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Georgia Dental
Hygienists’ Association
2011
“In the U.S., the fields of dentistry and medicine
have traditionally been worlds apart. But in light of
the growing evidence pointing to links between oral
and whole body health, this separation of
disciplines is slowly beginning to break down. The
notion that dentists (and hygienists) care for only
gums and teeth, while doctors look after everything
else is being rethought.”
Sharon Guynup, Editorial director
Oral and Whole Body Health, 2006
Objectives
 To discuss the systemic diseases that are impacted
negatively by poor oral hygiene.
 To provide scientific evidence about the benefits of
dental hygiene care
 To discuss the systemic effects of caries, gingivitis, and
periodontal disease
 To consider emerging evidence of other possible
disease associations.
 To provide suggestions for collaboration for the
patient’s well-being and health.
Oral health is a critical component of total
health
The first-ever Surgeon General’s Report on Oral
Health has called attention to this important
connection and states, that if left untreated, poor
oral health is a “silent X-factor promoting the
onset of life-threatening diseases which are
responsible for the deaths of millions of
Americans each year.”
American Dental Hygienists’ Association
Systemic Disease
 Current research has linked periodontal disease to a number of
systemic diseases.
 The greatest evidence exists for the connection with diabetes,
however numerous associations are being studied and
evidence continues to emerge.
 Some of these possible associations include: heart and lung
disease, pre-mature, low-birth weight babies, oral and
pancreatic cancers.
 Scientific evidence also supports the fact that many cases of
respiratory infections among the institutionalized originate
from oral bacteria.
“Periodontal disease is a chronic inflammatory disease,
and is linked to other serious health risks.”
 Inflammation
 Osteoporosis
 Heart Disease and Stroke
 Pregnancy Problems
 Diabetes
 Respiratory Diseases
American Academy of Periodontology
“Plaque is a bacterial challenge to the body. It’s an
infection. Patients don’t think of that”
JoAnn Gurenlian, RDH, PhD
Because of the abundance of current information on the
“Oral –Systemic Connection”, Meta analysis and
systemic reviews were primarily consulted for this
presentation.
Consequently, a large amount of research was
considered with the primary findings highlighted here.
Diabetes Facts:
Type II diabetes is increasing in incidence, even among
younger individuals.
The Center for Disease Control and Prevention reports
Diabetes diagnoses have increased more than 3 million in
almost two years. Currently, it is estimated that almost 8
percent of the US population has diabetes.
Numerous current scientific articles have been written that
support the relationship between oral health and the
effective control of diabetes.
Periodontal disease is more common in people with
diabetes. Among young adults, those with diabetes have
about twice the risk of those without diabetes.
Periodontal disease is more prevalent, progresses more
rapidly, and is often more severe in those with both type 1
and type 2 diabetes.
Periodontal disease has been named as the sixth
complication of diabetes.
http://www.cdc.gov/diabetes/pubs/estimates07.htm#9
U.S. Department of Health and Human Services. Oral Health in America: A
Report of the Surgeon General. Rockville, MD: U.S. Department of Health and
Human Services, National Institutes of Health, National Institute of
Dental and Craniofacial Research, 2000.
How does periodontal disease affect diabetes?
 Those patients with periodontal infections had worse glycemic
control over time. This may be a result of cytokines secreted
because of chronic inflammation. Cytokines are associated
with insulin resistance.
 Treatment of periodontitis improved glycemic control.
Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in
patients with non-insulin-dependent diabetes mellitus. J Periodontol. 1996;67(10 Suppl):10851093.
Also, periodontal disease in diabetic
patients increases the severity of
complications of diabetes such as
kidney and heart disease.
Some of the mechanisms that explain the increased
pathology seen in diabetic patients as a result of
periodontal infection:


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altered vascular physiology
reduced immune response
particularly protective response by
neutrophils
reduced ability for tissues to heal.
Diabetes and Periodontal Disease: Current Concepts
Robert Genco, DDS, PhD, Distinguished Professor, Oral Biology, School of Dental Medicine, State University
of New York, Buffalo, New York
http://www.cdc.gov/OralHealth/publications/library/conferences/periodontal_infections09.htm
Intraoral findings for Diabetes:
• Dry, burning mouth
• Gingival proliferation, gingivitis, periodontitis
• Abnormal wound healing
• Multiple carious lesions
• Candida infection – denture sore mouth, angular cheilitis,
median rhomboid glossitis
• Periodontal abscesses
• Acetone breath
• Increased salivary viscosity
• Asymptomatic parotid gland swelling
Dental Hygiene Treatment
 Carefully assess all patients for the signs and
symptoms of diabetes
 Educate diabetic patients about the importance of
their personal oral hygiene as well as regular
professional care.
 Actively prevent and aggressively treat periodontal
diseases in diabetic patients.
How does periodontal disease affect
respiratory health?
 The oral cavity provides a reservoir of bacteria for lower




airway infections.
Bacteria from the mouth can form a biofilm on ventilation
tubing, thereby inoculating the respiratory tract with oral
bacteria.
Oral bacteria may also be aspirated by the patient.
The severity of the oral disease is correlated with the
pathogenicity of the bacteria which may be transmitted.
The presence of cariogenic bacteria plus periodontal
pathogens have been found to be significant risk factors for
aspiration pneumonia.
Who is at risk?
Patients at the highest risk for respiratory
infection (pneumonia and bronchitis) are
institutionalized patients or medically
compromised patients with or without
respiratory disease who are unable to perform
self-oral care.
Also at risk are hospitalized elderly patients.
“There
is good evidence that mechanical oral hygiene
practices reduce the progression or occurrence of
respiratory diseases in high-risk elderly people in nursing
homes or hospitals. Mechanical oral hygiene practices
may prevent the death of about one in 10 elderly residents
of nursing homes from health care–associated
pneumonia.”
This author evaluated 328 articles published from 1996 to 2007 which discussed
the results of clinical studies linking oral hygiene to health care–associated
pneumonia or respiratory tract infection in elderly people.
Rosenblum, R. “Oral hygiene can reduce the incidence of and death resulting from
pneumonia and respiratory tract infection” J Am Dent Assoc 2010;141;1117-1118
Dental Hygiene Treatment
 Meticulous and frequent oral care is critical in
preventing these infections.
 “Oral hygiene intervention significantly reduced
occurrence of pneumonia in institutionalized
subjects” Scannapieco, FA, Bush, RB, Paju S. Associations between periodontal disease and risk for
nosocomial bacteria pneumonia and chronic obstructive pulmonary disease. A systematic review Ann Periodontal.
2003; 8:1, 54-69.
 Frequent toothbrushing and pre-operative use of
0.12% or 0.2% chlorhexidine mouthrinse or gel
reduced nosocomial respiratory tract infections
Sjorgren P Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systemic review of the preventive effect of oral hygiene on
pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes. J Am Geriatric Soc 2008;
56: 2124-2130
 Ideally, this care should be provided by licensed
dental hygienists.
 Presently, because of restrictive practice
regulations in our state, we are unable to provide
care in nursing homes and other institutionalized
settings without the direct supervision of a dentist.
 Hygienists can, however, train nursing home
personnel to provide this care until such time that a
licensed hygienist can be employed by the long
term care facility to provide oral care.
Coronary Heart Disease
Heart Attack
Atherosclerosis
Stroke
How does periodontal disease affect
heart disease?
 This association is still being studied, but it is thought
that the C-reactive protein and fibrinogen production is
increased in response to oral inflammation. C- reactive
protein increases clotting and is a marker for heart
disease.
 Risk is increased for diabetic patients and synergistically
increased if the patient is a smoker.
A relationship between periodontal disease and
atherosclerotic diseases, including heart disease and
stroke, has been established.
Oe Y, Soejima H, Nakayama H, Fukunaga T, et al. Significant association between score of periodontal
disease and coronary artery disease. Heart Vessels. 2009;24:103-107.
7. Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of
Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. Am J Cardiol.
2009;104:59-68.
 In a large 14 year study, patients with periodontal
disease were 25% more likely to develop coronary heart
disease (CHD) than their healthy counterparts.
 Men under 50 with periodontal disease were 72% more
likely to develop CHD
 Periodontal disease increased risk for both fatal and
non-fatal strokes two-fold.
DeStefano, F, Anda RF, Kahn HS, et al. Detna disease and risk of coronary heart disease and mortality.
BMJ. 1993; 306:688-691
Wu T, Trevisan M, Genco RJ, et al. Periodontal disease and risk of cerebrovascular disease: the first national
Health and nutrition examination survey and its follow-up study. Arch Intern Med. 2000; 160:2749-2755.
Model explaining the Oral inflammation-Systemic
Disease Associations
Periodontal pathogens
Or their products
Bacteremia
Oral Inflammation
Inflammatory
Mediators
IL-1, IL-6, TNF-a
Liver
Periodontal pathogens
eg. P gingivalis
Immune
Response
C-Reactive protein,
fibrinogen
Target Organ
Adapted from Scannapieco FA. Compend Cont Educ Dent. 204;25(7 suppl
1): 16-25
Dental Hygiene Treatment
 Educate patients about the importance of maintaining
their oral tissues through home and professional care.
 Dental professionals should always take the patients’
blood pressure before proceeding with treatment. This
is Standard of Care.
 Ask about tobacco use, and incorporate Tobacco
Cessation into the patient’s treatment plan.
Low birth-weight infants
“Enough evidence exists to show there is an
association between the presence of periodontitis
and preterm delivery and low birthweight infants.
However, the exact nature of that association is still
unclear”
M. John Novak, BDS, LDS, PhD
How does periodontal disease affect
preterm or low birth weight outcomes?
 It is thought that inflammatory molecules from the
mouth can get into the circulatory system. They can
reach the fetal membranes and cause preterm delivery.
 Oral bacteria has been found in fetal membranes
Dental Hygiene Treatment
 Although we do not fully understand the association,
dental professionals should promote overall health.
 Since we know that gingivitis and periodontitis are
infections, we should educate patients to control the
disease in their mouth through self and professional
care, especially during pregnancy.
A reverse association
How does Osteoporosis affect
periodontal disease?
Periodontal bone loss will progress more rapidly in
patients with osteoporosis.
Medications taken by patients with osteoporosis
should be considered before any operative
procedures. Intravenous bisphosphonates create a
greater risk for the patient than oral
bisphosphonates.
Dental Hygiene Treatment
 Dental professionals should pay careful attention to
rapid bone loss especially in post-menopausal women.
 Consider referral to the physician if the patient has not
previously been diagnosed with osteoporosis.
 Also consider the patient’s bisphosphonate
medications, especially the intravenous type when
designing the dental hygiene treatment plan.
Oral Cancer
Pancreatic and Breast Cancer
Alzheimer’s Disease
What cancers may be associated with
Periodontal Disease?
 New research is underway to investigate if there is an
association between periodontal diseases and oral or
pancreatic cancer.
 This research is based on the model that stomach
cancer is preceded by Helicobacter pylori, so perhaps
pancreatic cancer has an infectious connection.
 There are also studies looking into the possible
associations with breast cancer and Alzheimer’s.
Dental Hygiene Treatment
Dental professionals should stay current in their own
research of emerging evidence on these subjects, and
be prepared to pass pertinent information along to
our patients.
Caries and Periodontal Disease
Dental Decay (caries)
 Dental caries (decay) is the most common chronic disease
nationally affecting 53% of 6-8 years olds and 84% of 17
year olds.
 The cost of providing restorative treatment is more
expensive than providing preventive services.
 It is not only socially responsible, but fiscally prudent, to
increase access to preventive services. Each year millions of
productive hours are lost due to dental diseases.
 An estimated 51 million school hours per year are lost
because of dental-related illness.
 Students ages 5 to 17 years missed 1,611,000 school days in
1996 due to acute dental problems—an average 3.1 days per
100 students.
Community Voices: HealthCare for the Underserved.2001. Poor Oral Health Is No Laughing Matter.
Washington, DC: Community Voices: Health Care for the Underserved.
National Center for Health Statistics. 1996. Current estimates from the National Health Interview Survey,1996
“Early tooth loss caused by dental decay can result in
failure to thrive, impaired speech development,
absence from and inability to concentrate in school,
and reduced self-esteem.”
Office of Disease Prevention and Health Promotion.
2000. Healthy People 2010. In Office of Disease
Prevention and Health Promotion
Dental caries rarely lead to death, but it is possible as in
the 2007 Deamonte Driver case.
Deamonte did not have access to dental care. By the
time he sought medical treatment, the bacteria from
his abscess had traveled to his brain and he ultimately
could not be saved.
His hospitalization cost approximately $250,000. An
extraction would have cost less than $100.
Other Oral Health Problems
 Serious oral health problems also occur among adults. Each
year about 30,000 Americans are diagnosed with oral and
pharyngeal (throat) cancers, and more than 8,000 people die
of these diseases.
 In addition, almost 30% of elderly adults no longer have
their natural teeth due to tooth decay and gum disease.
 Take and carefully review every patient’s medical history.
 Take and record each patient’s vital signs, especially blood
pressure.
 Carefully conduct the intraoral assessment including oral
cancer screening and periodontal charting and gingival
assessment.
 Provide exceptional care including referrals to the
appropriate medical personnel.
 Stay informed about emerging evidence about the oral-
systemic connection.
Because
of the overwhelming
science supporting the “oral-systemic
connection”, patients with these
systemic and oral conditions should
have access to dental hygiene services
on a very routine basis.
The American Dental Hygienists’ Association and the
Georgia Dental Hygienists’ Association advocate that the
services of dental hygienists who are graduates from an
accredited dental hygiene program can be fully utilized in all
public and private practice settings to deliver preventive and
therapeutic oral health care safely and effectively.
If improvement in the nation’s health care system
is to occur, more equitable access to basic quality
oral health care at affordable costs is necessary.
Licensed dental hygienists are educated and
qualified to perform oral health care services.
Furthermore, dental hygienists serve as an efficient
pipeline for identifying and sending on those
who need the care of a dentist.
Georgia