By Melissa Patrick
Kentucky Health News
Three studies reported in the autumn edition of The Journal of Rural Health show different ways a regular health care provider can help patients get access to dental care, and all three articles say that integrating oral health and primary care would benefit patients.
The first study, using data from more than 26,000 participants in the 2012 Medical Expenditure Panel Survey, looked at whether having a "usual source of care" makes a difference in whether a person gets preventive dental checkups. A usual source of care, which researchers call a "USC," is a place where a person goes when he or she is sick or needs medical attention – not including an emergency room.
The study found that about 66 percent of individuals with a USC had a preventive checkup, while only 47 percent of individuals without a USC did.
Both rural and urban residents with a USC were 11 percent more likely to have at least one dental checkup per year. "This demonstrated that no matter where people live, having a USC was associated with a higher probability of having at least one preventive dental checkup," the article says.
However, the study also found that rural adults had "significantly lower odds" of getting an annual preventive dental exam that those living in urban areas – 51.5 percent vs. 63.4 percent, respectively.
The researchers said incorporating dental care into primary care "may help mitigate the challenges due to a shortage of oral health care providers in rural areas," and noted that previous research and the World Health Organization have recommended such integration.
The article offers an example of how this might work: "Primary care providers can be trained to provide regular dental screenings and oral health risk assessment, and oral-health care providers can help identify patients with increased risk for developing cardiovascular disease."
The article, "Preventive Dental Checkups and Their Association With Access to Usual Source of Care Among Rural and Urban Adult Residents," added that tele-dentistry and mobile dental clinics could be part of the solution to improve oral health access.
Preventive dental care is least likely in the South, where 58 percent of residents had a preventive dental service in the past year. Southern states, including Kentucky, have "a lower density" of health care providers, including dentists, the researchers noted.
They remind readers of the importance of annual dental exams: "Lack of preventive dental care can result in a higher prevalence of dental caries, periodontal disease, tooth loss, oral cancer, cardiovascular disease and other negative health outcomes, leading to a decreased quality of life."
Having usual source of care doesn't eliminate black-white disparities
The second study examined how having access to a USC affected the oral health of older adults, specifically looking at differences between African Americans and whites. It used data from more than 15,000 adults aged 50 and older from the national Health and Retirement Study.
The research also established that having a USC made dental care more likely, but the association between a USC and tooth loss in rural areas varied greatly by race, with blacks having more tooth loss than whites even if they had a USC.
The study found that 28 percent of rural blacks had lost all their teeth, compared to 18.7 percent of urban blacks, while 17.5 percent of rural whites had complete tooth loss, compared to 11.1 percent of urban whites.
The report found that both races in rural areas have substantially more tooth loss and fewer dental visits when compared to their racial counterparts in urban areas.
The same held true for dental visits, with 34.3 percent of rural blacks reporting having a dental visit in the previous two years, compared to 49.3 percent of urban blacks; 62.4 percent of rural whites had had a dental visit in the prior two years, compared to 73.5 percent of urban whites.
The study also showed sizable differences between the races in reports of a USC in both rural and urban areas. In urban areas, 88 percent of whites reported a USC, compared to 78 percent of blacks; in rural areas, 88 percent of whites reported having a USC, while only 70 percent of blacks did.
The report stressed that having a USC did not completely eliminate the differences in oral health between whites and blacks. It noted that even with a USC, older rural blacks appeared to have more tooth loss and fewer recent dental visits when compared to older rural whites.
"These findings may underscore continued disparities in community access to both health care and dental care and poorer quality of care for rural blacks," says then article, "The Role of Primary Care for the Oral Health of Rural and Urban Older Adults."
It reports that one in four adults age 60 and older have no natural teeth, "with blacks having significantly higher rates of missing teeth when compared to whites." It also found that Appalachia and the Mississippi Delta have higher rates of tooth loss than the U.S. population in general.
These regional disparities could be explained by "rapidly aging populations, a greater proportion of blacks, less fluoride in the water, and lower socioeconomic status" and "older rural populations, and particularly blacks, may also have had limited access to preventive dental care as children," the researchers write.
They conclude, "Access to primary health care was associated with improved oral-health outcomes, but it did not close the gap between whites and blacks in rural areas."
The researchers said an integration of primary and oral health care could particularly benefit older adults who smoke or have diabetes, which increases the risk of poor oral health. They also suggested that primary-care physicians need more oral-health education, and stressed the importance of new models of care, like the medical home, to better integrate geriatric dental care into the primary-care setting.
"These findings are important for public health because missing teeth may contribute to limited food choices, poorer nutritional intake, and lower quality of life," says the report.
Medical-dental referral networks help but aren't always dependable
The third article reports that collaboration between doctors and dentists works in rural areas.
The study looked at rural medical-to-dental referral networks. It involved 559 medical and dental professionals from 44 states who attended one of 10 continuing-education classes about collaboration. It also looked at whether rural health clinics, which get incentives to care for Medicaid and Medicare patients, but otherwise act a private practice, have different medical-to-dental experiences than other types of practices.
The study found that nearly half (48.7 percent) of the participants reported their medical-to-dental referral systems were dependable. A plurality (40.6 percent) said their referral system was bi-directional, meaning medical and dental practices referred to each other; 25.9 percent reported systems that were one-directional, with medical referring to dental; 33.5 percent reported having no referral system.
The survey found no rural-urban differences. "Our study demonstrates that, in this motivated study population, medical-to-dental referrals can work well, even in rural areas," the researchers wrote.
They also found that accountable-care organizations, which work under a prevention-focused care model, were over five times more likely than rural health clinics to report dependable medical-to-dental referral systems. Federally qualified health centers, which "have long been identified as medical-dental integrators," were just over three times more likely than rural health clinics report dependable referral systems.
Practitioners with electronic health records and the ones who made referrals by way of a "warm hand-off or internal information exchange," which is typical of an ACO or hospital network, were the most likely to report they had a dependable referral system.
The report notes that the federal Health Resources and Services Administration has made recommendations on integration of oral-health and primary-care practices, but both the medical and dental participants reported dissatisfaction with communication between the professions, and better guidelines are needed, says the report.
The article points out that the Patient Protection and Affordable Care Act was written to support collaboration between health professionals through the use of electronic health records, patient-centered medical homes and accountable-care organizations. That said, the researchers said they were surprised that states that expanded Medicaid under the ACA did not report that they had a more dependable medical-to-dental referral system.
"This may reflect previous findings that increasing benefits coverage may not necessarily lead to increased dental-care utilization, especially if certain environmental, social, and economic characteristics are absent," the article says. "When enabling conditions such as reduced administrative burdens, improved oral-health prioritization, dental-care affordability, higher Medicaid reimbursement, and a better understanding of dental benefits by patients are present, effective utilization appears more likely to occur."
The study is titled "An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality."
Kentucky Health News
Three studies reported in the autumn edition of The Journal of Rural Health show different ways a regular health care provider can help patients get access to dental care, and all three articles say that integrating oral health and primary care would benefit patients.
The first study, using data from more than 26,000 participants in the 2012 Medical Expenditure Panel Survey, looked at whether having a "usual source of care" makes a difference in whether a person gets preventive dental checkups. A usual source of care, which researchers call a "USC," is a place where a person goes when he or she is sick or needs medical attention – not including an emergency room.
The study found that about 66 percent of individuals with a USC had a preventive checkup, while only 47 percent of individuals without a USC did.
Both rural and urban residents with a USC were 11 percent more likely to have at least one dental checkup per year. "This demonstrated that no matter where people live, having a USC was associated with a higher probability of having at least one preventive dental checkup," the article says.
However, the study also found that rural adults had "significantly lower odds" of getting an annual preventive dental exam that those living in urban areas – 51.5 percent vs. 63.4 percent, respectively.
The researchers said incorporating dental care into primary care "may help mitigate the challenges due to a shortage of oral health care providers in rural areas," and noted that previous research and the World Health Organization have recommended such integration.
The article offers an example of how this might work: "Primary care providers can be trained to provide regular dental screenings and oral health risk assessment, and oral-health care providers can help identify patients with increased risk for developing cardiovascular disease."
The article, "Preventive Dental Checkups and Their Association With Access to Usual Source of Care Among Rural and Urban Adult Residents," added that tele-dentistry and mobile dental clinics could be part of the solution to improve oral health access.
Preventive dental care is least likely in the South, where 58 percent of residents had a preventive dental service in the past year. Southern states, including Kentucky, have "a lower density" of health care providers, including dentists, the researchers noted.
They remind readers of the importance of annual dental exams: "Lack of preventive dental care can result in a higher prevalence of dental caries, periodontal disease, tooth loss, oral cancer, cardiovascular disease and other negative health outcomes, leading to a decreased quality of life."
Having usual source of care doesn't eliminate black-white disparities
The second study examined how having access to a USC affected the oral health of older adults, specifically looking at differences between African Americans and whites. It used data from more than 15,000 adults aged 50 and older from the national Health and Retirement Study.
The research also established that having a USC made dental care more likely, but the association between a USC and tooth loss in rural areas varied greatly by race, with blacks having more tooth loss than whites even if they had a USC.
The study found that 28 percent of rural blacks had lost all their teeth, compared to 18.7 percent of urban blacks, while 17.5 percent of rural whites had complete tooth loss, compared to 11.1 percent of urban whites.
The report found that both races in rural areas have substantially more tooth loss and fewer dental visits when compared to their racial counterparts in urban areas.
The same held true for dental visits, with 34.3 percent of rural blacks reporting having a dental visit in the previous two years, compared to 49.3 percent of urban blacks; 62.4 percent of rural whites had had a dental visit in the prior two years, compared to 73.5 percent of urban whites.
The study also showed sizable differences between the races in reports of a USC in both rural and urban areas. In urban areas, 88 percent of whites reported a USC, compared to 78 percent of blacks; in rural areas, 88 percent of whites reported having a USC, while only 70 percent of blacks did.
The report stressed that having a USC did not completely eliminate the differences in oral health between whites and blacks. It noted that even with a USC, older rural blacks appeared to have more tooth loss and fewer recent dental visits when compared to older rural whites.
"These findings may underscore continued disparities in community access to both health care and dental care and poorer quality of care for rural blacks," says then article, "The Role of Primary Care for the Oral Health of Rural and Urban Older Adults."
It reports that one in four adults age 60 and older have no natural teeth, "with blacks having significantly higher rates of missing teeth when compared to whites." It also found that Appalachia and the Mississippi Delta have higher rates of tooth loss than the U.S. population in general.
These regional disparities could be explained by "rapidly aging populations, a greater proportion of blacks, less fluoride in the water, and lower socioeconomic status" and "older rural populations, and particularly blacks, may also have had limited access to preventive dental care as children," the researchers write.
They conclude, "Access to primary health care was associated with improved oral-health outcomes, but it did not close the gap between whites and blacks in rural areas."
The researchers said an integration of primary and oral health care could particularly benefit older adults who smoke or have diabetes, which increases the risk of poor oral health. They also suggested that primary-care physicians need more oral-health education, and stressed the importance of new models of care, like the medical home, to better integrate geriatric dental care into the primary-care setting.
"These findings are important for public health because missing teeth may contribute to limited food choices, poorer nutritional intake, and lower quality of life," says the report.
Medical-dental referral networks help but aren't always dependable
The third article reports that collaboration between doctors and dentists works in rural areas.
The study looked at rural medical-to-dental referral networks. It involved 559 medical and dental professionals from 44 states who attended one of 10 continuing-education classes about collaboration. It also looked at whether rural health clinics, which get incentives to care for Medicaid and Medicare patients, but otherwise act a private practice, have different medical-to-dental experiences than other types of practices.
The study found that nearly half (48.7 percent) of the participants reported their medical-to-dental referral systems were dependable. A plurality (40.6 percent) said their referral system was bi-directional, meaning medical and dental practices referred to each other; 25.9 percent reported systems that were one-directional, with medical referring to dental; 33.5 percent reported having no referral system.
The survey found no rural-urban differences. "Our study demonstrates that, in this motivated study population, medical-to-dental referrals can work well, even in rural areas," the researchers wrote.
They also found that accountable-care organizations, which work under a prevention-focused care model, were over five times more likely than rural health clinics to report dependable medical-to-dental referral systems. Federally qualified health centers, which "have long been identified as medical-dental integrators," were just over three times more likely than rural health clinics report dependable referral systems.
Practitioners with electronic health records and the ones who made referrals by way of a "warm hand-off or internal information exchange," which is typical of an ACO or hospital network, were the most likely to report they had a dependable referral system.
The report notes that the federal Health Resources and Services Administration has made recommendations on integration of oral-health and primary-care practices, but both the medical and dental participants reported dissatisfaction with communication between the professions, and better guidelines are needed, says the report.
The article points out that the Patient Protection and Affordable Care Act was written to support collaboration between health professionals through the use of electronic health records, patient-centered medical homes and accountable-care organizations. That said, the researchers said they were surprised that states that expanded Medicaid under the ACA did not report that they had a more dependable medical-to-dental referral system.
"This may reflect previous findings that increasing benefits coverage may not necessarily lead to increased dental-care utilization, especially if certain environmental, social, and economic characteristics are absent," the article says. "When enabling conditions such as reduced administrative burdens, improved oral-health prioritization, dental-care affordability, higher Medicaid reimbursement, and a better understanding of dental benefits by patients are present, effective utilization appears more likely to occur."
The study is titled "An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality."
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