Under One Roof 2019

Periodontal Disease:

Gingivitis-Periodontitis

90%

50%

• Most common oral disease in the world

a host inflammatory response to the bacteria

ASTHMA, DIABETES, ALLERGIES,LUPUS,ARTHRITIS,

AUTOIMMUNE

• Various patterns
• slow or rapid progressing
• aggressive, for short or long periods of time
• specific sites/regions of the mouth

Chronic inflammatory disease

Periodontal Disease

• Adults 30+
• Can also be in children and adolescents

• Prevalence may be severely under reported
• Not all age demographics being evaluated
• Surveys are always partial mouth evaluations
• Underestimate the prevalence, extent and severity since patients can areas of health and periodontal disease in an oral cavity.

Progression of Gingivitis to Periodontal Disease

# of protective flora

# of harmful bacteria and other species

Host susceptibility

• Significant genetic association
• 3 genes on chromosome 2Q13
• control the production of pro inflammatory cytokines

Genetic Factors

30%

Microbiome

https://www.theguardian.com/news/2018/mar/26/the-human-microbiome-why-our-microbes-could-be-key-to-our-health

A microbiome is "the ecological community of commensal, symbiotic, and pathogenic microorganisms that literally share our body space." Joshua Lederberg coined the term, arguing the importance of microorganisms inhabiting the human body in health and disease.

American

Human

Microbiome

Project

Bacteria

Fungi

Viruses

outnumber human cells

Weight, brain, immunity

How much does it weigh?

A. 8 ounces

B. 16 ounces (1 pound)

C. 24 ounces

D. 48 ounces

Periodontal Disease

Cure

Vaccine

Body's Repsonse

Biofilm, Immune system, Microbiome, Genetics and Lifestyle

Re-infection

Treatment: suppress/reduce flora, reduce/eliminate lesion,improve host

Vaccine

https://www.sciencedaily.com/releases/2016/12/161205113748.htm

http://biomedpharmajournal.org/vol8octoberspledition/periodontal-vaccines-a-sophisticated-treatment/

Why a Vaccine for Periodontal Disease?

$54 Billion

lost productivity

70%

65+

P. Gingivalis

*15% threshold

*Attachment LOSS

*Oral-Systemic connection

35%

severe

chronic

perio

$442 Billion

spent on disease/yr

50%

age 30+

periodontitis

Non Surgical Periodontal Therapy

Ongoing self care practices

S/RP

Adjuncts:

Laser

Antimicrobial

Next Frontier:

Create an environment where harmful bacteria won't thrive and improve the host response

Eliminate or Reduce contributing factors (risk)

Importance of highly skilled clinician

• Data may not reflect private settings: pt diversity, skill of clinician
• 10 minutes per tooth (70 minutes + time for anes/med HX,vitals)
• Mild to moderate disease
• Decreased time devoted to s/rp accounts for diminished results compared in classic trials

https://www.ncbi.nlm.nih.gov/books/NBK401538/

20-30%

do not respond favorably

Early Intervention=better results

Assess Risk: Prevent bone loss

Diagnose/Early detection:

Prevent further bone loss

Prevent tooth loss

If wait for significant signs and symptoms= may be too advanced/ too late

Early Detection Saves Lives!!

https://blueearthproducts.com/maintenance-cleaning/the-lifecycle-of-biofilm/

BIOFILM

https://www.statnews.com/2016/06/28/biofilms-bacteria-research/

Attachment-Growth-Detachment

http://drlauriesmiles.com/blog/2014/04/what-is-biofilm.html

BIOFILM

International Journal of Environmental Research and Public Health

Are we doing a disservice by not educating all of our patients?

Biofilm

Inflammation

Oral-Systemic link

Risk Factors

Genetic Link

How do you describe what is going on?

Who are you discussing periodontal disease with?

twitter

twinanimators.blog

How many species may live in the oral cavity?

BIOFILM

https://video.search.yahoo.com/yhs/search?fr2=piv-web&p=biofilm&hspart=att&hsimp=yhs-att_001#id=12&vid=8dc217903403de2780fad64c7e51ba8c&action=view

how is biofilm able to survive?

Biofilms can be up to 10,000 times more resistant to antibiotics than planktonic cells

Multiply

Adapt

Change

Resistant

how is biofilm able to survive?

1mm thick

96 hours

Chlorhexadine 24-48 hours

Porphyromonas Gingivalis

(P. Gingivalis)

Polymorphous Gingivalis

(P. Gingivalis)

• 1 of 3, advanced, progressive
• Calculus
• Adapts to environment and changes it's behavior to "fit in"
• 160X more resistant to low dose antibiotics, Metroniazole, than planktonic bacteria

WARNING!!

Children and Adolescents are subject to destructive forms of periodontal disease. Researchers have observed some of the organisms seen in periodontal disease in young children without symptoms. Healthy children do not usually harbor P. Gingivalis and Ti. denticola

nearly 4% of youth have periodontitis

Gingivitis may be nearly universally found in children and adolescents

nearly 4% of youth have periodontitis

Disparities among US population

Risk Factors

• Bacterial Culprits
• Family Factors
• Poorly contoured restorations, tooth abnormalities
• Poor alignment
• Species other than bacteria: Viral, Fungal
• Smoking
• Diet/Nutrition: Sugar and acid
• Poor oral hygiene
• Hormonal changes
• Diabetes/Medical History
• Medications
• Stress
• Age

Bacterial Culprits-11

Keystone Pathogens

Produce enzymes that may be destructive enough to

disrupt the immune system and

destroy connective tissue

Bacterial Culprits: Journal of Dental Research

subgingival

highly diverse microbiota

Pathogens

bacteria (11)

Viral

Fungal

• predominantly gram-negative anaerobic bacteria
• A. actinomycetemcomitans
• P. gingivalis
• P. intermedia
• B. forsythus
• C. rectus
• E. nodatum
• P. micros
• S. intermedius
• Treponema sp

17

• immune response
• geography
• genetics
• environment

other

micro

organisms

besides

bacteria

Immune Culprits

National Institute of Dental and Craniofacial Research, NIH

• October 2018
• Bacteria=inflammation, but immune system plays key role
• Periodontal disease may be driven by T Helper Cells (Th17) 17 cells
• which are triggered by an unhealthy bacterial community in the mouth
• Live in barrier sites: mouth, digestive tract, skin
• Help fight off Fungal infections, but also linked to psoriasis, colitis
• DUAL ROLE in health and disease

trigger certain immune cells

that destroy tissue

unhealthy bacteria

Family Factors

12X

Studies have shown that children of parents with periodontitis are 12 times more likely to have the bacteria that that are dominant in periodontal disease

Family Factors

30% of the population may have some genetic susceptibility

Early onset and rapid destruction may indicate strong genetic component

Disease Transmission:

Intimate partners/spouses may also be at risk due to long term exposure. Studies do not show risk from short encounters or sharing utensils.

P. Gingivalis may be contagious over long exposures over long periods of time

Genetic factors may include Il-1, the cytokine involved in inflammatory response.

American Association of Orthodontists

Smoking/Nicotine

Increase in

TYPES and

AMOUNTS of pathogens

11X

Change of oral flora

increase inflammation

Decrease in circulation, oxygen

Increase in recession/bone loss

Over production of CYTOKINES

Changes in Immune System and Host Response

When combined with

P. Gingivalis=even greater breakdown and immune system burden

40% of smokers lose their teeth by the end of life

Risk increases with amount of use

Exposure to second hand smoke may increase risk of periodontal disease by 50%

US Surgeon General

Vaping: 2nd hand vapor as dangerous as second hand smoke-under 25

AS dangerous as high levels of air pollution for all ages

Heat/Chemicals/Nicotine=cell damage

Marijuana

Journal of Periodontology October 12, 2016

1 time per month for 1 year

* indicators for mild, moderate and periodontal disease.

4mm pockets:29 sites

5mm pockets:25 sites

8mm pockets: 25 sites

less frequent use

4mm: 22

5mm:

8mm: 18

RISK

FACTOR

Teen Stats

https://www.cdc.gov/marijuana/factsheets/teens.htm

12th grade: 44%

11th grade: 36%

23%,6%

8th grade: 14%

5th grade 1%

https://www.drugabuse.gov/drugs-abuse/marijuana

Alcohol Consumption

" Alcohol Consumption and Periodontal Pathogens and Cytokines" Brazilian study

• may aggravate an existing case of periodontal disease
• poor oral hygiene may be associated with alcohol use

Youth Alcohol Consumption

Drug of Choice-most widely used

Pose enormous health risks

By 18: 60% of teens

Youth ages 12-20 drink 11% of all alcohol in the US

Poor Oral Hygiene

There still is a pronounced relationship between poor oral hygiene and high levels of plaque/biofilm and increased severity of disease

15 yr study: no deterioration of periodontal structures with proper oral hygiene and routine professional care

Hormonal Changes: inflammatory changes and gingival inflammation

• Menstruation
• before menstruation and before ovulation
• high level of progesterone, which blocks repair of collagen fibers and causes dilation of blood vessels
• Pregnancy
• may reside after childbirth, gingival overgrowth, may progress to periodonitits
• Birth Control- only limited research on certain types of synthetic progesterone
• Menopause
• Estrogen deficiency reduces bone density and may lead to tooth loss. study of 42,171 post menopausal women showed reduced tooth loss with treatment of estrogen hormonal therapy. May develop gingivostomatitis- gums appear dry, shiny and bleed easily. Change in taste sensation and experience burning mouth

Expectant mother's periodontal health vital to health of her baby

non surgical therapy is safe for pregnant women

Am College of Ob and GYN

Report encouraging pregnant women to sustain oral health and recommend regular cleanings throughout pregnancy.

"routine brushing and flossing, and seeing a periodontist, dentist or dental hygienist for a comprehensive periodontal evaluation during pregnancy may decrease the chance of adverse pregnancy complications to support the mothers health,but also ensure a safe pregnancy and healthy baby."

Men's Health

Periodontal Disease:

ED

Low sperm, low quality sperm, prostate cancer

Diabetes

• Research has shown that this is one of the systemic risk factors and can play a major role in initiation and progression of periodontal disease
• Associated with destruction of the PDL
• Crevicular fluid and saliva have higher concentrations of inflammatory mediators
• AAP and EFP concluded that periodontal treatment may be as beneficial as giving antidiabetic medication

Medications

• Diminished salivary flow
• anti depressants, antihistamines and beta blockers
• May induce gingival overgrowth, allow bacteria to thrive and inhibit natural immune fighting system to work
• More difficult for plaque removal

Generation Meds

Alarming rate of children growing up on prescription medications

9 out of 10 SPECIAL NEEDS CHILDREN

11% of all youth 4-17

Millions of youth on medications for behavioral issues, ADHD depression and anxiety

11%

Stress and the Immune System

300 articles

• reduces salivary secretions
• increased plaque accumulation
• salivary stress markers
• cortisol, CgA, b-endorphin, a-amylase

Depressed individuals have been shown to

possess higher levels of cortisol in ginigival crevicular

fluid and respond poorly to treatment.

Academic stress poor oral hygiene, increased

inflammation and increased concentration of

interluekin-1B

Stress in America: survey finds similar patterns of unhealthy behavior in teens and adults. Teen stress rivals that of adults in today's society (Age 13-17)

Stress

SLEEP

1-2 hr less/nt National Sleep Foundation

36% feel tired because of stress

58% vs 51%

40% irritable/angry

36% nervous or anxious

1/3 feel overwhelmed, depressed or sad

EXERCISE

23% skip meals

*make unhealthy choices

*may over eat

less likely to exercise

spend 3.2 hrs online per day

NUTRITION

American

Psychological Association 2014 age 13-17

Association of Periodontal Disease and Heart Disease

Under 65: 19% increase in risk of cardiovascular disease

Over 65: 44% higher

Periodontal disease association with stroke is even stronger that coronary heart disease

30%

High Blood Pressure

• Can occur at any age, birth-teens
• No symptoms or signs
• Early diagnosis and treatment are key
• Thickening of arteries can be seen in young adults
• 1 of 3 adults have HBP and Dx can be as early as age 25
• Rec annual BP on all children and teens
• HBP is a risk factor for perio disease- chronic inflammtion, damaged epithelium and damage to the walls of vessels
• Risk Factors for early HBP

Obesity, Sleep apnea and sleep disorders, family HX, lack of activity

Viral Causes: Virus may release tissue destructive cytokines, may stimulate bacterial overgrowth or may suppress immune system and play a role in the progression of periodontal disease

Herpes-Related ( herpes Simplex and Varicella Foster)

Cytomegla

Epstein Barr

Association of Periodontal Disease with other medical conditions

Respiratory Diseases

COPD

PD is also an independent risk factor for developing COPD

Pneumonia

oral and periodontal pathogens are also implicated in bacterial pneumonia

Asthma

If you have PD- you are 5x more likely to develop Asthma.

Di-directional relationship

8.4% of youth under the age of 18 have asthma

5X

Seasonal Allergies: Dry Mouth

• Mouth breathing
• Post nasal drip
• Medications that dry mouth

40% of Children

3rd most common chronic disease in 18 and under

The dental professional can play a key role in discussing risk factors for periodontal disease in youth that have allergies and asthma

Periodontal disease raises the risk of developing cancer!

Studies show:

tongue cancer

5.23X higher risk

with

each mm of bone loss

Autoimmune Diseases

MS, Rheumatoid Arthritis, Lupus, Crohns Disease

have been associated with a higher rate of periodontal disease

2002 Study- P. gingivalis and more advanced MS progression in the brain

Alzheimers Disease

BLOOD

SALIVA

SPINAL FLUID

96% P. Gingivalis

https://www.perio.org/consumer/alzheimers-and-periodontal-disease

Geography

Socioeconomic

and ethnic factors

People in poor, rural and under-served areas

have the highest level of dental disease.

90 million lack dental insurance.

SUGAR IS THE #1 FOOD CAUSE OF INFLAMMATION

Diet/Nutrition/Sugar/Acid

• Vit C deficiency=1 1/2 times more likely to develop periodontal disease.
• Vit C helps body repair and maintain
• connective tissue.
• Smoking depletes Vit C
• Vit B- if low- higher CRP
• Vit D-inhibits inflammtion, lack of=depression

• Acid Challenge: the bacteria that cause periodontal disease thrive in acidic environments.

• Sugar increases bacterial and cancer cell activity

Prevention of Periodontal Disease

World Health Organization

recommends

preventive strategies

which should be based on

RISK FACTORS

• Oral Hygiene Practices
• Diet/nutrition counseling
• Fluoride- STANNOUS
• Antimicrobial
• Tobacco cessation
• inhibit further progression and reduce the amount of destruction
• Risk protocols
• screenings, government policies, scaling/cleanings

Stannous Fluoride

Nutritional Counseling

Fiber Supplements

Plant and Fish/Seafood based diet

Tea- white and green

High

Risk

Behaviors

9 out of 10 smokers used by age 18

each day 3,200 youth 18 and young...

Cigarette Smoking

Academy of Periodontology

American Dental Hygienists Associti...