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Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
Your oral health:  How periodontal inflammation is connected to disease
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Your oral health: How periodontal inflammation is connected to disease

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How periodontal inflammation is connected to overall health -- you'd be surprised at the connection

How periodontal inflammation is connected to overall health -- you'd be surprised at the connection

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  • 1. In fla m m a tio n a n dP e rio d o n ta l Dis e a s e sA paradigm shift in periodontology and what itmeans for patient care
  • 2. Outline of Presentation All about inflammation: the paradigm shift in periodontology Inflammation, periodontal disease and cardiovascular disease Inflammation, periodontal disease and other disease states Risk factors for periodontal disease Treatment of periodontal inflammation Five Things to Remember Future Directions and Questions 2
  • 3. Media Coverage Re ce n t Ne w s Co ve r a g eThe Bos ton Globe November 2, 2009 )Audience: 713,083) We bMD January 12, 2010 (Audience: 10,845,896) Ea ting We ll January 1, 2010 (Audience: 530,309) Me n’s He a lth January 1, 2010 (Audience: 7,438,572) Me dica l Ne ws Toda y February 20, 2010 (Audience: 1,800,000) 2
  • 4. Periodontal Disease: A Quick Overview Periodontal disease is a chronic inflammatory disease that destroys the bone and gum tissues that support the teeth. The American Academy of Periodontology (AAP) estimates that 3 out of 4 Americans are affected by periodontal disease, ranging from mild gingivitis to more severe periodontitis. If left untreated, mild cases of gingivitis can lead to periodontitis.
  • 5. Periodontal Disease However, the periodontal disease of yesterday is not the periodontal disease of today.  Yesterday: researchers believed that gum loss in periodontal disease was caused by the bacteria in plaque.  Today: researchers have determined that the gum loss in periodontal disease is caused by the inflammatory response to the bacteria in plaque. 5
  • 6. J Periodontol 2008;79:1560-1568. 43
  • 7. What is Inflammation? Inflammation is the body’s first response to an injury. The first phase (acute inflammation) includes redness, swelling, heat, and altered function. It is self-perpetuating. There are several biological markers of inflammation in your blood, including C-reactive protein (CRP).  CRP is a protein found in the blood which can rise in response to inflammation.  Acute inflammation often causes elevated C-reactive protein.  Elevated CRP is a risk factor for several chronic inflammatory diseases. Inflammation appears to be a common link between several common diseases of aging.  These diseases include heart disease, arthritis, and periodontitis. 6
  • 8. Examples of Inflammation Sunburn Infection A cut on the skin 7
  • 9. Inflammation’s Objective Inflammation tries to contain the injury to the local site. The body’s reaction is immediate (called the innate response). Its ultimate purpose is to protect the body from further damage. 8
  • 10. Inflammation is Damaging when Uncontrolled Though inflammation can be helpful under certain conditions, uncontrolled inflammation, also called chronic inflammation, is harmful and causes tissue loss. Chronic inflammation occurs when there is a sustained infection, like periodontitis. Chronic inflammation involves more inflammatory mediators than the immediate innate response. 9
  • 11. Chronic Inflammation Chronic inflammation can negatively affect all organs and tissues of the body. Chronic diseases of aging are connected through common chronic inflammatory mechanisms. 10
  • 12. Periodontal Paradigm Shift: Because of this new focus on inflammation, there has been ashift in the way periodontists view periodontal disease and its relationship to other disease states. 11
  • 13. Periodontitis is a Chronic Inflammatory Disease of Aging Periodontitis involves a microbial challenge to the gums which stimulates an inflammatory response Genetic and acquired risk factors lead to immuno-inflammatory response A prolonged immuno-inflammatory response leads to destruction of connective and bone tissues, which leads to the possible loss of teeth. Chronic inflammatory diseases, such as periodontitis, arise over decades. Periodontal disease is a significant contributor to the total inflammatory burden on your body and can adversely affect your systemic health. 12
  • 14. “Inflammation and Periodontal Diseases: A Reappraisal” In January 2008 a workshop sponsored by the AAP brought together more than 80 leading experts:  Periodontists, cardiologists, diabetologists, geneticists, gerontologists, inflammation researchers This was an opportunity to engage in collaborative thinking and brainstorming across many different fields- using inflammation as a common finding. 13
  • 15. Workshop, cont. The workshop was developed to expand and advance our understanding of inflammation and the role it plays in diseases of aging. The experts from the diverse fields addressed topics of inflammation:  What is inflammation?  What specific mechanisms constitute inflammation?  What factors regulate inflammation?  Why do individuals have different expression levels of inflammation?  Is the inflammation in one disease common to the inflammation in other diseases? 14
  • 16. Workshop, cont. The experts engaged in discussion of the future of inflammation therapies and how they may change the future of periodontics. Proceedings from the Workshop were published in a supplement to the Journal of Periodontology in August 2008. (Available for free at: http://www.joponline.org/toc/jop/79/8s) 15
  • 17. Workshop, cont. What we learned:  Periodontal disease is a bacterially-induced chronic inflammatory disease that does not resolve by itself.  The inflammatory response is extremely complex .  Environmental and genetic factors affect expression of inflammation in individuals .  The initiation and resolution of inflammation are well controlled processes.  Diabetes, CVD, and stroke all share common inflammatory processes similar to periodontal inflammation.  Resolution of any inflammation in the body is helpful for overall health. 16
  • 18. The Workshop helped highlight the relationship between various disease states, and suggested that inflammation may be the basis for these relationships. 17
  • 19. Perio-Cardio Link:The relationship between periodontaldisease and cardiovascular disease (CVD) 18
  • 20. Cardiovascular Disease: A Quick Overview Cardiovascular disease generally refers to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain (angina), or stroke. The American Heart Association reports that cardiovascular disease is the leading killer of men and women in the United States.
  • 21. Inflammation and CVD Inflammation contributes to heart attacks as much as or more than cholesterol.* Atherosclerosis always begins with injury to the endothelium of blood vessels.  Periodontal pathogens have been found in atherosclerotic lesions. 19*Ridker PM, et al. N Engl J Med. 2005 Jan 6;352(1):20-8.
  • 22. Periodontal Disease and CVD Data derived from meta-analysis: meta-analysis combines the results of several studies that address a set of related research  Five prospective cohort studies hypotheses  Five cross sectional studies Ability to control for between-study variation  Five case control studies Subjects with periodontitis had a 1.14 - 1.59 fold greater risk for developing CVD compared to those without periodontitis.  Adjustments made for risk factors: smoking, diabetes, alcohol intake, obesity and blood pressureBahekar AA, Singh S, et al. Am Heart J 154:830-837, 2007 19
  • 23. C-Reactive Protein (CRP) CRP is a protein found in the blood that reflects the amount of inflammation in your body. Periodontitis and other sources of inflammation elevate CRP levels. Elevated CRP is a direct risk factor for CVD. 20
  • 24. AJC-JOP Consensus Paper The American Journal of Cardiology contacted the AAP after reading the August 2008 Journal of Periodontology supplement from the Workshop on Inflammation. A consensus paper was developed in collaboration with the American Academy of Periodontology and top cardiologists. The paper was published simultaneously in the Journal of Periodontology and the American Journal of Cardiology in June 2009. 21
  • 25. AJC-JOP Consensus Paper, cont. The consensus paper is a summary of research that shows a connection between periodontal disease and CVD. It explains the underlying biologic and inflammatory mechanisms that may be the basis for the connection. Clinical recommendations for treating patients with cardiovascular disease and periodontal disease are also included. 22
  • 26. CVD-PD Clinical Recommendations Examples of the clinical recommendations:  Dentists are asked to consider their patients’ heart health and risk for CVD.  Assess risk factors for CVD such as smoking and family history of CVD  Physicians are asked to consider their patients’ periodontal health and risk for periodontal disease.  Assess symptoms such as tooth loss or bleeding and swollen gum tissue  All health professionals are asked to educate patients on chronic inflammatory diseases and how they are related.  Health professionals are also asked to work together to ensure patients are in best health. 23
  • 27. The Relationship of Periodontal Disease to Other Inflammatory Diseases Inflammation appears to be the basis for the association between oral and systemic disease. One chronic inflammatory disease potentially influences the expression of other diseases:  Tissue destruction is caused by prolonged inflammation.  Moderate/severe periodontitis increases systemic inflammation.  Systemic inflammation is associated with most chronic diseases of aging.  For example, periodontal disease influences diabetes and diabetes influences periodontal disease. 24
  • 28. The Relationship of PeriodontalDisease to other Chronic InflammatoryDiseases of Aging  Cardiovascular disease  Arthritis  Diabetes  Alzheimer’s Disease  Cancers 25
  • 29. Arthritis Arthritis (Rheumatoid arthritis and osteoarthritis) is an inflammation of the joints. Patients with arthritis have a higher incidence of periodontal disease compared to healthy controls.* Source: National Institutes of Health Periodontal treatment decreases arthritis parameters:**  Patients’ number of swollen and tender joints decreased following periodontal treatment.  Patients’ assessment of pain also decreased following periodontal treatment.*Pischon N, et al. J Periodontol. 2008 Jun;79(6):979-86.**Ortiz P, et al. J Periodontol. 2009 Apr;80(4):535-40. 26
  • 30. Diabetes Worldwide incidence is expected to increase with increased prevalence of obesity. Major public health burden because of serious microvascular sequelae.  nephropathy  retinopathy  neuropathy  cardiovascular disease  periodontitis Total annual costs exceed $132 billion in US alone 28
  • 31. Risk Factors for Diabetes Genetics Diet Sedentary lifestyle Perinatal environment Age Obesity Chronic Inflammation  Type I and Type II Diabetes 28
  • 32. Diabetes Type I Diabetes  Adolescents and young adults  Autoimmune destruction of pancreatic islet cells that produce insulin  Increased CRP in patients with long termed type I diabetes Type II Diabetes  Occurs mainly in adults but prevalence among young people increasing due increase in childhood obesity  Characterized by increased cellular non responsiveness to insulin (insulin resistance)  Pancreatic beta cells do not secrete sufficient insulin 28
  • 33. Diabetes Hyperglycemia inhibits the resolution of inflammation. High CRP and IL-6 promotes insulin resistance. Patients with diabetes are three times more likely to have periodontal disease. Controlling periodontal disease helps control blood sugar levels. Insulin 28
  • 34. Obesity Patients with a higher body mass index (BMI) tend to have higher levels of CRP. Calorie reduction leads to decreased gingival bleeding and rate of periodontal disease progression.**Branch-Mays GL, et al. J Periodontol. 2008Jul;79(7):1184-91. 30
  • 35. Alzheimer’s Disease Progressive intellectual failure and a major cause of dementia Pathologic hallmarks:  amyloid plaques and neurofibrillary tangles which are distributed in the frontal neocortex and limbic system Alzheimer’s Dz is an innate inflammatory response in an attempt to remove the amyloid deposits from the brain 27
  • 36. Alzheimer’s Disease Antibodies and immune cells cross the blood brain barrier. Exposure to chronic periodontal disease quadruples an individuals risk of developing Alzheimers disease.**Watts A, et al. Neuropsychiatr Dis Treat.2008 Oct;4(5):865-76. © 2000 - 2009 American Health Assistance Foundation 27
  • 37. Cancers Pancreatic cancer  Men with a history of gum disease are 54% more likely to develop pancreatic cancer than men with healthy gums.* Head and neck cancers  Chronic periodontitis is independently associated with the incidence of head and neck cancers.**  Smoking increases this association.*Michaud DS, et al. Lancet Oncol. 2008 Jun;9(6):550-8. Epub 2008 May 5.**Tezal M, et al. Cancer Epidemiol Biomarkers Prev. 2009 Sep;18(9):2406-12. 29
  • 38. Other Inflammatory Diseases Asthma and other chronic respiratory diseases Osteoporosis Kidney disease Metabolic syndrome 31
  • 39. Risk Factors for Periodontal Disease Genetic risk factors  Can be minimized with proper diet, exercise, and oral hygiene. Biological risk factors  Other systemic diseases of inflammation may increase the risk of periodontal disease.  Predisposition to inflammatory conditions such as obesity, diabetes, or CVD 32
  • 40. Risk Factors for Periodontal Disease, cont. Behavioral risk factors Biologic Risk Factors  Poor oral hygiene  Smoking (specifically, nicotine intake)  Smokers have higher levels of CRP.  Stress  Sleep deprivation  Poor diet Behavioral Risk Genetic Risk Factors Factors 33
  • 41. Treatment of Periodontitis Reduction of tissue inflammation Reducing one type of inflammation may reduce another:  Patients with periodontitis and rheumatoid arthritis who received periodontal treatment:  Reduced inflammation in periodontal tissues.  Reduced severity of RA symptoms.** Ortiz P, et al. J Periodontol. 2009 Apr;80(4):535-40. 35
  • 42. The good news is that inflammation levels can be reduced.When chronic inflammation is controlled, the associated chronic inflammatory diseases may be controlled. 36
  • 43. How to Reduce Inflammation: What does this mean for patients? Reduce direct sources of inflammation:  Visceral fat  Exercise  Reduce calories  Chronic infections  Periodontists can help reduce inflammation in the oral cavity. Have your teeth professionally examined and cleaned regularly. Stop smoking. Activate inflammation resolution systems:  Add Omega-3 fatty acids to your diet.  Take a daily low-dose aspirin. 37
  • 44. J Periodontol 2008;79:1601- 1608. 43
  • 45. Inflammation: 5 things to remember1. There has been a paradigm shift in the field of periodontology. Periodontal disease today is defined by the inflammatory response to the biologic components of plaque. 38
  • 46. Inflammation: 5 things to remember2. The relationship between periodontal disease and other chronic inflammatory diseases of aging is better understood. These diseases include cardiovascular disease, respiratory diseases, diabetes and arthritis. 39
  • 47. Inflammation: 5 things to remember3. Treatment of chronic oral inflammation should be done by trained dental professionals. Co-management with periodontal specialists to help in evaluating, diagnosing, and treating periodontal inflammation and disease. 40
  • 48. Inflammation: 5 things to remember4. Reducing inflammation in the body can reduce the occurrence and severity of chronic inflammatory diseases. 41
  • 49. Inflammation: 5 things to remember5. Dentists and physicians need to work together to ensure the best health of their patients. 42
  • 50. Conclusions: Future Directions A paradigm shift is occurring in both medicine and dentistry in our understanding of preventing many of today’s systemic diseases. The incidence and amount of inflammation that patients experience may be critical to the onset and progression of certain systemic diseases. Prospective treatment studies are needed that define whether or not periodontal treatment makes a substantial difference in the expression of certain diseases. As we wait for such studies, we should educate our patients about what is known and to help them manage their own health by assisting in the reduction of inflammation. 43
  • 51. Future Directions Significant clinical limitation in diagnosing and monitoring periodontal inflammation  gingival inflammation and bleeding  periodontal pocket depth  gingival attachment level Classical approaches to controlling periodontal inflammation rely on attempts to suppress bacteria that incite inflammatory response  Mechanical (SC/RP, flap surgery)  Chemical (antimicrobials, antibiotics) Emerging and future approaches need to rely more on  Modifying the inflammatory response itself  Limiting the activities of pro-inflammatory pathways, effector cells and mediators 43
  • 52. Pathogenesis of Periodontal Disease P in k, He a lth y Tis s u e , No Clin ic a l S ig n s o f Dis e a s e Go o d Ora l Hyg ie n e Lo w S u s c e p tib ility He a lth No S ys te m ic Ris k Fa c to rs Na tu ra l En zym e In h ib ito rs Tis s u e De s tru c tive En zym e sBalance of Tissue Destruction in the Periodontium
  • 53. J Periodontol 2008;79:1592-1600. 43
  • 54. Pathogenesis of Periodontal Disease P o o r Ora l Hyg ie n e Dis e a s e S ys Hig hicSRisckeFatibto rs te m u s p ility cNa tu ra l En zym e In h ib ito rs • S m o kin g • Ge n e tic s • Dia b e te s Ove rp ro d u c tio n Tis s u e De s tru c tive En zym e s Imbalance of Tissue Destruction in the Periodontium
  • 55. Pathogenesis of Periodontal Disease Na tu ra l En zym e In h ib ito rs Dis e a s e Ch ro n ic Ove rp ro d u c tio n Tis s u e De s tru c tive En zym e sS tudie s s how s moke rs (Bo n e Lo s s , De e p e r P o c ke ts Are ha ve a le s s fa vora ble Gre a tly Affe c te d )re s pons e to tra ditiona l Smokers mode s of pe riodonta l the ra py Imbalance of Tissue Destruction in the Periodontium
  • 56. Pathogenesis of Periodontal Disease He a lth S RP + P e rio s ta t Dis e a s e S m o ke rs S m o kin g in c re a s e s le ve ls o f P ro -in fla m m a to ry m e d ia to rs ; in c re a s e re le a s e o f d e s tru c tive c o lla g e n a s e Na tu ra l En zym e In h ib ito rs Tis s u e De s tru c tive En zym e s P e rio s ta t® d e c re a s e s le ve ls o f P ro -in fla m m a to ry m e d ia to rs ; d e c re a s e o f c o lla g e n a s eAd d in g P e rio s ta t tip s th e b a la n c e to wa rd s p e rio d o n ta l h e a lth
  • 57. The Future of Periodontal Diagnosis Traditional diagnostic (i.e. PD, AL, BOP, etc.) measures are informative to evaluate disease severity. We need diagnostic determinants of disease activity. Extensive research has been ongoing in this area since the 1990’s  Presence of biomarkers of measured with the gingival crevicular fluid (GCF)  Presence of biomarkers present within saliva 43
  • 58. Gingival Crevicular Fluid Most appropriate analytical fluid of choice because it was specific to the periodontal tissues The three most promising biomarkers for predicting future disease activity  Beta-glucuronidase  Alkaline phosphatase  Cathepsin B Many diagnostic kits emerged based, many of which demonstrated high levels of sensitivity and specificity demonstrating disease activity at site level. 43
  • 59. Gingival Crevicular Fluid Problems  Too time consuming to perform  Site specific - the choice of site was problematic  168 potential sites within the mouth to examine  Too costly for routine use  Results did not translate to changes in therapeutic intervention 43
  • 60. Saliva Medium of choice in the 21st Century. Contains microbial and host response mediators. Simple to collect using non-invasive techniques. Provides whole mouth summary analysis. Already used as a diagnostic fluid for:  Determining hormone levels  Drug detection  Presence of HIV or Hep C virus 43
  • 61. Saliva Problems  Assays need to be highly sensitive.  Biochemistry varies with its origin (whole saliva or specific gland secretions)  Not possible to fully quantify markers within saliva using chairside technologies. Qualitative analysis may be all that can be achieved  Saliva contains mucins and cell debris making it challenging to work with. 43
  • 62. Saliva Identify the biomarkers for periodontitis - aid in diagnosis and therapeutic monitoring of disease activity. Difficult due to the complex nature op periodontal disease - no single etiology with multiple risk factors. Periodontal researchers do not fully understand the pathogenesis of periodontitis. However, identification of biomarkers the characterize periodontal tissue destruction will be attainable 43
  • 63. Question? Can salivary testing for inflammatory biomarkers be a way for medical profession to screen patients for periodontal disease and the dental profession to screen patients for cardiovascular disease, diabetes and systemic diseases? 43
  • 64. QuickTime™ and a decompressorare needed to see this picture. 43

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