Publications

Perspective on progress of oral and medical integration by Vivek H. Murthy, MD, MBA, VADM, U.S. Public Health Service Surgeon General.

Since the founding of dental schools as institutions distinct from medical schools, dentistry—its practice, service delivery, and insurance coverage, for example—and dental care have been kept separate from medical care in the United States. This separation is most detrimental to undeserved groups at highest risk for poor oral health. As awareness grows of the important links between oral and general health, physicians and dentists are collaborating to develop innovative service delivery and payment models that can reintegrate oral health care into medical care. Interprofessional education of medical and dental students can help produce clinicians who work together to the benefit of their patients.

Resources, tools, and tips for helping primary care providers engage patients in conversations about their oral health to identify patients with oral health concerns.

Authored and presented by:

Anita DuhlGlicken, MSW
Program Consultant, National Interprofessional Initiative on Oral Health
Associate Dean and Professor Emerita, University of Colorado School of Medicine

Renee W. Joskow, DDS, MPH, FAGD, FACD
Captain U.S. Public Health Service
Senior Dental Advisor, Health Resources and Services Administration

This article examines the effect of Medicaid adult dental coverage on use of dental care and dental health outcomes using state-level variation in dental coverage during 2000–2012. Our findings imply that dental coverage is associated with an increase in the likelihood of a recent dental visit, with the size of the effect increasing with Medicaid payment rates to dentists, and a reduction in the likelihood of untreated dental caries. We are among the first to detect an effect of Medicaid coverage on a clinical health outcome other than mortality. These findings may have implications for states expanding Medicaid coverage to adults with incomes of up to 138% of the federal poverty threshold under the Affordable Care Act as most of these states offer an adult dental benefit.

This white paper was commissioned by the National Interprofessional Initiative on Oral Health with support from the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation.

Forward

Strengthening the primary care delivery system, investing in prevention, and reducing unnecessary costs are national healthcare priorities. As the leaders of organizations committed to advancing oral health, we see a clear opportunity to improve health, reduce waste, and maximize the value of our limited healthcare workforce by incorporating oral health in routine medical care.

We commissioned an initiative to develop, test, and disseminate an actionable pathway for delivering preventive oral health care in the primary care setting, and improving the structure of referrals from primary care to dentistry. We assembled a Technical Expert Panel to guide this effort, which included primary care and dental care providers, medical and dental associations, payers and policymakers, a patient and family partnership expert, and oral health and public health educators and advocates.

Based on input from this panel, and a careful review of previous efforts to integrate once fragmented services into primary care, the authors developed an organizing framework, which we present in this white paper.

The Oral Health Delivery Framework has been endorsed by a broad array of organizations, and is consistent with how primary care teams manage preventive, acute, and chronic care needs for a wide range of clinical conditions across the lifespan. As such, we believe that implementation of the Framework is an achievable goal.

It has been 15 years since the U.S. Surgeon General identified oral disease as a priority health concern and documented pervasive and systemic barriers to dental care. Despite calls for all healthcare professionals to pay attention to oral disease, too little progress has been made in reconfiguring the healthcare delivery system to better meet our nation’s oral health needs. Only by partnering together can we reduce the burden of oral disease. We hope that the information presented in this white paper will inspire primary care teams and dental health professionals—and the stakeholders that support them—to end the artificial separation of oral and systemic health.

The U.S. Department of Health and Human Services (HHS) is committed to advancing the oral health and general well-being of all populations across the lifespan. The HHS Oral Health Strategic Framework 2014–2017 outlines a strategic alignment of HHS operating and staff divisions’resources, programs, and leadership commitments to improve oral health care and delivery.

The Framework is written for oral health, behavioral health, and primary care health professionals and program administrators within and outside of the federal government and other external stakeholder groups interested in oral health. It serves as an essential resource to (1) optimize the implementation of activities planned and those underway, (2) strengthen existing cross-agency collaboration, and (3) identify new avenues for private-public partnerships by creating maximum synergy with other current federal and non-federal oral health initiatives.

Lack of access to oral health care contributes to profound and enduring oral health disparities in the United States.  Millions of Americans lack access to basic oral health care.  In 2008, 4.6 million children – one out of every 16 children in the United States did not receive needed dental care because their families could not afford it.  Children are only one of the many vulnerable and underserved populations that face persistent, systemic barriers to accessing oral health care.   

The United States health care system is able to provide acute care but continues to struggle to address the need for ongoing care, especially for vulnerable populations such as the elderly, disabled, mentally ill, and special needs populations.  Safety net organizations that provide health services to uninsured, low-income, and vulnerable persons continue to look for ways to coordinate services among providers to improve access to quality care.  

The 2011 Institute of Medicine (IOM) reports, Advancing Oral Health in America and Improving Access for Oral Health for the Vulnerable and Underserved, recommended that the Health Resources and Services Administration (HRSA) address the need for improved access to oral health care through the development of oral health core competencies for health care professionals.  In response, HRSA developed the Integration of Oral Health and Primary Care Practice (IOHPCP) initiative with three inter-related components.  The first component was the creation of a HRSA prepared draft set of oral health core clinical competencies appropriate for primary care clinicians.  The second component was the presentation of a systems approach to delineate the interdependent elements that would influence the implementation and adoption of the core competencies into primary care practice.  Finally, the third was the characterization and outline of the basis for implementation strategies and translation into primary care practice in safety net settings.  

Though it is highly preventable, tooth decay is a common chronic disease both in the United States and worldwide. Evidence shows that decay and other oral diseases may be associated with adverse pregnancy outcomes, respiratory disease, cardiovascular disease, and diabetes. However, individuals and many health care professionals remain unaware of the risk factors and preventive approaches for many oral diseases. They do not fully appreciate how oral health affects overall health and well-being.

In Advancing Oral Health in America, the Institute of Medicine (IOM) highlights the vital role that the Department of Health and Human Services (HHS) can play in improving oral health and oral health care in the United States. The IOM recommends that HHS design an oral health initiative which has clearly articulated goals, is coordinated effectively, adequately funded and has high-level accountability. In addition, the IOM stresses three key areas needed for successfully maintaining oral health as a priority issue: strong leadership, sustained interest, and the involvement of multiple stakeholders from both the public and private sectors.

Advancing Oral Health in America provides practical recommendations that the Department of Health and Human Services can use to improve oral health care in America. The report will serve as a vital resource for federal health agencies, health care professionals, policy makers, researchers, and public and private health organizations.