Download Bill Maas Presentation - Grantmakers In Health

Returning the Mouth to the Body:
The Case for Integration
William Maas, DDS, MPH
Integrating Oral Health and Primary Care
Grantmakers in Health
Washington, DC
April 17, 2012
The Problem
The mouth IS connected to the body
But professional practices and public policies
often don’t operate as if it were
The Problem
The mouth IS connected to the body
And the health of the mouth is important
What we do about oral health matters
“Oral health is essential
to the general health
and well-being of all
Americans…
Improved oral health
can be achieved by all
Americans…”
What is oral health?
Oral health is more than
healthy teeth.
It being free of diseases
and disorders that affect
functions we often take for
granted, yet represent the
very essence of our
humanity.
Tooth decay and gum disease
Tooth decay
• the most prevalent chronic disease of childhood,
5x more common than asthma
• afflicts 90% of people with teeth by age 65
• why 25% of seniors have no teeth at all
Gum disease
• associated with poor control of diabetes, poor
birth outcomes, heart disease & stroke, …
What I’ll Cover
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Historical separation of dental & medical care
Surgical versus “medical” approach
Message of Surgeon General’s Report
Dental problems as infectious diseases
Patient centered primary care
Rethinking the “dental team”
Barriers to integration
Medicine and Dentistry:
Common roots in surgery
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1840 – Baltimore College of Dental Surgery
1863 – nitrous oxide anesthesia first used in NYC
1800s - “Health care” = surgery or quackery
1910 - Flexner Report & 1926 - Gies Report
• From trade schools to university-based
1913 - American College of Surgeons
1915 - American College of Physicians
Medicine:
Medicine and Surgery advance
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1930
1937
1938
1943
1948
1948
1969
2000
– American Academy of Pediatrics established
– National Cancer Institute established
- Food, Drug and Cosmetic Act
– mass production of penicillin
– National Heart Institute established
– Publication of first Randomized Controlled Trial
– Family Medicine established as a distinct specialty
- RCTs advance both medical & surgical approaches
Dentistry:
From resignation to repair to prevention
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1900 – present – Dentistry refines repair & rehabilitation
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1948 – National Institute of Dental Research established
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Local anesthetic
Better drills
Better filling material
Better cosmetic results
Immediately after founding of Cancer and Heart Institute
Understanding of dental disease at cellular level begins
1950 – Community water fluoridation prevents decay
1955 – Crest toothpaste with fluoride introduced
Medicine and Dentistry:
Interactive versus Solo
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Multi-year, hospital-based residencies develop skills in
referral among medical specialties and interdisciplinary
teams.
Only 18% of family medicine docs are solo practitioners
With exception of oral surgeons, <1600 dentists per year
undertook hospital-based residencies, most only 1 year.
In 2008, 59% of dentists were still in solo practice.
Medicine and Dentistry:
Financing of Care
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Hospital insurance for rare, expensive (insurable)
events
Medical insurance for unpredictable healthcare needs
Healthcare insurance for preventive services + the rest
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Dental prepayment for predictable events
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Poor with children, well-employed, seniors
High copayment for discretionary + rehabilitation
Today 50% of expenditures are out-of-pocket.
Dental prepayment for middle class (tax subsidy)
Dental prepayment for most children
Medicine and Dentistry:
Source of Financing of Care
Physicians services
• 31% - Medicaid and Medicare
• 8% - Out-of-pocket
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Remainder – Subsidized (tax exempt) insurance
Dental services
• <8% - Medicaid (up from <5% in 1970)
• 41% - Out-of-pocket (down from 90% in 1970)
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Remainder – Subsidized (tax exempt) insurance
First, the good news; then, the bad:
The need for action
“Great progress has
been made in reducing
the extent and severity
of common oral diseases
…however, not everyone
is experiencing the same
degree of improvement.”
Recognizing “profound and consequential disparities”:
Calling upon all health professions
“”What amounts to a
“silent epidemic” of dental
and oral diseases is
affecting some population
groups …
There are opportunities for
all health professions, …
to work together to
improve health.”
Institute of Medicine on Access
Improving Access to
Oral Health Care
for Vulnerable and
Underserved Populations
IoM Guiding Principles
Oral health is an integral part of overall health and,
therefore, oral health care is an essential
component of comprehensive health care.
Oral health promotion and disease prevention
are essential to any strategies aimed at
improving access to care.
Oral Health requires access to what?
To maintain oral health, individuals require access to:
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quality oral disease preventive services at regular
intervals
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treatment services when needed
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-Institute of Medicine, 2011
Timely – dependent on decisions of patient & provider
Quality – determined as safe, timely, effective, efficient,
equitable, and patient-centered.
IoM Recommendations
Vision: Rely on a diverse and expanded array of
providers who are competent, compensated, and
authorized to provide evidence-based care.
Stakeholders from both public and private sectors should
develop a core set of oral health competencies for
NON-dental health care professionals. Competence in
oral health care should be required by health
professional education programs and for recertification.
Causes of Tooth Decay:
The Reductionist View
Advances in dental science
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Better preventive agents (easier to use, longer
lasting, less expensive)
Improved diagnostic aides to better characterize
risk -> potential for better allocation of effort.
Better filling materials (easier to use, longer
lasting, less expensive)
Medical, not surgical, interventions
What influences biological variables
Fisher-Owens, S. A. et al. Pediatrics
2007;120:e510-e520
Contributions to Oral Health
DENTAL
MEDICAL
ORAL
HEALTH
ENVIRONMENT
(SOCIAL,
POLITICAL,
PHYSICAL)
Tooth decay of preschoolers
Fact: In 2004, LESS than 1/3 of kids 2-5 y.o. had cavities.
Although many of the rest were high risk (to get cavities later).
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Risk can be lowered by very simple preventive services
and changing the caregivers’ behavior.
For most preschoolers, dentist expertise and one-onone care is not necessary to lower risk.
For many other preschoolers, dentist expertise and
one-on-one care is not sufficient to lower risk.
Significance of caries as an infectious disease?
A change in perceptions
Why did pediatricians and family physicians get
involved?
“If dental caries is an infectious disease, I can do
something about that. Our practice is all about
preventing infections and controlling them to
prevent adverse health outcomes.”
Advances in technology:
Importation of fluoride varnish
Old technology = Professionally applied Fluoride Gels
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messy, requires suction (special equipment)
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requires continual attention for 3 minutes
New technology = Fluoride Varnish
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total dose easily controlled, safe for preschoolers
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no skills or special equipment required (1 minute)
Either = a billable service
What influences biological variables
Fisher-Owens, S. A. et al. Pediatrics
2007;120:e510-e520
Patient-centered Oral Health Care
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Care is provided when it is needed, where it can be
accessed, customized to needs of child
For a young child - is family-centered care
Child develops habits and patterns of behavior that
are shaped by care-giver
Caregiver is target for knowledge and motivation
Health professional’s assessment based upon caregiver reports as much as direct observations of
child
Patient-centered Care
The Institute of Medicine names 'patient-centered
care' as one of six domains of quality.
Research shows that orienting the health system
around the preferences and needs of patients has
the potential to improve patients' satisfaction with
care as well as their clinical outcomes.
All preschoolers need
patient-centered oral health care
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But many preschoolers do not require dental care (i.e.
“hands on” care of a dentist)
Who and what most influence parenting practices (espec.
diet and hygiene)?
Which professionals are best prepared to influence parenting
practices? (authority, skills, time)
Who has more opportunities to influence parents?
Is it realistic to think that dentists, however well
trained, can have as great an impact as other
disciplines could, collectively?
Oral Health “Dream Team”
Includes health professionals and social services
workers to influence parenting and home life:
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Frequent or timely contact
Culturally sensitive, language compatible
Expertise is acknowledged, respected
Can draw out parental concerns ( M.I.)
Offer credible solutions
Believe OH is integral to health and well-being
Know key behaviors and messages
Aware of other team members & referral options
Dentists still have a key role
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Hold oral health in highest regard
Know latest science and guides protocols
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risk factors
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prevention
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tooth preserving techniques
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dental filling materials
Know key behaviors desired and messages being
delivered
Could be aware of other team members and
provide input to referral protocols
Barriers to Integration
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Communication – lack of protocols, common language
Communication – common electronic health record
Uneven financing – personal vs societal responsibility
Different unit of care – fee-for-visit vs fee-for-service
Need common curriculum – Smiles for Life = good start
Professional “turf” concerns – fear loss of respect or $s
Others?
Conclusions
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The mouth is part of the body
Dental care is not the same as oral health & vice versa
Principles of patient-centered primary care justify more
attention to oral health in primary care practices (as well as
more attention to non-dental health problems in dental practices)
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Advances in science/technology will enable more focused
& effective interventions that can be delivered by PC
Some gaps could be closed by philanthropic investment
Thank You
Bill Maas
[email protected]