“HEENT unremarkable: Head normocephalic. Eyes reactive to light with movements intact. Hearing normal to a whispered voice. Nasal septum midline. Throat without lymphadenopathy.”
“Good,” approved my attending, “but what about the mouth?”
“… what about it?”
“Mouths matter too,” he said while scrawling “HEENTM” across my notepad.
Struck by his revision to the classic HEENT exam, I consulted Google to figure out what exactly I might look for when examining the mouth.
It turns out that the mouth can reflect vitamin deficiencies, kidney or liver dysfunction, diabetes, and some autoimmune conditions. Furthermore, oral health actually affects systemic health. Oral disease increases risk of microbial infections, heart disease, stroke, diabetes, respiratory disease, premature births, and pancreatic cancer.1 Dental work that improves oral appearance may benefit patients’ mental health,2 and conversely, release from dental fillings and opioids prescribed by dentists may have adverse effects. In light of the opioid epidemic, I was interested to learn that dentists prescribe more opioids to young adults than any other healthcare provider.3
Researching the tight coupling between oral and systemic health led me to question the apparent divide between dentistry and medicine. Most four-year medical schools spend fewer than five hours on oral health instruction, and residency programs spend even less time,4 crippling oral health literacy and appreciation among physicians.5 When taking a routine history, physicians ask patients about past illnesses, hospitalizations, surgeries, immunizations, allergies, substance use, diet, exercise, and sleep, but not dental care.
The divide in care tracks a divide in insurance. The financing of dentistry today resembles the general landscape of health insurance in the early 1960s. In 2011, 92 percent of dentists were privately employed, and dental services represented 20 percent of out-of-pocket health expenditures, second only to prescription drugs.5 Most dentists do not accept government insurance, but even if they did, Medicaid in most states is limited to emergency dental care, and Medicare is limited to rare dental procedures required by hospitalized patients. Currently 130 million Americans are without dental insurance, triple the number without medical insurance.5 The upshot is that millions of Americans without dental insurance go undiagnosed or untreated for gum disease, cavities, tooth loss, craniofacial cancers, and oral pain.6
I am not the first to chew on the dental-medical divide. The Institute of Medicine reported on the issue 40 years ago,7 Surgeon General Satcher followed-up with a 300-page report 20 years ago,1 and Surgeon General Murthy reiterated key points last year.8 But still, few are actively pushing the integration of dentistry and medicine. Physician groups like Doctors for America talk about issues ranging from gun control to climate change, yet overlook oral health. Even the relatively broad Affordable Care Act neglected the mouth by only offering dental insurance for children and pregnant women.
Integrating dentistry and medicine will require three lines of action. The main effort will be making oral health insurance more affordable, together with enlarging the oral health workforce to supply a growing demand for care. An army of dental hygienists, like the nurse practitioners who stepped up in the 1970s, will be critical in meeting the needs of our population. A second effort will involve structural changes in health facilities, such as the collocation of dental and medical services and the implementation of electronic health records that allow communication between dentists and physicians. Pilot clinics in Wisconsin and Oregon are making progress on this front, offering patients their annual physical and dental cleaning in one visit.9 Third, it will be important to harmonize the training of medical professionals, including not only dentists and physicians, but also nurses, physician assistants, dental hygienists, and dental therapists. Harvard Medical School models an integrated foundational curriculum between dental and medical students, but the integration of continuing education is uncharted territory. Could dentistry someday be considered a specialty of medicine?
As usual, my attending was right – mouths do matter. Please consider how you might contribute to sealing the dental-medical divide. In the meantime, I will do my small part to examine the mouths of my patients and write about the topic on the internet.
*The views and opinions expressed herein are those of the author and do not necessarily reflect the views of MDLingo.com, its affiliates, or its employees.