The Role of Academic Institutions in Fostering Interprofessional Educational Models
Romesh P. Nalliah, DDS, MS; Lisa A. Thompson, DMD; Lee A. Wellman; and Brian J. Swann, DDS, MPH
Dentistry is much broader than the conditions it treats. In 2014, the Harvard School of Dental Medicine convened a leadership forum, “Put Your Money Where Your Mouth Is: The Economic Imperative of Oral Health.” Based on the goals of that initiative to advocate for an integrated healthcare system, the authors have presented pertinent information from two major research projects and two major clinical programs, which, collectively, aim to bring oral health into primary care and raise the awareness of the connections between oral health and systemic health.
Dentistry is much broader than the conditions it treats, such as dental caries, pulpal disease, and periodontal disease. A growing body of evidence links oral and systemic health, indicating a crucial need to keep both in balance; myriad examples exist. A diagnosis of diabetes should prompt the provision of patient education regarding the connection between poor oral health and diabetic status.1 In addition, any patient taking a new medication should be advised about possible oral health consequences; many common drugs increase the likelihood for stomatitis and caries.2 If a patient is identified as having depression, the physician should make a referral to a dentist because of the association with poor oral health outcomes.3 These are just a few instances that demonstrate how oral health impacts the well-being of humans.
Multimorbidity is becoming more common as the general population ages.4 This growing phenomenon causes confusion among clinicians relying on the convenient evidence-based guidelines developed through simplistic evaluations of a single condition.5 Oral health is closely linked. In 2008 in the United States, 50,658 hospitalizations were primarily due to dental problems.6 Research has found 18.5% of these hospitalizations were associated with one comorbidity and 6.6% had three or more comorbidities.6
While science awaits the gold standard, researchers are using randomized controlled trials to build evidence that oral health and general health are linked. This gives rise to a multitude of questions. Can society afford to wait for the conclusion of these studies? Is it even possible to conduct a clinical trial that proves oral health is important for general health? Is it ethical to withhold oral health from your control group?
In 2014, the Harvard School of Dental Medicine (HSDM) convened a leadership forum, “Put Your Money Where Your Mouth Is: The Economic Imperative of Oral Health.” Based on the goals of that initiative to advocate for an integrated health system, the authors have presented pertinent information from two major research projects and two major clinical programs, which, collectively, aim to bring oral health into primary care and raise the awareness of the connections between oral health and systemic health.
Harvard’s two-pronged approach aims to: (1) build the evidence platform with innovative research while (2) concurrently delivering collaborative, holistic care (including oral health) in demonstrative projects. Two such research studies and two projects are described below.
Cardiac Valve Surgeries
In the first research study presented in this discussion, Allareddy et al7 performed a retrospective look at cardiac valve surgeries in the United States in which the authors compared patients who had no additional diagnosis of gingival or periodontal disease with those who did. Data from 2004 to 2010 on patients who had cardiac valve surgery were selected from the National (Nationwide) Inpatient Sample (NIS) database. The impact of gingivitis and periodontitis on hospital charges, length of stay, and infectious complications was examined in these patients.
The study revealed that outcomes included increases in median hospital charges ($175,418 with gingivitis or periodontitis versus $149,353 without) and median length of stay (14 days with gingivitis or periodontitis versus 8 days without). This remained true even after adjusting for the effect of confounding factors. In addition, those patients with gingivitis or periodontitis had significantly higher odds for having bacterial infections when compared with those who do not have dental disease.
While this study cannot be used to infer causative links, it does add to the growing body of knowledge about the systemic impacts of poor oral health. Strong consideration must be given for patients to have a thorough oral health evaluation prior to surgery because the research demonstrates that patients with periodontal disease incur significantly higher hospital charges.
The second project, also a research study by Allareddy et al,8 was a retrospective analysis of stem-cell transplants (SCTs) in the United States. Patients who underwent this procedure, with a concurrent diagnosis of gingival or periodontal disease, were compared with those who had no dental disease. The NIS database (2004 to 2010) was used, and all patients who had SCTs were selected. The outcomes evaluated were hospital charges, length of stay, and occurrence of infectious complications which included septicemia, bacteremia, mycoses, and postoperative pneumonia.
Whites with gingivitis or periodontitis comprised 53.1% of those undergoing SCTs (compared with 73.3% of those without). The mean charge for those with gingivitis or periodontitis was $397,518; it was $270,943 for those without. The mean length of stay for those with gingivitis or periodontitis was 34.4 days; it was 26.3 days for those without. The infectious complication rate among those with gingivitis/periodontitis was 52.1% (compared with 32.8% of those without). If a patient had gingivitis or periodontitis and a SCT, he or she was more likely to have infectious complications. Each infectious complication studied occurred more often in those with gingivitis or periodontitis when compared with those without.
Effective Clinical Programs
Elderly Patients in Primary Care
Greater than two-thirds of older adults have multiple chronic medical conditions, and two-thirds of U.S. healthcare dollars are spent on treating chronic diseases.9 In addition, Medicare does not provide dental benefits, and funding for dental benefits from state Medicaid programs is limited.10 Only those with private dental insurance are increasing utilization of dental services.10
With this in mind, a clinical program was created to address the oral health needs of older adults in a primary-care setting. In collaboration with the Beth Israel Deaconess Medical Center’s Multidisciplinary Geriatric Training Program for Physicians, Dentists, and Behavioral and Mental Health Professionals and Element Care (PACE11 program), the geriatric dentistry fellowship at the HSDM participates in a portable dental clinic at a PACE (Participants of All-Inclusive Care for the Elderly) program in Lynn, Massachusetts.
Patients are seen first by the primary care team, and a care plan is subsequently developed for each participant. Every care plan addresses acute and chronic health issues and develops interventions to address each condition. In addition to other services, all participants are offered oral health care and initially scheduled with the public health dental hygienist (PHDH) who provides oral cancer screenings, oral hygiene instructions, cleanings, and fluoride treatment on-site. The PHDH triages the patients and alerts the medical team and dentist of the oral health needs of the participants. Following the visit with the PHDH, participants are scheduled with the dental team for comprehensive, on-site oral healthcare.
The design of a PACE primary-care setting, with nurses, physicians, dentists, physical therapists, and social workers, care coordinators, and transportation employees working side by side in the same facility allows for all health professionals to interact directly, to communicate effectively, and to support one another in delivering optimal healthcare in a patient-centered model.
Group Visit Model
Early intervention could have a significant impact on healthcare costs in the United States. The cost burden of diabetes is estimated to be $245 billion,12 and the total economic burden of undiagnosed illness in the diabetic population reached $6.5 billion,13 impacting 86 million people. In a recent study, significant cost savings (between $1,600 and $2,600 per diabetic patient) were reported when they had a dental home. On average, patients with dental homes visit dentists more frequently than their medical doctors.14
One way to reach more patients is the group-visit model. Edward B. Noffsinger, PhD, wanted to build on that concept by developing a care-delivery model that would give patients more, not less.15 He determined that a medical specialist could increase access by seeing and treating 12 to 15 people in one group with the help of two nurses and facilitator. One unique derivative is that peer learning in group visits has proven to be extremely beneficial because of the great value that patients place on the opinions of their peers.
Group visit models have been implemented in the oral health department at the Cambridge Health Alliance and are being shared throughout the various disciplines such as infants/toddlers, denture patients, prenatal patients, and new patient orientation examinations.
Most recently, oral physicians were invited to address existing diabetic groups to discuss the oral risk factors that impact diabetes and other systemic conditions. The oral physician concept integrates primary health with dentistry—this model is now becoming the new standard for healthcare.16 General practice residents and predoctoral students worked with primary care physicians to develop and implement an oral health curriculum. An oral examination was conducted on each patient, and the group received oral hygiene instructions. The health team progressively educated the group about the relevance of oral disease and how the patient and provider, working together, can reduce its impact.
Existing research has shown that a physician’s knowledge about oral health is limited,17 and a large proportion of hospital visits for oral health complaints are inappropriately managed.18 Moreover, a great deal of evidence supports the assertion that patients with dental problems regularly present to hospitals with basic dental complaints. In 2012, only 1,820 dentists worked in U.S. hospitals;19 this represents about 1.2% of all dentists nationwide. Clearly, the hospital team needs to understand and be able to manage oral health complaints. Moreover, evidence from the two studies7,8 mentioned above suggests that hospitalized patients may benefit from having an oral health evaluation (and necessary treatment) before a medical procedure. Hospitals should also have the expertise and resources to be able to render dental services as needed. This doesn’t necessarily mean every hospital needs to employ a dentist, but hospitals should minimally have collaborative relationships with local dentists to deliver care (or mobile dental care) to hospitalized patients who require it.
The HSDM research and programs presented offer support for integrated healthcare. The study results show that the presence of gingival and periodontal conditions is associated with higher hospital charges, longer hospital stays, and higher odds for developing infectious complications. These findings also highlight the need for interdisciplinary collaborative care in hospital settings.
We recommend cost–benefit analyses be conducted at individual health centers and hospital protocols be changed to include a standardized oral health screening for every hospitalized patient. Training a nurse or medical assistant to perform such a screening is inexpensive, and our studies show that treating a single patient with periodontal disease before a SCT could save almost $130,000. Similar gains are seen for cardiac valve surgery; our team continues to study various other surgical procedures. Clearly, there is a large potential benefit to the patient and the institution.
Our research continues to draw connections between the mouth and body. Oral health providers are often an overlooked resource, and in the context of their significant medical training, dentists remain an underutilized part of the healthcare workforce.16 The opportunity for the dentist or oral physician to have a positive impact on overall health is significant.
Although structural and geographic limitations may inhibit true interprofessional collaborations such as PACE, cross training physicians and other health professionals about oral health is essential. It provides greater opportunities to educate the public about the need for healthy dentition. Improved health literacy may be a catalyst to motivate patients to take greater responsibility for their health; thereby decreasing healthcare costs. We can no longer afford anything less than a collaborative team approach to reducing and preventing disease.
About the Authors
Romesh P. Nalliah, DDS, MS
Clinical Associate Professor and Director
Pre-Doctoral Clinical Education, Cariology, Restorative Sciences, and Endodontics School of Dentistry
University of Michigan
Ann Arbor, Michigan
Lisa A. Thompson, DMD
Oral Health Policy and Epidemiology
Harvard School of Dental Medicine
Lee A. Wellman
Any Dental Detail
Brian J. Swann, DDS, MPH
Instructor in Oral Health Policy and Epidemiology
Harvard School of Dental Medicine
Chief of Oral Health
Cambridge Health Alliance
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