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CONFIDENTIAL AND PROPRIETARY
Diabetes Mellitus and the
Dental Professional
© Author / Presentation Reference Slide 1
CONFIDENTIAL AND PROPRIETARY
Contents
Diabetes – The Disease
• What is Diabetes Mellitus?
• Epidemiology
• Signs and symptoms
• Risk factors
Diabetes- Management
• Management of Diabetes
• Diagnosis
• Systemic Complications
Implications for Oral Health
• Oral Complications
• Management Considerations for the Dental Patient with Diabetes
© Author / Presentation Reference Slide 2
CONFIDENTIAL AND PROPRIETARY
What is Diabetes Mellitus?
“Diabetes is a group of diseases marked
by high levels of blood glucose resulting
from defects in insulin production,
insulin action, or both.”
© Author / Presentation Reference Slide 3
CDC Website (http://www.cdc.gov/diabetes/pubs/general11.htm
CONFIDENTIAL AND PROPRIETARY
Types of Diabetes
• Pre-Diabetes
• Diabetes Mellitus
• Type 1
• Type 2
• Gestational Diabetes
© Author / Presentation Reference Slide 4
CONFIDENTIAL AND PROPRIETARY
Types of Diabetes
• Pre-diabetes
–A condition that occurs when a person’s blood glucose
levels are higher than normal but not high enough for a
diagnosis of type 2 diabetes
–79 million people in the U.S. have pre-diabetes
–Almost always occurs before people develop type 2
diabetes
–More likely to develop type 2 diabetes within 10 years
–More likely to have a heart attack or stroke
© Author / Presentation Reference Slide 5
National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Types of Diabetes Mellitus
• Type1
–Autoimmune disease – body destroys insulin-
producing cells in the pancreas
–Require daily insulin for survival
–Also known as Insulin Dependent Diabetes Mellitus
(IDDM) or Juvenile Onset Diabetes
–Begins in adolescence
–Accounts for 5-10% of
diabetic population
© Author / Presentation Reference Slide 6
National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Types of Diabetes Mellitus
• Type 2
– Inability of the pancreas to produce enough insulin (insulin deficiency) and/or inability for the body to use insulin properly (insulin resistance)
– Also known as Non-Insulin Dependent Diabetes Mellitus (NIDDM)
– Multiple risk factors
– 40+ years
– Most common form of diabetes
– Accounts for 82-92% of diabetics
© Author / Presentation Reference
National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Types of Diabetes
• Gestational
–Occurs during pregnancy of 2-10% of females not previously diagnosed with diabetes
–Screening at 24-28 weeks of pregnancy
–Temporary but higher risk of developing Type 2 in future
© Author / Presentation Reference Slide 8
National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Diabetes – Epidemiology
•346 million
–346 million people worldwide have diabetes
•80%
–More than 80% of people with diabetes live in low- and
middle-income countries
•2030
–WHO projects that diabetes deaths will double between
2005 and 2030
© Author / Presentation Reference Slide 9
World Health Organization (http://www.who.int/mediacentre/factsheets/fs312/en/index.html )
CONFIDENTIAL AND PROPRIETARY
Prevalence estimates of Diabetes 2025
International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013.
http://www.idf.org/diabetesatlas
CONFIDENTIAL AND PROPRIETARY
Diabetes Facts
• Affects 29.1 million people (9.3%) of
the U.S. population all ages
– 21 million diagnosed
– 8.1 million undiagnosed
• Up to 27.8% of patients are unaware
they have the disease
• Leading cause of kidney failure,
amputation and blindness among
adults in the U.S.
• Major cause of heart disease and
stroke
• 7th leading cause of death
Slide 11
Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its
Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.)
CONFIDENTIAL AND PROPRIETARY
Number (in Millions) of Persons with Diagnosed Diabetes in the U.S., 1980-2009
CDC 2011
© Author / Presentation Reference Slide 12
www.cdc.gov/diabetes
CONFIDENTIAL AND PROPRIETARY
Diagnosed Diabetes Prevalence 2004
© Author / Presentation Reference Slide 13
0 - 6.5
6.6 - 8.0
8.1 - 9.4
9.5 - 11.1
> 11.2
Percentage of Adults with Diagnosed Diabetes Aged ≥ 20 Years www.cdc.gov/diabetes
CONFIDENTIAL AND PROPRIETARY
Diagnosed Diabetes Prevalence 2008
28/08/2014 15:28 © Author / Presentation Reference Slide 14
0 - 6.5
6.6 - 8.0
8.1 - 9.4
9.5 - 11.1
> 11.2
Percentage of Adults with Diagnosed Diabetes Aged ≥ 20 Years www.cdc.gov/diabetes
CONFIDENTIAL AND PROPRIETARY 28/08/2014 15:28 © Author / Presentation Reference Slide 15
Diagnosed Diabetes Prevalence 2011
0 - 6.5
6.6 - 8.0
8.1 - 9.4
9.5 - 11.1
> 11.2
CONFIDENTIAL AND PROPRIETARY
www.cdc.gov/diabetes
Age-adjusted
percent
0 - 19.4
19.5 - 23.8
23.9 - 27.0
27.1 - 30.7
> 30.8
County-level Estimates of Obesity among Adults aged ≥ 20 years:
United States 2009
CONFIDENTIAL AND PROPRIETARY
Diagnosed Diabetes/Obesity Prevalence
© Author / Presentation Reference
0 - 6.5
6.6 - 8.0
8.1 - 9.4
9.5 - 11.1
> 11.2
Percentage of Adults with Diagnosed obesity Aged ≥ 20 Years
www.cdc.gov/diabetes
0 - 19.4
19.5 - 23.8
23.9 - 27.0
27.1 - 30.7
> 30.8
CONFIDENTIAL AND PROPRIETARY
Signs and Symptoms of Uncontrolled Diabetes Mellitus
Polydipsia Polyuria Polyphagia
© Author / Presentation Reference Slide 18
3Ps of the uncontrolled diabetic state
http://www.cdc.gov/diabetes/consumer/learn.htm#2
CONFIDENTIAL AND PROPRIETARY
Signs and Symptoms of Uncontrolled Diabetes Mellitus
http://www.cdc.gov/diabetes/consumer/learn.htm#2
CONFIDENTIAL AND PROPRIETARY
Signs and symptoms of uncontrolled Diabetes Mellitus
http://www.cdc.gov/diabetes/consumer/learn.htm#2
CONFIDENTIAL AND PROPRIETARY
Risk Factors of Diabetes
http://www.cdc.gov/diabetes/consumer/learn.htm
CONFIDENTIAL AND PROPRIETARY
Obesity
• >120 % ideal body weight or a BMI, Body Mass Index, over 27 kg/m2
– WHO define obesity as BMI ≥ 30, but those with a BMI >27 are at high risk of heart disease and other problems
• Fat cells more insulin resistant (IR) than muscle cells—more insulin produced to keep blood glucose levels normal
• Risk Type 2 increases with degree of obesity and duration—increased insulin production can not be maintained indefinitely so hyperglycemia occurs
• Central obesity linked with IR; hypertension also linked with central obesity
© Author / Presentation Reference Slide 22
www.who.int/gho/ncd/risk_factors/obesity_text/en/
CONFIDENTIAL AND PROPRIETARY
Age Over 45 Years
• The basal metabolic rate (BMR) declines with increasing age
• Could lead to weight gain
• More fat cells insulin resistance over time
• Insulin resistance prolonged time pre diabetes diabetes
© Author / Presentation Reference Slide 23
ADA 2003, Diabetes Care 2003; 26(3): 917-932
CONFIDENTIAL AND PROPRIETARY
Contents
Diabetes – The Disease
• What is Diabetes Mellitus?
• Epidemiology
• Signs and symptoms
• Risk factors
Diabetes- Management
• Management of Diabetes
• Diagnosis
• Systemic Complications
Implications for Oral Health
• Oral Complications
• Management Considerations for the Dental Patient with Diabetes
© Author / Presentation Reference Slide 24
CONFIDENTIAL AND PROPRIETARY
Diabetes- Management
• Controlled rather than
cured
• Type 1
–Daily insulin therapy
– Injection
–New modalities
© Author / Presentation Reference Slide 25
National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
• Controlled rather than cured
• Type 2
–Weight reduction
–Exercise
– Improved diet
–Oral medications
– Insulin therapy long-term
© Author / Presentation Reference Slide 26
Diabetes- Management
www.diabetes.org National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Laboratory Diagnostic Tests
• Fasting Plasma Glucose (FPG)
• Oral Glucose Tolerance Test (OGTT)
• Postprandial blood glucose
• Glycosylated Hemoglobin (HbA1c)
– A measure of blood glucose control over a 4-
month period
– High Performance Liquid Chromatography
www.diabetes.org
CONFIDENTIAL AND PROPRIETARY
American Diabetes Association Recommendations for HbA1c Levels
< 6 Normal value
INTERPRETATION HbA1c (%)
< 7 Treatment goal for patient with diabetes;
diet, exercise and/or medications should
control glucose levels well enough to
maintain HbA1c values <7%
> 8 Physician intervention in diabetes
management regimen is recommended
to improve glycemic control
Borgnakke et al. Effect of periodontal disease on diabetes: Review.J Clin Period, 2013.
ADA Diabetes Management
ww.diabetes.org
CONFIDENTIAL AND PROPRIETARY
Systemic Complications of Diabetes
1. Retinopathy
Visual impairment up to and including blindness from retinopathy, glaucoma, cataract and corneal disease
2. Nephropathy
Renal failure
3. Neuropathy
Sensory loss and damage to limbs
4. Macrovascular Disease
–Heart Disease and stroke
–Leading cause of death
5. Poor Wound Healing
Foot ulceration, gangrene and lower limb amputation
6. Periodontal Disease (Loe 1993)
6th complication of diabetes
Slide 29
Ryan et al, 2003. www.diabetes.org National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)
CONFIDENTIAL AND PROPRIETARY
Contents
Diabetes – The Disease
• What is Diabetes Mellitus?
• Epidemiology
• Signs and symptoms
• Risk factors
Diabetes- Management
• Management of Diabetes
• Diagnosis
• Systemic Complications
Implications for Oral Health
• Oral Complications
• Management Considerations for the Dental Patient with Diabetes
© Author / Presentation Reference Slide 30
CONFIDENTIAL AND PROPRIETARY
Mechanisms Linking Periodontitis & Diabetes
© Author / Presentation Reference Slide 31
Workshop funded by an unrestricted
educational grant from Colgate to the
European Federation of
Periodontology and the American
Academy of Periodontology
CONFIDENTIAL AND PROPRIETARY
Diabetes and Periodontitis
• Poorly controlled diabetes increases the risk of
periodontitis
• Periodontal disease can make glycemic control
more difficult.
Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way
relationship. Ann Periodontol. 1998 Jul;3(1):51-61.
CONFIDENTIAL AND PROPRIETARY
Type 1 Diabetes - Periodontal Disease
• Increased risk of gingivitis
More gingival inflammation and bleeding in children with diabetes
than children without diabetes, after accounting for plaque1
• Periodontitis 6 times greater in young people with
Type 1 diabetes compared with those without
diabetes2
© Author / Presentation Reference Slide 33
1. DPERU, University of Adelaide Special Topic No. 3, Diabetes and Oral Health 2. Ryan et al, 2003.
CONFIDENTIAL AND PROPRIETARY
Type 2 Diabetes
People with diabetes are 2-3
times more likely to suffer from
periodontitis
Mealey BL, Oates TW; American Academy of Periodontology. Diabetes mellitus
and periodontal diseases. J Periodontol. 2006 Aug;77(8):1289-303.
Adapted from Lalla et al., 2008 ADEA Curriculum Resource Center,
www.adea.org/crc. Copyright©2011 by the American Dental Education Association
and Dental Learning Systems, LLC.
CONFIDENTIAL AND PROPRIETARY
Type 2 Diabetes – Extensive Literature Review
• Meta-analysis of 23 studies concluded that the prevalence and severity of periodontal disease is greater in diabetics than non-diabetics (Khader et al, 2006)
• Poor glycemic control leads to an increased risk for alveolar bone loss and more severe progression of periodontal disease (DPERU, University of Adelaide Special Topic No. 3, Diabetes and Oral Health)
• Periodontal disease can be more severe if the diabetic patient is a smoker (US Department of Health and Human Services, 2000)
• Glycemic control influences relationship between diabetes and periodontal disease (Mealey et al, 2007)
© Author / Presentation Reference Slide 35
CONFIDENTIAL AND PROPRIETARY © Author / Presentation Reference Slide 36
Periodontal Disease and mortality in
Diabetic patients (type 2 diabetes)
30
25
20
15
10
5
0 No or mild Moderate Severe
Periodontal Disease
cardiorenal deaths; all other natural deaths
Diabetes Care 28:27–32, 2005
CONFIDENTIAL AND PROPRIETARY
Effect of periodontal treatment in HbA1c levels : Controlled Clinical Trial
Calabrese N, et al. Diabetes Metab. 2011 Nov;37(5):456-459. 8 m
on
ths
Baseli
ne
Baseli
ne
8 m
on
ths
Periodontal Treatment Control n=44 n=49
P<0,001 P<0,033
5
6
7
8
CONFIDENTIAL AND PROPRIETARY
Management Considerations for the Dental Patient with Diabetes
• A Call to Action for Integrated Management of the Diabetic Patient
• Collaborate with medical colleagues
© Author / Presentation Reference Slide 38
IDJ Vol 58:4 2008.
CONFIDENTIAL AND PROPRIETARY
Identification of Unrecognized Diabetes and Pre-Diabetes in a Dental Setting
Algorithm of 2 dental parameters:
1.# Missing teeth
2.% deep periodontal pockets
601 patients
>30 year old
Not told they had
pre- diabetes or diabetes
Self reported risk factor:
Family history of diabetes
Hypertension
High cholesterol
Overweight
2nd appointment following overnight fast for FPG
Pre Diabetes 100-125mg/dL
Diabetes ≥126mg/dL
28/08/2014 15:28 © Author / Presentation Reference Slide 39
Lalla et al.,J Dent. Res. 2013.
Lalla et al.,J Dent. Res. 2011.
CONFIDENTIAL AND PROPRIETARY
Diabetes – Potential Oral Complications
• Periodontal disease
• Dental caries
• Salivary dysfunction / xerostomia
– Increased urination or alterations in salivary glands
– Drug-induced
© Author / Presentation Reference Slide 40
Pihlstrom BL. Periodontal risk assessment, diagnosis and treatment planning.
Periodontol 2000. 2001;25:37-58.
CONFIDENTIAL AND PROPRIETARY
Diabetes – Potential Oral Complications
• Periodontal disease (Periodontitis & Gingivitis)
• Dental caries
• Salivary dysfunction
• Oral infections (eg. Candidiasis)
– Antifungal agents
– Dentures
© Author / Presentation Reference Slide 41
Pihlstrom BL. Periodontal risk assessment, diagnosis and treatment planning.
Periodontol 2000. 2001;25:37-58.
CONFIDENTIAL AND PROPRIETARY
Diabetes – Potential Oral Complications
• Periodontal disease
• Dental caries
• Salivary dysfunction
• Oral infections (eg. Candidiasis)
• Oral mucosal disorders
– Lichen planus
• Pain management
• Steroids (topical/systemic)
– Burning mouth syndrome
– Glossodynia
© Author / Presentation Reference Slide 42
Pihlstrom BL. Periodontal risk assessment, diagnosis and treatment planning.
Periodontol 2000. 2001;25:37-58.
CONFIDENTIAL AND PROPRIETARY
Periodontal Disease is Common and Influenced by Many Factors
• Main cause – Dental Plaque
• Risk factors
–Age
–Smoking/Tobacco
–Genetics
–Stress
–Medications
–Clenching or grinding
–Other systemic diseases
–Poor nutrition and obesity www.perio.org.
CONFIDENTIAL AND PROPRIETARY
Stages of Periodontal Disease I
Reprinted by permission of the ADEA Curriculum Resource Center, www.adea.org/crc.
Copyright©2011 by the American Dental Education Association and Dental Learning Systems, LLC.
All rights reserved.
PMN polymorphonuclear neutrophils
CONFIDENTIAL AND PROPRIETARY
Stages of Periodontal Disease II
PMN polymorphonuclear neutrophils
Reprinted by permission of the ADEA Curriculum Resource Center, www.adea.org/crc.
Copyright©2011 by the American Dental Education Association and Dental Learning Systems, LLC.
All rights reserved.
CONFIDENTIAL AND PROPRIETARY
Stages of Periodontal Disease III
PMN polymorphonuclear neutrophils, PGE2 Prostaglandin E2, MMP matrix metalloproteinase
Reprinted by permission of the ADEA Curriculum Resource Center, www.adea.org/crc.
Copyright©2011 by the American Dental Education Association and Dental Learning Systems, LLC.
All rights reserved.
CONFIDENTIAL AND PROPRIETARY
Stages of Periodontal Disease IV
Reprinted by permission of the ADEA Curriculum Resource Center, www.adea.org/crc.
Copyright©2011 by the American Dental Education Association and Dental Learning Systems, LLC.
All rights reserved.
CONFIDENTIAL AND PROPRIETARY
Diabetic Emergency Symptoms
Hypoglycemia
• Nervous (shaky)
• Dizzy/ Confused
• Headache
• Hunger
• Cold clammy skin
• Fast heartbeat
• Irritability
• Syncope
Hyperglycemia
• Weak
• Tired
• Frequent urination
• Thirst
• Decreased appetite
• Blurry vision
• Itchy dry skin
• Fruity breath
Blood Glucose Levels
http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf
CONFIDENTIAL AND PROPRIETARY
Hypoglycemia - Management
• For early, mild symptoms
– Offer liquid glucose or fruit juices (not diet) are
preferred
– Give sugar snacks when liquid is not available
(soft consistency preferred)
• For more severe symptoms such as
drowsiness, convulsions or coma
– Seek immediate medical assistance (call 911)
Slide 49
www.diabetes.org http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf
CONFIDENTIAL AND PROPRIETARY
Hyperglycemia
• Accurate medical history
– Age, family history, hypertension, hypercholesterolemia
• Aggravated by infections
• Common symptoms may indicate diabetes or poorly controlled disease
– Weakness
– Tiredness
– Frequent urination
– Increased thirst
– Blurred vision
– Itchy skin
• Refer to a medical practitioner
© Author / Presentation Reference Slide 50
www.diabetes.org http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf
CONFIDENTIAL AND PROPRIETARY
Management Considerations for the Dental Patient with Diabetes
• Close collaboration with medical practitioner /
Adjustment of insulin or oral hypoglycemic medications
• Regular full periodontal assessments
• Consider antibiotics with surgical procedures
• Monitor blood glucose prior to and during treatment
• Have glucose sources available in case of a
hypoglycemic event
• Educate patients on potential oral complications
© Author / Presentation Reference Slide 51
www.diabetes.org
CONFIDENTIAL AND PROPRIETARY
Management Considerations for the Dental Patient with Diabetes
• Examinations
– Collaboration with medical practitioner
• Refer newly diagnosed patients with diabetes for oral assessment
• Medical history
– Full periodontal assessment
• Treatment considerations
– Respond well with good glycemic control
– Poor glycemic control results in
• Slow wound healing
• Possible need for systemic antibiotics
– Smoking cessation
© Author / Presentation Reference Slide 52
CONFIDENTIAL AND PROPRIETARY
Management Considerations for the Dental Patient with Diabetes
•Follow-up / Recall
– More frequent visits
•Homecare
–Plaque control is key
Brushing at least 2 x daily
Interdental cleaning
© Author / Presentation Reference Slide 53
CONFIDENTIAL AND PROPRIETARY
• Dentists have an opportunity and
responsibility to:
– Identify patients who are at risk for Diabetes
Mellitus (DM)
– Assist those with DM in achieving optimum
oral and total health
Dentist’s Role
CONFIDENTIAL AND PROPRIETARY
• Opportunity and responsibility to:
– Educate patients about the oral complications
of Diabetes Mellitus
– Promote proper oral health behaviors that
limit the risks of tooth loss, periodontal
disease, and oral soft tissue pathologies
Dentist’s Role
Taylor GW. Bi-directional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective. Ann
Periodontol. 2001;6:99-112.
CONFIDENTIAL AND PROPRIETARY
Glucometer in the Dental office
Blood glucose results are vital signs –
you may save a patient’s life!
www.diabetes.org
CONFIDENTIAL AND PROPRIETARY
Summary
• The number of people living with diabetes will increase
significantly in the future
• The complications associated with diabetes can be
directly linked to the level of glycemic control achieved
• Dental professionals have an important role to play in the
recognition, identification and management of the diabetic
patient
• Medical and dental professionals must work together to
achieve the best results for people with diabetes and the
community
© Author / Presentation Reference Slide 57
CONFIDENTIAL AND PROPRIETARY
Considerations for all your patients
• One effective option for preventing early gum disease
(gingivitis) is a triclosan/copolymer toothpaste, which
Colgate markets as Colgate Total®
• Colgate Total® is indicated to prevent and treat gingivitis and
plaque, and to help prevent caries.
• Colgate Total® is not indicated to prevent or treat serious gum
disease (periodontitis) or other diseases including Diabetes
Mellitus.
CONFIDENTIAL AND PROPRIETARY
Periodontal Disease at a Glance
Gingivitis Periodontitis
Cause Bacterial plaque / biofilm Bacterial plaque / biofilm
Signs Inflammation of the
gingiva: redness,
swelling, bleeding
Inflammation of the
periodontium: pocket
formation, attachment
loss, bone loss
Other • May/may not progress
into periodontitis
• Reversible
• Always preceded by
gingivitis
• Irreversible
CONFIDENTIAL AND PROPRIETARY
The Role of Plaque Control in Gum Health
Vast majority of research has
focused on this part of the
cascade
We need to focus our
efforts here….
CONFIDENTIAL AND PROPRIETARY
The Cochrane Collaboration
• International non-
profit organisation that
prepares, maintains, and
disseminates systematic
up-to-date reviews of
health care interventions
The Cochrane Collaboration. (http://www.cochrane.org/cochrane-reviews/about-cochrane-library)
CONFIDENTIAL AND PROPRIETARY
•Consists of over 28,000 dedicated people from over 100 countries.
•They work together to help healthcare providers, policy-makers, patients, and their advocates make well-informed decisions about health care
•The members of The Cochrane Collaboration are organized into groups, known as 'entities'
Background and Aims of The Cochrane Collaboration
CONFIDENTIAL AND PROPRIETARY
Cochrane Reviews are
now the
“gold standard” for
systematic reviews.
Background and Aims of The Cochrane Collaboration
CONFIDENTIAL AND PROPRIETARY 64
Evaluating Scientific Evidence
Bia
s
Stre
ng
h o
f
Evid
en
ce
CONFIDENTIAL AND PROPRIETARY
•The main work of The Cochrane
Collaboration is done by more than
fifty Cochrane Review Groups
•Methods Groups have been
established to develop and update
methodology
•The work of Cochrane Groups is
facilitated in various ways by the
work of Cochrane Centres around
the world.
•The consumer network help to
establish priorities and identify
outcomes relevant to patient
Organization of The Cochrane Collaboration
CONFIDENTIAL AND PROPRIETARY
66
0
10
20
30
40
50
60
Plaque PlaqueSeverity
Gingivitis BleedingGums
Calculus Caries
Perc
ent
Reducti
on v
s Regula
r Flu
ori
de T
ooth
past
e
Clinical Effects of Triclosan/Copolymer
Toothpaste
Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database Syst Rev. 2013 Dec 5;12:CD010514. doi: 10.1002/14651858.CD010514.pub2.
CONFIDENTIAL AND PROPRIETARY
Results •Plaque and Gingivitis:
– 22% reduction in plaque compared with control (1.70
vs 2.17; 20 studies, 2675 participants).
– 41% reduction in plaque severity compared with
control (0.22 vs 0.37; 13 studies, 1850 participants).
– 22% reduction in gingivitis compared with control
(0.95 vs 1.22; 20 studies, 2743 participants).
– 48% reduction in gingival bleeding compared with
control (0.14 vs 0.27; 15 studies, 1998 participants).
Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database Syst Rev. 2013 Dec 5;12:CD010514. doi: 10.1002/14651858.CD010514.pub2.
CONFIDENTIAL AND PROPRIETARY
Conclusions • This systematic review has shown that significant oral health
benefits can result from using a triclosan/copolymer fluoride
toothpaste when compared to the benefits of using a toothpaste
with fluoride alone (without triclosan/copolymer). There was a
22% reduction in plaque, a 22% reduction in gingivitis, a 48%
reduction in bleeding gums.
• There was insufficient evidence to show a difference between
either toothpaste in preventing periodontitis.
• There was no evidence of any harmful effects associated with the
use of triclosan/copolymer toothpastes in studies up to three
years in length.
Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database Syst Rev. 2013 Dec 5;12:CD010514. doi: 10.1002/14651858.CD010514.pub2.
CONFIDENTIAL AND PROPRIETARY
Summary
•The Cochrane Review of triclosan/copolymer
affirms the ingredient’s clinical benefit in
managing plaque, gingivitis, calculus, and caries.
•No side effects were noted in any of the studies
reviewed.
•Finally, this review reaffirms results reported in
previously authored systematic reviews1-3..
1.Gunsolley,,JC. J Am Dent Assoc. 2006. 2 Parakevas, S. Int J Dent Hyg. 2005. 3. Davies R et al. J Clin Periodontol.2004
CONFIDENTIAL AND PROPRIETARY
Triclosan Copolymer
copolymer forms a network trapping triclosan onto oral surfaces
Maintains anti-bacterial activity for up to 12 hours
Colgate Total® Mode of Action
1. Xu 2004
CONFIDENTIAL AND PROPRIETARY
Triclosan/copolymer dentifrice: plaque viability suppressed for 12 hours
after brushing as indicated by red color
Control (identical formulation except no triclosan/copolymer):
plaque rapidly gained viability as indicated by green color
0 hr 3 hrs 6 hrs 12 hrs
0 hr 3 hrs 6 hrs 12 hrs
Plaque Viability Study - Visual Results
CONFIDENTIAL AND PROPRIETARY
Before
Treatment
12 hours after
Colgate Total
CONFIDENTIAL AND PROPRIETARY
Before
treatment
12 hours after
Colgate Total
Top
vie
w
Cross-
sections
Top
vie
w
Cross-
sections
3D
projecti
ons
CONFIDENTIAL AND PROPRIETARY © Author / Presentation Reference Slide 74
Whole Mouth Antimicrobial Effects: Fine, et al. (2012)*
• A randomized, double-blind, crossover clinical study design was used to
assess the antibacterial effects of three commercially available
dentifrice formulations.
• Thirty five subjects met the inclusion/exclusion criteria and were
placed on a 4-week wash-out phase consisting in twice daily brushing
with the provided soft-bristle toothbrush and commercially-available
fluoride toothpaste.
• After the 4 weeks washout phase, subjects arrived at dental clinic 12
hours after brushing to provide baseline samples from 4 oral
microenvironments: teeth, saliva and scrapping from the cheeks and
tongue.
*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064.
CONFIDENTIAL AND PROPRIETARY © Author / Presentation Reference Slide 75
Whole Mouth Antimicrobial Effects: Fine, et al. (2012)*
• After baseline sample collection, subjects were (1) assigned their test
dentifrice according to a computer-generated randomization schedule,
(2) provided an overwrapped tube of their first-assigned toothpaste
and identical, new toothbrush, and (3) instructed to brush twice daily
with their assigned product for the next 13 days. On the morning of the
day 14, subjects reported to the dental clinic 12 hours after their
morning brushing for sample collection from the same oral
microenvironments harvested at baseline. Subjects left the clinic on
day 14 with instructions to start another 4 weeks washout phase, to be
followed by baseline sample collection, 13-day use of their second-
assigned toothpaste, and 12-hour, post brushing sample collection
pattern was followed for use of the third-assigned product by each of
the 35 subjects.
*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064.
CONFIDENTIAL AND PROPRIETARY
Whole Mouth Antimicrobial Effects: Fine, et al. (2012)*
*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064.
Triclosan/copolymer/fluoride
commercial toothpaste
Sodium Fluoride
Silica Toothpaste
Stannous fluoride/
hexamethasphosphate
commercial toothpaste
Plaque
Saliva, Cheeks, Teeth, Tongue
CONFIDENTIAL AND PROPRIETARY
Whole Mouth Antimicrobial Effects: Fine, et al. (2012)*
Conclusions
• Soft tissues can act as a reservoir for bacteria to recolonize teeth
• Dentifrice containing triclosan/copolymer demonstrated significant reductions in plaque at all 4 soft tissue sites and with all 6 micro-organisms compared with stannous fluoride or the sodium fluoride dentifrices.
*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064.
‡ Statistically significant reduction in cultivable anaerobic bacteria for Colgate Total ® compared with ordinary fluoride
toothpaste and stannous fluoride toothpaste
CONFIDENTIAL AND PROPRIETARY
Inhibits Bacterial Re-Growth* Results shown vs a non antibacterial toothpaste
75%
83%
83%
77%
*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064
CONFIDENTIAL AND PROPRIETARY
Clinical Case
Colgate Total® Toothpaste containing triclosan/copolymer* is the most clinically researched toothpaste.
*Colgate Total toothpaste is approved through the New Drug Application process to help prevent gingivitis. Not
approved for the prevention or treatment of serious gum disease or other diseases. "
* Colgate Total®, Colgate-Palmolive, New York, NY ** Colgate Total® is approved through the New Drug Application process to
help prevent cavities, gingivitis, and plaque
CONFIDENTIAL AND PROPRIETARY
Colgate Resources
• Colgateprofessional.com • Colgateoralhealthnetwork.com
© Author / Presentation Reference Slide 80
CONFIDENTIAL AND PROPRIETARY
Diabetes Educational Resources
American Diabetes Association: www.diabetes.org
American Dental Association: www.ada.org
Small Steps Big Rewards: www.ndep.nih.gov
Colgate Professional Website:
www.colgateprofessional.com
© Author / Presentation Reference Slide 81
CONFIDENTIAL AND PROPRIETARY
Thank you!