The effects of oral health on systemic health

1 The effects of oral health on systemic health Shawn F. Kane, MD, FAAFP, FACSM. The oral cavity is the intersection of medicine and dentistry and the window into the general health of a patient. Hundreds of diseases and medications impact the oral cavity, and pathologic conditions in the mouth have a greater systemic impact than many T he oral cavity has been described as the window to general health . 1 According to Seymour, statements such as You cannot have good general health without good oral health and The mouth is part of the body are now considered The oral cavity is also the intersection providers appreciate. It is unclear whether there is of dentistry and medicine, semi-independent professions that true causality or just an association between perio- share the same common goal of improving the health and qual- dontal disease and certain other systemic conditions, ity of life of patients.

2 At the heart of each profession is the basic including atherosclerotic vascular disease , pulmonary concept that appropriate interventions within the framework of disease , diabetes, pregnancy-related complications, that discipline will have an overall positive impact on patients'. osteoporosis, and kidney disease . Diabetes has a true health , welfare, and quality of bidirectional relationship with periodontal disease , and It has been estimated that more than 100 systemic diseases there is strong evidence that treating one condition and upward of 500 medications have oral manifestations, positively impacts the other. A shared trait of perio- which are typically more prevalent in the older population. dontal disease and these medical conditions is that they Hippocrates reportedly cured systemic conditions by pulling are chronic conditions that take a long time to develop infected Despite this, the relationship and impact of oral and become clinically significant.

3 Primary prevention conditions on systemic conditions has not been fully appreci- treating the patient prior to the onset of symptoms, ated until Is there direct causality between oral and myocardial infarction, stroke, diabetic complications, systemic health conditions, or is it just coincidence? This is the or significant periodontal disease is the challenge. main question that may have slowed the understanding of these Complications associated with these conditions cause processes as well as the interaction and collaboration between significant morbidity and mortality and are incredibly dentistry and medicine. Bidirectional relationships between oral costly to the healthcare system. Unfortunately, a lack and systemic conditions are becoming better understood, but of access to primary medical or dental care prevents more research into this area is As the impact of oral some patients from engaging the system until a nega- health on systemic health is clarified and proven, dental and tive event has occurred.

4 Despite the absence of clear medical professionals need to develop closer ties. evidence of causality and the direct impact of treat- Whether causal or coincidental, the impact and importance ments, the consequences of these chronic conditions of oral health on overall health has been the focus of multiple for the population are well understood. Dentists, family surgeons general of the United States as well as the World physicians, and all primary care providers must increase health Access to dental and medical care is a their collaboration and communication to maximize the complicated issue; availability of care, cost of care and insurance, benefit to patients. cultural issues, and fear are all factors that keep patients out of the office. From a population health perspective, it should not Received: June 13, 2017 matter who initially examines the patient and identifies a risk Accepted: July 11, 2017 factor or early evidence of a disease ; what matters is that the patient gets the care he or she needs.

5 A collaboration between General Dentistry Oral cavity and American Family Physician The mouth and oral cavity are focal points for the interaction of the body with the external environment. Speech, chewing, swal- lowing, and the early stages of digestion are all vital physiologi- Published with permission of the Academy of General Dentistry. Copyright 2017 by the Academy of General Dentistry. cal functions that involve the oral cavity, and the mouth plays a All rights reserved. For printed and electronic reprints of this article role in psychological for distribution, please contact There are multiple surface types in the oral cavity, and each is colonized with a unique population of 500-700 species of bacteria, viruses, fungi, and protozoa, a good number of which are significantly virulent and many of which have not been The level of oral hygiene significantly impacts Exercise No.

6 411, p. 35 the makeup of the oral microbiome. Individuals with good oral Subject code: Multi-Disciplinary Topics (149) hygiene tend to have a simple flora dominated by gram-positive 30 GENERAL DENTISTRY November/December 2017. Normal tooth Periodontitis Healthy Inflammation Enamel bone Plaque and calculus level Healthy Deepening gingiva pocket Bone loss Bone Figure. Development of periodontal disease . cocci and rods and some gram-negative cocci, while those with different populations, as public water fluoridation programs have poor oral hygiene have a shift to a more diverse and complex greatly impacted the disease in those areas where it is available, but flora dominated by anaerobic gram-negative caries still occurs in epidemic proportions in disadvantaged The oral cavity is also bathed in a complex mixture of fluids, Caries is a polymicrobial disease that results from the breakdown composed primarily of saliva and gingival crevicular fluid, that of dental enamel by lactic acid that is created when cariogenic plays a major role in maintaining a healthy oral ,13 bacteria in the biofilm digest dietary fermentable carbohydrates.

7 Saliva, like many other bodily functions, has an optimal range; Periodontal diseases are a group of chronic immune- underproduction (xerostomia), overproduction (sialorrhea), inflammatory diseases caused by the bacteria in the biofilm and and alterations in chemical makeup can lead to bidirectional primarily affecting tooth-supporting structures. Gingivitis and impacts on health . periodontitis are two forms of periodontal disease that exist on Bacteria and saliva play a direct role in the development of a spectrum ranging from bleeding, erythematous, and inflamed the dental biofilm, which is commonly referred to as plaque in gingival tissue to the loss of attachment and alveolar ,15. the lay community. Currently, there is a better understanding Gingivitis, the milder form of periodontal disease , is character- that not all plaque is bad and that the interrelationship between ized by local erythema, swelling, and easy bleeding.

8 Gingivitis is saliva and bacteria can protect the teeth by helping maintain usually pain free; as a result, patients can go years without diag- mineralization and reducing exposure to dietary The nosis of the disease , but it is easily treatable once ,9,10. initial bacteria attach to salivary molecules that are absorbed on Periodontitis, the loss of connective tissue and bone, is the the tooth surface. The bacteria multiply and lay down a polymer result of chronic inflammation caused by the persistent presence matrix that serves as the framework for more bacteria to attach of pathologic bacteria in the biofilm (Figure).1,10 The bacteria themselves. A commensal microflora of streptococcal species accumulate in pockets and pull the gingiva away from the teeth.

9 Characterizes the biofilm associated with healthy teeth and gin- This process triggers the body's immune response, which leads giva. These organisms prove to be beneficial by interfering with to damage to the supporting structures. Periodontitis is a lead- the colonization of more pathologic However, a disrup- ing cause of tooth loss around the ,10. tion in the oral ecosystem (dysbiosis) can lead to the predomi- nance of carbohydrate-fermenting gram-positive species, which systemic conditions impacted leads to tooth demineralization, thereby beginning the process by oral health of oral ,12 The benefits of good oral health are well studied and include economic, social, psychological, and physical Garcia Oral pathology et al reported that the greater the number of missing teeth, the Oral pathology is a broad topic, but this article will focus on the poorer the quality of Poor dentition also leads to issues oral conditions that have an established or accepted relationship with chewing and can negatively impact nutritional intake.

10 With systemic health : caries and the periodontal diseases of gingi- These relationships are obvious, but the significant impact and vitis and periodontitis. Dental caries is probably the most common relationship of oral and serious systemic conditions are areas infectious disease across humanity. The prevalence varies across that call for increased collaboration. Special ORAL- systemic health Section 31. The effects of oral health on systemic health Chronic health conditions create a massive burden on the are not conclusive, but current research is trending in favor of health of individuals as well as the entire healthcare system. the interpretation that improvement of oral health decreases the Routine and regular dental care not only prevents periodontal risk of atherosclerotic disease but also helps to stratify patients who are at significant risk for more serious systemic conditions.