The Oral Systemic Link Between Airway, Sleep and Heart Health

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Firstly, what is gum disease, and why should you take it seriously?

Before we understand the connection between our oral and heart health, it is good to know how it all starts. Gum disease is a common condition where the tissue surrounding a tooth gets infected and results in inflammation. A common cause for this condition is poor oral hygiene. An infection happens when bacteria enter the body or the bloodstream, typically through an opening in the gums.

It is essential to understand that gum disease is similar to damage to the skin or any other part of our body. Just like the skin covers and protects our body, the gums also hold our teeth together and play a vital role in oral health. The question is, however, whether we give the same attention to bleeding gums as we would give to bleeding that might happen anywhere else on our skin.

Generally, there’s much emphasis given to the wellbeing of the skin. If skin damage appears, there could be a raw and bleeding wound. Our immediate reaction would be to treat the injury and stop any bleeding. It is fair to state that a persistent skin bleed would seldom go untreated.

However, in the case of gums, the situation is somewhat different. We tend to overlook bleeding gums. Our gums may bleed when brushing or bleed for days, weeks, even months.

How does gum infection result in inflammation?

On the subject of oral health, the focus typically tends to be on teeth. However, we need to understand that our gums are as important as our teeth and need to be well taken care of.

There are various types of bacteria always present in our mouths. We can control these levels of bacteria by regular brushing our teeth twice a day. The absence of proper oral hygiene provides the ideal atmosphere for bacteria to multiply. Some of these bacteria multiply and produce acids that create cavities in teeth. Some others affect the gums and sometimes even the bones that support the teeth.

Gingivitis

Gums are infected when plaque and calculus get accumulated above the gumline. This accumulation of plaque causes irritation, redness and swelling(inflammation) in the gum line, which is called the gingiva. The gingiva is part of the gum around the base of the teeth. This inflammation leads to bleeding of this part which is an early sign of gum disease.

This condition needs immediate dental assistance as negligence at this stage may lead to more severe damage to the gums.

Periodontal disease

If gum bleeding goes untreated, the accumulated plaque and calculus may invade the gum tissue, reaching deeper levels of the gum, infecting the bone. Periodontal disease is the more severe form of gum infection.

Primary symptoms of gum infection

Bleeding of gums
Bad breath
Redness in gums
Tenderness and pain in gums
Receding and loose teeth

How our bodies react to bacteria that cause gum disease

Now, let’s understand how unchecked inflammation can affect the rest of our body.

When bacteria start infecting the gums and then the bones, the body reacts with its immune system in response, pumping out many substances to win this battle. This activity creates pus which is a mixture of bacteria, immune cells and dead tissue.

In response to an injury, body cells also release small chemicals called Cytokines.

Chemicals included in Cytokines

Tumor necrosis factor
Interleukin-1
Interleukin-6
Interleukin-8
Interleukin-17

The Cytokines then start attracting nearby immune cells.

Cytokines also dilate nearby capillaries which make them leaky. This action results in more blood being pumped into the affected area, which allows the immune cells that show up to slip out into the blood easily and then to the tissue.

Cytokines facilitate the signaling of immune cells to release a variety of compounds necessary to the inflammatory response.

In case the initial inflammatory response does not settle the infection, chronic inflammation takes place. This chronic immune-inflammatory response is what causes periodontal tissue destruction.

During this immune system response, the liver releases what is known as the C-reactive protein, or CRP (Cross-reactive protein).

This protein now transfers to other parts of the body where the other organs or blood vessels perceive it to be an inflammation signal to react. As a result, such organs and blood vessels start reacting to this unknowingly.

How does CRP resulting from the collateral damage caused by gum disease result in a heart attack?

CRP travelling to heart vessels could cause the inner lining (endothelial lining) to roughen. This roughening may trigger certain turbulences, including clogging or blood clotting. The re-occurrence of this process would create further damage to the inner lining. This damage may eventually cause more and more fibrin and platelets to grow and build up until it becomes occluded or blocked, resulting in the occurrence of heart issues. This condition is known as atherosclerosis. Although atherosclerosis is often considered a heart problem, it can affect arteries anywhere in the body.

Atherosclerosis can go on to affect coronary arteries causing a more significant blockage that may lead part of the heart to run out of blood supply. A low blood supply causes ischemia or lack of blood flow, resulting in partial damage of the heart and eventually could result in a heart attack.

How does CRP resulting from the collateral damage caused by gum disease result in a stroke?

The series of events discussed above could also take place in the brain. The blockage caused in parts of the brain would cause part of the brain to die, resulting in a stroke.

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Why should diabetes patients be particularly concerned about gum disease?

Those with diabetes face an increased risk of developing gum disease. High blood sugar levels could cause damage to nerves, blood vessels, heart, kidneys, eyes and feet. Similarly, gums can be affected too.

As high blood sugar levels lead to damaged blood vessels, it reduces the supply of oxygen and nourishment to the gums and paves the way to infections of the gums and bones.

People with diabetes, therefore, should have regular dental check-ups and be always concerned about maintaining a high level of oral hygiene.

How pregnant women could be more prone to gum disease and how gum disease can have implications for pregnant women

Pregnant women can be more susceptible to gum disease due to the hormone changes taking place during pregnancy. The various hormonal changes and imbalances may cause a pregnant mother’s gums to become more exacerbated.

When a pregnant woman has gum disease, this will lead to inflammatory conditions affecting the tissues surrounding the teeth. These inflammatory conditions would put the expectant mother at a higher risk of having preeclampsia or high blood pressure.

Gum disease also impacts the oxytocin levels in the pregnant mother that may induce an early delivery which would result in the premature birth of her child.

It is therefore vital that pregnant mothers include dental check-up to their routine medical check-up throughout their pregnancy.

The relationship between proper sleep and oral health

If you have been following our blog posts, you may have noticed that we are huge advocates for proper sleep and breathing. So it seems fit to conclude this article highlighting the importance of adequate sleep here too.

When it comes to sleep, three aspects primarily contribute to oral health.

Sealed lips
Tongue position
Proper breathing

The correct functionality and positioning of the above aspects during our sleep that are also seen to be interconnected contributes towards good oral health. Typically sealed lips facilitate proper nose breathing that would help to avoid any harmful effects from breathing through the mouth.

The tongue should ideally be resting on the roof of the mouth. Improper positioning of the tongue could block the airway and cause airway obstruction or airway resistance. This obstruction could get worse if we lie down on our back.

Relationship of AHI Index (Apnea-Hypopnea Index) to Oral health

Apnea-Hypopnea Index (AHI) The AHI is the number of apneas or hypopneas recorded during the study per hour of sleep. It is generally expressed as the number of events per hour.

Sleep apnea causes a person to breathe through the mouth (mouth breathing), which affects oral health. Mouth breathing can also lead to Additional consequences of dry mouth, increase in plaque, mouth sores, gingivitis (gum inflammation), and periodontal disease.

More recent studies from the Journal of sleep medicine have highlighted that habit correction is essential together with reconditioning of the lips compound and nasal breathing.

These can be through myofunctional therapy that improves the AHI (and index used for measuring and sleep apnea). It reduces AHI by 43%, for children according to a recent study published in August 2020.

In another study done in 2015, a meta-analysis report also highlighted that it could improve up to 50% for adults and 62% for children if they exercise their lips and tongue in breathing, which can help with obstructive sleep.

In conclusion, it has been established that people with poor oral hygiene are two or three times more likely to suffer a heart attack or stroke and other health conditions. Still the oral cavity or the mouth seems to be excluded when discussing overall health.

It is therefore extremely important that we pay good attention to oral health when it comes to systemic issues. We should regard it well, and optimise its health so that we can be healthier overall.

Dr. Yue Weng Cheu

Dr. Yue Weng Cheu completed his BDS degree at the National University of Singapore and was awarded The Pierre Fauchard Academy Foundation Annual Scholarship Award.