The need to expand the evidence base to drive policy was a theme both of the commissioned paper and of earlier discussions in the workshop, said Jane Weintraub, moderator of the final panel at the workshop, alumna, distinguished professor, and former dean at the University of North Carolina School of Dentistry, and adjunct professor in the University of North Carolina Gillings School of Global Public Health. During the panel session, Weintraub posed to four experts a series of research-related questions on the relationship between oral health and general health: Hugh Silk, medical director of a wellness and primary care center in Massachusetts as part of Community Healthlink, and professor in the Department of Family Medicine and Community Health at the Harvard School of Dental Medicine; Cassandra Yarbrough, lead public policy analyst for the Health Policy Institute at the American Dental Association; Ira Lamster, dean emeritus of the College of Dental Medicine at Columbia University and clinical professor at the Stony Brook University School of Dental Medicine; and Wendy
1 This chapter is based on presentations by Ira Lamster, dean emeritus of the College of Dental Medicine at Columbia University and clinical professor at the Stony Brook University School of Dental Medicine; Wendy Mouradian, associate dean and professor emerita of pediatric dentistry and strategic advisor for the Regional Initiatives in Dental Education program at the University of Washington; Hugh Silk, medical director of a wellness and primary care center in Massachusetts as part of Community Healthlink, and professor in the Department of Family Medicine and Community Health at the Harvard School of Dental Medicine; and Cassandra Yarbrough, lead public policy analyst for the Health Policy Institute at the American Dental Association. Their statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
Mouradian, associate dean and professor emerita of pediatric dentistry and strategic advisor for regional initiatives of dental education for the Regional Initiatives in Dental Education (RIDE) program at the University of Washington.
At times, the discussion extended into the broader issues surrounding integration. “Integration of oral health and primary care is a health literacy issue,” said Weintraub. “It’s also a quality of life issue, a health issue, and a health equity issue.” As a professor of dentistry, she said that “it is very gratifying to me, personally, to have so many people inside and outside of the oral health professions listening and learning together today.” The oral health community cannot achieve integration on its own, she observed. “We need to build a sense of belonging for oral health to be part of health and health care for patients, providers, and policy makers.”
In responding to Weintraub’s initial question about the most important areas of health literacy and integration for a research agenda, Silk turned first to issues involving education. The Center for Integration of Primary Care and Oral Health, a joint endeavor of several academic organizations supported by the Health Resources and Services Administration (HRSA) and based at the University of Massachusetts Medical School, has done surveys to determine what is happening across the country and not just in places where integration is happening.2 Based on this research, Silk and colleagues reported that hours of oral health training in family medicine decreased from 2012 to 2017 (Silk et al., 2018). The researchers found that only one-third of residents receive more than 3 hours of oral health education (Silk et al., 2018). Only 50 percent of respondents felt their residents were ready to answer questions about oral health on their board exams. Only one-quarter of pediatric directors responded that they felt satisfied with their graduating residents’ oral health competency. These are “devastating numbers,” said Silk, “despite the fact that we’ve been at this for quite a long time now.”
He noted that in 2006 the Accreditation Council for Graduate Medical Education established recommendations and accreditation standards for the inclusion of oral health in pediatric and family medicine programs. Then, in 2015, the council reversed these recommendations. Since then, the amount of oral health training in these programs has been declining. “We have to look at those kinds of standards” and their impact on training, he said.
2 More information about the center is available at https://umassmed.edu/fmch/centers/center-for-integration-of-primary-care-and-oral-health2 (accessed June 10, 2019).
At the same time, training for the application of fluoride varnish is rapidly rising in family medicine and pediatrics. Silk attributed this increase to the U.S. Preventive Services Task Force recommendation on preventive oral health services and to the availability of reimbursement. “What is driving education,” he said, is an important issue for integration.
His center has been looking at physician assistants, nurse practitioners, midwives, obstetricians, and other primary care providers. Glicken, in the Journal of Physician Assistant Education, reported that 96 percent of physician assistant programs are offering oral health instruction, and one-third are providing more than 10 hours of training (Glicken et al., in press). Among pediatric nurse practitioner programs, according to the Journal of the American Association of Nurse Practitioners, 100 percent are teaching oral health (Dolce et al., 2018).
Again, contributing factors are not hard to find. The DentaQuest Foundation has been supporting nurse practitioners and physician assistants over the past couple of years, and the National Interprofessional Initiative on Oral Health has focused on that issue as well. But other professional areas, he said, are not taking the subject seriously enough.
Yarbrough recounted a recent talk by Don Berwick, former administrator of the Centers for Medicare & Medicaid Services and current senior fellow at the Institute for Healthcare Improvement, in which he mentioned a clinic in Germany that has refocused its care on what matters most to patients being treated for prostate cancer. As a result, the clinic directed attention to improving erectile dysfunction rates and incontinence, “and you could see that their improvements in those areas skyrocketed compared to all the other clinics treating prostate cancer across Germany,” said Yarbrough.
In this regard, dentistry is about 20 years behind medicine, she said. “We haven’t started looking seriously at the outcome measures that patients care about when it comes to oral health.” She recalled Dean Schillinger’s presentation in which he discussed such measures of oral health as problems with dry mouth, embarrassment due to the condition of mouth and teeth, and the ability to interview for a job given the condition of mouth and teeth. “Issues like that impact your world beyond the clinical things that we think about in the dental office. That is one of the main areas that we should continue to focus on as we move forward.”
She also read for workshop participants the definition of oral health from the FDI World Dental Federation (Glick et al., 2017): “Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions
with confidence and without pain, discomfort, and disease of the craniofacial complex.” Those are the things that matter to people, Yarbrough said. Emphasizing these objectives will get more people to access care, and they are critical issues for providers to consider. Doing so would lead to such conversations as, “I see you’re losing a lot of weight. Is this because you have pain when you chew? Are you avoiding eating and keeping up with your nutrition? Here’s how my treatment plan can help.”
The new definition of oral health has influenced a working group at the International Consortium for Health Outcomes Measurement that is creating a new international oral health measure set. However, in terms of practitioners or providers using that definition, she has not seen much movement. Even the larger group practices do not have an incentive to use the definition because of the way dental benefits are reimbursed. That may be different for systems such as Kaiser Permanente, the Marshfield Clinic, or HealthPartners, but the disconnect between reimbursement and value still hinders systemwide change, she said.
Cost is one reason why people do not seek care, but “we need to push that agenda a little bit farther,” said Yarbrough. Is it because they feel they cannot afford to come in if they need more than a dental exam and a cleaning? Are they health literate enough to know that their dental benefit does not cover such procedures? Are they weighing such costs against other necessities? The fundamental issue, again, is the separation of dental from medical care, she said. “If we really want to integrate these two, we’re going to have to start buckling down on not separating dental in any capacity.”
Finally, she mentioned the need to measure the return on investment of integrating oral health into whole-body health. A number of studies have shown the effects of dental care on lowering health care costs for diabetic patients and individuals with heart disease. These studies need to be expanded, she said, which is why the initiatives being undertaken by HealthPartners, Kaiser Permanente, Marshfield Clinic, and others are so exciting. “These are the pilots, if you will, for the dental industry, in terms of really proving why it’s important to have that integration. I can’t wait to see some of that research come out that looks at a broader population beyond those suffering from very important and very expensive chronic conditions,” said Yarbrough. Such research could help encourage people to take their oral health seriously.
She also mentioned the momentum behind adding a dental benefit to Medicare. The Santa Fe Group, Oral Health America, AARP, and other advocacy, consumer, and policy groups are taking this very seriously. The current effort is mostly focused on diabetes, with a concerted effort under way to add dental benefits to Medicare for those individuals who have diabetes. This could eventually affect more than half of the Medicare population (Hasche et al., 2017; Ward et al., 2017), particularly if several
other chronic diseases are added to the mix. This advance then could act as a platform to roll out a dental benefit to the entire Medicare population.
In the U.S. health care system, Medicare sets the stage for the rest of the system, Yarbrough noted, so a dental benefit in Medicare could have much broader effects, including the creation of mandated dental benefits in Medicaid.
Lamster began by noting that a growing body of literature exists, along with growing professional support, for the expansion of the scope of dental practice to include primary health care (Lamster and Myers-Wright, 2017). The population in developed countries is aging, he pointed out, with a concomitant increase in chronic diseases. At the same time, tooth retention is increasing, which means that dental providers will see an increasing number of older patients with complex medical histories who are used to good oral health care and will demand continued good oral health care.
This confluence of trends has created an opportunity to use the dental office as a source of health care. The United States has hundreds of thousands of oral health care providers, and the time that they allot to patients, especially in the preventive phase, is much greater than in medical care, Lamster said. “This is an opportunity that is not to be missed.”
For the past 25 years, Lamster has been studying the relationship between oral health and diabetes mellitus. Though this is not the only relationship between oral health and a chronic disease, it is the one for which the volume and breadth of the data are greatest. Almost 10 percent of adults have diabetes mellitus, 25 percent of whom are undiagnosed.3 Patients with diabetes mellitus develop a wide range of changes in the oral cavity and contiguous structures, including not just periodontal disease but reduction in salivary flow, burning mouth syndrome, and swelling of the parotids. In Lamster’s studies, between 30 and 40 percent of patients were identified as dysglycemic, with 5 to 7 percent in the diabetes mellitus range and the remainder being in the prediabetes range. The latter is not a formal diagnosis but an identification of risk, said Lamster, and these previously unidentified patients should be referred to a medical provider. In a small pilot of about 100 patients to see how responsive they would be to that referral, Lamster reported, 70 percent reported 6 months later that they had seen a medical provider (Lalla et al., 2015).
Lamster also briefly described the body of literature demonstrating that people who have chronic disease and access to dental services have lower
3 These and other statistics about diabetes are available at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf (accessed April 23, 2019).
health costs and improved health outcomes compared with those who do not have access to dental services. These data, which come largely from private insurance companies, have potential confounders and may be the result of correlation rather than causation, but the analysis, which is ongoing, is suggestive.
Lamster also described an ongoing study of the Medicaid population in New York State, which is producing comparably promising results for patients with diabetes mellitus, cardiovascular disease, cognitive impairment, and respiratory disease. This study is suggesting that the health care dollars that are saved are actually greater among Medicaid patients than among patients who have private insurance.
Health literacy is “perhaps the best outcome metric that we could have as we move toward integrating the system,” said Mouradian. As a general and developmental pediatrician for the first 15 years of her professional life, Mouradian’s lack of knowledge of oral health was not challenged—even though her father was a dentist. But then she became involved with a craniofacial clinic, which she described as “the best model of integration that I believe exists today.” There she learned how little she knew about oral health and began “a personal mission to understand the ethical and health consequences of this medical–dental divide.”
As project co-director of the Surgeon General’s 2000 Workshop and Conference on Children and Oral Health for the National Institute of Dental and Craniofacial Research (NIDCR), Mouradian found that work on integration was scarce. When she and her colleagues put out a call for papers for the conference, they received five abstracts on the integration of medicine and dentistry. Much progress has been made since then. The background paper commissioned by the roundtable (see Chapter 2) demonstrates “the richness of the efforts and sheer numbers of programs.” More information needs to be gathered from these programs, and more standardization is needed, but the advances have been substantial, she said.
Returning from NIDCR to the University of Washington, Mouradian moved from the School of Medicine to the School of Dentistry. There she participated in many HRSA-funded projects to train medical students, medical residents, and faculty members in oral health. She found that most physicians in Washington and adjoining states did not know much about oral health and did not have it as a high priority, so she began to focus on the training of medical students. This training is “fundamental,” she said, because health professionals control the services that are actually offered to patients and educate patients about what is important and what is not important. Furthermore, other examples demonstrate that medical and
dental education can change, such as the effort to integrate community-based education into dental education, which was jumpstarted by the Robert Wood Johnson Foundation and other foundations. Over a decade, community-based rotations went from being implemented in just a few schools to being required by the Commission on Dental Accreditation. “I saw a change in our school from where faculty didn’t want students to go out and students didn’t want to go out, to where they were thrilled to send students out and students wanted to go,” she said. “I do believe the culture of education can change over time.”
Mouradian recommended establishing a similar process of medical and dental integration involving about a dozen schools around the country, not just one or two. She also agreed with Lamster that integration is a two-way street. Though dental students and dental faculty tend to insist that not enough time is available to learn about medical care while also learning dental skills, “when we actually put people together and we give them those experiences, it changes them,” said Mouradian. Such an initiative would also generate a large amount of useful data for research as dental students learn about primary care tasks that they can apply in their professions.
Finally, Mouradian observed that primary care providers need to involve dental providers more in general health care, and that dental providers need to be prepared to get involved. She continued:
I want to tell my dental students that it’s time for you to be doctors, real doctors. I know some of my dental colleagues might shrink as I say that, but it is a different culture. I live at that interface and I know that the training in dentistry has typically not allowed dental students to participate in whole-patient care and to take on that kind of responsibility. And that has an impact on the way they are willing to practice later.
She also urged moving oral health into Medicare and said that doing so could greatly enhance the education of patients, physicians, and other health professionals about oral health and dental care. If every Medicare patient could be informed at every medical visit about the opportunity to have dental care, the effects would be enormous. She said,
We’re not at the tipping point yet, but how far we’ve come in the last two decades is astounding. If we had another decade of concentrated efforts, including well-evaluated educational programs that picked up a dozen or more partnered dental and medical schools, nursing or physician-assisting schools, we could be at the tipping point.
As part of the discussion of interprofessional education, Lamster asked whether such programs could become more than window dressing and something that students will embrace. “Unfortunately, since dental education is so challenging today—financially and in other ways—unless it goes into the accreditation standards, it probably will not happen,” he said. Weintraub agreed about the importance of accreditation, noting that integration is just one of a number of competing priorities for accreditors but that accreditation is critical in driving changes in general education.
Mouradian pointed out that new accreditation requirements are not required for progress. For example, new accreditation requirements would not be needed for a group of medical and dental schools to work together on integration. However, such a collaboration could result in new accreditation standards, in the same way that community-based education standards have evolved. “I go back to the importance of large, well-measured, and well-studied education projects among the medical, dental, and other health professional schools.”
With regard to the diversity of education programs, Mouradian noted that most dental and medical schools have outreach programs to bring in underrepresented minorities, and some of those programs put medical and dental students together. Such programs provide an opportunity to promote interprofessional care. “I’ve long wanted to take a cohort of students from the very beginning and mix them all up,” she said. “We’d have a very different kind of student at the end. You could put a number of these important pipeline paradigms together, including underrepresented minority students, but also the opportunity to expose these students to a breadth of richness in integration.”
A major issue in the work of his center on the impact of oral health training for primary care clinicians, said Silk in response to a question on the greatest gaps in research, has been the use of outcome measures. He mentioned several valuable studies that have been done, including the Qualis Health study on workflow, the HRSA project that Joskow mentioned, the Medical Oral Expanded Care (MORE Care) rural health, and the Perinatal and Infant Oral Health Quality Improvement grants. However, many studies continue to rely on process measures rather than outcome measures. One problem is that research grants typically last for only a few years. That can be contrasted with Into the Mouths of Babes, which because of its extended existence and research has been able to see caries rates going down. “But that takes 20 years to prove,” Silk pointed out.
A major question is whether researchers will be content with process measures or will strive for more meaningful measures. He and his colleagues have been working on a tool that could be used in a clinical setting to make such measures. For example, because fluoride varnish reduces caries, increasing fluoride varnish rates would imply that the caries rate should go down, though “we still have to be careful with that inference.” The tool they are developing could be applied in a federally qualified health center or a private practice to work from process measures to better outcome measures, Silk said.
A related problem is the difficulty that clinics have communicating with each other. In an ongoing project involving obstetricians and dentists, the only way for the two groups to communicate has been to fax pieces of paper between offices and count them at the end of the month. “We have no way to know if people are making it to the referral, let alone then going into the records and seeing what happened with it.” An electronic health record that bridged that gap would be extremely valuable but does not yet exist except in closed systems, such as Kaiser Permanente and the Marshfield Clinic.
Yarbrough pointed out that even when health information systems are able to communicate with each other, outcome measures may not be meaningful or actionable. The Dental Quality Alliance has taken on the task of trying to create outcome measures that can propel the dental industry toward value-based payments and evidence-based care. But even those measures are systems measures: How many children went in for an exam? How many sealants were placed?
At the time of the workshop, the International Consortium for Health Outcomes Measurement was working on an oral health outcomes measurement guide. Yarbrough described the guide as including a good combination of systems measures with which clinicians are comfortable and outcome measures that patients care about.
One problem is getting dentists to implement such measures, Yarbrough added. Especially with dentists who work in private practice and do not necessarily communicate with others, either in medical practices or other dental practices, no obvious incentive exists for them to use outcome measures in their practice. “That’s something I’d like to see us think about more in the research community,” Yarbrough said. “How can we get folks to implement those?” This is an area where Medicare and Medicaid could play an important role, she added.
The introduction of dental benefits into Medicare raises three questions, noted Lamster. The first is how expensive it will be, which relates to
how sustainable it will be. The second is whether it will improve health care outcomes. The third—and the most important, in Lamster’s estimation—is whether it will save money, “because that’s what seems to be driving the decision-making process.” Without saving money, he said, “it just won’t happen.”
Mouradian responded by recalling Schillinger’s presentation (see Chapter 4) about the magnitude of the costs of not providing dental care, not only in terms of oral health but in terms of mental health, employability, and so on. In addition, the separation of medicine and dentistry has created an enormous duplication of infrastructure between medical and dental education, which has not only been expensive but has slowed the progress of research on oral health. The dental explorer and X-ray technology are more than 100 years old, she pointed out, yet until recently these were the primary technologies used in dentistry. She recommended producing a background paper like the one generated for the workshop on the unintended consequences and larger costs of failing to integrate oral health with general health, because considerable data and research are available on the subject. Such a background paper should also look at the ethical, legal, and social dimensions of integration, just as those were studied for the human genome project, she said.
Mouradian also pointed out that the consequences of failing to integrate are even deeper and broader than most people appreciate, beyond disparities, public health benefits, and costs to the system. For example, one consequence of the isolation of dentistry is that it is not prepared to participate in some of the major changes going on in medicine, such as advances in genomics, proteomics, and precision health care. Medicine is undergoing “a revolution,” she said. Health care decisions for providers and patients are going to become much more complex. Dentistry risks being marginalized by not participating in these areas. This observation also extends to complementary and alternative medicine, she said. When she went to her University of California, San Francisco–trained family practitioner, she was told that she needed to get rid of fluoride products and possibly take the amalgams out of her teeth. “Dentistry needs to be there, because there is a science that needs to be brought to bear, and because some questionable practices are being promulgated.”
New research is pointing to possible links between oral health pathogens and the amyloid plaques of patients with Alzheimer’s disease. “Where are we? Are we out there with those researchers? Are we participating?” she asked.
She also discussed a missing ethical dimension resulting from the dental–medical divide. Among the generally accepted principles of ethics are beneficence, nonmalevolence, and informed decision making. A lack of oral health literacy runs counter to every one of those principles, she observed.
She posed the question, for example, of whether patients could bring legal challenges to the dental or medical system because of not being informed about the importance of oral health care in managing their diabetes.
Weintraub observed that the commissioned paper found that interprofessional education results in increased knowledge, but that research has not focused on interprofessional collaborative practice and patient outcomes, especially outcomes not related just to oral health.
Yarbrough called attention to an issue that goes beyond the cost argument that better oral health would save money: what she called the “storytelling” aspect of policy. Shortly before the workshop, the state of Maryland added an adult Medicaid dental benefit to their program. Policy insiders said that the studies of integration were important factors. “But what actually drove the legislators to make the change was that we had one Democrat and one Republican and both of them were impacted by oral health on a personal level,” including one who had a brother who ended up in the hospital from an oral infection. “Those personal stories are what sometimes actually influence policy makers to pay attention to us.”
Silk agreed, noting that many people know the name Deamonte Driver and the story of how he died when bacteria from an abscessed tooth spread to his brain. Furthermore, such events among the population in general are not rare. Shah and colleagues (2013), in a study of 61,439 hospitalizations over 9 years in the United States that were primarily attributed to periapical abscesses, found that 66 of the patients died in the hospital. “We don’t know the names of one of those adults,” he said. “If we knew those 66 names, and we knew those stories, then maybe that would have an impact.” He also noted that, in meetings with medical students and state legislators in Massachusetts, the legislators have said that if they receive even five letters, e-mails, or texts about an issue, that is enough for them to start thinking about legislation, “because if five people take the time to write something, that’s a big deal.” As Weintraub pointed out, “A lot of policy makers have never had a dental problem. We need to get them to go to a Mission of Mercy clinic and see all the people standing on line with dental problems.”
Silk also observed that he worked in a setting with people who have significant mental health disease and addictions. Most of his patients do not have teeth, which affects their self-worth and makes the rest of their life a nutritional challenge. These patients need more than oral health literacy. They need access to care, including access to dentures so they can eat. “We have to get policy makers to understand this,” he said. “If you had those stories of people with Medicare and how disastrous their lives become,
that would certainly move us toward the Medicare benefit, and not just for diabetic patients.”
In response to a question about the provision of oral health services in urban versus rural settings, Silk noted that challenges can arise in both regions. Populations in either setting may not have enough providers. Teledentistry can be a valuable application both with rural populations and other populations, such as in the prison system. The MORE Care project, he observed, is focused on workflow issues in rural settings so that primary care teams are not overwhelmed.4 Qualis Health is another organization working on these issues.5
Mouradian mentioned the RIDE program, which includes a component that sends dental students into rural areas. These students can be alone in a dental office and not have access to a physician, she noted, which is one reason to provide them with training on systemic health issues. “They get a lot of training in CPR and interprofessional experiences because of the fact that they are isolated.” In addition, because of their isolated circumstances, rural areas open up opportunities for collaboration. “Some of our best partnerships are with more rural communities.”
Yarbrough referenced some of the organizations that look at shortage areas, including HRSA and the Health Policy Institute. “There’s an opportunity for us, in the near future, to come together and try to come to a more consistent definition of a shortage area,” she said. That will also require a better measure of access, which is also a concern of the Medicaid program.
A question about disruptive technologies led the panelists to consider the possibility that technologies in dentistry, such as changes affecting transportation or getting resources to people in need, could change the field. Silk described the straightforward technology of texting high-risk children and parents about brushing their teeth, about diet, and about other aspects of oral health. He also described a more advanced technology where electric toothbrushes could record how long they were on and the pressure
4 More information about the MORE Care project is available at https://www.dentaquestinstitute.org/learn/quality-improvement-initiatives/medical_oral_expanded_care (accessed June 10, 2019).
being applied to the teeth. Such technologies could especially be useful in research, he pointed out.
Yarbrough mentioned an application of smartphones where patients take a photograph of their mouth and send it to a dentist for a risk assessment and recommended treatment. It is an application of teledentistry, she pointed out, that could specifically target low-income individuals who do not have access to services in a dental office. “It’s trying to bridge that gap and meet the patient where they are.” More broadly, teledentistry could further integration, coordination, and communication across professions.
Lamster noted that some of the best work on teledentistry is coming out of Australia, where distances make the availability of dental specialists (i.e., an oral pathologist) very challenging in some remote areas. Other applications in Australia have focused on long-term care, the distribution of resources to children, and specialty care.
Weintraub mentioned the potentially disruptive technology of silver diamine fluoride, “which is not really a new technique but is new in the U.S. because of recent FDA [U.S. Food and Drug Administration] approval.” Applied to an open dental cavity, silver diamine fluoride causes the decay to harden and arrest so that it does not progress.
Information technology could also be a disruptive force in the integration of oral and general health care. The value of health literacy driving integration is that it simplifies the patient experience and helps them navigate the system of care, said Linda Harris, director of the Division of Health Communication and e-Health Team in the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services. Vehicles like the patient portal could help patients understand their experiences with health care systems and the value of those experiences. A pilot project could look at such opportunities from a patient’s perspective and ask whether a simplified system of care that combines dental and primary care provides them with more satisfaction and confidence. “The real value is going to lie with the patient,” she said.
With regard to the patient portal, Weintraub noted that many dental practitioners still are not using electronic health records. However, the system is moving in that direction, “so a pilot project would be great.”
Lamster observed that dentistry is at an inflection point. He doubted that the fee-for-service system will exist in any significant way in 30 years. Corporate dentistry will continue to offer opportunities for the introduction of new concepts—“sometimes for the right reasons, sometimes for the wrong.” He noted that, in a review of state laws that govern dental practice in all 50 states, about half of the states had a broad definition of what
dental practice is and the other half had a narrow definition, which clearly demonstrates that opportunities for change exist in some places.
Yarbrough noted that some of the best opportunities to try new and innovative ideas occur in publicly funded programs such as Medicare or Medicaid and in such entities as accountable care organizations. However, “after we do the innovative project, the pilot project, how do we convince folks that all of these great outcomes from that pilot or from that innovation are worth it and should be spread across the system as a whole? That’s the big piece that we haven’t answered yet.” Society continues to treat oral health as a commodity that can be interchanged with other goods rather than as an integral aspect of health. “If I had a cut in my arm, I’d go to the hospital and nobody would question whether or not I needed that fixed. But if I have a toothache, I go to the hospital and they give me a pain prescription and an antibiotic and then I go on my way.”
Mouradian responded that if patients, physicians, and other members of society fully understood the consequences of not having oral health, they would feel very differently about it. She suggested further exploring the possible consequences of physicians missing oral health diagnoses, because “physicians are very fear driven, we’re very afraid of missing something important.”
In response to a question about value-based care, Yarbrough observed that a preventive health care system requires team-based primary care, including a dentist or some other sort of oral health provider. Echoing Mouradian, she called for a large pilot project that would measure the return on investment of such care, in part to determine the value of integrating dental care into primary care.
I’d love to see a day where we don’t have to keep separating the two when we talk about it. Because, as somebody said earlier, most general practitioner dentists and pediatric dentists see themselves as primary care providers. We also need physicians to acknowledge them in that way, and the best way to do that is to have them work as a team rather than separately.
Finally, Silk called for better coordination among the public health, private health care, and government agency sectors. Many government agencies and nonprofit organizations are involved in integration, but “everyone is doing their own thing,” he said. Past policy reports have pointed to the need for oral health leaders. Such leaders—including some of the people at the workshop, he noted—could provide that vital coordination.