Fifteen years ago, the Surgeon General delivered a pivotal report, Oral Health in America (2000), in which he highlighted the role that all health professions can play in reducing the burden of oral disease in America. Over a decade later, the Institute of Medicine (IOM) reports, Advancing Oral Health in America (2011a) and Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011b), reemphasized the centrality of the non-dental health professions in improving oral health outcomes. In 2010, Healthy People 2020 named oral health as one of the 10 Leading Health Indicators, or high-priority public health issues that need to be addressed by health professionals.
Despite publication of these important national health policy reports, nationwide there is an unacceptably high burden of oral disease. According to the Centers for Medicare and Medicaid Services (2015), early childhood caries represent one of the most common chronic diseases of children, and a whopping 91% of adults have dental caries in their permanent teeth (National Health and Nutrition Examination Survey, 2011–2012). An estimated 47% of adults have some form of periodontal disease; this prevalence jumps to 70% for adults ages 65 and over (Eke et al., 2012). These findings are particularly rampant in minorities or those living in lower socioeconomic communities. Oral disease not only leads to pain and discomfort, difficulties eating and communicating, poor self-outlook, but is also increasingly associated with poor overall health outcomes, such as diabetes (Simpson et al., 2012) and cardiovascular disease (Shetty et al., 2010), among others. Delivering preventive oral healthcare is therefore paramount to reduce oral health disparities and improve oral-systemic health outcomes across the lifespan.
Qualis Health, one of the nation’s leading population healthcare management organizations, underscored the urgency of delivering such preventive oral healthcare as a component of general medical care in its white paper, Oral Health: An Essential Component of Primary Care. Calling on the expertise of primary care and dental care providers, leaders from medical, dental, and nursing associations, payers and policymakers, patient and family partnership experts, and oral health and public health advocates, the white paper introduces the Oral Health Delivery Framework, a method for integrating oral healthcare into primary care practice and the primary care medical home (PCMH) that capitalizes on primary care providers’ existing understanding of disease processes, existing clinical competencies and strategies to engage patients in health education and primary care referral structures. The five-step process requests that primary care teams:
- ASK about oral health risk factors and symptoms of oral disease when completing the health history
- LOOK for signs in the physical exam that indicate oral health risk or active oral disease
- DECIDE on the most appropriate response
- ACT by providing primary care preventative interventions and/or referral for dental treatment
- DOCUMENT findings in the electronic health records as structured data for decision support and population management
Using this approach, team-based primary care practices can readily weave oral healthcare into everyday assessment, diagnosis, treatment and referrals and provide care that is patient-centered and advances the quality and safety of care.
The white paper also recommends actions that stakeholders can take to encourage primary care’s involvement in the provision of oral healthcare. For instance, educators are urged to promote integration of interprofessional oral health clinical content and competencies as a standard component of the curriculum of physicians, nurses, nurse practitioners, midwives, physician assistants and other health professionals.
The Oral Health Nursing Education and Practice (OHNEP) program, the nursing arm of the National Interprofessional Initiative on Oral Health (NIIOH) aims to integrate oral health as an interprofessional competency in nurse practitioner and midwifery curricula and clinical practice nationwide, thereby leading the nursing profession to become the “new partner in prevention” along with other oral health champions in other primary care disciplines. Spearheading the integration of interprofessional oral health competencies into nurse practitioner education, OHNEP has developed the web-based and open source Interprofessional Oral Health Faculty Toolkit to serve as a starting point for nurse practitioner and midwifery faculty to use in their oral health curriculum integration. The Toolkit content is based on a consensus set of interprofessional oral health core competencies for non-dental providers, including the IPEC Competencies, the NONPF Core Competencies, ACNM Core Competencies, and the HRSA Interprofessional Oral Health core Competencies (2014).
Nurse practitioners and midwives, many of whom work in primary care, can readily include the oral health assessment and exam, risk assessment, intervention, and appropriate referral in their clinical “best practice” armamentarium using the HEENOT (head, eyes, ears, nose, ORAL CAVITY and throat) versus the HEENT approach (Haber et al., 2015) . Registered nurses, whose scope of practice also includes health promotion and illness prevention, are qualified to collaborate with nurse practitioners and physicians to assess and manage oral health issues within scope of practice. The nursing profession is an example of how a profession with a commitment to health promotion and disease prevention can make a significant interprofessional contribution to expanding access to oral healthcare in the primary care setting, particularly for vulnerable populations.
As research evidence continues to reveal the linkage between oral and systemic health, clinicians are finally beginning to “put the mouth back in the head.” Chronic diseases managed by nurse practitioners and midwives, such as diabetes, Celiac, HIV, are but a few of the health problems that have oral manifestations that can be collaborated on with dental colleagues using the Oral Health Delivery Framework. It is important for nurse practitioners, midwives and colleagues on the front line of primary care to have the interprofessional oral health competencies necessary to recognize both normal and abnormal oral conditions and provide patients with education, prevention, diagnosis, treatment and referral as needed.
The Oral Health Delivery Framework has been endorsed by leading nursing, dental, medical and public health organizations, including:
- American Academy of Nursing
- American Academy of Pediatrics
- American Association of College of Nursing
- American Association for Community Dental Programs
- American Association of Public Health Dentistry
- American College of Nurse Midwives
- American Public Health Association – Oral Health Section
- Association of Clinicians for the Underserved
- Association for State and Territorial Dental Directors
- Institute for Patient- and Family-Centered Care
- National Association of Pediatric Nurse Practitioners
- National Network for Oral Health Access
- National Organization of Nurse Practitioner Faculties
- National Rural Health Association
- Patient-Centered Primary Care Collaborative
- Physician Assistant Education Association
We encourage you to join the growing momentum of professional colleagues using the Oral Health Delivery Framework to eradicate oral disease!
Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011-2012. http://www.cdc.gov/nchs/data/databriefs/db197.htm
Centers for Medicare & Medicaid Services. (2015). Reducing Early Childhood Tooth Decay: An Overview for State Policymakers. Issue Brief. Retrieved from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/ecc-overview.pdf
Clark M.B., Douglass A.B., Maier R., Deutchman M., Douglass J.M., Gonsalves W., Silk H., Tysinger J.W., Wrightson A.S., & Quinonez R. (2010). Smiles for life: a national oral health curriculum. 3rd Edition. Society of Teachers of Family Medicine. Retrieved from smilesforlifeoralhealth.com
Eke, P. I., Dye, B. A., Wei, L., Thornton-Evans, G. O., & Genco, R. J. (2012). Prevalence of periodontitis in adults in the United States: 2009 and 2010. Journal of dental research, 91(10), 914-920.
Haber, J., Hartnett, E., Allen, K., Hallas, D., Dorsen, C., Lange-Kessler, J., … & Wholihan, D. (2015). Putting the Mouth Back in the Head: HEENT to HEENOT. American journal of public health, 105(3), 437-441.
Qualis Health. (2015). Oral Health: An Essential Component of Primary Care. White Paper. Available http://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf
Shetty, D., Dua, M., Kumar, K., Dhanapal, R., Astekar, M., & Shetty, D. C. (2012). Oral hygiene status of individuals with cardiovascular diseases and associated risk factors. Clinics and practice, 2(4).
Simpson, T. C., Needleman, I., Wild, S. H., Moles, D. R., & Mills, E. J. (2010). Treatment of periodontal disease for glycaemic control in people with diabetes.Australian Dental Journal, 55(4), 472-474.
U.S. Department of Health and Human Services, Health Resources and Services Administration. (2014). Integration of oral health and primary care practice. Rockville, MD: Health Resources and Services Administration. Retrieved from http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf