Systemic health and periodontitis link

1. PERIOMEDICINE-THE ORAL –
SYSTEMIC LINK
DR. SNOPHIA SURESH MDS PhD

2. Introduction
Periodontitis is one of the most prevalent diseases of the
oral cavity. Nowadays periodontitis has been recognized as
a contributing factor for many of the systemic diseases.
The maintenance of oral health has become an integral
part of general health. It is definitely the responsibility of
the dentist to reduce the inflammatory burden in the oral
cavity ….

3. Periodontal Medicine is a rapidly emerging
branch of Periodontology, focusing on the
wealth of new data, establishing a strong
relationship between Periodontal Health, or
disease and systemic health or disease.
OFFENBACHER 1996

4. Focal Infection Theory
Local infection affecting a small area of the
body can lead to subsequent infection or
symptom in other parts of the body due to
spread of the infecting agent itself or toxins
produced by it.
It probably would be better defined as a
metastatic infection..
WD MILLER 1890

5. Oral Cavity as Foci of infection was proposed
by W D Miller &William Hunter. ((1900- 1950)
They practiced preventive and therapeutic
edentulation and advocated extraction of caries
teeth, gingivitis and periodontitis to eliminate
the source of sepsis

6. Failure Of Focal Infection Theory
William Hunter’s concept of oral cavity as focus
of infection was discarded since it was not based
on sound scientific knowledge

7. Resurgence of focal infection theory was seen in
the form of Periodontal Medicine when Kimmo
Matilla et al. in 1989 examined a possible
relationship of oral infection in contributing to an
individual's risk for systemic disease

8. HOW PERIODONTAL DISEASE CAN
CAUSE SYSTEMIC DISEASE?

9. Periodontal disease
Periodontal disease is an immuno
inflammatory disease initiated by micro-
organisms and characterized by the
destruction of the supporting tissues of the
tooth

10. Periodontal Disease Model
PAGE R C 1991

11. Spread Of Periodontal Infection
Bacteria &
products
Proinflammatory
Cytokines
THODEN VAN VELZEN
et al.

12. • Gingival Micro capillaries
• Dental procedures
• Daily life activities
• Survival in the immune cells
Bacteremia
TAKEUCHI et al 2011,TOMASet al 2012, CARRION et al
2012

13. Periodontal Disease associated
With Systemic Diseases
CARDIO-VASCULAR DISEASES
ADVERSE PREGNANCY OUTCOMES
DIABETES MELLITUS
RHEUMATOID ARTHRITIS
PNEUMONIA
OBESITY
CANCER

15. Criteria for Causal Association
Epidemiological
Association
Impact of
Intervention
Biological
Plausibility
BRADFORD HILL

16. Periodontitis And Ischemic Heart
disease
Thrombogenesis Atherosclerosis

17. Blood Viscosity Increases
IHD
Fibrinogen, WBC count, Von wille
brand factor increases
Systemic or periodontal infection
Blood Viscosity
KWEIDER et al 1993

18. Oral Bacteria & Thrombogenesis
• Platelet Aggregation association protein
(PAAP)-Streptococcus sanguis,P. gingivalis
HERZBERG MC &
MEYER 1996

19. Oral Bacteria & Atherosclerosis
GIACONA et al 2004

20. AUTOIMMUNITY
SIMS et al
2002

21. Periodontal infection
Gram-negative bacteremia / LPS
Endothelial damage
Platelet adhesion/aggregation
Monocyte infiltration / proliferation
Cytokine / growth factor production
Thrombus formation
Atheroma formation
Vessel wall thickening
Thromboembolic events

22. Diabetes Mellitus
Diabetes mellitus is a complex metabolic disorder
characterized by chronic hyperglycemia.
Type 1 – defect occurs at level of beta cells
Type 2 – defect at level of insulin receptor or molecule.

23. Diabetes & Periodontal disease
Periodontitis
Impaired
PMN
leukocyte
function
Altered
subgingival
microbiota
Altered
Collagen
metabolism
Oxidative
Stress

24. Complications
LOE 1993
Retinopathy
Nephropathy
Neuropathy
Macro vascular
Disease
Altered wound
Healing
Periodontal disease

25. Periodontal Disease & Diabetes
Periodontal disease – pro-
inflammatory cytokine
Inhibtion of tyrosine
phosphorylation of insulin receptor
Increased Insulin resistance – Poor
glycaemic control
GROSSI et al 1997

26. Gram negative periodontal
infection
Increased insulin resistance
Worsened glycemic control Improved glycemic control
Improved insulin sensitivity
Periodontal treatment
Potential effects of periodontal infection and periodontal therapy on
glycemia in patients with diabetes.
SIMPSON et al 2010

27. Periodontitis on Adverse Pregnancy
Outcome
Preterm - < 37 weeks
LBW infants-<2500gms of weight
Preeclampsia

28. Periodontitis on Adverse
Pregnancy Outcome
Increase in hormonal levels initiate the process of
parturition by inducing placental cells to secrete
prostaglandins, that cause smooth muscle of the uterine
wall to contract.
As the pregnancy advances the level of PGE2 in amniotic
fluid rises steadily till the critical threshold level is
reached to induce labour.

29. Bacterial infection of
chorioamnion- Bacterial
products in amnion
Infl. response with cytokine
production in amnion
Increased amniotic PG (PGE2
& PGF2a)production-Pre
term labour
OFFENBACHER et al 1998

30. • Periodontal bacteria disseminate to the foeto-
placental unit via Hematogenous spread
• F. nucleatum , Capnocytophaga
HILL et al 1998

31. Pneumonia is an infection of the lungs caused by
bacteria, viruses or fungi.
Oropharyngeal colonization of potential
respiratory pathogens (PRPs) increases during
hospitalization.
Periodontitis And Pneumonia

32. Oral Bacteria & Pneumonia
Salivary enzymes modify
mucosal surfaces to allow
colonization by PRP
Salivary enzymes destroy
salivary pellicles on
pathogenic bacteria to
hinder their clearance from
mucosal surface
Cytokines originating from
periodontal tissues may
alter respiratory epithelium
to promote infection by
respiratory pathogen
SCANNAPIECO 1999

33. Periodontitis And Obesity
Obesity is defined as abnormal or excessive fat
accumulation that presents a risk to health
WANG et al 2011

34. Oral Bacteria and Obesity
Metabolic
Efficiency
Increases Appetite
Redirect energy
metabolism
GOODSON et al 2009

35. Periodontitis And Rheumatoid
Arthritis
Rheumatoid arthritis is an autoimmune disease
characterized by persistent synovial inflammation and
associated damage to articular cartilage and underlying
bone
SCOTT et al 2010

36. LIAO et al 2009

38. Periodontitis And Oral Cancer
Chronic or dysregulated inflammation has long been appreciated
as contributing to tumor development. Both P. gingivalis and F.
nucleatum establish chronic infections that involve intracellular
persistence within epithelial cells and have well-characterized
immune disruptive properties
RAKOFF-NAHOUM 2006

39. Oral Bacteria & Cancer
MAO et al 2007 RUBINSTEIN et al 2013

40. Other Associations
Erectile
dysfunction
Chronic
Kidney
Disease
Congnitive
impairment

41. Strong association occur between periodontitis with
cardiovascular disease, adverse pregnancy outcome,
diabetes and pneumonia
The association between periodontal disease with
Obesity, rheumatoid disease, and cancer do not imply
causality
European Federation of periodontology &
Americal academy of Periodontology

42. Conclusion
Periodontal medicine is still in its infancy and one
needs to conduct further research to know the exact
role of periodontal infections in the pathogenesis of
systemic diseases.
Considering the strength of association between the
two, it seems justified to state that good oral health is
important not only to prevent oral disease but also to
maintain good general health.