Impact of Bariatric Surgery on the Saliva of Patients with Morbid Obesity

Class 3 Obesity and Oral Health in Adults: A Scoping Review of the Challenges for Oral Healthcare Services

Background: Obesity is one of the most neglected public health problems affecting both developed and developing countries. The most clinically severe obesity (Class 3 obesity) has both clinical and service delivery implications on dental services. However, associations between Class 3 obesity and oral health are minimally explored in the literature and thus poorly understood. Aims: This scoping review aimed to explore the existing evidence on Class 3 obesity and oral health. Methods: A literature search was performed via Medline, Scopus, Google scholar and Embase research databases. Results: A total of 375 papers were sourced from the database search. Twenty seven full-text papers were included in the final literature review. Results revealed findings from both quantitative and qualitative studies. Papers included results pertaining to associations with dental disease, oral health and associated behaviours, oral health-related quality of life and the barriers experienced by adults with Class 3 obesity in accessing dental services. Conclusions: While mixed findings were identified, this scoping review reports associations between Class 3 obesity and poor oral health across various domains including clinical parameters and oral health related quality of life. The literature has also highlighted important barriers to dental care in those with the most severe Class 3 obesity. Based upon our findings, we have summarised current oral health management implications and directions for future research.

The changes on salivary flow rates, buffering capacity and chromogranin A levels in adults after bariatric surgery

OBJECTIVES

This study aimed to investigate changes in salivary flow rates, buffering capacity, and salivary chromogranin A (CHGA) levels in adults undergoing bariatric surgery (BS) compared with a non-obese control group.

MATERIALS AND METHODS

Salivary analyses were performed on 62 participants aged over 50 years, stratified into two groups matched for age and gender-individuals who had undergone bariatric surgery (BS) (n = 31) and a corresponding healthy control group (n = 31). Before saliva collection, participants completed a comprehensive 11-point visual numerical rating scale (NRS 0-10) xerostomia questionnaire, assessing subjective perceptions of two key aspects: dryness of the oral mucosa and resultant impact on oral functional ability. Three distinct saliva measurements were obtained: unstimulated whole saliva (UWS), stimulated whole saliva (SWS), and unstimulated upper labial saliva (ULS). The buffering capacity of unstimulated saliva was assessed using pH indicator strips, and concentrations of salivary Chromogranin A (CHGA) were quantified in stimulated saliva via enzyme-linked immunosorbent assay (ELISA).

RESULTS

After BS, more than 40% of BS group patients reported xerostomia, with 16.1% experiencing only mild symptoms without significant functional impact (p = 0.009). The prevalence of xerostomia and tongue dryness was higher in the BS group compared to the control group (p = 0.028 and p = 0.025, respectively). The comparative analysis unveiled no statistically significant differences in flow rates of unstimulated upper labial saliva (ULS), unstimulated whole saliva (UWS), and stimulated whole saliva (SWS) between the control group and patients who underwent bariatric surgery. However, in patients undergone BS with xerostomia, both ULS and UWS flow rates were significantly lower than in controls with xerostomia (p = 0.014 and p = 0.007, respectively). The buffering capacity was significantly lower in patients undergone BS than in controls (p = 0.009). No differences were found between groups regarding CHGA concentration and output values, nevertheless, higher values of CHGA concentrations were significantly correlated to lower flow rates.

CONCLUSION

According to the results, this study suggests that individuals undergoing BS may exhibit altered salivary buffering capacity and reduced unstimulated salivary flows in the presence of xerostomia. Additionally, the findings suggest that elevated concentration of salivary CHGA might be associated, in part, with salivary gland hypofunction.

CLINICAL RELEVANCE

The clinical significance of this study lies in highlighting the changes in salivary functions after BS. The identified salivary alterations might be attributed to adverse effects of BS such as vomiting, gastroesophageal reflux, and dehydration. Understanding these changes is crucial for healthcare professionals involved in the care of post-BS patients, as it sheds light on potential oral health challenges that may arise as a consequence of the surgical intervention. Monitoring and managing these salivary alterations can contribute to comprehensive patient care and enhance the overall postoperative experience for individuals undergoing BS.

Bypass gastroplasty impacts oral health, salivary inflammatory biomarkers, and microbiota: a controlled study

OBJECTIVES

Knowledge about the impact of gastroplasty on oral health and salivary biomarkers is limited. The aim was to prospectively evaluate oral health status, salivary inflammatory markers, and microbiota in patients undergoing gastroplasty compared with a control group undergoing a dietary program.

MATERIALS AND METHODS

Forty participants with obesity class II/III were included (20 individuals in each sex-matched group; 23-44 years). Dental status, salivary flow, buffering capacity, inflammatory cytokines, and uric acid were assessed. Salivary microbiological analysis (16S-rRNA sequencing) assessed the abundance of genus, species, and alpha diversity. Cluster analysis and mixed-model ANOVA were applied.

RESULTS

Oral health status, waist-to-hip ratio, and salivary alpha diversity were associated at baseline. A subtle improvement in food consumption markers was observed, although caries activity increased in both groups, and the gastroplasty group showed worse periodontal status after three months. IFNγ and IL10 levels decreased in the gastroplasty group at 3 months, while a decrease was observed in the control group at 6 months; IL6 decreased in both groups (p < 0.001). Salivary flow and buffering capacity did not change. Significant changes in Prevotella nigrescens and Porphyromonas endodontalis abundance were observed in both groups, while alpha diversity (Sobs, Chao1, Ace, Shannon, and Simpson) increased in the gastroplasty group.

CONCLUSIONS

Both interventions changed in different degrees the salivary inflammatory biomarkers and microbiota, but did not improve the periodontal status after 6 months.

CLINICAL RELEVANCE

Although the observed discrete improvement in dietary habits, caries activity increased with no clinical improvement in the periodontal status, emphasizing the need of oral health monitoring during obesity treatment.

Influence of Bariatric Surgery on Oral Microbiota: A Systematic Review

The study aims to systematically review the available literature to evaluate the changes in oral microbiota in patients after bariatric surgery (BS) and correlates these alterations in microorganisms with common oral manifestations. Relevant Electronic databases were systematically searched for indexed English literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed for framework designing, application, and reporting of the current systematic review. The focused PICO question was: "Is there any change in oral microbiota (O) of patients (P) who underwent BS (I) when compared with non-BS groups (C)?' Seven articles were selected for qualitative synthesis. On application of the National Institutes of Health (NIH) quality assessment tool, six studies were found to be of fair quality and one was of good quality. All the seven included studies evaluated the effect of BS on oral microbiota in humans. The outcomes of this review suggest that considerable changes take place in oral microbiota after BS which can be correlated with common oral manifestations. These changes are mainly due to the indirect effect of BS and may vary with the individuals. Due to variations in the included studies, it is difficult to proclaim any persistent pattern of oral microbiota found after BS.

Impact of bariatric surgery on oral health: a systematic review and meta-analysis

OBJECTIVE

To evaluate the impact of bariatric surgery (BS) on the oral health status of obese individuals.

MATERIAL AND METHODS

The search was performed on the Cochrane Library, Embase, Latin American and Caribbean Literature on Health Sciences (LILACS), LIVIVO, PubMed/Medline, Scopus, and Web of Science databases. Grey literature was also consulted through Google Scholar, OpenGrey, ProQuest, and MedRxiv. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tool. Pre- and post-surgical moments were compared through random effects meta-analysis. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) assessment tool was used to judge the certainty of evidence.

RESULTS

After searching the databases, 908 references were retrieved, with 30 articles selected for synthesis. When comparing the pre- and postoperative moments, there was no difference in the index of decayed, missing, or filled teeth. Furthermore, salivary flow and probing depth presented a slight increase. Post-surgery patients showed an increase (%) in tooth wear at the dentin level [MD = -6.23; IC95% = -8.45--4.01; I² = 0%].

CONCLUSION

Patients undergoing BS show no difference when considering the rate of caries or missing teeth and little to no effect was observed on salivary flow rates and periodontal probing depth. On the other hand, greater attention should be given to dentin wear in post-surgical patients of BS.

CLINICAL RELEVANCE

Patients undergoing BS should receive careful monitoring regarding oral health by doctors, dentists, and the entire multidisciplinary team involved before and after the surgical procedure.

Risk Factors for Dental Erosion After Bariatric Surgery: A Patient Survey

Introduction

Treatment of obesity by bariatric surgery has increased in recent years. Reported side effects that may predispose to dental erosion include reflux, vomiting, and an increased frequency of intake of food and drink.

Objective

The aim was to investigate long-term dietary behaviour and experiences related to symptoms of dental erosion at least 5 years after bariatric surgery.

Methods

An online questionnaire study was conducted amongst 250 patients who had undergone bariatric surgery at King Saud Medical City in Saudi Arabia 5 years ago or more. It comprised 36 questions on demographic data, dietary habits, general health, dental health, and oral symptoms. The data were analysed using Chi-square and sign tests (significance level P < .05).

Results

A significant increase in acidic reflux and vomiting was found after bariatric surgery and appeared to increase with time after surgery. Also, a significant association between presence of acidic reflux and symptoms of dental erosion was found. However, 68.5% reported improved overall well-being after surgery. The response rate was 21.6% (most were female, aged 30-59 years). Respondents were generally not advised to visit a dentist in connection with bariatric surgery.

Conclusions

This long-term cross-sectional study suggests a time-dependent, increasing occurrence of vomiting and acidic reflux after bariatric surgery. Vomiting and reflux became even more common after 5 to 10 years. A significant relationship emerged between a high frequency of acidic reflux and a high frequency of oral symptoms related to dental erosion. Daily occurrence of general symptoms related to dumping syndrome were reported by the majority. However, in a 5- to 10-year perspective, general symptoms related to dumping syndrome and symptoms from dental erosion did not seem to detract from the respondents’ overall satisfaction with daily living. Oral health problems might be reduced if patients who had bariatric surgery were referred to a dentist for prevention and monitoring.

Oral Health and Nutritional Characteristics of Adults With Morbid Obesity: A Multivariate Analysis

The relationship between oral health and nutritional aspects are complex, especially in individuals with chronic diseases and comorbidities, such as morbid obesity. Thus, the aim of the present study was to identify oral health and nutritional-related patterns in 113 individuals, aged 19–68 years (92 females), seeking treatment for morbid obesity. Sociodemographic variables and medical records were examined, in addition to the consumption of fruit, vegetables, candies, and processed foods. Measures of body mass index, neck, waist and hip, caries experience (DMFT index), Community Periodontal Index (CPI index), and salivary physicochemical aspects were gathered. Aspects of oral health-related quality of life and symptoms of dry mouth were evaluated by means of Oral Health Impact Profile (OHIP-14) and Xerostomia Inventory-XI questionnaires. K-means cluster analysis and, subsequently, comparisons between clusters (one-way ANOVA) were performed (α = 5%). Three clusters were generated: Cluster 1 (labeled “Young”; n = 77) was characterized by younger participants with higher BMI, who reported the use of distractors while eating, the smallest number of meals/day, and who consumed sweetened drinks and processed food the day before. Cluster 2 (labeled “Diabetic individuals”; n = 12) was characterized by older participants with the highest proportion of diabetic participants (100% were diabetic; 73% insulin users), lower BMI, higher DMFT index and OHIP-14 and xerostomia scores, and who reported having consumed fruit and vegetables the day before. Finally, Cluster 3 (labeled “Poor periodontal health”; n = 24) was characterized by participants with the worse periodontal condition (higher CPI), and lower salivary flow, pH, and buffer capacity. Cluster 1 and 2 were the groups that showed higher demand for nutritional and dietetic counseling, because of the poor eating behavior and higher serum glucose levels, respectively. On the other hand, Cluster 2 and 3 showed the higher demand for oral rehabilitation and dental treatment because of the loss of teeth and worse periodontal condition, respectively, besides the need for dietetic counseling. This sample of individuals with morbid obesity showed very unique oral-health and nutritional characteristics and special needs patterns that should be identified to adjust or change unhealthy habits, thus improving the assistance of this condition.

Salivary microbiome composition changes after bariatric surgery

Recent studies show that the salivary microbiome in subjects with obesity differ from those without obesity, but the mechanism of interaction between the salivary microbiome composition and body weight is unclear. Herein we investigate this relation by analyzing saliva samples from 35 adult patients with obesity undergoing bariatric surgery. Our aim was to describe salivary microbiome changes during body weight loss on an individual-specific level, and to elucidate the effect of bariatric surgery on the salivary microbiome which has not been studied before. Analysis of samples collected before and 1 day after surgery, as well as 3 and 12 months after surgery, showed that the salivary microbiome changed in all study participants, but these changes were heterogeneous. In the majority of participants proportions of Gemella species, Granulicatella elegans, Porphyromonas pasteri, Prevotella nanceiensis and Streptococcus oralis decreased, while Veillonella species, Megasphaera micronuciformis and Prevotella saliva increased. Nevertheless, we found participants deviating from this general trend which suggests that a variety of individual-specific factors influence the salivary microbiome composition more effectively than the body weight dynamics alone. The observed microbiome alternations could be related to dietary changes. Therefore, further studies should focus on association with altered taste preferences and potential oral health consequences.

Follow-up Study of Microflora Changes in Crevicular Gingival Fluid in Obese Subjects After Bariatric Surgery

The objective of our study was to investigate the effect of weight loss on the crevicular microflora following bariatric surgery. Crevicular fluid samples were taken from 57 subjects: 22 were in the normal control group; 18 in the obese control group; and 17 patients had had bariatric surgery, who underwent a repeat sampling 6 to 12 months after the operation. Crevicular fluid samples were analyzed by MALDI-TOF MS analysis. After surgery and weight loss, the mean germ count increased, albeit not significantly. Also, Candida albicans and non-albicans Candida species: C. dubliniensis, C. kefyr, and C. lusitaniae appeared after surgery (p < 0.05) in subjects where Neisseria was either absent throughout or eliminated after surgery. However, periodontitis did not develop during this time in our subjects.

Hyposalivation is prevalent in bariatric patients but improves after surgery

BACKGROUND

Obesity and type 2 diabetes can be associated with poor oral health. This can be because of hyposalivation leading to chronic oral inflammation (OI) and periodontal disease.

OBJECTIVE

To assess the prevalence of hyposalivation and OI in individuals undergoing Roux-en-Y gastric bypass (RYGB) and determine the relationship with metabolic and anthropometric parameters before and after RYGB.

SETTING

University hospital in Canada.

METHODS

This was a cross-sectional and prospective cohort study of 59 patients undergoing RYGB from September 2015 to December 2019. Anthropometric, biochemical, and oral measurements were taken before surgery and 1 and 6 months post RYGB. Oral parameters included salivary flow rate and neutrophil count as marker of OI.

RESULTS

Fifty-nine patients were enrolled with 29 completing this study. At baseline, the median age was 47 years and body mass index was 46.5 kg/m², 52 (88.1%) were female and 14 individuals (23.7%) had type 2 diabetes; 54.2% (n = 32) of patients had hyposalivation and 13.6% (n = 8) had high neutrophil count. Patients with hyposalivation had significantly higher fasting glucose (5.7 mmol/L) compared with those without hyposalivation (5.2 mmol/L) but no difference was found between high versus low neutrophil count. At 6 months post RYGB, all variables except oral neutrophil count significantly improved. Hyposalivation persisted in 7 (24%) individuals.

CONCLUSIONS

In our bariatric patients, more than half the patients had hyposalivation before RYGB and this was associated with higher fasting glucose. Hyposalivation improved post RYGB in parallel with improvements in metabolic parameters but there was no change in OI. Increased salivation may reduce the risk of periodontal disease.

Relationship between bariatric surgery and dental erosion: a systematic review

BACKGROUND

Bariatric surgery can have several oral repercussions, including tooth erosion due to decreased salivary flow associated with the action of acidic pH and behavioral modifications in the diet that lead to the dissolution of mineralized dental tissues.

OBJECTIVES

This systematic review aimed to evaluate whether bariatric surgery presented a greater risk of dental erosion.

SETTING

Dentistry School, Pernambuco University, Camaragibe, Pernambuco, Brazil.

METHODS

This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) and registered at the International Prospective Registry of Systematic Reviews (CRD42019124960). A search was performed in the PubMed/MEDLINE, Web of Science, and Cochrane Library databases using the following descriptors: "dental erosion OR tooth wear OR oral health OR dental wear OR tooth erosion OR salivary flow AND bariatric surgery OR gastrectomy OR obesity surgery".

RESULTS

The review included 553 articles (after exclusion of duplicates) submitted for title and abstract reading, of which 24 were selected for full text analysis. Five articles fulfilling the eligibility criteria were included in the qualitative and quantitative analysis review. Because of high heterogeneity of the studies, meta-analysis could not be performed.

CONCLUSIONS

Based on the review, we concluded that patients undergoing bariatric surgery had a higher incidence of dental erosion. All studies presented a high degree of dental erosion in patients submitted to bariatric surgery (P < .05).

Clinical periodontal conditions in individuals after bariatric surgery: a systematic review and meta-analysis

The aim of the present study was to perform a systematic review and meta-analysis to assess the influence of bariatric surgery on the clinical periodontal conditions in patients with obesity. This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered at the International Prospective Registry of Systematic Reviews (CRD42018099313). A search was conducted by 2 investigators in the PubMed/MEDLINE, Web of Science, and Cochrane Library databases for relevant articles published up to May 2018. The inclusion criteria were randomized controlled trials, prospective and retrospective studies, observational studies, longitudinal studies, and cohort studies with at least 3 months of follow-up. No language restrictions were imposed. The exclusion criteria were studies that did not evaluate or report the periodontal measurements, cross-sectional studies (without follow-up after surgery), studies that performed periodontal treatment, and those with insufficient periodontal data. The meta-analysis was based on the Mantel-Haenszel method and inverse variance. The quantitative analysis revealed no statistically significant differences with regard to bleeding on probing (P = .9; mean deviation: -.70; confidence interval = -11.43 to 10.04) or probing pocket depth (P = .41; mean deviation: -.46; confidence interval = -1.55 to .63) before and after intervention. Clinical attachment loss showed a statistically significant difference (P = .0002; mean deviation: .18; confidence interval = .07-.30). It can be concluded that bariatric surgery does not influence bleeding on probing or probing pocket depth, but leads to a worsening of clinical attachment loss.

Bariatric surgery as a risk factor in the development of dental caries: a systematic review

OBJECTIVES

Obesity is one of the most prevalent chronic pathologies in the world and has become a public health problem. At the present time, bariatric surgery (BS) is considered the best option and the only effective method of treatment, but it can occasionally result in a series of alterations at the oral level. This study aims to review the current literature to establish the possible association of patients who have undergone BS and a greater risk of dental caries.

STUDY DESIGN

This study is a systematic review of the literature.

METHODS

A search was made in the database of Medline (via PubMed), over the last 10 years, using the keywords 'bariatric surgery' OR 'gastrectomy' OR 'obesity surgery,' combined independently with the terms 'saliva' and 'dental caries' by means of the connector 'AND.' The criteria used were those described in the PRISMA® Declaration for performing systematic reviews. Inclusion criteria and study selection: (a) studies done with humans; (b) articles published in English and Spanish; (c) series of cases; and (d) clinical trials. The risk of bias was assessed independently by two authors. In both data extraction and risk of bias assessment, disagreements were resolved through discussion with a third author.

RESULTS

Two independent reviewers read the titles and summaries of the 79 articles found. Finally, nine of them were included in the study. In the various articles, the parameters that had clinical relevance to the risk of dental caries were evaluated.

CONCLUSIONS

Within the limitations of this study, it is plausible to think that patients who have undergone BS have a greater risk of dental caries. The oral complications associated with BS could be prevented or minimized by including in the multidisciplinary treatment of these patients a team of odontologists who would be responsible for prevention and oral assessment.