• 5/13/2008
  • New York, NY
  • Nicholas Bakalar
  • New York Times (nytimes.com)

Dental cavities are not good news, but when it comes to preventive oral health, they may be among the smaller problems.

The advice is familiar: brush and floss regularly, use fluoride mouthwash, limit snacks and sweet drinks, visit the dentist twice a year. Good suggestions, even if not everyone follows them: by age 12, 50 percent of children have cavities. But there are two much more serious problems, common dental diseases that can lead not only to loss of teeth but also to loss of life: periodontal disease and oral cancer.

Periodontal disease — a chronic bacterial infection of the gums that destroys the bone and tissues that hold the teeth — is the leading cause of tooth loss in adults. Some people are genetically susceptible, and the problem can be aggravated by smoking, taking certain medications, stress and other factors.

Several studies have found that gum disease is associated with an increased risk for heart attack. “It isn’t nailed down yet,” said Dr. Martin J. Davis, professor of clinical dentistry at the College of Dental Medicine at Columbia, “but there seems to be a link between the inflammation of gums and the inflammatory markers of heart disease.”

It may be that oral bacteria enter the bloodstream, attach to fatty plaques in the coronary arteries and cause clots to form. Or maybe inflammation itself increases plaque buildup. A 2007 study showed that periodontal disease increased the risk of heart disease in men by one third and doubled it in women, even after controlling for smoking.

Studies also suggest that gum disease is associated with the risk for stroke, altered glycemic control in people with diabetes and adverse pregnancy conditions like pre-eclampsia (pregnancy-induced high blood pressure), low birth weight and preterm birth. When periodontal disease is treated by reducing inflammation and lowering the quantities of harmful bacteria in the mouth, it can have a major impact on inflammation in the rest of the body.

Oral cancer is the second serious dental problem. It afflicts about 34,000 people a year and kills 8,000. Dr. Michael Kahn, a professor of oral pathology at Tufts University, compares oral cancer with the 11,000 cases of cervical cancer that are detected by the 60 million pap smears administered every year. “A person dies every hour around the clock from oral cancer,” he said, “yet it’s a struggle to get insurance to cover any of the new screening tests. It causes at least twice as many deaths as cervical cancer, but we’ve paid for pap smears — which have reduced cervical cancer by 90 percent.”

Smoking and alcohol abuse are the major causes, but 25 percent of oral cancers appear in people who have never smoked or drunk to excess. The suspected cause of at least some of these cancers is human papillomavirus, or H.P.V., the same sexually transmitted virus that causes most cervical cancers, which can invade the mouth during oral sex. “Some are already hypothesizing that if kids are inoculated against H.P.V.,” Dr. Kahn said, “there will be a turnaround in the oral cancers caused by H.P.V., too.”

For now, prevention, screening and early treatment are crucial to lowering the death rate.

The first sign of oral cancer is often a tiny white or red spot in the mouth, but the disease can be detected before a sore appears. In the last two or three years, manufacturers have produced noninvasive devices for detecting abnormal tissue that may be invisible to the naked eye, and some dentists are beginning to use them, even though their effectiveness remains controversial.

“The literature says they work,” Dr. Kahn said. “Some would like more or stronger evidence, but for others, they’re convinced. In dentistry, you don’t have much time to look. The theory is that if you use one of these devices, it gives you some additional help.” If a dentist finds a suspicious lesion, Dr. Kahn recommends referral to an oral pathologist as the next step.

There is more to good oral health than conscientious brushing and flossing, even though they remain important. “You have to take care of your mouth like any other part of the body,” Dr. Davis said, “because it’s linked to the rest of the body.”