Inflammation and Periodontal DiseasesA paradigm shift in periodontology and what it means for patient care

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Outline of PresentationWhat is periodontal disease?What is inflammation?All about inflammation: the paradigm shift in

periodontologyInflammation, periodontal disease and cardiovascular

diseaseInflammation, periodontal disease and other disease

statesRisk factors for periodontal diseaseTreatment of periodontal inflammationFive Things to RememberQuestions

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Periodontal Disease: A Quick Overview

The AAP estimates that 3 out of 4 Americans are affected by periodontal disease, ranging from mild gingivitis to more severe periodontitis.

Gingivitis is the mildest form of periodontal disease.It causes gums to turn red, become swollen, and bleed

easily.

Fortunately, it is easily reversible with good oral homecare.

If left untreated, gingivitis may advance to periodontitis.

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Periodontal Disease, Cont.Periodontitis is the more advanced form of

gum disease.The tissues and bone that support the teeth

are broken down and destroyed, resulting in loosened teeth that may need to be removed

There is an increased risk for other body problems.

There are many treatment options available, including non-surgical and surgical therapies.

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Periodontal Disease, Cont.However, the periodontal disease of yesterday is not

the periodontal disease of today.

Yesterday: researchers believed that gum loss in periodontal disease was caused by the bacteria in plaque.

Today: researchers have determined that the gum loss in periodontal disease is caused by the inflammatory response to the bacteria in plaque.

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What is Inflammation?Inflammation is the body’s first response to an injury.

The first phase (acute inflammation) includes redness, swelling, heat, and altered function. It is self-perpetuating.

There are several biological markers of inflammation in your blood, including C-reactive protein (CRP).CRP is a protein found in the blood which can rise in response to

inflammation. Acute inflammation often causes elevated C-reactive protein.Elevated CRP is a risk factor for several chronic inflammatory

diseases.

Inflammation appears to be a common link between several common diseases of aging.These diseases include heart disease, arthritis, and periodontitis.

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Examples of Inflammation

Sunburn

Infection

A cut on the skin

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Inflammation’s Objective

Inflammation tries to contain the injury to the local site.

The body’s reaction is immediate (called the innate response).

Its ultimate purpose is to protect the body from further damage.

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Inflammation is Damaging when Uncontrolled

Though inflammation can be helpful under certain conditions, uncontrolled inflammation, also called chronic inflammation, is harmful and causes tissue loss.

Chronic inflammation occurs when there is a sustained infection, like periodontitis.

Chronic inflammation involves more inflammatory mediators than the immediate innate response.

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Chronic Inflammation

Chronic inflammation can negatively affect all organs and tissues of the body.

Chronic diseases of aging are connected through common chronic inflammatory mechanisms.

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Periodontal Paradigm Shift:

Because of this new focus on inflammation, there has been a shift in

the way periodontists view periodontal disease and its

relationship to other disease states.

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Periodontitis is a Chronic Inflammatory Disease of Aging

Periodontitis involves a microbial challenge to the gums which stimulates an inflammatory response.

Genetic and acquired risk factors lead to the host’s immuno-inflammatory response.

A prolonged immuno-inflammatory response leads to destruction of connective and bone tissues, which leads to the possible loss of teeth.

Chronic inflammatory diseases, such as periodontitis, arise over decades.

Periodontal disease is a significant contributor to the total inflammatory burden on your body and can adversely affect your systemic health.

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“Inflammation and Periodontal Diseases: A Reappraisal”

In January 2008 a workshop sponsored by the AAP brought together more than 80 leading experts: Periodontists, cardiologists, diabetologists, geneticists,

gerontologists, inflammation researchers

This was an opportunity to engage in collaborative thinking and brainstorming across many different fields- using inflammation as a common finding.

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Workshop, cont.The workshop was developed to expand and advance our

understanding of inflammation and the role it plays in diseases of aging.

The experts from the diverse fields addressed topics of inflammation:What is inflammation? What specific mechanisms constitute inflammation? What factors regulate inflammation? Why do individuals have different expression levels of

inflammation? Is the inflammation in one disease common to the

inflammation in other diseases?

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Workshop, cont.The experts engaged in discussion of the future

of inflammation therapies and how they may change the future of periodontics.

Proceedings from the Workshop were published in a supplement to the Journal of Periodontology in August 2008.

(Available for free at: http://www.joponline.org/toc/jop/79/8s)

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Workshop, cont.What we learned:

Periodontal disease is a bacterially-induced chronic inflammatory disease that does not resolve by itself.

The inflammatory response is important.Environmental and genetic factors affect expression of

inflammation in individuals .The initiation and resolution of inflammation are well

controlled processes.Diabetes, CVD, and stroke all share common

inflammatory processes similar to periodontal inflammation.

Resolution of any inflammation in the body is helpful for overall health.

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The Workshop helped highlight the relationship between various disease

states, and suggested that inflammation may be the basis

for these relationships.

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Perio-Cardio Link:The relationship between periodontal disease and cardiovascular disease (CVD)

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Inflammation and CVDInflammation contributes to heart attacks as

much as or more than cholesterol.*Atherosclerosis always begins with injury to

the endothelium of blood vessels. Periodontal pathogens have been found in

atherosclerotic lesions.

*Ridker PM, et al. N Engl J Med. 2005 Jan 6;352(1):20-8.

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C-Reactive Protein (CRP)CRP is a protein found in the blood that reflects

the amount of inflammation in your body.Periodontitis and other sources of inflammation

elevate CRP levels.Elevated CRP is a direct risk factor for CVD.

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AJC-JOP Consensus PaperThe American Journal of Cardiology contacted the AAP

after reading the August 2008 Journal of Periodontology supplement from the Workshop on Inflammation.

A consensus paper was developed in collaboration with the American Academy of Periodontology and top cardiologists.

The paper was published simultaneously in the Journal of Periodontology and the American Journal of Cardiology in June 2009.

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AJC-JOP Consensus Paper, cont.The consensus paper is a summary of research that

shows a connection between periodontal disease and CVD.

It explains the underlying biologic and inflammatory mechanisms that may be the basis for the connection.

Clinical recommendations for treating patients with cardiovascular disease and periodontal disease are also included.

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CVD-PD Clinical RecommendationsExamples of the clinical recommendations:

Dentists are asked to consider their patients’ heart health and risk for CVD.

Physicians are asked to consider their patients’ periodontal health and risk for periodontal disease.

All health professionals are asked to educate patients on chronic inflammatory diseases and how they are related.

Health professionals are also asked to work together to ensure patients are in best health.

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The Relationship of Periodontal Disease to Other Inflammatory Diseases

Inflammation appears to be the basis for the association between oral and systemic disease.

One chronic inflammatory disease potentially influences the expression of other diseases:Tissue destruction is caused by prolonged inflammation. Moderate/severe periodontitis increases systemic inflammation. Systemic inflammation is associated with most chronic diseases

of aging. For example, periodontal disease influences diabetes and

diabetes influences periodontal disease.

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The Relationship of Periodontal Disease to other Chronic Inflammatory Diseases of Aging

Cardiovascular diseaseArthritisAlzheimer’s DiseaseDiabetesCancers

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Arthritis Arthritis (Rheumatoid arthritis

and osteoarthritis) is an inflammation of the joints.

Patients with arthritis have a higher incidence of periodontal disease compared to healthy controls.*

Source: National Institutes of Health

Periodontal treatment decreases arthritis parameters:**Patients’ number of swollen and tender joints decreased following

periodontal treatment.Patients’ assessment of pain also decreased following periodontal

treatment.

*Pischon N, et al. J Periodontol. 2008 Jun;79(6):979-86. **Ortiz P, et al. J Periodontol. 2009 Apr;80(4):535-40.

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Alzheimer’s DiseaseAlzheimer’s disease is an inflammation of the brain.

Antibodies and immune cells cross the blood brain barrier.

Exposure to chronic periodontaldisease quadruples an individual'srisk of developing Alzheimer'sdisease.*

*Watts A, et al. Neuropsychiatr Dis Treat. 2008

Oct;4(5):865-76.

© 2000 - 2009 American Health Assistance

Foundation

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DiabetesHyperglycemia inhibits the resolution of inflammation.

High CRP promotes insulin resistance.

Patients with diabetes are threetimes more likely to have periodontaldisease.

Controlling periodontal disease helps control blood sugar levels.

Insulin

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CancersPancreatic cancer

Men with a history of gum disease are 54% more likely to develop pancreatic cancer than men with healthy gums.*

Head and neck cancersChronic periodontitis is independently associated

with the incidence of head and neck cancers.**Smoking increases this association.

*Michaud DS, et al. Lancet Oncol. 2008 Jun;9(6):550-8. Epub 2008 May 5.

**Tezal M, et al. Cancer Epidemiol Biomarkers Prev. 2009 Sep;18(9):2406-12.

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ObesityPatients with a higher body mass index (BMI) tend to

have higher levels of CRP.

Calorie reduction leads to decreased gingival bleeding and rate of periodontal disease progression.*

*Branch-Mays GL, et al. J Periodontol. 2008Jul;79(7):1184-91.

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Other Inflammatory Diseases

Asthma and other chronic respiratory diseases

Osteoporosis

Kidney disease

Metabolic syndrome

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Risk Factors for Periodontal Disease

Biological risk factorsOther systemic diseases of inflammation may increase

the risk of periodontal disease.Genetics

Predisposition to inflammatory conditions such as obesity, diabetes, or CVD

Genetic risk factors can be minimized with proper diet, exercise, and oral hygiene.

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Risk Factors for Periodontal Disease, cont.

Behavioral risk factorsPoor oral hygieneSmoking (specifically, nicotine intake)

Smokers have higher levels of CRP.Stress Sleep deprivation Poor diet

Biologic Risk Factors

Behavioral Risk FactorsGenetic Risk Factors

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Treatment of PeriodontitisPeriodontists are experts in evaluating, diagnosing and

treating periodontal disease as well as controlling oral inflammation.

Periodontists have three or more years of additional specialized training after dental school.

It is important to refer a patient to an expert in the treatment of periodontal disease (a periodontist) if the inflammation is not resolved with regular teeth cleanings.

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Treatment of Periodontitis, cont.Chronically inflamed tissues from periodontal disease

that have not responded to non-surgical treatment may need additional procedures in order to become healthy.

Reducing one type of inflammation may reduce another:Patients with periodontitis and rheumatoid arthritis who

received periodontal treatment: Reduced inflammation in periodontal tissues. Reduced severity of RA symptoms.*

* Ortiz P, et al. J Periodontol. 2009 Apr;80(4):535-40.

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The good news is that inflammation levels can be reduced.

When chronic inflammation is controlled, the associated chronic inflammatory diseases may be controlled.

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How to Reduce Inflammation: What does this mean for patients?

Stop smoking.Reduce direct sources of inflammation:

Visceral fat Exercise Reduce calories

Chronic infections Periodontists can help reduce inflammation in the oral

cavity.Activate inflammation resolution systems:

Add Omega-3 fatty acids to your diet.Take a daily low-dose aspirin.

Have your teeth professionally examined and cleaned regularly.

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Inflammation: 5 things to remember

1. There has been a paradigm shift in the field of periodontology.

Periodontal disease today is defined by the inflammatory response to the biologic components of plaque.

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Inflammation: 5 things to remember

2. The relationship between periodontal disease and other chronic inflammatory diseases of aging is better understood.

These diseases include cardiovascular disease, respiratory diseases, diabetes and arthritis.

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Inflammation: 5 things to remember

3. Treatment of chronic oral inflammation should be done by a trained dental professional.

Periodontists are the experts in evaluating, diagnosing, and treating periodontal inflammation and disease.

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Inflammation: 5 things to remember

4. Reducing inflammation in the body can reduce the occurrence and severity of chronic inflammatory diseases.

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Inflammation: 5 things to remember

5. Dentists and physicians need to work together to ensure the best health of their patients.

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Thank you!

For more information visit www.perio.org

To view supporting studies and references visit www.joponline.org

Contact the American Academy of Periodontology’s Public Affairs Department at: 312/573-3242 or 800/282-4867 ext. 3242 PublicRelations@perio.org 43