As the nation slowly emerges from lockdown, we're beginning to appreciate the full impact of the pandemic and that the sickness and death directly caused by the virus are only part of the picture.
The three-month-plus suspension of routine, non-emergency medical care has created secondary, silent epidemics of untreated medical issues that require the urgent focus of both our public health officials and the public themselves. They include domestic violence and likely increases in undiagnosed cancers.
One largely ignored but significant threat to individuals' health is the delay in routine dental care. We're talking more than cavities and cracked teeth: Oral diseases can contribute to, and often reflect, serious health problems elsewhere in the body.
Most chronic dental conditions follow a characteristic trajectory: an irritating (but easily ignored)problem that progresses to varying degrees of pain and discomfort. Ordinarily, dentists can detect and arrest these problems at an early stage — but then, the COVID-19 pandemic swept in.
On March 16, the Centers for Disease Control and Prevention advised dentists to suspend all routine examinations and limit treatment only to emergencies. While the measure was necessary to limit exposure and conserve personal protective equipment, myriad oral health conditions have now gone undiagnosed or untreated for more than two months. The resulting dental procedures will be more extensive, the outcomes worse and more expensive, and the backlog will not disappear immediately.
Patients' overall health will likely suffer too. Many chronic medical conditions are evidenced in the mouth and first discovered in routine visits to the dentist. These include periodontitis, the bacteria-caused inflammation in the gums that can result in bleeding when the gum tissue is ruptured. This, in turn, provides a gateway for the bacteria to contaminate the bloodstream, potentially leading to abscesses, heart valve infections, and in the worst case, sepsis — a life-threatening immune response to infection that can damage multiple organ systems.
Periodontitis and diabetes are also closely associated, each magnifying the severity of the other. Controlling gum disease can help improve blood glucose levels in diabetic patients, while high blood sugar levels worsen outcomes for periodontal disease. In well-controlled diabetics, the risk for periodontitis is not significantly increased, but it rises exponentially as blood sugar increases. Increased blood sugar, meanwhile, results in poor wound healing, which then increases the likelihood of oral infections.
Pregnancy makes periodontal disease especially worrisome due to the possible migration of bacteria and inflammation-related chemicals through the mother's bloodstream to the uterus.
Similarly, a condition called "pregnancy gingivitis" afflicts 50% to 70% of pregnant women. Increased pregnancy-related hormone levels cause blood vessels in the gums to become more permeable, allowing bacteria in the mouth to move to other parts of the body. Studies have shown an association between periodontitis and premature births, preeclampsia, and gestational diabetes. This is why, until the lockdown, dental examinations were a routine part of medical care for mothers of the roughly 10,000 babies born in the United States every day.
Then, there are atherosclerosis and cardiovascular disease, which account for nearly a quarter of all deaths in the U.S. These result when a build-up of inflammatory plaques obstruct blood vessels, disrupting the supply of oxygen to the body and causing life-threatening events such as heart attacks and strokes.
Although no direct connection between gum disease and cardiovascular disease has been identified, people with gum diseases appear to have two to three times higher likelihood of having a heart attack or other cardiovascular event.
Ongoing research is investigating the relationship and assessing whether gum disease is an independent risk factor for heart disease. The going hypothesis is that bacteria from periodontitis can gain access to the body's circulatory system and penetrate the endothelial cells that line the inside of the blood vessels. One study found that around 40% of atherosclerotic lesions contained remnants of periodontal pathogens that normally are found only in the mouth.
The lack of routine dental exams during the pandemic can lead to a variety of other medical problems. Oral cancers, for example, are often detected during routine dental exams. Immunocompromised patients often have oral infections that are apparent to the dentist before the patient is aware of any abnormality. HIV/AIDS may present with non-healing ulcers or a black coating on the tongue. And with bulimia, the frequent vomiting exposes the teeth to stomach acid that erodes the enamel of the backs of the teeth.
Dentists are often the first to detect medical problems that require diagnostic testing and treatment. But in the absence of routine dental exams and cleaning during the pandemic, many oral conditions will be missed and treatment delayed.
It's one more way the coronavirus threatens our health.
Henry I. Miller, a physician and molecular biologist, is a senior fellow in healthcare at the Pacific Research Institute. Dr. Shiv Sharma is a practicing dentist in Palo Alto, California.