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Looking for the future today
 

Looking for the future today

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  • Are you saying that it could be either or that we don’t know?
  • What are you trying to say about the connection here.
  • No evidence to prove a causative relationship
  • These are upper numbers. As a rule of thumb if you are in the sulcus or beyond the apex, you have bacteremia
  • These are intervetion studies. They did something to try to stop the effect.
  • These are intervetion studies. They did something to try to stop the effect.
  • People with poorly controlled diabetes had more periodontal disease than well controlled In a study with Pima Indians, improved periodontal disease correlated with better glucose control We know that effective interventions promote multiple good outcomes Improved A1C promotes multiple good outcomes with reduced CVD, kidney, foot, eye, and oral complications. The challenge is how can we all work together to accomplish this?
  • These are intervetion studies. They did something to try to stop the effect.
  • Some recent studies have demonstrated that people with diabetes and severe periodontal disease have: 6x increased risk of poor glycemic control Higher rates of macrovascular disease - 82% of had 1 or more macrovascular complication (CVD, CVA) (vs 21% w/o) A death rate due to CVD that is 2.3x higher A death rate from nephropathy that is 8.5x higher
  • These are intervetion studies. They did something to try to stop the effect.
  • These are intervetion studies. They did something to try to stop the effect.
  • These are intervetion studies. They did something to try to stop the effect.
  • These are intervetion studies. They did something to try to stop the effect.
  • These are intervetion studies. They did something to try to stop the effect.
  • Endothelial dysfunction is a marker for arterialsclerosis. Treatment will reduce endothelial dysfunction long term. These two studies gives an indication of a possible relationship. Cannot generalize. It MAY have an effect in a subgroup of patients. iF it was me, I would have the treatment just in case I am in the sub-group.
  • HT hydroxy tryptamine What is Calicum Channle Blockers, Methyldopa, ACEInhibitors?
  • HT hydroxy tryptamine What is Cyclosporin A
  • HT hydroxy tryptamine
  • Remind me of what celiac disease is
  • What am I looking at here?
  • Glossitis – smooth tongue
  • Perio??? Absecess

Looking for the future today Looking for the future today Presentation Transcript

  • The Complexity of Oral Health and Its Systemic Impact National Health Care for the Homeless Council Friday, June 13, 2008 Wayne W. Cottam DMD, MS Associate Dean for Community Partnerships Arizona School of Dentistry & Oral Health Mesa, AZ [email_address]
  • Roger W. Cooper DDS, PhD Director: Periodontics Arizona School of Dentistry & Oral Health Michael Glick, D.M.D. Professor of Oral Medicine Arizona School of Dentistry & Oral Health Associate Dean for Oral-Medical Sciences College of Osteopathic Medicine – Mesa Mesa, AZ Most of the slides and information for this presentation was developed and is being used with permission by:
    • What we know for sure:
    • 1.
    • 2.
    • 3.
    • 4.
    • 5.
    The Oral-Systemic Connection
    • What we are pretty sure we know for sure:
      • Oral health is essential to the general health and well-being of all Americans and can be achieved.
      • Oral diseases and disorders affect health and well-being throughout life.
      • There IS a connection
    The Oral-Systemic Connection Oral Health in America: A Report of the Surgeon General - DHHS 2000
  • CASUAL Oral Health and Systemic Health – what type of an association? “ But let us inquire what are the causes of these things which happened to them.” Hippocrates
  • Oral Health and Systemic Health – what type of an association? CAUSAL “ But let us inquire what are the causes of these things which happened to them.” Hippocrates
  • Recent Research into Oral Disease and Systemic Health
    • Renal disease
    • COPD
    • Lung cancer
    • Pancreatic cancer
    • Diabetes mellitus
    • PVD
    • Stroke
    • CHD
    • Pre-eclampsia
    • Pre-term and low birth weight
    • Oral infections may cause or exacerbate systemic illness.
    • BUT HOW??
    The Oral-Systemic Connection
  • The Focal Infection Theory
    • “ A focal infection is a localized or general infection caused by the dissemination of microorganisms or toxic products from a focus of infection.”
    Pallasch and Wahl. CDA 2000;28:194
  • The Focal Infection Theory
    • Hippocrates - cure of arthritis by tooth removal
    • Charles H. Mayo (1914) – Mouth infection as a source of systemic disease. JAMA 1914;63:2025-6
    • R.L. Cecile and D.M. Angevine (1938) - “focal infection is a splendid example of a plausible medical theory which is in danger of being converted by its enthusiastic supporters into the status of an accepted fact”
  • Focal Infection Theory
    • Acute rheum.
    • Anemia
    • Angina
    • Appendicitis
    • Arrhythmias
    • Arthritis
    • Asthma
    • Brain abscess
    • Cardiac insufficiency
    • Cholecystitis
    • Chorea
    • Colitis
    • Duodenal ulcers
    • Diabetes
    • Endocarditis
    • Emphysema
    • Goiter
    • Gastric ulcers
    • Herpes zoster
    • Hodgkin disease
    • Hypertension
    • Indigestion
    • Insomnia
    Melancholia Myocarditis Myositis Nephritis Nervous disorders Neuritis Obscure fever Osteomyelitis Pancreatitis Paresthesia Phobias Pneumonia Polio Psychosis Septicemia Skin abscess Spinal myelitis Stupidity Thyroiditis Visceral degeneration
  • Focal Infection Theory
    • Acute rheum.
    • Anemia
    • Angina
    • Appendicitis
    • Arrhythmias
    • Arthritis
    • Asthma
    • Brain abscess
    • Cardiac insufficiency
    • Cholecystitis
    • Chorea
    • Colitis
    • Duodenal ulcers
    • Diabetes
    • Endocarditis
    • Emphysema
    • Goiter
    • Gastric ulcers
    • Herpes zoster
    • Hodgkin disease
    • Hypertension
    • Indigestion
    • Insomnia
    Melancholia Myocarditis Myositis Nephritis Nervous disorders Neuritis Obscure fever Osteomyelitis Pancreatitis Paresthesia Phobias Pneumonia Polio Psychosis Septicemia Skin abscess Spinal myelitis Stupidity Thyroiditis Visceral degeneration
    • Current research focuses on Periodontal Disease (Gum Disease).
    • A bacterially induced chronic inflammatory disease that breaks down tissue and bone.
    • Inflammatory mediators, bacterial lipopolysaccharides and other toxins are introduced systemically.
    • Some mediators stimulate the liver to produce acute phase proteins such as C-reacctive protein and others.
    • These toxins and mediators contribute to a systemic chronic inflammatory state that MAY contribute to other inflammation related diseases including diabetes, CV disease and others.
    The Oral-Systemic Connection
  • Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease Periodontal Inflammation
  • Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Liver C-Reactive Protein Serum Amyloid A Fibrinogen Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Liver C-Reactive Protein Serum Amyloid A Fibrinogen Atherosclerosis Cardiovascular Disease Other Systemic Disease Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Microbes & LPS Liver C-Reactive Protein Serum Amyloid A Fibrinogen Atherosclerosis Cardiovascular Disease Other Systemic Disease Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Microbes & LPS Liver C-Reactive Protein Serum Amyloid A Fibrinogen Atherosclerosis Cardiovascular Disease Other Systemic Disease Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Microbes & LPS Liver C-Reactive Protein Serum Amyloid A Fibrinogen Bacterial induced platelet aggregation & endothelial invasion Atherosclerosis Cardiovascular Disease Other Systemic Disease Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Immune Response Microbes & LPS Microbes Liver C-Reactive Protein Serum Amyloid A Fibrinogen Bacterial induced platelet aggregation & endothelial invasion Atherosclerosis Cardiovascular Disease Other Systemic Disease Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Immune Response Microbes & LPS Microbes Liver Atherosclerosis Cardiovascular Disease Other Systemic Disease C-Reactive Protein Serum Amyloid A Fibrinogen Antibodies to bacteria & cross-reactive antigens, e.g., heat-shock protein. Bacterial induced platelet aggregation & endothelial invasion Possible Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Other Systemic Disease
  • Its all about inflammation and bacteria!
  • Surface Area of Diseased & Ulcerated Pocket Epithelium (Assumption: 6 mm circumferential pockets involving 28 teeth)
  • Periodontitis: The Paradox of Inflammation EGF FGF VGF PDGF TGF-  TGF-  Wound Healing Neutrophils Monocytes Macrophages CD 4 and CD 8 cells Mast Cells Endothelium Fibroblasts IL-1 IL-6 IL-8 TNF-  PGE 2 Chemotaxis: PMNL, M  , CD 4 / 8 cells Induction of acute-phase response Activation of osteoclasts Inhibition of fibroblast growth Inhibition of collagen synthesis Inflammation Biofilm MMPs
  • Incidence of bacteremia
  • Bacteremia associated with daily events
    • Tooth brushing – 15 min x 25 %* = 4 min.
    • Mastication – 3 x 15 min. x 38 %* = 17 min.
    • Random – 24 x 60 min x 11%* = 158 min
    • Physiologic bacteremia / month = 5,370 min
    • Extraction – 15 min x 73 %* = 11 min
    * Positive blood culture after the event Guntheroth WG. Am J Cardiol 1984;54:797
  • Periodontal Disease and Diabetes
    • Recent research suggests a two-way connection between diabetes and periodontal disease.
    • Not only are people with diabetes more susceptible to periodontal disease, but the presence of periodontal disease may also make glycemic control more difficult.
    Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007
  • Periodontal Disease and Diabetes
    • People with diabetes are two to three times more likely than persons without diabetes to have periodontal disease.
    • Periodontal disease is more prevalent, progresses more rapidly and is often more severe in individuals with both type 1 and type 2 diabetes.
    Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007
  • Control of Glucose Matters in Oral Health
    • People with poor glycemic control had more periodontal disease and more severe periodontal disease than well controlled
    • In a study with Pima Indians, improved periodontal disease correlated with better glucose control
    Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007
  • Periodontal Disease and Diabetes
    • How uncontrolled diabetes affects periodontal disease:
    • Decreased neutrophil function - chemotaxis, phagocytosis and bacteriocidal .
    • Presence of advanced glycolated end products which weakens collagen and reduces the ability of gingiva to heal.
    • Less than optimal fibroblast function which impairs healing.
    • How Periodontal infection affects diabetes:
    • Systemic bacterial and viral infections result in increased systemic inflammation which increases insulin resistance and makes it difficult for patients to control blood glucose levels.*
    * Mealey, B. JADA 2006; 137:30S
  • People with diabetes and severe periodontal disease have:
    • 6x increased risk of poor glycemic control
    • 82% of had 1 or more macrovascular complication (CVD, CVA) (vs 21% w/o)
    • Death rate due to CVD= 2.3x higher
    • Death rate from nephropathy= 8.5x
    Working Together to Manage Diabetes – HRSA; National Diabetes Education Program – May 2007
  • Periodontal Disease and Pregnancy “ Most of the clinical studies indicate a positive correlation between periodontal disease and preterm birth. Recent studies also have shown that there are microbiologic and immunological findings that strongly support the association. Furthermore, the cohort studies have demonstrated that the periodontal disease precedes the pregnancy complication and is not a consequence of it ” Bobetsis A. et al JADA 2006;137: 7S
  • Periodontal Disease and Pregnancy
    • The proposed mechanism is similar.
    • Periodontal bacteria induce a local inflammatory response
    • Bacteria, bacterial virulence factors or inflammatory mediators gain systemic access and produce a systemic inflammatory response.
    • These elements reach the placenta and create another inflammatory response.
    • These elements may cross the placenta and enter the fetal circulation and trigger a new fetal-host immune response.
    Bobetsis A. et al JADA 2006;137: 7S
  • Treatment of periodontal disease and the risk of preterm birth
    • Preterm birth – 12.0% of 407 women in the treatment group. 12.8% of 406 women in the control group.
    Conclusion – “Treatment of periodontitis in pregnant women improves periodontal disease and it is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction.” N Engl J Med 2006;355:1885-64
  • Treatment of periodontal disease and the risk of preterm birth
    • “… there is insufficient evidence at this time for health care policy recommendations to provide maternal periodontal treatments for the purpose of reducing the risk of adverse pregnancy outcomes.”
    Bobetsis A. et al JADA 2006;137: 7S
  • Treatment of periodontal disease and the risk of preterm birth
    • Treatment of periodontal disease MAY improve pregnancy outcomes in a sub-group of patients.
    • Since treatment is safe and has no adverse outcomes, most recommend appropriate periodontal treatment for pregnant women.
  • Periodontal Disease and Heart Disease Common Risk Factors For Heart Disease Hypertension Diabetes Obesity Family Hx of Heart Disease Sedentary Life Style Excessive Alcohol Intake Smoking Chronic Periodontal Disease ?
  • Model for Relationship Between Periodontal Inflammation, Atherosclerosis, Cardiovascular and Cerebrovascular Disease Bacteremia Periodontal Inflammation Inflammatory Mediators IL-1, IL-6, TNF-  , PGE 2 Immune Response Microbes & LPS Microbes Liver Atherosclerosis Cardiovascular Disease Cerebrovascular Disease C-Reactive Protein Serum Amyloid A Fibrinogen Antibodies to bacteria & cross-reactive antigens, e.g., heat-shock protein. Bacterial induced platelet aggregation & endothelial invasion
  • Inflammatory Periodontal Disease ?
  • Gradient Relationship Between Incidence (%) of Total CHD and Level of Alveolar Bone Loss Age-adjusted level of bone loss Beck J, et al. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-1137. % Incidence CVD
  • Treatment of periodontitis and endothelial function
    • Treatment – 56 patients to community-based periodontal care. 58 patients to intensive periodontal treatment.
    Conclusion – “Intensive periodontal treatment resulted in acute, short-term systemic inflammation and endothelial dysfunction. However, 6 months after therapy, the benefits in oral health were associated with improvement in endothelial function.” N Engl J Med 2007;356:911-20
  • Periodontal Disease and HIV
      • HIV, being a T-Cell mediated condition is characterized more by viral, fungal, parasite and opportunistic cancers than bacterial infections. Therefore the bacterially induced chronic inflammation cycle is not seen as often.
      • It has been postulated that there may be some opportunistic bacterial periodontal conditions such as Necrotizing Ulcerative Periodontitis associated with HIV but the evidence is not clear.
      • HART drugs reduce salivation, resulting in dry mouth and
      • an increase in decay.
  •  
  • Immune suppression and oral lesions 0 100 300 200 400 500 + atrophic candidiasis CD4 cells/mm 3 Time
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time pseudomembranous candidiasis
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time oral hairy leukoplakia
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time necrotizing ulcerative gingivitis
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time necrotizing ulcerative periodontitis
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time necrotizing stomatitis
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time hypertrophic candidiasis
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time Kaposi’s sarcoma
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time major ulcers
  • Immune suppression and oral lesions 0 100 300 200 400 500 + CD4 cells/mm 3 Time CMV ulcers
    • Questions YOU had before coming here?
    • How can I assist my patient in managing their diabetes through improved oral health?
    • How does periodontitis affect the pregnant patient, fetus and newborn’s health.
    • What precautions do I need to take for my patients upcoming surgery?
    • What periodontal regimen is relevant for optimum health in my HIV patient.
    The Oral-Systemic Connection
  • Its all about inflammation and bacteria … Stupid!
    • What should YOU do?
    • Identify periodontal disease.
    • Check tooth mobility
    • Educate about periodontal disease.
    • Refer for periodontal disease.
    • Work with oral health colleagues to treat periodontal disease.
    The Oral-Systemic Connection
  • The Healthy Periodontium
  •  
  • With HEALTH the alveolar crest is 1.5 to 2 mm from CEJ With PERIODONTITIS (attachment loss), the distance from the CEJ to the alveolar bone is increased (> 2 mm)
  •  
  • Periodontal diseases
  •  
  •  
  •  
  •  
  • Amount of clinical attachment loss (CAL) determines diagnosis
  • Severe (Advanced) Periodontitis
    • Inflammation
    • Gingival form changes
    • Increased sulcus depth
    • Clinical attachment levels 5 mm or greater
    • Severe bone resorption
  •  
  • The Oral-Systemic Connection
    • Treatment of systemic illness may affect oral health
  • Treatment of systemic diseases may affect dental care
    • Hypertension – gingival overgrowth (CCB), ulcerations (methyldopa), lichenoid reactions (ACEI), oral dryness (diuretics)
  • Treatment of systemic diseases may affect dental care
    • Hypertension – gingival overgrowth (CCB), ulcerations (methyldopa), lichenoid reactions (ACEI), oral dryness (diuretics)
    • Immune suppression – gingival overgrowth (CSA), opportunistic viral and fungal infections
  • Treatment of systemic diseases may affect dental care
    • Hypertension – gingival overgrowth (CCB), ulcerations (methyldopa), lichenoid reactions (ACEI), oral dryness (diuretics)
    • Immune suppression – gingival overgrowth (CSA), opportunistic viral and fungal infections
    • Chemotherapy – mucositis, intraoral bleeding, ulcerations
  • The Oral-Systemic Connection
    • Oral signs are sometimes markers for systemic disease
  • Gingival overgrowth
  • Lupus erythematosus
  • Celiac disease
  • Folic acid deficiency
  • Folic acid deficiency
  • Leukemia
  • Diabetes Mellitus
  • Diabetes Mellitus
  • Thank you for your attention.