Nurses’ and general practitioners’ perspectives on oral health in primary care: a qualitative study

Introduction

Recommendations that oral health be an integral part of primary health care (PHC) services aim to ensure the efficient delivery of comprehensive, patient-centred and effective health care.^1–3 Good oral health is fundamental to good general health. Although (mostly) not life-threatening, oral diseases affect eating and communicating, education, finding employment, undertaking activities of daily living, overall quality of life, and health.⁴ Further, they are costly and burdensome for individuals, whānau, the health system and society.^4,5

Prevention and treatment of oral conditions are primarily dealt with by oral health professionals (OHP). Nevertheless, PHC practitioners – doctors, practice nurses and nurse practitioners – are well placed to contribute to their patients’ oral health and wellbeing. People attend their medical centre more often than they do a dentist. In Aotearoa New Zealand (NZ), over 85% of adults are enrolled with a PHC provider,⁶ whereas only 67% report seeing the same OHP, of whom only 39% usually visit for a check-up.⁷ In addition, many chronic conditions, including dementia, cancer, stroke, diabetes and mental health,^8,9 share disease risk factors (such as diet, tobacco and alcohol use), and, along with their treatments, have oral health implications.⁴

Primary healthcare teams can also provide initial management of patients’ oral health problems. Indeed, PHC practices are the first port-of-call for a substantial proportion of people with dental problems, especially acute complaints.^10–13 Further, significant disparities in oral health and access to oral health care exist in NZ, especially for Māori, Pacific, rural and disabled populations, largely owing to accessibility issues, particularly lack of service availability and high cost.^7,14 In NZ, adults’ oral health care is predominantly privately-funded, and unlike care for almost all medical conditions, eligibility for (very limited) publicly-funded care is primarily determined by an individual’s comorbidities, complex healthcare needs, and income.^15,16 The relatively lower cost of medical care, ‘permanency’^{17 (p. e880)} with a PHC team (likely among frequent attenders with long-term condition(s)) and the belief that medical practitioners are better able to diagnose and treat oro-facial infections, are some key reasons for oral health presentations to their PHC providers.^17,18

Opportunities frequently arise in PHC to ask patients about their oral health, incorporate oral health in the management of chronic conditions, provide advice on oral health and hygiene, financial assistance, and child oral health services enrolment, or facilitate referrals to a dentist. In doing so, PHC practitioners can contribute to reducing the risk and impact of oral conditions, and oral health inequities. However, general practitioners report lacking the necessary training to address most oral conditions, leaving them feeling underprepared and frustrated when presented with oral complaints,^12,19 and managing them with temporary, and not always appropriate, solutions such as antibiotics.^12,13,19,20 Further, they rarely or never engage patients in discussions about their oral health.²⁰

Given the high (and anticipated rise in) chronic disease prevalence,^21,22 and expected continued improvements in natural tooth retention among people of all ages,⁷ it is likely that more people at risk of oral disease or needing oral health care will present at PHC practices. It is critical, then, that PHC teams are knowledgeable and appropriately skilled in managing oral health presentations, and supported to do so, and that acceptable and feasible ways of integrating oral health into PHC practice and policies are found. There is limited local evidence to inform such strategies in NZ. This study aimed to address this gap by exploring doctors’ and nurses’ perspectives on the place of oral health, and how to improve its inclusion, in PHC.

Methods

This study took a qualitative approach. The general practices of a large primary health organisation (PHO) were purposively selected to include a range of practice profiles (by socioeconomic status, ethnicity and age of enrolled patient base). Practice managers or clinical leads were approached to gauge interest in participating. Nurses and doctors from interested practices were then invited to attend a practice-based focus group at a time and location convenient to them.

Six focus groups, guided by a semi-structured interview schedule (Supplementary Fig. S1), were conducted by two registered dentists – one a public health researcher (MS) and the other a hospital clinician (EH). Areas of questioning included the nature of oral health presentations, participants’ knowledge of oral health and relevant services, the factors that influence them to consider oral health in their day-to-day practice and manage oral health-related presentations, and suggested actions on how to include oral health in PHC. Participants’ years of practice, gender, ethnicity, age, and practitioner type (nurse, doctor) were also collected. The interview schedule was piloted during the first focus group, after which questions and topic areas were modified accordingly. New, emergent themes identified as data collection progressed were incorporated into the interview schedule. Data from the first focus group were included in the analysis. Data saturation was achieved by the final two focus groups. Focus group discussions were recorded (with consent) and transcribed verbatim. Data were collected from February to April 2018. Participants received no remuneration, but refreshments were provided.

Data were coded using NVivo 12 (Lumivero Denver, Colorado, USA, https://lumivero.com/products/nvivo/) and analysed thematically.²³ MS and EH read the transcripts, and identified and compared initial patterns and themes within each transcript and then across transcripts. Discordant views on codes were discussed until a consensus was reached. The transcripts were then coded according to the agreed coding schedule and analysed. Ethical approval was obtained from the University of Otago Human Ethics Committee (D18/015).

Results

The six focus groups comprised 4–15 participants (44 total) each; most were female and doctors, and just over half had 20+ years’ practice experience. Three practices had high enrolments of people on low incomes; one each had high enrolments of Pasifika, youth and older people (Table 1).

Themes were categorised as: current practice, and barriers and facilitators to engaging in oral health. Participants’ quotations are presented to illustrate key findings; additional quotations are presented in Supplementary Tables S1 and S2. Unless otherwise stated, ‘participants’ includes all practitioner types.

Discussion

This study explored the views of doctors and nurses from selected NZ PHC practices on the place of oral health, and how to improve its inclusion, in PHC. As published elsewhere,^{11–13,19,24} our participants reported regularly seeing oral health-related presentations, typically pain and infection, and/or for whom some oral health care would be beneficial. There was general agreement on the importance of good oral health for people’s overall health.

Consistent with previous research,^20,24–27 our participants’ oral health knowledge and confidence to address oral health presentations were low, largely owing to a lack of education and training opportunities during and following their undergraduate training. As in other countries,²⁴ not knowing how to manage or appropriately refer oral health problems, lack of referral pathways, and timely and affordable services available for referral frustrated and distressed our participants. Welsh study participants described the dissonance of either focussing on patients’ immediate needs and prescribing antibiotics or withholding antibiotics to nudge the patient towards visiting a dentist for definitive treatment.¹²

Lack of timely and affordable oral health services also appeared to prevent several participants raising oral health with patients. They felt ethically bound to then address any issues raised, an obligation they could not fulfil because they perceived there was little they could further recommend or do. This ‘ethical dilemma’ barrier has not been reported previously; it may be unique to NZ owing to its adult oral healthcare system. In 2022, a government grant for dental treatment for low-income adults increased from NZ$300 to $1000 and the scope of treatments available expanded to include ‘essential and urgent’ care. Initial indications of this much-needed change suggest that it has had a positive effect for intended recipients (R Clarke, pers. comm.). Exploring its impact on PHC practitioners’ views on raising oral health with their patients is warranted.

Lack of capacity and rising complexity of care are key issues weighing on PHC practitioners;^28–30 workload and time constraints are key barriers to integrating oral health in PHC.^20,24,27 Our participants described oral health as being one more thing in a long list of conditions that they would need to address in a time-limited consultation. Unless a patient presented with a specific problem with their teeth or mouth, oral health was not routinely part of our participants’ practice. Vernon et al.²⁵ found that, although all study participants thought oral health was important, less than one-quarter of them examined for it. Moreover, some doctors in our study considered oral-related matters to be the exclusive domain of dentists. General practitioners’ views of their responsibilities in this arena are mixed in the literature.²⁷ Informing PHC practitioners about the intersection of oral care with medicine, and providing them with clear guidance on how they can protect and promote patients’ oral health may facilitate PHC practitioners’ consideration of oral health in their practice.²⁷

Despite the challenges, the discussions prompted some participants to recognise oral health as a neglected area of PHC; most reflected that it had a place in PHC for the good of their patients. Given the likelihood that more people with, or at risk of, oral health issues, will present to medical centres, and in the absence of any forthcoming substantive changes to the provision and funding of oral health care in NZ, there is a growing need for PHC practitioners to include oral health in their day-to-day practice.

Encouragingly, as in other studies,²⁷ most participants expressed interest in learning more. Oral health education programmes for non-oral health practitioners have been successful in many settings, improving confidence in examining the mouth^20,31 and referring to oral health providers.³² As with non-oral health professionals in other countries, both nurses and doctors in our study could not recall learning about oral health and the oral cavity in their undergraduate training. If it were, many of the challenges in integrating oral health in PHC might be overcome; how to go about this in the NZ context warrants further exploration.

Interprofessional collaboration benefits both patients and practitioners.³³ Similar to the findings of Barnett et al.,¹⁹ our participants had little communication with, and were unsure how to refer to, dentists. As our participants indicated, establishing clear referral pathways to publicly-funded oral health care, with the criteria on par with those for virtually all other medical conditions, is required. This pathway could include screening or monitoring oral health in existing tools used in PHC, as suggested by our participants and others.²⁴

Financial support and a shared strategic vision giving oral health greater visibility and priority in PHC and the health system nationally at a systems-level, are effective facilitators in integrating oral health in PHC.²⁷ For some time now, practitioners and academics have called for oral health to be an integral part of PHC in NZ;^1,3 doing so would contribute to reducing the current inequities in access to oral health care in NZ.^7,14 Although steps can be taken at individual and professional levels, achieving integration will be challenging unless the current inadequacies in referral pathways for definitive treatment and access to affordable dental care, and other fundamental systematic issues with oral healthcare service provision in NZ, are addressed.

Conclusion

Primary healthcare practitioners believe oral health is important and are open to incorporating it into their practice; however, barriers to sustainably incorporating some oral health oversight into PHC exist. For effective integration, a series of individual-, professional- and system-level changes are required.

Supplementary material

Supplementary material is available online.