The Role of Oral Health Care Professionals in Providing Medical Services

Integrating OHCPs into Medical Care

The American Dental Association (ADA) has for many years enabled attendees at its Annual Session to be screened for numerous medical conditions, and it has also provided an open forum to explore the issue of dentists’ providing medical screenings in their dental offices.⁵ Furthermore, the ADA’s Council on Dental Practice has most recently provided a response to House Resolution 28H-2014, which asked for clarification on the implications of incorporating chair-side medical screenings during routine patient evaluations in a dental setting. Screening tests discussed included hemoglobin A1C for glycemic control, total cholesterol and high density lipoprotein cholesterol (HDL-C) for cardiovascular diseases (CVD), human papilloma virus (HPV) and human immunodeficiency virus (HIV) for infectious diseases, salivary biomarkers for various oncological conditions, blood pressure for hypertension, and biometric screening.⁶ Offering, performing, and interpreting medical testing in a dental setting will require new competencies in our dental curricula. The attitudes of various authorities and professional organizations about having these activities performed by dentists have recently been explored.⁷

Integration of OHCPs into medical care could advance efforts to control increasingly prevalent conditions such as CVD, diabetes mellitus, HIV infection, and hepatitis C infection, each of which is associated with significant morbidity and health care costs. The maldistribution of health care professionals and the potential future shortage of trained physicians, nurses, and other medical primary care providers provide an opportunity to expand the scope of practice for OHCPs beyond traditional oral health services.⁸ Integration of other health care practitioners could help alleviate the impact from the shortage of primary care providers.⁹ Studies have documented the impact of early intervention to reduce the incidence of disease and/or reduce the severity of disease.^10–18 In order to achieve this goal, numerous barriers need to be overcome, including changes to our traditional educational system for OHCPs. Enhanced education and training in medical disciplines,¹⁹ as well incorporating better and improved interprofessional education (IPE) and practice, will be essential.

A study by Herman et al. looked at the acceptance of medical screenings in a dental office by the insurance industry.²⁰ Although that study found the existence of barriers was acknowledged by the industry, another study found that “All respondents [insurers] supported incorporation of preventive screening into dental practice as an ideal model for integrated delivery of health care.”²¹

In addition, present health care expenditures are unsustainable and may drive the need for nontraditional models of health education and delivery.²² A study of patients’ attitudes toward medical screening in a dental setting found a willingness by patients to pay for such services.²³ Furthermore, performing medical screenings in a dental setting may result in significant savings in medical expenditures.²⁴ The cost incurred by the provider to offer point-of-care screenings and subsequent referrals is less than traditional medical laboratory fees.

Implications for Dental Education

Educational strategies need to heed these changes and recognize both opportunities and challenges. In particular, we need to recognize the following: 1) OHCPs are health care professionals even though they are educated and trained in a specific health care field; 2) OHCPs cannot abrogate their responsibility to enhance patients’ overall health and well-being; 3) OHCPs care for individuals who may be unaware of their risk for developing systemic diseases and whose systemic diseases/conditions are poorly controlled and/or managed; 4) oral health care settings can be an additional portal into the overall health care environment; 5) third-party reimbursement models will not continue to reimburse based on a surgical model but rather look at overall health outcomes; and 6) OHCPs can be integrated into emerging health care delivery models such as the medical or health home.

Acceptance of these points would challenge the current dental educational model, as well as the education and training of faculty. It would also require enhancing education and training in the biological sciences for aspiring OHCPs for the purpose of screening for medical conditions among individuals seeking care from an OHCP; providing opportunities for OHCPs to discuss oral-systemic disease relationships; providing opportunities for OHCPs to make a diagnosis for specific systemic diseases/conditions; providing opportunities for OHCPs to provide/alter medications for specific systemic diseases/conditions; providing opportunities for direct interaction between OHCPs and physicians; providing opportunities for OHCPs to provide select immunizations; providing opportunities for OHCPs to deliver and reinforce health messages; allowing OHCPs to receive reimbursement for medical assessments in a dental setting; and perhaps creating a more advanced dental degree that would prepare an OHCP to provide limited medical interventions.

Challenges for implementing competencies in monitoring and screening for medical diseases and conditions in dental curricula are different from those that would enable performing such procedures in a dental setting as these issues are under the jurisdiction of different regulatory and legal entities. However, providing dental students with the necessary training and skill sets to be competent in integrating these activities into oral health care delivery systems after graduation may motivate and encourage necessary regulatory changes.^25,26

Redefining and expanding the scope of practice for dentistry in a state’s practice act would require acceptance by both dental and medical licensing authorities.²⁷ Interestingly, “screening” is not covered in the medical practice act. Dental faculty members may oppose the introduction of what many may consider nontraditional dentistry if education and training in new skill sets were added at the cost of more traditional topics presently taught.

New and redefined competencies would need to be incorporated for OHCPs to achieve proficiency in monitoring and screening for medical diseases and conditions.^28–30 Enhancement of existing dental curricula should address additional skill sets, such as incorporating evidence-based medical and dental education and practice that will enable a practitioner to assess timely and relevant scientific information; types of screening available and appropriate; types of screening methods; interpretation of positive and negative screening test results; interpretation of the risk literature and medical testing;³¹ the utility of various tests; increased appreciation for confidentiality and patient privacy issues; and increased knowledge of specific medical disease and conditions that will be monitored and screened.

In their study, Strauss et al. found that it was possible to detect abnormal laboratory tests in the serum and urine of individuals seeking dental care.³² While devices for chairside HbA1c testing are available, the current technology does not afford as high a specificity as desirable, resulting in a number of false-positive findings.³³ This limitation would have significant implications if used for a definitive diagnosis, but would be less problematic if used for screening to identify patients at increased disease risk. In other instances, disease prevalence is an important consideration when embarking on routine disease screening. For example, when screening for HIV using the rapid HIV saliva test, the positive predictive value decreases in areas in which the HIV prevalence is <1%.³⁴ Understanding factors that limit the accuracy, reliability, and yield of any screening test is essential.

The idea of involving OHCPs in screening for complex diseases such as CVD has been discussed in earnest over the past two decades.^35,36 Several studies have suggested that a dental office is a suitable setting for the purpose of screening and referrals for many diseases and conditions, including CVD, HIV, and others.^36–43 Furthermore, studies have found that dentists, patients, and physicians were willing to perform medical screenings in a dental setting.^23,44–47 Other studies have explored how dentists can contribute to a related activity: that of increasing awareness of a healthier lifestyle.^48,49 Suggestions have also been made for OHCPs to become involved in other nontraditional health-related activities, including vaccinations.⁵⁰

Potential Curricular Changes

To embrace the evolving health care arena and to be a part of the future health care delivery dynamic that will encompass an interprofessional and patient-centered health care delivery model, dental school curricula should include substantive IPE opportunities. Such opportunities would provide the basic skills and training for future dentists to recognize and appreciate their patients’ oral health issues in the broader context of their overall health and well-being. However, there is little evidence that the addition of OHCPs have provided added patient benefits in an interprofessional practice model. Hopefully, future studies will provide support for this care model. In the meantime, we urge consideration of the following curricular changes.

First is introduction of a course on the concepts and foundation of preventive health attitudes and behavior and the factors impacting these behaviors (from both provider and patient perspectives). This course would include topics such as access to and utilization of oral health care, workforce dynamics, health disparities, medical adherence, cultural competence/sensitivity, and health literacy. The second proposed change is addition of a course on systems theory as applied to population-based oral health care with the goal of elucidating and understanding the key drivers and challenges (e.g., environment, social, economic, community, and provider inputs) and developing strategies to address these factors in a way that optimizes system characteristics (e.g., capacity, flexibility, quality, effectiveness and efficacy, equity, advocacy) and the desired outcomes of wellness and well-being.

A third suggestion is introduction of integrated grand rounds in which select cases are presented by an integrated health care team that addresses the dental component, medical component, and public health perspective. Fourth is addition of an integrated rotation in which a student team, consisting of medical, nursing, pharmacy, dental, and public health students, is sent on a field rotation to a rural area. This rotation could take place at a rural Department of Veterans Affairs hospital or a Federally Qualified Health Center (FQHC). Students from each discipline would identify one major issue influencing the health status of the patient population relative to their specialty and then work together to determine root causes and factors affecting the problem and to develop an interdisciplinary solution to address it, given available resources, drivers, and challenges to achieving optimal care and health outcomes.

Fifth, the student rotations (described fourth) would generate actual patient outcome data. This reinforcement would be necessary for this rotation to have an impact rather than being treated as merely a time away from school. Sixth, those same medical/hospital rotations during dental school should include several goals that will enhance the contribution of an OHCP in a health home. These goals should include, but not be limited to, better communication skills in a medical setting (verbal and written), a basic understanding of in-patient care and emergency care, the opportunity to observe how medicine is being practiced by experts, and first-hand experience in how the unique skills of OHCPs can be utilized and incorporated in a medical home.

Seventh, it would be beneficial for dental and medical students to have some degree of a joint curriculum, but if the knowledge attained through such an effort is not supported and utilized throughout the dental school experience, little will be gained. Eighth, several subjects now taught in the first two years of the dental curriculum can be changed to requirements for acceptance to dental school. This change would allow more time for additional topics that need to be taught but are presently only touched upon: for example, evidence-based dentistry, scientific writing, critical thinking, and genetics/genomics.

Ninth, today’s dental education and training do not adequately prepare students for the challenges presented, for example, by the maldistribution of health care professionals. OHCPs should be trained to provide screenings, monitoring, and basic medical services for individuals in areas lacking physicians, nurses, or physician assistants. A possible solution could be to create a new degree or certificate that would allow OHCPs to go beyond the limited scope of practice determined by state medical and dental boards. This new certification could be accomplished within a traditional four-year dental curriculum and/or a one- or two-year postdoctoral general dentistry program. With this practice expansion, OHCPs could bill private and public insurers for providing basic medical services in all states. Furthermore, large integrated medical systems will have medical records potentially available to all providers of a specific patient. When an appropriately trained OHCP performed a medical procedure, such as a blood pressure measure, HbA1c test, or dietary intervention, the procedure would not need to be repeated by other medical professionals, which would save both time and money. Such expanded care for patients by OHCPs would need to be based on what is acceptable to our medical colleagues and might be limited to patients with diseases or conditions that require only medications and/or lifestyle changes (e.g., diabetes mellitus, hypertension). However, it is important to emphasize that, at this time, OHCPs cannot render a medical diagnosis. Medical care should always be provided in collaboration with a physician at the same location or possibly online.

Finally, tenth, the involvement of OHCPs in medical monitoring and screening could greatly impact disease outcomes. Many individuals do not seek care from a physician until the emergence of signs or symptoms, which in the case of major chronic diseases, appear years after they could have been detected by appropriate biomarkers or lifestyle analysis. The number of patients who believe they are healthy, yet present with risk factors to chronic diseases, could thus be identified at an earlier stage by an appropriately trained OHCP. Unquestionably, early disease detection and intervention provide better patient outcomes.