Cape Town reproductive health nurse Gigi Akoojee was in hell. She'd had dental bridgework done many years earlier to restore a lost tooth and for a while now she'd been experiencing discomfort with aching gums. Finally it all came to a head with a pain so intense that she phoned her dentist in the middle of the night seeking relief. The guilty party? A mouth infection.

Akoojee, whose diabetes may have been an exacerbating factor, was prescribed antibiotics – to no avail. "They caused several unpleasant side effects, such as stomach upset and candida, but didn't clear up the infection," she recalls. When the excruciating pain continued unabated, her dentist took X-rays and referred her to a maxillo-facial surgeon. By now, the infection had spread into her sinuses and to one of her eyes, which was swollen, red and running with a mucus discharge. Few mouth infections loom as large as Akoojee's. But runaway dental infections can be treacherous. They have eaten through the skin in people's necks, choked off airways, migrated to the heart, burrowed into brains and, yes, even killed people.

Have we scared you enough yet? Here's the point: everyone is vulnerable, because bacteria that routinely lurk in the mouth cause tooth decay and gum disease. The problem: most people don't know they have these infections. They often cause no pain and few symptoms, but can lead to far worse. Gum disease may also heighten the risk for heart disease, diabetes, pneumonia and premature birth, according to recent clinical trials. But the good news is that with good old regular brushing and flossing, you may prevent all that. And by seeing your dentist often, you can nip most problems in the bud.

Regular dental checkups can pay off in other ways, too. For example, dentists can spot signs of diabetes, heart disease and cancer, along with a variety of rare skin and autoimmune diseases. Since people typically visit their dentists more often than they visit other doctors, that can lead to early diagnosis and early treatment. All of which means that your dentist can do much more than save your teeth and gums. Your dentist can save your life.

An Oral Epidemic
While there is some evidence that oral health in our children is improving, not all is well behind South African smiles. According to Professor Jean-Claude Petit, head of Oral Medicine and Periodontology at the University of the Witwatersrand, national surveys show that the oral health of 12-year-old children has improved over the past two decades, with a reduction of more than 50 percent in the numbers of decayed, missing and filled teeth.

But here's the bad news: a 1999/2002 survey by the University of Pretoria's School of Community Dentistry found that only six percent of 12-year-olds' cavities were treated and 85 percent of 15-year-olds showed signs of gum disease. For adults, the picture was much worse: just two percent of those surveyed had perfectly healthy gums. Dr Andreas Siebold, President of the South African Society for Periodontology, believes the incidence of advanced gum disease, known as periodontitis, in adults over the age of 30 is probably much the same as that in the US – one in three. And while one study shows that just under 13 percent of South Africans between the ages of 35 and 44 had no teeth at all, Neil Campbell, CEO of the South African Dental Association, puts the figure in the general population at about eight percent.

Dietary change is part of the problem. "We know that the number of untreated dental caries cavities used to be lower than it is now due to better traditional diets," says Campbell. "The recent move to Western diets with high refined sugars has increased decay rates. Also, most South Africans are not getting enough fluoride: drinking water in most areas has less than optimal fluoride levels, and toothpaste and toothbrushes are unaffordable for poor communities."

It's clear, however, that oral disease is widespread in this country because of lack of access to dental treatment. The vast majority of South Africans don't have medical insurance – and even those that do, often fail to take care of their teeth. "Of the seven million people on medical aid schemes, only about 35 percent use dentistry annually and these are an aware, privileged group," Campbell says. In the public sector, he asserts, there is poor prioritisation of oral healthcare services by the Department of Health and too few dental workers in rural areas. "The Department of Health alleges that it treats 83 percent of the population, but our estimates are that between seven percent and nine percent of the indigent population actually receive some form of treatment annually – usually extractions."

It's a situation Cape Town periodontist Dr Hans Van Heerden refers to as a "loaded gun". "There's a massive wave of disease waiting to happen," he warns.

Runaway Infections
Gigi Akoojee was admitted to hospital for an apicetomy, an operation to stem the tide of infection. First, the surgeon made a small cut in the gum over the root of her affected tooth and lifted the gum off the bone. Then he removed a small amount of bone with a drill to uncover the infected tissue, which he thoroughly cleaned away. Finally, he sealed the root with a small filling before stitching the gum back into place.

She was sent home with painkillers, antibiotics and antiseptic mouthwash, and it took about a week for the swelling and pain to recede. However, the surgeon had warned that the infection might recur and sure enough it did. Before very long, Akoojee had to prepare herself for a second apicetomy.

Infections like Akoojee's are rare, but not exceedingly so. Campbell says that patients with a big dental abscess can actually die from it if the organisms involved are resistant to antibiotics and the immune system is compromised, for example, if they have TB or HIV. "If it's ignored, it can spread either upwards to the brain or downwards to the heart," he cautions. "This can prove fatal."

A Silent Threat
Gum infections, too, harm more than just mouths. While mild gum infections called gingivitis may lead to red and swollen gums, they're not especially dangerous by themselves. But they can worsen into periodontitis, painless but chronic gum infections that, if left untreated, degrade bony sockets and ligaments that hold teeth in place. The immune system fights gum infections to keep oral bacteria from spreading to other parts of the body. It usually succeeds, but not always. Gum-disease bacteria can enter the bloodstream and move to the heart, creating life-threatening infections in previously damaged heart valves. What's more, scientists believe the resulting inflammation releases infection-fighting compounds that can inadvertently damage other tissues.

The arteries may be the most common target. People with periodontitis were twice as likely to die from a heart attack and three times as likely to die from a stroke, according to a study that examined 18 years of medical histories for 1147 people. Steven Offenbacher, director of the Center for Oral and Systemic Diseases at the University of North Carolina School of Dentistry, who co-authored the study, is helping conduct another to see if treating periodontitis in heart patients will cut the risk of heart attacks.

Pregnant women with serious periodontal disease have about four times the risk of delivering preterm babies, and they face an increased risk of pre-eclampsia, in which blood pressure climbs sky-high after the 20th week, threatening the lives of both mother and foetus. In an early clinical trial, researchers found that treating seriously infected gums reduces preterm births five-fold, but the work needs to be confirmed in larger trials.

Diagnostic Dentists
Benoni secretary Lynn Hotson, 62, went to her GP twice early in 2002, complaining that the glands in her neck were sore and swollen. He diagnosed postnasal drip and prescribed antibiotics, but they made no difference. Referred to an Ear, Nose & Throat (ENT) specialist, she was told that the postnasal drip was causing an infection, which in turn was causing a fungus and that she'd have to take medication indefinitely. Unhappy with this, she declined a further prescription.

The lump at the base of her jaw continued to get bigger, however, and at a regular checkup with her dentist in October 2003 she asked if there might be an abscess on the gum. He X-rayed her mouth and immediately referred her to a specialist. "After extensive tests the same day, followed by removal of the growth the next morning, I was diagnosed with non-Hodgkin's lymphoma," says Hotson. The cancer had already spread throughout her body, affecting her lymph glands, and she underwent a six-month course of chemotherapy. "I was devastated and very angry that the ENT hadn't even sent me for tests," she says. "But I'm lucky to have wonderful friends who rallied round to support me." Since May 2004, she's had six-monthly CT scans, which have shown her to be clear of cancer. "At the moment, I'm feeling very well and have resumed my usual lifestyle," she says. "I'll always be grateful to my dentist."

As well as spotting lymphoma, dentists can recognise signs of leukaemia and oral cancer. South Africa's National Cancer Registry reports an average of 1400 newly diagnosed oral cancer cases each year, three-quarters of them male, although experts say the incidence is much higher. Moreover, Statistics South Africa recorded 1050 deaths from oral cancers in 2002. "Before treating a patient, all dentists should perform a thorough oral clinical examination," says Petit. "When they detect a lesion that could be cancerous or is beyond the scope of their practice, they can either take a biopsy for histological diagnosis or refer the patient to a specialist in oral medicine or maxillo-facial and oral surgery."

Diagnosing cancer is just the beginning. Dentists can also spot signs of gastrointestinal diseases like Crohn's disease, skin diseases, autoimmune diseases like lupus, and more. "The mouth can show telltale signs of diabetes, anaemia, vitamin deficiencies and contagious diseases like measles," explains Van Heerden. Adds Petit: "Other examples include syphilis, candidiasis, shingles and multiple myeloma, which is disease that starts in the bone marrow."

If more people realised the consequences of not taking care of their teeth and gums, they'd probably call a dentist tomorrow. Still, the vast majority of South Africans haven't been to one in the past year. "Unfortunately, South Africa in general has a very low dental IQ," says Campbell. Healthy teeth and gums let us talk, smile, laugh and kiss without embarrassment. That's reason enough to take care of our oral health. But as medical science reaffirms that head and body are indeed connected, there's more reason than ever to brush twice a day, floss daily, get dental checkups every six months, or see a dentist promptly if you have a problem.

That's something Gigi Akoojee knows only too well. Three years after her first apicectomy, she's still struggling with the after-effects of infection. Because it caused deterioration of her bone, her periodontist hasn't been able to insert a tooth implant. Instead, he's had to take healthy bone from elsewhere and graft it on. She'll now have to wait for the graft to take before she can have an implant. "I've learnt a tough lesson," she says. "If you have a problem, ask your dentist lots of questions. If the problem continues, ask him to refer you to someone else. Persist until it gets resolved."

Adapted from an article by Dan Ferber