More Than Just Good Teeth: Oral Health and Well-Being

William R. Maas, D.D.S., M.P.H. is director of the Division of Oral Health at the CDC Center for Chronic Disease Prevention and Health Promotion in Atlanta. Programs of the division extend the use of proven strategies to prevent oral diseases, assist state and community dental public health programs, enhance surveillance of oral diseases and guide infection control in dentistry.

Q. What has prevented the public and professionals from acknowledging the link between oral and general health?

A. I think that until quite recently, unless symptoms were incapacitating, oral health had not been considered important enough in its own right. For example, a child with a nagging toothache in the classroom can't learn but isn't necessarily sick. And an adult with poor dentition might not be able to eat certain foods and may shun social interactions without being ill. That's changing now. Oral health is increasingly perceived as a vital factor in overall quality of life.

Q. What is driving the change in perceptions?

A. A number of factors. Biomedical research has reached a point where it can demonstrate that oral health and overall health are linked. And as greater understanding is gained in this area, multiple interactions are being identified. Pharmaceutical manufacturers and commercial considerations are also playing a part. There is greater interest for a drug that can safeguard, say, heart health as it protects health of the gums. The same disease that causes the loss of a tooth can now be considered a matter of life and death if the heart and blood vessels are also being damaged as a result of disease.

Q. Why have medical and dental practice developed along separate lines?

A. The causes go back over a century to separate training and practice traditions. Dentists still train in separate dental schools and mostly go on to dispense their services in small private practice. Physicians train and practice in the hospital setting. This tradition has created an artificial distinction between care of the mouth and care of the body. Even though many individuals know from experience that the two are linked, the delivery system doesn't reflect the belief that oral health is part of overall health.

Q. Has health insurance evolved around this dichotomy?

A. Health insurance was conceived as hospital insurance, taken out against unforeseen hospital stays due to illness. Dental expenses are considered more predictable and more manageable by good family budgeting. Ironically, dental insurance is more common for people with high salaries. Consequently, out-of-pocket dental expenses create a barrier for many people, relegating teeth to a lower priority.

Q. How realistic is the American ideal of perfect white teeth? Are white teeth healthier?

A. I think this ideal is just the latest stage in the raising of expectations. Around 150 years ago, people were resigned to losing their teeth by middle age, and it was viewed as progress when anesthesia reduced the pain of extractions. Next, dentures were greatly improved and we entered an era of replacement. Then better fillings came into use, so teeth could be repaired. By 1960, fluoride had proved its efficacy against tooth decay. People could reasonably expect to keep all or most of their teeth. Now they can aim even higher. White teeth are not intrinsically healthier than yellow teeth, but if society sets the standard for very white teeth, and self-esteem is damaged for those who can't reach that standard, then overall well-being is affected.

Q. Is there a marked difference in expectations of good oral health between generations?

A. Before 1950, multiple extractions and replacement with dentures was routine because it was thought that deteriorating teeth were a source of infection. Those born after World War II span the era of replacement and the era of fluoride-aided prevention that marks the dividing line between generations.

Q. How big is the gap between the public's perception of oral health and that of dentists?

A. A national study conducted in the early 1990s revealed that participants fared almost as well as dentists in assessing their own oral health. One third said that their oral health was good. Around 11 percent said it was excellent, 18 percent said it was very good. And 12 percent said their oral health was poor. These figures were largely borne out when participants were examined by dentists.

Q. How does the typical American diet and lifestyle affect oral health?

A. Not as much as it could, thanks to fluoride. Fluoride allows us to tolerate a wide range of unhealthy habits and foods. For example, the lidded sipping cups millions of young children drink from bring milk or sugary fruit drinks into prolonged contact with the teeth. Yet, thanks largely to fluoride, only about 20 percent of young children come into the dentist's office with severe cavities.

Q. Is there a proven bacterial link between chronic oral infections and conditions like diabetes, strokes and low birth weight?

A. The question is still being investigated, but evidence linking bacteria and resulting inflammation to these and other diseases is strong enough to motivate greater efforts to prevent periodontal disease.

Q. Can certain types of medication adversely affect oral health?

A. The most common and adverse side effect of many prescription and over-the-counter drugs is dry mouth. Not only is a dry mouth uncomfortable when eating and speaking, but saliva is vital to wash away and neutralize acids attacking the teeth. Drinks taken to remedy the problem often contain sugar, encouraging further decay. Dry mouth is a particular feature of asthma medication, so it affects millions of children. And at the other end of life, as more of us live longer and take more chronic pain medication, dry mouth is a growing problem.

Q. Do you foresee changing attitudes toward oral health as demographics change?

A. For the aging population, current Medicare definitions of "medically necessary" oral care are likely to become broader. For example, right now, treatment for serious periodontitis is not deemed "medically necessary" unless it could affect the outcome of treatment for a more serious condition such as leukemia. Also, the public may become less willing to put up with separate delivery systems and providers for overall and oral health as the link between the two is strengthened.

Advances in the Field: The Mouth as Diagnostic Tool

Scientists are using an ever-growing array of sophisticated analytical tools and imaging systems to test and study normal function and diagnose disease through oral cells and fluids. (1) Dushanka Kleinman, D.D.S., M.Sc.D., deputy director of the National Institute of Dental and Craniofacial Research at the National Institutes of Health, and chief dental officer for the Public Health Service, says this easier, noninvasive method of testing may become the diagnostic tool of choice. "Instead of using the special equipment and skills required to draw blood, a lesser-trained technician will increasingly be able to administer tests based on saliva or on cells inside the mouth," says Dr. Kleinman.

Saliva can be used to measure hormone levels or identify viruses such as hepatitis and German measles. It can give a timely warning about the possibility of pre-term labor and may soon give early warning of diabetes. Certain antigens can act as biomarkers for diseases, including cystic fibrosis. As an agent of detection, saliva also indicates levels of alcohol, tobacco, marijuana and other opiates in the blood. Insurance companies are using tests based on cells from inside the mouth to ascertain an individual's HIV status, and DNA taken from the cells in the inner cheek is being used as forensic evidence.

A number of factors are accelerating advances in oral diagnostics; the events of September 11 lent impetus to a growing interest in obtaining accurate biological information quickly. "Experts in nanotechnology and bio-engineering are working together, constructing templates to get fast, accurate test readings," says Dr. Kleinman, "and the ongoing miniaturization of technology is getting closer to creating a complete miniature laboratory on a computer chip."

Research is also benefiting oral health directly. For example, non-saliva-manufacturing cells have been re-engineered with a water-producing gene that changes them to saliva-producing cells, alleviating the uncomfortable and damaging symptoms of dry mouth caused by some cancer treatments.

"New tests are constantly being developed to make oral tissues and fluids an increasingly accurate mirror of health and sickness," says Dr. Kleinman. "Salivary diagnostics is an exciting new area of research."

Interview #2: : Cutting Teeth on Children's Oral Health

Burton L. Edelstein, D.D.S., M.P.H., is a pediatric dentist and chair of the division of community health at Columbia University School of Dental and Oral Surgery. He is also founding director of the Children's Dental Health Project in Washington, D.C., which provides technical assistance to policy makers.

Q. What is the current status of children's oral health in the United States?

A. The oral health of children in the United States is the best it has ever been. For those who have benefited from advances in prevention and treatment, there has been an enormous improvement since the Second World War. Yet many children from low-income and minority families continue to experience profound disparities and disease. Put another way, 75 to 80 percent of children's mouths are in good shape. Another 15 to 20 percent have addressable problems; but in around 5 percent, that is around 3 to 5 million children, we are seeing extreme dental disease.

Q. How does poor oral health affect children?

A. Overall, children suffering from dental problems lose an estimated 52 million school hours annually. (10) Poor children experience nearly 12 times as many restricted activity days from dental disease as do children from higher-income families, (10) and they are often already at risk for other socioeconomic problems. In addition to pain and suffering, untreated disease can lead to problems in eating and speaking. And children can't learn properly when they're in pain. Q. Within minority groups, which children are doing worst of all?

A. American Indian and Alaskan Native children have among the highest rates of tooth decay. Hispanic and African-American children also have disproportionately high rates of tooth decay. The Hispanic population is the fastest growing in the United States, so I think we'll be seeing a rise in disease for children in this group.

Q. Apart from financial reasons, why are these children experiencing more disease?

A. Specific cultural determinants play an important role. For example, certain parenting behaviors can impede or accelerate the transfer of bacteria to the child. Some American Indian cultures, particularly the Navajo, often feed infants by pre-chewing food in the traditional way. You couldn't invent a more perfect vehicle for transmitting bacteria! Specific items in the diet, such as certain sugar-laden drinks, can create conditions for disease; so can parental values and expectations about levels of oral health. Adults we've worked with in West Virginia often expect to lose all their teeth, yet in Oregon, many more patients expect to keep their teeth through life. Q. What are the barriers to improving children's oral health?

A. First of all, I'd like to make a clear distinction between barriers to accessing existing services and barriers to utilizing these services, especially among low-income and minority families. For access, the door has to be open; for utilization, parents have to be willing - or in the case of older children, they have to be willing - to walk through the door. For example, a study in Oregon explored what motivates a parent to use the services available. Some parents will automatically ensure that children see a dentist regularly; others will only visit when a child has been up during the night in pain.

Q. Is there adequate provision for children's oral health?

A. Yes, in theory. The Medicaid Expanded Early and Periodic Screening, Diagnosis and Treatment Planning benefit is a model for children's overall and oral health coverage and offers comprehensive benefits to eligible children. But its effectiveness is being limited by a number of factors. Certainly if the programs worked as they were supposed to, we'd have a considerable reduction in disparities.

Q. What factors are limiting access to better oral health for eligible children?

A. A major stumbling block is Medicaid's failure to pay dentists at what approaches market rates. The dental marketplace is more financially sensitive than its medical counterpart. People shape this marketplace by their willingness to pay for services. Little managed care or discounting takes place, and there is limited capacity in a typical one- or two-dentist practice to compensate for low Medicaid fees and missed appointments. However, resolving financial barriers is a necessary, but not sufficient, condition for improving access. Administration must become less cumbersome and payment must be made more quickly to dentists. You have to be pretty determined in order to become a Medicaid provider.

Q. What is preventing wider availability and better utilization of the services where they do exist?

A. Mutual low expectations and stereotyping can constitute a considerable barrier. Dentists sometimes question whether patients value the service they are offering, whether they will keep appointments. Even seemingly small considerations can make dentists think twice. Will the reception area be crowded and noisy because all the children in the family have accompanied the patient? Will this deter other patients from using the dentist's services? From the patient's point of view, the situation is exacerbated by the lack of diversity among providers, which fails to reflect the population as a whole. So patients from minority backgrounds can feel intimidated and disrespected by providers.

Q. How widespread is the use of fluoride in America? Why doesn't everyone have fluoridated water?

A. Some of the largest cities in the nation are now using fluoride, with Los Angeles the most recent convert. Elsewhere, cost can be a factor depending on the smallness of the community, and a substantial number of people depend on individual or shared wells. Adding fluoride to such facilities would not be cost-effective. However, naturally present fluoride levels vary across the country, sometimes providing enough fluoride to be effective.

Q. Would greater integration of medical and dental systems be beneficial to children's oral health?

A. To a certain degree, rational integration empowering physicians to promote oral health would be highly beneficial. Pediatricians should incorporate anticipatory guidance and risk assessment for oral health and dental disease in a much more effective way than at present. Risk assessment and effective referrals are a good thing; primary oral care by physicians - perhaps. But physicians carrying out dental therapy - probably not. Each profession should understand and respect the other's competencies and capacities.

Teeth for Life: Problems and Prevention

Oral Health in Infancy and Childhood

Threats to good oral health can begin in infancy. They include early childhood caries (baby bottle tooth decay), a rampant form of the disease often associated with inappropriate feeding practices. (11)

By the time children are 5 to 9 years old, more than 50 percent have at least one cavity or filling. (1) By late adolescence, about 80 percent of teenagers have acquired this preventable infectious disease. (12) In addition, tobacco use, excessive alcohol consumption and poor dietary practices contribute to the development of oral lesions, cancers and gum disease (periodontal disease and gingivitis) in some adolescents. (1)

Good habits should be instilled as soon as possible. Parents should begin brushing children's teeth with toothpaste at around 12 months. They should check for signs of gum disease such as red and swollen gums and bad breath. A balanced diet containing sufficient calcium and vitamin C can help guard against periodontal disease. Older children should also be educated about the health risks of smoking. It is the No. 1 preventable risk factor for periodontal disease. (13)

Adult Oral Health

Most adults show signs of periodontal or gingival diseases. Clinical symptoms of viral infections, such as cold sores and oral ulcers are also common in adulthood. Immunocompromised patients, such as those with HIV infection and those undergoing organ transplants, are at higher risk for oral problems such as fungal mouth infection.

A regular oral hygiene program and regular dental and periodontal appointments will keep teeth and gums healthy throughout normal adult life. An effective routine includes brushing with a soft-bristled brush for at least two and a half minutes, gentle flossing and using a plaque-disclosing tablet or solution to show up "hidden" plaque for removal. Signs of periodontal disease such as loose or separating teeth and bleeding gums during brushing should be treated promptly by a professional. Mouth guards are available for those who grind their teeth while sleeping, a habit that damages the supporting tissues of the teeth. (14)

Aging and Oral Health

In addition to common oral health problems, older adults can experience other difficulties: missing teeth, poor dentures, cavities, gum disease and infection can lead to changes in the diet, especially avoiding fruit and vegetables. Social interactions such as eating and conversation can become embarrassing and difficult. Many medications for chronic pain can dry up the flow of saliva, impeding eating and speaking and encouraging decay. Periodontal disease, accumulated over time, is potentially a factor in diabetes and cardiovascular diseases, a major cause of death among the elderly. Oral cancer is seven times more likely to occur in those 65 and older. (15)

Regular dental visits, at least once a year, are necessary to spot problems early in teeth gums and soft tissue, and for prevention, early detection and treatment of oral health problems. Such visits also provide an opportunity to review the patient's home care practices, which remain important to keeping teeth, and to adjust the fit of dentures. (15)

As our life expectancy increases, maintaining good oral health from infancy to advanced old age is both possible and essential for overall well-being. With regular care and dental visits, the possibility of keeping healthy teeth throughout life is well within reach.

Opportunistic Infections: Links to Systemic Diseases

National Institute of Dental and Craniofacial Research

The periodontium, the area of the mouth that includes the gingiva (gums) and bones that hold the teeth in place, plays a key role in the connection between oral health and systemic disease. Infections in these tissues not only harm the mouth but also are linked to a variety of conditions affecting the entire body. (16)

Diabetes Mellitus

The destructive inflammatory processes that define periodontal disease are closely intertwined with diabetes. Persons with noninsulin-dependent diabetes mellitus are three times more likely to develop periodontal disease than nondiabetic individuals. Add smoking to the mix, and the chances of developing periodontitis with loss of tooth-supporting bone are 20 times higher. An increased risk for destructive periodontal disease also holds for persons with insulin-dependent diabetes mellitus.

Recent findings offer evidence that chronic infections such as periodontal disease worsen glycemic control and that eliminating these infections could enhance metabolic control in persons with diabetes.

Heart Disease

A number of studies have shown that people with periodontitis are more likely to develop cardiovascular disease than individuals without periodontal infection. One such study suggests that the risk of fatal heart disease doubles for persons with severe periodontal disease.

Scientists theorize that certain types of these bacteria, which form biofilms and cause periodontal disease, also activate white blood cells in the body to release pro-inflammatory mediators that may contribute to heart disease and stroke.

Pre-Term Low Birth Weight Babies

Emerging evidence may link severe periodontal disease in pregnant women to a sevenfold increase in the risk of delivering pre-term low birth weight babies. NIDCR-supported researchers estimate that as many as 18 percent of the 250,000 premature low-weight infants born in the United States each year may be attributed to infectious oral disease.

In a recent study, mothers of pre-term low-weight newborns had significantly more severe periodontal disease than the mothers of full-term, normal weight babies did. Investigators believe that the molecular pathogenesis may be similar to that characterized for other maternal, bacterial, opportunistic infections, such as genitourinary infections, that are associated with low-weight pre-term births.

Integrating Medicine and Dentistry

The longstanding separation of medical and dental systems can be traced back over 100 years, when both professions developed discrete paths for training and practice. The result, says CDC Oral Health Division Director William Maas, D.D.S., "is an artificial separation between care of the mouth and the body, to the detriment of patients' overall health." This distinction is found at all levels of both professions, from professional training, through clinical care and continuing education, and in scholarly journals, research agendas and financing and delivery mechanisms. (10)

A recent national survey showed a lack of basic oral health knowledge on the part of many pediatricians. Conversely, an emphasis on technical training for dentists may contribute to an observed under-reporting of problems such as child abuse and neglect.

Chief Dental Officer for the Public Health Service, Dushanka Kleinman, D.D.S., believes that nurses, pharmacists, social workers and all health professionals should understand the tenets of oral health, as well as physicians. "Physicians and nurses should be able to perform triage in the oral cavity," she says, "but should they carry out more specialized procedures? More investigation is needed before we can answer that."

The Surgeon General's Report on Oral Health suggests several ways in which care providers can and should contribute to enhancing oral health. These include incorporating oral examinations into a general medical examination, advising patients in matters of diet and tobacco cessation and referring patients to oral health practitioners for care prior to medical or surgical treatments that can damage oral tissues, such as cancer chemotherapy or radiation to the head and neck. (1)

The Research

Bibliography

1. U.S. Department of Health and Human Services. (2000). Oral Health in America. A Report of the Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

2. U.S. General Accounting Office. (2000). Oral Health: Dental disease is a chronic problem among low-income populations. GAO/HEHS-00-72. Available: www.gao.gov

3. Slavkin, H.C., & Baum, B.J. (2000). Relationship of dental and oral pathology to systemic illness. Journal of the American Medical Association 284, 1215-1217.

4. Griffin, S.O., & Jones. K, SL. T. (2001). Economic evaluation of community water fluoridation. Journal of Public Health Dentistry 61(2), 78-85.

5. Centers for Disease Control and Prevention. (2002). Improving Oral Health: Preventing Unnecessary Disease Among All Americans. Available: www.cdc.gov

6. National Center for Chronic Disease Prevention and Health Promotion. (2002). Adult Oral Health Fact Sheet. Available: www.cdc.gov.

7. Albandar, J.M., Brunelle, J.A., & Kingman, A. (1999). Destructive periodontal disease in adults 30 years of age and older in the United States, 1988-1994. Journal of Periodontology 70, 13-29.

8. Tomar, S.L., & Asma, S. (2000). Smoking-attributable periodontitis in the United States: Findings from NHANES III. Journal of Periodontology 71, 743-751.

9. The American Academy of Periodontology. (2000). Fact Sheet on Periodontal Disease. Available: www.perio.org.

10. Mouradian, W.E., Wehr, E., & Crall, J.J. (2000). Disparities in children's oral health and access to dental care. Journal of the American Medical Association 284(20), 2625-31.

11. Tinanoff, N. (1997). Early childhood caries: overview and recent findings. Pediatric Dentistry 19(1), 12-16.

12. National Institute of Dental Research. (1989). Oral health of the United States children: the national survey of dental caries in school children, 1986-87; national and regional findings. Bethesda, MD: National Institute of Dental Research. DHSS (Publications No. (PHS) 89-2247).

13. The American Academy of Periodontology. (2001). Don't Brush Off Importance of Children's Oral Health. Available: www.perio.org

14. The American Academy of Periodontology. (2001). Tooth or Consequences: 10 Steps to Add Years to Your Life. www.perio.org

15. Vargas, C.M., Kramarow, E.A., Yellowitz, J.A. (2001). The oral health of older Americans. Aging Trends; No. 3. Hyattsville, Md.: Centers for Disease Control and Prevention; National Center for Health Statistics.

16. National Institute of Dental and Craniofascial Research. (no date). Oral Opportunistic Infections: Links to Systemic Diseases. Available: www.nidcr.nih.gov

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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