Lack of oral care can lead to life-threatening situationsSep. 29, 2016, 9:07 AM
Following trips to two different hospital emergency rooms, 24-year-old Geoffrey Slayden was raced by ambulance to Vanderbilt University Medical Center (VUMC) for surgery and a week of hospitalization, including several days in intensive care on a ventilator and feeding tube. The culprit: abscessed teeth.
After treating an increasing number of patients with life-threatening infections that all began as abscessed teeth — one of whom died as a result — Sam McKenna, DDS, M.D., head of the Department of Oral & Maxillofacial Surgery at Vanderbilt, has an important message for both the public and medical providers: Take oral health very seriously.
“There has been a definite escalation in the number of people we’re seeing who just don’t have access to necessary oral care services,” McKenna said. “They’re ending up here with some really horrible infections. The most extreme examples of this problem are two recent cases of necrotizing fasciitis, a condition associated with, at best, disfigurement and, at worst, death.
“Over the past 10 years we have seen a fourfold increase in the number of patients requiring surgical drainage of face and neck infections caused by tooth abscess. We saw on average nearly two cases per week in 2015-2016.”
Vanderbilt is often the safety net for these patients and receives referrals from local and regional hospitals. VUMC has the providers and support services to efficiently manage these patients, who frequently require prompt surgical intervention for infection after they arrive here, said McKenna. The Department of Oral & Maxillofacial Surgery is often called for serious oral health cases that come into the emergency department, and the Medical Center’s umbrella of oral care includes General Dentistry. Because of this, any issue that comes through the door can be treated, McKenna said.
“We shouldn’t be the place of last resort, but I think we often are for these patients,” he said. “The lack of access to affordable dental care has become a significant public health issue.”
According to an analysis by The Pew Charitable Trusts this year, more than one-third of Americans face serious challenges in accessing dental care, including lack of insurance, prohibitive cost, too few providers and mobility and transportation problems. Although the Affordable Care Act requires state Medicaid programs and private insurers to include dental care for children, the federal health law does little to expand dental coverage for adults. Further, Medicare provides no benefits for general dental care and few benefits for necessary oral surgical care.
The increasing erosion of private and public dental insurance, increasing costs and decreasing numbers of dentists who accept public coverage are all factors fueling the decrease in use of dental care by adults (ages 19-64), regardless of income level and insurance status, according to a 2013 publication by the American Dental Association’s Health Policy Institute. In 2011, only 36 percent of working-age adults saw a dentist, and more than one-quarter had untreated tooth decay.
For the elderly the statistics are worse; in a recent survey released by the Centers for Disease Control and Prevention’s National Center for Health Statistics, about one in five adults age 65 and over had untreated tooth decay.
Meanwhile, the incidence of working-age adults seeking dental care in emergency rooms has risen over the past decade. According to the American Dental Association, U.S. emergency rooms have seen a dramatic increase in patients seeking treatment for dental pain, from 1.1 million in 2000 to 2.1 million in 2010. The majority of these patients have preventable tooth decay.
Slayden, who said he hadn’t been to a dentist in four or five years because of a lack of insurance and money, was released from Vanderbilt with eight latex drains in his face and neck to continue to remove fluids from the infection site. He also had a peripherally inserted central catheter (PICC line) to deliver intravenous antibiotics at home. After follow-up exams and weeks of additional oral antibiotics, McKenna delivered the news that the best solution for his remaining bad teeth is to remove them all. Slayden said he’s fine with that. He’s just thankful to be alive, back at work, and looking forward to future plans to start a business in Colorado.
“I didn’t realize how near death I was, and, looking back, I wish I would’ve acted sooner,” he said. “I would tell other people to get a checkup right when you think something might be wrong. I did call around to find something affordable, even without insurance, but I was too late.”
McKenna hopes to better educate the public about the warning signs of serious dental issues: neck swelling and pain; difficulty or pain with swallowing; or a restricted oral opening. He has also provided Vanderbilt emergency room personnel information on additional resources for dental care.
For example, the Interfaith Dental Clinic in Nashville and Murfreesboro (www.interfaithdentalclinic.com), provides services for low-income, uninsured working individuals. The Middle Tennessee Oral Health Coalition (www.tnoralhealth.org) also provides information on low-cost dental clinics statewide on their website.
But it’s not enough to educate patients about the importance of daily dental care and regular visits to a dentist, McKenna said. Providers at community hospital emergency rooms and general practitioners need to be better educated, too, he said. He’s expanding outreach events to connect with these individuals. His biggest message: Often a simple computed tomography (CT) scan can diagnose an oral infection that has progressed beyond the reach of basic dental care.
Slayton didn’t receive a CT scan until he went to the second hospital, and by then he had taken an entire 200-count bottle of ibuprofen in a week for his nonstop pain and a large knot had formed in his lower jaw.
“I would like to help all emergency rooms know about this problem so that when they see people come in with certain red flags for infection, they consider CT imaging or prompt referral,” said McKenna. “A handful of Amoxicillin will rarely halt the progress of these infections. All that does is delay the definitive treatment of a very serious issue by two or three days. Once these infections get going, they can blossom quickly into a really bad problem.”