Dental caries management: A practical approach for your practice

Chronic disease management models in primary care have demonstrated significant benefits to the patient experience and patient health outcomes. In trying to prepare for the future, with or without COVID-19 implications, dental providers and clinics are facing opportunities to add value, consider alternative payment models, and to incorporate risk stratification and population health management along with medical systems. However, as alternative payment models emerge in dentistry, stand-alone dental clinics may face unique challenges in trying to prepare for the future while still providing patient care in the fee for service environment. This article focuses on a 6-months pilot project of how implementing a comprehensive caries disease management care model, evaluating caries risk, and implementing risk stratification strategies can prepare dental offices for future payment models and inclusion in the greater health system. There are two overall goals for this pilot. First, applying a caries disease management protocol to every patient visit, regardless of reimbursement. Second, applying quality improvement (QI) principles to change how a dental office approaches care delivery. The Institute of Medicine defines quality in healthcare as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations     

Kids get care: integrating preventive dental and medical care using a public health case management model

Kids Get Care is a public health-based program in the Seattle area designed to ensure that low-income children, regardless of insurance status, receive early integrated preventive medical, dental, and developmental health services through attachment to medical and dental homes (the usual sources of medical or dental care). The oral health component of the program focuses on cross-training medical and dental providers, providing partner medical clinics with a case manager, and educating staff in nearby community-based organizations about how to identify incipient dental disease and possible early childhood developmental delays. The program identifies a local, well-respected dentist to champion the delivery of oral health screening within a medical clinic and to provide oral health training to medical clinic staff. The program works with community agencies to educate families on the importance of healthy baby teeth, routine dental care beginning at age one, and general prevention. In its first year, the program trained 355 community staff and 184 primary care providers on how to conduct an oral health assessment. These staff and providers screened more than 5,500 children for oral health problems. One medical clinic more than doubled the number of fluoride varnishes it provided, increasing from 80 to 167 during a nine-month pilot phase. Other outcome studies are in progress.     

Pay-for-performance incentive program in a large dental group practice

Background

Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance.

Practice management

Laser treatment is now state-of-the-art in many disciplines of dentistry and is rapidly being recognized as the standard of care for many procedures. Seamless, efficient, and successful integration of lasers into a dental practice takes time and effort on the part of the dentist. Restructuring of fee schedules to reflect superior laser-based care and an internal and external marketing plan are essential for the dentist to recoup his or her investment in this new technology. Training the staff in laser technology and becoming familiar with new reimbursement codes (for medical and dental insurance) may become necessary. The mission statement and practice philosophy of providing superior care with less discomfort now can be realized with the integration of lasers into a dental practice.     

Costs of publicly financed dental care for children in three different types of practice settings.

This analysis of the Chattanooga Program has provided preliminary findings on the relative cost of providing dental care through three different modes of care delivery: private practice, public fixed clinics, and public modile clinics. Significant differences in costs were found. It is reasonable to conclude, tentatively, that public services were being used more efficiently than private services in the delivery of dental care involved in this program. The results contest the findings of previous studies which indicated that mobile clinics were relatively inefficient. This study, however, based on a limited time period and refers to a specific program. It would, therefore, be inappropriate to generalize too hastily from the results. At this time, further research is being conducted to extend the period of analysis, and to deal explicitly with differences in patient characteristics, service mixes, and quality, to explain the economic reasons for the apparent differences in efficiency by delivery mode, and to consider the implications of the findings for dental policy.     

Michigan Medicaid's Healthy Kids Dental program: an assessment of the first 12 months

BACKGROUND: In 2000, Michigan's Medicaid dental program initiated Healthy Kids Dental, or HKD, a demonstration program offering dental coverage to Medicaid-enrolled children in selected counties. The program was administered through a private dental carrier at private reimbursement levels. The authors undertook a study to determine the effect of these changes. METHODS: The authors obtained enrollment and utilization data for four groups: children covered in the first 12 months of HKD in 22 counties, children with private dental coverage in the same 22 counties in the same 12 months, Medicaid-enrolled children in the same 22 counties for 12 prior months, and Medicaid-enrolled children in 46 counties who were not included in the HKD program at any time. The authors compared access to care, dentists' participation, treatment patterns, patient travel distances and program cost. RESULTS: Under HKD, dental care utilization increased 31.4 percent overall and 39 percent among children continuously enrolled for 12 months, compared with the previous year under Medicaid. Dentists' participation increased substantially, and the distance traveled by patients for appointments was cut in half. Costs were 2.5 times higher, attributable to more children's receiving care, the mix of services shifting to more comprehensive care and payment at customary reimbursement levels. CONCLUSIONS: By increasing reimbursement levels and streamlining administration, the HKD demonstration program has shown that substantial improvements can be made to dental access for the Medicaid-enrolled population. PRACTICE IMPLICATIONS: The findings of this assessment suggest that appropriate attention to administration and payment levels can rapidly improve access for Medicaid-enrolled patients using existing dental personnel. By cooperating with state officials to design a program that addresses multiple issues, dental providers can help create a Medicaid dental program that is attractive to both providers and patients.     

Dental school faculty perceptions of and attitudes toward the new dental therapy model

The University of Minnesota School of Dentistry launched its new dental therapy program in September 2009 after the Minnesota state legislature had authorized the training and practice of a dental therapist in May of the same year. The creation of this mid-level dental provider is seen as a workforce solution to help address the problem of access to dental care experienced by some members of our society. However, there is a lack of consensus and even controversy in organized dentistry about dental therapy, one of the mid-level provider models. This study explored the attitudes and perceptions of dental school faculty members who have been tasked to prepare these new dental therapists to do their work. Focus groups were conducted with a randomly selected group of faculty members, the results of which were used to develop a survey of faculty members in all departments of the school. A total of 151 faculty members responded to the survey: 68 percent of these respondents were fifty-one years of age or older; 79 percent were male; and 39 percent were full-time and 61 percent part-time. Fifty-four percent were clinical faculty members, and the rest taught in the preclinical courses and basic sciences. The study found that these dental faculty members believe dentists have a personal responsibility in the care of the underserved but do not agree that the dental therapists are part of the solution to improve access. There was a clear divide between the part-time faculty members, who practice outside the institution, and the full-time educators with regard to the role of dental therapists. However, there was an overall consensus that dental faculty members have a commitment and responsibility to educate future dental therapists regardless of their personal position. This is encouraging to dental therapy students, who can be assured that they will receive the education they need to prepare them to practice.     

A new curriculum framework for clinical prevention and population health, with a review of clinical caries prevention teaching in U.S. and Canadian dental schools

To fulfill the Healthy People 2010 Objective 1.7, "Increase the proportion of . . . health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention," the Healthy People Curriculum Task Force has developed a curriculum framework for clinical prevention and population health for all the health professions. This framework has four components: 1) evidence base for practice; 2) clinical preventive services, including health promotion; 3) health systems and health policy; and 4) community aspects of practice. Within these four common components are nineteen domains, for which each health profession is identifying its own educational objectives. An inventory of knowledge and skills is being developed. A prerequisite to promoting change in the teaching of dental prevention and population oral health is to better understand the current status. Sixty-six of sixty-eight U.S. and Canadian dental schools provided input on the teaching of one important aspect of this wider topic--dental caries prevention--before a December 2002 Clinical Preventive Dentistry Leadership Conference in Cincinnati, OH. In clinical teaching, 68 percent of dental schools included caries risk assessment and also reevaluated preventive outcomes, but while 65 percent included remineralization procedures, only 38 percent specifically reevaluated this outcome. Faculty members have commonalities in attitudes about the advantages and problems in improving teaching in clinical prevention, yet dental schools act individually in curricular design and implementation. The conference introduced a method of conceptualizing change, so that dental schools might address organizational barriers in clinical curriculum development. Even with the new common curriculum framework, other barriers to improved dental prevention and population oral health exist: these include organizational change in dental schools, dental practices, and dental clinics; reimbursement issues and incentives; and lack of accepted and explicit standards in dental care.     

A dental school's role in developing a rural, community-based, dental care delivery system for individuals with developmental disabilities

The long-standing problem of access to dental care for persons with developmental disabilities in rural Northern California has been addressed in several communities by a unique community-based program. The goal was to create a coalition to coordinate dental school resources with those of a consortium of agencies to address problems in the local communities. This program established a community-based model demonstrating the provision of quality preventive and therapeutic dental services to these individuals.
Through this program, dental care delivery systems were formed in three rural communities involving local community dentists and agency personnel. The role of the dental school was: (1) to establish and then work with a consortium of hospitals, agencies, dentists, and other dental personnel; (2) to train local dental personnel; (3) to establish and equip hospital dental facilities; (4) to conduct dental screening and triage clinics; (5) to consult with local agencies and dentists; (6) to act as a referral center for patients with complex medical situations; and (7) to develop and disseminate preventive dentistry training materials.     

Complete denture services: clinical technique, lab costs, manpower, and reimbursement. One-year review

Complete denture services at comprehensive care public health clinics are not common in part because of clinician concerns regarding outcomes. Educational debt forgiveness has attracted recent dental graduates to public health dentistry; however, not all recent graduates receive denture education experiences necessary to attain proficiency. While fundamental patient assessment and denture construction are taught, psychological assessment and communication with denture patients requires experience. A thorough understanding of occlusion, phonetics, esthetics and laboratory steps is also necessary. Expecting recent dental graduates to become proficient providing complete dentures at minimal reimbursement levels, with no mentorship or on-site laboratory support, is unrealistic. Public health dental clinics operate at full capacity performing emergency, preventive and restorative procedures. Complete dentures come with a laboratory fee approximately one-half the total reimbursement, meaning a remake drops clinic revenue to zero while doubling expenses. It is understandable that full schedules, marginal reimbursement, unpredictability and the risk of an occasional failure block clinician interest in providing denture services. This one-year report of services describes a three-appointment complete denture technique offering improved patient and laboratory communication, reduced chair time and controlled cost, resulting in high-quality complete dentures.     

Providing a dental home for pregnant women: a community program to address dental care access--a brief communication

OBJECTIVE: This paper describes a community-based intervention to provide a dental home for women covered by Medicaid in Klamath County, Oregon. In 2001, 8.8 percent of pregnant women served by Medicaid in Oregon received care. The long-term goal of the program is to promote preventive oral care for both mothers and their new infants. METHODS: Pregnant women received home/Women, Infant and Children visits and were assigned a dental home under a dental managed care program [Dental Care Organization (DCO)]. All initial care was provided at the Oregon Institute of Technology Dental Hygiene Clinic under the contract with the DCO. Emergency, preventive, and restorative care was provided. RESULTS: Between February 2004 and January 2006, 503 pregnant women were identified; 421 women were contactable. Of these, 339 received home visits (339/421, 80.5 percent) and 235 received care (235/339, 69.3 percent). Overall, 55.8 percent of eligible women received care (235/421). Most who did not have a visit either moved or were not the caretaker of the baby. The missed appointment rate was 9 percent. CONCLUSION: A community health partnership led to a successful and sustainable model extending care to pregnant women and is being extended to promote preventive care for both new mothers and their offspring.     

Creating systems aligned with the triple-aim and value-based care

HealthPartners is an integrated health care system in the upper Midwest striving to provide value-based care that aligns with the triple-aim care. The dental delivery system at HealthPartners is focused on prevention by utilizing risk assessment tools (caries, periodontal disease, and oral cancer) built in to our record system. Integration with medical delivery system is facilitated by a shared electronic health record. Measurement is critical to determining if we accomplish our goals. The dentist compensation system is aligned with our care agenda. Implementation strategies, lessons learned, and future directions are discussed in the context of journey to achieve the triple-aim and value-based care.     

Financing and reimbursement of elders' oral health care: lessons from the present, opportunities for the future

This article describes current financing and reimbursement for elders' oral health care and presents innovative options and opportunities for the future. Current health and dental care financing data from the Centers for Medicare and Medicaid Services and Agency for Health Care Research and Quality are reviewed. Existing and potential reimbursement options for the future are presented. Options for future financing and reimbursement include extending dental insurance into retirement, inclusion of oral health care into existing comprehensive health care plans, developing retiree plans for selected, well-defined (by the sponsor) groups of retirees, pre-paying dental care during employment, development of an Elders Health Insurance Program for the poor and near poor, and developing optional "Part D (for Dental)" plans within the Medicare program. Given the absence of universal oral health insurance, a mix of financing options and reimbursement schema will be required to cover the costs of oral health care and eliminate disparities in oral health access and outcomes for the growing elderly population.     

Dental professionals' knowledge and perceived need for education in bioterrorism preparedness

Dental professionals should be well prepared to provide care during bioterrorist events. In this study, we assessed the knowledge, opinions about playing various roles during a bioterrorist event, and perceived need for education of dental professionals (dentists and dental hygienists) from one region (Oregon) that had been exposed to bioterrorism and from another region (New England) not exposed. This cross-sectional study used an eighteen-item pretested, self-administered questionnaire distributed at the 2005 Oregon Dental Conference (n=156) and 2005 Yankee Dental Conference (n=297). Dental professionals' knowledge and perceived need for education on bioterrorist preparedness were quantified by multivariate linear and logistic modeling. More than 90 percent of the dental professionals were willing to provide care during bioterrorist events. Perceived knowledge was high; however, actual knowledge was low. Dental professionals who wanted to attend a continuing education course and who thought dental professionals should play more roles during a bioterrorist attack had higher actual knowledge. Willingness to provide care was not supported by adequate knowledge. No significant differences between New England and Oregon dental professionals were observed in terms of actual knowledge or perceived need for bioterrorism education. Integrating training and education into the predoctoral dental and dental hygiene curricula and developing continuing education courses would improve knowledge and better prepare dental professionals to effectively perform American Dental Association-recommended roles during any future bioterrorism events.     

Serving underserved and hard-core smokers in a dental school setting

The dental profession has recognized tobacco cessation as an important part of comprehensive dental care, yet implementation of the Public Health Service clinical practice guideline on "Treating Tobacco Use and Dependence" remains a challenge. This is especially the case for patients presenting in dental clinics for whom smoking represents a large financial burden. Many of these smoking-addicted patients also present with multiple risk factors: dental, medical, and psychiatric. Innovative approaches are necessary to reduce barriers to providing smoking cessation services to underserved and high-risk smokers. A tobacco cessation clinic in a dental school setting provides an opportunity for dental students to learn about the management of difficult-to-treat cases and to bring their enhanced intervention skills back into the primary care dental setting. This paper describes a multidisciplinary approach to tobacco cessation in a dental school clinic within an academic medical center.     

Bridging the gap in caries management between research and practice through education: the Indiana University experience

Although dentistry recognizes that dental caries management encompasses more than restoring the consequences of the disease, caries risk assessment and management that go beyond traditional restorative care have not always had a strong and organized voice during clinical curriculum development and competency assessment in U.S. dental schools. This has resulted in confusion and great variability between the need for risk-based caries management and prevention and how practitioners apply these concepts in private and community settings. Dental education is in the unique position of being able to help bridge the gap to improve dissemination of new information and to enhance communication between research and the practice of dentistry to accelerate adoption of validated approaches for the diagnosis and management of dental caries. This paper presents one example of how a dental school totally revamped its approach to teaching cariology--from a few lectures scattered throughout the curriculum to a Cariology Management Program that is integrated into all four years of the curriculum, that includes both didactic and clinical components, and that emphasizes critical thinking and problem solving. From its inception, the program was centered on a competency requirement for graduation and the principles of evidence-based practice. The process, competency, and initial programmatic outcomes assessment measures are discussed. Barriers encountered are briefly reviewed from the following perspectives: dental school structure, faculty support/calibration, students, reimbursement, and standard of care/public expectations.     

Observing the behavior of senior dental students in relation to infection control practices

To achieve adequate infection control in the dental practice, dental students should be fully aware and prepared to adopt necessary procedures. But most studies of students' infection control behaviors rely on self-reported data. This study verified, through direct observation, how senior dental students performed basic infection control procedures and assessed how close to reality the reported behavior is to the observed behavior. Eight students were observed in three clinics: pediatric dentistry, minor oral surgery, and primary care promotion. The students were not aware of who was being observed or why. Later all twenty students comprising that clinical subgroup answered a questionnaire. Seventy-two patient-student contacts were observed. Students considered basic infection control procedures as relevant. The reported intention of adoption of these procedures after graduation dropped in relation to their reported relevance. Although the observed behavior in the three clinics was considered satisfactory, when compared to the reported behavior, it was found that the intention was more positive than the behavior itself. Even though the students were conscious about the importance of cross-infection control in the dental practice, the reported intention of future use and mainly the observed behavior should be improved.