Diabetes, bulimia, mouth cancer and vitamin deficiencies – these are some of the illnesses that can be evident in one’s mouth and that a dentist may be alerted to when you attend for a check-up.

In his career to date, Robin Foyle of the Wexford Dental Clinic and current president of the Irish Dental Association has observed oral (mouth) cancer in two patients, for example.

“The average dentist will come across two such cases in their career,” he says.

In my own case, I’ve come across two to date – but I have referred many more patients on for investigation, having noticed something atypical.

"Those ultimately didn’t turn out to be serious, thank goodness, but it’s always better to err on the side of caution, rather than miss something.”

Currently, though, every month or so, he says, a dentist in his practice comes across something unusual – and that patient would be referred on to their GP or a consultant. Dentists don’t diagnose non-dental illnesses, however, the Wexford-based dentist points out.

“Like GPs, we may suspect that something is wrong, based on our training – but it would be the appropriate consultant who would later provide confirmation and diagnosis.”

There is a huge number of systemic illnesses that can be observed in the mouth, he states, which are divided into three groups, namely:

1 Systemic conditions (illnesses that affect the whole body) that have oral manifestations (affect the mouth).

2 Dental or mouth diseases (oral pathology).

3 Dental or mouth diseases that can have systemic effects; for instance, affect the rest of the body.

1.Systemic conditions

VITAMIN DEFICIENCIES

In the first group, the common ones are vitamin deficiencies, he says. “Vitamin B12 and iron deficiencies will tend to cause bleeding gums and thin (atrophic) mucous membranes in the mouth as well as frequent ulceration.

“With vitamin deficiencies, a symptom like a red tongue is often a sign. In the past, teeth falling out of a person’s head would have been a sign of vitamin C deficiency: scurvy, which was common in sailors back in the 19th century.”

Conditions that can cause vitamin deficiency today include coeliac and Crohn’s disease. “Tooth enamel defects may or may not also be related to these diseases, but many other conditions can cause these symptoms too. That’s why it is important to rule out local dental conditions and refer for bloods and further investigation. Sometimes nothing would be picked up. It depends on the severity. There’s a spectrum,” says Dr Foyle.

DIABETES

If dentists notice that gum disease in a patient has become rapidly worse or isn’t responding to treatment, they may suspect that the patient has undiagnosed diabetes.

“Gum disease is relatively common and tends to run in families. It may rarely be related to immune problems, but when it doesn’t respond to treatment we would refer patients for investigation, as it could be diabetes-related.

“In someone who is known to have diabetes already, gum disease should be watched out for and treated too,” he explains.

CANCER OF LYMPHATIC* SYSTEM

Cancer of the lymph nodes – both Hodgkin’s and non-Hodgkin’s lymphomas – can be picked up by dentists during routine examinations too, he says, as happened in one of the two cases he referred.

“We could see unexplained swelling of lymph nodes and other unusual symptoms, like a non-healing mouth ulcer.

As a dentist you would generally be checking for lumps and bumps in someone’s mouth.

"We would also feel round the inside of someone’s mouth and usually underneath their chin and jawbone to check their lymph nodes.

“Both Hodgkin’s and non-Hodgkin’s can be evident when you check for these lumps and bumps and red and white spots in these areas.”

BULIMIA

The fact that a person has the eating disorder bulimia can be obvious to a dentist, because he or she will see a particular pattern of tooth erosion related to the stomach acid that comes up into the mouth when a person induces vomiting on a regular basis.

“The acid erosion related to bulimia has a particular pattern. It’s on the palatal side of the upper front teeth, usually from the first pre-molar to the first premolar on the other side,” says Dr Foyle.

“Obviously it has to be ongoing for a period of time for the acid attack at the back of the teeth to have an effect. It is frighteningly common, unfortunately. I have seen a lot of this kind of acid erosion.”

2. Mouth diseases

MOUTH CANCERS

The second group is oral pathology: dental or mouth diseases or disorders, which refers to conditions that originate in the mouth but that have consequences in the body generally.

“The common conditions that we look out for in this group at every dental check-up are squamous cell carcinoma, HPV infection and salivary tumours.

“The mouth is examined for ulcers that don’t heal; for red, white or speckled red and white gingiva and mucous membranes; as well as any unexplained swelling of the gums, tongue or lymph nodes.”

Oral cancers are very serious, and treatment for them is unpleasant and has lifelong effects, he adds. “It can mean the person having most of their tongue and half of their lower jaw removed. It’s that serious, so early detection is vital.”

HPV-RELATED MOUTH AND THROAT CANCER

Human papilloma virus (HPV) related oral cancers are increasing rapidly and in a much-younger population, he states. While the squamous cell cancer was typically found in older single men who smoked heavily and drank spirits regularly, HPV-related oral cancers affect a much younger group and often younger women in their 30s and 40s.

“It’s the same virus that causes cervical cancer, and is much more prevalent than it was. It can lie dormant for years, so you can get it later in life or young as well.”

HPV cancer can be contracted through engaging in oral sex with infected partners. “We tend to shy away from mentioning that, so that we don’t stop people from coming to get these things investigated, but that’s how it occurs by and large.

“People are getting vaccinated against the HPV virus now, so that might be a positive. There are about 200 strains of HPV and only a few cause cancer, but this type of cancer is on the increase and if it is caught early it won’t progress to malignancy.”

HIV/AIDS

While it is unusual to see oral manifestations of HIV/AIDS in dentists’ chairs these days because of early diagnosis and effective treatment, it was common in the 1990s to come across what’s called pseudomembranous candidiasis.

“This is white plaque on the mucous membranes that bleeds when removed and is a very strong indicator of HIV/AIDS,” he says.

3. systemic effects

CORONARY HEART DISEASE

“The third group of conditions is oral diseases that can have a detrimental effect on other body systems. There is growing evidence that patients with periodontal (gum) disease are at higher risk of coronary artery disease, which leads to heart attack and stroke.

“That is believed to be because the bacteria that are in the gum pockets that are causing the periodontal disease often have a negative effect on your heart and the arteries that supply blood to your heart,” says Dr Foyle.

Heart attacks can also sometimes present as pain in lower teeth/jaw and the story is told of a cardiologist going to his dentist and being told he hadn’t a toothache but a heart attack!

"Maintaining good oral hygiene is therefore important to reduce your risk of coronary heart disease.”

HIP REPLACEMENTS AT RISK

It is important to also remember that you are at high risk of damage to prosthetic joints – such as hip and knee replacements and also prosthetic heart valves – if you have gum disease or oral infections generally.

This is because oral bacteria are able to get into the blood stream and find their way to these artificial joints and cause damage.

For this reason patients who are undergoing hip or knee replacements or heart valve grafts are required to have a letter of dental fitness before undergoing any surgery.

Similarly, those who need chemotherapy must have a dental check-up and any issues dealt with before chemotherapy is scheduled.

“That’s because your immune system (during the therapy) is under stress and the impact of any infections magnified.” CL

SYMPTOMS OF GUM DISEASE

Healthy gums should be pink, firm and keep your teeth securely in place. Your gums shouldn’t bleed when you touch or brush them. Gum disease isn’t always painful and you may be unaware you have it. It’s important to have regular dental check-ups. Early symptoms include red and swollen gums and/or bleeding gums after brushing or flossing your teeth. This stage of gum disease is called gingivitis.

If gingivitis is untreated, symptoms advance, resulting in the tissues and bone that support the teeth also becoming affected. This is known as periodontitis, or periodontal disease. Symptoms of periodontitis can include:

  • • Bad breath (halitosis).
  • • An unpleasant taste in your mouth.
  • • Loose teeth that can make eating difficult.
  • • Gum abscesses (collections of pus that develop under your gums or teeth).
  • SYMPTOMS OF ORAL CANCER:

  • • Red, or red and white, patches on the lining of your mouth or tongue.
  • • One or more mouth ulcers that do not heal after three weeks.
  • • A swelling in your mouth that lasts for more than three weeks.
  • • Pain when swallowing.
  • • A tooth, or teeth, that become loose for no obvious reason.
  • • A persistent pain in the neck.
  • • A hoarse voice.
  • • Unexplained weight loss.
  • • Unusual changes in your sense of taste
  • • Earache.
  • • The lymph nodes (glands) in your neck become swollen.
  • (Source: HSE/NHS)

    NOTE

    Dentists are trained to be sensitive when talking to patients about any symptoms they find and they emphasise the value of regular dental check-ups in maintaining overall health.

    *The network of vessels through which lymph drains from the tissues into the blood..

    for more information

    www.dentist.ie

    www.hse.ie

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