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Thursday, May 3, 2012


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)

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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Wednesday, May 2, 2012




     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 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.

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

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NOTE: I will be in Portola this weekend for the Saturday morning clinic. I hope to see you there!