PERIODONTAL INFECTION AS A POTENTIAL RISK FACTOR FOR SYSTEMIC DISEASE

Oral infection c:n have an adverse effect on other organs of the body Oral iDfection especially Deriodontitis may effect th€ couse and pathogenesis of a number of systemic diseases, such as diabetes mellitus, cardiovascular disease, Fe-term low birth weight infant and resPiatory disease The purPose ofthis article is to €valuate the cunent status of oral infectjon especially periodontitis as a potential risk factor of systemic diseases. Three main pathways lintdng oral infection to secondary syst€mic effects have been proposed: metastatic infection, metastatic injury and metastatic inflammation Periodontitis can cause bacteria io enter the blood strearn and activate immune cells Thes€ activated cells produce inflammatory c)'tokines that hav€ a destructive effect thtoughout the entir€ body. Therefore, periodontitis as a mayor oml infection may eflect the host's susceptibility to syst€mic dis€ase lndonesian Jownal ofDentistry 2006; Special Edition KPPIKG xlY:379-382.


Introduction
The oral cavily is a site of most idfections and inflammatory diseases which has rccently b€en associated *ith systemic disease.rMost studies conceming the relationship between oral infection and systemic disease ar€ related to Freriodortal diseas; by far the common olal infection' Periodontal disease can cause bacteria to enter the bloodstream and aclivate immune cells.These activated cells produce inflammatory biological signals (c)4okine) that have destructive effect throughout the €ntire body.'Three mechanisms or pathways linking oral infection to secoDdary systemic effects have been proposed: metastatic infection, metastatic injury, and metastatic inflammation.
Oral infe€tion especially periodontitis may affect lhe course and pathogen$is of a number of systemic dis€ase such as diabetes mellitus, cardiovascular dis€ase, pre-t€rm low birth weight infanl, and resprralor) disease.' chronic periodontitis is probably the most prevalent and potentially has the strongest €pidemiologicai and plausible mechanistic associations with these systemic diseases.The p€riodontium which comprised of the sinsival, bone and other suPponng lissue thal -ancior the reet, plav a key role il' the-inlerPlay b€Meen oral health and s)$emic disease' Infection in these tissue, primarily by Gram-negative an aerobic bacteria.can initiate a senes of innammalory and immunologic changts leading to the desrudi;n ofconneclive tissue and bone lo Due to chronic nature of periodontal dis€ase, *hjch ar€ infection.and involvement of th€ host's immune system, it seems reasonable thal these infections mav affecl to overall health of individual The bacteria associat€d with periodontal disease can caus€ bact€ria enter and fav€l inio the blood strean and activate immurc cells These activated cells produce inflammatory biological siqnals (cyokine) lha( ha!e d€structiv€ effecl rh;oushou the enLre body r"' The pro' inflaimatory c)'tokines such as IL-l' TNFr and gamma ift;rferon as well as Fostaglandin E, (PGl-r) reach high tissue concentralrons rn oeriodontitis: Periodontal disease may in facr as a potential risk factor for systemic diseas€' Recent iesearch has found a relationship between periodontal infection and systemic disease such as diabetes mellitus, cardiovascular disease, Pre_term lo* tinfr w"igftt iniuot and respiratory disease.6

Diabetes Mcllitus
The relationship between diabetes and oral conditions has be€n shown in sev€ral studies' and may be two ways relationsbip-The production of endotoxins and other bacterial though periodontal infection mediated up regulation of macrophage rcsDonses to advanced glycation end products' Di;betes may increas€ the risk ofperiodontal disease which may be assoctaled wi!h poor gllcemic"conrol and increased complication fiom diabetes' -'' The severit and prevalence ofperiodontitis are increased in persons with diab€tes and pooriy controll€d diabetes.Periodontitis may exacerbate diabetes by decreasiry glycemic control This effect indicates a degree of s]'nergism and a link between diabetes m€llitus and periodontitis '"

Csrdiovrsculsr Disease
Oral infection may directly contribute to atherosenesis and tkomboembolic event by providing repealed \]stemic !ascular challenges of pro'rnllanrmatory cyokine.periodontal palhogen\ lnd lipopolysacharida lLPSl The pro-infldmmalorl c\4okin€ aspects of ca.diovascular diseas€, tbe microbial a;d the exposure may b€ associated wjth th€ more acute coronary h€art disease and stroke such as tkombus formation 'o' tr The changes caused by infection and/or the.. inilammalory response are believed to aflect the build up of plaque in the imer lining of the blood lessels supplying-rhe hean or brdin lhal occuh in atherosclerosis '" '' Periodonlitt dnd dtheroscleros'' have complex etiologies, genetic and gender oredisDosilions and ma) shdre pathogenk mechanism as well as cornmon risk factors, such as smoking, diabetes, behavioral factors, and age r13 Pre-term Low Birth Weight lnfant Periodontal infection may be a risk.factorfor pre-term low birth weight (PLBW) infant.'Changes in hormone levels during pregnancy plomole einqival inflammatron lermed pregnanc) gingi!i(is Periodontal disease rs associated \ ilh chronic Emm-nesali!e infections, which re'uk in local and lvv..,i .t.uanon.oi pro-'nndmmalor) oiosuelandin and .yokrne." Vatemal periodonlal infecLrlon mal influence pre-lenn deli\er!Ihrough mechanism involving inflammatory medBtorc or a dir€ct bacterial assault on th€ amnion '" The theory is that oral bacteria release toxins, which reach th€ placenta through tbe mother's blood stream and interfere with grot{b and development of fetus.At rhe same time the oral infection causes the mother to produce laboF triggering substances in quickly potentially triggering premalure labor and birth '

Respiratory Diseas€
The aspiration of oral contents is probably one of clearest link betwe€n periodontal diseas€ and respiratory infection.3Perhaps lhe most direct association between periodontal infeciion and systemic disease is seen in periodo titis and respiratory disease.Specifically, pe odontal and respiatory pathog€ns in plaque have been linl(ed to an increased risk for aspiration pneumonia and chronic obstruciive pulm;nary djseas€ lCoPDlD There is inueasing evidence that oral bacteria especially p€riodontal pathogens, may alter the course ofrespimtory infection.Also, it is known that the lower airway can be contaminated by microorganisms tkough aspiration of oropharlageal contents, inhalation of infectious aerosols, hematogenous spread or spr€ad from contigenous

Discussion
The oral cavily provides a continuous source of infectious agents and its conditions offen r€flects progession of systemic pathologic.''A large number of publications have suggested that oral infection, especially pedodontitis are potennat conFibutine lacror to vaflety ofclinicalll imponanl systemic disease.? There is mcreasing evidence thal the relationship between periodontal disease and systemjc disease may be bi-djrectional, The bi-drecLional interaclion between oral and syitemic health.That is, not only systemic disease which has oral manifestation, but p€riodontal disease can also €xac€rbate certain systemic condition' The p€riodontium plays a key role in the interplay betwe€n oral health and systemic disease.Recent r€search has found a relationship between periodontal infection and more serious health problem such as diabetes mellirus, cardiovascular dhease, pre-term low birth weight infant and resplatory disease.6 The severity and prevalence of periodontith are increased in patienh with diabetes and are wors€ in patients with poorly controlled diabetes.Periodontitis may exacerbate diabetes by decreasing glycemic control.This effect indicate a degree ofslnergism and a linl ber\^een periodonral dis€ase and diabetes mellilus'" " The evidence suggest thal periodontjtis induced bacter€mia will cause elevations in serum pro-inflammation c)lokines, Ieading 1o hyperlipidemia and ultimately causing an insulin resistance syndrome and contributing to destruction of pancreatic beta cell.Treating chronic periodontal infections is essential for managing diab€tes.'' So far, the causality and possible pathways of the association between p€riodontal disease and cardiovascular disease remain obscure.Factors that place individuals at risk factor periodontitis may also place them at risk for cardiovascular disease, Peiodontitis and cardiovascular diseas€ may shar€ common risk iactors, such as smoking, diabetes, b€havioral factors, age and gender.Th€ balanc€ of the evidence suggests that periodontal disease may be independent risk factor for cardiovascular Th€ infected periodontium can b€ regarded as a res€rvoir for both microbial products and infl ammatory mediator, periodonlal infections may will repres€nt a pathway of infectiouyinflammalory exposure to the matemal ietal unia and may be a potential risk factor for pre-term low bifih weight (PLBW) infant.'A propos€d mechanism suggest a concenfadon dependent relationship between increased matemal levels of prostaglandin E, in the gingival fluid found in the pocket and PLBW.More research€s are needed to confirm how periodontal disease is a risk factor for PLBW infant.This may help to reduce the mortality ofpremature birth.T The porenrial role oI oral pathogens in the palhogenesis of lower respiratory infections have been documented.These pathogens could be aspiated direcdy into the lower airway in high numbels especially in patients with severe periodoDtitis and could then cause infection-A relationship between poor oral healih and respiratory disease has been suggested by a number of rec€nt miuobiologic and epidemiologic studies.The factors involved in the pathogenesis of respiratory disease and periodontal disease are multidimensional.Increased attention to oml hcalth r. rhis high-risk populalron may.resull in a lower incidence of respiratory disease ""

Conclusion
Oral infecrion nay have an association with the occurence and severity of a wjde varieties of systemic diseases.Oral infection especially periodontith as a mayor oral infection may effect the host's susceptibility to systemic disease.The periodontal diseas€ and systemic disease association is the infection related host inflammatory r€sponse, which may influence a variety of homeostatic mechanisms.
The role of periodontal disease may play in diabetes m€llitus, as well as cardiovascular disease, pre-term low birth weight infant and respiratory disease, the best advice is for people to take 3 E l _ -t a excellent car€ of their oral health to help €nsur€ lhey keep their teeth as well as maintain overall health.