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Oral Health Care in the Future: Expansion of the Scope of Dental Practice to Improve Health


Abstract and Figures

The health care environment in the U.S. is changing. The population is aging, the prevalence of non-communicable diseases (NCDs) is increasing, edentulism is decreasing, and periodontal infection/inflammation has been identified as a risk factor for NCDs. These trends offer an opportunity for oral health care providers to broaden the scope of traditional dental practice, specifically becoming more involved in the management of the general health of patients. This new practice paradigm will promote a closer integration with the larger health care system. This change is based on the realization that a healthy mouth is essential for a healthy life, including proper mastication, communication, esthetics, and comfort. Two types of primary care are proposed: screenings for medical conditions that are directly affected by oral disease (and may modify the provision of dental care), and a broader emphasis on prevention that focuses on lifestyle behaviors. Included in the former category are screenings for NCDs (e.g., the risk of cardiovascular disease and identification of patients with undiagnosed dysglycemia or poorly managed diabetes mellitus), as well as identification of infectious diseases, such as HIV or hepatitis C. Reducing the risk of disease can be accomplished by an emphasis on smoking cessation and dietary intake and the prevention of obesity. These activities will promote interprofessional health care education and practice. While change is always challenging, this new practice paradigm could improve both oral health and health outcomes of patients seen in the dental office. This article was written as part of the project "Advancing Dental Education in the 21st Century."
Content may be subject to copyright.
Noreen Myers-Wright
,and Ira B. Lamster
Editors 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
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 nations 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 patients life. Oral health professionals will be part of that care.
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 efcacy and
effectiveness of human immunodeciency 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 immunodeciency virus, have contributed to this concept.
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.
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
RDH, EdD, Department of Health Policy &
Management, Mailman School of Public
Health, Columbia University, New York,
DDS, MMSc, Department of Health Policy
& Management, Mailman School of Public
Health, Columbia University, New York,
Conict of interest: The authors have no actual or
potential conicts 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.
J Evid Base Dent Pract 2016:16S:
ª2016 Elsevier Inc. All rights reserved.
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 efcacy and effectiveness of human immunode-
ciency 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 nations 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 patientsoverall health. Health care dollars can be
used more efciently by incorporating relevant primary health
care activities into oral health care visits.
Population Trends
Older and young adults living with chronic diseases represent
2 segments of the population in the United States that require
particular attention.
It is estimated that the population of Americans aged
65 years or older will grow to 89 million by 2050.
adults are disproportionately affected by noncommunicable
chronic diseases, notably cardiovascular disease and diabetes
mellitus (DM).
Two of every 3 older Americans have
multiple chronic conditions, and treatment for this
population accounts for 66% of the countrys annual health
Furthermore, edentulism in the United States
and other developed countries has been falling during the
past 3 decades.
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.
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.
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 Childrens 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
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.
The Affordable Care Act has increased dental benets to
children and low-income adults through expanded
Medicaid programs.
Although the greatest increase in
dental benetshasbeenseeninchildren,anestimated
17.7 million adults have gained some dental benets.
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
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
Volume 16, Supplement 44
detection of disease need to occur in multiple sectors espe-
cially for at-risk populations.
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.
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).
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.
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.
Interprofessional Practice
The need to improve health care for underserved populations
has increased interest in redening oral health care practice
settings. There has been more public health support for
increasing oral health services in medical settings.
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 qualied health
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.
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.
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.
DM is a
recognized risk factor for periodontal disease, and the
treatment of periodontal disease may improve patients
glycemic control.
There are a number of other oral
manifestations of diabetes including increased prevalence of
root caries, xerostomia, Candidainfection, 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
Point-of-care testing for DM in a dental setting can identify a
signicant percentage of patients with undiagnosed or poorly
managed dysglycemia.
Lalla et al developed a DM risk
identication 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 signicant public health impact through
improved chronic disease management.
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.
45 June 2016
Human Immunodeciency Virus
The use of highly active antiretroviral therapy has reduced
the prevalence of HIV-related oral lesions; however, oral
lesions remain an important clinical nding 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.
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.
HIV screening using
oral uids has been shown to successfully identify
undiagnosed HIV. Rapid HIV testing may use either blood
or oral uid samples and can provide results in 5-
40 minutes.
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.
However, this
disease often remains underdiagnosed and, consequently,
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.
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.
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.
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 uids.
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
identied subtypes.
pharyngeal squamous cell carcinomas has been shown to
modify therapeutic outcomes with HPV-positive tumors,
demonstrating higher survival rates than HPV-negative tu-
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.
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.
Tobacco Cessation Counseling
Although less prevalent than in prior years, 29% of adults living
below the federal poverty level identied as current
Tobacco use and alcohol consumption have been
associated more often with older adults than other adults.
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.
The risk for
HN-SCC increases across all age groups and sexes with
longer duration, higher frequency, and cumulative exposure
to cigarette smoking.
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.
Resources including online
information about tobacco cessation for dental professionals
are available online from the CDC,
Dietary Counseling
Obesity is associated with a number of morbid conditions
including DM, hypertension, and fatty liver disease. Recent
research suggests that the cumulative inammatory burden
associated with periodontal disease and obesity may predict
the onset of metabolic syndrome, dened 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.
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.
More than 1 in 5 young adults are obese
with the rates tripling from 11% in 1995 to 37% in 2008.
Dental providers are well versed in providing messages
about reducing fermentable carbohydrates, and those
experienced in using the 5As for tobacco cessation
counseling might use a similar technique for the
management of obesity.
Volume 16, Supplement 46
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.
health literacy in young adults has been identied as both a
signicant barrier to enrolling in health coverage and higher
levels of illness.
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.
Key to helping patients improve their health is increased
provider understanding of their own health literacy and the
need to change their communication practices.
Table 1. Comparison of patient care practice models.
Traditional oral health
Integrated oral health
Items included in medical
Items included in medical
Medical diagnosis Medical diagnosis
Medications presently
Complete history of
disease, medications, and
medical visits
Physician name and
Health Literacy
Assessment (formal or
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
Oral health examination Oral health examination
Charting of existing dental
Charting of existing dental
Charting of needed dental
Charting of needed dental
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
Tobacco cessation
counseling appointment with
Quit Line Referral
Oral health education HbA1c nger stick test
Blood pressure
Interactive patient health
education module provided
during each ofce 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 accesses dental
electronic health record
(continued )
Table 1. (continued)
Traditional oral health
Integrated oral health
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)
Phone referral made to
tobacco quit line
Oral health treatment plan Oral health treatment plan
Quadrant scaling by dental
hygienist with patient
Quadrant scaling by dental
Needed restorative
appointments scheduled
Needed restorative
appointments scheduled with
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
For Practices Located within Medical Practice Facilities.
47 June 2016
health providers can assess patientshealth literacy infor-
mallybyobservingapatients interest in written documents,
more formal evaluations using health literacy assessment
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).
Patients history of disease, current symptoms and diag-
nosed illnesses, current medications, allergies, and all cur-
rent health care providers would be included in the
patients record. Patients 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 patients 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-
tients 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 ofce, 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 patients 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.
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.
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 identied many
overlaps in learning objectives and competencies between
medical and dental education, additional emphasis is needed
in primary health care for oral health providers.
with current information regarding the etiology, treatments,
symptoms, and oral implications of chronic diseases is
important to enable oral health professionals to provide
patient-specic 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 efcient 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 patients oral
health needs, thereby increasing access to care.
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 efcient
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-identied smokers. These questions related to
the amount smoked, time of rst 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.
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 patients 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 identication of chronic diseases
in the dental setting and the potential importance of these
health interventions. Lalla et al.
demonstrated that an
algorithm of 2 dental parameters and a nger 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.
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
Further research is required to establish empirical
evidence of the feasibility and effectiveness of health
screening activities as part of routine oral health care.
The authors thank Cynthia Rubiera for her support with
graphic designs and editing.
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... 14 Individuals diagnosed with diabetes are at an 86% increased risk of the development or progression of periodontal disease which further emphasizes the association between these disease processes. 14 The bidirectional association between periodontal disease and diabetes has been further implicated with periodontitis contributing to the progression of diabetes and its systemic complications through the interdependent action between hyperglycemia and the hyperinflammatory response in periodontal tissues. 15 complications from excess serum glucose, insulin dysfunction, and heightened inflammatory response. ...
... This expedited status allows for increased access to dental care and the potential to decrease the risk for oral health complications which include periodontal disease, tooth decay, burning mouth syndrome, xerostomia, oral candidiasis, salivary gland hypertrophy, and restoration failure. 13,14,19 Minimizing the delay in receiving comprehensive dental treatment also reduces the risk of developing potential systemic diabetes complications of insulin dysfunction, excess serum glucose, and heightened inflammatory response. 13 Limited research has addressed oral-systemic health literacy in patient populations in the United States. ...
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Purpose: This pilot project was implemented to minimize barriers in access to care, reduce the risk for oral health and systemic diabetes complications, and optimize the health outcomes for patients with diabetes seeking comprehensive dental treatment. Methods: The intervention group included patients with diabetes who participated in hemoglobin A1c (HbA1c) testing during their initial dental screening appointment. The participants whose HbA1c value was ≤ 9.0% were expedited into the scheduling queue for the next comprehensive examination appointment. Health literacy was assessed regarding patients' understanding of the connection between oral health and diabetes. Results: The mean number of days between screening and treatment plan development was decreased by 38.4%. Of the participants in the intervention group with an HbA1c value ≤ 9.0%, 44% rated their understanding of the connection between diabetes and gum disease as "poor", whereas 86% of the patients who were ineligible due to an HbA1c value ≥ 9.1% rated their understanding as "very good" or "excellent". Conclusions: Patients with diabetes will continue to benefit from this quality improvement project to minimize barriers to dental care and improve overall health outcomes as this intervention is adopted as a permanent practice change. The need has been highlighted for comprehensive education in practice settings concerning medical and dental collaboration, and patient awareness of the interrelationship between diabetes mellitus and oral disease. An increase in oral examinations, assessment of routine oral health behaviors, and referral to dental providers from the primary care setting is warranted.
... Curriculum revisions should be a transformative process that leads to substantive modifications that provide oral health professionals the ability to work in an integrated health system, collaborating with other health professionals and improving patient outcomes (12,13). The association between systemic and oral health is well-documented in literature (14)(15)(16). ...
... Jeffcoat et al. (16), in a retrospective analysis of linked medical and dental insurance records, reported that there was a statistically significant reduction in treatment cost for pregnant women who received treatment for their clinically diagnosed periodontal disease compared to those who were untreated or undertreated. Lamster and Myers-Wright (13), suggested that oral health practice was changing and that "oral healthcare providers need to be comfortable treating these older, medically complex patients, which includes an understanding of how chronic diseases affect a person's ability to tolerate dental care and the linkages between chronic disease and oral disease". Curriculum transformation must continue to train graduates to prevent, diagnose, and treat oral diseases and prepare them to contribute to the improvement of overall health (12). ...
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For several decades, health professions education has been transforming; pedagogical constructs such as active learning, recorded lectures, electronic assessment, asynchronous content delivery, and interprofessional education and practice. However, the typical oral health curriculum has need for further transformation to ensure graduates' ability to function in an integrated health system. There is significant literature outlining associations between oral health and overall health, therefore, it is paramount that oral health learners develop skills to collaborate in an integrated model. Satcher, in 2000, outlined the gravity of oral health inequities and the importance of oral health. He said, “Too little time is devoted to oral health and disease topics in the education of non-dental health professional.” However, on the contrary typical oral health curriculum provide knowledge acquisition of topics related to overall health but isn't specifically designed to guide integrated care. In order to increase integrated care, groups like the Interprofessional Education Collaborative (IPEC) have developed competencies for interprofessional education and collaborative practice that guides the training of health professionals. One way to improve integration is accreditation standards that guide transformation as well incorporate IPEC competencies. Having competencies is important to prepare learners to function in clinics like Kaiser Permanente's medical-dental integration model that rely upon teams and teamwork and clarity of roles and responsibilities. This manuscript outlines principle of oral health curriculum that facilitate graduates ability to work in an integrated health system and how that contributes to the improvement overall health of patients.
... Clinical reasoning is an essential component of health care professional practice [1,2]. It can be defined as a skill, process, or outcome [3], which enables clinicians to identify, collect and process information, determine diagnoses, and provide accurate decisions regarding treatment options [4][5][6]. Diagnostic errors can be minimized ...
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Background Health professionals are known to use various combinations of knowledge and skills, such as critical thinking, clinical reasoning, clinical judgment, problem-solving, and decision-making, in conducting clinical practice. Clinical reasoning development is influenced by knowledge and experience, the more knowledge and experience, the more sophisticated clinical reasoning will be. However, clinical reasoning research in dentistry shows varying results . Aims This study aims to observe the clinical reasoning pattern of undergraduate dental students when solving oral health problems, and their accordance with their knowledge acquisition. Material and methods This qualitative study employed the think-aloud method and the result was assessed through verbal protocol analyses. Five respondents from final year dental undergraduate students were agreed to participate. A unique hypothetical clinical scenario was used as a trigger. The audio data were transcribed, interpreted, and categorized as a clinical reasoning pattern; and the concept maps created were assessed by a Structure of Learning Outcomes (SOLO) taxonomy as knowledge acquisition. Results Observations on clinical reasoning patterns and the level of knowledge acquisition in five undergraduate dental students showed varying results. They applied clinical reasoning patterns according to their knowledge acquisition during didactical phase. Learners with inadequate knowledge relied on guessing, meanwhile learners with adequate knowledge applied more sophisticated reasoning pattern when solving problems. Conclusions Various problem-solving strategies were encountered in this study, which corresponded to the level of knowledge acquisition. Dental institutions must set minimum standards regarding the acquisition of conceptual knowledge accompanied by improvement of clinical reasoning skills, as well as refinement of knowledge and procedural skills.
... Interdisciplinary learning and reforms would aid a novel generation of dental professionals to tackle more problems as more elderly require preventive, interventive, and aesthetic dentalcare. Further, the increasing occurrence of noncommunicable chronic conditions needs dentalcare providers to be accustomed to the pathogenesis, complications, and management of these conditions, be cognizant of the relation between oral and systemic health, and dispensing care which will improve both oral and systemic health (18)(19)(20). Due to this, upcoming dentalcare providers need to take into consideration a host of measures which impact the way in which the selection, customization and prioritization of oral health services is carried out: the degree and intensity of oral disease, general wellbeing, and health education, timeline, and resources at hand. Moreover, certain individuals may need alternate settings for the provision of dental services, and care choices would need modifications depending on the overall health status and independence and mobility. ...
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As individuals age, physiologic alterations take place in the oral cavity, and are thought to be a regular component of the ageing process. However, pathological developments that are not harmless, and that need professional care, are frequently encountered. The line between physiological ageing and actual pathological changes is not clear in all cases. The wellbeing of the oral cavity can be compromised with the initiation of tooth loss, soft tissue lesions such as oral carcinoma, neglected grossly carious teeth, neglected severe periodontitis, and orofacial neuralgia. For adequate oral health to be retained in older ages, oral diseases must be prevented and/or treated with emphasis in younger ages. Proper self-management measures—like brushing of teeth with a fluoridated toothpaste, dental flossing, and consuming nutrient-dense and balanced meals which have less refined carbohydrate are crucial preventive practices to be incorporated in daily life by people of all ages which includes the elderly. Dental care professionals can play a major role in prevention of dental problems and avoidance of more damage of oral tissues in older people. Professional activities comprise head, neck, and intraoral assessment of teeth and surrounding tissues for presence of oral manifestations of systemic illnesses, oral neoplasms, carious teeth, periodontitis, and impaired function and esthetics. Other measures for prevention comprise prophylaxis, dental care guidance, fluoride varnish provision, and proper therapy via restorations and reconstructions. Since the effects of dental conditions accrue as time passes, the necessity for sooner establishment of a preventive routine in life is vital for healthy ageing intraorally. Further, dental care for the geriatric population initiates in the younger ages through a stress on management of oral health issues early on, and from that point through an elaborate preventive plan moving ahead.
... Oral health care services have become increasingly complex, which initially focused on teeth and their supporting tissues, but now have to consider systemic conditions, their management and oral manifestations. 1,2 These conditions have an impact on the way dentists are trained, because it is related to the appropriateness, quality and efficiency of the treatment and preventive delivery services available to the population. 3 This has substantially changed the goals of dental education, with greater emphasis on the importance of clinical reasoning for competent dentists. ...
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Background: Critical thinking (CT) and clinical reasoning (CR), along with adequate clinical knowledge, are crucial components of thinking in clinical practice. This study aimed to assess, compare and analyze the relationship between CT skills, CR skills, and cognitive abilities in undergraduate (UDS) and clinical dental students (CDS).Methods: This natural experimental study was conducted using the quantitative descriptive-analytic methods with a cross-sectional design. Thirty UDS and sixty-one CDS were selected purposively. Demographic and academic data were obtained through questionnaires. The Critical Thinking Tool (CriTT) was used to measure CT skills, and CR skills were measured by the Diagnostic Thinking Inventory (DTI). Knowledge acquisition was measured through the Cognitive Ability Test (CAT), which is a set of multiple-choice questions specifically developed and validated for this study. The statistical differences between them were analyzed by one-way ANOVA, and their relationship was tested by correlation matrix analyses.Results: There were no differences in CriTT measurements between groups. The overall DTI score and subscale 2 (Structure of memory) showed significant differences between groups, as did the overall CAT score and all clinical science subscales. Correlation matrix analyses revealed CR skills were related to CT skills, while the cognitive abilities or knowledge acquisition were related to CR skills.Conclusion: Results showed the CR skills and cognitive abilities of clinical dental students are superior to undergraduate dental students. Generally, the results indicated the more skilled students are in critical thinking, the better are their clinical reasoning skills. Better cognitive abilities tended to improve clinical reasoning skills.
The California Dental Association and the University of the Pacific, Arthur A. Dugoni School of Dentistry convened a gathering of experts and stakeholders to conduct a strengths, weaknesses, opportunities and threats (SWOT) analysis with regard to oral health needs, dental education and workforce, financial and reimbursement structures and legislative opportunities as they relate to improving oral health for older Californians. The consensus was that change must begin in dental education, with relevant and innovative clinical experiences in geriatric care, including interprofessional education (IPE) and interprofessional practice (IPP) with appropriately trained faculty. Incentives for faculty and professional development are needed to develop role models who can appropriately manage the diverse and unique oral health care needs of older adults as part of an interprofessional team. Value-based care and novel dental benefit and reimbursement mechanisms are needed to support many older Californians who are lacking financial resources for care. Innovation in care delivery models to meet the needs of those who are most vulnerable and removed from opportunities for care are also needed to improve access to care and health outcomes across California. The entire health care team must be engaged. Oral health care must be perceived and practiced as an integral component of primary health care to achieve optimal health outcomes.
The importance of active adult learning methods and critical thinking skills is appreciated in dental and OMFS residency training. Known barriers to research are finding time in the curriculum and funding needed for research experiences. These barriers have inspired many institutions to design programs to provide research opportunities, but they can be expensive and of minimal interest to those not planning academic careers. During OMFS residency training, the primary emphasis is on mastery of all aspects of surgical care. Strong partnerships between PhD researchers and OMFS clinical investigators, formed to advance the field, can also have an impact on trainees' involvement in research and their understanding of rigorous evidence-based principles of clinical care.
Objectives: To understand patients' comfort with health risk assessments (HRAs) and patient and dentist factors associated with the provision of HRAs. Methods: In this cross-sectional study, 857 patients seen by 30 dental practitioners in the United States National Dental Practice-Based Research Network reported their comfort receiving HRA for six risk factors (tobacco use, alcohol use, dietary sugar intake, human immunodeficiency virus risks, human papillomavirus risks and existing medical conditions) and whether they discussed any of the risk factors during their visits. Multi-level logistic models were used to examine the impacts of patient, practitioner, practice characteristics on the (1) number of risk factors patients were comfortable discussing and (2) number of risk factors assessed in the current dental visit. Results: Only a small percentage (4%) of patients reported being uncomfortable receiving any HRA during their dental visits. However, over half of the patients (53%) reported that they did not receive any HRAs during the current visit. In the regression analyses, patients who were older, male and from the suburban were more likely to be comfortable with more HRAs. Dentists were more likely to provide HRA if they were younger, not non-Hispanic white, less likely to feel that providing HRAs was beyond their scope of practice, yet more likely to feel occasional discomfort in providing HRA. Conclusions: Interventions should focus on reducing dental practitioner perception that conducting HRAs is beyond their scope of practice and standardizing screening assessments for multiple risk factors.
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Background: Health professionals in carrying out clinical practice are known to use various combinations of knowledge and skills, such as critical thinking, clinical reasoning, clinical judgment, problem-solving, and decision-making. Most of these skills are acquired during undergraduate education, clinical training and honed through professional practice. Aims: This study aims to observe the clinical reasoning patterns of undergraduate dental students when solving oral health problems from hypothetical cases. Furthermore, assessing their structure of knowledge through a concept map defined by a SOLO taxonomy. Material and method: This qualitative study employed the think-aloud method and the result was assessed through verbal protocol analyses. Five respondents from the final year dental undergraduate student were agreed to participate. A unique hypothetical clinical scenario was used as a trigger. The audio data were transcribed, interpreted, and categorized as a clinical reasoning pattern; and the concept maps created were assessed by SOLO Taxonomy as knowledge structures. Result: A hypothetico-deductive, an elaborated hypothetico-deductive, and an inductive or deductive reasoning model were found to be applied by the participants when solving problems. The reasoning used reflects the knowledge possessed. The variability of the structure of knowledge assessed by the concept map reflected the acquired knowledge during the pedagogical stage, which in turn have an effect on clinical reasoning patterns. Conclusion: It concluded that undergraduate dental student applies clinical reasoning patterns according to their level of knowledge structure. It is suggested to improve dental education, whether curriculum, teaching and learning methods, instructional methods, or dental environment, which emphasize critical thinking and clinical reasoning in order to provide optimal dental health services.
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Oral cancer is the sixth most common malignancy in the world. Oral cancer is of major concern in Southeast Asia primarily because of the prevalent oral habits of betel quid chewing, smoking, and alcohol consumption. Despite recent advances in cancer diagnoses and therapies, the 5.year survival rate of oral cancer patients has remained at a dismal 50% in the last few decades. This paper is an overview of the various etiological agents and risk factors implicated in the development of oral cancer.
Purpose: Reach of individuals at risk for cardiovascular disease (CVD) constitutes a major determinant of the population impact of preventive effort. This study compares three proactive recruitment strategies regarding their reach of individuals with CVD risk factors. Method: Individuals aged 40-65 years were invited to a two-stage cardio-preventive program including an on-site health screening and a cardiovascular examination program (CEP) using face-to-face recruitment in general practices (n = 671), job centers (n = 1049), and mail invitations from health insurance (n = 894). The recruitment strategies were compared regarding the following: (1) participation rate; (2) participants' characteristics, i.e., socio-demographics, self-reported health, and CVD risk factors (smoking, physical activity, fruit/vegetable consumption, body mass index, blood pressure, high-density lipoprotein, triglycerides, and glycated hemoglobin); and (3) participation factors, i.e., differences between participants and non-participants. Results: Screening participation rates were 56.0, 32.8, and 23.5 % for the general practices, the job centers, and the health insurance, respectively. Among eligible individuals for the CEP, respectively, 80.3, 65.5, and 96.1 % participated in the CEP. Job center clients showed the lowest socio-economic status and the most adverse CVD risk pattern. Being female predicted screening participation across all strategies (OR = 1.45, 95 % CI 1.07-1.98; OR = 1.34, 95 % CI 1.04-1.74; OR = 1.62, 95 % CI 1.16-2.27). Age predicted screening participation only within health insurance (OR = 1.04, 95 % CI 1.01-1.06). Within the general practices and the job centers, CEP participants were less likely to be smokers than non-participants (OR = 0.49, 95 % CI 0.26-0.94; OR = 0.42, 95 % CI 0.20-0.89). Conclusion: The recruitment in general practices yielded the highest reach. However, job centers may be useful to reduce health inequalities induced by social gradient.
Objectives: To review the contribution of the Nurses' Health Studies (NHS and NHS II) in addressing hypotheses regarding risk factors for and consequences of obesity. Methods: Narrative review of the publications of the NHS and NHS II between 1976 and 2016. Results: Long-term NHS research has shown that weight gain and being overweight or obese are important risk factors for type 2 diabetes, cardiovascular diseases, certain types of cancers, and premature death. The cohorts have elucidated the role of dietary and lifestyle factors in obesity, especially sugar-sweetened beverages, poor diet quality, physical inactivity, prolonged screen time, short sleep duration or shift work, and built environment characteristics. Genome-wide association and gene-lifestyle interaction studies have shown that genetic factors predispose individuals to obesity but that such susceptibility can be attenuated by healthy lifestyle choices. This research has contributed to evolving clinical and public health guidelines on the importance of limiting weight gain through healthy dietary and lifestyle behaviors. Conclusions: The NHS cohorts have contributed to our understanding of the risk factors for and consequences of obesity and made a lasting impact on clinical and public health guidelines on obesity prevention. (Am J Public Health. Published online ahead of print July 26, 2016: e1-e7. doi:10.2105/AJPH.2016.303326).
There is an ongoing US HIV epidemic, with 1.2 million persons living with HIV/AIDS.¹ An estimated 14% of infected individuals are unaware of their HIV infection.² In 2009, there were 45 000 new transmissions.³ Although new HIV infections are declining, there is an increase among young men who have sex with men.² Preventing HIV in high-risk groups requires outreach using social and sexual network methods and new prevention interventions.²,4 Screening for HIV in health care settings, however, remains important for identifying patients who are unaware of their HIV infection.
Importance: The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicare and Medicaid in 1965. The law implemented comprehensive reforms designed to improve the accessibility, affordability, and quality of health care. Objectives: To review the factors influencing the decision to pursue health reform, summarize evidence on the effects of the law to date, recommend actions that could improve the health care system, and identify general lessons for public policy from the Affordable Care Act. Evidence: Analysis of publicly available data, data obtained from government agencies, and published research findings. The period examined extends from 1963 to early 2016. Findings: The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. Since the Affordable Care Act became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, primarily because of the law's reforms. Research has documented accompanying improvements in access to care (for example, an estimated reduction in the share of nonelderly adults unable to afford care of 5.5 percentage points), financial security (for example, an estimated reduction in debts sent to collection of $600-$1000 per person gaining Medicaid coverage), and health (for example, an estimated reduction in the share of nonelderly adults reporting fair or poor health of 3.4 percentage points). The law has also begun the process of transforming health care payment systems, with an estimated 30% of traditional Medicare payments now flowing through alternative payment models like bundled payments or accountable care organizations. These and related reforms have contributed to a sustained period of slow growth in per-enrollee health care spending and improvements in health care quality. Despite this progress, major opportunities to improve the health care system remain. Conclusions and relevance: Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation's most complex challenges.
Purpose Studies reported that the mandibular cortical width (MCW) measured on dental panoramic radiographs (DPRs) was significantly correlated with bone mineral density. However, MCW is not a perfect index by itself, and studies suggest the added utility of mandibular cortical index (MCI). In this study, we propose a method for computerized estimation of mandibular cortical degree (MCD), a new continuous measure of MCI, for osteoporotic risk assessment. Methods The mandibular contour was automatically segmented using an active contour model. The regions of interest near mental foramen were extracted for MCW and MCD determination. The MCW was measured on the basis of residue-line detection results and pixel profiles. Image features including texture features based on gray-level co-occurrence matrices were determined. The MCD were estimated using support vector regression (SVR). The SVR was trained using previously collected 99 DPRs, including 26 osteoporotic cases, by a computed radiography system. The proposed scheme was tested using 99 DPRs obtained by a photon-counting system with data of bone mineral density at distal forearm. The number of osteoporotic, osteopenic, and control cases were 12, 18, and 69 cases, respectively. The subjective MCD by a dental radiologist was employed for training and evaluation. Results The correlation coefficients with the subjective MCD were −0.549 for MCW alone, 0.609 for the MCD by the features without MCW, and 0.617 for the MCD by the features and MCW. The correlation coefficients with the BMD were 0.619, −0.608, and −0.670, respectively. The areas under the receiver operating characteristic curves for detecting osteoporotic cases were 0.830, 0.884, and 0.901, respectively, whereas those for detecting high-risk cases were 0.835, 0.833, and 0.880, respectively. Conclusions In conclusion, our scheme may have a potential to identify asymptomatic osteoporotic and osteopenic patients through dental examinations.
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 effectiveness 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.
Large-scale hepatitis C screening is required to prevent further spread of the infection, improve access to care in the context of new HCV drug regimens without interferon alpha and subsequently reduce the risk of long-term complications of chronic liver disease. Rapid diagnostic tests (RDTs) represent an attractive alternative to enzyme immunoassay using blood from venipuncture. The aim of the present study was to prospectively assess the clinical performance of CE-marked RDTs detecting anti-HCV antibodies in fingerstick capillary whole blood and/or oral fluid.
Background and objective: It is estimated that 3.6% and 13.6% of the Danish population suffer from undiagnosed type 2 diabetes and pre-diabetes, respectively. Periodontitis is an established complication to diabetes. Identification of individuals with diabetes and pre-diabetes is important to reduce diabetes-related complications including periodontitis. The objective of the study was to identify individuals with undiagnosed diabetes or pre-diabetes among individuals attending a dental setting for diagnosis and treatment. Methods: 291 adults with no history of diabetes were included in the study (periodontitis patients n=245, non-periodontitis control individuals n=46). Participants answered questionnaires concerning general health, including family history of diabetes. BMI, waist circumference, fat percentage, and glycated hemoglobin level (HbA1c) were recorded chair-side. Periodontal examination was performed and radiographic bone level measured. All individuals were informed about the HbA1c result, and referred to their physician if HbA1c levels were above those of the American Diabetes Association guidelines. Results: A total of 9 (3.1%) and 79 (27.1%) subjects were identified with HbA1c levels corresponding to guideline values for diabetes and pre-diabetes respectively. Higher proportions of patients with undiagnosed diabetes and pre-diabetes were observed in the periodontitis group (32.7%) than in the control group (17.4%) (p=0.054). Identification of diabetes and pre-diabetes based on a diagnosis of periodontitis yielded a sensitivity of 0.91 and specificity of 0.19. Conclusion: This study confirms that individuals with undiagnosed diabetes and pre-diabetes can be identified in the dental office by chair-side HbA1c recordings. Routine measurement of HbA1c in dental offices, eventually restricted to risk subjects, may help identification of individuals with diabetes and pre-diabetes at early stages of disease, which may prevent future complications.