Abstract
Clinicians need to be reminded about the established link between oral and physical health and the fact that mouth and gum inflammation may lead to illnesses such as heart disease, stroke, diabetes, autoimmune disease, and many more. An integrative approach to oral health care will include coaching patients about the facts regarding oral health, lowering inflammation, maintaining excellent oral hygiene, and choosing healthy lifestyle behaviors. As experts suggest, the mouth is a window into the body and must be uniquely cared for and risks appropriately assessed in each patient. However, oral health is a topic that often is not top of mind for many general clinicians, and they need to know the facts and obtain skills for helping patients stay healthy.
The Facts
The World Health Organization (WHO) commented on their website: “Oral health is a key indicator of overall health, well-being and quality of life. It encompasses a range of diseases and conditions that include dental caries, periodontal disease, tooth loss, oral cancer, oral manifestations of HIV infection, oro-dental trauma, Noma and birth defects such as cleft lip and palate.” 1 The WHO stated that, in fact, more than 3.5 billion people worldwide are affected by oral diseases and added, “There is a proven relationship between oral and general health.” 1 The good news is that like many other chronic diseases, there are lifestyle choices and risk factors that patients do have control over.
A Surgeon General's perspective article pointed out that “Oral health is much more than clean teeth. It involves the gums and their supporting tissues, the palate, the lining of the mouth and throat, the tongue, the lips, the salivary glands, the chewing muscles, the nerves, and the bones of the upper and lower jaws.” 2 The Surgeon General stated that “Although largely preventable, dental caries and periodontal disease are the two biggest threats to oral health, and are among the most common chronic diseases in the United States. Dental caries is the most common chronic disease in children: it is about five times as common as asthma and seven times as common as hay fever. The most common cause of tooth loss among adults is untreated periodontal disease.” 2 Astoundingly, 53 million people have untreated tooth decay, and at least one-quarter of adults 65 years of age and older have lost all of their teeth due to untreated oral disease, according to the Surgeon General.
Peck reported on the importance of oral health and that the oral environment is a “complex biological ecosystem, which provides an opportunity to understand mechanisms underlying pathological processes, and which therefore can be a model for other body systems.” 3 He added: “There have been significant advances in oral health improvement over the past 30 years, where there has been a change in focus from the acute management of the disease burden of dental caries and periodontal disease to an increased focus on prevention and more complex oral rehabilitation to improve function and aesthetics.” 3
A Window into Systemic Disease
Shannon M. Nanne, RDH, an international speaker and educator on oral health and the executive director of the Global Oral Cancer Forum, promotes the importance of an integrative approach to oral health care through excellent oral hygiene to prevent disease and improve health. She particularly emphasizes lifestyle changes required for a substantial impact on incidence, morbidity, and mortality of oral cancer worldwide. Nanne educates health professionals globally and in an interview commented: “One of my lectures is titled, ‘The Oral Cavity; A Window into Systemic Disease.’ Our mouths are filled with many bacteria, some of which are linked to tooth decay and periodontal disease. Studies have found that periodontitis is linked with cardiovascular disease, stroke and bacterial pneumonia. Additionally, pregnant women with gum disease may be at an increased risk of delivering preterm or low-birth-weight babies. A patient with gum disease has higher rates of cardiovascular disease including heart attacks or strokes compared to patients with good oral health. There is also a strong connection between diabetes and cardiovascular disease. Patients with diabetes benefit directly from periodontal treatment. A diabetic patient or a patient with HIV/AIDS can have more severe oral problems because of their body's particular resistance to infection.”
The Pennsylvania Dental Association affirmed on its website that “Diabetics are more prone to several oral health conditions, including tooth decay, periodontal (gum) disease, dry mouth and infection. According to ‘Oral Health in America: A Report of the Surgeon General,’ the relationship between type I and type II diabetes and periodontal disease has often been referred to as the ‘sixth complication’ of the disease.” 4
Peck reported that “a person with fewer than ten of their own teeth is seven times more likely to die of coronary disease than someone with more than 25 of their own teeth and that treating gum disease improves vascular health.” 3 Regarding Alzheimer's disease, Peck reported on a large study of older Japanese participants, which showed that compared with those with intact dentition, those with missing teeth were at greater risk for memory loss or early-stage Alzheimer's. Peck added, “The relationship between diabetes mellitus and periodontal disease appears bidirectional with diabetes increasing the risk for periodontitis and periodontal inflammation negatively affecting glycemic control.” 3
An Integrative Approach
In an integrative dentistry blog on the American College for Advancement in Medicine website, Pullman stated: “There is a changing paradigm in dentistry, not completely new, but one that fits the time. Forward thinking dentists are redirecting their focus from the repair of teeth to oral health conditions affecting the entire body. These issues include chronic infections, mercury and other heavy metal toxicities, periodontal disease, TMJ and chronic pro-facial pain, and sleep disordered breathing. Increasing evidence links these conditions to diabetes, cardiovascular disease, chronic pain, anxiety and depression, poor performance and learning, dementia, and even cancer.” 5 Pullman emphasized the importance of integrative dentists having a close working relationship with integrative physicians. She added: “Dentists who are cognizant of this important medical/dental connection are seeking collaboration with integrative physicians to provide appropriate interdisciplinary medical/dental solutions” such as the thought that “Removing toxic metals from the mouth requires medical support to detoxify the body.” 5
With a plethora of potential health complications related to oral disease, Nanne emphasized that clinicians can significantly help their patients and the dental profession by taking a full medical history from their patients. She stated: “Taking a full medical history is imperative. For example, endocarditis is a very real and serious risk related to oral and dental care for which the American Dental Association recommends the use of preventive antibiotics before certain dental procedures for patients with a wide variety of conditions. This is just one example of how important it is for clinicians, patients and dentists to understand a patient's medical history.”
Integrative medicine specialists should make sure they are always asking questions while they are performing a physical examination, according to Nanne who stated: “During a physical exam it may be very easy to spot a smoker, which gives clinicians an ample opportunity to discuss the ramifications of smoking including oral cancer where one person dies every hour of every day. This can be a good entry to discussing a person's lifestyle behavior choices. In fact, if a patient is smoking and drinking their chance of developing oral cancer increases 15 times.”
Coaching patients through the facts and actions needed to help is a significant part of integrative medicine today. Vernon and Howard, in an article on articulating an integrative approach to coaching oral health behavior change, describe a paradigm shift in oral health care to one of focusing on “the causes of oral disease instead of the consequences of disease.” 6 This clearly aligns with both integrative and functional medicine approaches to disease wherein establishing the root cause is essential.
According to Vernon and Howard, clinicians of all kinds can help people maintain good oral care by “being exquisitely attentive to how they ask questions, how they convey messages, how they explain findings, and how they pursue planning to promote health.” 6 Simple questions may include when did the person last see a dentist? Does the patient smoke or drink alcohol? Do they want to quit? Vernon and Howard recommended that providers be trained to “Effectively communicate physical oral disease findings and explain to patients how altering specific concrete behaviors could result in better oral health (and possibly systemic health)” and “Coach the patient in such a way that they are motivated, actively involved, and working collaboratively with their provider (over time) to act on plans to initiate and maintain behaviors that promote optimal oral health.” 6 Of course, coaching patients about the tenets of healthy lifestyle behaviors in the realms of healthy nutrition and healthy oral habits is essential.
Good Oral Hygiene Protects the Body
Prevention is key for good oral hygiene. Nanne stated: “Our mouths have many bacteria and most are harmless. However, our mouth is the entry point to our digestive and respiratory tracts, and some of these bacteria can cause disease. Normally the body's natural defenses and good oral health care, such as daily brushing and flossing, keep bacteria under control. However, without proper oral hygiene, bacteria can reach levels that might lead to oral infections, such as tooth decay and gum disease.”
Yamashita and Takeshita reported on the oral microbiome and human health and shared the history of “Dutchman Antony van Leeuwenhoek, using a microscope of his own construction and finding that various forms of microbes were present in plaque found on tooth surfaces.” 7 The authors stated: “His report described individual differences in the oral microbiome, and although he did not refer to it directly he realized that individual differences in the microbiome influenced the health of the oral cavity. Unfortunately, it would be 200 years before we developed a systematic theory that showed how the microbiome is related to disease in the oral cavity.” 7 The authors reported that “The recent rapid development of molecular genetics in high-throughput DNA sequencing enables us to grasp important aspects of the oral microbiota and its association with oral and systemic health. These studies may lead to promising dental treatments and interventions to manage the bacterial composition of the oral microbiome.” 7
Routine Oral Care
So what is an appropriate oral health routine for clinicians to recommend to their patients? Nanne stated, “I recommend that people brush their teeth at least twice a day, floss daily and schedule regular dental checkups and cleanings. I tell people, only floss the teeth you want to keep!” Nanne said that there are many oral issues in patients seen in clinical practice each day. “For example, dry mouth or xerostomia occurs in 25% of all patients seen in dentists' offices. Dry mouth can be caused by many things including over 1000 medications, diseases and cancer therapies. Treating a xerostomic patient is difficult because sometimes their mouth is so dry that the lips may bleed and the tissues can slough off. Having reduced saliva can cause tooth decay and infections, so it is imperative to emphasize avoiding a diet high in sugar. A specific regimen of oral care products must be recommended to these patients. I recommend products with natural enzymes to replicate saliva, an alcohol free mouthwash, a toothpaste without sodium lauryl sulfate (soap) and the use of salivary substitutes. Using products with a natural sugar called xylitol can reduce decay because the plaque is less sticky when xylitol is the sweetener in oral care products. Xylitol reduces the levels of Streptococcus mutans in saliva. It is very sweet and helps salivary glands excrete more saliva. Chewing gum with xylitol is essential to the stimulation of salivary flow and can help bring the pH balance level back to neutral.”
According to the Surgeon General's perspective, “Messages that encourage lowering sucrose intake, reducing acidic beverage consumption, and routinely brushing and flossing teeth should continue to be disseminated through all sources of media, including dental literature, television, newspapers, magazines, radio, and the Internet, and should be incorporated into the education curriculum targeting children, caregivers, and communities,” and “Together, we will be able to promote good oral health and encourage our children to be vigilant of their oral health status.” 2
Health Disparities
It is important to emphasize that significant disparities in oral health exist today, and the Surgeon General stated: “To decrease the disparities that exist among different groups, all stakeholders at the federal, state, and community levels must be engaged in the issues surrounding oral health promotion/disease prevention. Additionally, raising the country's understanding of the linkage between good oral health and good overall health will help to reduce the disparities associated with oral health and will lead to a healthier nation.” 2 Nanne encouraged, “Prevention is key, and there are free online educational materials available to clinicians to hand out to patients. Sending a patient home with something tangible makes a difference and reiterates what you have just discussed with them.”
Fiorillo added in an editorial: “Considering that economic difficulties can negatively affect the quality of oral health, and in turn that bad oral health can negatively affect general health, it is possible to deduce that the socio-economic conditions of a citizen have a short-term influence on solvable oral pathologies that, in the long term, besides becoming irreversible chronic oral diseases, also cause a decay in the general health of the individual.” 8
Conclusion
Integrative medicine clinicians are highly attuned to the importance of body, mind, and spirit as making up the whole of a person's health. Somehow, however, as clinicians we may see the mouth as “the dentist's job.” These facts and the mentioned advice remind clinicians how they can play an instrumental role in connecting the dots between oral and physical health and coaching patients to maintain excellent dental hygiene, which, in turn, helps them stay healthier overall. Fiorillo concluded: “Oral health, as demonstrated, has potentially multi-organ systemic implications, and as the results of the recent literature demonstrate, these implications range from an insulin resistance, due to a periodontal disease, up to far more complex multi-organ systemic complications involving the cardiovascular system or even neurodegenerative pathology. Therefore, being able to improve oral health could have great systemic implications for the organism, for the prevention of pathologies, and therefore for society and for the quality of life in individuals.” ■