The Potential Impact of Improved Caries Treatment and Control: A Case for Inclusion in the Oral Systemic Connection
Saving Lives One Tooth at a Time - Caries as a Global Heath Care Issue
Dental caries has remained a persistent health problem throughout the world. With the introduction of fluoride into public water supplies more than a half century ago, a dramatic downturn was seen in both incidence and severity of dental decay. In fact it was thought that caries, as a serious health problem, would be all but eliminated by the time of this writing. What was originally viewed as a simple concept (bacteria + sugar + tooth = cavity), is now understood to be a complex multifactorial infectious disease.
Most Severe Effects on Children and the Elderly
At the present time, more than a half century after the aforementioned start of public water fluoridation, caries is the most common childhood infectious disease in this country. It is five times more common than asthma.(2) It effects children’s nutritional intake, performance in school, growth and development, and their current and future health.
The plight of the elderly gets even less attention than that of the children. They are not active. They tend to be more confined. They are generally on more medications, many of which lead to xerostomia. The present day elderly population, because of overall improved medical care, has a much better chance of being dentate than did prior generations. As they age, they experience more gingival recession. In the presence of xerostomia, they suffer from an increased risk of root surface caries.(3) This makes their already neglected oral hygiene more difficult to maintain. They in turn, especially those who are in nursing homes, suffer from inadequate nutrition, more debilitation, and an increased risk of aspiration pneumonia. In Japan, pneumonia is the leading cause of death in nursing home populations.(4)
Direct Microbial Invasion
Studies are being published that show Streptococcus Mutans, an important microbe in the caries infection process, is also a significant pathogen in the formation of atheromatous plaques. One such study, published in the Journal of Oral Microbiology and Immunology(5), cites some serotypes of S. Mutans as being the most prevalent organisms found in human coronary artery endothelial cells. Caries infection is the chief cause of endodontic involvement. A study published in the International Endodontics Journal shows Porphyromonas Endodontalis, an important pathogen in pulpal infection, is capable of invading vascular cells.(6)
Oral Microbes and Cancer
There is increasing interest in the role of bacteria in cancer formation.(7) In terms of oral bacteria, one of their metabolic by-products is acetaldehyde. This is a potent carcinogen and is produced in high amounts, especially in the presence of alcohol and smoking.(6) A number of gastro-intestinal and oral microbial species possess alcohol dehydrogenase (ADH).This is a major enzyme involved in the metabolism of ethanol. It has been shown that patients in poor oral health exhibit higher levels of salivary acetaldehyde.(8) This has the potential to be a factor in not only oral cancer, but also cancer at distal sites such as the Pancreas.(9) Reducing the level of these oral microbes, such as would be seen with the aggressive treatment of both caries and periodontal disease, could be a factor in reducing cancer risk.(10)
Discussion
Dentistry is primarily involved in the prevention and treatment of infectious diseases of the oral cavity. This disease process becomes part of the overall inflammatory complex, which has significant health implications for the entire human body. The oral cavity is a major portal of entry. How we treat it has lifetime effects. These effects start from childbirth and last into the geriatric years. Reduction in the rate and severity of oral infections will likely result in reduced risk for systemic problems such as heart disease, stroke, pregnancy complications, dementia, osteoporosis, infectious lung disease, cancer, and diabetic control.
Caries is a worldwide problem and continues to be a United States problem, especially with regards to children and the elderly. Caries effects school age children in many ways. For the most severely afflicted, it sets up a condition in which there is a failure to thrive. This impacts long term health and development. Caries adds to the inflammatory burden and contributes microbes to other parts of the body that can have a significant impact on health.
Prevention and treatment of the caries infectious process also helps reduce the level of periodontal pathogens and their associated inflammatory response, where more established oral/systemic links exist. Therapeutic modalities that focus on disruption of oral biofilm in the treatment of periodontal disease should also be studied for the rate of caries reduction in the same patient population. Conversely, treatment protocols developed for high caries risk patient populations should be studied for their effects on periodontal disease.
1. The global increase dental caries. A pending public health crisis . Bagramian RA, Garcia-Godoy F, Volpe AR. 2009, American Journal of Dentistry, pp. 3-4.
2. United States Department of Health and Human Services (USDHHS). Oral Health in America: A Report of the Surgeon General. Washington, DC : National Institute of Health, 2000.
3. Root-Surface Caries Formation: Effect of In Vitro APF Treatment. Hicks MJ, Flaitz CM, Garcia-Godoy F. 1998, JADA, p. 449.
4. Preventing Aspiration Pneumonia by Oral Health Care. K, Ueda. 2011, JMAJ, p. 39.
5. Invasion of human coronary artery endothelial cells by Streptococcus mutans OMZ175. Abranches J, Zeng L, Belanger M, Rodrigues PH, Simpson-Hidaris PJ, Akin D, Dunn Jr WA, Progulske-Fox A, Burne RA. 2009, Oral Microbiol Immunol, p. 141.
6. Invasion of vasculat cells by Porphyromonas endodontalis. Dom BR, Harris LJ, Wujick CT, Vertucci FJ, Produlske-Fox A. 2002, Int Endod J, p. 366.
7. The role of bacteria in oral cancer. Chocolatewala N, Chaturvedi P, Desale R. 2010, Indian J Med Paediatr Oncol, p. 127.
8. Oral micro-organisms in the etiology of cancer. Meurman JH, Uittamo J. 2008, Acta Odontol Scand., p. 321.
9. A Prospective Study of Periodontal Disease and Pancreatic Cancer in US Male Health Professionals. Michaud DS, Joshipura K, Giovanucci E, Fuchs CS. 2007, J. Natl.Cancer Inst., pp. 171-175.
10. Reduction of oral acetaldehyde levels using a controlled-release chlorhexidene chip as a prevention strategy against upper digestive tract cancer. Rota MT, Poggi P. 2003, Med Hypotheses, p. 856.