We still know little about the relationship between oral health and diseases treated in specialised care. A contributing factor is the organisation of dental care on the sidelines of the rest of the health care system, dominated by private providers and free pricing. While personal finances do not represent a threshold for Norwegians’ treatment in specialised care (which is public health care), many people look at their pay packet before booking a check-up or treatment at the dentist. Another obstacle to knowledge is that the activities of the dental health service in Norway are not reported to central health registers. This makes it difficult to see any links between oral health and other diseases or treatments.
Knowledge of such relationships is particularly relevant for diseases or treatments that have systemic effects. Systemic here means that the disease/treatment is not limited to a single organ, but affects different organ systems in the body. Obesity is such a systemic disease that affects almost the entire body. The same applies to the surgical treatment of obesity, which produces both physiological effects and forces new behaviours that potentially affect oral health.
Assessment and follow-up after bariatric surgery should be multidisciplinary. This is organised differently in different hospitals, but oral medicine is not part of this multidisciplinary approach. As clinicians, we may not have heard patients complain about their oral health, but that may also be because we don't ask. We mainly find things we are looking for.
Below we have provided some arguments why we should focus more on oral health. Considering that patients between themselves on social forums share experiences of significantly worsened, this suggests that research is needed.
Obesity - a particularly vulnerable patient group?
Some diseases are closely linked to lifestyle habits and socio-economic differences in society. This is true for both oral diseases and obesity. A privately organised dental service can contribute to undertreatment and lost prevention for groups with particular challenges and poor means.
We know that the prevalence of dental caries (cavities) increases with higher BMI and that there is a high prevalence of gingivitis in the heaviest people. Gingivitis can develop into periodontitis and cause loss of tooth attachment as well as increase the risk of disease in other organs such as heart disease. Furthermore, other diseases, such as diabetes and depression, are linked to obesity and may themselves also predispose to poor oral health. In other cases, it is the treatment of the obesity-related diseases that indirectly affects oral health, such as the use of medicines reducing the saliva production.
The picture is further complicated by the fact that teeth may have been damaged by previous diet or eating disorders. We also know that dental anxiety is more prevalent among those with obesity which may contribute to delaying appointments for check-ups or treatment.
Is bariatric surgery associated with oral disease?
There is currently little research on oral health in bariatric surgery patients. However, there are short-term studies showing an increased incidence of acid damage, caries and gingival inflammation as early as 6 months after surgery. There is also seen reduced salivary secretion in bariatric surgery patients. However, the existing research has several limitations: The studies are few, based on few participants, have a short follow-up period, and researchers have made little distinction between different bariatric surgery procedures.
Also, with bariatric surgery comes altered eating patterns. Many people have to increase meal frequency to frequent small meals. Drinks are consumed between meals both for the sake of the limited stomach volume and to avoid dumping. This prolongs acid exposure to tooth enamel and can cause acid damage/erosion, weaker teeth and increased caries. Replacing water with acidic drinks contributes to unnecessary acid exposure. Some patients also struggle with vomiting, which also causes acid attacks on the teeth.
Other factors of potential importance for oral health after bariatric surgery are inflammation, the qualitative composition of saliva and the changes in microorganisms in the oral cavity. Little is yet known about their importance.