Periodontal and Chronic Diseases: A Literature Review Cathy Hollister, RDH, MSPH, PhD Nashville Area Dental Support Center Research Questions • What chronic conditions or systemic diseases are associated with periodontal disease? • Does periodontal treatment improve the systemic conditions? • What are the implications for medical and dental practice? Methods • Criteria ▫ Peer reviewed journal ▫ Published in the last 5 years ▫ Full text available • Pubmed search ▫ Periodontal AND diabetes ▫ Periodontal AND chronic disease • Reference List of articles Results • 46 articles ▫ ▫ ▫ ▫ 39 original research, 2 meta analysis 3 reviews 2 comment on health care practice • Topics of interest ▫ Associations 24 articles ▫ Impact of treatment 11 articles ▫ Implications for practice 11 articles Limitations • No consistent measures of periodontal disease ▫ Pocket depth, attachment loss, BOP ▫ Microbes, products of inflammation ▫ Tooth loss • Wide range of severity ▫ 4 teeth with 4mm CAL and BOP to hopeless teeth • Short duration • Small sample sizes Associations with Perio • Multiple chronic or inflammatory conditions ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ Type 2 diabetes Gestational diabetes Metabolic syndrome Artherosclerosis CVD Obesity Low birth weight or preterm babies Preeclampsia Chronic kidney disease Non-alcohol related liver disease COPD Squamous cell carcinoma Theory of Inflammatory Complications • Periodontitis contributes to the systemic inflammatory burden • The diseases or the treatment for diseases may suppress immune system • Suppressed immune system may increase the risk for periodontal disease and systemic consequences Hypothetic model for how peridontitis may act as a potential cause of local and systemic inflammation in chronic kidney disease patients. Akar H et al. CJASN 2011;6:218-226 ©2011 by American Society of Nephrology Systemic Disease Treatment Gram negative bacteria Products of Infection Loss of appetite Dry mouth Suppressed Immune System Interaction Effect Tooth Loss Other chronic infections Host response variations Compromised Nutrition Full impact of inflammation has not been explained. Directionality has not been clearly demonstrated. Take Home Message Host response to inflammation may be the common risk factor for both periodontal disease and other chronic diseases Take Home Message • Interactions between diseases is more than additive • OR • All of the pieces of the pie add up to a whole bake sale Directionality • Associations are clear, directionality is not • Perio and then chronic disease OR • Chronic disease and then perio? GDM • Patients with perio AND GDM were more likely to develop Type 2 DM than patients with GDM alone • Authors hypothesize that periodontal disease may contribute to impaired glucose metabolism and future risk of developing diabetes Perio in Healthy Individuals • Evidence of impaired metabolic function increases in the presence of periodontal disease • In 3 separate studies, patients without diabetes had higher A1c levels in the presence of periodontal disease • Does not prove directionality-but suggests a common risk factor- Host inflammatory response? CVD • Periodontal disease increased risk for CVD even after controlling for other known risk factors ▫ Diabetes duration ▫ Hypertension Fisher MA, Taylor GW, West BT, McCarthy ET. Bidirectional relationship between chronic kidney and periodontal disease: a study using structural equation modeling. Kidney Int. 2011 Feb;79(3):347-55. doi: 10.1038/ki.2010.384 COPD • Periodontal disease remained a risk factor after controlling for other know risk factors ▫ Smoking ▫ Environmental Exposures Zeng XT, Tu ML, Liu DY, Zheng D, Zhang J, Leng W. Periodontal disease and risk of chronic obstructive pulmonary disease: a meta-analysis of observational studies.PLoS One. 2012;7(10):e46508. doi: 10.1371/journal.pone.0046508. Pregnancy Outcomes • Equivocal evidence • Conflicting results showing association between periodontal disease and preterm, low birth weight, and preeclampsia Summary • Abundance of evidence of an association between systemic conditions and periodontal disease • Many questions remain ▫ How does the severity of periodontal disease or the type of treatment impact systemic disease? ▫ Is there a direct relationship or is inflammation the confounder that affects each condition? ▫ Does treatment for perio reverse improve the systemic condition? Perio Treatment Outcomes • Current research indicates that treatment improves periodontal health even in the presence of co-morbidities • Measures of periodontal health may improve but inflammation markers may not improve Reversibility: Impact of Perio Treatment on Systemic Conditions • Treat the periodontal disease, reduce the risk of other diseases or complications? • Maybe… Type 2 Diabetes: Moderate-Poorly Controlled DM (7.5-9.5 A1c) • Perio Tx: SRP, Exts, antibiotics • Improved after tx for Moderate Perio ▫ ▫ ▫ ▫ HgA1c lipid profile inflammatory cytokine levels Serum adiponectic (protein hormone secreted from adipose tissue instrumental in glucose regulation) Sun WL, Chen LL, Zhang SZ, Wu YM, Ren YZ, Qin GM. Inflammatory cytokines, adiponectin, insulin resistance and metabolic control after periodontal intervention in patients with type 2 diabetes and chronic periodontitis. Intern Med. 2011;50(15):1569-74. Meta Analysis: Perio & DM • 5 Studies ▫ ▫ ▫ ▫ Moderate DM patients (7.2-9.5 A1c) Moderate periodontal disease Non-surgical periodontal treatment Improvement in periodontal measures • All studies showed an absolute reduction in A1c, some not significant • Katagiri et al. C-reactive Protein ▫ CRP A1c CRP A1c Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: a systematic review and meta-analysis. Diabetes Care. 2010 Feb;33(2):421-7. doi: 10.2337/dc09-1378 Rheumatoid Arthritis • Researchers compared RA patients who DID and DID NOT receive perio treatment • Periodontal treatment improved RA markers regardless of drug therapies Ortiz P, Bissada NF, Palomo L, Han YW, Al-Zahrani MS, Panneerselvam A, Askari A. Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated with or without tumor necrosis factor inhibitors. J Periodontol. 2009 Apr;80(4):535-40. doi: 10.1902/jop.2009.080447 Pregnancy • Meta-analysis of OB outcomes research • Periodontal treatment did not reduce risk of preterm or low birth weight babies BUT • Treatment DID reduce risk of preterm, low birth weight babies Xiong X, Buekens P, Vastardis S, Yu SM. Periodontal disease and pregnancy outcomes: state-of-the-science. Obstet Gynecol Surv. 2007 Sep;62(9):605-15 Implications for Practice • Knowledge: ▫ How informed are dental and medical professionals on oral-systemic link? • Dental care utilization ▫ Do people with chronic conditions get more dental services? • Collaboration ▫ Does the health care system support collaborative care? Knowledge • 2 Studies, surveys among : ▫ Nephrologists & CKD nurses ▫ Internists and Endochronologists • Results: ▫ Medical professionals often have a good understanding of periodontal disease and its role in systemic diseases ▫ They may not be confident or consistent in performing oral health screenings or referrals Knowledge, continued ▫ Reasons for not acting on knowledge are not clear ▫ Most agree that periodontal disease should be included in medical training Bastos Jdo A, Vilela EM, Henrique MN, Daibert Pde C, Fernandes LF, Paula DA, Chaves Md, Bastos MG. Assessment of knowledge toward periodontal disease among a sample of nephrologists and nurses who work with chronic kidney disease not yet on dialysis. J Bras Nefrol. 2011 Dec;33(4):431-5 Owens JB, Wilder RS, Southerland JH, Buse JB, Malone RM. North Carolina internists' and endocrinologists' knowledge, opinions, and behaviors regarding periodontal disease and diabetes: need and opportunity for interprofessional education.J Dent Educ. 2011 Mar;75(3):329-38 Dental and Dental Hygiene Training • The majority of surveyed dental and dental hygiene schools include systemic disease complications • Most responding schools taught the oralsystemic link • Very few (<4%) had multidisciplinary courses • Less than 10% of respondents were confident that medical personnel understood the oralsystemic link Training to Action? • Dental hygienists reported that they did not routinely education DM patients on the oralsystemic link ▫ Lack of time ▫ Patient disinterest ▫ Inadequate information Yuen HK, Mountford WK, Magruder KM, Bandyopadhyay D, Hudson PL, Summerlin LM, Salinas CF. Adequacy of oral health information for patients with diabetes. J Public Health Dent. 2009 ; 69(2): 135–141. doi:10.1111/j.1752-7325.2008.00111.x Utilization • CKD and DM: Fewer patients with these conditions receive dental care than healthy patients • CKD ▫ 5 year study period: 15% of patients had a dental visit • DM ▫ 5 year study period: Fewer visits and procedures ▫ More likely to have perio tx or maintenance DM • Fewer procedures than healthy patients • More periodontally related procedures Collaborations: Barriers • Perceived or actual barriers impact collaborations • Reasons for non-collaborative care among both medical and dental professionals: ▫ Inadequate knowledge ▫ Feeling that nothing could be done to help ▫ Division between medical and dental care delivery “Syndemic” Paradigm: • Fragmented healthcare delivery system • Management of chronic diseases must occur in a new paradigm based on a “syndemic” approach • Syndemic refers to two or more linked health conditions that interact to increase the overall disease burden Iacopino A. New “syndemic” paradigm for interprofessional management of chronic inflammatory disease. JCDA 2009; Vol. 75(9):632-33 Paradigm Shift? • Treatment teams ▫ support comprehensive patient management • Bidirectional screening and referral • Collaborative reinforcement of educational messages • Communication and education among professionals ▫ Professional training and CE • Health policies that focus on risk reduction Challenge • Does your healthcare facility demonstrate: ▫ Adequate knowledge about systemic conditions and treatments? ▫ Common CE? ▫ Collaborative practices? ▫ Treatment teams? ▫ Supportive policies? • Develop an Action Plan!