The Surprising Connections between Oral Health & Well Being! Routine Oral Checks- A missed Opportunity for Dental, Oral & Overall, Health!

Introduction

The health of our mouth, or oral health, is more important than many people, general practitioners and the administrators realize. It is a key indicator of overall health, well-being, and quality of life. The significance of the mouth as part of our overall health is often overlooked and underappreciated, especially in developing countries and for those who have the biggest obstacles in getting access to dental care for want of dental services or its accessibility to rural and urban poor households [1].

India has more than the recommended dentist-to- population ratio by WHO (1:7500). There are about 55,000 dental clinics currently, but unfortunately over 90% of them are working in and around major cities. In contrast the over 75% of elderly population and young children who need oral/dental care reside in rural India. While there are about 312,927 dentists registered with the Dental Council of India (DCI), the government employs only 7500 dentists, or just 3% [1]. The rising prevalence of malocclusion and dental disorders among the population is fuelling the demand for orthodontic treatments and Implants, that are becoming a Main Growth Factor in Orthodontics. There is a total of 17580 Orthodontists in India as of December 04, 2023, and the number continues to grow in 2023, as over “20% of people seeking treatment want to replace their previous teeth with an implant.” A good oral health enables us to function as a human being (i.e. speaking, smiling, smelling, eating), it is also important for communication, human relationships, and financial prosperity. Poor dental health is a precursor for painful, disabling, oral conditions and costly health derangements. Poor oral health is linked to diabetes, heart disease, adverse pregnancy outcomes, stroke, and respiratory conditions, apart from tooth decay, gum disease and oral cancers. In India over 95% of adults over 50% of adults have of adults have dental caries and periodontal disease respectively.

There are many determinants that impact our oral health; however, diet and hygiene are controllable with the right habits. Tooth decay (cavities) is the most common chronic childhood disease, yet it is preventable through healthy diet choices and good hygiene habits. Plaque buildup leading to cavities, gingivitis or severe gum disease that put teeth, gums, and other parts of the body at risk [1].

Due to the shortage of dental doctors, primary care provider (PCP) / doctor, irrespective of the system they are trained (Allopathy, Ayurveda, Homeopathy, Unani, or Siddha) and shoulder the responsibility of basic dental and oral care. They play varied roles - a healer, an organized service provider and a scientist. Healing may not reverse the damage but curtails the illness or its consequences from controlling our lives. Oral health is a mirror of systemic health and vice-versa. Medical professionals are e primary caregivers in a given population and as such a vast majority of the population visits them for health-related problems. Every PCP as they grow in the profession strive to be driven by competence, newer medical developments & technologies, precision in decision-making and comprehensive treatment, for improving people’s lives. By understanding the importance of compassion and realizing that the science is incomplete without human touch, s/he emerges as a good healer. The system must take responsibility for empowering, and the individual PCP must make it a practice to scan the mouth in every visit of their patients, to gather meaningful information for early detection, treatment of many health conditions and preventive care opportunities of possible complications [2].

Do, primary care doctors pay closer attention to signs of illnesses like gum diseases to suspicious lesions, and general oral health that could provide a critical window into broader medical concerns? The answer at least in India is a big no! in most cases! A recent statement by the U.S. Preventive Services Task Force found that dental screenings by primary care doctors may not work well enough to catch patients most at risk of oral health issues [3, 4, 5]. But the fact is, a quick look by a Primary Care Physicians in all visits could catch health problems.

Case Reports

1. Precancerous Stage Patch in Buccal Mucosa of a Bhutan Lady: In one of my public Health Consultancy in Bhutan, in 2008, the Govt. coordinator took me to her house for lunch in one of trips. After the lunch her mother aged about 50years showed me her mouth complaining of a colourless, painless patch. She was chewing tobacco for nearly 20 years. Suspecting that to be Cancerous patch, I advised them to got to Kolkata, India for a Biopsy. I got a confirmatory message that it turned out to be in the initial stages of cancerous changes, an excision was done and is doing well even now. 2. Lakshmi, Raichur A Neglected Oral Pale Patch Turing into Squamous Cell Carcinoma with Secondaries over 1 Year: Lakshmi a 60-year-old lady from Raichur, Karnataka was referred on 26 October 2023 to Oncology department, Mazumdar Shaw Medical Centre, Bengaluru for non-healing ulcer on the left buccal mucosa for nearly 2 years. Initially she had a colourless painless patch over a year and that became an ulcer for last 1 year. She was consulting a private dentist in Raichur and later in government medical college, Bellary, when opening her jaw became difficult. She is known diabetic for over 10 years on oral anti-diabetic drugs, Hb1Ac poorly controlled. The oral cavity examination showed ulcerative growth in left side buccal mucosa, superior to gingiva-buccal sulcus, inferior to lower gingiva buccal sulcus medially up to gingival mucosa, anteriorly up to 2nd premolar, posteriorly up to retromolar trigone. Left level IB lymph node was palpable. While Biopsy confirmed squamous cell carcinoma stage iv, and secondaries small dots in lung field probably tiny lymph nodes that could not be taken out for biopsy in the CT scan. Two sessions of Chemotherapy since 5th November 2023 and the lady is due for assessment next week.

These two cases give a glimpse of what a PCP or GP can do or the family neglect and the miss an opportunity for early diagnosis and better management and the consequences of delayed diagnosis. 3. Recurring Aphthous Ulcers Sign of Undiagnosed Diabetes: A Female patient 30 years old came in my OPD with c/o ulcer on the margin of the tongue with redness and burning pain since 7days which is recurrent from 15 months. Initially when complaint started, suffering once in month but for 5 months suffers twice in a month. Applying glycerine at the ulcer in the last 5 months when aphthae appear. Associated with unsatisfactory bowel movements 15 days. History and family history: Nothing contributory. Currently she ate food 2 times a day Appetite -diminished, desires to eat spicy food and has aversion to vegetables. She was forced to drink small quantity of water in over long time. Sleep was not disturbed, nor was there any dreams. Urinary and Bowle habits were normal. Perspiration was scanty only in axilla.

Menstrual history- Menarche at 13yrs, no complaint, flow for 5 days, regular menses.

On examination- Patient talked only when asked something, not sharing her feeling with anyone. Never expressed her anger for fear of disrupting relationship. General and physical examination: i) Weight-65kg, - Height-5’1”, ii) pulse- 90/min – iii) BP- 114/82 mm/hg, iv) - RR-20/min - Pallor- absent -Icterus- absent - Cyanosis- absent. No Lymphadenopathy. Systemic examination of Respiratory, CVS and GI system added no additional information.

• Oral Cavity Examination Revealed: i) Lips- Red ii) Tongue- Aphthae ulcer on the margin of the tongue 6 to 7 in number, red margin of ulcer with yellow base, white coating of tongue. Gums- Pink Teeth- no caries. Neck & Throat Lymph nodes not enlarged Tonsils-NAD.

• Investigations Done: Blood sugar= Fasting 140mg/ Dl, PP= 220 mg/dl, Hb1Ac=7.8% Diagnosing her as diabetic put her on oral antidiabetics, diet, and exercise to reduce weight to 55 kg in 6 months’ time (Table 1).

4. A case of Scalded Mouth Syndrome: A male patient of about 57 years reported to me in June 2022 with complaints of mouth dryness and burning of oral soft tissues. Being a hypertensive for over a decade he was on hypertensive. In January 2022 in annual check-up, he was prescribed a new drug Zestril (Lisinopril an ACE inhibitor) for his resistant hypertension following a recent episode of mild heart attack.

On examination there were no signs of any inflammation or infection in the mouth. Suspecting it to be an adverse reaction to the Zestril, I withdrew the drug and asked him to continue earlier drugs and apply mucosal soothers. Over weeks’ time his problem was solved. Lisinopril is a medicine to treat hypertension and heart failure. It’s prescribed after a heart attack as it prevents future strokes and heart attacks.

5. A case of Cheilitis: A obese (BMI 40) lady of 40 years presented with complaints of oral dryness, peri-oral itching, burning, erythema, fissuring and oedema in May 2023. As her Blood test of biomarkers especially blood cholesterol was high with disturbed LDL/HDL ratio, a general practitioner had prescribed her Simvotin 20 mg tablet (Simvastatin, a cholesterol-lowering agent) daily. After about 2 weeks of use she started feeling dryness of mouth and then slowly excoriation was seen at the angles of the mouth. I asked her to stop Simvotin and replaced with Gemfibrozil (a generic fibrate to reduce cholesterol level) and asked her to apply topical moisturiser and cortico-steroid and antibiotic ointment twice day. The rash resolved after discontinuation within a weeks’ time [1, 2, 3, 4].

Discussions

The health of our mouth, buccal mucosa and gums and Teeth, is more important than many people, primary care physicians the administrators realize. It is a key indicator of overall health, leading to our well-being and quality of life. Adults aged 20 to 64 years have an average of 25.5 teeth. Older adults, smokers, and low socio-economic and educated people have fewer remaining teeth. Once people get to 64, the average number of teeth goes down to 22. Between the ages of 50 to 64, people have about a 10% chance of having no teeth remaining at all, which increases to 13% when they get to age 74. Once past the age of 74, the number jumps even higher to 26%. While many get their first set of false teeth between 40 and 49, the need to replace teeth becomes nearly universal as people age over 65 years. Dentures to replace missing teeth can mean easier eating, better speech, a healthier face, and a great smile. In India, on average, people receive dentures when they are above 40, as they start getting severe health issues like periodontal diseases that will damage the mouth’s soft tissues and bone that eventually lead to tooth loss [2].

It is a universal fact that the general primary health care providers (MLHP, Doctors in PHCs and general private care practitioners) irrespective of system they practice, don’t look in the mouth a lot, and if they do, they’re looking past the teeth and mouth into the throat. But just a quick scan of the mouth is simple and gives meaningful early detection, treatment, and preventive care opportunity. As we saw in our case studies, Aphthous ulcers, discoloured patches on buccal mucosa, Gingivitis, Glossitis are a few oral signs that primary care doctors can easily and must catch during checkups, investigate, treat, or refer in the larger interest of overall health [2, 5].

Conclusions

Due to limited accessibility to dental doctors, primary care provider (PCP) / doctor, irrespective of the system they are trained (Allopathy, Ayurveda, Homeopathy, Unani, or Siddha) are entrusted the responsibility of basic dental and oral care and they play varied roles - a healer, an organized service provider and a scientist.

There are several challenges for geriatric oral health care in India. i) At present, India has no independent oral health policy, oral healthcare has the lowest share in the overall health budget, ii) Health insurance which is offered to only 10% of the people in the organized sector usually only covers emergency dental treatments, iii) awareness about oral health prevention and various government schemes is poor due to the low literacy level among the older adults and hence their poor utilization iv) the dentist to population ratio is very low in the rural areas where over 71 % of the older adults reside, v) at the undergraduate level, there is very little training in dental care for medical graduates and geriatric care embedded in the dental disciplines, with the result that dental graduates are not oriented toward geriatric care and medical graduates not well versed in oral screening in general and dental care in particular vi) At the postgraduate level, there are no geriatric dentistry courses and vii) most importantly as healthcare is a state-controlled system, planning and implementation of healthcare schemes differ in different states and private dental care is flourishing only in urban areas.

The only solace is under the National Health Mission (NHM), the National Oral Health Programme (NOHP) was launched in 2013 and is still in a nascent stage [9, 10].