Having a great smile is where dental health begins and ends for many. That’s a big and short-sighted mistake. Yes, a good smile is a great place to start, but it’s only the beginning. Oral health, which covers a lot more than just teeth, is critical to a person’s overall well-being. Dr. Errine Kennedy, in fact, recently connected with WellWell to warn that overlooking oral health can amount to a death-defying risk. An expert spokesperson for the American Dental Association, she told WellWell just what those risks are and what can be done to minimize their damage to keep everyone smiling. Read on.
What’s the status of dental health in America in 2024? Are we doing a good job?
That’s a great question. And actually, we recently had an oral health in America report released and so we have a lot of updated information about what’s going on with oral health across different regions of the United States. The vague answer that I can give you is that it’s improving for some groups, but it’s not improving for all and we have oral healthcare challenges for some groups that make it incredibly challenging to continue to receive care for the first time.
We are an aging population. It still blows my mind today that we will have more older adults aged 65 and older in 2035 than we’ll have children. We are also a more diverse population and we are a more digitized population, which can have advances but also challenges for patients. Of older adults 65 to 74, only 13 percent are edentulous (complete loss of teeth). This is fabulous because in 1960 about 50 percent of this age range of adults were completely edentulous, meaning they were wearing dentures. However, we still have patients who are having challenges in certain demographics accessing dentures. And why has this happened? Well, for many adults prevention has increased due to community water fluoridation or having access to healthy food. Also, we see prevention increase when they’re in a school-based system or through their dentist. Our restorative materials have improved. I’m blown away by the profession of dentistry because we continue to advance. We even have new options. We’ve had dental implants for a long time, but they’re becoming more and more available to many different adults, which has changed access to care for edentulous patients.
However, 13 percent of the population is still completely edentulous. They’re facing multiple extractions. They’re trying to access dentures, many adults will go without teeth in certain areas, and so have we made advances.
Which groups seem to be falling behind or not keeping pace? Is that a matter of access to dental care, or are there other factors involved?
There are a couple of different factors involved. If you are in a lower socioeconomic status, it is likely that you are not seeing a dentist regularly because of financial challenges. You may not have insurance that allows you to afford certain aspects of dentistry or you may not be able to find a clinician that accepts your dental insurance. The American Dental Association has created a resource called Find My Dentist and it’s been really helpful. It’s something that can help you if you are struggling to find a dentist in your area to receive care. Certain racial and ethnic groups also are underserved. This depends on the oral health outcomes that you’re looking at, whether you’re looking at untreated cavities in children or untreated cavities in older adults. But we continue to have Health Equity disparities when it comes to everyone receiving health care on a regular basis. And by healthcare, I include oral healthcare.
What do we see as dental care coverage in terms of insurance in this country? Is it getting worse or better?
Well, there are some challenges when it comes to dental insurance. It’s different for adults versus children. So, in children, about 50 percent of the population have private dental benefits typically through their parents or their employer. Another about 38—almost 40 percent—have Medicaid or CHIP. That’s the Children’s Health Insurance program. Then there is a group of about 10 percent that have no dental benefits for their children in the United States. For adults, that landscape is very different, about 59, almost 60 percent have private insurance. Those are adults who are employed by an employer that provides dental benefits. Not every employer provides medical and dental benefits. About 7 percent have Medicaid dental benefits and about 6 percent of adults have Medicaid coverage, but they do not have dental benefits with that. So that means that they have health insurance through Medicaid, but they do not have a dental benefit. And then about 27 percent of those adults are currently without coverage. So that means one in three adults that you encounter when they go to a dental visit, are paying cash. As you can imagine, that could be a barrier for some adults receiving care. If you don’t have that dental insurance benefit, it may be challenging for you to access care and to be able to work through a payment plan.
Is there a difference between dental care and oral health or are they used interchangeably?
The term dental care is focused on your teeth. My focus and our focus as a profession is really to shift to oral healthcare because that focuses on the human being attached to the dentition. The oral cavity is the start of your digestive system. And so not only is your mouth connected to the rest of your body, but the way that we educate our students is to treat you as a whole person. So, looking at your medical history, looking at your social history, helping you identify challenges, and receiving great oral healthcare when you’re outside of the dental office. And it also shifts the focus to the medical management of disease in the last 40 years. The profession of dentistry has changed. We have become more minimally invasive. We have focused on less surgical treatment and more medical management of disease. In turn, we’ve shifted our focus and our focus was always prevention, but we have new resources and new data that will allow us to practice preventive dentistry in even more minimally invasive ways. I really think that the term oral healthcare helps us realize and remember we’re treating and looking for your whole oral cavity.
Oral care has a wider impact on your health. We are seeing it tied to heart disease, diabetes, pregnancy risk, dementia and cognitive abilities as you get older. How are they all connected?
What we have to understand about our oral cavity is that the inflammation that might be seen as a result of tooth decay or periodontal disease contributes to inflammation systemically. And that is often the connection between oral healthcare and how healthy your oral cavity is and the rest of your body. In addition to inflammation, we are learning more and more about your oral microbiome. There’s nothing I get more excited about than talking about the good bugs and the bad bugs and your oral cavity and how your saliva contributes to this microbiome. When you have gum disease that is left untreated and those pathogens or bacteria are below the gum surface and, they’ve not been treated either non-surgically or surgically, we found that that exacerbates diabetes. And when you have your blood glucose levels under control, it allows your body to have less inflammation and it contributes to the healing of periodontal disease. What does that mean for a patient? It means that controlling your blood glucose and working with your endocrinologist to control your chronic diabetes is incredibly important. Alongside working with your dentist to make sure that the microbiome of your oral cavity and your gum disease are treated as well. For Alzheimer’s, the same thing is true. We know that periodontal disease contributes to Alzheimer’s. We’ve also found that some of these same bugs contribute to heart attacks and strokes. They have found oral bacteria that are pathogens for cavities and gum disease and some of the plaques that cause heart attacks and strokes. They’ve even found connections when it comes to children with asthma. So, understanding the inflammation in your body and more importantly, the microbiome that’s contributing to that inflammation is what’s so important. That’s why it matters that we clean our teeth every day, brushing, cleaning in between our teeth and maintaining that oral cavity by eating healthy foods.
Is there a growing awareness of the greater impact of dental care and oral health on people?
I do see a greater understanding. I’m working in a college of dental medicine and we’ve changed our curriculum in the last couple of years to include a more broad, systematic approach and when we train dentists differently, we’re also training our college of medical students differently. And in the process of doing this, we’ve learned about all of the community partners that are helping. So today there’s a new oral health education that’s in schools that helps children understand the impact their oral health has on their overall body. We have oral health education that’s in community centers and with community events. We have oral health education that’s in long-term care facilities. So, this is completely widespread in every corner of the United States, which is the population that we’re referring to today. Have they all received this information yet? No. But do I see the start of this grassroots campaign? And do I think in three to five years it is going to be common knowledge that the benefit that you have when you have good oral health is that your whole body will be healthy? Yes.
Do you see that connection growing or do you wish it were higher?
I always wish it were higher. Again. I’m aiming for that ideal, but I will share with you a couple of examples of what I see working. One, we’re starting to include oral health education in so many different health professions, curriculums and programs…I see education changing and then I also see practice changing. Before I was at the College of Dental Medicine, I worked in a department at Massachusetts General Hospital where I worked alongside about 10 other dentists at the time. However, we worked closely with pharmacists, OBGYNs, primary care professionals and behavioral health clinicians. We were all working together. We didn’t just learn IPE or interprofessional education, we practiced it. And the best example that I’ve seen so far, honestly, and this is just my opinion, is a lot of OBGYNs, obstetrics and gynecologists, these Women’s Health centers and federally qualified community health centers are often placing dentists in the OBGYN office so that they are able to care for expecting mothers and women, prenatal, perinatal and postnatal. They’re also able to care for children that are born very quickly. It’s recommended today that you have an exam for your child by their first tooth or their first birthday. So. It’s easy to remember.
Why is it so critical for women, in terms of prenatal and postnatal care?
I’ll give 2 examples. One is that we know that women who care for their oral cavity during pregnancy are one of the ways to care for their baby. And we know this because there are years, decades of literature that show that if you have periodontal disease and you’re carrying your child, you are at risk for a low-birth-weight baby, which can put your child at risk when they’re recovering and you’re recovering after birth. The second piece is that we know that the child receives the majority of their microbiome from their closest caregiver. So, when a child is birthed, they are exposed to bacteria through the birthing process, whether it’s a cesarean section or whether it’s a natural birth or delivery. And after that, their microbiome diversifies or gets more complex and has a bunch of different bacteria, mostly between 0-3 years old. And it’s because they are being exposed to good bacteria. We want bacteria in our mouths. We just want them to be good bacteria from their mother or their closest caregiver. And then also from their environment. You see children picking up and putting things down and eating all sorts of different foods which fuel your microbiome. So, if we want children to have the best leg up or the best success for a healthy oral microbiome that they can maintain throughout their entire lives, they’re going to receive that from their closest caregivers. And the closest caregiver is different in every family. That child may spend a ton of time with the mother. They may spend a ton of time with the father. They may spend a lot of time with their grandparents or an aunt or an uncle or a nanny. So, encouraging and promoting healthy oral health behaviors is really for the village or the group that’s caring for that child.
During the pandemic, we saw a lot of video healthcare and it has continued. How has that impacted oral healthcare?
It’s actually improved oral healthcare, I think. I was one of the first adopters of teledentistry in my practice when I was in Massachusetts, during the pandemic. We used it for a couple of different things that we were able to triage if there was an urgent condition or a pain or swelling for a patient. Either you provide medication or get them scheduled for an appointment. We are also able to do oral health or oral hygiene coaching so we can provide some preventive resources. Health education using telemetry platforms helped with access to care, especially for anyone who is traveling from great distances during that time. Since the pandemic that’s exploded. Now there are entire companies that have dental hygienists that come in and provide preventive services. They also take a ton of collective information during the exam, using photos videos and charting that they can share with the dentist. The place that I think has been so incredibly revolutionary is one that I’ve seen while I’ve been here in Missouri. It is a telehealth program through Freeman Hospital. This program uses telehealth stations to go into K through 12 schools where if a child comes and has an earache or toothache or some sort of condition, they’re able to use this telehealth resource to communicate during the school day with the clinician that’s most appropriate for treating that condition. If medication is needed, they’re able to communicate and have consent from the parent and they’re able to call that medication into a pharmacy so that the child doesn’t have to miss school and the parent doesn’t have to miss work. It kind of makes that process completely flawless.
Americans spend $4 billion a year on toothpaste alone. When you think of toothpaste, you think of whitening, you think of veneers. Is the emphasis on having beautiful teeth misguiding people on what dental healthcare should be?
There is nothing more beautiful than your enamel. I tell that to every single patient. Your enamel is such an incredible material. It’s the hardest substance in your body. It can be completely remineralized if a lesion or cavity is caught. And it’s translucent. It’s beautiful. So, it’s OK to want to improve the aesthetics of your enamel in any way. But I always remind my patients the enamel that you’ve been given is absolutely beautiful. And it’s my job to help you protect and preserve it. I say that because some things are aesthetic and also help prevent disease, and I’m going to give the example of whitening. If you go to your dentist and you have whitening trays created and you put the gel in to whiten your teeth in the evenings, this active ingredient for most of those whitening products is carbamide peroxide. This has actually been shown in studies to help increase the pH of your oral cavity, which shifts the microbiome and helps prevent cavities and gum disease. And so that’s a really great example of something that, yes, it’s an aesthetic treatment, but it’s also helpful in shifting your microbiome and improving disease long-term.
What do we need to do personally to maintain oral healthcare beyond just brushing our teeth and flossing?
I put it in three buckets habits. Treatment, diet and nutrition. It’s important to establish a dental home and see a dentist regularly. The interval at which you see a dentist is based on your risk for various diseases. If you’re at a higher risk for developing tooth decay, your dentist may request to see you more frequently so that they can provide some of those minimally invasive treatments that I talked about. Then there’s the habits portion. This is what you’re doing every day, so brushing is really important, but it’s important because we’re aiming to reduce and shift the microbiome and harness the active ingredients that are in toothpaste. It makes me laugh how much we spend on toothpaste, but it’s because there are so many good ingredients in toothpaste that you might want to look for. One of the things I look for in my toothpaste is something called arginine. It’s an amino acid that’s naturally found in your body and what it does is it actually fuels the good bacteria in your mouth and helps them grow. And when those commensal bacteria, those good bacteria grow, they basically are in competition with the bad bacteria and those bad bacteria are not going to thrive in that environment. So, arginine is this really healthy way to boost your microbiome.
Additionally, look for fluoride. Remember when I said enamel is the most beautiful thing in your body and it’s just absolutely the fluoride that helps to reinforce and strengthen your enamel to prevent tooth decay in the future? Fluoride also impacts your microbiome. It actually makes it challenging for pathogenic bacteria to thrive. There are two other things that are helpful in toothpaste, sodium bicarbonate, which is just baking soda. Baking soda raises the pH of your mouth and helps your microbiome stay healthy. So, anything that has baking soda in it is always a good idea. And then xylitol is a really good example of a non-fermentable sugar. You may see this in sports drinks, you may see it in little packets that you may put in coffee. Sometimes it’s in candies and gum. But xylitol can also be in your toothpaste. It gives a sweet taste to the toothpaste. Xylitol basically kills off those bad bacteria because they cannot digest this sugar. So, xylitol is something that can be really helpful in toothpaste. Now, I’m going to give you a tip that a fabulous mentor of mine, Doctor Brian Novey, taught me. And it is to leave the foam alone. So, when I teach kids how to brush their teeth, we usually do it together and we use this circle motion and we point the bristles up towards our gum tissue so that it massages the gum tissue and helps remove the plaque or the microbiome that’s on your teeth. And then afterward, when you spit your toothpaste out, you would have little bubbles that look like they’re bubbling. Like you just did a chemistry experiment in your mouth. You want to leave those there. You don’t want to rinse them off because all of the good ingredients that I just shared with you are now doing their good work in your mouth. You want to leave those on as long as you can.
What about cleaning in between your teeth?
When you’re working with your dentist, someone likely told you to floss. There are different ways to clean in between your teeth today, and I think we’re acknowledging that. Your oral hygiene habits are personalized, so with my patients, I give them a bunch of different options. I let them know that they can floss in between their teeth daily. They can use interdental picks or the little brushes because sometimes that makes it a little bit easier depending on how your teeth are rotated or how close they are together. And then the fourth is a water flosser or a power flosser. These are filled with a liquid that can irrigate in between your teeth. Any of these will work. You want to consult with your dentist, your dental home and your dental hygienist on what might work best for you based on some of the challenges that you’re facing with oral health. That’s so important because when you brush, there are areas in between your teeth that cannot be accessed by a toothbrush.
Is there anything else we should be doing in terms of dental care?
People talk about using mouth rinse. Mouth rinse is helpful, but you want to make sure that it’s a pH-neutral mouth rinse so you can ask your oral healthcare team to help you identify one of those. But we have to be careful with broad-spectrum antimicrobial mouth rinses. There are bacteria on your gum and on your tongue that help regulate blood pressure. The body releases nitric oxide and they are fed when we use things like arginine or green leafy vegetables or lean proteins, and it helps us maintain our blood pressure. If we use broad spectrum mouth rinses, it’s been shown to kill those bacteria on the tongue or get rid of them, and we don’t want to get rid of all the good bacteria and so, that’s why I always tell my patients to leave the foam alone. And if you do want to rinse at the end of brushing and flossing if you’re like, I have to be a person that rinses, one of the things I always recommend is using a little bit of baking soda, water or a pH-neutral mouth rinse. I share the baking soda example with a little bit of water because if you have a sensitive mouth and sometimes we have ingredients that make something taste good or feel good, sometimes some patients are incredibly sensitive, but having a little bit of baking soda, water, where you take one piece of teaspoon of baking soda and a couple of water, mix it around and then you can switch with it. Don’t swallow, but using that can be helpful.
How often should we see a dentist and does it change with age?
Historically, patients have been seen about two times a year. I would always start with that if you haven’t seen a dentist in a while. Find a dental home and then listen to your oral healthcare team member. When we look at patients’ risks the frequency of visiting a dentist has changed over the last few years. Even with cavities or tooth decay, there are recommendations where I’ve had some patients who were at such high risk that I needed to provide preventative treatments that could only be provided in an office every month. When I started their treatment plan, I saw that patient every month for the first few months to help them navigate the initial stages of controlling their tooth decay. Other patients may have never had a cavity or tooth decay in their entire lives. They may be at such low risk that a dentist may recommend that they only come once a year. And so now we understand that your frequency of visits is linked to your risk category for different diseases. But, as a default, oftentimes your insurance will recommend that you have a visit twice a year.
What is it that people need to think about or be aware of as a takeaway?
One thing I want to make sure that everyone understands is that your oral health is essential to your body operating optimally – your overall health. Focusing on caring for your oral health daily is incredibly important. Then there is bringing in more people into your team in person-centered care. You, the patient, are the center of that team. You may have different team members that are on your team. You may have a dentist, a dental hygienist or someone who’s helping you with therapy, whether you have headaches or a sore jaw. You may also have a primary care doctor who’s a part of that care team. You may have an OBGYN that’s helping you manage components of your pregnancy or menopause that are contributing to how you’re managing your overall health and your oral health. I think it’s important to realize that the patient is at the center. You’re the quarterback and it’s important to have a bunch of people on your team that can help care for you because we all want you to be healthy and we all want you to have a long life with a high quality of life.
About The American Dental Association
The not-for-profit American Dental Association (ADA) is the nation’s largest dental association, representing 159,000 dentist members. The premier source of oral health information, the ADA has advocated for the public’s health and promoted the art and science of dentistry since 1859. The ADA’s state-of-the-art research facilities develop and test dental products and materials that have advanced the practice of dentistry and made the patient experience more positive.
Please visit Kansas City University and the American Dental Association to learn more.
