Perception and Utilization of Oral Screenings and Fluoride Application in Medical Offices Following the Michigan Caries Prevention Program Training

Introduction

Interprofessional collaboration has been defined as the process of developing and maintaining effective interprofessional working relationships with learners, practitioners, patients, clients, families, and communities with the goal of enabling optimal health outcomes.¹ In 2000, the United States (US) Surgeon General’s Report, Oral Health in America, highlighted the potential collaboration of all health care professions to improve oral health.² Ten years later, the World Health Organization (WHO) published the “Framework for Action on Interprofessional Education and Collaborative Practice” in order to promote interdisciplinary team-work for health care providers, as well as policy makers.³ More recently, the US Department of Health and Human Services Health Resources and Services Administration (HRSA) issued “Integration of Oral Health and Primary Practice” as a way to advocate for increasing oral health proficiency in primary care physicians, underscoring the need to address oral health in medical care.⁴

The Affordable Care Act (ACA) was signed into law in 2010 as a means to make healthcare coverage affordable to all. In addition to promoting affordability, the ACA has served as motivation for the implementation of interprofessional collaboration and education in health care.⁵ Not only is interprofessional collaboration seen as the most efficient path to patient-centered care, it also allows patients to receive optimal health care through integrated clinical networks in an affordable manner, a primary goal of the ACA. Furthermore, the ACA has supported the medical-dental integration (MDI) model of care, with the goal of intentionally connecting these services to improve access to care.⁶ This model also provides an innovative setting for dental hygienists to be employed as in-office advocates for oral health.⁷ By implementing interprofessional workforce models, providers can collaborate and provide services that improve patients’ overall healthcare outcomes, leading to increased levels of patient and provider satisfaction.^8,9

Despite efforts to improve oral health for Americans, vulnerable populations, particularly low-income children, the elderly, and ethnic minorities, still face challenges accessing preventive oral health services.^9,10 Although oral health-related diseases are preventable, low-income children face multiple barriers accessing care, including affordability, shortages of dentist providers for public-insured populations, and dependence on caregivers.^10,11,12 According to the National Health and Nutrition Examination Survey (NHANES) 2009-2010 data, 14% of children aged 3-5 years had untreated dental decay.¹³ Additionally, untreated dental caries was significantly higher in children aged 3-5 and 6-9 from low-income families as compared to cohorts living above the poverty level.¹³ According to a 2011 Institute of Medicine report, over four million children did not receive necessary dental care because their families could not afford it.^10,14 Interprofessional collaboration with other health professionals, such as medical providers, may help to address the oral health crisis affecting these vulnerable populations.¹⁵

Healthy People 2020 acknowledged the lack of access to oral health care as a public health concern and identifies two areas of need specific to children and adolescents, reduce the proportion of children and adolescents with dental caries or untreated decay in their primary or permanent teeth.”¹⁶ These priorities emphasized the need for improvement in preventive oral health services for children, as well as better access to care. The American Dental Association recommends that a child’s first dental visit take place at the time of the eruption of the first tooth or around six months of age 5 while the American Academy of Pediatrics, recommends that parents take their child to see a pediatrician at least six times in their first year of life.¹⁷ When these guidances are followed, a pediatrician will see a child much more frequently than a general dentist during the first year of life.^8,17,18,19 These early pediatric visits are crucial to a child’s development, and if proper oral education and caries prevention strategies are also provided, early childhood caries rates have the potential to decrease.^17,18 Pediatricians have the potential to address early childhood caries (ECC) incidence in their pediatric patients by learning how to perform oral screenings and apply fluoride varnish.^10,18

Research indicates that pediatricians are willing and eager to provide oral health services to their patients, but challenges exist^18,19,20,21 with lack of dental insurance and/or inability to pay for care being the most common barrier.²⁰ Interestingly, only about a third of respondents reported lack of professional training as a barrier.²⁰ Lewis et al. investigated barriers primary care physicians face and found that lack of oral health knowledge was a significant barrier as well as insufficient time, space and staffing for varnish application, in addition to the belief that the procedure should remain in the scope of a dental professional. Physicians reposted experiencing difficulty referring certain groups, such as uninsured and Medicaid patients, to a dentist.²¹ Additional barriers to fluoride application cited in a study by Nelson et al. included staff not agreeing to implement recommendations, limited time during patient visits, uncertain reimbursement opportunities, as well as parents opinions on the importance of oral health.²²

The Michigan Caries Prevention Program (MCPP) was created in 2014 by the Altarum Institute, in collaboration with the University of Michigan School of Dentistry, Delta Dental Michigan, and the Michigan Department of Health and Human Services. This program aimed to reduce the burden of childhood dental disease in the state of Michigan by offering training programs to implement preventive oral health services during well-child visits.²³ The Michigan Caries Program provided training on oral health screenings, oral health risk assessments, and fluoride varnish application to primary care physician offices all over the state of Michigan who accept Medicaid, from 2015 to 2017.²³ A total of 2,783 medical providers (physicians and nurse practitioners), received training via the Smiles for Life curriculum. The MCPP utilized a multi-faceted approach which included oral hygiene services, fluoride varnish application, parent education, and dental referral.²⁴

In a study conducted by Fontana et al., the intial implementaiton of the MCPP was assessed in two pilot locations by determining the barriers to adoption of services, as well as factors influencing successful outcomes.²⁴ The results demonstrated that participants felt more comfortable applying fluoride varnish following the training (78% compared to 54%).²⁴ In regards to barriers, “lack of patient/provider acceptance” was most commonly cited.²⁴ Additional barriers included “inadequate program monitoring and support,” “lack of expertise,” “time,” “integrating procedure into work flow,” and “reimbursement.”²⁴ Fontana et al. found that the availability of an “oral health champion” was crucial in order to overcome barriers and long-term sustainability.²⁴ The role of the champion was to promote the adoption of fluoride varnish on a regular basis, and engage participants in problem-solving and quality-improvement stratgies.²⁴

While some outcomes from the MCPP have been reported previously by Fontana et al., it is unclear which oral health services have been implemented post training and the impact of the program on the participants. The purpose of this study was to elicit feedback from the participants of the MCPP and determine which oral health services were implemented post-training, identify implementation barriers and assess provider comfort levels in performing oral screenings and fluoride applications.