The traditional divide between dentistry and medicine is
shrinking as data accumulate linking oral health with
overall health.
By Victoria Stagg Elliott, AMNews staff. March 3, 2008.
A few years ago, an extremely sick, 2 ½-year-old boy came
to the Houston office of pediatrician Ray Wagner, MD, with a
105-degree temperature. The illness, which required five
days of hospitalization and a course of intravenous
antibiotics, got its start in an infected tooth; which, in
turn, resulted from poor dental hygiene and a lack of dental
care. Dr. Wagner, who was then an assistant professor at the
University of Texas Medical School, decided to use this case
as a hook for an educational session on oral health.
"We discovered that early childhood caries [tooth
decay] was the most common chronic disease of
children," he said. "We were all shocked."
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Now a staff physician at El Rio Community Health Center in
Tucson, Ariz., he is one of more and more physicians who are
looking at patients' mouths and teeth before moving on
to their throats. These doctors are motivated by both
firsthand experiences and the scientific literature
documenting that health in this area makes a difference to
the whole body.
An increasing number of physicians are educating patients
on cleaning teeth and gums and advising parents on reducing
the risk of transmitting cavity-causing bacteria from their
own mouths to their children's. Fluoride varnishes are
being applied to teeth in doctor's offices, and dentists
are being added to the list of specialists consulted as
needed.
"The mouth is part of the body," said Wanda
Gonsalves, MD, associate professor of family medicine at the
Medical University of South Carolina in Charleston. She
began her career as a dental hygienist. "I'd really
like dentists and physicians to co-ordinate more and not
have the mouth treated as a totally separate entity."
The American Medical Association and other medical
organizations have supported water fluoridation, but a
movement is now emerging to have physicians more involved in
mouth health. This interest had its start with the release
of the surgeon general's 2000 report, "Oral Health
in America." It pushed the message that oral health
means more than teeth, is an integral part of wellness, and
nondentists need to be involved.
"You can't be healthy if you don't have good
oral health," said David Satcher, MD, PhD, who was
surgeon general at the time of the report's release and
is now director of the Center of Excellence on Health
Disparities and the Satcher Health Leadership Institute at
Morehouse School of Medicine in Atlanta.
Children's health
Physicians have since taken this report and applied it in
various ways. The American Academy of Pediatrics published
policy in the May 2003 Pediatrics urging pediatricians to
start evaluating oral health at six months of age. Revised
guidelines are expected before the end of this year. Also, a
major educational session on the subject is being planned
for the organization's annual meeting in October.
"We have to help physicians make [oral health] doable
and make it easy, so it becomes second nature and no
different than when you check the fingernails or the eyes or
the ears," said Martha Ann Keels, DDS, PhD, chair of
AAP's section on pediatric dentistry and head of
pediatric dentistry at Duke University in Durham, N.C.
An estimated 51 million school hours are missed annually
because of health problems affecting the mouth.
The U.S. Preventive Services Task Force recommended in
April 2004 that primary care physicians prescribe fluoride
supplements to preschoolers who primarily drink
unfluoridated water. The Society of Teachers of Family
Medicine launched "Smiles for Life," a curriculum
designed to educate medical students and residents on oral
health, in October 2005. A second edition will come out this
summer. The New York Academy of Sciences hosted a symposium
on this subject in January.
"Because of the historical separation of medicine and
dentistry, there is a framework of thinking which separates
dental care and oral health from medical care and general
health. [The NYAS meeting] was one of many efforts to
reconnect the mouth to the body," said Burton
Edelstein, DDS, MPH, professor of clinical dentistry, health
policy and management at Columbia University and a member of
the event's planning committee.
These actions also were taken because, although overall
dental health has improved, statistics related to children
suggest the future may not be so bright. Dental caries is
five times more common in children than asthma. An estimated
51 million school hours are missed annually because of
health problems affecting the mouth. Data released by the
Centers for Disease Control and Prevention's National
Center for Health Statistics in April 2007 indicated that
tooth decay in ages 2 to 5 increased for the first time in
years.
"We as pediatricians haven't done a very good job
of preventing disease in those youngest children," said
David Krol, MD, MPH, chair of the pediatrics department at
the University of Toledo's College of Medicine in Ohio
and a member of the AAP's Oral Health Initiative
Steering Committee. "Our previous policy in pediatrics
was that we don't need to send a child to the dentist
until they're age 3. By default, we were taking
responsibility for those children's oral health."
Experts are particularly concerned because having bad teeth
is a problem that goes far beyond the aesthetic and can
become more serious as a child grows into adulthood.
"We are understanding more and more that having early
childhood caries invariably sets you up to develop tooth
decay of the permanent teeth," said Dr. Wagner.
"Once the bacteria are well established in your mouth,
they persist, and they're very hard to get rid of. Early
oral disease predicts lifelong oral disease."
The mouth-body connection
And this circumstance can have implications beyond the
mouth. The first signs of some diseases such as osteoporosis
or HIV infection can show up in the mouth, but poor oral
health can also cause damage to the rest of the body. Over
the past decade, published studies have linked tooth loss to
dementia and associated it with poor pregnancy outcomes.
Dental plaque can be a source of ventilator-associated
pneumonia among intensive care patients. Tooth decay may
increase the risk of heart disease. Diabetes can increase
the risk of gum disease, and, conversely, leaving this
problem untreated can make blood sugar control next to
impossible.
While significant data has tied such conditions to
periodontal disease, attempts to improve them by going for
the teeth have had mixed results. A study in the Nov. 2,
2006, New England Journal of Medicine reported that treating
periodontal disease in pregnant women had no impact on the
risk of preterm birth, although related research is
continuing.
Tooth decay is 5 times more common in children than asthma.
Other studies have been more positive. One in the March 1,
2007, issue of the same journal found that treating
periodontitis could improve endothelial function. Others
also documented that caring for the teeth can improve
glycemic control in diabetics.
"In general the field is comfortable with the finding
that treating periodontal disease in a diabetic will
contribute to their glycemic control," said Robert
Genco, DDS, PhD, distinguished professor of oral biology and
microbiology at the State University of New York at Buffalo,
who has authored numerous studies on this subject. "It
probably wouldn't hurt [for physicians] to say this is a
possible complication and you should see your dentist.
People see their dentist anyway, but we have found that if
the primary care physician makes a recommendation like that,
the patients oftentimes will listen to that carefully and
act on it."
Although physicians are getting more involved in oral
health because of the science, the lack of access to dental
care faced by so many patients -- in part because there are
far fewer dentists than physicians -- also is an important
factor driving their interest and involvement.
"There aren't enough dentists in this country. We
really do need primary care physicians jumping on
board," said Catherine Hayes, DMD, DMSc, chair of the
Dept. of Public Health and Community Service in the School
of Dental Medicine at Tufts University in Boston, who is
investigating the impact of poor oral health on
children's growth.
Patients also have more difficulty financing dental care.
Far more lack dental than medical insurance. Medicare does
not cover most dentistry. Medicaid dental coverage for
adults is optional, although quite a few states do provide
this benefit to some degree. Children on Medicaid have
coverage, but because of low reimbursement rates and other
issues associated with the program or with living in
poverty, they can have a very difficult time finding a
dentist who will see them. These realities mean disparities
in oral health generally run directly along economic lines.
According to data from the Agency for Healthcare Research
and Quality, released in September 2007, 26.5% of those in
poor families saw a dentist annually, while 57.9% of those
from high-income families did.
"This is a problem that doctors have to grab hold of
if we're really going to make inroads here," said
Alan Douglass, MD, associate director of the family medicine
residency program at Middlesex Hospital in Middletown,
Conn., and co-chair of the STFM's oral health workgroup.
"This can't just be relegated to dentists. There
are just too many linkages to overall health, and the
reality is that while most patients in the United States
have access to some form of medical care, many fewer have
access to dental care."
And the consequences of not being able to access care can
be catastrophic. Last year, newspapers were filled with
stories of 12-year-old Deamonte Driver of Prince
George's County, Md., a Washington, D.C., suburb, who
died of a brain infection caused by untreated dental
disease. On and off Medicaid and occasionally homeless, he
was not able to get care.
"Deamonte Driver's inability to obtain timely oral
health care treatment underscores the significant chronic
deficiencies in our country's dental Medicaid
program," said Kathleen Roth, DDS, during a March 27,
2007, congressional hearing held in response to the
incident. She was president of the American Dental Assn. at
the time. "Fundamental changes to that program are long
overdue, not simply to minimize the possibility of future
tragedies, but to ensure that all low-income children have
the same access to oral health care services enjoyed by the
majority of Americans."
A bill was subsequently introduced in the U.S. House
calling for increased funding of federally qualified health
centers for dental services and training of more pediatric
dentists. The proposal is currently in committee.
ADDITIONAL INFORMATION:
Who gets dental care? Percentage of people who visit a dentist at least once a year:
By family income
Poor (100% of the federal poverty line or less) 26.5%
Low Income (100% to 200%) 29.9%
Middle Income (200% to 400%) 41.9%
High Income (400% or more) 57.9%
By race
Hispanic 28.9%
African-American 30.2%
Caucasian 49.4%
Other 41.5%
By education
Some or no school 21.9%
High school graduate 37.3%
College graduate 54.5%
Note: For the purposes of this report, the federal poverty line was $18,850, based on a family of four.
Source: "Dental Use, Expenses, Dental Coverage, and Changes, 1996 and 2004," Agency for Healthcare Research and Quality, September 2007
Centers for Disease Control and Prevention on oral health resources (cdc.gov/oralhealth)
Medicaid benefits online database, dental services, Henry
J. Kaiser Family Foundation, 2006
(www.kff.org/medicaid/benefits/service.jsp?yr=3&cat=6&sv=6)
"Oral Health in America: A Report of the Surgeon General," May 2000 (www.surgeongeneral.gov/library/oralhealth)
Copyright 2008 American Medical Association. All rights reserved.
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