The Journal of Primary Prevention

, Volume 34, Issue 4, pp 279–291

Dentists as Oral Physicians: The Overlooked Primary Health Care Resource

Authors

    • Department of Developmental BiologyHarvard School of Dental Medicine
  • Brian Swann
    • Cambridge Health Alliance
    • Harvard School of Dental Medicine
  • R. Bruce Donoff
    • Harvard School of Dental Medicine
  • Ruth Hertzman-Miller
    • Joslin Diabetes CenterHarvard Medical School
Report From The Field

DOI: 10.1007/s10935-013-0310-7

Cite this article as:
Giddon, D.B., Swann, B., Donoff, R.B. et al. J Primary Prevent (2013) 34: 279. doi:10.1007/s10935-013-0310-7

Abstract

The United States is currently experiencing a primary care shortage. One solution to improving health care is to increase the utilization of existing health care providers, particularly dentists, an opportunity that has been largely ignored. By employing mid-level providers for less complex procedures to deliver more accessible dental care at lower cost, dentists can redistribute tasks to their office workforce. They can then serve as oral physicians who can provide limited preventive primary care, including screening for chronic diseases, while continuing to oversee all dental care, whether provided by dentists or non-dentists. Thus, they could improve the health of the US population as well as increase access to dental care at lower cost, while partially alleviating the primary care shortage by filling a need for the screening aspects of primary care.

Keywords

Health care deliveryPrimary careOral physicianDentistry

Primary Care Importance

The strength of a society’s primary care system directly influences morbidity and mortality. Important attributes of primary care include direct patient access to a provider, comprehensive services, a focus on the whole patient rather than a specific complaint or organ system, and coordination with other providers as necessary (Starfield, Shi, & Macinko, 2005).

The United States is currently experiencing a primary care shortage (Steinbrook, 2009), one symptom of which is the rise of urgent care clinics in shopping centers and pharmacies, frequently staffed by mid-level providers and lacking in continuity (Ferris, McAndrew, Shearer, Donnelly, & Miller, 2010).

Dentists as a Novel Solution to the Shortage

Primary care is the point within a health care system where patients come for explanations of symptoms or to check up on their health status. The role of the primary care provider is to monitor patients’ health and assess and control risk factors for acute and chronic disease. Physicians—representing internal medicine, family medicine, pediatrics, or general practice—are the usual point of entry, with nurse practitioners, physician assistants, or pharmacists also serving when needed as adjunctive primary care providers. Patients are then referred for secondary specialty or tertiary subspecialty care.

One solution to the primary care shortage, therefore, is to increase the effective utilization of existing paramedical health care providers, particularly dentists, who by redistributing tasks in their offices to include screening for chronic diseases could help alleviate this shortage and improve the health of the US population. Since the majority of the US population has seen a dentist in the past 24 months, and as dentists must increasingly monitor the chronic disease problems of their patients, it has been suggested that dentists could and should serve as the primary care provider for their patients (Lamster & Wolf, 2008).

The Dentist as “Oral Physician”

While recognition of the need to diagnose and treat the ever-increasing number of aging dental patients with more complex health care problems has certainly called attention to the need for dentists and other paramedical professionals to broaden their role in the delivery of overall health care, the designation as oral physician has not yet been endorsed universally.

Dentists are in an ideal position to assume an expanded role in providing limited preventive primary care. Dentists are already de facto oral physicians trained in many of the required medical and surgical skills, often see patients who do not have another primary care provider, and typically schedule frequent return visits.

Dental training already includes the ability to recognize more than 100 manifestations of genetic disorders, systemic disease, and lifestyle problems (Long, Hlousek, & Doyle, 1998; Ward, Jamison, & Allanson, 2000). Some of the disorders that may be detected and monitored by dentists include hypertension, diabetes, osteoporosis, obesity and eating disorders, substance and tobacco abuse, domestic and child abuse, oral and skin cancer, sleep apnea, and salivary markers of other systemic disease. Dentists also have sufficient training to provide some aspects of preventive primary care such as taking, or supervising the delegation of taking vital signs to others, and administering vaccines or supervising others in doing so (Fox, 2013; Lamster & Wolf, 2008; Spielman, Fulmer, Eisenberg, & Alfano, 2005).

Many patients visit dentists more often than their primary care physicians. For example, in 2010, 61.1 % of those aged 18–64 and 57.7 % of those aged 65 years and over visited a dentist (Centers for Disease Control and Prevention, n.d.), while 62.7 % of those 18–44, 46.7 % of those 45–64 and 38.3 % of those 65 years and over visited a primary care generalist (Centers for Disease Control and Prevention, n.d.).

Because of their training in oral health and its relation to systemic disease, as well as the frequent contact with patients, dentists are in an ideal position to identify chronic physical and mental disorders (Raphael, 2010). Among specialists, periodontists have integrated the oral-systemic connection into training and practice, using diabetes as a prime example (Giddon, 2009; Giddon & Howell, 2011; Lamster & Wolf, 2008). Orthodontists, in particular, see their adolescent patients once a month for two-plus years during their critical formative years. Together with pediatric dentists, they have the opportunity to recognize developmental and behavioral problems, such as autism spectrum disorders and attention deficit-hyperactivity disorder. Therefore, regardless of whether general dentists become oral physicians, there is burgeoning involvement of dentists in screening for mental and physical disorders.

The Oral Physician’s Scope of Practice

If dentists are to serve the public in a role of primary care provider, it is important to determine conflicts with their scope of practice, which vary from state to state. Because many oral and systemic diseases are reciprocally related, it follows that screening for many systemic diseases is already within the scope of dental care. For example, periodontitis has been implicated as a factor in diabetes, coronary artery disease, structural heart disease, and pre-term delivery (American Academy of Periodontology, 2000b). Conversely, diabetes, obesity, depression, and immuno-compromised states, among others, affect periodontal health (American Academy of Periodontology, 2000a; Formicola et al., 2008). This oral-systemic disease interdependence was further demonstrated by recent reports that successful treatment of periodontal disease actually lowers the glycemic index (Gurav, 2012).

Given the shortage of primary care physicians, and the fact that additional screening will identify more patients requiring treatment, it may be reasonable to consider whether involving dentists in preventive screening for systemic diseases might actually increase the need for primary care physicians for the initiation of treatment. However, treatment of some of these diseases, and even in some cases post-test counseling (such as for a patient with a positive HIV test), is also possible and still within the more broadly defined scope of usual dental practice. Thus, for some systemic diseases, dentists are well-positioned to be the first line of screening, but not qualified to provide regular ongoing care. On the other hand, given the success of pharmacist-led clinics in treating hypertension and coronary artery disease (Reid, Murray, & Storrie, 2005; Reilly & Cavanagh, 2003), it seems likely that a protocol-based treatment algorithm for these conditions could be used successfully by dentists as well, with referral as a second-line option should basic treatment for these conditions be insufficient. The use of simple treatment protocols and follow-up monitoring, such as for simple hypertension, by dentists should help to alleviate concerns that the referrals from the proposed expanded roles of dentists as oral physicians may increase the burden on primary care physicians.

The Public Health Value of the Oral Physician

Adding basic primary care screening to dentists’ practices can be of significant benefit to the first two levels of prevention: primary prevention of health problems by communication, early diagnosis, assessment of risk factors, or immunization to prevent spread of disease; secondary prevention to avoid or reduce later complications of systemic disease.

Primary prevention refers to the identification of and counseling for risk factors for systemic disease, such as smoking, alcohol abuse/dependence, and obesity, before the disease occurs. Significant numbers of patients in dental offices suffer from alcohol abuse/dependence (Miller, Ravenel, Shealy, & Thomas, 2006), smoking (Victoroff, Lewis, Ellis, & Ntragatakis, 2006), and overweight/obesity (Marciani, Raezer, & Marciani, 2004), making these prime targets for dental intervention. All of these problems can be helped by counseling from a health care provider (Kaner et al., 2007; Peterson, 2007; Stead et al., 2008), which could include an appropriately trained dentist.

Secondary prevention refers to preventing complications of existing disease by early diagnosis and treatment. In the dental office, this could include screening for elevated blood pressure, diabetes, depression, and HIV. Undetected hypertension, dyslipidemia, diabetes, and depression are common in the dental setting (Giglio & Laskin, 2010; Glick & Greenberg, 2005; Greenberg et al., 2007; Harrison, 2011; Lalla, Kunzel, Burkett, Cheng, & Lamster, 2011).

Dentists’ Role in Primary Prevention: Lifestyle and Substance Abuse Counseling

Identifying lifestyle risk factors and providing brief counseling is one important task that dentists can perform for their patients, including screening for alcohol problems, smoking, and obesity. In one emergency dental clinic, heavy alcohol use was found in one-fourth of patients (Miller et al., 2006). Similarly, in a university-based dental clinic it was found that 29 % of patients smoked (Victoroff et al., 2006). With 69 % of the US population considered to be overweight or obese (FDA/NIH, n.d.), it was not unexpected to find in one study in an oral surgery clinic that the prevalence of overweight and obesity was 65 % (Marciani et al., 2004). Because brief counseling has been demonstrated to improve outcomes both for patients with alcohol problems (Kaner et al., 2007) and for smokers (Stead et al., 2008), dentists should strongly consider adding to their patient visits actual screening for elevated body mass index, tobacco and alcohol abuse, in addition to brief counseling. Although evidence for the effectiveness of brief counseling for obesity is less clear (Peterson, 2007), more extensive counseling is clearly associated with improvement (Armstrong et al., 2011).

Dentists’ Role in Early Diagnosis and Treatment: Cardiac Risk Factors and HIV Infection

There are several demonstrated examples of specific diseases in which screening in the dental office can improve rates of early diagnosis, including cardiovascular disease and diabetes. For example, both nationally representative and clinic-based surveys have revealed that among adult dental patients who reported no cardiac risk factors, about 18 % had a 10-year cardiac risk of >10 % (Glick & Greenberg, 2005; Greenberg et al., 2007). Twenty-eight percent of patients who did not report risk factors had undiagnosed hypertension, and 45 % of the men had low HDL-cholesterol levels. Glucose screening in a dental clinic revealed that 7 % of patients had previously undiagnosed diabetes (Harrison, 2011; Lalla et al., 2011). Detection of these undiagnosed systemic diseases by dentists, and subsequent treatment in a primary care setting, would thus contribute substantially to lowering morbidity and mortality of these patients over their lifetimes.

Early diagnosis and treatment of HIV not only improves individual outcomes, but can also reduce the spread of disease by increasing patient awareness and decreasing viral load (Campo et al., 2011). Accordingly, the U.S. Centers for Disease Control and Prevention (Nassry et al., 2012) recommends routine HIV screening of all sexually active adults. HIV screening may have the additional benefit of preventing the further spread of HIV by ensuring that patients are aware of their potentially infectious status and directing them to appropriate treatment. Screening for HIV has been shown to be feasible in the dental setting (Blackstock, King, Mason, Lee & Mannheimer, 2010; Nassry et al., 2012). Although HIV screening can readily be conducted in a dental setting, it is not yet clear if undiagnosed HIV is sufficiently prevalent in dental patients to warrant routine screening. For example, one study in New York City screened 3565 previously-undiagnosed individuals presenting to a dental clinic and detected only 19 new cases of HIV (Blackstock et al., 2010).

Dentists’ Role in Behavioral Screening

The prevalence of bulimia nervosa in the US is estimated at between 1 and 5 % (Makino, Tusboi, & Dennerstein, 2004) with at least one study showing a 5 % prevalence of eating disorders (e.g. bulimia and anorexia nervosa) in a dental setting (Giglio & Laskin, 2010). Because binging and vomiting have classic oral manifestations, dentists are well-placed to recognize and respond to signs of eating disorders. Women with eating disorders are often quite concerned about their oral health, yet may not be willing to tell the dentist about this often covert disorder without direct and sensitive questioning (Willumsen & Graugaard, 2005), even though 42 % of dentists report that they screen patients for eating disorders (Debate & Tedesco, 2006). Given that eating disorders have a wide range of negative physical and psychological effects, the most severe being death, the dentist/oral physician can, by screening for these conditions, provide a needed public and private health benefit (Anderson, Zionic, & Giddon, 2002).

Many published trials have shown that domestic violence screening in health care settings is beneficial to patients (Cronholm, Fogarty, Ambuel, & Harrison, 2011). Seventy-five percent of domestic violence survivors experience injury to the mouth or face (da Fonseca, Feigal, & ten Bensel, 1992; Jessee, 1995; Mouden, 1998), and over 9 % of female survivors of domestic violence present to the dentist’s office with evidence of facial trauma (Tjaden & Thoennes, 1998). Even though dentists are mandated by law to report suspected domestic violence (“Guideline on oral and dental aspects of child abuse and neglect,” 2008), they have historically under-recognized and under-reported evidence of domestic violence both in children and in adults (Barbara Aved Associates, 2006; Gironda, Lefever, & Anderson, 2010; Mouden, 1998). Several recent efforts have been made to promote dental professionals’ awareness of domestic violence and teach screening skills, notably by medical and dental insurance foundations (Barbara Aved Associates, 2006; Delta Dental of New Jersey, n.d.).

Psychiatric disorders frequently present during adolescence. In one survey of orthodontists, 50 % reported a suicide attempt by a patient in their practices (Loochtan & Cole, 1991). Because orthodontists see their patients once a month over an average two-year period during their most formative years, as noted earlier, they are in a unique position to observe physical and mental developmental, eating and psychiatric disorders and to counsel patients and their families on substance abuse and physical abuse, including bullying. Together with pediatric and general dentists, orthodontists may be particularly helpful in recognizing developmental and behavioral problems, such as autism spectrum disorders and attention deficit-hyperactivity disorder. Appropriate referral rather than abrogation will minimize degenerative consequences (Neeley, Kluemper, & Hays, 2006; Nelms, Gutmann, Solomon, Dewald & Campbell, 2009).

Acceptability by Dentists of Expanded Oral Physician Role

Dentists are increasingly comfortable with the concept of expanding their role in primary care. A recent survey of US dentists revealed that “[t]he majority thought it was important for dentists to conduct screening for hypertension (85.8 %), cardiovascular disease (76.8 %), diabetes mellitus (76.6 %), hepatitis (71.5 %) and human immunodeficiency virus infection (68.8 %)” (Greenberg, Glick, Frantsve-Hawley, & Kantor, 2010, p. 52). Dentists can readily participate in screening for diseases that can be diagnosed by the evaluation of the components and volume of saliva or other oral fluids and tissue samples (Lee, Garon, & Wong, 2009), which currently include HIV, hepatitis C, and diabetes; and in the future could, with established prognostic reliability and validity, include the diagnosis of breast and gastric cancer, among others (Drobnik et al., 2011; Gaidos, 2011; Lee & Wong, 2009; Yeh et al., 2010). Despite underreporting because of some reluctance to become involved, dentists recognize their responsibilities as mandated providers of domestic violence reporting (Barbara Aved Associates, 2006), especially in view of noting that most emergency department visits for domestic violence involve the head and neck area (Le, Dierks, Ueeck, Homer & Potter, 2001). Fifteen percent of dentists sometimes or often screen for domestic violence at checkups, and 82 % sometimes or often screen for domestic violence when their patients present with head or neck injuries (Love et al., 2001).

Acceptability by Patients of Dentists’ Expanded Primary Care Roles as Oral Physicians

Patients appear to be more comfortable than expected with their dentists’ providing several types of evaluation and procedures, including (but not limited to) screening for tobacco use (Campbell, Sletten, & Petty, 1999; Victoroff et al., 2006), alcohol use (Miller et al., 2006), HIV (Blackstock et al., 2010), diabetes, and cardiovascular risk factors (Greenberg et al., 2007). Patients generally support being asked about domestic violence by health care professionals (Caralis & Musialowski, 1997; Feder, Hutson, Ramsay, & Taket, 2006), although patients’ attitudes toward domestic violence screening by dentists in particular have not been studied. Dental clinic patients have indicated their willingness to have their dentists ask about and/or screen for a wide variety of systemic illnesses including cancer, heart disease, diabetes mellitus, HIV, hepatitis, obesity and nutritional status, psychological disorders, domestic abuse, and hypertension (Giddon et al., 2013; Greenberg et al., 2009).

Acceptability by Physicians and Other Health Care Professionals of Dentists’ Expanded Role as Oral Physicians

Although both medical and dental organizations have shown resistance to the “oral physician” concept and terminology, attitudes of individual physicians and dentists toward dentists’ taking on this expanded role are quite positive, with significant US and international advocates for this concept, though not necessarily agreeing with a change in nomenclature. The majority of US dentists believe they should screen for non-dental conditions including hypertension, heart disease, diabetes, hepatitis, and HIV (Greenberg, Glick et al., 2010). Somewhat in agreement, the majority of surveyed physicians “felt it was worthwhile for dentists to conduct screening for cardiovascular disease (57 %), hypertension (76 %), diabetes mellitus (69 %), and HIV infection (60 %)” (Greenberg, Kantor, Jiang, & Glick, 2010). Several US and international expert panels have also strongly urged dentists to become full participants in the health care team, including competency in some basic tasks such as screening for psychiatric disorders and extra-oral abnormalities (Formicola et al., 2008; Sanz et al., 2008). Nevertheless, there is still some concern on the part of the AMA, based on their ongoing campaign to require all health care practitioners, particularly those designated as “Dr.” to present their credentials to patients clearly enough for them to distinguish physicians from non-physicians (AMA Advocacy Research Center, 2010), to avoid further confusion resulting from the plethora of non-MD doctorates among many health professions.

Feasibility of Training

Educational institutions serve an important role in helping to develop, implement, and evaluate new didactic and clinical training models of interprofessional education (Wilder et al., 2008). Harvard University recently funded such a program to demonstrate that general practice dental residents can be trained to become oral physicians who can assume limited preventive primary care responsibilities (Giddon et al., 2012b). The curriculum for the “oral physician” residency is significantly modified from traditional general practice dental residencies, with the inclusion of rotations in the medical emergency department and the outpatient internal medicine clinic. Pre- and post-test assessments of eleven residents using multiple-choice tests as well as mock-patient interviews indicate both qualitative and quantitative increases in primary care knowledge, clinical practice, and interviewing skills over the course of the residency program (Giddon, Hertzman-Miller, Outlaw, Jayaratne & Swann, 2012a; Giddon et al., 2012b).

As the medical knowledge and practice in the dental school curricula have increased, the basic concepts of medicine essential for dentists to be able to practice limited preventive primary care are becoming more important in dental education. There are a number of dental schools in the US and abroad that have already or are in the process of increasing the number of curriculum hours for medicine in the pre-dental curriculum; in Japan, for example, “the hours of teaching medical subjects have doubled since 2008” (Tanaka, personal communication, 2012) and the dental curriculum in the Netherlands has increased from five to six academic years (Nash, 2012). Although graduates of these programs are not necessarily referred to as oral physicians, they are essentially trained to serve this function. It is important that dental education reinforces the medical content in the dental curriculum before a student graduates especially giving more time to models for practice, supports the concept of an “internship” after graduation, and endorses the use of dental therapists. All of these will help to modify the scope of dental practice to permit meaningful change.

It is apparent that these changes encompass a very large range in both quantity and quality of their addition to the didactic and clinical offerings. As shown in a recent unpublished survey of US and Canadian dental school curricula, there is variability in the content of basic science, physical diagnosis, and medicine courses and experiences for dental students. A few schools include identical courses integrated with those of their medical students, but most graduates, even if not mandated, receive additional medical and surgical training such as provided in a general practice or oral and maxillofacial surgery residency. Within the stomatologic model, for example in China, dental students –depending on which program they are in—may receive the equivalent of a medical degree with minimum emergency medical training to prepare them for primary care roles in medically underserved areas (Zheng et al., 2013).

The most recent combined programs in the US are designed to produce a double degree oral and maxillofacial surgeon with robust general surgical experience. In addition to Harvard and other schools which grant both dental and medical degrees primarily for the practice of maxillofacial surgery, two schools, NOVA Southeastern University’s College of Dental Medicine and Case Western Reserve, have pilot programs offering both degrees. It is possible that a carefully designed dental residency could provide the necessary medical experience and training in the context of a general practice dental residency similar to that of the Cambridge Health Alliance (Giddon et al., 2012b). At the same time there is concern by academic and practicing dentists as well as physicians and medical educators that there is already insufficient time in the existing curricula to learn the basic knowledge and skills required of dentistry to obtain and maintain oral as part of general health. The unfortunate result of this trend is that most of the new proprietary or non-university dental schools around the world emphasize the more biomechanical skills of dentistry at the expense of the biomedical aspects of their curricula.

Another factor constraining the integration of dentistry with medicine is that the respective cultures of dentistry and medicine do differ from each other, which has resulted in having “…separated oral health from overall health for more than a century. This schism has, for the most part, been widespread despite the obvious common scientific foundations and missions of both fields. It has played out in journals, scientific meetings, sites of practice, and health insurance systems. As a result, physicians have not considered oral health in their domain, and dentists have not considered overall health issues as their responsibility” (Formicola et al., 2008, p. 84). This schism may reflect a self-selection process based on pre-professional differences in personality and attitudes of physicians and dentists, a result of the training environment, or possibly the differences between dentists and physicians in aspirations and expectations. Dentistry is seen as a profession with a great lifestyle and financial rewards, requiring less time in school than medicine (Gallagher, Patel, Donaldson, & Wilson, 2007). Dental care is perceived to be mostly elective, provided by solo practitioners working with their hands, without having to make decisions about life and death responsibility or deal with the bureaucracy of third-party payment. Obviously the perceived and actual reality of differences in goals will have to be self-corrected, or more likely changed by the need to adapt to a new, more equitable and cost-effective health care system.

Overview of Facilitating Factors

Several factors are likely to enable dentists as oral physicians to provide limited preventive primary care. These include the increasing interest in primary care and coordination of dental and medical services, the development of mid-level dental providers, and external financial support for new training programs for dentists as oral physicians.

Both public and private insurers are endorsing the concept of the patient-centered “medical home,” which makes coordination of primary medical and dental care central to the provision of health care services. This concept extends to recommendations from the Institute of Medicine and the Department of Health and Human Services that oral and systemic health care systems become more integrated than now exists (IOM (Institute of Medicine) and NRC (National Research Council), 2011). This shift in third-party payers’ attitudes toward integration and coordination of oral and general health may act as an incentive for dentists to increase their involvement in primary care screening. As described in the subsequent section, there are still problems with compensation offsetting this optimism.

Another factor facilitating the integration of medical screening and primary care in dental offices is the development and implementation of a new class of mid-level dental providers. Although not yet endorsed by the ADA, recent dental care initiatives have shown that much of the basic care currently provided by dentists can be delegated successfully to mid-level providers such as dental therapists (Abrose, Hord, & Simpson, 1976; American Dental Hygienists’ Association, n.d.; Anon, 2010; Beazoglou, Brown, Ray, Chen, & Lazar, 2009; Bolin, 2008; Emmerling & Standley, 2011). By having simple, uncomplicated dental procedures performed by these mid-level providers, dentists will be able to use their more extensive training as oral physicians to perform more complex dental treatments, as well as being available to provide limited preventive and primary care services as part of the overall health care of their patients.

Other changes in pre- and post-doctoral dental education are also in the planning stage to increase the training of dentists as oral physicians capable of providing limited preventive primary care. The emergence of interprofessional training and practice demonstrates another opportunity for the dentists as oral physicians to make meaningful contributions to patient care; for example, “When a dentist rotates as a medical student on a clinical service they are instantly recognized as a special resource and an expert. They have the opportunity to both learn and teach a new generation of health professionals about oral health issues” (Assael, 2012, p. 669).

The Affordable Care Act includes several new funding streams for the education of general dentists (“Children’s Dental Health Project, 2010. Oral Health Provisions in the House Passed Health Reform Package,” 2011), including funding for training in public health. There is also an increasing trend to require general dentists to complete a post-doctoral residency program prior to licensure. This requirement, which is now in place in New York and is available as an alternative road to licensure in four other states (American Dental Association, n.d.), is an excellent opportunity to provide dedicated training to dentists as oral physicians.

Moreover, the designation of dentists as oral physicians will encourage and reinforce their interest and ability to provide limited primary and preventive care services within the current scope of dental practice. The American Dental Association’s definition of dentistry supports this broader concept of the dentist’s scope of practice, defining dentistry 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 structures, and their impact on the human body… [emphasis added]” (American Dental Association, 2007, para. 11).

Barriers to Acceptability

As noted earlier, there are several societal, economic, and training barriers to dentists’ taking on an increased primary care role, including cost, liability (Gary & Glick, 2012), profitability and the shortage of existing dental providers.

A major barrier to the dentist as oral physician is the potential financial impact of providing primary care services. Until quite recently, dentists within their currently successful practice model minimized receiving direct or indirect compensation from third parties, and had little experience in determining and collecting fees for primary care services and/or counseling services related to prevention. A recent sociological study of American dentistry reported that “[t]he key organizing principles [of the American dental office] reflect a belief in entrepreneurship, professional autonomy, and American exceptionalism” (Kitchener & Mertz, 2012, p. 5). In any case, any change in how dentists should be practicing as oral physicians must include a viable business plan in order to be widely adopted. Some boutique dentists, for example, have already expanded their practices to include enhanced concerns for the appearance and function of their patients’ faces and feet by offering facial and foot massages. Regardless, several potential solutions exist to overcome this financial barrier. The recent third-party payer coverage of tobacco cessation counseling by dentists (McMenamin, Halpin, & Shade, 2008) may help to alleviate the financial burden of providing preventive screening and counseling and is likely to represent the first in a series of such expansions of coverage.

The call for increased access to dental services constitutes another factor that might prevent dentists from offering additional non-dental services in their practices. If the Patient Protection Affordability and Care Act is implemented as currently structured, the payment model for dental care is likely to change over the next several years. Dental insurance, in addition to health insurance, will be offered on the public “Exchange” for those without employer-sponsored health insurance and who are not eligible for public assistance. Families with incomes between 133 and 400 % of poverty will receive a tax credit toward these plans (Children’s Dental Health Project, 2010, para. 3; U.S. Department of Health & Human Services, 2010), thus increasing the proportion of the population with dental insurance who are able to seek dental care that they would otherwise defer (Ross Health Actuarial, 2005). At present, these families have inadequate access to dental care (Sullivan, 2012). If the demand for dental services increases, it is likely that dentists could continue to prosper financially without offering additional services.

On the other hand, labor economists predict that this new demand will be met by individual dentists’ becoming more productive, both from the use of new technologies and working as a team with mid-level providers (Bureau of Labor Statistics, 2011). Given these ostensibly opposing factors, it is not clear whether an increase in patients with dental insurance will be an incentive or disincentive to the expansion of dentists into primary care.

In essence, what is required is a good business plan building on an already successful model to incorporate medical screening, possibly some boutique features, and other aspects of primary care. While dentists would still retain control of their economic destiny, their present successful business model can be modified so that they can practice, in effect, as oral physicians who, together with a well-trained staff, provide both dental and limited preventive primary medical care, including medical screening for chronic disease. Obviously, in order to at least break even, such a business plan would seek to minimize the additional cost of new personnel, training, space, supplies, equipment, and possibly increased insurance premiums associated with these additional services. The Marshfield Clinic model (Glurich, Acharya, Shukla, Nycz & Brilliant, 2013) emphasizes interprofessional care and shared electronic health records. Any future models must link education and training of the dentist to the health delivery system. This will no longer be the solo office or the medical home, but the health home.

Unfortunately, many dentists will still not want to become involved in the bureaucratic constraints of medical screening provided by physicians who have no choice. In addition to concerns about compensation from patients or third party payers, dentists who are willing to modify their practices to function as oral physicians must be alert to potential increases in liability, not necessarily realizing, as noted earlier, that they may be liable if they do not get involved with some of the medical issues facing their patients, particularly those who are older.

Because dentists are already classified as physicians under Social Security (“Compilation of the Social Security Laws, 2013”), there are in fact existing and pending billing and procedure codes available for dentists.

Moreover, the likelihood of more government intervention to assure access to affordable health care, including dentistry, has led to the emergence of consultants to train dentists and their staff how to utilize these existing and new diagnostic and billing codes to receive compensation from both medical and dental third parties (Taxin, n.d.). Some dentists well-versed in primary and preventive care are also achieving financial success by providing consultation services directly to employers, insurers, and other health care providers (Ferguson, 2006, 2010).

Similar to the procedure for smoking cessation, dentists can bill medical insurance for fabricating dental appliances if the patient has been diagnosed with obstructive sleep apnea (Department of Health and Human Services, 2012). Medicare pays for two types of appliances coded through Medicare’s Pricing, Data, Analysis and Coding Contractor. Many medical insurance companies also reimburse dentists directly for problems that are considered to be in the realm of general health; cross-billing of medical services by dental offices is increasingly common and in some cases is extended to include billing for health screenings. (“The Art of Practice Management,” n.d.). The current movement of AMA’s CPT codes and CMS’s ICD-10 codes toward “provider neutrality” will allow providers other than physicians to bill insurance for most services (Averill et al., 2009; Martin, 2012). In addition to taking a biopsy, checking a blood glucose or HbA1c level, and obtaining salivary samples for analysis of composition and volume, the dentist should be able to cross-bill medical insurance for treating dental ravages such as rampant caries due to xerostomia as the result of psychoactive medication for psychiatric illness, or management of the soft and hard tissue of the oral cavity consequent to radiation or chemotherapy. They can also be compensated for the administration of the flu vaccine (Pontikas, DeMaria, & Carrow, 2009).

Although some progress is being made, a continuing difficulty with trying to achieve diagnostic and at the level of managing chronically ill patients, billing parity with medicine, is the incompatibility of electronic data of different providers’ EHRs with access to practical (interface) diagnostic terms and procedure (billing) codes that map to each other to monitor quality and map to other (mandatory) terminologies (e.g. ICD and SNOMED for medical billing, research and Meaningful Use reasons; (“EZ Dental Codes Terminology Conference,” 2012; Kalenderian et al., 2011).

In general, the motivation of the dental health care providers to address these concerns about impending change emanates from several sources:
  1. 1.

    The obligation as a health care provider to obtain and maintain overall health;

     
  2. 2.

    Patients’ appreciation of dentists, who see them more regularly than their primary care physicians and are interested in their overall health (Hancocks, 2012). Patients are even willing to pay a small fee for disease prevention activities (Greenberg, Kantor, Jiang, & Glick, 2012); and

     
  3. 3.

    The opportunity to build a good practice, with or without expectations of additional compensation, as described by Hewett (Berry, 2012). Ferguson in fact has built upon this relationship to develop a web-based tool, MySmileGuide.com (Ferguson, 2010).

     

Working within the boundaries of organized dentistry, selected dentists practicing singly or in groups as de facto or actual oral physicians are already engaged in medical screening; they are not necessarily referring to themselves as oral physicians, because they believe they are doing the right thing (Berry, 2012). Rather than perceiving the designation of oral physician and the use of midlevel providers as a threat related to being absorbed by medicine or becoming more accountable with less independence, dentists should see this change as an opportunity to be labeled according to what they can and should be doing for the overall health of their patients while overseeing all dental care, whether provided by dentists or nondentists.

Even though practicing as an oral physician is within the scope of practice acts of most states, following the very broad definition of a dentist by the ADA, there are some states, such as Ohio, that have a very strict definition of the dentist that emphasizes technical skills. However, Case Western Reserve is moving forward with a curriculum revision that incorporates primary care into the scope of the dental training.

Some dentists have shown greater resistance to taking on a broader health care role than many other health professionals. For example, in response to a bill before the Massachusetts Legislature to allow dentists to use the term “oral physician,” the Massachusetts Dental Society supported by the Massachusetts Medical Society tried to undermine these efforts, citing among other reasons that the change will be too confusing to patients already confused by the distinction between the DDS and DMD (Lalumandier, Pyle, & Sawyer, 1999). However, similar bills have already been enacted in Massachusetts and in many other states to allow podiatrists and chiropractors the right to be designated as “podiatric physicians” and “chiropractic physicians,” respectively.

Conclusion

In summary, training dentists as oral physicians has been largely ignored as a possible path to improving the health care of Americans. These new oral physicians will broaden their role beyond the provision and supervision of dental care to the provision of limited preventive primary care. The changing regulations under the Patient Protection Affordability and Care Act will add another level of complexity, which may facilitate or impede implementing greater involvement of dentists as oral physicians in providing limited preventive primary care. Once the reimbursement hurdle is overcome, dentists as oral physicians will be fully able to use their valuable skills and training to improve the health of the US population.

Acknowledgments

Partially funded by a grant from the Milton Fund of Harvard University.

Copyright information

© Springer Science+Business Media New York 2013