Integrated Medical-Dental Delivery Systems: Models in a Changing Environment and Their Implications for Dental Education.

Models and systems of the dental care delivery system are changing. Solo practice is no longer the only alternative for graduating dentists. Over half of recent graduates are employees, and more than ever before, dentists are practicing in groups. This trend is expected to increase over the next 25 years. This article examines various models of dental care delivery, explains why it is important to practice in integrated medical-dental teams, and defines person-centered care, contrasting it with patient-centered care. Systems of care in which teams are currently practicing integrated oral health care delivery are described, along with speculation on the future of person-centered care and the team approach. Critical steps in the education of dental and other health care professionals and the development of clinical models of care in moving forward are considered. This article was written as part of the project "Advancing Dental Education in the 21st Century."

Assessing the association between receipt of dental care, diabetes control measures and health care utilization.

BACKGROUND: The literature contains few studies regarding the relationships between receipt of regular dental care and medical outcomes for people with type 2 diabetes. METHODS: The authors compared hemoglobin A(1c) (HbA(1c)) levels (< 7 percent versus < 7 percent), low-density lipoprotein cholesterol levels (< 100 milligrams/deciliter versus ≥ 100 mg/dL) and diabetes-specific hospital admissions and emergency department (ED) visits (one or more visits versus no visits) in 493 people with type 2 diabetes who received regular dental care (≥ two prophylactic visits, periodontal treatment visits or both during a 12-month period) with measures in 493 people with type 2 diabetes who did not receive any dental care. The authors matched patients, all of whom had private medical and dental insurance benefits during the study period, with regard to age, sex and previous utilization of ED visits and hospital admissions, and they followed them for three years. RESULTS: The authors analyzed the data by using multiple logistic regression, which showed that receipt of regular dental care was associated with lower diabetes-specific ED utilization (odds ratio [OR] = 0.61, 95 percent confidence interval [CI] = 0.40-0.92) and hospital admissions (OR = 0.61, 95 percent CI, 0.39-0.95) after they adjusted for age, sex, previous hospital admissions, previous ED utilization, race, baseline HbA(1c) values, Charlson comorbidity index score, body mass index status, periodontal risk status and primary care utilization. The authors found no significant association between receipt of dental care and control of HbA(1c) levels. CONCLUSIONS: The study results show an association between regular receipt of dental care and reduced diabetes-specific medical care utilization (that is, ED visits and hospital admissions). CLINICAL IMPLICATIONS: Although the results of this study could not show causality, they suggest that receipt of dental care may reduce diabetes-specific health care utilization. Prospective studies are needed to better understand the relationship of receipt of dental care with diabetes control and health care utilization measures.

The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan.

OBJECTIVES: We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. METHODS: We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. RESULTS: Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. CONCLUSIONS: Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.

Design of the Prevention of Adult Caries Study (PACS): a randomized clinical trial assessing the effect of a chlorhexidine dental coating for the prevention of adult caries.

BACKGROUND: Dental caries is one of the primary causes of tooth loss among adults. It is estimated to affect a majority of Americans aged 55 and older, with a disproportionately higher burden in disadvantaged populations. Although a number of treatments are currently in use for caries prevention in adults, evidence for their efficacy and effectiveness is limited. METHODS/DESIGN: The Prevention of Adult Caries Study (PACS) is a multicenter, placebo-controlled, double-blind, randomized clinical trial of the efficacy of a chlorhexidine (10% w/v) dental coating in preventing adult caries. Participants (n = 983) were recruited from four different dental delivery systems serving four diverse communities, including one American Indian population, and were randomized to receive either chlorhexidine or a placebo treatment. The primary outcome is the net caries increment (including non-cavitated lesions) from baseline to 13 months of follow-up. A cost-effectiveness analysis also will be considered. DISCUSSION: This new dental treatment, if efficacious and approved for use by the Food and Drug Administration (FDA), would become a new in-office, anti-microbial agent for the prevention of adult caries in the United States. TRIAL REGISTRATION NUMBER: NCT00357877.

Implementing a tobacco assisted referral program in dental practices.

OBJECTIVES: The objectives of this study are to design and implement a system-level tobacco-control intervention in a large prepaid dental group practice and assess effects on staff performance measures and patient satisfaction. METHODS: We matched 14 dental facilities on size, socioeconomic status, smoking rate, and periodontal status, and then randomly assigned them to intervention or usual-care control. We trained intervention staff in an "Assisted Referral" team approach for assessing tobacco use, providing tailored advice and brief counseling, and encouraging smokers to talk by telephone with a specially trained tobacco counselor. Patients could call from the office or ask that the counselor call them later. Telephone counselors helped patients explore motivations and barriers for quitting; review available cessation-support strategies, programs, and medications; and identify next steps. RESULTS: During the 14-month study period, 66,516 members had annual- or new-patient examinations. Both intervention and control sites had high rates of tobacco assessment (97 percent) and advice (93 percent). Intervention patients were more likely than controls (69 percent versus 3 percent, P < 0.01) to receive additional chair-side tobacco counseling and assistance, and 11 percent agreed to receive additional telephone counseling. Intervention patients were more satisfied than controls with the dental team's tobacco-control efforts (P < 0.03). Referral rates varied substantially for different staff. CONCLUSIONS: The Assisted Referral approach was successfully integrated into routine dental care, was well received by patients, and resulted in increased patient satisfaction. Because free telephone-based tobacco counseling is now available nationwide, the approach may be a practical strategy for most dental-care settings.