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Inside Dentistry
January 2015
Volume 11, Issue 1

Philips Oral Healthcare’s

“Oral Health and the Connected Body”

The recent Philips Oral Healthcare (POHC) continuing education symposium “Oral Health and the Connected Body,” the proceedings of which are summarized in the following pages, was a demonstration of the company’s commitment to improving general health through better oral health.

Although POHC is perhaps best known for its products—including Sonicare toothbrushes and Zoom! Whitening Systems—its corporate research organization, Philips Research, has a rich and prolific history. Celebrating its centennial this year, Philips Research services all the different Philips businesses in developing new ideas, technologies, and solutions for meaningful innovation in keeping with its track record of great innovations. These have ranged from the development of the first medical x-ray tube in 1918 to high-resolution MR, the invention of the compact disc to the recent innovation of personal connected lighting, known as Hue. A new addition in the oral healthcare space is AirFloss, an innovation designed to provide an effective, easy, more patient-compliant means to clean interproximally. Further AirFloss research investigates improving biofilm composition in collaboration with the ACTA Dental School in the Netherlands.

Current collaborative research initiatives are now focused not just on absence of disease, but rather on a more comprehensive view of oral health in terms of resilience. The hope is that this will lead to a better understanding of the interconnectedness between oral and systemic health, the discovery of novel experimental models to investigate the efficacy of interventions, new insights into other intervention targets to achieve oral health, and new prevention methods.

Other research supported by Philips has yielded findings about why smokers are more prone to develop pathogenic dental biofilm and are therefore less resilient than nonsmokers; the impact of nonsurgical periodontal and reinforced home oral hygiene on pregnancy outcomes; the influence of various modalities of professional periodontal therapy on oral and cardiac health; and the impact of periodontal treatment not only on periodontal health, but also on metabolic outcomes in diabetic patients.

Future investigations include studies on the potential of advanced diagnostics using saliva and identifying salivary markers indicative of periodontal disease severity; data sharing among relevant healthcare providers to advance the oral and overall health of their patients; and developing connected products to help patients achieve a healthy lifestyle more easily and more effectively.

Taken together, these initiatives represent a holistic approach to oral and general health and will allow POHC to improve people’s lives through meaningful innovation, which is ultimately what defines Philips. In short, POHC is taking the oral–overall health connection seriously and is well positioned for a healthy future they look forward to sharing with dental and medical practitioners, educators, students and presenters.

Connecting the Dots—A Perspective from Philips Research

Marko de Jager, PhD

In his opening presentation, Marko de Jager, PhD, provided an overview of the research activities commissioned by POCH. He explained that the company is transforming itself from one focused on individual product solutions to one of general health promotion that is poised “to act on synergies and emerging trends across the health continuum from healthy living and prevention at home, to diagnosis, treatment, and recovery at the hospital, and back to home care for independent living, yet connected to care givers when and where needed.”

Dr. de Jager further explained that this health continuum and the company’s cloud-based digital health platform will be driving innovation at Philips Research. In addition, with more than 1500 scientists and connections to 250 universities and institutes worldwide, Philips Research has a combination of unique technology, knowledge, and powerful resources that will help provide the best solutions to dental and medical professionals and their patients in the coming years.

He added that when it comes to oral–systemic health, the company is adopting a holistic approach. Its research aims to develop a more comprehensive view of oral health that recognizes that health is neither defined as the absence of disease nor as a static situation, but instead it is about resilience: the ability to tolerate an insult. Going forward, much of the company’s oral health research efforts will help refine an understanding of what contributes to oral health and its impact on overall health. To conclude, he invited dental and medical professionals for an ongoing dialogue with Philips about these new insights in oral health and the connected body, and how they may affect clinical practices and patient behaviors.

Marko de Jager, PhD, is principal scientist, Philips Research Netherlands, and specializes in biomedical engineering and research in biofilm management and oral–systemic health.

Unscrambling the Periodontitis-Diabetes Connection and its Implications for Patient Care

Evanthia (Evie) Lalla, DDS, MS

Diabetes mellitus and periodontitis have many commonalities. Both are widespread chronic inflammatory diseases that affect similar segments of the population and are often undiagnosed; they also have a tendency to exacerbate one another. Because successful outcomes for patients affected by either condition depend heavily on intensive interventions, lifestyle modifications, and life-long maintenance, early diagnosis is crucial. The link between the two diseases and the role of dentists in the management of affected individuals was the focus of a presentation by Evanthia Lalla, DDS, MS.

Calling periodontitis one of the least recognized complications of diabetes, Dr. Lalla stressed the need to raise awareness of the impact of diabetes on oral health. If left untreated, periodontitis can lead to tooth loss, negatively impact mastication and thus proper nutrition, dysregulate glucose management, and contribute to the development of other diabetes complications, such as kidney and heart disease.

The magnitude of the problem and the potential impact dental professionals could have is clear from recent Centers for Disease Control and Prevention estimates of diabetes prevalence; in the United States alone, 29.1 million people have diabetes mellitus, with about 28% of them remaining undiagnosed. An even greater number, 86 million US adults, have pre-diabetes, which is reversible, though 89% of those individuals are undiagnosed.

According to Dr. Lalla, dental professionals have the capability and responsibility to contribute to the early identification of undiagnosed hyperglycemia; inform, advise, and refer identified patients to a physician for proper diagnostic work-up and treatment; follow up with the patient to ensure definitive diagnosis and timely initiation of lifestyle management and/or pharmacotherapy have occurred; engage in active management of the patient with known diabetes; and work across professional boundaries with other healthcare providers to optimally co-manage patients with (or at-risk for) diabetes.

Evanthia (Evie) Lalla, DDS, MS, is professor of dental medicine at the division of periodontics at Columbia University College of Dental Medicine. Her research has primarily focused on the relationship between periodontal infections, diabetes mellitus, and atherosclerosis. She is the current president of the Periodontal Research Group of the IADR.

Oral Infections are Risk Factors for General Health

Bruno Loos, DDS, MS, PhD

In his presentation, Bruno Loos, DDS, MS, PhD, addressed the issue of oral infections as risk factors for general health. He specified numerous conditions and discussed studies linking them to periodontitis, as well as their status after periodontal treatment. Conditions included lung infections and chronic obstructive pulmonary disease, premature/dysmature birth, pregnancy complications, rheumatoid arthritis, diabetes, artherosclerotic cardiovascular disease (ACVD) and oral cancer.

Dr. Loos cited literature findings on inflammatory mechanisms that link periodontal diseases to ACVD. These include increased systemic levels of inflammatory mediators stimulated by bacteria and their products at sites distant from the oral cavity; elevated thrombotic and hemostatic markers that promote a prothrombotic state and inflammation; cross-reactive systemic antibodies that promote inflammation and interact with the atheroma; promotion of dyslipidemia with consequent increases in pro-inflammatory lipid classes and subclasses; and common genetic susceptibility factors present in both disease leading to increased inflammatory responses—with some or all simultaneously leading to increased atherogenesis and subsequently resulting in atherosclerosis and ultimately to endothelial dysfunction.

Intervention studies related to ACVD, he noted, tested whether the condition of the cardiovascular system improved, whether the level of endothelial dysfunction changed, if there was a decrease in the systemic levels of the plasma marker of cardiovascular disease—C- reactive protein—and whether there was a reduction of proinflammatory state after periodontal treatment; indeed, common, basic periodontal treatments most often result in these outlined improvements.

Finally, Dr. Loos addressed the link between oral infections and oral cancer, citing studies showing an association between oral infection and periodontitis with oropharyngeal cancers and head and neck squamous cell carcinomas (HNSCC), and among HNSCC patients, human papilloma virus. Studies generally found an association between chronic inflammation such as exists with periodontitis and malignant disorders.

Bruno Loos, DDS, MS, PhD, is full professor and chair in periodontology, Academic Centre for Dentistry in Amsterdam, University of Amsterdam, and VU University, The Netherlands, specializing in genetic and immunological aspects of periodontal diseases and relationships between general health and oral health corroboration.

Periodontal Infection and Pregnancy Outcomes

Steven Offenbacher, DDS, PhD, MMsc

In his presentation, Steven Offenbacher, DDS, PhD, MMsc, discussed different approaches to the treatment of periodontal disease to minimize the risk of negative pregnancy or neonate outcomes. While the best approach is prevention of disease and maintenance and monitoring of periodontal health, he noted, when disease is present, it cannot be ignored. Fetal systemic inflammation can occur when oral organisms cross the placental barrier to worsen pregnancy and neonatal outcomes.

Dr. Offenbacher described a model of periodontitis-associated pregnancy complications, where material periodontal disease leads to hematogenous dissemination, then placental and fetal exposure to microbes, poor placental perfusion, and inflammation—ultimately leading either to preterm membrane eruption, labor, and preterm delivery or fetal growth restriction and neonatal morbidity. In humans, these pregnancy complications are associated with specific organisms of maternal oral origin, which translocate to the fetal-placental unit.

Given the risks, he said, in patients with gingivitis, treatment during pregnancy should aim to to reduce bacterial load and signs of inflammation, but for those with frank periodontitis, aggressive therapy must be deferred, as maternal stressors, such as long appointments and/or higher levels of anesthesia, may pose increased risk for prematurity. Instead, standard nonsurgical periodontal therapy should be undertaken during the second trimester to reduce subgingival biofilm and signs of inflammation with careful maintenance follow-up.

Steven Offenbacher, DDS, PhD, MMsc, is chair, department of periodontology at the University of North Carolina at Chapel Hill School of Dentistry; director, Center for Oral and Systemic Diseases; and past president, AADR, and specializes in linking maternal periodontal diseases to adverse pregnancy outcomes in humans.

The Case Against High Fructose Corn Syrup

Brian Novy, DDS, and Betsy Reynolds, RDH, MS

Although media blitzes lead the general public to believe that the body makes no distinction between ingesting high fructose corn syrup (HFCS) or sucrose derived from beet or cane sugar, metabolic research suggests otherwise, said Betsy Reynolds, RDH, MS, and Brian B. Nový, DDS, FADI. Studies are emerging that have linked consumption of HFCS with heightened risk of heart disease, obesity, cancer, dementia, liver failure, caries, and more. With Americans consuming more than 60 lb of this sweetener annually, it is important for healthcare providers and consumers alike to understand the oral and systemic ramifications associated with the ingestion of HFCS.

HFCS and refined sugar are not biochemically identical or processed the same way by the body. To manufacture HFCS, sugars must be extracted from the corn through a chemical enzymatic process, resulting in a chemically and biologically novel compound in which fructose and glucose exist as monosaccharides in a roughly 55% fructose and 45% glucose ratio. Sucrose, on the other hand, exists as a disaccharide with one molecule of glucose tightly bound to a molecule of fructose in a 50% glucose and 50% fructose ratio. During digestion, gut enzymes cleave sucrose into “free” glucose and fructose for the body to absorb the monosaccharides. In the case of HFCS, since there is no chemical bond between fructose and glucose molecules, no digestion is required before the sugars can be absorbed into the bloodstream. It is this fundamental difference in metabolism that has many experts concerned. For instance, once the HFCS-derived glucose is ingested, the monosaccharide is rapidly absorbed into the bloodstream where it triggers a major spike in insulin. Fructose, on the other hand, is transported directly to the liver, where it triggers lipogenesis to produce triglycerides and cholesterol. For many investigators, these metabolic considerations are likely to increase appetite, weight gain, diabetes, heart disease, cancer, dementia, and more.

Brian B. Nový, DDS, FADI, is director of practice improvement, DentaQuest Institute, ADA Committee on Caries Classification and Council of Scientific Affairs Caries Management, specializing in caries and the cascade of events that begins in the mouth and ends in the heart. Betsy Reynolds, RDH, MS, is a researcher, author, and presenter specializing in the biologic basis for oral and systemic disease prevention and microbiologic and immunologic aspects of oral disease.

Women’s and Men’s Oral and Whole Body Health…What’s Sex Got to Do with It?

Maria Perno Goldie, RDH, MS

Equal rights aside, said Maria Goldie, when it comes to oral healthcare, men and women often require different approaches to treatment. Goldie made a point of differentiating between sex and gender, the former of which is generally based on a person’s respective reproductive organs and functions based on chromosomal complement, whereas the latter refers to economic, social, political, and cultural attributes, constraints, and opportunities associated with one or the other.

She noted the ways men and women are not created equal biologically. For example, because they have more active immune systems, women have the ability to fight off viral infections better than men. And because male neurons are about a third larger than female neurons, male and female brains take up significantly different amounts of dopamine. Women and men also metabolize some drugs differently.

In terms of oral health, both sex and gender play a role in differences in oral disease rates, tooth loss, and edentulism. Goldie cited findings suggesting sex-based differences in gingivitis in young people can be explained by oral health behaviors and oral hygiene status, which are influenced by lifestyle, knowledge, and attitude, whereas sex-specific differences in the incidence of periodontitis and tooth loss may be related to different phenotypes of obesity and their associations with low-grade inflammation. Cancers of the oropharynx, known to be linked to the oral human papilloma virus, are about three times more common in men than in women, according to the Centers for Disease Control and Prevention.

Sex and gender differences also have been found in prevalence, susceptibility, symptoms, pathophysiology, likelihood to seek treatment, treatments offered, response to treatment, morbidity, and mortality. Sex and gender medicine, Goldie says, seeks to advance a rigorous evidence-based approach to issues concerning sex and gender differences in science and healthcare, access to care, and the law, and will ultimately improve health outcomes for all.

Maria Perno Goldie, RDH, MS, is a researcher, author, and presenter specializing in women’s health, immunology, and sex-based medicine.

Periodontal Disease and Stroke

Souvik Sen, MD, MPH

Noting that numerous studies show periodontal diseases (PDs) to be associated with new and recurrent ischemic stroke/transient ischemic attack (TIA), neurologist Souvik Sen MD, MPH, stressed the importance of understanding the stroke-PD connection. The ultimate objective is to prevent or lessen the severity of this fourth leading cause of death and the leading cause of long-term adult disability through early recognition and intervention with treatments of proven efficacy.

Dr. Sen delineated the numerous steps involved in the oral–systemic pathway from PD to cerebrovascular disease. This process, he explained, begins with PD’s biofilm, presenting a microbial and local inflammatory challenge, which in turn mediates pocketing and bone loss. Next, the oral bacteria invade tissues to create inflammatory site of sepsis. Cytokines, bacteria, and bacterial products disseminate into the bloodstream and the systemic microbial and inflammatory challenge triggers hepatic acute phase response. The liver then releases acute phase reactant proteins, including fibrinogen, C-reactive protein, and interleukin-6; the latter two promote atherogenesis and oxidized LDL accumulation. The increased atheroma increases plaque instability, increasing risk for myocardial infarction and stroke.

Noting findings indicating that in stroke/TIA patients, high PD is independently associated with an increased risk of recurrent vascular events, Dr. Sen suggested further studies to determine whether periodontal treatment can reduce the rate of ischemic stroke/TIA in patients with first stroke/TIA, 25% of whom later have another major stroke, heart attack, or die in period of 1 to 2 years.

Souvik Sen, MD, MPH, is professor and chair of neurology at South Carolina School of Medicine, Columbia, South Carolina, specializing in acute stroke treatment, stroke and TIA pathophysiology, stroke prevention, and epidemiology.

Oral-Systemic Connections: Periodontal Disease, Pneumonia and COPD

Frank Scannapieco, PhD, DMD

In his presentation, Frank Scannapieco, PhD, DMD, focused on the connections between periodontal disease, pneumonia, and chronic obstructive pulmonary disease (COPD). Epidemiologic studies and randomized controlled clinical trials suggest an association between pneumonia and bacteria in dental plaque and have identified a possible association between COPD and periodontal disease.

Dr. Scannapieco explained that respiratory infection depends upon the aspiration of pathogens from proximal sites (eg, oro-pharynx into the respiratory tree). Bacteria recovered from dental plaque and/or tracheal secretions from a single intubated patient were genetically identical to bacteria isolated from the lung fluids of that same patient diagnosed with pneumonia. This suggests dental plaque is a reservoir for respiratory pathogen colonization in mechanically ventilated patients at risk for bacterial pneumonia.

Improved oral hygiene can help to reduce the risk for pneumonia in selected populations, such as those who are mechanically ventilated or living in nursing homes. Compared to other methods such as selective digestive decontamination, use of chlorhexidine may be associated with increased mortality, perhaps due to toxicity in vulnerable patients. Oral hygiene can prevent pneumonia in hospitalized elderly people and elderly nursing home residents as well. Dentures should be removed during sleep to prevent pneumonia events.

Dr. Scannapieco emphasized that further randomized clinical trials and basic studies are needed to verify these oral–systemic associations, explore potential explanatory mechanisms, and develop oral interventions to prevent lung infections.

Frank Scannapieco, PhD, DMD, is chairman of the department of oral biology, University at Buffalo, New York, specializing in oral and systemic disease with emphasis on salivary biomarkers of periodontal disease and aspiration pneumonia, nosocomial pneumonia—especially ventilator-associated pneumonia—and COPD.

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