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It has been recognized that oral infection, especially periodontitis, may affect the course and pathogenesis of a number of systemic diseases, such as cardiovascular disease, bacterial pneumonia, diabetes mellitus, and low birth weight.

Three mechanisms or pathways linking oral infections to secondary systemic effects have been proposed: 
(i) metastatic spread of infection from the oral cavity as a result of transient bacteremia, 
(ii) metastatic injury from the effects of circulating oral microbial toxins, and 
(iii) metastatic inflammation caused by immunological injury induced by oral microorganisms. Periodontitis as a major oral infection may affect the host's susceptibility to systemic disease in three ways: by shared risk factors; subgingival biofilms acting as reservoirs of gram- negative bacteria; and the periodontium acting as a reservoir of inflammatory mediators.

The theory of focal infection, which was promulgated during the 19th and early 20the centuries, stated that “foci” of sepsis were responsible for the initiation and progression of a variety of inflammatory diseases such as arthritis, peptic ulcers, and appendicitis . In the oral cavity, therapeutic edentulation was common as a result of the popularity of the focal infection theory. Since many teeth were extracted without evidence of infection, thereby providing no relief of symptoms, the theory was discredited and largely ignored for many years. Recent progress in classification and identification of oral microorganisms and the realization that certain microorganisms are normally found only in the oral cavity have opened the way for a more realistic assessment of the importance of oral focal infection. It has become increasingly clear that the oral cavity can act as the site of origin for dissemination of pathogenic organisms to distant body sites, especially in immunocompromised hosts such as patients suffering from malignancies, diabetes, or rheumatoid arthritis or having corticosteroid or other immunosuppressive treatment. A number of epidemiological studies have suggested that oral infection, especially marginal and apical periodontitis, may be a risk factor for systemic diseases.

The teeth are the only nonshedding surfaces in the body, and bacterial levels can reach more than 1011 microorganisms per mg of dental plaque. Human endodontal and periodontal infections are associated with complex microfloras in which approximately 200 species (in apical periodontitis) and more than 500 species (in marginal periodontitis) have been encountered. These infections are predominantly anaerobic, with gram-negative rods being the most common isolates. The anatomic closeness of these microfloras to the bloodstream can facilitate bacteremia and systemic spread of bacterial products, components, and immunocomplexes.

The link between dental diseases and a wide range of systemic medical conditions has recently acquired increased attention. Periodontal disease, in particular, has been implicated as a marker of cardiac disease. Dental caries, the most common oral infection, should be considered as a potential risk factor for all systemic diseases. Few studies have investigated this association. To investigate the potential relationship between dental caries activity, dental plaque levels and presence of mutans streptococci (Ms) in saliva (independent variables) and coronary heart disease (CHD) severity .



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