Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Periodontal health and COPD outcomes

  Chronic obstructive pulmonary disease (COPD) and periodontal disease are common, long-term conditions that can influence a person’s daily function, treatment burden and risk of hospital care. The mouth is part of the respiratory pathway, and inflammation or infection in the gums may affect the lower airways through aspiration, immune signalling and changes in the oral microbiome.

  This relationship is especially relevant for people with advanced COPD, frequent infective exacerbations, poor dentition, dry mouth or difficulty managing personal care. Smoking, diabetes, malnutrition and socioeconomic disadvantage can increase the likelihood of both gum disease and respiratory decline, making it difficult to separate individual causes.

  For Australian clinicians, the issue also sits within a divided healthcare system. A patient may see a GP in a bulk-billing clinic, attend a hospital respiratory service and use a private dentist, with limited communication between providers. Understanding the connection can support earlier prevention and more coordinated care.

  Why oral health matters in COPD

  Periodontal disease begins with bacterial plaque accumulating around the teeth and gum line. If it is not controlled, the gums can become inflamed, bleed easily and gradually lose their supporting tissue. Severe disease may lead to loose teeth, pain, difficulty chewing and a persistent burden of oral bacteria.

  COPD can make these problems harder to manage. Breathlessness may limit brushing, flossing or attendance at dental appointments, while fatigue and reduced hand strength can affect daily mouth care. Some inhaled medicines, particularly when used frequently, contribute to dry mouth or oral irritation. Inhaled corticosteroids also make careful mouth rinsing important because they can increase the risk of oral candidiasis.

  People with COPD may interpret bleeding gums, loose teeth or bad breath as minor concerns and delay treatment. A GP, practice nurse or respiratory physiotherapist who asks about chewing, dental pain and access to dental care can identify an issue that may otherwise remain hidden.

  How gum inflammation may affect the lungs

  Several biological pathways could explain the association between periodontal disease and COPD outcomes. Inflamed gum tissue can release cytokines and other inflammatory mediators into the circulation. These signals may add to the systemic inflammation already present in COPD, although the precise clinical effect varies between individuals.

  Oral secretions can also be aspirated into the lower airways, especially during sleep or in people with swallowing difficulty, reflux, frailty or severe lung disease. Oral bacteria may then contribute to airway colonisation and inflammation. This does not mean that periodontal bacteria directly cause every COPD flare; exacerbations have multiple triggers, including viral infection, environmental exposure and smoking.

  Research has reported links between poor periodontal status, reduced lung function, pneumonia and more frequent COPD exacerbations. Much of the evidence is observational, so shared risk factors may explain part of the relationship. Smoking is a major confounder, as it damages periodontal tissue and accelerates COPD. Diabetes, age, nutrition and access to healthcare also require careful consideration.

  Australian realities in prevention and access

  In Australia, adult dental care is often delivered through private practices, with Medicare providing limited general dental coverage for most adults. Private health insurance extras may help, but out-of-pocket costs can still delay periodontal assessment or professional cleaning. Public dental services vary by state and territory and commonly prioritise people who meet eligibility criteria, creating waitlists for others.

  Access is more difficult in rural and remote areas, including parts of regional Queensland, Western Australia and the Northern Territory. Travel to a larger centre may be necessary for periodontal treatment or specialist review. Aboriginal and Torres Strait Islander communities can face additional barriers linked to distance, cost, workforce shortages and the need for culturally safe, community-led care.

  A patient might say they are “crook,” short of breath or unable to get to the dentist because the nearest service is hours away. These practical details matter. A respiratory plan that assumes regular private dental visits may be unrealistic for someone in a remote community, a person on a low income or an older adult relying on family transport.

  Practical steps for integrated care

  Respiratory and primary care teams can include a brief oral health check in routine COPD reviews. Asking about bleeding gums, tooth mobility, mouth pain, dry mouth, denture problems and the last dental visit is simple and may reveal a modifiable contributor to poor health. Visual inspection should be undertaken within the clinician’s training and followed by dental referral when concerns are present.

  Useful measures include:

  • Encourage twice-daily brushing with fluoride toothpaste and regular interdental cleaning where practical.
  • Ask patients using inhaled corticosteroids to rinse, gargle and spit after each dose.
  • Refer for dental assessment when there is persistent gum bleeding, swelling, loose teeth, ulcers, severe halitosis or difficulty eating.
  • Coordinate smoking cessation, diabetes management, nutrition support and pulmonary rehabilitation rather than treating oral health in isolation.
  • Consider public dental services, Aboriginal Community Controlled Health Services, community clinics and telehealth-supported pathways when cost or distance is a barrier.

  Dentists can also ask about breathlessness, oxygen use, recent admissions and exercise tolerance before procedures. Short, planned appointments, clear communication with the GP and attention to infection risk may improve safety for patients with severe disease.

  What the evidence means for COPD care

  The current evidence supports attention to periodontal health, but it does not establish that treating gum disease will prevent all exacerbations or reverse airflow limitation. Periodontal therapy should be viewed as part of comprehensive care, alongside smoking cessation, vaccination, inhaler technique, medication adherence, physical activity and an evidence-based COPD action plan.

  Clinical teams should also avoid assuming that every patient with COPD requires extensive dental intervention. Assessment should be individualised, taking account of symptom burden, functional status, comorbidities, oral findings, treatment goals and the person’s ability to access care. Dental treatment may improve pain, nutrition, confidence and quality of life even when its direct effect on lung function is uncertain.

  Future research needs well-designed Australian studies that account for smoking, diabetes, socioeconomic status, ethnicity, remoteness and healthcare access. It would be useful to measure outcomes such as exacerbation frequency, antibiotic use, hospital admissions, oral health-related quality of life and changes in airway inflammation.

  A practical approach is to treat the mouth as part of the respiratory patient’s overall health rather than as a separate concern. During the next COPD review, document oral symptoms, reinforce inhaler and mouth-care technique, and connect the patient with an accessible dental pathway.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)