MyView: Building practice through interprofessional collaboration
September 17, 2018
Melinda Clark, M.D.
Editor’s note: The ADA Council on Advocacy for Access and Prevention asked Dr. Clark and Ms. Glicken to write this piece for the ADA News to provide readers with the medical perspective of the collaboration between physicians and dentists.
The U.S. Surgeon General Report in 2000 described oral disease as a “silent epidemic,” preferentially affecting minority populations, low socioeconomic strata and the extremes of age. Much effort has been put forth in helping at-risk populations access dental care, but significant care gaps persist. Costs of dental services total over $100 billion annually, with the majority of the dollars spent on restorative care, while oral health disease remains pervasive among low-income, rural, minority and other underserved populations. The Surgeon General report envisioned a national partnership to integrate oral health into primary care, thereby increasing access to preventive services and bridging the gap between medical and dental care.
Medicine and dentistry have entrenched the separation of the mouth from the body through siloed training programs, care delivery systems and payment structures. Consequently, effective collaboration between medicine and dentistry remains rare. Consider that the teeth are the only organ where specialty care is the norm for those who are healthy. We continue to rely on specialists to provide primary prevention with the hope that the current system will expand to meet the massive population need. While we wait, preventable conditions like dental caries remain the most common chronic disease across the lifespan.
The primary care delivery system is in the midst of transforming to meet national health care priorities of reducing health care costs, improving the patient care experience and improving population health outcomes. Primary care teams are positioned to be active partners in oral health integration with their focus on whole human patient-centered care, skills in screening and risk assessment, behavior change counseling and support for patient navigation through the health care system. Arguably the greatest advantage of incorporating oral health prevention into primary care is expanded access, especially for children, as they visit their primary physician on average 13 times in the first 30 months of life. Many young children never see a dental health professional during this critical time, lost opportunities unless the primary care providers educate families about the importance of oral health and discuss nutrition, oral hygiene, fluoride and establishment of a dental home. In 2014, the U.S. Preventive Services Task Force “Dental Caries in Children from Birth Through Age 5 Years” moved oral health prevention from a pet project to a mandate for primary care, with a grade B recommendation for fluoride varnish application starting from tooth eruption through age 5 for all children in the medical home. This standard of care was reinforced with the addition of fluoride varnish to the Bright Futures Periodicity Schedule from tooth eruption through age 5. These recommendations, and others related to chronic disease management in older adults, communicate new expectations for primary care practice and a sense of urgency across health professions to manage patient oral health.
Since the Surgeon General’s “call to action,” many national organizations have endeavored to aid their constituents in oral health integration by educating, training and supporting the components of oral health delivery. These activities are illustrative of the movement to incorporate oral health into overall health care, rather than a discretionary addition to an over-burdened health system. The following are examples of how select health profession and support organizations are working to integrate oral health prevention into primary health care delivery and ultimately reduce the burden of oral disease in America.
In 2001, the American Academy of Pediatrics was among the first nondental health professions to identify oral health as a strategic priority and the AAP Oral Health initiative is responsible for education, training and advocacy for pediatricians, dentists, other health professionals and families. The AAP Section on Oral Health is a 500-member-strong voice of pediatricians and pediatric dentists who work to improve medical-dental collaboration, produce policy, practice guidelines, and curriculum training for pediatricians, and advocate for children’s oral health. The AAP also trains and supports Chapter Oral Health Advocates who are pediatricians and pediatric dentists working across the United States and Canada to educate others on preventive oral health in the pediatrician’s office, fluoride varnish application and the importance of establishing a dental home by age 1.
Smiles for Life is a curriculum developed by the Society of Teachers of Family Medicine that has evolved into an interprofessional training program. The mission of SFL is to produce educational resources to ensure the integration of oral health and primary care. The curriculum has been endorsed by over 20 health profession organizations, including the American Dental Association, and continuing education credit is available for physicians, nurses, physician assistants, pharmacists, midwives, medical assistants and dental health professionals through the ADA CERP program. The eight Smiles for Life modules can be completed online or downloaded for educator use in the classroom setting. Since the launch in 2010, the website has seen over 1.2 million discrete site visits, with over 80,000 registered users completing over 250,000 hours of online training for credit. These materials are being utilized by health professions of all types and at all levels of training, which speaks to the readiness and willingness of the primary care workforce to engage in oral heath prevention.
In 2009, the National Interprofessional Initiative in Oral Health was founded by a group of funders, medical and dental leaders and national organizations to promote the integration of oral health in primary care education and practice. As a systems change initiative, the National Interprofessional Initiative in Oral Health provides backbone support and facilitates interprofessional learning, agreement and alignment across health professions. Examples of the initiative’s work include support for Smiles for Life and the commissioning of Qualis Health to create an implementation guide and tool kit to integrate oral health into whole person care.
The Physician Assistant Leadership Initiative in Oral Health (2009) and the Oral Health Nursing Education and Practice initiative (2011) were early efforts supported by the National Interprofessional Initiative in Oral Health and both remain at the forefront of innovation to integrate oral health across their professions. PAs engaged leadership across national regulatory and member organizations use a collective impact strategy to embed oral health competencies across the profession. A recent national survey of PA education program directors documented that these efforts are bearing fruit, with 96 percent of responding programs indicating they now include specific instruction on oral health and disease in their curriculum. The Oral Health Nursing Education and Practice Initiative works to integrate oral-systemic health into undergraduate and graduate nursing programs nationwide. The initiative’s interprofessional oral health toolkit for primary care nurse practitioner and midwifery programs is widely used by nursing programs across the country and is a resource for other health professions seeking to develop similar tools.
Oral Health 2020 is a network of national, state, and community-based change agents dedicated to improving the oral health of all. The network engages partners who share the vision of eradicating dental disease in children, incorporating oral health into the primary education system, inclusion of an adult dental benefit in publicly funded health coverage, creating a comprehensive national oral health measurement system, integrating oral health into person-centered health care and improving the public perception of the value of oral health in overall health.
These are a few of many examples of national undertakings to expand oral health preventive services in the primary care setting. Additional efforts, including embedding a dental hygienist within the primary care team has proven successful at the local level, but has yet to be accepted as standard for practice in medicine or dentistry. The training of community health workers, promatoras and other front line workers who meet individually with clients shows promise, as their contributions to chronic disease management is shown to be effective. We believe these lessons can be more robustly applied to the caries crisis.
We all want our patients to have healthy bodies and healthy mouths and to improve health outcomes while managing costs. We must continue to challenge the status quo that oral health is exclusive to the profession of dentistry. Certainly, dental health professionals should control the practice of dentistry, which is quite distinct from owning the oral health of the entire population. We hope to share the burden of prevention with dentistry as soldiers on the front lines of health care carrying oral health messages to the highest risk and most vulnerable every day. We must strive to embed oral health into all the health professions training at every level to empower them as a voice of advocacy for prevention. We must challenge the cultures of our professions to reform our training programs, payment structures, and system of care delivery to ensure preventive care services for all.
Dr. Clark is an associate professor of pediatrics at Albany Medical Center in Albany, New York. Ms. Glicken has a master’s degree in social work and is the executive director of the National Interprofessional Initiative on Oral Health and the associate dean and professor emeritus at the University of Colorado School of Medicine.