Does Tooth Loss Influence Sleep Apnea?

Link suggested between onset of OSA and loss of teeth

5 April 2012 -- Previous studies have speculated that there may be an association between edentulism and worsening obstructive sleep apnea (OSA), but research presented at the recent American Association for Dental Research annual meeting did not find a link.

"We came across some papers stating that individuals who slept in their complete dentures had an improvement in their OSA," study author Jeff Tanner, DDS, an oral and maxillofacial surgery resident at the University of California Los Angeles (UCLA), told DrBicuspid.com. "Their assumption was that tooth loss/edentulism contributes at least in part to the worsening of OSA."

When people become edentulous, several physiological changes take place, Dr. Tanner noted. For example, the vertical dimension of occlusion reduces, the tongue grows larger because of the space that is no longer occupied by teeth, the position of the tongue changes, and the tongue rests in a different position.

Since no prior study has ever examined whether or not tooth loss per se was a predictor of OSA, the researchers decided to investigate this connection.  "When we became interested in this topic we found that there were several publications that had dealt with this issue, but not so directly," Dr. Tanner stated said during the session.

VA health system data

Dr. Tanner and his colleagues hypothesized that people with fewer teeth -- especially those who are edentulous -- have more serious OSA after controlling for age and body mass index (BMI), which are known predictors of OSA.

They conducted a retrospective chart review of patients from the greater Los Angeles U.S. Department of Veterans Affairs (VA) health system who were referred to the dental service for treatment of OSA. The researchers looked at the electronic medical records of 210 male veterans who had already undergone a sleep study at the VA hospital and were able to collect the age and BMI of these patients. The researches also used an apnea-hypopnea index to classify the severity of the patients' OSA.

They then used panoramic radiographs to quantify teeth using three different methods: total teeth lost, mandibular teeth lost, and posterior dental functional units lost.

Here are the key results:

• Of the 210 subjects, 25.5% had not lost any teeth, 36.6% lost one to five teeth, 20.8% lost six to 16 teeth, and 17.1% lost more than 16 teeth.
• 30% of the individuals had mild OSA, 36% moderate OSA, and 34% severe OSA.
• The bivariate association between the number of dentition present and severity of OSA showed no significance.
• In multivariate analysis, age and BMI were significant predictors of OSA severity, while total teeth loss was not significant

"The degree of tooth loss is not associated with OSA severity," the authors concluded. "Tooth loss does not worsen OSA. "

More research needed

OSA is difficult to understand because of the causative factors, Dr. Tanner said.

Age and obesity are proven predictors so the study controlled for those variables; however, the authors were still not able to prove that tooth loss predicted a worsening of OSA, he noted.

This line of research could be improved by obtaining a sleep study on the same individual prior to edentulism, after edentulism, and wearing complete dentures, Dr. Tanner added.

"Only by conducting this type of study will we be able to be certain to state whether or not tooth loss predicts OSA," he said. "If in the future it could be stated that edentulism worsens OSA, it would be a strong case for dentists to attempt to restore patients back to a dentate state with implants which maintain alveolar ridge height unlike dentures."

Given that OSA is an epidemic that is just now catching the public's attention, "This connection would be huge, as that type of treatment would be medically driven dentistry, possibly covered by medical insurance," he concluded.

reported by DrBicuspid.com

Dental Visits Critical for Smokers

CDC report: More smokers avoid the dentist

Adult tobacco smokers are four times more likely to develop oral health problems but much less likely than nonsmokers to go to the dentist regularly, according to a report released February 7 by the U.S. Centers for Disease Control and Prevention (CDC).

The study, which included more than 16,000 adults between the ages of 18 and 64 who participated in the 2008 National Health Interview Survey, also found that although more than a third of smokers included in the report said they have three or more dental problems, 20% said they had not been to a dentist in at least five years. Among nonsmokers and former smokers, 10% had stayed away that long.

Cost was cited as the main reason that most adults with an oral health problem did not see a dentist in the past six months; 56% of current smokers, 36% of former smokers, and 35% of never smokers said they could not afford treatment or did not have insurance.

"Overall, current smokers had a poorer oral health status and more oral health problems than either former smokers or never smokers," the report authors noted. "However, current smokers were more likely to think that their oral health problem was important."

The evidence for an association between tobacco use and oral diseases has been clearly shown in every U.S. surgeon general's report on tobacco since 1964. Tobacco use is a risk factor for oral cancers, periodontal diseases, and dental caries, among other diseases.

reported by DrBicuspid.com, Feb 2012.

Dr. Notes:

Because cost is cited as a major factor for smokers and their reluctance to visit the dentist for regular check-ups, I thought I would present some facts.

The average cost for a pack of cigarettes in the state of Minnesota is $6.53.  That’s 33¢ per cigarette.  According to the American Lung Association, the average smoker inhales 3/4 pack, or 15 cigarettes, per day.  After doing the math you'd find that the annual cost for a smoker’s habit totals $1787 plus change.

Now consider this.  The average annual cost of routine dental care (includes 3 cleanings, exams and routine radiographs) would be around $275.  Again, if you crunch the numbers you would find that if the average smoker were to reduce cigarette consumption by 3 cigarettes per day, they could easily afford the out-of-pocket expense of routine dental care.  And these numbers don’t consider the inclusion of dental insurance, which 80% of smokers have, yet don’t utilize.

Our job as a dental office is to address and treat oral health.  We don't give lectures and we don't judge people based on their choices in life, especially their decision to smoke.  But we will provide guidance and advice for those who do.  Regular dental care is crucial for smokers if they wish to minimize the long term effects of their smoking habit.  Routine cleanings and exams can do a lot to help prevent a wide range of problems that smokers are predisposed to and help proactively identify the development of long-term complications that can result from oral tobacco use.

What Does Your Mouth Have to Say About Your Health?

Oral Health Can Provide Clues to Total Body Wellness for Patients

Cardiologists might not check your teeth and gums, but maybe they should start. Mounting evidence suggests a quick peek in the mouth may reveal a whole lot about your general health.

PICTURES: Foul mouth: what yucky signs say about your health

The lips, mouth, teeth and breath can signal medical problems and diseases beyond the plaque, gum disease and gingivitis diagnosed in the dentist's chair. Plaque buildup between teeth due to lax brushing and flossing is very different from plaque that builds up in arteries and causes heart attacks - but the toxins in mouth plaque stimulate a chronic inflammatory response linked to diseases like heart disease.

"The mouth is the gateway to the heart and there's clearly a link between poor dental health and cardiovascular conditions," says Dr. Kevin Marzo, Chief of Cardiology at Winthrop University Hospital in Mineola, New York. For example, he says, cardiac medications you put under your tongue travel quickly through the bloodstream. That means bacteria can too.

"The bacteria that cause dental plaque may promote inflammation in the body beyond the mouth including the lining of the blood vessels, increasing the risk for cardiovascular disease including heart attacks," says Marzo.

Research has shown when people with active gum disease are treated, their arteries actually get healthier. Some experts suggest managing inflammation in the mouth may reduce other inflammatory-related health issues, including arthritis - even wrinkles and aging. Besides heart disease, gum disease has been linked to respiratory diseases, stroke, and osteoporosis.

The mouth can also give doctors clues about a person's sexual health. Warts in the mouth that resemble cauliflower clusters may signal the human papillomavirus, or HPV, one of the most common sexually transmitted infections.

"I see them on the lips, tongue or roof of the mouth," says Dr. Susan Pugliese, Clinical Assistant Professor Division of Oral Medicine and Dentistry Department of Surgery at SUNY Downstate. "And I'm seeing them more frequently in patients over 50 who are dating." Pugliese says this age group may not connect what's going on in their mouth to their sex lives.

HPV is also a driver of oral cancer: the National Cancer Institute, estimates 65 percent of the approximately 8,000 cancers of the tonsils and base of the tongue seen in the U.S. in 2010 were from HPV infections; 80 per cent were in men. Cancers may appear as ulcers on the lips, inside of the cheeks, tongue or back of throat that don't heal, or white patches that don't slough off. A biopsy is typically recommended for suspicious warts or lesions in the mouth and throat.

HIV is often first detected in the mouth, as a bright red outline around the teeth, or as a white coating that can be scraped off the tongue, known as thrush. The coating signals an overgrowth of Candida, the same fungus that causes yeast infections in women and jock itch in men. The white coating can also signal glucose levels are out of whack, poorly managed diabetes or fluctuating hormones. It can also be harmless, signaling a sensitivity to additives in toothpaste, such as tartar control agents. Dentists may recommend an HIV test for young patients presenting with Candida who have other risk factors.

A person's breath also provides health clues. Bad breath may signal serious conditions that require medical attention such as respiratory infections, diabetes, acid reflux and kidney and liver problems. Dry mouth? That's sometimes caused by medications, such as antidepressants, anti-inflammatories, and heart drugs. Drinking water or chewing on fibrous foods such as celery may help.

Good oral hygiene is the best way to prevent gum disease and keep your mouth healthy. Healthy gums hug the teeth and don't pull away, have bounce, and don't bleed from brushing or flossing.

But while a clean, well-cared for mouth can promote good health, it can also disguise serious health problems... so don't skip regular visits to the doctor, and dentist.

If Your Teeth Could Talk...

The Mouth Offers Clues to Disorders and Disease;

Dentists Could Play Larger Role in Patient Care

The eyes may be the window to the soul, but the mouth provides an even better view of the body as a whole.

Some of the earliest signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalances and drug issues show up in the gums, teeth and tongue—sometimes long before a patient knows anything is wrong.

There's also growing evidence that oral health problems, particularly gum disease, can harm a patient's general health as well, raising the risk of diabetes, heart disease, stroke, pneumonia and pregnancy complications.

"We have lots of data showing a direct correlation between inflammation in the mouth and inflammation in the body," says Anthony Iacopino, director of the International Centre for Oral-Systemic Health, which opened at the University of Manitoba Faculty of Dentistry in Canada in 2008. Recent studies also show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes.

Such findings are fueling a push for dentists to play a greater role in patients' overall health. Some 20 million Americans—including 6% of children and 9% of adults—saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month.

"It's an opportunity to tell a patient, 'You know, I'm concerned. I think you really need to see a primary care provider,' so you are moving in the direction of better health," says the study's lead researcher Shiela Strauss, co-director of statistics and data management for New York University's Colleges of Nursing and Dentistry.

George Kivowitz, a restorative dentist with offices in Manhattan and Newtown, Pa., says he has spotted seven cases of cancer in 32 years of practice, as well as cases of bulimia, due to the telltale erosion of enamel on the back of the upper front teeth, and methamphetamine addiction. "We call it 'meth mouth,' " he says. "The outer surface of teeth just rot in a way that's like nothing else."

Some of the most distinctive problems come from uncontrolled diabetes, Dr. Kivowitz adds. "The gum tissue has a glistening, shiny look where it meets the teeth. It bleeds easily and pulls away from the bone—and it's all throughout the mouth."

An estimated six million Americans have diabetes but don't know it—and several studies suggest that dentists could help alert them. A 2009 study from New York University found that 93% of people who have periodontal disease are at risk for diabetes, according to the criteria established by American Diabetes Association.

It's not just that the same lifestyle habits contribute to both gum disease and high blood sugar; the two conditions exacerbate each other, experts say. Inflammation from infected gums makes it more difficult for people with diabetes to control their blood-sugar level, and high blood sugar accelerates tooth decay and gum disease, creating more inflammation.

Dr. Marcus notes that about 50% of periodontal disease is genetic—and even young patients can have significant bone loss if they have an unusually high immune response to a small number of bacteria. Giving such patients a low dose of doxycycline daily can help modify the immune response. "It doesn't really control the bacteria, but it helps reduce the body's reaction," he says.Diabetes also complicates dental-implant surgery, because it interferes with blood vessel formation and bone growth. "When you put a dental implant in, you rely on the healing process to cement it to the jaw, so you get a higher failure rate with diabetes," says Ed Marcus, a periodontist in Yardley, Pa., who teaches at the University of Pennsylvania and Temple University dental schools.

There's also growing evidence that the link between periodontal disease and cardiovascular problems isn't a coincidence either. Inflammation in the gums raises C-reactive protein, thought to be a culprit in heart disease.

"They've found oral bacteria in the plaques that block arteries. It's moved from a casual relationship to a risk factor," says Mark Wolff, chairman of the Department of Cariology and Comprehensive Care at NYU College of Dentistry.

Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere, which is why people contemplating elective surgery are advised to have any needed dental work performed first.

The American Heart Association no longer recommends that people with mitral valve prolapse (in which heart values close abnormally between beats) routinely take antibiotics before dental procedures, since it's now believed that oral bacteria enter the bloodstream all the time, from routine washing, brushing and chewing food.

But the American Heart Association, the American Medical Association and the American Orthopedic Association all urge people who have had a full joint replacement to take an antibiotic one hour before any dental visit for the rest of their lives to reduce the risk of post-surgical infections. "I have my guidelines taped to the door in my hygienists' room," Dr. Kivowitz says.

Dentists say they also need to stay up to date with all medications, supplements and over-the-counter drugs their patients are taking. Blood thinners can create excess bleeding in the mouth. Bisphosphonates, often prescribed for osteoporosis, can severely weaken jaw bones. Both should be stopped temporarily before oral surgery.

Antihypertensive drugs, calcium-channel blockers and some anti-inflammatory drugs can cause painful ulcerations of the gums. Many medications, from antidepressants to chemotherapy drugs, cause dry mouth, which can cause cavities to skyrocket, since saliva typically acts as a protective coating for teeth. Additional fluoride treatments can help.

Some proactive dentists have glucose monitors for another check on blood-sugar levels if they suspect diabetes. Some also take patients' blood pressure and hold off on invasive procedures if it's extremely high.

The Centers for Disease Control and Prevention recommends that dentists offer HIV testing, because some of the first symptoms appear in the mouth, including fungal infections and lesions. Dentists can do the HIV test with a simple mouth swab and get results in 20 minutes.

Breaking the bad news is often more difficult. "I went into oral surgery because I didn't think I would have to deliver that kind of news to patients," says Clifford Salm, an oral and maxillofacial surgeon in Manhattan who has found leukemia, lymphoma, AIDS and metastatic breast cancer after performing biopsies on suspicious spots. "It can be a difficult conversation," he says, "but most patients are very grateful."

Don't Be Fooled by White, Shiny Teeth
A gleaming, white smile is a sign of a healthy mouth, right? Not necessarily.  "Whiteness and the health of your teeth are totally unrelated," says Mark Wolff, an associate dean at New York University College of Dentistry.

In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease.

Even people who have no cavities can still have inflamed and infected gums. It could be that their saliva is particularly protective of their tooth enamel, while their brushing and flossing habits, needed to keep gum tissues healthy, could be lax.

"I get these patients in their mid-30s who don't have cavities, so they haven't been to a dentist in 10 years. But they have full-blown periodontal disease," says George Kivowitz, a restorative dentist in Manhattan. "They are losing all the supporting structure, and I have to tell them that these gorgeous teeth will fall out of your head if we don't turn this around."

Using whitening products more often than recommended can erode some of the enamel and cause teeth to appear translucent. But whether that actually harms teeth is controversial. "No one has really shown that it's damaging, but no one knows the long-term results," says Dr. Marcus, the periodontist in Yardley, Pa.

The Mouth-Body Connection: Garbage In=Garbage Out

Discover why good dental health depends on more than brushing and flossing, and why a clean, happy mouth gives your whole body something to smile about.

By Bonnie Blodgett

Let's face it. Most of us take our teeth for granted. Sure, we brush and floss (well, some of the time). And we know, of course, that teeth are essential for chewing our food and for maintaining a beautiful smile. But when we get a cavity – or even when we get diagnosed with gum disease that might culminate in root canals or tooth loss – we seldom think of these problems as posing permanent risks to our health and vitality.

We simply don't place the same importance on our dental health as we do on, say, the health of our vital organs. After all, the mouth is the domain of the dentist; the body, the domain of the doctor.

But that perspective is changing. Recent research provides convincing evidence that oral health and overall health are inextricably linked – that what's good for our mouth is also good for the rest of the body we work so hard to keep fit and healthy. Dentists increasingly screen for systemic diseases, which involve many organs or the whole body, through tongue assessments, saliva tests, blood pressure checks, and simple observation of the teeth and gums. As well they should: More than 90 percent of systemic diseases have oral symptoms such as lesions, according to the Academy of General Dentistry. Dentists are also checking for signs of inflammation that could affect heart health as we age. When they see trouble, they make referrals to physicians.

To emphasize the connection between oral health and overall health, Vincent J. Iacono, DMD and former president of the American Academy of Periodontology, offers the not-so-appealing metaphor of the mouth as a garbage dump on the edge of a river: "You wouldn't be surprised if the lake downstream ended up polluted with the garbage from the dump. A patient's bloodstream acts very much like the river in this analogy, in that it carries the bacteria from the periodontal plaques, possibly 'polluting' the arteries of the heart with periodontal bacteria, causing inflammation of the arteries, which may lead to a heart attack. This potential effect of periodontal bacteria further supports the need for periodic deep cleanings to enhance overall health and well-being."

This same effect has also convinced the American Heart Association (AHA) that dentists are very much on the front lines of healthcare. In addition to helping us keep our teeth firmly planted in our mouths as we age, oral-health experts are also destined to play a more important role in helping us maintain our vitality and overall quality of life.

A New Approach to Dental Health
This link between oral and overall health, now becoming common in conventional dentistry, has for years been a key tenet of what's known as holistic dentistry, which takes an integrated approach to dental care. Holistic dentists advocate for optimal nutrition. They take a minimally invasive approach to resolving dental problems. Some even evaluate a patient's skeletal structure and, of greatest controversy, often shun the use of fillings that contain mercury and call for replacing those amalgams.

Holistic dentists consider conventional dentists too quick to remove troublesome teeth, perform root canals, and insert "unnatural" substances and appliances into the mouth, arguing that these toxic substances create unhealthy imbalances in the mouth's natural ecosystem. But there are signs that the members of the Holistic Dental Association and the American Dental Association (ADA) may be inching closer together, at least philosophically.

Conventional dentists like P. Piero, DDS, of Holland, Mich., an ADA member in good standing, have some doubts about many of holistic dentistry's claims and methods. But Piero is pushing his colleagues further in the direction of what many in the profession are calling a "whole-person" approach to dentistry. Piero, who has spent two decades developing his own oral-care system (www.dentalairforce.com), represents a new breed of dental practitioner. He considers himself a teacher and passes along what he learns about oral health and hygiene to his patients. He isn't shy about discussing the difference between good and bad bacteria, their role in building plaque, and what happens when the bad guys get loose in the bloodstream. A visit to Piero may include a conversation about changes in diet and lifestyle – changes, he emphasizes, that could prevent not only tooth decay but also tooth loss. He knows that the longer his patients keep their teeth, the longer they're likely to live.

Healthy Mouth, Healthy Body
Good oral health calls for more than just brushing and flossing. It requires eating nutritious foods, exercising, avoiding cigarettes and alcohol, and controlling blood pressure. It may also mean looking to your dentist as a resource for more than cleanings and fillings. After all, troubles in the mouth not only predict disease, they can also exacerbate and even cause it.

John Laughlin III, DDS, of River Falls, Wis., has been practicing holistic dentistry for years. Many patients come to him when nothing else has eased their chronic pain or fatigue. Laughlin recalls one woman who came to him because she developed such severe flulike symptoms following a root canal that she "thought she was dying." She'd consulted several doctors who could find no cause for her symptoms.

Laughlin, suspecting an infection below the crown capping the root canal, referred her to an oral surgeon to have the tooth removed. The oral surgeon refused because, as Laughlin puts it, "he could see nothing wrong with the tooth." Six weeks and three doctors later, the woman finally signed papers absolving her surgeon of any responsibility for the outcome. He then removed the tooth – and found that the dead nerve remnant beneath it was not only infected but that the infection had spread to the bone, which was badly eroded.

More surgery was required to fill the large hole with bone taken from her inner cheek. The woman's symptoms immediately disappeared. She credits Laughlin with saving her life.

An equally convincing and more far-reaching example of the mouth-body health connection is evidenced by the well-established link between periodontal disease (infected gum tissue that can lead to tooth loss) and cardiovascular illness. Such disease is now considered as reliable a predictor of cardiovascular disease as smoking, diabetes, hypertension, high cholesterol and elevated serum triglycerides. A 2004 AHA study found that pericoronitis (infected wisdom teeth) heads the list of dental risk factors for heart disease. Others, in order of importance, are gingivitis, root remnants, cavities and missing teeth.

Periodontal disease has also long been associated with diabetes; now it's being linked to other chronic illnesses involving not just the heart but also the lungs and the brain, and to low-birth-weight babies and preeclampsia (a condition characterized by high blood pressure and the presence of protein in the urine). It is also known to be more prevalent in postmenopausal women, probably because of lower estrogen levels, which also cause bone loss and, not incidentally, heart disease.

How all these problems intersect remains somewhat mysterious. Consider tooth loss: Like other oral health problems, it involves a vicious cycle. An older person who has lost teeth and can't chew properly doesn't get all the nutrition available in food, which exacerbates the underlying problem that caused his or her teeth to have a precarious grip in the first place. In other words, the gum disease itself may have a nutritional basis (too many doughnuts and soft drinks, perhaps), which in turn caused systemic problems such as poor bone health or a chronic disease. Healthcare providers do know that tooth loss is a predictor of longevity (the longer we keep our teeth, the longer we live) and that losing teeth nearly doubles a person's heart-attack risk.

Inflammation and Cardiac Illness
Need more convincing about the mouth-body connection? Consider the death of a middle-aged man who'd had a defective heart valve replaced and seemed to be recovering well: He was told to take antibiotics before dental visits to prevent infection from bacteria that can escape from the mouth into the bloodstream during cleaning. Apparently the antibiotics weren't enough to prevent a massive infection, which led to a fatal heart attack.

The fact that inflammation – often a result of infection – causes strokes and heart attacks has been widely accepted and is now being studied in depth by the AHA. Nowadays, it's not unusual during a routine physical to be given a test for C-reactive protein, a marker for systemic inflammation, especially if you have other risk factors for heart disease. Bad teeth, poor oral hygiene and diet are usually implicated when inflammation is detected.

Saliva is our first line of defense against the "bad" bacteria that cause plaque to form on our teeth. Plaque buildup may cause gingivitis, which can lead to periodontitis and, if left unchecked, to something called acute necrotizing ulcerative gingivitis, or trench mouth. Bacteria from those conditions can enter the bloodstream after routine dental cleanings, or even after flossing and brushing at home. Bad bacteria can also make its way into the bloodstream when saliva flow is reduced because of antibiotics or medications, such as antidepressants, disrupting the normal bacterial balance of the mouth.

Bacteria that manage to slip into the bloodstream (called bacteremia) could cause an infection elsewhere, especially if a body's immune system has been weakened by a disease like AIDS or by cancer treatments. And if those bad bacteria find their way to the lining of diseased heart valves, the result can be infective endocarditis. That's the condition that took the life of that middle-aged man who thought he was on the road to cardiac health, but died after a routine dental cleaning.

The Case for Good Hygiene
In his practice, Piero addresses systemic problems with patients even as he is filling their cavities or helping them decide whether to straighten their crooked teeth. He considers anything unnatural in the mouth dangerous (whether a crown, an implant or a cosmetic veneer), but not because of the fear of mercury toxicity often cited by holistic dentists. Rather, he says, such things interfere with what he thinks is the most important issue in dentistry: the battle against bad bacteria.

"The mouth is a war zone," Piero says, referencing the more than 500 species of bacteria that inhabit it. "Bad bacteria are usually anaerobic – they live in the absence of air." Their excrement turns into plaque, which is actually a multilayered biofilm and very difficult to remove once it's got a foothold, and especially dangerous if its presence has created periodontal inflammations known as pockets. This process causes illness in other parts of the body not just by allowing bad bacteria into the bloodstream but also by causing the body to fight back with enzymes called cytokines that trigger a systemic inflammatory response. He believes this cycle is the primary link between oral and whole-body health.

"Hygiene is everything," says Piero, who recommends patients visit him four times a year for intensive cleanings, rather than the standard twice-yearly visits. "A 16-year-old kid can have perfect teeth, but his beautiful smile won't last long without good dental habits. It's like letting your new Ferrari sit out in the rain. I'm looking at the long term. Our kids are going to live to be 100. Their teeth have to last that long, too."

Piero points out that bacteria can be spread through any sort of contact. "Yes, periodontal disease is hereditary, but it is also an infectious disease. Kissing, eating – many activities bring new kinds of super-smart bacteria into the mouth. They are highly adaptive: They can change quickly to new conditions in order to survive."

Given the potential impact oral conditions can have on our total health, says Piero, it would be wise for us to show the same respect for our teeth that we would to other parts of the body. "The area of our exposed gum tissue equals that of our forearm, about 9 square inches," he points out. "What would we do if suddenly our forearm was inflamed? We'd run to the doctor. But periodontal disease is painless. Hidden." And so we ignore it.

Dentistry for Life
Jessica Saepoff, DDS, belongs to the ADA and five other major dental organizations. Like Piero, she has developed her own interpretation of holistic dentistry. Her practice, Natural Dental Health Associates, in Issaquah, Wash., specializes in alternative methods, which she considers not so much alternative as simply the most advanced. She routinely communicates with her patients' other holistic health practitioners so they can work together toward comprehensive health goals.

For Saepoff, dental care always comes down to personal choice. "I tend to attract patients who are opposed to taking even small theoretical risks, whether it's eating pesticides in their food or having mercury in their mouths," she says. "I understand that drilling is sometimes necessary, but the goal of my practice is to preserve natural tooth structure."

Whether you take the holistic path to oral health or the conventional approach, one thing is certain: The way you think about your teeth may change dramatically in coming years, as new studies shed more light on the myriad ways in which a healthy mouth is essential to overall health and vitality, and a key factor in longevity. With your doctor and your dentist by your side, you'll be able to keep your smile beautiful, and to keep flashing that great grin for years to come.

Bonnie Blodgett is a writer and editor in St. Paul, Minn. She publishes a quarterly for gardeners, The Garden Letter, and is working on a book about smell.

Gum Disease Can Increase the Time It Takes to Become Pregnant

Science Daily -- Professor Roger Hart told the annual meeting of the European Society of Human Reproduction and Embryology that the negative effect of gum disease on conception was of the same order of magnitude as the effect of obesity.

Prof Hart, who is Professor of Reproductive Medicine at the University of Western Australia (Perth, Australia) and Medical Director of Fertility Specialists of Western Australia, stated, "Until now, there have been no published studies that investigate whether gum disease can affect a woman's chance of conceiving, so this is the first report to suggest that gum disease might be one of several factors that could be modified to improve the chances of a pregnancy."  Researchers found that women with gum disease took an average of just over seven months to become pregnant -- two months longer than the average of five months that it took women without gum disease to conceive.

Periodontal (gum) disease is a chronic, infectious and inflammatory disease of the gums and supporting tissues. It is caused by the normal bacteria that exist in everyone's mouths, which, if unchecked, can create inflammation around the tooth; the gum starts to pull away from the tooth, creating spaces (periodontal pockets) that become infected. The inflammation sets off a cascade of tissue-destructive events that can pass into the circulation. As a result, periodontal disease has been associated with heart disease, type 2 diabetes, respiratory and kidney disease, and problems in pregnancy such as miscarriage and premature birth. Around 10% of the population is believed to have severe periodontal disease. Regular brushing and flossing of teeth is the best way of preventing it.

The researchers followed a group 3737 pregnant women, who were taking part in a Western Australian study called the SMILE study, and they analysed information on pregnancy planning and pregnancy outcomes for 3416 of them.  In addition, non-Caucasian women with gum disease were more likely to take over a year to become pregnant compared to those without gum disease: their increased risk of later conception was 13.9% compared to 6.2% for women without gum disease. Caucasian women with gum disease also tended to take longer to conceive than those who were disease-free but the difference was not statistically significant (8.6% of Caucasian women with gum disease took over one year to conceive and 6.2% of women with gum disease).  "Our data suggest that the presence of periodontal disease is a modifiable risk factor, which can increase a woman's time to conception, particularly for non-Caucasians. It exerts a negative influence on fertility that is of the same order of magnitude as obesity. This study also confirms other, known negative influences upon time to conception for a woman; these include being over 35 years of age, being overweight or obese, and being a smoker. There was no correlation between the time it took to become pregnant and the socio-economic status of the woman." professor Hart said.  Information on time to conception was available for 1,956 women, and of, these, 146 women took longer than 12 months to conceive -- an indicator of impaired fertility. They were more likely to be older, non-Caucasian, to smoked and to have a body mass index over 25 kg/m². Out of the 3416 women, 1014 (26%) had periodontal disease.

Prof Hart said that the reason why pregnancies in non-Caucasian women were more affected by gum disease could be because these women appeared to have a higher level of inflammatory response to the condition."  All women about to plan for a family should be encouraged to see their general practitioner to ensure that they are as healthy as possible before trying to conceive and so that they can be given appropriate lifestyle advice with respect to weight loss, diet and assistance with stopping smoking and drinking, plus the commencement of folic acid supplements. Additionally, it now appears that all women should also be encouraged to see their dentist to have any gum disease treated before trying to conceive. It is easily treated, usually involving no more than four dental visits." he added.

The SMILE study was one of the three largest randomised controlled trials performed in Western Australia. It showed conclusively that although treatment of periodontal disease does not prevent pre-term birth in any ethnic group, the treatment itself does not have any harmful effect on the mother or fetus during pregnancy.