As the nation emerges in fits and starts from the lockdowns spurred by the first wave of COVID-19 illnesses, we're beginning to appreciate the full impact of the pandemic, how tenacious it is, 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 societal and medical problems that require the urgent focus of both our public health officials and the public themselves. In a survey by the Kaiser Family Foundation, 48% of adults responded that they or someone in their household either rescheduled or decided to entirely forego medical appointments during the previous three months because of COVID-19. Notably, 11% of adults overall said their own or a family member's condition actually worsened as a result of postponing or skipping medical care due to the pandemic.
The effects were sometimes lethal. According to an analysis of federal data by the Washington Post, in New York City and five states hit hard by coronavirus infections, there were 8,300 more deaths from heart disease than would have been typical in March, April and May — an increase of roughly 27 percent over historical averages. Deaths from diabetes and Alzheimer's disease also were up.
There's more misery to come. Writing in the journal Science, National Cancer Institute Director Ned Sharpless expressed concern about marked declines in U.S. cancer diagnoses since the onset of the pandemic, attributing them to an estimated 75 to 90 percent decrease in mammograms and colonoscopies over the past few months. Clarifying that "there is no reason to believe the actual incidence of cancer has dropped," he offered what he termed a "conservative" estimate of more than an additional 10,000 deaths from breast and colorectal cancers over the next 10 years due to coronavirus-caused postponements in diagnosis and care.
Another significant threat to individuals' health is the delay in routine, but essential, prophylactic dental care. 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 as well. Many chronic medical conditions are reflected by findings in the mouth and first discovered in routine visits to the dentist. Some of these are discussed below.
Like the skin, stomach, and intestines, the mouth harbors large numbers and kinds of bacteria, which normally exist in a symbiotic relationship with the rest of the body. These bacteria are found in the pockets between the teeth and gums. If not cleaned by specialized tools, they feast on carbohydrate-rich food and multiply, causing inflammation in the gums and bleeding when the gum tissue is ruptured — a condition known as periodontitis. 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. Higher levels of blood sugar results in poor wound healing which, in turn, increases the likelihood of oral infections.
Pregnancy makes periodontal disease especially worrisome due to the possible migration of bacteria and inflammation-related chemicals though the mother's bloodstream to the uterus.
Similarly, a condition called "pregnancy gingivitis" afflicts 50-70 percent of pregnant women. Increased pregnancy-related hormone levels cause blood vessels in the gums to become more permeable, allowing bacteria in the mouth 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 lockdowns, dental examinations were a routine part of medical care for mothers of the roughly 10,000 babies born in the United States every day.
According to the Centers for Disease Control and Prevention, atherosclerosis and cardiovascular disease account for nearly a quarter of all deaths in the United States, due to a build-up of inflammatory plaques that obstruct blood vessels. This disrupts the supply of oxygen to the body and can cause 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 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.
In addition to those discussed above, other findings during oral examinations may suggest a variety of medical problems:
- Oral cancers are often detected during routine dental exams
- Immunocompromised patients often have oral infections which 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
- Bulimia — the frequent vomiting exposes the teeth to stomach acid that erodes the enamel of the backs of the teeth
Because dentists are often the first to detect a medical problem that requires diagnostic testing and treatment, in the absence of routine dental exams and cleaning during the pandemic, many oral conditions will be missed and treatment delayed.
This pandemic has real teeth; chalk up another way it threatens our health.
Dr. Shiv Sharma, a California dentist, owns Palo Alto Oral Health in California. Henry I. Miller, a physician and molecular biologist, is a Senior Fellow in Healthcare at the Pacific Research Institute. He was the founding director of the Office of Biotechnology at the FDA. Please follow him on Twitter at @henryimiller