Periodontal and Chronic Diseases: A Literature Review

Periodontal and Chronic
Diseases: A Literature Review
Cathy Hollister, RDH, MSPH, PhD
Nashville Area Dental Support Center
Research Questions
• What chronic conditions or systemic diseases
are associated with periodontal disease?
• Does periodontal treatment improve the
systemic conditions?
• What are the implications for medical and dental
• Criteria
▫ Peer reviewed journal
▫ Published in the last 5 years
▫ Full text available
• Pubmed search
▫ Periodontal AND diabetes
▫ Periodontal AND chronic disease
• Reference List of articles
• 46 articles
39 original research,
2 meta analysis
3 reviews
2 comment on health care practice
• Topics of interest
▫ Associations
24 articles
▫ Impact of treatment
11 articles
▫ Implications for practice 11 articles
• No consistent measures of periodontal disease
▫ Pocket depth, attachment loss, BOP
▫ Microbes, products of inflammation
▫ Tooth loss
• Wide range of severity
▫ 4 teeth with 4mm CAL and BOP to hopeless teeth
• Short duration
• Small sample sizes
Associations with Perio
• Multiple chronic or inflammatory conditions
Type 2 diabetes
Gestational diabetes
Metabolic syndrome
Low birth weight or preterm babies
Chronic kidney disease
Non-alcohol related liver disease
Squamous cell carcinoma
Theory of Inflammatory Complications
• Periodontitis contributes to the systemic
inflammatory burden
• The diseases or the treatment for diseases may
suppress immune system
• Suppressed immune system may increase the
risk for periodontal disease and systemic
Hypothetic model for how peridontitis may act as a potential cause of local and systemic
inflammation in chronic kidney disease patients.
Akar H et al. CJASN 2011;6:218-226
©2011 by American Society of Nephrology
Systemic Disease Treatment
Gram negative bacteria
Products of Infection
Loss of appetite
Dry mouth
Suppressed Immune System
Interaction Effect
Tooth Loss
Other chronic infections
Host response variations
Compromised Nutrition
Full impact of inflammation has not been explained.
Directionality has not been clearly demonstrated.
Take Home Message
Host response to inflammation
may be the
common risk factor for both
periodontal disease
and other chronic diseases
Take Home Message
• Interactions between diseases is more than
• OR
• All of the pieces of the pie add up to a whole
bake sale
• Associations are clear, directionality is not
• Perio and then chronic disease
• Chronic disease and then perio?
• Patients with perio AND GDM were more likely
to develop Type 2 DM than patients with GDM
• Authors hypothesize that periodontal disease
may contribute to impaired glucose metabolism
and future risk of developing diabetes
Perio in Healthy Individuals
• Evidence of impaired metabolic function
increases in the presence of periodontal disease
• In 3 separate studies, patients without diabetes
had higher A1c levels in the presence of
periodontal disease
• Does not prove directionality-but suggests a
common risk factor- Host inflammatory
• Periodontal disease increased risk for CVD even
after controlling for other known risk factors
▫ Diabetes duration
▫ Hypertension
Fisher MA, Taylor GW, West BT, McCarthy ET. Bidirectional relationship between
chronic kidney and periodontal disease: a study using structural equation modeling.
Kidney Int. 2011 Feb;79(3):347-55. doi: 10.1038/ki.2010.384
• Periodontal disease remained a risk factor after
controlling for other know risk factors
▫ Smoking
▫ Environmental Exposures
Zeng XT, Tu ML, Liu DY, Zheng D, Zhang J, Leng W. Periodontal disease and risk
of chronic obstructive pulmonary disease: a meta-analysis of observational
studies.PLoS One. 2012;7(10):e46508. doi: 10.1371/journal.pone.0046508.
Pregnancy Outcomes
• Equivocal evidence
• Conflicting results showing association between
periodontal disease and preterm, low birth
weight, and preeclampsia
• Abundance of evidence of an association
between systemic conditions and periodontal
• Many questions remain
▫ How does the severity of periodontal disease or
the type of treatment impact systemic disease?
▫ Is there a direct relationship or is inflammation
the confounder that affects each condition?
▫ Does treatment for perio reverse improve the
systemic condition?
Perio Treatment Outcomes
• Current research indicates that treatment
improves periodontal health even in the
presence of co-morbidities
• Measures of periodontal health may improve but
inflammation markers may not improve
Reversibility: Impact of Perio
Treatment on Systemic Conditions
• Treat the periodontal disease, reduce the risk of
other diseases or complications?
• Maybe…
Type 2 Diabetes: Moderate-Poorly
Controlled DM (7.5-9.5 A1c)
• Perio Tx: SRP, Exts, antibiotics
• Improved after tx for Moderate Perio
lipid profile
inflammatory cytokine levels
Serum adiponectic (protein hormone secreted
from adipose tissue instrumental in glucose
Sun WL, Chen LL, Zhang SZ, Wu YM, Ren YZ, Qin GM. Inflammatory cytokines, adiponectin, insulin resistance and
metabolic control after periodontal intervention in patients with type 2 diabetes and chronic periodontitis. Intern Med.
Meta Analysis: Perio & DM
• 5 Studies
Moderate DM patients (7.2-9.5 A1c)
Moderate periodontal disease
Non-surgical periodontal treatment
Improvement in periodontal measures
• All studies showed an absolute reduction in A1c,
some not significant
• Katagiri et al. C-reactive Protein
Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a
systematic review and meta-analysis. Diabetes Care. 2010 Feb;33(2):421-7. doi: 10.2337/dc09-1378
Rheumatoid Arthritis
• Researchers compared RA patients who DID and
DID NOT receive perio treatment
• Periodontal treatment improved RA markers
regardless of drug therapies
Ortiz P, Bissada NF, Palomo L, Han YW, Al-Zahrani MS, Panneerselvam A, Askari A.
Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor
necrosis factor inhibitors. J Periodontol. 2009 Apr;80(4):535-40. doi: 10.1902/jop.2009.080447
• Meta-analysis of OB outcomes research
• Periodontal treatment did not reduce risk of
preterm or low birth weight babies BUT
• Treatment DID reduce risk of preterm, low birth
weight babies
Xiong X, Buekens P, Vastardis S, Yu SM. Periodontal
disease and pregnancy outcomes: state-of-the-science. Obstet Gynecol Surv.
2007 Sep;62(9):605-15
Implications for Practice
• Knowledge:
▫ How informed are dental and medical
professionals on oral-systemic link?
• Dental care utilization
▫ Do people with chronic conditions get more dental
• Collaboration
▫ Does the health care system support collaborative
• 2 Studies, surveys among :
▫ Nephrologists & CKD nurses
▫ Internists and Endochronologists
• Results:
▫ Medical professionals often have a good
understanding of periodontal disease and its role
in systemic diseases
▫ They may not be confident or consistent in
performing oral health screenings or referrals
Knowledge, continued
▫ Reasons for not acting on knowledge are not clear
▫ Most agree that periodontal disease should be
included in medical training
Bastos Jdo A, Vilela EM, Henrique MN, Daibert Pde C, Fernandes LF, Paula DA, Chaves Md, Bastos MG. Assessment of
knowledge toward periodontal disease among a sample of nephrologists and nurses who work
with chronic kidney disease not yet on dialysis. J Bras Nefrol. 2011 Dec;33(4):431-5
Owens JB, Wilder RS, Southerland JH, Buse JB, Malone RM. North Carolina internists' and endocrinologists' knowledge,
opinions, and behaviors regarding periodontal disease and diabetes: need and opportunity for interprofessional education.J
Dent Educ. 2011 Mar;75(3):329-38
Dental and Dental Hygiene Training
• The majority of surveyed dental and dental
hygiene schools include systemic disease
• Most responding schools taught the oralsystemic link
• Very few (<4%) had multidisciplinary courses
• Less than 10% of respondents were confident
that medical personnel understood the oralsystemic link
Training to Action?
• Dental hygienists reported that they did not
routinely education DM patients on the oralsystemic link
▫ Lack of time
▫ Patient disinterest
▫ Inadequate information
Yuen HK, Mountford WK, Magruder KM, Bandyopadhyay D, Hudson PL, Summerlin LM, Salinas CF. Adequacy
of oral health information for patients with diabetes. J Public Health Dent. 2009 ; 69(2): 135–141.
• CKD and DM: Fewer patients with these
conditions receive dental care than healthy
▫ 5 year study period: 15% of patients had a dental
• DM
▫ 5 year study period: Fewer visits and procedures
▫ More likely to have perio tx or maintenance
• Fewer procedures than healthy patients
• More periodontally related procedures
Collaborations: Barriers
• Perceived or actual barriers impact
• Reasons for non-collaborative care among both
medical and dental professionals:
▫ Inadequate knowledge
▫ Feeling that nothing could be done to help
▫ Division between medical and dental care delivery
“Syndemic” Paradigm:
• Fragmented healthcare delivery system
• Management of chronic diseases must occur in a
new paradigm based on a “syndemic” approach
• Syndemic refers to two or more linked health
conditions that interact to increase the overall
disease burden
Iacopino A. New “syndemic” paradigm for interprofessional management of
chronic inflammatory disease. JCDA 2009; Vol. 75(9):632-33
Paradigm Shift?
• Treatment teams
▫ support comprehensive patient management
• Bidirectional screening and referral
• Collaborative reinforcement of educational
• Communication and education among
▫ Professional training and CE
• Health policies that focus on risk reduction
• Does your healthcare facility demonstrate:
▫ Adequate knowledge about systemic conditions
and treatments?
▫ Common CE?
▫ Collaborative practices?
▫ Treatment teams?
▫ Supportive policies?
• Develop an Action Plan!

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