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COLLABORATION AND TEAMWORK
A NEW PRACTICE APPROACH FOR ORAL HEALTH
PROFESSIONALS
Noreen Myers-Wright
a
,and Ira B. Lamster
b
Editor’s Note
Chronic disease management requires a lifetime of coordinated care.
These authors provide compelling informationtosuggestthatoralhealth
care professionals who expand their scope of practice to include health
promotion strategies and primary health screenings will contribute to risk
reduction.
ABSTRACT
The oral health care paradigm presented here would broaden oral health services
to include primary health care activities focusing on risk reduction and chronic
disease screening.
Background and purpose
Changes in our nation’s health care delivery system, shifting patient demographics, and
availability of new health insurance programs have resulted in exploration of new
practice models of health care delivery. Chronic diseases require coordinated care
efforts over decades of a patient’s life. Oral health professionals will be part of that care.
Methods
The practice model for this article was developed in the context of an academic
medical center that promotes oral health care professionals as health care providers
through interprofessional education. The combined experiences of the authors,
including a diabetes predictive model for oral health settings, the efficacy and
effectiveness of human immunodeficiency virus screening in a dental setting, the
feasibility of using a decision support tool for tobacco cessation, and the effec-
tiveness of integrating oral health education with comprehensive health services for
people living with human immunodeficiency virus, have contributed to this concept.
Conclusions
Prevention is increasingly recognized as a cost-effective means of reducing chronic
disease burdens. To be effective, health promotion activities that encourage healthy
living and early detection need to occur in a variety of health care settings. Oral
health professionals represent an underutilized group of health care providers that
can contribute to improved health of populations living with chronic diseases by
broadening their scope of practice to include primary health screenings and tailored
health promotion activities.
INTRODUCTION
Health care in the United States is evolving toward a coordinated system driven
by the desire for maximizing health outcomes. Evidence supporting the
Keywords: Chronic disease, Health promotion, Interprofessional collaboration, Oral health care model,
Health management, Health systems
a
RDH, EdD, Department of Health Policy &
Management, Mailman School of Public
Health, Columbia University, New York,
NY, USA
b
DDS, MMSc, Department of Health Policy
& Management, Mailman School of Public
Health, Columbia University, New York,
NY, USA
Conflict of interest: The authors have no actual or
potential conflicts of interest.
Corresponding author: Noreen Myers-Wright, Department
of Health Policy & Management, Mailman School of Public
Health Columbia University, 722 West 168th Street, 4th
Floor, 480D, New York, NY 10032.
E-Mail: nlm2119@cumc.columbia.edu
J Evid Base Dent Pract 2016:16S:
[43-51]
1532-3382/$36.00
ª2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jebdp.2016.01.027
43 June 2016
relationship between oral and systemic health and the de-
mand for complete patient care emphasize the need to
consider how oral health professionals can participate in this
evolving health care environment. Traditional oral health care
providers have been isolated from other health service pro-
viders through practice settings, insurance treatment codes,
health policies, as well as public perception of oral health as
separate from general health.
The practice paradigm for oral health presented here has
been developed in the context of an academic medical center
that promotes an appreciation of dental providers as health
providers through interprofessional education. The authors
combined experiences, including research that has developed
and evaluated a diabetes predictive model for oral health
settings, the efficacy and effectiveness of human immunode-
ficiency virus (HIV) screening in a dental school clinic, the
feasibility of using a decision support tool for tobacco cessa-
tion in dental practices, and the effectiveness of integrating
oral health education with comprehensive health services for
people living with HIV, have contributed to this model.
Changes in our nation’s health care delivery system, shifting
patient demographics, and availability of new health insurance
programs have led to the search for innovative practice
models of health care delivery. Dental practice can be
broadened to include a greater focus on reduction of risk
factors and screening for chronic diseases. This approach will
allow dentists and dental hygiene practitioners to work up to
their level of education, providing oral health care in the
context of general health care. Within this system, oral health
professionals can more fully use their time during clinical visits
to assess patients’overall health. Health care dollars can be
used more efficiently by incorporating relevant primary health
care activities into oral health care visits.
DRIVERS OF CHANGE
Population Trends
Older and young adults living with chronic diseases represent
2 segments of the population in the United States that require
particular attention.
1,2
It is estimated that the population of Americans aged
65 years or older will grow to 89 million by 2050.
1
Older
adults are disproportionately affected by noncommunicable
chronic diseases, notably cardiovascular disease and diabetes
mellitus (DM).
1
Two of every 3 older Americans have
multiple chronic conditions, and treatment for this
population accounts for 66% of the country’s annual health
expenditure.
1
Furthermore, edentulism in the United States
and other developed countries has been falling during the
past 3 decades.
1
Consequently, a greater portion of older
adults will require more oral health care services than
previous generations.
The young adult and adolescent segments of the popula-
tion in the United States are growing and are more diverse
than previous generations. The obesity rate among young
adults is strikingly high at about 25% and appears to be
rising; this trend comes with related health risks including
hypertension and diabetes.
2
Furthermore, the largest
number of new HIV diagnoses is found in young adult
populations between the ages of 13 and 24 years, with
most of these infections occurring in men who have sex
with men.
3
New service programs need to be considered
to increase utilization of oral health care by this segment
of the population. For example, preventive dental services
can be made available at high school and community
college health centers to provide oral health services that
include screening for chronic diseases, and health
education information.
Health Care Expenditures
Nearly two-thirds of health care costs are funded
through government programs such as Medicare, Medicaid,
and Children’s Health Insurance Programs, with private in-
surance and out-of-pocket expenses covering the remain-
ing costs. The value of integrating oral health care with
medical services is driven in part by the concern for con-
taining health care costs while improving overall health
outcomes. Health care costs are a large part of the gross
national product with chronic diseases accounting for more
than 86% of the $2.7 trillion annual medical care
expenditure.
4
New insurance programs
The Patient Protection and Affordable Care Act of 2010
was developed to reduce the number of Americans living
without health insurance, to reorganize the health delivery
systems and improve the quality of care provided to all.
5
The Affordable Care Act has increased dental benefits to
children and low-income adults through expanded
Medicaid programs.
6
Although the greatest increase in
dental benefitshasbeenseeninchildren,anestimated
17.7 million adults have gained some dental benefits.
7
Accountable healthcare organizations such as Kaiser
Permanente Dental Associates, Trillium Coordinated Care
Organization, and Hennepin Health have already begun to
integrate oral health into patient care coordination. This is
founded on the philosophy that a health care organization
cannot be responsible for the overall health of patients
without including oral health (see Blue and Riggs,inthis
issue).
8
Health Promotion and Disease Prevention
Prevention is increasingly recognized as a cost-effective means
of reducing the chronic disease burden. To be effective, health
promotion activities that encourage healthy living and early
THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
Volume 16, Supplement 44
detection of disease need to occur in multiple sectors espe-
cially for at-risk populations.
4
Tobacco cessation and
consumption of a healthy diet are 2 behaviors that have
been shown to decrease the risk of developing heart
disease, diabetes, and other chronic conditions.
9
In the
United States, the largest number of healthy years of life
lost has been attributed to potentially avoidable risks such
as high body mass index, uncontrolled high blood pressure,
and elevated plasma glucose (see Figure 1).
9
Professional Capacity
Primary care medical providers in the United States are facing
the challenge of managing burgeoning numbers of patients
with chronic diseases. There are appealing potential advan-
tages of including oral health care providers in the manage-
ment of patients with chronic diseases. The National Center
for Health Statistics indicated that 61.7% of adults in the
United States seek dental care at least once a year.
10
On a
local level, the 2013 New York City Community Health
Survey revealed that of the uninsured residents, 24.3% had
a preventive dental visit only vs 15.8% that had a visit only
with their medical provider.
11
Interprofessional Practice
The need to improve health care for underserved populations
has increased interest in redefining oral health care practice
settings. There has been more public health support for
increasing oral health services in medical settings.
12
Thirty-
eight states have direct access policies that allow dental hy-
gienists to provide care in public health clinics, school health
clinics, older adult care facilities, and federally qualified health
centers.
13
Alternative dental hygiene practices allow more
patients to access dental preventive services and, in some
states, limited restorative services as well as referrals for
more complex restorative care by dentists. Referrals for
medical care from dental practitioners can serve to further
develop interprofessional relationships of oral health and
medical providers. This referral network can be bidirectional
as increasingly aware medical and other health providers
refer patients for oral health care.
A NEW PRACTICE PARADIGM FOR DENTAL
CARE
Screening for Chronic Diseases
Safe, well-validated, and easy-to-use screening tools can be
applied in the oral health care setting for some prevalent and
important conditions such as DM, hepatitis C virus (HCV),
and HIV. Stratifying patients by risk factors such as self-
reported or measured medical conditions, tobacco use,
consumption of sugar-sweetened beverages, and personal
hygiene practices will help the oral health provider develop
individualized patient care plans and guide primary care in-
terventions. For example, a dental patient, who reports a
family history of diabetes, low physical activity, overweight,
and demonstrates gingival bleeding and multiple sites of deep
periodontal pocketing, would be a candidate for diabetes
screening and referral to a physician for follow-up diagnosis
and treatment.
It has been estimated that a single-year cost saving of $42.4
million for health care could be realized by early detection of
chronic diseases in the oral health care setting.
14
However,
further analysis of the impact of early detection on the cost
of care when considering the cost of patient education and
increased years of treatment is needed.
Diabetes Mellitus
It has been estimated that 29 million Americans have DM and
an additional 7.0 million remain undetected.
15
DM is a
recognized risk factor for periodontal disease, and the
treatment of periodontal disease may improve patients’
glycemic control.
16
There are a number of other oral
manifestations of diabetes including increased prevalence of
root caries, xerostomia, ‘Candida’infection, and burning
mouth syndrome. The many oral complications associated
with DM suggest that patients with undiagnosed or poorly
controlled diabetes may seek care from an oral health
provider.
Point-of-care testing for DM in a dental setting can identify a
significant percentage of patients with undiagnosed or poorly
managed dysglycemia.
17
Lalla et al developed a DM risk
identification protocol for dental settings that uses patient
self-report health history, periodontal examination data, and
HbA1c tests for high risk patients. This type of health
screening may have a significant public health impact through
improved chronic disease management.
18
Figure 1. Top 10 risk factors for health loss.
Source: Adapted from Institute for Health Metrics and Evaluation. The State of U.S. Health:
Innovations, Insights and Recommendations From the Global Burden of Disease Study. 2013.
THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
45 June 2016
VIRAL INFECTIONS
Human Immunodeficiency Virus
The use of highly active antiretroviral therapy has reduced
the prevalence of HIV-related oral lesions; however, oral
lesions remain an important clinical finding in patients with
poor medication adherence as well as those that are undi-
agnosed. Oropharyngeal candidiasis is a common infection
seen in people living with poorly managed HIV.
19
The
National Health Strategy for reducing the prevalence of
HIV includes early detection and improved medication
adherence. The US Preventive Service Task force has
recommended that HIV screenings be performed routinely
on all patients aged 13-64 years.
20
HIV screening using
oral fluids has been shown to successfully identify
undiagnosed HIV. Rapid HIV testing may use either blood
or oral fluid samples and can provide results in 5-
40 minutes.
20
Hepatitis C Virus
HCV is a major health burden and is associated with high
rates of morbidity and mortality. Furthermore, it has
become a major cause of chronic hepatitis, cirrhosis, and, in
some cases, hepatocellular carcinoma.
21
However, this
disease often remains underdiagnosed and, consequently,
undertreated.
22
It has been estimated that 3.9 million
Americans infected with HCV are unaware they are
infected, emphasizing the importance of developing new
opportunities for early detection.
22
The Centers for
Disease Control and Prevention (CDC) along with the
American Association for the Study of Liver Diseases
recommend screening for high-risk patients as well as all
people born between 1945 and 1965 as two-thirds of those
with HCV infection were born during that period.
22
Screening for HCV infection in individuals with no history
of liver disease or known liver abnormalities may identify
infected patients at earlier stages of disease before the
development of irreversible liver damage.
20
Ease of
screening has improved as a result of point-of-care rapid
HCV antibody tests approved by the Food and Drug
Administration; results can be obtained in 20-40 minutes
using capillary blood or oral fluids.
23
Human Papillomavirus
Human papillomaviruses (HPVs) are a large family of non-
enveloped DNA viruses primarily associated with cervical
cancers; however, evidence indicates that HPV is an inde-
pendent risk factor for oral-pharyngeal squamous cell car-
cinomas with HPV-16 and HPV-18, the most commonly
identified subtypes.
24
ThepresenceofHPVinoral-
pharyngeal squamous cell carcinomas has been shown to
modify therapeutic outcomes with HPV-positive tumors,
demonstrating higher survival rates than HPV-negative tu-
mors.
24
HPV-positive head and neck squamous cell
carcinomas (HN-SCCs) have been associated with males
that have histories of a high number of lifetime oral sexual
partners and marijuana use. HPV-negative HN-SCCs have
more frequently been associated with adults who have
histories of heavy tobacco use, alcohol consumption, and
poor oral hygiene.
25
The dental practice setting offers a
unique opportunity to raise public awareness of the risk
factors for HPV and HN-SCC through patient education
and routine HN-SCC screening during clinical examinations
for all patients.
24,26
HEALTH PROMOTION ACTIVITIES
Tobacco Cessation Counseling
Although less prevalent than in prior years, 29% of adults living
below the federal poverty level identified as current
smokers.
27
Tobacco use and alcohol consumption have been
associated more often with older adults than other adults.
28
Smoking is considered a risk factor for a wide range of
systemic conditions, and in the oral cavity it is a primary risk
factor for HN-SCC and periodontal disease.
15
The risk for
HN-SCC increases across all age groups and sexes with
longer duration, higher frequency, and cumulative exposure
to cigarette smoking.
28
Tobacco cessation is critical for reducing risks for poor
outcome of oral care including periodontal therapy and
implant failure. The US Department of Health and Human
Service Guidelines suggests that brief tobacco cessation
delivered in a variety of clinical settings increases quit attempts
and tobacco use abstinence.
29
Resources including online
information about tobacco cessation for dental professionals
are available online from the CDC, http://www.cdc.gov/
tobacco/campaign/tips/partners/health/dental/index.html.
30
Dietary Counseling
Obesity is associated with a number of morbid conditions
including DM, hypertension, and fatty liver disease. Recent
research suggests that the cumulative inflammatory burden
associated with periodontal disease and obesity may predict
the onset of metabolic syndrome, defined as having a com-
bination of 3 or more of the following: DM, hypertension,
elevated fasting plasma glucose, low low-density lipoprotein
cholesterol, or elevated triglycerides.
18
The prevalence of
obesity in the United States is on the rise, and it is
estimated that 33% of American adults aged 20 years or
older are obese.
31
More than 1 in 5 young adults are obese
with the rates tripling from 11% in 1995 to 37% in 2008.
2
Dental providers are well versed in providing messages
about reducing fermentable carbohydrates, and those
experienced in using the 5A’s for tobacco cessation
counseling might use a similar technique for the
management of obesity.
32
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Volume 16, Supplement 46
ADDITIONAL CONSIDERATION
Health Literacy
Inadequate health literacy has been associated with higher
mortality rates in older adults who may have less knowledge
about chronic disease and less self-management skills.
33
Low
health literacy in young adults has been identified as both a
significant barrier to enrolling in health coverage and higher
levels of illness.
34
Those with low literacy are usually at high
risk for oral diseases as oral health practices require skill
development, understanding concepts, and technique-
dependent behaviors.
35
Key to helping patients improve their health is increased
provider understanding of their own health literacy and the
need to change their communication practices.
36,37
Oral
Table 1. Comparison of patient care practice models.
Traditional oral health
practice
Integrated oral health
practice
Items included in medical
history
Items included in medical
history
Medical diagnosis Medical diagnosis
Medications presently
taking
Complete history of
disease, medications, and
medical visits
Physician name and
contact
Health Literacy
Assessment (formal or
observational)
Alcohol use Level of fear during oral
health visit
Tobacco use Alcohol use
Tobacco use, amount, time
of day, no. of quit attempts,
interest in quitting
Physician (MD) or nurse
practitioner (NP) name and
contact information
Access to electronic
medical health record
a
Oral health examination Oral health examination
Charting of existing dental
restorations
Charting of existing dental
restorations
Charting of needed dental
restorations
Charting of needed dental
restorations
Periodontal charting Periodontal charting
Screening for mucosal
disorders including oral and
pharyngeal cancer
Screening for mucosal
disorders including oral and
pharyngeal cancer
Prevention activities Prevention activities
Patient advised to quit
smoking and given print
literature
Tobacco cessation
counseling appointment with
Quit Line Referral
Oral health education HbA1c finger stick test
Blood pressure
Weight
Interactive patient health
education module provided
during each office visit
Referrals Referrals and collaboration
Paper report sent to
physician via regular mail
Report sent to physician
via encrypted email
Patient advised to contact
physician
a
Physician accesses dental
electronic health record
(continued )
Table 1. (continued)
Traditional oral health
practice
Integrated oral health
practice
a
Oral health professional
accesses medical electronic
health record
Patient advised and assisted
with MD or NP appointment
Patient advised and assisted
with registered dietician (RD)
appointment
Phone referral made to
tobacco quit line
Oral health treatment plan Oral health treatment plan
Quadrant scaling by dental
hygienist with patient
education
Quadrant scaling by dental
hygienist
Needed restorative
appointments scheduled
Needed restorative
appointments scheduled with
dentist
Implant therapy or
removable prosthesis
Implant therapy discussed
with patient but postponed
Four-month recall visit with
dental hygienist: perio
evaluation, patient asked
about tobacco use
Four-month recall visit with
dental hygienist, perio
evaluations, tobacco
cessation follow-up, medical
EHR reviewed
Patient health education
with dental hygienist
RD contacted, MD or NP
contacted as needed
a
For Practices Located within Medical Practice Facilities.
THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
47 June 2016
health providers can assess patients’health literacy infor-
mallybyobservingapatient’s interest in written documents,
thelengthoftimeusedtocompletehealthforms,and
more formal evaluations using health literacy assessment
tools.
37
THE INTEGRATED ORAL HEALTH PRACTICE
Health Information
An expanded health history would enable dental providers
to deliver patient-centered oral health care. Dental elec-
tronic health record (EHR) systems would ideally integrate
with medical EHRs (see Simmons article in this publication).
Patient’s history of disease, current symptoms and diag-
nosed illnesses, current medications, allergies, and all cur-
rent health care providers would be included in the
patient’s record. Patient’s weight and blood pressure would
be routinely measured and recorded. Health behaviors as
well as risk assessment for oral and systemic diseases would
be part of the dental health record. Determinants of health
such as health literacy, education, insurance coverage,
cultural norms, and patient’s fear of dental care may be
important considerations in this integrated model of care.
Finally, a comprehensive dental examination would be
completed including the traditional assessment of existing
dental caries, periodontal disease, and oral and head and
neck lesions. Communication with other members of pa-
tient’s health care team will need to become an important
part of the normal practice routine (see Table 1 and
Figure 2).
Restructured Dental Visit
In some instances, the integrated oral health practice may
require longer or multiple patient appointments and, in the
private dental office, will shift the distribution of activities. Each
initial patient visit would include an interview with the patient
or care providers to review the expanded medical and oral
health history, including their oral health concerns. Based on
the results of the oral examination and the health information
collected, the appropriate health screenings would be pro-
vided. An individualized care plan would be developed based
on health information, the oral examination, and health
screening. A patient’s care plan would include a dental
treatment plan, health education activities, provider referrals,
and follow-up care (see Figures 2 and 3).
Figure 2. Integrated oral health practice patient visit. Complete medical history: Personal history, family history, last medical
examination, medications, medical provider contacts, social service providers. Complete oral health history: last oral examination,
present oral health concerns, oral health behaviors, dental fears, health literacy, body mass index, hypertension. Oral health examination:
dentition, soft tissues, head and neck cancer screening, radiographs.
THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
Volume 16, Supplement 48
Figure 3. Sample case study.
Source: Adapted from case studies presented in Diabetes Mellitus and Oral Health: An Interprofessional Approac h (2014) p. 205-45. Lamster, Bittner, and Lorber.
THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
49 June 2016
Necessary Educational Changes
Treating dental patients from the perspective of general health
requires change in the dental and dental hygiene school
curricula. Although recent studies have identified many
overlaps in learning objectives and competencies between
medical and dental education, additional emphasis is needed
in primary health care for oral health providers.
12
Familiarity
with current information regarding the etiology, treatments,
symptoms, and oral implications of chronic diseases is
important to enable oral health professionals to provide
patient-specific care. Interprofessional education will prepare
all health care providers to function in an interdisciplinary
environment and develop comprehensive patient care plans.
Utilization of Technology
Digital support tools are becoming more widely available and
provide efficient ways of gathering the most comprehensive
patient information. Telecommunications and digital tech-
nologies have increased the ability of dentists and dental hy-
gienists to collaborate on the delivery of care in underserved
communities. Teledentistry provides for the sharing of infor-
mation and consultation on the management of patient’s oral
health needs, thereby increasing access to care.
13
Further, digital patient education tools can assist in providing
information in a format that is understandable and usable by
patients. Increased use of technology may enable efficient
time management and effective patient health promotion
efforts. A tobacco cessation decision support system incor-
porated into the dental EHR has been evaluated. Oral health
providers were required to assess 4 tobacco-related ques-
tions for self-identified smokers. These questions related to
the amount smoked, time of first cigarette, interest in quitting,
and number of past quit attempts This system increased to-
bacco cessation activities by dental professionals with residual
effects after the conclusion of the study.
38
CONCLUSION
Health promotion activities are increasingly recognized as an
integral component of patient care across all health pro-
fessions and are essential for patients living with chronic dis-
ease. Noncommunicable chronic diseases such as DM and
cardiovascular disease and chronic infectious diseases such as
HIV and HCV require coordinated care efforts over decades
of a patient’s life. Many oral and systemic diseases have
common risk factors such as tobacco use and poor diet. Early
disease detection and initiation of treatment combined with
lifestyle changes can contribute to a reduction in morbidity
and mortality from chronic diseases.
The proposed practice approach is conceptual, but there are
examples of both successful identification of chronic diseases
in the dental setting and the potential importance of these
health interventions. Lalla et al.
17
demonstrated that an
algorithm of 2 dental parameters and a finger stick HbA1c
is an effective method of identifying unrecognized
dysglycemia in at-risk patients. Sproat et al. examined dental
patients for hypertension and found 39% of the 144 patients
screened to have hypertension with 82% of these patients
previously undiagnosed.
39
Evidence of tobacco cessation
intervention by dental professionals concluded that these
tobacco cessation activities can increase tobacco abstinence
among both cigarette smokers and smokeless tobacco
users.
40
Further research is required to establish empirical
evidence of the feasibility and effectiveness of health
screening activities as part of routine oral health care.
ACKNOWLEDGMENTS
The authors thank Cynthia Rubiera for her support with
graphic designs and editing.
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THE JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE ANNUAL REPORT SERIES—DENTAL HYGIENE
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