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Diabetes and Periodontal Disease The Relation

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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Diabetes and Periodontal Disease The Relation

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