As we age, oral health plays increasing role in overall health A

Oral health is a critical component to overall health for all ages, but according to dental and medical experts from UConn Health, vigilance is especially critical for the elderly.
In a review article recently published in the Journal of the American Geriatrics Society, the authors outline the potential complications that can arise from poor oral hygiene in older adults and cite the  role of all health care professionals in working to promote good oral hygiene in this population.
"All health care professionals should work to promote good oral hygiene for their older patients," said Dr. Patrick Coll, professor of family medicine and medicine at the UConn School of Medicine and lead author of the review article. They "should consider an oral examination during an annual wellness visit, especially for those patients who are not receiving regular dental care."
The need is evident, say the authors. Data from the National Center for Health Statistics indicates that the prevalence of cavities is more than twice as high in older adults than younger adults. The prevalence of periodontitis -- a serious gum infection that damages the soft tissue and destroys the bone that supports your teeth -- also increases with age. As many as 64% of older adults in the U.S. have periodontitis.
Periodontitis is associated with a variety of medical conditions including cardiovascular disease and diabetes. Patients with replacement heart valves and prosthetic joints should be particularly careful regarding their oral hygiene, according to the authors.
It is well recognized that manipulation of teeth and their support structures can result in bacteria present in the oral cavity being released into the bloodstream, which may lead to infections in parts of the body far removed from the oral cavity, they write.
"Even tooth brushing for those who have poor oral hygiene can cause bacteria to be released into the blood stream and these bacteria can potentially cause joint infections and heart valve infections," says Coll.
Without good oral hygiene, the use of fluoride, and regular dental care, older adults are more prone to damage to the oral cavity and the extension of infection into surrounding tissues.
Tooth loss, for instance, can affect a person's ability to chew, which can lead to malnutrition. Chronic oral infection is a recognized risk factor for heart disease, and can also lead to the spread of infection to artificial joints and endocardial implants.
Researchers noted several populations of older adults who are at increased risk for oral health problems, including patients with diabetes, patients with dementia, and those in long-term care settings.
Patients with dementia--particularly those with advanced dementia--may neglect their oral health and may be reluctant to see a dental hygienist.
And, many residents in nursing homes also do not receive adequate dental care, despite federal requirements for nursing homes to provide both routine and emergency dental care. Nursing home facilities, the experts say, should adopt risk assessment tools to identify patients at high risk for poor oral hygiene and educate staff on the importance of good oral hygiene and how to provide it.
The experts recommend that all older adults should have biannual dental cleaning performed by a hygientist and a biannual oral health assessment by their dentist.
"Your mouth is a mirror to your body," says  Dr. Sree Raghavendra, co-author of the article and assistant professor in the Department of Craniofacial Sciences at the UConn School of Dental Medicine.
"This article is a prime example of true interprofessional collaboration that emphasizes the importance of the entire health care team coming together to take care of all of our patients and especially our geriatric population."

Gum disease linked with higher risk of hypertension

People with gum disease (periodontitis) have a greater likelihood of high blood pressure (hypertension), according to a study published today in Cardiovascular Research, a journal of the European Society of Cardiology (ESC).¹
Senior author Professor Francesco D'Aiuto of UCL Eastman Dental Institute, UK, said: "We observed a linear association - the more severe periodontitis is, the higher the probability of hypertension. The findings suggest that patients with gum disease should be informed of their risk and given advice on lifestyle changes to prevent high blood pressure such as exercise and a healthy diet."
High blood pressure affects 30-45% of adults and is the leading global cause of premature death,² while periodontitis affects more than 50% of the world's population. Hypertension is the main preventable cause of cardiovascular disease, and periodontitis has been linked with increased risk of heart attack and stroke.
"Hypertension could be the driver of heart attack and stroke in patients with periodontitis," said Professor D'Aiuto. "Previous research suggests a connection between periodontitis and hypertension and that dental treatment might improve blood pressure, but to date the findings are inconclusive."
This study compiled the best available evidence to examine the odds of high blood pressure in patients with moderate and severe gum disease. A total of 81 studies from 26 countries were included in the meta-analysis.
Moderate-to-severe periodontitis was associated with a 22% raised risk for hypertension, while severe periodontitis was linked with 49% higher odds of hypertension. Lead author Dr Eva Munoz Aguilera of UCL Eastman Dental Institute said: "We observed a positive linear relationship, with the hazard of high blood pressure rising as gum disease became more severe."
Average arterial blood pressure was higher in patients with periodontitis compared to those without. This amounted to 4.5 mmHg higher systolic and 2 mmHg higher diastolic blood pressures. "The differences are not negligible," said Dr Munoz Aguilera. "An average 5 mmHg blood pressure rise would be linked to a 25% increased risk of death from heart attack or stroke."
Just 5 out of 12 interventional studies included in the review showed a reduction in blood pressure following gum treatment. The changes occurred even in people with healthy blood pressure levels.
Professor D'Aiuto said: "There seems to be a continuum between oral health and blood pressure which exists in healthy and diseased states. The evidence suggesting periodontal therapy could reduce blood pressure remains inconclusive. In nearly all intervention studies, blood pressure was not the primary outcome. Randomised trials are needed to determine the impact of periodontal therapy on blood pressure."
Regarding potential reasons for the connection between the conditions, gum disease and the associated oral bacteria lead to inflammation throughout the body, which affects blood vessel function. Common genetic susceptibility could also play a role, along with shared risk factors such as smoking and obesity.
Professor D'Aiuto said: "In many countries throughout the world, oral health is not checked regularly, and gum disease remains untreated for many years. The hypothesis is that this situation of oral and systemic inflammation and response to bacteria accumulates on top of existing risk factors."
He noted that the study investigated gum disease as a potential risk factor for hypertension, but the reverse could also be true. "Further research is needed to examine whether patients with high blood pressure have a raised likelihood of gum disease. It seems prudent to provide oral health advice to those with hypertension," he said.

New study questions value of fluoride varnish

Fluoride varnish has become a popular anti-cavity treatment for children, and it isn't hard to see why. It's relatively easy to apply, and not just for dentists or dental hygienists. Pediatricians can do it as well, with minimal instruction. The sticky varnish goes on with a brush and then dries in a few hours. There's little risk of children swallowing the fluoride, as they might with other topical treatments such as gels.
Nor is it very expensive, with treatment costs generally ranging from about $25 to $55. That doesn't seem to be a prohibitive price to pay to guard a child against tooth decay.
Yet a new study by two University of Washington researchers and their colleagues questions the cost-effectiveness of fluoride varnish for preschoolers and calls its anti-cavity effects "modest and uncertain" in this age group.
Dr. Joana Cunha-Cruz and Dr. Philippe Hujoel of the UW School of Dentistry and four research colleagues came up with their conclusion after reviewing 20 clinical trials of fluoride varnish in 13 countries. They examined trials in which fluoride varnish was used by itself or in an oral health program, and also checked the results of using fluoride varnish compared with placebo, usual care, or no treatment.
"As much as we want fluoride varnish to be effective, the current evidence doesn't support a huge benefit for its use in young children," Dr. Cunha-Cruz said.
In their new study, which was recently published in the journal Caries Research, she and her colleagues noted that fluoride varnish applications are aimed especially at children with a high risk of caries, or tooth decay. It's not considered a primary form of treatment, but rather a complement to other fluoride treatments such as toothpaste or fluoridated water.
Nonetheless, the researchers reported that more recent clinical trials in both low-risk and high-risk groups "failed to show a protective effect of fluoride varnish applications."
"Cost-effectiveness analyses are needed to assess whether fluoride varnish should be adopted or abandoned by dental services," they said in their study.
The researchers don't assert that fluoride varnish doesn't work. Their analysis showed that the risk of developing new cavities declined by 12 percent among the children who received fluoride varnish, compared with those who did not. And they added that fluoride varnish could still be a cost-effective alternative in some cases. However, they also stated, "This was a rather modest benefit, as a large number of the children developed new dentine caries lesions, regardless of fluoride varnish use."
Concentrations of fluoride can also vary among different varnishes, Dr. Cunha-Cruz said.
That's not to say that there aren't highly effective topical treatment alternatives. Sealants do a good job of protecting the teeth, especially those hard-to-reach ones in the rear of the mouth, Dr. Cunha-Cruz said. Even better are sealants with glass ionomer, which releases fluoride, as opposed to resin-based sealants, which don't have it.
Sealants are more difficult to apply than varnish, but Dr. Cunha-Cruz said that they remain effective for two to three years. Silver diamine fluoride has also been growing in popularity and is very effective in stopping decay, she said, but more research is needed on its preventive effect. It can also discolor teeth, but that isn't as much of a concern for preschoolers who still haven't lost their primary teeth.
"The evidence still supports the use of fluoride toothpaste, which is easy and low-cost," Dr. Cunha-Cruz said. "The value of toothpaste lies in how it creates a daily presence of fluoride in the mouth." Fluoride rinse is also effective in this way, she said.
For now, she and her research colleagues are calling for more studies of fluoride varnish's cost-effectiveness among different populations and application settings. She suggests caregivers discuss the pros, cons and alternatives to fluoride varnish to prevent cavities with a child's dentist.
Meanwhile, aside from using fluoride toothpaste and rinses each day, Dr. Cunha-Cruz suggests another approach: "Reducing sugar intake is an even more cost-effective strategy."

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Acute periodontal disease bacteria love colon and dirt microbes

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True or false? Bacteria living in the same space, like the mouth, have evolved collaborations so generous that they are not possible with outside bacteria. That was long held to be true, but in a new, large-scale study of microbial interactions, the resounding answer was "false."

Research led by the Georgia Institute of Technology found that common mouth bacteria responsible for acute periodontitis fared better overall when paired with bacteria and other microbes that live anywhere but the mouth, including some commonly found in the colon or in dirt. Bacteria from the oral microbiome, by contrast, generally shared food and assistance more stingily with gum infector Aggregatibacter actinomycetemcomitans, or Aa for short.
Like many bacteria known for infections they can cause -- like Strep -- Aa often live peacefully in the mouth, and certain circumstances turn them into infectors. The researchers and their sponsors at the National Institutes of Health would like to know more about how Aa interacts with other microbes to gain insights that may eventually help fight acute periodontitis and other ailments.
"Periodontitis is the most prevalent human infection on the planet after cavities," said Marvin Whiteley, a professor in Georgia Tech's School of Biological Sciences and the study's principal investigator. "Those bugs get into your bloodstream every day, and there has been a long, noted correlation between poor oral hygiene and prevalence of heart disease."
Unnatural pairing
The findings are surprising because bacteria in a microbiome have indeed evolved intricate interactions making it seem logical that those interactions would stand out as uniquely generous. Some mouth microbes even have special docking sites to bind to their partners, and much previous research has tightly focused on their cooperations. The new study went broad.
"We asked a bigger question: How do microbes interact with bugs they co-evolved with as opposed to how they would interact with microbes they had hardly ever seen. We thought they would not interact well with the other bugs, but it was the opposite," Whiteley said.
The study's scale was massive. Researchers manipulated and tracked nearly all of Aa's roughly 2,100 genes using an emergent gene tagging technology while pairing Aa with 25 other microbes -- about half from the mouth and half from other body areas or the environment.
They did not examine the mouth microbiome as a whole because multi-microbial synergies would have made interactions incalculable. Instead, the researchers paired Aa with one other bug at a time -- Aa plus mouth bacterium X, Aa plus colon bacterium Y, Aa plus dirt fungus Z, and so on.
"We wanted to see specifically which genes Aa needed to survive in each partnership and which ones it could do without because it was getting help from the partner," said Gina Lewin, a postdoctoral researcher in Whiteley's lab and the study's first author. They published their results in the Proceedings of the National Academy of Sciences.
Q & A
How could they tell that Aa was doing well or poorly with another microbe?
The researchers looked at each of Aa's genes necessary for survival while it infected a mouse -- when Aa was the sole infector, when it partnered with a fellow mouth bacterium and when paired with a microbe from colon, dirt, or skin.
"When Aa was by itself, it needed a certain set of genes to survive -- like for breathing oxygen," Lewin said. "It was striking that when Aa was with this or that microbe that it normally didn't live around, it no longer needed a lot of its own genes. The other microbe was giving Aa things that it needed, so it didn't have to make them itself."
"Interactions between usual neighbors -- other mouth bacteria -- looked more frugal," Whiteley said. "Aa needed a lot more of its own genes to survive around them, sometimes more than when it was by itself."
How did the emerging genetic marking method work?
To understand "transposon sequencing," picture a transposon as a DNA brick that cracks a gene, breaking its function. The brick also sticks to the gene and can be detected by DNA sequencing, thus tagging that malfunction.
Every Aa bacterium in a pile of 10,000 had a brick in a random gene. If Aa's partner bacterium, say, E. coli, picked up the slack for a broken function, Aa survived and multiplied even with the damaged gene, and researchers detected a higher number of bacteria containing the gene.
Aa surviving with more broken genes meant a partner microbe was giving it more assistance. Aa bacteria with broken genes that a partner could not compensate for were more likely to die, reducing their count.
Does this mean the mouth microbiome does not have unique relationships?
It very likely does have them, but the study's results point to not all relationships being cooperative. Some microbiomes could have high fences and share sparsely.
"One friend or enemy may be driving your behavior, and other microbes may just be standing around," Lewin said.
Smoking, poor hygiene, or diabetes -- all associated with gum disease -- might be damaging defensive microbiomes and allowing outside bacteria to help Aa attack gum tissue. It's too early to know that, but Whiteley's lab wants to dig deeper, and the research could have implications for other microbiomes.

Poor oral health linked to cognitive decline, perceived stress

Oral health is an essential part of psychological well-being and overall health in older adults. Poor oral health is associated with decreased quality of life, depression, hypertension, and cognitive decline. Two Rutgers studies, co-authored by Darina Petrovsky, Bei Wu, and Weiyu Mao, and published in the Journal of the American Geriatrics Society, explored the relationship between poor oral health and cognitive decline and the effects of perceived stress and social support on dry mouth among older Chinese Americans.
Researchers interviewed more than 2,700 Chinese Americans aged 60 and older and found that nearly 50 percent of study participants reported experiencing tooth symptoms, 25.5 percent reported dry mouth. In the first study, those who reported tooth symptoms experienced declines in cognition and episodic memory, often precursors to dementia. In the second study, the researchers found that stress increased symptoms of dry mouth, leading to poorer overall oral health.
"Racial and ethnic minorities are particularly vulnerable to the negative consequences of poor oral health," said XinQi Dong, director of Rutgers University's Institute for Health, Health Care Policy and Aging Research. "Minorities have less access to preventive dental care that is further exacerbated by language barriers and low socioeconomic status. Older Chinese Americans are at particular risk for experiencing oral health symptoms due to lack of dental insurance or not visiting a dental clinic regularly."
According to Dong, the increasing oral health disease burdens among older Chinese immigrants point to the need for investigations of psychosocial factors due to the current emphasis on physical diseases and health behaviors in oral health.
"Efforts must be made to increase social support to alleviate stress and the resulting dry mouth issues reported by our study participants," Dong continued. "These efforts can help preserve older adults' health and well-being and limit cognitive decline."
Key findings:

• 47.8 percent of older Chinese Americans reported having teeth symptoms; participants who reported teeth symptoms at baseline experienced their global cognition and episodic memory decline
• 18.9 percent of older Chinese Americans reported gum symptoms.
• 15.6 percent of older Chinese Americans reported teeth and gum symptoms.
• 25.5 percent of older Chinese Americans reported dry mouth.
• More perceived stress was associated with higher odds of dry mouth.

"These studies demonstrate the importance of examining immigrant oral health outcomes later in life to understand the specific type of outcomes of different cultural groups," said Dong. "The studies further serve as a call to action for policymakers to develop programs aimed at improving oral health preventative and dental care services in this high-risk population. Darina Petrovsky, first author, added, "Examining current oral health practices among older Chinese Americans is crucial for developing culturally-tailored interventions to promote oral health and ultimately mitigate cognitive decline."
"Poor oral health is a top concern among older Chinese Americans. In our study, the prevalence rate of dry mouth is followed by diabetes and heart disease. Our findings demonstrate the importance of studying the linkage between stress and dry mouth in this vulnerable population." said author Weiyu Mao, Assistant Professor, School of Social Work, University of Nevada, Reno.
"Support from family and friends could be protective against dry mouth symptoms in relation to stress; however, the potential overload of such support could be detrimental to oral health outcomes among older Chinese Americans." Mao continued. "Intervention strategies need to expand beyond the common risk factors, such as health conditions and health behaviors, and account for the psychosocial determinants, including stress and social support, to better promote oral health and reduce oral health disparities in this population."
"Our research raises critical awareness for dental and healthcare providers of the role of perceived stress in dry mouth symptoms," added Dong. "Working collaboratively, dental, and healthcare providers can better identify oral health symptoms as risk factors of cognitive decline in this fast-growing vulnerable population. The primary focus should include promoting optimal oral health and improving the quality of life."

Mouthwash use could inhibit benefits of exercise

Exercise is known to reduce blood pressure - but the activity of bacteria in our mouths may determine whether we experience this benefit, according to new research.
An international team of scientists has shown that the blood pressure-lowering effect of exercise is significantly reduced when people rinse their mouths with antibacterial mouthwash, rather than water - showing the importance of oral bacteria in cardiovascular health.
The researchers now suggest that health professionals should pay attention to the oral environment when recommending interventions involving physical activity for high blood pressure.
The study was led by the University of Plymouth in collaboration with the Centre of Genomic Regulation in Barcelona (Gabaldon's lab), Spain, and was published in the journal Free Radical Biology and Medicine.
Why did the research take place? Lead author Dr Raul Bescos, Lecturer in Dietetics and Physiology at the University of Plymouth, said: "Scientists already know that blood vessels open up during exercise, as the production of nitric oxide increases the diameter of the blood vessels (known as vasodilation), increasing blood flow circulation to active muscles.
"What has remained a mystery is how blood circulation remains higher after exercise, in turn triggering a blood-pressure lowering response known as post-exercise hypotension.
"Previous research has suggested that nitric oxide was not involved in this post-exercise response - and only involved during exercise - but the new study challenges these views.
"It's all to do with nitric oxide degrading into a compound called nitrate, which for years was thought to have no function in the body. But research over the last decade has shown that nitrate can be absorbed in the salivary glands and excreted with saliva in the mouth.
"Some species of bacteria in the mouth can use nitrate and convert into nitrite - a very important molecule that can enhance the production of nitric oxide in the body. And when nitrite in saliva is swallowed, part of this molecule is rapidly absorbed into the circulation and reduced back to nitric oxide. This helps to maintain a widening of blood vessels which leads to a sustained lowering of blood pressure after exercise.
"We wanted to see whether blocking nitrate's ability to convert into nitrite by inhibiting oral bacteria would have any effect on post-exercise hypotension."
What did the study involve? Twenty-three healthy adults were asked to run on a treadmill for a total of 30 minutes on two separate occasions, after which they were monitored for two hours.
On each occasion at one, 30, 60 and 90 minutes after exercise they were asked to rinse their mouths with a liquid - either antibacterial mouthwash (0.2% chlorhexidine) or a placebo of mint-flavoured water. Neither the researchers nor the participants knew which liquid they were rinsing with.
Their blood pressure was measured and saliva and blood samples were taken before exercise and at 120 minutes after exercise. No food or drink except water was allowed during exercise and the recovery period, and none of the study participants had any oral health conditions.
What did the science show?
The study found that when participants rinsed with the placebo, the average reduction in systolic blood pressure was -5.2 mmHg at one hour after exercise. However when participants rinsed with the antibacterial mouthwash, the average systolic blood pressure was -2.0 mmHg at the same time point.
*Systolic blood pressure refers to the highest blood pressure level when the heart is squeezing and pushing the blood round the body.
These results show that the blood pressure-lowering effect of exercise was diminished by more than 60% over the first hour of recovery, and totally abolished two hours after exercise when participants were given the antibacterial mouthwash.
Previous views also suggested that the main source of nitrite in the circulation after exercise was nitric oxide formed during exercise in the endothelial cells (cells that line the blood vessels). However, the new study challenges this. When antibacterial mouthwash was given to the participants, their blood nitrite levels did not increase after exercise. It was only when participants used the placebo that nitrite levels in blood raised, indicating that oral bacteria are a key source of this molecule in the circulation at least over the first period of recovery after exercise.
What the authors say
Craig Cutler, study co-author who conducted the research as part of his PhD at the University of Plymouth, said: "These findings show that nitrite synthesis by oral bacteria is hugely important in kick-starting how our bodies react to exercise over the first period of recovery, promoting lower blood pressure and greater muscle oxygenation.
"In effect, it's like oral bacteria are the 'key' to opening up the blood vessels. If they are removed, nitrite can't be produced and the vessels remain in their current state.
"Existing studies show that, exercise aside, antibacterial mouthwash can actually raise blood pressure under resting conditions, so this study followed up and showed the mouthwash impact on the effects of exercise.
"The next step is to investigate in more detail the effect of exercise on the activity of oral bacteria and the composition of oral bacteria in individuals under high cardiovascular risk. Long-term, research in this area may improve our knowledge for treating hypertension - or high blood pressure - more efficiently."