Lisa E. Simon, DMD, Elizabeth J. Eve, DMD and Romesh P. Nalliah, BDS 2016-05-16 15:02:18
INTRODUCTION Research has demonstrated that lack of education is associated with fewer dental office visits by patients.1 Literature also shows that lack of attendance to the dentist is often associated with anxiety and dental phobias.2 This perpetuates a system in which a segment of the population is deterred from seeking regular dental care and instead turn to hospitals and health centers for emergency attention when dental issues arise. However, studies show that medical doctors have a limited knowledge of oral and systemic health interactions3 and that nurses lack adequate oral health knowledge.4 Only about 1% of dentists in Massachusetts practice in hospital settings.5 This statistic suggests that our hospitals, in general, are ill equipped to address oral health concerns. This matter is of nationwide significance—every year in the United States, about 1.35 million hospital emergency room visits (3,700 visits per day) are due to a dental problem.6 Troublingly, research shows that when patients present to the hospital emergency room with dental problems, the care they receive is often inappropriate. 7 Clearly, there is a need for oral health expertise in hospitals, and previous papers in scientific journals have called for this evolution in oral health care delivery.8 The current study is the outcome of a needs assessment at Massachusetts General Hospital Chelsea Healthcare Center (MGH Chelsea), a local community health center that operates several primary care and specialty medical practices, as well as an urgent care center.9 MGH Chelsea provides high-quality medical care to eligible patients but has not historically provided oral health care. The population it serves is richly diverse,10 with median household incomes about 33% below the median level for Massachusetts.11 Between 2000 and 2010, the white population declined 0.13% while the African American population grew 16.79%, the Hispanic or Latino population grew 28.50%, the Mexican population grew 51.06%, and the Native American population grew 96.04%.10 At present, 62.14% of Chelsea residents identify as Hispanic or Latino, and 33.62% identify as “some other race,” which represents races other than white, black or African American, American Indian, Asian, or Native Hawaiian. Untreated dental disease leads to disproportionate morbidity12 and time away from work and school.13 However, dental insurance is often separate from medical insurance, and only recently has there been a growth of interest in the impact of oral health on systemic health. Recent publications demonstrate that patients with chronic disease who receive regular dental maintenance have lower overall health care costs.14,15 The matter of oral health–related emergency room visits is an $800 million problem annually,6 and another $1.2 billion is associated with patients who were admitted and hospitalized primarily because of a dental problem.16 In the United States, Latino individuals are more likely to be missing teeth and have untreated dental disease.17 They are also less likely to receive a diagnosis of oral cancer prior to metastasis than white patients.5 In 2012, physicians at MGH Chelsea invited Harvard School of Dental Medicine (HSDM) to evaluate the problem of oral health among their patients and recommend a solution. Knowing that there would be a high proportion of Spanish-speaking patients at MGH Chelsea, we integrated the HSDM Spanish Language Outreach Club into the implementation team. A diverse group of students and faculty who could speak several other languages was assembled. Additionally, a training session to prepare students to be able to work with Interpreter Phones on a Pole (iPOP) services was delivered. The objective of this article is to describe the needs assessment that was implemented and document the outcomes. METHODS Free dental screenings were offered in examination rooms within the adult family medicine department during regularly scheduled Saturday morning clinic hours on December 8, 2012, and June 1, 2013. The screenings were advertised internally because the goal was to evaluate regular patients of MGH Chelsea to determine their burden of oral disease. Patients scheduled for routine medical visits were also offered a dental screening. Screenings were conducted in private examination rooms by two dental students under the supervision of a faculty dentist. Patients were examined for the presence of caries experience, defined as current active decay or pre-existing restorations, current untreated decay, the presence of sealants, and whether they had urgent dental needs—defined as current dental pain as reported by the patient— or evidence of frank infection on exam. Patients were also asked questions about their general health and access to medical and dental care. Patients were provided with copies of their oral screening results, as well as a list of dental providers in nearby communities who accept MassHealth, including private practitioners, community health center dental clinics, and dental school clinics. IRB approval was obtained (IRB#14-1180). RESULTS In total, 77 individuals were screened, with an average age of 41 years. The majority (79.72%) of those screened were Latino, 10.81% were white, 5.41% were African American, and 4.05% identified as American Indian. (See Table 1.) Most patients lacked a college education (86.76%), and 22.06% had not received more than an elementary school education. Most patients lacked dental insurance (43.59%) or were enrolled in MassHealth for dental insurance (41.02%). Consistent with the location of screenings within a medical practice, 90.91% of those screened reported having a regular primary care provider. Subjects screened reported the presence of numerous systemic illnesses. Twenty-three subjects (29.87%) indicated they had hypertension. A total of 22.1% of those screened had diabetes mellitus, with 6.49% reporting a diagnosis of Type I diabetes and 15.58% a diagnosis of Type II diabetes. Additionally, 19.48% of subjects reported having asthma, 10.59% reported a history of cancer, and 7.79% reported having cardiovascular disease. Only two subjects screened had had a stroke. Results of these screenings indicated a high level of oral health need among adult MGH Chelsea patients; 67.53% had clinically detectable untreated caries and 50.65% of those screened had urgent dental needs. While the average time since individuals’ last medical visit was 10 weeks (1 week–13 years), the average time since the last dental visit was 2.3 years, with one subject reporting that he had never seen a dentist. DISCUSSION Findings from the current study demonstrate that 67.5% of patients had untreated dental caries, which is higher than the rate noted nationally among Hispanic populations.17 In relation to general health, 19.5% of patients in the current study reported having asthma, even though the Centers for Disease Control and Prevention (CDC) data shows that only about 8% of Americans have asthma.18 Similarly, 10.6% of patients in our study reported having experienced some form of cancer; however, the National Cancer Institute data shows that only 4.1% of Americans have cancer.19 Additionally, more than 22% of those screened reported having diabetes even though the national rate for diabetes is 8.3%.20 Periodontal therapies are known to improve glycemic control in diabetics with diagnosed periodontitis, and this group may benefit from access to dental care.21 The needs assessment revealed that 50.7% of patients were found to have an urgent dental need; however, the health care center does not provide dental services. Strong consideration should be given to delivering dental care at all community health centers. In the current project, patients were transferred to the local dentist network. This is an imperfect measure because many dental providers may not have openings available. Federally supported health centers provide care at 291 sites in Massachusetts. Ninety-one percent of patients seen by health care providers in community health centers are low-income, and 68% earn less than 100% of the federal poverty line.22 These populations are especially vulnerable to poor oral health and tooth loss.23 Individuals at high risk of dental disease are more likely to visit a physician than a dentist over the course of a year.24 As federally funded health centers offer community-oriented primary care services, they are an excellent venue for the incorporation of oral health into primary care. However, only 83% of Massachusetts community health centers offer onsite dental services.25 It is interesting to note that although two-thirds of patients were found to have dental caries, almost 82% of patients self-reported their health to be good, very good, or excellent. One explanation may have been that patients did not know they had caries. Alternatively, patients may have known they had caries but did not consider it to be an important health issue that would lead to downgrading their opinion of personal health. The current study has several limitations: While oral health was examined with oral health screenings, other medical conditions were self-reported by patients and could be overestimated. Additionally, the needs assessment was only intended to evaluate existing patients of record at MGH Chelsea. Internal advertising to patients who attended MGH Chelsea was the only means of promoting the oral health screening event. It is possible that only those with more severe dental disease chose to attend the oral health screening event. Moreover, our advertising method would not include individuals who do not interface with the health care system, and may be even more vulnerable to poor oral health. However, there is no clear explanation for why the patients who presented to the oral health screenings had such a high burden of some systemic conditions. CONCLUSION Our study participants were existing patients of record of MGH Chelsea who presented to a free oral health screening. Their rates of dental disease, hypertension, diabetes, cancer, and asthma were much higher than national averages. Strong consideration should be given to assessment of risk for systemic disease among community health center patients who report that they require dental care. More importantly, innovative strategies like teledentistry and cross-training of the medical team should be considered to improve preparedness of the hospital team to manage dental problems. REFERENCES 1) Listl S. Cost-related dental non-attendance in older adulthood: evidence from eleven European countries and Israel. Gerodontol. 2014 Sep 10. doi: 10.1111/ger.12151. [Epub ahead of print] 2) Milgrom P, Newton JT, Boyle C, Heaton LJ, Donaldson N. The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London. Community Dent Oral Epidemiol. 2010;38(5):453-459. 3) Al-Khabbaz AK, Al-Shammari KF, Al-Saleh NA. Knowledge about the association between periodontal diseases and diabetes mellitus: contrasting dentists and physicians. J Periodontol. 2011;82(3):360-366. 4) Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs. 1996;24(3):552-560. 5) Massachusetts Department of Public Health Office of Oral Health. The status of oral diseases in Massachusetts. November 2009. Available from: http://www.mass.gov/eohhs/docs/dph/comhealth/oral-health-burden.pdf. Accessed 2014 Nov 20. 6) Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital-based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. JADA. 2014;145(4):331-337. 7) Tulip DE, Palmer NO. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J. 2008;205(12):659-664; discussion 648. 8) Nalliah RP, Allareddy V, Allareddy V. Dentists in the US should be integrated into the hospital team. Br Dent J. 2014;216(7):391-392. 9) Massachusetts General Hospital. Chelsea Healthcare Center. About us. Available from: http://www.massgeneral.org/chelsea/. Accessed 2014 Nov 22. 10) Zip-Codes.com. 2000/2010 census comparison – zip code. Available from: https://www.zip-codes.com/zip-code/02150/zip-code-02150-censuscomparison.asp. Accessed 2014 Nov 23. 11) City-Data.com. Chelsea, Massachusetts. Available from: http://www.city-data.com/city/Chelsea-Massachusetts.html. Accessed 2014 Nov 24. 12) Cohen LA, Bonito AJ, Eicheldinger C, Manski RJ, Macek MD, Edwards RR, Khanna N. Behavioral and socioeconomic correlates of dental problem experience and patterns of health care-seeking. JADA. 2011;142(2):137-149. 13) Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health. 2012;102(9):1729-1734. 14) Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum JJ. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014;47(2):166-174. 15) Cigna. Improved health and lower health costs: Why good dental care is important. A white paper. Available from: http://www.cigna.com/assets/docs/life-wall-library/Whygooddentalcareisimportant_whitepaper.pdf. Accessed 2014 Nov 22. 16) Allareddy V, Kim MK, Kim S, Allareddy V, Gajendrareddy P, Karimbux NY, Nalliah RP. Hospitalizations primarily attributed to dental conditions in the United States in 2008. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(3):333-337. Erratum in: Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(5):668. 17) National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in adults (age 20-64). Available from: http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm#Table2. Accessed 2014 Nov 2. 18) Centers for Disease Control and Prevention. National Center for Health Statistics. Asthma. Available from: http://www.cdc.gov/nchs/fastats/asthma.htm. Accessed 2014 Nov 22. 19) National Cancer Institute. Surveillance, epidemiology, and end results program. SEER stat fact sheets: all cancer sites. Available from: http://seer.cancer.gov/statfacts/html/all.html. Accessed 2014 Nov 22. 20) Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed 2014 Nov 22. 21) Perayil J, Suresh N, Fenol A, Vyloppillil R, Bhaskar A, Menon S. Comparison of Hba1c levels in non-diabetic healthy subjects and subjects with periodontitis before and after non-surgical periodontal therapy. J Periodontol. 2014;26:1-17. 22) National Association of Community Health Centers. Key health center data by state, 2013. Available from: http://www.nachc.com/statehealthcare-data-list.cfm. Accessed 2014 Dec 3. 23) Huang DL, Park M. Socioeconomic and racial/ethnic oral health disparities among US older adults: oral health quality of life and dentition. J Public Health Dent. 2015;75(2):85-92. 24) Tomar SL, Lester A. Dental and other health care visits among U.S. adults with diabetes. Diabetes Care. 2000;23(10):1505-1510. 25) National Association of Community Health Centers. Massachusetts Fact Sheet 2012. Available from: http://www.nachc.com/client/documents/research/maps/MA141.pdf. Dr. Simon is an instructor of oral health policy and epidemiology at the Harvard School of Dental Medicine. Dr. Eve is an orthodontic resident at the University of California San Francisco School of Dentistry. Dr. Nalliah is director of clinical education at the University of Michigan School of Dentistry.
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