68 Journal of Public Health Dentistry

Guest Editorial The Dentist and Preventive Medicine: Be All That You Can Be

Robert A. Fried, MD Chief, Clinical Services Branch Office of Disease Prevention and Health Promotion us Department of Health and Human Services 2132 Switzer Building 330 C Street, SW Washington. DC 20201

Like most organizations concerned with the nation's health, the American Association of Public Health Den- tistry has marly items on its agenda. As a nondentist, I may be presumptuous in advocating another item. But I believe the time has come for dentistry and medicine to end their long separation within the health care sys- tem of the United States. Collaboration on prevention offers a real opportunitv to facilitate a lasting partner- ship. The AAPHD is the logical leader on the dental side of such an effort.

A casual analysis might suggest that the two profes- sions have little in common. Most physicians in private practice feel that way, and it may be a common view in dentistry, as well. But physicians and dentists do share their patients-usually silently. This unspoken part- nership should be replaced by a pattern of consistent cooperation.

As medicine moves toward prevention, it can learn a great deal from its silent partner. The dental public health community-involving policy makers, program administrators, and practitioners-has long worked to protect ora1 health through such activities as support for fluoridation, dental health education in the schouls, and emphasis on clinical preventive services in the of- fices of individual practitioners. Building on that tradi- tion, the 1990 Objectives for the Nation (1) included 12 specific, measurable oral health objectives. The 1990 Objectives make possible a deeper alliance between dentistry and medicine, just as they create a n incentive for partnership between clinicians and public health workers generally. Dentists need leadership from den- tal public health to promote an expanded prevention awareness that includes other causes of disease and disability on which they can have a favorable impact.

Clin jcal preventive iiirdzcd services have generally heen classified as primary, secondary, or tertiary. Pri- j?lnry t7reuention means counseling patients about their avoidable health risks and what they can do to achieve and maintain health. Secoizdary p'eUeiItiO~1 refers to screenjng for potentially reversible early disease or risk

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factors for disease. Tertiary prevention seeks to forestall further progression of established disease or the devel- opment of COrnpliCatiOnS. Prevention-minded dentists can do important work in all three categories-not just for teeth and supporting structures, but for patients.

Dental practitioners can do primary prevention by counseling their patients about tobacco. The use of to- bacco products is a major risk factor for the two leading causes of death in the United States: cardiovascular disease and cancer. Smokers have a greatly increased risk of coronary heart disease, lung and other cancers, chronic obstructive pulmonary disease, and other ill- nesses (2). Smokeless tobacco is now recognized as an important causal agent of oropharyngeal cancer (3). As health care providers who see patients of both sexes and all ages, dentists are ideally positioned to counsel against the use of cigarettes and smokeless tobacco products. The dental encounter probably constitutes a "teachable moment" (4) when the patient is receptive to counseling about life-style issues. Minimal interven- tion by physicians has been shown to have a noticeable impact on patients' smoking behavior (5). There is rea- son to believe that dentists would do as well. The public health analogy may be the "programmable moment"- the opportunity for dental and medical public health professionals together to plan and carry out interven- tions that will have a greater impact on clinicians and on patients than either health profession could have on its own.

Secondary preven tion-screening for early disease and for risk factors-also can become part of dentists' repertoire. Oral examinations should focus on the de- tection of leukoplakias, some of which can be consid- ered premalignant lesions, and of oral cancer itself, which in the United States accounts for 5 percent of all cancers in men and 2 percent in women (6). Early treat- ment of oral cancer yields impressively high five-year survival rates (7). Dentists should also give strong con- sideration to determining their patients' blood pres- sures and encouraging them to follow UP on abnormal results. Collaboration among health professionals for hypertension control has been urged by the Coordinat- ing Committee of the National High Blood Pressure Education Program (8), of which the American Dental Associalion is a member. Participation by dentists can

Vol. 47, No. 2 , Spring 1987 69

help patients by detecting undiagnosed or uncon- trolled hypertension, as well as allowing dental care to be provided to high-risk patients in a proper fashion.

Finally, there is a potentially important role for den- tists in tertiary prevention. Systemic illnesses of all types can be manifested by oral pathology, and their early detection can lead to better outcomes. These ill- nesses include nutritional deficiencies, hematopoietic disorders, and connective tissue disease (9,lO). Den- tists sometimes can diagnose relatively uncommon dis- orders like hyperparathyroidism, which occasionally produces erosion of the lamina dura (11). Oral manifes- tations of certain sexually transmitted diseases may permit the dentist to identify patients at risk for the subsequent development of acquired immunodeficien- cy syndrome (AIDS) (12). Early diagnosis of AIDS helps stop transmission of the disease and may permit treat- ment with drugs that have recently been made avail- able. Tertiary prevention also includes preventing the complications of medical treatment. Particularly in the case of cancer therapy, prevention-oriented dentists can offer early detection and treatment of oral complica- tions (13,14), thus contributing to the avoidance of iat- rogenic disease.

If dentists are to get more involved with prevention of nonoral disease, they will need a predisposition to look; that inclination, in turn, probably develops only with training in prevention and early diagnosis of sys- temic disease. More importantly, a collaborative per- spective on patient and program management is re- quired. Policy makers in dental public health should consider working to change dental education to encom- pass a broader prevention perspective. In working more closely with their medical counterparts to imple- ment prevention programs, policy makers will send to practicing dentists and physicians an important mes- sage about cooperation.

Yet, to the dismay of many in public health, clinical physicians have not been involved fully with the over- all prevention effort. The roots of this relative apathy toward prevention lie deep within the historic split between public health and clinical practice. The Clinical Services Branch of the Office of Disease Prevention and Health Promotion is seeking to narrow the gap in sever- al ways. We have convened the US Preventive Services Task Force, on which a public health dentist serves, to make recommendations about the appropriate use of preventive services in the clinical setting (15). We are encouraging academics in primary care to do research on prevention. We hope to serve as an “honest broker” in a dialogue between major organizations of clinicians and federal prevention agencies. The AAPHD could serve in a similar role within dentistry that would build capacity among practicing dentists to ”think preven- tion” for the whole patient and work collaboratively with other health professionals.

Physicians are not necessarily predisposed to form- ing partnerships with their dental colleagues. Dental organizations might try to set the stage by working to share dental knowledge with medical practitioners. This is particularly important for preventive geriatrics,

since only a minority of the elderly seek regular dental care (16). Reviews of dentistry for physicians are begin- ning to appear in the family practice (17) and geriatric (18) literature. Combining of agendas is happening also on a policy and program level. The involvement of AAPHD and the American Dental Association with the Health Policy Agenda project of the American Medical Association (19) is a hopeful sign for those who believe in partnership. AAPHD should seek out other opportu- nities for “joint ventures” with public health and clini- cal medicine.

Talking about collaboration is one thing; arranging it is another. An ideal model might be a joint medical- dental practice with a common patient record. Such models are lacking in real life. Community-oriented primary care (20) offers one option for the creation of a partnership between dentistry and medicine that spe- cifically includes a preventive component.

But deeper involvement of the dental profession in the nation‘s prevention effort should not wait for the development of an ideal cooperative model. Patients, after all, are not packages of body parts to be distribut- ed to players within the health care system who have no real need to work together. They are, instead, com- plex, integrated beings in constant interaction with bio- logical, psychological, and social systems that affect their health. They have much to gain from joint efforts of practitioners of the healing arts to control the leading causes of morbidity and mortality. For those program managers, administrators, and clinicians-medical and dental-already converted to the prevention perspec- tive, the time is right to start putting into practice at a patient and program level what we have believed all along. The American Association of Public Health Den- tistry could take the lead in transforming the existing silent partnership into an explicit partnership aimed squarely at preventing disease and promoting health.

Acknowledgments The contribution of Stephen B. Corbin, DDS, who

engaged in dialogue about this subject and reviewed the manuscript, is gratefully acknowledged.

References 1. Department of Health and Human Services. Promoting Health/

Preventing Disease: Objectives for the Nation. Washington, DC: US Government Printing Office, 1980; DHEW publication no

2. Department of Health, Education, and Welfare. Smoking and Health: A Report to the Surgeon General. Washington, DC: US Government Printing Office, 1979; DHEW publication no (PHS)

3. Department of Health and Human Services. The Health Conse- quences of Using Smokeless Tobacco. A Report of the Advisory Committee to the Surgeon General. Washington, DC: US Gov- ernment Printing Office, 1986; DHHS publication no (NIH) 86- 2874.

4. Lewis CE. Teaching medical students about disease prevention and health promotion. Pub Health Rep 1982;97:210-15.

5. Russell MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. Br Med J 1979;2:231-5.

6. Shklar G. Oral pathology in the aging individual. In: Toga CJ, Nancy K, Chauncey HH, eds. Geriatric Dentistry. Lexington: DC Health, 1979.

(PHS) 79-55071.

79-50056.

70 Journal of Public Health Dentistry

7. Bhaskar SN. Synopsis of Oral Patholo$!'. 5th ed. St. Louis: CV Mosby, 1977.

8 . Coordinating Committee ot the National High Blood Pressure Education Program. Collaboration in high blood pressure control: among professionals and with the patient. Ann Intern Med

9. Zugerman C. The lips: anatomy and ditterential diagnosis. Cutis

10. Shafer WG, Hine MI<, Levy BhI. A Textbook of Oral Pathology. 3rd ed. Philadelphia: WB Saunders, 1971.

11. Potts JT. Disorders of parathyroid glands. In: Petersdorf RG, Adams RA, Braunwald E, lsselbacher KJ , et al . Harrison's Princi- ples of Internal Medicine. 10th ed. New York: McGraw Hill, 1983.

12. Silverman S. lntectious and sexually transmitted diseases: impli- cations for dental public health. J Public Health Dent 1986;46(1):7- 12.

13. Dreizen S, McCredie KB, Dicke KA, Zander AR, et al. Oral com-

1984;101:393-3.

1986;38:116-20.

plications of bone marrow transplantation. Postgrad Med

14. Carl W. Oral complications in cancer patients. Am Fam Phys

15. Mickalide AD. U.S. Preventive Services Task Force. Pediatr Clin N Am 1986;33:1007-9.

16. National Center for Health Statistics. State Estimates ot Disability and Utilization of Medical Services. Hyattsville: US Government Printing Otfice, 1978; DHEW publication no (PHS) 78-1241.

17. Ryan RN, Ware WH. Common dental emergencies which may be encountered by the family physician. J Fam Pract 1975;2:249-53.

18. Gordon SR, Jahnigen DW. Oral assessment of the dentulous elderly patient. J Am Geriatr SOC 1986;34:276-81.

19. Balfe BE, Boyle JF, Brocki SJ, Lane KR. A health policy agenda for the American people. JAMA 1985;254:2440-8.

20. Nutting PA, Wood M, Conner EM. Community-oriented primary care in the United States: a status report. JAMA 1985;253:1763-6.

1979;66: 187-96.

1983;27:161-70.