Systemic Diseases and Oral Health

The US population is at the beginning of a significant demographic shift; the American geriatric population is burgeoning, and average longevity is projected to increase in the coming years. Elder adults are affected by numerous chronic conditions, such as diabetes, hypertension, osteoarthritis, osteoporosis, cardiovascular diseases, and cerebrovascular diseases. These older adults need special dental care and an improved understanding of the complex interactions of oral disease and systemic chronic diseases that can complicate their treatment. Oral diseases have strong associations with systemic diseases, and poor oral health can worsen the impact of systemic diseases.

Key points

  • Oral disease management is more complex in patients with several systemic diseases.

  • Severe periodontitis adversely affects diabetes control.

  • Additional considerations exist for diabetic patients in a dental office setting.

  • Osteoarthritis of the hands reduces manual dexterity and constrains the patient’s capability of maintaining adequate oral hygiene.

Introduction

Several new studies have shown that an association exists between oral diseases and systemic chronic diseases. Inflammation has additionally been recognized as the key factor that connects many of these diseases. Chronic diseases are defined as long-lasting illnesses, with duration of more than 3 months that affect a person’s life and require constant medical treatment. Chronic diseases more frequently affect aging individuals; 80% have one chronic condition, and 50% have at least 2 conditions. Chronic conditions are the leading cause of death and disability in the United States. According to the National Vital Statistics, the 10 leading causes of death among the 65-years-and-over age group are heart diseases, malignant neoplasm, chronic lower respiratory diseases, cerebrovascular diseases, Alzheimer diseases, diabetes mellitus (DM), influenza and pneumonia, nephritis, unintentional accidents, and septicemia. The authors have chosen to select cardiovascular diseases (CADs), hypertension, diabetes, arthritis, osteoporosis, and stroke to discuss in this article. Their connection to oral health is highlighted and oral recommendations are provided. Aspiration pneumonia and cognitive impairment of older adults are discussed in the articles written by Drs Scannapieco, Shay, Brennan, and Strauss.

Fig. 1 shows the percentage of elder individuals affected by one or more chronic diseases.

Fig. 1
Co-morbidity among chronic conditions for Medicare fee-for-service beneficiaries, 2010.
( From Centers for Medicare and Medicaid Services. Chronic conditions among Medicare beneficiaries. Available at: www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf . Accessed June 13, 2014.)

The complexity of dental treatment in the elderly is greater because of the effects of these chronic diseases, the medications prescribed, and their adverse effects. Systemic diseases can influence oral health, and oral health has an impact on overall health. Social interactions, self-esteem, dietary choices, and nutrition are enhanced by good oral health.

It is important for oral health professionals to understand and recognize the impact of systemic diseases on oral health. With this expanded knowledge, they will be better able to recommend adequate prevention mechanisms and design appropriate oral health treatment plans.

Introduction

Several new studies have shown that an association exists between oral diseases and systemic chronic diseases. Inflammation has additionally been recognized as the key factor that connects many of these diseases. Chronic diseases are defined as long-lasting illnesses, with duration of more than 3 months that affect a person’s life and require constant medical treatment. Chronic diseases more frequently affect aging individuals; 80% have one chronic condition, and 50% have at least 2 conditions. Chronic conditions are the leading cause of death and disability in the United States. According to the National Vital Statistics, the 10 leading causes of death among the 65-years-and-over age group are heart diseases, malignant neoplasm, chronic lower respiratory diseases, cerebrovascular diseases, Alzheimer diseases, diabetes mellitus (DM), influenza and pneumonia, nephritis, unintentional accidents, and septicemia. The authors have chosen to select cardiovascular diseases (CADs), hypertension, diabetes, arthritis, osteoporosis, and stroke to discuss in this article. Their connection to oral health is highlighted and oral recommendations are provided. Aspiration pneumonia and cognitive impairment of older adults are discussed in the articles written by Drs Scannapieco, Shay, Brennan, and Strauss.

Fig. 1 shows the percentage of elder individuals affected by one or more chronic diseases.

Fig. 1
Co-morbidity among chronic conditions for Medicare fee-for-service beneficiaries, 2010.
( From Centers for Medicare and Medicaid Services. Chronic conditions among Medicare beneficiaries. Available at: www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf . Accessed June 13, 2014.)

The complexity of dental treatment in the elderly is greater because of the effects of these chronic diseases, the medications prescribed, and their adverse effects. Systemic diseases can influence oral health, and oral health has an impact on overall health. Social interactions, self-esteem, dietary choices, and nutrition are enhanced by good oral health.

It is important for oral health professionals to understand and recognize the impact of systemic diseases on oral health. With this expanded knowledge, they will be better able to recommend adequate prevention mechanisms and design appropriate oral health treatment plans.

DM

DM is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. There are 2 main types of diabetes.

  • Type 1 diabetes, or insulin-dependent diabetes mellitus (IDDM), is an autoimmune disease that causes the destruction of the insulin-producing β-cells in the pancreas. IDDM is primarily seen in children and younger adults and accounts for approximately 5% of diabetes cases.

  • Type 2 diabetes, or noninsulin-dependent diabetes mellitus (NIDDM), is characterized by resistance to insulin and inadequate production of insulin. NIDDM is the most common form of diabetes seen in adults, accounting for between 90% and 95% of cases.

  • Other types of diabetes including gestational and other genetically specific forms of diabetes account for less than 5% of total diabetes cases.

The following criteria from the American Diabetes Association may be used for the diagnosis of diabetes :

  • A1C ≥6.5%. The test is performed in a laboratory using the method of the national glycohemoglobin standardization program certified and standardized to the diabetes control and complication trials assay.

  • Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours.

  • Two-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

  • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).

Data from the 2011 National Diabetes Fact Sheet show that the prevalence of diabetes in people aged 65 years or older was approximately 26.9% (10.9 million). After adjusting for age and gender, the annual per capita health care expenditure is 2.3 times higher for diabetics than for those without diabetes. Diabetes is especially costly when it presents with complications. It is the seventh leading cause of death in the United States. According to the HealthPartners Dental Group, patients with poorly controlled or uncontrolled diabetes are more susceptible to other illnesses, including periodontal disease. Diabetics aged 60 years and older are more likely to be unable to walk one-quarter of a mile or climb stairs when compared with nondiabetics of the same age.

Systemic Complications of Diabetes

  • Heart disease and stroke. In 2004, heart disease was noted on 68% of diabetes-related death certificates and stroke was noted on 16%. Diabetics have 2 to 4 times greater incidence of stroke and/or heart disease death rates compared with adults without diabetes.

  • Hypertension and dyslipidemia are risk factors for CVD, and diabetes itself confers an independent risk.

  • Blindness and ocular problems. The leading cause of new cases of blindness among adults is diabetes.

  • Kidney disease. Diabetes is the leading cause of kidney failure, accounting for 44% of all new cases of kidney failure in 2008.

  • Neurologic problems. About 60% to 70% of people with diabetes suffer from some degree of nerve damage including impaired sensation on feet or hands, slowed digestion of food in the stomach, or other neurologic problems.

  • Amputations. Peripheral neuropathy and decreased pain sensation has been shown to increase the risk of skin breakdown and severe nonhealing infections. More than 60% of nontraumatic lower-limb amputations occur in people with diabetes.

  • Mental health. People with diabetes have twice the risk of depression. Depression is also associated with a 60% increase of developing type 2 diabetes. Diabetes management is further complicated by mental illness because it often leads to poor patient compliance. Patients with diabetes may also experience anxiety, stress, and anger.

  • Hearing loss. According to the American Diabetes Association, hearing loss is twice as common in people with diabetes. The results of a 2013 study revealed a close link between audiovestibular dysfunction and diabetes. Based on these findings, vestibular dysfunction and sensorineural hearing loss may be considered among the chronic complications due to NIDDM.

Oral Health Implications of Diabetes

  • Gingivitis and periodontal disease. Periodontitis is the major cause of tooth loss in elderly subjects and is considered to be the sixth complication of DM. Adults aged 45 years and older with poorly controlled diabetes (A1C >9%) are 2.9 times more likely to have severe periodontitis than those without diabetes. The likelihood is even greater (4.6 times) among smokers with poorly controlled diabetes. Diabetes also delays healing and increases the risk of oral infection and abscess formation.

A recent Korean study of an elderly population demonstrated the relationship between metabolic conditions and the prevalence of periodontal disease. The results showed that participants with longer durations of diabetes, high blood pressure, and obesity were significantly more likely to have periodontal disease.

Periodontal disease is associated with hyperglycemia and poor control of diabetes. The association is considered to be bidirectional: diabetes is a risk of periodontitis and periodontitis is a possible severity factor for diabetes.

Diabetes induces the formation of AGE (advanced glycation end-products), elevates cytokines levels, and enhances oxidative stress in periodontal tissues exacerbating periodontal disease. However, periodontal treatment can play an important role in controlling diabetes by reducing plasma HbA1C at 3 months by levels equivalent to adding a second drug to a pharmacologic regimen ( Fig. 2 ).

  • Xerostomia is dryness of the mouth, which is caused by salivary dysfunction. Researchers in Macedonia concluded that there is a significant correlation between the degree of xerostomia and salivary levels of glucose. Salivary hypofunction leads to dry and friable oral mucosa, decrease in lubrication, decreased antimicrobial activity, increased caries activity, increased oral fungal infections, glossodynia, dysgeusia, dysphagia, difficulty with mastication, and impaired retention of removable prostheses. Elderly populations are more often affected by xerostomia because of a higher prevalence of systemic diseases and the increased use of prescription drugs.

  • Dental caries have been found to be more common and more severe in diabetic patients. A decreased salivary flow rate, along with poor glycemic control and significantly increased value of HbA1C, was found to be associated with a higher number of carious teeth. Further research is needed to establish a better role for salivary flow rate and minerals with regard to dental caries of diabetic patients.

  • Oral mucosa lesions. Studies have shown that specific lesions, such as geographic tongue, denture stomatitis, and angular cheilitis, occur with significantly greater frequency among diabetics. The cause of geographic tongue in diabetics is still unknown, but may be associated with slower repair and delayed healing caused by the microangiopathy of the oral vasculature in diabetic patients.

  • Fungal infections. Several researchers have reported that diabetics have an increased predisposition to oral candidiasis, denture stomatitis, and angular cheilitis. There is a high incidence of candidiasis as well as a secondary relationship with salivary dysfunction in diabetic patients.

Fig. 2
Simplified schematic depicting etiologic factors and cascade of events contributing to periodontitis that are altered by diabetes. CAL, clinical attachment loss; IL-1β, interleukin-1β; IL-6, interleukin-6; MMPs, matrix metalloproteinases; TNF-α, tumor necrosis factor-α.
( From Ryan ME, Carnu O, Kamer A. The influence of diabetes on the periodontal tissues. J Am Dent Assoc 2003;134:34S–40S; with permission.)

Drug Interactions and Effects

Polypharmacy is a constant issue in the care of geriatric patients. For this reason, potential interactions with medications should always be considered when administering or prescribing any drugs in the dental setting.

  • Insulin, a hormone used to treat IDDM, is compatible with most medications prescribed in the dental office. However, extended doses of aspirin can enhance the hypoglycemic effect of insulin. Consequently, these drugs should not be used for prolonged periods of time.

  • Metformin is an oral antidiabetic drug that may cause an increased hypoglycemic effect with extended use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Similarly, the tablet form of the antifungal agent Ketoconazole can also enhance this hypoglycemic effect. Long-term use of metformin can lead to vitamin B12 deficiency. This deficiency is associated with atrophic glossitis, angular cheilitis, candidiasis, and recurrent aphthous stomatitis.

  • The quantity of epinephrine contained in the dental anesthetic has no significant effect on the diabetic patient’s blood sugar level.

Recommendations for Providing Dental Care to Diabetics

  • Dental providers should assess glycemic control routinely before any invasive procedures.

  • Patients should be asked about any changes in insulin dosage, hypoglycemic medications, and diet before their dental appointment.

  • Consultations with an interdisciplinary health team should be done when needed.

  • Routine screening for diabetes complications and close monitoring of patients should be done at each visit.

  • The oral health provider should emphasize preventive procedures, periodic oral examinations, and prevention of periodontal disease. Patients with diabetes require good oral hygiene habits for maintenance of their oral health.

Hypertension

Hypertension is defined as systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg. It is one of the most common and potentially dangerous medical conditions among the elderly, affecting approximately two-thirds of men and three-quarters of women 75 years and older.

The World Health Organization (WHO) describes hypertension as a global public health issue. In the United States, about 77.9 million (1 of every 3) adults have high blood pressure, and future projections suggest that the prevalence will increase by 7.2% by 2030 ( Table 1 ).

Table 1
Hypertension among elder adult populations (2007–2010)
65–74 y 75 + y
Men 64.1% 71.7%
Women 69.3% 81.3%
Data from National Center for Health Statistics. Health, United States, 2012: Table 64. Hypertension among adults aged 20 and over, by selected characteristics: United States, selected years 1988–1994 through 2009–2012. Hyattsville (MD): 2013. Available at: www.cdc.gov/nchs/data/hus/2012/064.pdf . Accessed August 1, 2014.

It is very important to routinely measure blood pressure at each geriatric patient’s dental appointment. Hypertension is called “the silent killer” because individuals do not present with signs or symptoms and may not realize they have it. Hypertension presents differently in elderly and younger people. Box 1 summarizes the specific features of hypertension among the elderly.

Box 1

  • Elevated systolic blood pressure (BP) is more common in the elderly

  • Impaired baroreflex sensitivity (receptor responsible to buffer blood pressure against sudden changes in posture)

  • Variability in blood pressure during daily activities

  • Hypotension during activities such as standing upright and eating

  • Association with cognitive and functional decline

  • CVD or sleep apnea increases BP at night or awakening

Features of hypertension among the elderly
Adapted from Lipsitz LA. A 91-year-old woman with difficult-to-control hypertension: a clinical review. JAMA 2013;310(12):1274–80.

Systemic Complications of Hypertension

  • Hypertension is associated with shorter overall life expectancy and a shorter life free of CVD.

  • Atherosclerosis is caused when hypertension damages the endothelium in the wall of the blood vessels ; it affects the aorta and its major branches, the coronary artery and the larger cerebral artery. The arterial changes include the narrowing of the lumen of the vessels, weakening of the arterioles, and eventual rupture of the vessel. Atherosclerosis is a common cause of myocardial infarctions and cerebrovascular accidents.

  • CVDs are associated with advanced hypertension. About 50% of people who suffer a first heart attack have blood pressure greater than 160/95 mm Hg. Reducing diastolic blood pressure from 90 mm Hg to 80 mm Hg in a study of people with diabetes reduced the risk of major cardiovascular events by 50%.

  • Cerebrovascular accident or stroke constitutes the leading cause of death in the United States and is also the leading cause of serious long-term disability. High blood pressure, high low-density lipoprotein cholesterol, and smoking are the key risk factors for strokes. Approximately 66% of people experiencing a first stroke have high blood pressure.

  • Increased blood pressure can cause dilation of the wall of an artery or vein, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.

  • Hypertensive retinopathy refers to the rupture and hemorrhage of the retinal arterioles. Examination of the eyes may show early changes of hypertension consisting of narrowed arterioles with sclerosis.

  • Alzheimer disease and hypertension are major determinants of cognitive dysfunction and are associated with alterations in the structure and function of cerebral vessels. These vascular alterations may impair delivery of energy substrates and nutrients to the brain and impede the clearance of potentially toxic products. A systematic review published in September 2013 showed the paucity of research addressing the association between hypertension and dementia. The available data point toward antihypertensives being effective in lowering blood pressure in people with mild to moderate dementia, but there is no evidence of benefit in cognitive outcomes.

  • Hypertensive nephropathy or end-stage renal disease is closely related to chronic hypertension.

Oral Health Implications of Hypertension

  • Drugs used for the treatment of hypertension can cause xerostomia, which potentially causes extensive tooth decay, mouth sores, and oral infections. Patients with xerostomia often complain of difficulty in swallowing and glossodynia. Thiazide diuretics, α-/β-blockers, angiotensin-converting-enzymes inhibitors, and calcium channel blockers increase the risk of xerostomia.

  • The Puerto Rican Elderly Dental Health Study suggests that periodontitis may contribute to poor blood pressure control among adults. However, more studies are needed to ascertain this finding.

  • Gingival hyperplasia is a side effect of Nifedipine, Diltiazepan, Verapamil, and Amlodipine (calcium channel blockers) used in the treatment of hypertension. In severe cases, surgical removal of tissue may be required.

  • Mucosa lesions such as lichenoid reactions may also be caused by several hypertensive medications.

Drug Interactions and Effects

  • Diuretics are the drugs mostly used for the management of hypertension. NSAIDs can decrease the efficacy of thiazide diuretics and β-blockers if used for more than 5 days. Elderly patients should be prescribed the lowest effective NSAID dose for the shortest duration possible. NSAIDs may also induce new onset hypertension or worsen pre-existing hypertension. Blood pressure should be routinely monitored in patients prescribed NSAIDs.

  • Patients medicated with nonselective β-blockers are at risk for acute hypertensive episodes if they receive vasopressors (ie, epinephrine) in local anesthetics. α-/β-Blockers and diuretics may potentiate the actions of anti-anxiety medications and sedative drugs.

  • β-Blockers affect the central nervous system and may cause orthostatic hypotension resulting in fainting and falls after a patient gets up from the dental chair. The prevalence of orthostatic hypotension is higher in older community-dwelling adults with uncontrolled hypertension than in those with controlled hypertension.

  • Calcium blockers cause vasodilation and reduction in heart rate.

  • Calcium blockers, such as Verapamil and Diltiazem, compete with macrolide antibiotics, such as erythromycin and azithromycin, for liver metabolism. The potentially elevated levels of macrolides could result in cardiac toxicity, and elevated levels of calcium blockers can cause bradycardias and atrioventricular block.

Recommendations for Providing Dental Care to Hypertensive Patients

Oct 29, 2016 | Posted by in General Dentistry | Comments Off on Systemic Diseases and Oral Health
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