Mouth Physical Exam & Cardiac Health

doctor and patient exam

The mouth-body connection suggests that oral health relates to overall health. A well-established link has been documented between periodontal disease and cardiovascular diseases like atherosclerosis, coronary heart disease, and acute coronary events including myocardial infarction.1-5 Meta-analyses have associated periodontal disease with elevated bacterial exposure and coronary heart disease and early atherogenesis.5 Other evidence suggests that oral health and systemic disease are also linked—what’s healthy for the mouth is also healthy for the rest of the body, and vice-versa.6-9

According to the 2000 US Surgeon General’s report, Oral Health in America, oral examination can reveal signs and symptoms of more than 90% of systemic diseases.10 However, in spite of these associations, some researchers feel there is a lack of awareness in the healthcare community on their possible importance.11 Nutrition-oriented physical exams, as taught in Functional Medicine, can help clinicians to identify early warning signs. This can enable personalized interventions for patients at risk. In the following video, IFM educator Michael Stone, MD, MS, identifies the signs to look for inside of the mouth during the patient physical exam:

IFM educator Michael Stone, MD, MS, is a board-certified family physician who practices in Ashland, Oregon. His interests and lectures have covered a wide range of topics—bezoars, neonatal hypocalcemia, exposure to vitamin D and chronic disease—and many subjects in between.

There are approximately 800 species of bacteria identified in the oral cavity, and periodontal disease is the most common oral condition in the population.12 In 2008, a systematic review found that periodontitis is a risk factor for coronary heart disease.13 One meta-analysis found that periodontal disease causes a 19% increase in the risk of cardiovascular disease.14 This increase in relative risk reaches to 44% among individuals aged 65 years and over.14

In addition to cardiovascular diseases, some studies suggest that infections in the oral cavity are contributing factors to systemic inflammatory diseases such as diabetes.6-8 New data suggest that this association is not indicated by traditional clinical signs of periodontal disease but rather by a cluster of host immune and inflammatory mediators.7 A 2015 study examining the relationship between periodontal microbiota and early diabetes risk found that higher levels of four species (A. actinomycetemcomitans, P. gingivalis, T. denticola, and T. forsythia) were associated with a two- to three-fold higher prevalence of prediabetes.15 The study speculates that if bacterial dysbiosis can contribute to prediabetes development in susceptible individuals, it may be possible that periodontitis and prediabetes (or diabetes) may be comorbid conditions due to shared microbial risk factors.15

Researchers are calling for further studies into the possible casual associations between oral conditions and systemic disease,16 and Functional Medicine clinicians can easily assess oral health in the physical exam. Modifiable risk factors that contribute to periodontal diseases include smoking, poor oral hygiene, hormonal changes in females, diabetes mellitus, medications, and stress.12 In a 2014 study, participants with excellent oral hygiene had a significantly lower cardiovascular disease risk as compared to those with poor oral hygiene.17 Encouraging healthy oral hygiene (including daily brushing and flossing) and supporting a healthy microbiome are just two ways practitioners can help prevent oral-systemic disease. In fact, the Journal of the American Medical Association published a report on the importance of oral health in comprehensive health care, stating that:

A 5-minute oral examination could help physicians not only recognize poor oral health but also detect clues to seemingly unrelated health issues.18

More information about how to perform an oral exam during a routine physical screening can be found in IFM’s free N Sight course. Learn more about the underlying risk factors and interventions for cardiac health at IFM’s Cardiometabolic APM.


  1. Bochniak M, Sadlak-Nowicka J. Periodontitis and cardiovascular diseases—review of publications. Przegl Lek. 2004;61(5):518-522.
  2. Singer RH, Stoutenberg M, Feaster DJ, et al. The association of periodontal disease and cardiovascular disease risk: results from the Hispanic Community Health Study/Study of Latinos [published online March 14, 2018]. J Periodontol. doi:10.1002/JPER.17-0549.
  3. Delange N, Lindsay S, Lemus H, Finlayson TL, Kelley ST, Gottlieb RA. Periodontal disease and its connection to systemic biomarkers of cardiovascular disease in young American Indian/Alaskan natives. J Periodontol. 2018;89(2):219-227. doi:10.1002/JPER.17-0319.
  4. Beck JD, Offenbacher S. Systemic effects of periodontitis: epidemiology of periodontal disease and cardiovascular disease. J Periodontol. 2005;76(11 Suppl):2089-2100. doi:10.1902/jop.2005.76.11-S.2089.
  5. Mustapha IZ, Debrey S, Oladubu M, Ugarte R. Markers of systemic bacterial exposure in periodontal disease and cardiovascular disease risk: a systematic review and meta-analysis. J Periodontol. 2007;78(12):2289-2302. doi:10.1902/jop.2007.070140.
  6. Babu NC, Gomes AJ. Systemic manifestations of oral diseases. J Oral Maxillofac Pathol. 2011;15(2):144-147. doi:10.4103/0973-029X.84477.
  7. Teng YT, Taylor GW, Scannapieco F, et al. Periodontal health and systemic disorders. J Can Dent Assoc. 2002;68(3):188-192.
  8. Masthan MK, Anitha N, Jacobina JJ, Babu NA. Oral infections causing systemic diseases. Biomed Pharmacol J. 2016;9(2). doi:10.13005/bpj/1019.
  9. Gonzales-Marin C, Spratt DA, Millar MR, Simmonds M, Kempley ST, Allaker RP. Levels of periodontal pathogens in neonatal gastric aspirates and possible maternal sites of origin. Mol Oral Microbiol. 2011;26(5):277-290. doi:10.1111/j.2041-1014.2011.00616.x.
  10. Evans CA, Kleinman DV, Maas WR, et al. Oral Health in America: A Report of the Surgeon General (Executive Summary). Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed July 25, 2018.
  11. Bouchard P, Boutouyrie P, D’Aiuto F, et al. European workshop in periodontal health and cardiovascular disease consensus document. Eur Heart J Suppl. 2010;12(Suppl B):B13-B22. doi:10.1093/eurheartj/suq001.
  12. Nazir M. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci. 2017;11(2):72-80.
  13. Humphrey LL, Fu R, Buckley DI, Freeman M, Helfand M. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23(12):2079-2086. doi:10.1007/s11606-008-0787-6.
  14. Janket SJ, Baird AE, Chuang SK, Jones JA. Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(5):559-569. doi:10.1067/moe.2003.107.
  15. Demmer RT, Jacobs DR, Singh R, et al. Periodontal bacteria and prediabetes prevalence in ORIGINS: the Oral Infections, Glucose Intolerance, and Insulin Resistance study. J Dent Res. 2015;94(9 Suppl):201S-211S. doi:10.1177/0022034515590369.
  16. Joshipura K, Ritchie C, Douglass C. Strength of evidence linking oral conditions and systemic disease. Compend Contin Educ Dent Suppl. 2000;(30):12-23.
  17. VanWormer JJ, Acharya A, Greenlee R, Nieto FJ. Oral hygiene and cardiometabolic disease risk in the Survey of the Health of Wisconsin. Community Dent Oral Epidemiol. 2013;41(4):374-384. doi:10.1111/cdoe.12015.
  18. Lee J, Somerman MJ. The importance of oral health in comprehensive health care. JAMA. 2018;320(4):339-340. doi:10.1001/jama.2017.19777.

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