Primary Care Dentistry, Airway, Inflammation, and Life Essentials

by Steve Carstensen, DDS, and Pat Mc Bride, PhD, CCSH

Within medicine, Dentists have the sole responsibility for preventive and restorative care of the hard tissue in the body that can’t repair itself. The teeth, which are supported by surrounding tissues, cannot and should never be treated as isolated units. There is a strong connection between whole-body health and oral health. So, this begs the question of how far away from the teeth, how deep into the supporting structures, and how connected must the body system(s) be, to fall outside the dentist’s consideration and care?

The American Heart Association (AHA) recently added Sleep to its healthy lifestyle meme, creating “Life’s Essential 8™”. This essay will look at the common connections between each of these essentials and show how the Primary Care Dentist (PCD) contributes to whole-body health, improve communications and co-collaboration with patients while providing customary dental care.

The “Essential 8” are aimed at improving cardiovascular health and lowering the risk of heart disease, stroke, and avoiding the negative quality-of-life impact any of these events cause.

Life’s Essential 8 are divided into two categories, Health Behaviors and Health Factors:¹

1. Healthy Behaviors
   1. Eat Better
   2. Be More Active
   3. Quit Tobacco
   4. Get Healthy Sleep
2. Healthy Factors
   1. Manage Weight
   2. Control Cholesterol
   3. Manage Blood Sugar
   4. Manage Blood Pressure

Healthy Behaviors: Eat Better

Dentists and their teams are in prime position to not only inquire about eating habits, but to advise and educate on nutrition and the effects of poor nutrition on the whole body. Most patients expect to be asked about sugar intake, as the the causal link between excess sugar and cavities discovered by Pierre Fauchard in the late 17th century is common knowledge. Overall US obesity rates continue to escalate. The Food and Action Center’s June 2024 publication notes that 42.4% of US adults and 19.3% of children are obese (BMI>30).² With most of our population being overweight or obese, normalizing BMI via mindful discussions including the increased risks and adverse system consequences of obesity such as diabetes, heart disease and sleep disordered breathing (OSA) must be included in the primary care dental setting. This is where dentists and their teams can add their professional voice to discussions of food choices. By expanding the conversation away from one which simply focuses on the adverse effects of sugar on teeth, to include information on how the whole body is impacted by eating highly processed foods. Illustrating the benefits of whole foods and how easily small changes in dietary choices can provide huge health benefits, the PCD can offer small (inoffensive) examples of good choices without feeling the need to become a nutritionist or offend people who are sensitive about weight.

A paper published in the journal Nutrients³ noted that almonds are shown to benefit cardiovascular health by decreasing systemic inflammation and affecting gut microbiome to increase beneficial biome populations and promote more efficient digestion. Nutrients such as vitamin E, fiber, and antioxidants which are concentrated in almond skins, aid the body to improve glycemic response in patients with type 2 diabetes (T2DM). Lower cholesterol and endothelial functional improvements have also been found with daily almond consumption. Since raw almonds are not cariogenic, the PCD can offer “real world” suggestions patients can easily relate to when making decisions regarding snack choices with solid nutritional benefits for whole-body health.

The value of healthy sleep has long been known yet this behavior was only added to the Essentials list in 2022.

Healthy Behaviors: Be More Active

Who doesn’t know that moving is better than sitting? Our patients need no reminder of the benefits of aerobic and strength exercise. If providers are observant, commenting on the Smart watch, Fitbit or any other wearables the patient has and if they use the fitness apps reveals much about their behaviors. For example, the PCD can link a better night’s sleep to having enough energy to take a walk, which for many people can be a starting point for a change in leisure habits from negative to positive for health.  Simply inquiring if a patient “counts their steps” or fills their activity rings on their wearable improves patient provider communications, promotes trust, and illustrates the PCD’s genuine care and concern for the patient and their daily lives. In Frontiers in Physiology, Guo, et.al, wrote about the link between exercise and inflammatory markers in obese and overweight populations.⁴ Their analysis of 22 studies including 1,135 subjects showed aerobic exercise reduces CRP (C-reactive protein) and IL6 levels (Interleukin 6), two markers of inflammation that affect the whole physiology. Strength training, which includes the use of weights, also reduces CRP, so a mix of activity (aerobic + strength training) will help people who list inflammation-linked chronic health conditions as part of their medical history and life challenges.

Healthy Behaviors: Quit Tobacco

Stopping smoking may be the single most important health change possible for your patients who struggle with the noxious addiction. The science behind nicotine addiction is clear, yet many people still do not realize cigarettes are as hard to quit as cocaine or heroin. It’s unimaginable that any smoker considers smoking a health benefit, but which motivator will prove to be the right one to facilitate smoking cessation is unique to each person. No one wants to age prematurely, so citing a study that shows smokers produce an enzyme that accelerates telomere shortening and induction of inflammation may help them see a way to decide to quit.⁵

Healthy Behaviors: Get More Sleep

Better sleep is why we are in the conversation, yes? How sleep relates to overall health is the subject of thousands of scientific papers, popular books and professional tomes. It’s why we started this magazine. Which bit of data is useful for the patient in your chair depends on your depth of knowledge and how you can apply it in a meaningful and mindful way. The value of healthy sleep has long been known yet this behavior was only added to the Essentials list in 2022. Welcome, I say! Sleep deprivation, whether it be from a lifestyle decision or a health concern interrupting normal physiology, is a major contributor to development and progression of various chronic inflammatory diseases.⁶ Considering that the quality of our health at any age is a result of accumulated physiologic challenges throughout all body systems, the soonest in life we can manage improvements in sleep quantity and quality will generate the best opportunity for optimum health span. The PCD is uniquely situated to partner with patients in their journey to better sleep by illustrating how simple changes to and in quality and quantity can exponentially improve overall health status and daytime functioning.

Simple suggestions to improve sleep can include the following:

• Stick to a sleep schedule. Waking at the same time every day is key.
• Gets some kind of exercise every day.
• Go outside.
• Avoid caffeine and nicotine.
• Do not take naps in the afternoon.
• Avoid large meals and alcohol before bed.
• Limit and turn off electronics at least 1 hour before bed.
• Create a cool, quiet, and dark sleep environment.

A primary care dentist engages the patient about why a tooth needed repair in the first place

Healthy Factors: Manage Weight

Dr. Robert Lustig, in a recent American Dental Association sponsored wellness program, Dentistry’s Role in Complete Health, pointed out the microbiology connections between obesity, caries, mitochondrial dysfunction, and T2DM. He pointed out differences in body fat deposits – some obese people are at lower risk of nonalcoholic fatty liver disease (NAFLD, an expression of chronic inflammation), while some thin people show no visible fat deposits but are sick with poor liver function. Managing weight is not just about how one looks, but how each body deals with energy balance. A non-inflammatory diet supports proper mitochondrial function, the baseline of our metabolism. Reduction in population NAFLD will lower the rate of T2DM and improve community health and decrease health care costs. In summary, fructose is very bad for health – watch your food labels. Ultraprocessed foods (look for many ingredients on the label) are always inflammatory.

Healthy Factors: Control Cholesterol

It’s pretty safe to say your patients know that high cholesterol is bad for their heart. Perhaps some understand that there is LDL (bad) and HDL (good) versions of cholesterol. The PCD has no time to get into the nuances of why that statement might be an incomplete presentation of a complex subject, but we are finding details that can help every health care professional provide important information useful to interested patients. We know that cholesterol is most dangerous in small-particle form, called Remnant Cholesterol, which targets organ damage through inflammatory pathways.⁷ Increasingly, PCD are exploring blood tests to uncover hsCRP (High-sensitivity C-reactive protein) as a marker for refractory periodontal disease. High levels of hsCRP are also associated with increased remnant cholesterol; while the PCD and dental hygienist discuss controlling oral disease, they can add value to needed changes by linking the effort to whole body health. Helping patients understand the link between hsCRP, poor oral health and periodontal disease is essential to this collaborative discussion.

Healthy Factors: Manage Blood Sugar

Glucose is necessary for our mitochondria; getting it from the digestive tract to inside the cells is a function of insulin. Uncontrolled blood sugar signals insulin resistance and decreasing ability to manage energy metabolism. This leads to a host of physiological problems, the most evident being obesity and T2DM. In turn, obesity increases chronic inflammation which leads to further insulin resistance. People who already have T2DM understand blood sugar very well; however, most people with unstable blood sugar may only feel symptoms easily confused with other sources, like hunger, fatigue, or anxiety. Careful review of patient intake or updated medical history is essential as many patients, especially those without health insurance, who do not have PCP’s or go to a physician unless they have an emergent situation. As you discuss general health issues, an inquiry about fasting blood sugar tests reveals your patient’s awareness of their individual health status and can improve discussions connecting overall systems issues to oral health. A history of Metformin prescriptions can be another clue, however, it is essential that the PCD be knowledgeable regarding current trends in “off label” Metformin use in medically managed weight loss for non-diabetic patients. Metabolic syndrome, a collection of sugar metabolism dysfunctions, also produces neuropathological issues like Alzheimer’s disease by affecting adenosine receptor signals in the brain, producing changes that no one wants to live with.⁸ Helping your patients understand that insulin resistance can lead to brain damage and loss of quality and quantity of life may help motivate them to improve diet choices.

Healthy Factors: Manage Blood Pressure

Less salt, right? Lower stress? What else is there, any patient may ask when queried about a high blood pressure reading during a routine PCD preventive visit. “Traffic was terrible, Doc” they might say. Hypertension falls in the category of disease that would be better if there were some symptoms to raise awareness in those who suffer from this challenge to health. They call hypertension a silent killer for good reason. Would it surprise you that research is showing a major contributor to chronic hypertension is gut microbiome dysbiosis?⁹ There is an enormous curiosity in physiology research around the role our digestive tract symbiotic microorganisms play in our overall health. Causative connections are being uncovered about contributions the gut microbiome and the immune system make to exacerbate hypertension and cardiovascular disease, and to mitigate them. When proinflammatory diets are the choice, high blood pressure can be an uninvited guest. The PCD, while discussing hypertension, can explore what the patient understands about how pre- and probiotics can help establish gut microbiome health and promote symptom relief easily felt by long-suffering patients. While these supplements are not proven with randomized controlled trials and individual responses vary widely, they are low risk to trial and often show remarkable effectiveness in a wide spectrum of patients.

Inflammation is a body’s generalized response to a stressor. When we can control the stressors, we allow a response towards homeostasis, our best condition for health. As part of primary care, the dental team who takes the time to learn, to communicate, and to support lifestyle choices towards health in our patient population will become increasingly important in the mission of improving healthspans. If you look back at the American Heart Association’s “Life’s Essential 8” you will find a common link to systemic inflammation. A dentist’s surgical repair of a decayed tooth is a necessary health service. A primary care dentist who engages the patient in an ‘upstream’ discussion of why that decayed tooth needed repair in the first place will be a better co-discovery partner during that person’s health span. Patients who wish to sleep and breathe better at night or have been diagnosed with OSA might request a mandibular advancement device from the PCD, or a positive air pressure system provided through their PCP or Sleep Medicine MD. Providing these non-invasive therapies manages symptoms in the short term; the discussion of the upstream ‘why’ can lead to patients making changes in their overall health, which could provide resolution of those issues. Dentists are trained to see the underdeveloped craniofacial respiratory complex; it’s time now for primary care dentists to see underlying physiologic challenges related to inflammation and point to different health paths that relieve downstream suffering for their patients.

Where Can the Interested PCD Turn for Learning?

Looking for education beyond traditional restorative dental lectures and workshops is the key. There are meetings and online conferences focusing on whole-person wellness sponsored by such groups as American Academy of Physiologic Medicine and Dentistry (AAPMD.org) and American Academy of Oral Systemic Health (AAOSH.org), two non-profits dedicated to enhancing health, mostly by training dental teams, with enthusiastic participation of dental hygienists, physicians, physical therapists, speech language pathologists, and functional medicine practitioners. Websites such as the American Heart Association and TED talks supply inexhaustible amounts of useful information much of which is in “small bites” so the PCD can learn new concepts easily and quickly.  Reading books by Robert Lustig, MD, Nathan Bryan, PhD, Susan Maples, DDS, Peter Attia, MD, Robert F. Barkley, DDS, and Alan Alda, among (many) others will raise the level of knowledge, awareness and exponentially improve PCD communication skills to turn complicated concepts into accessible and useful information to share. When the caring Primary Care Dentist knows their work and takes the time to know the unique individual presenting in front of them, then applies that knowledge in a way that is meaningful to that person, they can facilitate improved health choices made by the fortunate people they are privileged to serve.