The connection between oral health and general health is well understood within the dental profession, yet many patients are still unaware of this link and, as a result, may not fully appreciate the importance of maintaining good oral hygiene. This series will explore key systemic conditions associated with poor oral health and offer insights on how we can better support patients in improving their oral care.
The link between oral health and heart health
Studies have shown a link between poor oral health and an increased risk of cardiovascular disease. This connection is particularly evident in those with periodontal disease, as bacteria and inflammation in the mouth can spread through the bloodstream and directly affect the tissues of the heart. Bacteria present in dental plaque has been found in patients with infective endocarditis (an infection of the lining of the heart) and atherosclerosis (clogging of arteries)¹.
Not all patients with pre-existing heart conditions will also have long standing periodontal disease, but it is crucial for those who do to understand the associated risks. Treatment in the dental surgery, combined with a good oral hygiene routine, can help manage inflammation present during periodontal disease and reduce the bacterial load. It is likely that patients will need ongoing monitoring, as periodontal disease has no simple cure and can alternate between periods of activity and latency. Addressing common risk factors such as smoking, stress, diet and exercise can also help to improve the outcomes for both cardiovascular disease and periodontal disease.
The link etween oral health and respiratory health
Several fctors may explain the association between oral health and respiratory infections. Literature has shown that bacteria present in dental plaque have been associated with high-risk patients and aspiration pneumonia (bacteria entering the lungs via the lower respiratory tract and causing an infection). High-risk patients include those with dysphagia, COPD (chronic obstructive pulmonary disease), compromised immune systems or a history of respiratory disease, and those on ventilators². These factors increase their risk because they may have difficulties swallowing, require assistance with oral hygiene, or have a reduced ability to fight infections³,⁴. In the case of ventilated patients, their equipment can serve as a reservoir for bacteria. The inflammation present in periodontal disease can also worsen the chronic inflammation in pre-existing respiatory conditions such as COPD or asthma.
It is important for patients at risk of respiratory conditions to brush twice daily and clean between their teeth at least once a day to reduce the buildup of bacteria from dental plaque. If the patient requires assistance from a carer or relative, they should be provided with the necessary knowledge to provide effective oral care. Regular dental visits are also key to managing any concerns such as periodontal disease or decay. Dentures can also become a harmful source of bacteria if they are not removed and cleaned regularly.
The link between oral health and diabetes
There is a bi-directional link between oral health and diabetes, meaning that each can directly affect the other. Let's look at how this link occurs.
For patients with poorly controlled diabetes, this generally leads to higher levels of blood sugar which creates an environment in the mouth favourable for bacterial growth. This can increase the risk of periodontal disease. Poor control of blood sugars also impairs the body's healing capabilities, making it harder to recover from oral infections or minor wounds within the mouth. Diabetes can also reduce saliva production and reduce the buffering capabilities of saliva which help to prevent caries and oral infections⁵. Finally, patients with diabetes are more susceptible to fungal conditions such as oral thrush.
For patients with poorly controlled periodontal disease, the inflammation caused by the condition can make it harder for the patient to control their blood sugar levels, which can lead to increased insulin resistance, making the management of diabetes more difficult⁵.
For these patients, good oral health is essential for managing diabetes effectively. Similarly, effective management of diabetes will support the maintenance of good oral health. A good oral hygiene routine alongside regular dental visits to combat periodontal disease and prevent oral infections is key. Extra consideration should be given to patients with diabetes when booking dental appointments. For example, it wouldn’t be suitable to book a patient in during lunchtime if they are required to eat at this time. We should also ensure we take a holistic approach with patients and encourage regular visits to a suitable healthcare professional to help them maintain healthy blood sugar levels.
The link between oral health and pregnancy
Pregnancy is often an exciting time for patients, but concerns about the impact on oral health are frequently overlooked or simply not known. However, pregnancy can significantly affect oral health in various ways.
The inflammation present during periodontal disease can release inflammatory mediators into the bloodstream which have the potential to reach the placenta, potentially influencing its function and leading to complications such as premature labour or low birth weight. This risk is higher if periodontal disease is untreated. It is therefore important that periodontal disease is well managed, with a good oral hygiene routine at home and treatment from a dental professional.
Morning sickness, commonly caused by hormonal changes, frequently occurs during the first trimester of pregnancy but may last throughout the entire pregnancy. Despite the name, periods of sickness may last all day and are not always restricted to the morning. Frequent vomiting can lead to erosion of the enamel as the teeth are exposed to acids from the stomach. During this period, it is important that patients avoid brushing their teeth immediately after being sick. It is best to rinse with water or a fluoride mouthwash to neutralise the acid before brushing.
Toothbrushing generally may also trigger a pregnant patient to feel nauseous, which can act as a deterrent to performance of their usual oral hygiene routine. For these patients, it can be helpful to inform them that toothbrushing doesn’t have to take place in the morning; the evening brush is the most important, and if this isn’t possible, any toothbrushing is better than none at all.
It is not uncommon for snacking to increase during pregnancy, as it can help to reduce nausea. It can also be more comfortable to eat by snacking during pregnancy when stomach space is limited due to the growing baby. Where possible, it can be helpful to recommend tooth-friendly snacks such as cheese, vegetable sticks, fresh fruit and vegetables. Where this isn’t possible, patients should be informed of the importance of twice-daily toothbrushing with a fluoride toothpaste and should be asked to consider using a fluoride mouthwash after snacking to help neutralise the acids produced. Regular dental visits will also ensure that any signs of tooth decay are spotted early. These are free on the NHS during pregnancy.
Increased gingival bleeding is a very common occurrence throughout pregnancy. It is caused by the increased levels of oestrogen and progesterone, which make the gums more sensitive to bacterial plaque. The gums can become inflamed and bleed more easily, which is known as pregnancy gingivitis. If left untreated, pregnancy gingivitis can cause long-term issues with the periodontium, particularly in patients with a history of periodontal disease. The best treatment is to ensure a good oral hygiene routine despite the increased bleeding. This includes twice-daily toothbrushing and daily interdental cleaning to remove bacterial plaque. Regular hygienist appointments can also help to reduce the build-up of bacterial plaque and provide the patient with tailored oral hygiene advice.
Pregnancy can occasionally cause benign growths on the gums. Such a growth is known as a pregnancy epulis. These growths appear as red swellings which can bleed easily. They are caused by hormonal changes during pregnancy, and whilst they can look unsightly, they tend to go away by themselves after childbirth. It is best to advise that this area is cleaned as normal if possible. If these growths become problematic, a dentist may be able to remove them surgically.
The link between oral health and brain health
Bacteria such as porphyromonas gingivalis and the systemic inflammation associated with periodontitis have been found in the brains of Alzheimer's patients⁶. Alzheimer’s is a form of dementia affecting the brain and resulting in a gradual decline of cognitive ability. This can lead to memory loss, changes in behaviour, language problems and disorientation. Once Alzheimer’s has been diagnosed, patients may find it difficult to take in the right nutrition and maintain a good oral hygiene routine without support. If a patient with Alzheimer’s attends the surgery, it may be necessary to discuss assisted brushing with a family member or carer to ensure they are still brushing twice daily. Patients can reduce their risk to their brain health by ensuring they seek professional intervention for periodontitis.
The link between oral health and sexual health
Finally, it is less well known that poor oral health can have an impact on sexual health. Often this does not get discussed with patients as it can be an awkward conversation to have. Chronic inflammation associated with periodontal disease has been found to disrupt hormone levels and impair sperm function and motility in men, and impact ovulation in women, potentially affecting fertility⁷.
There is also some evidence suggesting a link between poor oral health and erectile dysfunction, as chronic inflammation can damage the blood vessels and affect the blood supply to the penis. Whilst this is not often the easiest discussion to have with patients, when approached carefully it can provide patients with the motivation required to improve their oral health⁷.
Evidence continues to emerge that highlights the connections between oral health and general health. As dental professionals, we play a pivotal role in helping our patients understand these links and providing guidance on how they can best take care of their overall health by incorporating daily habits to promote overall wellbeing.
Written by Melanie Pomphrett RDH, MSc, PGCert
References:
Shmerling, R.H., (2021). Gum disease and the connection to heart disease. Harvard Health Publishing. Online at: https://www.health.harvard.edu/diseases-and-conditions/gum-disease-and-the-connection-to-heart-disease
Manger, D., Walshaw, M., Fitzgerald, R. et al. (2017). Evidence summary: the relationship between oral health and pulmonary disease. British Dental Journal 222, 527–533. https://doi.org/10.1038/sj.bdj.2017.315
Gupta, A., Lilly M.S., Kannan,P. & Shivachandran, A., (2024). The impact of oral diseases on respiratory health and the influence of respiratory infections on the oral microbiome. Journal of Dentistry. Online at: https://doi.org/10.1016/j.jdent.2024.105213.
Scientific Reports (2021). Oral health and all-cause, cardiovascular disease, and respiratory mortality in older people in the UK and USA. Online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361186/
National Institute of Dental and Craniofacial Research (2024). Diabetes & Oral Health. Online at: https://www.nidcr.nih.gov/health-info/diabetes#:~:text=Did%20you%20know%20diabetes%20can,difficulties%2C%20and%20even%20tooth%20loss.
Stronger connections made between oral health and Alzheimer's disease. British Dental Journal (2022) 233, 527. Online at: https://doi.org/10.1038/s41415-022-5136-3
Eastham, J. & Seymour, R. Periodontics and Sexual Health: Is oral health a risk factor for sexual health? Dental Update. 42 (2): 160-165.
Resources
Mouth Care Matters Resources: https://mouthcarematters.hee.nhs.uk/links-resources/mouth-care-matters-resources-2/index.html
British Society of Periodontology, The Relationship Between Oral Health and Pregnancy: Guidelines for oral-health professionals https://www.bsperio.org.uk/assets/downloads/Guidelines_for_oral_health_professionals.pdf
European Federation of Periodontology, Oral health & Pregnancy video: https://youtu.be/br-iMGi6fYI
Alzheimer’s society, Dental and mouth care: https://www.alzheimers.org.uk/get-support/daily-living/dental-mouth-care
Oral Health Foundation, Oral health and general wellbeing: https://www.dentalhealth.org/oral-health-and-general-wellbeing
