The relationship between oral health and Alzheimer’s disease is an emerging discussion among dentists, neuroscientists and public health professionals. Oral health is a frequently overlooked component of the aging process with far-reaching consequences on the cognition and brain physiology of older individuals. From the discovery of a gum bacteria that is linked to the pathological hallmarks of Alzheimer’s disease (Dominy et al., 2019) to the finding that cognitive decline impairs oral hygiene (Naorungroj et al., 2013), there is increased discourse surrounding the gut-brain axis in the scientific community. Moving forward, an important mediator between the two fields will be care delivery and policy: introducing oral health components in geriatric care and neurocognitive components of aging in oral care.
To learn more about the crosstalks between oral health, aging, and Alzheimer’s disease, I spoke with Dr. Steffany Chamut, DDS, MPH, RICD, a dentist-researcher and advocate of equitable oral care delivery for the aging and rural population. Originally from Mexico, Chamut’s dental interests originate from her prosthodontic work with rural communities. As an AGE-Dental Public Health co-director, instructor of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine, and a curricular evaluation lead at the National Center for Equitable Care for Elders (NCECE), Chamut combines her interests in geriatric oral care, rural populations, and global health policy through research, teaching, and advocacy. Using her interdisciplinary expertise, Chamut undertakes various projects that directly tackle community needs. Following her master of public health and dental public health residency at the National Institute of Health, she helped establish the first dental school in Rwanda, where she was in charge of developing the prosthodontics curriculum that was mindful of rural social determinants of health. Our conversation focused on the epidemiology of oral health and Alzheimer’s disease, especially the social determinants of health that underlie this connection.
I would love to hear more about your educational or personal journey that led you into this very interdisciplinary field between oral health, aging, and Alzheimer's disease. What are the factors that convinced you to look into this area?
“Well, my path has been all over the place. I am originally from Mexico, and before dental school, I was volunteering in mission trips and rural communities, playing bingo in long-term care facilities.” Her personal experience “seeing [her] grandparents suffering from oral disease and having to have dentures from a young age” led her into a more specific field of prosthodontics, in which she completed postdoctoral training.
“At the end, I had to do a rotation for my program, and it happened to be in a geriatric dental office and a mobile dental office. So with the two, I was visiting hospitals and people in long-term care, and I saw the need and the neglect. A lot of people were suffering from cognitive decline, and the care that they were receiving from the nursing homes specifically was very low… Within [the caregivers’] competing priorities, oral health is at the bottom of the list of the things that they have to do. And if the patients don't complain, it's just totally ignored. So I was looking at very sad mouths of people who had dentures, and they were not cleaned for months.”
Chamut recounts one of her older patients, who passed away from an ill-fitting denture that caused a severe oral ulcer. She comments that the problem is not only due to “potential infections, but also nutritional: if you don't have a good dentition, you cannot eat the right foods to maintain your immune system.” Given the compromised dentition of older adults, “they have to rely on more cariogenic options, such as shakes for older adults that have a lot of sugar” that exacerbate the problem.
These observations led Chamut to pursue public health in the U.S. and explore how policies can implement changes in nursing home settings. Another project took up was an application for bringing oral health into aging for the NIA Healthy Aging Start-Up Challenge. Along the way, she found Alzheimer’s disease to be a substantial barrier to oral health and an idea she continued to explore.
“Continuing the research has led me to realize that a lot of people are working on the microbiome periodontal disease that is connected to bacteria that can travel to the brain. But I really think it’s more than that. There isn’t a lot of research in this regard, but I think we’re at a good point to find more biomarkers aside from the ones that have been studied starting from the oral health point of view.” Chamut’s excitement about the prospect of identifying further connections between the neurobiology of Alzheimer’s and oral health was visible.
What are some of the existing barriers to bringing oral health care to the aging population, especially those affected by Alzheimer’s disease?
“Oral health is very expensive. The current system is more focused on treatment rather than prevention. And prevention is always easier, cheaper, and more accessible. But older adults are retaining more of their teeth right now. Edentulism, or tooth loss, has declined, people are living longer, and are retaining more of their teeth. So what does that mean? People are more vulnerable to oral disease, and the complication of having more teeth leads to a higher count of bacteria. But at the same time, if people are retired, they don't have the funding or the financial means to continue the dental care that they need. And if the insurance doesn't cover those needs, they ignore those problems. So the problem only gets worse.”
“Medicare is very limited on dental, so [the coverage] remains the same without covering their needs. That is a major issue linked to policy. Every state covers different things on dental benefits because it's up to every state to, based on their funding priorities, cover what they want. This is a problem of equity: based on the state that you live in, you are less likely to have better oral health care if you are federally funded through the Medicare program. Also, every state has different priorities on oral health. A lot of states focus on public health programs for children, but not necessarily for older adults. I think that is another problem. And then for those that are living in nursing homes, they are facing more vulnerability in receiving care because they are in the facility. Transportation is also an issue, and not a lot of dentists go to the dental facilities to provide care.”
The current disconnect between medicine and dentistry perpetuates the problem at the levels of research and delivery. “In order to do research that really moves the needle forward, we need longitudinal studies. But from the dental field, we are very limited. . . There are a lot of longitudinal studies done on Alzheimer’s, but they don’t include any oral health components. Looking at the right data has been challenging because a lot of data is cross-sectional, and cross-sectional data cannot answer many questions and have limitations.”
Thus, Chamut highlights the need for “integrating oral health into medicine. As a medical provider, if you don't have training in oral health, you are not going to be talking about an area that is not an expertise of yours. Either you avoid it or you don't have the time.” The lack of communication between the two fields has important health consequences that often fall through the cracks, especially regarding medication.
“A lot of medications prescribed by the medical field affect the mouth of the patient because they have a side effect of dry mouth. When you have a dry mouth, you are at a higher risk of developing tooth decay because saliva plays a big role in protecting the tooth structure.” Pain medications also do hidden damage: cognitively impaired patients “receive certain medications that mask pain, so they don’t complain about oral health problems.” Chamut points out that this is a critical research consideration moving forward.
What are the future steps for this field? How do we address the above barriers?
“It's very important that we educate the patients,” Chamut suggests. While “a lot of patients care about having straight and white teeth,” there is less public awareness about the broader health consequences of oral health. For instance, it is not common knowledge that “for every tooth that you lose, your likelihood of suffering from cognitive decline increases 1.4%” (Qi et al., 2021).
Another suggestion is to foster a more open conversation between different fields. “This was out of the conversation ten years ago—nobody was talking about the potential connection of oral health and brain health. Talking outside my field with people like you, with people in conferences that are not dental-related, is a big step.”
Aside from convincing policymakers and funding institutions, the best thing generally seems to be to simply talk, form friendships, and discuss possibilities with people outside your field. “I can tell you too many things about my field; you can tell me too many things about your field. But we have to come to understand how your field is connected to mine, and how mine is to yours.”
About the Author
Bella Kim is a junior at Harvard College, studying Neuroscience.
References:
To learn more about the crosstalks between oral health, aging, and Alzheimer’s disease, I spoke with Dr. Steffany Chamut, DDS, MPH, RICD, a dentist-researcher and advocate of equitable oral care delivery for the aging and rural population. Originally from Mexico, Chamut’s dental interests originate from her prosthodontic work with rural communities. As an AGE-Dental Public Health co-director, instructor of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine, and a curricular evaluation lead at the National Center for Equitable Care for Elders (NCECE), Chamut combines her interests in geriatric oral care, rural populations, and global health policy through research, teaching, and advocacy. Using her interdisciplinary expertise, Chamut undertakes various projects that directly tackle community needs. Following her master of public health and dental public health residency at the National Institute of Health, she helped establish the first dental school in Rwanda, where she was in charge of developing the prosthodontics curriculum that was mindful of rural social determinants of health. Our conversation focused on the epidemiology of oral health and Alzheimer’s disease, especially the social determinants of health that underlie this connection.
I would love to hear more about your educational or personal journey that led you into this very interdisciplinary field between oral health, aging, and Alzheimer's disease. What are the factors that convinced you to look into this area?
“Well, my path has been all over the place. I am originally from Mexico, and before dental school, I was volunteering in mission trips and rural communities, playing bingo in long-term care facilities.” Her personal experience “seeing [her] grandparents suffering from oral disease and having to have dentures from a young age” led her into a more specific field of prosthodontics, in which she completed postdoctoral training.
“At the end, I had to do a rotation for my program, and it happened to be in a geriatric dental office and a mobile dental office. So with the two, I was visiting hospitals and people in long-term care, and I saw the need and the neglect. A lot of people were suffering from cognitive decline, and the care that they were receiving from the nursing homes specifically was very low… Within [the caregivers’] competing priorities, oral health is at the bottom of the list of the things that they have to do. And if the patients don't complain, it's just totally ignored. So I was looking at very sad mouths of people who had dentures, and they were not cleaned for months.”
Chamut recounts one of her older patients, who passed away from an ill-fitting denture that caused a severe oral ulcer. She comments that the problem is not only due to “potential infections, but also nutritional: if you don't have a good dentition, you cannot eat the right foods to maintain your immune system.” Given the compromised dentition of older adults, “they have to rely on more cariogenic options, such as shakes for older adults that have a lot of sugar” that exacerbate the problem.
These observations led Chamut to pursue public health in the U.S. and explore how policies can implement changes in nursing home settings. Another project took up was an application for bringing oral health into aging for the NIA Healthy Aging Start-Up Challenge. Along the way, she found Alzheimer’s disease to be a substantial barrier to oral health and an idea she continued to explore.
“Continuing the research has led me to realize that a lot of people are working on the microbiome periodontal disease that is connected to bacteria that can travel to the brain. But I really think it’s more than that. There isn’t a lot of research in this regard, but I think we’re at a good point to find more biomarkers aside from the ones that have been studied starting from the oral health point of view.” Chamut’s excitement about the prospect of identifying further connections between the neurobiology of Alzheimer’s and oral health was visible.
What are some of the existing barriers to bringing oral health care to the aging population, especially those affected by Alzheimer’s disease?
“Oral health is very expensive. The current system is more focused on treatment rather than prevention. And prevention is always easier, cheaper, and more accessible. But older adults are retaining more of their teeth right now. Edentulism, or tooth loss, has declined, people are living longer, and are retaining more of their teeth. So what does that mean? People are more vulnerable to oral disease, and the complication of having more teeth leads to a higher count of bacteria. But at the same time, if people are retired, they don't have the funding or the financial means to continue the dental care that they need. And if the insurance doesn't cover those needs, they ignore those problems. So the problem only gets worse.”
“Medicare is very limited on dental, so [the coverage] remains the same without covering their needs. That is a major issue linked to policy. Every state covers different things on dental benefits because it's up to every state to, based on their funding priorities, cover what they want. This is a problem of equity: based on the state that you live in, you are less likely to have better oral health care if you are federally funded through the Medicare program. Also, every state has different priorities on oral health. A lot of states focus on public health programs for children, but not necessarily for older adults. I think that is another problem. And then for those that are living in nursing homes, they are facing more vulnerability in receiving care because they are in the facility. Transportation is also an issue, and not a lot of dentists go to the dental facilities to provide care.”
The current disconnect between medicine and dentistry perpetuates the problem at the levels of research and delivery. “In order to do research that really moves the needle forward, we need longitudinal studies. But from the dental field, we are very limited. . . There are a lot of longitudinal studies done on Alzheimer’s, but they don’t include any oral health components. Looking at the right data has been challenging because a lot of data is cross-sectional, and cross-sectional data cannot answer many questions and have limitations.”
Thus, Chamut highlights the need for “integrating oral health into medicine. As a medical provider, if you don't have training in oral health, you are not going to be talking about an area that is not an expertise of yours. Either you avoid it or you don't have the time.” The lack of communication between the two fields has important health consequences that often fall through the cracks, especially regarding medication.
“A lot of medications prescribed by the medical field affect the mouth of the patient because they have a side effect of dry mouth. When you have a dry mouth, you are at a higher risk of developing tooth decay because saliva plays a big role in protecting the tooth structure.” Pain medications also do hidden damage: cognitively impaired patients “receive certain medications that mask pain, so they don’t complain about oral health problems.” Chamut points out that this is a critical research consideration moving forward.
What are the future steps for this field? How do we address the above barriers?
“It's very important that we educate the patients,” Chamut suggests. While “a lot of patients care about having straight and white teeth,” there is less public awareness about the broader health consequences of oral health. For instance, it is not common knowledge that “for every tooth that you lose, your likelihood of suffering from cognitive decline increases 1.4%” (Qi et al., 2021).
Another suggestion is to foster a more open conversation between different fields. “This was out of the conversation ten years ago—nobody was talking about the potential connection of oral health and brain health. Talking outside my field with people like you, with people in conferences that are not dental-related, is a big step.”
Aside from convincing policymakers and funding institutions, the best thing generally seems to be to simply talk, form friendships, and discuss possibilities with people outside your field. “I can tell you too many things about my field; you can tell me too many things about your field. But we have to come to understand how your field is connected to mine, and how mine is to yours.”
About the Author
Bella Kim is a junior at Harvard College, studying Neuroscience.
References:
- Dominy, S. S., Lynch, C., Ermini, F., Benedyk, M., Marczyk, A., Konradi, A., Nguyen, M., Haditsch, U., Raha, D., Griffin, C., Holsinger, L. J., Arastu-Kapur, S., Kaba, S., Lee, A., Ryder, M. I., Potempa, B., Mydel, P., Hellvard, A., Adamowicz, K., … Potempa, J. (2019). Porphyromonas gingivalis in Alzheimer's disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances, 5(1), eaau3333–eaau3333. https://doi.org/10.1126/sciadv.aau3333
- Naorungroj, S., Slade, G. D., Beck, J. D., Mosley, T. H., Gottesman, R. F., Alonso, A., & Heiss, G. (2013). Cognitive decline and oral health in middle-aged adults in the ARIC study. Journal of dental research, 92(9), 795–801. https://doi.org/10.1177/0022034513497960
- Qi, X., Zhu, Z., Plassman, B. L., & Wu, B. (2021). Dose-Response Meta-Analysis on Tooth Loss With the Risk of Cognitive Impairment and Dementia. Journal of the American Medical Directors Association, 22(10), 2039–2045. https://doi.org/10.1016/j.jamda.2021.05.009
