The Separation of Medicine and Dentistry
October 11, 2017
“My teeth are killing me. I haven’t been able to sleep or eat in days. Isn’t there anything you can do?”
As a safety net dentist, I’m sadly accustomed to my patients telling me that they are in pain. Even in Massachusetts, where most patients are insured and Medicaid provides dental coverage, the vast majority of my patients must wait unconscionably long to finally get a dental appointment, and often have not had reliable access to dental care. Yet the patient telling me this story wasn’t at a dental office – he was at a primary care visit with my preceptor, speaking to me as a first-year medical student.
I chose to enter medical school because I was heartbroken by how the separation of medicine and dentistry harmed my patients. Throughout my medical training, I have only seen even more unaddressed dental need. I have met patients with endocarditis or pneumonia from untreated tooth infections, patients with malnutrition because they can no longer chew, and far too many patients with pain they simply cannot stop. This suffering falls disproportionately on the most vulnerable, including communities of color, older adults, low income people, people with a history of incarceration, people with mental illness or substance use disorder, and rural dwellers.
Like the patients I meet who do not have access to dental care, many patients seek care instead from PCPs or the emergency department, where dental problems make up more than 1% of all visits. Unfortunately, the vast majority of medical settings are unequipped to provide definitive care to patients such as tooth extraction or a root canal, and patients in pain usually leave with nothing but antibiotics, narcotics, and a directive to see a dentist. As we work to repair the rift between medical and dental care in the US – through integrated care programs, dental integration into medical insurance, and expanding the reach of dental practitioners, medical providers will remain on the front lines for this highly prevalent and completely preventable form of suffering.
In spite of this, the vast majority of health professionals are taught almost nothing about oral health. Worldwide, most pharmacy, nursing, and medical schools do not cover any oral health content. Most U.S. physicians receive less than 5 hours of oral health training during medical school, and residency training also may not prepare physicians to care for, or even examine patients’ mouths. This can lead to dire consequences such as delayed diagnosis of cancer; half of Medicare beneficiaries diagnosed with metastatic oral cancer see 11 or more physicians in the year prior to diagnosis. Although providing dental anesthesia and some other dental procedures fall within the scope of practice of medical providers, most patients who seek care in the medical setting for a dental problem receive no definitive treatment at all.
Of course, if patients were actually able to see a dentist, the burden on other health professionals would be significantly reduced. Yet fewer than 1% of dentists work in a hospital setting and only 2% work in community health centers. The majority of dentists work in a private practice and do not accept Medicaid. This may help explain why even when adults get access to dental coverage through Medicaid, their access to dental care may not improve. Dental and medical electronic health records are rarely interoperable – at the community health center where I completed residency, for example, I could read but not edit my patients’ medical records and medical providers could not see patients’ dental charts. It’s not surprising that most physicians are unsatisfied with their ability to refer to and communicate with dentists.
Clearly, this must change. A newly-adopted accreditation standard now requires all dental schools to incorporate interprofessional education curricula, which can prepare future dentists to communicate with other providers. Some dental schools and health centers are even piloting innovative models where dental students provide care alongside other health professionals such as nurse practitioners and medical and nursing students. Graduates of these experiences may be more likely to serve vulnerable patients and more comfortable working outside the traditional dental setting. Similarly, dental hygienists have begun to work in the primary care or hospital setting, providing valuable oral hygiene and counseling to patients seeking medical care.
Institutions that train other health professionals are also beginning to adopt oral health curricula. This can range from online curricula to hands-on practice to longer elective rotations. Dentists and dental schools can serve as valuable allies for curriculum development, and interprofessional experiences with dental trainees can increase learners’ confidence working in teams in addition to building dental skills for future medical providers. Some medical schools and residency programs are even creating dental rotations, providing hands-on training in dental anesthesia and even tooth extraction. The Physician Assistant field should serve as inspiration for other health professions; noting a need for oral health training after a 2008 survey, by 2014 more than 78% of Physician Assistant training programs offered some oral health content to students.
I think of my patient’s question – “Isn’t there anything you can do?” all the time. While I was able to examine him more thoroughly and help him find a dental clinic nearby, even as a dentist I was ultimately unable to fix his problem in the primary care office. Both medicine and dentistry must do better. Until dental pain is no longer a form of suffering relegated almost exclusively to the most vulnerable people in the country, institutions must consider it a critical piece of their social mission to equip current and future health professionals with the ability to address the inequality that is staring them in the face.
Dr. Lisa Simon is a Fellow in Oral Health and Medicine Integration at the Harvard School of Dental Medicine and a second year medical student at Harvard Medical School. Dr. Simon’s work focuses on improving access to care for vulnerable populations and integration of oral health and medicine. Her research addresses barriers to oral health faced by low-income individuals in urban and rural areas in the United States, and effective use of interprofessional education to heighten the oral health knowledge of primary care providers, and the role of dentists in medical teams.