Looking for the future today

The Complexity of Oral The Complexity of Oral Health and Its Systemic ImpactHealth and Its Systemic Impact

The Complexity of Oral The Complexity of Oral Health and Its Systemic ImpactHealth and Its Systemic Impact

National Health Care for the Homeless CouncilNational Health Care for the Homeless Council

Friday, June 13, 2008Friday, June 13, 2008

Wayne W. Cottam DMD, MSAssociate Dean for Community PartnershipsArizona School of Dentistry & Oral Health

Mesa, [email protected]

Wayne W. Cottam DMD, MSAssociate Dean for Community PartnershipsArizona School of Dentistry & Oral Health

Mesa, [email protected]

Michael Glick, D.M.D.Professor of Oral Medicine

Arizona School of Dentistry & Oral HealthAssociate Dean for Oral-Medical SciencesCollege of Osteopathic Medicine – Mesa

Mesa, AZ

Michael Glick, D.M.D.Professor of Oral Medicine

Arizona School of Dentistry & Oral HealthAssociate Dean for Oral-Medical SciencesCollege of Osteopathic Medicine – Mesa

Mesa, AZ

Roger W. Cooper DDS, PhDRoger W. Cooper DDS, PhDDirector: PeriodonticsDirector: Periodontics

Arizona School of Dentistry & Oral Arizona School of Dentistry & Oral HealthHealth

Roger W. Cooper DDS, PhDRoger W. Cooper DDS, PhDDirector: PeriodonticsDirector: Periodontics

Arizona School of Dentistry & Oral Arizona School of Dentistry & Oral HealthHealth

Most of the slides and information for this presentation was developed and is being used with permission by:

What we know for sure:What we know for sure:

1.1.

2. 2.

3. 3.

4.4.

5. 5.

What we know for sure:What we know for sure:

1.1.

2. 2.

3. 3.

4.4.

5. 5.

The Oral-Systemic ConnectionThe Oral-Systemic ConnectionThe Oral-Systemic ConnectionThe Oral-Systemic Connection

Oral Health in America: A Report of the Surgeon General - DHHS 2000 Oral Health in America: A Report of the Surgeon General - DHHS 2000

What we are pretty sure we know for sure:What we are pretty sure we know for sure:

Oral health is essential to the general health and Oral health is essential to the general health and well-being of all Americans and can be achieved.well-being of all Americans and can be achieved.

Oral diseases and disorders affect health and Oral diseases and disorders affect health and well-being throughout life.well-being throughout life.

There IS a connectionThere IS a connection

What we are pretty sure we know for sure:What we are pretty sure we know for sure:

Oral health is essential to the general health and Oral health is essential to the general health and well-being of all Americans and can be achieved.well-being of all Americans and can be achieved.

Oral diseases and disorders affect health and Oral diseases and disorders affect health and well-being throughout life.well-being throughout life.

There IS a connectionThere IS a connection


CASUALCASUAL

Oral Health and Systemic Health – Oral Health and Systemic Health – what type of an association?what type of an association?


““But let us inquire what are the But let us inquire what are the causes of these things which causes of these things which

happened to them.”happened to them.”

Hippocrates



““But let us inquire what are the But let us inquire what are the causes of these things which causes of these things which

happened to them.”happened to them.”

Hippocrates

CAUSALCAUSAL

Recent Research into Oral Recent Research into Oral Disease and Systemic HealthDisease and Systemic HealthRecent Research into Oral Recent Research into Oral

Disease and Systemic HealthDisease and Systemic Health

• Renal diseaseRenal disease

• COPDCOPD

• Lung cancerLung cancer

• Pancreatic cancerPancreatic cancer

• Diabetes mellitusDiabetes mellitus

• Renal diseaseRenal disease

• COPDCOPD

• Lung cancerLung cancer

• Pancreatic cancerPancreatic cancer

• Diabetes mellitusDiabetes mellitus

• PVDPVD

• StrokeStroke

• CHDCHD

• Pre-eclampsiaPre-eclampsia

• Pre-term and low Pre-term and low birth weightbirth weight

• PVDPVD

• StrokeStroke

• CHDCHD

• Pre-eclampsiaPre-eclampsia

• Pre-term and low Pre-term and low birth weightbirth weight

Oral infections may cause or Oral infections may cause or exacerbate systemic illness.exacerbate systemic illness.

BUT HOW??BUT HOW??

Oral infections may cause or Oral infections may cause or exacerbate systemic illness.exacerbate systemic illness.

BUT HOW??BUT HOW??


The Focal Infection TheoryThe Focal Infection TheoryThe Focal Infection TheoryThe Focal Infection Theory

““A focal infection is a localized or general A focal infection is a localized or general

infection caused by the dissemination of infection caused by the dissemination of

microorganisms or toxic products from a microorganisms or toxic products from a

focus of infection.”focus of infection.”

““A focal infection is a localized or general A focal infection is a localized or general

infection caused by the dissemination of infection caused by the dissemination of

microorganisms or toxic products from a microorganisms or toxic products from a

focus of infection.”focus of infection.”

Pallasch and Wahl. CDA 2000;28:194Pallasch and Wahl. CDA 2000;28:194

The Focal Infection TheoryThe Focal Infection TheoryThe Focal Infection TheoryThe Focal Infection Theory

• HippocratesHippocrates - cure of arthritis by tooth removal - cure of arthritis by tooth removal

• Charles H. Mayo (1914)Charles H. Mayo (1914) – – Mouth infection as a Mouth infection as a source of systemic disease.source of systemic disease.JAMA 1914;63:2025-6JAMA 1914;63:2025-6

• R.L. Cecile and D.M. Angevine (1938)R.L. Cecile and D.M. Angevine (1938) - “focal - “focal infection is a splendid example of a plausible infection is a splendid example of a plausible medical theory which is in danger of being medical theory which is in danger of being converted by its enthusiastic supporters into the converted by its enthusiastic supporters into the status of an accepted fact”status of an accepted fact”

• HippocratesHippocrates - cure of arthritis by tooth removal - cure of arthritis by tooth removal

• Charles H. Mayo (1914)Charles H. Mayo (1914) – – Mouth infection as a Mouth infection as a source of systemic disease.source of systemic disease.JAMA 1914;63:2025-6JAMA 1914;63:2025-6

• R.L. Cecile and D.M. Angevine (1938)R.L. Cecile and D.M. Angevine (1938) - “focal - “focal infection is a splendid example of a plausible infection is a splendid example of a plausible medical theory which is in danger of being medical theory which is in danger of being converted by its enthusiastic supporters into the converted by its enthusiastic supporters into the status of an accepted fact”status of an accepted fact”

Focal Infection TheoryFocal Infection TheoryFocal Infection TheoryFocal Infection TheoryAcute rheum.Acute rheum.AnemiaAnemiaAnginaAnginaAppendicitis Appendicitis ArrhythmiasArrhythmiasArthritisArthritisAsthmaAsthmaBrain abscessBrain abscessCardiac Cardiac insufficiencyinsufficiency

CholecystitisCholecystitisChoreaChorea

Acute rheum.Acute rheum.AnemiaAnemiaAnginaAnginaAppendicitis Appendicitis ArrhythmiasArrhythmiasArthritisArthritisAsthmaAsthmaBrain abscessBrain abscessCardiac Cardiac insufficiencyinsufficiency


ColitisColitisDuodenal ulcersDuodenal ulcersDiabetes Diabetes EndocarditisEndocarditisEmphysemaEmphysemaGoiterGoiterGastric ulcersGastric ulcersHerpes zosterHerpes zosterHodgkin diseaseHodgkin diseaseHypertensionHypertensionIndigestionIndigestionInsomniaInsomnia


MelancholiaMelancholiaMyocarditisMyocarditisMyositis Myositis NephritisNephritisNervous Nervous disordersdisorders

NeuritisNeuritisObscure feverObscure feverOsteomyelitisOsteomyelitisPancreatitisPancreatitisParesthesiaParesthesiaPhobiasPhobias



PneumoniaPneumoniaPolioPolioPsychosisPsychosisSepticemiaSepticemiaSkin abscessSkin abscessSpinal Spinal myelitismyelitis

StupidityStupidityThyroiditisThyroiditisVisceral Visceral degenerationdegeneration



Focal Infection TheoryFocal Infection TheoryFocal Infection TheoryFocal Infection TheoryAcute rheum.Acute rheum.AnemiaAnemiaAnginaAnginaAppendicitis Appendicitis ArrhythmiasArrhythmiasArthritisArthritisAsthmaAsthmaBrain abscessBrain abscessCardiac Cardiac insufficiencyinsufficiency


Acute rheum.Acute rheum.AnemiaAnemiaAnginaAnginaAppendicitis Appendicitis ArrhythmiasArrhythmiasArthritisArthritisAsthmaAsthmaBrain abscessBrain abscessCardiac Cardiac insufficiencyinsufficiency












Current research focuses on Periodontal Current research focuses on Periodontal Disease (Gum Disease).Disease (Gum Disease).

A bacterially induced chronic inflammatory disease that A bacterially induced chronic inflammatory disease that breaks down tissue and bone.breaks down tissue and bone.

Inflammatory mediators, bacterial lipopolysaccharides Inflammatory mediators, bacterial lipopolysaccharides and other toxins are introduced systemically.and other toxins are introduced systemically.

Some mediators stimulate the liver to produce acute phase Some mediators stimulate the liver to produce acute phase proteins such as C-reacctive protein and others.proteins such as C-reacctive protein and others.

These toxins and mediators contribute to a systemic These toxins and mediators contribute to a systemic chronic inflammatory state that MAY contribute to other chronic inflammatory state that MAY contribute to other inflammation related diseases including diabetes, CV inflammation related diseases including diabetes, CV disease disease and others.and others.

Current research focuses on Periodontal Current research focuses on Periodontal Disease (Gum Disease).Disease (Gum Disease).

A bacterially induced chronic inflammatory disease that A bacterially induced chronic inflammatory disease that breaks down tissue and bone.breaks down tissue and bone.

Inflammatory mediators, bacterial lipopolysaccharides Inflammatory mediators, bacterial lipopolysaccharides and other toxins are introduced systemically.and other toxins are introduced systemically.

Some mediators stimulate the liver to produce acute phase Some mediators stimulate the liver to produce acute phase proteins such as C-reacctive protein and others.proteins such as C-reacctive protein and others.

These toxins and mediators contribute to a systemic These toxins and mediators contribute to a systemic chronic inflammatory state that MAY contribute to other chronic inflammatory state that MAY contribute to other inflammation related diseases including diabetes, CV inflammation related diseases including diabetes, CV disease disease and others.and others.


Possible Model for Relationship Between Possible Model for Relationship Between Periodontal Inflammation, Periodontal Inflammation,

Atherosclerosis, Cardiovascular and Other Atherosclerosis, Cardiovascular and Other Systemic DiseaseSystemic Disease



Periodontal Inflammation


Inflammatory MediatorsIL-1, IL-6, TNF-, PGE2







LiverC-Reactive ProteinSerum Amyloid A

Fibrinogen







Liver

C-Reactive ProteinSerum Amyloid A

Fibrinogen

AtherosclerosisCardiovascular DiseaseOther Systemic Disease





Bacteremia



Microbes& LPS


Fibrinogen






Bacteremia



Microbes& LPS


Fibrinogen






Bacteremia



Microbes& LPS


Fibrinogen

Bacterial induced platelet aggregation

& endothelial invasionAtherosclerosis

Cardiovascular DiseaseOther Systemic Disease





Bacteremia



Immune Response

Microbes& LPS Microbes


Fibrinogen


& endothelial invasionAtherosclerosis

Cardiovascular DiseaseOther Systemic Disease





Bacteremia



Immune Response

Microbes& LPS

Microbes

Liver



Fibrinogen

Antibodies to bacteria & cross-reactive antigens, e.g., heat-shock protein.


& endothelial invasion





Its all about inflammation and

bacteria!

Surface Area of Diseased & Ulcerated Pocket Surface Area of Diseased & Ulcerated Pocket EpitheliumEpithelium

(Assumption: 6 mm circumferential pockets involving 28 (Assumption: 6 mm circumferential pockets involving 28 teeth)teeth)

Surface Area of Diseased & Ulcerated Pocket Surface Area of Diseased & Ulcerated Pocket EpitheliumEpithelium

(Assumption: 6 mm circumferential pockets involving 28 (Assumption: 6 mm circumferential pockets involving 28 teeth)teeth)

Periodontitis: The Paradox of Periodontitis: The Paradox of InflammationInflammation

Periodontitis: The Paradox of Periodontitis: The Paradox of InflammationInflammation

EGFFGFVGF

PDGFTGF-TGF-

WoundHealin

g

NeutrophilsMonocytesMacrophagesCD4 and CD8 cells Mast CellsEndotheliumFibroblasts

NeutrophilsMonocytesMacrophagesCD4 and CD8 cells Mast CellsEndotheliumFibroblasts

IL-1

IL-6

IL-8

TNF-PGE2

Chemotaxis: PMNL, M, CD4 / 8 cellsInduction of acute-phase response

Activation of osteoclastsInhibition of fibroblast growthInhibition of collagen synthesis

Inflammation

Biofilm

MMPs

Incidence of bacteremiaIncidence of bacteremiaIncidence of bacteremiaIncidence of bacteremia

Tooth extraction: 95% Perio. surg.: 88%

Scaling: 80% Flossing: 58%

Perio. prophylaxis: 40% Toothpicks: 40%

Irrigation devices: 50% Tooth brushing: 26%

Endodontics: 15% Chewing: 51%

I&D of abscess: 25% Suture removal: 16%

Intralig. injection: 97% Buccal injection: 16%

Bacteremia associated with daily eventsBacteremia associated with daily eventsBacteremia associated with daily eventsBacteremia associated with daily events

Tooth brushing – 15 min x 25 %* = 4 min.Tooth brushing – 15 min x 25 %* = 4 min.

Mastication – 3 x 15 min. x 38 %* = 17 min.Mastication – 3 x 15 min. x 38 %* = 17 min.

Random – 24 x 60 min x 11%* = 158 minRandom – 24 x 60 min x 11%* = 158 min

Physiologic bacteremia / month = 5,370 min Physiologic bacteremia / month = 5,370 min

Extraction – 15 min x 73 %* = 11 minExtraction – 15 min x 73 %* = 11 min

Tooth brushing – 15 min x 25 %* = 4 min.Tooth brushing – 15 min x 25 %* = 4 min.

Mastication – 3 x 15 min. x 38 %* = 17 min.Mastication – 3 x 15 min. x 38 %* = 17 min.

Random – 24 x 60 min x 11%* = 158 minRandom – 24 x 60 min x 11%* = 158 min

Physiologic bacteremia / month = 5,370 min Physiologic bacteremia / month = 5,370 min

Extraction – 15 min x 73 %* = 11 minExtraction – 15 min x 73 %* = 11 min

** Positive blood culture after the event Positive blood culture after the event** Positive blood culture after the event Positive blood culture after the event

Guntheroth WG. Am J Cardiol 1984;54:797Guntheroth WG. Am J Cardiol 1984;54:797Guntheroth WG. Am J Cardiol 1984;54:797Guntheroth WG. Am J Cardiol 1984;54:797

Periodontal Disease and DiabetesPeriodontal Disease and DiabetesPeriodontal Disease and DiabetesPeriodontal Disease and Diabetes

Recent research suggests a two-way connection Recent research suggests a two-way connection between diabetes and periodontal disease. between diabetes and periodontal disease.

Not only are people with diabetes more susceptible Not only are people with diabetes more susceptible to periodontal disease, but the presence of to periodontal disease, but the presence of periodontal disease may also make glycemic periodontal disease may also make glycemic control more difficult.control more difficult.

Recent research suggests a two-way connection Recent research suggests a two-way connection between diabetes and periodontal disease. between diabetes and periodontal disease.

Not only are people with diabetes more susceptible Not only are people with diabetes more susceptible to periodontal disease, but the presence of to periodontal disease, but the presence of periodontal disease may also make glycemic periodontal disease may also make glycemic control more difficult.control more difficult.

Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007


People with diabetes are two to three times more People with diabetes are two to three times more likely than persons without diabetes to have likely than persons without diabetes to have periodontal disease.periodontal disease.

Periodontal disease is more prevalent, progresses Periodontal disease is more prevalent, progresses more rapidly and is often more severe in more rapidly and is often more severe in individuals with both type 1 and type 2 diabetes.individuals with both type 1 and type 2 diabetes.

People with diabetes are two to three times more People with diabetes are two to three times more likely than persons without diabetes to have likely than persons without diabetes to have periodontal disease.periodontal disease.

Periodontal disease is more prevalent, progresses Periodontal disease is more prevalent, progresses more rapidly and is often more severe in more rapidly and is often more severe in individuals with both type 1 and type 2 diabetes.individuals with both type 1 and type 2 diabetes.


Control of Glucose Matters in Oral Control of Glucose Matters in Oral HealthHealth

Control of Glucose Matters in Oral Control of Glucose Matters in Oral HealthHealth

• People with poor glycemic control had more People with poor glycemic control had more periodontal disease and more severe periodontal periodontal disease and more severe periodontal disease than well controlleddisease than well controlled

• In a study with Pima Indians, improved In a study with Pima Indians, improved periodontal disease correlated with better periodontal disease correlated with better glucose controlglucose control

• People with poor glycemic control had more People with poor glycemic control had more periodontal disease and more severe periodontal periodontal disease and more severe periodontal disease than well controlleddisease than well controlled

• In a study with Pima Indians, improved In a study with Pima Indians, improved periodontal disease correlated with better periodontal disease correlated with better glucose controlglucose control



How uncontrolled diabetes affects periodontal disease:How uncontrolled diabetes affects periodontal disease:• Decreased neutrophil function - chemotaxis, phagocytosis Decreased neutrophil function - chemotaxis, phagocytosis

and bacteriocidal .and bacteriocidal .

• Presence of advanced glycolated end products which Presence of advanced glycolated end products which weakens collagen and reduces the ability of gingiva to heal.weakens collagen and reduces the ability of gingiva to heal.

• Less than optimal fibroblast function which impairs healing.Less than optimal fibroblast function which impairs healing.

How Periodontal infection affects diabetes:How Periodontal infection affects diabetes:• Systemic bacterial and viral infections result in increased Systemic bacterial and viral infections result in increased

systemic inflammation which increases insulin resistance and systemic inflammation which increases insulin resistance and makes it difficult for patients to control blood glucose levels.*makes it difficult for patients to control blood glucose levels.*

How uncontrolled diabetes affects periodontal disease:How uncontrolled diabetes affects periodontal disease:• Decreased neutrophil function - chemotaxis, phagocytosis Decreased neutrophil function - chemotaxis, phagocytosis

and bacteriocidal .and bacteriocidal .

• Presence of advanced glycolated end products which Presence of advanced glycolated end products which weakens collagen and reduces the ability of gingiva to heal.weakens collagen and reduces the ability of gingiva to heal.

• Less than optimal fibroblast function which impairs healing.Less than optimal fibroblast function which impairs healing.

How Periodontal infection affects diabetes:How Periodontal infection affects diabetes:• Systemic bacterial and viral infections result in increased Systemic bacterial and viral infections result in increased

systemic inflammation which increases insulin resistance and systemic inflammation which increases insulin resistance and makes it difficult for patients to control blood glucose levels.*makes it difficult for patients to control blood glucose levels.*

* Mealey, B. JADA 2006; 137:30S* Mealey, B. JADA 2006; 137:30S

People with diabetes and severe People with diabetes and severe periodontal disease have:periodontal disease have:

People with diabetes and severe People with diabetes and severe periodontal disease have:periodontal disease have:

• 6x increased risk of poor glycemic control6x increased risk of poor glycemic control

• 82% of had 1 or more macrovascular 82% of had 1 or more macrovascular complication (CVD, CVA) (vs 21% w/o)complication (CVD, CVA) (vs 21% w/o)

• Death rate due to CVD= 2.3x higherDeath rate due to CVD= 2.3x higher

• Death rate from nephropathy= 8.5xDeath rate from nephropathy= 8.5x

• 6x increased risk of poor glycemic control6x increased risk of poor glycemic control

• 82% of had 1 or more macrovascular 82% of had 1 or more macrovascular complication (CVD, CVA) (vs 21% w/o)complication (CVD, CVA) (vs 21% w/o)

• Death rate due to CVD= 2.3x higherDeath rate due to CVD= 2.3x higher

• Death rate from nephropathy= 8.5xDeath rate from nephropathy= 8.5x


Periodontal Disease and PregnancyPeriodontal Disease and PregnancyPeriodontal Disease and PregnancyPeriodontal Disease and Pregnancy““Most of the clinical studies indicate a positive Most of the clinical studies indicate a positive

correlation between periodontal disease and correlation between periodontal disease and preterm birth. preterm birth.

Recent studies also have shown that there are Recent studies also have shown that there are microbiologic and immunological findings that microbiologic and immunological findings that strongly support the association.strongly support the association.

Furthermore, the cohort studies have Furthermore, the cohort studies have demonstrated that the periodontal disease demonstrated that the periodontal disease precedes the pregnancy complication and is not precedes the pregnancy complication and is not a consequence of it ”a consequence of it ”

““Most of the clinical studies indicate a positive Most of the clinical studies indicate a positive correlation between periodontal disease and correlation between periodontal disease and preterm birth. preterm birth.

Recent studies also have shown that there are Recent studies also have shown that there are microbiologic and immunological findings that microbiologic and immunological findings that strongly support the association.strongly support the association.

Furthermore, the cohort studies have Furthermore, the cohort studies have demonstrated that the periodontal disease demonstrated that the periodontal disease precedes the pregnancy complication and is not precedes the pregnancy complication and is not a consequence of it ”a consequence of it ”

Bobetsis A. et al JADA 2006;137: 7SBobetsis A. et al JADA 2006;137: 7S

Periodontal Disease and PregnancyPeriodontal Disease and PregnancyPeriodontal Disease and PregnancyPeriodontal Disease and PregnancyThe proposed mechanism is similar.The proposed mechanism is similar.• Periodontal bacteria induce a local inflammatory Periodontal bacteria induce a local inflammatory

responseresponse

• Bacteria, bacterial virulence factors or inflammatory Bacteria, bacterial virulence factors or inflammatory mediators gain systemic access and produce a systemic mediators gain systemic access and produce a systemic inflammatory response.inflammatory response.

• These elements reach the placenta and create another These elements reach the placenta and create another inflammatory response.inflammatory response.

• These elements may cross the placenta and enter the These elements may cross the placenta and enter the fetal circulation and trigger a new fetal-host immune fetal circulation and trigger a new fetal-host immune response.response.

The proposed mechanism is similar.The proposed mechanism is similar.• Periodontal bacteria induce a local inflammatory Periodontal bacteria induce a local inflammatory

responseresponse

• Bacteria, bacterial virulence factors or inflammatory Bacteria, bacterial virulence factors or inflammatory mediators gain systemic access and produce a systemic mediators gain systemic access and produce a systemic inflammatory response.inflammatory response.

• These elements reach the placenta and create another These elements reach the placenta and create another inflammatory response.inflammatory response.

• These elements may cross the placenta and enter the These elements may cross the placenta and enter the fetal circulation and trigger a new fetal-host immune fetal circulation and trigger a new fetal-host immune response.response.


Treatment of periodontal disease Treatment of periodontal disease and the risk of preterm birthand the risk of preterm birth


Preterm birth –Preterm birth –12.0% of 407 women in the treatment group.12.0% of 407 women in the treatment group.12.8% of 406 women in the control group.12.8% of 406 women in the control group.

Preterm birth –Preterm birth –12.0% of 407 women in the treatment group.12.0% of 407 women in the treatment group.12.8% of 406 women in the control group.12.8% of 406 women in the control group.

Conclusion –Conclusion –“Treatment of periodontitis in pregnant “Treatment of periodontitis in pregnant women improves periodontal disease and it women improves periodontal disease and it is safe but does not significantly alter rates is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal of preterm birth, low birth weight, or fetal growth restriction.”growth restriction.”

Conclusion –Conclusion –“Treatment of periodontitis in pregnant “Treatment of periodontitis in pregnant women improves periodontal disease and it women improves periodontal disease and it is safe but does not significantly alter rates is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal of preterm birth, low birth weight, or fetal growth restriction.”growth restriction.”

N Engl J Med 2006;355:1885-64N Engl J Med 2006;355:1885-64



“… “… there is insufficient evidence at this time for there is insufficient evidence at this time for health care policy recommendations to provide health care policy recommendations to provide maternal periodontal treatments for the purpose of maternal periodontal treatments for the purpose of reducing the risk of adverse pregnancy outcomes.”reducing the risk of adverse pregnancy outcomes.”

“… “… there is insufficient evidence at this time for there is insufficient evidence at this time for health care policy recommendations to provide health care policy recommendations to provide maternal periodontal treatments for the purpose of maternal periodontal treatments for the purpose of reducing the risk of adverse pregnancy outcomes.”reducing the risk of adverse pregnancy outcomes.”




Treatment of periodontal disease MAY improve Treatment of periodontal disease MAY improve pregnancy outcomes in a sub-group of pregnancy outcomes in a sub-group of patients.patients.

Since treatment is safe and has no adverse Since treatment is safe and has no adverse outcomes, most recommend appropriate outcomes, most recommend appropriate periodontal treatment for pregnant women.periodontal treatment for pregnant women.

Treatment of periodontal disease MAY improve Treatment of periodontal disease MAY improve pregnancy outcomes in a sub-group of pregnancy outcomes in a sub-group of patients.patients.

Since treatment is safe and has no adverse Since treatment is safe and has no adverse outcomes, most recommend appropriate outcomes, most recommend appropriate periodontal treatment for pregnant women.periodontal treatment for pregnant women.

Periodontal Disease and Heart Periodontal Disease and Heart DiseaseDisease

Common Risk Factors For Heart DiseaseCommon Risk Factors For Heart Disease

Periodontal Disease and Heart Periodontal Disease and Heart DiseaseDisease

Common Risk Factors For Heart DiseaseCommon Risk Factors For Heart Disease

Hypertension Diabetes

Obesity

Family Hx ofHeart Disease

Sedentary Life Style

Excessive Alcohol Intake

Smoking

Chronic Periodontal

Disease

?

Model for Relationship Between Periodontal Model for Relationship Between Periodontal Inflammation, Inflammation,

Atherosclerosis, Cardiovascular and Atherosclerosis, Cardiovascular and Cerebrovascular DiseaseCerebrovascular Disease

Model for Relationship Between Periodontal Model for Relationship Between Periodontal Inflammation, Inflammation,

Atherosclerosis, Cardiovascular and Atherosclerosis, Cardiovascular and Cerebrovascular DiseaseCerebrovascular Disease

Bacteremia



Immune Response

Microbes& LPS

Microbes

Liver

AtherosclerosisCardiovascular Disease

Cerebrovascular Disease


Fibrinogen

Antibodies to bacteria & cross-reactive antigens, e.g., heat-shock protein.


& endothelial invasion

Inflammatory Periodontal

Disease

?

Gradient Relationship Between Incidence (%)Gradient Relationship Between Incidence (%)of Total CHD and Level of Alveolar Bone Lossof Total CHD and Level of Alveolar Bone LossGradient Relationship Between Incidence (%)Gradient Relationship Between Incidence (%)of Total CHD and Level of Alveolar Bone Lossof Total CHD and Level of Alveolar Bone Loss

0

5

10

15

20

25

30

35

40

45

None < 20% 20-40% > 40%

0

5

10

15

20

25

30

35

40

45

None < 20% 20-40% > 40%

Age-adjusted level of bone loss

Beck J, et al. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-1137.

%Incidence

CVD

Treatment of periodontitis and Treatment of periodontitis and endothelial functionendothelial function

Treatment of periodontitis and Treatment of periodontitis and endothelial functionendothelial function

Treatment –Treatment –56 patients to community-based periodontal care. 56 patients to community-based periodontal care. 58 patients to intensive periodontal treatment.58 patients to intensive periodontal treatment.

Treatment –Treatment –56 patients to community-based periodontal care. 56 patients to community-based periodontal care. 58 patients to intensive periodontal treatment.58 patients to intensive periodontal treatment.

Conclusion –Conclusion –“Intensive periodontal treatment resulted in “Intensive periodontal treatment resulted in acute, short-term systemic inflammation and acute, short-term systemic inflammation and endothelial dysfunction. However, 6 months endothelial dysfunction. However, 6 months after therapy, the benefits in oral health were after therapy, the benefits in oral health were associated with improvement in endothelial associated with improvement in endothelial function.”function.”

Conclusion –Conclusion –“Intensive periodontal treatment resulted in “Intensive periodontal treatment resulted in acute, short-term systemic inflammation and acute, short-term systemic inflammation and endothelial dysfunction. However, 6 months endothelial dysfunction. However, 6 months after therapy, the benefits in oral health were after therapy, the benefits in oral health were associated with improvement in endothelial associated with improvement in endothelial function.”function.”

N Engl J Med 2007;356:911-20N Engl J Med 2007;356:911-20

Periodontal Disease and HIVPeriodontal Disease and HIVPeriodontal Disease and HIVPeriodontal Disease and HIVHIV, being a T-Cell mediated condition is characterized

more by viral, fungal, parasite and opportunistic cancers than bacterial infections. Therefore the bacterially induced chronic inflammation cycle is not seen as often.

It has been postulated that there may be some opportunistic bacterial periodontal conditions such as Necrotizing Ulcerative Periodontitis associated with HIV but the evidence is not clear.

HART drugs reduce salivation, resulting in dry mouth and an increase in decay.

Immune suppression and oral Immune suppression and oral lesionslesions


0

100

300

200

400

500 +

atrophic candidiasisatrophic candidiasis

CD4CD4 cells/mmcells/mm33

TimeTime



0

100

300

200

400

500 +


TimeTime

pseudomembranous candidiasispseudomembranous candidiasis



0

100

300

200

400

500 +


TimeTime

oral hairy leukoplakiaoral hairy leukoplakia



0

100

300

200

400

500 +


TimeTime

necrotizing ulcerative gingivitisnecrotizing ulcerative gingivitis



0

100

300

200

400

500 +


TimeTime

necrotizing ulcerative periodontitis

necrotizing ulcerative periodontitis



0

100

300

200

400

500 +


TimeTime

necrotizing stomatitisnecrotizing stomatitis



0

100

300

200

400

500 +


TimeTime

hypertrophic candidiasishypertrophic candidiasis



0

100

300

200

400

500 +


TimeTime

Kaposi’s sarcomaKaposi’s sarcoma



0

100

300

200

400

500 +


TimeTime

major ulcersmajor ulcers



0

100

300

200

400

500 +


TimeTime

CMV ulcersCMV ulcers

Questions YOU had before coming Questions YOU had before coming here?here?

• How can I assist my patient in managing their How can I assist my patient in managing their diabetes through improved oral health?diabetes through improved oral health?

• How does periodontitis affect the pregnant How does periodontitis affect the pregnant patient, fetus and newborn’s health.patient, fetus and newborn’s health.

• What precautions do I need to take for my What precautions do I need to take for my patients upcoming surgery?patients upcoming surgery?

• What periodontal regimen is relevant for What periodontal regimen is relevant for optimum health in my HIV patient.optimum health in my HIV patient.

Questions YOU had before coming Questions YOU had before coming here?here?

• How can I assist my patient in managing their How can I assist my patient in managing their diabetes through improved oral health?diabetes through improved oral health?

• How does periodontitis affect the pregnant How does periodontitis affect the pregnant patient, fetus and newborn’s health.patient, fetus and newborn’s health.

• What precautions do I need to take for my What precautions do I need to take for my patients upcoming surgery?patients upcoming surgery?

• What periodontal regimen is relevant for What periodontal regimen is relevant for optimum health in my HIV patient.optimum health in my HIV patient.


Its all about inflammation and

bacteria …Stupid!

What should YOU do?What should YOU do?

Identify periodontal disease.Identify periodontal disease.

Check tooth mobilityCheck tooth mobility

Educate about periodontal disease.Educate about periodontal disease.

Refer for periodontal disease.Refer for periodontal disease.

Work with oral health colleagues to Work with oral health colleagues to treat periodontal disease.treat periodontal disease.

What should YOU do?What should YOU do?

Identify periodontal disease.Identify periodontal disease.

Check tooth mobilityCheck tooth mobility

Educate about periodontal disease.Educate about periodontal disease.

Refer for periodontal disease.Refer for periodontal disease.

Work with oral health colleagues to Work with oral health colleagues to treat periodontal disease.treat periodontal disease.


The Healthy PeriodontiumThe Healthy PeriodontiumThe Healthy PeriodontiumThe Healthy Periodontium

With HEALTH the With HEALTH the alveolar crest is 1.5 to alveolar crest is 1.5 to

2 mm from CEJ2 mm from CEJ

With HEALTH the With HEALTH the alveolar crest is 1.5 to alveolar crest is 1.5 to

2 mm from CEJ2 mm from CEJ

With PERIODONTITIS With PERIODONTITIS (attachment loss), the (attachment loss), the distance from the CEJ distance from the CEJ to the alveolar bone is to the alveolar bone is increased (> 2 mm)increased (> 2 mm)

Periodontal diseasesPeriodontal diseasesPeriodontal diseasesPeriodontal diseases

Amount of clinical Amount of clinical attachment loss (CAL) attachment loss (CAL) determines diagnosisdetermines diagnosis

Amount of clinical Amount of clinical attachment loss (CAL) attachment loss (CAL) determines diagnosisdetermines diagnosis

Severe (Advanced) PeriodontitisSevere (Advanced) PeriodontitisSevere (Advanced) PeriodontitisSevere (Advanced) Periodontitis

InflammationInflammation

Gingival form changesGingival form changes

Increased sulcus depthIncreased sulcus depth

Clinical attachment levels 5 mm or Clinical attachment levels 5 mm or greatergreater

Severe bone resorptionSevere bone resorption

InflammationInflammation

Gingival form changesGingival form changes

Increased sulcus depthIncreased sulcus depth

Clinical attachment levels 5 mm or Clinical attachment levels 5 mm or greatergreater

Severe bone resorptionSevere bone resorption


Treatment of systemic illness may Treatment of systemic illness may affect oral healthaffect oral health

Treatment of systemic illness may Treatment of systemic illness may affect oral healthaffect oral health

Treatment of systemic diseases may Treatment of systemic diseases may affect dental careaffect dental care


HypertensionHypertension – – gingival overgrowth (CCB),gingival overgrowth (CCB),ulcerations (methyldopa),ulcerations (methyldopa),lichenoid reactions (ACEI),lichenoid reactions (ACEI),oral dryness (diuretics)oral dryness (diuretics)





Immune suppressionImmune suppression – – gingival overgrowth (CSA),gingival overgrowth (CSA),opportunistic viral and fungal opportunistic viral and fungal

infectionsinfections


Immune suppressionImmune suppression – – gingival overgrowth (CSA),gingival overgrowth (CSA),opportunistic viral and fungal opportunistic viral and fungal

infectionsinfections




Immune suppressionImmune suppression – – gingival overgrowth (CSA),gingival overgrowth (CSA),opportunistic viral and fungal infectionsopportunistic viral and fungal infections

ChemotherapyChemotherapy – – mucositis,mucositis,intraoral bleeding,intraoral bleeding,ulcerationsulcerations


Immune suppressionImmune suppression – – gingival overgrowth (CSA),gingival overgrowth (CSA),opportunistic viral and fungal infectionsopportunistic viral and fungal infections

ChemotherapyChemotherapy – – mucositis,mucositis,intraoral bleeding,intraoral bleeding,ulcerationsulcerations

Oral signs are sometimes markers forOral signs are sometimes markers forsystemic diseasesystemic disease

Oral signs are sometimes markers forOral signs are sometimes markers forsystemic diseasesystemic disease


Gingival overgrowthGingival overgrowth

Lupus erythematosusLupus erythematosus

Celiac diseaseCeliac disease

Folic acid deficiencyFolic acid deficiency

Folic acid deficiencyFolic acid deficiency

LeukemiaLeukemia

Diabetes MellitusDiabetes Mellitus

Diabetes MellitusDiabetes Mellitus

Thank you for your attention.Thank you for your attention.Thank you for your attention.Thank you for your attention.

Documents

Looking for the future today