It’s time to break down the wall between dentistry and medicine
Ever 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.
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 practiceremains 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.