Health, Oral Health, and Elderly Quality of Life

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Health, Oral Health, and Elderly Quality of Life

• Narumanas Korwanich
• Department of Family and Community Dentistry
• Chiangmai University

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• 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

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What is Oral Health?
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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

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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

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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

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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

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The Meaning of Oral Health

• A comfortable and functional dentition which
  allows individuals to continue in their desired
  social role
• Dolan, 1993

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Linkages with General health

• 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

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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

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HIV infection oral manifestration
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Nutrition Deficiency
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Iron Deficiency
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Vitamin B Deficiency
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Sampled analyte of Saliva
Category Analyte
Drugs of abuse Alcohol Amphetamine Barbiturate Cocaine LSD Marijuana Nicotine Opiate
Antibody HIV HPV HHV
Toxin Cadmium Lead Mercury
Category Analyte
Hormones Cortisol Progesterone Testosterone Substance P Met-enlephalin
Therapeutics Antipyrine Carbamazepine Cyprofloxacin Irinotican Lithium Methotrexate Phenytoine Phenobarbital Theophylline
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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

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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

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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)

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Sonis, et al 2007
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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).

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Infective Endocarditis

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

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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)

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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)

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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.

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Association of Oral Infection and DM, Heart
Disease, and Adverse Pregnancy Outcome
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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

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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

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DM - Periodontitis
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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

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DM - Periodontitis

• Darres 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

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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

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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).

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Periodontitis Heart Disease
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Periodontitis Heart Disease
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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

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Periodontitis - Pregnancy
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Periodontitis - Pregnancy
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Periodontitis - Pregnancy
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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

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Other Relationships
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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
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5 Rats aged 11 weeks old kept in 23c,
50humidity, 12 h light/dark
Extract all maxillary and mandibular molars
135 weeks
Test in radial arm maze
9 weeks
Test of Acetyl-choline releasing from parietal
cortex
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• 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

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Tooth Loss and Quality of Life
OIDP index
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Tooth Loss and Quality of Life
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Effect on well being and quality of life
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Oral Health

• Medical Concept
• Bio Psycho Social Concept

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Theoretical framework of consequences of oral
impacts (Locker, 1988)
Oral Health-Related Quality of Life Measure
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Oral Health-Related Quality of Life Measure
??????????????????? ??????????????????????????? ?
?????????????? ???????????????? ??????????????????
???????????????????
Impairment
???????????? ????????????????????
???????????????????????????? ??????????????????
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Impairments
??????????????????????????????????????????????????
? ?????????? professional
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Oral Health-Related Quality of Life Measure
Functional Limitation
?????????????????? ????????????? ?????????????????
????????
???? ????????????????????????????????????????
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Oral Health-Related Quality of Life Measure
Disability
???????????? ??? ?????????????????????????????????
??????? ??????????????????????????????????????????
?????????? ???? ??????????????????????????????????
????????????
Disability ?????????????????? Physical
disability, psychological disability ???
social disability
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???????????????? OHRQoL
????????
Physical Disability
???? ????????????????????????? ???????????????????
?????????????????????????????????
Psychological disability
????????????????????????????????
???????????????????????
Social disability
????????????????????????? ????????????????????????
?????????????? ???????????????????????????????????
???
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Oral Health-Related Quality of Life Measure
???????????????? OHRQoL
Handicap
??????????????? ??????????????????????????????????
??????? ??????????????? ???????????????????? ????
????????????????????????
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Authors Name of Measure
Cushing et al. 1986 Social Impacts of Dental Disease
Atchinson and Dolan, 1990 Geriatric Oral Health Assessment Index
Strauss 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
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OHRQoL
OIDP
The Oral Impact on Daily Performances
Adulyanon and Sheiham 1997
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Theoretical model of consequences of oral impacts
Impairment
Level 1
Level 2 Intermediate impacts
Functional limitation
Dissatisfaction with appearance
Pain
Discomfort
Level 3 Ultimate impacts
Impacts on daily performances
Physical
Psychological
Social
(modified from the WHOs International
Classification of Impairments, Disabilities and
Handicaps)
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OHRQoL measure
3 dimensions
Psychological sleeping and relaxing smiling,
laughing and showing teeth without
embarrassment maintaining usual emotional state
without being irritable
Physical eating and enjoying food speaking and
pronouncing clearly cleaning teeth doing light
physical activities
Social enjoying contact with people
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??????????????????????????????????????????????????
???????????? Effect of occluding teeth on
various health factors in Thai people
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• ????????????????????????????????????????????????
  ??????????????????????????????????????????
  ???????????????????????????????
• ??????????? (Body Mass Index BMI)
• ?????????????????????????????????????? (Oral
  Health Related Quality of Life ORH-QOL)
• ?????????????????????????? (Chewing Ability
  Index CAI)
• ????????????? (Mini-Nutritional Assessment)

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Sample

• ??????????????? 600 ?? ??????????? 60 ???????? 4
  ???????????
• ?????????????????????????? ???????????????
  (edentulous group)
• ??????????????????? (complete denture group)
• ??????????????????? (partial denture group)
• ??????????????????? (natural teeth group)

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Sample

• ??????????????????????????????????????? 1 ??
• ??????????????????????
• ??????????????????????????
• ?????????????????????? ?????????????????
  functional teeth
• ?????????? 2 degree
• ?? crown ??????????????????????????
• ???????????????????????????????????

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?????????????
Edentulous group Complete denture group Partial denture group Natural teeth group
??????? 30 30 30 30
????????? 30 30 30 30
???????? 30 30 30 30
??????? 30 30 30 30
????? 30 30 30 30
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Material and method

• ????????????????
• Tooth status ???????????????????? WHO
  ??????????????????????
• Occluding pairs
• MNA
• Anthropometry
• OIDP

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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
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MNA and Teeth Type
Malnutrition / 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
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MNA and Teeth Type
Odds Ratio for Malnutrition-Risk to malnutrition
/ Good nutrition among teeth type groups
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
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Chewing and Teeth Type
Self reported problem on biting, n() Self reported problem on biting, n() Self reported problem on biting, n() Self reported problem on biting, n() 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)
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Chewing and Teeth Type
Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n()
No Low Fair High Total
Edentulous 40(25.6) 32(20.3) 31(19.6) 55(34.8) 158(100.0)
Complete Denture 126(67.0) 39(20.7) 16(8.5) 7(3.7) 188(100.0)
Natural teeth with replaced teeth 94(59.1) 46(28.9) 14(8.8) 5(3.1) 159(100.0)
Natural teeth 102(64.2) 39(24.5) 15(9.4) 3(1.9) 159(100.0)
Total 363(54.5) 156(23.4) 77(11.6) 70(10.5) 664(100.0)
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Chewing and Teeth Type
Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n() Self reported problem on chewing, n()
No Low Fair High Total
Edentulous 104(65.8) 22(13.9) 15(9.5) 17(10.8) 158(100.0)
Complete Denture 172(91.5) 9(4.8) 6(3.2) 6(3.2) 188(100.0)
Natural teeth with replaced teeth 142(89.3) 6(3.8) 6(3.8) 6(3.8) 159(100.0)
Natural teeth 140(88.1) 11(6.9) 7(4.4) 7(4.4) 159(100.0)
Total 559(83.9) 48(7.2) 35(5.3) 35(5.3) 664(100.0)
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Chewing and Teeth Type
Eden/ Eden/ 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
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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
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BMI and Teeth Type
Eden CD NRT NT
Eden NS NS plt0.05
CD NS NS plt0.05
NRT NS NS plt0.05
NT plt0.05 plt0.05 plt0.05
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BMI and Teeth Type