"The times...they are a changing"

Albandar et al, in the J Perio 70:13-29, 1999, studied 9,689 persons ages 30-90. The authors concluded that only 35% of the population had periodontitis, and only 12.6% of the population suffered from a moderate to severe form of it. This and other studies demonstrate that periodontal disease is less prevalent today than it was a generation ago. Are we witnessing the "death knell" of periodontal practices as we know them today? Is treating periodontal disease unnecessary? Hardly...on either account.

To understand why it is essential to still treat - and detect - periodontal disease, let's review current notions about periodontal disease while dispelling some popular myths.

Myths...and facts

Myth 1: Periodontal disease occurs in a linear fashion. Once a person is diagnosed as having periodontal disease, it's all downhill from there....resulting in tooth loss.
Fact 1A: Periodontal disease occurs during brief periods of time, commonly referred to as "episodes." These episodic periods of periodontal breakdown occur in a matter of days or a few weeks, not over a period of months and years. In fact, it is not unusual to observe periodontal breakdown during the interval of consecutive 3-month periodontal maintenance treatments.
Fact 1B: Patients treated for periodontal disease are most likely to experience long periods of periodontal stability (measured in years) during which time little change will occur in their mouths...as long as they maintain good oral hygiene and have frequent dental care.

Myth 2: Everyone is going to get some form of gum disease.
Fact 2: Many people are "resistant" to getting periodontal disease, and dental decay for that matter. In fact, dental decay has been reduced by more than 70%.

The results:

• 34 patients had no attachment loss (no new periodontal pockets formed)
  
• 12% of the pockets present at onset grew worse (by at least 2mm)
  
• 5% of the patients accounted for 50% of the "new" disease

What does this mean? It supports our observations that:

1. Many untreated pockets did not get worse during a 6-year period
2. Persons with periodontal disease react differently, over time, to their particular condition.
3. Periodontal disease, as stated above, does not worsen linearly.
4. Some patients with advanced periodontal disease get worse in spite of continuous periodontal treatment.
5. Most periodontal pockets are inactive for long periods of time.

Are we saying that it's okay not to get periodontal treatment because not much will happen in the long run? Or that even with periodontal disease, you don't have to practice good oral hygiene, go to the dentist, or follow your dentist's recommendations because nothing much will happen? On the contrary. The best predictor of future periodontal breakdown is the existence of periodontal pockets. The fact remains that deeper pockets are likely to break down over time, and they do benefit from ongoing care. Even in the face of a nation of healthier mouths, everyone needs their periodontal status identified, treated when diagnosed, and maintained more closely than ever. If you need more reasons as to why you should listen to your dentist and/or hygienist coax you to better oral health, consider the following.

The prevalent theory, these days, is that atherosclerosis is an inflammatory disease resulting from an initial injury to the epithelium lining the coronary vessels. This initial injury leads to a chronic inflammatory process (not unlike the way bacterial plaque irritates our gums). Monocytes are drawn to the injury site through the endothelium, along with a migration of smooth muscle cells. These events are followed by hydrolytic enzymes, cytokines, chemokines, and growth factors...all of which are activated in the blood vessel causing more localized damage.*****

Truth and consequences

Society (and we agree) views good dentistry and healthy gums as an essential part of a person's overall health and well-being. To obtain this, consider the following:

1. What is the role of the host (i.e. patient) in the disease process?
2. What determines disease susceptibility?
3. What modifies disease severity?
4. What influences disease progression?
5. What contributes to the recurrence of periodontal disease?
6. What affects the "outcome" of periodontal therapy?

To answer these questions, we must consider various environmental and acquired risk factors.
These include:

A. Tobacco usage	F. Compromised host defense
B. Systemic diseases	G. Poor oral hygiene
C. Stress	H. Low socioeconomic/education status
D. Advancing age	I. Infrequent dental visits
E. Race, ethnicity	J. Genetics

These factors affect one's predisposition to periodontal disease, one's response to periodontal treatment, and the course of the disease once it is established. For a host of reasons, it's important to understand how periodontal status can change.

Example: A person with "moderate" periodontal disease having a few 5 mm. pockets and a little bit of bone loss, has his/her teeth "cleaned" once/year even though the dentist recommends more frequent cleanings. Years pass and subtle changes occur. A few pockets deepen, some new ones form...and then the patient suffers a heart attack. A triple coronary bypass is needed. By the time the patient returns to the dentist, periodontal breakdown is rampant and teeth need to be removed. Could this have been prevented? Most likely. The damage created by the stress of the MI could have been minimized (and even avoided) with ongoing dental/periodontal care. (Keep in mind, any number of life events causing stress could have served as an example here: a severe illness, divorce, job loss, or the passing of a loved one.) Maintaining optimum dental health helps reduce the damage that can occur when environmental/risk factors change. In fact in this example, better dental care may have even helped prevent the person's heart attack. (See the last article in this issue).

Paradigm shift

In the spirit of our first headline (The Times...they are a changing), let's describe modern dentistry as everything that has occurred from the days of Paul Revere - who, as a silversmith, fashioned one of the known sets of George Washington's teeth) - to the present. Perhaps the new paradigm shift should be labeled: 2001, a Dental Odyssey.

In any case, for more than two centuries, dentistry has followed a "repair" model. If a cavity was detected, it was filled. If a tooth was broken, it received a crown. If a tooth was lost, it was bridged by something removable or, better yet, one that was permanent. If there was a pocket next to a tooth, it was scraped or had surgery. If there was a hole in the bone, it received a bone graft. You get the picture.

Now, we propose that dentistry's paradigm shift - as in medicine - is to "wellness." In so doing, even if a patient does not have periodontal disease, we need to ask if he/she has risk factors that will cause this person to "get" periodontal disease later in life? And if so, what effects will this have on tooth and bone retention? The patient's overall medical health? How about this: can oral disease make systemic disease worse? The evidence is mounting for a resounding, "Plenty.on all accounts."

Here's what we know today. Systemic diseases are linked in varying degrees to oral disease. Some data are hard and fast, some are preliminary, and some are (for the time being) by inference alone. Regardless of the data, these concerns are real. Links now exist (in varying degrees) between periodontal disease and:

premature low birth weight (newborns)	mortality (shorter life expectancies)
aspiration pneumonia	atherosclerosis
diabetes mellitus	coronary heart disease
osteoporosis	stroke

While there is no hard data that causally links the above diseases and conditions to periodontal disease, evidence is mounting from retrospective studies that there may be something to worry about. Please note that NO prospective studies exist (at this time) that enables us to declare these relationships as cause-and-effect. They may prove to be only statistically associated. But does that matter? Should we wait for prospective studies to be completed before we alter the way we treat our patients? We think not.

Here's the paradigm shift: as dentists, we have a responsibility to promote wellness long before we provide "repair." We are obligated to not only inform our patients, but our medical colleagues, as well, about the interaction of periodontal/oral diseases with systemic diseases. This goes far beyond saving teeth.

Plaque attack!

Here's the sort of evidence that's appearing in the literature. The health risks of sixty patients with acute myocardial infractions (50 men, 10 women, mean age 53.8 + 9.5 years) were compared to those of sixty patients with chronic coronary heart disease (42 men, 18 women, 58 + 9.5 years). Besides studying serum total cholesterol, triglycerides, HDL- and LDL-cholesterols, and fasting blood glucose levels, all patients received a complete dental examination. Clinical factors and risk factors were assessed with logistic regression analysis. The results (for this group) were clear:

The acute myocardial infarction group had more visible plaque around their teeth, more periodontal pockets, and they smoked more than the patients with the chronic coronary disease. Diets were slightly different, too.

The authors discuss the fact that periodontal disease is a bacterial infection that may play a role in coronary heart disease, and that this was the only risk factor significantly different in the two study groups. They note that periodontal infections may cause vascular events release of lipopolysaccharides and inflammatory cytokines, and may contribute to platelet aggregation leading to thromboembolic events. They conclude by highlighting the need for prospective studies with large numbers of patients.

*Emingil G., Buduneli E., Aliyev, A., Akilli, A., and Atilla G.: Association between periodontal disease and acute myocardial infarction. J Perio 71:1882-1886, 2000.

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