Heartfelt with Dr Melissa Walton-ShirleyView all posts »
CV patients with bad teeth--Our new "Habitat for Humanity" opportunity and a worthy topic for "The View"May 1, 2011 18:17 EDT
The View cohost Sherri Shepherd recently described her six-week-long ordeal with dental issues. She endured intense discomfort and was left with a hefty price tag for a temporary crown and extensive bone repair. Although she wrote a personal check for her treatment, she lamented that she now understands why so many of her relatives "have no teeth." She concluded that she is "blessed to be able to afford good dental care" but realizes now why "most can't." Sharon, my patient, is someone who can't.
Sharon is 47 years old and a licensed practical nurse who attended college for four years. She has her Realtor's license and attended business school. She is bright, articulate, and attractive. Sharon became "uninsurable" at age 18 when she developed brittle type 1 diabetes. She has an inoperable LAD vessel, an occluded saphenous vein graft to her diagonal branch, and another with moderate disease. Her inoperable LAD supplies her totally occluded distal right coronary, and her stress exams always demonstrate mild ischemia. The treatment of her coronary artery disease is adequately covered by Medicare but her severe dental issues are not. With coverage that falls far short of paying for a full extraction, she is a symbol of a common tragedy in America, a member of the growing legion of the "underinsured," having just enough resources to get into a dental chair for an exam but not enough to get out of it fully treated.
Sharon's follow-up visit was overdue and affected by her lack of "gas money." When she attempted to stifle what used to be an exuberant smile, my heart sank. There were jagged shards of discolored porcelain where her pearly whites used to reside, and next to them, dark spaces that belie her financial woes. Dwarfing her cosmetic concerns or her low self-esteem is the fact that she is suffering and is aware that her longevity is threatened. "I bit into a slice of bread and lost a tooth," she said. "I drank a glass of water and lost another one." She has one crown. "It cost me $1000 and it was mistake, but I was desperate back then." She is obviously embarrassed due to her deteriorating smile, speaking at times with her hand over her mouth. Her gaze rarely met mine at the first of our office visits until she figured out that I could still see the same beautiful and intelligent person beyond her decaying teeth. I too felt embarrassed during our interview, but it was because our medical system has allowed her to fall through its cracks, or more correctly, through its large gaping abyss that is the lack of access to dental healthcare in this country.
|What used to be an exuberant smile|
Sharon understands the impact of dental issues on cardiovascular health better than many physicians. Her ability to master exhaustive med searches is telling with regard to her depth of understanding. Past conversations during routine visits included the topic of gene therapy for coronary artery disease, the effect of diabetes on renal failure as well as the impact of poor dental health on cardiovascular outcomes of stroke and heart attack. She has carried her message and her concerns to four dentists. While she was explaining her anxiety over the potential for coronary plaque rupture from gum disease, one dentist interrupted her saying that he could treat her "one tooth at a time" but he would have to charge her "several hundred dollars per tooth." Another flippantly remarked that he would "pull this tooth one time," and "this tooth another time," and "another tooth later," pretending to check off each tooth on an imaginary list. He was literally making fun of her inability to pay up front for the entire procedure. She called him a name she now regrets, told him she did not deserve to be spoken to "like that," and promptly left his office, never to return. She says he was upset because she told him she only had $500 from "Medicare-plus" to cover the extractions, which would cost several thousand dollars. She was indignant.
Although Sharon's dentists seemed unconcerned, several dentists do "get it" when it comes to the "acute coronary syndrome" (ACS)–gingivitis connection. Dr Thomas W Nabors, a retired dentist and frequent guest lecturer, spoke at the Bale/Doneen course in Las Vegas in February. He practiced for 38 years in a small rural town in Mississippi. "Every patient I saw had an infection, and this infection was periodontal disease. In 1983, I decided I was either going to stop general dentistry or find what is causing this infection," he said with conviction. "My avocation became studying microbiology and immunology and that led to the converging world of periodontal disease and vascular disease. I'm not a physician but I'm interested in this relationship and how this impacts your world." He then asked rhetorically, "How does the mouth and the tooth relate to the vascular tree? In the concept of inflammation there is an important phrase: cumulative inflammatory burden. If we look at it, there are factors and players such as chronic infections, portal of entry, break in tissue, etc. It's a gingival attachment point; when you add all of that together that increases risk." He then cited recent literature describing the oral biofilm-associated diseases and how they contribute to systemic diseases through hematogeneous spread. "Odontogenic infections may spread into adjacent tissues, causing osteomyelitis, noma [a disease in Third-World countries with polymicrobial infections occurring in children), deep neck infections, orbital cellulitis, skin ulcers, and. in rare cases. death. One in three children died in the past due to odontogenic infections. Now, 21 000 hospital admits and 150 deaths per year in the US and three-quarters of a million deaths per year worldwide occur because of it. More than 100 million Americans are infected." (I am certain my patient Sharon is infected.)
|She is aware that her longevity is threatened|
Dr Nabors then went on to explain, "The biofilm most associated with disease is really not attached to the tooth, it's the tissue around it, the 1-mm sample of subgingival microflora that is the culprit. The biofilm mass is made of different bacteria, most commonly streptococcus, and most are opportunistic due to a portal of entry." He then stated, "The literature is profuse in the past 30 years. It is all about a susceptible host with invading microorganisms." He then reflected, "What amazed me is how smart these organisms are . . . causing brain abscess, heart attack, stroke." He went on to describe the importance of a thorough gum exam. It struck me that a periodontal pocket of greater than 3 mm is to the dental world what atheroma is to the cardiovascular world; an end result of multiple missed opportunities. Dr Nabors is the developer of a lab test called "Myperiopath," which utilizes saliva samples to evaluate for the presence of the DNA of bacterial pathogens. He firmly believes that when proper treatment eradicates those pathogens, he can reduce vascular risk.
Other dentists, though concerned, feel their hands are tied. "Why can't you just put them on a payment plan?" I asked an oral surgeon and another dentist. "The overhead for dentists is incredible," they both said. "I tried that for the first three years of my practice and I lost hundreds of thousands of dollars," added one of them. "No one wanted to finish their payments. When I was finished with their treatment, they were nowhere to be found, so I had to stop," said the other. Then I asked, "Exactly how much does it cost to do a full extraction?" "Anywhere from $3000 to $8000, depending upon how much bone work is required," they answered. Another pointed to the entire access-to-dental-healthcare debacle—the issue of personal responsibility. One dental-health provider said, "If you don't care for your teeth, no one else will. These patients did not get to this point overnight," implying that good habits and regular visits can keep one from getting to the point of needing full extraction. However, if I took the attitude as a cardiologist that patients who neglect themselves and their vascular tree don't deserve my help, folks would die. What we don't care to acknowledge is that the lack of access to dental care is also killing people, but by a more subtle and much more latent method. Some have been blatantly neglectful, opting to invest in "Mountain Dew and cigarettes" rather than toothpaste and a brush, but others have just never had the education from their parents or their educational system about the importance of oral health. Some have reached adulthood never having visited their local dentist. I insist they shouldn't be made to suffer and die because of ignorance, and we should work to find ways to help them.
With no living relatives and no financial resources, my patient Sharon is nearly out of options. She visited a pawnshop recently to try and hawk her much-cherished "perfect" diamond engagement ring, a gift from her deceased husband of 20 years. She held it up to admire it while talking with me and said, "At that time it was valued at over $1500. The pawnbroker offered me $50 dollars." She left the lair of the crooked pawn broker with the ring still on her finger and found herself no closer to getting her much-needed full dental extraction.
In exasperation, I feel the urge to shout to the world that "Sharon just needs her stupid teeth extracted!" If I knew how, I'd grab a pair of pliers and do it myself. I think she's desperate enough she would almost let me. Unfortunately, the procedure is far more complicated than what a pair of pliers can accomplish. One of her teeth is barely visible at the gum. Others are just lose, waiting for their next opportunity to flee her irritated gums. Sharon does have a glimmer of hope, though. Just yesterday, someone told her she might qualify for a dental spin-down card. As savvy as she is, it's taken her years to get to this point. The wheels of legislation grind slowly. Funds are lacking. If our legislators understood that a $3000 dental extraction could avert a $16 000 admission for ACS or, even more impressive a $65 000 coronary bypass surgery, if there is any logic or justice in the world, we should be able to get funding for oral health.
Out of desperation, perhaps we should approach the dental-health crisis in America like the organizers of "Habitat for Humanity." Let's get our jeans on, pull out our drills, our hammers, our stethoscopes, BP cuffs, and other dental equipment. Let's designate one weekend per month in every community when physicians and dentists join together to provide much-needed screening and therapy of combined vascular and dental-health issues. Maybe Sherri Shepherd and the other folks at The View could help shine the spotlight on this problem more readily than those of us who are working in the trenches. Then, Sharon and patients like her would really have something to smile about. Living longer and healthier . . . now that's a great reason to flash a big ole mouth full of pearly whites.