Exploring the Connections Between Stroke, Oral Health, and the Role of Oral Systemic Practitioners

Stroke is a significant health issue worldwide, significantly impacting mortality and long-term disability. According to the Centers for Disease Control and Prevention (CDC), stroke remains a leading cause of death in the United States. Every year, approximately 795,000 Americans suffer a stroke. Of these, 87% are ischemic strokes, where blood flow to the brain is blocked (CDC, 2021).

The risk of having a first stroke is nearly twice as high for African Americans as for white Americans, and the death rate from stroke is also higher among African Americans. Furthermore, stroke costs the United States an estimated $34 billion each year, including the cost of health care services, medications, and missed days of work (CDC, 2021).

Emerging research highlights a potential link between oral health, particularly periodontal disease, and the risk of stroke. Oral systemic health, particularly the management of periodontal disease, plays a significant role in this prevention strategy. This article discusses the potential link between poor oral health and stroke and the steps that oral systemic practitioners can take to help prevent strokes.

Oral Health and The Heart

Periodontal disease, commonly known as gum disease, involves the inflammation and infection of the gums and other structures supporting the teeth. It is caused by bacteria in plaque, which, if not adequately removed, leads to gum deterioration and alveolar bone loss. Researchers have hypothesized that the inflammation associated with periodontal disease may have systemic effects, contributing to cardiovascular diseases, including stroke.

Periodontal disease, characterized by chronic inflammation of the gums and other structures supporting the teeth, has been associated with an increased risk of stroke. Inflammatory processes and bacteria associated with periodontal disease can contribute to the development of atherosclerosis, a condition that narrows and hardens the arteries and can lead to strokes.

One meta-analysis reported that individuals with severe periodontal disease had a significantly increased risk of stroke compared to those without periodontal disease (Lafon et al., 2014). The study suggests that the inflammation caused by periodontal disease may lead to vascular damage and blood clot formation, increasing stroke risk.

Oral Pathogens: A Direct Link to Stroke

Periodontal disease, commonly known as gum disease, is a significant health concern characterized by the inflammation and infection of the gums and supporting structures of the teeth. This condition results from bacteria in plaque, which, if not removed effectively, leads to gum deterioration and alveolar bone loss. Over time, researchers have discovered that the systemic effects of this inflammation may extend far beyond the mouth, contributing to cardiovascular diseases, mainly stroke (Kozarov et al., 2011).

The inflammation associated with periodontal disease is not merely a local issue but induces a systemic immune response. AAOSH Secretary and Board Member Ellie Campbell, DO, and author of the book The Blood Pressure BluePrint: The Holistic Guide to Defeating Hypertension, states that “The oral cavity, it turns out, may hold clues to a person’s cardiovascular health. The connection lies in the body’s inflammatory response – a shared element between the two conditions. Chronic inflammation, a hallmark of periodontitis, may contribute to systemic inflammation, affecting blood vessels and blood pressure” (Campbell, 2022). For example, bacteria such as Porphyromonas gingivalis, known for their role in periodontal disease, can enter the bloodstream and reach arterial walls. Here, they contribute to the development of atherosclerosis—a condition characterized by the narrowing and hardening of the arteries, significantly heightening the risk of ischemic strokes. These bacteria have been detected within atherosclerotic plaques and are implicated in their formation and the subsequent risk of rupture, leading to serious cardiovascular events (Lockhart et al., 2012).

Significant research, including clinical studies and meta-analyses, underscores the link between periodontal health and stroke risk. A notable meta-analysis reported that individuals with severe periodontal disease are at a significantly increased risk of stroke compared to those without periodontal issues (Lafon et al., 2014). The study highlights how inflammation from periodontal disease can lead to vascular damage and blood clot formation, further increasing the risk of stroke.

Additionally, a study observed that patients experiencing acute cerebrovascular ischemia were more likely to have oral infections, including periodontitis (Grau et al., 2004). This finding suggests a direct correlation between poor oral health and increased stroke risk, emphasizing the potential for periodontal pathogens to contribute to arterial narrowing and blockages.

Oral Systemic Practitioner’s Role in Stroke Prevention

The systemic inflammation triggered by periodontal disease and its associated pathogens highlights the critical need for effective oral hygiene and periodontal care as part of a comprehensive approach to reducing stroke risk. Controlling the oral bacterial load through regular dental check-ups and maintaining good oral hygiene can significantly mitigate the risk factors associated with strokes, ultimately benefiting cardiovascular health.

Given the relationship between oral health and stroke risk, oral systemic practitioners are uniquely positioned to intervene. Here are several ways dentists can help reduce the risk of stroke.

1. Regular Dental and Primary Care Checkups: Encouraging regular dental and primary care checkups allows for early detection and management of heart and periodontal disease. Regular dental examinations and treatments like scaling and root planing can reduce periodontal inflammation, potentially decreasing stroke risk. This can be pivotal in controlling blood pressure and the inflammation and bacterial profiles contributing to stroke risk.
2. Patient Education: Dental and primary care professionals can educate their patients about the links between oral health and overall health, including stroke risk. Understanding these connections may motivate patients to adhere to oral hygiene practices.
3. Interprofessional Collaboration: Dental professionals can work closely with physicians and other healthcare professionals to manage patients with periodontal disease and stroke risk factors. This collaborative approach can lead to a more comprehensive management plan.
4. Inflammation Reduction: Dental health professionals can help reduce oral inflammation through appropriate dental treatments and recommendations for improved oral hygiene, potentially decreasing the patient's stroke risk. In addition, primary and dental care professionals can help patients by checking blood pressure at every visit. 
5. Arterial Disease and Genetic Links: “About 50% of Americans carry genetic variants that greatly increase their risk for heart attacks and strokes at an early age,” states AAOSH Advisory Council Member Amy Doneen, DNP, ARNP, co-creator of the BaleDoneen Method (Doneen, 2019). Along with fellow AAOSH Advisory Council member Bradley Bale, MD, the two created the BaleDoneen Method, which uses a genetically guided precision-medicine approach that has been shown in two recent peer-reviewed studies to effectively prevent, detect, treat, and even reverse arterial disease, even in those with genetic risk. 
6. Lifestyle Modifications: Oral systemic practitioners can advise on lifestyle changes that reduce stroke risk besides dental and primary care. These include promoting a healthy diet, regular exercise, smoking cessation, and moderation in alcohol consumption, all of which directly affect oral and cardiovascular health.

Conclusion

The emerging body of research connecting periodontal disease to an increased risk of stroke underscores the critical role of oral systemic health in overall cardiovascular well-being. As the evidence grows, it becomes increasingly clear that dental professionals are not only caregivers for oral health but also essential partners in preventing conditions that contribute to strokes. This understanding mandates a more integrated approach in healthcare, where dental and medical professionals collaborate to manage the risk factors linked to systemic diseases. By addressing oral health comprehensively, we can significantly impact the prevention of stroke, potentially reducing the prevalence and severity of this life-altering condition. Thus, prioritizing periodontal health is not just about maintaining healthy teeth and gums; it's a vital strategy in the fight against stroke and cardiovascular diseases, highlighting the mouth as a critical gateway to systemic health and a healthier future.

AAOSH Resources

Within our library of resources, AAOSH offers a robust Core Curriculum that includes many courses on the mouth-heart connection.  We hope you will enjoy these two sample courses from our core curriculum. (Please Note: These are sample courses; watching these videos here does not provide CE credit. Please visit members.aaosh.com to search for these courses and earn CE credit.)

In addition to over 270 hours of continuing education within 14 core competency areas, AAOSH members also receive a discount on the Bale-Doneen Preceptorship—a science-based methodology medically proven and accepted to prevent and reverse heart attacks, strokes and many other chronic conditions, such as type 2 diabetes, dementia, kidney disease, and erectile dysfunction. To learn more about joining AAOSH, visit https://www.aaosh.org/about-membership.

A Guarantee of Arterial Wellness: The Bale-Doneen Method and The Critical Role of Oral Health

Presented by: Amy Doneen, DNP,  and Bradley Bale, MD

Original Publication Date: September 01, 2018

Course Description:

Embark on a groundbreaking exploration of the interconnected realms of oral and systemic health in our specialized course, presented at a national collaborative event. This course illuminates the imperative for change, backed by compelling statistics, providing a robust foundation for understanding and preventing cardiovascular disease. Delve into the intricacies of blood flow obstruction during cardiovascular events and unravel the nuances of risk assessment, distinguishing between risk factors and disease itself. Uncover the pivotal role of inflammation as a root cause and acquire practical skills for effective monitoring. Gain a comprehensive appreciation for inflammatory conditions, all while spotlighting the often underestimated impact of oral health on cardiovascular well-being. Join us at this collaborative event to revolutionize your approach to health by integrating oral and systemic perspectives and making informed strides toward comprehensive well-being. 

Learning Objectives:

• Identify and articulate the multifaceted reasons that render cardiovascular disease (CVD) a significant healthcare concern.
• Recognize a key morphological characteristic of arterial plaque with high predictive value for CVD events.
• Explain the factors causing blood flow obstruction in most CVD events to a patient.
• Differentiate between assessing CVD event risk using traditional risk factors versus the presence of atherosclerosis through critical analysis.
• Understand inflammation as a causal factor in arterial disease, fostering comprehension of its role in cardiovascular health.
• Evaluate oral health as a potential contributor to arterial inflammation, appraising its role in systemic health and cardiovascular disease.

Screen for Vascular Health with CIMT

Presented by: Alicia Williams, DO, FACC, FACOI

Original Publication Date: September 24, 2021

Course Description:

This course comprehensively explores Carotid Intimal Media Thickness (CIMT) and its vital role in vascular health assessment. Participants will gain a solid grasp of CIMT's foundational principles, emphasizing its scientific and research aspects. Furthermore, they will learn how to apply CIMT in clinical practice, including identifying, risk stratifying, and continuously monitoring vascular health status. Engaging case studies will provide practical insights, allowing learners to bridge theory with real-world scenarios. Additionally, the course delves into strategies for fostering collaboration between medical and dental professionals to enhance vascular health. This includes risk identification, patient triage, treatment, and motivation, empowering healthcare providers with comprehensive tools for proactive patient care.

Learning Objectives:

• Summarize the fundamental concepts of CIMT as a tool for assessing vascular health, focusing on the scientific and research aspects involved.
• Comprehend the clinical applications of CIMT in the identification, risk stratification, and ongoing monitoring of vascular health status.
• Utilize case studies to illustrate the practical implementation of CIMT in clinical settings, demonstrating the ability to translate theoretical knowledge into real-world scenarios.
• Evaluate and discuss strategies for collaborative efforts between medical and dental professionals to promote vascular health.
• This includes methods for identifying risks, triaging patients, providing treatment, and motivating them to take proactive measures.
  

References (In the order they appear):

Centers for Disease Control and Prevention (CDC). (2021). Stroke facts. Retrieved April 22, 2024, from https://www.cdc.gov/stroke/facts.htm.

Lafon, A., Pereira, B., Dufour, T., Rigouby, V., Giroud, M., Béjot, Y., & Tubert-Jeannin, S. (2014). Periodontal disease and stroke: a meta-analysis of cohort studies. European Journal of Neurology, 21(9), 1155–e67. https://doi.org/10.1111/ene.12415 

Kozarov, E., Sweier, D., Shelburne, C., Progulske-Fox, A., & Lopatin, D. (2006). Detection of bacterial DNA in atheromatous plaques by quantitative PCR. Microbes and Infection, 8(3), 687–693. https://doi.org/10.1016/j.micinf.2005.09.004 

Campbell, E. & The American Academy for Oral and Systemic Health. (2022)Beyond Blood Pressure: Unveiling the Hidden Link Between Hypertension and Oral Health. The Profitable Dentist. Retrieved April 22, 2024, from https://theprofitabledentist.com/beyond-blood-pressure-unveiling-the-hidden-link-between-hypertension-and-oral-health/ 

Lockhart, P. B., Bolger, A. F., Papapanou, P. N., Osinbowale, O., Trevisan, M., Levison, M. E., Taubert, K. A., Newburger, J. W., Gornik, H. L., Gewitz, M. H., Wilson, W. R., Smith, S. C., Jr, Baddour, L. M., & American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology (2012). Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: A scientific statement from the American Heart Association. Circulation, 125(20), 2520–2544. https://doi.org/10.1161/CIR.0b013e31825719f3 

Grau, A. J., Becher, H., Ziegler, C. M., Lichy, C., Buggle, F., Kaiser, C., Lutz, R., Bültmann, S., Preusch, M., & Dörfer, C. E. (2004). Periodontal disease as a risk factor for ischemic stroke. Stroke, 35(2), 496–501. https://doi.org/10.1161/01.STR.0000110789.20526.9D