By the 1920s the focal infection theory was prevalent in medicine and dentistry. It suggested that a local infection primarily of the oral tissues and organ systems would act as centers of interest to disseminate to other regions of the body and cause chronic disease.
By the 1940ss this theory was regarded as a falsity. Entering the 21st century, we have come to understand dental infections contribute to systemic diseases as a result of the inflammatory process.
As the field of periodontal medicine has evolved, we understand that infection in the oral cavity presents a substantial infectious burden for the entire body by releasing bacterial toxins and inflammatory mediators into the bloodstream.
These infections disrupt the body’s meridian systems. We often say that the oral cavity is a window into your overall health. With this understanding, our primary goal is rendering a person free of oral infections by using an integrative approach blending all elements of Eastern and Western medicine and dentistry.
Nutrition, lasers, stem cells, acupuncture, homeopathy, various detoxification methods and conventional dentistry can be combined to optimize the restoration of form and function. Many conventional paradigms have gone by the wayside. For instance, it is no longer healthy to save infected, broken down teeth, which act as a chronic inflammation source. These infections drain the body of life source.
We must focus on altering the terrain so disease cannot manifest its symptoms. We know that lifestyle changes will affect gene expression, and we know that most diseases are a result of lifestyle choices.
Particularly in patients with chronic autoimmune diseases, metabolic disease, cardiovascular diseases, diabetes, cancers and any other chronic disease, dental infections reduce the energy/immune response needed to focus on the imbalance, and increase inflammatory mediators, which are the source of all disease.
A simple question to ask is why have compounding risk factors present within the system.
We begin in part one discussing the role of periodontal inflammation in the systemic disease model.
About half of American adults have periodontal disease. Also known as gum disease, it can range from simple gum inflammation to serious chronic infection that results in loss of supporting bone and tissue around the teeth and jaw over time.
Over the years, many studies have shown that the detrimental effect of periodontitis is not just confined to the oral cavity. In many cases, active and untreated periodontitis may spread to the rest of the body and lead to compromised systemic health.
Periodontitis vs. Cardiovascular and Cerebral Vascular Disease
Cardiovascular diseases such as myocardial infarction and stroke are major health challenges in the United States, responsible for 30 percent of all deaths. Although myocardial infarction is the result of compromised blood flow to the heart, stroke occurs as a result of impeding blood flow to the brain.
Many studies have investigated the relationship between active periodontal disease and cardiovascular disease and found periodontitis was a significant risk factor for cardiovascular disease. Periodontal disease and cardiovascular disease may share common pathways where the chronic inflammation from periodontal infection predisposes patients to adverse cardiovascular conditions.
In a study published by European Journal of Preventive Cardiology, more than 15,000 patients with heart disease were examined for periodontal health. Researchers found that gum disease indicators such as tooth loss, bone loss and gum bleeding were more common in patients with heart disease. Patients with periodontitis also showed consistently higher blood glucose, cholesterol and blood pressure. This connection between gum disease and heart disease was also noted in a review published by the American Dental Association in an issue of JADA.
Comparable findings between periodontitis and stroke were also noted. In a study that evaluated periodontal conditions of 300 patients within seven days following a stroke, researchers found that patients who suffered a stroke had more periodontal attachment loss and bone loss compared to healthy persons.
A plausible mechanism suggested that oral microbes have the potential to get into the bloodstream, release toxins and injure blood vessels. This can lead to atherosclerosis and thrombosis by activating the coagulation cascade. As the vascular plaque increases, vessel walls thicken and vascular blockage ensues, which leads to ischemia and potentially deadly cardiovascular events such as heart attack and stroke.
Patients with a family history of cardiovascular disease or compromised cardiovascular health should have a periodontal screening and treatment by a periodontist to prevent serious complications. Treatment of any oral infection also must be completed prior to any heart procedure.
Many medications patients take for cardiovascular disease often change the body’s immunology, which contributes to tooth loss and nutritional depletion.
Periodontitis and Preterm, Low Birth Weight Infants
Periodontal diseases are characterized by a wide array of anaerobic bacterial infections of the gum, bone and tooth. It is a destructive, chronically inflammatory disease that destroys the teeth’s supporting tissue. Signs and symptoms include bad breath, bleeding gums, receding gums and shifting teeth. If you are a smoker, your gums will not bleed, because the capillaries become constricted. Eventually you lose your teeth and your health is further compromised.
In 1996, Offenbacher et al. found that the presence of active gum disease in the mother is closely related to preterm, low birth weight infants. The study consisted of 124 pregnant women with and without active gum disease. Researchers found that the presence of periodontitis harbored a statistically significant risk factor for preterm, low birth weight infants.
In another study conducted by Mannem et al. in 2011, 104 pregnant women were divided into two groups: one group with normal term infants; the other with preterm labor. Researchers found that mothers with pre-existing periodontal disease were more likely to have preterm, low birth weight infants compared to mothers with a healthy periodontium.
These studies suggested that periodontitis is not an isolated disease. Since the oral cavity is connected to the rest of body, bacteria in the gums may enter the blood stream and have a detrimental impact on the fetus. Therefore, practicing good oral hygiene and promoting periodontal health should be an important part of pregnancy protocol. Routine periodontal checkups during pregnancy may be essential for the health of the mother and child.
Periodontitis and Respiratory Disease
A link has also been found between gum disease and lung disease. It has been shown that oral bacteria may travel through blood in patients with active gum infection, leading to other systemic conditions. However, these harmful periodontal pathogens may also be inhaled and aspirated into the respiratory systems. Oral bacteria that cause periodontal disease can easily be drawn into the respiratory track. Once these bacteria colonize in the lungs, it can cause pneumonia and exacerbate serious lung conditions. The resulting inflammatory response may also diminish host defense and increase the chances of developing other respiratory diseases.
In an observational study, 100 patients were divided into two groups: 50 patients with obstructive lung disease and 50 patients without lung disease. It was found that patients with lung disease also showed increased prevalence of periodontal infection. Patients with worse periodontal health status were found to be at increased risk of chronic obstructive lung disease.
Another study published by Sharma et al. in 2011 looked at two groups of patients: 100 patients hospitalized for respiratory infection and another 100 patients that were healthy. Again, patients with respiratory illness also suffered from poor periodontal health. This study provides further evidence between the periodontium and systemic health.
Gum Disease and Diabetes
Diabetes is the result of high blood sugar over a prolonged period of time. If left untreated, diabetes often leads to serious complications that are life-threatening. People with diabetes often are more prone to attachment loss and tooth loss. In addition they are more susceptible to periodontal diseases and tooth loss from caries as a result of immune changes.
Many studies have shown that the relationship between diabetes and gum disease goes both ways – active, untreated gum disease might make it more difficult for people who have diabetes to control blood sugar. Severe gum disease can also lead to increased blood sugar, putting people with diabetes at a greater risk of diabetic complications. Diabetics often suffer more frequent tooth loss patterns as a result of the changing susceptibility.
Role of Epigenetics and Periodontitis
Epigenetics is the principle of cellular and physiological phenotypic trait variations that are caused by environment factors – how environmental changes can affect your genes’ expressions. Furthermore, genes respond to external stimuli of food, toxins, exercise and stress, and respond to that stimuli by suppressing or promoting an increase of enzymes and protein production that dramatically affects wellness.
Periodontitis has been shown to be a multifactorial disease characterized by chronic inflammatory mediators. Although the primary etiology of periodontitis is of bacteria origin, its chronic nature can influence a variety of factors within the human body. Much of this we are just learning to understand.
These changes have been shown to influence cytokine expression in the pathogenesis of periodontal disease. These changes occur as a result of periodontal inflammation and affect methylation of genes as well as alterations in the chromatin. It has been found that hypomethylation of the promoter region of IL-8 gene was seen in patients with chronic periodontitis independent of smoking. The same epigenetic changes were also found on the promoter region of COX-2 gene in patients with periodontitis via hypermethylation, leading to changes in the level of cytokines.
In other words, presence of periodontal infections is not just detrimental to your oral and systemic health – periodontitis also has the ability to alter genetic modifications on the DNA level with the potential to influence human immune response.
Periodontitis and Hyper-inflammatory Genotype
Certain individuals may have a hyper-inflammatory genotype, which make them more susceptible to periodontitis and other inflammatory, degenerative diseases such as rheumatoid arthritis. Studies have also found that the presence of specific genes may increase the susceptibility to periodontal infection.
A specific hyper-inflammatory genotype, IL-1, has been closely associated with heightened host response as a result of periodontal infection. In a study conducted by Lang et al., IL-1 gene polymorphism was studied. Patients who are negative for the IL-1 genotype showed less gum inflammation while patients with positive IL-1 genotype showed increased periodontal disease parameters.
In another study, association between IL-6 genotype and periodontitis has also been evaluated. Similar to patients who are positive for IL-1 genotype, patients who are positive for IL-6 genotype also showed increased susceptibility to periodontitis.
Patients with hyper-inflammatory genotype may be more susceptible to periodontal pathogens and therefore showed increased susceptibility to periodontal infection. Although the primary etiology is plaque, the same bacteria does not always cause gum infection in every patient. Some patients may be more susceptible to disease than others due to specific genotypes present. In patients with increased susceptibility to periodontitis, the health of periodontium must be closely monitored.
In conclusion, we must respect the notion that your oral health is not a separate entity from the rest of you. The problems of the teeth, gums and associated structures are not isolated from the rest of the body. They are in fact closely correlated. Often, our medical colleagues have only recently begun to understand this complex relationship.
In our next segment we will discuss treatment philosophies, protocols and options currently available to optimize your oral health.
Ryan T. Demmer, PhD; Moïse Desvarieux, MD, PhD. Periodontal infections and cardiovascular disease. The heart of the matter. JADA, Vol. 137 http://jada.ada.org October 2006.
Vedin O, Hagstro¨m E, Gallup D, et al. Periodontal disease in patients with chronic coronary heart disease: Prevalence and association with cardiovascular risk factors. Eur J Prevent Cardiol 2014.
Blaizot A, Vergnes JN, Nuwwareh S, Amar J, Sixou M. Periodontal diseases and cardiovascular events: Meta-analysis of observational studies. Int Dent J. 2009;59:197–209.
Prasad Dhadse, Deepti Gattani, and Rohit Mishra. The link between periodontal disease and cardiovascular disease: How far we have come in last two decades? J Indian Soc Periodontol. 2010 Jul-Sep; 14(3): 148–154.
Armin J. Grau, MD; Heiko Becher, PhD; Christoph M. Ziegler, MD, DDS; Christoph Lichy, MD; Florian Buggle, MD; Claudia Kaiser; Rainer Lutz, MD; Stefan Bültmann, MD; Michael Preusch, Cand Med; Christof E. Dörfer, DDS. Periodontal Disease as a Risk Factor for Ischemic Stroke. 2004; 35: 496-501.
Lang NP1, Tonetti MS, Suter J, Sorrell J, Duff GW, Kornman KS. Effect of interleukin-1 gene polymorphisms on gingival inflammation assessed by bleeding on probing in a periodontal maintenance population. J Periodontal Res. 2000 Apr;35(2):102-7.
- Nibalia, , , F. D’Aiutoa, N. Donosa, G.S. Griffithsb, M. Parkara, M.S. Tonettic, S.E. Humphriesd, P.M. Bretta. Association between periodontitis and common variants in the promoter of the interleukin-6 gene. Cytokine. Volume 45, Issue 1, January 2009, Pages 50–54.
DNA methylation status of the IL8 gene promoter in oral cells of smokers and non-smokers with chronic periodontitis. Oliveira NF, Damm GR, Andia DC, Salmon C, Nociti FH Jr, Line SR, de Souza AP. J Clin Periodontol. 2009 Sep; 36(9):719-25.
Alteration of PTGS2 promoter methylation in chronic periodontitis.
Zhang S, Barros SP, Niculescu MD, Moretti AJ, Preisser JS, Offenbacher S
J Dent Res. 2010 Feb; 89(2):133-7.
Vamsi Lavu, Vettriselvi Venkatesan,1 and Suresh Ranga Rao. The epigenetic paradigm in periodontitis pathogenesis. J Indian Soc Periodontol. 2015 Mar-Apr; 19(2): 142–149
Anders M. Lindroth,1 Yoon Jung Park. Epigenetic biomarkers: a step forward for understanding periodontitis. J Periodontal Implant Sci. 2013 Jun; 43(3): 111–120.
Surya J. Prasanna. Causal relationship between periodontitis and chronic obstructive pulmonary disease. J Indian Soc Periodontol. 2011 Oct-Dec; 15(4): 359–365.
Sharma N, Shamsuddin H. Association Between Respiratory Disease in Hospitalized Patients and Periodontal Disease: A Cross-Sectional Study. Journal of Periodontology. 2011;82(8):1155-1160.
American Academy of Periodontology. “Healthy gums, healthy lungs: Maintaining healthy teeth and gums may reduce risk for pneumonia, chronic obstructive pumonary disease.” ScienceDaily. ScienceDaily, 18 January 2011.
Offenbacher S1, Katz V, Fertik G, Collins J, Boyd D, Maynor G, McKaig R, Beck J. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol. 1996 Oct;67(10 Suppl):1103-13.
Satheesh Mannem and Vijay K. Chava1 The relationship between maternal periodontitis and preterm low birth weight: A case-control study. Contemp Clin Dent. 2011 Apr-Jun; 2(2): 88–93.