The Dental Home: Concepts, Definitions & Primary Care Considerations

1. The Dental Home: Concepts, Definitions &Primary Care Considerations James J. Crall, DDS, ScD Director, AAPD HS Dental Home Initiative

2. Presentation Overview • Brief overview of dental care delivery system • Dental Home: • Concepts, derivations and history • Definitions • Policy and program linkages • Considerations for primary care delivery • Dental Home-Medical Home Linkages J. Crall - OK HS DHI

3. Dental Care Delivery in the U.S. • Approximately 156,000 dentists (SGROH) • ~ 83% are primary dental care providers (~130,000) • 80% general dentists • 3% pediatric dentists • ~ 92% in private practice (generally independent owners) • ~ 90% of practices consist of 1 or 2 dentists • Projected to remain at ~ 160,000 through 2020 (ADA) • Declining dentist-to-population ratio beginning in 1990s • Lower DDS-pop ratios in rural and lower-income areas • > 90,000 dental hygienists • Most work as independent contractors or salaried employees in dentists’ offices J. Crall - OK HS DHI

4. Dental Home: Concepts, Derivations and History • Major oral diseases  chronic / multi-factorial • Caries • Periodontal disease • Prevalence, incidence and severity vary within populations and across the life span • Balance between risk factors and protective factors • Caries  early onset / prevalence increases with age • Periodontal disease  later onset / different organisms • General ‘care model’ consists of periodic visits to dentists for preventive services, diagnostic services and treatment of clinical manifestations • Emphasis on early diagnosis and treatment due to progress, destructive nature of caries and periodontal disease J. Crall - OK HS DHI

5. Caries Prevalence in U.S. Children Source: National Center for Health Statistics, CDC. Third National Health and Nutrition Examination Survey, 1988-1994 J. Crall - OK HS DHI

6. Dental Home: Concepts, Derivations and History • ‘Dental Home’ terminology is relatively new to dentistry (but the general concept is well-established) • American Academy of Pediatric Dentistry (AAPD): • Policy on the Dental Home initially adopted in 2001 • Conceptual basis similar to Medical Home concept promoted by American Academy of Pediatrics (AAP) • Characteristics of an ideal dental home and linkages to primary care outlined by Nowak & Casamassimo (2002): • “The Dental Home: A Primary Care Concept” • JADA 2002;133:93-98 J. Crall - OK HS DHI

7. AAPD Policy on the Dental Home • AAPD encourages parents and other care providers to help every child establish a dental home by 12 months of age. • AAPD recognizes a dental home should provide: • comprehensive oral health care including acute care and preventive services in accordance with AAPD periodicity schedules; • comprehensive assessment for oral diseases and conditions; • individualized preventive dental health program based upon a caries-risk assessment and a periodontal disease risk assessment; • anticipatory guidance about growth & development (e.g.,teething, oral habits); • plan for acute dental trauma; • information about proper care of the child’s teeth and gingiva, including prevention, diagnosis and treatment of disease of supporting tissues and maintenance of health; • dietary counseling; • referrals to dental specialists when care can’t be provided in the dental home; • education regarding future referral to a dentist knowledgeable and comfortable with adult oral health issues for continuing oral health care; referral at an age determined by patient, parent, and pediatric dentist. J. Crall - OK HS DHI

8. Dental Home Definitions • AAPD (2006): • The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. • Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate. J. Crall - OK HS DHI

9. Dental Home Definitions • ADA (2005): • Dental Home: The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, which includes comprehensive oral health care, beginning no later than age one, pursuant to ADA policy. J. Crall - OK HS DHI

10. Dental Home Policy & Program Linkages • AAP Policy Statement -- Oral Health Risk Assessment Timing and Establishment of the Dental Home (2003): • Every child should begin to receive oral health risk assessments by 6 months of age from a pediatrician or a qualified pediatric health care professional. • Infants assessed to be in 1 of the following risk groups should bereferred to a dentist as early as 6 months of age and no later than 6 months after the first tooth erupts or 12 months of age (whichever comes first) for establishment of a dental home: • Children with special health care needs • Children of mothers with a high caries rate • Children with caries, plaque, demineralization, and/or staining • Children who sleep with a bottle or breastfeed throughout the night • Later-order offspring (with family history of early childhood caries) • Children in families of low socioeconomic status J. Crall - OK HS DHI

11. Dental Home Policy & Program Linkages • Head Start program standards include reference to establishing dental homes for Head Start children • Linked to Medicaid EPSDT requirements • EPSDT dental periodicity schedules • State of Iowa Medicaid “I-Smile Dental Home Program” • The American Academy of Pediatric Dentistry’s definition of a dental home is the conceptual framework in this proposal. The I-Smile proposal consists of a dentist, supported by a network of dental and non-dental public and private healthcare providers providing preventive and care coordination services. These services include screenings, preventive therapies, education, and referrals for dental treatment by a dentist. J. Crall - OK HS DHI

12. Considerations for Primary Care Delivery • Medical Home – Dental Home Linkages • MI “Points of Light” Program • Identify community dentists willing to provide dental care for children beginning at an early age • Provide lists to primary medical care providers to facilitate referrals • Community-based Care Coordination • ABCD Program (WA et al.) • ‘Patient Navigators’ (CA, SC) • Primary Care Case Management • New models (ADA Community Oral Health Coordinator?) J. Crall - OK HS DHI

13. Population-based Oral Health Management J. Crall - OK HS DHI Adapted from: Crall JJ. Ped Dent 2005;27:323-330.

14. Developing Better Systems Based on Primary Care Principles Crall JJ. Ped Dent 2005;27:323-330. • Chronic disease • Primary care model (continuous care) • Service integration based on limits of current dental and primary care sectors • Questions and considerations for improving systems J. Crall - OK HS DHI

15. Models for Establishing Dental Homes • Direct on-site services in HS centers • Dental assessments (more than ‘screening’) • Preventive services (e.g., fluoride varnish) • Additional services, if necessary in dental offices or clinics • Radiographs • Restorative or other treatment services • Periodic comprehensive ongoing care J. Crall - OK HS DHI

16. Overcoming Challenges inEstablishing Head Start Dental Homes • Keeping appointments • Educate and motivate parents • Transportation • Getting dentists to participate • Outreach • Education of general dentists • Linking general dentists & pediatric dentists • Services for programs in remote areas • Team approaches (DH, GD, PD, others) • Medicaid J. Crall - OK HS DHI

17. Questions?