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Narumanas KorwanichDepartment of Family and Community
DentistryChiangmai University
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What is Oral Health?Linkage with General Health
The Mouth as a Mirror of HealthThe Mouth as a Portal Entry of InfectionAssociation of Oral Infection, Diabetes, Heart
Disease/Stroke, and Adverse Pregnancy Outcome
Effect on Well Being and Quality of LifeThailand Study
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The Meaning of Oral HealthOral health means much more than healthy
teeth
Traditionally, dentists have been trained to recognise and treat disease such as caries, periodontal disease and tumors
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The Meaning of Oral HealthBeing 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
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The Meaning of Oral HealthThey 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
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The Meaning of HealthOral 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
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The Meaning of Oral Health
A comfortable and functional dentition which allows individuals to continue in their desired social role
Dolan, 1993
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• 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
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The Mouth and Face as a Mirror of HealthA 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
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HIV infection oral manifestration
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Nutrition Deficiency
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Iron Deficiency
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Vitamin B Deficiency
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Sampled analyte of SalivaCategory Analyte
Drugs of abuse
AlcoholAmphetamineBarbiturateCocaineLSDMarijuanaNicotineOpiate
Antibody HIVHPVHHV
Toxin CadmiumLeadMercury
Category Analyte
Hormones CortisolProgesteroneTestosteroneSubstance PMet-enlephalin
Therapeutics AntipyrineCarbamazepineCyprofloxacinIrinoticanLithiumMethotrexatePhenytoinePhenobarbitalTheophylline
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The Mouth and Face as a Mirror of HealthConclusion
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
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The Mouth as a Portal Entry for InfectionOral 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
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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)
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Sonis, et al 2007
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Infective EndocarditisEndocarditis 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).
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Infective EndocarditisRisk factors
Rheumatic and congenital heart disease complex
Cyanotic heart disease in childrenMitral valve prolapse with regurgitation
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Oral Infection and Respiratory DiseaseChronic 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)
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Oral Transmission of InfectionSeveral 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)
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The Mouth as a Portal Entry for InfectionConclusion
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.
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Periodontitis - DMThere 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
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Periodontitis - DMDiabetic 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
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DM - Periodontitis
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DM - PeriodontitisThe 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
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DM - PeriodontitisDarre’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
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DM - PeriodontitisThe 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
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Periodontitis – Heart DiseaseSome 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).
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Periodontitis – Heart Disease
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Periodontitis – Heart Disease
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Periodontitis - PreganancyRemote 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
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Periodontitis - Pregnancy
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Periodontitis - Pregnancy
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Periodontitis - Pregnancy
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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
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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
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5 Rats aged 11 weeks old kept in 23c, 50%humidity, 12 h light/dark
Extract all maxillary and mandibular molars
Test in radial arm maze
Test of Acetyl-choline releasing from parietal cortex
135 weeks
9 weeks
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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
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OIDP index
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Tooth Loss and Quality of Life
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Oral Health
Medical Concept
Bio – Psycho – Social Concept
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Theoretical framework of consequences of oral impacts (Locker, 1988)
Disease ImpairmentFunctional
LimitationDisability Handicap
Death
Discomfort
Disease Impairment Functional Limitation
Disability Handicap
Death
Discomfort
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Psychological disability ความร��สู3กอ%บอายจิากการสู�ญเสู�ยฟั(น หร�อการเค�)ยวท�*ม�ป(ญหา Social disability
การหล�กเล�*ยงการเข�าสู%งคม การหล�กเล�*ยงการก�นอาหารร วมก%บผิ��อ�*น ซึ่3*งเป�นผิลจิากความสูามารถู
ในการเค�)ยวลดลง
แนวค�ดในการพ%ฒนา OHRQoL
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การสู�ญเสู�ยโอกาสู ซึ่3*งเป�นผิลมาจิากการจิ!าก%ดการท!างานของร างกาย ท!าให�บ-คคลน%)นๆ ไม สูามารถูด!าเน�นช่�ว�ติได�เหม�อนคนปกติ�ท%*วไปในสู%งคม
Handicap
แนวค�ดในการพ%ฒนา OHRQoL
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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
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The Oral Impact on Daily Performances
Adulyanon and Sheiham 1997
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Theoretical model of consequences of oral impacts
Level 1Impairment
Level 2Intermediateimpacts
Pain Discomfort Functional limitation
Dissatisfactionwith appearance
Level 3Ultimateimpacts
Impacts on daily performances
Physical Psychological Social
(modified from the WHO’s International Classification of Impairments, Disabilities and Handicaps)
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Physicaleating and enjoying foodspeaking and pronouncing clearlycleaning teethdoing light physical activities
3 dimensions:Psychologicalsleeping and relaxingsmiling, laughing and showing teeth without embarrassmentmaintaining usual emotional state without being irritable
Socialenjoying contact with people
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เพื่��อเปรียบเทียบสภาวะส�ขภาพื่รี�างกายในปรีะเด็�นต่�างๆ รีะหว�างผู้� ส�งอาย�ที�มีและไมี�มีฟั&นในช่�องปาก โด็ยปรีะเด็�นที�จะที*าการีศึ,กษาได็ แก� ด็.ช่นมีวลกาย (Body Mass Index; BMI) คุ�ณภาพื่ช่ว1ต่อ.นเน��องมีาจากส�ขภาพื่ช่�องปาก (Oral Health
Related Quality of Life; ORH-QOL) คุวามีสามีารีถในการีเคุ3ยวอาหารี (Chewing Ability
Index; CAI) สภาวะโภช่นาการี (Mini-Nutritional Assessment)
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Sampleผู้� ส�งอาย�จ*านวน 600 คุน อาย�ต่.3งแต่� 60 ป4ข,3นไป 4 กล��มี
ได็ แก�ผู้� ที�ไมี�มีฟั&นเหล�ออย��เลย และไมี�เคุยใส�ฟั&น (edentulous
group)ผู้� ที�ใส�ฟั&นที.3งปาก (complete denture group)ผู้� ที�ใส�ฟั&นบางส�วน (partial denture group)ผู้� ที�มีฟั&นธรีรีมีช่าต่1 (natural teeth group)
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Sampleต่ องมีสภาพื่ด็.งกล�าวมีาเป6นเวลาไมี�น อยกว�า 1 ป4 ต่ องผู้�านการีทีด็สอบคุวามีจ*าต่ องเด็1นมีารี.บการีต่รีวจเองได็ หากมีฟั&นเหล�ออย��ในปาก ฟั&นที�กซี่�ต่ องเป6น functional
teethไมี�โยกเก1น 2 degreeมี crown เหล�อมีากพื่อที�จะใช่ บด็เคุ3ยวสามีารีถใช่ งานได็ โด็ยไมี�มีอาการีเจ�บปวด็
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Edentulous group
Complete denture group
Partial denture group
Natural teeth group
กรี�งเทีพื่ 30 30 30 30
เช่ยงใหมี� 30 30 30 30
พื่1ษณ�โลก 30 30 30 30
ช่.ยภ�มี1 30 30 30 30
สงขลา 30 30 30 30
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Material and methodการีต่รีวจในช่�องปาก
Tooth status ต่ามีแบบต่รีวจช่�องปากของ WHO หรี�อการีส*ารีวจของจ.งหว.ด็
Occluding pairsMNAAnthropometry OIDP
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MNA and Teeth Type
n Mean MNA
SD
Edentulous 159 24.31 0.23Complete Denture 188 24.14 0.21Natural and Replace Teeth
156 24.80 0.24
Natural Teeth 159 25.54 0.19
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MNA and Teeth TypeMalnutrition / Risk to malnutritio
n (n)
Normal nutrition status (n)
Total (n)
Edentulous 33 121 154Complete Denture
37 148 185
Natural and Replace Teeth
24 131 155
Natural Teeth 13 144 157
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MNA and Teeth Type
Eden/** CD/** NRT/** NT/**
**/Eden 1.00
**/CD 1.09 1.00
**/NRT 1.49 1.36 1.00
**/NT 3.02* 2.77* 2.03 1.00
Odds Ratio for Malnutrition-Risk to malnutrition / Good nutrition among teeth type groups
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Chewing and Teeth TypeSelf reported problem on biting, n(%)
No Low Fair High TotalEdentulous 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) 159(100.0)
Total 371(55.7)
137(20.6)
76(11.4)
82(12.3)
664(100.0)
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Chewing and Teeth TypeSelf 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) 159(100.0)
Total 363(54.5)
156(23.4)
77(11.6) 70(10.5)
664(100.0)
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Chewing and Teeth TypeSelf reported problem on chewing, n(%)
No Low Fair High TotalEdentulous 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) 6(3.2) 188(100.0)
Natural teeth with replaced teeth
142(89.3) 6(3.8) 6(3.8) 6(3.8) 159(100.0)
Natural teeth 140(88.1) 11(6.9) 7(4.4) 7(4.4) 159(100.0)
Total 559(83.9) 48(7.2) 35(5.3) 35(5.3) 664(100.0)
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Chewing and Teeth Type
Eden/**Biting Chewing Swallowing
**/Eden 1.00 1.00 1.00**/CD 5.17* 5.90* 5.63***/NRT 4.69* 4.20* 4.38***/NT 7.84* 5.19* 3.86*
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BMI and Teeth Type
n Mean BMI SD
Edentulous (Eden) 155 22.5 3.9
Complete Denture (CD)
185 22.5 4.1
Partial Denture NRT) 158 23.3 3.7
Natural Teeth (NT) 157 24.6 3.7
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BMI and Teeth Type
Eden CD NRT NT
Eden NS NS p<0.05
CD NS NS p<0.05
NRT NS NS p<0.05
NT p<0.05 p<0.05 p<0.05
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BMI and Teeth Type