Mission of Mercy emergency dental clinics: an opportunity to promote general and oral health

There is a growing body of evidence that having poor oral health is linked to chronic diseases such as diabetes [1‐3] and heart disease [4, 5]. In addition, tobacco use is a risk factor for periodontal diseases and oral cancers [6, 7]. The primary aim of this study was to explore the relationship between chronic diseases and the types of dental services performed at a Mission of Mercy (MOM) emergency dental clinic.

Mission of Mercy (MOM) emergency dental programs have become a frequent choice of last resort for far too many people in need of dental care. These community-based, voluntary dental care settings occur annually throughout the country and attract large numbers of individuals seeking care for dental-related pain and disease. Many individuals seek care from periodic dental events such as MOMs due to the economic and policy issues related to the provision of oral health services for underserved populations. These issues include lack of funds to pay for adult dental services [8, 9], being uninsured and underinsured [10], and Medicaid dental benefits that vary from state to state [11] and seldom cover actual cost of dental care. Some MOMs also provide medical care and health education services in addition to traditional dental care services [12] in an attempt to address other health needs of the MOM attendees.

In 2014, the University of Maryland Center for Health Equity (M-CHE) in collaboration with Catholic Charities of the Archdiocese of Washington, DC, and the Maryland State Dental Association organized a two-and-a-half-day MOM event. The event included a new component for MOM programs in the state, a Health Equity Festival (HEF) comprised of primary care medical screenings, health education and navigation support for better care coordination. This was M-CHE’s first experience conducting a MOM event and the partnership was an opportunity to extend activities of critical relevance to achieving health equity and improving population health by providing the community with comprehensive services that addressed their immediate dental needs, as well as other related healthcare needs. Thomas et al. [13], describe how MOM participants seeking emergency dental services arrive with risk factors for other chronic disease typically cared for in primary medical care settings. However, given that MOM events are infrequent, time-limited, and focused predominantly on dental care, the capacity to provide additional primary care and social services is challenging. As part of the collaborative planning with MOM partners, including local hospitals, we created an environment that supported coordinated dental triage and treatment and added value with a complementary Health Equity Festival (HEF) dedicated to medical screening and public health education. The HEF included partnerships with non-profit, private sector, hospital and academic organizations and aimed to provide comprehensive wrap-around services. Health services were provided, including: HIV testing; carbon monoxide testing, body composition measurement, vision screening, flu vaccinations, nutrition education, oral health education, and legal consultations.

Recently, the Communities in Action: Pathways to Health Equity report [14] provided a conceptual model informed by prior models as a guide for practitioners and community members developing effective programs aimed at achieving health equity. The model includes three key elements that are necessary when implementing a “community-driven” initiative in order to be effective in addressing health inequities: 1) create a shared vision and value of health equity, 2) increase community capacity to shape health outcomes, and 3) foster multi-sector collaboration [14]. Although this report was published after our 2014 MOM event, we actually applied these same concepts in the design and operation of the MOM program based on our experience and lessons learned from prior community-engaged programs that we have implemented. For example, we have more than 15 years of experience developing and sustaining partnerships with other entities in an effort to create effective and comprehensive community wellness [15‐17]. Furthermore, the HEF built on the established community partnerships that shared a common vision of addressing needs of underserved populations. Together with these MOM partners, we organized the HEF to address those health needs documented by county and state needs assessments, and in the literature [10, 18]. We provided these additional services so MOM participants could be connected to essential networks within the community, which they may not have had access to prior to attending the MOM.

Although previous studies have explored the relationship between oral health conditions and chronic conditions [1‐5, 7], few studies to our knowledge have examined the relationship between the receipt of dental services at a MOM event and presence of risk behaviors and chronic conditions. This study expands on our prior publication of the 2014 Mid-Maryland MOM and HEF, by examining multiple chronic risks/conditions rather than only individual risks/conditions (e.g. diabetes) and the relationship with the type of dental services provided.

Our study reports findings of the relationship between having multiple chronic conditions/risks and receiving invasive (oral surgery-tooth extractions) and other dental services of participants from the 2014 Mid-Maryland Mission of Mercy (MOM) and Health Equity Festival (HEF). While participants primarily attended the event to receive dental care; nonetheless, our analyses revealed that a third of them had one or more chronic conditions and lifestyle risk behaviors and that these conditions were more prevalent in older than younger participants. In addition, those with two or more chronic conditions and risks were more likely to have oral surgery than those with one condition/risk.

By incorporating a HEF, based on the three key elements necessary when implementing a “community-driven” initiative aimed at achieving health equity [14], into the traditional MOM format, we helped participants identify other health concerns and treatment options – namely, emergency care, coordinated care, oral healthcare services, and primary care follow-up. Given the relationship between chronic risks like diabetes, high blood pressure, and oral health diseases, these conditions warrant the need for behavioral changes such as a healthy diet/nutrition, smoking cessation, practicing oral hygiene, and using fluoride [20, 21].

The dental service decisions were often based on the “most” urgent need identified by the participant, as well as availability of appropriate dental care providers at the MOM event. Consequently, we recognize that all of the services delivered may not have been the result of participants’ oral health and/or general health behavior but were due to limited time and resources. Due to varying Medicaid coverage for adult dental care [22], we recognize that certain oral diseases are often untreated, leading to infections, pain, and the inability to eat, which are all associated with more expensive and invasive, yet preventable dental services. Thus, we explored how an individual’s general health status impacts receipt of an invasive or non-invasive dental health service. Such findings provide evidence regarding the need for comprehensive, combined (general + oral) health services.

Our analysis of the data revealed additional links between chronic conditions/risks and oral healthcare; specifically as it relates to dental services. Prior research examined oral health behaviors such as hygiene practices [23, 24] and disease [25]. Our study examined associations with dental services delivered in a MOM community dental setting. An individual having one or more chronic conditions or oral health risk increased their likelihood of receiving three of the four dental services, preventive, full mouth debridement, restorative, and extractions. Still, an individual with more than one chronic condition and/or risk had a higher chance of an extraction than full mouth debridement.

In 2015, the American Dental Association conducted an assessment of self-reported oral health status, attitudes, and dental care utilization among Maryland adults, titled Oral Health and Well-Being in Maryland [26]. According to the report, 25% of low income adults had difficulty accessing a dentist, 31% of middle income adults and 41% of high income adults were fearful of visiting the dentist [26]. Our findings reveal that many MOM participants are in need of coordinated care for their primary and dental care needs. Although some of these services were based on urgent need, our findings demonstrate that certain services rendered [e.g., restorative or oral surgery services (specifically, tooth extraction) due to infections or deterioration] were preventable if the participant had access to comprehensive dental care.

It is also important to note that although the majority of the MOM participants were Hispanic and African American, white participants were more likely to have two chronic conditions/risks compared to all other racial and ethnic groups. This may be attributed to our sample not being representative of the general U.S. population. In addition, other factors such as income, education level, health insurance and level of health literacy may contribute to these findings.

We have considered several alternatives for inclusion in future MOM and HEF events: 1) reposition access to the HEF and integrate it into the flow of participant registration and medical triage; 2) allow some participants to enter the HEF prior to receiving their dental service, while others access it after their care; allowing for efficient data collection that neither overburdens the participant nor creates a barrier for the healthcare providers delivering services; 3) include self-rated health status, healthcare coverage, education status, physical activity frequency, and body mass index within the dental record; and 4) create data platforms to merge participant profiles with health and social service referral systems, which could be linked to appropriate HEF vendors who provide effective follow-up for oral health and primary healthcare to MOM participants, such as federally qualified health centers. These alternatives could ensure that MOM attendees are linked to ongoing primary care and dental services located in close proximity to their neighborhood.

Our findings reveal that attendees at the 2014 Mid-Maryland Mission of Mercy and Health Equity Festival were living with multiple risk factors or chronic conditions and in dire need of both combined (general + oral) health services. While such events will not solve the dental and general health needs of all Maryland residents, it is important to understand the role that an initiative such as MOM can play in addressing the overlapping chronic conditions such as diabetes with oral diseases. This assessment challenges us to consistently examine how we develop and implement these public health events and how we design their affiliated services. This will allow for streamlining future operations, and tailoring this type of forum with its related health equity activities for more effective follow-up and on-going care after a MOM event has ended. In the absence of a comprehensive policy solution to the oral health crisis, we have a moral obligation to alleviate human suffering with temporary solutions like MOM events. Given the frequency of Mission of Mercy dental clinics and the continued demand for the charitable services they provide, we must design them in a manner with a shared vision to eliminate oral health disparities and achieve health equity.