AN ORAL HISTORY
Think about this the next time someone in a white coat instructs you to “open wide.”
Your mouth is a window to your health.
Diagnosis through the mouth goes way beyond scanning for redness or white patches on the tonsils--the telltale traces of strep throat.
An oral exam can reveal many more signposts to illness:
--A dentist peering at tooth enamel can see evidence of bulimia, the eating and vomiting disorder that exposes teeth to erosive stomach acids.
--A periodontist probing inflamed gums thinks about eradicating bone-gobbling plaque bacteria that are suspected contributors to heart attacks, stroke and possibly arthritis.
--Dry, thick, stringy saliva or breath with tones of alcohol or acetone can be indicators of uncontrolled diabetes.
--A doctor of Oriental medicine studies the color, condition and coating of the tongue for signs of constipation, fever, poor circulation and even infertility.
“The mouth has been typically referred to as the gateway, the doorway to the body,” says Dr. Robert Schoor, director of postdoctoral periodontics at New York University College of Dentistry and president of the American Academy of Periodontology. “The mouth is a very fascinating place.”
The mouth is much more than the conduit to the digestive tract. It’s home to our sense of taste. And its connections to the brain allow us to communicate through our lips, tongue and palate. The mucous membrane lining of the mouth is full of blood vessels that provide a ready connection to other parts of the body. For example, drugs placed under the tongue, like nitroglycerin pills for chest pain, are rapidly absorbed through the membranes into the circulatory system.
Researchers are pursuing an emerging field that relates periodontal diseases--infections of the gums and tissues surrounding the teeth--to systemic disease. People with gum disease have higher rates of coronary artery disease than those with healthy mouths, and scientists are trying to understand what’s behind that association.
Last year, researchers at the University of Minnesota reported that Streptococcus sanguis, a bacterium commonly found in dental plaque, caused human blood to clot in test tubes. Clotting is worrisome because it’s the basis of heart attacks and strokes. When rabbits were injected with the bacteria, their hearts beat abnormally and blood pressure rose. The researchers thought it likely that a protein on the bacteria’s surface set clotting in motion.
Dr. Joseph Brent Muhlestein, a cardiologist at LDS Hospital in Salt Lake City, studies the role of chlamydia bacteria in heart disease and is conducting clinical trials of antibiotics to destroy the bugs. He says there has been talk about coordinating that work with the mouth bacteria studies.
“What we have is some epidemiologic findings that show if you have periodontitis and then you’re tracked for a long time . . . you’re more likely to end up with a heart attack than if you don’t have periodontitis,” Muhlestein said. Scientists don’t know what mechanism is at work, but researchers theorize that bacteria may trigger inflammation and set off a cascade of immune responses inside the arteries.
Link Between Plaque and Diseases Studied
That suggests there might be some connection between the sticky plaque you brush off your teeth and the plaque that builds up inside arteries. Although chlamydia has been found in plaque in blood vessel walls, Muhlestein suspects mouth bacteria act indirectly on the artery-clogging process “based on the fact we haven’t been able to find it directly in atherosclerotic plaque.”
In 2001, the National Institutes of Health are sponsoring a global conference on the role periodontal medicine plays in stroke, coronary artery disease, low birth weight, osteoporosis and diabetes.
Periodontists and dentists are trained to think beyond tooth decay and bleeding gums. They look for swollen glands and examine the palate, gums and other tissues for cancers that may masquerade as wounds that won’t heal.
The irregular patches provide “a sort of a suspicious flag which then warrants blood testing and further work-up,” Schoor said.
Medical and dental professionals regularly screen for AIDS-related conditions in the mouth.
“There are changes to the tongue, like hairy leukoplakia--a long linear lesion on the sides of the tongue--which help diagnose an HIV infection,” Schoor said. “More importantly, there are changes to the gum tissue which we call NUP, necrotizing ulcerative periodontitis, that’s highly suggestive of an HIV infection. There are yeast infections [that] might indicate a reduced immune state.”
AIDS patients, who have damaged defenses, tend to have “more rapid gum disease,” said Dr. Michelle Sackheim, a Beverly Hills periodontist who encourages patients to disclose their HIV status: “When I know they have AIDS and I can treat them the right way, they’re going to heal.”
Other specialists will probe the mouth. Alert dermatologists often check the mouth to firm up a skin diagnosis. For example, a dermatologist who sees fingernail abnormalities characteristic of a skin disorder called lichen planus will also examine the cheek lining for white streaks that are another symptom of the disorder. Or, if the papillae, the natural bumps on the tongue, have become elongated and blackened by “hairy tongue,” it’s often the sign of a reaction to antibiotics.
Periodontist May Be First on the Scene
Sexually transmitted diseases can show up in the mouth, although doctors often fail to check there, said Dr. Glynis Ablon, a Los Angeles dermatologist. Genital warts caused by the human papilloma virus can spread to the mouth during sexual activity and need to be treated, she said.
Schoor cited several illnesses in which the periodontist may be “the first to diagnose.” A very dry mouth might be the first symptom of Sjogren’s syndrome, an autoimmune disease that attacks glands that produce tears and saliva. Without protective fluids, teeth and gums become vulnerable to infection and decay.
Autoimmune diseases like scleroderma, in which tissues become overly thickened and stiff, might show up in problems with swallowing or in restricted movement in the jaw, Schoor said. Neurologic disorders like stroke might lead to problems speaking or swallowing.
But, Schoor cautions, “all these are suggestive, not conclusive.”
Dr. Jack Pulec, a Los Angeles ear, nose and throat specialist and editor of the Ear, Nose and Throat Journal, checks the mouth and throat. Cheilosis, a condition that produces painful fissures in the corners of the mouth, often strikes elderly people and those with cancers or other diseases that prevent proper vitamin absorption. Sometimes, food allergies produce dramatic streaks in the back of the throat.
“You see vertical bands of lymph tissue have puffed up. These people usually complain of a chronic sore throat,” Pulec said.
Medications may generate serious side effects in the mouth. Anti-seizure medications like Dilantin can produce overgrowth of gum tissue. Some antidepressants can dry up saliva.
Some Diagnoses Are Sensitive Matters
When medical and dental professionals see signs of conditions outside their formal training, such as eating disorders, they’re often pushed into a delicate exchange with patients.
Sackheim, for example, has diagnosed bulimia in several women in their 20s to 30s, who tend to have erosion on the inside of their upper front teeth.
“In one second, I can look and say they’re bulimic,” she said.
The real question is how to approach patients who “don’t know what it’s doing to them,” Sackheim said. ‘You start asking gently about habits. It’s a very tricky subject.”
Sackheim sees other oral tip-offs to underlying health problems, such as drug abuse.
“If I see a patient 35 years old with advanced gum disease, I start asking why. The first thing I ask [about is] heroin, cocaine, heavy drugs. If they are malnourished, the mouth is affected,” she said.
Women’s changing hormone levels also are reflected in their gums.
“Some women have monthly changes in the mouth,” Sackheim says. She often sees gum changes stemming from pregnancy and carefully treats expectant mothers because the bacteria that proliferate in gum pockets can affect the next generation. Maternal gum disease has been linked to increased risk of delivering a premature, low-weight baby.
The tongue also plays a large role in Oriental medicine; the doctor reads the tongue’s surface like a map of the body.
Dr. Steven Rosenblatt, a family practice physician who combines Eastern and Western medicine in his West Los Angeles and Santa Monica offices, examines the tongue “for the state of the functioning of different organ systems. For instance, the liver and the heart and the stomach and the gall bladder are geographically represented on the tongue.”
“Oriental medicine looks at different disease states as either being hot or cold, just like in the West we would look at certain conditions that come with fevers or inflammation,” he explained. A red or cracked tongue might lead to a diagnosis of stomach “overheating” due to stomach lining inflammation, said Rosenblatt, who set up the acupuncture program at UCLA and has been working to establish programs at Century City Hospital and St. John’s Medical Center.
Several years ago, Susan Krebs, a 51-year-old jazz singer and actor from Sherman Oaks, began seeing Rosenblatt for some lower intestinal distress that accompanied approaching menopause.
“He found the perfect herbs for me,” which brought relief, she said.
Krebs, who undergoes periodic tongue examinations, said she has learned to read some of the signs herself when she begins to feel out of whack.
“I can’t read it like he can, but if I start feeling mild symptoms, there’s a coating that’s not there when I’m feeling clear and healthy,” she said. “The great thing about this kind of medicine is you learn about your own body.”
Assessing the Tongue Dates to 300 BC
Dr. Stephen Benedict, an acupuncturist and doctor of Oriental medicine in Brentwood, says tongue diagnosis was first mentioned in the Huang Di Nei Jing, one of the classic texts of Oriental medicine, back around 300 BC. Asian doctors look at the flow of energy, called qi, through channels, called meridians.
Benedict, who specializes in infertility, says a heavy coating on the tongue may indicate “a type of stagnation” in meridians important to lower abdomen functioning.
“Advice might be given in terms of diet, foods, stretching, posture and movements, certainly acupuncture and acupressure treatment and last, but very much not least, would be nutritional supplements and Chinese herbal medicine,” he says.
