Can’t afford dental care = higher risk of developing cardiovascular disease, dementia

 Being unable to afford dental care may increase a person’s risk of developing cardiovascular disease or dementia, according to a new study led by researchers at Boston University School of Public Health (BUSPH).

Published in The Journals of Gerontology, Series A, the study found that older people who forego necessary dental procedures because of financial barriers may be more likely to experience heart failure, a heart attack, a stroke, or dementia.

Poor oral health has been previously linked to cardiovascular and neurological conditions, but the prior research was mostly limited to specific oral health issues, such as periodontitis or tooth loss. Being unable to pay for dental care is a modifiable problem that, if addressed, could potentially lower people’s chances of developing more serious or fatal health conditions.

“Cost is one of the main barriers to dental care,” says study lead author Ms. Mabeline Velez, an instructor of health policy and health services research at BUSPH and a PhD candidate at Boston University’s Henry M. Goldman School of Dental Medicine. “As a result, people often delay critical care or they accept the coverage available, which may be more drastic measures—such as getting a tooth pulled than is clinically indicated. Tooth loss, especially early in life, can cause a whole set of health problems later in life including increased mortality. Finding ways to make dental care more accessible and affordable for everyone is a preventative measure that we can take to improve health outcomes down the line.”

For the study, Velez and colleagues from BUSPH and the University of California, San Francisco utilized survey data among participants ages 55 and older in the All of Us study, an initiative that the National Institutes of Health launched in 2017 to develop a diverse database on a variety of health conditions. Analyzing electronic health records and survey responses, the team examined the associations of unmet dental care needs due to cost with new diagnoses of heart failure, heart attacks, strokes, and all-cause dementia. A total of 88,496 people were analyzed for incident heart attacks, 86,593 people for heart failure, 88,410 people for strokes, and 92,272 people for dementia.

They found that people who skipped dental checkups and procedures because they could not afford them had higher incidence of all of the above conditions. On a population level, eliminating the financial barriers that prevented people from receiving dental care could prevent 2-4 percent of each outcome among older adults. With the exception of strokes, the associations were reduced after the researchers accounted for socioeconomic, behavioral, and clinical factors. 

The researchers note that this weakened relationship signals that further data is needed to understand and address the underlying or systemic drivers of chronic diseases.

“Multiple studies have evaluated pieces of this puzzle, but this is the first time we can point to  financial barriers to care as being linked with the incidence of cardiovascular disease and dementia: two leading causes of disability and death among older adults,” says study senior author Dr. Kendra Sims, assistant professor of epidemiology at BUSPH. “This study serves as an indicator that if we alleviate upstream factors such as financial constraints, we can prevent chronic disease.”

Fewer than 30 percent of US adults 65 and older have dental insurance and nearly 8 percent say they are unable to afford necessary dental care. Medicare and Medicaid do provide dental coverage, but that coverage is limited and often excludes preventive services. Medicaid dental coverage also varies widely by state, and in some instances, only covers emergency care. 

Policies that facilitate access to preventive dental care could widely reduce poor oral health outcomes, with benefits that extend to cardiovascular and cognitive outcomes, the researchers say. For example, states that extended dental care under the Affordable Care Act reported an increase in dental visits, fewer missing teeth, and better overall oral functioning. 

These dental visits also present an opportunity to conduct other health screenings.

“People who can access and afford routine dental care typically visit the dentist twice a year,” Dr. Sims says. “What if insurance could cover screening for cardiovascular risk factors like diabetes or hypertension when a patient is in the chair?” 

For her dissertation, Ms. Velez is exploring how periodontitis, a condition where plaque built up on the gums causes inflammation and infection, can eventually lead to cardiovascular issues. 

“Periodontitis is very common, but it is a treatable disease,” she says. “I hope this new insight will encourage doctors to integrate dental care into general practice.”

A stiff defense: Rethinking gum disease

Penn Dental Medicine’s Kyle H. Vining and Hardik Makkar take a biomaterials approach to understanding periodontal disease, using a hydrogel system to investigate how the physical properties of the gum tissue impact inflammation.

Peer-Reviewed Publication

University of Pennsylvania

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Periodontitis is a serious chronic inflammatory form of gum disease that affects millions worldwide. It can lead to tooth loss and the destruction of supporting bone. This disease has also been linked to other health problems, including diabetes, respiratory infections, and heart disease—impacting quality of life and increasing health care costs.

Current treatments target bacterial infection and inflammation through nonsurgical therapies, such as scaling and root planing, commonly known as “deep cleaning.” However, they do not repair the gum’s extracellular matrix (ECM), the gingival tissue’s structural support that is damaged by chronic inflammation. Without this foundation, gingival tissue cannot function properly, allowing inflammation to persist and slowing healing.

Now, new research led by Kyle H. Vining and Hardik Makkar of the School of Dental Medicine demonstrates how the physical properties of the gingival tissue impact periodontal health and disease. Their findings are published in Advanced Materials.

Other studies have shown that physical properties such as structure and stiffness influence inflammation in chronic conditions such as rheumatoid arthritis and fibrosis, explains Vining, an assistant professor in Penn Dental Medicine’s Department of Preventive and Restorative Sciences. But the role of these properties in periodontal disease, which shares characteristics with other chronic inflammatory diseases, is not well understood.

“So, in this study, we took a biomaterials approach to prove that rigidity—the stiffness—of the healthy gingiva is important for maintaining gingival health,” says Vining, who is also an assistant professor in the School of Engineering and Applied Science.

The team used a “tunable” hydrogel composed of natural biopolymers, resembling a form of Jell-O, to isolate how the mechanical environment influences cellular behavior. “Hydrogel stiffness can be tuned to model the properties of human gingiva, from the firmness of healthy tissue to the softened features of diseased tissue,” he says.

They first encapsulated gingival fibroblasts—the predominant cell type in the connective tissue of the gums that is responsible for secreting and maintaining the ECM—in this hydrogel system to test whether changes in tissue stiffness drive these cells to exacerbate the inflammatory response that characterizes periodontal disease.

“In periodontal disease, bacteria secrete enzymes that break down the ECM, causing the tissue to soften,” says Makkar, a postdoctoral fellow in Vining's lab. And as the tissue softens, he adds, cells shift into a higher inflammatory state that triggers even more tissue degradation, creating a destructive feedback loop in which tissue damage and inflammation feed each other.

“When we stiffen these tissues experimentally, the inflammatory response goes down,” says Makkar.

To validate these results, the team used enzymes—instead of the hydrogel—to restore stiffness in human gingival tissue samples obtained from Penn Dental’s dental clinic and found that when they exposed them to microbial triggers, the stiffened tissues showed a significantly lower inflammatory response.

“By using a more human-centric research model, we’ve demonstrated that simply restoring the physical stiffness of the tissue can fundamentally change how cells respond to infection,” says Makkar.

This work contributes to a better understanding of the mechanisms underlying the inflammatory response in periodontal disease, says Vining. But these findings could also pave the way for new biomaterial-based therapies to complement current treatments that target only microbes.

“We envision developing an injectable filler,” he says. “So, if you have uncontrolled periodontal disease, and even after deep cleaning, the tissue is frail, we could inject the filler to help the tissue heal.” Vining notes that these fillers could ultimately make grafts more successful or perhaps even unnecessary.

“There is a lot we can do with the tissue itself,” adds Makkar, including “strengthening it so that it becomes much more resistant to potential future infections.”

Next steps for the team are twofold. One, says Makkar, is to use small molecules to inhibit the inflammatory pathways to better understand the mechanisms underlying these findings. And the second is to do proof-of-concept studies of injectable biomaterials to help treat periodontitis.

“Dental research is moving far beyond traditional treatments,” says Vining. “Our work exists at the interface of materials science and bioengineering. Penn is one of the few places in the world with the collaboration and infrastructure required to bridge these fields, allowing us to develop next-generation therapies to treat dental, oral, and craniofacial diseases."

Kyle H. Vining is an assistant professor in Penn Dental Medicine’s Department of Preventive and Restorative Sciences and in Penn Engineering’s Department of Materials Science and Engineering.

Hardik Makkar is a postdoctoral fellow in the Vining Lab.

Other authors are Kang I. Ko of Penn Dental, Yu-Chang Chen and Nghi Tran of Penn Engineering, and Rebecca G. Wells of the Perelman School of Medicine.

This work was supported by the National Institute of Dental and Craniofacial Research (NIDCR) through a training grant to the Center for Innovation & Precision Dentistry (CiPD) (R90DE031532 to Hardik Makkar). Additional support was provided in part by the Collaborative Research Grant from the Institute for Regenerative Medicine in the Perelman School of Medicine and the School of Dental Medicine at the University of Pennsylvania (Vining). This study was also partially supported by the National Institute of General Medical Sciences (NIGMS) (R35GM157079, Vining and Chen) and by a Graduate Research Fellowship from the National Science Foundation (No. DGE-2236662, Nghi Tran). Confocal microscopy was performed on an instrument purchased with support from an NIH Shared Instrumentation Grant (S10 OD032305-01A1).

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Journal

Advanced Materials

DOI

10.1002/adma.202520717 

Clear link between chronic kidney disease and periodontal disease

 

Recently analyzed evidence points to a connection between oral health and kidney health, according to work led by University of Cincinnati College of Medicine researchers.
Their article in BMC Nephrology combined evidence from more than 150 previously published papers, including observational studies, meta-analyses and interventional trials, and identified growing evidence of oral-renal interactions.

“We know there is an association between chronic kidney disease (CKD) and oral diseases,” said Priyanka Gudsoorkar, the study’s first author and an assistant professor-educator in the Department of Environmental and Public Health Sciences. “The emerging evidence supports a bidirectional relationship.”
Researchers said the relationship appears to be driven by immune dysregulation, endothelial dysfunction (narrowing of the blood vessels), microbial dysbiosis (oral microbial imbalance) and systemic inflammation. Periodontal disease and CKD have interlinked inflammatory pathways that may contribute to disease progression.

“Systemic inflammation is linked to a triad of other conditions: diabetes mellitus, cardiovascular disease and hypertension encompassing metabolic syndrome,” said Prakash Gudsoorkar, MD, the study’s corresponding author and an associate professor in the Division of Nephrology in the Department of Internal Medicine. He added that patients with kidney disease at all stages face increased risk for these conditions.

“This triad operates as a clinical cascade,” said Prakash Gudsoorkar, who is also a UC Health nephrologist. Diabetes and hypertension accelerate the decline of kidney function, while cardiovascular disease becomes a dominant risk factor. CKD also multiplies the risk of complications involving glycemic control, medication management and complex care needs. 

“We see oral disease severity increase as CKD progresses, and the literature supports a biologically plausible relationship,” said Priyanka Gudsoorkar. “What we still need are well-designed prospective studies and clinical trials to clarify the direction and magnitude of causality.”
However, the study found many physicians still treat oral health separately from chronic disease, rather than integrating it into a broader treatment strategy that could allow for earlier identification and better risk assessment.
This disconnect can be especially significant for patients undergoing dialysis and awaiting kidney transplants. Pretransplant dental clearance is typically required before surgery. For some patients, kidney transplant waits can stretch for years, and untreated oral infections can delay the procedure and become a preventable barrier to transplant readiness.

“Oral infection and untreated periodontal disease can complicate continuity of care,” said Priyanka Gudsoorkar, who is also director of the global health concentration within UC’s Bachelor of Science in Public Health program. 

“For many patients, transplant evaluation is the first point in their kidney care journey when a dental referral becomes a standard requirement,” she said. “So closer monitoring of oral health in patients on dialysis is needed, along with better management of periodontal inflammation.”

CALL FOR CARE INTEGRATION

Researchers are now calling on physicians to begin integrating oral and renal health more directly within clinical care systems. “We need to build a framework that supports oral and renal care integration across the CKD continuum,” said Prakash Gudsoorkar.

An improved framework, which could include implementing standardized care protocols and improved sharing of patient health records across specialties, could also enable earlier intervention and ease economic burden for patients, he explained.

TOPIC GAINS ATTENTION

As evidence of a link between CKD and oral diseases grows, the topic has gained attention among leading clinicians and researchers. 

“Mouth and Kidneys: Unveiling the Crosstalk Between Oral and Kidney Health,” written by Priyanka Gudsoorkar, Prakash Gudsoorkar and Sujay Mehta and published in the American Society of Nephrology’s Kidney News, was selected by the publication’s editor-in-chief as one of its top five articles of 2025. 

Highlighting the need for policy reform, Priyanka Gudsoorkar and Prakash Gudsoorkar also published a perspective in late 2025 in the International Dental Journal: “Integrating Oral Health Into Kidney Care: A Policy Imperative for Chronic Kidney Disease, the U.S. Experience.” 

The authors and other experts in clinical dentistry and nephrology have formed the Oral-Kidney Collaborative for Advancing Research and Evidence (OK-CARE), a multidisciplinary initiative to advance research, clinical collaboration and policy development at the intersection of oral health and kidney disease. 

Collaborators outside UC include: C. Elena Cervantes of Johns Hopkins School of Medicine; Isabella Lerma of Marquette University; Anay Dudhbhate of George Brown Polytechnic in Toronto, Canada; Sujay Mehta and Ramprasad Vasthare of Manipal College of Dental Sciences in Udupi, India; Edgar Lerma of the University of Illinois at Chicago; Lakshman Samaranayake and Chun Wang Chau of the University of Hong Kong; Sabine Karam of the University of Minnesota; Sompop Bencharit and Abhjit Kshirsagar of the University of North Carolina at Chapel Hill; and Ryan S. Lee, a dental subject matter expert.

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Journal

BMC Nephrology

Method of Research

Literature review

Subject of Research

People

Article Title

Bridging systems: oral-kidney connections - pathophysiological links, clinical implications, and health system integration – a narrative review

Snus linked to gum damage – gaps in knowledge about white snus

 

Snus is clearly linked to damage to the gums. The connection to tooth decay, however, remains unclear, according to a systematic review. When it comes to white snus, more studies are needed. 

The researchers reviewed 26 European studies on Swedish smokeless tobacco (snus) and oral health. The overall picture that emerges is nuanced. There is consistent evidence that snus can cause the gums to recede, particularly at the site where the snus is placed. Several older studies also report more gum inflammation among users of traditional snus, even after accounting for plaque levels. The risk of gum recession is lower with portion snus than with loose snus. Newer types of portion products may reduce the risk further. 

No clear evidence for periodontal disease 

One of the researchers behind the study is Mats Jontell, professor emeritus of oral medicine and pathology at Sahlgrenska Academy, University of Gothenburg: 

“When we weigh the evidence together, we see that snus affects the gums locally. It is not only a matter of the portion pressing against the tissue; there also appears to be an inflammatory reaction that leads to bone resorption, which over time causes the gums to recede. However, we see no clear evidence that it leads to destructive periodontal disease—the type of condition in which teeth gradually lose their attachment to the jawbone,” says Mats Jontell. 

When it comes to tooth decay, the results are contradictory. Some studies report more filled or decayed teeth among users of traditional snus, while others find no difference. Taken together, it is therefore not possible to conclude that traditional snus itself increases the risk of tooth decay. 

Risk during pregnancy 

One of the larger studies included in the review shows that children born to women who used traditional snus during pregnancy tended to have a higher risk of being born with a cleft palate compared with children of non-users. The risk was not elevated among women who had stopped using snus before their first antenatal care visit. 

Maria Bankvall is a senior lecturer in dentistry at the School of Health and Welfare, Jönköping University, and a co-author of the study: 

“Although this represents an increased risk rather than proof of causation, it is an important signal from a public health perspective. The use of nicotine products during pregnancy cannot be considered risk-free, especially as snus use is increasing among young women,” says Maria Bankvall. 

Major knowledge gap regarding white snus 

The main knowledge gap identified by the researchers concerns the new tobacco-free nicotine pouches, often referred to as white snus. Tobacco-free nicotine pouches have recently overtaken traditional snus, and their use is increasing rapidly, particularly among young people and women. However, there are virtually no studies on how these products affect oral health over the long term. Preliminary studies suggest that white snus may cause oral mucosal changes that differ from those previously observed. 

Because the majority of the studies in the review are observational, it is not possible to establish cause and effect. Lifestyle, oral hygiene, and socioeconomic factors may influence the results. By compiling the available research, however, the review provides an updated picture of what is supported by evidence and where the greatest uncertainties remain. 
The review is based on a systematic analysis of published studies in several scientific databases, in which the researchers assessed the quality of the material before including it. The study was funded with independent research funding with no links to tobacco products or white snus and has been published in the scientific journal Acta Odontologica Scandinavica.

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Journal

Acta Odontologica Scandinavica

DOI

10.2340/aos.v85.45421 

New molecular switch that boosts tooth regeneration discovered

Researchers uncover how SMAD7 directly activates Wnt signaling to promote dental pulp stem cell regeneration

Peer-Reviewed Publication

Editorial Office of West China School of Stomatology, Sichuan University

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image: 

Immunofluorescent staining and protein analyses show SMAD7 forming a transcriptional complex with β-catenin in the nucleus of human dental pulp stem cells, directly activating Wnt/β-catenin signaling and promoting regenerative gene expression.

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Credit: Dr. Tian Chen from Sichuan University, Chengdu, China Image Source Link: https://doi.org/10.1038/s41368-025-00393-5

Dental pulp injury caused by trauma or deep caries often leads to inflammation, tissue necrosis, and eventual loss of tooth vitality. In severe cases, bacterial invasion and sustained immune responses further compromise the pulp’s microenvironment, disrupting its natural capacity for repair. Although regenerative endodontic approaches aim to restore living tissue, predictable biological repair remains difficult to achieve. Central to successful regeneration is the precise regulation of stem cell signaling pathways that coordinate cellular proliferation, differentiation, and matrix remodeling. Among these, Wnt/β-catenin signaling plays a fundamental role in stem cell proliferation, differentiation, and tissue repair. However, the upstream molecular mechanisms governing this pathway in human dental pulp stem cells have remained incompletely understood. 

To address this question, researchers investigated the function of SMAD7, a protein traditionally regarded as a negative regulator of transforming growth factor-beta (TGF-β) signaling and often associated with inhibitory cellular responses. Using human dental pulp stem cells (hDPSCs), the team applied immunofluorescent staining, gene silencing techniques, nuclear protein quantification, and western blot analysis to examine intracellular signaling dynamics in detail. Their experiments revealed that SMAD7 directly interacts with β-catenin inside the nucleus, forming a transcriptional complex that enhances Wnt pathway activation. Mechanistically, phosphorylated SMAD2/3 (P-SMAD2/3), activated downstream of TGF-β signaling, can bind and “capture” β-catenin, thereby limiting β-catenin nuclear availability and suppressing Wnt/β-catenin signaling activation. In this context, SMAD7 functions as a critical mediator that restrains TGF-β–SMAD2/3 signaling and preserves β-catenin activity: loss of SMAD7 leads to increased P-SMAD2/3 accumulation, which sequesters β-catenin and weakens Wnt pathway output. These findings were published on January 6, 2026 of the journal International Journal of Oral Science.

The research was led by Dr. Tian Chen, postdoctoral researcher from the Department of Orthodontics at West China Hospital of Stomatology, Sichuan University, Chengdu, China.

At the mechanistic level, the study overturns the long-standing assumption that SMAD7 functions solely as an inhibitory signaling molecule. Instead, the findings demonstrate that SMAD7 can act as a direct transcriptional mediator of Wnt/β-catenin signaling. By forming a nuclear complex with β-catenin, SMAD7 promotes activation of genes associated with stem cell proliferation and regenerative differentiation. “We were surprised to observe SMAD7 functioning as a positive regulator within the nucleus,” said Dr. Chen. “This direct partnership with β-catenin provides a clearer explanation for how Wnt signaling is amplified during dental pulp regeneration.”

Beyond clarifying a molecular mechanism, the study highlights important translational opportunities. In the short term, targeting the SMAD7–β-catenin interaction could improve regenerative endodontic procedures by enhancing natural pulp healing responses. Biomaterials or small-molecule modulators designed to optimize this signaling axis may help preserve tooth vitality and reduce reliance on conventional root canal treatment. Such advances could directly improve patient outcomes by supporting biological repair instead of artificial replacement.

Over the longer term, the implications extend beyond dentistry. Wnt/β-catenin signaling is central to bone biology, craniofacial development, and broader tissue engineering applications. Identifying SMAD7 as a direct transcriptional partner of β-catenin opens avenues for interdisciplinary collaboration in regenerative medicine and stem cell-based therapeutics. Over the next decade, refined control of this pathway may contribute to precision strategies that guide tissue repair in oral and skeletal systems. “Our motivation comes from clinical challenges we see every day,” Dr. Chen added. “Understanding these molecular interactions brings us closer to therapies that regenerate living tissue and transform restorative care.”

 

Reference
DOI: https://doi.org/10.1038/s41368-025-00393-5

One in three diagnosed with pre-diabetes or diabetes during dental appointment

 

One in three people who have a routine test during dental appointments are diagnosed with pre-diabetes or diabetes.

Peer-Reviewed Publication

King's College London

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The test used in this study

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Credit: Credit: King's College London

One in three people who have a routine test during dental appointments are diagnosed with pre-diabetes or diabetes.

 

A new King’s College London study has revealed how a simple chairside test helps to screen patients who have other risk factors for the condition, such as high BMI and gum disease. The research addresses the large overlap between gum disease and diabetes.

 

Diabetes and pre-diabetes are steadily increasing worldwide every year. According to Diabetes UK, nearly 1.3 million people could be living with type 2 diabetes in the UK without being diagnosed. Screening and early detection are vital to reduce complications of the condition and related cost to the NHS.

 

In the study, a simple finger-prick blood test revealed more than 35% of patients who did not report any history of diabetes had higher than usual blood sugar levels consistent with pre-diabetes or diabetes.

 

Co-author Dr Giuseppe Mainas, specialist periodontist and research associate at King’s College London, said: “The findings suggest that dental visits may offer a valuable opportunity to identify those at risk of diabetes, particularly in older patients, those with higher BMI, and people with gum disease.”

 

 

 

The testing machine which can be used during dental appointments

 

Results of the HbA1c test, which measures glucose levels in the blood, are ready in as little as six minutes – reducing the need for lengthy lab testing and reducing pressures on the NHS.

 

HbA1c is a measure of how much glucose is bound to haemoglobin in the body, which is higher when blood sugar levels have been too high over time. The test gives an indication of average glucose levels over three months, unlike other diabetic tests which require patients to fast and only indicate glucose levels at that one moment in time.

 

Higher HbA1c levels were observed in patients with more severe gum disease – this was gradual and correlated, providing further evidence of the link between gum disease and metabolic health.

 

First author Professor Mark Ide, professor of periodontology at King’s College London, added: “When the test reveals high levels of HbA1c, patients can then see their GP to investigate further. This is something they might not have done without having the dental screening. Most of the patients in our study were surprised that they had elevated HbA1c levels and had no idea they might have pre-diabetes or diabetes.

 

“The other benefit of the HbA1c test is not having to fast, which could increase risk of fainting in the dental chair.”

 

The research is the largest UK study to date using this test during routine dental appointments at Guy's and St Thomas' NHS Foundation Trust, with a cohort of 911 patients participating in an Oral, Dental and Craniofacial Biobank at King’s College London.

 

The study builds on longstanding research into oral and metabolic health at King’s, with Dr Mainas co-leading a discovery last year showing that a Mediterranean diet helps to reduce gum disease last year. Another recent King’s study revealed how successful root canal treatment can help to reduce diabetes and cardiovascular risk.

 

Senior author Professor Luigi Nibali, Academic Lead and Director of the periodontology department at King’s College London, said: “The relationship between gum disease and metabolic health is bidirectional since impacts one another, as widely established by previous research. The inflammatory process can change the metabolic system, and the metabolic system impacts inflammation further. Gum disease can lead to complications of diabetes, and visa-versa.”

 

For future research, the team aims to explore the use of the test around the UK and in broader healthcare settings. “We would also like to investigate how other lifestyle factors, such as diet, affect HbA1c and gum disease”, concluded Dr Mainas.

 

Read the study published in the Journal of Dentistry: https://www.sciencedirect.com/science/article/pii/S0300571226002368