The Integrated Dental Medicine Model for Diabetic Care

Evaluation of the Integrated Dental Medicine Care ModelDr. Sean G. BoynesDirector of Dental MedicineCareSouth CarolinaSociety Hill, South CarolinaTriple combination of anesthetic agentsEfficient onset of (soft tissue) anesthesiaEffective duration of action

Cetacaine

2Why choose Cetacaine?Think articaine/lidocaine then marcaineCetacaine brand local anesthetic products use a unique triple combination of local anesthetic agents which efficiently produce a rapid onset and long duration of anesthesia in soft tissue / mucous membranes.

2Microcapillary tip facilitates subgingival delivery

Pleasant artificial banana flavor

0.1 ml0.4 ml

Topical Subgingival Application3The delivery system allows the clinician to use only as much product as needed, up to the maximum dose of 0.4ml. (full syringe)

Estimating 0.1 ml to be sufficient per quadrant, the 30 g bottle is enough to treat up to 300 quadrants.

Microcapillary tip facilitates subgingival delivery

The anesthetic has a pleasant artificial banana flavor.3Cetacaine Chairside vs oraqix Onset TimeDuration of Action# ApplicationsCost30 secs20 mins20119.9930 secs30-60 mins2079.99

Bolded text indicates a feature superior to oraqix

When you compare it to a leading competitor, while both products have an onset time of 30 secs, Cetacaine provides a longer duration, less waste, and a palatal flavor at significantly less cost per quadrant.

4Integrated Dental MedicineIs based in the fact that oral health is a vital aspect to overall systemic well beingA partnership between all health care providers that identifies and creates a care structure with the areas of overlap that can improve the patient experienceSets goals to improve both oral and systemic outcomesIntegrated Dental MedicineSystemic Treatment with Dental CareImproving oral health with medical communicationCreating opportunitiesMedicine providing preventive dental careSystemic Treatment with Dental MedicineDiabetesCardiovascular DiseaseStroke InterventionHIV/AIDSBehavior Health (Opportunity)Diabetes Oral Health ConnectionOral Health Complications of DiabetesTooth lossOral painExtensive Periodontal DiseaseCoronal and root cariesSoft tissue pathologiesDecrease in salivary functionDiabetes Oral Health ConnectionMedical and oral health inter-relationshipsGlycemic controlNeuropathyNephropathyRetinopathyCardiovascular disease

Diabetes impact on oral health

Salivary Flow Rate (Xerostomia)Saliva not only begins the digestive process; it protects teeth by preventing decay, regulating your mouth's acidity level and keeping bacteria in your mouth from running rampant.But when saliva's lacking, plaque builds, enamel erodes, cavities quickly form and fungal growth runs rampant

Salivary Flow Rate (Xerostomia)Diabetes and Dry MouthPrevalence of dry-mouth symptoms (xerostomia), Prevalence of hyposalivation Possible interrelationships between salivary dysfunction and diabetic complications. Self Report XerostomiaDoes your mouth usually feel dry?Do you regularly do things to keep your mouth moist?FOX QUESTIONNAIREDo you have to sip liquids to aid in swallowing foods?Does your mouth feel dry when eating a meal?Do you have difficulties swallowing dry foods?Does the amount of saliva in your mouth seem too little?Moore PA, et al. Type 1 diabetes mellitus, xerostomia, and salivary flow. Oral Surg, Oral Med, Oral Pathol, Oral Radio, Endod. 2001; 92:281-91.Self Report Xerostomia Diabetes Subjects Control Subjects

Does your mouth usually feel dry? (MOUTH DRY?) 15.8%10.3% p = 0.047

Do you regularly do things to keep your mouth moist?20.2% 14.1% p = 0.058 Fox Questionnaire:24.1% 17.6% p = 0.045 Salivary Flow Rate Measures Diabetes Subjects Control SubjectsResting Salivary Flow Rate (ml/min)0.22 + 0.0140.28 + 0.016 p = 0.045 Stimulated Salivary Flow Rate (ml/min) 0.89 + 0.0471.02 + 0.054 p = 0.071 Moore PA, et al. Type 1 diabetes mellitus, xerostomia, and salivary flow. Oral Surg, Oral Med, Oral Pathol, Oral Radio, Endod. 2001; 92:281-91.CONCLUSIONSHyposalivation and xerostomia were significant oral complications in type 1 diabetic patients. Xerostomia was frequently associated with more frequent snacking behaviors and with the current use of cigarettes. Higher rates of dental decay were found among diabetic subjects having low resting salivary flow rates. Elevated fasting blood glucose concentrations were associated with significant reductions in resting salivary flow rates.Loss of salivary amylase! Amylase produced in pancreas putting more pressure on the organ; decreases tastefulness Periodontal Disease

Periodontal DiseaseAccording to the Centers for Disease Control, over 47% of adults over 30 years of age have some form of periodontal disease (gum disease)Periodontal disease is more common in men, people living at or below federal poverty, those with less than a high school diploma and current smokersSome research suggests that people with periodontal disease were more likely to develop heart disease or have difficulty controlling blood sugar*

*National Institute of Dental and Craniofacial ResearchDiabetes and Periodontal DiseaseStrong and growing evidence points to an association between diabetes and periodontal diseaseOne third of patients with diabetes have oral complications, mainly periodontitis and tooth lossLarge body of evidence shows that periodontal disease is a complication of diabetes mellitusPeriodontal disease. Is more severe in individuals with diabetes, especially those with poor controlGuggenheimer J, et al. Insulin dependent diabetes mellitus and oral soft tissue pathologies. Part 1: prevalence and characteristics of non candida lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89:563-69.Grossi SG et al. Assessement of risk for periodontal disease. Risk indicators for attachment loss. J Periodontol. 1994; 65:260-67.Khader YS et al. Periodontal status of diabetics compared with nondiabeteics: a meta analysis. J Diabetes Complications. 2006; 20:59-68.Oral health impact on diabetesDentistry influencing systemic well being

Oral Health - DiabetesA national focus in recent yearsSurgeon Generals report, Oral Health in America, emphasized the need to better understand the correlation between systemic and oral diseaseReported oral health complications associated with diabetesPoor Glycemic ControlExpanding body of literature implicating severe periodontitis as a risk for poor glycemic controlPeriodontal treatment in individuals with diabetes can improve glycemic controlLeading to a reduction of the effects of diabetesMoore PA. The diabetes-oral health connection. Compend. 2002; 23:14-20.Taylor GW et al. Periodontal disease: asscoiations with diabetes, glycemic control and complications. Oral Dis. 2008; 14:191-203.Darre L et al. Efficacy of periodontal treatment on glycemic control in diabetic patients: a meta-analysis of interventional studies. Diabetes Metab. 2008; 34:497-506.Poor Glycemic ControlRemove all the teeth?!?!?![Edentulous] Periodontal disease and subsequent tooth loss significantly impact overall health by compromising a patients ability to maintain a healthy diet and proper glycemic control.Edentulous participants consumed fewer vegetables, less fiber and carotene, and more cholesterol, saturated fat and calories than participants with 25 or more teeth.Joshipura KJ, Willett WC, Douglas CW. The impact of edentulousness on food and nutrient intake. J Am Dent Assoc. 1996; 127:459-467.Poor Glycemic Control[Edentulous] University of Pittsburgh study found that diabetic participants who had partial tooth loss or who were edentulous were generally older, had lower incomes and education and had higher rates of nephropathy, neuropathy, retinopathy, and peripheral vascular disease.Moore PA. The diabetes-oral health connection. Compend. 2002; 23:14-20.Poor Glycemic ControlLandmark Study Pima Indian Tribe (Az)Effective treatment of periodontal infection and reduction of periodontal inflammation is associated with a reduction in level of glycated hemoglobin. In addition, at 3 months, significant reductions (P 0.04) in mean HbAlc reaching nearly 10% from the pretreatment value.Control of periodontal infections should thus be an important part of the overall management of diabetes mellitus patients.Grossi SG. Treatment of Periodontal Disease in Diabetics Reduces Glycated Hemoglobin. J Periodontol 1997;68:713719.Poor Glycemic ControlStewart et al. statistical review of study suggests that periodontal therapy was associated with improved glycemic control in persons with type 2 DM.During the nine-month observation period, there was a 6.7% improvement in glycemic control in the control group when compared to a 17.1% improvement in the treatment group, a statistically significant difference.Stewart JE, et al. The effect of periodontal treatment on glycemic control in patients with type 2 diabetes mellitus. J Clin Periodont. 2001; 28:306-10.CSC Oral Health Diabetes Clinic

Year TwoIntegrated Dental Medicine

Oral examinationOral health educationAppropriate referral for careMedical RoleOral ExaminationCaries identificationSurface caries easily identifiableIncipient decay harder to identify but more important with preventive strategiesGum diseaseGingivitis vs. periodontal diseaseCaries/Cavities

Caries/Cavities

Periodontal DiseaseRather than a single disease entity, periodontal disease is a combination of multiple disease processes that share a common clinical manifestation.The etiology includes both local and systemic factors.The disease consists of a chronic inflammation associated with loss of alveolar bone.Advanced disease features include pus and exudates [infection more difficult to anesthetize].Page RC, et al. Pathogenesis of inflammatory periodontal disease. A summary of current work. Lab. Invest. 1976; 34 (3): 23549.Periodontal Disease

Diabetes and Severe Tooth PainPatients less likely to eat full meal or eat at all with oral painHowever, patients will take regular dosage of insulin, metformin, etcHypoglycemia is the most common diabetic emergency in dental officesSeen with some regularity in large dental, especially clinics with emergency schedulesHaas DA. Management of medical emergencies in the dental office: conditions in each country, the extent of treatment by the dentist. Anesth Prog 2006; 53:20-24.Mealey BL. Diabetic emergencies in the dental office. Armenian Medical Network. http://www.health.am/db/diabetic-emergencies/ Diabetes and Severe Tooth PainNew hypothesis being examinedChronic severe oral pain may effect A1Cs / Daily BGLack of appropriate diet with same medicinal management Possible increase risk with cardiovascular issuesPatients with A1Cs lower than 6% have increased cardiovascular issues/eventsxDietary changes may occur: a diet in higher saturated fat and bad calories (convenience food)X- Calayco DC et al. A1C and cardiovascular outcomes in type 2 diabetes. Diabetes Care 2011; 34:177-183. ReferralDifferent aspectsSee immediatelySee this weekNormal appointment

ASK THE PATIENT:MUST BE SEEN TODAY!See tomorrow or this weekSee when availableOn a scale of 1 to 10 how badly are you hurting?Pain level 7 to 10Pain level 4 to 6

Pain level 3 or below

How long have you been hurting?This level for a week or less

This level of pain for a month or less

Had these symptoms for over a month

Describe the type of pain or discomfort you feel.Throbbing

Broken tooth, lost a filling

Chip tooth, broken filling

How are you sleeping at night?Keeps me awake at night

Able to sleep with medication

Able to sleep

What occurred to make the tooth begin to hurt?Unknown or bit down on something hard

Bit down on something or other cause

Sweets; candy causes it to hurt

Have you noticed any other symptoms?Fever and swelling

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Two or more checkmarks in this section results in the patient needing to be seen today.Three or more checkmarks results in patient needing appointment this weekThree or more checkmarks results in the patient being given the next available standard appointment timePatient Name: _____________________________________Date:_____________________Last Dental Visit: ________________________Location of Pain: Bottom left, Bottom right, Top left, Top rightPatient Address: _____________________________________ Contact Number: ____________________________________A1C>9 =STWDental Role

Periodontal disease as a predictorConflicting data; HOWEVER,Studies have demonstrated that it is an early complication of diabetesPre-existing periodontitis predicts poor cardiovascular and renal outcomesLalla E, et al. Diabetes related parameters and periodontal conditions in children. J Periodontal Res. 2007; 42:345-49Seremi A, et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care. 2005; 28:27-32.Shultis WA, et al. Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. Diabetes Care. 2007; 30:306-11.

Dental-Medical ScreeningIndividuals tend to seek routine and preventive oral care more frequently than routine and preventive medical careGlick M. The potential role of dentists in identifying patients risk of experiencing coronary heart disease events. J Am Dent Assoc. 2005; 136:1541-46.Dental-Medical ScreeningAnalysis of the NHANES revealed that an algorithm using simple periodontal measures, available only in dental settings, and risk factors known by patients may offer an unrealized opportunity to identify undiagnosed individuals.Finding supported by two other retrospective studies.Borrell LN, et al. Diabetes in the dental office: using NHANES III to estimate the probability of undiagnosed disease. J Periodontal Res 2007; 22:559-565.Li S, et al. Development of clinical guideline to predict undaignosed diabetes in dental patients. J Am Dent Assoc. 2011; 142:28-37.Stauss SM, et al. The dental office visit as a potential opportunity for diabetes screening: an analysis using NHANES 2003-2004 data. J Public health Dent 2010; 70:156-162.Lalla E, et al. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res 2011; 90:855-860Dental-Medical ScreeningScreening/Identification protocol reflects a clinical approach that can be easily used in all dental care settingsDentists are willing to incorporate screening for medical conditions into their practicesA national, random sample of U.S. general dentists was surveyed by mail by means of an anonymous questionnaireRespondents were willing to refer patients for consultation with physicians (96.4 percent), collect oral fluids for salivary diagnostics (87.7 percent), conduct medical screenings that yield immediate results (83.4 percent) and collect blood via finger stick (55.9 percent). Greenberg BL, et al. Dentists attitudes toward chairside screening for medical conditions. J Am Dent Assoc. 2010; 141:52-62.Integrated ModelCost EffectiveJeffcoat et al. found that $10, 672 was spent for medical care for patients with diabetes who did not have periodontal treatment.Revealed an average reduction of approx. $2,500 (23%) in cost per year of those with periodontal treatmentDental care estimated cost of standard fees (CSC)$463.00 Barriers to Diabetic Health PromotionDiabetic PatientsIncome, employment, and costTime priorities Dental-Medical StudentsFocus on requirements and clinical skillsPatient treatment versus Patient managementSurgeons mentality / Drill and FillDentist PractitionersCurrent knowledge and access to informationEconomics of dental practicePhysiciansCoordination of medical and dental careRelevance to medical management and complicationsRegulation/Accreditation AgenciesCounter ProductiveCounter Intuitive

Cardiovascular Disease

ASVD and Periodontal DiseaseA link between oral health and cardiovascular disease has been proposed for the greater part of the last century. Recently, concern about possible links between periodontal disease (PD) and atherosclerotic vascular disease (ASVD) has intensified This is driving an active field of investigation into possible association and causality. ASVD and Periodontal DiseaseBoth processes share several common risk factors, including cigarette smoking, age, and diabetes mellitus. Patients and providers are increasingly presented with claims that PD treatment strategies offer ASVD protection; these claims are often endorsed by professional and industrial stakeholders.

Lockhart et al. American Heart Association, April 18, 2012.Available data indicate a general trend toward a periodontal treatmentinduced suppression of systemic inflammation and improvement of noninvasive markers of ASVD and endothelial function. HOWEVER, The effects of PD therapy on specific inflammatory markers are not consistent across studies, and their sustainability over time has not been established convincingly.Lockhart et al. Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association? : A Scientific Statement From the American Heart Association, April 2012. http://circ.ahajournals.org/content/early/2012/04/18/CIR.0b013e31825719f3.long Lockhart et al. (AHA)HOWEVER, This review highlights significant gaps in our scientific understanding of the interaction of oral health and ASVD.HOWEVER, Identification of clinically relevant aspects of their association or therapeutic strategies that might improve the recognition or therapy of ASVD in patients with PD would require further study in well-designed controlled interventional studies.Oral Health and Stroke

Periodontal Disease and StrokePost hoc analysis of prospective longitudinal studies and smaller case control studies have reported the association between periodontal disease and strokeEarly studies demonstrated that periodontal disease appears to bear a stronger association with stroke than with coronary artery disease.Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol. 2003;8:38-53.Beck JD, Offenbacher S. Systemic effects of periodontitis: epidemiology of periodontal disease and cardiovascular disease. J Periodontol 2005;76:2089-2100.Periodontal Disease and StrokeIn a combined analysis of two prospective studies, periodontal disease was found to increase the risk of incident stroke nearly three fold.Proposed mechanisms include inflammation mediated pro-coagulant state, atherosclerosis mediated by direct microbial invasion of blood vessel wall, and interaction with recognized vascular risk factors.Janket et al. Meta analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95:559-569. Periodontal Disease and StrokeSeveral studies have also reported a major positive association between periodontal disease and ischemic stroke, in stroke free patient populations.A new study completed at the Univ. of South Carolina also found periodontal disease is independently associated with recurrent vascular events in stroke/TIA patients and aortic arch thicknessSim SJ et al. Periodontitis and the risk for non fatal stroke in Korean adults. J Periodontol 2008;79:1652-1658.Grau AJ et al. Common infections and risk of stroke. Nat Rev Neurol 2010; 6:681-694.Oral Health and StrokeRegular dental examinations allow for early detection and treatment of oral conditions associated with the risk of further vascular events. Loss of teeth or masticatory function is associated with poor compliance of home health care in stroke patients.Less than half of stroke survivors in the United States received dental care, leaving substantial room for improvement. Stroke survivors need education about the importance of regular dental care, particularly minority groups.

Sanossian N, et al. Subpar utilization of dental care among Americans with a history of stroke. J Stroke Cerebrovasc Dis. 2011 May-Jun;20(3):255-9. Epub 2010 Jul 24.

The Dental Intervention Model for Stroke PreventionA true controlled dental intervention study for stroke prevention is not availableCurrently in the early stages of research and development. A handful of studies reveal:Women may have better benefit than men.1Quality of life can be maintained if poor oral health is reduced through better daily oral hygiene practices, education, and professional maintenance.2The effects of healthy teeth in the prevention of stroke and cardiovascular disease appear to be quite compelling.3Brown TT, et al. The effect of dental care on cardiovascular disease outcomes: an application of instrumental variables in the presence of heterogeneity and self-selection. Health Econ 2011;20(10):1241-56. Tran P and Mannen J. Improving oral healthcare: improving the quality of life for patients after a stroke. Spec Care Dentist. 2009 Sep-Oct;29(5):218-21.Bernal-Pacheco O, Romn GC. Environmental vascular risk factors: new perspectives for stroke prevention. J Neurol Sci. 2007 Nov 15;262(1-2):60-70. Epub 2007 Jul 25.HIV/AIDS

HIV/AIDSOral examinations are an essential component for early recognition of disease progression and comprehensive evaluation of HIV-infected patients. Correlation between CD4 count and oral manifestationsGlick M et al. Oral manifestations associated with HIV related disease as markers for immune suppression and AIDS. OOO 1994; 77:344-349.

Oral Infection and HIV/AIDSOdontogenic abscess are known to progress and disseminate with immunosuppressionLinked with advanced HIVCan lead to brain abscessIssue with emergency room treatment and no dental follow up / interventionMay require longer antibiotic cycle following extractionPatient specificIncrease risk of dry socketSome success with SOCKIT oral gelShould be stressed to patients: the issues with oral health and the need to report any oral painWalsh LJ. Serious complications of endodontic infections: some cautionary tales. Australian Dent J 1997; 42:156-159.Twomey CR. Brain abscess: an update. J Neurosci Nurs 1992; 24:34-39.Happonen R. Periapical actinomycosis: a follow up study of 16 surgically treated cases. Endod Dent Traumatol 1986; 2:205-206.SOCKIT Oral GelSockIt! is a hydrogel wound dressing for management of any and all oral wounds. Providing fast, constant pain relief without causing a numb sensation; Protecting from chemical and microbial contamination; and Promoting optimal wound healing.

Pain Management-SOCKIT

Kennedy et al. Gen Dent 2009;57:420-427.

Behavioral Health

Depression and Oral HealthTMJ IssuesPatients diagnosed with TMJ/myofascial pain and other joint conditions had significantly higher levels of depression and somatizationWhen treating patients with facial pain, dentists should consider the possible presence of psychopathology and, if necessary, consult appropriate mental health professionals. Yap AUJ. Depression and somatization in patients with temporomandibular disorders. J Prosth Dent 2002; 88:479-484.Sipila K, et al. Association between symptoms of temporomandibular disorders and depression: an epidemiological study of Northern Finland 1966 birth cohort. Cranio: Journal of Craniomandibular Practice 2001; 19:183-187.Depression and Oral HealthDepression, loss of teeth, and denturesThree major sources that significantly influence patient responses to tooth loss and subsequent dentures exist. Parental/spousal influences, The symbolic significances of teeth Current life circumstances. Friedman N. The influences of fear, anxiety and depression on the patients adaptive responses to complete dentures Part I. J Prosth Dent 1987; 58:687-689.Friedman N. The influences of fear, anxiety and depression on the patients adaptive responses to complete dentures Part II. J Prosth Dent 1988; 59:45-48.

Depression and Oral Health- LLDLate-life depression initially occurs after age 65 and is a major public health concern because elderly people who are at high risk constitute an ever-expanding segment of the population. Individuals under treatment for LLD and those whose illness has not been diagnosed or treated often present to the dentist with significant oral disease. Friedlander AH et al. Late-life depression: its oral health significance. International Dental Journal 2003; 53:41-50.

Depression and Oral Health- LLDLLD is frequently associated with a disinterest in performing oral hygiene, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, and oral dysesthesias. Appropriate dental management necessitates a vigorous preventive dental education program, the use of artificial salivary products, antiseptic mouthwash, daily fluoride mouth rinse and special precautions when administering local anesthetics with vasoconstrictors and prescribing analgesics. Friedlander AH et al. Late-life depression: its oral health significance. International Dental Journal 2003; 53:41-50.Arthur H et al. Dental management of the geriatric patient with major depression. Special Care in Dentistry 2008; 13:249-253.Dementia and Oral HealthThe Leisure World Cohort StudyMen with inadequate natural masticatory function had a 91% greater risk of dementia than those with adequate natural masticatory function (10 upper teeth and 6 lower teeth). This risk was also greater in women but not significantly so. Dentate individuals who reported not brushing their teeth daily had a 22% to 65% greater risk of dementia than those who brushed three times daily.Paganini-Hill A. Dentitition, dental health habits, and dementia: the leisure world cohort study. Journal of the American Geriatrics Society 2012; 60:1556-1563.Medical Referral to Dental

Evaluating the Medical Referral ProcessQuality Study to evaluate pilot program of medical referrals into dental programUrgent Need AppointmentsAnalysis of all referrals until 50 (n=50) referrals were completed

Total of 69 referrals evaluated with 19 no shows (27.5% no-show rate)Total Division no show rate at time was approximately 4%Preliminary AnalysisUrgent Care Referrals from MedicalNO SHOW EVALUATION (n=19)Age: 22.6 19.3 Female: 42.1% / Male: 57.9%Reported pain level: 8.22 (1.8) [n=9]Referral Sources:Community Health Center- 47.4%CHC Pediatrician - 52.6%Preliminary AnalysisUrgent Care Referrals from MedicalNO SHOW EVALUATION (n=19)Time to Dental Team ContactLess than 24 hours: 52.6%24-48 Hours: 21.0%3-5 Days: 5.3%7-10 Days: 21.0%

MEAN TIME TO CONTACT: 1.94 (24-48 hours)Preliminary AnalysisUrgent Care Referrals from MedicalNO SHOW EVALUATION (n=19)Time to Dental ApptLess than 24 hours: 5.3%24-48 Hours: 21.0%3-5 Days: 21.0%7-10 Days: 47.4%More than 10 Days: 5.3%

MEAN TIME TO APPT: 3.26 (3-5 days)Preliminary AnalysisUrgent Care Referrals from MedicalNo Show - Medications RX:None: 63.1%Amoxicillin 500mg TID at 10 days: 15.8%Penicillin VK 500mg TID at 5 days: 10.5%Amoxicillin 500mg with Vicodin 7.5mg: 10.6%Preliminary AnalysisUrgent Care Referrals from MedicalNo Show Evaluation Description of Oral IssueDental Home Needed: 36.8%Multiple Cavities: 21.0%Loose/Mobile Teeth: 10.5%Pain/Swelling: 10.5%Oral Pain: 10.5%Abscess/Broken Tooth: 10.5%Preliminary AnalysisReason for No ShowUnable to Correspond: 73.7%Personal Conflict: 15.8%Transportation: 10.5%Preliminary AnalysisEvaluation of Medical Referral ProcessCompleted referrals by 12 physician teams (n=50)Referrals most likely completed by nursing staff and occasionally by front office2 physicians completing referral forms sent to CSCDM 0% no show rate on these referralsAddl information form completed in the presence of patient

Preliminary AnalysisEvaluation of Medical Referral ProcessAge: 39.3 19.8Male: 32.0% / Female: 68.0%Dental Coverage (Self Report)Yes: 66.0% (Actual- 52% [Medicaid-28%; private-24.0%])No: 34.0% (Actual- 48%)Referral SourceCommunity Health Center:38.0%CHC Pediatricians:30.0%School Based RNs:12.0%Hospital Emerg. Dept:6.0%Private Practice:6.0%Veterans Administration:4.0%Oncology Group Practice:4.0%

Preliminary AnalysisEvaluation of Medical Referral ProcessTime to Dental ApptLess than 24 hours: 6.0%24-48 Hours: 22.0%3-5 Days: 34.0%7-10 Days: 30.0%More than 10 Days: 8.0%

MEAN TIME TO APPT: 3.12 (3-5 days)Preliminary AnalysisEvaluation of Medical Referral ProcessQuestionnaire to patients consisting of a series of care related questionsCompleted by all 50 subjectsPreliminary AnalysisPatient QuestionnaireHave you been to the ER in the last year for the same oral/tooth issue that brought you here today?YES: 48.0%NO: 52.0%Preliminary AnalysisPatient QuestionnaireWhen was the last time you saw a dentist/hygienist for a cleaning and examination?Less than six months26.0%Within last year14.0%Within last two years12.0%Two to four years14.0%More than four years34.0%Preliminary AnalysisPatient QuestionnaireWhy did you not complete that care or continue with the dentist?Did not like dentist / office29.8%Cost of care23.4%Did not take insurance12.8%Transportation8.5%Lost dental insurance6.4%Confused by explanation of care4.2%Pain went away4.2%Family obligations2.1%

[8.5% stated that could not recall]Preliminary AnalysisPatient QuestionnaireRate the importance of your overall oral health8.54 out of 10 (2.13)Preliminary AnalysisPatient Questionnaire (Likert)8 questions used the Likert scale to determine agreement with statement1- Strongly agree2- Agree3- Neither agree or disagree4- Disagree5- Strongly disagreePreliminary AnalysisPatient Questionnaire (Likert)I found it unusual that my doctor/physician referred me directly to a dentist for care.1.16 1.69 (Strongly Agree)My teeth have a very important impact on my overall health.1.82 1.02 (Agree)It is absolutely necessary for the dentist to have knowledge of my own personal medical history or doctor treatment.1.74 0.99 (Agree)

Preliminary AnalysisPatient Questionnaire (Likert)Because the dentist only treats the teeth, it really is not necessary for him/her to know all of the medicine I take.3.02 1.62 (Neither)The dentist does not really need to know my entire medical history because I am being seen for an emergency/urgent care appointment.3.50 1.13 (Neither -to- Disagree)I feel it is very important for my doctor to talk with my dentist to help coordinate my complete health care.1.56 0.77 (Agree -to- Strongly Agree)Preliminary AnalysisPatient Questionnaire (Likert)I prefer and enjoyed this process of my dentist and doctor/physician talking to each other during my appointments with them both.1.70 0.76 (Agree)I do not feel comfortable talking with the dentist about my medical history.4.02 0.98 (Disagree)

Preliminary AnalysisComparing Medical HistoryComparisons between the Medical History provided by a physician completed H and P and patients self report to dental office (n=24)H and P included 1.15 0.37 more diagnoses than the patients dental self reportMissing:Smoking (7)Substance abuse (3)Arthritis (3)Diabetes (3)Joint replacement; MI; stomach ulcer (2)Asthma; nervous disorder; pulmonary hypertension (1)Preliminary AnalysisComparing MedicationsComparisons between the medication list provided by the physician and patients self report to dental office (n=25)Physicians medication list contained 3.13 2.91 more medications than the patients self reportMissingHydrocodone / APAP (10)Aspirin (7)Ibuprofen (4)Tobacco cessation [patch/gum] (4)Metformin (3)Albuterol; lisinopril; omeprazole; warfarin; xanax (2)Flonase; claritin; metoprolol; valium; plavix (1)Preliminary AnalysisPhysician RX for oral treatmentSignificant variation

14 different RX found with 12 physicians

Preliminary AnalysisPhysician RX for oral treatmentMOST COMMONLY SEENNone: (44.0%)Amox(500) TID 7days;Ibuprofen(800);Vicodin(7.5) (16%)Amox Suspension (125mg/5mL) (10.0%)Penicillin VK (500) TID 5days; Ibuprofen (800) (10.0%)Preliminary AnalysisPhysician RX for oral treatmentCategorical Breakdown (n=28)

Antibiotic (100%)Amoxicillin (60.7%)Penicillin VK (17.9%)Augmentin (10.7%)Clindamycin (10.7%)Pain Management (75%)Vicodin (39.3%)Ibuprofen (32.1%)Tramadol (3.6%)Preliminary AnalysisPhysician description of oral issueAbscess of tooth or teeth:36.0%Large cavities or cavity:26.0%In need of dental exam:12.0%Broken tooth:6.0%Large cavity with pain:4.0%A1C >9:4.0%6 other descriptors:12.0%

Preliminary AnalysisEvaluating possible variables with No-ShowsAge of No-Show patients: 22.6 [vs. 39.3]Sex of no shows (males vs. females)Physician vs. Nurse vs. Front OfficePatient with copy of referral in handNo difference with time to apptMean for both groups at 3-5 daysDescription of oral health issueDental home needed descriptor less likely to keep appointment as opposed to abscess/infection or oral painRX treatment not impactful Referral Source???Preliminary AnalysisA microcosm case study

Hello all,I wanted you to know of our clinical day yesterday. Approximately 50% of the kids seen had severe odontogenic infection requiring antibiotic coverage and complaining of pain that kept them up at night, I have provided pictures from just a few of the children seen yesterday and please understand that most of these kids on the schedule had similar issues. Since the initiation of this program ------------, we have been in an uphill battle to improve the oral health of the communities we serve. These communities are still in dire need of oral health care including more community outreach, education programs, and direct care. We have also supplied over 8,000 toothbrushes and toothpaste in the communities we serve and yet we continue to have children/families report not having toothbrushes or toothpaste at home (yesterday only 30% of the kids seen stated having their own toothbrush at home). Additionally, the school nurse ------- informed me that she feels we are still not getting forms back from children who need our services most. A sentiment shared by another nurse ---------. Almost all of the patients seen were new to our system and the majority has never seen a dentist before. The need for our services is still far outside of our ability to supply, especially as it relates to education and preventive programs. We must continue to work to improve oral health in these communities and find ways to expand our education programs that I feel includes involving our pediatrician offices in the education process so that parents understand the importance of oral health care. Please let me know if you have questions and more importantly let me know if you have any ideas on making sure we are reaching out to the parents/guardians of the kids that we are not getting forms back from.Regards,

Questions???