The Role of Non-Dental Health Professionals in Providing Access to Dental Care for Low-Income and Minority Patients

The disadvantaged suffer disproportionately from dental problems. These persons are more likely to have untreated oral health problems and associated pain, and also are more likely to forego dental treatment even when in pain. There has been increased emphasis on the potential role of physicians in alleviating oral health disparities, especially among children. In addition, many adults lacking access to traditional dental services seek care and consultation from hospital emergency departments, physicians, and pharmacists. The delivery of oral health care services by non-dental health professionals may assume increasing importance as the population continues to age and becomes more diverse. This is because, in general, the elderly and ethnic and racial minorities face significant economic barriers to accessing private dental services.

In the United States, poor oral health represents a significant public health problem. The 1989 National Health Interview Survey (NHIS) reported that approximately 39 million adults had suffered from some type of orofacial pain more than once during the preceding 6-month period. Orofacial pain and other dental problems contribute to reduced quality of life, physical disabilities, emotional distress, and impaired functioning across a variety of life domains. In addition to causing pain and suffering, dental problems also affect economic productivity. Data from the 1996 NHIS revealed that adults missed approximately 2,442,000 days of work because of acute dental conditions, and it has been estimated that children who have oral health problems lose 52 million hours from school and poor children suffer from approximately 12 times as many days of restricted activity caused by dental problems as children from families with higher incomes. These data probably understate the scope of the problem because orofacial pain and associated dental problems contribute to reduced productivity and a diminished learning environment even when individuals do not miss work or school. Additionally, low-income individuals report the greatest number of days of restricted activity and of lost work hours because of poor oral health, suggesting that the poor are most vulnerable to the deleterious effects of orofacial pain and other dental problems.

Individuals without a usual source of medical care are less likely to gain access to needed health services. Similarly, many individuals who lack access to dentists may be forced to use hospital emergency departments (EDs), physician offices, or other nontraditional settings and providers to deal with their dental problems. The poor and minorities are more likely than other segments of the population both to experience dental emergencies and to see non-dentists for the treatment of these problems because they experience greater levels of oral disease and frequently face cost and other barriers in gaining access to dentists.

Children residing in low-income communities are five times as likely to have untreated cavities, but only 36% of poor children had a dental visit during the preceding year compared with 70% of children from families with high income. The use of dental services has been linked consistently to economic status. Furthermore, individuals with dental insurance are more likely to use dental services. Not surprisingly, the poor, Hispanics, and African Americans are less likely to have dental insurance. Among children overall, medical insurance is approximately three times as prevalent as dental coverage. Even with dental insurance, African Americans and Hispanics continue to make fewer dental visits than whites and are less likely to have visited the dentist in the previous year. Most states limit or exclude dental benefits for adults. The State Children’s Health Insurance Program, passed in 1997, directed increased resources for improving children’s access to needed oral health services, but use rates for adult Medicaid recipients continue to deteriorate as many states facing financial difficulties tighten eligibility criteria and restrict and/or entirely eliminate adult dental benefits.

For adults, in particular, opportunities to receive free care at public clinics are extremely limited. Delay in obtaining needed dental services often results in additional pain and treatment that is more expensive and less conservative than would have been required initially. Although some poor individuals lacking coverage or facing loss of coverage because of Medicaid cutbacks may choose to pay for treatment out of pocket at a dental office, others may consult EDs, physicians, or pharmacists for pain relief. The following sections explore the role of these non-dentist health professionals in the provision of oral health care services.

Use of emergency departments for dental problems

Although data on the use of EDs for the treatment of dental problems are limited, African Americans and the poor have been found to be more likely than other groups to use EDs for medical care. The inappropriate use of EDs for non-urgent primary medical care services has received wide attention. Similarly, many of the patients seeking care for dental-related problems could be managed by dentists in their offices. Numerous reports have examined dental treatment provided in the hospital setting. Studies have involved care provided to both children and adults, and often have focused on oral trauma. Most studies have focused generally on hospitals with dedicated departments of dentistry and have described services provided by dentists in dental clinical facilities. Only a few studies have described the actual services provided in EDs or patient satisfaction with the care received.

Overall, visits to EDs increased approximately 14% during the period from 1992 to 1999. Nationally, from 1997 to 2000 there was an average of 738,000 visits annually to EDs for complaints of tooth pain or tooth injury. Overall, diseases of the teeth and supporting structures accounted for 0.7% of all visits to EDs. Individuals visiting EDs for dental rather than medical problems were significantly more likely to indicate Medicaid or self-pay as the payer, rather than private insurance. Only approximately 10% of dental-related visits had an associated procedure, as compared with 42% of ED visits for other problems. More than 80% of the visits resulted in prescriptions, most frequently for pain medications and antibiotics. This study raised the important issue of whether patients ever received definitive care for their dental problem. The authors concluded that EDs were an important source of care for dental-related problems, particularly for individuals lacking private dental insurance, but that ED services needed to be enhanced to provide better triage, diagnosis, and basic treatment.

More recently, diseases of the teeth and supporting structures were reported to account for 0.9% of all visits to EDs. National data from the 2001 Medical Expenditure Panel Survey (MEPS) revealed that 2.7% of all individuals who sought care for a dental problem outside of dental offices received care in an ED. Whites and middle- and high-income individuals were more likely to receive prescriptions for their dental problems than were African Americans and low-income individuals. Given the higher levels of dental needs among African Americans and those with lower incomes, it was assumed that these groups would be more likely to receive prescriptions. It was not possible to assess whether these demographic-linked differences were based on clinical findings or were influenced by practitioner knowledge, attitudes, or culturally based biases. The role of cultural issues in the delivery of oral health care services is receiving increased attention.

Several reports have examined changes in ED use at the University of Maryland Medical System following the elimination in 1993 of Medicaid reimbursement to dentists for the treatment of adult dental emergencies. Visits to the ED by Medicaid patients increased by 22% following the elimination of dentist reimbursement. ED use for dental conditions, unlike medical conditions, was most common on weekends. This finding suggested an inability to access dental offices on weekends. This hospital-specific project led to a statewide study covering all adult Medicaid-eligible persons treated in all Maryland hospitals and by office-based physicians. The rate of ED claims was 12% higher after dentist reimbursement was eliminated. The most frequent diagnosis codes cited were “unspecified disorder of the teeth and supporting structures” (34%), “periapical abscess” (24%), and “dental caries” (22%). During the 4-year study period, 85 hospital admissions resulted from ED Medicaid dental-related visits. The average cost for claims associated with hospital admissions was $5793. Although the objective of the original policy change eliminating dentist reimbursement from Medicaid achieved the goal of reducing overall dentist–related Medicaid expenditures from approximately $7.5 million for the 2-year period before the change to zero after the policy change, the policy change also resulted in poorer health outcomes and a diminution of access to care.

More recently, a Maryland telephone study examined the characteristics of low-income minority adults who had sought relief from toothache pain during the previous 12 months at EDs and physician offices as compared with those who sought care from dentists. In addition, it assessed patient satisfaction with the services received. A majority of the respondents suffering from toothache pain (58.6%) sought relief from dentists; only 8.7% and 20.1% contacted EDs or physician offices, respectively. ED contacts were least likely to be reported by the elderly, Hispanics, and higher-income respondents and were most likely to be reported by African Americans and the poor. The overwhelming majority of respondents who contacted an ED (80.5%) subsequently contacted a dentist for relief. Irrespective of demographic characteristics and consistent with other reports, ED use was positively associated with the severity of the pain experience. More than three fourths of the respondents (78.6%) reported that pain was the most important reason for contacting the ED. The only reason given by Hispanics for contacting EDs, however, was lack of knowledge of any dentists to contact. This finding highlights the importance of addressing access problems of Hispanics if disparities in oral health are to be reduced. The majority of all respondents (71.4%) reported that they were told to see a dentist; approximately 35% were given a prescription. No one received definitive treatment for the pain. Nevertheless, most respondents reported that the treatment or advice provided helped “a lot” (65.9%). Paradoxically, this high level of perceived effectiveness may reflect a high concordance of expectations with the actual care received.

Thus, it seems that many individuals lacking access to traditional dental services may use EDs for temporary pain relief. Unfortunately, most EDs lack readily available dental services and therefore generally do not provide definitive treatment. Nevertheless, costs are incurred when patients are assessed standard charges for ED visits (facility and physician charges). The magnitude of this problem is unknown. ED services would be enhanced by the addition of dental staff or ED physicians who have received specialized training in the delivery of emergency dental services.

Provision of oral health care services by physicians

Services for Children

There has been increased emphasis on the potential role of physicians in alleviating disparities in oral health, especially among children. Even though the availability of Medicaid services for children has improved, there is evidence that this step alone will not guarantee access to needed services. Concurrently, there has been a growing awareness of the need for better integration between medicine and dentistry if oral health disparities among children are to be addressed adequately. This need was reflected in the 1995 report by the Institute of Medicine, “Dental Education at the Crossroads,” which called for closer integration of medicine and dentistry at the levels of research, education, and patient care. In 2006 a major initiative of the American Dental Education Association and the Association of American Medical Colleges published a report highlighting the need for changes in professional curricula to foster a greater integration of medicine and dentistry. Numerous reports, conferences, and government agencies have recognized the need to address oral health disparities among children and have issued recommendations and promoted strategies to do so, including, notably, an increasing role for pediatricians and family physicians.

There is a strong rationale for using primary care physicians for delivering preventive services to children. Interventions are needed early in life, and well-child visits to pediatricians begin early and occur frequently. Poor children have better access to medical care than to dental care: 90% of poor children have a usual source of medical care. Furthermore, most general dentists will not treat young children, and in many areas of the country the number of pediatric dentists is very limited. There are, however, approximately 88,000 family physicians and 40,000 pediatricians, and 50% of all primary care office visits are provided by family physicians. It has been suggested that children who are found to be at risk for the development of dental caries or who possess recognized risks should be encouraged to establish a dental home 6 months after the eruption of the first tooth or by age 1 year, whichever occurs first. Pediatricians and family physicians are well placed to make this determination and subsequent dental referral.

Professional organizations have taken the lead in recognizing and advancing the role of physicians in providing needed oral health care services to children. For example, the American Academy of Family Physicians has published a practical guide on infant oral health, as has the Society of Teachers of Family Medicine Group on Oral Health. Furthermore, the American Academy of Pediatrics has established a policy describing the role of pediatricians in the oral health risk assessment of children and emphasizing the need for pediatric health care professionals to develop the knowledge to provide assessments on all patients beginning at the age of 6 months.

Unfortunately, there is evidence of only very limited involvement of medical schools, residency programs, and continuing medical education programs with oral health content. In general, the overall level of training in oral health of pediatricians at all levels is inadequate to provide the competencies needed to provide quality oral health care to children. Several studies have questioned physicians about the amount of oral health training they received while in medical school. A survey of pediatricians and family practitioners in Alabama found that 59% of the respondents reported receiving no preventive oral health information during their medical school training, and a national study of pediatricians reported that half of the respondents received no training in dental health issues during their medical school or residency experiences. Similarly, a survey of 3000 pediatricians revealed that 76% considered that participatory experiences and learning opportunities during their pediatric residency in the area of dentistry were insufficient. Unfortunately, recent reports indicate that there has been little improvement. A 2006 survey of graduating pediatric residents found that during their training, 32% received no oral health care training; among those who received training, 75% received less than 3 hours, and only 14% spent clinical time with a dentist. On a positive note, more than 85% of respondents believed pediatricians should perform oral screenings and counsel patients about correct brushing techniques.

Thus, although the need for further training is evident, physicians have indicated that they recognize the importance of and are interested in providing oral health care services to children. Nationally, more than 90% of the responding pediatricians agreed that they had an important role in identifying oral health problems in children and in providing counseling on caries prevention. Furthermore, 74% indicated that they were willing to provide fluoride varnish. Although physicians have expressed a willingness to provide preventive services to young children, the effectiveness of physician interventions aimed at preventing and managing dental caries in preschool children has not been established. The U.S. Preventive Services Task Force reviewed the effectiveness of five possible physician interventions: screening and risk assessment, referral, provision of dietary supplemental fluoride, application of fluoride varnish, and counseling. The Task Force concluded that there was not sufficient evidence to support the effectiveness of screening, referral, and counseling to prevent dental caries in preschool children. There was fair evidence of the effectiveness of fluoride supplementation and varnish. Unfortunately, there also was fair evidence that the physicians’ consideration of fluoride exposure was inadequate and therefore contributed to an increased risk of fluorosis among children receiving supplements.

In a related area, the characteristics of medical providers that influence their decision to refer children at risk for dental problems have been examined. The study population included 69 pediatric practices and 49 family medicine practices and focused on the referrals among Medicaid-eligible children in North Carolina. Overall, approximately 78% of all primary care clinicians reported that they probably would refer children who had signs of early dental caries or were at high risk. The most common method of referral was to provide the caregiver with a dentist’s name (96%); less frequently, calls were made from the physician’s office to a dental office to make an appointment for the referred child (54%). Practitioners who had a high degree of confidence in their screening abilities and low referral difficulty were most likely to make referrals. Another study used national data from the 2003 Medical Panel Expenditure Survey to examine the role of non-dentist health care providers in providing advice to children and adolescents on obtaining a dental checkup. Approximately 45% of children age 2 to 17 years were advised by a non-dentist health care provider to seek a dental checkup. Although no differences in likelihood of referral were found based on patient income, children from higher-income families were more likely to seek dental care. Similarly, the potential role of Early Head Start programs in providing referrals to primary care providers for the delivery of preventive dental care has been examined. Staffs were questioned about their opinions on the ability of physicians and nurses to screen children for dental problems and to provide preventive dental services during medical visits. The opinions generally were favorable, but education was deemed necessary for staff lacking familiarity with this approach to care delivery.

A number of studies have begun to explore the role of physicians in providing preventive dental services to children. A statewide project in North Carolina focused on the involvement of medical practices in the prevention of early childhood caries in low-income children. That program, “Into the Mouths of Babes,” targeted low-income children from birth until 35 months of age. Pediatricians, family physicians, and providers in community health centers received Medicaid reimbursement for providing preventive dental services including risk assessments, screening, referral, fluoride varnish applications, and counseling. Providers received lectures and interactive sessions, practice guidelines for the interventions, case-based problems, implementation strategies, resource materials, and follow-up training. Preliminary evaluations demonstrated that non-dental personnel were able to integrate preventive dental services into their practices.

The effectiveness of preventive services provided by physicians depends in part on the frequency of well-child visits. Therefore, another study attempted to assess the number of follow-up preventive dental visits in medical offices and their determinants among children who had received dental screenings, fluoride varnish, and counseling. Children were found to have received approximately 66% of the recommended number of remaining well-child visits. The authors concluded that efforts to increase the frequency of preventive dental visits may need to be linked to efforts directed at increasing well-child visits for medical care.

In another program, dental, medical, and educational faculty from the University of Washington Academic Health Center worked together to provide evidence-based, culturally appropriate pediatric oral health training to family medicine residents in five community-based programs. The educational program was directed at children from birth to 5 years of age and included dental development, the caries process, dental emergencies, and special needs topics. Preliminary evaluations of knowledge gained, attitudes and self-efficacy, and behavioral changes were encouraging. In another study directed at pediatric and family practice residents, residents received 1- or 2-hour training sessions in infant oral health. At a 1-year follow-up, the participants’ behaviors had improved, with 73% reporting referrals to dentists at age 1 year (compared with 28% at baseline); however, fluoride-prescribing practices showed little improvement.

Questions addressing the effectiveness of physician interventions are beginning to be addressed. Another North Carolina study was conducted at a private pediatric group practice to determine the accuracy of the care provider’s screening and referral for early childhood caries. Independent, blinded oral screening results and referral recommendations made by the pediatricians were compared with those of a pediatric dentist. The pediatricians received 2 hours of training in infant oral health that included clinical slides illustrating dental caries, instructions on how to recognize cavitated lesions, and information about determining the need for a dental referral. Providers were told to refer any child who had one or more cavitated carious lesions, soft tissue pathology, or oral trauma. Results indicated that with limited training, the pediatric primary care providers attained an adequate level of accuracy in identifying children needing referral. Only 70% of the children needing referral actually were referred, however. The authors concluded that it would be easy to incorporate dental screenings into a busy pediatric practice.

It seems likely that programs aimed at increasing the preventive oral health services provided by primary care providers will increase. For example, the Health Foundation of South Florida recently announced a new educational program directed at 700 pediatricians and family practice physicians in several Florida counties. The program will train providers who accept Medicaid to provide dental screenings, preventive procedures, and counseling to children. North Carolina continues to expand its “Into the Mouths of Babes” program. Presently more than 425 private practices and local health departments and 3000 providers have received training, resulting in more than 100,000 preventive visits per year. Similarly, the Washington Dental Services Foundation is working to increase primary care providers’ involvement in oral health by training family medicine residents and by developing and distributing continuing education materials. Recently, Baltimore became the first city in the country to provide fluoride vanishes to children in medical clinics. Plans are underway to expand the program statewide by July 2009.

Despite these positive steps, roadblocks to greater participation by primary care providers must be addressed. Experiences related to oral health must be increased for primary care residents, and continuing education opportunities must be made available for current practitioners. At the same time, the efficacy of physician interventions must be established. In addition, the ease of obtaining referrals to pediatric and general dentists must be enhanced if primary care providers are not to become frustrated, because only approximately 5000 pediatric dentists and few general dentists see children under the age of 3 years. Finally, time constraints imposed on busy practitioners as well as limited reimbursement for preventive services other than fluoride varnish probably will pose further impediments.

Services for Adults

Several authors have discussed the role of medical practitioners in addressing dental pain, providing treatment for temporomandibular disorders, and in the early detection of oral cancer. Compared with the increased emphasis on the role of physicians in providing needed oral screening and preventive services for children, however, studies examining the role of physicians in providing services to adults for the treatment of dental emergencies or other dental problems are limited. “Oral Health in America: A Report of the Surgeon General” commented on the lack of data on physician-based services for oral and craniofacial conditions. Several overseas studies have documented the use of medical practitioners for the treatment of adult dental problems. In the United States, the role of non-dental professionals in providing adult pain relief has been recognized also, and several studies, although limited in scope, have established that patients suffering from toothache pain have sought relief from non-dentist professionals. For example, among older Florida adults reporting toothache pain during the prior 12 months, approximately 11% reported seeing a physician. More generally, although in 1995 there were approximately 700 million total patient visits to physician offices in the United States, only 0.2% of these visits had a principal diagnosis relating to diseases of the teeth and supporting structures. From 1999 to 2000, visits for dental-related problems accounted for approximately 0.3% of all physician office visits. In 2002, there were approximately 890 million visits to office-based physicians.

The previously described Maryland study of EDs also examined the use of physicians to treat dental problems after the Medicaid reimbursement of dentists was eliminated. Unexpectedly, after dentist reimbursement was eliminated, the rate of claims for physician office visits decreased by 7%. It seemed that patients assumed that if dental visits were no longer covered, visits to physician for dental problems would not be covered, either. Although the rate of physician office claims did not increase after the policy change, the rate of physician office visits still was greater than that reported for EDs. National data from the 2001 MEPS survey previously cited found that approximately 7% of individuals who experienced a dental problem outside of the normal dental office–based delivery system received care from a physician. Patients who had dental problems were more likely to have made physician visits than ED visits. It seems, therefore, that individuals lacking a usual source of dental care prefer physician offices rather than EDs as a treatment site.

A survey of two family medicine practices found that 4.5% of their patient visits were related to oral problems. Pain and mucosal ulcerations were the problems most frequently encountered. The most frequent treatment provided was advice (62%), followed by prescriptions (48%) and office treatment (20%). The authors concluded that oral problems were a common occurrence in family medicine practices and suggested the desirability of including oral medicine topics in the training and continuing education of primary care doctors. Consistent with this study, a state-wide telephone survey of Maryland residents found that approximately 6% of individuals over the age of 20 years reported seeing a physician for a dental problem sometime during the prior 12 months. The problem most frequently mentioned was “toothache” (26.7%). The majority of respondents who had dental-related physician visits (80%) were satisfied with the treatment or advice they received. Approximately one third of the respondents who saw a physician (36.4%) reported that they had to see a dentist for the same problem. Respondents expressing greater dissatisfaction with their medical visit were more likely to report a follow-up visit with a dentist for the same problem. This dissatisfaction may have resulted from their expectations for obtaining relief for their dental problem not being met.

The previously cited Maryland study also examined the characteristics of low-income minority adults who sought relief from toothache pain at physician offices. Approximately 20% of the respondents sought relief from physicians, and approximately 83% of these respondents also subsequently contacted a dentist. Respondents’ use of physicians was associated directly with both the degree to which their pain interfered with their everyday activities and the severity of their pain. The majority of respondents were told to see a dentist/oral surgeon (66.7%). Consistent with other reports of physician-related dental services, respondents with higher incomes were more likely to receive prescriptions than were respondents with lower incomes, and those who had the lowest income were most likely to be told to see a dentist. This pattern of prescribing is contrary to that found with dentists, who were more likely to prescribe drugs for lower-income and minority patients. It was not possible to tell if this pattern of prescribing was based on clinical need or was influenced by physicians’ attitudes or biases. Awareness of racial/ethnic disparities in health care has been increasing. An Institute of Medicine report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” addressed the potential influence of provider bias, discrimination, and patient stereotyping in health disparities. The percentage of respondents who received prescriptions from EDs and physician contacts for toothache was considerably smaller than comparable figures reported nationally for ED and physician visits in general (ED: 76.7%; physician: 70.5%). This finding was particularly surprising, given that these visits were associated with toothaches. The relatively lower rates of prescribing may reflect providers’ concerns about encouraging dental-related visits or their discomfort in treating dental-related problems. None of the respondents received definitive treatment for their toothache pain; rather, most were instructed to see a dentist. Surprisingly, given the absence of definitive treatment and that only a minority of the respondents received a prescription/drug sample, a majority reported that the treatment/advice helped “a lot.” As with ED care, this high level of perceived effectiveness may reflect, paradoxically, a high concordance of respondent expectations with the actual care received. Of special note, 16.8% of the respondents delayed dental visits because of a perceived “medical complication,” that is, pregnancy. This concern was especially notable in Hispanic respondents, among whom it was the most common reason given for delaying care. Hispanics also were most likely to mention medical complications as a reason for visiting a physician. Apparently, Hispanics have misconceptions surrounding the appropriate use of dental services during pregnancy. The importance of health literacy in addressing health disparities has been gaining increasing recognition, and improving dental health literacy, especially among minority groups, is an important goal.

Unfortunately, like EDs, physician offices often are not the most appropriate setting for adults to receive care for a dental problem. As discussed previously, primary health care providers are increasingly receiving training in providing preventive services to children. Unfortunately, physicians generally have received minimal if any training in the management of adult dental problems. Several authors have provided guidance to physicians in this area. Recognizing this deficiency, the General Medical Services Committee of the British Medical Association published guidelines on the management of dental problems. Additional education and guidelines have proven beneficial in assisting physicians in dealing with dental problems. The children’s oral health curriculum developed by the Society of Teachers of Family Medicine Group on Oral Health, as previously cited, also contains educational modules directed at adult oral health issues. More recently, family practice and emergency room residents in New Mexico were provided dental training to gain an understanding of dental anesthesia, treatment planning, diagnosis, and the management of dental trauma and infections. Resident graduates were able to provide emergency dental procedures in rural EDs and practices. A similar training program was instituted in Maine, where family practice residents received training in emergency dental evaluation and treatment procedures and general oral health care. This innovative program concentrated on developing faculty skills as the basis for continued resident training. A survey of patients receiving tooth extraction services found that overall satisfaction was high. Training programs such as those just described undoubtedly will enhance physicians’ ability to provide effective adult emergency dental services.

Provision of oral health care services by physicians

Services for Children

There has been increased emphasis on the potential role of physicians in alleviating disparities in oral health, especially among children. Even though the availability of Medicaid services for children has improved, there is evidence that this step alone will not guarantee access to needed services. Concurrently, there has been a growing awareness of the need for better integration between medicine and dentistry if oral health disparities among children are to be addressed adequately. This need was reflected in the 1995 report by the Institute of Medicine, “Dental Education at the Crossroads,” which called for closer integration of medicine and dentistry at the levels of research, education, and patient care. In 2006 a major initiative of the American Dental Education Association and the Association of American Medical Colleges published a report highlighting the need for changes in professional curricula to foster a greater integration of medicine and dentistry. Numerous reports, conferences, and government agencies have recognized the need to address oral health disparities among children and have issued recommendations and promoted strategies to do so, including, notably, an increasing role for pediatricians and family physicians.

There is a strong rationale for using primary care physicians for delivering preventive services to children. Interventions are needed early in life, and well-child visits to pediatricians begin early and occur frequently. Poor children have better access to medical care than to dental care: 90% of poor children have a usual source of medical care. Furthermore, most general dentists will not treat young children, and in many areas of the country the number of pediatric dentists is very limited. There are, however, approximately 88,000 family physicians and 40,000 pediatricians, and 50% of all primary care office visits are provided by family physicians. It has been suggested that children who are found to be at risk for the development of dental caries or who possess recognized risks should be encouraged to establish a dental home 6 months after the eruption of the first tooth or by age 1 year, whichever occurs first. Pediatricians and family physicians are well placed to make this determination and subsequent dental referral.

Professional organizations have taken the lead in recognizing and advancing the role of physicians in providing needed oral health care services to children. For example, the American Academy of Family Physicians has published a practical guide on infant oral health, as has the Society of Teachers of Family Medicine Group on Oral Health. Furthermore, the American Academy of Pediatrics has established a policy describing the role of pediatricians in the oral health risk assessment of children and emphasizing the need for pediatric health care professionals to develop the knowledge to provide assessments on all patients beginning at the age of 6 months.

Unfortunately, there is evidence of only very limited involvement of medical schools, residency programs, and continuing medical education programs with oral health content. In general, the overall level of training in oral health of pediatricians at all levels is inadequate to provide the competencies needed to provide quality oral health care to children. Several studies have questioned physicians about the amount of oral health training they received while in medical school. A survey of pediatricians and family practitioners in Alabama found that 59% of the respondents reported receiving no preventive oral health information during their medical school training, and a national study of pediatricians reported that half of the respondents received no training in dental health issues during their medical school or residency experiences. Similarly, a survey of 3000 pediatricians revealed that 76% considered that participatory experiences and learning opportunities during their pediatric residency in the area of dentistry were insufficient. Unfortunately, recent reports indicate that there has been little improvement. A 2006 survey of graduating pediatric residents found that during their training, 32% received no oral health care training; among those who received training, 75% received less than 3 hours, and only 14% spent clinical time with a dentist. On a positive note, more than 85% of respondents believed pediatricians should perform oral screenings and counsel patients about correct brushing techniques.

Thus, although the need for further training is evident, physicians have indicated that they recognize the importance of and are interested in providing oral health care services to children. Nationally, more than 90% of the responding pediatricians agreed that they had an important role in identifying oral health problems in children and in providing counseling on caries prevention. Furthermore, 74% indicated that they were willing to provide fluoride varnish. Although physicians have expressed a willingness to provide preventive services to young children, the effectiveness of physician interventions aimed at preventing and managing dental caries in preschool children has not been established. The U.S. Preventive Services Task Force reviewed the effectiveness of five possible physician interventions: screening and risk assessment, referral, provision of dietary supplemental fluoride, application of fluoride varnish, and counseling. The Task Force concluded that there was not sufficient evidence to support the effectiveness of screening, referral, and counseling to prevent dental caries in preschool children. There was fair evidence of the effectiveness of fluoride supplementation and varnish. Unfortunately, there also was fair evidence that the physicians’ consideration of fluoride exposure was inadequate and therefore contributed to an increased risk of fluorosis among children receiving supplements.

In a related area, the characteristics of medical providers that influence their decision to refer children at risk for dental problems have been examined. The study population included 69 pediatric practices and 49 family medicine practices and focused on the referrals among Medicaid-eligible children in North Carolina. Overall, approximately 78% of all primary care clinicians reported that they probably would refer children who had signs of early dental caries or were at high risk. The most common method of referral was to provide the caregiver with a dentist’s name (96%); less frequently, calls were made from the physician’s office to a dental office to make an appointment for the referred child (54%). Practitioners who had a high degree of confidence in their screening abilities and low referral difficulty were most likely to make referrals. Another study used national data from the 2003 Medical Panel Expenditure Survey to examine the role of non-dentist health care providers in providing advice to children and adolescents on obtaining a dental checkup. Approximately 45% of children age 2 to 17 years were advised by a non-dentist health care provider to seek a dental checkup. Although no differences in likelihood of referral were found based on patient income, children from higher-income families were more likely to seek dental care. Similarly, the potential role of Early Head Start programs in providing referrals to primary care providers for the delivery of preventive dental care has been examined. Staffs were questioned about their opinions on the ability of physicians and nurses to screen children for dental problems and to provide preventive dental services during medical visits. The opinions generally were favorable, but education was deemed necessary for staff lacking familiarity with this approach to care delivery.

A number of studies have begun to explore the role of physicians in providing preventive dental services to children. A statewide project in North Carolina focused on the involvement of medical practices in the prevention of early childhood caries in low-income children. That program, “Into the Mouths of Babes,” targeted low-income children from birth until 35 months of age. Pediatricians, family physicians, and providers in community health centers received Medicaid reimbursement for providing preventive dental services including risk assessments, screening, referral, fluoride varnish applications, and counseling. Providers received lectures and interactive sessions, practice guidelines for the interventions, case-based problems, implementation strategies, resource materials, and follow-up training. Preliminary evaluations demonstrated that non-dental personnel were able to integrate preventive dental services into their practices.

The effectiveness of preventive services provided by physicians depends in part on the frequency of well-child visits. Therefore, another study attempted to assess the number of follow-up preventive dental visits in medical offices and their determinants among children who had received dental screenings, fluoride varnish, and counseling. Children were found to have received approximately 66% of the recommended number of remaining well-child visits. The authors concluded that efforts to increase the frequency of preventive dental visits may need to be linked to efforts directed at increasing well-child visits for medical care.

In another program, dental, medical, and educational faculty from the University of Washington Academic Health Center worked together to provide evidence-based, culturally appropriate pediatric oral health training to family medicine residents in five community-based programs. The educational program was directed at children from birth to 5 years of age and included dental development, the caries process, dental emergencies, and special needs topics. Preliminary evaluations of knowledge gained, attitudes and self-efficacy, and behavioral changes were encouraging. In another study directed at pediatric and family practice residents, residents received 1- or 2-hour training sessions in infant oral health. At a 1-year follow-up, the participants’ behaviors had improved, with 73% reporting referrals to dentists at age 1 year (compared with 28% at baseline); however, fluoride-prescribing practices showed little improvement.

Questions addressing the effectiveness of physician interventions are beginning to be addressed. Another North Carolina study was conducted at a private pediatric group practice to determine the accuracy of the care provider’s screening and referral for early childhood caries. Independent, blinded oral screening results and referral recommendations made by the pediatricians were compared with those of a pediatric dentist. The pediatricians received 2 hours of training in infant oral health that included clinical slides illustrating dental caries, instructions on how to recognize cavitated lesions, and information about determining the need for a dental referral. Providers were told to refer any child who had one or more cavitated carious lesions, soft tissue pathology, or oral trauma. Results indicated that with limited training, the pediatric primary care providers attained an adequate level of accuracy in identifying children needing referral. Only 70% of the children needing referral actually were referred, however. The authors concluded that it would be easy to incorporate dental screenings into a busy pediatric practice.

It seems likely that programs aimed at increasing the preventive oral health services provided by primary care providers will increase. For example, the Health Foundation of South Florida recently announced a new educational program directed at 700 pediatricians and family practice physicians in several Florida counties. The program will train providers who accept Medicaid to provide dental screenings, preventive procedures, and counseling to children. North Carolina continues to expand its “Into the Mouths of Babes” program. Presently more than 425 private practices and local health departments and 3000 providers have received training, resulting in more than 100,000 preventive visits per year. Similarly, the Washington Dental Services Foundation is working to increase primary care providers’ involvement in oral health by training family medicine residents and by developing and distributing continuing education materials. Recently, Baltimore became the first city in the country to provide fluoride vanishes to children in medical clinics. Plans are underway to expand the program statewide by July 2009.

Despite these positive steps, roadblocks to greater participation by primary care providers must be addressed. Experiences related to oral health must be increased for primary care residents, and continuing education opportunities must be made available for current practitioners. At the same time, the efficacy of physician interventions must be established. In addition, the ease of obtaining referrals to pediatric and general dentists must be enhanced if primary care providers are not to become frustrated, because only approximately 5000 pediatric dentists and few general dentists see children under the age of 3 years. Finally, time constraints imposed on busy practitioners as well as limited reimbursement for preventive services other than fluoride varnish probably will pose further impediments.

Services for Adults

Several authors have discussed the role of medical practitioners in addressing dental pain, providing treatment for temporomandibular disorders, and in the early detection of oral cancer. Compared with the increased emphasis on the role of physicians in providing needed oral screening and preventive services for children, however, studies examining the role of physicians in providing services to adults for the treatment of dental emergencies or other dental problems are limited. “Oral Health in America: A Report of the Surgeon General” commented on the lack of data on physician-based services for oral and craniofacial conditions. Several overseas studies have documented the use of medical practitioners for the treatment of adult dental problems. In the United States, the role of non-dental professionals in providing adult pain relief has been recognized also, and several studies, although limited in scope, have established that patients suffering from toothache pain have sought relief from non-dentist professionals. For example, among older Florida adults reporting toothache pain during the prior 12 months, approximately 11% reported seeing a physician. More generally, although in 1995 there were approximately 700 million total patient visits to physician offices in the United States, only 0.2% of these visits had a principal diagnosis relating to diseases of the teeth and supporting structures. From 1999 to 2000, visits for dental-related problems accounted for approximately 0.3% of all physician office visits. In 2002, there were approximately 890 million visits to office-based physicians.

The previously described Maryland study of EDs also examined the use of physicians to treat dental problems after the Medicaid reimbursement of dentists was eliminated. Unexpectedly, after dentist reimbursement was eliminated, the rate of claims for physician office visits decreased by 7%. It seemed that patients assumed that if dental visits were no longer covered, visits to physician for dental problems would not be covered, either. Although the rate of physician office claims did not increase after the policy change, the rate of physician office visits still was greater than that reported for EDs. National data from the 2001 MEPS survey previously cited found that approximately 7% of individuals who experienced a dental problem outside of the normal dental office–based delivery system received care from a physician. Patients who had dental problems were more likely to have made physician visits than ED visits. It seems, therefore, that individuals lacking a usual source of dental care prefer physician offices rather than EDs as a treatment site.

A survey of two family medicine practices found that 4.5% of their patient visits were related to oral problems. Pain and mucosal ulcerations were the problems most frequently encountered. The most frequent treatment provided was advice (62%), followed by prescriptions (48%) and office treatment (20%). The authors concluded that oral problems were a common occurrence in family medicine practices and suggested the desirability of including oral medicine topics in the training and continuing education of primary care doctors. Consistent with this study, a state-wide telephone survey of Maryland residents found that approximately 6% of individuals over the age of 20 years reported seeing a physician for a dental problem sometime during the prior 12 months. The problem most frequently mentioned was “toothache” (26.7%). The majority of respondents who had dental-related physician visits (80%) were satisfied with the treatment or advice they received. Approximately one third of the respondents who saw a physician (36.4%) reported that they had to see a dentist for the same problem. Respondents expressing greater dissatisfaction with their medical visit were more likely to report a follow-up visit with a dentist for the same problem. This dissatisfaction may have resulted from their expectations for obtaining relief for their dental problem not being met.

The previously cited Maryland study also examined the characteristics of low-income minority adults who sought relief from toothache pain at physician offices. Approximately 20% of the respondents sought relief from physicians, and approximately 83% of these respondents also subsequently contacted a dentist. Respondents’ use of physicians was associated directly with both the degree to which their pain interfered with their everyday activities and the severity of their pain. The majority of respondents were told to see a dentist/oral surgeon (66.7%). Consistent with other reports of physician-related dental services, respondents with higher incomes were more likely to receive prescriptions than were respondents with lower incomes, and those who had the lowest income were most likely to be told to see a dentist. This pattern of prescribing is contrary to that found with dentists, who were more likely to prescribe drugs for lower-income and minority patients. It was not possible to tell if this pattern of prescribing was based on clinical need or was influenced by physicians’ attitudes or biases. Awareness of racial/ethnic disparities in health care has been increasing. An Institute of Medicine report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” addressed the potential influence of provider bias, discrimination, and patient stereotyping in health disparities. The percentage of respondents who received prescriptions from EDs and physician contacts for toothache was considerably smaller than comparable figures reported nationally for ED and physician visits in general (ED: 76.7%; physician: 70.5%). This finding was particularly surprising, given that these visits were associated with toothaches. The relatively lower rates of prescribing may reflect providers’ concerns about encouraging dental-related visits or their discomfort in treating dental-related problems. None of the respondents received definitive treatment for their toothache pain; rather, most were instructed to see a dentist. Surprisingly, given the absence of definitive treatment and that only a minority of the respondents received a prescription/drug sample, a majority reported that the treatment/advice helped “a lot.” As with ED care, this high level of perceived effectiveness may reflect, paradoxically, a high concordance of respondent expectations with the actual care received. Of special note, 16.8% of the respondents delayed dental visits because of a perceived “medical complication,” that is, pregnancy. This concern was especially notable in Hispanic respondents, among whom it was the most common reason given for delaying care. Hispanics also were most likely to mention medical complications as a reason for visiting a physician. Apparently, Hispanics have misconceptions surrounding the appropriate use of dental services during pregnancy. The importance of health literacy in addressing health disparities has been gaining increasing recognition, and improving dental health literacy, especially among minority groups, is an important goal.

Unfortunately, like EDs, physician offices often are not the most appropriate setting for adults to receive care for a dental problem. As discussed previously, primary health care providers are increasingly receiving training in providing preventive services to children. Unfortunately, physicians generally have received minimal if any training in the management of adult dental problems. Several authors have provided guidance to physicians in this area. Recognizing this deficiency, the General Medical Services Committee of the British Medical Association published guidelines on the management of dental problems. Additional education and guidelines have proven beneficial in assisting physicians in dealing with dental problems. The children’s oral health curriculum developed by the Society of Teachers of Family Medicine Group on Oral Health, as previously cited, also contains educational modules directed at adult oral health issues. More recently, family practice and emergency room residents in New Mexico were provided dental training to gain an understanding of dental anesthesia, treatment planning, diagnosis, and the management of dental trauma and infections. Resident graduates were able to provide emergency dental procedures in rural EDs and practices. A similar training program was instituted in Maine, where family practice residents received training in emergency dental evaluation and treatment procedures and general oral health care. This innovative program concentrated on developing faculty skills as the basis for continued resident training. A survey of patients receiving tooth extraction services found that overall satisfaction was high. Training programs such as those just described undoubtedly will enhance physicians’ ability to provide effective adult emergency dental services.

Only gold members can continue reading. Log In or Register to continue

Oct 29, 2016 | Posted by in General Dentistry | Comments Off on The Role of Non-Dental Health Professionals in Providing Access to Dental Care for Low-Income and Minority Patients
Premium Wordpress Themes by UFO Themes