Founded 1993

Integration of Oral Health

Care into Prenatal Care and

Diabetic Management:

A Community Safety Net Clinic Experience

Objectives

1. Understand rational for incorporating oral health into primary care

(prenatal care and diabetic management).

2. Recognize that buy in by all clinical staff is a necessity, both at

provider and support staff level.

3. Understand that providing free oral health care does not insure

access.

4. Appreciate that constant monitoring and alterations of processes

are necessary to improve patient acceptance.

Olde Towne Medical and Dental Center

To assure access to quality health and wellness

care to the residents and workforce of the

Greater Williamsburg Community.

At the heart of this mission is the provision of preventative

care and early intervention services to a vulnerable and

disadvantaged population with services to children and

their family as a priority.

21 years ago OTMDC opened and provided primary medical. Almost

immediately the need for dental services was recognized, and adult

and pediatric oral care was added to clinics armamentarium.

Problem arose: Referral and access to specialty medical services was

limited.

A little history…

Pediatrics and well baby care

Gynecology

Prenatal care

Pulmonology

Orthopedics

Psychiatry and Licensed Clinical Social worker

HIV/AIDS care

Nephrology

Ophthalmologic diabetic and hypertensive retinal exams

So to meet changing patient needs,

and to address the difficulty obtaining

specialist consults…we now provide:

A little about Olde Towne Medical &

Dental Center (OTMDC)….

Established 1994 to offer primary medical and dental care to uninsured and

underinsured of our community

90% patients from York and James City Counties and greater City of

Williamsburg and 84% between ages 18-64

~15,000 patients visits a year for ~5,000 individual patients

80% of patients uninsured; 13% Medicaid/Medicare (1% Medicaid

dental)…42% below 100% of federal poverty level

Patient profile: 40% White; 32% African-American; 20% Latino; 4% Asian

NO PATIENT IS TURNED AWAY FOR INABILITY TO PAY

Rationale behind program….

There is an association between periodontal disease and premature labor

as well as low birth weight.

Good oral health may have a positive effect on cardiovascular disease,

diabetes and other disease states.

Optimal maternal oral health hygiene during the perinatal period may

decrease the amount of caries-producing bacteria transmitted to the

infant during common parenting behavior.

Diabetic patients with periodontal disease, caries and infected teeth have

difficulty obtaining glucose homeostasis

Integration of care

According to the World Health Organization integration

of care is defined as,

“The management and delivery of health services so

that clients receive a continuum of preventive and

curative services, according to their needs over time

and across different levels of the health system.”

Integration of care

What does this mean for providers?

Separate technical services (and their management support

systems) are provided, managed, financed and evaluated

either together, or in a closely co-ordinated manner.

So, it became apparent that we needed to

integrate our dental services into prenatal

care…

This was dictated by common sense…

American College of Obstetricians and Gynecologists (ACOG)

“…oral health care during pregnancy is safe and should be

recommended to improve the oral and general health of the

woman.”

American Dental Association (ADA) “Regular and emergency

dental care, including the use of local anesthetics and radiographs,

is safe at any stage during pregnancy.”

Rationale behind program….

There is an association between periodontal disease and premature

labor as well as low birth weight.

Good oral health may have a positive effect on cardiovascular

disease, diabetes and other disease states.

Optimal maternal oral health hygiene during the perinatal period

may decrease the amount of caries-producing bacteria

transmitted to the infant during common parenting behavior.

Safety of dental care in pregnancy…

Safety is a concern expressed by both patients and dentists.

According to the ADA and ACOG, having dental X-rays during your

pregnancy is considered safe with appropriate shielding.

Some women may elect to avoid dental work during the first

trimester knowing this is the most vulnerable time of development.

However, there is no evidence suggesting harm to the baby for

those electing to visit the dentist during this time frame.

Dental work while pregnant, such as cavity fillings and crowns,

should be treated to reduce the chance of infection.

Steps to integrating oral health into

primary care

Training system

Health Information Technology system

Clinical care system

Evaluation system

Training Systems: Incorporation process

1. Clinical staff overseeing process need to familiarize themselves with the

pertinent medical literature.

2. Adequate dental and obstetric staff are needed to insure that when the

program is begun, nothing has been “over promised.” Provider access

must be adequate to meet demand.

3. Dental and obstetric providers must enthusiastically buy into process.

4. Both obstetric staff and dental support staff, including the front desk, must

buy into the oral health initiative.

5. Develop patient information/coaching/counseling…”Buy In”

Initiating the process at OTMDC

From Oct-Dec of 2014:

Held educational discussions with dental and obstetrical providers

Held sessions with front desk and medical and obstetrical support staff.

Designated team leader for perinatal and dental.

Created dental hours dedicated to obstetric patients, and also setup “work in”

appointments each day for them

Obtained materials for patient education, from Dept. of Health as well as other

resources.

Began ongoing monthly monitoring of referral of pregnant patients to dental

service beginning January 2015.

Visits tracked on electronic health record…Allscripts

Health IT Systems

Allscripts is our EHR and our patient management system, which was

used to track visits and what was done during those visits using CDT4

procedures.

Crystal Reports was the program running in conjunction with

Allscripts to retrieve data from Allscripts.

Medical and dental appointments are managed through patient

management system.

Baseline…

A brief survey of prenatal patients at implementation of this

intervention revealed that of 53 patients,

25 did not have a dentist,

16 patients had a dentist but had not hand on oral exam in over

one year, and

12 patients had had an oral health exam within the past year.

Results

Year Appt. Scheduled Cancelled “No Show” Seen

Offered

2017* 149 117 30 25 62(42%)

(Jan-Jun)

2016 284 134 39 23 72(25%)

2015 278 155 46 28 81(29%)

*The data for 2016 and 2015 encompass the entire year, while 2017 is Jan-June only.

Assessment

Even though dental care was emphasized to be free, patient

acceptance and willingness to schedule an appointment was 56%

in 2015, 47% in 2016 and 78% in the first 6 months of 2017.

Patient failure to keep an appointment (No Show or Cancellation)

was 48% in 2015, 46% in 2016 and 47% in first 6 months of 2017.

The percentage of prenatal patients who actually received dental

care, either a screening exam, or treatment for a problem, was 29%

in 2015, 25% in 2016 and 42% in the first 6 months of 2017.

What didn’t work to increase patient

acceptance?

Repetitive mention of the importance of getting an oral health

exam at each prenatal visit…patients smiled and declined.

Providing educational materials…many patients discarded them in

waiting area or waste baskets.

Emphasis of free dental care…patients smiled and declined.

Offering same day dental visit and prenatal visit…patients

complained about too long a period at our center

What did work to increase

acceptance?

Beginning in 2017, when a new prenatal patient is

registered for our clinic, she is encouraged to schedule a

dental appointment.

This is the only change in our processes that we can

identify which thus far in 2017 has markedly increased

patient acceptance to 42%.

What are results of prenatal dental

visits?

Of the past 67 pregnant patients seen by our dentists,

we performed:

67 teeth cleanings

20 restorative care (dental fillings)

9 extractions

3 scaling & root planings (scraping teeth and gums)

Why do pregnant patients choose not

to see a dentist?

We surveyed 65 patients who repeatedly declined to make a

dental appointment, and asked the reason for their reluctance….

All stated they were not having a dental problem, and saw no

reason to see a dentist.

Several mentioned transportation issues, related to work hours for

themselves or the person they relied on for transportation.

No one mentioned fear of dentists or concerns of dental care

adversely affecting pregnancy, although this was asked directly.

Oral health and diabetes

What’s the association?

There is an increased recurrence of gum disease among

diabetics (American Diabetes Association, 2014).

Serious, untreated gum disease can adversely affect

blood glucose control and contribute to the progression

of diabetes (American Diabetes Association, 2014).

Diabetes and oral

health treatment

What’s the problem?• The separation between oral health and systemic health fails to serve

the holistic needs of patients.

What’s the solution? • Provide efficient communication between oral health care and

primary health care providers.

▫ Thus creating Integration of Care

Donoff, McDonough, Reidy, 2014

Healthy People 2020Healthy People provides science-based, 10-year national objectives for

improving the health of all Americans.

One of the goals of Healthy People 2020 is to

increase the proportion of persons with diagnosed

diabetes who have at least an annual dental

examination.

To achieve this goal, Olde Towne Medical and

Dental Center innovated a proactive approach

utilizing the integration of medical and dental

services for chronically ill patients, specifically

focusing on diabetics.

Implementation of integration of care

for our diabetic patients…

Medical

Providers began discussing the

importance of dental health

during medical visits

Patients were offered Free dental

screenings during their medical

visits

Dental screening was added to

the Diabetes care protocol

Dental

Increased volunteer dentist hours

Open access scheduling created

for diabetic dental screenings

Patients needing treatment were

placed in a tracking system for

recall

Additional observation

During this same period of time, 2015-present, we also initiated including oral

health exams in the care of our diabetic patients.

Of our 565 diabetic patients, 300 were contacted and offered FREE diabetic

dental screenings, 160 (53%) accepted referral to our dentists, but only 84 (28%)

actually scheduled an appointment.

Of those 84, only 53 (18% of the 300 offered screening) patients kept their

appointment. These 53 patients needed:

19 oral surgical procedures

2 root canals

27 fillings

Conclusion

In our patient population, acceptance of free dental

care is limited.

Preventive dental care is not considered a priority by the

patients we serve.

Patients who avail themselves of this dental care have a

significant number of dental problems which can be

addressed.

Ongoing challenge…

Educating our patients on importance of preventive

dental care.

Continuing availability of free dental exams for patients

who desire them.

Limitations of this study…

Olde Towne’s demographics are unusual…very large percentage of

uninsured, and growing every year! Was 62% before ACA, then 70% after

one year, then 76% after 2 years and now 79-80%.

29% of our patients each year are new…and from one year to the next,

20% “churn”. Think migrant tourist workers….

Low percentage of Medicare/Medicaid

Dental and medical units literally on same hall way….

Short term follow up…patient acceptance probably requires time.

This project was supported in part by a grant from

the Virginia Department of Health and the

Williamsburg Health Foundation.

Special thanks to Rahul Truter for assistance with

this project