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?