The Integration of Oral Care Into the Greater Healthcare System

Hygienists are prime players in helping patients manage long-term health

The Affordable Care Act (ACA) is impacting reimbursement for all healthcare services, including oral care. Looking ahead, instead of reimbursement for individual procedures, healthcare providers will be compensated for the outcomes of care. No longer will it be enough to provide a prescription for a disease or condition; rather, the provider will need to demonstrate an improvement in the outcome of disease. The reimbursement will shift from one of providing a procedure to proving that the oral condition has improved.

“Big data”—the collection of large amounts of information for analysis—will impact the healthcare professions, showing some procedures as unnecessary or ineffective. Its aim will be to better define standards of care, and its broad-ranging impact will affect how dentistry is practiced. The methods to treat even the two most common oral health conditions—caries and periodontal disease—will change based on this information-gathering. States like New York now require all prescriptions to go through electronic web-based services only. This creates the ability to acquire large data banks on drug usage.

The ACA will eventually lead to the oral healthcare profession having to use only electronic healthcare records (EHR) in the documentation of treatment. This will provide a mechanism to monitor outcomes of treatment, collect vast data, and affect reimbursement from both government and private insurance.

Technology is already impacting the delivery of oral healthcare. Now a reality, digital dentistry is changing how teeth are restored. Three-dimensional (3D) printing continues to make inroads in day-to-day dental laboratory procedures. Telemedicine and dentistry are allowing for global healthcare in areas that are underserved.

Genomics has advanced at a great pace, and the genetic basis of all diseases is now being explored. The terms precision medicine and, eventually, precision dentistry will apply in dental practices and will be demanded by patients. Precision tests will lead to personalized treatments.

Inflammation: The Oral/Systemic Link

If there is one thing that defines the link between oral health and systemic health it is inflammation. More health issues are now associated with systemic inflammation. The potential for cardiac problems and stroke increases in the presence of chronic inflammation in the body. Sources of inflammation can be remote to the target organs such as the heart, respiratory system, and reproductive system.

Oral diseases like gingivitis and periodontitis can no longer be evaluated as local diseases of the oral cavity. The complications of theses diseases and oral inflammation can impact the patient’s other organ systems.

The story of inflammation is a complicated one that is still being evaluated. The chronic inflammation process as opposed to acute episodes of inflammation from a form of trauma or acute infections is the greatest concern to healthcare providers. Chronic inflammation can be identified through blood tests by looking for markers of inflammation. Regardless of the source and origins, the biomarkers of inflammation are the same.

The oral cavity can be a rich source for these circulatory markers of inflammation, and special attention must be paid to maintaining a healthy inflammation-free periodontium. However, certain systemic diseases and conditions can make it difficult to eliminate inflammation from the oral cavity. Diabetes, obesity, and pregnancy can exacerbate the conditions of gingivitis and periodontitis. Inadequate levels of vitamin D3 and calcium can also hinder the treatment of these diseases.

Much work has been done in the past decade regarding the relationship between oral health and systemic disease. We’ve moved beyond just brushing and flossing to identifying potential risk factors for the development of caries and periodontal disease, many of which are also the risk factors for other diseases. Smoking, obesity, diet, gender, age, and diabetes are some of the risk factors affecting both oral and systemic health.

Part of the Healthcare Team

In the future, oral health will no longer be the sole domain of the dentist. Large healthcare organizations, the insurance industry, and the government see a need to integrate oral healthcare into the greater healthcare system. Healthcare teams made up of various types of healthcare providers, including nurse practitioners, social workers, and dental hygienists, will treat patients. The primary care physician will be required to provide an evaluation of the patient’s oral health, then part of the treatment plan to meet the desired outcome metrics will include improving oral health. Hygienists and nurses may initiate the treatment plan with referral to the dentist only to treat trauma, tooth replacement, or active infection.

Dental hygiene education is already changing to allow dental hygiene students to engage in interprofessional collaboration with other members of the healthcare team. Training has also moved out of the dental office setting into the areas of hospitals, community health centers, and global healthcare sites.

As technology has provided for better long-term management of chronic diseases, many management strategies now include patients’ altering their lifestyle choices. Weight control, diet, exercise, and medications to control inflammation will benefit both systemic and oral health. The dental hygienist is in a prime position to provide these services for managing long-term chronic lifestyle issues.

These changes are now happening rapidly, and the forces of the ACA, “big data,” technology, genomics, and evidence-based understanding of the overall effects of chronic inflammation are reshaping the world of healthcare as we know it. Tomorrow’s hygienist will be part of an exciting new world.

About the Author

James Burke Fine, DMD
Senior Associate Dean for Academic Affairs
Columbia University
College of Dental Medicine
New York, New York