Isn't Dentistry Part of Specialized Medicine?

 

When I was working at the Institute for Medical Research (IMR) in Kuala Lumpur in the 1960's till mid-1990's there was a Division of Oral Pathology there within the IMR. They have a dental chair there with all other facilities to treat periodontal diseases.

When I rotated to other departments, such as Community Medicine, Rural Health Research, Clinical Research, Biostatistics and Epidemiology, I worked together with my colleagues who were dental officers, not just among medical doctors.  We worked together as a research team with other experts such as nutritionists, medical anthropologists, sociologists, and biostatisticians alongside other medical doctors. We also work alongside the lab scientists and lab boys in biochemistry, microbiology, immunology, cellular and molecular biologists on whom we depend for lab support. We don't work in isolation because we need to design studies, investigations, examinations, and measurements collectively and analyze the data together as health-care experts. We share and contribute our expertise among each other.

We always have a few dental officers (dentists) and medical officers (doctors) working together though the nature of our job may be different, but we are not at loggerheads and antagonists with each other. We treated each other as colleagues of equal professional status. We teamed up to share together our separate scientific and health-care expertise. In short, we were all equal.

My closest colleagues were the dental officers.  So why then is dentistry separate from medicine when practiced separately outside, since the mouth and teeth are also part of the body like any other organs and body systems, a question I have often asked myself even during my young days in school? I asked myself, shouldn’t dentistry be a specialized part of medicine or at least part of general medicine?  Isn’t the extraction of the teeth a surgical procedure? Isn’t dentistry, also called dental surgery, similar to other surgeries in medicine?  If medicine can be divided into specialty and subspecialties such as ophthalmology (disorders of the eyes), otorhinolaryngology (ENT), gastroenterology (diseases associated with digestive tract: oesophagus, stomach, small intestine, colon and rectum, pancreas, gallbladder, bile ducts and liver.)  hepatology (liver functions and their diseases), orthopaedic (disorders of the musculoskeletal system- bones, joints, ligaments, tendons, muscles, nerves, etc),  nephrology (mainly disorders of the kidneys), urology (disorders  of the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs (testes, epididymitis, vasa differentia, seminal vesicles, prostate, and penis), cardiology (disorders of the heart and vascular system), dermatology (diseases of skin), etc,  why couldn't  dentistry involving the mouth and teeth be part of a medical speciality, instead of isolated separately as if the mouth and teeth are not part of body?   Don’t my readers, including medical doctors, think so? Studying dentistry separately and in isolation is like treating the teeth as not part of the body when it should be a specialized branch of medicine after a medical student has graduated to be a doctor to go on further into dentistry as a medical speciality?  After all, a university course in dentistry takes 4 -5 years, the same as a medical course. The basic medical sciences for both disciplines are almost the same, except in dentistry they concentrate on the mouth cavity, head and neck region in anatomy whereas in general medicine, a student covers other areas of the body except the teeth and oral areas. Why shouldn’t this be, I have often wondered?   Don’t my gentle readers, especially medical doctors, agree?  If they don’t then what are their reasons behind this separation? There must be some historical reasons behind this.

My strong belief is a doctor can always specialize into diseases of the mouth including the teeth which are part of the body instead of treating dentistry as a separate health care discipline that has no dealing with medicine in an un-holistic manner. Unfortunately, too, when doctors specialize, they begin to treat a patient as disorders of specific organs, and not the patient as a person. This is not holistic healthcare whether it is medicine or dentistry.  

Members of these two professions may have their own reasons, but as for me as a clinician, a nutritionist and a former medical researcher, this is highly unscientific and un-holistic to treat the mouth and its structures as if they are all not part of the body, but something else alien and outside the body.  

However, I do understand the separation between dentistry and medicine has historical roots. One reason for this division is the historical development of these professions. Medicine, as we know it today, has evolved over centuries, with various specialties emerging based on the complexity and specialization required to address different aspects of human health.

Dentistry, on the other hand, has its own long history but developed somewhat independently from general medicine. Historically, dental care was often provided by barbers, blacksmiths, and even general physicians, reflecting a less specialized approach to oral health. Over time, as dental knowledge, and techniques advanced, dentistry began to emerge as a different distinct profession.

There are also practical reasons for the separation. The mouth and teeth present unique challenges and require specialized training and equipment for diagnosis and treatment. Dentists undergo specific education and training focused on oral health, which includes not only the teeth but also the gums, jaw, and related structures. This specialization allows them to effectively address the diverse array of issues that can arise in the oral cavity.

While there are connections between oral health and overall health, such as the link between periodontal disease and systemic conditions like cardiovascular disease, the focus of dentistry remains primarily on the oral cavity. However, dentists often work closely with physicians and other healthcare professionals to ensure comprehensive care for patients.

So, while there are arguments for integrating dentistry more closely with general medicine, the historical development, unique challenges, and specialized nature of oral health care have contributed to the continued separation of these professions. However, interdisciplinary collaboration between dentists and medical professionals is increasingly recognized as essential for providing holistic patient care.

If that was the case, then surgeons too were once upon a time separate from physicians. Surgeons were once barbers and blacksmiths who amputated limbs and cut open bodies. They have no medical education. They were the barber surgeons. The first barber surgeons to be recognized as such worked in monasteries around 1000 AD. Surgery then was not part of a physicians' job as they so rarely performed surgery in the Middle Ages. During those years, Europe saw a proliferation of barbers, among other medical "paraprofessionals", including couching (ophthalmology), herniotomy, lithotomies, midwives, and pig gilders.

 In 1254, Bruno da Longobucco, an Italian physician who wrote about surgery, expressed concern about barbers performing phlebotomies and scarification. The barbers then were surgeons. The process of bloodletting (withdrawal of blood from a patient to cure or prevent illness and disease) practiced by monks was passed on to barber surgeons, thus cementing them within the surgical field. Barbers who had a knack for handling sharp instruments such as scissors and razors assisted in bloodletting for the sick. As the profession progressed, barber surgeons not doctors were charged with conducting surgical operations and looking after soldiers during and after battle. They were not medically qualified then, but they did surgical operations. So are dentists today, not actually medically qualified, or only partly medically qualified, but they extract teeth and do dental surgery. 

The evolution of surgical practice mirrors that of dentistry to some extent, but there are significant differences. Historically, surgery was indeed performed by individuals with various backgrounds, including barbers and non-physicians. However, as medical knowledge advanced and surgical techniques became more complex and specialized, the need for standardized education and training became apparent.

The development of anaesthesia, aseptic techniques, and a better understanding of anatomy and physiology led to surgery being recognized as a distinct medical specialty. Surgeons began to require comprehensive medical training to ensure they had the knowledge and skills necessary to perform surgery safely and effectively. But dentists today too, use x-rays, probes, pilers and local anaesthesia for a variety of dental procedures, from cavity and crown work to root planning and scaling for periodontal disease. Common local anaesthetic drugs used in dentistry include lidocaine, aptocaine, prilocaine, mepivacaine, and bupivacaine. Isn’t these used also in medicine and in surgeries?  

In contrast, dentistry, while also evolving and becoming more specialized, retained a somewhat separate path of development. The focus on oral health and the unique challenges presented by the oral cavity led to the establishment of dental schools and specialized dental education programs.

One key difference between surgery and dentistry is the level of invasiveness and systemic impact of procedures. Surgery often involves interventions that directly affect multiple systems within the body, requiring a deep understanding of physiology and pathology. Dentistry, while important for overall health, primarily focuses on the oral cavity and its associated structures.

That being said, dentists do receive extensive education and training in oral health, including anatomy, physiology, pathology, and dental procedures. While they may not have the same medical qualifications as physicians or surgeons, they are highly trained professionals capable of providing a wide range of dental services.

In recent years, there has been increasing recognition of the connections between oral health and overall health, leading to greater collaboration between dentists and medical professionals. This interdisciplinary approach helps ensure that patients receive comprehensive care addressing both oral and systemic health needs.

 Why then do some dentists go on to specialize in oral pathology when pathology whether oral or general pathology is part of specialized medicine, or is it a branch of specialized dentistry?

As far as I know, the specialization of some dentists in oral pathology reflects the recognition of the intricate connection between oral health and overall health. Oral pathology involves the study and diagnosis of diseases affecting the oral and maxillofacial regions, including the mouth, jaws, and related structures. While pathology as a field traditionally falls within the domain of medicine, oral pathology focuses specifically on conditions that manifest in the oral cavity.

Dentists who choose to specialize in oral pathology undergo additional training and education to become experts in the diagnosis and management of oral diseases. This specialized knowledge allows them to identify and interpret oral lesions, tumours, and other abnormalities that may have systemic implications. They play a crucial role in early detection, diagnosis, and treatment planning for conditions ranging from oral cancer to autoimmune disorders affecting the oral mucosa.

The decision of some dentists to specialize in oral pathology underscores the growing recognition of the importance of oral health in overall health and well-being. By having specialists who are specifically trained to diagnose and manage oral diseases, patients can receive more comprehensive care that addresses both their oral health needs and potential systemic implications.

While oral pathology may have its roots in medicine, its focus on the oral cavity and its unique pathology justifies its specialization within the field of dentistry. This interdisciplinary approach helps ensure that patients receive the specialized care they need to maintain optimal oral and systemic health.

So, if a patient has oral cancer for instance, is it the responsibility of the oral pathologist to treat, or must the case be referred to an ENT or oral surgeon?

As far as I am concerned, the treatment of oral cancer typically involves a multidisciplinary approach, with various healthcare professionals collaborating to provide comprehensive care tailored to the individual patient's needs. While oral pathologists play a crucial role in diagnosing oral cancer through biopsy and pathology examination, they typically do not provide direct treatment for the cancer itself.

Instead, the management of oral cancer often involves a team of specialists, which may include:

1. Oral and Maxillofacial Surgeons: These specialists are skilled in performing surgical procedures within the oral and maxillofacial regions. They may be involved in removing the cancerous tissue through procedures such as tumour resection or neck dissection.
2. Otolaryngologists (ENTs): Otolaryngologists specialize in the treatment of diseases and disorders of the ears, nose, throat, and related structures. They may be involved in the surgical management of oral cancer, particularly when it affects the throat or involves structures beyond the oral cavity.
3. Medical Oncologists: Medical oncologists specialize in the treatment of cancer using chemotherapy, targeted therapy, and other systemic treatments. They may be involved in developing and overseeing a patient's treatment plan, particularly if the cancer has spread or requires systemic therapy.
4. Radiation Oncologists: Radiation oncologists specialize in the use of radiation therapy to treat cancer. They may be involved in administering radiation therapy to target and destroy cancer cells in the oral cavity or surrounding tissues.
5. Dental Oncologists: Dental oncologists are dentists with specialized training in caring for cancer patients, particularly those undergoing radiation or chemotherapy. They may help manage oral complications of cancer treatment, such as mucositis or dental issues.

While oral pathologists typically do not provide direct treatment for oral cancer, their expertise in diagnosing the disease is critical for guiding the treatment plan. They work closely with the rest of the healthcare team to ensure accurate diagnosis, staging, and appropriate management of the cancer. This collaborative approach helps ensure that patients receive comprehensive care that addresses all aspects of their oral health and cancer treatment needs. since managing a sick part of the body is a very complicated process

Any health condition, whether it affects a specific part of the body or the body as a whole, can be a complex and multifaceted process. It often involves a combination of factors including accurate diagnosis, tailored treatment plans, coordination among healthcare providers, patient education, and ongoing monitoring.

Each part of the body has its own unique characteristics and functions, which can influence the approach to diagnosis and treatment. Additionally, many health conditions are interconnected, meaning that a problem in one part of the body can affect other systems or organs. This underscores the importance of a holistic approach to healthcare that considers the patient as a whole, and not a collection of separate organs or systems.

Furthermore, individual patients may have unique medical histories, genetic factors, lifestyle considerations, and personal preferences that can impact their healthcare journey. Tailoring treatment plans to meet the specific needs and circumstances of each patient is essential for achieving the best possible outcomes.

Given the complexity of managing health conditions, collaboration among healthcare professionals from different specialties is often necessary to provide comprehensive care. This interdisciplinary approach allows for the pooling of expertise and resources to develop personalized treatment strategies that address all aspects of a patient's health.

Ultimately, managing a sick part of the body requires a combination of medical knowledge, clinical skills, empathy, and collaboration to navigate the complexities of disease and promote healing and well-being.

Having explained all that, I still think a dentist should also study general medicine first before specializing into dentistry and later into oral medicine because the mouth and teeth are  part of the body system, and it can affect the general health of the body entire body,

For example, any infection of the mouth can affect the heart and cardiac valves to make them incompetent. The bacteria that infect the gums and cause gingivitis and periodontitis also travel to blood vessels elsewhere in the body where they cause blood vessel inflammation and damage; tiny blood clots, heart attack and stroke may follow. Supporting this idea is the finding of remnants of oral bacteria within atherosclerotic blood vessels far from the mouth. A rotten tooth with infection of the mouth can trigger off the body's immune response and inflammation that sets off a cascade of vascular damage throughout the body, including the heart and brain. This spread came initially from the mouth and teeth from dentistry to the whole body into medicine. Rheumatic heart disease for instance is a condition where the heart valves have been permanently damaged by rheumatic fever. The heart valve damage may start shortly after untreated or undertreated streptococcal infection, such as strep throat or scarlet fever. An immune response causes an inflammatory condition in the body. This started from an infection in the mouth which is the responsibility of a dentist or dental surgeon. Wouldn't both dentists and doctors agree with me? 

First of all, the health of the entire body begins with the mouth. It is the mouth that feeds, not the heart, eyes, nose, kidneys, bladder, lungs, brain. etc, etc that feeds. Feeding and nourishment for the entire body, and hence the entire life and health of the body begins with the mouth that feeds. Nutrition for the entire body begins in the mouth first. It must start in the mouth, the salivary glands, the teeth to chew before food can be swallowed. This affects how the body is going to get nourishment and overall health which becomes medicine for the entire body. This involves even the expertise of the nutritionist who is also a healthcare professional who too has to study for a 4-year structured programme that includes all the basic medical sciences similar to any medical or dental student in a university to qualify all of them as health care professionals. 

Indeed, the mouth serves as the entry point for nutrition and plays a crucial role in digestion. Oral health issues such as gum disease and tooth decay can have systemic implications, impacting not only the health of the mouth but also increasing the risk of conditions such as cardiovascular disease, diabetes, and respiratory infections.

In truth the training of a nutritionist as a health care professional too goes far beyond medical sciences and basic medicine, lab investigations and diagnosis. He has to be competent in areas like agriculture, food production, analytical food chemistry, sociology and human behaviour, economic, mathematical statistics, drug-food interactions among others. These are far more than what a medical doctor or a dentist needs to study and handle. 

These areas make a lot of scientific and logical sense and are shared by many in the medical, dental and scientific communities. Recognizing the interconnectedness of oral health with overall health is increasingly emphasized in both dental, medical and nutrition education.

Given these connections, there is a growing recognition of the importance of integrating oral health into general healthcare and promoting collaboration between dentists and physicians and also the nutritionist.  Some dental schools and medical schools are expanding their curricula to include interdisciplinary coursework that emphasizes the relationship between oral health and systemic health.

Moreover, some dental professionals pursue additional training in areas such as oral medicine or dental public health to gain a deeper understanding of the broader implications of oral health on overall health. This allows them to play a more active role in promoting preventive care, early detection, and management of oral health conditions that may impact systemic health.

While there are historical and practical reasons for the separation between dentistry and general medicine, the evolving landscape of healthcare emphasizes the importance of a more integrated approach. By recognizing the mouth as an integral part of the body and promoting collaboration between dental and medical professionals, we can better address the complex interplay between oral health and overall health, ultimately leading to improved patient outcomes.

This is my qualified professional and scientific opinion don’t you agree with me?

Summary:

Dentistry and medicine are currently two distinct professions practised under two separate health care laws. Since the mouth and its structures are part of the same body, it would be better to abolish the training of dentistry and put it under general medicine. Once a student graduate as a medical doctor, he or she can spend another two or three more years as deemed sufficient into the art and science of dentistry to qualify further as dental specialists just like any other branches of medicine. There is no need to repeat the full course of a 4-year course in dentistry any more as most of the basic medical sciences such as anatomy, physiology, microbiology, biochemistry, pharmacology were already taught to them in the first two preclinical years. That way a dentist or dental surgeon can also understand medicine to double up as a doctor and dentist to treat any disease, from mouth to rectum. But would members of both profession willing to agree to this integrative holistic approach? They may agree or disagree due to their different ancient historical roots they may wish to preserve. The final decision is entirely theirs  

 

-          Lim ju boo 

-          Lim ju boo