PERIODONTITIS PATIENTS WITH DIABETES:

A DOUBLE JEOPARDY

Is Periodontitis A Silent Epidemic In Malaysia?

22ND MDA SCIENTIFIC CONVENTION & TRADE EXHIBITION 2015

24TH JANUARY 2015

SUNWAY PYRAMID CONVENTION CENTRE

TUTI NINGSEH MOHD DOM BDS, MPH, PhD

Periodontology Research Team, UKM and partners

www.sihatgusi.info

• “Periodontitis patients with diabetes: a double jeopardy?”

• Is it really a double jeopardy?

• Or is there to too much ado over nothing?

Double jeopardy:

• Punishment of a person twice for the same offence?

• Considerable danger or trouble from two sources?

• Twice danger of harm, loss or failure

Is periodontitis a silent epidemic?

First of all what does it mean when we say

that a disease is a silent epidemic?

As we can see there are two elements to

this question:

• First, is periodontitis an epidemic?

• And second, is it a silent disease?

1. Is periodontitis an epidemic?

• A disease is said to be of epidemic proportions when its

occurrence is more than would be expected in a

community or region during a given time period.

Global epidemiology of periodontal disease

• Most countries > 90% have periodontal disease (Morris et al 2001, Borrell et al 2002)

• 5 – 20% adults affected with severe periodontitis (Petersen & Ogawa 2005)

• Trends:

• Europe: shallow pockets (37%), deep pockets (14%)

(Borrell et al 2002)

• Asia: shallow pockets (8 – 57%), deep pockets (5 –

28%)

(Corbet et al 2002)

• Global Burden of Disease Study of 291 diseases and injuries:

• Severe periodontitis is sixth most prevalent (11%)!

(1) Marcenes, W et al 2013. Global Burden of Oral Conditions in 1990-2010: A systematic analysis. J Dent

Res, 92, (7) 592 (2) Kassebaum, E. et al 2014. Global Burden of Severe Periodontitis in 1990-2010: A

systematic review and Meta-regression. JDR 93 (11): 1045

Global Burden of Disease Study, 2014

In 2010, about 94.0% of Malaysian adults have periodontal

disease

4.1% have bleeding

41.4% have calculus

30.3% have shallow pockets

18.2% have deep pockets

• This is translated into a total of 48.5% of the adult

population with periodontitis, or an estimated quantum of

11.5 million adults!

Source : National Oral Health Survey of Adults, Malaysia 2010

Is periodontitis an epidemic in Malaysia?

• The increase in prevalence and severity of periodontal disease among adults is multiple!

• The increase in prevalence of periodontitis among youngest adults is alarming!

YEAR NOHSA, 2000 NOHSA, 2010

Age group Adult 15-19yrs Adult 15-19yrs

Periodontal disease

(including gum disease and

presence of calculus)

87.2%

74.2%

94.0%

90.4%

Periodontitis

(CPI 3 and 4) 25.2% 3.0% 48.5% 19.8%

Severe periodontitis

(CPI 4 only) 5.5% 0.3% 18.2% 3.0%

Source : National Oral Health Survey Malaysia,2000 and 2010

• A silent disease or disorder is one that produces no clinically obvious signs or symptoms

• Periodontal disease has long been viewed as a silent disease because of its symptomless nature in the early stages and during most of its course

• As it is largely painless, most people with periodontal disease are unaware that they have it

2. Is periodontitis a silent disease? Does periodontal disease have any impact on people’s quality of life?

Impact of periodontal disease on quality of life: Evidence from the literature

Clinical Studies

• Reisine et al 1985

• Needleman et al 2004

• Brennan et al 2007

• Cunha-Cruz et al 2007

• Aslund et al 2008

• Patel et al 2008

• Jowett et al 2009

• Araujo et al 2010

• O’Dowd et al 2010

• Tsakos et al 2010

• Tuti NMD 2013

Population Studies

• Ng et al 2006

• Brennan et al 2007

• Lopez & Baelum 2007

• Lawrence et al 2008

• Marino et al 2008

• Bernabe & Marcenes 2010

• Jansson et al 2014

Reasons for seeking dental care among patients with periodontitis

0

5

10

15

20

25

30

35

40%

Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In

Malaysia. PhD thesis 2013.

Quality of life impacts among patients with periodontitis using Oral Health Impact Profile

Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In

Malaysia. PhD thesis 2013.

9 in 10 patients experience functional limitation, physical pain and

psychological discomfort

Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In

Malaysia. PhD thesis 2013.

0 10 20 30 40 50 60 70

Mobility

Self-care

Usual activities

Pain/discomfort

Anxiety/depression

EQ-5D descriptive scores for periodontal patients –percentage with scores 2 (some/ moderate

problems) and/or 3 (extreme problems)

Aggressive periodontitis Chronic periodontitis

Quality of life impacts among patients with periodontitis using general EuroQoL Index

Pain/discomfort and anxiety/ depression are experienced by up to 65% of periodontitis patients.

These impacts are experienced by more aggressive periodontitis patients.

• Periodontal disease may be a silent disease because its

early signs may not be clear to the patient.

• However in due time its subsequent manifestations may

impact the patients’ quality of life in various ways.

• Implication: There is a need to increase people’s

awareness of the early signs of periodontal disease

Economic Burden of Periodontitis

• When many people are affected with a particular

disease, huge amount of resources are needed

to treat it.

Average cost in RM

Provider cost Patient cost Total cost

Per patient/

year 2,524 296 2,820

Per outpatient

visit 337 39 376

Periodontal disease is expensive to treat

Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics

BMC Oral Health 14:56a

What the government pays! What society pays!

Disease severity Average Cost

(RM)

Mild 1,757

Moderate 2,545

Severe 3,174

The more severe, the more costly!

Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics

BMC Oral Health 14:56

Items Measurement

Number of adults estimated as having

periodontitis nationwide

11,522,627

Cost of managing a periodontitis patient RM 2, 820

Projected economic burden RM 32.5 billion

Economic burden as a percentage of

Malaysia’s *GDP

3.83%

*Malaysia's GDP (Gross Domestic Product), 2011 = RM 847.3 billion

Economic burden on the country is high!

Source: Economic Burden and Cost-effectiveness Analysis of

Periodontitis Management In Malaysia. PhD thesis 2013.

Managing severe periodontitis patients alone would cost the

government about RM 10.9 billion, which was 64.7% of the Ministry

of Health budget (MoH budget, 2011 = RM 16.9 billion)

8/7/2015 19

The double jeopardy?!

Systemic diseases Patients with periodontitis

(n, %)

None 176 (54.0)

Diabetes 88 (27.8)

Cardiovascular diseases 19 (5.8)

Hypertension 92 (28.2)

Others (congenital heart disease,

asthma, gout)

34 (10.4)

Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In

Malaysia. PhD thesis 2013.

Most prominent chronic diseases

Chronic diseases are the leading causes of death and disability worldwide.

Major chronic diseases currently account for about 40% of the global burden of disease and expected to rise to 60% in 2020

Linked by:

• Common and preventable biological risk factors: notably high blood pressure, high blood cholesterol and being overweight

• Related major behavioral risk factors: unhealthy diet and poor nutrition over a prolonged period of time, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress

Cardiovascular disease

Cancer

Chronic obstructive pulmonary

disease

Type-2 diabetes

Periodontal disease - the 6th complication of diabetes • In 1997, the American Diabetes Association stated PD as the sixth

complication of DM after retinopathy, nephropathy, neuropathy, macroangiopathy and delayed wound healing (Furukawa et al. 2007)

• Individuals with type 2 diabetes have approximately threefold increased odds of having periodontitis compared with those without diabetes (Shlossman et al 1990, Emrich et al 1991)

• There is a fourfold increased risk of progressive alveolar bone loss in adults with type 2 diabetes compared with that in adults who did not have diabetes (Taylor et al 1998)

• Adults with poorly controlled diabetes had an almost threefold increased risk of having periodontitis compared with that in adult subjects without diabetes, while subjects with diabetes and good glycemic control had no significant increase in risk (Tsai et al 2002)

Periodontal disease and childhood diabetes

• “Interestingly, in this study we found that periodontitis can start in childhood in diabetes, as early loss of tooth-supporting structures was significantly increased even in our 6 to 11-year-old subgroup.”

• Lalla E, Cheng B, Lal S, et al. Periodontal changes in children and adolescents with diabetes: A case-control study. Diabetes Care. 2006;29:295-299.

Jeffcoat, M., et. al., Periodontal Therapy Improves Outcomes in

Systemic Conditions, 2014

A considerable amount of medical resources is being used for managing DM, PD and their several complications that can occur. A healthy mouth could mean thousands in healthcare savings!

Needs and concerns of patients with diabetes

No previous knowledge between

oral health and diabetes

Lack of awareness of relationship

Between oral health and diabetes

Difficulties with reading materials

Do not understand language and

medical terms used

Valerio et al 2010

Care needed overwhelming

• Patients with diabetes do not know that periodontal disease is a

highly likely complication of diabetes, and that it may have an impact

on glycemic control

• Patients with periodontitis do not know they have a risk of getting

diabetes

Focus group discussion held in UKM Faculty of Dentistry, November 2014

8/7/2015 27

In reality, many people do not know the signs

and symptoms of periodontal disease

The need to educate people and

health care workers about

periodontal disease is

PRESSING!

• Detect silent diseases before they strike