In this webinar, we discussed medical-dental integration efforts and how oral health can be integrated during pregnancy. We discussed its importance, why the prenatal period is an ideal time to integrate oral health efforts, and how you might participate in similar integration efforts in your LOHP. Our primary presenters were Drs. Ana Coutinho and Monica MacVane-Pearson who spotlighted their work at La Clínica de La Raza where they have been integrating oral health into their prenatal care as part of the Consortium for Oral Health Systems Integration and Improvement (COHSII).

Learning objectives:

1. Understand the importance of oral health during pregnancy and the value of medical-dental integration.
2. Learn from a case study in medical-dental integration: La Clínica de La Raza and the Consortium for Oral Health Systems Integration and Improvement (COHSII).
3. Discuss ways in which to implement learnings in your local oral health programs.

Materials:

Speaker bios

Slide deck

Recording (1:29:42)

Q & A: 

Questions around the logistics of the La Clínica de La Raza program:

1. When a referral is made for dental care, how soon can a patient get an appointment? This depends on how urgent the patient’s needs are – urgent referrals can be seen day-of or within a couple of days. If the medical department has a patient onsite and calls over to dental, they can be seen immediately. For routine referrals, we block 8 appointments per week for pregnant patients thus appointments are available within three weeks. However, we have difficulty getting in touch with patients to schedule appointments and have many no-shows which creates delays in entering dental care.
2. How do you determine who has access to the EHR systems? Is it just admin? Who makes sure everything is put into patient charts in a timely manner? All of our medical staff have access to Epic as the EHR and all of our dental staff have access to Dentrix as the EHR. We have two medical staff (one provider, prenatal coordinator) who have access to Dentrix and 3 dental staff (provider, 2 admin) who have access to Epic to work on the referral queue. In terms of medical staff needing access to Dentrix, this is minimal since our dental staff do a great job of updating the referral status in Epic. Dentrix would just help us get the exact date of their appointment or any evaluation of the appointment.
3. Can you share the number of staff used during the program? In other words, to replicate this program, how many new staff or FTE will a clinic require? No new staff were added to this project, only existing staff, but probably 5% of time was reallocated to one dental assistant to review the referrals placed by medical staff members to implement the program. Because we are routinely doing education during visits, the only true need was to block appointments for pregnant folx and to find a workflow for referrals; all other duties were already being done.
4. Did you create a training for dentists on treating patients during pregnancy? Familiarity and comfort with treating pregnant patients is assessed during a dentist’s hiring interview. We go over policies and protocols during orientation and discuss it periodically during provider meetings.
5. Did you create a training for the medical assistants to apply varnish and document in the EHR? Our dental team trained the medical assistants on fluoride application during two in-person sessions. This training was the easiest since our medical assistants already apply fluoride to children and adults are much more patient. Getting medical assistants to do it though required encouragement. The dental team also taught the medical providers how to perform a quick oral exam with an initial training and then a follow-up refresher. All of the EHR documentation was already in our EHR/Epic from children and we created a phrase to use for a normal oral exam. Smiles for Life currently has a module for "Pregnancy and Womens Oral Health," which we had all providers (medical and dental) complete. It is ~1 hour. Additionally, NNOHA (National Network for Oral Health Access) is in the process of creating a webinar or self-paced modules in 2024 which would be targeted at dentists.

Questions around preventive services:

1. Have you considered chlorhexidine use during pregnancy? If not, why? While we have chlorhexidine in our clinics, it’s used on a case-by-case basis, not routinely use it for any particular population.
2. Does your clinic use silver diamine fluoride? If so, is it applied only on some patients (e.g., children and pregnant patients) or can it be applied on all patients? We do have SDF in our clinics. SDF is meant as holding care for caries that cannot be definitively treated. Normally pregnant women’s caries can be definitively treated during the pregnancy. If there were some reason we could not provide definitive treatment, SDF could be considered in consultation with the pregnant woman regarding risks/benefits/alternatives and any insurance/financial considerations. I would bet SDF has not been tested for use in pregnant populations, so the provider and patient would have to consider that too.
3. Do patients get more applications of fluoride if they are at high risk to reduce their risk? In this project, pregnant women receive fluoride varnish once in the medical department. In the dental department, the variety of fluoride-delivery modalities are recommended to patients of all ages based on caries risk.