Integrating oral health into primary care is 'critical,' but 'there is a long way to go'

Key takeaways:

• Integrating oral health into primary care is important for overall well-being but difficult to implement.
• Disparities exist for certain patients, like those from underrepresented racial and ethnic populations.

For the best care, oral health should be integrated into primary care practices, but the United States is still a long way from that, according to experts.

The U.S. Preventive Services Task Force announced Tuesday that there was not yet enough evidence to officially recommend oral health screening and preventive interventions for adults and children aged 5 years and older. It was the first time the task force had issued a final recommendation on the subject, after previously calling for more research to help make a decision.

However, there is some confusion on what constitutes oral health and what differentiates it from dentistry.

Natalia Chalmers, DDS, MHSc, PhD, chief dental officer at the Centers for Medicare & Medicaid Services, told Healio that dental care is just one part of a patient’s oral health.

She explained that a simple way to view the relationship between dental care and oral health is to think of oral health like “the condition of a car's engine” and dental care as “the regular maintenance and service you provide to keep that engine running smoothly.”

“In this analogy, oral health corresponds to the overall state of the car's engine, including its performance, efficiency and longevity. Just as the engine's condition depends on factors like the quality of the engine parts, driving habits, and fuel quality, your oral health relies on genetics, diet, lifestyle choices and hygiene practices,” Chalmers said. “Dental care can be likened to the maintenance and service of the car's engine.”

In other words, flossing, brushing, dental check-ups, teeth cleanings and fillings are like changing the oil and “conducting routine inspections to identify and address potential issues,” she said.

Oral health is a broad concept that includes things like salivary glands, saliva production, tooth health (including roots, blood flow and enamel), gingival health and integrity, oral flora (bacteria that colonizes the mouth) and more, Adam Hunt, DO, an osteopathic physician specializing in emergency medicine and member of the American Osteopathic Association and Michigan Osteopathic Association, said.

Connections to overall well-being

Although the USPSTF does not have enough evidence to recommend oral health screening in primary care, it is important for primary care physicians to educate and encourage patients to maintain their oral health, Chalmers said, considering that “inadequate oral health has far-reaching consequences that extend beyond the mouth, profoundly affecting one's overall wellbeing, nutritional intake and general health.”

“This interconnected relationship between oral and overall health underscores the importance of maintaining a healthy mouth. When oral health is compromised, it can lead to a cascade of issues,” she said. “For instance, poor oral health can hinder a person's ability to chew food properly, resulting in dietary limitations and reduced nutrient absorption. This, in turn, can contribute to malnutrition, which is a serious concern for overall health, particularly among vulnerable populations such as seniors. Additionally, oral health problems can lead to chronic pain and discomfort, negatively impacting an individual's quality of life.”

Additionally, Hunt said that “a link has been established between oral health and overall health — most notably, cardiovascular health.”

“Patients who have poor oral health have higher risk of cardiovascular events such as myocardial infarctions, strokes and endocarditis,” Hunt said. “Studies have shown that stress reduces the amount of saliva production. Saliva is a natural cleanse for the mouth, and without it or with a reduced amount, patients are at risk for gingivitis, tooth erosion, bacterial overgrowth and infection. There are many medications and medical conditions that reduce saliva production that lead to the same situation.”

Rena N. D’Souza, DDS, MS, PhD, the director of the National Institute of Dental and Craniofacial Research, also pointed to growing research indicating a strong connection between poor oral health and cognitive decline.

“Older individuals who have lost their teeth are more likely to experience cognitive decline,” she said. “This is not to say there is a direct cause and effect between tooth loss and cognitive decline. When a person loses their teeth, they may be uncomfortable in social settings and unable to maintain a balanced diet; these factors may also play a role in cognitive decline.”

Karen L. Smith, MD, FAAFP, a family physician and member of the American Academy of Family Physicians board of directors, also emphasized the importance of evaluating oral health as an early indicator for serious conditions like diabetes. In fact, the first sign of HIV that a PCP could identify is “a cotton mouth full of thrush,” she said.

Although oral health may not be completely integrated into primary care, Smith said that it is somewhat already part of being a family physician. Oral health care, she said, starts “when we give that first request of a patient: ‘open your mouth wide.’”

Integration

Smith said that when a patient opens their mouth at the beginning of their visit, she looks at the gums (“Are they receding? Are they bleeding? Are they really pale in color?”) and the teeth (“Are they present? Are they discolored? Are they chipped?”). She also looks at the tonsils and tongue to identify any lesions, changes in blood vessels, sores, growths and more.

“‘Open your mouth wide’ gives us entry into a host of not only preventable disorders, but possibly active disease or active disorders that we can intervene with,” Smith said.

Considering how oral health and one’s overall wellbeing are connected, D'Souza said that “it is critical for oral health care to be integrated into primary health care practices.”

The effort is already underway, she said; policymakers and health care professionals have been working to integrate oral health with primary care, especially for children, for decades.

“For example, Medicaid has been expanded to cover child oral health services, including caries risk assessment and sealant placements in children,” she said. “Efforts such as these have contributed to the reduction of untreated tooth decay in preschool children by nearly half — from 19% to 10% over 2 decades, putting early childhood caries at a historically low prevalence.”

However, she said the U.S. still has “a long way to go” when it comes to setting up the protocols, procedures and policies for “a fully integrated health care system.”

Full integration, she said, would involve PCPs incorporating oral health education, assessment, prevention and basic treatment services into their routine care.

“It involves physicians working closely with an interprofessional team of care providers, including physician assistants, nurse practitioners, dental hygienists, dental assistants and others,” D’Souza said. “It is essential for these teams to recognize the important connections between the mouth and the body. I think it is extremely important that we train our future generations of physicians to work in such settings.”

Smith said that collaborating with dentists is “vitally important” to her. She told a story of a dentist colleague who noted significant bleeding during a patient’s preventive services. The dentist mentioned the problem to the patient’s PCP and then learned the patient was diagnosed with advanced liver cancer.

“We have to recognize in health care how we work together, how we work in a collaborative fashion,” Smith said. “Recognizing that while family doctors may be the first point of contact for health care, (but) dental care is certainly something that we do not dismiss as being necessary in the life of an individual.”

Although many dental and oral diseases are preventable through this type of collaboration, D’Souza said “many individuals with limited access to dental care (also) find it difficult to access oral health care.”

Disparities

Recent research published in JAMA Network Open that evaluated the most common dental and oral health problems among Medicare beneficiaries in nursing homes revealed significant racial disparities.

The researchers found that Black beneficiaries had 5% higher odds of having cavities or broken natural teeth and 16% higher odds of having no natural teeth or tooth fragments compared with their white counterparts. American Indian or Alaskan Native beneficiaries had 45% higher odds of having inflamed or bleeding gums or loose teeth, 34% higher odds of having no natural teeth or tooth fragments and 20% higher odds of having cavities or broken natural teeth compared with their white counterparts.

Hunt suggested the wealth gap is also tied to oral health disparities.

“Patients of lower socioeconomic status are at higher risk for poor oral health due to many factors: lower rates of dental insurance, higher stress, less money that can be dedicated to dental care, higher rates of smoking and substance abuse,” he said. “Increasing insurance rates in this population would definitely make an impact, as well as providing education to people the importance of dental care and oral health.”

D’Souza said that early prevention, having an interprofessional team of health care providers and regular dental care “can help patients overcome these systemic health problems.”

“Routine dental check-ups, either from dental or primary health care providers, can catch problems early and provide patients with professional guidance on maintaining oral and overall health,” D’Souza said.

Cost

The U.S. spent $161.8 billion on dental services in 2021, according to an estimate from CMS. However, individual spending varies drastically by insurance coverage, or lack thereof. A recent survey from CareQuest Institute found that an estimated 68.5 million adults do not have dental insurance, and that number is only expected to grow, potentially hitting 91.4 million by the end of 2023.

Also, a 2020 article in JAMA revealed that, in 2016, oral disorders and well dental care resulted in the highest spending paid out of pocket, at an estimated $30.5 billion and an estimated $21.1 billion, respectively.

“Integration of oral health care into primary health care practices can provide care to more patients, improve patient outcomes, and reduce the cost of care,” D’Souza said. “Millions of people visit their primary care provider but do not have a dental home. Again, there is a long way to go. To make it a reality, there will need to be policy reforms that involve all providers coming to the table to make it feasible.”

Progress

Chalmers said that CMS “has achieved several significant accomplishments to advance oral health” over the past 2 years — namely, establishing a process to consider and review public recommendations for “Medicare payment for dental services inextricably linked to certain other covered medical services” and the fact that, as of October 2022, all 50 states and Washington, D.C., have offered some dental coverage for pregnant Medicaid enrollees through at least 60 days postpartum.

“These changes will strengthen access to dental services for more Medicaid and Medicare beneficiaries,” Chalmers said. “Access to oral health services that promote health and wellness is critical to allow beneficiaries and consumers to achieve the best health possible.”

Now, she said CMS is “undertaking a cross-cutting initiative to consider opportunities to expand access to oral health coverage using existing authorities and health plan flexibilities across Medicare, Medicaid/CHIP (Children’s Health Insurance Program), and the Marketplace.” CMS will also “consider opportunities to expand access to oral health coverage using existing authorities and health plan flexibilities,” she said.

“CMS plans to partner with states, health plans, and health care providers to find opportunities to expand coverage, improve access to oral health services, and consider options to use our authorities creatively to expand access to care,” Chalmers said. “Maintaining good oral health is not just about having a beautiful smile; it is an essential component of overall health, nutrition, and well-being.”

References:

• Chamut S, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.33367.
• Dieleman JL, et al. JAMA. 2023;doi:10.1001/jama.2020.0734.
• National health expenditures 2021 highlights. https://www.cms.gov/files/document/highlights.pdf. Accessed Oct. 26, 2023.
• New report: 68.5 million adults in the US don’t have dental insurance, may rise to 91.4 million by end of year. https://www.carequest.org/about/press-release/new-report-685-million-adults-us-dont-have-dental-insurance-may-rise-914. Published Sept. 6, 2023. Accessed Oct. 26, 2023.