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8 Closing Remarks Isham asked members of the Roundtable to reflect on the day’s pro- ceedings and the themes that emerged from the ensuing discussions. Isham noted that one theme that he heard reiterated throughout the day related to fragmentation and a lack of coordination between oral/dental health and medicine. He learned from the proceedings of the significant impact of public health interventions on oral/dental health outcomes, for example, water fluoridation. He observed that there are tremendous opportunities for prevention to significantly reduce the morbidity associ- ated with oral/dental disease. He stated that oral/dental diseases touch all Americans and there is clear evidence to guide both public policy and individual behaviors. Isham noted that the evidence from health literacy as it applies to medical practice is also directly applicable to oral/dental health practice. Isham said how impressed he was with the map of U.S. populations that lack water fluoridation. There is solid evidence that fluoridated water dramatically reduces caries in children, and yet, there is resistance to this public health intervention in many parts of the country. Isham stated that a determined effort is needed on the part of the oral health and medical communities to overcome resistance to evidence-based interventions. Roundtable member Kelly commented that human-centered design is essential to motivate behavior change. A community-focused frame- work is important, but behavior change needs to occur at the level of the individual. Roundtable member Ross was encouraged by discussions relating to 101
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102 ORAL HEALTH LITERACY social determinants of health and the need to intervene early with moth- ers, to ensure that infants receive the preventive oral/dental care that they need. Roundtable member Pleasant observed that many of the lessons from health literacy are applicable to oral health literacy. While it is important to avoid “reinventing the wheel,” he cautioned that oral health profes- sionals should be very careful not to adopt tools and methodologies that have not been proven in the context of dental practice. In terms of research and evaluation, Pleasant indicated that health outcome indicators are needed in the evaluation metric, as well as information on the costs of interventions under investigation. Roundtable member Brach observed that primary care providers are essential players in terms of oral health literacy because, according to some of the evidence provided during the workshop, they are respon- sible for 50 percent of the claims for dental services among some pedi- atric populations. She felt strongly that primary care providers, given their prominent role in addressing the needs of vulnerable populations, need to be targeted for education and training in the area of oral health literacy. Brach congratulated those in the oral health literacy community for adopting some of health literacy’s best practices, evidence, and knowl- edge and applying it to oral health. Roundtable member Parker raised a very practical issue. She asked how many people in the audience brushed their teeth for 2 minutes. This is recommended, but she herself admitted that it is a difficult recommen- dation to adhere to. She has four children and none of them was ever taught to brush for 2 minutes. She suggested that it is important to hold up a mirror, ask about our own health literacy, and acknowledge the dif- ficulties of practicing what is preached. Roundtable member Schyve found that a key message from the day’s proceedings was that poor oral health literacy leads to both poor general health and poor oral health. He observed that the implications of poor oral health literacy extend beyond oral health. A second key message is that oral health literacy is influenced at multiple levels, the community, the family, and the individual. To address the issue of oral health literacy, interventions are needed at the level of policy makers, public health orga- nizations, and individuals, Schyve said. He observed that solid research with a focus on outcomes is needed to provide evidence that prevention (e.g., fluoride, sealants) and medical/dental collaboration are effective. He stated that the adoption of interventions depends on complex systems and that an intervention’s success may be dependent on the context in which it is tested. This introduces a major challenge to research because it is necessary to demonstrate the effectiveness of interventions, not just overall, but in specific situations. Schyve said that much more research
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CLOSING REMARKS 103 is needed to understand how oral health literacy will be translated into actual behavior change. Roundtable member Loveland reiterated the finding from the work- shop that oral health literacy is dependent on health literacy. She added that oral health is a major determinant of general health and that the status of oral health in America is poor and in urgent need of attention. She was encouraged that there are initiatives under way to address this problem. As a physician, Loveland acknowledged that neither she, nor her medical colleagues, focused on oral health or oral health literacy but that medical/dental collaborations are very important. Medical school training is necessary, she said, but added that a lengthy period of time will pass before well-trained clinicians get into clinical practice. She expressed some skepticism about top-down approaches to changing provider behav- ior. Loveland said that professional societies, reaching out to one another, are likely needed to bring about collaboration. Roundtable member Francis said she was left after the day’s proceed- ings with a desire to find evidence behind oral health literacy interven- tions and that evidence on community-based and individual interven- tions is lacking. An understanding of the disease process is not sufficient when it comes to changing health behaviors. She observed that access to oral health care in the United States is twice as bad as access to physical health care with 100 million people lacking access to oral health care. Oral health literacy is critical to improving this statistic, she said. Francis found Jacob’s presentation and opinion that framing an issue in terms of a prob- lem, in this case water fluoridation, helps the public to accept potential solutions to the problem. She also found Wong’s comment about positive deviance instructive and felt that evaluating successes might be very informative. Lastly, Francis emphasized the importance of focusing on patient-centered care, self-efficacy, and the social determinants of health when intervening to improve oral health literacy. Roundtable member McGarry applauded the attention paid to public health throughout the day’s deliberations, but expressed some concern that the subspecialties within dentistry were not discussed. He observed that financial incentives that reward cosmetic approaches to dentistry may impede known public health prophylactic approaches. A preoccu- pation with cosmetic procedures, for example orthodontics, may take up much of dental practitioners’ time, leaving less time to address the needs of underserved populations. Roundtable member Ratzan, as a public health physician with an interest in communication, was surprised that the issue of tobacco use was not discussed during the workshop. In the context of oral health liter- acy, he stated that tobacco use is a very important topic. Ratzan described a score card developed by the World Health Professions Alliance that was
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104 ORAL HEALTH LITERACY announced at the United Nations in 2011. The World Health Professions Alliance includes the World Federation of Dentists, the World Medical Association, and the International Council of Nurses. It also includes the international organizations representing pharmacists and physical therapists. The oral/dental focus of the score card is on tobacco use, not on tooth brushing. The score card also addresses having a healthy diet and states that an unhealthy diet increases the risk of being overweight, obese, and developing oral diseases. Ratzan said that a multidisciplinary, interdisciplinary, plura-disciplinary approach applies not only to profes- sions, but also to how public health challenges are examined. He agreed with Brach, that there is a need to better define oral health literacy. He indicated that it is not yet clear whether oral health literacy is a subset of health literacy, and if so, how large a subset it represents. Ratzan observed a great deal of interest in public health by the dentistry professionals and concluded his observations with a plea, to think holistically and broadly about the impact of oral/dental interventions using existing indicators that are in place to monitor public health. Roundtable member Alvarado-Little expressed her appreciation of the focus on the community perspective. She greatly benefited from the presentation from Congressman Cummings and his reference to the few items in his family’s medicine cabinet to treat dental problems. Alvarado- Little works with the Latino community in Amsterdam, New York, and has found that families can preserve their limited resources and adapt dental practices to what might be available in the home. Alvarado-Little said she also benefited from the presentation by Wolpin who described the practices of mothers in a Hispanic migrant community where young mothers were using honey on pacifiers to help quiet babies at nighttime. These stories are very instructive and could be invaluable if shared with pediatricians working in similar communities. Pediatricians have access to families and are viewed as authority figures within the migrant com- munity. The family may not have contact with a dentist, but, Alvarado- Little said oral health messages could be shared by the pediatrician. Having a cultural component to interventions is very important, she said, because some of the beliefs and the customs within the communities are not so tied to socioeconomic status. Rather, behaviors are rooted in what is learned and observed in the traditions of families. Roundtable member Rush highlighted the value of workshop deliber- ations on the relationship between oral health and general health, particu- larly chronic disease, and the discussions relating to disparities in access to oral/dental care. Rush was especially interested in the interventions that targeted the parents and caregivers of children. He felt that it would be useful to examine the relationship between oral health and the health care of older adults, particularly the people who are providing support
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CLOSING REMARKS 105 for older adults, whether they are paid or nonpaid caregivers. He stated that the pain that older adults suffer is also shared by their caregivers. Roundtable member Humphreys found the discussion of positive deviance quite interesting and asked whether there are any data on this topic at the community level. She indicated that examining variance across communities with similar characteristics, for example, socioeco- nomic and minority status, to identify positive outliers in terms of oral/ dental health problems could be instructive. Those communities with a relatively good oral/dental health profile could be studied to identify the behavioral antecedents of these health outcomes. Humphreys added that representatives from communities with these positive attributes could form alliances with members of other communities that had more nega- tive attributes. For example, she mentioned that if water fluoridation was one of the attributes of the positively deviant community, then members of that community could be effective communicators regarding its value. Roundtable member Fritz remarked that she was surprised the pub- lic is not aware that dental disease is preventable. She pointed out that knowing dental disease is preventable is insufficient. It is also necessary to find a way to change behaviors and how to change behaviors needs to be addressed in both health literacy and oral health literacy. Fritz noted parallels between health literacy and oral health literacy, but said that more work is needed to find out if the solutions to problems are the same. Wong discussed the need to distinguish oral health and dental health and interventions aimed at individuals (e.g., pulling teeth) and those aimed at communities (e.g., water fluoridation). He said that the compe- tencies and skills needed at the individual or community level are distinct and need to be identified. Wong also highlighted the need to collaborate across allopathic medicine and dental/oral health. An audience member, from the University of Maryland School of Dentistry suggested that a collaboration with school teachers might be an effective approach to improving the oral health literacy of children. She pointed out that teachers are key communicators. Commander Pamella Vodicka, of the U.S. Public Health Service, a reg- istered dietitian and oral health program lead within the Maternal Child Health Bureau (MCHB) at HRSA stated that individuals may be reluctant to divulge their behaviors or that of their children if they think that they are being judged. In her experience, it is vital to have some cultural con- text and to learn about an individual’s circumstances. When working as a dietitian, one of her clients (a young mother) thought that if she did not tell her the “right thing,” her baby would be taken away from her. As part of her work at HRSA, Vodicka described an MCHB-funded cooperative agreement that supports two oral health literacy initiatives:
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106 ORAL HEALTH LITERACY 1. The Medicaid-CHIP State Dental Association has funding to col- laborate with partners to develop, implement, and evaluate an improved approach to strengthen Medicaid and CHIP oral health program infrastructures and capacity. The aim of this initiative is to assure quality and cost appropriate services for women, children, and families served by state oral health and Title V programs. 2. The Association of American Medical Colleges (AAMC) has been funded to develop an online model curriculum collection on oral health hosted on MedEdPORTAL©, AAMC’s free, peer-reviewed, open-access, online repository of educational resources and teach- ing materials. Commander Vodicka discussed another HRSA project that is being co-led by the Bureau of Health Professions and the Office of Strategic Priorities. A standard core set of clinical oral health competencies is being developed for non-dental primary care providers working in HRSA’s safety net settings. These competencies will pertain to the practice of physicians, physician assistants, nurse practitioners, and nurse midwives. Isham closed the session by thanking the speakers, the workshop planning committee, and IOM staff for an outstanding workshop.