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ePaper created 2016-04-13, 09:49:10 | version 1.38.0
Editor - Online Haseeb Uddin HEALTH INSIDER12 DENTAL TRIBUNE Pakistan Edition January 2016 raditionally, dentists have been taught that both dental caries and periodontal disease develop and progress as a direct result of patients’ over-frequent consumption of refined sugars and patients’ failure to remove bacterial plaque effectively. Miller’s acidogenic theory of caries development and the non-specific plaque hypothesis based on Loe’s work in the 1960s allow dentists to present a simple cause- and-effect explanation to patients. Since then, the dental profession has blamed patients’ poor oral hygiene for periodontal breakdown and dental caries while often failing to diagnose and treat other contributing causative factors. Unfortunately, while plaque is generally a necessary ingredient of common dental diseases, the explanation contained in these theories of its pivotal role is simplistic given current knowledge. This brief article will attempt to put the more significant risk factors in context. Plaque Gingivitis is a natural bodily response to bacterial accumulation and as such is non-specific. Effective plaque removal will generally reverse gingivitis. The concept of inevitable progression from gingivitis to destructive periodontitis if oral hygiene is not good is, however, flawed. Figure 1 shows a 46-year-old patient with non-existent oral hygiene over several years. Figure 2 shows the same patient one month later after around 90 min of scaling and polishing by a student dental hygienist. He had no active caries and no more than 10% bone loss. It has become increasingly evident that while some patients are “susceptible” to periodontal breakdown, others are more “resistant”. Common among these host-based factors leading to greater breakdown are the presence of diabetes and a smoking habit. Diabetes Several authors have demonstrated a clear relationship between degree of hyperglycaemia and severity of periodontitis, and the risk of cardio- renal mortality (ischaemic heart disease and diabetic nephropathy combined) is three times higher in diabetics with severe periodontitis than in diabetics without severe periodontitis.[1] Javed et al. showed that scaling and root planing in prediabetics reduced glycated haemoglobin (HbA1c) by 1% at three months,[2] and reductions in HbA1c of 0.3–1% have been confirmed in several other studies in both Type 1 and Type 2 diabetics. There are estimated to be 745,940 diabetics in the United Arab Emirates. In 304,000 of those cases, the condition has not been diagnosed, and 934,300 people have impaired glucose tolerance, a prediabetic state of hyperglycaemia, or elevated levels of blood sugar.[3] In the UK Prospective Diabetes Study, it was shown that Type 2 diabetics who reduce their HbA1c level by 1% are 19% less likely to suffer cataracts, 16% less likely to suffer heart failure and 43% less likely Continued on page 14 Reassessing risk factors for periodontal disease By Crawford Bain, UK Coronary heart disease patients with no teeth have nearly double risk of death oronary heart disease patients with no teeth have nearly double the risk of death as those with all of their teeth, according to research recently published in the European Journal of Preventive Cardiology.[1] The study with more than 15,000 patients from 39 countries found that levels of tooth loss were linearly associated with increasing death rates. “The relationship between dental health, particularly periodontal disease, and cardiovascular disease has received increasing attention over the past 20 years,” said lead author Dr. Ola Vedin, cardiologist at Uppsala University Hospital and Uppsala Clinical Research Center in Uppsala, Sweden. “However it has been insufficiently investigated among patients with established coronary heart disease who are at especially high risk of adverse events and death and in need of intensive prevention measures.” Analysis included 15,456 patients from 39 countries on five continents This was the first study to prospectively assess the relationship between tooth loss and outcomes in patients with coronary heart disease (CHD). The results are from a substudy of the STABILITY trial2, which evaluated the effects of the Lp-PLA2 inhibitor darapladib versus placebo in patients with CHD. The analysis included 15,456 patients from 39 countries on five continents from the STABILITY trial.[2] At the beginning of the study, patients completed a questionnaire about lifestyle factors (smoking, physical activity, etc), psychosocial factors and number of teeth in five categories (26-32 [considered all teeth remaining], 20-25, 15-19, 1-14 and none). Patients were followed for an average of 3.7 years. Associations between tooth loss and outcomes were calculated after adjusting for cardiovascular risk factors and socioeconomic status. The primary outcome was major cardiovascular events (a composite of cardiovascular death, myocardial infarction and stroke). Patients with a high level of tooth loss were older, smokers, female, less active and more likely to have diabetes, higher blood pressure, higher body mass index and lower education. During follow up there were 1,543 major cardiovascular events, 705 cardiovascular deaths, 1,120 deaths from any cause and 301 strokes. After adjusting for cardiovascular risk factors and socioeconomic status, every increase in category of tooth loss was associated with a 6 percent increased risk of major cardiovascular events, 17 percent increased risk of cardiovascular death, 16 percent increased risk of all-cause death and 14 percent increased risk of stroke. 746 patients had a myocardial infarction during the study Compared with those with all of their teeth, after adjusting for risk factors and socioeconomic status, the group with no teeth had a 27 percent increased risk of major cardiovascular events, 85 percent increased risk of cardiovascular death, 81 percent increased risk of all-cause death and 67 percent increased risk of stroke. “The risk increase was linear, with the highest risk in those with no remaining teeth,” said Vedin. “For example, the risks of cardiovascular death and all- cause death were almost double to those with all teeth remaining. Heart disease and gum disease share many risk factors such as smoking and diabetes, but we adjusted for these in our analysis and found a seemingly independent relationship between the two conditions. “Many patients in the study had lost teeth so we are not talking about a few individuals here,” Continued on page 14 Researchers are connecting levels of tooth loss — due primarily to poor dental hygiene that leads to periodontal disease — with increasing rates of death and stroke. (Photo: Judith Hakze, Freeimages.com) DT International C Fig. 1: Patient at presentation (he requested extraction of all mandibular teeth) Fig. 2: The same patient one month after scaling and polishing (he asked how he could maintain the teeth in this condition) DT International T