Health, Oral Health, and Elderly Quality of Life Narumanas Korwanich Department of Family and Community Dentistry Chiangmai University

Linkage with General Health 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

What is Oral Health?

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

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

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 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

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.

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

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

Periodontitis - Pregnancy

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

Other Relationships

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 135 weeks Test in radial arm maze 9 weeks Test of Acetyl-choline releasing from parietal cortex

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

Tooth Loss and Quality of Life OIDP index

Tooth Loss and Quality of Life

Effect on well being and quality of life

Oral Health Medical Concept Bio – Psycho – Social Concept

Theoretical framework of consequences of oral impacts (Locker, 1988) Oral Health-Related Quality of Life Measure Theoretical framework of consequences of oral impacts (Locker, 1988) Disease Impairment Functional Limitation Disability Handicap Death Discomfort

Oral Health-Related Quality of Life Measure การสูญเสียทางกายภาพ เกิดความผิดปกติทางโครงสร้าง หรือทางจิตวิทยา อาจเป็นแต่กำเนิด หรือเป็นผลจากการเกิดโรคหรือการบาดเจ็บ Impairment ตัวอย่างเช่น การสูญเสียฟันทั้งปาก การสูญเสียเนื้อเยื่อปริทันต์ การสบฟันที่ผิดปกติ

Impairments เป็นความผิดปกติระดับแรกที่ดัชนีทางคลินิกมุ่งประเมิน ประเมินโดย professional

Oral Health-Related Quality of Life Measure Functional Limitation การทำงานของร่างกาย ระบบในร่างกาย หรืออวัยวะบางส่วนถูกจำกัด เช่น การมีปัญหาเกี่ยวกับการเคลื่อนของขากรรไกร

Oral Health-Related Quality of Life Measure Disability ภาวะทุพพลภาพ คือ การที่ร่างกายไม่สามารถดำเนินไปได้ตามปกติ อาจเกิดจากการจำกัดการทำงานของอวัยวะบางอย่างทางกายภาพ หรือ รวมทั้งการมีข้อจำกัดทางจิตวิทยาและทางสังคมด้วย Disability สามารถจำแนกได้เป็น Physical disability, psychological disability และ social disability

แนวคิดในการพัฒนา OHRQoL ตัวอย่าง Physical Disability เช่น ความสามารถในการเคี้ยวลดลง เนื่องจากการสูญเสียฟันทำให้ไม่สามารถกินอาหารแข็งๆได้ Psychological disability ความรู้สึกอับอายจากการสูญเสียฟัน หรือการเคี้ยวที่มีปัญหา Social disability การหลีกเลี่ยงการเข้าสังคม การหลีกเลี่ยงการกินอาหารร่วมกับผู้อื่น ซึ่งเป็นผลจากความสามารถในการเคี้ยวลดลง

Oral Health-Related Quality of Life Measure แนวคิดในการพัฒนา OHRQoL Handicap การสูญเสียโอกาส ซึ่งเป็นผลมาจากการจำกัดการทำงานของร่างกาย ทำให้บุคคลนั้นๆ ไม่สามารถดำเนินชีวิต ได้เหมือนคนปกติทั่วไปในสังคม

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

OIDP The Oral Impact on Daily Performances OHRQoL Adulyanon and Sheiham 1997

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 WHO’s International Classification of Impairments, Disabilities and Handicaps)

OHRQoL measure 3 dimensions: Psychological Physical 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

ผลของการมีฟันบดเคี้ยวอาหารต่อปัจจัยทางสุขภาพในด้านต่างๆในคนไทย Effect of occluding teeth on various health factors in Thai people

เพื่อเปรียบเทียบสภาวะสุขภาพร่างกายในประเด็นต่างๆ ระหว่างผู้สูงอายุที่มีและไม่มีฟันในช่องปาก โดยประเด็นที่จะทำการศึกษาได้แก่ ดัชนีมวลกาย (Body Mass Index; BMI) คุณภาพชีวิตอันเนื่องมาจากสุขภาพช่องปาก (Oral Health Related Quality of Life; ORH-QOL) ความสามารถในการเคี้ยวอาหาร (Chewing Ability Index; CAI) สภาวะโภชนาการ (Mini-Nutritional Assessment)

Sample ผู้สูงอายุจำนวน 600 คน อายุตั้งแต่ 60 ปีขึ้นไป 4 กลุ่มได้แก่ ผู้ที่ไม่มีฟันเหลืออยู่เลย และไม่เคยใส่ฟัน (edentulous group) ผู้ที่ใส่ฟันทั้งปาก (complete denture group) ผู้ที่ใส่ฟันบางส่วน (partial denture group) ผู้ที่มีฟันธรรมชาติ (natural teeth group)

Sample ต้องมีสภาพดังกล่าวมาเป็นเวลาไม่น้อยกว่า 1 ปี ต้องผ่านการทดสอบความจำ ต้องเดินมารับการตรวจเองได้ หากมีฟันเหลืออยู่ในปาก ฟันทุกซี่ต้องเป็น functional teeth ไม่โยกเกิน 2 degree มี crown เหลือมากพอที่จะใช้บดเคี้ยว สามารถใช้งานได้โดยไม่มีอาการเจ็บปวด

จำนวนตัวอย่าง Edentulous group Complete denture group Partial denture group Natural teeth group กรุงเทพ 30 เชียงใหม่ พิษณุโลก ชัยภูมิ สงขลา

Material and method การตรวจในช่องปาก MNA Anthropometry OIDP Tooth status ตามแบบตรวจช่องปากของ WHO หรือการสำรวจของจังหวัด 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 25.54 0.19

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

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 **/NRT 1.49 1.36 **/NT 3.02* 2.77* 2.03

Self reported problem on biting, n(%) 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) 371(55.7) 137(20.6) 76(11.4) 82(12.3) 664(100.0)

Self reported problem on chewing, n(%) Chewing and Teeth Type 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) 363(54.5) 156(23.4) 77(11.6) 70(10.5) 664(100.0)

Self reported problem on chewing, n(%) Chewing and Teeth Type 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) 188(100.0) Natural teeth with replaced teeth 142(89.3) 6(3.8) 159(100.0) Natural teeth 140(88.1) 11(6.9) 7(4.4) 559(83.9) 48(7.2) 35(5.3) 664(100.0)

Chewing and Teeth Type Eden/** Biting Chewing Swallowing **/Eden 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 4.1 Partial Denture NRT) 158 23.3 3.7 Natural Teeth (NT) 157 24.6

BMI and Teeth Type Eden CD NRT NT NS p<0.05

BMI and Teeth Type