No cardiovascular prevention program is complete without a dentist and hygienist on the team. EVERY primary care patient should know the name of their medical doctor and their dentist, and physicians and dentists should strive hard towards open communication and interdisciplinary collaboration. Somewhere along the healthcare continuum, we separated the care of mouth from the care of the body, and it is past time to reconnect the two. Interdisciplinary partnerships will elevate the health of your patients dramatically and learning just a few new diagnostic and therapeutic tricks will make your practice more fun, interesting, and even more profitable. “Returning the Mouth to the Body” has been a subject covered by Adam C. Miller, DDS, MD in the Core Curriculum online education library of AAOSH, and we believe it is essential to educate practitioners and the public on how to overcome the unreasonable gaps between the dental and medical communities. 

For starters, is critical to recognize the role of simple oral hygiene as a potentially LIFE-SAVING strategy.  One recent study tracked 5,600 older adults for 17 years and reported that:  

• The risk for death during the study period increased by 20 to 25 percent, for those who neglected nighttime tooth brushing, compared to those brushing every night. 
• Compared with daily flossing, never flossing increased mortality risk by 30 percent. 
• Compared to those getting dental care two or more times a year, not seeing a dentist in the previous 12 months raised mortality risk by up to 50 percent!! (1)

But how can medical doctors possibly improve patient outcomes just by increasing awareness of oral health? Start with 5 simple steps… 

STEP 1. ASK HISTORY QUESTIONS RELATIVE TO ORAL HEALTH. SHOWING INTEREST IN ORAL HEALTH HELPS PATIENTS UNDERSTAND THAT YOU RECOGNIZE A LINK AND CONNECTION.  

HERE ARE SOME EXAMPLES: 

• When was your last dentist visit and tooth cleaning? 
• Do you have bleeding, tender or sore teeth or gums?   
• Has there been any shifting in your bite? 
• Are you a mouth-breather? 
• Do you have any foul taste/bad breath?   
• Are there any swelling/lumps in mouth?  
• Do you tongue or lips burn? 
• Did you ever have orthodontic treatment (braces/Invisalign? Or teeth pulled for teeth straightening)
• Do you get frequent ulcers or fever blisters in your lips/mouth?  
• Do you clench or grind your teeth? 
• Do you know the numbers of your “pocket depths” from your last dental cleaning? 
• Do you have heat, cold or sweet sensitive teeth? 
• Does your jaw click or pop or not open/close properly? 
• Do you have any loose or broken teeth? 
• Do you have dentures/partial? 
• Do you have any caps, crowns, or root canal teeth?
• Do you snore? 

STEP 2. PAY CLOSER ATTENTION ON PHYSICAL EXAM: 

EXAMINE LIPS, TONGUE, NATURAL TEETH, SALIVA, REPAIR WORK, SOFT PALATE/MALLAMPATI SCORE 

 Use a tool like the Oral Health assessment tool to keep track. (2) 

• Ask patient to open mouth wide (use a penlight or otoscope if needed)     
• Carefully inspect the surface of the tongue and the hard palate 
• Examine the entire buccal area and the gingivolabial (gingivobuccal) sulcus  
• Ask the patient to lift their tongue toward the roof of their mouth and inspect the floor of the mouth (use the tongue depressor if needed) Pay careful attention to the location of frenulum (not too anterior) 
• Inspect the uvula, tonsils, palatal folds, and posterior pharyngeal wall. Note Mallampati score (3)  
• Bonus points: learn Traditional Chinese Medicine meridians that run though the mouth (4) 
• Learn TCM tongue diagnosis (the core curriculum on the AAOSH website will include a tongue lecture by Oscar Sierra, herbalist and functional medicine provider by Q1 2023)   

STEP 3. ORDER PROPER LABS WITH INTENT TO SCREEN FOR INFLAMMATION AND OXIDATIVE STRESS 

We order the “fire panel” from Quest/Cleveland Heart Labs or Boston Heart Labs that includes: hsCRP, MACR, Myeloperoxidase, LpPLA-2 activity, F-2isoprostane, ADMA and SDMA, and OxLDL. These markers are highly associated with endodontal/periapical and gum disease. (5) 

If the patient reports bleeding gums, has any of these markers elevated without an obvious trigger, has had an atherosclerotic event, or is not in a relationship with an enlightened dentist who has already done it, THEN I also perform Oral DNA salivary diagnostics (a spit test for inflammatory mouth bacteria called “Periopath”.) Other labs are HR5 from Direct Diagnostics, OraVital, MicrobeLinx Dx, Direct Diagnostics and FidaLab that also find these nasty oral pathogens. 

Have a SUPER low threshold for ordering a sleep study. Obstructive sleep apnea wrecks the mouth and the body! (6) 

STEP 4. ENCOURAGE BETTER ORAL HOME CARE: 

• Avoid “toxi-paste” and only use toothpaste recommended by the biological dentist. Often, these will be SLS, paraben and fluoride-free and may include xylitol or hydroxyapatite. Common brands are Jason’s, Tom’s, Revitin or RiseWell, Spry. DoTerra has a nice one too, called OnGuard. 

SLS for example has been shown to cause oral mucosal lesions, especially in pre-menopausal women. (7) While the safe dose and exposure is not yet clearly defined, the endocrine disrupting nature of parabens is well established and avoiding exposure especially in children is prudent. (Endocrine disruptor compounds in environment: As a danger for children health. (8) 

• Floss is not as effective as “pressure washing” between the teeth using a Water Pik, or HydroFloss.  Consider adding Argentyn 23, or a drop of grapefruit seed extract to the water.  
• If flossing, avoid the habit of snapping the floss up and down, which irritates your gums and does a poor job of cleaning. Rather saw the floss in an up and down /zigzag motion, with the floss contoured in a C-shape to wrap around the tooth  
• Brush teeth and gums, cheeks, the roof of the mouth, and the vestibule (the area between the teeth, lips and cheeks). Use a tongue scraper – not a toothbrush – to clean the tongue.  
• Consider dental picks (such as G.U.M.  Soft-Picks) to efficiently remove debris between teeth.  
• Avoid standard sugar or alcohol-based mouth wash. They are too harsh, can raise blood pressure and kill the healthy commensal bacteria too.  
• Learn the ancient practice of oil pulling. Spit used oil in the trash NOT INTO THE SINK.  
• Choose dental products that contain xylitol, a compound with both a pre-biotic and antimicrobial effect. Xylitol products, such as toothpaste, gum, and lozenges help prevent cavities! Infants and children who use xylitol regularly (4-6X/day) rarely get cavities. (10) NOTE Xylitol is extremely toxic or even fatal to dogs, even in small amounts, so keep out of pet’s reach.   
• Go to bed with a clean mouth, after eating a plant based, high nutrient dense diet all day! 

STEP 5. PARTNER MEDICAL WITH DENTAL PROVIDERS AND SET MUTUAL GOALS TO TAKE YOUR PATIENT’S ORAL HEALTH TO THE NEXT LEVEL OF EXCELLENCE.   ASK THE DENTAL PROVIDER TO SCREEN FOR PERIODONTAL AND ENDODONTIC DISEASE AND CREATE A CARE PLAN FOR ERACIATION IF HIGH-RISK ORAL BACTERIA ARE IDENTIFIED 

An excellent oral evaluation should include:     

• X-rays or CT to check for signs of endodontic (tooth root) disease—NOT JUST bite wings to screen for caries (cavities.) If there is extensive repair work (crowns, fillings, root canals) your dental provider may recommend 3-D cone beam tomography [CBCT.] Some providers are suggesting screening CBCT if patients are at risk for cardiovascular disease, stroke or dementia, but insurance is unlikely to pay for screening only.    
• A periodontal exam to measure pocket depths. This painless exam uses a probe to measure how tightly the gum tissue is adhered to the tooth. A healthy pocket typically measures 1-3 millimeters and a depth of 4 mm or more or if there is “bleeding on probing” there is a concern for gum disease.   
• Oral cancer screening 
• Interpretation or care plan for any abnormal imaging or periodontal pathogen testing 
• A dental sleep medicine evaluation 
• A calendar for dental hygiene and tooth cleaning based on individual needs 
• If cavities are detected, options should include a home care plan for remineralization which may include ozonated dental products, option to receive painless topical silver diamine fluoride instead of drilling and filling, or conventional non-mercury containing filling material.   

Only by working together can the fields of medicine and dentistry achieve optimal patient outcomes. Adding just one or two new oral/systemic tests or treatments each year will soon have you well on your way to demonstrably improved patient health and a practice reputation that is in highest demand in your community.  

For a guide and directory to assist you in finding a likeminded oral systemic provider, please visit https://aaosh.memberclicks.net/directory  

REFERENCES: 

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124861/ 
2. https://siphidaho.org/comhealth/ship/KM05-Oral-Health-Asssessment-Tool-for-Primary-Care.pdf 
3. https://www.unitypoint.org/peoria/filesimages/Services/ProctorEMSSMOs/82MallampatiScore.pdf 
4. https://preventionandhealing.com/wp-content/uploads/2021/02/Meridian-Chart-Full.png 
5. https://www.sciencedirect.com/science/article/pii/S0003996921001308 
6. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000988 
7. https://pubmed.ncbi.nlm.nih.gov/8811477/ 
8. https://www.termedia.pl/Endocrine-disruptor-compounds-in-environment-As-a-danger-for-children-health,138,36648,1,1.html) 
9. https://academic.oup.com/ajh/article/28/5/572/174874 
10. https://www.nature.com/articles/4810022