ADHA Access August 2012 : Page 8

Obesity and Bariatric Surgery: Effects on the Oral Cavity By Jessica Matlock, Kristen Ferguson, Joy Calef and Stefanie Abbott { 8 AUG 2012 ccording to the Centers for Disease Control and Preven-tion (CDC), obesity is one of the leading health problems for individuals throughout the United States. It is estimated that 12.5 million people are considered obese. Although obesity is considered a health issue in itself, it is also related to many other health complications that individuals may have. It has been shown that obesity is a leading cause of diabetes and heart disease. Research also suggests that adults are nearly twice as likely to be obese as younger individuals. Even with media and medical information available at the push of a button, the prevalence of obesity continues to increase at an alarming rate. Some contributing factors include lack of exercise, inappropriate use of time, and the easy access to fatty fast foods. 1 With the continued rise in obesity and the ever-expanding American waistline, we now have to consider obesity as a disease and not just a condition. Obesity is a leading factor in heart disease, diabetes and many other diseases prevalent in our society today. Media influence has many Americans looking for the “fast track” to lose weight and feel better about themselves. The media offers hundreds of weight loss solutions that are not going to make the “quick” difference in people who are morbidly obese. While diet and exercise are truly the best and healthiest options for weight reduc-tion, our “quick-fix” society tends to prevent people who need to lose a great deal of weight from sustaining a healthy lifestyle. When diet and exercise do not work fast enough, some people will choose a more radical approach. This radical approach is weight loss surgery. For surgery to be an option for adults, they must fit one of the following categories. They must either have a body mass index (BMI) greater than or equal to 40, or have a BMI greater than or equal to 35 with a serious obesity-related health condition such as type 2 diabetes, heart disease, or sleep apnea. 2 Teenagers may be candidates for weight loss surgery if they meet the above criteria and in addition are at their full adult height. This generally occurs at age 13 or older for females and age 15 or older for males. 3 If a person meets these qualifications for weight loss sur -gery, there are two options that they may choose: laparoscopic A Types of Weight-Loss Surgery Lap Band • Silicon rubber band placed around upper part of stomach • Creates a small stomach pouch • Reversible Gastric Bypass • More radical and invasive approach • Separates the top part of the stomach and reroutes to join the small intestine • Irreversible As the number of people receiving bariatric surgery rises, the more likely it is that the dental team will treat a patient who has undergone such surgery and presents with the associated systemic, mental health and oral manifestations. (“lap”) band procedure or gastric bypass surgery. Both proce-dures can now be performed laparoscopically. The lap band pro-cedure is a relatively new approach in which the surgeon places a silicone rubber band around the top of the stomach, creating a very small stomach pouch. It requires frequent monitoring by the physician and can be adjusted as needed, depending on the speed of weight loss for the patient. 4 Is is considered a revers-ible procedure. When the patient eats, he or she feels full very quickly due to the deceased size of the stomach. The patient must eat small meals frequently, rather than normal portions all at once. Patients frequently experience vomiting if they fail to adjust the quantity of food consumed. Gastric bypass surgery is a more radical and invasive ap-proach. It separates the top part of the stomach and reroutes the small intestine to the newly created, smaller portion of the stomach. The effect is the same as with the lap band pro-cedure, but it is not reversible. The smaller stomach pouch allows the patient to feel full more quickly and will have the same results as the lap band if the patient overeats. While physical changes are easily seen, there are other oral and systemic effects that occur with weight loss surgery. As the number of people receiving bariatric surgery rises, the more likely it is that the dental team will treat a patient who has undergone such surgery and presents with the as-sociated systemic, mental health and oral manifestations. The following factors are important for a dental profes-sional to understand due to their systemic effects. Leptin, in-terleukin-6 (IL-6) and C-reactive protein (CRP) are cytokines related to obesity that affect the oral cavity. A cytokine is a substance that cells release to communicate with each other. 5 These three cytokines are released by adipose tissue and are pro-inflammatory. An obese person has more adipose tissue and thus more pro-inflammatory cytokines. Leptin is a major factor in regulating energy intake and energy expenditure, including appetite and metabolism. Leptin can directly increase the production IL-6, which increases the release of access

Strive

Jessica Matlock, Kristen Ferguson, Joy Calef and Stefanie Abbott

Obesity and Bariatric Surgery: Effects on the Oral Cavity According to the Centers for Disease Control and Prevention (CDC) , obesity is one of the leading health problems for individuals throughout the United States. It is estimated that 12. 5 million people are considered obese. Although obesity is considered a health issue in itself, it is also related to many other health complications that individuals may have. It has been shown that obesity is a leading cause of diabetes and heart disease. Research also suggests that adults are nearly twice as likely to be obese as younger individuals. Even with media and medical information available at the push of a button, the prevalence of obesity continues to increase at an alarming rate. Some contributing factors include lack of exercise, inappropriate use of time, and the easy access to fatty fast foods.1 With the continued rise in obesity and the ever-expanding American waistline, we now have to consider obesity as a disease and not just a condition. Obesity is a leading factor in heart disease, diabetes and many other diseases prevalent in our society today. Media influence has many Americans looking for the "fast track" to lose weight and feel better about themselves. The media offers hundreds of weight loss solutions that are not going to make the "quick" difference in people who are morbidly obese. While diet and exercise are truly the best and healthiest options for weight reduction, our "quick-fix" society tends to prevent people who need to lose a great deal of weight from sustaining a healthy lifestyle. When diet and exercise do not work fast enough, some people will choose a more radical approach. This radical approach is weight loss surgery. For surgery to be an option for adults, they must fit one of the following categories. They must either have a body mass index (BMI) greater than or equal to 40, or have a BMI greater than or equal to 35 with a serious obesity-related health condition such as type 2 diabetes, heart disease, or sleep apnea.2 Teenagers may be candidates for weight loss surgery if they meet the above criteria and in addition are at their full adult height. This generally occurs at age 13 or older for females and age 15 or older for males.3 If a person meets these qualifications for weight loss surgery, there are two options that they may choose: laparoscopic ("lap") band procedure or gastric bypass surgery. Both procedures can now be performed laparoscopically. The lap band procedure is a relatively new approach in which the surgeon places a silicone rubber band around the top of the stomach, creating a very small stomach pouch. It requires frequent monitoring by the physician and can be adjusted as needed, depending on the speed of weight loss for the patient.4 Is is considered a reversible procedure. When the patient eats, he or she feels full very quickly due to the deceased size of the stomach. The patient must eat small meals frequently, rather than normal portions all at once. Patients frequently experience vomiting if they fail to adjust the quantity of food consumed. Gastric bypass surgery is a more radical and invasive approach. It separates the top part of the stomach and reroutes the small intestine to the newly created, smaller portion of the stomach. The effect is the same as with the lap band procedure, but it is not reversible. The smaller stomach pouch allows the patient to feel full more quickly and will have the same results as the lap band if the patient overeats. While physical changes are easily seen, there are other oral and systemic effects that occur with weight loss surgery. As the number of people receiving bariatric surgery rises, the more likely it is that the dental team will treat a patient who has undergone such surgery and presents with the associated systemic, mental health and oral manifestations. The following factors are important for a dental professional to understand due to their systemic effects. Leptin, interleukin- 6 (IL-6) and C-reactive protein (CRP) are cytokines related to obesity that affect the oral cavity. A cytokine is a substance that cells release to communicate with each other.5 These three cytokines are released by adipose tissue and are pro-inflammatory. An obese person has more adipose tissue and thus more pro-inflammatory cytokines. Leptin is a major factor in regulating energy intake and energy expenditure, including appetite and metabolism. Leptin can directly increase the production IL-6, which increases the release of CRP. CRP can directly inhibit the binding of leptin, causing leptin resistance.6 As the resistance to leptin increases, metabolism is decreased and appetite is increased. When leptin, IL-6 and CRP are increased in an overweight individual, the systemic inflammatory response is higher, and more clinical attachment loss and periodontal disease result due to the systemic inflammatory response. However, when a patient undergoes bariatric surgery, the adipose cells are decreased and the inflammatory response is decreased, systemically decreasing the risk of diabetes and heart disease. As the inflammatory response decreases, there is less clinical attachment loss and periodontal disease in the patient, which is a positive outcome for patients who have undergone bariatric surgery. Mental outlook also improves when a patient undergoes bariatric weight loss surgery. Patients who underwent bariatric surgery were more motivated to adopt health-enhancing behaviors such as diet improvement and physical exercise. A high-quality diet and an increased level of physical activity are associated with an improved periodontal health. There is a connection with increased or adequate exercise. A person who exercises may experience less periodontal disease due to the decreased inflammatory response. Additionally, a person who has undergone bariatric surgery tends to have a better outlook on life. They are more likely to care about their appearance and therefore brush their teeth more often and have routine dental exams. In contrast, bariatric surgery can have a negative effect on the oral cavity. Although systemically, the cytokines in the blood serum have changed so that the inflammatory process is lowered, bariatric surgery has direct effects on the oral cavity. These effects can include increased caries rate and tooth erosion. This is possibly due to the stomach being reduced to a capacity of between 15 and 50 mL, which requires patients to consume small frequent meals and sip liquids throughout the day.7 If the patient consumes a diet high in carbohydrates, and the frequency of exposure is high, then the chance of developing caries is increased. Erosion can also be increased in patients who have undergone bariatric surgery because of the frequency of acid reflux orvomiting, which occurs in 73 percent ofpatients.4 Dental professionals can help prevent and treat the increased incidence of dental caries and erosion seen in patients who have had bariatric surgery. In addition, it is important to continue to evaluate their periodontal status. As previously stated, the incidence of periodontal disease in obese individuals may be higher because of the systemic inflammatory response. Once the patient gets her or his weight under control, the inflammatory response will start to decrease. This will significantly improve the outcome of the periodontal disease, in addition to conventional treatment. To attempt to decrease dental caries associated with the changes in diet and frequency of consumption, the patient needs to undergo nutritional counseling. Patients should be encouraged to include cariostatic food factors such as proteins, cheeses and grains in their diet.7 Approximately 73 percent of patients who have lap band surgery and a small percentage who have had gastric bypass surgery develop gasteroesophageal reflux disease (GERD), with one-third ofthese patients developing severe reflux and frequent vomiting.4 Patients who vomit frequently because of GERD are more likely to develop dental caries and erosion. To combat the caries and erosion, the patient needs to increase water consumption and stimulate salivary flow with fibrous foods to attempt to dilute the acidity.7 Dental professionals need to instruct bariatric patients with GERD to increase their frequency of brushing and fiossing after meals and snacks. After vomiting, the patient should rinse with water and wait 30 minutes to brush and fioss to avoid dispersion of the acid throughout the oral cavity. The patient should be instructed to use neutral sodium fluoride toothpaste daily to protect the teeth against the increased acidity associated with vomiting and GERD. Sodium fluoride may also be delivered through home-use fluoride trays for patients presenting with severe erosion associated with GERD. Stannous fluoride is not recommended due to its acidity. Patients should also be advised to maintain a four-month recall to monitor caries and erosion status.7 Other adjunctive treatment would include overthe- counter potassium nitrate products for sensitivity and xylitol products for caries prevention. In conclusion, patients who undergo weight loss surgeries have a decreased incidence of periodontal disease related to decreased systemic inflammation, and increased incidence ofdental caries and erosion related to GERD effects and dietary changes. With the rise of obesity, we will see an increase in dental patients who have undergone bariatric surgery. By understanding the associated oral manifestations, dental professionals will be able to provide comprehensive care for bariatric surgery patients. References 1. Overweight and obesity. Centers for Disease Control and Prevention. 2011. Available at: www.cdc.gov/obesity/data/index.html. 2. Ritchie C. Obesity and periodontal disease. Periodontal 2000. 2007; 44:154-63. 3. Inge T, Krebs N, Garcia V, et al. Bariatric surgery for severely overweight adolescents: concernsand recommendations. Pediatrics. 2004 Jul; 114(1): 217-23. 4. Moravec L, Boyd L. (2011). Bariatric surgery and implications for oral health: A case report. J Dent Hyg. 2011; 85(3): 166-76. 5. Venes D. (ed). Taber's cyclopedic medical dictionary, 20th ed. Philadelphia: F.A. Davis Company, 2005. 6. Lakkis D, Bissada N, SaberA, et al. (2011). Response to periodontal therapy in subjects who had weight loss following bariatric surgery and obese counterparts: a pilot study. J Periodontal. 2012; 83(6): 684-9. 7. Hague A, Baechle M. Advanced caries in a patient with a history of bariatric surgery. J Dent Hyg. 2008; 82(2): 22. Additional Resource Livingston E. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010; 200(3): 378-85. Stefanie Abbott (Monticello, Ark.), Joy Calef (Joplin, Mo.), Kristen Ferguson (Jonesboro, Ark.) And Jessica Matlock (Fayetteville, Ark.) Graduated from the University of Arkansas in Fort Smith May 2012 with dental hygiene degrees. Their research was conducted as part of table clinic presentations to dentists and dental hygienists from the Fort Smith area as well as at the Undergraduate Research Symposium at the university. They were awarded second place for their table clinic presentation at the Arkansas State Dental Meeting in April 2012. The faculty mentor for this edition of Strive is Pamela Davidson, RDH, Med, assistant professor, Dental Hygiene, College of Health Sciences, University of Arkansas-Fort Smith.

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