Integrating oral health into primary care

A patient with multiple chronic diseases, including diabetes, presented multiple times over two years with very high blood glucose readings reaching 400 mg/dL and uncontrolled hypertension. In the course of treatment, clinicians at Temple Health in Philadelphia discovered that the patient had previously been admitted to the ED several times for acute oral pain due to a broken tooth.

“This patient's issues with uncontrolled diabetes and high blood pressure traced back to her teeth—along with a broken tooth, she had very poor oral health and no dental insurance or access to care,” said Darilyn Moyer, MD, FACP, clinical adjunct professor at Temple University School of Medicine and ACP's Executive Vice President and CEO. “After each ED admission, she was sent home with antibiotics and pain medications and had been shorting herself on insulin and blood pressure medications in order to pay for them.”

Recognizing that the patient was caught in a vicious cycle, Dr. Moyer and her colleagues referred her to a social worker, who then connected her with subsidized dental care and financial assistance to afford her medication copays. Unfortunately, such cases are far from uncommon, noted Dr. Moyer, chair of the Primary Care Collaborative (PCC), which issued a report in March 2021 highlighting the importance of integrating oral health and primary care.

The report cited inequities that keep regular dental care out of reach for many low-income Americans, contributing to preventable ED visits, worsening chronic health conditions, and rising health system costs. It concluded with three overarching policy recommendations: Expand oral health coverage and access, create new payment models that align oral health and primary care, and expand the oral health workforce.

“Primary care is the front door of our health system and, with proper support and public investment, it is very well positioned to meet patients' needs in a holistic fashion,” said Ann Greiner, MCP, the PCC's president and CEO. “If we want to prevent downstream health issues and costs and provide care that is more equitable, we need a more comprehensive primary care model that includes oral health.”

Dental care, overall health

Medicine and dentistry have traditionally been separate domains, with distinct insurance structures and payment models, the report noted. Despite previous calls for integration—including two separate reports issued in 2011 by the Institute of Medicine and the Interprofessional Education Collaborative Practice—there remains little overlap between the silos of medical and dental care.

“Primary care physicians generally ask very little about oral health and aren't prepared to do anything about issues that arise, but it's clearly important to quality of life and costs,” said Russell Phillips, MD, FACP, co-principal investigator at Harvard's Center for Integration of Primary Care and Oral Health (CIPOH) in Boston. “Our challenge is to introduce dentistry into primary care so it is something that we feel prepared to manage, and to develop partnerships with dentists. It's important to see dentists as part of the health care team.”

Unmet dental needs remain prevalent across the United States, noted the PCC report. Each year, an estimated 111 million people see a physician but not a dentist, while 27 million have a dental visit but no medical care. Further, despite studies documenting the relationship between periodontal disease and other medical conditions, clinicians and the public have long accepted a status quo where dentists care for the mouth while physicians attend to the rest of the body, the report noted. Such fragmentation has stymied communication between dental and medical professionals and created barriers to establishing interoperable electronic systems, integrated payment policies, and combined training programs.

“While progress has been made, 70% of medical schools' curricula devote four hours or less to oral health and at least 10% have no oral health training, while more than half of nursing programs have no oral health component,” said Judith Haber, PhD, APRN, professor of nursing at NYU Rory Meyers College of Nursing in New York and a member of the advisory group for the PCC report. “We need to make this a required part of education that continues into residency programs. All the work we've done around promoting integration will be lost if oral health competencies do not flow into practice settings.” The siloed approach has led to health disparities among low-income and minority populations, as Medicare and most major insurers do not cover oral health as a standard benefit, she said.

Hugh Silk, MD, MPH, a family physician at Family Health Center of Worcester, Mass., professor of family medicine and community health at University of Massachusetts Medical School, and co-primary investigator at CIPOH, sees instances of disparities frequently in his practice, which focuses on homeless outreach and addiction medicine. For example, one recent case involved a woman who had been seen twice over the previous two weeks for acute pain on the side of her face that was radiating into her ear.

“The first physician she saw put her on antibiotics, and the second said her pain was likely due to stress,” said Dr. Silk, who also served on the PCC advisory group. “Then I asked her to take her dentures out and discovered an ulcer underneath, which was very clearly the cause of the pain in her ear.”

A full oral exam that included removing her dentures and reassessing them for proper fit resolved the patient's pain, he said. As in many patients seen in his practice, the problem might have been prevented had she had regular access to preventive dental care.

“If we work together and meet people where they are, we can make progress,” he said. “Primary care physicians can give some basic advice and screening related to oral care, while dentists can learn how to take blood pressure and give flu shots. We could be cross-pollinating and helping one another.”

A recent study suggested that improving access to preventive dental care could have a significant impact on improving health outcomes. Using data from the New York State Medicaid program, investigators reported in the Aug. 1 Journal of Dental Research that use of ED and inpatient services was significantly lower in the third year after receiving dental care in the two previous years.

“The New York database offered an opportunity to study the relationship between use of preventive dental services to health outcomes in a population with both a heavy systemic and oral disease burden,” said lead investigator Ira Lamster, DDS, clinical professor of dental medicine at Stony Brook University in Stony Brook, N.Y. “Notably, each additional preventive dental care visit was associated with a 3% reduction in risk for an ED visit and a 9% reduction in inpatient use.”

Preliminary results from a follow-up study, which is pending publication, suggest that preventive dental care has an even greater impact among patients with a heavy disease burden, said Dr. Lamster. In the second study, which looked at a subset of the New York Medicaid population who had at least one of four chronic diseases, each additional preventive visit (up to four) was associated with a 10% to 15% reduction in inpatient visits and between $289 to $682 in decreased hospital costs, compared to patients without access to preventive care.

“We found that if patients have preventive visits, health outcomes improve and health costs go down—and most of the savings are from less hospitalization,” he said. “We also found that when people progressed to severe oral infections, indicated by the need for root canal therapy or extraction, health outcomes worsened and costs and use of health services increased.”

What internists can do

Although insurance and payment system reform will take time, internists can take a few simple steps now to integrate oral health into their normal workflow.

“We screen all of our patients during the physical exam to make sure they are up to date on oral health,” said Karla Testa, MD, FACP, an internist at Westside Family Healthcare, a federally qualified health center (FQHC) in Wilmington, Del., who works with CIPOH as an oral health champion. “That includes asking whether they see a dentist and discussing issues that can affect oral health, such as smoking and drug and alcohol use.”

Internists should include the mouth in the traditional head, ears, eyes, nose, and throat exam (HEENT), said Dr. Haber, who led a March 2015 study in the American Journal of Public Health describing the HEENOT approach (adding “O” for oral health). During the physical exam, closely examine the inside of patients' mouths for abnormalities, including the lips, tongue, floor of mouth, upper gums, and upper palate, she said.

Primary care physicians also have an opportunity to partner with dentists on human papillomavirus (HPV) prevention, she added. For example, dentists can learn to administer vaccines against HPV, which is associated with oropharyngeal cancer, while internists can incorporate oral cancer screening into their physical exams.

Oral health is a critical part of caring for patients with diabetes, as inflammation triggered by periodontal disease puts patients at significantly higher risk for poor glycemic control, noted Dr. Lamster. In turn, inflammation associated with diabetes can trigger a variety of oral issues, such as dry mouth, Candida infection, and swelling of the parotid glands.

“Diabetes is the best example of a systemic condition that puts you at risk for oral diseases,” said Dr. Lamster. “Our research shows that diabetes and poor metabolic condition increases the risk of periodontal disease and makes existing disease worse. Conversely, if a patient has periodontal disease, their metabolic control is worse.”

Models of care

The PCC report highlighted a variety of integrated care models across the country that consolidate medical and dental care under one network or physical location. Such models can be especially beneficial for low-income older adults, who often develop greater oral health needs with age but receive no dental coverage under traditional Medicare.

For example, many FQHCs, which focus on caring for low-income and uninsured patients, co-locate medical and dental offices, making it easier to refer patients for follow-up care, according to the report. The models have many potential advantages, such as interdisciplinary team meetings and the ability to book appointments across specialties and share access to services, such as linguistic interpreters.

The report also noted the importance of interoperable health records, citing Marshfield Clinic in Wisconsin as an example. The clinic developed a fully integrated EHR, allowing medical and dental clinicians to view and manage patients' medications and visits and prompt oral health evaluations in the primary care setting. It also developed personalized risk algorithms for diabetes based on dental and medical data so that patients could be screened and referred during both types of visits.

While co-location and interoperable records are still relatively rare across the country, practices can make progress by emphasizing a team approach to care in both their practices and their communities, said Dr. Phillips. Community practices in CIPOH's network, for example, train medical assistants to screen patients for dental issues as part of the normal workflow.

“Tooth or gum pain or persistent bad breath can indicate oral problems or decay,” he said. “A nurse can follow up on these symptoms and make appropriate referrals to dentistry.”

Dental referrals are especially important for patients who may not seek out care for tooth pain due to lack of insurance or shame around oral health, the report stated. Getting appropriate dental care can improve self-esteem and employability, in addition to reducing pain, in patients recovering from substance use disorders, the report noted.

“People are often embarrassed to talk about dental issues because the condition of their teeth often affects their willingness to smile and engage with others,” said Dr. Phillips. “And physicians often don't probe further because there's a tendency not to ask about things that we don't have the capacity to address.”

Dental issues may also explain why patients miss appointments or don't fill prescriptions, said Dr. Testa. For example, while following up recently with a patient with poorly controlled asthma, Dr. Testa discovered that she had missed her medical appointment due to an acute dental problem and was struggling to afford the necessary restorative work, which was not covered under Medicaid. To assist low-income patients, Dr. Testa recommends developing a network of community-level resources, including state public health departments that can help patients access safety-net dental clinicians.

Ultimately, connecting patients to ongoing, preventive dental care is the best way to head off serious oral health issues and lower overall costs, noted Ms. Greiner. Making practice-level changes is a good first step, but internists should also actively advocate for systemic reform, she said.

“We need to have a broader conversation about expanding our care delivery model to allow for oral health implementation,” Ms. Greiner said. “Our current payment model, which is still largely fee-for-service, makes this very challenging. We need to invest more in primary care and push for changes in traditional Medicare to include a more robust oral health benefit.”