Role of Dentists as Oral Physicians in Physical and Mental Health
Dentists as a specialty of medicine are de facto oral physicians with principal responsibility for maintaining the structure and function of the mouth and surrounding orofacial area. Beyond providing dental care, dentists as oral physicians are expected to emphasize and integrate the relation between oral and systemic disease as contributors to overall health care and quality of life of their patients. As oral physicians, they need to recognize and reinforce their roles in mental health. Consistent with what is hopefully happening with other orofacial specialties, such as ophthalmology, ENT, proctology, gynecology, and urology, oral physicians are moving away from treating the hole in the patient toward treating the patient as a whole, in recognition of the increasing complexity of medical care for both young and aging patients. Among the greatest challenges to both patients and clinicians are the many observable biophysical and/or psychosocial characteristics which can be observed or inferred from the face and mouth, including age, gender, speech patterns, race, ethnicity, nationality, intelligence, health, and disability. These characteristics are often biased and stereotyped by other people and can lead to adverse judgments.
The purpose of this chapter therefore is to make the case for dentists to accept their obligation to operate as de facto oral physicians and treat the mouth and surrounding areas as part of the body and mind of their patients.
Sigmund Freud, the father of psychoanalysis and one of the first authors to describe psychosexual stages, described the early development of an infant’s worldview as centered first on the mouth as the source of pain and pleasure (Freud, 1961). Jean Piaget (Piaget 1952), in his seminal work Origins of Intelligence in Children, speaks of how an infant learns to distinguish objects accessible to the mouth from the mother or that which the child cannot devour which he then senses as the primordial basis of perception of self from others.
Consistent with Maslow’s theory of the hierarchy of needs (Maslow, 1943), the mouth is also invested in satisfying psychosocial as well as physical needs. These include satisfying the basic needs for survival by intake of food, water, and socialization, as well as the more complex need for love; then the use of the speech apparatus of lips, tongue, teeth to communicate with family and friends allows the individual to achieve self-actualization and the enjoyment of the finer sensory pleasures of life, particularly those emanating from the oral cavity. Some psychoanalysts have suggested that the need for oral stimulation may in fact be instinctive and follow a rhythmic daily cycle (Friedman & Fisher, 1967).
It should not be surprising, therefore, that the morphology and function of the mouth also are essential to the development of a favorable body image which is vital to self-esteem. Perceived physical attractiveness appears to be based on a hierarchy of body parts, of which the face is foremost. While the eyes are the most important feature in judgments of attractiveness, the orofacial area is second (Hassebrauck, 1998). Therefore, adverse changes in either the structure or function of the orofacial area can be a major stressor. Social stressors can also cause psychoneuro-endocrinological changes resulting in problems for the orofacial area, for example, bruxism via the involuntary action of the somatic nervous system and halitosis which may have many etiologies, one of which is related to reduction in the volume of saliva or xerostomia due to the involuntary action of the sympathetic branch of the autonomic nervous system. Changes in the composition of saliva may also have direct and indirect effects as markers of other psychiatric and medical disorders, for example, posttraumatic stress disorder (Young & Breslau, 2004), which can cause changes in salivary cortisol, epinephrine, and enzymes. There is some suggestion that one cause of orofacial birth defects such as cleft palate may be prenatal stress (Blomberg, 1980; Montenegro, Palomino, & Palomino, 1995). In addition, there are a number of other psychophysiologic, stress-related diseases specific to the orofacial area, such as temporomandibular disorders, acute necrotizing ulcerative gingivitis (ANUG) (Giddon, Zackin, & Goldhaber, 1964), head and soft tissue pathology, eating disorders, bruxism, clenching or grinding, chronic cheekbiting, burning mouth syndrome, phantom tooth pain, lichen planus, and recurrent herpes labialis.
Several studies have indicated that physical attractiveness is understandably associated with personal and professional success, including educational opportunities and the choice of a life partner (Napoleon, Chassin, & Young, 1980; Alley & Hildebrandt, 1988).
As expected, however, there still may be differences among individuals in concern or emotional investment in the orofacial area (Franzoi & Shields, 1984). Not everyone wants to expend resources to improve the orofacial area, but may see a greater potential for enhancing self-esteem and quality of life by improving fitness and the appearance of the body. For example, males are more interested in the appearance of a woman’s face when interested in long-term relationships, and conversely interested in the attractiveness of the body for short-term relationships (Confer, Periloux, & Buss, 2012). Although evolution suggests a correlation between the physical characteristics of the face and body, male and female judges were not able to match faces to nude bodies. Rather the judges simply matched the most attractive face to the most attractive body (Cruikshank et al., 2000); one explanation for this phenomenon is that females, more than males, are more likely in our culture to use makeup, hairstyle, and plastic surgery to alter perception of their faces.
Ethnocultural Differences in Perception of Appearance and Pain
As shown in recent years, there is considerable variation in the configuration and interpretation of ethnocultural differences in facial expression (H. Lee, Giddon, & Anderson, 2009). Since attitudes toward the mouth and illness behavior in general differ both within and between ethnocultural groups, the oral physician must have enough cultural competence to reduce reliance on stereotypes of responses to dysmorphia and pain (Giddon & Edwards, forthcoming).
Central to the understanding and management of patients from the ever-increasing pool of ethnoculturally diverse patients is recognizing the importance of communication between doctors and patients by being alert to disparities in health literacy (Nielsen-Bohlman & Institute of Medicine (U.S.). Committee on Health Literacy, 2004).
In general, ethnocultural variations in pain perception and reporting can profoundly influence diagnoses and treatment decisions (Mossey, 2011). There are also major differences among providers in the prevailing stereotypes about ethnocultural differences in pain perception, ranging from expressivity in some Mediterranean/Middle Eastern cultures (Zborowski, 1969) to nonexpressivity or stoicism, to macho behavior, where it’s a matter of honor not to show pain, as seen in some Hispanic cultures (Torres, 1998). Stoicism can exist for several reasons; for example, the stoicism of Chinese and many other Asians is marked by a reluctance to report pain, preferring to keep it a private matter with minimal intrusion into the quality of life of family and others (Nilchaikovit, Hill, & Holland, 1993), while in some African cultures, stoicism is seen in religious rituals that require one to bear pain, for example, scarification. Dentists not practicing as oral physicians can be oblivious to these behavioral nuances which often result in under- or overtreatment for pain (Nilchaikovit et al., 1993).
As one important example of the ethnocultural differences in provider awareness, clinicians in a labor and delivery unit in Israel (most of whom were Jewish) perceived Bedouin women as experiencing less pain than Jewish women, even though the women themselves—all of whom received similar treatment—assessed their pain as similar, thereby reinforcing the existence of culturally different interpretations of pain (Sheiner et al., 1999).
Although many health professionals chose dentistry over medicine because they wanted to avoid the bureaucracy and the concern about life and death decisions, mortality is not alien to the dental world (Otto, 2007), for example, deaths from outpatient anesthesia (1 in approximately 1.7 million) (D’Eramo, Bontempi, & Howard, 2008), the infamous death cited by Daschle (Daschle, 2008), and some deaths due to wisdom tooth surgery (Moisse, 2011).
The Oral Physician and Access to Dental Care
For the benefit of both patients and clinicians, it is also important for oral physicians and other healthcare providers who are entrusted with the integrity of the healthcare system to identify patients who overutilize the system, whether intentionally or not. Their conscious or unconscious motivations may vary from feeding a drug addiction through malingering to psychopathology (Williams et al., 2001). For example, Wasan, Anderson, and Giddon found that those patients with left-lateralized spinal pain have more psychopathology than those with right-lateralized pain (Wasan, Anderson, & Giddon, 2010).
There is in fact a public outcry about the disparities in access to affordable dental care, so much so that dental care is now one of the most sought-after worker benefits (American Dental Association, 2012a). This concern and interest has been highlighted by the recognition of the interrelation of oral and systemic disease, and realization of the orofacial manifestations of over 100 systemic diseases, some of which have a genetic basis (Long, Hlousek, & Doyle, 1998; Ward, Jamison, & Allanson, 2000; Smithson & Winter, 2004).
Role of Dentists as Oral Physicians in the Healthcare System
Dentists as oral physicians need to recognize and respond to having a greater role in the healthcare system.
In addition to being available as first and follow-up responders under the Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (H.R. 307, 2013), some of the general health issues which dentists are already trained to recognize and refer for include cardiovascular disease, hypertension, osteoporosis, skin cancer, nutrition, and tobacco cessation counseling. Recognition and treatment of the dental ravages of eating disorders such as bulimia are yet another mental dental connection (Tran, Anderson, & Giddon, 1998; Anderson, Zionic, & Giddon, 2002; Giddon & Anderson, 2002), as is relating facial trauma to domestic abuse.
As important as some of these concerns may be for practice, the present predoctoral or even postdoctoral curricula may not yet provide sufficient training to recognize and manage as oral physicians the psychosocial issues other than awareness of the oral manifestations of psychoactive and other medications across the age spectrum.
Historically, a dentist would only diagnose and treat the teeth and supportive structures. In relatively recent years, the scope of practice nationally has broadened. The ADA now accredits postdoctoral programs that “… prepare graduates to act as a primary care provider for individuals with chronic, recurrent and medically related disorders of the oral and maxillofacial region and to provide consultative services to physicians and dentists treating patients with chronic, recurrent and medically related disorders of the oral and maxillofacial region” (American Dental Association, 2012b). Participation in such programs reflects a greater understanding of the mouth, of which there may be one anatomical side and one political side, as part of the body and its relation to self-image and esteem and therefore critical to overall physical and mental health and quality of life.
Dentists are probably overtrained for what they actually do. Therefore, just taking advantage of dentists’ existing capabilities as de facto oral physicians can facilitate their being able to provide limited preventive primary care by utilizing the time saved by delegating routine procedures to mid-level providers such as dental therapists or hygienists (Anon, 2012).
One of the efforts to move dentists back in the direction of medicine was the change in dental degree from DDS to DMD for schools with a significant medical component in their predoctoral curricula. While Harvard, the University of Louisville, and the University of Oregon may have been the first to change the degree, many other schools have since followed, but not necessarily with the same emphasis on medicine. Although training varies from school to school, regardless of whether the degree granted is DMD or DDS, public perception is that the DMD is more competent than the DDS to deal with the medical issues associated with dental care (Lalumandier, Pyle, & Sawyer, 1999), and many graduates of DDS programs, when given the option to change their degree to DMD do so, even at additional personal expense. Moreover, for those with the more preferred DMD degree, the fact that medicine is part of the degree awarded should allow such degree recipients to be called physicians.
Factors Facilitating Dentists Becoming Oral Physicians
Some of the factors influencing the changes are as follows.
Use of Mid-Level Providers
In spite of evidence (Emmerling & Standley, 2011; Beazoglou et al., 2012) that properly trained nondentists can be employed to increase access at lower cost to dental care, the dental profession is resisting allowing mid-level providers, such as the new dental therapists in the United States, to treat patients requiring only simple restorations or emergency care. After unsuccessful legal battles by organized dentistry in which they maintained that these mid-level providers would be practicing dentistry without a license, dental therapists are now being trained under the auspices of the Alaska Native Tribal Health Consortium which is authorized to act on behalf of sovereign tribal nations in lieu of the U.S. government’s Indian Health Service (Halliday, 2007).
Time Saved for Primary Care by Using Mid-Level Providers
Although some authors disagree (Beazoglou et al., 2012), Giddon, Swann, & Hertzman-Miller (2012) have maintained that the time saved by such delegation to mid-level providers will allow the dentist as an oral physician to provide limited preventive primary care, including screening for chronic disease based on oral and systemic manifestations of disease and taking of vital signs (Giddon & Swann, 2011). Whether the dental profession approves or not, these mid-level providers will become a major source of dental manpower (Bertolami, 2011; Giddon et al., 2013).
Dentists Need a New Superordinate Designation as Oral Physicians
Mid-level providers/dental therapists will be called dentists, and this perception will likely become so pervasive that the public and/or patients will not be willing or even able to distinguish these mid-level providers from the medically and surgically trained dentists.
Rather than viewing the development of mid-level providers as a threat, the dentists should see them as an opportunity to reinvent themselves as oral physicians who will oversee all dental care, whether provided by dentists or nondentists. In fact, a bill has been brought before the Massachusetts legislature that would allow dentists to designate themselves as oral physicians (Bill H01490, Massachusetts Legislature, Joint Committee on Public Health, 2011), similar to what was already permitted for podiatrists and chiropractors: to become podiatric and chiropractic physicians, respectively.
Relative Shortages of Access to Lower Cost Dental Care and Primary Care Providers
As noted earlier, the limited access to affordable dental care (IOM (Institute of Medicine) and NRC (National Research Council), 2011) and the widely recognized shortage of primary care physicians (Julian, Riegels, & Baron, 2011) set the stage for a redistribution of the dental healthcare workforce. In this new system, the dentists, in addition to providing dental care which only they can provide, can also by delegation to mid-level providers be available as oral physicians to provided limited preventive primary care.
Medical and Surgical Training of Dentists
Training to become a dentist includes basic didactic and clinical skills in medicine and surgery sufficient to provide limited primary preventive care, such as obtaining vital signs, screening for chronic disease, including recognition of major psychiatric and behavior disorders.
Public Acceptance of Dentists as Oral Physicians
There are a number of studies showing that patients will accept dentists becoming involved in overall health as oral physicians. Although dentists often claim that patients will not allow them to provide any services other than those directly related to the teeth, several studies and other sources suggest that patients do appreciate such interest in their overall welfare (Greenberg et al., 2009) and are willing to pay a small fee to dentists (as oral physicians) for such a service (Greenberg et al., 2012). In the United Kingdom, for example, patients welcome dentists’ being concerned or even obligated to know more about general health (Hancocks, 2012). Some of the preventive services patients are beginning to welcome involve screening, including for tobacco use (Campbell, Sletten, & Petty, 1999; Victoroff et al., 2006), alcohol use (Miller et al., 2006), HIV (Blackstock et al., 2010), diabetes, and cardiovascular risk (Greenberg et al., 2007). In general, patients support being asked about domestic violence by healthcare professionals (Caralis & Musialowski, 1997; Feder et al., 2006), and in one study, the majority of survivors of domestic violence wanted their dentists to ask about the source of their injuries (Nelms et al., 2009).
Dental clinic patients have also indicated their willingness to have their dentists ask about and/or screen for important systemic illnesses, including cancer, heart disease, diabetes mellitus, HIV, hepatitis, obesity and nutritional status, psychological disorders, domestic abuse, and hypertension (Greenberg et al., 2009; Giddon et al., 2012), and this willingness appears to be associated with reporting themselves as having a particular medical condition, although whether or not they actually have the medical condition has yet to be determined (Berry, 2012).
Dentists Seen More Regularly Than Physicians
The dentist is seen on a more regular basis than the primary care or family physician (Strauss et al., 2012) and, except for emergencies, dental care is generally elective, compared to most medical care which is inelastic and on an as-needed basis.
Training of Oral Physicians
Harvard University recently funded a program to train general practice dental residents to become oral physicians. Working with Harvard Medical School, Harvard School of Dental Medicine, and the Cambridge Health Alliance, they are also cross-training with medical residents to learn more about oral health and disease (Giddon, 2010). Related to this effort, the Harvard Medical School curriculum now includes presentations on oral health and the prevention of oral disease (B. Swann, 2012, personal communication). Although there has been a significant recognition of the importance of interprofessional collaboration (Institute of Medicine, 2013), including the medical home concept, among health providers, there have been some obstacles or impediments to implementation. For example, the issue of what care dentists can or should provide was raised recently in legislation proposed in Illinois by the Illinois State Dental Society to allow dentists to give vaccinations, including flu vaccines, but was withdrawn partly because of opposition by the Illinois State Medical Society (Fox, 2013).
Dentists Becoming More Comfortable with Role in Primary Care
Dentists, particularly those in academic leadership positions, are becoming more supportive of taking a role in primary care. A recent survey of U.S. dentists revealed that “[t]he majority thought it was important for dentists to conduct screening for hypertension (85.8%), cardiovascular disease (76.8%), diabetes mellitus (76.6%), hepatitis (71.5%) and human immunodeficiency virus infection (68.8%)” (Greenberg et al., 2010). Some of these opportunities already exist; for example, screening for diseases that can be diagnosed from saliva or other oral fluids or tissue samples (Lee, Garon, & Wong, 2009), which currently include HIV, hepatitis C, and diabetes, and in the future may include markers to identify the presence of breast, gastric, lung, and possibly prostate cancer, among others (Drobnik et al., 2011; Gaidos, 2011; Giddon & Lisanti, 1962; Y. H. Lee & Wong, 2009; Yeh et al., 2010). Dentists’ ability to screen for psychiatric disorders, such as bipolar disorder (Deshauer et al., 2003), has also progressed over the years since the work of Giddon and Lisanti (Giddon & Lisanti, 1962). If the dentists as oral physicians do not take advantage of the many still untapped opportunities in their own domain of salivary assays, physicians and other health professionals certainly will.
Past and present screening by dentists for socio-medical problems include 42% of dentists who report that they already screen patients for eating disorders (Debate & Tedesco, 2006), 15% who sometimes or often screen for domestic violence at checkups, and 82% who ask about domestic violence when presented with head or neck injuries (Love et al., 2001).
Obligation of Health Professionals
Although there is some reluctance to be intrusive, dentists in general report being comfortable with their roles as mandated reporters of domestic violence (Barbara Aved Associates, 2006). The license to practice dentistry is not an entitlement but a privilege granted by the government to serve society as a health professional.
Compensation of Dentists for Nondental Health Services
Except for counseling for tobacco cessation, compensation for these additional services is not readily available. Some other conditions for which Medicare and other third-party payers may be able to compensate dentists/oral physicians, and for which there are already billing codes, are obesity and drug addiction. Given that dentists are the number two prescribers of narcotics (Denisco et al., 2011), they should have a significant role in recognition of addiction, helping patients to receive appropriate treatment. Brief addiction counseling, which has shown to be effective in general medical settings, could be applied successfully by dentists practicing as oral physicians.
Some insurance companies are already compensating dentists for dental and other preventive procedures (Anon, 2010; Delta Dental of Massachusetts, 2009). Thus, it may not be too long before preve/>