Flu-related complications potentially more likely in perio patients

The Set-Up

“With the emergence of new clinical data, health care professionals are becoming increasingly aware of the interrelationship of oral and systemic disease. In this article, Dr. Kelly Blodgett considers the possible connection of different inflammatory diseases,” Dr. Peter O. Cabrera, Team Lead

Given all the talk in the media about the H1N1 virus, chances are your patients are even more concerned than usual about coming down with the flu. But it’s your patients who have periodontal disease who really should be aware of their risk for contracting the flu and the possible complications they might experience if they do.

People with chronic periodontitis may be more prone to developing complications such as heart attack, pneumonia and stroke after having a major viral illness, such as the seasonal flu or H1N1^7-10. That’s why it’s so important for oral health professionals, who are on the “front lines” of fighting chronic infections, to place a heavy emphasis on managing periodontal disease to minimize other systemic health issues.

The purpose of this article is two-fold: First, to review the relationship between periodontal disease and cardiovascular disease. Secondly, to consider the pathophysiology of an influenza A infection as it relates to the cardiovascular system. Perhaps this will motivate us to help our patients seek appropriate treatment for their chronic oral infections.

Periodontal disease and stroke

There are studies that point to a relationship between periodontal disease and stroke. In one study that looked at the causal relationship of oral infection as a risk factor for stroke, people diagnosed with acute cerebrovascular ischemia were found more likely to have an oral infection when compared with those in the control group³.

Heart disease and perio

Within our profession, we now accept that there is a relationship between periodontal disease and the prevalence of cardiovascular disease. The oral cavityis an easy place for bacteremia to enter an otherwise sterile cardiovascular system. The incidence of bacteremia following oral health procedures such as tooth extraction, endodontic treatment, periodontal surgery and scaling and root planing is well documented¹. It takes less than one minute after an oral procedure for microorganisms from the infected site to reach the heart, lungs and peripheral capillary systems².

Different theories exist to explain the link between periodontal disease and heart disease. One theory is bacteria from the oral cavity can affect the heart when they enter the blood stream, attaching to fatty plaques in the coronary arteries and contributing to clot formation. These blood clots can obstruct normal blood flow, restricting the amount of nutrients and oxygen required for the heart to function properly. This may lead to heart attacks³.

Another possibility is that inflammation caused by periodontal disease increases intravascular plaque build up, which may contribute to artery swelling. Researchers have found people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease.

The take home message here is patients who have chronic periodontitis (particularly when it is untreated) may have a higher risk of developing heart disease than those who don’t have gum disease.

Periodontal disease and the pulmonary system
We also should consider the pulmonary system when talking about the effects of periodontal disease. Bacterial respiratory infections are acquired through inhaling fine droplets from the mouth and throat into the lungs. These droplets contain germs that can breed and multiply within the lungs to cause damage. Research suggests that bacteria found in the throat, as well as bacteria found in the mouth, can be drawn into the lower respiratory tract. People with respiratory diseases, such as chronic obstructive pulmonary disease, typically suffer from reduced protective systems-making it difficult to eliminate bacteria from the lungs. Scientists have found bacteria that grow in the oral cavity can be aspirated into the lung to cause respiratory diseases such as pneumonia, especially in people with periodontal disease⁴.

Heart disease and the flu

New information is coming to light indicating that patients with established cardiovascular disease may be at a higher risk for heart attack and stroke after exposure to influenza^7-10.

Influenza is associated with an increased number of proinflammatory, prothrombotic cytokines, and it causes endothelial dysfunction, increased plasma viscosity, tachycardia, and release of endogenous catecholamines. Clinical flu also is associated with psychological stress, dehydration leading to hypotension, and hemoconcentration, hypoxemia and demand ischemia⁵.

These changes in the cardiovascular system may lead to an increased incidence of clots dislodging from their stable plaque. It has been shown that people with chronic cardiovascular disease and cerebrovascular disease are at increased risk of experiencing an acute exacerbation of disease during influenza epidemics⁶.

How does this all tie together? Improved periodontal health may lead to improved cardiovascular health, and patients with better cardiovascular health typically experience fewer complications when they do come done with the flu.

Your role

So how do we use this information to help our patients who have periodontal disease? First and foremost, it is imperative that we do all we can to encourage patients to treat their chronic oral infections. The best place to start is to educate your patients about the value of appropriate treatment. Provide a solid knowledge base from which they can make an informed decision.

Don’t be afraid to pull at their “heart strings.” Ultimately, your patients will choose to pursue care based on an emotional drive to do so. They will justify this choice with the knowledge you provide them. Sharing a story about a patient who suffered the ill effects of untreated gum disease can be a potent motivator. Emphasize that improved periodontal health may lead to improved cardiovascular health, and patients with better cardiovascular health should fair better when they experience the seasonal flu.

These changes in the cardiovascular system may lead to an increased incidence of clots dislodging from their stable plaque. People with chronic cardiovascular disease and cerebrovascular disease are at increased risk of experiencing an acute exacerbation of disease during influenza epidemics6.

It’s also a good idea to encourage your patients to get the flu vaccine-for both the seasonal flu and the H1N1 virus. Because flu vaccination decreases the body’s acute response to seasonal influenza, it is wise for at-risk individuals, such as patients with chronic infections, to get vaccinated. This should reduce the likelihood of an adverse cardiovascular event.

About the author

Kelly J. Blodgett, DMD, MWCLI, DWCMID, has lectured extensively throughout the West Coast and Canada. The 2006 World Congress of Minimally Invasive Dentistry “Clinician of the Year” has a state-of-the-art practice in Portland that features lasers, VELScope, CEREC and other technologies.