Dentists focus on the inside of the mouth, and doctors care for the rest of the body.
This is how medical practice has worked for decades.
But a fledgling movement insists there is a better way and is advocating for a big change in the dentists’ role.
Because patients tend to visit dentists routinely more often than they visit doctors, members of this movement see dentists as perfectly situated to screen for a host of conditions, including glucose monitoring for diabetes, high cholesterol, hypertension, HIV, obesity and sleep apnea.
“Dentists are health care professionals who happen to be dentists. We need to be integrated into the health care of our patients,” said Dr. Michael Glick, dean of the University at Buffalo School of Dental Medicine.
Glick is one of the nation’s leading advocates for change. As editor of the Journal of the American Dental Association, he has used his position as a bully pulpit to make his views widely known.
He is not alone.
“Too much of the profession is focused on the technological side of dentistry and not enough on the biological side,” said Dr. Ira Lamster, professor of health policy and management at Columbia University and former dean of the school’s College of Dental Medicine.
“Millions of people with undiagnosed or poorly diagnosed diseases visit a dental office, making it an appropriate place for screening,” said Lamster, who in 2011 called on the profession to create a new 21st century model for dentistry in an article in the American Journal of Public Health.
If change occurs, it likely won’t occur quickly or easily.
Insurance companies and government agencies would have to decide that such services should be reimbursed. Dental schools would have to alter their educational programs. Dentists and doctors would have to interact on a regular basis. The medical community would have to accept a larger role for dentists.
And dentists themselves would have to embrace the idea of expanding their work, including making sure that patients get appropriate referrals.
“Some dentists may not want the aggravation, and there is concern that once you do it, you take on the responsibility for the patient and follow-up,” said Dr. John Nasca, a Williamsville dentist.
Nasca is also president of the Eighth District Dental Society in Western New York and stresses that his views do not reflect those of the organization. He favors the idea of dentists doing more, but acknowledges that it will require a slow evolution in the profession’s culture.
“We don’t just look into patients’ mouths and say, ‘Open wide,’ ” he said.
“I’m sure there are logistical issues to work out, such as insurance reimbursements, and concerns about counseling and appropriate follow-up and referrals for positive tests. If these can be addressed and as testing becomes easier, less expensive and more accurate, I think you will see these types of services offered in more dental practices in the years to come,” he said.
Research offers support for the link between periodontal disease and other conditions, as well as for an expanded dental role.
In 2010, a nationwide survey in the journal of the American Dental Association reported that dentists would be willing to screen their patients for medical conditions when they come into the office for dental care. The survey showed that more than three-quarters of the 1,945 dentists who responded thought it was important to screen for such disorders as heart disease, diabetes and HIV.
A 2012 study in the Journal of Public Health Dentistry found that a majority of patients surveyed were willing to be screened by a dentist.
“We usually see doctors when we have symptoms, but people routinely visit the dentist twice a year. The opportunity to screen is there, and we tried to answer the question of whether doctors and patients were willing to do it,” said Glick, who was involved in both studies.
Some of the most publicized research has been done by Shiela Strauss, associate professor of nursing at New York University’s Colleges of Nursing and Dentistry.
In 2009, she and her colleagues in a national survey of nearly 3,000 people found that a majority of the respondents with periodontal disease were also at risk for diabetes and should be screened. In addition, half of the individuals had visited a dentist in the previous year, suggesting that dentists should consider offering routine diabetes screenings in their offices.
Another study by Strauss’ team in 2011 concluded that nearly 20 million people each year fail to see a physician but do make at least one visit to a dentist. As such, she reported, dentists can serve as health care professionals who identify the warning signs of chronic illnesses and refer patients for expert help to prevent complications.
“This is not about diagnosing disease, which is what doctors do. It’s about screening,” Strauss said in an interview. “There are lots of people in the country and world who have diabetes but are unaware of it. If we identify them early, we can help prevent complications.”
Dentists are not allowed to diagnose diseases normally taken care of by doctors. The debate is over testing.
The American Dental Association definition of a dentist is broad enough to possibly include such things as diabetes screening, according to Lamster. But scope-of-practice laws, including New York’s, vary and usually focus on treating the mouth and the tissue around the head, neck, face and jaws.
Lamster said he and others have asked the state whether the law allows dentists to screen patients for diabetes using a finger-stick blood test.
“Dentists give injections deep into the mouth, so why not a finger stick?” he said. “The reason is antiquated scope-of-practice laws.”
A growing body of research indicates a link between oral health and overall health. But it’s still the rare dental service that screens for systemic diseases.
Susan Trzeciak said she believes her dentist’s willingness to provide care beyond what dentists traditionally provide made a significant difference. She was at UB’s dental clinic for routine care in 2009 when the dentist took her pulse and noticed an abnormal heart rhythm. At a second visit, he referred her to a cardiologist.
The result: She ended up getting a pacemaker.
“I think his taking my pulse saved by life,” said Trzeciak, 72, of Buffalo.
Glick and others argue that change will come if more dental schools change their educational programs to train dentists to test for chronic diseases. UB is one of the minority of schools that pushes the concept.
For instance, UB this fall took a lead role in a state project to test the idea of “chairside” screening for HIV by dentists. UB operates a dental clinic that gets about 60,000 visits a year.
More than 1 million people in the United States are infected with HIV, and about 20 percent don’t know they are infected. Early diagnosis of the virus means patients receive treatment sooner and reduces the chances of transmitting the disease.
In 2006, the federal Centers for Disease Control and Prevention recommended that health care providers, including dentists, offer routine HIV screening to all adolescent and adult patients. Advocates for expanding the role of dentists say the profession should offer rapid HIV saliva tests because they see regularly see patients, and oral lesions common in HIV infection are a key indicator of disease progression. But few dentists offer the test.
The one-year study at UB and four other dental schools in New York will look at the percentage of dental patients who agree to HIV testing, the percentage of dental patients who test positive, and the percentage of dental patients who are HIV-positive and successfully linked to counseling or medical treatment.
“The number of undiagnosed patients with HIV is a big problem because they can infect others,” Glick said. “Dentists should be involved.”
Even if chairside dental HIV screening turns out to be effective, it won’t be easy to make it routine.
As with testing for other medical conditions, there is little time and funding now to incorporate such training into dental school programs that are crowded with courses students must take. Testing every patient in every dental office could be expensive. Patients may be reluctant to accept HIV testing by dentists and, dentists may be reluctant to offer the service because of discomfort about communicating test results to patients, and the time and cost of offering the service.
Still, advocates like Glick say the profession must redefine itself, especially as private and government efforts to reform medical care transform the health system.
“We’re trying to teach that screening for medical conditions should be part of the care dentists provide,” he said. “The opportunity is there. If we don’t take it, dentists risk being marginalized.”