Health problems of the mouth can affect the whole patient, making primary care physicians a natural ally.
Fam Pract Manag. 2014 Jul-Aug;21(4):21-24.
Author disclosures: no relevant financial affiliations disclosed.
Evidence that poor oral health is connected to poor systemic health has grown over the last decade. Children with dental caries often face pain and nutritional problems, and caries build the foundation for adult dental disease. In adults, periodontitis, or deep inflammation of the gingiva, is strongly linked to poor diabetes control and is associated with vascular disease, arthritis, obesity, and adverse pregnancy outcomes. These connections underscore the value of addressing this major area of patient care in primary care practices.
Offering these services might be not only effective preventive care but also remunerative depending on the makeup of a physician's pediatric population. Although payer policies limit physicians' ability to be reimbursed for oral health services, four-fifths of state Medicaid programs reimburse for child oral health care.
The Institute of Medicine has defined roles for family physicians and other non-dental health care professionals in two reports on advancing oral health care.1,2 Also, Healthy People 2020 made oral health one of its top nine health indicators. While bold in mission, none of these documents provide detailed guidelines for medical clinicians, so this article will try to help prepare physicians to incorporate oral health services in their practices.
The family doctor and early childhood caries
Treating children and early childhood caries from birth through age 5 has generated the most evidence of beneficial intervention. Recently, the U.S. Preventive Services Task Force (USPSTF) recommended (level “B” – “moderate certainty that the net benefit is moderate to substantial”) that primary care providers apply fluoride varnish to the primary teeth of children.3
Many family doctors have been addressing the oral health of children for years. Researchers have shown that primary care doctors can apply fluoride varnish and examine the mouth accurately to identify caries.4 Moreover, they can do this work efficiently in their offices, enjoy tackling this problem, and find that the efforts result in fewer cavities.5,6
The American Academy of Pediatrics (AAP) suggests that primary care physicians should discuss oral health with parents starting when children are 6 months of age, which coincides with when primary teeth erupt. Such visits should include a risk history for caries, an oral exam, dental hygiene and diet advice, an assessment of the need for systemic fluoride, and a referral to a dentist with the first dental visit before the child's first birthday. Family physicians can start this discussion even earlier with women of childbearing age, as maternal oral health is a strong predictor of a child's oral health. Dietary patterns, oral hygiene practices, and oral flora that cause tooth decay are all passed along from the primary caregiver to the child.
In order to make providing oral health services easier and less time-consuming, we have involved the entire staff in the process. For example,
About the Authors
Dr. Silk is a family physician at Reliant Medical Center in Worchester, Mass., and clinical associate professor of family medicine and community health at the University of Massachusetts Medical School. Dr. Deutchman is a family physician at the University of Colorado Anschutz Medical Center in Aurora, Colo., professor of family medicine in the School of Medicine, and professor in the School of Dental Medicine.
1. Institute of Medicine (IOM). Advancing oral health in America. Washington, DC: The National Academies Press; 2011.
2. IOM. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press; 2011.
3. U.S. Preventive Services Task Force. Prevention of dental caries in children from birth through age 5 years. May 2014. http://www.uspreventiveservicestaskforce.org/uspstf12/dentalprek/dentchfinalrs.htm. Accessed May 14, 2014.
4. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric primary care providers' screening and referral for early childhood caries. Pediatrics.2002;109(5):e82.
5. Lewis C, Lynch H, Richardson L. Fluoride varnish use in primary care: what do providers think? Pediatrics. 2005;115(1):e69–76.
6. Pahel BT, Rozier RG, Stearns SC, Quinonez RB. Effectiveness of preventive dental treatments by physicians for young Medicaid enrollees. Pediatrics.2011;127(3):e682–689.
7. American Academy of Pediatrics. State Medicaid payment for caries prevention services by non-dental professionals. http://www2.aap.org/oralhealth/docs/OHReimbursementChart.pdf. Accessed May 27, 2014.
8. National Institute of Dental and Craniofacial Research. Dental caries in children. http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesChildren2to11. Accessed May 27, 2014.
9. Jeffcoat M, Jeffcoat RL, Gladowski P, Bramson J, Blum J. Periodontal therapy improves outcomes in systemic con-ditions: insurance claims evidence. Paper presented at: Meeting of the American Association of Research; March 21, 2014; Charlotte, NC.
10. HealthyPeople.gov website. Dental visits in the past twelve months, 2007 and 2009. http://www.healthypeople.gov/2020/topicsobjectives2020/nationalsnapshot.aspx?topicId=32. Accessed May 27, 2014.
11. Manski RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and 2004. MEPS Chartbook No.17. Rockville, MD: Agency for Healthcare Research and Quality; 2007.
12. United States Government Accountability Office. Medicaid – state and federal actions have been taken to improve children's access to dental services, but gaps remain. September 2009. http://www.gao.gov/new.items/d09723.pdf. Accessed Nov.1, 2013.
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