Connecting the Dots: The Role of Oral Medicine in Interdisciplinary Healthcare: Bridging Gaps and Enhancing Patient Outcomes

Principles of interdisciplinary oral care

There are a few fundamental principles for integrating interdisciplinary care in oral health. Firstly, there exists a bidirectional relationship between oral health and the general health of an individual. Various studies have demonstrated the concrete associations between oral diseases like periodontitis and systemic conditions like diabetes mellitus and hypertension among patients. This mutual bidirectional association is evident in the form of oral signs and symptoms, which occur in the oral cavity of patients who are diagnosed with systemic diseases. Poor oral health can increase the dissemination of microbes, thus aggravating these diseases. A seminal report titled ‘oral health in America: A report of the surgeon general’ highlights the association between periodontal diseases and chronic noncommunicable diseases like cardiovascular disorders, diabetes mellitus, stroke, pulmonary diseases, etc., Such chronic illnesses are the chief cause of readmissions in hospitals and these patients tend to have a couple oral complications. Other than periodontal diseases, oral conditions like dental caries have been evaluated for their role in causing higher asthmatic episodes in children diagnosed with asthma. Such children were three times more vulnerable to being irregular in school due to the high incidence of dental pain. Also, pregnant women who have poor oral care have a higher risk of giving birth to preterm and low birth weight babies. Various researchers have evaluated the relationship between mental illness and poor oral health. This connection is again bidirectional, as many psychiatric medications cause xerostomia, which is a known risk factor for oral diseases. A systematic review in 2015 studied the oral health among healthy population and among people diagnosed with psychiatric illnesses. They found that people with severe mental illnesses were thrice as likely to develop dental caries, subsequently leading to tooth loss. Oral diseases and their complications also cause eating difficulties, speech disabilities, low self-esteem and negative self-image, causing depression, thus reducing their quality of life. Such systemic complications of oral diseases are the major causative agents that impose significantly high disability and fatality burdens.^[2] A lack of well-established interdisciplinary care that combines social and economic aspects leads to negative health outcomes, causing health inequalities. The best solutions navigate towards reactive rather than preventive measures.

Expanding interdisciplinary health teams to cater to oral health is a pivotal step towards achieving holistic health among healthy and immunocompromised individuals. However, the issue lies in the fact that oral care is not frequently included in integrated service delivery. Though the WHO has declared oral health a key indicator to improve the quality of life, dental care is hardly available in medical setups. Dental clinics and hospitals can serve as a crucial point of care if equipped with qualified interdisciplinary teams. The American Dental Association Health Policy Resources Centre stated that about 27 million Americans visit a dentist annually, and they do not visit a general physician. Similarly, 108 million Americans visit a general physician but not a dentist. These facts highlight the reality of similar situations in countries like India, where the population visits a physician only when they have a serious problem, and the concept of integrated oral care is still unknown in larger parts of the country. Developing integrated healthcare settings that offer oral, physical, and behavioral management in the same place, has high potential to serve large populations effectively.

Current global scenario

Major healthcare associations like the WHO, American Dental Association (ADA), American Academy of Family Physicians (AAFP), Indian Dental Association (IDA), etc., have supported the integration of oral healthcare and general healthcare settings. They have formulated an ‘Oral health delivery framework’ that is defined as a multidisciplinary collaborative approach that aims at oral health screening, risk assessment, preventive treatment modalities, including anti-tobacco counselling and patient education in dental care. This framework can be constituted by a team of general dentists, general physicians, specialty physicians, radiologists, nurses, pharmacists, counsellors, and policy makers. This concept is new and requires implementation research in actual healthcare settings to evaluate the proof of concept. Sanders et al. in 2021 stated the development of an integrated healthcare team that was set up in a dental school to serve patients within the dental OPD.^[3] The authors state that this interprofessional patient model was highly effective, providing a unique learning environment for the dental graduates.

A positive and friendly partnership between the dental, medical, paramedical, and nursing schools can promote excellent patient delivery with utmost accuracy and can be time-saving too. In Western countries, there has been a rigorous move to include oral healthcare in interdisciplinary healthcare setups.^[4] Their results are good, and their practice lays the foundation for similar collaborations to be adapted in countries like India. Interdisciplinary teams have a major advantage over traditional setups as they deliver quick and planned treatment for a variety of patients. With the vast variations in epidemiological trends across the globe, interprofessional programs are required to maximize the health workforce, especially in countries with a limited health workforce. For example, India has a 66% shortage of specialist doctors, including dentists, due to factors like unequal distribution of physicians, greater concentration in urban sectors, brain-drain, vacant posts in government hospitals, etc. In such scenarios, an integrated oral program can benefit the patients largely and also help in the early detection of systemic disorders.

Experts suggest that providing oral health education is a primary interdisciplinary practice that must be followed in all dental/medical clinics and hospitals. Awareness about orofacial conditions through continuing medical programs has to be propagated to general physicians so that they are equipped to provide the right referral according to the diagnosis. Paramedical teams must be trained to answer basic questions about oral health, maintenance of oral cavity, tooth replacement, dental caries, periodontal diseases, etc. Preventive oral health counselling is provided by pediatricians in many countries, and this is also a good example of interdisciplinary practice. Early dental visits among children are one of the fundamental steps in promoting oral health among children, and this can prevent the incidence of early childhood caries. Such interdisciplinary activities have to be introduced to medical and paramedical staff so that they can in turn effectively work in an integrated oral care-based hospital/clinic setup.^[5]

Examples of integrated healthcare

Various examples of interdisciplinary oral health centers have been tried and tested globally. Some examples are the primary and dental care integration, mental health and dental care establishments, etc. Few authors have stated that a few issues like the lack of training and infrastructure, have developed flaws in the functioning of such setups, causing lack of proper workflow. Integration of electronic medical records is a vital step in preventing confusion and in the easy accessibility of patient information. Authors have further highlighted the lack of enthusiasm among medical professionals in being a part of integrated oral care systems. These findings propel us towards structured training programs that allow diverse perspectives and yet establish efficient interdisciplinary collaborations. Kaufman et al documented 42 articles that evaluated the effect of such collaborative healthcare systems on factors like healthcare utility and patient outcomes. He stated that there was a reduction in in-patient admissions and emergency visits and an optimal improvement in preventive management of chronic diseases.^[6]

Globally popular healthcare institutions which have initiated oral health-based interdisciplinary setups include George Washington University, the University of Missouri School of Medicine, Louisiana State University Health Sciences Centre, and the University of Dentistry of New Jersey. These academic institutions have offered training programs with a focus on strengthening medical students’ knowledge and skills in preparation for working in interdisciplinary medical and dental environments. A number of academic medical trainings were prepared with the intention of improving continuing medical education.^[7]

There are several initiatives that have been kick-started globally to promote and follow integrated oral health-based patient care. The interprofessional educational initiatives (IPE) and interprofessional practice (IPCP) are similar initiatives that are popular in Western countries. They have been implemented at different levels to train healthcare providers to facilitate and disseminate interprofessional models. Another example of a successful initiative is the ‘Smiling Brazil’ program that integrates oral health with public healthcare systems. Nationwide survey forms are distributed across Brazil to document epidemiological indicators, and these indicators help in the public decision-making process, thus selecting the appropriate treatment and referral options.

Around ten years after the implementation of this initiative, oral health epidemiological indicators have served as valid inputs in early detection and systemic disease diagnosis. There was a reduction in decayed/missing/filled teeth (DMFT) index from 2.8 in 2003 to 2.1 in 2010. Peres et al also stated that there was a significant reduction in tooth loss among teenagers.^[8] All the above were positive outcomes of the Smiling Brazil initiative.

Other examples of transdisciplinary collaborations include the following:

• 1.

  The creation and establishment of the field of ‘periodontal medicine’ based on an understanding of common mechanisms linked to periodontal diseases and others, leading to improved preventive and therapeutic strategies for overall healthcare

• 2.

  Identification of salivary gland fluids as biomarkers through sialometry for detecting certain diseases

• 3.

  The discovery of potential links between microbes in the oral cavity with gastrointestinal disorders, colon cancer, and Alzheimer’s disease etc.,

Any interdisciplinary setup needs a properly organized administrative team to understand the referral loops and the protocols to be followed for the smooth functioning of the organization. Special training must be provided to doctors who opt to work as part of an integrated setup, as it requires additional skills. Healthcare providers around the world have advocated different methods of providing transdisciplinary healthcare, and carefully structured research can help us identify the ones that suit our population.^[9]