Thanks to dental care for adults being omitted at the last minute from coverage under the National Health Insurance Law of 1994, most Israelis and many doctors are unaware of the firm connection between oral and body health.
“Say ahh” is a phrase commonly used by dentists and doctors during check-ups, asking patients to open their mouths for examination, according to the World Dental Federation. “It brings to life the notion of the mouth serving as a mirror to the body and reflecting overall health. We want people to understand the mouth and body connection because the more informed they are about the impact of oral health on their general health, the more likely they will be to engage in preventive oral care routines. It’s never too early or too late to start looking after your mouth; your body will thank you.” The federation established in 2007 its annual World Oral Health Day (WOHD) on March 20, but due to lack of awareness or involvement by the Israeli health authorities, it is not well known here.
WOHD, dedicated to raising global awareness on the prevention and control of oral diseases and making the connection between oral health and general health and well-being. It is the largest global oral health campaign; each year, it focuses on a specific theme and reaches out to the public, oral health professionals and policymakers, all of whom have a role to play in helping reduce the disease burden.
For the past two years, Jerusalem pediatric dentist Dr. Ari Kupietzky has been secretary-general of the International Association of Pediatric Dentistry (IAPD), which is based in Geneva. In the absence of state participation in WOHD, he volunteered to bring it to public attention and agreed to an interview with The Jerusalem Post.
The American-born dentist, who is married and has seven children and many grandchildren (who have healthier teeth than most), earned his dental medicine degree at the Hebrew University-Hadassah School of Dental Medicine in Jerusalem and a master of science degree in pharmacology from HU-Hadassah’s Medical School where he is a faculty member. He is also a visiting professor at Rutgers University in New Jersey.
The IAPD brings together some 15,000 dentists who treat children and teens in 69 countries, including Arab countries such as Kuwait, Iran, the United Arab Emirates, Egypt, Morocco and Saudi Arabia (which joined just last year). Founded in 1969, its serves as forum for the exchange of international information on pediatric dentistry; contributing to the progress and promotion of children’s oral health; to encourage research in the field; and to arrange scientific meetings. As every country has one vote, and the organization remaining apolitical he faced no difficulty in becoming secretary-general.
As secretary-general, he travels to Geneva at least once a year, but there are global summits, such as one due to be held soon in Bangkok on Early-Childhood Caries (cavities), and regional conferences in South Africa, Russia, Turkey and Holland. Kupietzky will lead an educational workshop – teaching the teachers – in Nairobi.
IN THE past, if a physician diagnosed diabetes or heart disease in a patient, he would be unlikely to refer him to a periodontist – a dentist who specializes in the prevention, diagnosis, and treatment of gum disease and oral inflammation.
Years ago, a physician who suspected heart disease, diabetes or almost any chronic disorder would probably not refer the patient to a gum specialist. The same is true for pregnant women. But today, things should be different, as medical research has identified the interaction, both ways, between poor dental health, especially of the gums, and bodily diseases. Studies have shown that patients with serious periodontal disease are 40% more likely to have a chronic condition in their bodies as well.
Oral diseases affect an estimated 3.9 billion people around the world, while chronic diseases kill 39.5 million people each year.
Gum infection and chronic inflammation result from bacterial buildup – plaque – on the teeth. The body’s immune system tries to combat the infection, but if it is too widespread, inflammation continues unless until the infection is overcome and produce chemicals that damage the gums and ligaments that hold the teeth in place.
The connection between type-2 diabetes and inflamed gums, said Kupietzky, is probably the best-proven and relentless connection between oral and body health. Periodontal disease can trigger diabetes and make it hard for the body to use insulin, while diabetes can cause gum inflammation. But controlling blood sugar in diabetics can improve the condition of gums, and treating periodontitis can improve their sugar balance.
As for the cardiology-periodontitis link, researchers have found that the vast majority of people with heart disease have chronically inflamed gums – many more than those without heart disease. This is not surprising, as smoking, overweight and a junk-food diet are shared factors in both conditions. Nicotine causes blood vessels to contract, making it harder for the mouth to fight infection. It also seems that inflamed gums trigger inflammation in the blood vessels, thus making it more difficult for oxygen-rich blood to reach the heart and the brain. This condition raises the risk of cardiac infarction and stroke.
Women who have become pregnant or intend to have a baby are advised to go to their dentists for checkups and treatment, if necessary, as oral infections and periodontal problems can slow the development of the fetus and even result in low birth weight and various chronic physical and even developmental conditions.
Even poor bone density – osteoporosis – which affects mostly women – can promote erosion of the jawbone and resultant tooth loss. Researchers are also looking into the suspected connections between periodontal disease and kidney disease, obesity, pneumonia, chronic obstructive pulmonary disease and rheumatoid arthritis.
AS FOR pediatric dentistry, Kupietzky said the specialty faces many challenges. In many countries in Europe, it is not even recognized because of politics and turf wars, he explained. It was started in the US in the 1940s, he said. It is recognized and taught in Israeli dental schools, and there are some 150 pediatric dentists around the country.
“Dentists here study 3.5 years beyond their dental school graduation to become pediatric dentists. I wanted to treat the whole person and not just the tooth. Pediatric dentistry is quite different in emphasis and treatment than in adult dentistry. Children’s teeth grow and develop. We also know how to treat special-needs children who have difficulty sitting still in the dental chair. Caries prevention and management are also crucial because babies can get caries soon after getting their first tooth around the age of six months. All you need is a ‘host’ (the tooth), bacteria and a ‘substrate’ (food), and a baby can develop cavities in his/her teeth.”
Baby-bottle tooth decay (now named “early childhood caries”), in which parents give a baby a bottle of formula or juice (but not plain water) that they keep in their mouth while falling asleep, has been recognized as a socially transmitted disease. A mother might “disinfect” a pacifier that falls on the ground by putting it in her mouth, but this does not kill the bacteria; instead, the parent transfers her own microbes into the baby’s mouth, and they can proliferate. In addition, when the bottle teat is held for hours in the mouth, the bacteria spread, ferment sugars, secrete acid and decay the teeth.
There are toddlers who have lost all their baby teeth from bottle tooth decay and have had to undergo extensive dental surgery under general anesthesia, and in very rare cases ending with fatal results.
The key to proper brushing is how long you do it – at least two minutes. “We recommend an electric toothbrush, because it does more in the same time and is a novelty for the child.”
Kupietzky also recommends that toddlers move from a bottle (if not breastfeeding) to the cup at around the age of one. While early pacifier use is encouraged to reduce the risk of sudden-infant-death syndrome, their use should be abandoned by age three (“and until then, they should never be dipped in honey”). Sucking thumbs is more harmful than late use of pacifiers, as they are always available and result in prolonged sucking habits.
THE MAIN aim of pediatric dentistry is early prevention, continued Kupietzky. Unfortunately, there has been no comprehensive, nationwide survey by the Health Ministry or professional organizations of the prevelance of early-childhood caries within Israeli children under age five since 1992. A local study of Ashkelon children found that 57% of youngsters under the age of five have dental caries.
A study at well-baby (tipat halav) clinics found that at age two-and-a-half, an astounding 81% had been given a bottle of milk or juice in bed. A total of 27% had never had their teeth brushed. A US survey of pediatricians, said Kupietzky, found that 39% of the physicians were unaware of the fact that dental caries is a preventable, chronic infectious disease; the rate is probably higher here.
“We pediatric dentists put a lot of effort in preventing and stopping dental infections early. I devote 40 minutes to the first encounter with parents of babies who got their first tooth. I do this with the child on his back, facing the mother, who is knee to knee with the dentist. The child sees his mother, not a stranger. Gradually, he gets used to it and doesn’t fear going to the dentist, which keeps many adults and children away.”
A healthy mouth, he notes, allows you to speak, smile, eat, drink and perform other physical functions throughout life, and it can also boast social interaction and promote self esteem. But an unhealthy mouth can cause discomfort, pain, disease and lead to social isolation, lack of self confidence, lost school days and missed work days by parents.
He thinks of his specialty as providing a “dental home” for families. “You should bring your child to the dentist within the first year of life. The dental office is a place where the parents are educated and the child is treated. We show them how to brush their child’s teeth. Around the age of two or three years, there is a lot of dental trauma, as young children fall down and may hurt their teeth. I recall the case of two toddlers who collided in nursery school. One was a patient who had previously established a ‘dental home’ at our clinic, but the other had never been seen by a dentist before. It was much harder to treat the one who was unfamiliar with going to a dentist.”
Parents are usually unaware of the problem of mouth breathing, in which children don’t breathe through the nose. If this becomes chronic, it can lead to changes in facial structure, even a long face. A pediatric dentist can recognize at an early stage mouth breathing and refer the child to an ENT to check for enlarged adenoids or tonsils or a deviated septum, and in addition deal with resulting orthodontic problems early on.
Kupietzky suggests to grandparents that they make a gift of a visit to a pediatric dentist to their grandchildren on their first birthday.
“Many parents think that children who don’t yet have all their baby teeth have no reason to go to the dentist. Yet, baby teeth can be affected, and if they’re diseased, it can spread to their developing permanent teeth below or cause orthodontic damage.”
THE HEALTH Ministry’s failure to restore fluoride to the country’s water supply is regrettable, noted Kupietzky. It was cancelled in 2013 by then-health minister Yael German, who argued that nobody should be “forced” to drink something he doesn’t choose to consume (she ignored the addition of chlorine to potable water to prevent the drinking of microbes). But her successor, health minister and then-Deputy Health Minister Ya’acov Litzman hasn’t managed in almost three years to restore fluoridation, even though he has tried to reverse all of her actions and decisions in the ministry.
Kupietzky, of course, endorses fluoridation of the water supply, as “fluoride is the most democratic, egalitarian and efficient way of delivering prevention to the population, especially youngsters who benefit most. It is very inexpensive. The main benefit is that when children’s permanent teeth are growing in jaws, the fluoride in the water is incorporated into the developing teeth. If provided at the right level in the water, fluoride poses no harm. But a lot of people now consume filtered water and bottled water that contains no fluoride, which complicates things. If not given through the water or oral pills, there are topical fluoride in toothpaste and rinses, along with treatments in dental clinics. There is also transparent fluoride varnish painted on teeth. But fluoridation is the best, as it can reach all sectors, including children who don’t brush their teeth and are not taken to the dentist.”
As for the free program for basic dental care for children up to the age of 16 that was added by Litzman to the health basket at the cost of hundreds of millions of shekels a year, Kupietzky said it mostly stresses treatment of cavities but not prevention and, as the service is provided by subsidiaries of the public health funds, there are few if any pediatric dental specialists. “We offer a non-threatening environment where we teach the family about caring for their mouths. Pediatric dentists strive to be early interventionists and not only surgeons, as a tooth filling is only treating the symptom but not the cause which is the underlying dental disease.”