Teeth, and what they have to do with the rest of you

Periodontal disease affects a substantial proportion of adults, progresses without pain for years, and is the leading cause of tooth loss in adults.

The two problems

Dental caries — decay — is caused by acid produced by bacteria metabolising fermentable carbohydrate, which demineralises enamel.

The critical factor is frequency of sugar exposure rather than total quantity, since each exposure produces an acid attack lasting some time.

Gum disease begins as gingivitis: inflammation from plaque at the gum margin, which is reversible.

Untreated it can progress to periodontitis, in which the supporting bone is lost irreversibly.

Bleeding when brushing is the earliest sign and is treated by most people as a reason to brush more gently, which is precisely wrong — it is a sign of inflammation requiring better cleaning, not less.

The connections beyond the mouth

Where the evidence is interesting and should be stated carefully.

Periodontitis is associated in numerous studies with cardiovascular disease, diabetes, adverse pregnancy outcomes, respiratory disease and, in some research, cognitive decline.

The relationship with diabetes is the best characterised and appears bidirectional: poor glycaemic control worsens periodontal disease, and treating periodontal disease produces measurable improvements in glycaemic markers in trials.

For cardiovascular disease the association is consistent and causation is not established, with shared risk factors including smoking accounting for part of it.

The plausible mechanism is chronic low-grade systemic inflammation and bacteraemia from a persistently inflamed area, which in advanced periodontitis is substantial in surface area.

What actually prevents both

The evidence-based basics, which are dull and effective.

Brushing twice daily with fluoride toothpaste, for two minutes, with attention to the gum margin.

Spitting rather than rinsing afterwards, which keeps fluoride in contact with the teeth — a small change with disproportionate effect and one almost nobody is told.

Cleaning between the teeth daily, with interdental brushes where the gaps allow, which are more effective than floss for most adults.

Reducing the frequency of sugar intake rather than only the amount.

Not brushing immediately after acidic food or drink, since enamel is temporarily softened.

Not smoking, which is a major risk factor for periodontal disease and which also masks bleeding, delaying diagnosis.

And regular professional cleaning and examination at an interval determined by risk rather than by convention.

What is oversold

Whitening products, which vary from ineffective to damaging, with unregulated products containing hydrogen peroxide at concentrations restricted in many jurisdictions for good reason.

Charcoal toothpastes, which are abrasive and generally lack fluoride, which is the ingredient that matters.

Fluoride-free toothpaste, which removes the single most evidence-supported component.

Mouthwash used routinely as a substitute for cleaning, and particularly used immediately after brushing, which washes away the fluoride just applied.

And oil pulling, which has minimal evidence and displaces things that work.

Dry mouth

An underappreciated driver of decay.

Saliva buffers acid, provides minerals for repair and clears debris, so reduced flow substantially increases decay risk.

Causes include many common medications — antidepressants, antihistamines, some antihypertensives, opioids — as well as Sjögren's syndrome, radiotherapy to the head and neck, dehydration and mouth breathing.

Management includes saliva substitutes, sugar-free gum to stimulate flow, high-fluoride toothpaste and more frequent review.

Anyone on several medications with a dry mouth is at genuinely elevated risk and frequently unaware of it.

Grinding and jaw pain

Common and connected to sleep.

Sleep bruxism causes tooth wear, fractures, jaw pain and headache, and is associated with stress and with sleep apnoea.

A custom guard protects the teeth without stopping the grinding.

Temporomandibular disorders cause jaw pain, clicking and restricted opening, and generally respond to conservative management — soft diet, heat, jaw exercises, addressing clenching — rather than to irreversible dental treatment.

Access

Worth naming as the actual barrier for many.

Dental care is publicly funded to varying and generally limited extents, and cost is a documented reason for delay, which converts small problems into extractions.

Emergency dental services, dental schools offering supervised treatment at reduced cost, and payment plans exist in most places and are underused.

And the prevention above is close to free, which is the strongest argument for doing it properly.

General information only, not medical or dental advice. Consult a qualified dentist about oral health, particularly if your gums bleed regularly.