Source: Ther Adv Cardiovasc Dis. 2009 Sep 22. [Epub ahead of print]       PerioFrogz Issue No.: 1209

Overview:

This study examined the effect of acute and chronic infections on acute coronary syndrome (ACS) and coronary obstruction. Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood flow to the heart, such as a heart attack. Chronic infection by bacteria including two perio pathogens is associated with the development of atherosclerosis and coronary obstruction.

Summary of research:

• Coronary angiograms done on 211 of 335 patients with ACS. Study controls consisted of 355 healthy patients.
• Percent of coronary obstruction was determined for each subject.
• Antibody levels of several bacteria, viruses and two periodontal pathogens, Aggregatibacter actinomycetemcomitans (A.a.) and Porphyromonas gingivalis (P.g.) were measured for all study and control subjects.

Results and Conclusions

• Periodontal pathogens did not correlate with acute coronary syndrome.
• Antibody levels of A.a. and C. pneumoniae were higher in patients with coronary obstruction or occlusion compared to those without obstruction.
• Enterovirus and cytomegalovirus correlated with ACS, not coronary obstruction.
• Infection by A.a. and C. pneumoniae associated with coronary obstruction.
• Clinical coronary events may arise from acute and chronic infections.

Key take-aways:

The impact of this research is very significant. Atherosclerosis is considered an inflammatory disease with infections as a significant cause. Acute infections such as those caused by viral infections may precipitate a heart attack but do not correlate with coronary blood vessel obstruction.

Chronic periodontitis with the periodontal pathogen A.a., or the body’s response to the bacteria, was shown to be associated with the development of atherosclerosis, and the resultant coronary blood vessel obstruction, which commonly causes a heart attack.

In other words, this study demonstrated that acute viral infections may bring on a heart attack, but they did not cause the coronary blood vessel blockage that caused it. Chronic infections including periodontitis were associated with the development of the atherosclerotic plaque, which will potentially cause a heart attack.

Implementation Strategies:

As dental professionals, our two biggest fears are over treatment and under treatment. This is especially true when it comes to periodontal disease since this infection can so easily be misdiagnosed in either direction. As this research indicates, we must know whether the specific bacteria Aa. is present in the patient’s mouth. To date there is only one way to find out, DNA-PCR, polymerase chain reaction, available as a result of the genome project.

It is paramount that as clinicians we have a model that aligns with the standard of care. Consider using the step-by -step diagnostic and treatment planning checklist below as a personal standard. Keep in mind that risk factors must be applied to the clinical data before a comprehensive treatment plan can be designed.

• Assessment of Medical & Dental Risk Factors / PST postitive?
• Radiographs showing crestal alveolar bone
• Full mouth pocket measurements – 6 points per tooth
  • Recession & clinical attachment loss
  • Mobility
  • Furcation
  • Muco-gingival involvement
• Bleeding / pus levels upon probing
• Bleeding / pus levels upon stimulation of the gingival col (* see diagram below)
• Quantity and quality of periodontal pathogens via DNA-PCR testing
• Aesthetic / Restorative considerations and needs
• Occlusal considerations and needs
• Consider transmissible nature of periodontal disease
• Patient compliance

*DEFINING GINGIVAL COL

“The col area is not keratinized and is vulnerable to bacteria invasion. Plaque control of the area is of great importance because most gingival and periodontal infection begins in the col area.”Clinical Practice of the Dental Hygienist, Esther M, Wilkins, BS, RDH, DMD; 2004, 9th Ed: 212, 337-339

Figure 20-9 Gingival Index. Probe stroke for bleeding evaluation. The broken line represents the level of attachment of the periodontal tissues. The probe is inserted a few millimeters and moved along the soft tissue pocket wall with light pressure in a circumferential direction.