One of the most health-challenging biofilms is found in the human mouth. In fact, the bacterial density of this biofilm community typically exceeds that found in the gastrointestinal tract, thus adding to the complexity of our understanding of nature’s balance between health and disease. In fact, the paradigm "a healthy mouth contributes to a healthy body" reaches beyond colorful, whitening toothpastes, fluoride-containing mouth rinses, and oversize veneers.
On a daily basis in the primary care setting, we see shockingly poor dental hygiene, especially in the older adult population where odontogenic infection may lead to anything from endocarditis to central nervous system abscess. Breakdown of buccal and gingival mucosa may be a dramatic proxy for protein-calorie malnutrition, vitamin deficiency, and simple neglect. HIV disease is another obviously significant public health challenge that may be reflected in oral health.
The post-fluoridation generation has fewer dental caries and less periodontal disease. However, other aspects of dental health, especially periodontitis, and chronic or systemic diseases which may be associated with oral health are on the rise. Approximately 30,000 cases of oral and pharyngeal cancers are diagnosed annually in the United States, and nearly 8,000 die of these diseases every year. These numbers are small compared to the health statistics associated with cardiovascular disease, which affects almost 40% of the Baby Boomer population in the U.S., and accounts for more than 29% of all deaths worldwide.
There is a growing body of evidence from in-vitro and animal studies that suggests a relationship between inflammatory processes mediated by several interleukins (IL-1, INFg, IL-6, IL-8) and the promotion of oral illness and systemic disease, including cardiovascular disease (Demmer and Desvarieux, 2006; Schillinger et al., 2006). The Schilliger et al. study suggests that periodontal infection is a potential risk factor for CVD and a significant predictor for progressive disease, regardless of one’s presentation of traditional CVD risk factors.
Upon examination of the data from an array of descriptive, cross-sectional, case-control, and longitudinal studies using the Bradford-Hill criteria, it appears that periodontal disease may indeed contribute to the pathogenesis of CVD (Meurman et al., 2004). These kinds of studies are supported, in theory, by fundamental understanding and molecular mechanisms of atherosclerotic pathophysiology. This understanding is provoked by observations that Chlamydia pneumoniae and cytomegalovirus infections can initiate a cascade of pathological responses which may trigger intravascular coagulation and infective endocarditis, thus increasing the risk of atherosclerosis.
Based on some primate models for periodontitis and its systemic sequelae, certain plaque-forming bacterial pathogens may present antigens, endotoxins, and inflammatory cytokines, which may contribute to progressive atherogenic and thrombogenic events. For example, the periodontopathogen Porphyromonas gingivalis, which possesses fimbriae, can induce platelet aggregation, induce metabolic dysregulation of lipid metabolism, stimulate production of inflammatory mediators, mediate LDL oxidation, promote foam cell formation, and accelerate atherosclerotic lesion formation and rupture.
The epidemiological and clinical evidence that suggests or demonstrates a relationship between nutrition and specific diseases and systemic disorders cannot be denied. The oral cavity is more than a gateway to the gastrointestinal tract. It frequently presents symptoms of nutrient deficiencies and nutritional disorders. The oral cavity may offer those of us in medicine and in the food industry a novel and valuable means of advancing our understanding and management of an entire spectrum of pathology. The health link between dental medicine and chronic disease, such as CVD and related vascular conditions, certainly deserves greater attention. We welcome reaction and suggestions from our colleagues in dentistry and oral & maxillofacial surgery.
by Roger Clemens,
Dr.P.H., Contributing Editor
Special Projects Advisor, ETHorn, La Mirada, Calif.
by Peter Pressman,
M.D., Contributing Editor
Attending Staff, Internal
Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif.
Demmer, R.T. and Desvarieux, M. 2006. Periodontal infections and cardiovascular disease. J. Am. Dent. Assn. 137: 14S-20S.
Meurman, J.H., Sanz, M., and Janket, S-J. 2004. Oral health, atherosclerosis, and cardiovascular disease. Crit. Rev. Oral Biol. Med. 15: 403-413.
Schillinger, T., Kluger, W., Exner, M., Mlekusch, W., Saveti, S., Amighi, J., Wagner, O., Minar, E., and Schillinger, M. 2006. Dental and periodontal status and risk for progression of carotid atherosclerosis. Stroke 37: 2271-2276.