Inflammation and Oral Systemic Connection P2

Daniel Vinograd

So, there is evidence that periodontal disease can actually trigger cardiovascular events.  Well, there’s a wealth of information out there.  I’m just going to bring up one brief study that I think is simple to explain and has a huge impact.  They looked at 628 at Pima Indians, and they used the Pima Indians because there’s a very low rate of cigarette smoking in that tribe.  They wanted to see if periodontal disease has any risk on these individuals dying of cardiovascular disease over a period of time.  Within 11 years, about a third of those individuals dropped dead; 204 died.

They sorted out the cardiorenal deaths, which was a majority of the deaths, and what they found was a bit shocking.  If the patient had no or mild periodontal disease, no Pima Indians suffered a cardiorenal death, none.  There were zero deaths if that was the case.  If they had severe periodontal disease, they were three times more likely to suffer a cardiorenal death.  Again, they made multiple adjustments for other potential risk factors.  That’s a very impressive study that periodontal disease is associated with the risk of cardiovascular events.  We’ll, of course, present additional evidence in that regard.

Do we have any evidence that periodontal treatment can actually impact cardiovascular risk?  There’s a wealth of that information as well.  The one study to talk about today deals with type II diabetics, 371 of them, and about half of them received excellent treatment for periodontal disease.  The others did not get treated, and they looked to see if it had any impact on the overall sugar control, the A1c.  The ones that had treatment had a very significant drop in the hemoglobin A1c of 0.4%, demonstrating much better glycemic control, which is related to cardiovascular risk.  In our course in November, we’ll talk about additional evidence in that regard.

So, what did the American Heart Association conclude in that highly publicized paper in April?  It was published in an excellent journal.  They had several huge conclusions.  One, there’s level A evidence that periodontal disease is independently associated with arterial disease.  That’s a huge conclusion.  Level A evidence is extremely difficult to obtain.  It was published in our journal JAMA several ago that the cardiovascular guideline, the vast majority of those are based on less than Level A evidence; 20% or less of the guideline’s actually Level A.  So, that’s very impressive that there’s Level A evidence, and independent means it’s been adjusted for the several risk factors.  Periodontal disease is still associated with arterial disease.  That’s a huge statement.  They also concluded that the evidence that’s out there looking at periodontal treatment does show a trend for cardiovascular risk

As you know, the unfortunate additional conclusion that got most of the press was, periodontal disease doesn’t cause arterial disease.  They weren’t able to prove that periodontal disease causes arterial disease.  Of course, that’s what the press latched on to, and crazy statements started flying around.  “Periodontal health doesn’t matter for cardiovascular health.”  That’s ridiculous.

In order to show causality, it’s extremely, extremely difficult to do that.  Number one, you have to have a definition that is extremely objective for pediondontal disease before you can show causality.  We believe that should include burden of bacteria.  Certain items at all aren’t subjective.  So, that’s a hurdle that has to be overcome before you’re going to show causality.  Another hurdle is in the studies, they’re trying to show that the treatment protocols have to be very objective and have to have objective points to prove that the treatments were effective, and again, probably including something showing effectively  that yes, we eradicated the bacterial burden.  Then, there are numerous known risk factors for cardiovascular disease.  Those are confounding.  Number four, to prove causality, all of those have to be controlled.  You have to have baseline from the control group to the treatment group.  You have to be matched where there’s no significant difference in the two groups of baseline.  By the end of the study, there can still be no significant difference in the known risk factors.  That’s a huge hurdle to overcome.

We do now know, and we’ll talk about this in our course in November, but most of the time, when there’s a plaque “rupture” where you’re going to get an event that blocks the flow of blood, a clot, that causes heart attack or ischemic stroke, we now know most of those “events” are not symptomatic.  The vast majority of them are asymptomatic.  You get small damages that, overtime, can lead to heart failure or dementia.  Sometimes, it just simply heals over, and the plaque on the wall of the artery continues to grow.

So, if you’re going to do a study to show causality, any study that’s going to include cardiovascular disease, in the future, are going to include being able to measure those asymptomatic events.  So, causality is going to be very tough to prove.  It’s going to take time and an extremely well-designed study and a better definition.

The fortunate thing is that causality is not a pre-requisite for including periodontal disease assessment and management in a cardiovascular wellness program.  If we had to show causality before we included things in our program, we would hardly be doing anything.  Few things have been show to actually have causality.  That’s not necessary.  Simply having Level A evidence, which is extremely difficult to accumulate, having Level A evidence that periodontal disease is independently associated with arterial disease along with evidence of therapy reducing that risk is plenty of information to demand that any cardiovascular wellness program include oral health and assessment of periodontal disease and managing that disease in their program to maintain cardiovascular wellness.

So, I look forward to hearing Dr. Nabors now.  He’s got a few more slides to go through with you.  I’ll just say a few more things in the end, but I really appreciate you being on-call.  We have to have your help to reduce the number of heart attacks and ischemic strokes in this country.  Periodontal disease is at the root of a lot of those.  Thanks.

Dr. Nabors:         Thank you so much, Dr. Bale, and I believe the listeners today can truly hear in the voice Dr. Bale how dedicated he is to preventing heart attacks and stroke and also his partner Amy Doneen.  These two individuals are very unique, and I think you can hear that in their voice and in the presentation that Dr. Bale just made.  I’ll tell you that Dr. Bale and Ms. Doneen’s speaking for 2 day programs about [30:58], and I’m always fascinated with their ability to keep the audience on the edge of their seats and providing new information every time they speak.

We mentioned here, and I’m privileged to be a part of what Dr. Bale’s doing and what Amy Doneen is doing.  I think all of us should have the privilege to look into our patients, not just our ill patients, but as our friends and family, that we now have a greater responsibility to help determine if our patients may be at risk for heart disease or ischemic stroke or diabetes.

I was also privileged to be a part of their time in writing this CE course called Inculpatory Evidence:  Periodontal Disease Assessment and Treatment is an Essential Element in Cardiovascular Wellness Programs.  That is being published by Pinwell and will be in Dental Economics this month.  We should see that publication in a matter of days.  So, please look at Dental Economics, and look at your web-based Dental Economics material.  You can take a 2-hour CE course perhaps, prior to coming to Las Vegas.

As Dr. Bale said earlier said today, as we look at our responsibility as health care providers, we really emphasize the prevalence of cardiovascular disease and the causes of cardiovascular disease.  He also helps us understand the important role that chronic infections play, and, in particular, the chronic infection that is called periodontal disease plays as an independent risk for factor for vascular events.  He also says, in that slide, that dentists can also play a role as screeners and as monitors and educators for our patient bases in helping them live longer.

This particular slide here is from a study that was done in 2002 by the Columbia University Columbia School of Dental Medicine.  There have been about five studies that have been done since 2002, one concluding in 2010, that clearly show that dentists can play an important role in systemic health.  Certainly, by observation and treatment of periodontal disease and being able to define periodontal disease more accurately by looking at more accurate parameters of periodontal disease risk.  It clearly shows, too, that dentists need to take a more proactive role in looking at health histories and looking at a number of issues.

In 1999, this goes back 13 years, the Journal of the American Medical Association said thatdentists can have a large impact on vascular diseases and diabetes in three areas.  Number one, as screeners; number two, as educators; number three, as monitors of risk factors.  We will be discussing all three of these areas in our course so that when you leave, you’ll know what it means to be a screener, an educator, and monitor of risk factors.

I’ll say this.  It’s not going to change the amount of time that you spend with the patients significantly. I realize what our training is, and that is to make sure the oral health is as good as we can possibly get.  It may require just a few more minutes to look at these very specific elements that you can learn in this course so that you can help advise your patients that may be at risk because you discovered their risk and save their life.  You know that this is happening today.  As we continue to look at this study in the Journal of the American Heart Association, we understand what we can do and what we need to know.

While we’ve been talking about the systemic connection for a number of years, I would also say that many of us have not changed our practice significantly.  I would also suggest that we can change it significantly, continue to do the things that we do and do well but also add this as a very important aspect of general health and well-being of our patient bases.  So, what we will learn at this course will be, we will help define our patients at risk for diabetes or cardiovascular diseases.  In other words, you will be able to look at your patients based on their medical history.  What are the real significant findings in the questionnaire that you are already getting?  We’ll offer maybe a revised version of the medical history.  In order words, the same medical history that Dr. Bale and nurse practitioner Doneen use in their review to determine from medical history, what risk may lie unnoticed in the medical history?

Blood pressure’s significantly important here.  Many of you are already taking blood pressure, and I will tell you from what I learned from Dr. Bale and Ms. Doneen is that blood pressure is a big deal.  We were taught primarily to use blood pressure to educate our patients, but we want to know if our patient is safe at the time that we are doing our dental procedures.  We have a responsibility to do that.  We can take our knowledge based on blood pressure where it is, and we can help educate our patients.  I will tell you that we will learn in this course that pre-hypertension is dangerous and that hypertension is ultimately a killer.  We need to know which of our patients are pre-hypertensive or which of our patients are in fact hypertensive.

Also in oral health, there are a significant things we can look in our patient’s mouth by just doing a good clinical exam.  I will also suggest to you that we will learn by using salivary diagnostics.  We can do an improved oral health exam, and we can help identify individuals that may be at risk for systemic disease based on our oral health findings.

Then, lastly, we really do need to understand risk factors.  It’s been about 2.5 years that I have been sitting at the [38:22] of Dr. Bale and Ms. Doneen, and I can tell you, I have a much higher regard for risk factors than I ever had before because we can look at risk factors.  You can look at your patients and the risk factors associated with the medical history, their blood pressure, and their oral health.  Then, you can add numerous risk factors that you will learn at this course, and you can know very, very quickly which of your patients are at extreme danger.

One such report that was published just in November 2011, is that if you know what to look for during an oral health exam, you can identify individuals that have a 63% increase risk for heart attack with no other test.  We are certainly advising that you learn what tests are available as you are working with your physician colleagues in your community, but this is striking news.  You can look at oral health and come up with this type of figure for your patient that may be at risk for heart attack.

I mentioned blood pressure, and the things that we will be looking at more closely as we listen and learn from Dr. Bale and Ms. Doneen, these two studies were published this month in [39:51], which came out of Europe, which was a perspective urban and rural epidemiology study.  It was published online September 5th of this year.  Then, also we have our CDC study that was published September 11th of this year.  They are in agreement that there is approximately 40% of the world population, including US population that are pre-hypertensive or hypertensive.  That’s a huge number.

For those of us in the dental setting, this is particularly important because we see our patients every six months or every three months based on their oral health status.   Approximately 50% of those who are pre-hypertensive or hypertensive are undiagnosed.  So, if you’re taking blood pressure of your patients, this is incredibly important to the health of your patient to be able to determine if they are pre-hypertensive of hypertensive.  As Dr. Bale stated, this is one of the leading causes and major causes that he and nurse practitioner Doneen are fighting today.  We can be a part of that fight just by understand the role of blood pressure, how important that is, and how important our role can be by taking blood pressure on every one of our patients.

Why is that important?  Blood pressure screening can prevent 46,000 deaths per year in the United States alone.  For those of us in the oral health profession, we’ll join with general health practitioners as a team, and that’s what the CDC was saying.  Clearly, when there’s a team effort, we discover more pre-hypertensive patients and hypertensive patients when everyone understands the significant risk factor associated with deaths in the United States.

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One Response to “Inflammation and Oral Systemic Connection P2”

  1. Ruth Martin says:

    I did not know that there are dentists that check blood pressure. I have been known to have low blood pressure in the past, but have not have it checked lately. I am going to ask my dentist if they could start doing it – as is sounds so important! Thanks for the eye opening info.

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Dr. Daniel Vinograd, DDS |
10450 Friars Rd, San Diego, CA 92120 |
Phone: 619-630-7174    •    Dr. Vinograd, DDS, is a Dentist in San Diego, CA, offering services as a periodontist, and providing teeth whitening, dental crowns, invisalign, implants, lumineers, dentures, root canals, holistic, family and cosmetic dentistry.


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