Care Coordination Among Pediatricians and Dentists

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´╗┐Care Coordination Among Pediatricians and Dentists

Discussion


This study of NC dentists who see infants and toddlers examined dentists' opinions about how physicians should promote oral health in early childhood. Using a case scenario of an 18-month-old low-caries-risk child provided an optimal situation whereby dentists would be most likely to provide care because no restorative treatment was needed. Our findings highlight the variation in dentists' opinions about physicians' role in preventing dental disease, and the factors influencing dentists' opinions, including guideline awareness and dental workforce availability.

We observed that almost one-half of dentists recommended physicians refer a low-risk 18 month old to a dental home at 3 years of age regardless of dentist availability, which differs from the AAPD recommendations of referring all children at one year. Responses to the case scenario varied by provider type, with 84% and 40% of PD and GD, respectively supporting referral now. A prior study reported similar findings, but did not examine the role of workforce availability in dentists' opinions regarding the age 1 dental visit.

When faced with a limited dental workforce, 34% of dentists recommended immediate referral, 37% recommended wait and refer with continued screenings during well-child visits, and 26% agreed that physicians should provide preventive oral health services including fluoride varnish during medical visits. No difference between PD and GD existed with the latter. The majority of dentists believed that a low-risk child should not receive professional-applied fluoride in medical homes. It is uncertain whether provider responses indicate opposition to physicians delivering oral health services or confusion due to varying guidelines. The most recent AAP policy statement (2008) states that administration of fluoride varnish by medical practitioners is appropriate for patients with significant risk, but also recommends annual once yearly fluoride application for low risk children. This recommendation differs from AAPD dental guidelines stating that children with low caries risk may not receive additional benefit from topical fluoride application. Additionally, we observed varying responses to how a low risk child should be triaged based on dental workforce availability. Thus, organizations should consider promoting uniform guidelines across professions that better reflect the current availability of dentists to encourage care coordination.

Regression results indicate that dentists were more likely to follow AAPD guidelines for the low-risk child in the case scenario if they agreed that referrals increase dental homes, believed the age one dental visit prevents ECC, and were aware of guidelines. While positive infant oral health attitudes, including guideline awareness, continue to be an important component influencing provider practice behaviors, strategies should focus on referral environments because promoting referrals may be even more important, above provider opinions, in promoting coordinated care. Early referral to a dental home, however, has been historically met with some reservation from dentists. Dentists report parents' lack of value for the age 1 visit as the most common barrier to performing infant evaluations, thus highlighting the importance of targeting parents to encourage successful referrals.

Strategies aimed at promoting coordinated care should support providers already collaborating and also encourage those who are not yet engaged. To encourage GDs to see young children, Garg and colleagues identified training and the presence or access to a pediatric dentist consultant as desired and potential facilitators. Engaging educational interventions for primary care providers, like small group discussions and interactive workshops, may also help promote behavior change. For example, Chapter Oral Health Advocates (COHA) trained physicians from 64 AAP Chapters to collaborate with physicians and dentists in their states to increase oral health awareness. Similarly, the Carolina Dental Home Initiative aims to fortify relationships between physicians and dentist to facilitate and improve referrals to dental homes. These types of initiatives require further assessment to determine their long term impact on providers' opinions and oral health outcomes.

Medical and dental school education provides an opportunity to promote interprofessional collaboration and encourage positive referral environments; particularly in light of our findings that recent graduates were less adherent to the AAPD guidelines than older graduates. New modifications in accreditation standards for dental education programs now incorporate collaboration with health care professionals and a standard of competency in communicating and collaborating with other members of the health care team to facilitate the provision of health care. Educational strategies on how best to promote collaborative care require further attention. A study by Chung and colleagues examined dental and medical students' knowledge and opinions on infant oral health. While dental students were more likely than medical students to provide correct responses regarding the timing and importance of the age 1 dental visit, fourth year dental students were less likely than first year dental students to recommend and agree it is important to establish a dental home by age 1. While counterintuitive, the authors concluded that increased experience may not always lead to desired results. Consideration of how increased student debt may influence their desire to provide less financially rewarding services warrants consideration, as well as the role of gender in promoting positive opinions regarding physician referral.

This study should be considered in the context of its limitations. First, we examined only dentists who care for infants and toddlers in NC. Because few NC dentists see infants and toddlers, we were unable to estimate separate regression models for PDs and GDs or examine interaction effects among variables. Strategies to engage dentists who do not currently see infants and toddlers may need to be different. Second, although case scenarios are widely used in simulating clinical practice, our specific case did not specify insurance type or financial status of the patient, possibly influencing responses. Third, although participation was lower than desired at 59%, it is consistent or better than other survey responses in this area. Finally, the generalizability of these findings is in the context of a state that has been engaged in the collaboration of physician involvement for more than a decade. Opinions may vary in other states and countries based on the level of established collaborations.

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