Tooth enamel is the strongest substance in the human body. It’s harder than steel. Which helps explain why the three words “root canal treatment” often strike such terror into patients sitting in the dental chair. It starts by boring a hole through enamel as effortlessly as if it were rice paper. Ninety-nine percent of the time, that gaping hole is filled and sealed immediately after treatment. A few months ago, I met a patient I’ll call Janet, to protect her privacy. She was one of the 1 percent.
I carefully peered my head into her mouth. The remaining pulp, or core, of the treated tooth—an amalgam of nerves, blood vessels, and immune cells—had blossomed out of the fractured crown into a twisting, intersecting polyp with the color and consistency of bubble gum. She had chronic hyperplastic pulpitis, a rare inflammatory condition that triggers pulp tissue to irreversibly expand above the walls of the enamel shell. I pulled my stethoscope off the shelf and checked what I had been trained to with every new patient: her blood pressure. 174 over 104, I whispered to myself, having expected only a slight deviation from the normal 120 over 80. This seemed impossible. I checked the other arm; 172/104. I waited 15 minutes and checked again. 164/100.
Hypertensive emergency, which can cause patients to spontaneously suffer a severe stroke, heart attack, or kidney damage, can occur when blood pressure reaches 180/110 or higher (it also presents with other symptoms, such as chest pain or a headache). While her blood pressure was trending downward, Janet was dangerously close to that threshold. I asked her if any physician in the past had ever told her that she had high blood pressure. A recent Dominican immigrant unsure of her past medical history, she told me she couldn’t remember. Her expanding pulp, a rarity for me, was only a distraction from a bigger concern—her blood pressure. I immediately called her primary care physician, discussed the situation, and told her to go see her doctor as soon as she could—when she did, he evaluated her and prescribed an antihypertensive drug. Janet, who had showed up for some basic dental work, could have been been inches away from a medical emergency.*
A 2016 Association of American Medical Colleges report projects that over the next 10 years, the U.S. will face a serious physician shortage, especially among primary care physicians in rural geographic areas. Despite increased health insurance coverage for millions of Americans over the last few years, affordable health care is still difficult to access in rural areas. Certain states, such as Tennessee, Iowa, and my home state of Arizona, are seeing insurance companies drop out of individual markets due to political uncertainty, making access to affordable care harder for a significant fraction of the U.S. population, including many of those I grew up with.
Many Americans are similarly struggling to receive proper dental care. The Journal of the American Dental Association reports that about 80 percent of dental care is either diagnostic or preventive—that is, clinical exams, radiographs, and dental cleanings. Only 20 percent of care is procedural: fillings, crowns, and yes, root canals. But at the same time, data suggests that the most common reason people avoid dental care is cost: The price of dental care and low number of dentists who accept Medicaid has left many low-income Americans without adequate access. But perhaps solving one problem, lack of access to affordable dental care, could help solve the other: lack of access to affordable health care.
Dental hygienists and dental therapists—mid-level dental providers—have an opportunity to offer much of that 80 percent of dental care, the diagnostic and preventive services, at a much lower price than dentists. Just as the rise of physician assistants and nurse practitioners in the 1960s helped address physician shortages in rural areas, mid-level dental providers could offer affordable dental services to many Americans who would otherwise go without care. Imagine this as the dental equivalent of receiving and paying for an annual physical at a local minute clinic compared to a physician’s office.
Analogous to the business theory of disruptive innovation, undercutting the price of 80 percent of dental care may have the unintended consequence of commoditizing much of the profession. To adapt, dentists could apply their advanced medical education and training to move into the primary care physician market and care for the otherwise underserved. This movement to create ‘oral physicians’ is already happening. Dentists at Kaiser Permanente Northwest in Eugene, Oregon, work alongside primary care physicians within a single practice to deliver comprehensive care to patients. The Marshfield Clinic in Wisconsin has created an integrated medical and dental electronic health record to share information about their patients with diabetes between clinicians, and monitor each patient’s blood glucose at both medical and dental visits. If adopted by other health systems, this model could create widespread access points for basic, preventive primary care services. Economists estimate that adding medical screenings for diabetes, hypertension, and hypercholesterolemia in dental offices could save the U.S. health care system between $42 million and $102 million per year, or up to $33 for each patient screened.
As a fourth-year student at the Harvard School of Dental Medicine, I spent my first two years of training alongside my medical colleagues at Harvard Medical School learning anatomy, and pathophysiology, and taking patients’ medical history and physical exams at a Boston teaching hospital. Now, I spend the bulk of my time caring for low-income patients, many with complex medical histories, at the university’s dental clinic. Along with Harvard, only Columbia University, the University of Connecticut, and Stony Brook University combine medical and dental education, meaning that more dental schools will need to adopt a pedagogy of comprehensive medical education if a model where dentists can deliver preventive medical care is to succeed.
But allowing dentists to disrupt primary care may provide affordable preventive care for patients living in areas with problems of health care access and affordability. The barrier between medicine and dentistry is relatively recent, more so due to culture than competency. Introducing gradual and meaningful diagnostic changes in dental practices, such as tracking blood pressure, blood glucose, and weight, just as we do for patients at dental schools, can establish a new standard for access to primary care.
*Update, Sept. 1, 2017: This paragraph has been updated to clarify the author’s thinking and actions concerning his patient Janet.