MEDICAL AND DENTAL INTEGRATED PREVENTIVE VISITS AT A COMMUNITY

HEALTH CENTERASHLEY POPEJOY, DDS, MS

WHO ARE YOU?

• Originally from Branson, Missouri

• BA Molecular Biology from William Jewell College

• DDS from University of Missouri- Kansas City

• Certificate in Pediatric Dentistry from University of Illinois-Chicago

• MS in Oral Sciences from University of Illinois-Chicago

• Diplomate of the American Board of Pediatric Dentistry

• Associate Director of Pediatric Dentistry for NYU-LangoneHospital AEPD- Missouri

• Director of Pediatric Dentistry at Jordan Valley Community Health Center

WHY INTEGRATION?

• Patient-Centered• Overcoming access-to-care

issues• Reinforcement of education• Inter-relationship of

medical/dental disease• Emphasis on preventive care• Early identification of at-risk

children

• The average infant will visit a pediatrician 16 times in their first year

• Only 2% of children have visited a dentist by the age of 2 (despite AAPD recommendation for “dental home by age 1”)

• Children under the age of 2 as a group visit a medical professional more often by 190x compared to a dental professional

American Academy of Pediatrics. Profile of Pediatric Visits. 2010.

WHY INTEGRATION?

0

200

400

600

800

1000

# OR casesAge 213%

Age 325%

Age 428%

Age 521%

Age 6+13%

Barriers to Care

Transportation

Financial

Communication

Employment/School Schedules

Pre-existing Medical

Conditions

Medical/Dental Phobia

• 41% of the population of Greene County, Missouri lives at or under 200% FPL

• 40% of live births in Greene County are born to mothers as Medicaid participants

Niezgoda, R and C. Goddard. State of the Community’s Health Executive Summary: Greene County, Missouri.

8 Pediatric Dental Residents

1 full-time attending

5 part-time attendings

6 FTE Pediatric medical providers

PediatricDental

•61 average patient visits/day Pediatrics•60 average patient

visits/day

THE PILOT

Identification• Care coordinator evaluates schedule for

potential integrated patients • Inclusion: under age 3, well-child visit/WIC

Communication

•Nurse contacts pediatric dental attending via phone

•Communicates room, age, and gender of child needing dental exam

•Dedicated open bay for integrated WIC exams

Examination•Pediatric dental resident comes to medical exam

room/WIC open bay in between dental patients•Performs knee-to-knee exam, toothbrush prophy,

fluoride varnish application, anticipatory guidance and schedules recall examination

ANTICIPATORY GUIDANCE

• Dental/oral development

• Non-nutritive sucking habits (thumb/finger sucking and pacifier use)

• Most children will spontaneous cease sucking habits by age 2

• Positive reinforcement negative reinforcement habit appliance

• Dietary counseling• Beverage containers and types

• Breastfeeding (WHO vs AAP recommendations)

• Oral hygiene instructions• Arguably, toothbrush prophy with

demonstration is the most clinically valuable guidance a parent can receive from these exams

• Trauma prevention• Car seats

• Electrical cords

• Pacifier size

• Avulsion instructions

• Fluoride exposure• Toothpaste amounts

• Supplementation?

• Teething• No Orajel/Ambesol

• No evidence that drooling=teething

• Caries Risk Assessment

American Academy of Pediatric Dentistry. Reference Manual. Guideline on Infant Oral Health Care. 2015-2016. 37(6): 146-50.

13011130

695

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1400

2016-2017 2015-2016 2014-2015

# of

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ions

Und

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rs

SUCCESSES

• 75% increase in children seen by a pediatric provider for a dental exam under the age of 3

• Addition of an organization-wide integration committee

• Inter-professional education opportunities• Overcoming barriers to care for some families• Preventive education for families and pregnant

women• Addition of walk-in Adult New Patient

examinations

AREAS FOR IMPROVEMENT

• Assisting with ‘resisters’• Communication tools • Greater involvement of optometry and

behavioral health• Addition of family practice• “No Child Left Behind”

# of

Enc

ount

ers i

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diat

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enta

l 27% growth

KEY CONSIDERATIONS• IDENTIFICATION

• Clear inclusion criteria

• Staffing to visit EVERY patient for screening?

• Documentation- who and when?

• Resisting complacency- need a champion to revisit at staff meetings and throughout the day

• COMMUNICATION

• Need 100% fail-safe

• EXAMINATION

• Difficulties of balancing with busy, efficient schedules

• Timing- immunizations? Medical providers running behind?

EVIDENCE-BASED INTERVENTIONS

• H. Hernegea, et al., 2017: Interprofessional education, collaborative practice, geographic proximity

• F. Ramos-Gomez, et al., 2017: Integrated curriculum for AEPD, partnership with WIC/Head Start

• N. Sengupta, et al., 2017: Coordinated referral process, fl- varnish in pediatric WCC visits

• P.A. Braun and A. Cusick, 2016: fl- varnish in WCC visits, use of telehealth

• ***J. Bernstein, et al., 2016: “Facilitators included an upper-level administration with the vision to see the value of integration, designated team leaders, and champions” ***

WHAT’S NEXT?

• Interventional pilots to involve medical professional education

• Silver diamine fluoride education for general dentists, pediatric dentists, and medical providers in the area

• Involvement of Women’s Health in integrated visits

• Continuation of behavioral health evaluation during dental examinations (coordinated referrals to BHC or Parents as Teachers)

REFERENCES1. American Academy of Pediatrics. Profile of Pediatric Visits. 2010.

2. Niezgoda, R and C. Goddard. State of the Community’s Health Executive Summary: Greene County, Missouri. 2004.

3. American Academy of Pediatric Dentistry. Reference Manual. Guideline on Infant Oral Health Care. 2015-2016. 37(6): 146-50.

4. Harnegea, H., et al. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open. 2017: 7:e016078. doi: 10.1136/bmjopen-2017-016078.

5. Ramos-Gomez, F, H Askaryar, C Garell, and J Ogren. Pioneering and interprofessionl pediatric dentistry programs aimed at reducing oral health disparities. Front Public Health. 2017: 5:207. doi: 10.3389/fpubh.2017.00207. eCollection 2017.

6. Sengupta, N., S. Nanavati, M Cercola, and L Simon. Oral health integration into a pediatric practice and coordination of referrals in a colocated dental home at a federally qualified health center. Am J Public Health. 2017: 107(10):1627-1629.

7. Braun, PA, and A Cusick. Collabroation between medical providers and dental hygienists in pediatric health care. J Evid Based Dent Pract. 2016: 16 Suppl:59-67.

8. Bernstein, J., et al. Integration of oral health into the well-child visit at Federally Qualified Health Centers: Study of 6 clinics, August 2014-March 2015. Prev Chronic Dis. 2016: 13:E58.