Written by Louis Malcmacher, DDS Thursday, 01 March 2012 00:00
Now that I have been in dentistry for more than 30 years, I believe that I have a historical perspective on this question. When I was in dental school, there was very little discussion or education about the overall wellness of our patients, and cosmetic dentistry was literally in its infancy. The primary purpose of a dentist was to concentrate pretty much solely on teeth and, of course, the patient’s periodontal health. Yes, we realized that teeth were connected to the rest of the body, but there really was not much involvement between professionals in dentistry and those who practiced other medical disciplines. Similarly, there also was not much expressed interest by the medical profession into what dentists could provide to their patients.
THE DEFINITION OF “DENTISTRY”
Slowly, during the past 3 decades, there has been recognition that there are many areas for dentistry to be influential on and involved in, and sometimes to be even a primary provider of certain care; treatment that in the past used to be considered as something only medical doctors should be handling. As we developed this point, though, let’s look at how dentistry is defined and what comprises the practice of dentistry. The definition of dentistry, according to the ADA (and also by many state dental boards as well), is as follows:
“Dentistry is defined as the evaluation, diagnosis, prevention, and/or treatment (nonsurgical, surgical, or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area, and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training, and experience, in accordance with the ethics of the profession and applicable law.”
As you are probably thinking, this is certainly a good definition of dentistry—at least of what dentistry was years ago. Notice a couple of things in this definition of dentistry—there is no mention of cosmetic dentistry, which means that cosmetic dentistry, whether it is on hard tissue or soft tissue, in or out of the mouth, really does not fit into what dentistry is. If the term dental is only referring to tooth-related problems, that obviously does not reflect the kind of dentistry that is practiced today in North America and in the rest of the world. Let’s look at some of these areas.
Much of aesthetic dentistry does not at all deal with form and function of the dentition, but is completely an elective procedure, and much of this dentistry is done on virgin teeth. This certainly includes procedures like teeth whitening, porcelain veneers, and surgical crown lengthening to fix a gummy smile. Is this technically within the scope of dentistry by the above definition? Probably not, but it certainly is not medicine either. It is the definition of dentistry in the year 2012.
TEMPOROMANDIBULAR JOINT SYNDROME/OROFACIAL PAIN
Is this medicine or dentistry? Should dentists be limited to only treating these conditions with occlusal equilibration, orthodontics, and full-mouth reconstruction? Of course the answer is no, because teeth are connected to the jaws, which are connected to the muscles in the entire head and neck area, and indeed to the rest of the body. A number of dental universities have facial pain residencies for general dentists. These general dentists treat patients far afield from only the teeth and may be doing therapeutic procedures on them that extend down to the middle of the back. Even in your own practice where your emphasis may not be on temporomandibular joint disorder or orofacial pain, you deliver bruxism appliances to patients who have headaches and muscle aches. Are these patients’ head and neck muscles within the realm of dentistry, even though they are not related to the teeth? Of course they are!
Conscious sedation in a dental office has become well accepted in modern dentistry. With proper training, in some states, intravenous (IV) sedation is allowed by general dentists. With any kind of sedation, the dentist is administering very powerful pharmaceutical drugs into the patient’s system. Is this practicing medicine or is this practicing dentistry? There is nothing specifically dental about conscious sedation itself, but it is certainly an important adjunct for many patients. Truth be told, dentists routinely prescribe and administer powerful and toxic pharmaceuticals to patients whether it be in the form of narcotics, antibiotics, steroids, and especially, local anesthetic agents. By the strict letter of the law, the definition of dentistry states that dentists can only touch teeth and that patients may really be required to go to other health care practitioners who administer conscious or IV sedation. Certainly, in 2012, the definition of dentistry obviously includes the ability to treat teeth and incorporate all the adjunctive services that go along with treating teeth.
DENTAL SLEEP MEDICINE
This area, treating snoring and mild sleep apnea, is a growing niche in dentistry in which dentists are administering home sleep tests, taking measurements with sophisticated equipment, and creating oral sleep apnea appliances. Dentists are even allowed to bill the patient’s medical insurance for these medical treatments. So are dentists here practicing medicine or dentistry? You decide.
OROFACIAL USE OF BOTOX AND DERMAL FILLERS
This is perhaps one of the most interesting categories of all. Just the term Botox seems to evoke passionate statements by some in and outside of dentistry that dentists should not be allowed to use Botox. That position is based purely on ignorance. Botox has been a therapeutic agent in dentistry with scientific papers and studies going back nearly 20 years. Botox is taught in some major dental schools in residency programs for its use in dental therapeutics and dental aesthetics and at many dental university and major dental society continuing education programs.
The vast majority of states already allow dentists to use Botox and dermal fillers in the oral and maxillofacial region for aesthetic and therapeutic uses because, like everything else we talked about, these procedures which are in the oral and maxillofacial structures are indeed nonsurgical minimally invasive dental procedures.
DENTISTRY: IS IT JUST ABOUT THE TEETH?
I could give further examples, but I think you are beginning to see the point. Dentistry is not just about teeth, and certainly, at this point and time, a dentist has to have dental and medical knowledge as it relates to the oral and maxillofacial areas, which we as dental professionals know much more about than physicians. Every single dentist reading this article treats much more than just teeth as soon as you inject a pharmaceutical agent, such as lidocaine 2% with 1/100,000 epinephrine into a patient, or when you prescribe narcotics and antibiotics. When you use Botox and fillers, conscious sedation, sleep apnea devices, and anything else, you have got to know the physiology, pharmacology, anatomy, adverse reactions, indications, and contraindications, and how to deal with any adverse reactions. You need training, training, training as it relates to any of the services you provide.
Simply to say that dentistry is just about the teeth is to propel dentistry back into the dark ages when most dentistry was done by the barber in barbershops. Dentists are highly trained professionals with the specialty in the oral and maxillofacial areas of the body. As president of the American Academy of Facial Esthetics, I have a large faculty comprised of physicians, nurses, and dentists. Our fast growing membership of more than 1,500 is composed of all healthcare professionals, more than 70% of which are dentists. The member physicians and nurses are always amazed at the amount of knowledge that dentists have about the head and neck and often defer questions and patients to the dentists that are a part of our organization because they understand that in many areas, a dentist can be the treatment provider of choice for many facial aesthetic and therapeutic challenges.
Do dentists practice medicine? You bet we do—every single day that we treat patients. I might even suggest that at this point in time, perhaps dentistry has become somewhat of a “specialty” of medicine. That specialty covers the oral and maxillofacial areas for both aesthetic and therapeutic treatment as defined by most state dental practice acts and extends well beyond just the teeth. Today’s dentistry has been completely redefined with new knowledge, technology, and dental education and training.
Disclosure: Dr. Malcmacher reports no disclosures.
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