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Washington dental society uses ADA roadmap to build medical-dental collaboration

June 03, 2019

By David Burger

Dr. Ronald H. Hsu leads training
Reaching out: Dr. Ronald H. Hsu leads training in April 2018 with Battle Ground Public School nurses at their Lewisville Campus in Washington state.

Vancouver, Wash. — Pediatric dentist Dr. Ronald H. Hsu has a personal experience that explains his passion for emphasizing medical-dental collaborations in his community.

About a decade ago, he encountered a young girl who was on blood thinners and needed a decayed baby tooth extracted. He scheduled an appointment and extracted the tooth a few days later, he said. The morning after, the parents called, saying that the bleeding from the extraction didn’t seem to be stopping.

Upon examination, Dr. Hsu confirmed that she was still bleeding and asked her parents if the international normalized ratio (INR) they reported at the first appointment was correct. Doctors measure a patient's international normalized ratio level regularly to measure how well a person’s blood clots if the patient is on anticoagulants.

“They insisted that it was because they had received the ratio just before the initial dental exam,” said Dr. Hsu, the immediate past president of the Clark County Dental Society in southwestern Washington state. “But then suddenly their eyes got big and told me that recently her physicians increased the dosage of her medications after the lab results got back, and they didn't know how the INR may have changed. If the physician for this little girl and I had been in constant contact, them knowing that she will need a bad tooth taken out and I knowing that her INR was below the therapeutic threshold, we could have worked together and been better prepared to manage this post-extraction bleeding incident.”

Dr. Hsu, Dr. Keith Collins, the current dental society president, and other dentists in the Clark County Dental Society have embarked on a mission to build bridges with the local medical community to serve their patients better.

“We know how interconnected oral conditions are to the rest of the body and how oral diseases can have devastating consequences, adversely affect the treatment efficacy and outcome for many chronic diseases,” Dr. Hsu said. “We need to work together.”

ADA guidance

Using the ADA’s document 10 Steps to Medical-Dental Collaboration as a roadmap, the dental society has made inroads in facilitating communication and connections with local physicians.

“Medical-dental collaborations apply our rapidly evolving knowledge to benefit patients,” said Dr. Collins, who invited physicians from different disciplines to speak at society meetings over the past year in a series he called Putting the Mouth Back in the Body. “We need to collaborate with other health care providers to share insights about ongoing developments about significance of recognizing, treating and preventing dental disease. Patients already get the concept that oral health is essential for health in general. Patients wonder how dental health became separated from medicine.”

Besides inviting physicians to speak at dental society meetings (and returning the favor), dentists like Dr. Hsu reached out to other members of the medical community. “He came up with the idea to give dental emergency kits to schools, and our board approved a grant to fund the kits,” Dr. Collins said. “Dr. Hsu went on to educate school nurses that serve 71,000 children in our community.”

Dr. Hsu revealed his motivation, saying that when dental trauma occurs, timely intervention is the absolute key to the chance of success, especially in avulsion cases, he said. “It is not uncommon that by the time patients arrive at my office, the critical window of time for success would be near closing, or the situation was already hopeless because the first aid rendered at the time of injury was the wrong thing to do. As I contemplated on how the kids can get more timely first aid, and having the correct aid given, I thought of school nurses.

“It's at least a place to start.”

Dr. Hsu gave credit to fellow dental society members for buying into the concept of building bridges between physicians and dentists. “Dr. Dave Carsten, a past CCDS president, is a dentist anesthesiologist. He is working with our medical colleagues all the time and has tried very hard to help both sides understand the importance of communicating with each other. Dr. Collins was already on the advisory board for a prominent local medical group and has diligently worked to facilitate communication between dentistry and medicine.”

Dr. Collins has helped create a formal speakers bureau for the society and said his next lecture will be in front of a political action committee with about 300 members, with the goal of spurring legislation for mutual benefit.

Within the last year, Dr. Carsten, who is on the faculty of the nearby Oregon Health & Science University, has begun what is an offshoot of a study club he was a mentor of for a half-decade. Called the Tilikum Crossing Seminar Series — named after a Portland bridge — the series features physicians and dentists speaking to other health care professionals, including dental students, with a unifying theme of “people coming together,” Dr. Carsten said.

“In health care, we are so siloed,” Dr. Carsten said. “We need to talk to one another. By doing so, we’re going to have better outcomes for patients. Connecting dentistry and medicine should not even be a discussion because it is one body. It is a false disconnect. That being said, we need to have an integrated medical history, continuing competence, common language, shared education, common goals, common protocols and avenues of clear communication.”

Drs. Justin Hollar, Kristin Nordahl, Dave Carsten, Ronald Hsu., Keith Collins and Dr. Beckerman
Togetherness: Leadership of the Clark County Dental Society gather to thank cardiologist James Beckerman, M.D., for speaking at their meeting. From left, Drs. Justin Hollar, past president; Kristin Nordahl, vice president; Dave Carsten, past president; Ronald Hsu. Immediate past president; Keith Collins, president; and Dr. Beckerman.

Collaboration need ‘dire’

James Beckerman, M.D., a local cardiologist, was the featured speaker at a Clark County Dental Society meeting this year, and said it was “really awesome what this team is doing, trying to change the conversation and broadening their education.” He said he believes some of the partition of dental and medical professionals stems from graduate schools, where many, if not most, of the dental and medical schools are separate entities that never spend time with one another.

Dr. Beckerman said he had just returned from a dental cleaning and was pleased that some of the pre-screening questions were related to overall health, not just dental health. He praised dentists who conduct blood pressure screens and sharing that information with providers and specialists like himself.

Dr. Stacey Condren, a local endocrinologist, spoke to the dental society at its February meeting. Dr. Collins said, “She agreed to lecture for us, then expressed concern as the date neared that she didn't know much about dentistry, commenting that ‘the dentists should be teaching the physicians some things.’ I assured Dr. Condren that we did not expect her to be an expert about oral health, and that we were ready to answer any of her questions before and during her lecture. Dr. Condren's lecture was wonderful.  She opened with a comment that she asked other endocrinologists in a private social network what she should do when invited to lecture to local dentists, and their reply was ‘Don't,’ apparently due to concern for gaps in knowledge.”

Dr. Condren said she enjoyed great interest from her audience. “The intersection between dental health and medical conditions seems obvious, but is still underappreciated,” she said. “There are so many areas of overlap, and yet the medical and dental communities rarely communicate with each other in order to facilitate patient care. As an endocrinologist, I see many patients with diabetes. I make sure to check at every visit that patients are up to date with their eye exams, that their cholesterol has been checked, et cetera. I only recently started asking if they are up to date with their dental care or have any oral issues.”

Dr. Hsu said that one thing they discovered is that by showing interest in what the physicians are doing, they would, in turn, show interest in what the dental community is doing.

After Dr. Collins invited Dr. Condren to speak, he was invited to speak to a group of endocrinologists to talk about periodontal disease and how that affects diabetes. “They were very excited to hear from Dr. Collins and we believe this will lead to more collaborations and communications,” Dr. Hsu said.

The need for collaboration is dire at this point at time, Dr. Hsu said, with advancement in knowledge in all fields of medical and dental sciences. “Every year we discover more complexities in the various fields of medicine, and more ailments are being identified, studied, treated and managed. It is impossible for any of us to know enough to understand the potential conflicts and contraindications between all of the conditions and the treatments of those conditions. Second, with the advancements I just mentioned, our patients are becoming more complex, many with multiple conditions and undergoing multiple treatments. More pharmaceuticals are being brought to the market, and the patients are taking more prescriptions. It is not uncommon for dentists in all disciplines to have patients who have 10, sometimes 20 or more different drugs that they must take weekly or even daily. Without close collaboration, we may inadvertently do harm to our patients.”

Dr. Hsu had a piece of advice to other dentists and dental societies looking to establish a beneficial medical-dental collaboration in their communities. “Be patient and have a plan,” he said. “From initial concept to actual execution there were months of planning and communication back and forth, setting up the various meetings. Things don't happen right away, and just because the physicians didn't get back to you it doesn't mean they are not interested. Everybody is busy, and some gentle persistence is needed to push things through. Don't give up. The rewards far outweigh the effort.”

The ADA document 10 Steps to Medical-Dental Collaboration is located at