Pediatric dentist Ray Stewart, DMD, MS, explores the reasons so many toddlers have cavities before their first dental visit, the condition’s impact on physical health, and longstanding barriers to fixing the problem. His antidotal plan emphasizes interprofessional education and collaboration, as well as preventive care, and he clarifies risk factors to help pediatricians identify patients needing referral.
mm. It's a pleasure to join all of you today, um, to talk a little bit about a subject that I've been very much interested in throughout my career. Um, you can probably tell by the gray hair here that that's uh, that's been been awhile. As a matter of fact, my residents sometimes, I think that I was uh, starting my pediatric dental career when the dinosaurs were still walking the earth. So I have been around a while and, and throughout my career I've really been focused on and uh, and, and very much interested in trying to get a closer integration between medicine and dentistry. Perhaps a better title of this would have been oral health care integration at UCSF because that's what we're talking about oral health. I think in most people that agree now is an integral part of, of overall health and you really can't separate um, oral health from from general health. There are a few objectives that I'd like to uh outline today. Um, we're gonna talk a little bit about the pediatric oral health challenges that face all of us as health care providers in California. We're going to identify why the pediatrician as a primary care provider has a role at very definitive and important role in pediatric oral health. We're going to talk about and try to identify the benefits of inter professional training and oral health between pediatricians and dentists and describe a little bit about the efforts that we are making here at UCSF toward a better medical dental integration. Um It probably comes as no surprise to anybody on on this webinar that early childhood carries is the most common disease of childhood. Um It's a disease which is virtually 100% preventable Um nationally, it results in over 520 million Medicaid dollars every year spent for er visits alone. Um it isn't an infectious and transmissible disease that is mediated by several as producing bacteria. Um It results in over 51 million hours of lost school hours per year and by estimate at the Surgeon General's Office. And it is estimated that it results in over $6 billion dollars of lost productivity from days uh of work lost by parents taking their kids in for emergency dental care and to put it in a little closer to home in a little uh better perspective, we currently are doing approximately 800 plus pediatric general anesthesia cases per month in the Berry alone And that is just at three service centers that are operating in North Bay and East Bay. It does not count no. Close 50-70 cases that we do here at Benioff Children's Hospital in Mission Bay. And it does not count countless other general anesthesia cases that are done in office in pediatric dental offices around the, around the state and around the Bay Area. As a, as a matter of fact, there are probably more general anesthesia cases done collectively in pediatric dental offices, then there are all together. So it's a very, very sizable phenomena in taking care of these young kids who are not able to tolerate procedures done in the regular dental office under normal dental circumstances that require general anesthesia for advanced behavior management. So the challenge we have is that early childhood carries has reached epidemic proportions. And that's not a recent occurrence. By the way here in California, more than half of the Children have already experienced decay by the time they go to kindergarten. And, and Over 17% of kids in that age group have never seen a dentist. 80% of the dental carries here in California occur in 20% of the population. As you might imagine. It's the uh it's the low income uh immigrant uh less educated population. Um That that actually uh has the greatest number of problems when it comes to early childhood carries. It's also an interesting figure that over 50% of California's Children, which is over five million now are enrolled in the Medicaid programs and have historically have poor access to oral health care. Some interesting other statistics are that In California, more than one half of the er visits for Children in the age category 0-6 are for dental reasons for dental emergencies. And only about 35% of kids in that same age group have received a preventive dental visit in that first year. So it's a major problem and it's one that's not getting any better. Um Over the years I've been doing pediatric dentistry now for well actually, uh this is my 50th year um in the specialty. And I can tell you that the epidemic of early childhood cherries Has not abated one bit. As a matter of fact, it has probably increased to twice the proportions that it was back in the 1970s and 1980s. Dentistry cannot solve this problem by itself. Oral health is part of or all overall health and must be a focus for all oral health care for all health care providers and organizations. And the main purpose of my of my presentation today is to convince all of you who are primary care pediatricians out there to get involved and help us try to ameliorate this go on going. And and really critical problem for kids in our society. Another problem that we face is that We have a problem of a story of two silos. Medicine, dentists and dentistry have traditionally operated in two separate silos and medicine, not so much in terms of integrated uh integration between the medical specialties and primary care and tertiary care. But in dentistry there is a silo that has been around for years and again, hasn't really succumbed to or changed with all of the changes that have that have occurred in health care, administration and funding over this past couple of decades. So, given the rising costs and growing recognition of evidence based link between oral health and general health, there's a growing need to break these silos down and that's what my presentation is all about today. The silo effect um is such that the dental profession absolutely cannot and has not solved this problem of access to care and having enough providers to satisfy the the actually dismal health status of Children as well as adults in our society. Yeah, it's absolutely essential that we must connect the body with the mouth. It's very clear that that the oral cavity is a sentinel of of many, many other oral general health conditions and oral health is absolutely a an integral part of general health for everyone. We have a unique opportunity in pediatric medicine and pediatric dentistry to actually play a role in and actively reduce if not completely eliminate these silos, pediatric medicine and pediatric dentistry shared several factors that kind of bring us together. And actually, I believe that that uh, that primary care providers in pediatric dentistry in pediatric medicine find it far easier to communicate and to develop inter professional relationships. Then perhaps other areas of dentistry and medicine have been able to do. Um Both both of us serve as primary care providers in our, in our respective specialties. Both of us provide health care services beginning in infancy and early childhood. With the first dental visit now recognized by both medicine and pediatric dentistry as being at one year of age, I can tell you that that has not been an ever present um uh milestone er and ever and ever present recommendation. Um I was involved in and wrote an article in pediatrics at just about uh the millennium in about 2001, where we we not only started the oral health section in the American Academy of Pediatrics, but also petition them to have the one year visit B. B. The the standard of care within their period audacity schedule. Prior to that time, age three was what pediatricians most of the time recommended as the time of the first dental visit. And we were able to convince them with a lot of evidence based Uh data that by three years of age for many kids, especially these Children that are uh in the uh in in the underprivileged and um and and Medicaid populations by the time they reach age three they are so far over the waterfall. And so have such horrendous uh dental health and oral health that it's way too late. So fortunately. And and uh the the academy saw the method in our and and the viability of our recommendations. And now the one your dental visit is is standard for you folks. And and it's really made a huge difference in our ability to see these kids. We both embrace a culture of prevention and we are both trained in a combined atmosphere of hospital as well as out patient services. There are a number of inhibiting factors however, that have led to the less than rapid and less than um, mm embrace by both pediatric medicine and pediatric dentistry. Um, and that's primarily in that dentistry has remained pretty much a cottage industry. Um, pediatric medicine, you guys have worked in an environment where the little, um, uh, the little private practice or solo practice is almost non existent anymore and you guys are constantly involved uh with multiple hundreds of employees and providers and big health networks and that sort of thing. Whereas pediatric dentists still primarily work in small networks with small offices that maybe have in a large office, 20-30 employees and providers more likely it's a maybe a couple of dentists and half a dozen dental assistants in front office people that are providing care uh in in kind of the, the um, the average uh down practice in this country in pediatric medicine, you work within a system that is accustomed to and and very dependent on sharing of electronic medical records. Whereas pediatric dentistry, again in their little silo and in their little mom and pop shops. Um and in in in locations other than academic. University medical center based systems work primarily from a proprietary electronic medical system that does not integrate well or at all with other dental or medical EMR systems. Most pediatric young practices operating environment depending on the procedure based or surgical model rather than a medical model for compensation. Um, the the value based care that that is very typical of the managed care systems that us pediatric primary care physicians work under uh simply does not exist in dentistry. There are a few examples of geographic managed care in dentistry in California, none of which has been very successful. And all have been criticized for actually having a very poor record in getting patients served and seen on a regular basis. Some of the other barriers uh in addition to the lack of electronic systems that permit integrated patient health records are that historically there has been a very poor um uh huh embrace embracement of inter professional education. Um It's it's unusual when you find medical schools and dental schools who actually have um have curriculums that combine uh dental students and dental residents in the in the in the medical school and medical residents and medical students in the dental schools. We've actually made some inroads here at UCSF in the last few years and we'll talk a little bit about that later in my presentation. Mhm. Inter professional education is not been traditionally a part of residency or medical student curriculums. Yeah, part of the reason for that is that there is not only a great deal of competition for time in the curriculums, but there's been really no funding or institutional support in most places for medical dental integration and then last but not least is the time and workflow challenges that exists in introducing oral health care that uh, into primary care physician offices. Your workflow is so jam packed with all of the requirements that you guys have to on your well baby visits and that sort of thing. That to introduce an additional thing like uh like carries risk assessments and uh and fluoride varnish applications and that sort of things has has been a real challenge. So medical dental integrate integration or probably more properly oral health integration is a problem that is begging for a solution. And I'm going to talk to you a little bit about today about some of the the trials and some of the efforts that we have made to come up with a solution, hopefully some of which may be applicable to your practices and you're the systems that you work in. There's really no disagreement at all among both professionals as well as as as other stakeholders, that greater medical dental collaboration has a positive influence on patient care systems and health outcomes. In a uh survey that was done by Identity quest, which is one of the larger dental insurance uh companies in the country who and many of the states throughout the nation are the administrators of their Medicaid. Dental um surveys Uh found that 93% of dentists, 86% of physicians, 82% of employers And 98% of administrators thought that it would be to everyone's advantage, both the system as well as the patients. If there was more close integration of the two and virtually everyone agrees that there are better health outcomes by addressing oral health as part of general health and overall health we feel and and I think uh in looking at the literature on on medical dental uh integration, There are four major areas that most people agree need to be addressed and solutions found for if we're to make any progress in this field. First of all, most everyone agrees that there needs to be expanded in a professional education. There needs to be more opportunities for dental students to take part in in uh in well patient exams and well child exams in the medical school. And likewise, we have developed an opportunity for residents and medical students to join us here in our pediatric residency clinics doing uh need any exams applying fluoride varnishes and learning how to do risk assessments. Early carries risk assessments at periodic well, child visits and early referral of high and moderate risk infants would probably be the largest step forward that any of us could make in terms of identifying these Children at an early stage of development. Many times even before they have their first Primary tooth emerged at 7-8 months of age, it is possible using certain well developed criteria to identify these Children and or families that are high risk for early childhood carries and other dental disease. Also the if we could um implement and have the pediatricians and there um uh and there staff routinely apply fluoride varnish at well child visits. We feel that this would also in addition to early child, the early curious risk assessments at well, child visits would be a major major hurdle that we have negotiated in terms of getting these kids in early and identified uh for early prevention and intervention. Yeah. And last but not least, the development of a seamless referral system to to a dental home. And um and that's also going to be require a close alignment and and the ability to have electronic medical record systems on both sides, both on the dental side and the um and the medicine side to be able to to facilitate these seamless referrals. I so often, as a matter of fact, just this last week had a colleague of mine, many of who you may you may be familiar with. Uh dr Susan fisher Owens, who's a pediatrician here in the CSS system and a big proponent of oral health and medical dental integration. I got a call from Susan saying that the providers at at the general hospital here in SAn Francisco, we're having difficulty reaching our um our scheduling staff to refer patients from general down here. And um it's it's even here in in a in a in a center in an environment where we probably have the greatest possibilities and and and resources to be able to facilitate developing a seamless referral system. We have yet to get to the point that it that it is seamless. Um it's also been very well documented that access to pediatricians trained in oral health risk assessment significantly reduces the disease burden of childhood carries in states and in institutions where pediatricians have had the opportunity to be trained in, in oral health risk assessment and in the vagaries of doing an infant oral exam and applying fluoride garnish. The populations that they serve have measurably better health outcomes when it comes to oral health. The US preventive services Task Force recommends that fluoride varnish be applied by primary care providers. My guess is that many of you on this call are already uh doing fluoride varnish applications at your well child visits. And if you are, I commend you for it. If you aren't, I would hope that um maybe we can maybe we can help you to do the inter professional training or to do some of the staff training to help you implement this in your practices. The American Academy of Pediatrics Resonant recommends that primary care pediatricians are familiar with. The management and prevention of dental carries. Again I. PE or in a professional education and last but not least, US pediatricians are probably in the best position of all of your medical colleagues to be able to put a dance in the early childhood jerry's burden with appropriate risk assessment referral in florida applications. The problem is is that many of you have maybe been trained in in environments or in institutions or in situations where you have not had the the training or the option to be able to expose yourself to those sorts of things that would make you comfortable at implementing this within your practices. Primary care pediatricians are without a doubt in the best position to identify infants and toddlers who are high risk for poor oral health and the early onset of early childhood carries. Um You guys um can and should help the uh you do you see patients for several visits before they ever get to the dentist for a an introductory or an infant oral health exam. You're you're seeing kids ah by by virtue of your period, a city scheduled, You're seeing them 10 times, but by the time they reach age too, they're very, very fortunate if they've gotten to see the dentist sometime between age one and 2. And I would say that Of all patients out there, probably less than 10 or 15% of Children are now being seen by by age one for their first dental visit in a professional education is going to be the key um to to facilitating this. Uh It can improve competencies both from nurse practitioners, midwives and dental and medical students and it's a very, it really doesn't impose a great deal of time to introduce these aspects into the curriculum. And as I pointed out, research suggests that oral health training more positively influences pediatricians when training includes is includes exposure to local dentists. Um in that residents do very, very well in adopting oral health practices into their into their workflow if they've been exposed to it during training. So access to pediatricians trained in oral health risk assessments significantly reduced to the disease burden. We've already talked about the task force that recommends fluoride varnish by primary care providers and the recommendations that pediatricians should be familiar with um with early early intervention and early identification. Most pediatricians have have at least been exposed to are are familiar with oral health risk assessment tools and um we um we can make these tools available and are perfectly willing to arrange to come out and do uh sessions with your staff's or with with your with your practices for lunch and learn types of things to introduce this phenomenon, if this is something that you'd like to follow through this. So where do we go from here? And can medical dinner immigration work Here are some of the things that we're doing here at UCSF to try and facilitate and have medical dental integration ingrained in our culture. Beginning this next july, our pediatric general residents will now have the opportunity to do an MPH program during their residency here with us. It'll be integrated into our three year residency program where UCSF pediatric dental residents will will do not only the the MPH program in affiliation at sent with SAn Jose state, but they will also be doing um early intervention and transitioning uh within the outreaches, outreaches and the and the affiliated practices that we have with several, several federally qualified health centers around the Bay Area. We are making a very focused effort to transition to a preventive early intervention approach rather than the old surgical approach where, regardless of what age the child was. If they had a cavity dated lesion On a one or more teeth, they were scheduled for restorative procedure. Whether that required general anesthesia or conscious sedation or could be done in the chair. We've been trained for all of our careers that if you see a hole there, it has to be filled. Well, we've come to realize that without education of the parents and the Children and without without modifying their dietary habits and their home cure habits simply filling these holes. Doesn't do a bit of good. These kids come back Uh six months or a year later and they have additional teeth uh, and additional capitation and greater disease. So with aims to reduce the number of Children that we are needing to treat under general anesthesia, especially Children under age three. In this last four or five years, we have adopted the use of silver die amine fluoride as an early intervention practice. And we're doing everything we can to treat these early curious allegiance. These early these early white lesions as well as capitated lesions using silver timing fluoride that carries these kids through for many months, often now up to three and four years. That what was severe decay at the time has been arrested. And essentially, uh these teeth don't require restoration other than for cosmetic reasons if their parents decide that they can't go around with these black looking teeth when they start school. We have now developed electives for pediatric medical residents to rotate through our pediatric dental clinics. And we have we have learning modules for both pediatric dentists and dental public health residents led by Susan Fisher owns on medical Dental integration. Okay. Mhm. We are well positioned in pediatric dentistry here. We each of one of our faculty members are an integral part of the teams um within our bending off Children's Hospital systems here in Mission Bay and at Oakland Children's Hospital, where we are are full members of and and participate in the cranial facial team. We are members of the bone marrow transplant team and participate in uh pre procedure evaluation and treatment of active, curious solutions before these Children undergo their uh their bone marrow transplants, same with hematology and oncology clinics where integral members of that team as well as cardiology and cardiac surgery evaluations and treatment of these kids. Prior to uh there's uh their surgical intervention. We also operate too. Um school based programs one at the tenderloin school here in SAn Francisco, and we are now beginning to develop a partnership with the pediatrics folks at SAn Francisco General Hospital in providing oral health care in addition to the pediatric primary care of the Children at the Mission Education Center here in san Francisco. We've recently expanded our pediatric young residency training programs to new to new federally qualified 100 Health Center sites, which in july of this year, we will be adding um faculty and rotations at Petaluma Health Center in Rohnert Park and the new La Clinica de Lara Della Rossa Facility in Vallejo, Pediatric dental and dental public health residents, uh being supported by the hearse, a grant that we were funded for this past year. And for the next five years, these residents will be engaging in quality improvement projects and medical dental integration projects at all of our federally qualified center sites as part of their uh masters in Public health program or they're done public health residencies. We have also been integrating behavioural health, uh teaming up with UCSF department of psychiatry here and our pediatric Donald group through a special program for Children with autism spectrum disorder and other neuro developmental disorders. We started that program uh about six months ago and we're seeing patients uh one day a month. We're now up to do two days a month where we have a behavioral uh behavior specialist from psychiatry that teams up with our residents and faculty providing desensitization. Uh and um and and oral health care for kids with autism spectrum. We're now doing, we're now up to two days a week and have full schedules within that clinic. So we're definitely trying to to expand our medical dental integration beyond what we were. Um The as far as clinical training, those the pediatric, the medical dental residents and dental students come to our clinics and learn need any pediatric dental exams, fluoride varnish application and carries risk assessment. The need any position is a great way to do infant oral exams and to provide fluoride garnish. Um And the carries risk assessment again, I think is the most important thing that we can have you as our as our partners in trying to achieve optimum oral health and kids learning how to do a carries risk assessment and being able to assign these kids to a low moderate or high again, uh Dental health and risk assessment. Risk factors that modify the treatment planning and would modify the need for a referral from your practices involved medical history. Certainly, Children with with special health care needs are automatically at a high risk category and should be referred as early as possible to get a dental home uh to to be integrated into a dental home. Um Children with behavioral issues such as autism and other neuro developmental disorders are absolutely at at high risk. Um, families that have previous history of rampant dental carries in older Children or poor dental health in in mothers and caregivers, as we know, these infants actually are inoculated with the bacteria from either siblings or parents or caregivers. And by virtue of that are at extremely high risk for Early childhood carries. Beginning soon after the 1st 2, 3 rocks. Um, Family history of Kerry's, the fact in the bay Area here we're blessed that most of our uh, most of our public water supplies have optimum fluoride levels in it. However many families use water filters, um, and reverse osmosis filters. Thinking that the water that is in the public uh system where um is unhealthy. They may have have emigrated here from places where you just don't drink public water out of a tap. But actually our water here is great. And for those people who use the public water for drinking and cooking and that sort of thing, get that additional fluoride protection uh, as well. And again, questions that you could ask to identify kids at uh, in your practice is uh, do parents and uh take care of the older siblings with regular oral hygiene practices? And and do they see the dentist regularly and Russian floss themselves? If they don't, these kids at least would fall into the areas of moderate risk. So um oh questions that uh that you can ask that relate to the the the level of risk assessment might be um oral hygiene and regular brushing habits for the child that you are examining or our siblings feeding in dietary practices. If you have Children that are coming in uh in the stroller and still have a bottle of milk or a bottle of juice or whatever else um sitting um with them in the in the stroller. These kids are automatically high risk kids. Uh during your examination, um the presence of plaque such as the heavy plaque that you see on on on this photograph or areas of D calcification and extensive white lesions around the gun lines. And these kids again automatically put these kids into the high risk category, acute and chronic decay. Already existent family history of curies, etcetera are all red flags that should encourage you to get this kid into a dental practice. Or if you do have a dental practice within your healthcare system, get these kids referred immediately so that early prevention and intervention can take place. Um There are a number of factors again and just very quickly. There are biological factors um that that need to be considered active carries in parents or primary caregivers, low socioeconomic groups uh frequent between meals, sugar snacks, put to bed with a bottle. All these would automatically put a child into high risk special health care needs and Children of recent immigrants, at least in moderate risk. And in many cases, I would say, could even be high risk, especially if these Children have not had, uh, in this, other Children in the family have not had dental care, protective factors like florid ation, regular tooth brushing, professional topical fluoride, etcetera. And clinical findings such as white spot lesions, visible carries. Or, um, you're not going to be measuring strip mutants levels in these kids mouths. But if if these kids have visible white spot lesions are carries, they're automatically in a very, very high risk category. Um, so what are the barriers, Why aren't more pediatricians doing carries risk assessment? Well, the big one is probably timer spring in an already impacted workflow. Um, you don't get compensated, uh, for the additional time and service the lack of training or the lack of comfort level between you and your staff to recognize and identify risk factors, difficulties. Once you identify a kid who is in higher moderate risk, um I hear from so many pediatricians, I just can't find anybody that will see my medical kids. None of the dental practice is out here will accept medical. Well, I would say that maybe the, maybe the practices don't, but certainly the federally qualified health centers in the community health centers in your area will, and I can tell you that we um, at all of our sites throughout the Bay Area, both in Oakland, North Bay and here in san Francisco, we will take your Medicaid kids. Uh, and then once you do refer kids, you don't get feedback or follow up from the dental provider that is inexcusable. And something again, that needs to be part of breaking down these silos that we've been talking about. Mm hmm. What are some of the possible solutions? Well, we've already mentioned some of them inter professional education opportunities and for example, our medical dental integration projects at the FQ HCS where our residents are rotating and where we have now begun to jointly higher um um staff who are full time in, in employees of the, of the FQ HC centers. But we are also hiring them as as uh, faculty uh, and reimbursing them for supervision of residents that are rotating to those sites. So all of these things we think have a really, really good chance of enhancing and reducing some of these barriers. Uh, the breaking down these barriers to seamless referrals again. Um, I think I hear from, from physicians that even within the same profession sometimes referrals and feedback from the people that refer to can be difficult, but between professions, it's even more intense and more magnified. So what do we need to do to break these silos down? We need to find a way to get integration between our electronic medical records and that's that's going to be a major task. Interestingly enough. Kaiser Permanente has been able to integrate their medical and dental electronic records up there uh and may serve as a model for future innovation. Our dental school now is converting over to Epic, which is what all of our medical centers around uh around the Bay Area. All of our Benioff Children's hospitals are on on Epic. And we are we will be converting over to Epic for our dental records and hopefully we'll be able to facilitate appointment scheduling and seamless referrals once we've done that. But believe me, it's a long drawn out process to get this done. If if you could just wave a wand and make it happen, it would have been done. also we're encouraging medical practice to employ uh in collaboration with dental providers if there if you do have dental providers within your systems or to join with us here at um yeah uh at the Benioff Children's hospitals uh and and our U. C. S. F. Practices throughout the Bay Area to employ uh mid level dental hygienists in RDS perhaps to do to provide preventive services uh in your primary care workflow. Uh it would just take 5-10 minutes following your well baby checks to have them do, carries intervention, carries risk assessment and apply fluoride varnish. If this is something that you find difficult to to incorporate into your existing workflow. Um And care coordination also is extremely important. Having a care coordinator that can facilitate referrals back and forth between the medicine and the dental practices is absolutely uh beneficial and we've proven time and time again that if we can integrate um uh a ah health care uh uh coordinator between our practices, it does wonders to to break down the barriers. So with that I've come to about the end of my time allotment here. Um I want to thank you all for joining me uh in this um I I cannot emphasize enough how important any input and suggestions that you may have as to how we can accomplish better integration, oral health and medical dental integration and reducing the magnitude and severity and social impact of early childhood carry. Um It is Essentially 100% preventable. So if we could just reduce this disease burden by a by 25 or 30%,, it would be take such a load off of our um off of the the financial impact that that dental carries and emergency room visits and and in hospital treatment of of these young Children who have advanced disease and can't be taken care of in a regular dental setting. Um if we could just reduce it by 25 or 30%, it would make incredible um uh an incredible difference in our whole health system.