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Inside Dentistry

May 2007, Volume 3, Issue 5
Published by AEGIS Communications


Putting Dentistry Front & Center: New Research Supports the Link between Oral Care and Overall Health-and Everyone' s Taking Note

Allison M. DiMatteo, BA, MPS

It really can’t be downplayed anymore. The association between oral disease and systemic health exists and presents real implications for overall well-being. As it relates to the connection between the treatment of severe periodontitis and improvements in endothelial function, the evidence in support of that association has been strengthened with the publication in early March of a research article by Maurizio Tonetti, DMD, PhD, and his colleagues in the New England Journal of Medicine.1

Their research showed that intensive periodontal treatment of patients with severe periodontitis resulted in acute, short-term systemic inflammation (eg, inflammatory biomarkers and markers of coagulation and endothelial activation) and endothelial dysfunction, as assessed by measurement of the diameter of the brachial artery during flow (ie, flow-mediated dilatation). Six months after therapy (scaling and root planing, local delivery of minocyline microspheres, and extraction of hopeless teeth), however, the benefits of treatment and oral health were associated with improvement in endothelial function.1

According to Tonetti himself, there is a growing body of evidence that says that there is a causal relationship between periodontitis and the processes of atherosclerosis. The study he and his colleagues just published “really shows that periodontitis can contribute to it and, very importantly, that if you treat periodontitis, the processes will reverse.” That’s not to say that periodontitis is a major cause of heart disease or atherosclerosis, he says. Rather, among the many risk factors that can contribute to the development of atherosclerosis, periodontitis is there.

Taking note of these findings have been members of organized dentistry, government research agencies, public health advocates, academia, and dental product manufacturers, among others. In essence, their comments suggest agreement that this research represents a significant landmark in terms of solidifying the importance of oral health to overall health. It further supports the need for not only intervention measures (ie, periodontal treatments), but even earlier preventive measures.

“I think my biggest hope for this study is that dentists understand that oral infections like periodontitis may have consequences beyond the mouth and need to be treated—not totally for the oral health benefits such as maintaining the dentition, but perhaps in a way that contributes to the patient’s general well-being,” Tonetti says. “It is also my hope that physicians and cardiologists will see dentists and periodontists more and more as partners with whom they can better treat their patients.”

If periodontal disease as a risk factor for systemic conditions such as atherosclerosis is becoming a more proven fact, then some say it’s time to take advantage of the tremendous prevention and treatment advancements the dental profession has introduced in recent years in order to curtail oral infection and inflammation at its earliest signs and stages (See Taking a Pulse of Periodontics in Today’s World, page 46). What’s more, others are hopeful that more adept social marketing will take place—similar to what accompanied the issue of cholesterol and heart health back in the 1970s. According to the American Academy of Periodontology (AAP), the findings of the study by Tonetti and colleagues support the need for additional research to determine whether the treatment of severe periodontitis could reduce the risk of developing atherosclerosis and cardiovascular events in adults.2

“One of the issues that we have been focused on for many years in the Office of the Surgeon General has been the concept of prevention, and this article, while primarily focused on interventive activities, also focuses on prevention activities,” explains Rear Admiral Kenneth P. Moritsugu, MD, MPH, Acting Surgeon General of the United States. “The Office of the Surgeon General is a science- and evidence-based office, and our role is to increase the information base so that the American people—the American public—can make good decisions about their own health. This includes oral health as well as the health of the entire body, and what Dr. Tonetti and his colleagues have outlined is very consistent with that approach.”

According to Ray Williams, DMD, professor and chair of the department of periodontology at the University of North Carolina School of Dentistry, now is an exciting time for those involved in dentistry and periodontology “as we are coming to fully realize the role of inflammation in the pathogenesis of periodontal disease. We appreciate that inflammation is becoming a major player in many of the systemic diseases that plague humans.”

Here’s the Inside story on how various members of the oral healthcare profession at large are responding to the news that yes, there’s more evidence to prove an association between periodontal disease and systemic events. Their perspectives reflect interests from scientific vantage points as well as the positioning of public policy; global health implications and individual well-being. They pose questions for the future but, overall, share their excitement and applause over the scientific literature’s most recent addition concerning oral care and its effect on the body.

What They’re Saying About the Research

“What we have here is a very well-conducted study of about 120 subjects showing that when periodontal disease is carefully and aggressively treated and periodontal inflammation is significantly reduced, there is an effect on the cardiovascular state of that individual,” observes Williams. “This is exciting news because it continues to further our understanding of the critical role of good periodontal health on a person’s overall health.”

Notes Jane C. Atkinson, DDS, program director of the clinical trials program at the Center for Clinical Research at the National Institute of Dental and Craniofacial Research (NIDCR), the article by Tonetti and colleagues demonstrates that treatment of severe periodontitis causes a systemic inflammatory response that influences endothelial function. “Intensive treatment of severe periodontitis initiated an acute systemic inflammatory response and altered endothelial function 24 hours after therapy. Long-term, the periodontal treatment appeared to improve endothelial function,” Atkinson explains.

Also important is the fact that this recent addition to the literature [Tonetti et al] confirms a January 2006 article by Elter and colleagues published in American Heart Journal that also reported that periodontal therapy can improve vascular endothelial function.3 At the time of that publication, the researchers concluded that their results represented proof of concept that improvement in endothelial function—as measured by flow-mediated dilation of the brachial artery (eg, which was used in the paper by Tonetti and his colleagues)—may be possible with the near-elimination of chronic oral infection. They also concluded that their results justified conducting a larger controlled trial.3

“This [Tonetti article] is truly a breakthrough article that is very specific in that it deals with the cardiovascular aspect of the systemic link,” explains Preston D. Miller, Jr, DDS, president of the AAP. “We also have links with obesity, diabetes, and other conditions, but this article specifically focuses on cardiovascular disease and the potential for altering atherosclerosis (ie, hardening of the arteries) by treating periodontal disease.”

Looking Toward Other Links

With attention to the study by Tonetti’s group has come a frenzy of renewed urgency to address periodontal disease, the periodontal health of patients, and the periodontal intelligence of the public—not just in the United States but also worldwide. “My reaction is one of great interest because the publication of this research reaffirms what Dr. C. Everett Koop said when we launched the Oral Health 2000 Coalition, which is that you’re not healthy without good oral health,” emphasizes Robert Klaus, president and chief executive officer of Oral Health America. Since 1955 the organization has been dedicated to oral health outreach programs and, particularly since 1992, to championing the idea that oral healthcare is essential to overall well-being.4

What the current article does is add to the knowledge and understanding that we have about this relationship, believes Foti Panagakos, DMD, PhD, director of professional relations for Colgate-Palmolive Company. He says that it again provides very meaningful data relative to the effectiveness of periodontal therapy on impacting a systemic disease, not unlike the results that Genco and colleagues showed in the Pima Indian studies with regards to diabetes and Hb1c levels after scaling and root planing.

“One observation I have is that the Tonetti article mirrors very much the data and information we already have within the United States Public Health Service (USPHS) and very specifically within the Indian Health Service,” explains Moritsugu. “Retired Captain G. Todd Smith, DDS, MSD, has been looking at nonsurgical interventions to periodontal disease and actually has a major program within the Indian Health Service to address this.”

Moritsugu elaborates that part of that program is focused on the concept that periodontitis has an association with a number of specific diseases, including diabetes, infective endocarditis, cardiovascular disease, pre-term/low birth weight infants, and pulmonary disease. He says the bottom line is that the information published by Tonetti and colleagues in the New England Journal of Medicine did not come as a surprise because the USPHS has been familiar with this kind of association within its programs.

Positioning the Perspectives

For a public health advocate and coordinator of outreach efforts like Klaus, there are several dimensions to the implications of the Tonetti study. One is the fact that if the public is made aware of periodontitis as a risk factor for cardiovascular disease—which is the #1 killer by far in the United States, he says—then hopefully more lives could be spared. Also, he says research such as this when published in the medical literature drives home the message that oral health is an integral part of overall health. Others echo his position.

There is an emerging body of evidence that links poor oral health to increased risk for systemic disease, including cardiovascular disease, explains John W. Robitscher, MPH, executive director of the National Association of Chronic Disease Directors (NACDD), a national public health association founded in 1988 to link each state’s chronic disease program directors and provide a national forum for chronic disease prevention and control efforts. Studies have demonstrated that chronic inflammation is a significant risk factor for atherosclerosis, and periodontal disease is an inflammatory condition, Robitscher says.

“When we look at the emerging studies coming from patients with diabetes, from mothers-to-be who have periodontal disease, and of endothelial function as a measure of cardiovascular conditions, we can no longer ignore the fact that prevention and treatment of periodontal disease plays an important part in a person’s overall well-being,” Williams emphasizes.

In this same vein, Neil Romano, president of Romano Group, LLC, and a long-time consultant to Oral Health America, sees the publication of the Tonetti article as “an unbelievably good teaching tool and opportunity for dentistry to position itself out in front of a major issue by showing the American people how important and closely connected the mouth is to the rest of the body.” He explains this is something that dentistry has been trying to do for a long time; this recent article in the New England Journal of Medicine provides an opportunity to do just that in an impactful way (See The Politics of Public Oral Health Policy, page 48).

“My initial and further reaction is that I welcome this scientific look at the relationship between the treatment of periodontitis and improvement in endothelial function,” explains Moritsugu. “Back in the year 2000 when we issued the Surgeon General’s Report on Oral Health in America, which was followed by our National Call to Action to promote oral health in 2003, we had already identified the issue that oral disease and disorders affect health and well-being, and that the mouth can be used to reflect that. As part of the Report and the Call to Action, the Office identified the need for further research in this area, and we’re glad to see Dr. Tonetti and colleagues’ addition to the scientific literature.”

In an interview with Inside Dentistry 1 month prior to the publication of the article by Tonetti and his colleagues, Louis F. Rose, DDS, MD, a clinical professor at the University of Pennsylvania School of Dental Medicine and a professor of surgery at Drexel University College of Medicine, observed that the oral-systemic connections are getting more and more attention among dentists and physicians because there’s now research to support what was previously just intuition. The present article under discussion is just one more such example.

“Now that we know that conditions such as cardiovascular disease are inflammatory diseases, it makes sense that periodontal disease—which is an inflammatory disease—may play a role as a risk factor for cardiovascular disease,” Rose said. “What we need are more intervention studies that demonstrate cause and effect.”

Marketing the Message to the Masses

Putting aside the fear factor and alarmist tactics, it is important to alert the public to the issue of periodontal disease as a risk factor for cardiovascular disease, explains Klaus. “The more people you can alert to the issue of periodontal disease and cardiovascular disease, the more lives will be spared and the more resources saved to be put to other uses,” Klaus explains.

However, Rose has always maintained that dental professionals should assure patients that periodontal disease is a preventable disease, a manageable and treatable disease, and one that may have an impact on other aspects of their health. The key word here, he says, is may.

“You can’t tell a patient that if you don’t floss, you’re going to die,” Rose says of such inaccurate and frightening presentations. “Rather, explain that periodontal disease is a chronic bacterial infection—meaning, it’s treatable—and since you wouldn’t want to walk around with an infection in any other part of your body, why would you want to walk around with a disease in your mouth?”

According to Robitscher, whose organization advocates for preventative policies and programs and encourages knowledge sharing and developing partnerships for health promotion throughout the United States and its territories, the recent published study by Tonetti and colleagues adds to the body of work that demonstrates a link between oral health and cardiovascular health. In addition, he sees it as supporting prevention as the best and most cost-effective way to spend limited health dollars. However, Robitscher notes that oral diseases also are increasingly linked to other chronic diseases, such as diabetes and obesity, and that these connections have relevance for public health activities and oral health programs.

“We know that there are similar risk factors for periodontal disease and chronic [systemic] disease,” Robitscher says. “Knowledge of these cross-cutting risk factors and providing high-quality education on prevention techniques to individuals will be important.”

Romano’s immediate hope is that dentists will use the article by Tonetti and colleagues as a springboard for more in-depth conversations with their patients, being fearless in their discussions about periodontal disease and its role in hindering good overall health. He recognizes that patients may realize that periodontal disease and oral lesions need to be treated, but they might not be able to connect those conditions to being potentially harmful to the rest of their bodies. “This research can connect it for them,” Romano explains. “This provides dentistry with the opportunity to make those connections and really assist in the overall healthcare of the patient.”

Panagakos emphasizes that gum disease needs to be treated whether a person has a cardiovascular disease or not because an improvement in oral health ultimately contributes to an improvement in the quality of life of the individual first and foremost. Secondly, he says, if there is an associated systemic disease occurring that has been shown to have a relationship to oral disease—similar to what the New England Journal of Medicine article described—then hopefully physicians will fully understand the implication of poor oral health and promote this understanding relative to cardiovascular disease with their patients.

“I hope this [Tonetti et al] article will encourage physicians and internists, as well as those who work specifically in cardiovascular disease, to seek out more information and to initiate a dialogue with their dental counterparts relative to the management of these patients moving forward,” Panagakos says. “The ultimate long-term positive outcome I can see from this study is a change in the way we manage patients.”

Acting Surgeon General Moritsugu notes that no one segment of society has the corner on keeping people healthy and improving the public’s health. If anything, he says, it’s important that the various components—the various professions and segments of society—bridge and collaborate with each other in a synergistic fashion.

“Together we can have a much larger impact on the health and well-being of the people of our nation than we can if we did things in a smokestack approach,” Moritsugu explains. “The impact of Dr. Tonetti’s article, as well as the information that we have specifically from the Indian Health Service, is that a collaborative team approach that bridges oral health providers with medical providers with ancillary providers with the communities at large and with the decision makers—all working together—will have a much greater impact than anyone working alone.”

Speaking globally, Williams explains that what is becoming increasingly apparent as he interacts with more and more people around the world is that periodontal disease is still very much a major disease among all people. The majority of the world’s population, he says, does not receive any treatment for periodontal disease, so there is still much to be done to bring prevention and treatment strategies to more people worldwide.

Williams further notes that the findings by Tonetti and his colleagues have tremendous worldwide implications, and he emphasizes very specifically that a renewed and aggressive effort needs to be made to increase the access to dental care to all people, not just those in our own backyard. “By doing so not only are we improving oral health, saving teeth, and reducing the suffering of people with poor oral health,” Williams explains, “but clearly good oral health will improve the overall condition of the individual.”

Conclusion
Of course there are those looking toward the future, knowing that the nature of any direct cause-and-effect relationship is slowly coming to light (See Questions to Consider for the Future, page 50). Williams cautions the skeptics, however, that just because there isn’t a known direct cause-and-effect relationship [between periodontal disease and systemic disease] that it does not mean that studies such as the one by Tonetti and his colleagues won’t lend validity to an increasing importance of oral health.

“These small steps simply point us in the right direction and remind us that there is a lot to be done to bring good oral health to a great many people who have no dental care,” Williams says.

When research such as this appears in the literature, it’s an opportunity for dentistry to reorient itself to the calling of health and oral healthcare and less to an association with cosmetics, believes Klaus. “The article by Dr. Tonetti and colleagues in the New England Journal of Medicine speaks powerfully to the need to reformat the message of dentistry toward oral healthcare, and it puts oral health directly in the crosshairs of medical research,” Klaus says.

It’s also an opportunity for dental professionals to remember to “involve, evolve, and resolve” themselves, believes Miller. “Whether as a specialist or general practitioner, we need to stay involved and informed by reading articles, taking continuing education courses, and getting involved with our dental colleagues, our medical colleagues, and other healthcare professionals,” Miller elaborates. “As the science dictates, we—as dentists—then need to evolve. Lastly, we need to keep our resolve because there will inherently be bumps in the road.”

SIDEBAR 1

Taking a Pulse of Periodontics in Today’s World

Dentistry is dynamic. The knowledge base is changing rapidly and being scrutinized considerably in response to advancements and discoveries. Research continues to mount to suggest associations between periodontal disease and other systemic conditions such as diabetes, adverse pregnancy outcomes, and cardiovascular diseases. With the publication of the research study by Tonetti and colleagues in the New England Journal of Medicine, periodontitis as a risk factor for atherosclerosis is added to the mix.

How and what is the dental profession doing today when it comes to the treatment of periodontal infections? How do the guidelines for managing patients with periodontal disease come into play? In what ways are insurance companies beginning to examine specific cost-benefit relationships that occur as a result of patients receiving periodontal care? Overall, how do people stand to benefit from the ongoing research surrounding the oral disease process in terms of prevention/treatment alternatives?

MANAGING TODAY’S PATIENTS WITH PERIODONTAL DISEASE

In September 2006, the American Academy of Periodontology (AAP) published its “Guidelines for the Management of Patients with Periodontal Diseases,”a which include suggestions on how co-treatment with the periodontist or treatment solely by the periodontist might benefit the patient. Preston D. Miller, Jr, DDS, current president of the AAP, explains that the American Dental Association (ADA) has guidelines for how and when to refer patients to specialists—which the AAP supports. The AAP guidelines have a different focus. By title, they are guidelines for patient management, and nowhere in the title does it mandate referral, since the ADA has already addressed those issues, Miller explains. “We feel our guidelines complement the ADA guidelines,” he says.

“Given the collegial and cooperative relationship periodontists have had with general dentistry long term, the emphasis of our guidelines is on patient care—to ensure the most complete and best periodontal care possible for the American public,” Miller explains. “The major focus of our Academy always has been and hopefully always will be to help the American public.”

The AAP guidelines classify patients in three categories (eg, Level 1, Level 2, Level 3); the first two deal with co-management of the patient by the general dentist and periodontal specialist and are very straightforward, Miller says. Level 3 identifies patients that should be treated by a periodontist; it’s this category that has created some controversy. In this category patients with periodontal diseases, regardless of severity, are the patients the referring dentist may prefer not to treat. Miller says that the significant aspect of that statement is the part that says “that the referring dentist prefers not to treat.” The guidelines were written to help general dentists refer those patients they do not want to treat and/or feel would benefit from specialty care.

“Different general dentists have different levels of training and experience. They also have different levels of interest, whether it be providing cosmetic, restorative, or periodontal treatments,” Miller says. “In no way do we want to encroach upon those general dentists who choose to treat these patients’ periodontal diseases.”

In light of the recent research presented by Tonetti and colleagues, the AAP guidelines become more timely. According to the AAP, they’re intended to help dental professionals in the rapid identification of those patients at greatest risk for the consequences of periodontal inflammation and infection and, therefore, those that are most appropriate for specialty referral.

EXAMINING THE COST-BENEFIT RELATIONSHIPS OF PERIODONTAL TREATMENTS

In recent months Inside Dentistry and its supplemental publications have shed light on research endeavors undertaken in part by insurance carriers in order to identify ways to control costs and simultaneously provide their members with better care. According to Glenn R. Melenyk, DDS, dental consultant for Blue Cross/Blue Shield of Michigan, studies have shown links between diabetes and periodontal disease. Now working with the University of Michigan and Dr. George Taylor, his organization is taking a step forward to prove that beneficial outcomes and cost savings on the medical side can be realized when patients with diabetes receive proper preventive dental care for periodontal disease. The 1-year study began October 1, 2006; a progress report is expected by early August.

“What makes this study important to dentistry is that our profession should be brought into the holistic treatment of the entire body,” Melenyk says. “For years it’s been dentists treating their part of the body and physicians treating the rest of the body; we forget that they’re all connected to an actual person. The mouth is not a gateway to the tonsils.”

According to Melenyk, through this research BC/BS of Michigan hopes to show that treating dental conditions such as periodontal disease (ie, a low-grade chronic infection) also treats the resulting inflammation that occurs throughout the body. While such treatment might not cure other systemic diseases, it would remove “that little insult and allow the body to better heal itself in conjunction with the medical care that the patient is receiving overall.”

WHERE DO WE STAND?

According to Melenyk, the number of claims he’s seen for periodontal care are remaining stable, if not increasing. That’s a good sign, he says, because it means more dentists are recognizing periodontal disease. There’s less and less aggressive surgery, Melenyk observes, and more early, conservative treatment such as scaling and root planing.

On the not-so-positive side of the equation, there’s been an increase in the number of cases of periodontal disease as a result of people’s lifestyles—not eating the right food, not brushing their teeth properly, and the obesity/diabetes/ periodontal disease link. Additionally, Melenyk says the unfortunate part is that the profession isn’t seeing the people who need periodontal treatment the most—those who don’t have insurance and can’t afford to see a dentist.

Ray Williams, DMD, professor and chair of the department of periodontology at the University of North Carolina School of Dentistry, explains that on the one hand dentistry is making tremendous strides in diagnosing and treating periodontal disease, in delivering breakthroughs in tissue engineering and salivary and peripheral blood markers for diagnosis, and in understanding oral infection, inflammation, and how to calm it. On the other hand, he says “we are still bringing all of these research advances to the few, and what we are not yet doing is making sure that all people have access to our knowledge and to our prevention and treatment strategies.”

SIDEBAR 2

The Politics of Public Oral Health Policy

Generally speaking, those we interviewed see the publication of the research article by Tonetti and colleagues as not only a breakthrough study but also an opportunity to inform, prevent, and treat periodontal disease. But what about those patients who have the disease but can’t get to or afford dental care? Some of our interviewees suggest that, additionally, we must also move beyond the dated thinking of the mouth being segregated from the rest of the body—at least as far as its significance to overall health is concerned—that continues.

According to John Robitscher, the recent article in the New England Journal of Medicine demonstrates the needs to work together, promote program integration at the state health department level, and co-sponsor interventions and public awareness campaigns at the local level in order to increase effectiveness and maximize results. He says it further suggests that practice-based networks in cardiovascular and oral health communities can work collectively to provide the additional data needed to justify significant policy changes that would help to reconnect the mouth to the rest of the body.

“Adequate prevention strategies require integration of improved oral healthcare into cardiovascular disease prevention and control programs and policies,” Robitscher emphasizes. “Adequate funding from the federal government is also critical.”

Neil Romano suggests that this research—which strengthens the connection between improvements in oral health and improvements in endothelial function—may bridge the long-time gap between dentistry and medicine, or between the mouth and the rest of the body. When that happens, from a public policy point of view, the result will likely be that patients will have a greater opportunity to receive better overall healthcare, Romano speculates.

After all, public policymakers were themselves once members of the public. They need to understand the intricate mouth/body relationship, he says, which will then elevate the practice of dentistry and the level of attention members of the profession receive as healthcare providers.

The Office of the Surgeon General—although not a policy office—does take seriously its role and responsibility of better informing the American public, which includes those individuals who make policy, explains Acting Surgeon General Rear Admiral Kenneth P. Moritsugu, MD, MPH. Therefore, the Office examines what the best science is, what the best data are, and what the best evidence is that can better inform every segment of the American population regarding the choices that they need to make.

“When we look at information that has already emerged, that has been crystallized in one area by Dr. Tonetti and his colleagues, I hope that those who are responsible for making choices—including policymakers—will be better informed by the science,” Moritsugu says.

SIDEBAR 3

Questions to Consider for the Future

Those who spoke with Inside Dentistry applaud the research and publication by Tonetti and colleagues and look forward to further endeavors by others in the profession toward a broader understanding of oral disease and its impact on systemic health. For example, more research needs to be conducted to fully understand the impact that improving oral health will have on not only cardiovascular disease, but also on other systemic diseases that have been associated with oral health and conditions in the oral cavity.

Ray Williams notes that periodontal disease as an inflammatory disease is being re-examined in terms of how dental professionals might effectively prevent and treat it. Related questions surround whether or not researchers should be developing new anti-inflammatory strategies to greatly supplement and augment current anti-infection strategies, he explains.

He also remarks that the collective evidence points to the importance of inflammation, which in turn provides the dental profession with a renewed focus on oral inflammation and “what we used to call perhaps a simple disease—gingivitis. Now we need to re-examine gingivitis or gingival inflammation and realize that this is a very significant form of inflammation that is not only harmful ultimately to the teeth, but possibly to the whole body,” Williams says.

Preston Miller, although emphasizing that the New England Journal of Medicine article is a breakthrough and BIG news, encourages readers to be cautious of making suppositions and drawing conclusions, because “science must be science.” For example, he’d like to see follow-up studies with scaling and root planing alone, as well as scaling and root planing with systemic antibiotics. “One key is to find the simplest protocol that produces the maximum results,” Miller says. “Another key would be the duplication of these results by individuals other than a highly trained periodontist, who often spends 4 to 6 hours scaling and root planing.”

In general—and not specific to any particular research study at present—Glenn Melenyk, DDS, a dental consultant for Blue Cross/ Blue Shield of Michigan, says that the insurance industry has a duty to determine what the best practices in dentistry are today to treat periodontal disease and incorporate them into members’ plans. Furthermore, he says that while it is the duty of the insurance carrier to help the people who are buying the insurance plan to save money, he also emphasizes that at the same time, the insurance carrier has a duty to allow for reasonable dental care. “It’s not all about saving money,” Melenyk explains.

According to Maurizio Tonetti, the lead author of the New England Journal of Medicine article, a series of three previous studies demonstrated that scaling and root planing alone produces an inflammatory response, the recovery time for which is shorter when systemic and/or locally delivered antibiotics are used in combination with scaling and root planing. Systemic antibiotics were not used in the current study in order to limit the treatment to one that would only act in the mouth, rather than potentially affect other parts of the body.

He says the occurrence of short-lived bacteremia following periodontal treatment has been known for many years, but that scaling and root planing remains a very safe and very good procedure for the vast majority of patients. In the present study, the worsening of blood vessel elasticity immediately after treatment was clearly associated with the normal bacteremia and trauma that occurs after scaling and root planing, Tonetti explains.

“What I think is so significant in this study is that we are talking about atherosclerosis (ie, hardening of the arteries),” Miller says. “Here, they tested the dilation of the brachial artery, the main artery in the arm, and they found that by treating the periodontal disease, that vessel became more dilated, thus enhancing blood flow.”

He said the assumption is that the same thing could happen in the coronary vessels, but science has yet to prove that. “So we can’t make that assumption,” Miller emphasizes. “I don’t know if the technology is available, but I would love to see a study evaluating the impact on the coronary vessels following root planing and scaling.”

Tonetti said that there are follow-up studies planned and also already in progress to further explore oral-systemic associations. However, he is unable to disclose the details of those investigations at this time.

References
1 Tonetti MS, D’Aiuto F, Nibali L, et al. Treatment of periodontitis and endothelial function. N Engl J Med. 2007;356(9):911-920.

2 AAP Statement on Periodontal Treatment and Improvement in Cardiovascular Health. March 1, 2007. American Academy of Periodontology. www.perio.org

3 Elter JR, Hinderliter AL, Offenbacher S, et al. The effects of periodontal therapy on vascular endothelial function: a pilot trial. Am Heart J. 2006;151(1):47.

4 Romano CJ. Do you see what they see? Patient perspectives on oral healthcare. Inside Dentistry. 2007;3(3):50-59.

Sidebar 4

The Inside Look From...

The staff and publishers of Inside Dentistry gratefully acknowledge the time, insight, and candid comments shared by our interviewees, without which this Inside look at the association between oral and systemic disease—and the potential implications of this most recent groundbreaking research—would not have been possible.The following individuals—all well-respected in the general oral healthcare, academic, and research arenas—made invaluable contributions to this presentation.

ACADEMIA

Louis F. Rose, DDS, MD
Clinical Professor
University of Pennsylvania School of Dental Medicine
Professor of Surgery, Division of Dental Medicine
Drexel University College of Medicine
lfrddsmd@verizon.net

Ray Williams, DMD
Professor and Chair
Department of Periodontology
University of North Carolina School of Dentistry
ray_williams@dentistry.unc.edu

ASSOCIATIONS

Preston D. Miller, Jr, DDS
President
American Academy of Periodontology
kimberly@perio.org
pdmjr@midsouth.rr.com

John W. Robitscher, MPH
Executive Director
National Association of Chronic Disease Directors
john@chronicdisease.org

CONSUMER ADVOCACY & PUBLIC AWARENESS

Robert Klaus
President and Chief Executive Officer
Oral Health America
robert@oralhealthamerica.org

Neil Romano
President
Romano Group, LLC
Consumer/Public Healthcare Advocate
neilromano@comcast.net

GOVERNMENT

Rear Admiral Kenneth P. Moritsugu, MD, MPH
Acting Surgeon General
U.S. Department of Health and Human Services
www.surgeongeneral.gov

INDUSTRY

Glenn R. Melenyk, DDS
Dental Consultant
Blue Cross/Blue Shield of Michigan
gmelenyk@bcbs.com

Foti S. Panagakos, DMD, PhD
Director of Professional Relations
Colgate-Palmolive Company
Foti_Panagakos@colpal.com

RESEARCH

Jane C. Atkinson, DDS
Program Director, Clinical Trials Program
Center for Clinical Research
National Institute of Dental and Craniofacial Research
jatkinso@mail.nih.gov

Maurizio S. Tonetti, DMD, PhD
Executive Director
European Research Group on Periodontology/European Network of Excellence
maurizio.tonetti@ergoperio.eu


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