Dentistry for the whole patient

"CARE for the patient, the whole patient and nothing but the patient" may well become the mantra to promote a shift to holistic healthcare. 'Holistic' is described in the Oxford Medical Dictionary as "an approach to patient care in which the physical, mental and social factors in the patient’s condition are taken into account, rather than just the diagnosed disease". Such use of the term 'holistic' has superseded the now outdated use, indicating complementary medicine, homeopathic and other alternative approaches to patient care. For clarity in contemporary literature, holistic may be qualified by the addition of 'whole patient' – 'whole patient holistic care'.

In dentistry, as in most if not all other aspects of healthcare, conditions treated as having a simple cause and effect aetiology may recur or possibly even be aggravated through a failure to recognise and manage all aspects of the causation – in other words by "not getting to the bottom of the problem".

Take, for example, a simple like-for-like replacement of a fractured restoration in a patient who has developed parafunctional occlusal activity. This activity might follow the acquisition of an occlusal interference, subsequent to a fracture, wear, or an extraction allowing passive eruption of an opposing tooth. Good long-term success in the replacement of the fractured restoration may only be achieved through initial management of the occlusal dysfunction. However, this may not guarantee success as the parafunctional activity, although triggered by an occlusal interference, could be found to have a more complex aetiology than is first apparent. Psychological stress would be top of the list of likely confounding aetiological factors. In this way, a holistic, whole patient approach is required to successfully manage an apparently simple, everyday problem in dentistry.

"TROUBLESOME" BLACK HOLE

Scaling-up such thinking to consider the management of a patient with, for example, a chronic non-communicable disease such as diabetes, it quickly becomes apparent that an inter-professional, coordinated team approach is indicated to manage and minimise the effects of the patient’s condition efficiently and effectively. The evidence base to support such thinking continues to grow¹.

Oral healthcare must be integral to such teamworking, given the now widely recognised association between oral disease and general health and wellbeing, specifically periodontal disease. Realising this goal will be a two-way process – expansion of the nature and scope of oral healthcare (dentistry) and other healthcare professionals being trained not to forget the mouth, its importance, how to prevent and manage certain oral conditions, and when to refer to a dental team for management ².

Dentists will become as much physicians as surgeons, and other healthcare professionals will come to better understand the mouth rather than tending to view it as that rarely to be ventured into and sometimes troublesome "black hole" in the lower third of the face. For example, in prescribing drugs, all healthcare providers should consider the effects that certain drugs and polypharmacy may have on salivary function and quality – xerostomia (apart from being very unpleasant) may greatly increase caries progression and be associated with candida infections and difficulties with dentures.

EXPANDING OPPORTUNITIES

With the integration of oral healthcare into general healthcare, there will be many different opportunities for dentistry, including involvement in screening, vaccination and other programmes. This will help prevent, diagnose and limit a range of conditions and diseases with life-changing consequences and high cost burdens. In this way, dental teams will add significantly to their existing role of managing dental problems and helping patients achieve and maintain oral health.

To create time and opportunity for members of the dental team to acquire and maintain the necessary knowledge, skills and understanding to realise their potential in inter-professional, shared-care of patients of all ages, there will need to be a fresh approach to dental education and workforce planning. No longer will estimates of future numbers of students in different dental programmes be largely based on projections of changes in the pattern and incidence of dental caries and periodontal disease, not to forget tooth wear. New and attractive career pathways may emerge, helping to recruit and retain bright, high-potential people into dentistry, assuming suitable recognition of expanded roles and responsibilities.

To achieve this, dentistry must be transformed together with its existing image, which sadly for many still reflects bygone practices and historic approaches to pain control. Given the scope of the challenge, there is little time to waste if the future and rapidly changing needs and expectations of patients are to be met.

MOVING MATTERS FORWARD

Growing evidence suggests that the integration of oral healthcare into general healthcare creates opportunities for efficiency savings, allowing more people to be managed better within existing resources. In addition, patient satisfaction should be favourably impacted, and through enhanced inter-professional auditing and understanding, the process of identifying future research and development (R&D) priorities should be greatly facilitated.

What then is stopping the planning and introduction of the necessary programme of change? Is it a lack of leadership, inertia in dentistry (as presently practised and perceived) or the opportunities afforded by the integration of oral healthcare into general healthcare provision not being on the “radar screen” of healthcare planners? Alternatively, is it down to a lack of joined-up thinking amongst all relevant stakeholders? In all probability, all of these factors and others are culpable.

So what is to be done to move matters forward? Do we need more publications aimed at stimulating debate? Or is it a matter of funding research to confirm the value of oral healthcare being integral to holistic general healthcare provision in the UK?

Personally, I believe that the key is strong, suitably empowered leadership which has the confidence and trust of those who will be influenced most by change – patients, dental millennials, funding agencies and those who will need to guide academic and postgraduate dentistry through the necessary transformational change. Is this a challenge for a College of Dentistry, which is now in the process of being formed, subsequent to the Faculty of General Dental Practice (UK) – FGDP(UK) – having announced its intention to become an independent body earlier this year?

The recent FGDP(UK)/Simplyhealth conference entitled Holistic dentistry: putting the mouth back in the body may be the first step in rising to the challenge. If forward thinking individuals and informed patients had their way, holistic, whole patient care, including oral healthcare provision, would be high on the agenda of promising developments in UK healthcare provision.

Professor Nairn Wilson is emeritus professor of dentistry, King’s College London and, amongst other positions, chair of the Shadow Board for a College of Dentistry and a non-executive director on the MDDUS Board

RFERENCES

1. The New York Academy of Medicine Inter-professional care coordination: Looking to the future. www. macyfoundation.org/ docs/grantee_pubs/ NYAM_Issue_Brief- Care_Coordination.pdf
2. Wilson NHF Holistic care should be coming your way. Br Dent J 2017 223: 568-569