Navigating the Dental Safety
Net in San Francisco
Irene V. Hilton, DDS, MPH
SFDPH Dental Services
UCSF Department of Family & Community
Medicine
Objectives


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To understand the the Dental Safety Net in
San Francisco
To identify appropriate dental referrals for
routine dental care and for dental
emergencies for DPH patients.
To learn what constitutes a dental
emergency and how primary care staff can
initiate management
Course

Describe SF Dental safety net
» Children
– Emergency & Routine & Specialty
» Adults
– Pregnant & Non-pregnant
– Routine & Specialty & Emergency

Dental Emergencies
– Assessment & Management
SF Dental Safety Net

FQHCs
»
»
»
»
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SFDPH
NEMS
NAHC
SMHC
Dental Schools- UCSF & UOP
VA- Emergency only unless 100% service
related disability
Clinic by the Bay
Dentists accepting DentiCal (≈ 40 offices)
2014 Changes
Prior to Jan. 1, 2014- estimate 200,000
adults w/o dental insurance in SF
 Jan. 1, 2014- ACA adds all US born
adults to MediCal- 15,000 new SFDPH
enrollees will have dental benefits
 May 1, 2014- California restores basic
dental benefits for adult MediCal
beneficiaries (cut July 2009)

SFDPH Dental Services

Surveillance
» K screening dental caries prevalence

Population based
» CHDP case management
» CCS handicapping malocclusion/orthodontics
» School based sealant program

Clinical Services
» 5 sites + YGC

Policy/Partnerships/Collaboration
SFDPH Dental Clinics
•
•
•
•
5 FTE dentists @ 5 sites + YGC
SAFHC & CPHC- children & perinatal
SEHC & PHHC- children & perinatal & adult
TW- Homeless & HIV, adult
• SFGH Oral Surgery
– UCSF managed collaboration
– Extractions only, GA
– Children & perinatal & adult
SFDPH Basic Dental Care
Provided
 Diagnostic
 Preventive
 Hygiene/cleaning
 Fillings
 Uncomplicated
extractions
 Emergency- open & drain
infected teeth
 Anterior root canal –
SEHC & PHHC
Not Provided
 Dentures, partials,
crowns, bridges,
implants
 Surgical extractions
 Root Canal - Posterior
teeth
 Specialist care
 Sedation
Medical Respite and Sobering
Center (Polk St)
Chinatown Public
Health Center
(CPHC)
CHPY Larkin Street Clinic
Maxine Hall Health Center
(MHHC)
Housing & Urban Health
Clinic (HUHC)
Medical Respite and Sobering
Center (Fell St)
Curry Senior Center
Tom Waddell
Health Center
(TWHC)
CHPY Cole Street Clinic
Ocean Park Health Center
(OPHC)
San Francisco General
Hospital Oral Surgery Clinic
(SFGH OS)
Castro Mission Health Center
(CMHC)
Potrero Hill Health
Center (PHHC)
Special Programs
for Youth (SPY)
Silver Avenue
Family Health
Center (SAFHC)
Southeast Health
Center (SEHC)
CHPY Hip Hop to Health
Clinic
CHPY Balboa Teen Health
Center
CHPY Hawkins Clinic
Interprofesssional Oral Health
Competencies for Primary Care
Assess & evaluation oral health status
 Preventive interventions
 Educate & address concerns
 Refer

Training Curriculums
Smiles for Life
www.smilesforlifeoralhealth.org
 Oral Health Nursing Education and
Practice (OHNEP)
http://www.ohnep.org/
 A+merican Academy of Pediatrics
http://www.ohnep.org/
 http://www.paeaonline.org/index.php?ht
=d/ContentDetails/i/144233

Accessing Care
Children
SF has universal care- MediCal +
Healthy Kids program
 Any child 0-18 has access to health care
coverage including dental
 MediCal covers to age 21- HK does not

Children- Routine & Emergency
Dental Care
Public & private providers
 Population desired since has payer
source
 Case management sometimes needed
 CHDP list every 6 months- website

Role of Primary Care

Discuss beliefs & attitudes that can be
barriers to optimal oral health for kids
» Tap water
» “Just baby teeth”
» Parent dental experience
Children- Specialty Care Issues

Pediatric Dentistry- management issues
» Age, amount of treatment, special needs
» Only UCSF does GA
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Orthodontics (age 11-19)
» CCS provider panel
» Refer to general dentist first

Oral surgery- SFGH wisdom teeth
Adult Dental Care
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Adults have huge pre-existing existing dental
needs, especially if have not accessed care
for several years
Most common dental diseases- cavities &
gum disease- are chronic progressive
conditions
Dental treatment $$$ because equivalent to
ambulatory same-day surgery
Return of Adult Denti-Cal!
May 2014

Returning
» Exam/x-rays
» 1 visit cleaning
» Fillings
» Front root canals
» Prefab crowns
» Full dentures
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Staying- emergency Tx
ACA & Adult Dental
Coverage?
US-born/documented < 133%
FPL
Denti-Cal
US-born/documented >133%
FPL
Φ
Undocumented
Φ
Perinatal May 1, 2014
Full Scope MediCal
 Exam/x-rays
 Hygiene/cleaning
 Emergency
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Fillings
Front root canals
Prefab crowns
Full dentures
Pregnancy Only MediCal
 Exam/x-rays
 Hygiene/cleaning
 Emergency
Perinatal
SFDPH has been providing full DPH
dental scope to perinatal clients,
regardless of payer status
 Only safety net provider offering this
 Tremendous demand from out of
network clients

Perinatal- Routine &
Emergency Dental Care
For in-network default is SFDPH clinics
 Complete referral form & fax to clinic
 https://www.sfdph.org/dph/files/MCHdoc
s/PerinatalOralHlthRefForm022009.pdf

Role of Primary Care

Discuss concerns that may be barriers
to optimal oral health for perinatal clients
» Dental anesthesia
» X-rays
» Getting dental treatment
Adults- Routine & Emergency
Dental Care
Full Scope MediCal
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FQHCs
» SFDPH- 5 sites
» NEMS
» NAHC
» SMHC
UCSF & UOP
Dentists accepting
DentiCal (≈ 40
offices)
No Dental Coverage

SFDPH
» SFHN memberDiscounted fees
» SFHN non-memberEmergency only

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VA- Emergency only
Other SF safety net
providers-sliding
scale/discount
Oral Surgery Clinic @ SFGH

Monday-Wednesday-Friday
9AM-11AM
 1PM-3:30PM
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
206-8104
What They Do
Extractions
 Biopsies

On call from ER
 Reduction of fractures
 Trauma
 Acute infection management
Who & How to Refer

Children
» Emergent- trauma, swelling, pain
» Routine- 0-5 with obvious need for
extraction- broken teeth
» General anesthesia
» Routine- late teens with third molar/wisdom
teeth
Who & How to Refer

Perinatal
» Emergent- trauma, swelling, pain
» Routine- obvious need for extractionbroken teeth
» MUST HAVE MEDICAL
CLEARENCE/PERINATAL ORAL HEALTH
REFERRAL FORM
» May need follow-up to insure care
Who & How to Refer- Adults
Full Scope MediCal
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Emergent- trauma,
swelling, pain
Routine- obvious
need for extractionbroken teeth
Wisdom teeth
No Dental Coverage
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
Self pay- same as
MediCal
Provider of last resortmedically indicated
Acute Dental Emergencies
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Trauma
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Pain
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Infection
Soft Tissue Trauma
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Intra-oral highly
vascularized
Only suture if
extensive
Antibiotic or tetanus
if indicated
Soft diet
Analgesic
Hard Tissue Trauma
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Jaw fractures
Limited opening
Bite “off”
Refer to SFGH OS
for reduction
Tooth Displacement- Avulsion
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Permanent tooth- hold the tooth by the crown
(part of tooth which is above the gumline).
IF there is dirt on it rinse it under tap water
(NEVER SCRUB), and immediately place it
back in the socket
If this is impossible, the tooth should be
placed in cold milk, special solution or wet
gauze. To dentist ASAP
Tooth Displacement- Avulsion

Studies indicate if tooth is re-implanted within
one-half hour after the accident, 95% success
rate for normal re-attachment and growth

Due to viability of periodontal ligaments which
attach root of tooth to jawbone
Other Tooth Trauma

Fractured crown
Intrusion
Extrusion
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Refer to dentist
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Pain  Infection
Occasional Pain
Occasional pain from decayed teeth
or lost fillings is not a true dental
emergency
 However, if left untreated these could
over time progress to the acute phase
 Dental referral indicated

Severe Constant Pain

Most frequently caused by trauma or
infection in the tooth or gums
Analgesic- Rx’d or OTC
 Dental referral indicated
 Extraction most frequent treatment
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Localized Swelling
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Limited to bone around infected tooth or
Draining fistula
If left untreated may progress to acute phase
Analgesic & antibiotic if appropriate
All swellings have to be definitively treated by
removing the source of infection (extraction or
root canal)
Dental referral indicated
Acute Swelling
New or increasing facial swelling
affecting the eyes or distention of the
mandible
 If other signs of infection are present i.e.
fever, nausea, disorientation, malaise,
blurring of vision or inability to swallow


Immediate referral to OS or ER
Other Acute Pain
Erupting teeth
 Soft tissue: Primary herpetic stomatitis,
acute periodontitis, burning mouth
 Mucositis from chemotherapy
 TMJ, trigeminal neuralgia, other
systemic conditions


Palliative care
Case
4 y/o male fell this afternoon while
running after cousin
 Mother stated slight bleeding from tooth
area, initial crying, couldn’t get a good
look
 Bump on head- bring to urgent care
 After assessment for other injuries…
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Clinical Exam


Visual findings?
What do you
recommend?
SFDPH Dental Services
http://www.sfdph.org/dph/comupg/oservic
es/medSvs/dentalSvcs/dentalSvcs.asp
“You cannot have good
health if you have bad teeth”