Primary Health Care Assessment and Intervention in the Dental Office

Geriatric periodontology: how the need to care for the aging population can influence the future of the dental profession

The world's population is aging, and it has been estimated that by 2050, the number of people 65 years of age and older will reach 1.5 billion. The aging population will be affected by noncommunicable chronic diseases, including diabetes mellitus, cardiovascular disease and cognitive impairment. This important demographic shift includes a reduction in tooth loss/edentulism, particularly in older adults of the developed countries in North America, western Europe and north-east Asia. Therefore, in the future, dental providers will be required to care for an expanded number of older adults who have retained teeth and are medically complex. As the linkage of oral disease and systemic disease has focused on the relationship of periodontitis and noncommunicable chronic diseases, a broad review of 'geriatric periodontology' is both timely and important. This volume of Periodontology 2000 covers a range of subjects under this heading. Included are the demographics of an aging world; the effect of aging on stem cell function in the periodontium; the periodontal microbiota associated with aging; the host response in the periodontium of aging individuals; an analysis of the prevalence of periodontitis in the USA on a national, state-wide and community basis; differentiation of physiologic oral aging from disease; treatment of periodontal disease in older adults; implant therapy for older patients; oral disease and the frailty syndrome; the relationship of tooth loss to longevity and life expectancy; and the relationship of periodontal disease to noncommunicable chronic diseases. Although 'geriatric dentistry' is not a recognized specialty in dentistry, and 'geriatric periodontology' is a descriptive title, the subject of this volume of Periodontology 2000 is critical to the future of clinical dentistry, dental public health and dental research. Any comprehensive focus on older patients can only be accomplished with an emphasis on interprofessional education and practice. If embraced, this shift will allow the dental profession to be more closely aligned with the larger health-care environment, and can improve both oral health and health outcomes for patients seen in the dental office.

The Dentist of the Future: Dental Surgeon or Oral Physician?

There is an accepted recognition of the need for the dentist to be able to diagnose and treat the number of older dental patients with more complex health care problems. Therefore in the future, dentists and other dental professionals will need to broaden their role in the delivery of overall health care and the designation of a dentist as an 'oral physician’ as well as a 'dental surgeon’ would seem logical. To deliver this developing role it will be necessary to ensure that undergraduate dental teaching programmes are designed appropriately to provide clinicians with the necessary clinical skills.18

A New Practice Approach for Oral Health Professionals

The oral health care paradigm presented here would broaden oral health services to include primary health care activities focusing on risk reduction and chronic disease screening.

BACKGROUND AND PURPOSE

Changes in our nation's health care delivery system, shifting patient demographics, and availability of new health insurance programs have resulted in exploration of new practice models of health care delivery. Chronic diseases require coordinated care efforts over decades of a patient's life. Oral health professionals will be part of that care.

METHODS

The practice model for this article was developed in the context of an academic medical center that promotes oral health care professionals as health care providers through interprofessional education. The combined experiences of the authors, including a diabetes predictive model for oral health settings, the efficacy and effectiveness of human immunodeficiency virus screening in a dental setting, the feasibility of using a decision support tool for tobacco cessation, and the effectiveness of integrating oral health education with comprehensive health services for people living with human immunodeficiency virus, have contributed to this concept.

CONCLUSIONS

Prevention is increasingly recognized as a cost-effective means of reducing chronic disease burdens. To be effective, health promotion activities that encourage healthy living and early detection need to occur in a variety of health care settings. Oral health professionals represent an underutilized group of health care providers that can contribute to improved health of populations living with chronic diseases by broadening their scope of practice to include primary health screenings and tailored health promotion activities.

Primary care in dentistry - an untapped potential

Dentistry is neither an allied health profession nor a paramedical profession. It is the only anatomically focused health care profession that is university-based and for which primary care responsibility is maintained by the profession. Dentists must have a reliable knowledge of basic clinical medicine for safely and effectively treating individuals with chronic and other diseases, which make them biologically and pharmacologically compromised. With changes in the life expectancy of people and lifestyles, as well as rapid advancement in biomedical sciences, dentists should have similar knowledge like a physician in any other fields of medicine. There are number of primary care activities that can be conducted in the dental office like screening of diabetics, managing hypertension etc., The present review was conducted after doing extensive literature search of peer-reviewed journals. The review throws a spotlight on these activities and also suggests some the measures that can be adopted to modify dental education to turn dentists to oral physicians.

Dentists as oral physicians: the overlooked primary health care resource

The United States is currently experiencing a primary care shortage. One solution to improving health care is to increase the utilization of existing health care providers, particularly dentists, an opportunity that has been largely ignored. By employing mid-level providers for less complex procedures to deliver more accessible dental care at lower cost, dentists can redistribute tasks to their office workforce. They can then serve as oral physicians who can provide limited preventive primary care, including screening for chronic diseases, while continuing to oversee all dental care, whether provided by dentists or non-dentists. Thus, they could improve the health of the US population as well as increase access to dental care at lower cost, while partially alleviating the primary care shortage by filling a need for the screening aspects of primary care.

A model for dental practice in the 21st century

The dental profession is responsible for the prevention, diagnosis, and treatment of diseases and disorders of the oral cavity and related structures. Although the majority of the US population receives excellent oral health care, a significant portion is unable to access regular care. Along with proposals to develop midlevel providers, the scope of practice for dentists needs to be reconceptualized and expanded. A broad number of primary health care activities may be conducted in the dental office, such as screening for hypertension, diabetes mellitus, and dermatopathology; smoking prevention and cessation activities; and obesity interventions. More than 70% of adults saw a dentist in the past year, which represents an unrealized opportunity to improve both oral health and general health.

US health care reform and the future of dentistry

The Patient Protection and Affordable Care Act has grand ambitions: to provide insurance coverage to more than 30 million currently uninsured Americans, to slow increases in health care costs, to reorganize the health care delivery system, and to improve the quality of care provided to all. Where does the oral health community fit in this initiative? Should dentists "scope up" to become a more active part of the primary care workforce? Or should dentists "scope down" and delegate parts of the traditional dental tool kit to midlevel practitioners? Our nation's public health largely depends on whether we can create a more integrated and public health-oriented delivery system. The oral health, physical health, and public health communities should address this challenge together.