CV patients with bad teeth--Our new "Habitat for Humanity" opportunity and a worthy topic for "The View"

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

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.

Your comments

	CV patients with bad teeth--Our new "Habitat for Humanity" opportunity and a worthy topic for "The View"
	# 1 of 13	May 4, 2011 04:59 (EDT)
	Steve Bornfeld, DDS	Dr. Walton-Shirley: I hardly need mention that this country is in a rapidly-expanding healthcare crisis--the end point of which can only be guessed at. Why dentistry is treated as a discipline isolated from medicine is historical, but it has influenced  the way dental care is provided, the way it is paid for and the way it is viewed by both the public and the healthcare industry. There is no question that the cost of dentistry is escalating beyond the ability of many to afford.  It is tempting to try to assign blame for this, and I understand the impulse.  I do it myself. The profession has missed opportunities to address some of these issues.  Recent opposition to the creation of a "dental therapist" career track is only the most recent example of organized dentistry protecting its turf.  The creation of the "dental therapist" was intended to help address access to care in underserved areas.  It might have helped (or not), but dentistry is mostly silent when asked to provide alternative ideas. I must say that I am not of the "floss or die" school of dentistry.  Although the evidence is mounting for an association between periodontal disease and cardiovascular and cerebrovascular disease (as well as pre-term birth and low birth rate), I am of the opinion that statements of causality are premature.  There are too many comorbidities and confounders in many of these patients.  The patient of your example is instructive.  While the concept of periodontal disease as a risk factor for CVD is relatively recent, the association of diabetes with both CVD and periodontal disease is well established. In the end, it really is not necessary to portray periodontal disease as a risk factor for early death to understand that it is nevertheless a pretty disabling condition in itself, with significant pain, compromised function and social cost. So what is needed?  Probably not an ad-hoc dental clinic set up in a football stadium, staffed with voluteer tooth schlepers in a "feel good" exercise that doesn't address the core problem. What's needed is not only the acknowledgement that dental problems are serious and expensive to treat, but also that they're MORE expensive NOT to treat, and that a truly civilized society will see the humane treatment of those less well-off as a right and not a privilege--just as in any other field of medicine. Best, Steve Bornfeld, DDS Brooklyn, NY
	# 2 of 13	May 4, 2011 06:09 (EDT)
	Melissa	Steve, I'm so appreciative of your post. I'd really like some continued discussion here of this problem which is sort of the "elephant in the room" for so many patients.  I invite other dentists to speak out about this problem and perhaps with increased awareness, we can help to shine the focus on a great unmet need.  Melissa
	# 3 of 13	May 5, 2011 12:05 (EDT)
	Barb	My Husband is already a heart patient and needs dental help deparately, but can not afford it. Do you have any answers for help in Las Vegas, nv. ?  We tried the dental school here, but his social Security and Retirement is too much. The trouble is,  that it is assessed on total income without considering general living expenses, like morgage utilities medicines and food. His meds alone take over $800.00 a month.     Thanx in advance for any info that you can give.
	# 4 of 13	May 5, 2011 09:59 (EDT)
	Melissa	Barb, I sympathize with your husband's situation. Though we cannot give specific individuals information here, you might forward a copy of this piece to your local dentists and to your congressmen.  It might get the necessary dialogue going that might some day effect change.  It might be prudent to make an appointment for a dental visit to get some more specific advice about how to temporize his problem from a local dentist. I wish you good luck. Melissa
	# 5 of 13	May 5, 2011 11:44 (EDT)
	Steve Bornfeld, DDS	Dear Barb, If you haven't yet tried, you may wish to contact the Nevada Dental Association--they may have information about local low-fee dental facilities: http://www.nvda.org/resources.shtml   Good luck! Steve
	# 6 of 13	May 6, 2011 12:40 (EDT)
	GRGE	Like my father and his, I suffer from cardiovascular problems that are exacerbated by chronic inflammatory conditions. I also have IBS and have often wondered about the possible correlation between periodontal disease and flare-ups of this painful and debilitating digestive disorder. I’ll never fully understand the toll that my “bad teeth” take on my overall health, but the physical pain, financial burden, social embarrassment and career limitations due to the unsightliness are with me always.  This article stresses the importance of establishing dentistry’s place in the current health insurance debate, and reshaping legislators’ understanding of the importance of adequate dental insurance coverage for all Americans. How is it possible that such highly educated people still don't get it?
	# 7 of 13	May 6, 2011 03:31 (EDT)
	Donnie	Dr. Walton-Shirley I am approaching 75, unemployed, with only income being a small social security check and meager savings account (which is diminishing each month).  I can blame my finacial situation on no one but myself. I am fortunate to have Medicare and VA benefits. They have taken care of my heart operation and most of my other medical problems, except dental which I need. To you patient, Sharon.  She is 47, has 4 years of college, plus business school, an LVN and licenced Realtor.   There has to be much more to this story than 'poor me'.  My guess is either alcohol, drugs, laziness, life style or just terrible mismanagement of finances. While she probably can't now get affordable insurance, that was a bad mistake a long time ago.  With that education and background, she should have easily prepared for medical care.  If she is now down and out, there is still Medicaid. Of course, I do agree with you that dental care should be handled the same as other medical care. Donnie
	# 8 of 13	May 6, 2011 04:55 (EDT)
	Amy Doneen	Dear Melissa, Thank you for bringing this very important issue to the surface on your blog.  Vascular events are driven by an inflammatory response which can lead to a plaque rupture and subsequent thrombus formation, ultimately changing the flow of blood in the lumen of the vessel.  The concept that the oral/systemic link exists is founded upon this inflammatory relationship.  The work of Dr. Thomas Nabors DDS provides insight into the pathogen driven inflammatatory relationship between the mouth and the vascular system.  For those of us driven by preventative vascular health, we embrace the opportunity to examine the oral pathogen burden and IL-1 presentation to lower our patient's risk of a cardiovascular event.  We also believe that waiting for "end-stage" disease as the trigger to offer treatment is costly in terms of dollars and quality of life.  The world of dentistry, like medicine, should not wait until patients have active gum and bone loss to identify the pathogen that may be playing a role in this process.  We, in medicine, should not wait until our patients have a heart attack or ischemic stroke to determine if an active pathogen in the mouth could be playing a role in vascular inflammation.  This is a wonderful opportunity for dentistry and medicine to join forces and treat the patient as a whole individual - solidifying the oral/systemic link.   Thank you again Melissa for your thoughtful and insightful reporting. Amy
	# 9 of 13	May 6, 2011 05:04 (EDT)
	Jack Moore	Does anyone know of the Weston A Price Foundation?  Doctor Price was a Cleveland dentist and former director of research at the American Dental Association.  He researched the connection between nutition and dental health (both decay and "malformation").  In summary, he discovered indigenous diets in several locations around the world where dental problems were virtually non-existent.  His research has been preserved and built upon by the WAPF, which was started in the late 1990s and now has 13,000 members worldwide.  Many regard it as a "radical" perspective on nutrition, but this is solely due to its adherence to whole foods and traditional diets that predate industrial agriculture and food manufacturing of the past 100+ years.
	# 10 of 13	May 6, 2011 05:15 (EDT)
	Steve Bornfeld, DDS	Donny-- As clinicians we have neither the luxury nor the authority to allow moral judgments to influence our treatment.  We have a responsibility to educate; then we must do the best we can with what we've got. People make bad choices all the time.  They pay for them too.  We cannot allow ourselves to play the blame game.   Steve Bornfeld, DDS Brooklyn, NY
	# 11 of 13	May 10, 2011 01:36 (EDT)
	Bradley Bale	Melissa, thank you for bringing up this important topic of the oral systemic connection to cardiovascular disease. The scientific evidence supporting this connection continues to pour in with sophisticated studies such as the one utilizing PET scanning to demonstrate a relationship with periodontal inflammation and carotid artery inflammation: Fifer K, et. al. J Am Coll Cardiol 2/15/2011;57:971-976. The awareness of this link is still poorly recognized by many healthcare providers and patients. Sharon's case illustrates the problem many individuals now have accessing proper care and this translates to any area of medicine or dentistry. Solving those issues is extremely complicated and involves professions beyond medicine or dentistry. We should really celebrate the progress we have made from a scientific stance in the oral systemic realm.  We now have excellent tests available based on DNA to identify oral pathogens known to be associated with heart attack and stroke risk.  We have the genetic testing for Interlukin-1 one to alert us to patients' who will have a much stronger inflammatory response to oral infections.  We have therapies now which can eradicate periodontal disease.  We possess clinical tools now to look for 'subclinical' oral disease allowing us to prevent more serious and costly outcomes.  Those of us combating CV disease need to be educating our colleagues about these wonderful advancements so they can be utilized more. Yes, access to care is a serious issue and deserves attention, but more basic education about the oral systemic link to CV wellness is sorely needed.
	# 12 of 13	May 23, 2011 09:29 (EDT)
	Kimberly Hartke	I am the publicist for the Weston A. Price Foundation westonaprice.org. I encourage people to check out our dietary guidelines. One of our members has also written an excellent book, Cure Tooth Decay by Rami Nagel. You can find it on my blog: http://hartkeisonline.com/resources/#books The standard american diet is woefully deficient in nutrients needed to create and maintain strong bones, joints and teeth. Discovering this information has been life changing for me and many thousands of others.
	# 13 of 13	May 26, 2011 02:35 (EDT)
	Melissa	Today, a dentist contacted me and offered to help with Sharon's situation. He has a "care plus" program which allows for the patient to arrangement payments through a credit agency and the procedure is interest free if paid off in 6 months, otherwise, there is a payment schedule available for all types of time frames. That sounds workable for lots of folks. Melissa

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