This document discusses the history and emergence of periomedicine as a subdiscipline of periodontics. It begins by defining periomedicine as dealing with non-plaque induced conditions and periodontal manifestations of systemic diseases. It then discusses the relationship between periodontal disease and various systemic conditions such as cardiovascular disease and respiratory infections. Specifically, it summarizes evidence linking periodontitis to increased risks of atherosclerosis, coronary heart disease, and acute respiratory infections. The document traces the history of theories surrounding oral-systemic links from ancient times through the focal infection era to modern research establishing periodontitis as a risk factor for certain systemic inflammatory and infectious diseases.

2. DONE BY
S.S.YASMIN PARVIN
DEPARTMENT OF PERIODONTICS
GUIDED BY
DR. J.SELVAKUMAR
PROFESSOR AND HEAD OF THE
DEPARTMENT
DEPARTMENT OF PERIODONTICS

3. WHAT IS PERIOMEDICINE:
SUBDISCIPLINE OF PERIODONTICS
THAT DEALS WITH NON PLAQUE –
INDUCED CONDITIONS / LESIONS OF
PERIODONTAL TISSUES INCLUDING
THE PERIODONTAL MANIFESTATIONS
OF SYSTEMIC DISEASES AND
SYNDROMES.

4. PERIOMEDICINE:
PERIODONTICS +GENERAL
MEDICINE
=
PERIODONTAL MEDICINE

5. OFFENBACHER 1996
Periodontal medicine as suggested by
“ a rapidly emerging branch of periodontology
focusing on wealth of new data establishing a
strong relationship between periodontal health
or disease & systemic health or disease”

6. QUESTIONS ANSWERED ??????????
1. Can bacterial infection of the periodontium
commonly known as periodontitis, have effect
remote from the oral cavity?
2. Is periodontal infection a risk factor for
systemic diseases or conditions that affect
human health?

7. PERIODONTAL MEDICINE WHEN DID
IT START ?
Mattila Association between dental health and acute
myocardial infaration BMJ 1989 Nieto FJ.
Infections and atherosclerosis: new clues from an old
hypothesis? Am J Epidemiol. 1998 Nov
15;148(10):937-48.
The Johns Hopkins University, School of Public Health, Baltimore,

8. • Periodontitis is a local inflammatory process
mediating the destruction of periodontal tissues,
triggered by bacterial insult.
• Recent evidence suggests the presence of chronic
inflammatory periodontal disease may significantly
affect systemic health conditions such as coronary
heart disease, stroke, or adverse pregnancy outcome.

9. INTRODUCTION :
• The interrelationship between oral and systemic health, has been a
matter of debate since the controversial theory of focal infection by
Dr. Miller.
• He stated that the oral pathogens had the capability to either directly
enter or release their toxic products into the systemic circulation. In
the past, a substantial part of focal infection was attributed to pulpal
and periapical pathologies.
Journal of Dental & Oro-facial Research Vol 11 Issue 1 Jan-
Jun 2015

10. • Extensive research on the complex relationship between oral and
systemic health, has given rise to the emerging field of “periodontal
medicine.”
• The concept has evolved with considerable evidence linking
periodontal status with systemic conditions including
atherosclerosis, bacterial endocarditis, diabetes mellitus, and
respiratory disease.
Journal of Dental & Oro-facial Research Vol 11 Issue 1
Jan-Jun 2015

11. PATHOGENESIS OF SYSTEMIC DISORDERS:
• The various modern pathogenic concepts for systemic disorders
include
1. auto intoxification
2. focal infection
3. psychosomatic disease, and
4. autoimmunity

12. ORAL SEPSIS PRIOR TO “GERM THEORY”
• “The Natural History of the Human Teeth,” written in 1778 by John
Hunter, Surgeon Extraordinary to the King of England, made a
controversial introductory note, acknowledging the unique nature of
diseases of the tooth, and emphasized on its impact on systemic disorders
. Oral sepsis post “Germ theory”
• Robert Koch proposed the “Germ theory” following the results of
numerous studies revealing the role of microorganisms in causing infectious
diseases
• . Miller, a student of Robert Koch studied the relationship between oral
bacteria and systemic diseases.
Journal of Dental & Oro-facial Research Vol 11 Issue 1
Jan-Jun 2015

13. IN 1944, APPLETON PROPOSED THREE PATHWAYS
FOR DENTAL INFECTION RESULTING IN SYSTEMIC
DISSEMINATION.
a. Metastasis of the infectious organism by active transport
in blood vessels or lymphatic channels
b. Passive diffusion into the lymph or blood enabling the
bacterial products to reach the most remote areas of the
body
c. The products of bacterial autolysis may in turn be a
potential allergen disseminating into the blood or lymph.

14. FOLLOWING APPLETON, MILLER PROPOSED THE
POSSIBLE ROUTES OF INFECTION FROM
PERIODONTAL POCKETS:
a. Blood and lymph
b. Direct extensions within the tissue
c. Swallowing and aspiration of infective material enabling
passage through gastrointestinal and pulmonary tracts
respectively.
Journal of Dental & Oro-facial Research Vol 11 Issue 1 Jan-
Jun 2015

15. TABLE 1: SOURCES OF INFECTION IN THE HUMAN
BODY AS DEFINED BY DR. FRANK BILLINGS.
1.Facial tonsils, the peritonsillar tissues and supratonsillar fossa
2.Abscesses of the gums and alveolar sockets, pyorrhea alveolaris, and septic types of gingivitis
(actual periodontal disease)
3.Sinuses of the head: Maxillary, ethmoidal, sphenoidal, and frontal
4.Bronchiectatic and pulmonic cavities
5.Chronic ulcers of the gastrointestinal tract
6.Chronic appendicitis
7.Cholecystitis and cholengeitis
8.Urinary tract
9.Genital tract
10.Local, septic, sub mucous, and subcutaneous foci anywhere in the body
Journal of Dental & Oro-facial Research Vol 11 Issue 1 Jan-
Jun 2015

16. HISTORY OF PERIOMEDICINE:

17. FOCAL INFECTION
King of Assyria 660- 626 BC
His physician stated:
“ Pain in his head , arms, and feet were
caused by his teeth and must be removed”

18. (669-626 BC)
In ancient Assyria a cuneiform table
gives the cure suggested by a physician for his
king “The pains in his head, arms & feet are
caused by his teeth & must be removed.”
(400 BC)
Hippocrates described a patient with
rheumatism whose arthritis was cured by
extraction of a tooth.

19. In 1813, Benjamin Rush, a famous physician
reported that several cases who was suffering from
long standing rheumatism did not respond to
medication and disappeared without recurrence
after extraction of aching tooth.

20. W.D. Miller - 1891
Miller voiced his concern about the collection
of microorganisms in the mouth & their entry
into the body from the mouth. He published a
classical article titled
‘the human mouth as a focus of infection’

21. In 1911 Frank Billings , Professor of Medicine &
head of focal infection research team at Chicago, replaced
the term Oral Sepsis with ‘Focal Infection’.
In 1915 he defined a ‘focus of infection as a
circumscribed area of tissue infected with pathogenic
organisms’.

22. 1915-1950
Focal infection was implicated as a causative factor for
miscarriage, phlebitis, anemia & toxemia in pregnancy & was
considered to be a predisposing factor for ‘Gastric cancer’.
What followed was the massacre of teeth. All teeth that
were
endodontically or periodontally involved were extracted to
avoid a possible focus of infection.

23. In 1951 Williams & Burket reviewed a
series of Papers on focal infection & found
‘that there is no good scientific evidence that
removal of infected teeth would relieve or cure
arthritis, heart disease, kidney, eye, skin or
other disorder…

24. In 1952 an editorial in the Journal of the American Medical
Association stated that focal infection theory has fallen out of
favor because many patients with diseases presumably caused by
foci of infection have not been relieved of their symptoms by
removal of the foci…. And also foci of infection are according to
statistical studies, as common in apparently healthy persons as
those with disease.

25. ….To unravel the mystery of oral
infection & systemic health….
Periodontal medicine
Over the past 15 years several studies have been published
pointing an association between Periodontal disease &
Systemic disorders such as
1. Cardiovascular diseases
2.Stroke
3. Preterm low birth weight deliveries
4. Respiratory diseases
5. Rheumatoid arthritis
6. Poor glycemic control in diabetic patients

28. CARDIOVASCULAR DISEASE
WHO 1995- 20% OF ALL DEATHS WORLDWIDE
DUE TO CVD.
DEVELOPED COUNTRIES- 50% OF ALL DEATHS
RANKS FIRST
DEVELOPING COUNTRIES- 16% OF ALL DEATHS
RANKS THIRD
INDIA—9,50,000 DEATHS FROM CVD

29. PERIODONTITIS & CARDIOVASCULAR SYSTEM:

30. PERIODONTAL DISEASE AND
CORONARY HEART DISEASE
RECENT RESEARCH HAS
ESTABLISHED THAT PERIODONTAL
INFECTION IS A PROBABLE RISK
FACTOR FOR CVS INCLUDING
ATHEROSCLEROSIS AND STROKE.

31. COROSTUNAIAND PERIODONTAL DISEASE
De Stefano Br Med J 1993
9760 cohort from NHNES
Persons with periodontal disease
had 25% increased risk of CHD
Poor oral hygiene was also
associated with increased risk
of CHD

32. Periodontal infections and cardiovascular
disease: the heart of the matter.
Demmer RT, Desvarieux M.
J Am Dent Assoc. 2006 Oct;137 Suppl:14S-20S;

33. Atherosclerosis
(Atheroma or arteriosclerosis)
Thromboembolism
Chronic Acute
Narrowing of arteries
Occlusion of coronary
arteries
Angina
Myocardial
Infarction

34. DANGERS OF ATHEROMA
• Atheroma tends to make thrombosis because the
associated surface serves to enhance platelet
aggregation and thrombus formation.
• One of the leading cause of death especially in
men is due to the complications of atherosclerosis
which leads to coronary thrombosis and
myocardial infarction

35. 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

37. PERIODONTITIS MAY FAVOUR
ATHEROMA
FORMATION
• Periodontitis once established results in a chronic
systemic vascular challenge
• Bacterial LPS and host derived inflammatory cytokines
(IL-1,PGE2 & TNFα) are capable of initiating and
promoting vasculitis and atheroma formation.

39. PERIODONTITIS AND C REACTIVE PROTEINS
C reactive protein is an independent risk factor for
cardiovascular disease because CRP triggers
complement mediated inflammation that contributes
to atheroma formation
Periodontal infections leads to elevated levels of CRP
and hence may put the patient at risk of atherosclerotic
processes

40. HEAT SHOCK PROTEIN:
• Heat shock protein are a family of proteins that are produced by cells in response to
exposure tto stressful conditions.
• Expressed in response to
1.Heat shock
2.Cold
3.Uv light
4.Tissue remodelling.
• Perform Chaperone function: stabilize new protein to ensure correct folding and refold
protein that were damaged by cell stress.
• Various heat shock proteins are:
1.Hsp 60
2.Hsp 70
Heat shock proteins in cardiovascular disease and the prognostic value of heat shock
protein related
Measurements A G Pockley, J Frostega˚rd Heart 2005;91:1124–1126. doi:
10.1136/hrt.2004.059220

41. HEAT SHOCK PROTEIN AND CARDIAC PROTECTION:
• The heat shock proteins (hsps) are expressed in normal cells
but their expression is enhanced by a number of different
stresses including heat and ischaemia.
• They play important roles in chaperoning the folding of other
proteins and in protein degradation.
• In the heart a number of studies have shown that prior
induction of the hsps by a mild stress has a protective effect
against a more severe stress. .
Heat shock proteins and cardiac protection David S. Latchman* Institute of Child Health,
University College London, 30 Guilford Street, London WC1N 1EH, UKReceived 9
February 2001; accepted 14 May 2001

42. HEAT SHOCK PROTEIN
• Moreover, over-expression of an individual hsp in cardiac cells in
culture or in the intact heart of either transgenic animals or using
virus vectors, also produces a protective effect, directly
demonstrating the ability of the hsps to produce protection.
• These findings indicate the potential importance of developing
procedures for elevating hsp expression in a safe and efficient
manner in human individuals using either pharmacological or gene
therapy procedures
Heat shock proteins and cardiac protection David S. Latchman* Institute of
Child Health, University College London, 30 Guilford Street, London WC1N
1EH, UKReceived 9 February 2001; accepted 14 May 2001

43.  An important component of cigarette
smoke – Aryl hydrocarbon
 They have the ability to inhibit bone
formation, particularly in the presence of
periodontal disease causing bacterial
cofactors thereby leading to periodontal
bone loss.
 Smoking/aryl hydrocarbons, mitigates
negative effects in 2 disparate systems:
the periodontium & vascular tissues.

44. Four specific pathways that has been proposed to
explain the plausibility of link between CVD &
periodontal disease.
a. direct bacterial effects on platelets
b. autoimmune response
c. invasion or uptake of bacteria in endothelial cells
or macrophages.
d. Endocrine –like effect on pro-inflammatory
mediators.

45. PERIODONTITIS- A POTENTIAL RISK FACTOR
FOR CARDIOVASCULAR DISEASES
Periodontitis is a chronic infection which can result in repeated
systemic exposure to Gram negative bacteria, LPS and other
bacterial products
Gram negative bacterimias occur even during simple dental
manipulations. A study of 336 patients has shown that 55%
of the patients with moderate to severe periodontitis experienced
a positive arterial blood culture immedietly after chewing.
Thus widespread prevalence of periodontitis, which increases
with age may represent a potentially significant risk factor.

46. PERIODONTAL MICROORGANISMS IN
IN ATHEROMATOUS PLAQUES
In a study of 50 human specimens of atheromatous plaques
obtained from Carotid Endarterectomy, periodontal
pathogens were found in the following proportions:
Bacteroides forsythus – 30%
Porphyromonas gingivalis – 26%
A.actinomycetemcomitans -18%
Prevotella intermedia -14%

47. STUDIES ON ASSOCIATION BETWEEN
PERIODONTITIS & CARDIOVASCULAR DISEASE
Beck and associates - 1996 (1221 individuals)
People with probing depth of greater than 3mm in all their
teeth after adjusting for all other risk factors were thrice
at risk of developing coronary heart disease.
People with 20% or more of alveolar bone loss were twice
at risk of having a fatal coronary heart disease.
With every 20% increase in mean bone loss the incidence
of coronary heart disease increases by 40%.

48. PERIODONTITIS AND MI
A study was conducted involving the Pima Indians
among whom smoking is at a very low level.
This study reported that the risk of Myocardial infarction
was 2.7 times higher in subjects who had periodontal
disease than in those who had little or no periodontal
infection.

49. PERIODONTITIS AND RESPIRATORY
TRACT INFECTION

51. RESPIRATORY TRACT INFECTION
Lower respiratory tract infection is the third most
common cause of mortality in 1990 causing 4.3 million
deaths.
Chronic obstructive pulmonary disease (COPD) was the
sixth leading cause of death causing 2.2 million deaths
More than 5% of all hospital inpatients develop
respiratory infection with 10 to 20% of this being
pneumonia

52. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Characterized by chronic obstruction to airflow with
excessive production of sputum resulting from chronic
bronchitis and emphysema
20 to 30% of all adults over 45 years of age gives a
history of asthma or bronchitis
It is interesting to note that it is rare to find lungs
completely free of emphysema post mortem

53. PERIODONTAL DISEASE AND ACUTE
RESPIRATORY INFECTION
pneumonia
Community
acquired
Hospital acquired
oropharyngeal
colonization with
PRP
Poor oral hygeine
increased risk for
nosocomial
infection

54. ORAL BACTERIA IN RESPIRATORY INFECTION
At least six studies have suggested a relationship between
poor oral health and respiratory infection
Teeth and periodontium can serve as a reservoir for
respiratory infection
Oral bacteria released from the dental plaque into the
salivary secretions are aspirated into the lower
respiratory tract to cause pneumonia

55. DENTAL PLAQUE – RESERVOIR OF
RESPIRATORY PATHOGENS
In a recent study on 57 patients admitted to MICU
during a 3 month period, as the amount of dental
plaque increased the proportion of respiratory
pathogens on the plaque also increased.
Same pathogens were recovered from tracheal secretion
aspirates
Individuals with chronic respiratory disease had greater
OHI than those without respiratory disease.

56. POOR ORAL HEATH- A RISK FACTOR FOR
RESPIRATORY DISEASE
Even after adjusting for injurious habits such as smoking,
patients with poor oral hygiene are four times at risk of
developing respiratory infection
The reason for increased risk is aspiration and also
periodontal disease associated enzymes that promote
adhesion and colonization by respiratory pathogens
leading to respiratory infection.

57. PERIODONTITIS AND MORTALITY RATE

58. ORAL HEALTH AND MORTALITY RATE
A STUDY
An epidemiological investigation was done on 1393
individuals aged 18 to 66 years
In 1970 – 71 clinical examination for caries lesions, number of
remaining teeth, dental restorations, plaque, periodontal
health were registered. A full mouth intraoral radiographic
examination was performed and bone loss was assessed
The mortality rate due to cardiovascular disease from 1970 to
1996 was recorded from death certificates

59. ORAL HEALTH AND MORTALITY RATES
RESULTS
Number of lost teeth, number of surfaces with caries,
number of teeth with apical lesions and marginal
bone loss were found to be significantly correlated to
mortality after adjustment for age and gender.
Even after excluding cases where death was caused by
cardiovascular disease there was a significant
relationship between poor oral health and an
increased mortality rate.

60. In a study done at stockholm (2001) on 1006 patients
referred by 350 dentists , presence of cardiovascular
disease, diabetes and rheumatoid disease were
significantly associated with an increased frequency of
lost teeth.
Number of remaining teeth and systemic disorders

61. PERIODONTITIS A RISK FACTOR FOR
SYSTEMIC DISEASE – OVERALL PICTURE
Disease Risk
CARDIOVASCULAR 1.2 to 2.8 times
STROKE 2.6 to7.4 times
PLBW DELIVERY 4.5 to 7.9 times
RHEUMATOID ARTHRITIS Biologic plausibility
RESPIRATORY DISEASE 4.5 times
GLYCEMIC CONTROL 10% reduction after treatment

62. CONCLUSION
 ORAL DISEASE AND IN PARTICULAR
PERIODONTAL DISEASE HAVE SIGNIFICANT
IMPACT ON GENERAL HEALTH
 SOME SYSTEMIC DISEASES CAN
SIGNIFICANTLY INCREASE SUSEPTIBILITY TO
ORAL DISEASE GROWING EVIDENCE
BETWEEN PERIODONTAL DISEASES PRE
TERM LBW, CVD, OSTEOPOROSIS
 ORAL DISEASE PREVENTION BE AN
IMPORTANT COMPONENT OF NATIONAL ,
COMMUNITY PROGRAMMES

63. • The emerging field of periodontal medicine
offers new insights into the concept of oral
cavity as one system inter connected with the
whole of body.
• The practice of periodontal medicine attempts
to inform patients about the potential effects of
periodontal health on overall health.
• Oral health is overall health!!

64. FOR WHOM???????
 GENERAL MEDICAL PRACTIONERS
 CARDIOLOGISTS
 GYNECOLOGISTS
 DIABETOLOGISTS
 FELLOW DENTISTS

65. REFRENCES:
1.Heat shock proteins in cardiovascular disease and the prognostic value
of heat shock protein related Measurements A G Pockley, J Frostega˚rd
Heart 2005;91:1124–1126. doi: 10.1136/hrt.2004.059220
2.Heat shock proteins and cardiac protection David S. Latchman* Institute
of Child Health, University College London, 30 Guilford Street, London
WC1N 1EH, UKReceived 9 February 2001; accepted 14 May 2001
3.Textbook of clinicalperiodontics, carranza
4.Journal of Dental & Oro-facial Research Vol 11 Issue 1 Jan-Jun 2015

66. J Am. Dent. Assoc.
Lawrence Meskin
“Practitioners get ready. Sharpen your
curettes; hone your periodontal skills. In a
society bent on prolonging life once the word
is out, the rush will begin”.
You will be busy next coming years and
always laughing your way to the bank !!!!