The NobleDentist Blog

This is an article that was published recently in the Edinburgh News – Edinburgh, Scotland, UK.

AS YOUR eyes meet, the anticipation of what’s to come builds. Slowly, you move towards each other and your lips finally touch.

Suddenly the moment is ruined as you recoil in horror when the full impact of their bad breath hits you like a ton of bricks. You gag, grab your coat and run.

Halitosis remains one of the last social taboos of the 21st century, with people suffering in silence rather than admit to having what is essentially a medical condition.

But bad breath (not to be confused with food breath or morning breath) affects an astonishing 96 per cent of the population at some point in their lives, due to a build-up of excess bacteria in the mouth that emits volatile sulphur compounds.

It can seriously affect not only relationships, but even job prospects, particularly if the sufferer’s role involves dealing with the public or making presentations to clients.

Now an awareness campaign has been launched to encourage people to freshen up their act. Fresh Breath Week, which started yesterday has been organised to bring the issue of halitosis, out into the open air.

There are many different types of bad bacteria in the mouth that cause halitosis, and dispelling the myth that oral malodour comes from the stomach is apparently the first step to finding a cure for sufferers.

Dr Phil Stemmer, founder of the Fresh Breath Centre, says: “Bad breath is no laughing matter – there have even been recorded cases of suicide due to halitosis.

“It has a huge impact on people’s lives. It can socially cripple a person to such an extent that they are afraid to speak to people, and it can often hamper their progress in the workplace. It affects their every waking moment. They avoid speaking to others or, when they do, they keep their hands over their mouths.

“The cause is almost always from the mouth, not the stomach as people tend to think. Excesses of bacteria give off odorous or smelly gases. It’s nothing to do with eating onions, garlic and curries. That will just give you morning breath. It’s much more serious and long-lasting than that.”

He adds: “Gums that bleed all the time are usually a sign of disease so watch out for these. The first thing to do if you think you have halitosis is to visit to your dentist or oral hygienist. Then get into a good oral hygiene routine.

“People are terribly embarrassed by halitosis. Yet it can be sorted out. We have a success rate of over 95 per cent. It gives them a huge confidence boost. We’ve helped many people whose relationships have split up. One lady wouldn’t leave the house for two years. And so many people have lost jobs over it, or have failed at interviews.”

The actual by-products of the bacteria responsible for bad breath are the oh-so pleasant-sounding cadaverine and putricine, together with indoles (the same gases that are given off by bowel bacteria).

Dr Jonathan Munns, a dentist based in Devon who runs the website freshbreathonline.com says he is aware of the problem because of patients who have been sufferers of halitosis – but he, too, has suffered from bad breath.

“As a dentist I am often in close proximity to people when talking and treating them. From a professional and socially acceptable perspective it is essential that I am quite sure that I am not offending people’s noses with smelly breath,” he says.

“I am lucky because I usually can wear a mask while working but I am even more fortunate because I believe I do know the cause and effective treatment for bad breath, and the cure doesn’t rely on sucking mints all day.

“Mouthwashes and mints don’t stop bad breath. Both products only temporarily mask over the problem. In fact, mouthwashes with any alcohol content will probably make halitosis worse by drying the mouth and increasing the presence of volatile, noxious gases.

“But there is a very effective way to treat and prevent the majority of bad breath. I would advise people to seek the opinion of a qualified dentist who can advise you about the state of your teeth and gums, together with offering you help with your own dental care.”

He says that rather than suffering the humiliation of asking someone if your breath smells, it’s safer too assume that all of us can have breath that smells offensive from time to time.

In order to prevent it, he says, we have to remove the plaque build-up on our teeth more effectively.

“Those who remove plaque less effectively tend to have halitosis together with gum disease,” he says. “When the gums become inflamed and swollen (gingivitis and periodontitis) they fill with more blood and the bacteria putrefy both food debris and blood. Any area where plaque accumulates can result in halitosis, even on plastic dentures which have not been regularly and thoroughly cleaned.

“So bad breath can largely be prevented by removing bacteria as far as possible from round the teeth and tongue on a daily basis.”

How to tell if you have a problem – and how to treat it

Try the lick-wrist test, which is far more effective than the hand-cupping technique. Stick your tongue out as far as possible, and lick the inside of your wrist using the back of your tongue. Allow the moisture to dry, and sniff.

Floss your teeth before brushing, and then smell the dental floss.

A constant bad, sour or even “metallic” taste in your mouth may be an indication that you suffer from bad breath.

To help prevent it, brush your teeth twice a day, preferably using an electric toothbrush, but always clean your tongue with a tongue-scraper as well. Brushing your tongue will just move the debris around, but a tongue-scraper will physically remove any bad bacteria lurking at the back of the tongue.

Use dental floss once a day.

Eat breakfast and at least two pieces of citrus fruit a day to stimulate salivary flow.

Drink at least two litres of water a day but steer clear of foodstuffs that cause dehydration such as coffee, alcohol and tea.

Twice a day, use a mouth rinse which physically removes the bacteria that causes bad breath, as opposed to just masking the smell. Shake it well then rinse and gargle for 30 seconds to remove clumps of debris, dead cells and bacteria. But make sure it’s alcohol-free. Alcohol in any shape or form makes bad breath worse because it dries out the mouth.

Bear in mind that another hazard for oral health is smoking. Apart from creating a risk of oral cancer, it increases gum disease by constricting blood vessels that deliver nutrients to the gums, contributes to bone breakdown and slows healing of the tissue.

This article was recently published in the Sydney Morning Herald – Sydney, New South Wales, Australia.

BULLIED at eight, raped at 11, a drunk by 13, Adam Reynolds has the classic traumatic past that leads to homelessness.

Mr Reynolds and his brother lived with their taciturn father in the tough Minto housing estate after his mother left when he was two. His father did his best. “The best dad I could have had,” he says. But it was not enough.

By 20, Mr Reynolds was in a cycle of living in and out of homeless shelters. The shelters, jointly funded by state and federal governments, provided a bed, food and a usually overwhelmed welfare worker. Some referred him to specialists, such as drug and alcohol counsellors, but Mr Reynolds was either too disorganised to go or discovered the wait for appointments was months. Now, aged 28, he is part of a new program called the Michael Project, which aims to stop the revolving door that spins the homeless from shelter to shelter.

The Federal Government has criticised the “churning” in its recent green paper on homelessness.

Funded by the largest single private donation in Mission Australia’s 149-year history, the Michael Project seeks to guarantee homeless people access to a range of services that will help them become independent. It is being officially launched today by the federal Minister for Housing, Tanya Plibersek.

The size of the donation is a secret at the request of the anonymous benefactor but it is large enough to also cover a major research component by the University of NSW and Murdoch University to track the progress of 150 clients over a year.

A barber, podiatrist, psychologist, dentist, occupational therapist, alcohol and drug counsellor, recreation officer and nurse are now accessible to the men who land at Mission Australia’s six city shelters and to the street sleepers helped by the Missionbeat vans. Some specialists have been hired and the charity has bought the services of a dentist at the Westmead oral health centre one a day a fortnight, and drives people to the appointments.

“We’re not getting people like Adam out of homelessness,” said Anne Hampshire, Mission Australia’s national manager of research. “You need to operate not just a house but a very intensive suite of services.”

Mr Reynolds is taking advantage of everything on offer. A cheerful extrovert, it is hard to imagine he tried to commit suicide when he arrived about three months ago. Now he is lined up to get his broken dental plate fixed and he is the star performer at the Milk Crate Theatre, a project for the homeless. He loved the trip to hear the Sydney Symphony rehearse, ran in the City to Surf and plays indoor soccer. His session with the podiatrist was “awesome”. Feet and teeth are particularly susceptible to problems among the homeless.

Every week he sees the psychologist about his agoraphobia: “I’ve never seen anyone in the past about my problem,” he said. At the literacy and computer skills class at the Parramatta College, Mr Reynolds is a keen participant.

He moved frequently before but now he is staying put for as long as he is allowed; even after he leaves the shelter, he will be able to have access to the special services. If the project improves his self-esteem and skills, Mr Reynolds, with his year 9 education and limited job history, will still face the huge barrier of the Sydney rental market.

“The Michael Project will not solve homelessness; a supply of affordable housing is the key,” Ms Hampshire said. “But we hope it will get people to a better place and we know extraordinary change can happen.”

This is an article that was recently published in the Courier Mail – Brisbane, Queensland, Australia.

ANGER is building in the bush as regional Queenslanders have to wait up to three and a half years for basic dental care due to lack of cash and planning.

A dental association chief says underfunding and lack of government planning has created a nightmarish situation for anyone in need of a check-up outside metropolitan areas.

Without urgent attention the shortage of dentists could continue for another decade, says Queensland president of the Australian Dental Association John Wills.

Dr Wills said a shortfall in State Government funding was the main problem.

“Most regional and rural areas are undersupplied with dentists, public and private,” he said. “There is a lack of funding and there needs to be upgraded infrastructure so that dentists will want to work in these regions, before the situation will improve.”

Queensland Health says it employs the equivalent of 256 full-time dentists, 47 fewer than funded for.

Despite recent improvements in recruitment, a long-term shortage of dentists led to a blow-out in the time patients have to wait to get dental care. Queensland Health figures show a 172-week wait for almost 12,000 regional dwellers wanting a check-up in the public system.

Statistics for more urgent cases could not be supplied by Queensland Health because of different reporting systems across the state.

Queensland Health’s oral health unit director Margaret Smith said every effort was being made to recruit more dentists to the public system.

Queensland Health offers dentists salaries from $74,088 to $146,559 depending on their experience and specialist capabilities.

Dentists working in regional or remote communities are offered additional allowances of between 7.5 per cent of their salary for places such as Rockhampton, Gympie and Proserpine, up to 30 per cent in remote Cape York, Charleville and Hughenden.

Ms Smith said Queensland Health had been working to recruit dentists for rural communities and had recently employed a second dentist to assist the public dentist in Charleville.

Dr Wills was not convinced enough had been done to entice dentists away from metropolitan or major regional centres to service communities in remote and rural areas of Queensland.

This article by Dr Flora Stay was recently published in Natural News.com – Phoenix, AZ, USA.

As women, when we think about hormonal health, we usually consider issues related to our monthly menstruation, menopause, sexual health or weight gain. In reality, hormone imbalance can affect our total well-being. For example, women’s sexuality has to do with a lot of factors including physical as well as emotional issues. We especially experience the wrath of this imbalance during pre and post menopause and during our menstruation cycle, also known to some as the dreaded PMS (Pre Menstrual Syndrome). But you probably never considered one other important physical factor affecting your sexual mood, which surprisingly is gum disease, also known as the silent disease. This connection is rarely talked about and might at first seem an odd one, but it becomes obvious when you learn the science behind how it all works.

Your Mouth Has a Lot to Say About Your Overall Health

During the different stages of our lives when hormones are fluctuating, from puberty to menopause and pregnancy, many tissues are affected, including our gum tissue. The gums can swell up, bleed easily and become slightly redder during these times of hormone related events.

Often, once the hormone balances, the gums won’t necessarily go back to their healthy state automatically. If you practice good home oral hygiene, your gums will go back to normal, if not it will get worse. With this state of chronic gum inflammation, your hormones and even worse, the immune system, can be affected causing a cascade of events, thereby eventually compromising overall health.

Important Little Signs Not to be Ignored

Slight bleeding, red gums and even some swelling, are all signs of inflammation that accompany gum disease. Most people don’t pay any attention to the signs of inflammation when it occurs in the mouth. It’s no wonder a study published in Journal of Periodontology in January of 1999, reported that at least 23 percent of women ages 30 to 54 have severe gum disease (periodontitis) and 44 percent of women ages 55 to 90 who still have their teeth have gum disease. As far as the general public, the National Institute of Dental and Craniofacial Research reported about 80 percent of U.S. adults currently have some form of the disease.

This is surprising in our day and you may wonder how could so many people have gum disease. But truth be known, many people go to the dentist only “when it hurts”. If you’re one of these individuals, you need a new perspective on oral health, especially if you’re sex life is not as exciting as it used to be or you have a hard time managing stress.

When your immune system is healthy, it becomes easier to handle stress, and your mood and hormones stay in balance. If you’re feeling run down, feel unable to handle stress with no interest in sex, make a visit to your dentist. Many people may have suffered for years with mood changes and ill health while being treated only with drugs, with the mouth never considered as part of the whole picture. The drugs alone may not help you if chronic inflammation from your gums is not treated.

There really is no excuse not to get regular dental check-ups or to practice good home oral hygiene. Find your soul-mate dentist, have your mouth checked and enjoy a fabulous love life.

This is an article that was recently published in Natural News.com – Phoenix,AZ,USA.

There is a Chinese proverb that goes like this: “A smile will gain you ten more years of life.” These words were written countless centuries ago, yet today they ring more true than ever. The links between oral health and overall health are being established on a near daily basis and the implications are astounding! Imagine if by simply brushing and flossing regularly, you were able to prevent a heart attack? We may not be there quite yet, however a definitive connection has been established between gum disease and heart disease, diabetes and pregnancy complications. And while the research moves forward, what we are learning today is that a healthy smile truly may add ten years to your life.

At the root of this research frenzy is something that scientists refer to as biofilm. If the word “biofilm” renders images of horror films or sci-fi scream fests, then you aren’t far off. In real life, biofilm is the sticky, colorless film that develops on teeth and is more commonly known as plaque. It is this complex reef-like substance that builds up over time, setting the stage for gum disease and potentially leading to life-threatening health problems.

Gum disease is also referred to as periodontal disease and encompasses the various stages of the disease, including gingivitis and periodontitis. Periodontal literally translates to “around the tooth”. Interestingly, as the disease progresses it manages to burrow itself more completely around the affected tooth or teeth.

The beginning stage of gum disease is gingivitis, which occurs when plaque buildup begins to inflame the gums causing them to redden, swell and easily bleed. Typically there is little to no discomfort during this stage. Because of this, gingivitis is generally detected during a regular dentist visit. If diagnosed and treated, gingivitis is completely reversible.

If gingivitis is not treated, it can lead to periodontitis, which occurs when plaque spreads below the gumline. The bacteria associated with plaque produces toxins, which trigger further inflammation. Over time, this heightened inflammatory response will ultimately deteriorate the bones and tissue that support the affected teeth, eventually leading to tooth loss. Once periodontitis sets in, treatment is crucial to manage the inflammation and minimize damage.

It is estimated that 80% of all American adults have some form of gum disease. Smoking, genetics, stress, medications (including oral contraceptives, anti-depressants and certain heart medications), pregnancy, clenching or grinding your teeth, poor nutrition, diabetes and other systemic diseases have all been implicated as risk factors for the disease.

The link between gum disease and systemic disease is at the center of a number of on going studies. What we currently know is that definitive links do exists between gum disease and heart disease, diabetes and pregnancy complications. Currently researchers are examining the possibilities that either inflammation, bacteria or a combination of the two are at the heart of the link between gum disease and other health problems.

In the case of heart disease, doctors have long been aware that heart patients run the risk of developing a mitral valve infection after a routine teeth cleaning. Bacteria released during the cleaning process can enter the bloodstream and travel to the heart where an infection may occur. (For this reason, heart patients are generally prescribed antibiotics prior to dental work as a safeguard.) Now researchers are finding new links between oral health and heart health. In a study recently published in The New England Journal of Medicine, scientists found that treating severe gum disease can improve the function of blood vessel walls, thereby improving heart health. Researchers are now shifting their focus to determine if treating severe gum disease will result in fewer heart attacks, strokes and other cardiovascular problems.

Diabetics run a particularly high risk of gum disease, developing the disease at a rate 3 to 4 times higher than non-diabetics. The suspected culprit is the body’s inflammatory response, which can have devastating effects on blood sugar control. Diabetics with untreated gum disease find it nearly impossible to manage their blood sugar levels and diabetes therapies often fail to work. However, with regular treatment for gum disease, blood sugar levels can generally be controlled effectively. Interestingly, the link between gum disease and diabetes doesn’t always originate with an insulin problem. A study in the Journal of Periodontology recently reported that gum disease predisposed certain people to developing early signs of diabetes. Clearly a link between oral health and blood sugar control exists.

A study published earlier this year in the Journal of Periodontology revealed that bacteria normally found in inflamed gums has been found in the placentas of pregnant women with high blood pressure. Scientists had already suspected that a link between gum disease and pregnancy complications existed. This suspicion was further confirmed in a study conducted at the University of Chapel Hill. Steven Offenbacher, DDS, PhD who headed the study announced earlier this year, “Our findings indicate that periodontal disease progression during pregnancy contributes to preterm deliveries and especially very preterm deliveries (less than 32 weeks) which places the baby at high risk for neonatal problems and disability.” While these findings may seem bleak, the good news is that pregnant women can safely receive treatment for gum disease during their pregnancy. Successful treatment could minimize infection and inflammation and reduce the risks to the unborn child.

The research continues on as scientists set forth to further understand the implications of oral health. While a greater understanding is essential to solving this puzzle, there are steps that you can take at home to take charge of your own health today. I recommend the following steps to all of my patients in order to maintain a healthy and beautiful smile:

• Make sure to brush after every meal and floss daily

• See your dentist every six months for an examination and annually for radiographs

• See your hygienist every four to six months for a thorough cleaning

• If you notice swelling, redness or bleeding in your gums, consult your dentist right away

• If you have been diagnosed with periodontal disease, follow and complete your treatment plan as described by your dentist, hygienist and periodontist.

Andy Rooney once said, “A smile is an inexpensive way to improve your looks.” I believe that it may just be an easy way to improve your health, too!

After a public holiday in Brisbane yesterday, the NobleDentist team have returned to work today.

We ask for a little patience as we address email and telephone enquiries from yesterday and today.
If you call our 1300 number and are prompted to leave a voice message then simply do so and a telephone consultant will return your call shortly. Thank you.

NobleDentist will have a smaller than usual number of staff working today due to a public holiday in Brisbane.

Membership applications submitted by 4pm will certainly be processed and posted to you today.

In the event you have an enquiry then emailing NobleDentist will still receive the quickest responses. There are however fewer than usual telephone consultants working today. If you are prompted to leave a message, simply do so as a telephone consultant will return your call shortly. Priority will be given to people requiring urgent appointments.

Everything will return to normal tomorrow – have a great day!

This is a paper by Williams, R C Barnett, A H; Claffey, N; Davis, M; Gadsby, R; Kellett, M; Lip, G Y H; Thackray, S that was published recently on the RedOrbit website.

Background: Evidence for a link between periodontal disease and several systemic diseases is growing rapidly. The infectious and inflammatory burden of chronic periodontitis is thought to have an important systemic impact. Current evidence suggests that periodontitis is associated with an increased likelihood of coronary heart disease and may influence the severity of diabetes.

Scope: This paper represents a UK and Ireland cross-specialty consensus review, undertaken by a group of physicians and dentists. The consensus group reviewed published evidence (PubMed search for review and original articles), focusing on the past 5 years, on the contributory role of periodontal disease to overall health. In particular, evidence relating to a role for periodontal disease in cardiovascular disease and in diabetes was considered.

Findings: Initial studies of large epidemlological data sets have sought to find links between periodontitis and systemic disease outcomes, but a causal relationship still needs to be demonstrated between perlodontal disease, cardiovascular disease and diabetes through prospective studies. There is a need for prospective studies assessing the association between periodontal disease and patients at particular risk of cardiovascular events which will allow assessment of both cardiovascular disease clinical endpoints and surrogate markers of cardiovascular risk. Of note, periodontal disease is also often more severe in subjects with diabetes mellitus, a group at already increased risk for cardiovascular events.

Conclusions: While further research is needed to define the population-attributable risk of periodontal disease to both cardiovascular diseases and to diabetes control and progression, health education to encourage better oral health should be considered as part of current healthy lifestyle messages designed to reduce the increasing health burden of obesity, cardiovascular disease and diabetes.

Introduction

Physicians and dentists are being drawn together by emerging evidence that suggests an association between oral disease and a number of clinically important diseases and conditions. Specifically, periodontitis, a chronic infectious and inflammatory disease of the gums and supporting tissues, has attracted much interest as a potential risk factor for cardiovascular diseases and type 2 diabetes, and also for its association with adverse pregnancy outcomes, respiratory disease, kidney disease and certain cancers1- 7. These associations between periodontal disease and certain systemic diseases highlight an urgent need for dentists and physicians to work more closely together in understanding and improving patient health.

This report summarises an overview of the current peer-reviewed literature made by an expert consensus group. The group, comprising both physicians and dentists, mainly drawn from the UK, met in London in January 2008 to review and debate the current and emerging evidence linking periodontal disease to cardiovascular disease and diabetes mellitus, and what this evidence currently reveals about the contributory role of periodontal disease to overall health. A literature search spanning the past 5 years was performed for PubMed cited articles (reviews and original articles) using key words relating to periodontal disease terms, cardiovascular disease and diabetes mellitus. Members of the consensus group were asked to review selected articles and supplement the reading list with any additional papers they felt relevant to the overview and consensus discussions. The article aims to highlight ongoing, contemporary discussion of periodontal disease to medical practitioners. The consensus represents one of the first attempts to bring together practising UK clinicians and dentists to discuss contemporary views on periodontal disease. The resulting consensus group article details concepts and ideas, for both clinical research and for daily practice, that recognise the complementary roles of the oral health and medical care teams in contributing to disease control and prevention.

The contribution of oral health to overall health

Current interest in the importance of periodontal disease to general health was rekindled in the late 1980s following reports of an association between dental health and acute myocardial infarction (MI)8. In a case-control study, subjects with acute MI had significantly more dental problems, such as periodontal disease, than subjects without MI, even after adjustment for age, social class, smoking, serum lipid concentrations and presence of diabetes8. Since then, research in the past two decades has sought to determine and define relationships between periodontal disease and the aetiology of other diseases with inflammatory or infectious components.

Defining periodontal disease

Periodontal disease is a general term used to describe diseases that affect the gingiva and cause damage to the supporting connective tissue and bone which anchor the teeth to the jaws9. Periodontal disease is caused by specific bacteria from the biofilm within the periodontal pocket (Figure 1). As anaerobic infection takes hold, a complex cascade of tissue-destructive pathways is set in motion, triggered by bacterial products and fuelled by inflammatory mediators. The surface area of the mouth affected by periodontal disease can be large, equivalent to the surface area of one to two hand-spans (~300cm^{sup 2})10. From the periodontal pocket, there are at least two potential pathways by which the apparently localised infection and inflammation can have an effect on systemic health. One is by passage of periodontal pathogens, and their products, through ulcerated epithelium into the circulation, leading to bacteraemia and/or provocation of systemic immune and inflammatory responses. The second is the passage of locally produced inflammatory mediators from the periodontal pocket into the systemic circulation11 (Figure 2). These biological mediators and pathological mechanisms through which periodontitis may contribute to systemic inflammatory diseases are currently the subject of intensive study, but will not be discussed further in this report, which focuses more on the clinical associations between oral infection and cardiovascular diseases as well as diabetes. Importantly, the publications reviewed and the research concepts defined within this article focus on periodontal disease characterised by periodontitis rather than gingivitis.

This overview considers four broad questions in reviewing the available published literature in the field:

• Is there evidence to suggest that subjects with periodontal disease have an increased risk of cardiovascular disease and events?

• Is there evidence that suggests treatment of periodontal disease can reduce the risk of secondary or primary cardiovascular diseases and events?

Figure 1. Penodontitis: in some subjects, for reasons that remain unknown, the chronic inflammation of established gingivitis spreads to provoke periodontal ligament and alveolar bone destruction. (Reproduced from Gaffar and Volpe12, with permission)

Figure 2. Theoretical pathways by which the gingival inflammatory response may impact systemic inflammation and systemic processes such as atherosclerosis. (Reproduced from Gaffar and Volpe12 (p. 22), with permission)

• Is there evidence to suggest that the relationship between diabetes mellitus and periodontal disease is two-way?

Is there evidence that treatment of periodontal disease may improve outcomes in diabetes mellitus?

These questions were posed to form the framework for consensus, commentary and research-generating hypotheses on the role of periodontal disease in both cardiovascular diseases and in diabetes.

Periodontal disease and cardiovascular disease – evidence for an association

The literature suggests that burden of pathogens, antigens, endotoxins and inflammatory cytokines of periodontitis might contribute to atherogenesis and thrombosis11-15. Common periodontal pathogens such as Porphyromonas gingivalis and Streptococcus sanguis have been found in arterial plaques from carotid endarterectomy samples and, furthermore, periodontal disease has been associated with elevated levels of inflammatory markers such as C-reactive protein1,14,16,17. There is growing evidence to support a role for C- reactive protein as a predictive, pathogenic factor for vascular risk and interest in therapies and interventions that may modify C- reactive protein. However, it is recognised that more research is needed as to the true clinical relevance of C-reactive protein at this time18. The literature also contains reference to studies indicating that periodontal pathogens themselves may cause platelet aggregation and thromboembolic events1.

Periodontal disease is thought to cause changes in both traditional and novel cardiovascular risk factors16,17,19-22. For example, severe periodontitis has been associated with adverse changes in blood pressure and in serum cholesterol levels16. A number of studies have also suggested an association between periodontal disease and carotid intimamedia thickening, the latter being a surrogate index of atherosclerosis19,20.

Our review of the current evidence base derived from large epidemiological datasets designed for other reasons and from small- scale longitudinal studies and periodontal intervention studies suggests an association between periodontal disease and an increased risk of cardiovascular disease. For example, in a meta-analysis of studies relating to the prevalence and incidence of coronary heart disease (CHD), it was found that the risk of developing CHD was significantly higher in subjects with periodontal disease compared with controls1 (Figure 3). In this systematic review of the literature, five prospective cohort studies that involved a total of 86092 patients, followed up for at least 6 years, found that subjects with periodontal disease had a 1.14-fold (95% CI 1.074- 1.213, p<0.001) greater risk of developing CHD than controls1. According to this recently published meta-analysis, both the incidence and prevalence of CHD were increased in subjects with periodontal disease after adjustment for variables known to increase risk for CHD. The authors of the meta-analysis considered that three of the five prospective studies were of good quality and they noted that cardiovascular assessments in these studies included the accepted measures of coronary artery disease and clinically defined CHD. This same review identified five case-control studies (1423 patients) and five cross-sectional studies (17724 patients) that were eligible for meta-analysis and these again supported a significant relationship between periodontal disease and CHD1. Figure 3. The relative risk of coronary heart duease in penodontitis – a meta-anatysis of data from prospective studies (adapted from Bahekar et al. 2007(1))

Nonetheless, our consensus is that there remains a lack of prospective studies at this time. Well-designed, prospective studies are needed to validate the assumption that risk of developing CHD is increased in subjects with periodontal disease.

Need for prospective studies

In planning prospective studies, it will be important to bear in mind the difficulties in isolating risk factors for cardiovascular disease within observational and epidemiological study designs. Strong confounding factors associated with cardiovascular diseases include age, gender, smoking, family history and diabetes mellitus. In epidemiological and observational studies, controlling for such confounding factors requires large numbers of subjects to be enrolled, and the subjects need to be followed over a long period of time. To date, the mining of large-scale cardiovascular disease epidemiological datasets – such as the National Health And Nutrition Examination Surveys I23 and III24 (NHANES I and III), the Framingham Heart Study25 (www.framinghamheartstudy.org) and the VA Normative Aging cohort26 – has not been fully utilised in the search for associations between periodontal disease and cardiovascular disease, possibly because of multiple confounders. One large-scale, ongoing observational study – the Atherosclerosis Risk in Communities (ARIC) study has reported studies involving periodontal disease13,17. While such sub-studies of observational datasets have methodological problems, the ARIC data do suggest that the host response to oral bacteria appears to be relevant to systemic atherothrombotic coronary events13. In this study, periodontal status and serum IgG antibody levels against 17 periodontal organisms were compared against prevalent CHD. Although clinical signs of periodontal disease were not associated with CHD, the systemic antibody response and the quality and quantity of host responses to periodontal infection did appear to relate to systemic atherothrombotic events13. Systemic exposure to more than one oral organism was related to an increased risk for CHD, particularly in subjects who had never smoked. For example, high antibody levels to Prevotella nigrescens and to Actinobacillus actinomycetemcomitans were each linked with an odds ratio of 1.7 (95% CI 1.1-2.6 and 1.2-2.7, respectively) and antibodies to Capnocytophaga ochracea to an odds ratio of 2.0 (95% CI 1.3-3.0) in non-smokers.

Another substudy of ARIC has reported that extensive periodontal disease and body mass index were jointly associated with increased C- reactive protein levels in otherwise healthy middle-aged adults17. While it is uncertain whether C-reactive protein contributes to atherosclerosis or is a marker of atherosclerosis and vascular damage, this marker is increasingly studied as a potential surrogate indicating potential elevated risk for cardiovascular diseases.

Associations and causality

Our consensus is that prospective studies are needed to clarify whether periodontal disease and cardiovascular diseases simply share risk factors in common or whether there is a true causal relationship. Further research is required to both establish causality and to determine the population-attributable risk of periodontal disease to cardiovascular disease. It will be important to account for potential confounding factors and shared risk factors in patient populations, most notably obesity and smoking. There is also a need for intervention studies that address both primary prevention and secondary prevention of clinical disease. We also note that in cardiovascular medicine, ‘hard’ clinical endpoints, such as death, fatal and non-fatal myocardial infarction and other coronary or cerebrovascular events are usually required to support a causal relationship. Reductions in risk factors such as hypertension and dyslipidaemia are viewed as acceptable surrogate study endpoints but these must then be shown to equate with a subsequent reduction in clinical event endpoints. Our view and the prevailing view in contemporary literature is that research into the pathophysiological drivers of cardiovascular risk associated with periodontal disease – such as C-reactive protein and other inflammatory or thrombotic markers – should be conducted in parallel with clinical-endpoint studies, to provide additional plausibility to clinical associations18.

Periodontal disease – a potentially modifiable cardiovascular disease risk factor?

Our review of the available literature suggests the need for further interventional studies into the effect of periodontal disease treatment on cardiovascular risk and outcomes27-28. Both primary prevention and secondary prevention studies are needed. Many of the published intervention studies to date have suggested that successful treatment of periodontal disease may alter or modify inflammatory markers. For example, one study in 94 otherwise healthy subjects with generalised periodontitis assessed levels of C- reactive protein and interleukin-6 (IL-6) before and after periodontal therapy and showed significant reductions in C-reactive protein and serum IL-6 following treatment27. In another intervention study in 120 patients with severe periodontitis, intensive periodontal treatment resulted, 6 months after therapy, in improvement in endothelial function, as measured by reductions in soluble E-selectin and greater flow-mediated dilatation, at 6 months33.

Although a review of available literature and evidence suggests there may be an effect of periodontal treatment on surrogate markers, this consensus group considers that, like the PAVE study (Periodontitis and Vascular Events), any treatment studies must determine the effects of periodontal intervention on established clinical endpoints. Acceptable clinical endpoints in cardiovascular studies include major adverse cardiovascular and cerebrovascular events, often assessed within a combined endpoint. Nonetheless, there is merit in intervention studies that demonstrate reductions in surrogates and known risk factors for clinical events, such as blood pressure, LDL cholesterol and alterations in endothelial function.

To date, plans for large-scale studies of periodontal intervention, with sufficient power to detect a treatment effect on cardiovascular endpoints, remain at the pilot stage. Very recently, first data from the pilot PAVE study – a randomised secondary prevention trial comparing periodontal therapy to community dental care and their impact on cardiovascular disease risk – have been published34. This study, in patients with established coronary heart disease, hopes to assess the effect of periodontal intervention and treatment on outcomes such as hospitalisation for myocardial infarction (MI), cardiac revascularisation, fatal coronary heart disease, unstable angina, and hospitalisation for ischaemic stroke.

Interventions for periodontal disease

Between 8 and 10% of the population are prone to very severe periodontal disease35. Although the consequences of periodontal infection may extend to including an increased risk for systemic disease, the oral condition itself is very treatable. Indeed, mechanical debridement of the subgingival biofilm can lead to improvement in periodontal status. In addition to treatment of established disease, prevention of periodontal disease is possible with good oral hygiene and good dental care.

If causality between periodontal disease and cardiovascular disease is confirmed, periodontal disease could be viewed as a potentially modifiable cardiovascular risk factor. Interventions to prevent periodontal disease, beginning in childhood, could be studied for long-term effects on health and disease. Although there are currently no appropriately powered intervention studies to link successful treatment of periodontal disease with a reduction in cardiovascular events, there is still a rationale for promoting the public health message that good oral health could contribute to good general health. Indeed, our consensus view is that physicians should be encouraged to consider poor oral health as a possible marker of an unhealthy lifestyle or poor levels of disease control. Furthermore, referral to a dental professional should be considered for patients who have poor oral health. Health education to encourage better oral health care needs to be seen as a natural extension of current healthy lifestyle messages, such as diet and exercise that are encouraged and promoted in a bid to reduce obesity, cardiovascular disease and diabetes. Identifying at-risk patient groups in which to study the impact of periodontal disease

Our consensus view is that it should be possible to identify select patient groups, who have had previous cardiovascular events and in whom periodontal disease is likely to represent an additional risk factor. These high-risk patient groups offer an opportunity for prospective study of the effect of periodontal disease on risk and the impact of periodontal intervention on events and pathophysiological mechanisms.

Inflammatory factors may be important in affecting plaque rupture in patients with coronary artery disease. This being so, a study of periodontal disease and its inflammatory load in these patients could be enlightening. Patients with unstable plaques could represent a cohort in which to study the influence of periodontal disease and the impact of periodontal treatment on cardiovascular clinical events. Diabetic patients represent another high-risk subgroup in which to study periodontal disease and its role in increasing cardiovascular risk.

As discussed earlier, intervention and secondary prevention studies in such patient groups need to be run prospectively, with patients randomised to receive standard treatment for periodontal disease versus community care/usual standard of oral care. Such studies should assess the impact of intervention on cardiovascular treatment goals and targets. These include currently accepted targets for blood pressure, plasma lipid levels and HbAj0 in patients with diabetes (see later also). These short-term but clinically acceptable surrogate endpoints may allow an assessment of the impact of periodontal intervention on established cardiovascular risk factors. In addition, there is the need to show the impact of intervention, longer-term, on clinical events such as coronary and cerebrovascular events, both fatal and non-fatal. This group considers that the ability to demonstrate that clinical interventions can impact on hard clinical endpoints is essential to effect real changes in clinical practice and influence preventive medicine practices. As part of such prospective research and study, the impact of periodontal intervention on surrogate markers could also be undertaken.

The possible two-way relationship in diabetes

Closer attention to oral health in patients with diabetes is a goal for both dentists and physicians. Undiagnosed diabetes may be suggested by poor oral health unresponsive to ‘usual1 cleaning measures. Physicians managing patients with type 2 diabetes need to encourage attention to good oral health as part of overall lifestyle management and to reduce the risk of periodontal disease.

The available literature highlights the importance of oral health in subjects with diabetes3’36”41.

Our review identified small-scale studies in patients with type 2 diabetes which suggest that improved oral hygiene can reduce dental plaque scores and may assist in diabetes control as assessed by overall decreases in fasting blood glucose levels36. When diabetes (both type 1 and type 2) is poorly controlled or there are diabetic complications, patients are more likely to have periodontal disease37. Indeed, one meta-analysis of 18 comparative, cross- sectional studies found that subjects with diabetes have significantly more severe periodontal disease as compared with healthy subjects3.

Nonetheless, our consensus view is that the current evidence- base does not really support a causal relationship between periodontal disease and risk for type 2 diabetes, although there may be a significant two-way association between the two diseases. As discussed earlier, diabetic subjects represent a patient group known to be at heightened risk for cardiovascular disease. It therefore follows that periodontal disease may aggravate existing cardiovascular risk factors in patients with diabetes. In addition, the link between chronic infection and adverse effects on patient health is an established association in diabetes42. Of note, severe periodontitis has been associated with systemic inflammation and a dysmetabolic status in otherwise healthy individuals43.

Once again, we identify that well-designed and conducted studies are therefore needed to further examine the effect of periodontal treatment on glycaemic control and clinical outcomes in patients with diabetes. Initial interventional studies have shown a reduction in HbA^{sub 1c} levels in patients with diabetes following periodontal disease treatment. However, the power of these early studies does not permit direct associations to be made4’5’39’44’45. In a study involving 44 patients with type 2 diabetes, an association could be made between periodontal treatment and improved glycaemic control44, and one study of an 11-year follow-up of over 600 patients with type 2 diabetes suggests a link between periodontal disease and cardiovascular mortality or diabetic nephropathy4 consistent with other observational studies . The small patient numbers and confounding factors in such studies make definitive connections difficult, but not impossible, to draw.

Figure 4. The effects of periodontal treatment on HbA^{sub 1c} – data from ten intervention studies and from combined study data (adapted from Janket et al. 2005(46)

In a meta-analysis of ten intervention studies that included 456 patients, it was noted that periodontal treatment resulted in a 0.66% reduction in absolute HbA^{sub 1c} levels among patients with type 2 diabetes46 (Figure 4). Such a reduction would be of clinical relevance and our group consider that an update to this meta- analysis, to include more recent studies, would strengthen the evidence base. In diabetes research it is sometimes acceptable to evaluate the effects of an intervention on HbA^{sub 1c} levels as a marker of glycaemic control and regulatory bodies may accept 0.6% reductions in HbA^{sub 1c} as clinically significant when reviewing drug-efficacy appraisals (www.fda.gov). An advantage of studying changes in HbA^{sub 1c} levels in prospective clinical studies is that changes in this endpoint should be evident within a year of any successful intervention. Thereafter, patient follow-up to around 5 years would provide data on the impact of treatment on clinical events. It is our consensus view that both micro- and macrovascular endpoints could be assessed during prospective studies in diabetic subjects. As in cardiovascular research, confirmation of the benefits of HbA^{sub 1c} reduction, in terms of an impact on clinical events, can be considered a worthy goal.

The potential importance of periodontal disease in diabetes is highlighted by emerging evidence to suggest that periodontitis predicts the development of overt nephropathy and end-stage renal disease in patients with type 2 diabetes5. In a study involving over 500 patients with type 2 diabetes, 38% of whom had moderate periodontitis and 22% of whom had severe periodontitis, over a 22- year follow-up period, subjects with periodontitis had between 2.3 and 3.5 times increased risk for end-stage renal disease5. Although the effects of oral treatment on this endpoint have not yet been studied, we consider that the findings of studies showing associations between periodontitis and macrovascular disease, provide a rationale for further investigation of the connections between oral health and diabetic progression.

Our consensus view is that, once again, clinical research in specific at-risk groups may hold the key to unlocking associations between periodontitis and diabetes-associated events. For example, studies in Asian and other ethnic subgroups with high-risk profiles might provide more immediate answers to research questions relating to periodontal disease than studies within the more heterogeneous diabetic population.

The growing interest and potential clinical importance of good oral hygiene in patients with diabetes has been demonstrated in the US, where health-insurance providers are actively encouraging dental check-ups and regular cleanings in an effort to reduce the overall costs of health events associated with diabetes care.

Conclusions

Our consensus group of physicians and dentists consider that good oral health is an integral component of good general health. Evidence for a link between periodontal disease and several systemic diseases is growing and periodontitis is associated with an increased risk for CHD and diabetes. However, a causal relationship needs to be demonstrated in prospective studies, including controlled intervention studies. Periodontal disease is often more severe in subjects with diabetes, a group already at increased risk for cardiovascular events. Research into the inflammatory pathophysiology of periodontitis, cardiovascular disease and diabetes is already identifying potential links between these conditions. Crossdiscipline communication and research endeavours between dentists and physicians are important to improve understanding of the risks associated with periodontitis and the contributory role of oral health and disease to patient health and disease control. The promotion of good oral health, as part of better overall health care, can be seen as a natural extension of current healthy lifestyle messages around diet, exercise and the cessation of smoking, which are designed to help reduce the burden of cardiovascular disease and diabetes.

This is an article by Tory Sheperd that was recently published in Melbourne Herald Sun – Australia.

POORER Australians have fewer teeth, research shows.

They also have more decay, and are more likely to have no teeth at all.

The National Survey of Adult Oral Health 2004-06 shows people from poorer suburbs are twice as likely to have fewer than 21 teeth – which is considered the minimum necessary – than those from richer suburbs.

People on concession cards are almost four times as likely to not have enough teeth.

The Australian Institute of Health and Welfare report has prompted calls for more funding, as dentists blame long public waiting lists for the gap.

South Australian Dental Service chief executive Martin Dooland said people forced to rely on the public system had to wait too long to be seen.

“The result is that concession card holders rely on episodic relief of pain instead of having checks,” Dr Dooland said.

He said a national workforce shortage was contributing to the problem, but added SA was ahead of the rest of the nation in increasing training capacity and reducing waiting lists.

Rose Park dentist and Australian Dental Association (SA) president Peter Alldritt has called on governments to fund a solution.

“This is a call for more funding to shorten waiting lists for public dental care and employ more dentists, who are the only practitioners trained to provide the complex treatment that adults need,” Dr Alldritt said.

Acting Health Minister Jay Weatherill said the state had invested an extra $56 million for public dental services.

“(The) extra money has had a major impact, reducing waiting lists from 49 months for treatment in 2002 to 19 months now. And we aim to reduce that to 11 months next year,” he said.

This is an article that was recently published in MarketWatch – USA.

Twin Study Published in the Journal of Periodontology Demonstrates that Flossing Can Decrease the Occurrence of Gum Disease-causing Bacteria.

In dental offices all over the world, patients are often told they are not flossing enough or instructed to floss more. As the old saying goes, you only need to floss the teeth you want to keep. After all, not flossing regularly can lead to tooth decay and to periodontal disease, the leading cause of tooth loss in adults.
A recent study published in the Journal of Periodontology (JOP), the official publication of the American Academy of Periodontology (AAP) demonstrates that including flossing as part of one’s routine oral care can actually help reduce the amount of gum disease-causing bacteria found in the mouth, therefore contributing to healthy teeth and gums.

The study, conducted at New York University, examined 51 sets of twins between the ages of 12 and 21. Each set was randomly assigned a 2-week treatment regiment with one twin brushing with a manual toothbrush and toothpaste and the other twin brushing with a manual toothbrush and toothpaste and flossing. At the end of the two week trial, samples were taken from both pairs of twins and compared for levels of bacteria commonly associated with periodontal disease.

The study findings indicated that those twins who did not floss had significantly more of the bacteria associated with periodontal disease when compared to the matching twin who flossed in addition to tooth-brushing with toothpaste.

“This study illustrates the impact flossing can have on oral health. The twins experimental model is a powerful tool to help sort out genetic and environmental factors that often confound the interpretation of treatment studies. This study demonstrates that flossing can have an important and favorable impact on an individual, as compared to that of a non-flossing individual with similar genetics and possibly similar habits,” explains Dr. Kenneth Kornman, editor or the Journal of Periodontology. “Twins tend to share the same or similar environmental factors such as dietary habits, health and life practices, as well as genetics. In this case, the only difference was flossing, and the outcome was significant. Flossing may significantly reduce the amount of bad bacteria in the mouth.”

The study results support that old saying, and show that including flossing as an integral part of your regular oral care can help reduce the amount of periodontal disease-causing bacteria in the mouth; therefore helping you keep your teeth. Periodontal disease is an infection caused by a build-up of bacterial plaque, a sticky, colorless film that constantly forms on your teeth. Flossing, or using interdental cleaners, helps clean the bacterial plaque from between your teeth that regular brushing can’t reach.

“As a practicing periodontist, I am constantly telling my patients to clean between their teeth more using dental floss or interdental cleaners,” says Dr. Susan Karabin, President of the AAP. “Patients tend to think that flossing can’t possibly make that much of a difference. But this study demonstrates that the addition of flossing to your dental hygiene routine can significantly reduce the amount of periodontal disease causing bacteria.