Mouth = Body: Emerging Strategies for Enhancing Periodontal Health & Wellness

A long-standing lament of many dental professionals is that patients and the medical community often fail to connect that the mouth is part of the body. For that reason, many welcomed the news linking periodontal infection to systemic health problems such as cardiovascular disease and stroke. A great hope ensued. If the medical community would tout that message, then promoting good oral health to patients would be much easier.

But does the adoption of this information make our job easier or more challenging? While most researchers agree that the oral-systemic link still needs more investigation to prove causality,1,2 emerging information indicates there are general health behaviors that dental professionals need to discuss with patients who may improve periodontal health.3,4 Rather than easier, the next challenge is likely the transition from procedure-based prevention to improved periodontal health from a total wellness perspective.

The mouth is part of the body

The biology behind the potential link between oral and systemic health has been predicated on infection and inflammation. Periodontal pathogens in the subgingival biofilm trigger an immune response that produces powerful pro-inflammatory agents such as IL-1ß. These agents are key in alveolar bone destruction and systemically can affect vascular smooth-muscle contraction, blood pressure, and other central nervous cell functions.5 Similarly, investigators have shown that people with periodontal disease have elevated levels of C-reactive protein, a marker of inflammation associated with increased risk for cardiovascular disease, or CVD.6

Treating periodontal disease reduces IL-1ß and C-reactive protein levels,7 and improves periodontal health. It is unknown whether treating periodontal disease will produce any positive changes in cardiovascular health.2 It seems likely that there is some type of relationship between periodontal disease and CVD, but the association is modest and might be influenced by shared lifestyle factors such as smoking, obesity, stress, or socioeconomic status.1,2

The body affects the mouth

Smoking, obesity, and diabetes are linked to both periodontal and cardiovascular disease. Smoking and diabetes are well-established risk factors for periodontal disease. Data on obesity is only emerging, but early evidence indicates that it might also play a role in increasing the risk for periodontal disease,8.9 potentially second only to smoking.4 Data on 13,665 adults in the third National Health and Nutrition Examination Survey, otherwise known as NHANES III, evaluated both BMI and waist circumference, or WC, for measures of overall and abdominal fat and the relationship to periodontal disease. For younger adults ages 18 to 34, both BMI greater than 30 and a high WC were associated with an increased prevalence of periodontal disease.8 Likewise, in a sample of 706 subjects ages 30 to 65, obese (those having a BMI greater than 30), nonsmoking women were 3.4 times more likely to have periodontitis than those with a normal BMI.9

In comparison, data from 12,110 people in NHANES III found certain health-enhancing behaviors were associated with a lower periodontal prevalence. People who maintained a normal weight (BMI of 18.5 to 24.9), engaged in the recommended level of exercise (five episodes of modest or three episodes of vigorous-intensity physical activity per week), and consumed a high-quality diet (USDA Healthy Eating Index, which conforms to Food Pyramid Recommendations) were 40 percent less likely to have periodontal disease than people who maintained none of the health-enhancing behaviors. With one and two observed behaviors, individuals were 16 percent and 29 percent less likely to have periodontal disease. Only 3 percent of the population in the study maintained all three behaviors. They were older and less likely to smoke, whereas those with none of the behaviors had more calculus, bleeding, and were less likely to have seen a dentist in the last six months. Of note, individual oral hygiene was less likely to explain the strong associations.3

The wellness approach to periodontal health

As the evidence for a link between oral and systemic health grows, it is likely our prevention approach will grow to include total wellness. In addition to practicing good oral-health behaviors, dental professionals are well-positioned to be advocates for all health-enhancing behaviors. Promoting smoking cessation, healthy eating patterns, and regular exercise can have positive benefits for oral and general health.3,10

Quitting smoking is one of the most significant changes patients can make to improve their health. Cessation has an immediate effect on overall health. From a periodontal standpoint, patients who do not smoke or have stopped smoking have better periodontal health than those who smoke, and they respond up to 50 percent better to either surgical or nonsurgical periodontal therapy than do smokers. Smoking also diminished implant success. Encouraging a patient to stop smoking is one of the most important things a dental professional can do.10

There are multiple avenues for bringing up healthy lifestyle choices. It is well-recognized that consuming a diet high in fruits, vegetables, and whole-grain while low in fat is good for almost everyone, as is regular exercise. Yet busy work and family lives can make it difficult. Nevertheless, unlike smoking - which requires total cessation - even modest diet and activity changes can be beneficial. According to the American Diabetes Association, during a three-year period, obese individuals with impaired glucose tolerance (pre-diabetes) who lost 5 to 7 percent of their body weight and participated in 150 minutes of exercise per week had a 58 percent relative reduction in the incidence of diabetes.11 It seems logical that this would be a benefit for periodontal health because diabetes and obesity both negatively affect periodontal health.

Refocusing strategies to include total wellness does not mean that self-care should be overlooked. Rather, as different approaches work for different people to lose weight, stop smoking, or exercise, a flexible approach might be beneficial for self-care as well. There are a myriad of manual and power toothbrushes to meet many preferences. Likewise, reframing flossing to tools for interdental cleaning opens the door to many effective choices, including nontraditional ones such as a dental water jet. From the wellness perspective, educating patients about positive outcomes from these processes, such as inflammation reduction and its benefit to total health, in addition to plaque removal, captures the complete picture of periodontal health and wellness.

Conclusion

Dental professionals have long recognized that people cannot achieve good total health without good oral health. Emerging information indicates that how well we take care of our bodies is also important to achieve good oral health. Many strategies that benefit oral and total health can be applied for a complete wellness approach.

References

1 Khader YS, Albashaireh ZSM, Alomari MA. Periodontal diseases and the risk of coronary heart and cerebrovascular diseases: A meta-analysis. J Periodontol 2004;75(8):1046-1053.

2 Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke: A systematic review. Ann Periodontol 2003;8:38-53.

3 Al-Zahrani MS, Borawski EA, Bissada NF. Periodontitis and three health-enhancing behaviors: Maintaining normal weight, engaging in recommended level of exercise, and consuming a high quality diet. J Periodontol 2005; 76(8):1362-1366.

4 Nishada N, Tanaka M, Hayaska N, Nagata H et al. Determination of smoking and obesity as periodontal risks using the classification and regression tree method. J Periodontol 2005; 76:293-298.

5 Delaleu N, Bickel M. Interleukin-1β and interleukin 18 regulation and activity in local inflammation. Periodontology 2000 2004;35:42-52.

6 Noack B, Genco RJ, Trevisan M, Grossi S et al. Periodontal infections contribute to elevated systemic C-reactive protein level. J Periodontol 2001;72(9):1221-1227.

7 D’Aiuto F, Nabali L, Parkar M, Suvan J et al. Short-term effects of intensive periodontal therapy on serum inflammatory markers. J Dent Res 2005;84(3):269-273.

8 Al-Zahrani MS, Bissada NF, Borawski EA. Obesity and periodontal disease in young, middle aged, and older adults. J Periodontol 2003; 74:610-615.

9 Dalla Vecchia CF, Susin C, Rosling CK, Oppermann RV et al. Overweight and obesity as risk indicators for periodontitis in adults. J Periodontol 2005; 76:1721-1728.

10 Johnson G, Hill M. Cigarette smoking and the periodontal patient. J Periodontol 2004; 75(2):196-209.

11 American Diabetes Association. Prevention or delay of type 2 diabetes. Diabetes Care 2004; 27(Suppl. 1): S47-S54.

Carol A. Jahn, RDH, MS
Jahn is the manager of Professional Education and Communications for Water Pik, Inc, where she develops and delivers continuing-education courses on topics such as periodontics, diabetes, and obesity. She may be reached at [email protected]