1. What does a link actually mean?

• It’s no surprise that the body and mouth are “linked”.
• The link between periodontal disease and systemic disease is not new. It was first published in early 1900s.
• Link can mean association or causation. Association (aka correlation) – things commonly seen together, easier to measure but less meaningful. Causation – one thing causes another, very difficult to measure but more meaningful.
• It’s important to be aware of the difference between and association/correlation/”link” and a causal relationship.

2. Which systemic diseases have been associated with periodontal disease?

• There are established links with diabetes and cardiovascular disease.
• There are less established links with chronic kidney disease, dementia and rheumatoid arthritis.
• There are key commonalities between these conditions: they are chronic, non-communicable, highly prevalent, have shared risk factors (smoking, obesity etc.) and inflammation is a key component.

3. What is the basic proposed mechanism for the perio-systemic link?

• Gingivitis causes a breakdown in the sulcular epithelium – local inflammation and micro-ulcers.
• The breakdown of this barrier leads to spread of bacteria/bacterial products/inflammation products into the systemic circulation to a distant site.

4. What are the challenges when investigating these links?

• Confounding – Observational/non-randomised interventional struggle to show causation.
• Ethical issue – Not possible to delay treatment or not offer treatment to patients with periodontitis and can’t inflict periodontitis!
• Case definition of periodontitis – Considering the perio-systemic mechanism may be more about inflammation, do we then need to consider bleeding or gingival inflammation, rather than probing depths, when it comes to defining periodontitis?
• Outcomes – Short term follow up is usually through surrogate measures but long-term outcomes including survival are likely to be more meaningful.

5. What’s the current evidence on the link between periodontal disease and diabetes?

• Majority of the evidence for type 2 diabetes (less evidence for type 1/gestational).
• Patients without diabetes, who have periodontal disease, have a higher HbA1C and greater risk of developing diabetes.
• Patients with type II diabetes who have periodontal disease have poorer glycaemic control and more complications.
• Treatment of periodontal disease yields improvement in HbA1C – Comparable to a second drug without the side effects of another drug!

Recommendations as a GDP:

• Ask patients with diabetes about their blood sugar control.
• Ensure diabetic patients are aware of the risk of periodontitis and other oral conditions (dry mouth, burning mouth, candida infections, caries).
• Screen for periodontal disease (at least annually) and manage accordingly.
• Non-surgical periodontal treatment is recommended regardless of glycaemic control.
• Surgical periodontal treatment or implants are not recommended in patients with poorly controlled diabetes due to poorer wound healing and higher risk of post-op infections.
• Replace missing teeth to improve diet and nutrition.

6. What’s the current evidence on the link between periodontal disease and atherosclerotic cardiovascular disease (ACVD – angina, MI, stroke, TIA, peripheral arterial disease)?

• Patients with periodontitis have a greater future risk of cardiovascular disease.
• Intervention trials have shown an improvement in levels of CRP (measure of inflammation) and endothelial function following periodontal therapy. None have looked at “hard outcomes” e.g. does the treatment of periodontitis prevent someone having stroke?

Recommendations as a GDP:

• Patients should be made aware of the risk.
• Treat periodontitis in these patients as there are known benefits. Should consider treatment split over multiple visits in these patients as periodontal treatment raises inflammatory load. Follow AHA guidelines in treating periodontitis (elective procedure).
• Address common risk factors (smoking, diet, exercise).
• Patients with periodontitis and other risk factors for ACVD should be referred to their GP for an annual check-up.

7. What’s the current evidence on the link between periodontal disease and adverse pregnancy outcomes?

• Adverse outcomes have been associated BUT interventional trials have not been conclusive.
• Recommendations:
  • Ask about possible pregnancy and get details on pregnancy (trimester, due date, previous complications).
  • Talk about periodontal issues in pregnancy (gingivitis, periodontitis, epulides).
  • Periodontal screening.
  • Detailed oral hygiene instructions and nonsurgical periodontal treatment.
  • Avoid radiographs and elective treatment in the first trimester.

8. What are the pros and cons of perio treatment to improve systemic health?

• Pro: Non-pharmacological intervention, reduced side effects, cheaper compared to drugs/cost of complications and other known benefits (improved tooth retention, function and quality of life, improvements in halitosis and cessation of drifting).
• Cons: Not conclusively proven.

9. How do you best explain this to patients?

• Describe the surface area of the inflamed tissue in severe periodontitis as that to an ulcer the size of the palm.
• The ulcer may have been there for decades, in a wet, warm and nutrient rich environment.
• This is a breach in the body’s first line defence and may lead to spread of local bacteria to rest of body.

10. Where can I find more resources?

• http://www.bsperio.org.uk/publications/index.php
• https://onlinelibrary.wiley.com/toc/1600051x/40/s14
• https://www.ncbi.nlm.nih.gov/pubmed/29208508

These notes were derived from a webinar produced by the British Society of Periodontology. Further resources can be found at: www.bsperio.org.uk.

General Dental,Periodontology