Dr. Carasol: “There’s a real opportunity to save lives in a dental practice”

In your opinion, what is the connection between oral and general health?

The relationship is crucial to supporting the body's balance. The oral cavity serves as a crossroads for the vital respiratory and digestive systems, as well as for speech. This means that oral health affects not only these systems but also many of the body’s tissues due to the effects of infections, tooth loss, malocclusions, and so on. Therefore, a healthy mouth contributes significantly to overall patient well-being, not only physically but also in terms of aesthetics, emotional well-being, and self-esteem.

Which general health issues can be affected by oral health problems? Could you give some specific examples?

Oral cavity disease is increasingly linked to issues in patients' overall health. Caries, malocclusion, and tooth loss can affect chewing, speech, aesthetics, quality of life, and many other aspects. These issues are of the utmost importance and limit many parts of patients’ daily lives.

Likewise, there are some very relevant cases, such as the connection between periodontitis and major diseases like diabetes mellitus, atherosclerosis/cardiovascular disease, respiratory infections, Alzheimer-type dementia, rheumatoid arthritis, certain types of cancer... and so on, in fact, a considerable number of pathologies. Some put this number at over fifty, although, in my opinion, that figure is exaggerated because many studies are based on small samples or present methodological weaknesses.

How do oral diseases, such as gingivitis and periodontitis, affect the rest of the body?

Periodontal disease, particularly periodontitis, can have an impact on certain distant organs and systems of the human body, contributing to these as factors or indicators of risk. However, they do not, of course, cause them. However, the influence is often significant and is generally caused by periodontal pathogens and toxic products entering the bloodstream, exacerbating the low-grade inflammatory reaction that they induce not only locally but also in numerous distant tissues. Another impact is the direct transmission of pathogens/toxins to the respiratory system through aspiration, especially in older and weaker individuals.

There is much talk about the relationship between periodontal disease and cardiovascular disease. What is the evidence for this connection?

The association between periodontitis and atheromatous cardiovascular disease has been proven by evidence derived from epidemiological studies. The main issues showed are acute myocardial infarction, ischemic stroke, and peripheral vascular disease. The hazard ratio (HR) is 2.20 for patients with advanced periodontitis compared to those without periodontitis. Recently, uncontrolled periodontitis has been associated with elevated systolic blood pressure. The chronic presence of bacteria and toxins in the bloodstream (bacteraemia) and its accompanying chronic systemic inflammatory sequelae influence the process of atheromatous plaque formation and maturation, along with the pathological consequences that arise from these processes. Furthermore, periodontitis and cardiovascular diseases share many genetic and environmental risk factors (e.g., smoking). Although there is no direct evidence of the benefits of periodontal treatment on cardiovascular events, there is clear evidence of its effect on indirect indicators of cardiovascular disease, such as high blood pressure and the sub-clinical markers of those diseases. Because of this, it is common practice for cardiologists to warn their patients about the increased risk of poor oral health associated with their cardiovascular disease, particularly in advanced cases of periodontitis and/or tooth loss. For the same reason, dentists should warn their patients about the added risk of an unhealthy mouth on certain cardiovascular diseases, while making it clear that this local situation is not the cause of these diseases. Lastly, all the professionals involved must insist on the enormous importance of controlling risk factors, particularly those which are common to both groups of illnesses, emphasising smoking primarily.

How does oral health affect metabolic diseases such as diabetes and obesity?

Diabetes is the pathology which has been most extensively studied in association with periodontitis, and its bidirectionality is a proven fact. Patients with poorly controlled diabetes are at a higher risk of developing or exacerbating their periodontitis, and patients with periodontitis have an increased risk of developing pre-diabetes or diabetes, with a possible direct relationship between the severity of periodontitis and diabetes complications. In fact, periodontitis has been defined as the sixth complication of diabetes.

The periodontal mechanisms that affect diabetes include bacteraemia, oxidative stress on the beta cell function, and low-grade systemic inflammation. On the other hand, the periodontal tissues of patients with poorly controlled diabetes are affected by exaggerated systemic inflammation, reduction in neutrophil functional efficiency, unbalanced responses of helper T cells, and the formation of advanced glycation end products, which, among other things, inhibit the healing of periodontal wounds.

Based on recent reviews, it is important to note that periodontal treatment resulted in clinically and statistically significant reductions in HbA1c (glycated haemoglobin) levels in individuals with type 2 diabetes, decreasing by 0.3% at six months and 0.5% at 12 months. These reductions are comparable to those achieved by adding a second medication to the initial Metformin regimen. Because of this, it is crucial to raise awareness in society and among doctors, dentists, patients and the population at large of the salience of both diseases together and the importance of visiting your doctor and dentist to evaluate the potential risks.

As regards obesity, adipose tissue acts as an endocrine organ, triggering inflammatory responses that can affect the periodontal tissues, whilst the chronic inflammation caused by periodontitis can contribute to the metabolic imbalances observed in obesity. In conclusion, the connection between obesity and periodontitis is complex, involving multiple factors and inflammatory mechanisms, as well as oxidative stress. However, the causal relationship between these two conditions is unclear, as the heterogeneity of the studies and uncontrolled confounding factors limit the strength of the evidence. More research is required to understand the underlying mechanisms and develop more effective strategies for periodontitis and obesity. Once again, collaboration among periodontal health professionals and obesity specialists is essential if progress is to be made in managing these pathologies, which appear to be interrelated.

What is the relationship between oral health and the risk of complications during pregnancy?

Adverse results in pregnancy, such as premature birth and low birth weight, are worldwide health problems, with 2.3 million newborns dying during their first month every year. Periodontitis has been suggested as a potential risk factor since the 1960s, but systematic reviews and meta-analyses have shown mixed results, indicating that further research is needed to clarify this possible association. However, there is a clear need for expectant women to receive periodontal care to prevent the appearance of pregnancy gingivitis and its possible evolution to periodontitis. In addition to the basic quarterly periodontal check-up, the second trimester is recommended for periodontal treatments, with the exception of surgical treatments, which should be postponed until after the baby is born.

Recently, the link between periodontal health and gestational diabetes has emerged as an extremely relevant area of investigation, once again proving the association between diabetes and bidirectional periodontitis. Hormonal changes during pregnancy, particularly raised progesterone levels, may worsen gum inflammation, exacerbating the risk of periodontal disease. On the other hand, periodontal disease can influence blood glucose regulation in pregnant women, negatively affecting the body's response to insulin. The conclusion is that the collaboration between oral health and medical professionals is essential to provide comprehensive care that covers both areas and improves outcomes for mothers-to-be and their babies.

What are the basic recommendations for supporting good oral health and also encourage good overall health?

They are very simple and clear. Patients should brush their teeth twice daily for two minutes each time, clean between the teeth with inter-dental brushes or floss if there is not enough space between the teeth for the former. Mouthwash may be recommendable in certain circumstances or as a motivational element to achieve a feeling of good oral-dental hygiene. And, of course, regular visits to the dentist, also warning of the possible association between oral pathology and certain systemic diseases and the importance of check-ups with their primary care physician or other medical professional. For dental professionals, educating and motivating patients to support proper oral hygiene is essential, as well as recommending regular dental visits—generally every six months—but this interval can vary significantly depending on the stage of periodontal disease. Dental healthcare teams need to involve themselves actively in these check-ups, particularly matters concerning periodontal maintenance. Furthermore, mitigating or eliminating controllable risk factors is a crucial task. For medical professionals, it is essential to promote awareness of the aforementioned associations and the significance of the bidirectional relationship with dentists to prevent and improve patients’ overall health. For society, it is essential to conduct educational and awareness-raising campaigns at all academic levels, including industry and politics, about the importance of oral health to the overall health of the population. It would be desirable for the National Health System to extend the coverage of oral and dental health to the broadest possible section of the population, as well as the groups currently covered by the System.

How does oral health influence the immune system?

Good oral hygiene contributes to keeping balance in the oral cavity between aggressors caused by genetic factors, external factors such as infection, risk factors like smoking, and the host's defence mechanisms. When oral hygiene is disrupted, diseases such as periodontitis can occur and disturb this balance. In this situation, there is not only an aggressor element composed of pathogens and their toxic products but also an intense local immune response, which contributes to tissue destruction that leads to periodontitis. A chronic, low-grade distant inflammatory response also develops, continuously exerting a negative influence on certain tissues and systemic organs, thereby contributing to an increased risk of certain systemic diseases, as previously discussed.

How important is preventing oral problems to reducing general risks to health?

It is essential. There is nothing as efficient and economical as prevention, and having a healthy mouth helps to avoid or delay the onset and progression of serious local problems, as well as mitigating the systemic impact of oral conditions. Prevention of oral cancer is of great importance, primarily through regular, thorough examinations during dental visits, as well as efforts to eliminate significant risk factors such as smoking and alcohol use.

How has the development of healthcare technology influenced the detection and treatment of oral disease and its links with general health problems?

The transformation in the dental profession, driven by industry and the development of new technologies—such as digitisation, artificial intelligence, and others—is significant. These advancements contribute to the improvement of diagnostic methods, as well as the basic and advanced treatment of diseases, and more efficient patient monitoring. This enhances the potential for early diagnosis and disease control, helping to mitigate the progression to advanced stages. If we add to the above, significant advances in preventive measures and improvements in oral health contribute to reducing the risk of poor oral health influencing associated systemic diseases, particularly periodontitis.

What is the role of regular visits to the dentist in preventing health complications in the long term?

It goes beyond controlling the aforementioned systemic associations. These days, it goes further. At the Spanish Periodontology Society (SEPA), we have developed the Promosalud project to screen patients for diseases they may not be aware of, such as high blood pressure and diabetes, during dental surgery. The reasons are that in Spain, 42.6 % of adults suffer from high blood pressure (more than 10 million), and 37.4% are unaware. As regards diabetes, more than 2.3 million, or 6% of patients with type 2 diabetes, are undiagnosed or do not know they are at risk. Why at the dental surgery? Because 55% of the Spanish population aged between 20 and 74 years make regular visits to the dentist but not to their primary care physicians because they think they are well, particularly during middle age. There is a real opportunity to save lives in dental practices by administering a test (FINRISC) to detect the risk of developing diabetes mellitus within the next ten years and systematically recording blood pressure. Promosalud is a quick, basic and efficacious means of systemic prevention. Additionally, showing concern for the patient's overall health from a preventive perspective enhances the prestige of the dental practice and the profession as a whole, as it considers the patient holistically. This approach is highly appreciated by individuals who visit the dental clinic.

What would you say are the main challenges to promoting oral health and its relationship with general health at this time?

One important issue is the general lack of awareness about the influence of poor oral health on systemic disease, and this is not limited to Spain. The matter must be addressed through educational campaigns and by raising awareness in the general population, either by health authorities or academics, introducing these associations in schools (with simple explanations) and universities, where they should become part of dentistry and medical courses.

It is also crucial to motivate dental professionals vis-a-vis the importance of these relationships and the essential role of dental surgeries in addressing them. It is essential to emphasise that we are not only treating mouths with teeth and gums but that these belong to a whole body that can be affected by conditions whose prevention and treatment depend on our professional ability. Similarly, close collaboration and mutual understanding between dentistry and medicine are essential, as both are key stakeholders involved in these processes.

And, of course, everyone—industry, authorities, media, and professionals—bears responsibility for conveying to citizens and patients the importance of oral hygiene and regular dental visits. Maintaining oral health can prevent, delay, or alleviate very serious systemic problems. That is our mission.