BFA Blog – October 11, 2017

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?”

Lisa Simon, DMD

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 colorolder adultslow income peoplepeople 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 programsdental 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.


Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions

Academic dental institutions are the fundamental underpinning of the nation’s oral health. Education, research, and patient care are the cornerstones of academic dentistry that form the foundation upon which the dental profession rises to provide care to the public. The oral health status of Americans has improved dramatically over the past twenty-five to thirty years. In his 2000 report on oral health, the Surgeon General acknowledges the success of the dental profession in improving the oral health status of Americans over the past twenty-five years, but he also juxtaposes this success to profound and consequential disparities in the oral health of Americans. In 2002, the American Dental Education Association brought together an ADEA President’s Commission of national experts to explore the roles and responsibilities of academic dental institutions in improving the oral health status of all Americans. They have issued this report and made a variety of policy recommendations, including a Statement of Position, to the 2003 ADEA House of Delegates. The commission’s work will help guide ADEA in such areas as: identifying barriers to oral health care, providing guiding principles for academic dental institutions, anticipating workforce needs, and improving access through a diverse workforce and the types of oral health providers, including full utilization of allied dental professionals and collaborations with colleagues from medicine.

CitationHaden NK, Catalanotto FA, Alexander CJ, et al. Improving the oral health status of all Americans: roles and responsibilities of academic dental institutions: the report of the ADEA President’s Commission. J Dent Educ. 2003;67(5):563-83.

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Management of Experiences in Community-based Dental Education

The successful management of community-based service-learning relies on developing and maintaining community partnerships that meet both the educational mission of the dental school and the service mission of the community clinic. The partnership enhances the dental curriculum by introducing students to a wide variety of practice models, patient populations, and perspectives on health care delivery systems. The partnership enhances the service mission of the community sites by providing them with a university affiliation, a window into the state-of-the-art techniques that students bring with them from the dental school, and a pool of future graduates who may choose to practice in that clinic setting. This “win-win” scenario is not automatic, but rather relies on carefully matching, maintaining, and evaluating the service-learning partnerships. This article describes the development and implementation of the community-based service-learning curriculum in the College of Dentistry, University of Illinois at Chicago.

Citation: Evans CA, Bolden AJ, Hryhorczuk C, Noorullah K. Management of Experiences in Community-based Dental Education. J Dent Educ. 2010;74(10 Suppl):S25-32.

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