Joining the Flock
Medical-dental integration shepherds dentistry into healthcare to improve outcomes
Heidi Geller
Medical-dental integration is recognized as a promising, whole-health approach to preventing disease and addressing the unmet dental needs of vulnerable populations. However, what exactly does this approach entail and what work is being done to make it more of a reality? As more and more providers continue to acknowledge the benefits of medical-dental integration, have we reached a tipping point where this model will inevitably become the standard of care?
At its core, medical-dental integration is a holistic approach to oral-systemic health that seeks to bridge the gap in communication between primary care providers and oral healthcare providers for patients.1 The division of education, practice, service delivery, and insurance coverage keeps dental care separate from medical care in the United States. According to an article published in the AMA Journal of Ethics, this separation is the most detrimental to undeserved groups who are at the highest risk for poor oral health outcomes.2 Many patients with toothaches are forced to wait until their symptoms become egregious enough to warrant care in hospital emergency departments because they have medical insurance but no dental coverage. And in hospital intensive care units, patients receive thousands of dollars of medical interventions a day for preventable conditions resulting from untreated dental disease, which places an unnecessary burden of disease on the US population and an unnecessary financial burden on the US healthcare system.3
"The culture has been that dentists and their dental teams stay in the mouth and that physicians and medical teams do everything else," says Brett Sealove, MD, chief of cardiology at the Jersey Shore University Medical Center and a physician who speaks about the oral-systemic connection. "We learn about the ills of systemic inflammation in the subdisciplines of medicine, such as those involving the musculoskeletal system, nervous system, cardiopulmonary system, and other systems. Dentistry needs to be part of the conversation." Fortunately, as awareness about the important links between oral and general health continues to grow, physicians and dentists are collaborating to develop innovative service delivery and payment models that can help to integrate oral healthcare and medical healthcare.
The Cost of the Oral-Systemic Connection
Conceptually, the link between oral disease and systemic disease has been understood for some time. An ever-growing body of evidence indicates a connection between periodontal disease and some health conditions, including diabetes, heart disease, cancer, arthritis, low birth weights, and more. A study published in the Compendium of Continuing Education in Dentistry in 2022 found that preventive dental care curbed healthcare costs among patients with diabetes and coronary artery disease.4 Five-year's worth of data was examined among 10,000 diabetes and coronary artery disease patients who were eligible for autoenrollment in a dental plan program affiliated with a large commercial health plan in Arkansas. According to the study's findings, a per-member cost savings of $515 to $1,718 per year was realized when patients with diabetes, coronary artery disease, or both had at least one preventive dental visit per year.
"This study demonstrates that when patients with these conditions receive even a single dental cleaning a year, total overall healthcare costs can be reduced," says Solomon Brotman, DDS, a co-author of the study and chief clinical officer for Life and Specialty Ventures—a dental insurance company that provides benefits in multiple states under the Blue Cross Blue Shield brand.
Bridging the Medical-Dental Health Divide
In 2000, US Surgeon General David Satcher, MD, PhD, released a report that illuminated inequitable gaps in the access to and care quality and affordability of oral healthcare in the United States. It concluded that oral health is a vital indicator of overall health and well-being.5
Almost 2 decades later, Surgeon General Vivek Murthy, MD, MBA, reiterated the US Department of Health and Human Services' commitment to medical-dental integration by adopting an agency-wide Oral Health Strategic Framework. This framework aimed to reduce oral health disparities by improving the dissemination of oral health information, increasing oral healthcare services, and integrating oral healthcare into primary care."2
Emphasizing the Oral-Systemic Connection in Education
Evidence shows that bacteria and inflammation in the mouth can be indicative of and even contribute to systemic conditions throughout the body. And the reverse is also true. Bacteria associated with certain systemic diseases or medical conditions can spur or exacerbate oral problems.6
Understanding the impact of these associations requires training beyond what is traditionally taught in dental, medical, and nursing schools. Fortunately, many institutions are recognizing the need and beginning to offer crossover curriculums, and some family medicine residency programs now require rotations in dental clinics for resident physicians.
Maria Geisinger, DDS, a professor of periodontology at the University of Alabama at Birmingham School of Dentistry, advocates for crossover curriculum and research. "There are more than 85 diseases associated with periodontitis, a chronic oral inflammatory disease," she says. "Understanding each other's capabilities is critical to creating a referral network that best serves our patients."
When the University of Alabama at Birmingham designed its new nurse midwifery program, Geisinger, along with faculty from the college's Doctor of Nursing Practice program, wove together a curriculum promoting the intersection of perinatal care and oral healthcare. "When we put the patient and his or her wellness at the center of everything that we do, it becomes easier to look at integration and build something different," she says.
Expanding the Scope of Practice in Oral Healthcare
Community-based oral disease prevention programs (eg, water fluoridation, school-based education, health-promoting policies), which are a foundation of public health, occur outside of the clinical care delivery system. As such, they do not rely on access to dental offices and generally reach a broader population, filling in gaps in access to prevention services, particularly for those individuals who do not regularly seek care in dental offices.5
Another way to fill gaps in access to prevention services for these patients is to provide dental hygiene treatment outside of dental practices. Clearing the way for direct access to dental hygienists helps individuals get the care that they need where they already receive support, which can be a significant benefit for at-risk patients. Dental hygienists examine patients for signs of oral diseases, such as gingivitis, and provide preventive care, including routine cleanings.7 Providing direct access to dental hygienists means empowering them to initiate treatment without dentist authorization. Gaining this direct access, however, has legal limitations.
Matt Crespin, RDH, past president of the American Dental Hygienists' Association and executive director of the Children's Health Alliance in Wisconsin, explains that because the practice of dentistry is overseen and regulated at the state level, not nationally, each state must determine its own legal supervision requirements for practicing dental hygiene. Only 21 states allow direct access to dental hygienists. In 2017, Crespin was involved in passing legislation in Wisconsin that lifted some supervision restrictions for dental hygienists to allow them to treat patients in medical practices. "We wanted to create a mechanism that allowed dental hygienists to see patients where they were already going," he says. "Our goal was to have providers practicing at the top of their scope."
This state law enables clinics—particularly community health centers that primarily provide care to people with low incomes—to hire dental hygienists to deliver basic preventive care, such as cleanings, fluoride varnishes, and sealants as well as provide education about oral health. The bill increased the settings in which dental hygienists can practice without the required supervision or authorization of a dentist. In addition to medical offices, these settings include nursing homes and patients' residences, which are serviced by home healthcare agencies.
The Wisconsin Medical-Dental Integration Project, which aims to address the burden of dental disease in Wisconsin through an innovative model of integrating dental care into regular medical checkups, was born from this legislation. This model of care delivery leverages the medical visit, the primary care team, and integrated dental hygienists to provide early oral health prevention and intervention services. The enrollment of qualifying healthcare organizations is strong as is the delivery of oral healthcare services and education by the participating dental hygienists.8 "We're seeing health systems and Federally Qualified Health Centers showing interest in this model," says Crespin. "It generates revenue and pays for itself." Wisconsin is one of 19 states that allow dental hygienists to become certified Medicaid providers.
Integrating Oral Healthcare Into Primary Care Clinics
Annually, more US citizens visit a physician than a dentist.5 Given this reality, integrating dental services into primary care settings may better serve the needs of at-risk patient groups, particularly very young children for whom pediatric well-child checkups result in 12 medical office visits before they are 3 years old.5
According to the National Institute of Dental and Craniofacial Research's 2021 report, Oral Health in America: Advances and Challenges, one project in North Carolina, Into the Mouths of Babes, has demonstrated the value of expanding scope of practice by training pediatricians to incorporate preventive oral healthcare services, such as oral assessment, fluoride varnish, and referrals to dental professionals. Appropriate training of the pediatricians enables them to efficiently incorporate preventive oral health services into their workflows and to improve access to care.5 Regarding the outcomes, the North Carolina Department of Health and Human Services notes that among children who attend four or more visits to the participating pediatricians before age 3, there is a 21% reduction in hospitalizations for dental care.9
Integrating dental hygienists into primary care settings is a proven approach to ensuring the delivery of preventive treatment. "What makes perfect sense is having dental hygienists occupy a treatment room in medical clinics," says Jo-Anne Jones, RDH, an international presenter focused on integrating oral care into primary healthcare settings. "These patients can then be directly referred to participating dental practices in the community if they require treatment."
Another project, the Colorado Medical-Dental Integration Project, incorporated dental hygienist-led screening and preventive treatments, such as dental prophylaxis, into pediatric primary care settings.5 Oral Health in America: Advances and Challenges concludes that integrating oral healthcare by dental hygienists into medical visits can significantly reduce the burden of oral disease.5
The Role of Insurance
In 2019, dental expenditures in the United States totaled $143.2 billion,10 which represents 4% of the total healthcare spending in the nation.11 A recent survey indicates that approximately 77 million US citizens do not have dental insurance,12 and for those who are eligible for Medicare and Medicaid, the covered services are limited.
Research indicates that insurers and Medicare/Medicaid could save money by providing dental coverage for preventive treatments.13 In 2021, the Journal of Dental Research published research that associated preventive oral healthcare with reduced healthcare costs.13 In this study, researchers examined extensive member data from the New York State Medicaid program that included 4 million adult dental beneficiaries with diverse racial and ethnic backgrounds who demonstrated a high prevalence of oral disease and comorbidities. The results revealed cost savings and better healthcare outcomes for those who received preventive dental services as well as reductions in all-use emergency room and inpatient admissions.
According to Oral Health in America: Advances and Challenges, there is an upsurge in new financial models being created by medical insurance systems to improve access to care while improving health. One of these approaches, "value-based healthcare," is being implemented by the US Centers for Medicare & Medicaid Services. A value-based system is designed to improve health by structuring reimbursement amounts around the outcomes achieved rather than the services provided. When payment is tied to achieving outcomes rather than simply providing services, it can positively influence the delivery of care. Although the economic costs of oral healthcare continue to be substantial, dentistry's adoption of value-based healthcare versus fee-for-service models has been slow going.
Dentistry has been slow to adopt value-based reimbursement due to concerns about payment system changes and government involvement in the financing of oral healthcare. The few early adopters of value-based care in dentistry are tied to medical organizations such as Oregon Transformation, Kaiser Permanente, and HealthPartners, which have shown that a value-based payment structure holds promise for decreasing the overall cost of healthcare and improving access to oral healthcare.5
Operationalizing Medical-Dental Integration
Imagine a scenario in which patients get their teeth checked by their dentists, and then based on gingival inflammation that their dentists noted in their electronic health records (EHRs), their primary care physicians can order tests to check for heart disease and other conditions. Across the country, pilot programs are testing medical-dental integration models as well as adding oral health screenings to well-child visits, enabling dental care providers to check insulin levels, using telehealth to connect providers from multiple disciplines, and more.
Geisinger points out that expanding the scope of dental office visits to include preventive screenings for various systemic conditions, such as oral cancers, diabetes, and brain conditions, may also increase the likelihood of early detection. "Screening for common diseases by dental teams can have a positive impact on patients' preventive care, diagnoses, and treatments," she says.
Improving Recordkeeping and Communication
A crucial piece of achieving dental-medical integration is improving the related information systems. One of the real barriers to integration is the fact that medical and dental professionals use different systems of recordkeeping. Traditionally, there's been no expectation that dental records will be shared with physicians or vice versa. Having patients' complete health histories, both dental and medical, and using an agreed upon nomenclature in a central, protected data repository is the first step to connecting what is happening in the mouth with the rest of the body.
CareQuest Institute for Oral Health recently analyzed provider experiences with EHRs by surveying medical and dental providers at Federally Qualified Health Centers known to be early adopters of medical-dental integration. Only 42% of dental providers in the survey reported being able to use their health centers' EHR systems to enter information into patients' medical records. Although 85% of dental providers reported that they can access their patients' medical information, 31% said they require special permissions in the EHRs to do so. The vast majority (88%) of medical and dental providers surveyed reported that they cannot revise their mutual patients' treatment plans, and although 85% of the medical providers surveyed said they can refer to outside healthcare providers through their EHR systems, only 50% of the dental providers surveyed indicated that they could.
"The inability of medical and dental providers to access and contribute to shared patient records continues to be a huge barrier to an integrated health system," says Rebekah Mathews, MPA, vice president of health transformation for CareQuest. "Your EHR should be a real-time resource that shows your health history, including care you've received; tracks health statistics, such as blood pressure and blood-glucose levels over time; and flags concerns to discuss with your care team. Even just requiring special permissions to access EHRs places an unnecessary burden on the provision of holistic care. If a dentist is unable to see that a patient has been experiencing increased blood glucose levels, there could be a missed opportunity to talk about monitoring indications of periodontal disease. Involving the dentist in disease management can improve the likelihood of controlling the condition as well as the experience of care."
CareQuest's MORE Care™ (Medical ORal Expanded Care) program, which is currently in a pilot stage in Ohio, supports advancing integrated, value-based care that is inclusive of oral health for more than 10,000 patients. As successful as the initiative has been, Mathews notes that it provides more proof of the need for the simplification of EHR integration. "We are seeing that all of our medical care teams are able to make referrals to their dental partners. And although it is great that they have set up their own processes for doing that, there is still a need for EHRs to be able to make that referral and information sharing structure simpler," she says.
CareQuest is using its surveys and its advocacy reach to drive further improvements. "A lot of work has been done to advance interoperability across the healthcare system in recent years," Mathews says. "Our intention is to spotlight that more needs to be done to support dental data sharing across EHRs. Simplification makes a difference. The effort here is not to elevate new requirements or burdens; it is to simplify access to information that should be available across care teams."
According to Mathews, CareQuest's research indicates that providers have a strong desire to use integrated EHRs to increase medical-dental integration, and that the key is having the proper tools. "Integrated EHRs are really helping to pave the way for earlier detection of oral and systemic diseases," she says, "and ultimately, that can result in improved outcomes as well as greater efficiencies, data insights, and collaboration."
One notable example of this is the collaboration between Epic Systems, an EHR software provider, and Pacific Dental Services (PDS), a dental service organization. Epic holds the EHRs of more than 250 million patients. To move its partnering practices toward medical-dental integration, PDS has converted almost 10 million patient records from its existing practice-management software to Epic and trained nearly 14,000 team members in the new system. As a result, PDS is seeing an impact on patient care, including a diagnosis of rheumatoid arthritis that had gone undetected until providers were able to access the patient's oral health records. "Oral healthcare is a critical component of overall health," points out PDS's founder and CEO Stephen E. Thorne IV, "and this investment has enabled our supported clinicians and their patients to more fully participate in the promise of a seamless, comprehensive healthcare system focused on whole-body health."13
Putting Medical-Dental Integration Into Clinical Practice
PDS formally put the medical-dental integration model to the test in when it launched three healthcare practices—a general dentistry practice, a pediatric dentistry practice, and a medical clinic—all in one location in Las Vegas, Nevada. This healthcare collaboration increases access to care and enables patients to be seen by medical and dental professionals who understand the critical link between oral health and whole-body health.6 The services delivered include primary medical care and oral care for adult and pediatric patients as well as salivary testing, preventive medicine for arterial health, pulmonary treatments and testing, chronic disease management, sleep studies, ultrasound imaging, standard and comprehensive blood testing, medical and surgical clearance, hormone therapies, facial esthetic treatments, and more.
"Intuitively, we know that we need to be seen as a whole person…that our healthcare providers should not see us as a random assembly of body parts," says Dan Burke, chief enterprise strategy officer at PDS. "The delivery of whole-health patient care is dependent on having access to all applicable health information as well as a shift in the mindset regarding the nuts and bolts of how care is delivered."
The Way Forward
There's no question that medical-dental integration models close care gaps for some of the most vulnerable populations in the United States by bringing multiple silos of care together into one place.14 "The opportunity for somebody to interface with any health professional at any level must be encouraged," says Mark Jansen, MD, vice president and chief medical officer of Arkansas Blue Cross Blue Shield. "That event needs to be brought into the corpus of collective whole-person care, whether that is dental, medical, behavioral, social enhancement, etc. All of that must be considered."
According to Oral Health in America: Advances and Challenges, improving access to oral healthcare can be achieved by recognizing dental care as an essential health benefit for all US citizens, expanding dental coverage for the uninsured, encouraging new professional models, and providing educational opportunities that encourage interprofessional learning and the delivery of care in new settings.5
"We are looking at how any door can be the best front door if that is the one that the member wants to go through." Jansen says.
References
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2. Simon L. Overcoming historical separation between oral and general health care: interprofessional collaboration for promoting health equity. AMA J Ethics. 2016;18(9):941-949.
3. Simon L. Medical-dental integration. J Am Dent Assoc. 2018;149(6):409.
4. Borah BJ, Brotman SG, Dohlakia R, et al. Association between preventive dental care and healthcare cost for enrollees with diabetes or coronary artery disease: 5-year experience. Compend Contin Educ Dent. 2022;43(3):130-139.
5. Oral Health in America: Advances and Challenges. Bethesda, MD: US Dept of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021.
6. PDS News Team. Pacific dental services launches one-of-a-kind dental-medical practice in support of whole-body health. Pacific Dental Services website. https://www.pacificdentalservices.com/newsroom/press-releases/pds-launches-medical-practice/. Published August 3, 2021. Accessed September 19, 2023.
7. Bureau of Labor Statistics, US Department of Labor. Occupational outlook handbook: dental hygienists. BLS website. https://www.bls.gov/ooh/healthcare/dental-hygienists.htm. Updated September 6, 2023. Accessed September 19, 2023.
8. Wisconsin medical dental integration. Children's Health Alliance of Wisconsin website. https://www.chawisconsin.org/initiatives/oral-health/wisconsin-medical-dental-integration/ Accessed September 19, 2023.
9. North Carolina Department of Health and Human Services. Into the Mouths of Babes (IMB). NCDHHS website. https://www.dph.ncdhhs.gov/programs/oral-health/partners-providers/mouths-babes-imb. Accessed October 9, 2023.
10. Centers for Medicare & Medicaid Services. National health expenditure data. 2020. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical. Updated September 6, 2023. Accessed September 19, 2023.
11. Hartman M, Martin AB, Benson J, Catlin A. National health care spending in 2018: growth driven by accelerations in Medicare and private insurance spending. Health Affairs. 2020;39(1):8-17.
12. CareQuest Institute for Oral Health. Dental Insurance Is Out of Reach for Many. CareQuest website. https://www.carequest.org/resource-library/snapshot-765-million-americans-without-dental-insurance. Accessed October 9, 2023.
13. Lamster IB, Malloy KP, DiMura PM, et al. Dental services and health outcomes in the New York State Medicaid program. J Dent Res. 2021;100(9):928-934.
13. Pacific Dental Services. Pacific Dental Services becomes world's first dental support organization to integrate Epic's comprehensive health records system into all supported dental practices. Cision PR Newswire website. https://www.prnewswire.com/news-releases/pacific-dental-services-becomes-worlds-first-dental-support-organization-to-integrate-epics- comprehensive-health-records-system-into-all-supported-dental-practices-301611284.html. Published August 24, 2022. Accessed September 19, 2023.
14. Delta Dental Institute. University of Colorado School of Dental Medicine report finds medical-dental integration models can improve overall health care outcomes in vulnerable populations. Delta Dental Institute website. https://www.deltadentalinstitute.com/news/press-releases/new-report-on-medical-dental-integration/. Published September 20, 2022. Accessed September 19, 2023.
