Pediatrics

The natural first intersection between oral and systemic health is in the child’s medical home. Of children who see medical and dental professionals, almost all see the medical provider, and see them first and more frequently. However, only 50% of all children 2 to 17 years saw a dentist in 2011 ; in 2009, the rate was less than 8% for children younger than 3 years. These facts establish the medical home as a valuable option for initial oral health education.

One of the best examples of oral health integration into pediatric primary care is Into the Mouths of Babes, in North Carolina, with a sophisticated and thorough approach to integrating oral health. However, medical clinics without those resources can still play an important role in children’s oral health promotion.

Just like medical providers write their clinical documentation as a “SOAP note” ( s ubjective/ o bjective/ a ssessment/ p lan), oral health can be integrated into the workflow using the SOAP structure. The subjective part of the note is when one is asking about patients’ concerns, risky and preventive actions and behaviors, and personal and family history. Oral health risk assessments are a natural part of this process, and often the relevant screening questions are already being asked (eg, screening for obesity risk factors). Dental caries risk assessments can be incorporated into medical visits workflows, which then can help prioritize the provider’s response (see also National Network for Oral Health Access Oral Health Infrastructure toolkit, http://www.nnoha.org/ohi-toolkit/ohi-toolkit-background/ ).

Because of the great overlap between root causes of disease relating to social disparities/social determinants of health, including access to care, healthy activities, and nutritious foods, the medical profession serves patients by screening for adverse childhood experiences and other social determinants of health, and providing related support. Examples of such services include the medical legal partnership to help address legal concerns, housing referrals to address housing instability, or food prescriptions/food pantries in the clinic. These interventions all facilitate resolution of concerns more basic on Maslow’s hierarchy of need, which only after they have been addressed will free families up to focus on important health initiatives.

Medical providers have a more specific role to support oral health. Understanding the family’s health provides insight into an individual child’s risk for oral health problems, and may open the discussion of dental anxiety, if any, or simply the self-efficacy about being able to prevent dental disease and pain.

The objective part of the medical evaluation is the physical examination, which should include the mouth, the teeth, and gums. The assessment and plan portion of the SOAP is the diagnoses and plan. The latter arguably is where the primary care provider can have greatest influence, by providing education, referrals, preventive services, and even treatments. Still, recognizing the issue and discussing it with the patient/family is key to moving to intervention and treatment.

Education

One could argue that the biggest role the pediatrician plays is introducing and then underscoring the importance of oral health. Teachable moments begin even before the first tooth has erupted. Guiding parents to see ways to soothe a baby that does not include food help with overall health in coming years. Similarly, getting the family to stop nighttime feeds (once appropriate) is better for the health of the teeth and mental health for the parents, and for the sleep routine for all. Perhaps most important is to encourage the family to pursue their own oral health, along with teaching about oral disease as an infectious disease that is spread vertically (mother to baby in utero, or after birth by caregiver to child) or horizontally (sibling to sibling, or baby to baby in a day care setting). This is particularly relevant when a child drops her pacifier on the ground, and the parent “cleans” it in his or her mouth instead of washing it off with water. This is a great opportunity to start discussing oral health, its role in systemic health, and the role of parents and patients in keeping healthy from the start or returning to full health as soon as possible.

Another educational program that can be shared out of the medical office is “Brush Book Bed.” This program, introduced by the American Academy of Pediatrics, extends the work of “Reach Out and Read” by having pediatricians give a toothbrush along with a book at well-child visits. Educational materials are available for the office encouraging families to establish a nighttime routine of brushing the teeth, reading a book, and going to bed. Pilot studies on this intervention found families brushed the child’s teeth more regularly, were more willing to go to a dentist, and liked the improved sleep hygiene for the child.

Another important role of primary care is that of making referrals to dental providers. Medical providers should refer to dental providers. Even as far back as 2004, dela Cruz and colleagues found that almost 80% of providers would refer patients with signs of early decay or having high risk for future disease. Medical colleagues underscore the importance of oral health when making a referral for dental care and treating it like other referrals, providing information and following up that it happened. A patient is more likely to go to a dental provider if they are referred by a medical provider, whether from pediatrics, obstetrics, or other fields. Assistance to providers in referrals, such as by community health workers, can increase the proportion of patients who arrive to a dental visit.

Since placing referrals has been insufficient to see epidemiology for this disease drop, it is important that medical professionals add prevention into their arsenal for fighting oral disease.

Prevention

Pediatricians have long been responsible for prescribing fluoride tablets in the setting of a patient who does not have access to adequately fluoridated water. Still, a prescription is insufficient to provide optimal oral health care. Beyond just mentioning the importance of starting tooth-brushing, with fluoridated toothpaste as soon as the first tooth erupts, pediatricians should be prepared to counsel on oral health issues. Moreover, they often are approached with questions around behavior issues, such as children refusing to brush. Therefore, responses are facilitated by an understanding of oral health and development.

Moreover, medical teams can counsel about tobacco use (for the parent or the child) and prescribe antibiotic prophylaxis (or antianxiety medications) as needed before patient visits.

A tangible way to support patients’ prevention is fluoride varnish. This prophylaxis has been used in the medical setting for more than a decade, as a way to help prevent oral health problems until that time when a child is established into a dental home. It is applied twice a year and decreases the risk of dental decay in primary teeth by 37%, and is effective in reversing up to 64% of decay.

Treatment

If dental caries is allowed to progress, it turns into a soft tissue infection which can further progress to life-threatening disease. It is imperative that medical providers (particularly those in the emergency department and those caring for children in general) are able to start appropriate antibiotic therapy, and then facilitate the child being seen by a dentist posthaste.

Silver diamine fluoride is another combined preventive and treatment tool that has been used in nontraumatic dental care. Medical providers around the country who live in low-access areas have started to apply silver diamine fluoride as a way to stop current and prevent further delay. Use of this intervention in the medical home is in its nascency. Still, it is important for medical providers to be aware of which dental providers in their community use this modality, to help educate families about this non-invasive intervention as an option that does not require sedation, and to refer accordingly, as well as not to be surprised if seeing the darkened, treated lesions during an exam.

Obstetrics

Pregnancy is a seminal moment in a woman’s life, when she often is more motivated than ever to improve her health status, even if just as a way of helping her baby. Moreover, pregnancy is a time when women may have access to care by having dental insurance coverage, which they do not normally have. It is completely safe to provide care to women during pregnancy, and some research has shown improvements with low birth weight, premature birth, and stillbirth.

The subjective questions are in the same realm as with pediatrics, but with the important caveat that pregnancy can cause additional risks, such as hyperemesis, with the impact of acid on the teeth, or even simple morning sickness, which often leads women to increase the frequency of their simple carbohydrate snacking, and thus influences the pH of the mouth and resulting increased caries formation.

Objectively, providers should be aware of and examine women for pregnancy granulomas and pregnancy gingivitis.

When reviewing the assessment and plan with a pregnant woman, it is an opportune time to reiterate the importance of oral habits because the woman is “brushing for two.” In addition, establishing good habits at this point can help set the foundation for the mother to provide quality infant oral health care. Referrals are particularly important for women when pregnant, for several reasons. Pragmatically, women who may not have coverage at other times in their life do during pregnancy, so it is important to capitalize on these services. Also, because women are at higher risk for oral health complications during pregnancy, it is important for medical providers to be aware of these conditions, so they can assist and refer appropriately.

Harborview Medical Center is an example of a facility integrating oral health with prenatal care, through patient education starting with the first prenatal visit.

Internal Medicine

A basic fact for adults is that regular health insurance does not include dental insurance. In 2017, more than 27 million Americans did not have health insurance, less than half the population that did not have dental insurance at the same time, approximately 74 million (∼23%). Even the Affordable Care Act did not include dental insurance as an essential and mandatory benefit (effectively saying that it was important, but would not involve a penalty if patients did not sign up for it). Thus, many adults have at baseline a decreased access to care.

However, increasingly literature is coming out about the role of oral health in systemic health. A prime example of this is with diabetes, a condition affecting more than 9% of the adult population and responsible for some of the greatest burden of disease. It is imperative that patients with diabetes be referred for regular oral health care. Research has shown that preventive periodontal care may decrease cost of overall medical care. Other conditions with strong systemic and dental illness include cardiovascular disease, pneumonia, end-stage renal disease, and stroke.

Great examples of integrated medical-dental care in the United States are Kaiser Permanente’s Eugene Oregon clinic and the Marshfield Clinic in Wisconsin.

Emergency Department

Nationally, the rates of visits in the emergency room for oral health problems is increasing. There is a major burden on the health care system of patients visiting the emergency department for nontraumatic dental pain, in terms of people and of dollars (estimated 1.6 billion). Emergency providers play an important role in stabilizing the patient’s pain and referring them to appropriate care.

Geriatrics

Patients in their golden years may not be receiving platinum oral health care. There is a particular challenge with getting patients from nursing homes to dental providers which is a fundamental access barrier. Expansion of care through registered dental hygienists in alternative practice and dental therapists may help lessen the load requirement of dentists by improving access to preventive care and basic treatment.

Medically, research reports the link between poor oral health and increase in systemic health issues. Medical providers must mention the need for continued oral health care (and not support the fatalism of “they’re going to fall out anyway” similar to the unconcern associated with ignorance about importance of keeping baby teeth healthy) and help prioritize this care for patients, particularly when they have multiple medical concerns, many of which are impacted by poor oral health. These include being more likely to develop and have more rapid cognitive decline with dementia, and more likely to have incidents/accidents in addition to the health conditions above.

Location

Thus, there are many ways medical professionals can support oral health care by offering education, referral, preventive services, and some treatment. There are also multiple models of how a medical home can integrate oral health.

The natural way medical providers deal with issues that they think are outside of their scope is with referrals. Many medical providers start by making referrals to oral health providers. Although this does increase the likelihood of a patient going to a dentist relative to if nothing is done, it has been ineffective to solve the oral health crisis.

Colocation is a significant but insufficient next step. For instance, even at federally qualified health centers (FQHCs) where medical and dental are colocated, fewer than 40% of patients regularly are seen in both settings (Hilton, personal communication, 2016).

Coscheduling, when dental appointments are scheduled from the medical office, is a further step at improving dental referral rates. Few electronic health records have the capacity to do this, but it would reduce barriers to making appointments. The Marshfield Clinic in Wisconsin is one example that does have an integrated electronic medical-dental record, and better metrics of care.

For in-clinic care, different pilots have taken place around the country, with having a dental hygienist or even a dentist spend some or full time in clinic, providing dental services in the medical care visit.

Last, medical and dental offices can work together in overseeing outreach activities, to provide a more holistic set of services.