Abstract
The dental profession is responsible for the prevention, diagnosis, and treatment of diseases and disorders of the oral cavity and related structures. Although the majority of the US population receives excellent oral health care, a significant portion is unable to access regular care.
Along with proposals to develop midlevel providers, the scope of practice for dentists needs to be reconceptualized and expanded. A broad number of primary health care activities may be conducted in the dental office, such as screening for hypertension, diabetes mellitus, and dermatopathology; smoking prevention and cessation activities; and obesity interventions.
More than 70% of adults saw a dentist in the past year, which represents an unrealized opportunity to improve both oral health and general health.
ALL PROFESSIONS, AND ESPEcially the health care professions, are in a constant state of self-assessment aimed at advancing their disciplines in a consistent and measurable fashion. For the health care professions, the goal is to improve patient health, increase efficiency in the health care system, and ultimately enhance society as a whole.
This evolution is expressly true for the dental profession. The changes that have occurred in the field over the past 50 years, and particularly in the past 20 years, have been transformative. Fluoridation of the water supply has been identified as one of the top-10 public health initiatives of the 20th century and has resulted in a 30% to 50% reduction in dental caries. 1 As another example, the introduction of osseointegrated dental implants has changed the clinical approach to managing partial and total edentulism (loss of teeth), and offers patients an expanded range of options for replacement. 2 Furthermore, the development of new dental materials has allowed the profession to offer aesthetic options to patients that can transform a smile, an appearance, and in some cases a life.
Nevertheless, the dental profession is now faced with many challenges and questions. Chief among these is the equity issue, as those who are poor, disabled, aged, and living in urban or rural areas have difficulty accessing oral health care services. 3–6 This challenge has led to proposed changes in the oral health workforce in the United States that has elicited contentious debate within the dental profession. The introduction of midlevel providers is especially controversial. 7 The perception exists that this change is being driven from outside the dental profession with calls to create a new type of dental provider in the United States that is equivalent to the “dental nurse” that has for decades provided services to students in New Zealand. 8 An issue that is equally relevant and related to any discussion of the oral health care workforce is the need for the dental profession to define its future, specifically in the context of health care reform in the United States. As the population ages and chronic illnesses affect a larger percentage of those seeking and requiring dental services, will the profession be prepared to comprehensively treat these patients? This situation is further complicated by the near total exclusion of oral health care services in Medicare and the general absence of dental services for adults in US health care reform. 9
The scope of dental practice has been defined by the American Dental Association House of Delegates as: The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law. 10
When one considers this rather broad definition and the ongoing debate about the future of the dental profession and dental education—which was addressed in reports by the Institute of Medicine 11 and the American Dental Association, 12 and which is currently being examined by the American Dental Education Association (ADEA) 13 —what are the compelling issues on the horizon? As defined for ADEA, 3 major concerns loom large. 14 First is the financial challenge of educating dental students in the university environment with implications for student career choices related to the accumulated educational debt at graduation. Second is the overwhelming issue of access to care for all Americans and the “resultant potential for marginalization of dentistry as a specialized health care service available only to the affluent.” 14(p16) Third, the fundamentals of dental education need to be revamped, because they are presently “convoluted, expensive and often deeply dissatisfying to its students.” 14(p16)
Accordingly, the following questions regarding future challenges for the profession need to be addressed by dental schools. First is how to provide care to the underserved in our society, specifically the poor, the disabled, the aged, and the geographically isolated. Second, and related, is what strategies should be employed to provide that care, which includes the use of midlevel providers, also known as dental practice extenders. Such practitioners would provide basic dental services to underserved populations, under the direct or indirect supervision of dentists. Third is how to meet the cost of providing requisite dental services. The introduction of new technologies and procedures has equipped the profession with more effective and efficient approaches to solving clinical problems. Yet, associated with these advances is a concomitant increase in the cost of services. Finally, an overarching question is what role dental professionals will fill with regard to the general health and well-being of patients under their care. Stated differently, where does the dental profession fit into the broad scheme of health care in the United States?
Advances in dental technology have led to dramatic improvements in the ability of practitioners to restore tooth structure, replace lost teeth, and change the appearance of intrinsically or extrinsically discolored or malposed teeth. These treatments offer what are arguably the most aesthetically pleasing and functionally efficient results in all of health care. Up to this point, the profession has focused heavily on this technical aspect of care, with recent emphasis on new restorative materials and osseointegrated implants to replace lost teeth.
Advances in clinical care in dentistry have been dramatic, but the profession has for decades attempted to define its more general relationship to patient health, specifically the importance of oral health to general health. There are at least 4 reasons to emphasize this aspect of oral health care.
The first reason is the ability of patients to tolerate dental care and any necessary modifications to care that are required before they can be treated uneventfully. For example, patients with artificial heart values will require antibiotic prophylactics before dental treatment. 15 In addition, patients with diabetes mellitus should be treated when they are not at risk for hypoglycemic episodes. 16
Second, many diseases and disorders can have important effects on oral health. For example, periodontal disease is more prevalent in patients with poorly controlled diabetes. 17 In addition, oral manifestations are a prominent part of the presentation of patients with HIV infection. 18 Distinct oral lesions were characterized early in the HIV epidemic and can be important in the staging of disease. 19
Third, oral infection, and specifically periodontal disease, has been identified as a risk factor for diseases and disorders at distant sites, including cardiovascular and cerebrovascular disease, 20 diabetes, 17 adverse obstetric outcomes, 21 and respiratory diseases. 22 Inflammation associated with periodontal disease, contributing to the total systemic inflammatory burden, is an underlying common theme for these relationships.
Finally, the US population is aging. Thus, dentists will care for a larger number of older patients, who will present with chronic diseases that are managed with an ever-increasing number of medications. It is estimated that by 2050, 1 in 5 persons in the United States will be 65 years old or older. In addition, people in the United States are retaining their teeth, and after years of use, these individuals will require more dental services. Unfortunately, Medicare does not provide general dental benefits, so being able to afford care, especially advanced care, will be beyond the means of many older adults. 23
The confluence of these factors suggests the need to reexamine the role of dentists and dental professionals in general health care. That is, oral health care can be reconceptualized as part of primary health care services. 24 As such, dentists have the opportunity to provide care that extends beyond the traditional boundaries of dental services. The introduction of certain primary health care activities as part of routine dental care can better ensure that dentists effectively manage the oral health care needs of their patients. At the same time, overall patient health may improve as primary care activities undertaken during dental visits may lead to appropriate referrals to other parts of the health care system.
As envisioned, primary health care in the dental office should begin by focusing on activities that directly impact the provision of oral health. 25
Prevalence of hypertension is high, and dentists have been encouraged to participate in screening for hypertension for more than 30 years. 26
In addition to other diseases attributed to smoking, the occurrence of both oral squamous cell carcinoma and periodontitis has been shown to be directly linked to smoking cigarettes. Smoking cessation, therefore, is a critical health care intervention that dentists must embrace and actively practice. Excellent support material is available for training. It is acknowledged that the rate of recidivism following cessation attempts is high; however, it has been shown that even a very basic intervention by a health care provider can have a measurable beneficial effect on the prevalence of smoking. 27
Diabetes is a major health care problem in the United States and around the globe. The current epidemic of type 2 diabetes is attributable in part to the epidemic of obesity. Approximately 7% of the adult population in the United States has diabetes, and 25% of these individuals are not aware of their condition. Diabetes is the only systemic disorder that has been definitively identified as a risk factor for periodontal disease. 28 Other oral disorders that have been associated with diabetes include xerostomia (salivary hypofunction) and fungal infections. Furthermore, periodontal disease has been identified as a risk factor for poor metabolic control in patients with diabetes. 17 Therefore, it is particularly important for dentists to be aware of patients who have a diagnosis of diabetes. Potentially, screening of patients for suspected diabetes can be made by using chair-side tests for blood glucose or glycosylated hemoglobin. These screening tests will need to be followed by a more comprehensive evaluation for diabetes, including a fasting plasma glucose or laboratory-based assessment of glycosylated hemoglobin.
Sleep apnea is a problem that may be first recognized in the dental office. It affects 4% of men and 2% of women between the ages of 30 and 60 years. 29 Serious health problems have been associated with sleep apnea, including cardiovascular and respiratory diseases. In addition, dentists can be very involved in treating these patients. This care can involve mandibular advancement appliances and surgery to remove portions of the soft palate and uvula.
Osteoporosis is a serious disorder among older adults wherein patients present with a reduction in bone mass and are at risk for fractures. Considerable evidence indicates that the density of the mandibular bone is related to general bone loss. The gold standard for assessment of skeletal bone universal density is dual-energy x-ray absorptiometry, but dental radiographs, and in particular panoramic films, may be helpful in directing patients to seek additional follow-up. 30 This assessment can be made from radiographs taken as part of regular dental care.
More than 30% of American adults are considered to be obese. This poses a serious public health challenge because obesity is a risk factor for many diseases, particularly type 2 diabetes and cardiovascular disease. Conversely, successful weight loss is associated with important health benefits. Oral health providers are experienced in delivering nutrition and carbohydrate intake messages. With appropriate training, they can actively participate in programs aimed at weight reduction. 31
When appropriate, these primary health care activities must trigger referral to other parts of the health care system. If the screening or intervention yields a positive outcome, and the patient receives treatment, health will improve, with reduction in morbidity and mortality. Furthermore, to more fully promote interprofessional practice, nondental health care providers must be better trained to identify oral and dental diseases.
The importance of primary health care messages is widely recognized. Many initiatives occur within the community including blood pressure screenings at consumer malls and smoking cessation messages promoted on television and billboards across the country. Nevertheless, if these activities take place in the dental office, they will need to be implemented in an organized fashion as part of the regular office routine. Oral health care providers will need to receive additional training with regard to background information and rationale, as well as the proper use of evidence-based techniques and procedures. By extension, these activities will need to be part of the dental school curriculum or perhaps a component of postdoctoral training. It may also be necessary to evaluate state and federal practice laws to be sure that the dental office is in compliance with the scope-of-practice guidelines for each jurisdiction. Furthermore, for all of the primary health care activities listed previously, a successful outcome requires communication with the patient's medical provider. If integrated care is provided, the result will be patients who are healthier, who are better able to tolerate outpatient dental care, and who realize improved oral health outcomes.
Reimbursement for services is critically important. Specifically, will these services be reimbursable from insurance companies and state agencies? This issue has begun to be addressed, as private insurance companies have begun to increase covered services (i.e., the frequency of cleaning visits) for individuals who have a medical diagnosis of diabetes mellitus or cardiovascular disease. Research has identified periodontal disease as a risk factor for both disorders. 32
Today, a majority of a dentist's time is spent on direct provision of care, with relatively little time spent on patient evaluation and interaction with other health professions. The goal of educating dentists as members of health care teams will require fundamental changes to dental education. The predoctoral curriculum must place increased emphasis on the importance of patients’ general health on the provision of oral health care. At present, dental schools in the United States vary greatly in this aspect of preclinical education. This change is in anticipation of a shift in the percentage of effort devoted to primary care activities in the dental office and the greater contact with other health care providers that would occur as a result. With this new model, a variety of patient benefits are anticipated. 33 Furthermore, more time will need to be devoted to the management of complex cases.
It is generally recognized, however, that at present dentists and physicians do not regularly interact on a professional basis. Exceptions include some hospital dental services and Federally Qualified Health Centers. The introduction of primary care activities in the dental office will change this situation.
This new model of dental practice has significant implications for dental education and requires a commitment by dental schools to add this aspect of training to the predoctoral curriculum. This change needs to begin during dental education with an emphasis on interprofessional education. This is not a simple matter, as the predoctoral dental curriculum is already recognized to be too crowded given the need for dental schools to graduate students who are competent to begin independent practice. At least in part this matter can be addressed by another controversial issue: the need for a mandatory postgraduate year (PGY1) in dentistry. 34
In the model proposed here, the importance of mandatory additional training for dentists beyond the usual 4 years of predoctoral dental school education cannot be overstated. For licensure as a dentist in most states in the United States, dental students must graduate from an accredited dental school and then pass a licensure examination that is region-specific and involves clinical procedures performed either in a simulation setting or with patients. The pathway to licensure in medicine is different and requires a minimum of 3 postgraduate years of additional training.
The requirement of a mandatory PGY1 for all dentists has been discussed for nearly 30 years. 35 At the time of this writing, only 2 states (New York and Delaware) require at least 1 year of postgraduate training to be licensed. Four other states (California, Connecticut, Minnesota, and Washington) offer graduates an option to obtain licensure: either an accredited postgraduate program of at least 1 year in length, or a clinical licensure examination. 36,37
The influence of a PGY1, specifically a 1-year general practice residency (GPR), on dentists’ practice patterns, has been evaluated. 35,38–41 A comparison of practice patterns of dentists who had completed a 1-year GPR versus those who went directly from dental school into practice revealed that dentists with a GPR were more likely to be affiliated with a hospital or long-term-care facility and were more likely to treat medically compromised patients. The types of services provided by dentists with a GPR experience also differed from the services provided by dentists who did not have this training. Dentists who completed a GPR were more likely to perform surgical procedures including tissue biopsies, oral surgery, periodontal surgery, and implant replacement. Dentists with GPR training were also reported to read a greater number of journals and publish more articles. Another interesting conclusion was that the wider range of services provided by GPR-trained dentists may help address access to care issues, as these general practitioners may choose to practice in more rural areas because they are not as dependent on the availability of dental specialists. 39
For this model to be successfully introduced, there will need to be a redistribution of responsibility among the members of the oral health care team. It is logical and necessary for dentists to assign treatment of uncomplicated problems to other members of the oral health care team, including midlevel providers. There is active discussion of this issue, which is controversial. 42,43 Nevertheless, with a change in the workforce, it can be expected that dentists will assume a more supervisory role. If this model is adopted, the practice of dentistry will see a shift away from its strong emphasis on procedures to a greater emphasis on cognitive activities.
In addition to incorporating aspects of primary care into dental practice, the dental practitioner of the future must consider 2 other areas of oral health care delivery that will contribute to the change in time utilization by dentists in practice. First is the need to improve diagnostic acumen for the full range of oral, dental, and craniofacial disorders that present in a dental practice. This range includes not only dental caries, pulpal diseases, and the periodontal diseases, but also mucosal diseases, salivary gland diseases, disorders of the temporomandibular joint, and other head and neck pain syndromes, as well as other bacterial, fungal, and viral diseases affecting the oral cavity. Many of these disorders are chronic, with periods of exacerbation and remission. They therefore require identification of active verses quiescent disease and an understanding of future disease risk that will allow an appropriate treatment plan to be developed for the patient's individual risk level. New diagnostic tests and devices will be part of this assessment, and many such techniques have been introduced. Decision support tools are also being developed. Only appropriate clinical evaluation of these techniques will identify those that should become part of dental practice. 44
Included in this new practice paradigm will be consideration of the use of saliva-based diagnostic tests. 45,46 Saliva is being studied as a diagnostic fluid for oral, dental, and craniofacial disorders, as well as for systemic disorders that range from breast cancer to diabetes. Who will “own” the use of saliva as a diagnostic fluid? Considering its ease of collection, certainly no single health care discipline will own it, but dental practitioners should be thoughtfully considering how the analysis of saliva can be incorporated into dental practice in the future.
Finally, dental practice is now faced with the introduction of new technologies that will change the delivery of dental care services. These services include cone-beam axial tomography, 47,48 digital impression techniques, 49,50 and computer-aided design and computer-aided manufacturing restorations. 51 These techniques will change how dentistry is practiced and will lead to new paradigms for dental care.
The concepts presented here are not new. In fact, similar proposals have been made by Gies 52 and Owre. 53 More recently, comparable suggestions were offered in the Institute of Medicine report Dental Education at the Crossroads. 11
In consideration of this expanded definition of dental practice, a related argument that has been debated in the literature is the use of the name “oral physician” in place of “dentist.” These arguments 54–57 center around other health professions that have added the term “physician” to their description, including podiatrists, chiropractors, and optometrists. For dentistry, the argument is based on the many oral manifestations of systemic diseases, described linkages between oral infection and inflammation and diseases and disorders at distant sites (e.g., cardiovascular disease), and the biomedical education that is a component of predoctoral dental education. Although most commentary is provided by academics in the United States, this argument is not limited to one country. Tanaka et al. 57 in Japan have argued that the aging of the population and advances in health care require this change. Their focus was in the complete integration of dentistry into medicine.
A modified argument has been presented by Nash, 54 who concluded that the name “oral physician” should only be used if dentists complete the MD degree. Assael 56 argued against the use of this designation. He stated that maintaining the dental profession's independence is important because the profession has evolved into a valuable health care discipline that is professionally rewarding for its members and important for the public. This special identity would be lost if the name “oral physician” were adopted. Furthermore, he concluded that the nature of the medical and dental professions is inherently different because dentistry demands a greater focus on technical solutions and is resource-intensive. This difference would be lost if it were another branch of medicine. Finally, he noted the contemporary challenges faced by the medical profession and argued that it would not be wise for dentistry to assume those problems.
This wider debate is not merely semantic but is central to the topic of this article. Much of this academic argument focuses on what is best for the dental profession and its members, but the more important issue is what is best for the patients served by the dental profession. It has been reported that in 2008, 71.2% of adults had seen a dentist or visited a dental clinic in the previous 12 months. 58 An introduction of primary health care activities in the dental office can have a positive impact on the overall health, not just the oral health, of dental patients. This can occur regardless of the name used to describe the providers of dental care.
The introduction of primary health care activities into the dental office will benefit patients who now routinely seek dental services (and who also utilize medical care services). Even if diagnosed, chronic diseases are not often well managed. 59 For those patients who do not generally utilize health care services and are likely to only be seen in a dental office for emergency situations, health care screenings may be performed at these visits. Here the health benefits may be modest, but this new model would increase the number of contact points for these dental patients with the health care system.
Why is this a particularly appropriate time to suggest these changes to the dental profession? There are 4 primary reasons. First, national health care reform presents the dental profession with new opportunities to examine its future and its place in the health care environment. Second, there is unprecedented pressure on the profession to be part of the solution to the access-of-care issue in the United States. It is essential that the profession lead this change, not have a solution imposed upon it. Third, oral health care providers are considered primary health care providers, 24 and should take advantage of that designation at a time when health care for patients with chronic diseases will become increasingly important. Fourth, the changes proposed here would allow the profession to have a greater positive influence on the health and well-being of patients. The expanded model will provide more people with more oral health care and allow more patients with complex dental and medical problems to receive appropriate care. Although change is always difficult, the result will create a broader definition of what an oral health care provider is and thereby move the dental profession into closer alignment with the larger health care system.
Human Participant Protection
No protocol approval was required because no human participants were involved in the research.
