First Impressions Magazine

A Walk on the Medical Side
The dental and medical professions may be converging after 100 or more years of walking down separate paths

Whenever a patient age 18 or over comes in to Dr. Holly Scott-Hetchler’s office in Lansing, Mich., for a routine visit, he or she can expect a cleaning, X-rays (if scheduled), an exam … and a blood pressure reading. Why the blood pressure? "First, there are some risks on our part if a patient has hypertension and we’re doing dental treatment," says Scott-Hetchler. "But more important, a lot of patients have no clue they have high blood pressure."

Many of the patients are a bit surprised when the hygienist puts on the wrist cuff, says Scott-Hetchler. (If the reading from the wrist cuff is elevated, the hygienist takes the reading with an arm cuff.) But very, very few decline the test. And really, why should they? "We don’t charge for it," says Scott-Hetchler. "I don’t think there is any billing for it." Patients with elevated readings are advised to see their physician, which they do about half the time, she says. "We see some people two or three times before they go to a doctor."

Scott-Hetchler first started checking blood pressure while in dental school, and she’s been doing it ever since acquiring her practice in Lansing in 2004. Chances are, other dentists will catch on. That’s because today, there’s plenty of literature making the case for reconnecting the head with the rest of the body, that is, linking oral health to overall, or systemic, health. That realization is driving some primary care doctors to do rudimentary oral exams and even some simple procedures, such as fluoride varnishing for patients who lack a dentist. And, as Scott-Hetchler demonstrates, some dentists are taking the opportunity to screen their patients for medical conditions while they’re in the chair. As they do so, they just might open up some new selling opportunities for First Impressions readers.

The mouth as mirror
Though dentists may have known it for awhile, it took Surgeon General David Hatcher’s 2000 report, "The Surgeon General’s Report on Oral Health" to bring home the point that the mouth is the mirror for general health and well-being.

"As the gateway of the body, the mouth senses and responds to the external world and at the same time reflects what is happening deep inside the body," according to the report. Specifically, the mouth can show signs of nutritional deficiencies and serve as an early warning system for diseases such as HIV and human papillomavirus, or HPV. What’s more, periodontal disease and candidiasis of the mouth, also known as "thrush," can be symptoms of diabetes, according to the National Diabetes Education program of the National Institutes of Health.

"A lot of diseases show up first in someone’s mouth, such as diabetes, HIV and bulimia," says Scott-Hetchler, who went to dental hygiene school prior to entering dental school. "That means that a lot of times, the dentist is the first to clue in to these things."

More than 120 disease symptoms can be detected through a routine oral exam, according to Delta Dental Plans Association, a network of independent, nonprofit dental-benefits companies. In fact, more than 25 percent of the 650,000 new cases of diabetes reported each year are first uncovered during a dental exam, according to the organization. And researchers have found that periodontitis is associated with other health problems, such as cardiovascular disease, stroke and bacterial pneumonia, according to the American Dental Association.

Full members of the healthcare team
"We’ll see clinicians and educators of the future see greater emphasis on a number of things, including: 1) diagnosis of systemic diseases that can be affected by oral disease; and 2) healthcare screenings and interventions in the dental office," wrote the authors of "New Opportunities for Dentistry in Diagnosis and Primary Health Care," one of the so-called Macy Reports, produced by the American Dental Education Association and the Josiah Macy Jr. Foundation. The report was based on the proceedings of a panel of dental education experts convened in 2006. "The opportunity now exists to create educational models that emphasize the dentist as a full member of the healthcare team."

According to the Macy Report, dental students should graduate with an understanding of the following:

Diagnosis of oral and dental disease.
Diagnosis of systemic diseases and conditions that can be affected by oral diseases. (How do oral and dental diseases affect systemic conditions, such as cardiovascular, cerebrovascular, respiratory diseases, diabetes, pregnancy?)
Diagnosis of systemic diseases that can modify oral and dental diseases.
Primary healthcare screenings and interventions, including checking for skin lesions while the patient is in the chair, or talking to overweight patients about diet management.

Because they’re there
One of the most compelling reasons for dentists to do basic health screening is the simplest: They tend to see patients more frequently than do medical doctors.

"One fundamental tenet of dentistry is the concept of prevention," says Jed Jacobson, DDS, MS, MPH, chief science officer and senior vice president of Delta Dental of Michigan. That’s why 50 to 60 percent of Americans visit a dental office every year, he says. "We also know that chronic disease - hypertension and diabetes being the most prominent - cost Americans and their employers a significant amount of healthcare dollars. If you catch these diseases early, you can prevent their progression, improve quality of life and reduce medical costs."

The question is, what percentage of dental patients have undetected hypertension or undetected diabetes? Using data from the NHANES 3 database of the Centers for Disease Control and Prevention, Delta Dental’s Research and Data Institute ascertained that a significant proportion of patients not only had hypertension and diabetes, but somewhere between one-third and one-half didn’t even know it, says Jacobson.

Armed with this data, Delta Dental of Michigan has embarked on a pilot project with 25 dentists in mid-Michigan in which participating dentists will screen their patients for high blood pressure. If they detect a problem, they will recommend that the patient see his or her primary care physician, or (with the patient’s consent) they will offer a referral through Ingham Regional Medical Center/McLaren Health Care and the Michigan Primary Care Association. Ingham will conduct follow-up calls to the patients offering health education and further assistance. It is Delta Dental’s expectation that the primary care provider or Ingham Regional Medical Center will let the dentist know of any follow-up action taken.

"There’s a level of credibility in the dentist’s office that is higher than that of a shopping center or walk-in pharmacy," says Jacobson. "The dentist is a healthcare provider who can engage their regular patient in conversation because of an established relationship."

Delta Dental will help provide blood pressure monitors for participating dental offices. After the results of the pilot project are reviewed, the program could expand geographically and eventually incorporate other chairside screenings for diseases, such as diabetes.

"In my view, not only is the performance of the screening test critical," says Jacobson, "the second critical piece is that we’re partnering with a regional healthcare center. It’s one thing to screen a patient for high blood pressure. But now, what are you going to do with the information? We know that non-healthcare-site screenings have a low yield, because there’s no follow-up. With this beta test, we have a prescription for action.

"What we are proposing is simple and straightforward for the dental office," he continues. "We’re very conscious of how very busy dental offices are, and of imposing something complex or something that could introduce liability, and we’ve been working through those issues." He cites a survey at the most recent American Dental Association conference indicating that dentists would not shy away from the extra work. "Some 80 to 90 percent [of dentists surveyed] felt that, given a prescription for action, [blood-pressure screening] would not be interruptive to the office, and they saw a need to act in this role."

As the pilot project develops, Delta Dental of Michigan hopes to answer some key questions, including:

How many patients were discovered with undiagnosed hypertension?
Did they receive follow-up treatment from a physician?
What is the cost of blood pressure screening?
What is the return-on-investment of blood pressure screening?
What kind of cost-savings did the project yield for the patient or his/her employer?
Should dentists be reimbursed for performing basic medical screening? If so, how much?

"We’re taking a leadership position," says Jacobson. "If this model works, in order for others [such as employers] to sign on, they’ll want answers to these kinds of questions."

Future
While the pilot project deals with hypertension, Delta Dental is also interested in exploring other aspects of the connection between oral and systemic health. For example, analyzing seven years of dental and medical claims from Chrysler employees and their dependents, researchers from the Delta Dental Research and Data Institute and the University of Michigan School of Dentistry will determine if medical costs were lower for people with diabetes who also had treatment for inflammation of the gums. People with diabetes and poor blood sugar control are more susceptible to periodontal disease, according to Delta Dental. But a growing body of evidence suggests that the reverse is also true - that periodontal disease can adversely affect blood sugar control in those with diabetes.

The development of two separate health professions - one medical and one dental - has its origins in the early 19th Century, but the time is right to pull them back together, according to the Macy Reports. If dentists are to become full members of the medical team, two questions must be answered. First, will they be reimbursed for performing basic medical services, such as blood pressure screening? And second, in what other activities or disease states will they get involved after hypertension and diabetes?

The answer to Question No. 1 is unknown. Currently there are no CDT codes that relate to screening (unless it’s vital signs monitoring associated with the administration of anesthesia). And the answer to Question No. 2 depends, to a certain extent, on technology. While it’s unlikely that dentists will draw blood or collect urine for the kinds of rapid tests found in today’s physician offices, it’s not unlikely that, when salivary diagnostics are improved, dentists will find themselves performing those kinds of tests. Meanwhile, dental products distributors should watch closely as their dental customers delve into the medical side.

Sidebar:
Primary care docs tune in to oral health matters

As dentists experiment with basic medical screening, some primary care physicians are starting to pay more attention to their patients’ oral health. In most cases, they are performing basic checks for abnormalities in their patients’ mouths. In some cases, however, they may apply fluoride varnishes, particularly to patients who lack a regular dentist.

Pediatricians are ideally suited to get involved in oral health matters, says David Krol, MD, associate professor and chair of the Department of Pediatrics at the University of Toledo College of Medicine. "I have the opportunity, as a pediatrician, to see a child multiple times before he or she is a year of age, which is more frequent than my dental colleagues will see them. I have the opportunity - and responsibility - to give them anticipatory guidance or education on how to maintain good oral health." Krol is co-chair of the American Academy of Pediatrics’ Oral Health Initiative Steering Committee.

In the late 1990s, the American Academy of Pediatrics formed a Section on Pediatric Dentistry and Oral Health to improve communication between pediatricians and pediatric dentists, and to provide an educational forum for the discussion of problems and treatments related to oral health. Then, in 2003, the Academy published a formal policy for its members on oral health, titled "Oral Health Risk Assessment Timing and Establishment of the Dental Home." Later, with support from the federal government, the Academy developed a training program on oral health risk assessment for pediatricians and other child health professionals. (Krol was one of its authors.)

Pediatricians aren’t the only ones whose awareness of the link between oral health and systemic health is increasing. Other primary care physicians are making the same connection, says Russell Maier, MD, program director of the Central Washington Family Medicine residency, Yakima, Wash., and a chairperson of the Society of Teachers of Family Medicine’s Group on Oral Health. "The simple fact that cavities are an infectious disease - which is preventable - is new to most people. And primary care is all about prevention." The fact that some of their patients - particularly those on government-funded programs such as Medicaid - lack access to a dentist is another factor drawing primary care physicians to matters of oral health, he says.

Since its founding in 2004, the Society of Teachers of Family Medicine Group on Oral Health has developed and distributed a series of training modules called "Smiles for Life: A National Oral Health Curriculum for Family Medicine." The Group is assisting medical schools and residency programs in implementing oral health education programs.