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Poor Oral Health May Cause Cardiovascular Diseases

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Poor Oral Health May Cause Cardiovascular Disease
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Table of Contents
TOC o “1-3” h z u Introduction: General Overview PAGEREF _Toc437246853 h 3Literature Review PAGEREF _Toc437246854 h 4Discussion PAGEREF _Toc437246855 h 9Risk factors PAGEREF _Toc437246856 h 10Obstacles to quality oral healthcare PAGEREF _Toc437246857 h 12Prevention and Control PAGEREF _Toc437246858 h 12Conclusion PAGEREF _Toc437246859 h 14Recommendations PAGEREF _Toc437246860 h 15References PAGEREF _Toc437246861 h 16

Introduction: General OverviewAccording to Dolce, Haber & Shelley (2012) oral terminology refers to mouth; gums, teeth and mouth supporting tissues. Oral health refers to the care given to the mouth to improve its appearance, prevent diseases, infections, and bad smell. According to Center for Disease Control and Prevention (CDC) (2007) asserts that oral health is fundamental to the well-being and general health of the general population. Poor oral health status is highly linked with other systematic diseases like diabetes, cardiovascular diseases (CVD). Oral health risk factors are shared as can also cause other systemic diseases; for instance, tobacco. Poor oral health is also known to affect nutrition and diet update as well as social activities like work and school.
Dolce, Haber & Shelley (2012) the poor oral health status in America is termed as a “silent epidemic”. Oral health has a high correlation with the overall wellbeing and health.

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Within the population of the US, there has been an overall improvement in oral health. Despite this, thousands and thousands of Americans still face the deficit in oral health service provision. Besides, there exist profound persisting disparities in oral health among the underserved and vulnerable populations; like ethnic and racial minorities, poor children and older adults. Today, for instance, tooth decay (dental caries) is highly preventable yet very infectious and across the life span is the common persistent disease that disproportionately impacts the underserved and vulnerable groups. According to Griffin, Jones, Brunson, Griffin, and Bailey, (2012) the quality of life is highly reported in correlation with poor oral health. This research hypothesizes that poor oral healthy may cause cardiovascular diseases.
Literature Review
According to Haheim (2014) cardiovascular disease (CVD), pathophysiology entails thrombosis and atherosclerosis inflammation. CVD though has can be highly prevented, up to 80%, is known to lead to premature death. In Europe, for example, CVD is responsible for 1.9 million deaths per annum. There is increasing evidence that supports that periodontal disease an oral infection has a correlation with the development of CVD. In reference to WHO data approximately 35%of the whole population suffers from mild-moderate periodontal infection globally. Although periodontal disease is less documented as a primary cause of CVD, in the stroke published guidelines by the American Heart Association (AHA), periodontal disease was indicated to have a risk of 95% (2.11) confidence level for those within 25-74 years.
In 2013, a cross-organizational workshop on systematic and periodontal diseases between American Academy of Periodontology (AAP)/ European Federation of Periodontology (EFP) did take place coming up with the following conclusions.
i. Epidemiological research indicates that the risk of CVD increase with periodontal disease development
ii. The periodontitis impact on atherosclerotic CVD reasonable biologically because as oral microbiota circulates indirectly or directly inducing inflammation and subsequently atherosclerosis pathogenesis.
iii. Biological and interaction mechanisms in clinical, in vitro and animal studies, support that such mechanisms are involved in atherosclerosis.
Joshipura, Douglass, Trichopoulos, Ascherio & Willet (1996) did a prospective cohort study to find out how periodontal disease and the number of present teeth correlate with coronary heart disease (CHD) incidence and to establish potential mediators of the association. The study was carried out in the US with a sample of 44,119 males within the health sector across the nation. Of the total sample, 58% were dentists aged 40-75 years. At baseline, the study sample reported no diabetes, or cancer or CHD. Upon six years follow up the study recorded CHD incidences amounting to 757 with non-fatal and fatal myocardial infarction and sudden death. Those men who reported pre-existing periodontal disease and those with ≤10 teeth, compared to those with ≥25 teeth of similar characteristics were at increased risk of developing CHD (95% confidence level; 1.67 relative risks). However, no relationship was attained among men with no pre-existing periodontal disease and CHD (95% confidence level; 1.11% relative risk).
Li, Kolltveit, Tronstad and Olsen (2000) deduced that periodontitis, an oral infection is likely to affect the pathogenesis and course of a various systematic disease like low birth weight, diabetes mellitus, bacterial pneumonia and cardiovascular disease. The study proposed three pathways that link systematic secondary effects with oral infections occurrence see Table 1.
i. Oral microorganisms resulting in an immunological injury that in turn causes metastatic inflammation
ii. Circulating oral microbial toxins effects causing metastatic injury
iii. Transient bacteremia causing metastatic infection spread emanating from the mouth cavity

Table 1: Summary of how these pathways lead to systematic disease:
Both periodontal disease and CVD have shared risk factors. Such include male gender, ethnicity or race, aging, stress, smoking, and tobacco. Periodontal disease describes various conditions that lead to inflammation and attachment apparatus destruction of the teeth. They include alveolar bone, root cementum, periodontal ligament and gingival. There are about ten species that cause harbor in the dental plaque, which are mainly gram-negative rods. The main bacteria associated with periodontal disease are Bacteroides forsythias, Porphyromonas gingivalis, Action bacillus, and Action mycetemcomitans. These bacterias initiate the vascular response, which involves intravascular coagulation, fatty vascular degeneration, vascular smooth muscle proliferation and inflammatory cell infiltrate within the walls of the vessel see diag1.
Periodontium as a reservoir of cytokine: The prostaglandin E2 (PGE2), gamma inferno and proinflammatory cytokines TNF-α, IL-1β, they realize high concentration in periodontitis. Hence, periodontium acts as a spillway for these mediators. They then enter the circulation systems and induce, and perpetuate effects within the systemic system. IL-1β encourages thrombosis and coagulations and slows fibrinolysis. Thromboxane, TNF-α, and IL-1β are likely to cause adhesion and aggregation of platelets, cholesterol deposition, and lipid-laden foam cells formation. These processes, consequently, contributes to the development of Cardiovascular heart-related diseases dig 2.

Diagram 1: shows dentally associated endocarditis proposed causal model

Diag2: The following diagrams show presumed mechanisms that link periodontal disease and oral infection to CVD.
According to Najafipour, Mohammadi, Rahim, Haghdoost, Shadkam and Afshari (2013), CVD burden is high in developing countries with three-quarters of such cases being reported in various countries. In fact, CVD mortality and morbidity in developing countries is likely to shoot in coming years following increased risk factors to CVD exposure. For instance in Iran, is facing CVD epidemic. Coronary artery disease prevalence in the country is high with 20% cases reported in Tehran, the capital city. The etiology of CVD is highly multifaceted; which is also determined by various risk factors that have a strong influence from environmental, socio-economic and genetic variables.
In CVD, the role of inflammation in its pathogenesis has taken most of research focus over the past years. Most researchers assert that the periodontal disease and mouth pathogens play a significant role as risk factors for CVD. A survey carried nationally in 2002, among 3100 Iranian aged 35-44 found that >55% of the samples had periodontal diseases. Subsequent epidemiological studies did investigate CVD and oral health relationship. The study reported that those suffering from the periodontal disease had 25% increased the risk of developing CVD. Compared to 22.5% non-CVD with periodontal disease, 84.4% CVD individuals also had periodontal disease. A meta-analysis did make a conclusion that poor oral health and periodontal disease can act as CVD pathogenesis risk factors.
Oyapero, Adeniyi, Sofola & Ogbera (2015) diabetes mellitus is a metabolic disease, with hyperglycemia characteristic that emanates from insulin act, or insulin secretion or both. From prospection, about 366 million people by 2030 will have diabetes mellitus. Chronic diabetes; hyperglycemia is linked with long-term damage to some organs such as the oral cavity, blood vessels, heart, nerves, kidneys and the eyes. Diabetes mellitus is likely to lead to periodontal disease, candidiasis (an opportunistic infection), oral tissues trauma, and salivary dysfunction within the oral cavity. In diabetes, periodontal disease is the 6th complication shining a light on the need for ensuring good oral health.
Poorly controlled or uncontrolled diabetic patient is highly vulnerable to periodontal disease development due to poor immune response following polymorphonuclear leukocyte function impairment. Also, such patients have increasing chances of inflammatory mediators expression like increased oxygen free radicals production and cytokines. Further, among the diabetic patients, periodontal disease is likely to affect control of glycaemic due to pro-inflammatory mediators production that initiate resistance of insulin and insulin action reduction. Oral health-related quality of life (OHRQOL) is highly linked with the status of oral health of patients with diabetes as well as complications of DM, the age of the patient and duration of diabetes. Periodontal disease causes morbidity due to increased tooth loss risk, decreased oral function hence affecting OHRQOL.
DiscussionFrom these collections, it is evident that periodontal diseases have a positive correlation with CVD. The main pointed reason is that emanating from inflammatory emanating from periodontal disease (Oyapero, et al., 2015; Najafipour et al., 2013; Li, Kolltveit, Tronstad and Olsen, 2000; Haheim, 2014). This occurs because according to Weinberg, Krisanaprakornkit and Dale (1998) the epithelial tissue in any part of the body forms the first defense line, from the environment and the organism. If this barrier is disrupted, bacterial invasion occurs, and inflammation takes place subsequently. This is so with the oral cavity in human; whereby the constant exposure of tissues to various microbial challenges is likely to result in bacterially-induced periodontal diseases.
Loesche (1994) also argues that many cases of CVD following epidemiological analysis they are likely also to suffer from edentulous or periodontal disease. Following various analysis of conventional risks that leads to heart attack and stroke, still there is a wealthy school of evidence that dental diseases and CVD have a strong linkage. From this research, those individual with increased dental morbidity like teeth lose are more likely to develop CVD and stroke compared to their counterpart. These facts are in line with other studies that supported tooth loss increased periodontal disease gravity (Oyapero, et la., 2015, Joshipura et al., 1996). Schillinger, Klunger, Exner, Mlekusch, Sabeti, Amighi, Wagner, Minar and Schillinger, (2006) adds that periodontal and dental diseases are significant potential factors in the atherosclerosis pathogenesis. Oral hygiene, dental status and tooth loss, in particular, can impact both present and future development of the carotid stenosis. Thus, the oral health status can be used to predict the future of atherosclerosis progression.
Risk factorsMathews, You, Wadley, Cushman and Howard, (2011) in their studies, found that those people from the low socio-economic background were more likely to lose more teeth. However, Correa-Faria, Martins, Bonecker, Paiva, Ramos-Jorge, and Pordeus, (2015) deduced that socioeconomic (low income) relationship with traumatic dental injury presented a weak argument in reference to this correlation Also, the aged regardless of race reported to lose more teeth. Those who reported to have lost more teeth from 6, were associated with the risk of stroke development with the problem worsening depending on how many more teeth one lost and age. This also was seen to affect cognitive performance. However, Russel, Gordon, Lukacs and Kaste (2013) pointed that women are more likely to lose teeth compared to men, in North America. According to Buchwald, Kocher, Biffar, Harb, Holtfreter and Meisel, (2013), Socio-economic factors, as well as smoking and obesity were highly linked to lead to tooth loss, with the most disadvantaged group in income being the highly affected. SES impacts increase the progression of periodontal disease, with adverse SES leading to systemic inflammation aggravation. Grossi, (2000) points out that periodontal disease in US population are a cause of public health problem. The author asserts that both psychological and behavioral factors link periodontal infections to systemic condition; that is stress and smoking.
Most of these risk factors highlighted for the periodontal disease were not linked to the CVD. However, this is fundamental as the research helps in understanding the likely risks to periodontal disease and poor oral healthy. If these risk factors are prevented or controlled, would reduce the possibility of developing a systematic condition like CVD. Nevertheless, other research raises concern about the correlation of periodontitis and CVD. There is rich information that these risk factors are potential for poor oral health leading to increased inflammatory mediators, with a potential of developing formation of atherosclerotic plague(Oyapero, et al., 2015; Najafipour et al., 2013; Li, Kolltveit, Tronstad and Olsen, 2000; Haheim, 2014). Nevertheless, the risk factors for periodontal infection are similar to that of CVD, such as age, tobacco use, diabetes, income and also cardiovascular medications is likely to increase periodontitis risk (Gordon, Barasch, Foong, Elgeneidy and Stafford, 2005). Moreover, periodontal disease moderate risk contribution to heart diseases is likely to contribute to increased mortality and morbidity. Therefore, is fundamental that a study is conducted to investigate how heart disease resulting from periodontal disease treatment and prevention can be clinically reduced (Genco, OffenBacher, and Beck, 2002).
Obstacles to quality oral healthcare
Oral healthcare faces various barriers (Griffin et al., 2012)
i. Oral health is one of the health disciplines that lack multifactorial professional support from the nondental professionals in health care such as physician assistants, physicians, pharmacist, and nurses. Among the nurses oral health has never been given sufficient attention by practicing nurses.
ii. The non-dental professional in health care lack substantial knowledge regarding basic oral health.
Proposed remedy
i. Public health should refocus efforts in ensuring that oral health is integrated into medical care
ii. Put in place community programs that promote healthy oral behaviors
iii. Improve preventive services access (Griffin et al., 2012)
iv. A comprehensive strategy should be established that addresses the long-term-care and homebound oral health needs
v. Carry out an assessment feasibility of having in place a safety net that includes basic and preventive restorative service to control, prevent, manage and treat infection and pain.
Prevention and ControlLoesche (2000) agrees that despite the increased link of developing CVD following periodontal disease infection, poor oral hygiene can be addressed. Periodontal diseases should be treated if they occur, thus preventing the adverse effects of developing CVD or cerebral vascular accidents. To maintain a healthy life, therefore, maintaining good oral health ought to receive high priority. Oyapero et al., (2015) adds that Oral health education is fundamental in preventing, appropriate dental recall visits, oral prophylaxis, and adequate home care. Periodontal disease treatment with the aim of eliminating pathogenic species and inflammatory control are likely to impact control or high blood sugar positively. Since CVD is linked with inflammatory effects of periodontal disease, such treatment may help relieve the CVD problems as well.
Gooch, Malvitz, Griffin & Mass (2005) Provides a broad approach to addressing this problem. The authors assert that five domains experiences shape prospects of person’s health: quality healthcare use, choices of behavioral, conditions within the environment, social circumstances (community social cohesion, housing, poverty, employment, education among others and finally, gestations and genetics. Behavioral choices are the key domain that influences health prospects in the US. Chronic disease model developed by CDC could be effective in oral health promotion. The Chronic Disease Model is a multi-component health promotion approach. The model has five underlying principles of public health. The principles are:
1. population-based approach requirement
2. public health special responsibility for populations at-risks
3. The need to ensure that efforts are based on the best available science
4. understanding that prevention is highly influenced by behaviors that are likely to be influenced by institutional policies and social circumstances and the understanding that prevention occurs outside of clinical environment
5. realizing of the worldwide partiality for primary disease prevention
The multi-component interventions which Chronic Disease Model uses to promote healthy behaviors include:
i. Increasing awareness among policymakers, professionals, and individual people concerning methods that research has found to manage, control or prevent disease effectively.
ii. Encouraging participation of all stakeholders in coming up with organizational changes and creating policies that support healthy behaviors such as going for preventive services it time, receiving oral assessment and avoiding tobacco use.
iii. Fostering healthy environments; for instance, adjusting the content of fluoride in water systems within the community.
iv. Putting in place effective preventive services both at community and clinical levels, where there is rich mature science to provide substantial hope of success.
Such a comprehensive and broad population-based programs if have to be implemented among the old population, show a need for more information. Such information will include preventive intervention effectiveness at community, clinical and self-care levels, disease determinants in the referred group, conditions and oral diseases burden.
ConclusionThere is broad evidence that poor oral healthy is likely to cause cardiovascular heart disease. Of significance is the periodontal disease that is accompanied by inflammatory factors. It is this inflammation that triggers systemic disease and infection development. Tooth loss, diabetes, smoking/tobacco use, stress, age and income status have been pointed as the key risk factors to periodontal disease development. Also, cardiovascular drugs are likely to aggravate the periodontal disease pathogenesis. This linkage, to some extend, fails to give a clear picture of how periodontal disease, in absence of the risk factors, could lead to CVD. All in all, risks for periodontal disease development share a commonality with CVD development, morbidity and mortality burden increase. The general population should, therefore, exercise good oral healthy practice to ensure improved quality of health and reduced CVD progress.
RecommendationsA cross-sectional study should be done to establish the linkage between the socio-economic status and periodontal disease burden on CVD. This is because, though SES is found to have a positive correlation with periodontal disease development. However, in another review the impact was minimal. A shred of evidence that CVD drugs are likely to adverse the periodontal disease development. This also may give out a conflicting conclusion since in the presence of pointed risk factors, in poor oral healthy periodontal disease impact is highly increased. The fact that one study pointed women to suffer more from tooth loss, further study should be done to evaluate whether more women than men also suffer from CVDs. The general population should be highly sensitized to embrace good oral health practices, like a dental check-up, brushing teeth regularly and using teeth for right purpose as a primary prevention of dental diseases and subsequently reduce the probability of developing CVD.

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