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The Oral Health and Chronic Disease Connection
May 2002
Executive Summary
Increased research and related program activity point to the connections between chronic oral infection and other chronic diseases such as diabetes, cardiovascular disease, osteoporosis, and obesity and the role of public health agencies in facilitating linked prevention efforts. These connections have particular relevance for public health agencies dealing with the escalating burdens of chronic conditions. While insufficient evidence exists to draw causal conclusions about some of these relationships, the connection between oral health status and certain chronic diseases suggest exploring a greater public health role to improve prevention, early identification, and treatment of chronic conditions.
According to the Surgeon General’s report on oral health, the mouth can function as an “early warning” system for some diseases, and can provide a useful means to understanding organs and systems in other parts of the body.[1] The early identification of oral disease may contribute to the early diagnosis and treatment for a number of systemic diseases. Specifically, recent research examining the relationships between oral health status and diabetes, cardiovascular disease, osteoporosis, and obesity draw attention to the importance of coordinating oral health and other health care services and establishing new partnerships between the dental, public health, and medical communities.
This access brief is the second
in a series of briefs addressing oral health and the role of state public
health.† This brief provides an overview
of the relationship between oral health and certain chronic diseases, focusing
on diabetes, cardiovascular disease, osteoporosis, and obesity, and provides
examples of innovative state programs addressing oral health and chronic
diseases. The relationship between oral health and oral cancer, and between
oral health and adverse birth outcomes will be highlighted in future issue
briefs.
Introduction
The Surgeon General’s landmark report on oral health stresses the important connection between oral health and general health and well-being. According to the report, the mouth can function as an “early warning” system for some diseases, and can provide a useful means to understanding organs and systems in other parts of the body.[2] Several signs and symptoms of disease, lifestyle behaviors, and exposure to toxins can be detected in and around the craniofacial complex. Further, the early identification of oral disease may contribute to the early diagnosis and treatment for a number of systemic diseases.[3]
Public health agencies can have a role in the prevention, early diagnosis, and treatment of oral and other chronic conditions by promoting improved disease management and collaboration with dental and medical professionals. Working together to identify communities at high risk for multiple chronic diseases and to coordinate oral health and other health care, the public health, dental and medical communities can improve the health and oral health status of Americans.
What is the Relationship Between Oral Health and
Chronic Disease?
Recent research on the relationship between oral health status and chronic disease shows the importance of coordinating oral health and other medical care, and the potential that this relationship may have in improving the early identification and prevention of complications related to certain chronic diseases. Specifically, research related to diabetes, cardiovascular disease, osteoporosis, and obesity indicate that oral health status can be an early warning system for patients suffering from or at-risk for these chronic conditions and will have important implications on improved prevention and disease management in the U.S.
Dental caries and periodontal disease are the most common oral diseases and are caused by bacteria in the dental plaque that form on oral surfaces. Both diseases can adversely affect quality of life and result in lifelong health problems. Dental caries is one of the most common chronic diseases in children, and periodontitis affects most adults at some point in their lives. Over time, untreated periodontitis can lead to the destruction of the soft tissue and bone that anchor teeth into the jaw. Research has indicated that certain systemic diseases, such as diabetes, arthritis, osteoporosis, and HIV can compromise oral tissues and heighten susceptibility to periodontal diseases. The following section examines the relationship between oral health and diabetes, cardiovascular disease, osteoporosis, and obesity.
Research on each of the following conditions supports the need for programs that coordinate dental and other health care and that expand health education around the links between oral health status and chronic conditions.
Diabetes
Oral health can be a significant complicating factor for individuals with
diabetes. According to the Centers for Disease Control and Prevention (CDC),
approximately 17 million Americans have diagnosed diabetes, and an estimated
5.9 million have undiagnosed diabetes.[4]
The prevalence of diagnosed cases of diabetes has increased steadily from 1990
to 2000 and is projected to continue.
Periodontal problems can complicate the management of
diabetes and poorly controlled diabetes may also intensify periodontal disease.
Studies have shown that individuals with diabetes are more susceptible to
periodontal disease, and that individuals with diabetes can suffer from greater
tooth loss than people without diabetes.[5],[6]
This risk is independent of whether it is Type I or Type II diabetes. According
to the National Institute of Dental and Craniofacial Research (NIDCR), people
with non-insulin dependent diabetes are three times more likely to develop
periodontal disease than individuals without diabetes.[7]
This likelihood increases when diabetes is poorly controlled. Severe
periodontal disease can increase blood sugar, putting people with diabetes at
risk for additional diabetes-related complications. Periodontal diseases
respond well to therapy and can be managed in patients with well-controlled
diabetes.
The importance of the relationship between oral health status and diabetes is also recognized in the Health and Human Services’ Healthy People 2010 goals and objectives for the nation. For instance, it is a national objective to increase to 75 percent the proportion of persons age two and older with diabetes who have at least an annual dental exam (from a baseline of 58 percent).[8]
Cardiovascular
Disease
Studies examining the relationship between dental infections and the risk for cardiovascular disease suggest the potential for oral microorganisms, such as periodontopathic bacteria and their effects, to be linked with heart disease.[9] Approximately 58 million Americans live with some form of cardiovascular disease. In addition, cardiovascular disease, primarily heart disease and stroke, is the leading cause of death for men and women of all racial and ethnic groups in the U.S., responsible for more than 960,000 deaths each year (40 percent of all deaths).[10]
According to NIDCR, people with periodontitis may be more likely to develop cardiovascular disease than individuals without periodontal infection.[11] Although there is not enough evidence to support periodontitis as an independent risk factor for heart disease or stroke, there are consistent findings showing an association. Periodontal disease may also exacerbate existing heart conditions. Longitudinal studies have reported periodontal disease to be a risk factor for coronary heart disease.[12]
Osteoporosis
The mouth may also serve as an early warning system for signs of osteoporosis. Osteoporosis is a degenerative disease associated with the loss of bone mineral. More than 40 million Americans have osteoporosis or are at risk of developing it. As the number of people in the United States living to older ages continues to grow, the number of individuals living with osteoporosis will also continue to rise. The National Osteoporosis Foundation estimates the national direct medical expenditures for osteoporosis and associated fractures to be $17 billion per year, about $47 million each day.[13]
Osteoporosis has been suggested as a risk factor for oral bone loss[14] and for tooth loss due to a decrease in bone density in the jaw supporting teeth. Women with severe osteoporosis are three times more likely to experience tooth loss than are women who do not have osteoporosis.[15] Routine oral exams and radiographic magnetic resonance imaging of oral bone may be diagnostic of early osteoporotic changes in the skeleton. Although additional longitudinal studies and further examination of imaging techniques for assessing osteoporosis are needed, public health interventions can help to reduce the potential severe complications in individuals at risk for or suffering from osteoporosis.
Obesity
The link between oral health and poor nutrition,
particularly excessive sugar consumption, may have important implications on
the rising prevalence of obesity and overweight among children and adolescents
in the U.S. Recently, several states have begun to focus attention on the
connection between increased soda consumption and rising rates of dental caries
and obesity among children and adolescents. Due to constrained education
budgets, many schools have entered into contracts with soda companies as a
significant source of additional revenue. Such contracts may have significant
negative effects on children’s and adolescents’ health and dental health.
The percentage of children and adolescents who are defined as overweight has more than doubled since the early 1970s. About 13 percent of children and adolescents are now seriously overweight.[16] According to the National Soft Drink Association, soft drink consumption continues to grow, and accounts for nearly 30 percent of the beverages Americans drink.[17] Heavy consumption of soft drinks can lead to dental caries and tooth erosion. Such consumption is also tied to excessive intake of sugar, which may be associated with obesity and Type II diabetes in children.
National and State Initiatives
Preventing complications related to periodontal disease,
dental caries and other chronic diseases require approaches that engage
individuals, health professionals, policymakers, and communities. This section
provides examples of how states are integrating oral health and other chronic
disease programs and services.
National Network for Oral Health Access
The National Network for Oral Health Access (NNOHA) is a
partner of the Health Disparities Collaboratives, a program launched by the
Bureau of Primary Health Care in 1998 to change primary health care practices
to improve health care and eliminate health disparities. NNOHA began its
partnerships for diabetes prevention and control in 1999 to enhance interaction
among physicians and dentists to assure a higher quality of care and to more
efficiently promote the message that dental care impacts overall health. The
NNOHA has been active with the Diabetes Collaborative at over 50 federally
funded clinics nationwide via a referral system. For more information about
NNOHA, contact Dr. John McFarland at jmcfarland@saludclinic.org
or visit www.healthdisparities.net.
Missouri Diabetes and Oral Health
Pilot, Missouri
Department of Health and Senior Services
The
Missouri Diabetes and Oral Health Pilot, which began in July 2001, has
been a collaboration between the Missouri Diabetes Control Program (MDCP) at
the Missouri Department of Health and Senior Services, the Missouri
Bureau of Dental Health, the People’s Health Center (a federally qualified
health center) and the Centers for Disease Control and Prevention (CDC). The
pilot aims to increase dental care referrals for patients registered in the
People’s Health Centers’ Diabetes Registry, in order to reduce complications
from diabetes.
The process begins when a patient arrives for a routine appointment and a nurse provides health education materials. During the routine examination, the primary care physician (PCP) also stresses the importance of good oral health as part of a self-management program. Following the visit, an appointment for a full dental exam is scheduled before the patient leaves the clinic. Patients are given a “tool kit” consisting of a toothbrush, toothpaste, disclosing tablets, and educational materials. Over 500 kits have been provided by MDCP to the People’s Health Center.
By the end of 2001, 52 percent of those enrolled in the People’s Diabetes Registry had been referred to a dental provider; 24 percent received a dental screening; and 13 percent received a comprehensive dental examination. By June 2002, the project hopes to increase the number of patients receiving a screening to 70 percent, and those receiving a comprehensive exam to 30 percent. MDCP would also like to increase the number of patients who show up at their appointment following the referral.
For additional information about the Missouri Diabetes and Oral Health Pilot contact Jo Anderson, Manager, Diabetes Control Program, Missouri Department of Health and Senior Services at AnderJ@dhss.state.mo.us.
Arizona Department of Health Services Osteoporosis
Program
In
1999, the Arizona Department of Health Services received an
appropriation from the Arizona state legislature to establish an osteoporosis
education program. The Office of Oral Health received a portion of these funds
to develop oral health education materials for dental professionals and the
public, and to develop a web-based education course for dental professionals
focusing on caring for individuals with osteoporosis. The Office on Oral Health
developed two fact sheets on osteoporosis and dental health, one for dental
providers called “Osteoporosis: A Dental Perspective” and one for the general
public called “Osteoporosis and Your Teeth.” These fact sheets provide general
information on osteoporosis and risk factors, information for the provider to
target individuals at risk for osteoporosis, and information for the public on
ways to reduce risk factors for osteoporosis.
The interactive, web-based
course, entitled “Osteoporosis: A Dental
Perspective,” presents current information regarding osteoporosis and
its relationship to oral health. The course is designed for dentists, dental
hygienists and dental assistants, and is co-sponsored
by the Arizona Department of Health Services and the Department of Dental
Programs at Phoenix College. It presents information on the risk
factors, diagnostic techniques and physiology of osteoporosis, and allows users
to assess their knowledge through a series of multiple-choice and true/false
questions. To date, the course has been used by nearly 200 dentists and
hygienists in Arizona, and by dental students in other states. The course
recently won the Health Educators Multi-Media Yearly (HEMMY) award from the
Arizona Public Health Association. A preview of the course is available at
http://www.pc.maricopa.edu/departments/dental/Preview/preview/. For additional information
on either of these projects contact Kneka Hayward, RDH, BS, Chief, Office of
Oral Health, Arizona Department of Health Services at khaywar@hs.state.az.us.
Oral Health and
Obesity Education - Department of
Pediatric Dentistry, University of Iowa
Recently, a few states have
introduced legislation to restrict soft drink consumption in schools as a way
to improve children’s oral health and reduce obesity. In Iowa, one such bill
was drafted in the Senate to study the prevalence of soft drinks in public
schools. Although the bill is not expected to pass, a number of health
education activities targeting the adverse health consequences of soda
consumption on nutrition continue throughout the state.
A series of panel
discussions have been organized around the state led by the Department of
Pediatric Dentistry at the University of Iowa in partnership with a myriad of
education and public health groups in Iowa. An initial public forum open to the
community was organized in response to this bill to raise awareness about the
relationship between soft drink consumption, oral health and obesity, as well
as the secondary health consequences of obesity in children and adolescents,
such as diabetes, cardiovascular disease and asthma. The forum featured a
nutritionist, pediatric endocrinologist, pediatric dentist, school
superintendent, and a state Senator. Recently, testimony was presented to the Iowa
Department of Public Health. Additional panels and presentations for
diverse health and education audiences are scheduled for later this year,
including a presentation to the Iowa School Administrators Association. The
group is using non-conventional, inexpensive means to focus on the systemic
issues related to soft drink consumption, dental caries and obesity. The group
is also developing a community education campaign targeted to educators, school
boards and families about the health consequences of poor nutrition related to
soft drink consumption.
For additional information
contact Jonathan Shenkin, DDS, MPH, Department of Pediatric Dentistry,
University of Iowa at jshenkin@blue.weeg.uiowa.edu.
Conclusion
Preventing
complications related to periodontal disease, dental caries and other chronic
diseases requires interdisciplinary approaches that integrate oral health and
other health care. Public health, dental, and other health professionals can
work together in the monitoring and early detection of chronic diseases, and
suggest referral and follow up to appropriate health professionals. Public
health agencies can help foster these relationships by increasing access to
services by creating links between community health centers and other sites,
and by targeting education to dental and health professionals and the public.
Community-wide health promotion efforts that integrate dental and medical care
can lead to a reduction in risk factors and improved disease management.
Specific strategies include:
·
reducing risk factors by increasing public and provider
knowledge of the relationship between oral health and general health and
well-being;
·
coordinating health care to improve health behaviors
and disease management; and
·
moving dental health programs and education into other
settings such as workplaces and community centers.
Public
health agencies can play an important role in forwarding all of these
strategies and in impacting many chronic conditions, reducing the costs and
burden of chronic disease, and improving quality of life.
****
This brief was produced by the Association of State and
Territorial Health Officials in collaboration with the Association of State and
Territorial Dental Directors. It has been made possible by cooperative
agreements with HRSA’s Maternal and Child Health Bureau (#00114) and the
Centers for Disease Control and Prevention’s National Center for Chronic
Disease Prevention and Health Promotion (#U50/CCU306138-09). ASTHO is grateful for their support. For additional
information, or to share information about oral health in your state, please
contact Lauren Raskin, MPH, Director for Maternal and Child Health Policy at lraskin@astho.org
or Stuart Berlow, MPP, MHSA, Analyst for
Prevention Policy at sberlow@astho.org.
The Association of State and Territorial Health Officials is the national non-profit organization representing the state and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. ASTHO's members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in state-based public health practice.
For additional information
contact:
The Association of State and
Territorial Health Officials
1275 K Street, NW, Suite 800
Washington, DC 20005
Phone: (202) 371-9090 Fax (202) 371-9797
Http://www.astho.org
References
[1] U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
2 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
3 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
4 Centers for Disease Control and Prevention. National Diabetes Fact Sheet. National Estimates on Diabetes. Available at http://www.cdc.gov/diabetes/pubs/estimates.htm#prev.
5 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
6 National Institute of Dental and Craniofacial Research. Detection and Prevention of Periodontal Disease in Diabetes. Available at http://www.nohic.nidcr.nih.gov/pubs/perio/perio.html.
7 National Institute of Dental and Craniofacial Research. The Oral-Systemic Health Connection. Available at http://www.nidcr.nih.gov/spectrum/NIDCR2/2menu.htm.
8 U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office. 2000. Available at http://www.health.gov/healthypeople/Publications/.
9 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
10 Centers for Disease Control and Prevention. Chronic Disease and Conditions. Cardiovascular Disease. Available at http://www.cdc.gov/nccdphp/cardiov.htm.
11 National Institute of Dental and Craniofacial Research. The Oral-Systemic Health Connection. Available at http://www.nidcr.nih.gov/spectrum/NIDCR2/2menu.htm.
12 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
13 National Osteoporosis Foundation. Disease Statistics. Available at http://www.nof.org/osteoporosis/stats.htm.
14 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes for Health, 2000. Available at http://www.surgeongeneral.gov/library/oralhealth/.
15 National Institute of Dental and Craniofacial Research, National Institutes for Health. 1999. Building a Better Mousetrap: Toward an Understanding of Osteoporosis. Available at http://www.nidcr.nih.gov/slavkin/slav1199.asp.
16 Centers for Disease Control and Prevention. Obesity and Overweight. A Public Health Epidemic. Available at http://www.cdc.gov/nccdphp/dnpa/obesity/epidemic.htm.
17 Academy of General Dentistry. Pouring Rights: Schools Long-term Deals to Sell Soda Kick Kids’ Nutrition in the Teeth. Available at http://www.agd.org/consumer/media/may01/pouringrights.html.