PCPs ‘integral part’ of oral health care
Tooth decay, also known as dental caries, affects 2.4 billion individuals worldwide, according to WHO. In the United States, HHS’s Human Services Oral Health Coordinating Committee reported that has shown that more than 9 in 10 adults have dental caries.
Poor oral health has been linked to a wide range of medical conditions, including stroke, atherosclerosis and infections, as well as poor personal outcomes like absences from school and work, lower school grades and decreased work productivity, Jeff Hummel, MD, MPH, medical director for health care informatics at Comagine Health, told Healio Primary Care.
Excessive increases in caries-inducing oral bacteria can lead to a chain of events affecting the heart and gut, Rodrigo Lacruz, MSc, PhD, associate professor of basic science and craniofacial biology at NYU College of Dentistry, added.
“Think as teeth and the oral cavity as the portal to a healthy life. These bacteria can lead to inflammation of the gums and can place stresses on other organs in the body,” Lacruz told Healio Primary Care.
The American Dental Association (ADA) states on its website that one of the best ways to maintain proper oral health is by using fluoride-containing products. However, data show that many individuals are not getting enough fluoride.
The National Academies of Science, Engineering, and Medicine, formally known as The Institute of Medicine, states that primary care physicians, who are more commonly seen by patients than dentists, “are in a good position to provide basic oral health education,” but the integration of oral health care into primary care is limited.
In recognition of World Oral Health Day held annually each March, Healio Primary Care outlined current recommendations and guidelines on fluoride use that PCPs should be aware of, and asked experts to discuss ways that PCPs can overcome barriers that hinder the integration of oral health into primary care.
ADA, USPSTF recommendations
The recommended amount of fluoride that individuals need to maintain healthy teeth varies by age, according to the ADA. Regarding at-home dental care for children, the association recommends:
- children younger than 2 years should use 0.1 g fluoride-containing toothpaste or 0.1 mg fluoride; and
- children aged 2 to 6 years use about 0.25 g fluoride-containing toothpaste or 0.25 mg fluoride.
The U.S. Preventive Services Task Force states that current evidence is insufficient to weigh the benefits and harms of routine dental screening examinations among children younger than 5 years in primary care settings. Still, the task force recommends that PCPs:
- prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride (B grade recommendation); and
- apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B grade recommendation).
According to Lacruz, "too much fluoride can cause dental fluorosis — a discoloration of teeth, usually with opaque white marks, lines, or mottled enamel and poor mineralization."
In adults, the ADA recommends 0.09% fluoride mouth rinse at least weekly or 0.5% fluoride gel or toothpaste paste twice daily.
Tips for PCPs
In his white paper, Oral Health: An Essential Component of Primary Care, Hummel and colleagues provide several ways that PCPs can discuss oral health with their patients:
- ask about symptoms that may indicate oral disease (eg, pain or bleeding in the mouth) and factors that place patients at higher risk for oral disease (eg, smoking);
- look for signs that signify oral health risk or actual oral health disease (eg, cavities);
- decide on the most appropriate way to proceed (eg, recommending an intervention such as fluoride-based mouthwash or referring to a dentist); and
- document the findings.
The authors of another article published in the Journal of the American Medical Directors Association provide tips on broaching the subject of oral health with patients.
“[Conducting] a short interview with patients and caregivers on current oral health practices may help to assess the risk for rapid oral health deterioration,” the authors wrote. “The interview should be followed by an oral health assessment, using validated tools, for nondental health care providers.”
In assessing risk, the authors added that PCPs should pay special attention whether a patient’s history contains one or more of the “7D’s” — dementia, depression, dexterity, drugs, diabetes, demotivation and diet.
“Based on the interview, the physician should decide on necessary follow-up procedures, which may include oral health counseling and/or dental referral,” they wrote. “Oral health counseling should include advice on daily oral, mucosal and denture hygiene; denture maintenance; dietary advice; smoking cessation; limitation of harmful alcohol consumption; management of xerostomia; and frequent dental review.”
Sources of fluoride
Outside of dental products, tap water is another common source of fluoride, Lacruz told Healio Primary Care. He discussed the U.S. Public Health Service guidelines for community water fluoridation.
“Water is fluoridated in centralized water plants to about 0.7 mg of fluoride per liter,” he said. “This concentration of fluoride is healthy and helps prevent caries and tooth decay.”
Where the public water supply does not meet those standards, the ADA stated that “dietary fluoride supplements can be as effective in preventing tooth decay as water fluoridation.” Clinicians can prescribe these supplements in the form of tablets, drops or lozenges, according to Douglas K. Owens, MD, MS, USPSTF chair and general internist at the Veterans Affairs Palo Alto Health Care System.
Another source of fluoride is food. A U.S. Department of Agriculture chart published within a 2016 Materia Socio-Medica report states that foods with the highest concentrations of fluoride prior to preparation include blackfish, shrimp, clams, wine and green tea, which all have at least 1 mg/L of fluoride per serving. At the other end of the spectrum are milk, cream, bananas, tomatoes and eggs, all of which have less than 0.03 mg/L of fluoride per serving.
Barriers hinder implementation
Within the past 20 years, the surgeon general, National Academies of Science, Engineering and Medicine, and Health Resources and Services Administration have called for all health care providers to participate in oral health care.
“Oral health needs to be an integral part of primary care because the mouth is an integral part of the body,” Hummel said. “Prevention is an intervention that both primary care providers and dentists need to share.”
However, studies suggest that PCPs are hesitant to provide oral health care. In 2005, the Society of Teachers of Family Medicine Group on Oral Health published an oral health curriculum for family medicine, and the society’s residency review committee added oral health as a requirement for family medicine residencies in 2006. According to the Robert Graham Center’s 2018 report on the state of primary care, in 2017, more than one-quarter of PCPs were aged at least 60 years and more than half were aged at least 45 years, meaning many PCPs likely received training before the oral health curriculum and residency requirement was introduced.
In addition, the National Academies of Science, Engineering and Medicine cited survey results that showed only three-fourths of family medicine residency directors knew about the oral health requirement within the first 5 years of its introduction, and only about two-thirds of family medicine residency programs incorporated oral health content, with the most common training duration being 2 hours per year.
Other barriers to implementing oral health into primary care include a lack of interest, time and sufficient funding, according to studies in several journals, including the Journal of Family Medicine and Primary Care, BMJ Open and others.
Hummel said increasing resources such as nurses and medical assistants in primary care could eliminate those barriers.
“The best way to overcome the barriers listed above is to raise the percent of health care expenditures for primary care from the current 7% to around 15%, as is the case in countries with health care systems that have better outcomes at lower cost than the U.S., and to assure that increased spending goes to support multidisciplinary teams in primary care,” he said.
Richard D. Krugman, MD, first vice chancellor for health affairs for the University of Colorado at Anschutz Medical Campus in Aurora Colorado and chair of the committee that oversaw the National Academies of Science, Engineering and Medicine report, shared “successful” strategies that his institution used to improve uptake of oral health care in primary care.
“We specifically designed an interprofessional campus where students from each of the [medical and dental] schools would be together for many of their classroom activities,” he told Healio Primary Care. “We put into place a 2-year long interprofessional education curriculum so that the students from the different professions would be working with each other for the first few years.”
Krugman also indicated that “co-locating dental chairs within primary care clinics with a single [electronic health record] for patients that can be shared among all medical practitioners would [also] be ideal” for removing the barriers.
A Pediatrics article described one medical system’s approach to implementing routine fluoride varnish applications in pediatric primary care. The medical system:
- hired a registered dental hygienist in an alternative practice and partnered with the University of California at San Francisco to develop and help implement policies and training curriculum;
- educated and prompted providers and nurses to discuss recommendations with families during patient visits;
- developed educational brochures and posters; and
- reviewed charts and provided feedback to providers regularly.
According to the authors, the approach led to 95% of all children aged 1 to 5 years who were seen for wellness checkups to receive a fluoride varnish application and oral health education during their visit.
Such partnerships are critical to reversing the negative trends on oral health, according to the contributors to Oral Health: An Essential Component of Primary Care.
“Too little progress has been made in reconfiguring the health care delivery system to better meet our nation’s health needs,” they wrote. “Only by partnering together can we reduce burden of disease.” – by Janel Miller
American Dental Association. Clinical recommendations for use of professionally applied or prescription-strength, home-use topical fluoride agents for caries prevention in patients at elevated risk of developing caries. https://ebd.ada.org/~/media/EBD/Files/ADA_Evidence-based_Topical_Fluoride_Chairside_Guide.pdf?la=en. Accessed March 17, 2020.
American Dental Association. Fluoridation FAQs. https://www.ada.org/en/public-programs/advocating-for-the-public/fluoride-and-fluoridation/fluoridation-faq. Accessed March 17, 2020.
American Dental Association. Oral health topics. https://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-supplements. Accessed March 20, 2020.
FDI World Dental Association. Make a pledge for World Oral Health Day. https://www.fdiworlddental.org/news/20190905/make-a-pledge-for-world-oral-health-day-2020. Accessed March 16, 2020.
National Academies Press. Advancing oral health in America. https://www.hrsa.gov/sites/default/files/publichealth/clinical/oralhealth/advancingoralhealth.pdf. Accessed March 16, 2020.
Qualis Health. Oral Health: An Essential Component of Primary Care. http://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf. Accessed March 17, 2020.
Robert Graham Center. The state of primary care in the United States. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook.pdf. Accessed March 17, 2020.
WHO. Inadequate or excess fluoride. https://www.who.int/ipcs/assessment/public_health/fluoride/en/. Accessed March 16, 2020.
Disclosures: Lacruz reports no relevant financial disclosures. Healio Primary Care could not confirm Hummel’s, Klugman’s and Owens’ relevant financial disclosures at the time of publication.