Penam Periodontics - Evidence based Personalized Periodontics


Periodontitis associated with Systemic Disease

Research has shown there is a strong connection between periodontal disease and other chronic systemic disease conditions such as diabetes, heart disease, arthritis and osteoporosis. In the latest classification of Periodontal diseases these have been assigned to distinct categories and their treatment approaches personalized to the disease category. However the microbial evidence is not able to separate the underlying genetic of these susceptibility diseases.

Periodontal disease is characterized by inflammation of the gum tissue, presence of disease-causing bacteria, and infection below the gum line. Infections and bacteria in the mouth can spread throughout the body and lead to a host of problematic health issues but the activation of the immune system in the local area may also lead to increased level of inflammatory mediator substances produced in the gum tissues as a result of the infection. Therefore, maintaining excellent oral hygiene and reducing the progression of periodontal disease through treatment may have benefits to your systemic health by reducing the spread of bacteria and reducing the inflammatory mediating molecules in your system.

Each of these systemic diseases have their own genetic susceptibility. Thus research evaluating the combined gene events that link the underlying disease to the progression of periodontal disease will result in not only an improved understanding of the disease process but also lead to new aetiologically based therapeutic approaches. These therapeutic approaches will largely be personalized to the gene/microbe disease of each patient. This is what is termed Personalized Evidence-based therapy and will require close working relationships between the periodontist and the patients own medical team.

Periodontal Disease and Diabetes

Diabetes is a serious metabolic disease that is characterized by too much glucose, or sugar, or too little insulin in the blood. There are two types: Type 1 and Type II and there are many patients with prediabetic states termed metabolic syndrome..

  1. Type 1 diabetes is an autoimmune disease where the body attacks the cells in the pancreas that make insulin. Insulin is the hormone that manages blood glucose and amino acid uptake into cells. These are the major fuel sources for the bodies. These patient will normally be given insulin to control the bodies metabolism. Eighty percent (80%) of patients have a genetic predisposition to the disease. 
  2. Type 2 diabetes is a progressive condition in which the body becomes resistant to insulins activity (Insulin resistance) and/or gradually loses the capacity of the pancreas to produce insulin. Type 2 diabetes has multiple causes and is associated with modifiable lifestyle risk factors. Type 2 diabetes also has strong genetic and family related set of risk factors.

Metabolic syndrome is in essence a pre type II diabetes state and shows many of the symptoms seen with type II diabetes. These glucose/insulin anomalies usually increase with age and are associated with a variety of health issues, such as heart disease and stroke, and kidney disease.

The connection between diabetes and periodontal disease results from a variety of factors. Diabetes sufferers with uncontrolled disease are more susceptible to all types of infections, including periodontal infections. Conversely the systemic inflammation induced by periodontal disease may increase insulin resistance further exaggerating the need to control diabetes. Inflammation, such as that occurring with periodontitis, will induce changes in insulin resistance and regulation of cellular glycolysis (sugar metabolism) effecting energy provision in all cells. So treatment of periodontitis has a positive benefit for diabetic and prediabetic patients. Treatment of periodontitis and a good recall maintenance program has positive benefits for controlling diabetets.

If you are a diabetic it is very important to control your blood sugars, to brush and clean between your teeth effectively, visit the dentist regularly, and to have your periodontitis treated. People with this condition may best be seen by a periodontitis.

Periodontal Disease, Heart Disease and Stroke

Coronary heart disease occurs when fats and fatty proteins (called atheroma plaque) build-up on the walls of the arteries. This causes the arteries to narrow, constricting blood flow. This type of response is predominately induced by or exacerbated by systemic inflammation.

Patients with periodontal disease are more than twice as likely to suffer from coronary artery disease and brain strokes then those with healthy mouths. Thus the influence of periodontal inflammation to increase systemic inflammation appears to be associated with increased risk of developing cardiovascular disease. One major gene link for both diseases is through a gene named CDKN2B-AS1. This gene is induced or upregulated by the major periodontal pathogen (Porphyromonas gingivalis) when ever there is an exacerbation of the disease meaning that it is upregulated by periodontitis. CDKN2B-AS1 is a long RNA producing gene which acts to regulate the expression of DNA itself by interfering or regulating the expression of genes which are important for the control of atheroma formation. This gene anomaly can be identified in patients.

One of the causes of the connection between periodontal disease and heart disease is oral bacteria entering the bloodstream. Oral bacteria such as Porphyromonas gingivalis have been found in the fatty deposits in the clotted arterial wall at autopsy. It appears that binding of these oral bacteria onto the damaged artery wall may be involved in initiation of the clot formation.

Coronary heart disease is the leading cause of death in the Western world for both men and women. Enacting positive oral hygiene practices and obtaining treatment for periodontal problems may help to reduce the risk of developing this unfortunate condition. These patients may be best treated by periodontists who would have a better understanding of the aetiology.

Periodontal Disease and Hypothyroidism

Hypothyroidism occurs when the levels of thyroid hormones are reduced due to multiple different causes. There is an increase in certain bacteria (P. gingivalis and F. nucleatum) in the dental plaque with the falling thyroid hormones levels. The available data suggest that certain white blood cells remove the iodine from the thyroid hormone and use it in the myeloperoxidase enzyme system to kill bacteria. As the thyroid hormone levels fall one is likely to see an increase in bleeding of the gums. The genetics of this reaction will be investigated.

Periodontal Disease and Respiratory Disease

Respiratory disease occurs when fine droplets are inhaled from the mouth and throat into the lungs. These droplets contain bacteria that can spread and multiply within the lungs to impair breathing. Recent research has shown that oral bacteria can be drawn into the lower respiratory tract and cause infection or worsen existing lung conditions, such as pneumonia, bronchitis and emphysema. Chronic obstructive pulmonary disease (COPD), a respiratory condition characterized by blockage of the airways, and caused mostly by smoking, has also been shown to worsen if the patient also has periodontal disease. This condition may be related to changes in vitamin D Status.

Periodontal Disease and Osteoporosis

Osteoporosis is a condition common in older patients, particularly women, which is characterized by the thinning of bone tissue and loss of bone density over time. Studies have found that women with periodontal disease were more likely to have periodontal bone loss in the jaws associated with periodontitis. It appears that inflammation derived from periodontal disease may be involved in this process. Our recent study at the University of Melbourne has identified an increase in a mutation in the glucocorticoid receptor, which has been linked to Glucocorticoid induced osteoporosis. This gene can be identified in patients and treatments such as immunoglobulin mediated inhibition of the receptor. This immunoglobulin therapy is available in Australia and may be linked to a reduction in periodontal disease associated bone loss as well as osteoporotic related changes in the skeleton.

Periodontal Disease and Arthritis

Recent evidence has shown a link between arthritis and periodontitis. This association is strong for Rheumatoid arthritis and not as strong for osteoarthritis. Once again this appears to be associated with an increase in the systemic inflammatory burden induced by the bacteria in the oral cavity. It has been shown that treatment of periodontal disease can reduce the signs and symptoms associated with rheumatoid arthritis.

Periodontal Disease and Smoking

Smoking has been linked to the worsening of periodontal disease. Patients who smoke have greater levels of periodontal tissue loss than and age sex matched patients with periodontitis. Factors induced by smoking appear to alter the immune response and this in turn seems to result in an increase in tissue destruction in smokers with periodontitis. The periodontal disease treatment outcomes for patients who smoke are not as good as those for patients who do not.

When people with periodontitis stop smoking, they frequently will report more gum bleeding and swelling. This appears to be related to the improvement in the inflammatory response. We will give you information about smoking and we will also encourage you to QUIT.

Periodontal Disease and Cancers

Links to a number of cancers have recently been identified and the increases in the rate are as follows:

  • Lung cancer: Two fold.
  • Prostate cancer: Three fold.
  • Pancreatic cancer: Two fold.
  • Oral cancer: Two fold.

Breast cancer is less likely to occur, whilst no difference has been noted for colon cancer. Both oral inflammatory conditions: Gingivitis and Periodontitis were linked at a similar rate (Hujoel et al 2003).

The link appears to be inflammation: Inflammation seems to modify the underlying increased susceptibility to cancer. Thus control of inflammation may reduce the risk. Deregulation of genes related to cell growth, called oncogenes, which are altered by inflammation appear involved in this process. 

Amyloidosis

Amyloidosis has been linked to the progression of periodontal disease. Patients who have this condition frequently have scalloping of their tongue. These scalloped indentations seem to match the pattern of their teeth but the underlying genetics suggests that the carriage of the alpha variant of the gene in peoples of Eastern Mediterranean (Italian, Greek, and Turkish) and South Eastern European descent may be related to their increased frequency of more severe periodontitis. The changes seem related to inflammatory inhibitory changes induced by the gene variant.

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