Oral and systemic health

INTRODUCTION — Oral and systemic health are closely related. Abnormalities in the oral cavity can affect systemic health and the growth and development of children. Likewise, systemic conditions or their treatments can affect the oral cavity or the feasibility of delivering dental care.

The oral conditions that affect systemic health and the systemic conditions that affect oral health and/or the delivery of dental treatment are reviewed here. The oral manifestations of systemic, genetic, or infectious disease are described in the topic reviews for those conditions.

ORAL CONDITIONS THAT AFFECT SYSTEMIC HEALTH — The oral cavity plays an important role in nutrition, speech, and facial appearance. Each of these functions may be affected by abnormalities in the oral cavity.

Children with cleft lip and/or palate (CLP), for example, have difficulty feeding, require speech therapy, and are at increased risk for otitis media. In addition, they are at risk for long-term psychosocial effects. A systematic review found an association between CLP and behavioral problems, dissatisfaction with facial appearance, depression, and anxiety, but the evidence was inconsistent [1]. In a subsequent case-control study, children and young adults with CLP had more behavioral problems, more depressive symptoms, were teased more often, and were less happy with their facial appearance and speech than children and young adults without CLP [2].

The most common chronic childhood disease is dental caries (ie, tooth decay), and its effects reach far beyond the oral cavity. Moderate or severe caries, particularly in young children, may affect nutrition and growth and development [3]. The pain and/or treatment of dental caries may contribute to inability to concentrate or poor performance at school and school absences [3]. The cost of treating children with dental problems in emergency departments and hospitals is high. Dental caries can lead to serious odontogenic infections that cause facial swelling or facial cellulitis, which often require urgent, expensive surgical treatment, administration of intravenous antibiotics, and, sometimes, admission to the hospital. In 2007, two deaths of children were attributed to systemic infections secondary to dental abscesses or their treatment. In addition, children die every year while receiving sedation for treatment for dental caries in dental offices [4,5].

Controversial associations between oral and systemic health — In addition to the psychosocial, speech, nutritional, and educational effects of oral disease are some controversial or less well-established associations between oral and systemic health. Pediatric health care providers should be aware of these associations and the evidence, or lack of evidence, to support them so they may advise their patients accordingly (table 1).

●Environmental lead exposure is associated with an increased prevalence of dental caries in the United States [6]. Data from animal studies support this association and provide a possible mechanism. Pre- and perinatal exposure to lead in rat pups results in decreased stimulated parotid function and increased prevalence of caries [7].

●Secondhand smoke exposure increases the risk for dental caries, with multiple mechanisms proposed [8].

●Maternal periodontal disease has been linked with preterm delivery and low-birthweight infants in case-control studies [9,10]. However, a systematic review of randomized trials concluded that periodontal treatment during pregnancy may reduce low birth weight, but it is not clear that it reduces preterm birth [11].

●Fluoride, dental amalgam, and composite resins that are used as sealants have been said to cause cancer and other systemic ailments. No data support these claims.

●Amoxicillin ingestion in the first few years of life has been linked to fluorosis in permanent teeth developing during that time, although a causal relationship is yet to be established [12].

●Existing evidence does not support a direct association between malocclusion and attention deficit hyperactivity disorder (ADHD). Some authors have postulated an indirect association based on observational studies suggesting an association between malocclusion and sleep-disordered breathing [13,14] and an association between sleep-disordered breathing and behavioral problems [15,16]. However, the children in the studies of sleep-disordered breathing and behavioral problems did not meet criteria for ADHD. Furthermore, in a randomized trial, neither attention nor executive function (two clinical features of ADHD) improved following adenotonsillectomy for obstructive sleep apnea [17].

●Molar incisor hypomineralization is a developmental condition of permanent first molars, and sometimes permanent incisors, that results in enamel defects that increase the risk of dental caries and breakdown. Its etiology is unclear. Molar incisor hypomineralization has been linked to prenatal and perinatal maternal factors and early childhood illnesses, including fever, asthma, and pneumonia [18,19]. (See "Developmental defects of the teeth", section on 'Molar incisor hypomineralization'.)

SYSTEMIC CONDITIONS THAT AFFECT ORAL HEALTH AND DELIVERY OF DENTAL CARE — In the same way that oral conditions affect systemic health, systemic conditions affect oral health and the delivery of dental care. An oral-systemic link should be considered when the condition or its treatment puts the child at risk for infection, alters oral physiology or homeostasis, or alters the ability to provide dental care.

Infection risk — The oral microbiome contains various bacterial species that are capable of causing specific odontogenic infections, commonly dental caries and periodontal disease. Systemic conditions that predispose children to periodontal disease include diabetes mellitus, disorders of the hematopoietic system, disorders that impair neutrophil function, and antineoplastic therapy [20-23]. The main complication of periodontal disease is tooth loss. However, bone loss and local and systemic spread of infection can occur, leading to periodontal abscess and orofacial "space" infections, particularly in immunocompromised patients. Children who have conditions that predispose them to periodontal infection should receive dental care at least every six months; their dentist may suggest a more frequent visit schedule.

In addition to periodontal infection, oral bacteria can cause serious infections, including infective endocarditis (IE), in at-risk children [24]. The risk of IE is highest for invasive dental or invasive oral procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa, such as tooth extractions or drainage of a dental abscess [25].

Antibiotic prophylaxis (table 2) is warranted for patients with conditions or implanted devices associated with the highest risk of an adverse outcome if IE occurs. These include [25]:

●Prosthetic cardiac valve or valve repair with prosthetic valve material.

•Prosthetic heart valve (surgical or transcatheter).

•Cardiac valve repair with prosthetic material (including annuloplasty rings or clips).

●Durable mechanical circulatory support device (ventricular assist device or artificial heart).

●Previous, relapsed, or recurrent IE.

●Certain types of congenital heart disease including:

•Unrepaired cyanotic congenital heart disease (patients with palliative shunts and conduits are still considered unrepaired).

•Completely repaired congenital heart defect with prosthetic material or device, during the first six months after surgical or transcatheter placement.

•Repaired congenital heart disease with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device.

•Prosthetic pulmonary artery valve or conduit (surgical or transcatheter; eg, Melody valve and Contegra conduit).

●Cardiac transplant recipients who develop cardiac valvulopathy.

Prevention on infective endocarditis is discussed in detail separately. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

The American Heart Association guideline recommendations regarding antibiotic choice and dental procedures for which prophylaxis is indicated [25] may also be applied to children who have any condition that places them at risk for serious consequences of systemic infection (eg, cancer, cancer therapy, other causes of immune compromise) [26-29]. Medical consultation regarding antibiotic consultation is critical for children who have conditions that impair immunity or who are receiving therapies that impair immunity.

Conditions that alter oral physiology or homeostasis — Systemic conditions or treatments that impair healing, decrease tissue oxygenation, or alter salivary function, calcium metabolism, or cellular turnover affect the oral environment (table 3). As examples:

●Children with leukemia develop periodontal inflammation as they lose their ability to fight infection. Antineoplastic therapy slows cellular turnover and can cause mucositis and oral ulceration [30].

●Some centrally acting medications (eg, antidepressants) diminish salivary flow and increase the risk of dental caries. In addition to lubrication, saliva plays an important role in enamel remineralization and secretory immunity.

●Some anticonvulsants (eg, diphenylhydantoin) cause gingival overgrowth.

●Patients with eating disorders have erosive tooth wear, low unstimulated salivary flow rates, and high counts of S. mutans and lactobacilli, all of which increase their likelihood of developing caries [31,32].

●Children with gastroesophageal reflux disease are at higher risk of having dental erosion [33].

●Children who are fed through gastrostomy or jejunostomy tubes have abundant calculus and high potential for dental erosion caused by gastroesophageal reflux and oral hypersensitivity [34].

●Children who are treated for neuroblastoma are at high risk for abnormal dental development, including microdontia, excessive caries, root stunting, hypodontia, and enamel hypoplasia [35].

●The management of children with inborn errors of metabolism often includes dietary therapies that are cariogenic or erosive [36,37].

●Inhaled steroids can cause oral candidiasis if the mouth is not rinsed with water after use.

●Early malnutrition during the development of teeth delays tooth development, affects the age distribution of dental caries (through delay of dental development), and increases caries in the primary and permanent teeth [38,39].

●More than one-half of prescribed and over-the-counter liquid medications for children contain sugar and may increase the risk of dental caries [40-42]. Steps to prevent caries, if no alternative to these medications exists, include brushing with fluoridated toothpaste or chewing sugar-free gum after taking the medication, taking the medication with meals, and avoiding ingestion before bed. (See "Preventive dental care and counseling for infants and young children", section on 'Fluoride toothpaste'.)

Conditions that alter ability to provide dental care — The provision of dental care requires patient cooperation and the ability to recline with the mouth open for extended periods of time. Cooperation may be limited in patients with emotional, mental, behavioral, or cognitive impairments (table 4). Cooperation also may be limited in children who have had unpleasant experiences with the health care system or who have constant pain caused by chronic illness. Behavior guidance techniques, including the use of pharmacologic agents, may be necessary to facilitate dental treatment for these patients.

Obesity may put children at higher risk for failed procedures or other adverse outcomes during sedation and general anesthesia [43,44], modalities that are frequently used to provide dental care to children who are unable to cooperate for treatment in a traditional dental setting.

Physical limitations or disabilities (eg, cerebral palsy) affect positioning, transferral to the dental chair, stabilization, and patient stamina [45]. Treatment in a wheelchair, positioning or stabilizing techniques, or the use of muscle relaxants or other drugs may be necessary to facilitate dental treatment for these patients.

Special circumstances in dental care — Additional treatment or precautions may be necessary in the provision of dental care for some children:

●Children with type 1 diabetes mellitus may require modification of their insulin regimen, depending upon their level of glycemic control [46].

●Children who are receiving long-term courses of glucocorticoids may require an increased dose before dental procedures that involve moderate to significant stress [47].

●Children who take medications to modify behavior (eg, methylphenidate) should take the medication at a time that will provide maximum response during the dental treatment.

●Prophylactic therapy may help to prevent asthma exacerbations triggered by dental treatment [48].

●Bisphosphonates are being used more frequently in children with conditions such as osteogenesis imperfecta and other conditions associated with osteoporosis. Bisphosphonates have been linked to osteonecrosis of the jaw in adults with a history of osteoporosis and cancer [49], but no reports have identified the problem in children treated with bisphosphonates [50].

●For children who are taking medications and require sedation for dental treatment, potential drug interactions between current medications and the sedative(s) should be evaluated; this may be done with the drug interactions program included with UpToDate.

APPROACH TO MANAGEMENT OF SYSTEMIC DISEASE WITH ORAL IMPLICATIONS — The first step in the management of the oral effects of systemic disease is the recognition of potential problems. The second is referral to a dentist who is familiar with oral and systemic interactions, such as a pediatric dentist or a general dentist who has hospital residency training. Early coordination between medical and dental providers is critical to the implementation of preventive strategies to improve outcomes.

SUMMARY

●Introduction – Oral and systemic health are closely related. Abnormalities in the oral cavity may affect systemic health, and systemic conditions may affect oral health. (See 'Introduction' above.)

●Oral conditions that affect systemic health – The oral cavity plays an important role in nutrition, speech, and facial appearance. Each of these functions may be affected by abnormalities in the oral cavity (eg, cleft lip and palate, dental caries). (See 'Oral conditions that affect systemic health' above.)

●Systemic conditions that affect oral health or dental care – Systemic conditions may affect oral health and/or the delivery of dental care if the systemic condition increases the risk of infection, alters oral physiology or homeostasis (table 3), or alters the physical, emotional, or mental status of the child (table 4). (See 'Systemic conditions that affect oral health and delivery of dental care' above.)

●Management of oral effects of systemic disease – The approach to the management of the oral effects of systemic disease involves recognition of potential problems and referral to a primary care dentist who is familiar with oral and systemic interactions (eg, a pediatric dentist or a general dentist who has hospital residency training). (See 'Approach to management of systemic disease with oral implications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Paul Casamassimo, DDS, MS, who contributed to an earlier version of this topic review.