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Functional Nutrition Evaluation CLINICAL INDICATORS:

DENTAL EXAMCompanion Guide

Version 5

nsight.org

Table of Contents

The Dental Examination of the Mouth from the Functional Medicine Perspective ..................... 3

Patient Positioning .......................... 3

Order of the Exam ........................... 3

Clinical Exam Findings.................... 4

Clinical Considerations Using the Functional Medicine Matrix Model ................................. 11

Fluorosis Considerations in Health Care Today ........................ 14

Conclusion .................................... 15

Acknowledgements ...................... 16

Dental Exam References ............... 16

© 2016 The Institute for Functional Medicine

IFM n Dental Exam n N Sight Videos and Resources: nsight.org 3© 2016 The Institute for Functional Medicine

“Food is medicine. This is one of the guiding principles of The Institute for Functional Medicine. Well. If food is medicine, we need patients with healthy mouths and healthy teeth.” —Mary Ellen Chalmers, DMD

The Dental Examination of the Mouth from the Functional Medicine PerspectiveThe mouth is the visible gateway to the rest of the body and reflects what is happening deep inside. The examination of the mouth provides a rich glimpse into a person’s health or disease status. The IFM Eight-Step Mouth Exam1 helps the clinician create a routine order and flow to the dental exam, which provides a framework for determining nutritional sufficiency and enhances the clinician’s ability to detect signs of systemic imbalance. Recent studies show a strong link between chronic oral inflammation and other health problems.2-4 Over 100 systemic diseases have oral manifestations, including cardiovascular disease, stroke, respiratory infections, pancreatic cancer, diabetes, and nutritional problems.5,6 Inflammatory mechanisms involving pro-inflammatory cytokines and metalloproteinases link periodontal disease to coronary heart disease and stroke.7-9

A thorough oral examination can identify signs and symptoms of disease that point to matrix imbalances. The Functional Medicine approach gathers key medical history and physical exam findings, including the dental exam, with the intent of uncovering antecedents, triggers, and mediators of disease. Practitioners are encouraged to use this Dental Exam Companion Guide in conjunction with the Functional Nutrition Evaluation; Mouth and Dental Exam Form and Eight-Step Mouth Exam Companion Guide.

The Equipment Used in the Eight-Step Mouth Exam

n Light sources: otoscope, penlight, headlamp, or magnifier with light

n Latex-free glovesn pH paper (5-9 pH range)n Gauze (2x2)n Galvanometer or aluminum foil stripsn Magnifier with light

n Q-tipsn Tongue depressorn Stethoscopern Maskn Cameran Headlamp

Patient PositioningThe patient should be seated at or below eye level to give the practitioner easy access for visualizing the jaw and mouth and palpating the temporomandibular joint area, as well as the muscles of the head and neck. Good visibility is essential for thoroughly accessing, identifying, and examining the structures of the mouth and the oral cavity.

Order of the ExamStart with a general observation of facial symmetry, movement, and facial expression to identify any facial paralysis, as well as associated affect and mood. Then proceed with the examination (Table 1).


1. Temporal Mandibular Joint Movement (C vs S pattern), change in condylar position, pain. Active inflammation, joint noises, pain at rest or with movement, muscle soreness, chronic muscle stress and tension, bite balance. Mastication association with mind, cognition, and TMJ dysfunction.

2. Lips Integrity, cracking, angular stomatitis. Positioning, abnormality with breathing patterns. Color: pallor, cyanosis, cheilosis.

3. Soft and Hard Palate Developmental defects: soft and hard palate. Tonsil size, evidence of tumors, abnormal tissue, tongue resting position, palate, chronic infection, pemphigus, bony abnormalities: torus palatinus (if present, consider torus mandibularis).

4. Tongue Color, size (macro- or microglossia), lateral borders smooth or scalloped, red papilla, geographic tongue, papillary change of glossitis, asymmetry of movement. Ask the patient to extend the tongue and move it side to side. Then grasp the tongue.

5. Gums Pink, red, or discolored gums, firm vs. boggy gums, bleeding gums, exudate, odor, obvious inflammation, gingivitis/periodontitis, signs of protein deficiency or methylation defects.

6. Buccal Mucosa Lesions, salivary flow, lichen planus, hyperkeratotic lesions, signs of gluten intolerance, xerostomia, Sjögren’s syndrome, pH.

7. Teeth Plaque, fillings, missing teeth, dentures, root canals, metal restorations, corroded amalgams, dissimilar metals, decay. Enamel erosion. Pain or shocks when biting aluminum foil or abnormal oral galvanism on galvanometer.

8. Chew and Swallow Check Taste

Painful chewing, multiple attempts at swallowing, choking during swallowing, check for desaturation. Evaluate taste to determine degree and type of taste sensitivity.

Table 1. The Eight-Step Mouth Exam

Clinical Exam Findings The clinical findings uncovered during the dental exam can have functional associations along with possible nutritional insufficiency correlations (Table 2). Suspicious findings in the mouth may parallel other physical exam abnormalities. For example, a finding of atrophic taste buds may be accompanied by decreased peripheral vibratory sense if the patient has a vitamin B12 deficiency. In that case, the practitioner should test the patient’s B12 status (methylmalonic acid) and evaluate the diet, nutrition, and lifestyle of the patient.

Table 2. Functional Dental Exam, Associated Nutritional Considerations, and Functional Matrix Considerations

Location

Dietary and Nutrient Insufficiencies, or Other Nutrient-associated Considerations

Functional Matrix Considerations

General

Facial asymmetry n Defense & Repair— autoimmune disease, infection

n Energy—oxidative stress

1. Temporomandibular joint (TMJ)

Movement

Open < 4 cm If inadequate food intake, possibility for multiple nutrient insufficiencies

n Structural Integrity—painn Communication—

associated hearing loss10

C or S pattern n Structural Integrity—painn Defense & Repair—inflammation


Location



Palpation

Tenderness on palpationor movement

Essential fatty acids (EFAs), vitamin D11-13 n Defense & Repair—inflammationn Structural Integrity—pain or crepitus

Condylar position change n Structural Integrity— (e.g., TMJ dysfunction)

n Communication—altered cognition

Muscles of Mastication

Medial & lateralpterygoids

Tenderness Magnesium, potassium, vitamin D, EFAs n Structural Integrity—muscle spasmn Communication—proprioception-

amygdala-hippocampus- cognition arc14-16

Asymmetry n Structural Integrity

Tone n Biotransformation & Elimination—metals

Bite Balance

Evenness of bite n Structural integrityn Communication—proprioception-


TMJ complex pain Methylation single nucleotide polymorphisms altering requirements for folate*, B12, B6, iron, vitamins C13,17

n Structural Integrityn Spiritual/Mental/Emotional

2. Lips

Positioning Protein if associated weight loss n Structural Integrity— loss of vertical dimension

Breathing Pattern

Mouth breather n Assimilation—oxygen/respiratoryn Defense & Repair—allergiesn Structural Integrity—sleep apnea,

deviated septum

Nose breather n Structural Integrity— ankyloglossia, sleep apnea

n Communication—hypothyroidism

Lesions

Cracking, fissuresCheilosis

n Water, EFAs, iron, zinc, thiamine, riboflavin, niacin, pyridoxine, folate, B12, biotin, vitamin C

n Excess vitamin A

n Structural Integrityn Assimilation

Angular stomatitis Iron, zinc, thiamine, riboflavin, niacin, pyridoxine, folate, B12, biotin, vitamin C


Herpes simplex virus 1 (HSV1)

Glutamine, leucine, lysine,zinc, vitamins A, E, and C

n Defense & Repair

Table 2. Functional Dental Exam, Associated Nutritional Considerations, and Functional Matrix Considerations(cont.)

*Folate = Folic acid and/or folates throughout this document.


Location



3. Soft and Hard Palate

Boney abnormalities n Structural Integrity— torus palatinus/mandibularis

n Assimilation

Cleft palate or orofacial n B complex, folate inadequacy during organogenesis (week 2-8)18

n Altered methylation—MTHFR SNP (MTHFD1, 1958; MTHFR677T )19

n Assimilationn Structural Integrity

Tonsillar hypertrophy n Nutrients of immune balance and function:20 protein, EFAs, iron, zinc, vitamins A, D, E

n Phytonutrients

n Assimilationn Defense & Repair—innate and

acquired immunity20,21

4. Tongue

Size

Small Protein undernutrition associated with weight loss


Large n Defense & Repair— allergy, drug reaction, infection

n Communication— hypothyroidism, acromegaly

n Biotransformation & Elimination—toxins

Shape

Scalloping n Structural Integrity—sleep apnean Defense & Repair—allergy-associated

enlargement of tongue

Color

Beefy redMagentaWhiteBrown

See Eight-Step Mouth Exam1 n Assimilationn Defense & Repair

Taste Buds

Atrophy Iron, zinc, riboflavin, niacin, folate, B6, B1222,23

n Assimilation—digestion/absorptionn Defense & Repair—gluten sensitivity

Geographic Niacin, B vitamins22,23 n Assimilation—dysbiosisn Defense & Repair—celiac disease,

gluten sensitivityn Biotransformation & Elimination—

mixed metals, galvanism

Lesions

Lichen planus Vitamin A, B12, folate n Structural Integrityn Biotransformation & Elimination—

mixed metals, galvanismn Defense & Repair—autoimmune disease,

gluten sensitivity

Cancers n Protein, EFAs, nutrients of immune surveillance: iron, zinc, vitamins A, C, D, and B vitamins, esp. folate

n Excess synthetic folate

n Defense & Repair n Energy—oxidative stressn Communication—hyperglycemia

(>200mg/dl)n Biotransformation & Elimination—mercury

amalgams, glutathione depletionn Structural Integrity



Location



Additional Findings

Enlarged submental node Zinc, iron, vitamins A, D, C n Defense & Repair—infection

5. Gums

Color

Red Vitamin C, CoQ10 n Defense & Repair—inflammationn Energy—redoxn Biotransformation & Elimination—

mixed metals, mercury amalgams

Darkened gum line(Burton line)

Nutrients involved in phase I and II detox process

n Biotransformation & Elimination—possible toxic or contaminant exposure (cadmium, lead, mercury, copper cisplatin, bismuth)

Reddened gum line(without margination)

Vitamin C n Structural Integrity

Texture

Boggy n Biotransformation & Elimination—side effects of medication (e.g., phenytoin)

n Defense & Repair—inflammation (periodontal disease)

Boggy next to restorations n Energy—Oxidative stressn Defense & Repair—autoimmune

response to restorative materials

Breath Odor24,25

Halitosis Niacin n Energyn Defense & Repair—dysbiosisn Structural Integrity—GERD

Ketones (sweet) n High simple carbohydrate diet in diabetics

n High fat diet—ketotic diet

n Communication— diabetes, insulin resistance

n Energy—oxidative stress, gluconeogenesis

n Defense & Repair

Di- or tri-methylamine(fishy)

High choline diets (excess) n Biotransformation & Eliminationn Energy—oxidative stress

Endogenous oral malodor n Defense & Repair—disrupted or imbalanced biofilm, anaerobic and fungal imbalance



Location



Appearance

Gum retractions Vitamins C, D n Structural Integrity— malocclusion/abfractions

Gingivitis (gingivaltenderness, ulcerative gingivitis, hemorrhagic)

Calcium, zinc, iron, CoQ10, vitamins A, C, D, B vitamins esp. folate26-34

n Structural Integrity— endothelial dysfunction

n Communication—insulin resistancen Defense & Repairn Energy—oxidative stress

Periodontal disease Calcium, selenium, zinc, iron, CoQ10, vitamins A, C,1,16 D (FOK1 SNP),35 and E, B vitamins esp. thiamine, riboflavin, niacin, folate26-34

n Transport—cardiovascular disease36,37

n Communication—diabetes, insulin resistance

n Defense & Repairn Structural Integrity

Hyperplasia Vitamin C n Biotransformation & Elimination— adverse drug reactions

6. Buccal Mucosa

Lesions

Proximity to dissimilar metals

n Biotransformation & Elimination—galvanism

n Defense & Repair—autoimmune response to metals

Lichen planus Vitamin A, B12, folate n Structural Integrity n Energy—oxidative stressn Defense & Repair n Biotransformation & Elimination—

dissimilar metals

Leukoplakia Iron, selenium, zinc, vitamin A, C, B12, beta carotene

n Assimilation n Defense & Repair n Structural Integrity n Biotransformation & Elimination—

dissimilar metals

Salivary Flow and Adequacy

Xerostomia Protein, vitamins A, C, and D n Defense & Repair—Autoimmune disease (e.g., Sjögren’s, celiac disease), hypersensitivity reactions (IgG, e.g., gluten)38,39

n Biotransformation & Elimination—medication side effects (e.g., SSRIs, stimulants, beta blockers)

n Structural Integrity

pH

<6.8 (6.8–7.4 normal) n Calcium, phosphorusn Alkalinizing foodsn Excess sugars

n Assimilation—altered salivary enzymes (inactivity)

n Defense & Repair—dysbiosis, poor hygiene

n Biotransformation & Elimination—increased toxicity of restorations

n Communication—burning mouthn Structural Integrity—GERD, tooth decay,

multiple restorations



Location



7. Teeth

Occlusion

Bite/Occlusal harmony n Structural Integrity n Communication—altered mastication,

occasional pain if balance is abnormal

Malocclusion Can cause pain with eating which can alter food choices with the potential for nutritional imbalances

n Structural Integrityn Communication—proprioception-


Tooth Health

Missing teeth The higher the number of missing teeth, the greater the risk of malnutrition

n Structural Integrityn Communication—

more teeth = higher cognition40,41

Decay, caries n Calcium, phosphorus, fluoride, vitamins A and D42

n Gluten sensitivity (HLA DQ/DR,)43,44 inadequate normal flora, dysglycemia, nutrient-associated xerostomia (vitamin A deficiency)

n Defense & Repair—dysbiosisn Energy—oxidative stressn Structural Integrity

Restorations Types45-49

Silver-mercury amalgam(can present as bright,black or corroded)

Increased Phase 1 and 2 biotransformation liver detoxification requirements

n Assimilation—Hg effects on GI floran Energyn Mental and Emotionaln Biotransformation & Eliminationn Defense & Repairn Transport

Yellow gold n Defense & Repair— autoimmune response

Silver-colored noble orbase metal crowns

n Defense & Repair— autoimmune response

n Biotransformation & Elimination—toxicity

Porcelain crowns n Structural Integrity— occlusion or bite discrepancy

Implants n Defense & Repair—heavy metals can trigger an autoimmune response

n Structural Integrity—can create problems with bone either from infection or autoimmune response

n Biotransformation & Elimination—toxicityn Energy—oxidative stress and

mitochondrial dysfunction

Root canals Nutrients of immune surveillance and biotransformation: protein, EFAs, iron, zinc, vitamins A, C, D, and B vitamins

n Defense & Repair—immune balancen Communication and Transport—higher

incidence of CHF and diabetes in patients with multiple root canals

n Structural Integrity—bone infectionn Biotransformation & Elimination—toxicity

from infection with poor healing



Location



Restorations Types45-49

Periodontal ligament painand or detachment

Zinc, antioxidants, vitamins A, D, B12 n Structural Integrity— disturbance of proprioception

n Defense & Repair

Irregular dentin Calcium, phosphorus, vitamin C n Structural Integrity

Portcullis (poorly fittingdentures)

If progressive weight loss, insufficient calories

n Structural Integrity n Communication—

proprioception-amygdala-hippocampus- cognition arc14-16

Enamel Changes

Enamel dysplasia n Vitamin D (during prenatal period), calcium, phosphorus

n Vitamin A (toxicity, during prenatal period)

n Structural Integrityn Defense & Repair—celiac

Dysmorphic enamel Vitamins A, D n Defense & Repair—celiac

Enamel erosion Anorexia and bulimia, eating disorders n Structural Integrity—GERD

Discoloring/Staining

White mottled or pitting n Calciumn Fluorosis (toxicity)

n Biotransformation & Elimination—toxicity

Brown n Fluorosis (toxicity)n Consider fluoride concentration in infant

formula and canned foods

n Biotransformation & Elimination—toxicity from fluorosis, adverse drug reactions

Galvanic Forces50

High galvanometricreadings

Low pH associated with poor intake of calcium, phosphorus, potassium rich foods; alkalinizing foods

n Biotransformation & Elimination—increased mercury vaporization

n Structural Integrity—increased salivary inadequacy–xerosis

Pain with tapping teeth onor chewing aluminum foil

n Structural Integrity—cracked toothn Defense & Repair—infectionn Biotransformation & Elimination—

increased vaporization of heavy metals (mercury) when dissimilar metals create a current

8. Chew/Swallow/Taste Eight-Step Mouth Exam1

Bitter taste SNPs TAS2R38 and TAS1R2 for caries risk and/or protection in primary teeth51

n Structural Integrity n Communication



Figure 1. The Functional Medicine Dental Exam: Findings and Potential Areas of Clinical Imbalance

Physiology and Function: Organizing the Patient’s Clinical Imbalances

Retelling the Patient’s Story

AntecedentsMercury Amalgams, Root Canals, Periodontal Disease, Metal Crowns, Dentures and Implants, Orthodontics (Nickel Based), Xerostomia (Dry Mouth), Poor Occlusion (Bite)—TMJ Jaw Osteonecrosis

Triggering EventsPlacement or Improper Removal of Mercury Amalgam, Root Canal Treatment, Placement of Dental Implants, Orthodontic Treatment, Placement of Metal Crown, Acrylic or Resin Denture, etc. in Susceptible Patients, Disturbance of Occlusion

Mediators/PerpetuatorsMercury Amalgams, Root Canals, Periodontal Disease, Metal Crowns, Dentures and Implants, Orthodontics (Nickel Based) Xerostomia (Dry Mouth), Poor Occlusion (Bite)—TMJ, Jaw Osteonecrosis

Name: Date: CC: © 2014 Institute for Functional Medicine

Modi�able Personal Lifestyle Factors

Exercise & MovementCentral adiposity and lack of exercise contribute to development and progression of periodontal disease

NutritionTooth Decay-Promoting Diet (High Sugar) Celiac Disease and Gluten Sensitivity

StressIncreased levels of stress can contribute to higher tooth decay rates

RelationshipsPoor dental health, with or without halitosis, or an unattractive smile can be a barrier in social relationships and a�ect self-esteem and the sense of well-being

Sleep & RelaxationNocturnal Bruxing, Grinding, and Clenching

FUNCTIONAL MEDICINE MATRIX

AssimilationPeriodontal Disease, Xerostomia, Occlusion Problems, Poorly Fitting Dentures, Mixed Noble and Base Metal Crowns, Mercury Amalgam

Defense & RepairPeriodontal Disease, Mercury Amalgams, Root Canals, Orthodontic Treatment (Nickel-based), Dental Implants, Mixed Noble and Base Metal Crowns, Jaw Osteonecrosis

EnergyMercury Amalgams, Dental Implants

Structural IntegrityTooth Decay, Periodontal Disease, Root Canals, Jaw Osteonecrosis, Dental Implants, Occlusion Problems, TMJ

CommunicationHigh Tooth Decay Rates, Root Canals, Periodontal Disease

Biotransformation & EliminationMercury Amalgams, Root Canals, Implants, Periodontal Disease, Jaw Osteonecrosis, Orthodontic Appliances (Nickel-based), Mixed Noble and Base Metal Crowns, Chrome Cobalt Partial Dentures, BPA-based Resin Fillings, Night Guards, and DenturesTransport

Periodontal Disease, Root Canals, Mercury Amalgams, High Tooth Decay Rates

Mental Emotional

Spiritual

Poor Occlusion (Bite) or TMJ

Problems

Clinical Considerations Using the Functional Medicine Matrix Model Physical exam fi ndings develop following an acute or chronic system adaptation to insuffi ciency or excess. The patient’s relevant antecedent conditions, triggering events, and mediating or perpetuating contributors, all shift the clinical balance. Common fi ndings from the Dental Exam can be organized on the Functional Medicine Matrix, as seen in Figure 1. This resource highlights the multiple areas of clinical imbalances that can originate from within the mouth.52 These fundamental imbalances are markedly infl uenced by nutrition and diet. The key nutrient functions for dental and oral health are shown in Table 3.


Table 3. Nutrients Needed for Proper Oral Tissue Synthesis and Dental Care12,52-67

Nutrient Type Specific Nutrient and Physiological Function

Macronutrients

Protein Needed for healthy tissue growth and maintenance

Fats DHA/EPAn Anti-inflammatory, membrane repair, adequate salivation

Carbohydrate Complex Carbohydratesn Maintain oral biofilms and minimize caries

Micronutrients

Minerals Calcium and Phosphorusn Necessary for dentin and bony tissue synthesisn Enhances mineralizationn Maintains jaw bone sufficiency and integrity

Chromium n Needed for proper glucose metabolismn Controlled intake helps to maintain healthier gums and overall health status57,58

Coppern Essential for copper-dependent enzymes (ceruloplasmin, cytochrome c oxidase,

superoxide dismutase 1, tyrosinase and others) n Role in hematopoiesis of red and white blood cellsn Key for energy production cofactors in mitochondrian Key for normal neural development and myelin formation and maintenance

Fluoriden Helps with bone health and enamel health at levels of 1 ppm57,59

Ironn Helps with RBC adequacyn Promotes resistance to disease, improves health of the teeth, skin, and bones, maintains

energy via cofactor in complex1,2,4

n Helps with cytochrome p450 biotransformationn Myoglobin formation

Magnesiumn Bone developmentn Enhances use of vitamin Cn Helps with calcium absorption

Zinc n Needed for adequate taste and smell n Helps regulate inflammatory process, aids in wound healingn Helps with healing, lowers susceptibility to infection, prevents loss of taste,

maintains metabolismn Component of >300 metalloenzymes

Seleniumn Prevents oxidative stress and damagen Component in glutathione peroxidase


Nutrient Type Specific Nutrient and Physiological Function

Vitamins Vitamin A n Necessary for epithelial tissue and enamel mineralizationn Epithelial differentiation, gene expression, humoral and cell-mediated response,

supports Th2 anti-inflammatory responsen Beta carotene may play a role in oral cancer prevention and leukoplakia56,60,61

Vitamin D n Protects against chronic inflammation of the gums, which can lead to gingivitis or

periodontal disease55

n Necessary for dentin, bony tissue synthesis, mineralization, and jawbone sufficiencyn Involved in cell proliferation and differentiationn Enhances innate immunity by increasing differentiation of monocytes to macrophagesn Calcium, magnesium, and phosphorus homeostasis

Vitamin E n Fat-soluble antioxidant whose role is to help balance the increased oxidative stress in

response to infection and inflammation at the mitochondrial and membrane leveln Optimizes and enhances immune Th1 response

Vitamin K n Aids with calcium absorption in bone and adequate blood clotting, helps in healing

B complexNeeded for normal functioning of glycolysis, Krebs cycle, protein– and fatty acid-drivenATP energy metabolism, and balance at the cytoplasm and mitochondrial membrane leveln B1–Thiaminen Coenzyme thiamine pyrophosphate functions in energy metabolism

n B2–Riboflavinn Flavoproteins: coenzymes involved in energy metabolism

n B3–Niacinn Nucleotide coenzyme involved in amino acid metabolism, cofactor in DNA repair,

SIRT metabolismn B6–Pyridoxinen Coenzyme in amino acid metabolismn Adequate intake maintains Th1 immune response

n B9–Folaten Needed for methylation balance blood supplyn Purine and pyrimidine synthesis, methylation balance, neurotransmitter balance.

Helps maintain innate NK cell activityn B12–cobalaminn Purine and pyrimidine synthesis, methylation balancen Immunomodulator for cellular immunity with effects on cytotoxic cells

(NK:CD8+T-lymphocytes)Vitamin C n Enables connective tissue cells to elaborate intercellular substancesn Forms collagen matrix, antioxidant required in wound healingn Deficiency can lead to easy bleeding or swelling of gums and gingivitis, tooth lossn Regenerates antioxidants: vitamin E, glutathionen Role in metabolism of histaminen Stimulates leukocyte functions, NK cell activity, lymphocyte proliferation, chemotaxis,

and delayed tissue hypersensitivity response

Phytonutrients n Decrease tissue oxidative stress, free radicals, and inflammation, and moderate dysbiosis52,53

Table 3. Nutrients Needed for Proper Oral Tissue Synthesis and Dental Care12,52-67


Relevant ATMs associated with the Mouth and Dental Exam include:

n Antecedents (e.g., predisposing factors, genetic/environmental): Mercury amalgams, root canals, periodontal disease, metal crowns, dentures and implants, nickel-based orthodontics, xerostomia (dry mouth), poor occlusion (bite), TMJ, jaw osteonecrosis.

n Triggering Events (e.g., activators): Placement or improper removal of mercury amalgams, root canal treatment, placement of dental implants, nickel-containing orthodontic treatment, pathologic disturbance of occlusion, and placement of noble or base metal crowns or acrylic resin dentures, etc., in susceptible patients.

n Mediators/Perpetrators (e.g., contributors): Mercury amalgams, root canals, periodontal disease, metal crowns, dentures and implants, orthodontics (nickel based), xerostomia (dry mouth), poor occlusion (bite)—TMJ, jaw osteonecrosis.

Functional Medicine Points of Connection—Key findings uncovered during the Dental Exam of the mouth can be organized on the Functional Medicine Matrix under the appropriate clinical imbalance. The areas most commonly populated on the Matrix include the nodes representing the processes of detoxification, elimination, immune modulation, and energy regulation. One of the goals of an advanced functional medicine exam and evaluation is to screen for and identify recognizable patterns of the underlying causes of disease.

n Biotransformation & Elimination (e.g., toxicity, detoxification): The biotransformation and elimination systems in the mouth and throughout the body can be altered by oxidative stress, infection, and changes in coenzyme requirements triggered by dental restoration or repairs; mercury amalgams, root canals, implants, periodontal disease, jaw osteonecrosis, nickel-based orthodontic appliances, mixed noble and base metal crowns, chrome cobalt partial dentures, BPA-based resin fillings, night guards, and dentures all can create oxidative stress in susceptible patients.

n Defense & Repair: Some patients may have allergic reactions to nickel or other metals used in restorations. Lower salivary pH (<6.8) can alter bacteria, while a pH <5.8 leads to enamel destruction. Periodontal disease is associated with over 500 different bacteria. The inflammatory cytokines released in the presence of oral infections or oral autoimmune disease increases the incidence and risk of additional autoimmune and inflammatory diseases.5

n Energy: Mitochondrial energetics and dysfunction are markedly affected by the combined burden of heavy metals, infection, inflammation, and oxidative stress originating within the mouth.

Fluorosis Considerations in Health Care TodayFluorosis in the United States has increased significantly in the last 20 years as more fluoride-containing processed foods and health products become available, accompanied by greater availability of dental caries programs. Excess fluoride ingestion through food or water can also result in dental fluorosis.63,68,69 The effects of fluorosis are both permanent and irreversible, yet are preventable in most instances.68,69

In 2000, 162 million people (65.8% of the population served by public water systems) received 0.7-1.2 mg/L of fluoride, depending on the local climate.63 Plasma fluoride levels are influenced by ingested and inhaled intake, renal function, rate of bone metabolism, and metabolic activity. In humans, plasma concentrations from long-term ingestion of 1–10 ppm of fluoride in the drinking water range from 1 to 10 umol/L. All stages of enamel formation are sensitive to fluoride levels, and even low fluoride levels of 1.5 umol/L are capable of inducing mild enamel fluorosis.63 Data from NHANES 1999-2004 show that the percentage of questionable to severe fluorosis has increased from 52.9% to 60.4% over the study period, while rates of mild to greater enamel fluorosis rose from 22.6% to 40.6% in 15 years. Among people 6–39 years of age, fluorosis is common: rates are 19.79% in white non-Hispanics, 25.8% in Hispanics, and 32.88% in black non-Hispanics.70


Teeth are formed in the jaw bone, beginning in pregnancy and continuing until the early 20s, with enamel calcification (i.e., fluorosis susceptibility) ranging from around the 14th week in utero to age 16. Ameloblasts are cells present in the bone during tooth development; their role is to deposit tooth enamel. These ameloblasts produce three proteins that help form the extracellular enamel matrix: amelogenin, ameloblastin, and enamelin. Amelogenin comprises at least 90% of the total protein in the enamel protein matrix.63,71 Chronic exposure to fluoride reduces the enamel matrix by 10%.64 Extremely high intake of fluoride through the diet or water induces a stress response and apoptosis in these ameloblasts.72 One early sign of fluorosis is thin white horizontal lines running across the surfaces of the teeth along the perikymata (the transverse ridges on the surface of the tooth corresponding to the incremental lines in the enamel known as Striae of Retzius).73,74 With higher levels of fluoride, the white lines in the enamel become increasingly defined and thicker. Patchy cloudy areas and thick opaque bands also appear on involved teeth. Increased dental fluorosis causes the teeth to appear chalky white and lose transparency. With prolonged exposure, the deeper layers of enamel are affected and the enamel loses mineralization. Teeth can develop enamel pits, and post-eruptive enamel fracture can occur. With moderate dental fluorosis, yellow to light brown staining is seen. In severe cases, the enamel is porous, poorly mineralized, stains brown, and has fewer minerals and more proteins than normal enamel.

Infancy (birth to 12 months) is a critical time to pay attention to exposure to fluorosis.63-65 For babies fed powdered or liquid concentrate infant formulas, the amount of fluoride in the water used to reconstitute the formula is important. Advised levels are below 0.4 ppm.75,76 Also, parents should be advised that a pea-sized amount of toothpaste containing 1450 ppm fluoride or 0.36–0.72 mg fluoride, consumed twice a day, increases the risk of fluorosis in children.77

Fluoride is found in ground water, infant formula, vegetables, fruit, tea, soil, and coal smoke.63,75,76,78 The US Environmental Protection Agency’s reference dose is 0.06 mg fluoride/kg/day.79

Conclusion The Functional Nutrition Evaluation, of which the Dental Exam is just one aspect, provides a framework for healthcare providers to connect physical exam findings with the patient’s history, timeline, and lifestyle. Being able to show links between life events, past or current nutritional status, and physical exam findings creates a better understanding of how functional imbalances span across the matrix and helps guide therapeutic interventions.

Most of the clinical imbalances leading to pathology have root causes such as infection or autoimmunity, disorders of oxidative stress, or impaired biotransformation. By searching for recognizable patterns in nutrition and within the Functional Medicine Matrix, practitioners can identify key points of connection from the comprehensive evaluation. The Functional Nutrition Evaluation can help you improve what you see and how you think about the various points of connections you uncover, better equipping you to not only manage patients with healthcare concerns, but to proactively identify underlying causes of disease that might contribute to a systemic impact. Be proactive—look in the mouth.

“While the concept of an oral-systemic connection is not new, integrating Functional Medicine with oral and dental health creates dimensions to this connection that will enhance our patient care.”

— Mary Ellen S. Chalmers, DMD


Acknowledgements IFM would like to acknowledge and thank the development team for their research, organization, and creation of the ABCDs of Functional Nutrition Physical Exam series. P. Michael Stone MD, MS and topic specific contributors developed the materials. The Functional Nutrition Evaluation; Dental Exam materials were co-developed with Mary Ellen Chalmers, DMD. The development team also included Kristi Hughes, ND, Nicole Dotson, ND, Deanna Minich, PhD, and Nicholas Morgan, ND, who all did excellent work in support of the materials.

To cite: Stone PM, Chalmers ME: Functional Nutrition Evaluation; Clinical Indictors: Dental Exam Companion Guide. Federal Way (WA): Institute for Functional Medicine: 2016.

Dental Exam References1. Stone PM. Functional Nutrition Evaluation: Eight-Step Mouth Exam. Federal Way (WA): Institute for Functional Medicine; 2014.

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