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Periodontitis – A New Disease Paradigm

   Inflammation is a defensive reaction that stimulates the body’s immune system to protect us living warm-blooded creatures from disease.  Regardless of the nature of the pathogens that attack our bodies, a sequence of events occurs whereby the offending agent(s) are localized and ultimately destroyed by our white blood cells.  These cells are properly called “phagocytes” because the word “phagocytosis” means “to ingest” which is exactly what they do to bacteria and other foreign invaders.

   It has recently become clear that periodontal disease is an inflammatory disease initiated by oral biofilm (plaque) (which is nothing more than colonies of bacteria that have become organized) on the surfaces of the teeth.  As science’s understanding of the pathways of inflammation has increased, it is becoming more evident that it is not the biofilm per se that causes damage to the tissues surrounding the teeth but the host response that is initiated by the biofilm’s presence that causes most of the damage to the bone and gum tissue.  We now know that damage done by our white cell’s efforts to fight off acute infections in the oral cavity – if not resolved – can lead to chronic inflammatory disruption in other parts of the body. 

   As the number of white blood cells increases in an inflamed area, many of the pathogens are eliminated by the phagocytes but, in doing so, these white cells produce their own toxins called cytokines as they do their job.  Cytokines are referred to as the “hormones of inflammation” and, in moderation, keep us from being overrun by noxious organisms.  These chemicals mediate blood clotting, fever, pain, vessel porosity and a host of other critical reactions in the inflamed area but ,in and of themselves, can be damaging when produced in excesive amounts. 

   When the inflammatory protagonists (causative agents) are removed, the phagocytes and the cytokines they produce are decreased and the damage is resolved.  However, if the cytokine production generated locally is not eliminated (as in chronic periodontal disease), resident cells may travel through the blood stream to other organs and tissues increasing the risk factors for diseases such as coronary  vessel blockage, strokes, pre-term babies, cancer and diabetes. It is also thought that this inflammatory process can lead to early aging due to the effect it has on  telemeres which are the end-caps covering the our chromosomes (but that’s another story).  The saying, “If it’s happening anywhere, it’s happening everywhere” refers to inflammation not being confined to just one part of the body. Again, patients with chronic periodontal disease are twice as likely to die from a heart attack, three times more likely to die from a stroke and more likely to get certain cancers.

  The strongest perio/systemic link is between periodontitis and diabetes.  When these two diseases are poorly controlled, they adversely affect each other dramatically. Uncontrolled diabetes is the number one risk factor for periodontal disease while periodontal disease worsens blood sugar control by increasing insulin resistance.

   Researchers now understand that the inflammatory response is genetically predetermined.  At least one-third (some think as high at one-half) of the population has the positive gene Interleukin-1 which is a major player in the expression of inflammation and bone destruction.  This group shows an increased bleeding tendency when the gums are probed and this can result in the clinical breakdown of the periodontal tissues.  Also, this predisposition to inflammation and resulting disease may change over one’s lifetime as susceptibility is modified by environment (e.g. smoking), stress, nutrition, exercise or the onset of other diseases of aging such as heart disease or diabetes.

   There is evidence that inflammation is more harmful to the cardiovascular system than established risk factors such as having high LDL cholesterol and low HDL cholesterol.  This would help to explain why almost half of all those who develop heart disease have few or none of the well-known risk factors for the disease other than high levels of inflammation.  Risk can be determined by a simple blood test that measures C-reactive protein (CRP).  This is an enzyme made by the liver in response to inflammatory stimuli and it serves as a barometer for our body’s overall level of inflammation.  Parade Magazine medical editor, Dr. Mark Liponis, called CRP the best “crystal ball” of health ever devised in a single blood test.  Elevated levels have been shown to precede and predict heart attacks, stroke, colon cancer, diabetes, hypertension, Alzheimer’s, aneurysms, atrial fibrillation, and even macular degeneration.  With periodontal disease being the most common inflammatory process in the body, it makes sense to test patients for CRP, identify its level and work to reduce the inflammatory contribution of gum disease in the cascade of processes that put our health at risk.  Studies have shown that improving periodontal disease can reduce CRP levels.

   Chronic periodontal disease is never really cured, only controlled.  Typical intervention procedures such as scaling and root planing – the first line of defense – boast some success in removing causative agents such as hard deposits (calculus) and biofilm from the teeth.   However, certain other surgical procedures may sometimes be needed to fill in lost bone or re-establish an ideal architecture so as to make patient home care more efficient.  And, most important of all, chronic periodontal patients have to forget about the old mantra of “getting your teeth cleaned every six months” because it only takes around 90 days for the biofilm to again reach a clinically relevant threshold (called “quarum sensing” of biofilm) where it once again becomes toxic to the tissues.  This periodontal maintenance interval is very important in controlling inflammation but is very often neglected resulting in tissues that are forever inflamed!  Remember, reducing inflammation around the teeth reduces the risk for selected systemic diseases and, unfortunately, there are no short cuts!

   In addition, mounting research has suggested that simply diagnosing existing disease is no longer sufficient in determining which patients may benefit from advanced periodontal care because the etiology (cause) is complex and not necessarily the same in every patient.  It is now becoming necessary to perform risk assessments which may include blood chemistries, microbial testing for specific bacterial species involved and even genetic screening as aids in resolving periodontal problems.  Some forms of the disease are more destructive than others and any treatment plan has to be based upon the case type.  Treating the disease locally (removing biofilm and calculus) while ignoring systemic factors can result in a less-than-successful outcome.

*If you are going to have blood chemistry done for just a regular check-up with your doctor, ask for a CRP test for inflammation levels and a Hemeglobin A1c for any tendency for diabetes.