Window of the Body: A look inside

Studying the mouth can give dentists an insight into the overall health of the patient

The Surgeon General's report on "Oral Health in America" was released in May 2000. It was the intention of this report to alert Americans to the importance that oral health has on a patient's general health. Donna Shalala, the secretary of Health and Human Services at the time, wrote: "The terms oral health and general health should not be interpreted as separate entities. Oral health is integral to general health; this report provides important reminders that oral health means more than healthy teeth and that you cannot be healthy without oral health" [from Introduction]. Furthermore, Surgeon General Dr. David Satcher wrote, "We know that the mouth reflects general health and well-being. This report reiterates that general health risk factors common to many diseases, such as tobacco use and poor dietary health practices, also affect oral and craniofacial health. U Recently, research findings have pointed to possible associations between chronic oral infections and diabetes, heart and lung diseases, stroke, and low-birth-weight, premature babies. This report assesses these emerging associations and explores factors that may underlie these oral-systemic disease connections" [from Preface].

The major theme of the report is to understand that oral health means much more than healthy teeth. It means being free of chronic oral-facial pain conditions, oral and pharyngeal (throat) cancers, oral soft-tissue lesions, birth defects such as cleft lip and palate, and scores of other diseases and disorders that affect the oral, dental, and craniofacial tissues. These are tissues whose functions we often take for granted, yet they represent the very essence of our humanity. They allow us to speak and smile; sigh and kiss; smell, taste, touch, and swallow; cry out in pain; and convey a world of feelings and emotions through facial expressions.

The craniofacial tissues also provide a useful means to understanding organs and systems in less accessible parts of the body. The salivary glands are a model of other exocrine glands, and an analysis of saliva can provide telltale clues of overall health or disease. The jawbones and their joints function like other musculoskeletal parts. The nervous system apparatus underlying facial pain has its counterpart in nerves elsewhere in the body. A thorough oral examination can detect signs of nutritional deficiencies as well as a number of systemic diseases, including microbial infections, immune disorders, injuries, and some cancers. Indeed, the phrase "the mouth is a mirror" has been used to illustrate the wealth of information that can be derived from examining oral tissues [from Executive Summary].

Physicians of the mouth?

Take a look at the curriculum of a dental school today: biochemistry, nutrition, physiology, anatomy, pharmacology, internal medicine, prevention of disease ... just to name a few courses. These are not simply courses that we use to cull the weak students from the good. This is our "boot camp," where we learn the basis of health care. When dental schools created the DMD degree, the concept was that the dentist was able to recognize that there is a person attached to the teeth. The Latin words Dentariae Medicinae Doctoris translate to Doctor of Dental Medicine, signifying the holistic approach to our profession. Certainly the DDS degree is totally equivalent to the DMD, but the latter may be a better representation of how we practice today. In times of war, military dentists take on the roles of triage and anesthesiologist so that all physicians can be trauma surgeons. The American Dental Association and the Centers for Disease Control and Prevention are developing ways for dentists to become recognized as a significant and readily available adjunctive health-care resource for responding to bioterrorism. [Han and Alfano, 2003; Giddon, 2004]

The Institute of Medicine report titled "Dental Education at the Crossroads" was published in 1995. Its essence was that dental schools should work with medical schools so that dentists are more prepared to deal with medically complicated patients. Our basic science education in many dental schools is done alongside that of medical students. New York State has now started granting dental licenses after a general practice residency in which the dentist will gain more hospital experience and clinical education.

Recognizing oral manifestations

Many systemic diseases have effects that are seen in the mouth, head, and neck. While many patients will see their physician only when ill, they may have routine visits with the dentist for a periodic prophylaxis. We should be looking into the patient's mouth as a window to the body. New research is rampant that connects periodontal health to other diseases and conditions: preterm, low-birth-weight babies; cardiovascular disease; weight loss in the elderly. It is essential for dentists to see the bigger picture.

Dentists may actually be the first to discover certain diseases in their patients. Diabetes mellitus leads to more aggressive periodontal disease and delayed healing. If your patient has a marked increase in bone loss or does not show an appropriate response to scaling and root planing, tooth extraction, or implant placement, it may be that he or she is manifesting the beginnings of diabetes. At this point, a referral to the physician is prudent, especially if there are other signs and symptoms (such as polyuria, polydipsia, or polyphagia). We dentists may feel comfortable interpreting the results of a lab test like the fasting plasma glucose, which should be below 126 mg/dl, or the glycated hemoglobin, below 7 percent. However, since we will not be treating the diabetes, it is not recommended to order these tests. Once diagnosed as diabetic, the patient can be assisted in the management of the disease with more frequent recall appointments, reinforcement of excellent oral hygiene, and perhaps a little more aggressive prescription of antibiotics for the treatment of orofacial infections. It is not typical to use antibiotic premedication for dental care in diabetics. Routine blood glucose testing in the dental office is becoming more popular before invasive procedures. At the bare minimum, ascertain that the patient has taken his or her medication and eaten normally before any dental procedure. If the treatment leaves the patient unable to chew comfortably, emphasize the use of liquid supplements or a food processor. If narcotic analgesics are prescribed, caution the patient that he or she must not sleep through mealtime and/or medications. A well-controlled diabetic patient can tolerate routine dental care with no modifications.

The lack of healing may be a byproduct of the use of systemic medications such as corticosteroids or other immunomodulators. Some of the diseases and conditions that are treated with these drugs are asthma and chronic obstructive pulmonary disease (COPD), lupus erythematosus, arthritis, multiple sclerosis, organ transplant patients, and dermatologic conditions. It is necessary for the dental team to know the condition that is being treated. Dental treatment must not be withheld from these patients, but a consultation with the physician is helpful to determine the need for supplemental steroids. For invasive dental procedures, supplementation with additional steroids may be indicated. A single extraction or most restorative procedures should be well-tolerated as long as there is adequate local anesthesia and postoperative pain-control management. Understanding the disease that is being treated may lead to other modifications of treatment. For example, the patient with COPD may be unable to stay supine for very long.

Some diseases and conditions will show signs in the oral cavity before any other part of the body. HIV may first appear as candidosis, oral hairy leukoplakia, Kaposi's sarcoma, rapidly progressing periodontitis, or necrotizing ulcerative gingivitis. Leukemia may cause an enlargement of the interdental papillae. Anemia often appears as a beefy red tongue that has lost its normal papillated surface. Gastroesophageal reflux or eating disorders may be revealed by a distinct chemical erosion of the enamel. Thyroid disease has a wide spectrum of manifestations in the head and neck region, from the enlargement of the tongue or the gland itself, to the bulging eyes of exophthalmos. Even pregnancy may cause changes in the gingival tissues, sometimes before the woman even knows that she is pregnant!

Bad breath is better than no breath!

We should look for oral changes and hear the patient's complaints, but don't forget your sense of smell. If there is a fruity, acetone-like smell, perhaps the patient is diabetic. The smell of urine in the mouth could be a sign of kidney disease or ineffective dialysis. If a patient arrives for an 8 a.m. appointment with alcohol on the breath, consider that his or her liver may not function normally and there may be excessive bleeding due to a lack of coagulation factor production. The smell of tobacco smoke should clue you in to the increased risk of oral cancer, periodontitis, and heart disease. A fetid odor, like decaying flesh, could be part of necrotizing ulcerative gingivitis and signify a compromised immune system.

Oral manifestations of prescription medications

The oral cavity is usually not considered in the prescribing of therapeutic medications. Many patients will not make the connection between the drugs that they are taking to the feeling they have in their mouth. It is well-known that several medications lead to gingival hyperplasia (phenytoin, calcium-channel blockers, and cyclosporine). Probably more than 400 of the drugs prescribed in America cause xerostomia. It is prudent to advise patients about saliva substitutes, fluoride applications, and frequent recall visits to intercept any dental pathology before it progresses. Other medications will cause a bitter or metallic taste, usually because the drug or its metabolites are secreted in the saliva.

Probably the most typical referral an oral medicine specialist receives is a patient with burning mouth syndrome. Begin with the patient's medical history, analyze the medications that he or she is taking, and then evaluate the patient's social and emotional well-being. You may often find no visible lesions or changes in these patients' mouths, yet their history leads us to a satisfactory treatment. At times, it is essential to contact the patient's physician to suggest a change in medication to reduce oral side effects. By no means is there always a cure, but working with the patient and his or her physician improves the quality of life for most.

Be part of the solution

This very brief overview of systemic diseases and medications should not take the place of careful study of a patient's condition. We, as health-care providers, should be wary of snap judgments and consider that what we say to the patient may be interpreted incorrectly. Physicians never diagnose from just one observation, and dentists need to be just as careful. Every patient who comes to my practice has his or her blood pressure, pulse rate, and respiratory rate taken. Notice when vital signs are above or below normal, then ask questions. If the patient's heart rate is 120 beats per minute, don't automatically assume that he or she is hyperthyroid, especially if that patient has just run in from the parking lot to avoid being late. However, if the same patient has a history of taking thyroid hormones and is now losing weight, ask questions to see if he or she is perhaps taking too much medication. A timely referral to the physician can save a patient's life! It is not a good trade for a patient to have a local anesthetic injection to fix a tooth, only later to experience a stroke due to the increase in blood pressure.

As Americans are living longer, they will have more chronic diseases, take more medications, and have more complex treatment plans. Be included in your patients' overall health care! Be available for the patient who will be having a hip replacement so that her dental cleaning is completed before the surgery. Get involved in the care of the patient on chemotherapy for cancer so that you can help minimize the risk of infection and oral mucositis. Refer that young executive who is showing you enamel erosion to have an evaluation for acid reflux. Counsel the patient who is a smoker or who has an eating disorder that help is available from support groups. The mouth is the window to the body — it's up to us to see what we're observing.