A Comprehensive Approach: Integrating Medical & Dental Care

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Dental and medical care have long been siloed, with dentists addressing only oral health and all other doctors handling every part of the body except the mouth as if it were not a vital organ. More recently, however, dental and medical practitioners have begun to think about total—oral-systemic—health.

“Total health has been a term used by many over the last decade, but its meaning can . . . [vary depending on the] individual,” says Bobbie DelSasso, RDH, BS, executive director of the American Academy of Oral Systemic Health (AAOSH), adding that the Academy’s focus “is on…collaboration between health care professionals to bring awareness to how systemic diseases can affect the mouth and vice versa.”

Some clinicians are tearing down the siloes, collaborating on cases or partnering to offer comprehensive care. And medical doctors are finally learning about the inner workings of the mouth—or at least taking the dentists’ word for it. As medical and dental care become more integrated, overall patient health is sure to improve. But what exactly does this medical-dental consolidation look like? And what does it mean for the future of dentistry?

The Merging of Medicine and Dentistry

Because poor oral health is linked to many chronic diseases, like diabetes, Alzheimer, and cardiovascular disease,^1,2,3 an integrated approach can be very beneficial. A 2021 study⁴ looked at 6 state health departments that conducted 2-year pilot programs to promote collaboration between oral and medical health practitioners and found that the departments were able to increase collaboration, deliver preventive education to patients, and implement better organized referral systems.

“Quite simply, focusing on oral-systemic health improves patient outcomes,” says Eric Giesecke, MBA, chief executive officer of Planet DDS. “And eventually, things like AI machine learning and predictive analytics will . . . help providers suggest treatment based on a holistic picture of . . . [the] patient’s health.”

With such obvious benefits, it comes as no surprise that medical-dental integrations are growing. And the precedent is there; along with the rise of DSOs and dental groups, specialists like orthodontists and oral surgeons have been joining general practitioners more and more frequently to form multispecialty practices. Giesecke thinks the transition could mimic the inclusion of in-house specialists by DSOs.

“A lot of DSOs are starting to bring specialties in-house, and so they need to be able to communicate across providers. And being on a single platform like Denticon allows you to do that more effectively,” he says. “Patient care is [also] improved when there’s more choice to be able to refer out to specific specialists. . . . If it’s not easy to do, people won’t do it as much and won’t be able to pick the best specialist for . . . [an] individual patient. But . . . we’re going to see more consolidation with dental specialties, and that might extend to medical as well.”

For her part, DelSasso is beginning to see more of these collaborations, primarily in the form of referrals, from dentists to doctors and vice versa. Dentists interested in establishing a relationship with an MD should start with mutual patients.

“Ask them who their cardiologist is,” she says, and then talk “with the cardiologist about . . . [patient] needs . . . perhaps [a] concern for heart issues before implant surgery or lung issues prior to general anesthesia. Many doctors . . . welcome conversations about mutual patients and . . . it’s a great place to begin . . . [to] grow each other’s practices too.”

In a perfect world, DelSasso would love to see practices that include doctors, nurse practitioners, nutritionists, myofunctional therapists, or other allied health care professionals collaborating with a dental practice in one location. She sees this trend growing steadily, although slowly, every year.

“The thing about integration is that it takes many dentists and doctors out of the[ir] traditional comfort box,” DelSasso explains, so change will take time. “But the more they hear [about] and work with other professionals who have moved to this type of practice,” the more interested they will be in making patients healthier while using fewer pharmaceuticals. 

Although only a handful of AAOSH dentists and cardiologists practice together in one office, DelSasso thinks this is “the ideal scenario.” However, she points out, “it takes a lot of effort to work together to achieve maximum success, and not all practices have the opportunity to do this.”

An In-House Collaboration

Barbara McClatchie, DDS, is one AAOSH member who is collaborating in-house with a medical partner. Five years ago, she and cardiologist Eric Goulder, MD, founded the first US center where a dentist and a cardiologist practice together under the same roof—in Worthington, Ohio. They apply the BaleDoneen Method and focus on addressing issues like inflammation, which links cardiovascular and periodontal diseases in an effort to establish better overall health.

On his side of the practice at the Heart Attack and Stroke Prevention Center of Central Ohio, Dr Goulder requires full-mouth periodontal charting radiographs, CBCT imaging to look for endodontic lesions, and salivary diagnostics to identify high-risk pathogens for all of his cardiology patients—most of whom also present with active periodontal disease. By analyzing the bacterial, genetic, microbial and protein biomarkers in saliva, she is able to better assess the patient’s risk and create personalized periodontal treatment plans.

Drs McClatchie and Goulder have found their collaboration to be extremely advantageous for patients. A recent case that benefitted from this approach was a 52-year-old man who had been hospitalized three times for cardiovascular problems. His identical twin had had a heart attack several years earlier and survived, but the patient was concerned about his cardiovascular health, and contacted Dr Goulder’s practice for assistance. After learning that the patient had not seen a dentist for almost 15 years, Dr Goulder’s team referred the high-risk patient to Dr McClatchie for proper periodontal diagnosis and protocols. Dr McClatchie’s team did radiographs and perio charting and discovered that he had radiographic calculus, as well as 162 sites of bleeding and eight teeth with pockets of six millimeters or more.

“Once we saw the results of his salivary diagnostic test, we knew he was full of high-risk pathogens that contribute to cardiovascular disease, diabetes, and dementia, and this put him in harm’s way during the periodontal therapy,” Dr McClatchie says.

The results showed Dr McClatchie and her team that the patient had high levels of porphyromonas gingivalis, a dangerous anaerobe linked with heart attacks, strokes, and Alzheimer's.

“By doing this saliva test, we learned more about him,” Dr McClatchie says. “We can’t just flush that bacteria into his body. This is where the comprehensive approach comes in. Before we did his periodontal therapy, we had the benefit of the bloodwork done by Dr Goulder, and we had all of his inflammatory panels. We knew we had to reduce the inflammation and start killing some of the bacteria before we push it systemically.”

Dr McClatchie has the patient wear PerioProtect trays for 2 weeks to treat the problem topically to reduce the bleeding due to inflammation, as well as to try to reduce the pocketing prior to therapy. After 2 weeks, another saliva test and perio chart would be performed before they completed the periodontal therapy. Three follow-up saliva tests and blood draws would be performed at the 2-week, 6-week, and 10-week marks to assess what the dental component was accomplishing systemically, with the hopes that inflammation markers would reduce. And all of this would be completed before Dr Goulder intervened with any treatment.

“Without doing these diagnostics, you could trigger a heart attack, stroke, or death if you just provided periodontal treatment,” Dr McClatchie says. “That's what our dental professionals need to understand: That there is a cause and effect from these bacteria. We don’t do periodontal therapy without doing saliva diagnostics. For me, it's like me doing dentistry without loupes; not knowing what you're pushing into the body makes me very uncomfortable.”

This approach of addressing oral inflammation before cardiovascular treatment helps eliminate causal variables, while also reducing risk factors. But this approach only works if both the physician and the dentist are on board—and this sort of collaboration can be complicated, since it wasn’t how most practitioners were trained.

“A dentist may say, ‘I saw calcifications in the carotid artery on a patient’s panorex,’ and I told them to go to their doctor and their cardiologist just writes it off because they haven't been trained that way,’” Dr McClatchie says. “But if you have calcifications in your carotid artery, you have cardiovascular disease. So, we need to be the eyes and ears for patients on many levels, looking at their health history and seeing where they have other chronic inflammatory diseases.”

The Challenges of Integration

Although the benefits of integrated care are obvious, practices interested in providing it face a number of challenges—both technical and philosophical. What is most important is that they “share the same philosophy of treatment; otherwise, the conflicts can be too great, and confusing for the patients,” DelSasso says.

Dental practices looking to add a medical partner should ensure that the potential referral practice practices in the same manner as the dentist. This includes evaluating everything from the practice’s legal and ethical guidelines, location, staff-to-patient ratio, accessibility of care, and age of the office. Even more critically, DelSasso says, is a mutual understanding of end goals and the determination to reach them.

“The practice must have the knowledge and need of working together in a symbiotic relationship of shared communication,” she says. “There is constant new learning with all the different treatment modalities out now, and both parties have to be willing to self-educate and grow.”

Communication, however, can be a big roadblock, particularly when making referrals. Although dental practice management software is quite advanced, there is no software that can talk across medical and dental platforms. Giesecke hopes this will change, but at this point, he sees technical incompatibility as a significant challenge.

“You’re starting to see some colocation of services that require you have systems that talk to each other really well from a medical and dental perspective,” Giesecke says. “Software to accommodate both is very early in its infancy. If you think about electronic health records, it didn’t really take hold at first as much as it did in medical. I think there probably needs to be some sort of market leadership—whether it be institutional like the ADA or private parties like companies—to encourage people to create a standard format. I think it’s going to take a group of practice management software companies to get together and decide that's the best thing for producing the best kind of dental and medical care. But the demand just isn’t there quite yet.”

For practices like Dr McClatchie’s that are already collaborating with medical partners, such a delay can prove particularly challenging. Sharing charts, cone beams, and general information often involves a walk down the hall. “Charting is a frustration because there’s no medical-dental software, so you have to have 2 sets of software,” Dr McClatchie says. “We are lucky to be under one roof and have a morning huddle, but it’s taken us 5 years to really get the flow. And every month we’re changing protocols as we try to see what works best.”

As Drs McClatchie and Goulder continue to hone best practices, Giesecke thinks ease of use will be critical in streamlining procedures for integrated practices.

“They need to make technology easy and convenient for the provider,” he says. “When you look at GP/specialist referrals now, the GP wants the provider to be able to get full access to the information, and the GP wants to know what the provider with a specialist did. Applying it the medical, usability and ease of use related to that is the most important way that will drive adoption.”

The Integrated Future

Integrated practices are leading the way in oral-systemic health and beginning to transform the dental industry’s approach to care, they still face challenges.

“Right now, in dental, we’re still very much in a world where someone comes in and they do a whole series of X-rays and current diagnostics, but don’t address many preexisting conditions,” Giesecke says. “There's not a lot of historical insight in terms of what that patient has done across their entire lifecycle of healthcare. Having that would potentially allow the provider to identify risks and be more able to treat it effectively. So, I think, an overall, integrated view of the patient itself across medical and dental will improve patient care.”

How can we expedite this transition? Breaking free of the mold requires dedication to expanding knowledge and exploring new avenues.

“I think education is the key,” DelSasso says. “We find so many MDs who haven’t been taught about the mouth, and when they are invited to learn they are amazed at what they discover. We also need to be open minded to learning new things that might be different from what was taught at school or what presents itself at the numerous dental and medical association meetings. You don’t know what you don’t know, and when MDs, chiropractors, nurses, physical therapists, nutritionists, etc. are brought together in the same arena as dentists and hygienists, magic happens.”

Dr McClatchie agrees. “You have to learn about both sides,” she says. “I have so much more medical knowledge now, and our cardiologist knows so much dental; he even knows tooth numbers now. He only had one lecture on the mouth in medical school. So you can’t expect our physicians to understand what we do, just like we didn’t learn the medical side in dental school. It’s about understanding how they all work together. Industry standard might be that medical professionals ask for dental clearance, but they might not really . . . understand why they are asking.”

A greater focus on education could also unite the fields and lead to better health care overall.

“Medicine and dentistry need to work together,” DelSasso says. “Only then can you get to the root causes of disease. If your physician could check your mouth for periodontal disease or inflammatory markers when your diabetes is acting up, then referring you to your dentist to get the perio under control, it might prevent dire effects of both diseases. The key is communication between practicing offices and open communication with the patients.”

According to Dr McClatchie, communication and education go hand in hand. Numerous organizations and training resources are available to clinicians who want to learn more about integrated practices and oral-systemic health, and she encourages doctors and dentists to take advantage of them.

“I would recommend joining the AAOSH,” she says. “Go to the BaleDoneen preceptorship to learn the medical and dental sides. Do your research and learn. It’s all about finding like-minded people and avenues to learn and support each other.”

Dr McClatchie and DelSasso believe that as more medical and dental professionals learn about and embrace comprehensive care, prevention will come to the fore and patients will be kept healthy from the start. “We're all treating end-stage disease, but we're not really talking about prevention, and we need to the role of the dental professional,” Dr McClatchie says. “There are so many tests that can give us warning signs if more people learn about it.”

Just as with collaboration, embracing new modalities can have only positive outcomes. “Healthcare is no longer one-size-fits-all,” DelSasso says. “There are so many options to treat disease that can improve your life and help you live healthier and longer. We have come around full circle in healthcare and are now looking back to root causes. Patients are much more informed about these things, and they are asking their doctors questions. It’s a great way for all doctors, both dental and medical, to take the necessary steps to learning about new alternative and integrative treatments, and better ways to prevent disease, not just treat disease.”

References

1. Jimenez M, Hu FB, Marino M, Li Y, Joshipura KJ. Type 2 diabetes mellitus and 20 year incidence of periodontitis and tooth loss. Diabetes Res Clin Pract. 2012;98(3):494-500. doi:10.1016/j.diabres.2012.09.039
2. Jaunmuktane Z, Mead S, Ellis M, et al. Evidence for human transmission of amyloid-β pathology and cerebral amyloid angiopathy. Nature. 2015;525(7568):247-250. doi:10.1038/nature15369
3. Liljestrand JM, Havulinna AS, Paju S, Männistö S, Salomaa V, Pussinen PJ. Missing teeth predict incident cardiovascular events, diabetes, and death. J Dent Res. 2015;94(8):1055-1062. doi:10.1177/0022034515586352
4. Linabarger M, Brown M, Patel N. A pilot study of integration of medical and dental care in 6 states. Prev Chronic Dis. 2021;18:210027. doi:10.5888/pcd18.210027