UAB GECUAB GECFaculty Scholars ProgramFaculty Scholars Program

Lillian M. Mitchell, DDS, FACPLillian M. Mitchell, DDS, FACPUAB School of DentistryUAB School of Dentistry

Director, Geriatric DentistryDirector, Geriatric Dentistry2009 UAB Geriatric Education Center Faculty 2009 UAB Geriatric Education Center Faculty

ScholarScholarMay 30, 2014May 30, 2014

Oral/Systemic Links:Oral/Systemic Links:Critical Health Issues Critical Health Issues for the Complex Older for the Complex Older

AdultAdult

Oral Health is vitally Oral Health is vitally important-important-especially in the older adultespecially in the older adult• Mouth is beginning of the digestive Mouth is beginning of the digestive

tracttract• Portal for all foods and nutrients to Portal for all foods and nutrients to

sustain lifesustain life• Critical to the prevention of chronic Critical to the prevention of chronic

and acute illnessesand acute illnesses• Direct link to overall health and quality Direct link to overall health and quality

of lifeof life• Decreases overall health expendituresDecreases overall health expenditures

Overview: Overview: Impact of Periodontal Disease on Impact of Periodontal Disease on CVD, Diabetes, other systemic CVD, Diabetes, other systemic issues issues • Periodontal disease:Periodontal disease:

• Impacts CV risk factorsImpacts CV risk factors

• Linked to development of arterial diseaseLinked to development of arterial disease

• PD linked to cardiovascular eventsPD linked to cardiovascular events

• PD treatment affects CVDPD treatment affects CVD

• PD linked to Diabetes mellitusPD linked to Diabetes mellitus

• PD linked to Respiratory diseasePD linked to Respiratory disease

• PD linked to arthritis and osteoporosisPD linked to arthritis and osteoporosis

What do we know?What do we know?

• Our population is living longer Our population is living longer

• Living with chronic diseasesLiving with chronic diseases

Chronic DiseasesChronic DiseasesLeading cause of Death & Disability in Leading cause of Death & Disability in USUS •7 out of 10 deaths among Americans 7 out of 10 deaths among Americans

•Heart disease, cancer, stroke – more thanHeart disease, cancer, stroke – more than

50% of all deaths each year50% of all deaths each year

•1 in every 3 adults is obese1 in every 3 adults is obese

•Arthritis - most common cause of disabilityArthritis - most common cause of disability

•One quarter of those with chronic conditions are limited One quarter of those with chronic conditions are limited in daily activitiesin daily activities

•Diabetes-leading cause of kidney failure, non-traumatic Diabetes-leading cause of kidney failure, non-traumatic lower extremity amputations, blindnesslower extremity amputations, blindness

Trends in population:Trends in population:

• People are living longerPeople are living longer• Most older adults are community dwellingMost older adults are community dwelling• Between 2000 and 2050:Between 2000 and 2050: 65+ pop. grows from 12.43% to 20.65%65+ pop. grows from 12.43% to 20.65% 85+ pop. grows from 1.51% to 4.97%85+ pop. grows from 1.51% to 4.97%

One quarter of the population will be One quarter of the population will be over the age of 65 by 2050!over the age of 65 by 2050!

(36 years from now)(36 years from now)

P.Glassman, P.Subar. Journal of Public Health Dentistry, 2010P.Glassman, P.Subar. Journal of Public Health Dentistry, 2010

Changing DemographicsChanging Demographics• Average life expectancy has increasedAverage life expectancy has increased

approximately 3 decades since early 1900’sapproximately 3 decades since early 1900’s

• Avg American Avg American malemale today will live to be today will live to be 7676 yrs old yrs old

• Avg American Avg American womanwoman today will live to be today will live to be 8181 yrs old yrs old

• Women represent the larger portion of the 65+ and Women represent the larger portion of the 65+ and 85+ age group85+ age group

• The 85+ group is the fastest growing segment of the The 85+ group is the fastest growing segment of the US populationUS population

Oral health <> General Oral health <> General healthhealth

Connected-cannot be Connected-cannot be separatedseparated

Four Common Causes of Four Common Causes of Chronic DiseaseChronic Disease

four four modifiablemodifiable health risk health risk behaviorsbehaviors

• Lack of Lack of physical physical activityactivity

• Poor nutritionPoor nutrition

• Tobacco useTobacco use

• Excessive Excessive alcohol alcohol consumptionconsumption

Lack of Physical ActivityLack of Physical Activity

• 1/3 adults do not meet 1/3 adults do not meet recommendations for aerobic recommendations for aerobic physical activityphysical activity

• In a 2008 survey, 23% of adults In a 2008 survey, 23% of adults reported reported no leisure-time physical no leisure-time physical activity at all in the activity at all in the preceding monthpreceding month

Poor NutritionPoor Nutrition

• Only 24% of adults reported eating 5 Only 24% of adults reported eating 5 or more servings of fruits and vegs or more servings of fruits and vegs per dayper day

• Less than 22% high school studentsLess than 22% high school students

Tobacco UseTobacco UseMore than 1 in 5 American adults smokeMore than 1 in 5 American adults smoke

Compared to non-smokers, Compared to non-smokers, womenwomen who smoke who smoke are 13 times more likely to get lung cancerare 13 times more likely to get lung cancer

Smoking causes Smoking causes 80% 80% lung cancer deaths in lung cancer deaths in womenwomen

90% 90% of lung cancer deaths in menof lung cancer deaths in menAlso-larynx, mouth, throat, esophagus, bladder, kidney, Also-larynx, mouth, throat, esophagus, bladder, kidney,

pancreas, stomach, acute myeloid leukemiapancreas, stomach, acute myeloid leukemia

Excessive Alcohol Excessive Alcohol ConsumptionConsumption• Increased risk of breast cancer with Increased risk of breast cancer with

increasing alcohol intake found in more increasing alcohol intake found in more than 100 studiesthan 100 studies

• Drinking alcohol is a risk factor for primary Drinking alcohol is a risk factor for primary liver cancer found in many studiesliver cancer found in many studies

• More than 50 studies report the link More than 50 studies report the link between alcohol consumption and colonbetween alcohol consumption and colon

(colorectal) cancer(colorectal) cancer

World Health OrganizationWorld Health Organization

• ““ElderlyElderly””

Population between 65 and 75 yrsPopulation between 65 and 75 yrs

• ““OldOld””

between 76 and 90 yearsbetween 76 and 90 years

• ““Very oldVery old””

over age 90over age 90

““Very Old TeethVery Old Teeth””100 year old woman100 year old woman

Systemic Conditions at Higher Systemic Conditions at Higher Risk in an Older PopulationRisk in an Older Population

• ArthritisArthritis• CancerCancer• COPDCOPD• DiabetesDiabetes• Cardiovascular diseaseCardiovascular disease• HypertensionHypertension• Mental Health conditionsMental Health conditions• OsteoporosisOsteoporosis• Parkinson diseaseParkinson disease• StrokeStroke• Sensory deficitsSensory deficits

Oral Conditions at Higher Risk Oral Conditions at Higher Risk in an Older Patient Populationin an Older Patient Population

• CariesCaries

• Periodontal DiseasePeriodontal Disease

• Traumatic InjuriesTraumatic Injuries

• Cancers of the Head and NeckCancers of the Head and Neck

• Oral Mucosal LesionsOral Mucosal Lesions

• Oral Manifestations of Systemic Oral Manifestations of Systemic DiseasesDiseases

Elderly adults are retaining Elderly adults are retaining their teeth longertheir teeth longer

• Must evaluate the Must evaluate the patientpatient’’s oral health in s oral health in context withcontext with

• Social, cultural, Social, cultural, educational, educational, economic,economic,

psychological, andpsychological, and

dietary life dietary life experiences experiences

• Quality of Life!Quality of Life!

Common Findings in Common Findings in Geriatric Medicine/DentistryGeriatric Medicine/Dentistry

High prevalence of chronic diseaseHigh prevalence of chronic diseaseFrequent use of medicationsFrequent use of medications

Difficulty in getting complete historyDifficulty in getting complete historyDifficult to obtain appropriate consultsDifficult to obtain appropriate consults

Why is Oral Health Why is Oral Health Important for theImportant for the

Older Adult? Older Adult?

• Affects the ability to consume and Affects the ability to consume and enjoy an adequate dietenjoy an adequate diet

• Can affect body weightCan affect body weight

• Impacts nutritional and systemic Impacts nutritional and systemic healthhealth

• Links between Periodontal disease and Links between Periodontal disease and Cardiac health; respiratory conditions; Cardiac health; respiratory conditions; diabetes mellitus; strokediabetes mellitus; stroke

What is more important?What is more important?

• Chronological ageChronological age

• Functional statusFunctional status

Functional status in Functional status in dentistrydentistry

Ability to travel for care and Ability to travel for care and

seek servicesseek services

Ettinger, RL. Oral Health and the Aging Population. JADA 2007;138(suppl_1)5S-6S

Functional Definition of Functional Definition of Older AdultsOlder Adults

• Functionally independent older adultsFunctionally independent older adults

• Frail older adultsFrail older adults

• Functionally dependent older adultsFunctionally dependent older adults

• 70% of the elderly population70% of the elderly population

(or 23.2 million older than 65 years)(or 23.2 million older than 65 years)

live in the community and visit the live in the community and visit the dental office independentlydental office independently

Medicare Current Medicare Current Beneficiary SurveyBeneficiary Survey

• Reveals that Reveals that preventive dental preventive dental carecare reduced dental bills and out-of- reduced dental bills and out-of-pocket payments by beneficiariespocket payments by beneficiaries

• They may have more dental They may have more dental

visits, but visits, but pay lesspay less for total dentalfor total dental

care care

Medicare Current Medicare Current Beneficiary SurveyBeneficiary Survey

• Beneficiaries in Beneficiaries in worse overall healthworse overall health status, with more physical and health status, with more physical and health limitations and difficulties with daily limitations and difficulties with daily activities, were concentrated in the group activities, were concentrated in the group that that did not visit a dentist for any did not visit a dentist for any reason!reason!

Moller et al. American Journal of Public Health, November 2010,Moller et al. American Journal of Public Health, November 2010,

Vol 100, No. 11Vol 100, No. 11

Significant barriers exist Significant barriers exist for needed dental care of for needed dental care of

thethe older adult older adult

• People 65+ have more caries (decay) People 65+ have more caries (decay) than than

children living in non-fluoridated areaschildren living in non-fluoridated areas

• Each decade the # of decayed or filled Each decade the # of decayed or filled root surfaces increases affecting root surfaces increases affecting more more than ½than ½ of all remaining teeth by age 75 of all remaining teeth by age 75

• MajorityMajority > older adults > periodontal > older adults > periodontal diseasedisease

BarriersBarriers

• Lack of perceived need for careLack of perceived need for care

• Declines in functional status is Declines in functional status is associated with lower levels of dental associated with lower levels of dental service useservice use

Incidence and Impact ofIncidence and Impact of

Periodontal DiseasePeriodontal Disease• Most older adults are at risk of Most older adults are at risk of

developing PD because they developing PD because they have teeth!!have teeth!!

• 52% have lost fewer than 5 teeth52% have lost fewer than 5 teeth

• Men more serious than womenMen more serious than women

• 26% are edentulous and26% are edentulous and

not at risknot at risk

Incidence of Periodontal Incidence of Periodontal DiseaseDiseaseData reported by CDC-NHANES-2009-Data reported by CDC-NHANES-2009-1010• 50% Americans 50% Americans >> 30 y/o have PD 30 y/o have PD

• 70% Americans > 65 y/o have PD 70% Americans > 65 y/o have PD

PD one of most prevalent chronic diseases,PD one of most prevalent chronic diseases,

Similar to CVD and DMSimilar to CVD and DM

Many patients don’t know they have it!Many patients don’t know they have it!

Published online before print JDR Aug 30, 2012Published online before print JDR Aug 30, 2012

Cardiovascular DiseaseCardiovascular Diseaseno longer a “Man’s” Diseaseno longer a “Man’s” Disease• Cardiovascular disease includes coronary heart Cardiovascular disease includes coronary heart

disease, high blood pressure, strokedisease, high blood pressure, stroke

• Leading cause of death among all American Leading cause of death among all American women~38% of all female deathswomen~38% of all female deaths

• In women 60+ yrs old- deaths are reported at 59% In women 60+ yrs old- deaths are reported at 59% in developed countries from CVDin developed countries from CVD

• Female heart attack victims-60% die suddenly; 46% Female heart attack victims-60% die suddenly; 46% survive-will be disabled by heart failure in 6 yearssurvive-will be disabled by heart failure in 6 years

American Heart Association American Heart Association 2011 US Statistics2011 US Statistics

• Approx 2,200 people die of CVD each Approx 2,200 people die of CVD each dayday

• An average of one death every 39 An average of one death every 39 secondsseconds

• More than 150,000 people <65 yrs old More than 150,000 people <65 yrs old were killed by CVD in 2007were killed by CVD in 2007

• Death occurred well before average life Death occurred well before average life expectancy of 77.9 yearsexpectancy of 77.9 years

Roger,V.L. et.al. Heart disease and stroke statistics-2011 update. Roger,V.L. et.al. Heart disease and stroke statistics-2011 update.

Circulation 12/15/2010Circulation 12/15/2010

Risk Factors for Risk Factors for Cardiovascular DiseaseCardiovascular Disease

• High total High total cholesterolcholesterol

• High triglyceridesHigh triglycerides

• High blood High blood pressurepressure

• Low HDLLow HDL

• SmokingSmoking

• DiabetesDiabetes

• Family historyFamily history

Oral Connections CVDOral Connections CVD

• Side Effects of medicationSide Effects of medication

• Xerostomia (dry mouth; lowers pH)Xerostomia (dry mouth; lowers pH)

• Gingival hyperplasiaGingival hyperplasia

• Taste impairmentTaste impairment

• Periodontal disease and CVDPeriodontal disease and CVD

• Oral bacteriaOral bacteria

• Inflammatory processInflammatory process

GreatestGreatest health threat and killer of health threat and killer of Women and Men is Women and Men is

Cardiovascular DiseaseCardiovascular Disease

• Adults,Adults,

regardless of sex or ethnicity,regardless of sex or ethnicity,

are 2 to 3 times more likely to suffer are 2 to 3 times more likely to suffer

a CV event, fatal or non-fatal,a CV event, fatal or non-fatal,

rather than a non-fatal deathrather than a non-fatal death

Feinstein,M et.al. Circulation July 2012; 126: 50-59Feinstein,M et.al. Circulation July 2012; 126: 50-59

Oral Systemic ConnectionsOral Systemic ConnectionsSAMESAME Inflammatory Inflammatory

MediatorsMediators• Periodontal DiseasePeriodontal Disease

• Coronary heart diseaseCoronary heart disease

• Rheumatoid ArthritisRheumatoid Arthritis

Gene sequence predisposing for CHD also Gene sequence predisposing for CHD also predisposes for periodontal diseasepredisposes for periodontal disease

Oral bacteria were found in the synovial fluid in Oral bacteria were found in the synovial fluid in joints of individuals with RAjoints of individuals with RA

Schaefer AS, et al. PLoS Genet. 2009 Feb:5(2)Schaefer AS, et al. PLoS Genet. 2009 Feb:5(2)

Ogrendik,M. Mod Rheumatol. 2009 Jun 24.Ogrendik,M. Mod Rheumatol. 2009 Jun 24.

AJC-JOP Editors Consensus AJC-JOP Editors Consensus PaperPaperJuly 2009July 2009

Dentistry and Medicine must work together to Dentistry and Medicine must work together to improve patient careimprove patient care

• Confirmed the connection between PD & CVDConfirmed the connection between PD & CVD

• Explained the underlying biologic and Explained the underlying biologic and inflammatory inflammatory mechanisms mechanisms that may be the basis for the connectionthat may be the basis for the connection

• Provided recommendations for treating patients with Provided recommendations for treating patients with periodontal disease or cardiovascular disease periodontal disease or cardiovascular disease

• C-Reactive Protein levels in pts with chronic PD fall in C-Reactive Protein levels in pts with chronic PD fall in range of those with CVDrange of those with CVD

Noack B,GencoRJ, Trevisan M,Grossi S, Zambon JJ, De Nardin E. Periodontal infections Noack B,GencoRJ, Trevisan M,Grossi S, Zambon JJ, De Nardin E. Periodontal infections contribute to elevated systemic C-reactive protein level. J Periodontol. 2001; 72(9):1221-7 contribute to elevated systemic C-reactive protein level. J Periodontol. 2001; 72(9):1221-7

European Society of European Society of Cardiology Cardiology Consensus Statement Consensus Statement

onon Perio Health and CVD Perio Health and CVD

• ““oral health has an influence on systemic oral health has an influence on systemic health in general and on CVD in health in general and on CVD in particular”particular”

• We should “promote oral health and We should “promote oral health and periodontal health as an important periodontal health as an important component in the prevention of CVD.”component in the prevention of CVD.”

Sanz,M: European Society of Cardiology April 2010Sanz,M: European Society of Cardiology April 2010

Based on evidence that Based on evidence that Periodontal Disease Periodontal Disease is is

independently associated independently associated with with Vascular DiseaseVascular Disease

ALLALL Cardiovascular prevention Cardiovascular prevention programs must include an programs must include an oral/systemic componentoral/systemic component

Evidence Evidence Periodontal Disease Periodontal Disease couldcouldimpact CV risk---impact CV risk---• What known CV risk factors does PD What known CV risk factors does PD

influence???influence???

Study: Bacteria causing PDStudy: Bacteria causing PD linked directly to Hypertension linked directly to Hypertension

• 653 ‘healthy subjects’ 653 ‘healthy subjects’ >> 55y/o tested for PD bacteria 55y/o tested for PD bacteria• Actinobacillus actinomycetum comitans (A.a.), Porphyromas Actinobacillus actinomycetum comitans (A.a.), Porphyromas

gingivalis (P.g.), Tannella forsythensis (T.f.), and Treponema gingivalis (P.g.), Tannella forsythensis (T.f.), and Treponema denticolor (T.d.)denticolor (T.d.)

• Highest tertile of the burden of these VS lowest tertile:Highest tertile of the burden of these VS lowest tertile:

1) Significant 1) Significant increase in Blood Pressure increase in Blood Pressure which creates which creates significantsignificant

increase risk increase risk for ischemic stroke and heart attackfor ischemic stroke and heart attack

(Systolic BP 9mm Hg higher; Diastolic BP 5mm Hg higher(Systolic BP 9mm Hg higher; Diastolic BP 5mm Hg higher))

2) Pt’s in highest tertile 2) Pt’s in highest tertile 3X3X more likely to have HTN more likely to have HTN

Adjusted for age, race/ethnicity, sex education, BMI, smoking, DM, cholesterol Adjusted for age, race/ethnicity, sex education, BMI, smoking, DM, cholesterol levelslevels

M.Desvarieuxa, et.al. Journal of Hypertension 2010, 28:1413-1421M.Desvarieuxa, et.al. Journal of Hypertension 2010, 28:1413-1421

Study: Bacteria causing PDStudy: Bacteria causing PD linked directly to Hypertension linked directly to Hypertension• It was the It was the concentrationconcentration of the bacteria & of the bacteria &

NOT the clinical diagnosis of PD which NOT the clinical diagnosis of PD which

correlated with Blood Pressurecorrelated with Blood Pressure

• Makes the case for checking the “burden” of Makes the case for checking the “burden” of bacteria and realizing that “subclinical” PD can bacteria and realizing that “subclinical” PD can harbor significant infection harbor significant infection

NOT the clinical diagnosis of PD which NOT the clinical diagnosis of PD which

correlated with Blood Pressurecorrelated with Blood Pressure

Periodontal DiseasePeriodontal Disease also also impacts CV Risk via:impacts CV Risk via:

• Lipid changes: HDLLipid changes: HDL

• Sugar changes: HgA1c & Type 2 Sugar changes: HgA1c & Type 2 diabetesdiabetes

• Arterial inflammation-Arterial inflammation-PD negatively PD negatively impacts the biomarkers used to monitor impacts the biomarkers used to monitor arterial healtharterial health

• (If artery is “hot” the patient is in peril)(If artery is “hot” the patient is in peril)

• Toll-like Receptors-Toll-like Receptors-

PD has association with Insulin ResistancePD has association with Insulin Resistance

Evidence supporting PD is Evidence supporting PD is associated with development of associated with development of Vascular diseaseVascular disease• PD is Independent risk factor CHDPD is Independent risk factor CHD• 2008 USP2008 USPreventionreventionSServiceservicesTTaskaskFForce orce performed performed

exhaustive review of prospective cohort studiesexhaustive review of prospective cohort studies

• Incidence of CHD in ”healthy” subjects with no known CV Incidence of CHD in ”healthy” subjects with no known CV risk factors; follow up 5 – 21 yearsrisk factors; follow up 5 – 21 years

• Concluded: Concluded:

Periodontal Disease is an independent risk Periodontal Disease is an independent risk factor of Coronary Heart Diseasefactor of Coronary Heart Disease

Humphrey LL, MD, et al J Gen Intern Med, Sept 2008, 23(12) 209-2086Humphrey LL, MD, et al J Gen Intern Med, Sept 2008, 23(12) 209-2086

Other associations with Other associations with Periodontal DiseasePeriodontal Disease

Evidence PD is associated with CV eventsEvidence PD is associated with CV events

• Study of Pima Indian tribe; Study of Pima Indian tribe; PD & CVD PD & CVD mortality with Type 2 DMmortality with Type 2 DM-median f/u 11 yr-median f/u 11 yr

• Prospective study 628 subjects;Prospective study 628 subjects;

• 204 died from CVD204 died from CVD

Saremi,MD,et al American Diabetes Association,Diabetes Care, 2005; Saremi,MD,et al American Diabetes Association,Diabetes Care, 2005; 7-97-9

Other associations with Other associations with Periodontal DiseasePeriodontal Disease

• Periodontal pathogens are found in Carotid Periodontal pathogens are found in Carotid Atheromas (plaques)Atheromas (plaques)

• Study PD & CVD Mortality/Type 2 DiabetesStudy PD & CVD Mortality/Type 2 Diabetes

• Cardio renal mortality; Cardio renal mortality; no PD-no deaths!no PD-no deaths!

• Severe PD: 3.2 times risk for deathSevere PD: 3.2 times risk for death

• Other studies demonstrating increased CV Other studies demonstrating increased CV event risk with Periodontal Diseaseevent risk with Periodontal Disease

Do we have evidence that Do we have evidence that PeriodontalPeriodontal TreatmentTreatment is associated with is associated with

reduced CV Risk?reduced CV Risk?YesYes

a study showed better glycemic control by a a study showed better glycemic control by a significant drop in A1c values after perio significant drop in A1c values after perio treatmenttreatment

371 DM subjects; half treated, half not371 DM subjects; half treated, half not

This indicates improvement in glycemic This indicates improvement in glycemic control which is related to CV risk.control which is related to CV risk.

Teeuw,W.J. et al Diabetes Care Feb 2010,vol 33,No 2:421-427Teeuw,W.J. et al Diabetes Care Feb 2010,vol 33,No 2:421-427

American Heart American Heart Association Association conclusions:conclusions:

• Level A evidence exists that PD is Level A evidence exists that PD is independently associated with arterial independently associated with arterial diseasedisease

• Available evidence shows a trend Available evidence shows a trend toward reducing CV risk with toward reducing CV risk with Periodontal therapyPeriodontal therapy

Peter B. Lockhart et.al. Circulation (published online April 18, Peter B. Lockhart et.al. Circulation (published online April 18, 2012)2012)

CausalityCausality is difficult to prove; is difficult to prove; is is not a prerequisite not a prerequisite for including for including Periodontal Disease Assessment and Periodontal Disease Assessment and Management in Wellness ProgramsManagement in Wellness Programs

• The level A evidence that Periodontal The level A evidence that Periodontal Disease is independently associated Disease is independently associated with arterial disease with arterial disease

• along with evidence indicating PD along with evidence indicating PD therapy may reduce CV risktherapy may reduce CV risk

• is more than adequate reason to is more than adequate reason to include PD Evaluation and Treatment in include PD Evaluation and Treatment in any Cardiovascular Wellness programany Cardiovascular Wellness program

Female 100 year old patient; gingival recession, abfraction lesions, few areas of deep pockets

DiabetesDiabetes

• 66thth leading cause of death leading cause of death

• 3 to 4 times higher risk of heart 3 to 4 times higher risk of heart problemsproblems

• 23% increase in deaths from heart 23% increase in deaths from heart disease in women with diabetes over disease in women with diabetes over past 30 yearspast 30 years

• Compared to 13% decrease in menCompared to 13% decrease in men

• Kidney disease, nervous system disease, Kidney disease, nervous system disease, dental disease, blindness, amputationsdental disease, blindness, amputations

Diabetes Risk FactorsDiabetes Risk Factors

• EthnicityEthnicity

African American, Hispanic, American African American, Hispanic, American IndianIndian

• Age (over 45)Age (over 45)

• ObesityObesity

• Family HistoryFamily History

• High Blood PressureHigh Blood Pressure

• High CholesterolHigh Cholesterol

Diabetes preventionDiabetes prevention• Weight controlWeight control

• High-fiber, low-fat dietHigh-fiber, low-fat diet

• Increasing physical activityIncreasing physical activity

Oral Connections and Oral Connections and DiabetesDiabetes• Obvious example of Obvious example of systemic disease systemic disease

predisposing a patient to oral predisposing a patient to oral infectionsinfections, and consequently the , and consequently the infection potentially worsening the infection potentially worsening the diseasedisease

Oral Connections and Oral Connections and DiabetesDiabetes

• WHY? Predisposition?WHY? Predisposition?

• Diabetes causes thickening of blood Diabetes causes thickening of blood vessels resulting in reduced circulation vessels resulting in reduced circulation and a slower flow of nutrients to needed and a slower flow of nutrients to needed areas in the bodyareas in the body

• Also, harmful wastes remain in the body Also, harmful wastes remain in the body longer, weakening resistance of oral longer, weakening resistance of oral tissues to infection~longer healing timestissues to infection~longer healing times

DiabetesDiabetes• Increased risk of periodontal disease and Increased risk of periodontal disease and

attachment lossattachment loss

• Periodontal disease may worsen blood glucose Periodontal disease may worsen blood glucose controlcontrol

• Diabetics more likely to have periodontal Diabetics more likely to have periodontal disease because they are more susceptible to disease because they are more susceptible to contracting infectionscontracting infections

• Ask patient about their “ABC’s”-A1C, blood Ask patient about their “ABC’s”-A1C, blood pressure, cholesterolpressure, cholesterol

• Ask about foot, eye, oral, medication related Ask about foot, eye, oral, medication related symptomssymptoms

Respiratory diseaseRespiratory disease

• Oral cavity is a potential entry Oral cavity is a potential entry point for respiratory pathogens point for respiratory pathogens into the tracheainto the trachea

• Biofilms on teeth and dentures Biofilms on teeth and dentures are a reservoir for these are a reservoir for these pathogenspathogens

• Pathogens can be shed and Pathogens can be shed and aspirated into the lower airway, aspirated into the lower airway, increasing the risk of infectionincreasing the risk of infectionHayes et al., 1998 Scannapieco FA, 1999

Respiratory DiseaseRespiratory Disease

• Nursing Home residents or extended Nursing Home residents or extended hospital stay patients are more at riskhospital stay patients are more at risk

• Evidence that Evidence that genetic identity is the same genetic identity is the same for bronchoalveolar lavage fluid and dental for bronchoalveolar lavage fluid and dental plaques of elderly patientsplaques of elderly patients

• Improved oral hygiene and frequent Improved oral hygiene and frequent professional oral health care reduced the professional oral health care reduced the progression or occurrence of respiratory progression or occurrence of respiratory diseasesdiseases

Azarpazhooh and Leake, 2006

Osteoporosis Osteoporosis

• Significant association with alveolar bone loss Significant association with alveolar bone loss and self-reported osteoporosisand self-reported osteoporosis

• Risk of Osteonecrosis of the Jaw (ONJ) if treated Risk of Osteonecrosis of the Jaw (ONJ) if treated with IV bisphosphonateswith IV bisphosphonates

• Alveolar bone loss affects ability to wear and Alveolar bone loss affects ability to wear and tolerate removable prostheses tolerate removable prostheses (dentures)(dentures)

• Severe bone loss may preclude implant Severe bone loss may preclude implant placement to stabilize lower denturesplacement to stabilize lower dentures

• Suggestion that hormone replacement therapy is Suggestion that hormone replacement therapy is associated with retention of more teeth in old ageassociated with retention of more teeth in old age

ArthritisArthritis

• Associated with alveolar bone lossAssociated with alveolar bone loss

• No clear cut linkNo clear cut link

• Patients tend to bleedPatients tend to bleed

• Limited manual dexterity impedes Limited manual dexterity impedes good oral hygienegood oral hygiene

Scully R and Ettinger R, 2007

AlzheimerAlzheimer’’s diseases disease

• Diminished salivary flow and poorer Diminished salivary flow and poorer oral healthoral health

• Lower numbers of teethLower numbers of teeth

• Decreased capability to understand Decreased capability to understand importance of oral hygieneimportance of oral hygiene

• Resistance to helpResistance to help