|Year : 2021 | Volume
| Issue : 1 | Page : 5-10
Association between oral health and alcoholic liver disease - A cross-sectional analytical study
Sreekanth Bose, R Yashoda, Manjunath P Puranik
Department of Public Health Dentistry, Government Dental College and Research Institute, Victoria Hospital Campus, Bengaluru, Karnataka, India
|Date of Submission||08-Feb-2020|
|Date of Decision||11-May-2020|
|Date of Acceptance||18-Sep-2020|
|Date of Web Publication||09-Mar-2021|
Department of Public Health Dentistry, Government Dental College and Research Institute, Victoria Hospital Campus, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Alcoholic liver disease (ALD) is a condition with compromised immunity and dental foci can act as a potential source of infection.
Aims and Objectives: This study was conducted to assess and compare the oral health among patients with alcoholic liver disease with healthy individuals and to determine an association between oral health and alcoholic liver disease.
Materials and Methods: A cross-sectional analytical study assessed 100 participants with ALD and 100 age and gender matched subjects. Demographic details, laboratory investigation results, medical, dental & family history, oral hygiene practices, information about tobacco and alcohol habits were collected. Caries, periodontal disease, oral mucosal lesions and intervention urgency were assessed using WHO (2013) criteria. Descriptive and inferential statistics were used. A p <0.05 was considered as significant.
Results: Mean age of participants in ALD and control groups were 43.71 ± 6.79 and 42.82 ± 6.23 years respectively. Caries experience (DMFT) was higher in ALD group (11.55±12.29) than comparison group (8.2±8.89) (p=0.001) giving an association with age of onset of alcohol abuse. Periodontal health was poor among ALD group with more teeth with gingival bleeding, shallow or deep pockets and loss of attachment giving an association between age of onset, duration of disease since diagnosed and MELD score. Among ALD group 7% had leukoplakia. Association was found between oral mucosal lesion and duration of disease since diagnosed and MELD score.
Conclusion: Oral health was poor among ALD group than comparison group. Dental caries was associated with alcohol abuse and oral mucosal lesion was associated with alcoholic liver disease whereas periodontal disease was associated with alcohol abuse and alcoholic liver disease.
Keywords: Alcoholic liver disease, dental caries, oral health, oral mucosal lesions, periodontal disease
|How to cite this article:|
Bose S, Yashoda R, Puranik MP. Association between oral health and alcoholic liver disease - A cross-sectional analytical study. J Dent Def Sect. 2021;15:5-10
|How to cite this URL:|
Bose S, Yashoda R, Puranik MP. Association between oral health and alcoholic liver disease - A cross-sectional analytical study. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:5-10. Available from: http://www.journaldds.org/text.asp?2021/15/1/5/310962
| Introduction|| |
Liver is the largest organ in human body with a wide range of functions including detoxification of various metabolites, protein synthesis, and production of biochemicals necessary for digestion. It is located in the right upper quadrant of the abdomen, below the diaphragm. The liver is a vital organ and supports almost every other organ in the body. Liver is also prone to many diseases because of its strategic location and multidimensional functions. The liver is, in many ways, the reflection of a person's health and should play a central role in worldwide public health policies.
According to WHO, about 46% of global diseases and 59% of the mortality is because of chronic diseases and almost 35 million people in the world die of chronic diseases. Current, but probably undervalued, worldwide estimations show that 844 million people have chronic liver disease (CLD), with a mortality rate of 2 million deaths per year. This can be compared with other major public health problems related to chronic diseases such as diabetes (422 million, 1.6 million deaths), pulmonary (650 million, 6.17 million deaths), and cardiovascular diseases (540 million, 17.7 million deaths).
CLDs represent a major world public health problem. It occurs throughout the world irrespective of age, sex, region, or race. Alcohol abuse is a leading cause of morbidity and mortality throughout the world by affecting normal anatomy and physiology of liver. Cirrhosis is an end result of a variety of liver diseases characterized by fibrosis and architectural distortion of the liver with the formation of regenerative nodules and can have varied clinical manifestations and complications. Liver disease represents 9.5% of alcohol-related disability-adjusted life year's worldwide, while individual rates vary in different regions. However, unlike other chronic diseases, a large proportion of alcoholic liver disease (ALD) can be cured, prevented, or treated.
The increasing use of alcohol and its drink-related problems has recently emerged as a major public health concern, and it is emerging as the commonest cause of CLD in India. Data from different Indian states indicate that 35% to 65% of all current drinkers meet criteria for hazardous alcohol use. Hypothetically, extensive alcohol consumption may affect oral health in several ways: In the first place, a direct effect, for example, in case of caries due to alcohol-related xerostomia; secondly, an indirect effect ascribed to changes in dental health behavior. This association can be caused by specific changes in behavior owing to the frequent state of intoxication, irrespective of changes in social situation, or may be explained by altered dental health behavior due to social situation, which in many cases of alcoholism is the outcome of a social come down. Finally, the social situation itself may have a more direct course of action, for instance, by affecting the ability of paying for expensive dental treatment.
Analogous mechanisms of tissue destruction have been reported for both diseases. ALD patients as a consequence of liver dysfunction have elevated levels of serum cytokines. These can initiate the destructive process of periodontal disease probably through enhancement of collagenase and metalloproteinase activity. Bacterial infections are frequent complications in patients with cirrhosis, especially in alcoholics. Increased susceptibility to infections may be related to compromised function of the immune system in such patients. A potential source of infection may be dental foci, which may lead to bacteremia and eventually to death.
Studies among ALD patients observed a higher prevalence of oral health problems such as caries,, greater bone loss and periodontal destruction, and high frequency of oral mucosal lesions. However, the evidence regarding the association between oral health conditions and ALD is scarce. On the contrary, a few studies have also suggested the influence of periodontitis on the clinical course of liver cirrhosis.
Hence, this study was conducted with an aim to evaluate the association between oral health and ALD among patients admitted to super specialty government hospitals in Bangalore city. The objectives of the study were to assess and compare the oral health among patients with ALD with healthy individuals and to determine an association between oral health and ALD. The null hypothesize was that there is no association between oral health and severity of ALD.
| Methodology|| |
A cross-sectional analytical study was conducted to evaluate the association between oral health and ALD among patients admitted to major government hospitals in Bangalore city from January 2017 to July 2018. ALD patients admitted in the Internal Medicine department ward (inpatients) from two government hospitals in Bangalore were taken as study subjects and age- and gender-matched patient attendees were taken as a comparison group.
The periodontal disease prevalence was used to calculate sample size which was found to be 90% in the pilot study.
The sample size was estimated using the formula:
Statistical power of 80%
95% confidence interval
10% margin of error (E)
α = 0.05
Design Effect (D) = 1.5
Zα/2 = 1.96
Prevalence (P) =0.9
The sample size was calculated as 64 and rounded to 100.
Institutional Ethical Committee and Review Board (GDCRI/ACM (2)/PG/PHD/5/2016-2017, dtd: May 29, 2017) approved the study protocol, and all participants signed an informed consent form. A structured pro forma was designed to collect the data. It consisted of two parts: The first part included participant's demographic profile, socioeconomic status (Modified Kuppuswamy scale), oral hygiene practices, and information regarding tobacco and alcohol abuse.
Laboratory investigation results of bilirubin, creatinine, and INR were used to calculate the model for end-stage liver disease (MELD).
It was calculated using the formula: MELD = 3.78× [serum bilirubin (mg/dL)] +11.2× [INR] + 9.57× [serum creatinine (mg/dL)] +6.43
Model for end-stage liver disease indicate the severity of alcoholic liver disease
Inpatients diagnosed with ALD were the inclusion criteria for the ALD group while age- and gender-matched patient attendees were included in the control group. Subjects with hepatic encephalopathy, exhibiting withdrawal symptoms, conditions that make an assessment of oral health status difficult such as dyspnea, intubated patients, unconscious patients were excluded from the study. Subjects with a history of ALD were excluded from the control group.
The study was carried out by a single trained and calibrated investigator in male and female wards of the department of internal medicine. Demographic data and other information were collected from the participants through interview. Participants were either on their bed or in a bedside chair, and examination was done under artificial light.
The results were analyzed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA). Student t-test, Chi-square test, and logistic regression analysis were performed. Statistical significance was considered at P < 0.05 (95% confidence interval was taken).
| Results|| |
Data were collected from 200 participants. The mean age of the ALD group was 43.71 ± 6.79 and that of the comparison group was 42.82 ± 6.23. Most of the study participants belonged to the upper-lower social class and were males.
More than ninety percentage of the participants in the ALD and comparison group were using toothbrush for cleaning the teeth. The use of smoking and smokeless tobacco was similar between the groups [Figure 1] and [Figure 2].
|Figure 1: Distribution of the study participants according to smoking status|
Click here to view
|Figure 2: Distribution of the study participants according to tobacco chewing status|
Click here to view
The mean caries experience and periodontal status among study participants are presented in [Table 1]. Mean decayed, missing, and filled teeth (DMFT) score among ALD and comparison group were 11.55 ± 12.29 and 8.2 ± 8.89, respectively. The difference was statistically significant (P = 0.001). The mean number of periodontally healthy teeth present was significantly lower among ALD group (5.45 ± 4.21) than the comparison group (10.14 ± 4.03) (P = 0.008). The distribution of the study participants according to caries experience and loss of attachment is given is [Table 2].
|Table 1: Mean caries experience and periodontal status among study participants|
Click here to view
|Table 2: Mean caries experience and loss of attachment among study participants|
Click here to view
In the present study, among the ALD group, 18 (18%) participants had ulceration; seven (7%) participants had leukoplakia; six (6%) participants had candidiasis, and three (3%) participants had abscess. Among the comparison group, five (5%) participants had ulceration; two (2%) had candidiasis and one (1%) participant had abscess.
Logistic regression analysis between alcohol habit, ALD, and oral health is presented in [Table 3]. Among the ALD group, participants with age of initiation of habit below 18 years were significantly more likely to have DMFT score more than 10 and loss of attachment compared to participants with age of initiation of habit 18 years or above and the association was weak. Participants with duration of disease since diagnosed more than 3 years and MELD score more than 40 were significantly more likely to have periodontitis and oral mucosal lesions compared to others with an observed moderate association.
|Table 3: Logistic regression analysis between alcohol habit, Alcoholic liver disease and oral health|
Click here to view
| Discussion|| |
ALD may well represent the oldest form of liver injury known to humankind. Evidence suggests that fermented beverages existed at least as early as the Neolithic period, and liver disease related to it almost as long. Alcohol remains a major cause of liver disease worldwide. It encompasses a spectrum of injury, ranging from simple steatosis to frank cirrhosis.
Age is one of the important demographic parameters in ALD. The prevalence of ALD is low among the young but increases considerably in middle age, reaches a peak in the 45–54 years. Hence the chance of developing CLD increases with age in alcohol abusers. In our study, most of the participants were above 35 years of age, with majority coming under the age group of 45–54 years in the ALD group. This is similar to previous studies.,,,,,,,, The mean age was 43.71 ± 6.79 years which is similar to a study done by Barak et al.
Gender differences in alcohol consumption are influenced by culture. India is a country with women having a culture of abstinence regarding alcohol. The abuse of alcohol is more common among males compared to females. Majority of the previous literature shows that men were consistently more likely than women to be affected by ALD.,,,,,,,,,,
In this study, almost all the participants were males. Females were only 2% of the study participants, which is similar to a study done in India and contrasting with a study done in Israel where an equal number of the participants were females.
Studies in literature have reported the influence of socio-demographic factors on the occurrence of ALD.,, Low socioeconomic status has been cited as a contributor in the development of habit of alcoholic abuse. In the current study majority of study participants in ALD belonged to lower and upper lower class.
Dental caries, otherwise known as tooth decay, is one of the most prevalent chronic diseases of people worldwide; individuals are susceptible to this disease throughout their lifetime. A high prevalence of caries is observed in many systemic conditions. In the present study, 90% of participants in the ALD group had caries experience. This finding was similar to previous studies.,,
DMFT score among patients with ALD was found to be 11.55 ± 12.29 which was lesser compared to a study conducted in Brazil (18.9 ± 14.35). The mean DMFT score of the ALD group was higher compared with the comparison group when DMFT score and its components were significantly higher among the ALD group, which was consistent with previous literature., The mean number of filled (F) teeth was very less (0.26 ± 0.71) among the ALD group compared to the other group (1.48 ± 1.8). This reflects the inadequate utilization of dental services among the alcohol liver disease group which could be due to compromised disease condition. Patients with ALD tend to give more importance to general health than oral health. This might be another reason for the neglect.
Logistic regression analysis showed that participants with age of initiation of habit below 18 years were significantly more likely to have DMFT score more than 10 compared to participants with age of initiation of habit 18 years or above. The analysis was not significant between DMFT and duration since diagnosed and DMFT and MELD score. Hence, it is interpreted that caries is associated with the habit of alcoholic abuse rather than ALD. This higher chance of occurrence of dental caries among the ALD group might be due to xerostomia developed by regular alcoholic abuse.
Periodontal disease is a common chronic disorder, with an estimated prevalence of 90% in adults. Patients with ALD have weak immunity and are prone to infections. Periodontitis because of its multiplicity of bacterial species and increased number of colonies can act as a potential source of infection in them. Approximately 400 species have been detected in the gingival sulcus, among them are Porphyromonas gingivalis and Tannerella forsythia, which are widely regarded as major pathogens in periodontitis.,
The total number of teeth and healthy teeth was significantly less among the ALD group. The INR which is an indicator of bleeding was elevated in the ALD group. Significantly more number of teeth were presenting with gingival bleeding which is similar to previous studies., Teeth with shallow and deep pockets were also more among the ALD group. Studies conducted in various parts of the world also showed a higher prevalence of periodontal disease among patients with ALD,,,,,, as reported in the current research.
Periodontitis showed an association with habit of alcoholic abuse and ALD. The production of pro-inflammatory molecules such as interleukin (IL)-12/23, tumor necrosis factor-alpha, and IL-1 is present in patients with cirrhosis due to liver dysfunction. These may lead to the recruitment of activated neutrophils which promote the progression of periodontal disease. On the other hand, the periodontal pathogens are Gram-negative bacteria with cell walls formed of peptidoglycans and lipopolysaccharides. Periodontal tissues might produce inflammatory cytokines and chemokines in response to these endotoxins. These pro-inflammatory cytokines are involved in the progression of cirrhosis.,, Hence, there might be a bi-directional relationship between ALD and periodontitis.
Among the ALD group, ulceration was most prevalent, followed by leukoplakia, candidiasis, and abscess. This is consistent with two studies conducted in Finland, and in contrast with a study done in Brazil, which showed less prevalence (13%). Participants with duration of diagnosed disease more than 3 years and MELD score more than 40 were significantly more likely to have oral mucosal lesions compared with their counterparts. This explains that ALD has a role in the development of oral mucosal lesions. ALD will lead to immunodeficiencies predisposing to infections, coagulation disorders, hormonal imbalance, and malnutrition which might be the reason for changes in oral mucosa.
To the best of our knowledge, this is the second study in India examining oral health among ALD patients. The strength of this comparative analytical study is that it evaluated the association between variables such as caries status, periodontal status, and oral mucosal lesions with alcohol abuse habit and severity of ALD.
The study was conducted in Government hospitals. The participants were from lower socioeconomic strata of society only. This will limit interpretations and the possibilities of generalization. The cross-sectional nature of the study will restrict to formulate a causal relationship between ALD and oral health. Information regarding oral hygiene practices, tobacco, and alcohol habit are obtained from interview. Hence the chance of social desirability bias can't be eliminated. Tobacco habit is a possible confounder and might have influenced the results of this research.
| Conclusion|| |
Patients with ALD are immune compromised having a higher chance of infections. Oral diseases can act as a focus of infection which can be life threatening. Participants with ALD had a higher prevalence of caries experience, periodontal diseases, and oral mucosal lesions compared with healthy individuals. There was an association between dental caries and age of initiation of alcoholic abuse habit. Chronic generalized periodontitis was associated with age of initiation of alcoholic abuse habit, duration of alcohol habit, and MELD score. Oral mucosal lesion had an associated with duration of alcohol habit and MELD score.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Everhart JE, Ruhl CE. Burden of digestive diseases in the United States Part III: Liver, biliary tract, and pancreas. Gastroenterology 2009;136:1134-44.
Byass P. The global burden of liver disease: A challenge for methods and for public health. BMC Med 2014;12:159.
Murray CJ, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Geneva, Switzerland: World Health Organization; 1996.
Marcellin P, Kutala BK. Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int 2018;38:2-6.
Bommer C, Heesemann E, Sagalova V, Manne-Goehler J, Atun R, Bärnighausen T, et al
. The global economic burden of diabetes in adults aged 20-79 years: A cost-of-illness study. Lancet Diabetes Endocrinol 2017;5:423-30.
Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: A 2012 update. Prev Chronic Dis 2014;11:E62.
GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545-602.
Murray CJ, Lopez AD. Evidence-based health policy–lessons from the Global Burden of Disease Study. Science 1996;274:740-3.
Lemoine M, Thursz M, Njie R, Dusheiko G. Forgotten, not neglected: Viral hepatitis in resource-limited settings, recall for action. Liver Int 2014;34:12-5.
Prasad R. Alcohol use on the rise in India. Lancet 2009;373:17-8.
Mashberg A, Boffetta P, Winkelman R, Garfinkel L. Tobacco smoking, alcohol drinking, and cancer of the oral cavity and oropharynx among U. S. veterans. Cancer 1993;72:1369-75.
Walsh K, Alexander G. Alcoholic liver disease. Postgrad Med J 2000;76:280-6.
Khairnar MR, Wadgave U, Khairnar SM. Effect of alcoholism on oral health: A review. J Alcohol Drug Depend 2017;5:266.
Pitiphat W, Merchant AT, Rimm EB, Joshipura KJ. Alcohol consumption increases periodontitis risk. J Dent Res 2003;82:509-13.
Mishra D, Singh HP. Kuppuswamy's socioeconomic status scale – A revision. Indian J Pediatr 2003;70:273-4.
Kamath PS, Kim WR. The model for end-stage liver disease (MELD). J Clin Exp Hepatol 2007;45:797-805.
Mann RE, Smart RG, Govoni R. The epidemiology of alcoholic liver disease. Alcohol Res Health 2003;27:209-19.
Panov V, Krasteva A. Oral health in patients with liver diseases. J IMAB 2011;17:140-2.
Lins L, Bittencourt PL, Evangelista MA, Lins R, Codes L, Cavalcanti AR, et al
. Oral health profile of cirrhotic patients awaiting liver transplantation in the Brazilian Northeast. Transplant Proc 2011;43:1319-21.
Guggenheimer J, Eghtesad B, Close JM, Shay C, Fung JJ. Dental health status of liver transplant candidates. Liver Transpl 2007;13:280-6.
Silva Santos PS, Fernandes KS, Gallottini MH. Assessment and management of oral health in liver transplant candidates. J Appl Oral Sci 2012;20:241-5.
Helenius-Hietala J, Meurman JH, Höckerstedt K, Lindqvist C, Isoniemi H. Effect of the aetiology and severity of liver disease on oral health and dental treatment prior to transplantation. Transpl Int 2012;25:158-65.
Novacek G, Plachetzky U, Pötzi R, Lentner S, Slavicek R, Gangl A, et al
. Dental and periodontal disease in patients with cirrhosis–role of etiology of liver disease. J Hepatol 1995;22:576-82.
Aberg F, Helenius-Hietala J, Meurman J, Isoniemi H. Association between dental infections and the clinical course of chronic liver disease. Hepatol Res 2014;44:349-53.
Oettinger-Barak O, Barak S, Machtei EE, Ardekian L, Baruch Y, Peled M. Periodontal changes in liver cirrhosis and post-transplantation patients. I: Clinical findings. J Periodontol 2001;72:1236-40.
Sandler HC, Stahl SS. Prevalence of periodontal disease in a hospitalized population. J Dent Res 1960;39:439-49.
Jiménez-Pinzón A, Segura-Egea JJ, Poyato-Ferrera M, Velasco-Ortega E, Ríos-Santos JV. Prevalence of apical periodontitis and frequency of root-filled teeth in an adult Spanish population. Int Endod J 2004;37:167-73.
Movin S. Relationship between periodontal disease and cirrhosis of the liver in humans. J Clin Periodontol 1981;8:450-8.
Helenius-Hietala J, Ruokonen H, Grönroos L, Rissanen H, Vehkalahti MM, Suominen L, et al
. Oral mucosal health in liver transplant recipients and controls. Liver Transpl 2014;20:72-80.
Oettinger-Barak O, Machtei EE, Barak S, Baruch Y, Ardekian L, Peled M. Periodontal changes in liver cirrhosis and post-transplantation patients. II: Radiographic findings:. J Periodontol 2002;73:313-6.
Raghava KV, Shivananda H, Mundinamane D, Boloor V, Thomas B. Evaluation of periodontal status in alcoholic liver cirrhosis patients: A comparative study. J Contemp Dent Pract 2013;14:179-82.
Anand AC, Pardal PK, Sachdev VP. Dental caries and periodontal disorders in chronic liver disease. Med J Armed Forces India 2001;57:26-30.
Hemmingsson T, Lundberg I, Diderichsen F, Allebeck P. Explanations of social class differences in alcoholism among young men. Soc Sci Med 1998;47:1399-405.
Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369:51-9.
Amaral Cda S, Luiz RR, Leão AT. The relationship between alcohol dependence and periodontal disease. J Periodontol 2008;79:993-8.
Furusho H, Miyauchi M, Hyogo H, Inubushi T, Ao M, Ouhara K, et al
. Dental infection of Porphyromonas gingivalis
exacerbates high fat diet-induced steatohepatitis in mice. J Gastroenterol 2013;48:1259-70.
Grønkjær LL. Periodontal disease and liver cirrhosis: A systematic review. SAGE Open Med 2015;3:11-21.
Jaiswal G, Deo V, Bhongade M, Jaiswal S. Serum alkaline phosphatase: A potential marker in the progression of periodontal disease in cirrhosis patients. Quintessence Int 2011;42:345-8.
Madianos PN, Bobetsis YA, Kinane DF. Generation of inflammatory stimuli: How bacteria set up inflammatory responses in the gingiva. J Clin Periodontol 2005;32 Suppl 6:57-71.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]