The Mouth Is More Than Just Teeth

MS3: I just saw a patient of yours, Mrs Sawyer. She is a 67-year-old woman with diabetes, hypertension, hyperlip­idemia—here for these problems. She also may have had a heart attack that was silent in the past, because that’s what your last note says. She had an abnormal ECG but never remembered having chest pain.

Dr G: Right. I remember that.

MS3: So she’s here today because of follow-up for those problems. Her A1c is less than 7; it was 6.6 recently. Her LDL cholesterol was 67. Her sugars run pretty good at home. Blood pressure is fine, below 130 over 80. She’s exercising at least a half hour every day. Eating well. Medications are fine—taking them well and no bad side effects.

Dr G: What else is important to check?

MS3: You mean, like health promotion or screening things?

Dr G: Right. Sure.

MS3: Well, the chart says she’s up to date on colonoscopy, immunizations, and PAP smear. I think that’s it, isn’t it?

Dr G: You really have a great fund of knowledge. Well, there’s one more thing to consider, something physicians can tend to ignore. I’m thinking of the mouth. (MS3 shrugs.) I’m thinking of her gingiva, or gums, and her teeth.

MS3: She has dentures on top. The bottom teeth look kind of rough.

Dr G: So why do I ask about the mouth?

MS3: Because you were a hygienist before you went to medical school?

Dr G: Very funny. Yes. And no. If she has poor oral hygiene, then what can happen?

MS3: She couldn’t eat very well?

Dr G: Right. So teeth need to function well to ensure good nutrition.

MS3: What if she’s not having any pain, and she is eating OK? I’m not sure what I’m paying attention to. Is there any other reason to pay attention to the teeth, I mean—to her oral hygiene?

Dr G: Excellent question. There’s some evidence that periodontal disease is connected to chronic inflammation, and chronic inflammation is connected to risk of coronary heart disease. There was a recent meta-analysis looking at this issue that found that the relative risk was somewhere around 1.30.1 Do you remember what that kind of risk means, in natural English?

MS3: I think it means a 30% increase in risk.

Dr G: Exactly. Now, is that important?

MS3: 30%? Is 30% important? Well, I guess it depends on how severe the condition is?

Dr G: So heart disease is serious? (MS3 nods.) Anything else that tells us about the importance of relative risk?

MS3: Sorry, I can’t think of anything.

Dr G: No, that’s fine. How about the prevalence of the condition?

MS3: Oh, OK. That’s right. So coronary disease is fairly common. And a 30% increased risk increase for such a common condition would then likely be important.

Dr G: Great.

MS3: But so what? I’m sorry; I didn’t mean it to sound like that. But, I’m just going to recommend flossing and brushing and send her to the dentist, right? Other than make sure that she is doing everything else to take care of her heart?

Dr G: What about her diabetes? The mouth is more than just healthy teeth. Periodontal disease in its mildest form, gingivitis, is a condition of inflammation of the gums that can also worsen her blood sugars. Of course, it goes the other way, too—her diabetes can worsen her periodontal disease.2 So, improving her oral hygiene will not only help her to maintain her teeth but also to improve her blood sugars or gum disease. So, next time you see someone like this— (MS3: Someone with a mouth, gums, teeth?)

Dr G: (smiles) Yes. Think of how the gingival are connected to the heart, to conditions like diabetes, to your overall health.

Wanda C. Gonsalves, MD, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor


  1. Humphrey LL, Fu R, Buckley DI, et al. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med 2008;23(12):2079-86.
  2. Mealey BL. Diabetes mellitis and inflama­tory periodontal diseases. Current Opinion in Endocrinology, Diabetes, and Obesity 2008;15(2):135-41.
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