IN the first episode of a new series called “Doc Talk,” Commonwealth Healthcare Corporation public information officer Guillermo Lifoifoi sat down with experienced general dentist Dr. Mary Bellama to talk about oral health and how it is important for overall health and women’s health.
May is CNMI Women’s Health Month.
Dr. Bellama has been a dentist for over seven years and joined CHCC in 2019. She is passionate about CHCC dental programs that focus on CNMI’s special populations, particularly children, medically complex individuals, including people battling oral cancer and women during pregnancy.
She spoke about two of the most common oral health conditions: cavities and gum disease.
“Pretty much everyone will experience one or both of these during their lifetime, so they are very prevalent, but a lot of people don’t know exactly what it means to have a cavity or what it means to have gum disease. So, let’s talk about cavities,” she said.
Cavities, also known as tooth decay, are caused by specific bacteria.
“We all have different types of bacteria in our mouth, that’s normal, but there’s a specific type of bacteria that causes cavities that bacteria feeds on sugar, and it produces an acid inside your mouth, which allows the bacteria to basically form a hole inside your tooth. So, once the bacteria forms a hole, it goes inside your tooth, you have a cavity. Cavities get bigger with time, the bigger a cavity gets, it can start to cause pain. Or if the bacteria gets all the way to the nerve of the tooth, it can cause an infection,” she explained.
Gum disease, or periodontal disease, comes in many forms, like gingivitis or periodontitis.
“Those are the specific types, and that’s caused by a couple of different bacteria. It’s not just one type of bacteria, but there are few. And when you develop gum disease, basically you have something on your teeth called plaque. Everybody develops plaque – that white fuzzy stuff that you brush off your teeth when you brush your teeth at night, or hopefully floss. And if that plaque isn’t cleaned off of your teeth, then it builds up and hardens, it becomes something called calculus or tartar. Inside that calculus is all sorts of bacteria that produces irritants. It makes your gums chronically inflamed, irritated, red, your gums can bleed, and over time that causes bone loss around your teeth. So, with gum disease, when it becomes advanced, it can cause an infection between your gum and the tooth, the teeth can become loose or mobile, and eventually the teeth can fall out,” she explained.
Bellama said that the key ingredient to look for in any toothpaste is fluoride, which prevents cavities.
Fluoride toothpaste can be used on children as young as when their first tooth starts to come in.
“When we talk about general prevention guidelines in oral hygiene, everyone should brush their teeth a minimum of two times a day. That includes infants who are just getting their first teeth. As soon as the first tooth comes in, it’s time to start to brush it. As well as older individuals who have a full mouth of teeth. So, you want to brush at least two times a day with a fluoride toothpaste,” she said.
It’s also important to floss, she added.
“You want to floss between every tooth, not just a tooth where like food or get stuck between. If you just floss that one area and neglect all the other teeth, then that’s not going to work to help promote good gut health. You need to floss between every tooth, and for children, too. You want to floss anywhere between teeth that touch and children,” she explained.
She said that for some people who do have gum disease, their dentist may recommend that they brush more than two times a day, including after every meal.
“You should follow whatever guideline is given to you by your oral health professional. For adults, they should typically have a cleaning anywhere between one and four times a year. And that recommendation is based on the individual needs of the patient. Someone who has active lung disease, we’re going to want to see them more frequently, probably every three months, versus somebody who has impeccable oral hygiene and their mouth is a picture of how they maybe only need a cleaning once a year. So, it’s important to make sure that they sign up for that,” she said.
Children, pregnant women
Dr. Bellama said women who are pregnant or plan to be pregnant are at a prime time to focus on good oral health, especially women in their second trimester.
“Poor oral health, specifically gum disease, has been linked to worse birth outcomes. Preterm delivery or early delivery, low birth weight for baby, other pregnancy complications like preeclampsia are all associated with higher levels of oral disease or dental disease during pregnancy. So, if you’re thinking about becoming pregnant, we’d encourage you to see a dentist to make sure that everything is in top shape. And if you are already pregnant, it’s a great time to come in and see a dentist before the baby comes,” she said.
“I know once you deliver, you have a newborn baby to take care of, so we encourage expectant mothers to come in while they’re pregnant. Maybe they have a little bit more time on their hands and they lead after delivery to see a dentist. It’s important to know that nearly all dental care is safe during pregnancy, and as recommended, it’s important to let your dentist know if you are expecting and when their due date is because it helps us plan care around your due date and take into consideration that you may be a little bit uncomfortable lying back in a position for a long period of time.”
“There are certain things that we do to accommodate expectant mothers, but the dental care that we provide cleanings, fillings, extractions, root canals, that’s all completely safe during pregnancy. Also, during pregnancy – we talked about cavities, how cavities are caused by bacteria, it’s actually interesting to note that bacteria is passed from mom to baby during the first couple months of your newborn baby’s life. So, if a mom has really high levels of that bacteria, if they have a lot of untreated cavities, they can pass that bacteria to their newborn child and put their child at greater risk for developing cavities later in life. So, not only is it important for you, you’re also setting up your future child to have better oral health during their lifetime,” she said.
The CHCC dental clinic, she noted, has programs to help expectant mothers with this, including a prenatal voucher program that provides coverage for women to come in and have their teeth cleaned that otherwise may not be covered under their insurance.
“If that’s something that you would like to avail, I would encourage you to talk to your prenatal care provider, and they can maybe set you up with a voucher to come see us,” said Bellama.
“We want to see mothers during pregnancy at any time, they’re able to make time to come through the door. I guess dental care during pregnancy is safe. It’s safe for us to do basically everything. So, if that means that you’re only able to get an appointment, and you’re already into the third trimester, we definitely still want you to come in for your appointment. There are always things that we can do to improve your oral health. Before you deliver, or set you up for appointments to have, if you find that you need to have some fillings on or something like that, we want to get you started on that as soon as possible.”
“The second trimester is the ideal time because at that point, most mothers are over morning sickness, so they might be a little bit more comfortable coming in, but they’re not so late in their pregnancy, that there may be uncomfortable lying in the dental chair. So, that’s why it has become the ideal time. But there are different things that we can do to make you comfortable in the dental clock. If somebody comes in and is having problems with morning sickness, that’s okay, we can take breaks so you can avoid things that maybe trigger any sort of nausea. If you come in later during your pregnancy and can’t lay flat, that’s fine, too. We’ll try dental treatment, you know, sitting in a less of a recliner or something like that,” she said.
Parents are encouraged to bring their children in for their first dental appointment by their first birthday.
For parents of infants and toddlers, discussions are had regarding the transition from bottle to table foods and sippy cups.
It is recommended that parents not put their children to bed with a bottle, as this is one of the leading causes of early childhood cavities, otherwise known as baby bottle tooth decay.
Dentists also speak with parents about what to expect when their child grows more teeth and how they can alleviate their child when they are teething, such as by using a toy that has been placed in a freezer.
At the dentist appointment, parents are also taught brushing techniques, frequency of brushing daily, what toothpaste to use, what toothbrush they might have the most success brushing with, and things of the sort.
“Those early appointments are super important, because that’s where we provide parent education… We can go over techniques of how they can brush their child’s teeth without making it a battle every night at bedtime, or dietary habits that promote good oral health,” she said.
“For young children, milk and water are the preferred beverage choices. Juice, even 100% juice, is super high in sugar. And we talked about how sugar is what the bacteria that causes cavity eats, so we want to limit sugar intake. You’re feeding the bacteria, so juice really should not be part of a regular diet in young children. We shouldn’t be giving sugar sweetened beverages to children at all – soda, sweet tea, fruit punch ice, those types of drinks are just loaded and artificial sugar, which is not great nutritionally for children, but also just causes all sorts of oral health issues like cavities.”
“It’s good to give guidance on what to expect in the future, as well as different tools and things that they can use at that time,” said Bellama.
Heart disease, diabetes
Gum disease has also been linked to heart disease — especially for women — and diabetes, Dr. Bellama noted.
“Heart disease is the number one killer of women in the United States. It accounts for roughly one in five deaths. It’s the second killer of women who identify as Pacific Islander, second only to cancer… We’re talking about something that affects one in three women over the age of 65 as well,” she said.
She added, “Heart disease is a big, big concern for women systemic health, and gum disease is a risk factor for developing heart disease, along with diabetes, high cholesterol, hypertension, smoking or alcohol consumption. So, in order to help protect yourself from developing heart disease, it’s a good idea to have good oral health to see a dentist and make sure that you’re staying on top of getting cleanings and things like that.”
Another systemic disease that is linked to oral health is diabetes.
“With diabetes, and gum disease or periodontal disease, I like to describe it as a two-way street. If you have diabetes that’s not controlled, you’re more likely to have advanced gum disease and tooth loss. But it also goes the other way around to say you’re doing all of the right things to keep your blood sugar levels in check, you’re checking your blood sugar, you’re taking your medication as prescribed by your primary care physician, you’re exercising, you’re doing all the right things, but you just can’t get your blood numbers where you and your physician want them. There have been studies to show that if you treat your gums, if you go in and make sure that you are getting cleanings regularly, and that your gums are healthy, you can actually help improve your blood sugar numbers and your hemoglobin valency, which is the number that your doctor looks at with a blood drive every few months to see how you’re doing controlling your diabetes,” Bellama explained.
A lot of this is about systemic inflammation, the underlying cause of most illnesses, she noted.
“Heart disease specifically is caused by a blockage in arteries that build up of cholesterol, so we want to keep our cholesterol down that blocks the flow of blood… There are all sorts of things that you can do to prevent and will lower your risk of developing heart disease: a good diet, exercise, making sure that you keep your blood pressure, your cholesterol in check. If that means working with your primary care physician to take medications that help you with controlling those things, then that’s really important. And having your oral health, taking care of making sure that your gums are healthy, is just one of the pieces of the puzzle to help prevent heart disease,” she said.
Bellama said there are a lot of other or systemic health conditions that people who have poor oral health are more likely to have other illnesses and diseases, but diabetes specifically is one of the few where it is known that if someone’s oral health improves, there is an improvement in their systemic health.
“But it’s not to say that it doesn’t exist for other conditions. Establishing causation rather than just correlation, scientifically, is something that is difficult to do, but every year, new research comes out that just emphasizes how important oral health is for your overall health,” she added.
“Cancer is actually the number one killer of women in the United States who identify as Pacific Islander, and in the CNMI, we have very, very high rates of oral cancer that’s primarily due to chewing betel nut,” said Dr. Bellama.
She added that oral cancer caused by chewing is something that is very preventable, noting that alcohol and tobacco consumption increases the risk of developing oral cancer.
“Prevention is the best way to not develop oral cancer, and to do that, I would recommend that somebody not chew. But that’s not the only cause of oral cancer. We also see oral cancers that are caused by HPV or the human papilloma virus. But fortunately, we actually have a vaccine for that. HPV also causes cervical cancer. So, if you get vaccinated — and we recommend vaccinated vaccination starting at 11 years for both boys and girls, that it can prevent oral cancer or HPV related oral cancers during their lifetime,” she said.
Beyond prevention though, there is also early detection.
“Oral cancer is very treatable. If it’s caught early, if an oral cancer gets to some of the more advanced stages, it becomes much more difficult to treat. So, everyone should have an oral cancer screening once a year. If you’re going in to see your dentist for a regular cleaning and checkup, your oral cancer screening should be part of that exam that the dentist does when they come into the room. But if you’re not going in for a cleaning, I encourage everyone to go in and just have an oral cancer screening,” said Bellama.
She said the oral cancer screening is quick and painless, typically takes about three minutes
“It really just involves the dentist looking inside your mouth, checking your cheeks under your tongue, and if we see anything that is cause for concern, then we’ll have a conversation about that. Usually, oral cancer is diagnosed by a biopsy, so we take a very small sample or area of the lesion or the credit in the mouth that doesn’t look quite right, we send it to a lab [to] look at it under a microscope and tell us whether it’s something to be concerned about or something that is fine,” she explained.
Bellama said Medicaid and several private insurances covers the cost of this entirely.
“If, for some reason, finances are a barrier for somebody to come in to have an oral cancer screening or to have a biopsy done, we’ve been very fortunate to be able to work with our partners at the Commonwealth Cancer Association, to provide financial assistance so that finances aren’t a barrier,” she added.
Furthermore, she said, “Everybody will most likely experience a cavity or may have some form of gum disease itself might in their lifetime. They are treatable. If they’re left untreated, they get bigger and they can cause infection, which can be a very serious infection, can spread to your bloodstream, or it can cause swelling that makes it difficult to breathe. Those can be very serious medical conditions, so don’t put off dental treatment if it’s recommended to you, whether a small cavity hurts or not. Sometimes cavities don’t hurt until they get really, really bad, but that doesn’t mean that the cavity is not there. And it’s a lot easier for us to treat small cavities than big problems.”
The CHCC dental clinic provides comprehensive care for children and adults, emergency care for adults, and treatment for special patient populations.
Services offered can be covered either by Medicaid or self-pay.
To schedule an appointment, call (670) 236-8369.
For more information, visit www.chcc.health