Running Time: 35 min
Discuss biological plausibility of periodontal-systemic links Discuss association between periodontal disease and other life threatening diseases and conditions Discuss key systemic link diseases and patient management of diseases Identify the components and functions of saliva, some treatment options and products available to help achieve oral comfort. Release: 9/26/2014 | Expires: 9/26/2017
Release Date: September 30, 2014Subtitle:
Welcome. My name is Karima Bapoo-Mohamed. I’m a dental hygienist from Edmonton, Alberta, Canada. And I’m also the associate clinical professor where I work part-time at the University of Alberta in Edmonton. As a dental hygienist, I am super excited to see a body of evidence coming out with the linkages of periodontal disease and its far reaches within the systemic disease context. So this way, we can actually help prepare and inform and educate our patients a little better. So this module really is dedicated to start out with, what is the biological plausibility of periodontal and systemic diseases links? We’re going to then see this association with some of the life-threatening diseases and conditions, and actually talk about the systemic links in the milieu of patient management of these diseases. And what is the implication for our patient, once we make those discoveries of high risk? And really end off the module with talking about saliva, its functions, and its indications, as far as salivary diagnostics go. So starting out with the first statement– actually, this is an interesting comment by the Surgeon General, which says, the mouth is a mirror of health and diseases. And it’s sentinel or an early warning system to access models of study for other tissues and other organs in the body. And really, it can be a potential force of pathology affecting different systems and different organs. So right there, this definition just tells us that the mouth is so much more than just periodontitis, or teeth cleaning, as we are normally referred to. So what are some of those systemic links? And there’s lots of literature out there, and some of the key ones we’re going to discuss a little later on. But when you look at the burden of periodontal disease, it;s is thought to have pretty wide variety of associations. They range from respiratory diseases of pneumonia or COPD. There are also suggestions of an adverse pregnancy outcome based on active periodontal disease, atherosclerosis relating to cardiovascular diseases, as well as chronic diseases and complications of dialysis has also be linked with periodontal disease. The list goes on. Obesity, osteoporosis, rheumatoid arthritis. We also notice that diabetes severity and intensity is increased with uncontrolled periodontal diseases. And of course, there is a genetic predisposition, as well. So we’ll get into all of this and talk about some of these diseases. Currently, there are some areas also under investigation between periodontal disease and the systemic links. And these include neurodegenerative diseases, such as Alzheimer’s, or peripheral vascular diseases. There’s also some thought on complications with solid-organ organ transplants, as well, based on active periodontal disease status of the mouth. So really, the biological plausibility of the periodontal systemic disease is the fact that periodontitis is an oral disease. But what’s interesting is it’s not limited to the local tissue destruction, that it has various inflammatory pathways. And these pathways link periodontal disease to different systemic damage. Some of the processes in which it does that is how metastatically, it will spread by gram negative bacteria, and really gain access to the vasculature by compromising the epithelial lining of the periodontal pockets. So really, what we do on a daily basis for hygiene and maintaining the integrity of that epithelial lining in periodontal pockets is critical, especially with the new evidence that’s coming out. And this metastatic injury can actually create a circulation of toxins of periodontal pathogens that can go and, in an opportunistic way, disable or harm different areas or components of your body. This, of course, is all underpinned with host immunity, which we will talk about. But I just wanted to share some of the key processes that come out. This is an interesting term coined for systemic periodontitis, which really, periodontitis is a localized relation. But as the term goals, it has a far-reaching effect through the bloodstream, affecting different organs in different parts of the body. Systemic inflammation happens actually by the bacteria crossing the epithelial wall up the gingival sulcus. And then, it will release a lot of toxins, disrupt that membrane– the basal membrane– and the epithelial membrane actually, where we work subgingivally with our scalers. And again, based on host response and patient immunity or lack of immunity, these toxins make it possible then for the bacteria to enter and go into the different areas of the body. The body reacts by production of cytokines, which is an inflammatory signal for the body to then go give a full-fledged inflammatory reaction. So the cytokines, as we mentioned, is a wide range of pro-inflammatory proteins. And they affect other diseases which are inflammation-based, such as diabetes, rheumatoid arthritis, ABS. Actually, obesity is also something that’s been suggested as being an anti-inflammatory disease. So by this pathway, we have compounds that enter the bloodstream. And some of the common factors of this is that periodontal disease reduces the overall ability for the patient to cope with other diseases. So really, the suggestion is if we can lower the total body inflammation, it might quell some of the periodontal disease. So it’s considered reversing it by saying, now that we know that the link exists and there’s an interdependence, a, we can control the periodontal disease so it doesn’t transcend into the other areas and organs causing this diseases. But the reverse way is if we can look after the total body’s inflammation, it may help us with the prevention and treatment and cure of periodontal disease locally. So really, the message for us as dental hygienists is we want to really monitor very closely our high-risk patients. And we’re going to take a good chunk of time discussing what are those high-risk conditions or diseases that we should be watching out for. And what are some of the preventative measures we could be taking for our patients? Periodontitis begins with the penetration of the gram negative, anaerobic bacteria. As we know, it goes into the gingival sulcus. What’s interesting, the P. gingavalis appears to be really greatly associated with the systemic response. So watching out for the levels of the P. gingivalis would give us a clue as to the risk of this patient maybe getting atherosclerotic plaque in their blood vessels later on. Genetics– tons of studies done around this area show that 50% of periodontal critical severity is explained by genetic influences. And they’ve isolated the gene, of course, the Interleukin-1 gene cluster, or IL1, as it’s often referred in most literature. There’s also another study that shows that there’s a risk factor of a myocardial infarct or heart attack, which is connected with periodontitis. And it’s a similar set of genes that cause one and the other. So really, it creates an urgency enough for early diagnosis, early discovery, and early treatment of periodontal disease, so that it reduces the risk of coronary diseases. Let’s talk about the association between periodontal diseases and some of these life-threatening diseases. Well, when we look at cardiovascular diseases, we know that the bacteria from the mouth can enter the bloodstream through a compromised epithelial lining. And once it’s in the bloodstream, the bacteria really can bind into platelets that causes clotting inside the blood vessels. And these little clots or clumps increase the risk of heart attack. One theory is that the bacteria stick to the fatty plaques in the bloodstream, and they directly contribute to this blockage of the artery. Another theory suggests that the bacteria, once they enter the bloodstream, they actually stimulate an immune response, which involves the C-reactive protein. And that stimulates the arterial wall thickening. So a few thoughts for pondering. But we do know that the bacteria in the mouth biologically has a plausible connection with cardiovascular diseases. So again, the increased risk of stroke, of coronary artery diseases, is heightened, because of the thickness of this carotid artery. And it is related to the plaque aggregation and the clotting that’s formed on there. This study actually shows the direct relationship between the presence of periodontal disease, and really that of the subclinical sign of atherosclerosis. We mentioned stroke earlier. And I said the C-reactive protein is basically present in the blood plasma. And it’s a sensitive marker– a sensitivity marker, I should say– for inflammation. So higher or elevated levels of C-reactive protein actually show that the body is in a state of a heightened sense of inflammation response. Something is triggering it to produce more CRP, which is then making the body get in a tailspin and really give us a higher inflammation. So really watch out for the CRP content in our body. When we look at the periodontal disease and how directly it’s connected to the body– just to recap, we talked about heart diseases. We talked about stroke. And of course, there is the suggestion of the premature low birth weight babies. Depending on the study you go to, it’s anywhere from seven times to four times greater risk of having low birth weight babies if you have uncontrolled periodontal diseases. How does that actually happen? Well, the possible mechanism we’re thinking is that yes, the gram negative bacteria enter, causing the risk of bacteremia. And it enters the bloodstream, stimulating the prostaglandin PGE and the TNFA. This releases a fetotoxic cytokine into the blood. And the production of this actually sends a signal for a preterm partuition. So really, when you have patients who are newly pregnant or along their way for pregnancy, it’s really important to have optimum oral hygiene and dental health taken care of. Diabetes– absolutely, we’ve heard so much evidence, and witnessed with patients. It seems like every third, fourth patient I see nowadays is now diagnosed diabetic. And there has been shown a threefold increase in periodontal disease among the uncontrolled diabetes, according to this one study. There have been other studies, as well, of how uncontrolled diabetic cohorts go as high as six times more likely than the non-diabetic population. But the incidence and prevalence of diabetes, it seems like, is on the rise. And the chemicals, such as the interleukin and the triglycerides, are the ones that actually are responsible for setting off that inflammatory reaction. Obesity, of course linked with type 2 diabetes, may predispose a person to periodontal disease or higher risk of periodontal disease. So let’s talk a little bit about what is type 1, type 2, just to refresh our memory. Type 1 diabetes is when the B cells, which are in the pancreas, that manufacture insulin are actually destroyed by the body’s immune system. So it really impairs the glucogen pathways. So really, there is glucose. But the cells are literally starving for glucose, because they just can’t access the glucose that’s in the blood supply. So what happens is the body, in a survival mode, is trying to look for glucose. And a process called glucogenesis happens, where they find glucose from non-carbohydrate sources, such as protein. And that result– or actually, lactose, as well, will be a source of sugar. And by this time, the blood levels of sugar become so high that they create this hyperosmotic condition. The kidneys now respond to this high elevated glucose levels in protein by clearing this extra glucose into the urine. So urine samples with high glucose would absolutely be an indication of diabetes. Type 2 diabetes actually makes up 90% of the cases that we see as how the incidence and prevalence of disease is. And again, it’s characterized exactly the same way. There is a high blood sugar content. However, it is more in the context of insulin resistance, or lack of insulin. So really, the primary reason in diabetes type 2, unlike type 1, is the B cell death is not an autoimmune destruction. So it’s actually due to fatigue, and just the body just gives up. It just can handle it. So the pancreas gradually lose their ability to produce insulin, and insulin resistance occurs. And the cells no longer respond in a normal way. And they can’t take up the glucose for the cellular needs. So what does that mean to us as dental hygienists? Well, there are so many undiagnosed, undetected cases of diabetes. And it behooves us as dental professionals to learn, what are some of the classic signs and symptoms? For example, a patient coming in with an unexplained weight loss may very well be that he’s starving his body. And he may be type 1 diabetic. Excessive thirst, frequent urination, constant hunger are other classic signs and symptoms of diabetes that may be undetected. So I think we, as dental hygienists, can play a very key role in perhaps triaging or segueing that care to the patient to a medical doctor as soon as possible. Alternatively, if I’m seeing things in the mouth that wow, they have really progressed a little too rapidly. For example, deepened periodontal pockets that weren’t that deep maybe a few recalls ago. It may make me suspicious that there may be evidence of some systemic disease going on, and it could very well be diabetes. Asking the questions, on some guided questioning, I suppose, on signs and symptoms, and making a referral to the medical doctor. So I think as hygienists, we can play a key role in helping detect some of these cases. And when we are updating our medical history with the patient, absolutely we’re asking if they’ve been diagnosed diabetic. Patients who are diabetic, we ask them, what’s your blood sugar level? Do you take them routinely? Have you taken them today? Another key parameter to ask is the A1C levels. What are your A1C levels? And this is something that the doctor may prescribe for the patient, for the diabetic patient to have it done occasionally. It’s a blood test that actually responds to the hemoglobin. And it talks about– What’s nice about the A1C is it gives you a blood sugar control reading over the last six to 12-week period. So you can really see if their blood sugars have been fluctuating rapidly, or it has been a fairly even keel. Just for our knowledge, of course, we want the A1C level to be less than 7% in most circumstances. So if you’re asking the questions, we want to know what number are we looking for to be the norm or to be the acceptable range for our patients, and really looking out for those higher-risk patients before they come into more complications. So controlling diabetes for patients who are more– actually, patients who have uncontrolled diabetes are actually more prone for rapid bone loss. And this is a fight between the osteoclastic and osteoblastic cell activity, where the osteoclasts win. And they actually cause a rapid destruction of bone. And actually, it’s at an accelerated pace, as well. Also, presence of periodontal disease depends strictly on that persistent presence of dental plaque. So what kind of home care routine and oral hygiene sustenance do the patients have in maintaining their oral care, especially now that they’ve been diagnosed diabetic? Hyperglycemia and periodontal disease– of course, maintaining that good glycemic control really helps control the damage to the vascular and neurological systems. And really, the hyperglycemia is the cause of these extra cytokines that are found in the inflamed gingival tissue. So again, watching out for these glycemic levels, because we know it can cause destruction of the alveolar bone. What are these cytokines? they are the pro inflammatory messengers that travel through the body. And really in diabetes, it can cause the cell death and the insulin resistance, right? So we want to watch out for it, because it can also– cytokines are also responsible for collagen destruction, as well as the alveolar bone loss, as we mentioned. There’s three types of cytokines that are listed on there. And the Interleukin IB is usually the one. Or prostaglandins we may hear of quite often, as well. So really, the common denominator, the biological denominator through all of this is the inflammatory action of diseases, and that diabetes releases more inflammatory peptides, because of the P. gingivalis and then this leads to a whole chain reaction of the cytokines. Let’s move on now to the key systemic links, and what are some of the disease that we want to manage with that. Obesity– we mentioned that earlier. Actually, the prevalence of periodontal disease is likely to be higher amongst obese patients. And there has been some evidence that’s pointing in that direction, that again, it’s the cytokines that are greatly influenced in the obesity. And that it affects, actually, a diverse range of population. So really again, to reinforce our role as dental hygienists– aside from oral care– we want to continue stressing the importance of maintaining a healthy weight, and staying and remaining healthy through our life. The Body Mass Index and probe reading’s interesting study, where those two are positively correlated. And they have noticed that there is an increase in the TNFA-alpha associated with obesity. And that may be influencing, actually, periodontal disease. And specifically, the proxy for that periodontal disease was increased pocket depth. So I thought that was fascinating. Patients with atherosclerotic diseases of CVD or events that have increased over time are also linked with chronic inflammatory diseases. Aside from periodontitis, it’s also linked with rheumatoid arthritis, psoriasis, systemic lupus, as well as respiratory and urinary tract infections. So when we look at respiratory infections, of course, pneumonia, chronic obstructive pulmonary diseases– known as COPD– have been linked with poor oral health in many studies. In fact, one study shows that 35 million Americans suffer from COPD as one of the pulmonary diseases. So really watching out and taking a comprehensive exam. Watching how our patients are breathing, just walking from the reception area to the dental operatory, to see are they out of breath. Is there a noisy sound when they’re breathing, may lead us to understand if there has been any history of pulmonary diseases. Pneumonia absolutely is a potential risk factor, as well, that’s been identified with cariogenic and periodontal pathogens. And dental decay has also been linked with pneumonia in certain studies. The higher cohort of population has shown that it’s women, the elderly, and people with, of course, preexisting health conditions and diabetics are at even higher risk for pneumonia if their oral hygiene isn’t optimum or well-maintained. We’ve talked about systemic diseases and its link with periodontal diseases. What I’d like to segue into is a lot of these systemic diseases have an oral manifestation that stares us right in the face. And that is xerostomia, or hyposalivation. A lot of the patients who are on a multitude of medication, for example, will have a dry mouth syndrome. So we’re going to spend the next few minutes talking about what is it that the saliva is composed of, what are its functions, and what are some of its treatment options we can present to our patients manifesting dry mouth syndrome. As we know, saliva– it’s mostly composed of water. And there is a small percentage of enzymes. And it does have a lot of secretions. We now have technology that enables us to actually do a saliva test, which really gives us another window into the body and exploring to detect diseases or monitoring our health. Function of saliva, of course, is maintenance of oral homeostasis. Saliva has a neutral or slightly alkaline pH, and it really helps neutralize things, keep things at an even keel in our mouth. Not having enough saliva absolutely has a pH implication in the mouth, not to mention that the patient’s quality of life is significantly impaired, as I’m sure you have witnessed in your private practices, where patients just can’t chew properly. Hyposalivation may be because of a multitude of things, actually. I mentioned earlier it could be not just the medication, but the combination of the medications that patients are taking. It could be a side effect of certain diseases that they have or certain conditions that they may have. It could also be a side effect of some medical treatments that they’re undergoing or have recently undergone. Hyposalivation may also be due to some nerve damage. It could be because of dehydration. It could be because of some surgical intervention and possibly some lifestyle choices that the patient has adopted that’s leading to xerostomia and dry mouth syndrome. The functions of saliva– we alluded to that earlier– absolutely is important for lubricating, moistening the food. Because if we don’t have enough saliva, the bolus isn’t formed when we have our food ingested, and it doesn’t allow us to actually push it down the esophagus and be absorbed and broken down by the stomach acid. So the function of saliva– yeah, carbohydrate breakdown doesn’t start in the stomach. It starts right here in the mouth with the help of our saliva. So a lot of times, patients who don’t have enough saliva may have stomach digestion issues, as well. And they never have made that connection that that could cause it. There’s also digestion. The digestive system is very much reliant on the saliva in the mouth there for absorbing and breaking it down, because the small interstine isn’t capable of absorbing the big chunks. So it has to start from the mouth. And of course, saliva has the antibacterial properties to really protect the body from all the infections, as well. And they’ll also have some remineralizing capacity. Saliva has calcium and phosphate. And people who don’t have enough saliva are at higher risk for dental caries, because its remineralizing ability of the enamel is now deteriorated or reduced. We mentioned medication to treat various diseases and ailments can actually cause hyposalivation. Some of these include depression, anxiety– pain medication is amazing for side effects of dry mouth. People on allergic medications– allergies or colds. Obesity, as well, can have a hyposalivation effect. Acne, epilepsy, hypertension– urinary incontinence medications can also cause xerostomia. This is just a quick list of some of some of the medications in the marketplace that do cause very dry mouth or hyposalivation. As you can see, morphine is up there as one of the largest percentage of incidence of dry mouth. And these are just some drugs that are less than 10% incidence. But a lot of them, you’ll probably recognize them as our depression medication, as well. So patients, as you’re updating the medical history, say they are on some antidepressant pills, curious to know what they are and what the dosage is, because it has an oral effect right away. Other diseases and infections, of course, include Sjorgens syndrome, the HIV/AIDS, Alzheimer’s, diabetes, anemia, cystic fibrosis, rheumatoid arthritis, as well, hypertension, and Parkinson’s disease. So let’s talk about a few of them, and how they relate to lack of saliva in the mouth. Sjorgens disease is actually an autoimmune disease where the body is now mistakenly attacking its own moisture-producing cells. So patients just for some reason now stop producing saliva in their mouth. It affects about 44 million Americans to date, and nine out of 10 are actually female patients. Average age of onset’s around the 40-years mark. These are just averages, but that’s what the statistics out there show. And the other statistics show that 55% occurs on its own. But 55% occurs in the presence of some other connective tissue diseases. And I have a slide showing what those connective tissue diseases are. But just for your information, how much saliva– how important is saliva? It’s just a little spit in your mouth. Well, believe it or not, you are producing one to two liters of this “spit” on a daily basis in your mouth. So not having that is a big void, and causes a lot of difficulties, as was mentioned based on the saliva. This is a patient manifesting– actually a Sjorgens disease patient manifesting a tongue that is absolutely dry and gritty. And part of the symptoms is also burning and itching sensation of the tongue and the eyes. They really have difficulty talking and chewing. And this lady carries a water bottle with her everywhere she goes. It is a very– actually, the corners of the lips can be really cracked and sore, aside from the tongue having cracks and sores on them, and always talk about this burning sensation in the mouth and the throat. So all of this actually impairs the sense of taste and smell for the patient, too. And we talked about the digestive system, how saliva’s so important for the breakdown of carbohydrates, and not having enough saliva will create digestive problems. The other four common diseases that are linked with Sjorgens is rheumatoid arthritis, systemic lupus, of course, scleroderma, and fibromyalgia. So patients who are diagnosed with Sjorgens you want to closely monitor or inspect for these other diseases, because usually, they are linked or can be linked with one of these four diseases. Let’s talk about risk factors, and then move on to how can we reduce or remove some of these risk factors for our patients. Some are controllable, like alcohol consumption, smoking. And even smokeless tobacco absolutely is a huge risk factor for our patients. Combining the alcohol with the tobacco actually increases the risk 15 times more, according to some studies. Exposure– excessive exposure to the sun, nutritional deficiencies. Exposures to viruses with your immunity not being quite as high would definitely become a risk factor for you. Crohn’s disease– again, there’s is an interesting study out there, the higher incidence of caries in patients with Crohn’s disease compared to patients who didn’t manifest any Crohn’s disease. So people who get diagnosed with Crohn’s– and I have actually more so than now– I don’t if it’s because my population base is aging in my dental hygiene practice. But I do have patients who are intolerant to wheat products, and Crohn’s disease is also another issue. So saliva has many properties that are similar to blood. And so this is why instead of doing blood samples all the time, the future research shows that maybe taking a saliva sample may really help eliminate the need for blood sampling. Saliva is actually already being tested for HIV, for certain hormonal and alcohol levels, as well. So at the end of this, let’s recap. We started out with the biological plausibility of, what is that periodontal disease link with the systemic diseases? Then, we talked about what are some of these key systemic diseases that are life-threatening? Like cardiovascular, you can get a massive heart attack having not controlled your periodontal disease. It’s interesting. I tell my patients, it’s not that I can get to your heart or your lungs or any of that, but I can sure get to your mouth, and so can you. So let’s work together on keeping this environment as clean as possible. We can’t sterilize your mouth. There’s good bacteria that live in your mouth. We just don’t want the opportunistic bacteria to get in and take over that environment for us. And the last thing we ended up with was, of course, the functions of the saliva as a byproduct of patient medications or diseases that cause dry mouth for our patients. I would like to end the module today with a Chinese saying on change. This is the Great Wall of China. And the saying goes, “When the winds of change are blowing, some people are running away from the wind and actually building shelters. But the others are building windmills.” So the idea here is to really look for any change as an opportunity for something positive. We could be building windmills from this new diagnosis, new body of evidence, and new research, and see how we could better be prepared and help our patients in creating awareness of this periodontal link with the systemic diseases. I thank you for your time. Bye bye.