Oral Health Group
Feature

Helping Patients Live Longer and Better Lives

February 19, 2019
by Dr. Kathryn Alderman


A New look at Systemic Inflammation, Microbiome, Gum Disease Diagnosis, Treatment and Keeping Dental/Gum Disease in Remission


Traditionally in dentistry we have been taught to ask our patients to brush, floss and visit us twice a year for checkups to stay healthy. In the last few years we have been hearing that by fixing dental problems and specifically dental/gum disease, we can help patients to prevent major medical problems, such as heart disease, diabetes, thyroid conditions and many other inflammatory related conditions.

It would be great to be able to help patients to be healthier by fixing their dental/gum disease but is it possible?

In this article, you can find the latest research and answer to the question:
Does the inflammation have a dental etiology or is the inflammation indicative of a systemic disease? What comes first, dental/gum disease or inflammatory-related medical condition?

As dental providers, we understand that the mouth is the gateway to the body. In our pathology classes, we learned about various intraoral soft tissue lesions that can often be the first indications that a patient may have an underlying chronic disease. We have known about the correlative links between untreated periodontal disease and diabetes or cardiovascular disease. Recent studies have shown that there may be links between dental/gum disease and many other auto-immune medical conditions. As dental providers, we often see that our patients who suffer from uncontrolled systemic inflammatory conditions have higher rates of dental/gum diseases.

When we examine a patient who shows signs of inflammation in the mouth, the question arises: Does dental/gum disease cause systemic inflammation or is the inflammation in a mouth is indicative of a systemic disease?

What is Inflammation?
Acute Inflammation is a good thing. It is our body’s natural response to injury and the first step in restoring health. The immune response is a protective mechanism against foreign invaders and toxic chemicals.

Acute inflammation (adaptive immunity) causes a complex cascade of events, sending white blood cells to the site of infection or injury. The inflammatory response causes chemicals to be released which help protect the body. The immune system brings red and white blood cells, dilates blood vessels, allowing more healing substances to travel in and out of the affected area. Once the foreign body has been defeated, the immune response reduces, leaving a few immune cells on guard in case of another attack.

When the acute inflammatory response does not successfully resolve an infection, the inflammation becomes chronic. Chronic inflammation (maladaptive immunity) is like having a slow burning fire in the body.

Chronic inflammation is a low-grade inflammatory response that can be present for months to years. Usually, chronic inflammation occurs because the body was unable to eliminate the initial injury or infection through the acute inflammatory response. When chronic inflammation continues long-term, it can begin a series of reactions that ultimately damage cells and lead to the clinical manifestations of disease. Chronic inflammation plays a role in all of the leading medical conditions like heart disease, diabetes, cancer and arthritis.

What is Microbiome and How it is Connected to the Overall Health?
The digestive system accounts for 70% of our immune system. The human microbiome is made up of more than 100 trillion different microorganisms. Half of these reside in the GI tract. Both the microbes as well as our own cells have co-evolved to share a symbiotic relationship. The microorganisms in our body are responsible for many of the necessary functions, such as vitamin and fiber processing. Another important job is to produce short-chain fatty acids that are precursors to many hormones, important part of diverse physiological roles in body functions. Microorganisms also play a role in gene expression regulation, including the acetylation of DNA-associated histone proteins and methylation of DNA. This is one of the major regulatory processes that is a part of many stages of genetic functions. This type of regulation is applicable to inflammatory genes that can affect the development of cancer, neuropsychiatric systems and many immune disorders as well as the progression of chronic disease.

When patients have an imbalance in our microbiome, they are more susceptible to chronic inflammation and infection. Some individuals are more sensitive to such imbalances due to genetic factors.

Inflammation in the Mouth
Having good dental health is not only about preventing decay, periodontitis or bad breath. Many medical conditions can be reflected by the oral health of the patient. The most common sign of chronic inflammation in the dental patient is gum disease. The level of severity of inflammation can be indicative of underlying systemic disease.

Acute Inflammation-Gingivitis
Every patient has thousands of bacterial species living in the oral cavity. Many of these bacteria are beneficial for the patient, however, an overgrowth of harmful bacterial pathogens can lead to inflamed gums, or gingivitis. The acute inflammatory response produces red, enlarged and bleeding gums to bring inflammatory chemicals and white blood cells in an effort to fight off the bacterial overgrowth.

Gingivitis is a reversible inflammatory condition and is successfully treated by a thorough debridement and effective daily plaque removal by the patient as well as maintaining a balanced diet with adequate vitamin C and D. A healthy body can effectively fight off gingivitis successfully in just a few days.

Chronic Inflammation-Chronic Periodontitis
Chronic periodontitis occurs when there are specific bacterial pathogens present in the mouth combined with the individual patient’s host response. If the acute inflammatory process is unable to eradicate the source of the infection, the patient will experience chronic inflammation in the mouth affecting the teeth and gums. The chronic inflammation causes the gum tissue to lose its integrity, detaching from the root surface and creating periodontal pockets where more harmful species of bacteria can colonize. The constant immune response to the presence of these pathogens creates inflammatory chemicals to be released, which is the cause of bone loss. When the condition is advanced, the teeth become loose and must be removed due to inadequate bone support.

Chronic periodontitis is one of the leading causes of tooth loss in adults.

The Oral-Systemic Link: Inflammation, Microbiome, Gum Disease Diagnosis and Treatment
There is a relationship between periodontitis and many other inflammatory conditions like rheumatoid arthritis, celiac disease, thyroid disease, heart disease, diabetes and Alzheimer’s. Chronic periodontal disease and these conditions share autoimmune characteristics, but the real question is, which came first? Is there a causal link between these conditions? Latest research shows that overall and gut health are more closely to dental health.

Below are three articles which discuss the connection between the microbiome, systemic inflammation and dental/gum diseases.

1. Gut Microbiota and Salivary Diagnostics: The Mouth Is Salivating to Tell Us Something

Authors: Kodukula Krishna, Faller Douglas V., Harpp David N., Kanara Iphigenia, Pernokas Julie, Pernokas Mark, Powers Whitney R., Soukos Nikolaos S., Steliou Kosta, and Moos Walter H., Published Online:1 Oct 2017 https://doi.org/10.1089/biores.2017.0020

Abstract Summary and Conclusion
The human microbiome is a network of microbes that affect every organ system in the body. Most of the microorganisms of this network are bacterial, but others include viruses, fungi and protists. Through study of the human microbiome, we have learned that most chronic medical conditions have microbial components. The oral cavity and GI portion of the microbiome account for the majority of the bacteria present in the body. By measuring the strains of bacteria in a mouth, the overall gut health can be predicted. By making modifications to the person’s microbiome, systematic health can be positively affected, including improved dental health.

2. Defining The Gut Microbiota In Individuals With Periodontal Diseases: An Exploratory Study

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032013/

The purpose of this study was to test the gut microbiome of patients who presented with periodontal diseases and find any correlation with periodontal inflammation and destruction of tissues.

Abstract Summary and Conclusion
Those who presented with active periodontal diseases had less diversity in the microbiome which is consistent with other chronic inflammatory diseases. The high levels of oral bacteria that were associated with periodontal disease and active inflammation were also present in the gut of all individuals regardless of the status of the periodontal health. Findings concluded that every patient who had an inflammatory condition had less diversity in the gut. Periodontally involved patients had a higher level of harmful versus beneficial bacteria in both the mouth and the gut. This conclusion suggests that periodontal disease is an important risk factor for many other systemic inflammatory medical conditions.

3. Can Diet Improve Gum Disease?

Journal of Periodontology (May 2009, Vol. 80:5, pp. 759-768).

Abstract Summary and Conclusion
The article discusses if following an anti-inflammatory diet may help reduce symptoms of periodontitis:

The first study mentioned in this article is on diet and periodontitis: In the May 2009 issue of The Journal of Periodontology, a study was published titled “The impact of the stone age diet on gingival conditions in the absence of oral hygiene.” This study used 10 individuals who followed a diet of unprocessed, whole foods including vegetables and protein sources indigenous to the area of Switzerland where the study took place for 4 weeks. During this time, the subjects did not brush or floss at all. Before and after the study, bacterial cultures were taken for analysis to screen for periodontal disease. At the end of this study, participants had higher levels of plaque accumulation, but the number of pathogenic microbes present in the plaque remained unchanged.

The second study mentioned in this article is on diet and periodontal health is from the July 2016 issue of BMC Oral Health. The study is titled, “An oral health optimized diet can reduce gingival and periodontal inflammation in humans—a randomized controlled pilot study.”

A group of 15 subjects who exhibited signs of active periodontal disease were used in a randomized control trial. Five were part of the control group, leaving 10 as the experimental group. The 10 experimental subjects followed a diet low in carbohydrates, high in omega 3 fatty acids, and high in fiber and vitamins. The control group did not alter their existing diets. None of the subjects flossed during the study, but brushed normally. Periodontal exams and bacterial culture samples were taken before and after the experiment. After four weeks, all signs of gum disease in the experimental group decreased by half, while all of the inflammatory markers increased from the baseline in the control group.

Findings in this article offer proof that patient’s diet plays a critical role in forming microbiome and influencing the levels of overall chronic inflammation and ultimately leading to the progression of periodontal disease.

Answering the question: Does dental/gum disease or the inflammatory-related medical condition come first?

Now that we know how the microbiome impacts the likelihood of a person to develop chronic inflammation throughout the body, the answer is more likely that the underlying medical condition can be correlated with the imbalance of the microbiome. Some individuals may have genetic risk factors in addition to an imbalance in the gut biome, placing them at greater risk for developing medical conditions.

Chronic inflammation can travel to all of the organ systems of the body, including the tissues in the mouth and jaw due to the vascular environment of the oral cavity. Having chronic inflammation can be both the initial cause of cardiovascular disease as well as dental/gum disease.

What Can Be Done To Improve Patient’s Microbiome And Reduce Systemic Chronic Inflammation?
In addition to maintaining good oral hygiene and receiving professional dental care to help reduce the bacterial load in the mouth, patients should be counseled on lifestyle factors like their diet, tobacco cessation, obesity and stress.

1. Counsel patients to change their diet. Eating plenty of omega 3 fatty acids like those found in fish and flaxseed.
2. Encouraging patients to eat high-fiber diets rich in fruits and vegetables and avoid processed foods to improve the individuals’s microbiome.
3. Encourage patients to lower their sugar intake and avoid drinking soda and energy drinks.
4. Encourage supplementation of vitamin C and D on a daily basis as well as taking probiotics with multiple strains of beneficial probiotic.
5. Eliminate foods like gluten or dairy that may be triggering an allergy response and creating intestinal inflammation for some patients.
6. Exercising regularly
7. Reducing stress: Massage, yoga, meditation, etc.
8. Getting adequate sleep: 7-8 hours every night.

Case Study
A 35-year-old male patient comes to you with cardiovascular disease and issues with high blood sugar. This patient also shows signs of moderate chronic periodontitis.

Will performing traditional quadrant scaling and root planing be adequate for helping this patient reduce the overall levels of chronic systemic inflammation and improve his overall health? The answer is no. Performing scaling and root planing will definitely reduce the load of harmful bacteria that is present in his oral microbiome but not enough alone in order to help this patient to be at his healthiest.

It is important to help this patient identify lifestyle factors and the role these play in the long-term prognosis of his periodontal condition as well as managing other cardiovascular disease and blood sugar issues. By changing the lifestyle habits and decreasing the overall amount of inflammation, this patient can become healthier. By developing healthier lifestyle habits, the overall health will improve and ultimately leading to the shift to the healthier microbiome.

Conclusion
Do inflammatory related medical conditions lead to the developing gum disease or vice versa?

The answer: It is more likely that the underlying medical condition can be correlated with the overall lifestyle habits, the genetic risk factors and imbalance in the microbiome, placing patients at a greater risk for developing inflammatory related medical conditions, including dental/gum disease.

As dental professionals we can we help patients live healthier and longer lives by treating dental/gum disease. But besides traditional dental /gum disease treatment and giving home care recommendations, dental professionals can be an important part of the health-care team and help patients to improve the quality of their lives by helping them to be educating on importance of healthy lifestyle habits for improving the prognosis of dental/gum disease and overall health.

Traditional treatment for dental/gum disease can be combined with a thorough review of the medical history as well as follow-up with the primary care physician if patients present with dental/gum disease. Patients who have not been under the care of a physician and are showing signs of periodontal disease should be referred for wellness screenings to rule out underlying medical conditions, allergies or vitamin deficiencies.

Dental professionals can educate patients about the link between their dental health and their overall health. and give tips on improving overall health. Patients who have knowledge about what they can do are empowered to take control of their own health and play an active role in their treatment and prognosis of dental/gum disease, as well as positively impacting overall health.


About the Author
Dr. Kathryn Alderman has an extensive education and research experience in the field of microbiology and biochemistry. Her knowledge and deep understanding of science allow her to explain the latest findings of inflammatory-related conditions, microbiome research and how it impacts our dental patients. She is actively practicing and manages highly successful multiple locations of Nebraska Family Dentistry, which is a multi-practice organization that caters to help patients to be at their healthiest. The organization has daily operational systems with the goal of increasing patient satisfaction and case acceptance.

Dr. Kathryn Aldermans has developed those systems that lead to higher patient retention and practices that do well in spite of increased competition. If you have any questions, you can contact Dr. Kathryn Alderman: nebraskafamilydentistry@gmail.com.