Patricia Corby, D.D.S.: Relationship Between Poor Oral Health and Systemic Disease

Dr. Pat’s background

• Dental degree in Brazil
• Specialized in periodontics and implant dentistry
• Moved to the US for research opportunities

Importance of oral health

• Often underappreciated aspect of overall health
• Connection between oral health and systemic health

Oral Health and Dentistry with Dr. Pat

• Dr. Pat’s background
• 32 teeth in the mouth, each with specific functions
• Enamel: hardest surface in the human body, protects underlying layers
• Dentin: cushion-​​like layer beneath enamel, contains tubules and is sensitive
• Pulp: heart of the tooth, contains nerves and blood vessels
• Periodontium: complex system surrounding the tooth, including bone and ligaments

Nervous connection to teeth

• Dental pain is one of the most severe types of pain due to nerve connections
• Nervous connection may serve as an early warning indicator for infections and inflammation
• Dental implants can still function for breaking down food, but natural teeth are better for overall oral health

Function of different teeth

• Incisors: 4 on each jaw, used for cutting food
• Canines: 2 on each jaw, used for tearing food
• Premolars: 4 on each jaw, used for crushing food
• Molars: 6 on each jaw, used for grinding food

Teeth and Oral Health

• Teeth types and functions:
• Incisors: used for cutting food
• Canines: strong, long roots for tearing food
• Premolars (bicuspids): breaking down food
• Molars: chewing food, important for digestion

Teeth roots:

• Incisors, laterals, and premolars have single roots
• Premolars have two roots
• Molars have three or four roots, depending on tooth size

Importance of proper occlusion (alignment) for oral health

• Prevents damage to ligaments and inflammation
• Poor occlusion can lead to facial pain and headaches

Saliva and Oral Microbiome

• Saliva plays a crucial role in oral health
• Protects and maintains a balanced oral microbiome
• Prevents dysbiosis (imbalance of bacteria)

Over 700 different bacteria live in the mouth

• Both aerobic and anaerobic bacteria, as well as facultative bacteria
• In a healthy mouth, approximately 50% aerobic, 50% anaerobic, and 30–40% facultative bacteria

Dysbiosis can occur when oral hygiene is neglected or other factors change the oral environment

• Allows harmful bacteria to grow and suppress beneficial bacteria
• Changes in abundance and diversity of bacteria

Twin Study on Oral Health

• Participants: 12–16-year-old identical and fraternal twins
• Study design:
  • Twins were asked to either brush only or brush and floss for two weeks
  • Dental hygienists supervised and monitored the participants
• Results:
  • Non-​​flossing group had increased gingival inflammation and bleeding
  • Periodontal bacteria (P. gingivalis, T. denticola, A. actinomycetemcomitans) became more abundant in non-​​flossing group
  • Demonstrates the importance of flossing for oral health and preventing periodontal disease

Oral Health and Periodontal Disease

• Caries and periodontal disease are similar in behavior and risk factors 
  • Caries: aerobic species, live in the presence of oxygen
  • Periodontal disease: anaerobic species, live in the absence of oxygen, hiding in periodontal pockets
• Periodontal pocket: inside the tooth
• Gingival pocket: between the gum and the tooth
• Periodontal disease progression: 
  • Starts with inflammation around the gums
  • Periodontal ligament gets inflamed and detaches from the tooth
  • Bacteria enters, causing inflammation, deterioration of ligaments, and bone loss
• Caries typically occur on the top surface of the tooth 
  • Root caries can occur when the root is exposed due to periodontal disease or other forms of trauma
• Early childhood caries: caused by baby bottle use, often on anterior teeth 
  • Most common dental disease worldwide

Sugar and Oral Health

• Sugar (fructose, sucrose, lactose, and complex starches) is harmful to teeth 
  • Kyogenic bacteria metabolize sugar, producing acid that destroys enamel
  • Glucose is the worst, especially in high concentrations (e.g., syrup)
  • All sugars can be metabolized by bacteria, including fructose from fruits and vegetables
• Sugar consumption has increased with modernization and added sugars in many products 

Oral Hygiene Practices

• Mechanical removal of plaque is essential for oral health
• Brushing disrupts the biofilm matrix, preventing accumulation and overwhelming bacterial growth
• Flossing cleans between teeth
• Toothpaste is important for fluoride exposure, which hardens enamel and protects against cavities
• Especially important for children at high risk of caries
• Brushing the oral mucosa and tongue can help decontaminate against bacteria
• Often neglected in oral hygiene routines

Oral Health in the Past

• People in the past likely used different devices to clean their teeth (e.g., sticks, plants)
• Diets were different, with less concentrated and refined sugars
• Oral health issues were still present, but modern diets and lifestyles may exacerbate problems

Oral Health and Cancer Patients

Oral health is crucial for cancer patients, especially those undergoing radiation treatment:

• Radiation damages salivary glands, causing dry mouth and changing the oral microbiome
• Opportunistic organisms can prevail, leading to fungal infections and local inflammation

Oral health should be personalized to the patient’s age, risks, and ability to brush:

• Standard of care currently does not include cleaning oral mucosa or periodontal treatment
• Research is being conducted to prove the benefits of more comprehensive oral care for cancer patients

Flossing and Brushing

• Flossing helps clean anaerobic bacteria hiding between teeth
• Brushing also stimulates and strengthens gums

Recommended order:

• Brush
• Floss
• Rinse or brush again
• Brush tongue

• Brushing first removes biofilm and bacteria from tooth surfaces
• Flossing after brushing can reintroduce bacteria into the mouth

Different surfaces of the mouth have different bacterial colonization

• Tongue, buckle, floor of mouth, and throat all have unique bacterial populations

Oral Health Research and Standard of Care

• Current standard of care does not include cleaning oral mucosa or periodontal treatment for cancer patients.

• Research is being conducted to prove the benefits of more comprehensive oral care for cancer patients.
• Goal is to make oral health care a part of the healthcare system for immunocompromised patients.

• Pilot study showed that cancer patients who received comprehensive periodontal treatment had suppressed inflammatory markers in saliva.

• Suggests a systemic benefit from improved oral health care during cancer treatment.

Oral Health and Systemic Infections

• Cancer patients are at greater risk of systemic infections arising from the mouth
• Immune compromise from treatment and loss of immune barrier in the mouth contribute to this risk
• Dry mouth from radiation treatment increases susceptibility to infections and inflammation

Improved oral health care for cancer patients could lead to better treatment outcomes and overall health

Oral Hygiene and Cancer Patients

Pilot study on oral hygiene in cancer patients:

• 16 patients participated
• Aimed to understand the impact of oral care on cancer treatment side effects

Oral care for cancer patients

• Combination of professional dental cleaning and self-care
• Professional cleaning removes plaque and toxins
• Self-​​care includes brushing, flossing, and regular dental check-ups

Current trial on oral hygiene in cancer patients

• Two groups: one with professional cleaning and self-​​care, the other with dental hygienist visits and self-care
• Both groups show reduced disease development

Head and Neck Cancer

• Study population: head and neck cancer patients scheduled for radiation treatment
• Strict inclusion criteria: minimum 50 gray of radiation delivered to oral cavity
• 90% of patients develop mucositis

HPV and head and neck cancer

• 90% of patients are HPV positive
• HPV-​​driven squamous cell carcinomas of the oropharyngeal region on the rise
• Sexual transmission and poor oral health contribute to the increase in incidence

Stages of Dental Decay

• Enamel decay
• Initial stage, can be reversed with fluoride treatment
• Minimal pain or sensitivity
• Dentin decay
• More advanced stage, can cause pain and sensitivity to cold
• Can be fixed without a root canal if not too close to the pulp
• Pulp decay
• Most advanced stage, requires a root canal
• Infection and inflammation cause severe pain and sensitivity to heat

Personal Experiences with Dental Decay

• Replacing old mercury fillings with white fillings
• Can lead to increased pain and sensitivity, sometimes requiring a root canal
• Wisdom tooth decay
• Can be fixed with a root canal if caught early enough
• Proper oral care can prevent further decay and complications

Root Canals and Systemic Health

• Root canals are a controversial topic in some circles
• Some believe they cause cancer, Alzheimer’s, and other health issues
• However, there is no substantial evidence to support these claims
• Root canals have evolved and become more sophisticated over time
• Microscopic surgery is now used to ensure aseptic conditions and precision
• Properly done root canals should not cause issues
• Relationship between poor oral health and systemic health
• Associations have been found between periodontal disease and diabetes, low birth weight, heart disease, and Alzheimer’s
• Causality can only be determined through clinical trials
• Treating patients and observing changes in markers can help establish causality

Oral Health and Down Syndrome

• Down syndrome patients are susceptible to Alzheimer’s and cardiovascular disease
• They often have poor oral health due to motor skills and cognitive issues
• Studies have found increased amyloid in the brains of Down syndrome patients
• It is unclear if the increase in amyloid is due to chromosomal abnormalities or poor oral care
• Longitudinal studies comparing intensive oral care support vs. standard care could help determine causality

Prevention and Oral Care for People with Disabilities

• Focus on prevention and intensive oral care for people with disabilities
• Educate caregivers on optimal oral hygiene practices
• Research on best methods for cleaning, toothpaste, and toothbrushes
• Aim to prevent dental issues and inflammation through proper oral care

Oral Health and Systemic Diseases

• Thought experiment: Two groups of people with different oral care
• One group receives excellent oral care
• The other group receives poor oral care
• Expect to see a difference in inflammatory markers, cytokines, and inflammatory cells
• Poor oral health could lead to an increase in systemic diseases
• Inflammation plays a significant role in cardiovascular disease, cancer, and Alzheimer’s disease
• Poor oral health may lead to a poor inflammatory environment, driving these diseases

Oral Health and COVID-19

• COVID-​​19 transmission through saliva
• ACE2 receptors, which COVID-​​19 binds to, are highly expressed in the mouth
• Oral hygiene may play a role in COVID-​​19 prevention
• No current focus on oral health in COVID-​​19 prevention measures

Dental Caries and Oral Thrush

• Dental caries increased during the COVID-​​19 pandemic
• Dental clinics closed, limiting access to care
• Masks and poor oral hygiene may contribute to the increase
• Oral thrush in individuals with normal immune systems
• Possible causes: lack of saliva, poor oral hygiene, medication side effects
• Dry mouth can be caused by anticholinergic medications, which are also associated with Alzheimer’s disease

Dry Mouth Solutions

• Sugarless chewing gum or lozenges can help stimulate saliva production 
  • Xylitol-​​based products may be beneficial
• Hydration and drinking water are important for oral health

Teeth Whitening

• The color of a person’s teeth is genetically determined # Tooth Color and Whitening
• Tooth color varies among individuals and can be influenced by genetics and environmental factors
• Some people have naturally yellow teeth that won’t change
• Excess fluoride in water can cause stains on teeth
• A study with twins showed that environmental factors, such as diet, can affect tooth color
• Black tea and red wine are common causes of tooth discoloration

Teeth Whitening Safety

• Teeth whitening involves bleaching the teeth
• Excessive use can be detrimental, causing loss of minerals and potential gum damage
• It is recommended to consult a dentist before using teeth whitening products
• Using approved products and following the correct procedure can make teeth whitening safe

Fluoride in Toothpaste and Water

• Not all toothpaste contains fluoride; look for toothpaste with 1000–1500 ppm of fluoride
• The American Dental Association endorses toothpaste with the correct amount of fluoride
• Fluoride is important for preventing tooth decay
• Fluoride can be found in drinking water in some countries, but not all

Fluoride Varnish

• Fluoride varnish can be applied to teeth every six months to help prevent decay
• It is especially helpful for children and those at high risk of tooth decay
• Prescription-​​based concentrated fluoride toothpaste can be used for those at high risk of decay

Oral Hygiene for Children

• Children should start using fluoride toothpaste once their first tooth appears
• Brushing before bedtime is crucial for preventing tooth decay
• Avoid giving children baby bottles overnight, as it can lead to decay

Dental Treatment for Children

• Treating tooth decay in young children can be challenging and may require sedation
• In some cases, a temporary barrier can be applied to the tooth to arrest decay until the tooth falls out naturally

Alternative Oral Hygiene Practices

• There is no clear evidence supporting the efficacy of tongue scraping or oil pulling for oral hygiene

Oral Hygiene Practices and Recommendations

Tongue scraping vs. brushing

• Both methods remove bacteria from the tongue
• Brushing with toothpaste provides additional antibacterial benefits
• Preference depends on individual comfort and ease of use

Types of dental floss

• Ribbon, rope, and wax-​​coated rope floss are common options
• Choice depends on personal comfort and tooth spacing
• Flossing is crucial for removing plaque and preventing gingivitis

Electric toothbrushes

• Oral B and Braun are both effective options
• Preference depends on individual comfort and enjoyment
• Electric toothbrushes can provide a more thorough cleaning than manual brushing

Ideal oral care regimen

• Brush teeth three times a day: morning, after meals, and before bed
• Floss daily to remove plaque and prevent inflammation
• Use a fluoride toothpaste for added protection against cavities
• Incorporate a water pick or mouthwash for additional cleaning, but not as a substitute for brushing and flossing

Importance of morning brushing

• Overnight, bacteria and biofilm accumulate in the mouth
• Brushing in the morning removes this buildup and refreshes the mouth
• Skipping morning brushing can lead to increased plaque and potential oral health issues

Additional oral care considerations

• Toothpicks can be used for removing food particles, but should not replace flossing
• Xylitol-​​based toothpaste with fluoride is a good option for cavity prevention
• Mouthwash can provide extra cleaning and freshening, but should not replace brushing and flossing

Oral Health and Toothbrushes

• Oral health is important for overall health
• Mechanical toothbrushes do a good job at cleaning teeth
• Soft-​​bristled toothbrushes are recommended for cleaning the tongue
• It’s important to clean and dry your toothbrush after use to prevent bacterial growth

Mouthwash

• Mouthwash can kill both good and bad bacteria in the mouth
• It’s not recommended for daily use, especially if you have a healthy oral environment
• Overuse of mouthwash can lead to bacterial resistance and possibly fungal overgrowth

Dental Checkups and Cleanings

• Regular dental checkups and cleanings are essential for maintaining oral health
• Six months is the recommended time between checkups for most people
• People with systemic health issues, such as diabetes, may need more frequent checkups
• Periodontal disease is a slow-​​progressing condition, but can be exacerbated by systemic health issues

Prevention and Oral Health

• Prevention is key for maintaining good oral health throughout life
• Dental care is a chronic noncommunicable disease
• People with systemic health issues are more susceptible to periodontal disease and should see a dentist more often
• Both diabetes and periodontal disease are preventable with proper care and prevention