Special Topic No. 8

References

1. Genco RJ & Williams RC 2010. Overview. 16. Herzberg MC & Weyer MW 1998. Dental plaque, 27. Howell TH, Ridker PM, Ajani UA, Hennekens CH In: Genco RJ, Williams RC (eds), Periodontal platelets and cardiovascular diseases. Annals of & Christen WG 2001. and disease and overall health: a clinician’s Periodontology 3:151–160. risk of subsequent in guide. Pennsylvania: Professional Audience US male . Journal of the American 17. US Surgeon General’s Report 2010. How Communications, 1–4. College of Cardiology 37:445–450. Association between cardiovascular diseases and periodontal disease - what do we know? Tobacco Smoke Causes Disease: The Biology Heart Diseases 2. Mattila KJ, Nieminen MS, Valtonen VV et al. and Behavioral Basis for Smoking-Attributable 28. Paquette DW & Genco RJ 2010. Association 1989. Association between dental health and Disease. Washington,DC: US Department of between periodontal disease and atheromatous acute myocardial infarction. British Medical Health and Human Services, pp. 3–12. diseases. In: Genco RJ, Williams RC (eds), Journal 298:779–781. Periodontal disease and overall health: a Seymour GJ, Ford PJ, Cullinan MP, Leishman 18. clinician’s guide. Pennsylvania: Professional There has been a growing body of research S & Yamazaki K 2007. Relationship between inspired researchers to revisit the relationship between 3. DeStefano F, Anda RF, Kahn HS, Williamson DF Audience Communications, 112–131. & Russell CM 1993. Dental disease and risk of periodontal infections and systemic disease. on periodontal disease carried out over the oral health and general health. This, in turn, led to a coronary heart disease and mortality. British European Journal of Clinical Microbiology & 29. Tonetti MS, D’Aiuto F, Nibali L et al. 2007. past five decades, and three distinctive series of research activities exploring the influence of Medical Journal 306:688–691. Infectious Diseases 13:3–10. Treatment of periodontitis and endothelial function. New England Journal of Medicine phases of this research, namely the periodontal disease on cardiovascular health to such an Figuero E, Sánchez-Beltrán M, Cuesta-Frechoso 4. Scannapieco FA 2006. Pneumonia in 19. 356:911–920. extent that publications on this theme have appeared in nonambulatory patients: the role of oral bacteria S et al. 2011. Detection of periodontal bacteria aetiopathologic phase, the risk factor nearly 200 different journals over the past two decades11. and oral hygiene. Journal of the American Dental in atheromatous plaque by nested polymerase 30. Paraskevas S, Huizinga JD & Loos BG 2008. phase and the periodontal disease–systemic Association 137:21S–25S. chain reaction. Journal of Periodontology A systematic review and meta-analyses on A new term—'periodontal medicine'—also evolved by the 1 82:1469–1477. C-reactive protein in relation to periodontitis. health phase, have been identified . More end of the 20th century, acknowledging the significance 5. Mealey BL 2006. Periodontal disease and Journal of Clinical Periodontology 35:277–290. diabetes: a two-way street. Journal of the 20. Loos BG, Craandijk J, Hoek FJ, Wertheim-van recently the focus has been on the third of periodontal–systemic relationships12. Notwithstanding American Dental Association 137:26S–31S. Dillen PM & van der Velden U 2000. Elevation 31. Offenbacher S, Beck JD, Moss K et al. 2009. phase, where the influence of periodontal this growing body of evidence, there may be a lack of of systemic markers related to cardiovascular Results from the Periodontitis and Vascular congruity among researchers with regard to comprehensive 6. Taylor GW & Borgnakke WS 2008. Periodontal diseases in the peripheral blood of periodontitis Events (PAVE) study: a pilot multicentered, disease on systemic diseases has been disease: associations with diabetes, glycemic patients. Journal of Periodontology 71:1528– randomized, controlled trial to study effects of considerably explored. Consequently, understanding of periodontal–cardiovascular relationships, control and complications. Oral Diseases 1534. periodontal therapy in a secondary prevention which further substantiates the need for this kind of 14:191–203. the emerging evidence may point to a model of cardiovascular disease. Journal of information sheet. 21. Lalla E, Lamster IB, Hofmann MA et Periodontology 80:190–201. 7. Offenbacher S, Katz V, Fertik G. et al. 1996. al. 2003. Oral infection with a periodontal significant association between periodontal Periodontal infection as a possible risk factor pathogen accelerates early atherosclerosis 32. Budoff MJ, Achenbach S, Blumenthal RS et al. disease and certain systemic diseases Risk Factors for preterm low birth weight. Journal of in apolipoprotein E-null mice. Arteriosclerosis 2006. Assessment of coronary artery disease Periodontology 67:1103–1113. Thrombosis & Vascular Biology 23:1405–1411. by cardiac computed tomography. A scientific and conditions including cardiovascular The aetiology for both cardiovascular diseases (CVD) statement from the American Heart Association 2,3 4 11 8. AIHW 2010. Australia’s health 2010. Australia’s Li L, Messas E, Batista EL Jr, Levine RA & Amar diseases , respiratory diseases , diabetes and periodontal disease (PD) is multifactorial in nature . 22. Committee on Cardiovascular Imaging and Health Series no. 12. cat. no. AUS 122. S 2002. infection 5,6 Porphyromonas gingivalis Intervention, Council on Cardiovascular and complications of diabetes and Modifiable risk factors for CVD include dyslipidemia, Canberra: AIHW. accelerates the progression of atherosclerosis Radiology and Intervention, and the Committee 7 smoking, diabetes mellitus, hypertension, physical inactivity in a heterozygous apolipoprotein E-deficient adverse pregnancy outcomes . Of these, 9. Claffey NM, Polyzois IN & Williams RC 2010. on Cardiac Imaging, Council on Clinical and obesity, while non-modifiable risk factors associated History of the oral-systemic relationship. In: murine model. Circulation 105:861–867. cardiovascular diseases are regarded as the Cardiology. Circulation 114:1761–1791. with CVD are age, ethnicity, sex and family history of Genco RJ, Williams RC (eds), Periodontal 23. Senba T, Kobayashi Y, Inoue K et al. 2008. The 33. Nichols TC & Paquette DW 2010. Dental and leading cause of mortality in Australians, 11,12 disease and overall health: a clinician’s association between self-reported periodontitis cardiovascular diseases . It has been established that medical comanagement of cardiovascular guide. Pennsylvania: Professional Audience and coronary heart disease—from MY Health accounting for not only over 16% of all these factors play a prominent role in atherosclerosis, disease. In: Genco RJ, Williams RC (eds), Communications, 42–54. Up Study. Journal of Occupational Health Periodontal disease and overall health: a deaths but also 16% of the total disease and that timely intervention in modifiable risk factors, in 50:283–287. 10. Crocombe LA & Slade GD 2007. Decline of the clinician’s guide. Pennsylvania: Professional burden in 20078. The aim of this information particular, is crucial in halting the atherosclerotic process edentulism epidemic in Australia. Australian 24. Geismar K, Stoltze K, Sigurd B, Gyntelberg Audience Communications, 238–249. as well as the clinical manifestations associated with it. Dental Journal 52:154–156. F & Holmstrup P 2006. Periodontal disease sheet is to update dental professionals 34. Johnson RK, Appel LJ Brands M et al. 2009. and coronary heart disease. Journal of 11. Lockhart PB, Bolger AF, Papapanou PN et al. Dietary sugars intake and cardiovascular health. on the cardiovascular–periodontal disease Local colonisation of dental plaque-forming bacteria, Periodontology 77:1547–1554. 2012. Periodontal disease and atherosclerotic A scientific statement from the American Heart relationship. systemic conditions including diabetes mellitus, vascular disease: does the evidence support an Association. Circulation 120:1011–1020. 25. Andriankaja O, Trevisan M, Falkner K et al. 2011. osteoporosis, and respiratory independent association? A scientific statement Association between periodontal pathogens and 35. Friedewald VE, Kornman KS, Beck JD et al. from the American Heart Association. Circulation risk of nonfatal myocardial infarction. Community diseases are associated with the aetiology of PD, whereas 2009. The American Journal of Cardiology and Background 125:2520–2544. Dentistry & Oral 39:177–185. Journal of Periodontology Editors’ Consensus: age, ethnicity, sex, smoking, stress and poor coping Oral had been cited as a cause for systemic illness 12. Williams RC & Offenbacher S 2000. Periodontal 26. Lund Håheim L, Olsen I, Nafstad P, Schwarze periodontitis and atherosclerotic cardiovascular behaviour, and obesity have a key role in the development medicine: the emergence of a new branch of P & Rønningen KS 2008. levels to disease. American Journal of Cardiology as far back as 1880 when an American dentist named Miller of the disease1,11,13–16. In fact, smoking has been implicated periodontology. Periodontology 2000 23:9–12. 104:59–68. single bacteria or in combination evaluated postulated the where microbes in the as a cause of PD in the US Surgeon General’s report17. 13. Hujoel PP, Drangsholt M, Spiekerman C & against myocardial infarction. Journal of Clinical oral cavity were implicated in systemic diseases9. This was Periodontology 35:473–478. Acknowledgement: This material was prepared DeRouen TA 2000. Periodontal disease and by Dr Najith Amarasena. followed by a remarkable increase in tooth extractions relative Interestingly, PD and CVD share many risk factors such coronary heart disease risk. Journal of the American Medical Association 284:1406–1410. to restorative treatments in dentistry until the late 1940s—all as smoking, diabetes mellitus, age, ethnicity, sex, periodontally and endodontically involved teeth were pulled socioeconomic status, stress and obesity, which would 14. Andriankaja OM, Genco RJ, Dorn J et al. 2007. 9,10 Periodontal disease and risk of myocardial Further information out to avoid possible foci of infection . However, with the possibly result in confounding any association between infarction: the role of gender and smoking. development of biomedical research and emerging evidence them11,13. For instance, smoking, which is strongly linked European Journal of Epidemiology 22:699–705. Dental Practice Education Research Unit against the focal infection theory, this era came to an end by with both PD and CVD, may hamper understanding PD– 15. Dorn JM, Genco RJ, Grossi SG et al. 2010. ARCPOH, School of Dentistry, the mid 20th century. Consequently, little was discussed about CVD relationships. Nonetheless, some studies have Periodontal disease and recurrent cardiovascular The University of Adelaide, South Australia 5005 the relationship between oral health and systemic diseases until shown that cardiovascular events may occur among non- events in survivors of myocardial infarction (MI): 1989. The finding that oral health was significantly worse in smoking patients with PD, even after controlling for other the Western New York Acute MI Study. Journal of Phone (08) 8313 4045 Toll Free 1800 805 738 Periodontology 81:502–511. patients with a history of acute myocardial infarction compared confounding variables, and hence PD may be related to Email [email protected] with control subjects, as revealed by Mattila and colleagues2, has CVD regardless of the confounding effects of smoking14,15. Website www.arcpoh.adelaide.edu.au/dperu COLGATE DENTAL EDUCATION PROGRAMS A joint program by Colgate Oral Care and The University of Adelaide Pathophysiological pathways accident (stroke), acute myocardial infarction and acute inflammation is corroborated by level of evidence A, neither patients already afflicted with, or at risk of developing, PD coronary syndrome. In these studies PD has been the causative role played by PD in CVD nor the effect of and CVD33,35. Various pathogenic mechanisms have been proposed assessed by self-reporting23, clinical or radiographic periodontal therapy in decreasing systemic inflammation is to explain the association between PD and CVD. These measurements24, bacterial colonisation25 and serological supported by levels of evidence A or B11. • Patients with moderate to severe PD should be advised mechanisms may individually or jointly contribute to a evaluation26, while odds ratios, relative risks or hazard that they may have a higher risk of developing CVD plausible association. ratios have been reported in the analyses as measures than periodontally healthy people, and PD patients of association. Despite a few cohort studies that have with one or more risk factors for CVD should seek 1. Effects of periodontal bacteria on platelets: Role of oral healthcare professionals in not been able to detect any significant role played by PD medical evaluation if they have not done so in the past Porphyromonas gingivalis and Streptococcus sanguis on the aetiology of CVD13,27, the majority of other studies the prevention and control of CVD 12 months. have been shown to stimulate platelet aggregation and have pointed to an association between PD and CVD, Given that both PD and CVD share common modifiable thrombosis16. Cardiovascular risk factors such as hyperlipidaemia, primarily based on the fact that they share common • risk factors including tobacco smoking, diabetes mellitus, hypertension, smoking and metabolic syndrome in PD aetiological pathways28. 2. Autoimmune reactions / : Cross- stress and obesity, medical and dental professionals in patients should be controlled and co-managed by dental reacting to periodontal bacteria and particular, and all healthcare practitioners in general, can and medical professionals. human heat shock proteins (HSPs) including HSP60 adopt a standardised approach to educate patients about such risk factors, as well as associated lifestyle changes on endothelial cells have been recognised. These • Human intervention studies: It has not yet been • Medical and dental professionals should work together for the successful prevention and control of both these autoimmune responses could provoke endothelial conclusively determined in human intervention trials to control common risk factors for PD and CVD in 18 conditions33 damage and atherosclerosis . whether surgical or non-surgical periodontal therapy has . This includes encouraging patients to: patients with both these conditions. any beneficial effects in modifying the risk for CVD or 3. Invasion and/or uptake of periodontal bacteria in • reduce their total calorie intake and consumption of • Standard treatment including plaque and gingivitis the complications of CVD1,11,28. There has been some endothelial cells and : Specific periodontal foods high in cholesterol, saturated- and trans-fatty control, and oral hygiene instructions including the use evidence, however, for improvement in endothelial pathogens and their components have been identified acids, and salt. of anti-plaque toothpaste as well as mouthrinse and function and substantial reduction of inflammatory in human atheromatous tissues. For instance, P. interproximal cleaning, should be provided to manage markers in periodontal patients who have been managed gingivalis and A. actinomycetemcomitans were present • increase their consumption of foods with low saturated PD in patients with CVD. with non-surgical periodontal treatment, corroborating in atheromatous plaque of 79% and 67% patients, fat and high fibre. the view that cardiovascular effects from PD could respectively19. partly be explained through endothelial dysfunction • control their weight via increased daily physical activity 4. Systemic inflammation: Both PD and CVD have been and associated systemic inflammation29. Paraskevas and reduced total calorie intake. Conclusion and colleagues30, in a systematic review exploring associated with increased systemic inflammatory There has been some evidence, emanating mainly the periodontal treatment – serum CRP relationship, • discontinue smoking. markers such as C-reactive protein (CRP), which has from observational studies, to suggest that PD may be suggested that evidence for the periodontal therapy- also been indicated as an independent predictor of It has also been recommended that sugar intake be associated with CVD irrespective of the effects of known related decline in serum CRP levels was mediocre. future CVD20. reduced, alongside other lifestyle changes, to curtail the confounding factors including tobacco smoking. Testimony The Periodontitis and Vascular Events (PAVE) study—a cardiovascular risk34. Accordingly, dental professionals for a causal relationship between PD and CVD or for multicentre pilot study investigating the effects of who have been routinely involved in advising their patients the beneficial effects of periodontal treatment on CVD Evidence for an association between PD periodontal therapy on the secondary prevention to cut down on sugar can effectively convey this message outcomes, however, is neither substantial nor convincing. of cardiac events—has revealed that any effect of and CVD in view of reducing the risk for both dental caries and Further research with well-designed intervention trials periodontal treatment in reducing high-sensitivity CRP cardiovascular disease. that incorporate standardised case-definitions as well A vast number of studies carried out to explore the levels may be neutralised by obesity and, consequently, relationship between CVD and PD have been reported in as consistent treatment protocols for PD, and that inflated among non-obese subjects31. The authors 11 control for effect-modifiers and confounders of the PD– the literature. Lockhart and colleagues , for example, highlighted not only the importance of considering CVD relationship, would be of paramount importance in a comprehensive review on this topic, identified well the role of other cardiovascular risk factors including Management of PD in CVD patients to address such concerns. Nonetheless, the currently over 500 peer-reviewed English publications, a majority of obesity in PD–CVD relationships but also the necessity The standard treatment for PD in CVD patients has been available evidence may be strong enough to support an which appeared in periodontal and dental-related journals of maintaining sustainable periodontal care in future shown to be effective without undesirable cardiovascular inter-professional multifaceted approach by dental and during the past six decades. These studies comprise studies. animal experiments as well as human observational consequences, and there has been no evidence to suggest medical professionals to modify common risk factors for and intervention studies including investigations into that PD in CVD patients should be managed differently31,33,35. PD and CVD and subsequently manage these conditions. endothelial function and systemic inflammation. Although there has been no strong evidence to support a Accordingly, dental professionals may have a pivotal role to Budoff and colleagues32 have stated that the level of cause and effect relationship between PD and CVD, or to play in improving both the periodontal and cardiovascular • Animal experiments: Studies using both mice and evidence in evidence-based research can be categorised suggest any substantial beneficial effect of periodontal health of their patients. pig models have demonstrated that periodontopathic into three levels, namely A (supporting data emanating therapy on CVD outcomes, currently available evidence may bacteria such as P. gingivalis could induce atherosclerosis from multiple randomised clinical trials), B (supporting data be adequate to advocate comprehensive interprofessional in these animals, and DNA components of P. gingivalis derived from single randomised trials or non-randomised coordination among medical and dental professionals in could be isolated from atheromatous lesions in trials) and C (consensus opinion of experts). A recent the co-management of PD in CVD patients33. The following them21,22. scientific statement from the American Heart Association basic recommendations, some of which have recently indicates that, while evidence for both periodontal– been concurrently published by two prominent cardiology • Human observational studies: Epidemiological studies cardiovascular disease relationships and the beneficial and periodontology journals, would be useful in guiding have been conducted where PD was used as exposure effects of periodontal therapy in reducing local periodontal medical and dental healthcare professionals who deal with for various CVD outcomes such as cerebral vascular