MEDICAL AND DENTAL INTEGRATED PREVENTIVE VISITS AT A COMMUNITY HEALTH CENTER ASHLEY POPEJOY, DDS, MS

MEDICAL AND DENTAL INTEGRATED PREVENTIVE VISITS AT A COMMUNITY HEALTH CENTER ASHLEY POPEJOY, DDS, MS

WHO ARE YOU? Originally from Branson, Missouri BA Molecular Biology from William Jewell College DDS from University of Missouri- Kansas City Certificate in Pediatric Dentistry from University of Illinois-Chicago MS in Oral Sciences from University of Illinois-Chicago Diplomate of the American Board of Pediatric Dentistry Associate Director of Pediatric Dentistry for NYU-Langone Hospital AEPD- Missouri Director of Pediatric Dentistry at Jordan Valley Community Health Center

WHY INTEGRATION? Patient-Centered Overcoming access-to-care issues Reinforcement of education Inter-relationship of medical/dental disease Emphasis on preventive care Early identification of at-risk children The average infant will visit a pediatrician 16 times in their first year Only 2% of children have visited a dentist by the age of 2 (despite AAPD recommendation for dental home by age 1 ) Children under the age of 2 as a group visit a medical professional more often by 190x compared to a dental professional American Academy of Pediatrics. Profile of Pediatric Visits. 2010.

WHY INTEGRATION? 1000 # OR cases Age 6+ 13% Age 2 13% 800 600 400 Age 5 21% Age 3 25% 200 0 Age 4 28%

Transportation Medical/Dental Phobia Pre-existing Medical Conditions Barriers to Care Financial Communication Employment/School Schedules

41% of the population of Greene County, Missouri lives at or under 200% FPL 40% of live births in Greene County are born to mothers as Medicaid participants Niezgoda, R and C. Goddard. State of the Community s Health Executive Summary: Greene County, Missouri.

8 Pediatric Dental Residents 1 full-time attending 5 part-time attendings 6 FTE Pediatric medical providers Pediatric Dental 61 average patient visits/day Pediatrics 60 average patient visits/day

THE PILOT Identification Communication Examination Care coordinator evaluates schedule for potential integrated patients Inclusion: under age 3, well-child visit/wic Nurse contacts pediatric dental attending via phone Communicates room, age, and gender of child needing dental exam Dedicated open bay for integrated WIC exams Pediatric dental resident comes to medical exam room/wic open bay in between dental patients Performs knee-to-knee exam, toothbrush prophy, fluoride varnish application, anticipatory guidance and schedules recall examination

American Academy of Pediatric Dentistry. Reference Manual. Guideline on Infant Oral Health Care. 2015-2016. 37(6): 146-50. ANTICIPATORY GUIDANCE Dental/oral development Non-nutritive sucking habits (thumb/finger sucking and pacifier use) Most children will spontaneous cease sucking habits by age 2 Positive reinforcement negative reinforcement habit appliance Dietary counseling Beverage containers and types Breastfeeding (WHO vs AAP recommendations) Oral hygiene instructions Arguably, toothbrush prophy with demonstration is the most clinically valuable guidance a parent can receive from these exams Trauma prevention Car seats Electrical cords Pacifier size Avulsion instructions Fluoride exposure Toothpaste amounts Supplementation? Teething No Orajel/Ambesol No evidence that drooling=teething Caries Risk Assessment

1400 1200 # of Oral Evaluations Under 3 Years 1000 800 600 400 1301 1130 695 200 0 2016-2017 2015-2016 2014-2015

SUCCESSES 75% increase in children seen by a pediatric provider for a dental exam under the age of 3 Addition of an organization-wide integration committee Inter-professional education opportunities Overcoming barriers to care for some families Preventive education for families and pregnant women Addition of walk-in Adult New Patient examinations

AREAS FOR IMPROVEMENT Assisting with resisters Communication tools Greater involvement of optometry and behavioral health Addition of family practice No Child Left Behind

# of Encounters in Pediatric Dental 27% growth

KEY CONSIDERATIONS IDENTIFICATION Clear inclusion criteria Staffing to visit EVERY patient for screening? Documentation- who and when? Resisting complacency- need a champion to revisit at staff meetings and throughout the day COMMUNICATION Need 100% fail-safe EXAMINATION Difficulties of balancing with busy, efficient schedules Timing- immunizations? Medical providers running behind?

EVIDENCE-BASED INTERVENTIONS H. Hernegea, et al., 2017: Interprofessional education, collaborative practice, geographic proximity F. Ramos-Gomez, et al., 2017: Integrated curriculum for AEPD, partnership with WIC/Head Start N. Sengupta, et al., 2017: Coordinated referral process, fl- varnish in pediatric WCC visits P.A. Braun and A. Cusick, 2016: fl- varnish in WCC visits, use of telehealth ***J. Bernstein, et al., 2016: Facilitators included an upperlevel administration with the vision to see the value of integration, designated team leaders, and champions ***

WHAT S NEXT? Interventional pilots to involve medical professional education Silver diamine fluoride education for general dentists, pediatric dentists, and medical providers in the area Involvement of Women s Health in integrated visits Continuation of behavioral health evaluation during dental examinations (coordinated referrals to BHC or Parents as Teachers)

REFERENCES 1. American Academy of Pediatrics. Profile of Pediatric Visits. 2010. 2. Niezgoda, R and C. Goddard. State of the Community s Health Executive Summary: Greene County, Missouri. 2004. 3. American Academy of Pediatric Dentistry. Reference Manual. Guideline on Infant Oral Health Care. 2015-2016. 37(6): 146-50. 4. Harnegea, H., et al. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open. 2017: 7:e016078. doi: 10.1136/bmjopen-2017-016078. 5. Ramos-Gomez, F, H Askaryar, C Garell, and J Ogren. Pioneering and interprofessionl pediatric dentistry programs aimed at reducing oral health disparities. Front Public Health. 2017: 5:207. doi: 10.3389/fpubh.2017.00207. ecollection 2017. 6. Sengupta, N., S. Nanavati, M Cercola, and L Simon. Oral health integration into a pediatric practice and coordination of referrals in a colocated dental home at a federally qualified health center. Am J Public Health. 2017: 107(10):1627-1629. 7. Braun, PA, and A Cusick. Collabroation between medical providers and dental hygienists in pediatric health care. J Evid Based Dent Pract. 2016: 16 Suppl:59-67. 8. Bernstein, J., et al. Integration of oral health into the well-child visit at Federally Qualified Health Centers: Study of 6 clinics, August 2014-March 2015. Prev Chronic Dis. 2016: 13:E58.