Your overall health and the health of your teeth and gums are linked
By Wendy Haaf
Thanks to advances in modern preventive dentistry, more Canadians than ever are retaining most if not all of their own teeth well into later life. According to Statistics Canada, the proportion of the population aged 65 to 79 with no remaining natural teeth fell from 43 per cent to 19 per cent between 1990 and 2003.
“That’s great from a functional, nutritional, and cosmetic point of view,” notes Dr. Tom Raddall, a general dentist in Liverpool, NS, “but it also presents a number of challenges.”
It turns out that a number of different factors contribute to making those longer-lasting teeth more prone to certain problems after age 65. This has implications for our overall health, since it and our oral health are inextricably intertwined. However, there are things we can do at 55 and beyond to help keep our mouths healthy, thereby improving the odds of keeping our own teeth as long as possible.
What’s more, even if you already have complete dentures, continuing with regular oral checkups and care can help protect your health. How? We asked experts from across Canada to answer this and other key questions about protecting your oral health.
Q.: What challenges are presented by our teeth lasting longer?
A.: A longer tooth lifespan means there’s more time for any problems to accumulate; these can range from mechanical wear and tear caused by nighttime tooth-grinding to ongoing low-grade infection of the gum tissue.
The latter, also known as gum disease or periodontal disease, boosts the chances for aggressive tooth decay and tooth loss and is linked with an increased likelihood of heart disease. It’s also extremely common in older adults: the 2007–2009 Canadian Health Measures Survey found that half of Canadians aged 65 to 79 had periodontal disease, with 15 per cent of people in that age group having a severe form. People who smoke are particularly susceptible, says Dr. Iqbal Petker, a dentist at Deer Lodge Centre in Winnipeg and an assistant professor at the Centre for Community Oral Health at the University of Manitoba’s College of Dentistry. “If you’re a smoker, you are four times more likely to have periodontal issues than a non-smoker,” he says.
Normal changes that occur with aging can also increase the potential for decay: we produce less saliva, which helps neutralize the bacteria-produced acids that gnaw away at enamel. In addition, “Our saliva has less immune capacity, so we’re less able to fight off the bacteria that cause cavities and gum disease,” explains Dr. Debora Matthews, assistant dean of research in the Faculty of Dentistry at Dalhousie University in Halifax.
We also become more likely as we age to develop chronic health problems that may require treatment with drugs, which can exacerbate a natural decline in saliva production. “There are upwards of 1,500 medications for which one of the side effects is dry mouth,” notes Arlynn Brodie, an assistant clinical professor in the dental hygiene program at the University of Alberta in Edmonton.
Other health problems can directly affect oral health. Diabetes, for instance, increases vulnerability to oral infections such as periodontal disease, particularly if blood sugars aren’t well controlled.
In addition, when people retire, they often pay less attention to dental health because they lose company-sponsored dental coverage.
“Older adults have limited access to dental care, whether it’s to see a dentist or a hygienist,” Matthews says, “because 50 per cent of adults over the age of 60 have no private dental insurance and dentistry is expensive.” (No doubt this is one of the reasons that, according to the 2007–2009 Canadian Health Measures Survey, 1 in 10 community-dwelling adults aged 65 to 79 avoided the dentist and 1 in 6 had untreated cavities.) Ironically, this is when preventive oral care becomes doubly important. “Prevention and continued checking and maintenance become even more critical as we get older, and our oral care needs become more complex as we age,” stresses Dr. Chris Wyatt, a professor of dentistry and chair of the Division of Prosthodontics and Dental Geriatrics at the University of British Columbia (UBC) in Vancouver. This type of care is much less expensive than dealing with the long-term effects of a neglected problem, in much the same way that fixing a pipe at the first sign of a leak is much cheaper than replacing a floor destroyed by water damage.
Q.: Why is periodontal disease associated with an increase in risk for heart disease?
A.: While scientists have known about the link between these two conditions for about 25 years, they’re still working out exactly how one influences the other, according to Maria Febbraio, a professor and researcher at the School of Dentistry at the University of Alberta in Edmonton.
One common connecting thread is inflammation, the immune-system-moderated process that underlies periodontal disease and plays a role in the formation of artery-narrowing atherosclerotic plaque. By giving periodontal disease to mice prone to atherosclerosis, Febbraio and other researchers have found that there is an increase in atherosclerosis.
Other research has discovered that the inflammation occurring with periodontal disease is mediated in part by white blood cells called macrophages, which have receptors that interact with bacteria. Like a key turning in an ignition lock, bacteria latching onto one of these receptors, called TLR2, help trigger the release of an immune-signalling protein called IL1B. Febbraio and her colleagues discovered that there’s another receptor involved in the release of IL1B, called CD36, which plays a role in the formation of atherosclerotic plaque. By studying mice that lack this receptor, Febbraio explains, “we found that if you take CD36 away, that increase in atherosclerosis goes away. More interestingly, you get less inflammation in the oral cavity, too.”
This offers hope that one day, it may be possible to offset the increase in heart disease risk that comes with periodontal disease by using medications that interfere with the release of IL1B.
Q.: Why does periodontal disease increase the odds for rapidly progressing cavities and eventual tooth loss?
A.: When bacteria settle in to gum tissue, the resulting immune system reaction leads to an erosion of the connection between the gums and the teeth, slowly causing the gums to recede or shrink. Eventually, the same process causes pockets to form beneath the gum line, where bacteria can collect, thrive, and ultimately, erode the bone to which a tooth is anchored. Gradually this exposes the surface of the root, which, since it’s not covered in enamel, is much softer than the rest of the tooth surface. Brushing too hard, particularly using a medium- or hard-bristled brush, can permanently push the gum tissue away, too. Consequently, Wyatt explains, “that exposed root is now vulnerable to decay, and root decay is a more aggressive type of disease than decay on the top of the tooth.”
Q.: Is root decay inevitable once the gums have receded?
A.: No. While the gum tissue won’t grow back or reaffix itself to the tooth, it is possible to reduce the risk for root decay.
“Often we recommend that people use either a daily fluoride rinse or a highly fluoridated toothpaste, like PreviDent, which contains five times the usual amount of fluoride,” says Dalhousie’s Dr. Matthews. “Sometimes, the extra fluoride will help to remineralize an early cavity so that it doesn’t actually become a cavity,” she adds.
If, based on your diet and other factors, your dentist and dental hygienist identify you as being at risk for root decay, they may also recommend having a fluoride varnish applied to the teeth after a professional cleaning, University of Albert’s Brodie says. “The fluoride is actually taken up into the crystal of the root structure to help protect it,” she says.
Needless to say, carefully removing any food debris by brushing two or three times a day and flossing daily becomes even more essential once any root surface is exposed. “Your home maintenance is even more important than what we can provide,” Winnipeg dentist Dr. Petker stresses.
Q.: Is it possible to control periodontal disease, as well?
A.: Yes. However, if pockets are present between the tooth and gum, ordinary brushing and flossing, while important, can’t go deep enough to remove the sticky or hardened film of bacteria that has formed inside.
“Those pockets need to be cleaned with an instrument to remove any calculus that’s deposited there and to clean the root surface of the tooth,” says Dr. Euan Swan, manager of dental programs at the Canadian Dental Association in Ottawa.
“That’s not possible to do on your own once pockets have formed,” Matthews adds. “You can get only one or two millimetres below the gum, no matter what you use, so you need a professional to get in there and disturb the bacteria before it causes inflammation and bone loss.”
Obviously this has to be repeated regularly, the interval between appointments depending on a number of factors, including how quickly bacterial buildup occurs.
If these measures alone don’t stop the progress of periodontal disease, “additional treatments are required, such as gum surgery or, in severe cases, bone grafting around the teeth,” says Dr. Liran Levin, a professor and head of periodontology at the School of Dentistry at the University of Alberta in Edmonton. “Once you get rid of the bacteria, either by a combination of home care and professional cleaning, or in advanced cases, surgery, there’s no inflammation and therefore no further erosion of bone.”
But that’s not the only benefit.
“There are studies showing that improved control of periodontal disease helps control other diseases, such as diabetes and cardiovascular disease,” explains Dr. Shawn Steele, a clinical professor at Western University’s Schulich School of Medicine & Dentistry and staff dentist at St. Joseph’s Health Care London, in Ontario.
Due to high concentrations of certain bacteria in the mouth, “older people with gum disease have a higher risk for pneumonia if they don’t have regular cleanings or have poor oral hygiene,” Raddall says. They are also at an increased risk of developing pneumonia during a hospital stay or following major surgery, so it’s prudent to see a dentist beforehand.
Getting periodontal disease under control is particularly crucial if you’re contemplating having a damaged or missing tooth replaced with a dental implant. (Dental implants are tiny screws that are surgically implanted in the jaw so that an artificial tooth or set of dentures can be attached.)
“The first step in any disease is to try to eradicate or at least stabilize the condition before moving on to reconstruction,” Levin says. “Otherwise, it’s like doing a breast reconstruction without first taking out a cancer.”
A complication, Levin explains, is that once in place “implants are much more susceptible to bacterial invasion than teeth are,” because essentially they create a direct pathway for bacteria, from the gum to the bone. As a result, scrupulous home cleaning (with both a regular toothbrush and a tiny implement called an interproximal brush) around the implant and regular dental visits to check the health of the surrounding tissue are crucial. “If we detect inflammation when it’s still in the soft tissue, then we can stop it before it invades the bone,” he says. Once the bone is affected, surgery is the only remedy.
Q.: What can I do to combat dry mouth?
A.: The first step is to check with your doctor or pharmacist to find out if any of the medications you’re taking could be contributing to the problem. Sometimes it’s possible to switch to another drug without this side effect. Failing that, “you can start by doing two things,” Steele says. “One is to replace the saliva with an over-the-counter mouthwash or lubricant that would help keep your mouth moist,” he says. (Some mouthwashes can have the opposite effect, so ask your dentist or pharmacist to suggest a few products.) “The other main way is to stimulate the production of saliva, which you can do by chewing sugar-free gum or candy, or, in severe cases, with systemic medications.”
Your dentist may also recommend fluoride varnish or a prescription-strength (1.1%) fluoride toothpaste to reduce your risk for root decay. (Incidentally, your oral care team is also a resource if you’re scheduled for radiation or chemotherapy treatments that can cause lingering oral side effects, such as a burning, very painful dry mouth. “Sharing this information with your dental care provider is very important,” University of Alberta’s Brodie stresses, “because we can help.”)
Q.: Why is it important to keep my dentist up-to-date on any medications I’m taking?
A.: This information can be important in deciding on any treatment plan. For example, Raddall says, some rural patients take long drives to his office to have a tooth extracted only to discover upon arriving that the procedure must be cancelled because they were taking medications, such as warfarin, that increase risk for serious bleeding.
Similarly, Dalhousie’s Dr. Matthews says, “people who are taking medications for osteoporosis are at a much greater risk of having serious complications if they have an extraction or dental surgery. The bone doesn’t heal as well, and they can get quite a bit of post-operative pain and further bone loss,” she continues. “So it’s always important to tell your dentist all the medications you’re on so he or she has an understanding of your whole health picture.”
In the same vein, as noted earlier, it’s a good idea to alert your dentist before booking surgery or a hospital stay or starting cancer treatment, to ensure your mouth is as healthy as possible ahead of time. It’s also a good idea to let him or her know about any recent diagnoses or operations you may have had; for example, if you begin to have breathing problems in the chair, it’s helpful for your dentist to know it’s probably due to asthma rather than another cause.
On the other hand, a precautionary measure once widely recommended following one particular type of surgery has begun falling out of favour, Matthews says. “New guidelines by the American Academy of Orthopaedic Surgeons and the American Dental Association state that there really is no evidence to support the belief that you need to take antibiotics before dental care if you’ve had a joint replacement. You’re not at any greater risk for a joint infection,” she says.
Since antibiotics themselves carry risks, including the risk of having diarrhea and an increased susceptibility to vaginal yeast infections, there’s little reason to take these risks on if no benefit is to be gained. “I think now most dentists would say it’s generally not necessary,” Matthews says, “especially after the first six months, but the thing to do is talk to your orthopaedic surgeon and your dentist because you need to make an informed choice.”
Q.: Why is it preferable to restore a tooth if possible rather than simply extracting it?
A.: “When you pull out a tooth, your teeth can move and shift into the newly created space,” Steele explains. “It’s like a fence: remove one post and the other ones can become wobbly.” And since the bone “foundation” of the tooth requires constant stimulation to stay robust and healthy—such as occurs when you chew—pulling a tooth causes gradual loss of bone in that portion of the jaw. Even replacing missing teeth with a denture or bridge can’t prevent bone loss, since they don’t stimulate the bone in the same way that natural teeth do, although they can help keep the neighbouring teeth from shifting out of place.
Q.: Why are regular checkups with a dentist recommended—regardless of whether a person has any remaining teeth?
A.: One of the things dentists do during oral checkups is examine and evaluate the health of the soft tissue in the mouth. That includes checking for early signs of problems such as fungal infections (which are more common among people who wear dentures) and oral cancer—something denturists (professionals who specialize in making and fitting dentures) don’t have the training to do. As with many other forms of cancer, the risk increases with age, and in recent years, Brodie says, “we’ve been seeing an increase in oral cancers caused by human papillomavirus, or HPV.”
“If we can detect oral cancer early,” Matthews adds, “the five-year survival rate increases to 80 per cent, as opposed to 50 per cent.” (If, between checkups, you notice an open sore, white patch, or redness in your mouth that doesn’t clear up within 10 to 14 days, the Canadian Dental Association’s Dr. Euan Swan says, “that should be followed up,” even if there’s no associated discomfort.)
In addition, due to the training they receive and the sheer number of mouths they see, dentists are sometimes the first health professionals to detect clues about the presence of chronic or systemic health issues. For instance, Steele explains, enamel erosion on the backs of the teeth can be due to stomach acid backing up into the throat and mouth, a bluish tinge to gum tissue could herald breathing issues, and rapid progression of periodontal disease is sometimes a sign of undiagnosed diabetes. In such cases, “we can refer back to the physician for further investigation,” he says.
Q.: Are certain treatments ruled out on the basis of age?
A.: “Age is not a restriction,” says UBC’s Dr. Wyatt. Rather, factors that might affect your eligibility are whether you’re healthy enough overall to tolerate a minor medical procedure or if you have enough healthy bone remaining to have an implant put into place. And even these limits are moving targets. For example, advancements in bone-grafting techniques have put implant surgery within reach of people who wouldn’t have qualified for it a decade or so ago.
Q.: If cost is an issue, what can I do to make dental care more affordable?
A.: If buying private insurance isn’t an option, there are ways to manage costs.
“Sometimes, local boards of health, community health centres, and hospitals offer programs for seniors,” Steele says. If you’re lucky enough to live near a university with a dental school, these typically offer high-quality care at reduced cost. In addition, “many cities have dental-hygiene schools, where you can at least get a good cleaning at a substantial discount.”
The only catch: Because in both cases students perform the work, which is then supervised and checked by qualified instructors, appointments take much longer than visits to a regular practice.
Finally, many dentists are willing to set up a payment plan to make a big bill easier on your budget.
Q,: So if I start taking better care of my oral health now, there’s a good chance I’ll be able to maintain it lifelong?
A. “People can have good oral health throughout their lifetime,” Brodie says. “Prevention is the key. If you can keep your oral health at an acceptable level throughout your life, you may need a crown here and there, but you won’t be faced with multiple extractions or full-mouth reconstruction.”
Photo: iStock/Marc Dufresne.