Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also produce and host this podcast series, Health Literacy Out Loud.

Our mouths are part of our body. Of course, that’s obvious. We all know that. But when we talk about health, why do we often consider those different parts separately? Most important, what can we do about them to understand the connection between oral health that affects our mouths and overall health that affects our whole body?    

I am delighted that Dr. Alice Horowitz agreed to be a guest on this podcast to help tell us more.

Alice is a Research Professor in the Department of Behavioral and Community Health at University of Maryland’s School of Public Health in College Park.

She was instrumental in initiating the need to address health literacy in dentistry. Her ongoing advocacy, research and teaching have helped professionals of all disciplines take needed action.

Alice has deservedly received awards for her wonderful work in dental public health.

Welcome to Health Literacy Out Loud.

Dr. Alice Horowitz: Thank you, Helen, very much. Thank you for inviting me. I look forward to our discussion today.

Helen Osborne: So do I. You and I have met in person a number of times over the years. We’re all focusing on health literacy. You’re always bringing up issues of oral health. It takes me listening carefully to you to put that all together. For me and for the whole audience, can you just start from the beginning? What do you mean by that term “oral health literacy”?

Dr. Alice Horowitz: It’s like “mouth health literacy.” It’s actually very similar to what the health literacy definition is. We use the new Healthy People 2030 definition.

Helen Osborne: That definition talks about both individual health literacy and organizational health literacy.

Dr. Alice Horowitz: Absolutely. We just insert personal oral health literacy, or organizational health literacy among dental organizations. I know sometimes the word oral confuses people, but it’s oral or dental. They’re both the same.

It means, similarly, we want people to know and understand, and the understanding part is critical, about how to keep their mouths healthy, because healthy mouths impact total health.

Helen Osborne: Thank you. This is very timely. I was getting my teeth cleaned this morning. You’re right about that term confusion. I have gotten a little mixed up over the years. Is oral health literacy about the spoken word, or is it about our mouth? Has that really been decided, that it’s really about the mouth at this point?

Dr. Alice Horowitz: Yes. It’s more than just teeth. I will say that. An example of that is the Dental Institute at NIH, National Institutes of Health, was originally National Institute of Dental Research. Then one very smart director changed it to Dental and Craniofacial, because it includes all of the structures: the jaws, the gums, the throat, all of these kinds of things.

That is why there are these three major oral diseases that we basically know how to keep healthy and to prevent them from happening. But we don’t.

Helen Osborne: What are those three basic diseases?

Dr. Alice Horowitz: The one that’s most prevalent, most frequently found, is what is called dental caries, or tooth decay, or cavities. We have known for decades how to prevent this disease, but it’s interesting because many people don’t even realize that, in fact, it is a disease. It’s caused by bacteria and interaction with sugars and a susceptible tooth.

The other major disease is periodontal disease, or gum disease. By the time a person is 30 or 35, they’re going to have some periodontal or gum disease.

That can be really impactful, especially for people who have other diseases. For example, if they have diabetes and they also have periodontal disease, it’ll be very difficult to control their A1C, to control the blood sugar.

Helen Osborne: Go on to the third one, and then maybe we can explore each of them a little bit and how the oral health literacy part connects with overall health. What’s the third major disease?

Dr. Alice Horowitz: Third major disease is oral cancer, oropharyngeal cancer. That’s cancer throughout the month and in the tonsil area. Not quite down the throat. That’s a little bit different.

But those are the three. Again, we know how to pretty much prevent them.

Helen Osborne: You’ve already started explaining some of these. I’m just really curious, and I think our listeners are too, about how oral health and overall health affect one and the other.

You’ve been talking about oral cancer. Is there more you want to say on that? Let’s go in backward order. We’ll do oral cancer. Then we’ll do the periodontal disease. Then we’ll do the caries.

Dr. Alice Horowitz: Oral cancer, as I mentioned to you, or oropharyngeal cancer, can be prevented by getting the HPV vaccine. HPV vaccine prevents six cancers. One of them is oropharyngeal.

The other thing that one must be very careful about is, of course, smoking or chewing tobacco. That also contributes to oral cancer that’s more likely under the tongue.

These are very important things that we need to keep in mind about that.

Helen Osborne: Thank you for all those examples. Going in backward order of how you first presented them, you talked about periodontal, or gum, disease. You started talking about diabetes in there. What’s that connection between the gums in our mouth and the rest of our body?

Dr. Alice Horowitz: In this case, periodontal disease, gingivitis, advanced gingivitis, any of those kinds of things are major infections. If you think about how big the area is of your two jaws, if you had an infection that big on your arm or leg, you’d go screaming to emergency.

Helen Osborne: When you say “that big,” do you mean if we open our mouth wide open, that big circle that’s there?

Dr. Alice Horowitz: Exactly.

Helen Osborne: That is a big space. That’s bigger than a wound on your knee or something sometimes.

Dr. Alice Horowitz: Exactly. But it’s in the mouth. It really doesn’t hurt until it’s too late. It’s sort of out of sight, out of mind, but this is critical. A way to prevent that from happening is by brushing and flossing daily. They really make a difference.

Of course, that brushing should be used with fluoride toothpaste. Then we can go into dental caries or tooth decay, and the best way to prevent tooth decay is the appropriate use of fluorides.

Helen Osborne: Thank you. Let’s go on to what you call dental caries. I might think of them as cavities. How does that affect overall health?

Dr. Alice Horowitz: It’s a little bit, in a way, in reverse. Remember, a certain bacteria, called strep mutans, has to be present for tooth decay, and there has to be sweets in the mouth and a susceptible tooth.

Many children are cavity-free and grow up to be adults and are cavity-free. But many more do not.

What happens is Mom has decay, and therefore the bacteria in her mouth. With these new babies, what happens is she, not on purpose, but inadvertently, transfers the bacteria that cause cavities to the baby, and the baby ends up with cavities.

Helen Osborne: By nursing or before the baby is born?

Dr. Alice Horowitz: It’s like sharing utensils. I have moms that the pacifier gets dropped on the floor and the mom sticks it in her mouth and then puts it to the baby. That’s also helping to transfer bacteria.

What we highly recommend in a lot of our work that we have done is to try and get Mom’s mouth really cleaned up, no more open lesions and no more cavities, before she delivers. That way, there’s less chance of her passing bacteria to her infant.

The other thing, then, we want her to do is as soon as she brings that baby home, she starts cleaning baby’s mouth with a little dampened baby washcloth. Put a little warm water on it and just go around the gums really nicely at least once a day.

This is to disturb the bacteria, and it’s also to get Mom and the baby in the habit of doing this. If we wait until a baby’s first tooth comes in at 6 or 8 months, then baby already has a mind of its own and Mom already has her own ways of doing things, so it’s hard to interject a new habit.

Helen Osborne: Alice, I’m learning so much from you as you not only broke that down so clearly into the three large categories of disease, but I’m also hearing from you what the problem is, how that can affect overall health and even more, you’re giving an overriding message of what can be done to prevent each of these situations.

I’m glad you’re talking with me on Health Literacy Out Loud so more people can be hearing this message so clearly.

I have a few questions to ask you about that, putting on my health literacy cap.

Dr. Alice Horowitz: Sure.

Helen Osborne: One is why don’t professionals of all ilks and everybody else consider this as much as you are considering this? Why is it, “Oh, I’ve got a cavity. Big deal”? Why is some of that not thought of in terms of the whole body?

Dr. Alice Horowitz: Excellent question. A major issue is that medicine and dentistry are taught in silos. That really helps separate everything.

One of the things that we’re doing right now is trying to educate OB-GYNs . . .

Helen Osborne:      Obstetrician-gynecologists.

Dr. Alice Horowitz: Yes, thank you. To recommend to their pregnant women that they get a dental appointment while they’re pregnant.

Many people think that they should not go to the dentist while they’re pregnant. They’re afraid to do that.

I had one mother tell me, when we were doing an interview, that her mother had told her that if she went to the dentist while she was pregnant, her baby would have a cleft lip.

Helen Osborne: Oh my goodness.

Dr. Alice Horowitz: It’s things like that. They perpetuate myths, and it’s unfortunate.

It’s important that we get other healthcare providers to help us, just as we need to also know about our patients. It’s a reciprocal thing. We should be referring back and forth.

Helen Osborne: I’m also thinking in my own situation. I was on some medicines, like some of us are, and then I needed a possibility of this dental procedure.

Then somebody asked a question. “But are you on this medicine that can affect the dental procedure?” I thought, “Oh my goodness. Nobody ever told me when they put me on that medicine that it can affect another part.”

You’re right. It’s that silo phenomenon.

Also, our podcast listeners can be from around the world. But in the US, we are certainly driven by issues of insurance. Insurance for primary care and the rest of the body is one type of insurance, and dental is separate.

Dr. Alice Horowitz: Correct.

Helen Osborne: Just like when I went to the dentist today, whatever payment they have, I had to write a check for the full amount. Then because we have insurance, I might get some fraction of it back. When I go to primary care, I might give them my $15 copay and I’m done.

Dr. Alice Horowitz: Yes, it’s very different. A few states are making changes. For example, here in Maryland, we now have adult Medicaid for dental.

Helen Osborne: Oh, good.

Dr. Alice Horowitz: We’ve never had this before.

Helen Osborne: For listeners, Medicaid is for those often at a lower economic level.

Dr. Alice Horowitz: Correct. They’re from families of low income.

More and more states are at least looking at this because it’s so expensive. Especially when we know how to prevent these diseases, it’s ludicrous to have people getting all these diseases that they don’t have to. But we have not shared the information that we should have.

Helen Osborne: Thank you for being such an ongoing champion.

Let’s be putting this now into context of health literacy. That’s what probably listeners are tuning in on. It’s, “How can I communicate better today than I did yesterday?” Now you’re introducing a whole other body of information that we need to consider and communicate about so that people can understand and act on it.

I welcome your tips for listeners of all professionals and ilks. It may even be the lay public. What can we do to help move ahead health literacy when it comes to issues that affect the mouth area?

Dr. Alice Horowitz: Great question. We need to talk slowly and clearly, don’t use any big words and use teach-back as much as possible.

Helen Osborne: Give us an example.

Dr. Alice Horowitz: An example of teach-back would be to demonstrate the best way to brush their teeth and to floss their teeth.

Another example that I use a lot, especially newer moms with young children, is what we call “lift the lip.” We literally use one finger to lift the lip of the child up above so you can see all of the front teeth.

What we’re looking for are white spots, a different color of the tooth right along the gum line. If it is a different color, it’s likely to be a lighter color. That means that’s beginning decay, beginning cavities. That is the kind that can be reversed.

Helen Osborne: The mom or any family member can take this away from that silo there.

Also, and I think of my own health experiences and dental experiences a lot, it can be very visual. I thought of that as you were talking about lifting the lip.

My dentist, who I really like, I’ve given him actually an A in health literacy, because when he’s explaining something in my mouth and I can’t see it, he will show me the X-rays. He will draw a picture. He’ll take out a model and take out his iPad, perhaps. It can be very visual in that way.

I’ve learned a lot about that, because when he’s talking about expensive stuff going wrong in the back of my mouth, I can’t see it, so I really appreciate that.

One other question I had for you is, as you were initially explaining those diseases, for many of the different terms you were using several terms. You used caries and cavities. You used periodontal and gum disease. Why do we have so many synonyms there, words that mean the same? One is this huge word, and one is this everyday word.

Dr. Alice Horowitz: Good question. I can’t tell you exactly why. But periodontal disease, “perio” means “around.” That’s referring to the soft tissue, the gums, that surround the tooth. There’s really not another way to describe that, I don’t think. But it’s gum disease, and that works well.

Dental caries or cavities, no provider should be calling it dental caries. It should be cavities or decay. Most people, but not all, know what decay is. It’s important that people know how to prevent that, because it is preventable.

Helen Osborne: I’m not just calling out the work in the dental community, but all of us. We need to be mindful that we as professionals might have different ways to explain something. Some are a little more clear than others, but some are not as clear to that harried parent who just has to deal with the baby and everything else that’s going on.

Just make it clear. They’re not as into the nuances of dental terms as we are, so all those principles of making it clear.

Alice, you have shared so much great information. You’re really an inspiration. Are there any resources that you would recommend that listeners might go to, to continue their learning about oral health literacy?

Dr. Alice Horowitz: Definitely. I would say it would be for any content area, but main sources would be NIH, National Institutes of Health. They have wonderful materials. CDC, similarly. Of course, the American Dental Association and American Dental Hygienists Association. Those are all good places with good information.

We actually have on our website . . .

Helen Osborne: When you say “our,” do you mean the University of Maryland?

Dr. Alice Horowitz: Yes, the Center for Health Literacy at the University of Maryland School of Public Health. We actually do have an under-two-minute video on “lift the lip.”

Helen Osborne: Fabulous.

Dr. Alice Horowitz: And how to clean baby’s mouth. They also work for teach-back because that’s what they’re actually doing. They’re teaching a mom to do what these procedures are. It demonstrates two things: how to do whatever X is, but it also demonstrates the method using teach-back.

Helen Osborne: You’re also using multimedia to educate people who need to know.

Dr. Alice Horowitz: Correct.

Helen Osborne: Thank you. We are going to have links to all of those resources on your Health Literacy Out Loud web page, so people just need to go there and can start their learning journey.

Alice, thank you for all you have done to champion this, to raise our awareness, to teach all of us more about oral health literacy, and thank you so much for being a guest on Health Literacy Out Loud.

Dr. Alice Horowitz: Thank you so much for inviting me. I enjoyed it very much. I’m sure there are other areas I should have covered and didn’t.

Helen Osborne: We always are learning. I’ve learned about podcast listeners that 20 minutes is our sweet spot.

Dr. Alice Horowitz: That’s cool.

Helen Osborne: Let’s put a semicolon in our podcast conversation right now, and people can keep learning more. Thank you so much for being a guest on Health Literacy Out Loud.

Dr. Alice Horowitz: Thank you.

Helen Osborne: As we just heard from Dr. Alice Horowitz, it is so important to consider oral health in context and in tandem with overall health. But doing so isn’t always easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out the first of every month. Get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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