By David Thill
Growing awareness of the importance of oral health creates opportunity for more than just dentists.
In 2007, Deamonte Driver, a 12-year-old boy outside Washington, D.C., died of a brain infection stemming from untreated tooth decay. Driver’s family couldn’t afford health insurance, and he wasn’t approved by Medicaid in time to visit an oral surgeon for the treatment that would have prevented his death. His death sparked a national outcry over the state of United States healthcare, and brought the importance of oral health into sharp focus.
Insurance kicks in
Since Driver’s death, oral health has become recognized as a critical component of overall health assessments, says Kevin Brown, senior vice president at Premier Medical Products. “For too long, oral healthcare has been separated from routine medical care,” he says. “By overseeing the medical products division of Premier Dental Products, this is a frequent topic of discussion for us.”
Incremental progress has been made in building awareness of the importance of oral health to systemic health. The beginning of 2015 brought the establishment of Medical CPT code 99188, allowing physicians and other professionals reimbursement from insurers, including Medicaid, for applying fluoride varnish to patients under six years of age. Brown notes that some states also allow medical practitioners to perform annual oral risk assessment exams.
In 2015, the American Academy of Pediatrics (AAP) added fluoride varnish to its Periodicity Schedule of Recommendations for Preventive Pediatric Health Care. Brown says that since pediatricians and family practice physicians are most likely to see these young patients – especially those like Driver, from underserved populations, who are often without a dental home – they are being targeted by professional organizations such as the AAP to get involved in oral health.
Bridging the gap
According to a 2015 article released by the American Academy of Family Physicians (AAFP), dental caries is the most common chronic disease among children. At the same time, the people who need the most urgent treatment for caries commonly lack access to insurance that covers it. Brown points to the 2013 Affordable Care Act, which includes basic oral health as a medical coverage benefit, as a step in the right direction.
The AAFP article quotes Kathryn Phillips, MPH, program director at consulting firm Qualis Health, who observed that though expanding access to affordable dental care is important, “that alone is unlikely to solve our current problem. The need is simply too great.”
The first step to incorporating oral health in overall health is for primary care physicians and their staff to be willing to talk with patients about oral health, adds Jeff Hummel, M.D., MPH, medical director for informatics at Qualis, in the same article. “Patients appreciate the attention to oral health, and they respond to coaching.”
In December 2015, the AAFP voiced its support for the Oral Health Delivery Framework, a five-step plan that primary care teams can take to incorporate oral health into their practices. Qualis formed the plan based on an initiative “to develop, test, and disseminate an actionable pathway for delivering oral health care in the primary care setting,” according to a white paper published by the firm. The Framework is currently being tested at several community health centers and private practices across five states.
In addition to offering preventive interventions, the plan also calls for the primary care physician to refer the patient to a dentist or other medical specialist. The AAFP notes the importance of the bridge between family physicians and dentists. “Dental professionals need to be part of team-based care, even if they are physically located beyond our walls,” says Mark Deutchman, M.D., professor in the Department of Family Medicine at the University of Colorado Anschutz Medical Campus School of Medicine, and a key member of the Framework’s development team.
David Krol, M.D., MPH, and chairman of the AAP’s Section on Oral Health, agrees. “The ultimate goal is always to get the child connected to a dental home,” he says.
Krol also observes that because referral is such an important part of the process, “relationship-building between physicians and dentists is critical for success. Once that relationship is developed, a strong collaboration built on trust and communication can be formed that benefits the patient.”
Reps needed
While pediatricians and family physicians recognize the value of providing their patients with these resources, they can find it challenging to branch out to an area that has traditionally been off-limits to the medical doctor. This is where the distributor rep can help.
Brown says that several of Premier’s distributor partners have noted that their physician customers “enjoy the convenience of being able to add a dental product to their normal order for medical supplies” without having to establish an account with a separate dental distributor.
Premier also provides reps with state-by-state revenue models to show their customers. These models “detail the possible revenue generated by applying fluoride varnish to their targeted patient group,” says Brown.
Distributors can help pediatricians understand the disease process and the value of providing fluoride varnish to patients, says Krol. Additionally, “distributors can play a role in helping pediatricians understand the costs of fluoride varnish, and processes for getting [insurance reimbursement] for application.
“Finally,” says Krol, “I think distributors can help pediatricians make the connections and open lines of communication to dental colleagues in their area, so that good referrals and good relationships can be built.”
“If reps can look at oral health as a component of overall health and discuss this with their accounts, both they and the accounts are certain to see the opportunities now and in the future,” says Brown. “It really is a win-win situation all the way around.”
David Thill is a contributing editor for Repertoire.
A vital service
Providing fluoride treatments isn’t just an opportunity for doctors to increase revenue; it’s a critical service to young patients. But proper training is essential, according to those with whom Repertoire spoke.
“Dental caries is a significant problem for many children in the U.S., and we know that not all children see a dentist early in life” – especially those most at risk for disease – says David Krol, M.D., MPH, chairman of the American Academy of Pediatrics Section on Oral Health.
“While national guidelines recommend all children see a dentist at age one, access is still a problem,” says Alan Douglass, M.D., director of the family medicine residency program at Middlesex Hospital in Middletown, Conn. Primary care physicians are the doctors who see children the most, so providing services such as fluoride treatments, which can reduce caries risk anywhere between 25 and 63 percent, is a tremendous benefit to patients.
Traditionally, physicians and dentists have operated parallel to each other. But now that physicians can offer these types of services, says Douglass, the two professions have the chance to work more closely to provide coordinated care. In fact, when a young child receives fluoride treatments from their doctor, they are more likely to see a dentist.
In order for pediatricians and family physicians to be prepared to administer these treatments, they must understand the caries process and the various interventions to address it, says Krol. From dietary interventions to antibacterial approaches to fluoride treatments, “a good understanding of the pathophysiology helps pediatricians understand the approach to prevent and address disease and maintain good oral health in their patients.” This cross training in oral health is increasing at all levels of pediatrician training: undergraduate, graduate, and continuing education.
Douglass points to programs such as the Society of Teachers of Family Medicine Smiles for Life curriculum, which provides online courses for family physicians and other healthcare providers to take for fluoride treatment certification, as some of the relatively quick and convenient training options available today. The curriculum is endorsed by the American Academy of Family Physicians and numerous other professional medical and dental societies.
As physicians provide dental services such as fluoride treatments, and dentists provide medical services such as blood pressure readings, the subject of crossover between the two professions is a popular topic of conversation, he says. “There are places where those intersections can be of great value to patients,” so long as the professionals providing the services receive adequate training.
“It’s all about having two-way referral systems,” says Douglass: dentists referring patients to doctors, doctors referring patients to dentists. “The place I don’t want to see us go is more and more people taking on different roles and not communicating.”
“I think it would be wonderful if all medical professionals recognized the importance of oral health,” says Krol. “The more we all work together for our patients, the better.”
Five steps for the primary care team
The Oral Health Delivery Framework delineates the activities for which a primary care team can take accountability, according to Qualis Health. Activities are grouped into five categories: Ask, Look, Decide, Act, and Document and Follow Up.
- Ask about symptoms that suggest oral disease and factors that place patients at increased risk for oral disease. Two or three simple questions can be asked to elicit symptoms of oral dryness, pain or bleeding in the mouth, oral hygiene and dietary habits, and length of time since the patient last saw a dentist.
- Look for signs that indicate oral health risk or active oral disease. Assess the adequacy of salivary flow; look for signs of poor oral hygiene, white spots or cavities, gum recession or periodontal inflammation; and conduct an examination of the oral mucosa and tongue for signs of disease.
- Decide on the most appropriate response. Determine a course of action using standardized criteria based on the answers to the screening and risk assessment questions; findings of the oral exam; and the values, preferences, and goals of the patient and family.
- Act by delivering preventive interventions and/or placing an order for a referral to a dentist or medical specialist. Preventive interventions delivered in the primary care setting may include: 1) changes in the medication list to protect the saliva, teeth, and gums; 2) fluoride therapy; 3) dietary counseling to protect the teeth and gums; 4) oral hygiene training; and 5) therapy for tobacco, alcohol, or drug addiction.
- Document the findings as structured data to organize information for decision support, measure care processes, and monitor clinical outcomes so that quality of care can be managed. (Follow up.)
Source: Oral Health: An Essential Component of Primary Care, by Qualis Health, June 2015, http://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf