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Cavity Searches: Using Dentistry as a Diagnostic Tool
You wouldn’t think of scheduling a dentist visit to check out your general health. But maybe you should.
Take the case of the 25-year-old woman who showed up in the chair of Center City periodontist Dr. Louis Rose. Her presenting complaint was bleeding gums, but a dental X-ray showed that she also had over 50 percent bone loss in several of her teeth. Yet, to Rose’s surprise, her mouth had very little plaque, the bacteria that leads to infected gums. “That was really odd,” says Rose. “I immediately thought there must be something wrong in her body, even though she reported she was very healthy.” He sent her to an internist to see what else might be going on. Sure enough, the woman was suffering from diabetes, which is frequently linked to gum disease. And, as often happens, Rose couldn’t arrest the problem in her mouth until her physician controlled the disease in her body.
Situations like this one aren’t so unusual. The mind/body connection is yesterday’s news. What’s cutting edge today is the mouth/body connection. The mouth is now understood to be a diagnostic gold mine for identifying diseases of the body, so much so that the Surgeon General’s 2000 report, Oral Health in America, stated that “the mouth reflects general health and well-being and … reflects what is happening deep inside the body.”
It’s been established by the Centers for Disease Control and Prevention that the common gum infection known as periodontal disease affects half of all adults over 30; after age 70, that number jumps to 70 percent. It’s more prevalent in men than women. And a whopping 64 million Americans have the more serious form known as periodontitis, which is related to conditions as varied as diabetes, heart disease and stroke, some respiratory problems, premature and low birth-weight babies, and osteoporosis. The jury is still out on whether one causes the other or simply aggravates the problem, but nobody questions that there is a link. Don’t think you’re out of the woods once you outgrow the cavities and fillings stage — especially if you don’t follow mom’s orders to brush and floss after meals.
Interest in the mouth as a canary in the body’s coal mine goes back at least 60 years. Dr. D. Walter Cohen, former dean of the University of Pennsylvania School of Dental Medicine and currently chancellor emeritus at Drexel University College of Medicine, first became interested in the dental/medical link when he was studying to be a dentist back in the 1950s. Autopsies he performed showed a striking connection between gum disease and diabetes. Several years later, Cohen got a National Institutes of Health grant to delve into the relationship more deeply at Penn. “The results,” he says today, “were a real eye-opener.” So much so that periodontal disease is now considered one of the leading complications of diabetes, along with blindness and amputation. And Rose, Cohen’s colleague, was so enamored of the medical aspects of dentistry that he became an M.D. after attending dental school. That is one reason he considers taking a careful and thorough medical history to be the most important part of an initial dental examination.
Conversely, a growing number of physicians are now taking the time to routinely poke around the mouth when they ask a patient to say “ahhhh.” Penn internist Dr. Mike Cirigliano always looks at his patients’ tongues and teeth to pick up evidence of things like eating disorders, anemia and damage from smoking and alcoholism. He says, “The mouth can definitely tell you a lot about what’s going on in the body.” Moreover, when infections in the mouth are ignored, they can be fatal. In 2007, the media obsessed over the tragic story of a 12-year-old Maryland boy, Deamonte Driver, who died after bacteria from an abscessed tooth spread to his brain because his mother couldn’t afford the $80 an extraction would have cost. His was not an isolated case. Researchers in Boston found that between 2000 and 2008, 66 people died after hospitalizations related to dental abscesses.
While dire complications are the extreme rather than the norm, uncontrolled bacteria in the mouth can be very nasty stuff that goes way beyond swollen, sore gums, loose teeth and bone loss. That’s because periodontal disease can also lead to a raging bacterial infection resulting from plaque, which lodges in your teeth and gums every time you eat. In most cases, the infection can be easily controlled by visiting a hygienist who has been trained to do the kind of deep cleaning that scrapes off plaque and tartar both above and below the gum line. Just polishing the teeth won’t cut it. The danger point is when the infection —which starts with gingivitis or bleeding gums — is ignored and left untreated. Those germs in your mouth can hitch a ride in your bloodstream and travel around your body triggering rampant inflammation, which, in turn, exacerbates certain medical conditions already present.
On the positive side, inflammation is a life-saving immune response that fends off all kinds of invading bacteria and viruses. Accidently hit your thumb with a hammer and the swelling sets off an inflammatory alarm triggering a flood of white blood cells sent to start the healing process. Nobody would live to adulthood without the inflammatory response. But you can get too much of a good thing. When inflammation is ongoing — due to a persistent stimulus such as the lingering infection caused by gum disease — it quietly smolders, wreaking havoc on the delicate balance in your body. There are no symptoms of chronic inflammation to warn you something is amiss. You don’t even feel sick. Just about the only visible evidence of inflammation is periodontal disease.
Chronic inflammation is particularly dangerous in people with conditions known to be intensified by it, like diabetes. How many doctors suspect gum infections when insulin levels start to spike? “We now know that diabetics who’ve had their gum disease treated with as little as one deep cleaning usually need lower doses of their insulin-regulating medication,” points out Dr. Joseph Fiorellini, dean of the University of Pennsylvania School of Dental Medicine. “And that’s a two-way street, because diabetes also increases the incidence of gum infections. It’s really important for diabetics to get regular dental care.”
Heart disease is so closely associated with inflammation that doctors test for its presence in heart patients by measuring a protein called CRP to assess risk. Dr. Steven Gilbert, a general dentist in Center City, once had a patient with severe heart disease who needed massive dental work, but she chose to forego treatment because of the cost. Three years later, her heart had deteriorated to the point where she needed a transplant. Her surgeon sent her back to Gilbert to have him sign a form that she was free of infection. To comply, he had to pull the majority of the teeth in her mouth that she had neglected. Unfortunately, she died before she got a new heart. “In my mind,” Gilbert says, “her untreated oral problems and all the infection they created in her mouth could very well have accelerated her heart disease.” It’s not so far-fetched: Research has shown that the bacteria in dental plaque matches the bacteria in the plaque that clogs arteries.
Since people are far more likely to see a general dentist like Gilbert to have their teeth cleaned regularly than visit a periodontal specialist like Rose, it is essential that your neighborhood dentist look for signs of medical breakdown in your mouth. “Anybody who only sees a hygienist on their dental visit is being short-changed,” Gilbert warns. “At every cleaning, your gums should be measured and examined and checked by the dentist.” He notes that certain medications can affect the mouth. Some anti-depressants and heart medications can cause dry mouth, and the loss of saliva makes you more prone to cavities and gum inflammation. One side effect of Prozac is teeth grinding. To an attentive dentist, any rapid or sudden change in the mouth is a red flag that should raise suspicion. One of Gilbert’s patients who had always been meticulous about his oral health called for an emergency visit to have his swollen gums examined. Gilbert noticed considerable bone loss he had never seen before. The man’s immune system had clearly broken down; three months later, he was diagnosed with lymphoma.
Infection is one of the most serious concerns in operations that replace an old, damaged body part with something new and artificial, whether that’s a heart valve or a hip. That’s one reason orthopedic surgeon, Dr. Robert Booth, who has performed 17,000 total knee replacements in the last 13 years alone, asks his patients to schedule a dental check-up before joint replacement surgery. “The mouth is the No. 1 source of post-operative joint infections after a three-month period,” he says. “I probably see eight to 10 people a year with infections that started in the mouth. While not everyone agrees with me, I advise all my patients with artificial knees to take two amoxicillin” — an antibiotic — “as a precautionary measure before any dental procedure.”
If you are planning to have a baby, you should visit your dentist when you stop using birth control. Dr. Owen Montgomery, chief of obstetrics and gynecology at Drexel University College of Medicine, personally believes there is compelling evidence that good dental hygiene before and at the start of pregnancy leads to better outcomes, such as fewer premature births and low birth-weight babies. “Dental infections increase the inflammatory response,” he says. And that does not promote a healthy pregnancy.
Poets may rhapsodize about the eyes being the window to the soul, but on a more practical level, the mouth is the window to the body. The quest for a dazzling smile isn’t the only reason to see your dentist regularly. o
Carol Saline is the chief medical affairs correspondent for Inside and Special Sections. This article originally appeared in Inside Magazine, a Jewish Exponent publication.