One of us (NB) has been reasonably conscientious about his health for the past 50 years. He sees his PCP twice a year and has tried to set an example for his patients by focusing on diet and exercise. I have done well, except I need a little work on stress reduction and sleep hygiene. Curiously, in 50 years and more than 100 office visits to health care providers, no physician has ever examined my mouth, except for the rare instance when I had a sore throat. Oral examination has been relegated solely to the dentist. This article’s purpose is to motivate physicians to not only take good care of their own dental hygiene, but to evaluate and recommend care for their patients’ dental health, and not leave oral examination solely to the dentist.
The mouth as a gateway to health
It is now well accepted that the mouth is the gateway to many medical problems. Poor dental health can dramatically affect more than a patient’s smile. Poor oral hygiene increases the risk for many medical problems, from heart disease to cancer, and now we have identified that poor oral hygiene can even lead to dementia. A meta-analysis of more than 30,000 people found that those who are edentulous had a 1.4 times higher risk of dementia, most likely because the factors that caused them to lose their teeth in the first place, such as smoking, drinking, and poor dental hygiene, would plus other factors that would predispose or lead someone to eventually succumbing to dementia.
Two-thirds of adults over 65 have periodontal disease. Gum disease is easily recognized when patients have bleeding gums during routine brushing, so this is a good simple question to ask your patients when you are doing a physical exam: Do your teeth bleed when you are brushing? Over time, when left untreated, periodontal disease can cause gum recession and resorption of the supporting alveolar bone, leading to tooth loss. Other symptoms of periodontal disease are loose teeth, pain during chewing, and persistent bad breath.
In addition to the increased risk of heart disease, periodontal disease has been linked to the development of diabetes, lung disease, rheumatoid arthritis, and certain cancers. The reverse may be true: A chronic medical condition may make people’s mouths more vulnerable to periodontal disease and tooth loss, so it is important for the physician to know what medications and medical treatment the patient is undergoing to make sure there is no negative dental effect.
Since many older patients have periodontal disease leading to tooth loss, the average older adult has approximately 20 remaining teeth. One in six adults age 65 and older has lost all their teeth. Poor hygiene and periodontal disease are associated with an increased risk of myocardial infarction, CHF, and CVA. Having multiple lost teeth has a higher risk of death than heart disease and cancer compared to those who retained at least 20 teeth. So having numerous missing teeth can be a window into the patient’s general health and overall hygiene, as people who eat healthy and take care of their bodies generally do not lose teeth.
Medications and dry mouth
About 60 percent of older adults complain of dry mouth. Saliva helps neutralize acids and remineralize tooth structure. Since saliva washes the teeth keeping them clean, dry mouth can increase the risk for cavities, tooth loss, and bad breath.
Older people are often polymedicated and take more than five medications a day. Since many of these medicines can cause dry mouth there is evidence that polymedicated patients have fewer natural teeth. A list of common medications that contribute to dry mouth includes:
- Anti-anxiety drugs such as Xanax
- Anticholinergic medications such as oxybutynin and other medicines prescribed for managing an overactive bladder
- Antidepressants like citalopram or Celexa
- Antihistamines to treat allergies, like loratadine or Claritin
It is very important as a physician to know if your patient is taking any of those medications so you can warn them of the potential dental implications and prescribe Biotine or other dry mouth rinses.
Advice for patients
Encourage at least a semi-annual visit to the dentist. Approximately 40 percent of older adults did not see a dentist in 2022. Regular dental care twice a year can help prevent dementia.
Older people who smoke are more than three times as likely as a non-smoker to lose all their teeth. Encourage your smoking patients to participate in a smoking cessation program. As we know, smoking cessation also reduces the risk of cardiac and pulmonary diseases.
Have your patients, particularly older ones, consider automating their toothbrushing with an electric toothbrush. The electric toothbrushes spin and vibrate to help remove food particles and plaque. The newer versions, such as the Quip, have a timer that indicates 30-second increments for each quadrant of the patient’s mouth to reach the American Dental Association-recommended two-minute brushing mark.
Daily flossing to remove particles that the toothbrush cannot reach is critical for good oral hygiene, possibly as important if not more so than brushing. Consider recommending a water flosser to clean in between the teeth. Some people are harder on their toothbrushes and wear them out more frequently. Luckily, they are inexpensive and minimally should be replaced every couple of months or if you notice the bristle starting to splay out. Soft toothbrushes are recommended as stiff or medium bristles can damage the gums, particularly for patients who brush vigorously.
Bottom line: It is important that physicians recognize the role that dental hygiene has in the health of our patients. Physicians have an opportunity to examine the mouth and if pathology is identified, recommend referral to a general dentist or oral surgeon. We can also provide education for proper dental hygiene which has the potential to improve overall health.
David Wadler is an orthodontist. Neil Baum is a urologist.
