Dentistry in the hospital: A Q&A

Photo of Dyani Gaudilliere (right) in OR; by Vladimir Nekhendzy

In the U.S., medicine and dentistry are separate — they typically have different insurance systems, training regimes and workplaces. So I was intrigued when I heard about hospital dentists. To learn more about what they do, I spoke with Dyani Gaudilliere, DMD, a clinical assistant professor of surgery and chief of the dental section at Stanford.

Why did you choose to combine dentistry with medicine?

“I started on the path towards dentistry in my teens, planning to become an orthodontist. I became increasingly interested in public health, with the goal of treating underserved populations.

At my dental school (Harvard), the dental and medical school courses were combined for the first two years with the goal of fostering a more integrated approach to dentistry, which prepared me well for my current work.

The split between medicine and dentistry is, in fact, completely artificial. The bacterial diseases of the teeth and gingiva affect the entire immune system and can cause serious systemic consequences. In addition, many systemic diseases and medications have oral manifestations.”

What do you do at Stanford?

“The majority of our patients at Stanford are being treated for cancer, organ transplantation, cardiac disease or joint replacement. Our goal is to rid these patients of bacterial disease in their teeth and gums prior to their treatments. It may be risky to treat them outside the hospital, without access to the their full medical records or emergency services. Lack of dental insurance can also be a barrier for patients whose chronic disease prevents them from being employed.”

Can you tell me more about your patients?

“One large category of patients we see are those with cancer of the head and neck. Targeted radiation to this area and chemotherapy have serious long-term side effects, ranging from dry mouth resulting in rampant tooth decay to severe jaw infections. For this reason, we perform dental examination and patient education prior to these treatments. We also partner with the head and neck surgeons to remove infected teeth during their cancer resection surgery. And we create special oral positioning devices to aid the radiation oncologists in spacing and immobilizing the tissues during radiation therapy.

We also see patients before medical treatments that will leave them immunocompromised, such as chemotherapy or organ transplantation. Chronic tooth or gum infections can suddenly become life threatening in a patient who is immunocompromised.

A third example is trauma. It is common for patients to get in minor bike accidents and fly right over their handlebars onto their teeth. We see these patients in the emergency department urgently in order to put the teeth and supporting bone back into place and then stabilize them with cemented splints.”

Are there many hospital dentists?

“I believe there isn’t enough awareness of the medical necessity of dental care, nor are there enough hospital dentists. Some hospitals are lucky to be affiliated with dental schools, whereas most have no in-house or emergency dental team at all. We regularly receive patients transferred from outside hospitals with large infections or oral trauma, because these hospitals didn’t have anybody with the right expertise to treat the conditions.

There are a lot of barriers we need to cross in order to fully integrate dentistry and medicine, but I think this integration is way overdue.”

What is your view on the separation between dentistry and medicine?

“The reason for the separation seems to be a combination of history and politics. Tooth extractions and other surgeries were historically performed by barber-surgeons rather than physicians, and oral care developed as a separate track from care of literally every other part of the body. Fast forward to today and you have dentists lobbying to sustain this separation in order to spare their profession from the regulations and changes occurring in the medical care world.

The idea that dentists would not need medical knowledge is laughable considering how much surgery they perform. Dentists who don’t understand medications and their mechanisms would not last long after their patient on blood thinners loses pints of blood after an extraction.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Advertisements

Genetic counselor offers insights on testing for inherited heart conditions

Illustration by waldryano
Illustration by waldryano

Genetic tests are now available for many conditions — everything from Alzheimer’s to familial hypercholesterolemia. But genetic testing isn’t necessarily the best option for everyone, and some of the tests aren’t highly accurate yet.

However, clinicians agree that genetic testing is important for people with hereditary heart conditions in their families. That’s why Stanford created the Stanford Center for Inherited Cardiovascular Disease, which specializes in caring for patients and their families with genetic disorders of the heart and blood vessels. Genetic counseling is a key part of the center, so I spoke with Colleen Caleshu, MSc, their lead genetic counselor to learn more.

What inspired you to become a genetic counselor?

“When I was in college, I was very interested in the science and molecular basis of disease. I was considering a PhD in genetics, but I was also drawn to peer counseling and psychology courses. When I looked at genetic counseling programs, they required an unusual combination of science and humanities such as psychology, ethics, genetics and biochemistry. Before going to graduate school, I spent a year with a research team that focuses on the psychological impact of familial breast cancer risk — that experience solidified that genetic counseling was what I wanted to do. For me, it comes down to a combination of loving the science and being intellectually challenged by a field that is moving really quickly, while also really being able to help people.”

What cardiovascular diseases does genetic testing identify?

“Genetic testing isn’t yet useful for all diseases or for all people. For cardiology, we recommend genetic testing when a patient is diagnosed with an inherited disease. The two most common inherited cardiac diseases are familial hypercholesterolemia and hypertrophic cardiomyopathy. We also care for patients with several other inherited heart muscle, arrhythmia and aorta diseases. If you put all of these genetic cardiac diseases together, greater than one in a 100 people have one in their genes.”

What is a typical genetic counseling appointment like?

“The clinic appointment is about an hour long. It involves establishing a relationship with the patient and their family to understand: Who are they? What are they experiencing? What are their values? What do they most need help with right now? Then we often shift to the medical side of things with a comprehensive four-generation family history. This involves a lot of detective work with the patient and afterwards — calling family members and searching medical records, death certificates and autopsy reports. The rest of the visit is a mixture of medical and genetics education, as well as psychological counseling. All medical conditions can have a psychological impact, but the genetic nature of these diseases mean they can strike healthy people at an unusually early age compared to most heart diseases. And they have reproductive and family planning implications.

Our genetic counselors also function within a broader, multidisciplinary team, including a cardiologist who gives his assessment, diagnosis and management recommendations. And all of this is based on a separate, hour-long intake appointment with a nurse that happens prior to the clinic appointment. “

How can genetic counseling help?

“Genetic counseling definitely benefits both the patient and the patient’s family — by helping them cope better with the familial heart condition and by helping healthy family members get the necessary medical workup and tests.

For example, a patient came to us a few years ago after being diagnosed with hypertrophic cardiomyopathy. Several generations of his family had the disease, and two of his siblings died suddenly from it a few years apart. He was really wrestling with whether or not to get an implanted defibrillator. He came to our center to get everything we offer.

We had several visits with him and his family members. At one point we had more than 10 family members in the room — the patient, siblings, nieces and nephews — grappling with a lot of pain and grief. We provided grief counseling and we addressed what it meant medically and psychologically for each family member. Using genetic testing, we were able to identify a disease-causing genetic variant in the original patient and his family. By proactively checking the heart of other family members, we were also able to diagnose people who didn’t know they had the disease — including members who went on to get implanted defibrillators to protect them from sudden death. Genetic counseling can absolutely save lives.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Looking beyond life as a bioscience university professor

Photo by Vic
Photo by Vic

Life as a tenured university professor seems idyllic with its job security, intellectual freedom, prestige, livable wage and flexible schedule. No wonder so many bioscience students aim to become professors.

But numerous factors, including a lack of available faculty positions, are making bioscience trainees consider other careers. That’s been the experience for Scott Carlson, PhD, a Stanford postdoctoral research fellow in biology, who recently told me:

“My dream job is a baffling question right now. When I started as a postdoc, I would have said my dream job was to be a professor at a program in interdisciplinary biology or bioengineering. After five years as a postdoc, I’m not sure anymore but I don’t know what to replace it with. Academia makes it impossible to explore other options. If I leave, my grants would disappear and it would be hard to get back in without recent publications.”

Carlson isn’t alone. It’s increasingly difficult to secure a spot as a tenure-track faculty member, even for those who spend years conducting research first as a student and then as a postdoc. According to the National Institutes of Health’s 2012 Biomedical Workforce Working Group Report, “Although the vast majority of people holding biomedical PhDs are employed (i.e., unemployment is very low), the proportion of PhDs that move into tenured or tenure-track faculty positions has declined from ~34 percent in 1993 to ~26 percent today.”

This decline in bioscience faculty positions is correlated with funding difficulties. For example, the success rate of researchers applying for new NIH grants dropped from 28.2 percent in 2000 to 16.3 percent in 2015, and the success rate for grant renewals dropped from 52.7 percent to 28.6 percent for the same years. In addition, grants tend to go to established investigators, making it even more difficult for postdocs or new professors to secure funding.

One solution proposed by the NIH working group is to change graduate training so it is no longer “aimed almost exclusively at preparing people for academic research positions.”

Stephanie Eberle, director of the Stanford School of Medicine Career Center, works with students, MDs, PhDs and postdocs from all the biosciences. She agreed that it’s time to “revisit the value of graduate education” and added:

“It isn’t just for an academic job, and it hasn’t been for a long time. We need to allow our trainees to explore other options while they’re here. For instance, we offer some biotechnology business and finance classes at Stanford. Improving our trainees’ business skills improves their chances in any career, academia included, by helping them stand out in a competitive market.”

However, Eberle and Carlson both acknowledged that this requires a change in culture. “There’s little direct pressure from colleagues, but there’s a strong implicit feeling that an academic career is somehow the most successful or prestigious career path,” said Carlson. “I didn’t get this sense as much when I was doing my PhD in bioengineering, but it’s pervasive in biology. I think it’s a big problem in academic culture and a huge disservice to the trainees.”

Eberle concluded:

“Most faculty assume all the students intend to go into academia, but some of our students don’t even want to go into academia in the first place. People aren’t talking and they’re making assumptions — that’s a problem. My charge is to help support our trainees’ combined academic, professional and career development. We need to help them find the career that fits them best.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.