Medicine and dentistry: working together for better health
From his years as clinical director for a network of dental treatment centers for individuals with disabilities, to the founding of an innovative program to provide oral health care to New Hampshire's poorest citizens, to his current work here at MIT Medical, Dental Service chief Jay Robert Afrow, D.M.D., M.H.A., has spent his professional life attempting to bridge what he calls an "artificial disconnect" between the field of dentistry and other areas of health care and medical practice. "We are constantly learning about new connections between oral and systemic health," Afrow notes. "And good oral health is as much a quality-of-life issue as good physical health."
Afrow learned that lesson firsthand as clinical director of the Tufts Dental Facilities Serving Individuals with Special Needs. Many of the patients Afrow treated through that program had oral problems that were directly related to their medical conditions or treatment. "For example, many medications have side effects that are seen in the mouth," he explains.
A variety of factors may limit access to dental care for people with disabilities, but even when dental care was available through the Tufts program, Afrow often had a hard time convincing clinicians in other medical specialties to see such care as a priority. "Many of our patients' other providers had the attitude of, ‘well, I'm worrying about more important things than their mouths.' Certainly many of our patients were dealing with serious, even life-threatening, medical conditions," he concedes, "But often, their biggest complaint was their inability to eat. Treating their dental problems made a tremendous difference in the quality of their lives."
After nine years at Tufts, Afrow moved north to work on his Master of Health Administration degree at the University of New Hampshire. Afrow's master's thesis proposed a new vision for providing public health dentistry to populations for whom such care is not readily accessible. When Catholic Medical Center offered him the opportunity to try implementing his plan, Afrow jumped at the chance and was appointed the first dental director of the newly created Manchester New Hampshire Dental Alliance at Catholic Medical Center.
"New Hampshire had about a dozen different organizations serving various underserved groups," Afrow explained. "Each paid private dental offices to provide care to their clients, but the money didn't go very far, and they could treat only a handful of people each year. I convinced these groups to pool their money and set up their own dental service."
The small dental practice operating out of donated space logged more than 5,000 visits in its first year, more than a hundred-fold increase in the amount of care these organizations had previously provided. In June 1999, a front-page article in the New York Times cited Afrow's clinic as a model for providing oral health care to traditionally underserved populations. "The program is still there today," Afrow proudly notes, "and in the last four years, six additional clinics have opened throughout New Hampshire, all operating on the same model."
In May 2000, Afrow accepted the position of dental service chief at MIT Medical, a job that has offered him the opportunity to build more bridges between dentistry and other medical areas. "In the last few years, the Dental Service has become much more proactive," Afrow says. "We've doubled our number of hygenists, and rather than simply treating people who come in with dental problems, we're actively trying to prevent problems before they get started." It's an approach that works, he adds, because dental clinicians at MIT Medical are part of a much larger medical team.
Afrow is excited by recent research showing that better oral health may lead to improvements in overall physical health and well-being. "Beyond the quality-of-life issues, research has shown that oral health—more specifically, periodontal disease—is related to conditions such as pre-term birth, cardiovascular disease and stroke, and diabetes control," Afrow explains. "In its simplest nature, periodontal disease is simply a low-grade chronic infection, and researchers are finding that the oral bacteria that causes periodontal disease is similar to bacteria they are culturing from the coronary arteries of people with heart disease. There's also evidence that these oral infections can interfere with insulin control for diabetics or stimulate early labor in pregnant women."
Afrow cites several recent pilot studies that have shown that treatment of periodontal disease in pregnant women can significantly reduce the incidence of premature births and low-birth-weight babies. "The average cost for such treatment is just a few hundred dollars per patient," he notes. "Compare that with the cost of a month-long stay in the neonatal ICU."
Clinicians in other specialties at MIT Medical know about the importance of good oral health, Afrow says. "For example, we get a lot of women coming up here from OB/Gyn and saying, ‘I'm pregnant, and my obstetrician told me I should come up and get my teeth checked, because I haven't been to the dentist in a while."
The current staff of the Dental Service is very much on the "cutting edge" of new developments in dentistry, says Afrow. Beyond dental hygiene and more routine types of care, "we're now doing titanium implants to replace missing teeth, without damaging adjacent, healthy teeth," he notes. "We're also on the forefront of new techniques in cosmetic dentistry, which has been very popular."
Afrow hopes to continue building bridges from the Dental Service to the rest of the MIT community. "We currently have the second highest volume of visits to any Service at MIT Medical, right behind Internal Medicine," Afrow comments. "About 13,000 visits per year." Afrow estimates that Dental Service patients are about evenly divided between MIT Health Plan members and non-members, mostly students but also Institute employees and affiliates. "We want to be a resource for the entire Institute community," he says.
"Fifty years ago, most people were toothless by age 50," Afrow marvels. "Today, 90 percent of the population has some teeth until the day they die. We can do a lot to help people keep their teeth. But the truth is that, as good as we are at what we do, good oral health is 90 percent dependent on what you do at home." He laughs. "In other words, brush and floss!"