• Share
  • Add this to...
  • Favorites
  • Del.icio.us
  • Digg
  • Facebook
  • Google Bookmarks
  • Yahoo MyWeb
• 
• 
• 
• 

How can health centers integrate oral health into the primary care setting? How can health IT be used to share information across all providers, including oral health?

Oral health and its implications are issues for both oral health and primary care providers alike. One of HRSA’s top strategic priorities and a goal of the 2010-2015 HHS Strategic Plan is the integration of oral health into primary care. A 2003 policy statement from the American Academy of Pediatrics (AAP) , which was reaffirmed in 2009, notes the importance of engaging primary care providers in children’s oral health. A child’s primary care provider first sees the child early in life, and can play a lead role in the prevention and identification of oral diseases – particularly early childhood caries (ECC).  Furthermore, because ECC is infectious and often transmitted from the mother, the mother’s primary care provider can also influence the oral health of the child by assessing the mother’s risk and providing her with health information and referrals using electronic health records, when available.  The AAP policy statement affirms that “Pediatricians should support the concept of the identification of a dental home as an ideal for all children in the early toddler years.”  Health centers can integrate oral health into the primary care settings by adhering to the guidelines of the AAP, listed below:

Provide every child at least 6 months of age with an oral health risk assessments by a qualified pediatrician or a qualified pediatric health care professional; the below guidance is issued to assist providers in determining risk for caries:

• The Caries Risk Assessment Tool can be used to determine the relative risk of caries of the patient.  Risk can also be assessed by identifying whether a child falls into one of the risk groups listed below:
  • • Children with special health care needs
    • Children of mothers with a high caries rate
    • Children with demonstrable caries, plaque, demineralization, and/or staining
    • Children who sleep with a bottle or breastfeed throughout the night
    • Children in families of low socioeconomic status

• Enter infants identified as having significant risk of caries or assessed to be within one of the risk groups into an  anticipatory guidance and intervention program provided by a dentist between 6 and 12 months of age
• Establish a dental home for the child by referring the child for an oral health examination by a dentist who provides care for infants and young children 6 months after the first tooth erupts or by 12 months of age. 

The dental home is a means of providing a continuous source of oral health care that encourages prevention and provides routine care. The care provided by the pediatric dental home should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. In achieving these ends, the dental home provides a care support system that will link the primary care provider with the oral health care provider. Ultimately, the AAP asserts that dental home should provide the child with:

• An accurate risk assessment for dental diseases and conditions
• An individualized preventive dental health program based on the risk assessment
• Anticipatory guidance about growth and development issues (i.e., teething, digit or pacifier habits, and feeding practices)
• A plan for emergency dental trauma
• Information about proper care of the child’s teeth and gingival tissues
• Information regarding proper nutrition and dietary practices
• Comprehensive dental care in accordance with accepted guidelines and periodicity schedules for pediatric dental health
• Referrals to other dental specialists, such as endodontists, oral surgeons, orthodontists, and periodontists, when care cannot be provided directly within the dental home

Also necessary for consideration in the adoption and implementation of a dental home are several environmental factors – as noted in a background paper prepared for a 2008 HRSA Maternal and Child Health Bureau (MCHB) Expert Meeting on the dental home . Some of the environmental factors presented and explored for consideration in the implementation of a dental home include:

• Expanding knowledge of the risk of early childhood caries and disease management
• Oral health disparity trends and the forces which drive these trends
• Parents’ perceived needs for dental care as well as barriers to obtaining it
• The relationship between the dental and medical professions and dentistry as an independent profession
• Capacity of the dental system to handle children, especially those with special needs,

A wide variety of non-oral health-specific professionals (such as nurses, physicians, physician assistants, or dieticians to name a few) can also play a pivotal role in the provision of oral health for children and a successful dental home. These health professionals often provide primary pediatric care and illustrate the need to integrate oral health into primary care. For instance, if an oral exam by a dentist is not possible within 6 months of a child getting his or her first tooth, another health provider may prove to be the only source of dental screening, and should therefore follow those recommendations made by Bright Futures for the various components of optimal oral health supervision . Some of these components include risk assessment for both the parents and children, performing an oral health screening exam, discussing oral health hygiene with the family and child, and even engaging in some preventive measures, such as the application of fluoride varnishes.

To ensure a functional medical home, the primary care provider and the oral health provider must communicate and share information.  Health IT can facilitate this communication in various ways, such as through health information exchange (HIE) or an electronic health record (EHR) with an oral health module that is accessible by both providers. This sort of technology allows for multiple providers to access and share information about a patient’s oral and overall health, which can be especially important given the connection between oral health and other systemic disease. An EHR or HIE could be used to share information between practitioners and allow both the dentist and primary care physician to appropriately tailor patient education and prevention messages.

A report from the California HealthCare Foundation (PDF - 689KB) , on the topic of retail health clinics, also notes that health IT can facilitate the integration of services into the dental home. The report notes that,

“Electronic dental records and digital x-ray technology would better enable clinics to streamline transfers of patient information to dental homes.  Digital intraoral cameras can greatly facilitate such transfers.  They yield high-quality images that can be sent to a dentist’s office along with x-ray images and the hygienist’s findings.” – Section 3, page 8

Related Resources

• Oral Health Initiative – Council of Community Clinics.  This site describes the integration of oral health and primary care for children ages 0 through 5 at clinics in the San Diego area.  This effort was enabled by the First 5 Commission of San Diego.
• Preventive Oral Health Intervention for Pediatricians – Developed by the American Academy of Pediatrics (AAP) (2008). 
• Dental Health Screening - A Web-based Course – This links to course materials from the University of Minnesota.
• Training Resources – This Web-site provides training resources from the state of Wisconsin for both child and maternal oral health.
• Oral Health Risk Assessment: Training for Pediatricians and Other Health Professionals – American Academy of Pediatrics (AAP).
• Caries - Risk Assessment Tool (CAT) – American Academy of Pediatric Dentists.
• The Dental Home: Summary from an MCHB Expert Meeting – National Oral Health Policy Center at Children's Dental Health Project, available from the National Maternal and Child Oral Health Resource Center – Georgetown University.