How to bring oral health to primary care

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More about the MCPP

A pig-tailed girl of 6 years, I readied myself for school each morning near a motion-activated talking tooth. When I passed by, this googly-eyed molar shouted, “Hey! Don’t forget to brush your teeth!” Adjacent to my animatronic reminder, a tooth-shaped hourglass ticked away the seconds while I brushed with an electric toothbrush and flossed with a water pick.

My father, a small-town dentist, announced that he was “off to stamp out tooth decay,” and dropped his office keys into the pocket of his zippered smock. Oral health was central to our daily routines. My childhood smile was cavity free.

A challenge for pediatricians

Yet for most children-and most pediatricians-oral health is often buried in a long list of priorities. In my general pediatric clinic now, a terrified 2-year-old sits crying in her mother’s lap, the scars of prior cardiac surgeries on her chest. Dental caries dot her smile. “Dentist?” her mother repeats to me. She is too busy with the child’s many appointments, and her child is too frightened. How do I improve this child’s oral health during a short health-maintenance visit? I have minutes to spare, and mom’s motivation to change appears to be low.

We know well that dental caries is among the most common chronic diseases of childhood-far more prevalent than asthma. We know that dental caries can impair development, school performance, quality of life, and overall health. Caries lesions (eg, cavities) lead to financial burdens, inconvenience and missed work for parents, and suffering for our young patients.¹

We also know that as primary care providers, we are expected to provide oral healthcare to children, in accordance with the recommendations of reliable resources including the American Academy of Pediatrics (AAP), the American Academy of Pediatric Dentistry (AAPD), the American Dental Association (ADA), the US Preventive Services Task Force (USPSTF), and the Bright Futures Periodicity Schedule.^2-5 However, the addition of this oral health responsibility is challenging: How are we to serve as pediatrician and play dentist, too?

How we faced the oral health challenge

Our clinic recently worked with the Michigan Caries Prevention Program (MCPP; see “More about the MCPP”) to incorporate and sustain solutions that would make this challenge less daunting. Through the MCPP, we received support as a pilot site to achieve 4 shared goals:

·      Identify children at risk for caries.

·      Apply fluoride varnish at well-child exams.

·      Educate about oral health.

·      Encourage patients to establish care with a primary dentist (find a dental home).

It worked! At the end of the pilot, we had good provider buy-in, were able to streamline documentation and billing, could complete varnish application in under 90 seconds, and were screening for oral health risk at sustained rates of 100%.^6,7

6 steps to success 

Here’s how you can make this happen in your own pediatric practice:

1. Find a co-champion of oral health. A single pediatric or family dentist in your area can help answer your questions about dentistry as they arise, provide a referral site, and be present at an initial training in assessment and varnish application. For us, key dental school faculty and local private dentists have proven to be invaluable allies.

2) Train your providers. A 1-hour MCPP training imparted our providers with comfort in the procedural aspects of fluoride varnish, anticipatory guidance, and confidence in how to screen for oral health risk factors. Similar trainings for pediatric providers are accessible online. The Smiles for Life national oral health curriculum (SmilesforLifeoralhealth.org) is free, endorsed by the AAP and ADA for primary care training in oral health, and available with instructions for moderating the training.⁸

3) Make oral health easy for providers. We found several strategies that are critical for efficiency and sustainability of provider efforts. First, we chose a target population of children presenting for well-child visits aged between 6 months and 3 years. For these children, we added oral health screening to our intake paperwork using a 1-page form with embedded educational messages (Figure 1). To create a visual reminder and to save time during the visit, we placed the necessary varnish supplies in a small packet in the exam room within arm’s reach of the provider (Figure 2). To assist our providers in referring patients to a dental home, we created an easily accessible electronic list of local dentists accepting pediatric patients with all insurance plans. Finally, to improve the efficiency of postvisit documentation and billing, we added language about the visit’s oral health screening and intervention to our electronic health record (EHR) note templates (Figure 3) and built the appropriate billing codes into our EHR order sets. (To support implementation of these steps, the AAP offers resources for ordering dental supplies,⁹ an oral health coding fact sheet,¹⁰ and a more in-depth oral health risk assessment tool.¹¹)

4) Make oral health easy for patients. We apply the fluoride varnish during routine well-child visits to ensure appropriate 3-month to 6-month intervals between varnish applications. When the family leaves the visit, they have several oral health reminders to take with them. The intake oral health screening tool is returned to them after we have circled specific preprinted “preventive habit” messages based on assessed risk factors (Figure 1). A list of local dentists accepting patients and accepting various types of insurance coverage is added to checkout paperwork if indicated. We make verbal recommendations to obtain the needed oral health products and, if needed, we dispense age-appropriate toothbrushes and fluoride toothpaste to eliminate confusion, inconvenience, and expense.

5) Make your efforts stick. We monitored our rates of screening and varnish application over time, and for the first few months we held weekly focus groups to review barriers and troubleshoot solutions. We incorporated tasks like ordering and organizing supplies into the job descriptions of certain staff members. We set procedures in place to provide oral health training to new staff and providers as they were hired. We have created a clinic culture that is supportive of oral health, and we believe that so long as someone continues to carry the torch of oral health champion, we will sustain it indefinitely.

6) Enjoy your results. It required a moderate level of “institutional inertia” to set this oral health initiative in motion, but once rolling, there were few questions or concerns from returning families. Gradually, we felt a shift. Families spontaneously offered updates on their child’s oral health. Consent to varnish became extremely brief. Lengthy discussions in defense of healthy preventive habits became rare. Families expressed gratitude for our oral health efforts.

Your inner animatronic tooth

Not every kid’s dad is a dentist. Not every kid lives with a robotic talking molar that greets him or her with oral health imperatives. Yet nearly every kid has a pediatrician who can take simple steps to guarantee healthy smiles-and that pediatrician can be you!

Acknowledgements

Dr Dickson would like to acknowledge the support of the University of Michigan Dental School faculty and staff, and the Michigan Caries Prevention Program staff; Margherita Fontana, DDS, PhD, who invited the University of Michigan East Ann Arbor (EAA) Pediatric Clinic to join in her inspired work; John Girdwood, PhD, who was critically present at EAA along the way, as well as Imen Alem, Emily Yanca, and Rachel Putnam-Farley.

She would also like to thank the University of Michigan’s Department of Pediatrics–Division of General Pediatrics for its support of oral health. Especially crucial were the EAA Pediatricians-Heather Burrows, Paramjeet Kochhar, Sara Laule, Adrienne Musci, and Gwendolyn Zirngibl-and the East Ann Arbor clinic staff, with key contributors Sandra Ellis and Ashley Major.

Importantly, Robert Dickson, MD, has provided a deep well of generous support and academic consultation for this project’s long duration.

And lastly, Dr Dickson owes her own smile and her interest in teeth to her father, Nicholas Schmit, DDS, who has been stamping out tooth decay as a general dentist in Delphos, Ohio, for 40 gentle years.

References:

1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007;(248):1-92.

2. Section on Pediatric entristry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics. 2008;122(6):1387-1394.

3. Clark MB, Slayton RL; Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.

4. Bright Futures/American Academy of Pediatrics. Recommendations for preventive pediatric health care. Available at: https://www.aap.org/en-us/documents/periodicity_schedule.pdf. Published April 2017. Accessed April 16, 2018.

5. Moyer VA; US Preventive Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111.

6. Girdwood J, Dickson AL, Putnam-Farley R, Alem I, Yanca E, Fontana M. Successful implementation of dental preventive strategies in medical clinics via inter-professional education and training (Poster 110). Presented at: University of Michigan 2nd Annual Health Professions Education Day; June 1, 2016; Ann Arbor, MI.

7. Fontana M, Girdwood J, McComas M, Yanca E, Aiura L, Dickson AL, et al. Program fidelity of a statewide medical-dental initiative to improve oral health. Poster presented at: American Academy of Pediatrics National Conference and Exhibition; October 22-25, 2016. San Franciso, CA.

8. Smiles For Life. Course 6: Caries risk assessment, fluoride varnish, and counseling. Available at: http://smilesforlifeoralhealth.org/buildcontent.aspx?tut=584&pagekey=64563&cbreceipt=0. Updated July 2017. Accessed April 16, 2018.

9. American Academy of Pediatrics. Dental supply companies contact information: fluoride varnish product list. Available at: http://resourcelibrary.stfm.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=fa44e938-96e5-d18f-cc16-b98c1628ddc6&forceDialog=0. Updated April 2016. Accessed April 16. 2018.

10. American Academy of Pediatrics. Oral health coding fact sheet for primary care physicians. Available at: http://resourcelibrary.stfm.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=606f7395-e4bd-21bf-7ceb-bec6b8dcdad2&forceDialog=0. Published January 1, 2016. Accessed April 16, 2018.

11. American Academy of Pediatrics. Oral health risk assessment tool. Available at: https://www.aap.org/en-us/Documents/oralhealth_RiskAssessmentTool.pdf. Published 2011. Accessed April 16, 2018.