Wednesday, March 22, 2017

The divide between dentistry and medicine can have deadly consequences; policymakers are getting more interested

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As anyone who has ever mistakenly thought that medical insurance would cover their visit to the dentist knows, the worlds of medicine and dentistry don't overlap much.

They almost never overlap when it comes to education, insurance coverage or practice. Physicians go to medical school, and dentists go to dental school. Your doctor likely isn't concerned with whether you floss regularly, and your dentist is probably uninterested in your exercise habits.

But they probably should be, since the body doesn't know it's supposed to keep oral health problems separate from other medical issues, and the two commonly overlap. In fact, oral health problems can lead to dire medical complications if left untreated, according to the National Institute of Dental and Craniofacial Research.

Mary Otto explores this strange divide in her new book, Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. One story that shapes Otto's book is the tragic case of 12-year-old Deamonte Driver, who died in 2007 after bacteria from an abscessed tooth infected his brain.

Otto discussed the history of dentistry, its practices and the cultural divide of good oral care in an interview with Julie Beck of The Atlantic magazine. She described the first push for reform in the 1920s by William Gies, a biological chemist.

"He visited every dental school in the country and in Canada for the Carnegie Foundation, for this big report, and he called for dentistry to be considered an essential part of the health-care system. He said: 'Dentistry can no longer be accepted as mere tooth technology.' He wanted oral health and overall health to be integrated into the same system, but organized dentistry fought to keep dental schools separate," Otto told Beck.

Former Surgeon General David Satcher called for reform again in his 2000 report "Oral Health in America." "He said we must recognize that oral health and general health are inseparable," Otto said. "And that too, was a kind of challenge. And it seems like things are changing, but very slowly."

An an example of the effect of separating dentistry from medicine, Otto said more than a million Americans visit emergency rooms with dental problems each year.

"It costs the system more than a billion dollars a year for these visits," she told Beck. "And the patients very seldom get the kind of dental care they need for their underlying dental problems because dentists don’t work in emergency rooms very often. The patient gets maybe a prescription for an antibiotic and a pain medicine and is told to go visit his or her dentist. But a lot of these patients don’t have dentists. So there’s this dramatic reminder here that your oral health is part of your overall health, that drives you to the emergency room but you get to this gap where there’s no care."

Otto said that all the health-care programs we’ve had in our nation's history, including private insurance, have on some level neglected oral health or treated it as a fringe benefit. She said oral care highlights the economic inequality in America, because many dentists are focused on expensive, cosmetic procedures.

"Of course there is a lot more money to be made with some of these really high-end procedures. But on the other hand there’s this vast need for just basic, basic care," Otto told Beck. "A third of the country faces barriers in getting just the most routine preventive and restorative procedures that can keep people healthy."

Rural and poorer areas face shortages of dentists. Otto said a group of dental hygienists in South Carolina, where 250,000 children living in rural areas aren't getting dental care, fought to change state law so they could serve the needy kids without them first having to see a dentist. The dentists' lobby fought back, but the Federal Trade Commission stepped in and won the case for the hygienists "in the interest of getting economical preventive care to all these children who lacked it," Otto said.

Dentists say they're not to blame for such problems. "Organized dentistry continues to say the current supply of dentists can meet the need, that if the system paid more for the care, more providers would locate in these poorer areas, that we Americans need to value our care more and go out and find care more aggressively," Otto said. "They see the fault as being with society at large."

What does Otto see as the solution? She said something that needs to be discussed more in dentistry is the "Triple Aim," a concept discussed in planning for the Patient Protection and Affordable Care Act. It involves bending the cost curve toward prevention, expanding care more broadly and more cheaply, and creating a better quality of care.

"It seems like it’s capturing an increasing amount of attention from state lawmakers, governors, and public-health officials who are interested in bringing costs down for all kinds of health care and seeing that these things show promise," she said. "They're saying we’re spending too much on emergency rooms, we're spending too much on hospitalization for these preventable problems, so there are cost incentives to get more preventive and timely routine restorative care to people."

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