Dental home: Patient centered dentistry

Abstract

Early childhood dental caries occurs in all racial and socioeconomic groups; however, it tends to be more prevalent in children in families belonging to the low-income group, where it is seen in epidemic proportions. Dental caries results from an overgrowth of specific organisms that are a part of normally occurring human flora. Human dental flora is site specific, and an infant is not colonized until the eruption of the primary dentition at approximately 6 to 30 months of age. The most likely source of inoculation of an infant's dental flora is the mother, or another intimate care provider, shared utensils, etc. Decreasing the level of cariogenic organisms in the mother's dental flora at the time of colonization can significantly impact the child's redisposition to caries. To prevent caries in children, high-risk individuals must be identified at an early age (preferably high-risk mothers during prenatal care), and aggressive strategies should be adopted, including anticipatory guidance, behavior modifications (oral hygiene and feeding practices), and establishment of a dental home by 1 year of age for children deemed at risk.

Full text

Journal of International Society of Preventive and Community Dentistry 8January-June 2012, Vol. 2, No. 1
Dental home: Patient centered dentistry
Review Article
K. L. Girish Babu, G. M. Doddamani1
Department of Pedodontics and Preventive Dentistry, 1Department of Orthodontics, The Oxford Dental College, Hospital and
Research Centre, Bommanahalli, Hosur Road, Bangalore, Karnataka, India
Corresponding author (email:<drgirish77@yahoo.com>)
Dr. Girish Babu KL, Reader, Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and
Research Centre, Hosur Road, Bangalore - 560068, Karnataka, India.
Abstract
Early childhood dental caries occurs in all racial and socioeconomic groups; however, it tends to be more prevalent in
children in families belonging to the low-income group, where it is seen in epidemic proportions. Dental caries results
from an overgrowth of specic organisms that are a part of normally occurring human ora. Human dental ora is site
specic, and an infant is not colonized until the eruption of the primary dentition at approximately 6 to 30 months of
age. The most likely source of inoculation of an infant’s dental ora is the mother, or another intimate care provider,
shared utensils, etc. Decreasing the level of cariogenic organisms in the mother’s dental ora at the time of colonization
can signicantly impact the child’s redisposition to caries. To prevent caries in children, high-risk individuals must
be identied at an early age (preferably high-risk mothers during prenatal care), and aggressive strategies should
be adopted, including anticipatory guidance, behavior modications (oral hygiene and feeding practices), and
establishment of a dental home by 1 year of age for children deemed at risk.
Key words: Anticipatory guidance, diet, early childhood caries, oral hygiene, patient centered dental home
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DOI:
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INTRODUCTION
In 2004, the American Academy of Pediatrics (AAP),
in association with the American Academy of Family
Physicians (AAFP), the American College of Physicians
(ACP) andthe American Osteopathic Association
(AOA), defined comprehensive guidelines for the
Patient-Centered Medical Home (PCMH) as the
central approach to improve health care in the United
States.[1] In the same year, the American Academy
of Pediatric Dentistry (AAPD) formally adopted a
policy endorsing the Dental Home (DH).[2] The
Patient-Centered Medical-Dental Home (PCM-
DH) represents an enhanced health care model. In
this model, each patient has a personal physician or a
dentist who leads a team of clinical care providers and
staff who take collective responsibility for delivering
comprehensive, coordinated care that addresses all of a
patient’s health care needs. The PCM-DH focuses on
the patient instead of a single organ system. It requires
a well-trained, and a large primary care workforce with
expertise in providing broad-based, collaborative health
care.[3] The team-based, coordinated, comprehensive
carestructureofthePCMDHoffersagreatpromise to
improve the delivery of both the disease prevention and
chronicdiseasecare.ThePCM-DHfeaturesapersonal
physician or a dentist who leads a multidisciplinary
team to deliver culturally competent and evidence-
based care. National and international studies have
found that the primary care improves health more than
the specialist care.[4] Countries with a strong primary
care system also have better early childhood health
outcomes.[5]
The American Academy of Pediatric Dentistry (AAPD)
developed a policy on dental homes that was first
adopted in 2001 and revised in 2004.[2] The definition
states:
“The dental home is the ongoing relationship between
the dentist and the patient, inclusive of all aspects of oral
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9 Journal of International Society of Preventive and Community Dentistry
Babu and Doddamani: Dental home
January-June 2012, Vol. 2, No. 1
health care delivered in a comprehensive, continuously
accessible, coordinated, and family-centered way.
Establishment of a dental home begins no later than 12
months of age and includes referral to dental specialists
when appropriate.”
Similar to the medical home, the dental home offers the
patients comprehensive, continuous, prevention-based
care that is accessible, family-centered, compassionate,
and culturally competent. Citing strong clinical
evidence that early preventive dental care promotes oral
health, the AAPD declared that “the establishment of a
dental home may follow the medical home model as a
cost-effective and higher quality health care alternative
to emergency care situations”.[2] At the center of the
PCM-DHisatrustingrelationshipbetweenthepatient
and his/her personal provider who leads a team to
address the patient’s needs. Generally, this provider is
a primary care physician; however, for dental care, it
could be a dentist.[3]
Need for establishing the dental home
Dental caries results from an overgrowth of specific
organisms that are part of normally occurring human
dental flora.[6]Streptococcus mutans and Lactobacillus
species are considered to be principal indicator
organisms of aciduric bacteria responsible for caries.
Human dental flora is site specific, and an infant
is not colonized with normal dental flora until the
eruption of the primary dentition at approximately
6 to 30 months of age.[7,8] The vertical colonization
of Streptococcus mutans from mother to infant is well
documented.[9,10] In fact, genotypes of Streptococcus
mutans in infants appear identical to those present
in mothers in approximately 71% of mother-infant
pairs.[11] Furthermore, evidence suggests that specific
organisms exhibit discrete windows of inoculation;
and, the acquisition of Streptococcus mutans occurs at an
average age of approximately 2 years.[12] The significance
of this information becomes focused when considering
2 points. First, high caries rates run in families,[13] and
are passed from mother to child from generation to
generation. The children of mothers with high caries
rates are at a higher risk of decay.[14] Secondly, the
modification of the mother’s dental flora at the time
of the infant’s colonization can significantly impact the
child’s caries rate.[15-17] Therefore, an oral health risk
assessment before 1 year of age affords the opportunity
to identify high-risk patients and to provide timely
referral and intervention for the child, thus allowing
an invaluable opportunity to decrease the level of
cariogenic organisms in the mother with a significant
caries risk before and during colonization of the infant.
Empiric evidence of the value of the dental home
• Children in a dental home are more likely to
receive appropriate preventive and routine oral
health care, thereby reducing the risk of preventable
dental/oral disease.[2]
• Children with special health care needs who had
a personal physician or nurse in the context of a
PCM-DHaresignificantlylesslikelytohaveunmet
dental needs than those without this care.[18]
• Parentsofspecialneedschildrenreportsignificantly
fewer unmet health care and family support service
needsiftheybelongedtoaPCM-DH.[19]
Creating awareness of dental home
In order establish a dental home; it is important to meet
the parents/ prospective parents early. Gynecologists,
pediatricians, family physicians are the people who
come in contact with them much before a dentist. He
must establish communication with them such that
effective and timely referrals are made to dentist. Also,
schools and pre-school day care centers can be informed
about the dental home.
• A notice such as – “Do you know you can benefit
your child’s teeth and oral health by starting
preventive dental care before child-birth?”- can
attract the attention of prospective parents if put
in a gynecologist’s office. Similarly, the following
messages[20] can be displayed in hospitals and
clinics of a pediatricians, gynecologist and all other
pediatric health care professionals:
• Firstvisitby the first birthday.A childshould visit
the dentist within six months of the eruption of
the first tooth or by age one. Early examination and
preventive care will protect your child’s smile now
and in the future.
• Dental problems can begin early. A big concern is
the Early Childhood Caries (also known as baby
bottle tooth decay or nursing caries). Children risk
severe decay from using a bottle during naps or at
night or when they nurse continuously from the
breast.
• Theearlierthedental visit, the betteristhechance
of preventing dental problems. Children with
healthy teeth chew food easily, are better able to
learn to speak clearly, and smile with confidence.
Start children now on a lifetime of good dental
habits.
• Encourage children to drink from a cup as they
approach their first birthday. Children should not
fall asleep with a bottle. At-will, night time breast-
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Journal of International Society of Preventive and Community Dentistry 10January-June 2012, Vol. 2, No. 1
Babu and Doddamani: Dental home
feeding should be avoided after the first primary
teeth begin to erupt. Drinking juice from a bottle
should be avoided. When juice is offered, it should
be in a cup.
• Childrenshouldbeweanedfromthebottleat12-14
months of age.
• Thumb sucking is perfectly normal for infants;
most stop by age of 2 and it should be discouraged
after age 4. Prolonged thumb sucking can create
crowded, crooked teeth or bite problems. Dentists
can suggest ways to address a prolonged thumb
sucking habit.
• Never dip a pacifier into honey or anything sweet
before giving it to a baby.
• Limitthefrequencyofsnacking,whichcanincrease
a child’s risk of developing cavities.
• Parents should ensure that young children use an
appropriate size toothbrush with a small brushing
surface and only a pea-sized amount of fluoride
toothpaste at each brushing. Young children should
always be supervised while brushing and taught
to spit out rather than swallow the toothpaste.
Unless advised to do so by a dentist or other health
professionals, parents should not use fluoride
toothpaste for children less than two years of age.
• Children who drink primarily bottled water may
not be getting the fluoride they need.
• Fromsix months to age 3, children may have sore
gumswhenteeth erupt. Manychildrenlikeaclean
teething ring, cool spoon, or cold wet washcloth.
Some parents prefer a chilled ring; others simply
rub the baby’s gums with a clean finger.
• Parentsandcaregiversneedtotakecareoftheirown
teeth so that cavity-causing bacteria are not as easily
transmitted to children. Don’t clean pacifiers and
eating utensils with your own mouth before giving
them to children. That can also transmit adults’
bacteria to children.
Environmental Factors in Implementing the Dental
Home for All Young Children[21]
Benefits of the dental home are substantial and
intuitive, although not yet substantiated by research,
and include an increasing emphasis on prevention and
disease management, advancements in tailoring care to
meet individual needs, and better health outcomes at
lower costs.
Forces explored are:
• Theadventof“socialmedicine”
• Expandingknowledge ofearlychildhood cariesrisk
and disease management
• Trendsinoralhealthanddentalcare disparitiesand
the forces that propel them
• Perceived needs for dental services and other
barriers to dental home utilization
• Dentistryasanindependenthealthprofession
• Dental system capacity for all children, including
those with special needs.
Advent of “social medicine” in pediatric healthcare
The social medicine approach to pediatric health
supervision clarifies that opportunities for children
to obtain and maintain oral health are established
by factors beyond the mouth and beyond the dental
chair. This has direct implications for oral health
supervision in the dental home as reported by Nowak
and Casamassimo who call for a dental home (1) that “is
characterized by [its] community;” (2) that recognizes
that “newer models of caries initiation…extend into
the family and community;” and (3) that a community-
based dental home “should be able to provide focused
prevention better than a haphazard or one-size-fits-all
approach.”
Expanding knowledge of early childhood caries risk
and management
As the science of caries risk identification, primary
prevention, and disease management continues to
develop, the dental home will be ideally situated to
develop and implement science-based/evidence-based
medical approaches to caries prevention and control.
There is strong potential for expanded roles for dental
hygienists as well as nutritionists, health educators, and
social workers in becoming effective disease managers.
Oral health and dental care disparities and their
drivers
The medical home concept, first built around “children
with special healthcare needs (CSHCN), emphasizes
the complexity of care required by these children and
the need for specialty-level care providers. Similarly, the
dental home concept will be particularly germane and
beneficial to these children and their families and will
require the disproportionate engagement of dentists
who specialize in pediatric dentistry as they have
additional expertise in managing care for CSHCN. The
dental home will need to be particularly accommodating
and sensitive to opportunities and constraints for oral
health among the disproportionately growing numbers
of young children who live in poverty and single parent
households. The sheer numbers of such children will
test the capacity of dental systems to accommodate
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11 Journal of International Society of Preventive and Community Dentistry
Babu and Doddamani: Dental home
January-June 2012, Vol. 2, No. 1
them in traditional dental offices.Children who
currently do not have a dental home are primarily those
who are from poor and low-income families and are
racial/ethnic minorities. These children will benefit
most from early and ongoing care in a dental home.
Perceived needs for dental services and other
barriers to dental home utilization
The dental home concept calls for outreach to children
at greatest risk of disease and continuing active
professional involvement in solving barriers to both oral
health attainment and to dental care.
Dentistry as an independent health profession
This separation of the health professions helps explain
why a child may require more than one “home.”
Dental and medical system adoption and capacity to
accommodate all children in dental homes
Because the total numbers of dentists are inadequate
to provide a dental home for the total numbers of
children, priority should be given to children at greatest
risk for dental disease, including those with earliest
signs of ECC, children from high-risk subpopulations,
and children with special healthcare needs.
Challenges to implementing the dental home
First, we simply do not have enough trained clinicians
to staff this model of care. Retooling practices and re-
educating clinicians to deliver team-based care will
require substantial short- and long-term financial
resources. Coordination of care underpinning the
PCM-DH requires productive use of information
technology.Current provider training programs do
not educate young physicians and dentists in the
fundamental precepts of the PCM-DH. They need
to learn how to deliver team-based care, use health
information technology to improve care, and adopt
evidence-based principles in practice. Continuous
quality improvement methodologies must also become
part of the curriculum.
Changes needed in medical and dental education
To institute the PCM-DH in our country, a
transformation must occur in which physicians and
dentists who practice independently with minimal staff
support or use of information technology will need to
learn to adopt the Chronic Care Model. Medical and
dental training programs need to develop innovative
training models that reflect evolving models of health
care delivery, such as the PCM-DH. As noted by the
Council on Graduate Medical Education, training
programs must emphasize health care systems, health
of populations, patient-and family-centered care,
continuous care, prevention, and wellness, as well as
the use of point-of service, evidence-based clinical
information.[22,23]
CONCLUSIONS
The dental home, like the medical home, holds strong
promise to improve the overall care of all children.
The dental home, like the medical home, will
particularly benefit children in whom therisk for
oral disease is exacerbated by social and/or medical
vulnerabilities.
Implementation of the dental home concept will benefit
from growing understanding of social medicine and
scientific approaches to clinical caries prevention and
control.
Effective dental home implementation will require
close attention to epidemiologic, health services, and
demographic trends in order to target those at the
greatest risk for the disease.
Oral health promotion from an early age in a dental
home will require extensive improvements in public
awareness and professional engagement and systems-
level improvements in care coordination between
medicine and dentistry.
Current dental system capacity cannot support
wholesale implementation of the dental home unless
the dental home’s functions are shared by other
agencies that interact with children where they live,
learn, and play.
The dental home concept extends to older children as
well as infants and toddlers, but holds greatest promise
for impact if focused on the youngest children.
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How to cite this article: Girish Babu KL, Doddamani GM. Dental
home: Patient centered dentistry. J Int Soc Prevent Communit Dent
2012;2:8-12.
Source of Support: Nil, Conict of Interest: None declared.
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