Poor gum health linked to increased risks in major surgery outcomes

Vienna, 12 May 2025 – A new study presented at EuroPerio11[i], the world’s leading congress in periodontology and implant dentistry, organised by the European Federation of Periodontology (EFP), reveals that many patients eligible for major surgery - especially those with gastrointestinal cancers - have oral and periodontal health issues, even if they regularly visit a dentist. These findings suggest that better attention to oral health is required, since it has been reported to affect outcomes and recovery in major surgery.

The research, led by Doctor Adelina S. Plachokova and her team at Radboud University Medical Centre in the Netherlands, examined the oral health of 79 patients eligible for major surgery. It found that over half of gastrointestinal cancer (GIC) patients had oral changes requiring clinical attention, with many showing signs of severe gum disease and a need for periodontal treatment.

“Despite regular dental visits, we saw signs that oral health was suboptimal in many patients undergoing major surgery, particularly in those with gastrointestinal cancers,” said Dr Plachokova. “This suggests we are missing opportunities to identify and address problems that could affect recovery after surgery. Current protocols as part of Enhanced Recovery After Surgery (ERAS) focus mainly on nutrition and the physical fitness of patients before surgery to improve clinical outcomes, and do not consider oral health[ii].

Research increasingly shows an association between periodontitis (advanced gum disease) and gastrointestinal cancers such as colorectal or oesophageal cancer. These links are backed by large cohort studies and meta-analyses that explore the possible biological pathways by which severe periodontal disease may increase the risk of developing such cancers.[iii]

But the implications go beyond cancer risk. Poor oral health may also affect surgical outcomes, potentially increasing the risk of infections, pneumonia, or delayed healing. “Japanese studies have shown that pre-surgical oral care could reduce complications and shorten hospital stays. In fact, Japan has made perioperative oral management a routine part of cancer care since 2012,” Plachokova explained.

The study compared 36 gastrointestinal cancer patients with 43 non-cancer patients, all eligible for major surgery. Participants underwent oral examinations using two tools: the Oral Health Assessment Tool (OHAT)[iv], a visual inspection-based score where higher values indicate poorer oral health and the Dutch Periodontal Screening Index(DPSI)[v], which measures gum disease severity through clinical examination.

Although most patients in both groups said they visited the dentist regularly, oral health problems were common, especially among those in the GIC group. Over half had severe gum disease, a third had no natural teeth left, and they had far fewer remaining teeth on average than the control group. Nearly 60% needed deep cleaning, a rate higher than in the general older Dutch population. 

Using the OHAT tool, researchers identified a range of problems including:

·       Decayed or broken teeth with some patients having four or more

·       Dry mouth and coated tongue, which may relate to nutrition or medication

·       Generalised plaque or tartar, even in denture wearers

·       Poor oral cleanliness and bad breath

·       Signs of mucosal dryness and potential soreness

“Oral health is closely linked to nutritional status, and we know that poor nutrition affects healing and recovery after surgery,” explained Plachokova. “Many patients with dentures, for example, had higher OHAT scores, likely because eating becomes more difficult. This is another good reason to include periodontal care in surgery prehabilitation.”

Why oral health matters before surgery

While most surgical prehabilitation focuses on diet, exercise, smoking, and mental health, oral health is often overlooked. Yet studies have shown that improving oral health before surgery could reduce complications, especially in cancer patients.

“This study highlights a critical gap in surgical care: despite regular dental visits, many patients, especially those with gastrointestinal cancers, are heading into major surgery with poor gum health,” said Professor Lior Shapira, EuroPerio11 scientific chair. “These early findings suggest that including oral assessments as part of pre-surgical preparation could improve recovery and reduce complications. While this was a small, single-centre pilot study, it is an important starting point. If future studies show that treating gum disease before surgery shortens hospital stays or lowers costs, it will make a strong case for integrating periodontal care into routine surgical protocols, ideally alongside existing nutritional screenings, given the close link between diet, oral function, and recovery.”

“We believe that oral health should be part of standard preoperative assessment, particularly for high-risk groups like GICs cancer patients, and may be a valuable additional item to the ERAS protocols ii,” said Plachokova. “Even a simple screening can help identify patients who need treatment before surgery.”

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[i] PR363: Oral and Periodontal Health in Patients Eligible for Major Surgery. Authors: A. Plachokova, E. van Eijkeren, R. van Dijk, M. de Vries, P. Krijtenburg, H. de Wilt – Radboud University Medical Centre, Netherlands.  

[ii] https://erassociety.org/specialty/colorectal/Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS^®) Society Recommendations. World J Surg. 2019 Feb;43(2):299-330. doi: 10.1007/s00268-018-4786-4. PMID: 30276441.

[iii] Michaud et al., 2018 : Michaud DS, Lu J, Peacock-Villada AY, Barber JR, Joshu CE, Prizment AE, Beck JD, Offenbacher S, Platz EA. Periodontal Disease Assessed Using Clinical Dental Measurements and Cancer Risk in the ARIC Study. J Natl Cancer Inst. 2018 Aug 1;110(8):843-854. doi: 10.1093/jnci/djx278. PMID: 29342298; PMCID: PMC6093423.

Zhang et al., 2020 : Zhang Y, Sun C, Song EJ, Liang M, Shi T, Min M, Sun Y. Is periodontitis a risk indicator for gastrointestinal cancers? A meta-analysis of cohort studies. J Clin Periodontol. 2020 Feb;47(2):134-147. doi: 10.1111/jcpe.13217. Epub 2019 Nov 25. PMID: 31697412.

Wang et al., 2024 :Wang Q, Gu W-J, Ning F-L, et al. Association between Periodontal Diseases and the Risk of Site-Specific Gastrointestinal Cancers: A Systematic Review and Meta-Analysis. Journal of Dental Research. 2024;103(10):962-972. doi:10.1177/00220345241263768

[iv] https://www.nice.org.uk/Media/Default/Oral%20health%20toolkit/Oral_health_assessment_tool.pdf

[v] Van der Velde et al., The Dutch periodontal screening index validation and its application in The Netherlands: https://doi.org/10.1111/j.1600-051X.2009.01495.x.

NOTES TO EDITORS

A second phase of the study will extend it to ACTA and Amsterdam UMC, making it a multi-centre project. The research protocol was awarded a scientific prize by the Dutch Society of Medical and Dental Interaction (VMTI) in 2024.