Dentist gives oral cancer screening. (U.S. Air Force/Airman 1st Class Jalene Brooks)

Tech. Sgt. Justin Wolf, 11th Medical Group dentist, conducts an oral cancer screening for a veteran at the at a health fair for Retiree Appreciation day on Joint Base Andrews Md., Oct. 27, 2018. The Retiree Appreciation Day event provided veterans easy access to military health care screenings and immunizations as well as individualized assistance with military finance, records, and benefits questions.

An Army veteran who asked to remain unnamed was deployed several times to Iraq and Afghanistan, and after he took off his uniform for the final time, began suffering from post-traumatic stress disorder (PTSD), anxiety, and depression. 

Wrecked from guilt about both actions and inactions in combat, he was left without a will to live. He quit taking care of himself, stopped showering, stopped brushing his teeth, and binged on junk food. What was the point, after all? 

After years of this, he was obese, and his mouth was deteriorating. His teeth became so painful that he couldn’t eat normally, couldn’t sleep, couldn’t even think straight. Finally, he reached out to the VA for help, but they told him they couldn’t cover his dental care – he would need to come out of pocket to fix his oral health. It would cost him thousands of dollars he didn’t have. He continued to spiral downwards, what was the point, after all?

Veterans diagnosed with post-traumatic stress disorder (PTSD) and other mental health ailments are still without a 100% guarantee of oral coverage, which includes dental care, through the Department of Veterans Affairs (VA).

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Oral and mental health ailments have been well-researched, correlated, and understood within American healthcare for decades, yet  85% of the approximately 9 million American veterans do not have dental or oral health coverage through the VA. 

Quan Nguyen, a Marine Corps veteran with deployments to Iraq and Afghanistan, is another one of those veterans. He’s been diagnosed with PTSD and has dealt with the destructive effects on his teeth and the rest of his well-being. But the VA ruled he would have no service-connected dental or oral health coverage. 

“The [VA] eventually did tell me that I wasn’t covered,” Nguyen said. “But I mean, it wasn’t simple. It was just all the paperwork, all the appointments they make you do, and it’s not all at once — I wish it were.”

Several VA specialists saw him as he underwent a process of never-ending appointments. He’s since turned to private healthcare, spending thousands to address the various issues he believes to be connected to PTSD, like degraded enamel of the teeth, migraines, and other problems.

Nguyen is one of over 1.3 million veterans who are diagnosed with PTSD. When asked how many of those veterans have oral health coverage, Kunich said the VA does not track that data. 

VA PTSD and oral care coverage

Many veterans blame the VA for a lack of resources and their decisions on service-connected and covered conditions. However, the VA is bound by legislation regarding what can and cannot be service-connected. Congress establishes and maintains the legislation that governs the VA and how conditions and diseases are service-connected. 

Under the existing statute specific to PTSD [Title 38 United States Code (U.S.C.) §§ 1712 and Title 38 Code of Federal Regulations (CFR) §§ 17.161-166], there is nothing that directs the VA to automatically service connect dental and oral health problems for veterans diagnosed with service-connected mental health ailments like PTSD, anxiety, and depression. 

“The VA is limited to providing dental benefits to those veterans who meet certain eligibility criteria and is obligated to fulfill the requirements of statutes enacted by Congress and to follow their intent. […],” said VA spokesperson Gary Kunich. 

Kunich explained that eligibility for comprehensive dental benefits is generally “based upon a disability rating of 100% by service connection or individual unemployability, dental disability rating or service-connected dental injury related to trauma.” He encouraged all veterans to check with their local VA medical center to know their dental and oral health benefits. 

Annaliese Cothron, co-founder & executive director for The American Institute of Dental Public Health (AIDPH), has long advocated for veterans and how they should have oral health coverage. She said that most veterans who have oral health coverage are typically rated at 100%, and few veterans are service-connected for dental or otherwise oral health problems unless it’s related to physical trauma to the face. 

“By and large, those who have coverage usually have a 100% disability rating from an unrelated cause to their oral or mental health,” Cothron said. “Very few veterans are actually being rated or given a disability rating in the dental and oral cranial facial space unless it’s direct trauma.”

Private oral healthcare is expensive, and only some veterans can afford it. Not being able to afford the care can lead to degraded oral health, such as rotten teeth, headaches, and other issues, which may compound mental health symptoms veterans suffer from. 

The VA has previously opposed legislation, citing underfunded staff and resources. However, Cothron says enacting legislation for the highest-cost veterans, based on their level of care, would be a financially savvy decision for the VA. According to AIDPH and CareQuest Institute for Oral Health, addressing veterans most at risk, like those with heart disease and diabetes, could save the VA up to $3.4 billion. 

“The cost savings are on their medical care,” Cothron said. “So, if you’re having poor oral health, or periodontal issues, if those are corrected and supported, you’re going to have improvements in your heart disease and diabetes conditions. The mouth doesn’t just happen in a silo. All of these things are interconnected.”

How are oral care and mental health connected?

The average layperson doesn’t generally understand how the mouth affects the body’s overall health and well-being. But just as toxic exposures have led to ailments like leaky gut syndrome and non-traumatic brain injuries, oral health can gravely affect the body when neglected. 

“There are considerations, like biochemically, within the body that we like to talk about, called the oral systemic connection. […]. It’s just how your body all flows together,” Cothron said. “Sometimes in the oral health space, we like to talk about the need to put the mouth back in the body because oftentimes this is highly under-considered because our healthcare system is so fragmented.”

Primary care is separate from dental care, which is separate from specialty fields in healthcare like cardiology or endocrinology. Then, mental health problems are often misunderstood on how much of a systemic effect they have, though that doesn’t just apply to veterans. 

“It’s just a thing that happens to everybody and also happens to veterans as a byproduct of having disproportionately higher rates of anxiety in a particular population,” Cothron said.  “Again, as a result of military service.”

PTSD, anxiety, and depression are some of the common mental health diagnoses found within the veteran community. Side effects of these mental health conditions can lead to grinding your teeth, which is called bruxism. If untreated, the grinding action will lead to deterioration of the outer enamel of the veteran’s teeth. 

Cothron explained how depression can lead to bad oral health problems. When someone is stricken with heavy depression, they have a hard time getting out of bed, let alone brushing and flossing their teeth. They will struggle to eat, leaving their mouth undernourished and vulnerable. 

“It’s pretty insidious because poor mental health and mental health issues can affect so many parts of your life,” Cothron said. “Oral health is often a byproduct of having these unmedicated mental health issues that we see commonly see with veterans.”

What may surprise some is the effects that are secondary to PTSD, all the way down to the cellular level. 

“When your body experiences a disproportionate amount of trauma, which will cause PTSD, your body circulates and produces more inflammation than it normally would because you’re producing more stress hormones,” Cothron said. “That often creates things like periodontal disease, and it can also exacerbate chronic disease conditions, too — like heart disease and diabetes.”

When inflammation goes unchecked within the body, it creates a vicious cycle that exacerbates existing chronic diseases and wreaks havoc on the body.  

The solution

As many veterans have done, take things into your own hands if the VA denies you oral health coverage. Yes, it’s expensive, but the medical bills that follow unchecked oral health problems will likely be more expensive. 

“At some point, you got to ask yourself, and this is an individual question that I can’t answer for anybody else, but what are you willing to do to be better? Some of us will do anything, and then, on the other end of the spectrum, there are people who are just stubborn as hell. […],” Nguyen said. “They won’t want to do anything, but at the same time, they’re always complaining, and they want some kind of magic bullet or solution that is not too difficult for them.”

Nguyen believes that people who are that stubborn like to blame it on their military service but were likely that way long before they joined. Cothron said it’s a simple thing for people to do: go see your dentist, and don’t try to go down too many rabbit holes online with unqualified opinions. 

“I know that there are some things that are easy to find on the internet to kind of access good information and good science, but for every good piece of information, sometimes there are five bad pieces of misinformation available right beside it,” Cothron said. “So, going to the sources is the easiest place to wade through some of that information.”

The AIDPH has conducted several research studies, including veteran surveys. Of the 85% of veterans who are not eligible, the remaining 15% are but don’t use their oral health benefits. 

“42% of veterans said that they didn’t know if they were eligible for dental care, versus the 85% that knew they qualify for medical care. So, because the process is complicated for dental care, the eligibility isn’t super clear. That’s the first thing that we have to do: if you are eligible, utilize that benefit. Get your dental care. You deserve it, you’re entitled to it, and it’s good for you.” 

Cothron agrees that the VA is underfunded and understaffed, limiting its ability to get more veterans in for their oral health needs, let alone all of their healthcare needs. Cothron said a major help would be Congress fully funding the VA and its regularly increasing costs for the millions of veterans under its care. 

The VA’s eligibility standards for oral health have not been updated in seven years, and new research has been published over that period, showing that the standards are outdated and no longer accurate. 

“We also know that this is not quote unquote, the VA that’s doing this. The providers don’t set the guidelines, it’s Congress,” Cothron said. “Congress not only has to fund it fully, but they also have to change the eligibility standards.”

Cothron said other alternative approaches can be used until Congress fully funds the VA. Extending the coverage to the highest-risk veterans, like those with heart disease, diabetes, and PTSD, is what Cothron believes is the best first step for the VA without the proper funding. 

“So while we’re strongly in the position of supporting all veterans in the VA to have dental care coverage, we believe that the place to start is extending out dental coverage to the highest cost, highest risk veterans so that the VA can really start to absorb those cost savings over time,” Cothron said. 

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