The most important perio-systemic facts

Cutting through the clutter to clearly define today's research outcomes

Periodontal health is increasingly being linked to playing a larger role in systemic health, according to extensive and recent research. A significant body of research has associated periodontal disease with an increased risk of cardiovascular disease, diabetes, and adverse pregnancy complications. Additionally, periodontal disease has been linked to other diseases, including respiratory disease, chronic kidney disease, rheumatoid arthritis, metabolic syndrome, erectile dysfunction, and cancer.

Among the vast amount of research available about the perio-systemic link are the findings of a joint workshop by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP). Supported by an educational grant from Colgate, more than 70 periodontology experts from throughout the U.S. and Europe pored over research for four days in November 2012 in Segovia, Spain. Attendees worked in groups to thoroughly examine the research to form a consensus about various potential perio-systemic links. The proceedings of the workshop were copublished in the Journal of Periodontology and the Journal of Clinical Periodontology.

I had the opportunity to participate in this interactive and exciting workshop. Below, I will share with you an overview of the attendees' work to help you better understand the facts behind the links between periodontal disease and other diseases. Developing a detailed understanding of the relationship between periodontal disease and other diseases, and applying this information to your practice, can help you better inform your patients of why overall health begins in the mouth. As a dental hygienist, you are often the person responsible for providing patients with information about their periodontal health. Your patients will appreciate your knowledge and care for their overall well-being.

-------------------------------------------------------------------------------------

Please consider reading these articles too:

• Basic care for periodontal disease may not be enough for patients with diabetes
• Are dentists interested in the oral-systemic disease connection?
• The fine art of patient engagement

-------------------------------------------------------------------------------------

Cardiovascular disease

The AAP and EFP participants concluded that strong epidemiologic evidence shows that periodontitis increases the risk of future atherosclerotic cardiovascular disease (ACVD). As a result, the group recommended that dental professionals should discuss risk factors of cardiovascular disease, including hypertension, obesity, and tobacco use, with their patients. Following American Heart Association guidelines for elective treatment procedures of periodontitis is also encouraged.

Additional clinical recommendations include:

• Be aware of the emerging and strengthening evidence that periodontitis is a risk factor for developing atherosclerotic cardiovascular disease, and advise patients of the risk.
• Periodontitis patients with other risk factors for ACVD, such as hypertension, overweight/obesity, smoking, etc., who have not seen a physician within the last year, should be referred for a physical.
• Modifiable lifestyle-associated risk factors for periodontitis (and ACVD), such as smoking cessation programs and advice on lifestyle modifications (diet and exercise), should be addressed in the context of comprehensive periodontal therapy. This discussion may be better achieved in collaboration with appropriate health-care providers.

Much more research is needed to better understand the relationship between cardiovascular disease and periodontal disease. Well-designed intervention trials on the impact of periodontal treatment to prevent ACVD clinical outcomes are needed, according to the AAP and EFP workshop participants.

Diabetes

Patients with moderate to severe periodontitis have an increased risk of development or progression of diabetes, according to the AAP and EFP workshop participants. Consistent evidence shows that severe periodontitis adversely affects blood glucose levels (expressed as HbA1c) in individuals with and without diabetes. As periodontal treatments may provide beneficial effects in some diabetic patients, regular comprehensive periodontal exams are recommended.

AAP and EFP workshop attendees developed the following guidelines to consider when treating patients with diabetes:

• Patients should be told that they are at increased risk for periodontitis and that their glycemic control may be more difficult.
• Patients presenting with a diagnosis of type 1, type 2, or gestational diabetes should receive a thorough oral examination, which includes a comprehensive periodontal evaluation.
• If periodontitis is diagnosed, it should be properly managed. If no periodontitis is diagnosed initially, patients should be placed on a preventive care regime and monitored regularly for periodontal changes.
• Patients who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition.
• Patients should also be evaluated for other potential oral complications, including dry mouth, burning mouth, and Candida infections.

Adverse pregnancy outcomes

Insufficient evidence exists to indicate that periodontal therapy can improve pregnancy outcomes, according to the AAP and EFP workshop results. Still, some studies suggest a modest link between maternal periodontitis and adverse pregnancy outcomes. Women of childbearing age should be advised of this potential systemic link so preventive periodontal care can be encouraged prior to conception.

However, periodontal therapy is considered safe in pregnant women and can result in improved periodontal health. Dental professionals should follow general obstetric guidelines and avoid such elective procedures in the first trimester, according to the group.

• The AAP and EFP workshop participants recommend that when treating pregnant women, oral health professionals should:
• Perform a comprehensive oral evaluation including a periodontal exam. The periodontal evaluation should include periodontal probing and evaluation of the periodontal inflammatory status (bleeding on probing).
• Provide periodontal health education about preventing and treating periodontal disease in women with healthy teeth and gums, and schedule for a reevaluation at a later stage during the pregnancy.
• Treat gingivitis with the goal of reducing the bacterial load and the signs of inflammation and maintain frequent monitoring of the periodontal status throughout pregnancy.
• Treat periodontitis using standard nonsurgical periodontal therapy with the goal of reducing the subgingival biofilm and the signs of periodontal inflammation. If possible, extensive traumatic interventions should be avoided.
• Provide supportive measures including periodontal hygiene instruction and re-evaluation after delivery of any periodontal therapy.

Other Systemic Diseases

The AAP and EFP Joint Workshop noted that evidence exists that indicates a connection between periodontitis and other systemic diseases, such as chronic obstructive pulmonary disease, pneumonia, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome, and cancer. While research has suggested that periodontal disease may be associated with other systemic diseases, more information is needed to understand whether there is a definite, causal link. However, despite the lack of causal evidence, your patients should still be informed that maintaining periodontal health might help reduce the risk for other diseases.

As research continues and delves deeper into the link between periodontal disease and systemic disease, more detailed findings are likely to come. Until then, what has already been discovered can be used daily at your practice to help improve your patients' periodontal health and also may contribute to their better overall health.

The Joint EFP-AAP Workshop on Periodontitis and Systemic Diseases was supported by an educational grant from Colgate Palmolive. Workshop proceedings can be found in the Journal of Clinical Periodontology and the Journal of Periodontology.

Joan Otomo-Corgel, DDS, MPH, is president elect of the American Academy of Periodontology. A resident of Manhattan Beach, California, Dr. Otomo-Corgel is an associate clinical professor in the Department of Periodontics at the University of California at Los Angeles (UCLA) School of Dentistry, and maintains a private practice limited to periodontics, oral medicine, and implantology in Los Angeles. Dr. Otomo-Corgel received her bachelor of arts degree in zoology from California State University – Fresno; her dental degree from the UCLA School of Dentistry; after completing her periodontal residency at the West Los Angeles Veterans Affairs Medical Center, she joined the faculty. Dr. Otomo-Corgel also holds a master's in behavioral sciences and health education from the UCLA School of Public Health. She has been a member of the AAP since 1977.