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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


If we don’t do it, who will?

Dentistry can’t shirk medical complexities

J Am Dent Assoc, Vol 135, No 8, 1076-1077.
© 2004 American Dental Association

It is vital that we adjust to the changing face of dental practice, and learn to manage extraoral health issues with skill and aplomb.

Dentistry is forever changing. In the operatory, new tools and techniques—some revolutionary, most incremental—deliver better results to the patient and make our lives easier. The business of dentistry evolves, too, though in ways the value of which is more difficult to gauge. For better or worse, without change we become a stagnant profession.

We are now in the early stages of what may prove to be a truly pivotal change, one that will help shape the profession for years to come. I refer to the dawning public awareness that the mouth is in fact attached to the body. According to some studies, dental treatment may lower blood sugar levels in diabetic patients, reduce premature births or decrease the risk of cardiovascular disease. While some of the more spectacular claims along these lines probably will prove illusory, there is good reason to believe that oral and systemic health are linked in ways not previously suspected.

Now, who is going to apply this new knowledge? Before you answer, think back to what you have read or been taught about "medically compromised" patients. Be honest—have you never been advised that expectant mothers should postpone treatment until after delivery? That the protocols for treating a severe diabetic are too complex for the nonspecialist? That to care for someone with cardiovascular disease is to invite a lawsuit?

Throughout my career in dentistry, I have been asked regularly to advise on appropriate dental treatment for patients whose general health status has made ordinary care infeasible or inappropriate. Sometimes the issue is a physical or psychological disorder, sometimes a diagnosed disease or malformation, sometimes other issues, such as aging, which the dentist or physician may deem appropriate to consider in the treatment plan.


During the last few years, though, the pace of these inquiries has quickened perceptibly, as physicians, social workers and family members have become aware of suspected oral-systemic links. The request often is accompanied by a frustrated account of a dentist’s flat refusal to treat the patient. And all too often, that refusal appears to be based on nothing stronger than a general disinclination to deal with "that kind of case."

American dentists are generous with their time, quietly providing care at reduced or no cost to patients who slip through our increasingly threadbare safety net. Yet when it comes to treating people with medical problems, those generous instincts sometimes are thwarted by fear of the unknown. Sure, there are situations in which a patient’s medical condition is so complex or fragile that a specialty referral is the only prudent option. But these are the exceptions. For the most part, a few straightforward, well-known precautions (such as premedication, monitoring, appropriate anesthesia) suffice to protect the at-risk person.

As you may know, some of my own research deals with the effects of periodontal disease on preterm birth. The early results, tentative and imperfect though they may be, have not escaped the notice of the OB/GYN community. The possibility of a strong causal connection has led some physicians to demand dental screening and treatment for expectant mothers. And when met with demurral or evasion, they have begun to look into providing dental hygiene in their own offices. I’m confident that MDs would prefer not to take on this responsibility, but they can and will if we dentists refuse to step up to the plate.


Now, while pregnancy isn’t a disease, this example highlights our collective reluctance to deal with complex medical issues. Unless this attitude changes soon, dentistry will have taken a marked step toward self-marginalization. Our patients are aging. With age come a host of medical issues, but no diminution of expectations for quality dental care. It is vital that we adjust to the changing face of dental practice, and learn to manage extraoral health issues with skill and aplomb.

After all, if we won’t do it, who will?