When magazine articles and advertisements talk about “a beautiful smile”, they’re not talking about eyes lighting up or lips curving appealingly in an expression of joy: they’re really talking about the vision of two even rows of symmetrical, nicely shaped white teeth. We already know how important good teeth are for our appearance and self-confidence. In this special triple-feature, we talk to two dentists and an orthodontist about the dangerous implications of poor dentition – eating difficulties that lead to poor nutrition, and oral hygiene problems that are related to a wide variety of unpleasant or even life-threatening conditions.
The mouth-body connection
Historically, the mouth has always been a useful indicator of the general state of the body, DR BERNARD SIEW tells Verne Maree. Though we can’t easily inspect internal organs such as the stomach or the heart, a simple oral inspection allows us to make inferences from different conditions we see in the mouth.
Inflammation is key, as its presence points to the loss of physiological balance – and chronic inflammation in the mouth often indicates that inflammation may be occurring elsewhere.
When you look into a patient’s mouth, can what you see there tell you anything about his or her overall health?
Yes, very much so – especially with regard to respiratory problems and diet. In modern times, chronic respiratory problems have become so common that we are seeing a general deformity of the jaws – a narrowing and a deepening – due to chronic mouth-breathing. Plaque and dental decay are rampant in patients with airway problems, and they often require orthodontic correction of the jaws.
You mentioned dietary problems. How do these show up?
I can detect problems of acid reflux by the wear patterns on the patient’s teeth. Any change in wear patterns, or the presence of sudden inflammation, indicate either physical or emotional stress. Professionals who travel frequently, are changing jobs or have personal difficulties may suffer from this unknowingly. Athletes in vigorous training have similar problems. It concerns me that so many patients are either unaware of their problem, or don’t grasp how severe the long-term consequences can be if these issues are not addressed.
A number of studies have linked poor oral health to arteriosclerosis, cardiovascular disease, premature birth and low birth weight, type 2 diabetes, cancer, heart disease and more. Can you explain this?
These links are often not causative. For example, gum disease may not lead to heart disease directly: Someone who eats poorly may develop type 2 diabetes, which then leads to heart disease and gum disease because it affects blood flow both to the heart and to the gums.
And, though tooth decay in pregnant women has been linked with low birthweight and premature birth, this may be due to her eating poorly and becoming malnourished. During pregnancy, hormonal changes often cause increased gum inflammation and pain, so a regular and thorough home-care regiment is vital.
What causes dental decay and gum disease?
Firstly, acid. The bacteria in plaque thrive in an acidic environment: they grow faster and act more aggressively. Secondly, sugar is food for bacteria and encourages their growth. Also, studies have shown that our white blood cells (soldier cells) become overactive when exposed to sugar, leading to excessive inflammation.
It is wrong to see dental caries and gum diseases as acute conditions that arise suddenly. In fact, they indicate chronic systemic problems. A cavity is the result of minerals having been leached out of a tooth over a long period of tooth disease, in the same way as a heart attack is the culmination of long-term heart disease.
How much have the new dental technologies and materials contributed to improving our oral health?
Well, improvements in composite resin materials have led to increasingly small filling sizes, which significantly delays the loss of tooth structure and therefore tooth loss. For another, zirconia crowns are tooth-coloured and very strong. So we can salvage a lot more of the natural tooth structure, which is vital to keeping the natural tooth healthy for as long as possible.
What’s more, the treatment of gum disease has improved with a better understanding of the complexity of the disease, and innovative biomaterials that allow for conservative surgeries that assist the growing of bone.
However, I firmly believe that the primary focus of both dentistry and medicine should be on preventing disease and maintaining health. Although innovation has been important in dentistry, technological advances are of little benefit to a patient who neither knows nor cares about preventing future disease.
Would you describe your approach as holistic?
Yes, I would. For example, we would recommend early treatment for a child patient’s problematic airways so as to prevent orthodontic problems, a dry-mouth and a higher risk in future of gum disease and dental caries. For this, I make dental devices such as hard-splint night-guards to prevent tooth-grinding and the breakdown of teeth.
As importantly, many of my patients are referred to me by mental health professionals to improve their sleep by means of a snore-device. Poor sleep is known to increase stress levels, and that can lead to even poorer sleep and a worsening of depression – a horrible cycle.
Why should we bother to keep the teeth we have? What’s wrong with losing them all in the course of time and then getting a full set of false teeth, like some of our grandparents did?
An interesting question, and one that I’m often asked. The answer is that we have 32 adult teeth, and we can survive perfectly fine with 20 to 24 of them; any fewer may affect both appearance and function. That said, thriving and surviving are two very different things. A set of false teeth does not function as well as a set of healthy, natural teeth. Malnourishment is much higher in people with false teeth, not to mention less quantifiable factors such as a sense of wellbeing, self-confidence and quality of life.
Orthodontics and overall health
According to orthodontist DR CATHERINE LEE, crooked teeth are not just an aesthetic issue; they’re potentially lifethreatening – and that’s because oral health is such an integral part of general health care. Here’s her reminder that straight, well-aligned teeth are essential for avoiding gum disease – and that gum disease has a proven link to lifethreatening inflammatory conditions such as heart attack and stroke.
Gum disease is caused by the build-up of dental plaque, which generally results from poor oral hygiene habits. “Other factors such as smoking, hormonal changes and various types of illness, such as diabetes, can also make our gums more vulnerable to gingivitis (gum inflammation) and less able to heal themselves,” explains Dr Lee. Chronic gingivitis can lead to periodontitis, causing irreversible damage to the supportive structures of the teeth.
Orthodontics wards off gum disease by enabling us to maintain good oral hygiene. Straight, correctly spaced teeth are far easier to keep clean than crooked or overlapping ones. “Even with the best will in the world, twice-daily brushing and daily flossing, it’s almost impossible for someone whose teeth are out of position to maintain a high standard of oral hygiene – they are fighting a losing battle.”
Gum disease is related to cardiovascular and other diseases because oral health is not something that stands alone and divorced from overall health. The two are inherently entwined and co-dependent, Dr Lee believes, and oral disease can quickly become systemic: “We now understand that the bacteria and toxins involved in gum disease readily enter the bloodstream and – through a rather complex process involving the liver – cause inflammation of the heart and the vascular lining, leading to vascular plaque formation, the breakdown of the vascular lining and the onset of heart disease and stroke – and probably other chronic inflammatory conditions. It has even been implicated in pregnancy complications.”
Gum inflammation and heart health – the link
- Researchers at Columbia University in New York found that improving dental care slows down the build-up of plaque in the arteries.
- Another study found that those with the worst oral hygiene had a whopping 70 percent higher risk of developing heart disease than twice-a-day brushers.
Seeking treatment in good time can help avoid gum disease and early tooth loss, says Dr Lee, not to mention jaw and facial pain associated with malocclusion (a bad bite). Early treatment is advantageous, so it’s vital to take your child for orthodontic assessment no later than the age of seven.
“Early treatment allows the orthodontist to work with the child’s growth in a complementary way,” she says.
An example of this is when the upper front teeth protrude ahead of the lower ones, often due to the lower jaw being shorter than the upper jaw. “While the upper and lower jaws are still growing, orthodontic appliances can be used to help the growth of the lower jaw catch up to that of the upper jaw.
“We can treat a severe discrepancy in jaw length quite well in a growing child,” Dr Lee explains. “But if left untreated until the jaws have stopped growing, or are growing only slowly, he or she might very well require corrective surgery. Children who may have problems with the width or length of their jaws should be evaluated for treatment no later than age 10 for girls and age 12 for boys.”
When the time comes, the choice of corrective braces depends on the individual’s needs and preferences. “With the use of advanced technology and materials, and working with the natural forces of your body, we gently guide your teeth to their ideal position. Nowadays, you can choose between toothcoloured, silver or clear braces, which teenagers can accessorise with fun, bright colours if they like.”
Fortunately, it’s never too late to correct crooked or crowded teeth – and, interestingly, nearly a third of Dr Lee’s patients are adult. For those who prefer more discreet treatment, technology such as Invisalign is a literally invisible, wire-free and comfortable way to move teeth gradually yet effectively, using a series of aligners that can be taken out when necessary – during teeth-cleaning and eating, for example.
You’d never let your car go for months or years without regular check-ups and servicing, would you? Of course not – its performance would suff er, and in time it would break down completely. It’s the same with teeth: maintenance is everything. (Or, as one wit put it, ignore your teeth and they’ll go away.) Verne Maree spoke with DR JOANNE LAM, who feels strongly about the importance of oral hygiene.
Even more important than regular check-ups is your twice-daily dental routine in front of the bathroom mirror. Most people do at least brush their teeth in the morning, if only to get rid of stale breath.
However, one in four adults – you know who you are! – admit they don’t brush twice a day; that’s according to the UK’s National Smile Month. They really should, and that’s because the ever-present bacteria in the mouth produce acid throughout the day – and more so while you’re eating. Getting rid of this acidic film at least twice in every 24-hour period will help prevent it eating into the enamel and causing cavities. It’s never OK to fall into bed without brushing.
Our teeth have many functions. “We need our teeth not only for chewing,” says Dr Lam, “but also for speech and overall wellbeing. And I believe that once a tooth is lost, there is no like-for-like replacement.”
You should always spend a full two minutes brushing your teeth and gums, every morning and every night. “It’s also important to clean your tongue,” she adds, “as the tongue holds the largest number of bacteria in the mouth. These bacteria produce sulphur-containing compounds, which are a major cause of bad breath.”
The Flossing Debate
How about flossing? On a personal note, I must admit that it’s only been two years since I started flossing every single night. I wasn’t alone. Less than a quarter of adults use dental floss regularly – and one in three people have never flossed their teeth. I’d just had some shiny new crowns fitted, so this worthy resolution was partly to protect the hefty investment. (It helped that my now better-aligned teeth had become easier to floss.)
Around August last year, widespread confusion was sown by a news story claiming that the benefits of flossing had yet to be conclusively proven. As Dr Lam points out, the British Society of Periodontology was quick to issue a press release explaining that daily cleaning between the teeth – be it with floss or an interdental brush – is essential for treating and preventing gum disease. Its American counterpart did the same. “Here at FDC Dental Group, we strongly promote flossing as part of routine oral hygiene,” she says.
Still not sure? If you’re a daily flosser, try not flossing for a week, and then giving it a go – the bad smell should convince you!
Scaling and Polishing
Unless it’s removed, plaque will become hard and stick to your teeth and roots. The germs will also damage the gum and the surrounding bone, resulting in shaky teeth which can cause pain and infection and may need to be extracted, says Dr Lam. “What’s more, dental decay can cause infection of the tooth, leading to toothache and the requirement for long, intricate treatments such as root canal treatment.”
Again on a personal note, my own family dentist works very closely with his resident oral health therapist (OHT); she generally gives me a thorough cleaning, including plaque removal, before I even see him.
Dr Lam agrees that this is a good thing: “We commonly advise cleaning (scaling and polishing) every six months to remove any hardened deposits of tartar from your teeth and beneath the gum,” she says. “It can also help remove any extrinsic staining and lift the colour of the teeth.” She notes, however, that as an OHT works within “the prescribed scope of dentistry”, a dentist must first prescribe cleaning to be done.
Removing all the plaque and tartar from the teeth and gums enables my dentist to provide a more thorough examination, she explains. What’s more, OHTs have been specially trained to help maintain gum health and provide routine gum treatment to patients.
“At FDC, our OHTs work closely alongside the dentists to provide a comprehensive treatment for our patients. They are all well versed in providing oral hygiene instruction, gum treatments and preventative treatments such as fluoride treatment or fissure sealants.”
Good oral health is achievable, Dr Lam reminds us. Try to see your dentist every six months, and if you have any dental concerns, don’t put it off in the hope that the problem will go away of its own accord. It won’t, so make an appointment as soon as possible.
Even if you haven’t seen a dentist for years, making an appointment is the first step towards a healthy mouth. “Urge your friends and family to visit their dentist if they haven’t for a while. It’s never too late.”