In this month’s letter, ADEA President and CEO Dr. Rick Valachovic explores opportunities for dentistry in the evolving primary care delivery system.
As promised in November’s Charting Progress, I want to continue exploring the intersection of dentistry and medicine by focusing this month on dentistry’s role within primary care. Those of you who attended the 2013 ADEA Deans’ Conference last month in Savannah heard and talked a great deal about this topic, and I know that many of you have been contemplating the dentistry/primary care relationship for much longer than that.
Dr. Monty MacNeil, Dean of my alma mater, the University of Connecticut School of Dental Medicine, published an essay at the beginning of 2013 that posed this question: Should dentists assume a more active role in the provision of primary (medical) care services to the patients we treat? Monty believes that dentists’ expertise and network of delivery points could be better harnessed, especially given the current and projected shortages of primary care providers. As he suggests in his essay, “This just might be our opportunity as a profession to demonstrate that we are an essential part of health care by providing a carefully selected ‘slice’ of medical services that fit with and reinforce the importance of oral health and quality dental care.”
Monty is not alone in his views. I’ve talked with many who believe that dentistry can and should become a portal to primary care. Just to be clear, we are not talking about medical diagnosis and treatment, which are—appropriately—the province of other health professions. We are talking about monitoring health risks, expanding preventive services, screening for specific conditions and, where appropriate, taking a role in their management. For example, we are experts at giving injections, so offering vaccinations might make sense. We also take medical histories, so if our patients tell us they haven’t seen a primary care provider in a while, certain screenings may be in order. We also know how to provide nutrition counseling and guidance on smoking cessation, and we know how to assess risk. I’m not just talking about caries risk assessment, which I discussed last month, but the risk of cardiovascular disease, diabetes and other chronic conditions that can impinge on our ability to treat oral diseases.
“As the field of dentistry evolves, and as we become more integrated into the health care system overall, this is the direction we need to be heading,” said Dr. Cecile (Ceil) Feldman, Dean of the Rutgers School of Dental Medicine, when we spoke last month. “I don’t think dentists should be managing chronic conditions. That’s not our training, but doing everything we can to match patients with someone who does have the training is appropriate and should be in our purview.”
Leveraging the expertise of other health professionals through referral is a central feature of collaborative practice, and preparing our students for an environment in which collaborative care delivery has become routine is the primary goal of interprofessional education (IPE). Interprofessional Education in U.S. and Canadian Dental Schools: An ADEA Team Study Group Report, published by the Association in 2012, discusses this topic. Dr. Allan Formicola, Dean Emeritus of the Columbia University College of Dental Medicine (Columbia CDM), served as lead author on the report, so I called him to hear his views on dentistry’s role in primary care.
“Up until 2000, when the Surgeon General’s report stated emphatically that oral health was essential to general health, most people looked at dentistry as a separate profession that took care of the mouth,” Allan told me. “When research studies started to demonstrate the effect of oral disease on systemic disease and vice versa, and when caries were recognized as the leading chronic disease in children, people started to think differently.”
Not surprisingly, the ADEA Team Study Group’s report reflects this evolution in how dentistry is perceived. The first rationale the report offers for IPE calls dentistry “a critical component of the primary care system,” the practitioners of which “must be able to communicate effectively with other primary care providers.” The second rationale points to the impact of chronic health conditions, such as diabetes, on patients’ oral health (and vice versa) and states that, “Such patients require coordination of care between dentistry and the other health professions.”
These principles are on display at the University at Buffalo School of Dental Medicine (UB SDM), where Dean Michael Glick has intensified the school’s commitment to IPE to support his vision of the dental office as a portal to primary care. In addition to taking medical histories, students are expected to take blood pressure readings and offer their patients screening for diabetes and HIV. Michael sees chair-side screening as a positive but insufficient step toward engaging dentists more fully in primary care.
“My problem with the screening process is: Does the dentist know what to do with that information?” he told me.
To ensure that the dentist (or the dental student) does know, UB SDM has engaged a pharmacist to help students and faculty interpret patients’ medical and medication histories, and Michael has placed a librarian on the clinic floor to help clinicians retrieve and appraise the scientific literature. Michael shared one impressive result of employing this interprofessional approach to reviewing patients’ medications: “We have actually detected potential major side effects that could have occurred that the patient was completely unaware of.”
Michael has also created a web-based program that students can use at the point of care to access up-to-date information on multiple medical conditions and how they impact dental care. Using a typical health questionnaire as a starting point, the Medical Support System for Oral Health Care Professionals guides users through appropriate follow-up questions and provides information on how to interpret different answers and test results. The program contains dental protocols for various medical disorders, including alerts when treatment might produce adverse events. The program also provides links to reliable sources of information on drug interactions, evidence-based dentistry and medical and statistical topics. You can see a demonstration video and learn about how to acquire the software, which Colgate-Palmolive Company will make available to dental schools free of charge for use by senior dental students.
The potential public health impact of using the dental office as a portal for primary care has been studied in relation to a rapidly growing health concern: diabetes mellitus. Dr. Ira Lamster, Allan’s successor in the dean’s office at Columbia CDM and currently Professor of Health Policy and Management at Columbia University Mailman School of Public Health, has devoted years to developing and testing a method for identifying patients with unrecognized diabetes or prediabetes in a dental setting. He conducted two studies to determine if the method could successfully identify diabetes or prediabetes in adult patients with at least one of four self-reported risk factors for the disease.
The study protocol included a periodontal examination and a point-of-care HbA1c test of the patient’s blood sugar. The results of the two studies varied slightly, but in both cases, Ira’s team was able to identify—using periodontal screening alone—approximately three quarters of patients with abnormal blood sugar. These results were equivalent or better than the use of the point-of-care blood test alone. Together, the screening and the test identified approximately 90% of those patients with diabetes or prediabetes.
The Centers for Disease Control and Prevention estimate that one in four cases of diabetes is undiagnosed. Given the serious and potentially life-threatening consequences of this disease when left untreated, the benefit of screening at-risk patients in the dental office seems undeniable. The question becomes, could we—and should we—make this screening the routine standard of care?
Ira’s answer is an emphatic, “Yes!” He argues that we need this information in order to effectively treat oral diseases, and conducting point-of-care testing while gathering data on a patient’s oral health increases the likelihood of identifying those at risk. As the population ages, this information will be all the more important.
“The population will be presenting with more noncommunicable chronic diseases including diabetes mellitus,” Ira points out. “One in 12 patients now has the disease. If dentists in the future are unable or uncomfortable managing these patients, that’s a significant deficiency.”
Ira believes it is incumbent on dental schools to be aware of these trends and teach in greater depth both about the oral complications of diabetes and about appropriate screening tools. Monty MacNeil agrees. In his view, academic health centers and their community-based partners are in a unique position to experiment with delivering some primary care services in the dental office while the larger practice community waits for reimbursement and other issues to be sorted out.
“Let’s not make the lack of reimbursement the barrier right now,” he told me. “We know that prevention and early identification of medical risk are keys to controlling rising health care costs. If we can demonstrate better health outcomes in partnerships like this with medicine, I think we’ll see reimbursement systems evolve around us.”
Ira also sees as a potential barrier the uncertainty around scope-of-practice boundaries, and he has made a formal request to the U.S. Department of Education for clarification on whether dentists can conduct screening for diabetes in the dental office. Ira told me that roughly 50% of the states have a scope-of-practice statement containing language similar to the American Dental Association’s scope-of-practice definition. This statement contains broad language that effectively acknowledges that in-office blood sugar testing falls within the dental scope of practice. In addition, all dentists adhere to the Clinical Laboratory Improvement Amendments regarding the use of in-office diagnostic tests, and know that when a positive test result is obtained, a referral to a medical provider is essential. Nevertheless, I imagine that many dental practices will welcome a clear statement by the government sanctioning diabetes screening in the dental office.
Assuming the aforementioned barriers can be surmounted, there remains a cultural question: Are patients and their oral health providers ready for this step? One study titled, “Dentists’ attitudes toward chair-side screening for medical conditions,” published in 2010 by a group at the Rutgers School of Dental Medicine (then the New Jersey Dental School), reported that 90% of dentists believe it is somewhat or very important to screen for specific medical conditions, with three quarters of respondents including diabetes mellitus.
Two additional studies, one by the same research team and another using data gathered by the Dental Practice-Based Research Network, found that patients also overwhelmingly accepted the idea of diabetes screening in the dental office. What’s more, most of them were willing to pay a modest amount out-of-pocket to have the screening done.
As we contemplate the role of dentistry in primary care, let us not forget that the practice of general dentistry is primary care. Unfortunately, as Michael Glick reminded me, we have not done a good enough job of communicating that to our colleagues in the other health professions. In the long run, IPE should make a major contribution to changing those misperceptions.
As Ceil Feldman put it, “It’s a two-way street. As dentists become more sensitive to and actively involved in identifying patients who need a medical home, physicians who see oral disease will start moving their patients to the dental side.”
Ceil went on to ask whether the medical home and the dental home will co-exist or eventually merge into one. That’s a question for another day, but as far as what occurs when all the professions collaborate in the delivery of primary care, I agree with Ceil’s conclusion: “The patients win out.”
Consciously working at the intersection of dentistry and medicine represents a new frontier in improving our patients’ health. Not only will doing so allow us to guide our patients toward appropriate care. It should also instill in our medical, nursing and pharmacy colleagues a better understanding of the care we can offer their patients.