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Inflammation is central to periodontal disease, triggered by the body’s response to periodontal pathogens in the biofilm. When the inflammatory response to bacterial infection becomes chronic, it causes damage to the supporting structures of the teeth (the root cementum, periodontal ligament and alveolar bone), causing the well-known process of bone loss and eventually even tooth loss.
But the impact and implications of periodontal inflammation are not necessarily limited to the mouth. As one example, microorganisms can travel from this area to other parts of the body, eliciting inflammatory responses at those sites. Furthermore, as we’ll explore, periodontal disease and the associated inflammation have been scientifically linked to a number of systemic health issues.
Periodontitis and Rheumatoid Arthritis
The connection between chronic periodontitis and rheumatoid arthritis has been studied for many years, with a biological link between the two first postulated nearly 40 years ago. Over the past decade or so, evidence has begun to mount. A review by Clifton O. Bingham and Malini Monib published in 2015 noted that “A number of recent studies have evaluated the periopathogenic roles of Porphyromonas gingivalis, the oral microbiome, and mechanisms of site-specific and substrate-specific citrullination. These are helping to further elucidate the interactions between these two inflammatory disease processes.”
Periodontal Disease and Pregnancy
The relationship between pregnancy and periodontal disease already gained attention as early as the 1960s. Suspected by empirical observations and confirmed by research, pregnant women are more likely to develop gingivitis, with an estimated prevalence of 67-100%. The reason for the increased inflammatory response is thought not to be the presence of periodontal bacteria per se, but the elevated levels of sex hormones influencing the host response. The prominence of so-called “pregnancy gingivitis” serves as an impetus for pregnant women to place an even stronger focus on oral care during this vital time.
Periodontitis and Diabetes Risk
The link between periodontitis and diabetes is among the more well recognized and better understood among systemic health issues. Like the relationship between pregnancy and periodontitis mentioned above, this association is bi-directional. Diabetes is a known risk factor for the development, progression, and severity of periodontitis. Already in the early 1990s, periodontitis assumed a spot on the list of chronic diabetic complications, and since then, it’s commonly accepted as the sixth complication of diabetes mellitus. And for a reason: the mechanisms by which diabetes affects periodontal health shows many similarities with those of other chronic diabetic complications, such as cardiovascular disease, nephropathy, neuropathy and retinopathy. These complications are the result of damage to the large and/or small blood vessels, and are mainly driven by (here we go again) inflammation. The same seems to be true for periodontitis. Because of the metabolic disturbances that characterize diabetes, the host immune response to periodontal pathogens seems to be even more exaggerated. This situation – often described as a hyper-inflammatory state – initiates and exacerbates the destructive processes that cause periodontal tissue breakdown.
Periodontitis and Cardiovascular Disease
Cardiovascular disease (CVD) is the leading cause of death in the world, and accounts for an estimated 45% of deaths in Europe. It’s a health issue that stands out on everyone’s radar. And CVD too has been connected to inflammatory periodontal issues.
The central process underlying CVD is atherosclerosis, in which the arteries become clogged because of the formation of atheromatous plaque. The pathogenic pathways that cause atherosclerosis show striking resemblances with those underlying periodontal disease. Inflammation is at the basis again, this time both directly and indirectly. As mentioned before, there is strong evidence that periodontal pathogens can enter the bloodstream and travel to distant sites, also known as bacteremia. These pathogens are also found in atherosclerotic plaques of patients with CVD, where most likely they contributed to the inflammatory processes that cause the formation of these plaques. Indirectly, periodontal inflammation may also increase systemic levels of inflammatory mediates and cytokines, further enhancing the process of atherosclerosis.
Periodontal Disease as a Possible Cause for Alzheimer’s
Another association that received a lot of media attention, reaching as far as the New York Times, is the one between periodontitis and Alzheimer’s disease. The famous newspaper reported about a study that showed that the relative risk for dementia was 22% higher in patients with severe periodontal inflammation and 26% higher in toothless patients, even after correcting for confounding factors such as age and smoking. These findings were confirmed in a comprehensive literature review published in 2020. Although there is an urgent need for methodologically sound, longitudinal studies, the review by Kamer et al. concluded that “periodontal disease, through its inflammatory and bacterial burdens, could be ‘a biologically plausible risk factor’ for Alzheimer's disease.”
Periodontal Disease and Cancer
Cancer is a broad term encompassing many different forms. A study published a couple of years ago in Oxford’s Journal of the National Cancer Institute “found a 24 percent increase in the relative risk of developing cancer among participants with severe periodontitis, compared to those with mild to no periodontitis.” The highest risk observed was for lung cancer, followed by colorectal cancer.
Some evidence points to inflammation and periodontal microorganisms when talking about how periodontal disease may be associated with an increased risk for certain cancers. However, this mainly concerns small-scale, experimental studies, highlighting that there is an urgent need for more research.
Oral care professionals can take the extra step of learning about their patients’ general health background, and offering additional guidance, information, and encouragement for those who might be at any heightened risk for the above systemic issues.
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