Metabolic syndrome represents multiple conditions that have risk factors for cardiovascular disease. The term is not for a solo disease but rather a group of medically high-risk conditions. When combined, the conditions cause serious health issues. According to the International Diabetes Federation, metabolic syndrome is defined as “a cluster of the most dangerous heart attack risk factors: diabetes and raised fasting plasma glucose, abdominal obesity, high cholesterol, and high blood pressure.”1
From a dental perspective, this is a medical emergency waiting to happen. A dental patient may exhibit these medical conditions through disclosure of medications if not by self-disclosure. The dental professional should know if the patient’s blood pressure, blood sugars, and cholesterol are stable. Any one condition of this syndrome is an increased oral health concern and medical emergency in the dental office. A compound of two or more conditions increases the risk substantially.
According to the American Heart Association, 47 million Americans have this syndrome (one out of six people). The health condition, which is increasing in incidence, affects one-third of adults in the United States, and 20% to 25% of the world’s population are twice as likely to die from metabolic syndrome than from a stroke or heart attack.2 The various names for metabolic syndrome include dysmetabolic syndrome, obesity syndrome, hypertriglyceridemia waist, insulin-resistant syndrome, syndrome X, and the deadly quartet.3
Metabolic syndrome is an interrelating dynamic, easily compared to a domino effect where one condition initiates other conditions to blossom. The conditions and the risk for cardiovascular fatality increase with each added component.
Diabetes is the most common chronic disease and the fifth leading cause of death. The two common conditions within metabolic syndrome are type 2 diabetes and obesity, which causes inflammatory damage to the body in and of itself. These two factors are commonly associated with high triglycerides and high blood pressure to initiate a metabolic syndrome. As obesity can cause diabetes, diabetes can increase high blood pressure, high blood pressure is commonly associated with high cholesterol, and they all significantly increase the chance of heart disease.
At least three risk factors need to be present to be diagnosed with metabolic syndrome, and the risk components are:
High blood glucose: Fasting glucose higher than 100mg/dL
Low high-density lipids: Less than 40mg/dL for men and less than 50 mg/dL for women
High triglycerides: More than 150 mg/dL
High blood pressure: Higher than 130/80 mm Hg
Obesity with a large waist circumference: Larger than 40 inches for men and 35 inches for women
The American Heart Association and the National Heart, Lung, and Blood Institute add other risk factors such as hormonal imbalance, aging, physical inactivity, a diet high in saturated fats, cholesterol, and simple sugars.2
Oral risks include inflammation commonly caused by bacteria and plaque, causing periodontal disease. Known inflammation in the mouth can be a factor in systemic inflammation. The longer those conditions are present, the more at risk it is systemically and vice versa. Oral infection slows healing, lowers immune system response, contributes to unstable blood sugars, and increases cardiovascular disease and stroke risks.
Systemic Links
Cardiovascular disease and oral health ─ Cardiovascular disease is a class of diseases involving the heart or blood vessels. This is quite an umbrella for an array of heart conditions ranging from angina to the widow-maker heart attack.
Specific heart conditions are required to take a premedication of an antibiotic before dental treatment as oral bacteria can travel into the bloodstream and land in the vulnerable heart to cause a serious infection. Research has shown the same oral bacteria that causes periodontal disease can elevate C-reactive proteins, a known marker for inflammation in the blood vessels. Inflammation in the blood vessels is capable of plaque growth, which increases the chances of detaching from the walls of the arteries and triggering blood clots. When the blood clot blocks an artery of the heart, it’s a heart attack. Whereas if it blocks an artery to the brain, it’s a stroke.5
Any oral infection, plaque, and bacteria in the mouth increase inflammation into the bloodstream and risks of cardiovascular disease. Patients with known cardiovascular disease most likely will be on a cocktail of medications involving blood thinners, high blood pressure, diuretics, calcium channel blockers, beta-blockers, ACE inhibitors, and even cholesterol-lowering agents. In addition to these medications are more medications to relieve contributed side effects.
Diligent home care is essential with the topical protocol of removing bacteria. Fluoride use is beneficial for a higher risk of decay, and xerostomia maintenance is imperative for oral health. Blood-thinning protocols with dentistry are also to be noted.
Obesity and oral health ─ Obesity is a prevalent condition involving excessive body fat, increasing medical risks that impair health. Among the adult population, about 69% are obese or overweight, causing it to fall into the top five leading causes of death. Obesity alone is associated with insulin resistance, high cholesterol, hypertension, and a substantial risk of cardiovascular disease.6
Obesity is associated with high levels of fats in the blood leading to elevated blood triglycerides, which in effect increases low-density lipids to produce arterial plaque. Prominent levels of fat in the blood and obesity show a link to periodontal disease as they are both chronic inflammatory conditions. There’s a strong correlation between the two. Cytokines, a proinflammatory, are released during active periodontal disease. The release of these cytokines from periodontitis contributes to increased systemic inflammation in obesity.7
Obesity alone is considered a morbidity and contributes to many factors such as heart disease, high blood pressure, high triglycerides, diabetes, and cancers. When one or more conditions are involved with obesity, they are considered comorbidities.
Orally, obesity contributes to an increase of caries, xerostomia, inflammation, and periodontal disease. People who have missing teeth tend to eat softer foods as chewing diminishes, encouraging more sweets and carbohydrates than vegetables, fruits, and meats. This menu can increase an obesogenic diet of saturated fats or trans fatty acids, increasing weight and health defects.
Extremely low saliva has been associated with a BMI greater than 25 of adults 50 and older and childhood obesity and type 2 diabetes.8 Losing 5% to 10% of body weight lowers blood pressure, triglycerides, and blood sugars. Losing 3% to 5 % of body weight lowers the risk of heart disease.9
Diligent home care is essential with the protocol of removing bacteria. Fluoride use is beneficial for a higher risk of decay, and xerostomia maintenance is imperative for oral health. If weight loss medications are used, they may cause xerostomia, altered taste, vomiting, raised blood pressure, and increased heart rate. Xerostomia is a concern for an increase in decay and more plaque accumulation for periodontal risks and inflammatory issues within the body. Increased blood pressure and heart rate increase a medical emergency situation.
Diabetes and oral health ─ In this discussion about metabolic syndrome, type 2 diabetes is more concerning than type 1 diabetes. It’s a health condition that struggles to transport glucose from the blood into the muscles for proper use for energy. When insulin doesn’t respond well or at all, too much sugar stays in the bloodstream, encouraging an overload while preventing the body to disperse and using sugars as intended for energy.
Diabetes affects 34.2 million people, 10.5% of the US population, while another 7.3 million are assumed to be undiagnosed.
High sugar levels not only appear in the blood but also in the saliva. The oral bacteria use the sugars as food and decalcify the tooth to cause decay and promote periodontal disease. Any infection in the mouth increases blood sugars. When blood sugars are unstable, it decreases the healing of infection. Unstable diabetes with high blood sugar weakens white blood cells that are prominent in fighting infections. And the cycle continues.
The three main factors from diabetes are xerostomia from the actual condition or use of medication to maintain it, infection to cause inflamed, bleeding gingiva and increased periodontal risks of tooth loss, and a slower healing response are all disasters for oral health. Thrush, mouth sores, and cheilitis are other common oral effects of uncontrolled diabetes.10
Diabetes is such a crucial factor that some insurers will pay for more than two cleanings a year. Diligent home care is essential with the topical protocol of removing bacteria. Fluoride use is beneficial, and xerostomia maintenance is imperative for oral health. Staying hydrated from excess thirst with diabetes will make the mouth feel more comfortable.
High blood pressure and oral health ─ High blood pressure (hypertension) is one of the most common chronic cardiovascular conditions without symptoms (until there are symptoms, as it’s known as “the silent killer”). If left untreated, it weakens and damages the blood vessels and results in a heart attack, stroke, or aneurysm. High blood pressure occurs when there’s a lot of force against the artery walls. It’s determined by the amount of blood the heart pumps and blood flow resistance within the arteries—the more blood pumped in the heart and the narrower the arteries, the higher the blood pressure.
High blood pressure has some disheartening numbers, according to the Centers for Disease Control and Prevention. In the United States, 116 million (about 47% of the population) have hypertension, with 34 million (about 45% of adults) having uncontrolled blood pressure. More than half a million deaths in 2019 were from high blood pressure as a primary or contributing factor.11
Patients with a healthy mouth tend to respond to medication treatment better than patients with periodontal disease. Blood pressure medications can cause swelling of the lips, altered taste (including a metallic taste), oral lesions (commonly a lichenoid reaction), gingival overgrowth, and xerostomia.12 While blood pressure medications cause oral symptoms of their own; certain medications can also cause high blood pressure. Common medications include birth control, medication for colds and decongestants, pain relievers, antidepressants, nicotine, migraine, corticosteroids, immunosuppressants, and hormones.
Blood pressure should be taken during appointments to avoid a medical emergency. If it’s too high, the patient should be referred immediately to a medical professional in lieu of dental treatment.
Dental concerns are a risk of a heart attack and caution with epinephrine-contained anesthetic as it can temporarily raise blood pressure. Diligent home care is essential with the topical protocol of removing bacteria to lower oral infection. Keeping plaque to a minimum also reduces certain bacteria from entering the bloodstream. Fluoride use is beneficial, and xerostomia maintenance is imperative for oral health.
High triglycerides and oral health ─ Triglycerides are a type of fat in the blood. When the triglycerides are high enough, the fat sticks to the artery walls and causes hardening and narrowing of the blood vessels (atherosclerotic cardiovascular disease). When this happens, it limits blood flow that carries oxygen and nutrients to vital organs, and it can cause blood clots, heart disease, and strokes. When triglycerides are high, it’s usually a relation to obesity or diabetes. Effects of this usually take time (often years) to accumulate for a consequence.
Treatment is healthier eating, managing weight, controlling blood pressure and diabetes, and exercise. If that doesn’t work, then medications such as statins are prescribed. Statins are prescribed to lower the risk of cardiovascular disease by altering cholesterol in the arteries, by either stopping the production of cholesterol or reabsorbing existing cholesterol. An important side effect in the case of metabolic syndrome is that statins possibly increase the risk of blood sugars in type 2 diabetes.13
Statins can be just as beneficial to the mouth as they can be a nuisance. With statins as a systemic anti-inflammatory, it can be beneficial in reducing gingival inflammation. Statins can be beneficial against bone loss as they enhance osteoblasts and suppress osteoclasts resulting in bone growth. Be aware this can be a crucial interference with orthodontics or a favorable contribution to periodontal disease.7 They also affect odontoblast differentiation and dentin formation, resulting in dental pulp calcification and a decrease in pulp chamber height, which leads to challenging endodontic therapy.
Oral health issues are not directly related to high triglycerides but to the treatment of medications such as statins. Common oral effects are difficulty swallowing, swelling of the lips or tongue, xerostomia, and halitosis.
Metabolic Syndrome in Children and Adolescence
Metabolic syndrome is becoming prevalent in children and adolescence as they are substantially incurring adult health diseases. The main conditions in this age group are obesity and type 2 diabetes. With these two comorbidities as the main actors, it increases cardiovascular risks as children become adults.
With the rising concerns of obesity and poor health in 19.3% of children and adolescents, screenings are recommended at an early age when the youth is obese, and there is a family history of obesity and/or diabetes. Obese youth include a staggering 13.4% of 2- to 5-year-olds, 20.3% of 6- to 11-year-olds, and 21.2% among 12- to 19-year-olds.4
Metabolic Syndrome Symptoms
There are no physical symptoms for metabolic syndrome per se, but medical problems develop with time. Many people may not recognize they have high blood pressure, cholesterol, or blood sugars until lab work or tests are done. A visible sign is obesity which can be a concern for the other possible conditions.
When reviewing the health history, it may be easy to determine a patient has metabolic syndrome, whether they know it by that name or not, but through their list of medications.
Metabolic Syndrome Treatment
Much of this is preventable through lifestyle habits. Initial treatment with all these conditions is to induce weight reduction, a healthy diet, physical activity, lifestyle modifications, and management of various disease-specific components. Secondary treatment is usually with medications for the full purpose of lowering the risk of a heart attack and diabetes.1 As well known, medications bring a host of side effects systemically and orally.
Dental Awareness
Metabolic syndrome is, unfortunately, a rising medical issue. Having one metabolic condition increases medical risks; having multiple metabolic conditions increases it greatly. With multiple comorbidities, they are susceptible to many other illnesses. These patients will tend to be polypharmacy patients, which increases more adverse medical risks. It’s more important for this group of medically compromised patients to educate them on stellar home care and to minimize oral bacteria and plaque accumulation.
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References
- Metabolic Syndrome. (2020, July 07). International Diabetes Foundation. https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html
- Robinson, J. (2021, October 27). What Is Metabolic Syndrome? https://www.webmd.com/heart/metabolic-syndrome/metabolic-syndrome-what-is-it
- Metabolic Syndrome. (n.d.). National Heart, Lung and Blood Institute. https://www.nhlbi.nih.gov/health-topics/metabolic-syndrome
- Childhood Obesity Facts. (2021, April 05). Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/childhood.html
- Oral Health & Risk for CV Disease. (2019, July 07). Cleveland Clinic. https://my.clevelandclinic.org/health/articles/11264-oral-health–risk-for-cv-disease
- Holland, K., Ajmera, R., Sharon, A. (2020, July 29). Obesity Facts. Healthline. https://www.healthline.com/health/obesity-facts
- Seidman, L.M., Aichelmann-Reidy, M.B., Bashirelahi, N. (2017, September /October). What Every Dentist Should Know about Statins. General Dentistry. https://agd.org/docs/default-source/self-instruction-(gendent)/gendent_so17_bashirelahi.pdf
- Tremblay, M., Gaudet, D., Brisson, D. Metabolic Syndrome and Oral Markers of Cardiometabolic Risk. Journal of the Canadian Dental Institute. 2011; 77: b125. https://jcda.ca/article/b125
- Prescription Medications to Treat Overweight & Obesity. (2021, June). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity
- National Diabetics Statistic Reports, 2020. (2020, August 28). Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html
- High Blood Pressure. (2021, September 27). Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/facts.htm
- Kumar, P., Mastan, K.M.K., Chowdhary, R., Shanmugan, K. Oral Manifestations in Hypertensive Patients: A Clinical Study. Journal of Oral and Maxillofacial Pathology. 2012; 16(2): 215-221. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424937/
- Arteriosclerosis/atherosclerosis. (2021, March 16). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/arteriosclerosis-atherosclerosis/symptoms-causes/syc-20350569
