Conference PPT (5 MB) - Institute for Oral Health

Oral Health in Aging America:
Oral –Systemic Health Linkages
Linda C. Niessen, DMD
LCN

Acknowledgements
• Baylor College of Dentistry, Texas A&M HSC
• DENTSPLY International

VA North Texas Health Care System

Purpose
• Examine the oral health-
systemic health link and the
role that oral inflammation
can play on systemic
diseases
• Discuss the most common
medical conditions and
medications and their
effects on oral health care
• Identify future oral health
system needs to insure oral
health in an aging America

Thesis
• The mouth is connected to the
rest of the body.
– New research is identifying the
effects of oral infection and
inflammation on target organs.
• Caring for older adults makes
these linkages readily
apparent.
– Dental professionals need
greater interaction with the
overall health care system.
• Patients are beginning to
understand the relationship
between oral health and
systemic health.

Thesis
• Oral–systemic link will re-assert
the importance and value of
prevention of oral diseases.
– Oral diseases play a pivotal role in chronic
disease management
• Patients value preventive care,
even when they don’t t comply.
• Preventive care tells patients
you value their future,
regardless of how long it is!

Changing Demographics and
Expectations
• This is not your mother’s
aging society
• Baby boomers will redefine
what it means to age
successfully, gracefully!
• It includes maintaining
good health and good oral
health
• Older adults will seek
information about their
health from a variety of
sources

Life Expectancy of Women and Men, US
20
15
10
5
0
65
years
75
years
85
years
95
years
100
years
Men-Black 14.5 9.4 5.7 3.6 2.9
Men-White 16.3 10.1 5.6 3.1 2.4
Women-Black 17.4 11.2 6.5 3.6 2.7
Women-White 19.2 12.1 6.7 3.5 2.7
Source: Centers for Disease Control and Prevention, US National Center for Health
Statistics, Life Expectancy by Age, Race and Sex in the United States, 2000.

Successful Aging
• Engages with life
• Avoids disease
• Maintains high
cognitive and
physical function

Successful Aging
100%
80%
70%
60%
40%
30%
20%
0%
Factors
Lifestyle
Genetics

Genes are not your destiny

Principles of Geriatric Medicine
• Age Related Changes
• Disease Related Changes
• Atypical Presentation of Disease
• Multiple Pathology
• Under Reporting of Disease Symptoms
• Functional Status Assessment
• Role of Interdisciplinary Team

Multiple Pathology
• Heart disease
• Hypertension
• Arthritis
• Stroke
• Diabetes
• Depression…
– before you even
look in the mouth
Your initial medical history and medication history will
take longer!

Chronic Diseases in Older Adults
• Top 5 Causes of Death
– Heart Disease
– Cancer
– Stroke
– Alzheimer’s s disease
– Respiratory disease
• Top 5 Chronic Diseases
– Arthritis
– Hypertension
– Heart Disease
– Hearing Impairments
– Cataracts
What we die from!
What we live with!

Heterogeneity of Elders
• Active Elders 85%
• Chronically Ill 10%
• Nursing Home 5%
Residents
The differences in status often result from the number of chronic
diseases and ability to maintain function, e.g. activities of daily
living.

Cardiovascular Disease in the Elderly
• Hypertension
• Myocardial Infarct
• Congestive Heart Failure
• Atrial Fibrillation
• Conduction System
Defects
• Valvular Heart Disease
Does your health history form capture these different forms of
heart disease and the medications taken to manage them

Cardiac Disease and Treatment
• Organ damage due to
hypertension
• Muscle damage due to
decreased blood supply
(angina, MI)
• Conduction system
defect (arrythmias)
• Pump malfunction (CHF)
• Atrial fibrillation
• Valvular disease
• Diuretics, ACEI, CCB,
β-blockers
• NTG, CABG
• Pacemaker, implanted
defibrillation
• Digoxin
• Plavix (clopigrel), ASA
• Prosthetic Valves

Oral Examination
• Caries
• Periodontal disease
• Oral soft tissue
lesion
• Missing teeth

Cardiovascular Disease and Periodontal
Infections
• Evidence continues to mount that periodontal
infections play a contributory role in the development
of cardiovascular disease (remember Dr. Roizen’s
video yesterday)
• Are we ready to recommend and reimburse
periodontal treatment in the patient with moderate-
severe, localized or generalized periodontal disease
as part of the management of his/her cardiovascular
disease
Source: R Demmer and M. Desvarieux. Periodontal
infections and cardiovascular disease. JADA 137: 14s-
20s, October, 2006.

Dental Implications of
Cardiovascular Treatment
• Physician consult
– When in doubt, ask
• Hypertension
– Check BP at each dental visit
• Medications
– Xerostomia –BB, ACEI, CCB, ARB
– Gingival Overgrowth-nifedipine
– Lichenoid reactions
– Bleeding – Plavix, Aspirin
• Valvular Disease
– New SBE Guidelines

CARDIAC CONDITIONS FOR WHICH PROPHYLAXIS FOR
DENTAL PROCEDURES IS RECOMMENDEDFOR
PREVENTION OF BACTERIAL ENDOCARDITIS*
• Prosthetic cardiac valve
• Previous infective endocarditis
• Congenital Heart Disease (CHD)
– Unrepaired cyanotic CHD, including palliative shunts and conduits
– Completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the e first 6
months after the procedure (endothelialization occurs within 6 month m
of
procedure)
– Repaired CHD with residual defects at the site or adjacent to the e site of a
prosthetic patch or prosthetic device (which inhibits endothelialization)
lization)
• Cardiac transplant recipients who develop cardiac valvulopathy
*Except for the cardiac conditions listed above, antibiotic prophylaxis is no longer
recommended for any cardiac condition or problem.
Source: Current American Heart Association Guidelines
Published May 8, 2007, Circulation, , Vol. 115.

Dental Procedures and
Rational for Revisions
• All dental procedures that involve manipulation of gingival
tissue or the periapical region of the teeth or perforation of
the oral mucosa (not needed for LA through non-infected
tissue, radiographs, placement of and/or adjustment of
removable or orthodontic appliances, shedding of 1 o teeth)
• Infective endocarditis (IE) more likely to result from frequent
exposure to random bacteremias associated with daily
activities
• Maintenance of optimal oral health & hygiene may reduce
incidence of bacteremia from daily activities and may be
more important than prophylactic antibiotics for a dental
procedure to reduce the risk of IE
Source: Wilson, et al. Prevention of infective endocarditis: Guidelines from
the American Heart Association. JADA 138:739-760, 760, June 2007.

Cerebrovascular Accident
• 500,000 new cases each
year
• 3rd most common cause
of death
• Can be thrombolytic or
hemorrhagic
• Most common sequelae-
motor loss of dominant
side

Cerebrovascular Accident
• Study reported a 400%
increase in stroke risk
associated with
periodontitis but found
no relationship between
caries and stroke.
• Oral inflammation plays
a role in the mechanism
of action
Source: Grau AJ, Becher H, Ziegler CM et al. Periodontal disease
as a risk factor for ischemic stroke. Stroke 35(2): 496-501, 2004.

Dental Implications of CVA
• Transportation to office
• Dominant hand function and
oral self care abilities
• Aphasia
• Depression
• Transfer to dental chair
• Loss of oral motor function
• Post-op op meds:
– Anti-coagulants
– Bleeding-need need INR data
– Gingival overgrowth

•Dilantin (Anticonvulsant)
•Nifedipine (Calcium
Channel Blocker)
•Cyclosporine
(Immunosuppressive)
•New BP medications
• Isn’t dental care
medically necessary
after a CVA as part of
the management

Diabetes Mellitus
• >9% of population
• Onset
– Type I-5-10% I
(Juvenile)
– Type II- 90-95% 95% (Adult)
• Medications
– Oral hypoglycemic
– Insulin
• Research on diabetes
and perio disease most
developed

Dental Implications
• Higher risk of infections
– periodontal disease
– oral candida
• Research is showing that when
diabetics have their periodontal
infections treated, their insulin
requirements decrease
• Doesn’t t this suggest that
treatment of periodontal
infections is part of the
management of the diabetic
patient

Source: Considerations for treating the dental patient with diabetes.
American Dental Association, 2003.
Considerations for Dental Treatment
• More frequent recall
• Emphasis on soft
tissue management
– SRP prn
– Antiobiotic treatment
• AM appointments (or
when insulin at peak)

Diabetes – The poster disease for
reconnecting reimbursement for
oral care with medical care
• In the management of the
diabetic patient, why can
the diabetic patient have
his:
– blood glucose managed
– cardiovascular disease
treated
– eye disease resolved
– foot care evaluated
– periodontal infections
ignored

Osteoporosis
• Loss of bone mass and
architecture
• Increased risk of
fracture
• Female to male ratio
4:1
• 1.5 million fractures
annually

Treatment of Osteoporosis
• Vitamin D
• Calcium
• Weight bearing
exercise (not
swimming)
• Strength training
• Fluoride (Pak et al)
• Bisphosphonates
– Fosamax, Aredia,
Boniva

Bisphosphonate Induced
Osteonecrosis of the Jaw (ONJ)
Slide courtesy of Dr. Harry
Gilbert, VAMC Houston
Zolendronic acid (Zometa) - IV
Novartis
Pamidronate (Aredia) - IV
Novartis
Alendronate (Fosamax) - oral
Merck
Risendronate (Actonel) - oral
Procter and Gamble
Pharmaceuticals

Risk of Osteonecrosis of the Jaw for
Patients Taking Bisphosphonates
• Risk for developing ONJ with IV bisphosphonates
is ~10-12% 12% (multiple myeloma, breast CA-any CA
metastatic to bone; drugs control osteoclasts).
• Risk for developing ONJ with oral bisphosphonates
is less than 1%.
• Lower risk for ONJ in first 6 months of IV therapy;
first 3 years of oral treatment.
Source: Migliorati, CA, JA Casiglis, J. Epstein, PI Jacobsen, MA Siegel, SB Woo.
Managing the care of patents with bisphospnhonate-associated associated osteonecrosis:
An American Academy of Oral Medicine position paper. JADA 136(12):1658
):1658-68, 68,
2005.

Strategies for Patients on
• Take a good history
Bisphosphonates
– Oral bisphosphonates < IV
Bisphosphonates
– Oral bisphosphonates < 3 yrs
• Consult with patient’s s MD
• Treatment Planning
– Informed consent
– Tooth conserving procedures
(endo v. extraction)
• Prevention
– Good oral hygiene
– Regular dental visits
Slide courtesy of Dr. Richard
Davis, Cleveland, VAMC
Source: Robert Marx, Bisphosphonate-induced Osteonecrosis of the Jaw, 2006.

Rheumatoid Arthritis and
Osteoarthritis
• Inflammatory
mechanism
• Disabilities
– How does patient get
to your office
– Evaluate oral hygiene
self care
• Medications
– Pain meds

Professional Oral Care
• Control biofilms with
scaling and root planing
based on patient’s s needs -
PRN
• Reinforce daily oral self
care
• Will require more of the
dental hygienist’s s time
• Consider reimbursing for
time rather than CPT code
– Or add co-morbities

Degenerative Joint Disease
• Can lead to joint
replacement
• Can have total joint
replaced or pins placed
to repair fractures
• Joint replacements
require antibiotics for
high risk patients

ADA Guidelines on
Prophylactic Antibiotics for
Patients With Prosthetic Joints
If:
Healthy
Risk Factors
NO
YES
Source: Antibiotic prophylaxis for dental patients with total
joint replacements. JADA, 134:895-898 July 2003.

Patients at potential increased risk
of hematogenous total joint
• All patients during first two years
following joint replacement
• Immunocompromised/immuno-
suppressed patients
– Inflammatory arthropathies: rheumatoid arthritis,
systemic lupus erythematosus
– Drug- or radiation-induced induced immunosuppression
• Patients with co-morbidities

Patients at potential increased risk
of hematogenous total joint
• Patients with co-morbidities
– Previous prosthetic joint infections
– Malnourishment
– Hemophilia
– HIV Infection
– Insulin-dependent (Type 1) diabetes
– First 2 years following joint placement
– Malignancy
Source: Antibiotic prophylaxis for dental patients with total
joint replacements. JADA, 134:895-898 July 2003.

Medication Use
• OTC Medications
(not perceived as
medicines or
serious)
• Multiple
prescription
medications
• Compliance
• Interactions
• Change frequently

Medications
• Prescription Meds
– Anti-hypertensives
– Diabetic meds
– Cholesterol
lowering
– Cardiac meds
– NSAID (anti-
arthritics)
– Anti-depressants
• OTC Meds
– Antacids (sugar
content)
– Analgesics (ASA)
– Vitamins (E and C)
– Herbal
Supplements
» Glucosamine
» Chondroitin sulfate
» Co-enzyme Q
Bleeding and oral dryness among concerns with multiple
medication use.

Saliva: A Natural Resource

Signs of Xerostomia
• Increased caries,
especially root caries
• Epithelial atrophy
• Inflammatory fissuring
• Oral candida infection

Differential Diagnosis of
Alterations in Salivary Flow
• Multiple medications
• Head and neck
radiation
• Endocrine changes
• Primary salivary gland
pathology

Medications Causing Oral Dryness
• Antidepressants
• Antihistamines
• Antihypertensives
• Antineoplastics
• Antipsychotics
• Antispasmodics
• Decongestants
• Diuretics
• Tranquilizers
Medications taken on a regular basis for a
long time cause more oral dryness.

Treatment Options
• Hydration
– Older adults often
don’t t thirst
– Frequent liquids
– Reduce liquids
containing caffeine or
alcohol
• Mechanical
– Chewing xylitol gum

Johnson JT,et al. Oral pilocarpine in post-irradiation xerostomia in patients
with head and neck cancer. New Engl J Med, 329:390, 1993
Prescription Medications
• Pilocarpine
(Salagen®)
– 5 mg. tid (not to
exceed 30 mg/day)
– Treat for minimum
of 90 days
– Contraindications:
Asthma, glaucoma
– Side effects:
sweating
• Cevimeline
(Evoxac)
– 30-60 mg. Tid (not
to exceed 180
mg/day)
– Contraindications:
asthma, glaucoma,
severe COPD
– Side effects:
sweating

Salivary Substitutes
• Provide palliative
relief from oral
dryness
• Replace minerals
and enzymes in
saliva
• Can use prn
• Contraindicated-
alcohol-based
mouthrinses
• Ingredients include:
– ions: Na, Cl, Mg, F, Ca,
Phosphates
– flavoring: lemon, mint,
neutral
– lubricants/sweeteners-
glycerin, sorbitol,
xylitol
– preservative-paraben
paraben
– enzymes- lactoferrins,
peroxidases, etc

Risk Assessment
Who is susceptible
LCN

Risk Assessment
There are no generic
patients.

Risk Assessment
Oral-systemic health
research is
demonstrating the
importance of oral
inflammation and
that oral care is
critical to the
management of
chronic diseases.

Maintaining teeth is
sometimes just as
difficult- but plays a
key role in daily
eating, speaking,
smiling, swallowing.
Losing teeth is
psychological and
physically difficult.

Conclusions
• Mouth is connected to the rest
of the body.
• Older adults demonstrate the
connection between systemic
diseases and medications on
oral health more readily than
other populations
• Presence of oral infection &
inflammation can exacerbate
systemic illnesses and vice
versa
• We need a social marketing
campaign about the
relationship b/w oral disease &
systemic diseases

Conclusions
• Oral diseases can play a
pivotal role in chronic disease
management.
• High level of interaction
between the dental care
system and the medical care
system is critical to healthy
aging.
• Linking financing &
reimbursement between oral
care system & medical system
may improve system
efficiencies and lower costs
• Very vulnerable continue to
have the least access to oral
health care

What would you do differently
as a result of this conference
• Will it be to control your own aging through gene expression
and reduce your stress per Dr. Roizen and Dr. Singer
• Become an advocate and care for more older adults per Dr.
Shuman
• Examine new methods of financing & reimbursement per Dr.
Jones
• Educate next generation of dental and medical professionals
together per Dr. Berkey
• Develop novel community delivery programs per Dr.
Helgeson
• Let your voice be heard and insure that oral health is included
in the debate on universal health coverage in the US per Dr.
Olsen

“May you die very young,
at a very old age.”