Whether they realize it or not, the majority of Americans over age five have at least one untreated dental cavity and most adult mouths harbor periodontal (gum) disease. Research shows that adults and children with major medical problems, such as diabetes, are at higher risk for periodontal disease. Additionally, a pregnant woman’s cavity-causing pathogens are passed along to her newborn, paving the way to another generation with poor dental health. [See "Oral Health in America: A Report of the Surgeon General
While physicians are in a good position to identify dental problems and refer patients for appropriate services, few do. Experts say this is partly because current medical education puts little emphasis on the connection between oral health and systemic disease. Dentists too don’t get the right message during their training, which can lead to shortfalls in care. Some dental practitioners erroneously believe that children under three need no dental care or that pregnancy is a reason to avoid dental treatment due to risks. For disadvantaged patients, who are more likely than the general population to worry about cost (“I have no insurance and can’t afford the fees”) or simply be misinformed (“I have bad teeth, just like my parents did and I have to live with them, just like my parents did”), the result is that many low-income families seek dental care only in emergencies or not at all.
To improve access to oral health services for low-income individuals in two target populations, children ages 0 to 5 and pregnant women, the Institute for Healthcare Improvement (IHI) in collaboration with the federal Health Resources and Services Administration (HRSA) launched the Oral Health Disparities Collaborative
Pilot Project in August 2005. Funded by a grant from HRSA, which oversees the country’s 701 community health centers (CHCs) serving the uninsured, isolated and medically at-risk, the project is an outgrowth of an earlier collaboration between HRSA and IHI aimed at reducing disparities in the care of diabetes patients
. “That project had an oral health component,” says Jay Anderson, DMD, MHSA, chief dental officer in HRSA’s Division of Clinical Quality, “Dental caries [tooth decay] is a significant problem among the kids we see in our health centers so we decided to build on that work.”
HRSA had several goals in funding the project, says Anderson, including “to establish a dental as well as a medical home for our patients by age one; to educate parents and professionals on the importance of oral health; and to do it all in a cost-effective way.”
At the heart of the program is recognition that, although dental disease has traditionally been treated in the acute or surgical stage, it is fundamentally a chronic condition, says Tracy Jacobs, BSN, RN, and the IHI Director for the Collaborative. “Our challenge was to shift the paradigm from emergency care toward outreach, prevention and proactive management,” says Jacobs. Accordingly, the Collaborative is based on the Chronic Care Model
which emphasizes, among other elements, interventions that support behavior change and system redesign.
In keeping with IHI’s methodology for exploring new content, the first step in the collaborative was to convene a panel of experts in pediatric and perinatal dental care and quality improvement. “We did a ‘brain dump’ and realized two things were critical to creating real change,” says Jacobs. “One was to bridge the gap between medical and dental care by ensuring that physicians understand the role of oral health in good primary care, and are actively engaged in the referring all their pregnant and very young patients to the dental clinic. The other was breaking the cycle of disease transmission from mother to child.”
Three of the four pilot locations participating in the Collaborative — High Plains Community Health Center in Lamar, Colorado; Salud Family Health Center in Ft. Lupton, Colorado; and Sunrise Community Health Center in Greeley, Colorado — were chosen because they were already looking at the issue of redesigning dental practice to achieve better access for patients and networking with medical providers. The fourth location — Community Health Partners in Livingston, Montana — was included because “they heard about the project and showed extraordinary interest in participating,” says Jacobs.
Community health centers provide the perfect setting to achieve the goal of improved oral health for low-income mothers and children, says Colleen Lampron, MPH, the project’s co-chair, along with Irene Hilton, DDS, MPH. “A great number of low-income women get their prenatal care at CHCs where, generally, both physicians and dentists are on staff. This can make referrals easier and it gives us the opportunity to alert pregnant women about the need to get dental care for their newborns.” An exception is High Plains in Lamar, which does not offer pregnancy services. There, the pilot team formed a partnership with a local women’s health clinic to provide oral health counseling to patients with positive pregnancy tests.
As part of the Collaborative, physicians are asked to screen the target populations, pregnant women and children ages 0 to 5, for obvious oral health problems and to provide some initial oral health counseling. The real key to success is making sure these patients are referred to dental practitioners for comprehensive examinations and appropriate counseling. For example, a first check-up for an infant involves looking in the baby’s mouth, as well as conducting a thorough risk assessment for dental decay, administering fluoride treatment, and providing guidance about prevention and self-management, based on the identified risk factors. “A great deal of the program consists of education”, emphasizes Lampron. “We need to inform caregivers about maintaining the oral health of their kids, right from infancy. Additionally, we want to inform pregnant women that there is an important health issue here. They need to look after their teeth for their baby’s sake as well as their own.”
Resistance from patients is less than might be expected. “Once the mothers-to-be hear that it’s about the baby’s health, not just their own teeth, they are usually very interested in pursing treatment for themselves.” It’s too soon to tell whether they will remain so if, for instance, their Medicaid coverage — which pays for dental care during pregnancy in many states — ends with birth. The modest sliding-scale dental fees generally imposed at CHCs may cause women to give low-priority to continued care. “It’s a problem,” admits Lampron, “and not just for the women. If they don’t keep up their dental health, their kids may not either but we’re hoping that education makes that difference.”
Education has been a crucial issue for the professionals as well, says Martin Lieberman, DDS, a member of the Collaborative’s faculty who directs five dental clinics in Seattle’s Puget Sound Neighborhood Health Center. He says at the HRSA/IHI pilot sites, it wasn’t easy to persuade busy physicians to take on responsibility for dental referrals or even to convince the dentists that the program was necessary. “Dental training has come a long way, but a lot of us learned in school that children under three were not candidates for care and that it was risky to treat pregnant women.” To counter professional resistance, says Lieberman, the Collaborative faculty provided the latest information on clinical best practices and support on how to use that information in daily practice. “We put the research literature in front of them, we trained them how to manage small children as patients and we explained treating pregnant women in the context of providing good prenatal care.” Educating professionals this way, says HRSA’s Jay Anderson, is the key to incorporating evidence-based knowledge on oral health into well-baby care.
Participating in the pilot has “forced a complete rethinking of how we do dentistry,” says Patrick Harrison DDS, the project’s team leader in Greeley, Colorado. “We didn’t see kids — too scary. We weren’t aggressive with in-office fluoride treatments — we just handed out the fluoride gel — and we definitely didn’t make any connection between the mom’s oral health and her child’s well-being. All that has changed now.”
A more durable challenge, says Colleen Lampron, has been stretching resources. “We have 18 full-time dentists at the pilot clinics. On average, that’s only one for every 20 medical providers so right now there’s more demand than we can meet,” a problem the project is partially tackling through system redesign. For example, says Lampron, “dental assistants and dental hygienists have been trained to do risk assessment and patient education and screening for fluoride treatments. We use the dentists only for procedures that really require their skills.”
Relatively small efficiencies can pay big time-saving dividends, notes Lampron. “The dental support staff has learned to complete all x-rays and set up the instrument tray according to the patient’s exact needs in advance. The dentist doesn’t have to wait for anything but can step into the room ready to work.” Participating teams are always on the lookout for new time-savers, says Lampron. “In Greeley, the health center’s physicians have online access to the dental clinic schedule so they can make an appointment for the patient without even contacting the dentist.” Greeley’s system also takes full advantage of Colorado’s more liberal dental practice act regarding who is allowed to perform dental work. “When a patient needs a filling, the dentist removes decay but the assistant places the filling. Then the dentist checks the work,” says Patrick Harrison. “It’s a terrific resource-extender.”
The pilot, originally funded for six months, is now supported through March 2007. Early data on results have been very encouraging. Some sites have been more successful than others, with the percentage of dental exams completed in their individual target populations ranging from 18 percent to 85 percent. Project-wide, between December 2005 and June 2006, the percentage of pregnant women receiving dental care has nearly tripled and the percentage of very young children has increased eightfold.
Another advancement has been newly-created professional guidelines for the oral care of pediatric patients. Authored by members of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry, HRSA’s Jay Anderson calls the guidelines “another step forward in overcoming the compartmentalization of health care services.” The take-home message from the project, says Anderson, is simple: “to improve the oral health of children, get to them early, create a ‘dental home’ and educate their caregivers.”