Medicine and Dentistry: Undoing an Illogical 150-Year Divide

By | November 20, 2018

It’s no secret that medicine and dentistry have evolved an unnatural professional separation that is helpful to no one and often causes unnecessary suffering on the part of patients. But we’re in a moment—driven by our greater understanding of the links between medical and dental outcomes—where we can further integrate the two fields to better meet the needs of patients.

History

Historically speaking, how medicine and dentistry came to be so siloed is somewhat puzzling. The Greek scholar Hippocrates, known as the “Father of Medicine,” didn’t hesitate to write extensively about dentistry. In his scrolls, he focused on subjects like tooth decay and gum disease, which he saw as being as elemental to medicine as lung disease, fractures and wounds. And during the renaissance and enlightenment periods, physicians like Pierre Fauchard, John Hunter, Francis Imlach and others all approached dentistry with a blend of biology, physiology and, of course, medicine.

Medicine and dentistry have co-existed for 150-years. It’s time to bring them further together.Getty

I’m no historian of science, but from what I can tell, the division between the practices was cemented — at least here in the United States — when medical schools began to be founded in the 18th and 19th centuries. Those schools somewhat unnaturally excluded dentistry—despite the fact that some physicians practiced both medicine and dentistry. Today we have 152 accredited US medical schools and66 schools of dentistry in the United States. Many of them are literally right across the street from one another. But aside from water mains, most schools share very little, and there has been almost no attempt to integrate either their respective curriculums or the work their graduates go on to do. Not surprisingly, dentists went on to found their own schools and identity, which evolved in isolation from those of their medical counterparts.

The Tight Connection Between Medical and Dental Health

The folly of this divide becomes evident when we contemplate the now widely recognized links between oral health and medical health. Put simply, the mouth is often a wide-open window into what is happening in the rest of the body—and sometimes a source of risk as well.

For example, throughout my medical training, my instructors often singularly stressed the relationship between dental health and endocarditis, an infection of the inner linings of the heart chambers and valves. This condition generally occurs when bacteria, fungi or other germs spread through the bloodstream and attach to damaged areas of the heart. In many instances, these bacteria come from tooth plaque and enter the bloodstream through bleeding gums. Dentists who see patients who are at high risk for the disease generally provide them with antibiotics before performing any procedures.  Yet the connection between medicine and dentistry stretches far beyond just endocarditis.

Today, healthcare professionals know more than ever about avariety of links between oral health and other health conditions. Some examples: gum infections (periodontitis) have been linked to premature birth and low birth weight; diabetes reduces the body’s resistance to infection, which can lead to severe gum disease; painful mucosal lesions of the mouth, again caused by impaired immunity, are common in people who have HIV/AIDS; and certain medications that cause dry mouth —  decongestants, antihistamines, and antidepressants, for example — can reduce saliva flow, causing an increase in bacterial acidity inside the mouth, which often leads to tooth decay.

And yet, even as the scientific relationships between these ailments are becoming better defined, dentists and physicians are playing ping pong with their patients. Diabetes is considered the exclusive domain of physicians. Gum infections require a visit to the dentist. Sadly, this attitude leads dentists and physicians to ignore any problems they simply deem beyond their respective domains—or leave it in the hands of the patient to follow-up. As a result, these ailments often go undiagnosed and untreated.

Moreover, for a variety of reasons — cost, convenience, access to transportation, among others — many patients with dentalproblems only see medical doctors. In other cases, patients with medical problems only see dentists. Philosophically, I believe that every single interaction point with the healthcare system is an opportunity to address the totality of a patient’s health needs.

Integrating Dental and Medical Care

In my organization, we view every dental visit as a medical visit and every medical visit as a dental visit. In one clinic in California, we have begun to embed dentists and hygienists into our clinical teams. When a diabetic patient visits the dentist, a nurse checks her hemoglobin A1C and adjust medicines if necessary. If a dental patient needs a flu shot, we administer it on the spot. If she is due for a routine screening like a mammogram, we schedule it while she’s in the chair. Likewise, we’ve implemented trainings for all of our medical staff to better understand how to do a basic oral examination and identify dental illnesses. Our annual physicals now examine the state of each patient’s dental health. Our desk staff also helps patients understand their dental benefits and refers patients to high-quality dentists in their communities.

From this experience, we’ve come to the conclusion that the deeper integration of medicine and dentistry is possible, but it also requires that we adopt the following imperatives:

  1. A new mindset. My experience integrating these practice areas revealed a gap in mindset around what the respective responsibilities are of physicians and dentists. That has to change. A dentist who acts when she sees a patient who presents symptoms of diabetes could make the difference between an early diagnosis and, years later, death on dialysis. Likewise, a physician who acts when he sees a patient with symptoms of tooth decay could make the difference between that patient keeping her own teeth well into her golden years or having to face a litany of costly and uncomfortable invasive dental surgeries.
  2. New clinical practice models. I believe that, in the future, physicians and dentists will practice side-by-side, working collaboratively off of common protocols. Perhaps the practice of the future will also include physical therapists, dieticians, pharmacists, optometrists and podiatrists — as we all begin not just to practice alongside each other, but to practice withone another.
  3. New payment models. The folks who design Medicare and Medicaid will have to think differently about how we pay for medicine and dentistry. I imagine a future in which dental professionals will be paid to provide medical care in the form of chronic disease management and preventative services; and in which medical professionals will be paid for basic oral health examinations. Mechanisms like full delegation of risk and bundled payments create a vehicle in which medicine and dentistry could be paid for together.
  4. Improved information systems. One of the real barriers we have to better dental and medical integration is that we have completely different systems of record keeping, with no exchange of health information and, culturally, no expectation that dental records will be shared with physicians or that medical records will be shared with dentists. We need robust, secure systems in which records can be unified and exchanged easily across practices so that physicians, dentists, and patients can collaborate and engage with one other.
  5. Improved outcomes measurement. The science of outcomes measurement is evolving and physicians and dentists need to work within common measurement systems in which we have shared accountability for all health outcomes. The science of outcomes measurement is early in both fields—and creating a common such outcomes measurement will be a big lift.  

Each one of these five imperatives is difficult by itself, and the totality might seem impossible. But taken together they present both an immense opportunity to greatly improve patient outcomes.  The ultimate solution will rely in further unifying the education of physicians and dentists; some schools like the Harvard Medical and Dental Schools combine the first two years of the four year MD and DMD programs.  This approach to integrating education is a clear step in the right direction.  Medical doctors and dental doctors should not live in their own siloes anymore For the benefit of our patients, we all need to make a deep commitment to bringing these fields inextricably back together—which is where they belong. 

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