A.StevensWrightson,M.D.MedicalDirector

BluegrassCommunityHealthCenterNovember13,2015

Objec&vesforPart1� Oralhealthaffectsoverallhealth� Medicalproviderhasamajorroleincaringfortheoralhealthoftheirpatients

� Whatismeantbyintegrationoforalhealthcareintoamedicalpractice

Objec&vesforPart2�  Discusstheetiologyofearlychildhoodcaries(ECC)�  Assessachild’sriskofdevelopingECC�  Performanappropriateoralexaminationonsmallchildren

�  RecognizethevariousstagesofECC�  Discusstheeffects,sources,benefits,andsafeuseoffluoride�  Describethebenefitsandindicationsforfluoridevarnish�  Demonstratetheapplicationoffluoridevarnish�  Describestrategiesforasuccessfuloffice-basedfluoridevarnish

program�  Adviseparentsoncariespreventionanddescribewhentoarrangedentalreferral

MyPa&ents

Pa&entMix�  15%<18�  80%18-64�  4%>65

�  46%Hispanic�  56%White�  12%AfricanAmerican�  2%Asian

�  37%Uninsured�  53%LEP

CalltoAc&on�  SurgeonGeneral’sReportin2000

� DentalCareisthemostcommonunmethealthneed� Oraldiseasecanseverelyaffectsystemichealth� Muchoraldiseaseispreventableoratleastcontrollable

�  Profounddisparitiesinoralhealthandaccesstocareexistforallages

MyIntroduc&ontoOralHealth�  In2001,HRSAcalledforthedevelopmentofcurriculaonoralhealthfornon-dentists,specificallyphysicians� UniversityofKentuckywasoneoftheinitialgrantees� DFCMpartneredwiththeDepartmentofPublicHealthDentistrytodevelopacurriculumcalledPOHEK,PhysicianOralHealthEducationinKentucky

OralHealthNeeds�  Childhoodcaries

�  Incidenceremainshigh,24%in1994,33%in2004,27%in2012�  Pain,poorschoolperformance,absenteeism�  Speechandlanguagedevelopmentproblems

�  Adultcaries�  25%ofyoungadultshaveuntreateddecay�  WorklossandcostlyERvisits�  Ultimatelychewingandnutritionrelatedissues

�  Periodontaldisease/Toothloss�  47%ofadultsdiagnosedwithmoderatetosevereperiodontaldisease�  Glycemiccontrolishinderedinpatientswithactiveoraldisease�  24%ofolderadultsareedentulous�  Associatedwithanincreaseinallcausemortality

�  Oralcancer�  Themajorityoforalcancersarestage3or4atdetection.�  5yearsurvivaldropsfrom83%to37%dependingonstage

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EarlyChildhoodCaries

Photos:DonaldGreinerDDSMS,JoannaDouglassBDSDDS

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Periodontaldisease

OralCancer

OralHealthDispari&es�  Children

�  30-50%oflowSESchildrenhaveECC�  80%ofthedecayisin20%ofchildren

�  Elderly�  43%oftheelderlyvisitthedentist�  70%lackdentalinsurance�  Poverty,lackofmobility,disabilityandinstitutionalizationall

contributetopooraccesstooralhealthcare�  Ruralandpoor

�  Geographicandeconomicbarrierstocare�  Minorities

�  HispanicsatallageshaveahigherrateofcariesandcariesexperiencecomparedtononHispanicwhites

�  SurvivalratesoforalcancerlowerinAfricanAmericanscomparedtowhites

Na&onalGoals�  HealthyPeople2000,2010,2020�  OralHealth:oneofthe12leadingindicators�  Goal

�  Preventandcontroloralandcraniofacialdiseases,conditions,andinjuries,andimproveaccesstopreventiveservicesanddentalcare

�  Thehealthofthemouthandsurroundingstructures…iscentraltoaperson’soverallhealthandwell-being

�  Conditionsaddressedinclude�  Caries�  Periodontaldisease�  Oralandpharyngealcancer�  Accesstocare

Na&onalGoals�  IOMreports2011

�  AdvancingOralHealthinAmerica�  ImprovingAccessforOralHealthfortheVulnerableandUnderserved�  Children�  Elderly�  Disabled�  Mentallyill

IOMreport:VisionforOralHealthCare�  ThecommitteeenvisionsoralhealthcareintheUnitedStatesinwhicheveryonehasaccesstoqualityoralhealthcareacrossthelifecycle.Tobesuccessful,anevidence-basedoralhealthsystemwill:�  Eliminatebarriersthatcontributetooralhealthdisparities�  Prioritizediseasepreventionandhealthpromotion�  Provideoralhealthservicesinavarietyofsettings�  Relyonadiverseandexpandedarrayofproviderswhoarecompetent,compensated,andauthorizedtoprovideevidence-basedcare

�  Includecollaborativeandmultidisciplinaryteamsworkingacrossthehealthcaresystem

�  Fostercontinuousimprovementandinnovation

IOMreport:VisionforOralHealthCare� Inaddition,thecommitteeestablishedtwoprinciplestoguideitsdeliberations:� Oralhealthisanintegralpartofoverallhealth,andtherefore,oralhealthcareisanessentialcomponentofcomprehensivehealthcare

� Oralhealthpromotionanddiseasepreventionareessentialtoanystrategiesaimedatimprovingaccesstocare

Dentalvisitinlast12months(Income/educa&on)

Dentalvisitinlast12months(Race)

OralHealthAccess� HP2020data(2007)

�  75%ofFQHCshadonsiteoralhealthservices�  Goal:83%

�  17%ofpatientsatFQHCreceivedoralhealthservices�  Goal:33.3%

� HP2020data(2012)�  76.5%withonsiteoralhealthservices

�  LookforexpansiongrantsfromHRSAsoon

�  20.5%ofpatientsreceivedoralhealthservices

WhyEngagePrimaryCare� Childrenareseeninaprimarycareprovider’soffice8-10timesormorebeforetheyseeadentist

� Patientsaremorelikelytobeabletoidentifyamedicalhomethanadentalhome

� Urgentdentalneeds,likeabscessesorfractures,areverylikelytobeseenbyamedicalproviderbeforethepatientseesadentist,especiallyforthosewithoutdentalinsurance

� Patientcenteredmedicalhome(PCMH)principlessupportintegrationoforalhealthservices

Na&onalGoals� HRSA:IntegrationofOralHealthandPrimaryCarePractice(2014)�  Creationofcoreclinicalcompetenciesformedicalproviders�  RiskAssessment�  OralHealthEvaluation�  PreventiveInterventions�  CommunicationandEducation�  InterprofessionalCollaborativePractice

�  Systemsanalysis�  Implementationstrategiesforchange

OralHealth:AnEssen&alComponentofPrimaryCare� Primarycareprovidersanddentistsmustworktogethertoaddresstheoralhealthneedsoftpatients.

�  “Thejobistoogreatforeitherdisciplinealone.”� Usingtheframeworkof“Ask,Look,Decide,Act,andDocument,”thispaperdescribesthemodelforintegratingoralhealthintoamedicalhome.

�  Inparticular,settingsthathaveembracedthePCMHstandardsaredescribedas“wellpositionedtoimplementtheFrameworkinfull.”

OralHealthDeliveryFramework

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OralHealthDeliveryFramework

OralHealthIntegra&on�  Ingredientsforsuccess

� Medicalprovidercommitment�  Culturethatvaluesoralhealth�  Integrationintoexistingpatientcareprocesses�  Teamleader/Champion�  Stafftraining� Datacollection�  ReferralSystem

�  OhioAssociationofCommunityHealthCenters�  EarlyChildhoodOralHealth(ECOH)

SmilesforLifeNa.onalOralHealthCurriculum:History�  2000-SurgeonGeneral’sReport�  2002-HRSAandprivategrants(CT,KY,TX,WA)�  2004-Development�  2005-1stEdition�  2006-Pregnancymodule�  2007-Varnishmodule�  2008-2ndEdition�  2009-CMEcredit�  2010-3rdEdition�  2011-GeriatricModule�  2012-OralHealthinMedicineDevelopmentAwards(AAMC)�  2013-EndorsedbytheAmericanDentalAssociation�  2014-EndorsedbytheNationalAssociationofCommunityHealthCenters

ThirdEdi.on

SmilesforLifeUsers

SmilesforLifeUserSurvey

SmilesforLifeU&liza&onbyState

OralHealthIntegra&onandthePa&ent-CenteredMedicalHome� Enhanceaccessandcontinuity� Team-basedcare� Populationhealthmanagement� Planandmanagecare� Trackandcoordinatecare� Measureandimproveperformance

Enhanceaccessandcon&nuity

�  Bringsoralhealthservicesintothemedicalhome:�  Education�  Screeningfororaldisease

andcorrelationwithsystemichealth

�  Fluoride�  Urgent/emergentcare�  Samedayaccess

Team-basedcare�  Oralhealthiswell-suitedtomedicalteamwork�  Patient/Empowerment�  Physicians�  PA’s�  APRN’s� MA’s�  Pharmacists�  Counselors�  Clerical

Popula&onhealthmanagement

Popula&onHealthManagement

� NorthCarolina�  IntotheMouthofBabes�  Trainsmedicalproviderstodeliverpreventiveoralhealthservicestohigh-riskchildrenwhoreceiveN.C.Medicaid.Servicesincludeoralevaluation,parent/caregivereducation,andfluoridevarnishapplication.ThegoalistoreducetheincidenceofearlychildhoodtoothdecayinNorthCarolina.TheproviderisreimbursedthroughN.C.Medicaid.

�  DatashowthatMedicaid-coveredchildrenreceivingtheprocedurehavefewercaries-relatedtreatmentsindentalofficesthanenrolledchildrennothavingIMBpreventiveservices.Childrenhaving4,5,or6IMBvisitsbeforetheir3rdbirthdayhavethemostbenefit.

USPreven&veServicesTaskForce�  TheUSPSTFrecommendsthatprimarycarecliniciansprescribeoralfluoridesupplementationstartingatage6monthsforchildrenwhosewatersupplyisdeficientinfluoride.Grade:Brecommendation.

�  TheUSPSTFrecommendsthatprimarycarecliniciansapplyfluoridevarnishtotheprimaryteethofallinfantsandchildrenstartingattheageofprimarytootheruption.Grade:Brecommendation.

�  May2014

Measureandimproveperformance� Plan,Do,Study,Act(PDSA)� Oralscreeningsperformed� Patientswhoreceivededucation� Childrenwhoreceivedvarnish� Pregnantpatientswithcompleteddentalreferrals� Diabeticpatientwhoreceiveoralhealtheducationaspartoftheircomprehensivecareplan

OralHealthDeliveryFramework

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Goal75%

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Pa&entCenteredHealthHome

Howtogetstarted?�  Startwiththebasics

�  LookatSmilesforLife�  Target

�  Children�  Diabetes�  Pregnancy

�  Gettoknowyourdentists(Critical!)�  Manypatientsbenefitfromcollaboration

�  Medicallycomplicated�  Thoseonanticoagulationtherapy�  Thosethatneedurgentoremergencyreferrals�  Aswellasyoungchildren,pregnantwomenandtheelderly

FinalThoughts� Oralhealthcanbeintegratedintothemedicalmanagementandcareofpatients

� ConsistentwithPCMHgoalsforpatient,staffandthecommunity

� Putthemouthbackintothebody!� Partnership,collaboration,andadvocacyareallrequired

� Changeisnecessarytoallowourpatients’healthstatustoimprove

Ques&ons??

ReferencesandResources�  Dye BA, et al. Trends in oral health status:US 1988-1994 and 1999-2004. National Center for

Health Statistics, Vital Health Statistics 11(2007)p. 248. �  Hardison JD, et al. The 2001 Kentucky children’s oral health survey: Findings for children ages

24 -59 months and their caregivers. Pediatric Dentistry 2003;25(4):365-72. �  Oral health of adults. Healthy People 2020, US Department of Health and Human Services.

2012.accessed at www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=32 on 7/28/15.

�  Mealy BL, Periodontal disease and diabetes: a two way street. Journal of the American Dental Association. 2006;137:26-31

�  Holmlund, A., et al. Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects: J-Periodontol 2006; 77(7): 1173-8.

�  US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institute of Health; 2000 accessed at www.nidcr.nih.gov/AboutNIDCR/SurgeonGeneral/.

ReferencesandResources�  Stein, P.S., Desrosiers, M., Donegan, S.J., Kryscio, R., Yepes, J. Tooth loss,

dementia, and neuropathology in the Nun Study. Journal of the American Dental Association 2007; 38:1314-22.

�  Brown DW. Complete edentulism prior to the age of 65 years is associated with all-cause mortality. J Public Health Dent 2009;69(4):260-266

�  U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

�  Office of Inspector General, Children’s dental services under Medicaid: access and utilization, San Francisco, Ca. US Department of Health and Human Services. 1996;OEI 09-93-00240 accessed 3/7/2013.

�  Manski, R.J. and Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and 2004. Rockville, MD; Agency for Healthcare Research and Quality; 2007. MEPS Chartbook No 17.

�  Wrightson AS, et al, Geriatric Oral Health. Smiles for Life: A National Oral Health Curriculum. 3rd edition. Society of teachers of Family Medicine. 2010. www.smilesforlifeoralhealth.com Accessed on 7/28/15.

�  Healthy People 2020 http://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Oral-Health/data Accessed on 7/28/15.

ReferencesandResources�  The Future of Patient-Centered Medical Homes Foundation for a Better Health Care System,

http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf

�  Clark MB, Douglass AB, Maier R, Deutchman M, Douglass JM, Gonsalves W, Silk H, Tysinger JW, Wrightson AS, Quinonez R. Smiles for Life: A National Oral Health Curriculum. 3rd Edition. Society of Teachers of Family Medicine. 2010. www.smilesforlifeoralhealth.com.

�  Integration of Oral Health and Primary Care Practice U.S. Department of Health and Human Services Health Resources and Services Administration February 2014

�  Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015.

�  Maxey H, Oral Health with Primary Care in Health Centers: Profiles of Five Innovative Models. National Association of Community Health Centers, 2015 http://www.nachc.com/client//Integration%20of%20Oral%20Health%20with%20Primary%20Care%20in%20Health%20Centers.pdf Accessed on 7/28/15.