Georgia Dental Hygienists’ Association

2011

“In the U.S., the fields of dentistry and medicine have traditionally been worlds apart. But in light of the growing evidence pointing to links between oral and whole body health, this separation of disciplines is slowly beginning to break down. The notion that dentists (and hygienists) care for only gums and teeth, while doctors look after everything else is being rethought.”

Sharon Guynup, Editorial director Oral and Whole Body Health, 2006

ObjectivesTo discuss the systemic diseases that are

impacted negatively by poor oral hygiene.To provide scientific evidence about the

benefits of dental hygiene careTo discuss the systemic effects of caries,

gingivitis, and periodontal diseaseTo consider emerging evidence of other

possible disease associations.To provide suggestions for collaboration for the

patient’s well-being and health.

Oral health is a critical component of total health The first-ever Surgeon General’s

Report on Oral Health has called attention to this important connection and states, that if left untreated, poor oral health is a “silent X-factor promoting the onset of life-threatening diseases which are responsible for the deaths of millions of Americans each year.” American Dental Hygienists’

Association

Systemic DiseaseCurrent research has linked periodontal

disease to a number of systemic diseases.The greatest evidence exists for the connection

with diabetes, however numerous associations are being studied and evidence continues to emerge.

Some of these possible associations include: heart and lung disease, pre-mature, low-birth weight babies, oral and pancreatic cancers.

Scientific evidence also supports the fact that many cases of respiratory infections among the institutionalized originate from oral bacteria.

American Academy of Periodontology

“Periodontal disease is a chronic inflammatory disease, and is linked to other serious health risks.”Inflammation      Osteoporosis Heart Disease and Stroke     Pregnancy Problems Diabetes Respiratory Diseases

“Plaque is a bacterial challenge to the body. It’s an infection. Patients don’t think of that”

JoAnn Gurenlian, RDH, PhD

Because of the abundance of current information on the “Oral –Systemic Connection”, Meta

analysis and systemic reviews were primarily consulted for this presentation.

Consequently, a large amount of research was considered with the primary findings

highlighted here.

Type II diabetes is increasing in incidence, even among younger individuals.

The Center for Disease Control and Prevention reports Diabetes diagnoses have increased more than 3 million in almost two years. Currently, it is estimated that almost 8 percent of the US population has diabetes.

Numerous current scientific articles have been written that support the relationship between oral health and the effective control of diabetes.

Diabetes Facts:

Periodontal disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes.

Periodontal disease is more prevalent, progresses more rapidly, and is often more severe in those with both type 1 and type 2 diabetes.

Periodontal disease has been named as the sixth complication of diabetes.

U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute ofDental and Craniofacial Research, 2000.

http://www.cdc.gov/diabetes/pubs/estimates07.htm#9

Those patients with periodontal infections had worse glycemic control over time. This may be a result of cytokines secreted because of chronic inflammation. Cytokines are associated with insulin resistance.

Treatment of periodontitis improved glycemic control.

Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. J Periodontol. 1996;67(10 Suppl):1085-1093.

How does periodontal disease affect diabetes?

Also, periodontal disease in diabetic patients increases the severity of complications of diabetes such as kidney and heart disease.

Some of the mechanisms that explain the

increased pathology seen in diabetic patients as a result of periodontal infection:

altered vascular physiology reduced immune response particularly protective response by

neutrophils reduced ability for tissues to heal.

Diabetes and Periodontal Disease: Current Concepts

Robert Genco, DDS, PhD, Distinguished Professor, Oral Biology, School of Dental Medicine, State University of New York, Buffalo, New York

http://www.cdc.gov/OralHealth/publications/library/conferences/periodontal_infections09.htm

• Dry, burning mouth• Gingival proliferation, gingivitis, periodontitis• Abnormal wound healing• Multiple carious lesions• Candida infection – denture sore mouth, angular

cheilitis, median rhomboid glossitis• Periodontal abscesses• Acetone breath• Increased salivary viscosity• Asymptomatic parotid gland swelling

Intraoral findings for Diabetes:

Dental Hygiene TreatmentCarefully assess all patients for the signs

and symptoms of diabetes

Educate diabetic patients about the importance of their personal oral hygiene as well as regular professional care.

Actively prevent and aggressively treat periodontal diseases in diabetic patients.

How does periodontal disease affect respiratory health?

The oral cavity provides a reservoir of bacteria for lower airway infections.

Bacteria from the mouth can form a biofilm on ventilation tubing, thereby inoculating the respiratory tract with oral bacteria.

Oral bacteria may also be aspirated by the patient.The severity of the oral disease is correlated with

the pathogenicity of the bacteria which may be transmitted.

The presence of cariogenic bacteria plus periodontal pathogens have been found to be significant risk factors for aspiration pneumonia.

Who is at risk? Patients at the highest risk for respiratory

infection (pneumonia and bronchitis) are institutionalized patients or medically compromised patients with or without respiratory disease who are unable to perform self-oral care.

Also at risk are hospitalized elderly patients.

“There is good evidence that mechanical oral hygiene practices reduce the progression or occurrence of respiratory diseases in high-risk elderly people in nursing homes or hospitals. Mechanical oral hygiene practices may prevent the death of about one in 10 elderly residents of nursing homes from health care–associated pneumonia.”

This author evaluated 328 articles published from 1996 to 2007 which discussed the results of clinical studies linking oral hygiene to health care–associated pneumonia or respiratory tract infection in elderly people.

Rosenblum, R. “Oral hygiene can reduce the incidence of and death resulting from pneumonia and respiratory tract infection” J Am Dent Assoc 2010;141;1117-1118

Dental Hygiene TreatmentMeticulous and frequent oral care is critical

in preventing these infections.“Oral hygiene intervention significantly

reduced occurrence of pneumonia in institutionalized subjects” Scannapieco, FA, Bush, RB, Paju S.

Associations between periodontal disease and risk for nosocomial bacteria pneumonia and chronic obstructive pulmonary disease. A systematic review Ann Periodontal. 2003; 8:1, 54-69.

Frequent toothbrushing and pre-operative use of 0.12% or 0.2% chlorhexidine mouthrinse or gel reduced nosocomial respiratory tract infections

Sjorgren P Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systemic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes. J Am Geriatric Soc 2008; 56: 2124-2130

Ideally, this care should be provided by licensed dental hygienists.

Presently, because of restrictive practice regulations in our state, we are unable to provide care in nursing homes and other institutionalized settings without the direct supervision of a dentist.

Hygienists can, however, train nursing home personnel to provide this care until such time that a licensed hygienist can be employed by the long term care facility to provide oral care.

Coronary Heart DiseaseHeart Attack

AtherosclerosisStroke

How does periodontal disease affect heart disease?This association is still being studied, but it is

thought that the C-reactive protein and fibrinogen production is increased in response to oral inflammation. C- reactive protein increases clotting and is a marker for heart disease.

Risk is increased for diabetic patients and synergistically increased if the patient is a smoker.

A relationship between periodontal disease and atherosclerotic diseases, including heart disease and stroke, has been established.

Oe Y, Soejima H, Nakayama H, Fukunaga T, et al. Significant association between score of periodontal disease and coronary artery disease. Heart Vessels. 2009;24:103-107.7. Friedewald VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. Am J Cardiol. 2009;104:59-68.

In a large 14 year study, patients with periodontal disease were 25% more likely to develop coronary heart disease (CHD) than their healthy counterparts.

Men under 50 with periodontal disease were 72% more likely to develop CHD

Periodontal disease increased risk for both fatal and non-fatal strokes two-fold.

DeStefano, F, Anda RF, Kahn HS, et al. Detna disease and risk of coronary heart disease and mortality. BMJ. 1993; 306:688-691Wu T, Trevisan M, Genco RJ, et al. Periodontal disease and risk of cerebrovascular disease: the first nationalHealth and nutrition examination survey and its follow-up study. Arch Intern Med. 2000; 160:2749-2755.

Adapted from Scannapieco FA. Compend Cont Educ Dent. 204;25(7 suppl 1): 16-25

Oral Inflammation

Bacteremia Inflammatory

MediatorsIL-1, IL-6, TNF-a

ImmuneResponse

Liver

Target Organ

Periodontal pathogensOr their products

Periodontal pathogens eg. P gingivalis

Model explaining the Oral inflammation-Systemic Disease Associations

C-Reactive protein,fibrinogen

Dental Hygiene Treatment

Educate patients about the importance of maintaining their oral tissues through home and professional care.

Dental professionals should always take the patients’ blood pressure before proceeding with treatment. This is Standard of Care.

Ask about tobacco use, and incorporate Tobacco Cessation into the patient’s treatment plan.

Low birth-weight infants

“Enough evidence exists to show there is an association between the presence of periodontitis and preterm delivery and low birthweight infants. However, the exact nature of that association is still unclear”

M. John Novak, BDS, LDS, PhD

How does periodontal disease affect preterm or low birth weight outcomes?

It is thought that inflammatory molecules from the mouth can get into the circulatory system. They can reach the fetal membranes and cause preterm delivery.

Oral bacteria has been found in fetal membranes

Dental Hygiene TreatmentAlthough we do not fully understand the

association, dental professionals should promote overall health.

Since we know that gingivitis and periodontitis are infections, we should educate patients to control the disease in their mouth through self and professional care, especially during pregnancy.

A reverse association

How does Osteoporosis affect periodontal disease?Periodontal bone loss will progress more

rapidly in patients with osteoporosis.

Medications taken by patients with osteoporosis should be considered before any operative procedures. Intravenous bisphosphonates create a greater risk for the patient than oral bisphosphonates.

Dental Hygiene Treatment

Dental professionals should pay careful attention to rapid bone loss especially in post-menopausal women.

Consider referral to the physician if the patient has not previously been diagnosed with osteoporosis.

Also consider the patient’s bisphosphonate medications, especially the intravenous type when designing the dental hygiene treatment plan.

Oral CancerPancreatic and Breast Cancer

Alzheimer’s Disease

What cancers may be associated with Periodontal Disease?

New research is underway to investigate if there is an association between periodontal diseases and oral or pancreatic cancer.

This research is based on the model that stomach cancer is preceded by Helicobacter pylori, so perhaps pancreatic cancer has an infectious connection.

There are also studies looking into the possible associations with breast cancer and Alzheimer’s.

Dental Hygiene Treatment

Dental professionals should stay current in their own research of emerging evidence on these subjects, and be prepared to pass pertinent information along to our patients.

Caries and Periodontal Disease

Dental Decay (caries)Dental caries (decay) is the most common

chronic disease nationally affecting 53% of 6-8 years olds and 84% of 17 year olds.

The cost of providing restorative treatment is more expensive than providing preventive services.

It is not only socially responsible, but fiscally prudent, to increase access to preventive services. Each year millions of productive hours are lost due to dental diseases.

An estimated 51 million school hours per year are lost because of dental-related illness.

Students ages 5 to 17 years missed 1,611,000 school days in 1996 due to acute dental problems—an average 3.1 days per 100 students.

Community Voices: HealthCare for the Underserved.2001. Poor Oral Health Is No Laughing Matter. Washington, DC: Community Voices: Health Care for the Underserved.

National Center for Health Statistics. 1996. Current estimates from the National Health Interview Survey,1996

“Early tooth loss caused by dental decay can result in failure to thrive, impaired speech development, absence from and inability to concentrate in school, and reduced self-esteem.”

Office of Disease Prevention and Health Promotion.2000. Healthy People 2010. In Office of DiseasePrevention and Health Promotion

Dental caries rarely lead to death, but it is possible as in the 2007 Deamonte Driver case.

Deamonte did not have access to dental care. By the time he sought medical treatment, the bacteria from his abscess had traveled to his brain and he ultimately could not be saved.

His hospitalization cost approximately $250,000. An extraction would have cost less than $100.

Serious oral health problems also occur among adults. Each year about 30,000 Americans are diagnosed with oral and pharyngeal (throat) cancers, and more than 8,000 people die of these diseases.

In addition, almost 30% of elderly adults no longer have their natural teeth due to tooth decay and gum disease.

Other Oral Health Problems

Take and carefully review every patient’s medical history.

Take and record each patient’s vital signs, especially blood pressure.

Carefully conduct the intraoral assessment including oral cancer screening and periodontal charting and gingival assessment.

Provide exceptional care including referrals to the appropriate medical personnel.

Stay informed about emerging evidence about the oral-systemic connection.

Because of the overwhelming science supporting the “oral-systemic connection”, patients with these systemic and oral conditions should have access to dental hygiene services on a very routine basis.

The American Dental Hygienists’ Association and the Georgia Dental Hygienists’ Association advocate that the services of dental hygienists who are graduates from an accredited dental hygiene program can be fully utilized in all public and private practice settings to deliver preventive and therapeutic oral health care safely and effectively.

If improvement in the nation’s health care system is to occur, more equitable access to basic quality oral health care at affordable costs is necessary.

Licensed dental hygienists are educated and qualified to perform oral health care services.

Furthermore, dental hygienists serve as an efficient pipeline for identifying and sending on those who need the care of a dentist.

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