Cardiac Imp Of Perio Ds

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  • I t has long been theorized that there is a relationship between periodontal disease and cardiovascular disease. Only in the last decade, however, has science made progress in identifying what dentists have long observed; that there are cardiac implications in periodontal disease patients. As science discovers new ways to identify the specific disease process, and pathogens, the dental profession discovers new ways to manage the disease from a medical approach. The dental practitioner will be challenged with a new paradigm in the next decade and well into the new millennium. Therefore, this report is submitted to update the provider on the subject.
  • Cardiac Imp Of Perio Ds

    1. 1. CARDIAC IMPLICATIONS OF PERIODONTAL DISEASE LCDR Kurt J. Brockman, DC, USN
    2. 2. WHERE IT ALL STARTED <ul><li>MATTILA & OTHERS (1989) </li></ul><ul><ul><li>First to link dental health and the heart </li></ul></ul><ul><ul><li>Myocardial infarction patients </li></ul></ul><ul><ul><li>Caries, Periodontal Disease, or both? </li></ul></ul><ul><ul><li>Classic risk factors? </li></ul></ul><ul><li>MATTILA (1993) </li></ul><ul><ul><li>Pathogenic mechanism </li></ul></ul>
    3. 3. THANK YOU DR CHOW! <ul><li>JADA EDITORIAL (1998) </li></ul><ul><ul><li>“Research has identified periodontal disease as a major risk factor for cardiovascular disease and stroke.” </li></ul></ul><ul><ul><li>“Practitioners, get ready!” </li></ul></ul><ul><li>DR CHOW </li></ul><ul><ul><li>“I really want to know more.” </li></ul></ul>
    4. 4. LOESCHE <ul><li>1995 </li></ul><ul><li>NHANES Study </li></ul><ul><li>PD 1.7 X CHD </li></ul><ul><li>PD 2.6 X Dead </li></ul><ul><li>Hypothesis </li></ul><ul><li>1998 </li></ul><ul><li>Review of literature </li></ul><ul><li>U.S. Veterans </li></ul><ul><li>Statistically significant “association” </li></ul><ul><li>Risk indicators </li></ul><ul><li>S. sanguis </li></ul>
    5. 5. PATHOGENISIS REVIEW <ul><li>Pathogenesis is still hypothetical </li></ul><ul><li>Bacteria produce destructive toxins </li></ul><ul><ul><li>gram negative = lipopolysaccharide </li></ul></ul><ul><ul><li>gram positive = mucopeptide complex </li></ul></ul><ul><li>Toxins attract White Blood Cells </li></ul><ul><li>Accumulation is inflammation </li></ul><ul><li>Inflammation is destructive as well </li></ul>
    6. 6. PERIODONTIUM <ul><li>The soft tissue is in intimate contact with the tooth and plaque. </li></ul><ul><li>The junctional epithelium is non-keratinized with exposed intercellular spaces. </li></ul><ul><li>The tissue is highly vascularized and plaque products have access to it. </li></ul>
    7. 7. PERIODONTIUM <ul><li>The plaque products provoke increased permeability and exudation. </li></ul><ul><li>Inflammatory components and mediators are present in the gingival crevicular fluid. </li></ul><ul><li>Periodontal disease appears to involve preferential diffusion through the junctional epithelium. </li></ul>
    8. 8. BECK <ul><li>Periodontal disease represents a previously unrecognized risk factor for atherosclerosis and thromboembolic events. </li></ul><ul><li>Common risk factors </li></ul><ul><li>Common etiologic pathway </li></ul><ul><li>Common mechanism </li></ul>
    9. 9. BLOOD MONOCYTE PHENOTYPE <ul><li>MØ+ phenotype </li></ul><ul><li>Common inflammatory response trait </li></ul><ul><li>Abnormally high inflammatory reaction </li></ul><ul><li>Early-onset and Refractory Periodontitis </li></ul><ul><li>Insulin-dependent Diabetes Mellitus </li></ul><ul><li>Cascade of action </li></ul>
    10. 10. BECK’S CASCADE Perio Pathogen LPS Endotoxin MØ+ PGE & IL Vasodilation Vasopermeability Connective Tissue Degradation Vasculature Platelets Endothelial Deposition Smooth Muscle Deposition
    11. 11. INFLAMMATORY MEDIATORS <ul><li>PGE, IL, & TNF </li></ul><ul><li>Gingival crevicular fluid </li></ul><ul><li>MØ+ secrete 3-10X more </li></ul><ul><li>NSAIAs? </li></ul>
    12. 12. THE PLAYERS <ul><li>Streptococci </li></ul><ul><li>Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Treponema denticola. </li></ul><ul><li>Platelet aggregation associated protein (PAAP) </li></ul><ul><li>Induce platelet aggregation </li></ul>
    13. 13. FRIEND OR FOE? <ul><li>Commensal vs. Opportunistic </li></ul><ul><li>Bacteremia </li></ul><ul><ul><li>Periodontal Disease </li></ul></ul><ul><ul><li>Toothbrushing 40% </li></ul></ul><ul><ul><li>Extractions 60% </li></ul></ul><ul><ul><li>Periodontal surgery 88% </li></ul></ul><ul><li>P. gingivalis & S. sanguis </li></ul>
    14. 14. RISK FACTORS <ul><li>Family History? </li></ul><ul><li>Age? </li></ul><ul><li>Social Class? </li></ul><ul><li>Smoking? </li></ul><ul><li>Cholesterol? </li></ul><ul><li>Diabetes? </li></ul><ul><li>Hypertension? </li></ul><ul><li>Periodontal Disease? </li></ul>
    15. 15. AAP <ul><li>1998 Position Paper </li></ul><ul><li>Risky patients for PD </li></ul><ul><ul><li>IDDM, Neutropenia, osteopenia, & stress </li></ul></ul><ul><li>Risky patients for CHD </li></ul><ul><ul><li>HTN, Hypercholesterol, smokers, etc. </li></ul></ul><ul><li>Perio patients risky for CHD? </li></ul><ul><li>New rationale for periodontal therapy? </li></ul>
    16. 16. AAP <ul><li>1996 Informational Paper </li></ul><ul><li>Periodontal Management of Patients with Cardiovascular Disease </li></ul><ul><li>Recommendations: </li></ul><ul><ul><li>Medical History </li></ul></ul><ul><ul><li>Physical Examination </li></ul></ul><ul><ul><li>Vital Signs </li></ul></ul><ul><ul><li>Medical Consultation </li></ul></ul>
    17. 17. AHA <ul><li>FACTORS </li></ul><ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Heredity </li></ul><ul><li>FACTOIDS </li></ul><ul><li>Smoking </li></ul><ul><li>Cholesterol </li></ul><ul><li>Blood Pressure </li></ul><ul><li>Physical Inactivity </li></ul><ul><li>Obesity </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Stress </li></ul><ul><li>Socioeconomic Status </li></ul>
    18. 18. WOW! <ul><li>Oral Risk Management Protocol </li></ul><ul><ul><li>Caries and Periodontal Protocol </li></ul></ul><ul><li>AHA </li></ul><ul><ul><li>SBE Prophylaxis! </li></ul></ul><ul><li>Periodontal Pharmacotherapeutics </li></ul><ul><ul><li>What to use and when? </li></ul></ul>
    19. 19. EUROPEAN WORKSHOP <ul><li>Adjunctive Antibiotics </li></ul><ul><li>Adjunctive Antiseptics </li></ul><ul><li>Adjunctive Antimicrobials </li></ul><ul><li>Others? </li></ul>
    20. 20. PERIODONTICS WORKSHOP <ul><li>Sustained Release Therapies </li></ul><ul><ul><li>tetracycline, doxycycline, minocycline </li></ul></ul><ul><ul><li>metronidazole, chlorhexidine </li></ul></ul><ul><ul><li>stannous fluoride, methylene blue, ofloxacin </li></ul></ul><ul><li>Systemic Antibiotics </li></ul><ul><ul><li>EOP (PPP, JP, & RPP) & RP </li></ul></ul><ul><li>Others... </li></ul>
    21. 21. MEDICAL APPROACH <ul><li>Mechanical </li></ul><ul><li>Chemical </li></ul><ul><ul><li>C & S, DNA, & GCF </li></ul></ul><ul><li>Environmental </li></ul><ul><ul><li>Risk factors & factoids </li></ul></ul><ul><li>Maintenance </li></ul>
    22. 22. FDA APPROVED <ul><li>PERIOSTAT </li></ul><ul><li>ATRIDOX </li></ul><ul><li>PERIOCHIP </li></ul>
    23. 23. PERIOSTAT <ul><li>Suppresses collagenase </li></ul><ul><li>Inhibits host response </li></ul><ul><li>20 mg capsule </li></ul><ul><li>bid for months </li></ul>(doxycycline hyclate)
    24. 24. ATRIDOX <ul><li>Sustained release gel </li></ul><ul><li>suppresses collagenase </li></ul><ul><li>1 application X 7 days </li></ul>(10% doxycycline hyclate)
    25. 25. PERIOCHIP <ul><li>Biodegradable chip </li></ul><ul><li>> 5 mm pockets </li></ul><ul><li>Maintenance supplement </li></ul>(chlorhexidine digluconate)
    26. 26. WHAT WE KNOW <ul><li>If you have MØ+, you have potential </li></ul><ul><li>Plaque in the gums, plaque in the arteries </li></ul><ul><li>Bacterial endotoxins & Host cytokines </li></ul><ul><li>CHD yes, CVA maybe </li></ul><ul><li>ASA/NSAIA benefits </li></ul><ul><li>PD linked to many systemic diseases </li></ul>
    27. 27. DOCTOR DENTIST <ul><li>Paradigm shift </li></ul><ul><ul><li>Medical instead of mechanical </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>The tools are changing </li></ul></ul><ul><li>Rationales </li></ul><ul><ul><li>Now have systemic implications </li></ul></ul><ul><li>The Next Ten Years? </li></ul>

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