Rev Clin periodontics Oral Rehabil Implantol.

2016; 9 (2): 203 --- 207

Magazine clinic Periodontics, implantology

and Oral rehabilitation

www.elsevier.es/piro

EPIDEMIOLOGY OF DISEASES Periodontal IN LATIN AMERICA

The diseases periodontal as Chronic Disease transmittable: Changes in

paradigms

Alicia Morales to , Joel Bravo to , Mauricio Baeza to , Fabiola Werlinger b and Jorge Gamonal to , c , *

to Department of odontology Conservatively, Faculty of Dentistry, University of Chile, Chile, Chile

b Unit of Health Public, Institute Research in Dental Sciences, Faculty of Dentistry, University of Chile, Chile, Chile

c Center epidemiology and Surveillance Mouth diseases (CEVEB)

Received on 14 June 2016; accepted 10 July 2016 Available Internet on July 30, 2016

WORDS KEY Summary Periodontal diseases (gingivitis and periodontitis) are a public health problem because of its high prevalence, impact
Disease chronicle; Gingivitis; on quality of life and high costs of treatment. Its main factors and risk indicators are shared with chronic non-communicable
periodontitis; periodontal diseases (NCDs). Furthermore, the presence of periodontal disease in a patient with CDZ could contribute to exacerbating and

disease; factors risk / or development through various pathogenic mechanisms, and the treatment of periodontal condition results in a reduction of
systemic inflammation in fl. Because of this, periodontal diseases should be considered as a CNCD, and should work on
creating, development and implementation of measures to promote health and prevent them actively and proposals emanating
from those NCD that target the same indicators / risk factors of periodontal diseases involved. © 2016 Society of
Periodontology in Chile, Oral Implantolog'ıa Society of Chile and literature make the assumption Pr' Society and Rehabilitaci'

on Oral de Chile. Published by Elsevier Espa~ na, SLU This is a art'ıculo

Open Access under license CC BY-NC-ND ( http://creativecommons.org/licenses/by-nc-nd/
4.0 / ).

KEYWORDS Periodontal disease as a chronic non transmissible diseases: Paradigm shift Abstract Periodontal diseases (gingivitis and
Chronic disease; Gingivitis; periodontitis) are a public health problem. They are highly prevalent, life quality and They Affect Their treament is expensive.
periodontitis; periodontal diseases; Their main risk factors and indicators are non transsmisible Shared with chronic diseases (NTCD). Also, the presence of
Risk factors
periodontal disease exacerbate or initiate Could the development of a NTCD. Furthemore, Periodontal treatment results in
systemic in fl ammation reduction. According To Explained above, periodontal diseases Should be Considered as NTCD. It is
highly advisible to

* author to correspondence.

Mail electronic: jgamonal@odontologia.uchile.cl (J. Gamonal).

http://dx.doi.org/10.1016/j.piro.2016.07.004
0718-5391 / © 2016 society Periodontics Chile, Oral Implantolog'ıa Society of Chile and Society Pr' on Oral
and literature make the assumption Rehabilitaci'

of Chile. Published by Elsevier Espa~ na, SLU This is an Open Access art'ıculo under license CC BY-NC-ND ( http://creativecommons.org/
licenses / by-nc-nd / 4.0 / ).
204 A. Morales et al.

focus on development, building and implementation of periodontal STI prevention practices and communications. , Moreover, it
is advisible to Participate in NTCD prevention programs, periodontal diseases Which targets same risk factors and indicators. ©
2016 Society of Periodontology in Chile, Oral Implantolog'ıa Society of Chile and Society Pr'

and literature make the assumption on Oral de

Rehabilitaci' Chile. Published by Elsevier Espa~ na, This is an open SLU
access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/
4.0 / ).

Epidemiology disease periodontal and / or environmental fifteen common to a number of other morbidities 16 .

The diseases mouth are currently understood as a public health problem worldwide 1 --- 3 . Thus Has been established, for example, the direct involvement of smoking and
it has been reported that fl gingival inflammation was present in 99% of adults 4 while diabetes mellitus in the progression of the loss of dental support tissues. In other
words, smoking and uncontrolled diabetes would present a higher prevalence,
the prevalence of periodontitis reach 30% 5 , only surpassed by no tooth decay treated virtually
100% of adults affected 6 . severity and extent of periodontal tissue destruction 16,17 .

Similarly, alcohol consumption 16.18 , Diets high in saturated fatty acids and sugars,
both gingivitis as periodontitis are diseases periodontal of condition ammatory fl and low in polyunsaturated fats, fiber, and vitamin A, C and E 19 , generate an increase
associated with the formation and bio fi lm persistence of bacteria in subgingival surface in the severity of periodontal diseases. Obesity also help in this regard through the in
fl systemic inflammation caused by the production of adipokines added to the habits
tooth. Gingivitis is the first manifestation Pathological answer immune-fl ammatory individual
to bio fi lm, characterized by the presence of inflammation gingival in no attachment of a harmful diet twenty .
loss 7 , being reversible if proceeding to the elimination of bio fi lm. Without But if this
persists, gingivitis becomes chronic, can progress to periodontitis 8 , stage characterized
by presence of gingival in fl amed in places where it has produced apical migration of Another indicator of risk involved would stress, which in addition to
junctional epithelium, acompa~ physiopathological mechanisms by which can generate a direct alteration of the
immune response, can intervene through unhealthy behaviors that increase the risk
of developing periodontal disease twenty-one .

swim by irreversible destruction Finally, in addition to these risk factors, it described the participation of social
tissues tooth attachment 9 and it constitutes one of the main causes of tooth loss 3 . determinants such as low socioeconomic status, which would also increase the
likelihood of developing periodontal destruction 22 .
Chile is no stranger to this reality. The prevalence of loss insertion ≥ 5mm in more
than 58% of the population adult 10 , positioning it as the second leading cause of lost dental
eleven , which adds other elements of relevance to their more global view, and the
Relationship
consequent impact negative quality of life of people 12 and generating high costs for intervention between periodontal disease and
eleven . This reality has us taken to review the way in which we currently understand the oral non-communicable chronic diseases
diseases within the context of health general, understood as a component indispensable
not only in fl uence the physical 13.14 and demands profound changes in the way of
Called chronic diseases (CDZ), such as cardiovascular disease, cancer, diabetes
exercising dentistry in our country 14 .
and chronic respiratory diseases, are responsible for two thirds of the deaths
worldwide 23 --- 25 , also affecting not only the health status of individuals but also
involving a high socioeconomic cost treatment 23,24 .

Understood as those diseases of long duration and generally slow progression

factors and indicators of disease risk periodontal
The factor Causal Gingivitis is the presence of supragingival plaque. Without however,
this does not necessarily generate the tissue destruction of periodontal support. Is required
a number of other conditions involved in modification of the answer immune-fl
ammatory host for this progress to periodontitis, conditions what they can correspond to
local, systemic factors
of 16 , They engage in risk factors, as well as several of its determinants, they affecting
periodontal disease, such as excess consumption of sugar and alcohol, smoking,
diet rich in fat and salt, obesity, stress and depression, genetic factors and
socioeconomic determinants 23.26 --- 29 .
It is further disclosed a signi fi cantly association between periodontitis and other
systemic conditions, such as premature birth and low weight of ni~
not at birth, arthritis meet-
matoide and metabolic syndrome 30 . So it is possible
The diseases periodontal as chronic noncommunicable diseases 205

consider the presence of periodontitis in a patient with NCCDs can contribute to their exacerbating
It causes an elevation in Proin fl ammatory mediators, producing an exacerbated
and / or development, through different mechanisms Pathogenic, either by infection direct insulin response 32 .
by pathogens Periodontal, either by mechanisms indirect product pathogenesis periodontitis
29,30 . Clinical studies report interesting results Concerning the effect of periodontal
Relation to obesity
treatment on reduction fl systemic inflammation and improvement in biomarkers disease
cardiovascular and endothelial function, as well as the decreased blood sugar
Obesity increases significantly the risk of metabolic diseases (diabetes mellitus type 2, fatty and dyslipidemias)
patients diabetes mellitus type 2 30 --- 33 .
liver, cardiovascular disorders (hypertension, coronary heart disease and stroke), central nervous system

disease (dementia), obstructive apneas and various cancers. Adipocytes, immune and endothelial cells and

fibroblasts contribute to the release of metabolites, lipids and bioactive peptides, also called adipokines. These

adipokines contribute to the regulation of appetite, fat distribution in the body, energy expenditure, endothelial

function, inflammation, blood pressure and hemostasis. Within the adipose tissue regulate adipogenesis,

migration of immune cells and adipocyte function and metabolism. At the systemic level, adipokines modi fi ed

mechanisms pathogenic common diseases Periodontal different biological processes in different target organs such as the brain, liver, muscle, vasculature, heart,

pancreas, immune system and others. They can exert speci effects fi on a variety of biological processes
disease and chronic non communicable
including immune response, inflammation, metabolism of glucose, insulin sensitivity, insulin secretion, blood

pressure, myocardial contraction, cell adhesion, function and growth vascular, adipogenesis and bone

morphogenesis, growth, lipid metabolism, lipid accumulation in the liver, appetite regulation, and other biological
both gingivitis as periodontitis occur due to interaction factors etiological heterogeneous,
processes. Therefore, alterations in the secretion of adipokines can be related to obesity, inflammation, metabolic
including bio fi lm formation subgingival, social factors and behavior, genetic and
disorders and cardiovascular comorbidities They can exert speci effects fi on a variety of biological processes
epigenetic variation, each one of the which modulates the response inmunein
including immune response, inflammation, metabolism of glucose, insulin sensitivity, insulin secretion, blood
amatoria fl. although Bacteria are necessary, their presence is not sufficient to explain
pressure, myocardial contraction, cell adhesion, function and growth vascular, adipogenesis and bone
the onset and progression of disease 3. 4 .
morphogenesis, growth, lipid metabolism, lipid accumulation in the liver, appetite regulation, and other biological

processes. Therefore, alterations in the secretion of adipokines can be related to obesity, inflammation, metabolic

disorders and cardiovascular comorbidities They can exert speci effects fi on a variety of biological processes

including immune response, inflammation, metabolism of glucose, insulin sensitivity, insulin secretion, blood
The tissue destruction periodontal soft and hard associated with periodontitis
pressure, myocardial contraction, cell adhesion, function and growth vascular, adipogenesis and bone
occurs by activation answer immune-in fl amatory against bacterial challenge and
morphogenesis, growth, lipid metabolism, lipid accumulation in the liver, appetite regulation, and other biological
therefore the destructive nature of the response is determined mainly because of the
processes. Therefore, alterations in the secretion of adipokines can be related to obesity, inflammation, metabolic
nature of the answer immune generated.
disorders and cardiovascular comorbidities cell adhesion, vascular function and growth, and bone

morphogenesis adipogenesis, growth, lipid metabolism, lipid accumulation in the liver, appetite regulation, and

other biological processes. Therefore, alterations in the secretion of adipokines can be related to obesity,
The narrow relationship periodontitis occurs NCCDs so due to a ammatory response
inflammation, metabolic disorders and cardiovascular comorbidities cell adhesion, vascular function and growth,
exacerbated fl presenting an altered immune response 35 . This concept involves effects pleiotropic
and bone morphogenesis adipogenesis, growth, lipid metabolism, lipid accumulation in the liver, appetite
immune response different demonstrations, depending on the complex interaction that
regulation, and other biological processes. Therefore, alterations in the secretion of adipokines can be related to obesity, inflammation, metabolic disorders and ca
occurs between genes, the environment, lifestyles and changes epigenetic 35 . It's
known that are about 57 the systemic conditions that are presupposed associated with periodontal
disease, con fi rming that the association established by a pathogenic mechanism commonRelation to cardiovascular disease
36 . The relationship with the 4 most significant described continuation.
Atherosclerotic vascular disease or atherosclerosis is the leading cause of death
worldwide. Approximately 30% of deaths are attributed to this cause 33 . Atherosclerotic
vascular disease can cause acute clinical events and progress by many â~

us, including
acute myocardial infarction, and stroke coronary syndromes.

Relationship with diabetes mellitus Atherosclerosis is initiated by an infiltration in the endothelium with fatty
substances which can progress for decades. In fl systemic inflammation can be
both diabetes mellitus as periodontitis are diseases Chronicles. Multiple studies have measured with various markers in-inflammatory, one of the most studied C-reactive
reported that diabetes mellitus (type 1 and 2) it is a risk factor for periodontitis. The diabetesprotein (CRP). More than a dozen epidemiological studies in individuals with no prior
mellitus produces a response to hyperin fl ammatory microbiota periodontal and alters history of atherosclerotic vascular disease have reported that serum levels of CRP
resolution inflammation and tissue repair, producing a increased severity and are a good predictor of future cardiovascular events, including myocardial infarction,
accelerated periodontal destruction. At periodontium of diabetic patients with stroke, peripheral artery disease and sudden cardiac death 33 .
periodontitis express multiple cellular receptor surface for end products of advanced
glycation and ligands, which an alteration in the metabolism the normal tissues. The association
is Bidirectional, periodontitis negatively affect glycemic control and contributes to development
of their complications. The effect of the infections Periodontal in diabetic patients
Among the markers in fl additional amatorios associated with cardiovascular
disease include the fosfolipasaA2 associated with lipoprotein 38 , the matrix
metalloproteinases and their inhibitors, the myeloperoxidase and Fibrinogen fi. Other
markers in-inflammatory, for example, IL-6, the soluble molecule-1 Intercellular
adhesion, cytokine-1
206 A. Morales et al.

currently it promotes various strategies for this integration emphasizing the

inhibitory macrophages, and CD-40 ligand soluble, remain high in patients at high risk vascular,
although less than PCR 33 . establishment of policies and promotion based on shared risk factors for NCDs
approaches, so that simultaneously prevent oral diseases and chronic diseases 3 .
The inflammation periodontal is usually associated with markers in-inflammatory systemic,
including PCR, factor necrosis tumoral- , IL-1, IL-6 and IL-8. The inflammation Systemic
is associated with cell activation involving cell adhesion molecules, Toll-like receptors, matrix
metalloproteinases and activation factor nuclear-k . The result of this interaction Within this perspective, the invitation is to incorporate periodontal diseases in
between the factors endothelium, monocytes and platelets can be atherogenic, contributingthe land that make up the NCCD, participating actively and jointly established
proposals for them.
atherogenesis or indirectly results adverse cardiovascular related to plaque rupture atheromatous
in subjects with periodontitis. exist Also data show that the inflammation of the
periodontium produces locally PCR 33 . This will necessarily require the active participation of dentists from a " bidirectional
look "
that is, not only have professional dentists capable of inserting collaboratively in
multidisciplinary health teams, fundamental requirement of cross-cutting effort in
health, but also get involved in community involvement, with a change from the
proposals focused on individual models to community-based intervention to promote
gingival health 28 and involving the participation of other health professionals, your
team and together political actors involved in decision-making.
Relationship with infections respiratory

It has been postulate that it is possible generation of respiratory infections such as consequence
of bacteremia due to a route direct anatomical. The oral hematogenous spread is usually Intensifying
each when there is a commitment of more than one lung, multiplicity of injuries and according
to nature of organisms. Episodes of bacteremia would be the result spread from niche oral
pathogenetic favored by poor oral hygiene or recent handling oropharyngeal. SelenomonasFinancing
spp., Streptococci of the group viridans, streptococcus intermedius Y Actinomyces odontolyticus
They have been implicated in the stress syndrome acute respiratory, This study was funded by FONDECYT 1130570 and CONICYT-PCHA / Magister National
Postpneumonectomy infections, septic pulmonary embolism and abscesses lung, respectively.
/ 2013 --- 22,130,172.
Notably, most such subjects infections respiratory present a compromised immune
status due to the presence of tumors malignant 39 .

With fl ict of interest

The authors declare no con fl ict of interest.

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