research studies on oral health

The Oral Health in America Report: A Public Health Research Perspective

ESSAY — Volume 19 — September 8, 2022

Jane A. Weintraub, DDS, MPH 1 ( View author affiliations )

Suggested citation for this article: Weintraub JA. The Oral Health in America Report: A Public Health Research Perspective. Prev Chronic Dis 2022;19:220067. DOI: http://dx.doi.org/10.5888/pcd19.220067 .

PEER REVIEWED

Introduction

Data needed, health disparities and social determinants of health, individual and community relationships, scientific advances and equitable distribution, educational opportunities, acknowledgments, author information.

In December 2021, the National Institutes of Health, National Institute of Dental and Craniofacial Research, released its landmark 790-page report, Oral Health in America: Advances and Challenges (1). This is the first publication of its kind since the agency’s first Oral Health in America: A Report of the Surgeon General described the silent epidemic of oral diseases in 2000 (2). This new, in-depth report, an outstanding resource, had more than 400 expert contributors. Its broad scope is exemplified by its 6 sections ( Box ), each of which includes 4 chapters: 1) Status of Knowledge, Practice, and Perspectives; 2) Advances and Challenges; 3) Promising New Directions; and 4) Summary. In this essay, I provide a public health research perspective for viewing the report, identify some advances and gaps in our knowledge, and raise research questions for future consideration.

Box. Section Titles, Oral Health in America: Advances and Challenges (1)

1. Effect of Oral Health on the Community, Overall Well-Being, and the Economy

2A. Oral Health Across the Lifespan: Children

2B. Oral Health Across the Lifespan: Adolescents

3A. Oral Health Across the Lifespan: Working-Age Adults

3B. Oral Health Across the Lifespan: Older Adults

4. Oral Health Workforce, Education, Practice, and Integration

5. Pain, Mental Illness, Substance Use, and Oral Health

6. Emerging Science and Promising Technologies to Transform Oral Health

A recurring theme in the report is the need for many types of data, from microdata — the molecular, nanoparticle level — to macrodata — the population and global level. Data are needed to guide public health policies and programs at the federal, state, and local levels. Future research using big data from multiple sources (eg, community health needs assessments, surveillance systems, GIS mapping, electronic health records, practice-based research networks) will provide timely, population-based information to evaluate and drive changes to policy and delivery systems and oral health advocacy efforts.

This new report includes descriptive national data from 3 cycles of the National Health and Nutrition Examination Survey (NHANES). To continue monitoring national oral health surveillance data and trends, oral health data need to be included routinely in NHANES and in other large national studies. Too often, questions about oral health are missing from surveys, or clinical oral health data are not collected. For example, very little about oral health was included as part of the planned data collection protocol for the National Institutes of Health All of Us Research Program. This program aims to collect health information from 1 million people (3). Local and state data are often outdated, incomplete, or unavailable. Most oral health data are cross-sectional and are useful for studying trends and associations, but population-based longitudinal data to study causality and the effectiveness of interventions and policies are sparse.

How does oral health care improve other health conditions? Proprietary claims data from insurance companies (4) show the inter-relationship between treatment of periodontal disease and systemic conditions, but secondary data analysis has many limitations and confounding factors. Clinical trials show that periodontal treatment improves glycemic control among people with diabetes (5), but long-term outcome assessments are lacking. We need more answers to convince policy makers and payers about the importance of including comprehensive adult oral health services in publicly financed programs such as Medicaid, which is currently lacking in many states, and Medicare, where those services are missing altogether.

Many examples of substantial oral health disparities and inequities are presented in Section 1 of the report. For some conditions and population groups, little improvement has been made, especially among adults and seniors. Section 1 also describes the adverse social, economic, and national security effects of poor oral health, barriers to care, social and commercial determinants of oral health, and related common risk factors. More than the clinical data collected in a typical dental history is needed to understand social determinants and employ local and upstream interventions. The report suggests obtaining social histories from patients to get information about where people live, learn, work, and play. For example, to learn about socioeconomic status, diet, and medications, we want to know not only “What’s in your wallet,” (as touted in a frequent television advertisement) but what’s in your refrigerator? What’s in your medicine cabinet? Telehealth has given clinicians a look inside patients’ homes. Collaboration with social workers, home health aides, and visiting nurses could inform us even more about the home environment. With integrated electronic medical and dental patient records, oral health professionals and medical colleagues can share information. Barriers to integration and assessment of population health outcomes affect many dentists who still use paper records or software specific to dental care that lacks diagnostic codes and interoperability with other health care records systems (6).

The report highlights the need for more information about adolescents and older adults and other understudied population groups. Section 1 describes many diverse, vulnerable populations (eg, people with special health care needs, low health literacy, mental illness, substance abuse disorders; victims of structural racism) who all need to be included in oral health research. Non-English speakers and hard-to-reach populations that have physical and/or financial barriers to traditional dental care are less likely to be recruited and represented in clinical trials, making results less generalizable and interventions less applicable. The applied research agenda being developed by the American Association of Public Health Dentistry (7) and the “Consensus Statement on Future Directions for the Behavioral and Social Sciences in Oral Health,” which is based on an international summit (8), are helpful in setting research and methodologic priorities, including qualitative, implementation, and health systems research.

Knowledge about the interrelationships between oral and systemic health has greatly expanded since the 2000 report. About 60 adverse health conditions have now been shown to be associated with oral health (1), which is part of the rationale for the integration of oral health and primary care. Research will advance our understanding of the mechanisms by which oral and systemic conditions are affected by upstream environmental and social factors, epigenetic factors, and the aging process, both individually and communally. For example, how do external exposures change our microbiomes? Our oral microbiome may be exposed to air containing Sars-CoV-2, water containing protective fluoride, or many kinds of food, beverages, medications, illicit substances, smoked products, and sometimes the biome of close personal contacts. How does the health of a community’s high caries risk groups change with policies such as a tax on sugar-sweetened beverages, Medicaid reimbursement changes, or health promotion efforts to improve oral health literacy and dietary behaviors? To what extent will increased application of value-based health care reimbursement with emphasis on disease prevention, early detection, and minimally invasive care improve oral health? Will the World Health Organization’s addition of dental products (eg, fluoride toothpaste, low-cost silver diamine fluoride, glass ionomer cement) to its Model List of Essential Medicines (9) increase their use to prevent and treat dental caries for under-resourced populations without access to conventional high-cost dental care?

The report’s Section 6 describes many exciting advances in biology, biomimetic dental materials, and technology. Rapid advances in salivary diagnostics are providing information about early, abnormal changes in remote organ systems in the body. Advanced imaging techniques and artificial intelligence can be used for early diagnosis of oral lesions before they are visible to the human eye. The validity and accuracy of these techniques need careful evaluation. Can these earlier clinical end points be used to shorten the length of expensive clinical trials? Guide new preventive strategies? At what point do providers intervene with early preventive or therapeutic strategies instead of letting the body heal itself?

Will populations at greatest risk for disease and the greatest barriers to accessing dental care be able to benefit from early intervention? Every intervention has a cost. If access to new prevention and therapeutic discoveries is not equitable, will health disparities worsen? We need community engagement in the research process and the tools from many disciplines to measure and facilitate the best outcomes. The national Oral Health Progress and Equity Network’s blueprint for improving oral health for all includes 5 levers to advance oral health equity: “amplify consumer voices, advance oral health policy, integrate dental and medical [care], emphasize prevention and bring care to the people” (10).

Who will analyze all these data mined from many micro and macro sources, and who will interpret the data? Health learning systems and complex software algorithms are being developed to provide automated diagnostic information. Data analysts with knowledge of these and other sophisticated tools and modeling approaches are needed.

The dental, oral, and craniofacial research and practice communities increasingly need to be part of interdisciplinary research and educational programs with opportunities for collaboration and learning. Federally qualified health centers and look-alikes are good sites for medical–dental integration, but many of these facilities do not provide dental care.

More positions are needed for dental public health specialists who can lead advocacy efforts, interdisciplinary teams of researchers, clinicians, and community partners and conduct research. For example, the new Dental Public Health Research Fellowship at the National Institute of Dental and Craniofacial Research will provide more intensive research training to further advance dental public health and population-based research. Mechanisms are needed to promote, facilitate, and reward sharing of research and training resources across disciplines in our competitive environment.

Public health perspectives are an important part of interdisciplinary approaches to guide, conduct, and apply research and implement policies to improve oral health. Preventive approaches exist as do barriers to their dissemination and implementation. To prevent disease and improve population oral and overall health, systems change and policy reform are needed along with scientific advances across the research spectrum, more population-level data and analysis, and community participatory engagement. I am optimistic that the next Oral Health in America report will describe fewer inequities and more progress toward oral health for all.

This article is based on a presentation made in the webinar, Oral Health in America — Advances and Challenges: Reading the Report through a Research Lens , sponsored by the American Association for Dental, Oral, and Craniofacial Research. The author received no financial support for this work and has no conflicts of interest to declare. The statements made are those of the author. No copyrighted materials were used in this article.

Corresponding Author: Jane A. Weintraub, DDS, MPH, R. Gary Rozier and Chester W. Douglass Distinguished Professor, University of North Carolina at Chapel Hill Adams School of Dentistry, Department of Pediatric and Public Health, Koury Oral Health Sciences Building, Suite 4508, Chapel Hill, NC 27599-7450. Telephone: (919) 537-3240. Email: [email protected] .

Author Affiliations: 1 University of North Carolina at Chapel Hill Adams School of Dentistry and Gillings School of Global Public Health, Chapel Hill, North Carolina.

• National Institutes of Health. Oral health in America: advances and challenges. Bethesda (MD): US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021. Accessed February 23, 2022. https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
• US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed February 23, 2022. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
• US Department of Health and Human Services. All of Us Research Hub Research Projects Directory. Updated 2/23/2022. Accessed February 23, 2022. https://www.researchallofus.org/research-projects-directory/?searchBy=workspaceNameLike&directorySearch=oral
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• Banava S, Reynolds J, Naavall S, Frantsve-Hawley J. Introducing the AAPHD 5-year research agenda. Presentation, National Oral Health Conference, April 12, 2022; Fort Worth, Texas.
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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• Open access
• Published: 03 October 2022

Quantitative data collection approaches in subject-reported oral health research: a scoping review

• Carl A. Maida 1 ,
• Di Xiong 1 , 2 ,
• Marvin Marcus 1 ,
• Linyu Zhou 1 , 2 ,
• Yilan Huang 1 , 2 ,
• Yuetong Lyu 1 , 2 ,
• Jie Shen 1 ,
• Antonia Osuna-Garcia 3 &
• Honghu Liu 1 , 2 , 4  

BMC Oral Health volume  22 , Article number:  435 ( 2022 ) Cite this article

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This scoping review reports on studies that collect survey data using quantitative research to measure self-reported oral health status outcome measures. The objective of this review is to categorize measures used to evaluate self-reported oral health status and oral health quality of life used in surveys of general populations.

The review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) with the search on four online bibliographic databases. The criteria include (1) peer-reviewed articles, (2) papers published between 2011 and 2021, (3) only studies using quantitative methods, and (4) containing outcome measures of self-assessed oral health status, and/or oral health-related quality of life. All survey data collection methods are assessed and papers whose methods employ newer technological approaches are also identified.

Of the 2981 unduplicated papers, 239 meet the eligibility criteria. Half of the papers use impact scores such as the OHIP-14; 10% use functional measures, such as the GOHAI, and 26% use two or more measures while 8% use rating scales of oral health status. The review identifies four data collection methods: in-person, mail-in, Internet-based, and telephone surveys. Most (86%) employ in-person surveys, and 39% are conducted in Asia-Pacific and Middle East countries with 8% in North America. Sixty-six percent of the studies recruit participants directly from clinics and schools, where the surveys were carried out. The top three sampling methods are convenience sampling (52%), simple random sampling (12%), and stratified sampling (12%). Among the four data collection methods, in-person surveys have the highest response rate (91%), while the lowest response rate occurs in Internet-based surveys (37%). Telephone surveys are used to cover a wider population compared to other data collection methods. There are two noteworthy approaches: 1) sample selection where researchers employ different platforms to access subjects, and 2) mode of interaction with subjects, with the use of computers to collect self-reported data.

The study provides an assessment of oral health outcome measures, including subject-reported oral health status and notes newly emerging computer technological approaches recently used in surveys conducted on general populations. These newer applications, though rarely used, hold promise for both researchers and the various populations that use or need oral health care.

Peer Review reports

A fundamentally different approach is currently needed to address the oral health of populations worldwide namely by considering the perspective of patients or populations and not only dental professionals' views [ 1 ]. It seems increasingly necessary to integrate the self-reported perceptions of oral health, as they can complete or even replace clinical measures of dental status in surveys of populations. Indeed, such subjective measures are easy to use in large-scale populations and can provide a broader health perspective as compared to clinically determined measures of dental status alone [ 2 , 3 ]. Since the topic is broad, this scoping review sets out to identify methods employed in population surveys that discussed self-reported perceptions of oral health, and the extent to which new computer-oriented technological approaches are being incorporated in the research methods.

The literature on oral health and dental-related scoping and systematic reviews includes studies that use specific populations in terms of disease or clinical conditions, treatments, political or social status and typically do not explore oral health status outcome measures [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. These studies only occasionally provide perspectives on general populations. A review by Mittal et al. identifies dental Patient-Reported Outcomes (dPROs), and dental Patient Reported Outcome Measures (dPROMs) related to oral function, oral-facial pain, orofacial pain and psychosocial impact [ 16 ]. The study affords a valuable and extensive review of self-reported oral health and quality of life measures, many of which are found in this paper. This scoping review, then, seeks approaches used in subject-reported surveys, including those with general populations, which may broaden the perspective on oral health outcome measures.

The objective of this review is to categorize measures used to evaluate self-reported oral health status and oral health quality of life used in surveys of general populations.

This work is implemented following the framework of scoping reviews [ 17 , 18 , 19 ] and is presented according to the recommendations of the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), as listed in Additional file 1 : Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [ 20 ]. Additional file 5 : Glossary of Terms provides definitions for the important terms used across the paper.

Search strategy and data sources

A health science librarian assisted in the development of a search strategy that identified papers concerning subject-reported oral health status surveys. The search terms consisted of three broad categories, including survey methods, subject-reported outcomes, and oral health and disease (see Additional file 2 : Search Terms for the full list of search strings). The search comprised peer-reviewed journal articles, conference proceedings and reviews with at least one keyword from each of three aspects. Four online databases: Ovid Medline, Embase, Web of Science, and Cochrane Reviews and Trials were used. In addition, a manual search used similar keywords for the gray literature achieved on MedRxiv. The search focused on peer-reviewed papers written in English and published between 2011 to September 2021. Publications in the last decade were reviewed to investigate the extent to which different methods were being used and the trends that occurred during this period. The final search was completed on September 29, 2021. Using the current decade provides a period where there is considerable interest in non-clinical oral health status outcome measures and the potential for examining technological innovation. All references were imported for review and appraisal. Duplicates were identified using Mendeley (Mendeley, London, UK) and manually verified. After removing the duplicates, data were tabulated in Microsoft Excel (Microsoft, Redmond, WA, USA) for recording screening results and data charting.

Study inclusion criteria

Studies that did not meet with the research objective were excluded using a screening tool (Additional file 3 : Search Tool). First, the titles and abstracts of publications were screened to determine if studies conducted quantitative surveys, and to assess if self-reported and/or proxy-reported OHS was a primary objective. Only surveys with more than three questions that related to OHS were considered. Studies with secondary analysis were excluded because the data collection methods were normally not developed as part of the research and were developed previously. Papers whose sole purpose was to validate well-known measures of oral health were also rejected since the intent was not to assess the OHS of a population. Literature reviews were likewise excluded, as were papers describing results from focus groups and other qualitative studies. Papers whose objectives were to validate measures or predict specific oral disease entities, such as caries or gingival bleeding, rather than overall OHS. Studies primarily focusing on general health status or other systemic diseases instead of OHS were eliminated. Randomized Controlled Trials (RCT) or quasi RCT studies that tested an active agent (e.g., therapy, experiment, and medicine) were excluded because the main research purpose was a comparison of treatment rather than an assessment of subject-reported OHS.

The research team performed the secondary screening through a full-text review. We dropped papers with full text missing or not in English. Then, we screened the available full-text works using a similar set of inclusion criteria aforementioned and further excluded papers without information about data collection methods.

Selection strategies

Figure  1 outlines the review process utilizing the PRISMA-ScR framework. The title-and-abstract screening was completed by a researcher (D.X.) against the inclusion criteria using a screening tool (Additional file 3 : Search Tool). To check for reliability and consistency, one of the researchers (L.Z.) randomly screened 10% of articles independently and compared the inclusion decisions. Given the result of title-and-abstract screening, two researchers (L.Z. and Y.H.) verified the eligibility of the remaining articles independently through full-text review. Inclusion discrepancies were resolved by an additional researcher (D.X.).

PRISMA framework with additional examples

Data extraction

The data charting form (Additional file 4 : Data Charting Form) consists of quantitative and qualitative variables for the data collection methods and their characteristics, such as outcome measures, use of assistive devices/tools or data sources, report type, and so on. The form has been pre-tested by two project staff (C.M. and M.M.) before being utilized. Two researchers (Y.H. and L.Z.) extracted data using the form. Two project staff (C.M. and M.M.) collaborated to review the charted study characteristics and the discrepancies have been addressed through discussion.

Data synthesis and analysis

The scoping review synthesizes the research findings based on dimensions and attributes of major oral health survey data collection methods using descriptive and content analyses. The review provides an overview of various related data collection methods in the recent literature, which refer to the quantitative methods to collect information from a pool of respondents, and the trends in using these new technological approaches, which involve computerized modes, Internet-supported devices and interactive web technologies. Through the literature review, we locate four major types of data collection methods: in-person, Internet-based, telephone-based, and mail-in based approaches.

Screening and study selection

After removing duplicates, the initial search revealed 2981 articles from four online databases for title-and-abstract screening; 2503 of which were excluded after being examined against the inclusion criteria. The interrater reliability of screening was measured by Kappa agreement as 0.94 (95% confidence interval [0.89, 0.99]) for title-and-abstract screening, which implies almost perfect agreement [ 21 ]. After full-text reviewing and excluding 239 articles, we summarized and categorized the remaining 239 studies based on the pre-tested data charting form. In addition, we identified 12 studies with various technological approaches to data collection. Figure  1 presented the PRISMA Framework used for this scoping review.

General characteristics of included studies

Table 1 presents various characteristics of the 239 articles that meet inclusion criteria that were published from 2011 to September 2021. Fifty-six percent of the papers are published in dental journals. About 40% of the papers are published in journals from the Asia-Pacific and Middle East region (APAC), and only 8.4% are from North America (NA). The majority of studies (69%) focus on the general population. Most (88.6%) of the studies use in-person surveys. Around two-thirds of the studies invite and recruit participants from the study sites, e.g., schools, clinics, and hospitals. Some studies recruit participants by having the research team visit communities (16%) or by sampling directly from a database (13%). In the latter case, participants are selected using probability and/or non-probability sampling methods, including convenience sampling (52%), simple random sampling (12%), and stratified sampling (12%). Most studies (193 or 80.8%) investigate self-reported outcomes. Dental examinations accompany the survey in 54% of the studies, while 32% of studies do not use any clinical exam or records. The data charting details are listed in Additional file 4 : Data Charting Form.

Characteristics of data collection methods

The four main data collection methods include in-person (N = 206, 86.2%), mail-in (N = 15, 6.3%), Internet-based (N = 6, 2.5%), and telephone-based (N = 3, 1.3%) surveys. The characteristics of the various data collection methods are summarized in Table 2 .

The majority of the studies using in-person surveys have high response rates with an average of 90.6%. Those studies using in-person survey methods represent half 55.8% of the studies employ face-to-face interviews, while 35.4% used a paper-and-pencil approach. Participants for 58.7% of the studies are recruited directly from clinics [ 22 ], hospitals [ 23 ], and community care centers [ 24 ]. For those sites with electronic records, additional data sources are directly linked to the survey, for example, clinical dental exams with visual components (e.g., X-ray [ 25 ] and pictures [ 26 ]) and medical records [ 23 , 27 , 28 ]. Moreover, different qualitative assessments (e.g., Malocclusion Assessment [ 22 ] and Masticatory Performance Test [ 24 , 29 ]) are captured in patient progress notes.

The mail-in survey method is used by 15 studies and may be more cost-effective than in-person delivery, though these were the two main sources, via post (80%) and by carriers (20%). Mail-in surveys have a relatively high response rate averaging 72%, especially when children or other respondents bring surveys home to complete. Similar to in-person surveys, mail-in surveys can incorporate additional resources, such as photographs and explanations of clinical conditions and treatments [ 30 , 31 ].

Only six studies are identified as using an Internet-based survey, mainly through computer-assisted web interviews (4 studies), and email (2 studies). Three papers employ direct recruitment and another three papers recruit participants through websites and databases. The average response rate is as low as 36.7% for this method with small sample sizes with a median of 259 participants.

Three studies use a telephone survey method covering large populations compared to other survey methods with more responders on average. Two of these studies recruit participants through an existing database, and all surveys used interviewers. Computer-Assisted Telephone Interviews (CATI) [ 32 ] and Voice Response Systems [ 33 ] which are commonly used in industry are not found in the studies.

In addition to the data collection methods, we further categorize the measures found in the 239 articles. Table 3 presents the frequencies and percentages of the various self-reported outcome measures. The three basic approaches are oral health impact measures [ 34 ], functional measures [ 34 ], and self- or proxy-ratings of OHS, with the terms defined in Additional file 5 : Glossary of Terms. These are used as single measures or in combination. The Oral Health Impact Profile-14 (OHIP-14) is the most prevalent single measure with 69 papers and 29% overall, of which 25 papers are about child impact, representing 10% of the total number of selected papers. The Geriatric Oral Health Assessment Index (GOHAI), a functional measure, is second with 21 papers and 9% overall. The GOHAI is the first among the studies on the elderly. There are also two adolescent papers representing 9% of the functioning category. The self- or proxy-rating of OHS has 18 single-measure papers representing 8% of these articles. Of these, 12 or 80% are children's measure's, representing 5% of all selected papers.

There is a total of 63 papers using more than one type of measure. Either combining functional and impact measures (36 and 15%) or self-rating OHS and one or more of the other measures (27 or 11%). The group of single impact measures is 50% of the overall and also represents where two or more measures were used. The single measure, GOHAI, based on function is only 9% of all measures but also played a role in combination with other measures. Finally, the self-reported OHS as a single measure represents 8% of the studies. Its role is mainly in combination with other measures and represented another 15% of the articles. In total. children's oral health measures form a considerable portion of the self-reported oral health outcome research papers, representing 16% of all studies. There are additional studies where children’s measures are used in combination with adults.

Currently, the use of technological approaches emerged in the field of survey research to improve the quality and quantity of data collection. After reviewing and charting all qualified 239 articles, twelve studies that employ technological approaches are summarized in Table 4 .

This scoping review provides an overview of data collection methods used for subject-reported surveys to measure oral health outcomes. Studies are characterized by four survey methods (in-person, mail-in, Internet-based, and telephone) and by summarized dimensions and attributes of data collection for each method, such as technological approaches, survey population or sampling methods. Studies typically employ in-person surveys and more studies were conducted in Asia-Pacific and Middle East countries than in any other world region. Most studies recruit participants directly from study sites. Both probability and non-probability sampling methods employ typically convenience sampling, simple random sampling, and stratified sampling. Studies that achieve the highest response rate on average use in-person surveys, while the lowest rate occurs in Internet-based surveys. Telephone surveys are used to cover a wider population compared to other data collection methods. Many studies, especially those using in-person and mail-in data collection methods, incorporate supplemental data types and technological approaches. Outcome measures are frequently used to evaluate impacts caused by functional limitations related to physical, psychological, and social factors.

Frequently used self-reported oral health status and OHRQoL measures are OHIP-14, an impact measure, and the GOHAI, a functional measure. Children’s oral health outcomes measures form a considerable portion of the self-reported oral health outcome research papers. Although OHIP-14 is the most utilized single measure, many other papers use only portions of this measure, while adding other outcome measures, such as dental care needs, satisfaction, oral health status, and so on. The validity of these measures is therefore compromised and could not provide insight into the degree that the studies are measuring self-reported oral health status or quality of life [ 4 ]. Other measures rate an individual’s oral health status using a simple self-rating scale, from very poor to excellent. This approach is more directly related to a person’s oral conditions and therefore their perceptions and behavior tend to be more consistent with this rating [ 56 , 57 ]. These self-rating measures focus on the overall dimension of perceived oral health status. Unlike the measures previously discussed, these simple ratings do not delineate the psychological, social and physical dimensions of oral health. Nevertheless, such measures can enable researchers to identify hidden dimensions by analyzing independent variables that account for the respondent’s perception.

This review identifies research that employs more conventional methods. The face-to-face interview and the pencil and paper format are conventionally used in many studies along with a clinical dental exam. While offering unique flexibility and easier administration, in-person approaches are more labor-intensive and normally take more time compared to other methods. Countries, such as Brazil, rely for years on these techniques to develop national epidemiological oral health surveys [ 28 , 58 , 59 ]. Although these surveys are very well-organized and established throughout the country, this review does not find that newer technological approaches are introduced into their conventional approach. In this case, there may be little incentive to change their approach because their methods are well understood and employing more technological approaches may be costly.

The use of Internet-based surveys is increasingly common in the medical field. Although these surveys end with potentially lower response rates, this approach is normally more cost-effective [ 60 ]. Internet-based surveys have many notable advantages, including easy administration, fast data collection process, lower cost, wider population coverage and better data quality with fewer overall data errors and fewer missing items [ 61 , 62 , 63 ]. However, this data collection method is constrained by sample bias, topic salience, data security concerns and low digital literacy that may affect response rates [ 62 ]. In settings where Internet-based surveys are not practical, longstanding and effective conventional oral health data collection methods in research will continue. It is evident from this review that the use of computerized technological approaches is limited. While such approaches in survey research improve the quality and quantity of data collection, only twelve studies in this review employ them. The most widely used technical approaches are Computer-Assisted Personal Interviewing (CAPI) and online survey platforms (e.g., Google Forms and SurveyMonkey).

Two noteworthy approaches to survey research methodology emerge from this review, particularly in: (1) sample selection, and (2) mode of interaction with research subjects. North American researchers found different platforms to access subjects for their studies. Canadian studies use random digit dialing to recruit and conduct computer-assisted interviews [ 54 ]. In the United States, researchers access existing polling populations or use Amazon’s MTurk platform for “workers” who are paid small amounts for each survey they respond to [ 64 ]. The second approach is the use of computers to collect self-reported data. The basic surveying technique is CAPI with interviewers directly entering the data into a database. There is also Computer-Assisted Telephone Interviewing (CATI), a survey technique, where the interviewer follows a scripted interview guided by a questionnaire that appears on the screen. A third Internet-based survey technique, the Computer-Assisted Web Interviewing (CAWI), requires no live interviewer. Instead, the respondent follows a script made in a program for designing web interviews that may include images, audio and video clips, and web-based information.

An innovative technological approach worth noting is the use of OralCam to perform self-examination using a smartphone camera [ 65 ]. The study applies research used in medicine to detect liver problems from face photos as well as other diseases [ 66 ]. The paper describes the use of a smartphone camera to interact with a computer using diagnostic algorithms, such as the deep convolutional neural network-based multitask learning approach. Based on over three thousand intraoral photos, the system learns to analyze teeth and gingiva. The smartphone camera takes a picture using a mouth opener. The computer’s algorithms analyze the captured picture, along with survey data, to diagnose several dental conditions including caries, chronic gingival inflammation, and dental calculus. This use of multitask learning technology, with the extensive availability of cell phones, may revolutionize oral health research and care.

This scoping review is limited to oral health survey-based studies in peer-reviewed journals and MedRxiv published in English between 2011 to 2021. A further limitation is that many of the reviewed papers do not adequately describe the methods they use to collect data. Publications using secondary data from national studies are excluded, The exclusion is based on the fact that these researchers are not engaged in designing the methods or conducting the data collection. Often, the publications refer to the original study to describe the method used. Also, the original data collection may have occurred before the time frame of this review. The fifteen papers that use secondary data published over this study’s time frame represent only about six percent of the reviewed papers. Thus, the overall impact of this exclusion is minimal on this scoping review’s results.

Conclusions

This scoping review provides an assessment of oral health outcome measures, including subject-reported oral health status, and notes newly emerging computer technological approaches recently used in surveys conducted on general populations. Such technological approaches, although rarely used in the reviewed studies, hold promise for both researchers and the various populations that use or need oral health care. Future studies employing more developed computer applications for survey research to boost recruitment and participation of study subjects with wide and diverse backgrounds from almost unlimited geographic areas can then provide a broader perspective on oral health survey methods and outcomes.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews

Asia-Pacific (including the Middle East)

Latin America

North America

Computer-Assisted Personal Interviewing

Computer-Assisted Web Interviewing

Computer-Assisted Telephone Interview

Oral Health-Related Quality of Life

Oral Health Impact Profile-14

Geriatric Oral Health Assessment Index

Oral Health Status

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C.M., D.X., M.M. and H.L. conceptualized the study and designed the data collection form and established the data analysis plan. A.O. developed search strategies and carried out searching on multiple databases. D.X., Y.L., Y.H., J.S. and Y.L. performed additional searching and tested the data charting form. D.X., Y.L., and Y.H. helped to screen studies for relevance and data charting. C.M. and M.M. reviewed full-text papers and verify the data charting results. C.M., D.X., and M.M. drafted the original manuscript. D.X. and L.Z. prepared Tables 1 , 2 and Fig.  1 . C.M., D.X., M.M., and L.Z prepared Tables 3 and 4 . All authors read and provided substantial comments/edits on the manuscript and approved the final version. All authors read and approved the final manuscript.

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Maida, C.A., Xiong, D., Marcus, M. et al. Quantitative data collection approaches in subject-reported oral health research: a scoping review. BMC Oral Health 22 , 435 (2022). https://doi.org/10.1186/s12903-022-02399-5

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Oral hygiene can reduce risk of some cancers

April 18, 2024—A healthy mouth microbiome can help prevent a number of diseases, including cancer , according to Harvard T.H. Chan School of Public Health’s Mingyang Song .

Song, associate professor of clinical epidemiology and nutrition, was among the experts quoted in an April 4 Everyday Health article about the connections between mouth, gum, and tooth health and overall health. “Alterations in the oral microbiome can cause systemic inflammation and increase disease risk indirectly,” Song explained. Microbes in the mouth can also travel to other parts of the body and directly increase the risk of conditions like diabetes , heart disease , Alzheimer’s disease , and various cancers, he added.

Previous studies co-authored by Song have shed light on the oral microbiome’s impacts on the risk of stomach and colorectal cancers. One study found that people with a history of gum disease have a 52% greater chance of developing stomach cancer compared with those without gum disease, and that losing two or more teeth raised stomach cancer risk by 33%. Another study found that people with gum disease had a 17% greater chance than those without gum disease of developing a serrated polyp—a type of polyp that can lead to colon cancer. The study also found that people who had lost at least four teeth had a 20% higher risk of a serrated polyp.

The takeaway, Song said, is to keep the mouth microbiome healthy. This can be accomplished through practicing oral hygiene—visiting the dentist regularly and brushing, flossing, and using mouthwash daily—as well as maintaining an overall healthy lifestyle through diet , exercise , and avoiding smoking .

Read the article in Everyday Health: The Health of Your Mouth May Affect Your Risk of Colorectal Cancer

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• Published: 04 September 2023

An online survey of oral health behaviours and impact on young children and families in Wales

• Anup J. Karki 1 ,
• Ulugbek Nurmatov 2 ,
• Mark D. Atkinson 3 ,
• Aideen Naughton 1 &
• Alison Kemp 2  

British Dental Journal ( 2023 ) Cite this article

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Introduction Studies outside Wales have consistently reported reduced quality of life as measured by the Early Childhood Oral Health Impact Scale. With relatively high levels of tooth decay in Wales as found through the regular dental surveys, it is important to understand different oral health-related behaviours and impact so that findings can inform oral health promotion in Wales.

Methods An oral health questionnaire was made available to volunteers registered with Health Wise Wales. Parents of children (2-6 years old) participated in the study. Frequency analyses were carried out to understand the oral health-related behaviours and regression analysis was carried out to understand the predictors of reported oral health impacts.

Results Overall reported oral health impact was low in this study. In total, 20% of parents reported that their child brushed their teeth less than twice a day and 23% reported toothbrushing without adult supervision. Drinking plain water twice a day or more was associated with good oral health in children.

Conclusion Overall, reported oral health impact was low, which is likely to be due to under-representation of study participants from the deprived areas in Wales. There is plenty of room for improvement in oral health-related behaviours.

Health Wise Wales (HWW), an online register of people in Wales who have volunteered to participate in research, provided access to a 'research ready' population for this study. The disadvantage of the HWW was that the register was not fully representative of the Welsh general population.

This paper provides an overview of oral health behaviours and reported impact on young children in Wales. Overall reported impact was low and 20% parents reported that their children brush their teeth less than twice a day.

Drinking plain water twice a day or more compared to drinking no water was a significant predictor of low oral health impact. Increased use of plain water by children to meet their hydration need may also indirectly help oral health.

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Public Health Wales, Capital Quarter 2, Cardiff, CF10 4BZ, Wales, United Kingdom

Anup J. Karki & Aideen Naughton

Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom

Ulugbek Nurmatov & Alison Kemp

Swansea University Medical School, Swansea, Wales, United Kingdom

Mark D. Atkinson

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Contributions

Anup J. Karki, Ulugbek Nurmatov, Mark D. Atkinson, Aideen Naughton and Alison Kemp contributed to the study design and writing of this paper for publication. Mark Atkinson carried out the statistical analyses.

Corresponding author

Correspondence to Anup J. Karki .

Ethics declarations

The authors declare that they have no competing interests.

HWW received ethical approval from the Wales Research Ethics Committee (REC) 3 on 16 March 2015 (reference 15/WA/0076). Applications to use the HWW for oral health data collection was reviewed by a Scientific Steering Group and Patient and Public Involvement representatives to assess if the proposed project fits with the ethos of the HWW and is scientifically sound. Participants for this study consented to complete the oral health questionnaire. Separate ethical approval was not required.

The datasets for this study are not publicly available due to privacy and/or ethical restrictions in accessing data collected by Healthwise Wales. Oral health questionnaire data that support the findings of this study can be obtained through the corresponding author on a reasonable request.

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Karki, A., Nurmatov, U., Atkinson, M. et al. An online survey of oral health behaviours and impact on young children and families in Wales. Br Dent J (2023). https://doi.org/10.1038/s41415-023-6230-x

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Received : 14 November 2022

Revised : 14 April 2023

Accepted : 04 May 2023

Published : 04 September 2023

DOI : https://doi.org/10.1038/s41415-023-6230-x

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• v.12(3); Jul-Sep 2021

Oral Health: A Gateway to Overall Health

Dr. dipti m. bhatnagar.

Department of Oral Medicine and Radiology, Rayat Bahra Dental College, Mohali, Punjab, India. E-mail: ni.oc.oohay@lajnumitpid

Impact of oral health on the overall health has emerged in 1989, and since then oral cavity has been described as a window to the general health of the patient. Various cliches “You cannot have good general health without good oral health” and “The mouth is part of the body” are indicative of oral and systemic health linkage.[ 1 ] Oral cavity is the harbor of a diverse group of microorganisms comprising of bacteria, fungi, and viruses that play a key role in the maintenance of oral and systemic health. However, when the oral microbiota balance is altered termed as “microbial dysbiosis,” active pathogens evade the host immune response resulting in variety of systemic diseases.[ 2 ] In 1879, Willoughby D. Miller observed a role of oral microorganisms in the development of brain abscess, pulmonary and gastric diseases and stated “oral foci of infection as a cause of systemic diseases.” The focus of infection refers to the localized area of tissue infected with microorganisms, and foci of infection may disseminate through bloodstream to organs thereby resulting in bacteremia, metastatic tissue injury, and inflammation.[ 3 ] Various systemic diseases such as cardiovascular, respiratory, gastrointestinal, kidney, and diabetes mellitus have been linked to oral microorganisms as a potential focus of infection. Among oral diseases, a significant relationship has been elucidated between periodontal disease and increased risk of diabetes mellitus, cardiovascular, preterm low birth weight.[ 1 , 2 ] In consideration to above, it is utmost important for oral health care professionals to educate patients and the general public regarding the importance of good oral hygiene and its influence on the general health.

Diabetes mellitus has become a major global illness affecting more than 171 million people worldwide, characterized by severe periodontal disease, increased susceptibility to infection, and poor wound healing. Severe periodontal disease can worsen the glycemic control in type II diabetes mellitus, and risk of developing diabetes complications of retinopathy and neuropathy becomes higher.[ 4 ] Moreover, oral microbes, particularly Streptococcus viridans and Streptococcus sanguis have been implicated as a causative agent of bacterial endocarditis characterized by inflammation of the inner lining of the heart.[ 5 ] Similarly, oral-derived bacteria can colonize the gut leading to impaired digestion.[ 1 , 6 ]

Oral care should be an integral part of medical care in medically compromised patients suffering from chronic diseases such as human immunodeficiency virus infection and cancer.[ 1 , 4 ] Furthermore, effect of medications such as antihistamines, antihypertensives, calcium channel blockers, antianxiety, antipsychotic drugs, anticoagulants, and immunosuppressants taken by the patient for systemic diseases can adversely affect the oral mucosal tissues resulting in dry mouth, lichenoid reactions, ulcerations, candidiasis, gingival bleeding and enlargement. Oral physicians are first to encounter adverse drug reactions in the oral cavity and should take the opinion of the concerned specialist for drug dosage modification or substitution by an alternative drug.[ 7 ]

Tobacco usage has become a public health problem, particularly among the youngsters.[ 8 , 9 ] Oral health care professionals should spread public awareness of deleterious effects of tobacco consumption on both systemic and oral health. Tobacco users should be educated that smoking not only affects the lungs or other organs but can also lead to initiation and progression of life-threatening diseases.

Oral health care professionals are fore frontiers in screening of oral diseases, and in educating patients about oral-systemic health connection. Counseling of patient about optimal oral health is an effective way to make them familiar with oral signs of various systemic diseases. Patients' perception of dental practitioner as a physician is essential for adherence to the counseling sessions and treatment compliance. Practitioners should have provocative verbal communication skills to impart comprehensive education to the patient.[ 10 , 11 ] Elderly population should be provided specialized care and education for healthy aging that is to maintain functional ability in the older age. The organization of educational campaigns, audio-visual aids, slogans, educational materials, and commercial advertisements are useful in increasing awareness of the public about the significance of oral health. Oral health care professionals should use referral forms for physicians to make them aware about oral-systemic health relationship.[ 12 ]

Now its time that oral health care professionals should increase awareness of general public about oral-systemic health connection and move toward interprofessional collaboration for understanding and management of sequelae of oral infections on overall health.

• Introduction
• Article Information

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• The Absence of Dental Care in Medicare and Health Inequities JAMA Network Open Invited Commentary September 12, 2023 Bruce A. Dye, DDS, MPH

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Chamut S , Shoff C , Yao K , Fleisher LA , Chalmers NI. Oral Health Among Medicare Beneficiaries in Nursing Homes. JAMA Netw Open. 2023;6(9):e2333367. doi:10.1001/jamanetworkopen.2023.33367

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Oral Health Among Medicare Beneficiaries in Nursing Homes

• 1 Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, Massachusetts
• 2 Office of the Administrator, Centers for Medicare & Medicaid Services, Baltimore, Maryland
• 3 Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services, Baltimore, Maryland
• Invited Commentary The Absence of Dental Care in Medicare and Health Inequities Bruce A. Dye, DDS, MPH JAMA Network Open

Older adults in the US encounter significant barriers to maintaining good oral health, and disparities in disease prevalence and access to oral care are persistent challenges. 1 Notably, a substantial portion of Medicare beneficiaries (51%) lack dental coverage, further exacerbating the problem. 2 This study’s primary goals were to describe the prevalence of dental problems among Medicare beneficiaries residing in nursing homes and identify characteristics associated with experiencing dental problems.

This cross-sectional study included Medicare beneficiaries residing in Centers for Medicare & Medicaid Services (CMS)–certified nursing homes in 2020. We used the CMS Minimum Data Set 3.0 Resident Assessment Instrument data 3 linked to the 2020 Medicare Beneficiary Summary File Base. 4 Race and ethnicity were self-reported to the Social Security Administration and integrated with enrollment in Medicare. We used χ 2 tests to test differences across groups, with statistical significance set at a 2-tailed P  < .05. We used 6 multilevel logistic regression models to estimate odds of experiencing each dental problem (eMethods in Supplement 1 ). Reporting of this study followed the STROBE reporting guideline, was covered by the Common Rule exemption 45 CFR §46.104(d)(4)(iv), and did not require institutional review board review.

The study sample comprised 2 355 366 Medicare beneficiaries (2 142 384 aged ≥65 years [91.0%]; 1 446 969 females [61.4%]; 303 738 non-Hispanic Black [12.9%], 141 383 Hispanic [6.0%], and 1 827 593 non-Hispanic White [77.6%]) ( Table 1 ). The most prevalent dental problem per 1000 beneficiaries was no natural teeth or tooth fragments (175.10 beneficiaries), followed by cavities or broken natural teeth (72.89 beneficiaries); pain, discomfort, or difficulty chewing (10.79 beneficiaries); broken or loosely fitting dentures (9.61 beneficiaries); inflamed or bleeding gums or loose teeth (2.15 beneficiaries); and abnormal mouth tissue (2.06 beneficiaries).

Significant differences in dental problem prevalence were observed across demographic and clinical groups ( Table 2 ). Non-Hispanic Black beneficiaries had 16% higher odds of having no natural teeth or tooth fragments (adjusted odds ratio [OR], 1.16; 95% CI, 1.15-1.18) and 5% higher odds of having cavities or broken natural teeth (aOR, 1.05; 95% CI, 1.03-1.07) compared with White beneficiaries. Similarly, American Indian or Alaskan Native beneficiaries had 34% higher odds of having no natural teeth or tooth fragments (aOR, 1.34; 95% CI, 1.27-1.40), 20% higher odds of having cavities or broken natural teeth (aOR, 1.20; 95% CI, 1.11-1.29), and 45% higher odds of having inflamed or bleeding gums or loose teeth (aOR, 1.45; 95%, 1.05-2.01) compared with White beneficiaries. Beneficiaries with 3 or more chronic conditions had increased odds of having broken or loosely fitting dentures (aOR, 1.26; 95% CI, 1.20-1.33), no natural teeth or tooth fragments (aOR, 1.57; 95% CI, 1.54-1.59), abnormal mouth tissue (aOR, 1.50; 95% CI, 1.34-1.67), and pain, discomfort, or difficulty chewing (aOR, 1.22; 95% CI, 1.16, 1.28) compared with beneficiaries with no chronic conditions. However, they had 16% lower odds of having cavities or broken natural teeth (aOR, 0.84; 95% CI, 0.83-0.86) and 27% lower odds of having inflamed or bleeding gums or loose teeth (aOR, 0.73; 95% CI, 0.66-0.81) compared with beneficiaries with no chronic conditions. Additionally, beneficiaries in rural nursing homes were more than 70% more likely to experience 3 of 6 dental problems and more than 30% more likely to experience the other 3 dental problems than beneficiaries in urban nursing homes.

This cross-sectional study’s findings highlight the considerable prevalence of dental problems among Medicare beneficiaries in nursing homes, revealing disparities across various demographic and clinical factors. Notably, beneficiaries with more chronic conditions were more likely to be edentulous, which makes eating properly and managing other health conditions challenging.

Our study was limited by its sole focus on Medicare beneficiaries in nursing homes, which may limit the generalizability of our findings to all US long-term care populations. Additionally, the possibility of reporting bias in nursing homes cannot be ignored. Although our models accounted for beneficiary similarities and assessment uniformity, variations in how patient assessments were conducted could pose a concern and introduce bias to our findings. Targeted interventions addressing oral health disparities in this high-risk population are essential to improve overall health and well-being.

Accepted for Publication: July 27, 2023.

Published: September 12, 2023. doi:10.1001/jamanetworkopen.2023.33367

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Chamut S et al. JAMA Network Open .

Corresponding Author: Natalia I. Chalmers, DDS, MHSc, PhD, Office of the Administrator, Centers for Medicare & Medicaid Services, 7500 Security Blvd, Mail Stop C5-02-01, Baltimore, MD 21244 ( [email protected] ).

Author Contributions: Dr Shoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chamut, Yao, Chalmers.

Acquisition, analysis, or interpretation of data: Chamut, Shoff, Fleisher, Chalmers.

Drafting of the manuscript: Chamut, Shoff, Chalmers.

Critical review of the manuscript for important intellectual content: Chamut, Yao, Fleisher, Chalmers.

Statistical analysis: Shoff.

Obtained funding: Chamut.

Administrative, technical, or material support: Chamut, Yao.

Supervision: Chamut, Yao, Chalmers.

Conflict of Interest Disclosures: Dr Chamut reported receiving a Health and Aging Policy Fellowship during the conduct of the study. No other disclosures were reported.

Funding/Support: We acknowledge the support of Christine Riedy, PhD, MPH (Oral Health Policy and Epidemiology, Harvard School of Dental Medicine), and the John A. Hartford Foundation, who along with partnerships from the Atlantic Philanthropies and West Health, have granted funding to the Research Foundation for Mental Hygiene, Columbia University for Dr Chamut’s Health and Aging Fellowship under the sponsor grant/contract number 2018-0074.

Role of the Funder/Sponsor: The supporters had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors. No official endorsement by the Department of Health and Human Services, Centers for Medicare & Medicaid Services, or the Health and Aging Policy Fellows program is intended or should be inferred.

Data Sharing Statement: See Supplement 2 .

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Oral health: A window to your overall health

Your oral health is more important than you might realize. Learn how the health of your mouth, teeth and gums can affect your general health.

Did you know that your oral health offers clues about your overall health? Did you know that problems in the mouth can affect the rest of the body? Protect yourself by learning more about the link between your oral health and overall health.

What's the link between oral health and overall health?

Like other areas of the body, the mouth is full of germs. Those germs are mostly harmless. But the mouth is the entry to the digestive tract. That's the long tube of organs from the mouth to the anus that food travels through. The mouth also is the entry to the organs that allow breathing, called the respiratory tracts. So sometimes germs in the mouth can lead to disease throughout the body.

Most often the body's defenses and good oral care keep germs under control. Good oral care includes daily brushing and flossing. Without good oral hygiene, germs can reach levels that might lead to infections, such as tooth decay and gum disease.

Also, certain medicines can lower the flow of spit, called saliva. Those medicines include decongestants, antihistamines, painkillers, water pills and antidepressants. Saliva washes away food and keeps the acids germs make in the mouth in balance. This helps keep germs from spreading and causing disease.

Oral germs and oral swelling and irritation, called inflammation, are linked to a severe form of gum disease, called periodontitis. Studies suggest that these germs and inflammation might play a role in some diseases. And certain diseases, such as diabetes and HIV/AIDS, can lower the body's ability to fight infection. That can make oral health problems worse.

What conditions can be linked to oral health?

Your oral health might play a part in conditions such as:

• Endocarditis. This is an infection of the inner lining of the heart chambers or valves, called endocardium. It most often happens when germs from another part of the body, such as the mouth, spread through the blood and attach to certain areas in the heart. Infection of the endocardium is rare. But it can be fatal.
• Cardiovascular disease. Some research suggests that heart disease, clogged arteries and stroke might be linked to the inflammation and infections that oral germs can cause.
• Pregnancy and birth complications. Gum disease called periodontitis has been linked to premature birth and low birth weight.
• Pneumonia. Certain germs in the mouth can go into the lungs. This may cause pneumonia and other respiratory diseases.

Certain health conditions also might affect oral health, including:

Diabetes. Diabetes makes the body less able to fight infection. So diabetes can put the gums at risk. Gum disease seems to happen more often and be more serious in people who have diabetes.

Research shows that people who have gum disease have a harder time controlling their blood sugar levels. Regular dental care can improve diabetes control.

• HIV/AIDS. Oral problems, such as painful mouth sores called mucosal lesions, are common in people who have HIV/AIDS.
• Cancer. A number of cancers have been linked to gum disease. These include cancers of the mouth, gastrointestinal tract, lung, breast, prostate gland and uterus.
• Alzheimer's disease. As Alzheimer's disease gets worse, oral health also tends to get worse.

Other conditions that might be linked to oral health include eating disorders, rheumatoid arthritis and an immune system condition that causes dry mouth called Sjogren's syndrome.

Tell your dentist about the medicines you take. And make sure your dentist knows about any changes in your overall health. This includes recent illnesses or ongoing conditions you may have, such as diabetes.

How can I protect my oral health?

To protect your oral health, take care of your mouth every day.

• Brush your teeth at least twice a day for two minutes each time. Use a brush with soft bristles and fluoride toothpaste. Brush your tongue too.
• Clean between your teeth daily with floss, a water flosser or other products made for that purpose.
• Eat a healthy diet and limit sugary food and drinks.
• Replace your toothbrush every 3 to 4 months. Do it sooner if bristles are worn or flare out.
• See a dentist at least once a year for checkups and cleanings. Your dentist may suggest visits or cleanings more often, depending on your situation. You might be sent to a gum specialist, called a periodontist, if your gums need more care.
• Don't use tobacco.

Contact your dentist right away if you notice any oral health problems. Taking care of your oral health protects your overall health.

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• Gross EL. Oral and systemic health. https://www.uptodate.com/contents/search. Accessed Feb. 1, 2024.
• Oral health. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/oral-health. Accessed Feb. 1, 2024.
• Gill SA, et al. Integrating oral health into health professions school curricula. Medical Education Online. 2022; doi:10.1080/10872981.2022.2090308.
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• Dental floss vs. water flosser
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• Sensitive teeth
• When to brush your teeth

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