Biofilm and Systemic Disease - Ara Elmajian D.D.S
Oral hygiene and regular maintenance have been an extremely important component of my philosophy since I began practicing dental medicine. Over the past three decades there has been a drastic shift in our understanding of microbiology and genetics. I have studied microbiology my entire adult life and I would like to share my observations of the past 35 years regarding the relationship of oral health and systemic disease, particularly autoimmune illness.
From the beginning it has been our goal to educate our patients on the merits of maintaining their oral health by stressing the importance of daily proper oral hygiene habits as well as regular cleanings and checkups. We have also strove to place biocompatible materials whenever possible in our patients’ mouths to further reduce burden on their oral and general health.
While we have been mostly successful in our efforts of prevention as seen in an entire generation of people we have been monitoring from a very early age who present with no restorations and healthy oral mucosa. There are however those individuals although compliant, who seem predisposed to dental disease particularly periodontal disease.
For this group of people no matter how diligent their oral hygiene regime they nonetheless develop gingivitis and periodontitis often resulting in loss of vital oral structures such as gum tissue and bone. It continued to perplex us that for these individuals daily, rigorous brushing and flossing as well as three month recalls for cleanings were never enough to prevent disease. There had to be something else underlying.
Over the past several years research in microbiology has discovered that very specific, harmful microorganisms are always present in periodontal disease and that certain people are predisposed to harboring these organisms in their mouths. Poor oral hygiene habits will further exacerbate the situation but even diligent habits are not a guarantee that disease will not occur.
The term “plaque” is now being referred to as “biofilm”. Biofilm is the aggregation of many types of microorganisms forming a colony on a solid surface where there is a continuous supply of fluid such as water, saliva etc. This aggregation of bacteria work together as a community utilizing the fluid as the vector for transmission.
There are close to 600 different species of bacteria that typically live in the mouth, most of which are considered friendly and innocuous. Some of these microorganisms however have been identified as extremely harmful. This is coupled with the fact that it only takes 5 hours for microorganisms in the mouth to double in number if left undisturbed. As they increase in number they quickly create an intricate network of channels and protective layers which have the ability to produce specific proteins and enzymes by way of quorum sensing.
Quorum sensing in the bacterial world is a complicated decision making process based on local density whereby groups of bacteria coordinate behavior and have the ability to regulate numerous processes such as secreting specific enzymes which have the ability to turn on and off the genes of other bacteria.
Harmful bacteria, spirochetes, fungi and protozoa present in the oral cavity provoke the immune system directly and indirectly which results in bone and tissue loss around the teeth.
How does this happen? In response to the above bacterial onslaught the immune system, as a defense mechanism sends in its troops in the form of white blood cells (WBC) to kill the invaders in the area of inflammation (around the tooth). The bacteria with their higher intelligence have the ability to confuse the defending WBC chemotactically (influenced by certain chemicals in the environment) and other ways thereby rendering them incapacitated.
The WBC has only a 3 day life cycle. If it does not engulf a bacterium and destroy it within that time frame it lyses or dies by breaking apart. The enzymes in its organelle such as lysozyme which were destined to kill the bacteria are now available to turn on the very tissue they were meant to protect. In the mouth this could translate into deep periodontal pockets surrounding a tooth or teeth due to the destruction of bone.
The body also responds to inflammation by delivering collagenase to the site to open more pathways for the capillaries to send in more troops to the area. Collagenase however also causes degradation of the collagen, a prominent protein found in the matrix of almost all dental tissue such as dentin, cementum, alveolar bone and the periodontal ligament which attaches the teeth to their bony sockets.
If this immune response continues over a prolonged period of time serious damage ensues leading to severe periodontal destruction.
This multifaceted process is further complicated, for example when a patient has one or more failed root canals as the pathogens in these scenarios are actually protected. Due to the lack of circulation and drainage in the area caused by the inflammation of the biofilm the microorganisms involved in the failed root canals thrive in the dentinal tubules of the teeth. Even if they appear dormant there is a continual burden of irritation in the area.
Another complication in the immune response to inflammation is when patients exhibit mixed metals in the mouth. Gold crowns, mercury fillings, porcelain fused to metal prosthetics and even some composite restorations existing in the same mouth can create deleterious effects due to galvanism hence heavy metal toxicity. Heavy metals reduce the resistance of the immune system in dealing with some of the harmful bacteria, protozoa and fungi. For example if left unchecked the fungi, c.albicans and s.cerevisae incubate with mercury. Both of these species are able to transform mercury to methyl mercury, a very harmful form. 95% of this methyl mercury is excreted back into the gut, creating a vicious, complicated cycle. Methyl mercury can cause damage to the nervous, cardiovascular and urinary systems to name a few.
Bacteria, yeast, protozoa and spirochetes have been identified in periodontal disease. A healthy mouth does not usually harbor protozoa or spirochetes.
In our clinic we utilize modern periodontal assessment tests which can identify several known harmful pathogens involved in gingivitis and periodontitis. These tests range from simple in office tests to more sophisticated methods involving sending samples off to a laboratory.
The Bana test is a simple in office test which can identify one or more of the pathogenic bacteria by means of enzymatic assay or testing for the enzymes that are produced by some of the species. It is quick and reasonably priced. If the results indicate the presence of pathogens we can take steps to reduce or eliminate their deleterious effects. Treatment options will be discussed later in this article.
DNA Testing for pathogens is a more sophisticated laboratory test that can identify the genetic markers for pathogens.
Another genotype test analyzes if a person carries the “turn on” inflammatory gene which produces interleukin or the anti-inflammatory expression. A person carrying the inflammatory gene would obviously be more prone to inflammation. For example a person who smokes and carries the gene would have a much greater risk for developing periodontal disease.
A Culture Test is sent to a laboratory if specific identification of multiple species (microorganisms) in the mouth is indicated.
Microscopy can be used to reveal the presence of spirochetes and protozoa.
The results of the above tests give us information that was not available to us early on in our careers as dentists in regards to preventing, diagnosing and treating periodontal disease. This information is significant and we are not only talking about periodontal disease anymore.
As all body cavities and systems (respiratory, digestive etc) are interconnected the implications of the presence of pathogenic organisms in the mouth extend well beyond the confines of the oral cavity.
The following are a few such examples.
Dental pathologies such as failed root canals and periodontal disease involving the maxillary (upper) teeth provide the pathogenic bacteria, spirochetes, protozoa and other harmful invaders easy access to the sinus cavities thus creating inflammation and disease of the sinuses. There are 37 million sinus infections in the U.S. every year. Most of those cases are treated with antibiotics which in many cases cause the pathogens to become even more virulent. Chronically infected root canalled teeth can provide a constant supply of harmful organisms being transported from the mouth to the sinuses. Wherever scars or caverns (cavitations) exist in the body such as with root canalled teeth the circulatory and lymphatic systems become disrupted and disabled thereby providing protection to the pathogens from the immune system.
Chronic infections involving root canalled teeth can also have an inflammatory response and negative effect on many major organs in the body such as the heart.
As mentioned earlier many patients have varying degrees of mixed metal restorations in their mouths. The moist oral cavity facilitates galvanism and the subsequent release of toxic metals such as mercury, nickel and others increases the damaging effects of the pathogens. When organic mercury is converted to methyl mercury in the presence of yeast in the mouth, this neurotoxic metal can cross the blood brain barrier from the oral cavity resulting in numerous possible catastrophic effects to the body such as neurological disorders.
There is mounting evidence that indicates people who have periodontal disease also have a much higher chance of developing cardiovascular disease (atherosclerosis, coronary heart disease, stroke etc) than those individuals who take preventive measures to eliminate the biofilm in their mouths.
Dental plaque biofilm is the major cause of periodontal disease and harbors many harmful strains of bacteria that during the course of the inflammatory response enter the bloodstream and can travel to other parts of the body, such as the heart.
Structurally speaking the loss of vertical dimension or height of the dental bite in children and adults also creates structural changes in the Eustachian tube which inhibits proper drainage in the ear canals. Reduction of the flow of serous fluids creates festering and increased virility of the microorganisms that cause middle ear infections. Over the years we have witnessed the resolution of many middle ear infections in children by simply raising their dental occlusion or bite utilizing a technique called “primary molar buildups.”
These are a few of the direct correlations I have observed over the years that exemplify the significance of the oral condition in connection with the rest of the body. The biofilm present in the mouth, especially the microorganisms that have been identified as destructive are able to travel throughout the body cavities and barriers. Depending on individual situations such as genetic predispositions these pathogens can wreak havoc on many of the body’s systems and organs. In time they are able to create failure in cardiovascular, digestive, urinary, reproductive, respiratory and musculoskeletal systems. In short periodontal disease has been linked to many systemic and autoimmune diseases.
The good news is that if we are able to influence the microflora early enough and keep the pathogens in check the body begins to rebuild itself.
It is crucial to recognize unresolved periodontal infections, take steps to identify the pathogens involved and implement a protocol to control the destructive patterns of these organisms in the mouth.
There are many treatment options available once test results have been obtained.
1. Use of pharmaceutical antibiotics specific to strains of bacteria.
2. Diligent oral hygiene treatments including regular debridement of biofilm especially from deep sulcular pockets and oral hygiene home instruction, lasers, ozone treatment and the use of natural antimicrobials and antifungals in the form of mouth rinses and tooth paste. These methods are beneficial in interrupting the process whereby the microorganisms double in number in 5 hours.
3. Rehabilitation of restorations using biocompatible dental materials previously determined by biocompatibility immune tests.
4. Removal of infected teeth as well as debriding any jaw bone cavitational sites.
5. In situations where sinus infections are prevalent sinus hygiene may be indicated utilizing sinus lavage treatments such as nebulizers with saline or other remedies.
In conclusion evidence based science has proven the connection of the oral condition to chronic systemic disease, including autoimmune disease. Prevention continues to be the primary focus in our dental/medical clinic in regards to both dental and systemic conditions. We also believe strongly in educating our patients and on their responsibility and commitment to partnering with us in ensuring optimal health.