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How can health IT help improve oral health care for special populations?

Unique Oral Health Needs
There is a broad range of special populations, including children, pregnant women, individuals with mental, physical or developmental disabilities, and those with other diseases such as HIV/AIDS, heart disease, cancer, or diabetes, who have unique needs with respect to oral health and therefore may require complex care and oral health care that is integrated with medical care. Further, it is important to note that many of the compounding diseases listed here (such as cancer, heart disease, and diabetes) more often affect among minority and underserved populations.  

Children
According to the Surgeon General’s 2000 Report on Oral Health in America, dental disease is the single most common chronic childhood disease, approximately five times more common than asthma and seven times more common than hay fever. Further, dental decay can lead to early tooth loss, which can cause impaired speech and low self-esteem. Additionally, the General Accounting Office (GAO) notes that poor oral health has been related to decreased school performance, as pain from tooth decay can be distracting and interrupt concentration on schoolwork. More information about how health IT can help provide quality oral health care to children is discussed in HRSA’s Pediatric Oral Health and Health IT Module.

Pregnant Women
Pregnant women are at an increased risk of gingivitis due to hormonal changes experienced during pregnancy. Several sets of professional guidelines and policy statements exist regarding perinatal oral health care and are highlighted in a July 2010 Issue Brief from the Children’s Dental Health Project (CDHP). Among the guidelines included in this Brief are the 2006 New York State Department of Health’s Oral Health Care During Pregnancy and Early Childhood Practice Guidelines which provide recommendations for prenatal, oral health and child health providers. These Guidelines note that pregnancy is an opportune time to educate women about preventing dental caries in young children, one of the most common childhood problems. Control of oral diseases improves a woman’s quality of life, and has the potential to reduce the transmission of oral bacteria from mothers to children. The CDHP Issue Brief also references the 2010 Oral Health During Pregnancy and Early Childhood: Evidence-Based Guidelines for Health Professionals from the California Dental Association (CDA). These Guidelines are intended to assist health providers as they deliver oral health services to pregnant women. It discusses oral conditions which are common among pregnant women, the association between periodontal disease and adverse pregnancy outcomes, and the control of oral diseases in pregnant women as a strategy to reduce the transmission of cariogenic bacteria from mother to child.

Several studies note a link between the oral health of mothers and their infants. As cited in the Fact Sheet “Oral Health and Health In Women: A Two-Way Relationship”, Jeffcoat et al. and Offenbacher et al. discuss evidence that a mother’s periodontal disease may contribute to the risk of having a preterm birth or low birthweight. Further, a policy brief on Access to Oral Health Care During the Perinatal Period notes that “currently, there are no comprehensive national guidelines dedicated to addressing appropriate oral health treatment protocols during the perinatal period.” As Eke et al. discuss in a 2005 article, for many women, pregnancy is the only time they have medical and dental insurance and thus provides a unique opportunity to access care.

Special Care Dentistry
Special care dentistry may be used in reference to care for individuals with disabilities or those with systemic diseases. The Special Care Dentistry Association (SCDA) defines special care dentistry as “that branch of dentistry that provides oral care services for people with physical, mental, developmental, or cognitive conditions which limit their ability to receive routine dental care.” The National Institute of Dental and Craniofacial Research's (NIDCR) defines special care in oral health as tailoring oral health management to the individual needs of patients who have medical conditions that cause them to require more than routine oral care. In this context, persons with special needs may include those with diabetes, heart disease, genetic disorders, or other diagnoses. The NIDCR notes that most patients with special needs can be successfully treated in general dental practices.

The American Academy of Periodontology discusses several ways in which gum disease may be linked to heart disease and stroke. One theory states that oral bacteria enters the bloodstream and contributes to clot formation, which can lead to heart attacks. A second theory is that inflammation caused by periodontal disease increases plaque buildup, which may contribute to swelling of the arteries. A 2009 paper by Vincent E. Friedewald et al. concludes that individuals with periodontal disease are twice as likely to suffer from coronary artery disease, compared to individuals without periodontal disease. Periodontal disease may also worsen existing heart conditions. Oral infections have also been linked to increased likelihood of suffering a stroke.

Diabetic individuals are also considered a special population with respect to oral health, as diabetes can lead to changes in the oral cavity and oral disease can impact the progress and/or control of the systemic disease. As noted by the National Diabetes Education Program, dentists and dental hygienists may need to pay particular attention to the effects of diabetes on the health of the gums and periodontal tissues. Diabetes can lead to increased likelihood of severe periodontal diseases, taste disorders, pain syndromes (burning mouth syndrome), fungal infections, dry mouth, and an increase in dental decay. Additionally, as Demmer et al. discuss in their 2010 Diabetes Care article, periodontal disease impacts A1C and is associated with type 2 diabetes.

Individuals receiving chemotherapy or organ transplantation are another group that has unique oral health needs. As noted by the National Institutes of Health’s National Institute of Dental and Craniofacial Research, these patients require a dental check before starting medical treatment due to the danger of chronic dental disease flaring under immunosuppresed conditions. Similarly, patients receiving heart valve replacements require a dental check prior to surgery to eliminate any dental disease that might infect the new valve. As discussed in a 2003 article from the Journal of the American Dental Association, it is necessary to eliminate the possibility that bacteria from the mouth enter the blood stream during a dental procedure and make their way to the heart.

Persons with HIV/AIDS
Poor oral health can have adverse effects on existing medical conditions, and diminish quality of life for persons with HIV/AIDS, as is discussed extensively in the New York State Clinical Guidelines for HIV and Oral Health.  Further, as noted in the Guidelines, people with HIV are more prone to gingivitis and periodontal disease whether or not they have developed full-blown AIDS. Persons with HIV/AIDS often experience oral manifestations of their illness. By some estimates, more than ninety percent of HIV-infected patients will have at least one HIV-related oral manifestation in the course of their disease. One commonly encountered problem is xerostomia (dry mouth), resulting from polypharmacy, HIV associated sinus disease and impact of the HIV virus directly on the salivary grands. Xerostomia significantly increases the risk of tooth decay and causes difficulty chewing, eating, swallowing, and talking. Difficulty swallowing or eating can impact the ability of the patient to remain compliant with their HIV treatment. Other manifestations may include:

• Oral candidiasis (thrush);
• Painful ulcers or canker sores;
• Oral warts;
• Fever Blisters;
• Hairy Leukoplakia; and
• Ulcers or canker sores.

Use of Health IT to Facilitate Improved Care Coordination
For many of the complex health issues discussed in this section, collaboration among multiple providers is emphasized during treatment. The National Diabetes Education Program’s Pharmacy, Podiatry, Optometry, and Dental Professionals’ Work Group developed guidelines describing how diabetes treatment should be a collaboration among all care providers, including oral health professionals. They note that cross-disciplinary treatment referrals can improve health care among special populations, such as patients with diabetes. The National Maternal and Child Oral Health Resource Center recommends that as part of the preconceptional planning and perinatal care, health care providers such as obstetricians should, among other things, discuss with a woman how oral health affects her health, how it will affect her child, and offer referrals to oral health professionals for treatment. The New York State Department of Health AIDS Institute developed Promoting Oral Health Care for People with HIV Infection, a set of guidelines for clinicians and administrators for initiating and maintaining a high standard of oral care for patients with HIV/AIDS which stresses the role of collaboration between oral health practitioners, medical providers, and social service support staff to achieve optimal health care outcomes. Health IT may also be used to track any oral health performance measures geared towards those providers who treat patients with HIV/AIDS.

Technologies such as health information exchange and electronic health records can assist with the collaboration needed between multiple providers with respect to the oral health care of these special populations. Health Information Exchange (HIE) can assist authorized users in retrieving patient information in a timely manner to ensure the provision of safe and efficient care. Particularly for individuals with multiple conditions, HIE can vastly improve coordination of services and expand the capacity of data sharing between multiple providers, including dentists. Electronic health records (EHRs) can also support care coordination for special populations by documenting services that have been received, sharing medical information among providers, and assisting with the development of care plans. In most cases, the electronic exchange of data is quicker, more efficient, complete and accurate than written, fax, or telephone communications.  Other functionalities, such as computerized provider order entry (CPOE), may be included as part of the EHR system or used on their own to “enable providers to enter medical orders into a computer system that is located within an inpatient or ambulatory setting.” Combining CPOE with clinical decision support (CDS) or a decision support system (DSS) affords significant opportunities for quality improvement activities that directly impact delivery systems and patient outcomes such as improvement of medication safety and workflow, and which can enhance coordination of care for special populations such as those discussed above.  
Additionally, the National Oral Health Policy Center at the Children's Dental Health Project has identified the following five opportunities to improve oral health through health IT:

• Refine electronic dental records and establish a standard for inter-user transfers of information;
• Link dental offices into virtual networks for patient care, quality effectiveness research, and improved administration;
• Link dental services to primary care medical services in virtual networks;
• Improve access to information, raise awareness and inform consumers about appropriate care; and
• Improve the quality of dental care through informatics-based comparative effectiveness research and sharing information on treatment norms.

The HRSA toolkits on Pediatric Oral Health and Health IT and Health IT for HIV/AIDS Care provide more information on how health IT can be applied to improve the care for special populations and some additional related resources are included below.

Related Resources

• Oral Health for Infants, Children, Adolescents, and Pregnant Women Knowledge Path (MCH Library) - This knowledge path directs readers to a selection of current, high-quality resources that analyze data, describe effective programs, and report on policy and research aimed at improving access to oral health care and quality of oral health for infants, children, adolescents, and pregnant women.
• Special Care: An Oral Health Profesonals Guide to Serving Young Children with Special Health Care Needs. This series of five modules is designed to provide oral health professionals with information to help ensure that young children with special health care needs have access to health promotion and disease prevention services that address their unique oral health needs in a comprehensive, family-centered, and community-based manner.
• Public and Private-Sector Efforts to Improve the Oral Health of Pregnant Women: Policies, Programs, and Practices - Paper from the National Maternal and Child Oral Health Resource Center. Provides a sampling of initiatives in the public and private sectors that represent how agencies have built upon the supposed relationship between periodontal disease during pregnancy and unfavorable birth outcomes. This non-systematic web-based review provides information on how academics, insurers, state governments, policy organizations, professional societies, practitioners, manufacturers, and others have featured the oral-systemic connection in their efforts to address the oral health of pregnant women.
• The Special Care Dentistry Association (SCDA) is an international organization of oral health professionals (including dentists, dental hygienists and assistants, non-dental healthcare providers, health program administrators, residents, students and hospitals) dedicated to promoting oral health for individuals with special needs. SCDA provides educational opportunities and information exchange for oral health care professionals who treat patients with special needs, giving members access to useful resources, industry news and exclusive networking and educational events. SCDA advocates for national legislation and is involved in shaping dental residency education, developing practice guidelines and institutional protocols designed to assist practitioners in providing oral healthcare services.
• Special Olympics Special Smiles is another organization dedicated to providing oral health services to individuals with disabilities. This organization, which began in 1993, works to increase access to oral health care for Special Olympics athletes, as well as people with intellectual disabilities. Dental screenings are used as a means to increase awareness of the state of the athletes' oral health for the athletes themselves, as well as their parents and/or caregivers.