Tooth troubles: Too often, medical insurance is undone by a lack of dental coverage

My patient sat quietly in our urgent-care dental clinic. He had just been diagnosed with tongue cancer and would soon undergo radiation therapy.

Before treatment, he needed all invasive dental treatments completed because radiation can take an enormous toll on the oral cavity, weakening the teeth and jawbone.

He had been referred to us in 2013 from the radiation oncology department at University Hospital in Newark, New Jersey. The clinic is affiliated with the Rutgers School of Dental Medicine, where I'm a faculty member. I oversee our dental residents as they treat patients at the urgent-care clinic.

A lifetime of neglect

My patient (I am not identifying him to protect his privacy) was unemployed, in his early 50s, with little income and a tough life. He worked odd jobs now and then. He was a smoker — three packs a day for more than 30 years — and a drinker, consuming a few cans of beer a day.

His broken-down teeth seemed to bear testimony to years of neglect. He had medical insurance, but no dental coverage.

For many of the patients we treat, daily life is such a struggle that brushing and flossing are a low priority. Other patients have never been properly educated about oral hygiene or have little familiarity with the health care system.

My patient had been aware of a slowly growing mass in his tongue but sought care only when he began having trouble swallowing and started experiencing severe pain that spread to his ear.

His smoking and drinking had inevitably contributed to the developing cancer on the floor of his mouth and the base of his tongue. While not a candidate for surgery, he was recommended for chemotherapy in conjunction with radiation therapy.

Because the treatment would expose his oral structures — including the jawbone, salivary glands and teeth — to radiation, a dental evaluation was prompted.

A resident examined his mouth: He was missing several teeth, and his remaining teeth had such advanced decay that conservative management with fillings or root canal treatment would no longer be feasible. He would need nearly 18 tooth extractions.

Emergency dental work

We know that radiation treatment to the jaw can significantly undermine bone healing after teeth are extracted. In about 10 percent of patients who have teeth extracted following radiation, the jawbone is unable to heal adequately and tends to die out, meaning it loses its viable cells and cannot repair or remodel itself anymore.

The affected bone loses the protective cover from overlying gum tissue, and because it remains exposed to the mouth, the risk of infections increases. In rare cases, the infections can cause the jaw to weaken and eventually fracture — an often painful disease called osteoradionecrosis, which has no known cure.

It is sometimes difficult to determine whether to recommend saving or extracting questionable teeth, although in this case we knew his situation could only worsen.

Leaving him with a mouthful of condemned teeth that would likely deteriorate merely stacked the odds against him.

When I explained all of this to him, however, he declined dental care because he could not afford it.

He said his teeth did not hurt him at that time; the debilitating pain he was experiencing was from his tumor, and he just wanted to get through his radiation treatment to ease his pain.

We could not deny his decision. Because osteoradionecrosis is rare and poorly predictable, a mandatory dental referral and clearance before receiving radiation to the jaw is not yet the standard of care.

My patient completed his course of radiation and chemotherapy, and his subsequent scans showed no evidence of residual disease.

The risk of waiting

He was restricted to a soft pureed diet that could be swallowed a little at a time, and he had to supplement his minimal intake with a feeding tube in his stomach.

Nearly a year later, he arrived back at the dental clinic just as we feared, with rampant tooth deterioration and painful abscesses where the infection had spread beyond the tips of the roots.

“Doc, the pain is killing me,” he moaned. He was ready to get his teeth extracted to relieve the pain.

He told us that he was scheduled to undergo an ear, nose and throat procedure under general anesthesia within the next week to repair a small skin defect caused by his tissue being stretched and thinned post-radiation, resulting in a perforation in his cheek.

He begged us to perform the extractions at the same time so that he would not be awake for the procedures.

Because time was of the essence, we agreed. He now had dental coverage along with his medical insurance, making it possible for him to afford the care he needed. We were able to go into the operating room right after the ear, nose and throat specialist had repaired the perforation and we extracted all of his remaining teeth.

For a few months, he seemed to be healing. But in time, a few of his dental extraction sites started to break down, exposing dead bone tissue on both sides of his lower jaw, establishing his diagnosis with osteoradionecrosis.

He developed a fungal infection in his mouth — a fallout of an immune system compromised by chemotherapy and radiation treatment. We knew that he was in danger of losing his jaw.

He had become dependent on the pain medications he had relied on so heavily to help him through his cancer, its treatment and now his unremitting pain. As he developed tolerance, the pain medications became increasingly ineffective.

For a while, we saw him monthly to monitor his condition, but we couldn't convince him to keep up with these visits, which so rarely seemed to bring him any relief.

Why insurance matters

If my patient had had dental insurance alongside his medical insurance at the time he needed it, his story could have had a very different ending. He could have undergone his 18 tooth extractions well before his radiation treatment, at the same time that an ear, nose and throat specialist performed his diagnostic biopsy, all under general anesthesia. His extraction sites could have healed by the time his biopsy result was available and his radiation therapy was being planned.

Or, even better, he could have taken his oral health seriously enough to have regular health checkups and periodic dental care. His tongue cancer could have been diagnosed several months earlier, and his teeth could have been stable enough to withstand the radiation without the need for extractions.

Instead, by the time he finally obtained dental coverage, the risk of osteoradionecrosis was irreversibly established. By the time he was able to see us monthly, he had developed osteoradionecrosis, and we had nothing substantial to offer him to improve his condition. On the other hand, even if he had had dental insurance coverage earlier, plans' annual caps on maximum expenses would probably have left him with significant financial burden.

When oral health is treated as if it were unrelated to overall health — as is the case in this country, where there is medical insurance and then there is dental insurance — the consequences can be dire.

Today, there are more than 108 million people who have no dental insurance, according to the Health Resources and Services Administration. The United States spends more than $64 billion each year on oral health care, of which only 4 percent is paid for by government programs. According to a 2000 surgeon general's report, for every adult who has no medical insurance, there are three who have no dental insurance, even though it has been estimated that almost everyone experiences dental disease in their lifetime.

While dental benefits are required for children under both Medicaid and the Children's Health Insurance Program, dental benefits for adults are optional. Traditional Medicare also does not cover the most dental care.

Under the Affordable Care Act, dental coverage for children is an “essential health benefit.” However, while the ACA mandates individual health care coverage for all eligible adults, it does not recognize dental coverage as essential for adults, perpetuating the perception of overall health as exclusive and independent of oral health.

The arguments against combining medical and dental benefits, whether valid or otherwise, are primarily financial. Secondarily, they reflect a mindset that perceives oral health as an optional milestone to strive for.

This artificial divide is especially explicit in a hospital such as ours, which offers urgent oral health care services under the same roof as other health care services. Having traditional insurance allows patients access to services elsewhere in the building, but once seated in the dental chair facing a dental emergency, patients often are told that their treatment must be paid for out-of-pocket.

It has been 16 years since the surgeon general acknowledged the silent epidemic of oral diseases affecting our most vulnerable citizens: poor children, the elderly and members of racial and ethnic minority groups. Yet poor oral health still disproportionately affects low-income adults, particularly those from racial and ethnic minority groups.

Mandating that medical insurance cover essential dental treatments such as tooth extractions, fillings and root canal procedures, particularly for cancer patients such as mine whose dental health and overall health are so closely related, might be an essential first step.

10 ways to improve oral health

<b>1. Brush and floss regularly: </b>Brush twice per day with a fluoride toothpaste for two minutes, paying special attention to the gum line and making sure to reach all surfaces of the teeth.

<b>2. Schedule a dentist appointment: </b>Regular checkups can help prevent dental health problems before they cause discomfort or require more comprehensive or expensive treatment.

<b>3. Replace your toothbrush: </b>Your toothbrush should be replaced every three to four months, as well as after you have been sick or if the bristles are frayed.

<b>4. Add mouthwash to your oral health routine:</b> Look for an antimicrobial mouthwash with fluoride — these rinses reduce bacteria and inhibit bacterial growth that can cause gingivitis.

<b>5. Kick that tobacco habit: </b>Smoking can contribute to gum disease, mouth pain, cavities and even tooth loss.

<b>6. Limit your sugar intake: </b>Reduce your consumption of sweet and sticky treats and refined carbohydrates, and replace them with healthier options. Drink water instead of soda.

<b>7. Switch to sugarless gum:</b> According to the American Dental Association, chewing sugarless gum following meals can neutralize and wash away acids produced by bacteria in the mouth.

<b>8. Cut back on soda, coffee and alcohol: </b>Keep your pearly whites stain-free by limiting your intake of dark-colored liquids. Soda, coffee and alcohol have high levels of acidity, which can strip down and wear away tooth enamel, leading to tooth discoloration. Avoid potential erosion by switching to an alternative, like sugar-free seltzer water.

<b>9. Take a multivitamin: </b>Calcium, copper, zinc, iodine, iron, potassium and vitamins B and D all contribute to your mouth's health.

<b>10. Plan for dental care in the upcoming year:</b> According to a Delta Dental of Illinois survey, people with dental insurance are nearly twice as likely to visit the dentist as those without insurance.

Source: Delta Dental of Illinois