Mouth matters

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Carole A Boyle: Dental Editor, Surgeons’ News

Lochana Nanayakkara: Convenor of Dental Education, RCSEd Dental Council

The demands on dentists are becoming more challenging as people live longer and retain their natural teeth, while also having greater expectations of aesthetics and function.

Oral infections and sepsis have been directly implicated in the aetiology of infections such as infective endocarditis, but there is a strong association with diseases including diabetes, cardiovascular disease, stroke and dementia. 

There is reported evidence that treating oral diseases can help to improve management of inflammatory diseases and the severity of symptoms of some inherited bleeding disorders. It is important to raise awareness of the relationship between oral health and systemic health, and how neglecting to manage oral diseases effectively can negatively impact general health.

A recent consensus report has called for closer collaboration between doctors and dentists to work together to improve the management of patients’ general health¹. In this article we discuss some of the associations and give examples from our clinical practice where dental interventions have produced better patient outcomes. 

Endocarditis

In the past the relationship between infective endocarditis and dental infections was so profound that patients would have extraction of all their teeth prior to prosthetic cardiac valve surgery. Although some still advocate for the routine use of prophylactic antibiotic cover for invasive dental treatment in people at risk, national guidelines do not support this.

The challenge in dentistry relates to periodontal disease that causes destruction of the periodontal attachment allowing normal oral commensal microbes to enter the blood stream causing a bacteraemia.

Periodontal disease is the most common inflammatory condition affecting 50% of the world’s adult population² – 83% of the British population present with some level of periodontal inflammation³. The early stages of periodontal disease, gingivitis, is not only preventable with good oral hygiene, but also completely reversible with effective professional intervention.

In a recent study looking at the microbiology of 108 cases of endocarditis over a period of three years⁴, 57% of infections occurred
on native valves and 29% occurred on prosthetic valves. Only 13% of infections of prosthetic valve endocarditis were caused by viridans-group streptococci (oral pathogens) as opposed to 47% of native valve endocarditis.

This highlights the importance of educating all patients about the importance of oral health and effective prevention, not just those considered high risk because they have prosthetic heart valves.

Cardiovascular disease

Many researchers have looked for association with cardiovascular disease and poor oral health. This is difficult as many of the risk factors, such as smoking, unhealthy diet and lower socioeconomic status, are shared.

A rapid review in 2017 suggested there is a strong association between oral health and atherosclerotic cardiovascular disease, but not with hypertension or heart failure⁵. Periodontal treatment can reduce surrogate markers of atherosclerotic cardiovascular disease, such as endothelial function, and markers of inflammatory and oxidative stress. The authors state that oral health promotion can improve oral health-related quality of life measures in stroke patients.

“It is important to raise awareness that neglecting to manage oral diseases effectively can negatively impact general health”

Diabetes

The association between oral health and diabetes has long been recognised – treatment of periodontal disease can improve glycaemic control in those with type 2 diabetes and should be part of prevention in those with prediabetes⁶.

Intensive periodontal therapy involving scaling and root surface debridement can reduce HbA1c at three to four months by between 0.27% and 1.03%. This could avoid the need for a second diabetes medication. Equally, people with periodontitis have higher levels of HbA1c, putting them at risk of developing non-diabetic hyperglycaemia and type 2 diabetes.

Dementia

An association with dementia and poor oral health is established – as dementia progresses the manual dexterity to use a toothbrush declines, but a causal link is less clear. A large national study in the US found that a common bacteria linked with periodontal disease, Porphyromonas gingivalis, can lead to plaques of beta-amyloid protein being deposited. This is a causative factor in Alzheimer’s disease. The results also showed that older adults with signs of gum disease and mouth infections at baseline were more likely to develop Alzheimer’s during the study period⁷.^.

There is a need for research in this area, but in the meantime it is sensible that all healthcare professionals encourage oral hygiene practices in those with early cognitive decline. 

Inherited bleeding disorders

Oral bleeding is one of the symptoms of inherited bleeding disorders alongside epistaxis and menorrhagia. Many people accept associated symptoms such as altered taste, bad breath, lack of confidence to smile in social situations and intimacy issues as part of their bleeding disorder.

Most commonly the bleeding is due to untreated periodontal disease, but since professional hygiene practices can cause inflamed tissues to bleed, accessing dental care can be challenging. Medical teams can help by empowering patients to seek routine non-invasive care, provide factor replacement therapy when needed and encourage dentists to use effective local measures such as topical tranexamic acid.

It important that dental and medical colleagues work together, recognising that oral health contributes to general health.