Let's Talk Oral Health

Expert Q&A: Mastering the Oral Systemic Link

• SUNSTAR Oral Health • Season 1 • Episode 7

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Prof. Maria Clotilde Carra answers burning questions about the impact of systemic health on oral health. From the impact of systemic conditions on periodontal disease to the overall holistic approach to oral care. 

Speaker 2:

This is let's Talk Oral Health the expert podcast for oral health professionals brought to you by Sunstar.

Speaker 1:

Hello everyone, Welcome to Sunstar let's Talk Oral Health Expert Series. This is the Q&A session following the episode we held on the systemic approach in the 360 strategy to prevent periodontal and peri-implant diseases. We invited back Professor Cara to answer directly to the questions you, our audience, had. Welcome back, Clotilde, and thank you for taking the time to answer to our audience these questions.

Speaker 2:

Hello Rachel. Thank you for inviting me. I'm very happy to be here and answer the questions.

Speaker 1:

Thank you for inviting me. I'm very happy to be here and answer the questions. Our conversation on the impact of systemic health on oral health stirred up some questions and we are eager to hear your complementary insights on the topic. Let's dive right into it with the first question. The first question is about peri-implant treatment efficacy, or rather lack of it. Relates to your paper and what you said about primordial and primary prevention of peri-implantitis. There are many similarities between periodontal and peri-implant diseases, even in the risk factors to control and in their prevention more or less evident. So if there are so many similarities, why are the peri-implantitis treatments less effective than the purulentitis ones? This is the question that we receive.

Speaker 2:

It's a very good question and indeed it's complex to treat peri-implant diseases. We know that indeed our treatments are less effective and the first reason is because we do not know today the exact causes of peri-implant disease. So we cannot target the precise etiology of this disease with our treatment. And this is probably the first reason why treatment is less effective. But we can cite several factors that may explain the fact that treatment are not so efficient. The first one are anatomical reasons. We know that the anatomy of the tissue surrounding an implant are not exactly the same as the periodontal tissue surrounding a tooth. So this is the first reason and we have to think that the implant is an artificial structure and has specific characteristics. For example the implant surface. We know the rough surface of titanium can harbor more bacteria than other surfaces. And also we have to think about the abatement and the structure of the implant.

Speaker 2:

Support is prosthesis. Sometimes it's not easy to probe this space and not even to clean this space for the patient but also for the clinicians. So all these factors will make the environment around the implant more complex and difficult to clean, richer of bacteria. And then we can also mention the composition of the biofilm surrounding the implant and in the specific area of the connection between the implant, the abatement and the level of the bone. So here there are some specificities that may explain, once again, the lower response to treatment. And also we have to consider that whenever the inflammatory lesion begins around an implant, it will develop much faster than around the tooth, and so the bone loss severity will also guide the treatment choice and the availability of treatment option to treat upper implantitis. So, because we are not so effective with our treatment and sometimes we even have to be aggressive, more aggressive with periodontal treatment around implants, the early detection of peri-implant disease is an abrupt intervention, a cardinal, trying so to focus on prevention of the progression of the disease and try to maintain the dental implants.

Speaker 1:

So, because there are so many points to be still evident and not necessarily fully controllable, the best strategy remains prevention, through a primordial or primary or other. Okay, thank you for this first answer. Let's move on to the second question, then, or rather a group of questions that we received about the host modulation techniques, with the role of nutrition and micronutrition in decreasing the inflammatory burden. You said during the episode that the link between obesity and periodontal diseases is even stronger at a young age, between age 18 and age 34. Why is that?

Speaker 2:

So the link between periodontitis and obesity is quite complex. Obesity is a chronic disease and is linked to several factors. We can mention that the inflammatory burden associated with obesity, so the low-grade systemic inflammation characteristic of this patient, may explain the exacerbation of periodontitis. But we also have in obese patients insulin resistance, so the metabolic problem that will also contribute to periodontal disease development or progression. And then we have to think that this type of patient may have poor lifestyle habits, like poor diet lifestyle habits like poor diet, low physical activity, and these are all factors that may contribute to the aggravation of periodontal disease.

Speaker 2:

And once again we have to look at the whole pictures, clinical pictures. So an obese patient, depending on the age, may also have hormonal changes and other comorbidity like, for example, obstructive sleep apnea or diabetes. So it may be quite complex to understand what is the contribution of obesity for periodontal diseases and what are the contributions of other risk factors. So statistically, in younger age, so like between 18 and 34, we have less chance to find comorbidities. So the obese patient may have less comorbidities, may be exposed to a lower number of risk factors, and so the contribution of obesity to toward periodontitis is stronger. We can say that obesity is considered a risk factor for periodontal disease at all ages, but at a younger age the contribution of obesity may be stronger be stronger.

Speaker 1:

So it means that it depends actually on the weight of the different factors that are to be taken into account, including the age here, for example, or the obesity but obesity for sure has an impact at any age. It's just more or less depending on all the factors that have to be factored in.

Speaker 2:

Exactly, it's a sort of a cumulative exposure. So for sure, when we are older we are exposed to more risk factors for a longer time. So the contribution of risk factors is more difficult to assess. When we are younger, just obese, but we are not smoking, the impact of obesity appears stronger.

Speaker 1:

Talking about the link between obesity and periodontal diseases. The next question we received was about diets, and the question was can you detail the diets that reduce gingival inflammation versus the ones that are pro-inflammatory and detail the evidence behind?

Speaker 2:

Yes, diet is a very important factor to consider today when we look at the risk profile of our patient and when we want to have a systemic approach in our periodontal treatment. So all nutrients, food, that have pro-inflammatory properties should be avoided or limited, whereas all food that have anti-inflammatory property and should be promoted. So we can make the example, for instance, of the Mediterranean diet, which is known to be rich in fruit and vegetables, seeds, olive oil and few intake of red meat, for example, and fish of red meat, for example, and fish and saturated fat. So this is considered a type of diet that has anti-inflammatory properties. On the contrary, western-type diet, rich in processed food, frozen meals, very often some snacks, packaged snacks that are rich in sugar and carbohydrates these are considered to be really pro-inflammatory, so not very good for gum health and periodontal diseases. Now we start to have literature saying that really consuming a high quantity of processed food is not good for our health. Start to have literature saying that really consuming a high quantity of processed food is not good for our health.

Speaker 1:

There are probably also other types of diets that are more or less evidence, but we hear a lot about this Mediterranean diet. What is the level of evidence behind this one? Is it for sure, something that works?

Speaker 2:

Unfortunately, the level of evidence is still limited on the topic. We cannot recommend a type of diet toward the benefit of our health, but we can recommend the intake, for instance, of five portions of fruit and vegetables to limit the intake of carbohydrates and sugar, and also processed food for the benefit of our health.

Speaker 1:

Linking to that, there is a question about specific vitamins that improve gum health, that are anti-inflammatory, and their mode of action. What would you say about the type of vitamins that have these kind of actions? What are they?

Speaker 2:

We can cite three main vitamins that have been linked to periodontal health. The first one for sure is vitamin C. It is known since centuries that it is really important for gum health. Whenever we have a deficiency of vitamin C, we have bleeding gums, gingivitis, periodontal disease that may appear, because it's very important for the synthesis of collagen at the level of the gums, so it will support the tissue integrity and also have antioxidant properties. So it's very good for gum health. Also, vitamin E is very good because it has antioxidant properties. And finally, we can cite vitamin D, which is essential for the bone metabolism, but it's also a very important role in the immune function and anti-inflammatory response. So, in general, vitamins are important because they will have to through mainly three main pathway the anti-inflammatory, antioxidant properties, the tissue integrity and the immune response. So they will boost the immune response.

Speaker 1:

But if these three vitamins that you mentioned C, e and D are effective, should that mean that the dentist should prescribe vitamin themselves or leave that to the nutritionist?

Speaker 2:

It's a very important question because we try to see if the supplement of vitamin will improve, for example, the response to a periodontal treatment, and indeed the literature is quite controversial. Why? Because it's not so easy to have an effect just with a supplement of vitamin E or C or D, because it depends if the patient, the individual patient, is in a situation of vitamin deficiency which need to be treated, or not. So give some supplement to a patient has no reason. There is no indication to do that. It really had to be a target to some specific patient that will require this type of supplementation. And I think it's important to work with nutritionists and to be able to refer patients that may be in suspect of a deficiency for vitamins in order to work in a multidisciplinary way in this systemic approach.

Speaker 1:

Yeah, collaboration with other professionals to ensure that we cover all the aspects to prevent the disease. We have come to questions about sleep, and this is the last set of questions that we received. You talked about sleep and obstructive sleep apnea. During our conversation, someone said that they did not know how to explain to their patients how sleep and periodontal peri-inflammatory diseases are linked, without being far-fetched or fear-mongering. So the question would be maybe can you tell us how you present this link yourself to your own patient?

Speaker 2:

Is it true that sleep and oral health appears distant, but indeed they are very much linked. So it's important for dentists to start talking about sleep with their patients. And how can we do it? And how can we do it? First of all, we have to provide clear information and evidence-based information to our patient. We have to avoid all exaggerated claims that can make fear, of course, and we have to try to use scientific data to motivate patient toward a behavioral change if needed. I mean if we understand the patient as a behavioral change. If needed, I mean if we understand that the patient has a poor sleep, has sleep disorders, and we can easily have the suspect clinically, because sometimes the patient falls asleep as soon as he's on the dentist chair during the treatment or snores, even snoring, and report to be very tired during the day. So all these key elements, together with other clinical elements, can make us ask a question do you sleep well? Do you snore? Do you suffer of obstructive sleep apnea? For example, do you make breathing pauses during sleep?

Speaker 2:

And it is important to do that because sleep is a key element of a healthy lifestyle, so, together with regular physical activity, the effect to avoid exposure to tobacco product, the effect of managing stress and have a balanced diet.

Speaker 2:

We also have, as a key element of healthy lifestyle, an adequate amount and a good quality of sleep. It's primordial to preserve health. We do know that. So, starting from the basic concept of healthy lifestyle, where we have to stress the importance of oral hygiene, the daily behavior of good oral hygiene to preserve oral health, to prevent oral diseases and periodontal diseases, we can, starting from that and arriving to talk about sleep and the importance to maintain and preserve a good night of sleep for health in general and for gamma health as well. Serve a good night of sleep for health in general and for gamma health as well. So emphasizing the importance of sleep is the first part, but then we have to encourage the patient to this kind of healthy sleep habits, so what we call a sleep hygiene, and then offer support and resources so advise the patient where this information can be found and eventually refer the patient to a specialist if needed.

Speaker 1:

Do you have an example of a website where a patient could find this information?

Speaker 2:

Well, there are several types of websites, but what I can advise is to look at the website of the scientific societies, because there are more evidence-based and the information are, of course, evidence-based. So are reputable sources and any different countries, as usually has a national scientific society dealing with sleep medicine and are usually very useful resources for information.

Speaker 1:

Oh yes, of course, thanks. The last question that we received around sleep was about obstructive sleep apnea that you mentioned during the conversation. Again, the question is what explanation to give to patients to link it to periodontal diseases. Again, very pragmatic, chair-side explanation to give to our patients. What would you say to give to other patients?

Speaker 2:

What would you say? Obstructive sleep apnea is a common sleep disorder. Prevalence data estimate that 1 billion of people worldwide are suffering from obstructive sleep apnea and most of them are undiagnosed, so untreated. This is because the first symptoms and sign and symptoms of obstructive sleep apnea are neglected by the patient and by the physician most of the time, because the first sign and symptoms are just fatigue, tiredness during the day, excessive daytime sleepiness, the fact of snoring during the night, so the sleep is not restorative night, so the sleep is not restorative, but the fact of being tired is quite common and unfortunately is so underestimated. But dentists can see these signs and symptoms and also use a questionnaire that has been validated to screen for obstructive sleep disorder, so to identify the patient that may be at risk of this disease or even be already in the need of treatment.

Speaker 2:

We must remember that obstructive zipapnea is linked to obesity, cognitive impairment, higher risk of cancer, higher risk of mortality.

Speaker 2:

So it's a very severe disease that needs to be diagnosed, needs to be followed up and treated, of course, and recent evidence suggests that among all these conditions related to obstructive zipapnea we can add periodontitis. Obstructive zipapnea patient would be actually almost two times at increased risk of having severe periodontitis than patients without obstructive zip apnea, and this is linked, probably, to the inflammatory burden. Of course I mentioned obesity, I mentioned a disease that's linked to a low-grade systemic inflammation, which for sure will contribute to the inflammatory burden, also at the level of the periodontal tissue, but is also linked to a specific way, which is the oral microbiota composition. Patients suffering from obstructive zipapnea usually breathe with their mouth during sleep, they snore and have less salivary flow, so they accumulate plaque, dental plaque, more important than patients that sleep well and they do not breathe with their mouth during sleep. And they also have a biofilm or a biofilm rich in periodontal pathogens or a biofilm rich in periodontal pathogens. So this kind of element will probably explain why patients with obstructive sleep apnea are at increased risk of periodontal diseases.

Speaker 1:

Well, thank you for this detailed answer on this obstructive sleep apnea. We have come to the end of our Q&A. Thank you very much, clotilde, for answering all the questions that our audience had after the episode we recorded together. Thank you as well to our audience for your interest in the episode and for the questions you submitted to us. We hope we were able to answer to most of them. To answer to most of them, make sure as well to check out the other episodes of our let's Talk Oral Health Expert series about the 360 strategy to prevent periodontal and peri-implant disease and the Q&A that follows each of the episodes. Once again, dr Cara, thank you very much for your time and for answering our questions. It was a pleasure to have you with us. See you all very soon.

Speaker 2:

Thank you for tuning in to today's episode of the let's Talk Oral Health podcast.

Speaker 1:

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