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By Anne Blythe
Iquebal Hasan was nervous when he first informed his father that he wanted to become a dentist, not a doctor.
Medicine had coursed through the family’s veins, with 16 doctors in his extended family tree. His dad, an internist, had been a celebrated physician to governors and even an Iranian prime minister.
Worried he might disappoint his father, his hero, Hasan gingerly posed a question: What did he think about him pursuing a degree in dental surgery.
Dr. Anzar Hasan Ibrahimi quickly eased any qualms his son had about departing from the family’s well-trod path into medicine, telling the apprehensive teen he thought it was “an excellent idea.”
“I still remember his exact words,” Hasan recalled recently from his office at the East Carolina University School of Dental Medicine in Greenville.
As it turns out some 30 years later, Hasan’s path has not been so divergent after all, as he is one of a growing number of dentists highlighting the crucial connection between oral and systemic health.
A peek into someone’s mouth can reveal far more than whether that person is brushing or flossing regularly. It can open a window into what’s happening in the rest of their body.
Manifestations of heart disease, cancer, diabetes, autoimmune syndromes, gastrointestinal problems and certain viruses can show up in the oral cavity.
Bacteria and germs left unchecked in the gums and soft tissue can contribute to cardiovascular disease, endocarditis (an infection of the inner lining of the heart) and could even contribute to preterm births or low birth weights.
With this in mind, Hasan, an assistant professor in oral medicine, has been working with others to build bridges between dentists, hygienists, physicians and nurses across the state, an effort some describe as “bringing the mouth back into the body.”
It’s important, they say, as North Carolina looks for ways to close the disparity in oral health care access between the state’s urban and rural areas, a problem exacerbated by North Carolina’s lack of providers. The state ranks 47th in the country in the ratio of dentists per population.
“Oral health care has changed from the early 1980s until now,” Hasan said. “Now we have more complexities.”
People are living longer, bringing a wider range of age-related complications when they sit down in a dentist’s chair. In addition, dentists see more patients with high blood pressure, diabetes, HIV and auto-immune diseases.
If dentists are watching for such ailments and related symptoms, they can better shape in-house treatments and know when to refer patients to doctors for earlier diagnoses.
When physicians treat patients with radiation for head and neck cancers, they can suggest more frequent visits to the dentist afterward to help stem some of the side effects that can lead to tooth loss and other troubles.
Such an approach can ultimately save on overall health care costs by curbing the number of emergency room visits for patients seeking unexplained pain relief, as well as eliminate some long-distance travel to specialized clinics for people whose local dentists were either unwilling or not confident enough to take complex cases.
These bridge builders say the integration of oral health and primary care is necessary to make sure providers, insurers and the public don’t treat dentistry as a separate and unequal auxiliary service that fails to meet the needs of many.
Champion for whole-health approach
Since Hasan’s arrival in North Carolina three years ago, the 48-year-old has shared his enthusiasm for collaboration in talks at county dental society meetings, medical school forums and anywhere he is invited.
Next year, he is going back to Patna, the eastern Indian city on the southern bank of the Ganges River where he did undergraduate and professional schooling, to present a paper to the Indian Dental Association.
“He loves to talk,” said Heather Perry, a hygienist in the ECU clinic who works closely with Hasan. “He is super, super passionate.”
Perry has been so inspired by Hasan that she enrolled in the American Academy of Oral Medicine Academic Affiliate Fellowship.
She and Hasan know how looking into a mouth with a broader focus on the entire body has led to diagnoses that had either stymied or gone undetected by physicians.
Perry counts herself among those examples. Her mouth had been extraordinarily and inexplicably dry. As someone familiar with Sjogren’s syndrome, an autoimmune disorder that tennis great Venus Williams suffers from, Hasan persuaded Perry, his friend and teammate, to allow him to biopsy a salivary gland.
That revealed what he suspected, and because of Hasan’s interest in her overall health, a physician now helps Perry manage the disorder with immunosuppressants.
Perry was certain he might be able to help one of her patients, too, a woman who had grown so accustomed to lesions in her mouth, she changed her diet to keep from exacerbating the piercing pain.
The woman had pretty much had it with dentists poking around, trying, unsuccessfully to help her. She was reluctant to change her care team, but Perry kept nudging her toward Hasan.
The woman finally relented, and Hasan suggested injections instead of topical treatment for the lichen planus that can cause painful sores or lacy, white patches inside the mouth or on the tongue and lips.
The once-reluctant patient returned with a big smile, hugs and heaping praise.
“Her first sentence was, ‘I’m a Southern woman, I like my spicy food,’” Hasan recalled.
“She said … ‘I like to cook,’” Perry, his hygienist, continued, “and now I can eat what I cook.”
All in the family
Hasan was a teenager when he was visiting his father at a hospital in Saudi Arabia where he worked for a stint, mulling the possibility of following in his footsteps but also questioning whether he could live in the long shadow cast by the man he so admired.
There, Hasan witnessed an oral procedure that so wowed him he decided to focus his passion and professional life on teeth, gums and the oral cavity.
Hasan enrolled in a dental surgery program in Patna, India, where he also met his wife. Amna Hasan was raised as a Sikh in northwestern India. Hasan is from a Muslim family in northeastern India.
Their cultures were very different, but their interest in each other and dentistry created a lasting relationship that has produced two sons and a comfortable life in Greenville.
Amna Hasan is a clinical assistant professor at ECU, where she focuses on pain management related to the joints, muscles and nerves that control jaw movement, as well as new treatments for sleep apnea.
Their sons, a junior at ECU who took the Medical College Admission Test, or MCAT, in March, and a 10th grader who already talks about being a cardiothoracic surgeon, both seem poised to further extend the family’s legacy in integrated health care.
A professor and practitioner
Hasan said he would love to see more U.S. universities set up oral medicine residency programs like the one he went through at Carolinas Medical Center, where he spent three years in oral medicine and general practice. Currently, there are only six such programs in the U.S.
“If we want to be more forward in quality health care, I do believe we need more programs like this,” Hasan said.
In the ECU office, where he thinks about these things, the shelves are filled with thank you notes, photos and gifts from around the world that his students have brought him. In any given week, he might spend three afternoons teaching, a couple more seeing his own patients, juggling that all with work in the clinic and research.
He also squeezes in time on occasion for badminton, a sport he played for his state in India and has dedicated much of his backyard to a full-size court.
As he talked about his home life and work life, brimming with enthusiasm for both, Hasan said some people might be surprised to know that he once was a big motorcycle rider and hunter.
“I had a wild side,” he said.
But his compassion is what people remember. Perry says she has seen Hasan spend money from his own pocket to buy lozenges for patients who cannot afford them. He also works with students to organize fundraisers for pediatric cancer patients and others with special needs.
Hasan is on board with the state’s goal to get more dentists in the rural areas, and he hopes an integral part of any plan is to support the bridge being developed between oral health and primary care. It’s important, Hasan says, for North Carolina’s dental schools to develop programs with such goals in mind.
“We talk about educating competent dentists in every county in the state,” Hasan said. “But we also need to train them clinically how to manage these populations with more complexities. I think ECU and UNC have an opportunity to be leaders and provide a model for the rest of the country.”