Exclusive Survey: Part of the team

It's time to come together. With everything we know and are learning about the oral-systemic link, dentistry can no longer be the missing piece of to the health care puzzle, an entity separate from the rest of the health care team. That simply isn't good enough for your patients. You have to become involved in your patients' overall health, and that means building relationships with their medical doctors.

Diabetes. Heart disease. Low birth-weight babies. These are just a few of the systemic conditions associated with periodontal disease, and among the reasons it’s so important for dentists and physicians to communicate, to have a relationship where both sides feel comfortable coming to the other for advice. And sure, as more research comes out about the oral-systemic link and both sides see the need for stronger MD/DDS relationships, the line separating dentistry from the rest of the health care team has gotten thinner. But many professionals on both sides of that line say there’s still a long way to go.

“It’s not about dentistry, and it’s not about medicine. It’s about overall health and well being,” said Dr. Sam Low, President of the American Academy of Periodontology. “Oral health care is part of that process, and that’s the concept that needs to occur.”

It starts in school

Before their careers even begin, dental students and medical students are separated, Dr. Low said. They typically don’t interact much during their schooling, and while dental students learn a lot about medicine and the rest of the body, medical students typically don’t learn much about dentistry and the mouth. So when a physician comes across a problem that a dentist should see, he may not even notice it, or if he does, he might not think to refer or even make a call to a DDS.

Yet patients consider themselves as a whole person, not as a body and a mouth, said Dr. Barbara Gottlieb, an MD who works at Brookside Community Health Center in Massachusetts. Often patients will come to MDs with dental problems, even though physicians aren’t properly trained in this area-making communication between the DDS and the MD vital. Physicians know a lot about the human body and its pathologies, but they simply aren’t taught much about the mouth and its relationship to the systemic conditions they see every day. They’re becoming more and more interested and educated, but they certainly don’t have the knowledge you do.

Luckily for Dr. Gottlieb, she can turn to the dentists who work in the health care center for advice, an advantage most physicians and dentists just don’t have.

“On the occasion where I have to communicate with dentists who are outside of my own system, the communication is a lot more difficult,” Dr. Gottlieb said. “Often the patient is the liaison, which you wouldn’t find with other specialists. You’d have provider-to-provider communication, and you wouldn’t just rely on the patient to say my dentist told me to do this or that. When that happens and I try to connect with the dentist to get more information, sometimes I don’t hear back.”

Taking the first step

Changing medical school curriculum and integrating the two disciplines is one way to solve the separation problem, but that’s not something you can control. There are, however, several things you can do to develop and maintain relationships with the physicians in your area. The easiest? Pick up the phone.

Yes, this can be intimidating. Because you don’t interact with physicians on a regular basis, you may be hesitant to make that call, said Dr. Kelly Blodgett. Maybe you’re worried about not being able to communicate the problem, or maybe you think the physician won’t want to bother with your call. You have to get over that. It’s highly unlikely the physician will call you, and if you want to provide the patient with the best care possible, you have to be the one to get the lines of communication flowing. And talking about something you have in common-a patient-is the best way to do that.

“It’s a health care provider on the other end of the phone, just like you,” Dr. Blodgett said. “Both of you are interested in seeing the patient healthy. Focus on that rather than, ‘they know things I don’t know and I don’t want to sound  ignorant.’ It’s not about that. It’s about helping the patient see better health.”

Most physicians are appreciative, even flattered, when you call them about a patient, periodontist Dr. Peter Cabrera said. Whether you’ve noticed a potential problem or have a question for them about medication a patient is taking, they tend to be happy for the contact. And after you call them three or four times and establish yourself as a doctor who knows what you’re talking about, they may even start calling you.

Beyond the phone

It’s also not a bad idea to reach out to physicians you know socially, Dr. Blodgett said. If you know someone at the golf course or local sports club, talk to him or her about the importance of including dentists as part of the health care team. This “grass roots” approach may help get some physicians thinking more about the oral-systemic link and what it means for their patients, and hopefully will help break down some of the barriers that still seem to exist between many GPs and MDs.

You don’t have to limit those in-person conversations just to people you already know. Don’t be afraid to stop in at a local physician’s practice and introduce yourself, even if you don’t necessarily have a patient to talk about, said Bob Spiel, MBA, of Spiel Consulting. Bring some information about the oral-systemic link, and maybe even some type of treat to help staff members remember you. Follow up by inviting the physician to breakfast or out for coffee. Little gestures like that can help remind the physician you’re there and happy to work with him whenever you can.

“It’s the one-on-one relationships that make a difference,” Dr. Low said.” If I were a young dentist starting out in practice I think I would attempt to stop by and see every general physician, OB/GYN and internist in the community.”

Take it on the road

If you really want to bridge the DDS/MD communication gap, think about speaking at an upcoming society meeting. Dr. Gottlieb said she rarely sees dentist speakers at meetings she attends, but thinks it would be beneficial. Dr. Vincent E. Friedewald, an MD who worked with the AAP on a consensus paper that was published in The American Journal of Cardiology, agrees and said local meetings are a great place to start.

“There’s nothing like going out and giving talks to local groups,” Dr. Friedewald said. “Call the local medical society and say ‘I think physicians are behind on this issue. They need to know more about perio.’ Become an expert on the topic, develop your own presentation, and be ready to travel and go talk. That certainly sets up relationships. I do a lot of speaking for professional groups and you meet a lot of people when you do that.”

Even if you’re not much of a public speaker, you still can educate your MD colleagues, said periodontist Dr. Mark Ryder. In the last five years, a lot more literature about the oral-systemic link has come out. Share that literature with physicians and educate them about the connection and the role dentists play in the overall health care picture.

The risk of not doing it

Medical treatment is becoming more complex, Dr. Cabrera said, and many of the patients you see have chronic illnesses. They take a lot of medications that have different side effects. If you don’t know exactly what they’re taking and how the medications interact, you may be doing your patient more harm than good when you provide treatment.

You also can help your patients by talking to their physician about changing medications when necessary. For instance, there are many medications that cause gingival enlargement, Dr. Ryder said, especially those formulated to control high blood pressure or to prevent organ transplant rejection. But, as a dentist, you know there are other drugs that treat the same problem with much less risk of this side effect, a side effect that makes it difficult for patients to eat and more likely for them to develop inflammation around their gums. You have to have the confidence in your knowledge to talk to the patient’s physician about this and remind him or her that subbing for this drug not only helps the person’s oral health, but the whole body health. When you do, you are providing an important service to your patients’ overall health.

You have to know more

If you see a patient with periodontal disease who hasn’t been to a physician in awhile, you can’t treat that patient without finding out what else is going on in the body, Dr. Blodgett said. Remember, when you’re managing periodontal health you’re managing whole body health. If you see a patient with inflammation and say nothing to his or her physician, that can become a liability issue.

In fact, Dr. Blodgett recently saw a 40-year-old patient with severe inflammation in his mouth, a patient who couldn’t remember the last time he saw an MD. Dr. Blodgett told him he couldn’t proceed with treating his periodontal disease until he saw a physician to find out what was going on with his overall health-something the patient appreciated.

“If you’re going to stir up bleeding in the mouth, you better know what’s going on in the rest of the body,” Dr. Blodgett said. “You don’t want to trigger an inflammatory event elsewhere. It’s not in the best interest of the patient to ignore the fact that the oral issue we’re managing is somehow tied into their systemic health.”

It’s best for the patient

One of the biggest problems in patient care is disjointed treatment, Dr. Cabrera said. Dentists often see it when they take a medical history-something you should be doing with every patient. The patient may be seeing an internist, a cardiologist and a psychiatrist, and they’re all prescribing three or four different medications. The dentist can be the common thread, the health care provider who knows everything that’s going on and who ensures the patient receives comprehensive, safe medical care.

Working as a team makes everyone’s job easier, and that, in turn, makes patients happier and healthier. If a dentist makes taking blood pressure part of every dental visit, he may notice an elevated blood pressure the physician missed. If a physician can look in a diabetic patient’s mouth and see something isn’t right, she can refer that patient to a dentist who can provide the needed care. It all comes down to working together and communicating to help each other become better dentists and better doctors.

“Communication is one of the most serious shortfalls we have in medicine. We don’t communicate enough or effectively enough,” Dr. Friedewald said. “There’s no question we put too much emphasis on the science of medicine and not the art of medicine. The art of medicine involves communication, especially with patients. We have a lot of room for improvement, all of us do-dentists, physicians and patients.”

Practice benefits

Not only is communicating with MDs good for your patients, it’s good for you and your practice. You’re delivering a higher quality of care, and from that comes a certain level of satisfaction. You can build your reputation as the go-to person, the dentist physicians call when they have questions. That earns you respect not only in the medical community, but also with your patients.

“Regardless of how things change, word of mouth is still the strongest source of referral, and being perceived as the go-to person is a huge benefit to the practice,” Dr. Cabrera said. “That’s the kind of credibility you earn. You don’t buy it through marketing, and you don’t develop it any other way than through time and quality.”

Referrals are another possible benefit, although you shouldn’t expect to get a new patient every time you make a phone call. And while it’s great when that happens, remember this is less about bringing more money into your practice and is more about patient care.

Make the time

Dentists and physicians are very busy people, so it’s easy to skip that phone call you meant to make. But relationship building isn’t something you can afford to skip. You have to prioritize it and organize your time to make sure it happens, Dr. Friedewald said. If you don’t, your practice and your patients will suffer.

“Communicating is important. The problem is we don’t get paid for it,” Dr. Friedewald said. “If you carve out an hour a day just for doing non-reimbursable activities like communicating and dictation and so on, that’s a lot of money lost. You have to weigh it. There are a lot of things in medicine you do because you’re a good doctor or dentist and it’s best for the patient. It’s a fine line you walk. How much do you do because it’s the right thing versus what you do because you have to make a living. That’s a balancing act we always walk.”

It’s easier if you work as a team

As more research and literature about the oral-systemic link comes out, more physicians are realizing the value of having dentists as part of the team. They want to work with you and they want to learn more, but oftentimes you have to be willing to make the first move. You have to be the one who reaches out, which is something dentists are starting to do more and is something that should continue to grow.
It all comes down to this: You can no longer say you just do dentistry. That can be your focus, but it’s no longer all you do. You’re really treating the whole body. But it’s not something you have to, or even should, do on your own.

“If I have a patient who, when I go through the medical history it appears to me they need a medical consult, I have a group of family physicians I refer that patient to. I need them as a resource. Forget if they send me patients,” Dr. Low said. “If I have a patient who is obese, pre-diabetic, hypertensive, taking no meds, hasn’t seen a physician in five years and has severe gum disease, it would be irresponsible on my part to not have the patient have a complete medical work up before I start my process. [If I didn’t], my perio management of that patient would not be successful.”

And, of course, the motivator will be different for every patient. For West, motivation came from the desire to have a healthy body. Have a conversation with your patients to find out why they’re there and tie that in to taking better care of their oral health. If a patient is motivated by esthetics, you would present the case differently than if the patient is motivated by disease prevention.

About this survey

The June 2010 Periodontics Survey was sent via e-mail to general practitioners and hygienists in the United States. The link was promoted on the MH and DPR Facebook pages, where we currently have 5,107 and 5,299 fans, respectively. The survey was completed by 582 people.