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, N.J. The clinic, located at the same hospital, is affiliated with the Rutgers School of Dental Medicine, where I’m a faculty member. Hence, I oversee our dental residents as they treat patients at the urgent-care clinic.
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.
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 prior to 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. 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 were able to extract 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.
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 most dental care. Under the Affordable Care Act, dental coverage for children is now an “essential health benefit.”
However, while the ACA mandates individual health-care coverage for all eligible U.S. adults, it does not recognize dental coverage as essential for adults, perpetuating the flawed 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 mind-set 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. It is time that we erased these disparities, particularly for patients with life-threatening illnesses, for whom dental care and medical care are intertwined. 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. We cannot afford to walk away from our obligation to strive for oral-health equity — an integral part of achieving overall health equity — no matter the financial implications.
Subramanian is an assistant professor in the Department of Diagnostic Sciences at Rutgers School of Dental Medicine. This article was excerpted from the December issue of Health Affairs and can be read in its entirety at healthaffairs.org.