Compelling evidence supports the evaluation of periodontal health too
JOANN R. GURENLIAN
According to the American Heart Association (AHA), cardiovascular disease (CVD) remains the leading cause of death in the United States and globally. In 2011 in the United States, nearly 787,000 people died from heart disease, stroke, and other forms of CVD. One person dies from heart disease every 90 seconds, and CVD claims more lives than all forms of cancer combined.
Take note, heart disease is the leading cause of death in women. The AHA evaluates the cardiovascular health of the United States by tracking seven health factors and behaviors that increase risk for heart disease and stroke that are referred to as "Life's Simple 7." These measures include not smoking, physical activity, healthy diet, body weight, and control of cholesterol, blood pressure, and blood sugar.1
Reducing the burden of CVD morbidity, mortality, disability, and cost has been a public health goal for years. This year, Labarthe and Stamler2 reported results of a four-decade community-wide prevention initiative in Franklin County, Maine, designed to improve population cardiovascular health through 2010. This community program focused initially on hypertension detection and control, and later on hypercholesterolemia, tobacco, diet, physical inactivity, and diabetes.
Approximately 150,000 participant encounters were documented over the four-decade time period. Positive and significant findings were noted for hypertension control (+24.7%), cholesterol control (+28.5%), smoking quit rates (+21%), fewer non-obstetric hospital discharges, and lower cardiovascular mortality in Franklin County than for the entire state of Maine in most years of the study. The authors concluded that other communities should consider adapting and implementing this program.2
As we learn more about the leading systemic health condition of our country and prevention models that may be useful in our communities, we are also learning that a significant number of individuals in the U.S. have periodontal disease, more than anticipated, and that the relationship between periodontitis and heart disease is becoming better defined. As reported by Eke et al., more than 47% of adults aged 30 and older have some form of periodontitis.3
Further, Zhang and colleagues4 identified how periodontitis is a risk factor for CVD. The investigators cultured human aortic smooth muscle cells and infected them with P. gingivalis (P.g.), a periodontal pathogen. They discovered that gingipains, virulence factors produced by P.g., increase expression of the pro-inflammatory angiopoietin 2 while decreasing expression of the anti-inflammatory angiopoietin 1 in the smooth muscle cells. The end result was increased inflammation, which is strongly associated with atherosclerosis.4
What does this research mean for CVD and periodontal disease and community-based prevention programs? To start, we may have more compelling evidence to help our patients take their oral health more seriously. Any chronic inflammatory oral disease such as gingivitis or periodontitis is not healthy for the mouth or rest of the body. Patients need to understand that a long-standing inflammatory condition has significant health consequences and cannot be allowed to continue. It must be treated aggressively until remission has been achieved. Then, patients should be monitored closely for signs of exacerbation.
In addition, public health initiatives that target CVD should consider adding oral health prevention measures as part of their program. "Life's Simple 7" should be modified to "Life's Simple 8" with the recognition that periodontitis is a risk factor for CVD and steps can be taken to improve the oral health and cardiovascular health of the public. It may be time for the American Academy of Periodontology, the ADHA, and the AHA to hold a conference and discuss ways to coordinate oral and heart prevention programs. One wonders what could be achieved in the next decade if an oral health component were added to the Franklin County model. Let's hope someone has the foresight to look ahead and make that a reality. RDH
1. Mozaffarian D, Benjamin EJ, Go As, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Committee. Heart disease and stroke statistics-2015 update: a report from the American Heart Association [published online ahead of print December 17, 2014]. Circulation. DOI:10.1161/CIR.0000000000000152.
2. Labarthe DR, Stamler J. Improving cardiovascular health in a rural population: Can other communities do the same? JAMA. 2015;313(2):139-140.
3. Eke PI, Dye B, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
4. Zhang B, Khalaf H, Zirsjö A, et al. Gingipains from the periodontal pathogen Porphyromonas gingivalis plays a significant role in regulation of Angiopoietin 1 and Angiopoietin 2 in human aortic smooth muscle cells. Infection and Immunity. 2015;IAI.00498-15 DOI:10.1128/IAI.00498-15.
JOANN R. GURENLIAN, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health-care providers. She is a professor and dental hygiene graduate program director at Idaho State University, and president of the International Federation of Dental Hygienists.