Publications

2018
Medical-Dental Integration in Public Health Settings: An Environmental Scan. University of Iowa Public Policy Center; 2018.Abstract

Executive Summary

Noncommunicable chronic diseases (NCDs) account for almost 90% of total deaths in the United States.1 The four most common NCDs—cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases—share common risk factors, including cigarette use, alcohol use, and dietary behaviors associated with obesity and elevated blood sugar.1 The most common oral diseases—dental caries, periodontal disease, and oral cancer—also share these same risk factors.

A coordinated approach to primary prevention, the “common risk factor approach,” argues that coordinated primary prevention of oral and systemic diseases will reduce programmatic costs, and increase efficiency and effectiveness..2 However, use and evaluation of this coordinated approach in primary prevention activities in the United States has not been well documented.

This report describes the results of an environmental scan to identify, categorize, and describe examples of medical-dental integration in US public health settings. Findings are intended to inform public health officials and other stakeholders about existing programs and policies that encourage coordination and integration.

ced_environmental_scan.pdf
Advancing Dental Care: Education and Training Review. NHS - Health Education England; 2018. advancing_dental_care_final.pdf
Simon L, Silk H, Savageau J, Sullivan K, Riedy C. Oral Health Training in Osteopathic Medical Schools: Results of a National Survey. The Journal of the American Osteopathic Association [Internet]. 2018;118 (7) :463-471. Publisher's VersionAbstract

Context: Oral health is a critical aspect of overall health, yet many vulnerable communities struggle to access regular dental care and instead seek urgent treatment from physicians. In addition to addressing the consequences of untreated dental disease, physicians are in an ideal position to provide preventive and referral dental services to patients. Osteopathic physicians make up a substantial portion of the physician workforce and can play a central role in increasing oral health care provision in medical settings.

Objective: To assess the extent of oral health curricula in osteopathic medical schools in the United States, including content taught, evaluation practices, and influences and barriers to providing oral health training perceived by educators at these institutions.

Methods: An invitation to participate in the survey was sent electronically to deans of education at all osteopathic medical schools in the United States. Four email reminders followed the initial invitation. In addition to descriptive statistics, the associations between the number of curriculum hours, affiliation with a dental school, and curricular content were evaluated.

Results: Of the 42 institutions contacted, 22 responded (response rate, 52%). The majority of respondents (20 of 22 [91%]) reported the presence of some oral health education at their institutions. Eighteen of 20 respondents (90%) reported that their institution offered at least 1 hour of oral health curriculum over the course of students’ education. Greater numbers of curriculum hours were not significantly associated with dental school affiliation or a formalized relationship with oral health educators. Institutions affiliated with dental schools were significantly more likely to include oral health in interprofessional education exercises (P=.023) but were not significantly more likely to cover any specific oral health topics. Seven of 17 respondents (41%) were satisfied with the level of oral health competence their graduates possessed.

Conclusion: Oral health education is present at many osteopathic medical schools, but the content covered and the extent of training varies considerably.

Silk H, Savageau JA, Sullivan K, Sawosik G, Wang M. An Update of Oral Health Curricula in US Family Medicine Residency Programs. Family Medicine [Internet]. 2018;50 (6) :437-443. Publisher's VersionAbstract

Background and Objectives: National initiatives have encouraged oral health training for family physicians and other nondental providers for almost 2 decades. Our national survey assesses progress of family medicine residency programs on this important health topic since our last survey in 2011.

Methods: Family medicine residency program directors (PDs) completed an online survey covering various themes including number of hours of oral health (OH) teaching, topics covered, barriers, evaluation, positive influences, and program demographics.

Results: Compared to 2011, more PDs feel OH should be addressed by physicians (86% in 2017 vs 79% in 2011), yet fewer programs are teaching OH (81% vs 96%) with fewer hours overall (31% vs 45% with 4 or more hours). Satisfaction with the competence of graduating residents in OH significantly decreased (17% in 2017 vs 32% in 2011). Program directors who report graduates being well prepared to answer board questions on oral health topics are more likely to have an oral health champion (P<0.001) and report satisfaction with the graduates’ level of oral health competency (P<0.001). Programs with an oral health champion, or having a relationship with a state or national oral health coalition, or having routine teaching from a dental professional are significantly more likely to have more hours of oral health curriculum (P<0.001).

Conclusions: Family medicine PDs are more aware of the importance of oral health, yet less oral health is being taught in residency programs. Developing more faculty oral health champions and connecting programs to dental faculty and coalitions may help reduce this educational void.

A State of Decay: Are Older Americans Coming of Age without Oral Healthcare?. Vol IV. Oral Health America; 2018.Abstract
This state-by-state report assesses the status of oral health for America’s 65+ population and the success or failure of states to address needs of that demographic.
astateofdecay2018_oha.pdf
Simon L, Ji Y, Jones M, Nalliah R, Fernandez-Golarz C, Cohen M. Integration of an Oral Health Team into a Student-Faculty Collaborative Clinic: Successes and Challenges. Journal of Healthcare for the Poor and Underserved. 2018;May (29) :2.Abstract
Vulnerable populations are more likely to access medical care than visit a dentist. We introduced a dental team into a student-faculty collaborative clinic that serves a low-income Latino population. Documentation of oral exam findings rose from 11.88% to 50.50% in the year following integration of dental students into the clinic.
2017
Dolce M, Parker J, Marshall C, Riedy C, Simon L, Barrow J, Ramos C, DaSilva J. Expanding Collaborative Boundaries in Nursing Education and Practice: The Nurse Practitioner-Dentist Model for Primary Care. Journal of Professional Nursing [Internet]. 2017;November-December (33(6) :405-409. Publisher's VersionAbstract

Highlights

  • The Affordable Care Act necessitates collaboration between nursing and dentistry.
  • Nurse practitioner education should include leadership and teamwork training.
  • The NPD Program holds promise for improving oral and systemic health for patients and populations.

Abstract

The purpose of this paper is to describe the design and implementation of a novel interprofessional collaborative practice education program for nurse practitioner and dental students, the Nurse Practitioner-Dentist Model for Primary Care (NPD Program). The NPD Program expands collaborative boundaries in advanced practice nursing by integrating primary care within an academic dental practice. The dental practice is located in a large, urban city in the Northeast United States and provides comprehensive dental services to vulnerable and underserved patients across the age spectrum. The NPD Program is a hybrid curriculum comprised of online learning, interprofessional collaborative practice-based leadership and teamwork training, and clinical rotations focused on the oral-systemic health connection. Practice-based learning promotes the development of leadership and team-based competencies. Nurse practitioners emerge with the requisite interprofessional collaborative practice competencies to improve oral and systemic health outcomes.

Borrell LN. Oral Health Inequities: An AJPH Supplement to Help Close the Gap. American Journal of Public Health [Internet]. 2017;107 (S1) :S5-S6. Publisher's Version
Simon L, Eve E, Dolce M, Allareddy V, Nalliah R. Physician Assistant Student Perceptions of an Interprofessional, Peer-to-Peer Oral Health Curriculum Led by Dental Students . The Journal of Physician Assistant Education. 2017;28 (4) :210-213.Abstract
PURPOSE Physician assistants (PA) are health care team members who often work in primary care. Providing oral health education to PAs during training could improve oral health for vulnerable patients who seek treatment in the primary care setting and who are less able to access dental care. The purpose of this study was to assess the effectiveness of a peer-to-peer oral health curriculum taught by dental students to their PA student colleagues. METHODS Dental students presented an interactive, case-based curriculum, followed by a hands-on oral examination training session. PA student feedback was obtained, and results were analyzed. RESULTS Students found the content to be highly relevant and well presented. Conveying oral health competencies to future primary care providers may reduce oral health disparities. CONCLUSIONS PA students reported improved understanding of oral health and indicated they would incorporate what they had learned into their future clinical practice.
Nasseh K, Vujicic M. The impact of the affordable care act's Medicaid expansion on dental care use through 2016. Journal of Public Health Dentistry [Internet]. 2017;77 (4) :290–294 . Publisher's VersionAbstract
OBJECTIVE:

To examine the impact of the Affordable Care Act on dental care use among low-income adults ages 21-64.

METHODS:

Our analysis uses national survey data from the 2010-2016 Gallup Wellbeing-Index. We use a differences-in-differences analysis to assess changes since the end of 2013 in dental care use among low-income adults. We compare changes in states that expanded Medicaid and offer adult Medicaid dental benefits versus changes in other states.

RESULTS:

Relative to the pre-reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased 3-6 percentage points in 2016.

CONCLUSIONS:

In Medicaid expansion states with adult dental benefits, evidence suggests that low-income adults have greater access to dental care.

nasseh_et_al-2017-journal_of_public_health_dentistry.pdf
Nicolas M.OreskovicMD MPH, German O.GallucciDMD PD, I.ChaseDDS I, E.MillirenMPH C, Tracy K.RichmondMD MPH. Oral health status and longitudinal cardiometabolic risk in a national sample of young adults. The Journal of the American Dental Association [Internet]. 2017;148 (12) :930-935. Publisher's VersionAbstract

Background

Dental and cardiometabolic diseases are highly prevalent, share many common risk factors, and begin during youth. Despite poor dental health being known to influence dietary behaviors that are in turn linked to cardiometabolic health, the role of oral health on concomitant and future cardiometabolic disease is understudied. We sought to determine the association of oral health with cardiometabolic markers during adolescence and early adulthood.

Methods

Our sample included 11,556 participants with data from waves 1 (when participants were aged 12 to 19 years) and 4 (when they were aged 26 to 32 years) of the National Longitudinal Study of Adolescent to Adult Health. Multivariable linear and logistic regression separately examined associations between different markers of oral health (that is, missing teeth, periodontal disease, and deferred dental care) and markers of cardiometabolic health (that is, lipids, blood pressure, and body mass index), adjusting for sociodemographic characteristics.

Results

Mean age was 29 years at follow-up (wave 4). In adjusted analyses, deferred dental care during both adolescence (β = 1.25; 95% confidence interval [CI], 0.6 to 2.0; P = .001) and early adulthood (β = 0.9; 95% CI, 0.4 to 1.3; P < .001) was associated with an increased body mass index during early adulthood. Deferred dental care in early adulthood was also associated with increased systolic (β = 0.9; 95% CI, 0.4 to 1.5; P = .002) and diastolic (β = 1.0; 95% CI, 0.5 to 1.5; P < .001) blood pressure values and an increased likelihood of being hypertensive (odds ratio = 1.2; 95% CI, 1.0 to 1.3; P = .03).

Conclusions

In this nationally representative study deferred dental care during adolescence and concurrently in early adulthood was associated with poorer cardiometabolic disease during early adulthood. Providing better access to dental care may have benefits not only for oral health but also for long-term cardiometabolic health.

Practical Implications

Deferred dental care during adolescence and early adulthood, but not recent tooth loss or periodontal disease, is associated with increased risk of cardiometabolic disease.

1-s2.0-s000281771730867x-main.pdf
Martin SA, Simon L. Oral Health and Medicine Integration: Overcoming Historical Artifact to Relieve Suffering. American Journal of Public Health [Internet]. 2017;107 (S1) :S30-S31. Publisher's Version
Etolue J, Obadan-Udoh E, Simon L, et al. Dental Providers' Perspectives on Diagnosis-Driven Dentistry: Strategies to Enhance Adoption of Dental Diagnostic Terminology. International Journal of Environmental Research and Public Health [Internet]. 2017;14 (7) :767. Publisher's VersionAbstract
The routine use of standardized diagnostic terminologies (DxTMs) in dentistry has long been the subject of academic debate. This paper discusses the strategies suggested by a group of dental stakeholders to enhance the uptake of DxTMs. Through unstructured interviewing at the 'Toward a Diagnosis-Driven Profession' National Conference held on 19 March 2016 in Los Angeles, CA, USA participants were asked how enthusiastic they were about implementing and consistently using DxTMs at their work. They also brainstormed on strategies to improve the widespread use of DxTMs. Their responses are summarized by recursive abstraction and presented in themes. Conference participants were very enthusiastic about using a DxTM in their place of work. Participants enumerated several strategies to make DxTMs more appealing including: the use of mandates, a value proposition for providers, communication and education, and integration with EHRs and existing systems. All groups across the dental healthcare delivery spectrum will need to work together for the success of the widespread and consistent use of DxTMs. Understanding the provider perspective is however the most critical step in achieving this goal, as they are the group who will ultimately be saddled with the critical task of ensuring DxTM use at the point of care.
Martin S, Simon L. Like Pulling Teeth: Expanding the Oral Health Workforce by Training Physicians in Dental Extractions. [Internet]. 2017;28 (3) :881-886. Publisher's VersionAbstract
In the United States, vulnerable populations at highest risk for poor oral health are more likely to visit a physician than a dentist. Patients in acute dental pain often present to hospital emergency departments or primary care offices where only palliative care is available. While numerous measures to improve oral health access in the United States are necessary, the authors propose that physician training incorporate techniques in dental diagnosis and primary dental care, including extraction where indicated, to allow providers to deliver definitive dental measures to patients unable to access the dental health care system. These skills will allow primary care providers to improve oral health, and ultimately strengthen ties to oral health providers that will improve patient care.
Simon L, Sue K, Williams R, et al. Dental Student-Delivered Care at a Student-Faculty Collaborative Clinic in a Correctional Facility. American Journal of Public Health [Internet]. 2017;107 (S1) :S85-S89. Publisher's Version
Simon L, Sengupta N, Nanavati S, Cericola M. Oral Health Integration Into a Pediatric Practice and Coordination of Referrals to a Colocated Dental Home at a Federally Qualified Health Center. American Journal of Public Health [Internet]. 2017;107 (10) :1627-1629. Publisher's VersionAbstract
We have integrated preventive oral health measures into preventive care visits for children at a federally qualified health center in Boston, Massachusetts. The program, started in 2015, covers 3400 children and has increased universal caries risk screening in primary care to 85%, fluoride varnish application rates to 80%, and referrals to a dental home to 35%. We accomplished this by minimizing pressures on providers' workflow, empowering medical assistants to lead the initiative, and utilizing data-driven improvement strategies, alongside colocated coordinated care.
Dolce MC, Parker JL, Marshall C. Expanding Collaborative Boundaries in Nursing Education and Practice: The Nurse Practitioner-Dentist Model for Primary Care. Journal of Professional Nursing [Internet]. 2017;33 (6) :405-409. Publisher's VersionAbstract
The purpose of this paper is to describe the design and implementation of a novel interprofessional collaborative practice education program for nurse practitioner and dental students, the Nurse Practitioner-Dentist Model for Primary Care (NPD Program). The NPD Program expands collaborative boundaries in advanced practice nursing by integrating primary care within an academic dental practice. The dental practice is located in a large, urban city in the Northeast United States and provides comprehensive dental services to vulnerable and underserved patients across the age spectrum. The NPD Program is a hybrid curriculum comprised of online learning, interprofessional collaborative practice-based leadership and teamwork training, and clinical rotations focused on the oral-systemic health connection. Practice-based learning promotes the development of leadership and team-based competencies. Nurse practitioners emerge with the requisite interprofessional collaborative practice competencies to improve oral and systemic health outcomes.
DMD LS, Kimberly Sue MD PD, BS RW, David Beckmann MD MPH, Matthew Tobey MD MPH, Marya Cohen MD MPH. Dental Student–Delivered Care at a Student–Faculty Collaborative Clinic in a Correctional Facility. American Journal of Public Health [Internet]. 2017;107 (51) :S85-S87. Publisher's VersionAbstract
People experiencing incarceration are uniquely vulnerable to poor health, including oral health. We implemented a dental clinic in a city jail in tandem with medical and mental health care. Students deliver dental care with a supervising dentist. Students also provide patient oral health education and train other students to conduct oral screenings. Dental students are exposed to correctional dentistry, and health professions students acquire oral health skills. All students learn about the unique needs of patients experiencing incarceration.
ajph.2017.303793.pdf
Kamyar Nasseh, Ph.D., Marko Vujicic PD, Michael Glick PD. The Relationship between Periodontal Interventions and Healthcare Costs and Utilization. Evidence from an Integrated Dental, Medical, and Pharmacy Commercial Claims Database. Health Economics [Internet]. 2017;26 (4) :519–527. Publisher's VersionAbstract
Periodontal disease has been linked to poor glycemic control among individuals with type 2 diabetes. Using integrated dental, medical, and pharmacy commercial claims from Truven MarketScan® Research Databases, we implement inverse probability weighting and doubly robust methods to estimate a relationship between a periodontal intervention and healthcare costs and utilization. Among individuals newly diagnosed with type 2 diabetes, we find that a periodontal intervention is associated with lower total healthcare costs (−$1799), lower total medical costs excluding pharmacy costs (−$1577), and lower total type 2 diabetes-related healthcare costs (−$408). © 2016 The Authors. Health Economics Published by John Wiley & Sons Ltd.
Sommers, Benjamin D. MD PD. Why Health Insurance Matters-and Why Research Evidence Should Too. Academic Medicine [Internet]. 2017. Publisher's VersionAbstract
In the current debate over the future of the Affordable Care Act (ACA), research evidence on the impact of the law and the effects of health insurance coverage in general is critical. Studies of health insurance expansion over the past decade have demonstrated that coverage expansions can produce significant reductions in mortality-particularly among minorities, those living in poorer areas, and those with chronic conditions potentially treatable with timely medical care. More recent studies of the ACA in particular demonstrate that the law has produced historically large reductions in the uninsured rate, with resulting improvements in access to care, perceived quality of care, and self-reported health. Yet much of the general public and many policy makers remain unaware of this evidence. Researchers and clinicians in academic medicine have a role to play in ensuring that critically important health policy decisions are made using rigorous evidence to best protect the interests of our patients.
why_health_insurance_matters_and_why_research.98224.pdf

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