Perio Insights | Scott Smith, DMD | Jeffrey Sibner, DMD | Amy Petrillo, RDH | Mark Weingarden, DMD | Mark Kress, MD
Perio Insights - with Marc M. Kress, M.D.
Welcome to Perio Insights, a segment designed to provide an interface where the science of dentistry juxtaposes with medical science. As a geriatrician and family physician,
I am primarily a clinician interested in bridging our specialties by offering research and content relevant to us all. Now and in upcoming months, I hope to offer you useful
information from the medical/dental literature that dovetails with and enhances your PerioFrogz experience.
Dr. Kress received his M.D. degree from Jefferson Medical College, Philadelphia. PA in 1981. He is board certified in family practice and geriatrics. Dr. Kress has been in private practice for over 25 years as the owner of a multi-specialty medical center in suburban Philadelphia. In addition to his clinical activities, Dr. Kress is a national lecturer and is the former stadium physician for the Philadelphia Phillies and Eagles.
| Perio Insights Article 110: | TOP |
June 2, 2010
According to Dr. Jerry Molitor, a rheumatologist from University of Minnesota, he reports on compiled research linking rheumatoid arthritis and periodontitis in the May 1, 2010 edition of Family Practice News.
He first analyzed data from 16,000 patients participating in the Atherosclerosis Risk in Communities study. This study began in the 1980's and recruited patients ages 45-64 and followed them for ten years. 6,661subjects underwent dental evaluation for periodontitis on their final study visit. Controlling for age, sex, and cigarette smoking, subjects with moderate or severe periodontitis had a statistically significant 2.6 fold increased risk of incident RA, compared with those subjects with little or no periodontitis.
The research also looked at the antibody cyclic citrullinated peptide (CCP), known to precede the clinical onset of RA or be associated as a marker indicating more severe RA. There were greater titers of CCP in this study noted amongst subjects with more advanced levels of periodontitis. A shared inflammatory response creating anti-citrullinated proteins similarly occurring in periodontal tissues and joints was proposed in a review from Inflammation 2004;28:311-8. A periodontal pathogen, Porphyromonas gingivalis makes an enzyme that results in citrullination of proteins. In support of these findings, research presented at the 2009 EULAR Congress in Copenhagen by Dr. Codrina Ancuta and her colleagues demonstrated higher anti-CCP antibody titers amongst participants with RA and more advanced periodontitis compared with similar RA patients without periodontitis. Prior research had demonstrated a positive effect of minocycline on RA. Treatment of periodontitis with minocycline has been shown to reduce the oral bacterial load of bacteria including Porphyromonas gingivalis. This suggests another potential mechanism of how minocycline may be beneficial in RA. (Arthritis Rheum. 1999;42:1691-5). As with other periosystemic associations, more research will be needed to confirm whether the association between periodontitis and RA is causal.
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December 26, 2009
There is an abundance of dental literature regarding the connection between periodontal disease and inflammation. A specific marker of that inflammation, C-reactive protein (CRP) was recently reviewed in the Annals of Internal Medicine October 6th 2009. The review focused on the significance of C-reactive protein as a risk factor for coronary heart disease. Based on data comparisons by meta-analysis it was determined that in intermediate-risk individuals (those with a 10-20% risk for coronary death or non-fatal heart attack over ten years), there is strong evidence that CRP is associated with coronary heart disease events.
Dental treatments of gingival inflammation to lower CRP as well as medical strategies of smoking cessation, weight loss and exercise to lower CRP have not yet yielded conclusive results. Lowering CRP has yet to demonstrate a direct relationship with primary prevention of coronary heart disease events.
It would be affirming to know that your treatments are having a direct positive impact on reducing the cardiovascular fatalities that now account for nearly 40% of all fatalities each year. Until conclusive research is completed, the take home message should be why not continue to pursue periodontal treatments that may ultimately engender quality of life as well as quantity of life improvements?
| Perio Insights Article 209: | TOP |
September 10, 2009
Interdisciplinary studies in dentistry and medicine continue to examine the relationship between periodontal disease and cardiovascular events. The implications of a causal relationship are huge. According to the Centers for Disease Control, heart disease is the leading cause of death for both men and women in the United States. In 2005, 652,091 people died of heart disease (27.1% of all U.S. deaths).
Carotid intima-media thickness as measured by ultrasound has been found by large epidemiologic studies to be a reliable marker for assessing cardiovascular risk. In the Atherosclerosis Risk in Communities (ARIC) study which enrolled approximately 16,000 adults, an increase of 0.2 mm in the mean carotid artery intima-media thickness was associated with an increased relative risk for heart attack and stroke of 33% and 28%, respectively. (Howard G, Sharrett AR, Heiss G, et al. Carotid artery intimal-medial thickness distribution in general populations as evaluated by B-mode ultrasound. Stroke 1993;24:1297-1304)
The above serves as prelude to an abstract that caught my attention from December 2008 published in FEMS Immunology and Medical Microbiology by lead author S. Piconi. In a small study involving 35 healthy individuals with mild to moderate periodontal disease, a longitudinal study was designed to focus on the affect of periodontal treatment on intima-media thickness. Other inflammatory cytokines were also monitored for a response to treatment. Results demonstrated a significant reduction in intima-media thickness as well as a significant reduction in inflammatory biomarkers.
This and other studies lay the groundwork for future research to determine whether treatment of periodontal disease will actually provide outcomes evidence for the reduction of strokes and heart attacks. If confirmed, an integrative treatment strategy bridging medicine and dentistry will emerge to eradicate cardiovascular morbidity and mortality. |
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| Perio Insights Article 109: | TOP |
July 26, 2009
Type 2 diabetes continues to grow in epidemic proportions despite the rigorous efforts of the medical community. Recently, the diagnosis of diabetes is being expanded to include the HEMOGLOBIN A1c test. This test measures the percent of bloodstream sugar bound to circulating red blood cells. This measurement indicates the patient’s glucose control over several months rather than the instantaneous result of a routine daily blood sugar measurement. Until recently, this A1c measurement was only used in monitoring a diabetic’s glucose control. Now, an A1c reading >6.5% establishes a diagnosis of diabetes. A diagnosis of diabetes may also be determined by you during dental examinations for your unsuspecting patients in the following manner.
In a recent abstract from the Journal of Periodontology 2009, Vol. 80, No. 6,
pages 907-914, Dr. Sheila Strauss, et. al. make the observation that blood on probing from the gingival crevicular space (when obtained without touching of tooth or gingival margin) can be glucose tested and found to correlate with blood tested from a capillary stick. This amount of gingival blood was only found in those patients with clinical evidence for gingivitis or periodontal disease.
How opportune if you were to make a new diagnosis for diabetes based simply on this easily performed procedure. Coordination with your medical colleagues at that point for follow up will provide timely care for your patient. Treatment commenced earlier in the course of diabetes is advantageous to the prevention of diabetic complications. Your astute diagnosis may have saved your patient’s health!