In the past month, the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org) (USPSTF) and the AAFP issued their respective and congruent recommendations on the prevention of dental caries in children from birth through age 5. These recommendations called for primary care clinicians to prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, and encouraged primary care physicians to apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
But if the results of a couple of recent studies buoyed by state and AAFP programs are any indicator, the oral health care already being performed by primary care professionals, including family physicians, is leading to positive outcomes.
Into the Mouths of Babes
In a study published in the April issue of Pediatrics(pediatrics.aappublications.org), researchers analyzed the impact of a North Carolina Medicaid preventive oral health care program called Into the Mouths of Babes(www.ncdhhs.gov) (IMB). The program, which started in 2000, trains family physicians and pediatricians to perform an oral health evaluation and risk assessment, educate parents/caregivers, apply fluoride varnish, and refer children to a dental home when appropriate.
According to study co-author Gary Rozier, D.D.S., professor of health policy and management at the University of North Carolina at Chapel Hill Gillings School of Global Public Health, these services are usually offered during well-child visits.
- A couple of recent studies suggest that oral health care primary care professionals, including family physicians, are performing is leading to positive outcomes.
- In a study published in the April issue of Pediatrics, researchers analyzed the impact of a North Carolina Medicaid preventive oral health care program and found it reduced dental caries among populations of children in low-income families.
- A study jointly released by the AAFP, American Academy of Pediatrics and American Academy of Pediatric Dentistry sought to identify what elements led to successful implementation of office-based oral health promotion.
Rozier described the particulars of the study. “In North Carolina, we have a good surveillance system for oral health that includes kindergarten and fifth-grade children,” he said. “Virtually every child every year has a clinical assessment in the schools by a trained dental hygienist from the public health department.”
Because that system has been in place since 1996, said Rozier, the researchers had annual data that allowed them to follow trends in dental disease for children entering kindergarten. The researchers also had Medicaid data that showed the increase in provision of preventive dental services in medical offices that saw children enrolled in the program.
“It seemed if we could link the two together -- trends in dental disease and trends in provision of preventive dental services, we could make some inferences about the effects of service delivery on trends in statewide disease,” Rozier explained.
An analysis of data from 1998 to 2009 found that the North Carolina IMB program reduced dental caries among children in low-income families, which, in turn, helped reduce oral health disparities among all preschool-age children in the state.
“The study found good evidence, in our opinion, that some of the decline of about 14 percent in dental caries between 2004 to 2009 can be attributed to implementation of (the IMB) program in pediatrician and family physician offices,” said Rozier.
Role of North Carolina AFP
The North Carolina AFP (NCAFP) Foundation was the fiduciary for the original IMB program funding, according to Gregg Griggs, EVP of the NCAFP.
“The program has paid great dividends in North Carolina,” Griggs said. “Our state Medicaid program has paid for dental varnish treatments in primary care offices, and it has shown real cost savings and real reduction in dental caries in young children.”
The NCAFP now works with the North Carolina Department of Health and Human Services to help chapter members and their staff gain training through the IMB program. And it just so happens that the person who now leads that statewide effort was once a staff member at the NCAFP.
Kelly Close, R.D.H., M.H.A., was hired by the NCAFP in 2000 to run the IMB program. Previously, she had been a public health dental hygienist at the county level for 16 years.
“The idea for IMB came from people in a community in the western part of North Carolina who realized that tooth decay in young children was one of their biggest health problems,” Close said. “Where do these young children go for care? They go to their primary care providers for immunizations. Maybe that is a way we can address this.”
That tactic proved so successful that when grant funding for the program expired in 2005, the state’s dental director decided to fund a coordinator position for IMB, and Close began her current position as Preschool Oral Health Coordinator in the Oral Health Section of the Division of Public Health at the N.C. Department of Health and Human Services. She told AAFP News she has now worked on the IMB program for 15 years and with hundreds of family physicians and thousands of medical professionals in general.
“Working with medical professionals has been the highlight of my career,” Close said. “They have such an influence on the parents of the children they see. They have such an opportunity to influence the parents’ behaviors in what they do for their children.”
The NCAFP also hosts quarterly meetings with partners that include the University of North Carolina School of Dentistry, the Oral Health Section of the state health department, the North Carolina Pediatrics Society and the North Carolina Medicaid program.
The chapter is working with its partners to organize dental/primary care mixers in different areas of the state where family physicians, pediatricians and dentists can come together to talk about how they can work together better.
According to Griggs, participants at the mixers will consider questions such as:
STFM Has Training Resources
For family physicians interested in learning more about basic oral health preventive services and how to provide them, the Society of Teachers of Family Medicine’s Smiles for Life initiative(elearning.talariainc.com) offers training modules, said Gary Rozier, D.D.S., professor of health policy and management at the University of North Carolina at Chapel Hill Gillings School of Global Public Health. Now in its third edition, the Smiles for Life curriculum is designed to enhance the role of primary care clinicians in the promotion of oral health for all age groups.
- What are oral health issues that primary care physicians should be looking out for?
- In what instances should primary care physicians refer patients to a dental specialist versus a general dentist?
- How can there be better communication between the dental side of the house and the medical side?
Overall, said Griggs, “(The program) has morphed into a broader initiative where they are really trying to use some broader tools to make sure folks have a dental home.”
Oral Health Care Promotion
A study report released last month chronicled the results a joint venture of partners that included the AAFP, American Academy of Pediatrics and the American Academy of Pediatric Dentistry. The report, titled “Interprofessional Study of Oral Health in Primary Care,” sought to identify elements that lead to successful promotion of oral health services in primary care offices.
For the study, six focus groups were conducted with primary care health professionals (17 pediatricians, 11 family physicians, 10 nurse practitioners and three physician assistants) who were currently providing oral health care for children from birth through age 12 years. Participants represented a variety of practice types and settings, including academic medical centers, private facilities, HMOs, federally qualified health centers and hospital-based offices.
Researchers also conducted on-site observations in 12 primary care practices that were actively conducting oral health care for children from birth through age 6 years.
The study found that the following factors were associated with successful implementation of an oral health promotion program:
- having an oral health champion to implement the program and sustain it,
- delegating oral health activities throughout the health care team,
- formally integrating oral health activities into the workflow, and
- including specific questions and prompts in electronic health record (EHR) intake and exam screens.
A Martinez, Calif., practice for example, used grant funds from a local university to hire a dental hygienist who not only provided staff training that included fluoride varnish application, but also engaged staff in the process by facilitating focus groups and addressing questions and concerns.
“The staff buy-in and enthusiasm created during this process was a factor in their success,” said Jan Silverman, assistant director of the American Academy of Pediatric Dentistry’s Pediatric Oral Health and Policy Research Center. Staff participated at all levels and were able to integrate oral health into the practice’s EHR system, allowing them to track their success.
But in the end, a simple “Why not?” approach might be the best way to promote oral health care at the practice level.
When the team visited a teaching hospital, they asked a medical resident about doing visual inspections of the teeth during health care visits. The response? “We look into the mouth to examine the throat anyway; it’s easy to look at the teeth at the same time.”
Related AAFP News Coverage
Family Physicians Are in Perfect Position to Address Oral Health