MyView: Two-legged stool
January 21, 2019
By Robert Darling, D.D.S.
Robert Darling, D.D.S.
What better way is there to illustrate the institutional and cultural divide in American health care than with a government form? I was asked to complete a leave of absence form for a patient and was troubled that I had to choose a reason among one of three highlighted boxes — medical, mental health or dental. It seems that at least one bureaucrat found it necessary to build border walls delineating health care above the neck versus health care below the neck.
So, how many fascial planes does an infection of odontogenic origin have to cross before you can check the medical box instead of the dental box? Now suppose the large carious lesion which preceded that infection was exacerbated by the xerostomic effects of the psychotropic medications the patient needs to address a serious mental health problem. Do you then check the mental health box on the form? Remember, the form instructed you to check just one box.
The medical community, and to a certain extent the general public, are finally realizing what our dental profession has known for years — the oral environment is intimately connected to the rest of the body. Oral pathogens and inflammatory products of periodontal disease can hitch a ride to anywhere the circulatory system can take them. Conversely, the body's inability to regulate glucose levels or to muster necessary immune system defenses can wreak havoc on the oral tissues.
As a profession, we have learned to accept, and in many cases regularly treat, patients with a whole host of complex medical issues including transplanted organs, artificial parts, chronic diseases and cancer. We have learned to deal with increasingly longer life spans and the polypharmacy which often accompanies those individuals.
While efforts to integrate dental health and systemic health have improved, there are few conversations about the third component to overall well-being — mental health. The human mind is the one system which provides our greatest challenge. When it is not functioning well, it is hard for us to deal with it, especially because current means of providing and paying for health care in American is one of our biggest obstacles.
The majority of our special needs patients run the gamut from children with significant cognitive impairment or autism to seniors with dementia. Nearly all psychotropic medications have some impact on salivary production, and those dry mouth issues coupled with poor diet and inadequate home care lead to rampant decay. Individuals with addictions, and/or serious or untreated mental health issues make up a large segment of the homeless population, who, as a result, often have difficult access to dental care or even basic hygiene. In short, the patient populations which provides some of our great professional challenges is also the population which is least able to afford and ultimately maintain the care that we can provide.
There will never be real health care form in our nation until oral health and mental health are included in the discussion. The dental profession championed the importance of the oral and systemic connection. However, ignoring the mental health component in favor of just the systemic component as we strive to reform American health care is spending a lot of time and money on a two-legged stool.
This editorial, reprinted with permission, first appeared in the September/October 2018 issue of the Wisconsin Dental Association Journal, of which Dr. Darling is the editor.