Most health care professionals recognize that, like medical care, dental care is unevenly distributed in this country, with many people receiving little or no attention. In 2000, US Surgeon General David Satcher, MD, PhD, issued a report in which he described the silent epidemic of poor oral health care, noting that “Dental caries (tooth decay) is the single most common chronic childhood disease—five times more common than asthma and seven times more common than hay fever.” Dr. Satcher also pointed out that 51 million hours of schooling are missed as a result of dental-related illness.
Little has changed in the decade since that report. What little reimbursement is provided by Medicare and Medicaid predominantly addresses acute dental care, with little attention to preventive care. Meanwhile, poverty in the US has increased, as have the ranks of the uninsured and underinsured. Dr. Satcher’s silent epidemic has only worsened in the 21st century.
It would be easy for NPs and PAs to stand by and excuse themselves from any involvement in dental care, citing arguments about scope of practice and reimbursement restraints. But this would undermine your professions’ commitment to individual and community health. Good oral health is an integral part of general health, and it is time for primary care professionals to assume greater responsibility for the oral health of their patients.
Oral screenings, the application of fluoride varnish, the appropriate use of agents like xylitol and chlorhexidine, and recognition of oral manifestations of systemic disease can dramatically decrease health care costs and improve the quality of life for a vast number of people. These procedures and practices are safe, inexpensive, and effective. They need to be incorporated into the daily practice of every primary care professional.
A number of factors must be addressed to permit NPs and PAs to deliver oral health care. The process starts with education. PAs and NPs currently lack the knowledge base and necessary skills associated with preventing oral disease. (There is little reason to believe that physicians have any more knowledge or skills.)
Most practice acts require NPs and PAs to follow approved protocols or to work under the direct supervision of someone with recognized training and knowledge. This brings an interesting possibility to the forefront. Is it realistic to envision PAs working under the supervision of a dentist? Could NPs function under protocols provided by dentists?
The answer to both questions is yes. But an even more direct route would be the creation of a series of educational certificate programs that are specifically focused on enhancing the oral health care skills and practices of primary care clinicians. Such an approach essentially reintroduces the mouth as part of the body.
What is needed to achieve this? Three things:
• Establish clinical competencies appropriate for NPs and PAs.
• Incorporate the necessary training within NP and PA curricula.
• Encourage PAs and NPs to utilize dental care skills in their nontraditional oral health care settings. (The converse of this should also be explored: New data suggest that dental offices may be a setting in which individuals at risk for cardiovascular disease can be identified through blood pressure, cholesterol, and BMI screening.)
Medical training has traditionally focused on the treatment of acute conditions, while dentistry has a stellar record of preventing two of the most common chronic conditions—caries and periodontal disease. The medical and dental professions are linked in an ongoing battle against sickness and disease, but at the same time they are separated by perceived impediments created by different training and treatment responsibilities. PAs and NPs have the potential to become a bridge between these disciplines and to help initiate an important interprofessional dialogue.
A concerted effort to make oral health care a priority for NPs and PAs will reap substantial rewards with minimal investment. The impact of such an effort on the quality of life for millions of people cannot be overstated.
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O. T. Wendel is Associate Provost at A.T. Still University (ATSU) in Mesa, Arizona, as well as Professor of Bioclinical Sciences at ATSU’s School of Osteopathic Medicine. Michael Glick is Professor of Oral Medicine at the Arizona School of Dentistry and Oral Health and Associate Dean for Oral-Medical Sciences at the School of Osteopathic Medicine, both part of ATSU. Dr. Glick is also Editor of the Journal of the American Dental Association.