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Diabetes and Periodontal Disease The Relation
 

Diabetes and Periodontal Disease The Relation

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Dr Kaumudi Joshipura explains the relation between Diabetes and Periodontal Disease.Dr Kaumudi presently works at a Dental School at Puerto Rico and is a MPH graduate Harvard School of Public Health.

Dr Kaumudi Joshipura explains the relation between Diabetes and Periodontal Disease.Dr Kaumudi presently works at a Dental School at Puerto Rico and is a MPH graduate Harvard School of Public Health.

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  • The ultimate goal of a clinical periodontal evaluation is to determine the periodontal health status of an individual and to let us quantify the differences between a healthy and a diseased periodontum. And this bring us to the question…
  • This figure ilustrates the difference when probing a healthy sulcus and a periodontal pocket.
  • Here are some examples to ilustrate how this measure is calculated
  • This is how we measure gingival recession and the technique consists of placing the probe’s tip at the gingival crest and measuring the distance to the CEJ so that in this example the measure will be approximately minus 5 mm Some of the causes for gingival recession include:

Diabetes and Periodontal Disease The Relation Diabetes and Periodontal Disease The Relation Presentation Transcript

  • Periodontal Inflammation and Diabetes: a two way relationship
    Kaumudi Joshipura
    BDS, MS, ScD
    Center for Clinical Research and Health Promotion
    School of Dental Medicine
    University of Puerto Rico
    Harvard University
  • Biological Pathways: Periodontal Disease, Systemic Inflammation and Cardiometabolic Conditions
    Common Risk Factors
    Age
    Smoking
    Obesity, Diabetes
    Physical Activity
    Genetics
    Race
    Alcohol
    Comorbidity
    Medications
    Fluoride
    Microbes
    Access to Care
    Periodontitis
    Caries
    Toothloss
    Systemic Inflammation Nutrition (Body Composition,
    (Biomarkers) Dietary intake; Nutritional Status)
    Dyslipidemia
    Arterial Stiffness
    Obesity
    Adverse Pregnancy Outcomes
    Hypertension
    Pre-diabetes
    Atherosclerosis
    Diabetes
    CHD
    PAD
    Stroke
    Gestational
    Diabetes
    Pre-eclampsia
    2
    Kidney Disease
    Cancer
  • Dental Caries
    Cavities are holes or structural damage to the teeth.
    There may be no symptoms, but if present, may include:
    Toothache or painful sensation in the teeth, especially after consuming sweet drinks or hot or cold food
    Risk factors include:
    Poor oral hygiene
    Fermentable carbohydrates
  • It is an infection and inflammation affecting the soft tissues and bone that support the teeth.
    Periodontitis occurs when infection and inflammation of the gums (gingivitis) progresses to involve other surrounding tissues.
    Periodontitis
  • Healthy Gingiva
    Periodontal Disease
  • Pocket Depth
    Healthy gingiva
    Periodontal Pocket
  • Attachment Level
    6mm
    6mm
  • Bone Loss
  • Gingival Recession
    Causes:
    • Periodontal Disease
    • Traumatic tooth cleaning technique
    • Local irritants (plaque or calculus)
    • Orthodontic tipping
    • Provisional crowns
    • Extraction of adjacent teeth
    • Occlusal forces
    9
  • U.S. Adults PeriodontalDiseasePrevalence (≥1 site Pocket Depth ≥4mm)
    NHANES III, 1988-94
    Adapted: Burt and Eklund, 2005
  • U.S. Adults Cumulative Periodontal Disease Severity ≥1siteAttachmentLossbyAge
    NHANES III, 1988-94
    Adapted: Burt and Eklund, 2005
  • Established risk factors
    Microbes
    Age
    Male gender
    Race
    Genetic factors
    Tobacco
    Diabetes
    Malnutrition
    Systemic disease
  • Potential novel risk factors
    Obesity
    Physical activity
    Alcohol
    Calcium
    Vitamin D
    Antioxidants, fiber, other…..
  • Predictors of Periodontal Disease
    These act indirectly through other risk factors:
    Education
    Employment
    Income
    Regular dental visits
    Marital status
    Dental insurance
  • Prognostic factors
    Plaque control
    Triclosan
    Scaling and root planing
    Other professional treatment
  • Impact of Periodontal Disease
    Periodontal Disease
    Bad Breath
    Systemic Diseases
    Systemic Inflammation
    Recession
    Tooth Loss
    Mobility
    Aesthetics
    Root Caries
    Chewing Difficulty
    Diet
    Hypersensitivity
    Pain
  • Biological Pathways: Periodontal Disease, Systemic Inflammation and Insulin Resistance
    Major Common Risk Factors
    Age Physical Activity
    Genetics Diet
    Smoking Obesity
    Periodontal Disease
    Type 2 Diabetes*
    Dyslipidemia (HDL, TG)Adiponectin
    Systemic Inflammation (CRP, Il-6, TNF-∞)
    β-Cell Dysfunction Insulin resistance
    Glucose Abnormalities
    Diabetes
  • Metabolic Syndrome and Periodontitis
  • Components of metabolic syndrome
    Abdominal obesity
    Atherogenic dyslipidemia 
    Hypertension 
    Insulin Resistance/Diabetes
  • Association between Obesity and Periodontitis
  • Studies on Obesity and Periodontitis among older adults
  • Relationship between abdominal obesity and periodontitis in elderly Puerto Ricans
    Puerto Rican Elderly Dental Health Study (PREDHS)
    Representative sample of adults age 70 and older
    San Juan Metropolitan area (N=183)
    Exposures: waist circumference, waist-to-hip ratio
    Outcome: moderate and severe periodontal disease
    Multivariate logistic regression
    Adjusted for age, gender, smoking, education, diabetes status, physical activity, total fruit and vegetable intake.
    Models for moderate and severe periodontitis additionally adjusted for number of teeth.
  • Relationship between obesity and periodontitis in elderly Puerto Ricans
    Multivariate-adjusted
    Moderate: OR=5.63 (1.44; 22.06)
    Severe: OR=1.12 (0.37; 3.41)
    Upper tertile % of sites with AL ≥ 3: OR=3.59 (1.37; 9.41)
    Upper tertile of Mean AL: OR=2.07 (0.84; 5.10)
    Multivariate-adjusted
    Moderate: OR=4.03 (0.92; 17.65)
    Severe: OR=1.98 (0.58; 6.80)
    Upper tertile % of sites with AL ≥ 3: OR=1.99 (0.74; 5.31)
    Upper tertile of Mean AL: OR=2.49 (0.91; 6.77)
    Muñoz, IADR, 2009
  • Association between Dyslipidemia and Periodontitis
  • Periodontitis and Dyslipidemia
    Joshipura et al, JDR 2004
  • Clinical Trial for the Treatment of Periodontitis and Lipids
    Fifty patients (31 females and 19 males, age 36-66 yr) who had ≥ 3 pockets with a PD S:4 mm
    Groups:
    Control: biochemical and periodontal evaluations
    Treatment: periodontal treatment
    Measurements taken at baseline and end of study
    Dental Assessment: PD, PI, GI, AL, BOP
    Biochemical measurments: LDL, HDL, VLDL, TG
    OZ, South Med J, 2007
  • Clinical Trial for the Treatment of Periodontitis and Lipids (cont.)
    Greater reduction of pocket depth and attachment loss in treatment group than in control group (11 % vs. 7% and 24.5% vs. 0%, respectively)
    Treatment Group: Significant reduction of 12.7% in total cholesterol and 25.7% in LDL compared with baseline values.
    Control Group: NS reduction 3.9% in total cholesterol and 2.5% in LDL
    There were also significant differences in total cholesterol and LDL levels between the two groups
    OZ, South Med J, 2007
  • Periodontitis and Diabetes
  • Diabetes and Periodontal Disease
    Oral care report 2001
  • Mechanisms for Diabetes-Perio Relationship
    Altered host response
    Alterations in connective tissue and wound healing
    Microangiopathy
    Alterations in gingival crevicular fluid
    Altered subgingival microflora (composition/virulence)
    Hereditary predisposition
    Taylor 2004 Compendium
  • Literature on Periodontitis and Diabetes
    Over 50 cross-sectional associations. Only few longitudinal studies
    A meta-analysis among type 2 diabetic patients showed an improvement after aggressive periodontal treatment, weighted mean difference of HbA1C before and after therapy of -0.40% (95% CI -0.77 to -0.04%, P = 0.03). Teeuw WJ, et al. Diabetes Care. 2010
    Not clear if A1c improvement due to perio improvement or due to antibiotics
  • Periodontal Disease and Incidence of Type 2 Diabetes Mellitus
    The multivariate Cox RR for periodontitis (comparing moderate/severe vs. none/mild) and type 2 DM
    1.17 (0.97-1.42) in men vs. 1.20 (0.96 -1.50) in women
    Updated Periodontitis
    1.32 (1.15- 1.51) in men
    Tooth loss (≥1 vs. 0 teeth lost during follow-up):
    1.25 (1.12 -1.40) in men vs. 1.14 (1.06 - 1.22) in women
    The associations among men persisted among never smokers.
    Confounders: age, smoking, family history of diabetes, physical activity, body mass index, alcohol, diet (sugar-sweetened soft drinks, fiber, glycemic load and polyunsaturated: saturated fat ratio) and in women-menopause status and post-menopausal hormone use.
    Joshipura, ADA, 2008
  • Periodontal Therapy and Insulin Resistance
    Only one clinical trial among type 2 diabetes patients showed that periodontal therapy was associated with decreased insulin resistance. Talbert J et al. J Dent Hyg. 2006
    Some RCTs showed positive findings; others showed no significant reduction in the level of plasma glucose.
    Inconsistent results from cross-sectional studies
  • Periodontitis as a risk factor for Diabetes
    NHANES I
    Periodontal pockets index 3 vs. Healthy
    OR = 2.26, 95% CI: 1.56-3.27
    Periodontal pocket index 4 vs. Healthy
    OR = 1.71, 95% CI: 1.09-2.69
    Periodontal pocket index 5 vs. Healthy
    OR = 1.50, 95% CI: 0.99-2.27
    Demmer et al., Diabetes Care, 2008
  • Conclusions for Diabetes Periodontitis Association
    The association between periodontitis and type 2 diabetes is potentially bidirectional, but neither direction has been established
    Periodontal treatment including antibiotics could lead to improvement in HbA1c
    Periodontitis is associated with several risks factors for diabetes as well as with diabetes complications
    More well designed longitudinal studies and clinical trials are needed
  • Complications of Diabetes
    Microvascular complications include
    Neuropathy
    Nephropathy
    Vision disorders
    Macrovascular complications include
    Heart disease
    Stroke
    Peripheral vascular disease
    Periodontal disease is also considered a complication of diabetes
  • Complications of Diabetes
    Microvascular complications include
    Neuropathy
    Nephropathy
    Vision disorders
    Macrovascular complications include
    Heart disease
    Stroke
    Peripheral vascular disease
    Periodontal disease is also considered a complication of diabetes
  • Summary of our work in HPFS (Males) and NHS (Females) relating perio and CVD
  • HPFS Multivariate Results
    Joshipura et al, JDR 2004
  • NHS Results
  • Clinical Trials for Biomarkers
    Tonetti et al. NEJM.
    Intensive vs. regular perio care 2-6 months
    Flow-mediated dilation E-Selectin
    D’Aiuto et al. Am Heart J.
    Intensive vs. regular perio care. 2-6 months
    CRP, IL-6, Total Cholesterol and CVD composite scores
  • Percentage of Edentulous Subjects' Dietary Intake
    (Adjusting Age, Smoking and Physical Activity)
    Hung, CDOE, 2005
  • Intake of total fruits and vegetables and risk of Ischemic stroke in the NHS and HPFS
    Joshipura et al., JAMA, 1999
  • Future Directions
    Oral and systemic association
    Additional cohort studies in different populations including developing countries
    Additional systemic outcomes
    Evaluate pathways with exposures, outcomes and mediators in the same models
    Evaluate role of periodontal microorganisms
    Evaluate role of genetic factors
    Clinical trials where feasible
  • Role of Physicians in Oral Health
    • Emphasize prevention of oral disease and retention of teeth.
    • Age-specific advise
    • Annual Routine Physical:
    • Include basic oral exam
    • Oral cancer visual screening
    • Referrals to dentist
    • Systemic Disease, Treatments: Communicate impact on oral health to dentists and patients.
    • Control of diabetes.
    • Nutrition counseling for better oral and general health and recommend prosthesis when needed.
  • Acknowledgements
    Grants:
    R01DE12102
    R01DE017176
    BOHCR – DE1184
    R03DE14004
    Office of Dietary Supplements, Florida Department of Citrus
    K-24 DE016884
    RCMI – G12 RR 03051
    RCMI CRC
    S21MD001830
    Dr. Alberto Ascherio
    Dr. Graham Colditz
    Dr. Constant Crohin
    Dr. Chester Douglass
    Dr. Sue Hankinson
    Dr. Frank Hu
    Dr. Hsin-Chia Hung
    Dr. Anwar Merchant
    Dr. JoAnn Manson
    Dr. Waranuch Pitiphat
    Dr. Eric Rimm
    Dr. Christine Ritchie
    Dr. Frank Speizer
    Dr. Walter Willett
  • Acknowledgements
    SOALS Team:
    Dr. Cynthia Perez
    Jennifer Colon
    Jhezanuel Goncalves
    Gustavo Sanchez
    Kristian Poventud
    Reinaldo Deliz
    Dr. Pedro Hernandez
    Oelisoa Andriankaja
    Dr. Cristina Palacio
    Jose Luis Vergara
    Barbara Guzman
    Laritza Berrios
    Lumarie Cuadrado
    Alberto Carrera
    Dr. Maribel Campos
    PREDHS Team:
    Dr. Maria L. Aguilar
    Michael Brunelle
    Dr. Ana Luisa Dávila
    Jenifer Guadalupe
    MonikJiménez
    Sasha Martínez
    Dr. Mauricio Montero
    Francisco Muñoz
    Vanesza Robles
    Dr. Enrique Santiago
    Jenifer Torres
    Dr. SonaTumanyan
    Yari Valle