BOX 2-1
Key Points Made by Individual Speakers.
VALUE OF ORAL HEALTH PROMOTION AND DISEASE PREVENTION
The session moderator, Isabel Garcia, dean of University of Florida’s College of Dentistry, opened by providing context for the workshop objectives. She discussed how the definition of oral health, as defined by bodies such as the FDI World Dental Federation (FDI, n.d.) and the World Health Organization (WHO, 2024), has shifted from the mere absence of disease to one that focuses on wellness and well-being. This shift, Garcia stated, makes it clear that oral health is a fundamental human right and should be part of health policies. Furthermore, calling oral health a human right provides the impetus for the oral health community to work with others outside of dentistry to reach the goal of oral health wellness and well-being. In recent years, she continued, there has been more recognition of the need to close the divide between dentistry and medicine that has contributed to inefficiency, dysfunction, and neglect of oral health. As dean of a dental school, Garcia believes that dental schools could contribute by adding more interprofessional and community-engaged education to their curricula and by expanding the interventions that reach out to the community. Garcia ended her introduction by emphasizing that this is a time for action as previous efforts in oral health have fallen short by not adequately addressing the oral health needs of underserved populations, particularly for people with special needs and disabilities.
The Value of Oral Health Promotion and Disease Prevention to Limit the Need for Costly or Invasive Interventions
Helen H. Lee is an associate professor at the Department of Anesthesiology, College of Medicine, at the University of Illinois Chicago, and director of the Medical Scholars program. Her research and work as a pediatric anesthesiologist focuses on oral health. Lee discussed her journey in becoming interested in the topic after first observing who was receiving care in the emergency room to treat toothache pain. To investigate this, Lee and her colleagues performed a series of studies, which showed racial and ethnic disparities in who gets treated and receives opioids, and disparities in terms of socioeconomic factors (Lee et al., 2012, 2016; Lewis et al., 2015). She and her team then conducted a series of studies to better understand the children who come to the operating room (OR) and receive general anesthesia for dental treatments (Lee et al., 2019, 2020a,b,c). They assessed how use and surgical rates are being determined by state Medicaid programs and found tremendous variability by state in terms of providing access and setting funding priorities. Their research then focused on the question, if policy levers were moved to increase access to preventive care through Medicaid reimbursements to dentistry, would that have long-term oral health outcomes? Additionally, would this approach lead to fewer children in the OR for general anesthesia? Results showed that when reimbursements were improved, there was an increase in the use of preventive dentistry. However, it did not make a difference for OR use (Lee et al., 2020a). Next, Lee focused on a public health intervention, which was access to community water fluoridation (Lee, 2020c). This intervention also did not lead to differences in surgical service use. Based on the research, Lee inferred that disease would persist when using a single intervention that only targets one layer of the social determinants.
Lee then provided an overview of the research done by Bruen et al. (2016) on several Medicaid state programs. These data showed that very small proportions of the population represented high users and large expenditures on state Medicaid programs for severe disease. Up to 50 percent of children that present for general anesthesia with severe cavities will develop a cavity again within 6 to 12 months. The research by Bruen et al. calculated the estimated costs of dental care under general anesthesia at $450 million in 2011 (Bruen et al., 2016), but this did not address children presenting in dental offices receiving general anesthesia. Lee’s research showed that in some states, a large proportion of general anesthesia cases were performed in dental offices, so the reported $450 million by Bruen et al. is likely an underestimation.
Additionally, even when high-risk populations—defined based on race/ethnicity or socioeconomic background—are provided access to regular preventive dental care, the disease persists (Lin et al., 2018). Therefore, Lee suggested there is a need to reflect more on what people do in their daily lives that keep them healthy, in particular, those who are at high risk. She then commented that this information is largely absent from the literature. Lee then acknowledged “some bumps with interprofessional collaboration” for things such as reimbursement and coding. While these are tied together, Lee sees each of them currently as obstacles to holistic care. It is very challenging to link the records between dentistry and medicine and, she added, funding and credit are issues multidisciplinary teams often grapple with.
The general public could benefit from more information on the importance of oral health promotion with disease prevention that is reinforced across multiple professions, she continued. Lee then noted that changes can be made to the future workforce by educating health professional learners when they are in school, but there is also potential to educate undergraduates before they decide which branch of health care they will specialize in. Reaching students early is when Lee believes learners are more open to the idea that the mouth is part of the body.
Lee closed with three examples of integrated health delivery systems. The first is out of the University of Illinois where interdisciplinary teams made up of medicine, dentistry, and psychology practitioners, community health workers, and hygienists work with community partners in medical and dental clinics to promote oral health and prevent chronic disease in children through prevention efforts (CO-OP Chicago, n.d.). The second, in North Carolina, involves a collaboration between medicine and dentistry focusing on prenatal oral health with the aim of having a multigenerational effect (PHOP, n.d.). The third is one that Lee herself is the coprincipal investigator. Known as PROTECT, this is a clinical trial looking at children presenting for anesthesia to manage severe dental disease, in which caregivers are provided with a parenting support program to promote health through healthy behaviors. PROTECT involves a collaboration among pediatric anesthesiology, clinical and community psychology, pediatrics, pediatric dentistry, and community health workers (University of Illinois Chicago College of Dentistry, 2024).
Oral Disease Prevention and Oral Health Promotion to Maximize Oral Health Care Experiences and Outcomes for Persons with Disabilities
Paul Glassman, the associate dean for research and community engagement at the College of Dental Medicine at California Northstate University, attended the meeting virtually. Glassman noted that a lot of money is paid for dental care. It is one of the most expensive sectors of health care in the United States, but the money is not spent effectively. He asked how oral health care can be better provided, in particular, for persons with disabilities. He described the situation for this population as “pretty dire.” According to a report produced by the Sacramento County Department of Health (2022) in California, many people with disabilities, not just in California, go into dental offices but are told they cannot be seen there. This means that persons with disabilities have no other option but to undergo general anesthesia for dental treatments rather than receive preventive care as an outpatient in a dental or health care clinic. Glassman argued that often, the rush to treatment using anesthesia is made too quickly, sometimes resulting in waits of up to 4 years before receiving treatment (Glassman et al., 2009).
The emphasis in the U.S. health system on treating oral disease seems to be in the wrong place. As a result, money is spent incorrectly; expensive care is prioritized over cost-effective preventive interventions. This leads to poor health outcomes and inappropriate care—patients have long waiting periods for care, resulting in worsened health conditions—with unnecessary pain and suffering for people with disabilities, Glassman said. He asked, “How can the participants of this workshop prevent having this same discussion a decade from now?” Glassman suggested the oral health community has an opportunity to fundamentally rethink oral health so prevention, promotion, and care take place in the community while dental offices can serve as the foundation and center of the delivery system. This would bring oral health promotion and disease prevention to those living in underserved communities. Most people could be kept healthy in community locations if the best evidence-based prevention is used, including early intervention and behavior change as supported by science, he said. Providing preventive services in the community could reserve the dental office for complex treatments that could only be performed in that environment.
To get there, Glassman discussed the need for advances in measurement and payment systems, prevention and behavior science, and delivery systems. For measurement and payment systems, he believes it is critical to start focusing on the idea of measuring and providing incentives, and for the health care systems, particularly the oral health care system, on producing population health. There is now a huge opportunity brought about by advances in prevention and behavior support science. Preventive measures include fluoride varnish and silver diamine fluoride, dental sealants and interim therapeutic sequestration. The beauty of these prevention measures is that all these things can be highly effective in controlling dental disease and can be done by someone like a dental hygienist. “You don’t need a dentist, you don’t need a dental drill, you don’t need a dental office,” he said. Additionally, Glassman brought up a mistaken belief that information is lacking in telling people to brush their teeth and eat better. The issue is changing behavior, he said, that is the challenge. To achieve behavior change, he suggested having messages delivered by trusted community members, people with similar life circumstances, and those who can provide peer support—that is how to affect behavior change.
Delivery systems are also important, said Glassman. For example, the virtual dental home brings care into communities (Pacific Center for Special Care, 2014). Glassman showed how the model works using an example of a young man, Dennis, with intellectual and developmental disabilities. Dennis was not particularly verbal, although he could speak, but he got nervous in an office, so it became a habit to just use general anesthesia. “That’s the way things were done for him,” Glassman said. Although when the virtual dental home was used, he was very cooperative receiving oral health preventive care from a dental hygienist in his own living room.
These measures, Glassman stated, are aimed at shortening the inhumane long lines people with disabilities are in to get the dental care they need. Changing the focus could improve the health of communities and people in general. To achieve this, he said it is important to start measuring and providing incentives for outcomes that are population based, not just for clinic attenders. This would foster delivery systems that reach people who do not typically come into dental offices or clinics, he said. Finally, Glassman noted that there is a need to begin to integrate oral health systems to include medical, educational, and social service systems. Each system needs to follow, understand, and use the best evidence-based approaches in procedures and behavior change support. What Glassman envisions are community-engaged oral health systems in which the dental office is not the center of the delivery system, as it currently is. Barriers he sees to achieving this vision include awareness, policies, and moving oral health care providers out of their silos, out of offices and clinics, and into the community where they can integrate with others outside the health system. This would provide an opportunity to change the value equation for oral health, particularly for people with disabilities.
Learning from and with Other Professions to Increase Oral Health Promotion and Disease Prevention
To further address the topic of oral health promotion and disease prevention, a panel of experts from different health professions was invited to speak about their experiences working in this space. Each presenter shared their unique experience as well as interprofessional perspectives on the topic.
Registered Dental Hygienist
Karen Hall is a registered dental hygienist working as an oral health integration manager at Capitol Dental Care in Oregon. She talked about her experiences in two small critical access care hospitals, providing assessments, oral health education, preventive services, and help with post-discharge navigation for patients to receive immediate dental care. In addition to those roles, Hall also helps with dental pain management for patients coming to the emergency room. One observation she shared was that patients who are treated by a team of experts and specialists are likely to receive a more holistic approach to their disease management, health, and recovery. Furthermore, from her interprofessional education experiences, Hall has seen the value of learning from others in the hospital setting.
Hall then described a hospitalized patient with a chronic infection; the medical team was having difficulty locating the source of the infection. A note in the chart said the patient had dental decay and neglect, but it had not been further evaluated. Following several days of hospitalization and not finding the source of the infection, the patient was referred to Hall for an assessment. Hall performed an extensive assessment, including dental X-rays using portable equipment, and discovered that the patient suffered from severe chronic periodontal disease, with three dental abscesses, and teeth that were broken down because of decay. After this assessment, the medical provider was able to prescribe medication appropriate for oral infections, and Hall discussed with the nursing staff the specific oral care needs of the patient to modify the daily care in the hospital. She also talked to the dietitian about the patient’s nutritional needs, given the patient’s inability to chew solid foods.
Looking beyond the hospital stay, Hall was able to organize a dental appointment for the patient immediately upon discharge. Hall underscored the interprofessional value of dental hygienists in a hospital setting for helping the entire medical team understand the linkages between oral health and patient care that, in the example she shared, led to an earlier discharge from the hospital. But most importantly, Hall emphasized how a culture shift in the hospital had taken place; not only is the medical team working together to help get the patient healthier and out of the hospital, but now the team has also embraced the dental provider as an important member of that team.
Pediatric Nurse Practitioner
The next speaker was Donna M. Hallas, a pediatric nurse practitioner who came to New York University Myers College of Nursing in 2007. When she started at the institution, Hallas was asked to determine how to work interprofessionally with NYU’s College of Dentistry, so she met with a pediatric dentist and dental hygienist, and they started working together. As a starting point, their small team performed a literature search to investigate whether there was a need for oral health prevention in newborn care. This turned out to be the case, and they started a study at Bellevue Hospital, in which mothers of children deemed high risk received oral health promotion education. After 6 and 12 months, the children whose mothers received the education showed no sign of dental decay.
Hallas continues to work with the College of Dentistry and has recently focused on individual children and adolescents with disabilities. One advantage of dentists and nurse practitioners working together in this space is that there is no competition for payment. Before embarking on a new project though, Hallas and her team asked, “What are our individual strengths? How can we help each other?” In answering the questions, they realized the 3rd-year nursing students would be able to do comprehensive history taking and teach dental students how to do that, while the dental students could teach the nursing students how to manage and help patients during the dental procedures. Hallas called this a win-win situation.
Physician Assistant
The third speaker, Cynthia Lord, is a physician assistant at the Lake County Free Clinic in Ohio. She shared her perspective as an educator and as someone having worked in an interprofessional oral health space for many years. Lord explained that today most health profession educational programs have an accreditation requirement for interprofessional education. The Interprofessional Education Collaborative (IPEC) was formed in 2009 by six national education associations. IPEC released the first Core Competencies for Interprofessional Collaborative Practice in 2011 (IPEC, 2023). These competencies have provided a framework to help prepare future health professionals for enhanced team-based care for patients and improved population health outcomes. Lord and her team aim to provide health profession students with real-life interprofessional experiences using the four IPEC competency areas of value and ethics, roles and responsibility, communication, and teamwork.
One example Lord described took place when she was at Case Western Reserve, where she worked with an interprofessional team of medical providers as an advisor and preceptor of a student-managed health clinic. In this clinic, student teams of social workers, physician assistants, medical nursing, and dental students see patients using a shared-visit model. At the end of each clinic, the students evaluate their teamwork and provide feedback to one another using a case-developed tool based on direct observation of team interaction. Another example is the Case Western Reserve’s collaborative practice course, which is required for all 1st-year medical, dental, physician assistant, social work, and speech-language pathology students, as well as 4th-year nursing students. The students spend 2 hours each week during two semesters working in small teams with students from different professions. Lord noted that half of the time is spent learning about teamwork, problem solving, conflict management, providing and receiving feedback, and the relevance to their future careers. These skills are then applied in the other half of the time while working in the community on a project with a local agency. At the end of the project, each team presents their project to the leadership from the community agency as part of the collaborative practice showcase. Lord said that these examples demonstrate how deep learning from and with other health professions can happen.
Registered Dietitian Nutritionist
Teresa A. Marshall is a professor of preventive and community dentistry at the University of Iowa and works as a dietitian. Marshall explained how the diet-to-oral health interface is bidirectional. She said that a poor diet increases the risk of oral disease, which leads to tooth and soft-tissue loss, making it harder to bite, chew, and swallow whole grains and fruit and vegetables, which make up a healthy diet.
Marshall added that poor oral health is associated with nutrient-poor diets, which exacerbates the risk of systemic disease. Rather than just focusing on dietary modification to reduce sugars in a patient with existing caries, it would be far more cost-effective to identify dietary risk factors in patients with a healthy mouth as a way of preventing disease.
Marshall also discussed how dietitians are involved with modifying textures, food compositions, and meal patterns for patients with limited oral motor skills associated with some disabilities. For individuals with inborn errors of metabolism, or those using medications with oral side effects, such as decreased saliva, extensive dietary modifications may be necessary to ensure adequate nutrient intake and to reduce the risk of caries.
Dietitians and oral health care professionals cannot work alone to prevent oral disease, said Marshall. Bringing the larger health community into a conversation can help spread the message that diet-related risk factors are the same for oral and systemic diseases, which can both be addressed as a team. Ideally, such a health care team would be composed of dentists, hygienists, dietitians, physicians, social workers, psychologists, community workers, and others to send a common dietary message to people, she said. This requires interdisciplinary training so every team member understands dental disease and how each can help facilitate prevention. Marshall finished her remarks by explaining that at the societal level, there is a need to create policies addressing the social determinants of health, such that healthy diets become the preferred choice and are available to all.
Health Psychologist
Daniel W. McNeil is the chair of the Department of Community Dentistry and Behavioral Science at the University of Florida. McNeil works as a health psychologist, and in his department, public health dentists, dental hygienists, and psychologists all work together. He explained that this type of collaboration results in a synergy that can be used for the goals of this workshop. He further commented that behavior is often discussed in terms of patients and prevention; however, other types of behavior are also crucially important, such as the behavior of providers, policy makers, and payers. This is how clinical health psychology can play a part in working together with other professions to change behavior at various levels, he said.
McNeil then asked the workshop participants to think about what all the speakers talked about, which was behavior, mainly as it relates to patients and prevention, although the behavior of providers and others is arguably even more important. For example, Paul Glassman talked about the response of dental providers to having individuals with disabilities come to their offices; Helen Lee talked about what people are doing in their daily lives. The behavior of providers and their personnel who support them, McNeil believes, is crucially important, and this is how clinical health psychology can be a part of the team working with other professions to change behavior at various levels. The behavior of policy makers and payers is another group that can have profound implications for the integration of care. In 2022, McNeil and others published a consensus statement on the role of behavioral and social sciences in oral health (McNeil et al., 2022). In it, the authors underscored the importance of embracing collaborations to achieve the goals set for interprofessional work in order to change the paradigm in dentistry.
DIALOGUE WITH THE INTERPROFESSIONAL PANELISTS
During a discussion with the audience that followed, an online participant asked about strategies to ensure that core competencies are centered around the patient and family experience: “How do you ensure this work meets the standard of ‘nothing about us, without us’ as wished for by people with disabilities?” Garcia answered that each academic unit has different standards to meet from various accreditors, and as dental educators, it has been helpful that there is an expectation to have interprofessional education that constitutes real engagement of students early in the curriculum. From the first day of becoming a dental student and throughout the curriculum, students meet and engage with other health professions. It is not a didactic exercise but one that takes interprofessional teams of students into the community for hands-on experiences, she said. To make that happen, Garcia emphasized the importance of making every encounter meaningful and practical, so students value the experience and develop interprofessional skills to take with them as they go into their various health professions.
Lee commented that in PROTECT, which is a community-informed clinical trial to change the behaviors of the surgical population as mentioned above, the study team realized that to help families change their behaviors that the team needed to understand what was going on in households of these families. The protocol included extensive formative assessments. Several interviews were conducted with community health workers, who were the interventionists for the trial, and had experience working in the West and South Side of Chicago, serving the families that were representative of the trial’s target population. Lee and her team also interviewed families who were coming into the hospital for their child’s care, and they interviewed pediatric dentists rooted in the communities. Then they ran the protocol, including everything from recruitment to flyers to retain participants. Through the community engagement advisory board they received feedback and hired research assistants who were undergraduates from the same neighborhoods.
Lord described work at her institution where students obtain experience not in a lecture or classroom but by practicing in the community as part of a team. The students are taught the IPEC competencies and use those in the field. Communication is important for this, as well as values and ethics. That is how, from the very beginning, students work with clients in the community and learn the importance of respect for patient and colleagues so when they become professionals this is already embedded within them. It is not something they learned about but instead something they grew up with and internalized.
Hall commented that working in a dental care organization that employs dental hygienists and community workers, it is obvious to her who has had interprofessional training. Those who are taught and have experienced positive collaborations across professions are more likely to facilitate those relationships in settings such as hospitals or other medical settings where the health professions collocate with dental team members. In her experience, people who have received the training are generally more eager to make those interprofessional relationships work.
Glassman added his thoughts on how to better integrate the voices of the community. A system of educating students with some kind of experience and then hoping they use it when they graduate often does not translate into real-world changes in the way dentistry is most often practiced. He said there is another way to think about it, both within and outside of educational institutions. Community structures, he reiterated, need to be integrated with other kinds of systems and pay attention to the voice of the community, develop systems that work, and then expose students to those. This is from an opposite starting point, with an emphasis on building community delivery systems. He thinks that dental education institutions have a role in exposing students to community-level health systems, which is the opposite approach from thinking about the starting point being educating students differently. Glassman believes in starting by changing the delivery systems and then letting students see what that looks like.
An audience member from Pacific Dental Services asked Glassman whether he envisioned patients themselves providing the dental prevention measures as discussed, such as sealants and fluoride varnish. Glassman responded by saying this is something that could happen, and anything that can be done to push forward preventive measures, in terms of procedures and behavior change and daily mouth care, is the right direction. Products in use now likely will not be deregulated, but in California there is a law stating that anybody can apply fluoride varnish; it does not have to be a dental professional. The caveat is that this person has to be in some program, trained, and monitored by a dentist. However, this is not the case in many states.
Placing emphasis on programs where support can be provided to people for incorporating effective innovations that become daily routines is the way to go, according to Glassman. Such innovations could bring oral health care into elementary schools. Glassman and his colleagues performed a 6-year demonstration of the idea of a virtual dental home with hygienists in elementary schools. Findings from the project showed that by using this model, low-income children with high disease rates could be kept healthy at school without needing to go to a dental office. The dentist was involved through a virtual review of records taken by the hygienist. This model is effective, said Glassman, but there is currently a lack of awareness, policy, and implementation to support bringing this and similar disease prevention models for oral health into practice.
Michael, who identifies as a person with disabilities from the Arc of Philadelphia, asked,
If the panelists were able to change the system, how would they go about getting more funding for the whole dental system so that everybody can get health care? What should be asked from the government to get more federal funding for the whole dental community?
Garcia responded that this question gets to the heart of the matter—advocating for funding. The ideas are there, she said, but systems would need to be developed, along with funding to support the system. When thinking about funding, Garcia felt it was important to think about all the interested groups and the community, noting that it would be helpful to see concerted efforts from the federal government focusing specifically on this. There is also a great opportunity to engage local agencies and nonprofit organizations. Garcia suggested there is a need to look broadly and try to engage more individuals to provide more funding opportunities. Whether these are local, state level, or from the dental industry, funding is what can help move many of the ideas proposed at this workshop.
Lord echoed Garcia’s call for funding but answered Michael’s question by asking people in the United States to value their mouth as much as their overall health. “The people in this country need to stand up and tell Washington that this is important to them,” she said, “because they [policy makers] think we all have an ulterior motive, that we all want more money, we want more power, whatever it might be.”
McNeil also commented on the funding aspect saying this may be another case for interprofessional activity:
Not only must dentists and dental hygienists speak up, but it is also important for consumers, patients, public advocacy groups, and other professional groups to say oral health is important and related to general health.
That, McNeil believes, would be a more persuasive message and goes back to the behavior of policy makers—how can their behavior in policy making be influenced?
Glassman reflected on the discussion before commenting that there is not really a need for more money. The issue is how the money is spent. In oral health, too much is spent on general anesthesia and on late-stage repair, said Glassman, so the problem is not spending the finances correctly. Glassman called it a bucket problem, where if money is saved in hospitalization, it does not go back to the dental providers. Rethinking dental care delivery systems and getting to people earlier in the disease process would allow for the wiser use of funds and could produce better health for the population at lower costs.
Publication Details
Copyright
Publisher
National Academies Press (US), Washington (DC)
NLM Citation
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Global Forum on Innovation in Health Professional Education; Cuff P, Wouters M, editors. Whole-Person Oral Health Education: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2024 Oct 18. 2, Framing the Workshop Objectives.