Tuesday, May 15, 2012
Dr. Rohde interviews Dr. Donald Clem on the important link between oral health and cardiovascular health.
Recently the American Heart Association issued a statement on the relationship between periodontal disease and cardiovascular disease. The statement concluded that while there is no causal relationship, periodontal disease and heart disease are independently associated. However, press coverage surrounding the statement’s publication discounted this association, and distorted the picture of what was really happening. I was able to sit down and clarify the facts with Dr. Donald Clem, immediate past president of the American Academy of Periodontology. He gave some great insights that, discussing the true facts, how we can educate our patients, and what research still needs to be done.
Dr. Rohde: Dr. Clem, you were probably as surprised as I was about the recent news from the American Heart Association. In your clinical experience, do you agree with what they said?
Dr. Clem: If you look at the statement from the AHA and actually read it, it says two things. It says that there is a link between periodontal disease and heart disease or cardiovascular disease. It also says that there is no long term causative evidence that shows that periodontal treatment will affect either the initiation or the progress of heart disease. We agree with that. Interventional studies really need to be done in that regard. However, the press statement came out to say that the AHA disavows any link between periodontal disease and heart disease. That is not what the statement actually said. It said that there is a link. That’s what is undeniable in the literature and is absolute.
DR: So how are the two linked systemically?
DC: We can consider it to be a risk factor for cardio-vascular disease, but not necessarily a causative factor. The difference between a risk factor and a causative factor is analogous to obesity being a risk factor for diabetes. Not all obese patients have diabetes or will acquire diabetes. However, it is a well established risk factor.
Periodontal disease as a risk factor for heart disease becomes evident from two standpoints: via direct and indirect linkages. We know that periodontal pathogens found in periodontitis have been found in the endothelial lining of patients with heart disease in carotid artery surgery. We also know that DNA from periodontal pathogens have been found in cardiac tissue.
DR: That is pretty compelling evidence. What would an example of the indirect linkage be?
DC: The indirect linkage that all of healthcare and medicine is profoundly interested in is the inflammatory burden. We know that patients may be predisposed to produce inflammatory mediators such as C-reactive protein, tumor necrosis factor and interleukins. These inflammatory mediators are produced when the body is challenged in some fashion. With periodontal diseases, if you are genetically predisposed to a certain inflammatory reaction, you may respond with high levels of C-reactive protein, which are the same inflammatory mediators seen in cardiovascular disease.
DR: This is definitely something that we, as dentists, should be discussing with our patients.
DC: The important message that all of dentistry as a profession should take away: Clearly there is an undeniable link in periodontal disease being a risk factor for cardiovascular disease. It is indeed premature to say that periodontal disease causes heart disease or can affect its outcome. Considering that these are both chronic inflammatory diseases of aging, and considering that cardiovascular disease in this country still accounts for one-third of the deaths, it is prudent for the practitioner to advise patients that their periodontal disease is a risk factor in their existing cardiovascular disease. It is also important for cardiologists to be concerned if their patients have periodontitis.
DR: So what else needs to be done? It seems we still don’t have the entire picture.
DC: Dentistry should be advocating for interventional studies from the NIH to further define and clarify the link between these two diseases. Up to this point, the NIH has spent $10 million in exploring this issue. More funding for research needs to be done. That’s why it is so important to clarify the statement from the AHA to advocate for these funding agencies to continue their funding for this important initiative.
Our patient population is aging at an extraordinary rate. Approximately 8,000 patients a day are reaching the age of 65. The numbers of patients 65 and older will double over the next few years, from 35 million to 71 million. We now know that these patients are dying from chronic inflammatory diseases of aging. The inflammatory burden must be managed, both in terms of cardiovascular disease and in terms of their oral health.