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WHY ISN’T DENTAL HEALTH CONSIDERED PRIMARY MEDICAL CARE?  
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Lola Butcher
March 21, 2024
Knowable Magazine
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_ Ailments of the mouth can put the body at risk for a slew of other
ills. Some practitioners think dentistry should no longer be siloed. _


Oral health and whole-body health are connected but doctors and
dentists typically are not, CREDIT: PAIGE STAMPATORI

 

The patient’s teeth appeared to be well cared for, but dentist James
Mancini did not like the look of his gums. By chance, Mancini knew the
man’s physician, so he raised an alert about a potential problem —
and a diagnosis soon emerged.

“Actually, Bob had leukemia,” says Mancini, clinical director of
the Meadville Dental Center in Pennsylvania. Though he wasn’t tired
or having other symptoms, “his mouth was a disaster,” Mancini
says. “Once his physician saw that, they were able to get him
treated right away.”

Oral health is tightly connected to whole-body health, so Mancini’s
hunch is not surprising. What is unusual is that the dentist and
doctor communicated.

Historically, dentistry and medicine have operated as parallel fields:
Dentists take care of the mouth, physicians the rest of the body. That
is starting to change as many initiatives across the United States and
other countries work to integrate oral and whole-body care to more
effectively tackle diabetes
[[link removed]],
cardiovascular disease, joint replacements and many other conditions.
The exact relationship between health of mouth and teeth and physical
ailments elsewhere in the body is not well understood — and in some
cases, is contentious — but experts agree there are links that
should no longer be overlooked.

In recent years, dental hygienists have started working in medical
clinics; physicians and dentists have started a professional
association to promote working together; and a new kind of clinic —
with dentists and doctors under one roof — is emerging.

“We are at a pivotal point — I call it the convergence era —
where dentistry is not going to be separated from overall health for
much longer,” says Stephen E. Thorne IV, founder and CEO of Pacific
Dental Services, based in Irvine, California. “Dentistry will be
brought into the primary care health-care team.”

Sick mouth, sick body

The list of connections between oral health and systemic health
[[link removed]] — conditions that affect
the entire body — is remarkable. For starters, three common dental
issues — cavities, tooth loss and periodontal disease — are all
associated with heart disease, the leading cause of death in the
United States. “To me, the number one hidden risk factor for the
number one killer in our country is oral health,” says Ellie
Campbell, a family physician in Cumming, Georgia, and board member of
the American Academy for Oral Systemic Health
[[link removed]], founded in 2010 to increase awareness of how
oral and whole-body health are related.

Periodontal disease, infection and inflammation of the gums and bone
that support the teeth, is the main culprit. Nearly half of adults 30
and older have periodontal disease; by age 65, the rate climbs to
about 70 percent. In the early stages, called gingivitis, gums are
swollen and may bleed. Periodontitis, a more serious condition in
which gums can pull away from the teeth, is the sixth most common
human disease.

Periodontitis is associated with a slew of systemic ills
[[link removed]]:
heart attacks, strokes, heart failure, diabetes, endocarditis, chronic
kidney disease, recurrent pneumonia, chronic obstructive pulmonary
disease, gastritis, rheumatoid arthritis, cancer and cognitive
impairment.

Bad habits, including tobacco use, alcohol consumption and high-sugar
diets, are implicated too. They raise the risk for cavities and most
oral diseases, and are also linked to ills such as cancer, chronic
respiratory disease and diabetes.

 
Such connections were apparently lost on officials at the University
of Maryland in 1837, when the university rebuffed a proposal from two
physicians to teach dentistry to the school’s medical students. At
the time, medicine wanted nothing to do with dentistry
[[link removed]], which was practiced by
unregulated and inadequately trained itinerants, says medical and
dental historian Andrew I. Spielman, a dentist and oral surgeon at the
New York University College of Dentistry. “There were a lot of
charlatans,” he says. “They had a very bad reputation.”

The dismissal prompted the rejected physicians, Horace Hayden and
Chapin Harris, to establish the world’s first dental school, the
Baltimore College of Dental Surgery. Today, dentistry is a highly
regulated profession, and the United States has 73 accredited dental
schools.

Despite their disparate training, both doctors and dentists are aware
that mouth health is important to whole-body health, Campbell says.
“Ask a family practice doctor and they will say ‘Oh yeah, if the
patient has diabetes, they’re going to have bad teeth and gums, and
I can never get their diabetes better until the dentist fixes their
gums,’” she says. “And the dentist is going to say, ‘Well,
I’ll never get their gums better until the primary care doctor gets
their sugar under control.’”

Mancini, the Pennsylvania dentist, says dentists often are asked to
examine a patient’s mouth before physicians will proceed with
certain treatments. “Physicians know any infection in a patient
who’s being treated for cancer could be very much
life-threatening,” he says. “The orthopedic guys are now sending
all of their patients to the dentist for the same reason.”

Hurdles to holistic care

But working together to improve a patient’s health is not as simple
as it might seem. A decade ago, the federal government hired the
National Network for Oral Health Access [[link removed]] to
run a pilot program merging oral and primary health-care centers. The
network’s dental consultant, Irene Hilton, a dentist with the San
Francisco Department of Public Health, said three barriers to
integration became clear.

The fragmented way that health care and dental care are paid for
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is one of them. While more than 90 percent of Americans have health
insurance, only 77 percent of US adults ages 19 to 64 have dental
coverage, which typically is sold separately from health insurance.
The nation’s largest insurer — the federal Medicare program —
generally does not cover dental services
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and nearly half of Americans 65 and over have no dental coverage.

That causes problems for patients who need, say, a joint replacement
that would be covered by insurance but who cannot afford the dental
work that is needed in advance. Surgeons won’t replace a knee until
patients first get their dental work done, Mancini says, “so we’re
kind of the barrier to them improving their life.”

 
Another barrier is that dentists and physicians are not routinely
trained to work with each other, Hilton says.

Dental students study anatomy, physiology and other sciences related
to the whole body, then home in on clinical care for mouth and teeth.
But many physicians have almost no training in oral health. A 2009
survey found that 10 percent of medical schools that responded offered
no oral health curriculum
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and 69 percent offered fewer than five hours on the subject.

A third issue is what Hilton calls infrastructure. In most cases, the
electronic health records used by physicians are incompatible with
those used by dentists, so sharing information electronically is
impossible. Likewise, dental offices are typically not embedded in
medical clinics, where doctor-dentist referrals might be easier.

If oral and systemic health are to be integrated broadly, “these are
the things that have to be overcome or addressed,” Hilton says.

The situation is not much different in other parts of the world. In
2021 the World Health Organization — noting that oral diseases are a
global public health problem
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affecting nearly 3.5 billion people — recommended that dentistry
focus more on prevention and be more integrated with primary care
services.

 

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Demonstrated links

In the past quarter-century, a great deal of research has demonstrated
the links between oral and whole-body health. For example, when
researchers followed 15,456 patients from 39 countries with stable
coronary heart disease for nearly four years, they found that those
who had lost the most teeth had the highest risk
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stroke, heart attack or cardiovascular death. Similarly, a study that
tracked 7,466 US adults ages 44 to 66 for an average of 14.7 years
revealed that those who had severe periodontitis had a greater risk of
cancer [[link removed]] than
those with no or mild periodontitis.

In 2015, the Harvard School of Dental Medicine launched an initiative
to support integration [[link removed]] of the
two fields — in education, insurance and professional practice. (The
initiative gets funding from dental product brands and health
insurance companies, and Thorne, the Pacific Dental Services CEO,
serves on its board.) “We’ve published papers identifying links
between periodontal disease and diabetes, hypertension, dementia,
adverse birth outcomes, low birth-weight babies, preterm birth,
spontaneous abortion, kidney disease,” says Jane Barrow, the
initiative’s executive director.

But correlation is not the same as cause and effect, and scientists
have not nailed down the exact relationship between periodontitis,
which affects more than 11 percent of the global population
[[link removed]], and various systemic
diseases.

Periodontitis is associated with bacteria in the bloodstream and
systemic inflammation, which can affect organs such as the liver and
bone marrow. That, in turn, can trigger or aggravate other conditions.
And the periodontal bacteria
[[link removed]]
— that travel via the bloodstream, inhalation or ingestion — may
also cause infections or exacerbate inflammation in other parts of the
body.

When the major professional societies for periodontology in the United
States and Europe convened a group of global experts in 2012 to review
the science, they concluded that it was “biologically plausible”
that the inflammation of periodontitis ups the risk of cardiovascular
disease and influences type 2 diabetes and other maladies – but
“plausible” was as far as they would go.

Seven years later, the European Federation of Periodontology and the
World Heart Federation again gathered experts to review new studies on
the link between periodontitis and cardiovascular problems. Again,
though scientists had made some headway in identifying possible
biological mechanisms to explain the link, experts have since
concluded that the evidence does not yet prove
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that periodontitis actually _causes_ strokes, heart attacks or
anything else.

Flipping the question on its head, does preventing or treating
periodontal disease help to prevent heart problems? Several
observational studies, in which researchers observe individuals and
measure particular outcomes, but don’t intervene, suggest that oral
health care, including toothbrushing and dental cleanings, make a
difference. For example, a study that tracked the health habits of
11,869 adults 35 and older in Scotland found that within eight years,
those who rarely brushed their teeth had more cardiovascular problems
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brushed twice a day.

 
That still does not prove that preventing periodontitis will hold
heart problems at bay: Some other habit or feature of the
toothbrushing group could have been the important factor. The
relationship is difficult to tease out, Barrow says, because people
who are taking good care of their mouths tend to take good care of
themselves in general. “Could you say that people who are taking
care of their mouths are in better health overall? You would probably
find that to be true,” she says. “Is it because they’re taking
care of their mouth? I can’t say that.”

And nobody else should say that either, according to a 2018 editorial
in the _Journal of the American Dental Association_. The coauthors, a
group of dental and public health researchers, cautioned against
overstating the oral-systemic health connection
[[link removed](18)30240-X/fulltext]. “The
main reason for maintaining good oral health is because it is
important in and of itself,” they wrote.

One of the contributors, Bryan Michalowicz, a dental researcher at
HealthPartners Institute in Minnesota, later led a team that reviewed
the medical records and insurance claims of 9,503 patients to see if
periodontitis treatment improved the health outcomes of those with
coronary artery disease, cerebrovascular disease or type 2 diabetes.

Overall, cardiovascular patients who received dental treatment and
follow-up maintenance saw no difference
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in the rate of heart attacks, strokes, bypass surgeries or angioplasty
procedures compared to those who were not treated, the team reported
in 2023. Likewise, periodontal treatment did not significantly lower
the blood-sugar levels in patients with type 2 diabetes.

Overdue integration

But the data suggesting connections have been enough to spark many
grassroots efforts at integration. In addition to the American Academy
for Oral Systemic Health, the National Network of Healthcare
Hygienists [[link removed]], founded by
hygienist Jamie Dooley in 2018, helps prepare hygienists who want to
integrate oral health into health-care systems.

And in California, Thorne’s business is trying to make those
interactions easy by putting dental and medical services under one
roof. In December 2023, Pacific Dental Services opened a clinic,
Culver Smiles Dentistry, in a space shared with a medical practice.
It’s the first of 25 planned dental-medical practices that will
operate through a partnership between MemorialCare
[[link removed]], a big Southern California health
system, and Pacific Dental.

Health-care leaders, Thorne says, are beginning to realize that they
can improve their patients’ health by incorporating dental care into
primary care.

It’s sort of crazy, he says, that our mouth and our jaw and our
throat have been considered separate from the rest of our body for so
long. “It is changing now, and health care is realizing that the
mouth is the gateway to so much of our overall health.”

_More articles by Lola Butcher
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_About Knowable Magazine
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