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The Oral Systemic Health Connection Dr. Steven Small

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The links and connections between oral infection and serious systemic health are irrefutable. Oral infection is linked to cardiovascular disease, from atherosclerosis to infarction, diabetes, low birth-weight babies, premature birth, still birth, osteoporosis, kidney disease, certain cancers, lung disease and the list continues to grow. We are long past debating the links. While scientists and researchers pursue the actual mechanisms and quantify specifics, the cumulative credible literature leaves no doubt that an unhealthy mouth is a factor in many serious general health problems. Oral health is integral to general health. The medical community is becoming increasingly aware, as the connection between oral health and major general health issues reaches the public ear and enters public discourse. Our patients read about it in newspapers and magazines, hear it on the radio and see it on television, for example with Dr. Oz on The Oprah Winfrey Show. To our patients, we are the experts and need to be prepared to address these issues in daily practice. Dentistry has a major obligation to meet this burgeoning reality and to accept its role on the front line in health care, wellness and longevity.

Programs are now in place that address the oral-systemic link with blood tests measuring systemic evidence of inflammation in the blood: C-Reactive Protein (CRP) and Interleukin-1 (IL- 1). CRP is synthesized in the liver and is released by the body as a response to inflammation. IL-1 is a pro-inflammatory cytokine composed of two distinct proteins, and elevated levels of IL-1 in the blood contribute to inflammation at sites distant from the periodontal tissues. Studies show an association between active periodontal disease and CRP levels, with periodontal treatment resulting in decreased CRP levels. Identifying the cause of oral infection and documenting the diagnosis can be done with direct tests that the dentist directs and controls, which is preferable. Oral infection is a pathologic level of harmful bacteria and organisms which are typically present in the natural oral environment or "ecosystem." If levels of harmful organisms can be kept in balance, than oral disease can largely be prevented.

Periodontal disease effectively creates a "safe harbor" for pathogens to survive, thrive and enter the bloodstream via the raw, open subgingival wounds that periodontal disease creates. These bacteria can trigger a body-wide inflammatory response, contribute to arterial thickening, cross the brain-blood barrier or the placenta-blood barrier. Pathogens can cause or exacerbate a significant list of serious systemic diseases and conditions.

The pathogens of oral infection cause three oral problems: periodontal disease, caries and halitosis. The manifestations of the problems are evidence of oral infection and treatment is indicated. We should be proud as a profession for our preventive approach, but professional in our assessment of success and failure.

Sadly, our best efforts have not reduced the incidence of periodontal disease. Still, an average of 75 percent of the population is affected to some degree, even with sophisticated home care methods and a variety of oral hygiene products. Nonsurgical periodontal programs and periodontal maintenance often relapse with disease recurrence, most likely from continued exposure to harmful pathogens.

The first step in treating and preventing further periodontal disease progression is accurate baseline diagnostics of the quantities and qualities of organisms in the oral cavity or "ecosystem." Microbiology and bacteriology of the oral cavity are now available to screen and test for harmful levels of pathogenic organisms in the oral cavity. The first test to consider is the BANA Test, invented by world-renowned periodontist and researcher, Dr. J. Walter Loesche and his colleagues at the University of Michigan. The BANA Test is the result of 15 years of research and is supported by more than 40 published studies. In a study published in the Journal of Clinical Microbiology in 1992, the BANA test was found to be as accurate as both DNA testing and laboratory culturing in detecting the three most virulent periodontal pathogens – the "Red Complex" comprised of Bacteroides forsythus, Porphyromonas gingivalis, and Treponema denticola. BANA is the acronym for benzoyl-DL-argininenapthylamide, a synthetic peptide that can only be hydrolyzed by these three periodontal pathogens. This synthetic peptide, along with a dye, is imbedded in test strips on which a subgingival plaque sample is placed. If any of the three bacterial species is present, they hydrolize the BANA enzyme producing B-naphthylamide. This enzyme reacts with the imbedded dye to produce a permanent blue color, indicating a positive test. If no color appears after incubation, none of the bacteria were present in the test sample. This enzyme will not be hydrolized by blood or saliva, only the three Red Complex bacteria.

Despite the highly sophisticated chemistry employed, this test is inexpensive and takes just a few minutes of operator time. Samples of subgingival plaque and tongue biofim are placed on the test strip. It is then placed in the small countertop incubator unit where it is gently heated for a few minutes. Although a positive test does not provide information about the quantity and virulence of these periodontal pathogens, it is an excellent way to introduce a discussion of the link between oral infections and systemic conditions. It is a valuable service, generates revenue and opens the door to a discussion of oral-systemic concerns. A positive BANA is a "red light" warning of the presence of the Red Complex periodontal pathogens.

The BANA Test is produced by BANAMet, LLC, and is available as a stand-alone testing tool from Oratec or as part of a comprehensive three-step approach to dealing with oral infection from Novora Biomedical Corporation.

Another chairside test offered by Novora Biomedical Corporation is a Gram Stain test and report on oral bacteria called PerioLinx developed specifically for dental practices. Plaque biofilm samples are taken from the dorsom of the tongue, base of the tongue, and from subgingival areas. Samples are placed on individual glass slides, packaged and shipped to the lab. Bacteria do not need to be kept alive for this test. An oral microbiologist fixes, stains and analyzes the results and a PerioLinx Report is sent to the office and the patient with graphic and written details of the number of gram negative and gram positive cocci, bacilli, fusiforms, as well as spirochetes, yeasts, vibrios and white blood cells present in the sample.

Addressing the oral-systemic health connection means understanding and dealing with the microbiology of oral infection. It all starts with an accurate diagnosis and identification of the causative factors – the pathogenic organisms in the oral cavity "ecosystem." Microbiological testing no longer needs to be reserved for researchers, it is readily available in the dental practice and promises to be an effective way to motivate patients and differentiate practices that adopt accurate screening and diagnostics. Clinicians now have options and systems to assist them is discussing periodontal disease with patients, and providing the scientific evidence in report form to educate and motivate patients to accept recommended treatment.
Author’s Bio
Dr. Steven Small has been in the practice for more than 30 years and was an associate professor at the University of Toronto's Faculty of Dentistry for more than 25 years. He is also the CEO of Capital Partners Corporation and the founder and CEO of Novora BioMedical Corporation (Novora). The Novora Team is a group of experts from the fields of dentistry, hygiene, pharmacy, microbiology and dental research working together to advance oral health-care education, diagnosis, treatment and monitoring by integrating oral-systemic dentistry into dental practices.
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