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Pediatric Patient-Centered Care in General Dentistry: We’re Closer Than You Might Think
Kimberly J. Hammersmith, DDS, MPH, MS, is an associate professor and the director of the advanced education program in pediatric dentistry at The Ohio State University College of Dentistry in Columbus. She is also a member of the section of dentistry at Nationwide Children’s Hospital. Conflict of Interest Disclosure: None reported.
Susan A. Fisher-Owens, MD, MPH, is a professor in the department of pediatrics at the University of California, San Francisco, School of Medicine and the department of preventive and restorative dental sciences in the School of Dentistry. Conflict of Interest Disclosure: None reported.
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Paul S. Casamassimo, DDS, MS, is a member of the section of dentistry at Nationwide Children’s Hospital and a professor emeritus of pediatric dentistry at The Ohio State University College of Dentistry in Columbus. Conflict of Interest Disclosure: None reported.
ABSTRACT
Patient-centered care (PCC) respects the individual and interacting contributions of the patient, family, community and environment to disease manifestation and health maintenance. This paper gives an overview of PCC in general health care, explains PCC aspects already in play in the prevention and treatment children receive from pediatric dentists and serves as a primer for general dental practitioners to incorporate PCC principles into their care of children.
Keywords: Patient-centered care, pediatric dentistry, dental caries
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Health interventions have evolved from a time when widespread illness, lack of scientific understanding and limited effective interventions ruled health care with a one-size-fits-all approach to today’s more sophisticated understanding of diseases, individual susceptibility and the role of social factors in their acquisition and management. Dental caries in children exemplifies a disease that has transitioned in the U.S. from a pandemic to a condition selectively affecting children due to individual characteristics and social circumstances.
For dental practitioners, this means tailoring prevention and therapy to the child and family rather than applying rigid models of care that may be wasteful and ineffective. In pediatric dentistry, patient-centered care (PCC), or more aptly, family-/child-centered care, has evolved due to more than a half-century of caries-focused epidemiology, research into treatment advances building upon the Keyes caries initiation model (a triad that requires host, substrate and cariogenic bacteria) [1] and development of evidence-based guidelines as the basis of the standard of care. [2] Caries risk assessment, selective use of fluorides, nonsurgical caries management, culturally and socially driven interventions to prevent or mitigate caries and other focused approaches characterize contemporary pediatric dental care.
The purpose of this paper is to provide the general dental community, which treats most of the children in the U.S., with some background and understanding of PCC for children as used in contemporary pediatric dentistry practice. We provide the rationale and basic tools to begin to tailor care to individual patient, family and community circumstances to maximize positive outcomes. Case examples are included to compare the two approaches.
Definitions of Patient-Centered Care and Relevance to Pediatric Dentistry
The National Academy of Sciences, Engineering and Medicine, formerly called the Institute of Medicine, defined PCC as care “that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” [3] In medicine, this concept of PCC, which has been around since the 1990s, has been associated with greater satisfaction for health care workers, less litigation [4] and reduced utilization of care and health care charges. [5]
The concept has been widely explored in medicine. Dimensions of PCC include:
■ Respect for patients’ values, preferences and expressed needs.
■ Coordination and integration of care.
■ Information, communication and education.
■ Physical comfort.
■ Emotional support (relieving fear and anxiety).
■ Involvement of family and friends. [6]
PCC can be practiced systematically by initiating the partnership and simply asking the patient to express concerns and experiences. Next comes shared decision-making (SDM) and working the partnership, and the last practice involves documenting the narrative and safeguarding the partnership. [7] Hoffman explored and explained the interdependence between the concepts of evidence-based medicine and SDM [8] and Forrest built on this to describe evidence-based decision-making. [9] Further, Stewart devised a model for the patient-centered clinical method, which includes six interactive components:
■ Exploring both the disease and the illness experience.
■ Understanding the whole person.
■ Finding common ground.
■ Incorporating prevention and health promotion.
■ Enhancing the relationship.
■ Being realistic. [10]
Ekman and colleagues go so far as to describe differences between personcentered care, patient-centered care and personalized medicine. Their preferred term, person-centered care, gives credence that patients are foremost people and should not be reduced to their diseases or objectified as the recipient of medical services. [7] With children, parents are integral and so the concept involves consideration of the parent-child dyad within whatever definition one chooses.
PCC in Dentistry
The concept of PCC is messier in dentistry, as we have had a hard time even defining it. [11,12] Two systematic reviews found that person-centered and patientcentered are used interchangeably at times, and PCC definitions are diverse, broad and sometimes absent. [11,12] One review even used expanded search terms of empowerment, patient-centered care and SDM when selecting articles. [11]
While concluding that PCC entails treating the patient as a person or individual, with a holistic nonjudgmental approach and free of dentist-patient relationship barriers, primary research on PCC in dentistry has largely originated from dental providers and staff without exploring patient perspectives. [11,12] It is unclear if dental professionals embrace the idea of patients having control over their treatment. [12] Additionally, published PCC research relates to specialty practices or populations, not general dental practice, [12] and we don’t have much evidence for improved patient satisfaction or oral health outcomes. [11,12] This dearth is likely because dental PCC research does not emphasize the involvement of family and friends, coordination and integration of care or physical comfort — three important dimensions of medical PCC. While dentists, largely alone in practice, may not need to coordinate or integrate care to the level that medical providers do, ensuring patient comfort and family/friend involvement has surely been a missed dimension in dental PCC research and practice. [12]
Dentistry has not embraced this concept to the degree medicine has, but in the last decade, some dental-specific models of PCC have emerged. Lee created a model whereby three key players are needed for optimized person-centered care in dentistry: the person or primary caretaker, the provider or coach and the care designer, which is an entity or system that frames, supports and incentivizes PCC and aids in sustainability. Each key player has a role within the actions of learn/examine, relate/share, plan/ design, act/provide/track/evaluate and revise. [13] Scambler developed a model with building blocks and a hierarchy of patientcentered care (information; information and choice; information, choice and tools for informed choice; patient in full control). [14] Deciphering where patients want to be on this hierarchy is part of the PCC process, as not all patients want to be in full control and PCC does not dictate that patients must be in control. [11]
The Beginnings of PCC in Dental Practice
Many patients now prefer to seek their own health information using the internet; rather than discouraging this, dentists should partner with patients, make decisions together and guide patients toward reputable and trusted resources when seeking their own information. [15] Similarly, the ethics code prescribed by the American Dental Association highlights patient autonomy, or the dentist’s duty to respect patients’ rights to self-determination, and involve patients in treatment decisions in a meaningful way, considering their needs, desires and abilities. [16] Dentists must also consider determinants of health, which can include personal, social, economic and environmental factors that influence health status. [17]
In dentistry, we agree that PCC is about humane care delivered alongside good communication and patient autonomy, but dentistry is far behind medicine in linking PCC with patient satisfaction or treatment outcomes. [11] As the dental care system becomes somewhat disrupted by new care models, including corporate entities and disease prevention and management rather than surgical treatment, PCC may be a way to improve health outcomes and quality of care. [13] Allen suggests that the overlap between value-based care and PCC is shared decision-making. [18] Care will be value based when dentists respond to patientreported outcome measures and patientreported experience measures, and that can only be done by sharing the decisionmaking responsibility with patients. [18]
In order to embody PCC, dentists will also have to adopt certain skills. Motivational interviewing and evidence-based decision-making (EBDM) are two techniques within patient-centered care. [19] Motivational interviewing is a collaborative tool to guide communication, with the practitioner telling less and asking more and the patient/interviewee deciding on their process and motivation for change toward a specific goal. EBDM involves critical thinking skills. [8] It is the intersection of patients’ values and preferences, evidence-based conclusions, the practitioner’s expertise and judgment and clinical/patient circumstances.[9,20] A new framework (FIGURE), derived from the Fisher-Owens model for children’s oral health, [21] suggests how inclusion of key areas not traditionally considered in dental care can work in synergy to advance a pediatric PCC approach. Caries and oral health are influenced by child-level factors (biology, health behavior and practices, insurance, etc.), family-level factors (social support, culture, health status of parents, etc.), and community-level factors (physical environment, social capital, dental and health care system characteristics, etc.).
Pediatric Dentistry Was a Good Place To Pilot PCC
We have many reasons to move away from a one-size-fits-all approach and instead adopt PCC in general dentistry for children. For one, oral health disparities among lower-income and minority children are pervasive and persistent. [22,23] Although the Affordable Care Act from 2010 expanded Medicaid access for children, oral health disparities remain across socioeconomic groups, with children in lower-income households and children of color having higher odds of untreated caries. [24]
Additionally, pediatric dentists have long noted the need to shift our practices to welcome more racially, ethnically and economically diverse patients [25,26] to model changes in the U.S. population. The number of children considered underserved is expected to increase. [27] Over the next 40 years, the percentage of non-Hispanic white children is projected to decrease from about half to 36%, while Hispanic children are expected to increase from 25% to 32%. The population of children of two or more races is expected to double to 11% in that time. International migration will account for slightly more than half of expected population growth. [28] Ethnic and cultural differences may affect acceptance of necessity of care, behavior guidance techniques for dental treatment, [29] dental care-seeking behaviors, [30] views on health and illness [31] and patient-provider relationships. [26] Previously underappreciated mainstream social factors need to be considered, such as the association of consumption of sugar-sweetened beverages and untreated tooth decay in young children. [32] California just began its 10-year plan to improve oral health via addressing determinants of health, including sugarsweetened beverages and low intake of fruits and vegetables. The plan will provide dental providers with tools to screen for these and community resources for patients to mitigate them. [33]
Middle- and higher-income families, whose children are not the ones to usually experience barriers to care, may have concerns about mercury, [34] fluoride, dye or nitrous oxide. TABLE 1 illustrates some societal changes over the past few decades that affect our pediatric patient population and how this has affected our roles in managing children’s disease.
Systemic barriers in dentistry limit adoption of PCC in its true sense. Dentistry lacks integrated medicaldental records and has weak health information technology platforms to collect sociodemographic data. [13] While International Classification of Diseases, 10th revision (ICD-10) codes related to social determinants of health have been introduced in medicine, [35] dentistry only has four case management codes, added in 2017, but they do not parallel the ICD-10 (TABLE 2). [36]
If dentistry can overcome its barriers, PCC may ultimately perform in dentistry as it has in medicine. Along with improvements in national health measures, PCC can show gains in individuals’ health as well as population health. [13] One manifestation of the interest of government and medicine in this concept, and an indicator of its likely expansion, is Medicaid’s primary care case management (PCCM) model, which has 16 states utilizing it as of 2016. Currently restricted to medical care, the PCCM approach encourages primary care providers to use patient-focused care with traditional fee-for-service compensation as well as financial support for case management. [37] Applied to dentistry, that model would engage dental care in the pursuit of value-based care and PCC.
Translating PCC to the Practice of General Dentistry for Children
Applying PCC principles blended with advances in science and our understanding of a complex, multidimensional etiology of dental disease often just expands what pediatric dentists already do. TABLE 3 depicts a comparison of some aspects of traditional clinical dentistry approaches with PCC modifications for selected procedures and management. Applying PCC concepts should be seen more as an overriding process than as a procedure.
Using an application of the Fisher-Owens model [21] as a touchstone for dental caries management, one approach would be to overlay the following considerations on decision-making for any dental finding. This model creates layers of consideration departing from the traditional biological view of the condition that includes bacteria, a susceptible tooth and sugar, but then looks at the child’s characteristics, any parental concerns, the readiness or capability of the community to support decisions and the dental care system’s ability to support trends such as the increased need for advanced behavior guidance. The following explains this stepwise approach in more detail.
What is indicated for a clinical situation starting with a traditional dentistry approach?
Dental caries or risk for dental caries may be the presenting problems in an initial pediatric dental intervention. The best practices and policies of the American Academy of Pediatric Dentistry would be a primary gateway to PCC by offering evidence-based, widely accepted interventions. [2] Preventive, behavioral, restorative and growth and development management would be the basis upon which to build PCC.
How do this child’s characteristics alter, if at all, the application of traditional dentistry?
We already do this in pediatric dentistry. The specialty’s almost universal acceptance of children with special health care needs suggests that inclusion of differing abilities and needs across all children is not a giant step. The major hurdle for practitioners might be to see children as a continuum rather than as special needs or not or caries-prone or not. The more we learn about socialization, behavioral health, dietary restrictions and differing intelligences and their influences on health, the more sense this makes.
Do family circumstances require modification of usual approaches?
Reality dictates that parents control the health of their child and are the pivots on which evidence meets expectation. Social, financial, educational and other characteristics of parents are pieces of the PCC model, and the challenge is to integrate familial realities with the child’s clinical needs.
Do community, culture and compliance alter traditional approaches?
The child and family will return to a family and community environment shaped by many factors relevant to oral health. Diet, including access to healthy food options, is a prime example of additional obstacles or opportunities relative to caries management, beyond those inherent in the child. Culturally driven food choices, access to food sources and water fluoridation are examples of these considerations in a PCC model.
Can the practice model sustain individualized oral health?
PCC means more permutations and combinations for care and a departure from an assembly-line approach. This has implications ranging from record-keeping through recall frequency/monitoring and demands a health record and patient management system beyond what is traditional. Pediatric dentistry practice is geared toward PCC, but a general dental practice might not be able to sustain the variations required in individualized care.
The Business of PCC in Dentistry
The evolution of dental care for children to a PCC model has already begun with the development and acceptance of best practices of the AAPD, the embrace of evidence-based dentistry for several pediatric dental procedures, [38,39] creation of case management codes [36] and expansion of the Keyes caries initiation model 1 to a more complex but more useful model espoused by Fisher-Owens et al. [21] Practice patterns, compensation and support services lag behind this evolution and challenge practices to implement a philosophy that supports both patient and practice health. Issues like data management, quality measurement and shifting a traditional standard of care all need to be addressed in a care model that distributes risk differently across patients, practices and payers.
It would be naïve to assume that movement toward a PCC approach is not without fiscal impact. The cost-efficiency of routine application of services across a patient pool stands to be altered. Patient management will require more attention to individualized monitoring — a need already apparent and growing in choices of nonsurgical management of dental caries with repeated silver diamine fluoride (SDF) application and more frequent visits. Billing codes supporting case management exist but are not universally covered, and more frequent monitoring visits may require prior authorization and justification of medical necessity.
Training staff in advanced caries risk assessment and nonsurgical management techniques may be necessary and practice software may not support variance from traditional approaches. Physical structure of the dental office may change: The COVID-19 pandemic altered our approach to open-bay dental offices and provides some stimulus to envision a newer mixed counseling-treatment environment for future office design that fosters PCC.
A major step in moving a PCC model forward is the ability to measure outcomes of care. Dentistry is woefully behind medicine in establishing meaningful and quantifiable measures of quality care and having data support tools to assess effectiveness of care. The Dental Quality Alliance of the American Dental Association has developed and tested several pediatric-oriented quality measures that are based on science and would indicate quality care and positive health outcomes, such as sealants on permanent molars. [40] The challenge and opportunity are there for organized dentistry and the software industry to partner on converting office management software to more comprehensive management systems that link to general health and allow individual providers to measure effectiveness of care in a PCC model; being able to document using team-based care is a natural first step. Technology advances such as a toothbrush that generates data on hygiene performance may be an illustrative next step in integration of patient outcomes with data collection and management for improved health. [41]
Finally, as mentioned earlier in this paper, is the ethical challenge [17] of placing PCC into a practice and community standard for care that might challenge a differing approach. Nonsurgical management of caries is currently being evaluated against traditional restorative care and illustrates how PCC might work in the future. The evidencedbased aspect of PCC can support a choice to begin to shift in this direction and relieve anxiety about doing so.
Building on Current PCC Practice Characteristics in General Dentistry for Children
A running theme in this article is that pieces of PCC are already operational in pediatric dentistry and can be adapted to general dental practice for the care of children. The following case studies complete this overview of PCC and provide descriptions of how a PCC approach might compare with a more traditional dental experience for child and family. It is likely that a PCC approach would result in better rapport with parents and thus strengthen the dentist’s ability to manage disease — certainly a hypothesis to be tested.
CASE 1: A medically healthy, 26-month-old child with severe early childhood caries. Parents live in a rural setting, are young, vegan, work outside the home and are currently uninsured with limited income. Child sleeps with sugar-sweetened-liquid bottle at night.
Traditional approach: General anesthesia and restoration, intensive fluoride therapy and sugar restriction. More frequent recall schedule until stable.
PCC approach: Absence of pain allows nonsurgical management for immediate care, which also respects their lack of insurance and limited income. Parental concerns about fluoride toxicity and lack of community water fluoridation negotiate a compromise to use a fluoridated dentifrice and dietary management of caries factors such as frequency of sugar consumption. Treatment of existing caries using SDF and more frequent monitoring is agreeable. Parental dietary counseling within constraints of dietary preferences.
PCC comment: This case illustrates consideration of all layers of factors influencing disease (the wishes of the family, the caries characteristics of the individual and fluoride availability in the community). It also shows an effective management approach respectful of all parties while remaining workable in the care system.
CASE 2: A 7-year-old male with autism spectrum disorder, who normally is combative in new situations, is resistant to oral examination. Parents adhere to behavioral modification and pharmacological management as well as restriction of sugar and coloring agents of any kind.
Traditional approach: Place the child in protective stabilization for clinical examination and fluoride application and then treat as needed using advanced behavior guidance techniques.
PCC approach: Hold several desensitizing visits using recommended pacing and environmental adjustments; after this, the dentist is able to complete an oral examination with parents’ assistance simulating toothbrushing. Absence of visual caries allows deferral of further dental diagnostics and treatment until a coordinated general anesthesia visit with ENT and laboratory blood drawing. Noncolored fluoride agents found for prevention. More frequent recall examinations to maintain familiarity.
PCC comment: This case management draws on opportunities to respect patient dignity and wishes of family and improve health care collaboration.
CASE 3: A 4-year-old non-English speaking child recently adopted by U.S. English-speaking parents is referred by their pediatrician for dental examination for early childhood caries. They have public insurance coverage.
Traditional approach: Attempt in-office care using nitrous oxide, excluding parents from the operatory, followed by routine prevention.
PCC approach: Consider general anesthesia to minimize behavioral issues and support parent/child attachment. Explore familial or cultural dietary habits that could perpetuate disease. Follow-up management with parents engaged at all visits.
PCC comment: This case and its management illustrate the extension of oral health considerations into the family and the community by respecting the immediate and long-term influence of management choices.
Summary and Directions
This brief description of PCC in pediatric dentistry is meant to broaden general dental practitioners’ understanding of the greater influences of social and environmental factors on oral health. Health care improvement and systemic change rest on addressing biologic as well as social and environmental factors to improve outcomes. As research suggests, consideration of nondental issues in PCC stands to result in better outcomes.
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THE CORRESPONDING AUTHOR, Paul S. Casamassimo, DDS, MS, can be reached at Paul.Casamassimo@nationwidechildrens.org.
