Internal Medicine Correlations in Oral Health Mark D. Baldwin D.O., FACOI Chair, Department of Internal Medicine Professor of Medicine LEARN. CARE. COMMUNITY.
None, just working for The Man Disclosures
Objectives Discuss the roles of chronic oral inflammation in cardiovascular disease Discuss common signs and symptoms in a dental office and their role in systemic illnesses Discuss non-dental causes of halitosis Discuss the role of obesity and diabetes in oral health Discuss the potential oral manifestations of organ transplants Discuss the current antibiotic prophylaxis and who gets it and who does not
Why I am qualified to speak on this topic Denison Holmes Baldwin D.D.S., U. of Maryland Class of 1891, gold medal for best crown and bridgework Mark R. Baldwin D.D.S., U. of Illinois Class of 1930
Oral and Systemic Health? Unfortunately most physicians forget that the teeth and gingiva are part of the rest of the body Comprehensive oral medicine is lacking from most medical schools curriculums Endocarditis risk factors and thrush are usually the limits of oral/systemic health interface Insurance coverage for dental issues lags behind the rest of the body The oral region can be a barometer of what may be going on in the body Patients may present to the dental office with signs or symptoms of a systemic illness
Role of Chronic Inflammation and Cardiovascular Disease Chronic low grade inflammation i.e. gingival disease, is a well know risk factor for cardiovascular disease-with or without coexisting diabetes mellitus
Why is This Important? Marked reduction in overall dental problems in the past 50 years In children 8 to 17 years old, 50% had no caries, while 25% accounted for 80% of caries 50% of American adults have some form of gingival disease 35% have periodontitis Periodontal disease highest in poor, African American, Hispanic Americans, less than a high school education-the same groups at highest risk for obesity/diabetes JAMA 2000;284:1215-1217
What s the Big Deal?
Role of Endothelium in Cardiovascular Disease Endothelial cells line the inner layer of vessels Susceptible to acute and chronic damage, endogenous or exogenous Inflammatory mediators from chronic inflammatory states damage endothelium and adjacent organs and tissues leading to Myocardial infarction/congestive Heart Failure. Stroke, Peripheral Vascular Disease, Chronic Kidney disease Circulation 2013;127:1219-1228 Postgrad Med J 2017;93:215-220
The Role of Gingival Disease and Chronic Inflammation
Risk Factors for Periodontal Disease Genetics(?) Smoking Alcohol Methamphetamine use 1 Diabetes Mellitus Obesity Metabolic Syndrome Osteoporosis Low dietary calcium Low vitamin D levels High dietary sugars/high fructose corn syrup 2 (NHANES III) Periodontol 2000. 2013;62:59-64. 1 J Am Dent Assoc. 2015;146:308-314. 2 Am J Clin Nutr. 2014;100:1182-1187
Common Oral Signs and Symptoms of Systemic Diseases
Anosmia and Dysgeusia Anosmia (loss of smell)-an early indicator of dementia, frontal lobe lesions, chronic sinus infections (especially in transplant and immunosuppressed patients), advanced kidney disease Dysgeusia (loss of sense of taste)-side effects of some medications, advanced kidney disease, diabetes, age, smoking, B 12 and Zinc deficiencies, Sjorgren s, but can also be seen with dementia as taste and smell are closely linked.
Halitosis-Non Dental Causes Renal failure-urine like odor (uremic fetor) Liver failure- dead mouse odor (fetor hepaticus) Ketosis-acetone/fruity uncontrolled diabetes, keto diet, starvation, anorexia, alcoholic ketosis Sinusitis Eur J Dent. 2016; 10: 292 300. Pulmonary infection/lung abscess GERD Chronic aspiration of gastric contents Psychological halitosis may be part of OCD or other psychiatric illness
Common Medications linked to Halitosis
Dry Mouth Xerostomia (dry mouth)-a common side effect of a number of medications, especially those with anticholinergic actions Sicca complex-xerostomia and/or xeropthalmia(dry eyes) may be isolated findings or part of an autoimmune process Sjorgren s Syndrome-systemic autoimmune condition with xerostomia (salivary gland dysfunction), xeropthalmia, dysphagia, polyexocrine glandular dysfunction, fatigue and arthralgias/ myalgias
Sjorgren s Syndrome
Bechet s Disease Recurrent aphthous ulcers >3 episodes in a 12 month period Anterior or posterior uveitis or retinal vasculitis Genital ulcerations Erythema nodosum (raised painful nodules) anterior lower legs
Systemic Lupus Erythematosus Multisystem autoimmune disorder Perioral ulcerations and malar (butterfly) frequently herald an acute flare
Malar Rash of Lupus
Thrush Common side effect of antibiotics Can be presenting symptom of immune deficiency Chemotherapy or radiation side effect
An inflammatory gastrointestinal disease that predominately affect the small bowel but can occur at any segment of the GI tract The inflammatory lesions involve every layer of the GI tract Perioral lesions are common Can present with an ulceration or polypoid nodule of the mucosa Crohn s disease
Eating Disorders-Anorexia/Bulimia Better recognized by hygienists than dentists Teenager/young adult F>M Can be seen in wrestlers who are chronically trying to make weight Gingivitis/periodontal disease Caries/ perioral ulcerations Erosion of the inner enamel due to recurrent gastric acid exposure J Dent Educ.2005 Mar;69(3):346-54.
Oral Manifestations of Obesity Altered oral flora may be linked to obesity by infectious etiology theory of obesity, increased appetite, increase insulin resistance via TNF-a Mountain Dew Mouth Accelerated caries and periodontal disease Obesity is the most common factor in Type 2 Diabetes J Dent Res. 2009;88:519 23
Acanthosis nigricans-type 2 Diabetes
Oral Manifestations of Diabetes Mellitus Strong association to glucose control in either Type 1 or Type 2 diabetics Impaired immunity, circulatory problems predispose to infections and lead to chronic inflammation and CVD Oral Condition Controlled Type 2 DM % Hyposalivation 68 84 Halitosis 52 76 Periodontitis 32 48 Perioral burning sensation 28 36 Taste Alteration 28 44 Uncontrolled Type 2 DM % Clinical Diabetes 2016:34:54-57
Organ Transplant Thorough evaluation and correction of oral issues is part of a pre transplant work up Post transplant medications alter the body s immune response Dent Res J (Isfahan) 2015; 12(3): 199 208
Antibiotic Prophylaxis Who Gets it Who does Not Also antibiotics are not indicated for: Renal Transplant recipient Pacemaker or AICD Joint pins, plates or prosthesis Circulation. 2007; 116:1736-54
Antibiotic Recommendation
Conclusions Oral health is a barometer of the overall health of the body The mouth can be a cause of an effect of systemic illness If something does not look right, there is a reason When in doubt get another opinion Thank you Mbaldwin@pnwu.edu