What is the evidence on the effectiveness of strategies to integrate oral health into primary care?

Abstract

Data sources and search strategy: Seven databases (MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar) were searched up to the third week in June 2022. Keyword search terms were based on four key concepts: oral health, primary health, strategies, and integration.

Study selection: Peer-reviewed studies that evaluated any strategies to integrate oral health into primary care (e.g., guidelines, policies, workforce programmes) were included in the review. Eligibility was restricted to papers written in English language. Papers in non-primary care settings or which did not describe an evaluation were excluded. Two reviewers independently screened titles and abstracts and thereafter full texts. Disagreements were resolved by consulting a third reviewer.

Data extraction and synthesis: Data were extracted by one reviewer; a second person verified accuracy. Covidence was used for data extraction. Two independent reviewers critically appraised the papers using the relevant tools (e.g. Critical Appraisal Skills Programme, Cochrane Collaboration, and STrengthening the Reporting of Observational studies in Epidemiology). PRISMA flow diagram was used to present the study selection process. Review findings were reported using a narrative synthesis approach. The Health System Building Blocks (HSBB) was used as a basis for structuring the results/discussion. Heterogeneity among the included studies was high and therefore no meta-analysis was conducted.

Results: Forty-nine studies were included, of which two were RCTs. Most studies described oral healthcare delivered by non-dental primary care professionals within primary care services. Other settings included community, schools, and care homes. Outcomes of interest included: access to oral healthcare, knowledge/attitudes/perceptions, change in dental caries estimates. Almost all studies, except two studies which found no difference in the outcomes measured, favoured an integration strategy. Integration was achieved by enhancing competency (e.g. oral health promotion-trained educators), re-orientating responsibilities of health professionals at an organisation level and/or policy changes (e.g. expanded health insurance policy coverage to include oral health). Integration strategies enhanced access through improved referral pathways, documentation processes, operating efficiency, the number of health staff on hand, increased visits for oral health issues, higher fluoride varnish application rates for children, and more visits to dental health professionals.

Conclusions: In this review, promoting an integrated approach for oral health was associated with improvements across a range of outcomes. Integrating oral health into primary care is complex but holds promise for reducing the burden of dental diseases. Identifying the best practice models of service integration requires further research and evaluation.