The missing link

There are many articles on the relationship between oral disease and systemic disease, and we have known for decades that periodontal disease can wreak havoc on our overall well-being. There is more than enough robust evidence to show that bacteria in gingivitis and periodontal disease can enter the bloodstream and cause a litany of systemic health issues.

If it is true for gingivitis and periodontal disease, which are naturally occurring and mostly due to negligence on the patient’s behalf or a genetic predisposition, then what does that say for old extraction sites with residual infected roots or a tooth that underwent root canal treatment 30 years ago without a dental dam that now has an associated cyst? I believe we need to ask more questions, and perhaps this is an opportunity for the dental community to finally sit at the same table as doctors with their heads held high because the truth of the matter is that we know from the literature that pathogens in periodontal disease cause a broader inflammatory response by means of cytokines entering the bloodstream and there is mounting evidence that cytokines pass through the blood–brain barrier, and this is also true for infected third molars, dental cysts associated with old or poorly performed root canal treatments, peri-implant pathologies and even metal hypersensitivities.

As such, we need to understand how we can improve our diagnostics and screening to make sure that our patients are receiving not only a dental check-up but also an inspection of cytokine-producing low-grade chronic infections or inflammation in the jawbone that can be naturally occurring or the result of old, outdated or poorly executed dental therapies. This is most important for people suffering from autoimmune disease or cancer, for whom any necessary lifestyle changes must be made immediately upon diagnosis in order to dramatically reduce anything that may cause inflammation in the body, such as adopting a low-sugar diet, quitting smoking and alcohol, implementing means to avoid or ameliorate stress, and having good sleep. But what if we could contribute a little bit more to these patients desperately seeking solutions to improve their systemic health? How can dentists help these patients?

“We need to change the paradigm.”

I believe that we have a unique opportunity in the dental arena to provide assistance to these patients, but we need to update our diagnostic tools—many of us are still only using 2D radiographs as our primary or only diagnostic tool. Why are we accepting the use of only radiographs when the rest of the medical industry uses new technologies, such as MRI, endoscopy, CT scans and blood panels, when needed? What other tools do we have to assist and enhance our diagnostic capacities? Why is it that when we do oral surgery we still only take radiographs and rarely CBCT scans? Why not perform blood tests as well? The lack of congruence here is huge. A surgery is a surgery, whether performed by a dentist or a doctor. The immune system sees it the same way; it does not differentiate between the kneecap and the jawbone. We need to change the paradigm.

I also think that it is important to start always measuring vitamin D levels chairside too. We all are well aware of the robust scientific evidence that shows the importance of optimal vitamin D and K2 levels for bone remodelling. Bone remodelling is central to periodontal disease, tooth extraction and implant surgery. Thankfully, there are new affordable chairside tests on the market that can help instantly measure this, and patient acceptance is high.

I am sure that many of you reading this article will have patients who have had cancer or are undergoing chemotherapy and who have no idea of the clear evidence of jawbone pathologies in and around areas of old dental treatments. Patients commonly think that if nothing hurts they are fine. However, at an immunological level, patients who have cancer must really endeavour to remove all sources of low-grade chronic inflammation and infection from their bodies to help their immune system to fight better. It will enhance all of the other therapies they are undergoing.

I understand how difficult it is for dentists in the very first appointment to give a comprehensive diagnosis, especially if it concerns issues that were not part of the patient’s primary reason for visiting. Patients too can be resistant if they perceive that we are selling to them. Also, some of the issues identified may be the result of our own work or that of a friend, colleague or peer in our community, making it incredibly challenging and even embarrassing to explain this to a patient. Most of our patients will have had work done elsewhere; this is the norm in dentistry.

In addition, patients often expect all dental treatments, no matter how long ago they were done, to last a lifetime, and if it does not hurt, then everything is fine, as if somehow pain is the only or first symptom to appear if something is wrong. We know that that is not the case. We also know that lifelong treatments are impossible to guarantee—the literature and evidence on this are very solid—and that most treatments have a ten- to 15-year lifespan, even when we do a good job.

Another factor contributing to the problem is that in many clinics around the world the time afforded to dentists in the first visit is not sufficient. I learned this as the founder of the Slow Dentistry Global Network, through which we clearly see that most clinics around the world simply do not have enough time in their daily workflow for in-depth diagnostics, and to compound this, often the only technology used is a periapical radiograph of the tooth being treated and not full-mouth radiographs. This means that the clinician does not have insight into the teeth overall. I believe that there is a huge grey area in dentistry today that is due to a combination of factors, leading to a complete lack of standardisation or benchmarking in dental and oral diagnostics.

When a patient goes to the cardiologist for a check-up, typically, there is a standard protocol and report that the primary care physician can understand. The same goes for other specialties. Why is this not standardised in dentistry? Why do some dentists only look at one tooth? Some look at just teeth and aesthetics and others look at everything. How do we improve on this? Are we not in fact our own worst enemy by not having a standardised approach to full-mouth diagnostics to employ for the first-time patient? Perhaps this is what we need to achieve in order to have a place at the table of the medical industry, something doctors can prescribe to their patients that dentists acknowledge and can fulfil that would provide clear and direct communication between both sides, truly bridging the divide and benefitting the patient. That is the mandate of every doctor and dentist.

A few other challenges that dentists have are also related to the time it takes to explain full-mouth diagnostics and also perhaps to the lack of training that many dentists have in understanding this, because many of us are focused mostly on teeth and not on immunology—it is already difficult enough to talk about one tooth, let alone the whole mouth! Usually, this is the domain of periodontists as well as oral surgeons, but I think that the entire dental community and mostly general practitioners have a huge role to play in changing this paradigm.

With that said, I have recently been developing artificial intelligence (AI) software called Missing Link that aims to help bridge the divide between dentists and doctors. This program has been using machine learning, based on thousands of panoramic radiographs taken over a long period and assessed by a team of highly trained dentists. Our AI engineers are some of the best in the world and have developed a proprietary technology around this platform. It is quite unique, as it does not really look at the teeth but at the bone around the teeth for any evidence of bone loss in the bone marrow that may have been caused by inflammation or infection, such as a periapical cyst. This is something easy for any dentist to understand, as it seeks to find a reduction in the Hounsfield units caused by radiolucency owing to a lack of bone where there should be bone. This is always present where there is elevated osteoclastic activity, but should not be present in healthy bone.