Perio-Systemic Connection Flashcards
Cardio Vascular Disease Proposed Mechanisms (2)
(1) Hyperinflammatory Macrophage Phenotype, Common Susceptibility Model – Genetic factors or Diet/Environmental factors (excess glucose) cause **ANGRY MACROPHAGES*phenotype that releases more inflammatory cytokines –> HYPERINFLAMMATORY STATE
(2) Direct INVASION/Injury by Periodontal Pathogens
- Bacteria enter the periodontium, circulate in the blood (bacteremia), stick in places such as the coronary arteries
- Internalized bacteria are safe from neutrophils in the epithelium or smooth muscle
- P. gingivalis was found in atherosclerotic plaques
Hyperinflammatory Macrophage Phenotype, Common Susceptibility Model –
– Genetic factors or Diet/Environmental factors (excess glucose) cause “angry” macrophage phenotype that releases more inflammatory cytokines
Direct Invasion/Injury by Periodontal Pathogens
- Bacteria enter the periodontium, circulate in the blood (bacteremia), stick in places such as the coronary arteries
- Internalized bacteria are safe from neutrophils in the epithelium or smooth muscle
- P. gingivalis was found in atherosclerotic plaques
Systemic Consequences of Periodontal Infection (2)
- Cardio Vascular Disease
2. Increased Inflammation throughout the body that disrupts normal function
What percentage of people have a perio issue
1/2
Risk Factors of Perio Disease (9)
Smoking Diabetes Poor OH Genetics Lack of Dental Care Obesity Alcohol Stress Medications
Hypothesis of Perio disease having a connection to systemic health issues- The causes include what (6 things are a result of poor perio health)
- Periodontitis
- Pro-inflammatory cytokines (from gram negative anaerobic bacteria causing inflammation)
- Bacteremia
- Cytokine spillover causes activation of the liver
- Acute phase reactants (CRP/IL-6)
- Activation and Bacterial Invasion of Endothelium - Atheroma (plaque formation)
Acute phase reactants include what (2)
CRP and IL-6
Which bacteria was found in atherosclerotic plaques?
P. Gingivalis-also the other red complex bacteria a.a and T. Forsynthia
Once the bacteria get into the blood stream, bacteria will try to end up where?
Places with endothelial receptors and often end up in places like the coronary arteries
Once bacteria is in the blood it can evade what?
Neutrophils
% of population with severe periodontitis?
Moderate?
5-10% severe
~30%
Focal infection theory
the place containing the epidemiological factors needed for infection (place, vector, targets, characteristics for spreading)
Sepsis caused by spread of microbes from distant, chronically infected sites (including the oral cavity) has been proven to be responsible for inflammatory diseases such as arthritis, peptic ulcers, and appendicitis
Sepsis caused by spread of microbes from distant, chronically infected sites (including the oral cavity) has been proven to be responsible for things like what? What theory is this based on?
inflammatory diseases such as arthritis, peptic ulcers, and appendicitis
This is based on focal infection theory
Bradford Hill Criteria for Causation Says what/tries to do what in general
How Do We Go from Association to Causation – prove that an exposure caused a morbid event (criteria can be fulfilled for an association to show that is was causal for an event)
Bradford hill (BH) strength of association
stronger association the more likely the casual connection
BH Consistency
relationship observed repeatedly such that designs are done across different populations
BH specificity
A factor influences a specific outcome or population
BH Temporality
Exposure comes BEFORE the outcome is seen-THIS IS MOST IMPORTANT
BH Biological Gradient
As exposure increases so does the outcome
Plausability of BH
association makes sense according to our kowledge
BH of coherence
Association does not contradict our knowledge
BH of experiment
causation more likely if evidence is based on randomized experiments
Meta analysis and systematic review are strongest IF
IF they are of RCTs only-what kinds of studies did they have access to
BH analogy
For analogous exposures and outcomes an effect has already been shown
The Hierarchy of Levels of Evidence
RCT’s to Cross Sectional Epidemiological Observations
o Systematic Review or Meta-Analysis are limited by the “science” they review – better to have a systematic review of RCTs vs Cross-Sectional Studies
o Positive Outcomes are easy to interpret – you are looking for True Positives, positive tests for true cases
o Negative Outcomes are difficult to interpret – wide confidence intervals, causal interference may be inconclusive
Positive Outcomes are hard or easy to interpret? What does it mean?
easy to interpret – you are looking for True Positives, positive tests for true cases
Negative Outcomes are hard or easy to interpret? What does it mean?
are difficult to interpret – wide confidence intervals, causal interference may be inconclusive
Dental Health and Myocardial Infarction (MI)- result?
Dental Index was found to be higher in MI patients vs. the controls
Oral Wounds with moderate to advanced periodontitis with a wound surface exposed to gram negative bacteria (that could enter as bacteremia) have more what?
Acute Phase Reactants – C-Reactive Protein, Plasma IL-6 levels raised in periodontitis patients vs controls
What type of perio treatment will lower the CRP the most?
Intensive periodontal therapy lowers CRP levels the most
Oral Wounds with moderate to advanced periodontitis with a wound surface exposed to gram negative bacteria (that could enter as bacteremia) is estimated to be what in size
be 8-20 cm (golf ball sized)
_____ levels were found to be raised in periodontitis patients vs controls
C-Reactive Protein, Plasma IL-6
Do people with perio disease have more atherosclerosis? How many had mouth bacteria in the study?
Not proven…2/3 of plaques had mouth bacteria in the plaques though
Spahr Arch (explain this)
Higher pathogen burden (namely A. actinmycetemcomitans) and Congenital Heart Defect in perio patients
What is the risk of bacteremia with perio? Compare tooth brushing and extraction
200x the risk during toothbrushing
Can perio pathogens survive in carotid plaques? Explain what happens
Yes- the body will just hold the bacteria in one place as macrophages accumulate lipoproteins and convert to large foam cells as part of plaques when in the presence of periodontal pathogens
Is there an association between MI/CVA and perio? Odds Ratio?
Yes, proven in cross sectional and longitudinal
Poor Odds Ratio though
Arguments against the Cardiovascular Associations (3)
- Adjustment for smoking is difficult
- Spurious associations
- Edentultation doesn’t improve morbidity
Bradford Hill Criteria Applicable to Perio and Cardio (His belief)
Specificity, Plausibility, Coherence, and Biological gradient,
Pregnancy Considerations of perio disease
Risk of Preterm, Low Birthweight (<2500g, <37weeks)
Are the studies for perio and pre term birth conclusive?
Non are
mother had poor perio through pregnancy (gingavitis), got an upper respiratory tract infection that ties up the immune system… What killed the baby?
The bacteria in the moms gingiva was found in the kids lungs
Compare preterm Antibodies in mom’s with perio disease and those without
Preterm had 3x the Fetal IgM to one or more periodontal pathogens (highest risk when
coupled with lack of maternal IgG to mother’s infections)
Bradford hill criteria for Perio and PTB
Specificity, Plausibility, (and Experiment) Coherence
