Of all parts of the human body, only feet and teeth have their own separate health care providers. Feet have podiatrists (although they also have orthopedists/medical specialists). Teeth have dentists and only dentists—there are no medical specialty fields that deal with teeth. Oral surgeons may do some crossover work in medicine, but in the U.S. at least they are still considered dentists. As we all know from living in/with our own bodies, feet and teeth have a lot to do with our overall health. I’ll deal with feet in some future posts, but today I want to take a closer look at teeth and oral health.
First of all, why are dentistry and medicine so separate? That seems to stem from a historical artifact, having to do with the history of Western Medicine, the separation of physicians (higher class) from surgeons (lower class, tied to trades). Surgeons—including ones who did crude dentistry—tended to be barbers, blacksmiths, and silversmiths. Supposedly Paul Revere, our Colonial patriot and silversmith also dabbled in dentistry. Revere developed the field of forensic dental science. The father of dentistry is considered to be the 17th Century Frenchman Pierre Fauchard. He encouraged the gargling of human urine as prevention of dental carries. I assume this was before the concept of minty fresh was popularized.
The continued separation of dentistry and medicine is problematic on many levels. It explains why we have separate medical and dental health insurance industries in our country. It explains why dental insurance and dental care are so expensive, and why dental care is viewed as a luxury item available mainly to the rich. It explains why the American Dental Association is engaged in a turf war trying to block the development and expansion of so-called dental mid-level providers (also called “supervised dental extenders” or “dental therapists.”). It explains why nursing and medical students get little to no education or training in oral health.
Dental problems lead not only to pain, infection (including fatal infection), and tooth loss, but they also contribute to the increased risk for serious medical conditions such as diabetes, heart disease, and poor birth outcomes. Poor people, persons of color, immigrants/refugees, and people living in rural areas of our country have a higher burden of dental problems and less access to dental care. In 2009 (latest available stats I could find) there were 830, 590 emergency room visits in our country specifically for dental problems; this was a 16% increase from 2006. The overwhelming majority of dentists in our country are located in affluent suburbs, and most refuse to treat Medicaid patients. The Healthy People 2020 report includes oral health as a leading indicator of U.S. population health, the first time oral health has been included in our national health guidelines.
The ACA has included children’s dental care as an essential health benefit, but worrisome loopholes in the proposed implementation of the law have developed. As currently worded, dental care would be ‘essential’ as long as dental coverage is offered as an ‘add on,’ meaning that parents could opt out of dental care without being assigned penalties. There is also concern that individual and small group markets under ACA don’t have to cover adult dental coverage. (see: “Gaps in health law dental coverage” by Paige Winfield Cunningham, 2/15/13, Politco).
Some of my nursing students have asked me about their potential ability to get more involved in oral health/dental primary care, over and above the usual dental hygiene/ oral health literacy they know they can do. This will vary by state professions licensing/regulatory laws, but in Washington State nurses can and do provide community-based fluoride varnish services for high-risk children and adults:
“Medical personnel working under the delegation of a licensed physician with documentation of completion of a training program on fluoride varnish are also qualified to apply fluoride varnish in health settings.” (source: Washington State Department of Health website, “Fluorides and Fluoridation.”)
Dental Crisis in America: The Need to Fix Access. U.S. Senate Report. Senator
Bernard Sanders/Committee on Health, Education, Labor and Pensions. Subcommittee on Primary Health and Aging. February 29, 2012.