Oral health and primary care: an important, intuitive combination for systemic health
Oral health has an ongoing and significant impact on various aspects of systemic health, and yet oral health and general health are perceived by many Americans as two distinct entities. This is reinforced by the American health care system, which largely does not integrate these areas of medicine. This lack of care coordination creates obstacles to access for those who cannot afford a separate dentist visit, such as those living with mental illness, poverty, disability or advanced age. The high out-of-pocket expenses for dental care are also a financial burden to the more than 100 million Americans who are uninsured or on Medicaid.
However, poverty and marginalization are not the only barriers to dental care in the United States. According to a national survey published by the American Dental Association and the Health Policy Institute, dental care may be bypassed due to low perceived need, lack of time, difficulty traveling to a dentist and anxiety. This lack of accessibility and emphasis on dental care is only made worse by the serious consequences of its neglect. In particular, gum disease is associated with several systemic diseases, including lung and colorectal cancer, rheumatoid arthritis, and mortality due to cardiovascular disease.
“Oral health, in general, gets overlooked by physicians,” Martin Lipsky, MD, Chancellor of the Health Sciences School at Roseman University in South Jordan, Utah, told Healio Family Medicine. “I was trained as a family physician, and when I think back to my training, I got maybe an hour or so of oral health, and the importance was never really hammered into me. In my current job as chancellor, we have a dental school, and I’m ultimately responsible for them. I’ve learned to have a much larger appreciation for oral health.”
Lipsky discussed the manifold effects of gum disease on systemic health and addressed how incorporating oral health into primary care could lead to earlier detection of various diseases. - by Jennifer Byrne
Q: What are the effects of periodontal disease on overall health?
A: There are quite a few factors people don’t think of. The first is the nutritional factor. If you have poor teeth or dentures, it can adversely affect your nutrition. Periodontal disease is the main reason people lose their teeth. If they lose their teeth, they might need to get dentures, which are sometimes uncomfortable, or they will gum their food. Then there is the issue of self-image. Periodontal disease causes discolored teeth and bad breath. Even more importantly, there is a connection between periodontal disease and systemic illness.
Q: How does gum disease affect the heart?
A: There is a clear connection. In fact, the American Journal of Cardiology recommends that patients with moderate-to-severe periodontal disease be advised that they’re at increased risk for heart disease. What happens in periodontal disease is a chronic infection of the gums. Eventually, you develop pockets of bacteria and infection between the teeth and gum tissue. We think this affects not just the mouth, but the inflammatory process. The thinking is that some of the chemicals that mediate inflammation go into the bloodstream, and so the inflammation is not limited to the gums but is also in the blood vessels.
Q: What are some of the other effects on systemic health?
A: We also think that inflammation can affect how beta cells that secrete insulin work, leading to diabetes. Nobody knows for sure, but there are theories that suggest an epidemiological association because the same inflammatory processes in the mouth are what is seen systemically with these diseases.
Why do so few people seem to understand the link between gum disease and systemic health? What should patients know about this?
A: I think part of it is that physician training doesn’t really emphasize oral health as much as it should, and of course, going to the dentist isn’t very glamorous. When people think of going the dentist, they think, “It’s going to hurt.” There’s a lot of dread, but our dental school dean says that just brushing for 2 minutes at a time, twice a day, can help alleviate a lot of dental disease. The other thing that’s overlooked is flossing. Flossing accomplishes a few things; certainly, it removes any food particles or items that get caught. What happens is, these bacteria develop biofilms that they live in. Our dental school dean compares it to setting up little hotels in your gingival pockets. Anything you do to disrupt their living quarters helps reduce periodontal disease. So when you get the floss down into to that crevice, it disrupts that biofilm where the bacteria are.
Q: How can oral health be incorporated into primary care?
A: First, you should make it part of your health questionnaires. Some physicians will ask, “Have you seen the dentist within the past year?” The recommendation is to see the dentist at least once, but ideally twice a year for your checkup and cleanings. Second, in terms of gum disease, there are some key things that are easy for physicians to recognize, like if someone has lost a tooth or if their teeth are loose. Sometimes periodontal disease causes bad breath, because the bacteria that are growing in there will release volatile chemicals that can cause the odor. You might also see red, swollen, or bleeding gums. Your gums should not bleed when you brush your teeth. A physician might see gums that are receding or discover that the patient has pain when chewing. These are all things that are easy for a family physician to recognize. I think their main role would be to recommend that person sees a dentist. If I send someone to a dentist or cardiologist, I usually check to make sure they go; I make my recall systems a little tighter. I don’t think people usually do that when they see periodontal disease. I think it’s helpful to close that loop to make sure they are getting the care they need.
Q: Do you think that oral health is going to be increasingly integrated into primary care? A: We’re going to see more and more of that. For example, in pediatrics now, many family physicians as well as pediatricians are taught how to apply dental varnish and fluoride varnish to prevent cavities. I’d have to say that 20 years ago, nobody was doing that in family medicine. Another thing I recently learned was that there is a special type of silver diamine fluoride-tipped sticks that, if put on a cavity, can arrest the disease. One of our researchers has said that this is usually not appropriate for most adults, because it can stain the teeth, and also it leaves the cavity there. It’s a temporary solution, but it may be useful for patients who are suffering from dementia or living in a nursing home, where access to dentistry is more difficult. This might be a technique that physicians can easily learn and use to reduce the discomfort and tooth loss that we see in that setting.
Are there certain topics that PCPs should bring up with their patients at certain ages?
A: Gum disease is far more prevalent in older adults than in younger adults. However, you build a lifetime of good health habits as a child and as a young adult. So for these age groups, I think primary care physicians should emphasize the importance of regular and good oral care. There’s a flip side to this, which is that when kids and teens see the dentist, the dentist can counsel kids about making sure to get their flu vaccine or HPV vaccine, because they’re more likely to see a dental provider than a physician provider during those years. It can work both ways.
Reference: American Dental Association. “Why adults forgo dental Care: evidence from a new national survey.” https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx. Accessed March 27, 2018.
For more information: Martin Lipsky, MD can be reached at 10920 S River Front Parkway, South Jordan, UT 84095; email: Assistant Lana Crichton, firstname.lastname@example.org
Disclosure: Lipsky reports no relevant financial disclosures.