MyView: Does dentistry have a role in health care?
November 19, 2018
Craig S. Miller, D.D.S.
The ADA News (“Who Calls the Shots?,” April 1, 2013
) reported that the Illinois Dental Society suggested that dentists offer flu shots, reasoning that this would increase availability of the vaccine and the percentage of the public being immunized. The Illinois Medical Association promptly objected, stating that such a procedure was outside the scope of dental practice. However, when pharmacies began offering in-store flu vaccination in 2009, even though retail pharmacists have historically never administered, much less injected, drugs to patients without specific orders from licensed prescribers such as physicians and dentists, there was no discernible pushback, comment or even question about it. Interestingly, this expansion of pharmacy practice did not occur because of any evolution of pharmacy training and education. It occurred, according to health care writer Bruce Japsen, because Walgreens and CVS lobbied state by state to modify practice acts to take advantage of a $6 billion dollar per-year market. (“How Flu Shots Became Big Sales Booster For Walgreens, CVS.” Forbes, Feb. 8, 2013).
Nelson L. Rhodus, D.D.S.
What does that say about the perception by the medical profession as to the role of dentistry in the provision of health care? How are dentists perceived by the public? According to Mary Jordan, writing in The Washington Post (“Unlikely Lobbying Force — Dentists,” July 5, 2017), dentists are seen by the public as quaint figures, with “a Norman Rockwell appeal … who clean your teeth, tell your kids to cut down on the candy and put their seal of approval on a range of minty toothpastes and mouthwashes.” While a very silly piece of writing, it nonetheless points out that what comes most immediately to the public mind when thinking about dentists is not scholarship or higher learning.
Why does this matter? It matters because there are patients who develop problems, sometimes extremely serious problems, which can require the inclusion of dentists on the health care team for complete and proper care of medical conditions and currently it is rare for dentists to be called in. The following list includes some examples of medical situations where dentists should be routinely involved.
John C. Robinson, D.D.S.
1. Patients who are to receive radiation therapy for head and neck cancer. Mismanagement of the teeth before or after radiation can lead to medical complications, including osteoradionecrosis. All of these patients should be seen by a dentist knowledgeable about the specific issues and protocols prior to initiation of radiation, and for ongoing care. While such referrals are more and more common, there are still cases where patients are receiving head and neck radiation without dental input, and they are put at risk for otherwise potentially preventable complications.
2. Patients who are to receive anti-resorptive therapies such as bisphosphonate medications also should be seen by a dentist prior to the initiation of therapy to minimize the risk of events that may trigger osteonecrosis. However, such consultations have not become common practice.
3. Patients who will receive surgical procedures such as joint or heart valve prostheses, and subsequent recommendations for antibiotic prophylaxis, should be preoperatively referred to a dentist for screening for existing dental infection and counseling as to minimizing daily bacteremias that occur when periodontal disease is present.
4. Patients with oral mucocutaneous lesions or diseases. These are medical conditions which affect the oral cavity and perioral regions. Dentists receive by far the most training in oral diseases, while physicians receive very little and often misdiagnose oral conditions. In addition, physicians are often not comfortable performing procedures such as biopsies in the mouth. Dentists, particularly oral medicine providers, are the most qualified to diagnose and manage oral diseases.
5. Patients with orofacial pain without clear diagnosis or when dental etiology is considered in the differential diagnosis. Patients often take these problems to physicians, who have no way of evaluating for dental causes of head and neck pain, and may pursue a neurologic or sinus-related diagnosis, when in fact the problem is dental. Conversely, dentists may approach such symptoms as dental or temporomandibular disorder-related without considering medical causes in differential diagnosis. These cases often require medical-dental collaboration for optimal management.
6. Patients with sepsis or distant infection with unknown or suspected oral source.
7. Hospitalized patients who develop urgent oral or dental problems. This can be a problem because many hospitals do not have dentists on staff. Also, it can be extremely difficult for dentists to receive reimbursement for such care.
Referrals for these examples tend to be infrequent. While there are exceptions involving individual doctors and institutions, in general the medical and dental professions tend to exist in parallel, with very little cross referral or consultation. One major medical health maintenance organization in northern California recently instituted a policy whereby requests from dentists for medical information about patients are now to be routed to the medical records department. This was done because instead of requests for information about patients’ diagnoses, status, medical management and other information that might guide dental management, the physicians were receiving requests simply for “medical clearance,” which they began to feel created medico-legal risk, especially since they had very little knowledge about the planned dental procedures. Such is the state of interprofessional communication and collaboration.
Furthermore, much of the public and the medical profession see dentists as dealing only with problems related to teeth, and has very little understanding of the scope and breadth of dental education and training. Dentistry has largely done this to itself by associating itself almost exclusively with teeth and cosmetics. In presenting itself to the public, rarely do issues of health or disease factor in. Attempting to make dentistry more attractive and less fearsome, many dentists use cute logos, advertisements and fictitious business names which do nothing to create an impression of education or seriousness. Dentists are portrayed in television commercials as addressing such horrors as thinning enamel, root sensitivity and poor denture seal.
We live in a time when health care has become highly specialized. There is a medical specialty for virtually every organ system — except the oral cavity. That organ system is the proper domain of dentistry, and dentistry aggressively needs to claim it as such. No profession is better trained or more qualified to diagnose and manage the disorders of the oral cavity, even beyond the teeth, and the public and the medical profession need to be brought to understand that. While not all dentists are interested or qualified to provide this type of care, those that are, in particular those trained in oral medicine, hospital dentistry and special care dentistry, need to be able to hold themselves out so that they can be identified and accessed.
Clearly the image of dentistry needs to evolve and grow. The public and the medical profession need to be made aware of the broader scope of dental education and training. Dentists need to hold themselves out in a manner that reflects scholarship and education and to integrate science and the highest quality evidence available into their practices. Medical plans need to understand the role of dentistry in care of certain medical conditions and reimburse appropriately. Medical HMOs in particular, which typically exclude dentists from their panels, need to recognize the need for inclusion of dentists in management of selected conditions and provide for appropriate contracting or outside referral authorizations. There are many such obstacles to address and overcome, but it is important that we do so as a profession.
Dentistry needs to improve its standing and stature within this domain; patients need us to be part of the health care system.
Dr. Miller is the professor and chief of the division of oral diagnosis, oral medicine and oral radiology in the department of oral health practice at the University of Kentucky College of Dentistry. Dr. Rhodus is the Morse Distinguished Professor and director of the division of oral medicine in the school of dentistry at the University of Minnesota. Dr. Robinson is an associate clinical professor of oral medicine at the University of California, San Francisco School of Dentistry.