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Hygiene Tribune Middle East & Africa Edition No.6, 2016

Dental Tribune Middle East & Africa Edition | 6/2016 hygiene tribune D6 The Relationship between Periodontitis and Atherosclerosis and Diabetes BySunstarGUM Heart attack is the leading cause and diabetes is the sixth-leading cause of death in the United States.1 What goes relatively unnoticed, however, are their respective relationships with oral health especially periodon- talbacteriathatbreedinflammation. ThisSunstarE-Briefexploresthecell- to-cell interactions behind the in- flammation process and features in- sightfromanexpertonthesubject. In exploring how periodontal bacte- ria trigger inflammation in tissues farremovedfromtheoralcavity,oral health professionals need to under- stand several underlying concepts and the direct role they play in peri- odontal diseases. Jepsen, DDS, MD, MS,PhDaprofessorandchairmanof the Department of Periodontology, Operative, and Preventive Dentistry at the University Hospital of Bonn in Bonn,Germanysaysthreethingsare most important to understanding cell-to-cell communication relative tothisoral-systemiclink. First, periodontal bacteria are dis- seminated into the body’s circula- tion. “Especially in cases of advanced periodontitis,” Jepsen notes, “and these bacteria are able to thereby elicit so-called systemic inflamma- tion.” The second key component of this cell-to-cell communication, accord- ingtoJepsen,isthatsystemicinflam- mationcanpromoteatherosclerosis. “Systemic inflammation can also lead to impaired blood sugar con- trol,” Jepsen says, “which may have negative effects on the periodon- tium.” And, the third consideration con- cerns the effects of oral health professionals’ work: “Oral health professionals should be aware that periodontal therapy may positively impact these conditions,” Jepsen pointsout. InflammationandArteries In periodontitis, the inflammatory response is caused by the spread of microbes.Thesemicrobescantrigger a similar inflammatory response in arterial tissues that sets the stage for the hardening of the arteries, or ath- erosclerosis, which can lead to heart attack. Additionally, fatty streaks are caused by white blood cells that travel into blood vessel walls and be- come macrophages. Macrophages assist in the uptake of low-density lipoprotein (LDL) cholesterol, or “bad cholesterol.” The absorption of LDL cholesterol, facilitated by periodon- tal bacteria, creates foam cells that eventually die and form a dead core within the fatty deposits. Other im- munecellsareaddedtothedeposits, which causes the artery to narrow further. This process gradually robs heart tissues of vital nutrients and oxygen. The substances created by periodon- tal bacteria can harm the underlying connective tissue within the arter- ies. The vascular deposits eventually break up and leave a wound that al- lows blood to coagulate, facilitating blood clot formation. The blood ves- sel is increasingly narrowed by the clot formation and can completely closethebloodvessel,raisingtherisk ofheartattackandstroke.Theblood- stream continues to transport the inflammatory substances produced by the damaged endothelial cells throughout the body, triggering a generalizedinflammatoryresponse. Effect onSugarMetabolism Periodontitis and diabetes tend to exacerbate one another. Type 2 dia- betes is also related to the general in- flammatory reaction caused by bac- teria associated with periodontitis. Such inflammation can negatively affect the regulation of blood sugar, orglucose. Blood sugar levels are regulated by the hormone insulin, which is pro- duced in the pancreas. Insulin binds to insulin receptors located on cell membranes. In turn, the binding activates glucose transporters that takebloodsugarintocells,whereitis processed for energy or storage. In a healthy body, this mechanism caus- es blood sugar levels to drop. This mechanismisdisrupted,however,in the presence of generalized inflam- mation, which creates substances that inhibit the binding of insulin and reduce the cell’s uptake of sugar. This leaves the body’s glucose levels high. Inflammatory substances that are by products of periodontitis ap- pear to play a special role in this dis- ruption. Even when diabetes is absent, a severe case of periodontitis can in- crease the body’s blood glucose lev- els. This condition eventually can make the body’s cells unresponsive to messengers, leading to insulin re- sistance. Diabetes not only affects blood glu- cose levels, it can also negatively im- pactperiodontalstatus.Forexample, when blood sugar remains elevated, significant numbers of proteins ad- here to the excess sugar that has at- tached to hemoglobin in red blood cells. This process creates advanced glycation end products (AGEs). Gly- cation occurs when insulin does not properly metabolize sugars, thereby promoting the destruction of col- lagen in blood vessels. In turn, this causes blood vessels to become brit- tleandformplaque. AGEs also promote periodontitis by crosslinking fibers of the connective tissue,impairingperiodontalwound healing. The body’s white blood cells and vascular wall cells also recognize AGEs, triggering the formation of messengers that encourage inflam- mation. The messengers summon inflammatory cells, while disturbing the wound healing process acceler- ating the destruction of periodontal tissues. SeeingIsBelieving Sunstar has created a three-dimen- sional (3D) video to better explain these concepts. The 3D video, Cell- to-Cell Communication Oral Health and Systemic Health, for which Jepsen was a creator, outlines spe- cific benefits that are important to oral health professionals. “The film illustrates how periodontitis may contribute to systemic conditions such as atherosclerosis or diabetes, or negatively influence their course. It also shows how diabetes negative- ly impacts the periodontal tissues,” Jepsensays. Jepsen describes the video technol- ogy as an excellent example of mod- ern science transfer. “It is hoped that [this video] will help oral health pro- fessionals communicate these find- ingstotheirpatients,”Jepsenadds. There is more to be learned about cell-to-cell communication that will be an asset to oral health profes- sionals, according to Jepsen. He says that in the future it may be possible to visualize the physio-pathological processes involved in the develop- ment of peri-implant infection/ inflammation. “The prevalence of peri-implant disease is dramatically increasing, posing an emerging pub- lichealthproblem,”Jepsensays.“The prevention and resolution of peri- implant inflammation is a new chal- lenge for the oral health care team,” headds. With periodontal diseases affecting more than 70% of some adult popu- lations in the US,2 the challenge of holding periodontal bacteria at bay persists. Oral health professionals, equipped with the understanding of how these microbes affect the entire body and trained with the clinical skills to address them at the source, will continue to shoulder a consider- able responsibility in helping at-risk patientsmaintaintheiroralhealth. References 1. Centers for Disease Control and Prevention. National Center for Health Statistics. Leading Causes of Death. Available HERE. Accessed Oc- tober27,2016. 2. Centers for Disease Control and Prevention.PeriodontalDisease.Oral Health. Available HERE. Accessed Oc- tober27,2016.

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