see the video: http://vimeo.com/27670206
I’ve been practicing in [inaudible] since 1986. The type of practice that I have…I am a general dentist and I do general dentistry. I can do fillings and crowns and bridges and cleanings. My practice has morphed into a little bit more complex restorative practices. That means…basically I do bigger cases. I tackle bigger and more complex cases. I don’t hold myself after being a specialist or a prosthodontist but in esthetic cases and implant cases and combination of various cases… I’ve just morphed into handling some of those cases and doing a lot with implants. What I want to talk about, what got Bill excited was that he saw brochures in the office when he came in about Cerec, Cerec technology and what that can do for patients. It was invisible aligners, invisible braces. That’s a new technology in dentistry. And then I wanted to mention a little about 3D imaging and how the cone beam scanning is being used in dentistry and how it relates to implant therapy. But probably the bulk we’ll talk about is periodontal disease and what does and how it relates to general health. When I first started practicing dentistry was its own little subspecialty of the mouth. It was…anything that happened in the mouth was dental. It was just either dental infection but it didn’t affect anything else in the body. It was just dental. That has changed dramatically over the 23 years I’ve been practicing. So now I get calls from physicians that I have to do and sign off on the patient’s oral health status prior to hip replacements, prior to going into therapy, how are they doing because it affects their diabetic management. It’s “My gosh. The mouth really is connected to the body.” And what goes on in the mouth really affects the body. And in periodontal disease that’s been very significant in what’s been discovered and they are just now getting into…They’ve discovered associations and we’ve all kind of knew it but now we’re actually doing studies designed particularly to find out what’s going on there. So periodontal disease is an infection of the gums in your mouth. But it’s a unique infection. It’s a really unique infection in that the bacteria that are causing the infection are on your teeth or on your tooth, they’re on the gums, under the gum line, in your mouth but still anatomically outside your body. It’s anatomically outside your body. So your immune system detects that this bacteria and the bacterial byproducts are there and all the cellular mediators go out to elicit the immune system to come in and clear this infection. And in that initial stages, it brings in lots of blood vessels and the gums get swollen and red because of the proliferation of blood vessels. We call that gingivitis – swollen, red, puffy gums. In gingivitis stage the gum has not broken down yet. It’s just a puffy, red, bleeding gum. In the later stages, once you’ve had gingivitis for a period time, chronic immune response now becomes instead of acute. Immune response becomes a chronic immune response. And the cells become involved and the immune system’s reaction becomes different in the fact that it starts essentially attacking the attachment apparatus on the gum of the tooth. So that little crevice around your tooth [inaudible] of plaque and bacteria, now gets deeper, And when that crevice gets deeper, it gets harder to clean. The harder it is to clean, the more periodontal diseased you get, the more periodontal diseased you get…and in so it’s a feedback loop that is in the wrong direction.
The worse it gets, the faster it gets worse. Prolixity of the immune response triggers all these inflammatory…inflammation and all the inflammatory markers and that’s what is believed to be the mechanism that affects diabetic…diabetes patients their glycemic control. The chronic infection makes insulin resistance occur so that type 2 diabetic patients have more difficulties controlling their blood sugar if they have periodontal disease. Mechanism is believed to be these immune mediators, product of the immune response going around sensitizing the beta cells for insulin resistance so the insulin isn’t as effective as it should be and so blood sugar goes up. And the problem with diabetes is it promotes…it is…it makes the fighting infection more difficult. Periodontal disease worsens diabetes, diabetes worsens the periodontal disease. Once again it’s that feedback loop going the wrong way that can spiral out of control. The other thing that chronic periodontal disease is involved with is cardiovascular disease, myocardial infarction and stroke. At first they did the studies and just found associations. People with periodontal disease seem to be more prone to have myocardial infarction and ischemic and strokes. Now they’re doing studied to particularly discern the mechanism of action, why is that. It seems to be once again the cellular mediators that trigger the immune response and increase platelet aggregation. They have actually have found the bacteria in the periodontal pocket in the arthrosclerosis plaques in the myocardial infarcts. They don’t quite know how that’s happening other than the fact that advanced periodontal disease bacteria does eventually enter body. It does in fact enter into the tissues in the advanced periodontal disease. So that bacteria can flow around but how does it get into atherosclerotic plaque? And that is something being studied. From the studies that had been done and the associative studies are founding out that cardiovascular disease, stroke, COPD…Because the inhaling the bacteria from periodontal disease is causing low grade chronic infection in the lungs which worsens the COPD symptoms. So periodontal disease, COPD and the same with asthma.
I did kind of a quick publication search on periodontal disease and the relationship with diabetes, COPD and the others that we’ve talked about. I just want to read some of this because I find it interesting. This is periodontal outcomes in patients with diabetes. Studies to date have reported conflicting associations between oral infection, coronary heart disease, and incident coronary heart disease. However, there is evidence that dental infection is associated with coronary atherosclerosis and that bacterial DNA has been identified in atherosclerotic plaques, and other studies have related dental infection to the incidence of coronary events. That coronary events being myocardial infarctions. This one is the COPD and…I’m sorry, stroke. Two lines of evidence further support the hypothesis that active periodontal inflammation increases stroke risk. First, edentulousness. Endentulousness is missing all your teeth. In which periodontal inflammation is usually absent. Obviously there is no periodontal disease because there is no teeth but they had periodontal disease cause that’s why they lost their teeth. First, edentulousness in which periodontal inflammation is usually absent was not an independent risk factor; in contrast, severe periodontitis was a more important risk factor in those with several teeth left. So the active infection was a bigger problem. Second, gingivitis, that early, early stages of periodontal disease which is bleeding, puffy gums but there has been no loss of attachment around the tooth. Gingivitis was strongly and independently associated with cerebral ischemia. Strokes. Cerebral ischemic strokes. When tested together with periodontitis, severe gingivitis even appeared as the more important risk factor. Gingivitis is an indicator for the actual status of periodontal inflammation. As shown recently, acute infection is a trigger for ischemic stroke. And when I first graduated from dental none of this, you know, this was… periodontal disease was a dental infection and managed the dental infection and you were good. Mouths connect to the body but what else does it have to do with it it’s turning out that it has quite a bit to do with it and it’s kind of scary because at times I wonder has the evidence come to the point that when I diagnose periodontal disease and review with the patient do I have to warn them that it increases the risk for cardiovascular disease, ischemic stroking, you know, has the evidence got to that point yet?
Student: Why would you not want to tell them?
Well because they’re still studying and if you scare someone to death, they’ll often leave your practice.
Student: Medicine now, they recognize that inflammation anywhere in your body, you increase your risk for…
Because cellular mediators, all those cytokines and [inaudible]
Student: When you get a gingivitis, does the flora in the mouth change? Most people have the same bacteria…
No. Gingivitis is [inaudible]. It’s the same flora. As periodontal disease worsens and becomes from gingivitis to periodontal disease the bacteria flora do change. The deeper the pocket gets, it becomes anaerobic environment so you get a shift to more virulent, aggressive strains of bacteria.
Student: So the gingivitis is primarily aerobic?
Yes. Aerobic flora. In advanced periodontitis it’s both. Cause of the depth of that pocket. And I think in millimeters, kind of a healthy pocket is an eighth of an inch or 2 to 3 millimeter and when you get periodontal disease we’re looking at your looking at 5 millimeter pockets and deeper. That 5 millimeters is the breakpoint in my mind. That’s not a set…there’s a whole diagnostic criteria hat basically boils down to can a patient clean to the depth of the pocket? Because if you can’t get a toothbrush bristle 5mm under the gum line, or even 4mm under the gum line in that area, I don’t care how many times per day you brush your teeth it’s like never brushing your teeth. And the flossing is the same way. If you can’t get the floss to the depth of the pocket it doesn’t matter how many times a day you floss. It’s anatomically impossible to clean that pocket. And that’s when periodontal surgery becomes involved. It corrects…it surgically…plastic surgery of the gums so that…to correct the pocketing so that the patient can maintain it. If we wave the magic wand and clean all the bacteria off the teeth, all the calculus off the teeth, in 24 hours, it’s back. It’s back. If the patient can’t brush it down at the bottom of that pocket it just…
Student: What about the rinse of some sort? Fluoride rinse?
Fluoride rinse works at the gum line but the periodontal disease is below the gum line. I don’t care what you put in your waterpik and turn it up as high as you want, it does not get under the gum line.
Student: [inaudible] That’s who you are right?
Student: I met her yesterday. You said he was…
Yes, so periodontal disease happens at the bottom of the pocket. You can’t clean the bottom of pocket with rinse. Now, that is a great segue into one of the other things that we do in our office and that is technology that’s been developed [video skips] The gingivitis goes away. It clears out the teeth, the gingival health looks fantastic. Because we were using a peroxide and peroxide is very bactericidal and it kills he bacteria. So the gingivitis clears up. Dr Keller developed an idea that hey, what if we could get peroxide gel up under the gum line into those pockets? Regular tray won’t do it because saliva gets into the tray and dilutes the gel and it doesn’t stay in a significant amount of concentration to do any good. So he designed a tray with gaskets specifically made for each individual patient. And where are those gasket seals are dependent on the measurements that I give the lab, of the pocket around each tooth. So when you insert the tray, the peroxide gel will go up under the gum line into those pockets and the gasket seal keeps it from leaking out and it keeps the saliva from leaking in for that 10-15 minutes period so that the peroxide gel stays in concentrations to be effective. They’ve shown very conclusively that they can get that gel to go deeply up underneath the gum line and it’s very bactericidal and it’s a way of managing periodontal disease. It can be used as a standalone treatment. It doesn’t do a lot to correct the boning defects and gingival defects that can occur that make it difficult to clean.