Oral Health & Whole Body Wellness: Current Evidence and Future DirectionsProgram contents and goals   • Review the impact ...
Links Between Periodontal Disease and Overall HealthEstablished ConnectionsEndocarditis   • Organic murmurs          – Ant...
•   Obesity           – Affects up to 30% of the US population           – Linked to a number of serious health concerns, ...
•   More frequent recall schedule (3-4 months)          – Morning visits          – Shorter visits   •   Proper home care ...
Treating Patients with Cardiovascular Disease   • Conduct medical history and physical exam   • Identify physical signs an...
Respiratory Disorders   • 2003 review           – Oral colonization by respiratory pathogens plus poor oral hygiene and pe...
Other   • Possible relationships between periodontal disease and        – Prosthetic device infection        – Rheumatoid ...
•   Nurses                  •   Pharmacists   •   In clinical practice           – In the dental office                   ...
– Relationship to systemic diseases          – Treatment          – Prevention   •   Caries          – Cause          – Tr...
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Oral Health


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Oral Health

  1. 1. Oral Health & Whole Body Wellness: Current Evidence and Future DirectionsProgram contents and goals • Review the impact of periodontal disease • Explore current understanding of links between periodontal diseases and overall health • Discuss possible future effects as the oral-systemic link becomes clearer • Address implications for your practiceImpact of Periodontal DiseasePrimary Periodontal Pathogens • About 20 to 25 bacteria have significant impact on periodontal health • Only a few closely associated with periodontitis – Actinobacillus actinomycetemcomitans – Porphyromonas gingivalis – Tannerella forsythia (formerly Bacteroides forsythus) – Treponema denticolaInflammation________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Systemic Effects • As gingivitis or periodontitis is established, the bacterial infection causes an increase in systemic inflammation • May cause problems in distant sites – Carotid artery – Heart valves – Arteries – Lungs – GutImpairment of the Repair Process • Effects of advanced glycation end products (AGEs) on connective tissue – Structural changes by forming cross-links in tissue fibers – Reactions with cellular receptors of advanced glycation end products (RAGEs) – Increased production of inflammatory molecules • Impact of smoking on the repair process
  2. 2. Links Between Periodontal Disease and Overall HealthEstablished ConnectionsEndocarditis • Organic murmurs – Antibiotic prophylaxis if murmur is severe enough • Mitral valve prolapse (MVP) with regurgitationMitral Valve Prolapse • Estimated to affect about 2% of the United States population • Patients with mitral valve regurgitation are at increased risk following dental procedures • Antibiotic prophylaxisBacterial endocarditis • Bacteria in the bloodstream adhere to receptive endocardial surfaces • Most often caused by alpha hemolytic oral streptococci • Can be caused by Actinobacillus actinomycetemcomitansDiabetes and Related Disorders • Diabetes – A metabolic disorder in which the body does not produce or use insulin properly – Affects approximately 7% of people in the United States—almost 21 million – Sixth leading cause of death among Americans • Diabetes – Type 1 diabetes • Insulin is not created at all • Accounts for about 5% to 10% of diabetes cases • Requires daily insulin supplementation – Type 2 diabetes • Insulin is produced, but used ineffectively • Accounts for 90% to 95% of diabetes cases • Occurs most often in people who are overweight • May or may not require medication • Insulin resistance – Common symptom of type 2 diabetes – Insufficient insulin produced by the pancreas, OR – Improper insulin functioning at the cellular level – Sugar is locked out of the cells and builds up in the blood • Production of AGEs • Metabolic syndrome – A set of “abnormalities” involving waist size, weight, blood pressure, lipid levels, and blood glucose levels – Affects about 47 million people in the United States – Associated with increased risk for developing diabetes and cardiovascular disease (CVD) as well as increased mortality from CVD and all causes
  3. 3. • Obesity – Affects up to 30% of the US population – Linked to a number of serious health concerns, including diabetes and periodontal disease (The Three-way Street) • Interaction between obesity, diabetes, and periodontal disease – Fat is an inflammatory tissue, which releases TNFα, C-reactive protein, and other cytokines – Cytokines can lead to insulin resistance and type 2 diabetes – Obesity is a risk factor for both type 2 diabetes and periodontal infection – Diabetes heightens risk for periodontal disease – Inflammation triggered by the proinflammatory cytokines manufactured by fat tissue and produced by gingival infection exacerbates both conditionsPeriodontal Disease and Diabetes • Higher prevalence of tooth loss in people with diabetes – Elevated inflammatory response – Decreased ability to fight infection • Treatment of periodontal disease reduces need for insulin • TNFα and other cytokines may interfere with the action of insulin and glycemic control – Glycated hemoglobin • From the 2000 Surgeon General’s report on Oral Health in America: “… the findings of greater prevalence, severity, or extent of at least one manifestation of periodontal disease in individuals with diabetes is remarkably consistent in the overwhelming majority of studies.” • Almost one third of people with diabetes have severe periodontal disease • Interaction between periodontal disease and diabetes is still being investigatedTreating Patients with Diabetes • If undiagnosed patient presents with signs of diabetes: – Warning signs of diabetes • Frequent urination • Extreme hunger • Unusual thirst • Extreme fatigue • Frequent infection/impaired wound healing • Blurred vision • Unusual weight loss • Sweet-smelling, fruity breath (acetone) – Oral signs of diabetes • Foamy saliva • Unusually dry and irritated tissue • Severe periodontal inflammation • Target glucose levels in type 2 diabetes – Fasting plasma glucose 90 to 130 mg/dL – Postprandial plasma glucose <170 mg/dL • Manage soft tissue inflammation
  4. 4. • More frequent recall schedule (3-4 months) – Morning visits – Shorter visits • Proper home care – Brushing at least twice per day • Power brushing provides more efficient plaque removal – Daily interproximal cleaning — floss, interproximal brush – Rinses and toothpaste that reduce gingivitis • Monitoring blood glucose levelsEmerging ConnectionsCardiovascular Disease (CVD) • Affects >70 million people in the United States • Most common CVDs: heart disease and stroke • Atherosclerosis and resulting CVD are the leading causes of death in the United States • Links between periodontal disease and heart disease and stroke? • Possible cause 1. Excess LDL 2. Inflammatory mediators promote cell division 3. Early atherosclerotic plaque 4. Further plaque growth 5. Plaque rupture and clotting may occur with early plaques 6. Heart attack? 7. Effect of oral bacteria in plaques? Heart Disease • Risk factors associated with heart disease – Hypertension – Hypercholesterolemia – Cigarette smoking – Stress – BMI – High fat, high carbohydrate diets – Diabetes Mellitus Stroke • Two major categories of stroke – Hemorrhagic • Caused by bleeding into the brain • Not associated with periodontal disease – Nonhemorrhagic, or ischemic • Caused by blockage of a blood vessel supplying the brain • Associated with periodontal disease
  5. 5. Treating Patients with Cardiovascular Disease • Conduct medical history and physical exam • Identify physical signs and symptoms of cardiac dysfunction – Craniofacial pain may be the only symptom of CVD • Evaluate vital signs – Take blood pressure & pulse • Seek medical consultation when indicated • Know concomitant medications • Be aware of conditions requiring antibiotic prophylaxisPreterm Birth and Low Birth Weight • Preterm birth (<37 weeks) – Nearly 1 in 8 (12.5%) in the United States – Inflammation due to infections thought to account for 30% to 50% of all premature deliveries • Low birth weight (<2500 g) – More than 8% of babies in the United States • Possible link – Inflammatory mediators secrete PGE2 and TNFα – May cause the maternal immune system to release chemicals that may foster premature labor – Periodontal bacterial products may impact fetal growthTreating Healthy Pregnant Patients • Help protect the developing baby • Help treat or prevent – Pregnancy gingivitis – Pyogenic granulomas (pregnancy tumor) • Educate new mothers about the transmissibility of Streptococcus mutans and the relationship with caries • Counsel about smoking cessationTreating Pregnant Patients with Periodontal Disease • Diagnose and evaluate periodontal condition • Assess medical status • Educate – Potential impact of periodontal infection on pregnancy – Treatment options • Consult with healthcare providers • Remember pregnancy considerations • Provide periodontal therapy • Motivate to maintain periodontal health • Avoid local delivery agents that contain tetracyclines or derivatives
  6. 6. Respiratory Disorders • 2003 review – Oral colonization by respiratory pathogens plus poor oral hygiene and periodontal diseases may be related to nosocomial pneumonia – Possible associations between periodontal disease and chronic obstructive pulmonary disease (COPD) • Periodontal disease does not directly cause respiratory illness • Periodontal pathogens found in cadaver lung tissue • Respiratory pathogens may be harbored in dental biofilm and on ventilation tubingOsteoporosis • Associated with significant periodontal bone loss • May be associated with more rapid breakdown of alveolar bone • Possible relationships between cytokines and lower bone qualityAging • Effects of aging on health – Reduced ability to fight infection – Loss of manual dexterity – Possible tooth loss (not directly caused by aging) and associated difficulty or pain on eating – Possible loss of appetite – Possible malnutrition – Decreased salivary flow – Increased medication requirements • Possible medication side effects, including xerostomia and drug- influenced gingival enlargements • Periodontal disease and aging – No causal relationship – Possible benefits of vigilant oral care • Slowing orally associated aging processes • Maintenance of appropriate nutritional intake • Oral health education is essential • Maintaining quality of lifeImpaired Renal Function • Recently identified associations – Periodontal pocketing (8 or more sites with PD >4mm) with increased odds for elevated serum creatinine – High serum antibodies to periodontal bacteria with impaired glomerular filtration rate – Periodontal disease in end stage renal disease (ESRD) with elevated C-reactive protein and more severe carotid atherosclerosis – Severe periodontitis in ESRD with low serum albumin
  7. 7. Other • Possible relationships between periodontal disease and – Prosthetic device infection – Rheumatoid arthritis – Brain abscesses – Pancreatic cancerOdds Ratios________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Research Challenges • Challenges to proving oral-systemic links – Complex etiologies of most diseases – Difficult to design well-controlled trials • Interventional randomized controlled trials are best—but expensive • Criteria to establish causal relationship – Biologic plausibility – Specificity of association – Strength of association – Dose-response effect – Temporal consistency – Consistency of findings__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Possible Future Directions • As the importance of the oral-systemic link becomes universally accepted, this information will change decisions in several arenas: – In dental and medical schools – In clinical practice – In research areas and funding – In insurance coverage • In dental and medical schools – Joint training of dentists and physicians, dental hygienists and assistants, and nurses – More systemic disease training for dentists and more oral health training for physicians and nurses – Early training stressing a unified primary care team • Dentists • Dental hygienists and assistants • Physicians
  8. 8. • Nurses • Pharmacists • In clinical practice – In the dental office • A more holistic view of patient health information • An active role in primary prevention of some systemic diseases – In the medical office • Increased appreciation of dental professionals as essential members of the healthcare team • Earlier referral for dental care in the face of systemic disease aimed at reducing inflammation • In research – Continued trial design modification to • Gather more evidence in support of oral-systemic links • Determine the mechanism of action of identified links • Examine the role of genetics • Validate the impact of intervention • Explore new interventions directed at the inflammatory response • Determine appropriate diagnosis and treatment guidelines • In insurance: increased coverage – Greater focus on oral health and the role in systemic diseases – Expansion of coverage to include oral health maintenance • Additional regular deep cleaning and periodontal maintenance for people with other health conditions • Implants to replace missing teeth • Increased coverage for adult fluoride treatments • Expanded sealant use for children and adults • Medically necessary dental treatmentPractice Implications • Emphasize the importance of oral health to overall well-being • Reducing inflammatory burden • Recognize systemic signs and symptoms and be prepared to refer patients to a physician • Clearer links between oral health and systemic health may necessitate practice adjustments for – People with diabetes – Pregnant women – Patients at risk for cardiovascular disease – Elderly patients • All patients should be screened for periodontal disease • Emphasize the importance of oral health to overall well-being: oral hygiene can provide a means to reduce the infectious and inflammatory burden for the patients • Recognize systemic signs and symptoms and be prepared to refer patients to physiciansPatient Education • Periodontal disease – Cause
  9. 9. – Relationship to systemic diseases – Treatment – Prevention • Caries – Cause – Treatment – Prevention – Transmissibility • The basis of oral health is good oral hygiene • A variety of interventions are available to fight against oral infection and inflammationMethods of Intervention • Mechanical plaque removal – Toothbrushing • Soft, well-designed toothbrush proven to remove plaque – Powered toothbrushes • Rotation-oscillation action provides significant, but modest, reduction in plaque and gingivitis compared with manual toothbrushes • Mechanical plaque removal – Interproximal cleaning • Floss helps to remove plaque between teeth and below gumline • Select floss that slides easily between teeth to prevent “snapping” into gumline – Other interproximal cleaning aids are available: • Interproximal/interdental brushes • Floss threaders/superfloss • Floss holders • Rubber-tip stimulators • Chemical plaque removal/reduction: Toothpaste – Should contain fluoride to prevent against caries • Stannous fluoride, sodium fluoride, sodium MFP – May contain ingredients countering gingivitis and/or sensitivity • Stannous fluoride, potassium nitrate, triclosan – May contain ingredients for cosmetic benefits against tartar and extrinsic staining • Sodium hexametaphosphate, pyrophosphate • Chemical plaque removal/reduction: Rinses – May contain ingredients countering plaque and gingivitis • CPC (cetylpyridinium chloride), essential oils, stannous fluoride – May contain ingredients to prevent caries • Sodium fluoride, stannous fluoride – May contain ingredients to whiten teeth or prevent extrinsic stain • Sodium hexametaphosphate, hydrogen peroxide – Consider alcohol-free formulations (Crest Pro-Health®)