Oral health and the general well-being of the human body are often viewed as two completely separate topics. When a toothache develops, or a tooth becomes infected, then a patient would make an appointment with a dentist’s office in order to obtain the right treatment for their condition. Upon the development of symptoms such as headaches, a sore throat, shortness of breath, stomach pain or perhaps joint inflammation, a patient would visit a general practitioner, or sometimes a specialist based on the particular affected area.
While a general practitioner would be unable to provide oral health services to a patient, and a dentist or oral hygienist should not be expected to diagnose arthritis or heart disease, modern scientific studies have provided evidence that a link between oral and systematic wellbeing may exist. In particular, periodontal disease, a condition that affects as much as 75% of the American adult population[1], may be a sign that other diseases may be present in the body. The connection between dental and overall wellbeing leads to a conclusion that dentists and oral hygienists should consider the presence of periodontal symptoms as a possible indication that additional health ailments may also be affecting a particular patient.
Periodontal Disease and the Pathogens of the Condition
Periodontal disease is the most common health ailment that affects the oral wellbeing of the American population. The term “periodontal disease” is used to describe the presence of two particular oral diseases, including gingivitis and periodontitis. These conditions are associated with inflammation within the gums, which causes complications such as pockets developing between the gums and the teeth, the gum receding away from the teeth, and sometimes even a reduction of teeth attachment to the bone[2].
Although both conditions are widely prevalent, they are largely misunderstood. Gingivitis is a mild form of the periodontal disease which causes redness, swelling, and irritation of gingival (part of the gum around the base of your teeth). The primary cause of gingivitis is poor oral hygiene which causes the formation of plaque on the teeth. This leads to inflammation of the gum tissues and various symptoms including bad breath. Besides lack of dental hygiene, other factors play a role in the development of gingivitis such as smoking or chewing tobacco, genetics, hormone fluctuations, some medications, vitamin C deficiency, among others.
Periodontitis is a serious infection of the gums that affects and gradually destroys soft tissue and bone that supports your teeth. Progression of this gum disease can loosen teeth and make them fall out. Like gingivitis, this gum disease has a lot to do with the buildup of plaque. Ongoing inflammation, particularly when left unmanaged, can lead to periodontitis.
Several pathogenic substances have been associated with the development of periodontal disease. Some common pathogens that are found present amongst the population who suffer from this disease include[3]:
· P.gingivalis
· Treponemadenticola
· Tannerella forsythia
A recent study[4] also suggested that additional pathogens may also be responsible for the development of periodontal symptoms. The pathogens suggested in the study include:
· Bacteroidetes
· Spirochaetes
· Firmicutes
· Candidatus
· Proteobacteria
· Synergistetes
· Sacchaaribacteria
In addition to the presence of pathogens and bacterium buildup on the surface of the tooth, as well as on the gums, additional factors can also greatly contribute toward a higher risk of periodontal disease.
A Connection between Periodontal Disease and Systemic Ailments
While a great number of bacterium species and pathogens associated with periodontal diseases are only present in the mouth, there are some of these pathogens that might also present themselves and an opportunity for infection in other parts of the body. Additionally, inflammatory responses in the body are the most dreadful factor behind periodontal diseases, causing damage to the gums and bone that surrounds teeth. The inflammatory responses observed in some patients who suffer from symptoms that present itself as a periodontal disease may be contributed to by underlying health ailments.
Connections between oral and general health are not something new to science. In the early 1900s, a British doctor described how the overall wellbeing of a patient’s body would improve considerably when an infected tooth was removed from the mouth[5]. More accurate data and appropriate technology to perform more advanced studies, however, were still lacking at that time. Today, however, scientists have made several breakthroughs in linking together periodontal disease and additional systemic diseases, including:
· Diabetes – figures show that 30.3 million or 1 in 10 Americans have diabetes and 84.1 million or 1 in 3 people in the US have prediabetes[6]. Both diabetes and periodontal disease are prevalent across the US and the globe so it’s obvious there is some sort of a link between them. Evidence shows that diabetes is a risk factor for periodontal disease, but recent evidence shows these conditions have a two-way relationship. That is because periodontal disease affects glycemic control and contributes to severity of diabetes. As you can guess, inflammation plays a crucial role here. Periodontitis involves inflammation of gums and both Type 1 and Type 2 diabetes are also linked to elevated levels of systemic markers of inflammation[7]
· Respiratory disease – a term that refers to any of the disorders and diseases of the airways and lungs that affect respiration and make it difficult for an affected individual to breathe. Since oral cavity is the secondary external opening for the respiratory tract, everything that occurs in your mouth also has an impact on respiratory health. That’s why respiratory diseases and periodontal disease are connected. For example, studies show that periodontal disease is one of major risk factors for development of chronic obstructive pulmonary disease (COPD)[8]
· Rheumatoid arthritis – about 1.3 million American adults and about 1% of world’s population are diagnosed with RA[9]. The number of people with this type of arthritis could be even higher as many affected individuals don’t seek doctor’s help and hence don’t receive diagnosis. Rheumatoid arthritis is a chronic inflammatory disorder that affects joints and even some other organs. It is classified as an autoimmune condition i.e. the immune system attacks joints in your body. Evidence shows that inflammatory periodontal microenvironment plays a role in development of RA and it could augment systemic inflammation and immune responses in disease progression[10]
· Metabolic syndrome – it is not a single disease, but a group of conditions involving high blood sugar, hypertension, abnormal cholesterol and triglyceride levels, and excess body fat that occur together and increase your risk of heart disease, diabetes, and stroke. Periodontal disease and metabolic syndrome are connected through oxidative stress. Oxidative stress leads to inflammation which is present in patients with both metabolic syndrome and periodontal disease[11]
· Cognitive impairment – periodontal disease and cognitive decline make an unlikely relationship, but the link between two conditions has been scientifically proven. For example, scientists from the United Kingdom confirmed the relationship between cognitive decline and periodontitis in patients with Alzheimer’s disease[12]
· Chronic kidney disease – it is a gradual loss of kidney function. A growing body of evidence confirms that patients with chronic kidney disease have higher prevalence of periodontal disease due to inflammatory burdern[13]
· Cancer – believe it or not, periodontal disease is associated with cancer, too. Bacteria from your mouth can spread to other parts of the body[14], thus contributing to inflammation and cancer progression
· Atherosclerotic cardiovascular disease – inflammation is one of several links that connect periodontal disease with cardiovascular problems. Inflammation is a natural response from the immune system. Long-term inflammation can damage tissues, including blood vessels, and allow bacteria to penetrate into the bloodstream[15]. It’s also important to mention that atherosclerosis, which is a major cause of heart attack and stroke, involves low-grade inflammation as well
In addition to these particular systemic diseases, scientists have also discovered a link between a higher risk of adverse effects during pregnancy and the presence of periodontal disease.
Conclusion
While oral wellbeing and overall physical health are viewed as different subjects, connections between certain conditions affecting the teeth and gums may point out underlying health issues deeper in the patient’s body. The reaction of the immune system in response to bacteria and pathogens on the teeth and gums, as in periodontal disease, might signal deeper inflammatory and immune responses, indicated additional problems that need further investigation, not only to deliver a treatment protocol but also to act as a preventative measure for future complications.
References
[1] Jemin Kim, Salomon Amar. Periodontal disease and systemic conditions: a bidirectional relationship. HHS Public Access. 7 July 2008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2443711/
[2] Angelo Mariotti. Periodontal pathology. ScienceDirect. https://www.sciencedirect.com/topics/medicine-and-dentistry/periodontal-pathology
[3] Nicholas S. Jakubovics. Community Interactions of Oral Streptococci. ScienceDirect. https://www.sciencedirect.com/topics/medicine-and-dentistry/periodontal-pathogen
[4] Multiple Authors. Newly Identified Pathogens Associated with Periodontitis. Journal of Dental Research. September 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541103/
[5] Lewis Winning, Gerard J. Linden. Periodontitis and systemic disease. British Dental Journal.27 November 2015. https://www.nature.com/articles/bdjteam2015163?proof=true
[6] National diabetes report, 2017, CDC https://www.cdc.gov/features/diabetes-statistic-report/index.html
[7] Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012;55(1):21-31. doi:10.1007/s00125-011-2342-y. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228943/
[8] Prasanna SJ. Causal relationship between periodontitis and chronic obstructive pulmonary disease. Journal of Indian Society of Periodontology. 2011;15(4):359-365. doi:10.4103/0972-124X.92570. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283933/
[9] Rheumatoid arthritis facts and statistics, RheumatoidArthritis.org https://www.rheumatoidarthritis.org/ra/facts-and-statistics/
[10] Bingham CO, Moni M. Periodontal disease and rheumatoid arthritis: the evidence accumulates for complex pathobiologic interactions. Current opinion in rheumatology. 2013;25(3):345-353. doi:10.1097/BOR.0b013e32835fb8ec. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495574/
[11] Lamster IB, Pagan M. Periodontal disease and metabolic syndrome. International Dental Journal 2017 Apr;67(2):67-77. Doi: 10.1111/idj.12264 https://onlinelibrary.wiley.com/doi/full/10.1111/idj.12264
[12] Ide M, Harris M, Stevens A, et al. Periodontitis and cognitive decline in Alzhemer’s disease. PLoS One 2016 Mar. Doi: 10.1371/journal.pone.0151081 http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151081
[13] Wahid A, Chaudhry S, Ehsan A, Butt S, Ali Khan A. Bidirectional Relationship between Chronic Kidney Disease & Periodontal Disease. Pakistan Journal of Medical Sciences. 2013;29(1):211-215. doi:10.12669/pjms.291.2926. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809193/
[14] Heikkila P, But A, Sorsa T, et al. Periodontitis and cancer motility: register-based cohort study of 68,273 adults in 10-year follow-up. International Journal of Cancer 2018 Jan;142(11):2244-53. Doi: 10.1002/ijc.31254 https://onlinelibrary.wiley.com/doi/full/10.1002/ijc.31254
[15] Bartova J, Sommerova P, Lyuya-Mi et al. Periodontitis as a risk factor of atherosclerosis. Journal of Immunology Research 2014 Mar. Doi: 10.1155/2014/636893 https://www.hindawi.com/journals/jir/2014/636893/