Best Practices: Treating dental care as healthcare

In one case, a cancer patient was losing weight because his treatments were hurting his oral health. Once his teeth were pulled and he was fitted for dentures, he gained 10 pounds. In another, getting dentures helped lift the self-image of a 20-year-old unemployed woman, who subsequently found a job.

Those stories, shared by Greg Nycz, executive director of the Family Health Center of Marshfield (Wis.), a collection of community health centers in the state, are testament to the idea that oral health and medical health are inseparable. For the most part, the U.S. healthcare system treats them otherwise, but some providers are going against the grain and seeing profound benefits for patients.

The Family Health Center of Marshfield, for instance, contracts with the Marshfield Clinic Health System to provide dental and medical care. The process of expanding dental care hasn't been simple, but since 2002, those clinics have seen 135,905 patients, many of whom struggled for years to get care for their teeth and gums.

The Marshfield Clinic, a large medical practice that also operates hospitals, first weighed providing dental care after the U.S. surgeon general published a report in 2000 describing the lack of access to dental care as a “silent epidemic” that primarily afflicts the poor. The report called for “an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health.” Poor oral health has been linked to heart disease, diabetes and a spate of other health problems.

In early 2002, Nycz met with the Marshfield Clinic's leaders, and they agreed Marshfield needed to provide dental care. Their first dental clinic opened in November that year in Ladysmith, a town of about 3,000 in northwest Wisconsin. The patients who flocked there from all over the state confirmed the broad trends researchers have found: Rural areas are more likely to have shortages of dental providers, and the frequency of dental visits aligns closely with socio-economic status.

Marshfield now has 10 dental centers across Wisconsin. Some are located near clinics run by the Marshfield system, while others are stand-alone.

Although it's not unusual for federally qualified health centers to co-locate dental and medical services, Marshfield's clinics are different from most because they integrate medical and dental electronic health records. Colin Reusch, a senior policy analyst with the Children's Dental Health Project, a Washington, D.C., group that aims to improve children's oral health, calls this “fairly uncommon.”

Having joint records “enables our physicians to pull data if they want to learn more about a patient's dental history,” Nycz said. “It also allows our dentists, who may be dealing with a patient with complex medical conditions, to be able to do a more intelligent treatment plan.”

Marshfield benefits from several factors that have made combining dental and medical care feasible.

In Wisconsin, Medicaid covers dental benefits for adults. This means that Marshfield can come close to breaking even while treating Medicaid beneficiaries, rather than losing money. For uninsured patients in poverty, it charges $10 for dental services, be they preventive, restorative or emergency. Meanwhile, patients deemed near-poor receive discounts of 50% to 70%. Grant revenue and donations, along with income from the few commercially insured patients that the clinics treat, help cover the rest of the costs.

Another advantage is Marshfield's in-house EHR system and IT staff, which allowed the system to handle integrating the EHRs with the help of a grant from Delta Dental of Wisconsin.

Patients are healthier as a result of integrated dental and medical care, said Dr. Jane Grover, director of the American Dental Association's Council on Access, Prevention and Interprofessional Relations. “Having patients be able to follow a great diet, be able to eat comfortably and chew, that's essential,” she said.

That may seem obvious, but most of the healthcare system has yet to catch up with Marshfield. “I think the rest of the healthcare and dental care delivery system would be wise to take some cues from them, especially when it comes to the integration of care,” Reusch said.