Periodontal diseases vs atherosclerosis and heart attack

What is the first sign of periodontal disease and can it be overlooked?

Periodontal diseases affect all tissues around the tooth, i.e. gingiva, alveolar bone, periodontal fiber, and tooth root cementum. It often also involves the loss of bone tissue in the jaws. However, its antecedent sign (which heralds the disease) is gum bleeding, often overlooked and ignored by patients. Bleeding tends to occur during daily oral hygiene such as brushing your teeth – and, unfortunately, discourages some from doing so. And yet, this is a red flag, a signal that you need to see a dentist, who will offer first aid and suggest next steps if necessary.

Why do our gums bleed?

This is usually caused by bacterial biofilm. Pathogenic bacteria in the oral cavity are usually Gram-negative. Their activity causes an infection of the gingiva with subsequent active hyperemia. This means that initially, hyperemia may be compensated for by our microvessels. Eventually, though, they lose the ability to handle the situation, and then another sign appears, i.e. passive hyperemia. This in turn may lead to gum bleeding. Without any intervention and with continued neglect of oral hygiene, this ultimately leads to the development of periodontal abscesses. 
In a way, bleeding is a turning point. This is when pathogenic bacteria start to dominate in the oral ecosystem. This serves as an inflammatory factor, and triggers the release of immunomodulators. I mean the whole world of interleukins: interleukin 1, interleukin 6, tumor necrosis factor (TNF-α), cytokines, metalloproteinases... All these factors lead to the collapse or significant deterioration of our protective barrier, which may lead to the destruction of jaw bone tissue. An inflammation develops, which is a self-powered mechanism that must be stopped quickly. 

How do we stop it, if it is self-powered? How do we treat periodontal diseases?

In conservative treatment, hygiene is of utmost importance. This involves not only brushing your teeth correctly at home, but also undergoing certain procedures at a dental practice. It is worth taking advantage of the oral hygiene procedures covered by the NHF, such as scaling (once a year), which reduce the amount of oral cavity bacteria responsible for the release of inflammatory interleukins. 
One thing to remember, though, is that once periodontal disease develops, it is often also necessary to initiate surgical treatment in the oral cavity, e.g. bone reconstruction surgery. That is why, when you experience gum bleeding, it is necessary to see a dentist. They will evaluate the condition of the oral cavity and offer further guidance. One point worth noting is that treating periodontal disease often requires interdisciplinary cooperation with other specialists from other areas: conservative dentistry, endodontics, orthodontics, prosthetics, and pediatric dentistry when treating children, who are also likely to experience dental hygiene neglect. For the elderly, dental prostheses are very important. It is also important to cooperate with cardiologists, as sometimes heart disease treatment is ineffective if the patient’s oral cavity is in a poor condition.

Does this mean that the condition of our oral cavity has an impact on our cardiovascular system?

Of course it does. Inflammation was found to be the major factor behind myocardial infarction already towards the end of the 19th century. Yet back then, the mechanism of this relationship was unknown. We got to explore the world of interleukins only in the second half of the 20th century. This is when a hypothesis was formulated that the condition of the periodontium may be related to acute coronary syndrome. Also our department conducted research on this topic. We initiated it at the turn of the 21st century. The research group also included scientists from the 1st Chair and Department of Cardiology at the Central Clinical Hospital at the University Clinical Center of the Medical University of Warsaw in Banacha street, with which we have been cooperating to this day. We have published a research paper on the relationship mentioned above. It is worth noting that up until 2006, only six such papers had been published on this topic, two of which were ours. The research we continue to conduct in a group of cardiology patients covers various parameters of periodontal disease, such as bleeding and plaque. It turns out that for patients with lower values for indicators in this respect, cardiological healing was much faster, and inflammatory signs were less prominent. We observed this group of patients for half a year. The relationship is also confirmed by other research, where ultra-modern inflammatory markers were used. But the matter is by no means closed, and papers that discuss it continue to appear.

How is it possible that periodontal diseases increase the risk of heart attack? What is the mechanism here?

Everything starts with the bacteria. When bleeding occurs, bacteria enter the bloodstream and travel throughout the body. They may also reach the myocardium. Additionally, atheroma develops in blood vessels, and may be smaller or greater in size. When bacteria from the oral cavity enter the vessels, they have the potential to activate the atheroma. This in turn leads to its degradation and the release of foam cells, made of cholesterol, into the blood vessel. Cholesterol particles block the smallest vessels. When this happens in coronary vessels, this leads to infarction, and when in the brain – to stroke, embolism, or clotting.

Are periodontal diseases a complaint of the elderly?

Not necessarily. Our study also included a 34-year old woman who suffered myocardial infarction for the third time. We were surprised because periodontal diseases more commonly affect men, who are also more prone to heart attacks. So we need to remember that medicine is not a discipline where you should only rely on statistics. 
However, we can indeed say that periodontal diseases are more commonly experienced by the elderly. This is natural, because certain physiological changes occur in the oral cavity 60- or 80-year-old patients, affecting hygiene. Less saliva is secreted – and its function is to wash and clean the oral cavity. If the patient additionally has some teeth missing, then the pathways of saliva movement around the cavity are disturbed, which in turn reduces its pressure. And we all know the difference between washing something with water that is or is not under pressure. Elderly people also often experience difficulties with manual handling, which make it more difficult to maintain proper oral hygiene. Such people also often have other comorbidities.

What other conditions may be related to periodontal diseases?

Diabetes is one such example. In this case, the correlation is reverse than for heart conditions. Diabetes facilitates periodontal disease. Diabetic patients may have microangiopathies, i.e. abnormal capillary vessels. Those microvessels nourish the bones of the facial skeleton: they distribute blood within the bone marrow and cancellous bone. When those vessels deteriorate, this leads to bone malnourishment and subsequently bone attrition. In practice, this means that teeth begin to loosen.
When we consider the fact that our country ranks first in the world in terms of diabetes prevalence among youth, then we should expect a marked increase in the incidence of periodontal diseases and cardiological conditions in 10 to 15 years. 
What is more, periodontal diseases and hear conditions are often accompanied by systemic diseases that manifest in the oral cavity.

What kinds of diseases could they be?

All kinds of hematological diseases, e.g. leukemias, hemophilias, certain congenital or genetic disorders. We recently had a pediatric patient who is among the seven people registered in the world as having certain hematological deficiencies. Those deficiencies manifest in the inflammation of gingiva and tongue. The girl receives treatment not only in Polish centers, but also in Milan and New York. 
Also neoplasms such as multiple myeloma may manifest in the oral cavity. We have been collaborating in this area with a clinic of the Jagiellonian University for years. Multiple myeloma involves the necrosis of bone tissue in the jaws, with the release of bony sequestra. Also other neoplasms may develop in the oral cavity. They often affect the tongue, lips, maxillary sinuses. Of Obviously, dentists do not treat those serious diseases themselves. Multi-center cooperation with other specialists is crucial.
And what should we do to prevent periodontal diseases, what are the best ways to take care of oral hygiene?
We all know that we should brush our teeth at least twice a day. It is also good to use mouthwash – but make sure to use it prior to brushing your teeth rather than afterwards. Use soft toothbrushes – their bristles are able to enter the space between the teeth and remove food remnants. It is also important to use dental floss correctly. When used incorrectly, it may cut the gums, leading to spectacular bleeding – which in turn discourages its use. Oral hygiene should also include scaling, i.e. the removal of dental tartar, at least once a year. This recommendation is especially valid for patients with cardiological, diabetic, nephrological, hematological, gynecological, pediatric, orthopedic, or oncological conditions. In such cases, however, the procedure must be carried out in consultation with the treating clinic, often with targeted antibiotic protection.
 

Interviewed by: Iwona Kołakowska
Fot.: Michał Teperek
Communication and Promotion Office