Financial costs of the U.S. obesity epidemic reach new heights

Sharon Begley, Reuters  Apr 30, 2012

NEW YORK – U.S. hospitals are ripping out wall-mounted toilets and replacing them with floor models to better support obese patients. The Federal Transit Administration wants buses to be tested for the impact of heavier riders on steering and braking. Cars are burning nearly a billion gallons of gasoline more a year than if passengers weighed what they did in 1960.

The nation’s rising rate of obesity has been well-chronicled. But businesses, governments and individuals are only now coming to grips with the costs of those extra pounds, many of which are even greater than believed only a few years ago: The additional medical spending due to obesity is double previous estimates and exceeds even those of smoking, a new study shows.

Many of those costs have dollar signs in front of them, such as the higher health insurance premiums everyone pays to cover those extra medical costs. Other changes, often cost-neutral, are coming to the built environment in the form of wider seats in public places from sports stadiums to bus stops.

The startling economic costs of obesity, often borne by the non-obese, could become the epidemic’s second-hand smoke. Only when scientists discovered that nonsmokers were developing lung cancer and other diseases from breathing smoke-filled air did policymakers get serious about fighting the habit, in particular by establishing nonsmoking zones. The costs that smoking added to Medicaid also spurred action. Now, as economists put a price tag on sky-high body mass indexes (BMIs), policymakers as well as the private sector are mobilizing to find solutions to the obesity epidemic.

“As committee chairmen, Cabinet secretaries, the head of Medicare and health officials see these really high costs, they are more interested in knowing, ‘what policy knob can I turn to stop this hemorrhage?’” said Michael O’Grady of the National Opinion Research Center, co-author of a new report for the Campaign to End Obesity, which brings together representatives from business, academia and the public health community to work with policymakers on the issue.

The U.S. health care reform law of 2010 allows employers to charge obese workers 30% to 50% more for health insurance if they decline to participate in a qualified wellness program. The law also includes carrots and celery sticks, so to speak, to persuade Medicare and Medicaid enrollees to see a primary care physician about losing weight, and funds community demonstration programs for weight loss.

Such measures do not sit well with all obese Americans. Advocacy groups formed to “end size discrimination” argue that it is possible to be healthy “at every size,” taking issue with the findings that obesity necessarily comes with added medical costs.

The reason for denominating the costs of obesity in dollars is not to stigmatize plus-size Americans even further. Rather, the goal is to allow public health officials as well as employers to break out their calculators and see whether programs to prevent or reverse obesity are worth it.

LOST PRODUCTIVITY

The percentage of Americans who are obese (with a BMI of 30 or higher) has tripled since 1960, to 34%, while the incidence of extreme or “morbid” obesity (BMI above 40) has risen sixfold, to 6%. The percentage of overweight Americans (BMI of 25 to 29.9) has held steady: It was 34% in 2008 and 32% in 1961. What seems to have happened is that for every healthy-weight person who “graduated” into overweight, an overweight person graduated into obesity.

Because obesity raises the risk of a host of medical conditions, from heart disease to chronic pain, the obese are absent from work more often than people of healthy weight. The most obese men take 5.9 more sick days a year; the most obese women, 9.4 days more. Obesity-related absenteeism costs employers as much as US$6.4-billion a year, health economists led by Eric Finkelstein of Duke University calculated.

Total annual cost of presenteeism due to obesity:

US$30-billion

Even when poor health doesn’t keep obese workers home, it can cut into productivity, as they grapple with pain or shortness of breath or other obstacles to working all-out. Such obesity-related “presenteeism,” said Finkelstein, is also expensive. The very obese lose one month of productive work per year, costing employers an average of US$3,792 per very obese male worker and US$3,037 per female. Total annual cost of presenteeism due to obesity: US$30-billion.

Decreased productivity can reduce wages, as employers penalize less productive workers. Obesity hits workers’ pocketbooks indirectly, too: Numerous studies have shown that the obese are less likely to be hired and promoted than their svelte peers are. Women in particular bear the brunt of that, earning about 11% less than women of healthy weight, health economist John Cawley of Cornell University found. At the average weekly U.S. wage of $669 in 2010, that’s a $76 weekly obesity tax.

MORE DOCTORS, MORE PILLS

The medical costs of obesity have long been the focus of health economists. A just-published analysis finds that it raises those costs more than thought.

Obese men rack up an additional US$1,152 a year in medical spending, especially for hospitalizations and prescription drugs, Cawley and Chad Meyerhoefer of Lehigh University reported in January in the Journal of Health Economics. Obese women account for an extra US$3,613 a year. Using data from 9,852 men (average BMI: 28) and 13,837 women (average BMI: 27) ages 20 to 64, among whom 28% were obese, the researchers found even higher costs among the uninsured: annual medical spending for an obese person was US$3,271 compared with US$512-for the non-obese.

Nationally, that comes to US$190-billion a year in additional medical spending as a result of obesity, calculated Cawley, or 20.6% of U.S. health care expenditures.

That is double recent estimates, reflecting more precise methodology. The new analysis corrected for people’s tendency to low-ball their weight, for instance, and compared obesity with non-obesity (healthy weight and overweight) rather than just to healthy weight. Because the merely overweight do not incur many additional medical costs, grouping the overweight with the obese underestimates the costs of obesity.

A hospital room in Birmingham, AL that has oversized chairs and strengthened mobile medical beds to accommodate the increasing size of overweight Americans.

     Marvin Gentry/Reuters

An oversized chair and an oversized hospital bed are pictured in the children's and women's maternity ward at the University of Alabama Hospital in Birmingham, Alabama.

Contrary to the media’s idealization of slimness, medical spending for men is about the same for BMIs of 26 to 35. For women, the uptick starts at a BMI of 25. In men more than women, high BMIs can reflect extra muscle as well as fat, so it is possible to be healthy even with an overweight BMI. “A man with a BMI of 28 might be very fit,” said Cawley. “Where healthcare costs really take off is in the morbidly obese.”

Those extra medical costs are partly born by the non-obese, in the form of higher taxes to support Medicaid and higher health insurance premiums. Obese women raise such “third party” expenditures US$3,220 a year each; obese men, US$967 a year, Cawley and Meyerhoefer found.

One recent surprise is the discovery that the costs of obesity exceed those of smoking. In a paper published in March, scientists at the Mayo Clinic toted up the exact medical costs of 30,529 Mayo employees, adult dependents, and retirees over several years.

“Smoking added about 20% a year to medical costs,” said Mayo’s James Naessens. “Obesity was similar, but morbid obesity increased those costs by 50% a year. There really is an economic justification for employers to offer programs to help the very obese lose weight.”

LIVING LARGE, BUT NOT DYING YOUNG

For years researchers suspected that the higher medical costs of obesity might be offset by the possibility that the obese would die young, and thus never rack up spending for nursing homes, Alzheimer’s care, and other pricey items.

“Growing obesity rates increase fuel consumption.”

That’s what happens to smokers. While they do incur higher medical costs than nonsmokers in any given year, their lifetime drain on public and private dollars is less because they die sooner. “Smokers die early enough that they save Social Security, private pensions, and Medicare” trillions of dollars, said Duke’s Finkelstein. “But mortality isn’t that much higher among the obese.”

Beta blockers for heart disease, diabetes drugs, and other treatments are keeping the obese alive longer, with the result that they incur astronomically high medical expenses in old age just like their slimmer peers.

Some costs of obesity reflect basic physics. It requires twice as much energy to move 250 pounds than 125 pounds. As a result, a vehicle burns more gasoline carrying heavier passengers than lighter ones.

“Growing obesity rates increase fuel consumption,” said engineer Sheldon Jacobson of the University of Illinois. How much? An additional 938 million gallons of gasoline each year due to overweight and obesity in the United States, or 0.8%, he calculated. That’s US$4-billion extra.

Not all the changes spurred by the prevalence of obesity come with a price tag. Train cars New Jersey Transit ordered from Bombardier have seats 2.2 inches wider than current cars, at 19.75 inches, said spokesman John Durso, giving everyone a more comfortable commute. (There will also be more seats per car because the new ones are double-deckers.)

The built environment generally is changing to accommodate larger Americans. New York’s commuter trains are considering new cars with seats able to hold 400 pounds. Blue Bird is widening the front doors on its school buses so wider kids can fit. And at both the new Yankee Stadium and Citi Field, home of the New York Mets, seats are wider than their predecessors by 1 to 2 inches.

The new performance testing proposed by transit officials for buses, assuming an average passenger weight of 175 instead of 150 pounds, arise from concerns that heavier passengers might pose a safety threat. If too much weight is behind the rear axle, a bus can lose steering. And every additional pound increases a moving vehicle’s momentum, requiring more force to stop and thereby putting greater demands on brakes. Manufacturers have told the FTA the proposal will require them to upgrade several components.

Hospitals, too, are adapting to larger patients. The University of Alabama at Birmingham’s hospital, the nation’s fourth largest, has widened doors, replaced wall-mounted toilets with floor models able to hold 250 pounds or more, and bought plus-size wheelchairs (twice the price of regulars) as well as mini-cranes to hoist obese patients out of bed.

The additional spending due to obesity doesn’t fall into a black hole, of course. It contributes to overall economic activity and thus to gross domestic product. But not all spending is created equal.

“Yes, a heart attack will generate economic activity, since the surgeon and hospital get paid, but not in a good way,” said Murray Ross, vice president of Kaiser Permanente’s Institute for Health Policy. “If we avoided that heart attack we could have put the money to better use, such as in education or investments in clean energy.”

The books on obesity remain open. The latest entry: An obese man is 64% less likely to be arrested for a crime than a healthy man. Researchers have yet to run the numbers on what that might save.

© Thomson Reuters 2012

Dental Visits Critical for Smokers

CDC report: More smokers avoid the dentist

Adult tobacco smokers are four times more likely to develop oral health problems but much less likely than nonsmokers to go to the dentist regularly, according to a report released February 7 by the U.S. Centers for Disease Control and Prevention (CDC).

The study, which included more than 16,000 adults between the ages of 18 and 64 who participated in the 2008 National Health Interview Survey, also found that although more than a third of smokers included in the report said they have three or more dental problems, 20% said they had not been to a dentist in at least five years. Among nonsmokers and former smokers, 10% had stayed away that long.

Cost was cited as the main reason that most adults with an oral health problem did not see a dentist in the past six months; 56% of current smokers, 36% of former smokers, and 35% of never smokers said they could not afford treatment or did not have insurance.

"Overall, current smokers had a poorer oral health status and more oral health problems than either former smokers or never smokers," the report authors noted. "However, current smokers were more likely to think that their oral health problem was important."

The evidence for an association between tobacco use and oral diseases has been clearly shown in every U.S. surgeon general's report on tobacco since 1964. Tobacco use is a risk factor for oral cancers, periodontal diseases, and dental caries, among other diseases.

reported by DrBicuspid.com, Feb 2012.

Dr. Notes:

Because cost is cited as a major factor for smokers and their reluctance to visit the dentist for regular check-ups, I thought I would present some facts.

The average cost for a pack of cigarettes in the state of Minnesota is $6.53.  That’s 33¢ per cigarette.  According to the American Lung Association, the average smoker inhales 3/4 pack, or 15 cigarettes, per day.  After doing the math you'd find that the annual cost for a smoker’s habit totals $1787 plus change.

Now consider this.  The average annual cost of routine dental care (includes 3 cleanings, exams and routine radiographs) would be around $275.  Again, if you crunch the numbers you would find that if the average smoker were to reduce cigarette consumption by 3 cigarettes per day, they could easily afford the out-of-pocket expense of routine dental care.  And these numbers don’t consider the inclusion of dental insurance, which 80% of smokers have, yet don’t utilize.

Our job as a dental office is to address and treat oral health.  We don't give lectures and we don't judge people based on their choices in life, especially their decision to smoke.  But we will provide guidance and advice for those who do.  Regular dental care is crucial for smokers if they wish to minimize the long term effects of their smoking habit.  Routine cleanings and exams can do a lot to help prevent a wide range of problems that smokers are predisposed to and help proactively identify the development of long-term complications that can result from oral tobacco use.

What Does Your Mouth Have to Say About Your Health?

Oral Health Can Provide Clues to Total Body Wellness for Patients

Cardiologists might not check your teeth and gums, but maybe they should start. Mounting evidence suggests a quick peek in the mouth may reveal a whole lot about your general health.

PICTURES: Foul mouth: what yucky signs say about your health

The lips, mouth, teeth and breath can signal medical problems and diseases beyond the plaque, gum disease and gingivitis diagnosed in the dentist's chair. Plaque buildup between teeth due to lax brushing and flossing is very different from plaque that builds up in arteries and causes heart attacks - but the toxins in mouth plaque stimulate a chronic inflammatory response linked to diseases like heart disease.

"The mouth is the gateway to the heart and there's clearly a link between poor dental health and cardiovascular conditions," says Dr. Kevin Marzo, Chief of Cardiology at Winthrop University Hospital in Mineola, New York. For example, he says, cardiac medications you put under your tongue travel quickly through the bloodstream. That means bacteria can too.

"The bacteria that cause dental plaque may promote inflammation in the body beyond the mouth including the lining of the blood vessels, increasing the risk for cardiovascular disease including heart attacks," says Marzo.

Research has shown when people with active gum disease are treated, their arteries actually get healthier. Some experts suggest managing inflammation in the mouth may reduce other inflammatory-related health issues, including arthritis - even wrinkles and aging. Besides heart disease, gum disease has been linked to respiratory diseases, stroke, and osteoporosis.

The mouth can also give doctors clues about a person's sexual health. Warts in the mouth that resemble cauliflower clusters may signal the human papillomavirus, or HPV, one of the most common sexually transmitted infections.

"I see them on the lips, tongue or roof of the mouth," says Dr. Susan Pugliese, Clinical Assistant Professor Division of Oral Medicine and Dentistry Department of Surgery at SUNY Downstate. "And I'm seeing them more frequently in patients over 50 who are dating." Pugliese says this age group may not connect what's going on in their mouth to their sex lives.

HPV is also a driver of oral cancer: the National Cancer Institute, estimates 65 percent of the approximately 8,000 cancers of the tonsils and base of the tongue seen in the U.S. in 2010 were from HPV infections; 80 per cent were in men. Cancers may appear as ulcers on the lips, inside of the cheeks, tongue or back of throat that don't heal, or white patches that don't slough off. A biopsy is typically recommended for suspicious warts or lesions in the mouth and throat.

HIV is often first detected in the mouth, as a bright red outline around the teeth, or as a white coating that can be scraped off the tongue, known as thrush. The coating signals an overgrowth of Candida, the same fungus that causes yeast infections in women and jock itch in men. The white coating can also signal glucose levels are out of whack, poorly managed diabetes or fluctuating hormones. It can also be harmless, signaling a sensitivity to additives in toothpaste, such as tartar control agents. Dentists may recommend an HIV test for young patients presenting with Candida who have other risk factors.

A person's breath also provides health clues. Bad breath may signal serious conditions that require medical attention such as respiratory infections, diabetes, acid reflux and kidney and liver problems. Dry mouth? That's sometimes caused by medications, such as antidepressants, anti-inflammatories, and heart drugs. Drinking water or chewing on fibrous foods such as celery may help.

Good oral hygiene is the best way to prevent gum disease and keep your mouth healthy. Healthy gums hug the teeth and don't pull away, have bounce, and don't bleed from brushing or flossing.

But while a clean, well-cared for mouth can promote good health, it can also disguise serious health problems... so don't skip regular visits to the doctor, and dentist.

Heart Disease - Are We to Blame?

World Renown Heart Surgeon Speaks Out On What Really Causes Heart Disease

PreventDisease.com

March 1, 2012

We physicians with all our training, knowledge and authority often acquire a rather large ego that tends to make it difficult to admit we are wrong. So, here it is. I freely admit to being wrong.. As a heart surgeon with 25 years experience, having performed over 5,000 open-heart surgeries,today is my day to right the wrong with medical and scientific fact.

I trained for many years with other prominent physicians labelled “opinion makers.” Bombarded with scientific literature, continually attending education seminars, we opinion makers insisted heart disease resulted from the simple fact of elevated blood cholesterol.

The only accepted therapy was prescribing medications to lower cholesterol and a diet that severely restricted fat intake. The latter of course we insisted would lower cholesterol and heart disease. Deviations from these recommendations were considered heresy and could quite possibly result in malpractice.

It Is Not Working!

These recommendations are no longer scientifically or morally defensible. The discovery a few years ago that inflammation in the artery wall is the real cause of heart disease is slowly leading to a paradigm shift in how heart disease and other chronic ailments will be treated.

The long-established dietary recommendations have created epidemics of obesity and diabetes, the consequences of which dwarf any historical plague in terms of mortality, human suffering and dire economic consequences.

Despite the fact that 25% of the population takes expensive statin medications and despite the fact we have reduced the fat content of our diets, more Americans will die this year of heart disease than ever before.

Statistics from the American Heart Association show that 75 million Americans currently suffer from heart disease, 20 million have diabetes and 57 million have pre-diabetes. These disorders are affecting younger and younger people in greater numbers every year.

Simply stated, without inflammation being present in the body, there is no way that cholesterol would accumulate in the wall of the blood vessel and cause heart disease and strokes. Without inflammation, cholesterol would move freely throughout the body as nature intended. It is inflammation that causes cholesterol to become trapped.

Inflammation is not complicated -- it is quite simply your body's natural defence to a foreign invader such as a bacteria, toxin or virus. The cycle of inflammation is perfect in how it protects your body from these bacterial and viral invaders. However, if we chronically expose the body to injury by toxins or foods the human body was never designed to process,a condition occurs called chronic inflammation. Chronic inflammation is just as harmful as acute inflammation is beneficial.

What thoughtful person would willfully expose himself repeatedly to foods or other substances that are known to cause injury to the body? Well,smokers perhaps, but at least they made that choice willfully.

The rest of us have simply followed the recommended mainstream dietthat is low in fat and high in polyunsaturated fats and carbohydrates, not knowing we were causing repeated injury to our blood vessels. This repeated injury creates chronic inflammation leading to heart disease, stroke, diabetes and obesity.

Let me repeat that: The injury and inflammation in our blood vessels is caused by the low fat diet recommended for years by mainstream medicine.

What are the biggest culprits of chronic inflammation? Quite simply, they are the overload of simple, highly processed carbohydrates (sugar, flour and all the products made from them) and the excess consumption of omega-6 vegetable oils like soybean, corn and sunflower that are found in many processed foods.

Take a moment to visualize rubbing a stiff brush repeatedly over soft skin until it becomes quite red and nearly bleeding. you kept this up several times a day, every day for five years. If you could tolerate this painful brushing, you would have a bleeding, swollen infected area that became worse with each repeated injury. This is a good way to visualize the inflammatory process that could be going on in your body right now.

Regardless of where the inflammatory process occurs, externally or internally, it is the same. I have peered inside thousands upon thousands of arteries. A diseased artery looks as if someone took a brush and scrubbed repeatedly against its wall. Several times a day, every day, the foods we eat create small injuries compounding into more injuries, causing the body to respond continuously and appropriately with inflammation.

While we savor the tantalizing taste of a sweet roll, our bodies respond alarmingly as if a foreign invader arrived declaring war. Foods loaded with sugars and simple carbohydrates, or processed withomega-6 oils for long shelf life have been the mainstay of the American diet for six decades. These foods have been slowly poisoning everyone.

How does eating a simple sweet roll create a cascade of inflammation to make you sick?

Imagine spilling syrup on your keyboard and you have a visual of what occurs inside the cell. When we consume simple carbohydrates such as sugar, blood sugar rises rapidly. In response, your pancreas secretes insulin whose primary purpose is to drive sugar into each cell where it is stored for energy. If the cell is full and does not need glucose, it is rejected to avoid extra sugar gumming up the works.

When your full cells reject the extra glucose, blood sugar rises producing more insulin and the glucose converts to stored fat.

What does all this have to do with inflammation? Blood sugar is controlled in a very narrow range. Extra sugar molecules attach to a variety of proteins that in turn injure the blood vessel wall. This repeated injury to the blood vessel wall sets off inflammation. When you spike your blood sugar level several times a day, every day, it is exactly like taking sandpaper to the inside of your delicate blood vessels.

While you may not be able to see it, rest assured it is there. I saw it in over 5,000 surgical patients spanning 25 years who all shared one common denominator -- inflammation in their arteries.

Let’s get back to the sweet roll. That innocent looking goody not only contains sugars, it is baked in one of many omega-6 oils such as soybean. Chips and fries are soaked in soybean oil; processed foods are manufactured with omega-6 oils for longer shelf life. While omega-6’s are essential -they are part of every cell membrane controlling what goes in and out of the cell -- they must be in the correct balance with omega-3’s.

If the balance shifts by consuming excessive omega-6, the cell membrane produces chemicals called cytokines that directly cause inflammation.

Today’s mainstream American diet has produced an extreme imbalance of these two fats. The ratio of imbalance ranges from 15:1 to as high as 30:1 in favor of omega-6. That’s a tremendous amount of cytokines causing inflammation. In today’s food environment, a 3:1 ratio would be optimal and healthy.

To make matters worse, the excess weight you are carrying from eating these foods creates overloaded fat cells that pour out large quantities of pro-inflammatory chemicals that add to the injury caused by having high blood sugar. The process that began with a sweet roll turns into a vicious cycle over time that creates heart disease, high blood pressure, diabetes and finally, Alzheimer’s disease, as the inflammatory process continues unabated.

There is no escaping the fact that the more we consume prepared and processed foods, the more we trip the inflammation switch little by little each day. The human body cannot process, nor was it designed to consume, foods packed with sugars and soaked in omega-6 oils.

There is but one answer to quieting inflammation, and that is returning to foods closer to their natural state. To build muscle, eat more protein. Choose carbohydrates that are very complex such as colorful fruits and vegetables. Cut down on or eliminate inflammation- causing omega-6 fats like corn and soybean oil and the processed foods that are made from them.

One tablespoon of corn oil contains 7,280 mg of omega-6; soybean contains 6,940 mg. Instead, use olive oil or butter from grass-fed beef.

Animal fats contain less than 20% omega-6 and are much less likely to cause inflammation than the supposedly healthy oils labelled polyunsaturated. Forget the “science” that has been drummed into your head for decades. The science that saturated fat alone causes heart disease is non-existent. The science that saturated fat raises blood cholesterol is also very weak. Since we now know that cholesterol is not the cause of heart disease, the concern about saturated fat is even more absurd today.

The cholesterol theory led to the no-fat, low-fat recommendations that in turn created the very foods now causing an epidemic of inflammation. Mainstream medicine made a terrible mistake when it advised people to avoid saturated fat in favor of foods high in omega-6 fats. We now have an epidemic of arterial inflammation leading to heart disease and other silent killers.

What you can do is choose whole foods your grandmother served and not those your mom turned to as grocery store aisles filled with manufactured foods. By eliminating inflammatory foods and adding essential nutrients from fresh unprocessed food, you will reverse years of damage in your arteries and throughout your body from consuming the typical American diet.

Dr. Dwight Lundell is the past Chief of Staff and Chief of Surgery at Banner Heart Hospital , Mesa , AZ. His private practice, Cardiac Care Center was in Mesa, AZ. Recently Dr. Lundell left surgery to focus on the nutritional treatment of heart disease. He is the founder of Healthy Humans Foundation that promotes human health with a focus on helping large corporations promote wellness. He is also the author of The Cure for Heart Disease and The Great Cholesterol Lie.

It's Not Just About Teeth!

What your dental hygienist knows could save your life

The eyes may be the windows to the soul but the mouth is a gateway to the rest of the body. We once believed that the worst outcome of poor dental hygiene was tooth loss, but research clearly links oral health to overall health, so far more is at stake. The earliest signs of a number of serious health issues are reflected in the teeth, gums and tongue, often long before a diagnosis is made.

There are millions of bacteria in the mouth and ignoring oral health routines can lead to inflammation causing these bacteria to grow and spread at alarming rates and to find their way into the bloodstream. Unchecked plaque on your teeth can result in gingivitis, periodontal disease and tooth decay. Research suggests that periodontal disease is a risk factor contributing to serious life-threatening illnesses such as lung and heart disease, stroke and diabetes.

Dental hygienists have the skills, knowledge and judgement to facilitate early detection of these issues. At a dental visit your hygienist will assess your health history, examine your head and neck and check your mouth. Together you will develop an oral hygiene care plan that includes prevention and treatment therapies to ensure the best overall health possible. If necessary, your dental hygienist may refer you to other healthcare professionals. You can't afford to wait. Periodontal disease can be prevented and controlled, thereby decreasing your chances of other serious illnesses.

If Your Teeth Could Talk...

The Mouth Offers Clues to Disorders and Disease;

Dentists Could Play Larger Role in Patient Care

The eyes may be the window to the soul, but the mouth provides an even better view of the body as a whole.

Some of the earliest signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalances and drug issues show up in the gums, teeth and tongue—sometimes long before a patient knows anything is wrong.

There's also growing evidence that oral health problems, particularly gum disease, can harm a patient's general health as well, raising the risk of diabetes, heart disease, stroke, pneumonia and pregnancy complications.

"We have lots of data showing a direct correlation between inflammation in the mouth and inflammation in the body," says Anthony Iacopino, director of the International Centre for Oral-Systemic Health, which opened at the University of Manitoba Faculty of Dentistry in Canada in 2008. Recent studies also show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes.

Such findings are fueling a push for dentists to play a greater role in patients' overall health. Some 20 million Americans—including 6% of children and 9% of adults—saw a dentist but not a doctor in 2008, according to a study in the American Journal of Public Health this month.

"It's an opportunity to tell a patient, 'You know, I'm concerned. I think you really need to see a primary care provider,' so you are moving in the direction of better health," says the study's lead researcher Shiela Strauss, co-director of statistics and data management for New York University's Colleges of Nursing and Dentistry.

George Kivowitz, a restorative dentist with offices in Manhattan and Newtown, Pa., says he has spotted seven cases of cancer in 32 years of practice, as well as cases of bulimia, due to the telltale erosion of enamel on the back of the upper front teeth, and methamphetamine addiction. "We call it 'meth mouth,' " he says. "The outer surface of teeth just rot in a way that's like nothing else."

Some of the most distinctive problems come from uncontrolled diabetes, Dr. Kivowitz adds. "The gum tissue has a glistening, shiny look where it meets the teeth. It bleeds easily and pulls away from the bone—and it's all throughout the mouth."

An estimated six million Americans have diabetes but don't know it—and several studies suggest that dentists could help alert them. A 2009 study from New York University found that 93% of people who have periodontal disease are at risk for diabetes, according to the criteria established by American Diabetes Association.

It's not just that the same lifestyle habits contribute to both gum disease and high blood sugar; the two conditions exacerbate each other, experts say. Inflammation from infected gums makes it more difficult for people with diabetes to control their blood-sugar level, and high blood sugar accelerates tooth decay and gum disease, creating more inflammation.

Dr. Marcus notes that about 50% of periodontal disease is genetic—and even young patients can have significant bone loss if they have an unusually high immune response to a small number of bacteria. Giving such patients a low dose of doxycycline daily can help modify the immune response. "It doesn't really control the bacteria, but it helps reduce the body's reaction," he says.Diabetes also complicates dental-implant surgery, because it interferes with blood vessel formation and bone growth. "When you put a dental implant in, you rely on the healing process to cement it to the jaw, so you get a higher failure rate with diabetes," says Ed Marcus, a periodontist in Yardley, Pa., who teaches at the University of Pennsylvania and Temple University dental schools.

There's also growing evidence that the link between periodontal disease and cardiovascular problems isn't a coincidence either. Inflammation in the gums raises C-reactive protein, thought to be a culprit in heart disease.

"They've found oral bacteria in the plaques that block arteries. It's moved from a casual relationship to a risk factor," says Mark Wolff, chairman of the Department of Cariology and Comprehensive Care at NYU College of Dentistry.

Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere, which is why people contemplating elective surgery are advised to have any needed dental work performed first.

The American Heart Association no longer recommends that people with mitral valve prolapse (in which heart values close abnormally between beats) routinely take antibiotics before dental procedures, since it's now believed that oral bacteria enter the bloodstream all the time, from routine washing, brushing and chewing food.

But the American Heart Association, the American Medical Association and the American Orthopedic Association all urge people who have had a full joint replacement to take an antibiotic one hour before any dental visit for the rest of their lives to reduce the risk of post-surgical infections. "I have my guidelines taped to the door in my hygienists' room," Dr. Kivowitz says.

Dentists say they also need to stay up to date with all medications, supplements and over-the-counter drugs their patients are taking. Blood thinners can create excess bleeding in the mouth. Bisphosphonates, often prescribed for osteoporosis, can severely weaken jaw bones. Both should be stopped temporarily before oral surgery.

Antihypertensive drugs, calcium-channel blockers and some anti-inflammatory drugs can cause painful ulcerations of the gums. Many medications, from antidepressants to chemotherapy drugs, cause dry mouth, which can cause cavities to skyrocket, since saliva typically acts as a protective coating for teeth. Additional fluoride treatments can help.

Some proactive dentists have glucose monitors for another check on blood-sugar levels if they suspect diabetes. Some also take patients' blood pressure and hold off on invasive procedures if it's extremely high.

The Centers for Disease Control and Prevention recommends that dentists offer HIV testing, because some of the first symptoms appear in the mouth, including fungal infections and lesions. Dentists can do the HIV test with a simple mouth swab and get results in 20 minutes.

Breaking the bad news is often more difficult. "I went into oral surgery because I didn't think I would have to deliver that kind of news to patients," says Clifford Salm, an oral and maxillofacial surgeon in Manhattan who has found leukemia, lymphoma, AIDS and metastatic breast cancer after performing biopsies on suspicious spots. "It can be a difficult conversation," he says, "but most patients are very grateful."

Don't Be Fooled by White, Shiny Teeth
A gleaming, white smile is a sign of a healthy mouth, right? Not necessarily.  "Whiteness and the health of your teeth are totally unrelated," says Mark Wolff, an associate dean at New York University College of Dentistry.

In fact, many dentists worry that people who whiten their teeth may have a false sense of complacency, since their teeth can still be harboring tooth decay and serious gum disease.

Even people who have no cavities can still have inflamed and infected gums. It could be that their saliva is particularly protective of their tooth enamel, while their brushing and flossing habits, needed to keep gum tissues healthy, could be lax.

"I get these patients in their mid-30s who don't have cavities, so they haven't been to a dentist in 10 years. But they have full-blown periodontal disease," says George Kivowitz, a restorative dentist in Manhattan. "They are losing all the supporting structure, and I have to tell them that these gorgeous teeth will fall out of your head if we don't turn this around."

Using whitening products more often than recommended can erode some of the enamel and cause teeth to appear translucent. But whether that actually harms teeth is controversial. "No one has really shown that it's damaging, but no one knows the long-term results," says Dr. Marcus, the periodontist in Yardley, Pa.