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The patient’s teeth seemed to be well maintained, but dentist James Mancini was not happy with the appearance of his gums. By coincidence, Mancini knew the man’s doctor, so he alerted about a possible issue—and a diagnosis soon came out.
“Actually, Bob had leukemia,” says Mancini, clinical director of the Meadville Dental Center in Pennsylvania. Although he wasn’t fatigued or experiencing other symptoms, “his mouth was a catastrophe,” Mancini says. “Once his physician saw that, they were able to get him treated right away.”
Oral health is closely connected to whole-body health, so Mancini’s intuition is not surprising. What is uncommon is that the dentist and doctor communicated.
In the past, dentistry and medicine have functioned as parallel fields: Dentists care for the mouth, physicians the rest of the body. That is beginning to change as many efforts across the United States and other countries aim to integrate oral and whole-body care to more effectively address diabetes, cardiovascular disease, joint replacements and many other conditions. The exact relationship between health of mouth and teeth and physical ailments elsewhere in the body is not well understood—and in some cases, is contentious—but experts agree there are links that should no longer be overlooked.
Recently, dental hygienists have started working in medical clinics; physicians and dentists have formed a professional association to encourage collaboration; and a new type of clinic—with dentists and doctors under one roof — is emerging.
“We are at a crucial point—I call it the convergence era—where dentistry is not going to be separated from overall health for much longer,” says Stephen E. Thorne IV, founder and CEO of Pacific Dental Services, based in Irvine, California. “Dentistry will be brought into the main care health-care team.”
Unhealthy mouth, unhealthy body
The list of connections between oral health and systemic health—conditions that affect the entire body—is remarkable. For starters, three common dental issues—cavities, tooth loss and periodontal disease—are all associated with heart disease, the leading cause of death in the United States. “To me, the number one hidden risk factor for the number one killer in our country is oral health,” says Ellie Campbell, a family physician in Cumming, Georgia, and board member of the American Academy for Oral Systemic Health, founded in 2010 to increase awareness of how oral and whole-body health are related.
Periodontal disease, infection and inflammation of the gums and bone that support the teeth, is the main culprit. Nearly half of adults 30 and older have periodontal disease; by age 65, the rate climbs to about 70 percent. In the early stages, called gingivitis, gums are swollen and may bleed. Periodontitis, a more serious condition in which gums can pull away from the teeth, is the sixth most common human disease.
Periodontitis is associated with a variety of systemic ills: heart attacks, strokes, heart failure, diabetes, endocarditis, chronic kidney disease, recurrent pneumonia, chronic obstructive pulmonary disease, gastritis, rheumatoid arthritis, cancer and cognitive impairment.
Unhealthy behaviors like smoking, drinking alcohol, and consuming lots of sugar can increase the chances of getting cavities and oral diseases. They are also connected to serious illnesses such as cancer, respiratory disease, and diabetes.
Back in 1837, officials at the University of Maryland turned down a proposal to teach dentistry to medical students, not recognizing the connection between dental and overall health at that time. The field of medicine did not want to be associated with dentistry. Dentistry was originally practiced by unregulated and poorly trained individuals, according to Andrew I. Spielman, a dentist and oral surgeon at the New York University College of Dentistry. He mentioned that there were many frauds and they had a bad reputation.
The rejection led the two physicians, Horace Hayden and Chapin Harris, to establish the first dental school, the Baltimore College of Dental Surgery. Nowadays, dentistry is closely regulated, and there are 73 accredited dental schools in the United States.
Both doctors and dentists understand that oral health is important to overall health. Campbell mentioned that family practice doctors acknowledge the connection between diabetes, poor dental health, and the impact on diabetes treatment. Dentists also recognize the impact of diabetes on oral health and its influence on gum health.
Mancini, a dentist from Pennsylvania, stated that physicians often request a dental examination for patients before proceeding with certain treatments. He explained that infections in cancer patients can be life-threatening, and orthopedic specialists now refer their patients to dentists for the same reason.
Problems with providing comprehensive care
However, collaborating to improve a patient’s health is not as straightforward as it may seem. A pilot program was initiated by the federal government ten years ago to combine oral and primary health-care centers. The network’s dental consultant, Irene Hilton, a dentist with the San Francisco Department of Public Health, identified three obstacles to integration. The fragmented manner in which health care and dental care are financed is one of the obstacles. While over 90 percent of Americans have health insurance, only 77 percent of US adults aged 19 to 64 have dental coverage, which is usually sold separately from health insurance. The federal Medicare program, the largest insurer, generally does
not include dental services , and nearly half of Americans aged 65 and over do not have dental coverage. This creates problems for patients who need a procedure like a joint replacement, which would be covered by insurance, but cannot afford the necessary dental work beforehand. Mancini explained that surgeons will not perform a knee replacement until the patient has completed the required dental work, making dental care a barrier to improving their quality of life. Most Americans have health insurance, but not many have dental insurance. The data are from early 2023, before the Covid-19 public health emergency ended and states reassessed who was eligible for Medicaid, so the number of Americans without dental insurance may be higher than reported.Credit: Knowable Magazine
Dentists and doctors are not regularly trained to work together, according to Hilton.
Nearly 70 percent of medical schools surveyed provided fewer than five hours of oral health education, and 10 percent had no oral health curriculum at all.
Another issue is what Hilton refers to as infrastructure. Most of the electronic health records used by doctors do not work with those used by dentists, making it impossible to share information electronically. Additionally, dental offices are not usually located within medical clinics, which makes doctor-dentist referrals harder. Hilton says that in order to integrate oral and systemic health more widely, these are the challenges that need to be addressed and overcome.The situation in other parts of the world is similar. In 2021, the World Health Organization suggested that dentistry should focus more on prevention and be more integrated with primary care services, recognizing oral diseases as a global public health problem affecting nearly 3.5 billion people.
In the past 25 years, much research has shown the connections between oral and overall health. For instance, a study following 15,456 patients from 39 countries found that those with the most tooth loss had the highest risk of stroke, heart attack, or cardiovascular death. Similarly, a study tracking 7,466 US adults revealed that severe periodontitis was associated with a higher risk of cancer compared to no or mild periodontitis.
affecting nearly 3.5 billion people
Demonstrated links Research over the past 25 years has shown the connections between oral and overall health. For example, a study following 15,456 patients from 39 countries found that those with the most tooth loss had the highest risk of stroke, heart attack, or cardiovascular death. Similarly, a study tracking 7,466 US adults revealed that severe periodontitis was associated with a higher risk of cancer compared to no or mild periodontitis. had lost the most teeth had the highest risk
of having a stroke, heart attack or cardiovascular death. Similarly, a study that tracked 7,466 US adults ages 44 to 66 for an average of 14.7 years revealed that those
who had severe periodontitis had a greater risk of cancer than those with no or mild periodontitis. In 2015, the Harvard School of Dental Medicine began an initiative to support integration of the two fields—in education, insurance and professional practice. The initiative receives funding from dental product brands and health insurance companies, and Thorne, the Pacific Dental Services CEO, serves on its board. According to Jane Barrow, the initiative’s executive director, they have published papers identifying links between periodontal disease and diabetes, hypertension, dementia, adverse birth outcomes, low birth-weight babies, preterm birth, spontaneous abortion, and kidney disease. an initiative to support integration In 2015, the Harvard School of Dental Medicine launched an initiative to support integration of the two fields—in education, insurance, and professional practice. The initiative is funded by dental product brands and health insurance companies, and Thorne, the CEO of Pacific Dental Services, sits on its board. Jane Barrow, the executive director of the initiative, has stated that they have published papers identifying links between periodontal disease and various health issues, such as diabetes, hypertension, dementia, adverse birth outcomes, and kidney disease.
But correlation is not the same as cause and effect, and scientists have not yet determined the exact relationship between periodontitis, which affects more than 11 percent of the global population, and various systemic diseases. more than 11 percent of the global population Periodontitis affects more than 11 percent of the global population.
Periodontitis is linked to bacteria in the bloodstream and systemic inflammation, which can impact organs like the liver and bone marrow. This can then trigger or worsen other conditions. germs in the gums—that move through the blood, breathing, or swallowing—can also lead to infections or worsen swelling in other body parts.
In 2012, major professional societies for gum disease in the United States and Europe gathered a group of global experts to assess the science. They concluded that there was a “biological possibility” that the inflammation of gum disease increases the chance of heart disease and affects type 2 diabetes and other illnesses – but that was as far as they would go. Seven years later, the European Federation of Periodontology and the World Heart Federation assembled experts to review new studies on the connection between gum disease and heart issues. Although scientists had made progress in identifying possible biological mechanisms to explain the link, experts have now determined that theevidence has not yet proven
that gum disease actually
causes strokes, heart attacks, or anything else. Looking at it from a different angle, does preventing or treating gum disease help to avoid heart problems? Several observational studies, where researchers observe individuals and measure specific outcomes, but don’t interfere, suggest that oral health care, including toothbrushing and dental cleanings, make a difference. For instance, a study that followed the health habits of 11,869 adults 35 and older in Scotland found that within eight years, those who seldom brushed their teeth had more heart problems causes compared with those who brushed twice a day.
Research exploring the connection between gum disease and heart problems indicates that ongoing swelling and oral germs play a role. Credit: Knowable Magazine That still does not provide evidence that preventing gum disease will prevent heart problems: Some other behavior or characteristic of the toothbrushing group could have been the important factor. The relationship is hard to figure out, Barrow says, because people who are taking good care of their mouths tend to take good care of themselves overall. “Could you say that people who are taking care of their mouths are in better health overall? You would probably find that to be true,” she says. “Is it because they’re taking care of their mouth? I can’t say that.”
. The coauthors, a group of dental and public health researchers, cautioned against
overhyping the connection between oral and overall health . “The main reason for maintaining good oral health is because it is important in and of itself,” they wrote.Bryan Michalowicz, a dental researcher at HealthPartners Institute in Minnesota, and his team reviewed the medical records and insurance claims of 9,503 patients to see if gum disease treatment improved the health outcomes of those with heart disease, cerebrovascular disease or type 2 diabetes. Overall, patients with heart problems who receiveddental treatment and follow-up care saw no difference
The team reported in 2023 that there was no significant decrease in the rate of heart attacks, strokes, bypass surgeries or angioplasty procedures for those who received periodontal treatment compared to those who did not. Similarly, periodontal treatment did not significantly reduce the blood-sugar levels in patients with type 2 diabetes.
Overdue integration But there have been enough data suggesting connections to inspire many grassroots efforts at integration. Along with the American Academy for Oral Systemic Health, the National Network of Healthcare Hygienists
, which was founded by hygienist Jamie Dooley in 2018, assists hygienists who are interested in integrating oral health into health-care systems.
In California, Thorne’s business is working to make those interactions convenient by combining dental and medical services under one roof. In December 2023, Pacific Dental Services launched a clinic, Culver Smiles Dentistry, in a space shared with a medical practice. This is the first of 25 planned dental-medical practices that will operate through a partnership between MemorialCare, a large Southern California health system, and Pacific Dental.
According to Thorne, health-care leaders are beginning to realize that they can enhance their patients’ health by including dental care into primary care. Thorne finds it unbelievable that the mouth, jaw, and throat have been considered separate from the rest of the body for so long. “It is changing now, and health care is realizing that the mouth is the gateway to so much of our overall health.”This article originally appeared in
Knowable Magazine
Ailments of the mouth can put the body at risk for a variety of other illnesses. Some practitioners believe that dentistry should no longer be isolated.
This article originally appeared in Knowable Magazine
