By Jannette Whisenhunt, RDH, BS, MEd, PhD
Do you remember learning about Aggregatibacteractinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia in perio class? They were hard enough to pronounce, much less spell! These little bacteria can cause a huge problem to your heart.1 In our everyday routine, we often focus on the teeth and gingival tissues and don’t think as much of how that tissue health affects the rest of our body. There are several inflammatory disease processes that affect the mouth. One of the most common inflammatory disease processes is cardiovascular disease (CVD); as hygienists we see patients with CVD every day. Since it is such a common disease, we need to be familiar with how it affects the oral health of our patients.
High blood pressure, atherosclerosis, arrhythmia, angina, prior heart attacks, heart valve replacement - there are so many different types of “heart disease,” and each patient has his or her own special circumstances. No one treatment fits all, but there is one main thing in common with all of them: inflammation. This is where periodontal disease can start to cause some problems. Virulent oral bacteria can spread throughout the body and be found in the heart.2 Many studies have linked heart disease to periodontal disease!
My son’s best friend, a very smart young man, has been like a son to me since he was three. He is now doing his residency at Tulane University Hospital as a medical doctor. We had a long discussion a few weeks ago about periodontal and cardiovascular disease. He has helped me write this month’s article and found some very interesting studies. Dr. Joshua R. Howell told me that it is amazing how well linked periodontal disease and cardiovascular disease are. It only stands to reason that if we can improve one disease process that we can help improve the other! Check out the following abstract from an article recently published in Postgraduate Medical Journal:
Periodontal disease (PD) is generated by microorganisms. These microbes can enter the general circulation causing a bacteraemia. The result can be adverse systemic effects, which could promote conditions such as cardiovascular disease. Level A evidence supports that PD is independently associated with arterial disease. PD is a common chronic condition affecting the majority of Americans 30 years of age and older. Atherosclerosis remains the largest cause of death and disability. Studies indicate that the adverse cardiovascular effects from PD are due to a few putative or high-risk bacteria: Aggregatibacteractinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola or Fusobacterium nucleatum. There are three accepted essential elements in the pathogenesis of atherosclerosis: lipoprotein serum concentration, endothelial permeability and binding of lipoproteins in the arterial intima. There is scientific evidence that PD caused by the high-risk pathogens can influence the pathogenesis triad in an adverse manner. With this appreciation, it is reasonable to state PD, due to high-risk pathogens, is a contributory cause of atherosclerosis. Distinguishing this type of PD as causal provides a significant opportunity to reduce arterial disease.3
Atherosclerosis is commonly known as hardening of the arteries of the heart, and is a common cause of a heart attack.4 Many times these “clogs” are caused by a backup of bacteria and plaque in the blood vessels triggered by inflammation. It all starts with inflammation, the cause of so many disease processes in the body. Wouldn’t it be great if you knew that your patients could escape having a heart attack because they kept their mouths healthier? Your detailed education could be the key to that happening!
Cardiologists are telling their patients to “get their teeth looked after” to help their heart disease. We need to make sure that we, their dental hygiene providers, are explaining how important excellent oral health is to excellent cardiovascular health.5 I think we do a great job of telling our patients how to keep their teeth and gingiva healthy, but we don’t always explain to them how their heart is affected by periodontal tissue health.
This study of several clinics in 2015 showed a direct correlation between periodontal disease, in particular the bacteria P. gingivalis, and LDL cholesterol levels. It also suggests that having a test to measure these bacteria may be helpful for preventing heart disease progression:
It has been revealed that atherosclerosis and periodontal disease may have a common mechanism of “chronic inflammation.” Several reports have indicated that periodontal infection is related to atherosclerosis, but none have yet reported such an investigation through the cooperation of local clinics. This study was performed in local Japanese clinics to examine the relationship between periodontal disease and atherosclerosis under collaborative medical and dental care. A pilot multicenter cross-sectional study was conducted on 37 medical patients with lifestyle-related diseases under consultation in participating medical clinics, and 79 periodontal patients not undergoing medical treatment but who were seen by participating dental clinics. Systemic examination and periodontal examination were performed at baseline, and the relationships between periodontal and atherosclerosis-related clinical markers were analyzed. There was a positive correlation between LDL-C level and plasma IgG antibody titer to Porphyromonas gingivalis. According to the analysis under adjusted age, at a cut-off value of 5.04 for plasma IgG titer to Porphyromonas gingivalis, the IgG titer was significantly correlated with the level of low-density lipoprotein cholesterol (LDL-C). This study suggested that infection with periodontal bacteria (Porphyromonas gingivalis) is associated with the progression of atherosclerosis. Plasma IgG titer to Porphyromonas gingivalis may be useful as the clinical risk marker for atherosclerosis related to periodontal disease. Moreover, the application of the blood examination as a medical check may lead to the development of collaborative medical and dental care within the local medical clinical system for the purpose of preventing the lifestyle-related disease.6
I think the day is upon us when dental practices will order lab tests for levels of bacteria in saliva, prescribe antibiotics for periodontal disease, and consult with cardiologists - and these things will even be common! I encourage you to learn all you can about the various inflammation-based diseases and try to connect for your patients how oral health affects overall health. This study by Hansen showed that patients with periodontal disease are at a higher risk of cardiovascular diseases that are fatal:
Periodontitis and atherosclerosis are highly prevalent chronic inflammatory diseases, and it has been suggested that periodontitis is an independent risk factor of cardiovascular disease (CVD) and that a causal link may exist between the 2 diseases. Using Danish national registers, we identified a nationwide cohort of 17,691 patients who received a hospital diagnosis of periodontitis within a 15-year period and matched them with 83,003 controls from the general population. We performed Poisson regression analysis to determine crude and adjusted incidence rate ratios of myocardial infarction, ischemic stroke, cardiovascular death, major adverse cardiovascular events, and all-cause mortality. The results showed that patients with periodontitis were at higher risk of all examined end points. The findings remained significant after adjustment for increased baseline co-morbidity in periodontitis patients compared with controls, for example, with adjusted incidence rate ratio 2.02 (95% CI 1.87 to 2.18) for cardiovascular death and 2.70 (95% CI 2.60 to 2.81) for all-cause mortality. Patients with a hospital diagnosis of periodontitis have a high burden of co-morbidity and an increased risk of CVD and all-cause mortality. In conclusion, our results support that periodontitis may be an independent risk factor for CVD.”7
Dr. Howell also said that the American Heart Association has stated that there needs to be more research done in this area. Cardiologists are realizing more and more that they need to look into the mouth and its relationship to the body. Realizing that there are simple saliva tests that can determine the levels and types of periodontal bacteria in the mouth can be very useful, and both dentistry and medicine should use this valuable tool.
Educating our patients with heart disease to safeguard their oral health because it will help their heart health may encourage them to take better care of their mouths! Helping them to understand that taking care of their periodontal disease can make their heart disease easier to control is something we need to be talking about every day to our patients. Use this bit of information to help them become healthier all over.
Keeping ourselves updated and informed of the disease processes that our patients may have is a responsibility we have to our profession, and we need to stay current with what to do for these patients. We have to remind ourselves sometimes that we are part of the “health-care” system and not just in “dentistry.” Happy scaling! RDH
Jannette Whisenhunt, RDH, BS, MEd, PhD, is the Department Chair of Dental Education at Forsyth Technical Community College in Winston-Salem, N.C. Dr. Whisenhunt has taught since 1987 in the dental hygiene and dental assisting curricula. She has a love for students and served as the state student advisor for nine years and has won the student Advisor of the Year award from ADHA in the past. Her teaching interests are in oral cancer, ethics, infection control, emergencies and orofacial anatomy. Dr. Whisenhunt also has a small continuing education business where she provides CE courses for dental practices and local associations. She can be reached at [email protected].
1. Weinberg MA, Westphal Theile CM, Fine JB. Oral Pharmacology for the Dental Hygienist. 2nd ed. Upper Saddle River, New Jersey; Pearson: 2013.
2. Neild-Gehrig JS, Willmann DE. Foundations of Periodontics for the Dental Hygienist. 2nd ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins; 2010.
3. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2017;93(1098):215-220.
4. The patient with cardiovascular disease. In: Wilkins E. Clinical Practice of the Dental Hygienist. 11th ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins; 2013:1036-1056.
5. Gurenlian JR, Spolarich AE. Immune system dysfunction. In: Daniel SJ, Harfst SA, Wilder RS. Mosby’s Dental Hygiene Concepts, Cases, and Competencies. 2nd ed. St. Louis, Missouri: Mosby Elsevier, 2008:855-882.
6. Kudo C, Shin WS, Minabe M, et al. Analysis of the relationship between periodontal disease and atherosclerosis within a local clinical system: a cross-sectional observational pilot study. Odontology. 2015;103(3):314-21. doi: 10.1007/s10266-014-0172-3.
7. Hansen GM, Egeberg A, Holmstrup P, Hansen PR. Relation of periodontitis to risk of cardiovascular and all-cause mortality (from a Danish Nationwide Cohort Study). Am J Cardiol. 2016;118(4):489-93. doi: 10.1016/j.amjcard.2016.05.036.