Medical dental integration: A solution for oral health disparities

The US health-care system faces significant issues including lack of availability, affordability, accessibility, and acceptability of quality care.¹ Disadvantaged and marginalized communities face disparities in access to health care, quality of care, and poorer health outcomes.^2,3 Data reports illustrate an invisible threat among marginalized populations, with disproportionately higher rates of mortality and morbidity,^1,4 including dental diseases. The integration of oral health into primary care using medical dental integration (MDI) models can expand access to affordable, quality care, reducing the oral health burden on the US health-care system.

Oral health disparities

Dental caries is the most common chronic disease among children in the US^5,6 According to the Oral Health Surveillance Report 2011-2016, the prevalence of dental caries and untreated tooth decay remains highest among Mexican-American (73%, 23%), non-Hispanic Black (54%, 22%), and poor and near-poor combined (62%, 22%) children compared to non-Hispanic white and non-poor (40%, 11%) children.⁷ The CDC shows that non-Hispanic Black (40.2%) and Mexican-American (37.1%) adults aged 20-64 years have higher rates of untreated tooth decay than non-Hispanic whites (22.2%).⁷

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The Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services (HHS) report that Mexican-Americans and non-Hispanic Blacks of all age groups are more likely to be affected by periodontal disease than non-Hispanic whites.^2,8 In the United States, marginalized populations are disproportionately affected by many diseases. including COVID-19, diabetes, and cardiovascular disease.⁹ Disparities in oral health are a critical factor when considering overall health.

MDI in primary care

Unequal access to affordable care and the systemic connection between oral health and overall health have a significant impact on individual health outcomes. The Surgeon General’s Report and World Health Organization (WHO) agree that access to care is a critical human rights issue and a major public health problem in the US^1,8 Health-care workers, such as registered dental hygienists, play a significant role in advocating for health equality, including access to dental care.

The integration of oral health care by dental hygienists during medical visits can significantly reduce the burden of oral disease.^4,8 About 108 million Americans visit their physician each year, but not necessarily their dentist; this includes 60% of children ages 1 to 4 years.¹⁰ A child may see a primary care physician up to 11 times before their first dental visit. Bright Futures and the American Academy of Pediatrics (AAP) recommend that children receive an oral health risk assessment at the 6-, 9-, 12-, 18-, 24-, and 30-month visits, as well as at the 3- and 6-year well-child visits.¹¹ The AAP and the US Preventive Service Task Force (USPSTF) recommend fluoride varnish application every three to six months for children 6 months to 5 years of age.¹² The role of a medical-dental integrated hygienist, besides being a child’s first preventive dental experience, will also be a cost-savings benefit.

Cost benefits of MDI

The US healthcare system has seen an increase in emergency department (ED) visits for dental conditions, resulting in $2.7 billion spent on ED dental care per year.¹³ About $520 million of these dental-related ED visits are paid for by Medicaid,¹⁴ and 69% of those visits are for untreated dental conditions in children.¹³

It’s estimated that the $520 million in ED costs would pay for about one million routine dental visits a year.¹⁴ Annually, children lose about 34 million school hours because of unplanned dental care, and adults lose over $45 billion in US productivity due to untreated dental disease.^15,16 Atchinson and colleagues case study analysis shows that integration of oral care into primary care reduces the overall cost of health care.¹⁷

Additionally, Nasseh et. al. estimated a cost savings of $102.6 million annually with integration when dental offices screen for chronic medical conditions such as hypertension with a referral to a medical provider.¹⁸ Similar cost savings can be seen when integrating a dental hygienist into primary care offices. Mosen agrees that medical-dental integration (MDI) programs, where patients receive dental care at their primary care office, have higher rates of health-care compliance and care utilization, closing medical care gaps.¹⁹ MDI between oral health and chronic disease prevention programs benefits patients and saves money.¹⁷

A new health-care infrastructure

The US health-care system needs to evaluate MDI models as an effective health care infrastructure. Improved collaboration and communication between medical and dental teams will enhance the quality of health care delivery with improved health outcomes. MDI models are integrated care delivery systems that effectively improve access to care that disadvantaged and marginalized communities would not otherwise have. MDI can add oral health screenings to well-child visits, enable dental hygienists to discuss oral health education with expectant mothers, and use electronic health records (EHR) to connect providers from multiple disciplines with their patients and outside dental referral sources. Integrated care visits amount to decreases in ED visits, reducing health care costs and increasing preventive oral health visits. MDI is an impactful solution when discussing oral health disparities among marginalized communities.

References

1. Human rights.  World Health Organization. December 10, 2022. https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health.
2. CDC health disparities and inequalities report. United States 2013. Centers for Disease Control and Prevention. November 22, 2013. https://www.cdc.gov/mmwr/pdf/other/su6203.pdf
3. Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering, and Medicine. 2017. https://nap.nationalacademies.org/catalog/24624/communities-in-action-pathways-to-health-equity
4. Oral Health in America: Advances and Challenges. National Institute of Dental and Craniofacial Research. 2021. https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
5. Children’s oral health. The Centers for Disease Control and Prevention. Reviewed 2022. https://www.cdc.gov/oralhealth/basics/childrens-oral-health/index.html
6. Oral health facts. World Health Organization. Updated 2023. https://www.who.int/news-room/fact-sheets/detail/oral-health
7. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Centers for Disease Control and Prevention. 2019. https://www.cdc.gov/oralhealth/publications/OHSR-2019-index.html
8. Oral health in America: A report of the Surgeon General. National Institute of Dental and Craniofacial Research. 2000. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
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11. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. American Academy of Pediatrics; 2017
12. U.S. Preventive Service Task Force. Screening and interventions to prevent dental caries in children younger than 5 years. JAMA. 2021;326(21):S2172-2178
13. Emergency Department Visits for Dental Conditions – A Snapshot. American Dental Association, Agency for Healthcare Research and Quality. 2020. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/community-initiatives/action-for-dental-health/emergency-department-referrals/ed_referral_hpi_infographic.pdf
14. Yarbrough C, Vujicic M, Nasseh K. Estimating the cost of introducing a Medicaid adult dental benefit in 22 states. Health Policy Institute Research Brief. American Dental Association. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/ada/ada/science-and-research/hpi/files/hpibrief_0316_1.pdf
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17. Atchinson KA, Weintraub JA, Rozier RG. Bridging the dental-medical divide. Case studies integrating oral health care and primary health care. J Am Dent Assoc 2018;149:850-858.
18. Nasseh K, Greenberg B, Vujicic M, Glick M. The effect of chairside chronic disease screenings by oral health professionals on health care costs. Am J Public Health. 2014;104(4):744-750.
19. Mosen DM, Banegas MP, Dickerson JF, et al. Examining the association of medical-dental integration with closure of medical care gaps among the elderly population. J Am Dent Assoc. 2021;152(4):302-308.