research studies on oral health

The Oral Health in America Report: A Public Health Research Perspective

ESSAY — Volume 19 — September 8, 2022

Jane A. Weintraub, DDS, MPH 1 ( View author affiliations )

Suggested citation for this article: Weintraub JA. The Oral Health in America Report: A Public Health Research Perspective. Prev Chronic Dis 2022;19:220067. DOI: http://dx.doi.org/10.5888/pcd19.220067 .

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Introduction

Data needed, health disparities and social determinants of health, individual and community relationships, scientific advances and equitable distribution, educational opportunities, acknowledgments, author information.

In December 2021, the National Institutes of Health, National Institute of Dental and Craniofacial Research, released its landmark 790-page report, Oral Health in America: Advances and Challenges (1). This is the first publication of its kind since the agency’s first Oral Health in America: A Report of the Surgeon General described the silent epidemic of oral diseases in 2000 (2). This new, in-depth report, an outstanding resource, had more than 400 expert contributors. Its broad scope is exemplified by its 6 sections ( Box ), each of which includes 4 chapters: 1) Status of Knowledge, Practice, and Perspectives; 2) Advances and Challenges; 3) Promising New Directions; and 4) Summary. In this essay, I provide a public health research perspective for viewing the report, identify some advances and gaps in our knowledge, and raise research questions for future consideration.

Box. Section Titles, Oral Health in America: Advances and Challenges (1)

1. Effect of Oral Health on the Community, Overall Well-Being, and the Economy

2A. Oral Health Across the Lifespan: Children

2B. Oral Health Across the Lifespan: Adolescents

3A. Oral Health Across the Lifespan: Working-Age Adults

3B. Oral Health Across the Lifespan: Older Adults

4. Oral Health Workforce, Education, Practice, and Integration

5. Pain, Mental Illness, Substance Use, and Oral Health

6. Emerging Science and Promising Technologies to Transform Oral Health

A recurring theme in the report is the need for many types of data, from microdata — the molecular, nanoparticle level — to macrodata — the population and global level. Data are needed to guide public health policies and programs at the federal, state, and local levels. Future research using big data from multiple sources (eg, community health needs assessments, surveillance systems, GIS mapping, electronic health records, practice-based research networks) will provide timely, population-based information to evaluate and drive changes to policy and delivery systems and oral health advocacy efforts.

This new report includes descriptive national data from 3 cycles of the National Health and Nutrition Examination Survey (NHANES). To continue monitoring national oral health surveillance data and trends, oral health data need to be included routinely in NHANES and in other large national studies. Too often, questions about oral health are missing from surveys, or clinical oral health data are not collected. For example, very little about oral health was included as part of the planned data collection protocol for the National Institutes of Health All of Us Research Program. This program aims to collect health information from 1 million people (3). Local and state data are often outdated, incomplete, or unavailable. Most oral health data are cross-sectional and are useful for studying trends and associations, but population-based longitudinal data to study causality and the effectiveness of interventions and policies are sparse.

How does oral health care improve other health conditions? Proprietary claims data from insurance companies (4) show the inter-relationship between treatment of periodontal disease and systemic conditions, but secondary data analysis has many limitations and confounding factors. Clinical trials show that periodontal treatment improves glycemic control among people with diabetes (5), but long-term outcome assessments are lacking. We need more answers to convince policy makers and payers about the importance of including comprehensive adult oral health services in publicly financed programs such as Medicaid, which is currently lacking in many states, and Medicare, where those services are missing altogether.

Many examples of substantial oral health disparities and inequities are presented in Section 1 of the report. For some conditions and population groups, little improvement has been made, especially among adults and seniors. Section 1 also describes the adverse social, economic, and national security effects of poor oral health, barriers to care, social and commercial determinants of oral health, and related common risk factors. More than the clinical data collected in a typical dental history is needed to understand social determinants and employ local and upstream interventions. The report suggests obtaining social histories from patients to get information about where people live, learn, work, and play. For example, to learn about socioeconomic status, diet, and medications, we want to know not only “What’s in your wallet,” (as touted in a frequent television advertisement) but what’s in your refrigerator? What’s in your medicine cabinet? Telehealth has given clinicians a look inside patients’ homes. Collaboration with social workers, home health aides, and visiting nurses could inform us even more about the home environment. With integrated electronic medical and dental patient records, oral health professionals and medical colleagues can share information. Barriers to integration and assessment of population health outcomes affect many dentists who still use paper records or software specific to dental care that lacks diagnostic codes and interoperability with other health care records systems (6).

The report highlights the need for more information about adolescents and older adults and other understudied population groups. Section 1 describes many diverse, vulnerable populations (eg, people with special health care needs, low health literacy, mental illness, substance abuse disorders; victims of structural racism) who all need to be included in oral health research. Non-English speakers and hard-to-reach populations that have physical and/or financial barriers to traditional dental care are less likely to be recruited and represented in clinical trials, making results less generalizable and interventions less applicable. The applied research agenda being developed by the American Association of Public Health Dentistry (7) and the “Consensus Statement on Future Directions for the Behavioral and Social Sciences in Oral Health,” which is based on an international summit (8), are helpful in setting research and methodologic priorities, including qualitative, implementation, and health systems research.

Knowledge about the interrelationships between oral and systemic health has greatly expanded since the 2000 report. About 60 adverse health conditions have now been shown to be associated with oral health (1), which is part of the rationale for the integration of oral health and primary care. Research will advance our understanding of the mechanisms by which oral and systemic conditions are affected by upstream environmental and social factors, epigenetic factors, and the aging process, both individually and communally. For example, how do external exposures change our microbiomes? Our oral microbiome may be exposed to air containing Sars-CoV-2, water containing protective fluoride, or many kinds of food, beverages, medications, illicit substances, smoked products, and sometimes the biome of close personal contacts. How does the health of a community’s high caries risk groups change with policies such as a tax on sugar-sweetened beverages, Medicaid reimbursement changes, or health promotion efforts to improve oral health literacy and dietary behaviors? To what extent will increased application of value-based health care reimbursement with emphasis on disease prevention, early detection, and minimally invasive care improve oral health? Will the World Health Organization’s addition of dental products (eg, fluoride toothpaste, low-cost silver diamine fluoride, glass ionomer cement) to its Model List of Essential Medicines (9) increase their use to prevent and treat dental caries for under-resourced populations without access to conventional high-cost dental care?

The report’s Section 6 describes many exciting advances in biology, biomimetic dental materials, and technology. Rapid advances in salivary diagnostics are providing information about early, abnormal changes in remote organ systems in the body. Advanced imaging techniques and artificial intelligence can be used for early diagnosis of oral lesions before they are visible to the human eye. The validity and accuracy of these techniques need careful evaluation. Can these earlier clinical end points be used to shorten the length of expensive clinical trials? Guide new preventive strategies? At what point do providers intervene with early preventive or therapeutic strategies instead of letting the body heal itself?

Will populations at greatest risk for disease and the greatest barriers to accessing dental care be able to benefit from early intervention? Every intervention has a cost. If access to new prevention and therapeutic discoveries is not equitable, will health disparities worsen? We need community engagement in the research process and the tools from many disciplines to measure and facilitate the best outcomes. The national Oral Health Progress and Equity Network’s blueprint for improving oral health for all includes 5 levers to advance oral health equity: “amplify consumer voices, advance oral health policy, integrate dental and medical [care], emphasize prevention and bring care to the people” (10).

Who will analyze all these data mined from many micro and macro sources, and who will interpret the data? Health learning systems and complex software algorithms are being developed to provide automated diagnostic information. Data analysts with knowledge of these and other sophisticated tools and modeling approaches are needed.

The dental, oral, and craniofacial research and practice communities increasingly need to be part of interdisciplinary research and educational programs with opportunities for collaboration and learning. Federally qualified health centers and look-alikes are good sites for medical–dental integration, but many of these facilities do not provide dental care.

More positions are needed for dental public health specialists who can lead advocacy efforts, interdisciplinary teams of researchers, clinicians, and community partners and conduct research. For example, the new Dental Public Health Research Fellowship at the National Institute of Dental and Craniofacial Research will provide more intensive research training to further advance dental public health and population-based research. Mechanisms are needed to promote, facilitate, and reward sharing of research and training resources across disciplines in our competitive environment.

Public health perspectives are an important part of interdisciplinary approaches to guide, conduct, and apply research and implement policies to improve oral health. Preventive approaches exist as do barriers to their dissemination and implementation. To prevent disease and improve population oral and overall health, systems change and policy reform are needed along with scientific advances across the research spectrum, more population-level data and analysis, and community participatory engagement. I am optimistic that the next Oral Health in America report will describe fewer inequities and more progress toward oral health for all.

This article is based on a presentation made in the webinar, Oral Health in America — Advances and Challenges: Reading the Report through a Research Lens , sponsored by the American Association for Dental, Oral, and Craniofacial Research. The author received no financial support for this work and has no conflicts of interest to declare. The statements made are those of the author. No copyrighted materials were used in this article.

Corresponding Author: Jane A. Weintraub, DDS, MPH, R. Gary Rozier and Chester W. Douglass Distinguished Professor, University of North Carolina at Chapel Hill Adams School of Dentistry, Department of Pediatric and Public Health, Koury Oral Health Sciences Building, Suite 4508, Chapel Hill, NC 27599-7450. Telephone: (919) 537-3240. Email: [email protected] .

Author Affiliations: 1 University of North Carolina at Chapel Hill Adams School of Dentistry and Gillings School of Global Public Health, Chapel Hill, North Carolina.

• National Institutes of Health. Oral health in America: advances and challenges. Bethesda (MD): US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021. Accessed February 23, 2022. https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
• US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed February 23, 2022. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
• US Department of Health and Human Services. All of Us Research Hub Research Projects Directory. Updated 2/23/2022. Accessed February 23, 2022. https://www.researchallofus.org/research-projects-directory/?searchBy=workspaceNameLike&directorySearch=oral
• Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med 2014;47(2):166–74. CrossRef PubMed
• Baeza M, Morales A, Cisterna C, Cavalla F, Jara G, Isamitt Y, et al. Effect of periodontal treatment in patients with periodontitis and diabetes: systematic review and meta-analysis. J Appl Oral Sci 2020;28:e20190248. CrossRef PubMed
• Atchison KA, Rozier RG, Weintraub JA. Integration of oral health and primary care: communication, coordination and referral. Washington (DC): National Academy of Medicine; 2018. Accessed February 21, 2022. https://nam.edu/integration-of-oral-health-and-primary-care-communication-coordination-and-referral/
• Banava S, Reynolds J, Naavall S, Frantsve-Hawley J. Introducing the AAPHD 5-year research agenda. Presentation, National Oral Health Conference, April 12, 2022; Fort Worth, Texas.
• McNeil DW, Randall CL, Baker S, Borrelli B, Burgette JM, Gibson B, et al. Consensus statement on future directions for the behavioral and social sciences in oral health. J Dent Res 2022;101(6):619–22. CrossRef PubMed
• World Health Organization. Executive summary: the selection and use of essential medicines 2021: report of the 23rd WHO Expert Committee on the selection and use of essential medicines, virtual meeting, 21 June–2 July 2021. Geneva (CH): World Health Organization. Accessed April 9, 2022. https:// www.who.int/publications/i/item/WHO-MHP-HPSEML-2021.01
• Oral Health Progress and Equity Network. OPEN blueprint for structural improvement. Accessed April 22, 2022. https://openoralhealth.org/wp-content/uploads/2022/04/OPEN_FLS_BlueprintOverview_F.pdf

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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Introduction

The etiology and pathogenesis of dental caries, preventive strategies, caries risk assessment, anticipatory guidance, dietary counseling, oral hygiene, other important anticipatory guidance topics, collaboration with dental providers, social determinants of children’s oral health, conclusions, recommendations for pediatricians, lead authors, section on oral health executive committee, 2019–2020, liaisons, 2019–2020, maintaining and improving the oral health of young children.

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David M. Krol , Kaitlin Whelan , THE SECTION ON ORAL HEALTH; Maintaining and Improving the Oral Health of Young Children. Pediatrics January 2023; 151 (1): e2022060417. 10.1542/peds.2022-060417

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Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries remains greater than 40% among children 2 to 19 years of age. Although dental visits have increased in all age, race, and geographic categories in the United States, disparities continue to exist, and a significant portion of children have difficulty accessing dental care. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of disease, interventions to maintain and restore health, and the social determinants of children’s oral health.

Dental caries is the most common chronic disease of childhood, despite increased dental visits. 1   Twenty-three percent of US children 2 to 5 years of age, 52% of children 6 to 8 years of age, and 57% of youth 12 to 19 years of age have caries. 2   Total prevalence of dental caries in youth 2 to 19 years of age in 2015 to 2017 was 45.8%. 3   Significant disparities persist in the receipt of childhood preventive dental care, with young children, uninsured children, children living in poverty, non-Hispanic Black children, children from non–English-speaking households including immigrants and refugees, and children with special health care needs less likely to receive needed preventive oral health care. 2 – 5   American Indian/Alaska Native children have the highest rates of dental caries in the United States. 6   The reasons for these disparities are multifactorial and further explained in the Indian Health Service Data Brief “Oral Health of American Indian and Alaska Native Children Aged 1–4 Years: Results of the 2018–19 IHS Oral Health Survey” and in the American Academy of Pediatrics (AAP) policy statement “Early Childhood Caries in Indigenous Communities,” which focuses on the specific challenges within this population. 6 , 7   There have been slight improvements over time. There has been a 10-percentage point decrease in untreated tooth decay in the primary teeth of children 2 to 5 and 6 to 8 years of age and the permanent teeth of adolescents 12 to 19 years of age when comparing 2011–2016 data with 1999–2004. Mexican American children, children near the poverty line, and children below the poverty line saw improvements in untreated tooth decay; however, disparities continue to persist. 2  

A dynamic process takes place at the surface of the tooth that involves constant demineralization and remineralization of the tooth enamel (the caries balance). 8 , 9   Multiple factors affect that dynamic process and can be manipulated in ways that tip the balance toward disease (demineralization) or health (remineralization). These factors include bacteria, sugar, saliva, and fluoride. Because these factors can be manipulated, it is possible for pediatricians and families to prevent, halt, or even reverse the disease process.

Different oral structures and tissues have different and distinct microbial communities (microbiomes). 10   The oral microbiome at the surface of the tooth is referred to as dental plaque. During the disease process of dental caries, bacteria that are aciduric and acidogenic predominate in the dental plaque. Streptococcus mutans is most commonly associated with dental caries, although a larger pathogenic community exists. 11   When environmental factors make it possible to select for these pathogenic bacteria in dental plaque, the disease process begins.

A key environmental factor that allows for selection and proliferation of these pathogenic bacteria is dietary sugar intake. Because these bacteria have the ability to ferment sugars, produce acid, and decrease the pH of the dental plaque, they make possible the selection of other aciduric, acidogenic bacteria that will contribute to disease. As more bacteria produce more acid, the pH at the surface of the tooth decreases. This process causes the demineralization of the tooth enamel. Unimpeded, these long periods of low pH and demineralization will result in cavitation.

Saliva is an important factor in buffering the low pH and bringing these demineralization pressures back to a balance with remineralization. 12   In addition to acting as a buffering agent, saliva also flushes the oral cavity of food particles, provides an environment rich in calcium and phosphate to aid in remineralization, and includes proteins that have antimicrobial activity. When salivary flow is impeded (eg, by disease, iatrogenic), the pH is able to decrease to a lower level, tipping the scales toward demineralization (disease). In addition, the time it takes to buffer back to a normal pH is longer. 12  

Another important factor that can affect the balance of demineralization and remineralization is fluoride. More in-depth reviews of fluoride are available elsewhere. 13 – 15   It is important, however, for pediatricians and other child health care providers to understand how fluoride influences the caries balance. Fluoride has 3 key effects on the caries balance: (1) inhibition of demineralization at the tooth surface, (2) enhancement of remineralization, which results in a more acid-resistant tooth surface, and (3) inhibition of bacterial enzymes. 15   The primary effect of fluoride is topical, via fluoridated toothpastes, mouth rinses, varnishes, and silver diamine fluoride, although there is still value in systemic fluoride exposures via fluoridated water and supplements. 15 – 17  

Ideally, primary prevention efforts will anticipate and prevent caries before the first sign of disease. Preventive strategies for this multifactorial, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Assessing each child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for maintaining and improving oral health. There is no single tool that takes into consideration all risk factors and accurately predicts an individual’s susceptibility to caries. However, pediatricians can monitor oral health, both in the office and via telehealth, by focusing on the key risk factors for dental caries associated with diet, bacteria, saliva, and status of the teeth (ie, current and previous caries experience). Consistent with Bright Futures guidelines, pediatricians can perform an oral health screening examination of the mouth at each well-child visit to look for signs of caries. Each visit is an opportunity to assess risk, discuss risk reduction, modify behaviors, and identify goals for improving oral health. The AAP/ Bright Futures Oral Health Risk Assessment Tool, which includes photographs of clinical findings on the examination of the oral cavity, can be found at https://downloads.aap.org/AAP/PDF/oralhealth_RiskAssessmentTool.pdf.18 .

Sugars (but not sugar substitutes) are a critical risk factor in the development of caries. 19 , 20   This does not include sugars that are naturally occurring and present in whole fruit and vegetables or dairy products. The risk of caries is greatest if sugars are consumed at high frequency (and, thus, high amount) and are in a form that remains in the mouth for long periods of time. 19   Examples of key behaviors that place a child at high risk for caries include continual bottle/sippy cup use (with fluids other than water), sleeping with a bottle (with fluids other than water), frequent between-meal snacks of sugars/cooked starch/sugared beverages, sticky foods (raisins, fruit snacks, and gummy vitamins for example), and frequent intake of sugared medications.

The most important and predictive risk factor for caries is previous caries experience. This finding is not surprising, considering the factors that initiated the disease process often continue to exist over time. Early acquisition of S. mutans is also a major risk factor for early childhood caries and future caries experience. 21   Strong evidence demonstrates that mothers are a primary source of S. mutans colonization for their children (eg, utensil sharing, cleaning pacifier with mouth). 22   Thus, an important factor associated with caries risk in young children is the recent or current presence of active dental decay in the primary parent/caregiver. Because it is likely that bacteria will be vertically transmitted, prevention, diagnosis, and treatment of oral diseases in the child’s parent/caregiver are highly beneficial, especially during pregnancy. Dental care and treatment can be provided and is encouraged during pregnancy. There is no additional fetal or maternal risk compared with the risk of not providing dental care. 23  

Abnormalities in salivary flow and the structure of the teeth are associated with caries development. Diseases (eg, diabetes mellitus, Sjögren’s syndrome, cystic fibrosis) and medications (eg, antihistamines, anticonvulsants, antidepressants) result in xerostomia (decreased salivary flow). Xerostomia causes reduced availability of saliva to buffer the acid produced by pathogenic bacteria, thus enhancing their ability to damage the tooth enamel. Variations in the anatomic structure of the teeth can also increase the risk of decay. For example, teeth with enamel defects, frequently found in children born preterm, are at increased susceptibility for disease, as are molars with deep pits and fissures. Finally, there is increasing evidence of an association between secondhand smoke exposure and dental caries in children. 24 , 25  

Pediatricians can target anticipatory guidance to assist families in preventing dental caries by having a clear understanding of its etiology and the risk factors that lead to and facilitate the spread of this disease. Because the disease of dental caries is multifactorial, anticipatory guidance can also be multifaceted, with a focus on decreasing the risk of disease.

Because intake of sugars is such an important risk factor for dental caries, pediatricians can incorporate anticipatory guidance associated with preventing dental caries into conversations about dietary habits and nutritional intake. Risk of caries may be lower with exclusive breastfeeding for 6 months and continued breastfeeding as complementary foods are introduced for 1 year or longer, as mutually desired by the infant and breastfeeding parent. 26   To decrease the risk of dental caries and increase the chances for the best possible health and developmental outcomes, pediatricians can educate and provide guidance to families on establishing a bedtime routine conducive to optimal oral health (eg, the AAP Brush, Book, Bed program for parents). 27 , 28   Pediatricians can discourage parents/caregivers from putting a child to bed with a bottle to limit sugars on the teeth after brushing and encourage them to wean infants from a bottle by 1 year of age. Parents/caregivers can be counseled on the importance of reducing the frequency of exposure to added sugars in foods and drinks. 29   By limiting the amount and frequency of intake of foods with added sugars, as well as avoiding sugared beverages and juice drinks, caries risk is decreased. Pediatricians can encourage children to drink only water between meals, preferably fluoridated tap water, while discouraging 100% juice intake before 1 year of age, limiting juice to 4 ounces daily for children 1 to 3 years of age and to 4 to 6 ounces daily for children 4 to 6 years of age. 30   Lastly, providers can counsel families to foster eating patterns consistent with guidelines from the US Department of Agriculture. 31  

The value of good oral hygiene lies in controlling the levels and activity of disease-causing bacteria in the oral cavity and delivering fluoride to the surface of the tooth. It is important to remember that pathogenic bacteria can be passed from parent/caregiver to child. 22   Thus, anticipatory guidance for both parent/caregiver and child is important. Pediatricians can encourage parents/caregivers to model and maintain good oral hygiene, including regular brushing, flossing, and having a relationship with their own dental provider. Parents/caregivers should be counseled on brushing of a child’s teeth twice a day as soon as the teeth erupt with a grain-of-rice–sized amount of fluoridated toothpaste. After the third birthday, a pea-sized amount can be used. Pediatricians can also encourage parent/caregiver assistance and supervision of brushing children’s teeth until mastery is obtained, usually at around 10 years of age. 32 , 33  

The delivery of fluoride to the teeth includes community-based options (water fluoridation), self-administered modalities (fluoride toothpaste, rinses, and supplements), and professional applications (fluoride varnish and silver diamine fluoride). Fluoride is a critically important primary care preventive measure for families, especially those who do not have early and/or consistent ongoing dental care. As part of well-child anticipatory guidance, pediatricians can assess fluoride intake at each preventive visit, including the consumption of fluoridated tap water, and encourage families to protect their child’s teeth with regular delivery of oral and topical fluoride.

Water fluoridation is a community-based intervention that optimizes the level of fluoride in drinking water, resulting in preeruptive and posteruptive protection of the teeth. 34   Water fluoridation is a cost-effective means of preventing dental caries, with the lifetime cost per person equaling less than the cost of 1 dental restoration. 35 , 36   Most bottled waters do not contain an adequate amount of fluoride. Many families at higher risk for dental caries consume primarily bottled water, reducing potential exposure to fluoridated tap water. Fluoride supplements can be prescribed for children 6 months or older whose primary source of drinking water is deficient in fluoride. 16  

Fluoride toothpaste is an important way to deliver fluoride to the surface of the tooth. Fluoride toothpaste has been shown to be effective in reducing dental caries in both primary and permanent teeth. 37 , 38   Fluoride mouth rinses are another strategy for topical fluoride application and are associated with reduction in caries in the permanent teeth of children and adolescents, most particularly in a school setting. 39  

Fluoride varnish is a professionally applied, sticky resin of highly concentrated fluoride. Application of fluoride varnish 2 to 4 times a year, to either the primary or permanent teeth, is associated with a substantial reduction in dental caries. 40 , 41   In most states, pediatricians can apply fluoride varnish onto the teeth of young children and be paid for the service. The US Preventive Services Task Force recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation). 16   More details and recommendations on fluoride can be found in the AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting.” 14  

Silver diamine fluoride is a colorless ammonia solution containing silver and fluoride ions that is applied to the tooth. It is used to arrest caries lesions in primary and permanent teeth, including those that have already cavitated to the dentin, and has been shown to be effective in arresting caries in children. 42   When applied to the tooth or any surface, it will stain the surface black. Pediatricians may see more children with such staining and should be aware of its source. Silver diamine fluoride treatment is best used as part of an ongoing caries management plan with the aim of optimizing individualized patient care consistent with the goals of a dental home. A dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered manner. 43  

A frequent topic of discussion with parents/caregivers is nonnutritive oral habits, such as use of pacifiers and thumb/digit sucking. The AAP recommends that parents/caregivers consider offering a pacifier at naptime and bedtime because of a protective effect of pacifiers on the incidence of sudden infant death syndrome after the first month of life. 44   Evaluation by a dentist is indicated for nonnutritive sucking habits that continue beyond 3 years of age. Pacifier suckers are less likely to develop malocclusions (ie, overjet) compared with digit suckers; however, longer duration of pacifier or digit sucking is associated with an increased risk of developing malocclusions. 45   Breastfeeding also decreases the risk of malocclusions. 46  

Dental injuries are common. Twenty-five percent of all school-aged children experience some form of dental trauma. 47   Pediatricians can help prevent such trauma by encouraging parents/caregivers to cover sharp corners of household furnishings at the level of walking toddlers, recommend use of car safety seats, and be aware of electrical cord risk for mouth injury. Pediatricians can also encourage mouthguard use during sports activities in which there is a significant risk of orofacial injury (basketball, field hockey, and baseball, for example). 48 , 49   More information on dental trauma is available in the AAP clinical report “Management of Dental Trauma in a Primary Care Setting.” 50  

The AAP, the American Academy of Pediatric Dentistry, the American Dental Association, American Dental Hygienists’ Association, and the American Association of Public Health Dentistry all recommend a dental visit for children by 1 year of age. Although pediatricians have the opportunity to provide early assessment of risk for dental caries and anticipatory guidance to prevent disease, it is also important that children establish a dental home.

Depending on where a pediatrician’s practice is located, there are different members of the dental team with whom they may need to coordinate care and may even include as part of their office staff. 51   In addition to dentists, dental hygienists, and dental assistants, some states have expanded scope of practice or even developed new oral health professionals. Such professionals include expanded function dental assistants, dental health aide therapists, dental therapists, advanced dental therapists, independent practice dental hygienists, community dental health coordinators, registered dental hygienists in alternative practice, public health dental hygienists, expanded practice dental hygienists, and others.

There are emerging data regarding pediatric health care providers’ dental referral behaviors and patterns. One study found that children 2 to 5 years of age who received a recommendation from their health care provider to visit the dentist were more likely to have a dental visit. 52   Another study found that children with more preventive well-baby visits between ages 1 and 2 years and ages 2 and 3 years were more likely to have earlier first dental examinations than children with fewer well-baby visits. 53 , 54   However, the number and timing of well-baby visits before 1 year of age were not significantly related to first dental examinations. The US Preventive Services Task Force found no study that evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. 55   Early dental visits have been associated with decreased costs in most 56 – 58   but not all studies. 59  

With early referral to a dental provider, there is an opportunity to maintain good oral health, prevent disease, treat disease early, and potentially decrease cost. Establishing such collaborative relationships between physicians and dentists at the community level is essential for increasing access to dental care for all children and improving their oral and overall health.

The determinants of oral health, like oral health itself, are multifaceted. The driving determinants of oral health include genetic and biological factors, health behaviors, access to care, physical environment, and social environment. 60   The focus of this clinical report, to this point, has been focused on biological factors, health behavior, and access to oral health services. The AAP, however, also recommends screening for risk factors related to social determinants of health during all patient encounters. 61   It is important for pediatricians to understand that an approach to children’s oral health must also address social determinants. These social determinants, such as poverty, racism, education, access to healthy foods, culture, and physical environment, as well as access to medical and dental care influence oral health status and oral health inequities in much the same way as they influence overall health and health inequity. Pediatricians can consider and address determinants of oral health at the child, family, and community level. 62   With a robust understanding of how social determinants influence oral health, pediatricians can advocate for policy, system, and environmental changes that create sustainable, comprehensive improvements in children’s oral health and oral health equity. Appropriate payment for screening for social determinants is necessary to facilitate the implementation of screening in pediatric practices.

Oral health is an integral part of the overall health and well-being of children. 63   Pediatricians who are familiar with the science of dental caries, capable of assessing caries risk, comfortable with applying various strategies of prevention and intervention, connected to dental resources, and familiar with the social determinants of children’s health can contribute considerably to the health of their patients. This clinical report, in conjunction with the oral health recommendations of the fourth edition of the AAP Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , serves as a resource for pediatricians and other pediatric primary care providers to be knowledgeable about addressing dental caries. 64   Because dental caries is such a common and consequential disease process in the pediatric population and such an integral part of the overall health of children, it is essential that pediatricians include oral health in their daily practice of pediatrics.

Assess children’s oral health risks at health maintenance and other relevant visits.

Include anticipatory guidance for oral health as an integral part of comprehensive patient counseling.

Counsel parents/caregivers and patients on ways to reduce the frequency of exposure to sugars in foods and drinks.

Encourage parents/caregivers to maintain their own good oral health and to brush a child’s teeth at least twice a day as soon as teeth erupt with a smear or a grain-of-rice–sized amount of fluoride toothpaste, increasing to a pea-sized amount at 3 years of age.

Advise parents/caregivers to assist in and monitor brushing until 10 years of age.

Refer to the AAP clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting,” 14   for fluoride administration and supplementation decisions.

Be aware of the dental resources in your community as sources of referral and consultation.

Build and maintain collaborative relationships with local dental providers.

Recommend that every child has a dental home by 1 year of age.

Promote policy, system, and environmental changes that address social determinants of children’s oral health.

Advocate for insurance coverage by all payers for fluoride varnish as a preventive service, as recommended by the US Preventive Services Task Force.

David M. Krol, MD, MPH, FAAP

Kaitlin Whelan, MD, FAAP

Patricia A. Braun, MD, MPH, FAAP, Chairperson

Jeffrey M. Karp, DMDC Eve Kimball, MD, FAAP

Karen Sokal-Gutierrez, MD, MPH, FAAP

Anupama Rao Tate, DMD

John H. Unkel, DDS, MD, MPA, FAAP

Tooka Zokaie, MPH, CLSSGB, American Dental Association

Matt Crespin, MPH, RDH, American Dental Hygienists’ Association

John Fales, DDS, MS, American Academy of Pediatric Dentistry

Ngozi Onyema-Melton, MPH, CHES

Kera Beskin, MPH, MBA

Drs Krol and Whelan conceived and developed the draft clinical report and equally shared in revising the draft; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: No external funding.

FINANCIAL/CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts to disclose.

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Oral Health

“There is no health without oral health.” You may have heard this statement but what does it mean? The health of our mouth, or oral health, is more important than many of us may realize. It is a key indicator of overall health, which is essential to our well-being and quality of life.

Although preventable to a great extent, untreated tooth decay (or cavities) is the most common health condition worldwide. When we think about the potential consequences of untreated oral diseases including pain, reduced quality of life, lost school days, disruption to family life, and decreased work productivity, making sure our mouths stay healthy is incredibly important. [1]

What is a Healthy Mouth?

The mouth, also called the oral cavity, starts at the lips and ends at the throat. A healthy mouth and well-functioning teeth are important at all stages of life since they support human functions like breathing, speaking, and eating. In a healthy mouth, tissues are moist, odor-free, and pain-free. When we talk about a healthy mouth, we are not just talking about the teeth but also the gingival tissue (or gums) and the supporting bone, known together as the periodontium. The gingiva may vary in color from coral pink to heavily pigmented and vary in pattern and color between different people. Healthy gingiva is firm, not red or swollen, and does not bleed when brushed or flossed. A healthy mouth has no untreated tooth decay and no evidence of lumps, ulcers, or unusual color on or under the tongue, cheeks, or gums. Teeth should not be wiggly but firmly attached to the gingiva and bone. It should not hurt to chew or brush your teeth.

Throughout life, teeth and oral tissues are exposed to many environmental factors that may lead to disease and/or tooth loss. The most common oral diseases are tooth decay and periodontal disease. Good oral hygiene and regular visits to the dentist, combined with a healthy lifestyle and avoiding risks like excess sugar and smoking, help to avoid these two diseases.

Oral Health and Nutrition: What You Eat and Drink Affects Your Teeth

Just like a healthy body, a healthy smile depends on good nutrition. A balanced diet with adequate nutrients is essential for a healthy mouth and in turn, a healthy mouth supports nutritional well-being. Food choices and eating habits are important in preventing tooth decay and gingival disease.

Minerals like calcium and phosphorus contribute to dental health by protecting and rebuilding tooth enamel. [2] Enamel is the hard outer protective layer of the tooth (fun fact: enamel is the hardest substance in the human body). Eating foods high in calcium and other nutrients such as cheese , milk , plain yogurt , calcium-fortified tofu , leafy greens , and almonds may help tooth health. [2] While protein-rich foods like meat, poultry, fish, milk and eggs are great sources of phosphorus.

When it comes to a healthy smile, fruits and vegetables are also good choices since they are high in water and fiber , which balance the sugars they hold and help to clean the teeth. [2] These foods also help stimulate saliva, which helps to wash away acids and food from teeth, both neutralizing acid and protecting teeth from decay. Many fruits and vegetables also have vitamins like vitamin C , which is important for healthy gingiva and healing, and vitamin A, another key nutrient in building tooth enamel.[2]

Water is the clear winner as the best drink for your teeth—particularly fluoridated water. It helps keep your mouth clean and helps fight dry mouth. Fluoride is needed regularly throughout life to protect teeth against tooth decay. [3] Drinking water with fluoride is one of the easiest and most beneficial things you can do to help prevent cavities.

Is carbonated water a healthy choice for my teeth?

How snacking can affect your dental health

Malnutrition and oral health.

Nutrition and oral health are closely related. The World Health Organization defines malnutrition as deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. This means that malnutrition can be over-nutrition or undernutrition. Dental pain or missing teeth can lead to difficulty chewing or swallowing food which negatively affects nutrition. This may mean eating fewer meals or meals with lower nutritional value due to impaired oral health and increased risk of malnutrition. On the other hand, lack of proper nutrients can also negatively affect the development of the oral cavity, the progression of oral diseases and result in poor healing. [5] In this way, nutrition affects oral health, and oral health affects nutrition.

Nutrition is a major factor in infection and inflammation. [5] Inflammation is part of the body’s process of fighting against things that harm it, like infections and injuries. Although inflammation is a natural part of the body’s immune response to protect and heal the body, it can be harmful if it becomes unbalanced. In this way inflammation is a dominant factor in many chronic diseases. Periodontal diseases and obesity are risk factors involved in the onset and progression of chronic inflammation and its consequences. [6]

Oral Health and General Health

While it may appear that oral diseases only affect the mouth, their consequences can affect the rest of the body as well. There is a proven relationship between oral and general health. Many health conditions may increase the risk of oral diseases, and poor oral health can negatively affect many general health conditions and the management of those conditions. Most oral diseases share common risk factors with chronic diseases like cardiovascular disease , cancers , diabetes , and respiratory diseases. These risk factors include unhealthy diets, particularly those high in added sugar, as well as tobacco and alcohol use. [7]

Infective endocarditis (IE), an infection of the inner lining of the heart muscle, can be caused by bacteria that live on teeth. [8] Gingivitis and periodontitis are inflammatory diseases of the gingiva and supporting structures of the teeth caused by specific bacteria. There is evidence that the surface of inflamed tissue around teeth is the point of entry for the specific bacteria that cause as much as 50% of the IE cases in the U.S. annually. This means that improving oral hygiene may help in reducing the risk of developing IE. In addition, periodontal disease may be associated with heart disease and shares risk factors including tobacco use, poorly controlled diabetes , and stress . [9,10]

Oral health is an important part of prenatal care. Poor oral health during pregnancy can result in poor health outcomes for both mother and baby. For example, studies suggest that pregnant women who have periodontal disease may be more likely to have a baby that is born too early and too small. [7] Hormonal changes during pregnancy, particularly elevated levels of progesterone, increase susceptibility to periodontal disease, which includes gingivitis and periodontitis. For this reason, your dentist may recommend more frequent professional cleanings during your pregnancy.

If you are struggling with morning sickness, the stomach acid from vomiting can erode or wear away tooth enamel. To help prevent the effects of erosion, rinse your mouth with 1 teaspoon of baking soda mixed in a cup of water, then wait 30 minutes before brushing your teeth. [11]

Conditions that impact oral health

Certain conditions may also affect your oral health, including:

• Anxiety and stress. Stress is a normal human reaction that everyone experiences at one point or another. However, stress that is left unchecked can contribute to many health problems including oral health issues. While behavioral changes play a leading role in these poor oral health findings, there are certain physiological effects on the body as well. Stress creates a hormone in the body called cortisol. Spikes in this hormone can weaken the immune system and increase susceptibility to developing periodontal disease. Evidence has shown that stress reduces the flow of saliva which in turn can contribute to dental plaque formation. [12] Certain medications like antidepressants and anti-anxiety medications can also cause dry mouth, increasing risk of tooth decay. Additionally, stress may contribute to teeth grinding (or bruxism), clenching, cold sores, and canker sores.
• Osteoporosis and Paget’s Disease . Medical conditions such as osteoporosis are a fitting example of why it is so important to let your dentist know about all the medications you are taking. Certain medications like antiresorptive agents, a group of drugs that slows bone loss, can influence dental treatment decisions. That is because these medications have been associated with a rare but serious condition called osteonecrosis of the jaw (ONJ), which can damage the jawbone. Bisphosphonates (Fosamax, Actonel, and Boniva) and Denosumab (or Prolia) are examples of antiresorptive agents. Although it can occur spontaneously, ONJ more commonly occurs following surgical dental procedures like extracting a tooth or implant placement. Be sure to tell your dentist if you are taking antiresorptive agents so they can take that into account when developing your treatment plan.

A healthy, pain-free mouth can lead to a better state of mind!

Eating concerns: what to eat if you have….

Depending on the type of orthodontic treatment, your braces may have brackets, bands, and wires. In this case, it is important to avoid eating hard or sticky food. This includes things like nuts, popcorn, hard candy or gum, which could break or displace parts of your orthodontics and potentially delay your treatment. Enjoying pasta, soft veggies, fruits, and dairy products are good choices. Having good oral hygiene is key in making sure tooth decay do not form around the braces. This means making sure the teeth and braces are thoroughly cleaned of food debris so that plaque does not accumulate. Allowing plaque to build-up can cause white spots on the surfaces of the teeth. You can ask your dentist for tips on how to maintain good oral hygiene.

If you have clear trays or aligners that are removable, you should always remove your trays before eating or drinking any liquid other than water. Regardless of whether food is hard or soft, removing your tray before eating helps to ensure effectiveness of your treatment.

If you wear dentures, adjusting to what and how you eat can be a major challenge. When you first get dentures, your mouth and tissue need time to adjust to chewing and biting. Starting with soft foods like soups, smoothies, and applesauce for your first few meals can help make the transition more comfortable. Be mindful of hot dishes and drinks as it can sometimes be difficult to gauge the temperature of your food. After a couple of days, you can move onto more solid foods as your mouth begins to adjust to the dentures. Take care to avoid hard or sticky food and tough meats which could break or damage your dentures. Denture-friendly foods include slow-cooked or ground meats, cooked fish, ripe fruits, and cooked vegetables. A good tip is that if you can cut the food with a fork, chances are the food will not damage your dentures.

Dry mouth or xerostomia can make it difficult to talk, chew, and swallow food. Symptoms of dry mouth may include increased thirst, sore mouth and tongue, difficulty swallowing and talking, and changes in taste. [14] If you are experiencing a dry mouth, it is important to talk to your oral health care provider (as well as primary care provider) to better understand the potential causes and management. Regardless of the cause, you have lots of options for making it easier to eat. First, ensure that you drink plenty of fluids and sip cold water between meals. Chew your food well if you’re having trouble swallowing and only take small bites. Combining solid foods with liquid foods such as yogurt, gravy, sauces, or milk can also help. You want to avoid foods that are acidic, hot, or spicy as these may irritate your mouth further. Good oral care also plays a key role in alleviating dry mouth and preventing tooth decay, which is a common oral complication of dry mouth.

Oral Health Tips

Here are some actions you can take to support good oral health: [15]

• Drink fluoridated water and brush with fluoride toothpaste.
• Practice good oral hygiene. Brush teeth thoroughly twice a day and floss daily between the teeth to remove dental plaque.
• Visit your dentist at least once a year (the average person should go twice a year), even if you have no natural teeth or have dentures.
• Do not use any tobacco products. If you smoke, seek resources to help you quit.
• Limit alcoholic drinks. Some alcoholic beverages can be very acidic, resulting in erosion of tooth enamel, and those with a high alcohol content can lead to dry mouth. Also be mindful of drink mixers, many of which are high in sugar and can increase the risk of tooth decay.
• If you have diabetes , work to support control of the disease. This will decrease the risk for other complications, including gum disease. Treating gum disease may help lower your blood sugar level.
• If your medication causes dry mouth, discuss other medication options with your doctor that may not cause this condition. If dry mouth cannot be avoided, drink plenty of water, chew sugarless gum, and avoid tobacco products and alcohol. Your oral health care provider may be able to recommend over-the-counter or prescription medications to improve your dry mouth as well.
• See your doctor or a dentist if you experience sudden changes in taste and smell.
• When acting as a caregiver, help those who are not able to brush and floss their teeth independently.
• Chew sugar-free xylitol gum between meals and/or when you are unable to brush after a meal.

Bottom Line – There Is No Health Without Oral Health

As growing research and studies reveal the link between oral health and overall health, it becomes more evident that taking care of your teeth isn’t just about having a nice smile and pleasant breath. Studies show that poor oral health is linked to heart disease, diabetes, pregnancy complications, and more, while positive oral health can enhance both mental and overall health. Good oral hygiene and regular visits to the dentist, combined with a healthy lifestyle and avoiding risks like excess sugar and smoking, help to keep your smile and body healthy.

• Oral Cavity (mouth) starts at the lips and ends at the throat including the lips, inside the cheeks and lips, the tongue, gums, under the tongue, and roof of the mouth.
• Enamel is the hard calcified tissue covering the surface of the tooth.
• Gingiva (gums) is the soft tissue covering the necks of the teeth and the jaw bones.
• Periodontium is a group of specialized tissues that surround and support the teeth, including the gingiva and bone.
• Periodontal disease (gum disease) includes gingivitis and periodontitis. Gingivitis is the mildest form, in which the gums become red, swollen, and bleed easily. Gingivitis is reversible with professional treatment and good at-home oral care. If untreated, gingivitis can advance to periodontitis where chronic inflammation causes the tissues and bone that support the teeth to be damaged. Overtime, teeth can become loose and may fall out or need to be removed. [16]
• Check out the Harvard School of Dental Medicine for more information and resources for oral health
• Peres MA, Macpherson LM, Weyant RJ, Daly B, Venturelli R, Mathur MR, Listl S, Celeste RK, Guarnizo-Herreño CC, Kearns C, Benzian H. Oral diseases: a global public health challenge. The Lancet . 2019 Jul 20;394(10194):249-60.
• American Dental Association. n.d. Nutrition: What you eat affects your teeth . Mouth Healthy.
• Kohn WG, Maas WR, Malvitz DM, Presson SM, Shaddix KK. Recommendations for using fluoride to prevent and control dental caries in the United States. (2001).
• Chi DL, Scott JM. Added sugar and dental caries in children: a scientific update and future steps. Dental Clinics . 2019 Jan 1;63(1):17-33.
• Ehizele AO, Ojehanon PI, Akhionbare O. Nutrition and oral health. Benin Journal of Postgraduate Medicine. 2009;11(1).
• Suvan JE, Finer N, D’Aiuto F. Periodontal complications with obesity. Periodontology 2000 . 2018 Oct;78(1):98-128.
• Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. International journal of health sciences . 2017 Apr;11(2):72.
• Lockhart PB, Brennan MT, Thornhill M, Michalowicz BS, Noll J, Bahrani-Mougeot FK, Sasser HC. Poor oral hygiene as a risk factor for infective endocarditis–related bacteremia. The Journal of the American Dental Association . 2009 Oct 1;140(10):1238-44.
• Borrell LN, Papapanou PN. Analytical epidemiology of periodontitis. Journal of clinical periodontology . 2005 Oct;32:132-58.
• Lockhart PB, Bolger AF, Papapanou PN, Osinbowale O, Trevisan M, Levison ME, Taubert KA, Newburger JW, Gornik HL, Gewitz MH, Wilson WR. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? A scientific statement from the American Heart Association. Circulation . 2012 May 22;125(20):2520-44.
• American Dental Association. (n.d.). Pregnant? 9 Questions You May Have About Your Dental Health
• Reners M, Brecx M. Stress and periodontal disease. International journal of dental hygiene . 2007 Nov;5(4):199-204.
• American Dental Association. (n.d.). Osteoporosis and Oral Health .
• Cancer Treatment Centers of America. (n.d.). Dry mouth .
• Centers for Disease Control and Prevention. 2021. Oral Health Tips .
• The American Academy of Periodontology. (n.d.). Gum Disease Information .

Last reviewed December 2022

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Research for Healthy Living

Oral Health

In the early part of the 20th century, it was common for women and men to lose many teeth as they aged, leaving them to rely on dentures. That story began to change dramatically in the 1940s and 1950s, when NIH scientists showed that the rate of tooth decay fell more than 60 percent in children who drank fluoridated water. This discovery laid the foundation for a major component of modern dental health. 

Today, research on oral health extends far beyond teeth. NIH researchers consider the mouth an expansive living laboratory to understand infections, cancer, and even healthy development processes. For example, we know that oral tissues and fluids, which are home to about 600 unique microbial species, can have remarkable protective roles against infection and possibly other conditions.

NIH research on oral health is working to understand and manipulate the body’s innate ability to repair and regenerate damaged or diseased tissues. These approaches will guide prevention and treatment of health problems not only in teeth and in the mouth, but also in other organs and tissues.

Optimal health for women and men

Certain health conditions are more common in women than in men, such as osteoporosis, depression, and autoimmune diseases. Others are more common in males, such as autism and color blindness. And there are those conditions that affect women and men differently, such as heart disease. While chest pain is common to both women and men suffering a heart attack, women may experience other symptoms such as nausea, back or neck pain, and fatigue, which they may not link to problems of the heart. NIH researchers are studying these differences, toward providing personalized care for individuals. The sexes can also have very different responses to even very common drugs like aspirin. So, NIH research ensures that females, including pregnant women when it is safe to do so, are included in sufficient numbers in clinical trials that test new medicines. Currently, slightly more than half of clinical trial participants are women.

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Why Oral Hygiene Is Crucial to Your Overall Health

Gum disease has been associated with a range of health conditions, including diabetes, heart disease, dementia and more. Here’s what experts say you can do to manage the risk.

By Hannah Seo

The inside of your mouth is the perfect place for bacteria to thrive: It’s dark, it’s warm, it’s wet and the foods and drinks you consume provide nutrients for them to eat.

But when the harmful bacteria build up around your teeth and gums, you’re at risk of developing periodontal (or gum) disease , experts say, which is an infection and inflammation in the gums and bone that surround your teeth.

And such conditions in your mouth may influence the rest of your body, said Kimberly Bray, a professor of dental hygiene at the University of Missouri-Kansas City.

A growing yet limited body of research , for instance, has found that periodontal disease is associated with a range of health conditions including diabetes, heart disease, respiratory infections and dementia.

Exactly how oral bacteria affect your overall health is still poorly understood, Dr. Bray said, since the existing research is limited and no studies have established cause-and-effect.

But some conditions are more associated with oral health than others, experts say. Here is what we know.

The health issues linked with oral health

About 47 percent of people aged 30 years and older in the United States have some form of periodontal disease, according to the Centers for Disease Control and Prevention.

In its early stages, called gingivitis, the gums may become swollen, red or tender and may bleed easily. If left untreated, gingivitis may escalate to periodontitis, a more serious form of the disease where gums can recede, bone can be lost, and teeth may become loose or even fall out.

With periodontitis, bacteria and their toxic byproducts can move from the surface of the gums and teeth and into the bloodstream, where they can spread to different organs, said Ananda P. Dasanayake, a professor of epidemiology at the New York University College of Dentistry.

This can happen during a dental cleaning or flossing, or if you have a cut or wound inside your mouth, he said.

If you have inflammation in the mouth that is untreated, some of the proteins responsible for that inflammation can spread throughout the body, Dr. Bray said, and potentially damage other organs.

Of all the associations between oral health and disease, the one with the most evidence is between periodontal disease and diabetes, Dr. Bray said. And the two conditions seem to have a two-way relationship , she added: Periodontal disease seems to increase the risk for diabetes, and vice versa.

Researchers have yet to understand exactly how this might work, but in one review published in 2017 , researchers wrote that the systemic inflammation caused by periodontal disease may worsen the body’s ability to signal for and respond to insulin.

In another study , published in April, scientists found that diabetics who were treated for periodontal disease saw their overall health care costs decrease by 12 to 14 percent.

“You treat periodontal disease, you improve the diabetes,” Dr. Dasanayake said.

If large amounts of bacteria from the mouth are inhaled and settle in the lungs, that can result in bacterial aspiration pneumonia , said Dr. Frank Scannapieco, a professor of oral biology at the University at Buffalo School of Dental Medicine.

This phenomenon has been observed mainly in patients who are hospitalized or older adults in nursing homes, and is a concern for those who can’t floss or brush their teeth on their own, said Dr. Martinna Bertolini, an assistant professor of dental medicine at the University of Pittsburgh School of Dental Medicine.

Preventive dental care such as with professional teeth cleanings, or periodontal treatments like antibiotic therapy, can lower the risk of developing this kind of pneumonia, Dr. Scannapieco said.

Cardiovascular disease

In a report published in 2020 , an international team of experts concluded that there is a significant link between periodontitis and heart attack, stroke, plaque buildup in the arteries, and other cardiovascular conditions.

While researchers haven’t determined how poor oral health might lead to worse heart health, some evidence suggests that periodontal bacteria from the mouth may travel to the arteries in vascular disease patients, potentially playing a role in the development of the disease.

And a 2012 statement from the American Heart Association noted that inflammation in the gums has been associated with higher levels of inflammatory proteins in the blood that have been linked with poor heart health.

Some research also suggests that better oral hygiene practices are linked with lower rates of heart disease.

For example, in a study published in 2019 , researchers reviewed the health records of nearly 250,000 healthy adults living in South Korea and found that over about 10 years, those who regularly brushed their teeth and received regular dental cleanings were less likely to have cardiovascular events than those who had poorer dental hygiene, formed more cavities, experienced tooth loss or developed periodontitis.

Pregnancy complications

A number of studies and reviews have found associations between severe periodontal disease and preterm, low birth weight babies, Dr. Dasanayake said. Though more research is needed to confirm the link.

In a 2019 review , researchers found that treating periodontal disease during pregnancy improved birth weight and reduced the risk of preterm birth and the death of the fetus or newborn.

And in a 2009 study , researchers found that oral bacteria could travel to the placenta — potentially playing a role in chorioamnionitis, a serious infection of the placenta and amniotic fluid that could lead to an early delivery, or even cause life-threatening complications if left untreated.

Research also suggests that bacteria from your mouth may activate immune cells that circulate in the blood, causing inflammation in the womb that could distress the placenta and fetal tissues.

There is longstanding research that periodontitis may induce preterm birth in animals like mice, and that treating these infections can protect against low birth weights and preterm birth.

Researchers have been increasingly interested in the role of oral health in dementia, particularly Alzheimer’s disease, Dr. Scannapieco said.

“Bacteria that are found in the mouth actually have been identified in the brain tissue of patients with Alzheimer’s,” he said, implying a potential role for them in the disease.

In a recent review , scientists noted that oral bacteria — especially those related to periodontitis — could either affect the brain directly via “infection of the central nervous system,” or indirectly by inducing “chronic systemic inflammation” that reaches the brain.

However, there’s no evidence that oral bacteria alone could cause Alzheimer’s, the review authors wrote. Rather, periodontal disease is just one “risk factor” among many for people who are predisposed to Alzheimer’s or other forms of dementia.

Other conditions

Oral bacteria have also been robustly linked with a number of other conditions such as rheumatoid arthritis and osteoporosis , Dr. Bray said. And emerging research is starting to link oral bacteria with kidney and liver disease, as well as colorectal and breast cancers .

But more research is needed to confirm all of these links, the experts said. And we still don’t know if regular dental care and periodontal treatments may help prevent or improve any of the conditions mentioned above, Dr. Scannapieco said.

What you can do

The best way to maintain good oral health is to follow the classic dental care advice , including brushing your teeth twice a day and flossing every day, Dr. Scannapieco said.

“Not all people really appreciate their oral health, and they’re only reminded of it when they have a toothache or some pain,” he added. But it’s important to be just as diligent and proactive about your oral health as you are with exercise or diet or any other aspect of well-being.

Hannah Seo is a reporting fellow for The Times, covering mental and physical health and wellness. More about Hannah Seo

• Open access
• Published: 08 May 2024

Association of phthalate metabolites with periodontitis: a population-based study

• Mengyao Bian 1 ,
• Wenxiang Jiang 1 ,
• Manting Wang 1 ,
• Ying Shi 1 &
• Zhifang Wu 1  

BMC Oral Health volume  24 , Article number:  541 ( 2024 ) Cite this article

Metrics details

Widespread exposure to phthalates may raise the probability of various diseases. However, the association of phthalate metabolites with periodontitis remains unclear.

Totally 3402 participants from the National Health and Nutrition Examination Survey (NHANES) 2009 to 2014 cycles were enrolled in the cross-sectional investigation. We utilized weighted logistic regression to evaluate the association of ten phthalate metabolites with periodontitis. Restricted cubic spline analysis was applied to investigate potential nonlinear relationships.

The weighted prevalence of periodontitis in the study was 42.37%. A one standard deviation (SD) rise in log-transformed levels of mono-2-ethyl-5-carboxypenty phthalate (MECPP), mono-n-butyl phthalate (MnBP), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-isobutyl phthalate (MiBP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono-benzyl phthalate (MBzP) was associated with higher odds of periodontitis, with odds ratios (95% confidence intervals) of 1.08 (1.02-1.14), 1.07 (1.02-1.11), 1.10 (1.05-1.15), 1.05 (1.01-1.09), 1.09 (1.04-1.14), and 1.08 (1.03-1.13), respectively. Individuals with the highest quartile concentrations of MECPP, MnBP, MEHHP, MEOHP, and MBzP were associated with 32%, 20%, 30%, 25%, and 26% increased odds of periodontitis, respectively, compared to those with the lowest quartile. Additionally, mono-(3-carboxypropyl) phthalate (MCPP) demonstrated an interesting inverted J-shaped relationship with periodontitis.

Conclusions

The findings indicate an association of certain phthalate metabolites with periodontitis among US adults.

Peer Review reports

Introduction

The high prevalence of periodontitis has turned into a major public health issue, burdening the entire world [ 1 , 2 ]. Notably, periodontitis is known to share a bidirectional relationship with various systemic conditions, suggesting that treating periodontal problems may promote overall health [ 3 , 4 ]. In recent decades, fundamental research on periodontitis has progressively shed light on the pathogenesis of periodontitis. Current understandings of host-microbe interactions implicate genetics, epigenetics, lifestyle choices, and environmental influences to be critical variables in the onset and progression of periodontitis [ 5 ]. Specifically, the establishment of feedforward loops between dysbiosis within complex microbial communities and heightened host inflammatory reactions appear to significantly contribute to the progression of periodontitis [ 6 ].

Among environmental contributors, endocrine-disrupting compounds (EDCs) are known to impact human health by altering epigenetic mechanisms [ 7 ]. Phthalates, one of the common EDCs, are extensively used in a myriad of products, such as medical supplies, personal care items, food packaging, cosmetics, paints, and toys [ 8 ]. Phthalates can be ingested, inhaled, absorbed through the skin, or administered during medical procedures [ 9 ]. Existing studies have linked phthalate exposure to numerous health issues, including endocrine system dysfunction, metabolic disorders, infertility, neurologic disorders, respiratory diseases, and cancer [ 10 , 11 , 12 ]. The oral cavity, which serves as a common channel of the respiratory and digestive systems, is also susceptible to phthalate exposure. It is questionable whether periodontitis is also associated with phthalate.

A prior study indicated a notable link between mono-n-methyl phthalate and periodontitis [ 13 ]. However, the underlying mechanisms are not yet fully understood. The interaction between them may be multi-faceted, involving complex biological processes such as the body's immune-inflammatory responses and oxidative stress [ 14 , 15 , 16 ].

Considering the known association of phthalates with various disorders, and given the shared risk factors between periodontitis and systemic diseases [ 17 , 18 ], we hypothesized that phthalates might be linked to periodontitis. This hypothesis aligns with current understandings of the multifactorial nature of periodontitis, involving both systemic health and environmental exposures. Given the relatively stable presence of phthalate metabolites in the urine across extended periods, they are reliable biomarkers for assessing phthalate exposure [ 19 ]. Hence, using cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), we sought to investigate the potential association of urinary phthalate metabolites with periodontitis.

Study design and population

The study utilized data from the United States civilian, which was comprehensively surveyed by NHANES through a multi-stage, stratified random sampling methodology. Data on demographics, examination, diet, and laboratory results were collected every two years in this survey. Our cross-sectional study selected data from the NHANES 2009–2014 cycles. Finally, 3402 individuals were selected for inclusion in subsequent analysis. Figure  1 illustrates the process of inclusion and exclusion. The datasets employed for the analyses in this article are publicly accessible for download.

Flow diagram of this study. The final 3402 participants included complete data on urinary phthalate metabolites, urinary creatinine, age, sex, race/ethnicity, and body mass index for calculating the adjusted concentrations of phthalate metabolites. MEC, mobile examination center; NHANES, National Health and Nutrition Examination Survey

Periodontitis assessment

Participants aged ≥ 30 years who had a minimum of one natural tooth, were eligible for a full-mouth periodontal examination (FMPE) in NHANES 2009–2014. Licensed dentists used a Hu-Friedy PCP-2 periodontal probe to assess probing pocket depth (PPD) and clinical attachment loss (CAL) at six sites per tooth. Additional information regarding the periodontal examination methodology is detailed in previous studies [ 20 , 21 ]. For each participant, we calculated the mean probing pocket depth (PPD) and the mean clinical attachment loss (CAL). Periodontitis was classified following the severity criteria set by the Centers for Disease Control and Prevention (CDC) / American Academy of Periodontology (AAP) [ 22 ]. For our analysis, we grouped mild, moderate, and severe periodontitis into a single category, termed 'total periodontitis'.

Phthalate metabolites measurement in urine

Urine samples from the participants were carefully processed, and then stored at -20 °C before being transported to the CDC's National Center for Environmental Health for analysis. They used high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry (HPLC–ESI–MS/MS) to quantitatively detect phthalate metabolites in urine. The NHANES Laboratory Procedures Manual (LPM) offers comprehensive guidelines for the collection and processing of specimens. In our investigation, we measured concentrations of ten specific phthalate metabolites, including mono(carboxynonyl) phthalate (MCNP), mono(carboxyoctyl) phthalate (MCOP), mono-2-ethyl-5-carboxypenty phthalate (MECPP), mono-n-butyl phthalate (MnBP), mono-(3-carboxypropyl) phthalate (MCPP), mono-ethyl phthalate (MEP), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-isobutyl phthalate (MiBP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono-benzyl phthalate (MBzP). Besides, mono-(2-ethyl)-hexyl phthalate (MEHP) and mono-isononyl phthalate (MiNP) were excluded because of the high percentage (> 20%) of values below the limit of detection (LOD). For values under the LOD, they were replaced with the LOD value divided by the square root of 2. The LOD for each phthalate metabolite varied slightly throughout the survey cycles and details are provided in Supplementary Table 1.

To reduce the bias in measurement inaccuracy brought on by urine dilution, investigators usually recommend standardizing measured urinary biomarker concentration based on the concentration of urinary creatinine [ 23 ]. We adopted a new method proposed by O'Brien et al. to adjust urinary phthalate metabolite concentrations [ 24 ]. We first created a model for urinary creatinine that took into account the covariates of age, sex, race/ethnicity, and BMI. The concentrations of adjusted phthalate metabolites were calculated by multiplying the measured metabolite concentration with the ratio of the predicted creatinine concentration to the actual observed creatinine concentration. All concentrations of phthalate metabolite shown in this article have been adjusted.

We identified several variables as potential confounders in our study: age, sex, race/ethnicity, education level, annual family income, smoking status, BMI status, hypertension, and diabetes mellitus (DM). For race/ethnicity, we categorized participants as non-Hispanic White, non-Hispanic Black, Mexican American, and other races. Education level was classified into three groups: less than high school, high school, and more than high school. Annual family income was stratified at the $20,000 mark, distinguishing between incomes under and over this threshold [ 25 ]. Smoking status was categorized as 'never' for individuals who have smoked fewer than 100 cigarettes in their lifetime, 'former' for past smokers with a history of over 100 cigarettes, and 'current' for those who have smoked more than 100 cigarettes in their lifetime and continue to smoke occasionally or daily [ 26 ]. BMI was calculated using weight in kilograms divided by height in meters squared, and participants were classified as underweight/normal (BMI < 25), overweight (25 ≤ BMI < 30), or obese (BMI ≥ 30).

Statistical analysis

In our research, we expressed continuous variables as mean and standard error (SE) for those following a normal distribution. For data not adhering to a normal distribution, we used the median and quartiles for representation. Categorical variables were described using counts (n) and weighted percentages. Additionally, we utilized Pearson correlation coefficients to evaluate the relationship between each pair of log-transformed phthalate metabolite levels.

To investigate the association of natural log-transformed phthalate metabolites with periodontitis, we conducted weighted logistic regression analysis in three different models: a crude model without adjustment, Model 1 adjusted for age, sex, and race/ethnicity, and Model 2 further included adjustments for education level, annual family income, smoking status, BMI status, hypertension, DM, along with the covariates in Model 1. The results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Additionally, we utilized restricted cubic spline (RCS) analysis to assess potential nonlinear relationships, setting knots at the 10th, 50th, and 90th percentiles of the phthalate metabolite concentrations. Furthermore, we categorized phthalate metabolites into quartiles to further analyze their association with periodontitis. A linear trend test ( P for trend) was conducted by assigning median values of the quartiles to the phthalate metabolite variable treated as continuous.

We further investigated the consistency of the observed associations across different demographics, specifically age groups (< 60 and ≥ 60), genders, and race/ethnicity categories. In sensitivity analysis, we excluded pregnant women and cancer patients.

Given the minimal amount of missing data (< 5%), we opted for a complete case analysis approach. All analyses were adjusted for sample weights and performed using R software (version 4.3.1). We determined statistical significance based on P values being less than 0.05 in a two-tailed test.

Study population

Within the 2009–2014 survey cycles, 10,683 participants, aged ≥ 30 years, underwent detailed periodontal assessments and possessed at least one natural tooth. We excluded participants who lacked complete information on phthalate metabolites ( N  = 7256) and body mass index (BMI) ( N  = 25). Finally, 3402 individuals were selected for inclusion in subsequent analysis, representing an estimated 141.71 million noninstitutionalized US adults aged ≥ 30 years. The weighted prevalence of total periodontitis, with its subcategories (mild, moderate, and severe), was found to be 42.37%, 4.61%, 30.63%, and 7.12% respectively. Compared with participants in the no/mild periodontitis group, those with moderate/severe periodontitis were more frequently older, men, with less education, low income, smokers, and those with hypertension and DM (Table  1 ). Supplementary Table 2 provides detailed characteristics of the study subjects based on the severity of periodontitis.

Table 2 displays the median levels of urinary creatinine-corrected phthalate metabolites, along with their 25th and 75th quartiles, for both periodontitis and non-periodontitis groups. Notably, individuals with periodontitis exhibited lower levels of MCNP and MCOP, but higher levels of MECPP, MnBP, MEP, MEHHP, MEOHP, and MBzP when compared to those without periodontitis ( P  < 0.05). However, the levels of MCPP and MiBP did not show any statistical differences between the two groups ( P  > 0.05).

Correlations of phthalate metabolites

Figure  2 in our study illustrates the correlation coefficients among various phthalate metabolites, as determined through Pearson correlation analysis. Overall, the metabolites of phthalates demonstrated generally positive correlations with each other. Among these, the correlation between MEHHP and MEOHP was notably strong, registering a coefficient of r  = 0.96. Additionally, there were also substantial correlations observed between MEOHP and MECPP ( r  = 0.89), and between MECPP and MEHHP ( r  = 0.88). This pattern of correlations suggests a significant degree of interrelation among these specific phthalate metabolites in our study population.

Pearson correlation heatmap of phthalate metabolites. The concentrations of phthalate metabolites were standardized with covariate-adjusted creatinine and log-transformed. * P  < 0.05; ** P  < 0.01; *** P  < 0.001

Association of phthalate metabolites with periodontitis

Table 3 in our study presents the association of phthalate metabolites with periodontitis. In Model 2, which adjusted for all potential confounders, we observed that an increase of one standard deviation (SD) in the log-transformed levels of several phthalate metabolites was associated with higher odds of periodontitis. Specifically, the ORs were 1.08 (95% CI: 1.02–1.14) for MECPP, 1.07 (95% CI: 1.02–1.11) for MnBP, 1.10 (95% CI: 1.05–1.15) for MEHHP, 1.05 (95% CI: 1.01–1.09) for MiBP, 1.09 (95% CI: 1.04–1.14) for MEOHP, and 1.08 (95% CI: 1.03–1.13) for MBzP.

Our RCS analysis revealed an inverted J-shaped relationship between log-transformed MCPP and periodontitis, with a statistically significant nonlinearity ( P for nonlinear = 0.0017), as shown in Fig.  3 . The inflection point for log-transformed MCPP was identified at 1.48 ng/mL.

Restricted cubic splines of the relationship between urinary phthalate metabolites with periodontitis ( A ) MCNP. B MCOP. C MECPP. D MnBP. E MCPP. F MEP. G MEHHP. H MiBP. I MEOHP. J MBzP. ORs (red solid line) and 95% CIs (red shaded region) were calculated using the median log-transformed urinary phthalate metabolites levels as the reference value. The horizontal dashed line represented the reference OR of 1.0. All of the models were adjusted for age, sex, race/ethnicity, education level, income, smoking status, body mass index status, hypertension, and diabetes mellitus

When controlling for age, sex, and race/ethnicity, we observed notably higher ORs for periodontitis in individuals within the highest quartile of metabolite levels compared to those in the lowest quartile. The ORs were 1.68 (95% CI: 1.21–2.33, P for trend = 0.02) for MECPP, 1.55 (95% CI: 1.17–2.05, P for trend = 0.01) for MnBP, 1.66 (95% CI: 1.21–2.30, P for trend = 0.005) for MEHHP, 1.59 (95% CI: 1.11–2.27, P for trend = 0.03) for MEOHP, and 2.05 (95% CI: 1.57–2.69, P for trend < 0.001) for MBzP. However, further adjustment for factors in Model 2 slightly attenuated these associations, with ORs for MECPP, MnBP, MEHHP, MEOHP, and MBzP being 1.32 (95% CI: 1.13–1.55, P for trend = 0.01), 1.20 (95% CI: 1.05–1.38, P for trend = 0.02), 1.30 (95% CI: 1.11–1.52, P for trend = 0.003), 1.25 (95% CI: 1.05–1.49, P for trend = 0.02), and 1.26 (95% CI: 1.10–1.44, P for trend = 0.01), respectively.

Subgroup analysis

In our subgroup analysis, we observed consistent effects across different demographics, including age, sex, and race/ethnicity, for the majority of the log-transformed phthalate metabolites. Specifically, the impacts of log-transformed MCNP, MCOP, MECPP, MnBP, MCPP, MEHHP, MiBP, MEOHP, and MBzP on periodontitis were uniform across these subgroups, as indicated by non-significant interaction terms (all P for interaction > 0.05), detailed in Supplementary Fig. 1. However, sex appeared to modify the relationship between log-transformed mono-ethyl phthalate (MEP) and periodontitis, as evidenced by a significant interaction term ( P for interaction = 0.003).

Notably, the positive correlation between log-transformed MECPP, MnBP, MEHHP, MEOHP, and MBzP and periodontitis was apparent across all examined subgroups, underscoring the potential broad impact of these specific phthalate metabolites on periodontal health.

Sensitivity analysis

We found similar relationships between phthalate metabolites and periodontitis in sensitivity analysis (Supplementary Table 3), proving the validity of our findings.

In this study, individuals with periodontitis exhibited higher levels of MECPP, MnBP, MEP, MEHHP, MEOHP, and MBzP when compared to those without periodontitis. Moreover, we observed a positive association between log-transformed MECPP, MnBP, MEHHP, MiBP, MEOHP, and MBzP and periodontitis, after adjusting for factors. It is important to note that the potential link between phthalate metabolites and periodontitis involves complex biological mechanisms that are not yet fully understood.

Research exploring the link between phthalates and periodontitis is limited. A previous study using NHANES data from 1999 to 2004 investigated the relationship between 156 environmental factors and periodontitis [ 13 ]. It reported that among current smokers, every one-point increase in the log-transformed level of mono-n-methyl phthalate was associated with a 47% increase in the likelihood of periodontitis (95% CI: 1.13–1.92) after adjusting for variables such as age, sex, race/ethnicity, socioeconomic status, and number of teeth. However, mono-n-methyl phthalate was included in the NHANES 2009–2010 and 2011–2012 cycles but was absent from the 2013–2014 cycle, and hence was not examined in our research. Instead, our study expanded the scope to include an additional 10 phthalate metabolites. By doing so, we conducted a more thorough analysis that encompassed multiple indicators, significantly enhancing the reliability of our findings. The observed pattern of consistent association between various phthalate metabolites and periodontitis underscores the potential biological effects these chemicals have in promoting such conditions. Given the ubiquity of phthalates in the environment, even a marginal increase in periodontitis risk could significantly affect public health. It is worth noting that the potential harm of phthalate metabolites may vary depending on factors such as individual differences, exposure time, pathways, and mixtures. As such, there is currently no clear consensus on safety thresholds for phthalate metabolites in urine.

Phthalates are categorized based on carbon chain length into low molecular weight (LMW) and high molecular weight (HMW) phthalates. MEHP, MECPP, MEHHP, and MEOHP are primary metabolites of di (2-ethylhexyl) phthalate (DEHP), a common HMW phthalate. phthalates are becoming increasingly prevalent due to their extensive application, thus elevating the risk of human exposure to these chemicals. The oral cavity, being a channel for both the respiratory and digestive systems, may be exposed to phthalates through various means. Phthalate metabolites have been detected in human saliva, though at lower levels than in serum and urine [ 27 , 28 ].

Park et al. suggested that DEHP may reduce estrogen receptor alpha (ERα) activity [ 29 ]. Estrogens, as sex steroids, play a critical role in modulating the host immune response and maintaining bone homeostasis [ 30 ]. Notably, estrogen's influence extends beyond female bone turnover to encompass male bone metabolism as well [ 31 , 32 ]. For instance, estrogen deficiency has been implicated in the onset of osteoporosis in elderly men [ 33 ]. Animal experiments have indicated that estrogen deficiency can exacerbate periodontal bone loss in rats with ligature-induced periodontitis [ 34 , 35 ]. This leads us to speculate that phthalate metabolites might impact the progression of periodontitis by interfering with estrogen functions.

Previous research has indicated that chronic inflammation might act as a mediator in the link between Mono (2-ethylhexyl) phthalate (MEHP) exposure and the onset of depressive symptoms [ 36 ]. Specifically, the mediating effects of interleukin-6 (IL-6) and generalized inflammatory factors in this context were quantified as 15.96% (95% CI: 0.0288–0.1971) and 14.25% (95% CI: 0.0167–0.1899), respectively. In addition, another study has shown that dibutyl phthalate (DBP) can induce apoptosis in grass carp hepatocytes, mediated through mechanisms of inflammatory response and oxidative stress [ 14 ]. This highlights the broader biological impact of phthalates. In the field of periodontal health, the inflammatory response is intricately connected to the pathogenesis of periodontitis [ 15 ]. Maintaining a balance between the body’s defense system and oxidative stress is crucial in preserving periodontal tissue health [ 16 ]. The interplay of inflammatory reactions and oxidative stress, often resulting in mutual reinforcement, can lead to increased osteoclast activity and subsequent bone loss. This connection underlines the importance of understanding the complex interplay between environmental factors like phthalate exposure, oxidative stress, and inflammatory responses in the pathogenesis of periodontitis.

Phthalate metabolites have been shown to alter the composition of the gut microbiota in mice [ 37 ], which also could have implications for human health through the gut-brain axis [ 38 ]. Another study has observed variances in the respiratory tract microbiota among individuals exposed to different phthalate concentrations [ 39 ]. Although there are no studies directly linking phthalate metabolites to changes in oral microbiota, the well-established connection between the development of periodontitis and alterations in oral microbiota leads us to hypothesize that phthalate metabolites could influence periodontitis by affecting the microbiota.

In summary, phthalate metabolites may influence periodontitis through three main mechanisms: impacting estrogen function and affecting host inflammation as well as the structure of the microbiome. Future clinical prospective studies should investigate the role of individual biological components in periodontal disease. This includes a thorough examination of host immunity, epigenetic changes, and microbiome composition, all of which are critical to health and disease. By incorporating these variables, we can gain a better understanding of how environmental factors like phthalate exposure contribute to or mediate disease processes. This method will allow for a more thorough investigation of the complex interactions between genetic predisposition, microbial ecology, immune responses, and environmental influences in the development of periodontal disease.

However, it's crucial to recognize the limitations of our study. Firstly, due to its cross-sectional design, we cannot infer a causal link between phthalate metabolites and periodontitis. Secondly, despite adjusting for potential confounders based on prior studies and clinical knowledge, there may still be unmeasured or unknown confounding factors. Thirdly, differentiating the impacts of short-term versus long-term exposure to phthalate metabolites on periodontitis is challenging. Fourthly, the classification criteria for periodontitis used in this study do not allow for a diagnosis in patients with only one tooth. Furthermore, third molars were excluded from the periodontal assessments, potentially leading to an underestimation of the periodontitis prevalence. Lastly, the periodontal examination did not include individuals under 30 years old or those residing in institutional settings like nursing homes, hospitals, hospices, or prisons.

Our study has identified a positive association of certain phthalate metabolites with periodontitis. These findings suggest a potential link between environmental exposures and periodontal health. However, conclusive findings regarding causality are not possible due to the nature of our study design. Therefore, future research should focus on tracking the long-term effects of phthalate metabolite exposure on periodontal health through prospective cohort studies. Additionally, advanced technologies including the microbiome, metabolomics, and proteomics analyses can be integrated with in vitro and in vivo experimental methods to elucidate the potential biological mechanisms linking phthalate exposure to periodontal disease. Only through this continued research can we fully understand the implications of phthalate exposure on oral health and potentially inform public health interventions and policy changes.

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Acknowledgements

The authors extend their gratitude to the NHANES for making their databases available for this research.

This research received support from the National Key Research and Development Programme of China, under the grants 2022YFC2405900 and 2022YFC2405901.

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Mengyao Bian, Wenxiang Jiang, Manting Wang, Ying Shi & Zhifang Wu

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Bian, M., Jiang, W., Wang, M. et al. Association of phthalate metabolites with periodontitis: a population-based study. BMC Oral Health 24 , 541 (2024). https://doi.org/10.1186/s12903-024-04316-4

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Study Evaluates Role of Oral Health Professionals in Encouraging HPV Vaccination

A recent study published in the journal  Vaccine: X explored the potential role of oral health professionals in identifying candidates for human papillomavirus (HPV) vaccination, given the link between HPV and oral cancers. Conducted in Edmonton, Alberta, the study implemented a case-finding strategy in two dental offices. Over 4 weeks, 656 patients were screened, with 179 identified as vaccination candidates, representing a 20.4% yield. Despite 74.8% of patients consenting to discussions about HPV vaccination, only 16% of those who received prescriptions from dentists actually received the first vaccine dose within 6 weeks. This translated to a mere 4.5% of consenting patients ultimately receiving vaccination. The study concludes that case-finding for HPV vaccination candidates in dental offices is feasible, but the low uptake highlights the need for further intervention refinement. The findings suggest the necessity of additional strategies, such as follow-up discussions with oral health professionals, to improve vaccination rates. Overall, while dental offices hold promise as sites for HPV vaccination promotion, optimizing intervention approaches is imperative for enhancing efficacy. Click here to read more.

Kristen Pratt Machado is executive editor for Dimensions of Dental Hygiene and Decisions in Dentistry and director of publishing operations for Belmont Publications, Inc. She has been with Belmont Publications since its inception in 2002.

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Take care of your teeth and gums. Oral health can affect your brain.

Poor oral hygiene is associated with an increased risk for myriad health problems, including heart disease, diabetes, cancer, rheumatoid arthritis and early death . The state of our teeth and gums, though, may be vital for our well-being beyond the mouth and body.

Emerging evidence suggests that what goes on in our mouth can affect what goes on in our brain — and may even potentially affect our risk for dementia.

“People should really be aware that oral health is really important,” said Anita Visser , professor in geriatric dentistry at the University of Groningen in the Netherlands.

Severe periodontal disease — chronic inflammation of and damage to the gums and bone that support the teeth — affects about 19 percent of people older than 15 or more than 1 billion people worldwide, according to a 2022 World Health Organization report . More research is needed, but recent observational studies have suggested that oral health may be a modifiable risk factor for Alzheimer’s, the most common type of dementia.

Scientists are still working out whether and how the health of our mouths and minds meld, but they have identified two potential culprits that might explain how gum disease could lead to Alzheimer’s disease: bacteria and inflammation.

Connecting dental and mental health

One of the first studies to document the link between gum disease, tooth loss and Alzheimer’s disease focused on a cohort of aging nuns who were part of a larger study on aging. Researchers tracked 144 of the nuns and found that severe tooth loss was associated with dementia risk up to 6.4 times higher than compared with those who lost fewer teeth.

Other more recent longitudinal studies also found that a higher incidence of tooth loss was associated with cognitive decline. In one small 2016 study of 60 patients with mild to moderate dementia, periodontitis was associated with a sixfold increase in cognitive decline.

Another study, in 2017, of almost 28,000 Taiwanese patients reported that having chronic periodontal disease for 10 or more years corresponded to a 1.7 times increase in the risk for Alzheimer’s disease . A 2022 meta-analysis of 47 longitudinal studies reported that tooth loss and poor oral health are associated with both cognitive decline and dementia.

This research paints an emerging picture of an association between poor oral health and dementia, but there are a number of confounding factors that prevent researchers from drawing definitive conclusions of causation.

The higher rate of dental problems among those with dementia may be a symptom rather than a cause of cognitive decline. People with dementia have a difficult time maintaining their oral health and have an increased risk of developing gum disease , meaning that the association between oral and cognitive health may be bidirectional.

Other known risk factors for dementia, such as smoking and lower educational levels, are also associated with worse oral health . Tooth loss has secondary effects that can affect nutrition and overall health, which can also affect cognition, Mario Dioguardi , a researcher in dental science at the University of Foggia, said in an email.

“It’s really complicated,” said Visser, who wrote a recent review on the association of oral health and Alzheimer’s. “And this is why we cannot say, ‘Oh, if you have periodontitis, you will get Alzheimer’s disease.’ But we know now that if you have severe periodontitis, the chance of getting Alzheimer’s disease is bigger.”

Mouth bacteria may infect the brain

Research has found that bacteria that normally reside in our mouth may also infect the brain and potentially contribute to neurodegeneration in Alzheimer’s disease.

A 2019 study published in Science Advances reported that the DNA of P. gingivalis bacteria, a key pathogen in gum disease, could be found in brain autopsies from Alzheimer's patients. Bacterial DNA was also detected in the cerebrospinal fluid of people living with a probable Alzheimer's disease diagnosis.

Toxic enzymes from the P. gingivalis bacteria were also found in the Alzheimer’s patients’ brains and correlated with the amount of tau protein pathology, a hallmark of the disease.

Orally infecting mice with the bacteria led to the presence of P. gingivalis DNA as well as the accumulation of amyloid β cellular waste — a hallmark of Alzheimer’s — in their brains.

The researchers were able to inhibit the bacterial enzymes in mice infected with P. gingivalis , which reduced amyloid β production and neuroinflammation. (A recent clinical trial targeting those bacterial enzymes fell short, however, and the Food and Drug Administration placed a hold on future trials.)

“The mechanisms through which periodontal bacteria can access the central nervous system remain unknown” but could reach the brain through circulation in the blood or along peripheral nerves, wrote Dioguardi, who was a co-author on a recent review on the role gum disease and oral bacteria play in Alzheimer’s.

Mouth inflammation can affect the brain

If we do not brush our teeth for several days, each tooth develops a thin biofilm called dental plaque that teems with acid-producing bacteria.

“Your body doesn't like these bacteria,” Visser said. “They're on the edge of your teeth and on the edge of your gum.”

With plaque buildup comes inflammation of the gums as our immune system tries to fight off the infection. Gingivitis, the mildest form of periodontal disease, is still reversible; brushing and removing the plaque buildup will allow the gums to heal.

But more severe gum disease, or periodontitis, can follow if the gingivitis is not addressed.

“The whole body is fighting against this bacteria,” Visser said. “ The immune system is really provoked and alert and working really hard against these bacteria.”

This chronic inflammation becomes a vicious cycle: more swelling of the gums enlarges the gap between the teeth and gums, allowing more bacteria to enter, which can lead to inflammation of not only the gums but also the underlying bone. Continued unabated, the body will reject the tooth, causing loosening and eventual loss of the tooth.

This chronic inflammation can spill from the mouth into the rest of the body. Gum disease is linked to an increase in pro-inflammatory molecules in the blood, Dioguardi said.

Chronic inflammation in the body can, in turn, lead to chronic neuroinflammation in the brain, which induces neurodegeneration and plays a key role in Alzheimer’s.

Oral health and dementia

Visser is conducting a longitudinal study collecting oral health data — X-rays of teeth and samples of bacteria — from several hundred patients with cognitive impairment to get more information about how their oral health affects their cognitive risk.

Already, “we saw some really severe cases of oral health problems which are missed by the doctors,” she said.

The challenge of untangling the relationships between our lifestyle, our teeth and our brains remains. “There are so many confounders, lifestyle, smoking, educational level diet,” Visser said. “So it’s really hard to do this research.”

Until more is known, researchers stress that oral hygiene remains one of the simplest and most important ways you can take care of yourself.

“Raising awareness among the population about the increased risk of Alzheimer’s associated with tooth loss and periodontitis can lead to heightened attention towards oral health, ” Dioguardi said in an email.

For better health — and possibly for a healthier brain — keep brushing.

Do you have a question about human behavior or neuroscience? Email [email protected] and we may answer it in a future column.

• Open access
• Published: 05 May 2024

Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives

• Einar Furulund 1 , 2 , 3 ,
• Karl Trygve Druckrey-Fiskaaen 2 , 3 ,
• Siv-Elin Leirvåg Carlsen 2 , 3 ,
• Tesfaye Madebo 2 , 4 , 5 ,
• Lars T. Fadnes 2 , 3 &
• Torgeir Gilje Lid 1  

BMC Nutrition volume  10 , Article number:  70 ( 2024 ) Cite this article

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People with substance use disorders often have unhealthy diets, high in sweets and processed foods but low in nutritious items like fruits and vegetables, increasing noncommunicable disease risks. This study investigates healthy eating perceptions and barriers among individuals with opioid use disorder undergoing opioid agonist therapy. Interviews with 14 participants at opioid agonist therapy clinics in Western Norway, using a semi-structured guide and systematic text condensation for analysis, reveal that most participants view their diet as inadequate and express a desire to improve for better health. Barriers to healthy eating included oral health problems, smoking habits, and limited social relations, while economic factors were less of a concern for the participants. Participants did find healthy eating easier when they were in social settings. This study underscores the importance of understanding and addressing these barriers and facilitators to foster healthier eating patterns in this population, potentially enhancing overall health and well-being.

Peer Review reports

Introduction

Substance use disorder (SUD), particularly opioid use disorder (OUD), is complex and extends beyond the risk of overdose, suicide, and infection. Noncommunicable diseases, such as chronic lung diseases, cancer, and cardiovascular diseases, all contribute to increased morbidity and mortality [ 1 , 2 ]. Nutrition is an important but often overlooked aspect of SUD recovery [ 3 ]. Individuals, particularly those with OUD, often report unhealthy eating habits consisting of a high consumption of sweets, sugar-sweetened and processed foods and a low consumption of fruits and vegetables [ 4 , 5 , 6 , 7 , 8 ]. Comorbidities might arise or worsen because of an unhealthy eating behavior [ 9 , 10 ]. Furthermore, substance use can severely impact an individuals’ nutritional habits and diet, as substances are often favored over food [ 11 ]. According to recent Norwegian research [ 12 , 13 ], approximately half of the patients receiving opioid agonist therapy (OAT) are deficient in vitamin D and folic acid.

Despite the established link between dietary habits and health outcomes in the general population, few studies have focused on nutritional interventions for populations with SUD and OUD [ 14 ]. A diet containing a higher intake of fruits and vegetables may reduce morbidity in high-risk populations by improving cardiovascular and mental health, as well as biomarkers of cellular stress defense [ 15 , 16 , 17 , 18 ]. However, it is unclear to what extent interventions aimed at other high-risk groups could be applied directly to OAT patients. This research gap highlights the need for improved understanding of dietary behaviors and attitudes to healthy eating among individuals in OAT.

Materials and methods

This study aims to provide insights into the dietary habits and views of healthy eating among individuals with opioid use disorders receiving opioid agonist therapy. In addition, we intend to lay the framework for the development of dietary interventions that could improve health outcomes and quality of life for individuals receiving OAT by identifying barriers and facilitators.

ATLAS4LAR project aims to improve the health and well-being of individuals with opioid use disorder undergoing OAT [ 19 ]. The project enrols OAT patients from Stavanger and Bergen, two cities in Western Norway, into a cohort and a health registry. This article was based on participants in this cohort. A semi-structured interview guide on dietary habits and perceptions of and barriers to healthy eating was developed as a collaboration between the study group, research nurses, clinicians, and user representatives. The interview guide covers topics of physical activity, smoking cessation [ 20 ] and healthy eating; this article focuses on healthy eating. A COREQ checklist [ 21 ] was applied and is included in the supplementary file.

Study sample and setting

Interviews were conducted with 14 patients at OAT clinics in Stavanger and Bergen, the two largest cities in Western Norway. All patients who completed an annual health assessment and willing to complete an interview about lifestyle were eligible to participate in the study. There were no specific exclusion criteria. Most patients receive follow-up on a weekly basis from multidisciplinary teams, including monitoring of OAT medication intake such as buprenorphine and methadone. For more information regarding the included outpatient clinics, see Fadnes et al. (2019) [ 22 ]. The research nurses collaborated with OAT clinicians to recruit a purposive sample from four different clinics in Bergen and Stavanger. Our goal was to recruit participants from various OAT clinics and ages and genders; the study sample characteristics are outlined in Table  1 .

Data collection

Among the 14 participants, thirteen completed the full interview guide, with one participant leaving the interview after twelve minutes with an incomplete interview. All the 14 participants consented to the interviews being audio recorded. All interviews were conducted during the ongoing COVID-19 pandemic in January and February 2021. Necessary precautions were taken to minimise the risk of transmitting viruses during the interview. This included symptom checklists for COVID-19, maintaining distance, and occasionally wearing facemasks. Three research nurses with training in qualitative interviewing contacted patients by phone or when they had an appointment at the clinic and conducted the interviews. They were instructed to move between topics and questions based on interview dynamics. The final interview guide included three nutrition-related issues: (1) reflections on their daily diets, (2) opportunities to prioritise healthy eating in their daily lives, and (3) reflections on the need to change their diets. See the supplementary file for the interview guide. A total of forty to sixty minutes were spent on each interview.

Data analysis

Due to COVID-19 and geographical distances between researchers, we conducted our meetings through Microsoft Teams for video conferencing and used NVivo 20 for the data analysis A pseudonym reflecting the gender of the participants was assigned to each recording, and it was transcribed verbatim by the study’s authors (EF, SELC, and KTDF). The analysis followed the four steps of systematic text condensation [ 23 , 24 ]. At first, the authors spent extensive time reading the transcripts to better understand what was being said. This thorough reading led to identifying preliminary themes, their presentation, and a collaborative discussion in a workshop. As a result of this discussion, some central themes were agreed upon for further analysis. Afterwards, a second reading was conducted to identify meaningful units, which were then categorized under the earlier themes. The lead author led the data analysis in close collaboration with SELC, KTDF, and TGL. TM and LTF also contributed significantly, ensuring a collective analysis effort. This collaborative approach facilitated the generation of condensed versions that captured the essence of the categorized themes. Ongoing discussions on terminology and limitations among all co-authors ensured clarity and coherence throughout the process. In the end, these condensed insights formed the basis of an overall narrative that addressed the aim of the study.

14 participants were interviewed, 11 male and three females, and all receiving OAT (Table  1 ). All participants had relatively stable housing conditions, and six lived alone. Five had injected drugs within the past six months before the interview. Thirteen reported smoking at least three times a week. The median debut age for tobacco, alcohol and cannabis was 13 to 14 years, while for stimulants it was 23 years and for opioids 25 years.

In this analysis, the researches extracted three themes and several subthemes reflecting the complex interactions between personal health, social environment, and dietary practices. For instance, the theme “Dietary Patterns and Health Practices” explored varied dietary habits among participants, from structured meals incorporating traditional Norwegian foods to periods of unhealthy eating dominated by fast foods and convenience items. Sub-themes include the impact of drug use on dietary habits and the role of smoking in influencing taste and appetite. The theme “Barriers and facilitators to healthy eating” discussed factors influencing patients’ ability to maintain a healthy diet, including economic constraints, access to cooking facilities, and treatment facilities’, and physical and social environment. Sub-themes highlighted the role of oral health in dietary choices and the potential of nutritional interventions within OAT clinics. The last theme, “Social and psychological dimensions of eating”, addressed the social context, focusing on how living arrangements and social interactions influence dietary choices. This theme also delves into the stigma associated with substance use and its impact on participants’ nutritional choices and self-perception.

Participants differed greatly in their eating patterns. Most participants acknowledged the importance of increasing fruit and vegetable consumption and expressed a wish to eat healthier. Some perceived their diet as well-balanced, which included multiple meals of traditional Norwegian foods. Others reported having unstable dietary habits, expressed as having healthy periods of eating nutritious foods, and less healthy periods with mainly intake of unhealthy foods such as fast foods. Additionally, some said they almost did not eat for long periods. Some participants felt they needed more knowledge to implement a nutritious diet into their daily lives.

Economy and access to a kitchen were not important barriers to healthy eating

Although most participants said they could afford healthy food and maintain a healthy diet, some highlighted that they could not afford high-priced food like fresh fish or meat several times a week. Nevertheless, it was possible to cook nutritious food despite having little money. Some participants also mentioned vitamin supplements as a means of enhancing their nutrition.

“Yes, I want to eat healthier food. Much of what is healthy is not that expensive. Buy some tomatoes, cucumber, lemon, and salad. Then, we look for where there is an offer, and we go to each store and pick what is on offer”. - Thomas.

For many participants, the kitchen was a space of both opportunity and challenge. While some engaged in regular meal preparations, others found themselves limited to heating pre-processed foods. Living in treatment facilities posed challenges due to their strict schedules and predetermined diets. Some participants had experienced being responsible for prepare food for the institution and other patients. These routines could be quite demanding, and they could become tired of cooking. An interesting introduction to smoothies was noted in some substance use treatment facilities, for making smoothies accessible where the institutions did buy the fruits and vegetables and stood with available equipment. This was without any cost to the patients. The participants expressed appreciation for the smoothies, citing their taste and feeling healthy as key reasons for the positive reception. After discharge from these institutions, none of the participants regularly continued to make or purchase smoothies.

“If you live in an institution or in those places where you are not completely in charge and do not have your own apartment, then it is probably more difficult to inspire yourself to cook and eat healthy …” - Thomas.

Struggling with stigma related to substance use

Several participants knew of food distribution centres that provided free food. Some said it was a helpful initiative to distribute free food to people in need. In contrast, others experienced barriers such as the stigma of being seen at these centres, or the risk of meeting people under the influence of drugs.

“And I do not like going to those Salvation Army [having a food provision service] centres, because I meet so many weird people [trying to sell drugs] … It can be tough to say no [offers for drugs] to those people sometimes”. - Erik.

Some participants mentioned the drug-related stigma linked to low weight. Some participants did not view their weight as crucial to their overall well-being. However, a few participants reported that their family members focused on the participant’s weight and associated this with their life situation, specifically their substance use.

“… about the kilos. It is not something like that, I think I’m very thin or something like that, but I hear from family members that I have now lost weight. Then, I know that they associate it with illicit drugs and that things are not going well. That probably affects me more than just those kilos”. - Kristian.

Some participants stated that they struggled to gain weight, even though they wanted a better appetite to increase their body weight. Some also made choices accordingly, such as eating a high-fat diet. Despite this, weight gain remained a constant struggle. While some participants had specific goals to increase their body weight by five to ten kilograms, they faced challenges in achieving this in a healthy manner. Despite their intention to gain weight, the participants expressed concerns about excessive sugar intake and its impact on their overall health. The struggle to balance weight gain with a nutritious diet and a lack of self-confidence in the kitchen made it difficult for them to adhere to balanced and healthy eating.

“To gain more weight, I try to eat fat-rich foods. Yes, it is the usual routine with breakfast, lunch and dinner, and there are also snacks in between, and of course, then I eat supper”. - Peter.

Oral health status and smoking impact negatively on healthy eating

Poor oral health was a major barrier that greatly impacted the participants’ diet. Missing several teeth, poorly adapted dentures and pain in their mouth restricted many from eating many of the fruits and vegetables. Some described hard fruits and vegetables such as apples and carrots as impossible for them to eat. Participants with poorly adapted dentures expressed difficulties in eating and needing to clean their dentures after eating, which were perceived as embarrassing and stigmatising in social settings.

“Meat, yes, and then it gets stuck. So, I always have to take [the denture] out after I finish eating. Then, I need to go to rinse my mouth. It was not how I imagined it when I got it [denture]…. The only thing I have been able to chew is bananas and oranges, because they are soft”. - Jacob.

Several participants reported that smoking negatively impacted their taste, reduced their appetite of food, and affected their daily food consumption. Smokers who reduced or stopped smoking, experienced an increase in appetite and a positive impact on the taste of food.

“When I stopped smoking, my taste returned to normal, and my appetite improved since smoking “killed” some of my taste for food”. - Thomas.

The social context is important for all aspects of eating

Most participants expressed that food has a social function, particularly among those who live alone. Participants who had cohabitants also said their diet would have been negatively affected if they had lived alone. Establishing or maintaining healthy eating habits were challenging to many who regularly were eating alone. Some participants did not see the value of making an entire meal just for themselves. Furthermore, when participants were alone, purchasing unhealthy foods such as doughnuts and fast food was easier.

“I see I have such a good diet only because I live with someone. It is better to be two people eating together rather than alone… yes, it has a lot to say. Many complain and say exactly that [to me]; ‘you are lucky to be two people’ [eating together]”. - Jacob.

Some participants found that creating a shopping list simplified the grocery shopping process. Although many lacked the discipline to organize a shopping list and preferred not to shop alone, they found it more manageable to shop with family or friends. Alone, participants said to buy unhealthy food, high in fat, and sugar. In contrast, shopping with others often led to healthier choices. However, for a few participants, the challenge was not in purchasing nutritious food but in the actual cooking and preparation of meals.

“I go to the store every other day to buy food. Instead of thinking ahead that tomorrow I will have this for dinner, and then I will have that for dinner the next day”, I make a list like that in my head. However, I do this [buys the food], and the food ends up in the freezer, and then it stays there”. - Oliver.

Preferences relevant to nutritional interventions in the clinic

We specifically asked participants about their preferences for establishing nutritional interventions in their OAT clinic. Most participants wanted to consume more fruits and vegetables, recognising their health benefits and appealing taste. They thought the OAT clinics should promote a healthy diet more actively, e.g., with posters in the waiting room. These posters could include basic information about different foods and about the consequences of not eating healthy. Other suggestions were more extensive, with a clinic-initiated patient-oriented educational cooking programme, focusing on easy recipes of affordable and tasty food.

The study offers fresh insights into the viewpoints and choices of patients regarding healthy eating within the context of OAT. Numerous participants highlighted challenges such as oral health concerns, smoking habits, and reduced social interactions that hinder their ability to adhere to a healthy diet. Interestingly, economic constraints were cited by only a minority of participants as barriers. Additionally, some individuals expressed that they found it easier to sustain a healthy diet when they had social support and stressed the importance of having a structured grocery shopping list.

It is essential to acknowledge that several factors play a role in dietary choices among the OAT population [ 25 ]. Our research has shown a notable shift in the average age of individuals in our sample compared to previous studies. This demographic transformation toward an older population is associated with an increased susceptibility to chronic diseases and a higher risk of malnutrition [ 26 ]. Specifically, the average age of patients undergoing Opioid Agonist Therapy (OAT) now stands at 47, with a median age of 49 within our dataset. A decade ago, the typical age for this OAT patient group was 42, marking a significant increase of five years over the past decade. Notably, the proportion of OAT patients aged 60 and above has tripled in 2021 when compared to data from 2015 [ 27 ]. Furthermore, within our sample, we have observed significant variations in dietary habits and meal frequency among this demographic. Nevertheless, in the context of an ageing population, the importance of adopting healthy eating habits becomes even more pronounced to reduce the risk of chronic diseases, including cardiovascular and metabolic disorders.

In Norway, people with SUD have a high level of social support offered by the government in terms of financial help, free or subsidised health care services, and mostly stable living conditions [ 28 ]. Previous studies have found that people with long-term SUD experience economic challenges and unstable living conditions, making it difficult to achieve adequate nutrition [ 4 , 29 ]. Our participants, however, did not see the economy as a primary obstacle to healthy eating. Despite some financial limitations, such as the need to prioritise and adhere to a budget, they were generally able to afford several healthy foods as components for their diets. Interestingly, some participants who lived together with others said they were always looking for reasonable offers on food at the store, almost like a sport. This may support that they do not necessarily have a stable and strong economy but have strategies to manage economic limitations. However, even with a stable living situation and kitchen access, they still found attaining a healthy diet to be difficult.

Poor oral health significantly hinders the ability to maintain a nutritious diet primarily due to missing teeth, oral pain, or dentures. Many participants expressed how their oral health directly influenced their diet. These physical constraints and the potential for social discomfort provide insights into the infrequent consumption of fruits and vegetables, even when individuals are aware of their nutritional benefits. This aligns with findings on older adults [ 30 ], with many reporting poor oral health due to lacking and damaged teeth. As a result, they have fewer choices for food, such as fruits, vegetables, and fibre, increasing their risk of unhealthy food choices [ 30 ]. However, not all the participants in our study described difficulties eating healthy food. Interestingly, some were introduced to smoothies at treatment facilities and found them appealing. After being discharged, however, they did not continue to make or purchase smoothies.

A large study found an inverse relationship emerged between cigarette smoking and eating healthy food. Specifically, as individuals increase their daily smoking, their intake of healthy foods, such as fruits and vegetables, declined. This is in line with our findings, where participants shared that smoking adversely affected their ability to taste the food [ 8 ]. This effect may be attributed to nicotine’s widely recognized capacity to suppress appetite, potentially prompting individuals to turn to smoking as a substitute behavior for eating [ 31 ].

The absence of individuals to share meals with and feelings of loneliness posed a significant obstacle to the participants’ attempts to sustain a nutritious diet. Many conversations centred around the challenges of grocery shopping and meal preparation for solitary individuals. These observations align with previous research, which has shown that people living alone typically consume fewer fruits, vegetables, and fish compared to those who have meal companions [ 32 ]. Although our data do not allow direct comparisons, the narratives from our participants are consistent with these findings. In contrast, those living with others credited their dietary stability to their shared living arrangements. They believed that having someone to share meals with added an extra layer of meaning and purpose to meals.

Many participants were interested in adopting healthier eating habits, a positive and noteworthy finding considering their substance use history. This shift towards healthier diets may indicate an awareness of the correlation between health and nutrition even after prolonged substance use. These individuals recognized the potential for an improved diet to enhance their health. Some associated a healthy diet with weight gain as a sign that their drug problem is under control. Those who wanted to increase their weight said they needed to pay attention to their diet, which could be exhausting. A number of epidemiological studies have investigated the relationship between drug use and body weight, and most of the evidence demonstrates an inverse correlation [ 33 ]. A regular diet can have therapeutic benefits, including improving health, self-esteem and social relationships [ 25 ].

During the interview, participants were asked for intervention preferences relevant to their dietary and nutritional needs. Interestingly, not all participants came up with specific suggestions for this topic, yet some proposed the idea of making information available in the waiting rooms or initiating cooking courses. As an alternative, some participants suggested that smoothies would be beneficial to consume more fruit and vegetables without damaging their teeth. The potential of smoothies as effective dietary interventions has been explored in different populations, including adolescents in schools and older adults [ 34 , 35 ].

The current study has several strengths and limitations. The qualitative design provides an in-depth understanding of participants’ experiences, and of barriers and facilitators to healthy eating. However, one limitation regarding its design is that nutritional status was not measured in our study. The participants described their nutritional status through their eating habits, detailing their behaviour and experiences associated with eating patterns. Research nurses assisted with providing insights into how to perform the interview and the interview guide on how to phrase the questions in an understandable way. User representatives offered valuable insight to ensure the relevance and highlighted cultural and societal factors. Even though research nurses are separate from the clinical care, bias may still occur. Some patients may be more inclined to present themselves rather than express their feelings or give feedback. Through collaboration in frequent digital meetings and using a theoretical framework, we were able to test ideas and interpretations, and thus reduce the influence of investigator bias [ 36 ]. It is likely that social desirability influenced the interview process and results. When data were collected, the study participants were receiving treatment from OAT outpatient clinics where they were interviewed, which may have made them more susceptible to social desirability bias during interviews [ 37 ]. The interview guide was designed to minimise such bias, as well as the choice of interviewer being a research nurse and not their contact person/clinician. The participants could steer the order of the topics in the discussion, which probably enabled them to speak more freely from their perspectives.

Together with earlier work, this study emphasises the importance of understanding patients’ perspectives and needs regarding nutrition [ 25 , 38 ]. According to patients, diet and nutrition are important and bidirectionally interlinked with their substance use. Healthcare providers should address the diet and nutrition of patients to facilitate recovery. However, strategies to improve oral health among OAT patients, and motivational and educational strategies to improve cooking skills, are necessary prerequisites in addition to the more specific interventions, to improve patients’ recovery and their overall health.

The OAT platform facilitates communication between healthcare professionals and hard-to-reach patients. To prioritize nutrition, five key topics have been proposed: incorporating discussions about food and nutrition history into clinical consultations, conducting anthropometric measurements including regular weight monitoring, utilizing biochemical data to identify dietary limitations, evaluating potential health implications of individuals’ nutritional profiles, and tailoring approaches based on clients’ personal histories and perspectives [ 39 ]. The results indicate that a combination of individual, social, and environmental factors influenced participants’ dietary habits and eating patterns.

Conclusions

In conclusion, our findings shed light on several critical aspects of a healthy diet among patients in OAT. Oral health issues, smoking habits, and limited social interaction emerged as significant impediments to upholding a nutritious diet. Healthcare professionals should proactively tackle these obstacles, while future research should prioritize devising effective strategies to overcome these barriers and improve the dietary patterns, nutritional well-being, and overall health of individuals undergoing OAT.

Data availability

Because of data protection regulations, the raw interview data for this study are not publicly available.

Abbreviations

Substance use disorder

Opioid use disorder

opioid agonist therapy

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Acknowledgements

In addition to the participants, we would like to thank the dedicated clinical staff for their enthusiasm during the planning stages of the study. Rannveig Elisabeth Nesse deserves recognition for her assistance with the transcription of the interviews. We also acknowledge the ATLAS4LAR Study Group: In Bergen: Vibeke Bråthen Buljovcic, Jan Tore Daltveit, Trude Fondenes, Per Gundersen, Beate Haga Trettenes, Mette Hegland Nordbotn, Maria Olsvold, Marianne Cook Pierron, Christine Sundal, Jørn Henrik Vold. In Stavanger: Maren Borsheim Bergsaker, Eivin Dahl, Tone Lise Eielsen, Torhild Fiskå, Marianne Larssen, Eirik Holder, Ewa Joanna Wilk, Mari Thoresen Soot.

This study is funded by the Western Norway Regional Health Authority («Strategiske forskningsmidler» through the ATLAS4LAR project - August 3, 2020 to December 31, 2029). Open access funding was provided by the University of Bergen. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Einar Furulund & Torgeir Gilje Lid

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Einar Furulund, Karl Trygve Druckrey-Fiskaaen, Siv-Elin Leirvåg Carlsen, Tesfaye Madebo & Lars T. Fadnes

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Einar Furulund, Karl Trygve Druckrey-Fiskaaen, Siv-Elin Leirvåg Carlsen & Lars T. Fadnes

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All authors (EF, KTDF, SELC, TM, LTF and TGL) were involved in the study’s design, analysis of the data and contributed to the manuscript. EF wrote the first draft and led the writing process. All authors read and approved the final manuscript.

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As part of the ATLAS4LAR project, the Regional Ethics Committee for Health Research (REC) southeast, Norway (no. 1555386/sørøst) approved this study (dated 23 September 2020). All patients involved in this study provided written informed consent.

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Furulund, E., Druckrey-Fiskaaen, K.T., Carlsen, SE.L. et al. Healthy eating among people on opioid agonist therapy: a qualitative study of patients’ experiences and perspectives. BMC Nutr 10 , 70 (2024). https://doi.org/10.1186/s40795-024-00880-8

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DOI : https://doi.org/10.1186/s40795-024-00880-8

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