What does holistic dentistry mean for your practice?
While dental professionals might agree that oral health care has never been limited to a portion of the patient, practitioners hold varying opinions as to how to expand patient care. Holistic for some means integrated medicine--a collaboration among dental, medical and associated specialists. For others, collaboration outside the office expands to include practitioners from nontraditional disciplines, such as naturopaths, acupuncturists or massage therapists.
While they may not agree on whom to include for collaboration, both paths focus on gathering a complete health history and how oral health affects or is impacted by every other part of the patient's condition.
Integrated, Collaborative Care
It's not holistic dentistry, stated Burton L. Nussbaum, DDS, "It's holistic medicine." Nussbaum is a nationally recognized expert in the treatment of children with disabilities. He and the doctors with whom he practices provide care and consultative services in a number of hospitals and institutions, including Children's Hospital of Philadelphia and Thomas Jefferson University Hospital. "Dentistry is a part of health care," he explained. "It's not an island unto itself. Holistic medicine is treating each person as an individual--as a whole person--and taking care of their unique needs. You're not trying to fit people into a cookie-cutter formula."
Jennifer Ernst, RDH, a dental hygienist working for the State of Hawaii Developmental Disabilities Division (DDD), also described "holistic" as treating the entire patient. The DDD employs an interdisciplinary approach to treatment planning, care coordination and oral health care delivery for more than 3,500 Hawaii residents with developmental disabilities.
"The interdisciplinary approach works both ways; it also leads to holistic diagnosis and treatment planning by medical professionals when dentists are included on the team," explained Ernst. "To do this, we utilize a dental hygienist, a dentist, a developmental pediatrician, two psychologists and a psychiatrist who collaborate with case managers and nurses to resolve some of the most challenging clinical needs."
Holistic, Naturopathic Care
Tom McGuire, DDS, observed that "there is no official definition of holistic dentistry, no degree offered, nor do all holistic dentists agree on everything." He defined it as a philosophy that recognizes that the mouth is a part of the whole body, and holistic treatment combines sound dental science and technical experience with a deep concern for patients' physical and emotional well-being and comfort.
"The holistic dentist fully understands the important relationship of oral to overall health and realizes that you cannot be truly healthy without good oral health!" McGuire continued.
McGuire established the Dental Wellness Institute in 1997, to improve the health of the patient by bridging the gap between medicine and dentistry. "One of my goals has been to bridge that gap, as the reality is that until the health professional takes his or her patients' oral health into consideration when treating them for any existing health problem, they will not be taking a 'truly holistic' approach to health and their patients will not achieve the results they are seeking," he stated.
McGuire noted that he believed that the fundamental definition of holistic dentistry must include the practice of mercury-free and mercury-safe dentistry, something he communicates through his books and educational material found on his Web site. McGuire has been a mercury-free, holistic dentist for over 30 years, and in 2004, he formed the International Association of Mercury Free Dentists (IAMFD) to support mercury-free and mercury-safe dentistry.
"I don't believe any dentist could accurately consider him- or herself a holistic, or biological, dentist if they weren't mercury safe and did everything possible to minimize the patient's exposure to mercury vapor during amalgam removal," said McGuire.
Jolie Davis, RDH, has worked in a health-centered, mercury-safe dental practice in Winter Park, Fla., for the past eight of her 17 years as a practicing hygienist, and has been an appointed examiner to the Florida State Dental Hygiene Boards since 2002. She defines holistic dentistry as a practice in which the dental team learns as much as possible about the patient's oral and physical health. She feels the dental hygienist's role in the holistic practice is to gather information and educate the patient about dietary habits and lifestyle choices. The goal is to make patients aware of the oral-systemic link, explained Davis.
Davis' own exposure to a holistic practice came when she interviewed and was hired by her current employer, James E. Hardy, DMD, PA, author of the 1996 book, Mercury Free, which details mercury issues in dentistry. Davis bought a copy of the book during her job interview and studied Hardy's position on the subject.
"In doing that, it opened my eyes to different things. I started investigating holistic medicine and what that encompassed," Davis commented.
Holistic Practice in an Average Appointment
As noted earlier, a holistic practice delves deeply into a patient's health history. In those practices with more of a naturopathic environment, noted Davis, the dentist may spend a lot of after-hours time researching the biocompatibility of materials, not just for the patients' safety, but also for the staff who have to handle those products. Holistic dental practices may focus on being mercury free, or as McGuire called it, mercury safe. McGuire described that mercury-safe practices "believe mercury amalgam (silver) fillings are a health hazard, do not use amalgams, and use a safe removal protocol designed to minimize a patient's exposure to mercury during amalgam removal." (1)
This conscientious attitude about potentially hazardous material extends to all areas of the practice. Davis, for example, works latex-free; not only does she use non-latex examination gloves, she also uses latex-free rubber prophy cups. The entire staff avoids wearing perfume and cologne and uses electrostatic air filters with UV lights in the air conditioning system to purify the air. They also use mercury vapor ionizers in the operatories.
Beyond these measures, the practice views each patient "holistically," as an individual. Davis carefully reviews lifestyle and eating habits. After a lengthy medical history review, Hardy shares recommendations about physical, emotional and mental health based on the patient's profile. The practice works in conjunction with naturopaths and traditional physicians alike, depending on the patient's needs.
"If we have a patient with known or potential allergies or sensitivities to dental materials, we have doctors, both traditional and holistic, that we work with hand-in-hand and we recommend further testing (in a medical office) when necessary," Davis explained.
McGuire noted that differences exist in holistic practice from state to state. Some state dental boards, according to McGuire, are more open to the concept and practice of holistic dentistry; such is the case in California. Others, such as New Jersey, are more restrictive.
"I believe many dentists would be more holistic, particularly in being mercury safe, if state boards weren't so threatening. Many dentists who don't yet understand how to become mercury safe think they could lose their licenses if they do," he commented. He continued that even though the dental profession uses more elemental mercury than any other business, it is the only one that isn't regulated or monitored for mercury vapor exposure. Although dentists aren't legally required to protect their patients from mercury, McGuire believes they have a moral and ethical obligation to do so. He said that making a dental practice mercury safe isn't difficult; he often consults with dentists who are interested in doing so, explaining why there is no risk of losing their license.
A Holistic Approach to Treat Patients with Special Needs
Probably the best example of the holistic approach occurs when treating patients with special needs. In finding treatment solutions for this vulnerable population, the holistic care definition includes both a collaborative approach and creative thinking to give the patient comfort and comprehensive care. Because the term "special needs" encompasses everything from complex medical conditions to behavioral issues and/or intellectual disabilities, it is virtually impossible to separate an oral health checkup from any other health care treatment.
One of the goals of the DDD in Hawaii is to improve the competency and willingness of community dentists to provide this type of holistic care to better improve access to care for these individuals, said Ernst.
"Our first message is to treat the individual with respect and dignity. We want to help the medical and dental communities understand that the majority of persons with developmental disabilities can be treated in the dental office given a little preparation," she stated.
Nussbaum holds a similar opinion. He primarily treats pediatric patients with special needs that range from behavioral issues (for example, otherwise healthy kids who may have a fear of dentists or who have been traumatized in some other health care setting) to those young people with medical syndromes or who have been treated for complex medical concerns, such as cancer. These "over-doctored" patients may be resistant to or afraid of further treatment.
In his practice, patient evaluation begins with the first call. The receptionist determines the patient's unique health care situation and assigns an appropriate appointment time to match that individual's needs. This takes into account time to answer caregiver or family questions, as well as an opportunity to evaluate the patient and acclimate them to the operatory environment. First-time patients fill out a complex health history and intake form.
Nussbaum recently treated a 3-year-old who was preparing for his third open-heart surgery and had an abscessed tooth. "He needed somebody who was capable of treating him within a hospital environment," said Nussbaum, adding that some dentists do not feel comfortable going into that setting.
Some of Nussbaum's patients have been through as many as four dentists before coming to see him. To make these patients comfortable, Nussbaum adapts each appointment to suit what the patient needs. For example, in treating an individual with autism, Nussbaum has found that putting the patient under a lead apron during exam time offers a gentle, reassuring pressure. He sings to another patient to allay anxiety. In finding that unusual antidote, Nussbaum gauges the expectations of the parent or the caregiver.
"For some people, I come in before my regular office hours just to see them," Nussbaum said. "I don't want to be rushed."
The DDD in Hawaii recommend a similar approach. The treating dental office must obtain all necessary background information including physical, psychological and pharmacological considerations prior to the appointment. This may include consulting with the primary care physician, previous dentist, referring agency, psychologist, behaviorist, state case manager/social worker and parent and/or caregiver. Dental team members should get to know and utilize the resources of case managers in state programs for persons with developmental disabilities which exist in all states. These case managers can provide this valuable information and care coordination assistance to the dental team.
"Obtaining the 'whole' picture of the patient will increase the odds of a successful appointment," Ernst said, adding that it may be necessary to dedicate the first appointment to orienting the individual to the dental reception area and staff. The next appointment may be exploring the operatories and equipment.
"This desensitization process reduces anxiety and fear of new things that many individuals face. It may be necessary to re-think the medical model and go outside the dental office," Ernst continued. "Treating an individual in a setting where they are comfortable, in their home or day program, is an idea that is worth thoughtful consideration."
It is important for a dental team to create an environment of trust, she said. This is essential between at least one key dental team member involved in direct patient care. Desensitization should begin much earlier than the first appointment and can be started outside of the dental office.
Success will be assured if the patient has already demonstrated trust by allowing the dental hygienist, dental assistant or dentist to brush teeth without resistance before scheduling chair time. Seek out community providers of services for persons with developmental disabilities and offer an in-service training for families, their clients and staff, she said. Get to know the patient in their "natural" environment before meeting them in the dental office. This outreach can save chair time and is a marketing tool to other family members who need a new dentist.
She advised the dental hygienist who has an interest in treating patients with developmental and intellectual disabilities to contact his or her state's department of developmental disabilities, be willing to start slow, remain flexible and expect the unexpected. Ernst encouraged those clinicians to take online classes, read journal articles and attend conferences to expand their knowledge about different disabilities, specific oral health care needs and treatment recommendations.
What if the dental hygienist has an interest in expanding the services already provided in the practice to include holistic treatment or the treatment of patients with special needs? First, discuss with the dentist the extent of his or her interest in expanding services.
Ernst recommended that the dental hygienist discern with the dentist the type of disability with which they are most competent and comfortable treating. The practice will need to establish connections with patients' physicians, caregivers and state agencies. In addition, they will want to prepare scheduling accordingly and develop protocol for pre-visit preparation. It's a great step forward for improving access to care for these individuals.
It's a step Nussbaum supported.
"We're not doing anything magical. I just treat the kids like anybody else. It's just a matter of figuring out what it would take to [meet the patient's needs]," he said. He advised that practices consider the range of patients they could treat, from those with hearing or sight challenges and physical or intellectual disabilities, to those with complex medical problems. Make a plan in advance.
Nussbaum admitted frustration that other dentists don't see patients with special-care needs.
"Sometimes I feel we're the only game in town," he said. "More dentists could treat more patients. You can't blame people, but when a patient calls in pain with a toothache and has to wait for care, it gets frustrating."
Ernst commented that dentists need the support, confidence and willingness of staff to commit to providing care to these individuals.
"Dental hygienists are naturally caring individuals and recognize the importance of going the extra mile to help disadvantaged populations," she concluded. "The dental hygienist's training makes him or her the ideal person to help prepare the dentist and the patient for visits."
Nussbaum conceded that many dental hygienists are in a tough position as employees of the dentist and not partners in decision making.
"You are not going to get the dentist to do what they are not comfortable doing," he commented. "It's a lot easier to make a bleaching tray than to do an exam and a cleaning on a 250-pound person who has Down's syndrome."
Most people, Nussbaum asserted, can do something. "Most people can treat a lot of patients if they are willing to spend an extra couple of minutes. People who are difficult will need a specialist. People who aren't really difficult require extra time and some extra loving care."
Conclusion: Can the Holistic Approach Be Adopted into Traditional Practice?
Dental hygienists who have an interest in adopting any holistic practices need to seek the support of the rest of the dental team.
"Understand the type of practice you're working in," Davis said. "If the dentist you work with is supportive to new ideas or suggestions, move forward," she advised.
"Changes come in small steps. Just reading this article is one. I have learned so much in practicing dental hygiene for the past 17 years, and I continue to learn new things from my patients daily. They share with me books, thoughts and ideas," said Davis, who recommends that dental hygienists need to be more proactive about what types of products are not only going into their bodies, but what is going on them as well.
Davis encourages dental hygienists to take continuing education courses to learn more about holistic health practices, such as acupuncture, alternative dentistry and courses on systemic health.
"I attended an excellent course last year entitled, 'Nutritional Influences in Oral and Systemic Health' given by Dana Laake, RDH, LBN, sponsored by Sonicare," said Davis. Information she learned at the program enabled her to talk with patients about nutrient deficiencies caused by pharmaceuticals, such as statin drugs. Some of her patients were already aware of the problem and were impressed that their dental hygienist was current with their health issue. Others, who were not informed, were able to return to their cardiologists with informed and intelligent questions.
"Attending seminars is vital because as dental hygienists, we play an important role in our patient's health care," Davis stated. "We have patients we see on a regular basis who may not go to a doctor regularly. We can recommend and encourage them to seek out a physician's care, if needed. It's important for us to be aware of medications and supplements they are taking and the things that they do."
She shared as an example a patient who indicated on her health history that she was taking vitamins and supplements. Davis decided to inquire further. The patient was taking a fat-soluble vitamin that put her over the recommended safe limits for some vitamins and minerals.
"Our focus is to make people aware of the mind-body relationship," said Davis. "My patients laugh when I tell them, in regard to the old saying, 'Your body is a temple' that the mouth is the front door."
(1.) McGuire, T (2008) The poison in your teeth. Sebastapol, CA: The Dental Wellness Institute. Used by permission of the author.
Susan Elliott-Smith is a freelance writer in Chicago.
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|Date:||Jan 1, 2009|
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