GINGIVITIS AND HEART DISEASE

Gingivitis or inflammation of the gum tissue, is caused by acid waste products of bacterial plaque that is allowed to remain chronically around the teeth and below the gumline. Untreated, this inflammation can cause loss of bone, gum recession and possible loss of teeth. Recently, evidence has been presented that indicates untreated periodontal disease can cause heart disease.

• Statement from the American Academy of Periodontology on the Link Between Gum Disease-Heart Disease
  
  
• National Institute of Health Funds Research to Explore Gum Disease-Heart Disease Link
  
  
• Transmission of Periodontal (Gum) Disease Between Family Members
  
  
• Gum Disease Linked to Heart Illness (USA Today)
  
  
• Microbes that Bite Bacteria Can Be the Couriers of Disease: Chronic Tooth Infections can Kill More than Smile. (USA Today)
  
  
• Heart Disease & Gingivitis - Dental Hygienists See Signs & Symptoms of Heart Disease in Patients (University of Colorado Health Sciences)
  

Statement from the American Academy of Periodontology on the Link Between Gum Disease-Heart Disease

The American Academy of Periodontology is concerned about new research linking gum disease to a heart attack or stroke. A recent study presented at the American Association for the Advancement of Science meeting suggests that the bacteria present in gum diseases may trigger blood clots which can contribute to a heart attack or stroke.

According to Dr. Timothy Rose, AAP President, this new study supports accumulating research that identifies gum disease as significantly increasing the risk for heart disease. The AAP believes emerging research in this area may establish periodontal disease as a risk factor for cardiovascular disease.

Gum disease, also known as periodontal disease, is one of the most common infections - often more prevalent than the common cold. Common signs of gum disease include bleeding gums or pus between the teeth. Left untreated, this chronic infection can destroy the bone that supports the teeth and may lead to tooth loss.

Further research in this area is currently underway and being funded by the National Institutes of Health. The Academy urges people who are at-risk for cardiovascular disease or have signs of gum disease to consult with a dentist experienced with treating periodontal disease. Regular periodontal screenings and evaluations, treatment, and professional maintenance are critical to the long-term management of periodontal disease.

Top of page

National Institute of Health Funds Research to Explore Gum Disease-Heart Disease Link

CHICAGO -- The National Institutes of Health recently approved a grant of $1.3 million to further study the link between periodontal (gum) diseases and cardiovascular disease. This funding will support the most comprehensive research to date to define the link between these two diseases.

According to the grant recipient, Dr. Robert Genco, Distinguished Professor and Chairman at State University of New York at Buffalo and Editor of the Journal of Periodontology, emerging research has identified infection and inflammation caused by periodontal disease as significantly increasing the risk for coronary heart disease.

Supporting one of Genco's theories, a recent study in the New England Journal of Medicine found that men with high levels of a marker for inflammation are at an increased risk for a heart attack. Genco will study the link between periodontal disease and cardiovascular disease over five years. The study includes 1,000 subjects of both men and women from Caucasian and African-American descent, along with 2,200 control subjects. All known risk factors for heart disease will be assessed: stress, hostility, diabetes, smoking, weight, high blood pressure, blood lipids, family history, diet, alcohol and physical activity.

Genco theorizes that inflammation caused by periodontal diseases contributes to plaque build-up in the arteries which creates greater risk of heart disease. The study will explore the association between these two diseases. More than $250 billion is spent annually in direct and indirect costs related to cardiovascular disease.

Genco's study coincides with another grant for $2.2 million in which collaborating researchers will also explore this link. The emerging area of periodontal and systemic links is one that could have significant impact on public health, Genco noted. The findings may be life-saving for some of the nearly one million people who die annually from heart disease, he suggests.

Previous studies demonstrated a link between periodontal disease and cardiovascular disease but were limited in size and/or scope, or did not fully control for all risk factors. The Journal of Periodontology, the official publication of The American Academy of Periodontology (AAP), publishes original papers of the highest scientific quality to support the practice, education, and research in the dental specialty of Periodontology.

The AAP is a 7,000-member organization of dentists specializing in the prevention, diagnosis and treatment of tissues surrounding the teeth and in the placement and maintenance of dental implants. Periodontics is one of eight dental specialties recognized by the American Dental Association.

Top of page

Transmission of Periodontal (Gum) Disease Between Family Members

Periodontal (gum) disease may be passed from parents to children and between couples, according to an article in the September 1997 issue of the Journal of the American Dental Association.

This research concurs with other recent findings that support the association between periodontal disease and family members. Researchers suggest bacteria that cause periodontal disease pass though saliva. This means that the common contact of saliva in families puts children and couples at risk for contracting the periodontal disease of another family member. Periodontal disease can lead to tooth loss. Based on this research, The American Academy of Periodontology (AAP) recognizes that treatment of gum disease may involve entire families. If one family member has periodontal disease, the AAP recommends that all family members see a dental professional for a periodontal disease screening.

Top of page

Gum Disease Linked to Heart Illness
USA Today

By Tim Friend
Tues., Feb. 17, 1998

PHILADELPHIA -- The most common strain of bacteria in dental plaque can cause blood clots that induce heart attacks when they escape into the bloodstream, researchers reported Monday.

Mark Herzberg of the University of Minnesota said the findings are the first to link bacteria to the formation of potentially fatal blood clots. Previous studies had found the incidence of heart disease is about twice as high in people with periodontal disease, but scientists didn't know why. ``Now we show a potential biological reason,'' Herzberg told the 150th annual meeting of American Association for the Advancement of Science.

In lab tests, Herzberg and colleagues injected bacteria from dental plaque into the bloodstream of rabbits. The bacteria caused blood clots to form within minutes. Rabbits are a proven model for testing hypotheses about human heart disease and heart attacks.

Chronic inflammation of the gums due to plaque also could be involved in the inflammation of the lining of the blood vessels that is known to lead to the build-up of plaque in the arteries, Herzberg said.

Additional studies presented at the meeting show that bacteria in plaque also are linked to:

• A potentially fatal disease called infective endocarditis in which the sac around the heart becomes inflamed.
  
• Lung infections in people with chronic lung diseases such as chronic obstructive pulmonary disease.
  
• A weakened immune system that can slow wound healing and diminish a person's response to vaccines against hepatitis B and influenza.
  
• A higher risk of giving birth to premature, low-birth weight infants.

Reducing risk of diseases linked to dental bacteria is a common lesson preached by dentists: Have the teeth cleaned regularly and floss daily. If necessary, have bone implants to replace dental bone lost from periodontal disease, says researcher Frank Scannapieco, State University of New York, Buffalo. Bacteria reside in pockets caused by bone loss where the teeth are attached.

Top of page

Microbes That Bite Bacteria Can Be The Couriers of Disease Chronic Tooth Infections Can Kill More Than Smile.
USA Today

By Steve Sternberg
Tues., April 14, 1998

The obituaries said nationally known syndicated humorist Lewis Grizzard died of heart disease, but there may have been more to it than that. At least one doctor who evaluated his case believes that Grizzard's heart valve problems stemmed from neglect of his teeth.

``He had bad teeth. He wouldn't floss, he wouldn't brush,'' says Atlanta oral surgeon Thomas Boc, who consulted on the case. ``He was a classic example of somebody whose chronic dental infection led to chronic heart disease, valve failure and ultimately death.''

Grizzard, 47, died in March 1994. Such cases, though extreme, are anything but unique. Doctors have known for years that dental infections pose a risk to heart valves, but new research suggests that dental infections also may be implicated in hardening of the arteries, heart attack, stroke and spontaneous, pre-term births.

The research indicates the buildup of oral bacteria won't just wreck your smile, give you bad breath and cost you your teeth. It may cause trouble ``a mile away, somewhere else in the body,'' says Dennis Mangan of the National Institute of Dental Research (NIDR), Bethesda, Md. If the eyes are a window into the soul, this theory holds, the mouth is a portal to the rest of you.

Some of the associations are firmer than others. But of this there is no doubt: Even the healthiest mouth is laden with bacteria, underscoring the need for good dental hygiene. ``The mouth is not a sterile environment,'' Mangan says.

That's putting it mildly. More than 200 types of bacteria dwell in the mouth. Of those, about 20 have been identified. The bacteria fall into two major groups, distinguished by their shapes. Some are like rods, others like balls.

A person with healthy gums needn't worry. A constant flood of saliva -- major glands in the mouth supply more than a quart a day -- flushes most of these germs down the hatch, into a cauldron of lethal digestive juices.

Saliva, the wonder drug

If a drug company manufactured saliva, the marketing department might tout it as a wonder drug. For example, saliva carries proteins that stop many bacteria from sticking to teeth. It also has proteins that cause bacteria to clump for easier disposal and buffers like bicarbonate to neutralize bacterial toxins. In a test tube, proteins in saliva can kill bacteria. Doctors have found that the mouths of people whose glands can't make enough saliva become a frequent target of bacteria, viruses and fungi.

In most people, periodontal trouble begins with painless, symptom-free infections at or beneath the gumline. Roughly half of all adults suffer the first stage of these infections, known as gingivitis, says Robert Genco, State University of New York, Buffalo. The percentage climbs with age. By age 60, 25% of people have advanced infections called periodontitis.

The danger zone lies in an area of the mouth known to dentists as the sulcus, which is the shallow trench where the teeth emerge from the gums. Typically, trouble begins when ball shaped streptococci and other bacteria stick to the teeth. Streptococci use a glue, made from sugar, that is similar to the substance mussels use to cling to the pilings of a dock. Porphyromonas gingivitis bacteria uses tendrils known as fembria.

These different strains of bacteria are symbiotic, meaning that they live together in highly organized colonies. Fluid-filled channels between the colonies carry off antibiotics, making the bacteria up to 1,000-fold more antibiotic resistant than bacteria floating freely through the blood. This makes the colonies extremely tough to dislodge.

Bill Costerton of the Center for Biofilm Engineering at Montana State University, Bozeman, has witnessed this bacterial buildup cell by cell, on a tiny scale covering just a millionth of a millimeter. Costerton uses an experimental technique, adapted from space-age technology, called a confocal scanning laser scope. This device, which does not harm the bacteria, bounces intersecting blades of photons off bacterial colonies. A $500,000 computer turns the reflected photons into a colored image. "We can watch bacteria settle on the tooth surface,'' he says.

Bacterial towers

Streptococci settle first in a layer one or two cells deep; porphyromonas uses the strep for a foundation and builds towers 500 cells deep. ``Strep will grow down the tooth, then porphyromonas widens the sulcus and makes it extremely pathogenic,'' Costerton says.

This is when the trouble really starts. The trench not only grows, but the body responds by activating the immune system, flooding the tissues with inflammatory substances known as cytokines. A recent report in the New England Journal of Medicine linked one of these, C-reactive protein, with more extensive buildup of fatty deposits inside blood vessels.

Brent Muhlestein of the LDS Hospital, Salt Lake City, told the American College of Cardiology two weeks ago that antibiotics appeared to mute this inflammatory response. But the study, designed to determine whether antibiotics can reduce the risk of heart attacks, cardiovascular deaths and unexpected bypass operations, will not be complete for a year and a half.

In February, the University of Minnesota's Mark Herzberg reported, however, that the bacteria in dental plaque can cause heart-attack-inducing blood clots. In that study, the researchers injected rabbits with dental bacteria. Clots formed within minutes. Genco, of Buffalo, says porphyromonas tends to clump with blood-clot producing cells called platelets.

Researchers believe that these clumps irritate blood vessel walls, leaving abrasions where fatty deposits may cling, narrowing the arteries. Blood clots, perhaps formed to repair the damage, may cause heart attacks, he says.

In a study of the Pima Indians, Phoenix -- a tribe plagued by a high rate of heart complications from diabetes -- Genco and his colleagues have found that those with gum infections have triple the heart attack risk as those who don't have gum infections. Genco calls the rate ``astonishing.'' Since few Pima smoke, he notes, cigarettes can't be blamed for the difference.

Not every study has produced positive results. William Christen of Brigham and Women's Hospital, Boston, says that researchers looked at whether gum disease influenced heart attack risk in 22,000 doctors participating in the long-term Physicians Health Study. It did not appear to, but the study was based on the doctors' own reports of gum disease.

A study of 44,119 male health workers, by a research team at Harvard's School of Dental Medicine, yielded similar results overall -- but the researchers did find a link between tooth loss and and the risk of coronary artery disease among men with a history of gum disease. This suggests the importance of tooth loss as a measure of the severity of gum disease; this may be a more accurate marker than a doctor's memory.

Although all facts are not in yet, some dentists and oral surgeons say there's strong anecdotal evidence that dental infections play a role in heart disease. ``We've been seeing this for 20 years,'' Boc of Atlanta says. ``It's been a very contentious issue between oral surgeons and cardiologists. We were often called to the operating room before bypass surgery to remove infected teeth. Almost to the patient, the ones who came in for heart surgery had an associated dental problem.''

Boc says cardiologists didn't appreciate the extent of the probable link between dental infections and heart disease. ``It was like screaming at a brick wall. They didn't see an association. They couldn't see it. They weren't dentists, and there was nothing in the literature about it.''

Cardiologist Muhlestein, of Salt Lake City's LDS Hospital, says most of the reports have been in dental journals until recently. ``I'm just finding out it's all there and getting into it. It sounds very interesting as a hypothetical explanation that might be real.''

Top of page

Heart Disease & Gingivitis
University of Colorado Health Sciences

FOR IMMEDIATE RELEASE

December 2, 1998

Contact: Mike Cobb
(303) 315-5571 or
MikeCobb@uchsc.edu

Two out of three dental hygienists recently surveyed report seeing signs of hypertension and heart disease in certain patients, according to practicing dental hygienists who participated in the 1998 American Dental Hygienists' Association/Colgate Oral Health Care Survey.

These observations, as well as evidence in scientific literature linking periodontal disease to stroke, heart disease, and pre-term low birth weight babies, speak to the important role dental hygienists can play in preventing medical, as well as oral, ailments. Nearly nine out of 10 respondents plan to take a proactive role in educating patients about these possible links in the immediate future.

"Dental hygienists are catalysts for prevention of poor oral health as well as much larger systemic health problems, such as stroke, heart disease and pre-term births," said Donna Stach, RDH, MEd, associate professor in the University of Colorado School of Dentistry's Hygiene Program. "It is more important than ever that we arm dental hygienists with the information they need to motivate patients toward making oral hygiene a priority."

The computerized survey was sponsored by the Chicago-based ADHA, the largest national organization representing the professional interests of registered dental hygienists nationwide, and the Massachusetts-based Colgate Oral Pharmaceuticals, the professional oral care products subsidiary of Colgate-Palmolive Co.

In addition, the survey showed that gingivitis is the number one oral health problem receiving inadequate patient attention. "Registered dental hygienists play a critical role in preventing symptoms of gingivitis and poor oral hygiene," Stach said. "They also play an even bigger role in motivating patients to be concerned about how their oral health affects overall health."

Of those practicing dental hygienists active in their communities, more than two-thirds said the community outreach programs of choice are child-specific oral health initiatives. In addition, one third of respondents volunteer for elderly oral health programs.

When asked which population group is most likely to be denied access to oral health care, one-third of practicing dental hygienists who responded said the low-income populations, and another third said home-bound individuals.

Additional Survey Findings:

According to practicing dental hygienists, three out of four patients do not change their toothbrush as often as they should. Instead, only one out of three patients change their toothbrush once every three months, as recommended.

When practicing dental hygienists were asked if they could change one oral health habit of their clients, they reported the following: 46% of their patients do not floss, or floss irregularly; 20% visit their dentists irregularly; 16% use tobacco, and 15% do not brush properly.

The University of Colorado Health Sciences Center is one of four campuses in the University of Colorado system. Located in Denver, Colo., the campus includes schools of medicine, nursing, pharmacy, and dentistry, a graduate school and two hospitals.