Katherine Weno, Senior AdvisorNCCDHP, Centers for Disease Control and Prevention

Krista Postai, Chief Executive OfficerCommunity Health Center of Southeast Kansas

* Understand the role dental staff play in early Identification of chronic disease & mental illness

* Recognize opportunities to integrate care

* Learn how a safety net clinic can evolve into treating the whole person

* Avoid costly mistakes and staff conflicts during organizational change

Today’s Objectives….

Centers For Disease Control and PreventionAmerica’s Health Protection Agency

Founded in 1946 Part of the U.S. Department

of Health and Human Services

Headquartered in Atlanta, GA 15,000+ employees in 170

occupations Field staff in all 50 states and

more than 50 countries

National Center Chronic DPHP’s Nine Divisions

Smoking and Health

Cancer Prevention and

Control

Nutrition, Physical Activity

and Obesity

Community Health

Diabetes Translation

Reproductive Health

Population Health

Heart Disease and Stroke Prevention

Oral Health

HI

CO

ND

KS

IACO

Cooperative Agreement DP13 - 1307 State Oral Disease Prevention

Rhode IslandID

SC

NY

GA

WIMN

LA

Connecticut

Vermont

Maryland

Legend:“Component 1” Grantees“Component 2” Grantees

VA

New Hampshire

WV

MS

MI

Topics for Chronic Disease and Oral Health Collaboration at CDC

Tobacco CessationHeart Disease and Stroke PreventionDiabetes Prevention and ManagementObesity Prevention

Led to new funding opportunity in 2016:1609: Models of Collaboration for State Chronic

Disease and Oral Health Programs

Tobacco and Oral HealthTobacco use – smoking and smokeless is associated with: Tooth loss Periodontal disease Oral cancer Increased caries risk Poor dental surgical/ restorative

outcomes Second hand smoke may impact caries

in childrenHanioka T, Ojime M, Tanaka K, et al: Causal assessment of smoking and tooth loss: a systematic review of observational studies. BMC Public Health 2011;11:221. Eke PI, Thornton-Evans G, Dye BA, Genco R. Advances in Surveillance of Periodontitis: The Centers for Disease Control and Prevention Periodontal Disease Surveillance

Project. J Periodontol 11 February 2012: 1–9Aligne CA, Moss ME, Auinger P, et al: Association of pediatric dental caries with passive smoking. J Am Med Assoc 2003;289:1258-1264.

Dentists and Tobacco Cessation Activities Tobacco dependence education taught in a majority of dental schools

and hygiene educational programs ADA Policy: “The Association urges its members to become fully

informed about tobacco cessation intervention techniques to effectively educate their patients to overcome their addiction to tobacco. This information should include education on primary prevention of tobacco use. “

HP 2020: Increase tobacco screening in health care settings

• Screen dental patients for tobacco use (TU-9.3) Increase tobacco cessation counseling in healthcare settings

• Provide counseling for tobacco cessation (TU-10.3)

Davis, Arnett, Loewen, Tobacco Dependence Education A Survey of US and Canadian Dental schools, JADA 2016:147(6):405-412http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/summary-of-policy-and-recommendations-regarding-to

Dental Professionals and Tobacco Cessation

Counseling for Tobacco Use and Cessation by Dental Health Care Providers, Jennifer L. Cleveland DDS, MPH1 ; Jon Ruesch MA2; Laurie Barker MSPH1 ; Chien-Hsun Li MS, MA3; Gina Thornton-Evans DDS, MPH, 2010 ADA Annual Survey of Dentists

*Oral Path, Radiology, and Public Health < 10 respondents (not listed) ** ** % who answered Always/usually ⱡ Total based on all GPs and specialists

1609 Grantee Project - TobaccoGeorgia

Pilot tobacco cessation project for dental professionals working with young pregnant women

Tobacco cessation and quitline referral training for targeted dental providers Development of a oral health provider tool kit on tobacco Education campaign in collaboration with GA Medicaid program Social Media campaign Oral health/chronic disease program advisory group to oversee project

Oral Health and Diabetes Diabetics at higher risk for periodontal disease

Diabetics with periodontal disease may have more difficulties with glycemic control Glycemic Control can be improved by periodontal treatment

Diabetes is often associated with dry mouth Tooth decay Fungal infections Tooth loss -Diabetes doubles tooth loss in US adults African American diabetic adults lose more teeth than whites and Mexican American

Pregnancy related diabetics with periodontal disease are at higher risk of poor maternal outcomes

Eke PI, Dye B, Wei L, Thornton-Evans G, Genco R. Prevalence of Periodontitis in Adults in the United States: 2009 and 2010. J Dent Res.Bei Wu, Forty-Year Trends in Tooth Loss Among American Adults With and Without Diabetes Mellitus: An Age-Period-Cohort Analysis. Preventing Chronic Disease, Vol. 12,

November 2015http://www.nidcr.nih.gov/OralHealth/Topics/Diabetes/Xiong X, Elkind-Hirsch KE, Vastardis S, Delarosa RL, Pridjian G, Beukens P. Periodontal disease is associated with gestational diabetes mellitus: A case-control study. J

Periodontol. 2009;80(11):1742–49

CDC Collaborations

http://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-dental-professionals.pdf

Healthy People 2020 Objective:Diabetes Objective #8 (D–8): Increase the

proportion of persons with diagnoseddiabetes who have at least an annual dental

examination.Target: 61.2%.

Baseline: 55.6%

Working Together to Manage Diabetes:A Toolkit for Pharmacy, Podiatry, Optometry, and Dentistry (PPOD)

1609 State Grantee - Diabetes Colorado Department of Health and Environment Collaboration between the oral health unit and diabetes unit to in include

oral health providers in diabetes prevention and case management Collaboration with Federally Qualified Health Centers to facilitate trainings,

screening and bi-directional referral Oral health providers/medical providers will have mutual performance

measures on diabetes in their Medicaid program Oral health is included in their state chronic disease plan, and staff from

both the oral health program and the diabetes program are administering the project

Oral Health and Heart Disease/Stroke

No strong evidence of direct link -Poor oral health doesn’t cause heart disease, and dental treatment doesn’t prevent heart disease/stroke BUT Share risk factors: smoking, age,

diabetes, poor nutrition Both cause inflammatory reactions

Hypertension One third of Americans have

hypertension (70 million) Over half of these have poorly

controlled hypertension 40% don’t even know they have it

Strategy: Increase Opportunities for Blood Pressure Screening in

Community Sites Vital signs: awareness and treatment of uncontrolled hypertension among adults--United States, 2003-2010. MMWR Morb Mortal Wkly Rep 2012,61:703-709James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood

pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014,311:507-520.Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010,303:2043-2050.Donahue KE, Vu MB, Halladay JR, Miller C, Garcia BA, Cummings DM, et al. Patient and practice perspectives on strategies for controlling blood pressure, North

Carolina, 2010-2012. Prev Chronic Dis 2014,11:E69; quiz E69.

Measuring Blood Pressure in Dental Offices Recommendation: BP readings for all new patients, at every

recall for all patients, hypertensive patients at every appointment

Dentists should also take health and medication histories, refer and follow up with hypertensive patients

Well accepted practice in dental community: Standard taught in dental and dental hygiene schools Over 90% of dentists were willing to measure BP for patients, 96% of dentists

would refer a patient with high BP to a physician Most dental patients (80.4–93.4%) would like to have their BP measured during

dental visitsHerman. W, Konzelman J., New national guidelines on hypertension: A summary for dentistry, J Am Dent Assoc, Vol. 135, May 2004 Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists' attitudes toward chairside screening for medical conditions. J Am Dent Assoc 2010,141:52-62.

1609 State Oral Health/Heart Disease Grantees

Minnesota - Bi-directional referrals by dentists and medical providers working in community health clinics. Primary care providers will screen patients for periodontal disease and provide referrals to dental clinics. Dental professionals will monitor patients’ blood pressure to identify patients with hypertension and refer to medical providers.

Maryland - The Office of Oral Health and the Center for Chronic Disease Prevention will do a pilot social marketing campaign on hypertension targeting African American women 35-65 in areas of with documented high health needs. Dental providers in pilot area will screen and refer for hypertension and tobacco cessation.

Oral Health and Obesity Prevention

Te Morenga L, Mallard S, Mann J (2013) Dietary sugars and body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies. Br Med J (Clin Res Ed). doi: 10.1136/bmj.e7492

Role of Food in Caries –• Sugars and carbohydrates

are metabolized by bacteria, producing acid. The acid demineralizes tooth enamel over time

• Caries doesn’t occur without sugar

• Increased caries is associated with increased sugar consumption

1609 Grantees – Oral Health and the Reduction of Sugar Sweetened Beverages

Alaska - The Oral Health Program and the Obesity Prevention and Control Program collaborating to train dental professionals and tribal dental providers to educate and counsel children and child caregivers to reduce child consumption of sugared beverages and promote increased consumption of water, including fluoridated water where available. The program will also seek to increase awareness and promote behavior change through public service announcements on this issue.

New York - The Oral Health Program and the Chronic Disease Program will develop a healthy beverage social media campaign targeting African American and Hispanic teenage boys in Western New York. Messages will focus on the contribution of sugar sweetened beverages to chronic diseases such as obesity and tooth decay.

• Build relationships through common goals• Think about new partners – commercial

insurers, workplaces, community groups• Be ready for opportunities• Think about how you will show your impact

from the start of the project

Parting Thoughts

11 Sites5,250 sq. miles

175,859 population

2016 County Health Factors

All SEK counties in bottom quartile of Kansas

Our Health* SEK has the highest rates of…

Heart diseaseCancerStrokeDiabetesAsthmaDepression

*1 in 2 adults obese

* 25% lack adequate prenatal care;

*Age-adjusted death rate is 1,075 vs. state average of 780.4 per 100,000

Our beginnings…

CHC/SEK …Designated FQHC 2003.4,000 patients to 40,000 patients11,000 visits to 150,000 patient visits

CHC/SEK Dental Program…the largest safety net in Kansas

23,000+ children from 11

counties screened annually

Outreach to Children

Area Schools, Head Starts, WIC, Child Care Facilities

Outreach to Veterans and Families coming in 2017…

CHEROKEELABETTEMONTGOMERY

WILSON CRAWFORD

BOURBON

COUNTY

ALLENWOODSON

NEOSHO

● Columbus

FREE DENTAL CARE FOR VETERANS & THEIR FAMILIES…

Early Initiatives…*Blood Pressures

*Blood Glucose, INR

*HIV/AIDs Screening

*Case Collaboration

*Joint Inservices

MORE PROGRESS FORWARD…

*Joint policies & procedures

*Shared provider experiences

*EMR access and reminder system

*Roving hygienists

*Expanded provider meetings

FULL INTEGRATION…

*Medical record for all!

*Hygienist embedded inmedical clinic

*Dental clinic connected

*Dental Coordinator

*Integrated Care Coordinator*Depression & Substance Abuse Screening

MORE TO COME…

*Mission Control – Communication Center Coordinates Care

*Common clinic design – one stop appointments

*Leadership Team expansion

QUESTIONS?

CONTACT INFORMATION…

kpostai@chcsek.org620-235-1867