Innovative Slate Flosser makes daily flossing easier which is crucial in preventing gum disease.

“I’ve never had a cavity, but at every visit, they said my gums were receding more,” he recalled. “They told me if I didn’t start flossing, it could lead to bone loss and surgery.”

MacDonald isn’t alone. A recent CDC report says 47.2% of adults aged 30 years and older have some form of periodontal disease.

Warning signs of periodontal disease include:

• Red or swollen gums
• Tender or bleeding gums
• Loose teeth
• Gums that have pulled away from your teeth

Receding gums are cause for concern because they expose tooth enamel and put more areas at risk of decay. According to periodontist Dr. Nate Johnson, this eventually results in bone loss which could mean tooth extraction.

“Regular dental check-ups, daily brushing, and flossing (not aggressively but consistently) are important to preventing periodontitis. Flossing is brushing between your teeth,” said Johnson. “But patients often say, ‘When I floss, my gums bleed, so I’m afraid to floss.'”

That was MacDonald’s experience.

“I didn’t like to floss. It’s hard—it’s uncomfortable.”

Then he discovered the Slate Flosser. It’s an electric flosser that combines high-grade floss with 12,000 sonic vibrations per minute. Gum Sweeps remove plaque and bacteria between gums and teeth. The device flosses teeth, stimulates gums, and cleans the tongue for complete oral care.

“I’ve used it for over a year, and my gums don’t bleed anymore,” MacDonald said. “It’s so easy to use. I can floss in 30 seconds. It even gets plaque off my hard-to-reach back teeth.”

Johnson is also a fan.

“I purchased a Slate Flosser,” he said. “The first time I used it, my teeth felt so clean I felt like I didn’t even need to brush!”

He quickly bought flossers for his wife, three kids, and all 12 members of his dental team.

“I recommend it to many of my patients,” said Johnson. “The Slate Flosser is easy to grip and can be used in your morning shower.”

As for MacDonald, he recently received some great news.

“When I returned to the dentist, they said my gums have stopped receding!” said MacDonald. “I’m a converted flosser.”

More about Slate Electric Flosser at https://slateflosser.com/.

Gum (periodontal) disease is caused by infection in the gums and is the leading cause of tooth loss.  It gets more common with age, and 50% of 60-year olds will have periodontal disease in at least a mild form.

However, untreated gum disease also has wide-ranging and serious effects on the rest of the body, where it correlates with an inflammatory response that affects the course of disease in other conditions.

In type 2 diabetes, it increases the risk of heart failure, in cardiovascular disease it increases the risk of stroke or heart failure, in rheumatoid arthritis it increases the severity of disease, and in emphysema (also known as chronic obstructive pulmonary disease or COPD), it increases the risk of irreversible step-changes in disease severity.

For people with these conditions, early detection and treatment of gum disease is a priority.

Gum disease is usually identified in the dentist’s chair, when dental hygienists or dentists look for indicators such as tooth movement, sensitivity, gum bleeding or swelling.

Professor Tim Albrecht from the University’s School of Chemistry and Dr. Melissa Grant from the School of Dentistry devised a new technique that could provide a rapid and accurate assessment of both the presence and extent of gum disease from a sample of saliva that can be taken in any healthcare setting.

Their method consists of a specialised probe and a detector that provides a quantitative measurement of biomarkers that indicate both the presence of gum disease and its severity. The biomarker panel was identified and validated by a team of researchers at the university’s Periodontal Research Group and published earlier this year  in the Journal of Clinical Periodontology.

The researchers have received funding from the EPSRC Impact Acceleration Account to develop a prototype of this new device, which is expected to be available within a year.

Professor Albrecht said: “We believe the device we are prototyping will be the first dental probe that can identify periodontal disease in this way.  It will detect periodontitis quickly and easily in a variety of healthcare settings, opening up opportunities for monitoring and early intervention in the patients with comorbid disease, who would benefit most from rapid treatment for periodontitis.”

Dr Grant said: “The ability to detect and profile disease biomarkers in real time will allow monitoring for disease severity, and in particular the transition between milder and more severe forms of gum disease.  This will benefit not only dental health, but also reduce costs and capture patients for whom periodontal treatment may, in the long run, be life-saving.”

In the long-term, they expect to develop a probe that is small enough to be inserted into the space between gums and teeth, allowing dentists to collect fluid from specific areas in the mouth, and accurately identify the site of infection.

University of Birmingham Enterprise has filed patent applications covering the probe and the detector, and their use in disease detection and monitoring, and will welcome discussions with companies wishing to license the technology or collaborate in its development.

About the University of Birmingham

The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 6,500 international students from over 150 countries.

University of Birmingham Enterprise helps researchers turn their ideas into new services, products and enterprises that meet real-world needs. We also support innovators and entrepreneurs with mentoring, advice, and training and manage the University’s Academic Consultancy Service.

The research, conducted in mice and using human cells and plaque samples, lays the groundwork for a non-invasive treatment for gum disease that people could apply to the gums at home to prevent or treat gum disease.

Gum disease (also known as periodontitis or periodontal disease) is one of the most prevalent inflammatory diseases, affecting nearly half of adults 30 and older. It is marked by three components: inflammation, an imbalance of unhealthy and healthy bacteria in the mouth, and destruction of the bones and structures that support the teeth. Uncontrolled gum disease can lead to painful and bleeding gums, difficulty chewing, and tooth loss.

“No current treatment for gum disease simultaneously reduces inflammation, limits disruption to the oral microbiome, and prevents bone loss. There is an urgent public health need for more targeted and effective treatments for this common disease,” said Yuqi Guo, an associate research scientist in the Department of Molecular Pathobiology at NYU Dentistry and the study’s co-first author.

Past research has linked increased succinate—a molecule produced during metabolism—to gum disease, with higher succinate levels associated with higher levels of inflammation. Guo and her colleagues at NYU College of Dentistry also discovered in 2017 that elevated levels of succinate activate the succinate receptor and stimulate bone loss. These findings made the succinate receptor an appealing target for countering inflammation and bone loss—and potentially stopping gum disease in its tracks.

Strengthening the link between succinate and gum disease

The researchers started by examining dental plaque samples from humans and plasma samples from mice. Using metabolomic analyses, they found higher succinate levels in people and mice with gum disease compared to those with healthy gums, confirming what previous studies have found.

They also saw that the succinate receptor was expressed in human and mouse gums. To test the connection between the succinate receptor and the components of gum disease, they genetically altered mice to inactivate, or “knock out,” the succinate receptor.

In “knockout” mice with gum disease, the researchers measured lower levels of inflammation in both the gum tissue and blood, as well as less bone loss. They also found different bacteria in their mouths: mice with gum disease had a greater imbalance of bacteria than did “knockout” mice.

This held true when the researchers administered extra succinate to both types of mice, which worsened gum disease in normal mice; however, “knockout” mice were protected against inflammation, increases in unhealthy bacteria, and bone loss.

“Mice without active succinate receptors were more resilient to disease,” said Fangxi Xu, an assistant research scientist in the Department of Molecular Pathobiology at NYU Dentistry and the study’s co-first author. “While we already knew that there was some connection between succinate and gum disease, we now have stronger evidence that elevated succinate and the succinate receptor are major drivers of the disease.”

A novel treatment

To see if blocking the succinate receptor could ameliorate gum disease, the researchers developed a gel formulation of a small compound that targets the succinate receptor and prevents it from being activated. In laboratory studies of human gum cells, the compound reduced inflammation and processes that lead to bone loss.

The compound was then applied as a topical gel to the gums of mice with gum disease, which reduced local and systemic inflammation and bone loss in a matter of days. In one test, the researchers applied the gel to the gums of mice with gum disease every other day for four weeks, which cut their bone loss in half compared to mice who did not receive the gel.

Mice treated with the gel also had significant changes to the community of bacteria in their mouths. Notably, bacteria in the Bacteroidetes family—which include pathogens that are known to be dominant in gum disease—were depleted in those treated with the gel.

“We conducted additional tests to see if the compound itself acted as an antibiotic, and found that it does not directly affect the growth of bacteria. This suggests that the gel changes the community of bacteria through regulating inflammation,” said Deepak Saxena, professor at NYU Dentistry and the study’s co-senior author.

The researchers are continuing to study the gel in animal models to find the appropriate dosage and timing for application, as well as determine any toxicity. Their long-term goal is to develop a gel and oral strip that can be used at home by people with or at risk for gum disease, as well as a stronger, slow-release formulation that dentists can apply to pockets that form in the gums during gum disease.

“Current treatments for severe gum disease can be invasive and painful. In the case of antibiotics, which may help temporarily, they kill both good and bad bacteria, disrupting the oral microbiome. This new compound that blocks the succinate receptor has clear therapeutic value for treating gum disease using more targeted and convenient processes,” said Xin Li, professor at NYU Dentistry and the study’s lead author.

Additional study authors include Scott Thomas, Yanli Zhang, Bidisha Paul, Sungpil Chae, Patty Li, Caleb Almeter, and Angela Kamer of NYU College of Dentistry; Satish Sakilam and Paramjit Arora of NYU Department of Chemistry; and Dana Graves of the University of Pennsylvania School of Dental Medicine.

The research was supported by the National Institutes of Health (DE027074, DE028212, AG068857, and R01DE017732); the development of the gel and oral strip is funded by the National Institute of Dental and Craniofacial Research (R41DE028212). Li and Saxena are the co-founders of Periomics Care, an early-stage biotechnology company within NYU Dentistry.

About NYU College of Dentistry

Founded in 1865, New York University College of Dentistry (NYU Dentistry) is the third oldest and the largest dental school in the US, educating nearly 10 percent of the nation’s dentists. NYU Dentistry has a significant global reach with a highly diverse student body.

Visit dental.nyu.edu for more.

European Guideline on Advanced Gum Disease Announced at EuroPerio10 Congress

“Periodontitis has a huge impact on people’s lives, with bleeding gums, loose teeth, halitosis, and substantial, or even complete, tooth loss if left untreated,” said author Professor David Herrera of University Complutense of Madrid, Spain. “Those affected can experience difficulty eating and speaking clearly and some feel ashamed, frustrated and vulnerable. However, as today’s document shows, most advanced disease can be successfully treated and teeth maintained in the long-term.”

Approximately 1.1 billion people worldwide had advanced gum disease (severe periodontitis – stages III and IV) in 2019, making it the most common chronic inflammatory non-communicable disease.

Periodontitis, a chronic form of gum disease, is caused by bacteria that accumulate on the teeth. Inflammation starts in the gums, then progressively destroys the ligament and bone supporting the teeth, causing the teeth to loosen and fall out.

This guideline focuses on stage IV periodontitis, which is the most advanced stage. In addition to the inflammation and loose teeth in stage III, patients with advanced disease have some of the following: loss of five or more teeth due to periodontitis, teeth moving out of position, flaring (“buck”) teeth, and difficulty in chewing.

Clinical assessment of advanced “gum disease” includes five components. One, evaluate the extent of breakdown of structures supporting the teeth, aesthetics, and the ability to chew and speak. Two, establish the number of teeth already lost due to periodontitis.

Three, determine which remaining teeth can be saved. Four, assess all factors in the mouth which could hinder or enable retention of teeth and/or placing dental implants, such spaces without teeth and the availability of bone. Five, ascertain the patient’s overall prognosis, including the probability of disease progression or recurrence, considering the possible presence of risk factors such as smoking and diabetes.

Professor Maurizio Tonetti of Shanghai Jiao Tong University School of Medicine, Shanghai, China, co-author of the guideline, explained: “This detailed diagnostic process is crucial as it enables us to design a multidisciplinary treatment plan based on what is technically and biologically feasible, cost-effective, and in line with the patient’s preferences and expectations.”

Treatment aims to control inflammation and prevent further damage of the supporting tissues of the teeth, and to restore tooth function.

Therapy begins with the recommendations for stages I to III periodontitis which include good oral hygiene, not smoking, controlling diabetes, and professional cleaning of the teeth above and below the gum line to remove bacteria, as stated in the previous guideline published in 2020 (2). Additional treatments for stage IV disease can involve orthodontic therapy to straighten or move teeth, and construction of prostheses to replace missing teeth, either supported by teeth or by dental implants.

Professor Herrera said: “Extracting teeth to place dental implants is not a reasonable option if teeth can be retained.”

He added: “Behavioural change is one of the pillars of therapy and the patient’s motivation and compliance are extremely important for success. This includes toothbrushing, cleaning between the teeth, sometimes using a mouth rinse to reduce inflammation, not smoking, and controlling blood sugar for those with diabetes. The benefits of periodontal therapy extend beyond the mouth to improved nutrition, quality of life, and systemic health, as, for example, better control of blood sugar in patients with diabetes due to the two-way relationship between diabetes and periodontitis.”

Professor Andreas Stavropoulos, EFP president, said: “This guideline for stage IV periodontitis complements that for stages I to III (3), meaning that for the first time in history we now have European recommendations for the interdisciplinary and evidence-based management of all stages of this disease. Application of the guideline is expected to improve the quality of periodontal treatment in Europe and worldwide. The EFP will be working with national periodontology societies to translate and adapt the guideline to the local context.”

EFP – The Global Benchmark in Periodontology

The European Federation of Periodontology (EFP, ww.efp.org) is a non-profit organisation dedicated to promoting awareness of periodontal science and the importance of gum health. Its guiding vision is “periodontal health for a better life.”

Founded in 1991, the EFP is a federation of 37 national periodontal member societies that represents more than 16,000 periodontists, dentists, researchers, and oral-health professionals from Europe and around the world. It supports evidence-based science in periodontal and oral health, and it promotes events and campaigns aimed at both professionals and the public.

The EFP organises EuroPerio, the world’s leading congress in periodontology and implant dentistry, as well as other important professional and expert events such as Perio Master Clinic and Perio Workshop. The annual Gum Health Day on May 12, organised by the EFP and its member societies, brings key messages on gum health to millions of people across the world.

The EFP also organises workshops and outreach campaigns with its partners: projects to date have covered the relationship between periodontal disease and diabetes, cardiovascular disease, and caries, as well as women’s oral health during pregnancy.

The EFP’s Journal of Clinical Periodontology is the most authoritative scientific publication in this field. The federation also publishes JCP Digest, a monthly digest of research, and the Perio Insight magazine, which features experts’ views and debates.

The EFP’s work in education is also highly significant, notably its accreditation programme for postgraduate education in periodontology and implant dentistry.

The EFP has no professional or commercial agenda.

REFERENCES

1) David Herrera, Mariano Sanz, Moritz Kebschull, Søren Jepsen, Anton Sculean, Tord Berglundh, Panos N. Papapanou, Iain Chapple, Maurizio S. Tonetti. Treatment of stage IV periodontitis –The EFP S3 level clinical practice guideline. J Clin Periodontol. 2022. doi:10.1111/jcpe.13639

2) At EuroPerio10, the session “The multidisciplinary treatment of stage IV periodontitis” will take place on 16 June at 16.30 h at the Hall A of the Bella Center in Copenhagen. More details at https://europerio10.abstractserver.com/program/#/details/sessions/20

3) Mariano Sanz, David Herrera, Moritz Kebschull, Iain Chapple, Søren Jepsen, Tord Berglundh, Anton Sculean, Maurizio S. Tonetti. Treatment of stage I-III periodontitis –The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47(Suppl 22):4–60. doi:10.1111/jcpe.13290.

DISCLOSURES: Please see the paper.

A series of new studies by researchers at NYU College of Dentistry highlights how e-cigarettes alter oral health and may be contributing to gum disease. The latest, published in mBio, finds that e-cigarette users have a unique oral microbiome—the community of bacteria and other microorganisms—that is less healthy than nonsmokers but potentially healthier than cigarette smokers and measures worsening gum disease over time.

“To our knowledge, this is the first longitudinal study of oral health and e-cigarette use. We are now beginning to understand how e-cigarettes and the chemicals they contain are changing the oral microbiome and disrupting the balance of bacteria,” said Deepak Saxena, who led the research with Xin Li; both are professors of molecular pathobiology at NYU College of Dentistry.

Gum disease affects nearly half of U.S. adults over 30 years of age. Smoking cigarettes is a known risk factor for developing gum disease, but less is known about the impact of e-cigarettes—which vaporize nicotine and other chemicals—on oral health, especially the long-term consequences of vaping.

The researchers studied the oral health of 84 adults from three groups: cigarette smokers, e-cigarette users, and people who have never smoked. Gum disease was assessed through two dental exams six months apart, during which plaque samples were taken to analyze the bacteria present.

Changes to gum health

All participants had some gum disease at the start of the study, with cigarette smokers having the most severe disease, followed by e-cigarette users. After six months, the researchers observed that gum disease had worsened in some participants in each group, including several e-cigarette users.

A key indicator of gum disease is clinical attachment loss, measured by gum ligament and tissue separating from a tooth’s surface, leading the gum to recede and form pockets. These pockets are breeding grounds for bacteria and can lead to more severe gum disease. In a study of the same participants published in Frontiers in Oral Health, the research team found that clinical attachment loss was significantly worse only in the e-cigarette smokers—not nonsmokers and cigarette smokers—after six months.

A unique microbiome

The researchers analyzed the bacteria found in the plaque samples and determined that e-cigarette users have a different oral microbiome from smokers and nonsmokers—building on findings the team previously reported in iScience and Molecular Oral Microbiology.

While all groups shared roughly a fifth of the types of bacteria, the bacterial makeup for e-cigarette users had strikingly more in common with cigarette smokers than nonsmokers. Several types of bacteria, including Selenomonas, Leptotrichia, and Saccharibacteria, were abundant in both smokers and vapers compared to nonsmokers. Several other bacteria—including Fusobacterium and Bacteroidales, which are known to be associated with gum disease—were particularly dominant in the mouths of e-cigarette users.

When plaque samples were gathered and analyzed in the six-month follow-up, the researchers found greater diversity in bacteria for all groups studied, yet each group maintained its own distinct microbiome.

“Vaping appears to be driving unique patterns in bacteria and influencing the growth of some bacteria in a manner akin to cigarette smoking, but with its own profile and risks to oral health,” said Fangxi Xu, a junior research scientist in Saxena’s lab and the study’s co-first author.

An altered immune response

The researchers found that the distinct microbiome in e-cigarette users was correlated with clinical measures of gum disease and changes to the host immune environment. In particular, vaping was associated with different levels of cytokines—proteins that help regulate the immune system. Certain cytokines are linked to an imbalance in oral bacteria and can worsen gum disease by making people prone to inflammation and infection.

TNFα, a cytokine that causes inflammation, was significantly elevated among e-cigarette users. In contrast, cytokines IL-4 and IL-1β were lower among e-cigarette users; IL-4 tends to be reduced in people with gum disease and increases after treatment, which suggests that certain bacteria in the mouths of e-cigarette users may be actively suppressing immune responses.

The researchers concluded that the distinct oral microbiome of e-cigarette users elicits altered immune responses, which along with clinical markers for gum disease illustrate how vaping presents its own challenge to oral health.

“E-cigarette use is a relatively new human habit,” said Scott Thomas, an assistant research scientist in Saxena’s lab and the study’s co-first author. “Unlike smoking, which has been studied extensively for decades, we know little about the health consequences of e-cigarette use and are just starting to understand how the unique microbiome promoted by vaping impacts oral health and disease.”

This research was supported by the National Institute of Dental & Craniofacial Research (DE025992, DE027074), the National Cancer Institute (CA206105), and the NYU Mega-Grants Initiative. The study included additional collaborators from NYU College of Dentistry, NYU Grossman School of Medicine, and the University of Pennsylvania.

About NYU College of Dentistry

Founded in 1865, New York University College of Dentistry (NYU Dentistry) is the third oldest and the largest dental school in the US, educating nearly 10 percent of the nation’s dentists. NYU Dentistry has a significant global reach with a highly diverse student body. Visit dental.nyu.edu for more.

FEATURED IMAGE CREDIT: Ethan Parsa from Pixabay.

A new worldwide consumer oral health awareness survey across 15 countries has revealed an amazing snapshot of oral health, habits, concerns and desires across the globe.

In the largest survey of its kind totalling 15,000 respondents, findings range from the countries best at brushing teeth twice a day with fluoride toothpaste, to the top worst dental habits and most common dental issues.

The inaugural 2021 Global Healthy Thinking Report by international oral healthcare company, Sunstar, with brands including GUM, Butler and Ora2, also provides insight into which countries have seen the worst oral health impact during the pandemic, which countries are looking after their teeth best, and those who have the best smile satisfaction.

Worldwide findings include:

Most and least oral health issues – Thailand has the most and worst problems with oral health, just 1 in ten have no problems and just 5% are happy with their teeth. The UK ranked the highest, 40%, for not having any problems with their teeth.

Worst habits you would like to give up – Germany and Spain ranked equally the highest at 27% for smoking as the worst habit harmful to their dental health. 22% of Italians, Indonesians and Brazilians said drinking coffee, tea and staining drinks was their worst habit, while China ranks highest for sweets as their worst habit, 31%.

Most forgetful toothbrushers – Indonesians were the most forgetful at brushing their teeth, 45%, while Brazil ranked next highest at 40%. 33% of Italians, Argentinians and Britons said they never forget to brush their teeth. Germans forget the least, 20%.

Best for cleaning between teeth – China leads the way on cleaning between teeth at 21%, followed by Italy, 20% and Spain 18%. Indonesia ranked the lowest at just 7% for those who use an interdental cleaner, electric airflosser or floss.

Smile satisfaction – People in the Netherlands are the happiest with their teeth, and 18% would not want any cosmetic treatment to improve their smile. While just 5% of Thai, Spanish, Italians and Brazilians said they would not choose one cosmetic smile treatment. The US was one of the lowest, only 7% said they would not want any cosmetic treatment and are happy with their teeth.

Understanding of the mouth/body link – 76% of Argentinians understood smoking affected dental health, while just 39% of Singaporeans understood the mouth/body link.  While the Japanese have the best understanding that dental health can also affect life expectancy, 38%, just 12% of British do.

Which countries reported most bad breath? Asian countries reported bad breath when describing their oral health more commonly than elsewhere in the world, with the worst in Japan, 34%. Brazil reported the least, just 8%. In Europe, bad breath is most common in Italy, 15% and least in the UK, 10%.

Which countries have seen the worst oral health impact during the pandemic? Argentinians have missed the most dental appointments during the pandemic, 44%. Just 12% of Japan have missed dental appointments, the lowest worldwide. Americans said they have experienced more tooth sensitivity during the pandemic, 25%. Indonesians ranked highest, 45%, for choosing to now clean their teeth more regularly as a result, followed by China at 38%.

Comments Martijn Verhulst, Medical Liaison Manager, Sunstar Scientific Affairs, on the survey findings: “We are proud to have conducted this largest survey of its kind to further our knowledge into consumer oral health.

“Positive findings included the numbers of people worldwide who are keeping their mouth healthy and fresh by brushing their teeth twice a day, using fluoride toothpaste and tongue brushing.

“But there did seem to be less understanding globally of the overall mouth/health link and the impact oral health has on your overall well-being, or how habits like smoking can impact your oral health. While this link is better known in Japan, for example at Sunstar we say “100 years mouth, 100 years health”, there does seem to be a need for greater understanding of this connection.

“We strongly advise that consumers get their teeth checked twice a year by a qualified professional to assess their oral health and any dental decay or gum disease. Regular dental checks are also important for identifying any issues early and before they can cause wider harm. A reputable dentist is also likely to spot signs of other medical conditions such as oral cancer or even diabetes if they can monitor your oral health frequently.”

A copy of the 2021 Sunstar Global Healthy Thinking report containing all the survey findings and analysis can be downloaded here https://www.sunstar.com/healthy-thinking-report/oral-survey-2021/

About the Research

15 countries surveyed across Europe, North/South America and Asia comprising;

– UK, Germany, France, Spain, Italy and Netherlands

– US, Mexico, Argentina, Brazil

– Japan, China, Singapore, Thailand and Indonesia

(Nationally representative sample, 1,000 minimum per country, 18-65 age group, equal gender split).

ABOUT SUNSTAR

SUNSTAR is a multinational company headquartered in Switzerland and founded in 1932 in Osaka, Japan. Today, SUNSTAR is a leading global company in the Mouth & Body Care field, a major presence in the Health & Beauty Care and the Environment & Amenity business fields, and a world leader in the Safety Support & High Technology field. In fiscal year 2019, consolidated net sales of the SUNSTAR Group totalled over 1.2 billion Swiss Francs. The products and services of SUNSTAR are distributed in more than 100 countries, and the company has 4000+ employees worldwide. Under the motto “Always strive to help people everywhere achieve better health and enhance their quality of life”, SUNSTAR continuously provides high-value-added products and services all over the world. www.sunstar.com

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Researchers at the National Institute for Dental and Craniofacial Research (NIDCR) have catalogued 120,000 oral mucosa cells by type and function. The NIDCR believes this cell atlas will serve as a detailed community resource to help researchers answer key questions about oral biology and disease.

The NIDCR’s researchers conducted a census of oral mucosal cells from gum and inner cheek tissues of people with and without severe periodontitis. By analyzing gene expression cell by cell, they were able to catalog cells by type and function and reveal a previously unknown role for connective tissue cells in orchestrating immune responses linked to periodontitis.

“There’s been a huge international effort to create a cell by cell atlas of the human body,” said senior author Niki Moutsopoulis, DDS, PhD, a principal investigator at NIDCR.

That initiative, the Human Cell Atlas, was launched in 2016 and is led by scientists at the Broad Institute in Cambridge, Massachusetts, and the Wellcome Sanger Institute in Cambridge, United Kingdom.

“We wanted to do our part by contributing data from the oral mucosa,” said Moutsopoulos.

The oral mucosa is composed of four main types of cells. Epithelial cells form the surface layer, while endothelial cells line the blood vessels that supply nutrition and oxygen. Stromal cells give structure to the mucosa, and immune cells survey the surroundings to capture and destroy foreign particles. 

However, Moutsopoulos and her colleagues performed a deeper dive, the NIDCR said, identifying distinct subpopulations with unique traits and functions among the four cell types. One type of stromal cell, called fibroblasts, caught the researchers’ attention.

“The most striking part of the study was the prominent immune signature of fibroblasts in the oral environment,” said Moutsopoulos. “We usually think of stromal cells, such as fibroblasts, as mere producers of connective tissue. But our analyses suggest that they also play a role in immune function, particularly related to recruiting neutrophils.”

Neutrophils are immune cells that migrate into the oral cavity to defend us against pathogens and are thought to play a protective role against periodontitis. In fact, the NIDCR said, genetic deficiencies in neutrophil recruitment are linked to severe periodontitis. But neutrophils also are known to over-congregate in the gums of people with common forms of periodontitis.

Gene expression data from the new study suggests that stromal cells are wired to induce inflammatory responses and send signals that recruit neutrophils in healthy people. The same stromal cells appear to become over-activated in periodontitis, resulting in an exaggerated immune response that could contribute to disease progression.

“This new piece of information is one of the many insights that can be gleaned from the oral cell catalog,” said first author Drake Williams, DDS, PhD, a clinical research fellow at NIDCR.

“Another opportunity afforded by this atlas is that we were able to map the expression of genes linked to periodontitis susceptibility at the cell level, within the oral tissues. We envision that this information will provide clues towards understanding cell-specific functions that mediate periodontitis pathogenesis in different subsets of patients,” said Williams.

The oral cell catalog also can be used to understand oral diseases beyond periodontitis, NIDCR said. The data from healthy volunteers, who were carefully screened for oral and systemic health, serves as a baseline that can be compared against other disease states.

The researchers have contributed their cell atlas to the oral and craniofacial network of the Human Cell Atlas project. They plan to expand the catalog to include cells from patients with inherited forms of oral mucosal diseases.

“The study provided an opportunity to view the oral mucosa through a new lens,” said Moutsopoulos. “We really enjoyed putting it together and had fantastic colleagues that contributed to this effort.”

The study, “Human Oral Mucosa Cell Atlas Reveals a Stromal-Neutrophil Axis Regulating Tissue Immunity,” was published by Cell.

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Poor oral hygiene has a negative impact on athletic training and performance, according to Sunstar, which notes that maintaining a healthy mouth should be an essential part of athletes’ training programs and has partnered with the FDI World Dental Federation to launch Sports Dentistry Guidelines.

In a study of 302 athletes, 40% said they were bothered by their oral health, while 28% reported an impact on their quality of life, and 18% reported an effect on their training and performance. Also, 55% of the athletes had cavities, 45% had dental erosion, and 76% had periodontal disease.

Athletes are at high risk of developing oral diseases for several reasons, Sunstar said. For example, they require a lot of calories, which often are consumed via sugary protein sports bars. Also, athletes consumer a lot of sports drinks, which are mostly acidic and have high sugar content. Training leads to increased mouth breathing and reduced saliva flow, causing dry mouth and creating ideal conditions for bacteria to grow as well.

Sports-related stress is another risk factor that can cause gum disease, tooth erosion, cavities, and teeth grinding. In aquatic sports, low pH in swimming pool water can cause tooth erosion.

Just as athletics can impact oral health, oral health can impact athletic performance, Sunstar said. Poor oral health overall affects quality of life and well-being, which are key for optimal athletic performance, the company said.

Also, tooth decay and gum disease can cause and maintain inflammation in the body, which can negatively impact athletic performance. And athletes who have an infected tooth, mouth abscess, or some other painful condition could possibly perform badly or even withdraw from competition or training.

Sunstar offers advice for athletes:

• Make your oral health a priority, just like other parts of your training program, and include it as part of your daily routine like training, nutrition, and physio.
• Brush your teeth twice a day for at least two minutes with a fluoride toothpaste, ideally 30 minutes after eating, and clean between your teeth using interdental brushes, picks, or floss.
• Chew sugar-free gum or rinse with water after meals and snacks when brushing isn’t an option.
• Ensure you visit your dentist at least twice a year for a complete oral health checkup.

“We are striving to raise awareness of the importance of good oral hygiene to athletes and to their overall performance,” said Dr. Marzia Massignani, PhD, senior manager of scientific affairs at Sunstar. 

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People in the United Kingdom are prioritizing their smiles. According to a poll by the Oral Health Foundation (OHF), 68% of adults said they couldn’t go a day without brushing their teeth, deeming it more than three times as important as exercise (21%).

Respondents also said that brushing was more essential than eating breakfast (43%) and washing (41%). Previous OHF polling has found that 97% of the population brushes their teeth at least once a day.

“For most people, the importance of brushing their teeth has been instilled in them since childhood. Like all habits, the earlier they are developed, the easier they are to keep throughout life,” said Dr. Nigel Carter, chief executive with the OHF.

The OHF conducted the poll as part of National Smile Month, a campaign aimed at reducing oral disease by highlighting the importance of a healthy mouth.

“Toothbrushing is such a vital habit to get into, so I’m delighted to see it top the list of Britain’s most valued day to day tasks,” Carter said.

“Daily brushing and cleaning between your teeth are important because it removes plaque. If the plaque is not removed, it continues to build up, feeding on the bits of food left behind and causing tooth decay and gum disease,” Carter said.

Calling tooth decay and gum disease two of the most common oral health conditions in the world, the OHF said that 31% of adults in the UK have tooth decay, 75% of those over the age of 35 are affected by gum disease, and 66% of adults have visible plaque.

“The best way to prevent tooth decay and gum disease, and keep your teeth for life, is by sticking to an effective oral health routine,” said Carter.

“Brushing should be done twice a day, with the most important time being last thing at night. Brushing should last two minutes and be done with a fluoride toothpaste,” he said.

During the pandemic, the OHF said, oral health declined far less than other areas of well-being, with 12% reporting decreases in oral health, compared to 43% saying the pandemic had a negative effect on their mental health and 42% saying it negatively impacted their weight.

Also, 34% said the pandemic negatively affected their exercise habits, 22% said their sex drive declined, and 21% said their eyesight got worse.

Elaine Tilling, dental hygienist and clinical education manager for TePe Oral Hygiene Products, said the pandemic has created a greater desire for self-care and prevention of disease.

“So much has been out of our control during this time, but taking responsibility for your own health has been a necessity, which for many people has been a positive experience,” said Tilling.

“Dental disease is preventable, and it is the importance of undertaking this that the pandemic has changed. Taking the time needed to brush effectively and to clean between the teeth daily if practices often enough helps to embed these habits for life,” said Tilling.

“Lockdown has had a significant impact on many people’s physical and mental health. The good news for oral health is that it seems to have been relatively pandemic-proof, declining far less than other areas of general well-being,” said Carter.

“With the exception of regular dental visits, good oral health can be achieved at home. Along with keeping an eye on the amount and frequency of sugar consumption and snacking, an oral health routine takes no more than five minutes a day, a relatively short amount of time when measured against the benefits,” Carter said.

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More effective prevention of gum disease could save billions in healthcare costs and lead to healthier lives, according to the European Federation of Periodontology (EFP).

The EFP commissioned the Economist Intelligence Unit (EIU), which is the research and analysis division of the Economist Group, to provide a comprehensive analysis of the financial and human cost of gum disease in France, Germany, Italy, the Netherlands, Spain, and the United Kingdom.

The report makes it clear that periodontitis is largely preventable with good oral hygiene and regular dental checkups, the EFP said. But little progress has been made in the prevention and management of periodontitis in Western Europe, with prevalence remaining largely unchanged over the past 25 years. 

Many people only visit a dentist when they have a problem and avoid regular appointments because of the cost, the report said.

Also, most if not all periodontitis treatment in Spain and Italy is paid for by patients or private insurance, so periodontitis treatment for low-income families is almost unaffordable, the report said.

And while dental care appears to be free on paper in the United Kingdom and in France, the report continued, only part of the dental procedures involved in treating periodontitis are covered, and the remainder of the costs are paid for out of pocket.

After providing evidence that professional management of periodontitis is cost-effective, the EFP said, the report argues that “publicly covered dental care for periodontitis deserves a review from policymakers and commissioners Europe-wide.”

The report then seeks to capture the attention of policymakers in the six countries studied, emphasizing the economic and societal benefits of action in the early treatment of periodontitis and arguing that “given the prevalence and preventable nature of periodontitis, new ways of thinking about gum health are needed to increase awareness and action at a national level.”

The report makes four recommendations.

First, the report says that the prevention, diagnosis, and management of periodontitis is cost-effective. It called the role of home care by patients of paramount importance in preventing gingivitis and periodontitis.

Efforts to eliminate gingivitis, preventing progression to periodontitis, would save considerable costs over 10 years compared to “business as usual,” ranging from 7.8 billion Euros in the Netherlands to 36 billion Euros in Italy, the report said.

But neglecting to manage gingivitis could significantly increase costs and reduce healthy life years, the report continued, so “an emphasis on self-care and prevention is critical from both an individual and a societal perspective.”

Second, the report says that better integration of dental and general healthcare is required. Sharing information across disciplines may improve both patient care, because of the common risk factors shared by some dental and physical health conditions, and contribute significantly to dental and general health research, the report says.

Integration also may encourage shared responsibility across healthcare disciplines to address unmet oral health needs in vulnerable and marginalized communities, the report says.

Third, a synergy of societal and individual public-health campaigns is needed. One without the other would exacerbate oral health inequalities both within and across countries, the report said. Societal-level prevention is crucial to the prevention of periodontitis, as it is highly prevalent in deprived areas.

Individual public health campaigns need to pay special attention to less affluent communities and embed prevention and early intervention in community settings such as schools for the prevention of caries and health centers for the prevention of gum disease, the report says.

Finally, the report says dental care needs to be more affordable. The cost of accessing a dentist is a barrier to early treatment for many people, the report says, so they are more likely to go to the dentist when there is something wrong rather than for checkups or preventive treatment, which is essential for avoiding periodontitis.

Not all periodontitis treatment is covered by the public health system in the United Kingdom and France, and the patient pays for the remainder. In Spain and Italy, most of not all periodontal treatment is paid for by the patient or via private insurance. Periodontitis treatment for low-income families is almost unaffordable.

Professionally managed periodontitis is cost-effective, the report says, and policymakers and commissioners across Europe should review publicly covered dental care for the disease.

Few studies have modelled the economic burden of periodontitis and the return on investment (ROI) of treatment, the EFP said. The report’s authors developed a model to examine the ROI of preventing and managing periodontitis, with separate modelling for France, Germany, Italy, the Netherlands, Spain, and the United Kingdom.

The model used in the study was based on EFP treatment guidelines that outline four intervention points in the progression from health to gingivitis, undiagnosed periodontitis, and diagnosed periodontitis. The estimates for the current national situation in each country determined the number of individuals starting at each stage of the model.

The authors modelled the transition between the stages over a 10-year period according to five scenarios:

• Baseline: current prevention and treatment situation continues.
• Rate of gingivitis management falls from 95% to 10%.
• Incident gingivitis is eliminated through improved oral homecare, preventing periodontitis.
• No periodontitis is managed.
• 90% of periodontitis is diagnosed and managed.

The model calculated the impact of each scenario on total costs, ROI, and the change in healthy life years compared to the baseline. The cost of continuing with the baseline scenario ranged from 18.7 billion Euro in the Netherlands to 96.8 billion Euro in Italy over 10 years.

In all countries, reducing gingivitis management lowered healthy life years and had a negative ROI. Eliminating gingivitis led to rises in healthy life years, reduced costs, and a strong ROI in all countries.

No management of periodontitis resulted in reductions in healthy life years and a negative ROI for all countries. Diagnosing and managing 90% of periodontitis increased healthy life years in all countries, and despite cost increases, there was a positive ROI.

Eliminating gingivitis and increasing the rate of diagnosing and treating periodontitis to 90% had a positive ROI for all countries and gains in healthy life years compared to business as usual. Neglecting to manage gingivitis had the opposite effects.

The report calls for greater emphasis on self-care and prevention at the individual and societal level, including nursery-based dental care and toothbrushing workshops in schools. While the workshops would primarily target caries prevention in children, instilling good oral hygiene regimens into the daily routine from a young age also should benefit periodontitis prevention in adult years, the EFP said.

“It is hugely challenging to determine to economic and societal costs of a complex disease like periodontitis, which is why we needed an independent expert group like the EIU to undertake this modeling,” said Iain Chapple, former treasurer and secretary general of the EFP.

“Their data clearly demonstrates that by far the biggest ROI comes from the prevention of periodontitis, i.e., by treating gingivitis, something traditionally regarded as trivial and ignored, rather than with treatment being directed at periodontitis, which is of course too late for prevention,” said Chapple.

“I am delighted with the analysis presented by the EIU, highlighting the benefit to healthcare providers of treating gum disease early to realize gains in health life years, advancing the European Federation of Periodontology’s purpose of promoting periodontal health for a better life,” said EFP secretary general Nicola West.

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