To practice truly comprehensive dentistry, consider a patient's current condition in terms of (in order) health, function and aesthetics. The benefits of doing so include improving patient lives, as well as increasing revenue, attracting and retaining more patients, and giving staff a sense of greater purpose and vision.
The "HFA model" challenges dentists and their teams to focus on practices that take the patient's entire health into consideration, from initial assessment to interventions made.
Health: Oral and systemic health are fundamentally connected; there's not just a focus on teeth.
Function: The practice examines not just how teeth fit together but also phonetics, respiration, digestion and how this system operates with the rest of the body.
Aesthetics: The appearance of a patient's teeth, mouth and jaw structure can profoundly affect his or her sense of self-esteem, as well as the patient's perceived and real ability to interact socially and advance professionally. Mental and social health should also be considered within a dental assessment.
It's up to us
According to the NIH and the U.S. surgeon general's office, a physical examination of the mouth can indicate disease, drug and alcohol abuse, domestic abuse and additional critical information about a patient's general health status.
Unfortunately, many people still consider good dental care to be a luxury, and many dentists resign themselves to the public's view. But for patients who suffer from diabetes, heart disease or other physical and emotional ailments, good oral health could mean the difference between life and death.
The only way patients will understand the effect oral health has on their overall health is if their dentist tells them. No other health professionals are adequately trained in oral health to be prepared to share that information with them. Failure to recognize this limits dentistry's power in the marketplace, diminishes the field's standing in the healthcare community, and promotes risks to patients in achieving and maintaining their health.
Dentist as a primary diagnostician: In 2012, I diagnosed a patient with severe anemia, after examination of her palatal and gingival tissue, and requested blood work to verify the diagnosis. Her internist called her after receiving the results and immediately sent her to the emergency room for a transfusion. (Her physician was surprised to learn that her dentist made the diagnosis!)
Medical/dental drug interactions: In 2010, I contacted a patient's cardiologist and advised him to take the patient off his current blood pressure medication because of the deleterious effects it was having on his gingival tissue. I diagnosed this patient with gingival hypertrophy (Fig. 1) caused by amlodipine after appropriate periodontal therapy failed to resolve or maintain proper gingival architecture. The cardiologist did not comply with my request until I forwarded a photo; the patient was taken off the medication that same day. (After several gum surgeries tissue health was restored as seen in Fig. 2.)
Heart connection: In 1999, a 55-year-old presented in my office with moderate/advanced periodontal disease. He refused treatment beyond a basic cleaning, but I spent a year educating him on the connection between heart disease and gum disease. He finally agreed to periodontal surgery and received a clean bill of health from his primary care physician to proceed, but three days before surgery, he suffered a fatal heart attack. I was always concerned that his heart attack was directly related to his untreated gum disease.
Psychological health: In 2011 a stay-at-home mom presented to the practice with the complaint of feeling embarrassed and reluctant to speak or smile without placing her hands over her mouth (Fig. 3). When her children got a bit older, she re-entered the workforce to become a real estate agent. After treating her using the HFA model (Fig. 4), the patient wrote me a letter saying, "I am no longer ashamed to show my teeth and smile. I have been selected Rookie of the Year, and I made six figures. I believe my confidence soared because of my new smile."
Direct impact: My decision to embrace the HFA model was affirmed more recently by a painful personal loss. In 2014, my brother Tony died from a sepsis infection that is believed to have originated in his mouth. I remain steadfast in the belief that dentists can and should embrace their role as lifesaving medical professionals.
A different way to practice
To many dentists, the HFA model represents a different approach to service delivery, but the process and practice can be smoothly integrated into any dental practice with the proper blueprint. First, the practice must develop a vision that commits itself to:
- Using the full training and abilities afforded by the profession, regardless of influences to the contrary.
- Establishing a trusted team of medical and dental specialists committed to a collaborative model.
- Including informed patients and well-trained team members in the treatment-planning process.
These tools and actions can be implemented over the course of a year to aid in becoming a catalyst for the total health and well-being of patients:
Intake process: I created a comprehensive medical history form for new patients that includes detailed questions relating to common systemic conditions that often have oral links.
Education: Provide customized pamphlets and educational videos that explain dentistry as a branch of medicine and emphasize the concept of the mouth as a gateway to the body. Play general videos on loop in the waiting room, and more individualized videos within the patient area that can be shown during breaks in service. The dentist and staff can select specific videos that pertain to each patient's medical history.
Staff involvement: Educate all staff as to why the practice is choosing to follow the HFA model—even those who work in reception and billing, so they can be prepared to reinforce the model with positive attitudes toward it. This can be helpful in situations where patients express doubt while filling out medical forms, or when patients and their families engage staff in discussion while watching educational videos.
Enrolling the team in the HFA vision and engaging them in its planning and implementation is an integral part of a comprehensive dental practice. When the team is committed to collaborating around an agenda and philosophy that is grounded in sound dental practices, the practice will benefit. Staff will become revenue generators and relationship builders who play a significant role in the education and care of your patients.
Discussion: Have a conversation with all new patients regarding the practice's focus on health, function and aesthetics. Explain what this means and how it will affect their care, and offer an opportunity for them to ask questions.
Heart health: Take a blood pressure reading on all patients before treatment of any kind.
Collaboration: Initiate and maintain cross-clinical communication with patients' other healthcare providers. Invite collaboration on treatment protocol and require additional medical testing and physician's clearance, where necessary.
For example, if a patient presents with uncontrolled diabetes and untreated moderate gum disease, steps could include:
- Determining baseline metrics by conducting a comprehensive periodontal evaluation to determine the stage of gum disease and requesting lab work including an A1C reading.
- Asking the endocrinologist and internist to partner on the management and monitoring of the case. Inform the patient that all three doctors will be involved in improving his health.
- Monitor progress: After all the treatment recommendations have been followed, retest the patient for improvement.
Integration and Integrity
For most in the field, dentistry is more than a profession—it's a mission. The practice of true comprehensive dentistry gives dentists and their staff the opportunity they desire to make an impact on the quality and quantity of patients' lives.
When patients understand how their oral health affects total health and longevity, they're more likely to take ownership of the problem. The benefits to a dental practice include a higher case acceptance rate and a boost in patient compliance. Educated patients are proactive patients, inspired to step into the vision for optimal wellness that we've helped them create.