The Gatekeepers of Systemic Inflammation

DeWitt Wilkerson, DMD
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The COVID-19 crisis has dramatically changed our world and our profession. It stimulates respiratory distress interactions with the body’s immune system and inflammatory responses. It has the potential to produce fatal outcomes for the immunocompromised and those with elevated levels of pre-existing systemic inflammation due to diabetes, respiratory disease, atherosclerosis, obesity, liver disease, kidney disease, autoimmune diseases, arthritis, sleep apnea, etc. Our whole society is very concerned about staying healthy in a viral world, both during the current worldwide pandemic and for the long-term future.

Other than wearing PPE, social distancing, and increased sterilization precautions, how does this current pandemic affect our profession? COVID-19 should stimulate all dental professionals to take a hard look at how we fit into the total health model of the patients we serve. If we can find significant ways to serve as frontline “gatekeepers of systemic inflammation,” providing services that help reduce atherosclerosis and accelerated aging, there may actually be a long-term silver lining to a horrific worldwide pandemic. Reducing the systemic risk factors appears to be a key offensive strategy. So, my fellow oral health professionals, let’s do our part to attack this crisis together!

READY!
Brent Bauer, MD, wrote an online newsletter article for Mayo Clinic titled “Buzzed on Inflammation.” He said, “Inflammation is the new medical buzzword. It seems as though everyone is talking about it, especially the fact that inflammation appears to play a role in many chronic diseases.” Drs. Brad Bale and Amy Doneen, world-renowned cardiovascular specialists and co-authors of Beat the Heart Attack Gene, concluded, “Systemic inflammation is the number one factor in atherosclerosis and accelerated aging.” They also emphasized the role of inflammation in peripheral microvascular diseases, including everything from wrinkles to ED to dementia. Staying healthy in a viral world requires the proactive pursuit of an anti-inflammatory lifestyle. This is true for us, our patients, and everyone else in our communities. Dental professionals are oral medicine specialists. It is our responsibility to understand the connection between oral and systemic inflammation.

Let’s now identify and briefly discuss the Big 3 oral-systemic inflammatory connections.

1. Oral Pathogens
Bacterial pathogens are responsible for 2 major issues with local and systemic implications: (1) caries/periapical infections and (2) periodontal inflammation/infections.

Studies reveal oral periodontal pathogens are commonly found in carotid atheromas (plaque) under microscopic examination following carotid endarterectomies (cleaning out the arteries).1,2 In addition, there is the chronic presence of high-risk oral pathogens in periodontal tissues: Aa, Pg, Tf, Td, and Fn stimulate macrophages, monocytes, foam cells, cytokines, neutrophils, MMPs, and prostaglandins due to the body’s immune and inflammatory responses. This creates an inflammatory cascade commonly known as periodontal disease. These same bacterial pathogens are found in carotid artery plaques, presumably arriving through the bloodstream. If the same response occurs in the arterial lining that occurs in the lining of teeth, an inflammatory cascade can be anticipated that would elevate the risk of unstable atherosclerosis. This is a very big deal!

Furthermore, the examination of obstructing thrombi (clots) from 101 acute heart attack patients demonstrated the microscopic presence of periodontal pathogens in 35% and periapical pathogens (Streptococcus) in 78% of the thrombi. So, in conclusion, dental infections and oral bacteria are associated with the development of acute coronary thrombosis (heart attacks). Dental health and dental care should be one major element in the effort to prevent heart attacks.3

Whose battle is it to fight the deleterious consequences of high-risk oral pathogens that damage the health of both the mouth and the whole body?

It is the author’s opinion, and that of a growing number of other health professionals, that now the answer is dental professionals as the gatekeepers of systemic inflammation. This should be the expectation for every dental team. We will succeed in eradicating these infectious and inflammatory agents through education and testing and via the implementation of proven methods.

2. Oxygen Deprivation, Poor Breathing, and Sleep
Without oxygen, we cannot live more than 10 minutes! When oxygen saturation levels in the bloodstream are depleted, an inflammatory cascade quickly follows. A sympathetic “fight-or-flight” response stimulates cortisol release from the adrenals, increasing heart rate and blood pressure. Chronic O2 desaturations can lead to cardiac arrhythmia, insulin resistance, diabetes, sleep disturbances, memory loss, heart attacks, and strokes. Often, these problems begin in early childhood through nasal allergies, nasal congestion, conversion to mouth breathing, swollen tonsils and adenoids, obstructed airways, restless sleep, snoring, sleep apnea, GERD, and ADHD-like behavior.

Breathing and sleep disorders are implicated in the mouth through the observance of dental malocclusions such as crowding, crossbites, anterior open bites, maxillo-mandibular retrusion, and maxillary vertical excess, along with bruxism, worn teeth, scalloping of the tongue, tongue thrust and tongue-ties, high Mallampati scores (descended soft palates and uvulas), dry mouth, increased caries, and periodontal inflammation.

Whose battle is it to fight the deleterious consequences of high-risk oxygen deprivation, poor breathing, and sleep, damaging the health of both the mouth and the whole body? Again, the answer is dental professionals as the gatekeepers of systemic inflammation.

This should be the expectation for every dental team. We will succeed in eradicating these inflammatory conditions through education, testing, and the implementation of proven methods.

3. Blood Sugar Dysregulation
Dr. Tony Iacopino is the Dean of the University of Manitoba College of Dentistry and a researcher of the relationship between diabetes and periodontal disease. In one study, he identified dental students with no periodontal pocketing or bleeding on probing. The project involved the volunteer students each ingesting 1 gal of ice cream every day for 7 days, then re-evaluating their periodontal conditions. The alarming findings were that each student presented at the end of the week with gingival inflammation and bleeding on probing!

Diet, blood sugar and fat levels, and the periodontal response appear to be related. A diet high in refined sugars, grains, pastas, breads, cereals, and vegetable oils is associated with greater risk of developing metabolic syndrome, insulin resistance, high blood pressure, elevated total cholesterol, and weight gain around the waist. This can lead to Type 2 diabetes. Diabetes has been compared to having shards of glass continuously scraping the walls of the arteries all day long, creating tremendous inflammation and destruction throughout the body.

There is a strong correlation between a poor diet, blood sugar dysregulation, insulin resistance, diabetes, and periodontal inflammation. So, whose battle is it to fight the deleterious consequences of high-risk blood sugar dysregulation, damaging the health of both the mouth and the whole body? Once again, the answer is dental professionals as the gatekeepers of systemic inflammation. This should be the expectation for every dental team. We will succeed in eradicating this inflammatory condition through education, testing, and the implementation of proven methods.

Understanding the Big 3 oral-systemic inflammatory connections helps us determine the focus of our frontline work on behalf of those we serve. Now we are ready to develop a strategy of effective implementation as gatekeepers of systemic inflammation.

AIM!
Our target is improved complete health for every patient we serve through the reduction of oral and systemic infection and inflammation. We can get started by addressing the Big 3. Our “arrows” for hitting the target will be education, personalizing the Big 3 through patient self-assessment tools or testing for the Big 3, and implementation. These are proven clinical methods to reduce the Big 3.

1. Education
As the gatekeepers of systemic inflammation, we must make our patients aware of the risks that the Big 3 pose to their complete health. Starting an effective patient education program can be as easy as creating a written introduction, followed by a self-assessment questionnaire; for example:

“Integrative dentistry describes our commitment to ensure that your oral health positively contributes to your complete health. Our comprehensive examination process, coupled with our state-of-the-art diagnostics, allows us to identify bite, TMJ (jaw joint), and periodontal (gum) disease early, when it is easiest to treat. We also focus on other key relationships to oral health, such as breathing and sleep disorders, diabetes, gastric reflux, and nutrition. Our integrative assessment process facilitates creating an individual plan for your long-term health. We want your beautiful smile and healthy mouth to positively impact your overall well-being.

“Please review the attached self-assessment questionnaire” (Table 1).

2. Testing
Positive medical and dental histories, self-assessments, and clinical exam findings prompt the usage of appropriate testing, such as:

• Salivary testing for high-risk oral pathogens, HPV, and genetic inflammatory risk factors (in addition to several other available salivary tests).

• A hemoglobin A1c (HbA1c) Fingerstick Test, which measures the amount of blood sugar (glucose) attached to oxygen carrying hemoglobin in red blood cells. It shows what the average amount of glucose attached to hemoglobin has been over the past 3 months, which is typically how long a red blood cell lives. If the HbA1c levels are high, it may be a sign of diabetes, which can lead to heart disease, kidney disease, and nerve damage. The results of the fingerstick test are obtained in 6 minutes.

• High-resolution pulse oximetry (HRPO), heart rate variability (HRV) monitoring, or a home sleep test (HST), which measure autonomic nervous system activity during sleep—“rest and digest” predominantly parasympathetic healthful sleep vs elevated fight-or-flight sympathetic activity, often related to oxygen desaturations, stress hormone release, elevated heart rates, and sleep fragmentation. Testing results guide the diagnosis and implementation of an anti-inflammatory oral-systemic strategy.

3. Implementation
Following this practice model will result in new strategies, including expanded periodontal protocols, managing airway restrictions with tools such as mandibular advancement devices, expanding dental arches orthodontically, tongue-tie release surgery, nutritional counseling, and regular collaboration with a variety of dental and medical specialists.

FIRE!
The world is in crisis, and we find ourselves as oral health specialists living in a unique time in history. On a great day we save a smile, but on an amazing day we can even save a life! As dedicated health care professionals, we can and should be the gatekeepers of oral-systemic inflammation:

• We understand many of the important underlying factors, so we are ready!

• We know the target and have the offensive arrows of education, testing, and implementation—aim!

• Now, let’s all passionately move forward with unwavering commitment! This is our calling! Fire!


References

  1. Figuero E, Sánchez-Beltrán M, Cuesta-Frechoso S, et al. Detection of periodontal bacteria in atheromatous plaque by nested polymerase chain reaction. J Periodontol. 2011;82:1469-1477.
  2. Gaetti-Jardim E Jr, Marcelino SL, Feitosa ACR, et al. Quantitative detection of periodontopathic bacteria in atherosclerotic plaques from coronary arteries. J Med Microbiol. 2009;58(pt 12):1568-1575.
  3. Pessi T, Karhunen V, Karjalainen PP, et al. Bacterial signatures in thrombus aspirates of patients with myocardial infarction. Circulation. 2013;127:1219-1228, e1-e6

Dr. Wilkerson resides and practices in St. Petersburg, Fla, where he serves as the director of dental medicine for the Dawson Academy. He is a past president of the American Equilibration Society and the immediate past president of the American Academy for Oral Systemic Health. He is author of The Shift: The Dramatic Movement Toward Health Centered Dentistry (2019). Dr. Wilkerson can be reached at wittwilkersondmd.com or via email at wittwilkersondmd@gmail.com.

Disclosure: Dr. Wilkerson reports no disclosures.

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