Where dentists are lacking, M.D.s dive in

When the crowns fell off her two front teeth, Karen Crawford knew she could not afford to replace them. So, she tried to Super Glue them back on.

After that didn't work, Crawford looked into getting dentures. But she discovered the dentists near her home in Waterville, ME, wanted $120 for each of the 11 teeth they would need to pull.

Disabled and unable to work, Crawford, 55, resigned herself to hiding her mouth whenever she smiled -- until she saw her family doctor.

"What if I pulled them for you for free?" she recalled William Alto, M.D., saying at her regular checkup. Although it sounded strange at first, Crawford agreed and before long had all her top teeth safely removed.

Crawford was one of the first patients to participate in an innovative program that has physicians doing dentistry. Launched four years ago, it is part of the Maine-Dartmouth Family Medicine Residency program, in which medical residents get special training in oral health.

Across the U.S., more and more physicians are focusing on teeth. Earlier this month, the American Academy of Pediatrics held a summit on oral health and recommended that pediatricians screen children for dental problems and apply fluoride varnishes where needed. Pediatricians in North Carolina and Washington have already begun following that recommendation. And Washington physicians are learning to understand oral health problems in the elderly as well.

Many state Medicaid programs now pay for physicians to perform such preventive services. Laws in about half the states allow physicians to do dental work.

Getting physicians involved in oral health addresses two major problems: the lack of access to dental care and the continuing disconnect between oral and systemic disease.

"Somehow the oral cavity got taken out of the human body, and we're trying to put it back in," said James Schmidt, D.M.D., president of the Maine Dental Association.

Dr. Schmidt, who recently retired as chief of dental services at the Togus VA Medical Center in Maine, now works with residents twice a month, teaching them how to do basic exams, read x-rays, and even pull teeth. He also taught rudimentary dental skills to three of the program's faculty members, including Dr. Alto.

Scant resistance from dentists

Dr. Schmidt emphasizes that he is not trying to turn medical doctors into dentists. He's not teaching them to fill cavities or do complex extractions. Crawford still had to buy dentures from a dentist (relatives chipped in for a $450 discount set).

Rather, Dr. Schmidt's goal is to help physicians better manage their patients.

Many residents moonlight in emergency rooms, so they see a lot of patients dealing with severe dental pain. Dr. Schmidt teaches them about oral anesthetics and what antibiotics can help with dental abscesses. He also talks about how diseases in the mouth can exacerbate problems elsewhere in the body.

Maine's program grew out of Dr. Alto's inability to get some of his patients' dental care. When a teenager came to his office one day with severe periodontal disease, Dr. Alto felt compelled to take action. The girl, Jamie Doty, had gone to the emergency room so often during the previous six months that physicians there refused to give her more prescription painkillers, suspecting she was getting hooked on the drugs.

Dr. Alto volunteered to pull Doty's teeth if she could not find an oral surgeon to do so. He had learned to do extractions when he was a resident, and he did all kinds of surgery -- including oral surgery -- during the 12 years he worked in the South Pacific and Papua New Guinea.

Doty said she contacted local oral surgeons and confirmed that no one would take her case. "Dentists have become a monopoly," she complained. "It's all about money."

Dr. Alto pulled 22 of Doty's 26 teeth, leaving the others because of their complicated roots. When a local oral surgeon discovered what had occurred, he became incensed and contacted the state dental board, Dr. Alto said. The state's dental and medical boards met, in part, to determine whether Dr. Alto had violated the law. They decided that state law allowed him to pull teeth, since it says physicians have the legal right to treat disease.

Dr. Alto used the controversy to get Dr. Schmidt to give him and other faculty members more dental training. Before long, they launched the residency program and helped set up a network of dentists and oral surgeons willing to help indigent patients.

Both Dr. Alto and Dr. Schmidt said a few dentists have groused about the invasion of their turf. But no one contacted by DrBicuspid.com had a complaint. The American Association of Oral and Maxillofacial Surgeons had no comment. The ADA provided only a written response, saying in part, "The ADA remains focused on other proven solutions to providing oral healthcare to those in need."

Dr. Schmidt responded that the program's main goal is to help doctors integrate oral and systemic health. But it's great, he said, "if, along the way, we can find an uninsured patient and help."