While health care experts and health philanthropy are becoming increasingly aware that oral health is essential for healthy development and healthy aging, nationwide, there remains an unacceptably high burden of oral disease. Dental caries is the most common chronic disease of childhood. In other words, more kids suffer from a completely preventable disease of the mouth than any other chronic condition.
Adults aren’t faring much better: One quarter of adults has untreated dental caries, and a fifth of adults have destructive periodontal disease, which can result in pain, tooth loss, and systemic infection. (See Healthy People 2010: Final Review, page 21-9.)
A person’s oral health impacts their overall health and their quality of life. Patients with a chronic disease, such as diabetes, are both at increased risk for oral complications and for adverse health outcomes if their oral complications go untreated. Late-stage oral disease results in a substantial amount of wasteful health care spending. Medications used to treat many mental health conditions have a significant impact on production of saliva, and that can negatively impact oral health. Moreover, a series of intriguing new reports (we link to just one example here) demonstrate the potential for savings in total health care costs across a spectrum of health conditions with the successful treatment of periodontal disease. This is an example of the potential benefits of addressing oral disease.
Enhancing access to affordable dental care is important and has been a favorite cause of oral health grantmakers for many years. Mobile dental vans, school-based hygiene and treatment programs, and loan repayment for dentists working in underserved areas are all important strategies to address barriers to access but are unlikely to be sufficient as a long-term strategy for reducing the burden of oral disease. To effectively combat oral disease, we need to expand the oral disease prevention workforce and intervene earlier in the course of that disease.
To reduce the burden of oral disease, the efforts and skills of both primary care providers and dentists and their respective teams will be required. The job is too great for either discipline alone.
Recently, three philanthropies with an interest in oral health policy partnered with Qualis Health to explore a new approach to delivering oral health preventive care. The foundations are the REACH Healthcare Foundation, Merriam, Kansas, which funds in six counties in the Kansas City metropolitan area; Washington Dental Service Foundation, Seattle, Washington, which funds statewide; and the DentaQuest Foundation, a national funder based in Boston, Massachusetts.
Our joint effort came about as the result of years of experience funding a variety of programmatic and policy approaches to increasing access to oral health care. While all of those efforts were valuable and enjoyed marginal success, none were successful in dramatically and sustainably addressing the burden of oral disease in the general population. We were also watching with growing interest efforts by our funder colleagues to advance models that integrate behavioral health in primary care settings.
With assistance from a Technical Expert Panel comprised of dentists, primary care providers, nurses, practice managers, other health care sector leaders, and policy makers, Qualis Health, the consultants with which we contracted, developed the Oral Health Delivery Framework.
The framework proposes delivering oral health preventive care and providing self-care guidance in the primary care setting because it offers the opportunity to expand access for nearly all patients, particularly high-risk and vulnerable patients, such as pregnant women, the elderly, and the uninsured, who bear the greatest burden of oral disease. This model acknowledges that primary care teams have (1) the skills necessary to understand and intervene in the oral disease process; (2) the relationships needed to engage patients and families in oral health self-care; and (3) a structure for coordinating referrals to dentistry and supporting patients during transitions of care through a more effective, team-based approach to care.
The primary care delivery system is in the midst of a transformation, striving to provide more patient-centered and value-oriented care. This evolution provides new opportunities, and a new responsibility, for addressing oral health as a component of comprehensive, whole-person care.
The Oral Health Delivery Framework delineates the activities, such as looking inside the mouth for active infection and applying fluoride varnish, for which a primary care team can be accountable. These activities are within the scope of practice for primary care, and if organized efficiently, can be integrated into the office workflow of diverse practice settings. Activities are grouped into five action categories: Ask, Look, Decide, Act, and Document & Follow Up.
Philanthropy has an important role in not only advancing new models of care but also introducing adaptations and expansions into existing models. Such is the case with bringing oral health preventive care to the realm of primary care and setting the expectation that primary care and dental teams collaborate with one another to improve patient and family oral health.
Our foundations are pleased to introduce our colleagues to the Oral Health Delivery Framework in the form of a recently released white paper Oral Health: An Essential Component of Primary Care.
To learn about the experience of early leaders in the field, grantmakers may also want to explore the case examples from Washington and Wisconsin that are included in this white paper, as well as those included in Oral Health Integration in the Patient-Centered Medical Home (PCMH) Environment: Case Studies from Community Health Centers (2012) gleaned from the field in a variety of community health centers in four states: Idaho, Massachusetts, Washington, and Wisconsin.
We welcome our funder colleagues’ feedback, questions, and experiences to further inform this important integration advance in the field.
Related resources:
Introductory video: https://www.youtube.com/watch?v=8XPxDSiR9ig&feature=youtu.be
Executive summary pf 2015 White Paper: http://www.safetynetmedicalhome.org/sites/default/files/Executive-Summary-Oral-Health-Primary-Care.pdf
Oral Health: An Essential Component of Primary Care (2015) (full white paper in PDF): http://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf
Oral Health Integration in the Patient-Centered Medical Home (PCMH) Environment: Case Studies from Community Health Centers (2012) (white paper in PDF): http://www.qualishealth.org/sites/default/files/white-paper-oral-health-integration-pcmh.pdf
Editor’s Note—Related Content in Health Affairs:
Dianne Riter of the Washington Dental Service Foundation et al., “Delivering Preventive Oral Health Services in Pediatric Primary Care: A Case Study,” GrantWatch section, November 2008 issue.
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