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REVIEW 10.1111/j.1469-0691.2007.01802.

Oral infections and systemic diseasean emerging problem in medicine


R. Rautemaa1,2,3, A. Lauhio4, M. P. Cullinan5,6 and G. J. Seymour5
1
Department of Bacteriology and Immunology, Haartman Institute, University of Helsinki,
2
Department of Oral and Maxillofacial Diseases, 3Microbiology Unit of Helsinki University Central
Hospital Laboratory Diagnostics, 4Division of Infectious Diseases, Department of Medicine, Helsinki
University Central Hospital, Finland, 5Faculty of Dentistry, University of Otago, Dunedin,
New Zealand and 6School of Dentistry, University of Queensland, Brisbane, Australia

ABSTRACT
The relationship between oral and general health has been increasingly recognised during the past two
decades. Several epidemiological studies have linked poor oral health with cardiovascular disease, poor
glycaemic control in diabetics, low birth-weight pre-term babies, and a number of other conditions,
including rheumatoid arthritis and osteoporosis. Oral infections are also recognised as a problem for
individuals suffering from a range of chronic conditions, including cancer and infection with human
immunodeficiency virus, as well as patients with ventilator-associated pneumonia. This review
considers the systemic consequences of odontogenic infections and the possible mechanisms by which
oral infection and inflammation can contribute to cardiovascular disease, as well as the oral conditions
associated with medically compromised patients. A large number of clinical studies have established the
clinical efficacy of topical antimicrobial agents, e.g., chlorhexidine and triclosan, in the prevention and
control of oral disease, especially gingivitis and dental plaque. The possible risks of antimicrobial
resistance are a concern, and the benefits of long-term use of triclosan require further evaluation. Oral
infections have become an increasingly common risk-factor for systemic disease, which clinicians should
take into account. Clinicians should increase their knowledge of oral diseases, and dentists must
strengthen their understanding of general medicine, in order to avoid unnecessary risks for infection
that originate in the mouth.
Keywords Bacteraemia, odontogenic infections, oral disease, prevention, review, triclosan
Accepted: 17 June 2007
Clin Microbiol Infect 2007; 13: 10411047

be achieved or maintained. Often, only an arrest


INTRODUCTION
of disease progression can be attained, and
Advances in the understanding, prevention and chronic asymptomatic infections may persist. In
treatment of oral diseases during the past addition, chronic or malignant diseases of the
50 years have led to a significant increase in mucosa are increasingly common. The mouth has
the number of individuals retaining more of thus become a significant potential source of both
their natural teeth for longer periods of time. infection and inflammation that contributes to the
However, many of these teeth have been heavily total burden of disease and to overall health and
restored and are prone to further breakdown, well-being.
and this increasingly dentate population is at The oral microbiota is both rich and unique.
risk for periodontal disease. The goal of modern A similar microbiota does not exist elsewhere.
dental care is oral health, but this cannot always In healthy individuals, viridans group strepto-
cocci constitute the majority of the indigenous
oral flora. However, the most common bacteria
Corresponding author and reprint requests: R. Rautemaa, isolated from pus samples from odotontogenic
University of Helsinki, Faculty of Medicine, Haartman
Institute, Department of Bacteriology and Immunology, PO
infections are facultative anaerobic streptococci
Box 21, 00014 University of Helsinki, Finland and anaerobic Gram-negative bacilli, e.g., Prevo-
E-mail: riina.richardson@helsinki.fi tellae and Fusobacterium spp. [1,2]. Currently, a

 2007 The Authors


Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases
1042 Clinical Microbiology and Infection, Volume 13 Number 11, November 2007

significant proportion of Prevotellae isolates The mouth clearly represents an important


worldwide are b-lactamase producers, and reservoir of microorganisms and any infection
b-lactam antibiotics alone are thus ineffective caused by these organisms should alert the clini-
against these organisms. For this reason, metro- cian to the possibility of an oral source [68].
nidazole has been used in combination with While there have been a number of reports of
penicillin in order to achieve improved efficacy brain abscess being caused by oral microorgan-
against anaerobes. isms [9], the classical example is endocarditis
Actinobacillus (now Aggregatibacter) actinomyce- caused by viridans group streptococci. According
temcomitans and Porphyromonas gingivalis are also to the infectious diseases register of the Finnish
key oral pathogens and have frequently been National Public Health Institute (http://www.
associated with periodontal diseases. It is also ktl-fin/tartuntatautirekisteri), the number of adult
interesting to note that both of these organisms septicaemias caused by viridans streptococci
can invade oral epithelial cells, which contributes has almost doubled in the past 10 years, which
to their immune evasion and resistance to anti- is directly proportional to the number of indivi-
biotic treatment [3,4]. Actinomyces spp. are part of duals remaining dentate throughout their lives.
the normal oral microbiota and constitute the bulk Viridans group streptococci are currently the fifth
of the structural elements of the dental plaque most common cause of septicaemia among adults
biofilm. These organisms are also found in cases in Finland.
of peri-implantitis, which is an infection of dental In this context, it is therefore important for
implant supporting tissues, and which may result infectious disease physicians to give increasing
in loss of the implant [5]. In addition, they can attention to oral health. The possibility of an oral
cause actinomycosis of jaws. Candida albicans is source should be considered for any infection of
the most common yeast found in the oral cavity, unknown origin. Oral infections often remain
although the proportion of non-albicans Candida asymptomatic, and may still result in bacteraemia
isolates has increased in recent years, especially in despite an absence of overt symptoms. Minor oral
patients with fragile health. procedures, including brushing of teeth, as well
as invasive dental procedures, e.g., removal of
dental calculus, root treatment and surgery, may
ODONTOGENIC INFECTIONS
all result in bacteraemia, even in an otherwise
The spread of oral infections is generally confined healthy individual [10,11]. Furthermore, an oral
by anatomical barriers or tissue planes, e.g., infection may provide the physician with clues for
muscle and bone. However, spread of infection diagnosis of a systemic disease. For example, oral
back and down to the larynx and the media- candidosis, in the absence of any other explana-
stinum can occur [1]. A central principle is that tion, could suggest infection with human immu-
oral infections cannot be resolved merely by use nodeficiency virus at a stage when the CD4+ cell
of antibiotics, and successful treatment is always count is still high and the disease is still otherwise
based on properly conducted dental procedures. asymptomatic.
Nevertheless, antibiotic treatment is important
and, as stated above, a combination of penicillin
THE MEDICALLY COMPROMISED
and metronidazole should be considered. An
PATIENT
odontogenic infection can spread very rapidly,
and the airway may become obstructed within a An increasing number of systemic diseases, e.g.,
few hours. If this occurs, rapid intubation or gastroenterological and rheumatological, are trea-
tracheostomy and intensive care may be required. ted with moderate-to-severe immunosuppressive
An example of a life-threatening infection origi- agents. Malignancies, with their associated ther-
nating in the mouth is Lemierres syndrome, apies, also affect an increasingly large proportion
which is a rare septic condition that usually of the population. The oral health of medically
requires intensive care. Isolation of Fusobacterium and immunologically compromised patients is
necrophorum is common, and a suppurative fundamental to the overall care of these patients.
thrombophlebitis in the vena jugularis interna Oral infections are typically chronic and often
and metastatic abscesses in the lungs or the brain present with minor symptoms; however, they
can develop [1]. remain controlled while the immune defences

 2007 The Authors


Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases, CMI, 13, 10411047
Rautemaa et al. Oral infection and systemic disease 1043

Fig. 3. The mouth of a male aged 58 years with severely


damaged dentition and periodontitis.

Fig. 1. The mouth of a patient with severe stomatitis


caused by chronic candidosis. The patient was diagnosed common in patients receiving cancer therapies
with an autoimmune disease against adrenal and parathy- [1518]. Oral mucosal lesions may provide a
roid glands.
portal of entry for systemic infection that may
prevent or delay the continuation of cancer
treatment [1921], thereby having a significant
effect on the final prognosis (including mortality),
and a major impact on the costs of care [22].
Regular removal of bacterial plaque from tooth
surfaces is important in order to keep the micro-
bial load and challenge to a minimum during
cancer treatments [23,24]. In this context, tooth-
brushing alone may be insufficient or impossible
to carry out because of pain, and the use of
antimicrobial toothpastes and mouthwashes may
Fig. 2. An orthopantomogram of a male aged 36 years be necessary [17,25]. When the mucosa is dam-
who was suffering from dental fear. The whole dentition is aged, brushing may lead to substantial bactera-
severely damaged, and the remaining roots are foci for emia, and the use of an antimicrobial mouthwash
chronic and acute osteitis.
is therefore recommended before or instead of
brushing. Several reports have demonstrated that
and tissue responses of the patient remain intact. a chlorhexidine mouthwash is effective in con-
In a susceptible immunocompromised patient, trolling both the oral infection per se and the
even an asymptomatic, chronic osteitis or a mild consequences of any bacteraemia [17,25]. Careful
Candida mucositis (Fig. 1) can become a source of mechanical (brushing and flossing) or chemical
life-threatening generalised infection [12,13]. It is (antimicrobial mouthwashes) oral hygiene should
therefore important to ensure that all foci of oral always be a part of cancer therapy. Barker et al.
infection are eliminated whenever possible before [22] highlighted considerable variation among
commencing treatment. This is also important centres in their understanding and appreciation
before cardiac surgery or the placement of joint of the significance of oral health in medically
prostheses [14]. Imaging of the teeth and tooth- compromised patients; they concluded that an
supporting bone and jaws should be the minimum increase in oral complications has evolved with the
routine (Fig. 2). A thorough clinical examination development of cancer therapies, and that medico-
by a dentist experienced in oral medicine is also dental collaboration is therefore important.
highly recommended. Osteomyelitis of the jaw is a rather uncommon
Poor oral health (Fig. 3) and extensive stoma- infection, with diabetes and haemodialysis
titis, responsible for significant morbidity, are being known risk-factors [1]. However, there is

 2007 The Authors


Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases, CMI, 13, 10411047
1044 Clinical Microbiology and Infection, Volume 13 Number 11, November 2007

increasing evidence of osteonecrosis of the while epidemiological studies indicate associa-


mandible being associated with high-dose or tions, they do not establish causality. Care must
long-lasting bisphosphonate therapy. Bisphosph- be taken in interpreting these cross-sectional
onates, which are pyrophosphate analogues, are epidemiological studies and, as emphasised by
strong osteoclast inhibitors that are used in the Hujoel et al. [35], studies of longitudinal interven-
treatment of osteoporosis and solid tumours with tion and pathogenic mechanisms are urgently
bony metastasis. The safe optimal dose and required. A number of short-term studies exam-
duration of treatment should be evaluated and ining the effect of periodontal treatment on the
the subset of patients at increased risk for surrogate markers of cardiovascular disease have
osteonecrosis should be identified, as the necrosis been performed [3638]. In general, these studies
seems to be irreversible and the treatment of these show that periodontal treatment results in a
patients is very difficult [26]. significant reduction in such markers of cardio-
Actinomycosis of the cervicofacial region, vascular disease, e.g., interleukin-6 and C-reactive
caused primarily by any of several members of protein. These changes are also accompanied by
the bacterial genus Actinomyces, is another rare an improvement in endothelial function and
infection, usually presenting as a mass adjacent to arterial elasticity.
the mandible, which may penetrate the surround- Possible biological mechanisms linking perio-
ing bone and muscle and form a fistula to the dontal and cardiovascular disease include
skin. Carious teeth, dental manipulations and molecular mimicry between the bacterial heat-
maxillo-facial trauma are known sources of infec- shock protein GroEL and human heat-shock
tion [1,27]. The pathogenesis is related to the protein 60 (hHSP60). This hypothesis, first sug-
ability of these organisms to act as intracellular gested by Wick et al. [39,40], involves cross-
parasites and thus resist phagocytosis. Actino- reactivity between the immune response mounted
mycosis has a tendency to spread without respect against a bacterial infection and hHSP60
for established tissue planes or anatomical barri- expressed on stressed or damaged endothelial
ers, and this can sometimes be confused with cells. Yamazaki et al. [41] have shown that T-cells
malignancy. reactive with both GroEL and hHSP60 have
identical nucleotide sequences in their T-cell
receptor b-chain genes, and that such T-cells exist
SIGNIFICANCE OF ORAL
both in the atherosclerotic plaques themselves
INFECTIONS IN THE
and in the periodontal tissues. Cross-reactive
DEVELOPMENT OF SYSTEMIC
T-cells have also been shown to be present in
DISEASES
the peripheral blood of patients with atheroscle-
The importance of the role of infection and rosis [42,43], and antibodies to GroEL cross-react
inflammation in the initiation and progression of with hHSP60, and vice versa. In addition, P. gin-
the endothelial damage in atherosclerosis is now givalis has been shown to enhance the develop-
widely accepted [2830]. Chronic inflammatory ment of atherosclerosis in an animal model, and
periodontal diseases are found worldwide and this enhancement is associated with increased
are among the most prevalent chronic infec- levels of anti-GroEL antibody [43].
tions in humans. Individuals with severe chronic Other possible mechanisms linking periodontal
periodontitis have been reported to have a sig- and cardiovascular disease include direct infec-
nificantly increased risk of developing cardio- tion of the blood vessel walls by periodontal
vascular disease, including atherosclerosis, organisms. Leukocytes do not adhere to healthy
myocardial infarction and stroke, even after endothelium, but if the endothelium is damaged,
adjusting for many of the traditional risk-factors e.g., by direct infection, the endothelial cells will
[3133]. express adhesion molecules to which white blood
Since the early work carried out in Finland cells adhere. Monocytes adhere and migrate into
[2834], there have been >50 studies investigating the intima, where they phagocytose the oxidised
the relationship between periodontal and cardio- low-density lipids that form the so-called foam
vascular disease, with the majority showing a cells. The foam cells then release matrix metallo-
significant, albeit modest, positive association, proteinases that degrade extracellular matrix
even after adjusting for confounders. However, components in the vessel wall, resulting in

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Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases, CMI, 13, 10411047
Rautemaa et al. Oral infection and systemic disease 1045

atherosclerosis [44]. These cholesterol plaques progression of periodontal disease over a 35-year
that form at the site of injury can rupture, period in adults and adolescents with pre-existing
increasing the likelihood of myocardial infarction disease [4648]. It is expected that these benefits
or stroke. An interesting finding is that the known will compound with continued use over even
matrix metalloproteinase inhibitor tetracycline is longer periods of time [47]. This could have a
as effective as periodontal treatment in lowering significant impact on disease expression in the
the level of C-reactive protein in coronary heart population at large. The consequences of long-
disease patients with periodontitis [44]. Extensive term use of any antimicrobial agent are a concern,
studies have shown that systemic diseases, e.g., and the therapeutic advantages have to be
diabetes and cardiovascular disease, and perio- weighed against the possibility of reduced sus-
dontitis share links between biomarkers of ceptibility and the emergence of resistant strains.
systemic inflammation (C-reactive protein, inter- To date, there is no evidence that triclosan
leukin-6, tumour necrosis factor-a, matrix metallo- formulations for oral use will select for triclosan-
proteinase-9). resistant strains [49,50], but there are well-docu-
These pathogenic mechanisms are not mutually mented therapeutic benefits. It is interesting to
exclusive, but clearly establish the role of infection note that the major therapeutic benefit, in terms of
in the pathogenesis of atherosclerosis. Despite the chronic periodontitis, is seen in susceptible
lack of definitive long-term intervention studies, patients or those with pre-existing disease. Med-
the importance of preventing and treating infec- ically and immunologically compromised pa-
tions, especially chronic infections such as peri- tients represent a susceptible population, such
odontitis, should become paramount in terms of that it would be reasonable to expect that triclo-
the advice and treatment given to patients with san-containing toothpastes would be of value in
coronary heart disease. the control of oral infection in these patients.
However, this remains to be shown, and further
studies are necessary to determine the effect
PREVENTION OF ORAL INFECTIONS
of these products in medically compromised
Oral infection continues to be a major public patients.
health problem worldwide. Good oral hygiene is
essential for good oral health, and the routine
CONCLUSIONS
control of dental plaque is fundamental. How-
ever, the widespread prevalence of oral disease The number of individuals retaining more of their
indicates the inability of most individuals to natural teeth for longer periods of time has
achieve a level of plaque control consistent with increased during the past few decades. Adequate
good oral health. Approaches aimed at improving oral hygiene is difficult to achieve, and chronic
the oral hygiene of the population have therefore asymptomatic infections of teeth, their supporting
included the addition of antibacterial agents to tissues and oral mucosa are common. Mainte-
oral care products. While chlorhexidene is con- nance of oral health is a special challenge for
sidered to be the reference standard, it has medically compromised patients or those with
significant side-effects that limit its widespread acute illness. The mouth is a significant potential
long-term use. source of infection and inflammation that con-
Triclosan is an alternative antimicrobial agent tributes to the total burden of disease, and to
with a broad spectrum of activity against oral overall health, which should be systematically
microorganisms. This agent is more suitable for taken into account by all clinicians.
long-term use, as it does not have significant side-
effects and, importantly, it has a long history of
ACKNOWLEDGEMENTS
safe use in consumer products. Its dual antimi-
crobial and anti-inflammatory properties offer R. Rautemaa declares support during recent years from the
advantages in the management of periodontal Finnish Dental Society Apollonia, Helsinki University Central
Hospital Research Funds (EVO), and the University of Hel-
diseases and oral mucosal conditions, and there sinki, Finland. G. Seymour and M. Cullinan declare support
are now numerous studies demonstrating its during recent years from the NHMRC of Australia, the
effectiveness in reducing plaque and gingivitis Australian Dental Research Fund, Colgate Oral Care Australia
[45]. Triclosan has also been shown to slow the and Colgate Palmolive Ltd, USA.

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Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases, CMI, 13, 10411047
1046 Clinical Microbiology and Infection, Volume 13 Number 11, November 2007

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Journal Compilation  2007 European Society of Clinical Microbiology and Infectious Diseases, CMI, 13, 10411047

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