Spring 2019

Primary Care Meets the Dentist Chair

An associate professor explores expanding the scope of dental practice.

By Helene Ragovin

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Illustration: Denis Carrier

Could dentists help fill gaps in the nation’s primary-care system by screening their patients for chronic disease, or administering vaccines? The answer is far from certain, but School of Dental Medicine associate professor David Leader, D85, MPH13, is investigating what it would take to expand the scope of dental practice—and whether such a move would be practical, or even welcome.

Leader, along with colleagues from the American Dental Association’s Health Policy Institute (HPI), published a research brief in December 2018, available on the HPI website.

“This is not the first time anyone’s talked about the topic,” Leader said, but scant research exists. He sees this paper as a first step: “I’m hoping one of my students in the DMD/MPH program will decide to work on this as a capstone project.” Leader is also an associate professor of public health and community medicine at the School of Medicine.

Nine percent of the population—that’s about 27 million people—see a dentist at least once a year, but not a physician.

The worsening primary-care physician shortage in the United States is driving the research—the American Association of Medical Colleges estimates that by 2025, the country will be short 14,900 to 35,600 primary-care doctors. Furthermore, even though approximately 50 percent of adults in the U.S. have one of ten common chronic conditions, such as hypertension or diabetes, about 12 percent say they don’t have a steady source of medical care. Meanwhile, 9 percent of the population—that’s about 27 million people—see a dentist at least once a year, but not a physician. “If dentists looked at things like blood sugar, obesity, blood pressure,” Leader said, “it would have a dramatic effect on prevention.

“Do dentists want to do that? How do physicians feel about it? How do insurance companies feel about paying dentists to do those extra things?” asked Leader, the first member of the Tufts faculty to undertake an ADA Health Policy Fellowship. To find out, he interviewed dentists, physicians, public-health professionals, and insurance industry experts.

Tasks that dentists could take on when their patients come in for regular cleanings and exams could include monitoring blood sugar and blood pressure or giving vaccines. Leader’s paper says that previous research indicates the overall health-care system could save anywhere from $5 million to $65 million if dentists screened their patients over age forty for diabetes, high blood pressure, and high cholesterol. Of course, expanding the scope of practice would affect dentists’ time and expenses. Questions remain about how dentists would be reimbursed by insurance, and what adjustments would be necessary for licensing and boards of registration. What additional training would dentists need, and, in turn, how would dental schools need to revise their curricula?

While the looming physician shortage is significant, many regions throughout the country also lack adequate numbers of dentists. As of 2017, about 5,800 locations, many of them rural, were designated as dental-care Health Profession Shortage Areas by the federal government. One of the ideas, said Leader, “is that if you have a dentist looking to open a practice, open one in a dentist/physician shortage area. You can provide dental services and some basic systemic services. When a patient comes for their dental checkup, you can also do part of the physical checkup.” Being able to provide more care to patients in a sparsely populated area could make such a practice economically viable, Leader said.

This new system could be a boon to oral health, too. Often, a dentist must postpone needed treatment until a patient’s undiagnosed or neglected medical condition is brought under control. Take the middle-aged woman who showed up at Leader’s office with periodontal disease. She was overweight and had not seen a physician in fifteen years, and—judging by the state of her gums—she most likely had untreated diabetes. “It took weeks for her to find a physician who could check her blood sugar,” Leader said. “And in all that time, we couldn’t clean her teeth.” If the dental team had been
able to do the test and provide counseling, they could have started on her periodontal treatment sooner.

“It’s a basic precept,” he said. “Treat patients where they are, when they’re available.”

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