Transcribed by Jacqueline Heath

DOD [32] Systemic Diseases and Other Conditions Related to Dental Caries September 9th, 2014

[1] Systemic Diseases and Other Conditions Related to Dental Caries

Can you hear me in the back, last row back there? You can hear me?Um, I think I maybe can explain how I ended up doing this lecture, because Im not the caries person in your curriculum, and there will be very few times that you hear me doing a lecture on the subject of caries. But when I was working on a study that I am going ot describe for you in this, in this lecture, I was, there was a whole group of us, it was a team effort, it was a multi-centered study, each one of the investigators got a topic. So my topic, if I had been there right at the beginning and I could have grabbed my topic, it would have been, it was a study of women and HIV, and my area of HIV has always been oral manifestations. And, um, there arent so many anymore and well talk about them later in the year, but somebody else was doing oral manifestations so I didnt get that. We had a periodontist on the team, so of course he got the perio part. And then we had a microbiologist, and the microbiologist got the microbiology part. The um, saliva person got the saliva part. And then, there was this whole pile of caries data. And the question is whos going to deal with the caries data? Well, they looked around the room and everyone else on the research team had their subject except for Phelan, so they said, you do the caries. So for that study I worked with a couple of other people that were epidemiologists and a little bit more knowledgeable in some of the areas of assessing caries than I was. And so I ended up being the person that did the publication on caries. So when Dr. Allen was working on this course, and he had a chance to look at the literature and discovered the paper I did on caries and HIV, he said, ah, will you do the lecture on systemic diseases and caries? and so I said, I guess I will. And so Im going to show you a little bit about that study because it illustrates probably the most important thing that I can teach you. So thats why Im here. Youll see me in a number of other settings in this school. But this is my only caries lecture. So well take it from here.

[2] Ven diagram: dental cariesUm, youve seen this ven-diagram before, and it really talks about all of the interactions that are related to the development of caries. And again, there are other people in this course that are going to spend a lots more time on this, but it is important that we remember that caries, there are number of different factors that can be combined or in order for a patient to develop caries.

[3] Systemic Disease Factors that May Affect Caries Experience

When we look at the subject of systemic diseases and other factors we will call it, because they arent all systemic diseases, and thats part of the reason I titled this a little differently. There are many factors that affect the risk of developing caries. Medications, and there are number of different reasons this might be true. The biggest one, or the most traumatic of the medication related problems would be, what do you think? Xerostomia. Okay. There are 100s, 100s of medications that have the potential for decreasing salivary flow. And if you google medications and xerostomia, if you find the right subject, you will get PAGES AND PAGES of medications that have the potential for causing xerostomia. Now, they dont all cause xerostomia equally. They dont all and weve talked a little bit about xerostomia versus hypo salivation. Im going to spend most of the time in this lecture, I will use the term xerostomia because were not talking about a measurement at this point, but there are just 100s of them. If you mix and match them, then it even gets worse. So medications are a big one. Diet can be a major factor in certain diseases in certain people. Salivary flow is related to more than medications. There are number of disease sin which salivary flow is a problem. And both stimulated and unstimulated can be involved in the increased risk of caries. Um. The way people response to oral discomfort. At some point well talk a little bit about a condition called burning mouth, or burning tongue. There is a set of patients who develop sensation very, very dramatic discomfort. And they do a number of things to try to alleviate this discomfort. And one of the things that works for some of them is to suck on lozenges that would help a little bit. And if theyre sucking on sugar lozenges, thats going to increase their exposure and is going oo make a difference. And so, um, when a patient has oral discomfort, we need to figure out what that patient is doing because we may find that what that patient is doing increases his or her risk of developing an increased risk of caries. And then there are some diseases that have an effect on enamel and the enamel is less well mineralized. And those patients will have an increased risk because the enamel is not as, is not as protected as it ought to be.

[4] Dental Caries and HIV Disease

Im going to tell you about a study that I was involved in, and this is the one that got me into this lecture in the first place. But for a number of years I was part of a multi-centered study, looking at the effects of HIV in women. The study was started because all of the studies before that had been primarily in men and it was the National Institute of health that believed it was time to get a study that spent more time studying the effects in women. And so that was when we started. And so, in that study we looked at a number of different components. All of the patients, subjects that were a part of the study had examinations done on a regular basis, we calibrated the examinations, and we pooled all our resources. At baseline, we started out with 584 HIV positive women and 151 HIV negative women, and that was our initial cohort. By the time we got the 5th year of this study, the number was reduced. It was interesting if you actually look at the study. Because the big drop was actually between year one and year two. And it had nothing to do with death of subjects, they just dropped out at the first visit and it was hard to get them back again. So by the time we got to the fifth year, we had 240 HIV positive women and 66 HIV negative women. And we did the examination every 6 months. And the study took place here in NY. And we had patients that we saw in the Bronx. We saw patients here at NYU. We saw patients at a hospital down the block a bit. There was a component of the study in Chicago, in a component in San Francisco and another component of the study in Los Angeles. And we would get together on the telephone and we would get together for annual meetings to try to keep this whole thing together. It was a sub-study of a much larger study that included more, more sites but did the entire social framework of women in HIV in addition to the medial component.

[5] Data Collected

So in our study, we were able to take the caries data that we collected and transform it into DMFS and DMFT, and DFSs, and DF, root surface [she kind of stuttered through that, but in the slide it says DFSrc] caries, and if those arent familiar to you yet, they will be at some point in your career here. In addition to the caries information, we documented the individuals ages, the womens race, their ethnicity, their anti-retroviral therapy, their smoking status and their stimulated and unstimulated salivary flow. And everyone had salivary flow collected, so we were actually in this study able to talk about hyposalivation because we had some measured salivary flow.

[6] Results

And somehow, in our study, this was the results. And both the baseline and at 5 years, the HIV positive women had a statistically significant higher coronal caries prevalence, when you measured it by DMFS. And um, this was associated with low, unstimulated and stimulated salivary flow. We didnt find any difference in root caries and the analysis didnt show any difference in caries incidence between the two groups. So we could find a difference in prevalence but we couldnt find a difference in incidence. And the difference was there at the very first examination.

[7] What is causing the difference?

So, the question then becomes, whats causing the difference? Well, we did have some information that it might be salivary flow. Because we had measured salivary flow. Another possibility was that most of our HIV positive women had access to Medicaid. Most of our HIV negative women did not. So there is a possibility, and we have to do, were probably never going to be able to tease this one out. The HIV positive women may have had more dental treatment than our HIV negative women. So what that means when youre doing a clinical assessment of caries, youre counting decayed, missing, and filled. Is it not easier to see a restoration than it is to see a very subtle carious lesion? So one possibility might have been that the HIV positive women actually had some of this might have been accounted for by their access to dental care, and the HIV positive [she said positive but I think she meant negative, like she said before] women didnt. We think that the medications in HIV probably affected their salivary flow and there are a number of medications that the women were using that contained a high sucrose content. And so it may have been the sugar content of some of their medications. And so when we look at this, one of the things that Id like to say, and Ill probably say it over and over again in this presentation, and that is, association is not causation. And I think you probably have heard that from your SAPL program, yes? Its come up before, and so when we see an association, and most of what Im going to show you in looking at the increased risk of caries related to systemic diseases and some other conditions doesnt mean that that disease itself is the cause. It may, but trying to get that information requires studies that really are able to tease out all of the different factors that might be involved in, in, in causing that increased caries risk. What it does mean for you practically is that when you are doing your medical assessment of patients and youre finding out about their diagnosed diseases, their review of systems and their medications, and you will learn as you begin to assess patients, that, and I think you did a little bit of this last year in the clinics, in the program that we did between 4 and 6, you did get a chance last year to do some work in the clinic. That um, that when you take the history on your patients, there are really going to be 3 parts on the medical history. One of them is going to be the outright medical history that tells you what it is that the patient knows he or she has. So youll be able to get a list of the diagnosed diseases that the patient knows about. And then we have a technique that we call the review of systems. And the review of systems is, have you ever had any problem with your heart? Have you ever had any problem with your circulation? Do you have any problem with bleeding? Do you have any problem with your skin? And we have a whole list of questions. And the idea of the review of system is to try and get the patient to tell you about something that got missed in the medical history. And finally in that package, we get the patient to list every one of his medications. That should all match. So every disease that needs a medication should have a medication. Every abnormality identified in the review of systems should have a disease attached and every medication should either, should have some reason for it begin there. So the diseases that should be treated should have their medication, and the medication should have a disease. So when youre taking this history, youre going to be able to get the kind of information that you need to get to know that this patient may have, may or may not have, but may have an increased risk of developing dental caries. And then you can move from there. Youre going to do your examinations and youre going to find out whether you can actually measure that risk. But for some patients, there is a delay from the time that you first see the patient to the time that you may see, especially a patient that develops a dry mouth and starts taking a new medication, you may not see the increase in caries for 6 months or even a year if the patient just started taking a medication and just began at the time of you first interviewing the patient to have a dry mouth. Or, if that patient just started popping life savers for whatever reason, you may not see the result of that change in behavor for a very very long time. So youre doing some detective work when youre doing your medical history, review of systems, your medications. And also when you do your dental history and you ask about habits. You might get a lot of nos. But the yeses that you do get are going to be important in trying to figure out the best way to treat that patient that you are taking care of at this point in time.

[8] Johnston L and.

Um, this is another study that just came out. And its doing something similar. What they did, there was a registry that they used from the University Of Pittsburg School Of Dental Medicine. And um, they were able to get information on DMFT, and DMFS. They were able to pull over 1000 patients. And in this study, we are not talking about how the study was done at this point, but I just want to show you what they found. They found a number of medical problems that seem to be, from their uh, their analysis, to be associated with a higher caries experience. Hepatitis, asthma, high blood pressure, stroke, liver disease, and diabetes were the ones they found in this study. Now again, I put down on the bottom that association isnt the cause. And it doesnt tell us that disease itself is the cause. But its probably something about that disease that puts the patient at higher risk of developing caries.

[9] Systemic Diseases that may cause increase caries risk

So I pulled the literature for whatever I could find that suggested um, a systemic disease that might be, that might increase caries risk.

[10] Psychiatric Disorders

Psychiatric disorders. The reason that psychiatric disorders are probably associated with an increased risk of caries or increased caries experience is a better way to put it, is the medications. And the medications that some patients with psychiatric disorders are taking dramatically decrease saliva. And you wil see someof these patients with a saliva that is so dry that you can barely slide your finger along the mucosal surfaces. So again, when you have a patient that in your medical history gives you a history of depression, or a history of psychiatric problems that you might have to pursue a little more carefully, look carefully at that patients medications, find out whether that patient is experiencing um, any kind of decrease in salivary flow. And then if you are really being thorough, you may want to measure that patients, that patients unstimulated and stimulated flow. Which of those flows stimulated or unstimulated is going to be most affected by the medications? How many think stimulated? How many think unstimulated? Okay. Its unstimulated. Um, usually, except for one drug that isnt used very often, and thats lithium. Lithium actually destroys salivary tissue. So once you start destroying salivary tissue, then you cant get stimulated flow either. But the effect of medications most of the time is on unstimulated flow. And thats why patients can be so successful at something like lozenges to stimulate, because theyre stimulating, and the stimulated salivary flow works pretty well.

[11] Autoimmune Disease

Ok. Um, weve talked a bit about Sjogren syndrome and primary and secondary. Secondary is, to be as simple as possible, Sjogren syndrome is another autoimmune disease, but it is Sjogren syndrome that is responsible for a progressively decreasing salivary flow. In Sjogren syndrome, its both unstimulated and stimulated because they are losing their salivary gland tissue. The salivary gland acini are being replaced by? Last lecture. By. Nope! I dont mind if you say the wrong answer, Im just happy if you participate. So its not replaced by connective tissue. That would be fibrosis, and there are situations where that could happen. But in Sjogren syndrome there is something very specific that happens in the salivary glands that replaces those acini. Its an autoimmune disease, and were talking about a disease thats related to immunologic cells and if were going to have an autoimmune response to salivary gland tissue, what cells do you think are going to come in there? Pick one of the white blood cells. And its not neutrophils. Lymphocytes. So, and, in Sjogren syndrome, its usually CD-4 Lymphocytes that come into the, that come in and just completely over time replace the salivary gland tissue is Sjogren syndrome. And Im a little concerned that we talked a little too much about Sjogren syndrome but I, I think youve talked about it at least once and you didnt remember so we can do it again. Well talk again in GP when we get to autoimmune diseases. So, in SS a couple of things that happen. One of them is decreased salivary flow. Both unstimulated now and stimulated because they dont have any salivary glands left to stimulate. And its progressive, so it gets worse and worse and worse and worse over time. Also, they have a problem with a fungal infection candida. And youve done some candidiasis with Dr. Shah and one of the medications that is sometimes used for oral candidiasis is nystatin, and its a liquid. Nystatin suspension. The problem with nystatin suspension is that it is absolutely loaded with sugar. And the company that makes it believes that it tastes so terrible that they have to put sugar in it to mask the taste. So those patients that are using that on a regular basis can have a problem with caries. There are other antifungal medications and when we do catch a patient that has been using that medication, we usually try to, the others that are very successful and we have some that are there are others that are quite a bit better and we will talk about that in infectious diseases a little later. And then these patients are going to attempt to stimulate salivary flow and in their attempt to stimulate salivary flow, they are going to, if they arent trained, theyre going to try to use something with sugar and its our responsibility to help them. Youre going to learn all kinds of wonderful preventive techniques. I m not going to talk about those in this lecture but for a SS patient, we put in gear our whole preventive package for those patients to try to prevent disease.

[12] T-cell mediated immune disorders

Um, candidiasis is a condition that tends to happen in those patients with T-cell mediated disorders. And um, HIV infection is one of those. There are some congenital T-cell mediated disorders. And T-cells seem to be critical in preventing the development, the over, the overgrowth of candida. So if a patient has a problem with candidiasis and is taking Niastatin, particularly, the, well actually the only one that will work orally is the suspension.

[13] Diabetes Mellitus

Ok, there is, well the first slide I showed you from Pittsburg, actually from that study, diabetes came up on the list of people that seem had, that seem to have an increased caries experience. There are really conflicting results in diabetes. The, one of the best studies I could find was this one in 98. And this one was not able to find a difference between patients with diabetes and patients that didnt have diabetes. So they just couldnt find an effect of diabetes on caries experience. I think the um jury is still out on diabetes and there will be more studies looking at the different ways, or the different factors. In diabetes we have some changes particularly in the innate immune responses. It is possible that something about this disease might be related to caries but it is really not teased out at all.

[14] Asthma

Um, there has been some work with Asthma and it appears that people with asthma have an increase in their caries experience. And the first study that I picked was a systematic review that came out in 2011 and they saw the increase in caries experience in the asthmatic patients. But they also recognized that they could not identify from that systematic review and the papers they were looking at it, the reason for it. And again, association is not cause at this point. What is causing the problem in asthmatics. In 2013, another study was published and in this one, they found a couple of things that were measurable. They found that there were a couple things about asthmatics and their medications that seemed to increase the level of LB. maybe thats part of the answer for the story. And those patients that had more severe asthma tended to have a low salivary flow rate. That flor is misspelled. Its salivary flow rate. On the slide, I just see that there is a misspelling. And so were talking about salivary flow rate there. So maybe these are the reasons. So again, its probably not the disease itself, its probably something about how the disease is managed or um probably um related to the medications. But again, its trying to tease out what it is about the disease that might put the patient at risk. Um this one is not understood at all.

[15] beta-thalassemia major

Um, there is an inherited disorder in the hemoglobin molecule, its called beta thalassemia, and there is a major, there is one that s called major and one that is called minor. We will talk about it when we get to genetics a little bit later. And there have been a couple of studies that have shown that these patients have had an increased caries prevalence when you combine them, when you compare them to a general population. It isnt clear why but there are more than one study that is able to see that. So its one of them that is out there. And in the recommendations for managing patients with this condition, the dental component is high on the recommendations for how these patients are managed by their medical providers, that their medical providers are expected to get these patients to dental care.

[16] Hypophosphatasia

There is a condition known as hypophosphatasia. And in this condition there is a problem with the mineralization of the tooth structure. And the same kinds of factors that might not cause caries in a person with intact tooth structure seem to put these patients at an increased risk of caries.

[17] Bulimia and Anorexia Nervosa

There are two eating disorders, bulimia and anorexia nervosa. they are different and there is a spectrum of eating disorders. Bulimia is the one where individuals vomit after they eat. And um, in order to be able to eat and get rid of the calories and the nutrients. And in anorexia nervosa, those patients in that category, and again well talk about this a little bit more later on, in that category the individual with that problem just dont eat. So there are two different categories or a spectrum of eating disorders. But here the problem in bulimia is dental erosion, not dental caries. But these individuals, they tend, with the problems that theyre having tend to have an increased sucrose intake, which is probably the reason for the reporting of increased caries experience.

[18] Allergy

In allergy, a number of the anti-histamines are xerostomic and that seems to be at least, excuse me, the most likely reason for those individuals having an increase in caries activity.

[19] Hypertension/High Blood Pressure

The medications associated with high blood pressure are just about, not everyone, but many of them, and many blood pressure patients are taking multiple medications will decrease salivary flow.

[20] Medication Induced Xerostomia

Um, and so heres a category, or a list of categories of those medications that are associated with xerostomia: antihistamines, decongestants, antidepressants, antipsychotics, antihypertensives, antiretrovirals, diuretics, and at the end of this year youre gonna have a course in pharmacology and you will have to learn about these in great detail. I am not in this lecture asking you to know about the mechanism of these, but I do think that you should know the categories and you can fill in the names of the medications later. Right now, one of the things for you and the generations of dentists following you, its very easy for you to look up medications. All you have to do is put the name into your cell phone or whatever personal device youre carrying around and you get all of the information about the patients medications. In our clinics we are going to ask you to look them all up. The more you look them up, the more youas we go into the era of our - electronic health record, youre going to be able to look them right up in the electronic records and be able to get that information, so the world is going to get easier and easier for you I think.

[21] Methamphetamine Associated Dental Caries- Meth Mouth

I want to spend a couple minutes and I think youve already talked about meth mouth, at least the group last year had. Has anyone talked about meth mouth yet? Ok. Some of you will see patients with this condition. Not all of you, but you need to be aware that its out there and many of the patients that develop this problem are functioning. Theyre not people that are homeless and out on the street. Theyre not street people ,theyre actually people that are working a full week and doing this meth thing on the weekends, and develop this very very destructive dental problem, and its called meth mouth.

[22-24] Pictures of Meth Mouth

And Ill show you some pictures. The teeth just fall apart. By the time the problem is identified, the teeth are disintegrating. And it will happen very very quickly. What will happen is the tooth will look intact and it will just collapse; it will fall apart because what will happen with this material, this chemical is its just destroying the integrity of the mineralization and the protein matrix of teeth so they can look pretty much intact for a little bit and then suddenly, they just, they collapse as if, its like a building just collapsing on itself.

[26] What are the Effects of Crystal Meth?

And so, um, crystal meth, or methamphetamine is a schedule [?] to a substance and it isnt a legal substance. Its very addictive. And it, its a stimulant. Its smoked usually, using glass pipes that are similar to the pipes that have been use in, in other setting s to smoke crack cocaine. And there are number of street names for this condition. Um the people that are, Ill call them the functioning group, they are the people that are working all week and doing this on the weekend, have actually gotten a lot of information about meth mouth. So I think over time we will see it less and less because they have begun to learn how to protect their teeth from the damage thats caused by this material. So, the high lasts about 8 hours, what Ive uh, in interviewing people that have been involved in using meth, what they tell me is they can start on Friday night and they can go until Sunday, and they come down from their highs on Sunday night and then they go back to work on Monday morning. So theyre kind of doing this for the whole weekend. It gives them a rapid heart rate. They increase blood pressure. There is a risk of stroke associated with the use of, with the use of this material. And in some settings, there is paranoia, confusion, they can have, uh psychotic symptoms. It isnt a really nice, uh its not for everybody a very very nice high.

[27] Effects of meth cont: functioning individual may use.

But they develop during their week during the time theyre using this, an intense dry mouth. During the time that theyre doing their meth thing, usually their dry mouth just comes along for the ride, its as they come off the high that they, that they begin to recognize how dry their mouths are. When their mouths are so dry that its difficult for them to swallow and they dont eat. So as they come off, theyre intensely thirsty, and theyre very very hungry, and they drink gallons of Gatorade. Well, if you look at the contents of Gatorade, again, its not what you would recommend if you were giving somebody something in this condition to prevent caries. They crave beverages that have very high sugar content. So what theyre doing, theyre coming off their high, theyre very thirsty and theyre increasing their sugar intent dramatically.

[28] Crystal Meth Effect on Teeth

The drug itself is acidic and you can imagine what an acidic drug will do to the tooth structure. And the drug is also xerostomic. So in addition to having an effect on the tooth structure itself, it will also has an effect on the persons thirst, and um, the drug use, as I said before, results in cravings for very very high caloric beverages.

[29] Rampant Caries Associated with Methamphetamine Use

So what has been identified as meth mouth has been a dramatic increase in smooth surface caries. Now thats not what you see when youre going to do your exams. Smooth surface caries is unusual. So anybody that develops caries on the smooth, buccal, particularly the buccal surfaces and the labial surfaces of the teeth, something is going on that is different, a different kind of caries from the, if we want to call it routine caries that is getting less and less routine I hope. And then, they develop caries on the interproximal surfaces of anterior teeth. Now, um, the interproximal surfaces of posterior teeth are usually at higher risk of teeth for caries than anterior teeth. And then the teeth, in addition to caries, the teeth disintegrate because of the acid effect on teeth.

[30-31] Pictures of Meth Mouth

And so, this is the kind of disaster that you may see. And weve had a couple of students that have worked here with patients with the disastrous effect of meth on teeth. Here you can see, that dramatic disintegration. Its a combination of caries and just destruction of the tooth surface. Hold on just a minute, I want to say something before I forget. In a patient with bulimia, a patient with bulimia is vomiting. So that individual, you will see erosions on the lingual surfaces of teeth because those are the surfaces of the teeth that are exposed to acid. And so youll see a very very smooth, uh, erosion on the lingual surfaces and it is usually more severe on the anterior than the posterior and more severe on the maxillary than the mandibular. Here, acid materials coming from the outside, so you tend to see destruction even more dramatically on the labial and the buccal surfaces. Where as in bulimia you see it on the lingual surfaces. And then bulimia, its very smooth. Ill show you a picture when we get to our nutritional piece of general pathology where you get to see the smooth erosion in bulimia. You had a question. [student question] Oh, I would have probably have to extract many of these. If you look down here, we have some perio, bad, serious perio problems as well. So, yeah no, whether or not, no, if you look over here I dont think you could restore these. And thats usually what is happening. Trying to get this early ad trying to stop this early would salvage some teeth but many people with meth mouth have ended up with uh, with complete dentures. And some of them with implants.

[32] Factors that May Affect Caries Experience

Okay. So, were back to the beginning. When we talk about factors that affect caries experience, we have medication, and we have a whole host of medications for whatever reason people are taking them, and you will be come, by the end of this year you will become so knowledgeable in diseases and medications you wont even recognize yourself. Diet, you already know. And when patients have difficulty eating and their diet changes, and youre going to be, youre going to learn how to assess patients diets, how to recommend an appropriate diet for them. And so youll be working on this as well. Weve talked quite a bit about salivary flow, I dont have to mention that any more than just to put it on the list. Weve talked about those patients that are doing things to reduce their oral discomfort that can put them at increased risk for dental disease for caries. And effects on enamel, whether or not theyre developmental effects or whether or not theyre exogenous effects on enamel is part of your, part of the detective work in assessing your patients as you see them initially and then as you follow your patients, um, through, after you graduate, through the years of your practice.

[33] What to study for this lecture

So, this is what I think you need to focus on when youre studying for this lecture. I would like you to be able to look at the HIV study and describe the possibilities and, for this one, I would love to be abe to give you an open ended, um, open ended, non-multiple choice test but it doesnt go that way. And I can do it in general pathology, but only with one word, not an explanation. But I want you to understand how that study went and the kinds of things we looked at. I would like you to look at the systemic diseases and be able to list them, that we talked about because I think that if you have those systemic diseases in your rolodex in your head when you patients come through with a history of those disease youll be thinking about what you might be doing to prevent caries in those patients. And then I would like you to know what the results are on teeth of crystal meth. And that should do it for what you should know for this lecture.