SOUTHLAKE DENTAL HYGIENE STUDY CLUB. Schedule of Events. Facebook 10/21/13

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1 SOUTHLAKE DENTAL HYGIENE STUDY CLUB Matthew Steffer, DDS, MS Southlake Periodontics & Implant Dentistry Schedule of Events Quarterly meetings January 2013, evening April 2013, morning July 2013, evening October 2013, morning Alternate morning and evening meetings Facebook 1

2 Sponsor Peyton Eoff, Product Support Specialist THE PERIODONTALSYSTEMIC LINK October 11, 2013 Course Objective Review systemic connections of: Diabetes Smoking Cardiovascular Disease Pregnancy Discuss effects of condition on periodontium Discuss treatment and management of conditions and periodontal presentation 2

3 Oral-Systemic Link Oral-Systemic Link Diabetes 3

4 Overview of Diabetes Discussion What is diabetes mellitus? Systemic presentation Oral presentation Diabetes and periodontal disease Association of disease Treatment of patients with diabetes and periodontal disease What is diabetes mellitus? Abnormal elevation of blood glucose levels Causes Deficiency of insulin secretion by pancreas Resistance to insulin Types Type I Type II What is diabetes mellitus? Type I Formerly juvenile onset or insulin-dependent Type II Formerly adult onset or non-insulin dependent Epidemiology 21 million Americans n ~6M undiagnosed 9% of population 4

5 Type I diabetes Cause Autoimmune destruction of pancreatic β-cells Incidence 5-10% of cases Type II diabetes Physiology Resistance of target cells to insulin Insulin production increases n May diminish over time n Some patients need insulin supplements Incidence 85-90% of cases Effects of Diabetes Long-term damage to Heart Eyes Kidneys Nerves Vascular system 5

6 Effect of Diabetes How? High blood sugar Proteins become irreversibly glycated n Link to cell-to-cell interactions n Thought to link diabetic complications Form Advanced Glycation End Products (AGEs) n Found in periodontium n Higher in diabetics Proteins Become glycated Advanced Glycation End Products (AGEs) Prediabetes Elevated blood sugar levels Higher than normal Lower than criteria for diabetes Types Impaired fasting glucose n (IFG) Impaired glucose tolerance n (IGT) Fasting Plasma Glucose Casual Plasma Glucose 2-hour postload glucose Normal Diabetes IGT IFG < to S/S of diabetes < to 199 Prediabetes Impaired Fasting Glucose High risk for developing type 2 diabetes Impaired Glucose Tolerance High risk for developing type 2 diabetes Significant predictor of myocardial infarction and stroke 6

7 Classic signs Symptoms of diabetes Polyuria Polydipsia Unexplained weight loss Diagnostic Criteria Tests 1. S/S of diabetes + casual plasma glucose 200 mg/ dl 2. Fasting plasma glucose 126 mg/dl 3. Two-hour postload glucose 200 mg/dl 4. Hemoglobin A1c >6.5 Diagnosis Positive test on 2 or more days Hemoglobin A1c (HbA1c) Glycohemoglobin Formation of glucose and hemoglobin protein Stable during lifespan of erythrocyte (~120 days) Gives a 3 month window of patient s diabetic control HbA1c (%) Mean Plasma Glucose (mg/dl) 7

8 In-Office Testing Clinical Laboratory Improvements Amendment (CLIA) Established by Congress in 1998 Regulates laboratory testing What is a laboratory? A facility that performs testing on materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or assessment of the health of, human beings. In-Office Testing Finger sticks for checking blood glucose Considered a laboratory test Office subject to all laboratory regulations Waiver/Exemption Finger sticks qualify as a waived laboratory test under CLIA regulations n pdf/addenda/cliac0210/ Addendum%20F.pdf Effects on Periodontium Gingival inflammation More pronounced in diabetics Increased gingival bleeding Poor metabolic control can increase the severity of gingival inflammation in diabetic children, whereas improvement in glycemic control may be associated with decreased gingival inflammation. 8

9 Effects on Periodontium Periodontitis Strong association with diabetes Odds n Increased x in diabetics Prevalance n 60% in diabetics n 36% in non-diabetics Periodontitis Risk n Poorly controlled 2.9x greater than controlled Poorly-controlled n More bone and attachment loss Mechanism of Association Oral microbial flora Similar in diabetics and non-diabetics Findings in diabetics Altered immune cells Elevated TNF-α Increased inflammatory cytokines in gingival crevicular fluid Other findings Altered connective tissue metabolism Inhibition of osteoblastic cells Result Increased inflammation, attachment loss, bone loss Periodontal Disease on Diabetes Increases the risk of worsening of glycemic control 6x in one study Increased risk of diabetic complications Cardiovascular, cerebrovascular, and peripheral vascular events 9

10 Periodontal Disease on Diabetes Treatment Scaling & root planing + antibiotics associated with improvement in diabetic control n Doxycycline, 20 mg PO q12h Tetracyclines Decrease MMP production (ie. Collagenase) n Associated with breakdown of connective tissue Periodontal Disease on Diabetes Results of treatment Improvement in glycemic control n Reduction in HbA1c levels n Reduction in blood sugar levels Improvement in level of inflammation Not all studies confirm these findings Some patients showed no improvements or got worse Diabetes on Response to Therapy Patients with poor diabetic control May have more rapid recurrence of deep PDs May have less favorable long-term response 10

11 Smoking Topics for Discussion Effect of tobacco smoking on the prevalence and severity of periodontal diseases Effect of smoking on the response to periodontal therapy Mechanisms of periodontal disease progression in smokers Role of smokeless tobacco products, cigar and piper smoking in periodontal diseases Periodontal effects of tobacco cessation Tobacco Use ~25% of US population smokes cigarettes Larger among other countries Tobacco use has declined since 1970s Less among women and minorities Increased popularity in youth High school student use n 27.5% (1991) n 36.4% (1997) 11

12 Effect on Severity of Disease Association of smoking and periodontal disease has been shown early on 1946 association with acute necrotizing ulcerative gingivitis (ANUG) 1980s-90s association with destructive periodontal diseases Effect on Severity of Disease Smokers vs. Non-Smokers Deeper probing depths More clinical attachment loss Higher prevalence of furcation involvement n Smokers 2x more than non-smokers Greater alveolar bone loss Likelihood of disease 2.6-6x more likely to exhibit periodontal destruction 12

13 Effect on Severity of Disease Quantity of Smoking Attachment loss severity n 1 cig/day: destruction increased 0.5% n 10 cig/day: destruction increased 5% n 20 cig/day: destruction increased 10% 10% 8% 6% 4% 2% 0% Attachment Loss Severity 1 cig/d 10 cig/ d 20 cig/ d Effect on Severity of Disease Quantity of smoking in pack-years Subjects with severe bone loss had pack year levels 5x that of subjects with normal bone levels Young adults Smokers 3.8 times more likely to have periodontitis than nonsmokers Response to Periodontal Therapy Maintenance patients Smokers 2x more likely to lose teeth SRP Less PD reduction Less CAL gain Surgical therapy Less PD reduction Less CAL gain More bone destruction 13

14 Smoking on Periodontal Surgery Free gingival grafts Diminished root coverage Connective tissue grafts Mixed results Regenerative procedures Less clinical attachment gains Despite drawbacks from smoking, periodontal procedures still produced clinical improvements Smoking on Dental Implants Success rates diminished 89% in smokers 95% in non-smokers Greater marginal bone loss around implants Newer rough surfaces have almost negated effects of smoking Why do smokers have more disease? Higher levels of bacteria A. A. n 3.1x higher risk P. Gingivalis B. Forsythia n 2.3x higher risk Rates of bacteria increase as smoking increases Diminished immune response Deleterious effect on neutrophil function Decreased gingival blood flow 14

15 Smokeless Tobacco Clinical findings Dental caries Gingival recession n 25-30% of users Mucosal changes Smokeless tobacco keratosis 50-60% of users Generally reversible with discontinuation of use Smokeless Tobacco Smokeless keratosis may progress to oral cancer Squamous cell carcinoma Cigar & Pipe Smoking Less information available compared to cigarette smoking Less periodontal disease than cigarette smokers, more than non-smokers n 1968 VA hospital study Increased tooth loss n 1.3x risk in cigar smokers n 1.6x risk in cigarette and pipe smokers 15

16 Smoking Cessation Periodontal status of former smoker Intermediate between smoker and never smoker n Effects of smoking not fully reversible n Beneficial to periodontal health Smoking Cessation Response to treatment Never smokers and former smokers more favorable than smokers No association to number of years and response to therapy n Early benefit to cessation Cardiovascular Disease 16

17 Overview of Topics Atherosclerotic Cardiovascular Disease (CVD) Coronary Artery Disease (CAD) Cerebrovascular Disease Peripheral Artery Disease (PAD) Causes Accumulation of lipids within the arterial vascular wall Coronary Artery Disease Findings Plaque narrows the inner arterial walls n Reduces blood flow to the heart Can lead to chest pain or heart attack Cerebrovascular Disease Types Stroke n Hemorrhagic n Non-hemorrhagic Transient ischemic attack Dementia Causes Lipids & inflammation Blocked blood flow to the brain 17

18 Peripheral Arterial Disease Cause Build-up of plaque in peripheral blood vessels Affected areas Primarily legs May affect arms, kidneys, brain Symptoms Pain, numbness Infection, gangrene CVD and Inflammation Inflammation Important factor in development of CVD C-reactive protein (CRP) n Serves as a biomarker for inflammation Incidence of CVD events increase with chronic inflammation Periodontitis Rheumatoid arthritis Psoriasis Lupes Infections CVD and Periodontitis Strength of periodontal link CAD n Strong association n Periodontal ds is an independent marker Cerebrovascular disease n Periodontal disease is a strong risk factor n Increased risk for stroke PAD n Direct link suggested by several small studies Direct causal relationship has not been established. 18

19 Then how are they connected? Theories 1. Inflammatory 2. Bacterial Increased Inflammation Chronic Periodontitis Gram negative bacteria CVD Atheromas Common Risk Factors Clinical Recommendations Patient information Patients with periodontal disease should be informed that there may be an increased risk of CVD with periodontitis Medical evaluations Likely good practice for patients with periodontal disease to be evaluated for risk of CVD n Based more on clinical opinion, rather then evidence Evaluations should likely include blood lipid profile and CRP 19

20 Clinical Recommendations Risk Factor Treatment Abnormal Lipids n Lifestyle change n Drug therapy Cigarette smoking n Discontinue Hypertension n Treat to target BP n Lifestyle change n Drug therapy Pregnancy Overview of Topics Pregnancy Overview of physiologic changes Oral changes Oral conditions associated with pregnancy Treatment recommendations 20

21 Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis Increased inflammatory response to dental plaque. Saline rinses may help. Typically peaks during the third trimester. More prone if gingivitis present before pregnancy Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis A highly vascularized, hyperplastic, and often pedunculated lesion 5% of pregnancies Up to 2 cm in diameter A Anterior gingiva Usually regress after pregnancy Excision is rarely 21

22 Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis PDL may temporarily loosen during pregnancy Increased mobility Tooth loss is uncommon unless complications are present Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis Gastric acid Vomiting secondary to morning sickness Hyperemesis gravidarum Gastric reflux Rinsing with a baking soda solution may help neutralize the associated acid. Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis May result from Increased acidity in the mouth Greater intake of sugary snacks and drinks secondary to pregnancy cravings Decreased attention to prenatal oral health maintenance. 22

23 Oral Conditions & Pregnancy Pregnancy gingivitis Benign oral gingival lesions Tooth mobility Tooth erosion Dental caries Periodontitis Untreated gingivitis can progress to periodontitis Signs and symptoms include Tooth mobility Bone loss Bacteremia Periodontitis & Pregnancy Outcomes Incidence of periodontitis in pregnancy 40% Prevalence higher among African Americans Cigarette smokers Users of public assistance programs Preterm Labor Maternal periodontal disease & preterm labor Study in 1996 suggested association n Supported by other studies Theory Bacteria and inflammatory products may be transferred to placental tissues, uterus, cervix May precipitate preterm labor, particularly in African Americans Recent studies have failed to show benefit of periodontal therapy to reduce preterm labor and low infant birth weight Conflicting results with respect to the effect of periodontal disease on pre-eclampsia Lack of evidence for a causal relationship 23

24 Preventative Dental Care Safe during pregnancy prevention, diagnosis, and treatment of oral conditions Dental radiographs n with shielding of the abdomen and thyroid Local anesthesia n lidocaine with or without epinephrine Conditions that require immediate treatment may be managed at any time during pregnancy. Extractions Root canals Restoration of untreated caries Delaying treatment may result in more complex problems. Preventive Dental Care Pregnant women 56% did not have dental care 60% did not have their teeth cleaned during their most recent pregnancy Prevention is key! Insurance Some insurance companies are catching on and paying for an extra prophy when pregnant Summary 24

25 Cardiovascular Disease Smoking Pregnancy Inflammation Diabetes Periodontal Disease Thank you! 25