Oral Health: More Than Just the Absence of Disease
Sanda Moldovan, DDS, MS, CNS
As the medical community gains a clearer understanding of the oral-systemic connection, it is becoming increasingly evident that oral health plays a critical role in one’s overall health. Nutrition, oral hygiene, and probiotics are some of the key factors that help dental patients not just fight disease, but promote good quality of life.
To prevent oral diseases, it is necessary to understand what oral health is. The World Health Organization defines oral health as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity.”1 However, based on the American Dental Association’s 2014 updated definition of oral health, it is more than just the absence of disease: “Oral health is a functional, structural, aesthetic, physiologic and psychosocial state of well-being and is essential to an individual’s general health and quality of life.”2 With today’s knowledge of the oral-systemic connection, it is apparent that oral health is more than just healthy teeth and gingiva. The mouth is a gateway to a person’s health and happiness.
A strong relationship between medical and dental professionals is crucial in the prevention of oral diseases. A lack of dental-health awareness lingers in the medical communities, making it important for dental clinicians to work closely with medical professionals to help patients realize the interdependence of oral health and overall health. The medical community should be aware that patients with diabetes or human immunodeficiency virus, for example, need to practice excellent oral hygiene. The same is true for pregnant women, because the mother’s poor oral health can affect the baby’s health. Furthermore, hormonal imbalances may cause gingival growths, which can occur during pregnancy, and leukemia symptoms can manifest as spontaneous gingival bleeding. Medical and dental teams can support each other in treating the whole patient more effectively.
Moreover, good oral hygiene practices improve postsurgical outcomes. A recent systematic review3 that examined patients undergoing thoracic surgery concluded that preoperative improvement in oral hygiene significantly reduced nosocomial, lower respiratory tract infections, and surgical-site infections.
Being nutritionally fit is important for preventing disease. Nutritional deficiencies can be seen in the mouth, including scurvy, which occurs from a lack of vitamin C, or a red glossy tongue, which is indicative of iron deficiency.4 Therefore, performing a thorough periodic oral examination at least every 6 months may help prevent certain conditions from exacerbating or causing serious health problems. A dental practice should have an understanding of current nutritional advances, because today more than 80% of Americans have at least one nutritional deficiency, many of which can be recognized orally.5
With a multitude of nutritional news channels available online, filtering good information from bad can be difficult. Dental patients depend on their dental professionals to confirm what is presented in the news or on the Internet. Surveys show that only a small percentage of dentists and hygienists offer their patients some form of nutritional counseling regularly; it seems to be offered more frequently to children, but it is still done infrequently.6 Recommendations for a healthy, anticariogenic, anti-inflammatory diet should be incorporated in dental hygiene programs.
The Partnership for Healthy Mouths Healthy Lives enforces the message that brushing 2 minutes twice per day is necessary for prevention of caries and gingivitis. However, reducing bleeding interproximally also needs to be considered. Among the myriad of oral hygiene products, an oral irrigator has shown to be particularly effective in reducing gingival bleeding and maintaining healthy gingiva. In recent years, several studies have shown that an oral irrigator or water flosser was more effective than string floss at controlling gingival inflammation when combined with brushing.7,8 This reduction in gingival inflammation was seen around teeth and dental implants.9
Smoking Cessation Smoking remains one of the largest preventable causes of mortality globally, as well as a main risk factor in periodontitis, tooth loss, and oral cancer. One of the roles of oral healthcare providers is to motivate patients to quit smoking. A new product on the market (TBX-FREE, www.tbxfree.com) has shown promising results, with an 88% success rate in 21 clinical trials.10 Containing no nicotine or other carcinogens, the product utilizes cytisine, which is delivered in a dissolvable oral strip.
Both caries and periodontitis result from dysbiosis, or a change in the healthy oral biofilm. Factors leading to dysbiosis include: dry mouth; a processed, carbohydrate-rich diet; poor oral hygiene; smoking; and stress. Therefore, prevention of caries and periodontitis requires not just simply a change in oral hygiene habits, but also a lifestyle change.
Research on oral probiotics has increased exponentially. A number of well-controlled studies indicate that probiotics, particularly Lactobacilli, suppress Candida growth and biofilm development in vitro.11
Oral chewable probiotics are being investigated for the prevention and treatment of dental caries. Streptococcus salivarius strain has been shown to inhibit the growth of Streptococcus mutans.12 Regarding gingival health, several chewable probiotics are now being offered as an adjunct to post scaling and root planing to prevent recurrence of periodontitis or gingivitis. One systematic literature review concluded that available studies indicated an effect of probiotics on the oral microbiota and clinical periodontal therapy outcomes.13 More studies are needed to determine the exact strains and doses necessary for optimum effect. The good news is there is no toxicity associated with the use of oral probiotics. Results from current studies show that probiotics are effective against recurrence of caries, periodontitis, peri-implantitis, oral mucosal lesions, and halitosis.14
The American Cancer Society recommends oral cancer screening every year for patients aged 40 years and older, and every 3 years for patients aged between 20 and 40 years. Although a visual examination remains the gold standard, several screening tools are available for use in the dental office. A dye, or a light with or without a 1% acetic acid rinse, can be used to visualize abnormal tissues that could potentially turn carcinogenic.15 Early detection of oral cancer is important for long-term survival.
Oral cancer cells can develop in the presence of human papilloma virus (HPV). A saliva test is available (Oral DNA Labs, www.oraldna.com) to check for the presence of HPV in the mouth. Being HPV-positive is a risk factor for oral cancer; however, most people with HPV infections do not develop oral cancer.16 The American Cancer Society recommends eating a healthy, plant-based diet; limiting smoking and drinking; avoiding ill-fitting dentures and appliances; and performing early biopsies of leukoplakia and erythroplakias.
Chemoprevention is the use of medications to prevent individuals at higher risk, such as those with leukoplakia and erythroplakias, from developing oral cancer. Current research has shown promising results with vitamin A–based medications and oral rinses. Certain nonsteroidal anti-inflammatory drugs (NSAIDs), extracts of black raspers, and Bowman-Birk inhibitor, an extract from soybeans, are being studied for oral cancer prevention.17
Maintaining good oral health is a critical component of a person’s overall health. The dental community must increasingly build relationships with the medical profession to heighten awareness of the interconnecting of strong oral hygiene and prevention and total health.
1. Oral health. World Health Organization website. http://www.who.int/topics/oral_health/en/. Accessed April 7, 2016.
2. ADA Policy–Definition of Oral Health. American Dental Association website. http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/ada-policy-definition-of-oral-health. Accessed April 7, 2016.
3. Pedersen PU, Larsen P, Håkonsen SJ. The effectiveness of systematic perioperative oral hygiene in reduction of postoperative respiratory tract infections after elective thoracic surgery in adults: a systematic review. JBI Database System Rev Implement Rep. 2016;14(1):140-173.
4. Caruso D. Dr. Sanda Moldovan discusses the overlooked importance of oral health. Life Extension website. April 2015. http://www.lifeextension.com/magazine/2015/3/sanda-moldovan/page-01. Accessed April 7, 2016.
5. Moldovan S. Update on nutrition for better healing. Inside Dentistry. 2015;11(7):45-49.
6. Hayes MJ, Franki J, Taylor JA. The frequency of dietary advice provision in a dental hygiene clinic: a retrospective cross-sectional study. J Dent Hyg. 2016;90(1):12-17.
7. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Efficacy of Ttwo interdental cleaning devices on clinical signs of inflammation: a four-week randomized controlled trial. J Clin Dent. 2015;26(2):55-60.
8. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the plaque removal efficacy of a water flosser compared to string floss in adults after a single use. J Clin Dent. 2013;24(2):37-42.
9. Magnuson B, Harsono M, Stark PC, et al. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding: a 30-day randomized clinical trial. Compend Contin Educ Dent. 2013;34 spec no 8:2-7.
10. Elrashidi MY, Ebbert JO. Emerging drugs for the treatment of tobacco dependence: 2014 update. Expert Opin Emerg Drugs. 2014;19(2):243-260.
11. Walker GV, Heng NC, Carne A, et al. Salivaricin E and abundant dextranase activity may contribute to the anti-cariogenic potential of the probiotic candidate Streptococcus salivarius JH. Microbiology. 2016 Jan 7. doi: 10.1099/mic.0.000237. [Epub ahead of print]
12. Teughels W, Loozen G, Quirynen M. Do probiotics offer opportunities to manipulate the periodontal oral microbiota? J Clin Periodontol. 2011;38 suppl 11:159-177.
13. Gungor OE, Kirzioglu Z, Kivanc M. Probiotics: can they be used to improve oral health? Benef Microbes. 2015;6(5):647-656.
14. A Simple Mouth Cancer Screening Protocol. Mouth Cancer Foundation website. http://www.mouthcancerfoundation.org/mcsas/mouth-cancer-screening-protocol. Accessed April 7, 2016.
15. Can oral cavity and oropharyngeal cancers be prevented? American Cancer Society website. January 27, 2016. http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavity-and-oropharyngeal-cancer-prevention. Accessed April 7, 2016.
16. Dionne KR, Warnakulasuriya S, Zain RB, Cheong SC. Potentially malignant disorders of the oral cavity: current practice and future directions in the clinic and laboratory. Int J Cancer. 2015;136(3):503-515.
17. Matsubara VH, Bandara HM, Mayer MP, Samaranayake LP. Probiotics as Antifungals in Mucosal Candidiasis. Clin Infect Dis. 2016 Jan 29. pii: ciw038. [Epub ahead of print]