I want to start today's episode with a confession. I recently sat in a dentist's chair staring at the ceiling tiles, like we all do, and my hygienist gave me that look, and you know which one I'm talking about. I got gently scolded for my lack of flossing again. So, definitely not the first time. And the hygienist was lovely about it, but it definitely got me thinking. As I sat there trying to make excuses, Something clicked. We treat the mouth like it's separate from the rest of the body. In medicine, we often stop our physical exams at the tonsils. And anything in the mouth, we say, well, that's not us, that's dentistry. And so. I thought I'd do video to look further into oral health. And disclaimer, I am not a dentist. Just a dude who decided he wants to learn a little more about the mouth. And so today we're going to break down why oral health is actually a really, really important thing and how it's linked to multiple major systemic diseases like diabetes, cardiovascular disease, and even Alzheimer's potentially. And so, I reviewed a bunch of literature to build a strategy for how we, as primary care clinicians, need to rethink the mouth. So, let's dive in. And so, my goal with this presentation today is that I can convince you to at least start thinking about oral health in your day-to-day interactions as clinicians. Calling it a vital sign can be helpful. That is not necessarily, I'm not expecting you to look into the mouth on every single patient all the time, but saying, hey, this could be a missing vital sign just gets you at least pause, right? And Once again, it's not that they have to talk about every single patient, but it's something that I need to be reminded of. And that is a challenge for anybody watching as well. That maybe we need to start thinking about this more. And specifically, I want to talk about this. So, when we're talking about poor oral health, we're usually not quite sure what we're talking about, right? So, Specifically in the medical world, a lot of times we say, like, oh, maybe someone has some missing teeth or they just look off. But in reality, the two most common things we see are dental caries and periodontal disease. And I want to define those so we actually know what we're talking about. So, first, dental caries are aka cavities, and they're not just holes in the teeth, right? So, a lot of times they say, oh, like cavities, go get them taken care of. It's actually a biofilm-dependent infectious disease. And bacteria, specifically Streptococcus mutans and Lactobacillus species. They ferment dairy sugars into acids, which then demineralize the enamel or the protective coating of the tooth. And there is a systemic link to this, right? So, according to a review that I looked at, this process starts early. Often as early childhood carries. That's why we ask about it and recommend brushing in our infants. And it sets a trajectory for a lifelong inflammation. So, specifically, it's not just local pain, right? So, yes, they are painful, and we don't want that. Dental pain is like the worst pain, if you ask anybody. But severe decay can lead to chronic kind of low-grade bacteria getting into the bloodstream. That's what we're looking for. And there's actually a known association between untreated caries and systemic inflammatory markers like HS CRP, so the high-sensitivity CRP. A study that looked at NHANES data found that higher CRP levels are significantly associated With root carries. And this suggests that inflammation from a quote-unquote simple cavity contributes to the total inflammatory burden of the patient. That's something I would have never thought about: that hey, inflammation in the teeth can actually lead to inflammation throughout the body. And then, on top of that, we have periodontal disease. We think of things like gingivitis and periodontitis. So, specifically, this is kind of a spectrum, and how I was learning over here. I didn't know much about this, but this is how I think about it. So, gingivitis is the early reversible stage where plaque or a biofilm causes inflammation that's limited just to the gums. So, think about redness and bleeding when you brush or are you doing flossing again. Guiltiest charge. It's getting better though. I've been washing out for like a month and we're doing well. But if left untreated to in a susceptible host, it can lead to periodontitis. And this is the critical tipping point here, right? So periodontitis. Is a chronic, potentially irreversible inflammatory disease where the supporting tissues like the periodontal ligament and the alveolar bone underneath it are actually destroyed, leading to pockets. Loose teeth and tooth loss. And this transition is driven by a shift in the microbial community. So essentially, a dysbiosis in the mouse, and that's leading more towards a pathogenic anaerobic bacteria and a dysregulated host immune response. And so, once again, Periodontal disease, if it's left to its progression, will go down further beyond the teeth, destroy the ligaments, all that stuff, the bone underneath it, can be a big issue. And so, those are the two main things that we were talking about. And now, there are a couple of other areas I want to discuss in terms of where poor oral health has been implicated, including cardiovascular disease, diabetes, Alzheimer's, and respiratory pathology. So, this is what literature is pretty darn exciting. Let's talk about cardiovascular disease first. That's kind of something that I really like talking about. So, the link is that patients with periodontitis have a higher risk of atherosclerotic cardiovascular disease. And so, the potential mechanism, what's going on, according to literature that I was looking at, periodontal bacteria enter the bloodstream and then it activates host inflammatory responses that favor atherma formation. So, essentially, what happens is we've seen dental Bacteria in the plaques in cardiovascular. So we know it's getting from the mouth into the plaques. That's very interesting. There was also a review that I looked at that showed that Non-surgical periodontal therapy or deep cleaning does reduce serum CRP and IL-6 levels, which are key markers in cardiovascular risk. I'm just more giving you the mechanism away and made it happening. We're saying, hey, this oral irritation, this periodontitis leads to inflammation and can lead to increased risk of cardiovascular disease. I thought that was pretty fascinating. Then let's talk about diabetes. It's kind of this bi-directional relationship. So, this is probably the strongest link we have. Diabetes increases the risk of severe periodontitis, and severe periodontitis worsens glycemic control. So, it's kind of this. Feedback loop here. And a review that I looked at found that non-surgical periodontal therapy can actually reduce HBA1C levels in patients with type 2 diabetes. Essentially, Treating the gums helps treat diabetes. And so, non-surgical, we'll talk more about this. It's pretty extensive. It's not just like, hey, brushing your teeth is good for you, but if someone has. Type 2 diabetes and periodontal disease, this specific type of cleaning can reduce HbA1C by levels similar to like some oral medications, which is actually pretty crazy to think about. Next, let's talk about Alzheimer's disease and cognitive decline. So I'll say right off the gate that this is not like a causative thing. We do not know this. It's more kind of like a fun food for thought. But there has been some evidence indicating there might be an oral brain access, meaning going from the mouth to the brain. A paper that I looked at. Found that oral pathogens like P. gingivalis and their toxins have been found in the brains of Alzheimer's patients, which they posit could potentially cause triggering of neuroinflammation and amyloid accumulation. Once again, Much further than I'm going to say, like, I'm not going to say it's causing anything. You know, I've seen people online say, this is the link. We don't know that. We can't know that based on the day that we have, but it's just at least interesting to think about, right? That's kind of where I want to just put that little in there, a little pebble in your shoe to say, hey, let's think about that. But one thing I do want to talk about that is pretty well known is actually the link between oral health and respiratory health, or specifically pneumonia, right? So, for our hospitalized patients or elderly patients, we know that. Aspiration of oral bacteria is a big risk. And a couple of position statements that I looked at mentioned that oral care could potentially be the number one intervention. To prevent non-ventilator hospital-acquired pneumonia. So, our non-ventilator hospital-acquired pneumonia, if you just brush your teeth, that might be the biggest risk factor to decline that, which is actually pretty crazy. All right, so maybe you listened to that and said, Okay, Jordan, I hear you. What do you recommend I do? Well, I'm glad you asked. Based on the data, here's kind of the gold standard for maintaining a healthy mouth. This is what we're looking at. First and foremost is mechanical disruption. Is super important, right? So the biofilm or plaque must be physically disrupted. Mouthwash alone doesn't cut it. And we do this by brushing. Brush twice a day with a fluoride toothpaste. And recommendations are using a soft bristle toothbrush to avoid cervical erasion, which is wearing down the tooth neck, which can cause sensitivity. And on top of that, they mentioned getting between those teeth, the medical word is interproximal cleaning, and it's recommended either flossing or interdental brushes. And there are studies suggesting that for many patients, interdental brushes may actually be more effective than floss at reducing inflammation. If the spaces between the teeth are large enough. So, if you have great pearly whites and they are right next to each other, that may not be the case. You may have to do floss and that's okay. But Getting between the teeth is very important. And then they also mentioned probiotics. Well, there's emerging research that maybe oral probiotics may help re-establish a healthy microbiome. That's still up to date. But the big things are going to be brushing twice a day and flossing or some sort of way to get between the teeth. No groundbreaking news there, right? As everyone talks about. And so, although that seems pretty standard, I did want to talk about a potentially controversial take, which is mouthwash. So, obviously. We've all heard about mouthwash. Maybe we were told to use mouthwash or tell patients who use mouthwash, but the data actually is kind of up in the air. So there's an interesting link potentially between mouthwash and blood pressure. So, a review that I looked at highlighted the enterosalivary nitrate nitrite nitric oxide pathway. So, basically, specific bacteria on the tongue convert dietary nitrate into nitrite, which is then swallowed and converted to nitric oxide. A potent basodilator that lowers blood pressure, right? That seems a check out, right? But indiscriminate use of antibacterial mouthwashes, specifically really strong and powerful ones, may kill these good bacteria. And this can actually lead to an increased blood pressure and disrupt Vascular function. So, the general recommendation is to avoid routine daily use of strong antibacterial mouthwashes unless prescribed for a short term for a specific reason. Obviously, we know mechanical cleaning is the best, so mechanical cleaning is going to do better. But I thought that was interesting, right? You think, oh, I just mouthwash every day. That's not necessarily the case. Some mechanistic plausibility. Once again, I'm not saying this is the greatest link in the world, but it's something to consider for trying to optimize for patients. And so I wanted to propose something that Hey, we can talk about the mouth in primary care. Once again, not for every single patient in every single time. I get that, but something to think about, right? When we see these patients who have hypertension or diabetes. We should be thinking about, hey, could there be something else going on? And so, based on some consensus reports I looked at, there's a three-step strategy for primary care providers, and it's ask, look, and act. And we'll go into it here. So, step one is asking or the interview, right? Don't just ask, do your teeth hurt. Ask specific screening questions like, do your gums bleed when you brush, which is a sign of active inflammation? Another question is, do you have loose teeth, a sign of advanced bone loss? And when was your last dental visit? Always important. And then for next, we're going to look. So the exam, right? Lift up the lips. So you don't need a probe. You don't go in there, just look at the lips, look at the gums. We're looking for inflamed, red, swollen gingiva. Does anything jump out to us? Also, looking for obvious signs of decay or broken teeth. And why you might ask? Well, because if you see inflammation there and you're struggling to control a patient's HVA1C or their CRP is high or some reason. Or their blood pressure is high, this might be the source. Like maybe coming from the mouse, might be playing a role. And obviously, I'm not saying it's the entire thing, but if we can attack things from a multi-pronged approach, that's usually appropriate. And no, what I'm not saying is you need to become a dentist. But you can see those signs that, hey, you should really talk to your dentist. Very important. Obviously, I know that dental insurance is separate from medical insurance and it's a whole thing. I'm not getting into that, but just something that we need to consider. And on top of that, for step three, the medical referral, for diabetics, we can tell them that, hey, treating your gum disease is actually a part of treating your diabetes. Evidence shows it can lower A1C by 0. 4%, which is clinically significant, right? A lot of people hear 0. 4% and they kind of scoff at it, but there's medications you start that get that about the same amount of change there. So that's pretty cool. And as I mentioned before, This is not just brushing your teeth, right? It's something called scaling and root planning or deep cleaning. And it's a non-invasive, standard clinical treatment performed by dental hygienists or periodontitis. It involves meticulously removing plaque. And calculus from both above and below the gum line to eliminate bacterial source of infection. And so, by creating this clean, biologically acceptable roof surface, the gums can heal and reattach and kind of get back to the normal setting, hopefully. And crucially, this therapy reduces the patient's overall systemic inflammation burden, which directly contributes to better glycemic control and insulin sensitivity. That's kind of just interesting worth mentioning. On top of that, another population we should mention and talk to are pregnant patients, so referring early can be helpful. One paper that I saw noted that periodontal therapy is safe during pregnancy and may reduce the risk of adverse outcomes like preterm birth. In specific populations. So, at least worth having this discussion with pregnant patients and then hospitalized patients. If you work in the hospital, ensure nursing staff is performing oral care or giving them the option to do that, right, with a toothbrush. I just did a week on inpatient, and I was telling patients, hey, have you brushed your teeth? I actually was asking them because that's what I was looking at. And it is the single most effective way to prevent hospital-acquired pneumonia. That's really what, if you can think about that, just brushing your teeth, preventing a pneumonia. Which can lead to morbidity and mortality. That's something we should be doing. And so, overall, the mouth is not Las Vegas. What happens there doesn't stay there. I know that's cheesy, but What happens there enters the circulation, triggers the immune system, and can affect the heart, brain, pancreas, all the organs, the whole body. And as primary care clinicians, bridging the gap isn't just about saving teeth, it's about saving lives. And so. You know, that hygienist who looked at me and scolded me may have actually been very beneficial. You know, from there, it's gotten me to think about this and trigger it and understand that the mouth is another part of the body we should be worrying about, right? We should be thinking about at least in primary care. Hopefully, this is something that was at least a little interesting to you. I know it's a little off the beaten path, but it was really near and dear to my heart this past week. And so, I just wanted to mention with you. But if you enjoyed this, thank you so much for listening. I appreciate it. If you share it with a friend, that would mean the world to me. But now, get up your phone, get outside, have a good rest of your day. We'll see you next time.
