Could GPs have a role to play at the frontline of oral health decline?
Australia’s oral health report card
Did you know that poor oral health represents the most prevalent chronic disease in Australia, with about one third of adults and one half of children living with untreated decay1? It’s also the second most costly disease group behind cardiovascular disease, and the third highest cause of preventable hospital admissions in Australia2.
There are three important points in that sentence that bear repeating:
(i) tooth decay and gum disease are hugely prevalent and extremely costly;
(ii) they are diseases and not a normal part of life; and
(iii) they are chronic, that is, they are long-lasting and have persistent effects.
“What kind of effects?” I hear you ask
Simply put, some incredibly serious ones.
Oral diseases such as tooth decay and gum disease:
- are unsightly, affecting the way people feel about themselves3 and the way that they are judged by others4;
- are often painful and cause loss of sleep, inattention, and reduced school or work attendance5;
- are associated with a wide range of systemic diseases such as cardiovascular disease, diabetes, respiratory disease, stroke, kidney disease, dementia, adverse pregnancy outcomes, and disability6, and
- are infectious and transmissible7, meaning that the conditions can spread around the mouth, within the body, and between people (e.g., parent to child through sharing of utensils, etc.).
So, let’s look at the facts:
- Oral diseases are preventable, and because they share risk factors with other significant health problems such as obesity, well designed programs to prevent and reduce oral diseases can have broad health effects;
- Oral diseases can be detected early, and early intervention will reduce the impact of the disease on the individual, the spread within the family (e.g., parent-to-child), and the social and economic costs to both the individual and community;
- Early childhood caries is a fast-developing infectious disease with multifactor etiology; it can indicate alterations in child health and lack of adequate care8;
- Oral diseases can be used to indicate risk for systemic diseases9, and therefore identification and management of those risk factors can help to manage risk; and
- Identification of oral diseases could potentially prompt further investigations for systemic disease and permit early intervention10.
Tooth decay and gum disease are not trivial hygiene problems or superficial aesthetic issues; they are significant health issues that need to be addressed as part of a coordinated multidisciplinary preventive health-care initiative.
What is the role of GPs in oral health management?
Given the relationship between oral health and general health, it seems natural to consider the role of GPs in oral health management. GPs are at the coalface of general health care; they are a trusted source of diagnosis, treatment and information, and they provide essential screening of health issues and referral to specialist health services for the Australian population. It is therefore odd that oral health sits outside their care.
GPs are well placed to offer oral health screening and education; they have access to the Australian population across socio-economic strata, culture, and age, particularly in rural and isolated areas where dental services are often unavailable. National data indicates that over 80% of people consult GPs within a 12-month period, and that GPs are most likely to coordinate multidisciplinary care11.
GPs are regularly consulted by young families, and this provides an opportunity to identify early oral health problems and intervene. The inclusion of teeth and gums during routine examinations or throat inspections can provide valuable information about diet, health knowledge and priorities of the patient, and a ‘teaching and referral opportunity” Oral health information can alert the GP to potential health problems that may not yet have manifested, and perhaps indicate further investigations if appropriate.
There is much to be gained by including oral health screening, referral, and education within the purview of GPs.
So, can GPs incorporate oral health into their general practice?
As good as the idea might sound, there is limited research about the feasibility of incorporating oral health into general health care offered by GPs. The available evidence suggests that several potential barriers would need to be overcome. Firstly, it appears that GPs often avoid giving health advice to patients when it has not been explicitly asked for e.g., nutritional counselling in relation to obesity12. In this instance, GPs are concerned that:
- they lack the knowledge, skills, and resources to initiate prevention conversations;
- they lack time (and compensation for time); and
- unwelcome advice about potentially sensitive issues may offend or alienate a patient.
Despite these concerns, survey responses from patients confirm that preventive nutritional advice from GPs is welcome and expected as part of primary care13, and would be considered helpful14.
A second barrier that is apparent for GPs is that they lack training in oral health and feel that oral health is the dominion of dental professionals15.
How can we help GPs feel confident to include oral health in their overall health assessments?
The issue of a lack of training around oral health has been recognised by the Royal Australian College of General Practitioners, and professional development training is available under the Curriculum for Australian General Practice. This initiative could be incorporated as part of general medical training.
Medical training could also incorporate training in:
- screening for oral health problems (e.g., Lift the Lip)
- how to initiate difficult conversations
- referral pathways for oral health problems
- associations between oral health and general health
It would be particularly advantageous if advanced levels of oral health management training could be made available to GPs working in rural and remote areas.
Other strategies include the development of resources to support GPs and thus limit the amount of time taken during appointments for screening, or identification and referral, and additional support/education/referral resources could be developed for GP waiting rooms (e.g., videos).
Where to from here
It seems sensible to consider the benefits of cross- and multi-disciplinary approaches to health care and how this approach to health might be incorporated in to the training of our health professionals. Population health can benefit from coordinated prevention strategies delivered across health domains. Cross-disciplinary training in the recognition of health indicators and where to refer conditions beyond one’s expertise, can help to improve opportunities for early intervention. It is important to move oral health in from the cold and to recognise the importance of a coordinated approach to its management and the potential flow-on effects for general health.
To rephrase some famous words:
“The mouth bone’s connected to the head bone…”
1AIHW (2015). Chronic diseases. Australian Government. Available at http://www.aihw.gov.au/chronic-diseases/.
2Oral Health Monitoring Group, COAG Health Council. Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan 2015–2024. Adelaide: COAG Health Council, 2015.
3U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
4Willis, M., Esqueda, C., & Schacht, R. (2008). Social perceptions of individuals missing upper front teeth. Perceptual and Motor Skills, 106, 423-435.
5U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
6Dental Health Services Victoria (DHSV) (2011). Links between oral health and general health – the case for action. Available at https://www.dhsv.org.au/__data/assets/pdf_file/0013/2515/links-between-oral-health-and-general-health-the-case-for-action.pdf accessed 17 July 2015.
7Caulfield, P., & Dasanayake, A. (2005). Dental caries: an infectious and transmissible disease. Compen Contin Educ Dent, 26(5 Suppl 1): 10-6 https://www.ncbi.nlm.nih.gov/pubmed/17036539.
8Losso, E., Taveres, M., da Silva, J., & Urban, C. (2009). Severe early childhood caries: an integral approach. Journal de Pediatria, 85, 295-300.
9Rautemaa, R., Lauhio, A., Cullinan, M., & Seymour, G. (2007), Oral infections and systemic disease-an emerging problem in medicine. Clin Microbiol Infect, 13, 1041-1047.
10Bhavana, K., Preethi, N., Aarathi, K., Savitha, L. (2015). Oral manifestation of systemic disease. Journal of Pearldent, 6, 1-7. Available at http://www.indianjournals.com/ijor.aspx?target=ijor:jop&volume=6&issue=2&article=001.
11Australian Bureau of Statistics, 2016. Patient experiences in Australia: Summary of findings 2015-16. Cat No 4839.0. Available at http://www.abs.gov.au/ausstats/abs@.nsf/mf/4839.0.
12McMeniman, E., Moore, R., Yellan, M., & McClure, R. (2011). Childhood obesity: how do Australian general practitioners feel about managing this growing health problem? Australian Journal of Primary Health, 17, 60-65.
13Andersen, M.K., Christensen, B., & Sondergaard, J. (2013). Child overweight in general practice – parents’ beliefs and expectations -a questionnaire survey study. BMC Fam Pract, 14, 152. doi: 10.1186/1471-2296-14-152.
14Edmunds, L.D. (2005). Parents’ perceptions of health professionals’ responses when seeking help for their overweight children. Fam Pract, 22(3), 287-292. doi: 10.1093/fampra/cmh729.
15Barnett, T., Hoang, H., Stuart, J., Crocombe, L. (2016). “Sorry, I’m not a dentist”: perspective of rural GPs on oral health in the bush. The Medical Journal of Australia, 204, (1): 26 Available at https://www.mja.com.au/journal/2016/204/1/sorry-i-m-not-dentist-perspectives-rural-gps-oral-health-bush.
The Oral Health Advisory Panel (OHAP), is a group of independent healthcare professionals with the aim of raising awareness of the importance of good oral health and its impact on general wellness. The Panel aims to take oral health beyond the dental clinic.
Follow the Oral Health Advisory Panel via twitter @OHAPanel to stay up to date with practical advice on good oral health habits.