New research highlights gulf between primary care, dental care


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A pediatrician sees a child with untreated tooth decay, but doubts a dentist will be available in the child’s community. The pediatrician does not write a referral.

A dentist notices a patient’s suspicious oral lesion, but fails to follow up. Care is delayed.

A pregnant woman with an infected tooth is advised to seek dental care but has no regular oral health provider. She ends up in an emergency room where her underlying dental problem remains unresolved.

Cases like these serve as reminders of the gulf between America’s systems of primary care and dental care – and its human impact, according to a discussion paper, newly published by the National Academy of Medicine.

Physicians and dentists fail to collaborate or even to communicate. Patients suffer; the most vulnerable often get lost in the divide.

“A siloed dental profession cannot solve people’s oral health problems alone, nor can the medical profession solve general health problems alone,” write the authors of the paper, Kathryn A. Atchison, R. Gary Rozier and Jane A. Weintraub, a team of prominent dental and public health educators.

Knitting the systems together will require serious work on many levels. But the effort is necessary to ensure better health outcomes, they note.

“To provide whole-person, integrated, patient-centered, comprehensive care, it is important to connect the mouth with the rest of the body,” they write. Their commentary highlights recommendations included in a full report commissioned by the National Academies of Sciences, Engineering, and Medicine (NASEM) Roundtable on Health Literacy. The report, by the same authors, is scheduled for release at a NASEM workshop on Dec. 6.

Currently, most primary care services are provided by practitioners working in large physician groups and health care organizations. Meanwhile, most dental services are provided by smaller private dental practices, operating separately from the primary care system.

The fragmented system is not conducive to interprofessional communication or referrals between primary care and dental professionals.

“State-level surveys suggest that referrals in either direction are highly variable and their effectiveness is unknown,” the authors observe.

On different levels, both patients and providers lack the health literacy skills necessary to bridge the divide. And broken links in communication can not only compromise health but expose providers to legal risk. Communication breakdowns are a leading factor in malpractice claims, the authors warn.

Still, there are places where meaningful steps have been taken to address the gap between primary and oral health services. The authors see promise in community-based referral initiatives dedicated to getting populations of at-risk children, pregnant women and chronic disease patients into dental care.

They are also encouraged by the push by the nation’s network of Federally Qualified Health Centers to co-locate primary care and dental services.

But until such approaches are common practice, other efforts must be made to deliver more holistic care, they say.

“There is an enormous need for the health care professions to develop and implement a system integrating medicine and dentistry, recognizing that physical proximity of practices is unlikely to be the norm for many years to come,” they write.

The authors recommend new strategies to encourage and incentivize interprofessional referrals, to enhance interprofessional education and communication, to bolster care coordination and to integrate medical and dental records.

“Until sometime in the future when a greater proportion of dental practices is incorporated into large health care settings, it is imperative to build on the ways the profession has developed to connect these two siloed systems of care so that patient care can be improved, particularly for vulnerable, low literacy populations,” they write.

“Our vision is a patient-centered health home that includes bidirectional access and communication across oral health and primary care.”

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