Tooth Technician or Oral Health Doctor?

Scrubs was a favorite television show of mine during dental school and residency. In one memorable scene, the irascible well-seasoned chief of staff Dr Kelso says, while chiding a particularly poor performing intern, “Is that how you feel, future dentist?” Although I found it hilarious, a fellow classmate was quite offended and declared it patently unfunny considering dentists are doctors too. Dentistry is more than being a tooth technician; it is being a doctor of oral health (ie, the mouth and facial regions) and even the head and neck in the case of the specialty of orofacial pain. But therein lies the rub. Better walk the walk if you talk the talk. The necessity of properly assessing and understanding a patient's medical status is rightly emphasized in dental education. It is not something to be cavalierly glossed over due to mounting production pressures, yet from time to time that unfortunately seems to be the case.

In the April 2022 issue of the Journal of the American Dental Association, survey data obtained from 258 members of the American Dental Association Clinical Evaluators Panel detailed how practicing dentists use and access patient health information.¹ Stated objectives included understanding how dentists assess their patient's health status, how frequently this information is updated, and how dentists interact with medical colleagues. The American Dental Association Clinical Evaluators Panel is “used to take the pulse of ADA member perceptions and feedback regarding professional products, materials, and clinical techniques.” Based on the demographic data, respondents closely approximated recently published American Dental Association dentist workforce statistics with respect to sex, geographic region, and race/ethnicity, although the mean respondent age was slightly higher than average (55 years vs 49.3 years).^2,3 Additionally, 84.9% of respondents reported being in general practice, while 15.4% practice a dental specialty.

Many of the clinical insights from the study include aspects of patient care that most would consider well established and generally known. For example, vital signs are collected, medical histories and medication lists updated, and medically compromised patients are treated, all with regularity. The authors note that dentists do interact closely with other physicians, particularly for patients with medical complexities. Those findings appear to be on par with dentistry upon initial examination.

However, diving deeper into the article's infographic revealed several eyebrow-raising datapoints. According to the survey, the person who discussed/reviewed a new patient's medical history was the dentist 60% of the time, followed by the dental hygienist (19%), dental assistant (17%), and other (4%). In comparison, the person who discussed/reviewed medical history for returning patients was primarily the dental assistant (34%) or dental hygienist (32%), followed by the dentist (21%), and other (13%), of which a third identified as being front-office staff or the office manager.

Knowing your patient is fundamental to safe patient care and medical emergency prevention. A health history review (medical history, review of systems, medication list, etc) should be one of the first steps completed for all dental patients, not just those undergoing sedation or general anesthesia. Starting with the form completed by the patient, the health history review ideally includes initial assessment by and verbal interview with the treating dentist, and it should be concisely reviewed at each return visit. Building intended redundancy into the process by having a subordinate prescreen patients can be quite helpful; however, it should not be delegated in its entirety. Putting aside dental hygienists with their potential to work independently, the percentage of dentists who discuss/review health histories for new and returning visits should be 100% rather than 60% and 21%, respectively. Especially worrisome is the significant percentage delegating this critical step to “others” who likely lack the same level of medical education as the treating dentist or dental hygienist.

The infographic also shed light on the type of information obtained and recorded at every dental visit, with a majority updating changes to medical history (75%) and the medication list (66%), while a minority included visits with other health care providers (33%). Although it is commendable that more than half stated patients are asked about medical history and medication updates at every visit, the outliers highlight further room for improvement.

Treating patients without a full picture of their current health history considerably elevates the potential for patient harm and medical-legal risks. Patients should be asked if any changes to their medical history or listed medications have occurred since their last visit. Inquiring about any significant visits with other health care providers is also appropriate as potential pitfalls may be discovered preoperatively. This line of questioning is easily completed and takes virtually no time. If delegated, notable findings can be easily relayed to the dentist for further discussion prior to starting treatment. Furthermore, it is generally advisable to consider taking an entirely new health history at regular intervals (eg, every 2–3 years) to help ensure any major changes are not inadvertently missed.

Lastly, a large majority (85%) reported routinely collecting some combination of vital signs (pulse, blood pressure, respiratory rate, room air oxygen saturation, or temperature) upon presentation, and 57% of those respondents stated they collect those same vitals at every visit. The 15% of outliers who do not routinely collect vital signs upon the patient's arrival are particularly troubling. The survey data fail to discuss any particular combinations, however; blood pressure is probably the most likely, and hopefully heart rate as well, and both would certainly be indicated for any dental patient undergoing treatment requiring local anesthesia, particularly with added epinephrine, let alone sedation or general anesthesia. Assessing a patient's respiratory rate, oxygen saturation, or temperature may be unneeded for otherwise healthy patients undergoing routine dental care. However, some notable exceptions come to mind where their use would be clearly indicated: a patient with significant pulmonary disease, those taking medications that may depress the central nervous system, signs and symptoms suggestive of a systemic or serious odontogenic infection, or perhaps even suspected opioid use.

Obtaining baseline vital signs is a commonly delegated task performed in many offices. They can be taken immediately upon the patient's entry into the dental operatory and the findings, normal or otherwise, easily relayed to the treating dentist with little to no delay in treatment. Given the widespread incidence of cardiovascular disease and hypertension in the United States, it is quite shocking that only a little more than half of all respondents take vital signs at each visit, although those who do should be commended. Identifying irregularities preoperatively is one key to preventing perioperative medical emergencies and urgencies in the dental office but obviously requires vital signs are actually assessed prior to treatment.

While this survey did identify some bright spots for dentistry, it also seemingly underscored several areas of concern. Clearly there is room for improvement with respect to who discusses/reviews patient health histories, when health information is updated, and obtaining appropriate vital signs. All dentists must ensure they are working with a thorough and up-to-date medical history for every patient, regardless of whether the planned treatment includes noninvasive care only or local anesthesia, sedation, or general anesthesia. This cornerstone of care is critical to serving as our patient's oral health doctor rather than their tooth technician.