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  1. UAB GECFaculty Scholars Program Lillian M. Mitchell, DDS, FACP UAB School of Dentistry Director, Geriatric Dentistry 2009 UAB Geriatric Education Center Faculty Scholar May 30, 2014

  2. Oral/Systemic Links:Critical Health Issues for the Complex Older Adult

  3. Oral Health is vitally important-especially in the older adult • Mouth is beginning of the digestive tract • Portal for all foods and nutrients to sustain life • Critical to the prevention of chronic and acute illnesses • Direct link to overall health and quality of life • Decreases overall health expenditures

  4. Overview: Impact of Periodontal Disease on CVD, Diabetes, other systemic issues • Periodontal disease: • Impacts CV risk factors • Linked to development of arterial disease • PD linked to cardiovascular events • PD treatment affects CVD • PD linked to Diabetes mellitus • PD linked to Respiratory disease • PD linked to arthritis and osteoporosis

  5. What do we know? • Our population is living longer • Living with chronic diseases

  6. Chronic DiseasesLeading cause of Death & Disability in US • 7 out of 10 deaths among Americans • Heart disease, cancer, stroke – more than 50% of all deaths each year • 1 in every 3 adults is obese • Arthritis - most common cause of disability • One quarter of those with chronic conditions are limited in daily activities • Diabetes-leading cause of kidney failure, non-traumatic lower extremity amputations, blindness

  7. Trends in population: • People are living longer • Most older adults are community dwelling • Between 2000 and 2050: 65+ pop. grows from 12.43% to 20.65% 85+ pop. grows from 1.51% to 4.97% One quarter of the population will be over the age of 65 by 2050! (36 years from now) P.Glassman, P.Subar. Journal of Public Health Dentistry, 2010

  8. Changing Demographics • Average life expectancy has increased approximately 3 decades since early 1900’s • Avg American male today will live to be 76 yrs old • Avg American woman today will live to be 81 yrs old • Women represent the larger portion of the 65+ and 85+ age group • The 85+ group is the fastest growing segment of the US population

  9. Oral health <> General health Connected-cannot be separated

  10. Four Common Causes of Chronic Diseasefour modifiable health risk behaviors • Lack of physical activity • Poor nutrition • Tobacco use • Excessive alcohol consumption

  11. Lack of Physical Activity • 1/3 adults do not meet recommendations for aerobic physical activity • In a 2008 survey, 23% of adults reported no leisure-time physical activity at all in the preceding month

  12. Poor Nutrition • Only 24% of adults reported eating 5 or more servings of fruits and vegs per day • Less than 22% high school students

  13. Tobacco Use More than 1 in 5 American adults smoke Compared to non-smokers, women who smoke are 13 times more likely to get lung cancer Smoking causes 80% lung cancer deaths in women 90% of lung cancer deaths in men Also-larynx, mouth, throat, esophagus, bladder, kidney, pancreas, stomach, acute myeloid leukemia

  14. Excessive Alcohol Consumption • Increased risk of breast cancer with increasing alcohol intake found in more than 100 studies • Drinking alcohol is a risk factor for primary liver cancer found in many studies • More than 50 studies report the link between alcohol consumption and colon (colorectal) cancer

  15. World Health Organization • “Elderly” Population between 65 and 75 yrs • “Old” between 76 and 90 years • “Very old” over age 90

  16. “Very Old Teeth”100 year old woman

  17. Systemic Conditions at Higher Risk in an Older Population • Arthritis • Cancer • COPD • Diabetes • Cardiovascular disease • Hypertension • Mental Health conditions • Osteoporosis • Parkinson disease • Stroke • Sensory deficits

  18. Oral Conditions at Higher Risk in an Older Patient Population • Caries • Periodontal Disease • Traumatic Injuries • Cancers of the Head and Neck • Oral Mucosal Lesions • Oral Manifestations of Systemic Diseases

  19. Elderly adults are retaining their teeth longer • Must evaluate the patient’s oral health in context with • Social, cultural, educational, economic, psychological, and dietary life experiences • Quality of Life!

  20. Common Findings in Geriatric Medicine/Dentistry High prevalence of chronic disease Frequent use of medications Difficulty in getting complete history Difficult to obtain appropriate consults

  21. Why is Oral Health Important for the Older Adult? • Affects the ability to consume and enjoy an adequate diet • Can affect body weight • Impacts nutritional and systemic health • Links between Periodontal disease and Cardiac health; respiratory conditions; diabetes mellitus; stroke

  22. What is more important? • Chronological age • Functional status

  23. Functional status in dentistry Ability to travel for care and seek services Ettinger, RL. Oral Health and the Aging Population. JADA 2007;138(suppl_1)5S-6S

  24. Functional Definition of Older Adults • Functionally independent older adults • Frail older adults • Functionally dependent older adults • 70% of the elderly population (or 23.2 million older than 65 years) live in the community and visit the dental office independently

  25. Medicare Current Beneficiary Survey • Reveals that preventive dental care reduced dental bills and out-of-pocket payments by beneficiaries • They may have more dental visits, but pay lessfor total dental care

  26. Medicare Current Beneficiary Survey • Beneficiaries in worse overall health status, with more physical and health limitations and difficulties with daily activities, were concentrated in the group that did not visit a dentist for any reason! Moller et al. American Journal of Public Health, November 2010, Vol 100, No. 11

  27. Significant barriers exist for needed dental care of the older adult • People 65+ have more caries (decay) than children living in non-fluoridated areas • Each decade the # of decayed or filled root surfaces increases affecting more than ½ of all remaining teeth by age 75 • Majority > older adults > periodontal disease

  28. Barriers • Lack of perceived need for care • Declines in functional status is associated with lower levels of dental service use

  29. Incidence and Impact ofPeriodontal Disease • Most older adults are at risk of developing PD because they have teeth!! • 52% have lost fewer than 5 teeth • Men more serious than women • 26% are edentulous and not at risk

  30. Incidence of Periodontal DiseaseData reported by CDC-NHANES-2009-10 • 50% Americans > 30 y/o have PD • 70% Americans > 65 y/o have PD PD one of most prevalent chronic diseases, Similar to CVD and DM Many patients don’t know they have it! Published online before print JDR Aug 30, 2012

  31. Cardiovascular Diseaseno longer a “Man’s” Disease • Cardiovascular disease includes coronary heart disease, high blood pressure, stroke • Leading cause of death among all American women~38% of all female deaths • In women 60+ yrs old- deaths are reported at 59% in developed countries from CVD • Female heart attack victims-60% die suddenly; 46% survive-will be disabled by heart failure in 6 years

  32. American Heart Association 2011 US Statistics • Approx 2,200 people die of CVD each day • An average of one death every 39 seconds • More than 150,000 people <65 yrs old were killed by CVD in 2007 • Death occurred well before average life expectancy of 77.9 years Roger,V.L. et.al. Heart disease and stroke statistics-2011 update. Circulation 12/15/2010

  33. Risk Factorsfor Cardiovascular Disease • High total cholesterol • High triglycerides • High blood pressure • Low HDL • Smoking • Diabetes • Family history

  34. Oral Connections CVD • Side Effects of medication • Xerostomia (dry mouth; lowers pH) • Gingival hyperplasia • Taste impairment • Periodontal disease and CVD • Oral bacteria • Inflammatory process

  35. Greatest health threat and killer of Women and Men is Cardiovascular Disease • Adults, regardless of sex or ethnicity, are 2 to 3 times more likely to suffer a CV event, fatal or non-fatal, rather than a non-fatal death Feinstein,M et.al. Circulation July 2012; 126: 50-59

  36. Oral Systemic ConnectionsSAME Inflammatory Mediators • Periodontal Disease • Coronary heart disease • Rheumatoid Arthritis Gene sequence predisposing for CHD also predisposes for periodontal disease Oral bacteria were found in the synovial fluid in joints of individuals with RA Schaefer AS, et al. PLoS Genet. 2009 Feb:5(2) Ogrendik,M. Mod Rheumatol. 2009 Jun 24.

  37. AJC-JOP Editors Consensus PaperJuly 2009Dentistry and Medicine must work together to improve patient care • Confirmed the connection between PD & CVD • Explained the underlying biologic and inflammatory mechanisms that may be the basis for the connection • Provided recommendations for treating patients with periodontal disease or cardiovascular disease • C-Reactive Protein levels in pts with chronic PD fall in range of those with CVD Noack B,GencoRJ, Trevisan M,Grossi S, Zambon JJ, De Nardin E. Periodontal infections contribute to elevated systemic C-reactive protein level. J Periodontol. 2001; 72(9):1221-7

  38. European Society of Cardiology Consensus Statement on Perio Health and CVD • “oral health has an influence on systemic health in general and on CVD in particular” • We should “promote oral health and periodontal health as an important component in the prevention of CVD.” Sanz,M: European Society of Cardiology April 2010

  39. Based on evidence that Periodontal Disease is independently associated with Vascular Disease ALL Cardiovascular prevention programs must include an oral/systemic component

  40. Evidence Periodontal Disease couldimpact CV risk--- • What known CV risk factors does PD influence???

  41. Study: Bacteria causing PD linked directly to Hypertension • 653 ‘healthy subjects’ > 55y/o tested for PD bacteria • Actinobacillus actinomycetum comitans (A.a.), Porphyromas gingivalis (P.g.), Tannella forsythensis (T.f.), and Treponema denticolor (T.d.) • Highest tertile of the burden of these VS lowest tertile: 1) Significant increase in Blood Pressure which creates significant increase risk for ischemic stroke and heart attack (Systolic BP 9mm Hg higher; Diastolic BP 5mm Hg higher) 2) Pt’s in highest tertile 3X more likely to have HTN Adjusted for age, race/ethnicity, sex education, BMI, smoking, DM, cholesterol levels M.Desvarieuxa, et.al. Journal of Hypertension 2010, 28:1413-1421

  42. Study: Bacteria causing PD linked directly to Hypertension • It was the concentration of the bacteria & NOT the clinical diagnosis of PD which correlated with Blood Pressure • Makes the case for checking the “burden” of bacteria and realizing that “subclinical” PD can harbor significant infection NOT the clinical diagnosis of PD which correlated with Blood Pressure

  43. Periodontal Diseasealso impacts CV Risk via: • Lipid changes: HDL • Sugar changes: HgA1c & Type 2 diabetes • Arterial inflammation-PD negatively impacts the biomarkers used to monitor arterial health • (If artery is “hot” the patient is in peril) • Toll-like Receptors- PD has association with Insulin Resistance

  44. Evidence supporting PD is associated with development of Vascular disease • PD is Independent risk factor CHD • 2008 USPreventionServicesTaskForce performed exhaustive review of prospective cohort studies • Incidence of CHD in ”healthy” subjects with no known CV risk factors; follow up 5 – 21 years • Concluded: Periodontal Disease is an independent risk factor of Coronary Heart Disease Humphrey LL, MD, et al J Gen Intern Med, Sept 2008, 23(12) 209-2086

  45. Other associations with Periodontal DiseaseEvidence PD is associated with CV events • Study of Pima Indian tribe; PD & CVD mortality with Type 2 DM-median f/u 11 yr • Prospective study 628 subjects; • 204 died from CVD Saremi,MD,et al American Diabetes Association,Diabetes Care, 2005; 7-9

  46. Other associations with Periodontal Disease • Periodontal pathogens are found in Carotid Atheromas (plaques) • Study PD & CVD Mortality/Type 2 Diabetes • Cardio renal mortality; no PD-no deaths! • Severe PD: 3.2 times risk for death • Other studies demonstrating increased CV event risk with Periodontal Disease