September 19, 2019
by Julie DiNardo, RDH, Kate Marten, RDH, Dr. David Engelberg, Dr. Elena Pankratieva, Shakira Wynter BHS/RPN, Geena Sakellaris, RN
The integration of services is a route increasingly taken by healthcare organizations to improve outcomes and access, and to reduce costs. A new American study has shown, for example, a greater level of integration in medical services and a focus on patient outcomes can reduce costs significantly.1 Starting in early 2019, new preventive oral healthcare services have been offered in a Toronto group medical practice to adult patients with Type 2 diabetes. To our knowledge, this is the first integration of oral hygiene services into the management of a chronic disease in medical practice.
This article outlines the reasons for starting this new oral healthcare service, how it has developed, the response by the patients, and the experience of the medical team.
Why integrate oral healthcare into the management of diabetes?
In late 2018, a breakthrough study was published in The Lancet to show that improved periodontal health significantly improved glycemic control (HbA1C) in adults with moderate to severe periodontal disease and with Type 2 diabetes.2 HbA1C levels dropped by 10% when study participants received periodontal scaling and root planing (SRP) every 3 months for a year, compared to those with a super-gingival dental cleaning at the same intervals (Figure 1). Systemic inflammation also improved, as measured by levels of C-reactive protein.
This study culminates years of similar studies, including the Cochrane Review, which have reported better oral health can be consequential to the management of diabetes.3 The study’s results are also confirmed by American health insurers which have shown from their claims experience, that better oral health means lower medical claims by diabetics and others with multiple chronic diseases.4 For example, Aetna estimates that lowered oral inflammation could reduce medical premiums by 17% primarily by reducing hospitalization and use of the Emergency Room of very sick individuals such as adults with diabetes. This is an extraordinary level of healthcare cost savings, well beyond what has been achieved integrating medical services.
From a medical perspective, moreover, it is also important to understand that poor oral health is bidirectional with diabetes. Diabetics have three times the level of caries and periodontal disease.5,6 Indeed, periodontal disease has been called the sixth complication of diabetes, along with heart disease, nerve damage, vision problems, kidney disease and peripheral arterial disease.7 While poor oral health has not historically been a concern of the medical team, this concern needs to change, particularly in an aging community with limited access to the dentist and more co-morbidities which bring on poor oral health. In the case of diabetes, this condition most often appears after age 60, a time of life when the majority of Canadians lose their dental insurance, have fixed incomes, and reduce their use of professional dental care. With these older Canadians, a referral to a dentist by the physician can be frustrated by poor compliance – the patient rarely goes to the dentist. Witness a recent analysis which found that fewer than 1 in 10 American adults with both diabetes and periodontal disease, actually received periodontal care.8
So, there are good reasons to improve the access and adherence of diabetics to oral health services with new models of delivery in the medical practice. If the medical team is to manage diabetes in its aging caseload, services to improve oral health are a valuable part of the patient’s visit to the doctor’s office.
The Current Model of Managing Adult Diabetes
For several years, the Ontario Ministry of Health has reimbursed physicians for a series of regular medical services for diabetics (Figure 2). Every 3 to 6 months, physicians test glycemic control, blood pressure, body mass index and the self-management behavior of their diabetic patients. Annually, other tests and evaluations are conducted including: lipid control, a risk assessment of microvascular and macrovascular complications from diabetes including nephropathy, retinopathy, periph-eral neuropathy, erective dysfunction and cardiovascular disease. Immunization against influenza and pneumonia are also provided.
This program has governed how the physician and the medical practice handles the diabetic patient. Visits are scheduled accordingly in the Electronic Medical Record (EMR) and the resources assigned to perform these services regularly. Notably, because the Ontario program excludes evaluating and treating poor oral health, the activity to manage oral inflammation in adults with diabetes as described in this article is a leading and innovative approach.
Likewise, diabetic patients follow this Ministry of Health program without mentioning they have sore gums, their teeth regularly bleed when they are brushed, or that they have loose teeth. These complaints are reserved for the dentist if the patient has one, or are simply accepted as being part of getting old. In very few cases, does the patient consider these conditions to be important to their diabetes.
In short, both the medical team and the patient are engaged in a well-established flow of medical procedures which excludes oral health. So far, the mouth is not considered to be part of the body when it comes to managing diabetes.
The current model of managing both diabetes and oral health is also based on “free” services. The patients rarely pay for anything when visiting the doctor, and they can resist paying for dental services which are not covered by their dental plan. Because the proposed preventive oral health service in this pilot project was paid for by the patient out of pocket, the authors were concerned this would minimize patient acceptance.
The Toronto pilot study’s medical practice and the integration team
This project is taking place in a group family medical practice in downtown Toronto. This medical practice primarily serves office workers in the financial services industry; most have a dentist, make regular dental visits, have a dental insurance plan and have incomes at or above the Canadian average. In other words, the caseload is younger and more insured for dental services than most Canadian diabetics.
The integration team involves two family physicians, the clinic’s coordinator and two independent hygienists. The coordinator of 11 affiliated medical practices is also an active member of this small team.
One medical examination room is assigned for this oral health service. The limited equipment used in this service (a small compressor for air, a backrest for the examination room chair and disposables) is set up quickly in this examination room and when not in use, is stored at the back of the clinic. Sterilization of instruments takes place in the medical practice. Lastly, posters and patient brochures are displayed (Figure 3) and a short questionnaire to record patient feedback is used during the consultation with the patient.
The hygienist records all aspects of the patient visit in the EMR. Patient visits are also scheduled via the EMR. All hygiene activity follows a manual of procedures which in turn is based on rules and regulations set by the College of Dental Hygienists of Ontario (CDHO).
The preventive oral health service is offered one day a week to diabetic patients served by the two participating physicians.
Innovating a New Oral Health Service in Diabetes Care
This pilot study has introduced several new procedures to serve these diabetic patients.
• A new pathway for the patient which fits into the normal patient flow and recall patterns in this medical practice.
• A new procedure which combines debridement of the periodontium with a high-strength, long-lasting, broad spectrum, topical antiseptic (Prevora). This medication has shown remarkable efficacy and safety over many years and many patients in reducing oral inflammation and treating periodontal disease even amongst those patients unresponsive to SRP9; moreover, it simultaneously protects against root caries which is also a key component of poor oral health in diabetics and older patients. If the patient requires a full mouth SRP, he/she is referred to an outside dental professional as there are time and space limits to conducting this service in a medical setting.
• An outreach education program to the diabetic patient which involves telephoning patients on behalf of the physician to schedule a consultation on oral health in the medical practice. This approach alleviates complexity and work for the physician and the clinic coordinator, and accelerates adoption by the patients.
• A revenue-sharing model to reward all parties from the benefits of better oral health. For the pilot study, the price per treatment has been set at $120. This revenue is shared by the medical clinic, the hygiene team and the supplier of Prevora.
The critical step on the patient pathway is the consultation with the hygienist in a medical examination room. This takes up to 20 minutes, involves an education of the patient on the role of better oral health in managing their chronic condition and an assessment of risk factors for poor oral health. Much of this information is new to the patients and they are very receptive to it. Patients also complete a short questionnaire about their oral health status, about what they know about their oral health, and what they think of this new service. The risk assessment by the hygienist is recorded in the EMR for future reference by the medical team and the hygienist.
At the end of the consultation, the hygienist makes a recommendation for treatment or future re-examination, whichever is appropriate. The treatment appointments are scheduled if possible to coincide with the regular medical visits. In the first year, there are 4 treatment visits and thereafter, two per year or as indicated by the hygienist’s clinical judgement.
Favourable Response by Patients
In this first 6 months, it has become clear that the diabetic patients respond very favorably to the consultation and to this new service. It is also clear that this service fits readily into the setting of a busy group family medical practice and is a valued part of the medical care. The service has proven, moreover, to be economically viable for the patient, the medical practice and hygiene team. Clinical outcomes regarding oral inflammation and diabetes markers will be evaluated in 2020 when sufficient data is available.
These are the most important interim observations of this study:
• When reached by phone by the hygienist as part of the medical team, the vast majority of patients agree to a consultation on their oral health. They also attend this consultation; there are few cancellations.
• For every 10 consultations with these diabetic patients, 4 have good oral health and 6 are candidates for more preventive oral healthcare due to oral inflammation and periodontal disease.
• Amongst the patients needing more preventive oral healthcare, almost all agree to enter the preventive treatment plan.
• The price of the treatment plan is accepted by the patient.
• The patient survey data show that 2 of 3 diabetics are not aware that the health of their gums and their diabetes are inter-related.
• A significant majority rate this service as being very important and most also indicate they will be using this new service in the next year (Figure 4).
Response by the medical team
Perhaps the most important finding so far is that independent hygienists can join the medical team; there is confidence, trust and a professional working relationship between all healthcare professionals involved in this new service. This is the necessary foundation for taking next steps.
The next steps
This project will continue to enroll the diabetic patients of more family physicians in this practice given the teamwork and favorable acceptance to date. Treatment and outcomes will be recorded in the EMR so that patterns in oral health, glycemic control and blood pressure will become evident over the next 12 months. In addition, the team is considering expanding the selection criteria for this service to include patients with co-morbidities which are also linked to poor oral health. Cardiovascular disease, cerebrovascular disease, respiratory disease and mild cognitive impairment are good candidates for an adjunctive preventive oral health service delivered when the patient visits the physician.
A pilot study of integrating preventive oral health services with the medical management of adult diabetes is underway in a Toronto group family medical practice. After six months, the hygiene team has become part of the medical team and the patients are very receptive to this new service. The pilot study will continue with more physicians and more patients, and is expected to generate data on changes to oral health, glycemic control and blood pressure in 2020.
About The Author
i. Julie Di Nardo, RDH, founder of the Gleam Smile Centre, Hamilton, Ontario.
ii. Kate Marten, RDH, founder of LifeSmiles Dental Hygiene, Whitby, Ontario
iii. Dr. David Engelberg, DMD, MD, CCFP, FCFP, family physician, MCI The Doctor’s Office, Royal Bank Plaza Clinic, Toronto, Ontario
iv. Dr. Elena Pankratieva, family physician, MCI The Doctor’s Office, Royal Bank Plaza Clinic, Toronto, Ontario
v. Shakira Wynter, BHS/RPN, Clinic Manager, MCI The Doctor’s Office, Royal Bank Plaza Clinic, Toronto, Ontario
vi. Geena Sakellaris, RN, Regional Clinic Manager, MCI The Doctor’s Office, Toronto, Ontario