MESSAGE FROM THE EDITOR
ELEPHANTS FIGHTING Dr. Richard F. Roadcap
A recent patient broached the subject of COVID-19 testing, and I commented the rapid “Sofia” antigen test was not as reliable as the gold standard “PCR” test. The patient, who was retired and did not have a background in healthcare, asked “Do you mean the polymerase chain reaction test?” Not only is the topic of the pandemic on the tip of the tongue, medical jargon is the subject of everyday conversation. Our patients can say “Pfizer” and “Moderna” as if they were the names of grandchildren. Their heightened awareness obliges us to spend hours sifting through newsfeeds that don’t make us a better dentist. A silver lining to the dismal public health events of 2020 may be improved dentistphysician communication. For most of my career, these last three words have been considered an oxymoron, in the manner of “jumbo shrimp” or “mature teenagers.” Many efforts at interprofessional communication have fallen short, as dentists and physicians fall back upon the education and training that’s kept them apart. Even before they enter college, prospective dentists and MDs are partitioned in the classroom, and that separation often continues for life. I won’t try to bring up the subject of educational reform, as that is beyond the scope of most practicing dentists. In this issue, third-year dental student Vanessa Sturz does an excellent job of outlining VCU’s efforts to bring clinical dental education and medicine under the same roof. No, practicing dentists (certainly mid and late career) just want to talk to their patient’s MD. Even with dentistry’s splendid record of practicing safely, and the meticulous screening done in most offices, we still want to know when to proceed and when to defer treatment. Co-morbidities were more prevalent than
ever before the pandemic, yet many physicians don’t understand the nature of our treatment and can’t assess the risks of routine dental care. Subjects that often fall victim to poor communication include: • Antibiotic prophylaxis • Platelet inhibitors (e.g., clopidogrel) and anticoagulants (e.g., warfarin, Eliquis®) • Medications designed to treat osteoporosis, including bisphosphonates such as Fosamax® and denosumab, a monoclonal antibody A study in Japan1 found poor communication between dentists and physicians led dentists to request discontinuation of drugs used to treat osteoporosis, resulting in increased fractures with no reduction in medicationrelated osteonecrosis of the jaw (MRONJ). Two faculty members at the University of Pennsylvania School of Dental Medicine (Akintoye, Hersh) responded, in a letter, to this study saying, “Just as ‘two fighting elephants cause the grass to wither’, lack of communication between physicians and dentists managing osteoporosis patients may hamper patient care outcomes.” Likewise, a recent study in Europe recommended that physicians ask, in writing, for a dental evaluation prior to starting so-called bone-modifying agents.2 The authors advised completion of invasive dental procedures before therapy started. I’ve never been asked for my opinion before a patient began Fosamax® or other drug intended to treat osteoporosis. On numerous occasions I have been asked by an orthopedic surgeon to examine a patient prior to joint replacement surgery. In most instances the patient is in need of routine dental procedures that need not delay surgery;
however, fulminant dental infection should be prevented at all cost. All we can do is advise physicians of our findings and allow them to determine if they should proceed. More than once I’ve had a patient appear for a non-invasive procedure and tell me their physician had stopped anticoagulant therapy prior to the appointment, without seeking my opinion. A teachable moment ensues, with the opportunity to educate both patient and MD on the unnecessary, and perhaps risky, change in medication. Published research in both medicine and dentistry has shown that continuing anticoagulants when patients undergo dental surgery is safe in the vast majority of cases.3 The authors of one study, in their discussion, offer the comment “In brief, there is an immense need for cooperation between physicians and dental surgeons. Although they both admit lacking full knowledge concerning oral anticoagulation in dental surgeries, dentists and physicians tend to mutually criticize.”4 Both professions have suffered from the COVID-19 pandemic, and many elective medical and dental procedures were postponed in the first half of 2020, until it could be demonstrated that they could be performed safely. Dentistry’s years of using, and perfecting, PPE can teach medicine how to practice with safety. Medicine can teach us how to screen and triage patients who may not exhibit any symptoms of a deadly upper respiratory disease. Malcolm Gladwell, in his 2008 book Outliers, says plane crashes usually involve the same ingredients: an exhausted crew, bad weather, poor communication, and one or more sources of stress. (Watch Gladwell talk about the importance of good communication.)5 Maybe the pandemic’s gift will be the
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