Health, Oral Health, and Elderly Quality of Life

Narumanas KorwanichDepartment of Family and Community Dentistry

Chiangmai University

What is Oral Health? Linkage with General Health

The Mouth as a Mirror of Health The Mouth as a Portal Entry of Infection Association of Oral Infection, Diabetes, Heart

Disease/Stroke, and Adverse Pregnancy Outcome

Effect on Well Being and Quality of Life Thailand Study

The Meaning of Oral Health Oral health means much more than healthy teeth

Traditionally, dentists have been trained to recognise and treat disease such as caries, periodontal disease and tumors

The Meaning of Oral Health Being free of chronic oral-facial pain conditions, oral

and pharyngeal (throat) cancers, oral soft tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues, collectively known as the craniofacial complex.

U.S. Department of Health and Human Services, 2000

The Meaning of Oral Health They represent the very essence of our humanity. They allow us to speak and smile; sigh and kiss; smell,

taste, touch, chew, and swallow; cry out in pain; and convey a world of feelings and emotions through facial expressions.

They also provide protection against microbial infections and environmental insults.

U.S. Department of Health and Human Services, 2000

The Meaning of Health Oral health is a standard of the oral and related

tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being

WHO, 1982

The Meaning of Oral Health

A comfortable and functional dentition which allows individuals to continue in their desired social role

Dolan, 1993

• The mouth and face as a mirror of health• The Mouth as a Portal Entry for Infection•Association of Oral Infection and DM, Heart Disease, and Adverse Pregnancy Outcome

The Mouth and Face as a Mirror of Health A physical examination of the mouth and face: signs

of disease, drug use, domestic physical abuse, harmful habits or addictions such as smoking, and general health status

Imaging of the oral and craniofacial structures: skeletal changes e.g. osteoporosis, salivary, congenital, neoplastic, and developmental disorders

Oral cells and fluids, especially saliva: assess health and disease

HIV infection oral manifestration

Nutrition Deficiency

Iron Deficiency

Vitamin B Deficiency

Sampled analyte of SalivaCategory Analyte

Drugs of abuse AlcoholAmphetamineBarbiturateCocaineLSDMarijuanaNicotineOpiate

Antibody HIVHPVHHV

Toxin CadmiumLeadMercury

Category Analyte

Hormones CortisolProgesteroneTestosteroneSubstance PMet-enlephalin

Therapeutics AntipyrineCarbamazepineCyprofloxacinIrinoticanLithiumMethotrexatePhenytoinePhenobarbitalTheophylline

The Mouth and Face as a Mirror of Health Conclusion

For the clinician the mouth and face provide ready access to physical signs and symptoms of local and generalized disease and risk factor exposure

Oral biomarkers and surrogate measures are also being explored as means of early diagnosis

The Mouth as a Portal Entry for Infection Oral microorganisms and cytotoxic by-products

associated with local infections can enter the bloodstream or lymphatic system and cause damage or potentiate an inappropriate immune response elsewhere in the body

Oral Mucositis from Therapy Chemotherapy alters the integrity of the mucosa and

contributes to acute and chronic changes in oral tissue and physiologic processes (Carl 1995)

Bacterial, fungal, and viral causes of mucositis have been identified (Feld 1997)

Sonis, et al 2007

Infective Endocarditis Endocarditis is caused by bacteria that adhere to

damaged endocardium(Weinstein and Schlesinger 1974)

Bacteremias from oral infections that occur frequently during normal daily activities, coincidental even with chewing food, toothbrushing, and flossing, contribute more substantially to the risk of infective endocarditis (Bayliss et al. 1983, Dajani et al. 1997, Strom et al. 1998).

Infective Endocarditis Risk factors

Rheumatic and congenital heart disease complex Cyanotic heart disease in children Mitral valve prolapse with regurgitation

Oral Infection and Respiratory Disease Chronic obstructive pulmonary disease, characterized

by obstruction of airflow due to chronic bronchitis or emphysema and by recurrent episodes of respiratory infection, has been associated with poor oral health status (Hayes et al. 1998, Scannapieco et al. 1998)

A positive relationship between periodontal disease and bacterial pneumonia has been shown (Scannapieco and Mylotte 1996)

Oral Transmission of Infection Several studies provide evidence that when the oral

environment is compromised, the mouth can be a potential site of transmission of infectious microbes

Oral transmission represented 7.8 percent of primary HIV infections (Dillon et al. 2000)

The Mouth as a Portal Entry for Infection Conclusion

Although oral tissues and fluids normally provide significant protection against microbial infections, but under certain circumstances, can disseminate to cause infections in other parts of the body.

The control of existing oral infections is clearly of intrinsic importance and a necessary precaution to prevent systemic complications.

Periodontitis - DM There is growing acceptance that diabetes is

associated with increased occurrence and progression of periodontitis

Diabetics have increased levels of systemic pro-inflammatory mediators

Diabetics have an altered response to wound healing and an abnormal immune response

Periodontitis - DM Diabetic patients had a worse oral hygiene and higher

severity of gingival and periodontal diseases, but they have the same extent of the periodontal diseases as compared to non-diabetics

Khader et al. 2006

DM - Periodontitis

DM - Periodontitis The interaction of periodontal bacterial byproducts

with mononuclear phagocytic cells and fibroblasts is known to induce the chronic release of cytokines (IL-1, IL-6, TNF-), PGE2 and CRP

Several recent studies have suggested that periodontal disease is a crucial aggravating factor in the health of patients with diabetes, mainly because it maintains a chronic systemic inflammatory process

DM - Periodontitis Darre’s study (2008)

Aim - To investigate that periodontal disease may favour the incidence or aggravation of diabetes and its complications

Material and Methods – Literature search from 7 databases were as input of meta-analysis

DM - Periodontitis The standardized mean difference in HbA1c with the

treatment of periodontal disease was 0.46 (95% CI: 0.11, 0.82)

These findings suggest that periodontal treatment could lead to a significant 0.79% (95% CI: 0.19, 1.40) reduction in HbA1c level

These results suggest that specific treatment of periodontal disease in diabetic subjects may improve their glycemic control

Periodontitis – Heart Disease Some studies have presented evidence of the presence

of bacteria and viruses in atheromatous plaques (Chiu et al. 1997, Johnston et al. 2001)

Majority of the clinical studies are seroepidemiological, reporting on associations between CHD and presence of serum antibody against the infectious agents (Mendall et al. 1994, Pasceri et al. 1998, Patel et al. 1995, Ridker et al. 1998, Saikku et al. 1992, Zhu et al. 2000).

Periodontitis – Heart Disease

Periodontitis – Heart Disease

Periodontitis - Preganancy Remote site infections, such as periodontitis, may

cause PTB through hematogenous transportation of specific pathogens, organisms, or inflammatory cytokines in the amniotic fluid or chorioamniotic membranes.

Periodontal disease during pregnancy has been postulated to be 1 of the causes of PTB and LBW infants

Several case-control studies suggested that periodontitis is an increased risk factor independent of other factors

Periodontitis - Pregnancy



Conclusion• The mouth and face as a mirror of health• The Mouth as a Portal Entry for Infection• Association of Oral Infection and DM, Heart Disease,

and Adverse Pregnancy Outcome

Cognitive Impairment 5 extracted molar versus 5 non-extracted molar rats

were compared to each other in learning ability and acetylcholine release in parietal lobe brain

To examine the effects of tooth loss on the central nervous system

Kato et al., 1997

5 Rats aged 11 weeks old kept in 23c, 50%humidity, 12 h light/dark

Extract all maxillary and mandibular molars

Test in radial arm maze

Test of Acetyl-choline releasing from parietal cortex

135 weeks

9 weeks

It has been demonstrated that the neuronal activity in the brain and the cerebral blood flow were increased by mastication

Thus, one possible explanation may be that the dysfunction of cholinergic neuronal system in the teethless aged rats is caused by the long term decrease of neuron activity of the brain and/or the cerebral blood flow by the loss of teeth

OIDP index

Tooth Loss and Quality of Life

Oral Health

Medical Concept

Bio – Psycho – Social Concept

Theoretical framework of consequences of oral impacts (Locker, 1988)

Disease ImpairmentFunctional

LimitationDisability Handicap

Death

Discomfort

Disease Impairment Functional Limitation Disability Handicap

Death

Discomfort

การสญเสยทางกายภาพ เกดความผดปกตทางโครงสรางหรอทางจตวทยา อาจเปนแตกำาเนดหรอเปนผลจากการเกดโรคหรอการบาดเจบ

ตวอยางเชน การสญเสยฟนทงปาก การสญเสยเนอเยอปรทนต การสบฟนทผดปกต

Impairment

เปนความผดปกตระดบแรกทดชนทางคลนกมงประเมนประเมนโดย professional

Impairments

การทำางานของรางกายระบบในรางกายหรออวยวะบางสวนถกจำากด

เชน การมปญหาเกยวกบการเคลอนของขากรรไกร

Functional Limitation

ภาวะทพพลภาพ คอ การทรางกายไมสามารถดำาเนนไปไดตามปกต อาจเกดจากการจำากดการทำางานของอวยวะบางอยางทางกายภาพ หรอ รวมทงการมขอจำากดทางจตวทยาและทางสงคมดวย

Disability สามารถจำาแนกไดเปน Physical disability, psychological disability และ social disability

Disability

เชน ความสามารถในการเคยวลดลง เนองจากการสญเสยฟนทำาใหไมสามารถ

กนอาหารแขงๆได

Physical Disabilityตวอยาง

Psychological disability ความรสกอบอายจากการสญเสยฟน หรอการเคยวทมปญหา Social disability

การหลกเลยงการเขาสงคม การหลกเลยงการกนอาหารรวมกบผอน ซงเปนผลจาก

ความสามารถในการเคยวลดลง

แนวคดในการพฒนา OHRQoL

การสญเสยโอกาส ซงเปนผลมาจากการจำากดการทำางานของรางกาย ทำาใหบคคลนนๆ ไมสามารถดำาเนนชวตไดเหมอนคนปกตทวไปในสงคม

Handicap

แนวคดในการพฒนา OHRQoL

Authors Name of Measure

Cushing et al. 1986 Social Impacts of Dental Disease

Atchinson and Dolan, 1990 Geriatric Oral Health Assessment IndexStrauss and Hunt, 1993 Dental Impact Profile

Slade and Spencer, 1994 Oral Health Impact Profile

Locker and Miller, 1994 Subjective Oral Health Status Indicators

Leao andSheiham, 1996 Dental Impact on Daily Living

Adulyanon and Sheiham, 1997 Oral Impact on Daily Performances

McGrath and Bedi, 2000 OH-QoL UK

The Oral Impact on Daily Performances

Adulyanon and Sheiham 1997

Theoretical model of consequences of oral impacts

Level 1 Impairment

Level 2Intermediateimpacts

Pain Discomfort Functional limitation

Dissatisfactionwith appearance

Level 3Ultimateimpacts

Impacts on daily performances

Physical Psychological Social

(modified from the WHO’s International Classification of Impairments, Disabilities and Handicaps)

Physicaleating and enjoying foodspeaking and pronouncing clearlycleaning teethdoing light physical activities

3 dimensions:Psychologicalsleeping and relaxingsmiling, laughing and showing teeth without embarrassmentmaintaining usual emotional state without being irritable

Socialenjoying contact with people

เพอเปรยบเทยบสภาวะสขภาพรางกายในประเดนตางๆ ระหวางผสงอายทมและไมมฟนในชองปาก โดยประเดนทจะทำาการศกษาไดแก ดชนมวลกาย (Body Mass Index; BMI) คณภาพชวตอนเนองมาจากสขภาพชองปาก (Oral Health

Related Quality of Life; ORH-QOL) ความสามารถในการเคยวอาหาร (Chewing Ability Index;

CAI) สภาวะโภชนาการ (Mini-Nutritional Assessment)

Sample ผสงอายจำานวน 600 คน อายตงแต 60 ปขนไป 4 กลม

ไดแก ผทไมมฟนเหลออยเลย และไมเคยใสฟน (edentulous

group) ผทใสฟนทงปาก (complete denture group) ผทใสฟนบางสวน (partial denture group) ผทมฟนธรรมชาต (natural teeth group)

Sample ตองมสภาพดงกลาวมาเปนเวลาไมนอยกวา 1 ป ตองผานการทดสอบความจำา ตองเดนมารบการตรวจเองได หากมฟนเหลออยในปาก ฟนทกซตองเปน functional

teeth ไมโยกเกน 2 degree ม crown เหลอมากพอทจะใชบดเคยว สามารถใชงานไดโดยไมมอาการเจบปวด

Edentulous group

Complete denture group

Partial denture group

Natural teeth group

กรงเทพ 30 30 30 30

เชยงใหม 30 30 30 30

พษณโลก 30 30 30 30

ชยภม 30 30 30 30

สงขลา 30 30 30 30

Material and method การตรวจในชองปาก

Tooth status ตามแบบตรวจชองปากของ WHO หรอการสำารวจของจงหวด

Occluding pairs MNA Anthropometry OIDP

MNA and Teeth Type

n Mean MNA SD

Edentulous 159 24.31 0.23

Complete Denture 188 24.14 0.21

Natural and Replace Teeth 156 24.80 0.24

Natural Teeth 159 25.54 0.19

MNA and Teeth TypeMalnutrition

/ Risk to malnutrition

(n)

Normal nutrition status (n)

Total (n)

Edentulous 33 121 154

Complete Denture 37 148 185

Natural and Replace Teeth

24 131 155

Natural Teeth 13 144 157

MNA and Teeth Type

Eden/** CD/** NRT/** NT/**

**/Eden 1.00

**/CD 1.09 1.00

**/NRT 1.49 1.36 1.00

**/NT 3.02* 2.77* 2.03 1.00

Odds Ratio for Malnutrition-Risk to malnutrition / Good nutrition among teeth type groups

Chewing and Teeth Type

Self reported problem on biting, n(%)No Low Fair High Total

Edentulous 39(24.7) 26(16.5) 29(18.4) 64(40.5) 158(100.0)Complete Denture 119(63.3) 41(21.8) 21(11.2) 7(3.7) 188(100.0)Natural teeth with replaced teeth

97(61.0) 42(26.4) 14(8.8) 6(3.8) 159(100.0)

Natural teeth 115(72.3) 28(17.6) 11(6.9) 5(3.1) 159(100.0)Total 371(55.7) 137(20.6) 76(11.4) 82(12.3) 664(100.0)


Self reported problem on chewing, n(%)No Low Fair High Total


94(59.1) 46(28.9) 14(8.8) 5(3.1) 159(100.0)



Self reported problem on chewing, n(%)No Low Fair High Total


142(89.3) 6(3.8) 6(3.8) 6(3.8) 159(100.0)



Eden/**Biting Chewing Swallowing

**/Eden 1.00 1.00 1.00**/CD 5.17* 5.90* 5.63***/NRT 4.69* 4.20* 4.38***/NT 7.84* 5.19* 3.86*

BMI and Teeth Type

n Mean BMI SD

Edentulous (Eden) 155 22.5 3.9

Complete Denture (CD) 185 22.5 4.1

Partial Denture NRT) 158 23.3 3.7

Natural Teeth (NT) 157 24.6 3.7

BMI and Teeth Type

Eden CD NRT NT

Eden NS NS p<0.05

CD NS NS p<0.05

NRT NS NS p<0.05

NT p<0.05 p<0.05 p<0.05

BMI and Teeth Type

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Health, Oral Health, and Elderly Quality of Life