What’s the Risk? Smoking, Acid Reflux, Diabetes and More

Dental professionals will often also interview a patient for other health concerns as they may have an effect on the patient’s saliva flow, acid exposure, or diet/food frequency.1

Some of these health concerns are the following:

1. Frequent Tobacco Use

Frequent tobacco use, particularly smoking, can cause dry mouth and reduced salivary flow.


2. Acid Reflux

Patients with acid reflux can have stomach acids reflux into the throat or mouth regularly bathing the teeth with very low pH (pH 1.5–3.5) stomach acids. Patients with this condition may notice a sour taste in their mouth and/or a burning sensation in their upper abdomen/chest.

Patients with acid reflux are also often taking over-the-counter or prescription acid reflux medications that cause dry mouth.


3. Diabetes

Individuals who are diabetic often have diet restrictions and eat many small meals and snacks sprinkled throughout the day in order to keep the amount of carbohydrates down at each meal. As a result, their blood sugar stays more balanced, which prevents high and low blood sugars. Conversely, the frequent eating/snacking in order to control blood sugar does not allow for their saliva to maintain a healthy pH level. For diabetics, diet is often an unmodifiable risk factor, and professional oral care therapies are frequently the best option for preventing or reversing a caries infection.

Dry mouth is also one of the most common oral health problems for diabetics; in many cases, it is due to medications prescribed for treating diabetes. The combined effect of frequent snacking and low saliva flow places individuals with diabetes at an increased level of risk for the caries infection.


4. Bulimia

Individuals with bulimia can have many issues placing them at greater risk for caries infection and tooth loss. Usually, dental professionals will notice acid erosion on the lingual surfaces of the maxillary incisors (back side of the upper front teeth) and on the mandibular incisors (lower front teeth) caused by the regular exposure to stomach acid. Beyond acid erosion, the regular acid challenge in the mouth can increase the likelihood of acidic bacteria overtaking the biofilm.


5. Head and Neck Radiation Therapy

Radiotherapy for head and neck cancer results in severe and chronic salivary gland dysfunction in most individuals. This results in significant side effects, including dry mouth, difficulty swallowing, and malnutrition, which are linked to significant reductions in patients’ quality of life and increased caries risk. Many patients going through head and neck radiation therapy have such a reduced volume of saliva flow that they literally can watch their teeth dissolve due to the accelerated caries rate. They pose a real challenge to the dentist as they are also at risk for post extraction osteoradionecrosis, where the bone does not heal following tooth extraction. In years past, many of these patients would have all of their teeth extracted prior to the radiation treatments. Today, with the advances in radiation treatment, and the ability to manage dental caries, most of these patients keep their teeth but are at significantly increased risk for decay, and the dental profession needs to monitor and manage their care closely.


6. Sjögren’s Syndrome

Sjögren’s syndrome is a chronic disorder of the immune system in which the patient’s white blood cells attack the saliva and tear glands. This leads to dry mouth and eyes because the body’s tear and saliva production is reduced. Many patients often don’t know they have Sjögren’s syndrome. Reaching a diagnosis can be difficult and generally takes an average of 6.5 years from the onset of symptoms to make the correct diagnosis. Part of the difficulty with diagnosing Sjögren’s is that many of the symptoms, like dry mouth, mimic symptoms of other issues such as dry mouth caused by medications. Saliva substitutes are essential for patients with Sjögren’s syndrome.


7. Other Drug Use

While other drug use is often not something patients choose to discuss with their dental professionals, it is a risk factor for the disease and illicit drugs have severe oral health consequences. Other drug use includes drugs such as methamphetamine, marijuana, opiates/heroin, cocaine, ecstasy, and derivatives of such drugs like crack cocaine. The primary reason these drugs increase the risk for caries infection is the side effect of dramatic reduction in saliva flow. Many other drug users also commonly have a high caries-producing diet and frequent intake of carbonated beverages. There is quite an extensive list of risk factors for caries, which ultimately leads to cavities. But as mentioned earlier, there are ultimately four primary risk areas that are typically the root causes of dental disease: bacterial biofilm imbalance/infection, poor saliva/inadequate saliva flow (which has many causes), frequent snacking/acidic drinks/poor diet, or simply the wrong home care product routine per the individual’s risk factors. By identifying the specific issues facing each individual patient, dental professionals and patients can choose to make specific risk factor changes targeted uniquely to the patient’s needs. These include behavioral changes and/or prescription/professional products designed specifically as protective factors to put the patient back on the road toward oral health.


  1. John D. B. Featherstone, Sophie Domejean-Orliaguet, Larry Jenson, Mark Wolff, and Douglas A. Young, “Caries Risk Assessment in Practice Ages 6 Through Adult,” J Calif Dent Assoc 35, no. 10 (2007):703–13.


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