Hi and welcome, or welcome back. You are listening to the Perio Patient Podcast, a podcast for my patients and anyone else who cares to listen. My name is Dr. Ben Young and I am a periodontist in private practice in San Antonio, Texas. This is episode 96 and the title is Dentists and Physicians.
If you have been or currently are a patient of mine you should be aware that I consider you to be the Appointment Manager of your own care. This designation is important because what I am tell you is that you need to learn to interact with healthcare providers in a particular way. Certainly with respect and they should respect you, but also with confidence that your questions and concerns have great weight. If you have questions then it is important that they address everyone one of them to the level of detail necessary to enable you to do your job – and that is to give them permission to proceed, or to deny them that permission. There is too much intimidation going on in the world right now and you and I have to be able to confidently stand as independent autonomous decisions makers with rights and responsibilities of our own. Does this mean we will be right in all of our decisions? Of course not, but still it is wrong to force adults to do things they do not wish to do. Are there exceptions? I’m sure but they must be within the law starting with the Constitution. I’m speaking in a general way here so it would probably be easy to find examples that don’t line up. In general, however, I am giving you a principle to practice when discussing your care or the care of your children with healthcare providers.
We are still ahead of the elections, so one last plug from me.
Please go and vote. I plan to vote election day afternoon and I hope I stand in an extremely long line. I’ll bring a book and visit with others. It should be fun, actually, at least I plan to make it so.
In the future, when I hear anyone complain about the government, I think it might be a fair question, before going further into a discussion, especially if it is a complaint, to ask whether or not we all voted in the last election. What do you think? If I’m not willing to vote, then why should anyone listen to my complaints?
It seems to me, and I am speaking for myself here, that I have worried a lot about things I have had little to no control over my whole life, and then, when I have something I can do, especially one that really isn’t that difficult to accomplish, I often feel that the fact it isn’t that big, that I can blow it off. Voting, it turns out is a very big deal and our votes count for more reasons than we can at first imagine. First, we are telegraphing an example to follow when we go through the hassle of voting. If we stimulate others to vote, then we are further strengthening our country’s future. Second, we are voting for more than one candidate, so we actually have multiple votes to cast. And finally, I believe we are respecting our ancestors who gave us this form of government – holding the potential for liberty, even though at time, it appears to have strayed. Also, we are respecting those who gave their lives to protect our liberties. There is a cost to living free and I hope and pray we pass this important lesson down to the next generations to come.
Now on to thinking about dentists and physicians.
In general, the training of dentists and physicians in the United States are accomplished in different environments at first. Later they can blend together, but the first goal is to train each student to be competent in their own disciplines first.
This is a good thing in the sense that it defines objectives for education and enables people to graduate after a reasonable amount of time and in a more or less affordable way. I have to be general in my descriptions here because advances in knowledge and changes in the economy are never as static as educators planning courses would wish.
So, dentists graduate from dental schools and physicians graduate from medical schools. What is interesting about this is not that dentists are limited to some extent in general medical instruction. For example, anatomy courses emphasize the head and neck over the pelvis and spine. This makes sense. But what is generally not known is that medical schools bypass much of the oral cavity because they assume the dentists are on this – they don’t need to know too much. That’s interesting and in a sense makes sense. Both programs only have so much time they can train students so why spend time teaching things that others will obviously know at a much higher level?
But here is the problem for many dentists. Most graduate and go to work in dental-only environments. Most physicians move from medical school right into internships and specialty training. Most of this is accomplished in hospitals. This results in the physician’s general medical education to continue to broaden so they not only understand what all specialists do, but they learn how to interact with them.
Unfortunately, physicians have only brief encounters with dentists. Yes, there are hospital trained dentists, but these are few and far between. Yes, there is a specialty that intersects both and this is the Oral Maxillofacial Surgeon, but these are no longer general dentists, they are actually head and neck surgeons able to operate effectively in the oral cavity with all the structures there including teeth.
If you are a dentist, you know you don’t know medicine like physicians, but you also understand that there is a benefit, even a necessity at times, to interacting with physicians and other healthcare providers on behalf of patients. Now I am tempted to say the patients who need this most are those labeled “medically compromised” but who is able to provide this label? I would say this is best accomplished by the patient’s primary care provider – usually someone with training in family medicine or internal medicine and if we are talking about children, usually pediatricians. Of course, there are crossovers.
Having practiced periodontics in the military, the dental school, and in the private sector, and also having had the opportunity of interacting with many in other healthcare disciplines over the years, permit me to give you a few tips on managing dental-medical interactions.
- Understand the dentistry is a sub-specialty of medicine. It doesn’t matter where you were trained. What matters is human physiology and pathology. There are important, even vital aspects to patients, that impact their oral health and visa versa. The fact that we at present have arbitrary barriers based on our respective training backgrounds is not an excuse for not talking openly with others providers, but is actually a responsibility. Overcome any shyness.
- Write consultation letters well. This means explain what it is you need. Generally you state your planned treatment to include any medicines, including anesthesia, you plan to use or prescribe. You are not asking for permission to do a dental procedure. You are asking if the physician or other provider sees any risks to the patient from their medical perspective. Sometimes, if the answer that comes back is too cryptic, then speak by phone. Remember, you are both talking about a patient who should be important to both of you. You are not wasting the other person’s time having such a conversation.
- Continue to study general medical topics and also look for opportunities to provide helpful dental information to you medical colleagues. Remember, their training in dentistry is extremely limited.
With this in mind, let me share with you a few interesting current articles.
I found this at ScienceDaily.com. It was published this year (2022) in the Journal of the American Dental Association. The principle author’s last name is Nalliah and the title is Association between periodontal care and hospitalization with acute myocardial infarction.
The popular press gave it the title: People who receive periodontal care have better outcomes after heart attack, study finds.
Researchers studied patients receiving periodontal care, dental cleanings or no dental care during 2016-2018 and who had acute myocardial infarction (heart attack) in 2017. They found that patients who had heart attacks and received periodontal maintenance care had the shortest length of stay in the hospital, and more follow-up visits. The longest length of stay was experienced by the no-dental-care group.
The study did not establish a causal relationship between periodontal disease and heart disease, but research like this adds weight to the understanding that there is an association between oral health and overall health, Nalliah said.
There are 800,000 myocardial infarctions in the United States annually, and those with periodontal disease are at increased risk for hospitalization after a heart attack.
Nalliah and colleagues wanted to examine the association between periodontal care and heart attack hospitalization, and follow-up visits in the 30 days after acute care.
They used what is known as the MarketScan database. So let me describe what this is.
The IBM® MarketScan® Research Databases are a family of research data sets that integrate de-identified patient-level health data (medical, drug and dental), productivity (workplace absence, short- and long-term disability and workers’ compensation), laboratory results, health risk assessments (HRAs), hospital discharges and electronic medical records (EMRs) into data sets available for healthcare research. Data are contributed by large employers, managed care organizations, hospitals, EMR providers, Medicare and Medicaid.
Back to this study between periodontal disease and myocardial infarctions: The researchers found 2,370 patients who fit the study criteria.
But here may be a problem, the data set comes from an administrative database of more than 265 million privately insured patients.
Of those, 47% percent received regular or other oral health care,
7% received active periodontal care (root planing and periodontal scaling) and 10% received controlled periodontal care (maintenance).
More than 36% did not have oral health care before they were hospitalized after a heart attack.
We found that periodontal care is significantly associated with better follow-up visits after AMI hospitalizations. The Agency for Healthcare Research and Quality has identified post–acute care visit as the quality measure aimed to improve patient care and improve the patient experience.21
This might indicate that patients who obtain periodontal maintenance are compliant patients and also go to post-acute care visits.
Results from our cohort study suggest fundamental health differences between the periodontal care group and the other groups. Consistent with previous research, we found that the prevalence of periodontal disease seems to increase with age.7 In addition, as previous research has shown, we found a higher prevalence of periodontal disease in men.22
Age is a factor in both periodontal disease and AMI’s.
Let me read some of the authors’ comments in the discussion section of their paper, because they have thought a lot more about this subject than you and I have.
In various other medical procedures, longer LOS (the abbreviation for Length of Stay) has an impact on overall cost of care and is associated with more complications.25, 26, 27
In our study, mean LOS was highest in the no care group and lowest in the controlled periodontal group (Table 2).
[Why might this be? Chronic inflammation is likely higher in the no care group.]
Results from research on hospitalized patients has shown that LOS and complication rates are higher when the patient has periodontal disease; this has been reported for cardiac valve surgery,27 stem cell transplants,28 and leukemia.29 Our results add weight to existing evidence that periodontal disease status may impact overall health outcomes.
We presented some important implications for clinical care delivery. The cardiologist and primary care team of a patient who has 1 or more of the broadly accepted risk factors for AMI 30,31 must ensure that their patient is receiving regular oral health care to prevent or manage periodontal disease.
In addition, dentists could play a role in regular monitoring of the risk factors associated with AMI. For example, some dentists already measure blood pressure, and many have the resources to measure blood glucose levels. Dentists are also trained in smoking cessation and nutrition. Finally, because dentists receive basic medical training, they could be mobilized to measure weight and cholesterol. The 6-monthly dental visits pose an opportunity for vigilance around tracking the risk factors for AMI.
More partnership between dentists and primary care physicians and cardiologists and better sharing of care information among providers could aid in early intervention and prevention of AMI and its complications.
Our study had some limitations that must be considered when reviewing the results. First, MarketScan data do not include all private insurances markets. Some states may have incomplete data. We used regions, rather than states, to adjust for regional variation. Because it is insurance data, we did not have death information. Also, MarketScan data do not include many important social determinants of health that influence outcomes of care. We have examined all available social determinants, such as age, sex, geographic location, employment status, and insurance type; we only included significant factors in our final model. It is well known that there are disparities among racial and ethnic minorities and disadvantaged populations seeking oral health care32 and those populations tend to have a higher risk of hospitalization for AMI.33
Our cohort is a relatively healthy population, as patients must be alive during the study period. We used various chronic conditions to adjust for underlying disease and health status, but our adjustment cannot account for unmeasured confounding variables. Our cohort patients were those who had AMI; we did not know whether periodontal care was associated with lower rates of hospitalization for AMI, which is beyond our study’s scope. Another limitation was that if patients needed care but were not receiving care, our data set would not pick up this information because we were reliant on the treatment rendered for payment (and subsequent submission of dental billing codes to their insurer).
Furthermore, we could not include patients who changed insurance during the study period or enrolled in Medicaid, we could not include the uninsured, and, lastly, we used administrative claims databases to conduct this study, which are subject to inaccurate billing codes. The MarketScan databases use rigorous methods to ensure that medical and dental claims and enrollment data are complete, accurate, and reliable. As an observational study, we cannot address the causal pathway between periodontal care and AMI care. Finally, we did not include insurance types and employment classification in our model adjustment, but we focused on each characteristic that is known to be associated with AMI care.
Well that’s it for today. Thank you, as always for listening – and if you think this is a good idea, one easy thing you can do right now is to pass it on to others. We need to get the word out, I hope you agree.
You have been listening to the Perio Patient Podcast. I am still Dr. Ben Young. Don’t forget to vote. Bye for now.