Dentistry’s New Role in Cardiovascular Health
Evidence indicates periodontal disease harms more than teeth and gingiva
Scott Trettenero, DDS; Arthur Molzan, DDS; and Thomas Roberts, DDS, PA
It has long been known that periodontal disease is a scourge on humanity. It is the number one reason that people lose their teeth, and tooth loss has many negative effects on quality of life. According to one study's estimate, 47.2% of US adults (ie, 64.7 million people) have some level of periodontitis. Furthermore, the study found that among adults aged 65 and older, the rate of prevalence increased to 70.1 percent.1 These statistics are obviously unacceptable to dental professionals who struggle to motivate patients to take care of their oral health; however, new information is becoming available that will greatly help in getting these patients to follow through with recommendations.
Periodontal Disease Causes Cardiovascular Disease
A recently published, peer-reviewed study has indicated that periodontal disease is causing much more damage to people's overall health than previously realized.2 The study revealed that certain types of bacteria that are known causes of periodontal disease have also been proven to be major causes of cardiovascular disease (CVD)-the leading killer of men and women, globally. Its conclusion has potentially life-saving implications, stating that dentistry has a key role in the prevention of heart attacks and strokes.
According to the study's results, the adverse cardiovascular effects from periodontal disease can be linked to a few high-risk pathogenic bacteria: Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and/or Fusobacterium nucleatum. These specific bacteria, which are known to be the most pathogenic in the breakdown of the periodontium, have been shown to move from the oral environment into the general circulation, causing inflammation of the arteries.
The researchers were able to determine that these bacteria also independently cause heart attacks and strokes. To be considered causal for CVD, it had to be demonstrated that these bacteria had an effect on three accepted essential elements in the pathogenesis of atherosclerosis: lipoprotein serum concentration, endothelial permeability, and the binding of lipoproteins in the arterial intima.
There is conclusive scientific evidence that the high-risk pathogens that cause periodontal disease can influence these three elements in an adverse manner. Thus, it is reasonable to state that periodontal disease caused by high-risk pathogens is also a contributory cause of atherosclerosis. Dentists who recognize that periodontal disease is causal for CVD and treat it appropriately will be providing a significant service to reduce the burden of arterial disease.
"Periodontal disease is now considered a medical disease," says Marc Penn, MD, PhD, a former director of the cardiac ICU at the Cleveland Clinic, Cleveland, Ohio. However, periodontal disease is a medical problem with a dental solution.3
How Oral Bacteria Cause Systemic Inflammation
Bacteremia with germs from the oral cavity has been well documented since 1954. The landmark study indicated that the systemic spread of oral microbes throughout the body occurs quickly and frequently.4 This results in inflammation (ie, acute and chronic), which is currently being recognized as a major player in many diseases. The largest cause of oral inflammation is the presence of pathogenic bacteria, and oral inflammation has been shown to be a major source of systemic inflammation.
Bacteria enter systemic circulation directly, and they also produce endotoxins such as lipopolysaccharides. These endotoxins generate inflammatory cytokines, upregulate endothelial adhesion molecules, and enhance the formation of blood clots-actions that can favor the development of arterial disease and ultimately result in a heart attack or stroke. Oral pathogens have been shown to be frequently associated with the formation of blood clots that result from atherosclerosis.5
According to a report by ScienceDaily, research has shown that periodontal therapy with antimicrobial protocols can be beneficial in slowing the progression of CVD.6 Dentistry's impact on heart health appears to be as significant as the management of traditional cardiovascular risk markers such as cholesterol and body mass index.
The Necessity of Antimicrobial Therapy
Periodontal disease and the potential, resultant risk of CVD needs to be treated by defining and targeting the pathogenic bacteria. The only way to successfully reduce inflammation is to effectively address the microbial aspect of the disease. In the interest of developing more effective periodontal therapies, dentistry could consider adopting some of the "medical model" for treating and evaluating infections as an adjunct to present-day therapies. The current therapies in dentistry are mainly concerned with the improvement of anatomical measurements and essentially ignore the microbial influence of disease.
Unfortunately, nonantimicrobial periodontal therapies have been shown to be inadequate in the elimination of these pathogenic bacteria. With traditional mechanical therapy (ie, scaling and root planing), the oral biofilm and microbial loads return to their pretreatment levels in just 3 to 7 days.7 It has become apparent that the appropriate management of these pathogens requires additional actions, including the provision of antimicrobial therapy.
Fortunately, there are technologies available to help dentists properly diagnose and monitor the bacterial levels present in their patients' mouths. There are only about a dozen bacteria known to elicit the inflammatory response that is directly responsible for periodontal breakdown, and of these specific pathogens, five have been shown to independently cause CVD. A simple culture or bacterial DNA test can easily be performed to pin down the etiologic agent(s) involved in each case. Several diagnostic tests are commercially available, and point-of-care tests are currently under development.
Knowledge of the exact organisms can then guide the selection of therapeutic modalities. The final element in the medical model-monitoring of treatment results-simply involves posttreatment retesting for the presence of the etiologic agent(s). Therapeutic success is achieved when the initial therapy or subsequent therapies result in full eradication of the etiologic agent(s) or their reduction to levels below established thresholds of risk.
Conclusion
The concept that periodontal disease possesses a causal status in its relationship with CVD is now rapidly gaining acceptance. Dentists have a new and elevated responsibility to motivate their patients to take care of their periodontal issues. It is no longer just the oral environment that is at risk from these deadly bacteria, and patients who understand their risks may be more likely to accept treatment. Medical doctors will be looking to dentistry to provide this piece of the CVD solution. This will involve treating the 50% to 60% of their patients who have periodontal disease and are at risk for heart attacks and strokes. What if standard of care guidelines changed tomorrow, and physicians were required to address periodontal disease as causal for CVD? Is dentistry ready to adequately answer their calls?
References
1. Eke PI, Dye BA, Wei L. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
2. Bale B, Doneen A, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2017;93:215-220.
3. Bale B, Doneen A. Beat the Heart Attack Gene. New York, NY: Turner Publishing; 2014.
4. COBE HM. Transitory bacteremia. Oral Surg Oral Med Oral Pathol. 1954;7(6):609-615.
5. Pessi T, Karthunen V, Karjalainen PP, et al. Bacterial signatures in thrombosis aspirates with myocardial infarction. Circulation. 2013;127(11):1219-1228.
6. Petersilka GJ, Ehmke B, Flemmig TF. Antimicrobial effects of mechanical debridement. Periodontol 2000. 2002;28:56-71.
7. University of Sydney. Treating gum disease improves vascular health in Indigenous Australians: study. ScienceDaily Website. https://www.sciencedaily.com/releases/2014/06/140626101710.htm. Published June 26, 2014. Accessed August 16, 2018.
