A case for the integration of medicine and dentistry

There’s a window in the driveway to the dental school that always catches my attention.  Usually, the old, horizontal blinds are hanging at a lopsided, half-open-half-closed stance.  Occasionally, though, they are open all the way, and you can see inside.

For the first few months of my dental school education, I felt like that was my only window into dentistry: through the obstructed, double-paned division between me and the dental school basement.  If you looked past the cobwebs, through the dust of street sweepings, you could make out handpieces and stone models and alginate!  I wanted to be with that alginate!

But then, we had our first dental clinic, and then another, and another, always separated by at least two medical patient encounters, and I realized, without ever holding a handpiece or taking an impression, my clinical dental education, my life on the other side of that window, had already begun.

Every Wednesday, I meet another medical patient — in a hospital, at an outpatient medical clinic, or even in a family telephone call!  And reliably, these patients — including my family — present with medical concerns demanding expertise far beyond my short medical career, their chief complaints including bronchotracheomalacia, asthma exacerbations, and suicidal ideation, among other concerns.  Even more reliably, these chief complaints find a way of relating directly to what I have studied in class: the sympathetic activation of anxiety leading to changes in systolic blood pressure, the collapsing tracheal collagen leading to obstructive pulmonary disease.  My patients simply cannot help but integrate their medical ailments into physiology — who would have thought?!

But until these past few months, I hadn’t realized just how much dentistry I was performing when obtaining a hospital patient’s history of present illness or conducting a systemic, head-to-toe physical exam.

“Rosa,” I asked of my most recent hospital patient, leaning closer to the middle-aged woman with chronic respiratory illness.  “I know you have been in a lot of pain these past few months, so for your overall wellness, I was wondering if you could tell me how it has been taking care of your other needs, like your teeth, for instance?”

Rosa was reluctantly coughing through her phlegm, afraid to disrupt the tracheal stent she had placed.  “You know,” she answered, leaning towards me in return, “I keep forgetting to tell my doctor, but the pain is so bad that I clench on my teeth.” Rosa’s eyebrows were rising, her voice growing steady with the sudden energy of remembering something important.  “It’s so bad that I break my molars!”

Rosa and I finished our conversation about her surgeries and social supports, her kids in soccer leagues and her doctor in Baltimore.  “Thank you,” she said as I left, pointing to her teeth with another weak cough.  Had I not introduced dentistry into the realm of medicine, Rosa and I would have never clarified the true extent of her pain nor the added oral health cost of her condition.  We would have never spoken the same one-to-ten pain scale language, a language which Rosa seemed to believe even her attending doctor had yet to understand.

After meeting Rosa, every patient encounter was, quite simply, different.  Instead of separating my hospital experiences from my dental clinic experiences, the lines increasingly blurred.  The elderly man with an inguinal hernia was also a patient overdue for an oral cancer screening.  The young, Spanish-speaking mother presenting for a lower partial was also a woman slipping by the recommended preventative cervical cancer screenings.  Of course, these patients had stories and families and histories to share, but from a scientific standpoint, there was no line separating the dental from the medical domain.  All of their concerns and circumstances — medical, social and dental — had to find a place on the problem list.  And, surprisingly, in their existing charts, not all of these problems were yet offered their necessary place!

One day, I did finally make it into that room behind that window at the dental school.  And inside, just below the window, there’s a picture of a man with the title of DMD: doctor of dental medicine.  Not even a dash separates the dental from the medical, the teeth from every other nerve, tissue, and vessel of life.  Though our hospital and dental clinic walls sometimes create artificial barriers between the mouth and the rest of the body, there is no true separation.  And in my clinical experiences at Harvard, I have come to very much appreciate that fading barrier.

With a diabetic dental patient, how could I not concern myself with his HbA1c levels marking his three-month history of blood sugar control?  Diabetes and periodontitis are reciprocally related, after all.  With a man checking all the risk factor boxes for pancreatic cancer, how could I overlook his periodontal condition?  Both the American Medical Association and American Dental Association highlighted news of the correlation between pancreatic cancer and certain oral bacteria just this past week!  And with my post-operative cardiac patient, how could I not observe his oral health condition, infection a concerning risk in his recovering days?

I may have known this fact coming into dental-medical school, but I had to make my way across that dusty glass at the driveway of the dental school to finally appreciate the true importance of a rather simple concept: every dental patient has a cardiovascular system, and every cardiovascular patient has (real or prosthetic) teeth.

Our job as physicians and dentists is to always treat the patient as a whole.

So as dentists, it’s time we all proudly bring stethoscopes to work, as physicians, it’s time we all always include oral health questions and examinations in the visit, and as patients, it’s time we keep our medical providers accountable for remembering all of our moving parts.

Mirissa D. Price is a dental student who can be reached at her self-titled site, mirissa d. price.

Image credit: Shutterstock.com

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