Fluoride and a physical: Patients see docs at the dentist

A man walked into Harvard’s dental clinic for a root canal — and left with a warning about high blood pressure that may have saved his life.

That dramatic intervention took place last spring, leading to the discovery of early kidney disease, according to Dr. Bruce Donoff, dean of the Harvard School of Dental Medicine. It’s the kind of story the school aims to replicate as it launches two initiatives this year that will bring primary care into the dentist’s office.

The new programs add to an explosion of initiatives across the country aimed at ending the longstanding divide between how we treat the mouth and the rest of the body. At the same time, there is an increasing scientific evidence for how oral health is tied to wider wellness, from infections caused by mouth microbes to oral complications of diabetes.  

Harvard’s initiatives aim to address what might be a counterintuitive observation: Though the popular conception is that people avoid the dental office out of dread, there are actually many people who see a dentist more than any other health professional. An estimated 19.5 million Americans skipped the doctor’s office and saw only a dentist in 2008, according to a study published in the American Journal of Public Health. Dutiful patients may visit a dentist twice a year, giving a dentist the chance to keep tabs on how they are managing chronic diseases — or catch diseases that have gone undiagnosed.

Yet most dentists aren’t doing that. They aren’t trained to pay attention to the whole body. And the reverse is true, too, Donoff said. In a general physical exam, a physician typically checks out the head, eyes, ears, nose, and throat — but ignores the teeth and gums.

In response, Harvard is reimagining how it trains dental students, aiming to break down what Donoff calls an “artificial and harmful separation” between oral and general health.

In September, the dental school launched a primary care clinic at Harvard’s bustling teaching practice, where dentists-in-training treat 14,000 patients per year. Now, for the first time, physicians from Harvard Medical School’s faculty are on hand every Wednesday to help dental students conduct physical exams and in-depth medical histories. If needed, they refer patients to primary care providers and follow up to make sure they go to appointments.

There’s a lot that dentists can learn about the body by looking in the mouth, said Dr. Lisa Simon, a Harvard dental school graduate who is now supervising students in the clinic. Eroded enamel could be a sign of acid reflux. A swollen tongue may point toward malnutrition. And signs of oral or facial trauma are often a red flag for domestic violence or child abuse.

And since many patients see their dentist more often than their primary care provider, Simon said, “the visits are a wonderful opportunity to monitor potentially chronic conditions like high blood pressure, diabetes, or depression.” Besides looking in the mouth, dental students are gathering information — and making interventions as needed — through extensive interviews, which include questions like, “Do you feel safe at home?”

In January, Harvard will add to this initiative by bringing nurses into the mix. In addition to the Wednesday morning primary care clinic, Northeastern University will send nurse practitioner students to Harvard’s teaching practice throughout the week to work alongside Harvard’s dental students under the supervision of an advanced-practice registered nurse. Students will teach each other about oral and general health. The program, funded by a three-year, $1.2 million federal grant, places a nurse practitioner right inside the clinic, offering an annual wellness exam and basic primary care.

The program aims to teach students to work in interprofessional teams — a trend that has been gaining momentum nationally as a way to treat the whole patient. In the past five years, 200 such programs have emerged at health science schools around the country, bringing together medical, nursing, dentistry, physician assistant, and sometimes pharmacology students to address oral health, said Judith Haber, executive director of New York University’s Oral Health Nursing Education and Practice Program, which helps other schools get on board.

New York University pioneered the effort in 2006, when it opened a dental clinic right across the hall from a primary care clinic and started cross-training students at its nursing and dental schools. Other schools have followed suit, Haber said. At the University of New Mexico, midwives-in-training learn to monitor pregnant women’s oral health. At the University of Washington, dental, medical, and nursing students team up to tend to homeless patients in a program called Teeth and Toes. At Case Western Reserve University, nurse practitioner and dental students work together to check dental patients’ overall health and administer vaccines.

The efforts, backed by federal grants, philanthropy, and the schools themselves, have been spurred in part by a series of federal reports, including the US surgeon general’s 2003 call to action for health professionals to take more responsibility for oral health. Proponents make an economic case, pointing to research that shows that patients with diabetes or cardiovascular disease who receive gum disease treatment have lower health costs and better overall health outcomes.

So far, the movement has been directed mostly at students, not practicing professionals, said Marcia Brand, executive director of National Interprofessional Initiative on Oral Health. However, some offerings for medical professionals do exist. For example, more than 33,000 health care professionals have taken online courses through Smiles For Life, which trains them to incorporate oral health into routine primary care.

Brand said she hopes more people join what has become a “head-banging, aha moment: Why is oral care separate?”

For NYU’s Haber, the aim is clear: “We’re putting the mouth back in the head, and putting the head back in the body.”