The dental home

Background. The pediatrics community

has promoted the concept of a medical home

to improve families’ care utilization. The

authors describe the medical home and pro-

pose a dental home concept to improve fam-

ilies’ access to dental care.

Description. The dental home is a locus

for preventive oral health supervision and

emergency care. It can be a repository for

records and the focus for making specialty

referrals. When culture and ethnicity are

barriers to care, the dental home offers a

site adapted to care delivery and is sensi-

tive to family values.

Clinical Implications. The dental

home can provide access to preventive and

emergency services for children. Establish-

ment of the home early in the child’s life

can expose a child to prevention and early

intervention before problems occur, reduce

anxiety and facilitate referral.

The dental home

A primary care oral health

concept

ARTHUR J. NOWAK, D.M.D., M.A.; PAUL S.

CASAMASSIMO, D.D.S., M.S.

he concept of a dental home for children is new

to most of the dental profession. For medical

practitioners, however, the concept of identi-

fying a child with a practitioner in a familiar

and safe health supervision relationship is

well-established.

The U.S. surgeon general’s recent con-

cern about the low use of oral health services by children

and the persistence of early childhood caries

suggest

that dentistry should consider taking a closer look at the

potential benefits of an analogous concept of a “dental

home.” It could improve access to and provide children

with a source of care and anticipatory guidance as early

as 1 year of age.

This article provides a rationale for creating a dental

home, what a family could expect once they find a home

and what improvements in oral health

might occur as a result. We compare the

characteristics of the medical home and

its demonstrated benefit to children’s

health with what a dental home might

offer for children’s oral health.

THE MEDICAL HOME CONCEPT

The American Academy of Pediatrics, or

AAP, proposed a definition of a medical

home in 1992 in the form of a policy

statement.

The essential concept is that

medical care of children of all ages is

best managed when there is an estab-

lished relationship between a practi-

tioner who is familiar with the child and

the child’s family. This relationship fos-

ters care that is accessible, coordinated and compas-

sionate and that encourages mutual responsibility and

trust. The medical home also presumes that the physi-

cian caring for the child is well-trained and capable of

supervising health and managing illness.

The medical home becomes the place where a child

receives preventive instruction, immunizations, coun-

ABSTRACT

JADA, Vol. 133, January 2002 93

The dental

home could

increase

opportunities

for preventive

oral health

services for

children that

can reduce

disease

disparities.

TRENDS

seling and anticipatory guidance. In a

rather bold statement for today’s health

care, the framers of this definition pro-

posed that management of acute illness

be available 24 hours a day. They also

proposed that long-term continuity be

an important consideration and that

the provider initiate and coordinate

subspecialty care and function as the

child’s link to community agencies

regarding health issues. The medical

home’s physical location should be the

safe repository of the child’s medical

records.

In a subsequent publication,

the

AAP addressed the medical home con-

cept for children with special health

care needs in managed care programs.

This view of the medical home empha-

sized the need for coordination of spe-

cialized medical and community serv-

ices and acknowledged the role of

subspecialists as a more appropriate

home for these children, based on indi-

vidual need. The complexities of care,

as well as the introduction of an addi-

tional care manager, were emphasized

as all the more reason for a care-

supervising medical home.

Table 1 delineates the seven characteristics of

a medical home.

Cultural competence was added

to the original six in the description by AAP to

account for the need to reach underrepresented

populations who traditionally have had difficulty

gaining access to care.

DOES THE MEDICAL HOME AFFECT CARE?

The medical home construct was not a health pro-

motion, but rather a response to empirical and

systematic observations dating back 20 years or

more that the primary care relationship between

the physician and the child fostered access and

use of services. The dental home is supported

empirically by testimonial and professional

opinion.

6,7

An exhaustive review of the numerous

studies describing the benefits of the medical

home is beyond the scope of this article, but some

areas for which evidence exists include immu-

nizations,

appropriate use of care for acute and

routine illnesses,

and the relationship between

publicly financed programs and the medical

home.

Immunization status does not seem to be

improved with a medical home

; race, insurance

status and family income are more important.

However, in a comparison of a capitated state-

funded primary care program with traditional

Medicaid and private insurance, Kempe and col-

leagues

found that

immuniza-

tion shifted

to the pri-

mary care

site for

children in

capitated

programs

and that

other serv-

ices were

compa-

rable to

those of

children

with other

payment

mecha-

nisms. St.

Peter and

colleagues

noted that

children

with a source of care were more likely not only to

receive services but also to get both care when

sick and well care at these sites. A continuity of

care relationship also seems to be associated with

less use of emergency departments as a source of

nonemergent care.

11,12

The literature suggests

that for medical care, both the likelihood and

appropriateness of care are better when a patient

has a medical home.

HOW A DENTAL HOME WOULD

AFFECT CARE

In an era in which access to care has received such

emphasis as a solution to oral health disparities, it

would seem that the benefit of a dental home

would not be questioned. The concept of a dental

home, however, is too new to have been studied as

a predictor of oral health. In 1999, Nowak

described the term in relation to the desired recur-

rence of preventive oral health supervisory ser-

vices as propagated by the American Academy of

Pediatric Dentistry, or AAPD. National data on

the characteristics of patients who have had a

dental visit in the past year do not provide useful

information for children on the benefits of a dental

home as indicated by a dental visit.

Indirect measures, analogous to those used in

medicine, suggest that a dental home, or a rela-

94 JADA, Vol. 133, January 2002

TRENDS

TABLE 1

CHARACTERISTIC DESCRIPTION

d Care provided in the child’s community

d All insurance accepted and changes in coverage

accommodated

d Recognition of the centeredness of the family

d Unbiased complete information is shared on an

ongoing basis

d Same primary care providers from infancy through

adolescence

d Assistance with transitions (for example, to school)

provided

d Health care available 24 hours per day, seven days

per week

d Preventive, primary, tertiary care provided

d Families linked to support, education and community

services

d Information centralized

d Expressed and demonstrated concern for child and

family

d Cultural background recognized, valued, respected

Accessible

Family-Centered

Continuous

Comprehensive

Coordinated

Compassionate

Culturally Competent

* Source: American Academy of Pediatrics.

CHARACTERISTICS OF A MEDICAL HOME.*

tionship with a dentist, has beneficial conse-

quences of appropriate care, has reduced treat-

ment costs and provides access to otherwise

unavailable services. One measure is the associa-

tion of children seeking emergency dental care

with an established dental relationship. Sheller

and colleagues

found that the emergency visit

was the first contact for 52 percent of children 3.5

years of age and younger who had a caries-related

emergency in a children’s hospital. In another

study of the same patient population, Zeng and

colleagues

noted that 62 percent of 1,482 chil-

dren seen for dental emergencies in a children’s

hospital from 1982 to 1991 had no regular source

of dental care. Von Kaenel and colleagues’

study

had similar findings. The suggestion here is that

the majority of children whose parents sought

emergency dental care for them in a

hospital have no dentist.

Doykos

suggests that early asso-

ciation with a dentist has the benefit

of reduced cost of care, with the differ-

ence being attributed to an increased

need for treatment services for those

who delay the first dental visit. In a

recent analysis of the Access to Baby

and Child Dentistry, or ABCD, program in Wash-

ington state, Grembowski and Milgrom

found

that children in the ABCD program had an

increased use of services, particularly preventive

services, compared with children not enrolled in

the program. While the ABCD program is not a

“dental home” program, it does train both families

and dentists to manage young children and their

oral health early and appears to have resulted in

beneficial relationships between dentists and

families sooner than traditional norms.

Iben and colleagues

compared appointments

broken by Medicaid dental patients in private and

clinic settings and found higher rates in private

practice. More germane to the “dental home” is

that, in spite of this, the private practice was able

to see more Medicaid patients than the clinics

studied. If a private practice setting is seen as the

ideal home, then for those with traditional access

problems it offers the advantage of efficiency and

greater likelihood of exposure to preventive serv-

ices. If one can assume that lack of access is

equivalent to “dental homelessness,” then the

detriment of not having a dental home becomes

important. Minority children have more access

problems and fewer sealants than do nonminority

children.

21,22

National data on adults strongly associate

having natural teeth with care utilization and

less dental caries.

The surgeon general’s report

provides a snapshot of the U.S. military, in which

everyone has a “dental home,” and in which

dental care utilization is high and dental disease

low. The report also identifies the continuation of

early childhood caries as a problem. Current stan-

dards of care, maintained by the medical commu-

nity, delay dental intervention until 3 years of

age.

Unfortunately, by that age, 5 to 10 percent

of preschool-aged children have caries, and in

some populations who even have good access to

and utilization of medical services the rate is

double that of the general population. By 5 years

of age, six of 10 children have experienced dental

caries.

It seems unlikely that this caries starts

between 3 and 5 years of age. It is

reasonable to ask whether estab-

lishment of a dental home by age 1

year—with the benefits of early

detection, risk assessment, appro-

priate amounts of prescribed fluo-

ride, sealants and early interven-

tion of incipient disease—would

reduce the prevalence of caries in

preschoolers and ultimately reduce the 60 percent

of 6- to 8-year-olds with dental caries.

It could be argued that the concept of the

dental home never has been studied. However, if

access and utilization are used as indirect meas-

ures of the benefits of a dental home, then the

concept has merit to improve oral health of

children.

CHARACTERISTICS OF THE DENTAL HOME

Although a dental home most often connotes a

building, place or clinic, it also has to be a phi-

losophy embraced by the dental practice. The

characteristics and practical advantages are

listed in Table 2. A practice based on periodic

emergency care counters the concept of a dental

home. A practice that embraces children early

and continues to follow them periodically through

life would be the ideal. The dental home may

begin in the office of a pediatric dentist and then

move to that of a family practitioner, once the

child has matured and is more comfortable being

treated by the parents’ dentist.

As in medicine, the dental home should

embrace prevention at the earliest time possible

to prevent or at least reduce the effects of oral dis-

ease. It also should provide a place for children to

JADA, Vol. 133, January 2002 95

TRENDS

A dental home has to

be a philosophy

embraced by the

dental practice.

be treated in case of emergency, where parents

can feel comfortable and not have to worry that

the management of their child’s oral emergencies

would be minimal.

THE DENTAL HOME ADVANTAGE

The dental home embraces the importance of

early intervention with optimal preventive strate-

gies chosen based on the risk of the patient and

would encourage the first dental visit by approxi-

mately 1 year of age. Parents may welcome pro-

fessional support and anticipatory guidance to

ensure that their children have healthy mouths

at this age. Practitioners can provide personalized

preventive approaches for children based on their

families’ histories, the oral examination and the

risk factors identified. These risk factors include

medical history, dietary habits, medication, fluo-

ride availability and parental attitudes. Abun-

dant literature supports the role of risk factors

early in life

26-30

as predictors of dental caries. The

AAPD’s Recommendations for Periodic Preventive

Care

provide a framework for the practitioner to

consider when developing office policies and rec-

ommendations.

An important feature of a dental home is to

provide anticipatory guidance to the parents so

that they are aware of their children’s growth and

development, as well as possible risk factors that

occur as children age. Anticipatory guidance pro-

96 JADA, Vol. 133, January 2002

TRENDS

TABLE 2

CHARACTERISTIC

DESCRIPTION PRACTICAL ADVANTAGES

d Care provided in the

child’s community

d All insurance accepted

and changes in coverage

accommodated

d Recognition of the cen-

teredness of the family

d Unbiased complete

information is shared

on an ongoing basis

d Same primary care

providers from infancy

through adolescence

d Assistance provided

with transitions (for

example, to school)

d Health care available

24 hours per day, seven

days per week

d Preventive, primary,

tertiary care provided

d Families linked to sup-

port, education and

community services

d Information centralized

d Expressed and demon-

strated concern for child

and family

d Cultural background

recognized, valued,

respected

d Source of care is close to home and accessible to

family

d Minimal hassle encountered with payment

d Office ready for treatment in emergency situations

d Office is nonbiased in dealing with children with

special health care needs, or CSHCN

d Dentist knows community needs and resources

(fluoride in water)

d Low parent/child anxiety improves care

d Care protocols are comfortable to family (behavior

management)

d Appropriate role of parents in home care is estab-

lished

d Appropriate recall intervals are based on child’s

needs

d Continuity of care is better owing to recall system

vs. episodic care

d Coordination of complex dental treatment is pos-

sible (traumatic injury)

d Liaison with medical providers for CSHCN is

improved (congenital heart disease)

d Emergency access is ensured

d Care manager and primary care dentist are in

same place

d Records centralized

d School, workshop, therapy linkages established

and known (cleft palate care)

d Dentist-child relationship is established

d Family relationship is established

d Children less anxious owing to familiarity

d Mechanism is established for communication for

ongoing care

d Specialized resources are known and proven if

needed

d Staff may speak other languages and know dental

terminology

Accessible

Family-Centered

Continuous

Comprehensive

Coordinated

Compassionate

Culturally Competent

IDEAL CHARACTERISTICS AND PRACTICAL ADVANTAGES OF A DENTAL

HOME.

vides a framework for practitioners and their staff

members to periodically engage parents in conver-

sations about the anticipated needs of the

children.

Another advantage of the dental home is that

preventive intervention can be personalized to the

needs of the child. Risk assessment remains an

emerging science, and, although empirical sugges-

tions are available for children who are at greater

risk, the observations of the practitioner still are

valid. In fact, recent consensus validates the

power of the dentist’s opinion on individual caries

risk.

Too often, a “shotgun” approach is sug-

gested, and all children are given the same pre-

ventive intervention no matter what their risks.

Studies confirm that this approach is both ineffi-

cient and ineffective.

An individualized preven-

tive program can be recommended for optimum

protection of children in different risk categories

within a good cost-benefit range.

SPECIALIZED CARE REFERRAL

Another feature of the dental home would be coor-

dination of specialized care for the child. When a

child has been observed over a period, appropriate

recommendations can be made for other treat-

ments such as orthodontic referral and observa-

tion. Using age-related guidelines and recommen-

dations from the orthodontic community,

appropriate scheduling of referrals can be made to

optimize treatment and eliminate numerous

referrals before treatment is initiated.

It is known that after children are 2 or 3 years

of age, dentists see them more frequently than do

primary care medical providers. This provides a

wonderful opportunity for the primary dental

provider to recognize changes in growth and

development that can be discussed with the

parent, as well as make appropriate recommenda-

tions to seek further consultation from the child’s

physician. The continuous care provided by a

dental team also would recognize other develop-

mental milestones that may suggest needed

attention. For example, dental practitioners can

observe problems with speech development at

periodic visits, discuss them with the parents and

make appropriate referrals to speech pathologists.

In a dental home, the office can track the

sequencing of preventive interventions. For

example, the timing of the placement of dental

sealants on permanent first molars can be antici-

pated from previous appointments and scheduled

appropriately, or primary tooth exfoliation and

permanent tooth eruption can be monitored so

that growth and development problems are

reduced. Another example is ensuring the appro-

priate use of supplemental fluoride when families

change residence and are served by new commu-

nity water supplies, choose to purchase home

water-processing units or begin to use bottled

water, all of which frequently can be associated

with fluoride deficiency.

Behavioral research supports a child’s

increased levels of comfort and reduced anxiety

levels as familiarity increases with the dental

environment.

Being greeted cheerfully by the

receptionist and staff in a nonthreatening, child-

friendly environment reduces anxiety and

improves behavior. This becomes an important

issue for many parents who do not want to see

their children experience stress in a health

provider’s office. Maternal anxiety remains a

strong predictor of child anxiety.

Provider and

staff stress diminishes when children are happy

to be in the office and can engage in the care

experience without fear.

Lastly, the dental home can provide a personal-

ized and individualized recall program for the

child. Too frequently, recall programs are based

on a schedule suggested by reports when caries

was a normally distributed problem among all

children, who thus needed close monitoring.

Today, the majority of dental problems occur in

high-risk populations, and all children may not

require the same schedule of periodic supervision.

Frequency of oral health supervision visits also

may need to change during the child’s life, as

there are times when more frequent observation

and monitoring are necessary to ensure the

child’s health and to answer the parent’s

questions.

Having a place to receive emergency treatment

can be important. Going to a provider and an

office that are familiar and where the child has a

history of care can reduce the parent’s anxiety in

case of an unintended injury. To be able to pick

up the telephone and immediately contact the

office either during or after working hours and be

sure that the dentist is available can be impor-

tant to the family.

Gaining access to dental care is a major health

issue for children with special health care needs.

Families with such children who have a dental

home can know that an office is accessible and

that the dentist and staff members are trained in

and comfortable with treating special needs. All

JADA, Vol. 133, January 2002 97

TRENDS

children with special health care needs should be

welcomed in the dental office, and if the relation-

ship is established early in the child’s life, signifi-

cant oral-systemic problems can be prevented or

managed.

CONCLUSIONS

We conclude that the dental home is an impor-

tant concept for the dental profession to embrace.

Evidence supports the advantages of receiving

early professional dental care and intervention

that are complemented by anticipatory guidance

for parents, as well as periodic supervision visits

based on the child’s risk of dental disease. The

dental home could increase opportunities for pre-

ventive oral health services for children that can

reduce disease disparities.

The dental home is a concept that deserves

support, further investigation and, in conjunction

with the medical home, would provide the com-

prehensive health care to which all children are

entitled. ■

Dr. Nowak is a professor emeritus, departments of Pediatric Den-

tistry and Pediatrics, University of Iowa, Iowa City.

Dr. Casamassimo is a professor and the chair, Section of Pediatric

Dentistry, The Ohio State University College of Dentistry, Columbus;

and the chief of dentistry, Columbus Children’s Hospital, Ohio. Address

reprint requests to Dr. Casamassimo at Department of Dentistry,

Columbus Children’s Hospital, 700 Children’s Drive, Columbus, Ohio

43205, e-mail “[email protected]”.

“Bright Futures in Practice: Oral Health” (Casamassimo P, ed.

Arlington, Va.: National Center for Education in Maternal and Child

Health; 1997) provides an in-depth understanding of preventive oral

care and information that is comprehensive, contemporary and cultur-

ally based. To order a copy, call the National Center for Education in

Maternal and Child Health at 1-703-524-7802 or go to “www.ncemch.

org/pubs/default.html” on the World Wide Web.

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