Stepped Care Delivery

There are many approaches to promoting oral health in the medical home. They range from oral health promotion with a coordinated dental referral to fully integrating a dental hygienist into the medical care team.

The best approach for your practice will depend on your practice size, the oral health needs of your patients, and your patients' ability to access dental services. The framework below describes a risk-based approach to meeting the oral health needs of patients ranging from low to very high risk.

Assessing Patient Risk for Oral Diseases

In small medical practices, the integrated hygienist can help assess every patient’s risk for oral diseases. In large practices, an approach that includes an assessment by the medical provider with risk-based, tiered patient management and treatment planning may be more efficient. Determining a patient’s risk for oral diseases is important to develop the best approach for disease prevention and management.

Risk Assessment Tools

Risk assessment initiates a conversation between the patient and provider about oral health behaviors and experiences. Many oral health risk behaviors can be improved through interviewing techniques designed to motivate behavior change such as self-management goal setting. Reassessing a patient’s risk at each visit helps the patient-provider team work toward optimal health. Risk assessment also takes into account medical conditions, medications, family history, oral examination, dental insurance, existing dental home, and other factors.

The following are easy to use risk assessment tools:

American Dental Association Risk Assessment Tool.
Cavity Free at Three Risk Assessment Tool.
CAMBRA Risk Assessment Tool.
Smiles for Life Oral Health Curriculum (this curriculum includes a risk assessment application for smart phones).

Oral Health Risk Assessment and Stepped Care Delivery in Medical Practices

Integrating a hygienist into a medical care team often requires a blended approach of care delivery from the medical provider and hygienist. The following framework and table summarize this approach.

A patient is “tiered” based on his/her risk for dental and gum disease. A “Tier 1” patient is considered to be at the lowest risk for dental and gum disease. In comparison, a “Tier 5” patient is considered very high risk.

Clinical Care
Patient Risk Tier	Patient Description	Clinical Care
1. Very low risk	Optimal oral health behaviors. Established dental home with regular dental care. Private dental insurance. Caregivers with good oral health. No medical conditions or medications that impact oral health. Teeth and gums exam normal.	PCP promotes oral health: Caries risk assessment. Oral health instruction. Self-management goal setting. Routine dental referral back to dental home. Risk-based recall.
2. Low risk	Optimal oral health behaviors. Established dental home with regular dental care. Public dental insurance. Caregivers with good oral health. No medications that impact oral health. Teeth and gums exam normal. No medical conditions impacting oral health.	PCP promotes oral health and provides basic preventive oral health care: Caries risk assessment. Oral health instruction. Fluoride varnish application. Self-management goal setting. Routine dental referral back to dental home. Risk-based recall.
3. Moderate risk	Less than optimal oral health behaviors. No established dental home. Irregular dental visits. Medicaid/CHP+ coverage or no dental insurance. Caregiver or sibling with caries or gum disease. Taking risky medications (e.g. frequent sugary medications; xerostomia-producing medications such as antihistamines, antihypertensive, antidepressants, diuretics, non-steroidal anti-inflammatories; and others). Medical condition that increases risk for dental and/or gum disease (e.g. developmental delay, cleft palate/lip, asthma, allergies, seizures, cerebral palsy, sleep apnea, etc.). Tobacco use (smoke and smokeless). Pregnancy. Diabetes. Xerostomia (dry mouth). Malocclusion (poor bite).	PCP promotes oral health and is supported by intervention from hygienist ranging from brief to comprehensive care: PCP assesses patient’s caries risk. Hygienist comes into medical room for exam to provide risk-based oral health education, fluoride varnish, self-management goal setting, and comprehensive dental hygiene visit in dental exam room as appropriate. Risk-based recall. Coordinated referral to dentist.
4. High risk	Poor oral health behaviors. No established dental home. Infrequent dental visits. Medicaid/CHP+ coverage or no dental insurance. Treated or untreated dental disease on exam. Insipient dental decay (white spot lesions). Gum disease on exam. Piercings. Edentulism (tooth loss). Drug-abuse. Medical conditions that increase risk for oral disease (see above). Malocclusion.	PCP promotes oral health and is supported by collaborative care team which includes dental hygienist: PCP assesses patient’s caries risk. Hygienist provides risk-based oral health instruction, self-management goal setting, performs comprehensive dental hygiene visit. Risk-based recall. Coordinated referral to dentist.
5. Very high risk	Active dental decay. Active periodontal disease. Oral pain. Mouth/tooth trauma. Dental erosions. Edentulism.	PCP promotes oral health and is supported by comprehensive dental hygienist care. PCP assesses patient’s caries risk or patient has dental hygiene visit. Hygienist provides risk-based oral health instruction, self-management goal setting, performs comprehensive dental hygiene visit. Risk-based recall. Coordinated referral to dentist.