Medical-Dental Partnerships Medical-Dental Partnerships To Promote Oral HealthTo Promote Oral Health

Wendy E. Mouradian, MS, MDWendy E. Mouradian, MS, MDPediatrics, Pediatric Dentistry, Health Pediatrics, Pediatric Dentistry, Health

Services (Public Health)Services (Public Health)

Children’s Hospital Regional Medical CtrChildren’s Hospital Regional Medical Ctr

University of WashingtonUniversity of Washington

AcknowledgementsAcknowledgements

• Comprehensive Center for Oral Health Research (NIH - NIDCR)

• Maternal and Child Health Bureau, HRSA (Leadership Education in Pediatric Dentistry)

• Bureau of Health Professions, HRSA (Interdisciplinary Children’s Oral Health Promotion)

Summit ThemesSummit Themes

Whatcom County:• Engage community members

• Present local data

• Discuss “best practices”

• Raise awareness of dental caries as an infectious disease

• Problem solve: children, adults, elderly

Surgeon General’s Report on Surgeon General’s Report on Oral Health (2000)Oral Health (2000)

• Oral diseases are common and consequential• Linked to overall health and well-being• Profound disparities in oral health status • Disparities: SES, rural, minorities, vulnerable

Preventive measures exist• Research / translation of science needed

http://www.nidcr.nih.gov/sgr/sgr.htm

Vulnerable PopulationsVulnerable Populations

• Children

• Elderly

• Special Needs

• Adult populations

Medical-dental Educational Medical-dental Educational CollaborationsCollaborations

Journal of Dental Education –Aug 2003Overview and commentary – children’s oral

health• Washington State (family medicine residents)

– Mouradian et al• North Carolina (pediatricians, family physicians)

– Rozier et al

Medical-dental Educational Medical-dental Educational CollaborationsCollaborations

Journal of Dental Education –Dec 2003Overview and commentary – special pop.

• Elderly populations – Pyle et al

• Mental retardation, other special needs – Fenton et al

Medical-dental Educational Medical-dental Educational CollaborationsCollaborations

Journal of Dental Education –Apr 2004Overview and commentary -Public health

approaches

• Kids Get Care (case management model)– Hennessey et al

• OPENWIDE (CT – Head Start)– Wolfe et al

Children’s Oral HealthChildren’s Oral Health

• Dental care is most common unmet health need of children

• More likely to lack dental insurance• Access to dental care limited u/ Medicaid• Disparities by SES, rural areas, special

health needs/disabilities

Impact on ChildrenImpact on Children

• Disease burden- 52 million school hours

• Pain, infection, growth problems, ER visits

• Hospitalizations and surgeries

• Long term impact on economic, quality of life

• Children with special needs: impact on general health

Reach Children EarlyReach Children Early

• Prevention works

• Dental disease develops early <1-2 yrs

• Disease transmitted from mother

• Reach in primary care, child care, Head Start, educational, social systems

Washington State Smiles Survey, Washington State Smiles Survey, 20002000

• Disparities in oral health outcomes by race/ethnicity, SES

• Many children lack access to dental care

• Washington state data do not compare favorably with national data

Kathy Phipps, MPH, DrPH, consulting epidemiologist

Prevalence of ECCPrevalence of ECC

10

19

8

0

2

4

6

8

10

12

14

16

18

20

Percent of Children

Washington1-year-olds

Washington2-year-olds

NHANES III2-year-olds

Trends Over TimeTrends Over Time

19.2

40.7

Sealants

46.0

54.6

Caries Experience

16.921.6

Untreated Decay

1994

0

10

20

30

40

50

60

Per

cen

t o

f C

hild

ren

2000

Adult Oral HealthAdult Oral Health• Periodontal disease is common

– Maternal periodontal disease and LBW– Periodontal and cardiovascular disease– Pulmonary impact of oral disease

• Mothers choose health care for families

• Oral-systemic health: diabetes, others

• Oral cancer: 8000 people die a year

Older Adults Older Adults

• More periodontal disease

• More oral-systemic health impacts

• More oral cancer

• Impact of medications

• Long term care facilities

• Complex social arrangements

Mental Retardation and Special Mental Retardation and Special NeedsNeeds

• Lack of data on oral conditions

• Impact of medications, conditions– Down syndrome and periodontal disease– Effect of anti-convulsants

• Difficulty with self-care

• Complex guardianship, living arrangements

Key themes: Special populationsKey themes: Special populations

• Importance of oral-systemic interactions: need for interdisciplinary collaboration• Diminished mental/ motor capacity need for special arrangements and emphasis

upon prevention• Difficulty accessing care need for better training, other solutions• Complex social and cultural factors• Lack of good data

ContextContextDisparities may worsen:• Demographics: diversity; child poverty;

survival those with special needs, elderly• Workforce gaps: not enough dentists;

retiring; most not in Medicaid; physicians lack training

• Policy gaps: lack of insurance; oral care not “medically necessary” (especially impacts special needs population)

PartnershipPartnership

• Department of Pediatric Dentistry

• Department of Family Medicine

• UW Affiliated Family Practice Residency Network

• Department of Medical Education and Bioinformatics

ICOHPICOHP

Goal 1: Training family medicine residents and faculty in oral health promotion

Objectives: • Develop curricula in children’s oral health, 0-5• Pilot, implement in WWAMI sites• Evaluate effect of training on knowledge,

attitudes, behavior • Disseminate curricula

UW FP Residency Network: UW FP Residency Network: SitesSites

Alaska

WashingtonMontana

Idaho

Wyoming

Family Practice Residency

Affiliation Under Negotiation

Rural Training Track

Geographical barriersGeographical barriers

AssumptionsAssumptions

• Biggest obstacle will be buy-in

• Tailor curriculum to physician needs

• Integration with dental sector in community critical

• Sustainability will require additional work

Focus Groups: Focus Groups: Faculty/ Residents, StaffFaculty/ Residents, Staff

Barriers• Oral health not on their radar screen; lack

knowledge/self-efficacy• Providers busy: oral health not a priority• Concerned about the evidence base• Confusion about physician role• Lots of baggage about dentists

Focus Groups: Focus Groups: Faculty/ Residents, StaffFaculty/ Residents, Staff

Opportunities

• Care about children in pain

• Unable to answer parents’ questions

• Prevention is a high priority

• Already providing health education

• Acutely aware of access issues

• Committed to underserved communities

Address Barriers and OpportunitiesAddress Barriers and Opportunities

• Increase motivation– Oral health important– Impact on children

• Increase practitioner knowledge – Normal dental development– Caries process

Address Barriers and OpportunitiesAddress Barriers and Opportunities

• Review evidence base (USPSTF; CDC Fluoride recommendations)

• Frame in terms of primary care roles:– Anticipatory guidance– Nutrition/feeding– Injury prevention; emergency management– Special issues for CSHCN

Address Barriers and OpportunitiesAddress Barriers and Opportunities

• Address resentment towards dentists: Work with dentists one-on-one:

– partner with ABCD, community health clinics, pediatric dental trainees

– Increase communication, lines of referral

• Reinforce principles of family-centered, culturally competent care– already part of residency culture / training

Modules:Modules:Frame to issues raisedFrame to issues raised

• Module 1: Public Health Overview; Oral Health Promotion and Practice

• Module 2: Normal Dental Development/ Pathology

• Module 3: Dental Caries; Collaborating with Dentists

• Module 4: Dental Trauma and Emergencies• Module 5: Oral-systemic Health Interactions

Respond to Requests for More Respond to Requests for More InformationInformation

• Module 6: Atraumatic Restorative Technique

• Module 7: Maternal oral health

• Module 8: Adolescent oral health

• Module 0: Managing the change process

Trainings to dateTrainings to date

• Seattle

• Yakima

• Spokane

• Olympia

• Boise

• Anchorage

• Pending: Valley, Vancouver

Frame for Primary Care Frame for Primary Care ProvidersProviders

PCP Roles: 1. Anticipatory guidance/ counseling

2. Risk assessment - oral screening, history (maternal history)

3. Applying fluoride varnish

4. Dental referral / collaboration

5. Monitor oral-systemic health interactions

6. Manage simple dental trauma

7. Maternal oral health counseling

North CarolinaNorth Carolina

• North Carolina: Statewide Medicaid program: pediatricians/family practitioners provide oral health education / screening exams / apply fluoride varnishes to young children 0-3 / dental referrals

• Partnership: Supported by dental, pediatric, family practice societies

Others to watchOthers to watch

• MCH Oral Health training for non-dental providers

• http://www.mchoralhealth.org/PediatricOH/index.htm

• Minnesota training, fluoride varnishes• http://meded1.ahc.umn.edu/fluoridevarnish

/xindex.htm• AAP –presentations for chapters – stay

tuned

Medical MantraMedical Mantra

• Address medical training gaps• Change perceptions among medical

professionals • Integrate oral health into systems of care

especially for vulnerable populations • Develop medical-dental collaborations • Leadership in policy/ education• Standard of practice that includes oral health

Key Points Key Points

• Disparities in oral disease /access to care

• Impact on vulnerable populations

• Workforce critical: not enough providers

• Prevention is key - if started early

• Integrate oral health into overall health

• Partnerships are needed to make this happen