Jo-Anne Jones is an international award-winning speaker and the president of an educational and clinical training company. Jo-Anne was selected as one of DPR’s 2013 Top 25 Women in U.S. Dentistry. The Elizabeth Craig Award of Distinction was presented to Jo-Anne in recognition of her exceptional and ongoing commitment to promoting the dental hygiene profession. Jo-Anne may be reached at jjones@jo-annejones.com.

Jo-Anne Jones

What’s the Connection Between Oral Health and Brain Health? Image courtesy of solvod/stock.adobe.com.


Conceptually, the oral-systemic link is not new. Existing research illustrates the undeniable association between periodontitis and other systemic diseases; however, this research has recently expanded into the potential interface of oral pathogens and the exacerbation of Alzheimer disease (AD) and Alzheimer disease–related dementia (ADRD). The prevalence of this fatal disease and its devastating impact on lives and families only strengthens the urgency of finding ways to fight something that presently has no cure.

We aim to recognize the incidence of AD and ADRD in the United States, to understand the biological pathway in which periodontal pathogens can exacerbate degenerative changes in the brain, and to identify the role of dental professionals in promoting the importance of professional and daily oral care to mitigate disease risk. Periodontal disease is treatable, and we are situated ideally to treat, educate, and promote evidence-based therapeutic interventions to sustain oral health and mitigate the risk of systemic disease.

The strong prevalence of AD has touched many of our lives. It takes an emotional toll that is almost impossible to articulate. We see our loved ones become someone so unfamiliar to us, making the loss even more devastating. The research on the connectivity between oral health and brain health is growing rapidly.

Before we delve into the research surrounding periodontal pathogens and the deterioration of brain health, specifically AD, we must understand the disease itself. AD and ADRD are progressive neuroinflammatory and neurodegenerative diseases of the brain. The disease was named after the medical doctor who first discovered it over a century ago, Alois Alzheimer.

Ranking as the seventh leading cause of death in the United States, AD is estimated to impact more than 6 million Americans. Those who are 65 years and older are most at risk, and by 2050, Americans living with the illness could double, barring any medical developments or cures.

AD is fatal, as there is presently no cure for the disease. The terms Alzheimer disease and dementia are often misunderstood. The brain changes associated with AD are the most common contributors to dementia, accounting for 60% to 80% of cases.

 Dementia is an overall term for a collection of particular symptoms, including memory loss and decline of cognitive skills.

Despite years of research, no one knows the ultimate cause. The deterioration within the brain leading to AD can begin many years before symptoms emerge. Early symptoms may include lack of remembrance of conversations, events, or names. As AD further progresses, impaired communication, disorientation, confusion, behavioral changes, and poor judgment become apparent. The continuance of damage into other parts of the brain eventually impacts organ function and motor skills, making simple activities, such as swallowing or walking, very challenging.

 AD is an all-encompassing neurodegenerative, insidious disease.

The pathologic pathway of AD has 3 major trademarks: the accumulation of β-amyloid plaques, neurofibrillary tangles, and neuroinflammation.

 The combination of β-amyloid plaques accumulating outside of neurons and the tangled strands of proteins inside neurons results in heightened inflammation and neuron death.

As periodontal disease develops, sulcular wounds in the epithelium serve as a portal of entry for pathogens to travel to the brain. Simple daily tasks, such as brushing, flossing, and even chewing, can access the portal of entry pathway.

, a leading culprit in the exacerbation of periodontal disease, being the link between these 2 inflammatory and degenerative conditions.

can colonize in the brain, causing damage to brain neurons and contributing to the production of β-amyloid plaques.6 Furthermore, toxic enzymes called gingipains are released by 

. Gingipains belong to a group of specific proteinases recognized as major virulence factors found in inflamed gingival tissues of individuals with periodontal disease. Gingipains have also been found in 96% of brain samples from deceased patients with AD and in the cerebrospinal fluid of living patients, according to study results reported in 2019 in 

The research revealed that the pathogenesis of AD appears to be directly related to both secretion and load of gingipains, resulting in neuronal damage.12 Of particular interest was the location of the concentration of gingipains; they were most prominent in the hippocampus, which is one of the primary regions associated with memory.

 The investigators also noted that the amount of gingipains tended to rise over time, suggesting a tipping point when dementia symptoms first begin.

At present, there are very limited pharmaceuticals currently approved to treat AD. The objective of present pharmaceuticals is to target the protein β-amyloid to reduce the amyloid plaques. However, this approach is not addressing the root etiologic pathway. A new breakthrough presently in animal studies is designed to inhibit gingipain invasion and resulting neuronal damage.13 Pretreatment of mice with gingipain inhibitors protected the hippocampal neurons from the neurotoxic impact of gingipains. In turn, this reduces the 

 Conversely, broad-spectrum antibiotics and specific β-amyloid medications did not protect the brain cells from the toxic effects of 

 These more recent findings suggest a new conceptual framework for both treating and mitigating risk for the disease.

As dental professionals, we are not powerless in our ability to make an impact on this insidious disease. Per the Scientific American, “poor oral health is both common and treatable and could lead to a new paradigm for prevention that includes optimal oral care.”

 Helping our patients understand the critical importance of optimal oral health is key. There are several initiative-taking strategies that we may employ.

Our risk assessments overlap with a variety of modifiable risk factors that exacerbate the progression of AD. This is where the intersection of prevention and education can reach the public in ways other health care providers may not. Taking medical history can be instrumental in educating patients on how these factors may elevate risk for AD and ADRD. Supportive science directs our attention to the fact that AD is associated with many systemic diseases and lifestyle behaviors. These include cardiovascular disease, diabetes, chronic inflammatory pathogens, smoking, and sleep patterns.

One person dies every 34 seconds in the United States from cardiovascular disease; it is the leading cause of death.

 The taking of blood pressure readings at a dental appointment is a powerful opportunity to uncover a silent killer—hypertension. Studies also illustrate that elevated blood pressure in middle age results in drastic increases in dementia risk later in life.

Chairside testing can play a vital role in prediabetes and diabetes diagnosis, which would have otherwise gone undetected.

 Point-of-care testing for blood glucose levels has become far more commonplace in dental practices. The American Dental Association added a current dental terminology (CDT) code, D0411, for chairside HbA1c, and in 2019, the association added CDT code D0412 to check blood glucose levels. Findings suggest that individuals with type 2 diabetes or a form of metabolic glucose disorder may have a predisposition for predementia or a mild cognitive impairment. In fact, individuals with elevated blood glucose levels, irrespective of diagnosed disease, have a faster cognitive decline rate.

 Research is also focused on a new type of diabetes, type 3, which is correlated with AD.

The reduction of the burden of chronic inflammation is integral to mitigating risk for systemic disease. A proactive treatment approach begins with adjusting the interval of care to meet the needs of the patient. The following may comprise part of our treatment plan:

Antimicrobial rinses (eg, chlorhexidine, povidone-iodine)

Laser decontamination to delay pathogenic colonization

Attainment of a balanced oral microbiome with oral probiotics

Lifestyle behaviors are also strong contributors to the disease process. Helping our patients understand modifiable risk factors can be very empowering and lead to more positive choices regarding behaviors. Smoking and its known toxins increase oxidative stress and contribute to inflammation known to be associated with AD. A 2017 study concluded that smoking increased the incidence of dementia later in life. Educating our patients of the association with AD and ADRD and directing them to smoking cessation programs is a tangible way to address another modifiable risk factor.

Dentistry has become far more proactive in identifying sleep apnea through identification of symptoms. Once assessed, the patient is 1 step closer to diagnosis and subsequent referral to a specialist. A 2013 study found that adults who experienced poor or fragmented sleep patterns were more prone to develop AD.

 Conversely, research has identified that healthy sleep patterns contribute to decreasing amyloid accumulation and increasing amyloid clearance from the brain.

Effective daily self-care strategies are imperative in reducing the oral inflammatory response and managing a healthy oral biofilm. As dental professionals, we wish to provide recommendations that are both effective and supported by strong science. It is a well-known fact that power toothbrushes deliver a statistically superior result than manual toothbrushes. Chairside trial programs are a powerful way to introduce patients to the benefits of power toothbrushing, clarify any misconceptions, and assist with proper technique. A literature search conducted in PubMed concluded that high-quality flossing is difficult to achieve. Ineffective flossing routines by much of the population are not providing any significant benefits over brushing alone. Interdental brushes are more effective than brushing alone and superior to flossing in widened embrasures. Oral irrigators hold the most promise for reducing inflammatory markers and accessing subgingival pocket depths. There are several innovative devices on the market today, and it is important to play a supportive role in the day-to-day oral care practices of our patients.

As dental professionals, we have the highest gratification any human being can have, and that is to serve others. There are many opportunities for dental professionals to play a part in diminishing the risk for AD and ADRD. Periodontal disease is treatable, and we are ideally positioned to raise awareness, educate, and promote evidence-based therapeutic interventions. 

Chronic gum disease may harm brain, joints and gut. 

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Dementia vs. Alzheimer’s disease: what is the difference? Alzheimer’s Association. Accessed February 2, 2023. https://www.alz.org/alzheimers-dementia/difference-between-dementia-and-alzheimer-s

Stages of Alzheimer’s. Alzheimer’s Association. Accessed February 2, 2023. https://www.alz.org/alzheimers-dementia/stages

Tom SE, Hubbard RA, Crane PK, et al. Characterization of dementia and Alzheimer’s disease in an older population: updated incidence and life expectancy with and without dementia. 

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Ryder MI. Porphyromonas gingivalis and Alzheimer disease: recent findings and potential therapies. 

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Kumar PS. From focal sepsis to periodontal medicine: a century of exploring the role of the oral microbiome in systemic disease. 

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Mei F, Xie M, Huang X, et al. Porphyromonas gingivalis and its systemic impact: current status. 

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As a veteran dental hygienist, recognized thought leader, and international, award-winning speaker, Jo-Anne Jones, RDH, has delivered more than 1000 presentations across Canada, the United States, and the United Kingdom. Jones is a 2021 Fellowship Award recipient with the International Academy of Dental Facial Esthetics. Jones is also a past recipient of the Elizabeth Craig Award of Distinction for her exemplary commitment to the dental hygiene profession. Additionally, she was nominated by Dental Products Report® as one of the Top 25 Women in Dentistry in 2013. Jones is a key opinion leader for many leading dental corporations across North America, including Philips Oral Healthcare.

Articles

The connectivity between the brain and the mouth is intricate, and poor oral health can lead to increased risk of degenerative diseases such as Alzheimer disease and Alzheimer disease–related dementia. 

What’s the Connection Between Oral Health and Brain Health?

	Xerostomia, or dry mouth, if not effectively managed, can significantly impact oral health and subsequently overall health. For a patient suffering with xerostomia, it’s so much more than simply a “dry mouth.”

	Unfortunately we’re not talking about a small segment of our population that’s affected by xerostomia. It’s estimated that as much as 65 percent of the population suffers from xerostomia,

 with the loss of saliva resulting in a devastating cascade of symptoms.

	Saliva is essential to the protection, lubrication and preservation of the oral cavity. Like a number of issues we experience in life, the benefit of adequate saliva isn’t fully appreciated until there isn’t enough. Subsequent oral discomfort can range from mild to severe and affect every facet of day-to-day living. The challenges of xerostomia can also present social implications by altering the ability to speak, swallow, chew and digest food. Furthermore, xerostomia has a negative impact on dental caries, plaque accumulation, gingivitis, periodontitis, candidiasis, oral infections, mucositis, burning mouth syndrome and oral lesions.

There are a number of etiologic pathways that initiate a xerostomic condition. One of the most common is medication-induced xerostomia.

	“Nearly 70 percent of Americans are on at least one prescription drug, and more than half take two,” say researchers at the Mayo Clinic and Olmsted Medical Center. “Twenty percent of patients are on five or more prescription medications,” according to the findings.

	There are more than 1,100 drugs, both prescription and over-the-counter (OTC), that contribute to or induce xerostomia.

 A number of these xerogenic drugs are the most commonly prescribed medications such as antihypertensives, antidepressants, antihistamines, antiacne, antianxiety, muscle relaxants and opioid analgesics. We see patients every day in our dental practices who are taking some of these commonly prescribed drugs.
	Head and neck radiation is also a contributing cause of xerostomia. Gray (Gy) is the unit used to measure the total amount of radiation the patient is exposed to. Typically, head and neck radiation for treatment of oral and oropharyngeal cancer is in the range of 45-70 Gy. In the majority of cases, Intensity-Modulated Radiation Therapy (IMRT) is practiced, delivering a precise dosage of radiation to the tumor with the objective of minimizing collateral damage to the surrounding tissue or salivary glands. 

Read more: 3M announces new clinical-grade xerostomia relief spray

	A mold of the head and neck area is made prior to the start of radiation therapy, referred to as a radiation mask (Fig. 1). The mask ensures that the head is held in the same position, so the radiation targeting can be exact. Despite best efforts, the end result is severe depletion of saliva - and that which remains becomes thick and ropey.  

	Another etiologic pathway is systemic disease, and in particular, autoimmune diseases. Autoimmune disease affects 5 to 8 percent of the U.S. population, 78 percent of whom are women.

 It’s the third most common disease category following cancer and heart disease.

	Sjögren’s syndrome, a chronic inflammatory autoimmune disease, is characterized by dry mouth and dry eyes. The disease is precipitated by lymphocytes leaving the bloodstream and infiltrating into the acinar glands. This migration results in degradation, atrophy and necrosis of the acinar glands, impeding the flow of saliva and tears.   
	“With upwards of 4,000,000 Americans suffering from Sjögren’s, it is one of the most prevalent autoimmune diseases, with nine out of 10 patients being female,” says the Sjögren’s Syndrome Foundation.

	Sjögren’s syndrome can affect any age group, but most patients are diagnosed in their early 50s. One of the first recognizable symptoms of Sjögren’s syndrome is xerostomia, which often precedes the actual diagnosis of the disease.

	Diabetes is yet another disease we see almost daily in private practice. With one in four Americans currently diabetic, it’s forecasted that “prediabetes will climb from 90.6 million in 2015 to 107.7 million in 2030.”

	This increased prevalence means that 30 percent of all Americans and 51 percent of all seniors would have prediabetes.

 Not dissimilar to a number of other systemic diseases, one of the first clinical manifestations of diabetes is xerostomia, often present prior to the diagnosis of the disease.   

	Moreover, diminishing saliva may simply be a sign of physiological aging. The U.S. Census Bureau estimates that by 2020, 54.8 million people will be over 65 years of age, and by 2035 there will be 78 million people - with one in five at retirement age. We clearly have a silver tsunami approaching.

	The goal of today’s dental professional should include comprehensive assessment of salivary flow, possible identification of causative factors, elevating the comfort level of the patient and the administration of preventive measures to avoid further oral complications. There are a number of conservative lifestyle changes that will assist the xerostomic patient who’s struggling with mild to moderate discomfort. These include reducing the intake of caffeine products, sucking on ice chips, sipping water throughout the day and with meals, avoidance of sticky, salty, spicy or hard foods, limiting alcohol intake, avoiding mouth rinses containing alcohol, chewing xylitol gum, or sucking on xylitol mints (Fig. 2), use of fluoridated or amorphous calcium phosphate toothpastes, using a humidifier at night while sleeping, and the use of lubricants on lips. Of utmost importance is regular preventive dental care and the use of fluoride varnishes proactively or extended contact varnishes on any vulnerable white spot lesions or exposed root surfaces (Fig. 3).

	Fig. 2                                                                               Fig. 3

	As dental professionals, we want to ensure that our recommendations are not only effective but scientifically supported. A 2011 Cochrane Review began with the following statement, attesting to finding “no strong evidence” that any specific topical therapy (e.g., sprays, lozenges, mouth rinses, gels, oils, chewing gum, or toothpastes) was effective for relieving the symptoms of dry mouth. Although chewing gum was shown to increase saliva production, there was no strong evidence that dry mouth symptoms were improved. The authors noted that “patient preference is an important consideration, together with consideration of the potential adverse effects.”

	The initial results of the Cochrane Review left the dental community with a sense of defeat in being able to recommend a product that would in fact deal with xerostomia effectively. Of further note, and of great importance in the same Cochrane Review, was the statement observing that “oxygenated glycerol triester (OGT) saliva substitute spray shows evidence of effectiveness compared to an electrolyte (or water-based) spray.”

Trending article: The top 5 dental discoveries of 2018

	Oxidized glycerol triesters (OGT) have a unique ability due to a lipid formulation to adhere and protect the oral cavity through increased substantivity. There are also studies published in professional journals that scientifically support the OGT technology and its elevated efficacy when compared to water-based solutions. A multicenter controlled parallel-groups trial to evaluate the efficacy, safety and acceptability of OGT spray versus a saliva substitute in the treatment of psychotropic medicines-induced xerostomia resulted in the following: after two weeks of use, patients reported that the OGT spray significantly decreased the initial:

	The vast majority of subjects attested to the fact that the spray had improved their dry mouth symptoms and their quality of life, and they wished to continue using the spray. 

	3M Xerostomia Relief Spray (Fig. 4) employs a lipid-based approach to lubricating and moisturizing the oral mucosa with the aforementioned, innovative OGT technology. The lipid-based formulation is insoluble in water, meaning it provides a protective film or barrier that moistens and lubricates with better adherence to the oral mucosa. The prescription-strength spray demonstrates much longer lasting relief, up to four hours, when compared to many other xerostomia prescription medications. 

	The streamlined ordering process is accomplished through the online pharmacy, Transition Pharmacy (TPS), which is registered in all 50 states. The prescription is initiated in the dental practice by completing a downloadable form available on the 3M site, followed by TPS contacting the patient for additional insurance and payment information. After the claim is processed, the product is shipped directly to the patient within a few days. TPS will also automatically remind the patient of the next month’s refill requirement.  

	Making treatment recommendations with the confidence to be assured of efficacy is integral to our day-to-day practice success. It’s also our ethical responsibility to consciously provide our patients with evidence-based recommendations. 

	As dental professionals, we’re situated on the frontlines of assessing, diagnosing and strategically managing xerostomia both chairside and with self-care recommendations. Are you speaking up for your patients who are suffering from xerostomia by initiating the conversation? A proactive conversation about the symptoms and the impact of xerostomia on both oral and systemic health stands to accomplish a great deal. It may be the initial awareness of a systemic illness that otherwise may have gone undetected or the proactive treatment of an oral condition that would have deteriorated quickly without intervention. We have the solutions to effectively elevate the comfort level of the xerostomic patient, so no one needs to continue to suffer in silence. It’s time to take action!

	1. The American Academy of Oral Medicine.  Integrating Medicine and Dentistry.  http://www.aaom.com/index.php%3Foption=com_content&view=article&id=107:xerostomia&catid=22:patient-condition-information&Itemid=120  Accessed November 2018.
	2. https://newsnetwork.mayoclinic.org/discussion/nearly-7-in-10-americans-take-prescription-drugs-mayo-clinic-olmsted-medical-center-find/ Accessed November 2018.  
	3. https://www.sjogrens.org/files/articles/QuickFacts.pdf Accessed November 2018.      
	4. Fairweather D, Rose, N, Women and Autoimmune Diseases Emerg Infect Dis. 2004 Nov; 10(11): 2005–2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3328995/ Accessed November 2018.
	5. http://www.sjogrens.org/ Accessed November 2018.      
	6. Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S.  Diabetes 2030:  Insights from yesterday, today and future trends.   Popul Health Manag.  2017 Feb 1; 20(1): 6-12.
	7. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html Accessed November 2018.      
	8. Furness, S., Worthington, H. V., Bryan, G., Birchenough, S., & McMillan, R. Interventions for the management of dry mouth: topical therapies. Cochrane Database of Systematic Reviews 2011, Issue 12.
	9. Mouly S, Orler, JB, Tillet Y, Coudert AC, Oberli F, Preshaw P, Bergmann JF. (2007). Efficacy of a new oral lubricant solution in the management of psychotropic drug-induced xerostomia. Journal of Clinical Psychopharmacology, 27(5).
	 

Why the time is now to initiate conversations with patients suffering from dry mouth.