Guest Editorial

Family Physicians Are in Perfect Position to Address Oral Health

September 18, 2013 05:30 pm Hugh Silk, M.D., M.P.H.

Oral health has a major impact on an individual patient's overall health and wellness. As family physician and former U.S. Surgeon General David Satcher, M.D., Ph.D., once said, "You are not healthy without good oral health."

Hugh Silk, M.D., M.P.H.

The mouth affects the entire body across the life cycle. Examples include untreated caries leading to pain, unnecessary emergency department visits and missed school, as well as the systemic inflammation of periodontitis, which can be associated with worse control of diabetes, increasing obesity rates and heart disease.

With this in mind, Healthy People 2020 made oral health one of its top nine health indicators(www.healthypeople.gov), yet, only 44.5 percent of people age 2 years and older had a dental visit during the past 12 months, and half of U.S. seniors perceive their dental health as poor or very poor.

Fortunately, we, as family physicians, are in the perfect position to address oral health. In fact, the Institute of Medicine lays out clear roles for family physicians and other non-dental professionals in its ground-breaking report on advancing oral health care(www.iom.edu) and its report on improving access to care for vulnerable and underserved populations(books.nap.edu).

The American Dental Association (ADA) agrees.

"With physicians, nurses, physician assistants and other members of the primary care team joining the fight for oral health, we have a real chance to eradicate the silent epidemic of dental disease," said ADA executive director Kathleen O'Loughlin, D.M.D., M.P.H., last year in an endorsement of the Society of Teachers of Family Medicine's online oral health curriculum, Smiles for Life, which is designed to enhance the role of primary care clinicians in the promotion of oral health.

More on that program later.

Oral health promotion and prevention is something that needs to be addressed across the life cycle. Because we see patients from cradle to grave, we can and should address this. In this era of the patient-centered medical home (PCMH), we act as leaders of the team, coordinating all aspects of a patient's health as their first contact and helping with referrals to relevant specialists, including dentists and periodontists.

According to a new American College of Obstetrics and Gynecology Committee Opinion(www.acog.org), physicians should perform a risk history and oral exam for pregnant women during the intake visit and make a referral to get dental care during pregnancy, which evidence shows is safe. This will help the mother avoid dental issues during pregnancy and offer her newborn a lower risk for caries.

Only 34 percent of pregnant women report visiting the dentist, however. We can do better!

For infants and children, the American Academy of Pediatrics suggests(pediatrics.aappublications.org) that primary care health professionals discuss oral health with parents starting when children are 6 months of age. We see children for well care six to 10 times before they ever see a dentist. We are their dental home until we help them find one. Such visits should include a risk history for caries, an oral exam, dental hygiene and diet advice, as well as a referral to a dentist aiming for the first dental visit by age 1.

In 43 states, medical professionals are being paid(www.pewstates.org) -- $13 to $78, depending on the state -- by Medicaid to offer these screenings as well as fluoride varnish two to four times per year based on risk.

Recently, the U.S. Preventive Service Task Force proposed a level B recommendation for primary care health professionals to apply fluoride varnish(www.uspreventiveservicestaskforce.org) to the primary teeth of children. The AAFP already recommends fluoride supplementation for children in communities with inadequate fluoride in the water supply.

As part of my residency program's PCMH initiative, we divide these tasks up among the medical assistant, nurse and physician to make it easier and less time-consuming.

For older children and adolescents, additional considerations should be addressed. We, along with our staff members, are perfectly poised to remind young athletes to wear mouth guards to prevent dental injuries; discuss the risks of oral piercings, including infection and dental trauma; and continue to focus on healthy diets for caries prevention, which overlaps with obesity prevention.

In addition, we should not forget about the dental health of our adult patients. Our country is facing an epidemic of obesity, uncontrolled diabetes and cardiac disease. Controlling periodontitis can improve these conditions by reducing oral-systemic inflammation, so we need to make it part of our preventive care. We should take a minute at well visits to promote brushing teeth twice a day, flossing daily and regular dental visits.

The oral cavity contains much more than teeth, however, and we often have the first opportunity to offer advice about soft tissue lesions, such as aphthous ulcers, candidiasis or leukoplakia. We can help our patients avoid oral cancers through tobacco cessation counseling or early identification of one of the 30,000 cancers that are diagnosed annually.

The mouth also is dramatically affected by medications. For example, medications that dry the mouth (e.g., selective serotonin reuptake inhibitors, antihistamines) put elderly patients at higher risk for caries. In a country where 70 percent of seniors lack dental insurance, we need to play a role.

Finally, whether we like it or not, we get many urgent oral care questions on call and through office visits. We should be able to do basic triage as we do for other urgent health care issues.

How can you accomplish this? Further educate yourself and your staff on oral health care topics via Smiles for Life(elearning.talariainc.com), which offers free CME. The site covers all of the topics mentioned above and has downloadable smartphone apps.

Make systems changes in your office as part of quality improvement to make addressing oral health easier. For example, change your electronic health record (EHR) prompts for well visits and prenatal care to include oral health findings and advice.

Offer access to patient education about oral health on your office website or with handouts. You also can refer patients to resources from the ADA(www.mouthhealthy.org) or the American Academy of Pediatric Dentistry(www.mychildrensteeth.org).

If we are truly going to be patient-centered, then we can't afford to ignore this key element of wellness. Ask, examine, offer advice and make referrals. Simple tweaks to office flow, patient education and EHRs can make such actions easy and meaningful.

Hugh Silk, M.D., M.P.H., is a clinical associate professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, Worcester.


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