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Dental TribuneAsia Pacific Edition | 1+2/2016 12 TRENDS&APPLICATIONS Traditionally, dentists have been taught that both dental caries and periodontal disease develop and progress as a direct result of pa- tients’ over-frequent consumption of refined sugars and patients’ fail- ure to remove bacterial plaque ef- fectively. 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. Sincethen,thedentalprofession has blamed patients’ poor oral hy- giene for periodontal breakdown and dental caries while often fail- ingtodiagnoseandtreatothercon- tributing causative factors. Unfor- tunately, while plaque is generally a necessary ingredient of common dental diseases, the explanation contained in these theories of its pivotal role is simplistic given cur- rent knowledge. This brief article will attempt to put the more sig- nificant risk factors in context. Plaque Gingivitis is a natural bodily re- sponse to bacterial accumulation and as such is non-specific. Effec- tive plaque removal will generally reverse gingivitis. The concept of inevitable progression from gin- givitis to destructive periodontitis if oral hygiene is not good is, however, flawed. Figure 1 shows a 46-year-old patient with non-exis- tentoralhygieneoverseveralyears. Figure2showsthesamepatientone month later after around 90 min- utes of scaling and polishing by a studentdentalhygienist.Hehadno active caries and no more than ten per cent bone loss. It has become increasingly evi- dent that while some patients are “susceptible”to periodontal break- down, others are more “resistant”. Common among these host-based factors leading to greater break- down are the presence of diabetes and a smoking habit. Diabetes Several authors have demon- strated a clear relationship be- tween degree of hyperglycaemia and severity of periodontitis, and the risk of cardio-renal mortality (ischaemic heart disease and dia- betic nephropathy combined) is three times higher in diabetics with severe periodontitis than in diabetics without severe peri- odontitis.1 Javed et al. showed that scaling and root planing in prediabetics reduced glycated haemoglobin (HbA1c) by 1 per cent at three months,2 and reductions in HbA1c of 0.3 to 1 per cent 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 peo- ple have impaired glucose toler- ance, a prediabetic state of hyper- glycaemia, or elevated levels of blood sugar.3 In the UK Prospective Diabetes Study,itwasshownthatType2dia- betics who reduce their HbA1c level by 1 per cent are 19 per cent less likelytosuffercataracts,16percent lesslikelytosufferheartfailureand 43 per cent less likely to suffer am- putationordeathduetoperipheral vascular disease. Clearly, not only will control of diabetes facilitate management of periodontitis, but also, probably more importantly, effective man- agement of periodontitis is likely to have major beneficial effects on the serious sequelae of diabetes. Unfortunately, the medical profes- sion is largely ignorant of the po- tential benefits of establishing and maintaining periodontal health. The publication Type 1 Diabetes in Adults: National Clinical Guide- line for Diagnosis and Manage- ment in Primary and Secondary Care (updated in July 2014) was compiledbyaconsensusreference group made up of 30 members.4 These included physicians, en- docrinologists, nurses, ophthal- mologists, dieticians, podiatrists and lay people, but no dentists. Its 153 pages make no mention of dentistry or periodontal disease. The National Institute for Health and Care Excellence document on Type 2 diabetes, also updated in 2014,toofailstomentiondentistry or periodontal disease. Smoking We have known for over 20 years that smoking increases the risk of periodontal breakdown. Odds ra- tiosfordevelopingperiodontaldis- ease as a result of smoking consti- tute a range: 2.5,5 3.97 for current smokers and 1.68 for former smok- ers,6 and 3.25 for light smokers to 7.28 for heavy smokers.7 A smoker with 20 pack years (20 cigarettes per day for 20 years) is up to 600 per cent more likely to lose teethowingtoperiodontaldisease, whereasapatientwithpoorplaque controlhasarounda15percentrisk of progressing to destructive peri- odontitis. Why then do we refer to hygienephasetherapywhensmok- ing is a much greater risk factor thanpoororalhygiene?Howmany dentists spend as much time on smoking cessation counselling as on oral hygiene instruction? Sugar Traditionally, teaching on caries prevention has focused on the numberofsugarexposuresperday, especially between meals. Academic paedodontists suggest that provid- ed there are two daily exposures to fluoride in toothpaste, a maximum of six sugar exposures a day is un- likely to lead to significant enamel decalcificationinchildren. However, a large study con- ducted in 2015 by Bernabé et al. evaluated 1,702 adults over 11 years andconcludedthat“theamountof, but not the frequency of, sugars intake was significantly associated with DMFT [decayed, missing and filledteeth]throughoutthefollow- up period”.8 It thus appears that, at least in adults,“how much”is more impor- tant than “how often” with regard to sugar consumption. This is all the more significant since DMFT measures real outcomes over sig- nificant time spans, while many studies on both caries and gingi- vitis are very short term and use surrogate outcomes, such as de- calcification on an enamel sample, or plaque and gingivitis indices as the basis of their conclusions. Patients are only really interested in real outcomes. Obesity The third National Health and Nutrition Examination Survey showed that body mass index was significantly associated with peri- odontaldisease.Otherstudieshave indicated a less strong association, and with the compounding vari- able of blood sugar levels in pre- diabetics, it is presently unclear whether obesity is in fact an in- dependent risk factor or is asso- ciated with the established role of diabetes. Regardless, obesity is a known risk factor for Type 2 dia- betes and cardiovascular prob- lems,anditispartofthedentalpro- fessional’s role to inform patients of these interrelationships. Recent research in England has suggestedthat1.4millionobesepa- tients would benefit from gastric band or bypass (bariatric) surgery. Currently, around 8,000 people a year receive the treatment on the National Health Service (NHS). If all 1.4 million were offered sur- gery, the researchers estimate it would avert nearly 5,000 heart at- tacks and 40,000 cases of Type 2 diabetes over four years. Theydonot,however,discusspo- tential costs of this surgery, which canvaryfrom£3,000to£11,505,ac- cordingtoNHSEngland.Assuming £5,000 per procedure, this would total around an additional £7 bil- lion in health costs. Nor is there much discussion on death rates (0.5 to 1 per cent with the present skill level of surgeons). Even if surgical skills do not diminish, we should anticipate between 7,000 and 14,000 additional deaths. It is likely that comprehensive periodontal treatment of all obese/ prediabetic patients would be significantly less costly and, hope- fully, result in few if any fatalities. Conclusion It is clear that the simple story of plaquecontrolpreventingprogres- sion of common dental diseases is largely fiction rather than evi- dence-based fact. While effective oral hygiene will always be a signif- icant part of the management of dental diseases, the modern dental professionalmustbeequallyaware of the other common risk factors outlined in this article. Editorialnote:Acompletelistofreferences isavailablefromthepublisher. Crawford Bain, a UK-certified specialist in pe- riodontics, pros- thodontics and restorative den- tistry, is cur- rently Professor of Periodontol- ogy and Direc- torofPost-GraduatePeriodonticsatthe Hamdan bin Mohammed College of Dental Medicine in Dubai in the United Arab Emirates. He can be contacted at crawford.bain@hbmcdm.ac.ae. PRINT DIGITAL EDUCATION EVENTS The DTI publishing group is composed of the world’s leading dental trade publishers that reach more than 650,000 dentists in more than 90 countries. VISIT US DURING AT BOOTH 102 ADX16 AD Plaque, sugar, obesity, diabetes and smoking Reassessing risk factors for periodontal disease By Prof.Crawford Bain,United Arab Emirates Left: Patient at presentation (he requested extraction of all mandibular teeth).—Right: The same patient one month after scaling and polishing (he asked how he could maintain the teeth in this condition). DTAP0116_12_Bain 12.02.16 13:00 Seite 1 DTAP0116_12_Bain 12.02.1613:00 Seite 1