Download Common Risk Factors in the Management of Periodontal and

DENTISTRY’S ROLE IN RISK ASSESSMENT:
MANAGEMENT AND DIAGNOSIS OF SYSTEMIC
CONDITIONS
COMMON RISK FACTORS IN THE
MANAGEMENT OF PERIODONTAL
AND ASSOCIATED SYSTEMIC DISEASES:
THE DENTAL SETTING AND
INTERPROFESSIONAL
COLLABORATION
Robert J. Genco, DDS, PhD,a and Frances Doherty Genco, RDH, BSb
ABSTRACT
SORT SCORE
A
B
C
NA
SORT, Strength of Recommendation Taxonomy
LEVEL OF EVIDENCE
1
2
3
See page A8 for complete details regarding SORT and
LEVEL OF EVIDENCE grading system
a
Office of Science, Technology
Transfer and Economic
Outreach, State University of
New York at Buffalo, Baird
Research Park, Amherst, NY
14228, USA.
b
School of Dental Medicine,
Department of Oral Biology,
State University of New York at
Buffalo, Foster Hall, Buffalo, NY
14214, USA
Corresponding author. E-mail: rjgenco@buffalo.
edu
J Evid Base Dent Pract 2014;14S:
[4-16]
1532-3382/$36.00
ª 2014 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jebdp.2014.03.003
Volume 14, Supplement 1
There is a role for dentistry in the interprofessional management of chronic diseases
by addressing common risk factors
Background
A critical scientific foundation has developed for management of risk factors
common to major diseases including periodontal disease, caries, diabetes, heart
disease, and cancer.
Purpose
The purpose of this paper is to critically review this scientific literature. This will
provide the basis for the current and future role of the dental setting in common
risk factor identification and modification; with an emphasis on the role of the
dental hygienist.
Methods
A systematic review of the literature and analysis of the relevant papers was undertaken to support the recommendations.
Conclusions
We propose that the appropriate risk factor management procedures be adopted
in the dental setting for smoking cessation, reduction of sugar consumption, and
weight control in those patients at risk for one or a combination of the following
diseases: periodontal disease, caries, diabetes, heart disease and certain cancers.
Key words: Periodontal disease, diabetes, heart disease, stroke, cancer, modifiable risk factors, dental hygienist, dental
office
INTRODUCTION
T
he goal of this chapter is to provide a rationale and the scientific basis for a
strategy for controlling major chronic diseases. This strategy includes modification of risk factors common to these chronic diseases: periodontal disease, caries,
cardiovascular disease, diabetes, and cancer. Periodontal disease affects about 50%
of adults in the US,1 and is related to cardiovascular disease,2 diabetes3 and cancer.4
The systemic diseases related to periodontal disease, cardiovascular disease, stroke,
cancer and diabetes, were 4 of the 7 leading causes of death in the US in 2010.5
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Since there are several risk factors common to periodontal
disease, cardiovascular disease, stroke, diabetes, and cancer, it
is reasonable to propose that control of these common risk
factors will markedly reduce their mortality and morbidity, as
well as contribute to optimal oral health. The main common
risk factors for all these include smoking, poor diet and
obesity. These factors will be discussed in detail and the evidence for the effect of intervention on these diseases will be
discussed.
the disease does not however prove causality. Causality is
difficult to prove and requires evidence that the factor precedes the disease usually from longitudinal studies. Further
evidence for causality also includes knowledge of the mechanism of action of the risk factor on the disease. Finally, the
evidence that modification of the risk factor will prevent or
moderate the disease is important in establishing true causation. As these lines of evidence are established, risk factor
reduction in individuals or populations is often justified. We
will discuss modifiable risk factors for periodontal disease,
which are common to cardiovascular disease, stroke, cancer
and diabetes. These will be targets for the proposed strategy
of common risk intervention in the dental office.
It is important to note that over 80% of children 2–17, and
over 60% of adults had a dental visit in 2011.6 Hence we
propose that contact with oral health care providers can be
an important, and to date underutilized, opportunity to assist
the patient in controlling risk factors for oral disease as well as
an opportunity for detection and modification of risk factors
for cardiovascular disease, stroke, diabetes and cancer. We
propose that the dental hygienist can be a key member of the
dental team in encouraging healthy lifestyle modification such
as smoking cessation, advocating a healthy diet and weight
control among other healthy behaviors.
Smoking as a Risk Factor for Periodontitis
Smoking has been long associated with periodontitis and
tooth loss. For example, in 1947 an association was found
between tobacco smoking and acute necrotizing ulcerative
gingivitis.11 Since then many studies have also shown an
association of cigarette smoking and common adult forms of
periodontitis.12 Studies of periodontal risk factors are often
confounded by other factors such as oral hygiene and dental
plaque levels, however, where proper statistical correction is
made for these factors, smoking is found to be a major
independent risk factor for periodontal disease (Figure 1).
Even mild smoking was found to increase the odds 4–5 fold
for both periodontitis and alveolar bone loss.13,14
RISK FACTORS FOR PERIODONTAL DISEASE
It is well established that gingivitis and periodontitis are
chronic bacterial infections caused by dental biofilms. Periodontitis is caused by subgingival bacterial communities with
virulence potential which likely directly cause tissue destruction, or trigger destructive immunopathologic host responses
which in turn lead to periodontal hard and soft tissue
destruction and eventually loss of teeth.7 Recent studies using
DNA sequencing reveal that the subgingival microbiome
associated with periodontal disease contains complexes of
previously known pathogens as well as many other potential
periodontal pathogens that were previously not detected
because they are not able to be cultured, or had not been
previously recognized.8 There is much to be clarified
regarding the role of these polymicrobial complexes in periodontitis; however, it is clear that subgingival biofilms are the
primary cause of periodontal disease.9
The Two-way Relationship Between Diabetes and
Periodontal Disease
It has been long known that diabetes mellitus, both type 1 and
type 2, are risk factors for periodontal disease.10 A systematic
review of the effects of periodontal disease on diabetes was
recently published3 which summarizes evidence for the twoway relationship between periodontal disease and diabetes. In
this review, a systematic analysis of studies show that periodontal disease worsens glycemic control as well as cardiovascular and renal complications of patients with disease. For
example, a longitudinal study of Pima Indians with type 2
diabetes found those with severe periodontitis at baseline had
over 6 times the risk of developing poor glycemic control
over 2 years as compared to those with diabetes and little
periodontal disease at baseline.15
The concept that the rate of progression and severity of
periodontitis is often determined by systemic risk factors is
fairly recent. The identification of risk factors for periodontitis
and their role in disease induction and progression as well as
risk modification in the management of this disease was
recently reviewed by Genco and Borgnakke10 and will be
summarized here.
Strength of Evidence for Periodontal Risk Factors
Further studies on this population showed that patients with
type 2 diabetes and periodontitis are more likely to die from
heart disease and kidney disease than those with diabetes and
little or no periodontal disease16 (Figure 2).
From epidemiologic studies, factors that occur more often or
at higher levels in patients with periodontal disease as
compared to those with little or no periodontal disease, are
considered putative risk factors, sometimes called risk indicators or risk modifiers. Mere associations of a factor with
Effect of Periodontal Therapy on Glycemic Control in Patients
With Diabetes
Several meta-analysis have been published reviewing randomized controlled clinical trials studying the effects of
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Figure 1. There is a positive relation between periodontal
disease of increasing severity and number of pack-years smoked.
randomized controlled trial of non-surgical therapy failed to
show such an effect.23 Although this was a large study of over
500 patients, the scaling and root planning therapy apparently
was only partially effective in resolving the periodontal disease.
For example, reduction in bleeding on probing was only 19%
as compared to the approximately 45% reduction previously
seen in numerous studies, and 42% of sites bled after treatment and there were 10% of sites with 5 mm or greater
pocket depth after treatment.24 Furthermore in this study
72% of the sites had residual plaque suggesting poor
compliance with oral hygiene.23 This clinical trial23 failed to
achieve clinical results comparable to what has been found in
previous studies both on those with diabetes as well as those
without diabetes, and is not clear from this study that one can
conclude that non-surgical periodontal therapy does not alter
HbA1c. Further research where periodontitis is successfully
treated is needed to clarify this issue.
From Grossi et al.14
The clinical significance of reducing HbA1c levels in patients
with diabetes is well documented, especially in controlling
micro-vascular complications such as retinopathy and
nephropathy.25 Also studies in the general population show
that an average reduction in HbA1c of 0.2% is associated with
a reduction in mortality of approximately 10%,26 and the
numerous clinical trials of periodontal therapy summarized in
Table 2 show a reduction of 0.36–0.65% in HbA1c levels.
Figure 2. Mortality rates for all natural causes by periodontal
disease (adjusted for age and sex to the 1985 Pima Indian
population). Cardiorenal deaths ( ); all other natural deaths
( ).
What Are the Mechanisms That Explain the Bidirectional
Relationship Between Diabetes and Periodontal Diseases?
Mechanisms which are proposed to explain why patients with
diabetes suffer from more periodontal disease are reviewed
by Genco and Borgnakke10 and they include:
A. Patients with diabetes have a hyperactive inflammatory
response and the bacterial challenge of periodontal
infection results in exaggerated inflammation and periodontal tissue destruction.
B. The receptors for advanced glycation end products are
elevated in patients with diabetes. Periodontal infection
results in increased levels of these advanced glycation end
products, which activate their receptors resulting in production of increased levels of proinflammatory cytokines
such as IL6 and TNFa, leading to more periodontal
disease.
periodontal therapy on glycemic-control in patients with both
diabetes and periodontal disease.21
Although these studies varied in design, populations treated,
and treatments rendered, the results of the several metaanalysis are similar (Table 1). They show a statistically significant decrease in HbA1c of 0.36–0.65% in the treated group
over a short period of 3–6 months. This is comparable to the
reduction of HbA1c that occurs when a second antiglycemic
medication is added to metformin, and is hence clinically
significant.
C. There is evidence for a reduction in healing in patients
with diabetes. One such mechanism is increased fibroblast
apoptosis which may result in delayed wound healing in
patients with diabetes.
D. There is evidence for altered immune responses in
patients with diabetes. Impaired functions such as impaired
phagocytosis and neutrophil chemotaxis may predispose
patients with diabetes to more severe periodontal
disease.10
Not all studies have shown reduction in HbA1c in patients
with diabetes who have had periodontal therapy. A recent
Volume 14, Supplement 1
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Table 1. Effect of non-surgical periodontal treatment on glycemic control in people with type 2 diabetes: Meta-analysis including more
than 1 RCT published as of December 28, 2013
Reference [Author (year)]
# studies
17
Darre et al (2008)
# RCTa
9
18
Teeuw et al (2010)
Pooled # subjects
HbA1ce change
95% CId
p-value
485
20.46%
c
0.11; 0.82
0.01
180
20.40%
c
20.77; 20.04
0.03
9
b
5
3
19
Simpson et al (2010)
Cochrane Review
3
3
244
20.40%
20.78; 20.01
0.04
Sgolastra et al (2013)20
5
5
315
20.65%
20.43; 20.88
,0.05
Engebretson and Kocher (2013)21
9
9
775
20.36%
20.54; 20.19
,0.0001
6
6
422
20.41%
20.73; 0.09
0.013
Liew et al (2013)
22
RCT 5 randomized controlled trial.
Remainder of the studies (non-RCT): Clinical controlled trials.
c
Standardized mean difference (SMD).
d
CI 5 confidence interval.
e
HbA1c 5 A1c 5 glycosylated hemoglobin.
Adapted from ref 21.
a
b
Table 2. Risk factors common to diabetes, cardiovascular disease, stroke, cancer, and periodontal disease
Risk factors
Periodontal disease
Diabetes
CVD
Stroke
Cancer
Smoking
X
X
X
X
X
Alcohol
X
X
X
X
X
Obesity
X
X
X
X
X
X
X
X
X
X
X
X
Altered lipids
X
X
Hypertension
X
X
Diabetes
X
Physical inactivity
X
Less is known about the mechanisms which account for the
effects of periodontal disease on worsening glycemic control
and increasing complications in patients with diabetes. However, systemic inflammatory responses as seen in periodontal
disease may contribute to insulin resistance and hyperglycemia. For example, TNFa can promote insulin resistance by
interfering with insulin signaling mechanisms, reducing intake
of glucose into cells. The systemic inflammatory response
associated with periodontal disease thus many account, in
part, for the effects of periodontal disease on poorer glycemic
control and increased cardiovascular and renal complications
in patients with both diseases.
adipokines are elevated in patients who are overweight or
obese.28 These in turn are associated with increased risk of
insulin resistance, diabetes and cardiovascular disease. Evidence that obesity is also a risk factor for periodontal disease
is summarized in two systematic reviews29–31 and is illustrated
in Figure 3.
From the meta-analysis summarized in Figure 3 it can be seen
that the overall odds of having periodontal disease in obese or
overweight individuals is approximately 2. The mechanisms to
explain this increased susceptibility are likely the same as that
for the effect of obesity on other chronic diseases, namely an
increase of systemic inflammation from adipose tissue.32
There are also studies which suggest that the oral flora in
obese individuals have higher levels of T. forsythia as compared
to non-obese individuals.33
Obesity and Risk for Periodontal Disease
Obesity is a growing major public health problem as its
prevalence has tripled since the 1980’s.10,27 Furthermore,
obesity is associated with diabetes, heart disease and some
cancers. These associations likely result from proinflammatory
mediators produced by adipose tissues.28 These inflammatory
mediators are thought to contribute to increased susceptibility and progression of diabetes and cardiovascular disease
and cancer. For example, TNFa, IL-6, CRP and a series of
Metabolic Syndrome as a Risk Factor for
Periodontal Disease
Metabolic syndrome is defined as having 3or more of the
following: obesity, increased blood pressure, hyperglycemia,
and altered blood lipids. There is epidemiologic evidence that
metabolic syndrome increases the risk for peridontitis.31,34
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Figure 3. Forest plot of studies of periodontal disease in overweight and obese subjects compared with those with a normal body mass
index.31
Further study is needed to better establish the role of each of
the components of metabolic syndrome and their relationship
to periodontal disease. Intervention studies have begun testing
the effects of periodontal therapy on components of the
metabolic syndrome and vice versa. Intervention studies
testing the effect of treatment of periodontal disease on
metabolic syndrome reported that the treated patients had a
decrease in C-reactive protein, total leukocyte counts, and
serum triglycerides along with an increase in serum high
density lipoproteins.35 These changes were seen in the
treated group with metabolic syndrome which suggests that
periodontal therapy has the potential to improve some of the
abnormalities seen in metabolic syndrome. More research
assessing the association between metabolic syndrome and
periodontal disease is needed as metabolic syndrome is an
important risk factor for type 2 diabetes and cardiovascular
disease.36
RISK FACTORS FOR DIABETES,
CARDIOVASCULAR DISEASE AND CANCER
Tobacco use and poor diet are major risk factors for diabetes,
cardiovascular disease, and cancer. Tobacco cessation and
healthy diets are known to modify the risk for these
diseases.37
Risk Factors for Diabetes
The modifiable risk factors for diabetes include38,39:
a) Having prediabetes or being at high risk for diabetes,
characterized as fasting plasma glucose of .100 and
124 mg/dl, or HbA1c level of $5.7–6.4%.
b) Being overweight or obese, especially around the waist.
c) Having high blood pressure ($140/90 mm Hg).
d) Having low HDL (less than 40 mg/dl for men and less than
50 mg/dl for women) and/or high levels of triglycerides
(200 mg/dl or higher).
Evidence is Emerging for Several Other Potential
Risk Factors Associated With Periodontal
Disease Including Low Dietary Calcium, Low
Plasma Vitamin D, Excessive Alcohol
Consumption, Osteoporosis in Postmenopausal
Women and Stress
e) Smoking.
The modifiable risk factors for diabetes which are common to
periodontal disease including smoking, being overweight or
obese and having hyperglycemia.10
Since these potential risk factors are not common risk factors
for chronic diseases such as diabetes and cardiovascular disease, they presently are not among the common risk factors
to be addressed here.10 Of course their identification and
modification is of importance in the management of periodontal disease.
Volume 14, Supplement 1
Cardiovascular and Cerebrovascular Risk Factors
There are many risk factors associated with heart disease and
stroke. Some such as age, ethnicity, and genetic factors which
cannot be changed. However, there are modifiable risk factors
for heart disease which include40:
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a) Tobacco exposure
cancer and hepatitis infection which increases the risk of
liver cancer.
b) Obesity
g) Diabetes is associated with increased cancer of the colon,
pancreas, and possibly other sites.
c) Unhealthy diets
d) Physical activity
There are many other risk factors for cancer including gastric
abnormalities, race, age, gender, and genetic factors which are
not able to be modified. There are also a large number of
environment hazards associated with increased risk for cancer
including environmental toxins and radiation that are not
easily modified in clinical practice but are targets for public
health measures.37
e) Harmful use of alcohol
Modifiable risk factors for stroke include41:
a) Cigarette smoking
b) Diabetes
c) Being overweight or obese
Again as with diabetes, cardiovascular disease and stroke,
cancer shares many risk factors with periodontal diseases.
These common risk factors include cigarette smoking, overweight and obesity, diabetes, diet and alcohol consumption.
d) Physical inactivity
e) Obstructive sleep apnea
f) Cardiovascular disease, including heart failure, heart
defects, heart infection or abnormal heart rhythm.
In summary, exposure to tobacco, diet, overweight and
obesity, and excessive alcohol consumption are risk factors
common to periodontal disease, diabetes, cardiovascular
disease, stroke, and certain cancers. Certain of these common
risk factors can be modified in clinical dental practice (eg.
smoking, sugar intake) and others by collaboration with our
medical colleagues (eg. obesity, inadequate physical activity
and excessive alcohol consumption).
g) Use of some birth control pills or hormone therapies that
include estrogen.
h) Heavy or binge drinking
i) Use of illicit drugs such as cocaine and methamphetamines.
As is the case for diabetes, many of the risk factors for heart
disease and stroke also increase the risk for periodontitis.
These common risk factors include smoking, obesity, diabetes,
unhealthy diets, and harmful use of alcohol.10
The importance of identifying and treating this common set of
risk factors has been emphasized by the American Cancer
Society, the American Diabetes Association, and the American Heart Association.37,42 They have recommended that all
health care providers assess these common risk factors and
institute measures to reduce them in an effort to prevent
these diseases at an early stage. Thus, there is an imperative
for dentistry to actively participate in the management of
these common risk factors to reduce the ravages of oral
diseases and at the same time to provide expert help in the
efforts to reduce major systemic diseases.
Risk Factors for Cancer
There are many forms of cancer and many share modifiable
risk factors including37:
a) Tobacco consumption, including smoking cigarettes for
most cancers, and use of chewing tobacco for oral
cancer.
b) Excessive alcohol consumption
Periodontitis and Systemic Diseases
c) Overweight and obesity increase the risk for cancer at
numerous sites including breast (among postmenopausal
women), endometrium, esophagus, gallbladder, liver,
prostate, ovary, pancreas and kidney.
There is evidence accumulating that suggests that periodontal
disease is independently associated with several systemic
conditions including diabetes, cardiovascular disease and
stroke, and cancer. Several critical and systematic reviews of
these associations are found in the Workshop jointly held by
the European Federation of Periodontology and American
Academy of Periodontology.43
d) Certain diets may lead to reduced risk of some of the most
common types of cancer. However, components of the
diet are known to increase the risk for certain cancers,
however, the specific role of these dietary components is
not clear.
It was concluded that studies of the association of periodontal
disease with cancer is hampered by the difficulty in controlling for
confounders such as smoking and socioeconomic status. However, several studies find an independent association between
periodontitis and cancer after controlling for these effects.44,45
e) Physical activity may reduce the risk of breast and colon
cancer.
f) Infectious agents including: Heliobacteria pylori infection
which increases risk for gastric cancer, human papilloma
virus (HDV) infection which increases the risk of cervical
In summary, evidence is emerging that periodontitis is a risk
factor for diabetes, cardiovascular disease and some forms of
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cancer. Definitive studies showing a clinically significant effect
of preventing or treating periodontal disease on diabetes,
cardiovascular disease or cancer are lacking. However, it is clear
that modification of common risk factors will have clinically
significant effects on periodontal disease, heart disease, diabetes and cancer, and hence it is important to implement
common risk factor modification into dental practice.
have been shown to be feasible and successful in the dental
setting, with the dental hygienist playing a major role.48,49
Tobacco cessation counseling can occur naturally during a
preventive appointment and recent studies show that dental
hygienists are willing to learn cessation techniques.50 If tobacco
cessation was not part the education of the dental hygienist,
there are self-study programs and continuing education programs to help develop skills in counseling patients. Counseling
programs can be successful, for example, in one study those
who receive counseling achieve a 2–3 times greater stop rate
as compared to those who try to stop on their own.50
COMMON RISK FACTOR MODIFICATION
Modification of risk factors common to dental diseases as
well as other major chronic diseases can be incorporated
into dental practice. Motivational interviewing is one
behavior change approach being used in dentistry (see
Mitchell, Forrest, and Overman, Critical Thinking Skills for
Patient-Centered Care, in this publication) For example, recommending reduction of dietary sugars will likely reduce the
risk of caries, but also have major impact on preventing
diabetes, and heart disease through its contribution to
weight loss. Treating tobacco use or dependence will have a
major impact on periodontal disease, but also will be
important in preventing heart disease and some cancers.
Practical advice on implementing risk factor modification in a
dental practice, with an emphasis on the role of the hygienist will be discussed below.
Advantages of Tobacco Cessation Programs in Dental Offices
Helping patients free themselves of tobacco addiction is
rewarding to the dental team, and may extend life as well
as greatly improve the patients’ quality of life.
Oral health care professionals are often aware of patients
who smoke from their medical histories and oral
examination.
Oral health professionals have interviewing and counseling
skills, as well as the trust and rapport of patients which are
beneficial in effecting behavioral change.
Patients visit dental offices on a regular basis, hence
follow-up with tobacco cessation programs can be
incorporated into the regular recall routine.
Treating Tobacco Use or Dependence in the
Dental Office
Tobacco-cessation protocols can be brief, and need not
unduly prolong dental treatment routines.
A recent report46 on The Health Consequences of Smoking
reviews evidence for a causal link of smoking to diseases
affecting nearly all organs of the body (see Figure 4).
Furthermore the report notes that smoking-caused illnesses
will result in newly half a million deaths and cost the U.S. more
than $130 billion in 2014.
Professional services which include a tobacco cessation
program can be an excellent practice builder.
Perceived Barriers to Tobacco Cessation Treatment in the Dental
Office
Oral care professionals:
Tobacco use imposes an enormous public health burden and
rapid elimination of the use of tobacco products will dramatically reduce this burden. The U.S. Department of Health and
Human Services presents strategies for treating tobacco use
and dependency.47 It provides key recommendations for
clinicians in delivery and support for treatment of tobacco use
and dependence. Currently they are built around the 5A’s Brief
Intervention Model (Ask, Advise, Assess, Assist, and Arrange).
The U.S. Department of Health and Human Service Guidelines
state: “that tobacco dependence treatment delivered by a
variety of clinical types increases abstinence. Therefore all
clinicians (physician, nurse, dentist, psychologist, or counselor)
should provide smoking cessation interventions.”
May feel it is not their responsibility. In reality, tobacco use
contributes to significant oral disease, and should be
controlled as part of restoring the patients’ oral health.
May believe it takes too much time. However, effective
interventions can be brief, and made part of a routine oral
hygiene visit.
Do not feel they can charge a fee for their service.
However, fees can be changed as treatment of tobacco
dependence is an important component of periodontal
and implant treatment, and management of a patient at
risk for oral cancer. Furthermore these services are often
covered by insurance.
Dentists and dental hygienists are trained to detect oral
lesions, periodontal disease and failing implants that are
related to tobacco use. Dentists and hygienists are also in a
position to help treat and prevent tobacco dependence, and
over the last several decades tobacco cessation strategies
Volume 14, Supplement 1
Are concerned about the effectiveness of the program.
However studies have shown well executed tobacco
cessation programs in dental offices can be effective.
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Figure 4. The health consequences causally linked to smoking. Note: the condition in red is a new disease that has been causally linked
to smoking in this report.
USDHHS 2004, 2006, 2012.
Provide individual health information as it relates to
tobacco use, pointing out actual disease and conditions
associated with smoking in individual patients, such as
periodontal disease, stained teeth, irritated mucous
membranes, and suspected oral precancerous lesions.
The Dental Team for Treatment of Tobacco Dependence
Role of the Dentist.
Determine plan of action for the office.
Appoint an office coordinator for the program.
Work with hygienists to counsel patients.
Provide quit strategies.
Refer selected patients to the relevant “Tobacco Quit
Line” for coaching and information about the program.
Record quit date, interventions prescribed and side effects.
Monitor compliance with nicotine replacement or other
therapies recommended to patient.
Recommend and prescribe nicotine replacement products
such as nicotine gums, patches, or lozenges. The dentist
can also prescribe Buproban (Zyban) and Varenicline
(Chantix) or a combination of these drugs with nicotine
replacement therapy to assist the patient in smoking
cessation.
Monitor tobacco use status at each visit.
Work with the dentist in referring certain patients for
those it is difficult to quit to “Tobacco Quit Line,” a coach
or physician for nicotine addiction therapy.
Monitor progress of program and train new personnel as
needed.
The dental assistant and receptionist should also support the
dentist and dental hygienist in the tobacco cessation program
in providing brochures and other information about tobacco
cessation, making follow-up calls about quit dates, and sending
appropriate patient follow-up letters and letters to the
Role of the Dental Hygienist.
Assess tobacco use for every patient, and determine for
smokers their willingness to quit.
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patient’s physician. They also should encourage and support
patients who are going through the quit program.
inhalers, nicotine nasal sprays and nicotine patches. In
addition there are 2 FDA approved oral medications for
nicotine cessation, Buproban (Zyban) and Varenicline
(Chantix). A combination of counseling and medications
often gives the patients the best chance of becoming a
successful quitter. The decision to use this combination
should be made by the dentist, in conjunction with the
hygienist and patient. However, there is insufficient evidence for use of any of these medications for pregnant
women, adolescents, smokeless tobacco users and light
smokers (less than 10 cigarettes per day).
The 5 A’s Brief Intervention Model for Treating Tobacco Use and
Dependence
The 5 A’s model includes the follow Ask, Advise, Assess,
Assist and Arrange.47
Ask. Tobacco users are increasingly considered outcasts in
our society and approaching them about their tobacco use
should be done with care. If they indicate they use tobacco in
their medical history, follow-up to obtain information about
how long, what form and the number of cigarettes or cigars
they smoke per day. Don’t be judgmental, and present
yourself as someone who wants to help. Let them know that
as a dental provider it is important for you to have knowledge
of their tobacco use as it may predispose to periodontal
disease, dental implant failure, oral cancer, and other oral
lesions. Furthermore, inform the patient that your office
considers treating tobacco use and dependence as an
important part of the management of their oral disease. It is
critical to their oral health as well as to their overall health.
Counseling. Involves helping the patient develop coping
skills to avoid temptation, as well as to recognize trigger situations and to develop techniques to avoid smoking binges.
Provide basic information about quitting such as the
addictive nature of smoking, and what to expect from
withdrawal symptoms.
Encourage the patient, let them know that there well
tested effective tobacco cessation programs exist, and that
one-half of people who ever smoked have quit.
Communicate and encourage the patient to talk. Ask
about patients’ fears about quitting, difficulties encountered with quitting, and reasons the patient wants to quit.
Advise. In a clear, strong and personalized manner urge
every tobacco user to quit. Note changes in the mouth such
as stained teeth, gingival recession, periodontal pockets or
mucous membrane lesions that are likely related to their
tobacco use. Tell them that these diseases can be treated, and
with tobacco cessation tissues will often return to normal.
Provide practical tips. For example, have the patient strive
for total abstinence; note that quitting is more difficult
when there is another smoker in the house or when
alcohol is consumed.
Assess-readiness to Quit. Assess whether the tobacco user
is willing to quit. It may help to gage the patient’s readiness to
quit by using a scale of 1–10, 1 being no desire to quit and 10
being ready to quit today. If the patient scores a 5 or 6, ask
what it would take for them move up the scale to an 8 or 9.
Provide supplemental materials such as the National Quit
Line Number 1-800-QUIT-NOW. Also provide brochures, pamphlets, videos, apps and other aids to quitting.
Recognize adverse side effects of smoking cessation
including withdrawal symptoms nightmares and stress.
Also acknowledge they may gain weight after quitting.
Assist-with Quitting. If a patient tells you they want to quit,
help the patient develop a quit plan. The quit plan helps a
patient preparation for quitting, and includes the following
(STAR):
Arrange
The last phase of the 5A’s program is arrange, i.e. to refer the
patient for more advanced treatment as necessary.
Set a quit date
Tell family and friends
For patients not ready to quit or who have failed to quit with
your plan
Anticipate challenges, especially nicotine withdrawal, which
may occur in heavy smokers
Reopen the discussion at each visit, in a non-judgmental,
but helpful manner.
Remove tobacco products from environment. Make home
and work ‘smoke-free.’ For some patients quitting may be
very difficult including those who have tried and failed to
quit many times, those who smoke more than 15 cigarettes a day, or those who have been smoking for a long
time (5 or more years). For such patients an FDA
approved medication may help them quit. These medications include: nicotine replacement therapy in various
forms including nicotine gum, nicotine lozenges, nicotine
Volume 14, Supplement 1
Recommend a local tobacco cessation clinic or quit coach,
especially if they are heavy smokers, or have failed to quit
after many attempts. They may have to be treated for
nicotine addiction by a physician under controlled
conditions.
Details of tobacco cessation medications as well as other
information is available.51 There are other approaches for
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JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE
Table 3. Dietary counseling for specific conditions
smoking cessation which have been shown to be successful.
These include the Ask-Advise-Connect approach.52
Orally Focused
Nutritional Counseling in the Dental Office
Poor nutrition is a risk factor for poor oral health as well as for
diabetes, cardiovascular disease and osteoporosis. It is clear
that dietary counseling is important in dental practice as poor
nutrition affects caries, periodontal disease, and healing after
oral surgery. Furthermore, patients who have reduced
masticatory function due to tooth loss often have poor
nutrition contributing to caries, obesity, diabetes and heart
diseases. Specific dietary counseling for obesity also may
reduce the risk for diabetes, cardiovascular disease, certain
forms of cancer as well as periodontal disease and caries.
Caries
Periodontal disease
Xerostomia
Loss of masticating function
Oral surgery patients
Systemically Focused
Diabetes
Cardiovascular disease
Stroke
Certain cancers
Eating disorders
refined sugar in a 12 ounce can of soda is about 33 g. Also a
slice of pecan pie and a cup of chocolate ice cream each have
about 33 g of sugar.
Deleterious Effects of Refined Sugars on Systemic
Health – “toxic sugar”
The link between poor diet, including increased consumption
of refined sugars, with obesity and diabetes has been well
described.57–59 It is clear from several recent studies however
that obesity does not fully explain the variation in trends in
diabetes associated with sugar consumption.60–62 One
hypothesis to explain more fully the effect of sugar on diabetes proposes that although refined sugar added to the diet
does contribute to obesity, these sugars can also increase
diabetes risk independent of the obesity effect. Laboratory
and clinical studies have shown that deleterious liver changes
and pancreatic cell death have been associated with sugar in
the diet, leading to increased risk for diabetes independent of
the increased risk associated with obesity.63
In dental practice there are two modes of dietary counseling;
one Orally Focused directed to specific oral conditions such as
caries and periodontal disease. The second is Systemically
Focused dietary counseling in collaboration with other health
care professionals such as a physician, dietician or nurse. Systemically Focused nutritional counseling is usually carried out
for patients who suffer from or are at risk for diabetes, cardiovascular disease, stroke, osteoporosis, cancer, eating disorders, hypertension or other systemic conditions (Table 3).
Orally Focused Nutritional Counseling
Restricting Refined Sugar Intake. Historically numerous
studies and systematic reviews clearly implicate refined dietary
sugars as a key dietary causative agent in the development of
dental caries.53 A systematic review of the effect of restricting
dietary sugars on reducing caries was recently published by
Moynihan and coworkers.54 From this review,54 it was
concluded that caries are lower when the free sugar intake is
less than 55 g/day for 7–10 year-olds, 50 g/day for 4–6 yearolds and 32 g/day for 1–3 year-olds. Furthermore, this review
shows that even lower dietary consumption of free sugars
resulted in even lower caries. This review also noted that in
adults, similar clinically relevant reductions in caries occur with
comparable reduction of free sugar intake. Furthermore, these
anticariogenic effects of restriction of dietary sugar occur
despite the protection offered by fluoride.55,56 These
papers,54–56 document the association of refined sugar with
dental caries, and support restriction of the intake of free
sugars to less than 50 g/day for older children and adults, and
30 g/day for children 1–3 year-olds.54–56 It is also likely that
even lower levels will result in lower caries rates, but further
studies are needed before this can be a recommendation.
A recent epidemiologic study relating sugar availability and
diabetes prevalence among 40 million people in 175 countries
showed that the duration and degree of sugar exposure of a
population directly and independently correlated with diabetes prevalence.60 Furthermore, this study showed that
declines in sugar availability were associated with subsequent
reduction in diabetes prevalence in these populations. Hence
it appears that differences in sugar availability (and likely
consumption) explain differences in diabetes prevalence not
fully explained by obesity.60 They found that for every 12
ounce can of soft drink available, the diabetes prevalence goes
up by 1%. Furthermore, there was no difference if the
countries used high fructose corn syrup or cane sugar in the
soft drink.60
The message is clear, it is not simply overeating that can lead
to diabetes, it overeating sugar. It is not just obesity, but insulin
resistance which leads to diabetes and sugar can led to insulin
resistance and hence to diabetes (Figure 4). This study60 as
well as laboratory and animal studies63,64 that suggest that
sugar directly affects the liver and pancreas leading to insulin
resistance gives us further reason to strongly recommend
restriction of refined sugars in the diet.
The recommendation to limit daily consumption of refined
carbohydrates also should be coupled with recommendations
to reduce overall cariogenicity of the diet by limiting the
overall consumption of high retention carbohydrates and to
limit the number of exposures to refined carbohydrates to
fewer than 3 per day. For practical advice, consider that the
Restricting dietary sugar will clearly result in less caries, and
also less obesity. In addition, it is likely also to reduce the risk
13
June 2014
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE
Figure 5. The relationship of refined sugar in the diet, obesity,
diabetes, dental caries and periodontal disease.
have different dietary requirements and challenges. However
overweight is often a common problem and sugar restriction
a common recommendation.
General Counseling Tips for a Dental Patient
Restrict dietary intake of refined sugar to 50 g/day for
adults and older children and 30 g/day for children from 1
to 3 years old.
Limit eating event to 3 times per day with no more than 2
snacks per day.
Snacks should be healthy food choices low in cariogenic
potential, such as cheese, raw vegetables, and fresh fruit.
for diabetes and its complications including cardiovascular
disease and periodontal disease (Figure 5).
Incorporate low fat, calcium rich foods in the diet.
Nutrition and Obesity
Nutritional counseling to assist patients to fight obesity is
justified in dental practice based on its role in increasing the
risk for periodontal disease.65 Suvan et al, have recently presented evidence that obesity is also linked to poor clinical
outcomes after periodontal therapy.65 Obesity is an emerging
epidemic that has doubled in prevalence since 1980, and
hence dietary counseling to assist patients to reduce overweight or obesity is of great potential public health benefit.66
Obesity is a chronic disease associated with diabetes, heart
disease, cancer and a number of other conditions described
earlier in this paper. Nutritional counseling to assist dental
patients to reduce obesity is important and perhaps best
carried out in collaboration with other health care professionals, especially if the patient is at risk for or has diabetes
or heart disease. Clearly, one recommendation that can be
made in the dental office is to restrict sugar intake. Further
nutritional counseling is appropriate for those who are
overweight or obese. For these patients, weight reduction
programs are often successful; however patients often regain
the weight. Major lifestyle changes are often needed to bring
about life-long healthy eating habits and sustained weight
reduction. Hence it is important that the dental setting
coordinates weight reduction programs with the patient’s
physician.
Whole grains and whole grain products that do not have
added sugar or salt can be recommended as a source of
carbohydrate.
Reduce salt intake.
Read the food labels and be aware of serving sizes.
For the patient education the following resources are helpful:
➢ www.ada.org/public/topics/diet.asp
Association)
Dental
➢ www.aafp.org (American Academy of Family Physicians)
➢ www.eatright.org (American Dietetic Association)
➢ www.osteo.org (NIH resource center on osteoporosis)
➢ www.vrg.org (vegetarian resource group)
In summary, diet counseling in the dental office can be very
specific with recommendations to restrict refined sugar to 50 g/
day for adults and older children and 30 g/day for children 1–3
years old and to reduce frequency of consumption of cariogenic
carbohydrates. In addition, dietary counseling for weight loss is
best in collaboration with health care professionals to achieve a
balanced non-cariogenic overall healthy diet is suggested.
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For example, a recent meta-analysis shows that a very low
carbohydrate diet is better at leading to greater weight loss
than a low fat diet.67 Other reviews show no differences in
weight loss comparing low carbohydrate diets to low fat
diets.68
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