For more than a century and a half, U.S. medical education has treated medical and dental care as largely independent domains. And by not doing more to teach oral examination skills, medical schools and primary care residency programs have left trainees ill-equipped to identify oral conditions, make proper referrals for them or help patients understand oral disease prevention.
Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) by Jesse Feierabend-Peters, MD, PhD, a first-year resident in the Lawrence Family Medicine Residency Program, in Lawrence, Massachusetts, and Hugh Silk, MD, MPH, professor of family medicine and community health at the University of Massachusetts Medical School, in Worcester.
Using a hypothetical case of a physician who examines a patient and finds a large mass midline in the hard palate, the authors explored the importance of educating doctors in evaluating and promoting patients’ oral health. They also proposed curricula and outlined a scope for training.
Why oral health matters
In recent years, the definition of primary care has rightly expanded to include social, economic and environmental determinants of health, and oral health falls well within this purview, the authors noted.
“Oral disease, while largely preventable, affects a substantial portion of the U.S. population, with an incommensurate impact on poorer communities and communities of color,” they wrote, adding that neglected oral health contributes to a number of adverse socioeconomic, psychological and health outcomes.
Untreated dental caries, for example, causes local pain and infections. But it also has social implications, such as school absences and difficulty gaining employment, as well as dire medical repercussions, including increased risk of death.
Other oral health problems have similar effects. Consider periodontal disease.
“This chronic inflammatory process has far-reaching consequences, including exacerbating diabetes and heart disease and contributing to poorer birth outcomes,” the authors wrote. “Conversely, uncontrolled diabetes can affect oral inflammation and mouth health.” They noted higher rates of caries and periodontal disease among historically marginalized racial and ethnic groups in the U.S., as well as patients in groups that have been economically or socially marginalized.
Yet oral health receives little attention during medical training, the authors noted, pointing to a study of program directors of 195 family medicine residencies that showed most programs provided no more than three hours of oral health curriculum. Some provided no training at all.
What to do about it
“Primary care clinicians must have adequate skills, knowledge and training to avoid overdiagnosis, underdiagnosis and inadequate management of common oral problems,” the authors wrote.
What they need is “competency in performing a consistent and thorough oral, face and neck examination; the ability to distinguish between normal and abnormal findings; and an oral cancer examination of patients.”
“Models already exist that can help guide this oral health training,” says the article.
National academic organizations such the American Council of Graduate Medical Education, the Association of American Medical Colleges and the American Academy of Oral Medicine should embrace those guidelines and tie them to educational requirements, the authors wrote.
No time to waste
Each year, many in the U.S. see a primary care doctor but not a dentist, making physician visits their only real chances to get an oral exam and preventive advice.
Meanwhile, the consequences of untreated oral disease are dire, “including harm to psychological and financial well-being and increased morbidity and mortality,” the authors wrote.
It’s an issue of health equity, they added, further arguing that “it is unethical not to train medical students and primary care residents in oral health.”
The January issue of AMA Journal of Ethics further explores inequity along the medical-dental divide.
