Physicians, dentists collaborate on oral health

A shortage of dentists has led to some physicians providing preventive dental care for their patients.

By Damon Adams, amednews staff. Dec. 1, 2003.

Deborah Harper, MD, lives in a community with no water fluoridation. At her practice in Spokane, Wash., the pediatrician sees children with teeth rotting to the gum line.

Under these circumstances, she won't turn her back on a row of teeth, so she checks for tooth decay in her patients and shows them how to properly use a toothbrush. If need be, she refers them to a dentist.

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Dr. Harper isn't seeking to take the place of dentists; instead, she wants to be their partner. In a new push across the country, physicians and dentists are working together to address oral health problems, to provide basic dental care to those who would not get it otherwise, and to combat a shortage of dentists.

Physicians are no longer giving their patients' teeth the brush-off.

National groups such as the American Academy of Family Physicians want physicians to team with dentists. In North Carolina and Washington, family doctors and pediatricians do fluoride varnishes and oral assessments for children. In Maine, a family medicine residency teaches doctors to handle emergency dental care.

"I'm just identifying problems. I'm really good at finding cavities," Dr. Harper said. "I'm in their mouth anyway, so it doesn't take me any more time."

Tooth decay is the most common chronic childhood disease.

Doctors and dentists agree the partnership is needed.

Tooth decay is the most common chronic childhood disease, according to a spring 2003 report by the U.S. Dept. of Health and Human Services.

In 2000, the first Surgeon General's report on oral health cited a "silent epidemic" of dental and oral diseases and called for health professions to work jointly to improve the nation's oral health.

Hundreds of communities are enduring dentist shortages as dentists retire and dental schools struggle to keep up. Some dentists don't take Medicaid patients, prompting some of those patients to head to the emergency department when they have a dental flare-up. About 108 million Americans lack dental insurance.

In the last few years, physician groups and the American Dental Assn. have started to act.

This spring the American Academy of Pediatrics issued a policy statement recommending that pediatricians get basic knowledge to perform oral health risk assessments on patients starting as young as 6 months old.

108 million Americans lack dental insurance.

Last year AAFP delegates passed a resolution that encourages working with dentists and other groups to train physicians to prevent, identify and appropriately refer oral health problems. A resolution this year calls for the AAFP to explore having family physicians provide fluoride varnish treatments to children.

The American Dental Assn. is considering drafting a paper next year to address collaboration with physicians, said Al Guay, DDS, the ADA's chief policy advisor.

The American Medical Association has a representative on an ADA council that deals with interprofessional relations, Dr. Guay said.

"Since physicians see children earlier in life, it made sense for a collaboration," he said. "People don't think of taking their kids to dentists at an earlier age, so the pediatrician may pick up on problems or be one of the first links to educating parents."

Troubled by access problems for low-income children, health care leaders in North Carolina got federal funding to train physicians and nurses to deliver preventive oral health services to high-risk children up to age 3. That program, Into the Mouths of Babes, started about three years ago.

About 1,500 to 2,000 physicians and nurses have been trained to offer oral screening, parent education and fluoride varnish. Medicaid reimburses them.

Last year, the program had 40,000 visits, said Gary Rozier, DDS, professor of health policy and administration at the University of North Carolina School of Public Health in Chapel Hill, a program partner.

"Dentists have no problem with it here because they know they could see these kids if they wanted to, but they don't have the time," he said. "They realize we do have a shortage of dentists."

The North Carolina Dental Society said dentists raised concerns about physicians getting paid more, but those worries have subsided. For the most part, the dentists don't view physicians as a threat.

"If there's a real problem, [patients] are sent to a dentist," said Faye Marley, executive director of the 3,200-member society.

National dental leaders said dentists should not object to physicians providing basic dental prevention -- as long as they don't try to become a substitute for dentists.

No substitutes, please

"There shouldn't be turf battles. If we look at this as supplementing the children's dental home, it can only benefit the child," said Paul Reggiardo, DDS, a pediatric dentist in Huntington Beach, Calif., and president of the American Academy of Pediatric Dentistry.

In Washington, the Access to Baby and Child Dentistry Expanded program was launched in 2002. It partners dentists and physicians in much the same way as the North Carolina program. Dr. Harper, the Spokane pediatrician, and A. Chris Olson, MD, another Spokane pediatrician, participate in Washington's ABCDE program. They said the effort seems to be working.

"The impact it's had on our office -- we're just more aware of oral health," Dr. Olson said.

In Maine, the dentist shortage is so acute that some emergency departments have seen more people coming in with severe tooth pain. Many have no dental coverage and can't pay for a dental visit.

This year, Maine-Dartmouth Family Practice Residency in Fairfield received a one-year $50,000 grant to train family physicians in preventive and emergency dental care.

"One of the solutions is to introduce the mouth back into the body, rather than have it just be the purview of the dentist," said Wendy Wolf, MD, MPH, executive director of the nonprofit Maine Health Access Foundation, which awarded the grant.

Physicians said they want to help dentists with dental care, not take it over.

"Honestly, [collaborations] can only benefit dentists. When you identify a problem, you send them to the dentist," said David Schneider, MD, a member of the AAFP's commission on public health and a family physician in San Antonio, Texas. "I don't want to drill teeth. That's not my thing."