Evaluation of the Integrated
Dental Medicine Care Model
Dr. Sean G. Boynes
Director of Dental Medicine
CareSouth Carolina
Society Hill, South Carolina
Topical Subgingival Application
•
Microcapillary tip facilitates subgingival delivery
0.1 ml
•
0.4 ml
Pleasant artificial banana flavor
Cetacaine Chairside® vs oraqix ®
Onset Time
Duration of
Action
#
Applications
Cost
30 secs
20 mins
20
119.99
30 secs
30-60
mins
20
79.99
Integrated Dental Medicine
• Is based in the fact that oral health is a vital
aspect to overall systemic well being
• A partnership between all health care providers
that identifies and creates a care structure with
the areas of overlap that can improve the patient
experience
• Sets goals to improve both oral and systemic
outcomes
Integrated Dental Medicine
• Systemic Treatment with Dental Care
• Improving oral health with medical
communication
• Creating opportunities
▫ Medicine providing preventive dental care
Systemic Treatment with Dental Medicine
•
•
•
•
•
Diabetes
Cardiovascular Disease
Stroke Intervention
HIV/AIDS
Behavior Health (Opportunity)
Diabetes Oral Health Connection
• Oral Health Complications of Diabetes
▫
▫
▫
▫
▫
▫
Tooth loss
Oral pain
Extensive Periodontal Disease
Coronal and root caries
Soft tissue pathologies
Decrease in salivary function
Diabetes Oral Health Connection
• Medical and oral health inter-relationships
▫
▫
▫
▫
▫
Glycemic control
Neuropathy
Nephropathy
Retinopathy
Cardiovascular disease
Diabetes impact on oral health
Salivary Flow Rate (Xerostomia)
• Saliva not only begins the digestive process; it
protects teeth by preventing decay, regulating
your mouth's acidity level and keeping bacteria
in your mouth from running rampant.
• But when saliva's lacking, plaque builds, enamel
erodes, cavities quickly form and fungal growth
runs rampant
Salivary Flow Rate (Xerostomia)
• Diabetes and Dry Mouth
▫ Prevalence of dry-mouth symptoms (xerostomia),
▫ Prevalence of hyposalivation
▫ Possible interrelationships between salivary
dysfunction and diabetic complications.
Self Report – Xerostomia
• Does your mouth usually feel dry?
• Do you regularly do things to keep your mouth
moist?
• FOX QUESTIONNAIRE
▫ Do you have to sip liquids to aid in swallowing
foods?
▫ Does your mouth feel dry when eating a meal?
▫ Do you have difficulties swallowing dry foods?
▫ Does the amount of saliva in your mouth seem too
little?
Moore PA, et al. Type 1 diabetes mellitus, xerostomia, and salivary flow.
Oral Surg, Oral Med, Oral Pathol, Oral Radio, Endod. 2001; 92:281-91.
Self Report – Xerostomia
Diabetes Subjects
Control Subjects
Does your mouth usually feel dry? (MOUTH DRY?)
15.8%
10.3%
p = 0.047
Do you regularly do things to keep your mouth moist?
20.2%
14.1%
p = 0.058
Fox Questionnaire:
24.1%
p = 0.045
17.6%
Salivary Flow Rate Measures
Diabetes Subjects
Control Subjects
Resting Salivary Flow Rate (ml/min)
0.22 + 0.014
0.28 + 0.016
Stimulated Salivary Flow Rate (ml/min)
0.89 + 0.047
1.02 + 0.054
p = 0.045
p = 0.071
Moore PA, et al. Type 1 diabetes mellitus, xerostomia, and salivary flow.
Oral Surg, Oral Med, Oral Pathol, Oral Radio, Endod. 2001; 92:281-91.
CONCLUSIONS
• Hyposalivation and xerostomia were significant oral complications in
type 1 diabetic patients.
• Xerostomia was frequently associated with more frequent snacking
behaviors and with the current use of cigarettes.
• Higher rates of dental decay were found among diabetic subjects
having low resting salivary flow rates.
• Elevated fasting blood glucose concentrations were associated with
significant reductions in resting salivary flow rates.
• Loss of salivary amylase!
Periodontal Disease
Periodontal Disease
• According to the Centers for Disease Control, over 47% of
adults over 30 years of age have some form of periodontal
disease (“gum disease”)
• Periodontal disease is more common in men, people living at
or below federal poverty, those with less than a high school
diploma and current smokers
• Some research suggests that people with periodontal disease
were more likely to develop heart disease or have difficulty
controlling blood sugar*
*National Institute of Dental and Craniofacial Research
Diabetes and Periodontal Disease
• Strong and growing evidence points to an
association between diabetes and periodontal
disease
▫ One third of patients with diabetes have oral
complications, mainly periodontitis and tooth loss
▫ Large body of evidence shows that periodontal
disease is a complication of diabetes mellitus
▫ Periodontal disease. Is more severe in individuals
with diabetes, especially those with poor control
Guggenheimer J, et al. Insulin dependent diabetes mellitus and oral soft tissue
pathologies. Part 1: prevalence and characteristics of non candida lesions. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2000; 89:563-69.
Grossi SG et al. Assessement of risk for periodontal disease. Risk indicators for
attachment loss. J Periodontol. 1994; 65:260-67.
Khader YS et al. Periodontal status of diabetics compared with nondiabeteics: a meta
analysis. J Diabetes Complications. 2006; 20:59-68.
Oral health impact on diabetes
Dentistry influencing systemic well being
Oral Health - Diabetes
• A national focus in recent years
• Surgeon General’s report, Oral Health in
America, emphasized the need to better
understand the correlation between systemic
and oral disease
▫ Reported oral health complications associated
with diabetes
Poor Glycemic Control
• Expanding body of literature implicating severe
periodontitis as a risk for poor glycemic control
• Periodontal treatment in individuals with
diabetes can improve glycemic control
▫ Leading to a reduction of the effects of diabetes
Moore PA. The diabetes-oral health connection. Compend. 2002; 23:14-20.
Taylor GW et al. Periodontal disease: asscoiations with diabetes, glycemic control and
complications. Oral Dis. 2008; 14:191-203.
Darre L et al. Efficacy of periodontal treatment on glycemic control in diabetic patients: a metaanalysis of interventional studies. Diabetes Metab. 2008; 34:497-506.
Poor Glycemic Control
Remove all the teeth?!?!?!
• [Edentulous] Periodontal disease and
subsequent tooth loss significantly impact
overall health by compromising a patient’s
ability to maintain a healthy diet and proper
glycemic control.
▫ Edentulous participants consumed fewer
vegetables, less fiber and carotene, and more
cholesterol, saturated fat and calories than
participants with 25 or more teeth.
Joshipura KJ, Willett WC, Douglas CW. The impact of edentulousness on food and nutrient
intake. J Am Dent Assoc. 1996; 127:459-467.
Poor Glycemic Control
• [Edentulous] University of Pittsburgh study
found that diabetic participants who had partial
tooth loss or who were edentulous were
generally older, had lower incomes and
education and had higher rates of nephropathy,
neuropathy, retinopathy, and peripheral
vascular disease.
Moore PA. The diabetes-oral health connection. Compend. 2002; 23:14-20.
Poor Glycemic Control
• Landmark Study – Pima Indian Tribe (Az)
▫ Effective treatment of periodontal infection and
reduction of periodontal inflammation is
associated with a reduction in level of glycated
hemoglobin.
▫ In addition, at 3 months, significant reductions (P
≤ 0.04) in mean HbAlc reaching nearly 10% from
the pretreatment value.
▫ Control of periodontal infections should thus be
an important part of the overall management of
diabetes mellitus patients.
Grossi SG. Treatment of Periodontal Disease in Diabetics Reduces Glycated
Hemoglobin. J Periodontol 1997;68:713–719.
Poor Glycemic Control
• Stewart et al. – statistical review of study
suggests that periodontal therapy was associated
with improved glycemic control in persons with
type 2 DM.
▫ During the nine-month observation period, there
was a 6.7% improvement in glycemic control in
the control group when compared to a 17.1%
improvement in the treatment group, a
statistically significant difference.
Stewart JE, et al. The effect of periodontal treatment on glycemic control in
patients with type 2 diabetes mellitus. J Clin Periodont. 2001; 28:306-10.
CSC Oral Health Diabetes Clinic
Year Two
10
9
8
7
6
5
4
3
2
1
0
3
6
9
12
months months months months
A1C
Number of
Medications
Integrated Dental Medicine
Medical Role
• Oral examination
• Oral health education
• Appropriate referral for care
Oral Examination
• Caries identification
▫ Surface caries easily identifiable
▫ Incipient decay harder to identify but more
important with preventive strategies
• Gum disease
▫ Gingivitis vs. periodontal disease
Caries/Cavities
Caries/Cavities
Periodontal Disease
• Rather than a single disease entity, periodontal disease is
a combination of multiple disease processes that share a
common clinical manifestation.
• The etiology includes both local and systemic factors.
• The disease consists of a chronic inflammation
associated with loss of alveolar bone.
• Advanced disease features include pus and exudates
[infection – more difficult to anesthetize].
Page RC, et al. Pathogenesis of inflammatory periodontal disease. A
summary of current work. Lab. Invest. 1976; 34 (3): 235–49.
Periodontal Disease
Diabetes and Severe Tooth Pain
• Patients less likely to eat full meal or eat at all
with oral pain
• However, patients will take regular dosage of
insulin, metformin, etc…
• Hypoglycemia is the most common diabetic
emergency in dental offices
▫ Seen with some regularity in large dental,
especially clinics with emergency schedules
Haas DA. Management of medical emergencies in the dental office: conditions in each country,
the extent of treatment by the dentist. Anesth Prog 2006; 53:20-24.
Mealey BL. Diabetic emergencies in the dental office. Armenian Medical Network.
http://www.health.am/db/diabetic-emergencies/
Diabetes and Severe Tooth Pain
New hypothesis being examined
• Chronic severe oral pain may effect A1Cs / Daily
BG
▫ Lack of appropriate diet with same medicinal
management
• Possible increase risk with cardiovascular issues
▫ Patients with A1Cs lower than 6% have increased
cardiovascular issues/eventsx
• Dietary changes may occur: a diet in higher
saturated fat and “bad calories” (convenience
food)
X- Calayco DC et al. A1C and cardiovascular outcomes in type 2 diabetes.
Diabetes Care 2011; 34:177-183.
Referral
• Different aspects
▫ See immediately
▫ See this week
▫ Normal appointment
Patient Name: _____________________________________
Date:_____________________
Last Dental Visit: ________________________
Location of Pain: Bottom left, Bottom right, Top left, Top right
Patient Address: _____________________________________ Contact Number: ____________________________________
ASK THE
PATIENT:
MUST BE
SEEN
TODAY!
See tomorrow
or this week
See when available
“On a scale of 1 to
10 how badly are
you hurting?”
Pain level 7 to
10
Pain level 4 to 6
Pain level 3 or below
“How long have
you been
hurting?”
This level for a
week or less
This level of pain for a
month or less
Had these symptoms for
over a month
“Describe the type
of pain or
discomfort you
feel.”
Throbbing
Broken tooth, lost a
filling
Chip tooth, broken filling
“How are you
sleeping at night?”
Keeps me awake
at night
Able to sleep with
medication
Able to sleep
“What occurred to
make the tooth
begin to hurt?”
Unknown or bit
down on
something hard
Bit down on
something or other
cause
Sweets; candy causes it to
hurt
“Have you noticed
any other
symptoms?”
Fever and
swelling
------
------
A1C>9 =STW
Two or more checkmarks
in this section results in
the patient needing to be
seen today.
Three or more
checkmarks results
in patient needing
appointment this
week
Three or more checkmarks
results in the patient being given
the next available standard
appointment time
Dental Role
Periodontal disease as a predictor
• Conflicting data; HOWEVER,
• Studies have demonstrated that it is an early
complication of diabetes
• Pre-existing periodontitis predicts poor
cardiovascular and renal outcomes
Lalla E, et al. Diabetes related parameters and periodontal conditions in children. J
Periodontal Res. 2007; 42:345-49
Seremi A, et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care. 2005;
28:27-32.
Shultis WA, et al. Effect of periodontitis on overt nephropathy and end-stage renal disease in
type 2 diabetes. Diabetes Care. 2007; 30:306-11.
Dental-Medical Screening
• Individuals tend to seek routine and preventive
oral care more frequently than routine and
preventive medical care
Glick M. The potential role of dentists in identifying patients’ risk of experiencing coronary heart
disease events. J Am Dent Assoc. 2005; 136:1541-46.
Dental-Medical Screening
• Analysis of the NHANES revealed that an
algorithm using simple periodontal measures,
available only in dental settings, and risk factors
known by patients may offer an unrealized
opportunity to identify undiagnosed individuals.
• Finding supported by two other retrospective
studies.
Borrell LN, et al. Diabetes in the dental office: using NHANES III to estimate the probability of
undiagnosed disease. J Periodontal Res 2007; 22:559-565.
Li S, et al. Development of clinical guideline to predict undaignosed diabetes in dental patients. J Am
Dent Assoc. 2011; 142:28-37.
Stauss SM, et al. The dental office visit as a potential opportunity for diabetes screening: an analysis
using NHANES 2003-2004 data. J Public health Dent 2010; 70:156-162.
1
• At least one of the following self-reported risk factors
• Family history of diabetes
• Hypertension
• High cholesterol
• Overweight/Obesity
2
• Continue to receive a periodontal examination
• Simple algorithm composed of two dental parameters
• Number of missing teeth
• Percentage of deep periodontal pockets
• Optimal cut-offs of ≥26% deep pockets and ≥4 missing teeth
3
• A point of care HbA1C test
• Fasting – at second appointment
• The addition of a fingerstick HbA1C with 2 dental parameters
are of significant merit (73% to 92% increase in sensitivity)
Lalla E, et al. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent
Res 2011; 90:855-860
Dental-Medical Screening
• Screening/Identification protocol reflects a clinical
approach that can be easily used in all dental care
settings
• Dentists are willing to incorporate screening for medical
conditions into their practices
▫ A national, random sample of U.S. general dentists was
surveyed by mail by means of an anonymous questionnaire
▫ Respondents were willing to refer patients for consultation
with physicians (96.4 percent), collect oral fluids for
salivary diagnostics (87.7 percent), conduct medical
screenings that yield immediate results (83.4 percent) and
collect blood via finger stick (55.9 percent).
Greenberg BL, et al. Dentists’ attitudes toward chairside screening for medical
conditions. J Am Dent Assoc. 2010; 141:52-62.
Integrated Model
• Cost Effective
▫ Jeffcoat et al. found that $10, 672 was spent for
medical care for patients with diabetes who did
not have periodontal treatment.
▫ Revealed an average reduction of approx. $2,500
(23%) in cost per year of those with periodontal
treatment
 Dental care estimated cost of standard fees (CSC)
 $463.00
Barriers to Diabetic Health Promotion
• Diabetic Patients
▫ Income, employment, and cost
▫ Time priorities
• Dental-Medical Students
▫ Focus on requirements and clinical skills
▫ Patient treatment versus Patient management
▫ Surgeons mentality / Drill and Fill
• Dentist Practitioners
▫ Current knowledge and access to information
▫ Economics of dental practice
• Physicians
▫ Coordination of medical and dental care
▫ Relevance to medical management and complications
• Regulation/Accreditation Agencies
▫ Counter Productive
▫ Counter Intuitive
Cardiovascular Disease
ASVD and Periodontal Disease
• A link between oral health and cardiovascular
disease has been proposed for the greater part of
the last century.
• Recently, concern about possible links between
periodontal disease (PD) and atherosclerotic
vascular disease (ASVD) has intensified
▫ This is driving an active field of investigation into
possible association and causality.
ASVD and Periodontal Disease
• Both processes share several common risk
factors, including cigarette smoking, age, and
diabetes mellitus.
• Patients and providers are increasingly
presented with claims that PD treatment
strategies offer ASVD protection; these claims
are often endorsed by professional and
industrial stakeholders.
Lockhart et al.
American Heart Association, April 18, 2012.
• Available data indicate a general trend toward a
periodontal treatment–induced suppression of
systemic inflammation and improvement of
noninvasive markers of ASVD and endothelial
function.
• HOWEVER, The effects of PD therapy on
specific inflammatory markers are not consistent
across studies, and their sustainability over time
has not been established convincingly.
Lockhart et al. Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an
Independent Association? : A Scientific Statement From the American Heart Association, April 2012.
http://circ.ahajournals.org/content/early/2012/04/18/CIR.0b013e31825719f3.long
Lockhart et al. (AHA)
• HOWEVER, This review highlights significant
gaps in our scientific understanding of the
interaction of oral health and ASVD.
• HOWEVER, Identification of clinically relevant
aspects of their association or therapeutic
strategies that might improve the recognition or
therapy of ASVD in patients with PD would
require further study in well-designed controlled
interventional studies.
Oral Health and Stroke
Periodontal Disease and Stroke
• Post hoc analysis of prospective longitudinal
studies and smaller case control studies have
reported the association between periodontal
disease and stroke
• Early studies demonstrated that periodontal
disease appears to bear a stronger association
with stroke than with coronary artery disease.
Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis,
cardiovascular disease, and stroke. A systematic review. Ann Periodontol. 2003;8:38-53.
Beck JD, Offenbacher S. Systemic effects of periodontitis: epidemiology of periodontal disease and
cardiovascular disease. J Periodontol 2005;76:2089-2100.
Periodontal Disease and Stroke
• In a combined analysis of two prospective
studies, periodontal disease was found to
increase the risk of incident stroke nearly three
fold.
• Proposed mechanisms include inflammation
mediated pro-coagulant state, atherosclerosis
mediated by direct microbial invasion of blood
vessel wall, and interaction with recognized
vascular risk factors.
Janket et al. Meta analysis of periodontal disease and risk of coronary heart disease and stroke. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95:559-569.
Periodontal Disease and Stroke
• Several studies have also reported a major
positive association between periodontal disease
and ischemic stroke, in stroke free patient
populations.
• A new study completed at the Univ. of South
Carolina also found periodontal disease is
independently associated with recurrent
vascular events in stroke/TIA patients and aortic
arch thickness
Sim SJ et al. Periodontitis and the risk for non fatal stroke in Korean adults. J Periodontol 2008;79:16521658.
Grau AJ et al. Common infections and risk of stroke. Nat Rev Neurol 2010; 6:681-694.
Oral Health and Stroke
• Regular dental examinations allow for early detection
and treatment of oral conditions associated with the risk
of further vascular events.
• Loss of teeth or masticatory function is associated with
poor compliance of home health care in stroke patients.
• Less than half of stroke survivors in the United States
received dental care, leaving substantial room for
improvement.
• Stroke survivors need education about the importance of
regular dental care, particularly minority groups.
Sanossian N, et al. Subpar utilization of dental care among Americans with a history of stroke. J Stroke
Cerebrovasc Dis. 2011 May-Jun;20(3):255-9. Epub 2010 Jul 24.
The Dental Intervention Model for Stroke Prevention
• A true controlled dental intervention study for stroke
prevention is not available
• Currently in the early stages of research and development.
• A handful of studies reveal:
▫ Women may have better benefit than men.1
▫ Quality of life can be maintained if poor oral health is reduced
through better daily oral hygiene practices, education, and
professional maintenance.2
▫ The effects of healthy teeth in the prevention of stroke and
cardiovascular disease appear to be quite compelling.3
1.
2.
3.
Brown TT, et al. The effect of dental care on cardiovascular disease outcomes: an application of
instrumental variables in the presence of heterogeneity and self-selection. Health Econ
2011;20(10):1241-56.
Tran P and Mannen J. Improving oral healthcare: improving the quality of life for patients after a
stroke. Spec Care Dentist. 2009 Sep-Oct;29(5):218-21.
Bernal-Pacheco O, Román GC. Environmental vascular risk factors: new perspectives for stroke
prevention. J Neurol Sci. 2007 Nov 15;262(1-2):60-70. Epub 2007 Jul 25.
HIV/AIDS
HIV/AIDS
• Oral examinations are an essential component
for early recognition of disease progression and
comprehensive evaluation of HIV-infected
patients.
• Correlation between CD4 count and oral
manifestations
Glick M et al. Oral manifestations associated with HIV related disease as markers for immune
suppression and AIDS. OOO 1994; 77:344-349.
Oral Infection and HIV/AIDS
• Odontogenic abscess are known to progress and disseminate
with immunosuppression
▫ Linked with advanced HIV
▫ Can lead to brain abscess
▫ Issue with emergency room treatment and no dental follow
up / intervention
• May require longer antibiotic cycle following extraction
▫ Patient specific
• Increase risk of dry socket
▫ Some success with SOCKIT oral gel
• Should be stressed to patients: the issues with oral health and
the need to report any oral pain
Walsh LJ. Serious complications of endodontic infections: some cautionary tales. Australian Dent J
1997; 42:156-159.
Twomey CR. Brain abscess: an update. J Neurosci Nurs 1992; 24:34-39.
Happonen R. Periapical actinomycosis: a follow up study of 16 surgically treated cases. Endod Dent
Traumatol 1986; 2:205-206.
SOCKIT Oral Gel
• SockIt! is a hydrogel wound dressing for
management of any and all oral wounds.
▫ Providing fast, constant pain relief without
causing a numb sensation;
▫ Protecting from chemical and microbial
contamination; and
▫ Promoting optimal wound healing.
Pain Management-SOCKIT
Kennedy et al. Gen Dent 2009;57:420-427.
Behavioral Health
Depression and Oral Health
• TMJ Issues
• Patients diagnosed with TMJ/myofascial pain
and other joint conditions had significantly
higher levels of depression and somatization
• When treating patients with facial pain, dentists
should consider the possible presence of
psychopathology and, if necessary, consult
appropriate mental health professionals.
Yap AUJ. Depression and somatization in patients with temporomandibular disorders. J Prosth Dent
2002; 88:479-484.
Sipila K, et al. Association between symptoms of temporomandibular disorders and depression: an
epidemiological study of Northern Finland 1966 birth cohort. Cranio: Journal of Craniomandibular
Practice 2001; 19:183-187.
Depression and Oral Health
• Depression, loss of teeth, and dentures
• Three major sources that significantly influence
patient responses to tooth loss and subsequent
dentures exist.
▫ Parental/spousal influences,
▫ The symbolic significances of teeth
▫ Current life circumstances.
Friedman N. The influences of fear, anxiety and depression on the patients adaptive responses to
complete dentures Part I. J Prosth Dent 1987; 58:687-689.
Friedman N. The influences of fear, anxiety and depression on the patients adaptive responses to
complete dentures Part II. J Prosth Dent 1988; 59:45-48.
Depression and Oral Health - LLD
• Late-life depression initially occurs after age 65
and is a major public health concern because
elderly people who are at high risk constitute an
ever-expanding segment of the population.
▫ Individuals under treatment for LLD and those
whose illness has not been diagnosed or treated
often present to the dentist with significant oral
disease.
Friedlander AH et al. Late-life depression: its oral health significance. International Dental Journal 2003;
53:41-50.
Depression and Oral Health - LLD
• LLD is frequently associated with a disinterest in
performing oral hygiene, a cariogenic diet, diminished
salivary flow, rampant dental decay, advanced
periodontal disease, and oral dysesthesias.
• Appropriate dental management necessitates a vigorous
preventive dental education program, the use of artificial
salivary products, antiseptic mouthwash, daily fluoride
mouth rinse and special precautions when administering
local anesthetics with vasoconstrictors and prescribing
analgesics.
Friedlander AH et al. Late-life depression: its oral health significance. International Dental Journal 2003;
53:41-50.
Arthur H et al. Dental management of the geriatric patient with major depression. Special Care in
Dentistry 2008; 13:249-253.
Dementia and Oral Health
• The Leisure World Cohort Study
▫ Men with inadequate natural masticatory function
had a 91% greater risk of dementia than those with
adequate natural masticatory function (≥10 upper
teeth and ≥6 lower teeth).
▫ This risk was also greater in women but not
significantly so.
▫ Dentate individuals who reported not brushing
their teeth daily had a 22% to 65% greater risk of
dementia than those who brushed three times
daily.
Paganini-Hill A. Dentitition, dental health habits, and dementia: the leisure world cohort study. Journal of
the American Geriatrics Society 2012; 60:1556-1563.
Medical Referral to Dental
Evaluating the Medical Referral Process
• Quality Study to evaluate pilot program of
medical referrals into dental program
▫ Urgent Need Appointments
• Analysis of all referrals until 50 (n=50) referrals
were completed
• Total of 69 referrals evaluated with 19 no shows
(27.5% no-show rate)
▫ Total Division no show rate at time was
approximately 4%
Urgent Care Referrals from Medical
• NO SHOW EVALUATION (n=19)
▫
▫
▫
▫
Age: 22.6 ±19.3
Female: 42.1% / Male: 57.9%
Reported pain level: 8.22 (±1.8) [n=9]
Referral Sources:
 Community Health Center- 47.4%
 CHC Pediatrician
- 52.6%
Urgent Care Referrals from Medical
• NO SHOW EVALUATION (n=19)
• Time to Dental Team Contact
▫
▫
▫
▫
Less than 24 hours: 52.6%
24-48 Hours: 21.0%
3-5 Days: 5.3%
7-10 Days: 21.0%
▫ MEAN TIME TO CONTACT: 1.94 (24-48 hours)
Urgent Care Referrals from Medical
• NO SHOW EVALUATION (n=19)
• Time to Dental Appt
▫
▫
▫
▫
▫
Less than 24 hours: 5.3%
24-48 Hours: 21.0%
3-5 Days: 21.0%
7-10 Days: 47.4%
More than 10 Days: 5.3%
▫ MEAN TIME TO APPT: 3.26 (3-5 days)
Urgent Care Referrals from Medical
• No Show - Medications RX:
▫
▫
▫
▫
None: 63.1%
Amoxicillin 500mg TID at 10 days: 15.8%
Penicillin VK 500mg TID at 5 days: 10.5%
Amoxicillin 500mg with Vicodin 7.5mg: 10.6%
Urgent Care Referrals from Medical
• No Show Evaluation – Description of Oral Issue
▫
▫
▫
▫
▫
▫
Dental Home Needed: 36.8%
Multiple Cavities: 21.0%
Loose/Mobile Teeth: 10.5%
Pain/Swelling: 10.5%
Oral Pain: 10.5%
Abscess/Broken Tooth: 10.5%
Reason for No Show
• Unable to Correspond: 73.7%
• Personal Conflict: 15.8%
• Transportation: 10.5%
Evaluation of Medical Referral Process
• Completed referrals by 12 physician teams
(n=50)
▫ Referrals most likely completed by nursing staff
and occasionally by front office
▫ 2 physicians completing referral forms sent to
CSCDM – 0% no show rate on these referrals
 Add’l information – form completed in the presence
of patient
Evaluation of Medical Referral Process
• Age: 39.3 ±19.8
• Male: 32.0% / Female: 68.0%
• Dental Coverage (Self Report)
▫ Yes: 66.0% (Actual- 52% [Medicaid-28%; private-24.0%])
▫ No: 34.0% (Actual- 48%)
• Referral Source
▫
▫
▫
▫
▫
▫
▫
Community Health Center:
CHC Pediatricians:
School Based RNs:
Hospital Emerg. Dept:
Private Practice:
Veterans Administration:
Oncology Group Practice:
38.0%
30.0%
12.0%
6.0%
6.0%
4.0%
4.0%
Evaluation of Medical Referral Process
• Time to Dental Appt
▫
▫
▫
▫
▫
Less than 24 hours: 6.0%
24-48 Hours: 22.0%
3-5 Days: 34.0%
7-10 Days: 30.0%
More than 10 Days: 8.0%
▫ MEAN TIME TO APPT: 3.12 (3-5 days)
Evaluation of Medical Referral Process
• Questionnaire to patients consisting of a series
of care related questions
• Completed by all 50 subjects
Patient Questionnaire
• Have you been to the ER in the last year for the
same oral/tooth issue that brought you here
today?
▫ YES: 48.0%
▫ NO: 52.0%
Patient Questionnaire
• When was the last time you saw a
dentist/hygienist for a cleaning and
examination?
▫
▫
▫
▫
▫
Less than six months
Within last year
Within last two years
Two to four years
More than four years
26.0%
14.0%
12.0%
14.0%
34.0%
Patient Questionnaire
• Why did you not complete that care or continue
with the dentist?
▫
▫
▫
▫
▫
▫
▫
▫
Did not like dentist / office
Cost of care
Did not take insurance
Transportation
Lost dental insurance
Confused by explanation of care
Pain went away
Family obligations
[8.5% stated that could not recall]
29.8%
23.4%
12.8%
8.5%
6.4%
4.2%
4.2%
2.1%
Patient Questionnaire
• Rate the importance of your overall oral health
▫ 8.54 out of 10 (±2.13)
Patient Questionnaire (Likert)
• 8 questions used the Likert scale to determine
agreement with statement
▫
▫
▫
▫
▫
1- Strongly agree
2- Agree
3- Neither agree or disagree
4- Disagree
5- Strongly disagree
Patient Questionnaire (Likert)
• I found it unusual that my doctor/physician
referred me directly to a dentist for care.
▫ 1.16 ±1.69 (Strongly Agree)
• My teeth have a very important impact on my
overall health.
▫ 1.82 ±1.02 (Agree)
• It is absolutely necessary for the dentist to have
knowledge of my own personal medical history
or doctor treatment.
▫ 1.74 ±0.99 (Agree)
Patient Questionnaire (Likert)
• Because the dentist only treats the teeth, it really
is not necessary for him/her to know all of the
medicine I take.
▫ 3.02 ±1.62 (Neither)
• The dentist does not really need to know my
entire medical history because I am being seen
for an emergency/urgent care appointment.
▫ 3.50 ±1.13 (Neither -to- Disagree)
• I feel it is very important for my doctor to talk
with my dentist to help coordinate my complete
health care.
▫ 1.56 ±0.77 (Agree -to- Strongly Agree)
Patient Questionnaire (Likert)
• I prefer and enjoyed this process of my dentist
and doctor/physician talking to each other
during my appointments with them both.
▫ 1.70 ±0.76 (Agree)
• I do not feel comfortable talking with the dentist
about my medical history.
▫ 4.02 ±0.98 (Disagree)
Comparing Medical History
• Comparisons between the Medical History
provided by a physician completed H and P and
patient’s self report to dental office (n=24)
▫ H and P included 1.15 ±0.37 more diagnoses than
the patient’s dental self report
▫ Missing:





Smoking (7)
Substance abuse (3)
Arthritis (3)
Diabetes (3)
Joint replacement; MI; stomach ulcer (2)
 Asthma; nervous disorder; pulmonary hypertension (1)
Comparing Medications
• Comparisons between the medication list provided
by the physician and patient’s self report to dental
office (n=25)
▫ Physician’s medication list contained 3.13 ±2.91 more
medications than the patient’s self report
▫ Missing







Hydrocodone / APAP (10)
Aspirin (7)
Ibuprofen (4)
Tobacco cessation [patch/gum] (4)
Metformin (3)
Albuterol; lisinopril; omeprazole; warfarin; xanax (2)
Flonase; claritin; metoprolol; valium; plavix (1)
Physician RX for oral treatment
• Significant variation
• 14 different RX found with 12 physicians
Physician RX for oral treatment
• MOST COMMONLY SEEN
• None: (44.0%)
(16%)
• Amox Suspension (125mg/5mL) (10.0%)
• Penicillin VK (500) TID 5days; Ibuprofen (800) (10.0%)
• Amox(500) TID 7days;Ibuprofen(800);Vicodin(7.5)
Physician RX for oral treatment
• Categorical Breakdown (n=28)
• Antibiotic (100%)
▫
▫
▫
▫
Amoxicillin (60.7%)
Penicillin VK (17.9%)
Augmentin (10.7%)
Clindamycin (10.7%)
• Pain Management (75%)
▫ Vicodin (39.3%)
▫ Ibuprofen (32.1%)
▫ Tramadol (3.6%)
Physician description of oral issue
•
•
•
•
•
•
•
Abscess of tooth or teeth:
Large cavities or cavity:
In need of dental exam:
Broken tooth:
Large cavity with pain:
A1C >9:
6 other descriptors:
36.0%
26.0%
12.0%
6.0%
4.0%
4.0%
12.0%
Evaluating possible variables with No-Shows
▫ Age of No-Show patients: 22.6 [vs. 39.3]
▫ Sex of no shows (males vs. females)
▫ Physician vs. Nurse vs. Front Office
 Patient with copy of referral in hand
▫ No difference with time to appt
 Mean for both groups at 3-5 days
▫ Description of oral health issue
 “Dental home needed” descriptor less likely to keep
appointment as opposed to “abscess/infection or
oral pain”
▫ RX treatment not impactful
▫ Referral Source???
A microcosm case study
Hello all,
I wanted you to know of our clinical day yesterday. Approximately 50% of the kids seen had severe
odontogenic infection requiring antibiotic coverage and complaining of pain that kept them up at
night, I have provided pictures from just a few of the children seen yesterday and please understand
that most of these kids on the schedule had similar issues. Since the initiation of this program -----------, we have been in an uphill battle to improve the oral health of the communities we serve. These
communities are still in dire need of oral health care including more community outreach, education
programs, and direct care. We have also supplied over 8,000 toothbrushes and toothpaste in the
communities we serve and yet we continue to have children/families report not having toothbrushes
or toothpaste at home (yesterday only 30% of the kids seen stated having their own toothbrush at
home). Additionally, the school nurse ------- informed me that she feels we are still not getting forms
back from children who need our services most. A sentiment shared by another nurse ---------.
Almost all of the patients seen were new to our system and the majority has never seen a dentist
before. The need for our services is still far outside of our ability to supply, especially as it relates to
education and preventive programs. We must continue to work to improve oral health in these
communities and find ways to expand our education programs that I feel includes involving our
pediatrician offices in the education process so that parents understand the importance of oral
health care. Please let me know if you have questions and more importantly let me know if you have
any ideas on making sure we are reaching out to the parents/guardians of the kids that we are not
getting forms back from.
Regards,
Questions???