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CONTINUING EDUCATION Course Number: 181 Oral Effects Associated With Obesity and Bariatric Surgery Authored by Alison L. Glascoe, DDS, MS; Ronald S. Brown, DDS, MS; Derrick K. Eiland, DDS; and Cheryl E. Fryer, DDS, MS, MA Upon successful completion of this CE activity, 2 CE credit hours may be awarded A Peer-Reviewed CE Activity by Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in indentifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp. Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. June 1, 2012 to May 31, 2015 AGD PACE approval number: 309062 Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements. CONTINUING EDUCATION obesity as a calculation of the ratio of body weight (kg) by the square of height (m2).5,6 This calculation is also known as the Body Mass Index (BMI).5,6 A person having a BMI > 30 kg/m2 is considered obese.5,7,8 Oral Effects Associated With Obesity and Bariatric Surgery Systemic and Oral Factors Associated With Obesity Obesity is associated with and is considered a risk factor for many systemic chronic conditions such as diabetes, chronic kidney disease, cardiovascular disease, high blood pressure, stroke, arthritis, respiratory complications such as sleep apnea syndrome, and various forms of cancer.9,10 Many of these conditions, such as cardiovascular disease, secondary to atherosclerosis, stroke, high blood pressure, diabetes, and cancers are leading causes of death in most developed countries. Obesity is associated with psychosocial problems such as lack of self-esteem and a sense of lacking personal strength.5 Obesity has also been associated with significant oral health problems such as periodontal disease, caries, and xerostomia.1,9,11-15 Dental caries may develop secondary to xerostomia (ie, dry mouth). Xerostomia can increase one’s risk for caries formation since there is a reduction in the amount of saliva present in the mouth. Saliva contains enzymes, buffering agents, and antibodies which protect the teeth against bacterial decay.16 Many obese patients suffer from sleep apnea.5 When one has sleep apnea, one stops breathing during periods of time while sleeping. Sleep apnea has secondary medical manifestations such as hypertension, cancer, and congestive heart disease.5 Xerostomia is highly associated with sleep apnea. Effective Date: 01/01/2015 Expiration Date: 01/01/2018 Learning Objectives: After reading this article, the individual will learn: (1) the current state of the medical and dental literature regarding obesity, and (2) the bariatric surgical treatments for obesity and the positive and negative outcomes from bariatric surgical treatment. About the Authors Dr. Glascoe is an associate professor in the department of preventive services at Howard University College of Dentistry in Washington, DC. She is a Diplomate of the American Board of Periodontology and maintains a private practice in periodontics in Baltimore. She can be reached via e-mail at the address [email protected]. Dr. Brown is a professor in the department of clinical dentistry at Howard University College of Dentistry and a clinical associate professor in the department of otolaryngology at Georgetown University Medical Center, Washington, DC. He can be reached at [email protected]. Dr. Eiland is a native of Washington, DC, and graduated from Howard University College of Dentistry. He is an active member of the American Academy of Oral Medicine. He has had a long-term private practice in Washington, DC, and is presently an assistant professor within the oral diagnosis section of the department of comprehensive dentistry of Howard University College of Dentistry. He can be reached at [email protected]. Dental Treatment and the Obese Patient Treating the obese patient population in a conventional dental primary care setting is often very challenging and risky. For example, providing and achieving profound dental anesthesia, which is a basic essential for rendering restorative treatment against most carious lesions, and providing sedation are often difficult when treating the obese patient.17,18 Besides the challenges practitioners face when trying to render dental care to the obese dental patient, many dental practitioners endure physical challenges associated with treating the obese patient population. For example, most standard dental chairs are equipped to take a static load of approximately 300 pounds (lbs) but may not be able to lift or recline at this load.17 Bariatric dental chairs are available and able to withstand a static load of approximately 1,000 lbs, but the cost is typically 4 times the cost of a standard dental unit.17 Dr. Fryer is on faculty at Howard University College of Dentistry, where she serves as director of faculty development and director of the Caries Management Clinic for third-year dental students. She can be reached at [email protected]. Disclosure: The authors report no disclosures. A ccording to the National Health and Nutrition Examination (NHANES) 2007 to 2008, it is estimated that 9 million Americans (approximately 32.2% of the adult male and approximately 35.5% of the adult female population) are obese.1,2 Obesity has become more problematic as lifestyles have become more sedentary. Obesity has become a major public health concern worldwide.1-3 The World Health Organization (WHO) has estimated that more than one billion people worldwide are overweight or obese.1,4 The WHO has classified Bariatric Surgical Techniques There are many reasons to motivate the obese patient to make lifestyle changes in order to lose weight. There are many op- 1 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery tions for weight loss that include dieting, physical exercise, pharmacologic adjuncts, and surgical intervention.9,19-21 Bariatric surgery is an intervention that is a successful option both clinically and cost-effectively for those who are moderately to severely obese.9 One of the many benefits of weight loss as a result of surgical intervention is a significant reduction in mortality and a reduction in the development of co-morbidities such as diabetes and cardiovascular disease.9 Bariatric surgery for weight loss is only recommended for those who have been unsuccessful in using nonsurgical methods for weight loss. Currently, there are 3 main bariatric surgical techniques.22,23 The gastric band is a procedure that involves placing a silicone ring around the stomach.22,24 This ring divides the stomach into 2 compartments: a small one above that will store small quantities of food, creating the sensation of satiety, and a larger area below where normal digestion will occur.22,24 The misuse biliopancreatic procedure involves removing three fourths of the stomach and shortening the intestine.22,23 This procedure results in reducing the absorption of nutrients.22,23 The final surgical option is called gastric bypass Roux-en-Y procedure.22 Currently, this is the most commonly performed bariatric surgical procedure. This procedure involves stapling the stomach to create a small pouch, thereby reducing the amount of food that can be consumed.22,25 A part of the small intestine is diverted, delaying the mixing of food with gastric juices.22,25 This technique entails a combination of malabsorptive and restrictive procedures. With the Roux-en-Y technique, the gastric capacity is reduced. A restrictive ring is placed, segmenting the duodenum (the first section of the small intestine) and the jejunum (the middle section of the small intestine). This segmentation or exclusion of the digestive system ultimately results in a decrease in the amount of food digested and in the quality of ingested nutrients.5,26,27 tential positive outcomes of bariatric surgery that affect systemic health include a reduction in sleep apnea, a decrease in systolic and diastolic blood pressures, a reduction in the risk for coronary artery disease, a reduction in total cholesterol, a reduction in the risk for diabetes, changes in plasmatic hormones related to ovulation, and a reduction in systemic inflammation.9,22,31 Adverse Effects of Bariatric Surgery Despite the potential for many positive outcomes, adverse effects or complications of bariatric surgery may also frequently occur. Some factors that may influence the results of bariatric surgery include the age of the patient. In general, the elderly tend to develop more postoperative surgical complications, which doctors and researchers attribute to a lower functional reserve of this population. In addition, the elderly tend to have more metabolic diseases such as diabetes that contribute to less favorable outcomes.22,32 Adverse effects and manifestations following bariatric surgical procedures include changes associated with the following: gastro-esophageal, respiratory, cardiovascular, endocrine, and psychological.22,33 Some common gastro-esophageal complications include regurgitation, gastric ulcers, chronic vomiting, reflux, diarrhea, anemia, dehydration, and an increased risk for gastro-esophageal cancers.22 Previously, mortality figures were considerably higher than at present. In a study of 6,118 patients undergoing bariatric surgery, there were 18 deaths recorded within 30 days of the surgery.34 Currently, mortality rates secondary to bariatric surgery are less than 1%.35,36 The oral cavity is an integral part of the human digestive system, and thus one would expect that anything that affects the other components of the digestive system would potentially affect the oral cavity. High acidic levels in the mouth are an essential contributing factor for the development of dental caries.22,37,38 Dental plaque found in the oral cavity is composed of cariogenic bacteria.20 These bacteria metabolize carbohydrates or sugars. A by-product of this metabolism is the formation of organic acids such as lactic acid, which dissolves away the mineral content of tooth structure resulting in the formation of dental caries.3,22 High acidic levels in the mouth not only contribute to caries formation but are also an essential contributing factor for the development of tooth erosion.37-39 Tooth erosion is defined as the chemical dissolution of dental tissues by a chemical process (acid or chelating agents) without the bacterial involvement.22,40 The presence of dental caries and tooth erosion often result in hypersensitivity to external stimuli. There are 3 main sources of acid in the oral cavity: (1) bacterial fermentation of the carbohydrates, specifically sugar, that are consumed from foods and beverages; (2) foods with high intrin- Positive Outcomes of Bariatric Surgery There are several potential positive outcomes as a result of bariatric surgery. Some are associated with improving the psychological and emotional health of the patient. Examples would include an increase in the quality of life, weight loss, an improvement in self-esteem, emotional stability, and greater satisfaction with one’s body image and in relationships.1,28,29 Researchers have also noted an increase in patients chewing their food more completely but doing so more slowly following bariatric surgery, which may be related to an increase in metabolic energy.30 This would also potentially optimize the digestive process.30 There are also significant changes that occur in systemic health following bariatric surgery. Examples of some of the po- 2 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery sic levels of acid; and (3) gastric acid.37,41-43 Gastric acids may be introduced into the oral cavity secondary to vomiting, chronic reflux, and regurgitation, which all are frequent occurrences following gastric bypass surgery. Treatment options for dental caries and tooth erosion include a team approach involving all members of the dental team: dentists, hygienists, dental assistants, and administrative support workers. All on the dental team can play a part in patient education and motivation. This would include motivating the patient to adhere to a strict recall regimen. In addition, patient education and dietary or nutritional counseling need to be reinforced by all team members. These patients would benefit from fluoride supplementation provided both in the dental office and at home. In addition, clinicians should consider using fluoride-releasing restorative materials and dental adhesives whenever possible.44 Post-bariatric surgery, patients are also at an increased risk for nutritional and mineral deficiencies secondary to poor absorption of nutrients by the stomach and intestine. Examples include an increased risk for iron, zinc, copper, vitamin A, vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K, calcium, and folic acid deficiencies.15,22,33,45 An iron deficiency increases one’s risk for developing anemia. A vitamin B12 deficiency may result in oral burning and neuropathy.46 A vitamin E deficiency can result in neuromuscular problems, anemia, and impairment of the immune response.47,48 Such deficiencies, including folic acid deficiency, may also result in anemia, which would decrease healing secondary to periodontal therapy.30 Nutritional deficiencies such as vitamin C or ascorbic acid deficiency can impair the formation and subsequent repair of collagen.27 Collagen is the predominant component of the skin, gingiva, and the attachment apparatus: periodontal ligament, cementum, and bone. Collagen maintenance is therefore of utmost importance for periodontal health. A deficiency in ascorbic acid may affect the ability of the periodontium to regenerate and repair. It may also result in an increase in gingival bleeding, reduction in tissue tone (ie, the development of a more friable gingival tissue), hemorrhage in the periodontal ligament, osteoporosis of the alveolar bone, and tooth mobility, all of which increase the risk for periodontal disease.4 There are 2 main forms of periodontal disease. The most common is the plaque-induced gingival disease called gingivitis, which is a reversible form of periodontal disease. Gingivitis is characterized by bleeding gingival tissues and is not associated with moderate to severe alveolar bone loss (ie, periodontal pocketing and gingival attachment loss). The second most common form of periodontal disease is periodontitis. Periodontitis is a destructive, irreversible inflammatory process that results in atrophy or loss of the underlying bone and connective tissue support around the teeth.46,49 Patients with periodontal disease frequently complain of bleeding and painful gums, hypersensitive teeth, and mobile teeth. For those at risk for developing periodontal disease, patient education and motivation, monitoring the patient during frequent recall dental appointments, and aggressively treating any site showing signs of active periodontal disease are ways to reduce the risk for periodontal disease. A vitamin D deficiency is another potential outcome of bariatric surgery. Vitamin D is essential to maintain normal calcium metabolism, and is necessary for healthy bone growth.5,50 When vitamin D levels are deficient, calcium absorption becomes insufficient, which may result in secondary hyperparathyroidism.5 As a result of this process, the body removes calcium from bone and reabsorbs it from the kidneys in an effort to re-establish homeostasis.5 Patients who are deficient in vitamin D are at an increased risk for developing osteoporosis. Osteoporosis is characterized by loss of trabecular bone and thinning of the cortical bone, leading to an increased risk of fractures.5 Osteoporosis may affect the mandible and maxilla. A reduction in bone density of the mandible and maxilla may increase one’s risk for periodontal disease and potentially be a contraindication for the placement of dental implants.5,26 Osteoporosis may also result in alveolar bone loss.5 Methods to be used to reduce the risk for the development of nutritional deficiencies include frequent monitoring of these patients and counseling by physicians and nutritionists; however, once a nutritional deficiency has been diagnosed, the patient must receive nutritional and mineral supplementation.51,52 Another consideration for the dental patient following bariatric surgery is associated with the prescription and administration of certain drugs. Following bariatric surgery, patients may be at an increased risk for kidney disease. Local anesthetics and medications may be metabolized by the kidneys, thus these (including tetracycline) should be avoided in those with kidney disease. Additionally, local anesthetics act on renal function by self-regulating blood flow and the glomerular filtration rate.5 Care must also be heeded for those at risk of gastric ulcers secondary to bariatric surgery, particularly when prescribing medications such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of pain control. Aspirin, NSAIDs, and oral bisphosphonates (bisphsophonates are often used in the treatment for osteoporosis) must be avoided in patients with gastric ulcers and those who have had bariatric surgery.5 Patients who have had bariatric surgery are at an increased risk for the development of gastric ulcers around the connections between the stomach and the intestine where areas have been segmented or reduced.53 3 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery 2nd ed. Oxford, England: Wiley-Blackwell; 2008. 17. Levine R. Obesity and oral disease—a challenge for dentistry. Br Dent J. 2012;213:453-456. 18. Reilly D, Boyle CA, Craig DC. Obesity and dentistry: a growing problem. Br Dent J. 2009;207:171-175. 19. Lau DC, Douketis JD, Morrison KM, et al; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ. 2007;176:S1-S13. 20. Hussain SS, Bloom SR. The pharmacological treatment and management of obesity. Postgrad Med. 2011;123:34-44. 21. Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13:1-190, 215-357, iii-iv. 22. Barbosa CS, Barbério GS, Marques VR, et al. Dental manifestations in bariatric patients: review of literature. J Appl Oral Sci. 2009;17(suppl):1-4. 23. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med. 2005;142:547-559. 24. Cunneen SA. Review of meta-analytic comparisons of bariatric surgery with a focus on laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2008;4(suppl 3):S47-S55. 25. Jones KB Jr, Afram JD, Benotti PN, et al. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg. 2006;16:721-727. 26. Marsicano JA, Grec PG, Belarmino LB, et al. Interfaces between bariatric surgery and oral health: a longitudinal survey. Acta Cir Bras. 2011;26(suppl 2):79-83. 27. Netto BD, Moreira EA, Patiño JS, et al. Influence of Roux-en-Y gastric bypass surgery on vitamin C, myeloperoxidase, and oral clinical manifestations: a 2-year follow-up study. Nutr Clin Pract. 2012;27:114-121. 28. Wang A, Powell A. The effects of obesity surgery on bone metabolism: what orthopedic surgeons need to know. Am J Orthop (Belle Mead NJ). 2009;38:77-79. 29. Pataky Z, Carrard I, Golay A. Psychological factors and weight loss in bariatric surgery. Curr Opin Gastroenterol. 2011;27:167-173. 30. Huether SM, McCance KL. Understanding Pathophysiology. 3rd ed. St. Louis, MO: Mosby; 2004. 31. Maciel Santos ME, Rocha NS, Laureano Filho JR, et al. Obstructive sleep apnea-hypopnea syndrome—the role of bariatric and maxillofacial surgeries. Obes Surg. 2009;19:796-801. 32. Fatima J, Houghton SG, Iqbal CW, et al. Bariatric surgery at the extremes of age. J Gastrointest Surg. 2006;10:1392-1396. 33. Mango VL, Frishman WH. Physiologic, psychologic, and metabolic consequences of bariatric surgery. Cardiol Rev. 2006;14:232-237. 34. Smith MD, Patterson E, Wahed AS, et al. Thirty-day mortality after bariatric surgery: independently adjudicated causes of death in the longitudinal assessment of bariatric surgery. Obes Surg. 2011;21:1687-1692. 35. Vines L, Schiesser M. Gastric bypass: current results and different techniques. Dig Surg. 2014;31:33-39. 36. Musella M, Milone M, Gaudioso D, et al. A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution. Int J Surg. 2014;12(suppl 1):S183-S188. 37. Heling I, Sgan-Cohen HD, Itzhaki M, et al. Dental complications following gastric restrictive bariatric surgery. Obes Surg. 2006;16:1131-1134. 38. Borgström MK, Edwardsson S, Svensäter G, et al. Acid formation in sucrose-exposed dental plaque in relation to caries incidence in schoolchildren. Clin Oral Investig. 2000;4:9-12. 39. Zero DT, Lussi A. Erosion—chemical and biological factors of importance to the dental practitioner. Int Dent J. 2005;55(4 suppl 1):285-290. 40. Magalhães AC, Wiegand A, Rios D, et al. Insights into preventive measures for dental erosion. J Appl Oral Sci. 2009;17:75-86. 41. Newbrun E. Sugar and dental caries: a review of human studies. Science. 1982;217:418-423. 42. Lussi A, Jaeggi T, Zero D. The role of diet in the aetiology of dental erosion. Caries Res. 2004;38(suppl 1):34-44. 43. Ali DA, Brown RS, Rodriguez LO, et al. Dental erosion caused by silent gastroesophageal reflux disease. J Am Dent Assoc. 2002;133:734-737. 44. Dionysopoulos D, Koliniotou-Koumpia E, Helvatzoglou-Antoniades M, et al. Fluoride release and recharge abilities of contemporary fluoride-containing restorative materials and dental adhesives. Dent Mater J. 2013;32:296-304. 45. Song A, Fernstrom MH. Nutritional and psychological considerations after bariatric surgery. Aesthet Surg J. 2008;28:195-199. 46. Brown RS, Glascoe A, Feimster T, et al. Vitamins and the treatment of oral and dental diseases. Dent Today. 2010;29:51-57. 47. Brigelius-Flohé R, Traber MG. Vitamin E: function and metabolism. FASEB J. 1999;13:1145-1155. CONCLUSION As obesity increases in America, dentists will be challenged to render safe dental care to the obese patient population. Dentists should partner with other health professionals to educate and promote healthier lifestyle practices. Many chronic inflammatory systemic diseases, such as diabetes and cardiovascular disease, are not only risk factors for obesity but for oral diseases such as periodontitis. Obesity is also a risk factor for xerostomia and dental caries. These oral diseases and conditions impact dental practices on a daily basis. As more patients seek surgical intervention for the treatment of obesity, dentists should also expect to see some of the potential adverse effects of bariatric surgery affect their practices as well. These include an increase in the presentation of caries, tooth erosion, periodontal disease, oral burning, and alveolar bone loss. Obesity and bariatric surgery might also influence how dentistry is practiced in regards to medications clinicians use daily such as local anesthesia, and what is prescribed for pain management, because many in this patient population have the potential for kidney disease and gastric ulcers following bariatric surgery. References 1. Pataro AL, Costa FO, Cortelli SC, et al. Influence of obesity and bariatric surgery on the periodontal condition. J Periodontol. 2012;83:257-266. 2. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235-241. 3. Haenle MM, Brockmann SO, Kron M, et al. Overweight, physical activity, tobacco and alcohol consumption in a cross-sectional random sample of German adults. BMC Public Health. 2006;6:233. 4. World Health Organization. The World Health Organization warns of the rising threat of heart disease and stroke as overweight and obesity rapidly increase [press release]. September 22, 2005. who.int/mediacentre/news/releases/2005/pr44/en. Accessed October 10, 2014. 5. Moura-Grec PG, Assis VH, Cannabrava VP, et al. Systemic consequences of bariatric surgery and its repercussions on oral health. Arq Bras Cir Dig. 2012;25:173-177. 6. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253. 7. Balsa JA, Botella-Carretero JI, Peromingo R, et al. Role of calcium malabsorption in the development of secondary hyperparathyroidism after biliopancreatic diversion. J Endocrinol Invest. 2008;31:845-850. 8. Ferreira VA, Magalhães R. Obesesidade e pobreza: o aparente paradox [dissertacao]. Escola Nacional de Saude Publica, 2003. ensp.unl.pt/dispositivos-deapoio/cdi/cdi/sector-de-publicacoes/revista/2000-2008/pdfs/2-06-2006.pdf. Accessed on October 24, 2014. 9. Lakkis D, Bissada NF, Saber A, et al. Response to periodontal therapy in patients who had weight loss after bariatric surgery and obese counterparts: a pilot study. J Periodontol. 2012;83:684-689. 10. Field AE, Coakley EH, Must A, et al. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med. 2001;161:1581-1586. 11. Perlstein MI, Bissada NF. Influence of obesity and hypertension on the severity of periodontitis in rats. Oral Surg Oral Med Oral Pathol. 1977;43:707-719. 12. Marsicano JA, Sales-Peres A, Ceneviva R, et al. Evaluation of oral health status and salivary flow rate in obese patients after bariatric surgery. Eur J Dent. 2012;6:191-197. 13. Mathus-Vliegen EM, Nikkel D, Brand HS. Oral aspects of obesity. Int Dent J. 2007;57:249-256. 14. Saito T, Shimazaki Y, Kiyohara Y, et al. Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women: the Hisayama study. J Periodontal Res. 2005;40:346-353. 15. Palle AR, Reddy CM, Shankar BS, et al. Association between obesity and chronic periodontitis: a cross-sectional study. J Contemp Dent Pract. 2013;14:168-173. 16. Fejerskov O, Kidd E, eds. Dental Caries: The Disease and Its Clinical Management. 4 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery 48. National Institutes of Health, Office of Dietary Supplements. Vitamin E Fact Sheet for Health Professonals. ods.od.nih.gov/factsheets/VitaminE-HealthProfessional. Accessed October 20, 2014. 49. Laurence B, Glascoe A, McIntosh C, et al. Periodontal Disease and Systemic Health for Medical Students. Washington, DC: MedEdPORTAL Publications; 2013. mededportal.org/publication/9468. Accessed October 20, 2014. 50. Staud R. Vitamin D: more than just affecting calcium and bone. Curr Rheumatol Rep. 2005;7:356-364. 51. Malinowski SS. Nutritional and metabolic complications of bariatric surgery. Am J Med Sci. 2006;331:219-225. 52. Pech N, Meyer F, Lippert H, et al. Complications, reoperations, and nutrient deficiencies two years after sleeve gastrectomy. J Obes. 2012;2012:828737. 53. Scheffel O, Daskalakis M, Weiner RA. Two important criteria for reducing the risk of postoperative ulcers at the gastrojejunostomy site after gastric bypass: patient compliance and type of gastric bypass. Obes Facts. 2011;4(suppl 1):39-41. 5 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery POST EXAMINATION INFORMATION To receive continuing education credit for participation in this educational activity you must complete the program post examination and receive a score of 70% or better. Traditional Completion Option: You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). All information requested must be provided in order to process the program for credit. Be sure to complete your “Payment,” “Personal Certification Information,” “Answers,” and “Evaluation” forms. Your exam will be graded within 72 hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided. Online Completion Option: Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the “Online Courses” listing and complete the online purchase process. Once purchased, the program will be added to your User History page where a Take Exam link will be provided directly across from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter of Completion will be provided immediately for printing. General Program Information: Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or print letters of completion and results. POST EXAMINATION QUESTIONS 4. Obesity is associated with which oral condition? a. Xerostomia. b. Pulpitis. c. Root fracture. d. Avulsion. 1. In order to be classified as being obese, the Body Mass Index must be > ____. a. 10%. b. 30%. c. 50%. d. 90%. 5. A standard dental chair is equipped to handle a static load of approximately how many pounds (lbs)? a. 200 lbs. b. 300 lbs. c. 500 lbs. d. 1,000 lbs. 2. It is estimated that there are more than how many obese people worldwide? a. 500,000. b. 1,000,000. c. 750,000,000. d. 1,000,000,000. 6. A bariatric dental chair is equipped to handle a static load of approximately how many pounds? a. 200 lbs. b. 300 lbs. c. 500 lbs. d. 1,000 lbs. 3. Obesity is a risk factor for which of the following? a. Pregnancy. b. Cardiovascular disease. c. Skin cancer. d. Asthma. 7. What is the most common bariatric surgical procedure done today? a. Misuse biliopancreatic procedure. b. Gastric bypass Roux-en-Y procedure. c. Gastric band. d. None of the above. 6 CONTINUING EDUCATION Oral Effects Associated With Obesity and Bariatric Surgery 8. Providing and achieving profound dental anesthesia and providing sedation are often difficult when treating the obese patient. a. True. b. False. 9. What is a common nutritional or mineral deficiency encountered by patients post bariatric surgery? a. Vitamin C. b. Echinacea. c. Fluoride. d. None of the above. 10. For those at risk for developing gastric ulcers, what medication(s) should be avoided? a. Amoxicillin. b. Aspirin. c. Azithromycin. d. 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June 1, 2012 to May 31, 2015 AGD PACE approval number: 309062 What aspect of this course was most helpful and why? Dentistry Today, Inc, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in indentifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp. What topics interest you for future Dentistry Today CE courses? 8