Oral Health Part 3 – Theme-specific Presentations

Oral Health Part 3 – Theme-specific Presentations


>>Male Speaker: We’re ready to continue with
the overview presentations. Our next six presenters will provide important
background information and perspectives on the proposed themes for the new surgeon general’s
Report on Oral Health. I will briefly introduce all six of them now
in order so that we can transition smoothly between each of their presentations. So, this will take a little bit of time, but
it will be worth it; you need to understand who we have here today. Our first presenter is Dr. Margherita Fontana. She is here to discuss oral health across
the lifespan for infants, children, and adolescents. Dr. Fontana is a professor in the Department
of Cariology, restorative sciences, and endodontics at the University of Michigan School of Dentistry. She holds a dental degree from the Central
University of Venezuela and a PHD in Dental Sciences from Indiana University. She formerly served as the president of the
Cariology Group of the International Association for Dental Research and the chair of the Cariology
section of the American Dental Education Association. Her research focuses on caries management
in children and in the year 2012, she received the Presidential Early Career Award for Scientists
and Engineers for her work on caries risk assessment in children. After Dr. Fontana, the next presenter, virtually,
will be Dr. Linda Niessen. She is going to discuss oral health across
the lifespan for working age and older adults. Dr. Niessen serves as a Dean and Professor
at Nova Southeastern University’s College of Dental Medicine in Fort Lauderdale, Florida. She holds a Doctor of Dental Medicine, a Master
in Public Health, and a Master of Public Policy all from Harvard University. Her research interests include geriatric oral
research and education, epidemiology of oral diseases in older adults, and oral health
public policy. In 2017, she was named a fellow of the American
Association for the Advancement of Science and lauded for contributions to the field
of dental public health, particularly geriatric oral medicine, dental services, and health
policy. After Dr. Niessen, we will hear from Dr. Raul
Garcia to share important perspectives on the effects of oral health on the community,
overall wellbeing, and the economy. Dr. Garcia is Professor and Chair of Health
Policy and Health Services Research in the School of Dental Medicine at Boston University. He holds a Doctor of Dental Medicine and a
Master of Medical Science and Oral Biology from Harvard University. His research interests include the mechanisms
of periodontal disease progression, alveolar bone loss, skeletal bone mineral density,
tobacco control and prevention. His current work involves a variety of population
studies with the focus on underserved populations. Dr. Garcia has earned numerous honors throughout
his career including the Career Development Award in Health Services Research from the
U.S. Department of Veterans Affairs and the American Dental Association Meritorious Award
in geriatric dental health care. Our fourth presenter is Dr. Scott Tomar to
discuss the broad and important theme of special topics. Dr. Tomar is currently a Professor in the
Department of Community Dentistry and Behavioral Science at the University of Florida College
of Dentistry. He holds a Doctor of Dental Medicine from
Temple University, a Master in Public Health from Columbia University, and a Doctorate
of Public Health from the University of Michigan. He is the immediate past chair of the Oral
Health Section of the American Public Health Association and a diplomat of the American
Board of Dental Public Health. His research interests involve the understanding
and control of modifiable risk factors for disease and populations. Much of his recent work involves public health
surveillance for oral diseases and conditions and increasing access to prevention services
in vulnerable communities. The next presenter will be Captain Renee Joskow
to highlight important issues and perspectives on oral health integration and workforce. Captain Joskow serves as a chief dental officer
for the Health Resources and Services Administration, where she provides the overall direction and
guidance for HRSA’s Oral Health Investments and portfolio and serves as liaison for facilitating
communication and relationships across the U.S. Department of Health and Human Services. She is a dentist and a Medical Epidemiologist,
with both a Doctorate of Dental Surgery and a Master of Public Health from Columbia University. She is board certified in the specialty of
Dental Public Health and a fellow of the American College of Dentists, the Academy of General
Dentistry, and the New York Academy of Dentists. She proudly holds the rank of Captain 0-6
in the U.S. Public Health Service. Finally, our last presenter will be Dr. Rena
D’Souza, who will address the theme of emerging technologies and promising science to transform
oral health. Dr. D’Souza is a professor of Dentistry and
an adjunct professor of neurobiology and anatomy, as well as pathology from the University of
Utah. She received her Bachelor of Dental Surgery
from the University of Bombay and her Doctorate in Dental Surgery and PHD in Pathology and
Biomedical Sciences from the University of Texas Houston. Dr. D’Souza is known for her research in craniofacial
development, genetics, tooth development, and regenerative dental medicine. In 2018, she was appointed as president of
the International Association of Dental Research where she will lead over 11,000 members from
about 100 countries worldwide. Without any further ado, I will turn it over
to Dr. Fontana. [applause]>>Margherita Fontana: Good afternoon. It is really — I’m very excited. It’s an honor and a privilege to be here with
all of you today. Greetings from the University of Michigan. I hope that the excitement from this morning
continues because I think we’re all here passionate about oral health and serving the communities
that we are so privileged to be able to serve and impact. So, I am here with a very small task over
the next 15 minutes to tell you major issues and contributions to children — infants,
children, and adolescent’s health. So, not a small task. And the age span that I’m really covering,
it’s from birth to about 18 years of age, which is a period where children go from not
having any teeth to having the primary dentition to eventually, start shedding those primary
teeth to being replaced with the permanent teeth, that will hopefully accompany of all
us throughout the rest of our lifetime, but I can’t start talking about children’s oral
health before talking a little bit about prenatal health. So, if you will permit me at least one slide
to talk about the importance of prenatal health and maintaining children healthy [sic], I
will do so. So, dental care, it’s very safe and important
during pregnancy, and yet many women still don’t seek care during pregnancy. This is an area that has a huge potential
for improvement and impact. There is also growing evidence that poor oral
health in the mother, in particular for example, periodontal disease, can have adverse consequences
on pregnancy outcomes, for example, preterm birth or low-birth weight, and we know that
preterm birth is one of the main reasons for neonatal fatalities prior to birth, which
has tremendous cost and a huge burden to society. We also know that there is growing evidence
that mother’s caries experience is a good predictor of child’s experience. So, this is not only for the biological factors
that we will be discussing soon, but it’s probably most importantly because of the behavioral
factors that are associated with those who take care of those who are more vulnerable. So, what is dental caries? As the World Health Organization classifies
dental caries is a non-communicable disease, it’s a microbial disease that is caused by
organisms that are part of our normal flora. We all acquired them early in life, they live
in peace and are very important actually to maintain our health and wellbeing, but when
subjected to environmental pressures, in particular sugars, they change, this population changes,
and this change is modulated, of course, by many host factors and ultimately, can result
in disease. What I like about this slide is the identification
that there’s many risk factors beyond that tooth, the microbial relationship, that exists
at the child level, at the family level, and at the community level, which really means
that from a caries management and prevention perspective, there is a role for everyone
to play; from the individual, to the parents, to the families, to the communities, to the
physicians, to the dental workforce, to the policy holders, et cetera, et cetera, to the
teachers, social workers, et cetera, et cetera. It has to be really a team effort. So, a brief overview about some characteristics
of children from infancy to early childhood, and I’m arbitrarily defining this from zero
to 8 years of age. Primary teeth will start to erupt in the period
between zero to 3 years of age. Children will initially be breast and/or bottle
fed and eventually will migrate to solid foods and/or drinking drinks by using sippy cups
for example, which if the content of the bottle or the sippy cups are juices, in many cases
juices rich in sugars, or other surgery drinks, it will increase the risk for dental caries. Children, like most vulnerable populations,
are dependent. They are dependent on an adult for dietary
choices and for oral hygiene practices in the early stages of life, and early childhood
caries is one of the most common chronic diseases of childhood. It is really one of the most common diseases
of humans, as you saw in the previous slides, and although we have made great advances with
the exposure to fluorides to decrease the burden of this disease, there are still huge
disparities and inequities in who is expressing the disease and at what stage they are expressing
the disease. It’s a diet-driven disease, and diet is a
common risk factor for many other conditions like obesity, diabetes, et cetera, so it provides
a unique opportunity to have a broad impact beyond just oral health. In the case of young children that have huge
amounts of disease, very severe disease, treatment is many times under some form of sedation
or general anesthesia, which by itself is risky for young children, not only because
it can cause problems with neurological development, as the FDA specified in 2016 in one of their
latest reports, but it also can have other negative consequences. Of course, children that are young are exposed
to trauma, and of course, children can be born with a range of craniofacial defects
that can have huge impacts, not only for the individual, but for the family and society
that these individuals grow and live in. Now a brief mention about primary teeth. I love this graph from the American Dental
Association because I think a lot of people think primary teeth are temporary so who cares
about them, but really, I think what this graph is meant to show is that we start acquiring
these primary teeth when we are depending on the group between six to 10 to 12 months
of age early in life. The reality is that we don’t end up shedding
or losing those primary teeth until we are about 12 — 10 to 12 years of age, which means
that a large portion of childhood we have primary teeth. Therefore, primary teeth are essential for
children’s development regarding nutrition, they are essential for chewing, essential
for speech development, and for the development of social skills. They are also very important for alignment,
spacing, and occlusion for the eventual permanent dentition that is going to start erupting
around six years of age. Now, there’s huge consequences, not only at
the individual, but at the family and societal level from having dental caries, especially
untreated disease, and this is not only at the biological level, but at a quality of
life, and economic impact level. It can result in pain, it can result in infection,
and this morning already the surgeon general mentioned the fact that children and individuals,
adults in this country are still dying of the consequences of dental disease, which
is tremendously sad. It can impair function, chewing and nutrition,
like I said, and speaking, and it can have huge functional consequences with school absences,
as has been previously mentioned, and poor school performance, and then poor self-esteem. Difficulty sleeping, which is obviously going
to impact not only the child, but the family; parents missing hours of work to take their
children to seek the care that they need, and huge economic consequences for society. Dental care remains one of the most costly
and inaccessible treatments, especially to many young children, especially those from
certain groups of the population. Now, we have effective measures in strategy. Fluoride is one of those that fortunately
we are very blessed to have great access here in the United States, at least some groups
of the population do. We have community water fluoridation — you’ve
already heard the statistics about that today — access to fluoridated toothpaste, dietary
fluoride supplements for those who might not be exposed to effective levels of fluoride
in the water, and have high levels of disease risk and experience, over-the-counter mouth
rinses for those who might be at increased risk and who are old enough to be able to
spit and not swallow them, and then professional measures such as fluoride varnish and the
newer one — the newer kid on the block, silver diamine fluoride, which provides an alternative
for treating an advanced stage of the disease or cavities, which have exposed dentin in
lieu of traditional restorative care. The last two, by the way, use off label for
caries control in the United States currently. We also have dental sealants, as you have
heard, which are a tremendously effective strategy, not only to prevent the disease
from happening in the pits and fissures of teeth, but to arrest initial stages of that
disease, the stage where there is still not a hole in the teeth, and those have been advocated
very strongly for school-based programs and for use in dental — in other types of settings
where dental professionals can work. Regarding oral care practices in infancy and
early childhood, well, we should all be promoting breastfeeding, it has very well-proven benefits
beyond just oral health as the American Academy of Pediatrics correctly states, and there
is some evidence to suggest that children that are exclusively bread fed in the first
year of life compared to children who are drinking a bottle with things that are other
than sugary drinks, for example, juices, et cetera, ad libitum are less likely to develop
dental caries. We should also be promoting good oral health
and I would say not only for the child and the primary care giver, for the entire families
because many of those habits and behaviors are familial. Brushing twice a day with a fluoridated toothpaste,
and in the case of children receiving assistance by an adult, limiting sugary snacks and drinks;
once teeth erupt, not putting the child to sleep with anything, and drinking fluoridated
tap water, of course. We should be supporting interprofessional
care for anticipatory guidance and provision of prevention strategies that are effective
in settings beyond dental settings, for example, medical settings. And, we should be promoting establishment
of a health or dental home early in life as soon as teeth erupt so that we can promote
base behaviors around oral hygiene practices and dietary practices, use of sealants, fluoridated
water, fluoridated toothpaste, and if disease occurs, treat it early in a less invasive,
less costly, and less painful way. Now, in middle childhood and early adolescence,
permanent teeth are going to start erupting and this is a period of mixed dentition where
we have teeth at different planes of occlusion, which really difficults [sic] oral hygiene
tremendously. We forget we think only the young need help,
but in reality, this mixed dentition stage also need help to be able to perform adequate
oral hygiene practices. We have expanded eating choices, more independence,
food that we were able to control before in the home environment now is in schools, and
friends, and sports, and different types of performance associations, et cetera. Dental caries continues to be one of the most
common diseases. I think people don’t realize that early childhood
caries, although it affects approximately 25/26 percent of the population, if you look
in total, it almost doubles between six to 10 years of age and it increases — continues
to increase as you saw the graphs by Gina previously into adulthood. Behavioral health is tremendously important. Children are more independent, have now started
becoming much more interested in image and self-esteem, and here is where the danger
of eating disorders can start playing a role in having really devastating consequences
on the dentition. Sports trauma can be a big issue. Issues with malocclusion, especially in particularly,
if you have lost earlier primary teeth without maintaining the space for the erupting permanent
tooth, and then experimenting with tobacco and e-cigarettes among other things. So, oral health practices continue to promote
good oral health with daily brushing with fluoride toothpaste, limited sugary snacks
and drinks, treating existing cavities early on, promoting the use of sealants, fluoride
varnish, water fluoridation, silver diamine fluoride, promoting HPV vaccine for carries
prevention, promoting use of bite splints or sports — which is like a sport’s mouth
guard during sports, and promoting tobacco screening and education. Now, because we have many safe and effective
preventive strategies that exist, dentistry, however, has in many cases, especially with
younger children, limited access to them, especially from more vulnerable groups, and
therefore, a more interprofessional workforce, pediatrician, family physicians, nurses, et
cetera have been called and become essential and important partners in maintaining good
health and oral health. The American Academy of Pediatrics Periodicity
Schedule now includes fluoride varnish and anticipatory guidance. Medicaid reimburses fluoride varnish in all
states in the United States, and some states also cover oral examinations and other services,
and there is great training and resources available, and in fact, in all health professions
now interprofessional care and education are part of the mandatory curriculum. So, we have an evolving workforce, which is
going to be ready to practice in a different environment than we were all maybe functioning
in. I would advocate to you that we need a better
coordinating system and infrastructure to provide preventive oral health services and
education amongst all of those involved. We need oral health education and preventive
messaging that is more consistent and simple to facilitate understanding and implementation
and follow through by those who we want to impact, and we need better infrastructure
and electronic health records, et cetera, to better facilitate flow of patients and
information between all of those who need to collaboratively work to maintain our children
healthy [sic]. And like the FDA says, oral health needs to
be part of all health policies. It can’t just be side — or not part of the
table in every instance. Now, in the area of targeted healthcare, where
precision medicine and precision dentistry are so important, risk-based caries management
and risk-based disease management in children becomes really crucial and there are a lot
of opportunities, but a lot of gap in the science guiding this process, but we have
very good management protocols available, and we should promote implementation of those
preventative interventions. We should implement evidence-based clinical
guidelines, many of which that are developed and are being developed by many of you in
the audience around fluoride, and sealants, and restorative strategies that conserve tooth
structure, maintain teeth, reduce pain, and help reduce costs, and not create a group
of children that are going to be scared of seeking care as adults because caries is a
disease that needs lifelong management, and we need them not to be scared to seek help. In conclusion, oral health as has been said
many times here before, and I repeat it again, is really integral to general health. Dental caries can be, in those that are affected
by it, a progressive disease that requires intervention at different stages, and different
stages do require different interventions. You see in the upper part of the slide an
image showing it from a healthy tooth to an abscess, the staging of the disease process
that goes from an initial loss of minerals in the tooth where there’s not a hole to a
stage where it is cavitated and there is a hole to the infectious process. We have safe and effective interventions and
preventive measures, but they’re underused resulting in huge disparities and inequities. High-risk group, however, may need additional
strategies. Some of the strategies have been effective
for many, but we know that there’s groups of the populations that might need additional
strategies, and there is a lot of opportunities for research around this area. Interprofessional efforts are necessary to
help decrease the disparities and personalized, targeted, and risk-based approaches are promising,
but evidence is needed, especially around cost effectiveness of these approaches to
change help. And I leave you with a couple of questions
for our discussions tomorrow. What are the implications of what I have just
discussed with you on existing and new developing oral health policies around prevention, around
sugar consumption, around health promotion, around treatment strategies and treatment
availability, and around work force and training? And what are the implications for research,
not only clinical research, but the dissemination research, health services and policy research,
and coordination of care. I think the opportunity are many [sic]. So, thank you very much to all and thank you
for the following individuals that really held — provided a great review and commentary
and ideas to the development of this presentation. Thank you all. [applause]>>Margherita Fontana: And I’m supposed to
say this — [laughter] I’m supposed to say that now we’re going to
pass it to Linda and I think Linda is joining us virtually, right?>>Linda Niessen: Right.>>Margherita Fontana: Great. Thank you.>>Linda Niessen: Correct. [unintelligible]>>Linda Niessen: Good afternoon. My name is Linda Niessen, and it’s really
an honor to be part of this surgeon general’s listening session on oral health. I’m sorry that I can’t be with you in person,
but it’s great to have the technology work. This afternoon, I’m going to talk about the
other two thirds of the U.S. population; the working age, and older adults, and I’m going
to build on the Hamilton Analogy, and while we don’t want to throw away our shot, Angelica
Schuyler, Alexander Hamilton’s sister-in-law, talked about looking for minds at work when
she was going downtown in New York City, and as participants in this important listening
session, your minds at work are going to combine the energy, the expertise, and the enthusiasm
as you talk through all of these issues tomorrow. So, this afternoon as we begin talking about
working age and older adults, I want to focus on the variables that affect oral health as
you go from working age to older adulthood, talk about the continuity of oral health throughout
one’s lifetime, and also the barriers that occur in oral health from working age to older
adults. Essentially, we’re talking about this couple
in their 30’s and the continuity of their health and oral health as they become this
couple in their 70’s. So, the working age population is 180 million
Americans between age 18 and 64, but health issues that affect them are often reproductive
health and women’s health, autoimmune diseases, and then the beginnings of chronic disease
as populations diverse by age, sex and activity, and their oral disease burden varies as well. In addition, because they’re in the workforce,
they often have a work place dental benefit. The older adult population represents only
40 million Americans, but they’re often out of the workforce and their health issues are
related to chronic diseases, as the chronic diseases have continued to progress and now
often have quality of life implications. Again, they’re often diverse and their oral
disease burden varies, and we’re going to talk about some of the inequities in the oral
disease burdens, and because they are now out of the workforce, their health insurance
may have switched from a work place health insurance to Medicare and they may have lost
their dental benefit that was work place related unless, of course, they might have a Medicare
Advantage Plan. If we take this perspective, instead of looking
at populations, look at an individual with a chronic disease. So, we take the patient with diabetes. This diabetic patient has health insurance
and is now able to get the diabetic ophthalmic care, the diabetic cardiology care, the diabetic
nephrology care for kidney disease, and even their podiatrist is reimbursed if they have
diabetic neuropathy for foot care. However, if they have diabetic periodontal
disease, that may not be reimbursed if they don’t have dental insurance as part of their
health insurance. Similarly, if we took a patient who had rheumatoid
arthritis, who may first be diagnosed with rheumatoid arthritis in their working-age
life, and then that middle age, but as the disease progresses it isn’t until they get
to older adulthood where now they may have access to care issues, additional comorbidities,
they may have transportation issues, and ultimately daily oral self-care issues as well. I want to briefly say a few words about opioid
prescriptions, and this slide shows that opioid prescriptions are primarily prescribed in
the working-age population; and Dr. Scott Tomar is going to talk a lot more about this,
and you heard Surgeon General Adams talk about this as an important initiative. Well, this is an issue that affects our working-age
population to a greater extent than our older adults. In 2000, you heard Dr. Caswell Evans talk
about the genesis of the first surgeon general’s report on Oral Health, and also that same
year, the American Dental Association also published a report, The Future of Dentistry. What was interesting about one report that
looked at oral health in America, the other that looked at the future of dentistry, they
both identified access as an important issue for the population, and they identified that
access varies by age, by education, by finances, by dentition, by medical status, by what we
now call the social determinants of health. And the other interesting piece, in the year
2000 — this was a banner year there for oral health reports. The Institute of Medicine published a report
looking at extending Medicare coverage for preventive and other services, and in this
report, they also took the patient perspective of what patients have — what limits access
to oral health care, what physical access was an issue for many patients who had various
chronic diseases. Financial access was certainly an issue, vis-�-vis
reimbursement rates for Medicaid; and then they identified medically-necessary dental
services, what were health conditions that would worsen if the population didn’t have
access to needed dental services, and they identified four that had strong evidence to
support them: head and neck cancer, leukemia and lymphoma, organ transplants, and heart
valve repair and replacement. So, this report identified these important
conditions be part of a dental benefit. If you look at studies on oral health and
well-being in older adults, you find out that on average 33 percent of older adults view
their oral health as very good. However, if you go to the right side of this
chart and you look at household income, if you look at the bright green color, what you
see is in the high-income older adults, 46 percent of high-income older adults view their
older health as very good while only 14 percent of low-income older adults view their oral
health as very good. This is one of the inequities that Dr. Caswell
Evans talked about when he talked about the first surgeon general’s report. Similarly, when we look at correlation of
oral health with general health, what we see is, if we are going to focus here on the yellow
bar graphs, on the far left, you see that 36 percent of elders who have 20 teeth or
less report their oral health as poor or fair. Elders who have untreated carries, 11 percent
of them report their oral health as fair or poor, but if you — if elders have both, fewer
teeth and untreated carries, 62 percent of elders will report their oral health as fair
or poor. Similarly, we know chronic diseases can impede
access and self-care. The rheumatoid arthritis, osteoarthritis,
stroke, dementing illnesses, neurologic illnesses; all can affect someone’s ability to seek care,
obtain transportation to care, and most importantly, their daily oral self-care. So, this continues, these — as these chronic
diseases continue form working age adults to older adults, the impact on oral disease
plays a much greater role. We know that as you become older, you take
more medications, over 400 medications can affect your oral health. It affects your ability to taste, to choose,
to speak, to swallow. And we see higher rates in vulnerable elders,
the population that might be an assisted living, or even nursing homes. Medications can affect dry mouth, which can
ultimately, increase the risk for roof carries. This slide, which is somewhat busy, was a
study by the ADA’s Health Policy Institute; and what was important is it identifies that
the most important barriers dental care are financial. Dr. Fontana talked about the far-left side
of this slide, and if you go to the far left, you see ages two to 20. And if we focus on the green, the percent
of the population with financial barriers by age and income, in 2011 and 2012, you see
133 percent at the Federal Poverty level and below; 6.8 percent of children have financial
barriers, compared to 4 percent of children above 133 percent. So, as Dr. Fontana spoke about, the expanding
Medicaid, the state children’s health insurance programs, have really made a tremendous difference
in eliminating inequities between access to care, and — or in eliminating the financial
barriers in these children’s group. However, if you go to the center of this chart,
and you look at the age 21 to 64, what you see is tremendous inequity in low-income working
adults: 35.4 percent of working adults below 133 percent of the federal poverty level,
have financial barriers to dental care compared to 18.8 — 11.8 percent, excuse me — of the
working adults who are 133 percent or above. Similarly, if we go to the far right and you
look at the 65 plus population, 16.2 percent of older adults 65 plus who are below 133
percent of the federal poverty level have financial barriers to dental care compared
to only 3.4 percent of those older adults. But perhaps what is greatest is the discrepancy
in that working age adult; 35 percent of our working age population below 133 percent have
financial barriers to dental care. And if we look at the Medicaid adult dental
benefit, this make contribute to this issue. If you look at the states with the various
colors, I’m going to refer you, the green states are — yeah, greenish blue — those
states have extensive Medicaid adult dental benefits. The grey states have none. Tennessee, you see Tennessee there, have none,
no adult dental benefit. The purple, reddish purple states have an
emergency care benefit for adults only. And then the yellow states are those in the
middle, primarily have limited adult dental benefits. And we look — if we look at Medicaid adults
with and without a dental benefit, what we see and what we learn is that 60 percent of
adults without a Medicaid dental benefit are more likely to say that the appearance of
their mouth and teeth affects their ability to interview for a job, compared to only 35
percent of adults who have a Medicaid dental benefit. Similarly, if you look at adults who have
a Medicaid dental benefit, those with a dental benefit are more likely to say life in general
is less satisfying due to the condition of my mouth and teeth. And this is 15 percent of the adults with
a dental benefit will say that compared to 25 percent will say life in general is less
satisfying due to the condition of the mouth and teeth in adults who don’t have an adult
dental benefit. So, the key findings on working age and older
adults are that inequalities exist, or inequities exist, in access to and outcomes of oral health
in both groups. Dental decay and tooth loss are associated
with an individual’s rating of their general health as fair and poor. Chronic diseases that begin in middle age
continue to worsen in older adults and have greater effects on oral health as the individual
ages. And both education and finances are barriers
to dental care and create great inequities in this population. So, as you begin to deliberate, I’ve also
taken the time to provide some questions; and also have you think through, can we — you
know, it takes a team to provide oral health care, and can we provide the right person,
can we deploy the correct work force in the right location, in the right setting, or where
the patient is, with the right knowledge base? Can we improve the health literacy of our
population? Can we provide the right service? What is the scope of practice that we want
to make sure the patient receives? And can we do it with the right financing? Can we provide an oral health benefit throughout
one’s lifetime? And issues related to oral health throughout
our lifetime include finances. These appear to have the greatest effect on
access, which varies dramatically by race, ethnicity, age, sex, dentition status, retirement
status, barriers to good oral health, and oral health outcomes, disease rates for carries,
toothless, periodontal disease. Can we lower those? Can we lower the incidence rate of oral cancer? Can we look at wellbeing for both working
adults as well as older adults? And really, this speaks to the importance
or preventive oral health services. You know, prevention isn’t just for children
anymore. It’s for adults throughout their life. So, can we think about how we can improve
oral health? And finally, as we — as you begin the deliberations,
and as you participate, and the surgeon general looks to your mind at work, can we answer,
can we address some of these questions? Can we keep our children, can we keep our
parents as orally healthy as our children? Our children are carries free, or, you know,
a certain percentage of them are carries free. [alarm ringing] Oops. Sorry. That is my 15 minutes. Can we access dental care, can access to dental
care remain stable throughout a lifetime? Can preventable oral services be available? Can we have resources for caregivers, particularly
as older adults become limited in their abilities, and require assisted care, and nursing home
care? And finally, is it possible to have a dental
benefit throughout one’s life regardless of one’s age, one’s medical status, one’s oral
health status? So, thank you for the opportunity to be with
you. I look forward to hearing the results of the
deliberation tomorrow. And it is now my pleasure to introduce Dr.
Raul Garcia. [applause]>>Raul Garcia: Thank you very much, Dr. Niessen. I think we need to put back the slides. Oh, stole my thunder. Stole my thunder. I have to go back. [laughter] So, I — Scott talks about special topics,
I think I talk about everything else. My topics really are cross cutting across
this theme of the effect of oral health on the community, wellbeing, and the economy,
and let’s throw in military readiness while we’re at it as well. And again, obviously, this is not news to
you that the mouth is actually connected to the body, but, you know, it seems to be news
to many people in this country that are in important position of setting policy and making
important decisions about people’s health and wellbeing. I mean, if it’s not connected, then why is
it we still have separate educational systems for oral healthcare professionals as other
healthcare professionals? We have separate licensure and regulation
systems. We have separate systems of care. Even where oral healthcare is co-located in
a facility with medical care, they could be as well in different buildings or different
countries at the lack of integration; in large part because of a lack of integration among
electronic health records. Dental electronic health records don’t talk
to medical electronic health records, and that lack of integration, and that level communication
is a major barrier to moving forward. And of course, we have distinct and separate,
as has been touched upon already, payment systems. So, there is clearly a need that was mentioned
earlier about integration of oral health, care, and medical care, of putting the mouth
back into the body, but we have many challenges ahead of us, some of which will require good
science to be done to figure out how to solve these problems; but in turn, how to translate
that good science, that good evidence, into action to change policy and programs in communities. So, we talked about the two-way street. These was the theme of the surgeon general’s
report in the year 2000, that the mouth is in fact connected to the body. And we know a lot about how the body affects
the mouth, the oral consequences of systemic disease in the mouth of medical problems,
the sequelae of medical treatments for various conditions that have consequences, negative
oftentimes, for the mouth. But there is also another direction that increasing
attention has been given since the report in 2000, but it is how the mouth can affect
the body. We know incontrovertibly that mouth conditions
are important determinants of people’s wellbeing as measured by health and the quality of life,
and other measures. There is no question that it impacts employability,
social interactions, a sense of wellbeing. What we seem to still lack proof of is the
extent to which chronic oral conditions actually have direct impacts on medical outcomes; the
extent to which this chronic complex multi-bacterial oral disease of dental carries or periodontal
disease can have actual consequences for the cause, or the course of other chronic complex
multi-bacterial conditions, such as heart disease and diabetes. There clearly are very strong epidemiological
associations between oral infections and chronic oral inflammation, and a variety of medical
outcomes, but the question remains to this day, are these causally related, or as Dr.
Glick would like offer as an alternative, are they only casually related? Well, even though I as a periodontist would
love to be able to motivate my patients by instructing them to floss or die, we are not
quite yet at the stage — [laughter] — where we can claim that an oral health
intervention either prevents the medical condition, or actually ameliorates, or improves the medical
condition. But this is an important and intriguing area
with huge consequences for America’s health, and America’s financial health in regards
to the cost of healthcare. So, good science still needs to be done in
this area to move this science forward, and policy forward. So, talking about chronic complex multi-bacterial
health conditions, you have to stand back, and it’s not all about care. It’s not all about biology. A lot of it has to, due to larger societal
issues. So, I refer you to Healthy People’s 2020 framework
for understanding how the social determinants of health really fit into, not just oral conditions,
but all chronic health conditions as a way of thinking ahead about how to conceptualize
the 2020 report from the surgeon general. And in that regard, in regards to health and
healthcare access, clearly to reiterate, dental care is the most pronounced issue regarding
cost of care and barriers to care. These are data from health affairs recently,
generated by the American Dental Association, which really shows, the red — on the red
bar, it is the largest single item that people say financial barriers keep them from getting
access to. And of course, as Linda noted earlier, the
impact of oral conditions on people’s employability is highly evident in regards to younger people
who lack income and also lack insurance for oral healthcare, as well as those low-income
adults that need good oral health just to be able to interview for the job, never mind
to get employment. So, it talks about the need to focus, not
just on downstream interventions, which we tend to do as dental professionals; or oftentimes,
even as policy makers, which we try to ameliorate the consequences of already pre-existing conditions,
or to improve the course of those conditions. But to give at least equal, if not greater
attention to the importance of upstream interventions, where we want to prevent the onset of disease,
but more importantly, even at population-based prevention efforts, we need to think more
broadly than health-related risk factors. We need to think about the societal detriments
that really affect the course of people’s health for their lifespan. So, Dr. Arias mentioned about their school
dental sealant program targeting certain population groups of children, those that are Title 1
schools where 50 percent of the children are actually qualified for free or reduced meal
programs. Well, this is an example of how I like to
say that equality is inherently unfair. Treating people the same way is not fair treatment. It’s not equitable treatment. So, if you look at the child in yellow, let’s
say that was a child in a Title 1 school. You give them the same size box as another
child, that’s not going to get them to the stage where they can actually see ball field
or actualize their full potential. They enter that path to that fence in a different
route, with a different set of social disadvantages than other children. That child needs three boxes. So, to get equitable outcomes, they need to
be treated differently. So, again, a focus on equity means interventions
varied based on population and patient needs. Treating people all the same is not going
to be efficient or effective, unfortunately. Now, military readiness was touched on very
eloquently by Adm. Adams, and I just have to say, I think military readiness is a perfect
indicator, a perfect example of an overall community’s health. If you cannot have a population of young adults
ready and fit for military service to protect our nation, what does that say about our nation’s
health and investment in health and wellbeing? And in fact, oral health is one of the major
drivers of not being ready to serve. Let me quote, “No one can be healthy whose
teeth are deficient or in bad condition. Soldiers require that these organs should
be sound.” These were words that were written 150 plus
years ago by the certain general of the U.S. Army talking about recruits in the Civil War. And sadly, it’s still true today. Back then, the classification 4F, which is
basically not acceptable for service, came from lacking four front teeth, which were
required to bite off the cartridge and break it open, so the powder and gunshot can go
into the rifle. And throughout the 20th Century the most common
disqualifier for youth military service was due to dental oral health conditions. And even in this century, even in this decade,
it still remains a major problem for military readiness. So, if you want to improve our nation’s national
security by improving military readiness, address oral health as barriers, because the
recruits are coming from those populations that most are in need of improved oral health:
lower income, disproportionately racial ethnic minorities. So, to change the subject slightly, oral health
literacy. You know, people have to understand what is
going on with their mouths. People have to understand what their care
providers tell them about their mouth health. Systems of care have to be comprehensible
to populations to better address their health needs. And so, it really can be encapsulated in this
theme of health literacy, and in particular, oral health literacy, of which many of you
in this audience have been leaders in this field. I simply turn your attention to an upcoming
important convening of the National Academy of Medicine, just in a couple of weeks, which
is going to focus on how to integrate dental and general health through improved health
literacy practices. So, getting to the close. So, dental stuff, dental intervention, dental
care, is a major investment of our nation. The good news is that targeted investments
that are population based are effective. And you’ve heard about some earlier, and you’ve
heard the dental sealants, and clearly community water fluoridation is a major example of that. So, we have solutions that work in large part
when targeted to those most in need. Let me just close with this two-way street
situation again. We understand the mouth is connected to the
body, and we know that there are consequences of medical conditions to the mouth. But there are also important things, and as
noted earlier, can be done by mouth professionals, the dental office visit, that one shot encounter
that Dr. Tabak mentioned, where oral health professionals can make major beneficial impacts
on the overall health and well-being of their patients. As one example is, screening in office, dental
office settings for certain chronic medical conditions can save large amounts of money
that more than pay for themselves. But also, as importantly, the evidence is
not conclusive, but it is highly intriguing, and this is evidence done by the American
Dental Association again, that shows where in those individuals with newly diagnosed
diabetes, adult onset diabetes, that actual periodontal intervention in those individuals,
not a randomized study, these are observational date from large insurance databases. Periodontal interventions in those diabetics
actually can be associated with a significant reduction in the costs of their medical care,
in the cost of their diabetes care. If this is actually proven to be true in fact,
the impact on our nation’s health will be enormous, that simple dental interventions
for preventable condition can have measurable impacts on the course of the medical outcome
in millions and millions of Americans with diabetes. So, to close, oral health matters. It clearly is true, as said by a former surgeon
general, C. Everett Koop, “A person cannot be healthy without good oral health, but neither
can communities, nor our nation obtain and maintain overall health without good oral
health.” I think a key challenge to all of us is, how
can we encourage communities as a whole to place greater value and investment on oral
health? Thank you. [applause] And now, to deal with everything else that
hasn’t been talked about yet, Dr. Scott Tomar.>>Scott Tomar: Thank you, Raul. Such a — I’ve got something of an inequity
here, so actually, I’m going to step over here to the side, so I can see this monitor. I apologize if you can’t see either. So, I was actually, I was asked to talk about
a collection of topics under the heading of special topics. I’ve tried to group these into some meaningful
organization. So, we’ll talk a little bit about individual’s
behaviors and exposures that impact oral health. And we’ll talk about some of the already existing
and emerging problems along that. Provider’s behaviors that impact oral health,
and we’ll talk about some of those; in particular, antibiotic and opioid prescribing practices,
and adherence to infection control guidelines. And oral healthcare providers as change agents,
and how to change them. And I’ll talk a bit about that. I’ve been involved in the research over the
years in a number of different conditions, and some of the challenges we’ve had. So again, just to try to put these in a conceptual
model, mental health actually directly impacts many of the behaviors that we’ll be talking
about in terms of individual’s behaviors that have an impact on oral health. And I think one of the breakout groups will
be talking about mental health issues. It will probably be beyond what we’ll be talking
about this morning, but it really does have a direct impact on a number of the behaviors
we’ll be talking about. Some of these that direct and indirect effect
on oral health, things like addiction and substance abuse, tobacco use. You know, for years, we’ve known that tobacco
use has much higher prevalence among people with mental health conditions. And now we have the emerging problem of electronic
nicotine delivery systems. At the very time where we’re seeing tremendous
success in conventional cigarette smoking. Believe it or not, we will probably hit the
Healthy People 2020 target of no more than 12 percent of U.S. adults smoking, which is
actually amazing when I think about where we started not that long ago. But at the same time, now we have an emerging
problem, an epidemic before we really have data on its real health consequences. A number of other preventative and destructive
behaviors tied to mental health in addition to things like pain perception and coping
and use of oral health services. And so, you know, some of these I’ve already
mentioned, things like alcohol abuse, substance abuse, things that have direct impact on oral
health, are really caused by mental health. And this is probably an area that the group
that we’re talking about, interprofessional collaboration, really an area where I think
oral health needs to be working with those in behavioral health, dealing with some of
these things. And again, as I mentioned, tobacco and some
of these new nicotine delivery systems. You know, like many things we’ve seen, those
of us that have been involved in tobacco control for any length of time, we saw this pattern
years ago with smokeless tobacco. We saw it with cigars in the 1990s. We’re seeing it with e-cigarettes. When you introduce a new novel product into
a population, advertise it heavily, the group that responds most rapidly, and most, and
at the highest prevalence, are young people. So, you know, even though, even a product
that theoretically is marketed to adult tobacco use who is looking to reduce their harms;
in reality, the primary drivers of this epidemic are young people. These are data for high school students, just
an epidemic growth in the use of these products. And again, before we really have the epidemiology
on the oral health effects, we’re really just getting started on that. Sort of the other broad area, provider behaviors
that impact oral health; a number of things that we as providers do that have effects
on oral health, both positively and negatively, things like pain diagnosis and management,
and related to that, opioid prescriptions. And I’ve got some additional data on where
oral health fits in that. Antibiotic prescriptions, and then perhaps
inappropriate prescription for antibiotics, infection control, and adherence to the guidelines,
and dentist examination, and diagnostic skills; particularly, related to things like oral
the oral cancer. We saw some data earlier this morning. We really haven’t made a tremendous amount
of headway in terms of changing the distribution, of stage of diagnosis in oral and oropharyngeal
cancers for many decades. Dentists prescribe a lot of opioids, at least
as of the, you know, this particular study came out a few years ago. It may have changed, you know, since then,
but at least as of 2015, about 18.5 million prescriptions written by dentistry that year,
accounting for about 29 percent of all opioid prescriptions that were written. So, just a huge impact on opioids. And as we heard from the surgeon general report,
from the surgeon general this morning, that is a huge area of interest for DHS, and in
DHHS in general, and the surgeon general in particular. One of the things that really struck me, and
this is from the same study that Linda Niessen showed some data from. I mean, what really struck me was this increased
rate. This is not just a number, but the rate per
1,000 dental patients in opioid prescriptions by dentist. And I don’t know what would be driving that
kind of increase over that five-year period. You know, that’s, what, about a 65, 70 percent
increase over a five-year period, among young people. These are 11 to 18-year-olds. So, I don’t know whether there is an epidemic
of asymptomatic disease free third molars that needed to come out, but something clearly
driving this prescribing behavior. Antibiotics, in 2015, dentists wrote more
than 25 million prescriptions for antibiotics, or about 9 percent of all ill patient prescriptions
for an oral antibiotic. And generally, apart from prophylactic, antibiotic
prophylactic, guidelines, there is really limited national guidance on prescribing practices. And at least some data suggest that dentists
are not prescribing appropriate categories of antibiotics when they do prescribe. So clearly, we need more data on prescribing
practices and appropriate antibiotic selection for use in oral health. You know, I mentioned already, infection control
guidelines. And, you know, these came out a few years
ago, but CDC put out some degree of updated guidelines. And these, four different behaviors within
those guidelines, to always document percutaneous injuries, whether the dental office has designated
an infection control coordinator, a separate dental order line system, and try to use a
safer syringe, or scalpel. And as you can see, the degree of adherence
to those guidelines is, you know, was really not universal for any of them, but really
rolled to be low for several of these recommendations. And so, you put it together, there is, you
know, only about a quarter of dentists that implemented three or four of these four guidelines. You know, about three quarters did not. So again, you know, it’s a few years old,
but don’t have newer data to suggest that it has changed dramatically. And one of the areas that, again you know,
that I’ve been involved in a number of studies, you know, in this area where those two circles
overlap, where that red arrow was pointing, where provider’s behaviors and individual
behaviors overlap. You know, the areas where I consider that
oral healthcare providers have an opportunity to serve as a change agent to help change
individual’s behaviors; things like counseling and communication, appropriate referral, a
recommendation of things like HPV vaccine, or HIV testing in their office, adoption of
[unintelligible] based practice. And — go back to that — so, I mean, one
of the things that we found, and again, I’ve been involved with studies related to intervening
on tobacco use, overweight and obesity, eating disorders, recognizing signs of abuse. The one thing they have in common is we generally
have not had great success in having oral healthcare providers effectively serve in
that role as behavior counselors. And probably anywhere, we really need much
more research on, how do we increase the — their effectiveness in that role? And so now, I’ll leave you with many more
questions than answers, but, you know, is there a — what do we know about this bidirectional
association between oral health and mental health? This is it. I hope it’s an area that the interprofessional
group discusses. What is the role of oral health and increasing
and decreasing substance abuse? And I think there’s a number of areas, both
directly and indirectly, that oral health can play a major role. What are the oral health effects and implications
of electronic nicotine delivery systems? I said, this is an epidemic that has grown
faster than our knowledge of the oral health implications of it. And it scares me in some ways that the cat
is already out of the bag long before we have figured out exactly what this means for the
nation’s oral health. What are our effective strategies for changing
behavior — provider behavior on infection control and prescribing? As I mentioned, you know, we have all — you
know, we certainly have a lot to learn about effective ways to help our patients and individuals. We need, also, additional research on what
works better on change of ourselves. And effective strategies for increasing providers
will list incompetence and counseling. You know, I, as a faculty member in a college
of dentistry, I could say that we do a little bit in our school. Probably not nearly enough. And I would love to hear from others that
maybe have had better success. But I’d say, in general, dentist and then
probably to some extent dental hygienist and other healthcare providers really, you know,
really need additional strategies for increasing their competence and intervening on their
patient’s behaviors. And with that, it’s my pleasure to turn it
over to Renee. [applause]>>Renee Joskow: Well, good afternoon. In my 15-minute shot we’ll briefly discuss
two topics that I personally am very passionate about. These are my passions, Adm. Adams, which is
workforce and oral integration. We’ll also touch upon, briefly, the implications
for access to care. I just want you all to know that I’m presenting
my own personal opinions and not the official policies of the Department of Health and Human
Services, HRSA, or the U.S. government. So, I’m going to start by setting the stage
for the breakout sessions and the discussions that we’re going to have tomorrow, and discussions
that you might have during breaks or in between sessions. And I want to talk about those building blocks
that can be leveraged in order to improve oral health. So, let’s focus today’s discussion on three
fundamental interrelated pieces: workforce, integration, and access. Now if we think about the pathway to better
oral health, we first need to consider the critical role of workforce. And many of the speakers have touched upon
that, as did Adm. Adams this morning. Now these children, I know firsthand, have
a demonstrated interest in oral health. They actually have demonstrated to me that
they know how to put dental sealants on teeth. They had the opportunity to do that at a Take
Your Child to Work day at our building. But my question to you is, are these the faces
of the next generation of oral health and medical health professionals? Will they be, perhaps, the next engineers? The scientists? The teachers? The nurses? Well let’s briefly look at trends in the oral
health workforce. So, this graph is a snapshot of graduates
of three accredited dental education programs since 1990. You can see that there have been increases
in the graduates of all three programs over the 26-year period represented here. Now the dental assisting data line, which
peaked in about 2010, may not fully capture the dental assistant workforce because some
states don’t require formal education or certification for dental assistance. Now in addition, economic factors impact career
— career opportunities as well as employment choices. Now for dental hygiene and dentistry, we see
relatively parallel growth since the first surgeon general’s report in oral health in
2000, indicated by the blue arrow. Although there were differing views in the
literature, regarding workforce supply projections depended upon the models used, if we look
back a little further, we see a different picture emerge. Let’s use dentistry as an example. Well, we see a substantial increase in dental
school graduates through the mid-1980s. Followed by a steep decline associated with
the closure of two dental schools between 1986 and ’88, an additional four dental schools
that closed between 1990 and ’93, and a seventh school closing in 2001. Now, other factors to consider or change in
class sizes as well as new and expanding programs for foreign trained dentist, or also called,
advanced stemming programs, leading to graduation from a U.S. dental school. All of these contributed to increasing trends
that began around 1993. But that trend was supported by a new error
of dental school openings. Well, one new dental school opened in ’97. Followed by 12 additional openings from 2002
to 2016. And one more, still, is scheduled for opening. In addition to the total number of graduates,
we have seen changes in the demographics of those dental school graduates. In 1977, 9.6 percent of the 5,177 graduates
were minorities. As compared to an increase now to 35.8 percent
of graduates in 2016. Now you can see from the graph, that increase
in diversity of dental graduates, overly nearly 30 years, rises with Asian and Hispanic graduates. And you see more modest growth for Black and
African — Black and Alaska Native and American Indian graduates. When we consider the adequacy of the dentist
workforce, which many people have talked — touched upon already, in order for them to meet the
needs of the public. And of course, the geographic distribution
is critical like that that would be reflected in say, HRSA’s health professional shortage
areas. We can also think about the supply of general
practitioners as it compares to specialists. So, the supply of dentists depicted here include
— excuse me, those working in clinical private practice, dental schools, faculties, uniformed
and other federal services, hospital staff, state local governments, et cetera. General dentists rose by 20 percent from 2001
to 2017. Whereas, specialists rose by 27 percent during
the same period. And although not shown here, it’s worth noting
that overall the percentage of female dentists has been increasing from 16 percent in 2001
to 31 percent in 2017, almost doubling. Now, the question I ask you to consider is
do we have an adequate workforce to support not only the need to provide clinical services,
but do we have a sufficient supply of graduates with the training and expertise in dental
public health for disease surveillance? Or to plan and oversee population-based initiatives? Or with the experience in formal principles
of learning and education in order to create and staff robust academic faculties? Or those trained in basic science or translational
science who would be able to apply the bench and basic science discoveries into pre-clinical
and clinical environments? And then take clinical practice and proceed
across a continuum to community practice and engagement. We also need to think beyond just the dental
and oral health professionals if we want to progress most efficiently along that pathway
to better oral health and overall health and address the unmet need of certain populations. The directive articulated in the 2000 surgeon
general report on oral health, that oral health is integral to overall health, has served
as a beacon to illuminate the imperative that we work together, leveraging all resources
and personnel available. In 2012, the Health Resources and Services
Administration launched the Integration of Oral Health and Primary Care Practice initiative. Which used a systems approach to explore what
it would take, the action steps, to integrate oral health and primary care. And I emphasize “and” because it’s meant to
be bidirectional. We leverage national expertise. Several of you who are here in the room participated
in that. And what we learned is that the three systems
depicted here in blue, green, and yellow gears: the healthcare professions, healthcare systems,
within which the care is provided and within which the providers work, and finance. These were the three most frequently cited
systems, and the highest ranked, that were necessary for oral health and medical or primary
care integration. However, essential, essential to the interconnectedness
and success of any effort is overarching communication. And the group also felt that all of this is
encompassed in the context of that. Now, we have seen the term, integration, manifest
in many ways. To describe integration, we can look to the
behavioral healthcare framework for integration as it’s depicted here, which includes six
levels and classifies the extent of integration as my colleagues were talking about, co-located,
whether you’re separate, whether you’re down the hall, whether you have a — the phone,
speed dialed for the physicians that your patients are also seeing. In one level, the care is coordinated where
the key element is communication. And that becomes the language that spans that
separation of where the care is being provided. The next level is where the care is co-located,
which still doesn’t guarantee integration. But there is, in fact, a physical proximity
between where the care is received and where the third level is actually what we would
consider complete or true integration. Where you actually have transformational practice
models where practice, change, workflow improvements, and an elevation and excitement among the
healthcare providers we find when they’re working together. Now this framework has also been adapted for
oral health to address oral health integration and primary care in school-based health centers. And that is shared with us and is available
in the National Maternal and Child Oral Health Resource Center. So, some of the approaches — this is what
we’ve seen. And I challenge you all, as we get to the
third bullet, to think about what else we need. Well, obviously, we need a willing and competent
workforce in order for integration to be successful. And a couple of approaches have been, if we
expand the competencies, the oral health competencies, for non-dental health professionals. I mentioned HRSA’s initiative, and we were
actually charged with developing these core, essential, minimal, what are the least, fewest
things that are doable that the non-dental providers can actually do that will make a
difference and impact the oral health? HRSA has continued, and we continue to test. And I thank some of you — many of you who
are in the room who are working on these initiatives. We’re testing that efficacy and the outcomes
on oral health and the systems change. Another approach is to engage the roles of
champions in oral health for those they serve. This might include: community health workers,
community dental health coordinators, dental hygienists, medical assistance, et cetera. But I’d like you to think about, are there
other approaches that could be successful? Are there things or groups or ways that we
can think about this that still might be developed? And please bring those ideas to the breakout
sessions. Well to have better oral health and achieve
overall general health, we need to have a diverse — a diverse workforce of interdisciplinary
teams. We need to understand the critical systems
at play to achieve oral health integration and reconnect the mouth and the body. These components can create the effect of
opening doors to improving access. Although there are many complex factors that
influence access to care, it’s critical that the patient be front and center. Now from a systems perspective, I would propose
to you that to achieve true patient centeredness, we must reframe the concept of a separate
patient-centered medical home and a patient-centered dental home with a truly integrated workforce
to achieve a patient-centered health home or wellness home. Now these concepts are not new, and the idea
of team-based care interdisciplinary teams or examining the adequacy and application
of the current workforce. We’ve been there before. And I decided that I wanted to bookend my
conversation today, and this talk, with the 1926 Landmark report. Which is the bookend on the left. The GEIS report, Dental Education in the United
States and Canada. Now, in the early days of dental education,
there was a discussion of a small group of physicians who practiced dentistry as though
it had been an accepted specialty of medicine. Although, as the GEIS report points out, that
after a series of lectures to the students of medicine, the medical faculty was not very
warm to this idea of dentistry as a specialty of medicine. Now, it seems that the charge to the dental
workforce remains remarkably the same as it did in the GEIS report. And I’d like to quote and — read a quote
for you, “The key to progress in dentistry are the practitioner, who serves the patient
directly. The teacher, who instructs and trains the
practitioner. And the investigator, who extends the knowledge
on which the teaching and most of the improvement in practice depends.” This is still from the report, “Lately, the
number of dentists has been growing more rapidly than the general population. But it is far from adequate. And the distribution is very irregular,” end
quote. Now the juxtaposition of workforce education
and overarching health systems integration was challenging back then as it is today. But I will share with you that — on the right
now, is the right bookend which is advancing dental education in the 21st century. Developing the Phase II Strategic Analysis
and Recommendations, which was recently — excuse me, recently published in the Journal of Dental
Education and authored by two of my mentors, Drs. Bailey and Formicola, from my days at
Columbia University. And in summary, we have to maximize momentum. You’ve heard everybody’s and seen everybody’s
excitement as we started the day with the speakers from the first session. Each of the speakers setting the groundwork
for the science and the discussions that will come. But although we’ve made progress since the
surgeon general’s report in 2000, which is the document on the lower left, we have the
opportunity with this meeting and the new surgeon general’s report to maximize the momentum
and see that these sentinel reports and activities move into action. In 2003, we had the National Call to Action
stating that every provider can play a catalytic role as a community spokesperson, addressing
key health problems and service needs. And we need a racially and ethnic representative
health workforce of those populations that they’re serving. In 2009, the U.S. oral health workforce in
the coming decade and IOM report was to address the question of the current status of oral
health services for the U.S. population. And also, to address what workforce strategies
hold promise to improve oral health? The HHS Oral Health initiative, in 2010, called
for the implementation of an HHS-wide effort to improve the nation’s oral health by realigning
existing resources creating new activities. And that initiative’s key message was, oral
health is integral to overall health. Then you have the two IOM reports in 2011,
Advancing Oral Health in America, which acknowledged the 2000 surgeon general report as raising
awareness of the importance of good oral health, and as Dr. Evans talked about earlier. And that oral health remains largely ignored
in health policy. But this report contained many recommendations
for HHS, as did the report next to it. Including investment in the workforce and
innovations. The HRSA report, which we talked about those
core competencies, was released in 2014. And then, in the interest of time, our most
recent document, at least from the federal side, that’s been released in 2016, championed
by the HHS Oral Health Coordinating Committee, and that is the oral health strategic framework
where there were five goals. And one of those goals was, in fact, integrating
oral health in primary care. Including strategies to advance interprofessional
collaborative practice and support development in policies to reconnect the mouth and the
body. As well as create programs and support innovation
using systems change. To move along the pathway to better oral health,
we need appropriate, competent, distributed, and diverse reflective workforce that operates
and communicates across all systems of care. With the net result of impacting access to
care and health. So to close, what you leave behind is not
what’s engraved in stone monuments, but what is woven into the lives of others. As we look back on the 2000 surgeon general’s
report, it’s important that we use the report as a pillar to ground our discussion. But it is from this strong foundation that
we must spring into action to implement change. It is the relationships. Our interactions and those of the workforce
together with patients and the communities that will endure. So, as you interact with one another today,
and in sessions and discussions tomorrow, I urge you to think about the connections
necessary to work as integrated teams. To improve the lives and health of ourselves
and those we serve. Thank you so much. [applause] It is my great privilege and honor to introduce
my colleague, Dr. Rena D’Souza.>>Rena D’Souza: They save the best for the
last [laughs]. [laughter] I’m blinded by the lights. I mean, literally, they were in my face. Thank you, Kaycee for the introduction. And to Nicole and Cassie, for guiding us through
the process. I also want to thank the most admirable admiral,
I think he just walked out of the room, Dr. Adams, for his humanistic understanding of
the importance of oral health. And his true commitment, I think, to improve
oral health for all. I’m really pleased to round out the session. Now, how do I advance? Is it this one? Okay. With a brief introduction — oh. I don’t even have my –>>Male Speaker: Just push that green arrow.>>Rena D’Souza: Sorry. With a brief introduction to the beauty of
the craniofacial complex, and how science and technology can advance oral health for
all. Following up from Dr. Salomon’s description
of the big drivers, I will highlight just a few of the most impactful advances in science
and technology, while citing a few examples of innovations in oral health research. I hope that my big picture questions at the
end will provide the framework for our brainstorming tomorrow. Are faces truly distinguishers as unique human
beings? Providing us with identity and a sense of
wellbeing. The tissues and organs in the craniofacial
complex, in fact, serve as excellent models for studying other mammalian biological systems. But good oral health means more than healthy
teeth alone. Rather, it implies being free from devastating
birth defects or facial pain, cancers, autoimmune disorders like Sjogren’s. And of course, caries and periodontal diseases,
which remain the most prevalent of infectious diseases of human kind. So, over the past 20 years, the science base
for dental research has broadened significantly. Encompassing multiple disciplines. Every organ tissue and cell in the craniofacial
complex is — has been studied from individuals to populations at risk. But by far, the most significant transformational
scientific leap was made early in the 21st century when the mysteries of the human genome
were disclosed. And the advances in the human genome project
are driving several fields of biomedicine today. And I must say, that while there is a genetic
basis for all diseases except trauma, it is important to understand that there are myriad
factors that, in fact, affect the progress and resolutions of chronic dental diseases. Unprecedented, is the conversion of science
and technology. In the past, science would advance a little
ahead of technology and vice versa. But today, it truly has converged to where
tools and technologies are available hands-on. So, most of us grew up in the reductionist
era. Maybe studied mechanisms and had hypothesis-driven
research projects. But now, we actually — we’re loosely coupled
to clinical observations and related to diagnosis and treatment. But in this golden era, we can now coalesce
clinicians, scientists, social and behavioral researchers, and patients, for the first time
in our history. The conversion of science and technology,
in fact, will surely impact all constituents of the dental profession. In fact, the four P’s, predictive dentistry,
preventive dentistry, personalized dentistry, and participatory dentistry, will drive the
practice and delivery of oral health for all. So, I want to start off with an example of
an exciting advancement in the field of genetic disorders. As you know, birth defects, craniofacial defects
constitute the most common amongst all birth defects. An example of Ectodermal Dysplasia, very rare
genetic disorder where you lack sweat glands, have sparse hair, and lack most of your teeth. Colleagues in Germany, with approval from
the government, were able to inject a replacement protein that replaced the defective protein
into the intra-amniotic cavity of a pregnant mother — of a mother. And the twin boys, now a year and a half old,
have sweat glands. And most of their teeth, as you can see in
that view, have been restored. Cleft palate is one of the most common birth
defects. And in fact, we have researched now in mice,
in a genetic strain of mice, where a delivery of a small molecule replacement therapy was
able to reverse the cleft defect in utero. Computing par is changing the way research
is done. Big data, data sharing, artificial intelligence,
and deep learning are changing the landscape of even the most threatening of conditions. And here is an example, what I just read in
Time Magazine, where humans train self-learning computers or program them with algorithms. And this computer was able to analyze 2,100
PET scans and was able to predict those that were at risk for Alzheimer’s. And they were 100 percent accurate. This was done by a computer. Central to NIH’s Century Cures Act, is the
Precision Medicine initiative. It’s called All of Us. And it’s truly a revolutionary approach that
aims to enroll 1 million individuals over the next 10 years. What I’m most excited about is the fact that,
for the first time on a national scale, we include individuals across the life span. Women and individuals from different racial
and ethnic groups. Also, pregnant and lactating women. One of the most exciting technology advances
is represented by the field of salivary diagnostics, that offers a user-friendly approach for the
diagnosis of several cancers and disease conditions that have compromised oral health and general
health. An example of work in our field, on a smaller
scale, is our population-base studies being conducted at Duke and UNC, that use both broad
and wide approaches to study determinates for caries and periodontal disease. As Dr. Solomon described, the microbiome emerged
as a new field following the discovery of the human genome. So, the identification of a new strain of
bacteria by our oral health researchers, that in fact counteracts the effects of strep mutants,
the principle microbe involved in caries, is the predictor of a development of probiotics
that will be, hopefully, useful in preventing caries. Another important initiative is the Brain
Project. Which combines neurosciences and pain research
through a very sophisticated modern imaging techniques that expose molecular circuits
that work in healthy individuals as well as those affected with psychosis, neurodegenerative
disorders, and chronic pain. An example of the work done by Bill Maxter’s
group, is in fact, once again, using a large data-sharing approach and large populations
to understand the genetic and risk determinates for chronic pain, including that involving
the temporomandibular joint. I included the slides, particularly, to emphasis
that for emergent crisis such as the opioid problem we face today, that the tri-pronged
approach of managing pain whilst trying to develop new methods to treat addiction, which
obviously involves behavioral and social techniques, as well as [unintelligible] reversal, are
extremely important. The Moonshot Cancer initiative, that was really
the love child of Joe Biden, Vice President Biden, has really driven, I think, taken all
that precision medicine has to offer and applied it to cancer therapy, especially immunotherapies. And this has been done primarily by — to
the identity, development, and validation of robust biomarkers. These biomarkers are now being used to drive
individualized approach, as we’ve seen recently for immunotherapies, that direct the right
medication to be given to the right patient at the right stage of cancer. Here is an example of work done by Silvio
Gutkind, now at UC Davis, where he identified mTOR as being a very important marker for
oral, head, and neck squiggle cell carcinoma. In his basic science approaches and his pre-clinical
mouth models of cancer led to clinical trials and a population-based study that identified
treatment. A counter effect to mTOR would actually halt
the progress of cancer. Very interestingly, individuals — now this
a large-scale population study that risk — that also took metformin, which is the most common
drug for the treatment of diabetes type 2, showed a halt in oral cancer progress. Obviously, this is epithelial-based cancers,
not carcinomas. Now, I bring this up because it really highlights,
underscores, the importance of the conversions-based signs with pre-clinical animal model testing,
as well as the use of population-based approaches. As Renee so eloquently summarized, there is
no better time for us to come together and to worry and to train the future workforce. This, in fact, involves individuals in each
of the spectrums of science that help us translate from bench to bedside, or chair to community. And that investment, I’m pleased to say — to
note that NIH has made a clear — several sets of initiatives now, encouraging this
future pipeline for dental research, as well. So, I must say, as Renee stressed, that coming
together as a community that united practitioners with healthcare researchers and providers
is — this is the time to do it. Put the patient at the center, with the student
at the center, with the community at the center. I pose these big questions for our brainstorming
tomorrow to specify — or to stress the need for research to actually inform the strategies
we use to promote health, prevent and treat disease, and overcome disparities. And how can dental and oral and craniofacial
health be understood in the context of the whole body? These are big questions. What strategies will be effective, specifically,
to engineer a diverse dental research workforce, and how can we build an evidence base for
stakeholder engagement and community involvement, to ensure that, in fact, all people have the
opportunity to lead healthy lives? I’d like to thank Larry Tabak and Martha Somerman
for sharing slides that helped me capture the cutting edge of where we are in biomedical
research, and I thank you for your attention. And for me, it is a pleasure to introduce
our new Chief Dental Officer, Tim Ricks. Thank you. [applause] Thank you.>>Tim Ricks: Well, it’s been an exciting
afternoon. I hope you all have enjoyed yourselves. We’ve gotten some — a really great overview
of the themes for this surgeon general’s report from these speakers, so please join me in
thanking our speakers once again. [applause] And as a token of our appreciation, we have,
on behalf of the Office of the Surgeon General, we have Certificates of Appreciation, and
a brand-new minted Chief Professional Officer coin for each of our speakers. [applause] So, Dr. Rena D’Souza. Let’s go right here.>>Rena D’Souza: Thank you.>>Tim Ricks: Thank you. Dr. Margherita Fontana. [applause] Dr. Raul Garcia. [applause] Thank you. Captain Renee Joskow. [applause] Dr. Gina Thornton-Evans. [applause] Dr. Scott Tomar. [applause] I’m getting better as we go, so. [laughter] And then, we have two — the two for our other
speakers who aren’t here: Dr. Caswell Evans and Dr. Linda Niessen. [applause] And as the surgeon general said in his speech,
we really have to, moving forward, as these speakers have sort of set the tone for the
surgeon general’s report, tomorrow, I challenge you all to think outside the box. Think of our non-traditional partners that
are in the room. Think of non-traditional partners that may
not be in the room and think of how we can work together to promote oral health before
the surgeon general’s report is released in 2020 and afterwards. At this time — Dr. Rollins mentioned the
Oral Health Coordinating Committee. This committee represents all of the various
offices and agencies in the Department of Health and Human Services, and I’d like to
recognize them. I probably won’t get another chance to do
it in a public forum. So, if they will, all the members of the OHCC,
come forward. Including the steering committee. So, first, Dr. Judith Albino. [inaudible commentary]>>Tim Ricks: It’s like, “Where am I supposed
to stand?”>>Female Speaker: That’s left over from “Hamilton.” There’s a mark on the floor, like, where you’re
supposed to stand on the stage. I said, “That’s from ‘Hamilton.'”>>Judith Albino: Thank you. [inaudible commentary]>>Tim Ricks: [laughs] Is Dr. Marco Beltran
here?>>Male Speaker: Tomorrow.>>Female Speaker: Tomorrow.>>Tim Ricks: Tomorrow, okay. Capt. Gail Cherry-Peppers. [applause] Dr. Ed Craft. [applause] Capt. Bruce Dye. [laughter]>>Bruce Dye: That’s ominous. [applause]>>Tim Ricks: Mr. Casey Hannan. [applause] Dr. Fred Hyman.>>Female Speaker: He was here.>>Tim Ricks: There he is. [applause] Our photographer, Capt. Michael Joss. [laughter] [applause] Miss Nicole Johnson.>>Male Speaker: Come on down [laughs].>>Tim Ricks: Thank you. [applause] Captain Renee Joskow, again. [laughter] [applause]>>Renee Joskow: Thank you.>>Tim Ricks: And I’d like to especially recognize
our retired Admiral, who’s led this charge, the surgeon general’s charge. For the first few months, he was in charge
— put together the steering committee and you know, it was really easy, 12 weeks ago,
to pick up where he left off. So, Rear Adm., Retired, Nick Makrides. [applause] Dr. Rich Manski. [applause] Don’t run off. Don’t run off without the coins, guys. Dr. Rochelle Rollins. [applause] Thank you. Mr. Andrew Snyder. [applause]>>Andrew Snyder: Thank you.>>Tim Ricks: Thank you. Mr. Fontaine Sprouse. [applause]>>Fontaine Sprouse: Thank you.>>Tim Ricks: Thank you. Dr. Gina Thornton-Evans, again. [applause] And Commander Nathan Mort. [applause] Okay. So, I’m supposed to tell you a few things. So, let me see if I can do that. All right, how do I work this? Oh, is this — okay. So, for tomorrow, the — you should have a
packet and a piece of paper in your packet that gives you your assigned breakouts. So, here are the breakout room assignments. So, if you will look at your sheet that has
a list of attendees and it has your name, and under “breakout,” the first column, one
— here are where the rooms, the breakout groups are. So, group one is in Rosslyn I, group two is
Rosslyn II. Three is Salon I, four is Salon II, five is
Salon III. Group six is Alexandria, group seven’s McLean,
group eight is Mt. Vernon. Okay, and then, the remainder of the schedule
— so, that breakout is from 9:00 a.m. to 10:30 a.m., then we’ll take a break. The groups will come back into this room to
have about an hour discussion. It’ll be — it’ll have to be a summary of
the discussions in the breakouts. And then, we’ll talk more about the afternoon
at that point. But again, I want to challenge all of you
to think outside the box. You know, when we start talking about integrating
oral health into primary care, which is the way it used to be said, everybody in oral
health said, “Well, okay, what can primary care do for us?” So, to sort of paraphrase, you know, JFK asked
not what primary care can do for us, ask what we can do for them. So, let’s think outside the box. Think about non-traditional partners. Talk among yourselves this evening, and I
hope you all have a great evening. Thanks again for paying attention and having
a wonderful session today. [applause]>>Female Speaker: Produced by the U.S. Department
of Health and Human Services at taxpayer expense.

Author: Kevin Mason

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