By: An Nguyen, DDS, MPH

Many of history’s most significant revolutions were slow, steady endeavors, and this is true for the ongoing revolution in dentistry that has gained momentum over the past decade.

It is visible in the emergence of terms like “oral-systemic health” and “medical-dental integration” found across the health landscape and the use of “chronic disease management” and “non-communicable disease” as related to oral health. It is notable in the proliferation of these concepts in peer-reviewed literature, continuing education offerings and policy decisions. Underlying this trend is an affirmation of a belief long held by many in the dental profession: oral health is health and, as such, is “essential” for overall health and wellness.¹ This recognition holds significant potential to address issues that have long siloed dentistry from broader health efforts, have chronically underappreciated or marginalized the dental professional’s contributions to health and maintained persistent health disparities. This context makes today a time of significant opportunity and innovation for health care in America.

In the late 1800s, Dr. G.V. Black advanced the biological and technical bases for dentistry, establishing a biomedical approach under which the profession has largely operated since.² This approach has been important for the technological progression of skills and tools, and it has contributed to the rise of an infrastructure that has driven the longstanding transactional economic model for dentistry. However, chronic diseases do not behave in strict biomedical ways; routinely, there are no simple interventions that will cure the underlying etiology of these conditions. Chronic diseases are diseases of biology and behavior, and they occur within social contexts that require an appreciation of the environmental conditions that influence lifestyle choices and a commitment to long-term management by both the patient and health system. By extension, the dental professional’s engagement in the management of “oral-systemic” conditions requires approaches beyond what the era of G.V. Black can offer; the intrinsic nature of this work requires a transformation in how dental teams and the health care system must function.

Fortunately, for more than thirty years, medical practitioners have successfully applied a chronic disease management approach in their work, and there are lessons learned from these experiences that can inform the kinds of shifts needed for dentistry to effectively engage in whole body health care.³ Likewise, dentistry has begun this transition, and practices like caries management by risk assessment (including risk-based care and minimally invasive dental approaches) provide significant insight into what will be needed as dentistry moves into comprehensive health management and builds upon and beyond the biomedical approach of the G.V. Black Era.⁴ To advance a dentally integrated schema for complete health, these cases make a central concept clear: new ways of thinking that leverage skills from and collaborations with other professional disciplines will no longer be optional; the proposition that oral health is essential for overall health is incumbent on the dental profession’s ability to develop and engage in new interdisciplinary skills and partnerships.

Today, the proportion of dental practitioners who engage in systemic chronic disease management and interdisciplinary practice is still small; however, their experiences provide a view to identify some key, practical skills needed to support whole body health, namely the ability to: (1) understand the medical mindset; (2) apply evidence-based behavioral science approaches; (3) engage in quality improvement activities; and (4) use measurement to support the identification of high quality, sustainable dental initiatives. Together, they provide context for the interdisciplinary shift needed to effectively support dentistry’s role in the Complete Health Era.

THE MEDICAL MINDSET
There must be recognition that, to date, most chronic disease management has been held within medicine, and partnering as an equal in this care will require dental professionals to understand the language and evidence-based practices of their medical peers. Supporting effective clinical outcomes requires breaking down conventional peer-based hierarchies in the health system.

BEHAVIORAL SCIENCE
The transactional, procedure-based nature of dental care must shift to prioritize longitudinal relationships, including the development of the dental team’s ability to promote healthy behavior choices for patients who may be ambivalent about or even resistant to change. In this context, skills like motivational interviewing and shared decision-making are critical to shift the provider’s role from clinical expert to supportive collaborator whose responsibility is to promote positive behavior changes.

QUALITY IMPROVEMENT SCIENCE
Underlying the changes needed to support oral-systemic health integration in practice are two basic assumptions: (1) dentistry has a role in ensuring complete health and (2) a current gap exists in chronic disease outcomes that dentistry can help improve. These assumptions provide the basis for dentistry to move beyond procedurally based definitions of quality to a broader, more holistic viewpoint, where quality improvement science can provide the basis for discovering best practices and new workflows for whole health that enhance the value and efficiency of care.

MEASUREMENT
Identifying which best practices to adopt and bring to scale requires effective markers of progress, and this cannot occur without effective measurement. Especially as interdisciplinary chronic disease management prompts the need for novel systems for operational and financial management, success in these new environments requires the development and use of reliable, valid, and feasible measures made by dentistry for dentistry to ensure that care is reimbursed and evaluated upon clinically important domains of health.

While the adoption of a chronic disease management approach in oral health will undoubtedly reveal other areas of needed change for dental professionals and dental care delivery, the identification of these four areas—with roots in practices like medicine and public health, psychology, engineering and physics, and mathematics and sociology—underscore the interdisciplinary nature of the work ahead for the practice of dentistry.

The endurance of G.V. Black’s legacy has largely insulated dentistry from sweeping revolutionary experiences, making generational practice changes outside of technological advancements for the profession less obvious for most within it. However, the emergence of oral-systemic health and chronic disease management approaches for any number of conditions—from diabetes to pregnancy, cardiovascular disease, sleep disturbances or metabolic diseases—has the potential to significantly shape the future of dentistry They will impact dental education, clinical practice, economic models, the workforce, and inform the necessary interdisciplinary skills to drive oral health for the future.⁵ Undoubtedly, these changes will result in tension and even resistance for some currently in dental practice; in some ways, these reactions can mirror for practitioners what patients experience when asked to engage in behavior change: what might feel like a hard change to make might also be the one needed most, because the path to better outcomes always requires doing something different. Just as it does for today’s Complete Health Era, lessons from behavioral science can support dental professionals to move through the Stages of Change—from awareness to desire and knowledge and, eventually, to the ability and confidence to navigate the changes needed to be a part of building a system that is better for the whole health needs of the people and communities the noble profession of dentistry seeks to serve.

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Dr. An Nguyen is Chief Dental Officer at Clinica Family Health and Wellness and a nationally recognized leader in health quality. She is the current President for the National Network for Oral Health Access (NNOHA) and is an active leader with several other national dental, health advocacy and quality-focused organizations.