Episode #634: Primary Care Dentist: The Changing Role Of Dentists In Healthcare, With Dr. Steven Carstensen

Dentists do more than clean and fix teeth. They are the entry point to healthcare for patients. To help you embrace your role in improving community health, Kirk Behrendt brings back Dr. Steven Carstensen, chief dental editor of Dental Sleep Practice Magazine, with advice for navigating the changing role of dentists in healthcare. Start giving patients the best care possible! To learn how, listen to Episode 634 of The Best Practices Show!

Episode Resources:

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Links Mentioned in This Episode:

Learn more at Dental Sleep Practice

Learn more about the American Academy of Physiological Medicine & Dentistry

Learn more about World Sleep Academy

Read Outlive by Peter Attia and Bill Gifford

Read Healthy Heart, Healthy Brain by Bradley Bale and Amy Doneen

Main Takeaways:

Practice the four Ps of medicine.

Dentists are the entry point to healthcare.

Be a curious, connected, resource-based dentist.

Reach out to physicians to collaborate on patient care.

Focus on whole-person health and evidence-informed care.

Quotes:

“I was reading something about P4 medicine. P4 medicine uses four different words. The four Ps are predictive, preventive, personalized, and participatory. Those are interesting words. What can I get from that? Well, I’ll explain them a little bit. Predictive is using big data. Preventive is using some biomedical innovations that we have, some ways we can gather information from patients. Preventive is what we would think of — it’s how do we use that data, and even different data like molecular data and blood data. And then, participatory is when we engage our patients. Well, great. How do you get across thoughts like that? You get across stuff like that and connect with people through story. So, when people tell you, ‘I’m concerned about this,’ or you notice something and you see it with new eyes, something that you learned at a recent course, something that you heard presented and you go, ‘Wow, how am I going to talk to that patient about these things?’ well, you can give them data. You can do a mini lecture there in the dental office. But really, what people listen to is story. What does it mean to them? What is their reality now? What’s new for them? What could be different?” (3:09—4:34)

“The four elements [Dr. Pankey] came up with were know yourself, know your patients, know your work, and apply your knowledge. Well, we think about these things. If you know yourself, you know that you’re not interested in being an average dentist. You want to be a curious dentist. You want to be a connected dentist. You want to be a resource-based dentist for your patients. You get to know your patients. Alone in medicine, dentists and dental hygienists and other dental professionals, we spend the time to get to know our patients better than anybody else. I was scheduled for a physician’s visit later on today. Twenty minutes is what I’m given. Well, nobody gets to know me in 20 minutes. It’s a brand-new doctor for me, at that point. But we see our patients over, and over, and over again, so we get to know them really well and we get to be curious and learn more about our profession. We learn more new things. We learn more about what impact we can have. We learn some more materials, those kinds of things. And then, we wrap all of that up and we apply our knowledge. We can’t just do that by a technique. We can’t do that with new materials. We have to do that with the other bases.” (4:48—6:01)

“You think about primary care. Primary — first. Right? Well, by definition, the U.S. association of family practice says a primary care practice serves as a patient’s entry point into the healthcare system. Okay. But how many people go to their primary care doctor as an entry point into the healthcare system? They really go there to complain about a problem. They come to the dentist because they want to enter into the healthcare system. So, we do that for them. And then, if we notice some issues, we can be another entry point.” (7:35—8:08)

“We are able to observe overall health. Now, we don’t have training that physicians have. We can’t listen to hearts or understand how the gut works. But we have some knowledge base about that, and when we see some things going south in the oral cavity, when we get the answers to curious questions on a health history and we pay attention to what they’re actually saying, and we look at their list of medications, for example, and we’re curious why they’re having to take that medication, that gives us a chance to get a view into their overall health and offer up some observations, and let them share with us their story. Maybe they’re frustrated with many undiagnosed problems or, ‘I don’t like taking these pills,’ and they don’t have a chance to share that with anybody else.” (8:13—9:03)

“There are really three ways to address the problem. If your patient has a problem and you want to help, you can do it. They can do it. If they can do self-care, then we can get them to breathe better. We can get them to exercise. We can get them to control the hole under their nose. Or someone else can do it. So, if we have a problem that we recognize, we get the patient engaged with that issue, they say, ‘I want a solution to this problem.’ Well, if we become a good community partner, then we are a resource of finding a connection for them to go somewhere else and get it done well with someone who thinks like us. Because if we send them to a narrow-based community health partner, a specialist of some type of primary care, and that narrow-based person can’t see what’s going on, then they’re going to do their expertise, but nothing else. If we send them to a curious, engaged community health partner, then we’re going to be able to have them reflect back the value of whole-person health. That way, you do it, they do it, somebody else does it. That concept helps create the best person possible because they don’t have just one pathway for health. They have all three pathways for health.” (10:16—11:36)

“The Census Bureau says there are 393 million Americans. There are 300,000 physicians out there that identify themselves as some kind of family practice, and there are 160,000 dentists. So, that’s not enough for what’s in our population, I guess. But if we’re going to address some things, then we have to add our skills to the overworked primary care doctors. We can’t solve it as dentists — we need the 300,000 primary care doctors as well. They need us because together we have almost 500,000 people paying attention to health. And underneath us, what do we have? Three, four, five team members? So, if somebody comes and sees you, and you’re curious about their blood pressure, you’re curious about their medication, you’re curious about supplements and lifestyle, well, you have to understand why you’re curious. Don’t just check a box on a health history and ignore it. Be wondering what’s going on. Well, you may not have time, as the doctor, to be able to make that conversation happen. So, your team has to be just as curious and know why they’re curious. So, it’s a great opportunity to engage your team with whole-person health and expect in your culture, in your office, ‘In this office, we pay attention to whole-person health.’ I’m echoing Mary Osborne here. ‘In this office, we want to make sure that what we offer you is more than just a tooth cleaning. We offer you the connection between that and how your heart is doing these days, and I notice you’re taking blood pressure medications. Can you tell me why you’re doing that?’” (12:34—14:19)

“[Dr. Peter Attia] writes about medicine in three different phases. Medicine 1.0, he calls it, is back in the day when they didn’t understand a lot of things — bloodletting and those kinds of days. Medicine 2.0 is what we all know. It’s evidence-based. It’s where we look at studies, and we look at research, and we think, ‘Okay, let’s make decisions based on that,’ which is really good until we come to the limitations of the individual person in the chair. And this is where it gets exciting because he talks about medicine 3.0 as evidence-informed, which means we are able to take the good evidence but use our brains and use our clinical wisdom and use our curiosity to meet the patient in the chair where they are. That means if they tell us a story that’s a little different than the evidence — you know, they weren’t participants in that study, so we can’t see them as that. But we can see them as the person who says, ‘Look, I tried that medication. I tried that treatment. I’m wondering what I’m going to do to not have a heart attack when I’m old.’ The things that are important to them, we can use the evidence to say, ‘Oh, let’s try it this way. Let’s go to this person. Have you thought about physical therapy? What about a myofunctional therapist? That might meet your needs,’ all the tools that we have available to us. And so, it’s evidence-informed, not necessarily limited to evidence-based. Not bad, not ignoring the evidence, but thinking about it as well.” (14:45—16:17)

“What they’re learning in science now is that what we have to do is a risk-based assessment. So, somebody can have a lot of apneas and hypopneas, but they don’t have much cardiovascular effect at all. They don’t have that gene that Bale and Doneen talk about. They don’t have problems with their heart. So, their cardiovascular risk is really low. But somebody can have a few events and have a brittle heart health issue, and their risk assessment is really high. So, instead of counting the numbers of events, they count the risk base. And so, they’re coming up with new ways to do that. It’s based around oxygen levels and things like this, which are really exciting. Well, if you’re going to be a primary care dentist and be involved with whole- person health, there’s nothing that prevents you from sending somebody home with an oximeter. We don’t have to test them for sleep apnea events. We can test them for risk-based oxygen level events, and there’s nothing about dentistry that prevents us from checking oxygen levels. So, what this might do is finally break open this logjam we have of getting people diagnosed for poor health based on breathing and oxygen levels through the nighttime. The thing that was defined 40 years ago, the thing that is keeping people unhealthy because they don’t recognize the problem, or they’re afraid of the solution, or they don’t want to do the test, if we have a simpler way to do that, now we can be better community health partners. And if they recognize that they have a problem, we might be able to decide that we can fix it. We might be able to say the patient can fix it by positional therapy or some other thing, or we might decide that somebody else needs to fix it by sending them off to the primary care physician or the ENT or the sleep doctor.” (18:41—20:31)

“Healthcare is going into ways of gathering data that we’ve never had before. Think about your Oura Ring, your Fitbit, your Apple Watch, whatever you use. That data is all going into a cloud. And so, scientists can use that cloud data to identify populations at risk in healthcare projections. As we are able to contemplate the impact or the importance of what we’re seeing, healthcare is going to have to address those issues. And the current models we have across the board aren’t going to be able to address some of those issues. That means that we have to recruit curious, trained, involved healthcare professionals to see what we can do to make community health better and early in life as possible. So, if we can identify a child, for example, who isn’t breathing correctly, isn’t growing correctly, isn’t developing the proper habits, then we can change their healthcare trajectory early in life, and maybe we don’t have all these 40, 50, and 60-year-olds with cardiovascular disease. That’s generational. But as we’re curious about it, as we’re able to see better and better ways of assessing people’s risk now, not numbers so much but risk, then we’re going to be able to engage patients on different levels, apply our knowledge at different parts of their lives. And as we know them better, we’ll be better and better doctors across the way.” (21:09—22:43)

“Start with your health history and look at it for the first time. Take a new, fresh pair of eyes at it and wonder why you’re asking these questions. Make sure you’re clear on that one. Sit down with your team. Go through that with them and see what they think the “why” is behind answering the questions and develop that culture. You’re going to find some of your team members are going to get very excited about being more important to your patients. And then, talk to your patients about that. When they check the box that, ‘I’m taking anti-hypertensives,’ ask them how they feel about it. That’s going to lead you into conversations that you’ve never had before. When you do that, you’re going to reach out and go, ‘Man, I’ve got to know more about this stuff.’ You’re going to get Outlive by Peter Attia. You’re going to listen to Bale and Doneen talk about heart health issues. You’re going to become a resource for your patients, and then you’re going to wonder, ‘What doctors are you seeing?’ and you’re going to call up those primary care doctors, and you’re going to go, ‘I want to help.’ And they’re looking for people to help them.” (23:20—24:26)

“There are primary care physicians out there that are looking for dentists that can be partners with them because they know they can’t do it all either. Of course, plenty of physicians think that all we do is fix teeth and clean teeth. But there are physicians out there that recognize that, ‘Look, there are a group of dentists out there that are really doing a better job and being better doctors.’ And when two good doctors get together, they provide great patient health options.” (24:41—25:13)

Snippets:

0:00 Introduction.

2:52 P4 medicine and the power of story.

4:34 P4 medicine and the Pankey philosophy.

7:04 Dentistry as the entry point to healthcare.

9:03 The benefit of a multidisciplinary approach.

12:29 Be curious and know why you’re curious.

14:21 Medicine 1.0, 2.0, and 3.0, explained.

16:17 Evidence-informed healthcare, explained.

20:33 Where healthcare is headed in the future.

22:53 Last thoughts.

24:28 Become a community resource.

25:21 More about Dr. Carstensen and how to get in touch.

Dr. Steve Carstensen Bio:

After Dr. Stephen Carstensen graduated from Baylor College of Dentistry in 1983, he and his wife, Midge, a dental hygienist, started a private practice of general dentistry in Texas before moving to native Seattle in 1990.

In 1996, he achieved a Fellowship in the Academy of General Dentists in recognition of over 3,000 hours of advanced education in dentistry, with an increasing amount of time in both practice and classwork devoted to sleep medicine. A lifelong educator himself, Dr. Carstensen is currently the Sleep Education Director for both The Pankey Institute and Spear Education, recognized as among the finest places for dentists to further their education. As a volunteer leader for the American Dental Association, he was a Program Chairman and General Chairman for the Annual Session, the biggest educational event the Association sponsors.

He is a Consultant to the American Dental Association for sleep-related breathing disorders and co-author of a textbook for dentists treating the disease.

For the American Academy of Dental Sleep Medicine, he’s been a Board Member, Secretary-Treasurer, and President-Elect. In 2006, he achieved Certification by the American Board of Dental Sleep Medicine.