may play a role in the development of periodontal diseases.
A literature review published in the August 2007 issue of the Journal of Periodontology (JOP) saw a strong relationship between stress and periodontal diseases; 57% of the studies included in the review showed a positive relationship between periodontal diseases and psychological factors such as stress, distress, anxiety, depression and loneliness.
“More research is needed to determine the definitive relationship between stress and periodontal diseases” said study author Daiane Peruzzo, PhD. “However, patients who minimize stress may be at less risk for periodontal disease.”
Researchers speculate that the hormone cortisol may play a role in the possible connection between stress and periodontal diseases. A study in the July issue of the JOP found that increased levels of cortisol can lead to more destruction of the gums and bone due to periodontal diseases. It is well known that periodontal diseases left untreated can ultimately lead to bone loss or tooth loss.
“Individuals with high stress levels tend to increase their bad habits, which can be harmful to periodontal health. They are less attentive to their oral hygiene and may increase their use of nicotine, alcohol or drugs,” explained Preston D. Miller, DDS and AAP president. “Patients should seek healthy ways to relieve stress through exercise, balanced eating, plenty of sleep and maintaining a positive mental attitude.”
Patients should to also keep in mind their “pocket size guide” to periodontal health; periodontal probing depths of one to two millimeters with no bleeding are not a concern but probing depths of three and four millimeters may need a more in depth cleaning called scaling and root planing. Probing depths in excess of 5mm may require more advanced treatment and patients should talk to their dental specialist.
Two studies in the June 2007 issue of the Journal of Periodontology (JOP) suggest that periodontal diseases are a threat to women of all ages due to hormonal fluctuations that occur at various stages of their lives.
One study looked at 50 women who were between the ages of 20 to 35 with varying forms of periodontitis. The study found that women who currently were taking oral contraceptive pills had more gingival bleeding upon probing and deeper periodontal pockets (signs of periodontitis) than those who were not taking oral contraceptive pills.
“Younger women often think that periodontal disease is a condition associated with old age,” explained study author Brian Mullally, PhD. “Our study shows that it is very possible for younger women to experience periodontal disease. It is important for women to alert their dental practitioners about any medications they are taking, such as oral contraceptive pills, because it is possible that their oral health may be affected. It might also be prudent where possible for young women to ensure that their periodontal health has been checked before commencing oral contraceptive therapy.”
Another study in this month’s issue of the JOP examined 1,256 postmenopausal women and looked for a potential association between periodontal bacteria and bone loss in the oral cavity. The study results showed that women with periodontal bacteria in their mouths were also more likely to have bone loss in the oral cavity, which can lead to tooth loss if not treated.
“Our study’s findings are important for postmenopausal women because they suggest that good periodontal health is extremely important in the postmenopausal years,” said study author Renee Brennan, PhD. “We found that oral bone loss was associated with presence of oral bacteria. In fact, 62% of the women in our study had at least one species of subgingival bacteria present, and the women with these bacteria had more evidence of oral bone loss. Interestingly, women who had a Body Mass Index in the overweight range were much more likely to have oral bone loss associated with presence of oral bacteria. Oral bone loss has been associated with osteoporosis in this group as well. This association has been difficult to study because many risk factors for periodontal disease and osteoporosis—including smoking, age, medications, and overall general health—are similar. It should be noted that our study was limited in that it included a relatively healthy group of mostly Caucasian women and that future studies are needed to determine the effects of periodontal bacteria on bone loss in other groups of postmenopausal women.”
“Taking care of your teeth and gums is a lifelong commitment,” explained Preston D. Miller, DDS and AAP president. “Women should pay special attention to their oral health as they enter different stages of their lives because additional periodontal care may be needed during different points such as the reproductive years or menopause. Knowing your ‘pocket size’ depth can be a good way for women to keep track of their periodontal health; periodontal pockets of one to two millimeters with no bleeding are not a concern but pockets of three and four millimeters may need a more in depth cleaning called scaling and root planing.”
Maintaining periodontal health may contribute to a healthy respiratory system, according to research published in the Journal of Periodontology. A new study suggests that periodontal disease may increase the risk for respiratory infections, such as chronic obstructive pulmonary disease (COPD) and pneumonia. These infections, which are caused when bacteria from the upper throat are inhaled into the lower respiratory tract, can be severely debilitating and are one of the leading causes of death in the U.S.
The study included 200 participants between the ages of 20 and 60 with at least 20 natural teeth. Half of the participants were hospitalized patients with a respiratory disease such as pneumonia, COPD, or acute bronchitis, and the other half were healthy control subjects with no history of respiratory disease. Each participant underwent a comprehensive oral evaluation to measure periodontal health status.
The study found that patients with respiratory diseases had worse periodontal health than the control group, suggesting a relationship between respiratory disease and periodontal disease. Researchers suspect that the presence of oral pathogens associated with periodontal disease may increase a patient’s risk of developing or exacerbating respiratory disease. However, the study authors note that additional studies are needed to more conclusively understand this link.
“Pulmonary diseases can be severely disabling and debilitating,” says Donald S. Clem, DDS, President of the American Academy of Periodontology. “By working with your dentist or periodontist, you may actually be able to prevent or diminish the progression of harmful diseases such as pneumonia or COPD. This study provides yet another example of how periodontal health plays a role in keeping other systems of the body healthy.”
Periodontal disease is a chronic inflammatory disease that affects the gum tissue and other structures supporting the teeth. Previous research has associated gum disease with other chronic inflammatory diseases such as diabetes, cardiovascular disease, and rheumatoid arthritis.
Dr. Clem stressed the importance of routine oral care in helping to prevent periodontal disease. “Taking good care of your periodontal health involves daily tooth brushing and flossing. You should also expect to get a comprehensive periodontal evaluation every year,” he advised. A dental professional, such as a periodontist, a specialist in the diagnosis, treatment and prevention of gum disease, can conduct a comprehensive exam to assess your periodontal disease status.
According to the National Kidney Foundation, one out of nine Americans suffers from chronic kidney disease (CKD), and millions more are at risk. A debilitating disease, CKD can affect blood pressure and bone health, and can eventually lead to heart disease or kidney failure. A study published in the Journal of Periodontology (JOP), the official publication of the American Academy of Periodontology (AAP), suggests that edentulous, or toothless, adults may be more likely to have CKD than dentate adults. In the study, conducted at Case Western Reserve University, endentulism was found to be significantly associated with CKD, indicating that oral care may play a role in reducing the prevalence of chronic kidney disease in the U.S. population.
The study examined the kidney function and periodontal health indicators, including dentate status, of 4,053 U.S. adults 40 years of age and older. After adjusting for recognized risk factors of CKD such as age, race/ethnicity and smoking status, the results revealed that participants who lost all their teeth were more likely to have CKD than patients who had maintained their natural dentition.
“The rationale for examining edentulous adults in this study is to observe the long-term effects of periodontal disease on the presence of chronic kidney disease,” states study author Monica Fisher, PhD, DDS, MPH. “Periodontal disease is a leading cause of tooth loss in adults; therefore endentulism is considered to be a marker of past periodontal disease in the study’s participants.”
While additional research is needed to fully understand why tooth loss is associated with higher prevalence of CKD, the destructive nature of chronic inflammation may play a role. Both periodontal disease and chronic kidney disease are considered inflammatory conditions, and previous research has suggested that inflammation may be the common link between these diseases. Since untreated periodontal disease can ultimately lead to tooth loss, edentulous patients may have been exposed to chronic oral inflammation.
According to David Cochran, DDS, President of the American Academy of Periodontology and Professor and Chair of the Department of Periodontics at the University of Texas Health Science Center at San Antonio, treating periodontal disease can do a lot more than save your natural teeth. “Researchers have long known that gum disease is related to other adverse health conditions, and now we can consider chronic kidney disease to be one of them. It is exciting to think that by controlling periodontal disease and therefore helping to preserve natural dentition, the incidence and progression of CKD may be reduced.”
Periodontists, the dentists specially trained in the prevention, diagnosis and treatment of gum disease, recommend regular brushing and flossing and routine visits to a dental professional in order to maintain comprehensive oral health. If gum disease develops, consulting a periodontist is an effective way to determine the most appropriate course of treatment.
Melatonin could be the latest supplement to join the fight against periodontal diseases. According to a literature review in the June 2007 issue of the Journal of Periodontology, melatonin may promote bone formation and stimulate the body’s immune response, which are two factors that can affect a person’s periodontal health.
Since its discovery in 1917, melatonin has been found to be involved in many biological functions such as setting the body’s sleep rhythms and fighting off free radicals that may lead to cancer and other autoimmune diseases. The authors of this study conducted an extensive review of the literature (e.g., PubMed, Science Direct, Web of Knowledge, etc.) to evaluate the potential effects of melatonin on the oral cavity, including: melatonin as an antioxidant and free radical scavenger; melatonin as a host modulation agent; melatonin as a promoter of bone formation; and melatonin and periodontal disease. This review found strong evidence that melatonin may play a key role in periodontal health by helping to maintain bone levels in the oral cavity through suppressing the cells that work during bone resorption, and enhancing the body’s host response to the periodontal bacteria. One of the most devastating effects of periodontal disease is bone loss in the jaw which often leads to tooth loss.
“Although the review did not directly look at melatonin as a treatment option for periodontal diseases, this is an area that might be worth investigating in the future,” said review author Antonio Cutando, DDS. “Melatonin has important physiological functions that have not yet been explored in dentistry or in the treatment of periodontal diseases.”
Melatonin also has strong antioxidant and anti-inflammatory effects that help to improve the body’s immune response to infection. Recent studies have shown that salivary melatonin levels may actually vary according to the degree of periodontal disease, indicating that melatonin may act to protect the body from periodontal bacteria and inflammation.
“While natural supplements such as vitamin D, calcium, and vitamins E and C have been shown to have possible effects on periodontal diseases patients should be aware that supplements alone are not a substitute for periodontal care,” explained Preston D. Miller, DDS, and AAP president. “Patients should make an effort to know their pocket probing depths, which are the key to understanding their periodontal disease. A healthy probing depth of one to two millimeters with no bleeding represents a healthy mouth. Probing depths of three to four, that bleed, generally need more than a simple cleaning- they may require a procedure called scaling and root planing. When probing depths reach five millimeters or greater the patient has reached a level which may require surgical treatment to restore lost bone. Patients should keep this pocket size guide to their oral health in mind and should not hesitate to ask their dental professionals about their probing depths if this information is not volunteered.”