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'2020 hindsight' gives us a crystal-clear vision for the future

Dec. 1, 2020
COVID-19 has changed the world, and the virus' effects are ongoing. But one thing has become clear—the health-care profession is taking an in-depth look at comorbidities.

Thanks to COVID-19, 2020 has given the entire globe a new perspective on health. With the pandemic making its round from continent to continent and causing widespread casualties, the importance of taking care of oneself has never been more front and center. After all, many patients who experienced a grave result from contracting the virus did so because of preexisting conditions.1

The effects of the virus’s impact on the world and its population are still ongoing, but one thing has become clear—the health-care world is taking an in-depth look at comorbidities.

What are comorbidities?

Comorbidities, or coinfections, are categorized as coinciding health conditions that can be of both a psychological or physiological nature, one often affecting the other. One condition that thrives in the presence of another is diabetes. Frequently diabetes will go hand in hand with obesity because of the effect insulin resistance has on both conditions.2

Another example of comorbidity is inflammation and mouth breathing.3 Inflammation in the body can lead to arthritis, heart disease, Alzheimer’s disease, and even cancer. For those who breathe mostly through their mouths, xerostomia is common, impacting the mouth’s ability to flush away certain bacteria. Dental professionals are very aware of the effects these bacteria can have when they enter the bloodstream or reside in the sulcus or on the tooth. Mouth breathing can impact the functionality4 of the respiratory system and lessen the amount of oxygen in the bloodstream, often causing a condition called hypoxia, which can lead to heart failure, high blood pressure, decreased lung function, and chronic inflammation.5

Many other negative health conditions exacerbate one another. This level of chronic coexistence leads to an even further strain on the body’s health and, in the case of COVID-19, a decreased ability to ward off a new infection.

Coexisting conditions are the norm in the United States 

It is no secret that many Americans’ diets can be poor and require a complete overhaul. From the convenience of fast food, sugary ingredients, and the sheer number of tasty options, many Americans do not get all of the vitamins and minerals they need from their food choices. What might not be so well-known is that this lack of nutrients can lead to comorbidities in people who suffer from chronic conditions. A lack of proper quantities of vitamin B can also lead to worsened or new depression, anxiety, and elevated levels of stress.6

This chain reaction of one health deterioration to another shows just how important it is to examine comorbidities to the fullest extent when a patient visits a dental practice. Recent research shows a link between COVID-19 and various other diseases, including obstructive sleep apnea syndrome (OSAS).7 One study stated that, although the virus may not cause OSAS, having the two together can increase dire complications.8

 Other vitamin and nutrient deficiencies that can lead to chronic health conditions or worsen existing ones include vitamins A, C, D, E, folate, copper, potassium, and magnesium, to name a few. Specifically, vitamin D deficiency can lead to chronic inflammation throughout the body and a lowered immune response. This lowered immune response has led researchers to believe that those with depleted stores of vitamin D are at a much higher risk of death when infected with COVID-19.9

A lack of sleep equals a lack of health 

Along with nutrient and vitamin deficiencies, how healthy a person is can depend greatly on their quality of sleep. Conditions such as anxiety and depression can worsen sleep, as can sleep apnea. Insomnia can also be the result of chronic pain, asthma, kidney disease, neurological disorders, cognitive decline, and thyroid issues.10 A lack of good shuteye is such a widespread problem that it’s actually the number one complaint many primary care physicians receive from their patients.11

As mentioned above, OSAS can be a huge factor in recovery when a person has a COVID-19 diagnosis. Many people diagnosed with COVID-19 who had OSAS required intubation due to their inability to battle the virus and breathe properly.12 This connection between the two is just one of the many examples of comorbidities that could mean the difference between effective treatment and a vital loss of health.

Oral health is just as vital for vigor

Another perhaps surprising comorbidity that has been found to affect other conditions directly is periodontal disease. Many people separate their mouth health from their well-being, but the impact of dismissing it can be damaging. Periodontal disease can be a contributing factor in the development or worsening of other conditions, including heart disease, Alzheimer’s disease, respiratory infections, arthritis, and Parkinson’s disease, according to research published in the Journal of Oral Microbiology.13 The belief is that the mouth shares different inflammatory pathways with the rest of the body, so when the mouth is diseased, that infection becomes hard to contain. When it comes to treatment, a collaborative approach is a must because both conditions could benefit from the cure of the other.

The start of a long-overdue conversation 

The collaboration of health-care professionals has not been seamless. Many professionals fail to confer on a patient’s health outside of referral forms. Comprehensive, collaborative health care determines the efficacy of treatment, and when medical professionals are not on the same page, things can become foggy for patients and their recovery.

 Especially considering the presence of comorbidities in those with periodontal disease or other mouth-related illnesses, dental hygienists have a duty as oral health-care professionals to exhaust every avenue with their patients and work together within their medical communities. This collaboration between health-care professionals could lead to a more holistic approach that can address all health issues at once.

 The presence of many coinfections and conditions that worsen symptoms and outcomes for patients with COVID-19 has shown just how dire the need is to work together toward the common goal—optimal health.


  1. Coronavirus disease 2019 (COVID-19): Your health. People with certain medical conditions. Centers for Disease Control and Prevention. August 14, 2020. Accessed August 25, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
  2. Chobot A, Górowska-Kowolik K, Sokołowska M, Jarosz-Chobot P. Obesity and diabetes—Not only a simple link between two epidemics. Diabetes Metab Res Rev. 2018;34(7):e3042. doi:10.1002/dmrr.3042
  3. Veron HL, Antunes AG, Milanesi J de M, Corrêa ECR. Implications of mouth breathing on the pulmonary function and respiratory muscles. Revista CEFAC. 2016;18(1):242-251. doi:10.1590/1982-0216201618111915
  4. Niaki EA, Chalipa J, Taghipoor E. Evaluation of oxygen saturation by pulse-oximetry in mouth breathing patients. Acta Med Iran. 2010;48(1):9-11.
  5. Eltzschig HK, Carmeliet P. Hypoxia and inflammation. N Engl J Med. 2011;364(7):656-665. doi:10.1056/NEJMra0910283.
  6. Young LM, Pipingas A, White DJ, Gauci S, Scholey A. A systematic review and meta-analysis of B vitamin supplementation on depressive symptoms, anxiety, and stress: effects on healthy and ‘at-risk’ individuals. Nutrients. 2019;11(9):2232. doi:10.3390/nu11092232
  7. Woo J, Weber G, Nathan N. A COVID-19 conundrum: obstructive sleep apnea (OSA) and noninvasive ventilation (NIV). Anesth Analg. 2020;131(2):317. doi:10.1213/ANE.0000000000004998
  8. Pazarlı AC, Ekiz T, Ilik F. Coronavirus disease 2019 and obstructive sleep apnea syndrome. Sleep Breath. 2020:1. doi:10.1007/s11325-020-02087-0
  9. Biesalski HK. Vitamin D deficiency and co-morbidities in COVID-19 patients–A fatal relationship? Nfs Journal. 2020;20:10-21. doi:10.1016/j.nfs.2020.06.001
  10. Sleep and disease risk. Harvard Medical School. December 18, 2007. Accessed August 25, 2020. http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-disease-risk
  11. Grandner MA, Malhotra A. Sleep as a vital sign: why medical practitioners need to routinely ask their patients about sleep. Sleep Health. 2015;1(1):11-12. doi:10.1016/j.sleh.2014.12.011
  12. Suen CM, Hui DSC, Memtsoudis SG, Chung F. Obstructive sleep apnea, obesity, and noninvasive ventilation: considerations during the COVID-19 pandemic. Anesth Analg. 2020;131(2):318-322. doi:10.1213/ANE.0000000000004928
  13. Holmstrup P, Damgaard C, Olsen I, et al. Comorbidity of periodontal disease: two sides of the same coin? An introduction for the clinician. J Oral Microbiol. 2017;9(1):1332710. doi:10.1080/20002297.2017.1332710

Julia Worrall, RN, CCRN, also known as the Sleep RN, is a highly sought-after expert in sleep and airway health, connecting what was once thought to be disconnected. She is asked to speak at conferences and high-level meetings and featured on podcasts around the world. As a passionate airway advocate and mentor, Ms. Worrall continues to march forward on her mission to drive innovative research  and prevent disease through area-specific education. 

Michelle Strange, MSDH, RDH, is the cofounder and cohost of A Tale of Two Hygienists podcast. Her passion for dentistry and its connection to overall health extends to her community and global efforts, most notably in her work as a weekly dental hygienist volunteer and annual dental mission trip leader.