KDA Today

KDA Today

For Immediate Release

Date: Apr 22nd, 2022
Contact: Dr. Beverly Largent
Phone: 800-292-1855
Email: kda@kyda.org

Bridging the Divide Between Medical and Dental Care

My inbox is mostly cluttered with advertisements from company websites, where I shopped for Christmas gifts. There are important messages from random vendors that I have never visited, interspersed with phishing e-mails. I delete approximately 30 a day, but some days there is a pearl and this week I have found one. The message was from KDA member Dr. Terry Norris, Regent of the American College of Dentists for Regency 4. In his message, Dr. Norris linked to the January 2022 issue of the AMA Journal of Ethics which discussed the divide between Medicine and Dentistry and the resulting disparity in care for our citizens. The codes of ethics of various organizations have held my interest for some time and access to care issues have been a topic most of my dental career. Perhaps now is a good time to write a disclaimer.

Few would argue that the thoughts, ideas and ideals we subscribe to are a result and sum of our experiences. Certainly, that is true for me. In the twenty-five-plus years that I was active in organized dentistry, access to care was a prominent topic. I have attended seminars, served on panels, lobbied the US Congress, all in the name of access to care. I have been present in meetings with dental colleagues and medical colleagues when the issue of “dentistry should be a subset of medicine” topic was discussed, without results or first steps. In my 37 years of practice, I treated mostly Medicaid children. This was my choice, one reached after a tumultuous inner battle and trying hard to deny my destiny. I served for three years on the ADA Council of Ethics, Bylaws and Judicial Affairs which was personally impactful. During that tenure, I had the questionable and uncomfortable experience of being the ADA representative at a three-day meeting on ethics. My takeaway from that meeting, after nearly 15 years, was that there was an underlying sentiment that the ADA Code of Ethics is trash; dentists are money grubbers; and everyone deserves the highest quality of dental care to be provided without question by the dental community. For many years, I have cringed when I have found an article by one of the participants of this event. Fast forward to January 2022 and the AMA Journal of Ethics which espouses some cures for the access and disparity issues, and a general lack of knowledge about the cost, delivery and difficulty of providing dental care, or even motivating the most educated dental patient. Again, the underlying sentiment is that dentists somehow created or are responsible for the disparity in oral health and oral health services that exist in this nation.

The editor of the AMA Journal of Ethics is Lisa Simon, MD, DMD. In Volume 24, Number 1:E3-5, she discusses the inarguable statistics of ED (emergency department) visits, revealing that only about 50% of people who visit the ED actually see a dentist within six months. Disparities in dental care are exaggerated in poor communities. She closes her short introduction with the following statement: “Exploring the ethics of oral health within the AMA Journal of Ethics is, itself, a milestone insofar as it acknowledges that oral health is a vital component of human health and that delivery of oral health care is a component of health care ethics. Authors from diverse disciplines, including medicine, dentistry, social work, nursing and economics explore how our current system for medical and dental separation harms patients and clinicians and how the future of health care can bring about innovation that will ensure oral health for individuals and communities.” In all, there were eight papers which discussed this topic, with seventeen contributors. I did not include the article on diabetes which also appeared in this issue.

Many of the authors signaled the first divide in Medicine and Dentistry when the University of Maryland, School of Medicine declined to integrate a dental curriculum. In 1849, as a result of this decision, the first dental school in the United States was established. Approximately fifty years later, there were national discussions about health insurance, which was opposed by the AMA. In 1939, both the AMA and the ADA opposed nationalization of health insurance, fearing loss of autonomy. The idea was again proposed by President John Kennedy, focusing on elder care. In 1965, during the term of President Lyndon Johnson, Medicare and Medicaid were established as a part of his “War on Poverty.” Dental services were not a part of Medicare and were optional for Medicaid. Because of policy decisions in 1965, dentists have remained untouched by government intervention, as compared to the medical community. (Jorie Braunold, MLIS, AMA Journal of Ethics, January 2022, Volume 24, Number1: E89-98. History of Medicine; Why don’t Medicare and Medicaid Cover Dental Health Services?)

Two of the eight articles were case studies and commentary. One concerned the responsibility of the dentist to find a physician for a health compromised patient; the second discussed the difficulty of an ED physician making a referral to a dentist. Interestingly, through a thorough review of the ADA Code of Ethics, it was determined that it was the dentist’s ethical duty to find a physician for her patient and that a simple referral was inadequate. The solution sought was universal health coverage. There was no such ethical burden placed on the ED physician to locate a dentist for the patient presenting with dental pain. The solution, again, was universal health insurance, the suggestion that all dental practitioners be forced to participate and that adequate records be kept, ensuring that everyone participated at a predetermined level. It was suggested that there be a dental clinic in the ED, staffed by a hygienist to care for dental patients entering the ED in pain and making necessary referrals. The last recommendation is in my opinion for the comfort of the Emergency Department, at least given the practice parameters for hygienists in Kentucky, who currently can do nothing for a patient with acute dental pain.

The paper, titled, “Promoting Children’s Health Equity with Medical-Dental Integration” (AMA Journal of Ethics, January 2022, Volume 24, Number 1: E33-40, Zea, Henshaw), reports on a 16-year-old study integrating oral health assessment, fluoride varnish and oral health care instructions. The number of child well visits where dental services were given increased by 50% post pilot study. The term “oral health assessment” is, in my mind, a fuzzy term. Was this assessment based on a report of pain, a cursory look in the mouth or a dental examination? There was no long term follow up of the patients or the results of repeated visits. Did this Medical-Dental intervention change the parental view of oral health and their active participation in caring for their child’s teeth? There was no mention of a dentist or a dental home in the study. In 2015, there was published, results of a similar program in North Carolina titled, “Into the Mouths of Babes” in which long term studies show that the program has contributed to a statewide decline in dental caries rates since 2004 and helped reduce the gap in tooth decay between children from low- and other-income families at a community level when the children received four interventions. (Achembong LN, Kranz AM, Rozier RG. Office-based preventive dental program and statewide trends in dental caries. (Pediatrics 2014 Vol.133 No. 4 pp.e827-e834 (doi: 10.1542/peds2013-2561). Clearly, this type of intervention is successful, but a more powerful statement could have been made.

Other areas addressed include education of the physician and continued training of the Primary Care Clinician, who usually receives less than three hours training about oral health. Most authors are calling for an integration of Medicine and Dentistry, often advocating for a medical degree, along with a dental degree. All agree that the Medical/Dental divide is a perplexing dilemma and is contributing significantly to poor oral health. Equity strategies call for a close in the insurance gap between medical and dental care, implementation of Teledentistry, administration of school based dental care and the addition of new categories of dental practitioners.

I am personally disappointed in the January 2022 edition of the AMA Journal of Ethics. All of the options and opinions listed in the various articles have been discussed for years and many have been implemented with long term results that have been published, two of which are the early physician intervention with fluoride varnish and school based treatment. Unfortunately, some school based treatment in other countries provide questionable results. We would do well to look at recent history when establishing a wish list for dental inequities. Without fail, the authors point to lack of insurance, which to be sure is a huge problem, but money does not solve all problems. Unlike treatment of diabetes without patient dietary cooperation, we do not have a pill or a shot that will halt or postpone the advances of the disease. I am deeply concerned that the term “dental assessment” is equated to a dental examination; and that an assessment and fluoride varnish are termed “dental care”. Certainly, it is an advancement and a very good foundation, but it cannot relieve pain or restore function. I am appalled that there is only one reference to a dentist in all of the eight articles, and that the dental visit cited was determined to be a waste of time for the patient. I believe the answer to the Medical/Dental divide lies in a better understanding of the practice of dentistry. My last day of practice included a head covering, face shield, mask, gloves, sterile instruments and a disinfected area. As I compare that dental exam to the medical examination I received this month, there is a huge divide. Standing naked in the presence of a dermatologist with a flashlight does not require the same overhead as a dental exam, yet he did a full body exam—I only examined one small part of the body.

Dentists, like other health care providers, understand poverty and its many ramifications. We have an innate desire to help people. We are smart. Engage those of us treating the mouth--the gateway to the body—and we can and will find an answer.

Press Releases