Open Wide –Mouth is the window to the body. HEENT to HEENOT
Dr. Vinod Miriyala BDS, MPH, CAGS, DDS Dr. Anna Novais DMD Objectives
Make the case that oral health is an essential component of primary care. Present a practical framework for how to deliver preventive oral healthcare as a component of routine medical care. Share resources and information about existing practice in the state to implement this in your health center. Understanding the problem
Lack of access to basic dental services contributes to profound and enduring oral health disparities in the United States. Millions of children and adults do not receive needed clinical and preventive dental services. In 2011, 6.1 percent of children and 16.4 percent of adults under the age of 65, did not receive needed dental care because their families could not afford it. Children are only one of the many vulnerable and underserved populations that face persistent, systemic barriers to accessing oral health care. Understanding the Problem
Dental caries (cavities) and periodontal disease (gum disease) are largely preventable. Yet nationwide, among all ages, incomes, and life experiences, we have an unacceptably high burden of these chronic diseases. We’ve seen little improvement in oral health status over the past 20 years, and pervasive disparities remain: Poor and near‐ poor 5‐year‐olds are more than two times as likely to have tooth decay than their middle‐income peers. The Burden of Oral Disease: Children Decay: Tooth decay is the most common chronic disease of childhood. • Pain and infection can result in impaired nutrition and growth. • Untreated decay puts children at risk for dental disease in adulthood. Ages 2–5 Ages 12–15 25% 50% The Burden of Oral Disease: Adults
25% ages 20–64 have untreated caries. 19% ages 35–44 have destructive periodontal diseases.
Cumulative result? 25% of adults 65 and older have no teeth.
Oral cancer kills over 8,000 people each year, 2.0x the number who die of cervical cancer, a major preventive care focus. Access and Affordability Challenges In most communities, dental care is the most common unmet health need. 40% of the population lacks dental insurance, 2.5x the percentage of those lacking medical insurance. Many patients turn to the ER as a last resort; most are sent home with painkillers and antibiotics, but their problem hasn’t been solved. Late‐stage interventions (e.g., extractions) waste valuable healthcare resources and introduce unnecessary risks for patients.
7 Why Oral health is important
Oral health is essential to general health and well‐ being at every stage of life. A healthy mouth enables not only nutrition of the physical body, but also enhances social interaction and promotes self‐esteem and feelings of well‐being. The mouth serves as a “window” to the rest of the body, providing signals of general health disorders. Why Oral health is important
Mouth lesions may be the ‐ first signs of HIV infection, ‐ aphthous ulcers are occasionally a manifestation of Coeliac disease or Crohn’s disease, ‐ pale and bleeding gums can be a marker for blood disorders, ‐ bone loss in the lower jaw can be an early indicator of skeletal osteoporosis, and ‐ changes in tooth appearance can indicate bulimia or anorexia.
The presence of many compounds (e.g., alcohol, nicotine, opiates, drugs, hormones, environmental toxins, antibodies) in the body can also be detected in the saliva. Why Oral health is important
Bacteria from the mouth can cause infection in other parts of the body when the immune system has been compromised by disease or medical treatments (e.g., infective endocarditis). Systemic conditions and their treatment are also known to impact on oral health (e.g., reduced saliva flow, altered balance of oral microorganisms). Why Oral health is important
Periodontal disease has been associated with a number of systemic conditions. Though the biological interactions between oral conditions such as periodontal disease and other medical conditions are still not fully understood, it is clear that major chronic diseases – namely cancer and heart disease –share common risk factors with oral disease. Common Risk Factor Approach
Recognition that oral health and general health are interlinked is essential for determining appropriate oral health care programs and strategies at both individual and community care levels. That the mouth and body are integral to each other underscores the importance of the integration of oral health into holistic general health policies and of the adoption of a collaborative “Common Risk Factor Approach” for oral health promotion. What can we do
The United States health care system is able to provide acute care but continues to struggle to address the need for ongoing care, especially for vulnerable populations such as the elderly, disabled, mentally ill, and special needs populations. Safety net organizations like FQHC’s that provide health services to uninsured, low‐income, and vulnerable persons continue to look for ways to coordinate services among providers to improve access to quality care. IOM Report –Oral Health in America
The 2011 Institute of Medicine (IOM) reports, Advancing Oral Health in America and Improving Access for Oral Health for the Vulnerable and Underserved, recommended that the Health Resources and Services Administration (HRSA) address the need for improved access to oral health care through the development of oral health core competencies for health care professionals. HRSA Response to IOM Report
HRSA developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative with three inter‐ related components. ‐ Creation of a HRSA prepared draft set of oral health core clinical competencies appropriate for primary care clinicians. ‐ Presentation of a systems approach to delineate the interdependent elements that would influence the implementation and adoption of the core competencies into primary care practice. ‐ Characterization and outline of the basis for implementation strategies and translation into primary care practice in safety net settings. HRSA’s Response
HRSA provided the following five domains as part of a starter set. Each domain contains a core set of clinical competencies: • Risk Assessment • Oral Health Evaluation • Preventive Interventions • Communication and Education • Inter professional Collaborative Practice How Can We Improve This Picture?
Expand the oral disease prevention workforce by engaging primary care teams in the fight against oral disease. Why Us? We have regular contact Population receiving with high‐risk groups:Total population at regular medical care risk for caries and •Childrenperiodontal disease •Pregnant women •Adults with diabetes Population receiving regular dental care We are well equipped for the work: We routinely assess risk, screen for disease, offer preventive interventions, and refer patients to specialists when treatment is needed. We can apply these core competencies to oral disease.
18 This Is a Natural Extension of What We Already Do…
• Provide information about healthy diet, measure BMI. • Advise on sunscreen, look for suspicious moles.
• Oral disease is a common problem with serious health impacts. • Patient and family behavior (self-care) is key. • Most problems can be recognized early and treated to reduce impact. 19 Oral Health Delivery Framework
Five actions primary care teams can take to protect and promote their patients’ oral health. Within the scope of practice for primary care, possible to implement in diverse practice settings.
Preventive interventions: Fluoride therapy, dietary counseling to protect teeth and gums, oral hygiene training, therapy for substance use, medication changes to address dry mouth.
Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015 20 HEENT to HEENOT
Health care providers have performed physical assessment of the head, ears, eyes, nose, and throat (HEENT) in the same fashion since its inception centuries ago. For the majority of primary care providers, the traditional HEENT examination excludes examination of the oral cavity, as well as omitting oral health and its linkages to overall health in the health history. A simple solution to this problem is to introduce a paradigm shift to teaching the HEENT examination by using the “HEENOT” approach. Incorporating “O,” for oral cavity assessment, adds a comprehensive focus on the oral‐systemic history and examination of the teeth, gums, mucosa, tongue, and palate. The HEENOT approach means that educators and clinicians can “NOT” omit oral health and intraoral assessment from the history and physical examination performed by DO’s, MDs, PAs, NP’s and other health professionals. HEENT to HEENOT
This strategy will increase oral health screenings, detection of oral health comorbidities, and preventive interventions, including referrals to dental colleagues by primary care providers in community‐based settings for acute or chronic health problems commonly seen in primary care practice. Plan
Decide on a population of patients to target: adults with diabetes, pediatrics, pregnant women, other? Clinical assessment Workflow analysis: current and future state Planning for structured referrals EHR modifications and report creation
23 Additional Resources
Oral Health Implementation Guide
Sections 1 and 2: Introduction and the Case for Change
24 Oral Health: An Essential Component of Primary Care
• White paper, published June 2015 • A call to action: . Case for change . Oral Health Delivery Framework . Supporting actions from stakeholders . Case examples from early leaders: Confluence Health, The Child and Adolescent Clinic, Marshfield Clinic Available at: http://www.safetynetmedicalhome.org/change‐ concepts/organized‐evidence‐based‐care/oral‐health
Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015 25 Smiles For Life™
Smiles for Life: A National Oral Health Curriculum was originally developed in 2005 by the Society of Teachers of Family Medicine Group on Oral Health. It consisted of four modules, and was based in part on materials developed by regional consortia of family physicians, dentists, and educators between 2001 and 2004 including: Washington Interdisciplinary Oral Health Project (ICOHP) University of Texas Health Science Center San Antonio Project Smile Physician Oral health Education in Kentucky (POHEK) University of Connecticut Schools of Medicine and Dental Medicine Smiles For Life™
https://www.smilesforlifeoralhealth.org/build content.aspx?tut=555&pagekey=62948&cbre ceipt=0 46 highlighted dental counties 40 out of 55 FQHCs
Elevated Blood Pressure ‐Metrics Ohio’s FQHC – Blood Pressure Metric
As partners in patient‐centered care, the integration of oral health and primary care is a priority in Ohio’s FQHCs. Screening for hypertension by the dental team during daily intake is an effective method to educate and appropriately refer patients to their physician. To date, 18% of all patients screened in the dental setting have been identified as having elevated blood pressure and referred for follow‐up care.
OACHC –Oral Health Metrics
Dental sealant measure – UDS measure Patient no show rate Treatment plan completion rate Caries risk assessment rate
Inter collaborative projects: ‐ Fluoride varnish applications in medical settings ‐ Elevate Blood pressure screenings in dental settings Shared Patient’s data and other quality metrics in Ohio’s FQHC – Cincinnati Health Department data
* Treatment completed, caries risk assessment,Sealant utilization data (UDS required),Denta and Medical shared users, Broken appointments. A Collaborative Action to Integrate Oral Health with Primary Care in Health Centers
Anna Novais, DMD Denise Saker, MD, MPH, FAAP
March 6th, 2019 The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Presentation Title Here No RelationshipsAdditional Line to ifDisclose Needed
Anna Novais, DMD Denise Saker, MD, MPH, FAAP Date Here PRESENTATION OBJECTIVES
1- Describe critical steps for the successful implementation of an integrated medical-dental care practice in a community health center.
2- Describe the role of each medical and dental team member in the establishment of an interprofessional practice.
3- Demonstrate how oral health care services have been incorporated into pediatric care visits by both medical and dental teams. Interprofessional Collaboration BACKGROUND STORY
● Bobbie Sterne Health Center
(formerly Elm Street Health Center)
● Urban Community Health Center
● City of Cincinnati Primary Care (Cincinnati Health Department) All Children Thrive Collaborative Cincinnati Children’s Hospital
• Multi-disciplinary initiative
• Address an area of great need which has an impact on the health of children in poverty
• Dental caries and oral health deficit
• We wanted to work towards establishing a Dental Home for our patients. Interprofessional Collaboration All Children Thrive
SMART AIM Increase the number of patients age 9 to 27 months establishing a dental home at Elm Street Health Center from 24% to 50% by 12/31/18.
TEAM MEMBERS Last Name First Name Role *Saker Denise Pediatrician *Wadhwa Gauri Health Center Manager Childress Toshia Medical Assistant Robinson Sharma RN (PHN-2) Novais Anna Dentist McClanahan Kelsey Dental Assistant Carter Nancy Associate Dental Director Funk Hollin RN (PHN-3) Hallums VaLinda Administrative Technician Interprofessional Collaboration AN INTEGRATED DENTAL HOME
• Use the Electronic Health Record to document the dentist as part of the child’s care team
• Refer our patients to the dental office IN OUR HEALTH CENTER – (cards/improved tracking)
• Dr. Novais learned about efforts to integrate oral health and primary care at the NNOHA (National Network for Oral Health Access) meeting and remembered that Dr. Saker is ALWAYS trying to have her patients seen for dental care at Bobbie Sterne.
• We HAVE AN IDEA!!! An integrated health home Interprofessional Collaboration Established Practice
. Interprofessional Collaboration American Academy of Pediatrics
• Oral Health should be part of primary care
• How to do it? Practice Tools
• Resource:
https://www.aap.org/en-us/advocacy- and-policy/aap-health-initiatives/Oral- Health/Pages/Oral-Health-Practice- Tools.aspx American Academy of Pediatrics Campaign for Dental Health
• Resources in English and Spanish • Addresses fluoride questions Interprofessional Collaboration How to Make it Happen?
• Enlist the expertise of the health center manager to organize meetings
• Discuss schedule coordination, common goals
• Develop a workflow (using the EHR, workstations, fluoride administration, signaling)
• Have a practice session (or 2!)
• Tweak the workflow (PDSAs)
• Create a workstation for dental
• Set a date to start regular sessions Interprofessional Collaboration How to Make it Happen?
High Level Process Map Template
Process: Establishment of Dental Home Beginning Boundary: Patient Arrives in Clinic
Ending Boundary: Patient Leaves Clinic
Patient RN/MA Dental Provider RN/MA Patien registered rooms provider assesses Exits Patient t patient enters for patient Patient Leaves Arrive knee to STARTs knee visit STOP Interprofessional Collaboration How to Make it Happen? AND HERE WE GO! Interprofessional Collaboration Care Team Update/Dental Home Interprofessional Collaboration Integrated Care: Medical-Dental Pediatrics
• Pilot program: started at Elm Street Health Center and expanded to the Northside Health Center.
• 6mo-5yo age focus on “Dental Peds Days”
• Dental utilizes medical facility (3 medical rooms); oral exams provided in conjunction with well-child visits.
• Medical schedule accommodated to serve similar age group
• Medical/dental visits from 8am-12pm twice a month (usually 12 pts scheduled)
• Integration may improve fiscal sustainability and contributes to the IHI Triple Aim: improves care, population health, and reduces cost. Interprofessional Collaboration Integrated Care: Medical-Dental Pediatrics
● Early oral health education for parents
● Early detection of caries for high-risk kids
● Early establishment of a dental home
● Early exposure to a dental provider
● Fluoride, SDF for caries prevention
● Convenient multi-purpose patient visits
● Increased dental patients and encounters
● Ability to intervene in the oral health of parents Interprofessional Collaboration Integrated Care: Medical-Dental Pediatrics
● Dental Exams: 112 ● Dental Preventive treatments: 103 ● Treatment Complete: 65 ● Dental NPs: 50 ● Dental Center Referrals: 25 ● Hospital Referrals: 2
Productivity ● Average pts/day: 10 ● Time: 8‐12AM→ 2.5 pts/hr ● Separate encounters for medical and dental
Better outcomes: early intervention, improved access, and a facilitated referral system. Interprofessional Collaboration Medical-Dental Pediatric Care Dental Armamentarium Interprofessional Collaborations Brush, Book, and Bed Program Interprofessional Collaborations Brush, Book, and Bed Program Bobbie Sterne Dental Center Integrated Care: Medical-Dental Pediatrics
STAFF EQUIPMENT
• • 2 FT Dentists/2 PT Dentists 8 fully plumbed, operational dental operatories
• 1 Hygienist
• 1 Dental Lab • 1 Front Office Dental Assistant
• 1 Expanded Functions Dental • Nitrous Oxide Sedation Assistant (EFDA)
• Health center offers • 2 Certified Dental Assistants comprehensive dental (CDA) treatment and co-located with medical (Primary care, Peds, • 3 Dental Assistants (DA) OB/GYN) and WIC services. Chronic Disease Management Innovative Interventions Making a Positive Difference
1- Silver Diamine Fluoride (SDF 38%)
● Multiple SDF applications ● Prevention focus (remineralization) ● Arrests lesion (tooth preservation) ● Antimicrobial and reduces pain ● Non-invasive procedure ● Positive dental experience ● Sealants placed on occlusal fissure ● (cost-effective vs. restorations) ● Less OR (GA) and pediatric referrals ● Maximizes prevention and restorative appointments ○ Can be applied by DAs, EFDAs, DHs Chronic Disease Management Innovative Interventions Making a Positive Difference
2- SDF-modified Atraumatic Restoration (SMART) Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Oral Health Competencies Interprofessional Collaboration Integrated Care: Medical-Dental Pediatrics
THANK YOU!!! Oral Health Isn’t Optional !! Thank you
Open Wide and Ask Questions