AAP Voices Blog

Oral Health, the Medical Home, and You

Several years ago a colleague took an interest in expanding our medical home to include oral health. My initial reaction was… “This will break me.” It just felt overwhelming to be asked to take on something else: applying fluoride varnish in the office after receiving training on how to integrate this into our visits. I kept wondering how I would manage to complete this additional task. Who would help me with the squirming toddler? How long would this take? So many questions and concerns. But how, as the medical home champion, could I not champion this new and much-needed initiative?

General pediatricians cover so many different topics in a routine well child exam that it can often feel overwhelming. We assess our patients’ diets, sleep, development, social circumstances, and evaluate them for depression and anxiety, to name a few of the issues “in our lane.” Count oral health among them. Although we have received minimal training in medical school and residency, we are usually the first member of the frontline healthcare team able to address it. We educate families on the importance of oral health, we screen for oral conditions such as caries, and offer preventive care and connection to dental care in the community.

In our local area, finding a pediatric dentist who accepts Medicaid can be very difficult. And when families secure an appointment, it is often months in the future. For patients whose caries are so severe that treatment in the operating room under general anesthesia is required, securing a date our hospital is very complicated. Access to these slots is extremely limited. Patients with special health care needs, autism, intellectual disability, and congenital heart disease need access to the pediatric dentists who are experienced in the care of CSHCN.

So, how could I not get on board? These are just some of the stark disparities in access to oral health care faced by pediatric patients. I saw no alternative but to embrace the integration of oral health into our medical home.

“Today our medical home has implemented and standardized oral health as an integral part of patient care. …Here's the good news! Practically speaking, this likely has added one minute to a visit – no more than that. It is a minute well spent when we consider the impact across the lifespan of a child, and then an adult, and what having poor oral health entails.”

Today our medical home has implemented and standardized oral health as an integral part of patient care. General pediatricians and trainees apply fluoride varnish at all well care visits for patients 6 months through age 5. EMR notes include a templated section for oral health to prompt assessment of how parents brush teeth, their daily routines, and how recently they have seen a dentist. This results in a quick conversation that leads to fluoride application for patients who have not seen a dentist in the last 3-6 months. Finally, we have standardized order sets in the EMR for referral to dental providers at our medical center.

Here's the good news! Practically speaking, this likely has added one minute to a visit – no more than that. It is a minute well spent when we consider the impact across the lifespan of a child, and then an adult, and what having poor oral health entails. In doing so, we are playing a critically important role in preventing caries – the leading disease in children – before it starts.

Our next challenge was to address the limited access to regular dental care, both at our medical center and in the community. Many of our CSHCN are unable to access care that they can only receive with academic dental professionals at the children’s hospital. We needed to strengthen our partnership with them to identify ways to more efficiently connect those children with special needs to care internally at our medical center. Simultaneously, we needed to develop a different approach for referrals to dental care for those children without special health care needs.

To address the pernicious problem of limited access to dental checkups, our medical home team decided to branch out beyond the home and into the neighborhood. We met with our dental colleagues to discuss the access issues faced in our practices and theirs. After listening to each other and understanding the needs of both providers and patients, we set some goals to accomplish together. These included an escalation “chat” in our EMR directly from the pediatrician or nurse care managers who work only with medically complex children, allowing them to secure dental appointments in a more timely manner. For families, we jointly developed a resource page of general pediatric dental practices in the local area that accepted Medicaid. This is easily generated in the EMR and populates our patients’ after-visit summary in English and Spanish. The resulting model increases capacity at our medical center for those patients who cannot safely and comprehensively receive dental care outside of a medical center, while we connect families of children with need for routine dental care to local vetted dental practices.

I hope I have encouraged you that you too can integrate oral health into your medical home. We are key players in ensuring we address the oral health of our patients and the best approach is to find the one that works for you, your team and your patients. We can all be champions of oral health for kids!

Additional Resources:

• The National Resource Center for Family/Patient-Centered Medical Home
• American Academy of Pediatrics, How should I set up my practice to include oral health?
• American Academy of Pediatrics, Campaign for Dental Health