Periodontal Disease, Seattle Washington

Oral-Systemic Connection

Newly released medical recommendations encourage cardiologists to examine the mouth and dentists to ask questions about heart health. Seattle dentist Dr. Shawn Keller has established relationships with physicians and dentists in the Seattle area in order to raise the standard of care and ensure that his patients' health is at their best. Both the American Journal of Cardiology and the Journal of Periodontology have published various articles discussing the 'oral-systemic connection' and have legitimized the science and previously suspected links that exist between the presence of chronic low-grade infections in the mouth and the occurrence of cardiovascular disease.

This causes collaboration between the medical and dental fields in the treatment of their respective patients with regard to periodontal disease and heart disease. Many dentists aware of the oral-systemic connection have already been emphasizing the relatedness of these health conditions. Through various studies, the connection has finally been made official. Physicians and dentists are now expected to examine a patient's mouth for signs of gum disease, and dentists are asked to inquire about heart health and family history of heart disease. Seattle dentists and physicians are now entering into this multilevel of care.

Seattle Periodontal Disease

The organization of the health professions into specialties and subspecialties according to body organs and systems is often more pragmatic than scientific. The human organism is a single unit composed of a seemingly infinite number of biologic processes so intertwined that abnormalities of almost any of its parts or processes have profound effects on multiple other body areas, exemplified by the common and complex theme of inflammation. In recent years, the immune system, once believed to be only a vital defense against infection and a promoter of healing, is now considered a significant active participant in many chronic diseases, such as cardiovascular disease and periodontal disease

Periodontal disease is a bacterially induced, localized, chronic, inflammatory disease, destroys connective tissue and bone that support the teeth. Periodontal disease is common, effecting 30% to 50% of adults in the United States. It has an even higher prevalence in developing countries where periodontal maintenance is not stressed as much.

Patients with periodontal disease are often asymptomatic. Physical signs and symptoms are non-specific and can include swollen, discolored, tender, and bleeding gums, long appearance of teeth (due to gum recession caused by bacteria and bone loss), increased spacing between teeth, pus between teeth and gums, loose teeth, change in tooth sensation when biting due to increased mobility, bad taste, and halitosis. Seattle dentist Dr. Shawn Keller has treated various patients who had spontaneous oral pain or pain while chewing, which often lead to complication of the disease.

The clinical diagnosis of periodontal disease requires evaluation by a dentist or hygienist, they look for gingival inflammation, loss of connective tissue surrounding the teeth measured by a periodontal probe, and bone loss which can be seen through x-rays.

Although moderate to severe cases of periodontal disease may affect systemic inflammatory and immune markers elevated blood levels of C-reactive proteins, such changed are either not captured by current standard laboratory test panels or are interpreted as nonspecific indicators of a chronic, low-grade, acute-phase inflammatory response. Dental patients with uncomplicated periodontal disease have no systemic signs of infection, such as fever or leukocytosis.

Periodontitis

The following non-oral risk factors associate strongly with increased risk for periodontal disease severity: smoking, diabetes, genetics, mental anxiety, depression, obesity, and physical inactivity.

Individuals who smoke have 6 to 7 times more bone loss than non smokers in studies in the United States and other countries. The possible reasons for this relationship, explains Seattle dentist Dr. Shawn Keller, is increased sub gingival infections by periodontal pathogens, increased smoking induced inflammation, and altered collagen metabolism and wound healing.

Periodontal disease is also more prevalent among patients with type I and II diabetes. Dental patients with type II have a faster rate of bone loss than those without diabetes. Dentists say that children with type I diabetes also have a higher chance of their periodontal disease worsening, this acceleration is related to metabolic control. It has been suggested by dentists and physicians that inflammation may be the link between the diseases. Periodontal treatment in diabetic patients improves glycemic control. Results from the National Health and Nutrition Examination Survey and follow-up studies suggest that non-diabetic adults with periodontal disease develop type II diabetes more often than those without periodontal disease.

Periodontal Disease Treatment

All appropriate treatment for periodontal disease focus on the resolution of gingival inflammation and healing of the soft and hard tissue attachment of the teeth to the bone process by removing any plaque or bacteria present. Seattle dentist Dr. Shawn Keller always reinforces good oral care by reviewing proper brushing and flossing with his patients. Antibiotics may also be used as an adjunct to conventional bacteria removal in severe cases that may also require deep cleanings every three months. Dentists say that effective prevention of periodontal disease calls for excellent oral hygiene, including personal brushing and flossing as well as maintaining your routine visits to your Seattle dentist or hygienist.

Heart Disease Men

A study was done by PubMed that found that among all of its 9,760 subjects, those with periodontal disease had a 25% increased risk of coronary heart disease relative to those with minimal periodontal disease. Dentists say that poor oral hygiene, determined by the extent of dental debris and calculus, was also associated with an increased incidence of coronary heart disease. In men younger than 50 years at baseline periodontal disease was a stronger risk factor for coronary heart disease. Both periodontal disease and poor oral hygiene showed stronger associations with total mortality than with coronary disease. Seattle dentists and physicians have concluded that periodontal disease is associated with an increased risk of coronary heart disease, particularly in young men. Whether this is a causal relationship is unclear.

Oral Infection

We are entering an era of medical awareness and understanding in which both dentists and physicians need to shoulder the responsibility for a patient's medical well being.

That oral infections may have an impact on systemic health is not a new concept, says Seattle dentist Dr. Shawn Keller. More than 2,000 years ago, Hippocrates suggested that arthritis could be cured by the removal of infected teeth. The notion that a focus of infection in the mouth could affect other parts of the body was a very fashionable hypothesis in the late 1800s and the early 1900s and was known as the "focal infection theory". Dentists say that teeth were extracted under the pretext of curing a myriad of different disease and conditions as anemia, insomnia, phobias, polio and even stupidity. Most of the rationales for this choice of treatment were based on what were, at that time, plausible medical theories that were perpetuated until accepted as facts.

Although the focal infection theory seemed to be forgotten by the 1920s and 1930s, there is a renewed interest in the effect of oral infections on the development and exacerbation of systemic diseases. Particularly, the association between periodontal disease and general health has been elucidated and discussed both in the professional literature and the lay press. Dentists say that this connection has popularized the terms "oral-systemic" and "periodontal medicine".

How do we position oral health within systemic health? Is it a matter of identifying oral infections that may cause or exacerbate systemic illness, or identifying how oral treatment modalities affect systemic conditions and how treatment of systemic illness affect oral health, or using oral tissues and fluids to identify systemic conditions? All of these questions have been discussed by Seattle dentists and physicians and are, to a certain extent, equally valid.

Numerous chronic medical conditions are caused by or associated with infectious diseases. The more familiar are liver disease, caused by hepatitis viruses; peptic ulcer or cervical cancer, which is associated with a human papilloma virus infection. Periodontal disease is a chronic infectious disease that Seattle dentists postulate to affect other chronic conditions through various pathways, including the generation of inflammatory mediators, by direct effect of bacterial colonization, or as a result of toxins produced by periodontal pathogens. Thousands of articles have discussed periodontal disease and its association with heart disease, stroke, pneumonia, preterm births, low-birth weight babies, osteopenia, osteoporosis and diabetes.

Several decades ago, it was recognized that oral infections had a significant impact on morbidity and mortality of medically compromised patients, such as those with cancer or those undergoing chemotherapy. Dentists say that the elimination of oral infections before initiating radiation therapy, chemotherapy or various cardiac conditions today is the standard of care in most medical institutions in the United States. These circumstances are not chronic in nature, and timely interventions many times can prevent and even eliminate significant complications.

Treatment of oral infections and mucosal lesions with medication ranging from topical analgesics and antibiotics to systemic glucocorticoids may affect bleeding tendencies, general bacterial resistance, liver functions, glycemic control and more. Dentists say that there is no doubt that the effect of management for oral conditions is not limited to the oral cavity. Furthermore, the effects of epinephrine and the use of dental radiographs have been implicated in causing adverse effects in specific patient populations. However, interventions for systemic conditions also may have a dramatic impact on oral health. Xerostomia can be induced by hundreds of medications, gingival overgrowth can be stimulated by different classes of medications, the developments of osteonecrosis of the jaws recently has been associated with specific drugs, and oral ulcerations secondary to radiation and chemotherapy are very common.

Diagnosis of leukemia can be supported by oral biopsies. The use of oral fluids as diagnostic modality is a burgeoning field that is providing, for the first time, an alternative to traditional serology. Salivary samples today are used for such varied tasks as making a diagnosis of an infectious disease to serving a marker for blood alcohol levels. Dentists claim that future use for oral fluid diagnostics is almost unlimited, including testing for cancers and many other systemic conditions.

Neurological problems affecting oral functions, development of infections such as oral candidiasis, pain in the jaws secondary to cardiovascular disease or even metastic cancers are only a few examples of conditions that may manifest initially in the oral cavity. As dentists, we are experts in distinguishing between normal and abnormal oral conditions. This can be challenging but is necessary for more and more patients surviving and living with increasingly more multifaceted health problems.

Periodontal Disease Seattle

Periodontitis is now seen by Seattle dentists as resulting from a complex interplay of bacterial infection and host response, often modified by behavioral factors. Dentists say that there has been a fundamental change in the prevailing periodontal disease model of the 1960s, which suggested that the susceptibility to periodontal disease increases with age, and that all individuals are susceptible to severe periodontal disease. More recent research has changed the belief in universal susceptibility to the current view that only 5% to 20% of any population suffer from severe generalized periodontal disease, and that only moderate disease effects a majority of adults.

One major risk factor is smoking, as there is now a clear association between smoking and periodontal disease independent of oral hygiene, age, or any other risk factor. In human periodontal disease, there is no simple, direct pathogen-disease link. There are three pathogens that have a strong association with progressive periodontal disease and they may be the cause of continued loss of periodontal attachment in all periodontal disease classifications despite diligent periodontal therapy. Dentists say that this loss of attachment, or destruction of the periodontal ligament and loss of adjacent supporting bone, is seen in adult periodontitis, as well as in early-onset periodontitis, which affects young people who otherwise appear healthy. The three forms of early-onset periodontal disease are prepubertal periodontitis, localized and generalized juvenile periodontitis, and rapidly progressive periodontitis. Dentists say that they are distinguished from adult periodontitis by the age of onset of the disease, the rapid rate of disease progression, manifestations of defects in host response, and the composition of the subgingival microflora. Prepubertal periodontitis is associated with attachment loss around teeth of the deciduous and/or permanent dentition, and is often associated with severe congenital defects of hematological origin, and alterations in neutrophil chemotaxis function.

Periodontal disease may also be associated with systemic conditions such as metabolic disorders such as diabetes, female hormonal alterations, drug-induced disorders, hematologic disorders, leukemia, and immune system disorders. Dentists say that these systemic disorders have been documented as capable of affecting the periodontium and/or treatment of periodontal disease.

In order to rationally treat and prevent periodontal disease, we need to know the etiologic agents for specific patients, and the mechanism of bacterial pathogenesis in periodontitis. In systemic diseases in which the periodontal tissues are affected as well, early detection and carefully managed therapeutics with the physician and dentist working together may prove beneficial to the patient's general health and quality of life.

While many patients respond well to conventional periodontal therapy, others do not. Strategies that have improved our understanding of how bacteria cause medically important infections are starting to be successfully applied to examine mechanisms of bacterial pathogenesis in periodontitis. Dentists say that in order to rationally treat and prevent recurrence of periodontal diseases, we need to know the identity of etiologic agents for specific patients, and the virulence properties of the pathogenic species involved. Future studies are necessary to determine these answers, and improve our understanding of the mechanism of bacterial pathogenesis in periodontitis. This knowledge, in turn, should lead to the development of highly specific antimicrobials to prevent and treat periodontal disease.

What becomes evident from this review is that the periodontal tissues are often associated with manifestations of a wide range of systemic diseases. Early detection and carefully managed therapeutics with the physician and dentist working hand-in-hand may prove beneficial to the patient's general health and quality of life. Dentists say that tt is important that physicians recognize and familiarize themselves with these possible oral manifestations, and refer for the treatment of the periodontal disease. When there are signs of destructive oral disease of the hard and soft tissues, it is important that the Seattle dentist or hygienist determines is there may be an underlying systemic factor requiring referral to the physician.

Periodontitis Risks

An article from Dentistry Today read: Virginia Commonwealth University researchers have found that changes in the plasma lipoprotein profile of patients with severe periodontitis may contribute to these patients' elevated risk for heart disease and stroke. The finding suggest that it may be beneficial to test Periodontitits patients for changes in their plasma lipoprotein profiles so that available medication can be taken if necessary.

In the December issue of the Journal of Lipid Research, researchers found that patients with generalized aggressive periodontitis generally had elevated plasma levels of a particular bad subclass of the low density lipoprotein (LDL).

Previous research has shown that people who have predominantly small-dense LDL in their blood are three to six times more likely to develop heart disease or suffer a stroke. Dentists say that a person may have predominantly small LDL without having alarmingly high blood levels of cholesterol. Therefore, unhealthy levels of small dense LDL are not always detected in regular cholesterol tests.

According to the study, a second factor influencing the cardiovascular risk of patients with severe periodontal disease may be platelet activating activating factor acetylhydrolase, an enzyme that is associated with small dense LDL. Dentists say that this enzyme is able to break down some of the inflammatory, atherogenic components of LDL, and this increases the risk for cardiovascular disease.

Periodontal Disease Risks

As your healthcare providers, we believe that patient education is one of the best ways we can help you stay healthy. Therefore, we would like to share with you that there is a growing body of research that suggests that infection from the oral cavity may increase risk and complications for a number of serious diseases and conditions. Heart disease and stroke are among these. Dentists say that although this research is relatively new and there are a number of questions which remain unanswered at this time, it does appear that there may be a link between gum disease and increased risk for heart disease and stroke. Research to better understand the relationship between gum disease and cardiovascular diseases such as heart disease and stroke is currently underway. Dentists say that while we wait for the findings of this research, it is important to identify those individuals who may be at a greater risk for heart disease or stroke because of undiagnosed and untreated gum infection. First, it is important to point out the risk factors for heart disease and stroke which medical research has already identified.

The American Heart Association has identified certain factors that increase the risk of heart and blood vessel diseases. These include the following:

Increasing age
Family history of premature coronary artery disease
High blood pressure
Low HDL cholesterol
Obesity and overweight
Alcohol
Tobacco smoke
Diabetes
Physical inactivity
Stress

It has been estimated that each year 250,000 sudden deaths from coronary heart disease occur before the victim reaches the hospital. For many of these victims these was no previous recognition of cardiovascular diseases, therefore, it is extremely important that you discuss these risk factors and your specific risk profile with your dentist and medical care provider. It is also significant that of the 1.5 million heart attacks and 600,000 strokes that occur in the United States each year, almost half will affect people who appear to be healthy with normal or low cholesterol levels. Dentists say that as a result, scientists are now searching for other risk factors for heart disease and stroke. Whether gum disease is categorized as a risk factor for heart disease and stroke remains undetermined at this time. So what do we already know about how gum infections may affect cardiovascular health?

Diseases of the heart and blood vessels are most commonly related to thickening of the arterial walls, a condition called atherosclerosis. It is believed that atherosclerosis results from damage to the artery wall that, in turn, results from inflammation within the artery wall along with deposits of fat. The combination of fat deposits and artery wall inflammation leads to the development of an "atheroma" or plaque.

Part of this inflammatory damage is from infections of various sources. Many researchers believe that bacteria from gum infections could be one of the infections involved with this injury to the artery wall. Bacteria cause an inflammatory tissue response that allows the bacteria to enter the blood from the gum pockets. Dentists say that when your gums bleed, a path for bacteria to enter your bloodstream is created. This bacteria can move through blood vessels to distant sites in the body, including the heart. When this happens the artery becomes less elastic and the inside of the artery becomes smaller and smaller. What happens next is small blood clots may form and arteries get clogged which causes blood flow to be cut off. This results in a heart attack or stroke depending on the location of the blood clot. Dentists say that the role that gum disease plays in this process is an area of research which is still under investigation at this time. In the meantime it is important for you to recognize the following warning signs of gum disease:

Gums that bleed during brushing or eating
Increased space that starts to develop between teeth
Gums that feel swollen or tender/li>
Gums that are receding
Persistent bad breath
Pus between teeth and gums
Changes in the way your teeth fit together when you bite
Sores in your mouth

You should discuss warning signs of gum disease and risk factors for heart disease with your Seattle dentist and medical care provider, and it is recommended that adults be evaluated by their dentist or dental hygienist for periodontal disease.

Pancreatic Cancer

Gum disease may raise the risk of developing deadly pancreatic cancer, even among those who have never smoked, according to research reported in Boston at the American Association for Cancer Research's Frontier in Cancer Prevention Research meeting. Two previous studies found positive associations between tooth loss or periodontal disease and pancreatic cancer. However, "residual confounding" by smoking and other known risk factors may have accounted for the findings.

To investigate further, 16 years of health data was analyzed on nearly 52,000 male doctors in the Health Professionals Follow-up Study. Dentists say that this ongoing study is looking at lifestyle factors related to cancer and other chronic diseases.

A total of 216 men developed pancreatic cancer during follow-up. After factoring out smoking, diabetes, obesity, physical inactivity, diet and other potentially confounding factors, men with a history of gum disease had a 63% higher risk of developing pancreatic cancer relative to men without periodontal disease. Dentists say that smokers with periodontal disease doubled their chances of developing pancreatic cancer.

In the past there have been various reports dismissing the oral-systemic link, claiming the link to be in fact just related to smoking, given that smoking increases the risk of pancreatic cancer. This study is the first to clearly establish the link and the increased risk for patients with periodontal disease.

Gum disease results in chronic inflammation over many years and people with gum disease harbor high levels of harmful bacteria in the mouth and gut and tend to have higher amounts of cancer-causing nitrosamines.

Pancreatic cancer, the fourth leading cause of death from cancer in the United States, is one of the most deadly cancers, largely because it is often not detected until it has spread beyond the pancreas. Dentists say that only about 5% of pancreatic cancer patients survive the first five years after being diagnosed. Talk to your Seattle dentist about scheduling an appointment to discuss any questions you might have about your own risks of developing pancreatic cancer.

Acute Heart Attacks

Heart attack survivors who suffer advanced gum disease show significantly higher levels of protein in their blood called C-reactive protein (CRP) than such patients without gum disease. Dentists say that that the presence of gum disease might increase the risk of a second heart attack in people with a history of heart disease.

In this study, not only did the heart attack patients with periodontal disease have higher levels of CRP than those without gum disease, but the CRP levels were directly related to the severity of the gum disease. The more severe the gum disease, the higher the CRP levels are, says Seattle dentist Dr. Shawn Keller

There are many known risk factors for heart disease, including high blood pressure, high cholesterol, diabetes, and cigarette smoking, but all these combined only explain about two-thirds of heart attacks. Since about a third of people who suffer from heart attacks don't have those risk factors, there's a wide search going on for other conditions that may contribute to increased risk.

Studies being done all over the country have linked periodontal disease, an advanced form of gingivitis, with increased risk of heart attacks, but it has been unclear what the two conditions have in common, says Seattle dentist Dr. Shawn Keller.

The one thing we know the two conditions share is that they tend to initiate an immune response, also called an inflammatory response, in the body. Dentists say that the most common marker for this response is this C-reactive protein, which is considered predictive of future adverse events like heart attacks.

The most exciting find was that among people with a heart attack, those with periodontal disease had much higher CRP levels than those with a heart attack but no periodontal disease. Dentists say that it seems that the presence of periodontal disease on top of a heart attack has a synergistic effect and a much accentuated CRP release.

This gives dentists and physicians an insight into possible mechanisms underlying the association between gum disease and heart disease. Now dentists and physicians believe that patients with a heart attack and periodontal disease have an exaggerated inflammatory response with higher CRP levels that might put them at risk for future heart attacks. Dentists say that this raises the possibility of lowering the risk of these patients having another heart attack by maintaining their periodontal health.

Cardiovascular Disease

In May 2000, the public health community was alerted to the need to promote oral health by the first surgeon general's report on oral health. Although the precise mechanisms of interaction are not clear, sufficient evidence exists to conclude that oral lesions, especially advanced periodontal pathologies, place certain patients at increased risk of developing cardiovascular disease and stroke. These observations are leading Seattle dentists and physicians to interact more closely in caring for patients. Dentists say that in addition, a greater burden is being placed on the dental community to become more familiar with oral microbiology and the pharmacological approaches available to treat oral diseases that may have systemic implications. The patient with cardiovascular disease may present a challenge to the dentist, depending on the degree of hemodynamic compromise and the stability of his or her condition. Dentists say that many of the dental treatment approaches used for these patients are based on consensus opinion established through years of experience and informed clinical judgment. Few of the approaches are founded on controlled clinical trials that have assessed the effect of different treatment modalities on well-defined outcome criteria.

In many instances, such studies are limited by ethical or medico-legal considerations involved with placing patients at risk of developing systemic complications. Research also may be limited by the difficulty in obtaining study populations of adequate size for relatively rare disorders such as infective endocarditic.

Heart Disease

If you've worried about heart disease, you can easily spend thousands of dollars each year trying to prevent it, paying hand over fist for prescription medicines, shelves of healthy cookbooks, fitness machines for your home, and a gym membership.

Or maybe not. A number of recent studies suggest that you may already have a cheap and powerful weapon against heart attacks, strokes, and other heart disease conditions. Dentists say that it is none other than the humble tooth brush.

"There are a lot of studies that suggest that oral health, and gum disease in particular, are related to serious conditions like heart disease" says Seattle dentist Dr. Shawn Keller.

So can preventing periodontal disease, a disease of the gums and bone that support the teeth, with brushing and flossing prevent heart disease?

The evidence isn't clear yet, Seattle dentists say, but it's intriguing. According to the American Academy of Periodontology, people with periodontal disease are almost twice as likely to have coronary artery disease. One study found that the presence of common problems in the mouth, including gum disease, cavities, and missing teeth, were as good as predicting heart disease as cholesterol levels.

When it comes to the connection between periodontal disease and heart disease, it's not a connection that people naturally think of, says Seattle dentist Dr. Shawn Keller.

It has been found that people with higher blood levels of certain disease-causing bacteria in the mouth were more likely to have atherosclerosis in the carotid artery in the neck. Clogging of the carotid arteries can lead to stroke.

Atherosclerosis, also called hardening of the arteries, develops when deposits of fats and other substances in your blood begin to stick to the sides of your arteries. These deposits, called plaques, can build up and narrow your arteries, clogging them like a plugged-up drain. Dentists say that if these plaques ever block the blood flow completely, you could have a heart attack or stroke, depending on the location of the blockage. Note that not all plaque is alike. The plaque in your arteries have nothing to do with dental plaque your hygienist scrapes off your teeth. Dental plaque is a sticky residue of bacteria, acid, and food particles that can irritate your gums and eat away at tooth enamel.

So what might hardening of the arteries have to do with gingivitis? Dentists suggest that the bacteria from the mouth can enter the bloodstream through the gums. These same bacteria have been found clumped in artery plaques. So one theory is that these bacteria stick to the fatty plaques in the bloodstream, directly contributing to blockages.

Other possibilities lie in the body's own defense mechanisms against bacteria. One of the body's natural responses to infection is inflammation. Dentists say that it's possible that as these bacteria travel through your body, they trigger a similar response, causing the blood cells to swell. This swelling could then narrow an artery and increase the risk of clots.

That inflammation could be the root of the problem adds to data researchers are gathering that suggest more and more diseases, including periodontal disease, heart disease, and arthritis, are partially caused by the body's own inflammatory response.

So could periodontal disease, gingivitis, or another dental disorder, pericoronitis (when gum tissue around the molars becomes swollen and infected) cause heart attacks and strokes? It's far too early to say.

There's no question that there appears to be a connection, says Seattle dentist Dr. Shawn Keller, but the exact relationship between cardiovascular disease and periodontal disease isn't clear.

But even if periodontal disease isn't actually causing heart disease, the connection could still be important. For instance, periodontal disease might be an early sign of cardiovascular problems. Heart disease can be hard to catch early, because many of the conditions that precede it have no symptoms. Dentists say that you won't ever feel your arteries hardening or your cholesterol rising. But you might notice bleeding or painful gums.

If further studies bear out the connection between periodontal disease and heart disease, the next step would be to try treatment, says Seattle dentist Dr. Shawn Keller. Might taking antibiotics not only help heal oral infections but, as a result, also lower your risk of heart disease? No one's sure, but it's possible.

It's still too early for official preventive steps, since researchers don't know exactly how heart disease and periodontal disease are connected.

Obviously, people worried about heart disease need to pay attention to the established risk factors, I wouldn't want people to think that if they just started to brush their teeth more, they could go back to smoking or ignore their diabetes.

Diabetes Seattle Dentist

A reasonable interpretation of the present evidence indicates that diabetes, when a complication of periodontitis, acts as a modifying and aggravating factor in the severity of periodontal infection. Dentists say that diabetics with periodontitis who were young and poorly controlled those who were long-durations diabetics, especially those over 30 years old, demonstrated more attachment loss, bone loss, and deeper probing pocket depths than their nondiabetic controls. It seems that the earlier the onset of diabetes and the longer the durations, especially without consistent control, the more susceptible the individual will be to periodontal disease. Dentists say that consequently, once a diabetic contracts periodontal disease, it is usually more destructive. Although plaque scores of diabetics may be comparable to or even less than those of nondiabetics, diabetics often exhibit higher gingival index scores. The elevation of this particular clinical parameter is indicative of the microangiopathy associated with diabetes. Diabetic microangiopathy, retinopahy, ketoacidosis, and hypoerglycemia result in impaired wound healing, immunosuppression, and susceptibility to bacterial infection. Individuals ages 30 to 40 suffering from diabetic retinopathy had significantly more gingival inflammation that controls or diabetics without complications. Collagen metabolism is defective in diabetics and is one component underlying delayed would healing. Heyperglycemia was associated with increased collagenase and protease activity in the gingiva of rats. Vascular wound healing in rats, particularly new re-endothelialization across vascular anastomoses, was significantly impaired. Dentists say that diabetic abnormalities in immune response include impaired neutrophil chemotaxis, Phagocytosis, and adhesion. Decreased neutrophilic chemotactic response seems to be attributable to protein factors in diabetic serum that competitively bind neutrophil receptors, thereby preventing completement-mediated phagocytosis. Because diabetics are not able to eliminate circulating immune complexes (CIC) effectively, serum CIC levels are elevated. There are microbiological differenced in the characteristic flora of NIDDM patients and IDDM patients with periodontitis. Dentists say that these differences are not associated with diabetic impaired immune response. Ultimately, bacterial plaque is the primary etiology of periodontal diseases. Evidently, the host's response to bacterial plaque and ability to heal following surgery is altered by diabetic disease. Therefore, a thorough history regarding onset of diabetes, duration, and diabetic control would prove useful in the clinical management of diabetics presenting for treatment of periodontal disease.

Oral Inflammation

Treating periodontal disease with scaling and root planning combined with a topical antibiotic gel can significantly lower the levels of two inflammatory proteins associated with a heightened risk of heart disease, says Seattle dentist Dr. Shawn Keller.

Blood drawn from 102 subjects with periodontal disease showed elevated levels of both C-reactive protein and fibrinogen, proteins associated with increased risk for heart disease and blood clotting. All of the subjects were free of other conditions that could cause elevated levels of the proteins.

Scientists from the UB school of dentistry's department of oral biology divided the subjects into two groups to determine if periodontal therapy would be effective in lowering the levels of the heart disease markers. One group received scaling and root planning treatment while the second group received treatment with special topical antibiotic Atridox followed by scaling and root planning.

Based on a treatment regimen at three, six and nine months and blood samples taken at six weeks and at three, six, nine and 12 months, repeated periodontal treatment resulted in a significant reduction in the systemic levels of the inflammation markers, the UB scientists said.

People who have high levels of CRP in their blood are at high risk of heart disease, says Seattle dentist Dr. Shawn Keller, the results showed that in people who had elevated levels of CRP at baseline, removal of dental plaque bacteria by scaling or scaling combined with topical antibiotics produced a statistically significant reduction, bringing CRP levels close to the low-risk level. Dentists say that both treatments also significantly reduced levels of fibrinogen in patients with elevated fibrogen levels.

Periodontitis Vaccine

Caroline Genco's mica may eventually change the way we treat heart disease and change our view of oral health as well.

In her Boston University laboratory she's found that giving genetically altered mice an oral dose of the bacteria that causes periodontal disease leads to the development of plaque build-up in the aorta just like that commonly found in many heart attack victims. But if Genco first gives the mice a vaccine to protect against the bacteria, there's no build-up at all.

If you give the vaccine, it prevents the bacteria from getting there in the first place. That means a vaccine given in childhood may one day be used to prevent heart disease. They already have a patent pending on this vaccine.

That day may be a long way away, but research like that being done by Genco demonstrates the kind of links now being made between oral health and systemic diseases. Dentists say that the mouth, long treated as a separate - and often lesser - healthcare concern, is starting to be more formally integrated into medical practice. Increasingly the mouth is being viewed both as a window on the health of an individual and as a potential contributor to disease.

A thorough oral exam, for example, creates opportunities for diagnosing a wide range of diseases. Dental x-rays that show bone loss, for example, may prompt a Seattle dentist to refer a patient for a bone scan for osteoporosis. Dentists say that infected gums may lead a dentist to suggest blood sugar testing. "I will often send a patient to be checked for diabetes" says Seattle dentist Dr. Shawn Keller.

But the connections go well beyond such diagnoses. There's data associating poor oral health with respiratory disease, premature birth, heart disease and stroke. Studies show that if you have gum disease, you are twice as likely to die from a heart attack and three times as likely to have a fatal stroke.

Some of the strongest data comes in the area of premature birth. Intervention studies on high-risk pregnant women show that treatment of periodontal disease can significantly reduce the likelihood of premature birth. In a study of 1,000 patients, we found an 87% decrease in the amount of preterm births. That is absolutely remarkable says Seattle dentist Dr. Shawn Keller.

The exact role that dental bacteria play in these diseases is still being unraveled. Increasingly however, the medical community is viewing dental disease as an infection that creates chronic state inflammation in the body. Dentists say that this inflammation strains the immune system, making the body more susceptible to a wide range of health problems. With more than 500 different kinds of bacteria found in the mouth, researchers are now busy trying to tease out the behavior of specific bacteria to better understand their role in various diseases.

The experts say they are standing on the edge of a vast, unexplored territory. As of yet, there is no proof that dental disease actually causes or even contributes to the development of disease. "It's not floss or die" says Seattle dentist Dr. Shawn Keller. To show there is a causative relationship, we have to have much more extensive studies.

Yet, as the data piles up, the enticing possibilities are beginning to work their way into medical practice. Discussion of oral health is starting to show up in medical textbooks, in medical school curriculum and in patient management. Insurers are even starting to revise their coverage.

We don't want to get ahead of ourselves. We need to have scientific evidence every step of the way. Dentists say that still, it is prudent to inform people that these health linkages exist. No matter what the research shows, encouraging people to take better care of their teeth and gums carries no risk. People will just end up with healthier mouths.

Pregnancy and Periodontitis

You probably think you've got your preconception planning all figured out: Take vitamins, ban alcohol and sushi, make sure you're up-to-date on vaccinations, and, of course, go to a lot of movies with your partner while you still can. Bet you weren't planning to schedule a dentist appointment too, were you?

It turns out that getting a thorough dental exam before you conceive is as important as an overall medical checkup. In the past few years, mounting research has indicated a link between poor oral health and preterm birth, low birth weight, and possibly pre-eclampsia (a dangerous pregnancy complication). One study in The Journal of The American Dental Association found that pregnant women with chronic gum disease were four to seven times more likely to deliver prematurely (before 37 weeks) than those with healthy gums; women in the group with more severe periodontal disease delivered even earlier (before 32 weeks).

"If I have a new patient who tells me that she delivered prematurely twice, I'll ask her if she had her gums checked before or during her pregnancy" says Seattle dentist Dr. Shawn Keller. "If she says no, I'll consider whether gum disease could be responsible for the bad outcomes."

It doesn't really take horrible habits to develop gingivitis; simply being lax about brushing or flossing for a day or two can do it. Dentists say that gingivitis develops when bacteria build up between your teeth and gums, causing soreness, swelling, and sometimes bleeding; if it's not treated, it can lead to periodontal disease, where the bacteria begin to produce toxins that eat away at the tissue as well as the bone supporting the teeth. That, in turn, can lead to tooth loss. According to the National Center for Health Statistics, 45 percent of women aged 35 to 44 have gingivitis; 15 percent have more severe gum disease. Dentists say that most people don't even know they're running around with low-grade oral infections. Your gums may not bleed, and even if they do, many people assume this is normal during brushing and flossing, which is the biggest mistake you can make, says Seattle dentist Dr. Shawn Keller. Healthy gums do not bleed. If you were washing your hands and your hands started to bleed, you'd be frightened. You should think the same way about your gums.

In general, women are more susceptible than men to gingivitis, especially during pregnancy, when increased hormone levels make gums supersensitive to plaque and bacteria (the old wives' tale that claims a woman loses a tooth with each pregnancy may be based in truth, since before modern dental care existed, pregnant women probably did lose teeth due to untreated gum disease.)

Women taking ovulation-inducing drugs during fertility treatments are at greater risk for gingivitis, too. One study found that women who used ovulation-inducing medications for more than three menstrual cycles had higher levels of gum inflammation and bleeding than women not on the drugs, presumably due to increased levels of progesterone and estrogen. Dentists say that while the effect of oral health on fertility isn't clear, it has been shown that the presence of infection anywhere in the body is associated with unsuccessful embryo development and implantation failure in IVF patients.

It's not yet known precisely how gum disease influences pregnancy outcomes; experts suspect that inflamed gums can lead to inflammation throughout the body, which in turn might produce abnormalities in the placenta or uterus. Researchers hope to show that amniotic fluid taken from women who delivered preterm carries the same organisms that cause gum disease. Another study in the Journal of Periodontology found that pregnant women with periodontal disease have significantly higher levels of C-reactive protein (CRP), a marker of systemic inflammation.

So, if you're trying to conceive, it's crucial to make an appointment with your Seattle dentist as soon as possible. As a result of all the recent buzz about the important of dental health during pregnancy, several large insurance providers are adding dental coverage specifically for pregnant women. Fortunately, just as it doesn't take much to get rid of it, either. Dentists say that if you start brushing and flossing regularly as soon as you notice that your gums are red or bleeding, you can get rid of the inflammation and reverse the infection in two or three days, says Seattle dentist Dr. Shawn Keller.

If you do develop gum disease while you're pregnant, don't panic, it's not too late to go to your Seattle dentist and get it under control. One misconception many women have is that it's not safe to visit the dentist during pregnancy, in fact, if you're especially prone to gingivitis, your dentist may recommend that you come in more frequently- perhaps every two to three months- while you're pregnant, and might also prescribe a prescription antibacterial mouthwash to prevent bacteria buildup.

A preconception dental visit is also a good idea in case it turns out you need more extensive treatments - such as fillings, root canal, wisdom-tooth extraction, or x-rays. Once you're pregnant those kinds of procedures, unlike routine exams and cleanings, are potentially risky. Dentists say that local anesthesia is harmless during pregnancy, but x-rays are best avoided. Procedures requiring general anesthesia will only be performed on pregnant women in emergencies, since there are known risks to the mother and baby.

Cosmetic procedures like tooth whitening, which involve chemicals, should also be done before pregnancy, or postponed until afterwards. Although there is no hard evidence that the chemicals used to bleach the teeth are harmful during pregnancy, Dr. Keller says it's best to avoid them. If a woman delivers a baby with a defect or other problem, you don't want her to worry that it was caused by the whitening chemicals, even though that would be unlikely, it's better to remove that concern entirely by holding off on the procedure. Dentists say that as research mounts on the connection between oral health and pregnancy, dentists and physician s may soon start screening their patients' mouths as a routine part of a preconception or prenatal checkup. Until then, it's up to you to call your Seattle dentist, make an appointment and open wide.

Baby Teeth

A fetus starts developing teeth by around the sixth to eighth week of pregnancy. By the time a baby is born, it has all its primary teeth and the beginnings of some permanent ones, though of course you can't see them yet.

While your diet is obviously important during pregnancy, it probably has little effect on your baby's future dental health, says Seattle dentist Dr. Shawn Keller. The percentage of kids with decay in their baby teeth is on the rise, which probably results from a combination of factors, including diets high in sugar and increased drinking of bottled water, which doesn't usually contain fluoride. Dentists say that several recent studies also suggest that pregnant women can pass on decay-causing bacteria to their babies. Another good reason to enter into pregnancy with a clean mouth!

Pregnant Patients

Recent research has shown that the oral health of pregnant mothers can affect the health of their babies. For this reason, it is more important than ever that pregnant women receive routine dental care throughout their pregnancy.

It is important to take care of your teeth and gums. Overall health is affected by oral health. Dentists say that gum disease has been linked to heart disease and cardiovascular health. Gums that are free of disease are important to having a healthy mouth and a healthy body. This becomes even more important for expecting mothers.

In one recent study, the authors examined 124 pregnant or postpartum women. Women who had preterm, low-birth-weight infants were found to have significantly worse periodontal disease than subjects with normal birth weight infants. Dentists say that even after controlling for risk factors such as tobacco, drug and alcohol use, prenatal care, and nutrition, women with clinical evidence of periodontal disease were 7.5 times more likely to have premature, low-birth-weight infants than control subjects.

Preterm low birth weight is a major concern, because it is related to 60% of infant mortality. Prematurity and low birth weight is estimated to result in 5 million neonatal intensive care unit hospital days per year and $5 billion in annual costs. Dentists say that besides infant deaths and the high costs associated with preterm and low birth weight, other serious life-long disabilities such as mental retardation and cerebral palsy may also occur.

Women with oral health problems also tend to have children that are more prone to periodontal disease. Just like adults, a children's oral health can have a negative impact on their health status. These children may experience pain and suffering that could be avoided.

Oral disease can be reduced or avoided by taking a few simple steps. It is necessary to care for your teeth and gums by brushing your teeth twice a day, and flossing once a day. Eating a healthy diet, and avoiding sugary snacks and soda pop will also reduce tooth decay and gum disease. Finally, regular dental care is the cornerstone of good oral health.

There has been some controversy regarding what treatment is appropriate for pregnant patients, here are some basic guidelines:

Dentists say that elective dental procedures can be delayed until after delivery, however most common dental procedures can be safely performed during pregnancy. Emergency dental treatment should be provided any time during the pregnancy regardless of trimester. The best time to address active dental disease is during the second trimester and early part of the third trimester. When treating a pregnant patient it is important to make sure that appointments are kept short and that the patient is in a comfortable position to avoid possible supine hypotension and syncope. Always protect the patient and fetus by using a lead apron when making radiographs. Avoid prescribing medications that are considered teratogenic by the FDA such as tetracycline, doxycycline, streptomycin, benzodiazepines, and erythromycin estolate. When local anesthetics are used, a local anesthetic that has a vasoconstrictor is advisable. Avoid nitrous oxide during the first trimester. Consult with an obstetrician before using after the first trimester. It is acceptable to use chlorhexidine throughout pregnancy. Systemic fluoride is not advised during the course of pregnancy. Dentists say that there are not safety concerns, but rather prenatal fluoride is not considered to be beneficial.

Hemodialysis and Periodontitis

End-stage renal disease (ESRD) patients on hemodialysis experience a greatly increased rate of astherosclerotic complications. In both hemodialysis and general populations, it has become evident that inflammation plays a central role in the pathogenesis of atherosclerotic complications. C-reactive protein (CRP), the major acute phase protein in man, has been found to predict allcause cardiovascular mortality is ESRD patients on hemodialysis maintenance therapy. Dentists say that hepatic CRP synthesis is upregulated by proinflammatory cytokines released locally at sites of infection or inflammation, although many patients experience elevated levels of CRP values in the absence of overt infection or inflammation. Destructive periodontal diseases in the general population have been associated with both an increased prevalence of atherosclerotic complications and en elevation is serum CRP values. In view of diseases in the general population, and since periodontal evaluations are normally not performed as part of a medical assessment, destructive periodontal diseases may be an over looked source of inflammation in ESRD patients on hemodialysis therapy. Dentists say that the intent of this report is to review the possible role destructive periodontal diseases and associated periodontal infections may play in the management of the ESRD patient on hemodialysis maintenance therapy.

Pancreatic Cancer Risks

A humble toothbrush could be a powerful pancreatic cancer prophylaxis, suggest results of an observational study that associated periodontal disease with the malignancy.

Men with periodontitis and tooth loss, or both, had an overall 64% greater risk of cancer of the pancreas than men with good oral health, showed data from Health Professionals Follow-Up Study.

The strength of the association was underlined by the finding that men with periodontal who never smoked cigarettes -- one of the few known risk factors for pancreatic cancer -- had a more than two-fold greater risk for the malignancy, reported epidemiologist Dominique Michaud, Sc.D., of the Harvard School of Public Health, and colleagues. "Our study provides the first strong evidence that periodontal disease may increase the risk of pancreatic cancer. This finding is of significance as it may provide some new insights into the mechanism of this highly fatal disease," said Dr. Michaud, in the Jan. 17 issue of the Journal of the National Cancer Institute.

The investigators hypothesized that systemic inflammation may play a key role in the pathogenesis of pancreatic cancer, an idea supported by the finding that people with periodontal disease have elevated levels of inflammatory markers in serum, most notably C-reactive protein.

Alternatively, carcinogenic nitrosamines and high levels of oral bacteria found in the mouths of people with periodontal might interact with gastric acids to promote the development of pancreatic cancer, Dr. Michaud said.

She and colleagues extracted data on periodontal disease from the Health Professionals Study, which followed a cohort of more than 51,000 male health professionals from the ages of 40 to 75 years at baseline in 1986.

The baseline questionnaire asked participants whether they had ever had periodontal disease with bone loss, and the participants were asked to report any tooth losses on biennial follow-up questionnaires.

During 16 years of follow-up, 216 men out of the original 51,529 in the study cohort were diagnosed with incident pancreatic cancer.

The authors created Cox proportional hazard models to estimate relative risk and control for potential confounders, including smoking, age, body mass index, diabetes, race, physical activity, and dietary factors.

They found that among all men with periodontal disease, the multivariable relative risk for pancreatic cancer compared with men with no periodontal disease was 1.64. The crude incidence rate for pancreatic cancer among all men with periodontal disease was 61/100,000 person-years, compared with 25/100,000 for all men in the cohort without periodontal disease.

When they restricted the analysis only to men who never smoked, the investigators found that the relative risk of cancer of the pancreas among those with periodontal disease was 2.09. Among never-smokers with gum disease and tooth loss, the crude incidence rate was: 61/100,000 person-years, compared with 19/100,000 among all never-smokers with healthy gums

manifested by periodontitis with recent tooth loss, was associated with the greatest risk."

When they looked for an association between other measures of oral health (e.g., caries) and pancreatic cancer, however, they found that neither the baseline number of natural teeth, nor cumulative tooth loss during follow-up were strongly associated with increased risk for pancreatic cancer.

Dr. Michaud and colleagues noted that among the men in the study with periodontal disease, levels of C-reactive protein were 30% higher compared with men with no periodontal disease, lending credence to the idea that inflammation could play a role in carcinogenesis

"Alternatively, periodontal disease could influence pancreatic carcinogenesis through increased generation of carcinogens, namely nitrosamines," said Seattle dentist Dr. Shawn Keller. "Individuals with periodontal disease and poor oral hygiene have elevated levels of oral bacteria and have much higher nitrosamine levels in their oral cavity due to nitrate-reducing bacteria. Nitrosamines and gastric acidity have been hypothesized to have an important role in pancreatic cancer; numerous studies support this hypothesis."

Oral cancer and Gum Disease

Dr. Sara Grossi of the University of Buffalo in New York said that she believes these findings provide the first link between oral cancer and oral infection, and could offer a new strategy for identifying oral cancer in its early stages and perhaps preventing the disease. She reported the findings in San Antonio this week at the American Association of Dental Research's annual meeting.

Gum disease is a chronic bacterial infection of the gums that can eventually lead to tooth loss. Some studies have linked gum disease to a higher risk of heart disease and stroke.

Grossi and her colleagues analyzed date from the Third National Health and Nutrition Examination Survey, which the U.S. Centers for Disease Control and Prevention conducted between 1988 and 1994. Dentists say that specifically, the team looked at roughly 14,000 study participants who were 20 or older and had six or more natural teeth.

The researchers found that people with periodontal disease had a 1.7 fold increased risk of precancerous mouth lesions, and a 4.2 times greater risk of mouth cancer.