Navigating the Dental Safety Net in San

Francisco

Irene V. Hilton, DDS, MPHSFDPH Dental Services

UCSF Department of Family & Community Medicine

Objectives

To understand the the Dental Safety Net in San Francisco

To identify appropriate dental referrals for routine dental care and for dental emergencies for DPH patients.

To learn what constitutes a dental emergency and how primary care staff can initiate management

Course

Describe SF Dental safety net» Children

– Emergency & Routine & Specialty

» Adults– Pregnant & Non-pregnant– Routine & Specialty & Emergency

Dental Emergencies– Assessment & Management

SF Dental Safety Net

FQHCs» SFDPH» NEMS» NAHC» SMHC

Dental Schools- UCSF & UOP VA- Emergency only unless 100% service

related disability Clinic by the Bay Dentists accepting DentiCal (≈ 40 offices)

2014 Changes

Prior to Jan. 1, 2014- estimate 200,000 adults w/o dental insurance in SF

Jan. 1, 2014- ACA adds all US born adults to MediCal- 15,000 new SFDPH enrollees will have dental benefits

May 1, 2014- California restores basic dental benefits for adult MediCal beneficiaries (cut July 2009)

SFDPH Dental Services

Surveillance» K screening dental caries prevalence

Population based» CHDP case management» CCS handicapping malocclusion/orthodontics» School based sealant program

Clinical Services» 5 sites + YGC

Policy/Partnerships/Collaboration

SFDPH Dental Clinics

• 5 FTE dentists @ 5 sites + YGC• SAFHC & CPHC- children & perinatal• SEHC & PHHC- children & perinatal & adult• TW- Homeless & HIV, adult

• SFGH Oral Surgery– UCSF managed collaboration– Extractions only, GA– Children & perinatal & adult

SFDPH Basic Dental CareProvided Diagnostic Preventive Hygiene/cleaning Fillings Uncomplicated

extractions Emergency- open & drain

infected teeth Anterior root canal –

SEHC & PHHC

Not Provided Dentures, partials,

crowns, bridges, implants

Surgical extractions Root Canal - Posterior

teeth Specialist care Sedation

Castro Mission Health Center (CMHC)

Potrero Hill Health Center (PHHC)

Silver Avenue Family Health Center (SAFHC)

Southeast Health Center (SEHC)

Tom Waddell Health Center (TWHC)

Chinatown Public Health Center (CPHC)

Ocean Park Health Center (OPHC)

Maxine Hall Health Center (MHHC)

Housing & Urban Health Clinic (HUHC)

Curry Senior Center

CHPY Cole Street Clinic

CHPY Hip Hop to Health Clinic

CHPY Balboa Teen Health Center

CHPY Hawkins Clinic

CHPY Larkin Street Clinic

Medical Respite and Sobering Center (Fell St)

Special Programs for Youth (SPY)

Medical Respite and Sobering Center (Polk St)

San Francisco General Hospital Oral Surgery Clinic (SFGH OS)

Interprofesssional Oral Health Competencies for Primary Care

Assess & evaluation oral health status Preventive interventions Educate & address concerns Refer

Training Curriculums

Smiles for Life www.smilesforlifeoralhealth.org

Oral Health Nursing Education and Practice (OHNEP) http://www.ohnep.org/

A+merican Academy of Pediatrics http://www.ohnep.org/

http://www.paeaonline.org/index.php?ht=d/ContentDetails/i/144233

Accessing Care

Children

SF has universal care- MediCal + Healthy Kids program

Any child 0-18 has access to health care coverage including dental

MediCal covers to age 21- HK does not

Children- Routine & Emergency Dental Care

Public & private providers Population desired since has payer

source Case management sometimes needed CHDP list every 6 months- website

Role of Primary Care

Discuss beliefs & attitudes that can be barriers to optimal oral health for kids» Tap water» “Just baby teeth”» Parent dental experience

Children- Specialty Care Issues

Pediatric Dentistry- management issues» Age, amount of treatment, special needs» Only UCSF does GA

Orthodontics (age 11-19)» CCS provider panel» Refer to general dentist first

Oral surgery- SFGH wisdom teeth

Adult Dental Care

Adults have huge pre-existing existing dental needs, especially if have not accessed care for several years

Most common dental diseases- cavities & gum disease- are chronic progressive conditions

Dental treatment $$$ because equivalent to ambulatory same-day surgery

Return of Adult Denti-Cal! May 2014

Returning» Exam/x-rays» 1 visit cleaning» Fillings» Front root canals» Prefab crowns» Full dentures

Staying- emergency Tx

ACA & Adult Dental Coverage?

US-born/documented < 133% FPL

Denti-Cal

US-born/documented >133% FPL

Φ

Undocumented Φ

Perinatal May 1, 2014Full Scope MediCal Exam/x-rays Hygiene/cleaning Emergency

Fillings Front root canals Prefab crowns Full dentures

Pregnancy Only MediCal Exam/x-rays Hygiene/cleaning Emergency

Perinatal

SFDPH has been providing full DPH dental scope to perinatal clients, regardless of payer status

Only safety net provider offering this Tremendous demand from out of

network clients

Perinatal- Routine & Emergency Dental Care

For in-network default is SFDPH clinics Complete referral form & fax to clinic https://www.sfdph.org/dph/files/

MCHdocs/PerinatalOralHlthRefForm022009.pdf

Role of Primary Care

Discuss concerns that may be barriers to optimal oral health for perinatal clients» Dental anesthesia» X-rays» Getting dental treatment

Adults- Routine & Emergency Dental Care

Full Scope MediCal FQHCs

» SFDPH- 5 sites » NEMS» NAHC» SMHC

UCSF & UOP Dentists accepting DentiCal (≈ 40 offices)

No Dental Coverage

SFDPH» SFHN member- Discounted

fees» SFHN non-member-

Emergency only

VA- Emergency only Other SF safety net

providers-sliding scale/discount

Oral Surgery Clinic @ SFGH

Monday-Wednesday-Friday

9AM-11AM 1PM-3:30PM

206-8104

What They Do

Extractions Biopsies

On call from ER Reduction of fractures Trauma Acute infection management

Who & How to Refer

Children» Emergent- trauma, swelling, pain» Routine- 0-5 with obvious need for

extraction- broken teeth » General anesthesia» Routine- late teens with third molar/wisdom

teeth

Who & How to Refer

Perinatal» Emergent- trauma, swelling, pain» Routine- obvious need for extraction-

broken teeth» MUST HAVE MEDICAL

CLEARENCE/PERINATAL ORAL HEALTH REFERRAL FORM

» May need follow-up to insure care

Who & How to Refer- AdultsFull Scope MediCal

Emergent- trauma, swelling, pain Routine- obvious need for extraction- broken teeth Wisdom teeth

No Dental Coverage

Self pay- same as MediCal

Provider of last resort- medically indicated

Acute Dental Emergencies

Trauma

Pain

Infection

Soft Tissue Trauma

Intra-oral highly vascularized

Only suture if extensive

Antibiotic or tetanus if indicated

Soft diet Analgesic

Hard Tissue Trauma

Jaw fractures Limited opening Bite “off”

Refer to SFGH OS for reduction

Tooth Displacement- Avulsion

Permanent tooth- hold the tooth by the crown (part of tooth which is above the gumline).

IF there is dirt on it rinse it under tap water (NEVER SCRUB), and immediately place it back in the socket

If this is impossible, the tooth should be placed in cold milk, special solution or wet gauze. To dentist ASAP

Tooth Displacement- Avulsion

Studies indicate if tooth is re-implanted within one-half hour after the accident, 95% success rate for normal re-attachment and growth

Due to viability of periodontal ligaments which

attach root of tooth to jawbone

Other Tooth Trauma

Fractured crown Intrusion Extrusion

Refer to dentist

Pain Infection

Occasional Pain

Occasional pain from decayed teeth or lost fillings is not a true dental emergency

However, if left untreated these could over time progress to the acute phase

Dental referral indicated

Severe Constant Pain

Most frequently caused by trauma or infection in the tooth or gums

Analgesic- Rx’d or OTC Dental referral indicated Extraction most frequent treatment

Localized Swelling

Limited to bone around infected tooth or Draining fistula If left untreated may progress to acute phase

Analgesic & antibiotic if appropriate All swellings have to be definitively treated by

removing the source of infection (extraction or root canal)

Dental referral indicated

Acute Swelling

New or increasing facial swelling affecting the eyes or distention of the mandible

If other signs of infection are present i.e. fever, nausea, disorientation, malaise, blurring of vision or inability to swallow

Immediate referral to OS or ER

Other Acute Pain

Erupting teeth Soft tissue: Primary herpetic stomatitis,

acute periodontitis, burning mouth Mucositis from chemotherapy TMJ, trigeminal neuralgia, other systemic

conditions

Palliative care

Case

4 y/o male fell this afternoon while running after cousin

Mother stated slight bleeding from tooth area, initial crying, couldn’t get a good look

Bump on head- bring to urgent care After assessment for other injuries…

Clinical Exam

Visual findings? What do you

recommend?

SFDPH Dental Services

http://www.sfdph.org/dph/comupg/oservices/medSvs/dentalSvcs/dentalSvcs.asp

“You cannot have good health if you have bad

teeth”