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At a recent oral-systemic health conference (the American Academy for Oral Systemic Health Scientific Session; October 17-19, 2019; Nashville, Tennessee), it was clear to the author that the dental healthcare providers in attendance were concerned about inflammation as a progressively destructive force. Scientific data on inflammation suggest a connection between the mouth, mind, and body, and the medical consequences of ignoring that connection can be severe. Often, dentists may be focused primarily on the oral cavity and optimizing dental wellness, whereas physicians may be focused on optimizing total wellness and quality of life for their patients. Separately, healthcare professionals may not immediately recognize the holistic aspects of challenges such as inflammation. Inflammation has introduced many symptoms and illnesses into the culture and has had a pervasive and daunting effect on many patients. On a daily basis, dental professionals are confronted by periodontal disease (PD), increases in caries resulting in partial or total edentulism, periodontal pathogens, endodontic pathology, and the effects of smoking. Causes of inflammation may include genetics, sleep apnea, rheumatoid arthritis, insulin resistance, and second-hand smoke. Increases in patient populations entering a dental practice with multiple comorbidities has impacted case management and presentations for providing dental service to optimize oral and dental wellness.
Diseases of the Mouth, Mind, and Body
The American Journal of Cardiologyand Journal of Periodontology have published consensus statements that patients with PD should receive a complete physical and blood pressure monitoring annually and that health professionals should understand the importance of the link between oral health and the disease process within overall health.1 The American Heart Association (AHA) reviewed 537 peer-reviewed articles regarding PD and the link between PD and cardiovascular (CV) health.2 The findings suggested that oral pathogens and inflammatory response challenge vascular wellness and that oral health may be a direct contributor.
The research resulted in a position statement from the AHA, supported by the American Dental Association, that there is an association between PD and cardiovascular disease (CVD), although the conclusion stopped short of supporting a definitive causal relationship. In response to the position statement, a joint quote from Bale and Doneen, a physician and nurse practitioner who are among the co-authors of the book Beat the Heart Attack Gene, and Nabors, a dentist, stated: "In light of the science presented in their [AHA]'s article coupled with the substantial burden CVD places upon our society, we cannot afford to wait for the acquisition of causality data to incorporate assessing and treating PD in an effort to minimize CV risk."3 Healthcare providers are aware of inflammation and its deleterious effects on CV health. CVD is the leading cause of death, also encompassing end-stage diseases such as vascular dementia and major CV events such as myocardial infarction and stroke.4
Leading Causes of Death
The top eight causes of death in America, according to the Centers for Disease Control and Prevention, are the following4:
• heart disease
• chronic lower respiratory diseases
• influenza and pneumonia
Do these causes of death have in anything in common? Seven of them have been linked to inflammation and oral bacteria. Statistical data have shown a correlation of patients with periodontitis having higher rates of pancreatic and oral cancers. The periodontal pathogens Porphyromonas gingivalisand Aggregatibacter actinomycetemcomitans have been associated with a 62% increase in acute pancreatic cancer, with a survival rate of just 8%.5 Another study showed high levels of Leptotrichia and Campylobacterspecies in the saliva of patients with pancreatic cancer, suggesting a link between saliva and pancreatic cancer.6 Additionally, lung infections are prevalent in patients with PD. Oral bacteria aspirated into the airway cause lung infections such as pneumonia, and a greater loss of lung function is exhibited at higher levels of advanced PD.7,8
The fastest-growing disease state in the United States is diabetes. Diabetes is considered a coronary risk equivalent: patients with diabetes should be considered similarly to patients at risk for myocardial infarction. By understanding and identifying patients in a prediabetic or insulin-resistant state, healthcare providers can work with these patients to stop progression and prevent diabetes.9 Periodontal conditions increase the risk of developing diabetes by the following percentages, with the risk becoming generally greater as the severity of conditions increases10:
• gingivitis: 40%
• periodontitis: 50%
• edentulism: 30%
• partial edentulism and advanced
If PD is discovered in a patient, a reason for inflammation being present must be determined. Patients with PD are more likely to develop coronary plaque in their arteries. Poor oral hygiene is associated with greater levels of CVD risk and low-grade systemic inflammation.11 Patients who have had a stroke exhibit a high incidence of PD, which makes them 4.5 times more likely to suffer an ischemic stroke. The more severe the PD condition, the greater the risk for a cerebral ischemic event.12
Several studies have presented a correlation between Alzheimer's, dementia, and tooth loss. Patients with PD are 2.6 times more likely to develop Alzheimer's and experience resultant difficulties such as decreasing oral hygiene abilities and increased severity of dementia.13 The main bacterium in PD, P. gingivalis, was found to cross the blood-brain barrier, invade the regions of the brain associated with Alzheimer's, and cause amyloid proteins in mice. P. gingivalis has also been identified in spinal fluid of patients with Alzheimer's, which could lead to a diagnostic test.14
The Patient and Dental Professional Relationship
What can dental professionals do to help patients with periodontal conditions? Dentists and their teams can improve wellness in everyday dentistry by diagnosing and treating periodontal conditions presented by patients, providing endodontic therapy, and conducting caries risk assessments with conservative operative dental procedures. Certainly, before any therapy is performed, patients must understand the disease state in their oral environment. Communicating with the patient about the mouth-mind-body connection can be challenging. Thorough health history review must take place, along with an explanation of the risk factors associated with oral cavity inflammation and the impact it can have or that may be occurring. The patient's oral wellness, or decline in oral wellness, can be explained in the context of inflammatory risk factors and associated total systemic health.
Patients should understand that treatment recommended by their dental team is part of an attempt to create a long-term, enduring care plan for them. Keeping recommendations simple and to the specific point of optimizing patients' oral health and its impact on overall wellness can be communicated in less than 3 minutes. Compassion and tactical empathy will allow patients to feel that their care is being advanced in their visit. People who have good emotional health are aware of their thoughts, feelings, and behaviors. They have learned healthy ways to cope with the stress and problems that are a normal part of life. They feel good about themselves and have healthy relationships. However, many things that happen in life can disrupt emotional health, leading to strong feelings of sadness, stress, or anxiety. Even good or wanted changes can be as stressful as unwanted changes. The body responds to the way a person thinks, feels, and acts-the mind-body connection. When a person is stressed, anxious, or upset, the body reacts in a way that may tell the person that something is not right. For example, an individual may develop high blood pressure or a stomach ulcer after a particularly stressful event, such as the death of a loved one. Poor emotional health can weaken the body's immune system, making a person more likely to get colds and other infections during emotionally difficult times. The link between periodontitis and Alzheimer's is documented.14 Inflammation from the bacterial biofilm present in one's mouth overpopulates the soft tissues of the oral cavity. The bacteria proliferate the ulcerated soft tissues and enter the blood stream. In the unique nature of this inflammatory process, the body's immune system does not detect this attack.15
Another significant concern is oral cancer, including cancer in areas close to the mouth; someone dies from oropharyngeal cancer in the United States every hour, 24 hours a day, with 53,000 new cases evaluated and diagnosed annually.16 Cancer may appear as a lump or sore in the mouth or red or white patches on the soft tissue of the mouth. Early detection is critical. The dental office can provide options such as oral anomaly screening and salivary diagnostics. Salivary collection is swift and pain free. Saliva from the patient is collected, the sample is delivered to an oral DNA testing facility, and the results of the saliva can be downloaded from the laboratory that has completed the testing. To recommend testing to a patient, a doctor may say something like this: "Mrs. Smithers, we have a new oral abnormalities screening device that is now available. This device allows me to see abnormal cells that may be changing. This will only take a couple of minutes and is pain free. I will go ahead and do this for you now, or I can ask your hygienist to complete this for you at your next visit. Which do you prefer?" Enhanced early detection may indeed save lives.16
Alternatives to Opioids and Chlorhexidine: Preemptive Analgesia and Postoperative Care
In the treatment of periodontal and related dental conditions that may involve concerns of inflammation, pain management must be considered. Opioid consumption must be reduced. What can be done to help preemptively provide pain management that is an alternative to prescription medications? Additionally, is there a more effective alternative to chlorhexidine rinses? The Journal of Clinical Periodontology published an article on the delay and disturbance in regard to bone wound healing in humans after chlorhexidine rinses.17
The definition of preemptive is a measure against something possible, anticipated, or feared; preventive; deterrent. Preemptive analgesia is a measure taken before qualified dental therapies to prevent or deter the possibility of inflammation, swelling, and pain after a procedure. Qualified procedures include sinus elevations, impacted third molars, dental implants, bone grafting, soft-tissue grafting, full mouth reconstruction, and all-on-X full-mouth dental implant and restorative reconstruction. Many patients prefer not to ingest preoperative medications and often search or ask for alternatives to opioids. Additionally, if exposure of surgical sites to toxins can be limited, there is a greater chance of ensuring optimal healing.18
There is a strong association between PD and CVD. A trend for reduced systemic inflammation and improvement in endothelial health has been observed when effective periodontal therapy is provided and achieved. Diseases of the body may result from the presence of inflammation. Poor overall wellness and the presence of PD can lead to a decline in health, negatively impact quality of life, and decrease life expectancy. Patients with heart disease, stroke, Alzheimer's, diabetes, chronic lung infections, and other diseases have become more prevalent within dental practices. This medical complexity suggests there may be a need for case management and presentation of dental services to be delivered differently, with overall wellness considered. In regard to treatment, there is also a need for non-opioid preemptive analgesic alternatives.
About the Author
Thomas M. Bilski, DDS
1. Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology editors' consensus: periodontitis and atherosclerotic cardiovascular disease. Am J Cardiol. 2009;104(1):59-68.
2. Lockhart PB, Bolger AF, Papapanou PN, et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? A scientific statement from the American Heart Association. Circulation. 2012;125(20):2520-2544.
3. Nabors T. Bale/Doneen/Nabors response to the AHA and ADA statements regarding periodontal disease and cardiovascular disease. The American Academy for Oral Systemic Health. https://aaosh.org/baledoneennabors-response-aha-ada-statements-regarding-periodontal-disease-cardiovascular-disease/. Published April 12, 2012. Accessed January 17, 2020.
4. Murphy SL, Xu JQ, Kochanek KD, Arias E. Mortality in the United States, 2017. Hyattsville, MD: National Center for Health Statistics; 2018. NCHS Data Brief, No. 328.
5. McGinley L. These oral bacteria are linked to an increased chance of getting pancreatic cancer. Washington Post. https://www.washingtonpost.com/news/to-your-health/wp/2016/04/20/these-oral-bacteria-might-increase-your-chances-of-getting-pancreatic-cancer/. Published April 20, 2016. Accessed January 17, 2020.
6. American Society for Microbiology. Bacteria in mouth may diagnose pancreatic cancer. Science Daily. https://www.sciencedaily.com/releases/2014/05/140518164419.htm. Published May 18, 2014. Accessed January 17, 2020.
7. Linden GJ, Herzberg MC; Working group 4 of joint EFP/AAP workshop. Periodontitis and systemic diseases: a record of discussions of working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol. 2013;40(suppl 14):S20-S23.
8. Geppert EF. Chronic and recurrent pneumonia. Semin Respir Infect. 1992;7(4):282-288.
9. Bale B, Doneen A, Cool LC. Beat the Heart Attack Gene. Nashville, TN: Turner Publishing Company; 2014.
10. Borgnakke W, Ylöstalo PV, Taylor GW, Genco RJ. Effect of periodontal disease on diabetes: systematic review of epidemiologic observational evidence. J Periodontol. 2013;84(4 suppl):S135-S152.
11. Humphrey LL, Fu R, Buckley DI, et al. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23(12):2079-2086.
12. Grau AJ, Becher H, Ziegler CM, et al. Periodontal disease as a risk factor for ischemic stroke. Stroke. 2004;35(2):496-501.
13. Kondo K, Niino M, Shido K. A case-control of Alzheimer's disease in Japan--significance of life-styles. Dementia.1994;5(6):314-326.
14. MacKenzie D. We may finally know what causes Alzheimer's - and how to stop it. New Scientist. https://www.newscientist.com/article/2191814-we-may-finally-know-what-causes-alzheimers-and-how-to-stop-it/. Published January 23, 2019. Updated January 30, 2019. Accessed January 17, 2020.
15.Jepsen S, Sanz M, Stadlinger B, Hendrik T. Cell-to-Cell Communication: Oral Health and General Health. Quintes-
sence Publishing; 2016.
16. Oral cancer facts. Oral Cancer Foundation. https://oralcancerfoundation.org/facts/. Updated February 27, 2019. Accessed January 17, 2020.
17. Bassetti C, Kallenberger A. Influence of chlorhexidine rinsing on the healing of oral mucosa and osseous lesions. J Clin Periodontol. 1980;7(6):443-456.
18.Lee CYS,Suzuki JB. The efficacy of preemptive analgesia using a non-opioid alternative therapy regimen on postoperative analgesia following block bone graft surgery of the mandible: a prospective pilot study in pain management in response to the opioid epidemic. Clin J Pharmacol Pharmacother. 2019;1(2):1006.