The first time I heard Dr. Bradley Bale, MD, and Dr. Amy Doneen, DNP, speak about their latest research and the effect of oral health on arterial disease was at a 2016 AAOSH conference. From that point, I began to view my role as a dental hygienist much differently. It opened my eyes up to multiple ways we can impact our patients to aid them in arterial wellness and reduce their risk of the top two deadly diseases – heart attack and stroke.1,2
It is well documented that numerous risk factors influence the onset and progression of periodontal disease3 and that periodontal disease is among the most common inflammatory diseases. It is also well documented that numerous factors other than active periodontal disease influence chronic inflammation, which plays a significant role in the most challenging and deadly diseases faced today. We also understand that there is a bi-directional relationship between periodontal disease and systemic conditions, and that there are medical conditions that trigger or impair host response, such as diabetes.4,5 How often do we suspect a patient has undiagnosed diabetes? How often do we find blood pressure levels elevated at a level of concern, yet a patient’s physician says their blood pressure is “fine”? How often do we or our patients dismiss “white coat syndrome” as unimportant? The more I learned, the more I realized we need to “up our ante” to increase our patients’ awareness and share steps they can take to be advocates for their own health with the end goal of reducing the systemic impact of chronic inflammation.
Pathogen Testing as Part of Risk Assessment
In addition to health history, family history, and clinical findings, risk assessment must be an integral part of our assessment. Identifying the numerous risk factors that will impact oral health, periodontal disease development and progression, as well as systemic inflammation, is essential and will guide us in our treatment planning. Having just three risk factors can speed up periodontal tissue breakdown exponentially.6 (Most of our clients easily present with three risk factors, if not four.) There are many risk factors that we can begin to aid our clients in modifying. Screening for elevated blood pressure is also extremely important to evaluate.
Positively influencing oral health must go beyond simply assessing and treating clinical symptoms. The Bale-Doneen peer-reviewed study was the first to reveal a treatable cause of cardiovascular disease (CVD), namely periodontal disease, due to certain high-risk oral bacteria. The research was published in the April 2017 issue of Postgraduate Medical Journal (PMJ).7 Given this research, it behooves change and demands more from the dental professional. Recommending DNA pathogen testing as part of risk assessment is essential to understand the overall pathogenic burden as well as to identify whether there is an increased risk for periodontal tissue breakdown as well as systemic disease. This will help guide us in our treatment recommendations and identify those individuals with whom we may need to be more aggressive in initiating treatment.
Blood Pressure: The Silent Killer
High blood pressure is a major modifiable risk factor for cardiovascular disease (CVD) with evidence for causation.8,9 In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new comprehensive high blood pressure guidelines with the goal to help people address high blood pressure and the problems that may accompany it, like heart attack and stroke, much earlier. The changes were made as a result of the Systolic Blood Pressure Intervention Trial (SPRINT)10, a nine-year randomized clinical trial enrolling 9361 participants, designed to test whether a treatment program aimed at reducing systolic blood pressure (SBP) to a lower goal than the current recommendations would reduce cardiovascular disease (CVD) risk. The SPRINT trial showed that by lowering SBP to <120 mm Hg resulted in significant cardiovascular benefit in high-risk patients with hypertension compared with routine BP control to <140 mm Hg. As a result of this study, what was once considered “normal levels of BP” have been re-evaluated and presented with the 2017 guidelines, which must now be our reference point.
I have come across many dental professionals who are as yet unaware of the latest guidelines, and I also question how many physicians refer to them given the number of patients who consistently say their physician says their BP is “fine”, when our screening would potentially place them in the category of Stage 1 or 2 Hypertension. Individuals see their dental professionals more frequently than they see their physician, so we have an opportunity to help identify those with unstable blood pressure levels. Most will be grateful to you for bringing elevated BP readings to their attention. Others will be in denial, or even angry that you are putting off their treatment until their blood pressure has been evaluated by their physician. I would rather make an unpopular decision than put someone at risk.
White Coat Hypertension (WCH)/White Coat Syndrome
Some patients may warn you that their blood pressure is always higher when they are in your chair or at their physicians. Often this is ignored and taken lightly. However, consider that if their blood pressure rises with the anxiety of being in your chair, is it likely also consistently rising when they are in heavy traffic, trying to meet a deadline at work, dealing with a family crisis or other stressful situations.
In June 2019, a systematic review and meta-analysis concluded that patients with untreated WCH are more than twice as likely to die from a cardiac event as those whose blood pressure readings are always normal.11
The Pre-Diabetic/The Undiagnosed Type 2 Diabetic
Individuals with type 2 diabetes have a considerably higher risk of having a heart attack or stroke. How often have you wondered whether a patient has undiagnosed diabetes because the response to your therapies has been less than you expected and they continue to present with significant bleeding. Numerous individuals claim that their doctor had tested them for diabetes and they were negative, or have normal AIC levels, or have been labeled as a prediabetic. Most doctors use blood tests to check for diabetes – A1C and FPG (Fasting Plasma Glucose) tests, which often result in false negatives. At the Endocrine Society’s annual meeting in March 2019, the results of a large study were presented comparing the traditional Hemoglobin A1c (Hg A1c ) to the less utilized Oral Glucose Tolerance Test (OGTT) for diagnosing diabetes in 9,000 undiagnosed adults. The results demonstrated that Hg A1c over-diagnosed normal glucose tolerance (NGT) by 42% and under-diagnosed diabetes in 73% of adults. It further concluded that the OGTT should be used to accurately evaluate for diabetes and pre-diabetes instead of Hg A1c.
Unfortunately, the OGTT is less widely used, partially because it is a less convenient method of testing. However, I now inform patients that this is the gold standard for positively identifying whether or not they have diabetes.
C-Reactive Protein (CRP) and High-sensitivity C-reactive Protein (hs-CRP)
CRP is an important biomarker in the circulation of systemic inflammation. Several studies have identified CRP as a strong independent risk factor for CVD.13,14
The standard CRP test measures CRP in the range from 10 to 1000 mg/L. A normal reading is less than 10 mg/L. A high reading is equal to or greater than 10 mg/L. Extremely high numbers indicate acute infection.
The hs-CRP test accurately detects lower levels of the protein than the standard CRP test, measuring in the range of 0.3 to 10 mg/L, and is used to evaluate for risk of CVD. A reading of 0.5 is optimal, under 1 is low risk, 1-3 is considered moderate risk, and greater than 3mg/L is considered high risk for cardiovascular disease, and this risk increases in those with type 2 diabetes.15
Knowing and understanding one’s CRP level will give an indication of systemic inflammation and can be a great motivator towards modifying lifestyle.
Vitamin D deficiency is extremely common, especially during the winter months. It is essential for bone growth and remodelling and also plays a significant role in systemic health. Numerous studies show that low levels increase risk of type 2 diabetes16 and CVD17 with some studies showing low levels double the risk of a heart attack or stroke.18
The Ultimate Treatment Plan
Periodontal Disease Management: Treating PD is essential for the reduction of heart attack and stroke risk,19 and begins with a decrease in the biofilm burden. In addition to traditional debridement (which as a stand-alone treatment does not eliminate harmful pathogens), other modalities can include the OraVital® System, Guided Biofilm Therapy®, Diode Laser bacterial reduction, and increasing the frequency of hygiene maintenance appointments. Dental caries and endodontic disease must also be considered as significant players in driving heart attack risk.20
While reducing the biofilm burden is an essential part of therapy, we must also address the inflammatory burden.
The Host Response and Systemic Inflammation
In the 2015 JADA Evidence-Based Clinical Practice Guidelines,21 the ADA voted in favour of subantimicrobial-dose doxycycline (Periostat®) for the non-surgical treatment of chronic periodontitis. However, the benefits of Periostat® go well beyond providing an increase in attachment level with the added benefit of host modulation therapy and decreasing systemic inflammation, which is key for those who present with other chronic inflammatory mediated diseases such as diabetes, rheumatoid arthritis, osteoporosis and heart disease.22 Chronic inflammation creates an excessive production of collagenase and reduced tissue repair. In relation to periodontal disease activity, this is extremely relevant as collagen makes up 60% of the gingival tissues and 90% of bone. However, what really gave me pause to consider that Periostat® may also help prevent a CVD event is this: when soft plaques build up in artery walls, the body forms a protective cap around it, which is primarily made up of collagen. If the body is in a chronic inflammatory state and there is an overproduction of collagenase occurring, there will eventually be a degradation of the collagen-rich cap, leading to plaque rupture, thrombosis and heart attack or stroke.
Blood Pressure Monitoring: A baseline blood pressure reading/screening should be done at each initial visit to the practice, whether that first appointment is with the dentist or the hygienist. While annual screening is adequate for some, others with elevated readings should be monitored at every appointment especially if they present with other risk factors.
Collaboration with multiple health professionals is ideal. Collaboration with physicians is essential. Send a letter to inform of blood pressure readings of Stage 2 hypertension or hypertensive crisis. When a patient presents with periodontal destruction, bleeding, and other risk factors, send a letter asking to work with them to identify the systemic impact of your mutual patient’s advancing infection. This can include a request for an overall evaluation for possible blood dyscrasias, vitamin D deficiency, diabetes, and hs-CRP levels.
Inspiring Optimal Cardiovascular Health
We know that oral health is critical to overall health. I have known people who died of heart attacks much too young – two that come to mind had advanced periodontal disease. Our periodontal therapy program has evolved considerably since then, and I have no regrets if I choose to delay periodontal therapy until someone’s severely elevated blood pressure is under control.
As dental health professionals committed to life-long learning, if we can continue to learn all we can about the oral systemic connection to expand our awareness and implement change, we make an even bigger impact. In the words of Mya Angelou, “Do the best you can until you know better. Then when you know better, do better.”
- AlJehani Y. A. (2014). Risk factors of periodontal disease: review of the literature. International journal of dentistry, 2014, 182513. https://doi.org/10.1155/2014/182513 (Retraction published Int J Dent. 2021 Feb 12;2021:8735071) www.ncbi.nlm.nih.gov/pmc/articles/PMC4055151/
- Kim, J., & Amar, S. (2006). Periodontal disease and systemic conditions: a bidirectional relationship. Odontology, 94(1), 10–21. https://doi.org/10.1007/s10266-006-0060-6
- Martínez-García, M., & Hernández-Lemus, E. (2021). Periodontal Inflammation and Systemic Diseases: An Overview. Frontiers in physiology, 12, 709438. https://doi.org/10.3389/fphys.2021.709438
- Bale, B. F., Doneen, A. L., & Vigerust, D. J. (2017). High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgraduate medical journal, 93(1098), 215–220. https://pmj.bmj.com/content/93/1098/215?etoc
- Fuchs, F.D., Whelton, P. K., (2019) High Blood Pressure and Cardiovascular Disease. Hypertension. 2020;75:285–292 https://doi.org/10.1161/HYPERTENSIONAHA.119.14240
- Wu, C. Y., Hu, H. Y., Chou, Y. J., Huang, N., Chou, Y. C., & Li, C. P. (2015). High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults. Medicine, 94(47), e2160. https://doi.org/10.1097/MD.0000000000002160
- Sprint Study: The SPRINT Research Group: A Randomized Trial of Intensive versus Standard Blood-Pressure Control; 2015 N Engl J Med; 373:2103-2116
- DOI: 10.1056/NEJMoa1511939 www.nejm.org/doi/full/10.1056/nejmoa1511939
- Cohen, J. B., Lotito, M. J., Trivedi, U. K., Denker, M. G., Cohen, D. L., & Townsend, R. R. (2019). Cardiovascular Events and Mortality in White Coat Hypertension: A Systematic Review and Meta-analysis. Annals of internal medicine, 170(12), 853–862. https://doi.org/10.7326/M19-0223
- Martín-Timón, I., Sevillano-Collantes, C., Segura-Galindo, A., & Del Cañizo-Gómez, F. J. (2014). Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?. World journal of diabetes, 5(4), 444–470. https://doi.org/10.4239/wjd.v5.i4.444
- Shrivastava, A.K., Singh, H.V., Raizada, A., Singh,S.J. (2015) C-reactive protein, inflammation and coronary heart disease. The Egyptian Heart Journal,Volume 67, Issue 2,Pages 89-97, ISSN 1110-2608,
- Ridker, P. M., Hennekens, C. H., Buring, J. E., & Rifai, N. (2000). C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. The New England journal of medicine, 342(12), 836–843. https://doi.org/10.1056/NEJM200003233421202
- Gagnon, C. MD et al. Serum 25-Hydroxyvitamin D, Calcium Intake, and Risk of Type 2 Diabetes After 5 Years: Results from a national, population-based prospective study (the Australian Diabetes, Obesity and Lifestyle study) (2011) EPIDEMIOLOGY / HEALTH SERVICES RESEARCH https://diabetesjournals.org/care/article/34/5/1133/38718/Serum-25-Hydroxyvitamin-D-Calcium-Intake-and-Risk
- Kim, H. A., Perrelli, A., Ragni, A., Retta, F., De Silva, T. M., Sobey, C. G., & Retta, S. F. (2020). Vitamin D Deficiency and the Risk of Cerebrovascular Disease. Antioxidants (Basel, Switzerland), 9(4), 327. https://doi.org/10.3390/antiox9040327
- Lavie, C. J., Lee, J. H., & Milani, R. V. (2011). Vitamin D and cardiovascular disease will it live up to its hype?. Journal of the American College of Cardiology, 58(15), 1547–1556. https://doi.org/10.1016/j.jacc.2011.07.008
- Larvin, H., Kang, J., Aggarwal, V. R., Pavitt, S., & Wu, J. (2021). Risk of incident cardiovascular disease in people with periodontal disease: A systematic review and meta-analysis. Clinical and experimental dental research, 7(1), 109–122. https://doi.org/10.1002/cre2.336
- Pessi, T., Karhunen, V., Karjalainen, P. P., Ylitalo, A., Airaksinen, J. K., Niemi, M., Pietila, M., Lounatmaa, K., Haapaniemi, T., Lehtimäki, T., Laaksonen, R., Karhunen, P. J., & Mikkelsson, J. (2013). Bacterial signatures in thrombus aspirates of patients with myocardial infarction. Circulation, 127(11), 1219–e6. https://doi.org/10.1161/CIRCULATIONAHA.112.001254
- Smiley, C. J., et al (2015). Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. Journal of the American Dental Association (1939), 146(7), 525–535. https://doi.org/10.1016/j.adaj.2015.01.026
- Timothy Donley, DDS, MSD; Jo-Anne Jones, RDH; Lorne M. Golub, DMD, MSc, MD (Honorary); Ying Gu, DDS, PhD; Maria Emanuel Ryan, DDS, PhD (2015) Addressing the Inflammatory Response in Periodontal and Related Systemic Disease Oral Health Group Pgs 38-50
Bradley,B. MD., Doneen,A. DNP. (2014) Beat The Heart Attack Gene. Wiley.
About the Author
Lorraine obtained her Dental Hygiene Diploma from George Brown College in 1985. She has presented on a variety of topics and is passionate about the Oral Systemic Connection and promoting medical/dental collaboration. Lorraine also enjoys inspiring others via blogging and writing. Her article, “A Healthy Mouth—A Healthier Heart” was published in Oral Hygiene in February 2018 and she is a co-author of the recently published book, “Get Your Spit Together.”