US Pharm. 2014;39(2):15-27.
For many years, keeping one’s teeth clean has been commonly acknowledged as essential to preventing cavities. However, even today, too few people engage in the additional oral care regimen needed to prevent gingivitis and periodontitis. What is the evidence that failure to thoroughly cleanse the oral cavity heightens the risk of serious health issues?
What is Periodontitis?
Periodontitis is defined as an infectious and inflammatory intraoral disease that results from sustained failure to properly cleanse the mouth and gums.1 Teeth are supported in their sockets of alveolar bone by an organized mass of connective tissue ligament fibers that extend from the tooth surface to the bone.1 This support system of bone and periodontal ligaments is collectively known as the periodontium. The periodontium provides a firm anchoring for each tooth, while allowing the teeth to absorb the impact of chewing.
The key to oral health is constant attention to the cleanliness of the teeth and gums (gingiva), especially to the gingival sulcus.1,2 The gingival sulcus is a small slit-like area surrounding each tooth where it meets the gums, an area referred to as the dentogingival junction. In the early stages of dental neglect, patients usually develop caries (cavities) and gingival inflammation (gingivitis). Warning signs of gingivitis include swollen and bleeding gums. With prompt attention, the patient may be able to reverse simple gingivitis.3
If patients with diagnosed gingivitis do not take immediate action to reverse it by thoroughly cleaning the gingival sulcus, the gingiva begin to shrink away from underlying bone.2 As the gingival sulcus widens, gram-negative anaerobic bacterial colonies extend downward below the gumline into subgingival spaces, areas that are almost impossible for patients to clean. Bacterial infection of the gingiva causes further widening of the sulcus and continued downward extension of the bacterial colonies to produce periodontal pockets of infection. Eventually, sustained neglect allows bacteria to reach the area where the periodontal ligaments are located. Infectious destruction of the periodontal ligaments causes tooth mobility. When teeth begin to loosen, the patient is diagnosed with periodontitis. Unless dental intervention is successful, tooth loss will result from advanced periodontal ligament destruction.
Prevalence of Periodontitis
Periodontitis is an age-associated infection. At least 47.2% of those aged 30 years and above have periodontal disease to some degree.4 The percentage rises to 70.1% in patients aged 65 years and above. Women (56.4%) have periodontitis more often than men (38.4%). Percentages in other subpopulations are 65.4% for those living below the federal poverty level, 66.9% for those with less than a high school education, and 64.2% for current smokers. The incidence is higher in those with other oral conditions (poor oral hygiene, crooked teeth, defective fillings, bridges that do not fit properly) and other medical conditions (diabetes, immunodeficiency, pregnancy), as well as in those with a hereditary predisposition for gum disease and women taking oral contraceptives.3,4 An estimated 20% to 30% of those with periodontitis have a severe form of the condition.2
Warning Signs of Periodontitis
Periodontitis affects the gingiva, periodontium, and teeth, causing symptoms in each of those areas.4 The gingiva are inflamed, erythematous and sore, with visible bleeding. Bleeding may be spontaneous or occur only when brushing. The gingiva shrink away from the tooth root due to uncleaned calculus (tartar) on tooth surfaces. Rampant disease below the gingival line causes halitosis and a persistent bad taste in the mouth. As the periodontium supporting the teeth is slowly eroded by subgingival calculus, the teeth become mobile in their sockets, changing the patient’s occlusion and the fit of partial dentures. Teeth are often sensitive and chewing becomes painful.
Periodontitis and Cardiovascular Disease
Cardiovascular disease (CVD) is a broad term that encompasses heart disease, acute myocardial infarction (MI), atherosclerosis, stroke, coronary heart disease (CHD), angina, coronary artery disease, hypertension, and heart failure. CVD is responsible for 12 million deaths yearly in the United States, or approximately 30% of all deaths.5 With these figures in mind, it is clearly critical to identify risk factors for CVD to reduce the risk of untimely death. If controlling one’s oral health is a risk factor for CVD, the link must be explored, confirmed, and publicized.
The 2005 NIH Study
Four agencies of the National Institutes of Health (NIH) supported research to determine whether there might be an association between periodontal bacteria and CVD.6,7 The agencies involved were the National Institute of Dental and Craniofacial Research; the National Institute of Neurological Disorders and Stroke; the National Heart, Lung, and Blood Institute; and the National Center for Research Resources.
Researchers took a large number of subgingival plaque samples from 657 subjects, assaying them for 11 known periodontal bacteria.7 They also measured the subjects’ carotid artery intima-media thickness (IMT). These measurements were critical, as the IMT is a strong predictor of stroke and MI. The research demonstrated that there is a direct relationship between periodontal microbiology and subclinical atherosclerosis.
The results of this multiagency collaboration were published in the journal Circulation in 2005.7 They proved to be of such gravity that the NIH took the unusual step of publicizing them in a news bulletin. The agency pointed out that this research was the first to identify a direct association between bacteria involved in periodontal disease and CVD. The bacteria implicated were Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola. The researchers were careful to stress that their study identified an association, but could not be taken as proof that the bacteria were the direct or indirect cause of CVD.
The 2008 Literature Review
In 2008, a group of investigators attempted through an exhaustive literature review to assist the U.S. Preventive Services Task Force in identifying periodontal disease as an independent novel risk factor for CHD.2 The researchers focused on population-based, prospective studies. Seven studies were subjected to meta-analysis, all having examined bone loss, periodontal pockets, inflammation, gingivitis, and tooth loss. This landmark study concluded that patients with those conditions increase their risk of CHD by a startling 24% to 35%. Further, the study suggested that gingivitis also elevated the risk of death from CHD.2 A possible link between gingivitis and cardiovascular disease has generally been overlooked or ignored, but it indicates that the number of people at heightened risk for CHD due to dental neglect may be far higher than generally accepted.
How Periodontal Disease Might Cause CVD
An association between the oral microbiome and cardiovascular disease may not be unique, in that research is also implicating other organisms in heart disease, such as Chlamydia pneumoniae, Helicobacter pylori, and cytomegalovirus.5 Investigators have elaborated on the possible mechanism by which an oral infection could cause systemic disease. It may be that atherosclerosis is the result of endothelial injury induced by “repeated systemic challenge with lipopolysaccharide and inflammatory cytokines” or through “platelet aggregation and activation through the expression of collagenlike platelet aggregation-associated proteins,” which increases the risk of atheroma and thromboembolic events.5 It may also be that bacteria shed from chronic periodontal infection enter the circulatory system directly.3
Implications for Pharmacists
Patients can reduce the risk of caries, gingivitis, and periodontitis by adhering to a strict and thorough daily dental cleansing regimen. The goal is to remove the sticky substance known as plaque from teeth before it becomes the hardened substance known as tartar (dental calculus).1 When patients ask about dental care, pharmacists should attempt to ascertain whether the patient is acting under the advice of a dentist. If the dentist has given patients specific instructions on which products to use, it is best to simply direct them to those products and stress the need to comply with the regimen and instructions they were given.
The pharmacist’s task is far more difficult when patients ask about home care for caries, gingivitis, or periodontitis, but have not seen a dentist. The unfortunate fact is that existing caries, gingivitis, and periodontitis should be referred for professional dental care. However, patients are often resistant to pharmacist advice regarding the need for a dental visit. Some are far too apprehensive about visiting a dentist, and others are financially unable to do so.1 In these cases, it is imperative for pharmacists to leave patients with the understanding that use of nonprescription products or devices does not substitute for professional dental care and to continue to stress the need for professional care.
Patients should be instructed to adhere to the three cornerstones of dental hygiene: brushing, flossing, and using a periodontal aid.1 Generally, patients are advised to choose a fluoridated toothpaste and use a soft bristle brush or consider purchase of an ultrasonic toothbrush. Brushing twice daily, if done correctly, should be sufficient to disrupt the growing bacterial colonies on most tooth surfaces. However, brushing alone is not sufficient.
In order to remove plaque from between the teeth, patients should be urged to purchase dental floss and examine any of several online pictorials on its proper use. A periodontal aid is also helpful in removing residual plaque left after brushing. The Perio-Aid (available online) is an ideal periodontal tool that is not likely to harm the teeth or gingiva.8 Patients should avoid dental cleaning products with metal hooks or scrapers. It is difficult to use these devices safely, and their use is best left to the dental hygienist.
Cleaning Your Mouth Properly
The best way to prevent gingivitis, periodontitis, and the diseases they cause is to properly clean your teeth. For the most appropriate cleaning advice, visit your dentist. Dental personnel can give you practical demonstrations of tooth and gum care.
One of the three most important steps is twice-daily brushing with a fluoridated toothpaste. You should angle the brush so that the tips of the bristles move slightly below the gumline. Consider an ultrasonic toothbrush because of its increased efficiency. Second, you should also floss your teeth once daily, as flossing removes material the toothbrush cannot reach. Finally, obtain a periodontal cleaning device known as a Perio-Aid from your dentist or online. Used daily in conjunction with a toothpick, it provides an extra measure of cleanliness.
The goal of these interventions is to remove a jellylike substance known as plaque from your teeth. If you fail to do this, the plaque will harden to tartar, which is almost impossible to remove without dental assistance. Tartar can lead to gum inflammation (gingivitis) and damage to the system that supports your teeth (periodontitis).
Signs of Periodontitis
What are the warning signs that you could have periodontitis? You may experience a persistent bad taste in your mouth that cannot be eradicated by brushing or the use of mouthwash. You or others around you may notice a foul odor to your breath (halitosis). You may see that your gums are red or inflamed (swollen). They may also be tender or sore, and they may bleed, either spontaneously or when you brush (known as bloody toothbrush syndrome). Your gums may appear to be shrinking away from your teeth. You may notice that your teeth have become loose, that they no longer fit together the same way they once did, or that partial dentures no longer fit properly. It may be painful to chew, and your teeth may be sensitive.
Treatment of Periodontitis
Periodontitis is a chronic condition due to long neglect that will not improve on its own. It must be treated by medical intervention. There are several specialties within dentistry such as straightening teeth (orthodontics) and performing root canals (endodontics). It is best to consult the dental specialist known as a periodontist. This type of dentist is specially trained to recognize and treat periodontitis. Your teeth may require interventions, such as deep cleaning of the tooth surfaces below the gumline or the use of medications taken orally or placed under the gums. You may also require corrective surgery.
Periodontitis and Heart Disease
There is growing evidence that periodontitis can increase your risk of heart disease. Cleaning your teeth and gums is easy and only takes a few minutes out of your day. If it can prevent early death from heart disease, it is certainly worth the effort.
Remember, if you have questions, Consult Your Pharmacist.
1. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
2. Humphrey LL, Fu R, Buckley DI, et al. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23:2079-2086.
3. Periodontal diseases. National Institutes of Health (NIH). Research Portfolio Online Reporting Tools (RePORT). http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=111. Accessed December 27, 2013.
4. Periodontal disease. CDC. www.cdc.gov/OralHealth/periodontal_disease/index.htm. Accessed December 27, 2013.
5. Dhadse P, Gattani D, Mishra R. The link between periodontal disease and cardiovascular disease: how far we have come in last two decades? J Indian Soc Periodontol. 2010;14:148-154.
6. Study finds direct association between cardiovascular disease and periodontal disease. NIH News. www.nih.gov/news/pr/feb2005/nidcr-07.htm. Accessed December 27, 2013.
7. Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation. 2005;111:576-582.
8. Perio-Aid. Marquis Dental Manufacturing Company. www.perio-aid.net. Accessed December 27, 2013.
9. Looking at the periodontal-systemic disease connection. NIH. National Institute of Dental and Craniofacial Research. www.nidcr.nih.gov/Research/ResearchResults/InterviewsOHR/TIS072005.htm. Accessed December 27, 2013.
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