LETS TALK ABOUT TEETH BABY…
Suna Kassier MSc, RD (SA) Discipline of Dietetics and Human Nutrition
JUST KIDDING… ACTUALLY TALKING ABOUT…
THE BIG SIX!
COMPLICATIONS OF DIABETES MELLITUS:
• Retinopathy
• Neuropathy
• Nephropathy
• Cardiovascular disease
• Peripheral vascular disease
• No 6
→ periodontal disease!
Thomas et al. 2010; Kidambi & Patel 2008; Moore et al. 2003; Taylor 2001
WHAT IS PERIODONTAL DISEASE?
• One of most common chronic disorders of infectious origin known to man
AND
• One of two major dental diseases that affect humans worldwide
→ Chronic inflammation of soft tissues surrounding teeth (ginginvitis) by bacteria in plaque
→ infiltration by leucocytes that → emission of oxidants, proteases, metabolic byproducts
Deshpande et al. 2010; Thomas et al. 2010; Ritchie 2009; Xiong et al. 2009; Kuo et al. 2008; Poul 2005;Petersen 2003
WHAT IS PERIODONTAL DISEASE? (cont.)
→ destruction of
supporting structures
surrounding teeth:
* periodontal ligament
* alveolar bone
* cementum
* soft tissues (periodontitis)
→ tooth loss
Preshaw et al. 2012; Thomas et al. 2010; Xiong et al. 2009;
Kuo et al. 2008; Poul 2005; Petersen 2003
WHAT IS PERIODONTAL DISEASE ? (cont.)
Stages according to Community Periodontal Index (CPI)
1. gingival bleeding
2. gingival bleeding & calculus
3. shallow periodontal pockets (4-5 mm)
4. deep periodontal pockets (≥ 6 mm)
tooth mobility tooth loss
Preshaw et al. 2012; Thomas et al. 2010; Xiong et al. 2009; Petersen 2003
WHAT CAUSES IT?
- ↓ oral hygiene
- ↓ socioeconomic status
i.e. education & income
- urbanisation e.g. ↑ alcohol, stress
- genetic predisposition
- smoking
- severe vitamin C deficiency & malnutrition
→ depletion of antioxidants &
impaired acute phase response
Preshaw et al. 2012; Thomas et al. 2010; Xioung et al. 2009; Berlin 2008;
Kidambi & Patel 2008;
Lamster et al. 2008; Teeuw et al. 2008; Brownlee 2005; WHO 2005)
WHAT CAUSES IT? (cont.) • Severe oral diseases and non-communicable chronic diseases
→ share common risk factors
• Bidirectional association:
chronic systemic diseases
e.g. CVD, DM, adverse pregnancy outcome
↕
periodontal disease
• Association between periodontal disease and DM
→ most consistent
→ activation of pathways that ↑ inflammation, oxidative stress
Thomas et al. 2010; Xioung et al. 2009; Kidambi & Patel 2008;
Lamster et al. 2008; Teeuw et al. 2008; Brownlee 2005; WHO 2005
SOME STATISTICS…
• WHO declared DM a global epidemic
• Prevalence: 10 - 90% in adults depending on diagnostic criteria
• CPI score 4: 10 % - 15% of adult populations
• CPI score 2: most prevalent score → reflective of poor oral hygiene
Preshaw et al. 2012; Xiong et al. 2009; WHO 2008; Boehm & Scannapieco 2007; Smyth & Heron 2006; Petersen 2003; WHO 2003
RELATIONSHIP: PERIODONTAL DISEASE & DM
• Significant association:
→ DM & severity of periodontal disease
• Type 1 or 2 DM ↑ risk of developing
periodontal disease
BUT
• Periodontal disease may ↑ risk for type 2 DM
and poor glycaemic control
• Relative risk of diabetics developing
periodontal disease 3x higher
• Odds of destructive loss of attachment
3x higher than among non-diabetics
Preshaw et al. 2012; Thomas et al. 2010; Deshpande et al. 2010; Xiong et al. 2009;
Kapp et al. 2007; Taylor et a. 2004; Ryan et al. 2003
RELATIONSHIP:
PERIODONTAL DISEASE & DM (cont.) • Longitudinal survey:
→ level of glycaemic control in diabetics (HbA1c) → associated with: severity of periodontal disease and loss of attachment
• Insulin resistance, vascular changes, altered oral microflora, abnormal collagen metabolism, hyperglycaemia, hyperlipidaemia, altered immune function
→ metabolic alterations that exacerbate bacteria-induced inflammatory periodontitis
Preshaw et al. 2012; Saini et al. 2011; Demmer et al. 2010; Xiong et al. 2009;
Allen et al. 2008; Teeuw et al. 2008
OTHER ORAL COMPLICATIONS OF DM
• ↓ Saliva flow → plaque formation → tooth decay
• Dry mouth (xerostomia)
• Changes in saliva composition
• Taste dysfunction → ↑ detection threshold → inhibits ability to maintain healthy diet
• Oral fungal and bacterial infections e.g. oral thrush due to compromised immune system
• Stomatitis
Al-Maskari et al. 2011; Eldarrat 2011; Chomkhakhai et al. 2009;
Lamster et al. 2008
OTHER ORAL COMPLICATIONS OF DM (cont.)
• Angular cheilitis
• Delayed wound healing of mucosa in oral cavity
• Dental caries
• Burning mouth syndrome
Al-Maskari et al. 2011; Chomkhakhai et al. 2009; Lamster et al. 2008; Southerland et al. 2008
RELATIONSHIP: PERIODONTAL DISEASE & GESTATIONAL DM (GDM)
• Women with GDM
→ ↑ risk of type 2 DM later in life
• Periodontal disease
→ local and host immune responses
→ can cause transient bacteremia
• Viable bacteria & bacterial products from subgingival plaque and pro-inflammatory cytokines from inflamed periodontal tissue
→ enters circulation
→ triggers maternal systemic inflammatory response
Xiong et al. 2009
RELATIONSHIP: PERIODONTAL DISEASE & GDM (cont.)
• Pregnancy itself
→ stressful state with
↑ inflammatory activity
e.g. sustained cytokine levels
→ can result in β-cell destruction
↑ gingival inflammation
↑ insulin resistance
→ exacerbation of preexisting
insulin resistance
→ GDM
Xiong et al. 2009
RELATIONSHIP: PERIODONTAL DISEASE & GDM (cont.)
• Periodontal disease~ ↑ risk of GDM
• Dose-response:
↑ risk of GDM ~ ↑ severity of periodontal disease
• ? Periodontal disease ↔ GDM
• ? Genetic cause
Xiong et al. 2009
RELATIONSHIP: PERIODONTAL DISEASE & CARDIOVASCULAR DISEASE (CVD)
• Periodontal disease: - ↑ cardiovascular morbidity in diabetics • Self reported tooth loss ~ CVD inflammation from poor oral health ~ development of CVD • Cardiorenal mortality 3x higher in diabetics
with severe periodontitis compared to those with no/mild periodontitis
Preshaw et al. 2012; Saini et al. 2011; Li et al. 2010; Demmer et al. 2006; Okoro et al. 2005; Pihlstrom et al. 2005; Saremi et al. 2005
RELATIONSHIP: PERIODONTAL DISEASE & STROKE
• Chronic infections
risk factor for stroke
• Data derived from 51 529 male health professionals (HPF Study)
baseline periodontal disease & tooth loss
~ risk of ischemic stroke
• Stroke shares several etiologic factors with periodontal disease and tooth loss
• NHANES:
periodontal disease ~ risk of ischemic stroke Joshipura et al. 2002; Wu et al. 2000
RELATIONSHIP: PERIODONTAL DISEASE & STROKE
(cont) Mechanism: periodontal microorganisms found in atheromas endotoxin ~ damage endothelial cells periodontal disease production of cytokines, clotting factors contributes to atherosclerosis & thrombosis common genetic factors ~ periodontal disease & cardiovascular disease Joshipura et al. 2002; Wu et al. 2000
RELATIONSHIP: PERIODONTAL DISEASE & RENAL
FAILURE • Incidence of :
(i) macroalbuminuria
(ii) chronic renal failure
2-fold and 3-fold increase
respectively in a
“dose-dependent matter” in
diabetics with severe periodontitis
when compared to those without
Preshaw et al. 2012; Shultis et al. 2007
RELATIONSHIP: PERIODONTAL DISEASE & OBESITY
• Immunologic activity of adipose tissue → secretion of adipokines (e.g. cytokines such as tumor necrosis factor-α) → NB role in development of insulin resistance & periodontal disease → relationship between BMI, waist:hip ratio & periodontal attachment loss, mean pocket depth, mean gingival bleeding index, mean calculus index → longitudinal studies may provide better insights
Preshaw et al. 2012; Ritchie 2000
WHAT DIABETICS SHOULD DO
• Good oral hygiene
• Regular dental check-ups
• Nutritionally balanced diet
→ maintenance of host resistance
& integrity of periodontal tissues
• Smoking cessation
Chesnutt 2010; Thomas et al. 2010
RELATIONSHIP: PERIODONTAL DISEASE & NUTRITION
• ↓ Vitamin C, Zn levels
↑ Cu levels in diabetics with
periodontitis compared to
non-diabetics with periodontitis
• Insufficient evidence
→ supplementation in
adequately nourished
individuals
Thomas et al. 2010; Nevia et al. 2003
SUGAR AND DENTAL HEALTH • So what about sugar? • Causes of dental caries → complex → multifactorial: nutritional status oral hygiene exposure to fluoride dietary habits genetics socioeconomic status general health medication • All fermentable CHO (including cooked starches and sugars in fruits) → ↑ cavity formation
International Food Information Council Foundation 2010; Touger-Decker & van Loveren 2003
SUGAR AND DENTAL HEALTH (cont.) • Plaque bacteria in mouth
→ metabolize CHO component → organic acids
→ ↓plaque ph
→ dissolves tooth structure & enamel
→ tooth decay
• Dietary factors
→ form of food
→ frequency of exposure/consumption
→nutrient composition of diet
→eating sequence
→ salivary flow
→ presence of buffers
→ ORAL HYGIENE!
International Food Information Council Foundation 2010; U. S. Department of Agriculture 2005;
American Dietetic Association 2003; Touger-Decker & van Loveren 2003
WHAT DOES THIS MEAN?
• Controlling sugar consumption does play a role in caries prevention
→ not the most NB aspect → regular tooth brushing with fluoride toothpaste more NB • No reliable relationship → quantity of sugar consumed dental caries • Significant relationship → frequency of consumption dental caries • Recommendation: Moderate use of added sugars and sweets
International Food Information Council Foundation 2010
NHANES III & NHEFS DATA
• National Health and Nutrition Examination Survey (USA)
Longitudinal study (n=12 419) • Relationship: - ↓ dietary vitamin C ~ ↑ risk for periodontal disease - smokers with ↓ vitamin C intake ~ ↑ risk of periodontal disease - dose – response between vitamin C levels and periodontal disease
Centers for Disease Control and Prevention 2012; Nishida et al. 2000
NHANES III & NHEFS DATA (cont.) • HbA1c of > 9%
significantly prevalence of
severe periodontitis in those with DM than without
• Association between baseline
periodontal disease → development type 2 DM
• BMI ≥ 30kg/m²
risk of periodontitis
compared to BMI 18.5 – 24.9kg/m²
• Meta-analysis:
significant association between
obesity and periodontitis
• Adults with physical activity
significantly risk of periodontitis
Chaffee & Weston 2010; Demmer et al. 2008; Al-Zahrani et al. 2003
SHIP STUDY
• 2 923 non-diabetics followed up for 5 years
most advanced
periodontitis at baseline
5x increase in HbA1c
• First study to report that periodontitis predicts progression
of HbA1c in non-diabetics
Demmer et al. 2010
HOW DOES PERIODONTITIS AFFECT EATING ABILITY
• Patients without dentures eat selected soft foods
ease with chewing
ease with swallowing
deprived of benefits
of eating healthy food
Eldarrat 2011
PREVENTION • ↓ Level of knowledge r.e. oral health among diabetics vs. non-diabetics • Irregular dental visits ~ poor metabolic control & organ complications • Poor metabolic control ~ ↑ risk of periodontal disease • Diabetics with ↑ dental self-efficacy, ↑ tooth brushing , ↓dental plaque → ↓ HbA1c
Eldarratt 2011; Orlando et al. 2010; Dar et al. 2008; Southerland et al. 2008
IN CONCLUSION…
• Diabetics: → education about risk for oral and dental disease and how risk is related to ↓glycaemic control → encouragement to have annual dental check-ups
Eldarrat 2011; Lancet 2009; Demmer et al. 2008
HAVE YOU HUGGED YOUR TOOTHBURSH
TODAY?