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Heart of The Matter

Monday, March 19, 2012
The close association between oral health and systemic health raises the question of just how connected the oral cavity is to the body's most important muscle—the heart. Considering that cardiovascular disease (CVD) is the nation's No. 1 killer, dental hygienists may play an important role in reducing the risks of this serious health threat.1 Research has demonstrated a link between periodontal diseases and atherosclerotic disease, heart disease and stroke.2 The fact that CVD often causes death underscores the need to reduce all risks—including any that might relate to the oral cavity.

"Any oral infection can theoretically become a risk indicator for CVD," observes Michael P. Rethman, DDS, MS, a board certified periodontist, past president of the American Academy of Periodontology and former chair of the American Dental Association's Council on Scientific Affairs. "Oral microbes and the systemic effects of biochemicals released into the circulation by inflammation have been implicated in aggravating CVD."

Rethman characterizes the connection between CVD and periodontal diseases as an "association" rather than a causal relationship. Oral infections, he says, do not cause CVD for the majority of patients; conversely, eliminating oral infection does not cure CVD. There may be more to this relationship than what research has thus far revealed, however. One study found test subjects with chronic periodontitis exhibited up to a 1.59-fold greater risk of developing coronary heart disease than subjects who did not have periodontal disease.3 Risk factors attached to these test subjects included diabetes, obesity, alcohol consumption, high blood pressure and smoking.

IDENTIFYING PATIENTS AT RISK Scientific study has failed to identify a specific age cohort for patients with periodontitis who are most at risk for CVD. Rethman points out, however, that chronic periodontitis and CVD both tend to manifest during middle age. "Both are diseases of aging. Many individuals with periodontitis were or are smokers, and smoking has been implicated in both periodontitis and CVD, albeit separately," he notes.

The presence of C-reactive proteins (CRPs which are found in blood and increase in the presence of inflammation anywhere in the body, may also prove helpful in risk assessment. Some research indicates CRPs—associated with chronic periodontitis—may be independent biomarkers capable of predicting cardiovascular events.4 The literature shows that as baseline levels of high-sensitivity CRPs rise, so does an individual"s risk of a first heart attack or ischemic stroke.4

While there is research to support an association between periodontal diseases and CVD, a determination of cause-and-effect has yet to be made. Frieda Atherton Pickett, RDH, MS, adjunct associate professor in the graduate division of the Department of Dental Hygiene at Idaho State University, Pocatello, and a prolific oral health researcher, notes that if a causal relationship is established, the implications will be significant. "CVD and periodontal diseases affect large numbers of people, and if maintaining oral health reduces CVD—even if only by a small percentage—this could still benefit a significant number of patients. However, the relationship may be purely coincidental and the associations spurious," she cautions.

The role of the dental professional could shift considerably if a causal link between CVD and oral health is established. Pickett points to a 2008 study that concluded randomized intervention trials would help answer the question of what this new role might look like. That answer may be slow in coming, however, because at present only one pilot study is actively exploring the effect of dental interventions on CVD. "If a group could find funding to study oral care procedures in individuals who have CVD and follow them for many years, the results might give the dental profession guidance to answer this clinical question," Pickett observes.

Although oral infections and inflammation have not been implicated as a cause of CVD, Rethman says there is still good reason to improve oral health as a measure to improve morbidity and mortality rates for CVD, noting, "The costs of improved oral health seem fairly trivial in the context of even the small likelihood such interventions will lessen or delay the costs associated with worsened CVD."

STAY AHEAD OF THE CURVE In the United States, CVD is responsible for 1 death every 39 seconds.5 One way dental hygienists can help patients is simply to position good oral hygiene as a benefit to systemic health. "It's OK to suggest that more aggressive periodontal therapy may improve cardiovascular health," says Rethman, "but it's important to explain that improved periodontal health should be sought for its own benefits, and not because optimal oral health is likely to noticeably improve or repair cardiovascular health—despite the possibility that it might."

Cardiovascular disease is known as a silent killer. But if dental hygienists speak to patients about the potential impact of good oral health on overall health—and educate them about the possibility of an oral/systemic link—it could move health care one step closer to silencing a killer.

References

1. Centers for Disease Control and Prevention. Heart disease facts and statistics. Available at: www.cdc.gov/heartdisease/statistics.htm. Accessed March 5, 2012.
2. Genco RJ. What the future may hold. Dimensions of Dental Hygiene. 2010;83):22–24.
3. Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis. Am Heart J. 2007;154:830–837.
4. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med. 1997;336:973–979.
5. Roger V, Go A, Lloyd-Jones D, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:2–220.
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