Please activate JavaScript!
Please install Adobe Flash Player, click here for download

Dental Tribune Middle East & Africa No.1, 2017

Dental Tribune Middle East & Africa Edition | 1/2017 18 GENERAL DENTISTRY “Plaque, Sugar, Diabetes and Smoking – Reassessing Risk Factors” ByProf.CrawfordBain,UAE Introduction Most dentists base their practice on an understanding of various risk factors thought to contribute to the common Dental Diseases. We have been taught that Dental Plaque (Bio- film)isuniversalinthedevelopment of caries and periodontal diseases, the former requiring the added in- gredient of frequent sugar exposure and the latter, if it is to progress to significant bone loss, needing the presence of one or more of com- pounding factors such as Genetic Susceptibility, Smoking and Diabe- tes. Accordingly dental prevention has focused on effective regular plaque removal and a reduction in the frequency of sugar exposure and cigarette use, as well as the overeat- ing/under-exercising combination which pre-disposes to type 2 Dia- betes. Twice daily brushing with a fluoride containing toothpaste com- bined with interproximal cleaning as well as restriction of sugar expo- surestomealtimeshavebeenwidely advocated as effective preventive measures, while twice yearly check- ups have been recommended to fa- cilitate early detection and manage- mentofdentalproblems. It is the purpose of this article to re- view the existing justifications for these commonly held beliefs and, where necessary, offer more evi- dence based approaches to the effec- tive reduction and ideally preven- tionofDentalCariesandPeriodontal Diseases. Measuring the Effectiveness ofPreventiveMeasures Webster’s dictionary describes an OUTCOME as “Something that oc- curs as a result or consequence of an action”. Most dental research uses Surrogate Outcomes to measure ef- fectiveness of preventive and treat- ment interventions. These include a reduction in Plaque Index; less bleeding on probing (BOP), reduced percentages of bacterial pathogens and reductions in other easily meas- urable clinical and microbiological indices which assess hard or soft tis- sue as well as the quantity and qual- ityofplaque. Ultimatelypatientsare more interested in Real Outcomes that relate to their comfort and qual- ityoflife. In medicine a new cancer drug may easily be assessed in its effectiveness of reducing blood white cell counts (a Surrogate Outcome) whereas 5 and 10 year survival rates when us- ing the drug, compared to alterna- tive treatments or a placebo are the Real Outcomes which are important to the patients. By definition they take many years to establish. In den- tistry we are often presented with Surrogate Outcomes; for example plaque removal using power verses manual toothbrushes, but seldom find True Outcomes such as com- parative tooth loss or caries develop- ment when evaluating both. There are simple practical reasons for this. Studies using Surrogate Outcomes are relatively fast and cheap giving a sponsoring company results and a researcher a publication within a few months. Studies using Real Out- comes as measures are very costly; need larger sample sizes and take years to complete. Few companies and few researchers see corporate or academic benefits in participating. Yet these are the studies we need for long term effective prevention. Let’s lookatwhatwehave. DentalCaries There are essentially 2 diseases to consider; Enamel Caries, most com- monly seen in the first 30 years of life, and Root Caries, commonest in the last 30 years of life. From age 30 to 60 fresh carious lesions are un- common except in extreme cases. Surrogate outcomes include plaque indices; percentage of decalcifica- tion and reduction in Lactinobacil- lus counts. For many years we have had a widely accepted real Outcome measure DMFT but because of the long-term nature of using this measure, commonly Surrogates are measured, with the implication that theycanbeextrapolatedtoRealOut- comes. In a recent systematic review assess- ing the effect of Dental flossing on interproximal caries it was conclud- ed that “……self-flossing has failed to show an effect” (1). In lay terms floss- ing does not work to prevent inter- proximal decay, although surrogate outcomes like plaque indices and bleeding on probing almost invari- ablyimprove. If we cannot, honestly, advocate the use of floss to prevent caries, how about toothbrushing? Fortunately we have a longitudinal study with a 26 year follow-up that indicates that “…brushing at least once a day …49% reductioninriskoftoothloss.”(2) There is now also compelling evi- dence that power brushes are more effective than manual brushes in plaque removal and reduction of in- flammation (3), however to date we have been unable to identify studies where these results can be extrapo- lated to real outcomes in the long term. Traditionally the number of sugar exposures per day has been consid- ered important in the initiation of careous lesions. Some studies sup- port this; Ccahuana-Vásquez R. A et al in 2007 examined the “Effect of Frequency of Sucrose Exposure on Dental Biofilm Composition and Enamel Demineralization in the PresenceofFluoride”(4) Tenvolunteerslivinginafluoridated area wore palatal appliances bear- ing human enamel slabs for 14 days. Slabs were exposed to 20% sucrose solution either 0 (control), 2, 4, 6, 8 or 10 x day and the volunteers used fluoridedentifrice3xday.Histologic and microbiological assessment led to the conclusion that“. The findings confirm that fluoride (3 times/day) canreduceenameldemineralization ifsucroseconsumptionisnothigher than6times/day.”(4) How does this relate to the reality of general dental practice? It is a 14 DAY study with purely Surrogate Outcomes. No data on actual devel- opment of caries on patients’ teeth, no DMFT. It is a meaningless aca- demic exercise leading to a publica- tion after only 2 weeks of “clinical” research.Yetitiscitedtoconfirmthe conventional wisdom of number of exposures to sugar being more im- portant. By contrast Bernabé et al followed 1702 adults for over 11 years and concluded “... the amount of, but not the frequency of, sugars intake was significantly associated with DMFT throughout the follow-up period.” They go on to confirm that there is “... a linear dose-response relation- ship between sugars and caries, with amountofintakebeingmoreimpor- tantthanfrequencyofingestion.”(5) The length of this study is 11 years, not 14 days. The outcome (DMFT) is real not surrogate and the sample size is vast, compared to the 10 vol- unteers in Ccahuana-Vásquez study, and yet Cognitive Dissonance will leadmanydentiststopreferthefind- ingsofCcahuana-Vásquezsincethey reaffirm the prevailing conventional wisdom. Root Caries is in fact a testament totheeffectivenessofthedentalpro- fession in extending the life of teeth into old age. It is however a major challenge to a profession largely un- familiar with its management. Fac- tors contributing to this increasing problemarelistedintable1. How can we minimize the develop- ment of root caries? A recent Ran- domised Controlled Trial (RCT) by Tan (6) investigated 306 generally healthy elders having at least 5 teeth with exposed sound root surfaces living in 21 residential homes. They were randomly allocated into one of four groups and followed for 3 years. A control group was given oral hy- giene instruction and regular profes- sional cleanings while 3 test groups had either 1% Chlorhexidine varnish or 5% Na Fluoride varnish applied every 3 months or 38% Ag Diamine Fluoride applied annually. The re- sultsareshownintable2. Clearlythedentalanddentalhygiene professions have an obligation to of- fer such active preventive measures toourageingdentatepopulation. PeriodontalDiseases While Bacterial Plaque is a necessary ingredient in the development of periodontal diseases, the fanaticism with which the Dental and Dental Hygiene professions have focused on “plaque control” has taken atten- tion away from the important role of other risk factors. It is beyond the scopeofthisarticletodiscussgenetic predispositiontoperiodontaldiseas- es, and at present this appears to be a non-correctible factor largely man- aged by extra vigilance. We should however be aware of the relative im- portance of Bacterial Plaque, Smok- ing and type 2 Diabetes as major, potentially manageable, periodontal riskfactors. BacterialPlaque In a systematic review examining the efficacy of dental floss in addi- tion to a toothbrush on plaque and parameters of gingival inflamma- tion,Berchieretalconcludedthatthe evidence reviewed “… did not show a benefit for floss on plaque and clini- calparametersofgingivitis”(7) On the other hand several studies have shown that thorough tooth brushing even once a day effectively controls these same surrogate meas- ures.(8)(9) In an 8 year study of treated perio- dontitis patients, Ramfjord et al 1982 (10) found that the quartile with the worst OH did just as well as the quartilewiththebest OHPROVIDED they had a one hour hygiene main- tenance visit every 3 months. They measured attachment levels, a true outcome. One should bear in mind howeverthateventheworstquartile had a reasonably low plaque index comparedtobaseline. In assessing the importance of periodontal patient compliance (at- tendance) with a recall regimen, a Systematic Review of 710 articles, of which 8 were selected with a mini- mum 5 year follow-up concluded that the Erratic Compliance group have almost double risk of tooth loss compared to regular compliance group(aTRUEOUTCOME)(11). While there may be many situations in the periodontal patient where flossing and other interproximal cleaning methods may assist in preventing or delaying disease pro- gression, it is now clear that, as a uni- versally recommended method for prevention of the commoner dental diseases, routine use of dental floss offers little if any benefit. The profes- sionshouldfocusoneffectivebrush- ingandregularattendance. Smoking We have known for over 20 years of the association between smok- ing and progression of Periodontal diseases. Smoking significantly in- creased the risk of tooth loss due to periodontaldisease(Oddsratios(OR) 2.5 to 6.6). When corrected for other variables, smoking significantly in- creased the risk of increased attach- ment loss compared to matched non-smokers(OR2.4to9.2)(12) A longitudinal study of 349 patients followed for 10 years found that smokers lost almost twice as much bone as non-smokers over this pe- riod, while a smoker who quit had slowerbonelossthanthecontinuing smoker(13). In a later study Hyman and Reid (2003) assessed loss of attachment – another True Outcome – differen- tiating between younger and older patients and found an OR of 18.6 of Loss of attachment >3mm in Smok- ers age 20 to 49. Not surprisingly a Loss of attachment >4mm in Smok- ers age over 50 had an even greater ORof25.6(14). Rather than try to use multiple figures such as the above, I feel it is reasonably to advise smoking patients that continuing smokers progressively increase the risk of tooth loss, and that by the time they have smoked 20 cigarettes a day for 20 years (20 pack/years) they are around 600% more likely to lose teeth due to periodontal disease (OR 6). Smoking cessation counseling should thus be as fundamental to dental prevention as is oral hygiene instruction. Diabetes Preshaw et al in 2012 (15) described bothaclearrelationshipbetweende- gree of hyperglycaemia and severity of periodontitis as well as describing a risk of cardiorenal mortality (is- chaemic heart disease and diabetic nephropathy combined) which is three times higher in diabetics with severe periodontitis than in diabet- icswithoutsevereperiodontitis.This 2 way relationship between these 2 major diseases mandates not only effective glycemic control in order toachievethebestoutcomesofperi- odontal therapy, but also effective periodontal management to reduce the risk of the severe complications ofdiabetes. In a systematic review and meta- analysis Engebretson and Kocher (2013) (16) found a mean treatment effect of a reduction of HbA1c of 0.36% after periodontal treatment in type 2 diabetics. This is consid- eredequivalenttothetype2diabetic needing one less drug for glycemic control. In a recent controlled study in pre- diabetics, thorough non-surgical periodontal treatment reduced the HbA1C levels of the participants by over1%.(17) According to Diabetes UK, if such a reduction could be sustained in Diabetic patients it might result in a diabetic being 19% less likely to suf- fer cataracts, 16% less likely to suffer heart failure and 43% less likely to suffer amputation or death due to peripheral vascular disease. Clearly these are enormous potential health benefits. Discussion It seems apparent that many of our traditional approaches to preven- tion, while clearly well intentioned, have a weak evidence base. It is chal- lenging for any health care profes- sional to be asked to question the veracity and benefits of a long used set of preventive recommendations and there will inevitably be a temp- tation to lapse into Cognitive Disso- nance and possibly even denial. It is however our Duty of Care to offer all patients the most current evidence based advice for the prevention and managementofdentaldiseases. It is beyond the scope of this article ÿPage20 Table1:Factorscontributing to theincreaseinroot caries Table2:Root cariesreductionusingvarious topicalagents(Tanet al2010) •AgeingDentatepopulation •Moreexposedroots •Reducedsalivaflow •Drugswithsugarbaseanddrymouthside-effects •Reducedmanualdexterity •Moresugarcontaining“ready-meals”(Widower’sdisease) NewLesions 1)OHIonly 2.5 2)OHI+1%CHXvarnish3/12 1.1* 3)OHI+5%NaFlvarnish3/12 0.9* 4)OHI+38%AgdiamineFl12/12 0.7* *p=0.001 2)OHI+1%CHXvarnish3/121.1* 3)OHI+5%NaFlvarnish3/120.9* 4)OHI+38%AgdiamineFl12/120.7*

Pages Overview