From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care

A content analysis was used to synthesize, summarize and report the study’s findings. This included a descriptive analysis of the results and a schematization based on the integration framework (Rainbow model), proposed by Valentijn et al. [8] (Fig. 1). The data were also classified into two tables (Tables 1 and 2), according to the oral health outcomes and type of programs. Extracted data were grouped into various categories as shown in Tables. A triangulation was conducted by the scoping review team and the results were discussed and revised.

The stakeholders included representatives of academic health care organizations, policy decision-makers and health care professionals, as well as community and patient representatives. They were engaged through a workshop [9] and several meetings in the various steps of the scoping review including preliminary reviews of a few published articles, discussions on the study research questions and study findings, and developing effective dissemination strategies.

As presented in Fig. 2, from the total of 104 publications included in the full review, 67 reported on theoretical and applied models as well as policies in regard to the integration of oral health into primary care. These publications were from 6 countries: the United States of America (USA), Australia, Canada, Brazil, the Netherlands and the United Kingdom (UK). The publications included conceptual frameworks (n = 6), policies and strategic plans (n = 35), programmes descriptions (n = 16) and related applied research studies (n = 10). The majority of research studies were published in the last decade and were conducted in the USA.

The review identified two frameworks developed in the USA. The first, used in the Integration of Oral Health and Primary Care Practice (IOHPCP) Initiative, was proposed by the Health Resources and Services Administration [3, 10]. It covers five domains including risk assessment, oral health evaluation, preventive intervention, communication and education and inter-professional collaborative practices [3, 11]. This framework has been adopted by some Federally Qualified Healthcare Centers (FQHC) for the implementation of their tailored programmes [12]. The second, the Oral Health Delivery Framework, was recently developed in partnership with primary care and dental care clinicians, policy makers and stakeholders from medical, dental, and nursing associations, as well as end-users. The activities proposed in this framework promote proactive coordination between dental and non-dental primary care providers and include: screening patients for oral diseases, identifying particularly high-risk populations, offering fluoride varnish for paediatric patients and high-risk adults, performing patient education, dietary counseling and oral hygiene training, and developing structured documentation and referral processes [13]. Since 2015, this framework has been implemented in 19 primary health care organizations from public services and private practice in five US states, to examine its feasibility and sustainability [14].

The scoping review found that policies and strategic plans in regard to integration of oral health in primary care are rooted in universal acceptance of the primary health care approach established by the WHO Alma-Ata declaration of 1978 [15]. The first strategic plan was published in 1982 through collaboration of organizations such as the World Dental Federation (FDI) and the WHO [16]. The scoping review identified an important WHO strategic plan entitled “Oral health: Action plan for promotion and integrated disease prevention,” which was presented to the World Health Assembly and the Executive Board in 2007 [17]. Accordingly, the 193 WHO member countries agreed on implementation of the WHO Global Oral Health Programme [17‐19]. In the last decade, all of these countries have set general policies for oral health action, using these guidelines with the concept of common risk factor [18‐21]. However, because of the worldwide variation in oral health care organizational systems [22], the specific policies on oral health integrated care differ not only between countries, but also within countries at national and provincial levels. In most countries, policies have focused on care coordination plans, rather than fully oral health integrated strategies. In some countries such as Canada, Australia, the USA and the UK, policies for integrated care put emphasis on specific population groups such as early childhood, children and adults with special needs, elders, rural and remote communities, as well as Aboriginal and Indigenous populations [23‐34].

As a pioneer in the category of developing countries and based on its health reform entitled Unified Health System, Brazil has implemented different governmental, federal and municipal policies to completely integrate oral health professionals into multidisciplinary primary care teams [35, 36]. In 2004, Brazil launched a National Policy for Oral Health (NPOH) and linked this specific strategic plan to other public health care policies including the reorganization of primary care, the reorganization of specialized care, fluoridation of the water supply and oral health surveillance [37]. According to the reviewed publications, these policies were successful in the implementation of a sustainable integrated oral health care network [37] and optimizing oral health care services for all groups of citizens, despite some persistent challenges such as cost and resistance from the private oral health care sector [38, 39].

In a number of industrialized countries, various strategies have been tailored to foster WHO principles. In 2011, 42 US states adopted policies under Medicare/Medicaid to encourage general physicians, paediatricians and other primary care providers to provide some basic oral health care [40‐43]. The US Health Department of Health and Human Services oral health strategic framework 2014–2017 recommended the primary oral health care approach as a means to overcome the segmentation of health care delivery [10, 44].

In Europe, a collaboration of the Association for Dental Education in Europe, the Council of European Chief Dental Officers, the European Association of Dental Public Health and the European Dental Health Foundation permitted the implementation of a platform to support oral health policies through the development of cross-sectoral approaches and collaboration with health and social care professions [45].

In the UK, integrated dental care services are governed by the National Dental Health Services board [32, 46]. Following the Health and Social Care Act adopted in 2012, dental professionals collaborate with various stakeholders and Local Authority Public Health teams to achieve continuity of care across private and public sectors [32, 47]. The British Dental Association supports strategic collaborations with all health and social care professionals to enable global comprehensive care and to reduce oral health inequalities [48].

Tables 1 and 2 summarizes the identified integrated oral health care programmes and related applied research outcomes [12, 49‐73]. In general, programmes designed to integrate oral health into primary care have been implanted in the public sector and in partnership with various private and public health organizations, governmental bodies, schools and universities (Table 1). These programmes use various strategies to empower integrated care, including building interdisciplinary networks, training non-dental care providers, oral health champion modelling, enabling care linkages and care coordinated process, as well as the use of e-health technologies [57‐71].

In many countries a ‘high-risk strategy’ approach has been used to create integrated oral health care programmes. Accordingly, integrated care has focused on groups with the highest risk factor levels for oral diseases such as: child and maternal age-groups, the elderly and persons with physical and mental disabilities, low-income population groups, as well as rural, remote, Indigenous communities.

As an example, about 80% of the FQHC in the USA, which provide health care services to underserved populations, also deliver either comprehensive or preventive dental services [74]. According to the technical report conducted by Maxey et al. [65] and as presented in Table 1, five FQHCs have been identified as leaders in integrating oral health with primary care.

Our scoping review also identified some programmes initiated by dental schools in collaboration with community-based organizations. Thus, the Infant Oral Care Program was developed by the University of California (UCLA) to increase family-centred access to care and utilization of dental services [69]. Another example is the Rochester Adolescent Maternity Program, created in 2003, which provides oral health educational guidelines within prenatal services [61]. In 1969, the First Nations and Inuit Health branch of Health Canada, in collaboration with the University of Toronto, developed the “Sioux Lookout Project” [57]. Through this programme, dental clinics and facilities were integrated in the nursing stations in remote First Nations Communities. Dental services were offered by fly-in dentists and certified dental assistants. Similarly, the Centre for Rural and Remote Oral Health in Australia uses networked “hub and spoke models of care” in which dental clinics are integrated in rural and remote Aboriginal Medical Centres [52].

Although this scoping review didn’t identify major publications on sustained outcomes and cost/benefit analysis for these programmes, most of the publications mentioned that integrated primary health care services increase performance of the health care system by creating a supportive environments [12, 49, 53, 57‐59, 62, 63, 65, 69‐73]. Although supportive environments can potentially improve oral health outcomes, from the review it was not clear to what extent these outcomes were improved, and if the needs of vulnerable and disadvantaged populations were completely addressed (Table 2). Positive outcomes included enhanced interprofessional collaboration, satisfaction of non-dental primary care providers with the oral health care training, increased performance of non-dental care providers, and patient satisfaction with care delivery [50‐52, 54, 56, 58‐61, 64, 66‐69]. Objective outcomes included an increase in the number of trained non-dental health care providers, the number of dental visits, screening and preventive acts, referrals, as well as a decrease in the percentage of patients’ dental treatment non-attendance and finally improved access to dental care [12, 49‐52, 54, 55, 60, 69, 70, 72, 73]. Haughney et al. (1998) reported on the follow-up of a co-located model of integrated care and demonstrated that after three years, the total number of medical/dental visits as well as dental visits by the 0–5 year age group and by the elderly increased by 90%, 32% and 24%, respectively [49]. Gerritsen et al. [51]compared integrated versus incidental dental care in two nursing homes in a city in the Netherlands with 35,000 inhabitants. In the centre providing integrated care, although the cost of dental care increased by 86%, the average dental care time for patients was 20 times greater and translated into a reduction of more than 40% of dental treatment needs among seniors [51].