Dr. Richard ValachovicIn this month’s letter, ADEA President and CEO Dr. Rick Valachovic talks with a champion of dental and primary care integration.

Michael Glick, D.M.D., has a vision for dentistry’s future. The University at Buffalo School of Dental Medicine (UB SDM) Professor sees dentistry becoming a portal to primary care.
During his tenure as Dean at UB SDM, Michael put this vision into practice. The school’s dental clinics became places where students routinely screened patients for hypertension, diabetes, and, if patients chose, HIV. The clinics also became exemplars of interprofessional care, with pharmacists, librarians and social workers on hand to help interpret patients’ medication histories, find evidence to guide treatment and connect patients to follow-up medical care and other resources.

Why introduce primary care screening into an academic dental setting? “As health care professionals, we can do much more to impact our patients’ health than we’re doing right now,” Michael told me. Most people who arrive at the dental office perceive themselves as healthy, but noncommunicable diseases take a long time to develop. By the time there are signs and symptoms, the diseases may be far advanced.

Michael considered this problem and then posed a question: “Would it be possible in a dental office to do some screening for individuals who may be at risk for developing these diseases?” His answer was, “Yes,” and several studies that he and others have conducted support this conclusion. Not only is such screening feasible, it is also accepted, even welcomed, by dentists, patients and physicians.

These findings have implications for academic dentistry. Screening for hypertension has become the norm in dental school clinics, and a number of schools are engaged in other types of primary care screening as well. (I wrote about some of these in 2013.) But the integration of primary care screening within a dental clinic setting is far from universal.

I asked Michael what would have to change for every dental school to screen for a few common health conditions in its clinics as he and his colleagues have done at Buffalo. “Not much,” he responded. “The expertise exists in every dental school to do these screenings. It’s just a matter of making it a priority.”

That said, Michael acknowledged that integrating primary care screening in nonacademic clinical practices is another matter. Many private practice offices don’t want to take on procedures that are not reimbursable by third parties. Some dentists feel uncomfortable screening for conditions that don’t manifest themselves in the oral cavity. And others have a legitimate fear that they would be courting trouble if they screen and diagnose patients but don’t provide appropriate follow-up care.

“You need a support system to ensure that the dentist knows what to do next. In a dental school, you have that support system, but you may not have that in private practice,” Michael said.

Nevertheless, Michael argued that such conditions as uncontrolled hypertension have costly consequences, and if timely screening in a dental office can mitigate those, it makes sense to integrate screening in dental practices—both for the health of patients and to reduce health care costs. As health care moves toward a value-based reimbursement system, the logic of this approach becomes all the more clear.

Michael has wrestled with some of these larger issues in his role as co-chair of the FDI World Dental Federation’s Vision 2020 think tank. In 2016, the FDI, of which ADEA is a supporting member, released a new definition of oral health, which reads: “Oral health is multi-faceted 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.”

The definition further states that oral health:

  • Is a fundamental component of health and physical and mental well-being. It exists along a continuum influenced by the values and attitudes of individuals and communities.
  • Reflects the physiological, social and psychological attributes that are essential to the quality of life.
  • Is influenced by the individual’s changing experiences, perceptions, expectations and ability to adapt to circumstances.

“This new definition moves dentistry from treating disease to treating a person with disease,” in Michael’s view. This shift in thinking aligns with his goal to graduate health care professionals “that happen to be dentists” as well as with trends in health care reimbursement. Michael told me that third-party payers have expressed a willingness to pay for oral health rather than dental procedures, especially as care moves to a context in which the patient is looked at holistically. He is now working with others at the FDI to develop a tool to measure oral health in all its dimensions—a step that could facilitate dentistry’s transition to value-based payment.

When we spoke last month, Michael laughed as he thought back to how he became a champion of dentistry’s role in primary care.

“I applied to both medical and dental school and could’ve gone to either,” he said, “but I thought, ‘I don’t want to be with sick people. I don’t want to be in a big institution,’ so I decided to go to dental school.”

As you may already know, it wasn’t long before Michael deviated from that path—entering academic dentistry and specializing in the care of individuals with complex medical issues, including people who had organ transplants and people with HIV/AIDS and other communicable diseases. He sees primary care activities as a natural extension of that work, having always viewed dentistry as a part of medicine.

Michael expects the relationship between dentistry and primary care to evolve slowly, but he is eager to see dentistry do more in this realm. As he and his co-author from Touro College of Dental Medicine at New York Medical College, Barbara Greenberg, M.Sc., Ph.D., wrote in the Journal of Dental Education last year, prevention and early intervention are effective for reducing the incidence and severity of increasingly prevalent conditions, such as cardiovascular disease, diabetes mellitus and infections from HIV and hepatitis C—all associated with significant morbidity and health care costs. Dental settings have shown themselves to be suitable for screening and referring patients with these conditions, so why not prepare dentists to engage in these activities?

Beyond screenings, Michael envisions a future in which dentists might give immunizations and perform other functions currently delegated to physician assistants and others, especially in regions where physicians are scarce. Currently, state law prevents these practices, but who knows what tomorrow may bring? In the meantime, let’s seize the opportunities before us, and begin to view the dental office as a portal to primary care.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic talks with North Carolinians to find out how a new model of dental education is bringing dental care to rural parts of the state.

What happens when you recruit students who are committed to rural practice and prepare them to be dentists in rural practice environments? Can such an investment make a measurable difference in improving access to dental care?

East Carolina University (ECU) set out to answer these questions when it opened the doors of its School of Dental Medicine (SoDM) in 2011. The plan for the school had many unique features, which I’ve described in this column before, but what most set this groundbreaking venture apart was the decision to move a substantial portion of clinical education to the community by building eight, identical 16-chair Community Service Learning Centers (CSLCs) in underserved areas across the state. Senior dental students—all of whom hail from North Carolina—spend three nine-week rotations at the CSLCs, practicing dentistry alongside ECU SoDM faculty and residents.

The first entity to partner with ECU to bring dental education to a rural corner of the state was a Federally Qualified Health Center (FQHC) in Ahoskie, a town of nearly 5,500 in eastern North Carolina. Health Center Chief Executive Officer Kim Schwartz, M.A., remembers well her first meeting with Greg Chadwick, D.D.S., M.S., ECU SoDM’s Dean. The conversation that ensued was scheduled for 45 minutes. It lasted almost three hours, and after three years of planning, development and construction, the Roanoke Chowan Community Health Center in Ahoskie became the first FQHC in the nation with a co-located dental school clinic and residency program.

Dentistry’s arrival in Ahoskie worked out well, not least for Nicole Beasley, D.M.D. She grew up in Jackson, about 30 miles away, and recalls having to drive an hour to get to a dentist when she was young. She saw a career opportunity in her community’s lack of dental care and chose to attend ECU SoDM for two reasons: She felt at ease there, and she knew its mission dovetailed with her own aspirations.

After graduation, Nicole completed an Advanced Education in General Dentistry residency at the Ahoskie CSLC, and today she practices at an FQHC in Jackson. “I had always thought I wanted to be back home, but after graduating, I was weighing my options,” she told me. “When it came down to it, I just knew that the whole reason I went to dental school was to be here in the first place. Here’s where I can do the most good.”

Maggie Wilson, D.D.S., M.B.A., Vice Dean and Associate Dean for Student Affairs at ECU SoDM, couldn’t agree more with Nicole’s assessment. “It’s only once our graduates are out there in a practice, in a rural community or an underserved area, that our mission is realized,” she told me.

Maggie and Greg put me in touch with Nicole and another graduate who exemplifies ECU SoDM’s promise. Gustavo (Gus) Gasca, D.M.D., had difficulty accessing dental care as a child because he moved from Florida to North Carolina to Michigan and back each year as his Mexican-born parents followed the harvest. Gus told me he and his siblings needed to have primary teeth extracted, and their permanent teeth came in misaligned. In his brother’s case, the problem was extreme enough to draw unwanted attention from his middle and high school classmates.

As it happened, the family’s desire to see Gus go to college led to a marked improvement in their oral health. So Gus could take advanced placement courses, the family decided to live in North Carolina year-round, a choice that made the family eligible for Medicaid. Gus’s mother was finally able to address her dental pain, and his brother got the orthodontic treatment he needed.

“Getting braces changed my brother’s self-esteem,” Gus told me, and watching that transformation eventually led Gus to pursue a career in dentistry. Today he is practicing at Pollock Advanced Dental Group in Burgaw, where he primarily treats Medicaid patients and is the only dentist in a 20-mile radius who speaks Spanish. He is delighted to be “giving back.”

Where are ECU SoDM’s other graduates?

  • The majority—83 of 148—are practicing in North Carolina.
  • Seven are practicing out of state, and two will likely return when their spouses complete residencies.
  • Another 38 graduates are in General Practice Residencies.
  • Fifteen are pursuing advanced dental specialties.
  • Two are in the military.
  • One is a faculty member at ECU SoDM.

Perhaps the better question is: Are these graduates engaged in work aligned with ECU SoDM’s mission of placing dentists in rural, underserved communities? Apparently many are.

“We’d like to track this by county,” Greg told me, “but even in doing that … you have to peel the onion back. One of our graduates is working in Mecklenburg County. That’s urban, but he’s working in two Medicaid practices and seeing 100% Medicaid patients, so his work is clearly mission aligned.”

Back in Ahoskie, Kim sees ECU SoDM’s mission in practice every day. The Ahoskie CSLC provides continuous care for an established panel of patients and prioritizes care for individuals who arrive at the FQHC with dental needs. An arrangement with the Roanoke-Chowan Foundation allows the center to provide complex procedures on a sliding fee scale for uninsured patients.

Kim calls the impact of this care “miraculous.” One patient saw her diabetes improve after receiving dentures that allowed her to get off a soft diet of applesauce and sweet potatoes. Another patient found a job after his missing front teeth were replaced. A third was able to sleep again after being treated for the condition causing her dental pain, Kim told me. “To literally have this clinic right here in Ahoskie, this little rural town in eastern North Carolina, and to be known for it. … People are very proud of that fact and proud of the association with ECU,” she says. “They finally have an option for oral health and (this is not too strong a word) hope that there’s someone looking out for their oral health needs.”

There’s no question in Kim’s mind that by providing one-stop shopping for medical and dental care at Ahoskie, ECU SoDM has improved the lives of some of the health center’s most vulnerable patients. The school’s statewide numbers are also impressive. Since that first CSLC opened in 2012, Greg told me, ECU SoDM students, residents and faculty have treated 49,720 patients at the Greenville campus clinic and the eight CSLCs distributed throughout the state. More than 15,000 of those patients were enrolled in Medicaid.

These numbers are welcome news in a state with one of the lowest dentist-to-population ratios, roughly five per 10,000. According to the Health Resources and Services Administration, North Carolina has roughly 140 Health Professional Short Areas when it comes to dental health. So why are so few dentists practicing in rural parts of the state?

When I asked Nicole if she had thought about opening her own practice in the area, she expressed doubts about her ability to make that happen. She says it’s difficult to find front-desk staff, dental assistants or a business manager. Additionally, because so few people have private insurance, it can be challenging to develop an adequate patient base. Instead, she has set her sights on one day being the Ahoskie CSLC clinic director—a goal with which no one at her alma mater will argue.

Despite the obstacles, rural practice can be financially viable. “A lot of people look at the Medicaid fee scale and say, no way can I take part in that,” Maggie observes, but that reaction is too hasty, she tells students. “You can serve Medicaid patients and still earn enough to pay off your loans, send your kids to college, buy a home, etc., but you need a well-designed vision and a practice plan.”

To equip students with the tools they need to care for underserved patients in a sustainable way, the ECU SoDM curriculum explores public policy, financial barriers to care and the sociology of poverty. The school has also hired Hillary Harrell, who serves as Student Financial Support Manager. She works with students to help them figure out how they will pay for dental school, teaches in the practice management curriculum, and assists students, residents and graduates with identifying practice opportunities that are aligned with ECU’s mission. Her support ranges from critiquing business plans to helping students arrange for loan repayment to coaching students on salary negotiation. With a number of first-generation college students among ECU SoDM’s graduates, many without a family member to guide them, Maggie says, Ms. Harrell can be a lifeline.

So, what’s next for Ahoskie? According to Kim, the CSLC could use several more dentists just to meet the routine needs of the patients at the FQHC. That may happen one day, but Greg plans to proceed cautiously.

“We have room for expansion within the facilities, but we’re trying to make the center sustainable—not just economically but also educationally. We’re not just a safety net clinic. Students need to do crowns, bridges, root canals, partials and not just provide basic care.” Greg echoes Nicole’s concerns when he adds, “In rural areas, it’s hard to recruit a mix of patients who can afford more complex treatments, and Medicaid doesn’t cover much.”

It has been clear for years that Greg and his colleagues are contributing to the transformation of dental education. Six years into ECU’s experiment, it seems irrefutable that the CSLCs are achieving their early goals and having wider impacts. By bringing dental care to rural populations, ECU SoDM students, residents, faculty and graduates are not only making a measurable dent in their state’s access-to-care challenges, they are also helping to reinvigorate communities. When CSLC practitioners eliminate pain and restore smiles, they participate in a process that can lead to employment and improved economic circumstances. Kim also reports that the presence of young dentists drawn from the community is inspiring a new generation to consider pursuing dental careers.

These are some of the good things that happen when you recruit students who are committed to rural practice and prepare them to be dentists in rural practice environments. I look forward to hearing more good news as the program grows.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic talks with two educators at Louisiana State University Health New Orleans School of Dentistry about their recipe for interprofessional education.

At the Louisiana State University Health New Orleans School of Dentistry (LSUSD), interprofessional education (IPE) has become an integral part of the culture, growing from the personal experiences and commitment of its faculty members.

LSUSD’s focus on IPE came about in large part thanks to an individual many of you know: ADEA Past President (2010–11) Sandra Andrieu, Ph.D., Associate Dean for Academic Affairs and Director, Program in Advanced Dental Education at LSUSD. Sandra awoke to the urgency of preparing health professionals to provide collaborative care through her husband’s experiences with Parkinsonism and Lewy body dementia. Along with ADEA Senior Scholar in Residence Leo Rouse, D.D.S., FACD, she represented ADEA on the Interprofessional Education Collaborative (IPEC) expert panel that drafted Core Competencies for Interprofessional Collaborative Practice. And thanks in large part to Sandra’s zeal, ADEA members received a thorough introduction to IPE at the 2011 ADEA Annual Session & Exhibition in San Diego.

Following her success in San Diego, Sandra established a grassroots working group at LSU, and in 2012, university administrators supported the effort by appointing a formal IPE Committee. The group set an initial goal: to give each student at least one IPE experience while enrolled at LSU. This decision prompted the creation of an elective course that drew strong attendance from students across all LSU Health Sciences Center (LSUHSC) schools. From there, individual programs began developing IPE experiences with each other, an effort that continues to grow.

Then in 2013, LSU seized on the opportunity provided by its upcoming health sciences center accreditation to develop an IPE infrastructure able to catapult their efforts to the next level. Faculty endorsed a Quality Enhancement Plan that involved creating a Center for Interprofessional Education and Collaborative Practice, hiring a director, Tina Gunaldo, Ph.D., D.P.T., M.H.S., and naming Center liaisons from each of the six LSUHSC schools—steps that have dramatically increased IPE activity at other universities.

“We realized that we were siloing IPE, which is exactly what we didn’t want to do,” Sandra reflected. “IPE can’t be something separate; it needs to be integrated into the culture and the curriculum. We wanted it to become part of the fabric of education at the Health Sciences Center.”

Sandra and her colleagues could not have achieved what they did without the full backing of LSUSD’s Dean, Henry Gremillion, D.D.S., MAGD, who started his deanship in 2008 and currently serves as ADEA’s Board Director for Deans. Henry has recognized the importance of interprofessional collaboration since graduating from LSUSD in 1977. At the start of his career, he was that rare solo practitioner who was not isolated. Far from it.

In his small community, Henry set up shop next door to the town physician and across the street from the town pharmacist. He remembers the three of them being in and out of each other’s workplaces on an almost daily basis, providing de facto coordinated care for the town’s 2,000 residents. As a result, Henry was already acculturated to collaborative practice when he started a residency in orofacial pain at the University of Florida. The program brought dentists together with neurologists, neurosurgeons, psychologists, physical therapists, and anesthesiologists, as well as ear, nose and throat specialists, deepening his understanding of interprofessional practice.

“My entire practice life has pretty much been spent in an interprofessional collaborative care environment,” Henry told me, “so when I arrived at LSU School of Dentistry as Dean, I was ecstatic about coming back to my alma mater and being a part of IPE’s growth and expansion.”

By 2016, LSU’s IPE initiatives had far exceeded the university’s initial IPE goals, but Dr. Gunaldo, Sandra and the other liaisons weren’t satisfied. In their view, each of the school’s achievements was isolated, and therefore vulnerable to shifts in priorities that might arise in the future.

That insight was the inspiration for Team Up, a new two-year longitudinal course now required of all first- and second-year LSUHSC students. On the first Monday of every month, they come together in 65 teams of 11 students each to learn “from, by and with each other” with the help of a faculty facilitator. The teams also develop their observational skills through a Health Partner program that has teams connect with a member of the community to learn about that person’s health care goals, access to resources and experience of receiving care. In the second year, Team Up sessions will analyze a wide range of clinical cases.

“I think all of us were a bit naïve and thought what we were doing before Team Up was great,” Sandra told me, “but experience offers wisdom, and we now know that to make IPE sustainable and meaningful, students have to see it reflected across all programs every day. Now IPE is no longer an appendage to the curriculum. It’s embedded in established courses and threaded throughout the curriculum.”

IPE has touched a chord with the more than 185 LSUHSC faculty who volunteer to facilitate Team Up on Monday nights. They also meet as a group to prepare ahead of time, a process the faculty has found extremely rewarding.

“What we learn from each other is amazing,” Sandra says. “We see things from different perspectives, so our knowledge has grown by leaps and bounds.”

Students have also been swept up in LSU’s IPE spirit. The InterProfessional Student Alliance (IPSA) is thriving. In addition to hosting workshops, members of the volunteer organization engage in interprofessional projects ranging from research on “hotspotting” and patient engagement to teaching cooking and nutrition to hungry families.

Three years ago, IPE at LSU took on a clinical dimension as well with the construction of an urgent-care-type clinic staffed by nurse practitioners on the school of dentistry grounds. It’s a place where dental, dental hygiene and nursing students, along with dental practice residents, gain clinical exposure to an interprofessional environment and learn about patients’ general health conditions, as well as their immediate dental needs.

“The feedback I’m getting from students is that they really love it,” Henry told me. “The day we had our ribbon-cutting,” Henry recalls, “a patient came in from 40 miles away because he required extractions. Well, the team found out during that visit that he also had hypertension and diabetes—which he did not know he had. I was visiting with him that day, and he was actually in tears because he felt like it was the first time he had someone care about him as a whole person and not just look at the individual parts.”

Despite living far away, the patient returned to the clinic for follow-up care and education about his chronic conditions, a pattern Henry would like to see repeated in other interprofessional clinics throughout the state.

Indeed, LSUSD is developing another ambitious program—this one focused on enhancing care for the state’s rural population. The school just accepted its first applicant to the Rural Dental Scholars Track, which will allow the student to work at a Federally Qualified Health Center in northern Louisiana to experience on a daily basis the value of practicing with other health professionals.

I asked Henry and Sandra to give me LSU’s recipe for IPE success. They listed several familiar ingredients:

  • A core group of committed faculty.
  • Support from senior administrators.
  • Investment in an IPE center.
  • Hiring a center director dedicated to advancing IPE.

They also highlighted the momentum generated by the accreditation process and the pivotal decision to embed IPE in the curriculum through Team Up. Then, reflecting on the history of IPE’s development at LSU, Sandra revealed what struck me as its “secret ingredient.”

“The discussions that brought IPE to light were personal,” she told me. “When we first got together, we talked about our own struggles and our family members’ struggles with health care. Those experiences provided the passion and it’s never waned,” she emphasized. “If someone came and told us, you have to teach IPE, it would never have gained the traction that it has. You have to believe in your gut that this is a need.”

Clearly, she and Henry have a fire in the belly when it comes to preparing students to communicate interprofessionally and provide collaborative care. They and their colleagues are not engaged in IPE just because they see it as an abstract good. They’ve seen people they care about—whether family or strangers—suffering needlessly because of poor communication and uncoordinated care. They don’t want that to happen to anyone else.

Of Note 

The ADEA Commission on Change and Innovation in Dental Education 2.0 (ADEA CCI 2.0) is addressing some of the same concerns Sandra and Henry raise by exploring person-centered care. If you haven’t read ADEA Chief Learning Officer Anthony Palatta’s recent Journal of Dental Education Guest Editorial or the latest ADEA CCI 2.0 white paper, I encourage you to do so. You will also find related commentary from an interprofessional group of educators in the latest ADEA CCI Liaison Ledger.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic explores how one dental school and one state are framing a response to the opioid epidemic that keeps dental pain mitigation in sight.

Dental pain is real, and most of us were taught that the most effective way to alleviate severe pain was with opioid painkillers. As a result, most dentists prescribe them—with benefits but also unintended consequences for our patients. Today, the majority of young people aged 12–18 who become addicted to painkillers were first prescribed them by a dentist. Given that each year 3.5 million people, most of them young, have their third molars extracted, our role as significant opioid prescribers should come as no surprise. But the bottom line is this: Despite our best intentions, dentists have contributed to what has now become an epidemic, and we need to take an active part in resolving it.
Many of us in academic dentistry are doing just that. ADEA co-hosted a summit on the opioid epidemic with the Substance Abuse and Mental Health Services Administration (SAMHSA) in August. The meeting convened representatives of 17 southern and mid-Atlantic dental schools to learn about the scope of the problem and share strategies that academic dental institutions can use to prevent prescription drug misuse and addiction. These strategies include:

  • Screening patients to identify their risk for substance misuse.
  • Educating faculty and students about pain management, addiction and prescribing practices
  • Consulting prescription monitoring programs (PMPs) to identify patients who may be “doctor shopping.”
  • Developing relationships with addiction treatment providers to facilitate referrals.

Most of the dental schools present at the summit had already taken concrete steps in these directions, and the three Boston-based dental schools—Boston University Henry M. Goldman School of Dental Medicine (GSDM), Harvard School of Dental Medicine (HSDM) and Tufts University School of Dental Medicine (TUSDM)—had gone even further, engaging in a state-sponsored effort to create dental education core competencies for the prevention and management of prescription drug misuse.
(To learn what’s happening in other states, see the 2017 ADEA Summary of State Legislation and Regulations Addressing Prescription Drug and Opioid Abuse on the ADEA Advocacy and Government Relations key state issues webpage.)

Ronald Kulich, Ph.D., of the Craniofacial Pain and Headache Center at TUSDM, co-chaired the competency-creation effort and spoke at the summit. He explained that in 2015, Massachusetts Governor Charlie Baker asked the state’s medical schools to develop a set of core competencies that would address the opioid epidemic. When these were complete, the dean of the Tufts medical school approached the TUSDM dean, Huw Thomas, B.D.S., M.S., Ph.D., and asked him to sign off on their use by dental schools. Huw asked Ron to weigh in.

“Their fit for dentistry was, at best, not perfect,” Ron told me. “Dentists deal with acute pain. We wanted to make sure that pain was in the forefront.”

TUSDM volunteered to form a new working group, which Ron co-chaired with Huw and David Keith, D.M.D., B.D.S., Professor of Oral and Maxillofacial Surgery at HSDM. The Governor’s Dental Education Working Group on Prescription Drug Misuse developed an independent set of dental core competencies, which have now been adopted by the three Massachusetts dental schools and can serve as a guide to dental educators elsewhere in the country.

This policy initiative was one of several in the state, which has been hard-hit by the opioid epidemic. Massachusetts has also established a PMP that collects dispensing information on controlled substances to help prescribers deter drug diversion—the practice of making prescription drugs available to another person for illicit use—and assess whether their patients might be at risk for drug abuse.

I wanted to discuss these activities further with Ron and find out what steps TUSDM is currently taking to prepare graduates to prescribe appropriately. Ron arranged for me to speak with two of his TUSDM colleagues as well: William Jackson, Psy.D., Assistant Professor and Co-Director of the Interprofessional Facial Pain and Headache Rounds, and Ellen Patterson, M.A., M.D., Assistant Professor and Director of Interprofessional Education. Ellen is taking the lead on translating the core competencies into the predoctoral curriculum.

Content related to prescribing and addiction has already been woven into the first and second years:

  • Starting with Introduction to the Dental Patient courses in years 1 and 2, students learn to identify risk factors for addiction and to use screening tools. (Tufts uses the NIDA Quick Screen developed by the National Institute on Drug Abuse. A SAMHSA-developed tool, SBIRT, which covers screening, brief intervention and referral to treatment, is also available and has been integrated in the curriculum at GSDM.)
  • Students and faculty also are invited to take part in weekly Interprofessional Facial Pain and Headache Rounds, during which faculty and regional experts present on pain and addiction. (Other health professionals are welcome to attend. Contact Ron if you’re interested.)
  • Tufts hosts a yearly educational program where students hear from law enforcement about the diversion of prescription drugs for nonprescription uses. Students “rub shoulders” with police and learn that they are “not the bad guys,” Ron says, and the officers in attendance gain a better understanding of the complex decision-making challenges prescribers face.

Tufts also prepares students to routinely use the Massachusetts PMP in their practice. “Dental students are not familiar with the vast array of medications catalogued in the PMP,” Ellen told me, “and the electronic health records used by most dental schools are not typically set up to flag medications that carry risks of addiction.”
Ron agrees that dental records are not well designed for that type of intervention, and they reveal other challenges as well. “We mined about six years of dental records looking at opioid use and other things,” he told me. “Ibuprofen was spelled 12 different ways, and that’s just the ‘tip of the iceberg.’ So we have work do to in terms of how prescription drug monitoring is adopted by the field in general.”

The next step will be to build prescribing education into the clinical portion of the curriculum so students understand that discussing a patient’s risk for addiction is part of their job.

“Risk assessment for substance use is about more than identifying which medications patients have been prescribed,” William told me. “It’s also about assessing behavior. How are patients using those medications? Are they engaged in risky behaviors?”

“This broader risk assessment is not yet standard practice in dentistry,” Ellen added. “To achieve that will require a culture shift.”

The Tufts team is creating video vignettes to help students and faculty become more comfortable with discussing medication use with patients. “These are not difficult or lengthy conversations. They are just awkward conversations,” Ellen said, “but once you’ve done it a few times, it becomes second nature.”

Ellen is a physician and rightly observes that during their training, medical students watch both residents and attending physicians conducting patient assessments over and over again. Dental students rarely get that experience. She hopes the videos will provide a similar type of exposure so that dental students become comfortable with the process.

Ellen plans to eventually train a cadre of standardized patients with whom students can practice these interactions. Simulating patient assessments will help students appreciate the human complexity of treating dental pain in a way that mitigates risk for their patients. As William pointed out, “Pain is not just a physical sensation. There are a lot of psychological aspects to the pain experience.”

Ron and Ellen agreed. “When we’re asked to assess pain,” Ellen observed, “we immediately think about the intensity of the pain on a scale. But really, what we need to be measuring is function. The patient’s ability to function is a much better measure of whether or not their treatment is successful.”

Functional assessment represents a significant departure from the “fifth vital sign” view of pain that was introduced by the American Pain Society in 1996 and disseminated by The Joint Commission, which accredits hospitals. Sadly, as Ron points out, this back and forth in our relationship with pain is nothing new.

“Back in the 1800s, we were going through the same process in terms of concern about opioid use and conflict of interest with physicians who were prescribing various pain treatments. Fears associated with opioids, overprescribing and concerns over non–evidence-based medicine has been happening in cycles for the last 200 years.”

Fortunately, there are also periods of progress, but these require the type of broad-based approach that Massachusetts is championing and that Tufts and some others are putting into practice.

William wants dental schools to understand that revising curricula is not sufficient on its own. Policy work at the state level is vital to solving the problem, and so is institutional assessment. “We need to ask, How are opioids being prescribed, and what type of pain medications are being used within the dental school?”

Tufts is monitoring its own prescribing practices and has found that faculty now write 20 prescriptions per 1,000 visits as compared to 30 prescriptions five or six years ago. Perhaps most notably, the endodontic department, which adopted a policy of prescribing over-the-counter medications first, now has an exceptionally low opioid prescribing rate.

The school has also begun collecting data on use of the state’s PMP through the efforts of a third-year dental student, Jessaca York, and her supervisor, Bhavik Desai, D.M.D., Ph.D. “They found that there were 15,000 visits over three years with almost no documentation of PMP results,” Ron told me. Now that Tufts has this baseline data, Ron and his colleagues will watch to see how things change. They’ll also be assessing their students in about 18 months to see whether they have acquired the desired pain-management and risk-prevention skills.

So, the call to action is clear: We must act on multiple levels to reduce patients’ risk for addiction. We need government policies and resources that support better prescribing, institutional accountability for prescribing practices and curricula that prepare the next generation to take a holistic approach to treating pain.

Tufts may be unique in its three-pronged approach to addressing the opioid crisis, but it is not alone. Harvard’s and Boston University’s dental schools are also trailblazers, and many other ADEA member institutions include individuals who are taking courageous steps to change prescribing practices within their establishments.

Allied dental programs also have a vital role to play in this effort. Ron, Ellen and William pointed out that patients may spend most of their dental visit talking with dental hygienists or other allied personnel.

“Dental hygienists have a very preventive focus,” Ellen said. “We think they’re an underutilized resource in addressing this issue. Even though they don’t typically prescribe opioids, they are very much part of the solution.”

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic considers how the movements toward health care integration and paying for value might affect dentistry.

Those who attended the 2017 ADEA Annual Session & Exhibition in March likely heard the buzz generated by a Chair of the Board Symposium on health care transformation. The speaker, Nirav Shah, M.D., M.P.H., Senior Vice President and Chief Operating Officer for Clinical Operations at Kaiser Permanente in Southern California, posed several provocative and urgent questions:

  • How can we minimize the variation in the delivery of dental care?
  • How can we provide patient-centered rather than dentist-centered care?
  • How will we prepare to shift from a procedure-based to an outcome-based profession?
  • What areas of dental care are ripe for bundled and other forms of value-based payment?
  • How will we help thousands of solo practitioners adapt to greater delivery system integration?
  • How might dental hygienists and dental therapists help solve the need for unmet care?

The primary goal, said Dr. Shah, is to evolve an ecosystem of health care providers working for the greater good; in his view, the key to reaching that goal is standardization. He used the automotive industry to illustrate his point. From Henry Ford’s introduction of the assembly line to Toyota’s development of lean manufacturing, automobile makers have transformed their industry and produced products that are affordable, reliable and widely accessible—three fundamental goals of health care delivery that today remain elusive.

“In complicated systems, standardization is innovation,” Dr. Shah says. He and his colleagues have applied this principle at Kaiser Permanente with some truly remarkable results.

Take, for example, the way Kaiser Permanente handles hip-replacement surgery. For more than half of its patients, hip replacement has become an outpatient procedure. How? To begin with, the patient goes into the surgery fully informed about and prepared for the recovery process. A nurse has already visited the patient’s home to make sure there is a bed on the ground floor and that handrails are installed in the bathroom. Walkers and canes have been delivered, and a pharmacist has visited to explain how the patient’s medication will change. Family members who will be providing care in the home are educated about their roles as well.

On the provider side, evidence-based care rules the day. Anesthesiologists are taught to use an anterior block, which allows the patient to walk off the operating table without pain, and every patient receives that block. Orthopedic surgeons are told which devices to use, and everyone on the team is thoroughly acquainted with the ins and outs of how these work. Patients are sent home the same day, minimizing the risk of hospital-acquired infections, and a physical therapist comes to the home the next morning. The result? According to Dr. Shah, Kaiser Permanente achieves “better care, higher quality, lower costs and better safety.”

The advent of bundled payments that reimburse providers for all of the services associated with an episode of care has been key to incentivizing these types of innovations. The Centers for Medicare & Medicaid Services reimburses Kaiser Permanente and other providers a fixed amount per joint replacement, unless, of course, something goes wrong.

Under the current fee-for-service reimbursement model, hospitals take in more revenue when patients develop infections during their stays or are readmitted to the hospital following discharge. Under the bundled-payment model, providers are docked a percentage of their reimbursement when these adverse events occur, so investing up front in better patient care is financially wise as well as good practice.

The success of the hip-replacement bundle and other value-based payment experiments suggests that we’ll be seeing a continued shift away from fee-for-service medicine toward greater care integration. How this shift will impact dentistry is less clear, but no one doubts that we will also be swept up in the coming change. During his talk, Dr. Shah asked where bundled payments might work well for dental care, and ADEA members had lots of ideas—dental hygiene care for diabetes patients, dental implants for full mouth rehabilitation, and orthodontic care, among other services.

Dr. Shah described similarly impressive protocols Kaiser Permanente has put in place for averting diabetes-related blindness and for easing kidney-failure patients into a home dialysis regimen that allows them far greater control over their symptoms. He told us that in each case, treatments have become less expensive, safer and more patient-centered, and the quality of patient health has improved in tandem.

These achievements rest on several strategies:

  • Moving care out of the hospital or clinic and into the home.
  • Reducing the amount of care in the hands of specialists and empowering the whole team.
  • Requiring that providers follow evidence-based protocols.
  • Practicing transparency to improve quality.

How might we in dentistry adopt, and perhaps adapt, some of these practices to serve our own goals of increasing access, lowering costs, and improving care quality and the patient experience?

In Dr. Shah’s view, we need to begin by reducing our traditional isolation. He is firmly convinced that quality care emanates from teams, not from individuals. When it comes to one- and two-person primary care practices, Dr. Shah insists that the data show these practices provide substandard care. What does that mean for the legions of dentists in private practice? Dr. Shah challenged us to create an “off-ramp” to lead existing solo dental care providers into large integrated systems of medical and dental care that can “deliver reliably on quality.” Kaiser Permanente has already blazed a path, integrating dental- and medical-care delivery in its Oregon facilities. Dr. Shah called the arrangement a “spectacular success,” and said the company plans to replicate the model in other regions where it provides care.

Dr. Shah also had some concrete proposals for adapting our educational model to better prepare students for the integrated, person-centered care environments of the future. Among his suggestions:

  • Spend less time teaching students about surgery and more time teaching them about prevention.
  • Educate them to work in teams.
  • Foster their creativity, perhaps by having them work on some of the “wicked” problems that continue to burden health care.
  • Help them develop leadership and performance-improvement skills.
  • Acquaint them with systems engineering and encourage them to co-design care models and workflows in collaboration with their patients.

Medical education is adopting these approaches, Dr. Shah told us, but he also expressed frustration at the slow pace of change. It currently takes about three years, he said, for new hires to unlearn the habits (such as ordering too many tests) that Kaiser Permanente wants physicians to break. To address this concern, Kaiser Permanente is creating its own medical school in Pasadena, CA, to prepare physicians who are ready to deliver “Permanente medicine” upon graduation. The curriculum will emphasize leadership skills, quality improvement and systems engineering, positioning graduates to lead change wherever they go.

Kaiser Permanente’s foray into medical education represents a “deliberate decision to start over” rather than reform an educational system that has been focused on the basic sciences and research since the release of the Flexner Report on medical education in 1910. Kaiser Permanente’s departure from the educational status quo—like many of the other ideas Dr. Shah espoused—will be controversial. In dental education, for instance, we have striven to embrace innovation while still retaining and expanding our research enterprise. Likewise, not all dentists would be comfortable with the flattened hierarchy that characterizes Kaiser Permanente teams, and many of us would question the use of evidence-based protocols that obviate provider decision-making or undervalue the provider’s clinical experience in determining the best course of care.

Nevertheless, Dr. Shah’s provocative ideas demand the consideration of anyone with a stake in shaping the future of dental care delivery. If we choose to embrace integrated delivery models, expanded care teams and increased standardization, what might we gain?

Dr. Shah argues that standardizing care delivery will ultimately free health care providers from the time-consuming activities that currently prevent them from getting to know their patients, engaging with them in care planning and customizing care to better meet their individual needs. If Dr. Shah’s experience is any guide, he and others at Kaiser Permanente are onto something big, and our community would do well to consider the thought-provoking questions he posed. Coming to a consensus on the answers won’t be easy, but we must try—for the sake of our professions and our patients’ health.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic describes an ADEA initiative that supports adjunct allied faculty and may serve as a model for future online educational offerings.

What if future academic allied leaders were already in our midst, just waiting for an easily accessible opportunity to develop their skills and move to the next level? That was the premise behind a pilot leadership program developed by ADEA last year in collaboration with the American Dental Hygienists’ Association (ADHA).

ADEA/ADHA Leadership Essentials for Adjunct Faculty (ADEA/ADHA LEAF)—fine-tuned in 2017 and now called ADEA LEAF—is an interactive, self-paced online course specifically for part-time allied dental faculty members. Using Canvas, a learning management system made available by Eastern Washington University (EWU), the course guides participants as they assess their strengths, secure mentors, set goals and develop conflict management skills and a personal leadership philosophy.

Rebecca Stolberg, RDH, M.S.D.H., Professor in the College of Health Science and Public Health at EWU, is the course director and served on the ADEA/ADHA Work Group that created the program. Why the focus on adjuncts?

“When you look across allied dental programs, we all have way more part-time or adjunct faculty than full-time faculty,” Rebecca points out. “Program directors support their full-time faculty with development dollars—if they can—but adjunct faculty don’t get much in terms of professional development.”

Leadership development for adjuncts is not just about filling that opportunity gap. It’s also about developing a cadre of educators and program directors who can fill anticipated vacancies as full-time faculty members retire. Rebecca has been in dental hygiene for almost 30 years, and she is concerned. “We hire our alumni the day they graduate because we don’t have educators out there to hire,” she says with dismay, noting that many flounder without the leadership development skills that ADEA LEAF is trying to impart.

A dearth of seasoned professionals who can take on teaching and leadership roles also affects dental professional associations, state boards and other entities that rely on experienced, capable individuals to shape policy and keep our professions strong.

In its first year, ADEA LEAF impacted several of these areas. Of the 17 dental hygienists in the initial cohort, three are now full-time educators, four have entered graduate programs, two have been appointed to advisory positions by their institutions, and four have increased their teaching loads. These excellent outcomes are a testament to the can-do spirit of the program.

For Annette Stelter, RDH, an adjunct faculty member in the Department of Dental Hygiene at West Coast University, participating in ADEA/ADHA LEAF in 2016 was “absolutely profound.”

“Here I thought I was going into retirement, and now at 50, I’m going back to school to get my master’s degree to have another career,” she says. She attended the program on the recommendation of her dean, who knew of Annette’s interest in ultimately obtaining a full-time faculty position.

To achieve this goal, she was planning to pursue a master’s degree in dental hygiene, but she says that ADEA LEAF gave her a taste of what organizational leadership was all about and persuaded her to change direction. “Until I took the course, I wasn’t even considering this as an option,” Annette told me. Now she is pursuing a master’s degree in organizational leadership and hopes eventually to become the clinic manager at her school.

Annette also praises the program’s structure and the way it balances independent and interactive learning. Through the course, she made friends across the country, and a year later she is still in touch with them.

ADEA/ADHA LEAF alumna Anne Miller, M.S., an adjunct faculty member at UC Blue Ash College, a regional college within the University of Cincinnati, also appreciated the balance between independent and interactive learning. “We didn’t have a lot of live conversation, but we got to know each other through the discussion boards,” she says. “As the course progressed, people felt safer and safer to share more about their desires and their dreams.”

Anne’s dream is to become a full-time faculty member who can influence new dental hygienists to view themselves as professionals.

“Dental hygiene programs could focus more on leadership skills and talk about what you can bring to your position no matter what title you hold,” she says. For Anne, who also belongs to her state dental hygiene association and serves as president of her local component, the program offered an affirmation of her career plans. She envisions eventually moving into a clinic coordinator position, or perhaps one day, becoming a program director.

This is exactly what the work group was hoping for when it conceived of ADEA/ADHA LEAF—a program that would instill in participants a belief that “I can go on and do this,” as Rebecca put it. Although ADEA has many established leadership programs for full-time faculty, a number of these folks have sent inquiries to Rebecca about LEAF. “People are eager for this type of development,” she told me, “and the more economical, the easier the access, the better.”

Annette agrees, and adds that she would like leadership essentials to be “part of the curriculum in all the dental hygiene programs. It’s important to have these skills even when you’re working in collaboration with patients.”

ADEA is in the early stages of developing an updated portfolio of e-learning opportunities that we hope to make available to all of our members, perhaps as early as 2018. In the meantime, ADEA LEAF puts leadership skills within reach of current adjunct faculty and starts them down a path toward deeper leadership development.

The second iteration of the course starts this month with a few refinements from its original format. The 25-credit course will run for eight weeks with adjunct dental assisting and dental lab technician faculty invited to attend alongside their dental hygiene colleagues. At $14 per continuing education (CE) credit hour, the program is a phenomenal bargain, and—not surprisingly—it quickly sold out.

West Coast University Dean of Dental Hygiene Michelle Hurlbutt, RDH, M.S.D.H., D.H.Sc., plans to send members of her adjunct faculty to the ADEA LEAF program each year. If Annette’s enthusiasm for continued professional development is any gauge, Michelle is making a wise investment in the health of her program and her profession.

Dr. Richard ValachovicIn this month’s letter, Dr. Rick Valachovic shares news of a joint effort with the American Dental Association to change how dental professionals are assessed for licensure.

If you’ve ever talked with your colleagues about the clinical exams used for dental and dental hygiene licensure, you’ve heard this familiar litany of complaints: They are costly for students, often unfair to patients and fraught with potential for ethical compromise.

We’ve been hearing these grumblings for decades, but by and large, we’ve resigned ourselves to the idea that the way things are is the way they will remain. I’m happy to report that this grudging acceptance is giving way to new optimism. Change is visible on the horizon. Getting there is just a matter of time.

During the past 10 years, a few pioneering states have experimented with alternative ways to assess clinical competency for initial licensure—mandatory postgraduate training, portfolios, curriculum integrated format (CIF) exams and objective structured clinical exams (OSCEs). Most recently, Colorado opted to accept all of these alternatives as well as all of the traditional state and regional exams as pathways to licensure for both dentists and dental hygienists.

Colorado’s decision may be a bellwether of a nationwide shift away from the status quo and a major step toward license portability.

“It’s been a problem for dentistry for some time that state laws vary so much,” says Karen Hart, Director of the Council on Dental Education and Licensure at the American Dental Association (ADA). “When new and mid-career dentists want to move from one state to another, often they are required to retake the licensure exam, which includes demonstrating their skill on a patient. That’s burdensome, and according to available, albeit limited, published psychometric analyses of current patient-based licensure examinations, patient-based exams do not consistently and reliably determine an individual’s competency.”

ADEA went on record in 2011 opposing the use of live patients in licensure exams, and the ADA has held a similar position since 2005. With the increased migration of dentists across state lines in recent years, licensing reform became a top ADA priority, prompting that organization to invite ADEA to form the ADA/ADEA Joint Licensure Task Force—a recent development that should finally give isolated state-level experiments the fuel they need to scale up to a national level.

The Joint Task Force held its first meeting a year ago in August, and this February released a report with five recommendations:

  • Increase awareness and understanding of emerging licensure models.
  • Promote further development and piloting of alternative licensure models.
  • Increase understanding of the accreditation process.
  • Promote research and distribution of findings from alternative licensure models.
  • Publicly recognize and collaborate with others engaged in alternative licensure models.

ADEA and the ADA haven’t always seen eye-to-eye on every issue, but both organizations have fully endorsed the Joint Task Force recommendations. Even more importantly, both organizations have committed to concrete action to move the Joint Task Force recommendations forward. The ADA has established a steering committee to oversee the development of a Dental Licensure OSCE (DLOSCE), similar to the one currently used to license dentists in Canada and Minnesota. In parallel, ADEA will develop a template for a portfolio licensure exam along the lines of the one developed in California. These activities will advance our goal of creating valid and reliable assessments that states can use to test for clinical competency without involving patients. Over time, these alternatives might expand to include the use of manikins or haptics as the technology and economics of virtual testing evolve.

ADEA Immediate Past Chair of the Board Cecile Feldman, D.M.D., M.B.A., Dean of Rutgers, The State University of New Jersey, School of Dental Medicine, championed the idea of ADEA and the ADA coming together on common ground to improve the way U.S. dentists are licensed for practice. She serves on the Joint Task Force as Co-Chair and is the first to agree with my assessment that change is on the horizon, but she also points out that a long road lies ahead.

“The partnership between the ADA and ADEA was a natural,” she told me as we reflected on what has been achieved so far. “If you think of the licensing process as a three-legged stool, the testing and licensure folks are the other major piece of this. Whether they’re going to make some of the changes we feel strongly about remains to be seen.”

Indeed, at an April meeting of the American Association of Dental Boards, it quickly became clear that the ADA’s proposed DLOSCE remains controversial among the very dental boards that might ultimately be called upon to recognize it.

“The DLOSCE will take two to three years to develop,” Karen estimates, “and then we will have to advocate state-by-state for its adoption. In the meantime, we will work with state dental boards, state dental associations and dental schools on license portability so that all of the clinical licensure exams can be accepted by each state.”

Reaching these goals will require continued patience but also a sense of urgency. Our efforts are occurring at a time of heightened federal interest in occupational licensing. There has been a lot of discussion about just how much certification and licensure is really needed to protect the public, with the Federal Trade Commission devoting considerable energy to address this concern. In July, the agency’s Economic Liberty Task Force held its first public roundtable on the matter.

Given these pressures, I’m heartened by the strong partnership ADEA has formed with the ADA and the rapid progress we’ve made in a single year. As we move forward on achieving universal acceptance of a nonpatient-based licensure exam, we are inviting the American Student Dental Association to join us under the umbrella of a newly established Coalition for Reform in Dental Licensure.

Those of us who have been tackling this problem for decades know that it will take some time to convince everyone that change is not just possible, but in everyone’s best interest, including the public’s. There is a growing recognition that the issues dental boards handle on a routine basis have little to do with the dentists entering the profession and a lot to do with the behavior of dentists already in practice. Whether fraud, substance abuse, inappropriate prescribing or failure to meet standards of care, misconduct can arise at any point in a decades-long career. If licensure becomes more standardized, could more board resources be spent on curbing these behaviors? Maybe.

ADEA is planning to review the complaints that dental boards address to identify specifically which disciplinary actions occur most frequently in all 50 states and the District of Columbia. This research may reveal whether new dentists who gain licensure through alternative means are any more likely to be censured than their peers in states that use patient-based exams. If the answer is no, it will become harder to justify using patient-based exams or not letting licensed dentists and dental hygienists practice across state lines.

As Cecile has said, “The boards’ perception that these clinical exams are effective in preventing unqualified practitioners from entering practice—the two just aren’t related.” For those who disagree, this coming research should shed additional light on the matter and hasten the day when alternatives to live-patient licensure exams are implemented across the nation.