It was the “Floss or Die” poster that got to 54-year-old Jack Kelsch of Wareham.
Kelsch works as a grants administrator at the Harvard School of Dental Medicine, where the perils of periodontal disease are standard water cooler fare and “deep pockets” means gum disease, not money.But as Kelsch discovered, that poster was no joke.
Most people know gum disease can lead to tooth loss, or, as some put it, “Ignore your teeth and they’ll go away.” But can it also lead to heart disease? Stroke? Death from all causes?
Yes, according to a growing body of evidence showing that infections in the mouth – notably periodontal disease in the “pockets” where the teeth meet the gums – can indeed have a major impact on health.
Luckily, this gloomy picture is offset by more upbeat news: A number of new treatments for periodontal disease have been approved by the US Food and Drug Administration in recent months.
Periodontal disease is a serious problem for 29.6 million Americans, according to the American Academy of Periodontology. (Others say as many as 67 million Americans – one in three adults – have it to some degree.)
It all starts when bacteria – a strain different from those that cause tooth decay – take up residence in the gums. White blood cells from the blood then flock to the area to fight the infection, triggering inflammation.
At first, this just results in gingivitis – swelling and redness of the gums, says Dr. Nadeem Karimbux a periodontist at the Harvard Dental Center. But when chronic inflammation destroys gums and bone around teeth, it’s periodontitis.
Periodontal infection is troublesome enough in the mouth. But it can be even more serious if it spreads.
Several years ago North Carolina researchers showed that periodontal disease in pregnant women was associated with an increased risk of low birth weight babies.
In 1993, a study of 7,610 Americans published in the British Medical Journal showed that men and women with periodontal disease had a 25 percent higher risk of coronary heart disease and a 46 percent higher risk of death from all causes than those without gum disease.
Last summer, newly-published data on more than 1,000 Boston men showed that those with the worst periodontal disease were twice as likely as those with the least to die of heart disease, and three times as likely to suffer stroke, even when other factors such as smoking and cholesterol were accounted for.
In fact, the deeper the pockets of infection, the greater the risk of death from all causes, says the author of that study, Dr. Raul Garcia, director of the Veterans Affairs Dental Longitudinal Study at the Boston VA Outpatient Clinic and a health policy professor at Boston University School of Dental Medicine.
These findings fit, somewhat, with those from a 1996 Harvard study of more than 44,000 male health professionals. That study didn’t find a link between periodontal disease per se and heart disease, but did find a link between heart disease and the main consequence of gum disease: tooth loss. Another Harvard study of 22,037 doctors, on the other hand, found no such link.
The apparent link between periodontal disease and other health problems may be explained by recent studies showing that oral bacteria can indeed become travelling troublemakers.
When bacteria from the periodontal pockets enter the bloodstream, notes Garcia, they may contribute to the formation of plaque on artery walls. This leads to blood clots that can cause heart attacks and strokes. In fact, several recent studies have found bacteria from the mouth in parts of the brain damaged by strokes and in diseased coronary arteries.
Bacteria from the mouth can also directly cause infections in other parts of the body. That’s why the American Heart Association has long recommended that certain heart patients undergoing dental procedures take antibiotics to prevent a heart infection called bacterial endocarditis.
If your dentist or hygienist discovers, by poking around with a probe, that your pockets are deeper than four or five millimeters and you’re starting to lose bone around the teeth, you’re probably a candidate for scaling and root planing. This is a deeper cleaning process than the one we’re all supposed to have every six months. It involves scraping bacteria off tooth roots, under local anesthesia, and can take up to an hour for just one quadrant of the mouth.
If that doesn’t do the trick, surgery is often required – opening the gums, cleaning tooth roots and the jawbone of bacteria, then stitching the gums together tightly to reduce the pockets.
Oral antibiotics might seem a logical solution for periodontal disease, but they’re not. They cause side effects and can create resistant strains of bacteria.
But new ways of delivering antibiotics and other germ-killing drugs just to the gums, not the whole body, and a new understanding of how some antibiotics work, hold promise.
In recent years, periodontists have been using Actisite, a plastic fiber impregnated with antibiotics that is placed in the gums. So far, though, there’s no proof that five years after treatment, it’s better than scaling and root planing alone, says Karimbux of Harvard.
A newer approach to local control of disease is PerioChip, developed in Israel and marketed in this country by Astra Pharmaceuticals, Inc. It was approved in May by the FDA.
The chip, which Jack Kelsch had implanted last month, is about the size of a baby’s fingernail. Inserted into pockets after scaling and root planing, it releases a bacteria-killing chemical, chlorhexidine, over a week.
Yet another new local treatment is Atridox, made by Atrix Laboratories, Inc. Approved by the FDA in September, this gel is injected into the pocket, where it solidifies and releases an antibiotic, doxycycline, also over about a week.
The latest remedy, Periostat, approved just last month, is also based on doxycycline. It acts not by killing bacteria, as the antibiotic usually does, but by attacking an enzyme called collagenase, a tissue-destroying substance pumped out by white blood cells, including those that flock to the gums.
A decade ago, researchers showed that low doses of doxycycline can reduce levels of collagenase, says Brian Gallagher, CEO of CollaGenex Pharmaceuticals, Inc., which makes Periostat.
Studies show that Periostat, a twice-a-day pill, increases the attachment of gums to teeth, when used with scaling and root planing. This makes it a useful adjunct to current treatment “but not a magic bullet,” says Dr. Robert S. Schoor, president of the American Academy of Periodontology.
If you have a deep pocket and scaling reduces it by one millimeter and Periostat by a half-millimeter, “that’s a 50 percent improvement” over scaling alone, he says. “But you still have a deep pocket and you haven’t cleaned the roots of poison.”
Other researchers are investigating ways to use bone grafts – either synthetic or from cadavers – to combat the bone loss that leads to tooth loss in severe periodontal disease.
Used alone, none of these treatments is likely to reverse periodontal disease, but used with existing treatments they should help.
Prevention, of course, is also key – brushing, flossing, and professional cleaning.
Remember the poster: “Floss or die.”
Signs to watch for
The American Dental Association and the American Academy of Periodontology recommend that you see your dentist if you have any of the following symptoms. It is also possible to have periodontal disease without these signs:
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Gums that bleed easily, or are red, swollen or tender.
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Gums that have pulled away from the teeth.
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Pus between the teeth and gums when the gums are pressed.
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Persistent bad breath or bad taste.
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Permanent teeth that are loose or separating.
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Any change in the way your teeth meet when you bite.
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Any changes in the fit of partial dentures.
To keep teeth and gums healthy, you should brush twice a day and floss once. And have regular dental checkups.