Diabetes, CVD and Periodontal Disease -Mouth, the black hole in the medical universe William Hsu, MD Medical Director for Asian Clinic Joslin Diabetes Center Assistant Professor of Medicine Harvard Medical School Diabetes and Periodontitis Increasingly prevalent, long subclinical phase, easily screened Connected by physiologic link Outcome depends on intensive interventions, active maintenance, and lifestyle modification Shared issues: hypoglycemia, smoking, etc. Potential benefits for co-management of conditions ARS #1 Did you know the connection between diabetes and periodontitis? 6 th Complications of Diabetes The hidden complication Large surface area Both an inflammatory as well as infectious disease Is it a macrovascular or microvascular complication? Longitudinal Study of Oral Health Status of Pima Indians Objective: To determine the prevalence and the incidence of periodontal disease and its relationship to NIDDM. Population: 2,273 Pimas, 701 were examined at least twice. Nelson et al., Diabetes Care 13:836, 1990 1
Effects of Diabetes on Periodontal Health Diabetes Mellitus Type Study Design Type 1 Type 2 Type 1 or 2 Gestational (GDM) Type Not Reported # With Effect/#All Studies Cohort 3/3 4/4 0/0 0/0 0/0 7/7 Crosssectional, 22/23 20/23 15/18 3/3 11/15 72/83 Descriptive Total: 25/26 24/27 15/18 3/3 11/15 79/89 (Taylor, G., 2009) Periodontal Disease Affects Glycemic Control; 2 Yr. Study Systemic Inflammation 40% 35% 30% % with 25% worsening 20% glycemic 15% control 10% 5% 0% 11% Without Periodontitis 37% With Periodontitis Taylor et al. 1996 ARS # 2 Do you routinely ask your patients if they have periodontal disease? Diabetes Mellitus Periodontal Disease Glycemic Control?? Periodontal Therapy 2
Impact of Hyperglycemia When glucose >200mg/dL Impaired adherence, chemotaxis, phagocytosis of neutrophils Altered wound healing Oxidative stress and proinflammatory cytokines TNF- and IL-6 A1C (%) eag 6 126 7 154 8 183 9 212 10 240 A1C-Derived Average Glucose Study Can Periodontal Treatment Affect Glycemic Control? 125 Type 2 DM patients, severe periodontitis, 5 groups Periodontal status, HbA1c and pooled subgingival plaque sample at baseline, 3 months, 6 months Grossi et al., J Perio 1996, 1997 Clement S et al. Diabetes Care. 2004;27:553-591. Nathan DM et al. Diabetes Care. 2008;31:1-6. Can Periodontal Treatment Affect Glycemic Control? SCRP-Doxy SCRP-Placebo 0-0.1-0.2-0.3-0.4-0.5 * -0.6 * p< 0.04 Ultrasonic SCRP with -0.7 water irrigant -0.8-0.9-1 Change in HbA1c at 3 Months N=125; type 2 DM, RCT (Pilot) Reduction in HbA1c (%) Effect of Periodontal Treatment on Diabetic Glycemic Control RCT Diabetes Type Results Aldridge (1995) 1 N Aldridge (1995) 1 N Skaleric (2004) 1 Y Grossi (1996,1997) 2 Y Kiran (2005) 2 Y Rodrignes (2003) 2 Y Jones (2007) 2 Y Cochrane Database Systemic Review There is some evidence of improvement in metabolic control in people with diabetes, after treating periodontal disease. There are few studies available and individually these lacked the power to detect a significant effect. Most of the participants in the study had poorly controlled Type 2 DM with little data from randomised trials on the effects on people with Type 1 DM. Improving periodontal health is an important objective in itself. However, in order to understand the potential of this treatment to improve glycaemic control among people with diabetes, larger, carefully conducted and reported studies are needed. Journal of Periodontology October 2000, Vol. 71, No. 10, Pages 1554-1560 3
FASEB J. 2009 Apr;23(4):1196-204 Diabetes and Periodontal Disease People with diabetes are 2-3 times more likely to develop periodontal disease. People with periodontal disease and diabetes are more likely to have poor glycemic control, and periodontal treatment may improve glycemic control. People with periodontal disease and diabetes are more likely to have heart and kidney disease. ARS # 3 Do you look for hidden infection like periodontal disease when glucose control is suboptimal? Comanagement of the Patient with Diabetes Managing the whole Patient Dental Professional Infection Wound Healing Inflammation Hypo- and Hyperglycemia Lifestyle Modification Smoking Nutrition Medical Professional Overall health = Oral health, Nutrition and Diabetes Collaboration and comprehensive training among health professionals to provide team approach 4
Need for Screening at Multiple Healthcare Locations In the U.S. population, 27% undiagnosed rate from 30% in 2005 and from 50% ten years ago Demand vs supply of diabetes work force 4000 office-based endocrinologists 15,000 certified diabetes educators ( CDE) 26 million with diabetes Primary care physicians and other health care workers Nutrition, Diabetes and Oral Health Nutrition risk factors associated with oral disease Nutrition related diseases exacerbating oral disease Oral conditions leading to nutrition problems CDC. National Diabetes Fact Sheet 2011 Nutrition Risk Factors Associated with Oral Disease Food form (liquid, solid, sticky, slowly dissolving) Frequency of consumption Fermentable carbs / frequency of contact Acidic content of food Soft drinks, fruit juices, citrus fruits Nutritional composition of the diet Lacking food groups / deficiencies Saliva stimulation More stimulation = more saliva = less caries Nutrition Perspective Nutrition and eating patterns of patients with diabetes affecting Oral Health Oral health affects nutritional status, diabetes and overall Health Nutritional considerations in patients with periodontal disease Practical dietary approaches to achieve good oral health and glycemic control Oral Conditions Leading to Nutrition Problems Oral cavity Sensitive indicator of nutritional status Tooth loss Indicator of overall health Affects nutrient intake ( soft foods, high in fat and sugar; low in fiber) Oral candidiasis Affects nutrient intake Xerostomia May increase intake of candies, high carb beverages Diabetes, Oral Disease and Nutrition Reducing Risks Frequent Hyperglycemia Elevated glucose in saliva; can increase susceptibility to oral infections and fungal growth; associated with impaired wound healing Frequent Hypoglycemia Excessive snacking leads to excessive caloric intake Treatments may contain poor nutrients Xerostomia Increased risk in diabetes. Reduced saliva = Increased caries risk 5
Nutrition Interventions for Periodontal Disease Promote a balance diet and supplement as necessary Recommend meticulous oral hygiene Avoid sugary and sticky foods carbonated drinks, candies, fruit rolls and pastries or brush/floss/rinse afterwards Drink lots of water Chewing sugarless gum An eating plan: prevent hypos, reduce frequency of snacking and bg control, weight reduction Integration of medical and dental care of patients Role of Dentist Role of Physician Role of educators and hygienists Screening Questions 1. Do you think you might have gum disease? 2. Have you ever had treatment for gum disease, such as scaling and root planing, sometimes called deep cleaning? 3. Have any of your teeth become loose on their own without an injury? 4. Have you ever been told by a dental professional that you have lost bone around your teeth? 5. During the past 3 months, have you noticed a tooth that doesn t look right? 6. Do you have diabetes? 7. Are you over 50 years of age? 8. Overall, how do you rate the health of your teeth and gums? Excellent or good Fair or poor 9. Aside from brushing your teeth with a toothbrush in the last 7 days, how many times did you use dental floss or any other device to clean between your teeth? 3 or more times 0 times 10. Aside from brushing your teeth with a toothbrush in the last 7 days, how many times did you use mouthwash or other dental rinse products used to treat dental disease or dental problems? 3 or more times 0 times Three or more yes answers, or a combination of 3 yes and 0 times answers that total 3 or more should alert the clinician to the possibility that the patient may have periodontal disease and trigger a referral to a dentist. 6
What Can Internists Do? ARS # 4 Ask the question Look in the mouth Recommend dental screening, daily flossing, routine professional cleaning Make proper referral Do you plan to integrate dental question(s) in the review of system for your diabetic patients? 7