Expanding the Physician’s Role in Addressing the Oral Health of Adults

Abstract

Many disadvantaged adults visit physicians or hospital emergency departments to receive relief from dental pain. Physicians also see patients with general questions or concerns about their oral health. Unfortunately, because physicians generally have received little oral health training, patients often do not receive comprehensive emergency services or appropriate counseling.

This situation has begun to change, as there has been a growing sentiment among the dental and medical communities that better integration and coordination between medicine and dentistry would be beneficial. Reports from the Institute of Medicine and professional associations and foundations reflect the need for better integration.

I have outlined the rationale for and progress toward expanding the physician’s role in addressing the oral health of adults.

There is a high prevalence of oral disease among disadvantaged adults, who face financial and other impediments to receiving dental services.¹ Although Medicaid provides dental coverage for many poor children, it provides only limited and in many cases no coverage for poor adults. However, physicians receive Medicaid reimbursement for treating adults with dental problems as do hospital emergency departments (EDs), which also receive reimbursement for facility charges. Dentists are not required by law to provide care to persons who are not able to pay, whereas EDs are. It follows that many poor adults lacking coverage choose to receive emergency dental care at EDs and physician offices.^2–4 Of course, physicians also see patients who have general questions about their oral health, because the physician is frequently the first source of information for many health-related issues.

Most dental emergencies involve acute pain or infection. Relief of acute symptoms usually requires palliative treatment, at a minimum often involving nerve block, abscess drainage, a temporary sedative filling or dressing, and, less frequently, tooth extraction. The emergency encounter ideally should include appropriate health education and disease prevention counseling and an appropriate medical or dental referral as indicated. However, because physicians generally receive little training related to oral health,^5–7 patients seeking care from EDs or physicians usually only receive prescriptions for antibiotics and pain medications and thus do not receive comprehensive emergency services (i.e., diagnosis; treatment such as abscess drainage, local anesthesia, temporary sedative filling or dressing, and in some cases tooth extraction; counseling; and appropriate referral).^6–8 As a result, recidivism is common, which bogs down the system with repeat visits and may contribute to opiate dependency and antibiotic resistance.^9,10 Furthermore, the opportunity to counsel patients regarding the prevention of dental problems and the maintenance of good oral health is lost because of physicians’ general lack of comfort and knowledge regarding oral health–related issues.

CURRENT STATUS

The number of dental-related ED visits has been increasing. Nationally, in 2008 there were 124 million ED visits.¹¹ During the period 1997 to 2000 there was an average of 738 000 dental-related visits, accounting for 0.7% of all visits.⁸ The 2001 Medical Expenditure Panel Survey found that, nationally, 2.7% of all individuals who suffered a dental problem received treatment in an ED.¹² More recently, in 2009, preventable dental conditions were responsible for 830 590 ED visits nationally, representing a 16.0% increase from 2006.¹³ Statewide reports also have documented adult Medicaid recipients’ use of EDs for dental problems.^2,3,14,15

Dental-related ED visits are costly. Nationally, one-year costs for visits for dental caries were $110 million,¹⁶ pulpal or periapical lesions $163 million,¹⁷ and gingival and periodontal lesions $33 million.¹⁸ Unfortunately, because most EDs lack readily available dental services, they often are unable to provide comprehensive emergency dental services,⁸ requiring patients to seek additional urgent care services from dentists.^19,20

Far less is known about the provision of care or counseling for dental problems by office-based physicians. Nationally in 1995, 0.2% of the 700 million physician visits had a principal diagnosis relating to diseases of the teeth and supporting structures.²¹ During the period 1999 to 2000, visits for dental-related problems accounted for 0.3% of all physician visits.²² Nationally in 2001, 7.0% of individuals experiencing a dental problem received care from physicians.¹² This is consistent with a survey of family medicine practices that found that 4.5% of patient visits were related to oral problems.²³ Similarly, data from a telephone survey of Maryland residents found that 6.0% of adults reported seeing a physician for a dental problem sometime during the prior 12 months,²⁴ whereas 20.0% of Maryland adults with toothaches reported physician visits.¹⁹

Unfortunately, many of these patients do not receive comprehensive urgent care services and are instead provided only palliative care.^19,24 Thus, although visits to EDs and physicians for dental problems are well documented, care delivered in these settings is far from ideal. Oral Health in America: A Report of the Surgeon General commented on the lack of data on physician-based services for oral and craniofacial conditions.¹ Many individuals, especially those lacking access to traditional dental services, will continue to seek urgent dental care and counseling from EDs and physicians. Many other patients will continue to seek general oral health–related advice and counseling from their physicians. These patients not only experience less than ideal oral health care services but also suffer from a lack of coordination between their physician and dental provider. This issue will grow in importance with the aging of our population, as the elderly are expected to experience increasing need while facing financial barriers to care.²⁵

CHANGING ENVIRONMENT

Historically, oral health has received little attention in medical school curricula.^26,27 In 2004, the Josiah Macy Jr. Foundation examined oral health education and published a report highlighting a role for physicians in the identification and referral of patients with oral health problems.^28,29 In 2008 the American Association of Medical Colleges published oral health learning objectives.³⁰ The increasing interest in preparing physicians to provide comprehensive coordinated care is reflected in the 2010 grant to the American Association of Medical Colleges from the Human Resources and Services Administration for the development of an oral health in medicine model curriculum for medical schools.³¹ The purpose of the model curriculum is to aid physicians in understanding the impact of oral health on general health to enable physicians to provide coordinated comprehensive care. Similarly, in 2011, an expert panel of physician and dental educators released a report identifying shared oral health–related required knowledge, skills, and attitudes associated with the recognition, diagnosis, treatment, and referral that are appropriate for both medical and dental students.³² The panel’s recommendations reflected its belief that the dental and medical professions have a shared responsibility for the oral health of the public.

Often, professional organizations have taken the lead in promoting the physician’s role in providing child oral health care services. As an example, in 2004, the American Academy of Family Physicians published a practical guide addressing the oral health of infants³³ as has the Society of Teachers of Family Medicine Group on Oral Health.³⁴ In addition, in 2003, the American Academy of Pediatrics established a policy on the pediatrician’s role in the oral health risk assessment of children that emphasizes the need for pediatricians to develop the knowledge to provide patient assessments beginning at patient age of six months.³⁵ The increasing involvement of physicians with the oral health of children is reflected in the fact that 44 states have extended Medicaid reimbursement to pediatricians and family physicians for providing preventive dental services to low-income children, including risk assessments, screening, referral, fluoride varnish applications, and counseling.³⁶

Concurrently, there has been a growing sentiment among the dental and medical community that better integration and coordination between medicine and dentistry would be beneficial. This is especially true given that poor oral health has increasingly been linked to a host of general health problems, including cardiovascular disease, respiratory disease, and diabetes.³⁷ Better integration would prepare physicians to include relevant oral health practices in their overall health care and preventive services, resulting in fewer inefficiencies and duplication of services, better triage of problems, and more appropriate treatment, prevention, counseling, and referral. The need for better integration was reflected in the 1995 Institute of Medicine report Dental Education at the Crossroads, which called for closer integration of medicine and dentistry at the levels of research, education, and patient care.³⁸ In 2006, a major initiative of the American Dental Education Association and the American Association of Medical Colleges called for changes in professional curricula to foster greater integration between medicine and dentistry.³⁹ This changing environment is reflected in the 2008 American Association of Medical Colleges oral health education report, which supported significant curricula changes to address oral health disparities that health professionals’ lack of oral health knowledge and training might aggravate.⁴⁰

Most recently, the 2011 Institute of Medicine report Advancing Oral Health in America called for enhancing the role of nondental health care professionals in an effort to reduce oral health disparities.³⁷ The potential for physicians to improve access to needed oral health care services is reflected in the relative size of the personnel pool (691 000 physicians vs 155 700 dentists).^41,42 The organizing principles of this new initiative emphasized disease prevention and oral health promotion, improving oral health literacy, reducing oral health disparities, and enhancing the role of nondental health care professionals. A companion report also released in 2011 that focused on improving access to oral health care for vulnerable and underserved populations stressed the importance of providing oral health services in a variety of settings, relying on a diverse and expanded group of providers, and including collaborative and multidisciplinary teams working across the health care system.⁴³ Similarly, a 2012 report funded by the W. K. Kellogg Foundation and the DentaQuest Institute advocated the use of nondental professionals in the delivery of dental services as a means to improve oral health quality.⁴⁴

This increased emphasis on the role of nondental health care professionals is also reflected in the 2011 report Core Competencies for Interprofessional Collaborative Practice,⁴⁵ which was produced by an expert panel established in 2009 by the Interprofessional Educational Collaborative, consisting of the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association, the Association of American Medical Colleges, and the Association of Schools of Public Health. The panel was asked to identify individual-level core interprofessional competencies for future health care professionals. The four core competencies the panel identified were values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork. In some programs, progress toward achieving the goal of greater integration and coordination between medicine and dentistry has already been achieved. Presently, allopathic family medicine residency programs are required to include hands-on oral health educational experiences in their curricula,⁴⁶ as are emergency residency programs,⁴⁷ and the American Board of Family Medicine certification examination now contains oral health–related questions.⁴⁸

FUTURE DIRECTIONS

Numerous reports have cited physician lack of training as an impediment to providing needed oral health care services.^49–52 Physicians receiving oral health–related training will be capable of providing not only more comprehensive emergency care but also more appropriate and comprehensive counseling related to the causes of dental problems, methods of prevention and treatment, and more general oral health–related issues. Doctor–patient communication has a significant impact on the delivery of health care. New initiatives of the Agency for Healthcare Research and Quality encourage patients to take a more active role in their own health care by asking appropriate questions of their providers⁵³ and advocate improved communication between patients and practitioners.⁵⁴ Communication problems can contribute to racial and ethnic disparities in the delivery of services and associated disparities in health.^55,56 It is possible that physician unfamiliarity with oral health–related issues contributes to poor doctor–patient communication. Comprehensively trained physicians will be more at ease discussing oral health–related issues that will likely facilitate better patient rapport and compliance with recommendations.

Obviously, increasing access to dentists for the provision of definitive dental services is the most effective policy option for addressing dental emergencies among disadvantaged adult patients. Emergency oral health care services received in EDs or physician offices are inherently inefficient. Not surprisingly, increasing access is a current focus of the dental profession and public health community.^43,57 Unfortunately, the focus to date has been primarily with children, and many states limit or exclude adult Medicaid dental benefits. This situation has worsened as states attempt to cope with the current economic downturn.^2,11

The Patient Protection and Affordable Care Act did not address adult access to needed dental services. Insurance and Medicaid reform are needed to increase dentist incentives to provide needed services to disadvantaged individuals. However, even if dental access for adults is improved, there will remain a need for the provision of some urgent dental services by EDs and physicians and more appropriate and comprehensive counseling services. This is true because for some patients the ED and the physician are the only accessible points of entry to the health care system and for others the physician is an important source of information for all health concerns.

Physicians currently treat many disadvantaged patients with dental problems and consult with patients concerning general oral health–related issues. These patients deserve the highest quality and most effective care possible. Comprehensive care would result in fewer return visits (thus saving office time and money) and more appropriate recommendations and dental referrals. This is especially important in rural areas and inner cities with limited dentist availability. Physicians who receive comprehensive oral health–related training also will be able to provide more appropriate and effective counseling. The Institute of Medicine report emphasized the importance of additional education and training for physicians to improve their health literacy to facilitate their ability to communicate effectively with disadvantaged patients.³⁷ There is increased evidence of professional interest in this area. Several recent articles in the Journal of the American Board of Family Medicine reflect both practitioner interest in additional training and the prevalence of dental disease among presenting patients.^58,59

Recently, the Society of Teachers of Family Medicine’s Group on Oral Health developed an oral health curriculum containing educational modules directed at adult oral health issues.³⁶ Although a majority of family medicine residency programs are using this curriculum, on average very little time is devoted to oral health, with a majority of programs devoting only one to two hours annually.⁶⁰ Enhanced training will undoubtedly increase the ability of physicians to provide more effective adult emergency dental services and counseling. Studies have shown that physicians who receive oral health–related training demonstrate an improved ability to diagnose oral problems and make more appropriate dental referrals.^61,62

Opportunities for additional training should be made available through continuing education courses and professional meetings to practicing physicians, especially pediatricians and family and emergency medicine practitioners. Similarly, providing appropriate training for physician assistants, nurse practitioners, and other health care practitioners would also be advantageous. The extent of training may logically vary according to the specialty and possibly the location of the training program. Educational programs located in areas without an adequate number of dentists may choose to incorporate the most invasive procedure, simple tooth extraction, and those in areas with an adequate number of dentists may not. Similarly, emergency medicine programs might be expected to include more invasive procedures in their training.

The greater involvement of physicians with their patients’ oral health is consistent with evolving clinical practice models that have included the pediatric medical home, the advanced medical home, and, more recently, the dental home. These models of care have evolved to include the health home, which incorporates the medical home and dental home and involves collaboration between primary medical providers, dentists, and other nondental health care professionals. This model encompasses three broad domains, including oral health, general health, and the social environment, and reflects a model of care that is patient-centered, comprehensive, coordinated, accessible, and continuously improved through a system-based approach to quality and safety.^63,64 By enhancing the physician’s ability to provide more comprehensive and effective oral health advisory and treatment services and more effective communication with dentists, this expanded physician role is consistent with the evolving health home model. Recognizing this, the Advisory Committee on Training in Primary Care Medicine and Dentistry in its recently released report The Redesign of Primary Care With Implications for Training recommended an increased emphasis in training programs on promoting interprofessional practice in the patient-centered medical–dental home model of care.⁶⁵

Low-income and minority adults suffer disproportionately from oral problems.⁶⁶ The imperative to address these health disparities has been recognized nationally^1,67 and has been given a high priority in the Institute of Medicine report Advancing Oral Health in America.³⁷ The potential for physicians to help address this problem by providing higher quality and more comprehensive oral health–related services to adults is clear; however, it will remain unfulfilled as long as physicians lack the necessary training.