Put the mouth back in the body!

In pursuit of an answer why dentistry is separate from medicine.

Even though my mother and I are of different professions, if one was to listen about our working day, a certain similarity could be ascertained between the two. After all, we spend all of our working hours in scrubs, confined to white-tiled, sterile spaces, relieve our patients of pain, and pry into their mouths. Yet, while I am a periodontist in training, my mother is an anesthesiologist and a subspecialist in intensive care medicine. I wield curettes and scalpels, she employs a laryngoscope and endotracheal tubes. Many, if not most, lunches in our family house were spent in endless discussion of the human body, the wonders and faults of its mechanisms, strange conditions, and diseases. Judging by my mother, doctors were all-knowing creatures.

After enrolling in dental school, our Sunday lunch topics slowly shifted towards the mouth. I would share my happiness about successes in the dental morphology class. The Carabelli cusp in the maxillary first molar’s plaster model finally ended looking like a tubercle rather than a pyramid. After learning more about the structure of the teeth in cariology class, I was elated for being able to truly understand oral findings in patients with Osteogenesis imperfecta, the topic of my high school graduation thesis. I could not help but to sing praises of bacterial communication’s ingenuity and the way quorum sensing of periodontal pathogens affects biofilm formation.

… To my horror, it turned out my mother could identify the maxilla, but did not know how to locate specific teeth. For her it was self-explanatory that the collagen’s defective structure in OI patients caused brittle bones. She never even considered it being a component of the tooth’s dentin though. Sure, she nailed microbiology because she was leading battles against opportunistic pathogens in the intensive care unit and dreaded over patients with ventilator-associated pneumonia all the time. She and her laryngoscope were regular trespassers in the oral cavity. Yet, periodontitis as an infectious disease associated with the establishment of a highly pathogenic biofilm wasn’t really on her radar.

She wasn’t the exception though. The more I shared about my university curriculum with friends from the medical school, the more I revealed the complete absence of the mouth in theirs.
There’s a large gap between dentistry and medicine, starting with our separate education, and the blame is evident on both sides. Historically, dentistry has been seen as a sort of a trade, mechanics rather than intellectual effort. I’m sure many of us still get jokes about barbers-surgeons and their extraction skills.

Why are we, in 2019, working on the same subject (humans), but remain separate? When did the mouth divorce the rest of the body?

Doctors are doctors...

Periodontitis sets the best example of how oral conditions extend beyond the oral cavity. Yes, it is a chronic local inflammatory disease that affects the periodontal tissues, but with each emerging interdisciplinary research, we learn more about its far-reaching systemic effects. Nature does not know the boundaries of our semantically divided body systems. And while medical specialists cooperate daily to keep the integrity of their patients’ different systems, why aren’t dental healthcare professionals allowed to play in the same sandbox?  Periodontal bacteria, their products, and inflammatory mediators are haematogenously spread and, as such, are capable of interacting with other systemic diseases. Connections among some of them such as diabetes, obesity, and cerebrovascular diseases are well studied and established. With others, such as Alzheimer’s dementia, we are just now witnessing new research elucidating and confirming what we used to assume.

The real problem lies in the fact that periodontitis is among the most prevalent diseases worldwide. Usually, a number of 11% is quoted when talking about its prevalence, accounting for around 740 million people affected by periodontitis globally – but that is for severe disease forms only! In reality, 8 out of 10 people aged 35 and above experience some form of periodontal-related issue. But how many times have you heard your friends, neighbors, or even family members complaining about feeling ashamed about their bad breath when interacting with others or spontaneous gingival bleeding during a work presentation? Let’s be honest, it’s embarrassing, they don’t talk about it, but nor do we do enough among ourselves. And so I (too often) see confused patients who first go through a maze of medical examinations, ordered by their primary care medical doctors, for stomach issues, potential malignancies in the ENT area, or coagulopathies. Until somebody finally looks into their mouth.

... and dentists are dentists.

If I am already discussing the downfalls of medical-dental relationship, it is only fair to put us, dental healthcare professionals in the spotlight as well. The number of times I’ve witnessed gingivitis, periodontitis, and periodontal abscesses being treated primarily with antibiotics is frightening. Actually, dentistry seems to be neither mechanics nor intellectual effort when in the era of antimicrobial resistance, we are mindlessly prescribing multiple rounds and freak combinations of antibiotics (metronidazole+clindamycine? hello?) and just leaving the bacterial biofilm causing the entire havoc there, intact.

The multiple factors that influence the initiation and progression of the periodontal disease should also be addressed by us, regardless of how unassuming their connection is to the mouth. We are blessed with the opportunity to see our patients regularly, but are we capitalizing on it? In a form of a companion, we should advise and support our patients in changing their life style habits – their quest to cease smoking, lose weight, do sports, address stress, and find ways to cope with it. It is our responsibility to think and work outside of the box (mouth, that is) as well.

 

Prescription of antibiotics without mechanical disruption of biofilm is like throwing bombs on fallout, nuclear shelters - so why are some of us still doing it?

Moving forward... but are we there yet?

Things are certainly moving forward, and in a very positive direction. In recent years the European Federation of Periodontology has held several workshops and established projects on periomedicine. The latest two, Perio&Diabetes (2017) and Perio&Cardio (2019) were jointly organised by the EFP and the governing medical associations, the International Diabetes Federation (IDF) and World Heart Federation (WHF), respectively. The recommendations resulting from the Perio&Diabetes workshop are not only aimed at the oral healthcare team, but were also extended to medical professionals, pharmacists, patients, the public, universities and research centres, as well as policymakers! Let’s take a moment and acknowledge how far-sighted that is.

Furthermore, the new 2017 Classification of periodontal and peri-implant diseases and conditions has introduced a multidimensional system of disease staging and grading that we are all familiar with from oncology. And while the stage of the disease addresses the severity and the complexity of its management, the grade adds another dimension by considering the disease’s rate of progression. So, for the first time, we are now also incorporating individual patient risk factors into the diagnosis. Smoking and glycaemic status can modify the estimate of the patient’s future course of disease. And this is just the beginning – a lot of space has been left for the incorporation of new knowledge. C-reactive protein values and biomarkers might soon, as specific and new evidence emerge, also direct the disease’s grade.

 

Individual patient factors are included in the grading system of the new 2017 Classification and plenty of space has been left to expand it as new research data emerge

Personally, I think the way to address the marital problems between medicine and dentistry is through mutual communication and education. Projects like the ones from the EFP are doing it on a large scale, institutional level. What we can do on an individual level is to start from our own education. We have a responsibility towards our patients in treating them as a whole, and not as a hands-on challenge. Empowered by knowledge, we can then also effectively communicate change in the healthcare community.

While my mother might be close to retirement, she never stopped learning. Her pre-anaesthetic assessments now also include the thorough examination of the oral cavity. She doesn’t even have a problem about adding an advice or two about interdental cleaning (“Did you know 40% of your teeth are left dirty if you use just a toothbrush?”) or addressing the need for referral to some of the dental specialist (“Poor woman, didn’t even have posterior teeth to chew on”). An all-knowing creature, I tell you.

 

Suggested reads:

Tonetti MS, Chapple IL, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference. J Clin Periodontol. 2015 Apr;42 Suppl 16:S1-4.

Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. J Periodontol. 2018 Jun;89 Suppl 1:S159-S172.