Key learning points:
– Several research studies have suggested a link between periodontal disease and the complications of atherosclerosis
– The pathogenesis of periodontal disease is thought to be due to the accumulation of dental plaque with consequent mucosal infection and inflammation
– Practice nurses can play an important role in raising awareness of the importance of good dental health and encourage patients to see a dentist or dental hygienist every six months
Periodontitis is recognised as an inflammatory disease of bacterial origin.1 A report by the Colgate oral and dental health resource centre in conjunction with Columbia University College of Dental Medicine states: “periodontal diseases are infections of the structures around the teeth”. These include the gums, the cementum that covers the root, the periodontal ligament and the alveolar bone. In the earliest stage of periodontal disease, gingivitis, the infection affects only the gums. In more severe forms of the disease all of the supporting tissues are involved.2 The same report revealed that it is well accepted that bacteria in dental plaque are the major cause of periodontal disease. Plaque is the sticky substance that forms on teeth soon after brushing. More than 500 bacterial strains may be found in dental plaque.3
In an effort to eliminate the bacteria, the cells of the immune system release substances that inflame and damage the periodontal structures.2 When plaque builds up on the teeth, it eventually spreads below the gum line where a toothbrush has difficulty reaching. The gums become inflamed, swell and detach from the tooth. This process forms a ‘pocket’ between the tooth and the gum. Bacteria can grow rapidly in these pockets. This encourages further plaque buildup and if left untreated, the supporting structures of the teeth are destroyed and the teeth become loose.2
In recent years, gum disease has been linked to other health problems. Many questions remain and studies have provided varying answers about how much of a connection exists between gum disease and other medical problems but more research is needed. Researchers are studying possible connections between gum disease and:
· Atherosclerosis and heart disease – gum disease may increase the risk of clogged arteries and heart disease. Data from both human and animal studies has suggested that periodontitis is also associated with the progression of atherosclerosis.1 It is also believed to worsen existing heart disease.
· Stroke – gum disease may increase the risk of the type of stroke which is caused by blocked arteries
Is there a link?
Several hypotheses linking periodontal disease and the complications of atherosclerosis (coronary heart disease, peripheral arterial disease, myocardial infarction, angina, acute coronary syndrome and non haemorrhagic stroke) have been proposed.4
2.The link may reflect an individual predisposition to develop an energetic inflammatory response to intrinsic (age, sex, genetics) or extrinsic stimuli (diet, smoking) that then predisposes a patient to both periodontal disease and atherosclerosis.
3.The presence of an inflammatory focus in the mouth may potentiate the atherosclerotic process by stimulating various inflammatory pathways. The degree of inflammation resulting from periodontal disease is enough to elevate the C-reactive protein (CRP) signifying that a systemic inflammatory response has been mounted.
4.The presence of periodontal disease may lead to intermittent episodes of bacteremia with inoculation of atherosclerotic plaques by oral pathogens such as, porphyromonas gingivalis. When these bacterias proliferate, inflammation and plaque instability ensues.
It has been highlighted that “the pathogenesis of periodontal disease is thought to be due to accumulation of dental plaque with consequent mucosal infection and inflammation. Abnormal host responses, with upregulation of matrix metalloproteinases, contribute to a more rapid disease progression in some patients”.4 They explained that “periodontal disease is more common with cigarette smoking, obesity and diabetes, and it affects up to 75% of the population in the US. Increasing evidence over the past 20 years has suggested a link between periodontal disease and atherosclerosis”.4 Offenbacher et al state that “it is generally believed that atherogenesis and plaque rupture, two critical elements of cardiovascular pathogenesis that lead to chronic disease burden and clinical events are a consequence of systemic and vascular inflammatory processes”.5 They also make known that “inflammation impairs the function of the endothelium, promotes atheroma formation within the major elastic arteries, and comprises the structural integrity of the arterial plaque by creating vascular regions of unstable plaque that lead to susceptibility to thrombotic and embolic events”.5
Some cross sectional studies have shown a higher incidence of atherosclerotic complications in patients with periodontal disease.4 Interestingly, in the National Health and Nutrition Examination Survey III cohort, severe periodontal disease was linked to an almost four fold higher incidence of myocardial infarction than identified in patients without periodontal disease.4 In cross sectional studies, the cardiovascular risk linked with periodontal disease seems to depend upon the severity of the oral disease, and it was independent of common cardiovascular risk factors such as, smoking, obesity, diabetes and lower socio-economic status.4 Many prospective studies have proposed up to a 2.5 fold increased risk of developing complications of atherosclerosis among patients with periodontal disease.4 In a model of early atherogenesis, the presence of periodontitis significantly increased the extent of atherosclerotic lesions,1 but no periodontal bacteria could be identified in the vessel wall lesions. A similar experiment in mice demonstrated the same increase in atherosclerotic lesions, but in this case, periodontal pathogens were isolated from the vessel wall.1 The inflammatory burden of periodontitis is significant1 but it remains unclear what the role of periodontal bacteria plays in directly stimulating the inflammatory response in the vessel wall. The plausibility of such a role was strengthened when viable porphyromonas gingivalis were isolated from human atheromatous plaques.1 Conversely, two prospective studies failed to discover an association between periodontal disease and atherosclerosis after adjusting for other risk factors.4 Generally it is felt that periodontal disease can be linked to atherosclerosis but causation has not yet been fully proven.
Congenital heart disease (arising in 8/1000 live births) is common and an increasing number of children and adults have undergone successful cardiac surgery. There is strong evidence to suggest that untreated dental disease and the risk of oral bacteremia is an important aetiological factor in infective endocarditis.6 Endocarditis can be life threatening and is an infection of the inner surface of the heart or the heart valves. Oral bacteria have an affinity for damaged endothelial cells or blood clots within the heart, where they attach, divide and form larger bacterial colonies that trigger inflammation within the heart.
Patients may be alerted to the fact they have gum disease if they develop: bad breath that will not improve, red or swollen gums, tender or bleeding gums, pain when chewing, loose teeth, sensitive teeth or receding gums. Foster and Fitzgerald explained that periodontal disease broadly consists of two elements, gingivitis and periodontitis. Gingivitis is an inflammatory response of the gums to plaque and is present to some extent in most mouths. It is characterised by redness, swelling and bleeding (upon brushing) of the gums. Gingivitis can be reversed by controlling dental plaque (brushing teeth, flossing and using mouthwash). It can, however, lead to chronic periodontitis that cannot be reversed and is where the gums, periodontal ligament (which anchors the tooth in the jaw bone) and bone become progressively infected and inflamed. This subsequently causes destruction of the periodontium and loss of the tooth.6
There is a need to promote better dental health of all children and adults. It is recognised as a global public health concern.6 Practice nurses and other health care professionals alike play an important role to reinforce this advice, raise awareness of the importance of good dental health and encourage patients to see a dentist or dental hygienist every six months. They can educate patients regarding plaque control (tooth brushing twice a day, flossing and using mouthwash), dietary habits (particularly the frequency of sugary food and drink consumption) and promote the use of sugar free chewing gum. Prevention of poor oral health is the cornerstone of success for dental management.
As discussed in the Colgate oral and dental health resource centre report,2 the bacteria in plaque is the main cause of periodontal disease. Several other factors also contribute which include other diseases, medications and oral habits. These factors can increase the risk of gum disease or can make it worse once the infection has set in. It was illuminated that factors include:
2.Smoking and tobacco use. The risk of periodontal disease is higher the longer you smoke and more you smoke. Stopping smoking can play an important role in controlling periodontal disease.
3.Misaligned or crowded teeth, braces or bridgework. Anything that makes it more difficult to brush or floss the teeth is likely to enhance plaque and tartar formation. This increases the risk of developing gum disease.
4.Grinding or clenching teeth – these habits exert excess force on the teeth. This pressure can speed up the breakdown of the periodontal ligament and bone.
5.Stress can make periodontal disease worse and harder to treat. Increased glucocorticoid secretion can depress immune function, increase insulin resistance and potentially increase the risk of periodontitis.7
6.Fluctuating hormones – puberty, pregnancy and the menopause can temporarily increase the risk and severity of gum disease.
7.Medication – several medications can cause patients to have a dry mouth, for example certain drugs for depression, hypertension and overactive bladders. If saliva is reduced, plaque is more likely to form. Other medications can cause the gums to enlarge which makes them more likely to trap plaque e.g. phenytoin, cyclosporin and nifedipine.
8.Diseases – diabetics patients with rheumatoid arthritis and HIV patients are more likely to develop periodontitis.
9.Poor nutrition – for example vitamin C deficiency can cause bleeding gums.
Foster and Fitzgerald highlighted that poor oral health is also a risk factor for candidiasis, bacteremia and potentially life threatening septicaemia, particularly if the patient is immunosuppressed (e.g. HIV infection, receiving cancer therapies, using other immunosuppressant drugs such as steroids, methotrexate or azathioprine). Immunosuppressive therapies are commonly used in many inflammatory conditions such as rheumatoid arthritis, connective tissue disease, inflammatory bowel disease and myopathies. Transplant patients and those with polymyalgia rheumatica also use them. Inhaled corticosteroids (used in both asthma and COPD patients) can also increase the risk of oral candida.6 The main barriers to attending a dentist can include fear, lack of access to dental services by NHS patients, cost, lack of concern regarding dental care and apathy.6
Research is pointing towards an association between periodontal disease and the complications of atherosclerosis. More research is needed to ascertain the depth of this association. Periodontal disease encompasses a spectrum of severity and is thought to be triggered by an accumulation of dental plaque that results in mucosal infection and inflammation. Practice nurses have a key role in raising awareness of the importance of good dental health, educating patients about why good dental health will benefit them and encouraging them to see a dentist or dental hygienist regularly.
1. Van Dyke TE, Starr JR. Unraveling the link between periodontitis and cardiovascular disease. Journal of the American Heart Association 2013; 2:e000657
2. Colgate. Oral and dental health resource centre. What is periodontitis? www.colgate.com/app/CP/US/EN/OC/Information/Articles/Oral-and-dental-hea... (accessed 29 May 2015)
3. Kroes I, Lepp PW, Reiman DA. Bacterial diversity within the human subgingival crevice. Proceedings of the National Academy of Sciences USA 1999; 96 (25): 14547-145529
4. Haynes W, Stanford C. Periodontal disease and atherosclerosis- from dental to arterial plaque. Arteriosclerosis, Thrombosis and Vascular Biology 2003; 23: 1309- 1311.
5. Offenbacher S, Beck JD, Moss K et al. Results from the Periodontitis and vascular events (PAVE) study: a pilot multicentred, randomized controlled trial to study effects of periodontal therapy in a secondary prevention model of cardiovascular disease. Journal of Periodontology 2009; 80(2): 190-201
6. Foster H, Fitzgerald J. Dental disease in children with chronic illness. Archives of Disease in Childhood 2005; 90:703- 708
7. Merchant AT, Pitiphat B. A prospective study of social support, anger expression and risk of periodontitis in men. Journal of the American Dental Association 2007; 134(12): 1718-1723
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