If we don’t do it, who will?
Dentistry can’t shirk
medical complexities
http://jada.ada.org/cgi/content/full/135/8/1076?ck=nck
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?
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