Diabetes mellitus
Uncontrolled diabetes can reduce life expectancy by as much as 30% or more. The American Diabetes Association suggests that adult patients are within treatment goals when the hemoglobin A1c (HbA1c) is <7%. Many studies have been conducted to understand the relationship between glycemic control and periodontal disease. The question is, can a diabetic’s condition be improved with healthy gums, or will it be worse with periodontal disease? A population study has shown that HbA1c >9% placed subjects at up to three times greater risk for progressive, severe alveolar bone loss (a measure of periodontal disease), and severe periodontal disease put subjects at risk for poor glycemic control.5,6 Other studies have shown that treating periodontal disease in diabetic patients with poor glycemic control significantly reduced HbA1c.7,8 The therapies included cleaning the tooth roots, antimicrobials (chlorhexidine 0.12% rinses), and doxycycline. These findings are of great clinical significance in view of the fact that periodontal disease is very amenable to treatment. They may also be expanded to attenuate some of the more severe complications of diabetes mellitus. One study has reported that patients with severe periodontal disease were at greater risk for stroke, transient ischemic attack, angina, and MI; an additional study suggested up to a 3.2-fold greater risk for ischemic heart disease and nephropathy than those without periodontal disease.9,10
Respiratory disease
Associations between periodontal disease and chronic obstructive pulmonary disease (COPD) have been investigated based on case reports of anaerobic periodontal pathogens in lung tissues. In one study of 46 cases of deadly anaerobic empyema, the most common microorganisms isolated were Fusobacterium nucleatum, Prevotella, Bacteroides, and Peptostreptococcus (all etiologic agents in chronic periodontal disease).11 These findings led to population-based studies that examined the risk of COPD in patients with periodontal disease. In one such study, adjusted for smoking status, risk of having COPD was 4.5 times greater in subjects with poor oral hygiene (high levels of oral biofilm and calculus) than for subjects with excellent oral hygiene.12 Another long-term study determined that alveolar bone loss at baseline was an independent predictor of COPD in men.13 Subjects with bone loss involving the mouth had a 60% increased risk of being a COPD patient (odds ratio 1.6). Perhaps the most compelling study of oral health and lung disease (pneumonia) was undertaken in nursing homes in Japan. This controlled study divided subjects into those who received weekly professional oral care and those with no professional care. Over the two-year follow-up, residents who attempted to maintain their own oral health were twice as likely to contract pneumonia and twice as likely to die.14
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Osteoarthritis
Osteoarthritis (OA) afflicts millions of Americans and is the primary medical complaint of the elderly. Although a myriad of therapies have been advocated, no clear evidence exists to promote one safe, efficacious, long-lasting solution. Rather, most sufferers rely on systemic analgesics and/or anti-inflammatory preparations or topical analgesics. A large population-based study reported that subjects with OA reported fair to poor health three times more frequently than those without OA.15 Additionally, OA patients claimed significant limitation of normal activities, which is the foundation for the belief that many OA patients have reduced ability to perform adequate oral hygiene. By extension, these patients are at risk for poor oral health status and periodontal disease as well as for subsequent interactions with CVD, diabetes, and the respiratory system.
Clinician and patient responsibilities
Although researchers have not yet confirmed specific cause-and-effect relationships between oral health and systemic disease, studies are ongoing. In the meantime, it is imperative that clinicians educate their patients regarding the importance of oral health. Patients should be challenged to take ownership of their oral health, visit a dental provider regularly, and set treatment priorities for a healthy lifestyle.
Dr. Astroth is associate professor at the University of Colorado School of Dental Medicine and director of the Senior’s Dental Clinic, both in Aurora.
References
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2. Joshipura KJ, Rimm EB, Douglass CW, et al. Poor oral health and coronary heart disease. J Dent Res. 1996;75:1631-1636.
3. Genco R, Chadda S, Grossi S. Periodontal disease is a predictor of cardiovascular disease in a native American population (abstract). J Dent Res. 1997;76:408.
4. Beck JD, Garcia R, Heiss G, et al. Periodontal disease and cardiovascular disease. J Periodontol. 1996;67(10 Suppl):1123-1137.
5. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin dependent diabetes mellitus. J Periodontol. 1996;67(10 Suppl):1085-1093.
6. Taylor GW, Burt BA, Becker MP, et al. Non-insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years. J Periodontol. 1998;69:76-83.
7. Westfelt E, Rylander H, Blohme G, et al. The effect of periodontal therapy in diabetics. Results after 5 years. J Clin Periodontol. 1996;23:92-100.
8. Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol. 1997;68:713-719.
9. Thorstensson H, Kuylenstierna J, Hugoson A. Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics. J Clin Periodontol. 1996;23(3 Pt 1):194-202.
10. Saremi A, Nelson RG, Tulloch-Reid M, et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care. 2005;28:27-32.
11. Civen R, Jousimies-Somer H, Marina M, et al. A retrospective review of cases of anaerobic empyema and update of bacteriology. Clin Infect Dis. 1995;20 Suppl 2:S224-S229.
12. Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease in a national sample survey population. Ann Periodontol. 1998;3:251-256.
13. Hayes C, Sparrow D, Cohen M, et al. The association between alveolar bone loss and pulmonary function: the VA Dental Longitudinal Study. Ann Periodontol. 1998;3:257-261.
14. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50:430-433.
15. Cook C, Pietrobon R, Hegedus E. Osteoarthritis and the impact on quality of life health indicators. Rheumatol Int. 2007;27:315-321.
