21/08/2015 23:58 © Author / Presentation ReferenceSlide 1 The Oral Health-Systemic Health...

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The Oral Health-Systemic Health Relationship


Oral sepsis theory : a long-standing and fascinating story

2000 BC 1000 BC 1 AD 1500 AD

Egyptians: tooth pain

associated with disease in

reproductive system

Assyrians: pains in head, arms & feet

caused by teeth

Greeks: Hippocrates

finds arthritis cured with

tooth extraction

Romans: Galen states head

is source of all ills (teeth are the

result not the cause of disease)


In the mid to late 1800’s,

Diseases were thought to be caused by:

Bad Blood Bad Air Evil Spirits


Robert Koch

Introduced the“germ” theory

of diseasein 1876

Louis PasteurEdward JennerJoseph Lister


WilloughbyD. Miller

Graduated fromPenn Dental School in 1879,then on to Berlinand Koch’s new Institute


“The Human Mouth as a Focus of Infection”

Ostitis Osteomyelitis SepticemiaPyaemia Meningitis PneumoniaGangrene Angina SinusitisNoma Actinomycosis DiphtheriaTuberculosis Syphilis Thrush

WD Miller, Dental Cosmos 33: 689-713,1891


In 1899, William Hunter a young MD from Edinburgh practicing in London attended a talk by Miller:

“Oral infection as the cause of mostsystemic diseases.”

From that time on, Hunter was a major advocate for the concept that oral infection was the cause of systemic diseases


A century of progress in understanding the nature of periodontal disease

• The role of the infectious burden and specific bacterial types in disease causation

• The role of the susceptible host in periodontal tissue destruction

• The incidence, prevalence and natural history of periodontal disease

• The risk for periodontal disease

• Periodontal disease as a risk for systemic disease


1912 1912

The term “oral sepsis” replaced The term “oral sepsis” replaced withwith““focal infection”focal infection”

““The Era of Focal Infection”The Era of Focal Infection”


RHEUMATOLOGYRHEUMATOLOGY

1938 RL Cecil, 1938 RL Cecil, Ann Intern MedAnn Intern Med

200 patients with rheumatoid200 patients with rheumatoid arthritis studied; teeth removed;arthritis studied; teeth removed; no patient got better and 3 gotno patient got better and 3 got worseworse


1952 Editorial, J Am Med Assoc 150:490

“…“…many patients with diseases many patients with diseases presumably caused by foci of infectionpresumably caused by foci of infectionhave not been relieved of their symptoms by have not been relieved of their symptoms by removal of foci such as teethremoval of foci such as teeth. Many patients . Many patients with these same diseases have no evident with these same diseases have no evident focus of infection; also foci of infection are as focus of infection; also foci of infection are as common in apparently healthy persons as common in apparently healthy persons as those with disease.”those with disease.”

JAMA 150: 490, 1952


1952-19891952-1989

There is very little interest in the There is very little interest in the relationship of periodontal disease to the relationship of periodontal disease to the rest of the bodyrest of the body

Exception for SBE Exception for SBE (Subacute Bacterial Endocarditis)(Subacute Bacterial Endocarditis)


Matilla,K, Niemeier,M,Valtonen, V et al,Matilla,K, Niemeier,M,Valtonen, V et al,Br Med Journal 298:Br Med Journal 298: 770-782, 1989 770-782, 1989Association between dental health andAssociation between dental health andacute myocardial infarction acute myocardial infarction

Patients presenting to the emergency room Patients presenting to the emergency room with awith aheart attack had moderate to severe heart attack had moderate to severe periodontal disease. Age and gender periodontal disease. Age and gender matched subjects who had no heart problems matched subjects who had no heart problems also had no or very little periodontal diseasealso had no or very little periodontal disease

19891989 “A New Era” “A New Era”


1989, following Matilla’s report

Dentistry begins to carefully re-look at the relationship of periodontal disease to systemic conditions


World Health Organization

• WHO Executive Board Report on Oral Health, January 27, 2007

• Platform accepted:– “acknowledging of the intrinsic link between oral health, general

health and quality of life”


What is the biological plausibility to suggest that periodontitis may contribute to a person’s risk for having a heart attack or stroke?


Risk Factor: an exposure that increases the probability that disease will occur

e.g. obesity increases the likelihood for hypertension

e.g. cigarette smoking and lung cancer


Risk factors for periodontal disease

• SmokingSmoking Drugs Drugs

• Age Existing Bone Loss Age Existing Bone Loss

• Diabetes MellitusDiabetes Mellitus Probing Depth > 5mm Probing Depth > 5mm

• Bacterial Burden Bleeding on ProbingBacterial Burden Bleeding on Probing

• Specific bacterial Root FormSpecific bacterial Root Form

• Inheritance Pulpal InvolvementInheritance Pulpal Involvement

• Stress Stress Caries Caries

• Race/Ethnicity Race/Ethnicity Types Furcation Involvement Types Furcation Involvement

• Phagocyte Dysfunction Tooth MobilityPhagocyte Dysfunction Tooth Mobility

• HIV Infection Crown to Root Ratio HIV Infection Crown to Root Ratio

• Gender (male)Gender (male)


•Periodontal disease is an inflammatory disease caused by anaerobic and facultative bacteria


Bacteria

Dental biofilm

Gingivitis

Periodontitis


Bacteria

Dental biofilm

Gingivitis

Periodontitis

Inflammatory reactions


Bacteria

Dental biofilm

Gingivitis

Periodontitis


RISK FACTORSRISK FACTORS•Diabetes mellitus•Smoking•Poor oral hygiene•Male gender•Race/ethnicity•Low socio-economicstatus


Bacteria

Dental biofilm

Gingivitis

Periodontitis



DENTAL EFFECTS• Connective tissue degradation• Alveolar bone resorption

• Tooth mobility• Abscess• Tooth loss


Bacteria

Dental biofilm

Gingivitis

Periodontitis


ASSOCIATED MEDICAL CONDITIONS

• Diabetes• Cardiovascular diseases• Preterm Low birth weight• Respiratory Disease


DENTAL EFFECTS• Connective tissue degradation• Alveolar bone resorption

• Tooth mobility• Abscess• Tooth loss


Periodontal pocket - probed to 5mm depth


Waite, DE and Bradley, RE Oral infections JADA 71: 587-592, 1965

Surface area of generalized moderate periodontitis


2004


Periodontal Disease as a risk factor

• Diabetes

• Cardiovascular Diseases

• Adverse Pregnancy Outcomes

• Pulmonary Diseases


Periodontal Disease as a Risk

• Diabetes• Cardiovascular Disease• Adverse Pregnancy Outcomes• Pulmonary Disease


Review of different types of Diabetes _______________________________________

• Type 1 diabetes (10 – 15 % of all cases)

– also called insulin dependent diabetes mellitus (IDDM). The pancreas undergoes an autoimmune attack by the body itself, and is rendered incapable of making insulin. The patient with type 1 diabetes must rely on insulin medication for survival.

• Type 2 diabetes (85 – 90 % of all cases)

– Patients can still produce insulin, but do so relatively inadequately for their body’s needs. In many cases, the pancreas produces larger than normal quantities of insulin, but there is a lack of sensitivity to insulin by the cells of the body, it is called insulin resistance.

• Gestational diabetes:

– Blood sugar elevation during pregnancy is called gestational diabetes, it usually resolves once the baby is born. However, 25-50 % of these women will develop a Type II diabetes later in life.


Diabetes and Periodontal Diseases: A Two-Way Street_______________________________________

• Patients with diabetes are at greater risk for developing infections

• Periodontal infection may impair diabetes control


Periodontitis and Diabetes ___________________________________

• May increase insulin resistance

• May aggravate glycemic control

– Severe periodontitis:

– prevalence of proteinuria

– number of cardiovascular complications: stroke, angina, MI, heart failure, intermittent claudication


Periodontitis and Diabetes________________________________________

• Diabetes mellitus has a significant impact on tissues throughout the body, including the oral cavity

• Poorly controlled diabetes increases the risk of periodontitis

• Periodontal infection and treatment may alter glycemic control


Diabetes increases the risk of developing periodontitis________________________________________

Ciancolla et al in 1982

• Type I diabetes was associated with a five-fold increased prevalence of periodontitis in teenagers.

Lalla et al, 2006

• Periodontal destruction can start very early in life in diabetes and becomes more prominent as children become adolescents.

In addition, epidemiologic research supports an increased prevalence and severity attachment loss and bone loss in adults with diabetes*


There is sufficient clinical evidence to show that poor control of diabetes increases the risk for developing a number of oral manifestations of the disease, including periodontitis.

Does treating periodontal infections have a beneficial effect on glycemic control in people with diabetes?


Taylor GW et al

The effects of periodontal treatment on diabetes

JADA 2003, Vol 134


This review, consisted of MEDLINE research, identified 12 studies- 3 randomized clinical trials- 9 non-randomized follow-up studies

-7 studies reported a beneficial effect of periodontal treatment on glycemic control, with either a reduction of HbA1c levels, or a reduction in circulating TNF-alpha levels or finally a reduction in insulin requirements.

- However 5 studies reported no beneficial effect.

Taylor et al, 2003


Periodontitis and Diabetes - Conclusions

Despite the variation and limitations of the evidence, it can be concluded that: - periodontal diseases may contribute to poorer glycemic control in people with diabetes - treating periodontal infections could have a beneficial effect on glycemic control in patients with either type 1 or type 2 diabetes.


Periodontal Disease as a risk factor

• Diabetes

• Cardiovascular Diseases

• Adverse Pregnancy Outcomes

• Pulmonary Diseases


Review Review Cardiovascular Terms

Atherosclerosis:Progressive disease process through which atheroma are formed; involves large to medium sized muscular and large elastic arteries

Atheroma: Elevated intimal fibrolipid plaque

Coronary Heart Disease: Clinical diagnosis made by physician based on tests, signs and symptoms


What is the biological plausibility to suggest that periodontitis may contribute to a person’s risk for having a heart attack or stroke?


Infection-inflammation have been linked to the risk for coronary heart disease for several years


Bacteria and soluble bacterial products, such as LPS, can enter the bloodstream and can reach distant sites, e.g. the endothelium of a blood vessel, where it can initiate a local inflammatory response and resultant injury

Dave S et al, Compendium July 2004


• The local inflammatory response to bacterial biofilm in the periodontal pocket may cause or amplify systemic inflammatory events.

• Inflammatory cells, such as monocytes and leukocytes, “stick” to and activate the endothelial cells lining the arteries

• The monocytes are converted to macrophages which start to accumulate lipids to become “foam cells”, a hallmark of atherosclerosis, proliferate and thicken the walls of the arteries.

Dave S et al, Compendium July 2004


Mast cells in the area produce proteases which can be implicated in plaque remodeling and rupture, thus creating a thrombus.

Libby P et al, circulation 2007


Epidemiological data have been analyzed to examine for a possible relationship between exposure (periodontitis) and the outcome (cardiovascular disease)

Epidemiological Evidence


1. NHANES 1 Follow-up Study 2. VA Normative Aging Study3. Health Professions Follow-up Study4. Nutrition Canada Study5. Physician’s Health Study6. Mini-Finland Health Survey

Available Data


Up to 2007 there are 16 studies of the 6 existing data sets

DeStefano F et al, 1993Mattila K et al, 1995Beck JD et al, 1996Joshipura K et al, 1996, 2003Mendez et al, 1998Morrison et al, 1999Wu et al, 2000Hujoel P et al, 2000, 2001,2002Jansson et al, 2001Howell TH et al, 2001Hung et al, 2003Ajwani et al, 2003Tuominen et al, 2003


DeStefano F et al From NHANES 1 follow up study

Dental disease and risk of coronaryheart disease and mortality

Br Med J 1993;306: 688-691.


20,749 subjects initially studied 9760 subjects included in this study of Periodontitis-CHD

Subjects with periodontitis had a 24% increased risk of coronary heart disease relative to those who had minimal periodontal disease

DeStefano et al, 1993


Beck JD et alFrom VA Normative aging study

Periodontal disease andcardiovascular disease

J Periodontol 1996; 67: 1123-1137.


Age-adjusted and multivariate incidenceodds ratios for total coronary heart disease,fatal coronary heart disease and strokeaccording to bone loss at baseline

Total Fatal Stroke CHD CHD

N cases 203 58 40

Odds ratios 1.5 1.9 2.8

Beck at al, 1996


Morisson HI et alFrom Nutrition Canada Study

Periodontal disease and risk of fatal coronary heart and cerebrovascular diseases.

J Cardiovasc Risk. 1999; 6(1): 7-11


A statistically significant association between periodontal disease and risk of fatal coronary heart disease was observed with a rate ratio of 2.15 for severe gingivitis.

Non-statistically significantly increased rate ratio (1.81) was observed for severe gingivitis and cerebrovascular disease.

These data suggested that poor dental health is associated with an increased risk of fatal CHD.

Morisson et al, 1999


Joshipura K et al From Health Professions Follow-up Study

Poor oral health and coronary heart disease

J Dental Research 1996; vol 75, 1631-1636


Health status monitoring of 44,119 males participating in the Health Professionals Follow-up Study over a 6-year period.

Examine the incidence of coronary heart disease in relation to number of teeth present and periodontal disease.

Overall, no significant association between tooth loss and coronary heart disease (RR = 1.04)However, men with 10 or fewer teeth were at increased risk of CHD compared with men with 25 or more teeth (RR = 1,67)

Joshipura et al, 1996


Periodontitis and Cardiovascular Disease – Conclusions

There is clearly an association between

periodontal disease and cardiovascular

disease.

Further research is required to better

understand its nature.



• Diabetes• Cardiovascular Disease• Adverse Pregnancy outcomes

•Preterm low birth weight infants (PLBW)•Preeclampsia

• Pulmonary Disease


Preterm Birth:A birth that occurs before 37 weeks of gestation (WHO 1977)

Low Birth Weight:Birth weight under 2500 grams or 5 lbs.

PreeclampsiaIt is a disorder that affects at least 5-8% of all pregnancies.Characterized by high blood pressure, protein in the urine, swelling, headaches and sudden weight gain.

Definitions

Known Risk Factors for Preterm Low Birth-weight

Maternal Age. Drug, Alcohol and Tobacco usage Intake of medicine Genetic History Acute infection and inflammation of the genital organs Diabetes and hypertension 25-50% occur without any known etiology


Biochemical Mediators of Prematurity

Can induce: uterine contraction cervical dilation labor or abortion inhibit fetal growth

which mediate preterm delivery, low birth weight

LPS, PGE2, IL-1β, TNFα, IL-6


• PLBW may be associated with sub clinical genitourinary or other infections.

• A variety of biologically active molecules such as prostaglandin E2 (PGE2) and TNF, which are normally involved in normal parturition, are raised to artificially high levels by the infection process, which may foster premature labor.

Adverse Pregnancy Outcomes


• Periodontal infection – Release of LPS and endotoxins by oral bacteria

trigger release of immune modulators such as PGE2 and TNF in gingival crevicular fluid

– Bacteria, bacterial by-products and mediators may enter the circulation

Adverse Pregnancy Outcomes


IL-1, IL-6,TNF,PGE2

Systemic challenge

PGE2, IL-1ß, TNF

Systemic challenge

Bacteria, LPS

Periodontitis

Maternal response

PLBW

Direct

2 Possible mechanisms


Offenbacher, S et al

Periodontal infection as a possiblerisk factor for pre-term low birth-weight

J Periodontol 1996; 67: 1103


Case-control study of 124 pregnant or postpartum mothers

Women with periodontal disease were seven times more likely to have preterm low birth (PLBW) weight babies than women not affected by the disease.

Offenbacher et al, 1996


Multivariate Logistic Regression Model of All PLBW

0 1 2 3 4 5 6 7 8

Treated BV

Parity

Age

Afro-American

Alcohol

Periodontitis

ODDS Ratio

Periodontitis & Pre-term, low birth-weight infants



Lopez, NJ et al

Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease : a randomized controlled trial

J. Periodontology. 2002 Aug;73(8):911-924


400 pregnant women with periodontal disease randomly assigned to either experimental group (n=200, periodontal treatment before 28 weeks of gestation) or a control group (n=200, periodontal treatment after delivery)

Periodontal disease appears to be an independent risk factor for PLBR.

Periodontal therapy significantly reduces the rates of PLBR in this population of women with periodontal disease.

Lopez et al, 2002


Offenbacher, S et al

Progressive Periodontal Disease and Risk of Very Preterm Delivery

Obstetrics & Gynecology 2006;107:29-36


Prospective study of obstetric outcomes, entitled Oral Conditions and Pregnancy (OCAP) was conducted with 1,020 pregnant women who received both an antepartum and postpartum periodontal examination.

This study demonstrated that maternal periodontal disease increases relative risk of preterm birth.In addition, women with progressing periodontal disease during pregnancy are more likely to have very preterm deliveries compared with women whose disease does not progress.



Michalowicz, BS et al

Periodontal treatment in pregnant women improves periodontal diseases but does not alter rates of preterm birth

Evidence-Based Dentistry, 2007; 8, 5-6


Multicentre randomized controlled trial2 groups:Treatment group n=413 (scaling and root planing before 21 weeks’ gestation)Control group n=410 (following delivery)

Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight or foetal growth restrictions.

Michalowicz et al, 2007


Xiong, X et al

Periodontal Disease and Adverse Pregnancy Outcomes : A systemic Review

British Journal of Obstetrics and Gynecology, 2006 Feb; 113(2):135-143


In this review, 25 studies were identified:• 13 case control studies• 9 cohort studies (prospective)• 3 controlled trials (2 were randomized)

18 studies suggested an association between periodontal disease and an increased risk of adverse pregnancy outcomes (odds ratio ranged from 1.10 to 20.0)7 other studies yielded no evidence of such an association.

Xiong et al, 2006


Conclusion of this systemic review :

Periodontal disease may be associated with an increased risk of adverse pregnancy outcome. However, more methodologically rigorous studies are needed for confirmation.

Xiong et al, 2006


Periodontitis and Preeclampsia

Most studies have been focused on the role of Most studies have been focused on the role of periodontal disease in pre-term birth.periodontal disease in pre-term birth.Recent investigations suggested that periodontal Recent investigations suggested that periodontal disease is more prevalent in pre-eclampsia disease is more prevalent in pre-eclampsia (Contreras et al, 2006,Cota et al, 2006, Kunnen et (Contreras et al, 2006,Cota et al, 2006, Kunnen et al, 2007, Herrera et al, 2007)al, 2007, Herrera et al, 2007)

Although most of studies to date indicate a positive Although most of studies to date indicate a positive correlation between Periodontitis and correlation between Periodontitis and Preeclampsie, it is still too early to attribute a Preeclampsie, it is still too early to attribute a cause-and-effect relationship.cause-and-effect relationship.


Periodontitis and Adverse Pregnancy Outcomes - Conclusions

There is an association between periodontal disease and increased risk for adverse pregnancy outcomes In addition, the balance of evidence suggests that periodontal intervention may reduce the incidence of adverse pregnancy outcomes



• Diabetes• Cardiovascular diseases• Preterm Low Birth Weight Infants• Pulmonary Disease


Oral bacteria, cytokines and the lower airway


Potential Mechanisms

• Periodontal infection and respiratory pathogens in plaque have been linked to an increased risk for aspiration pneumonia and chronic obstructive pulmonary disease.

• In hospitalized patients and those in nursing homes, bacteria that colonize teeth can potentially be aspirated into the lung and can lead to pneumonia.


NHANES III – Pulmonary disease

Patients with a history of chronic obstructive pulmonarydisease have significantly more periodontal attachmentloss than subjects without COPD

Scannapieco, 2001, 2003Azarpazhooh and Leake, 2006


Yoneyama T et al

Oral care reduces pneumonia in older patients in nursing home

J Am Geriatr Soc, 2002 Mar;50(3):430-3


11 nursing homes in Japan417 patients randomly assigned to an oral care group or no oral care group

During follow-up, pneumonia, febrile days and death from pneumonia decreased significantly in patients with oral care.

Oral care must be useful in preventing pneumonia in older patients in nursing home.

Yoneyama et al, 2002


Azarpazhooh A et al

Systemic review of the association between respiratory diseases and oral health

J Periodontol 2006 Sep;77(9):1465-82


19 studies selected.

Conclusions :•Fair evidence of an association of pneumonia with oral health (level II-2, grade B)•Poor evidence supporting a weak association (level II-2/3, grade C)•Good evidence (level I, grade A) that oropharyngeal decontamination with different antimicrobial interventions reduces the progression or occurrence of respiratory diseases.

Azarpazhooh et al, 2006


Oral Health and Pulmonary disease - Conclusions •Some evidence exists that poor oral hygiene and periodontal disease may increase the risk of developing community-acquired pneumonia.

•However, stronger evidence exists to support the relationship between poor oral hygiene and bacterial pneumonia in special-care populations.

•Health professionals need to become more involved in the care of hospitalized and nursing home populations.


Should dentists and physicians be doing more to ensure greater awareness of the influence that oral diseases can have on systemic conditions?

The question in 2007 is :


The Oral Health-Systemic Health Relationship

A New Partnership Between Dentistry and Medicine ?

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