From Health to Disease — How to Gum-up the Works?
This post discusses the progression of a normal molar and its associated structures, including its sulcus, from a state of health to one of serious periodontal—and therefore systemic—disease. Figures 5.1 through 5.5 illustrate this movement by showing a typical lower right first molar that eventually loses its supporting structure of bone and is, therefore, lost to the disease. Just this one molar alone could exact a severe toll on the health of the person in whose mouth it resides, and since periodontal disease is seldom confined to just one tooth, the cumulative effect of several infected teeth can be, and often is, severe.
Let’s begin our trip with a healthy tooth and oral tissue, as illustrated in Figure 4.1. This figure shows the protective layer of gum tissue surrounding the first molar. This tissue is doing its Job of protecting the body from infection, toxins, and other potential injuries by keeping out the approximately 400 types of microorganisms that live, multiply, and die mainly in the sulcus. In addition, the gum tissue lining the sulcus protects it from the dead skin cells (desquamated epithelial cells) that slough off into it from the gum-tissue wall. Food debris forced under the gum tissue can also present a problem, as can the act of consuming a typical diet with the chewing required to process food for proper digestion, which puts stress and abrasions on the healthy gum tissue.
In reference to frank (obvious) periodontal disease only, the molar and its underlying bone will remain healthy as long as the gum-tissue barrier remains intact, which is not an easy thing to do since the sulcus is a potential cesspool of microorganisms and debris under the gums. However, as long as the sulcular tissue lining the sulcus wall remains healthy and intact, the microorganisms, toxins, and other unhealthy elements will stay out of the body. But how do you know when your gums are healthy? You know because healthy gums do not bleed when brushed, flossed, or stimulated by toothpicks or other devices designed to facilitate cleaning the sulcus under the gums.
Keep in mind that gum disease affects from 75 to 95 percent of the adult population. Figure 5.1 depicts gingivitis and its associated inflammation, indicating the beginning of gum disease and its potentially serious systemic effects.
Gingivitis is a condition in which the gums are inflamed, swollen, tender, and discolored (usually red, and sometimes very red). The causes of gingivitis vary from poor oral hygiene or smoking to harsh oral health efforts, such as the use of hard toothbrushes or overzealous flossing. Additionally, hormonal or metabolic disturbances, such as pregnancy or diabetes, can lead to an increased risk of gingivitis. Ongoing studies of periodontal disease show that the causes of the disease can vary, but several facts emerge when there is a diagnosis of gingivitis. First, gingivitis is the initial stage of a potentially destructive process that leads to periodontal disease, and perhaps even more ominously, gingivitis is where inflammation makes its appearance as a potentially harmful systemic condition with potentially deleterious health effects down the road.
Figure 5.1. Gingivitis (inflammation of the gums)
In spite of the actual health challenges presented by gingivitis, the common perception is that this condition is just bleeding gums and, therefore, of little consequence. Dr. Larry Emmott probably said it best when, in referring to a study of more than 50,000 people in four countries that verified the connection between periodontal disease and heart disease, he stated that he was very impressed by research that “could serve to wake up a society that is at risk of becoming dangerously blase about periodontal disease.”
Dr. Emmott was being gentle in his assessment of the collective attitude concerning periodontal disease. Mine would be that people have always been dangerously blase about this potentially fatal disease and, for the most part, continue to be unconcerned to this day. (You constitute an exception since you wouldn’t be reading this if gum disease were of no interest or concern to you.) So, when the gum infection called gingivitis is present, we are dealing with a potentially serious condition that could be the gateway to a more serious condition if it isn’t reversed at this stage.
The good news is that gingivitis is almost always reversible, but it doesn’t go away on its own. Unfortunately, people frequently resort to toxic toothpaste and mouthwashes in an attempt to bring their gingivitis infection under control; in (Toxic Toothpaste and Scary Mouthwash!), you will learn that using products that specifically warn the user to call the poison control center immediately if their child, or others, ingests some of the toothpaste or mouthwash is not conducive to regaining health.
At fifteen, soon after my kindly dentist informed me of my gingivitis, I had my first and only experience with a mouthwash that must have been the prototype for firewater. I used it just once. I also used a natural bristle brush that was exceedingly hard—but I didn’t use it for long. Something in the back of my pre-dental mind told me something wasn’t quite right with my tools and techniques. Now, four decades later, we still have firewater and hard brushes and I’m still investigating products. I’ll have more to say about this later, but delicate oral tissues need some help in order to heal a gingivitis inflammation and its potential consequences; harsh toxic products do not provide that help. If gingivitis is present, it must be dealt with aggressively by having health professionals and their patients pay attention to this problem and do something safe and effective about it.
Early periodontitis represents the progression of gingivitis to a more deep-seated infection characterized by bone loss and considerably increased levels of inflammation. Sulcus probing will go to a depth of 4—5 mm due to bone loss and swelling, and bleeding and pus will frequently show up with the probing. Gentleness is required when probing because these infected tissues will be very tender. This stage of periodontal disease begins to trigger my concern about the potentially serious side effects of CRP and, depending on the age and sex of my patient, my advice will vary.
When men at this stage of the disease are at least in their late twenties, I begin to become concerned because this is when men who were thought to be a perfectly healthy start to die of unexplained heart attacks. I am just as concerned about women, but they seem to have a cardioprotective mechanism at play until they are perimenopausal, which usually begins in their mid-forties. Occasionally, however, women also die unexpectedly of heart attacks well before menopause, so I recommend aggressive treatment of this disease, regardless of age or sex.
Figure 5.2. Early Periodontitis
Figure 5.2 illustrates a sulcus that is deep and wide. To explain how the systemic effects of gum disease are dose-related, I will ask you to imagine that the gum tissue wrapped around the molar in Figure 5.2 is unwrapped. How would much surface area of infected, inflamed tissue that is? If we measured 5 mm deep and estimated about 40 mm around, and then laid this out and looked at it, there might be from one-third to a square inch of infected, inflamed tissue. Since this raw infected tissue is no longer a barrier, microorganisms and inflammatory components (creating CRP) have nothing to stop them from entering the circulatory system to potentially wreak havoc on the health of this person.
Multiply this infected area by six, or even twelve, teeth with probing depths of 5 mm all the way around each tooth. If that infected tissue were laid out, it could measure from two to four square inches. While this might be hard to visualize, the mere fact that we can’t see this ulcerated, infected tissue doesn’t mean the person isn’t affected by it. He or she is very much affected (infected), and the more surface area involved, the bigger the problem. That is what is meant by dose-related. In full-blown gum disease, if all the affected gum tissue around a full complement of teeth were laid out, it would be equivalent to the entire back of your hand. Further, imagine there are twenty-four to twenty-eight teeth embedded in the back of your hand, all with the same inflammation and infection we saw when we toured Bif’s mouth. Visualize this painless process out in the open and it wouldn’t be hard for the person to understand that serious illness was involved, would it? This unpleasant mental picture graphically illustrates what the body has to deal with in terms of a systemic infection with loads of inflammation and elevated CRP. Since processes that may be out of sight can still wreak havoc on your health, I hope this illustration has helped you visualize the sheer extent of the problem that is, for the most part, incapable of showing itself.
Before any periodontal therapy is begun, I recommend getting a high sensitivity CRP test, because CRP is a marker of the degree of inflammation and the ensuing potential health risk. As you recall, CRP is responsible for quite a number of serious health conditions, including heart attacks and strokes, and the higher the CRP number, the higher the likelihood of a serious problem, so a baseline CRP reading is well-advised before treatment is begun. This is what I do in my practice. Although a pretreatment CRP test isn’t even close to mainstream dental practice now, I see it as a logical part of a dental health assessment in the future.
The person with the early periodontitis in Figure 5.2 is potentially in even greater peril if the illness is also systemic, and it gets worse.
The next stage of disease, the moderate periodontitis depicted in Figure 5.3, is a very deep-seated infection, and anyone who comes to me with this condition tends to have a characteristic look and demeanor, but doesn’t generally associate any of this with gum disease, or even realize the condition is there. While this stage of periodontal disease is termed “moderate” in dental terms, it is far more serious than that when viewed as a systemic infection.
Anyone with moderate periodontitis is generally going to have considerable redness and swelling in the mouth, usually with a buildup of hard deposits above and below the gum margin, perhaps an unpleasant odor, and possibly several loose teeth. This person will often be dull-eyed, listless and tired, pale to almost Jaundiced in appearance, and will admit to being a little blue or depressed if questioned.
Figure 5.3. Moderate Periodontitis
It should come as no surprise that people with moderate periodontitis have been affected by their disease for a considerable length of time, perhaps many years, and are already undergoing treatment by their physicians for some of their conditions. These could include arthritis and rheumatoid arthritis, diabetes, fibromyalgia, high blood pressure, high cholesterol, pulmonary edema, and shortness of breath. Inasmuch as their immune systems can be severely challenged by circulating microorganisms and inflammatory components, such as leukotrienes, proinflammatory cytokines, and prostaglandins, as well as the resultant CRP, it would not be an exaggeration to view such people as very ill, would it? Are you starting to see just how ill people like this really are?
Additionally, people in this category are almost invariably on several prescription medications, many of which carry life-threatening side effects of their own. The statin drugs, for instance, do a marvelous Job at reducing cholesterol, but they also dramatically reduce coenzyme (Q10, an immune-system stimulant and an antioxidant, which is required for life itself. CoQ10 has a number of health-enhancing properties, some dramatic, and studies indicate that its levels are notably reduced in diseased heart and periodontal tissues. (Prescription drugs can be beneficial, even necessary, but, as I mentioned earlier, they were also the number-four cause of death in 2001, with an estimated 265,000 deaths. There are other, safer, effective methods than statins for addressing elevated cholesterol levels, unhealthy HDL/LDL ratios, and low CoQ10 levels, which let you take a pass on the adverse side effects.)
It is important to point out again that people are affected by all the cumulative inflammation present in their bodies. All inflammation raises CRP levels, so an adult male with arthritis, prostate inflammation, and moderate periodontal disease—not an uncommon combination of ailments—would need some serious help in regaining his health (and there is much that can be done). Anyone with these conditions should not regard them as the result of just getting older as if these problems were inevitable. They are not, and the individual should know that these conditions exist primarily because he or she did not have the benefit of nutritional regimens and lifestyle choices that may have prevented them in the first place. It is not the scope of this blog to go in depth into areas outside of dental health issues, but you should be aware that regimens for periodontal health can, and frequently do, positively affect other health conditions.
It is always a good idea to consult with your personal physician if you have any questions about a periodontal health and wellness program because a review of the recommendations obtained from a number of highly credible medical sources shows that most of the risk lies in doing nothing.
Figure 5.4 illustrates end-stage periodontal disease. As discussed, someone with this level of disease almost invariably has a number of related diseases. It’s practically inevitable because the mouth mirrors the health of the body.
In this condition, the surface area of the inflamed periodontal tissue in the infected sulci can exceed several square inches. The tissue is neither an effective barrier nor a contributor to health since its inflammatory components elevate CRP levels.
Figure 5.4. Severe Periodontitis
As with the other three stages of periodontal disease depicted in this post, professional help is required to treat severe periodontitis effectively. And, although it may not be widely recognized at the present time, the treatment of periodontal disease at this end stage is as risky for the uninformed, unprepared patient as it is for the treating dentist. Any dentist faced with this level of disease should be aware that it can be dangerous to manipulate infected, inflamed tissues in an unprotected patient; by doing so, the dentist may dramatically elevate CRP in periodontal patients who probably already have elevated levels of CRP.
Dentistry Today reports, “As an independent risk factor for cardiovascular disease, high normal levels of CRP are associated with risk of angina, heart attack, and death,” and adds that severe infection or inflammation can raise CRP levels to levels 500 times greater than normal. Five hundred times over high normal limits is very risky territory to be in and, as if a 500-fold elevation of CRP weren’t enough, consider the additional increase in inflammation when a well-meaning dentist or hygienist starts cleaning the already inflamed, infected sulci using ultrasonic, water-spraying, vibrating tips at the deepest levels of these infected areas. Besides dramatically increasing inflammation, this puts the microorganisms in an almost blender like a vortex, with a percentage of the debris being forced into the adjacent ulcerated tissue, the sulcular wall labeled “gingiva” in Figure 5.5. When this ultrasonic or hand scaling is done around twelve or fourteen teeth (half a mouth), CRP levels will rise even further, perhaps as much as 300 percent above the pretreatment baseline, according to one double-blind study.
While several theories concerning the connection between periodontal disease and cardiac disease exist, all agree that there is some connection. On July 26-27 of 2001, the American Dental Association (ADA) held the first symposium ever to discuss and provide perspectives on the periodontal-systemic disease connection. The first installment in a planned series was titled “Taking Oral Health to Heart: Exploring the Interrelationship Between Oral and Cardiovascular Disease.”
Potential mechanisms of association were reported, suggesting that there is evidence from studies to support the idea that periodontal pathogens have systemic effects that cause the progression of coronary artery disease. Studies showed that Porphyromonas gingivalis “can cause platelet aggregation, increase lipids, enhance atheroma formation and increase calcification.” Moreover, at least one study recovered P. gingivalis from the heart and liver tissue, while others found it in atheromas (clots) and the coronary and carotid endothelium (the innermost lining of arteries). If this theory is correct, it would be very well indeed to keep the sulcular walls intact and acting as a true barrier to keep P. gingivalis confined to the mouth, and not circulating throughout the body.
Figure 5.5. Microorganism Battle
A second possible mechanism is offered by two researchers from The University of North Carolina, epidemiologist Dr. James Beck, Ph.D., and a professor of Periodontology, Dr. Steven Offenbacher. They contend that the oral-systemic “association is related to host mechanisms, such as inflammatory response and antibody production.” According to Dr. Beck, “The clinical signs of periodontal disease are not a specific indication of systemic effects,” stating further that clinical signs of the periodontal disease may only represent the relationship between periodontal disease and coronary heart disease. “People can have the organisms and the infection that cause periodontal disease, but not have clinical signs of the disease. We believe it’s the host’s inflammatory response that causes the disease,” stated Dr. Beck. Supporting this theory of association, Dr. Offenbacher said, “researchers are finding a correlation between the depth of the periodontal pocket and the levels of some of these inflammatory mediators.
If this association is correct, and it’s my firm conviction that it is, helpful solutions are at hand. It is my opinion that there is an anti-inflammatory regimen that could prevent either, or both, diseases and could even reverse existing disease to some degree (this regimen is not drug-based, has an exceptional degree of safety, and has been very effective for many of my patients). Inflammation is finally being implicated as a very real problem, not only in periodontal disease but in systemic disease as well.
Dr. Robert Genco, chairman of the SUNY—Buffalo Department of Oral Biology, also reported support for the role of inflammatory mediators in pericardiac associations. Dr. Genco was the person who observed that CRP levels increase up to 500 times in the presence of severe infection or inflammation. He also reported that periodontal patients had higher than normal levels of CRP and that a periodontal procedure performed in combination with the patient taking a nonsteroidal anti-inflammatory resulted in decreased CRP, while scaling and root planning alone “appears to have the opposite effect” (they elevate CRP).
Go back to Figure 5.5 and imagine that the inflamed, infected tissue depicted was all torn up around twenty-eight teeth as a natural result of a deep-cleaning procedure. It should be obvious that, with all the microorganisms introduced into the circulatory system by deep cleaning, and with the dramatic increase in inflammation caused by the procedure, the whole process represents a serious physiological assault on the person receiving the therapy. It is risky business for the unprotected patient.
There is any number of safe and effective things you can do to improve your oral and systemic health, as well as increase the margin of safety during periodontal procedures. These primarily involve using a very wide range of nutritional elements, such as antioxidants, vitamins, and minerals, many of which are exceedingly effective anti-inflammatories. Additionally, there’s a potent Cox-II inhibitor, Zincosamine, that would be worthy of some professional consideration because, in a study, it was shown to specifically neutralize the substances known to elevate CRP levels. At the very least, anyone with arthritis would likely get relief using it, as most of the study did.
From the disease progression depicted in Figures 5.1—5.5, we’ve seen that, while the molar tooth is the central part of the picture, systemic disease caused by either inflammation or microorganisms entering the body through the diseased sulcular tissues is clearly the BIG picture. (What is the Least Toxic Toothpaste and Mouthwash?) will deal with the pitfalls and inadequacies of home care as it is taught and practiced at the present time and, with your knowledge of the sulcus—gained from the tour of our accommodating patient, Bif—I believe you will clearly understand why the methods and materials most people use for home care these days fall short in helping them achieve oral or systemic health. I don’t know about you, but I’m ready to take on gum disease and start fighting back.