Patient wellness and the importance of collaboration between medical and dental practitioners

December 11, 2013

Oral health has found a new seat at the wellness table. Sure, we’ve always tried to prevent caries and structural breakdown of teeth, but with more focus recently being placed on the link between oral health and systemic health, new areas of collaboration between the medical community and the dental community are coming to light.

 

One of the hottest areas of interest lately is understanding the impact of the human papilloma virus (HPV) on the face of oral cancer. HPV has changed the demographics of disease and has affected who and how dental professionals screen for oral cancer. In years past, most patients presenting with oral cancer were males over 60 years old with a history of either moderate to heavy alcohol consumption or tobacco use, or both. Now, we are seeing people as young as their late teens or early 20s presenting with the disease. We are seeing more oral cancer in women, in individuals with no social history that would contribute to the disease, and who are otherwise healthy. So, the “at risk” group for oral cancer has greatly expanded with a clearer understanding of HPV as an etiological factor for the disease. Because the vast majority of HPV-related cancers occur in the tonsils, oropharynx, base of tongue, posterior pharyngeal wall, and the larynx, the dental professional must adapt screening techniques to properly evaluate these areas as well as they are able. These adaptations may include repositioning the patient to better evaluate the tonsils and throat or referring a patient to an otolaryngologist if clinical signs give the clinician reason to suspect oral cancer might be present, but the primary lesion cannot be visualized. Because of the expanded pool of patients at risk for oral cancer, many dental practices are encouraging patients to make an oral cancer screening part of an annual wellness plan. Much like having a Pap smear, PSA test, or mammogram, an oral cancer screening can detect cancer at a much earlier stage, thus improving the prognosis for the patient should cancer be detected.

Click here to watch a video with Dr. Abbott discussing the main reasons why dental practices aren't screening for oral cancer

Wellness in dentistry extends even beyond just the oral cancer screening. CAMBRA is a method of assessing caries risk and making restorative recommendations based on a patient’s caries risk. The methodology employed by CAMBRA is analogous to a physician using risk information to assess for heart disease. Caries detection technology allows for early intervention of dental decay which may permit the dentist to place a more conservative restoration that preserves natural tooth structure and function while still ridding the tooth (an thus the body) of destructive bacteria. Salivary diagnostics can screen for the presence of periodontal pathogens and even HPV so patients can be aware of susceptibility to periodontal disease or the risk of oral cancer. Through utilization of such technologies, patients can monitor and improve oral health, knowing that in so doing they are supporting good systemic health.

 

I believe that with a better understanding of the link that ties oral health to systemic health, we are beginning to see a more concerted effort between physicians and dentists. One of the areas where this collaboration is most apparent is the field of dental oncology. Dental oncology is an intersection of dentistry and oral medicine that focuses on the unique and sometimes complicated care of patients undergoing treatment for cancer. The scope of care in dental oncology extends far beyond those patients with oral or head and neck cancer since essentially all types of cancer therapies can wreak havoc on oral hemostasis and present a wide variety of oral complications. As such, communication between the dentist and the medical oncologist, radiation oncologist, and oncological surgeon is imperative. Ideally, the dentist sees the patient soon after the diagnosis of cancer is made and before any surgery or treatment has begun. The dentist must have a clear understanding of the diagnosis and recognize potential oral complications that might be realized before, during, and after treatment. The patient’s hematological status must be closely monitored to ensure that the patient is never at risk for infection or a bleeding episode. Close communication must be maintained throughout the patient’s treatment by all parties of the cancer care team.

 

While the need for specialized dental and oral health care may diminish for the cancer survivor whose life returns to normal, many patients require specialized care for the remainders of their lives. This is particularly important for survivors who have received head and neck radiation, those who have received IV-administered bisphosphonate therapies, and bone marrow or stem cell transplant patients. These populations of survivors have special oral health care needs that last a lifetime and have the potential to grow more complicated as the patient grows older. Again, collaboration between the medical practitioner and the dentist is essential to maintain not only oral health, but systemic health as well. Many complications subsequent these treatments can very quickly affect the patient’s overall health and quality of life and, if left untreated or not treated adequately, can jeopardize the patient’s life.

 

Another population beyond the cancer patient that needs a collaborative effort between medical and dental health care professionals is that of the organ transplant patient. Like the oncology patient undergoing chemotherapy, these patients experience severe immunosuppression. However, unlike the patient with cancer, these patients remain immunosuppressed for the remainder of their lives. Dental clearance is required in most circumstances before a transplant surgery is offered. Again, lab results and clinical findings must be freely exchanged between physician and dentist to ensure that the patient’s oral health status is satisfactory before the commencement of immunosuppressive therapy, and constant follow-up is required as dental complications after transplant services can be problematic. With more and more hospitals across the country offering organ transplants, dentists will be seeing more of these patients in their practices.

 

The true value this collaborative effort obviously lies in the level of care provided to the patient, but for the dental office that incorporates level of service into its practice, the benefits are unending. Once a relationship is established between the physician and dentist, patients can be mutually referred between the two practices. This has a bottom-line business benefit for both establishments. The level of treatment acceptance is considerably higher in patients who have been referred by their physician to a dental practice. The dental practice is seen as going above-and-beyond … something I refer to a “pedestal factor” … when it is willing to care for needs beyond the norm. Physicians appreciate having a practice to refer patients to who can effectively meet the oral health care needs of their patients. It begins and ends with communication! Let the physicians know what you are doing (or can do) for their patients, and that you are willing to work with them, then be the doctor you are! Realize you know more about the mouth and teeth than the physicians who are referring to you … that’s why they are referring to you. Provide written reports of your findings, recommendations, and necessary treatments. Realize you are an integral part of the patient’s health care team. And finally, enjoy the reward of knowing you can make a positive difference in the overall health of your patient.

Editor's Note: You can read more thoughts about the collaboration between the medical and dental communities in the January issue of Dental Products Report.