Patients usually don't expect their mouths to get much attention when they visit a primary care physician, but there is reason to change that.
Because dental care is the most common unmet health need in most communities, panelists at a recent webinar(www.pcpcc.org) hosted by the Patient-Centered Primary Care Collaborative discussed how and why primary care physicians should consider incorporating oral health into their practices.
The most vulnerable populations do not have adequate insurance coverage for dental care, which leads to problems across populations. For instance, dental caries is the most common chronic disease among children, 20 percent of adults have destructive periodontal disease, 25 percent of seniors have lost all of their natural teeth by age 65, and dental disease may be linked to diabetes and poor pregnancy outcomes.
Because primary care physicians are the only medical specialists many patients see, they are well-positioned to play an important role in oral health, panelists said. They can screen for signs of early oral disease, administer treatments such as applying fluoride varnish and refer patients who need further attention to dentists.
Primary care physicians are a critical part of reducing the "prevention gap" that makes national rates of dental disease unacceptably high, panelists said.
- Dental care is the most common unmet health need in most communities.
- Panelists at a recent webinar hosted by the Patient-Centered Primary Care Collaborative discussed how primary care physicians can incorporate oral health into their practices.
- Patients appreciate a physician's attention to oral health, said one panelist, and they respond to coaching.
"Expanding access to affordable dental care is an important goal in its own right, but that alone is unlikely so solve our current problem," said Kathryn Phillips, M.P.H., program director at Qualis Health. "The need is simply too great."
Jeff Hummel, M.D., M.P.H., medical director for informatics at Qualis Health, said the way physicians have incorporated behavioral health into primary care can be a model for treating oral health issues. But first, primary care physicians and their staff need to be willing to talk with patients about oral health.
"Patients appreciate the attention to oral health, and they respond to coaching," Hummel said.
Qualis Health has sought to facilitate those physician-patient conversations through a project that began in 2014.(www.safetynetmedicalhome.org) Working with family physicians and other primary care specialists, the program is based on three key steps to incorporating oral health into primary care:
- identifying what primary care physicians can do about oral health,
- discussing how to incorporate oral health into a busy workflow, and
- building a referral network with dentists.
Hummel recommends that practices identify a specific population to focus on, such as patients with diabetes or pregnant women.
Then, the main evaluation to be made by a physician is whether a patient demonstrates risks for or signs of oral disease. Physicians may decide to address problems they find through application of fluoride, dietary counseling, oral hygiene training or a medication review to identify possible side effects. Most cases of oral disease, said Hummel, will require a referral to a dentist.
"Primary care is not used to thinking about teeth and gums and instead looked past them, but it's the same anatomy and physiology," Hummel said. "Prevention is where primary care lives, and structured referrals are how we do business."
Medical assistants can facilitate the process by asking patients about dietary habits and ordering necessary referrals pending final review by the physician. They also can handle fluoride varnish, examine a patient's mouth for cavities and periodontal disease, and take notes to help the physician make a final decision.
For primary care practices that choose to create referral networks with dentists, the process can be simple for patients. Instead of telling the patient to find a dentist, the primary care team could send the patient to a specific dentist with a specific request.
Even as primary care practices adjust to changes such as ICD-10 and chronic disease management, Hummel said physicians can incorporate oral health without additional staff or equipment. Although the details of reimbursing primary care physicians for coordinating care with dentists have yet to be worked out, said Hummel, "I don't think providers expect to bill for looking in a patient's mouth any more than they would bill for looking in a patient's ears."
Tending to patients' oral health also can generate new revenue, given that, for instance, Medicaid covers fluoride varnish treatment for children. In fact, Medicaid rates are sufficient in many states for dental clinics located in federally qualified health centers to expand capacity.
A field test is underway to evaluate the integration of oral health at 19 primary care practices, which vary widely in terms of size, location and electronic health record vendor. Qualis Health plans to publish the results in September 2016.
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