E

ver since the first dental school was founded in the United States in 1840, dentistry and medicine have been taught as — and viewed as — two separate professions. That artificial division is bad for the public’s health. It’s time to bring the mouth back into the body.

In 1840, dentistry focused on extracting decayed teeth and plugging cavities. Today, dentists use sophisticated methods for prevention, diagnosis, and treatment. We implant teeth, pinpoint oral cancers, use 3-D imaging to reshape a jaw, and can treat some dental decay medically, without a drill. We’ve also discovered much more about the intimate connection between oral health and overall health. Periodontal disease, also known as gum disease, has been linked to the development of diabetes, high blood pressure, and cardiovascular disease. Pregnant women with periodontitis are more likely to develop pre-eclampsia, a potentially serious complication of pregnancy, and deliver low-birth-weight babies.

As taught in most schools today, dental education produces good clinicians who have a solid understanding of oral health, but often a more limited perspective on overall health. Few dental students are equipped to take a holistic view that may include taking a patient’s vital signs, evaluating their risk of heart disease or stroke, spotting early warning signs of disease, or even assessing their mental health or looking for signs of drug abuse.

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There’s a better way to educate dentists so they can play larger roles in the management of their patients’ chronic diseases.

My school, the Harvard School of Dental Medicine, was founded 150 years ago on July 17, 1867. It was the first American dental school affiliated with a university and its medical school, and the first to grant the doctor of dental medicine (D.M.D.) degree. The school’s mission is “to develop and foster a community of global leaders dedicated to improving human health by integrating dentistry and medicine at the forefront of education, research, and patient care.” At commencement, dental graduates are welcomed into a “demanding branch of medicine.”

Harvard dental students have always spent more than a year of their education attending the same classes as their medical school peers. They learn just as much about what’s going on in the chest cavity as the oral cavity. Under a new curriculum, in their second year they work in a primary care clinic in the dental school, side by side with fourth-year dental students, nurse practitioners, and primary care physicians to learn how to assess a patient’s overall health. In a collaboration with Northeastern University’s Bouvé School of Nursing, nurse practitioners and nursing students work with dental students and faculty members to manage chronic diseases and provide oral care.

Poor oral health is more than a “tooth problem.” We use our mouth to eat, to breathe, and to speak. Oral pain results in lost time from school and work and lowered self-esteem. Inflammation in the gums and mouth may help set the stage for diabetes, cardiovascular disease, and other chronic conditions. Dental infection can lead to the potentially serious blood infection known as sepsis. In the case of 12-year-old Deamonte Driver, an infected tooth led to a fatal brain infection.

Writing in the Millbank Quarterly, John McDonough, professor of public health practice at the Harvard T.H. Chan School of Public Health asked, “Might oral health be the next big thing?” I believe that it needs to be — and should be.

Just as dental and medical education are currently separate, so too are the ways care is delivered and how care is — or isn’t — covered by insurance. That poses problems for access to care.

Today, 130 million Americans, most of them adults, have no dental coverage. Medicare has no dental benefits, and Medicaid has few benefits for adults. The high cost of dental care affects even those with coverage.

It’s no wonder that the Centers for Disease Control estimates that the U.S. loses $6 billion in productivity each year due to oral health issues. Emergency department visits for oral pain cost nearly $2 billion a year and contribute to the epidemic of opioid addiction. And mounting evidence shows that poor oral health results in increased general medical costs.

To help break down barriers between medicine and dentistry, the Harvard School of Dental Medicine has created the Initiative to Integrate Oral Health and Medicine. In an effort to improve general health and lower medical costs, it brings together leaders in academia, health care, and industry to find innovative ways to integrate the two disciplines. Through the initiative, we seek to transform how dentistry is taught, practiced, financed, and evaluated so it becomes seamlessly integrated with the comprehensive health and social services required to keep individuals and communities healthy.

The school has also established the Oral Physician Program, a general practice dental residency program at the Cambridge Health Alliance, which integrates oral health, primary care, and family medicine training. We also plan to establish a new combined DMD/MD program with a hospital-based residency to train a new type of physician focused equally on oral health and primary care.

Other institutions are also expanding the concept of dental care and chipping away at the barriers between dental care and primary care. Kaiser Permanente Northwest, for example, has opened a truly integrated medical-dental practice in Eugene, Ore. The Marshfield Clinic in Wisconsin is advancing the concept with integrated medical-dental electronic health records.

Here’s what an integrated dental health/primary care visit might look like to a patient: When you go for a routine teeth cleaning, you would be cared for by a team of physicians, dentists, nurses, and physician and dental assistants. One or more of them would take your blood pressure, check your weight, update your medications, see if you are due for any preventive screenings or treatments, and clean your teeth. If you have an artificial heart valve or have previously had a heart infection, or you are taking a blood thinner, your clinicians will manage these conditions without multiple calls to referring doctors.

Finding the political will to integrate dentistry and primary care is a challenge. Various organizations including the DentaQuest Foundation, the Santa Fe Group, and Oral Health America have taken up the task. The majority of this work is designed to raise awareness of oral health, educate non-dental health care providers, and create political interest in promoting oral health. However, while interprofessional education has met with some success, interprofessional practice remains elusive.

The culture of the dental profession must change to promote closer connections between dentistry and primary care. The move from solo practice to small- and large-group practices may provide the impetus for such change. Recent editorials in the dental literature, including the Journal of the American Dental Association, talk about the need for integration, including the use of diagnostic codes, integrated medical and dental electronic records, and the potential for melding medical and dental practices.

Unfortunately, incentives for creating this practice of the future are minimal at this time. Dentistry’s reliance on procedures for payment and separate insurance coverage presents a problem. The slow movement toward bundled payments for health care to create value based upon outcomes, rather than volume, could help.

In 2000, the surgeon general’s report “Oral Health in America” drew attention to the gap in oral health in the U.S. In a 2016 update, then-Surgeon General Vivek Murthy strongly recommended integrating oral health and primary care. Closer collaboration between dentistry and primary care could change the culture of health care, close the access gap, and improve general health by providing primary care services during dental visits. It could also improve population health and chronic disease care.

We cannot drill, fill, and extract our way to better oral and overall health. We need a fundamentally different approach, one that accentuates disease prevention and health management using a multidisciplinary, integrated, and patient-centric approach to overall health. And that means breaking down the wall between dentistry and medicine.

Bruce Donoff, D.M.D. and M.D., is professor of oral and maxillofacial surgery and dean of the Harvard School of Dental Medicine.

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  • Their ‘Mission’ statement and their actions are in total opposition.
    Dr. Gallucci of Harvard Dental school was contacted by a fellow professional from England to review my case. A phone call was set up (he had forgotten about) but we did connect and I did get the promise of an evaluation appointment. Unfortunately, the evaluation never happened because no one followed thru, despite the numerous emails and phone calls, I was left hanging. This is how you can expect to be treated if you ever develop a problem.
    They are free to pick and choose who they want to help or not and they answer to no one!!
    Read my story, listen to the audio within the context of the story, it speaks volumes pun intended.
    What happened to me is happening more often than you think and these guys are ‘well aware’!! Never in my wildest dreams did I think I’d be taken for $74,000 and kicked to the curb for questioning their lies and deceptions.
    Remember, LISTEN to the audio, it’s SHOCKING to say the least!! You’ll never look at dentistry the same way again!
    http://www.welcometodds.com/dee-s-dental-story
    http://www.welcometodds.com/dds-page-1
    http://www.welcometodds.com/dds-page-3

  • And it’s time to break down the wall between the ADA and its defense of mercury dental amalgam, an outdated product that should no longer be used in human teeth, on which its affiliates held patents.

  • I am puzzled?
    The school’s mission has a lofty vision but i do not see the same commitment in many of the private practice dentists.
    My community has a very limited (almost non existent) indigent care dental clinic. My community has a number of free medical clinics and mechanisms for sliding scale payment for medical care, but despite the community’s robust dental practices, many people must travel over 50 miles to obtain dental care purely based on financial factors. Many people in our community are unable to see a dentist at all because of the pay up front policy by every group in the community. The only resort for care becomes the emergency department.
    You state “Emergency department visits for oral pain cost nearly $2 billion a year and contribute to the epidemic of opioid addiction.”
    The study referenced supports the desperation of suffering patients to find relief at the only place available, the local emergency department. If the dentists were truly “dedicated to improving human health,” i would suspect the dental community would urgently take actions to mitigate this lack of access.

    You can blame many factors for the current opioid epidemic. You make an unfair statement not supported by your reference, implicating emergency department care as the cause of the opioid epidemic. In fact, i would directly implicate the dental community for withholding “sophisticated methods for prevention, diagnosis, and treatment” from many in need.

    Why try to expand dentists’ scope of practice to include primary care when it appears they are not adequately providing basic dental care.

  • I don’t know of many physicians who view bundled payments as a good thing. Instead of treating patients and getting paid for each visit, bundles payments incentivize less follow-up care and the avoidance of treatment in order to maximize profit.

    Breaking down the wall sounds good in theory, but why on Earth would dentists want to have to use ICD-10 and its nearly 90,000 codes with all of the billing complexities that entails?

    Also, breaking down the wall will introduce managed care and meaningful use in ways that dentists have been largely able to avoid until now. Do we really want to go down that road? Have patients really benefitted from seeing their physicians less due to burdensome paperwork?

    I am all for educating dentists on the rest of the body, but not if it comes at the expense of their dental training. Many dental students do not undergo residency training. They need as much exposure to the actual practice of dentistry during school that they can get. Demanding that they spend more time learning procedures not related to the practice of dentistry may mean that we produce worse dentists. One way around this would be requiring a residency, but with many dental schools costing significantly more than medical school these days, that seems an untenable solution.

    The wall between medicine and dentistry has largely served to protect dentistry from the problems that now plague medicine. I think this is a case of being careful what we wish for.

  • Great stuff.
    .been preaching this for years. I have collaborated with all of our local medical groups. Thousands of docs…and me. Ibwould love to aid in the battle. Btw your verbiage is straight off of one of my websites
    popc.com…..great minds think alike!

  • Excellent article.
    We use to have some multi professional actions but it does not create real integration
    Once more congratulation,Prof Bruce!!

  • I completely agree with Dr. Donoff’s view of a Dental Specialty of Medicine in form and function, unfortunately he failed to mention in his article the role of Dental professionals in Early Detection and Prevention of Oral Cancer? AHR DMD.

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