More than Just the Teeth

By Victor Lee

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It was nine thirty in the morning and I just finished calling my patient for the second time. I start the process to cancel my patient for missing the appointment and it pops up on the patient management screen that my patient has arrived. It turns out that she came from east Bronx and it took her over two hours to get to the clinic. I greeted my patient and asked her what brought her into today. As I took her blood pressure, she explained that she hasn’t been the dentist in ages. Her reading was165/92. Stage II Hypertension. I checked her other arm to make sure the reading was correct, and I asked her what her normal blood pressure was. She didn’t have the slightest idea. I bring her blood pressure reading to the attending faculty member and I was instructed to send her home. She could not be treated until she had a medical clearance form signed from her doctor. This form is literally a permission slip from the physician for the patient to see the dentist. One of the most frustrating things for any provider to do of their patients is to turn them away. It made me wonder what type of care our healthcare system is giving our patients. I thought about what type of compliance do I expect to receive from this patient who traveled all this way to see me only to send her home.

Lately, the healthcare system has been fascinated by this notion of patients-centered care. Though it is easy to speak about it, it is much harder to put this into practice. In the example above, can a clinic say they are patient centered when all they can do for a patient, after a 2 hour commute, is send them home? If we want to address this matter then we must ask questions about the training that the dental students receive. We need to start thinking about how dentists can provide care for their patients if they cannot understand the bigger picture of what they’re up against. This is also reflective of the holistic direction that healthcare is moving toward. And if we expect dentists and doctors to collaborate with each other then they must have the same basic understanding of how the body works. The paradigm for health practices is shifting towards group practices and more inter-professional collaborations to address this need for patient centered care. Dentists are only realizing this when they are already part of the profession. It is crucial that we introduce this to students early on in their professional training so that when the idea has to be put to practice in the professional world it can become a reality. Curriculum change to a more complete education is vital for preparing dentist for a more integrated healthcare system that is patient centered.

We are transitioning from an era where the only body part that dentist paid attention to was the mouth to a time where a dentist needs to fill the role of a full-on health care provider. Dental education must be designed to prepare students to see what they are going to encounter when they go into practice. They are going to see more complex cases and patients with multiple medical complications. It is no longer acceptable nor is it fair for a dentist to pass their patients through the primary care physician before receiving treatment. Dentists must be trained to identify these problems and part of the solution for their patient’s care. If we truly want to move forward to a more patient focused care, a dentist must understand that the mouth is an extension of the body. On the other hand, physicians must also be prepared to identify common issues that can arise in the in oral cavity. It is a two way street for both parties.

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The other side of the coin tells us that having a more in-depth medical curriculum is unnecessary for dental students. In reality, why would a dentist ever need to learn about the different bones and joints in the knees? Many wonder why would anyone ever consult their dentist about their renal disease. The truth is that they are two different fields of study, but they are more closely related than many people think. Patients getting treated for osteoporosis, which mainly affect the knees and joints will also be more prone to jaw fractures. This is an important detail to understand when patient undergo any kind of oral surgery. Patients with renal failure may also benefit from nutritional consultations from both the dentist and the physician. This transdisciplinary can optimize the patient’s oral and overall health. This approach in its truest form is patient-centered care. This is the type of care we want to design our education around.

The didactic course is a critical element of dental school education. It usually consists of the first 16 to 24 months of a 4-year dental program. At the end of it all, a student must take the part I of the National Board Dental Examination. The exam consists of 400 questions ranging from dental anatomy to biochemistry to pathology. This exam is basically the culmination of their dental education up to that point. In many instances, the material is hardly touched or brought up again during the rest of their dental education. As mentioned earlier, this information is becoming more and more valuable to the dental practitioner as they will need to apply this knowledge to their treatments. More often than not the biomedical curriculum is catered to this exam, which is just the memorization of pure fact rather than the applications of the knowledge. This is a disservice not only to our students but also our patients if we don’t utilize the resources in education.

The biomedical curriculum has been a hot topic since the inception of dental schools. There have been valid arguments on both sides on the level of detail versus the amount of application that a dental student should to know of the other systems in the human body. This has lead to huge disparity in curriculum hours devoted to a subject like the cardiovascular system. With the healthcare moving to a more holistic approach to patient care, a dentist should have the same basic understanding of what physicians know. More importantly, they should learn how they can apply that same knowledge to their own practice and patient care. What the information allows us to do is treat our patients better. If we have a getting understanding of where their overall health stands then we can do a better job getting patient where they need to be.

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If we want to live in the society where healthcare providers collaborate, we must have an education system the mirrors this sentiment. We come from a past where dentistry was practiced in an entirely separate entity from medicine. Patients with pain their mouth would exclusively go to the dentist and for everything else to their physician. This cannot work any longer. Patients with systemic diseases can have dramatic changes the type of treatment they receive from a dentist if the dentist is equip the knowledge to fully understand those medical implications. Even prescription medications can have severe contraindications for types of treatment. Schools must teach their students so that they can learn to apply this information during their training so that they can administer proper treatment in the future. This is not limited to only giving dental student a more board biomedical curriculum but also teaching medical students the working of the oral cavity.

Back to the example at the beginning of this piece and the question of helping patients like the one with hypertension. The first is being able to understand the implications of what happens when a patient presents with uncontrolled high blood pressure or other signs of poor health. Just sending them to their primary care physician is not an example of patient-centered care, particularly then when they traveled all this way to see the dentist and may not see a doctor regularly. Providing a little bit of basic information of why their condition may affect their treatment and their overall health much better than doing nothing for the patients. This also can also help the student see the condition as something they should monitor rather than just a hindrance of their dental care. The schools need to integrate how the provider should go about working with the physician in order to properly treat the patient.

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