Oral Health Care Systems

Elisa M. Ghezzi, DDS, PhDAdjunct Clinical Assistant Professor,

University of Michigan School of Dentistry (eghezzi@umich.edu)Chair, Coalition for Oral Health for the Aging (http://www.micoha.org)

Oral Health for an Ageing Population SymposiumFDI Annual World Dental Congress

Poznan, Poland10 September 2016

Presentation OutlineHealth system conceptsFunctions of oral health care

systems◦ Health promotion and education◦ Prevention◦ Assessment and diagnosis◦ Treatment

Considerations in oral health care system development◦ Disparities◦ Barriers◦ Strategies

Health systemAll the activities whose primary purpose is to

promote, restore, and/or maintain health

The people, organizations, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve

The result of combined efforts of government agencies, institutions, and resources with the main aim of improving the health of their people

WHO Health Systems Strengthening Glossary

Key components of health care systems

Leadership and governance

Health information systems

Health financingHealth workforceResourcesService delivery

World Health Organization 2010; Kandelman 2012

Oral health care systemsGoal: Maintain the health and

function of the mouth through ◦ Disease control◦ Prevention◦ Health promotion

Variability in OHCS ◦ Services provided◦ Priority of funding◦ Program sustainability◦ Research priorities and data acquisition◦ Population served◦ Vary by country and within country

Kandelman 2012

Dependency of Aging US Population

41.3 million Elders in USA, 2012/13

Seattle Care Pathway: Actions required to maintain oral health at different levels of dependency Communication: Health promotion and education Prevention Assessment and Diagnosis Treatment

Level of Dependency None: fit, exercise regularly Pre: Well controlled chronic systemic conditions Low: Chronic conditions affect oral health Medium: Chronic conditions impact access to oral health

care High: Complex medical problems; Unable to access

dental clinicPretty 2014

The Oral Healthcare Continuum

Health Promotion and EducationGoal: Individual ownership

◦ Empower to manage own oral health

Impact of increased disease and dependency ◦ Higher caries and periodontal disease

risk/Increased surveillance◦ Decrease in oral hygiene◦ Increase in medications

Preparing for future decline ◦ Functionally stable dentition◦ Maintenance plan

Health Promotion and Education: Level of Dependency

Implications of increasing dependency on oral health care and specific treatment outcomes, especially involving complicated oral prostheses

Monitor communications all caregivers, including the patient, family, friends, and members of the interprofessional healthcare team to allow for continuous adjustments by everyone to the palliative care

Explain to the patient and other attending healthcare providers, including physicians, the significance or conditions likely to complicate the management of oral health as dependency increases

Expand communications to all members of the interprofessional healthcare team; Emphasize preventive strategies to manage the risk of caries and periodontal disease, and maintain oral function without infection

Maintain communications with members of the interprofessional healthcare team; Increase vigilance of the daily oral care plan

None Pre Low Medium High

Pretty 2014

Thai community based oral healthcare model

Prayoonwong 2015

Prevention: Level of Dependency

Develop homecare plan to prevent or control infection, pain, and dysfunction

Offer palliative treatment on demand from the patient to control pain and infection and maintain social contacts and activities

None Pre Low Medium High

Pretty 2014

Consider prescriptions for caries and periodontal disease

Oral cancer: risk modification and education

Tooth surface loss

Develop daily oral care plan

Mucositis

Assess the cause for the impact on oral health

Base preventive strategies on mitigating the aggravating factors

Adjust methods of delivering pre-dependency prescriptions as needed

Assess risk of adverse effects from polypharmacy

Offer relief from dry mouth as required

Monitor effectiveness of the daily oral care plan

Maintain contact with other members of the interprofessional healthcare team to monitor and help their contributions to the oral health regimens

Re-assess the needs to increase concentrations of fluoride in toothpastes and mouthrinses

Prescribe application of preventive and therapeutic products by nurses and other care staff

Reassess risk of adverse effects from polypharmacy

Reassess need for relief from dry mouth and effectiveness of daily oral care plan

PreventionWorkforce: Long Term Care

◦Direct care staff◦Accountability◦Relationship building

 Workforce: Professional intervention

◦Dental hygiene services Maximize exposure/minimize cost Direct access and collaborative dental

hygiene practice Reduce cost & oversight requirements

Prevention Community-based health promotion and oral disease

prevention

◦ Oral health care programs including professional care and caregiver instruction in long term care facilities demonstrated reduction in oral disease

◦ Daily and professional oral care demonstrated decrease in pneumonia related complications and improved cognitive and physical function

◦ Education of caregivers improved daily oral care for institutionalized elderly

◦ Outreach services removing financial and transportation barriers improved oral health status and quality of life

Peterson 2005

Assessment/Diagnosis Goals

◦ Determine need for further care ◦ Triage to appropriate treatment

Methods◦ Questionnaire◦ Oral assessment and examination (aided by cleaning

and full mouth radiographs)◦ Telemedicine

Workforce◦ Professional preventive care◦ Social services◦ Direct care staff/Caregivers

Assessment: Level of Dependency

Adopt appropriate local, regional, or national periodic recall intervals

None Pre Low Medium High

Pretty 2014

Identify conditions threatening oral health and determine appropriate periodic recall

Consider additional diagnostic tests

Develop strategic oral healthcare plan to include professional and self care

Recognize that risk is elevated by increasing dependency

Assess long-term viability of oral health

Consider use of the wider interprofessional healthcare team for delivery of care plans

Assess possibility of elder abuse

Identify cause of increasing dependency

Assess risk of oral disorders

Increase frequency of periodic recalls as needed to assess elevated risks

Develop strategic oral healthcare plan to include professional care and self-care

Prepare for the growing risk of oral disorders as dependency increases

Assess long-term viability of oral health and management strategies

Participate with social and other medical services to assess health risks generally and review frequency of periodic recalls to manage elevated risk of oral disease

Reassess long-term viability of oral health-related preventive strategies

Examine patient’s physical, cognitive, and social context for barriers to emergency palliative and elective oral care

Monitor the burden of oral care on the patient and others, including family and friends, providing care

Monitor the oral healthcare plan with attention to the increasing complexity of delivering each element of the plan

Increase vigilance for signs of elder abuse

Virtual dental home Based on the principles of

◦ Bringing care to places where underserved populations live, work, or receive social, educational, or general health services

◦ Integrating oral health with general health, social and educational delivery systems

◦ Using telehealth technologies to connect a geographically distributed, collaborative dental team with the dentist at the head of team-making decisions about treatment and location of services

Evidence is emerging for improving both health care delivery and health outcomes while reducing oral health care costs

Glassman 2012

Treatment: Level of Dependency

Routine

None Pre Low Medium High

Pretty 2014

Consider long-term viability of restorations and prostheses

Plan treatment outcomes for easy maintenance

Identify, repair, or replace strategically important teeth to maintain function

Plan for ongoing maintenance, including restorative and surgical treatments, to maintain function and prevent or control infection and pain

Repair and maintain strategically important teet with conservative treatments

Design oral prostheses to simplify oral hygiene and prevent infection

Use prosthodontic attachments between overdentures and abutment teeth or implants to simplify hygiene and maintenance

Offer palliative treatment on demand from the patient to control pain and infection and maintain social contacts and activities

Oral health servicesTypes of Services

◦ Preventive and periodontal services Restorative and endodontic services Oral surgery Prosthetic and implant services

Workforce◦Oral health care professionals: dentists, dental

hygienists, assistants◦Expanded roles: Dental Therapists

Under supervision of a dentist Provide preventive, diagnostic, restorative, and

simple surgical care

Location Dependent on treatment needs, funding, health status, and access Local community

◦ Private practice◦ Group practices◦ Community health clinics

Hospital setting Government based

◦ Eligible military veterans (Veterans Administration Medical Centers)◦ Federally Qualified Health Clinics (FQHCs)

Mobile dentistry Community based/Population approach

◦ Telemedicine/Virtual Dental Home◦ Education

Community dwelling elders (Oral Health America) Caregivers (non-professionals) Health care providers

National public health programs

Disparities in access to oral health care

42% of US person 65+ with a dental visit in 2012

By Income24% vs 57%

By Dental Benefit StatusPrivate 67%Public 13%

Uninsured 37%

Barriers to Access to Health Care Systems for the Aging Use of professional oral health services is low among older

people, particularly among the socio-economic disadvantaged Financial limitations

◦ 24% of those 65+ in US had private dental coverage (Manski 2009)◦ Being in the labor force is a strong predictor of dental coverage

Cultural perceptions◦ Lack of dental care tradition◦ Negative attitudes toward oral health

Cognitive, Physical, Functional, Behavioural decline◦ Comorbid conditions◦ Impaired mobility

Perceived needs

Petersen 2005

Disparities in oral health status In persons 75+ in Thailand, tooth loss was associated with social

inequality.

Having 19 or fewer teeth was associated with◦ Lower level of education◦ Lower income◦ Not owning luxury goods◦ Non married status

Background: Thai Ministry of Public Health launched the Thai universal coverage scheme (UCS) in 2001 oral health coverage focuses mainly on dental services of existing disease◦ Elderly who are poor are more likely to choose tooth extraction due to inability

to afford expensive treatment options and travel costs for multiple appointments◦ Socially disadvantaged less likely to use dental services◦ 2012: 6.5% of elderly Thai people reported seeing a dentist for routine check

ups vs 44% for toothache

Geographically, 70% of Thai elderly reside in rural areas

Srisilapanan 2014

Barriers to Development of Health Care Systems for the Aging Low priority

◦ nonexistent oral health policies◦ absence or low commitment of third-party payers◦ negative attitudes of oral health professionals◦ absence or lack of interest or ignorance on the

part of the patients about predisposing risk factors poor oral hygiene cultural beliefs health care traditions

Kandelman 2012

Improving the Oral Health of older people:

WHO Global Oral Health Programme Oral health policy

Few countries have clearly stated policies and goals specifically for oral health promotion and care for older adults

National health authorities should develop policies, measurable goals and targets for oral health

Oral health care National public health programs should incorporate oral health promotion and disease

prevention based on common risk factor approach Control of oral disease through organization of affordable oral health services Target: needs for care are highest among disadvantaged, vulnerable groups in both

developed and developing countries Developing countries: Challenges to provision of primary oral health care due to workforce shortage Developed countries: Need to reorient health care services toward prevention with prevention

oriented third party payment systems Education and training for service and care

Increase health professionals and caregivers in oral health education programs to overcome barriers in oral health service utilization, improved self-care capacity, and provide a healthy diet and nutrition

Research Public health, biomedical, clinical Systematic efforts must be made to translate existing knowledge into practice Outcomes of oral health intervention programs are needed for policy development

Petersen 2005

Achieving oral health in an ageing societyDetermining the appropriate health care

system and provisions1. Provide policymakers with evidence regarding policy

effectiveness2. Inter-professional collaboration for a sustainable system3. Increasing people’s awareness of oral health measures

and the value of oral health4. Improving oral health care outreach via integrated

oral/general healthcare system

Step 4: Contributing to and achieving a healthy ageing society3. Seeking a more effective/efficient healthcare system4. Continue monitoring healthcare inequality

Fukai 2016