By Jenna Makowski
As an increasing number of clinical studies probe correlations between the mouth, the body and systemic conditions like cardiovascular disease, diabetes and stress, Northern Virginia’s top dentists confirm what they’ve suspected all along: a healthy body is contingent on a healthy mouth. Read some of the advice they’re giving their patients, and see how it aligns with your own experience of the mouth-body connection.
Linking Gum Disease
To the Rest of the Body
Six Degrees of Kevin Bacon: It’s a popular party game, with the premise that each person is only six introductions away from every other person on the planet.
While Microsoft conducts studies to prove that there are indeed on average 6.6 degrees separating you from every corner of the external world, medical researchers are directing the same thinking internally. And they are finding, with growing clarity, that the human body functions on a similar system of connectivity.
For example, how many degrees separate your mouth and your heart? Three.
As the correlation between gum disease and heart disease continues to evolve, the door has opened to consider possible links with other chronic inflammatory conditions whose prior connections with the mouth might have been laughable. Seemingly remote diseases, for example, like Alzheimer’s. A recent study conducted by NYU researchers shows early but potentially strong correlations between inflammation in the mouth and inflammation in the brain. Though further research is needed, the implications for ensuring that aging populations have continuous access to dentists’ offices will no doubt shape future conversations and debates in the world of healthcare.
Poor oral hygiene leads to an overgrowth of bad bacteria. These bacteria, which cause gum disease, may enter the bloodstream and cause inflammation, which in turn is a common indicator of heart disease.
The nuances of such connections belie complexities that modern science is just beginning to understand, and findings are cautiously being shared as “correlations” or “associations” until the exact links are clarified—if they ever are. But the ramifications are changing the ways that doctors think about the teeth, and dentists think about the body.
One of the most common afflictions of the mouth treated by dentists in the United States, gum disease affects up to 75 percent of adults. The root cause of the inflammatory disease is bacteria, which build up from rogue plaque and cause the redness, swelling and bleeding known as gingivitis. When left untreated, gingivitis can develop into more serious periodontitis, when the bones and tissue connecting the teeth to the jaw erode.
Caused by factors that range from poor oral care and bad nutrition to weakened immune systems or unfortunate genetics (or any combination thereof), gum disease is reversible when diagnosed early, manageable when diagnosed late, and largely preventable.
It’s also a hot topic in dental research, as findings are increasingly correlating gum disease with a myriad of other diseases; for example, cardiovascular disease.
The terms of the relationship between gum disease and heart disease are important. As the American Heart Association pointed out in a recent study, a direct causal relationship has not been identified. But the association is very real.
As Dr. Justin Zalewsky cautions, “There’s a correlation between the two that is not yet directly proven.”
It’s about risk factors. “The connection has been growing in the last 15 or so years, when cardiac researchers found oral bacteria in cardio plaque,” explains Dr. Brian Feeney. “Having gum disease shows an increased risk of heart attack. It’s not saying that if you have one, you will have the other. But there’s an increased risk.”
The research is just beginning, and the lynchpin seems to be inflammation. “It’s like having a pool of bacteria in your mouth,” says Dr. John Kling. “If there is also inflammation or open, bleeding wounds, bacteria can enter the bloodstream.”
From there, the bacteria get caught in cardiac vessels, creating more inflammation. Or, as the American Academy of Periodontology points out, inflammation in the mouth triggers plaque build up and swelling in the arteries. Inflammation in the blood vessels is a major risk factor for a heart attack.
Approximately three out of four Americans at some point in their lives have exhibited signs of gum disease, a condition largely controlled—or prevented—with good brushing, flossing and regular dental care. Sometimes, however, gum disease persists.
For such cases, a growing number of Northern Virginia dentists are using an oral “swish and spit” test that reads the mouth’s bacteria count. Dr. Gordon Rye has been offering the test for nearly two years.
“If a patient is resistant to healing, or if we clean them up but [the swelling and bleeding] come back, then we test for bacteria. If it comes back positive, we treat using antibiotics. [The goal] is to change the ratio [of good versus bad bacteria] and increase good bacteria, like a probiotic.”
Dr. Rye’s results have been largely positive. One patient treated 20 years of chronic gum inflammation with medication. In the process, Dr. Rye (and the patient’s cardiologist) believes she also lowered her risk of a heart attack.
“The fear,” Dr. Rye cautions, “is over-treating with antibiotics, and we don’t want to do that.” For patients suffering from chronic gum disease, however, the oral test may be a viable course of treatment.
Research has also shown that significant numbers of premature and low-weight births are accompanied by unhealthy gums. A formative study conducted in 1996 suggested that mothers-to-be who had periodontitis exhibited a risk up to seven times higher of delivering prematurely.
Furthermore, hormonal changes accompanying pregnancy can lead to highly sensitized gums more prone to gingivitis, or can aggravate symptoms that already exist.
Though more research is needed to find the exact link between gum disease and early labor, it’s possible that inflammation provoked by bacteria is involved. Sores in the gums from periodontitis become doorways to the rest of the body, and bacteria may travel from the mouth and through the blood to the uterus. The inflammation it triggers may cause early contractions and possibly premature birth.
Likewise, the verdict is still out on the most effective forms of periodontal treatment—particularly in severe cases of periodontitis—in regards to lowering the risk of premature birth. Prevention is optimal.
The American Dental Association stresses diligent oral hygiene at home during pregnancy. And dentists like Dr. Sherry Kazerooni are taking a proactive role in mitigating the risk of developing gingivitis.
“How many times should you visit the dentist each year?” challenges Dr. Kazerooni. For most people, that answer is two—the average number of visits covered by most insurance companies. But for some patients, particularly ones who are pregnant, Dr. Kazerooni encourages dental cleanings every three months.
For women, a visit to Dr. Kazerooni’s office is accompanied by self-authored newsletters and information leaflets outlining what she believes expectant mothers should know about their oral health and the health of their unborn children.
“There’s a lot the public doesn’t realize about these connections,” Dr. Kazerooni explains. “Hormonal changes can lead to gum problems … and gum disease can lead to premature labor.
While the language around gum disease and other inflammatory conditions hinges on correlations, the connection with diabetes is more directly proven.
“There is a bi-directional relationship between diabetes and periodontal disease,” says Dr. A. Garrett Gouldin. “Control of diabetes can directly affect one’s ability to control periodontal disease.” And vise versa.
When poorly managed, diabetes can compromise the immune system, making it harder for the body to fight infection. Inflammation, the body’s basic reaction to infection, runs rampant. This puts diabetics at a heightened risk of developing gum disease, or makes already present gum disease more difficult to manage. Higher levels of inflammation are associated with a decrease in insulin sensitivity and higher blood sugar.
On the spectrum’s positive end, effectively treating and managing gum disease reduces inflammation in the body. This also reduces glucose levels, and thus bolsters the management of diabetes.
“When a diabetic patient is at or near the threshold for pharmaceutical intervention,” explains Dr. Rye, “controlling periodontal disease may lower the need for intervention below that threshold.”
While it’s not possible to cure diabetes with gum disease treatment, the simultaneous management of both can result in a higher quality of life.
Seeing the correlation between stress and gum disease requires a more holistic (or, for the more scientifically-minded, systemic) perspective. Stress—particularly when prolonged—wreaks havoc on the body/mind balance.
“With stress there’s a change in the immune response,” explains Dr. Gouldin. “Many people find that when they are stressed, they are more likely to catch a common cold.”
When the immune system is compromised—whether it’s related to stress, poor nutrition, diabetes or other infectious diseases—there is a higher risk of developing gum disease or other infections. Research is unraveling a correlation with the hormone cortisol, which when released during stress, weakens the immune system and leaves strained bodies more prone to infection.
Adding fuel to the fire, when you’re stressed, you might be less likely to take care of your body—to brush your teeth, to eat healthly or to sleep soundly—which in tunr invites disease. Then, when infections manifest themselves, they in turn create more anxiety. It’s the vicious-cycle syndrome.
Ideally, says Dr. Gouldin, proper treatment requires a balanced care plan that encompasses full bodily and mental nurture—balanced diet, sleep, exercise and meditation.
Beyond Gum Disease:
Other Mouth-Body Connections
Stress and the Teeth
Beyond gum disease, the mouth is also a repository for symptoms of other bodily afflictions. Just as there is a correlation between stress and the gums, stress can also affect the teeth.
Tooth grinding, known in the world of dentistry as bruxism, can be the result of stress manifesting itself during sleep. The teeth become punching bags, taking the brunt of the subconsciousness’ attempt to release stress and unwind. The results vary, from the gradual wearing away of enamel, which causes teeth to become hyper-sensitive and vulnerable to cracks and fractures.
Like gum disease, bruxism can be mitigated by stress management. Sometimes, however, dental intervention is necessary to protect the teeth.
“Have a bite guard fabricated,” suggests Dr. Gouldin.
Bite guards, sold in over-the-counter pharmacies, are worn at night to protect the teeth from the impact of grinding. Though, Dr. Gouldin recommends a customized bite guard, created by your dentist. Store-bought bite guards are “a bad idea,” he explains. “Professionally made appliances fit more snugly, are harder, and are more precisely adjusted.” In other words, more effective. An important consideration, given that bruxism affects your whole mouth—and the cost of fixing or replacing all your teeth is far more expensive in the long run.
While stress may be one cause of bruxism, other factors such as abnormal bites, missing and crooked teeth, or sleep disorders may also contribute.
Certain sleep disorders can manifest other symptoms in the mouth.
“One of the hottest topics in dentistry right now is sleep apnea,” says Dr. Chong Lee.
Sleep apnea is a condition in which the airways become blocked during sleep. The first to notice symptoms, however, usually isn’t a
dentist or a physician. Nor is it the one suffering from the condition. Family members or partners who wake in the middle of the night to loud snoring or gasps for breath are often the first to realize that something is afoot.
The risks of sleep apnea extend beyond the pokes and prods that come from disgruntled bed partners. According to the American Academy of Dental Sleep Medicine (AADSM), sleep apnea can be life-threatening.
Sleep apnea sufferers may actually stop breathing for short periods of time, limiting oxygen flow to the organs. This can lead to hypertension, stroke or suffocation.
The AADSM exists, in part, to foster collaboration between physicians and dentists, as the condition offers fertile ground for the two medical communities to work together—hopefully indicative of a future trend in all areas of body and mouth disease.
Though a sleep physician should be the one to properly diagnose sleep apnea, “dentists look for symptoms,” explains Dr. Lee. For example, they can check the back of the throat to see if it’s wide enough for oxygen to pass.
Dentists also play a crucial role in the treatment of sleep apnea, creating custom-fit oral appliances that move the jaw forward, allowing the air passages to open. The optimal result is a night of easy breathing and snore-less sleep. And perhaps a saved marriage in the process.
Dr. Lee also reminds those who suffer from, or who are at risk of, TMD to take that into consideration when getting an oral appliance. TMD, which stands for temporomandibular disorder, arises when the TMJ, the temporomandibular joints, become imbalanced. In other words, when the delicate complex of bones and muscles that operate your jaw are thrown out of whack. TMD may be caused by a myriad of factors, from sudden or sustained trauma to genetic predisposition. Sometimes sleep apnea goes hand-in-hand with TMD, while other times a new dental appliance may cause TMD or aggravate already present symptoms. If you suffer from TMD, it’s important to have an oral appliance crafted to a specific bite position, which is determined with special diagnostic instrumentation.