Preventive Exam 3 [Periodontal Disease: Association with Diet: Marshall]

Chronic Diseases

Disease with a slow progression which once developed is slow to resolve

- Systemic: Obesity, hypertension, cardiometabolic disease

- Oral: Periodontal disease

Public health concern of chronic diseases

60% of adults have 1+ chronic diseases

42% of adults have 2+ chronic diseases

12% of adults have 5+ chronic diseases

Prevention is very important

Risk factor definition

An attribute or exposure that increases the chances of an outcome

- Nature: Not modifiable (Age, gender, genetics)

- Nurture: modifiable (smoking, alcohol use, diet etc)

An individuals risk is shaped by

by both nature and nurture

Periodontal disease

Complex chronic inflammatory disease

Initiated by dysbiotic microbial plaque biofilm below gingival margin

Immune-inflammatory response contributes to sequelae of event

- Destruction of connective tissue

- alveolar bone loss

- tooth loss

Etiology of periodontal disease

Interaction between pathogenic bacteria and host immuno-inflammatory response

Predisposing factors:

Host

Environment:

- Diet related

-- Obesity

-- Malnutrition

Obesity is a risk factor for many of our chronic systemic diseases:

- Hypertension

- Cardiometabolic disease

- Cancer

- etc

Disease definition

A condition that impairs physiological function... resulting from causes such as infection, genetics or environmental stress

Social considerations of obesity: A disease or a state of being?

The WHO and AMA have defined obesity as a disease

Consequences of obesity

Premature morbidity and mortality

Psycho-social/emotional consequences

- Discrimination

- Lower wages

- Lower quality of life

- Lower self-esteem

- Increased susceptibility to depression

Memoirs of an Obese Physician: Takeaway

" Physicians also harbor a similar prejudicial view of obese patients. As a medical student and now as an attending physician and as someone who has been obese for much of my life, I have had to face both simmering and overt prejudice from the profession I hold in the highest esteem"

- Joseph Majdan

There is some prejudice in healthcare profession

Main job is to take care of the patient

Patients who feel ostracized by their caregivers don't come back for care

Definition of obesity

Presence of excess body fats

- >22% in young men, >32% in young women

BMI

- Underweight <19

- Expected 19-25

- Overweight >25-30

- Obese >30-40

- Morbid obesity >40

Distribution of body fat (android vs gynoid)

Abdominal/visceral fat is associated with great risk of _____ ______ than subcutaneous fat

metabolic disease

Etiology of obesity

Energy in > energy out

Contributing factors of Etiology of obesity

Genetic predisposition

- 1 parent obese = 40% chance of it yourself

- 2 parents obese = 80%

- 0 parents obese = 20%

Fetal and maternal explanation

- Fetal programming

- Epigenetic mechanism

Thrifty genotype

- Ancestors that survive famine is less suited in our current environment

The nutritional transition

- urbanization and immigration

- Nutrition globalization

- Agriculture and ultra-food processing

Social/cultural perceptions of food/weight

MULTIFACTORIAL ETIOLOGY

Adipocytes expand to

store fat

Excessive adipose tissue

Hypertrophic obesity: enlarged adipocytes

Hyperplastic obesity: increased number of adipocytes

Adipocyte growth

Normal size = 70 microns

Signal to make more when they get to big

Adipocyte number

generally increases throughout childhood and adolescence

Constant during adulthood unless challenged

Does not decline

Adipose tissue is a blend of adipocytes of different

Sizes

We have a blend of fat cell sizes, some small, some large, and some very large,

Problems begin when the small adipocytes cannot...

And when large and very large adipocytes are...

Expand to hold more lipid

At capacity with limited ability to store more fat

Large and very large fat cells are associated with

impaired insulin response, increased secretion of free fatty acid and proinflammatory cytokins

Small fat cells with impaired ability to expand contribute to

metabolic complications

SUMMARY: Dysfunctional adipocytes IMAGE

Problems with large adipocytes

Increased risk of

- Inflammation

- Metabolic dysfunction

- Non-obese type 2 diabetes

- Type 2 diabetes

- Cardiovascular disease

- Hypertension

TAKE HOME: The majority of the problem lies with the ______ adipocytes

large

TAKE HOME: The chronic diseases we typically associate with obesity are pretty much thought to be a result of the

Large fat cells

Not the number but the large size

Treatment of obesity

Energy deficit

Fat cells do not

go away

Fat cells can

return to "normal" size

If fat cells are to small

the body perceives starvation state- cascade of events to increase intake and efficiency of storage and to decrease energy expenditure

Normal fat cell size is thought to decrease

metabolic effects associated with obesity

Not all obese have

metabolic complications

Prevention of obesity

Energy balance (intake and activity)

Maintenance of a normal number of normal size adipocytes

Normal intrauterine environment

- Mother's weight WNL

- Expected pregnancy weight gain

- Balanced diet

Obesity and periodontal disease

Obesity:

- State of low grade chronic inflammation

- Impaired immune function

Periodontal disease

- Complex chronic inflammatory disease

- Immune system and inflammatory response contributes to disease process

STUDY: Association between obesity and periodontitis in US adults: NHANES 2011-2014

Objective: to explore association between periodontal disease and BMI and waist circumference in adults

Design:

Cross-sectional; NHANES 2011-2014

Subjects >30 years of age with complete BMI, waist circumference and periodontal data

Independent variable

- BMI

- Waist circumference

Dependent variable

- Periodontitis: mild + moderate + severe

Continuous BMI- Higher BMI associated with prevelence of periodontal disease; categorical trends mostly

Continuous WC: Increase in WC association with increase periodontal disease

SUMMARIZE: Association between obesity and periodontitis in US adults: NHANES 2011-2014

Both BMI and waist circumference (abdominal adiposity) were associated with periodontal disease in adults

STUDY: Adiposity and periodontal disease

Objective: To investigate associations between obesity and periodontitis

Design: Cross sectional study; NHANES data

Subjects:

- 2452 nonsmokers

-13-21 years

Independent variables

- weight

- waist circumference

- skinfold thickness

- models adjusted for gender, race, poverty, dental visits and calcium intake

Dependent variable

- 1+ sites with both tissue attachment loss of 3MM and probing depth of 3MM

Results:

- Weight (7 kg higher with PD)

- Waist circumference (8cm higher for PD)

Skinfolds

- No association

SUMMARIZE: Adiposity and periodontal disease

Slight association between adiposity and periodontal disease, particularly adiposity

STUDY: Obesity, Metabolic Syndrome and Periodontal Disease

Objective: To determine if metabolic syndrome is an independent risk factor for periodontal disease and to identify which metabolic component contributes most to the association

Design: Cross sectional; NHANES III

Subjects: 7431; 20-90+ years

- 3517 males

- 3914 females

Independent variables: Metabolic syndrome

- abdominal obesity

- high triglycerides

- low HDL cholesterol

- Hypertension

-High fasting plasma glucose

Dependent variables

- Periodontal disease

Results

Metabolic syndrome

- Prevalence of metabolic syndrome was 17.3% and was higher in those who had Periodontal disease

- More pronounced in women than in men

Abdominal obesity:

- Increase risk of periodontal disease with increase abdominal obesity for both men and women

SUMMARIZE: Obesity, Metabolic Syndrome, and Periodontal Disease

Association between periodontal disease and metabolic syndrome was more pronounced in women

Abdominal obesity was primary metabolic factor associated with periodontal disease in both men and women

SUMMARY: Obesity and Periodontal disease

An association exists between obesity and periodontal disease

- Visceral fat is likely more important than total body

- Fat cell size is likely more important than total body fat

Malnutrition

Loss of normal nutrients to function

Loss of normal nutrient function effects

Growth

Maintenance

Repair of damage tissue

Malnutrition can result from either a ________ in energy or nutrients or an _____ in energy or nutrient requirements

decrease, increase

either can lead to a decline in nutritional status leading to a cycle that eventually leads to increased morbidity and mortality

Vicious cycle of malnutrition

Cyril Enwonwu looked at the bacteria present in mouths of individuals who are either well-nourished or severely malnourished.

Shows: Percent of individuals in each group who have the bacteria present in the mouth

Facultative and aerobic flora were present in both the well-nourished and the malnourished individuals

Nonsporing anaerobes and Spirochetes only 20% of the well-nourished had the gram negative rods where most all the malnourished had them

Anaerobic cocci and rods are present in more subjects with _____ than in _____

malnourishment than in well nourished

SUMMARY of Nourishment and bacteria

The distribution of oral bacteria differs between individuals with PEM and without

The different distribution has the potential to alter susceptibility to periodontal disease

Dietary intakes

Serum/Tissue levels

Supplement intakes

If you are at a above normal or toxic rate then taking supplements are likely to do harm and if you are adequately nourished its pointless

Supplements: Clinical pracitce

Do no harm

Want to make sure total intake is within broad normal limits

- <5x RDA/AI

-

/= EAR

Supplements: Research

Results of supplemental intakes are pretty much meaningless unless need for more is documented

- correct dietary deficiencies

- Low serum/tissue levels

STUDY: Vitamin C and Periodontal Health

Objective: To investigate effects of Vitamin C deficiency on periodontal disease

Design:

- clinical trail vs case series

- All received some treatment (no control)

Subjects:

- 12 healthy men

- 25-43

- nonsmokers

Independent variable: vitamin C

- Baseline: 250

- Depleted: 5

- repletion: gradual for 56 days

Dependent variable

- Plasma and leukocyte ascorbate levels

- Plaque index

- gingival index

- probing depth

- attachment level

- subgingival plaque samples

Results

Vitamin C depletion did not alter:

- Plaque index

- Probing depths

- Attachment level

- Subgingival plaque samples (microbes)

Vitamin C depletion did alter:

- Gingival index

There are some graphs from this study but are kind of pointless if you just know the results

SUMMARIZE: Vitamin C and Periodontal health

Vitamin C deficiency is associated with increased bleeding, likely due to increased capillary fragility. In periodontal tissue- but not with altered microflora or loss of periodontal integrity

Experimental conditions: adequate oral hygiene, remaining dietary variables unchanged

Referring to this study because running out of lecture time:

STUDY: Vitamin C and periodontal Disease #2

Chapple et al [NHANES III data]

Observational: cross sectional

Results:

High vitamin C serum levels is associated with decreased periodontitis in smokers and nonsmokers

STUDY: Calcium and Periodontal Disease

Objective: Investigate association between dietary calcium and periodontal disease

Subjects: NHANES III

- Observational cross-sectional

Independent variable

- 24 hour recall: calcium intake

Dependent

- Dental exams: attachement loss, gingival bleeding

Results:

Low dietary intakes of calcium were associated with more severe periodontal disease

STUDY: Diet quality and Periodontal Disease

Objective: examine association between diet quality and severe periodontal disease

Design: cross sectional

Subjects: 13920 US hispanic/latinos (aged 18-74)

Independent: diet quality

- 2X24 hour recalls

- alternative healthy eating index

Dependent: Periodontal disease

- Clinical exams

- Severe periodontal disease

Results:

As you move from a low diet quality to a high diet quality you see a decrease risk of periodontal disease

High quality = Less PD

SUMMARIZE: Diet quality and periodontal disease

Higher diet quality was associated with lower odds of severe periodontal disease

STUDY: Investigating oral and systemic pathways between unhealthy and healthy dietary patterns to periodontitis in adolescents; a population-based study

Objective: To investigate direct and indirect pathways by which unhealthy and healthy diets might impact periodontal disease

Design:

Cross sectional analysis of birth cohort: Brazil

Subjects

2515 adolescents (high school)

52% female

Not obese

Independent:

Unhealthy diet

Healthy diet

Dependent:

Periodontal disease

Results:

Unhealthy positively associated with PD

Healthy negatively associated with PD

SUMMARIZE: nvestigating oral and systemic pathways between unhealthy and healthy dietary patterns to periodontitis in adolescents; a population-based study

Healthy diets composed of fruits, vegetables, fiber and dairy products are associated with a reduced risk of periodontitis

Unhealthy diets high in nutrient poor ultra-processed food are associated with an increased risk of periodontitis

Neither deficiencies nor toxicities of energy, protein or other nutrients cause

periodontal disease

"I never said a bad diet is going to cause periodontal disease"

- We have no direct causal effect

- It predisposes one to periodontal disease

Nutrition via diet maintains

tissue health, a functional immune system and repairs damaged tissue

Inadequate nutritions =

inadequate energy, protein or other nutrients and is likely increase susceptibility to disease

NON-compliance with MyPlate

Increase of oral or systemic diseases

Optimal diet to prevent PD

My plate

Oral Health clinician's responsibility in regards to diet

Assess patient's nutritional status

Assess diet

Counsel patient relative to MyPlate

Refer patient to registered dietitian