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Scientific american oral care Scientific american oral care Document Transcript

  • • Mouth - Body CONNECTIONS• The Facts and Fictions of INFLAMMATION• PREGNANCY and PERIODONTAL DISEASE• Linking DIABETES, OBESITY and INFECTION• Reflections from a SURGEON GENERAL• HEALTH POLICY of the Future• Blurring the DOCTOR-DENTIST BarrierA custom publication production in collaborationwith the Procter & Gamble Company
  • The mouth speaks for the body. We speak for the mouth. Crest and Oral-B. Today, the combined company of Crest and Oral-B exceeds more than Together for the first time. 100 years of innovation, information, and expertise. This combined heritage, Dedicated to uncovering coupled with a shared dedication to improving outcomes for dental all the links between professionals and patients alike, puts the new company of Crest and Oral-B at good oral health and the forefront of breakthrough science and oral health solutions. Crest and whole-body wellness. Oral-B are passionately committed to evolving the field of oral health and its relationship to whole-body wellness. Do we have all the answers today? No. Are we collecting evidence to suggest that there are some important links between oral and systemic health? Absolutely. Join us on the journey as we work to uncover the most critical information regarding the important role good oral health can play in achieving whole-body wellness.© 2006 P&G PGC-1713C OPAD06506 Dedicated to healthy lifesmiles
  • SCIENTIFIC AMERICAN PRESENTSORAL AND W HOLE BODY HEALTH INTRODUCTION » OUR MOUTHS, OURSELVES As the relationship between the mouth and the rest of the body becomes clearer, it is changing the way 3 dentists, doctors and patients view oral health. BY SHARON GUYNUP INVADERS AND THE BODY’S DEFENSES Gum disease illustrates how local infections may have systemic consequences. 6 BY PHILIP E. ROSS HEART HEALTH IN THE INFLAMMATION AGE Arterial plaques, once thought to be fatty deposits, are a result of the inflammatory process. 12 BY PETER LIBBY THE THREE-WAY STREETOR AL AND WHOLE BODY HE ALTHis published by S CIENTIFIC A MERICAN, Two decades of biomedical and dental detectiveINC ., 415 Madison Avenue, New York, work have linked obesity, diabetes and periodontalNY 10017-1111. Copyright © 2006 S CIENTIFIC A MERICAN, INC . All rightsreserved. No part of this issue maybe reproduced by any mechanical,photographic or electronic process,or in the form of a phonographic 18 BY ROBERT J. GENCOrecording, nor may it be stored in aretrieval system, transmitted or INTERVIEW »other wise copied for public orpr i v a te us e w i thou t w r i t ten BUZZ TALK WITHpermission of the publisher. MARJORIE K. JEFFCOATSubscription inquiries for The Dean of the University of Pennsylvania School ofS CIENTIFIC A MERICAN MAGAZINE:U.S. and Canada (800) 333-1199; 23 Dental Medicine on the facts and fiction surrounding oral health’s relationship to the rest of the body. CREDITOther (515) 248-7684b SCIENTIFIC AMERICAN PRESENTS: ORAL + WHOLE BODY HEALTH PROTCTOR & GAMBLE
  • A custom publication produced in collaboration with CREST and ORAL-B WHAT EVERY WOMAN NEEDS TO KNOW Growing evidence suggests that poor oral hygiene during pregnancy can adversely affect the health of newborns. BY STEVEN OFFENBACHER 24 AS THE BODY AGES When it comes to the complications of oral disease, the elderly are particularly vulnerable. BY FRANK A. SCANNAPIECO 30 INSIGHTS » ORAL HEALTH AROUND THE WORLD Maurizio Tonetti, an oral health professional who has worked in four different countries, offers some thoughts on the future of global oral health. 35 PUBLIC POLICY & ORAL HEALTH » A WHOLE NEW GAME Governments, insurers, clinicians and the public must all recognize the changing face of dental medicine. BY SHEILA RIGGS 36 INTERVIEW » DISCUSSION WITH DAVID SATCHER The former U.S. surgeon general reflects on his landmark report that put oral health on the national agenda and the policy steps that still need to be taken. 40CREDIT w w w. s c ia m . c o m SCIENTIFIC A MERIC A N c
  • RESEARCH SNAPSHOT » A custom publication produced in A NOVEL APPROACH TO collaboration with CREST & ORAL-B INFLAMMATIONPROJECT MANAGEMENT Understanding how the body “turns off” inflammationPublication and Media Director : may yield new treatments for periodontal disease 42 and other inflammatory conditions.Jeremy AbbateEditorial Director: Sharon GuynupFeatures Editor: Larry Katzenstein BY THOMAS E. VAN DYKEArt Director: Jeff Mellin & CHARLES N. SERHANIllustrators: Matt Collins, Tami Tolpa,Keith KasnotCustom Photography: John Soares PATH TO PREVENTION »Production Consultant: Richard Hunt MOUTHFUL OF BUGSCopy Editor: Michael Battaglia Pathogenic bacteria are a way of life.Research: Anna Kline So, too,must be brushing and flossing.BOARD OF ADVISERSRobert J. Genco: DistinguishedProfessor, Department of Oral Biology,School of Dental Medicine, StateUniversity of New York at Buffalo 46 BY ROBERT H. KAGANJim Beck: Distinguished Professor,Department of Dental Ecology, Schoolof Dentistry, The University of North INTERVIEW »Carolina at Chapel Hill THE ADA’S TAKEMarjorie K. Jeffcoat: Dean, University of How the American Dental Association, the world’sPennsylvania School of Dental Medicine leading dental organization, views the growing 49Steven Offenbacher: Director, Center forOral and Systemic Diseases, University connections between a healthy mouth and a healthyof North Carolina at Chapel Hill body — a conversation with Daniel M. Meyer.Maurizio Tonetti: Chair, Division ofPeriodontology, University ofConnecticut School of Dental MedicineThomas E. Van Dyke: Professor,Department of Periodontology andOral Biology, Boston UniversityGoldman School of Dental Medicine A Message from the A MERICAN A CADEMY OF P ERIODONTOLOGYSCIENTIFIC AMERICANEDITORS & PROJECT STAFF THE AMERICAN ACADEMY OF PERIODONTOLOGY (AAP) congratulates Procter & GambleEditor In Chief: John Rennie Professional Oral Health, Scientific American and all of the contributors to this specialExecutive Editor: Mariette DiChristinaManaging Editor: Ricki L. Rusting supplement for providing in-depth and balanced information on the association betweenNews Editor: Philip M. Yam periodontal diseases and general health conditions.Special Projects Editor: Gary StixSenior Editor: Michelle Press The AAP has been a leader in tracking periodontal and systemic research for over a decade.Editors: Mark Alpert, Steven Ashley, The research results to date have been promising, and the prospect that periodontalGraham P. Collins, Steve Mirsky,George Musser, Christine Soares treatment may significantly improve general health outcomes is exciting. However, there isArt Director: Ed Bell still a great deal to learn about the impact of periodontal infection and infl ammation onAssociate Publisher, Production: general health. Additional research into these complex associations is essential if patientsWilliam Sherman are to reap the benefi ts of improved health.Production Manager: Christina HippeliPrepress and Quality Manager: Silvia Given the potential impact on diabetes, pre-term low birthweight, cardiovascular diseaseDe Santis and other conditions, we believe this research merits the investment and should be prioritizedDirector of Ancillary Products: DianeMcGarvey by the National Institutes of Health and other funding agencies.Associate Publisher, Circulation: The Academy and its member periodontists are proud to collaborate to advance oral andSimon AroninCirculation Director: Christian Dorbandt systemic health. Readers are encouraged to visit for more information aboutGeneral Manager: Michael Florek periodontists and periodontal health.Business Manager: Marie MaherPresident and Chief Executive Officer:Gretchen G. Teichgraeber — KENNETH A. KREBS, D.M.D.Vice President and Managing Director, CREDITInternational: Dean Sanderson President, American Academy of PeriodontologyVice President: Frances Newburgd SCIENTIFIC AMERICAN PRESENTS: ORAL + WHOLE BODY HEALTH PROTCTOR & GAMBLE
  • INTRODUCTIONOUR MOUTHS, OURSELVES As the interrelationship between the mouth and the rest of the body becomes clearer, dental professionals, doctors and patients will need to rethink the term “oral health” BY SHARON GUYNUP ORAL AND WHOLE BODY HEALTH 3
  • S I N C E T I M E I M M E M O R I A L , people have struggled to maintain adequate oralhealth. As far back as a.d. 250, Kemetic Egyptians used myrrh and other antiseptic herbs to treat infected gums. The Nubiansthat dwelt in the Nile River valley two centuries later drank beer as a palliative for unhealthy teeth; it may have worked well,as it was brewed from grain contaminated with the same bacteria that produces tetracycline. Lengthening teeth and receding gums have historically “oral-systemic link” emerges almost daily. For example, inbeen considered a consequence of surviving into adulthood. May 2006 it was announced at an American Society for Mi-(In his 1852 novel The History of Henry Esmond, Esq., Wil- crobiology meeting that researchers have identified genes inliam Thackary used the expression “long in the tooth” to certain oral bacteria that allow the organisms to invade anddescribe a middle-aged person.) The few teeth that didn’t de- infect human arterial cells. This certainly expands to thecay in youth usually loosened with the passing years, as the discussion of the possible biologic pathways that might linktissues supporting them were eroded by periodontal disease. the mouth and the heart (or other parts of the body). Addi-Those teeth ultimately fell out. tionally, this year will see the results of two major studies Today, people are living longer, and gum disease has sup- examining the relationship between oral disease and preg-planted tooth decay as the most common cause of tooth loss nancy complications in expectant adults. The disease affects about 80 percent of Americans So what exactly is the connection between what happensover age 65, according to the American Dental Association. in your mouth and your overall health? Some of the millionsAt the turn of the last millennium, then–U.S. surgeon gen- of bacteria that lurk in our mouths (numbering more than alleral David Satcher called periodontal disease the “silent the cells in our bodies) are the primary culprits—along withepidemic” in his landmark report, Oral Health in America. the subsequent inflammation they cause. These microrgan-Given the state of public health, good oral hygiene may prove isms form complex colonies of sticky plaque. This tenaciousto be more critical than just preserving your smile. A grow- plaque — what microbiologists call a “biofi lm” — is com-ing body of research suggests that periodontal disease may posed of durable, coral reef–like structures, building up at theplay a role in a variety of systemic health problems as wide gum line and in between teeth.ranging as diabetes, respiratory illness, pregnancy complica- Some of the approximately 500 species of bacteria in yourtions, and heart disease. mouth are not innocuous flora. They cause gingivitis, infect- It is this body of research—and the attendant health pol- ing gums. Your immune system steps in to fight these invad-icy implications it engenders—that is the subject of this cus- ers—gums become inflamed, and may bleed when you brush.tom publication from Scien-tific American, Oral andWhole Body Health, pro- The fields of dentistry and medicine have traditionallyduced with the generous sup-port of the Procter & Gam- been worlds apart. But in light of the growing evidenceble Company. Here we pres- pointing to links between oral and whole body health, thisent, for the benefit of both separation of disciplines is slowly beginning to professionals and pa-tients, the latest pieces in theever-growing puzzle of oral disease’s connection to systemic Interestingly, if this same type of infection appeared on a per-health. You’ll hear from some of the pioneering researchers son’s arm or another body part, they would no doubt go run-themselves about their ongoing explorations into the mouth- ning to the doctor for treatment—but bleeding, tender gumsbody relationship. are often ignored. Like any new area of scientific inquiry, some data paint a Untreated, this tenderness progresses into full-blown peri-very clear picture while other results are still inconclusive. odontitis, and here the immune system shows its dark side.Several studies, for example, have found that blood-sugar This simmering inflammation ulcerates gums and summarilylevels in diabetics with periodontal disease were significant- destroys the soft tissue and bone that anchors your teeth. Itly reduced when the patients’ gum disease was treated. Oth- also sends inflammatory substances throughout the body.ers, like the ones examining the connection between peri- Researchers are discovering that out-of-control inflamma-odontal disease and heart conditions, have not yet uncovered tion may prove to be the engine that drives an ever-growinga defi nitive causal relationship. But new information on this list of greatly feared, chronic illnesses from clogged arteries4 ORAL AND WHOLE BODY HEALTH
  • and heart attacks to arthritis and cancer. This inflam- es on their Web site, mation link is just one of a number of hypotheses ex- warning: “if you or plaining how chronic oral infection may trigger or someone you know intensify systemic diseases. had periodontal dis- Another concern is that the microbial ecosystem in ease, diagnosed or your mouth doesn’t just stay there. Stealthy, virulent undiagnosed, and ei- bacteria overgrow in inflamed gum tissues; with each ther ignored or treat- bite of food or stroke of a toothbrush, some of those ed unsuccessfully, microbes can seep into your bloodstream, traveling to before or during the distant parts of your body. The question is: can they set same time as any of the up shop elsewhere and cause harm? It is known that some mentioned systemic dis- of these bad bugs, when inhaled, can cause pneumonia, par- eases, you may be eligible ticularly in the elderly. Some are also able to move through arter- for damages caused by these ies to the uterus and have been found in the placenta. systemic diseases.” Although BUGS WITH STAYING POWER: an extreme example, it embod- clearly the mouth is in many ways the “gateway” to the Once thought to be a mere ies the confusion and hype sur- rest of the body. However, this connection is often overlooked. congregation of pathogens, rounding this topic and under- dental plaque is now known to In the U.S., the fields of dentistry and medicine have tradition- be a dynamic – and tenacious – scores the need for objective, ally been worlds apart. But in light of the growing evidence microbiological community credible analysis. And it ig- pointing to links between oral and whole body health, this called a biofilm. nores the fact that oral disease separation of disciplines is slowly beginning to break down. is complex. The notion that dentists care for only gums and teeth, while For example, changing hormone levels can cause flare-ups doctors look after everything else is being rethought. in women during pregnancy and while premenstrual—or in There is a dawning realization that often it is a dentist or perio- those taking oral contraceptives. Other medications can also dontist who first discovers a larger health problem, because of make gums more susceptible to infection, including antihis- what they see in a patient’s mouth—and that doctors need to look tamines, antidepressants, cancer drugs, steroids, and espe- at more than the tonsils when a patient opens wide and says “ah.” cially those that cause “dry mouth,” disrupting the mouth’sP R E V I O U S P A G E P H O T O : J O H N S O A R E S M O U T H I M A G E S : C L I P A R T. C O M C O L L A G E I L L U S T R A T I O N : J E F F M E L L I N For example, diabetics tend to develop periodontal disease at three bacterial ecosystem. Genetic, microbial, immunological and to four times the rate of nondiabetics. If a dental professional sees environmental factors influence both the risk and progression gum inflammation in someone who brushes and flosses regu- of infection. For example, the American Academy of Peri- larly, they need to ask, “Have you checked your blood sugar odontology says that perhaps one third of Americans may be lately?” Or, conversely, the doctor of a patient with uncontrolled genetically susceptible—making them up to six times more blood sugar may need to refer them to a dental professional. likely to develop periodontal disease. It could be that in some There is already a ripple effect in some sectors of the insur- cases these same factors or susceptibility might independent- ance industry. Some insurers are finding it more cost-effective ly cause harm elsewhere in the body, creating a mere illusion to include periodontal treatment among covered services for of oral-systemic causality. diabetics and pregnant women. But if additional research so- Of course, one of the most important differences between lidifies the links between gum disease and other chronic ill- periodontal disease and other systemic conditions is that the nesses, sweeping changes will be needed to provide access to former has a known cause and is quite treatable. Dental profes- care. This will be crucial for the segments of society—the poor sionals should never lose sight of the fact that they are address- and the elderly—who are most at risk for oral disease as well as ing a disease that significantly contributes to disability and a conditions such as heart disease and diabetes. It is a huge public lack of well-being in the population. This fact alone makes it health issue: periodontal treatment and prevention can cost important to treat this condition, regardless of whether it might between $100 and $1,000 annually per patient. contribute to other serious illnesses. And although no one Over the past few years, newspapers, magazines and oth- should overstate the oral-systemic link, proffers Robert Genco, er national media outlets have hyped numerous stories about a professor of oral medicine and microbiology at the Univer- the possible systemic health risks of periodontal disease as sity at Buffalo, no one should underestimate what can happen well as inflammation’s general link to a broad range of dis- if it’s ignored, either. While the mouth’s relationship to the rest eases. Some articles have greatly exaggerated or oversimpli- of the body will certainly be a matter of public health, of patient fied the connection, enough so that the expression “floss or awareness and of the changing roles among caregivers, it will die” has become a standing joke among researchers. first and foremost be a matter of science. • Even some opportunistic law fi rms have jumped on the bandwagon. One in Arizona solicits potential malpractice cas- SHARON GUYNUP is editorial director of Oral and Whole Body Health. ORAL AND WHOLE BODY HEALTH 5
  • >>Gum disease illustrates how local infections may have systemic consequencesINVADERS& THE BODY’S DEFENSES BY PHILIP E. ROSS IF EVER THERE WAS A MAGIC BULLET —a drug so discriminating that it attacked microbes while sparing healthy tissue— it would be the monoclonal antibody, a human-tuned form of an immune molecule honed by eons of natural selection. Yet, as the world learned this spring, when such an antibody nearly ic effects are nowhere better illustrated than killed several subjects in a British clinical in chronic gum disease. Although it origi- trial, even these drugs can cause serious side nates in a bacterial assault, some two thirds effects. No one should have been too sur- of the damage is caused by the inflammatory prised; the natural immune response also response to the perceived invader. What is causes damage, which is why it fully mobi- worse, inflammation somehow communi- lizes—in a process called inflammation— cates itself to distant points, explaining the only when the enemy is at the gates. possible association of gum disease with oth- In recent years, a lot of media attention er conditions: adult-onset (or type 2) diabe- has been lavished upon the process of inflam- tes, premature birth, stroke and cardiovascu- mation (including a cover story in Time mag- lar disease. However infection travels from azine on this “silent killer”) as researchers the mouth to infl ame distant organs, it is continue to uncover evidence linking it with clear that it turns the body against itself. In other serious diseases. Whether or not in- the words of the cartoon character Pogo, >> flammation turns out to be the “holy grail” of “We have met the enemy and he is us.” medicine is yet to be seen. But inflammation’s Only a handful of the more than 500 spe- problem of friendly fi re and potential system- cies of bacteria that live in the mouth are6 ORAL AND WHOLE BODY HEALTH
  • S INFECTION AND INFLAMMATION in the mouth have been linked to a variety of systemic conditions, including pregnancy complications, type 2 diabetes, heart disease and stroke. While recent national media coverage spotlighting inflammation has spawned much interest in the JOHN SOARES topic, more research is needed to uncover exactly how infection and inflammation affect the body. ORAL AND WHOLE BODY HEALTH 7
  • MOUTH A PRIME LOCATION The hard, non-shedding surface of the teeth and the nutrient-INVADERS rich, oxygen-poor environment of the mouth provide ideal conditions for the growth of oral bacteria. They easily attach themselves to the tooth and gum. Of the over 500The Progression of microorganisms that live in dental plaque, only a handful havePeriodontal Disease been implicated in gum disease.implicated in gum disease. They are par- dead and dying neutrophils, and any the ligaments that anchor teeth in theirticularly hard to eradicate because they cellular detritus that may litter the bat- sockets, loosening them until they at lastform biofilms: tough, many layered, tlefield. Meanwhile, the macrophages fall out. Nowadays this happens less fre-mineral encrusted communities. Hud- secrete fatty acids and interleukin-1 quently; the patient notices the bleedingdling in the deepest layers are the oxygen- (IL-1), a primary regulator of infl am- and goes to a dentist. The dentist or den-shunning, or anaerobic, bacteria that ap- matory and immune responses, as well tal hygienist scrapes away inflammation-pear to cause the most damage. as tumor necrosis factor alpha (TNF ), riddled material and treats the infection When bacteria come in contact with a protein that heightens inflammation. with antibiotics. Treatment, however,gums, they secrete toxins that break The resulting mayhem may be likened cannot prevent the influx of bacteria.down gum lining, creating a tiny ulcer. to urban warfare, with immune sol- The disease will recur if the patient doesThe body’s bloodhounds, the neutro- diers running from house to house, not stick to a rigorous routine of brush-phil cells, then attack these invaders. If tossing in grenades, spraying rooms ing, flossing, rinsing and dental clean-they keep the biofi lm at bay, the battle with machine-gun fi re, all before ask- ings. And although the damage in peri-reaches a standoff, termed gingivitis. If, ing who is friend and who is foe. No odontal disease is primarily the result ofhowever, the bacteria continue to ad- wonder the tissue breaks down. The the inflammatory process, it can only bevance into the gums, the immune sys- ulcers sink deeper into the gum, creat- prevented or treated by addressing thetem signals a higher state of alert, mo- ing a “periodontal pocket”; full-blown bacterial biofilm that is infecting thebilizing macrophages (Greek for “big periodontitis begins. gums. What is worse, the chance of earlyeaters”). These white blood cells swal- If the disease is allowed to progress, detection is lessened in those who arelow bacteria, along with the gorged, the advancing inflammation eats away most vulnerable—smokers. Just as to-8 ORAL AND WHOLE BODY HEALTH
  • TENACIOUS BUGS A HEATED STRUGGLE Oral bacteria are particularly hard to eradicate because they form Continued defensive strikes by the immune system heighten tough, many-layered, mineral-encrusted communities, known as inflammation as specialized white blood cells (macrophages, biofilms. If untreated, these biofilms become lodged in the gingival as well as others) secrete inflammatory substances. This crevices around the tooth. The immune system launches a defensive intense inflammation can ultimately break down gum tissue, strike against these bacterial invaders by dispatching neutrophils. creating a periodontal pocket — the beginning of full-blown The first signs of inflammation (redness, swelling) begin to appear. periodontal disease. bacco smoke irritates the gums, height- neutrophils have trouble homing in on tomb fat in situ, creating atherosclerot- ening inflammation, it also tends to mask bacteria, showering them with chemical ic plaque. This buildup, combined with telltale bleeding. grenades called superoxides. “But instead inflammation, fattens the arterial wall, Other factors that predispose people of destroying bacteria, they destroy the gradually restricting blood flow to tis- to gum disease include bad oral hygiene periodontal ligament that ties the tooth to sues. Sometimes, for reasons that are and an unlucky bequeathal of genes. the jaw,” says Charles N. Serhan, profes- not well understood, the thin layer of One very invasive form of periodontal sor of anesthesiology at Harvard Medical tissue covering the plaque ruptures, disease is found in just 0.1 percent of School. “It’s like rheumatoid arthritis, an spurring clots to form in a matter of Americans, a distribution that indicates autoimmune disease where a lot of the minutes, often triggering a heart attack a genetic component. People with these degradation of the synovium [the lining of or stroke. This is why the most com- and other predisposing genes must work the joints] is done by neutrophils.” Serhan mon fi rst symptom of heart disease is extra hard to care not only for their is looking for ways to shut down this ex- sudden death. teeth but even for the artificial implants cessive immune response. If infection in the gums not only pre- that may replace those teeth. Periodon- When inflammation strikes sites far cedes inflammation in the arteries, but tal disease can strike the tissues sur- from the gums, it progresses there much encourages it, the question is how does rounding implants as well. as it does in the mouth. In the lining of it happen. One theory holds that bacte- Genetic variation is of particular in- the heart’s arterial wall, for instance, ria are the primary vehicles in commu-M AT T COLLINS terest because it may illuminate the mech- macrophages engulf whatever detritus nicating disease; another lays the blame anisms that underlie all varieties of peri- they find, including fatty particles. on proinflammatory chemicals that leak odontal disease. In one invasive form, When the macrophages die, they en- out of the gums and into the blood- ORAL AND WHOLE BODY HEALTH 9
  • stream. Direct inflammation currently valve. What if a similar weakness ex- sidered innocuous. Yet critics of theholds sway, particularly in the popular ists in the arterial lining? bacterial-cause theory point out thatpress. Still, there is evidence supporting Researchers have, in fact, found oral bacteria survive poorly in theboth theories, and each may explain traces of oral bacteria in arterial plaque. bloodstream. They also note that proin-part of the problem. Yet as critics of the infection theory flammatory chemicals demonstrably Oral bacteria can get into the blood- point out, the method they used to iden- leak from the gums into the blood-stream. Robert Genco, a professor of tify the bacteria—a highly potent DNA stream, adding to the body’s inflamma-oral medicine and microbiology at the amplification tool—cannot tell how tory burden. In a test tube, proinflam-University at Buffalo, took moment-by- many bacteria were present in the matory agents from one group of cellsmoment blood tests in healthy patients plaque or whether any of them were can spark a response in another group.undergoing routine teeth cleaning. The alive when they entered it. Injecting proinfl ammatories into ani-bacterial count spiked when cleaning be- Paul Ewald, an evolutionary biolo- mals also produces such a response.gan, then fell back to normal less than a gist at the University of Louisville, has Some argue that these chemicals aloneminute after it was over—that is how fast been a leading advocate of the role of can explain the association of gum dis-the body’s immune system rousts such infectious agents in chronic illnesses. ease and systemic illness.invaders. Yet in people with periodontal He argues that gum disease fits into the Here is how it might play out. Imag-disease, such bacterial inundations of the evolutionary model he has devised be- ine that there is some small irritation inblood occur every time a loosened tooth cause it is chronic, widespread and of the wall of the coronary artery, per-moves in its socket, providing many op- great antiquity, and therefore cannot be haps the result of chemicals absorbedportunities for a stray bacterium to relo- simply the result of defective genes. from cigarette smoke or car exhaust. Ifcate to some distant location. “If it were just a case of the immune the overall inflammatory burden is low, Oral bacteria, once established else- system going haywire, you’d think that then perhaps these sites will remainwhere in the body, are bad news. Genco natural selection would have weeded it quiescent. If, however, proinfl amma-injected Porphymonas gingivalis, a out,” he says. “But if you are looking at tory chemicals have leached from themain culprit in periodontal disease, un- actual combat between the immune sys- periodontal pocket into the blood-der the skin of rodents and found that it tem and [an] infectious agent, you’d ex- stream, it might heighten local inflam- mation in the artery, beginning the process of atherosclerosis.If infection in the gums not only precedes How do the two theories stack up? Itinflammation in the arteries, but encourages it, is not easy to say from the evidence nowthe question is how does it happen? in hand, which comes mainly from ob- serving correlations between gum dis- ease and other diseases; either or both ofinvariably produced fatal infections. “It pect it to be an evolutionary arms race, the proposed mechanisms could be re-causes gross necrosis of skin and under- one that would never stabilize.” That sponsible. Take the evidence linkinglying tissue; if you inject into the belly, same arms race would have tuned the periodontal disease with prematurethe intestines will be exposed,” he says. bacteria to a high pitch of virulence and birth, which could be caused by the in-A rare, analogous condition has been invasiveness, hence their ferocious be- fection reaching the uterus or, alterna-seen in humans, in which a dental infec- havior when ensconced in another part tively, by the release into the bloodstreamtion spreads down the neck to the area of the body. of such proinflammatories as prostaglan-surrounding the carotid artery, where it Biologists are now investigating the din E2, a drug used by obstetricians todigests tissue. possibility that many chronic illnesses, induce labor. There is also evidence that Perhaps the most persuasive exam- once attributed to other causes, may in oral disease destabilizes blood sugar con-ple of a secondary infection from oral fact stem from infection. Several strik- trol in diabetic patients, although thesources comes from patients who have ing examples have been demonstrated mechanism remains unclear. It is knownmitral valve heart defects. Such pa- in the past two decades: Stomach ulcers, that high blood sugar contributes to gumtients are warned to take antibiotics long attributed to stress, spicy food and disease and that all kinds of stress badlybefore their dental appointments so genes, turn out to derive, almost always, impact diabetic control. Periodontal dis-that tooth cleaning will not send bac- from the bacterium Helicobacter pylori. ease may put stress on the body byteria to infect or inflame the valve, Cervical cancer, it is now known, can spreading bacteria, increasing the in-which could destroy it or produce clots develop only in women who have been flammatory burden, or both.that might block arteries. The critical infected by certain varieties of the hu- So, too, many treatments whose suc-element here is the vulnerability of the man papillomavirus (HPV), long con- cess may seem to confi rm one theory or10 ORAL AND WHOLE BODY HEALTH
  • INFLAMMATORY MOLECULES produced locally in tissue can get into the bloodstream and travel throughout the body. FIGHTING INVADERS The inflammation-causing bacteria can also infect blood and travel to distant points. THE IMMUNE SYSTEM INCLUDES, among other components, antimicrobial molecules and various phagocytes (cells that ingest and destroy pathogens). These cells, such as dendritic cells and macrophages, also activate an inflammatory response, secreting proteins called cytokines that trigger an influx of more defensive cells from the blood. another turn out to be hard to interpret. We need interventionist studies to learn Genco notes that “the insurance com- Aspirin, an anti-inflammatory, is used whether treating oral disease unmistak- panies are driven by economics, and to reduce the risk of heart attack, but ably shows a preventative benefit against even though the science isn’t absolutely again, no one can say that this proves heart disease. Such trials are needed to there yet, they are taking action.” that inflammation, pure and simple, is justify any public investment in such The smart money, therefore, is bet- the culprit. It could be that aspirin mere- treatment, and several are now planned ting on healthy gums. To keep them that ly limits clotting. and in line for funding. way, there are no magic bullets, no What is needed are large clinical tri- In the meantime, insurance compa- chemicals that can be added to drinking als in which patients are divided, at ran- nies—which are used to basing policies water, as fluoride was added to stave off dom, into two groups: one that gets on purely actuarial data—are respond- tooth cavities. There is no substitute for treatment for periodontal disease, an- ing. This year, Aetna Dental announced brushing, flossing and regular dental other that gets a placebo. Two such stud- the results of a study of policyholders visits. It should be easier to justify than ies are trying to determine whether such that had both dental and health insur- in the past, for the dentist’s or hygien- treatment alleviates the risk of prema- ance. It showed that treating periodon- ist’s ministrations may turn out to pro- ture birth in women with gum disease. tal disease in heart patients lowered the tect not only your teeth, but, quite pos- Another is testing whether antibiotic total cost of treating both conditions. sibly, the rest of you as well. • treatment can alleviate heart disease. Yet,TA MI TOLPA even here, one must beware of the pos- PHILIP E. ROSS, a former S CIENTIFIC A MERICAN contributing editor, is currently the online sibility that antibiotics themselves may editor of IEEE Spectrum, the magazine of the Institute of Electrical and Electronic exert a subtle anti-inflammatory effect. Engineers. He has written for Forbes and Red Herring. ORAL AND WHOLE BODY HEALTH 11
  • It is clear that inflammation is linked to heart disease, andthat one of the body’s most common sources of inflammationis periodontal disease. Does poor oral health contribute toheart disease risk? Although the jury is still out whilescientists investigate this link, here is what we know aboutinflammation’s role in atherosclerosis. | BY PETER LIBBYHeartHealth INFLAMMATION AGE INTHEO N L Y A D E C A D E A G O, most physicians would have confidently described sometimes fail. It also highlights the need for better prevention, detectionatherosclerosis as a plumbing problem: Fat-laden gunk gradually builds up on and treatment. In industrialized na- tions, deaths from heart attacks andartery walls. If a deposit (plaque) grows large enough, it closes off an affected strokes exceed those from cancer—and they are also becoming more prevalent“pipe,” preventing blood flow. Eventually, Such research has established in- in developing countries.the blood-starved tissue dies. If that flammation’s key role in atherosclerosis.happens in the heart or the brain, a heart This process—the same one that causes IGNITING TROUBLEattack or stroke occurs. infected cuts to become swollen, hot we know that inflammation symp- Few believe that tidy explanation and painful—underlies everything from toms reflect a pitched struggle on a mi-anymore. Twenty years of research show the creation of plaques to their growth croscopic battlefield. After sensingthat arteries bear little resemblance to and rupture. (rightly or wrongly) a microbial inva-pipes. They contain living cells that When microbes invade, inflamma- sion, certain types of white bloodcommunicate with one another and tion (literally meaning “on fi re”) fights cells—the immune system’s frontlinetheir environment. They also partici- infection. But with atherosclerosis, in- warriors—convene in the threatenedpate in the development of the fatty de- fl ammation proves harmful; our own tissue. There they secrete chemicals toposits that grow within vessel walls— defenses bombard us with friendly fire, limit infection: oxidants that damagefew which actually shrink vessels to a just as they do in lupus and other auto- invaders and signaling molecules (in-pinpoint. Most heart attacks and many immune disorders. This revised picture cluding proteins called cytokines) that M AT T COLLINSstrokes stem from interior plaques that resolves two disturbing mysteries: why orchestrate the activities of defensiverupture suddenly, spawning a blood clot many heart attacks strike without warn- cells. Their presence in tissue signifiesthat blocks blood flow. ing and why preventative therapies an inflammatory response. >>12 ORAL AND WHOLE BODY HEALTH
  • CROSS-SECTIONOF HEALTHYCORONARY INFLAMMATION’S MANY ROLESARTERY INFLAMMATION—a central player in atherosclerosis—occurs when white blood cells, the body’s first line of defense against infec-Blood channel tion, invade and become active in tissue. These diagrams depict atherosclerotic plaque growth in a coronaryIntima artery; the close-ups highlight some inflam- matory processes triggered by elevatedMedia low-density lipoprotein (LDL) in the blood.Adventitia LOL T cell Endothelial 1 Monocyte Adhesion cell Scavenger Foam 2 molecule receptor cell 3 Blood channel INTIMA Modified LOL Chemokine Plaque Thrombus 4 5 Microphage Inflammatory Elastic tissue mediators MEDIA Smooth muscle cellsBIRTH OF A PLAQUE PLAQUE PROGRESSION1 Excess LDL accumulates in ar tery walls, undergoing chemical changes. ModifiedLDLs stimulate endothelial cells todisplay adhesion molecules, which 2 Monocytes mature into active macrophages in the intima; with T cells, they produce inflammatory mediators, including cytokines that carr y signals 3 The macrophages display “scavenger receptors” to help ingest modif ied LDLs; macrophages feast on them, filling with frothy, fatty droplets. These 4 Inflammatory molecules trigger further plaque growth. A fibrous cap develops over the lipid core when the molecules induce smooth musclecapture circulating monocytes (key between immune system cells and “foam cells” combine with T cells, cells to migrate to the intima surface,players in inflammation) and T cells factors that promote cell division. comprising the fatty streak—early multiplying and producing a tough,(immune cells). Endothelial cells atherosclerotic plaque. fibrous matrix that glues cellsalso secrete “chemokines,” luring together. The cap makes the plaquesnared cells into the intima. larger and walls it off from the blood. Cholesterol studies on both animals As LDLs accumulate, their lipids mature into active macrophages, readyand cultured cells have elaborated in- oxidize—a corrosive process similar to to unleash their weapons against theflammation’s role in atherosclerosis. Sci- the one that rusts pipes. Cells in the body’s enemies. These warriors set aboutentists have long known that although blood vessel wall react to these changes clearing perceived invaders from vesselwe need cholesterol, excessive amounts by calling for reinforcements from the walls. Scavenger receptor molecules cap-clog arteries. But until recently, no one body’s defense system. Adhesion mole- ture modified LDL particles and helpknew how this happened. Low-density cules on the endothelial cells that line macrophages “eat” them—until they’relipoprotein (LDL)—also known as bad vessels latch like Velcro onto mono- so full of fatty droplets that they lookcholesterol—is composed of fatty mol- cytes, inflammatory cells that normally foamy under a microscope, giving themecules (lipids) and protein. Its job: trans- circulate in the blood, attaching them to their “foam cell” nickname.port cholesterol (another lipid) from its artery walls. Endothelial and smooth T lymphocytes (a type of white bloodsource in the liver and intestines to other muscle cells inside vessels then secrete cell) also attach themselves to arteryorgans. The trouble begins when LDLs chemokines—chemicals that attract walls, releasing cytokines that intensifyfrom the blood collect in the intima, the monocytes. Much as hounds track the inflammation. The fi rst visible athero-interior wall of an artery. At low concen- scent of their prey, more monocytes fol- sclerotic lesion, a yellow “fatty streak,” KEITH K A SNOTtrations in the blood, LDLs can pass in low the chemical trail into the intima. is a mix of foamy macrophages and Tand out of the intima; in excess, LDLs Stimulated by chemokines and other lymphocytes. These lesions are a precur-become stuck in the cell matrix. substances, the monocytes multiply and sor of the complex plaques that later dis-14 ORAL AND WHOLE BODY HEALTH
  • PLAQUE RUPTURE sel surface. Once there, they form a fi- channel. This also explains why bypass5 Foam cells secr ete inf lammator y subs tances that weaken the cap, digesting matrix molecules and damagingsmooth muscle cells that normally repair it.Foam cells may produce tissue factor, a potent brous covering over the original plaque. Underneath this cap, some foam cells die, releasing their load of lipids. surgery or therapies such as angioplasty or stents that widen obstructed arteries can ease angina—yet often fail to pre- Atherosclerotic plaques usually ex- vent a heart attack. Even when blockedclot-promoter. If the plaque ruptures, a clotforms. A large clot can halt blood fl ow to the pand outward, not inward to block an arteries are treated, they often clog upheart, causing a heart attack—the death of artery’s blood-carrying channel. When again fairly quickly—it seems that thecardiac tissue. they do push in, blood flow to tissues is treatment itself elicits a robust inflam- restricted, especially when arteries matory response. Thrombus would normally expand. During exer- Matrix-degrading enzyme cise or stress, blood flow through a com- BEYOND BAD CHOLESTEROL Cytokines that disrupt smooth promised heart artery fails to meet the several other atherosclerosis risk fac- muscle cells Fibrous increased demand. This causes angina tors exhibit intriguing inflammatory fea- cap pectoris, a feeling of tightness or pres- tures: diabetes, for instance, elevates sure usually under the breastbone. Nar- blood sugar levels, which can enhance rowing in other arteries can cause pain- LDL’s inflammatory properties. Smoking ful cramping of the calves or buttocks causes oxidants to form, possibly hasten- during exertion. ing LDL oxidation—and fostering arte- rial inflammation even in people with CAUSING CRISES average LDL levels. Obesity contributes only about 15 percent of heart at- to diabetes and vascular inflammation. tacks are caused by large plaques that Conversely, high-density lipoprotein block arteries. Autopsies have shown (HDL) seems beneficial; as levels of this that most attacks occur after a plaque’s “good cholesterol” decline, the likeli- fibrous cap ruptures, prompting a blood hood of suffering a heart attack goes up. clot to develop over the break. Inflamma- HDL may achieve its beneficial effects tion makes the cap vulnerable. My labo- in part by reducing inflammation, be- ratory found that when stimulated by cause along with cholesterol, HDL inflammatory chemicals, macrophages transports antioxidant enzymes that secrete enzymes that degrade a cap’s break down oxidized lipids. strong collagen fibers and stop smooth Given inflammation’s usual respon-CUTAWAY VIEW OF ARTERYAFFLICTED BY ATHEROSCLEROSIS muscle cells from extruding fresh colla- sibility in the body—blocking and elim- gen to repair and maintain it. inating infectious agents—biologists Clots form when blood seeps have wondered whether arterial infec- through a fi ssure in a cap and coagu- tions might contribute to inflammationfigure arteries. Many Americans begin lates. Although our bodies produce sub- in the arteries. Recent studies suggestplaque buildup as early as their teens. stances that can prevent or degrade that atherosclerosis can develop in the blood clots, infl amed plaques release absence of infection. However, circum-FUELING PLAQUE GROWTH chemicals that impede this clot-busting stantial evidence suggests that certainwhen an inflammatory response in, machinery. If a clot does clear naturally microorganisms, such as herpes virusessay, a scraped knee successfully blocks or with medication, the healing process or the bacterium Chlamydia pneumoni-infection, macrophages release molecules may kick in once again, restoring the ae could induce or aggravate atheroscle-that promote healing. A “healing” pro- cap but also enlarging the plaque by rosis. C. pneumoniae appears in manycess is also part of the chronic, low-level forming scar tissue. Considerable evi- atherosclerotic plaques—and can trig-inflammation that operates in athero- dence suggests that plaques grow in fits ger inflammatory responses.sclerosis. But instead of restoring artery and starts as inflammation comes and Infections might also act from a dis-walls, the process perversely remodels goes and as clots emerge and dissolve. tance, in an “echo effect.” When thethem, generating a bigger plaque. This new picture of atherosclerosis body fights infections, inflammatory me- Recently, biologists have learned explains why many heart attacks seem diators can escape into the blood andthat both macrophages and cells within to come from out of the blue. Plaques travel to distant sites. Because the mouthan inflamed vessel wall secrete sub- that rupture may not protrude very far can be a source of chronic infection, re-stances that create a kind of scar tissue. into a blood channel—and may not searchers are exploring the potential im-Smooth muscle cells migrate to the ves- cause angina or appear on images of the pact of gum disease. Infection from peri- ORAL AND WHOLE BODY HEALTH 15
  • EVALUATING THE DATA:Could Periodontal Disease Increase the Risk forCardiovascular Disease? BY K AUMUDI JOSHIPURAHEART DISEASE AND PERIODONTAL DISEASE have several loss-induced dietarythings in common. One of them is inflammation, which both narrows changes(e.g.,shunningcoronary arteries and breaks down the tissues that hold teeth in fruits, vegetables andplace. Could periodontal disease increase your risk for developing dietary fiber) thatheart disease, perhaps due to bacterial pathogens or inflammatory increase heart risks.chemicals carried by the blood from the mouth to the heart? If so, The link between thecould you reduce your heart disease risk by preventing or treating two diseases mayperiodontal disease? derive from factors that Research suggests that there may be links between the two influence both. Forconditions. Animal studies in particular offer provocative evidence example, cigarettethat certain biologic pathways might allow one disease to influence smoking is a major riskthe other. Periodontal bacteria are found in the plaque deposits that factor for heart diseasenarrow coronary arteries; inducing periodontal disease in rabbits and for periodontalcauses plaque accumulations in their coronary arteries. disease, and a genetic Other evidence comes from observational human studies. The sus c ep tibili ty tolargest such study, the National Health and Nutrition Examination inflammation mightSurvey (NHANES), involved 10,000 Americans between the ages of 18 cause someone to develop both diseases (see chart).and 74. It found that people with periodontal disease were much more Although periodontal disease seems to be associated with heartlikely to be diagnosed with heart disease than those without disease, more studies are needed before we can say with certaintyperiodontal disease. that one disease actually causes the other. Meanwhile, everyone Not all studies have yielded similar results. For example, my colleagues should be conscientious about treating gum disease, but it is not yetand I examined a group of health care professionals and failed to find an clear that doing so will protect you from heart disease. •overall association. Interestingly, our study and several others did detecta significant association between tooth loss (often a result of severe KAUMUDI JOSHIPURA is director of the Division of Dental Publicperiodontal disease) and heart disease. So the “connection” between Health at the University of Puerto Rico and also teaches at Har-periodontal disease and heart disease may be indirect, involving tooth- vard University.odontal disease pumps a continuous flow measuring the heat of blood vessels (be- tion’s ability to ward off infection out-of bacteria and cytokines into the blood- cause heat normally accompanies in- weighed its drawbacks. Today, as we livestream. Bacteria also produce toxins that flammation); and altering existing im- longer, exercise less, eat too much, andcan trigger inflammatory responses. Cy- aging technologies, such as MRI or CT smoke, many of us suffer from inflam-tokines and bacterial toxins can stimu- scans, to improve their ability to peer mation’s dark side—including its abilitylate the white cells in atherosclerotic inside vessel walls. Scientists are trying to contribute to atherosclerosis and otherplaques, prompting plaque growth or to develop molecular imaging tech- chronic disorders. Scientists continue torupture. Despite these links between in- niques to “visualize” biological process- pursue a deeper understanding of in-fection and atherosclerosis, current clin- es such as infl ammation, looking be- flammation’s role in atherosclerosis, andical evidence does not support the use of yond the anatomical features of blood to decipher the intricate interactions thatantibiotics to prevent recurrent compli- vessels. Geneticists are hunting for genes ignite and drive the inflammatory pro-cations following a heart attack. that predispose some people to chronic cesses in the arteries. These insights inflammation and atherosclerosis so should enable us to make further inroadsTOWARD EARLY DETECTION they can seek more aggressive monitor- against a disease with growing world-noninvasive methods for identifying ing and treatment. wide impact that causes extensive dis-vulnerable plaques might help pinpoint For most of human history, inflamma- ability and takes far too many lives. •at-risk individuals who lack warningsigns of potential heart attack or stroke. PETER LIBBY, who earned his M.D. from the University of California, San Diego, is chief ofIdeas include testing for elevated levels cardiovascular medicine at Brigham and Women’s Hospital, Mallinkrodt Professor ofof C-reactive protein, a substance in the Medicine at Harvard Medical School, and co-editor of Heart Disease, a classic cardiologyblood that signifies acute inflammation; textbook (W.B. Saunders, 2001).16 ORAL AND WHOLE BODY HEALTH
  • Smart Pair.Comprehensive Care. Oral-B® Triumph™ The world’s smartest toothbrush fights plaque and bad brushing habits. MOTIVATIONAL TIMER Tracks brushing time and gives positive feedback at 2 minutes. 4 BRUSHING MODES Deliver a customized experience—clean, soft, massage, and polish. BRUSHING GUIDANCE Encourages regular brushhead replacement. MULTILANGUAGE DISPLAY Can be programmed in 13 different languages. Crest® PRO-HEALTH™ A comprehensive toothpaste for all of these areas:  CAVITIES  TARTAR BUILDUP  GINGIVITIS  WHITENING  PLAQUE  FRESHENS BREATH  SENSITIVITY Dedicated to healthy lifesmiles“The ADA Council on Scientific Affairs’ Acceptance of Crest PRO-HEALTH Toothpaste is based on its finding that the product is effective in helping to prevent and reduce tooth decay, gingivitis and plaque above the gumline, to relieve sensitivity in otherwise normal teeth, and to whiten teeth by removing surface stains, when used as directed.”© 2006 P&G PGC-1713B OPAD06508
  • the three-way street Two decades of biomedical and dental detective work have linked obesity, diabetes and periodontal disease BY ROBERT J. GENCO I N T H E E A R LY 19 6 0 S , researchers from the National Institutes of Health (NIH) journeyed to the parched desert lands of the Gila River Indian Community in central Arizona to study the health of the Pima Indians. In the course of routine medical exams, they made a startling discovery: the Pima people proved to be fatter than any other group of people on Earth except for the Pacific Nauru islanders. Nearly half of those over the age of 35 had type 2, or adult-onset diabetes, eight times the national average. In order to survive in the desert, it seems that their thrifty genes may have evolved to carefully conserve fat through times of drought and famine. After World War II, when the tribe changed their traditional diet to an American one, their fat intake rose from about 15 percent to a whopping 40 percent of calories—and their genetic evolution backfi red. >>18 ORAL AND WHOLE BODY HEALTH
  • N O R T H W E S T E R N U N I V E R S I T Y L I B R A R Y, E D W A R D S . C U R T I S ’ S “ T H E N O R T H A M E R I C A N I N D I A N ,” 2 0 0 3 HISTORY INTERRUPTED: When Arizona’s Pima Indians adopted a fatty American diet, their thrifty desert genes backfired. Almost half of adults over 35 developed type 2 diabetes—and also contracted severe gum disease at twice the normal incidence. ORAL AND WHOLE BODY HEALTH 19
  • 2 diabetes research from our studies both on the Pimas and on the popula- tion of Erie County in New York State, along with research from around the globe—Japan, Brazil, Chile, Finland, Slovenia and other nations. In nearly all of the studies, it was found that diabet- ics suffered from more severe periodon- tal disease that often appeared years or even decades before it did in the general population—and once a diabetic patient had periodontal disease, their sugar control worsened and they suffered fur- ther complications, including nerve damage and kidney disease. We combined the results of these studies and formulated a hypothesis that we and others could begin testing. This informational mosaic has given us a reasonable understanding of how obe- sity and diabetes are linked to infections such as periodontal disease. It also re- vealed a potential explanation of whyIN 1983, H. was healthy. Three years later, she suffered from out-of-control type 2 diabetes and diabetes is a significant risk factor forsevere gum disease, with abscesses ulcerating her gums and loose, shifted teeth. oral infection and inflammation—and why it often leads to periodontal disease As the NIH studies continued over clinics.) Diabetics fared the worst, with at a much earlier age than normal. Pa-the following decades, the researchers twice the normal incidence of gum dis- tients with type 2 diabetes are twice asdelved into other health issues including ease—and much more severe oral infec- prone to periodontal disease as nondia-kidney problems and heart disease. They tion than nondiabetic patients. betics, all other factors being equal.also suspected that there might be a In 1983 we examined H, a 32 year- An important piece of this puzzlehigher than normal incidence of gum old woman who was extremely over- emerged 10 years ago during the Eriedisease. In 1981 the Dental Institute weight, but otherwise quite healthy. In County study, conducted in metropoli-asked me to assess the periodontal health her follow-up exam two years later we tan Buffalo, N.Y. We discovered thatof the Pimas. At that time, I was in the were shocked to discover that her health obesity and periodontal disease were re-midst of clinical studies at the University had deteriorated precipitously: she suf- lated. We collected information on bothat Buffalo Periodontal Disease Research fered from uncontrolled type 2 diabetes the general and oral health of 1,250Center examining the body’s response to and had developed advanced gum dis- adults. After statistical adjustment forbacterial infection in the mouth—so I ease. Abscesses ulcerated her gums, and other periodontal risk factors includingwelcomed the opportunity to examine a her teeth were loose and had shifted out age, gender, socioeconomic status, smok-very different population. I spent three of position, leaving large gaps between ing, diabetes and dental plaque, the rela-days at the Gila River reservation con- her front teeth. Under normal circum- tionship remained strong: obesity ap-ducting several dozen clinical exams. stances, the progression of this condi- pears to be an independent risk for peri-Never before had I seen such severe, un- tion would have taken 15 to 20 years to odontal disease. Investigations by Nabiltreated periodontal disease. reach that level of infection. Bissada and his colleagues at Case West- In 1982 we established our first den- Her case sparked a question that we ern University in Cleveland and by Toshi-tal clinic in a trailer on the reservation, couldn’t answer. Could there possibly yuki Saito of Kyushu University in Fu-run by Dr. Marc Shlossman, and initi- be a connection between obesity, diabe- kuoka, Japan, mirrored our findings.ated a study to track the Pimas’ oral tes and oral infection? It took 21 years Another important clue surfaced inhealth. Since then, we have examined of medical and dental detective work, the mid-1990s that helped to explain the3,600 people, giving checkups every piecing together data from many sourc- role obesity plays in infection. We learnedtwo years. (Regular dental care was es, to understand this triangular rela- that fat tissue is not only a repository forprovided by the reservation’s dental tionship. We gathered the results of type fat cells but is increasingly viewed as a20 ORAL AND WHOLE BODY HEALTH
  • metabolically active endocrine organ.Scientists at the Dana Farber Institutein Boston found that fat tissue in the“obese mouse,” a species bred to be fat the DIABETIC inand diabetic, produced a protein calledtumor necrosis factor (TNF). Fat cellsproduce and secrete several proteins—like TNF—that act in a hormonelike the DENTAL CHAIR BY BRIAN L. MEALEYfashion, regulating the intake and ex-penditure of energy. These proteins, New research suggests that periodontal CURRENTLY, 20.8 MILLION Americanscalled proinflammatory cytokines, are have diabetes, according to the American disease can also affect a diabetic patient’spowerful substances that mediate and Diabetes Association. About one third of ability to control his or her blood sugarregulate the body’s inflammatory pro- those with the disease are unaware that levels, and can contribute to diabeticcess. The obese mice carried toxic con- they have it, and of those who have been complications such as heart and kidneycentrations of cytokines—immune re- diagnosed, only a little more than half disease. Inflammatory diseases of manysponse molecules—in their blood. have it under control. kinds—including those that affect the Human fat cells pump out tumor Diabetes is a disease where the body mouth—can increase insulin resistance. Innecrosis factor alpha (TNF ), which does not produce or properly use insulin, people with type 2, increased resistancekills tumors and triggers production of a hormone made in the pancreas. Insulin caused by gum disease can make bloodother proinflammatory cytokines. But “unlocks” cells, allowing sugars derived sugar harder to control. However,it also has a dark side: it can cause in- from carbohydrates and other food to periodontal treatment reduces the level ofsulin resistance and high blood sugar enter. Sugar is the basic fuel for cells, inflammation in the tissues around thelevels (common diabetic symptoms) providing energy for daily life. teeth, thereby improving blood sugarand break down bone as well as acti- There are two types of diabetes: In control in many diabetics.vate endothelial cells that line blood type 1 diabetes, the pancreas no longer Thus, care of patients with diabetesvessels, which can lead to heart disease makes insulin. Sugar cannot enter the poses a particular challenge to dental cells and builds up in the bloodstream. In professionals. Diabetes often worsensand stroke. Interleukin-6 (IL-6), an im- type 2, the pancreas does not produce oral health, particularly that of the gummune protein, is another product of hu- enough insulin, or the hormone does not tissues and bone, which, in turn,man fat cells. Like TNF , it dissolves function properly at the cellular level, a deteriorates blood sugar control. Thebones and causes inflammation—and condition called insulin resistance. In this patient and dental professional must workprompts the liver to secrete C-reactive together to stop this vicious cycle before case, too, sugar is locked out of the cells,protein, whose presence signals high it begins by being attentive to daily oral so it builds up in the blood. In both types ofrisk for heart attack. These are just two hygiene: brushing and flossing, getting diabetes, cells may be starved for energy.of the dozen or more cytokines pro- Over time, high blood sugar can damage regular oral health checkups, and properlyduced by human fat tissue. vision, even causing blindness. It can also treating periodontal disease early on. • This relentless release of cytokines trigger kidney failure, nerve damage andinto the bloodstream provides a possi- heart disease, and in people with diabetes BRIAN L. MEALEY is director of theble explanation of how obesity intensi- wounds heal poorly. Periodontics Postgraduate Programfies infections, including periodontal Diabetes also increases the risk for at the University of Texas Healthdisease. The diverse colonies of bacte- periodontal disease, an infectious Science Center at San Antonioria that flourish in the mouth spark the process that inflames gum tissues,infl ammatory response that is so de- causing them to bleed; it also destroysstructive to gum tissue. The infection the bone and soft tissues that supportintensifies as gum tissue produces its teeth. While periodontal disease occurs inown cytokines. At the same time, fat nondiabetic people, too, gum diseasetissue churns out cytokines that travel is more common and more severethroughout the body. This cytokine in diabetics. Dentists monitor theiroverload heightens the overall inflam- diabetic patients closely for thesematory response, causing great tissue oral conditions and may referdamage. Infected gums become chron- patients to a periodontist (gumically infl amed, the bone around the specialist) to diagnose andteeth dissolves, and the teeth loosen treat periodontal disease.and eventually fall out. ORAL AND WHOLE BODY HEALTH 21
  • One of these, adiponectin, regulates in- sulin response and inhibits infl amma- OBESITY tion inside blood vessels. We need great- er understanding of this and other regu- latory chemicals manufactured both in fat tissue and in other parts of the body that could mitigate the chronic inflam- mation and insulin resistance sparked by cytokines. We believe that the triangular inter- DIABETES PERIODONTAL action among obesity, type 2 diabetes DISEASE and periodontal disease is mediated by the cytokines produced by both fat tis- sue throughout the body and by infected gums. More research is needed to evalu- ate other influences, like the impact ofA TRIANGULAR RELATIONSHIP: Obesity can intensify infections, such as periodontal disease; cytokines diet and the importance of genetics onproduced by fat cells are known to trigger insulin resistance, which can lead to type 2 diabetes. inflammation and susceptibility to theDiabetes, in turn, is known to increase the risk for periodontal disease. New research suggests that aforementioned conditions. A moreperiodontal disease can affect a diabetic patient’s ability to control blood sugar levels. complete understanding should help physicians and dental professionals em- To test this hypothesis, we exam- acerbate more dangerous, tenacious oral ploy treatments or preventive measuresined blood test results from the Erie infections, their presence also helps ex- to reduce the onset of diabetes and itsCountry study subjects. All those who plain why obesity is such a serious risk potentially life-threatening complica-suffered from periodontal disease had factor for diabetes and cardiovascular tions such as heart and kidney disease.elevated levels of soluable receptors for disease: TNF and other cytokines are Addressing obesity in the manage-TNF in their blood, but levels were known to trigger insulin resistance. This ment of diabetes or periodontal diseasehighest in seriously overweight patients. can ultimately lead to full-blown type 2 is clearly important—as is tandem treat-Over the last decade, a large body of diabetes, which spikes blood sugar lev- ment in patients who have both condi-research from laboratories and clinics els and elevates fats in the blood. This tions. Studies show that periodontalin many countries has highlighted the condition contributes to complications treatment leads to improved blood sug-role of TNF and other cytokines in of diabetes, including heart, kidney and ar control. Because periodontal diseasedamaging tissue—and in predisposing retinal disease, along with susceptibility in diabetics leads to a higher rate ofan individual to diabetes. TNF trig- to infection, and other complications. complications, such as cardiovasculargers certain cells to produce tissue- or It seems that inflammation creates a disease and diabetic kidney disease, webone-dissolving enzymes. Other cyto- triangular interaction between obesity, strongly suggest aggressive treatmentkines induce inflammation by increas- diabetes and periodontal disease: Obe- and prevention of periodontal disease ining the amount of blood leaked from sity is a risk factor for both type 2 dia- patients with diabetes as part of thevessels and by stimulating the release of betes and periodontal infection, and overall management of not only theirtoxic substances (such as reactive oxy- diabetes also heightens risk for gum dis- oral health, but their diabetic state.gen species) from inflammatory cells in ease. Inflammation links all three, trig- Current treatments for periodontalthe region, damaging tissue. Another gered by the proinflammatory cytokines disease are effective. If maintained, re-kind summons phagocytic cells to the manufactured by fat tissue and pro- currence can be, by and large, prevent-site of the infection that then envelop duced locally by gum infection. ed—and of all the ways to mitigate dia-and “devour” perceived invaders. At But fat tissue is complex, and further betes risk in the fi rst place, good orallater stages of inflammation, antibodies studies will likely illuminate the role of hygiene is much easier to maintain than(proteins that target and destroy spe- other substances secreted by these cells. strict diet or exercise regimens. •cific bacteria and viruses) form. Al-though they are usually protective, they ROBERT J. GENCO has studied periodontology and its relation to wider health conditionscan also turn against cells, as in autoim- for over 30 years. He attended the University at Buffalo School of Dentistry and earnedmune disorders. a Ph.D. in immunology from the University of Pennsylvania. He is currently a distin- But proinflammatory cytokines guished professor at the University at Buffalo and vice provost and director of the Uni-manufactured by fat cells don’t only ex- versity’s Office of Science, Technology Transfer and Economic Outreach.22 ORAL AND WHOLE BODY HEALTH
  • INTERVIEW >> SCIENTIFIC AMERICAN: Most of the buzz about the oral-systemic link has been among research- ers. What should consumers or patients know about this topic at this stage? JEFFCOAT: The consumer needs to know three things: First, oral disease is a disease like any other—and in and of itself is deserving of treatment. Number two, everything in the body is connected. Having a chronic infection is a serious problem that you should not ignore. It can indeed make you systemically sick. Three, patients should not think that treating periodontal disease will guarantee them lifetime health, but it is one step they can take to be healthier overall. Consumers have to understand that all the data is not yet in. We cannot definitively say if BUZZ TALK with eventually all curriculums will address this MARJORIE K. JEFFCOAT issue is some way or another. So the patients, in your opinion, that would benefit most from this data would be expect- THE DEAN OF THE UNIVERSITY OF PENNSYLVANIA SCHOOL OF DENTAL MEDICINE ant mothers? Right now, yes—pregnant wom- – A PIONEERING DENTAL RESEARCHER HERSELF – ADDRESSES THE FACTS AND en and diabetics. Although we have smaller studies on diabetics than we do on expectant FICTIONS ABOUT ORAL HEALTH’S RELATIONSHIP TO THE REST OF THE BODY mothers, we do know that any untreated infec- tion in a diabetic can affect glucose control. So treatment will affect one’s susceptibility to the best information possible. We’re already treating oral infection and oral inflammation is other diseases—heart disease, stroke, diabe- starting to see changes in reimbursement for a reasonable thing to do until all the studies tes, etc. We do know that it is one risk factor for some of these things. Insurance companies have finished. preterm birth. But people act on these correla- are taking notice. Cigna and others now cover tions because they want to feel they have con- periodontal treatment during pregnancy. It’s What about the elderly and some of the data trol of their health. Professionals do, too. They a business decision; they feel it will help save linking oral disease with respiratory problems want to provide every possible treatment money in the long run. in patients who are in intensive care units or avenue for the patient. hospitals? Getting care to these populations Do you hear a lot of misinformation? I do. Some is still the biggest challenge. Often in a nursing As a prominent researcher you must have a people want information because they’ve home there are extra costs for dental care. lot of people asking you about this topic? heard a little bit about this topic—and some Family members who monitor their elders’ All the time. I don’t know how many phone will believe anything they read on the Internet. care should be made aware of the importance calls I took today—from patients, from doc- Some media outlets do not provide the whole of good oral care. For many, it will help to tors, from drug companies, from the media. story or all of its complexities. reduce the risk of getting pneumonia. They want to know the real scoop: what we really know at this time. How is this topic – the mouth’s relationship Are consumers becoming more skeptical of to the rest of the body – affecting dental health messages they see or read about in the Has this issue spawned more collaboration education? I think more [dental] schools media? We have two highly distinct popula- between the fields of dentistry and medicine? are integrating total health into their cur- tions: the “worried well” —those who are Yes. And I have found that collaboration riculum. Dental education can be a contro- always looking for ways to improve their health,JEFF MELLIN between the two fields comes quite easily. It is versial topic, and I think some schools will and those who are skeptical of everything they very important that both disciplines take own- probably not adopt this whole-body see or read—this population is very hard to deal ership of these issues so that patients can get approach for some time. But I do feel that with in terms of getting messages across. • ORAL AND WHOLE BODY HEALTH 23
  • WHAT EVERYWOMANNEEDS TO KNOW Growing evidence suggests that poor oral hygiene during pregnancy can adversely affect the health of newborns BY STEVEN OFFENBACHER24 ORAL AND WHOLE BODY HEALTH
  • In 1981 Judith F. was referred to mefor periodontal care. She was very upset, having just discovered why her front teeth were shifting: she had been diagnosed withsevere gum disease. Her dentist had explained to her that periodontal disease is sometimes a “silent” infection that may be pain-less and without symptoms until very late in the disease process. She had also recently miscarried after having a very difficulttime conceiving. She recounted how her gums had flared up after she became pregnant, which prompted her to go to the dentist.As crazy as it might have sounded at the time, she was convinced that the simmering infection in her gums was somehow relatedto her pregnancy complications. I suspected that her intuition may erated by oral bacteria. The result: at low mothers with untreated periodontalhave been correct—but told her that doses, about 15 percent miscarried and disease who were also being tracked.we really did not know scientifi cally 30 percent of the surviving offspring These findings provided the rationalewhether periodontal disease could were abnormally small. When given high for the National Institute of Dental andcause pregnancy problems. However, I doses, 100 percent of the mothers mis- Craniofacial Research to support twodid tell her that both her obstetrician carried. We later induced gum disease in multicentered, randomized clinical tri-and I were in agreement that any infec- pregnant hamsters. Overall, the result- als. One of these, the Obstetrics andtion during pregnancy is a potential ing babies weighed 18 percent less than Periodontal Therapy (OPT) Study at thecause for concern. normal. We also found elevated levels of University of Minnesota, led by Bryan Just before Judith came to me, my prostaglandin-E2 (PGE 2) in the ham- Michalowicz, tracked the pregnancies oflaboratory had begun what would be- sters’ placentas—similar to the human more than 800 pregnant women follow-come a 25-year scientific inquiry explor- physiological response to preterm deliv- ing gum disease treatment. The seconding the potential role of periodontal dis- ery and low-weight births. This chemical trial, run by our group at the Universityease in pregnancy complications. This is produced as a response to infection; it of North Carolina at Chapel Hill, is en-research has included a multitude of lab- mediates inflammation in both the pla- titled MOTOR (Maternal Oral Therapyoratory experiments, animal studies, centa and the fetus—and also can induce to Reduce Obstetric Risk) and will ulti-and randomized human clinical trials. labor. Around that time, obstetrics re- mately follow 1,800 women. The fi nd- Today, growing evidence supports search had linked PGE 2 to premature ings from these large, randomized andthe concept that gum infection may in- and low-weight SGA (small for gesta- controlled trials should ultimately provedeed play a role in pregnancy complica- tional age) births. whether or not gum disease can causetions, possibly inducing miscarriage and In a landmark paper published in pregnancy complications. Earlier esti-premature birth as well as inhibiting the 2002, Nestor Lopez in Chile reported mates from pilot studies suggest that upgrowth and development of the unborn the results of his study of 400 pregnant to 18 percent of all preterm births maychild. Clearly, there are many causes for women with periodontal disease: half be attributable to gum disease.problems that can arise during pregnan- had scaling and root planing periodon- Unfortunately, pregnancy complica-cy; but it now appears that with addi- tal treatment during pregnancy; the tions are far too common, with abouttional research, oral infection might be other half were treated after their ba- one in 10 babies being born too early inadded to the list of possible risk factors. bies were born. Just 1.8 percent of the the U.S.—nearly double the rate of oth-From a public health perspective, what is treated women gave birth early, com- er industrialized countries. Improve-most important is that periodontal dis- pared with 10.1 percent in the delayed ments in prenatal care and neonatal in-ease is both preventable and treatable. treatment group. tensive care medicine have improvedAs a clinician who is trying to help pa- Marjorie Jeffcoat at the University the survival rates of these babies, buttients, I know that it is critical to identify of Alabama also saw similar benefits in the rate of premature delivery hasnew causes of disease—and to find ways a study of 123 mothers with periodon- steadily climbed since the 1950s. Theto prevent them. tal disease. After treatment, their rate failure to prevent preterm deliveries is In one of our earliest experiments at of preterm delivery (earlier than 37 due in part to the fact that we do notEmory University in 1981, we gave ham- weeks) was 4.1 percent, compared with understand all of the risk factors, whichsters intravenous doses of the toxins gen- 13.7 percent in another group of 733 include race, smoking, alcohol and drug26 ORAL AND WHOLE BODY HEALTH
  • use, low income, and poor education, among others. More than one quarter of all complicated pregnancies occur for no known reason. Periodontal disease may contribute to the common problems of pregnancy by presenting an infectious, inflamma- tory challenge to the fetus: when bacte- ria or their products slip through the placenta and reach the baby, they trig- ger an immune and infl ammatory re- sponse—which stresses the fetus. Since pregnancy is such a critical time for hu- man development, this could potential- ly have debilitating effects on an infant’s health, creating problems that could last a lifetime. Infections are thought to account for between 30 and 50 percent of all premature deliveries. Maternal infec- tions during pregnancy, especially when they spark a fever, have long been known to cause miscarriage, premature birth and babies that are born abnor- mally small for their gestational age. This is attributed to the fact that bacte- ria or viruses in the bloodstream trigger the production of infection-fighting chemicals that threaten the “mother- child unit” and impair fetal growth and development. The chemicals and hor- BREAKING THOUGH: When oral bacteria in the mother’s blood mones that mediate the inflammatory breaches the placenta and reaches response can also dilate the cervix and the fetus, it triggers an immune and trigger uterine contractions, leading to inflammatory response, stressing the unborn child. Infections may preterm labor. account for up to 50 percent of But it’s not just infection and bacte- premature births. rial products that pose a threat—inflam- mation does, too. Inside the placenta, sclerotic damage to heart arteries: the inflammation in the mother. At first, the membranes normally remain intact, vessels shrink and do not function prop- thought of a linkage between a distant holding the fetus suspended in amniotic erly, compromising the flow of blood oral infection and pregnancy complica- fluid until just hours before delivery and nutrients to the fetus, and impair- tions was considered “preposterous,” but when the water “breaks” to start labor. ing growth. Abnormal blood flow in the accumulating scientific evidence is unveil- However, inflammation can make these placenta can also result in an imbalance ing its biological plausibility. membranes more fragile; their early rup- in the mother’s blood pressure, causing The increase in hormonal activity ture often initiates preterm labor. preeclampsia, a mild kidney malfunc- during pregnancy can cause gums to When the placenta becomes in- tion that can lead to life-threatening bleed more easily and may promote bac- flamed, structural changes occur that convulsions. This condition can only be terial overgrowth. This bleeding is not can endanger the fetus and shorten ges- cured by delivering the baby. normal and signals ulceration between tation. Studies in mice have shown that It now seems that oral infection may the tooth and gum. In full-blown peri- placental infl ammation causes edema be one of a number of factors that can odontal disease, the infected area aroundM AT T COLLINS and kills off tissue. It also can cause produce these pregnancy complications. all 32 teeth becomes a huge ulcerated changes to the intertwined fetal/mater- Any oral disease, from mild gingivitis to area—about the size of the palm of your nal blood vessels that resemble athero- severe periodontitis, causes infection and hand. These infected areas no longer ORAL AND WHOLE BODY HEALTH 27
  • HAVE INFECTION, WILL TRAVEL: Bacteria from dental plaque can enter the bloodstream through small ulcers in the gum and can then travel throughoutthe body. The increase in hormonal activity during pregnancy can cause gums to bleed more easily and promote bacterial overgrowth.have the natural skin barrier between the caused at least 10,000 miscarriages and to the organisms that normally live inbacteria in dental plaque and the moth- stillbirths, and more than 20,000 babies our mouths with the fi rst human fi nd-er’s bloodstream. Bacteria enter the blood were born with birth defects. Rubella ings being reported in 2001. Studiesand travel to the placenta, which normal- was fi rst identified as a cause of birth on mice reported in 2002 and laterly blocks penetration to the fetus. defects several decades ago when re- studies in rabbits proved that oral bac- For many years, doctors believed searchers discovered the virus floating in teria could cross the placenta andthat the environment inside the uterus amniotic fluid and that fetuses carried reach the fetus. Some recent work bywas relatively isolated and protected, antibodies to it—proving that the virus Dr. Yiping W. Han at Case Westernwith few organisms passing to the pla- had indeed entered the placenta to infect Reserve University demonstrated incenta or the fetus. But this infection bar- the growing baby inside. 2006 that maternal oral bacteria have M AT T COLLINSrier can be breached by a few organisms, We conducted studies at U.N.C., been found in human amniotic fluidincluding the rubella virus. A rubella Chapel Hill to learn whether unborn providing proof of transmission. This(German measles) outbreak in 1964-65 babies would show antibody responses strongly suggested fetal infection in28 ORAL AND WHOLE BODY HEALTH
  • this study—but proving transmission cert to trigger labor contractions, rup- not involve infection. In fact, thereto the fetus of a large population of ture the amniotic sac, and impair blood may be underlying conditions, expo-oral bacteria will be difficult, as babies flow in the placenta. So the onset of la- sures or genetic traits that predisposeare not born in a sterile environment. bor is actually a naturally occurring in- mothers to abnormal pregnancy out- About eight years ago, we found that flammatory response—the mother’s comes. Some of these risk factors mayin utero exposure to the mother’s oral body uses inflammation to “reject” the also predispose mothers to periodon-bacteria is a fairly common event. Re- baby—but labor can be triggered early tal disease, such as susceptibility tosearch conducted by Phoebus Madianos by the abnormal presence of these in- severe inflammation. Nevertheless, thein our lab, published in 2001, showed flammatory chemicals. progression of periodontal diseasethat contact with enough periodontal This mechanism—a silent infection during pregnancy can result in fetalbacteria to induce a fetal immune re- leading to fetal inflammation—may exposure—and trigger a fetal infl am-sponse resulted in a two- to three-fold also provide a possible explanation for matory response—which may increaseincrease in risk for preterm delivery. the Barker hypothesis, developed in the the risk for pregnancy complications. It appears that if the magnitude of early 1900s by David Barker and his The potential importance of theseexposure is low, either because of a mild colleagues in Southampton, England. linkages on health care costs and fam-infection or effective protection from They followed the health of low birth ily well-being have not been lost onthe mother’s antibodies, then the fetus weight babies and discovered that pre- health insurance companies; someis shielded from these bacteria. But if maturity harms health later in life. It now provide coverage for periodontaloral bacteria cross the placental barrier seems that deficits in a baby’s fetal and care during pregnancy.early in gestation, the probability that infant growth “programs in” risk fac- Although we do not yet havethey will cause problems is much higher tors for adult diseases and a lifetime of enough evidence to say unequivocallythan if the security breach occurs late- various disabilities and impairments, that periodontal infections can causeterm. For example, about 28 percent of including diabetes, high blood pressure adverse pregnancy outcomes, the dataall unborn babies are exposed to the and cardiovascular disease. Preterm ba- supporting this idea are mountingCampylobacter rectus (or C. rectus) bies are particularly prone to long-term quickly. According to our research,bacteria—but evidence of exposure to disability, because their respiratory and when oral bacteria breaches thethe bacteria is found in 52 percent of neurological systems are especially im- “armed guard” of the placenta andinfants born before 32 weeks gestation pacted by premature birth—and the reaches the fetus, that baby’s risk of(eight weeks early). earlier the delivery, the greater the risk being born early rises to 2.8 times that When an unborn child’s immune of long-term conditions such lung dis- of an unexposed baby. Perhaps in thesystem kicks in to fight off those bacte- ease, asthma, mental retardation, cere- future a vaccine will be developed toria, the risk for preterm delivery in- bral palsy and impaired cognitive func- combat these organisms. But in thecreases between four- and seven-fold, tion. Preterm babies are also at high risk meantime, the good news is that weafter adjusting for traditional obstetric for neonatal death. know how to prevent and managerisk factors. Elevated levels of the chem- Studies in our laboratory demon- periodontal disease—and treatmenticals and hormones that regulate the im- strated in 2004 that when pregnant mice can be provided safely during preg-mune-inflammatory system create a were exposed to the C. rectus oral bac- nancy to improve a mother’s oraltoxic in utero environment that stresses teria, brain damage in their offspring health, reducing infection and inflam-the fetus. It was once thought that the was similar to that seen in conditions mation that may harm her unbornmother’s body determined when labor such as cerebral palsy and mental retar- child. An increased dialogue amongkicked in, but we now know that the dation, which can be caused by in utero expectant mothers, their obstetriciansbaby also contributes to the timing of infections. But clearly, more research is and their dental professionals to diag-delivery. Stress may cause the fetus’s ad- needed, as animal models do not always nose, prevent and manage maternalrenal glands to produce the hormones reflect what happens in humans. oral infections appears to be a promis-that help precipitate its own delivery. Certainly, there are many reasons ing strategy for optimizing maternal At birth, these babies’ umbilical cord for pregnancy complications that do health during pregnancy. •blood carries higher-than-normal levelsof C-reactive protein, a marker of in- STEVEN OFFENBACHER is director for Oral and Systemic Diseases and a distinguishedflammation which reflects liver activity professor at the Department of Periodontology, School of Dentistry at the University ofin both mother and child. Other chemi- North Carolina at Chapel Hill. He researches the mechanisms of periodontitis-associ-cals, like PGE2 and TNF (tumor ne- ated pregnancy complications, risk factors for periodontitus, and bone regeneration.crosis factor alpha), mediate the body’s He holds D.D.S. Doctor of Dental Surgery and Ph.D. Biochemistry degrees from Virginiainflammatory response and act in con- Commonwealth University. ORAL AND WHOLE BODY HEALTH 29
  • When it comes to the complications of oral disease, the elderly are particularly vulnerable AS THEBODYAGES In the U.S., periodontal disease affects an estimated one in 10 adults, and one in five over the age of 65. It is the leading cause of tooth loss in adults. But emerging evidence linking periodontal disease to serious health problems, par ticularly in the elderly, is making diagnosis and treatment even more crucial. | BY FRANK A. SCANNAPIECOE V E L Y N J O N E S , an 89-year-old woman, came to my office last year for a rowed and thickened the vessels carry- ing blood to her lungs, making her heartroutine dental cleaning. She lived in a local nursing home and had not been to a work harder and causing fluid to build up in her in over a year. Aside from high blood pressure, which was being treated with After treatment with calcium chan- nel blockers, which increase blood and diuretics, she apparently had no other oxygen flow to the heart, her condition medical problems. A dental exam re- improved. But on her third day in the vealed red, swollen gums and several hospital she developed a fever and loose teeth. cough, which proved to be pneumonia. Mrs. Jones said she’d had a cold and She was placed on antibiotics. Two days felt tired. She also appeared short of later, lung cultures revealed that her breath, light-headed, and complained of pneumonia had been caused by the in- chest pain. I took her blood pressure, testinal bacterium Escherichia coli, which was elevated. Suspecting that she which was also found in her blood. She might have a heart problem, I urged her was switched to a different antibiotic on to see a physician immediately. Her day six, but her condition worsened. caregiver drove her from my office to She experienced kidney failure on day JOHN SOARES the hospital, where she was admitted seven, and died on day nine. Believe it with a diagnosis of pulmonary hyper- or not, Mrs. Jones’s poor oral health tension: high blood pressure had nar- may have contributed to her death.»30 ORAL AND WHOLE BODY HEALTH
  • HEALTHY MOUTH, HEALTHY BODY: Maintaining proper oral health is important at any age. Diseases that threaten the elderly can be exacerbated by poor oral care.ORAL AND WHOLE BODY HEALTH 31
  • Over the past several decades, re- searchers have found that tooth and gum health may influence the health of the entire body. Their provocative stud- ies have shown that gum disease may increase a person’s risk for heart attack, stroke, diabetes and—as in Mrs. Jones’s case—pneumonia. These fi ndings are especially pertinent to older people, be- cause the likelihood of developing oral disease increases with age. Oral bacteria can contaminate a How poor oral health might affect ventilator tube overall health still is being actively inves- tigated. Some researchers theorize that when the gums bleed, bacteria from the mouth enters the bloodstream and mi- grates to other parts of the body where they trigger health problems. For exam- ple, some heart valve infections are clear- ly linked to recent dental work. Among people with heart valve problems, oral Bacteria can grow on bacteria that enter the blood may attach the tube and make to the valves, causing a potentially fatal their way to the lungs inflammatory disease called endocarditis. As a preventive measure, dentists since the 1950s have routinely prescribed antibiot- ics to patients with valve problems before even the simplest of procedures, such as a routine cleaning or filling a cavity. To see if oral health might be associ- ated with heart disease, in 1989 a team of Finnish investigators studied 100 re- cent heart attack patients and a similar number of closely matched people with- out a history of heart disease. The heart patients had substantially worse dental health, including a much higher preva- lence of periodontal disease, than the control subjects. This fi nding sparked considerable interest. Numerous follow- up studies conducted since then have mostly supported a link between peri- odontal disease and an increased risk for heart disease. Other research has found a similar association between periodontal disease and stroke. Both heart attack and stroke are caused by atherosclerosis, the buildup of fatty deposits within the arteries that channel blood to the heart and brain. M AT T COLLINSAN INFECTIOUS PATH: When patients are hooked to a ventilator, their risk of pneumonia can increase With evidence now showing that inflam-20-fold, making it the leading killer among hospital-acquired infections. Oral bacteria in dental plaque mation helps fuel atherosclerosis, re-can “jump” to the tube and begin to grow on it, eventually making their way down into the lungs. searchers are exploring whether cyto-32 ORAL AND WHOLE BODY HEALTH
  • ORAL DISEASE & alveolar bone that supports the teeth. Researchers are exploring also more vulnerable to periodon- tal destruction. Lifestyle factors OSTEOPOROSIS BY JEAN WACTAWSKI-WENDE how alveolar bone is lost—and how it may be connected to osteo- porosis and body-wide bone loss. such as cigarette smoking and low calcium intake as well as the effects of aging may also put indi- Because osteoporosis is a sys- viduals at greater risk for low bone >> IS BONE LOSS from oral infec- tion associated with osteoporo- sis? Research on osteoporosis and oral bone loss has shown a fairly consistent relationship, sometimes makes comparison and interpretation difficult. How does bone loss occur? Bones are living, growing tissues that undergo con- temic disease, it may affect bones in the mouth in a number of ways. Bone loss around teeth may occur independent of oral inflammation. Osteoporosis may lead to more density and loss of alveolar bone. Ongoing studies will provide further insight into the interaction of osteoporosis and periodontal bone loss, which will be increas- including a recent University at stant remodeling in Buffalo study that linked osteo- response to the porosis and periodontal disease, stress placed upon which caused loss of both oral them. About 10 per- bone and teeth—especially in cent of the body’s women aged 70 years and older. total bone mass is But other types of studies have “remodeled” each produced inconsistent results, or year—removed and have revealed no connection at then replaced. Cells all. This is due, in part, to study called osteoclasts design variation. For example, lay on the bone sur- several negative studies have face, breaking down included subjects in their 40s and existing bone in a 50s, when osteoporosis and low process known as resorption. Their rapid breakdown of alveolar bone ingly important in the prevention bone density prevalence is low. counterparts, osteoblasts, then after oral bacteria invades. of these two very prevalent disor- Assessment of both osteoporosis secrete collagen and minerals to Systemic factors that affect ders in older Americans. • and periodontal disease can also lay down new, replacement bone. bone remodeling may also modify differ across studies, which In osteoporosis, there is an how local tissues respond to peri- JEAN WACTAWSKI-WENDE imbalance: Either too much bone odontal infection. Specifically, is associate chair of the is resorbed or too little bone is people with overall bone loss are Department of Social and formed. This skeletal disorder known to have increased system- Preventive Medicine at decreases the quality, density wide production of cytokines the State University of (amount) and strength of bone, (specifically IL-1 and IL-6) that New York at Buffalo. which becomes abnormally may impact bone quality through- porous and spongy, and fractures out the body—including the easily. According to the National bones of the oral cavity. Osteoporosis Foundation, an esti- Periodontal infection, in turn, mated 10 million Americans have increases local cytokine produc- the disease; almost 34 million tion that boosts local osteoclast more have low bone mass. Three activity—accelerating alveolar quarters of these are women. bone loss. Periodontitis, a bacterial infec- Both osteoporosis and gum dis- tion in the mouth, is the primary ease share a number of risk fac- cause of tooth loss in adults. It tors. Individuals with a genetic destroys both gum tissue and the predisposition to bone loss areJOHN SOARES ORAL AND WHOLE BODY HEALTH 33
  • kines and other inflammatory chemicals in those people living in nursing homes oral cancers. Researchers hypothesizefrom diseased gums may travel through or admitted to the hospital. that bacterial toxins, enzymes and thethe blood and contribute to the problem. Chronic obstructive pulmonary dis- chemicals involved in inflammation may In Mrs. Jones’s case, excess dental ease (COPD), which limits the flow of cause mutations in human cells that leadplaque and periodontal disease may air into the lungs, is also associated with to uncontrolled growth and, ultimately,have set the stage for nosocomial (hospi- poor oral hygiene and periodontal dis- cancer. This work is still in its infancy,tal-acquired) pneumonia, a leading ease. COPD usually stems from long- but results so far are provocative.cause of death among older Americans. term cigarette smoking and can involve One recent study on the health statusElderly, institutionalized people like a spectrum of conditions, including em- of a cross-section of the U.S. populationMrs. Jones are at particular risk for de- physema and chronic bronchitis. People included an assessment of the oral health of more than 13,000 people. People diag-Clearly, more dedicated efforts to keep gums nosed with periodontal disease had a sig- nificantly higher risk of also having oralhealthy may reap health dividends far beyond cancer compared with those who hadimproving oral health and keeping your teeth. healthy gums, even after controlling for age, a history of smoking and other fac-veloping pneumonia while hospitalized with COPD are at increased risk for tors that might have skewed the results.because, along with other factors, they periodontal disease, which, when pres- Finally, periodontal disease has alsotend to have poor oral hygiene. So when ent, seems to cause lung function to de- been associated with rheumatoid arthri-they enter the hospital, their dental teriorate further. Because smoking is tis (RA), an autoimmune disease thatplaque—the bacterial biofilm that forms also a major risk factor for periodontal inflames joints and can cause destruc-on teeth—is more likely to become colo- disease, it is diffi cult to separate the tion of cartilage, bone and ligaments.nized by the disease-causing bacteria roles that each of them plays in COPD. The two diseases share some basic char-that lurk in hospitals. The swallowing Preliminary studies by my colleagues acteristics: both the gum tissues affect-difficulty that often accompanies old and me indicate that, while smoking is ed by periodontal disease and the jointsage also increases the amount of bacte- clearly the major cause of COPD, peri- affected by RA contain similar cyto-ria in the mouth—it is not washed away odontal disease may exacerbate it. kines and growth factors. These chemi-by saliva, increasing the likelihood that Other systemic diseases that affect cals promote the dissolution of bone, ait and other oral debris will inadvertent- older individuals may also be influenced problem shared by both diseases. Thisly be inhaled into the lungs. by oral health status. For example, osteo- suggests the presence of a common un- This risk is magnified if a mechani- porosis disproportionately affects post- derlying inflammatory ventilator is needed to assist patients menopausal women, thinning bones and People with advanced RA are known towho cannot breathe on their own by often leading to bone fracture. Periodon- be at increased risk for developing peri-pumping air into the lungs via a tube tal disease apparently does not increase odontal problems—and vice versa.inserted into the mouth or nose. Venti- one’s vulnerability to osteoporosis, but Clearly, more dedicated efforts tolated patients are up to 20 times more people with the latter appear to face an keep gums healthy may reap health divi-likely to develop pneumonia than those increased risk of developing oral disease dends far beyond improving oral healthbreathing on their own. Oral bacteria and tooth loss. My colleague Jean Wac- and retaining your teeth. The good newscan grow on the tube and travel into the tawski-Wende and our research group at is that controlling and even preventinglungs. Not surprisingly, between 10 and the University at Buffalo have found a periodontal disease is possible through25 percent of these patients develop ven- strong and consistent association be- relatively low-tech means: daily brushingtilator-associated pneumonia (VAP), tween osteoporosis and periodontal dis- and flossing, plus regular trips to yourmaking it the leading cause of death ease that causes both tooth and jawbone dentist’s office for cleanings and check-from hospital-acquired infections. loss—especially among women ages 70 ups. Knowing that maintaining oral hy- Improving oral hygiene among the and older [see box on page 33]. giene could help prevent more seriousinstitutionalized elderly would be a cost- Oral infection and the gum inflam- conditions may be just the incentive botheffective way to reduce the risk of pneu- mation it causes may also contribute to young and old need to make it a habit. •monia caused by bacteria in the mouth.More than a dozen studies have shown FRANK A. SCANNAPIECO studies oral microbiology and the interface between oral andthat simple measures, such as super- systemic health—specifically, the role of oral conditions in the process of respiratoryvised toothbrushing and regular use of infection. He is professor and chair of the Department of Oral Biology, School of Dentalantibacterial mouthwashes, can reduce Medicine at the State University of New York at Buffalo. He has been engaged in dentalby more than half the risk of pneumonia research and education for over 20 years.34 ORAL AND WHOLE BODY HEALTH
  • INSIGHTS ORAL HEALTH AROUND THE WORLD problem and the recommendation of effective and accessible interventions or preventive measures. WITH PROFESSIONAL EXPERIENCE IN FOUR DIFFERENT Also, in Western society, these messages are likely to reach the portion of the COUNTRIES – THE UNITED STATES, ITALY, SWITZERLAND AND THE population that could benefit least. The UNITED KINGDOM, MAURIZIO TONETTI , CHAIR OF THE people you reach with these messages are the ones whose “health IQ,” or health DIVISION OF PERIODONTOLOGY AT THE UNIVERSIT Y OF awareness, is so developed that they are CONNECTICUT HEALTH SCIENCES CENTER HAS A TRULY GLOBAL unlikely to be the ones harboring massive undetected disease. PERSPECTIVE ON ORAL HEALTH. HERE HE OFFERS A FEW INSIGHTS ON ORAL HEALTH AND SYSTEMIC DISEASE: ON CHANGES AT THE WORLD HE ALTH >> ORGANIZATION (WHO) ON ORAL HEALTH: ON EDUCATION AND THE CONVERGENCE OF very, very few resources, but the usefulness Historically, before a relatively recent DENTISTRY AND MEDICINE: A common of what they are doing is limited by the fact reorganization in the 1990s, oral health was biomedical curriculum is much more that there is no coordination or consistent part of a WHO branch that focused on prevalent in Europe than in the U.S. Until methodology being employed. In Europe we infections. Now, they have placed it with 1980, in most countries, dentistry was a have been—and in other areas of the world we chronic noncommunicable diseases. They medical specialty, so you became a physician, are still—at the level of pilot [studies] have grouped together areas where risk and then specialized in dentistry—rather involving a few hundred patients. The building factors of the population base are similar than, say, cardiology or orthopedics. So, the blocks to be able to do the real clinical trial are because they think this is the best way to foundation of dentistry in the majority of there. Now it’s time to do the real studies. We fight these diseases; many countries are European countries has very, very deep need to focus efforts and develop a vision in following this approach. medical roots. In the United States most order to make a coordinated research effort dental schools have their own faculty happen. ON ORAL HEALTH IN EUROPE: Europe is not a teaching such courses as anatomy, homogeneous reality. You have countries that pharmacology and biology. In Europe it’s not ON P RE S S C O V ER A GE OF T HE OR A L are responsive to the needs of populations: like this. There is a biomedical science faculty C ONNEC T IONS T O O V ER A L L HE A LT H : they have public health systems that are that includes medicine and dentistry. In Europe we have been much more cautious probably the envy of the world—probably, I A strong biomedical curriculum is needed than in the U.S. We have kept the dental would say, better than the U.S. But Europe, not only because of the possible systemic profession very well informed by making sure being made of 25 states these days, has a implications of oral diseases, but also that these topics are discussed at professional wider discrepancy of care than between, say, because of the fact that people are living meetings, but by and large we have not had Connecticut—which is probably one of the longer. So all of a sudden, dentistry has major press releases on the topic. Over the states with the best access to dental care and become an important component of life last two years there has been an increased best health policy in the U.S.—and Louisiana, expectancy, of the well-being of people. awareness, and the media has started to or rural Alabama. Health care is a state issue, communicate. I think this is perhaps a better not a European Union issue. Oral health care ON RESEARCH ADDRESSING THE ORAL- approach than the U.S. media in traditional EU countries is generally good, SYSTEMIC LINK OUTSIDE THE U.S.: There’s lots hype; wait until you have but significant disparities among the various of enthusiasm and attention, but unfortunately enough data and then countries and disadvantaged groups andCOURTESY OF THE UNIVERSIT Y OF CONNEC TICUT all of this has translated into fragmented go to the people. Ideally, individuals exist. As in the U.S., in Europe the efforts. There is no body, no organization communication should major burden of oral disease is to be found in a that has been able to catalyze and focus include bo th the minority of the population. • research activity in places as diverse as Africa, the Far East, Europe—even within Europe—and in the United States. “The foundation of dentistry in the We are missing a tremendous opportunity because there are lots majority of European countries has of people around the world that very, very deep medical roots.” are doing research with ORAL AND WHOLE BODY HEALTH 35
  • S U S A N H A D C A R E F U L L Y M O N I T O R E D H E R H E A L T H IN the months leading up to the delivery of her first child. She visited her obstetrician for regular checkups, downed prenatal vitamins every morning, and stopped smoking. Although she worked full daughter, she wondered what had gone time, she made sure to get plenty of rest. wrong. Her baby had arrived just eight Many of her friends at work were par- months into her pregnancy. ents and they gave her advice daily, tell- Susan is not alone. According to the ing her: keep exercising; don’t jog, swim March of Dimes, each day 1,300 babies instead; don’t eat too many tuna fi sh in the U.S. are born prematurely for rea- sandwiches. One thing she heard over sons linked to specific risk factors like and over again—an old wives’ tale, re- smoking or high blood pressure. And if ally—was that she shouldn’t go to the emerging research proves true, peri- dentist because of “x-rays in the air.” So odontal (gum) disease will be a new ad- Susan skipped her annual dental check- dition to that list. In fact, if the bacteria up even though she was concerned by and inflammation from gum infection how her gums bled when she brushed do indeed play a role in preterm deliver- her teeth. Everyone assured her that this ies—as well as other conditions such as was normal. pneumonia, stroke, heart disease and As she lay in her hospital bed after diabetes—the reverberations across our the premature delivery of her tiny little health care system will be seismic and transformative. “Medically necessary dentistry” will become the new sloganPUBLIC POLICY & ORAL HEALTH: of our time.A WHOLE NEW Governments, insurers, clinicians & the public must all recognize the changing face of dental medicine. BY SHEILA RIGGS36 ORAL AND WHOLE BODY HEALTH
  • The generations-old barriers that in- between what we know and what we cious information through the lens of a advertently disconnect the mouth from do when it comes to an issue that cross- primary care physician. the body in terms of patient care are sub- es unusually hardened divides in our Dentists are usually the most acces- stantial. Most of our physicians and den- health care system? sible members of the medical team. Typ- tists are trained in different schools, ically, Americans visit their dentist twice practice in different settings, and receive A WHOLE NEW GAME a year for preventive care. According to payment through different systems. let us assume that all the research link- Dr. Michael Glick, editor of The Journal When your physician asks you to “open ing periodontal disease to many of our of the American Dental Association, wide,” he or she is examining your nation’s most prevalent and costly chron- “Dentists can play an important role in throat, not your mouth. Meanwhile, ic health conditions reaches the same the primary prevention of cardiovascu- your dentist focuses on saving your teeth conclusion: the presence of active oral lar disease…and refer patients for more and gums; he or she doesn’t necessarily disease causes system-wide complica- in-depth evaluation.” view periodontal treatment as a way to tions, and treatment and prevention will Referrals will come more easily when prevent inflammation that can cause improve overall health. Our whole per- dentists and physicians train together in harm throughout the rest of your body. ception of dentistry will need to change, classrooms. It is also crucial that they It takes an average of 17 years be- as will its role in our health care system. work side by side in clinical settings dur- fore Americans benefit from new In this new paradigm, dentists ing graduate school, for example, co- knowledge gained from medical re- should be recognized as the physicians treating a pregnant patient. Defining and search, according to Carolyn Clancy, of one part of the body, not just the sur- implementing a unified primary care team M.D., director of the Maryland-based geons of a perfect smile. Dentists take from day one in school will create a pow- Agency for Healthcare Research and blood pressures and health histories as erful new norm. Team members should Quality. This rais- well as gather insights from their pa- include physicians, nurses, pharmacists, es an important tients on risk factors impacting oral dentists and dental hygienists to question: How health, like tobacco use and soda con- both demystify the oral cavity for long will the sumption. Now they physicians and to empower the time lapse be must view this pre- work of the dental team. >>JOHN SOARES ORAL AND WHOLE BODY HEALTH 37
  • Curriculum changes, however, are If our assumption about periodontal health plans in their “pay for perfor-not sufficient. This new knowledge ulti- disease proves true, such “pay for perfor- mance programs”: insurance companiesmately must translate into the everyday mance” programs should also include pay physicians a bonus for meeting orpractices of physicians and dentists and teeth cleaning and dental care. Likewise, exceeding treatment covered by insurance companies— when the federal government tracks how Another standard component of dis-and there are precedents. Numerous many Americans with diabetes receive ease management is a program that con-“quality improvement initiatives” related essential monitoring and care in their an- nects pregnant Minnesotans or those suf-to medical care are currently underway nual National Healthcare Quality Re- fering from chronic conditions with a reg- istered nurse. In regular checkup phoneIt takes an average of 17 years before calls, their nurse helps them improve life- style habits and coordinate care. TheseAmericans benefit from medical research. same nurses could also educate their pa- tients on the importance of dental clinics and hospitals nationwide. port, a new dental component will need Currently, more than 250,000 pa-These initiatives implement standardized to be added to their survey. tients with diabetes, heart disease andtreatment guidelines to insure that pa- other conditions are enrolled by twotients receive proper care. They also es- MINNESOTA AS A PRACTICE FIELD medical insurance companies who al-tablish who is responsible for carrying minnesota, a state known for its health ready partner with one of Minnesota’sout each step outlined by these new care reform, may be the ideal place to largest dental insurers, Delta Dental.guidelines. Hospitals and clinics using launch this revolution. All the major Broadening dental coverage for thesethese new initiatives are examining their stakeholders currently working to im- populations with fewer co-pays wouldprotocols to make sure no step in patient prove the quality of the state’s health encourage preventive is overlooked. For example, patients care are in place—and they are capable Employers, consumers and innovatorshospitalized with a heart attack should of getting this new research into prac- are also active in health improvement ef-begin beta-blocker therapy (medication tice sooner rather than later. Included in forts in Minnesota. Companies are actingthat lightens the heart’s workload) with- this group are educators, health care to lower health care expenses, which havein seven days of discharge. New proto- professionals, insurers, employers, con- spiraled dramatically upward over thecols dictate who is responsible for issuing sumers and entrepreneurs. past decade: The cost to employers inthe prescription. On the educational front, the deans 2003 for a healthy newborn’s two-day These efforts are frequently spon- of the University of Minnesota’s medical, hospital stay was about $1,700, while asored by insurance companies or em- dental, pharmacy, nursing and public premature or underweight baby’s averageployers. Using fi nancial incentives, they health schools are discussing joint classes 24.2-day stay was around $77,000, ac-speed the time it takes for new research and a linked curriculum. “We are work- cording to the March of Dimes.on health care practices to become ev- ing through the details of launching on- An employer coalition called theeryday patient treatment. They must campus and clinic-based educational op- Buyers Health Care Action Group is innow also be injected with a healthy portunities, like at the Rice Memorial place to encourage and reward improve-dose of dentistry, which would recon- Hospital in Willmar,” said Patrick Lloyd, ment initiatives in Minnesota’s healthfigure programs to include gum disease dean of the School of Dentistry. care. Recently, they issued a report com-as a preventable risk factor for several Another important initiative is the paring the performance of the state’scommon health problems. Minnesota-based Institute for Clinical health plans in both clinical areas (such Some very large employers now di- Systems Improvement (ICSI), a health as prevention and chronic disease man-rectly pay bonuses to doctors; the insurance–funded think tank that estab- agement) and in administrative prac-“Bridges to Excellence” diabetes care lishes guidelines for medical treatment tices (like extending personal digital as-program is one example. General Elec- and improved care. For over a decade, sistant devices to physicians and nursetric and other companies provide a bo- ICSI has worked with virtually every practitioners). In the future, employernus of $80 per patient to physicians medical group and hospital system coalitions should evaluate insurers’ ef-who meet National Committee for throughout the state, designing ways to forts to encourage their employees withQuality Assurance standards in caring implement the best clinical practices. chronic conditions to seek dental care.for their diabetic employees, with a fo- ICSI’s “collaboratives” are currently in But it could be the entrepreneurs atcus on improving patients’ blood sugar place to improve care to pregnant wom- one of Minnesota’s 450 medical devicelevels, blood pressure and cholesterol en and to those suffering from diabetes companies that offer the best solutions.levels. This saves employers about $350 and heart disease. The standards created For example, one company is developinga year per patient. by these collaboratives are rewarded by a topical liquid for use by dentists that38 ORAL AND WHOLE BODY HEALTH
  • said Christopher H. Fox, executive di- rector of the International and American Associations for Dental Research. “While the cost for these trials is high, it is pennies compared to the lifelong treat- ment costs for low birth weight babies or for patients with cardiovascular dis- ease.” The landmark government report issued in 2000, “Oral Health in Ameri- ca: A Report of the Surgeon General,” made a similar call for future research. When Medicare was established in 1965, Congress made a blanket exclu- sion of dental care. Medicaid coverage varies state to state, but adult periodon- tal services are covered in just nine states, according to a U.S. Government Ac- countability Office report to Congress. So although the poor and the elderly have some of the highest occurrences of heart conditions and diabetes, there is little public assistance available for peri- odontal treatment, which costs between $100 and $1,000 per year depending on its severity. In developed countries, 44 to 57 percent of adults have moderate peri- odontitis; 7 to 15 percent have an ad- vanced form of the disease. In their 2003 “Public Health Impli- cations of Chronic Periodontal Infec- THE BURDEN OF DISEASE: Poor oral health impacts individuals and whole communities and results tions in Adults” report, the Centers For in pain, suffering, impairment of function and reduced quality of life. According to the World Health Disease Control and Prevention (cdc) Organization (WHO), oral disease is the fourth most expensive condition to treat in most industrialized countries. As more research links oral health to overall health, policymakers will need to address suggested restructuring benefits to pro- new models of prevention and treatment. vide dental infection control services to Medicaid and Medicare recipients. If disrupts plaque biofi lm, removing the tional policymakers should fund studies preventing and treating periodontal dis- harmful effects of the bacteria that cause to confirm whether periodontal disease ease does indeed avert preterm deliver- periodontal disease in the fi rst place. is indeed a risk factor for often prevent- ies and decrease the illness burden of Ongoing research into oral-systemic able “medical” conditions that affect Americans with diabetes and heart dis- health links will certainly spawn much millions of Americans. “In order to ease, covering dental treatment for more development among product mak- move from uncovering an association adults in our public entitlement health ers and life sciences companies. between periodontal disease and various programs should be considered. In the end, these solutions will be systemic diseases and conditions, to ac- So that the next time Susan is preg- necessary to change the cultures of the tually demonstrating causality, large- nant, there will be a brand-new member medical and dental practices to embrace scale clinical trial research is needed,” on her health care team—her dentist. • the new research fi ndings on the con- nectedness of the mouth to the body. SHEILA RIGGS received her dental degree (D.D.S.) from the University of Iowa College of Dentistry and went on to earn her doctorate of medical sciences (D.M.Sc.) in oral epide- FEDERAL GOVERNMENT’S ROLE miology from Harvard University. She was recently appointed president and CEO of THE FEDERAL GOVERNMENT also has Delta Dental Plan of Minnesota, one of the largest dental benefi t providers in the upperM AT T COLLINS “skin in this game” both as a primary Midwest, which serves more than 3.3 million individuals at 8,500 Minnesota-based funder of medical research and as the companies and is leading the effort to integrate the latest dental and medical research provider of Medicaid and Medicare. Na- into its dental offerings. ORAL AND WHOLE BODY HEALTH 39
  • INTERVIEWTHE FORMER U.S. SURGEON GENERAL REFLECTS ON HIS is mounting evidence. We still don’t have that definitive, long-term study becauseSEMINAL REPORT THAT PUT ORAL HEALTH ON THE NATIONAL those take a long time, but more and more studies support the associations.AGENDA, AND THE POLICY STEPS THAT STILL NEED TO BE TAKEN And I don’t mean just public education.>>S CIENTIFIC A MERICAN : “Oral Health in America”was a landmark report. What factors com-pelled you to issue it?S ATCHER : I think the request from the oral report—and how did it help mobilize efforts for better oral care and greater awareness? Both in the public and private sector, we’ve seen increased focus on oral health, funding programs and educating the population. The Clearly, in the future, it will be critical that medical students, dental students, nurs- ing students and public health students be educated about the significance of oral disease as it relates to systemic disease— and about some of the things we can do tohealth community, including dentists and National Center for Dental and Craniofacial intervene.others, had probably been there for many Research at NIH (National Institutes of Health) has now In light of continued evidence linking oral funded several and systemic health, is the mandate to Centers of Excel- address socioeconomic differences in oralDISCUSSION with lence on oral health health care access even more pressing?DAVID S ATCHER research. In the private sector, the Robert Wood John- I think it is. Our report stated that 20 percent of the population now suffers more than 80 percent of oral health disease. About one son Foundation fund- third of the elderly, by the time they’re 65,years. When I got to Washington—having ed 19 dental schools to develop outreach are edentulous. We know that periodontalcome from the CDC (Centers for Disease programs into communities around them. disease is more common in African-AmericanControl and Prevention)—I was especially Other foundations have also focused men in general, and that it’s more common inconcerned about areas that had not been increased attention on oral health. smokers. So I think we’re now in a position todealt with, like mental health and oral health, The other thing that I appreciate is that begin to target populations [who are mostand obesity. So oral health was very high on it’s led to new partnerships between doc- adversely affected].our list because it had been neglected by the tors and dentists and other oral health pro-surgeon general’s office. We tried to make it fessionals. I think [the report] rejuvenated Many people without health care might go tovery clear that this was not about the dental the field in many ways. a dentist, whereas they may not have had aprofession, it was about oral health, and that medical checkup in some years. What kind oforal health was everybody’s business— As more evidence comes in linking oral responsibility should fall on the dental pro-everybody who was concerned about health health to other medical conditions, what fession in those cases, where perhapsand health care. further efforts do you feel need to be taken, they’re treating a diabetic patient that alsoWere there specific issues around oral healththat were of particular concern at that time, “We tried to make it very clear that this was notboth to you and to the medical and dental com-munities? Well, one issue was disparities in about the dental profession, it was about oralhealth. If you go back to the “Healthy People health, and that oral health was everybody’s2010” report that we released in January business—everybody who was concerned about2000, we looked at two major areas. One was health and health care.”the quality of life of people as they get older;one of those issues was edentulousness in either clinical practice, public education has gum disease? Well, I think diabetes is a(tooth loss). The second was the issue of dis- or policy? I think in all of those areas there good example, because the association withparities in health among different racial and is a need for enhanced education and com- periodontal disease is probably most clear.ethnic groups. I don’t think there is any area munication about the magnitude of the Since we know that people with diabetes arethat demonstrates health disparities more problem of oral disease—and its signifi- at greater risk for oral health disease, coun-than oral health—there are 108 million cance. Especially when you begin to tie peri- seling patients about being tested for diabe-Americans who lack dental insurance. odontal disease to low birth weight or tes [or making sure that their diabetes is adverse pregnancy outcomes, increased under control] is important. The educationSince that time, what steps have been taken risk for diabetes or cardiovascular disease about diet that dentists give is important fortoward addressing the issues outlined in the and stroke. Those are the ones where there both the health of the mouth and for the over-40 ORAL AND WHOLE BODY HEALTH
  • all health of a person with diabetes: increas-ing fruits and vegetables, and decreasingsweets, meats and calories. Dentists, by focusing on the mouth, havean opportunity to look at what’s happeningto the whole person. And by partnering withthe health professional, they can work tomake sure that the [patient] gets the carethat he or she deserves. I was thinking aboutthe role that dentists are playing in helpingpeople [to] quit smoking, because theyfocus on how their teeth and gums lookwhen they smoke. And so, in recent years amajor avenue for smoking cessation hasbeen to get dentists involved. I think thatthese [medical-dental] partnerships arebeing forged both ways. The mouth is animportant mirror and a window to the body:it’s not just what is going on in the mouth,it’s what’s reflected in the mouth about thestate of health of the body.What other comments do you have that youthink would be good for both dental profes-sionals and the general public to hear?The overriding message that came out of thatreport is the importance of access to oralhealth care; the fact that so many Americansdon’t have access to oral health care is amajor concern ... and that it disproportion-ately impacts low income families and minor-ities. Hopefully, as a nation, we should bemoving towards universal access to oralhealth, as well as health care in general. Iknow that there were some states that sig-nificantly increased their Medicaid coveragefor oral health after our report. [But] many ofthose states, after they had budget prob-lems, cut back Medicaid again, which, ofcourse, hurt all aspects of health care. • COURTESY OF THE MOREHOUSE SCHOOL OF MEDICINE D A V I D S AT C H E R c o m p l e t e d h i s f o u r- y e a r t e r m a s t h e 1 6 t h s u r- geon general of the United States in February 2002. He also ser ved as assistant secre- tary for health from February 1998 to Januar y 2001, mak ing him only the second person in history to have held both posi- tions simultaneously ORAL AND WHOLE BODY HEALTH 41
  • RESEARCH SNAPSHOT: A Novel Approach to Resolving Inflammation Understanding how the body naturally “turns off” inflammation may yield new sible to rein in runaway inflammation treatments for periodontal disease and other inflammatory conditions and the tissue destruction it causes. We and our colleagues have identi- By Thomas E. Van Dyke and Charles N. Serhan fied powerful compounds, produced naturally by the body, that put the brakes on the inflammatory response. S c i e n t i s t s h av e k now n for a l mos t 50 y e a r s If we can manufacture these novel anti-inflammatory chemicals and use that periodontal disease is caused by bacterial infections. However, them as medicines, they might offer safe and effective treatments—not the tissue damage that occurs in periodontal disease—destruction only for periodontal disease but also for heart disease, arthritis, Alzheim- of the bone and ligaments that hold that periodontal disease results er’s disease and other health problems teeth in place—cannot entirely be ex- mainly from the body’s failure to where chronic inflammation appears plained by the action of infecting or- turn off its inflammatory response to to play an important role. ganisms. Instead, the real culprit seems infection. The result is chronic in- Much of our work on inflamma- to be the patient’s own inflammatory fl ammation, which causes much of tion in periodontal disease has fo- response to that infection. the tissue damage that we observe in cused on its cause: the immune reac- Infl ammation evolved as a pro- periodontal disease. tion that the body mounts against in- tective response to infection and to Why, for some of us, does this in- fection. This attack triggers the classic traumas such as wounds and insect flammatory response to oral bacteria signs of inflammation including heat, bites. Yet infl ammation can also be persist rather than subside? The an- redness, swelling and pain. We’ve deleterious—especially when it per- swer may lie in our genes: Studies indi- been particularly interested in the in- sists, instead of fading away as it cate that much of our susceptibility to nate immune response—the body’s should. Our research collaboration periodontal disease is genetically influ- fi rst line of defense. This response is over the past nine years indicates enced. But fortunately, it may be pos- initiated by neutrophils, a type of white blood cell crucially important in eliminating infectious organismsCAN GUM DISEASE CAUSE HEART DISEASE? by engulfi ng them through a process called phagocytosis—which literallySEVERAL PROVOCATIVE STUDIES suggest that people with periodontal disease have an means “cell eating.”increased risk of heart disease. To further investigate this link, we induced periodontal As they congregate at the site ofdisease in rabbits by tying a thread around some of their teeth and treating their gums infection or trauma, neutrophils se-and teeth with a bacterium known to cause periodontitis in humans. Six weeks later, crete “proinfl ammatory” chemicalsafter the rabbits had developed periodontal disease, we examined their major blood that cause the fi rst, or acute, phase ofvessels. The rabbits with periodontal disease had much more atherosclerosis—fatty inflammation. Normally, in the nextplaque deposits in their major blood vessels—than the healthy control rabbits. step, neutrophils cease their chemical onslaught and inflammation subsides.But which component of periodontal disease—the infection or the inflammation— But in periodontal disease there is awas the culprit? To find out which had caused the atherosclerosis, we once again glitch: neutrophils continue churningtried inducing periodontal disease. This time, besides ordinary rabbits, we used out proinflammatory chemicals,“inflammation-resistant” rabbits that we genetically engineered with Larry Chan which create a complex, chronic le-(Baylor Medical College) to have abnormally high lipoxin levels in their blood. The sion that destroys the gum and boneresistant rabbits not only failed to develop periodontal disease—their arteries holding teeth in place.were almost completely free of plaque, compared with the nonresistant rabbitsthat developed periodontal disease. Clearly, inflammation’s failure to enter its last or “resolution” phase canThis study adds to mounting evidence that periodontal disease may contribute to have serious consequences. This fi nalatherosclerosis. It further suggests that periodontal inflammation plays a key rolein the potential periodontal disease–heart disease connection. — TVD42 ORAL AND WHOLE BODY HEALTH
  • RY DRUGS TODAY’S ANTI-INFLAMMATO tar get onl y spe cifi c asp ect s of lly cause inflammation —and typica har mfu sid e eff ect s in phase so. TRAUMA OR INFECTIONltriggers the early doi ng oth er A (“go” traffic pr ofe n and of inflammationspi rin , ibulights). Here, ara- non ste roi dal ant i-in fla mm ato ry chidonic acid is converted to proinflammatory b mediators leukotriene B4 (LTB 4for example, cur drugs (NS AID s), ) and prosta- n pro duc tion wh ile glandin E2 (PGE2) that gla ndiedema, fever and pro sta cause isk for i n c r e a s i 2 levels e r s r pain. Later, elevated PGEn g u s help’ resolve tin al ble edi ng. By inflammation gas tro int es production of by stimulating urr ing con tra s t, nat ura lly occ enzymes that form anti-inflammatory lipoxins inflammation (“stop” traffic lights), which are also-resolvgenerated nds, ing compou ct within blood vessels via platelet-neutrophilaffe such as resolvins and lipoxins , interactions. The fiasp ect s in all nal step of haltingma tion. They inflam inflam- mation is the switch of families in ate d media- r lula and create a coo rdin lipid cel mo lec ula r tors from proinflamma tory to resresolvins and ngs pon se tha t bri gs protectins. Exudatelam ma tio nbiosynthesizeDru inf neutrophils to a hal t. se natural compounds, these two chemicalicking the from omega-3 mim families at fatty acids in thenow in dev elo pm ent , off er gre diet. potential for treating inflammation e effects “naturally” and without sidTA MI TOLPA ORAL AND WHOLE BODY HEALTH 43
  • RESEARCH SNAPSHOT: phase has traditionally been consid- tion, then it is lipoxins that can be ered a passive event—a petering out considered the “red lights” that help of immune activity that paled in com- bring inflammation to a halt. parison to the acute phase’s neutro- The synthesis of these inflamma- phil attack. That assumption re- tion-stopping compounds starts late quired drastic revision after one of us in the acute inflammatory response. (Serhan) carried out the first system- Before that, inflammation is in full atic study of the natural history of swing: enzymes from platelets and inflammation by examining inflam- other cells attracted to the area me- matory pus in skin lesions of rabbits tabolize arachidonic acid (a major and mice. fatty acid in cell membranes) to create We observed that neutrophils, leukotrienes and other proinflamma- which lead the white cell onslaught tory compounds. Then, once these during inflammation’s acute phase, inflammatory chemicals have crowd- UPPER PHOTO shows inflammation and erosion secrete two compounds well known ed together, an abrupt shift occurs, of gums in rabbits with periodontitis. In lower for provoking inflammation and at- and enzymes induced in neutrophils photo, topical resolvin prevents inflammation and tracting additional white cells to the convert arachidonic acid into inflam- tissue destruction of periodontitis. area: leukotriene B 4 , followed by mation-dampening lipoxins. The in- prostaglandin E 2 . But at the end of flammatory response ceases as lipox- the acute phase, we saw something ins increase in quantity at the expense tis, cardiovascular disease and other surprising: neutrophils stopped se- of proinflammatory compounds. inflammatory conditions. We now sus- creting classic inflammatory chemi- pect that the resolvins formed from cals and instead began collaborating serhan recently discovered yet omega-3s may in part account for the with other cells to synthesize com- another family of inflammation-re- anti-inflammatory properties of these pounds that halted inflammation. solving compounds that we’ve dietary fatty acids. We dubbed these anti-inflamma- dubbed “resolvins.” In contrast to li- The actions of lipoxins and re- tory compounds lipoxins, since they poxins, whose starting material is solvins in the body are similar but were derived from the lipids (fatty ac- arachidonic acid, the resolvins are not identical. Their net effect is to ids) released from neutrophils’ cell derived from fatty acids in the diet— rapidly halt inflammation and mini- membranes and from other cells that specifically from omega-3 fatty acids mize tissue damage. Furthermore, congregate early in inflammation. If that are especially plentiful in fish. taking aspirin results in more potent it is prostaglandins and leukotrienes Several well-designed clinical stud- and longer-lasting lipoxins and re- that give the “green light” that ac- ies indicate that diets rich in omega-3s solvins [see box on page 45]. celerates tissue injury and inflamma- help in treating and preventing arthri- In our federally funded Special- ized Center for Oral Inflammation A NTI-INFL A MM AT ORY DRUG S and Resolution, we are studying how target only specific aspects of the structure of resolvins gives them inf lammation—and typically their potent anti-inflammatory abil- cause harmful side effects in doing so. Ibuprofen and other ity. Based on our fi ndings, we rea- nonsteroidal anti-inflammatory soned that the topical application of drugs (NSAIDs), for example, curb lipoxins and resolvins as medicines prostaglandin production while might prove useful in treating or even increasing users’ risk for gastro- preventing inflammatory diseases intestinal bleeding. By contrast, naturally occurring inflamma- like periodontitis. We also wondered tion-resolving compounds, such if these compounds might help as resolvins and lipoxins, affect against other inflammatory prob- all aspects of inflammation. They lems such as cardiovascular disease create a coordinated cellular and and the complications of diabetes. molecular response that brings inflammation to a halt. Drugs To test resolvins’ ability to prevent mimicking these natural com- periodontitis, we chose an established pounds could potentially treat inflammation “naturally” and without side effects.44 ORAL AND WHOLE BODY HEALTH
  • REVVING UP LIPOXINS AND RESOLVINS WITH ASPIRINmodel of human gum infection—therabbit model. We tied silk thread ASPIRIN’S POTENT ANTI-INFLAMMATORY PROPERTIES were recognized soon after it wasaround certain rabbit teeth to trap bac- introduced a century ago. But not until many decades later did Sir John Vane, Sune Bergströmteria and then added a disease-causing and Bengt Samuelsson—in research for which they shared a 1982 Nobel Prize—discoverhuman bacterium, Porphyromonas how aspirin actually works. Aspirin blocks the enzyme COX-2. This provides relief bygingivalis, to induce periodontitis. Af- preventing arachidonic acid in cell membranes from being converted into prostaglandins—ter dividing the rabbits into two groups, the chemical messengers that cause the pain and swelling of inflammation.we swabbed a resolvin-containing so- By blocking the COX-2 enzyme, aspirin andlution on the gums of one group and an similar drugs do a good job of shutting off theinactive solution on the gums of the prostaglandins that fuel the early, acute phaseother. The results were striking: rab- of inflammation. But they may also set the stagebits receiving the topical resolvin solu- for chronic inflammation by hindering the body’stion were completely protected against own attempt to heal: As the illustration on pageperiodontitis, whereas the placebo 43 shows, prostaglandins are vital for producinggroup developed severe gum disease the lipoxins that help to resolve inflammation.[see photos on page 44]. This suggests a better strategy for quelling inflammation: Instead of halting acute inflammation, focus instead on helping the body in its effort to resolve the inflammatory further explore this connection When we swallow aspirin, it not only inhibits COX-2 but also modifies its action. Researchbetween inflammation and suscepti- by one of us (C.S.) has shown that aspirin-modified COX-2 catalyzes the production of “newbility to disease, we studied genetically and improved” resolvin and lipoxin compounds that have more potent and longer-lastingengineered rabbits that have elevated anti-inflammatory effects than the naturally occurring variety.levels of lipoxins when their white These previously unappreciated aspects of aspirin’s activity may help researchersblood cells are activated. These rabbits develop truly anti-inflammatory compounds that would not just muffle acutealso have a very low incidence of ath- inflammation but would actively resolve inflammation and heal wounds. These drugserosclerosis [see box on page 42] in would be especially useful against periodontal disease, heart disease and othertheir major vessels. We tried to pro- important health problems that arise from chronic inflammation.duce gum disease in these “inflamma-tion-resistant” rabbits using the same — TVDsilk thread and bacteria technique de-scribed above. With their elevated lev-els of circulating lipoxins, these rabbits flammatory drugs are the NSAIDs ing inflammation rather than justproved resistant to periodontitis. (nonsteroidal anti-inflammatory turning off one or another individual While we know that bacteria drugs), which include naproxen, ibu- inflammatory pathway [see sidebarcauses periodontal disease, it now ap- profen and many other compounds. on page 44]. In addition, these natu-pears that its progressive form may be The NSAIDs short-circuit just one in- ral compounds would be expected toprimarily driven by inflammation— flammatory pathway (the one that produce few side effects.which could alter the way this condi- converts arachidonic acid into prosta- Our studies have shown that lipox-tion is controlled and treated. In peo- glandins). Moreover, NSAIDs cause ins and resolvins may be ideally suitedple susceptible to periodontal disease, thousands of deaths annually in the for treating periodontal disease. •for example, topical application of li- U.S., mainly due to gastrointestinalpoxins or resolvins could possibly bleeding. Other, more powerful anti- THOMAS E. VAN DYKE stu of inflammation as a the dies the resolution rap is a professor in the De eutic target. Heprevent or lessen its severity. inflammatory drugs, such as Remicade par More broadly, our research has for treating rheumatoid arthritis, do so odontology and Oral Biolog tment of Peri-shown that inflammation involves the by dampening the immune response, sity’s Goldman School of y at Boston Univer- Decoordinated response of a large num- which may increase vulnerability to in- directs the Clinical Resea ntal Medicine, associate director at the rch Center, and isber of biochemical pathways. But to- fections as well as to cancer. cine General Clinical Re BU School of Medi-day’s anti-inflammatory drugs defuse By contrast, lipoxins and re- search Center.only one pathway or another and can solvins might offer major advantages CHARLES N. SERHAN stu molecular mechanisms tha dies the cellular t tion. He holds the Gelma resolve inflamma-be risky to use. Consider two exam- over existing anti-inflammatoryples: by far the largest class of anti-in- drugs. They act by “centrally” defus- n Professorship at Harvard Medical School , is a senior biochem- ist and an endowed dis tinguished scientist at Brigham and Women’s Ho is also chairman and pro spital. Dr. Serhan fes cine, infection and immuni sor of oral medi- ty School of Dental Medicine at the Harvard . ORAL AND WHOLE BODY HEALTH 45
  • PATH TO PREVENTIONMOUTHFUL BUGS of Pathogenic bacteria are a way of life. So, too, must be brushing and flossing. | BY ROBERT H. KAGAN T H E MOU T H I S A C AU L DRON OF B UG S . die for bacteria to find inroads: diseases, such On average, some 500 species sit in the oral as diabetes, can decrease the ability of the im- cavity going about their daily business as mune system to respond effectively to bacteria, their hosts sleep, talk, chew and swallow. and this can tilt the balance toward the latter, “Bacteria are lurking in the tongue, nasal cav- triggering the beginnings of oral disease. Lo- ity, tonsil area, gingival pockets [and] float- calized neglect—not taking adequate care in- ing in saliva,” explains John C. Gunsolley, a side the mouth—can also lead to pathogenic professor in the department of periodontics bacterial overgrowth. This can occur when at Virginia Commonwealth University in periodontal pathogens such as Actinobacillus Richmond. “Our skin has bacteria on it, actinomycetemcomitans, Prophyromonas we’re never completely sterile. Swab any ex- gingivalis or Tannerella forsythia begin to in- ternal portion of the body, you will fi nd bac- crease their presence in the mouth and over- teria. It’s nothing to be alarmed at. It’s what colonize soft tissue. When these bacteria ex- nature is.” pand in the pockets of the gums, they can trig- JEFF MELLIN adapted from vintage illustration provided by Clipar The body is constantly fighting these bac- ger redness and inflammation from gingivitis, teria, and healthy bodies are able to keep them a warning sign for possible progression to peri- at bay. When our immune systems stop re- odontitis and the destruction of gum tissue sponding, however, our bodies become bacte- and bone that can result. rial buffets. Within a day or two of dying, Eliminating pathogenic bacteria complete- bodies start to smell, Gunsolley says. That’s ly might make the mouth safe from periodon- the bacteria taking over. But we don’t have to tal disease, Gunsolley explains. Experiments >>46 ORAL AND WHOLE BODY HEALTH
  • BATTLING BACTERIA AND INFLAMMATION Home Care Chemotherapeutic • Brushing & Flossing • Chlorhexidine • Stannous flouride • Cetylpyridium chloride Professional Care • Essential oils • Scaling and root planing • Triclosan • Flap surgery • Antimicrobial inserts • Grafts (BONE, SOFT TISSUE) into pockets • Tissue regeneration surgery • Systemic antibiotics • Bone (OSSEOUS) surgeryORAL ARSENAL: A variety of interventions are available to combat infection and inflammation in the mouth.have been done with rats where peri- pathogenic bacteria that populate a pa- and root planing as well as placing anti-odontal pathogens were eliminated from tient’s mouth and how much damage microbial inserts into gum pockets, orparts of the mouth, and the rats resisted they might do. Gunsolley points out additional interventions [see box above].attempts to induce periodontitis as long that although there are no good metrics But fi rst and foremost, Gunsolley em-the areas stayed bacteria-free. But even- or devices to measure a mouth’s bacte- phasizes, is good mechanical oral hy-tually, bacteria find their way back into rial load, the body’s response to bacte- giene: brushing and flossing. This, ulti-the mouth, as humans (and rats) have ria is effective in determining treat- mately, is the ideal way to disrupt plaque,bacterial reservoirs that make it impos- ments. If a mouth appears healthy, with especially at the gum line. JEFF MELLIN adapted from vintage illustration provided by Clipar t.comsible to completely eliminate the mi- no infl ammation or redness, then the Traci Portnoff, D.M.D., in privatecrobes for extended periods of time. The main indication is mechanical: brush- practice in Westborough, Mass., and apractical issue, then, is one of balance: ing and flossing. Both brushing, wheth- former instructor in oral medicine atoral disease can often be avoided or kept er with a manual or electronic tooth- the Harvard School of Dental Medi-at bay if the number of bad bacteria are brush, and flossing break up plaque— cine, agrees: “The bottom line is ifkept in check, Gunsolley says. the mass of bacteria and food that forms [someone is] not brushing, they are not a biofi lm, which coats tooth and gum doing anything. You need physicalZEN AND THE ART OF MOUTH surfaces. The goal is break up biofi lm stimulation.” While Portnoff certainlyMAINTENANCE on a daily basis before it adheres, Gun- employs advanced technologies to dealkeeping microbes in check is an on- solley says. with indications of gingivitis or peri-going practice, and a goal met by two The next level of treatment is often odontal disease from pathogenic bac-main approaches: mechanically sweep- chemotherapeutic, where chemicals in teria, her fi rst line of defense and mosting away bacteria so they cannot take mouthwashes or antiplaque agents in important battle cry to patients re-root in the mouth, and reducing their some toothpastes are used to nonselec- mains the same. “Our main focus isnumbers through chemical means. The tively combat bacteria in the mouth. hygiene instruction,” she emphasizes.level of bacteria in a mouth will deter- This decreases the number of pathogen- “There’s no substitute for the brushingmine the types of tools to use under ic bacteria and thus reduces inflamma- and flossing.” •each approach. tion. If there is serious gingivitis or peri- A first step in addressing oral hy- odontal disease, then other treatments ROBERT H. KAGAN is a science writergiene is to determine the amount of are generally added, including scaling based in Boston, Mass.48 ORAL AND WHOLE BODY HEALTH
  • INTERVIEWDANIEL M. MEYER, ASSOCIATE EXECUTIVE DIRECTOR OF THE component of some of these conditions, or itDIVISION OF SCIENCE AT THE AMERICAN DENTAL ASSOCIATION, may be a minor component. Whether or not treating oral health condi-SPEAKS WITH SCIENTIFIC AMERICAN ABOUT ORAL HEALTH, ETHICS, tions will affect systemic health depends onAND THE STATE OF THE SCIENCE LINKING GUM INFECTION WITH the disease—and we’ll know more about that as future research unfolds. Until we haveOTHER SERIOUS DISEASES. [intervention] studies, where we can measure>>S CIENTIFIC A MERIC AN : What is the ADA’s(American Dental Association) position onthe science behind the possible linksbetween periodontal diseaseand other systemic conditions? need to be clarified. It would be naive of us to think that the mouth is separate from the rest of the body; the mouth is an excellent location results in consideration of other variables that may influence health, I think we have to be guarded in treatment recommendations. But treating oral conditions such as periodon- tal disease has its own undisput- ed benefits and may have broaderDANIEL M. MEYER: The ADA is a sci-ence-based organization. It’s had THE ADA’S TAKE systemic health outcomes. I think it’s going to be decades before we fully understand car-a rich history of basing its poli- How the world’s leading dental diovascular diseases. And again, Icies, clinical recommendationsand guidance for providers, organization views the growing think we have to be very cautious about any of the oral health rela-patients and the public on sound connections between a healthy tionships, because they may palescientific principles. Oftentimes, mouth and a healthy body. in comparison to other risk fac-the science is there and clearly tors. But good oral health makessets a sense of direction, but at sense, is appropriate to all cases,times we need more information. As far as oral- to diagnose, prognose, treat and intervene on and contributes to good general health.systemic relationships, we’re dealing with a whole host of disease processes. Oral healthnew discoveries and new scientific informa- has to be a part of general health care, so it’s You make a good point. Regardless of peri-tion. The burden of proof of a causal relation- not too early. odontal health’s relation to your heart, it stillship is not yet met; but research is ongoing is important for your mouth and your teeth.and it looks promising. Inflammatory process- Which of the possible links do you feel are We want patients to be focused on good oral-es in the oral cavity could play a role in causing stronger and which do you feel will need con- health and oral hygiene, but we also wantproblems in other parts of the body. siderably more research before there are any them to take care of their bodies. » It’s important that we distinguish between strong conclusions either way? The relation-sound science and pseudoscience—and ship to cardiovascular disease is less clear.between causal relationships and casual rela- Regarding the relationships to preterm births,“Fundamental to it all, good oral health makes sense,it is appropriate to all cases, and certainly good oralhealth does contribute to good general health.”tionships. We want to make sure that every- depending on what studies you’re has the best scientific information to we’re getting varying results. Bacteria andmake good treatment and clinical care deci- various health conditions can coexist, butsions that will improve the quality of life and we’re talking about bacteria that not only existhealth for our patients. in the oral cavity but may exist in other parts of the body as well. Whether or not they resultDo you feel that it’s too early for there to be in a cause-and-effect relationship or influenceclinical implications or do you feel that the relative risk remains unclear. These diseasesevidence is solid enough in any of these areas are complex. Some have multiple risk factors—to change either medical or dental care? behaviors, genetic conditions and predis-Obviously there is a relationship between oral posing factors, including environmentalhealth and general health. Other relationships issues. So oral health can be a major ORAL AND WHOLE BODY HEALTH 49
  • As more evidence links the health of the mouth an opportunity to work together with the AMA, some people and by the media at the health of the body, do you feel the role to share information, to update the public and I don’t know who coined the phrase, but itof the dentist needs to change, and if so, how? the profession on where we are at this time. does lend itself to the misconception that allI do. I think the role of the dentist, as well as We didn’t want to overstate relationships, but you have to do is floss and you won’t die.any health care provider, needs to evolve as we didn’t want to understate them, either.research evolves, expanding as information If the role of the dentist does indeed need tobecomes available. In all of medicine and den- You mentioned that there is a lot of misinfor- shift to incorporate risk for—let’s choosetistry, the role of the provider has changed mation. What are some examples? There are pregnancy outcomes—what would that meanconsiderably over the last several decades. I those that would say that some of these are regarding liabilities for dentists? We will havesee the dentist becoming much more integral causal relationships, that there is a direct to wait and see. We’re treating individuals,to the general health care team. Dentists gen- relationship between oral bacteria, and, for often with a host of prior medical conditions.erally treat healthy, ambulatory patients example, cardiovascular disease. That hasn’t People are living longer now, taking a variety ofrather than afflicted or debilitated patients so been demonstrated yet. There are still con- medications, many of which interact or causethey can be involved in early intervention, flicting studies that call into question the dry mouth—which can cause other oral andearly diagnosis, risk assessment and disease strength of some of these relationships. Our health complications. So with care comes the concern for side effects and risks. You have toWe’ve had patients calling up thinking that they can weigh the benefits against the risks. We are treating patients for complex diseases, buttreat their heart conditions by simply going in and perhaps we don’t fully understand all of thehaving their teeth cleaned or scale and root planed. health implications, or all of the side effects, or all of the interactions. Along with that theremanagement of many diseases, and [they concern is to keep things in the proper per- certainly are medical and legal risks.can] refer those individuals to appropriate spective—so when someone goes to a physi-health care providers. For example, to help cian or a dentist, that the level of care is con- Which in the U.S. is a big issue. We are per-detect cardiovascular conditions it would be sistent with the quality and strength of sci- haps the most litigious society in the world.beneficial for dentists to do blood pressure entific evidence. Right. And so, are dentists preyed upon? Yes.screenings, and we’re looking at new tech- Are health care providers preyed upon? Arenologies like salivary diagnostics. The chemi- Are there any other obvious myths around patients preyed upon? Yes. And so that’scals that you see in blood should also be periodontal disease and general health that always a concern.detected in saliva, and although this technol- come to mind? There are misconceptions thatogy needs to be refined, it allows dentists to need to be addressed. We’ve had patients call- Do you think this new data could create a morebe part of the early diagnostic team. We need ing up thinking that they can prevent or treat complex legal matrix? It’s already been broughtto take more of a medical approach to some of heart conditions by simply going in and having to our attention. There are lawyers’ Web sitesthese conditions, and to align ourselves with their teeth cleaned or scaled and root planed. saying, “If you’ve ever had a history of peri-other health care providers to address them. odontal disease... and if you have any of the Getting your teeth cleaned wouldn’t be the following conditions, then you may be eligibleIs the ADA promoting a closer relationship magic bullet there. No, it wouldn’t be. We’ve for legal action.” Does concern us? Obviouslywith the medical community? We are. We’re had people call up asking, “If I brush my we don’t want harm done to patients, but weworking very closely with the American teeth with this certain toothpaste, will that also recognize that there are individuals whoMedical Association, a variety of health orga- help cure my heart disease?” No. Could uti- may take advantage of the fact that some ofnizations including the American College of lizing an appropriate toothpaste improve these issues are still evolving. We don’t yetObstetricians and Gynecologists, the oral health? Yes. Is oral health a component know everything that we need to, and with thatAmerican Academy of Periodontology, and of general health? Yes. We do know how comes a level of risk and a real need to enlight-various professional and research organiza- proper oral hygiene, proper lifestyles can en the public and the profession on relevanttions to address these issues collectively. influence health—and oral health; but to care—and the need for more research. make huge extrapolations? We’re very con-Specifically, the AMA and ADA had co-orga- cerned about that. Does the ADA have a specific program ornized a press event on periodontal disease. regimen approving dental care/dental proce-What prompted that? The concern is that there I’ve heard a number of researchers use the dures for specific problems? Yes. If you go tois a lot of misinformation. We were receiving expression “floss or die,” and I’ve wondered, you’ll see that we do provide guid-many requests from the public about these where it originated. That mentality does ance on a whole host of topics related torelationships and were concerned that they frighten me a bit because some things that patient/provider safety—including oral-sys-be put into proper perspective. We saw this as are said facetiously are taken to heart by temic relationships. •50 ORAL AND WHOLE BODY HEALTH
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