Transcript o/s links - UAB Lister Hill Library

UAB GEC
Faculty Scholars Program
Lillian M. Mitchell, DDS, FACP
UAB School of Dentistry
Director, Geriatric Dentistry
2009 UAB Geriatric Education Center Faculty Scholar
May 30, 2014
Oral/Systemic Links:
Critical Health Issues for
the Complex Older Adult
Oral Health is vitally
importantespecially in the older adult
• Mouth is beginning of the digestive tract
• Portal for all foods and nutrients to sustain
life
• Critical to the prevention of chronic and
acute illnesses
• Direct link to overall health and quality of
life
• Decreases overall health expenditures
Overview:
Impact of Periodontal Disease on CVD,
Diabetes, other systemic issues
• Periodontal disease:
• Impacts CV risk factors
• Linked to development of arterial disease
• PD linked to cardiovascular events
• PD treatment affects CVD
• PD linked to Diabetes mellitus
• PD linked to Respiratory disease
• PD linked to arthritis and osteoporosis
What do we know?
• Our population is living longer
• Living with chronic diseases
Chronic Diseases
Leading cause of Death & Disability in US
•7 out of 10 deaths among Americans
•Heart disease, cancer, stroke – more than
50% of all deaths each year
•1 in every 3 adults is obese
•Arthritis - most common cause of disability
•One quarter of those with chronic conditions are
limited in daily activities
•Diabetes-leading cause of kidney failure, nontraumatic lower extremity amputations, blindness
Trends in population:
• People are living longer
• Most older adults are community dwelling
• Between 2000 and 2050:
65+ pop. grows from 12.43% to 20.65%
85+ pop. grows from 1.51% to 4.97%
One quarter of the population will be
over the age of 65 by 2050!
(36 years from now)
P.Glassman, P.Subar. Journal of Public Health Dentistry, 2010
Changing Demographics
• Average life expectancy has increased
approximately 3 decades since early 1900’s
• Avg American male today will live to be 76 yrs old
• Avg American woman today will live to be 81 yrs old
• Women represent the larger portion of the 65+ and
85+ age group
• The 85+ group is the fastest growing segment of the
US population
Oral health <> General health
Connected-cannot be separated
Four Common Causes of
Chronic Disease
four modifiable health risk behaviors
• Lack of physical
• Tobacco use
• Poor nutrition
• Excessive
activity
alcohol
consumption
Lack of Physical Activity
• 1/3 adults do not meet recommendations
for aerobic physical activity
• In a 2008 survey, 23% of adults reported
no leisure-time physical activity at all in
the preceding month
Poor Nutrition
• Only 24% of adults reported eating 5 or
more servings of fruits and vegs per day
• Less than 22% high school students
Tobacco Use
More than 1 in 5 American adults smoke
Compared to non-smokers, women who
smoke are 13 times more likely to get lung
cancer
Smoking causes 80% lung cancer deaths in
women
90% of lung cancer deaths in men
Also-larynx, mouth, throat, esophagus, bladder, kidney,
pancreas, stomach, acute myeloid leukemia
Excessive Alcohol
Consumption
• Increased risk of breast cancer with
increasing alcohol intake found in more
than 100 studies
• Drinking alcohol is a risk factor for primary
liver cancer found in many studies
• More than 50 studies report the link
between alcohol consumption and colon
(colorectal) cancer
World Health Organization
• “Elderly”
Population between 65 and 75 yrs
• “Old”
between 76 and 90 years
• “Very old”
over age 90
“Very Old Teeth”
100 year old woman
Systemic Conditions at Higher Risk in
an Older Population
•
•
•
•
•
•
•
•
•
•
•
Arthritis
Cancer
COPD
Diabetes
Cardiovascular disease
Hypertension
Mental Health conditions
Osteoporosis
Parkinson disease
Stroke
Sensory deficits
Oral Conditions at Higher Risk in
an Older Patient Population
• Caries
• Periodontal Disease
• Traumatic Injuries
• Cancers of the Head and Neck
• Oral Mucosal Lesions
• Oral Manifestations of Systemic Diseases
Elderly adults are retaining
their teeth longer
• Must evaluate the
•
•
patient’s oral health in
context with
Social, cultural,
educational, economic,
psychological, and
dietary life experiences
Quality of Life!
Common Findings in Geriatric
Medicine/Dentistry
High prevalence of chronic disease
Frequent use of medications
Difficulty in getting complete history
Difficult to obtain appropriate consults
Why is Oral Health Important
for the
Older Adult?
• Affects the ability to consume and enjoy an
•
•
•
adequate diet
Can affect body weight
Impacts nutritional and systemic health
Links between Periodontal disease and
Cardiac health; respiratory conditions;
diabetes mellitus; stroke
What is more important?
• Chronological age
• Functional status
Functional status in dentistry
Ability to travel for care and
seek services
Ettinger, RL. Oral Health and the Aging Population. JADA 2007;138(suppl_1)5S-6S
Functional Definition of
Older Adults
• Functionally independent older adults
• Frail older adults
• Functionally dependent older adults
• 70% of the elderly population
(or 23.2 million older than 65 years)
live in the community and visit the dental
office independently
Medicare Current Beneficiary
Survey
• Reveals that preventive dental care
reduced dental bills and out-of-pocket
payments by beneficiaries
• They may have more dental
visits, but pay less for total dental
care
Medicare Current Beneficiary
Survey
• Beneficiaries in worse overall health status,
with more physical and health limitations and
difficulties with daily activities, were
concentrated in the group that did not visit a
dentist for any reason!
Moller et al. American Journal of Public Health, November 2010,
Vol 100, No. 11
Significant barriers exist for
needed dental care of the
older adult
• People 65+ have more caries (decay) than
children living in non-fluoridated areas
• Each decade the # of decayed or filled root
surfaces increases affecting more than ½
of all remaining teeth by age 75
• Majority > older adults > periodontal disease
Barriers
• Lack of perceived need for care
• Declines in functional status is associated
with lower levels of dental service use
Incidence and Impact of
Periodontal Disease
• Most older adults are at risk of
developing PD because they have
teeth!!
• 52% have lost fewer than 5 teeth
• Men more serious than women
• 26% are edentulous and
not at risk
Incidence of Periodontal Disease
Data reported by CDC-NHANES-2009-10
• 50% Americans > 30 y/o have PD
• 70% Americans > 65 y/o have PD
PD one of most prevalent chronic diseases,
Similar to CVD and DM
Many patients don’t know they have it!
Published online before print JDR Aug 30, 2012
Cardiovascular Disease
no longer a “Man’s” Disease
• Cardiovascular disease includes coronary heart
disease, high blood pressure, stroke
• Leading cause of death among all American
women~38% of all female deaths
• In women 60+ yrs old- deaths are reported at
59% in developed countries from CVD
• Female heart attack victims-60% die suddenly;
46% survive-will be disabled by heart failure in 6
years
American Heart Association
2011 US Statistics
• Approx 2,200 people die of CVD each day
• An average of one death every 39 seconds
• More than 150,000 people <65 yrs old were
killed by CVD in 2007
• Death occurred well before average life
expectancy of 77.9 years
Roger,V.L. et.al. Heart disease and stroke statistics-2011 update.
Circulation 12/15/2010
Risk Factors for
Cardiovascular Disease
•
•
•
•
•
•
•
High total cholesterol
High triglycerides
High blood pressure
Low HDL
Smoking
Diabetes
Family history
Oral Connections CVD
• Side Effects of medication
• Xerostomia (dry mouth; lowers pH)
• Gingival hyperplasia
• Taste impairment
• Periodontal disease and CVD
• Oral bacteria
• Inflammatory process
Greatest health threat and killer of
Women and Men is
Cardiovascular Disease
• Adults,
regardless of sex or ethnicity,
are 2 to 3 times more likely to suffer
a CV event, fatal or non-fatal,
rather than a non-fatal death
Feinstein,M et.al. Circulation July 2012; 126: 50-59
Oral Systemic Connections
SAME Inflammatory Mediators
• Periodontal Disease
• Coronary heart disease
• Rheumatoid Arthritis
Gene sequence predisposing for CHD also
predisposes for periodontal disease
Oral bacteria were found in the synovial
fluid in joints of individuals with RA
Schaefer AS, et al. PLoS Genet. 2009 Feb:5(2)
Ogrendik,M. Mod Rheumatol. 2009 Jun 24.
AJC-JOP Editors Consensus Paper
July 2009
Dentistry and Medicine must work together to improve
patient care
• Confirmed the connection between PD & CVD
• Explained the underlying biologic and inflammatory
mechanisms that may be the basis for the connection
• Provided recommendations for treating patients with
periodontal disease or cardiovascular disease
• C-Reactive Protein levels in pts with chronic PD fall in
range of those with CVD
Noack B,GencoRJ, Trevisan M,Grossi S, Zambon JJ, De Nardin E. Periodontal infections
contribute to elevated systemic C-reactive protein level. J Periodontol. 2001;
72(9):1221-7
European Society of Cardiology
Consensus Statement on
Perio Health and CVD
• “oral health has an influence on systemic
health in general and on CVD in particular”
• We should “promote oral health and
periodontal health as an important
component in the prevention of CVD.”
Sanz,M: European Society of Cardiology April 2010
Based on evidence that
Periodontal Disease is
independently associated with
Vascular Disease
ALL Cardiovascular prevention programs
must include an oral/systemic component
Evidence Periodontal Disease could
impact CV risk--• What known CV risk factors does PD
influence???
Study: Bacteria causing PD
linked directly to Hypertension
• 653 ‘healthy subjects’ > 55y/o tested for PD bacteria
• Actinobacillus actinomycetum comitans (A.a.), Porphyromas gingivalis
(P.g.), Tannella forsythensis (T.f.), and Treponema denticolor (T.d.)
• Highest tertile of the burden of these VS lowest tertile:
1) Significant increase in Blood Pressure which creates significant
increase risk for ischemic stroke and heart attack
(Systolic BP 9mm Hg higher; Diastolic BP 5mm Hg higher)
2) Pt’s in highest tertile 3X more likely to have HTN
Adjusted for age, race/ethnicity, sex education, BMI, smoking, DM, cholesterol levels
M.Desvarieuxa, et.al. Journal of Hypertension 2010, 28:1413-1421
Study: Bacteria causing PD
linked directly to Hypertension
• It was the concentration of the bacteria &
NOT the clinical diagnosis of PD which
correlated with Blood Pressure
• Makes the case for checking the “burden”
of bacteria and realizing that “subclinical”
PD can harbor significant infection
NOT the clinical diagnosis of PD which
correlated with Blood Pressure
Periodontal Disease also impacts
CV Risk via:
• Lipid changes: HDL
• Sugar changes: HgA1c & Type 2 diabetes
• Arterial inflammation-PD negatively impacts
•
•
the biomarkers used to monitor arterial health
(If artery is “hot” the patient is in peril)
Toll-like ReceptorsPD has association with Insulin Resistance
Evidence supporting PD is associated
with development of Vascular disease
• PD is Independent risk factor CHD
• 2008 USPreventionServicesTaskForce performed
•
exhaustive review of prospective cohort studies
Incidence of CHD in ”healthy” subjects with no known
CV risk factors; follow up 5 – 21 years
• Concluded:
Periodontal Disease is an independent risk
factor of Coronary Heart Disease
Humphrey LL, MD, et al J Gen Intern Med, Sept 2008, 23(12) 209-2086
Other associations with
Periodontal Disease
Evidence PD is associated with CV events
• Study of Pima Indian tribe; PD & CVD mortality
with Type 2 DM-median f/u 11 yr
• Prospective study 628 subjects;
• 204 died from CVD
Saremi,MD,et al American Diabetes Association,Diabetes Care, 2005; 7-9
Other associations with
Periodontal Disease
• Periodontal pathogens are found in
Carotid Atheromas (plaques)
• Study PD & CVD Mortality/Type 2 Diabetes
• Cardio renal mortality; no PD-no deaths!
• Severe PD: 3.2 times risk for death
• Other studies demonstrating increased CV
event risk with Periodontal Disease
Do we have evidence that Periodontal
Treatment is associated with
reduced CV Risk?
Yes
a study showed better glycemic control by a
significant drop in A1c values after perio
treatment
371 DM subjects; half treated, half not
This indicates improvement in glycemic
control which is related to CV risk.
Teeuw,W.J. et al Diabetes Care Feb 2010,vol 33,No 2:421-427
American Heart Association
conclusions:
• Level A evidence exists that PD is
independently associated with arterial
disease
• Available evidence shows a trend toward
reducing CV risk with Periodontal therapy
Peter B. Lockhart et.al. Circulation (published online April 18, 2012)
Causality is difficult to prove;
is not a prerequisite for including
Periodontal Disease Assessment and
Management in Wellness Programs
• The level A evidence that Periodontal
Disease is independently associated with
arterial disease
• along with evidence indicating PD therapy
may reduce CV risk
• is more than adequate reason to include
PD Evaluation and Treatment in any
Cardiovascular Wellness program
Female 100 year old patient; gingival recession, abfraction lesions,
few areas of deep pockets
Diabetes
• 6th leading cause of death
• 3 to 4 times higher risk of heart problems
• 23% increase in deaths from heart disease
in women with diabetes over past 30
years
• Compared to 13% decrease in men
• Kidney disease, nervous system disease,
dental disease, blindness, amputations
Diabetes Risk Factors
• Ethnicity
African American, Hispanic, American Indian
• Age (over 45)
• Obesity
• Family History
• High Blood Pressure
• High Cholesterol
Diabetes prevention
• Weight control
• High-fiber, low-fat diet
• Increasing physical activity
Oral Connections and Diabetes
• Obvious example of systemic disease
predisposing a patient to oral infections,
and consequently the infection potentially
worsening the disease
Oral Connections and Diabetes
• WHY? Predisposition?
• Diabetes causes thickening of blood
vessels resulting in reduced circulation and
a slower flow of nutrients to needed areas
in the body
• Also, harmful wastes remain in the body
longer, weakening resistance of oral
tissues to infection~longer healing times
Diabetes
• Increased risk of periodontal disease and
attachment loss
• Periodontal disease may worsen blood
glucose control
• Diabetics more likely to have periodontal
disease because they are more susceptible
to contracting infections
• Ask patient about their “ABC’s”-A1C, blood
pressure, cholesterol
• Ask about foot, eye, oral, medication
related symptoms
Respiratory disease
• Oral cavity is a potential entry point
for respiratory pathogens into the
trachea
• Biofilms on teeth and dentures are a
reservoir for these pathogens
• Pathogens can be shed and aspirated
into the lower airway, increasing the
risk of infection
Hayes et al., 1998
Scannapieco FA, 1999
Respiratory Disease
• Nursing Home residents or extended hospital
•
•
stay patients are more at risk
Evidence that genetic identity is the same for
bronchoalveolar lavage fluid and dental plaques
of elderly patients
Improved oral hygiene and frequent professional
oral health care reduced the progression or
occurrence of respiratory diseases
Azarpazhooh and Leake, 2006
Osteoporosis
• Significant association with alveolar bone loss
•
•
•
•
and self-reported osteoporosis
Risk of Osteonecrosis of the Jaw (ONJ) if treated
with IV bisphosphonates
Alveolar bone loss affects ability to wear and
tolerate removable prostheses (dentures)
Severe bone loss may preclude implant
placement to stabilize lower dentures
Suggestion that hormone replacement therapy is
associated with retention of more teeth in old
age
Arthritis
• Associated with alveolar bone loss
• No clear cut link
• Patients tend to bleed
• Limited manual dexterity impedes good
oral hygiene
Scully R and Ettinger R, 2007
Alzheimer’s disease
• Diminished salivary flow and poorer oral
health
• Lower numbers of teeth
• Decreased capability to understand
importance of oral hygiene
• Resistance to help