This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.

Good dental health is about more than just preventing cavities – and Michigan health care providers are increasingly recognizing that by integrating dental care into their primary care practices.

"Studies have shown long-term that patients with gum disease have more premature births and low birth weight babies and heart disease. Tooth loss is a risk for coronary artery disease and is connected with diabetes. Cardiovascular disease has been linked to periodontal disease," says Dr. Timothy Hill, Cherry Health's director of dental services and interim chief oral health officer. "The reality is dental care is important for whole body health care, not just for the toothache and difficulty eating."

Timothy Hill.

The negative effects of poor oral health extend into all elements of patients' lives. Oral pain and missing teeth may limit people's ability to get or keep a job, do well in school, or interact positively in relationships. And all these effects occur disproportionately in those Michiganders who are already among the state's most vulnerable. According to the 2020 Michigan State Oral Health Plan, 55.3% of Michiganders with household incomes under $20,000 did not visit a dentist in 2014, and Latinx and African-American children have much higher rates of untreated dental caries.

However, Michigan providers including Cherry Health, Grace Health, and HUDA Clinic have introduced integrated oral health models to begin addressing the issue. Here's how they're improving health and reducing disparities from the dental chair.

Cherry Health: Serving "anybody and everybody"

Cherry Health, a federally qualified health center (FQHC), integrates dental services into its eight medical clinics in Grand Rapids, Wyoming, Hastings, and Greenville.

"Broken teeth create poor aesthetics. People are not willing to smile because they're embarrassed and that can affect job interviews, friendships, and create a poor self-image," Hill says. "Dental care is important not just from the eating aspect, but for how you feel about your life."

One of Cherry Health's dental clinics.

Cherry Health also provides dental care at five school-based sites in Cedar Springs and Grand Rapids. Although focused on the underserved, Hill says its dental clinics accept "anybody and everybody," even those with insurance so that patients who have improved their ability to pay can continue care at their established dental home. Cherry Health's dental clinics provide preventive and restorative care, oral surgery, crowns and bridges, and emergency care.

"We feel that all of those services are necessary to provide good oral health," Hill says. "When providing the best oral care, it's hard to eliminate any portion of dental health care."

Because Cherry Health embeds dental clinics within medical care locations, clients can access care seamlessly and immediately when medical needs arise during a dental appointment, or vice versa. Hill cites two common examples: adults experiencing high blood pressure during a dental visit and children requiring general anesthesia for an oral procedure.

"Having multiple (clinicians) to talk to and different ways of looking at things allows us to treat our patients better," Hill says. "A kid in medical had bumped his face and the right side was swollen. He came back a couple days later with the left side swollen. Because dental care was there, I could take an X-ray. We found out he had an infected tooth and got that addressed. We were able to look at (his injury) from different aspects, in trauma and also as a tooth issue."

HUDA: Free dental care for uninsured and underinsured adults

Ten years after establishing its medical clinic, Detroit's HUDA Clinic began offering dental services in 2014, based on the needs of the clinic's client population.

"We decided to integrate dental care into our community health clinic along with our other services to create a one-stop shop for healthcare," says HUDA Clinic executive director, Eman Altairi. "A unified, comprehensive approach helped our patients with their health outcomes. When they come for physical care and realize we offer dental care, that prevents them from waiting (until a dental emergency occurs.)"

HUDA also provides primary care, mental health, podiatry, and ophthalmology services with no copays or fees. Its dental services include cleanings, X-rays, extractions, and restorative fillings. When patients have oral health issues beyond that scope, HUDA refers them to the University of Detroit Mercy School of Dentistry for low-cost treatment. HUDA also helps patients obtain dentures affordably.

"Funding is an issue, but we are always looking for ways to broaden opportunities for our clients," Altairi says.

While some of HUDA's hygienists are paid, all its dentists are volunteers. All funding comes from donations and grants.

"When it comes to oral health issues … pain might lead to neglect of other health issues. Oral health, a lot of times, is neglected till the last possible moment, when there's excruciating pain," Altairi says. "Emergency dental care is important, but we also educate patients about their oral health. Dental care is very hard to access in an underserved community."

Clinicians provide nutritional advice to dental patients and invite them to take fresh vegetables from the clinic's community garden.

"We don't know if they will come again, so we make the most out of their visit as far as oral health education," Altairi says.

HUDA hopes to include dental health as part of its outreach to children at local schools and is seeking more dental professionals to volunteer with the program.

Grace Health: Care for a quarter of Calhoun County residents

Grace Health, another FQHC also provides dental care alongside primary care, behavioral health, vision, physical therapy, and podiatry. Its dental clinics in Battle Creek and Albion treat patients of all ages with Medicaid and patients over age 60 qualifying for Calhoun County Senior Millage services. Grace Health provides dental exams, cleanings, X-rays, fillings, crowns, root canals, complete and partial dentures, periodontal treatment, and some oral surgery, with referrals to area oral surgeons in complex cases.

Dr. Kevin Steely, Grace Health dental director, says approximately a quarter of Calhoun County residents are Grace Health patients. Its Battle Creek clinic has 20 dental chairs and its Albion clinic has eight.

"We have a lot of visits," Steely says.

Kevin Steely.

Grace Health's integrated model is particularly helpful in its OB/GYN and pediatric practices.

"In the pediatrics department, kids come in and the pediatrician takes a look in their mouth," Steely says. "If they see anything, we are able to interact and make an appointment. It's convenient having them on the same site, 200 yards from where I'm sitting."

Grace Health's Portable Dentistry program also sends dental hygienists to schools where they screen, clean, and apply fluoride and sealants to insured and uninsured children at no charge. Steely has seen children as young as 15 who have needed all of their teeth extracted.

"These kids, who have not even gotten their wisdom teeth, are in dentures," he says. "A higher incidence of children who are underinsured are on ADD-type medications. … My question is: is the issue ADD or are they just in pain?"

He adds that preventive dental care is remarkably inexpensive. If children get good oral health care from infancy, they are likely to have good dental health — and improved whole health — the rest of their lives.

"The integrated healthcare model has helped patients. The challenge is providing a billable service," Steely concludes. "We, as dentists, can become very focused on the work we are doing and not always think about the rest of the patient. Here, we hear the story of what is going on in our patients' lives. We've become more competent because we know there's more than dental problems going on."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.
 

Eman Altairi photo by Nick Hagen. Kevin Steely photo courtesy of Kevin Steely. Cherry Health photos courtesy of Cherry Health.