Medical-Dental Partnerships To Promote Oral Health

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Medical-Dental Partnerships To Promote Oral
Health

• Wendy E. Mouradian, MS, MDPediatrics, Pediatric
  Dentistry, Health Services (Public Health)
• Childrens Hospital Regional Medical Ctr
• University of Washington

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Acknowledgements

• Comprehensive Center for Oral Health Research
  (NIH - NIDCR)
• Maternal and Child Health Bureau, HRSA
  (Leadership Education in Pediatric Dentistry)
• Bureau of Health Professions, HRSA
  (Interdisciplinary Childrens Oral Health
  Promotion)

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Summit Themes

• Whatcom County
• Engage community members
• Present local data
• Discuss best practices
• Raise awareness of dental caries as an infectious
  disease
• Problem solve children, adults, elderly

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Surgeon Generals Report on Oral Health (2000)

• Oral diseases are common and consequential
• Linked to overall health and well-being
• Profound disparities in oral health status
• Disparities SES, rural, minorities, vulnerable
  Preventive measures exist
• Research / translation of science needed
• http//www.nidcr.nih.gov/sgr/sgr.htm

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Vulnerable Populations

• Children
• Elderly
• Special Needs
• Adult populations

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Medical-dental Educational Collaborations

• Journal of Dental Education Aug 2003
• Overview and commentary childrens oral health
• Washington State (family medicine residents)
• Mouradian et al
• North Carolina (pediatricians, family physicians)
• Rozier et al

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Medical-dental Educational Collaborations

• Journal of Dental Education Dec 2003
• Overview and commentary special pop.
• Elderly populations
• Pyle et al
• Mental retardation, other special needs
• Fenton et al

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Medical-dental Educational Collaborations

• Journal of Dental Education Apr 2004
• Overview and commentary -Public health approaches
• Kids Get Care (case management model)
• Hennessey et al
• OPENWIDE (CT Head Start)
• Wolfe et al

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Childrens Oral Health

• Dental care is most common unmet health need of
  children
• More likely to lack dental insurance
• Access to dental care limited u/ Medicaid
• Disparities by SES, rural areas, special health
  needs/disabilities

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Impact on Children

• Disease burden- 52 million school hours
• Pain, infection, growth problems, ER visits
• Hospitalizations and surgeries
• Long term impact on economic, quality of life
• Children with special needs impact on general
  health

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Reach Children Early

• Prevention works
• Dental disease develops early lt1-2 yrs
• Disease transmitted from mother
• Reach in primary care, child care, Head Start,
  educational, social systems

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Washington State Smiles Survey, 2000

• Disparities in oral health outcomes by
  race/ethnicity, SES
• Many children lack access to dental care
• Washington state data do not compare favorably
  with national data
• Kathy Phipps, MPH, DrPH, consulting
  epidemiologist

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Prevalence of ECC
Washington 1-year-olds
Washington 2-year-olds
NHANES III 2-year-olds
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Trends Over Time
Caries Experience
1994
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Adult Oral Health

• Periodontal disease is common
• Maternal periodontal disease and LBW
• Periodontal and cardiovascular disease
• Pulmonary impact of oral disease
• Mothers choose health care for families
• Oral-systemic health diabetes, others
• Oral cancer 8000 people die a year

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Older Adults

• More periodontal disease
• More oral-systemic health impacts
• More oral cancer
• Impact of medications
• Long term care facilities
• Complex social arrangements

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Mental Retardation and Special Needs

• Lack of data on oral conditions
• Impact of medications, conditions
• Down syndrome and periodontal disease
• Effect of anti-convulsants
• Difficulty with self-care
• Complex guardianship, living arrangements

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Key themes Special populations

• Importance of oral-systemic interactions
• need for interdisciplinary collaboration
• Diminished mental/ motor capacity
• need for special arrangements and emphasis
  upon prevention
• Difficulty accessing care
• need for better training, other solutions
• Complex social and cultural factors
• Lack of good data

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Context

• Disparities may worsen
• Demographics diversity child poverty survival
  those with special needs, elderly
• Workforce gaps not enough dentists retiring
  most not in Medicaid physicians lack training
• Policy gaps lack of insurance oral care not
  medically necessary (especially impacts special
  needs population)

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Partnership

• Department of Pediatric Dentistry
• Department of Family Medicine
• UW Affiliated Family Practice Residency Network
• Department of Medical Education and
  Bioinformatics

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ICOHP

• Goal 1 Training family medicine residents and
  faculty in oral health promotion
• Objectives
• Develop curricula in childrens oral health, 0-5
• Pilot, implement in WWAMI sites
• Evaluate effect of training on knowledge,
  attitudes, behavior
• Disseminate curricula

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UW FP Residency Network Sites
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Geographical barriers
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Assumptions

• Biggest obstacle will be buy-in
• Tailor curriculum to physician needs
• Integration with dental sector in community
  critical
• Sustainability will require additional work

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Focus Groups Faculty/ Residents, Staff

• Barriers
• Oral health not on their radar screen lack
  knowledge/self-efficacy
• Providers busy oral health not a priority
• Concerned about the evidence base
• Confusion about physician role
• Lots of baggage about dentists

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Focus Groups Faculty/ Residents, Staff

• Opportunities
• Care about children in pain
• Unable to answer parents questions
• Prevention is a high priority
• Already providing health education
• Acutely aware of access issues
• Committed to underserved communities

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Address Barriers and Opportunities

• Increase motivation
• Oral health important
• Impact on children
• Increase practitioner knowledge
• Normal dental development
• Caries process

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Address Barriers and Opportunities

• Review evidence base (USPSTF CDC Fluoride
  recommendations)
• Frame in terms of primary care roles
• Anticipatory guidance
• Nutrition/feeding
• Injury prevention emergency management
• Special issues for CSHCN

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Address Barriers and Opportunities

• Address resentment towards dentists
• Work with dentists one-on-one
• partner with ABCD, community health clinics,
  pediatric dental trainees
• Increase communication, lines of referral
• Reinforce principles of family-centered,
  culturally competent care
• already part of residency culture / training

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ModulesFrame to issues raised

• Module 1 Public Health Overview Oral Health
  Promotion and Practice
• Module 2 Normal Dental Development/ Pathology
• Module 3 Dental Caries Collaborating with
  Dentists
• Module 4 Dental Trauma and Emergencies
• Module 5 Oral-systemic Health Interactions

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Respond to Requests for More Information

• Module 6 Atraumatic Restorative Technique
• Module 7 Maternal oral health
• Module 8 Adolescent oral health
• Module 0 Managing the change process

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Trainings to date

• Seattle
• Yakima
• Spokane
• Olympia
• Boise
• Anchorage
• Pending Valley, Vancouver

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Frame for Primary Care Providers

• PCP Roles
• 1. Anticipatory guidance/ counseling
• 2. Risk assessment - oral screening, history
  (maternal history)
• 3. Applying fluoride varnish
• 4. Dental referral / collaboration
• 5. Monitor oral-systemic health interactions
• 6. Manage simple dental trauma
• 7. Maternal oral health counseling

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North Carolina

• North Carolina Statewide Medicaid program
  pediatricians/family practitioners provide oral
  health education / screening exams / apply
  fluoride varnishes to young children 0-3 / dental
  referrals
• Partnership Supported by dental, pediatric,
  family practice societies

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Others to watch

• MCH Oral Health training for non-dental providers
• http//www.mchoralhealth.org/PediatricOH/index.htm
  
• Minnesota training, fluoride varnishes
• http//meded1.ahc.umn.edu/fluoridevarnish/xindex.h
  tm
• AAP presentations for chapters stay tuned

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Medical Mantra

• Address medical training gaps
• Change perceptions among medical professionals
• Integrate oral health into systems of care
  especially for vulnerable populations
• Develop medical-dental collaborations
• Leadership in policy/ education
• Standard of practice that includes oral health

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Key Points

• Disparities in oral disease /access to care
• Impact on vulnerable populations
• Workforce critical not enough providers
• Prevention is key - if started early
• Integrate oral health into overall health
• Partnerships are needed to make this happen

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