Moving dental health into primary care

About a year and a half ago, Brandee Winter took her son to a dentist for an abscessed tooth. The dentist's office pulled the tooth and did a cleaning, she recalled. The bill came to $400.

She and her husband own a diner in Winston, Ore. Because they were self-employed, they couldn't afford dental insurance. She paid the stiff price out-of-pocket.

“He needed it done, because he was in pain,” Winter said of her son, who is 9. “We took our savings and went and did it.”

This past summer, when her son's tooth had some suspicious coloring to it, Winter was relieved to learn that the WIC office in Myrtle Creek, Ore., where she and her family live, was offering free preventive dental services. She had gone to the benefits office for a check-up for her youngest, a 3-year-old daughter, and a hygienist there told Winter she could bring in all four of her children, including her son, who is the eldest.

The hygienist checked her son's tooth and cleaned his teeth. She applied a sealant, which prevents tooth decay, on teeth that needed it. She checked the teeth of Winter's other children, too. She gave all of them toothbrushes, floss and timers, and showed them how to use them.

“This is such a blessing for families who are in situations like mine,” said Winter. “Either you save your money and pay cash to see a dentist, or you don't go at all.”

Winter's experience is not unusual in the U.S., where the No. 1 reason people avoid going to the dentist, whether they have dental insurance or not, is cost. And in the end, the healthcare system and patient pay the price.

A person's oral health—the state of his or her gums and teeth—has a major impact on health, medical costs and quality of life. Serious gum disease is associated with diabetes, heart disease and other medical conditions.

A growing body of research suggests that treating gum disease can help diabetics control their blood glucose and lower overall medical costs for patients with the chronic condition. About 30% of low-income adults report that the condition of their mouth and teeth affects their ability to interview for a job, research by the American Dental Association's Health Policy Institute has found, and 42% report difficulties biting and chewing.

Local initiatives to expand access to dental care, especially among the most vulnerable, are focused on integrating oral health with primary care or providing dental services in settings such as schools or offices of the federal Women, Infants and Children program. But national progress has been piecemeal in the absence of policies to support oral healthcare. Separate insurance systems, incompatible electronic health records, and a lack of education hinder dentists, physicians and other providers when they try to work together.

Historically, “the dental profession has largely operated outside of the mainstream healthcare delivery system,” said Judith Haber, a professor at New York University's Rory Meyers College of Nursing who has been involved in numerous national initiatives on improving oral health. In recent years, growing recognition of oral health as vital to overall health has spurred interest in the public and private sectors to integrate the two, she said, but changing these systems takes time.

“We have a ways to go yet,” Haber said.

The role that dental health plays in a patient's overall health has often been overlooked, although that is starting to change. Cavities, or dental caries, are the most common chronic childhood disease, but they can be reduced through the use of topical fluoride varnish and sealants. Dental pain is a common reason patients end up in the emergency room, accounting for 2.1 million such visits in 2010, according to the American Dental Association. A growing body of research has identified a connection between oral health and chronic diseases such as diabetes.

Untreated dental problems can be deadly. In 2007, a Maryland youth, 12-year-old Deamonte Driver, died from the complications of a toothache after bacteria from the abscess spread to his brain. The infection, of the kind that often begins with a simple cavity, could have been treated or prevented.

But Driver's family lacked insurance and other resources to get care. His death, widely covered in the media, cast a spotlight on the devastating inadequacies of oral healthcare in the U.S., especially for poor or uninsured patients.

The majority of people who have dental insurance get it through their employers. Medicaid coverage of adult dental services varies by state, although the Affordable Care Act increased access to dental insurance in part by expanding Medicaid. Medicare, the federal insurance program for the disabled and for people over 65, doesn't cover dental care except for emergency procedures at a hospital.

For children, the ACA, whose fate is up in the air, mandated that health plans cover oral health risk assessments for kids up to 10 years old for free. Some experts contend this essential benefit exists more in theory than practice. In some marketplaces, qualified health plans are not required to include dental coverage if the marketplace also sells separate dental plans, which families then have to buy separately. Nor does the essential health benefit ensure that care will be comprehensive or coordinated.

Even if children do receive dental risk assessments, the crossover between the dental and medical spheres for follow-up care or other monitoring can be limited, said Colin Reusch, senior policy analyst at the Children's Dental Health Project. “There's not a lot of coordination between providers, beyond some referral,” he said.

The Children's Health Insurance Program requires states to provide children with the dental services “necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” But children covered by CHIP nevertheless are less likely to visit the dentist than children with private insurance. Children who are uninsured see the dentist least of all.

In 2013, 46.9% of children covered by CHIP visited a dentist in the previous year, according to a June brief by the Medicaid and CHIP Payment and Access Commission. Of the children with private insurance, 61.7% had seen a dentist in the past year compared to just 26.9% of children who were uninsured.

The reason Brandee Winter could take her children to the local WIC office for a dental checkup was because of an experimental project by researchers at the University of Washington and Advantage Dental Services, which provides dental services for Oregon Medicaid beneficiaries.

The project is part of a randomized controlled trial across 14 rural counties in Oregon to test whether paying Advantage on a capitated basis and offering performance-based incentives to providers who offer care in the most efficient setting—not necessarily a dentist's office—can get dental care to children who ordinarily would not receive it. The trial is funded with a grant from Finding Answers, a program of the Robert Wood Johnson Foundation.

The beauty of the initiative is that it's designed to use resources efficiently, according to Dr. Peter Milgrom, a professor of oral health sciences at the University of Washington and principal investigator for the project. Children are assessed for their caries risk level, and only if a child needed a sealant would he or she get it, for instance.

“The kids who don't need a lot of care don't get it,” Milgrom said. With the appropriate care, expensive trips to the emergency room for dangerous, painful conditions such as tooth abscesses can be prevented, he said.

“Reducing childhood caries is a key area of interest, I think, for both the medical profession and the dental profession,” said Dr. Jane Grover, director of the Council on Advocacy for Access and Prevention at the American Dental Association. “If we can save some of those disease patterns from starting, then we can reduce costs very effectively across the board.”

Other efforts to increase access to dental care among underserved populations have adopted a different approach, such as integrating it with primary care.

In a pediatric project at Jacobi Medical Center in New York City's borough of the Bronx, where 66% of patients are uninsured or on Medicaid, the hospital's dental residents teach primary-care providers to conduct oral exams, teach parents about diet and dental health, and apply fluoride varnish. By getting basic care during pediatric visits, children receive preventive dental care that they otherwise might not.

“There's no special dental chair or equipment that's needed,” said Dr. Nadia Laniado, director of community dentistry and population health at Jacobi. “If they require more extensive work, they're referred to clinic.”

In 2015, the U.S. Preventive Services Task Force gave the protocol a high rating, which means primary-care providers can now be paid to apply fluoride varnish for children up to the age of 6 as long as the Affordable Care Act remains in force. For the state's poorest children, New York's primary-care providers can bill for it through the state Medicaid program.

“Even though there's a moral imperative, there's also now financial incentive as well, to incorporate this in their daily protocol,” Laniado said.

At Jacobi, the logistics of the projects could hardly be simpler. Dentists, who are on the third floor of the hospital, head down to pediatrics on the first floor to train the pediatricians. They teach through practice, and after two or three rounds, primary-care providers are usually able to work on their own. If they want to learn more, they can take online educational modules through Smiles for Life, a national curriculum for oral health.

Outside a hospital, it would be harder for dental residents to train primary-care providers, Laniado acknowledged. “In a hospital, just by definition, we are integrated,” she said.

But even a big hospital such as Jacobi has trouble integrating dental care into its primary-care settings. The hospital uses separate EHR systems that are not compatible—Epic for medical records and DentalVision for dental files.

“Right now, we kind of have a workaround where in the medical record we can add a separate box or add questions and say, 'Did the patient have a dental exam?' But that's not standard, and there's no code for that,” Laniado said. “It should be seamless, but it's not.”

Laniado's project, like Milgrom's, is grant-funded. The federal Health Resources & Services Administration earmarked $2.5 million for the program over five years.

Although support is growing for efforts to integrate dental and medical care, especially among children, initiatives to make oral care widely accessible and affordable are far from comprehensive.

Several months ago, the Bluegrass Community Health Center in Lexington, Ky., held a clinic at a day center for the homeless. Nine patients signed up to see the medical provider that day, recalled Dr. Steve Wrightson, a family doctor and the clinic's medical director. For five of them, oral health problems, such as tooth pain and abscesses, were the reason.

That's not unusual. “We see it quite a bit, particularly with low-income individuals,” said Wrightson, who sits on the steering committee of Smiles for Life, the oral health curriculum. “The oral health concerns are extremely prevalent.”

Integrating dental care more fully with medical care would help address those problems and prevent major problems as people age, Wrightson said. Although it's helpful for primary-care providers to refer patients to dental providers, not all of providers have the option of doing so, and many patients can't afford dental care.

“I really feel that integration means having the medical providers take on the medical responsibility of more of that dental care,” Wrightson said. “The medical provider really needs to take up the slack.”