Cardiovascular disease is the global leader when it comes to the causes of disability and death. Inflammation is universally understood to play a primary role in the development of atherosclerosis (atherosclerotic cardiovascular disease, or ASVD). Likewise, a mountain of evidence demonstrates that periodontitis is a potential risk element for atherosclerosis and cardiovascular disease.
The mechanism of this relationship is twofold: the chronic inflammatory aspect of periodontal disease, which is distributed throughout the body by bacteremia, and the periodontal pathogens themselves. The bacteria enter the bloodstream as well as the atherosclerotic lesions, which leads to further inflammation and atherosclerotic progression.1 It makes sense then that resolution of periodontitis and a return to pristine oral health should reduce the incidence of cardiovascular disease. However, studies demonstrating this effect are lacking.
So, assuming a dentist or hygienist understands and accepts the research findings about the relationship between periodontal disease pathogens and heart disease, yet there is insufficient information on the potential for beneficial cardiovascular effects of perio treatment, how should he or she proceed? And how do we dialogue with our patients?
It is apparent that clinicians will proceed with different levels of care based on their clinical judgment and preferences. But it is important that everyone in the dental office is on the same page. It would not be favorable for the practice if different levels of care were provided under the same roof. If family members, friends, or coworkers start comparing experiences and perceive varying levels of care, it could be very problematic for the office.
Keeping in mind the two mechanisms noted above, protocols can be developed that provide for maximal plaque and calculus removal by the clinician and effective daily plaque removal by the patient. A protocol addressing both mechanisms would need to be in place.
Hygiene services and home-care instruction sound like business as usual in the dental office, don't they? But what should be done about discussing with patients the implications of bacterial reduction and the control of inflammation beyond the oral cavity? As dental professionals, this is perhaps where we can make the most impact. Many patients have some understanding of the connection between the mouth and the body, but they lack the specifics.
It is critical to be careful with the information we convey to patients. We cannot say that periodontal treatment will ensure the patient does not have a heart attack or an adverse pregnancy outcome or remove the need for diabetes medications or insulin. What we can say is, “Research indicates a relationship between gum disease and heart disease.” We cannot make promises of a desired outcome, resolution of a disease, or cure of a disease or condition in the body following periodontal therapy.
Helping patients understand that our primary concern is the health of their heart and coronary arteries—despite the fact that we operate between the chin and the nose—may make an impact on them, motivating them to do what is necessary to achieve optimal oral health. As individual practitioners, we get to decide what we will do for our patients. Just something to think about.
Reference
1. Gheorghita D, Eördegh G, Nagy F, Antal M. Periodontal disease, a risk factor for atherosclerotic cardiovascular disease. Orv Hetil. 2019;160(11):419-425. doi:10.1556/650.2019.31301.
Editor's note: Would you like to learn more about the latest in oral-systemic research? Write to Dr. Richard Nagelberg about topics you’ve read about in this blog or to submit items you’d like to see covered here.
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