Oral Health as a Model

One last big-picture, foundational post, then I'm going to try to initiate some dialogue on some of the finer points of the Health Care Bill (as I understand it).

In oral health, the majority of disease boils down to caries (the disease of cavities) and periodontal disease. The outcome of caries could be as minor as a need for sealants or a filling. Or the extent of disease in a given tooth could require a crown or a root canal. Or it can result in an infection (accompanied by tooth pain - excruciating, from what I hear), requiring extraction as the worst case scenario. Actually, an even worse case-scenario of dental infection would be the case of Deamonte Driver, who suffered a brain infection and died. Less dramatic outcomes of extraction could involve bridges or implants or partial dentures or complete dentures. So you see, a lot of the dental profession deals with the outcome of caries. The potential outcomes of periodontal disease are gingivitis, gingival recession, bone loss, gum infections, tooth mobility, tooth loss.... These are almost certain, unless managed with proper brushing and flossing and routine visits to the dentist/hygienist or periodontist (gum disease specialist).

Both diseases - caries and periodontal disease - are actually infectious diseases. When we are young, our mouths are colonized with different strains of bacteria, usually transmitted by mother or other primary caregiver. Some of these bacteria are more effective at causing decay. Some are more effective at causing gum disease. I'm more familiar with the problem of dental caries, being a specialist in pediatric dentistry, so I'll spend more time writing about that.

The way we get cavities is that these strains of bacteria that cause cavities basically consume the sugar we eat. Then they produce acid, which breaks down the mineral in our tooth, resulting over time in a cavity. There are certain things that promote cavity formation - eating lots of sugar and not brushing or flossing away the sugar or the bacteria that are rapidly multiplying because they get lots of sugar. There are certain things that prevent cavity formation - not eating lots of sugar and brushing and flossing.... you get the idea. Now granted, there are some preventive factors that are completely out of our control, like immune response, quantity and quality of saliva...

Here's what I'm trying to get at. It's something one of my colleagues calls the "biobehavioral" model for oral health. There is certainly an aspect of oral health that is completely out of our control. It's just the biology we're dealt. But there's another aspect of health that is dependent on behavior - adding in healthy behaviors and avoiding unhealthy behaviors. So in pediatric dentistry, we counsel parents to decrease on-demand bottle or breast-feeding by the time a child is 12-18 months. We advise parents not to let children go to sleep with a bottle. We recommend avoiding juices and sodas until the child is of school age (and certainly not in the bottle). Not easy, huh? How about brushing a kid's teeth two times a day and/or flossing for them until they're able to do it themselves. These things to avoid and things to add have been shown to be associated with a reduced rate of dental caries.

But what if a parent of a child determined to be at high-risk for dental caries decides to ignore our advice? Is it the insurance company's responsibility? Is it the dentist's fault? We've seen it happen in our clinics. Families who bring child after child in to treat dental disease that is so severe that the kids have to be put to sleep in order to take care of all the cavities. We remind them of the behaviors that promote cavities and right after the dental procedure...here's your Big Gulp, baby...and two years later...here's our next kid, doc. Obviously, that doesn't happen all the time. There are certainly families who work with us to prevent disease, but still...

Overall health is like this also. There are some diseases we just can't prevent. But there are diseases that are worsened or even activated by our own choices. Diabetes and poor diet control. High blood pressure and diet control. Pulmonary diseases and smoking. Cervical cancer or STDs from early sexual activity or multiple partners. HIV...

One of my big-picture problems with the Health Care Bill was that the underlying philosophy seemed to remove responsibility from the individual and place it with government or employer. So if someone else is paying for treatment, why do the hard work to change unhealthy behaviors? If someone else makes global treatment decisions, why do the hard work of thinking through treatment options?

The problem is that we DO have a great deal of control over our health. So I feel we should also have a great deal of control over the means by which health care is compensated.

Your thoughts?