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Dental Care Takes on New Role in Traditional Medical Care Settings

September 16, 2013
By Cindy Hutter

Focus on Dental Cavities
Learn more about a national improvement initiative NICHQ is participating in that is designed to foster the rapid spread of an alternative disease management model for early childhood tooth decay.

Many general and specialty medical clinics for treating children and young adults are putting an increased value on oral healthcare. The focus is having a positive effect on patient outcomes across the health spectrum.
Medical care providers report patients with better dental hygiene not only reduce their amount of tooth decay, which is linked to a variety of chronic conditions, but form healthier eating habits that help lead to lower obesity rates and fewer dental-related emergency room visits. The link between oral hygiene and health outcomes, paired with the reality that dental decay is almost entirely preventable when medical professionals help patients access the care that they need, is driving the shift to teach families the importance of dental care from infancy. However, lower-income families often have difficulty in gaining access to professional dental care and there are misconceptions about how early oral care should begin.

“There has been a real shift in dental care and primary care for children,” says Michelle Fleck, a nurse at Boston Children’s Hospital Primary Care Center in Massachusetts. (The recommendation used to be that children don’t need to see a dentist until 3 years old, but now the American Academy of Pediatrics recommends that children see a dentist as soon as they start to have teeth or by 1 year old.) “By doing early childhood cavity assessments we have found a great deal of children with tooth decay, so incorporating dental health into our primary care practice has helped families to catch issues early and seek out dental care, which they would not have traditionally done.”
Boston Children’s Hospital is one of 13 pediatric practices participating in the NICHQ-led CHIPRA Massachusetts Medical Home Initiative. These practices have been making practice-level policy changes to provide more comprehensive care, including around oral health. Practices are offering fluoride varnish to patients, which makes tooth enamel harder and helps to prevent cavities.
Applying varnish during a well visit in a pediatrician’s office can help to reduce the incidence of cavities in at risk child, especially since children typically visit the pediatrician much more frequently than the dentist, says Ami Gardiner, LPN, of Holyoke Pediatrics Associates in Holyoke, Mass., another participant in the medical home initiative.

Given that offering varnish is a straightforward way to improve oral health in children, why don’t all pediatric practices adopt this practice? The transition isn’t easy. General practitioners require training in how to apply the varnish. Practices also need to set up systems to support the tracking and application of varnish, as well as have support for the change. It’s taken the Children’s team nearly two and half years to offer varnish across the practice. The practice still considers itself in the evaluation stage with just over 50 percent of patients who should have a cavity assessment receiving one. They continue to show steady progress month-to-month.

This flip chart from Boston Children’s Hospital Primary Care Center teaches families techniques for good dental hygiene.
This flip chart from Boston Children’s Hospital Primary Care Center teaches families techniques for good dental hygiene. View the full flip chart.

There’s reason beyond cavity prevention to implement this change, however. Teaching good dental habits early in life doesn’t just prevent cavities, it can also improve healthy eating behaviors. Dental health educational materials (see right) that Children’s Hospital provides to families teaches the importance of limiting juice, sugar-sweetened beverages and junk foods for better oral health. The materials encourage teeth brushing to be the last thing that happens before a child goes to sleep and to only offer water as a beverage the child takes to bed.
“Oral health education can prevent childhood obesity by starting good habits early,” says Fleck. “Parents have been very receptive to this education. A lot of times parents are just unaware the brushing starts very early or that giving a child a bottle with milk after brushing is problematic.”
Oral Health Reduces Hospital Admissions
For patients dealing with special healthcare needs, dental care may not always be a priority. Sickle cell disease, where blood cells change shape under certain conditions, causing intense pain and tissue damage, may not seem to have much to do with dental health. Studies have shown, however, that there is a relationship between lessened symptoms of sickle cell disease and better oral health.
The Maryland iHOMES Network, a participant in NICHQ’s Working to Improve Sickle Cell Healthcare (WISCH) program, determined that many of its late adolescent and adult patients with sickle cell disease were ending up in the emergency room with dental problems.
“We’ve seen multiple patients admitted to the hospital with a tooth infection triggering a pain crisis,” explains Sophie Lanzkron, MD, a hematologist at iHomes. “We’d admit these patients to the hospital and know they have a dental issue and have very limited options of what to do about it. We couldn’t give them penicillin, treat them and send them home to go see a dentist because they didn’t have a dentist or couldn’t pay to have a tooth extracted.”
Because sickle cell pain crises can be brought on by physical stress or infection, Lanzkron and Rosalyn Stewart, MD, hypothesized that dental treatment may be an effective tool for improving health for people with the disorder. To test their theory, in 2012, iHomes started working with dentists to offer preventive dental care—cleanings, filings and X-rays—for their sickle cell patients without dental insurance free of charge. While they have a small sample size of 11, a decline in sickle cell-related emergency care for those patients suggests that dental care is improving their overall health.
“We saw decreases in emergency room and infusion unit visits. We also saw less inpatient visits and decreases in admissions after dental appointments,” says Maryland iHOMES Network Senior Research Data Analyst Lauren Whiteman, MPH.
The iHomes team plans to continue coordinating free preventative dental care for their patients, however, funding the service is a challenge. Dental care is typically covered under Medicare for children but, for adults, the options are very limited. The team says it will keep applying for grants to continue the work. 

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