Medicine should stop treating oral health in isolation from the rest of the body

Signs of chronic diseases begin with our oral health. A reform in how we teach dentistry and get insurance is necessary to treat preventable diseases.

By Yasemin Isbilir

Dentistry has a long history of helping humans fight disease. The ancient Egyptians cleaned their teeth with frayed twigs, and Greek physicians prescribed mouth rinses of salt and vinegar to prevent disease. However, the notion that dentistry is separate from the world of medicine is a historical failing that comes to us from a combination of education, through the separation of medical and dental schools, and legislation, through the creation of modern insurance. In fact, the influences of our oral cavity do not disappear below the neck.

New research on the oral microbiome and inflammation makes this separation between medicine and dentistry care harder to justify. The mouth and body share the same immune system and the same bloodstream. The oral microbiome is second only to the microbial community of the gut by size and plays a part in regulating inflammation throughout the body. Poor oral hygiene has consequences linking to many chronic diseases, including diabetes, heart disease, and Alzheimer’s. Because our current system draws a line between medicine and dentistry, our growing knowledge around how the body interacts in preventable diseases does not fully benefit the populations we seek to help.

To this point, our healthcare system has failed to account for inflammation as a shared pathway linking oral and systemic disease. A coordinated model of care would begin to address this gap. Primary care physicians should train to screen for oral inflammation, and dentists and dental hygienists should refer patients with poor oral health, which is often a sign of the existence of underlying conditions such as diabetes and hypertension.

Dr. Thomas Van Dyke, a professor at Harvard School of Dental Medicine and vice president of clinical and translational research at the American Dental Association Forsyth Institute, has spent his career studying this link.

“The problem is in the way medicine and dentistry are practiced, how they’re insured, and how medical and dental records are kept,” Van Dyke says. “It’s like they’re totally different professions, and the mouth is not part of the body.” He believes that while the research between oral inflammation and systemic disease is still in its infancy, there are enough intervention and longitudinal studies where the weight of the evidence is not just an association anymore.

A solution to our existing inefficiencies is encouraging healthcare providers to take on new tasks. Vulnerable populations—low-income individuals, people of color, and those in rural areas—suffer the most from preventable diseases and are less likely to go to the dentist. For many people, primary care may be where oral problems are first noticed and their first and only interaction with receiving care they need. We do not want to lose them after this point, so physicians should take on the task of recommending patients visit the dentist.

This is especially important because the compounding nature of chronic illnesses makes it one of the fastest growing burdens on our economy. According to the Centers for Disease Control and Prevention, chronic diseases are to blame for most of our healthcare costs. Of our $4.9 trillion in annual healthcare spending, 90 percent comes from treating people living with chronic or mental health conditions. These diseases include those associated with oral health complications. For example, diabetes affects more than 38 million Americans and contributes to $413 billion in medical costs annually. Alzheimer’s disease and other dementias contribute $360 billion and are estimated to triple by 2050.

Likewise, dental disease itself is a massive contributor to this economic burden. Tooth decay affects people of all ages and is one of the most common chronic diseases. Untreated cavities cause pain, infections, and difficulty participating in daily activities like eating and speaking. Consequently, dental diseases impact things such as school attendance and work performance. Dental diseases alone result in 34 million in educational hours lost each year and $46 billion in lost productivity.

To reduce this burden, we should have healthcare providers identify and refer patients with dental issues. Early detection and treatment of dental and chronic conditions can prevent the need for expensive interventions. By including basic oral health screenings and referrals in medical settings, we could benefit from both a decrease in medical and dental costs. This would improve patient well-being and lower the economic pressure that is associated with chronic illnesses.

A barrier to implementation is our current insurance system. The creation of Medicare and Medicaid in the 1960s excluded dental care. This decision led to how insurances, clinical practices, and educational institutions operate with regard to dentistry. Medical training rarely covers oral disease, and dental education rarely includes training for other systems. Dental insurance, as Van Dyke explains, is akin to a limited “coupon” system that provides only a few thousand dollars a year regardless of medical need. Medical visits, by contrast, are more often reimbursed based on value and patient outcomes.

These structural discrepancies discourage coordination as dentists do not get paid for consultations the same way that physicians do, and dentistry as a field is very procedure based. Although dentists regularly see signs of systemic illness, they have no reason to refer patients to a physician. Similarly, most physicians never ask about oral health or inspect the gums during a checkup. A patient can have their blood pressure checked at a medical visit but not their gum health, even though both are predictors of cardiovascular risk. The cost of this neglect falls on the patient and increases the economic burden of chronic disease.

Still, practical interventions exist. School-based oral health programs can take an educational approach and identify children with early signs of cavities or gum disease and teach preventative habits that are important to build before adulthood.

Also, community health centers that hire dental hygienists to work with primary care providers can spot inflammation early, make referrals, and educate patients about the link between oral and systemic health. These interventions are economically sensible. Preventing diabetes complications, reducing hospitalizations from heart disease, and lowering the prevalence of chronic inflammation saves money over the long term, while improving patients’ quality of life.

Another problem lies in the separation of medical and dental patient data. Even as electronic health records become more common, they are rarely integrated across medical and dental platforms. This makes shared patient data difficult to access. Some countries, like the United Kingdom and Scandinavian nations, have introduced combined care where dentists and general practitioners exchange information for high-risk patients.

In the U.S., a few programs have started integrating oral and medical data, but this remains rare. For example, the Veterans Health Administration shares medical and dental records, which in turn helps physicians and dentists make more informed decisions when agreeing on treatment plans for patients. Additionally, state-funded community clinics have begun to include dental hygienists in their primary care teams. Patients are screened for gum inflammation during checkups and referred for treatment if needed.

Dr. Priyadarshini Natarajan, a dentist and researcher at the Auckland University of Technology, looks at how we could accelerate a shift in the collaboration of oral and medical data. “Dental and medical data operate in siloes, leading to missed opportunities for early detection and prevention,” Natarajan says.

Natarajan co-authored a cross-sectional study published in March in Scientific Reports using nationally representative data of over 13,000 adults. Her team found associations between periodontal disease and diabetes, and dental caries and hypertension. “We can include dental assessments in national guidelines for diabetes, hypertension, and any other chronic disease management, if we develop a shared care model,” Natarajan says. She notes that oral health is a source of medical insight and that the more informed clinicians are about their patients’ health, the more comprehensive they can be in their services.

An argument against integration is that it is too complicated and expensive, that medical professionals are already overburdened, and that dentists cannot take on new roles. However, prevention saves money, and the long-term cost of neglect should scare us. In a study published in March in the International Journal of Cardiology, Francesca D’Aiuto and peers found that treating gum inflammation can lower blood markers of chronic disease, improve health outcomes for diabetes patients, and reduce overall healthcare costs. Therefore, improving the quality of life of an individual outweighs short-term costs, and encourages populations that avoid the dentist to get the care they need.

Evidently, inflammation as a pathway to disease does not abide by the professional separation of dental and medical care. We can no longer ignore one of the body’s most inflammatory sites in our pursuit of chronic disease management. We should change how we care for people to accommodate our growing knowledge by mandating oral health screenings and referral programs in primary care medical settings. Primary care physicians should routinely check for gum inflammation, and dentists should refer patients to physicians when they see signs of disease. Greater implementation between these two fields could lower rates of preventable diseases like diabetes, cardiovascular disease, and Alzheimer’s, and build a healthcare system that treats the mouth as part of the body it belongs to.