lets talk about teeth baby · • significant association: → dm & severity of periodontal...

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?