Many adults lack adequate preventative oral healthcare due to multiple factors. Oral health is important due to its effects on systemic health as well as for quality of life issues.https://scholarworks.uvm.edu/fmclerk/1387/thumbnail.jp

Duguay, James

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University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2018Adult Oral Health Access and AdvocacyJames DuguayUniversity of VermontFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Dentistry Commons, Medical Education Commons, and the Primary Care CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationDuguay, James, "Adult Oral Health Access and Advocacy" (2018). Family Medicine Clerkship Student Projects. 344.https://scholarworks.uvm.edu/fmclerk/344Adult Oral Health Access and AdvocacyHinesburg, VTJames Duguay Family Medicine Clerkship February – March 2018Mentor: Dr. Michelle Cangiano, MDProblem Identification and Description of Need Poor oral health (periodontitis) is associated with increased risk for cardiovascular disease, bacteremia, and systemic low grade inflammation. [1-4] According to a 2016 report:[5] 31.6% of US adults aged 20-44 with untreated dental caries. 64.0% of US adults aged 18-64, and 62.7% of adults over 65 had a dental visit in the past year In Vermont, 44% of adults do not have dental insurance.[6] In the Burlington area, 77% of adults visited the dentist in the last year, compared to 71% for all of Vermont.[6] In the Rutland area, 68% of adults visited the dentist in the last year.[6]Public Health Cost and Unique Cost Considerations in Host Community In Vermont, 14 percent of all health care expenditures are paid out of pocket, while 60 percent of dental services are paid out of pocket. [7] Medicare doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you're in a hospital. Part A can pay for if you need to have emergency or complicated dental procedures, even though the dental care isn't covered.[8] In State Fiscal Year 2015, 130 Rutland area residents and 196 Burlington area residentsutilized General Assistance Vouchers for dental services, for a total of $80,420 and $127,342 respectively.[9] In 2014, 3,272 (18%) Medicaid-eligible Burlington area adults and 1,702 (16%) Medicaid-eligible Rutland area aged 19-64 years were treated for extractions, endodontics or restorations totaling $1,239,625 and $774,028 respectively of potentially preventable spending. [9] 10 visits to the Emergency Department per 1000 in Vermont in 2013 were for disorders of the teeth and jaw.[10]Community PerspectiveSheila Bannister, RDH, MEdAssociate Professor in the Dental Hygiene department at Vermont Technical College providing instruction in Dental Materials and Community Oral Health. Sheila has served twice as President of the Vermont Dental Hygienists’ Association and is currently Legislative Chairperson for her professional organization. Sheila’s passion is increasing access to oral health care in Vermont. 1) What do you see as the biggest barriers to regular preventative dental care for adults in our area?Financial. For elderly patients it's often a matter of fixed income, not having the money to get care, no dental insurance. For those on Medicaid, the benefits are slim ($ 510/annual I believe) and even if someone is fortunate enough to have Medicaid dental benefits, it's a serious challenge to find a provider that accepts the insurance. For those who make too much money to qualify for Medicaid but not enough to live comfortably, preventative dental services are often out of their financial reach, and if it comes to choosing the basic necessities or preventative dental care, obviously the necessities win out. 2) If you could give advice to a busy primary care provider on how to talk about oral hygiene during a time-limited office visit, what would it be?Keep it as simple as possible. Focus on whole body (including the mouth) health and the big picture. Give the patient one fact about nutrition and oral health (ie: negative effects of sports drinks) and recommend they see a dentist at least annually for an exam, same recommendation as it is for annual physical. Inquire about the patients' dental home status. Make the patient aware that their oral health is as important as the health of every other part of their body. 3) In terms of increasing community oral health, what have you seen that works and what could work better?Community oral health: the Tooth Tutor program in Vermont schools has been very successful. Hygienists are also involved with Head Start and this is a great age to reach kids (and their parents). I would like to see more involvement in WIC. It would also be very helpful to have all PH district offices (I believe there are 12) employ a public health dental hygienist. I think only 3 of them do now (funding). There is a mobile dental van at the Plainfield Health Center that goes to schools; these types of services could be expanded. There is a school based program for preventative services at the H.O. Wheeler school run through the Community Health Center in Burlington. More programs like this would help. More education for parents and children. More community health centers and funding. And, the elderly are completely left out of any community oral health programs; it's important to focus on kids but much of the geriatric population, especially those in assisted living facilities, are completely neglected. 4) What resources are available to both patients and providers to increase access to preventative oral healthcare?Resources: If a patient can't/doesn't have a dental home they can come to the Vermont Technical College for significantly reduced fee services (cleaning, radiographs, sealants, etc.) if they have the ability and time to get there during school sessions. Unfortunately, due to our overload of patients, we can often only see someone once a year. As frustrating as it is, I can't think of other resources that are available. If I think of anything else I'll let you know. 5) How can primary care providers and oral health providers work more closely?Medical and dental working together is, in my opinion, what might break the cycle of dental disease as we know it. In dental hygiene school, students are taught to discuss smoking cessation, nutrition, oral cancer, and the effects of oral health on systemic health (diabetes etc) with all their patients. Anything dental is often seen by patients as strictly cosmetic, separate from the body; they often don't connect the mouth with the body and often what we talk about is news to them. I believe this is because the professions are separate, the education is often done is separate locations, they aren't connected in the public's mind and, often, probably not connected in the professionals mind either. I think it has to start with education. For example, this! A medical student doing a project about increasing access to preventative oral health care! Thank you! In addition, I think something that would help is introducing application of F. varnish for every patient seen in the medical office for an exam. If insurance would code it for medical purposes (they may have, I don't know) it would be such a simple thing to do while talking to your patient. One minute of discussion while F. varnish was applied; almost no time added into the appointment, no mess, no extra equipment, no learning curve. This procedure would benefit the patient, allow the practitioner time to briefly discuss oral health, and connect the mouth with the body in the patients’ mind.Community PerspectiveRobin Miller, RDH, MPHOral Health Director, Vermont Department of Health’s Office of Oral Health1) What do you see as the biggest barriers to regular preventative dental care for adults in our area? The biggest barrier cited by Vermonters is cost. Although Medicaid in VT does cover oral healthcare for Vermonters, there is a $510 cap on services for oral health services. People are potentially be hesitant because they are afraid they may need a larger procedure and then will not have the funds. May end up going in and then find out they will get a more expensive treatment. Only 25% of Vermonters eligible for dental benefits on Medicaid access dental care.  Adults insured by Medicaid can find it difficult to find a dentist that accepts. Cost and access to transportation is a barrier for some.  Tooth Tooters – Schools hire dental hygienists to provide care. There is no cap for children on Medicaid. Cultural barriers. If you do not grow up going to regular dental visits, it is hard to start as an adult. 2) If you could give advice to a busy primary care provider on how to talk about oral hygiene during a time-limited office visit, what would it be? Consider not overcomplicating it. You do not have to be an expert to talk about the connection of systemic health and oral health. A chronic ongoing infection in your mouth, it will impact your ability to be as healthy as you could be.  Referring to 802 QUITS. Also recommend tobacco users be referred to. Women on Medicaid have no cap on oral health during the pregnancy and for 60 days afterwards. Excellent time to talk to them about their oral health and the oral health of their baby.  Ask about last dental exam on the pre visit questionnaire.  Reach out to dental care providers so that there are open lines of communication and comfort referring back and forth. Bridge the gap and get to know each other as community healthcare partners. 3) In terms of increasing community oral health, what have you seen that works and what could work better? The proliferation of Federally Qualified Health Centers has increased access for the adults most in need.  More medical-dental integration would help to increase community oral health access and utilization. Vermont last year passed legislation to allow Dental Therapists to practice in the state. This will increase access to high-quality, cost-effective routine dental care by bringing preventative care to where patients need it most. 4) What resources are available to both patients and providers to increase access to preventative oral healthcare? The resources for health professionals section of our oral health website. This section has information about the expanded Medicaid coverage during pregnancy (in the Working with Families section), as well as the Qualis medical/dental integration guide and the Smiles for Life oral health curriculum (a series of Continuing Medical Education courses designed to integrate oral health and primary care).Intervention and Methodology Produce a simplified handout for providers and patients that lists concise reasons and benefits of maintaining oral health as well as selected resources for patients worried about cost. Distribute handout to providers in digital form.Results/Response The handout was distributed to Hinesburg Family Practice providers and was positively received as a useful resource. Evaluation of Effectiveness and Limitations Evaluation of Effectiveness: Effectiveness would be measured by utilization of the handout by providers. At follow up visits or the next health maintenance visit, patients could be asked if the information was helpful to them or if they utilized any of the resources listed. Limitations: Although cost is a major identified barrier to preventative oral healthcare for many adults, there are a diverse range of other barriers. Addressing all of these barriers will be highly individualized to the patient and will take time. Much like addressing the lifestyle habits that contribute to morbidities familiar to family medicine providers, it is difficult to change deeply ingrained behaviors in patients.  Recommendations for Future Interventions Work to develop a collaborative relationship with individuals and organizations in the area advocating for increased access to preventative oral healthcare. Create a ‘dot phrase’ for Epic to insert information into the printouts given to patients at the end of a visit. Organize CME sessions for providers to learn about ways they can be directly involved with the oral health of their patients. Get medical curriculum involved. We spend time learning about the health care team; recognizing the importance of oral health and integrating oral health professionals into team-based care is essential. Facilitate open communication between local dental providers and primary care providers to strengthen the medical-dental relationship. Compile similar data and resources specific for children in the area.References1. Schenkein, H.A. and Loos, B.G. Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases. J. Periodontol. 2013; 84: S51–S692. Kebschull, M., Demmer, R.T., and Papapanou, P.N. Gum bug, leave my heart alone!–epidemiologic and mechanistic evidence linking periodontal infections and atherosclerosis. J. Dent. Res. 2010; 89: 879–9023. Lockhart, P.B., Bolger, A.F., Papapanou, P.N., Osinbowale, O., Trevisan, M. et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circulation. 2012; 22: 2520–25444. Liljestrand, John M., et al. “Immunologic Burden Links Periodontitis to Acute Coronary Syndrome.” Atherosclerosis, vol. 268, 6 Dec. 2017, pp. 177–184., doi:10.1016/j.atherosclerosis.2017.12.007.5. National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville, MD. 2017.6. CDC Behavioral Risk Factor Surveilance Survey (BRFSS) 2016, https://www.cdc.gov/brfss/index.html7. Green Mountain Care Board. 2010 Vermont Health Care Expenditure Report. March 2012. Available at http://gmcboard.vermont.gov/resources_reports.8. https://www.medicare.gov/coverage/dental-services.html9. Medicaid Claims Data, Vermont Dept. of Public Health http://www.healthvermont.gov/health-statistics-vital-records/surveillance-reporting-topic/oral-health10. Vermont Uniform Hospital Discharge Data Set, http://www.healthvermont.gov/health-statistics-vital-records/health-care-systems-reporting/hospital-discharge-dataInterview Consent Form

Adult Oral Health Access and Advocacy

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Adult Oral Health Access and Advocacy

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