Let's Close the Gap between Doctors and Dentists
Roy, Patricia J., Medical Economics
I never feel so unprepared and frustrated as when I get an emergency call from a patient with a dental problem. Teeth are just not my thing. I used to be afraid that my training was deficient until I heard from medical colleagues who felt the same way. Dental problems aren't addressed in medical school, and they should be.
Several recent patient encounters have shown me that something needs to be done. Not only should primary-care doctors know more about general dentistry, but dentists have to start assuming more responsibility for the care of their patients.
And the two professions must start working together. If we don't, managed care will eventually demand it. If the reason isn't obvious, I can explain with an example from my practice.
Just before Christmas, a patient I'll call May developed a dental abscess in a long-present area of decay. Her dentist wasn't able to see her until after the holiday, so she made an appointment for Dec. 28. In the meantime, he told her to take aspirin or acetaminophen.
Unfortunately, he didn't tell her what to I do if standard doses of the analgesics didn't work. Two days later, her husband brought her to the ER, vomiting and hyperventilating, after she had consumed 100 aspirin tablets in 48 hours. She was still miserable from the pain.
Mary was admitted, stabilized, and placed on I.V. antibiotics and parenteral pain meds. She responded nicely and was discharged two days later -- just in time to make her dentist's appointment.
Of course, this all could have been avoided had Mary's dentist given her proper instructions, been available over the holiday, or at least had someone covering for him. Because he did none of these things, what should have been a minor dental-office problem instead required an expensive ER visit and hospitalization. And her HMO ended up footing a large bill that it had no control over. Since I'm Mary's primary-care doctor, this case will be charged to my utilization account, although it involves expenses I couldn't control. Under a capitated system, that's just not fair]
Also not fair: Since many of my patients have medical insurance, but no dental insurance, they come to me first, hoping I can solve the problem. Or even if they do have dental insurance, it might not cover prescriptions written by a dentist. So they'll ask me to phone the Rx in. I don't do it, because it seems like fraud. But the patient is the one who pays.
So what are we to do? I have some suggestions, all arising from things I've seen in my practice.
Persuade insurers to cover dental care. We ought to lobby for better dental coverage so that health insurers don't end up expecting primary-care doctors to provide dental care. That's not just for our sake, but for our patients'.
Patients who need major dental work, but who don't have dental coverage and can't afford the dentist's bill, are a dilemma for me. Many dentists won't see them until they have the money in cash for the procedures they need. So I end up prescribing antibiotics often, and pain meds occasionally. I also encourage them to find a dentist who'll accept payment in installments. But that's not the way it ought to be.
And to encourage preventive care, more insurance plans should capitate dentists the same way they do primary-care doctors. And I, for one, would welcome a few general dentists into our primary-care network.
Educate dentists about medical problems. As I mentioned, our training ought to teach us to recognize common dental problems. But that's not enough: Dentists need to learn about common medical problems. I would love to see joint CME for dentists and physicians, and to see local medical and dental societies ask each other to provide speakers on relevant topics.
I often see patients who come in thinking they have a sinus infection because their "teeth hurt." What they really have is an abscessed tooth. And occasionally, a dentist will send over a patient who thought he had an abscessed tooth. …