Innovations in Dental Care and DentiCal – Development Disabilities

Innovations in Dental Care and DentiCal – Development Disabilities


– It’s my honor to
introduce our next speaker, Doctor Paul Glassman. Doctor Glassman is a
professor of dental practice, director of community oral health, and director of the Pacific
Center for Special Care at the University of the Pacific Arthur Dugoni School of
Dentistry in San Francisco. He’s also the director of a
California statewide task force on oral health for people
with disabilities and aging. And he’s served on many national panels, including the IOM Committee on Oral Health Access to Services, which produced the IOM report on improving access to oral healthcare for vulnerable and underserved populations and the board of directors
of the Denta Quest Institute. Doctor Glassman is well known for his innovative work in dental healthcare. We look forward to hearing what’s the latest in this area today. Doctor Glassman. (crowd applauding) – Great, thank you. It’s a pleasure to be here. So, dental care. Not optional, even though, as you heard, our Medicaid system seems to think it is. And California has eliminated
adult dental benefits at a time of a recession
and now brought them back. So, we’re now actually in an era where we’ve got full benefits in our Medicaid program for dentistry, which is different than most other states. Most other states still don’t. But we still have a dental system that’s not working very well, and I’ll give you some
information about that, not working very well for most people, and not working very well for people with developmental
disabilities in particular. So, first of all, disclosures. Nothing to disclose. For people with
developmental disabilities, these are the main issues, in terms of people getting dental care. One is the ability to actually access and have dental care
done in a dental office. Access is an issue, sometimes, because of the large number of people who may be on low income, on Medicaid, and who can’t find a dentist willing to accept someone on Medicaid. Let alone someone who’s gonna take more time and effort to treat. For some dentists, the
complex health histories and not being familiar
with how to navigate all of the consultations and all of the
considerations, is a barrier. And the major thing, though, is actually the ability to
apply preventative procedures. Dental disease is among the most preventable of all diseases. And yet, we have rampant dental disease among large portions of the population. So, I’m gonna spend just a couple minutes, really, quickly, with
sort of a big overview of what’s happening in
the dental industry now. So, I think it lends some context to innovations in dental care. And you’ll see why these
innovations, I think, are critical for the future. So, one is just the fact that we spend lots of money in the United
States on dental care. This is the CMS projections
of how much was spent back in 2000 up to 2025. A 300% projected increase
up to $200 billion. That’s with a B. $200 billion spent on dental care. And a lot of people think
even that 200 billion, that’s actually still a small percentage of our total national
healthcare expenditures, which was about four and a half trillion. Our policymakers don’t
pay very much attention to dental care for that reason. But, in fact, dental care is
a bigger business than that. If you compare dentistry with everything else combine
together, it’s about 4 or 5%. But, if you look at our
natural expenditures by disease condition,
dental care is number three. We spend more money on dental care than we do on mental
disorders, cancer, COPD, every other condition
except for just a couple. So, it’s actually, really, a very big business in our country. But the fact that we spend all that money, I think, as most people know, doesn’t translate into most people having access to dental care
or having good dental health. In fact, if you just look at
basic utilization numbers, this is data from the
American Dental Association, the highest utilizers of dental services, and this is across the income spectrum. The highest utilizers of
dental services are children. And, for children, it’s
still less than half of the children in the country
actually get dental services. The marker here is a very low bar. It’s an annual dental visit. It doesn’t mean people
had all their needs met or they had good dental health. Just means they interacted with the dental care system
once during the year. So, even the highest utilizers, children, less than half the children in the country have even an annual dental visit. About 43% of seniors and only about 1/3 of working age adults. So you can see the dental care system is not reaching most people. And, if you were to do this, get other slides that I had
but didn’t put in today, show that the lower your income are, these numbers drop drastically, so that low income children,
about 33% low income seniors, it’s only about 20% of
those working age adults who are actually getting
any kind of dental services. So, by my calculations, 200 million people in the United States are not getting dental services. We have a dental industry that is primarily serving the wealthiest and healthiest people in the country. I think far different than
the general healthcare system. So, that’s one bit of data. So, the macroeconomics
of the dental care system in the country, which, by my
view, is failing miserably to provide dental care to the population of people in the United States. What’s interesting, though, actually, if you look at the
utilization of dental services in the Medicaid program, nationally, by looking at people with
developmental disabilities, they tend to actually have higher utilization than other people. Now, it’s still not good. But, tend to be higher utilization. This is the data from a report
that was recently released, showing, if you look at the
two bars on the left side, these are diagnostic
preventative services. The yellow bars are those with
developmental disabilities. The blue bars are those without. More people with developmental
disabilities tend to get, at least, than other people
in the Medicaid system, diagnostic preventative services. And the other little blip says
adjunctive general services. These are services that
are associated, generally, with people having
dental care at a hospital or under general anesthesia. So, it’s sort of puzzling to me why is it those numbers look good, when I think everyone
in this room would agree that dental service is probably
the number one unmet need or if you ask people or caregivers or people in developmental
disability systems what’s the biggest problem you have? It’s often getting dental care for people. And I’m not sure what the answer is. Although, I think you have people who are in a system where
there are caregivers, where there are people who are bringing them to dental offices. But I think what we find
is, in dental offices, the right things to keep people healthy are not necessarily being done because of all the challenges that we talked about a few minutes ago. So, let’s talk now about a few things that are happening that
I would call innovations. Or at least changes in
thinking about dental care across the dental industry. And one of the reasons I wanna give a little more background to this idea of disruptive innovation. The dental industry is an industry that is ripe for disruptive innovation. How many of you have
heard this term before? Disruptive innovation? This guy, Clayton Christensen,
who wrote these books and, actually, a bunch of others, is a professor of business at Harvard. And he’s one of these people that gets $10,000 a day to speak
to Fortune 500 companies. I’ve been trying to get that job, but, so far, no one’s offered it to me. But he talks about his idea
of disruptive innovation. He talks about companies. In this case, we’ll
translate it to companies or industries or, for this
particular presentation, I’m talking about the dental industry. Sometimes companies
tend to innovate faster than their customers’ needs evolve. That they can start to
produce products or services that are actually too
sophisticated, too complicated, and too expensive for many
customers in their markets. And companies continue to do this even after their customer
base starts to drop off, because, historically, that’s
how they made the most money is by having more bells and whistles, adding more expensive products. But the problem is, when
companies persist in doing that at a time when they outstrip
their customers’ demands, needs, and ability to access services, they unwittingly open a door
to disruptive innovation. He talks about disruptive innovations as a whole new product or service comes in at the bottom of the market and begins to take over
and eventually begins to disrupt the market so that you get people who now were, historically, unable to access those service, now can. So, there’s lots of examples
in the US industries. The automobile industry, where the American
automobile manufacturers were making these block
long cars back in the 1980s. And then the Japanese
automobile manufacturers came in with low cost Toyotas. Very low cost, very high
quality, good gas mileage. And practically put the
US automobile industry out of business. The computer industries,
where IBM was making these very expensive mainframe computers. And then the Apple laptop
almost put them out of business. And what we have is a dental industry where the dental industry has continued to develop fantastic innovations. Implants and veneers
and all kinds of things that most people in the
country can’t afford, don’t need, and don’t have access to. And so, it’s an industry that has actually positioned itself now, that’s really ripe for
disruptive innovation. For different ways of thinking about how do you get dental health to people. So, one of the things that’s a new way of thinking about dental care is a shift in thinking
about dental disease being amenable to acute
surgical interventions as opposed to thinking
about dental diseases as chronic diseases that really require a system of chronic disease management, like is so prevalent in managing other medical chronic diseases. So, what am I talking about here? I’m talking about our two major diseases, dental caries and periodontal disease, are both chronic diseases. Chronic diseases, in the sense that diabetes is a chronic disease. You go to your physician’s office. And your physician doesn’t fix
your diabetes today, right? You go to a dental office and
you got a hole in a tooth, the dentist puts a filing
in that hole in that tooth. That does actually not fix
the dental caries disease that caused the whole tooth to
be there in the first place. The same with the other major
disease, periodontal disease. There’s nothing a dentist
can do on a given day that’s gonna fix that disease. These are both chronic
diseases that require management over time. It’s not the way the
dental industry is set up, even in terms of treatment,
payment, or anything else. So, there’s a thinking now that we’re talking about chronic diseases. And one of the things
that people think about when you’re talking
about chronic diseases, is looking at what is
it that caused people to have good health and
long lives over time? And it’s very clear. This is a meta-analysis
of a bunch of studies showing that the major thing that happens that keeps people having health, this is whether it’s general
health or oral health, is behaviors. These are individual behaviors. These are things that people do by themselves and for
themselves every day. These are things like the use of alcohol and tobacco and your diet. What’s your diet like? Do you exercise? Do you brush your teeth with
some kind of fluoride product? These are all things people
have some control over, or the people caring for
them have some control over, on a daily basis, every day. That’s the major thing that actually can cause people to have dental health or not. There’s some, of course,
contribution by genetics. So, you have to pick your
parents very carefully, if you wanna do something about that one. And then we can do some
things as a society. But the contribution of procedures performed by healthcare professionals, and this is true for general
health and oral health, is very small compared to the ability to actually maintain health by the things that we do every day. So, in recognition of that, we have been developing something for a long time at my institution, which is a package of training materials called Overcoming
Obstacles to Oral Health. It started out back in the 1990s. We’re now working on
our sixth edition of it. Started out being on VHS cassettes and then it went to CDs and
then it went to USB things. Now, by later this year,
it’s gonna be a free resource available on the internet
that anyone can access. I’m gonna give you just a couple minutes of some idea of the content of it. But we think that the idea of helping individuals and caregivers
being able to practice what we call good daily mouth care is actually the most important key to people having dental health. Because, when you don’t
have good dental health, getting disease repaired is
so difficult for many people. And particularly for those with
developmental disabilities. So, this was put together by
a whole bunch of organizations that collaborated together. The basic idea is a
pyramid training approach where you have oral health professionals who are able to collaborate with and train social service professionals,
nurses, facility managers and leave the materials with them. Now it’s gonna be readily
accessible over the internet and be able to have those individuals work with parents and caregivers and direct care staff
who have high turnover. So, a new person comes into a facility. The manager can set them
down in front of a computer and take them through a
whole bunch of lessons and help support their
doing a much better job of daily mouth care. Without giving all of the
details of lessons to you, I’m gonna flip through a couple
slides and give you a flavor of the kind of things that are in there. So, this is divided up
into several things. Several, what we call the
obstacles to good oral health. One of them being informational. That’s, of course, when people don’t know what to do or how to do it. But that’s not true for many people, they know that to do, they
just face other barriers, like physical obstacles where someone just can’t perform oral hygiene procedures ’cause of physical problems or behavioral obstacles where people are resistive to having someone, have anything near their
face or near their mouth and letting someone,
if they can’t complete their oral hygiene procedures themselves. And, finally, organizational obstacles, which is one that we’ve added since the first edition of this, because, with the
growing recognition that, in any kind of system of care, unless those at the top and
those who are organizing the system put a priority on oral health, daily care and the direct care staff are probably not gonna
pay much attention to it. So, if you’re working in
any kind of organization, whether those are residential
facilities or daycare programs or other services that are provided for people with
developmental disabilities, any kind of system, getting
the system to recognize the importance of oral health
actually becomes really key to having the daily mouth care activities take place, that need to. So, it includes materials like recognizing what dental disease looks like. The difference between a
healthy and an unhealthy mouth. How to remove plaque using
specialized toothbrushes. These are examples of
two sided toothbrushes. It makes it a little
easier to remove plaque. Understanding basic
infection control procedures. How to store toothbrushes. We’ve found, working with
a lot of direct care staff, a very basic thing that would be obvious, they just don’t understand. Needs training and emphasis. Adapted instrumentation for being able to do daily mouth procedures. We call these mouth rests. Some people call them mouth props. But just helping someone
hold their mouth open while something’s being done, that can be made so disposably, easily. Positioning for being able to help someone achieve oral hygiene or good oral health. I’ll just tell you a little
story about this one slide. So, this is an example of a dental hygienist holding an instrument. But imagine that’s a toothbrush in the hands of a caregiver. Now, I often am talking to caregivers. And some of you may have the opportunity to have the same kind of conversation. Where I’m asking them are
they helping this individual to do their daily mouthcare? And they say, yeah, he or
she can’t do it themselves. So, I have to help them. I say, how do you do that? Where are you, are you standing up? Are you in the bathroom? Where are you while
you’re in the bathroom? Are you standing up? Yeah, I’m standing behind the person and trying to help them. Well, you can imagine a
sort of resistant person. You’re trying to do something
like this and you can’t see. And the person’s head’s moving around. It’s just really difficult for
a caregiver to do a good job. So, we have evolved, mostly through toothpaste
commercials, actually, the idea that you brush
your teeth with toothpaste. And the reason you do that, you’re gonna try to do two things. One is to remove plaque, which is the bacterial accumulation. And the other thing you
can do is apply fluoride. Both of which are critical. But we do it all at once, right? The toothbrush is removing the plaque. You don’t have to do it all at once. So, the instruction to
the caregiver would be, why don’t you try going
into the living room. You have a couch. Can you lay down? Have someone put their
head in your lap like that? Maybe cradle their head to hold it. Use one of those mouth rests to help them hold their mouth open. Just wet the toothbrush
with a little bit of water just to soften it up a little bit. Don’t have any, ’cause, as
soon as you have toothpaste in there, you gotta be spitting out. And it’s just impossible
to get it done on a couch. Remove all the debris,
remove all the plaque. Do a good job at cleaning
between the teeth. And then go into the bathroom and then put some fluoride toothpaste on the thing and put it around, ’cause the fluoride will actually
diffuse around the mouth. So, it doesn’t all have
to be done in one step. That’s just an example of a tip or trick that’s a part of these training materials that can help people do a better job of what we call daily mouth care. There’s also a whole bunch of stuff in our training materials about behavioral intervention techniques or behavioral support techniques. I won’t talk to you about what they are, ’cause I assume most people
have an idea of what those are. But it’s pretty critical if
you’re working with caregivers. Often don’t really have the training to get someone who’s resistive to having the toothbrush in their mouth to get them to a place
where they’ll accept it. So, that kind of training
is really critical, if you’re gonna make a difference
in daily oral healthcare. And there are manuals
for the administrators and for direct care staff. Just some examples of all that. And the last thing is something we call a daily mouth care plan. And, as you know, in many care systems, including those for
developmental disabilities, you have all kinds of planning processes. And, often, there’s no
mention of oral healthcare on those planning processes. We’ve developed a separate instrument for people to actually plan
both behavioral interventions, what the problems are the person’s having, what’s the method of dealing with those problems or
issues at the moment. For the purpose of
communication and making sure people are following an orderly
plan to improve oral health. Okay, so that was all
about daily mouth care. The other big innovation that’s happening in oral health services is what I call the declining role of the dental drill. So, when I was in dental school, we’re talking now, particularly,
about tooth problems. When I was in dental school,
even the very, very beginning of any kind of what we call
demineralization of the tooth, the only thing you could do
was reach for a dental drill and drill out that part of the tooth and put an artificial substitute in. We now have all kinds of things that can be done, short of doing that. And that dental drill can be reserved for much more serious problems. So, fluoride varnish,
as some of you may know, is a fluoride product that can be used, once or two or three times a year. That has proven benefits. It can actually reverse
demineralization of enamel in teeth that’s already begun. There’s a new product out that you may or may not have heard of, ’cause It’s been around for a
long time in other countries, but just been approved by the FDA in the United States very recently, called silver diamine fluoride. This is something, one drop
on the surface of a tooth, it stops the decay, deposits a little, thin layer of silver
on that area of decay. It takes a long time for
it to start up again. So, it’s something that’s
proven very effective and it’s starting to get
much more widespread use in the dental profession now. Dental sealants have been
around for a long time. And, very clearly, among the things with the strongest evidence of efficacy in the dental profession, is
the ability to stop decay, to seal grooves in teeth
to keep them from decaying. And now something
relatively newer is called interim therapeutic restorations. So, this is a technique that can be done. When I was in dental school,
what I was taught was that, if you have a tooth with some decay in it, you have to remove it
all, because if you don’t, there’s gonna be bacteria
left underneath the filling and they’re gonna continue to grow and then bad things’ll happen. Well, the science, I’d say new science, I mean new, I mean 20
years, so new science, is such that it’s pretty clear now, you don’t actually have to remove all the decay from a tooth. With our new modern adhesive
restorative materials, seal the bacteria in place. So, people call it
sealing caries in place. The bacteria stop growing. So, not only is it okay to do it, but it’s actually better for teeth. To use the very scientific explanation, if you’re mucking around in
a deeper part of the tooth and you’re getting close
to where the nerve is, you’re much more likely to
end up with nerve damage or toothache or needing a root canal or something like that afterwards. So, it’s actually better for teeth to leave some of the decay in
the deeper part of the tooth. And the reason I’m going into this little mini-dental lesson
on dental restorations is, the point of this is that removing decay, when you’re removing
just the surface decay and you’re sealing decay in by bonding a tooth colored filler material in there, that can be done without any anesthetic. No drilling. No shots. And it can be done by a dental hygienist in a residential facility or in a community day program. So, it removes the need
for the dental drill. It removes the need for the dental office. And there’s a whole bunch of teeth that can actually be kept healthy
without the need for sitting in a dental chair in a dental office. It’s really a huge paradigm shift in terms of the previous idea that dental care happens
in dental offices. We now have lots of ways
to keep people healthy without resorting to what I call the high cost surgical suite, which is what the dental office is. There’s a lot of ways that
allied dental personnel can keep people healthy
in community settings. So, we’ve got new science. We’ve got this whole idea of dealing with chronic dental care as chronic diseases. And the next leg of this three circle Venn diagram you’re gonna see built here is the idea of different delivery systems. How do you actually get
dental care to people? We’ve been working for
more than a decade now on something we call ommunity-based telehealth connected team deliver systems. And we did part of this
through a pilot project from our Office of Statewide
Health Planning and Development here in California. How many of you have heard of this workforce pilot project mechanism? So, a few of you have. So, California’s actually unusual in that, if you want to change the scope
of practice of a profession, in every other state,
the only way to do it would be to go to the legislature
and have them pass a law that changes the scope of a practice. So, you go to legislature
and you say to them, we’d like to have dental hygienists be able to take out people’s appendix. And someone might say to you, how do you know that’s a good idea? And you say, well, we don’t know, ’cause they’ve never tried it before, ’cause they’re not allowed to do it. But, if you’ll pass a
law and let them do it, we’ll see how it works out. Of course, that’s a ridiculous idea. But that’s kind of how it
happens in most other states, is someone goes to the legislature, proposes a change in scope of practice, and the legislature’s
have to take it on faith that it’s a good idea. California has a mechanism
where you can actually go to this Office of Statewide
Health Planning and Development. You can apply for what’s called a Health Workforce Pilot Project. It’s a big deal. There’s lots of paperwork
and public hearings. But, if you get approval for
that, you can actually try things that are outside of
the normal scope of practice. This is not just for dental care. It’s nursing and every
other health profession. You can create a whole
new profession this way. And then you can go to
the legislature saying, we’ve tried this thing
in a pilot environment. It was heavily evaluated. Here’s the data that shows
it’s safe and effective. And now we want you to pass a law. Which obviously makes a lot more sense than the way it’s done in other states. So, we have this mechanism in California. We used it to test out some new ways of getting dental care to people. And the idea was to do
it in community settings. And we were testing two
new specific duties. One was the ability for
allied dental personnel to decide which X-rays to take before a dentist got
involved in seeing them. And the second was to be able to place these things that I just talked about, these interim therapeutic restorations. So, the realization
that we’re coming to is, and I think general healthcare
is much further along in realizing that
healthcare is a team sport. And dental care is a team sport, as well. So, we came up with this system. We call it a virtual dental home. I’m sure most of you
have heard of the term medical homes or health homes. The general idea of the home concept is you’re trying to keep
someone from getting lost in the complicated
healthcare system we have. Making sure they’re getting back for the things they need to get back to. Helping to educate them to be able to manage their own disease. Getting people to
advanced surgical services when they need them. And, in the general healthcare system, there’s a pretty broad recognition that lots of different kinds of entities can do that set of services. In dental care, if you look
at the dental literature, it’s almost entirely referring to the dental home as
the dentist’s office. And what we wanted to
be able to demonstrate, was you could have all those concepts that are part of the home
system, a dental home, but it can be done in what we call a geographically distributed telehealth-connected team environment. So, it wasn’t everybody in the
same place at the same time. This telehealth system could connect all the right people together. And you could deliver all the
services of the dental home. So, we’ve been testing this for, now, it’s getting to
be more than a decade. The general idea, this is a dental hygienist
who’s in a school. That little thing in her hand, it looks like a hairdryer, but it’s not. It’s actually a
miniaturized X-ray machine. And inside the young lady’s mouth, we no longer use film,
that’s a digital sensor. So, she’s taking X-rays. This is a photograph of the tooth. You can see the picture of the tooth on the laptop computer in the back there. This is actually a gentleman who’s got intellectual disabilities. He’s at the Golden Gate Regional Center. He had had all of his previous dental work done in the hospital operating room. He would walk into a dental office. He’d be nervous. The dentist would look at him and say, I can’t work on this guy. He’s gonna have to go to the hospital and have dental care
under general anesthesia. And yet, in his own house,
that’s his favorite chair. That’s where he watches TV. He’s got that thing over his face, ’cause he didn’t like the
light, but that was his idea. So, he’s able to have, here,
a full set of X-rays taken. The hygienist can clean his teeth. She can apply those small
restorations when he needs them. He may never have to go
back to the hospital again. So, you can see how just
changing the environment and changing the way that
you’re delivering service can make a huge difference in terms of people’s ability to get dental care and to have procedures
done that they might not do in the context of the scary
surgical suite dental office. This is one through portable equipment. This all packs up. And, with a trip to the car,
you’re in one place one day and you’re in another place the other day. And we’ve been testing this
across the age spectrum from young children in
preschools and elementary schools all the way up through
people in nursing facilities, residential facilities for
people with disabilities. So, it has broad application. So, we did a formal test. The general idea being
that the allied personnel are collecting records in some place. All the records are going
up to a cloud-based system where a dentist who’s not
in the residential facility or the daycare program or the school is able to get access to them, can see a full set of dental records, make a diagnosis and a treatment plan. And then provide instructions for the allied personnel who are there. So, this is an example of one of those small restorations being placed. This one’s in a school,
but you could picture this same thing in a residential facility for someone with disabilities or a daycare program
using portable equipment. That small hole, for many
people, nothing happens at all until that turns into a
bigger hole and a bigger hole. And then, at some point,
they have a toothache. And, at some point, they have an infection and they end up in the emergency room or the hospital operating room. Now, in about 10 or 15 minutes, with no shots, no drilling,
that decay is sealed in place and that tooth put into a holding pattern. Sometimes for many years before anything else has to be done for it. So, just an example of an
innovation in dental care that’s allowing us to really
think very differently about how we improve the oral
health of lots of people, including those with
developmental disabilities. These are just some examples
of those kind of restorations with beginning decay that’s
been sealed in place. This one was actually done
in a nursing facility where, for lots of people who were
taking many medications… There’s about 400 medications
that cause dry mouth. And dry mouth is devastating for teeth in terms of leading to
rampant dental caries. And it often starts like this one does in the upper left picture,
right up at the gum line. And the dental hygienist,
again, no shots, no drilling, was able to seal all those areas in place and put those teeth into a holding pattern for a long period of time. So, we did this test across California in 13 different communities. Demonstrating this system. About 50 different sites. And there’s a whole report on our website, if you wanted to read the details. But basically what we found was that we could make this idea of
telehealth-connected teams work. We could have people in different places. They could communicate together and form a full system of care
connecting through telehealth. We think about it as hub and spoke system where the hub is where the dentists are. That’s the places like the dental office or the dental clinic. And the spokes are any
kind of community site where you might have someone
who’s a dental hygienist can go with equipment, set up
their equipment for the day, and be able to see people
in that environment. And, in fact, what we found was, as a a result of that demonstration, that this was a way to
reach a lot of people who were not getting
access to dental care, was a way to emphasize prevention and early intervention,
to get to people early before small problems became big problems. We actually found the majority of people could be kept healthy and
verified healthy onsite. About 2/3 of children
didn’t need anything else other than the dental hygienist the only one physically touching them. About 2/3. Which we are working with very low income, high disease rates populations. And that’s a really big deal. Because most of the children
in these populations were not getting any care at all until they had big problems. And a little bit less
with people with adults, people with disabilities. About 50 or 60%. But, still, high numbers of people that could be kept healthy
with a dental hygienist the only one physically touching them. And the word verified in there, is really actually pretty important, can be kept healthy and
verified healthy on site, because most kind of dental care systems where people are going into the community or school-based care, we’ve
done something for 20 years of having hygienists be
in residential facilities doing some kind of hygiene procedures. All those other kind of systems where the dentist is not involved, everyone gets told, okay,
we did X, Y, or Z today. But you need to go see a dentist, because we didn’t do a
complete examination. And so, then there’s a whole process of getting someone to a dental office, which is often difficult to do. Now, using the telehealth system and being able to bring the
dentist into the school, the residential facility, the care home, being able to bring the dentist in through the telehealth system. Now we can actually have the dentist say, I’ve reviewed the records,
do a complete examination and treatment plan, you are healthy now. Next thing you need is
to have a recare visit, a recall visit by the hygienist in three or six months or whatever it is. And so, being able to actually verify that people are healthy onsite,
using the telehealth system becomes a big deal, as well. The only thing that’s
really critical here, is the bullet that says
continuous presence. So, we describe this system as
a continuous presence system, meaning that wherever the site
is, where the hygienists are, and these are typically group sites, it’s not really economically
feasible to do this, where you’re just going
one home at a time. Although, there are some
instances where that is done. But any kind of a group setting, having the hygienist be there on a regular basis all year long. Now, regular basis
doesn’t necessarily mean five days a week. It might be one day every other week or it might be one day a month. But having the hygienist
there on a regular basis actually changes a lot of
thinking in the environment. It raises people’s
awareness about oral health. People are starting to
think about dental care more than they were before. It has a huge impact. And I think the most important
thing, as I said earlier, which is daily mouth care. You know the hygienist is coming back. And you know they’re gonna be looking in the person you’re caring for’s mouth. And you know, if you haven’t
been brushing their teeth, it’s gonna be obvious to the hygienist. And you don’t wanna look bad, so you wanna actually pay attention. Because you know they’re coming back. So, this idea of continuous presence for an oral health
professional in the environment makes a big difference in
the most important thing, which is actually this
daily mouth care idea. It also begins to
integrate oral healthcare in with the community organizations. Whether these are social
service or educational or general health organizations. Having a member of the dental team there, begins to integrate the
oral health services. So, it’s not an isolated
system, like it often is. And it actually brings
the dentist in through the telehealth system without the dentist having to be in those locations. So, as a result of that
10 year demonstration, we had a bill that was passed and was signed in 2014, AB 1174. It took those duties we were testing and made them a part of
the scope of practice of allied dental personnel. Made the Washington Post. I said, California to launch
Medicaid-funded teledentistry. So, the Medicaid funding
was a part of the bill. It wasn’t the only thing in the bill. But that’s what made the news. But it did require our
California Medicaid system to pay for dental services, whether they were performed in person or whether they’re performed using telehealth connected team services. That’s now part of the
DentiCal System in California. The American Dental
Association has subsequently, I had the opportunity to testify at their house of delegates, it subsequently adopted
a policy saying that teledentistry is an important tool a dentist should be able
to use and get paid for. And so, it’s beginning to
get national attention now. California’s adopted, now,
regulations and bulletins out to dentists about how to bill using telehealth-connected teams. The other one was for the
fee for service system. And this is something we work with the California
Primary Care Association. The billing system’s a little
different for health centers. But we now have guidance for both the fee for service system
and the health center system about how to use
telehealth-connected teams and be able to bill for them. A little run-through of
our history with all this, is that it started in 2009
with this proof of concept of this idea of using
telehealth-connected teams. Got to the legislation in
2014 and regulations in 2015 and since that time, it’s been expanding, both in California. We have grant funded projects now, where we’re working
right now with about 40 different health centers and
private practice dentists, to teach them how to
do this kind of system. It’s actually pretty
different than the normal way of delivering dental care,
so people still need training and technical assistance in doing it but we’ve got a lot of interest in it now. And we’ve had about eight
or nine other states that have copied California’s legislation and now are paying, their
Medicaid system’s required to pay for telehealth delivered services and teledentistry in particular. And we’ve got a funded
replication project system going, now, in Oregon
and Colorado and Hawaii. So, it’s going to be
ubiquitous across the country in the next, probably, decade, that everyone was going to
be using this style of care to reach lots of people. As you heard earlier,
the 200 million people who are not getting dental
care in our country, this is not going to
reach every one of them but I think it’s going to allow the dental profession to go a long ways towards delivering more dental
care to a lot more people. The last thing just to touch on, I think many of you are aware of this, is just the whole way
that we’re beginning, as a country, to think differently about financial incentives and I’m sure you’re all
aware that we’ve entered an era of accountability
where our policymakers are asking not just
what are we paying for, but what are we getting
out of what we pay for? And with our national goal having now become the the Triple Aim, the the goal of improving
experiences of care for people, improving the health of the populations and doing all that at
a lower cost per capita and now, it’s evolved from the Triple Aim to the Quadruple Aim, with the addition of the fact that provider satisfaction has actually got to be included if we’re going to have a
health care system that works. There wasn’t in the original formulation but that’s actually a part of it now. And so, we’re moving towards systems where there’s a lot more measurement and outcomes-based care and
people beginning to figure out, how do you pay for health outcomes as opposed just for paying
for health professionals just to do a lot of stuff? And we feel that this idea
of getting to people early, providing prevention, early
intervention services, in sites where people are receiving other kinds of services,
getting dental care integrated, is going to be a key
to actually being able to reach those goals of
producing better health, having people have better experiences, and doing all that at a
lower cost per capita. To rely solely on the
high cost surgical suite, which is a dental office, we’re really going in the
opposite direction of those aims. So, dental care in the future. I think we’re all going to climb into one of these machines at some point, then the dentist who’s at their house is going to be doing
something with data gloves. (crowd laughing) Yeah but that’s not this year, though, so that’s a little bit
further down the road. But what I think is actually coming sooner than then many people realize is this idea of using
geographically distributed telehealth-enabled oral health teams, I think is going to be, it’s
already beginning to spread. We’re getting lots of interest. I think that’s going to be
a big part of dental care. Actually, what I say now,
is if we were to be able to jump in the time machine
and get 20 years in the future and you were to ask dental providers across the dental industry, are you using telehealth connected teams as part of your work? They would say, well, of
course we’re doing that. Why would we not do that? The same way, if you ask someone today, are you using some kind of smart phone? They’d say, well, of course I do. Why would I not do that, right? But you ask someone 20 years ago, they would not even know
what the word meant. So, I think we’re going
to see a lot more adoption of this style of expanding
the role of dentists, having dentists be able
to expand their reach much further using this idea
of telehealth connected teams. I think as we do that, as we
focus more on health outcomes, we’re gonna see much
more focus on dental care using biological and
medical and behavioral and social tools as a
way of improving health, rather than, as I say, the
declining use of the dental drill is the sort of primary focus
of how dental care happens. And we’re gonna see dental care become much more integrated
with general health, educational, and social service systems. And I don’t think this is
optional for the dental industry because if we’re gonna actually get back to interacting with the
majority of the population, we’re going to be pushed to do this as we focus on health outcomes, as we get further into the
area of accountability. So, I want to finish up with
just a couple of thoughts about people with
developmental disabilities, in particular, in relation
to all of these innovations. So, one is, to repeat what I said earlier, which is that daily mouth care is the key, number one and everything
else pales in comparison. If you don’t have good daily mouth care, people are not going to
have good oral health, no matter what any dental professional does to them or with them. The second issue is if
things do get to the point where they need disease repair, being able to perform procedures without having to use
sedation or anesthesia is really critical. At dental dental schools
across the country, across the state, which are
often the primary providers of local and general
anesthesia dental services, although the other dentists
are doing it as well, we have huge waiting lists. We have more than a
year-and-a-half waiting list at my dental school for someone
who’s already been deemed that the problems are severe enough, they need to have dental care
under general anesthesia. Can you imagine, it’s
like you heard earlier about the payment system. Well, this is not a payment system, it’s just a capacity system. Yeah, you’ve got this disease, it’s so advanced you need to be treated under general anesthesia
and come back in a year and a half and we’ll see what
the waiting list looks like. I mean, you know, it’s
an impossible situation and we’re not going to
solve that by producing more opportunities for general anesthesia. It’s just way too expensive
and the only solution is to be able to reduce the
need for general anesthesia by getting to people earlier. Which leads to the last bullet, which is that prevention,
early intervention care, delivered in community settings is most likely to result
in better mouth care and then better oral health and reduce the need for the consequences of treating disease when they’re
much further down the road. Now, we have a payment system right now, the Medicaid or Medicaid
dental program, Denti-Cal, which does not support any of the stuff that’s required to be able to do what I just been talking about. It doesn’t support care coordination. It doesn’t support
education, oral activities. It doesn’t support caregiver
support activities. It doesn’t support, really,
anything that’s needed to have an effective system
of community-delivered care. Which means that if we’re
going to be able to do this and there’s already
some experience with it, it actually falls back to the
opportunity to do it today and today’s payment environment falls back to the regional centers. So, regional centers can, and some have, been able to come up with funding to be able to pay
dentists for doing things that are out of the norm or go beyond what the Denti-Cal system pays for. And, in fact, we have projects going now. I’ve worked with a lot of, I had the opportunity to work with a lot of the regional centers across the state in various ways over the 40 years I’ve been doing this kind of work. So, it’s getting to be a long time and we have three specific
projects going right now with the Alta Regional Center and Golden Gate in North Bay, where we’re specifically using this idea that we’ve been talking about today, this idea of using
telehealth connected teams. So, in those projects, we’re helping the recruit providers, we’re actually doing
training for the providers on how to work with people with
developmental disabilities. We’re helping them set up this whole idea of telehealth connected teams, to be able to know how to reach people without having them have to come into a dental office or a clinic. We’re figuring out and helping them work with regional centers to
integrate dental services in with residential
facilities and day programs and other places where people in the regional center system are located. And the regional centers are
actually using their funding to pay for some of these education and prevention and care management and early intervention services. I think it’s critical, actually, if you’re involved in a
regional center system and thinking about how
to improve oral health and realizing that’s
one of the top problems that the people who are being served have, is to think about ways to support systems, systems like this. I know a number of regional
centers around the state are paying a fair amount of
money for dentists to take, to support dentists, to be able to do dental care under
general anesthesia. And while I think that that’s admirable because the backlog is so huge, as you heard, and it’s a needed service when people get to that stage. I think that we need
to shift that pendulum to maybe, in addition, have
the regional centers realize the value of getting
to people much earlier and preventing disease
before it gets to the point of needing general anesthesia
and there are mechanisms and these three regional centers have figured out how to do it. There are mechanisms to be
able to pay dental providers and to set up systems like this. So, I think that the innovations
that I’ve talked about, I think there’s a lot
of hope for the future, for being able to do things differently and do things differently in
a much more effective way. I’ll be happy to talk at the panel and a few minutes for
questions and answers or even at lunch, if
you want to talk to me or there’s my email address, if you want to get in
contact with me afterwards. So, thank you. (crowd applauding)

Author: Kevin Mason

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