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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”