SHOULD ORAL HEALTH BE A PART OF HEALTH CARE?

 

 

 

DOES ORAL HEALTH HAVE A PLACE IN PRIMARY CARE?

 

HOW IMPORTANT IS ORAL HEALTH IN PRIMARY CARE?  This is a primordial gripe of mine--that in the US the people who set up health care have not noticed that oral health (i.e., teeth) are important to health. Existing statistics show that 33% of the entire US population is edentulous by age 60, all of which is easily preventable. This great neglect of oral health starts from the first day of medical school when students are taught how to do physical exams--"Open your mouth. Say "aaahhhh", and then they look at the uvula (an anatomic structure of no clinical significance) and the tonsils (which are irrelevant if the patient is not symptomatic with sore throat). Each and every time one of us does this part of the exam we are looking right past the teeth. Dental health turns out to be very easy to assess. If we hadn't been taught systematically to ignore it, it is something that we would do just because it was obvious.

     Whenever studies have been done to evaluate the most important components of a routine physical exam, the teeth and gums are always in the top 5 high-yield targets, both for pediatrics and adult medicine. (I mean, think of it; most of a comprehensive routine physical exam is pure wasted effort--but NOT the teeth!)  So when was the last time, when you asked the patient to "Open up and say 'aaahhhh'," that you actually noted the status of the teeth and gums. Make an effort. It matters. Only if you catch these problems early can you manage them without dental referral. We, as primary care physicians, are the ones who get the biggest opportunity to see teeth and give instruction and advice that would be accepted.

 

The Secrets of the Oral Health Exam

 

1. Look for holes. Holes are not supposed to be there. Holes are easy to spot. If there is any question whether it is a hole or not, it is not a hole. Big holes are left by missing teeth, which are extremely obvious. Every physical exam should describe the approximate (%) of teeth that are either carious or missing.

 

2. Look at the gums (right up front--your nose is almost bumping into them when you look at the uvula). Health gums should have nice, sharp, steep interdental pink tissue (papillae). The first sign of gum disease is that the tips of these become blunted and the height of the papilla becomes lower as the gums recede. This is a very early sign at a stage where it is still quite correctable with good hygiene. In the more advanced stage the entire gum recedes from the bottom of the exposed part of the teeth and you start to see the roots. Every physical exam of the head and neck should include a description of the height of the interdental papillae and the relative placing of the gum line across the normal neck of the teeth.

 

      People who have either of these findings should receive dental care. But, ay, there's the rub. Most of our patients will not have insurance for dental health. It is not regarded as part of general health coverage. We can get you a gastric bypass surgery but not a simple teeth cleaning. We sit back and wait for this time bomb to go off, and then the patient presents to the emergency room as the only place they can get any care for their acute dental pain. I am amazed at the number of patients I treated for recurrent tooth abscess with antibiotics. They take the antibiotics and a pain medication, but are unable to see a dentist for definitive treatment so they just come back in when it hurts again. And it goes on and on. What we need is a study that shows that good dental care saves general health costs down the road. I have never seen one. If you have, please let me know.

 

     Recently I got an email from a reader, Adam Jason, who has a special interest in this problem. He has prepared an infographic available on the web. I share it with you here by permission. It is a worthy reminder of an important health and primary care issue.

 

  

Emergency Room Dentists:

The High Costs of Life or Death Dental Care (Infographic)

Posted on April 10, 2012 by Jason (Frugal Dad)

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It’s hard to believe but we seem to have forgotten about our teeth. We’ve been looking into the costs of America’s famously straight, white smiles. Instead of facts on cosmetic dentistry, we’ve come up with some troubling statistics on rapidly rising trend: emergency room dental visits. It turns out that dental care is suffering right along with general healthcare.
Our latest graphic explains the costs and causes of this overall decline in preventative care. Dental care is really an investment against future costs, but we can’t blame the uninsured for avoiding costly cleanings and checkups. It’s a costly gamble to forego dental insurance. Routine checkups at the ER will get astronomical fast, not to mention the terrifying costs behind contracting a serious dental disease or injury.
Going along with the infographic, it comes down to reform. Insurance-wise, it seems that dental costs need to be reduced in order for more employers to provide coverage. On an individual scale, it seems a more extensive dental hygiene regimen could really help Americans with or without insurance.

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About Jason (Frugal Dad)

Jason founded FrugalDad.com in 2007, back when being frugal was still unpopular. My Google Profile+

 

 

 

 

 

 

 

   350

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HOW TO SAVE YOUR MIND WHEN ALL ABOUT YOU ARE LOSING THEIRS

A VIEW FROM THE OFFICE

HOW TO SAVE YOUR MIND

     Your mind is a terrible thing to lose, and the fact is that you don't have to. I am often asked, "What can I do to prevent Alzheimer's disease?," and it turns out there is a nice, simple, effective answer, but it takes a lot of work. The answer is exercise. Chapter One of John Medina's book, Brain Rules, makes this point very nicely.

     Research shows that overall the greatest predictor of successful aging was the presence or absence of a sedentary lifestyle. The primary benefit of exercise is to the heart and vascular system, but it also has a very specific benefit for brain function. "When couch potatoes are enrolled in an aerobic exercise program, all kinds of mental abilities begin to come back online. Positive results were observed after as little as four months of activity."

   
     "A lifetime of exercise can result in a sometimes astonishing elevation in cognitive performance, compared with those who are sedentary. Exercisers outperform couch potatoes in tests that measure long-term memory, reasoning, attention, problem-solving, even so-called fluid-intelligence tasks (the ability to reason quickly and think abstractly, improvising off previously learned material in order to solve a new problem).

      But how much activity does it take? The encouraging answer is, "Not much." "If all you do is walk several times a week, your brain will benefit. Even couch potatoes who fidget show increased benefit over those who do not fidget." The effect is so significant that your lifetime risk for general dementia is literally cut in half if you participate in leisure-time physical activity. "Aerobic exercise seems to be the key. With Alzheimer's, the effect is even greater: Such exercise lowers the odds of getting the disease by more than 60 percent." "You have to participate in some form of exercise just twice a week to get the benefit. Bump it up to a 20-minute walk each day, and you can cut your risk of having a stroke...by 57%."

     Exercise is also a powerful treatment for depression as it influences the neurotransmitters serotonin, dopamine, and norepinephrine. "For both depression and anxiety, exercise is beneficial immediately and over the long term. It is equally effective for men and women, and the longer the program is deployed, the greater the effect becomes. It is especially helpful for severe cases and for older people."

     In fact, "the benefits of exercise seem nearly endless because its impact is system-wide, affecting most physiological systems. Exercise makes your muscles and bones stronger, for example, and improves your strength and balance. It helps regulate your appetite, changes your blood lipid profile, reduces your risk for more than a dozen types of cancer, improves the immune system, and buffers against the toxic effects of stress. By enriching your cardiovascular system, exercise decreases your risk for heart disease, stroke, and diabetes. When combined with the intellectual benefits exercise appears to offer, we have in our hands as close to a magic bullet for improving human health as exists in modern medicine."

      How did exercise become so important in the history of the survival of our species. The answer is pretty simple--once upon a time, it was necessary. Our prehistoric ancestors in the homo species (erectus and sapiens) walked about 10 to 20 kilometers a day for men and about half that for women in the pursuit of food. That's 12 miles a day. In addition the species was steadily expanding its range--by about 25 miles per year. Survival required constant motion, quick reflexes, and quick thinking. What's unfortunate is that survival (in good health) still requires that even when it is not obvious.

     If you've drifted away from this healthy habit over the course of your life, don't despair. The Atherosclerosis Risk Factors in Communities Study (ARIC) has shown that even long-term couch potatoes with no healthy habits who convert to not smoking, exercising 20 minutes a day, eating 5 servings of fruits and vegetables a day, and getting their BMI to less than 30, enjoy a 40% reduction in mortality over a period as short as 4 years. It's really amazing that it only takes 4 years of good habits to make up for a lifetime of bad habits. You can do it.

     So, why not take advantage of this simple secret. It's easy to do. Dr. Medina offers two simple suggestions: (1) Wear your gym clothes all day. Eliminate the barrier to exercise that changing clothes imposes. Employers should encourage this. (2) Adapt yourself during your PC time managing email or surfing the web by doing it while on a treadmill. Dr. Medina says it took him only 15 minutes to become fully proficient on the laptop keyboard while walking at a 1.8 mile per hour pace. My additional suggestion is to find a way to capitalize on our preference, nay, need for, regular rituals. Create either four 5-minute ritual walks for your every day routine--walking to the store or post office, exploring a neighborhood park, walking from the parking lot to work or up several flights of stairs, etc., or create two 10-minute rituals. Whatever works for you--it just needs to add up to 20 minutes a day every (or almost every) day. And, either before your walk or right after, consume a fruit or vegetable (a smoothie or a glass of V8 juice), and then relax. Hey, you've got the whole lifestyle challenge beat according to the "Formula for Health", assuming you're not smoking and your weight (read "BMI") is heading down to 30 or below.

     You could even organize a neighborhood outing for 10-15 minutes every day after work. Invite the local kids and their parents to join you for a walk or ride. Making this kind of activity communal is the single best contribution you can make for your community. It will be immensely rewarding.

     And remember, you don't need to get Alzheimer's disease. It is essentially completely preventable.

REFERENCE:

Medina J. Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School. Pear Press. 2008.

Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School [Paperback]

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IS YOUR 'CHECK ENGINE' LIGHT ON?

A VIEW FROM THE OFFICE

IS YOUR 'CHECK ENGINE' LIGHT ON?

     Have you ever been annoyed by your car's 'check engine' light? I mean, have you responded to this light and taken the car in to be checked, only to find there  was nothing really wrong and nothing to be done. [This analogy is provided by Dr. H. Gilbert Welch in his book "Overdiagnosis: Making People Sick in the Pursuit of Health".] The problem now is that your car is so computerized that it even has sensors to detect the function of other sensors. At a certain degree of complexity something has to be at least slightly askew a large fraction of the time. The point that Dr. Welch makes is that getting frequent recommended medical check-ups produces essentially the same result. Your doctor will likely tell you on most of these occasions that "you're 'check engine' light is on" and there's something you have to do to turn it off (despite the often overwhelming odds that everything is just fine). Examples of such situations include the mammogram or chest x-ray with a "suspicious spot," the Pap smear with minor abnormalities like "ASCUS," the stool blood test that is positive (due to hemorrhoids, which are much more common than colon cancer), the blood pressure that is elevated 10 mm Hg more than usual, the freckle that looks just slightly darker than all the other ones, etc. The question for you the patient should be, How often are you metaphorically willing to have your engine checked? It can get to be quite a nuisance. Even more than that, as Dr. Welch points out, it can at times be frankly hazardous to your health.

     Consider this table that he provides for us [his table 2.1]. In it he shows the effects when, hopefully, well-meaning "experts" decide to change the criteria for diagnosis of common conditions. Their imputed motivation for doing this is to catch more people with this condition [i.e., their 'check engine' light is on], so that we might prevent more bad disease outcomes like blindness from diabetes, stroke from hypertension, a heart attack for high cholesterol, and a compression fracture from osteoporosis. The problem is that at the lower range of these physiological variables there are actually a few bad outcomes, but only a very few. As you can see in the table, as you lower the threshold for diagnosing diabetes, hypertension, high cholesterol, and osteoporosis, you are instantly creating literally millions of patients with a "new" disease condition. They are now "sick" and are expected to get "treatment." Only a small percent of such newly diagnosed patients (typically 1-8%) will benefit from this treatment; essentially, a minimum of 92% of the new diagnoses are being subjected to medical scrutiny, testing, and treatment with absolutely no benefit to show for it.

.

CONDITION	PREVALENCE		NEW CASES	% INCREASE
	Old criterion	New Criterion
Diabetes: the criterion for diagnosis was changed from a sugar level of 140 down to 126 mg%.	11,697,000	13,378,000	1,681,000	14%
Hypertension: the criterion for diagnosis was changed from 160/100 to 140/90 mm Hg.	38,690,000	52,180,000	13,490,000	35%
High cholesterol: the criterion for  diagnosis was changed from a total cholesterol of 240 mg to 200 mg/dL.	49,480,000	92,127,000	42,647,000	86%
Osteoporosis: The criterion for diagnosis was changed from a “T score” of 2.5 to 2.0	8,010,000	14,791,000	6,781,000	85%

The other problem is that the motivation for these new diagnostic criteria among the "experts" is not always beneficent. Often it is frankly commercial. "The head of the diabetes cutoff panel was a paid consultant to Aventis Pharmaceuticals, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Novartis, Merck, and Pfizer--all of which make diabetes drugs. Nine of the eleven authors of recent high blood pressure guidelines had some kind of financial ties--as paid consultants, paid speakers, or grant recipients--to drug companies that made high blood pressure drugs. Similarly, eight of the nine experts who lowered the cholesterol cutoff were paid consultants to drug companies making cholesterol drugs. and the first cutoff for osteoporosis was established by a World health Organization panel in partnership with the International Osteoporosis Foundation--an organization whose corporate advisory board consisted of thirty-one drug and medical equipment companies."

     Dr. Welch summarizes the outcomes for persons affected by these new guidelines in this table: 

“If 100 patients are diagnosed on the basis of elevated but near normal levels of a variable and treated for a lifetime, there will be…”
CONDITION	WINNERS (avoided a heart attack)	TREATED FOR NAUGHT (had a bad outcome despite treatment)	LOSERS (not helped because they were never going to have a heart attack anyway)
Mildly elevated cholesterol	8	14	78
Mildly low T score for osteoporosis	5	44	51

     This problem also exists with all our fancy new imaging technologies like CT scans and MRIs, as well as for old technologies like plain x-rays and ultrasounds. Here are some typical examples:

• "Gallstones: In people without any symptoms of gallbladder disease (pain, nausea, or problems with fatty foods, for example), about 10% have gallstones when scanned by ultrasound.
• "Damaged knee cartilage: In people without knee pain or a history of knee injury, about 40% have meniscal damage in their knees when scanned by MRI.
• "Bulging discs in the back: In people without any back pain, over 50% have bulging lumbar discs when scanned by MRI."

     And, of course, as I have said in prior blogs, this problem applies to cancer screening. I have already covered prostate cancer, cervical cancer, colon cancer, and breast cancer. Let's take a look at 3 other relatively common cancers--thyroid cancer, melanoma, and lung cancer. 

Thyroid cancer: Thyroid cancer is responsible for about 1,600 deaths each year in the US. The number of cases of thyroid cancer diagnosed each year in the US is much greater       --37,000 cases. This discrepancy is explained by two basic factors:  (1) treatment for the most common thyroid cancers is pretty good; and (2) there is a large portion of thyroid cancers that exist in asymptomatic patients and which is never going to cause any symptoms. In  one autopsy study of 101 older patients who had died of other causes in a hospital, pathologists found clusters of thyroid cancer cells in a full 33% of patients. The researchers in this study concluded that "the smallest forms of thyroid cancer were so common that they should be regarded as normal findings." The moral of this story is that you don't really want your doctor examining your neck (thyroid gland) for lumps because nodules are extremely common (now that we use ultrasound routinely; prevalence is 30-65%), yet death from thyroid cancer is very rare. The United States Preventive Services Task Force recommended against any form of routine thyroid cancer screening in 1996.

Melanoma: There are about 8,400 deaths in the US each year from malignant melanoma. The incidence of melanoma, however, is much higher--around 116,000 cases per year. In recent years there have been many efforts directed at increasing early diagnosis of melanoma and these have resulted in a doubling of the number of cases diagnosed between 1975 and 2005. It would seem like that should be a good thing. But when you look at the annual death rate from melanoma in the same period there has been absolutely no change. This means that all of these extra diagnoses have not reduced the death rate. We have just labelled more people with a diagnosis of melanoma that was going to have no effect on the overall death rate. What we are finding with our increased tendency to biopsy pigmented lesions is that there are many people who have microscopic clusters of abnormal melanin-producing cells who were never going to have any clinical disease from it. Increased screening does not appear to be helping at all. 

Lung cancer: "From a public health perspective, lung cancer is the cancer that warrants the most attention. It's responsible for 162,000 deaths annually in the US. That's more than breast cancer, prostate cancer, melanoma, thyroid cancer, and colon cancer combined. About 215,000 Americans get the diagnosis annually. That means most people diagnosed with lung cancer die from it." Since we know that people who smoke or used to smoke are the ones who have the highest risk for lung cancer, you would think it might make sense to screen this group of patients for lung cancer. If so, you would be wrong.

     Three randomized trials completed in the 1990s showed the screening chest x-rays did not lead to a reduction in lung cancer deaths. "In fact, in two of the studies, screening appeared to cause more deaths." Virtually all cases identified by screening underwent surgery, and the surgery has a significant mortality rate. But this is not the only problem. The other problem is that, after 20 years of follow-up, it appears that approximately 50% of all cancers detected by screening were lung cancers that were small and were never going to cause a problem, yet almost all of these "overdiagnosed" patients underwent surgery.

     Finally, there is the problem of "incidentalomas". This is a new term in medical jargon that refers to abnormal findings on an imaging procedure that was carried out for a purpose unrelated to cancer screening. For example, if a chest CT scan is done for a pulmonary problem, it may also unexpectedly find a "spot" in the liver or kidney. If an ultrasound is done on a carotid artery to assess circulation, it may also see a cyst or nodule in the thyroid gland. 

.

Organ	% of people with an incidentaloma on CT scan	10-year risk of cancer death	Maximal chance that the incidentaloma is a lethal cancer	Chance that the incidentaloma is NOT a lethal cancer
Lung (smokers)	50%	1.8%	3.6%	96.4%
Lung  (never smokers)	15%	0.1%	0.7%	99.3%
Kidney	23%	0.05%	0.2%	99.8%
Liver	15%	0.08%	0.5%	99.5%
Thyroid (ultrasound)	67%	0.005%	< 0.01%	Ø  99.99%

.

When you reflect on the data in this table, it should be clear to the average person that, if an "incidentaloma" is discovered while some imaging test is done for another purpose, this result should simply be ignored. Otherwise you risk biopsy or surgery for no reasonable expectation of benefit.

COMMENT: I have been citing examples of these kinds of problems for years, but Dr. Welch puts them all together in one easy to read book with tables and diagrams that makes this otherwise dense information very accessible. While he makes a clear case that our traditional (and rather frivolous) approach to screening and diagnosis for these diseases poses significant hazards to your health, he provides less guidance on another approach to health promotion and disease avoidance other than better consumer information. Here is where my approach to prevention through the "Formula for Health" really shines.

    Adopting the 5 simple health habits identified in the "Formula for Health" has been shown in 13 major observational studies and 1 randomized controlled trial to be associated with benefits of the magnitude illustrated in the second poster. This approach requires no screening test, no blood testing or imaging, and creates no risk of overdiagnosis. In fact, it represents the maximum that you can do to improve your overall health. The problem with our modern medical technology is that "overdiagnosis" (with subsequent treatment without benefit) has become a bigger problem than the diseases they were designed to avoid. We have to find another way. A healthy lifestyle (The Formula for Health) is this way.

References:

Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwartz and Steve Woloshin (Jan 3, 2012)

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