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 •