ORAL HEALTH PROMOTION IN PATIENTS WITH MORBID OBESITY AFTER GASTROPLASTY: A RANDOMIZED CLINICAL TRIAL

EFFECT OF AN ORAL HEALTH PROMOTION PROGRAM ON GASTROPLASTY PATIENTS: A RANDOMIZED CLINICAL TRIAL

BACKGROUND

Bariatric surgery can cause oral health problems in individuals, such as an increase in dental caries, periodontal diseases and dental erosion, which can be avoided if oral health promotion actions are implemented.

AIMS

To assess the impact of an oral health promotion program implemented among gastroplasty patients.

METHODS

This randomized clinical trial involved 208 patients undergoing gastroplasty; they were divided into two groups: Intervention Group, with participation in the Oral Health Promotion Program for Bariatric Patients, or Control Group. Assessments were carried out preoperatively, and six and 12 months postoperatively. The oral conditions assessed were: dental caries, periodontal diseases, tooth wear, dental plaque, and salivary flow. Sociodemographic information was obtained through application of structured questionnaires. For data analysis, the Chi-Square, Fisher's Exact, and Mann-Whitney tests were performed - α=5%.

RESULTS

Patients in the Intervention Group, when compared to those in the Control Group, presented: fewer changes in enamel (6M: p<0.0001; 12M: p=0.001), in dentin (6M: p<0.0001; 12M: p<0.0001), moderate tooth wear (6M=0.002; 12M=0.005), gingival bleeding (6M: p<0.0001), dental calculus (6M=0.002; 12M: p=0.03), periodontal pocket 4-5 mm (6M=0.001; 12M: p=<0.0001); greater reduction in the bacterial plaque index (6M: p<0.0001; 12M: p<0.0001), and increased salivary flow (6M: p=0.019).

CONCLUSIONS

The oral health promotion program had a positive impact on the prevention and control of the main problems to the oral health of the gastroplasty patients.

Periodontal Therapy in Bariatric Surgery Patients with Periodontitis: Randomized Control Clinical Trial

Background: Bariatric surgery (BS) patients may experience the progression of periodontitis during recovery. We aimed to determine whether non-surgical periodontal therapy before BS improves the periodontal and systemic health parameters after the surgery. Methods: BS candidates with periodontitis were randomized into the test (TG) and control group (CG). One month before BS (pre-BS), patients in the TG (n = 15) received non-surgical periodontal therapy, while patients in the CG (n = 15) received only mechanical plaque removal. Patients were re-examined 3 and 6 months after BS. Differences between the TG and CG in clinical periodontal parameters, systemic health-related serum biomarkers, parameters of obesity, and prevalence of obesity-related diseases were evaluated. Results: From the 30 included patients, 26 were re-examined at 3 months and 20 patients at 6 months. Periodontal parameters bleeding on probing (p = 0.015), periodontal pocket dept (PPD, p = 0.0015), % PPD > 4 mm (p < 0.001), and full-mouth plaque levels (p = 0.002) were lower in the TG than in the CG at 6 months after BS. There is a general improvement in systemic health after BS without significant differences (p > 0.05) between the TG and CG at the 6-month follow-up. The TG shows a tendency for improvement in metabolic syndrome components at the 6-month follow-up compared to pre-BS (p < 0.05). Conclusions: Non-surgical periodontal therapy in periodontitis patients before the BS may improve periodontal health 3 and 6 months after the surgery. The possible benefits of periodontal therapy on the overall health of BS patients should be further explored.

Impact of gastroplasty on salivary characteristics, dental health status and oral sensory aspects: a controlled clinical study

BACKGROUND

Saliva is a non-invasive source of biomarkers useful in the study of different pathophysiological conditions. The qualitative and quantitative study of saliva, as well as the assessment of oral health, can be particularly useful for a better understanding of obesity due to its importance in the food oral perception and ingestion.

OBJECTIVES

To evaluate the effect of treatment of morbid obesity (dietary counselling versus gastroplasty) on salivary characteristics, oral sensory perception and dental health in a controlled study.

METHODS

73 adults (60 females; 19-59 years) with morbid obesity were divided in: Control group (CG; n=34) followed-up during a 6-months dietary program, and Gastroplasty group (GG; n=39) evaluated immediately before, 3, and 6 months after gastroplasty. Dietary habits, Oral Health Impact Profile and xerostomia complaints were investigated by interview. The clinical examination included anthropometric and caries experience evaluation. Salivary flow rate, buffering capacity, total protein and alpha-amylase levels, and sensitivity for the 4 basic tastes were assessed. Two-way mixed model and sign test were applied.

RESULTS

Physical and clinical aspects did not differ between groups in the beginning of the study, and GG showed a rapid weight loss after surgery (p<0.001). An improvement in most of the dietary aspects was observed, especially in the GG. A worsening in the dental health status was observed over time in both groups, with an increase in the number of filled and decayed teeth. CG showed a better oral health-related quality of life, while xerostomia complains increased in GG after gastroplasty. Salivary flow rate remained stable in both groups, but a decrease in buffering capacity, total protein, and alpha-amylase activity was observed in GG after 6-months; taste sensitivity increased from baseline to 6-months in GG (p<0.05).

CONCLUSION

After 6-months of follow-up, patients undergoing gastroplasty presented an improvement in dietary habits and taste sensitivity. However, changes in saliva composition and a worsening in dental health status and xerostomia complaints were also observed.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

The effect of bariatric surgery on periodontal health: systematic review and meta-analyses

INTRODUCTION

We aimed to determine whether periodontal health deteriorates after bariatric surgery (BS).

METHODS

A search was performed in Medline and Embase, for prospective cohort studies with data on change in periodontal parameters after BS. Meta-analysis was performed with available data.

RESULTS

The results of 4 included studies consistently show significant (p < 0.05) worsening of bleeding on probing (4.21% (95% CI: 0.32, 8.11)), clinical attachment loss (0.16 mm (95% CI: 0.05, 0.27)), periodontal pocket depth (PPD) (0.14 mm (95% CI: 0.06, 0.23)) and percentage of PPD 4-5 mm: 1.72% (95% CI: 0.11, 3.34) 6 months after BS, but no change after 12 months.

CONCLUSIONS

BS may have a transient negative effect on periodontal health.

Oral Health Implications of Bariatric Surgery in Morbidly Obese Patients: An Integrative Review

BACKGROUND

To identify the implications of bariatric surgery on the oral health of patients with morbid obesity.

METHODS

Two reviewers independently performed a search of the electronic databases: MedLine, PubMed, SciELO, LILACS, and Scopus, for clinical trials in humans and cohort studies. The search strategy used was Bariatric Surgery and Oral Health or Mouth Disease and Humans and Periodontitis. A total of 26 articles were obtained, and after title screening and full reading, 8 articles were included in this review.

RESULTS

Increased food intake at shorter intervals and increased frequency of regurgitation in these patients were associated with the increased development of dental caries, dental erosion, and increased salivary flow rate.

CONCLUSION

Intense oral control is recommended for the prevention and early treatment of these conditions and to avoid nonsystemic effects in these patients.

INCISIONAL HERNIOPLASTY TECHNIQUES: ANALYSIS AFTER OPEN BARIATRIC SURGERY

BACKGROUND

Rives-Stoppa retromuscular technique: A) polypropylene mesh fixed on the posterior rectus sheath; B) rectus abdominal muscle; C) anterior rectus sheath being sutured. The best technique for incisional hernioplasty has not been established yet. One of the difficulties to compare these techniques is heterogeneity in the profile of the patients evaluated.

AIM

To analyze the results of three techniques for incisional hernioplasty after open bariatric surgery.

METHOD

Patients who underwent incisional hernioplasty were divided into three groups: onlay technique, simple suture and retromuscular technique. Results and quality of life after repair using Carolina's Comfort Scale were evaluated through analysis of medical records, telephone contact and elective appointments.

RESULTS

363 surgical reports were analyzed and 263 were included: onlay technique (n=89), simple suture (n=100), retromuscular technique (n=74). The epidemiological profile of patients was similar between groups. The onlay technique showed higher seroma rates (28.89%) and used a surgical drain more frequently (55.56%). The simple suture technique required longer hospital stay (2.86 days). The quality of life score was worse for the retromuscular technique (8.43) in relation to the onlay technique (4.7) and the simple suture (2.34), especially because of complaints of chronic pain. There was no difference in short-term recurrence.

CONCLUSION

The retromuscular technique showed a worse quality of life than the other techniques in a homogeneous group of patients. The three groups showed no difference in terms of short-term hernia recurrence.

Poor Oral Hygiene and High Levels of Inflammatory Cytokines in Saliva Predict the Risk of Overweight and Obesity

The study aimed to determine if oral hygiene influences not only oral health but also potentially metabolic disorders such as overweight or obesity. Participants were 94 patients: 40 with increased body mass and 54 with normal body mass. The methods included dental examination, a questionnaire concerning hygienic habits and an assessment of selected salivary inflammatory markers. The new parameter named “cleaning index” (describing the interaction between average time of tooth brushing in minutes and its frequency per day) significantly correlated with Body Mass Index (R_Spearman = 0.300). The multivariate regression model incorporating cleaning index, approximal plaque index, receptor 1 for tumor necrosis factor-alpha (TNFα-R1) and interleukin-15 (IL-15) had a high power to predict overweight or obesity (AUC = 0.894). Patients with poor oral hygiene (approximal plaque index >40%) were more than eight times more likely to suffer from obesity than patients with good oral hygiene. Cleaning index higher than 4 decreased the odds by about 85%. Oral hygiene habits, adjusted by salivary concentrations of selected inflammatory markers may allow predicting effectively overweight or obesity risk. Early proper dental prophylaxis and treatment could lead to the better prevention of metabolic disorders.

DUODENAL-JEJUNAL BYPASS REDUCES LIPID ACCUMULATION IN THE BROWN ADIPOSE TISSUE OF HYPOTHALAMIC OBESE RATS

BACKGROUND

Effects of duodenal-jejunal bypass surgery (DJB) on the proliferation of nuclei and the area of adipocytes in the brown adipose tissue of obese rats. Thermogenic activity in the brown adipose tissue (BAT) of obese individuals is reduced, and this condition may be modified by bariatric surgery (BS).

AIM

To characterize fat deposition in BAT from hypothalamic obese (HyO) rats submitted to duodenal-jejunal-bypass (DJB) surgery.

METHODS

For induction of hypothalamic obesity, newborn male Wistar rats were treated with subcutaneous injections of monosodium glutamate (MSG). The control (CTL) group received saline solution. At 90 days, the HyO rats were submitted to DJB or sham operation, generating the HyO-DJB and HyO-SHAM groups. At 270 days, the rats were euthanized, and the BAT was weighed and submitted to histological analysis.

RESULTS

Compared to BAT from CTL animals, the BAT from HyO-SHAM rats displayed increased weight, hypertrophy with greater lipid accumulation and a reduction in nucleus number. DJB effectively increased nucleus number and normalized lipid deposition in the BAT of HyO-SHAM rats, similar to that observed in CTL animals.

CONCLUSION

DJB surgery avoided excessive lipid deposition in the BAT of hypothalamic obese rats, suggesting that this procedure could reactivate thermogenesis in BAT, and contribute to increase energy expenditure.

ASSESSMENT OF ALVEOLAR BONE PATTERN IN OBESE AND NON-OBESE WOMEN, BEFORE AND AFTER BARIATRIC SURGERY: A PROSPECTIVE COHORT STUDY

BACKGROUND

Right and left periapical radiographs in A eutrophic example of normal bone level; in B of morbidly obese before bariatric surgery, presenting bone loss; and in morbidly obese C after six months of the operation presenting great bone loss. Bariatric surgery may have a negative impact on oral bone structure.

AIM

To verify the alveolar bone pattern through radiomorphometric indices of panoramic radiography and linear measurements performed in periapical radiographs in eutrophic and morbidly obese patients before and after bariatric surgery.

METHODS

The sample consisted of 31 women aged 20-35 years old, divided into two groups: obese group (GO-obese grade III) and control group (GC-eutrophic). Twenty eutrophic and 11 obese morbidities were evaluated in the pre and postoperative bariatric surgery (six months). Radiomorphometric and plaque indices were evaluated at T0 (baseline) and T1 (six months) times, in both groups. In the radiographic analysis the trabecular pattern through the Lindh visual ladder and the bone loss were evaluated by calculating the distance from the cement-enamel junction to the bone crest in periapical radiographs. Panoramic radiographs were used to measure the mandibular cortical index (ICM), mentonian index (IM) and panoramic mandibular index (MPI), in addition to the Turesky plate index.

RESULTS

There was a significant loss of bone in T1 in patients submitted to bariatric surgery, when compared to eutrophic patients (p<0.05). The trabecular pattern became sparser after surgery with a visual difference. The plate index showed a slight improvement after surgery and the eutrophic maintained similar values over time.

CONCLUSION

The standard alveolar bone presents greater bone loss in obese patients and worsens this standard after bariatric surgery when compared to eutrophic patients. The same happens with the trabecular pattern that becomes sparser after bariatric surgery.

BARIATRIC SURGERY IN BRAZILIAN PUBLIC HEALTH SYSTEM: THE GOOD, THE BAD AND THE UGLY, OR A LONG WAY TO GO. YELLOW SIGN!

BACKGROUND

In Brazil, there has been a significant increase in obesity rates in all age groups. Data from 2017 show that obesity affects 19% of the population. Due to the magnitude of the problem, public health policies have aimed to prevent complications related to obesity by increasing the offerfor bariatric surgeries.

AIM

To analyze the current status of bariatric surgery performed in the Brazilian public health system, including data from macroregions and also the effect of digestive surgery training on the number of procedures.

METHODS

The database of the public health registry (DATASUS) was assessedbetween 2008 and 2018 for descriptive analysis of data and evaluation of the selected parameters. The main surgical techniques, comorbidities, mortality and the costs profile of the system were evaluated.

RESULTS

There was a 339% increase in the number of bariatric surgeries in the period evaluated. Gastric bypass was performed in 94% of cases whereas sleeve in 2.4%. Other techniques were used in 3.6%. There were discrepancies in the number of surgeries performed in different regions of the country.

CONCLUSION

There was a considerable advance in the number of bariatric surgeries performed by the public health system between 2008 and 2018. However, there is a need to increase the offer of this service and alsospecialized training, as well as a correction in the distribution of these procedures in the national territory to achieve integrality among its users.

N-SLEEVE GASTRECTOMY: AN OPTION FOR OBESITY AND GERD

Background:

Obesity represents a growing threat to population health all over the world. Laparoscopic sleeve gastrectomy induces alteration of the esophagogastric angle due to surgery itself, hypotony of the lower esophageal sphincter after division of muscular sling fibers, decrease of the gastric volume and, consequently, increase of intragastric pressure; that’s why some patients have reflux after sleeve.

Aim:

To describe a technique and preliminary results of sleeve gastrectomy with a Nissen fundoplication, in order to decrease reflux after sleeve.

Method:

In the current article we describe the technique step by step mostly focused on the creation of the wrap and it care.

Results:

This procedure was applied in a case of 45 BMI female of 53 years old, with GERD. An endoscopy was done demonstrating a hiatal hernia, and five benign polyps. A Nissen sleeve was performed due to its GERD, hiatal hernia and multiple polyps on the stomach. She tolerated well the procedure and was discharged home uneventfully 48 h after.

Conclusion:

N-sleeve is a feasible and safe alternative in obese patients with reflux and hiatal hernia when Roux-en-Y gastric bypass it is not indicated.