Making Medical-Dental
Collaboration Work - Lessons
from Across the Country
Hugh Silk, MD, MPH
Clinical Associate Professor
April 13, 2012
Family Medicine and Community Health
Learning Objectives
By the end of this talk participants will be able to discuss:
• Some of the national efforts creating medicaldental momentum
• Educational opportunities for collaboration
• Massachusetts - an example of a comprehensive
oral plan in evolution
• Medical providers and fluoride varnish - a
gateway to more oral health and how we are
making it work
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Acknowledgment: Some materials
today are used from Smiles for Life
8 annotated 50 minute PowerPoint modules
www.smilesforlifeoralhealth.org
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National Medical-Dental
Efforts
But first – why is this important
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The Big Picture
“You are not healthy without good oral health…”
David Satcher, Surgeon General 2000
• Dental care: the most common unmet health need
• Oral disease can severely affect systemic health
• Profound disparities in oral health and access to
care exist at all ages
• Much oral disease is preventable or at least
controllable
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Still Need to Know More!
• Dental caries is the most common
chronic disease of childhood
• Severe gum disease affects 19% of
adults aged 25-44 ~ links to DM, CAD
• 30,000 oral cancers diagnosed
annually; 8000 die
• 50% of the elderly perceive their dental
health as poor/very poor; 33% have
untreated cavities
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And you know the Consequences
• Mounting evidence of aggravating
effects on systemic conditions
• Oral pain
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Poor school performance in children
Work loss in adults
Poor chewing and poor nutrition
Costly emergency department visits
• Dental decay and tooth loss
– Aesthetics and self-image
– Speech and language development
– Costly restoration
Photos: Donald Greiner DDS MS, ICOHP
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The Disconnect
• Children are 2.5 times more likely to
lack dental coverage than medical
coverage
• > 50% of MDs had little or no oral
health training
• Little communication and
cooperation between medical and
dental providers
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More recently…
• 62% of OB-Gyn residency programs
provide no prenatal oral health education
• < 50% of pediatric residencies have 2
hours or less of oral health education
• Only 32% of family medicine residency
directors are satisfied with their residents'
competency in oral health
• 1 in 10 medical school have no OH
curriculum
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Why is this such a big deal?
Because…
• 50 million Americans live in rural or poor
areas where dentist d o not practice
• Only 43% of elderly visit the dentist
• Preventable dental conditions were the
primary reason for 830,590 ED visits (2009)
• Only 34% of pregnant women visit the
dentist
The Medical Home is the Dental Home!
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How we practice
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Prenatal visits - ~13 visits ~4 hours
Infants (WCC) – 11 visits before age two
Children & Teens – 18 visits, plus sick visits
Adults – annually
Geriatrics – admission to NH, every 30
days
• Specialty visits, ED visits, VNA, etc
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However, some good news…
• >90% of physicians think oral health should
be addressed at well visits
• 75% of OB/GYN directors “agreed” that
residents should address oral health
• 95% of peds and FM programs have some oral
health training
• 45% of peds programs teach fluoride varnish
• 80% of medical schools teach about oral cancer;
70% about oral-systemic relationships
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Since 2000
2001
American Academy of Pediatrics: Section on Oral Health
2003
Society of Teachers in Family Medicine: Smiles for Life
2006
NY DPH: Oral Health During Pregnancy and Early Childhood
(2010 CDA Revised OH During Pregnancy Evidence Based Guidelines)
2009
American Dental Association: Access to Care Summit
2010
Dept. of Health and Human Services: Oral Health Initiative
2010
Physician Assistants Leadership Summit on Oral Health
2011
Healthy People 2020: Oral Health = Leading Health Indicators
2011
Institute of Medicine and Health Resources & Service Admin HRSA:
Advancing Oral Health in America
2011
IOM: Improving Access to Oral Health Care for Vulnerable and
Underserved Populations
2011
Assn. of American Medical Colleges: oral health curricula
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Patient-Centered Medical Home
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Personal physician: ongoing relationship with a personal physician trained
to provide continuous and comprehensive care
Physician directed medical practice: the personal physician leads a team
who collectively take responsibility for the ongoing care of patients.
Whole person orientation: provide for all the patient’s health care needs
Care is coordinated and/or integrated across specialists, hospitals, home
health agencies, and nursing homes.
Quality and safety are assured by a care planning process, evidencebased medicine, clinical decision-support tools, performance measurement,
participation of patients in decision-making, information technology, quality
improvement activities
Enhanced access to care is available (e.g., via "open scheduling,
expanded hours and new options for communication").
Payment should reflect the value of "work that falls outside of the face-toface visit," should "support adoption and use of health information
technology for quality improvement," and should "recognize case mix
differences”
– Wikipedia
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“Health Homes”
Move beyond dental and medical homes:
• Set up in same building and conduct
meetings together (e.g. a ‘good’ CHC)
• Have a professional perform “visiting”
consults (e.g. hygienist in MD office once
a week)
• Create lists for proper referrals – know
who does what, what insurance they take,
what patient sets they see, etc
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Culture Change
• Change is difficult
• Change leads to creative solutions
• “Change your thoughts and you change
your world”
– Norman Vincent Peale
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Work synergistically
• Support cross pollination of ideas:
– Dental supporting fluoride varnish done by
medical providers
– Medical supporting dental doing oral cancer
screens, blood pressure monitoring, nutrition
advice
– More inter-professional health in
schools/residencies
– And more!
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Moving Beyond “Our Offices”
• Medical and dental sitting on Head Start,
WIC, school health committees
• Work together on water fluoridation
campaigns
• State Task Force; State Oral Health Plans
• Watch Your Mouth – trainings to learn the
same media messages, social marketing
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The Colorado Experience
• Cavity Free at Three (cavityfreeatthree.org)
• Training practicing oral health and medical
professionals together
• Meet in CHCs, Health Department offices,
Community Centers
• Giving joint faculty appointments in medical and
dental schools
• Use AHEC (Area Health Education Centers)
• “Train-the-trainer” model
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Colorado: Cavity Free at Three
• Train medical and dental to do oral exams,
anticipatory guidance and varnish for all
children under three
• Medical need to learn dental elements;
dental need to learn to be comfortable with
young children and sometimes about
varnish
• Also combine forces for community social
marketing
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Colorado Results
• started in 2008
• 54 Cavity Free at Three, Master Trainers throughout
Colorado
• have had 89 training presentations since inception
• over 1500 multi-discipline individuals trained
• have requests for presentations at 100+ new sites
• distributed over 22,434 fluoride varnish kits through the
trainings
• We estimate the total number of children and families in
Colorado exposed to Cavity Free at Three to be 40,000!
• educational materials have been translated to 8
languages, available at www.cavityfreeatthree.org.
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Educational opportunities for
collaboration
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www.niioh.org
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Third Edition
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Aphthous Stomatitis
Three Clinical Forms
• Minor: less than 7mm, most common
• Major: greater than 7mm
• Herpetiform
Symptoms
• Recurring, painful, solitary, or multiple
ulcers
• White/yellow pseudomemembrane,
surrounded by an erythematous halo
Treatment
• Most mild aphthae require no treatment
• Orabase, topical or intralesional steroids
• Avoid trigger foods and chemicals
Photos: Joanna Douglass, BDS, DDS
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Physician Assistants – On the Move!
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Association of American
Medical Colleges
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Massachusetts - an example of a
comprehensive oral plan in
evolution
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• State plan
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• Backed by:
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The Players
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Better Oral Health Committees
Oral Health Advocacy Taskforce
Oral Health Caucus
Department of Public Health
Massachusetts Medical Society
Massachusetts Dental Society – CAPIR
Dentaquest Foundation
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CMOHI – a regional example
1) Providing school-based dental services for underserved children
– screen, educate, fluoride and sealant applications
– added Head Start centers
2) Increasing the amount of oral health care for underserved
– Actively recruited Medicaid dentist
– Expand/promote Community Health Centers, Dental Hygiene School
3) Advocacy for oral health policy
– Change local legislative, administrative, and regulatory policies
4) Establishing a dental residency program
– Used local health centers/med school
– create interest in treating the underserved; pool of future local dentists
5) Educating health professionals on oral health
– medical students, residents and practitioners using Smiles for Life
– Educate on common issues; build confidence in referrals
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Results
1) 28 schools; 4,423 children (40%);
>20 000 service visits
2) Medicaid dentists 14% -> 55%
Doubled CHC capacity
3) Reimbursement, “cap” policy; 3rd party payer
4) 9 or 15 residents in area, underserved
5) increase local residencies education – peds,
FM, EM and Grand Rounds OB, IS, IM
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Partners
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Commonwealth of Massachusetts
Legislature
*Family Health Center of Worcester
*Great Brook Valley Health Center
Health Care for All and Health Law
Advocates
Massachusetts Coalition for Oral
Health
Massachusetts Delta Dental
Foundation
Massachusetts Dental Society
Massachusetts Department of Public
Health
Massachusetts Society for the
Prevention of Cruelty to Children
(MSPCC)
*Oral Health Initiative of North Central
Massachusetts
*Quinsigamond Community College
Dental Hygiene School
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Southbridge Public Schools
Southern Worcester Neighborhood
Center
*The Health Foundation of Central
Massachusetts
*UMass Medical School's Office of
Community Programs
*UMass Memorial Health Care
United Way of Webster and Dudley
Webster Public Schools
Worcester City Council
Worcester Department of Public
Health
*Worcester District Dental Society
*Worcester District Hygienists'
Association
Worcester Public Schools
South Worcester Neighborhood Center
* Denotes member on steering committee
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Medical Initiatives
• MA Medical Society – Oral Health Summit
– OB, Peds, Fam Med, Int Med, Pub Health,
ENT, Emerg Med, Cards, Endo, MDS, othr
dental experts – DPH, DH, CHW
– The resolution – A Taskforce
– The “hook”
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Medical Education
• Medical Schools
– One by one
– UMass – “every course – spiral curriculum”
• Medical Residencies
– Fluoride varnish = gateway
– Emergency Medicine (procedures)
– IM (lesions), OB (safety/referrals)
• PAs, Pharmacy, Nursing
• CME – AAFP, AAP, on-line
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UMMS Year 1
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Anatomy – saliva, teeth, mouth
Genetics – cleft lip/palate
Doctoring – physical exam
Cancer concepts – ICE case – oral cancer
Infections – strep, biofilm, herpes, thrush
Host Defense – perio and inflammation
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UMMS Year 2
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Cardiology – perio-CAD; SBE prophylaxis
Pulmonology – aspiration pneumonia
The Brain – oral pain
Nutrition – sugar and cavities
Population Health Clerkship –
– 2 weeks in oral public health –
• Headstart, care mobile, prisons
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UMMS Year 3
• Oral Health Clerkship
– Geriatric
– Prenatal
– Pediatric
– Urgent care
– Systemic
– Fluoride varnish
• Disabilities Clerkship
– Special Needs Oral Health
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UMMS Year 4
• Clinical Emergent Problem Solver
– Sepsis from oral infection
• Elective – oral public health
• Oral Health Interest Group –
– 2 talks per year
– 1 community service event
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Medical Providers and
Fluoride Varnish
A gateway to more oral health and
how we are making it work
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Building Upon the Work
Done by Others
• The Gurus
– North Carolina
– Washington
– Maryland
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• AAP 2008 – Preventive Oral Health
Interventions for Pediatricians
– 9 recs including risk history and FV
• 2011 National Quality Forum – includes
FV during WCC as 1 of 43 measures
• In 2007 only 7.5 % of 2-4 year olds in the
US had any fluoride treatment
• In 2009 only 5% of physicians self
reported providing fluoride varnish in MA
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Comprehensive program:
tri-state (CT3.5, MA , RI )
6.5
1.0
• Preparation - Project Coordinator prior to site training to allow our
trainer to enter a practice ready to implement change
• Commitment – ensure the office starts varnish use “same day”
• Practice work flow – identify eligible patients; work it into visits
• Clinical record – incorporate oral health prompts into the record
• Billing –Add codes to encounter forms or EHR billing system
• Train ALL staff – establish buy-in; use web-based training for those
who are absent
• Hands on practice - hands-on patient experiences with hygienist
• Supply provisions - comprehensive informational packet, patient
posters, laminated fact cards, carrying cases with 50 free varnish
packets, patient handouts, gauze, gloves, billing stickers/information
• Follow-up – “adopt a practice”
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Promotion
• Each state AAP, AAFP meeting – booths,
talks, handouts
• Newsletters
• List serves
• Medicaid lists of biggest practices
• Local success stories
• Personal connections
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Building Bridges
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Medicaid – promotion, data, “fixes”, lists
State DPH – trainings
state Dental Society – train age 1 visits
Head Start – coordinate; messaging
Dentaquest – hands on
AAP – promotion, forum
AAFP – presentation, forum
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The next generation
• Training all pediatric and family medicine
residents
• Leaving in place a plan for future training
• Converting offices – continuous education
• >50% of graduates stay in the state
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Year One
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16 residencies
100 offices
Skilled trainers
Residencies with future plan
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Conclusions
• Medical providers have to be part of the
oral health solution
• Education is a key area to focus on
• Learn from our success and mistakes in
Massachusetts
• Takes a Village!
• Fluoride Varnish may be the entry way for
many medical providers
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Questions
www.smilesforlifeoralhealth.org
hugh.silk@umassmemorial.org
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