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How depression threatens oral health, and other oral-systemic links

March 3, 2016
Depression is one of the most common mental health conditions in the United States. It has been linked to poor oral health care. Read more below. 
Depression is one of the most common mental health conditions in the United States. It has been linked to poor oral health care. Read more below. Severe periodontal disease increases the risk of some systemic diseases. This article will outline chronic kidney disease, coronary artery disease, stroke, and depression and their proposed links to severe periodontal disease.

Severe periodontal disease increases the risk of death in chronic kidney disease patients, a new study suggests. The authors found the 10-year death rate among chronic kidney disease patients was 41% for those with severe periodontal disease, compared with 32% for those without severe periodontal disease. (1)

According to a 2012 Scientific Statement from the American Heart Association, “A link between oral health and cardiovascular disease has been proposed for more than a century.” (2) The latest research to delve into this association comes from Karolinska University Hospital in Sweden and is known as PAROKRANK (Periodontitis and Its Relation to Coronary Artery Disease). (3) The PAROKRANK study found a 28% increased risk of first myocardial infarction (MI) in patients with periodontitis after controlling for variables such as diabetes and smoking. (3) As this was an observational study design, a direct cause and effect cannot be established, but only an association between the two conditions. The study was multicentered, case-controlled, and enrolled 805 patients. In an editorial published regarding the study, it was stated that the study “adds to the strong evidence for an association between periodontitis and myocardial infarction, but does not prove causation.” (4)

READ MORE | Mental well-being is everyone's business

In a study of patients entering the hospital for acute stroke, researchers have discovered an association between certain types of stroke and the presence of Streptococcus mutans. (5) They investigated the roles of cnm-positive S. mutans in this single hospital-based, observational study that enrolled 100 acute stroke subjects. The cnm gene in S. mutans isolated from saliva. The results showed that the presence of cnm-positive S. mutans was significantly associated with intracerebral hemorrhage and increased number of deep cerebral microbleeds. (5) Cerebral microbleeds may cause dementia, and were diagnosed with MRIs. Strokes can be either ischemic strokes, which involve a blockage of one or more blood vessels supplying the brain, or hemorrhagic strokes, in which blood vessels in the brain rupture, causing bleeding.

And lastly, there have been assertions of links between oral health and depression, and depression and cardiovascular disease. Depression is one of the most prevalent mental health issues in the United States of America. In a 2010 study, the it was shown that there were significant relationships between depression and oral health, oral health behavior, and oral health-related quality of life. (6) As depression affects a person’s ability to cope with daily life, it comes as no surprise that depression might be related to health and oral health-related self-care behavior and thus potentially affect patients’ oral health. In addition to a lack of motivation for self care, depression and oral health might be related through salivary changes in depressed patients. (6) Decreased salivary flow can lead to several oral health problems, such as an increase in pathogenic bacteria and dental decay. (7)

READ MORE | Oral bacterium possibly associated with systemic disease found in Alabama schoolchildren

An older paper corroborates this information. (8) According to the paper, physiological consequences of depression may lead to poor oral health due to xerostomia, cariogenic diet, and impaired immune functioning contributing to oral infection. (8) Antidepressant medications have been shown to cause hyposalivation, which may lead to decay or other dental problems. Case reports also describe possible occurrences of antidepressant-induced bruxism. (8) As well, patients with cardiovascular disease are three times more likely to develop depression, which makes mental health monitoring critical. (9) A study reported last month in the Journal of the American College of Cardiology is one of the latest to confirm the association between heart disease and depression. (9)

The gut microbe Bacteroides fragilis. Photo courtesy CDC.

It is easy to see that the mouth is connected to the rest of the body, and vice versa. Taking a thorough medical history and performing intra- and extra-oral examinations can assist us in delivering the best care to our patients.

Other oral-systemic and oral health news
Also regarding bacteria, there is new science of how intestinal bacteria may control bone strength. (10) This enormous ecosystem of tiny organisms, mostly bacteria, is referred to as the gut microbiome. Many things affect the quality of the microbiome, and even small imbalances in the composition of our microbiomes can have major effects on disease, and may affect our bones. Exciting new studies show how it may be possible to treat or prevent a number of diseases associated with changes in the immune system, including osteoporosis.

And lastly, in the news, there is a 10-minute cancer test which can be taken at home with just a drop of saliva being developed. David Wong, professor of oncology at University of California, Los Angeles, stated that it is possible to detect tumor DNA when is it circulating in bodily fluids, a method known as a liquid biopsy. According to Dr. Wong, the saliva test is 100 per cent accurate. (11) Let’s hope it is available soon!

Editor's note: This article originally appeared in RDH eVillage Focus. Our editorial team would be happy to deliver content like this to your inbox twice a month. Just let us know by subscribing here.

1. Sharma P, Dietrich T, Ferro CJ, Cockwell P, Chapple IL. Association between Periodontitis and mortality in stages 3-5 Chronic Kidney Disease: NHANES III and linked mortality study. J Clin Periodontol. 2016;43(2):104-13. DOI: 10.1111/jcpe.12502.
2. Lockhart PB, Bolger AF, Papapanou PN, et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circulation. 2012;125(20):2520-44.
3. Rydén L, Buhlin K, Ekstrand E, et al. Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study. Circulation. 2016;133(6):576-83. doi: 10.1161/CIRCULATIONAHA.10.1161/CIRCULATIONAHA.115.020324.
4. Stewart R, West M. Evidence for an Association Between Periodontitis and Cardiovascular Disease. Circulation. 2016;133(6):576-83. doi: 10.1161/CIRCULATIONAHA.115.020324.
5. Tonomura S, Ihara M, Kawano T, et al. Intracerebral hemorrhage and deep microbleeds associated with cnm-positive Streptococcus mutans; a hospital cohort study. Sci Rep. 2016;6:20074; doi: 10.1038/srep20074 (2016).
6. McFarland ML, Inglehart MR. Depression, self-efficacy, and oral health: An exploration. OHDMBSC. 2010;9:214–22.
7. Anttila S, Knuuttila M, Sakki T. Depressive symptoms favor abundant growth of salivary lactobacilli. Psychosom Med. 1999;61(4):508-512.
8. Reese R. Depression and dental health. Clinical Update. Naval Postgraduate Dental School, National Naval Dental Center, Bethesda, Maryland, Vol. 25, No. 1, January 2003.
9. Al Mheid I, Held E, Uphoff I, et al. Depressive symptoms and subclinical vascular disease: The role of regular physical activity. J Am Coll Cardiol. 2016;67(2):232-234.
10. How Your Gut Affects Your Bones. Scientific American Guest Blog. Published February 10, 2016. Accessed March 3, 2016.
11. New 10-minute test for cancer developed by scientists. The Telegraph. Published February 13, 2016. Accessed March 3, 2016.

Maria Perno Goldie, RDH, MS, is editorial director of RDH eVillage Focus.