Now that evidence for oral-systemic causality—i.e., causality between periodontal pathogens and the development of atherosclerosis—has been demonstrated, Dr. Richard Nagelberg addresses the question of how to give patients their best chance for good overall health, not just good oral health.My last blog post provided the evidence for oral-systemic causality. The authors of the journal article, "High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis," (1) demonstrated causality between periodontal pathogens and the development of atherosclerosis (arteriosclerotic vascular disease or ASVD) by using a unique approach. Until then, it was assumed that a large, multicentered interventional study was necessary to demonstrate causality. The problems with such a study are cost and length of time; it could take decades to complete.
The method used in the Bale/Doneen/Vigerust study (1) was to examine the three elements necessary for the formation of an atherosclerotic plaque, which is called the pathogenesis triad. Five bacterial species—Aggregatibacter actinomycetemcomitans(Aa), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf), Fusobacterium nucleatum (Fn), and Treponema denticola(Td)—were found to influence all three elements, and it was concluded that they are a contributory cause of ASVD.
The authors stated that periodontal disease due to these bacteria must be controlled to reduce the risk of ASVD. The conclusions reached did not include the impact of disease resolution on the oral cavity, because the study's authors are all medical professionals—not dental professionals.
So how do we proceed and give our patients their best chance for good overall health, not just good oral health? Pre-op and post-op salivary bacterial testing is the key. The appropriate question to ask is notwhy should we do this? The right question is why wouldn’t we provide salivary testing? Our primary responsibility is disease detection, management, and prevention. We need to be thinking beyond the oral cavity, especially since research now demonstrates that periodontal pathogens cause atherosclerosis. It does not do us any good to sit up and take notice if we just keep sitting.
The impact and central importance of periodontal pathogens being directly responsible for atherosclerotic plaque development cannot be overstated. It is akin to the effect of smoking on cardiovascular health. Practicing blindly, without identifying the specific periodontal pathogens in our patients’ mouths, is a prescription for compromised results in the oral cavity and arterial walls. The future of health care, including dental health, is salivary diagnostic technology. Salivary bacterial identification has been available to the dental profession for more than seven years.
Our focus as dental professionals for generations has been the oral cavity. Recent research demonstrating the ability of periodontal pathogens to cause atherosclerosis widens the scope of our responsibilities as dental professionals. A thorough examination of the patient’s health history and family history are good starting places to determine those at risk for cardiovascular disease. The potential to reduce the risk of atherosclerotic plaque development is an enormous opportunity that we should embrace.
The ability to identify and control the level of periodontal pathogens has the potential to reduce or eliminate this pathway to atherosclerosis. We cannot determine how effective we have been at bacterial reduction without initial salivary testing and retesting some time later. All the tools we need are currently available. Salivary diagnostic testing is inexpensive, not time-consuming, and noninvasive. Why wouldn’t we provide this service for our patients? Would they want or expect it if they knew it was available and that it could be completed quickly, easily, and inexpensively? You bet.
1. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2016. doi: 10.1136/postgradmedj-2016-134279. [Epub ahead of print].