Never underestimate the power of a beautiful smile.

Last year I met a patient whom we will call Stacy. Stacy had only four lower front teeth with all other lower teeth and all upper teeth decayed and broken down. Her goal was to have dentures so that she could gain employment– she had been rejected for several job opportunities and felt this was related to her appearance. She had about $1,200 to put toward her treatment, however, her estimated cost of care was over $6,000. Fortunately, I work at a University and we were able to re-direct her to the student clinics where she received her care for $1,200.


Research has shown that the number of decayed and missing teeth actually can predict depression in certain populations. That’s because, the investigators suggested, oral health is related to quality of life. A different study found that oral health of a child with special needs actually predicts whether their mother will have depression or not. What this study found is that there is an association between the number of decayed and missing teeth of the child and the mom’s risk of depression – this has incredibly powerful implications for dentists as healthcare providers.


While there is significant awareness of the fact that oral health affects general health there is less knowledge about the how it affects mental health. Depression is a common, complex, and multifactorial disease and treating oral health is only a small part of any solution. However, imagine the scenario of someone who has visibly poor oral health – research shows that poor oral health is a risk factor for unemployment! Not having a job will hinder their ability to purchase high quality healthy food, access healthcare and undermine their ability to gain a better education. All of these factors are known to be associated with poorer health and wellbeing.

In 2014 we published a study that found 12,080 patients hospitalized in US hospitals (during the 4 years of the study) for an oral health condition had a concurrent mental health condition. The mean length of stay was 3 days and the hospital charges were over $1 billion which has significant implications for federal and state expenditures. Moreover, when these patients first presented to the ER their hospital charges were much more than when patients without mental health conditions presented to the ER with the same dental condition. Dental health and mental health are closely related and dentists and mental health professionals should bear this in mind as they render care. We must all be careful not to treat in silos conditions that are inter-related and multifactorial in nature.

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How to kill 313 people without lifting a finger!

Every year in the United States an insidious thing happens. Across the 5,627 hospitals in America, there are 1.4 million emergency room visits for basic dental conditions. Conditions that a Dentist or, dare I say, even Dental Therapists could correct. These are not complex medical issues but dental caries, pulpal and periapical lesions, gingival and periodontal lesions.


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Many in the dental profession will remember the sad passing of a boy named Deamonte Driver in Washington, DC. It was particularly sad because, in a time before the Affordable Care Act, his family just became ineligible for Medicaid and the death happened so near to Capitol Hill. Moreover, his family was more focused on his brother’s oral health because he had six cavities…..Deamonte was thought to have better oral health than his brother. Deamonte’s death was tragic and unnecessary, however, did you know that another 312 people die every year in our hospitals after attending because of a basic dental problem?!


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This information is aggregated from two studies we completed – one considering hospitalized patients with dental problems and another looking at emergency room visits for dental problems. Roughly 277 in-patients and 36 ER patients die after coming to the hospital because of a dental problem. It is not necessarily so that the dental problem caused mortality, however, the dental problem did necessitate their hospital visit which lead to their ultimate demise.

Medical care is seen as a necessity while dental care is sometimes considered a luxury. Medicare includes negligible dental coverage (and, it’s true, the ADA had something to do with that) and Medicaid has limited dental coverage. Yet, our studies found that when patients end up in hospital because of a dental problem, 25% of hospitalized patients and 8% of ER patients were Medicare. Additionally, 18% of hospitalized and 31% of ER patients were Medicaid. The federal and state governments end up paying for these dental problems through ER’s and hospitals where it is considered a “medical necessity.” But research shows that ER’s manage many dental problems inappropriately and 96% of dental related ER visits require a subsequent dental visit anyway!


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The dental profession, healthcare advocates and all sane people must push for better dental coverage for our government patients – the affordable care act brought great improvements but failed to resolve this crisis. Doing nothing will mean another 313 people will die this year in 2017. And that’s how we can kill 313 people by doing nothing.

Have an evidence-based, Merry Christmas!

In 2014 I was blessed to win first prize for outstanding research at the International Medical Education Conference in Malaysia. After all the congratulations and fanfare, I collected my cash prize and got into a taxi to head to the airport. The taxi driver offered to take me for $50 US – he apologized that it was so much but he knew he wouldn’t find a passenger returning to the sleepy beach town where I was staying.

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On our 90 minute drive this simple man, his congenial personality and stories of his children warmed my heart. When I left him at the airport I gave him $400 US – I had just received much more than this as a prize and it was not hard to give away. This was the most memorable and satisfying moment of my trip to Malaysia in 2014. Even though I made 5 oral presentations, won the prize, and spent a unique weekend in a monastery. Yet, giving away this money was the most memorable moment of my trip – I still remember the look on his face.

The ancient book of Acts quotes Jesus Christ saying “it is better to give than receive.” But did you know that science actually confirms this? A large body of research already shows that level of income has a limited impact on level of happiness. Dan Kahneman popularized this message with his TED talk on the same. In fact, having a lot of money has been associated with a reduced interest in donating to charity or spending time with others. However, remarkably, these are the very things that research has proven to bring happiness!

A study about Christmas festivities actually revealed that activities involving family and religion had the biggest impact on happiness during Christmas. Whereas, gifts were associated with less happiness and actually increased peoples’ stress levels!


A team of researchers from University of Michigan found that helping others (giving money) has been associated with reduced mortality by buffering stress. Another study by Doug Oman and Thoresen McMahon showed that those elderly who were volunteering at two or more organizations (giving time) had a 63% lower mortality rate than those who did not volunteer at all.

This Holiday Season, be sure to focus on giving. As a healthcare provider what can we do? Medical and Dental societies have many opportunities to volunteer and donate toward worthy causes that match our mission and values. We should, selfishly, look for opportunities to give because they bring the most happiness.


Can we afford to lose the Affordable Care Act??

Health and quality of life are essential to the success of a nation. Dr. Francis S. Collins (Director of the National Institutes of Health) has spoken of how improving a nation’s health can boost economic growth. The World Bank has published an evidence supported theory that 50% of the difference in economic growth between developing and developed nations is attributable to poorer health outcomes and lower life expectancy in the developing nations.
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The, highly respected, OECD Observer, has noted that health of citizens and the success of the economy go hand-in-hand. In fact, they state that “health performance and economic performance are interlinked” and “wealthier countries have healthier populations.” Moreover, countries with poorer healthcare frameworks and support structures for their citizens struggle to achieve sustained growth. What wealthy and well-insured Americans must realize is that lack of access to care of the lower income groups is a problem for everyone. In this sense, the Affordable Care Act can be considered a step in the right direction.ACA in Texas.jpgsource:

There is already tremendous pressure on the US healthcare system as America ages. My alma mater has published a report on aging and cites concern about adequate healthcare and housing for the expected older population. There will be more non-workers needing support from the working population. Additional pressure is going to fall on Medicare and the intertwined healthcare and economic future of the United States could be unfavorable without prudent leadership.

The Affordable Care Act (ACA) has improved access to millions of Americans and the work is not complete yet – the ACA is a dynamic regulation and must evolve and change as needed. One basic example is that adult oral health was mandated to be offered but not mandated to be taken like medical insurance is. This can result in conflicting activity like treating diabetes without caring for periodontal disease even though one worsens the other and vice versa. It is critically that the new government does not eliminate the ACA but works to diligently improve it.

There is a major problem whenever someone in this nation cannot access healthcare; workers can’t got to work; children can’t go to school and teachers can’t teach. There is an exponentially negative impact on the entire United States and failing to consider the poorest citizens will have terrible consequences for the entire nation. When unskilled workers cannot access healthcare and miss days of work the efficiency of their employer is impacted. The new President of these United States must improve access to healthcare for all Americans, not worsen it!

Legislated Neglect of American Children?

The United States (US) government defines neglect of children as the failure of a parent or guardian to provide necessary food, clothing, shelter, medical care or supervision. Interestingly, the legal responsibility is to the individual and not to an institution or organization. Yet, by it’s own definition of neglect, the US government may have neglected many American children by hindering their right to oral healthcare services.


One of our recent studies found that 215,073 American children go to a hospital emergency room (ER) with a dental problem each year – is this reasonable? Medicaid was supposed to protect children and ensure equity in spite of their parents’ limited financial resources. Are we okay with the fact that the most vulnerable people, children, cannot find care in a regular setting and have to attend an ER for dental care – a place notoriously inefficient at managing dental problems? In fact, ER visits rarely meet the dental need of patients – 96% of patients going to the ER for a dental problem require a subsequent visit with a dentist.

Although Medicaid is supposed to protect our most vulnerable, the Affordable Care and Patient Protection Act (ACA) has stopped short of mandating dental insurance – it only mandates that dental insurance must be offered. However, the most vulnerable populations are also the least educated and have the lowest health literacy. These groups often choose not to take the dental coverage. Additionally, ACA has allowed the states to choose their own implementation plans and, for example, the state of Utah has chosen to exclude routine and emergency dental care – they only permit prevention. Ummmm, okay Utah.


Three-quarters of the children who attend an ER with a dental problem were from areas where mean household income was less than $49,000. Abraham Maslow (1943) was a psychologist who identified a hierarchy of needs. Maslow’s theory suggests that when the lower level needs are not met, individuals are not likely to consider higher level matters to be necessary. For example, if you’re worried about your safety because you live in an unsafe suburb, you are not likely to worry about seeking a dental examination for your child who is not complaining about any pain. Subsequently, the failure to mandate the coupling of medical insurance to dental insurance leaves the most vulnerable population at high risk of neglect and need for urgent oral health interventions.

The greatest irony in this study is that Medicaid failed to insure every child for routine and emergency dental care, yet it was the major payer when those patients presented to the ER. In the ER it fell under medical insurance (which is mandated). In it’s attempt to reduce expenditure, Medicaid limited dental coverage, however, Medicaid continued to cover those dental problems in the ER.

It’s not just about teeth!

Recently I attended a social event where I was asked why I reversed from 4 days a week of clinical practice and 1 day of academia to 4 days of academia and 1 day of clinical practice – a decision I made almost 10 years ago. I began to answer with “I reduced my days of practice because…” and a fellow guest completed my sentence for me – “…..because it’s just teeth! It must have got boring.”

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Dear Guest, it isn’t just about teeth and that isn’t why I moved into academia. It was a growing recognition of how complex and nationally important oral health is, and my interest to contribute to research and policy that would change the nation’s healthcare system for the better. Nobody seems to know the current research that is in conflict with the “just teeth” argument! Nobody seems to know that, when periodontal disease is uncontrolled, a stem cell transplant has hospital charges $85,991 more than when periodontal disease is controlled. Nobody seems to know that when gingival disease is treated, a patients’ annual diabetic costs reduce by $2,840; a patients’ stroke costs reduce $5,681; and a patients’ pregnancy complication costs reduce $2,433. Nobody seems to know that when periodontal disease is controlled, cardiac valve surgery is more successful and associated with hospital charges that are $26,000 less.2173-fort-belvoir-community-hospital-3909.jpg

In fact, nobody seems to know that about 1.4 million emergency room visits per year are due to common dental problems and incur hospital charges of about $1 billion. Moreover, about $1.2 billion of hospital charges are incurred when 51,000 of those 1.4 million get hospitalized with an average length of stay of 3.44 days – remember, they came to hospital with “just” a dental problem. And it should be recognized this does not include oral cancer or trauma – this is just caries, pulpal disease, periodontal disease or resultant cellulitis. If you’re interested to know, there is another 17,000 hospitalizations per year for oral cancer with hospital charges of over $1 billion. And, jaw fractures result in about 22,000 fracture reduction procedures in US hospitals with charges of another $1 billion.

It’s not “just” all of the above either – we have found that obesity increases hospital charges among those who were hospitalized for a dental condition. And the presence of mental health conditions increases hospital charges for those attending the hospital with a dental condition. To summarize, we have underestimated the impact of oral health on the human body and the healthcare system. Oral disease is increasing the hospital complications in non-oral surgeries, reducing their success rates and increasing length of stay. And it’s all attributable to the same problem as the dinner guest – we didn’t know any better.

Society has pigeon holed dentistry much to it’s own detriment. It’s difficult for society to think about oral health in terms other than “just teeth,” but, failing to evolve society’s understanding of the importance of oral health will worsen the health of our nation and the efficiency of our healthcare system.

To floss or not to floss…

The Associated Press (AP) was established in 1846. AP was the first to break the news of the attacks on Pearl Harbor on December 7, 1941. AP is a non profit collaborative that is co-owned by 1,400 newspapers across these United States. Through it’s collaborators, AP news items reach half of the world every day! That being said, AP has a critical responsibility to report the news accurately and without bias. Unfortunately, AP published an article questioning the value of flossing which could have significant negative effects. Numerous studies have shown that those with lower socioeconomic status (SES) suffer worse health. Moreover, research confirms that those with lower SES have the lowest health literacy. What this means is that the most vulnerable populations are most likely to read too much into the nonsense published by AP about flossing.Screen Shot 2016-08-05 at 2.31.50 PM.pngSource:

Basically, what AP is saying is not wrong – there is “weak evidence.” However, the article is written in a way that could be interpreted that there is existing, high quality research that shows the effectiveness of flossing is limited or weak. AP has chosen an alarming headline of “Medical benefits of dental floss unproven.” However, a more appropriate heading could be “Research into the benefits of flossing is not high quality.”floss-is-boss-300x246.jpgSource:

The weakness is not in the commonsense health activity of flossing…the weakness is in the research. Consider the challenges of studying flossing independent of other factors. Firstly, how do you isolate flossing from all other methods of plaque reduction -even chewing fibrous foods reduces plaque? Some individuals have continuously spaced teeth which allows toothbrush bristles to caress the in-between surfaces and do the job of flossing. Next, someone who doesn’t floss but has a non-cariogenic diet (low sugar, infrequent snacking) is at significantly less risk of decay. There is a multitude of variables that I won’t bother mentioning here. However, the point of this brief blog is simple – AP has been irresponsible in the pursuit of gaining readers – they have allowed misinterpretation to occur to the naïve. Unfortunately, they have paid no regard to the critical health effects their articles could lead to. As mentioned in a previous blog, over 300 people die in our hospitals every year due to a preventable dental complaint. In fact, 1.4 million people go to our emergency rooms with a basic dental problem every year in America. However, in the absence of plaque, decay cannot grow and periodontal disease cannot thrive. How do you remove plaque? Brushing and flossing. Keep on flossing, my friends.

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