Dentistry Matters
By Diane Peters
Dentists know, based on what they see every day in the chair, that the care they provide has an impact on people’s lives. Most obviously, dentistry improves overall oral health. But a healthy mouth also affects physical health and mental well-being. And it has an economic and social impact in both the short and long term.
But what dentists observe professionally and what’s been proven in the medical literature differ. “We actually know very little in formal terms. There’s a lot of associational data,” says Faculty of Dentistry associate professor Carlos Quiñonez, who is also director of the graduate specialty program in dental public health at the Faculty. “Do we know that improving people’s oral health will result in improvements in systemic health or overall health? We have an army of dentists out there living it. But we don’t have the causation data.”
Having the evidence on impacts matters. Data influence the advice other healthcare professionals offer, the terms of public and private coverage, funding for dental research and how the public views dental care. A true understanding of dentistry’s role shines a light on the fact that one in three people in Canada lacks dental coverage and that six million people in this country avoid going to the dentist every year for financial reasons. Yet caries is the most widespread non-communicable disease in the world and periodontitis is also extremely common, impacting 10 per cent of the world’s population.
“The government doesn’t always understand the importance of dental care,” says professor Michael Glogauer. After all, dental offices across Canada — and in many other countries — were forced to close for everything but emergency care when COVID-19 began spreading in March 2020.
It’s a situation that’s perplexing for those working in the profession. “Why does dentistry have to constantly prove its worth?” associate professor Michael Casas, 8T8 Dip Paedo, 9T2 MSc asks rhetorically. “No one is interested in dentistry until they have a toothache, and then they want to see a dentist right away.”
A new living lab clinic at the Faculty of Dentistry should contribute to a more sophisticated understanding of dentistry’s effects. It will seek evidence about the value of providing pro bono dental care to those who cannot afford it and, ideally, offer evidence-based guidance for healthcare stakeholders. In the meantime, those working in the profession continue to promote dentistry’s deep and wide-ranging value.
ORAL HEALTH MATTERS
Fundamentally, regular dental care leads to better oral health. Healthy, pain-free mouths allow people to live with a basic level of wellness. “Our mouth is what we use to eat every day. Where we talk every day,” says Aimee Dawson, professor in the Faculty of Dental Medicine at Laval University. She treats patients at Clinique Spot, an interprofessional clinic offering no-charge care to people with barriers to accessing health care; plus, she runs a no-charge dentistry clinic at Laval every summer.
Dawson notes that people without access to dental care often present in emergency settings with pain or tooth problems affecting their ability to function. “When people are suffering from pain or they don’t feel like they look okay, that’s a primary care issue.” Cutting one’s tongue on a jagged tooth, dealing with injured teeth that impact chewing or coping with missing front teeth translates to a very real disability.
“Missing teeth limit a person’s speaking abilities, which are required for job interviews and customer service opportunities,” says Melvin Hsu, director of Dental and Oral Health Services for the City of Toronto. The challenge can be worse for people speaking in their non-native language.
Oral pain can stop people from functioning entirely. “Pain from a toothache is the worst kind of pain,” says Glogauer. “Ironically, until you have this kind of pain, you don’t understand why dental care is so important.” Everything from sleep and eating is impacted when your teeth are in pain or are not functioning optimally.
Glogauer also contends that while cancers often come with debilitating side effects, oral cancers are among the worst. “You can be disfigured. You can’t talk, you can’t eat, you can’t do the normal things you do with your face like smiling or having intimate relations.”
Crooked, discoloured or missing front teeth don’t always affect function but they alter how someone looks. “There’s a very strong image in Western society of the way our teeth should look,” says professor Paul Allison, former dean of the Faculty of Dentistry at McGill University. Those who can afford it will spend thousands on orthodontics to improve their appearance not out of mere vanity: being attractive influences everything in a person’s life from their success in education and job interviews to how well they marry.
When someone’s oral appearance strays far from our beauty ideal, it can become a barrier to the basics such as getting treated with respect in public, being able to rent an apartment or landing a job. “It’s hard to get a position working with the public when you don’t have teeth,” says Hsu.
SOCIOECONOMIC VALUE
When people get dental care that helps with pain and their appearance, that in turn can positively impact their overall health.
Having robust social supports bolsters overall health, and dentistry’s contribution to this can be seen readily in seniors, notably those accessing the new Ontario Seniors Dental Care Program. This program provides basic dental care, surgery and partial coverage for dentures to low-income people over 65. While the new program has been onerous for many people to access, Hsu says community teams have already seen coverage change lives. “What we find is seniors increase their socializing, interacting more with their family and friends,” says Hsu. “We find that once they have healthy teeth, they go out more and are able to eat and sleep better.”
For working-age adults grappling with precarious employment or housing, a healthy smile has tangible value. “They’re able to gain more self-confidence when they interview for jobs. They have more success when they seek housing,” says Hsu.
Counterproductively, our complex dental care system requires vulnerable patients to invest considerable time into figuring out if and how they might qualify for services. “We deal with a lot of newcomers in the city, and language and cultural barriers are a huge thing,” says Hsu, whose staff frequently assist people in navigating the system.
For those with the means to pay for regular and comprehensive dental care, oral health can act as an early warning system for mental health concerns. “Just look at the rise of broken teeth because of stress and people grinding their teeth during the pandemic,” says Glogauer.
A SYSTEMIC CONNECTION
The mouth is connected to the rest of the body, so what happens to the teeth and gums affects general health especially as it relates to infection. “It’s clear that infection in the mouth is a sign of overall systemic health issues,” says Glogauer. “When you look at large studies, there’s links between gum disease and almost every inflammatory disease known to humans.” That list includes some cancers, preterm birth, diabetes, cardiovascular disease, strokes and more.
In seniors, periodontitis, caries and other oral-health conditions can have a life-or-death impact. One 2017 study linked so-called oral frailty — trouble chewing, poor tongue pressure, lacking natural teeth and other factors — with more than double the risk of physical frailty, disability and even mortality. The study concluded that oral problems were a predictor of greater ill-health. Meanwhile, a 2016 review study showed that when dental professionals offered oral interventions to elderly people in hospitals and nursing homes with pneumonia, it lowered their mortality rate.
In children, numerous studies — including one conducted in Toronto — show a connection between caries and stunted growth and malnourishment, including iron deficiency leading to anemia. Casas, who is also dentist-in-chief at the Hospital for Sick Children, says it’s likely that kids with painful teeth avoid nutritional foods that are tough to chew, while a starch-heavy diet further make caries worse. “After they get their teeth fixed, they catch up,” he says.
Some healthcare teams see dental health as an imperative. “Those who have a medical condition sometimes can’t have their treatment or operation until we fix their teeth,” says Casas about the protocol at SickKids. “If they get a dental infection, there’s a risk of those bacteria seeding out and getting to the heart,” says Casas of kids going into cardiovascular surgery. For those with cancer, a dental infection can lead to sepsis or affect their immune system. “The most common source of infection for a child is dental,” he adds.
While research and clinical practice acknowledge the link between oral and systemic health, the precise pathways remain a mystery. “All you can do is show the relationships. We can’t prove the cause,” says Glogauer. His own animal studies show that oral disease primes the immune system to trigger inflammation in the rest of the body — a line of research he and others hope will help clarify cause and effect.
DIAGNOSTIC VALUE
People with the means to pay for dental care tend to visit their dentist more regularly than any other healthcare provider, which benefits their overall health. A 2012 study out of Brown University in the U.S. showed that people who visited their dentists annually were more likely to be diagnosed with earlier-stage oral and pharyngeal cancers. “Receipt of regular dental examinations at least annually may reduce the public health burden of oral and pharyngeal cancer by facilitating earlier detection of the disease,” the study’s authors concluded.
Dramatically, a Faculty of Dentistry study tracked the diagnosis of oral cancer in Ontario over 11 years and found that dentists caught 10 per cent of carcinomas and dysplasias in that time period. “Regarding oral cancer, it’s quite clear we are at the forefront of cancer diagnosis,” says assistant professor Marco Magalhaes 0T9 PhD, 1T5 MSc OP/OM, who was lead author on the study.
Magalhaes notes that, despite dentistry’s life-saving role in catching early cancers, patients who get a diagnosis in a dentist’s chair must pay out of pocket for the biopsy — the same isn’t true if that biopsy is performed elsewhere in the healthcare system.
Since oral health is a predictor of overall health, Allison thinks the healthcare system is missing an opportunity: if dentists and family doctors were in regular contact as part of someone’s primary care team, key pieces of information such as someone’s propensity toward caries or a tendency to inflammation via gum disease could inform their care. “It’s another helpful screening tool,” he says.
THE ROLE OF RESEARCH
Dentistry research helps establish best practices for controlling oral bacteria and developing new filling materials. But many projects have an interdisciplinary component that affects our understanding of a range of health conditions.
The mouth offers straightforward access to tissues for biopsy and observation, speeding up the research process. One of Magalhaes’s projects involves tracking early-stage cancerous lesions to understand the factors that cause some to become aggressive cancers and others not. “I’m finding ways to characterize the factors that can promote cancers to progress,” he says. This understanding could be extrapolated to other types of cancers, too.
However, dental research earns fewer grants than other biomedical disciplines, while the interdisciplinary work of dentistry can be misunderstood by grant committees. “When I applied for my very first grant, the first comment I got from a reviewer was, ‘Why is this researcher from dentistry looking at breast cancer?’” Magalhaes says. Being cross-appointed to Laboratory Medicine & Pathobiology at U of T helps him with funders now; plus, he has started calling himself a cancer researcher to avoid confusion.
CHANGING THE CONVERSATION
More research may help build a stronger understanding of dentistry’s impact on the body, mind and society, and assign dollar figures to dental care’s return on investment. COVID-19 may provide a new opportunity to examine how this public health crisis has impacted oral health among the already vulnerable.
As the evidence mounts about dentistry’s ability to change health from a myriad of perspectives, the challenge becomes translating that into change — and proposing what that change could look like.
Even dental public health researchers such as Quiñonez admit they don’t know which approach to public care would work best. An entirely public model may not make sense or be economically feasible. Successful programs in other countries, such as Germany, offer a mixed system of public and private care that’s able to provide near-universal coverage to their population. Allison says that children in Quebec benefit from a program that offers fully covered dental care that includes cleaning, extractions, endodontics and fillings for everyone under 10. “It’s very simple, it’s just part of the system,” says Allison.
Negotiating a new social contract that’s more equitable, straightforward and still affordable could arise partly from more evidence but also from the dental profession better conveying the message about their work’s value. “We need to highlight how important oral health is in the grand scheme of things,” says Glogauer. “This is an opportunity for a rallying cry.”
Illustration by Jeannie Phan
Interested in more stories? Read the PDF edition of the U of T Dentistry Magazine Winter/Spring 2021 Issue