4Whole Health Through Oral Health

SCHOOL-BASED HEALTH CENTERS

Karen Hall, the oral health integration manager of Capitol Dental Care in Oregon, shared data about school-based health centers that provide holistic health services for students, staff, and community members. In the United States, there are 3,900 school-based health centers, said Hall, and in 2022, a survey was performed on 40 percent of the centers in the United States (School-Based Health Alliance, 2023). Most of these centers are located onsite at an elementary, middle, or high school. Many school-based centers bring in mobile clinics to provide additional services, such as dental or vision care. Each provider at the center bills separately and has different referral pathways to specialists to get care outside of the center.

Hall explained this concept by using one center as an example: the Central Health and Wellness Center. This school-based center provides comprehensive care, including dental, behavioral health, mental health, and primary care. Providers often screen patients for services outside of their area of expertise; for example, the medical provider screens for dental needs and will make the necessary referral if an intervention is indicated. Staff have identified benefits to working at the center, including providing wraparound services for patients to receive holistic care, which has resulted in shared learning by staff and lower staff turnover rates. Further, Hall said, family members can see different providers during the same appointment visit, saving them time and making it easier to coordinate with work and school. Hall noted that approximately 1,266 unique patients were served in 2023 at the wellness center for a total of over 2,100 visits. Roughly half of the patients were community members, and 30 percent were served by more than one provider, she said.

A member of the audience asked Hall if families have to opt in for each of these services. Hall answered saying that patients are required to provide signed consent for each of the services. This led Weyant to ask how funding is secured for the centers. Hall said that each entity has its own funding mechanisms and sees mainly patients from the Medicaid population. Overall, this has been a sustainable way of funding the centers.

ORAL HEALTH PROMOTION AND CARE FOR PATIENTS WITH MENTAL HEALTH CONDITIONS IN ZIMBABWE

Cleopatra Matanhire, Department of Oral Health, University of Zimbabwe, and director of the Oral Ling Axis Trust, and Kudzai Murembwe-Machingauta, training coordinator at Oral Ling Axis Trust and technical lead for Covid Go at OPHID at the Africa University Zimbabwe, described the situation in Zimbabwe and outlined their work in creating a basic package of oral health promotion and care for patients with mental health conditions. The duo, from medicine and dentistry, explained that the health care system in Zimbabwe is constrained in terms of money and human resources. The Ministry of Health and Childcare Services in Zimbabwe provides free services and dental care for people living with mental health conditions. Matanhire and Murembwe-Machingauta provided training for mental health care professionals to raise community awareness of the oral health and dental treatment needs of these patients. They discussed the situation at an institute for mental health where many mental health providers work, but the institute had only one dental technician, who was underused. The pair provided interprofessional training so other providers could conduct simple oral exams, refer patients to dental providers when needed, and raise alarms when patients reported being in pain. This change in approach brought providers together, helping them to find new ways to collaborate.

In the future, Matanhire and Murembwe-Machingauta plan to take their efforts into communities to engage caregivers and work with churches and places where they believe they can have a positive impact. However, the economic situation in Zimbabwe has led to a shortage of basic oral hygiene aids, said Matanhire. This led them to a new plan where they will go back to more traditional oral medicines readily available in the environment to overcome this obstacle while also studying the value of these traditional medicines for oral health. Further, the medical–dental team intends to expand into the private sector to help make treatments more accessible and bring training to a virtual platform to allow and expand their reach beyond the provinces in which they currently work. Overall, their goal is to influence policy and to ensure that training for mental and oral health professionals is adequate to cater to the needs of vulnerable populations.

Before leaving the stage, Weyant asked Matanhire and Murembwe-Machingauta whether dental providers in Zimbabwe also ever perform mental health assessments. Matanhire responded that dental providers are trained in Zimbabwe together with medical colleagues in all courses and rotations. To a certain extent, she said, there is already a level of knowledge there to facilitate the possibility.

INTEGRATING ORAL HEALTH INTO GENERAL HEALTH AT INFANCY

Rita S. Villena, chair of the Pediatric Dentistry Department at the University San Martin de Porres in Peru, spoke next. She discussed a program initiated in Peru, where there is a high percentage of early childhood caries in the first 36 months of life, in part because of inequalities in the country with access to care. Villena implemented a new initiative as part of the already existing mother and child program, which is a mandatory and easy-to-access program that includes health checks and vaccinations. For this program, a protocol was created to integrate oral health into general health, working with nurses in charge of the program. The nurses received training, after which a study was performed. Villena said the study showed that education and the use of an oral health information and record card included with the vaccination card was an effective way to decrease the prevalence of cavities. Furthermore, in the study group, there were no pulp-involvement lesions and therefore no one required more invasive treatments. The study showed that these effects resulted in lower costs. Villena said the oral health information card was essential as a tool to connect the nurses in the program with the dentist. Villena argued that installing good habits “during infancy” is easier than changing bad habits at later ages.

Weyant asked if Villena was planning to scale her educational intervention, and if so, how she plans to undertake the expansion. Villena said that having established the scientific support for the initiative, she and her colleagues do plan to expand the program. Recently, the idea was proposed to the Ministry of Health so, if approved, Villena is hopeful she will be able to offer the program to the whole country. A follow-up question asked Villena what barriers she thinks she will need to overcome, particularly when moving the initiative from private to public organizations. Villena responded that a key barrier to scaling up the program will be training the workforce, which includes training dentists to treat infants. Weyant added that such training would have to be ongoing as turnover of staff occurs.

COMMUNITY-BASED OUTREACH EDUCATION IN FLORIDA

The next to present was Olga S. Ensz, director of community-based outreach at the University of Florida. She discussed the Putting Families First service learning experience at the University of Florida that has been in place for 25 years. In this program, students form interprofessional teams and are connected with an individual or family member in the community. This experience allows students from different backgrounds to come together and become immersed in a community member’s life outside of a clinical setting, to recognize the unique challenges and social determinants the community member may face, and to collaborate with them to promote their oral and overall health and well-being, Ensz said.

The program includes students from dentistry, medicine, nursing, pharmacy, public health and health professions, and veterinary medicine. The goal of the project is to develop a collaborative person-centered health promotion project. Specifically, it aims to have students understand how social, cultural, economic, and political determinants affect individual, animal, and population health. Further, Ensz said, the program advocates recognizing the importance of interprofessional collaboration in health care, because once students understand how to work interprofessionally, they will be ready to enter the workforce as members of a collaborative practice team.

In the discussion with the audience, a participant asked whether there are data to say if the program improves patient outcomes. Ensz answered that it is unclear whether the program affects health outcomes of the community members participating as that is not measured. However, it is known that participants develop a greater awareness of resources that are available to them and they enhance their medical knowledge. Another audience member asked if there were data on whether students continued this type of interprofessional collaboration later in their careers. Ensz explained that currently no data are captured as to whether this program enhances interprofessional collaboration in practice after education.

MINI MOUTH CARE MATTERS IN ENGLAND

Urshla Devalia, consultant pediatric dentist at Eastman Dental Hospital at UCLH (London) and national lead for Mini Mouth Care Matters, was the final speaker of this session. She began her presentation saying that in England there are major issues in the health care system with dental services where the funding system does not incentivize prevention care. This results in many children and young people needing anesthetic treatment for teeth to be removed. In the UK, the British Society of Pediatric Dentistry has coordinated with the Royal College of Pediatrics and Child Health to provide a definition of dental neglect. This is defined as the persistent failure to meet a child’s basic oral health needs, likely to result in serious impairments of a child’s oral or general health or development.

Devalia described the oral health situation as being “in the worst crisis the nation has seen in the last 75 years, according to research conducted by the Nuffield Trust” (Williams et al., 2023a). While the cause of the crisis is multifactorial, stemming mainly from lack of funding and too few oral health providers serving in the National Health Services, the situation and personal experiences as a pediatric dentist motivated Devalia and her colleagues to start a program in the UK called Mini Mouth Care Matters (Mini MCM). The program was launched in 2019 and focused on “making every contact count.” Training was delivered to make sure that medical and allied health care professionals were provided with the knowledge, skills, and tools to recognize what healthy and unhealthy mouths look like.

The project started in the inpatient setting and was later expanded. For this program a hospital guide and a suite of online course materials were developed. Devalia said that all practitioners were trained to look into the mouth and, using the Mini MCM mouth care assessment tool, identify those children and young people with unmet dental needs and direct them to appropriate services. With the health care team taking the oral health advice and prevention to the patients, they can reinforce prevention messages and seek out those who require care, as opposed to those attending dental clinics in an emergency situation.

More recently, Devalia worked with care providers for children and young people with special needs to “work with those groups who don’t necessarily have a voice to see what matters to them to tailor the resources appropriately.” She presented some examples of the projects that aimed to improve the situation for those with disabilities. A dental passport was developed that each patient carries with them, stating their likes, dislikes, and what they want to avoid when coming into the dental clinic to help those with sensory needs. Her team also created information for families to help them cope with children who might have sensory challenges with toothbrushing, and a dental pain communication chart was created for nonverbal patients.

Devalia described how she used all of the resources in a remote setting. Teledentistry enables assessments to be performed with a parent or caregiver present who the child is comfortable with. The parent or caregiver can then discuss the child’s situation with a dentist who can determine where the child needs to be seen to ensure dental interventions take place in an appropriate setting for that child or young person. When asked if there was any additional reimbursement for the health providers doing the mouth assessments, Devalia noted that in the British system this is not an issue as everybody is paid their salary within a hospital setting, so there is no need for additional funding for a project like this. Hall then asked if dentistry is also privatized in the UK. Devalia responded that because dentistry is free for children under 16 years of age, and up to 18 years for those in full-time education, privatized pediatric dentistry is not common.

An audience member noted that the United States and the UK spend substantial amounts of funding and health care resources on trying to treat tooth decay in primary teeth in children under the age of 6 years, and then the rest of their lives it seems to become scarce. While not disagreeing, Devalia did comment that the wider picture and social determinants of health should be considered, “Inequalities are common, and teeth are often the collateral damage,” she said.