A tune for all ages, "Heart and Soul" needs to be amended to: "Heart and Soul...and Daily Plaque Control"

True to life, nothing remains the same forever, even old standards like "Heart and Soul." We're referring to our old nemesis: dental plaque. Only this time, we're not talking about saving teeth, we're talking about saving lives. Witness the following articles that have appeared recently in our journals:

• "Periodontal Disease and Coronary Heart Disease Risk."*
• "Evaluation of Systemic Markers Related to Cardiovascular Diseases in the Peripheral Blood of Periodontitis Patients."**
• "Identification of Periodontal Pathogens in Atheromatous Plaques."***
• "The Relationship Between Periodontal Disease and Systemic Conditions."****

Wow, what are they telling us? Are we going to get a heart attack if we don't floss enough? The answer is, "Could be." Here are some facts to consider:

1. Patients who have suffered myocardial infarcts (MI) - after adjusting for age, social class, smoking, serum lipids, and diabetes - have a worse Total Dental Index (TDI) than do those in a healthy control group.
2. There is a significant association between dental infections and atheromatosis. While oral infections correlate to the incidence of stroke, it's the periodontal component that seems to be the culprit.
3. Bacteria from periodontal disease have been found in atherosclerotic plaques, which may lead to coronary vascular disease.
4. Risk factors for cardiovascular diseases are elevated in periodontitis.

Heard enough? There's more...like understanding how this may work.

The prevalent theory, these days, is that atherosclerosis is an inflammatory disease resulting from an initial injury to the epithelium lining the coronary vessels. This initial injury leads to a chronic inflammatory process (not unlike the way bacterial plaque irritates our gums). Monocytes are drawn to the injury site through the endothelium, along with a migration of smooth muscle cells. These events are followed by hydrolytic enzymes, cytokines, chemokines, and growth factors...all of which are activated in the blood vessel causing more localized damage.*****

If that wasn't bad enough, lipids accumulate at the site, too, forming an atheromatous plaque that can turn fibrous, becoming a "cap." This fibrous cap can erode and rupture, leading to a thrombus formation, arterial occlusion, and infarction.

Here's where it all comes together. When an individual is genetically predisposed to have an inflammatory response when challenged by bacteria, they produce more cytokines, prostaglandins, and tumor necrosis factor. These biological mediators have a direct effect on periodontal pockets, vascular endothelium, and smooth muscle.

What happens when periodontal pockets are challenged by bacterial plaque? The cellular response is to vasodilate (widen the capillaries and arterioles) and increase vascular permeability. This is followed in quick order by inflammatory cell recruitment, connective tissue degradation, and bone destruction. Translation: bone loss occurs and the gum pockets get worse.

Ah, but the head is connected to the body! What happens when major blood vessels are exposed to inflammatory cell recruitment? Vascular smooth muscles proliferate, vascular fatty degeneration occurs, and intravascular coagulation ensues, creating a greater risk for stroke and cardiovascular disease.

So are we all going to die from an MI or a slow cerebral leak...just because we skipped a night of flossing? Hardly. What can be surmised from the studies above, is that untreated periodontal disease may have some bearing in the health of people prone to cardiovascular disease. The results are a bit equivocal and should be viewed not as an indictment for untreated periodontal disease, but as a guideline for better health. What is needed now, are large prospective studies, that will help us better understand the interconnected role periodontal bacterial plaque plays in patients prone to heart disease.

*Hujoel P.P., Drangsholt M., Spiekerman C., and DeRouen T.A.: Periodontal Disease and Coronary Heart Disease Risk. JAMA 284:1406-1410, 2000.
**Loos B.G., Craandijk J., Hoek F.J., Wertheim-van Dillen P.M.E., and van der Velden U.: Evaluation of Systemic Markers Related to Cardiovascular Diseases in the Peripheral Blood of Periodontitis Patients. J Perio 71:1528-1534, 2000.
***Haraszthy V.I., Zambon J.J., Trevisan M., Zeid M., and Genco R.J.: Identification of Periodontal Pathogens in Atheromatous Plaques. J Perio 71:1554-1560, 2000.
****Rose L.F., Steinberg B.J., and Minsk L.: The Relationship Between Periodontal Disease and Systemic Conditions. Compendium 21:870-877, 2000.
*****Deliargyris E.: MI patients more likely to have periodontitis than healthy people. Paper presented at this year's meeting of the American Heart Association.

Diabetes and Periodontal Disease...
now there's something that can't be sugar-coated!

Like the periodontal diseases which are now classified into many different forms, Diabetes Mellitus (DM) comprises a group of disorders with the common characteristic of altered glucose tolerance or impaired lipid/carbohydrate metabolism. There are 12-14 million individuals with DM in the US, though half of those who have DM are unaware they are suffering from this condition. And while diabetics used to be classified by the types of medication and manner in which they controlled their problem, the American Diabetic Association now defines Type 1 DM (less common) and Type 2 DM (most common) based on the disease etiology. These "types" are defined by impaired glucose tolerance, impaired fasting glucose, and include gestational diabetes, plus others secondary to pancreatic disease, drug therapy, endocrinopathies, infections, and genetic disorders.

What's the relationship between DM and periodontal disease? Numerous studies have demonstrated that individuals with more advanced systemic complications from DM usually have a higher frequency of periodontal disease...and it is not because these individuals have more plaque and calculus. In study after study, those with poorly controlled DM - both Type 1 and Type 2 - have greater bone loss and more missing teeth than well-controlled individuals. Furthermore, uncontrolled diabetics were at risk for progressive periodontal problems including frequent dental infections and experienced poor healing.

The dental consequence of having DM is clear: make certain that your periodontal condition is treated and well-maintained. One reason for this is that the presence of advanced periodontal disease and dental infections may increase insulin resistance and contribute to a worsening of the diabetic state. It is possible for dental infections to become life-threatening to an uncontrolled diabetic.

Diabetics should take heart. As their dental problems are cared for, their glycemic control improves. As their diabetic condition comes under control, their dental problems can more easily be treated. It has been established that a well-controlled diabetic experiences the same short-term responses to periodontal therapy as non-diabetic individuals. While procedures rendered to diabetic individuals should be of shorter duration and less traumatic so as not to stress their systems, well-controlled diabetics can expect to receive "normal" care for all their dental needs, including periodontal surgeries and dental implants.

Committee on Research, Science and Therapy of the American Academy of Periodontology. J Perio 71:664-678, 2000.

"Guys and Dolls"

While all dental practices are filled with male and female patients, it is apparent that women seek personal care more than men. This is probably true for a host of reasons. Women learn to accept "grooming" from others at an early age. The stereotype is that they braid each other's hair, have their nails polished, and usually have strong role models in mothers and sisters who receive regular gynecologic care. This acceptance of allowing "strangers" to care for them continues throughout their lives. For these and many other reasons - including cosmetic needs and just being practical - women seek dental treatment more than men do. In fact, women are often better dental patients because they are used to receiving regular care from others.

Where do men fit into this scheme of receiving care from others? They get haircuts; that's about it. They grow up expected to follow the macho values of being rugged, self-sufficient, and always trying to win...to come out on top. These values continue into adulthood where men still don't like to lose control and have others have the upper hand...not in the boardroom and not in the dental chair. This explains why men often squirm and wiggle as they are treated. When asked to open their mouths wider, they involuntarily open their eyes and close their mouths...unconsciously retaining those last few moments of control. Not all men behave in a dental chair in this manner, but it does happen.

Having labeled "guys and dolls," it's time to get more technical when it comes to men and their periodontal health. We all know that men have shorter life spans and greater risks for heart attacks. They have higher cancer rates, too. Now, we learn that men have more periodontal disease than women. Various studies report that 30-54% of all men have periodontal problems as compared to 23% of women.*

The reasons? Men have poorer oral hygiene habits and they don't seek out professional care as often as women do. Maybe it's the macho thing, maybe it's not liking others to care for them, or maybe it's not being comfortable in giving up control....even in a dental chair. No matter the reason, these facts are unassailable:

- people (men?)with advanced periodontal disease are 4.5 times more likely to have chronic respiratory disease.
- people (men?) with periodontal disease may have nearly twice the risk of having a fatal heart attack as those without periodontal disease.

There are remedies to these scary statistics. For starters, improve your oral hygiene with proper toothbrushing techniques and flossing daily. Seeking professional dental care is necessary to help remove the hard-to-reach plaque and tartar left on the teeth, and to help restore the gums to better health. Moreover, receiving a complete periodontal examination and then treating gum pockets will not only improve your dental heath, but your overall medical health as well. Men, are you listening?

*AAP Patient Page, September/October 2000, Vol. 1, No. 3.

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