 Okay, so just some intro remarks. So oral health is health, which we know, right? In fact, it has been more than 20 years since the 2000 Surgeon General's Report on Oral Health in America, and more than 25 years since Surgeon General C. Everett Coop said, you're not healthy without good oral health. Bringing the seemingly basic idea of more public attention, independent of its associations with other bodily diseases, since that's often how we like to talk about oral health. Oral health is important in its own right and can have great repercussions for well-being. So to this effect, in 2021, the ADA issued a statement saying that oral health is integral to overall health, dentistry is essential to health care. Yet in the United States, dentistry and dental health is separated from medical care and medical insurance. And this has contributed to poor oral health and social, economic and physical suffering for many Americans, but that suffering is not equal. Marginalized populations, such as people from low income backgrounds, immigrants, racial and ethnic minorities, the elderly, children, living and poverty all have a higher incidence of oral disease. This all means that ignoring inequities in oral health is unethical and something we can no longer minimize or try to sweep under the rug. Yet in 2020, National Institutes of Health Report, Oral Health in America advances and challenges that Annette spoke about, ethical and social issues that arise in a dental profession received very little, almost no attention. Is this an indication of how much dental professionals care about these issues? Myself and esteemed panelists here hope that this is not the case, and especially since dentists as a part of their social contract are called upon to follow high ethical standards which have to the benefit of the patient as their primary goal according to the ADA code. So as Annette said, I am a bioethicist, so I appreciate you all allowing me in your space. My research focuses on why marginalized populations have adverse health outcomes. As a bioethicist, if we were talking about strictly health care, we would be speaking about the incidence of disease in terms of social, cultural, political determinants of health or those non-biological, but social explanations for why disease is socially patterned. And oral health from my viewpoint is no different, should be the same. Less access to dental care because of the geographic location of dentists, low incomes but high costs of oral health care, no real existence of dental insurance in the same way that we have medical insurance, cultural practices as well as a lack of dental literacy and a lack of substantial political power continue to adversely impact people's oral health. One second. So in other words, our oral health is greatly influenced by factors outside of ourselves. Those factors like systemic inequities that we can be born into and oftentimes have little to no power to remedy. So as a matter of ethics, when discussing a systemic problem, we have to address the root of the problem and its effects at both the individual and the population level, and that's what we'll be doing today. How we educate dental professionals and with whom we practice dentistry with can also contribute to inequities in oral health. DEI or Diversity, Equity and Inclusion is a hot button term right now we often hear, but how are we meaningfully addressing DEI issues in education and in our practice? These are ultimately questions of justice and as the ADA code says of the principle of justice, the dentist has a duty to treat people fairly. This principle of justice expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues, and society. Under this principle, the dentist's primary obligations include dealing with people justly and delivering dental care without prejudice and I think that without prejudice is key there. So how are we living up to this value of justice that the ADA code calls on us to exemplify? And what are dentists and dental educators to do? We know that some populations are underserved. We know that the ADA code calls on dental professionals to share an advocacy to and in care of the underserved. We also know the ADA code says under the principle of beneficence, the dentist's primary obligation is to serve, service to the patient and the public at large, but how do we do this when the problem of poor oral health and disadvantaged communities seems so large, so overwhelming? Yet so worthwhile for our individual patients as well as for entire communities. So our team panelists here will address the ethical issues and issues of social, commercial, and political determinants of health that contribute to poor oral health outcomes from marginalized populations, what professional obligations dental professionals have to addressing these issues, and then just what can educators do to prepare future dental professionals for a profession increasingly becoming more committed to DEI and social justice issues? And so sorry the format, we'll have a few questions from the panelists and then we will open up to questions and then move on to more questions from the panelists. Go back and forth. So we'll have plenty of time for Q and A throughout and also Q and A at the end. So please come up to the mic. And if you want to address your question to a particular panelist, please do that, okay? Everyone? Thank you. Great. So let's go ahead and get started. So let's just sort of talk about just the basic framework, right? Let's talk about how do we frame this oral report? So we know that we have social, cultural, political determinants of health. We know that they greatly influence people's oral health. Why do you think that social and ethical issues were not more prominently featured in the report? And what are some implications of this absence? So let's go ahead and start with Lisa. Sure, and I'm first of all just so honored to be a part of this incredible history and especially to be a part of this panel. I hope everyone including the audience will come and be there. And Scott, I'm a little intimidated because I know you were an associate editor. I think maybe you can try that. Can you hear me now? Yes. Okay. Let's just give it to her. It's rare with a teacher voice like mine to be told I am insufficially loud, so I'll take it as a compliment this time. And I'll confess, Scott, I'm a little intimidated to answer this question first because I was a mere contributing author and you were an associate editor on the report. So you're gonna give us the real details. But I think that in part the answer is that a lot of things happened in the process of making this report. And I imagine there may be some other contributors here in the audience as well. But when the report was being written, it was intended to be a follow up to the Surgeon General's report, but of course a pandemic and a change in administration led to some very big challenges in making that happen. So I think in part there were maybe some competing priorities. The other thing I think is key to note about the report is that it's very difficult, I would imagine, to create something that addresses every aspect in the field. We've all dedicated our entire profession to. There were a lot of cooks in the kitchen. And I think sometimes, especially as vendors tend to be more detail oriented folks, they're tended to be splintering or over attention on very small topics or ensuring that we got enough of everything in there. So for example, I was asked to write a summary paragraph on the oral health of people experiencing incarceration, which I would argue could be like its own report. And then another one on rural populations. Then those became distrops in the bucket of enormous report trying to accomplish so many issues. But what I think is then missing is that central mile high point that as an issue of justice calls upon us to try to think about oral health in a particular way, through a specific plan. Scott? Yes, so this originally, many of you probably know, that this report was originally intended to be released as a surgeon general's report. I, you know, earlier in my career, I was with Centers for Disease Control Prevention and was involved in putting together a number of surgeon general's reports, primarily those related to tobacco and health, but also the first surgeon general's report on oral health. The nature of government reports, really good at laying out the problems. And this report I think does a pretty good job of updating the 2000 report on laying out all the problems. Probably is less effective at really laying out some policy solutions. As was mentioned, what we're primarily dealing with in the current problems in oral health, so much of it is related to things that happen outside of the dental office. It's really a social, commercial, political determinants that influence oral health and oral health care in the US. But it also happens to be some of the very issues that frankly government reports are probably a little hesitant to weigh in on the terms of policy changes that might help to alleviate some of the inequities that we see. But what I'm hoping that this afternoon that we can maybe discuss some of the things that perhaps are not in the report or not adequately highlighted in the report on things that we as individual dentists and we as the American College of Dentists could help to do to deal with some of those determinants that again happen outside of the dental office. Great. Frances, so do you want to comment on what, can you tell us any sort of foreseeable implications of the report not having social or political determinants featured more prominently? I mean, I feel, and good afternoon, everyone. I'm so happy and honored also to be here. Thank you, Harry and the organizers who have us here. I just want to share like, I'm not the only one too short-sighted. This I wrote, I was one of the contributors on the oral health disparities for children and I wrote literally like 10 pages. And when I went back to the report, I think maybe they had three paragraphs of what I, I guess we all have to deal with this. And I mean, like someone told me when I complain, as you know, me, I'm very vocal. So I complain, I say, just be happy that we have this second oral health report. It's just a little step. But we, I feel, after doing this for 35 years or plus, I feel that this is not a time for more reports, it's a time for action. And we need some more implementation items, especially on policy changes and system change approaches, which is what Scott refers that was not really addressed on this report. But having said that, it's great that we bring the magnifying glass to the issues of oral health disparities, first and foremost, but we really lack on what we're here all about, which is an ethics, and to really the aspects of how we can improve our access to dental care for all in a more equitable and more diverse way, right? So this is what I wish there was a specific report on that. And I'm so thrilled because with this panel, as we've been discussing, we hope we can bring our own report from ACV that can really bring the light to some very specific issues of policy change, addressing, if not all, at least some of the highlights that we think are important. Okay, so I know this next question is a very big question, but I'm gonna ask it anyway of our panelists and hopefully we can have some discussion in a little bit. So I'm gonna start with you, Carlos. What is one of the more pressing ethical and social issues facing dentistry or dental education? Again, I understand the magnitude, but that's why we're starting with you. I'm so glad you're starting, Carlos. Let's go in the road, Carlos, you start us off. He's the smartest of us all. Not at all. I'm a philosopher, you know, so I have to ask the big questions. Yeah, so you chose the country preacher from South Carolina to start with a large question, right? So good afternoon, everyone. I think I'll back up, in your introductory remarks, you talked a lot about justice. And so I think one of the challenges, you know, I think in a dental profession is even how we define justice. And so I have some colleagues, Carlos Cuenones in Canada and Eleanor Fleming at Maryland, who we just wrote a paper together, really problematizing really kind of social contract theory. And I'm kind of getting in the weeds of philosophy on some level, but this notion of, we talk about the social contract, right, that we have with our patients, with communities, that it's not just our interest, that it's the interest of the patient that is now centered, that is above our own self-preservation, if you will. And so if you look at the history of social contract theory, it was really developed at a time where someone like me certainly would not be offering any insights on any theory at all because it was created in a time where black and brown folks or women were not really a part of these kinds of discussions. So to boil that down a little bit, this notion of justice and a simply defining it as fairness, I think is an ethical challenge, right? Because if justice is simply fairness, then I'm looking at a lens as a provider to where I'm treating everyone fairly, but then that absolves me of any responsibility to actually intervene when I see challenges, particularly of, say, an oppressive nature, right? So I brought up Carlos and Eleanor because the piece we wrote really is asking the question of should we redefine or reimagine the definition of justice as not simply fairness, but anti-oppression. And so that's a bit of a leap and probably a bit controversial, but I think we could even look to some of our Jesuit, I see Pam back there, we could look at some of our Jesuit colleagues, right? And we look at how, and Loyola as well, like when we look at how justice is defined in some of these institutional ways, it really is looking sort of at anti-poverty and really helping the least of us combatting oppression and not simply fairness. So if you come to the table with a lens that is, I have this responsibility to intervene when I see problems that's totally different than I just am supposed to treat everyone fairly. And so I'd probably start from that lens if that makes sense. Yes. Great. Lisa, same question. Pressing ethical or social issue? Carlos, you are a beautifully top-actified. Not hardly. I mean, I actually am just grappling with what you just said. I love this proactive rather than reactive approach to justice. I think it's really beautiful and something I'm gonna take with me into my work. I am a big picture thinker, which is perhaps why I practice medicine now and not dentistry. But I think that the pressing issues are at least for me more infrastructural even than they are individual. It's really great to be in a room with so many dentists who are really committed to ethics as the core lens to which we deliver care. But I feel that for many dentists, that's actually not the case and that's been a huge frustration for me in my admittedly so far brief career. But part of that is the rules of the game. We practice in a silo where the incentives are fundamentally misaligned from our patients. And I think that leads to a fair amount of fear and conservatism on the part of many who practice dentistry and the lack of engagement with the white supremacist structures that uphold the way dentistry has always been and continues to be practiced and medicine to a lesser extent. But I think that that makes it very difficult to change things. I am very interested in changing the rules of the game so that's no longer true. And I would argue that that comes down to very boring things like health insurance policy and who gets coverage and how we get reimbursed and whether it's value based and all these sorts of very concrete things. But the big picture is that it is fundamentally important that we in line our incentives as providers with those of our patients and that simply doesn't exist in dentistry right now. As much as I would like all of our profession to be fundamentally focused on doing their best for the people we care for, I think there need to be structures in place to support and encourage that because all of us have challenges or moments of weakness or time through that. That can't be true unless we work in a system that makes it so. Great. I know how we think about dental insurance is important to you and we think about the comprehensive nature of oral health care is health care and oral health is health. So great, thanks for that. Francisco, same question. Yeah, I mean, for me, we have to start from our very, very much crisis of dental education we have at the moment. We have to do a hotel reform. It's not possible that we still be teaching the same classes, same courses for the last 34 years. We need to revamp and rechange and rethink the way that we're really engaging new dental students in dental schools and how we engage this whole era of medical dental integration. Like I was telling Lisa, she's our role model for the future. She's our future amazing medical dental integrated individual that kind of provides we need for the future to address these issues of disparities. But having said that, if you think about it, most of the diseases we deal with are, would you like to say 65, 70% are behavioral diseases. Where do you hear that we're doing or we're training behavioral interventionist? Which is what we really need. We don't need more drillers or billers and billers. We need to have behavioral interventions that really get engaged in risk assessments, assessing where the social determinants of health of these patients really get into the very patient-centered individual approaches and then act accordingly to notch them on a behavioral change, right? So we need to really get to this new, totally rethinking of the way we're gonna be teaching the new dental providers of the future. Think about it, whoever we are here in dental location we're responsible for the next 30, 40 years of dental location in this country. Where are we? Why can't we have really the audacity to revamp and change these stuff that we're dealing with for years, right? So that makes me mad and that makes me into action. So we have created a whole curriculum reform at least in my world in the advocacy of diversity, equity, inclusion will really bring the issue of justice and ethics very much in the center and the core. One of the things that we really learned and I just came from the American Academy of Pediatrics they had an amazing national meeting and I really learned so much from them because they're 20 years ahead of us, why? Because indifference from us, the dentist which I'm sorry to say that where at the end of the day it's not about what's going on, it's about your business, about creating the best, the benefit for the individual themselves into their practice. The pediatricians at the end of the day regardless of what they discuss the center is a child. That's what we have to do. That's the piece that we're missing here. We don't see our patient as the center of the equation we do. I have more issues with justice. I think Carlos started us off well. Your turn, Scott. Yeah, so similar to Carlos's comment about how we can reframe the ethical principle of justice I think in the same way of beneficence. So we traditionally we think of beneficence we want to do good for our patient. As a public health dentist I tend to think of that on more of a community level doing good for the health, the oral health of the community which would involve, again, looking at things through a different lens. And I'm excited that even to to the regulatory framework in dentistry for example, the boards of dentistry typically spend a lot of their time and energy focusing on, aside from sanctioning people that run afoul of state practice acts the thought is, most of their activity is focused on the health and wellbeing of those who are in the dentist chair. There tends to be little or no attention to the health and wellbeing of people that for a variety of reasons can't or don't get into the dentist chair. And so again, to me it's just looking at the population through the lens that we might apply now to a patient but really looking at a broader perspective. And again, what I hope that American College of Dentistry is sort of the ethical guardians of dentistry. Again, I would just challenge us to think more broadly in how we apply these ethical principles. Great. So one more question from the panelists before we open it up to discussion and questions. So get your questions ready. So we know that nations that spend more on social programs have, their citizens have better oral health. So this is largely because of population level determinants of health and how they act independently of individual behaviors and therefore require population level interventions. So let's think about a little bit more broadly about what ACD can do. So this will go to you Scott first. How does the idea of addressing social and commercial determinants of health relate to the core principles of ACD? And just what is ACD's role in reducing oral health inequities in this country? Thank you. As Francesca said, so much of the diseases that we deal with in dentistry have a strong behavioral component. One thing we've learned from other successful behavioral interventions is that they tend to work best when you don't focus on at the individual level. So I'll give you the example, tobacco control and again, earlier in my career, I was with the office of smoking health at CDC. And I was fortunate enough to be in the days where we really were rolling out comprehensive tobacco control. So again, if we look at the situation today compared to where we were 30 years ago, we are at the lowest prevalence of cigarette smoking that we've ever had since we've been tracking it. About 5% of high school seniors that graduated this past year were smokers compared to 30 to 40% just 30 years ago. Same thing with adult smoking, we're down to about 12%, down from 30%, not too many decades ago. And how did we get there? It's not because suddenly people realize that smoking's bad for you. I mean, we knew that when I was in high school, but what we did was we changed the environment. We changed the social acceptability of tobacco use, cleaning the rare laws, restrictions on advertising and promotion, effective counter advertising. So here we're dealing and I know Francisco can speak much better to early childhood caries than I can, but here we're dealing with a disease such a strong behavioral component. We know what a lot of the major risk factors are, but we've invested almost nothing in effective food policy, control of sugar substances. We expect it all to fall on the parents and yet we've done nothing to help them to create an environment that reduces their exposure to advertisement for these products. The ready availability that the high sugar content products are cheaper and easier to access than fresh fruits and vegetables. And so I think that we really have to invest much more in trying to take a population level approach to managing what we know are the major risk factors. Effective food policy, things like taxes on sugar, sweetened beverages, other things that other countries are frankly probably ahead of us on that, but we really have not invested much at all in that. And I think dentistry has a major role to play in helping to advocate for these kinds of things. Same question, Francisco. What's ACV's role in all of this? Yeah, for me, and we just wrote a very exciting paper on oral health literacy as a framework, social determinants of health and really bring the bridge into structural racism and discrimination. We strongly believe that our communities of underrepresented minorities have enough color really pay the price of being mistreated and giving less treatment options than the regular community at large. For many, many reasons that I don't have time to spell out, but oral health literacy should really be the premises to start early from the consumers perspective, the family's perspective, as well as from the provider's perspective. I think we both, both communities have to be very much engaged into learning more about each other to really work with, you know, for us prevention is really key. As Scott mentioned, early childhood cares has been my passion, my crusade, my journey, all my life. It's been what I dream, I breathe, I live, and trying to come up with intervention modes. I mean, how many of you have you really been advocates or endorsed the H1 visit, for example, right? How many of you treat infants and toddlers in their practice? How many of you engage with wigs and early head starts and community health centers? How many of you really bring the issues of access to care for rural communities or where there's no dentist, right? How many of you engage with pediatricians, with family physicians or nurses, to have a more interprofessional practice and a form of giving access to care? Families want a one stop shop. They don't want to go like ping-pong to 20 places. Transportation, daycare is their major huge barriers as well as language barriers for them. So how are we addressing this in our daily lives? I'm asking you as providers, as policymakers, as part of the ACV, we need to be much more standing up front and be the voice of what needs to be done of change. I really am, I sound like a part of the, I am so sick and tired of getting engaged in more reports. I like to be engaged in an act up or like an action item plan. Like we're gonna do A, B and C and we're all gonna go for it and speak about it and be advocates. Like Carlos mentioned, this is not the time just to, oh, I'm not gonna do what is bad. No, I need to, when I see it, I need to call it out and engage and try to change it, right? This is the piece that we're missing there on equity. And again, I mean, this is a very important thing for me, H1 visit is essentially an issue of equity. This issue with Head Start and early Head Start programs that they suddenly, we don't call them cavities anymore, we call them COVID-ties because the children that we were perfectly fine are coming back with a horrendous amount of decay. We've never seen anyone in my life the amount of children with decay again, right? Why? Because they're staying at home, parents are using very, very high sugar foods and drinks to feed them, to keep them busy, to just keep them of being screaming at all. And this issue that we have for 38 years with early Head Start of toothbrushing in the school classroom was so powerful. That's what was an issue of equity. All children from all races, all socioeconomical status, they could at least have a role model of toothbrushing in their classroom, right? There were the ones that say, mommy, my teacher brushed my teeth, why aren't you brushing them for me at night, right? And for the National Office to help and to put a very, very strong stop that toothbrushing in March of 2020, it really put everyone like, oh my God, we're gonna be transmitting COVID in the Head Start with toothbrushing. And after many majors, and Pam was helping us out and many of the underrepresented minority national associations were helping us, the HDA, NDA, DDS, they used very strong letters for this. They finally, September, October of 2021, they came back with this lame kind of like, well, it is okay to toothbrush again, but it's up to each Head Start program to decide when they wanna do it. Who on their right mind is gonna do that? You tell me, right? So we need each and every one of you to be advocates to go out there and go to your community, ask, are you brushing the kids here? Can I help you? We have resources, videos. That's for me and the issue of equity hands on that we can do. And forcing this one visit, really working about oral illiteracy and really try to bring the simple issue of toothbrushing back into the children at most need. So let's open this up to questions. We really want this to be a discussion. So before the panelists continue to talk, if you have a question or anything that we've talked about so far, please come up to the mic. I see someone, see a couple of people. We'll try to take a couple of questions before we move on. Yes, please. Great. Thank you for the photo, Scott, by the way. Thank you very much for the photo. I'd like to hear a little bit about vaping. What has Dentistry ADA, what have you looked at with vaping? I go to concerts a lot and I see a lot of people vaping. Vaping. Vaping. Yeah, so this is unfortunately another example where the epidemic is far ahead of the science on control. So vaping, for those that don't know, it's only been in the United States since 2007. So it's a relatively, still relatively new product in this country. The manufacturers, and a lot of it now is actually under the control of global tobacco companies who are very, very good at marketing product, particularly to young people. So these are products that on the one hand, they're trying to position them as harm reduction products for adult smokers who want to reduce harm. But in reality, similar to what we've seen with other novel tobacco products, the primary adopters of these products are young people. The epidemic of vaping really took off among high school kids and young adults. There's actually relatively few adults that have truly quit smoking using it. And again, in an era of evidence-based health care, if you look at the evidence for vaping, being an effective smoking cessation strategy, it's not, so far, there's really no good evidence that it's an effective strategy, at least long term. But what we're seeing is actually now another young generation using extremely high dosing nicotine products. We don't yet know what this will mean for adult brain development. We have a 15, 16-year-old exposed to incredibly high levels of nicotine. We don't know long term what this is going to pretend. But again, we're trying to put the genie back in the bottle after the epidemic is already out there. And we're still learning about health effects. Great. Get back here. Yes, I'm Susan Davis. This is for the woman doctor on the panel. I'm sorry I didn't catch your name. No worries. I'm Lisa. It's lovely to meet you. I understood you to say that dental education comes from a white supremacist perspective. I would like to have an explanation for that. OK, thanks for your question, Dr. Davis. And I hope some of the esteemed colleagues on the panel would also help with bringing about this framework. It sounds like that was a really challenging concept. But I think it's important to point out that the first dental schools were founded in the 1840s when the only people who were able to matriculate were white identifying men. This is not in many ways, though in some ways it was an issue of malevolence, but rather a historical fact that requires, as Carlos has mentioned, proactive efforts to countermand. We are now graduating for the first time ever dominantly female identifying dentists. But it took more than 150 years to get to that level of gender equity. And dentistry, even more so than medicine, which itself has serious issues with graduating physicians and a physician workforce who reflects the beautiful diversity of the rest of the nation. But dentistry lags even farther behind. These are only one small aspect of what it actually means to try and counterbalance a system that was founded when everyone on this panel would not be able to become a dentist or be a part of our profession. But it is a key ruling framework, because I think in part it encourages the sort of proactive response to justice that Carlos so beautifully laid out at the start of this talk. And it can be challenging to hear those words. I think that for many of us, perhaps especially if you are like me, white identifying, it can perhaps feel threatening. But that's important, because that's the individual work that we can do to think about our colleagues and what we want our profession to be and how we can better serve everybody in our nation and our obligation to our patients and to our community. If I just want to add, I mean, we have here leaders in our underrepresented minority associations, Pam, what is the percentage of African-American dentists in the country at the moment? I can tell you for Hispanics, it's like less than 4% nationwide. I mean, it is still pathetic, the lack of representation in the dental profession. Pam, what is the percentage of African-American dentists in the country? Yeah, so after all these years, right, since 1840, that we've come to a 4%, it is for me sad, pathetic, and really disgusting. And we're in the city of Houston, right? And it is one of the most diverse cities, yet our own dental school is the number of dentists of color that we graduate is, I think it's less than 10%. And that's all that is indigenous, that is black, that is Latino, right? And I think that when you talk about any sort of profession that has long roots in oppression, has long roots in white supremacy, you have to talk about it in a historical context, right? You can't ignore the history of the profession. I think that does a great disservice to patients. It does a great disservice to people that eventually want to be a part of this profession and call you colleagues. So I think what our panelists are getting at is that we just can't ignore the history of it and how that history continues to be present, how that history continues to repeat itself. If I can interject here. So I think when we have conversations where race is evoked, we have to level set. And what I mean by that is we have to level set and we have to say, look, when we talk about these things, no one is disparaging anyone else. No one is attempting to evoke guilt. No one is attempting to rewrite some historic narrative. But what the data shows us is that this conversation is about improving patient outcome. Yes, absolutely. This conversation is about improving patient outcomes because the data shows us that black and brown dentists treat more underserved patients. The data shows us black and brown dentists treat more patients on public insurance like Medicaid. This is data that has been around a good amount of time. And I think one of the challenges, one, we live in a country that doesn't really like to talk about our racial history from a center of truth, if you will, right? We talk about it from different people's experiences. And so your experience can be true for you. This person's experience can be true for them, but there actually is a truth that took place that maybe is absent of your particular experience. Does that make sense to everybody? Yes. And so I think we have to level set. And in that, I read an article recently that was fascinating. And I think it's instinctive and organic, but it was interesting to see it written. And that is this, that when we talk about race and there's a multitude of racial groups and ethnicities, but it was specifically talking about African-Americans or black and white folks in this instance. And I was saying that when, and this is a generalization in some regard, but when we talk about race and racism, white people tend to think of how far we've come, right? How far we have come. And 20, 30 years ago, it was this way, look at how far we've come now. Whereas with black and brown folks or people who are from minoritized or historically oppressed or systemically excluded backgrounds, they tend to think of current realities connected to historic narratives. So when we throw out race and racism, we're already talking about two different things because you have some people who are talking about it's so much better. Oh my gosh, we have 95 students in the dental class and five or six of them are black. There were no blacks in my class in 1972. Hello. That's true. It's true of your experience. And it is better that better is relative, right? A colleague this morning brought up when we talked about moral, a moral compass and how that is a relative term because my moral compass and moral center can be different from Lisa's, which is different from Francisco's, which is different from Scott's, right? And so when we talk about race and racism, I think one of the challenges and why it's so difficult and why it's so hard, we're entering from so many different vanishes and we almost can never get to a place where we're actually talking about the same thing. So that's why the colleague's question when Lisa threw out white supremacy, I cringed a little bit because... We all did, we all did. But I'm in a different skin disease, right? I'm glad you did. Yes. And so I know that's an uncomfortable point or it's a trigger where I lose 75% of the audience. So I can't say it if I wanna get something across. But that's because we're entering from these different vantage points. And as the conscience of dentistry, I think it is the ACD and it's incumbent upon them. And I think they have been doing this is to push these conversations because I think what can make a difference is the advocacy of everyone in this room who can leave and say, I understand this from a totally different perspective than I have. And I can go tell someone at the Texas Dental Association meeting, look, maybe you should think about this a little bit differently. I was at this meeting and they said, da, da, da, da, da. I think that power is one that really could make a difference in the ACD. Otherwise, we'll stay in these silos, we'll stay in these vacuums, we'll keep shouting over each other and the inequities will remain. And then also to remember, discrimination of any sort is a social determinant of health. And so that can also prevent people from getting to oral health care that they need. Let's go to one more question. Well, we'll get one more. Go ahead, we'll get. So good afternoon. I'm Cheryl Lee, President of the National Dental Association. I'm really happy to be here. Thank you. Happy to have you here. And so I really came up to the mic because I wanted to understand about the decrease in the percentages of smokers. And you had brought up about the vaping because I wanted to know if there was, excuse me, a comparison between the increase, was the decrease as a result of the increase in vaping and electronic cigarettes, which I really don't know a whole lot about, but I know that it was an increase and a concern for our students. And then since standing here, this social determinant and the amount of students of color being enrolled and even graduating from our dental schools is a major concern as well as the political determinants. All of this is real. And I know Adia has been focusing on the amount of African American males now because it really is pathetic to use your words. And so, but that was my question. But then standing here, I'm like, well, this is a whole lot. And I don't know how we're gonna get all of this in because it's so important to us in our communities because we really are the boots on the ground in all of this. So I thank you for this panel decision. Thank you. Thank you. Appreciate it. We'll go one last question and then we'll move on. Yeah, hi, I'm Sean Mead. I'm a new fellow, so I guess I probably shouldn't be talking, but I will. For anybody who is doubting the role of white supremacy or race-based marginalization at least in medical and dental education, I would just refer you to the FlexD report and the implications of that resulted in the closure of all but two historically black medical colleges in the United States and the somewhat dubious claim of quality. So just something to think about. I encourage you to look at the FlexD report and understanding what the implications of that were for medical education, as we know it today, basically throughout the 20th century. I do have a positive comment, though. And would you comment on the use of technology to address some of the healthcare disparities? I don't think that was talked about fully. It's kind of a double-edged sword and they go a couple different ways. There are limitations and advantages, but I would just love to hear some of your thoughts on the use of technology, leveraging like telehealth to reach some of these underserved areas. Great. Scott or Francisco, you want to take this one? Well, I mean, I really appreciate your comment. And if anything good COVID has left us or is leaving us with this amazing open to technology to all socioeconomical status or races or formats, everyone is familiar with Zoom. I mean, telehealth was so unused before 2019, especially in dentistry. And now to have this opportunity and this array and as we mentioned earlier, for me what I deal with in every day's life on children's oral health disparities is the lack of understanding and awareness of the families to have oral health in their radar screen in health and not in disease, right? Because it might be priority number 385, if the child's okay, but if the child's in pain, it becomes one, two, and three. And that's where the problem starts, right? That's the conundrum of where to find a pediatric dentist or dentist to take care of my child. So we don't want to avoid that. And we don't want it to make it one, two, or three, or five. But if we can bring oral health into the red screen number 15 without pain, that'll be a huge gain, right? So the idea is to bring pediatric dentistry to people's households. And we have such amazing learning experiences. Families would not like to travel two, three hours to get to an appointment for 20 minutes, three buses they might have to take. You name it, right? Paying for parking at the university, everything. So the fact that we can bring pediatric dentistry to their living room, their bathroom, their nook wherever they're at is just amazing. So we do a lot of risk assessments now. We do screenings. And we learn something that we learn that we really were so excited about is that the use of cell phones in low-income families, I mean, it's like using their television, right? They all have some sort of format. So we're able to connect even the more rural or where there are frontier areas where there weren't access to care. We had a very exciting study that we just finished on a clinical trial where we were assessing tooth brushing at home. Because as you know, it's a huge challenge regardless of any of your socioeconomic status. Again, a race, parents' biggest nightmare is to brush their child's teeth at night. And we really wanted to see if we could learn from the cash incentive programs, from vaccinations, where in some countries like India, Africa, Mexico, we learned that by adding a $5 phone card to families, they went vaccination rates in some communities from 38% to 90% in six months. It was just incredible, right? So we wanted to see if these incentives will work for families. So we just finished a big on trial with Stuart Ganski and the group at UCL7, UCLA where we found that really families are very engaged. We're working with low-income Hispanic families and rural areas. And they were very engaged in tooth brushing. And we worked with health economists where we found out that we're gonna give them incentives for brushing. And they say, no, when we did the focus groups of qualitative program, we found out that families were really thrilled with lottery system. So we're measuring by seconds, minutes, and hours how much they were brushing at home through the cloud and through the, we had a, I don't wanna make any commercial thing with a electric brand toothbrush that was working with us. And based on the score of your weekly month, you get into a raffle tickets depending on your scoring of brushing. And we were able to text message the parents to say, oh, you did greatly some Monday Tuesday, what happened to you on Wednesday, right? You missed the brushing of your kid. So we're giving feedback to the families. It was so powerful to have this kind of like technology into the households, bringing them to their families to a place that they feel safe and really addressing the issue of oral health disparities. So we are thrilled with the findings of not just a health but really interactive approaches where everyone can do it from our health center, our community, and you don't need to use the dentist to that. We have amazing community oral health care workers that are the bridge between the providers and the families, which would be an amazing opportunity for each and every one of you, wherever states you're from, to really endorse and engage with community oral health care workers. They really make the magic and they can do risk assessment, they can do the counseling, they can really can't hold the parents to do this kind of work, which is very simple, but for them might be challenging. Great, thank you. I think Scott has a... Oh, go ahead. I just wanted to address the earlier question about the role of vaping and the decline of youth smoking. So actually the decline in smoking by middle and high school students started around 1998 or so, more than 10 years before e-cigarettes really took off on the market. So I know proponents of vaping like the claim that that's really what's driving the decline, but the decline was already happening long before these things came on the market. And again, getting back to my earlier comment, what we think really is driving the decline was probably the seminal event, the master settlement agreement that states reached with the major tobacco companies in the late 90s that fundamentally changed how these products were advertised and promoted to young people. So for example, now you don't see t-shirts, frisbees, all the other things that... All the youth oriented things that used to be prevalent. You don't see billboards. You just don't see the things that once were highly prevalent among young people. At the same time, they've removed things like billboards. You don't see those anymore. You don't see advertisements on TV or radio for tobacco products. And at the same time, it was really when we saw the growth in smoke-free regulations. So again, you could sit in a room like this. Nobody would think of smoking 30 years ago. That was a very different story. So again, I think it was all the environmental changes. We've changed the social norm around tobacco use. Really is what led young people. Again, I don't think... We knew decades ago that smoking was bad for us, but we're just in a completely different environment around the social acceptability of it. Again, e-cigarettes came along after things were already declining for quite a while and really has not changed the shape of that curve. So I know the proponents say that this is accelerating it, but it's just not evident in the data that's true. Great. I do want to say about the advancing technologies. I always, because I teach ethics, I get to ask questions and not always provide the answer. So that's fun to me. But one of the things I think is important is that the typical inequities that we see with anything, we see with advancing technologies as well. So I would say that when you're dealing with these various advancing technologies, say that is a teledentistry type of thing, if it's in a very rural, super rural area, is there Wi-Fi that's gonna enable the folks in that community to be able to log on to your technological advancement? Does that make sense? I think in the same way, even with say like augmented reality or artificial intelligence, I'll use an example, most of us are very familiar with automatic sinks or automatic hand dryers, right? And so they've fixed most of that now, but when they very first came out years ago, they were not recognizing melanated skin because most of the testing had been done only on white skin. So when someone that's darker complexed like myself would put their hand under the warmer, nothing happened. So I think we have to think about as technologies advance, and that connects to clinical trials and all kinds of... And that still happens, it's not old. It still happens. All you do is quickly go on social media and it happens. It still happens to me all the time. But that's why we have to connect with community, like our work was, right now we're working with migrant Head Start programs, which are very rural communities where there's no access, so we link to their Wi-Fi. I mean, we're trying to address more decisions, but we really learned, I was really surprised because one of our first years of planning was how many of these low-income families had access just to a cell phone, right? And we're surprised, like almost 98% of them have them. So it was really incredible that we still have so much to discover and to do, especially to reach out. Let's do one more question, then we're gonna move on. We apparently still wanna give you some more time. Maybe to you, Terry, because you're gonna... Hi, I'm Subrata Shah, I'm an affiliate professor in School of Dentistry, University of Washington. My sort of comment or question is, some panel members mentioned that there is obviously a lot of need in the under sub-communities for medical and dental care. Like in the state of Washington, I know there is a lot of Native American areas, but there is very little dental and medical care. I'm also familiar with individual practitioners who really does a lot of volunteer work. When I was at La Merenda, there was two, this particular dental faculty and practitioner who used to take a whole plain full of supplies, go to South America and serve the people who'd never seen a dentist in five years and so on. However, the need is far more than the people who are volunteering and do this very good work. So should there be, like there's a need, there's a requirement for CDE and CME credits for every practitioner to maintain their license. So should we even talk about that there should be requirement for serving the under-subbed areas of those communities just to maintain your professional standards and professional license? Want to take this one? Yes, go this one. Sure, thank you so much for your question. I have many, many thoughts about this. Me too. And I think it's a very interesting possible solution. It provides some incentive for doing what I think we want our profession to do. But again, I'm a systems person and my thinking is I don't want people to need to get a bonus to do, to provide care in a way that is necessary across our country. Like how would you amortize the CDE? Is CDE enough of a mechanism to push or pull people where they need to be? And in the Indian Health Service, for example, salaries for very remote dental appointments actually are quite high. In terms of income being approved driver, if you want to make a lot of money, you can be an Indian Health Service dentist in Alaska. But those positions are still primarily unfilled, which I think speaks to the need to think about what drives dentists to become dentists, to practice where they choose to practice and how easy or pleasurable or important or meaning making it is to be a dentist in that community. And think about bigger scale issues than even having a single mission or a volunteer approach or a temporary commitment to a community. I am not an ethics teacher, but I will use Kylo's approach and say that that is a question to which I do not have an answer. And it is certainly one that the health system at large struggles to answer. But I would like to think that some of it starts with who becomes a dentist and how we build pathways so that everyone in the United States sees dentists who look like them, who serve their communities, who make them feel like this is a profession for them. I think it has to do with how we train dentists and what they believe themselves to be and what our identity is and what our job is going to be when we go into the world. And then I think about how we fund dental care, how we are part of the health system, how we use technology and tools and community empowerment to make rural health care be delivered. Great. I'll stop there. Okay. No, I think this is a great segue into a question that, so I know that you've talked about this before about how we separate medicine and dentistry. I know that you are our panelists that represents one of those. And I'm gonna be a little bit selfish since I mostly work with medical students and in medical schools. And so I want to ask you, I know that you've said before that the separation of medicine and dentistry is an accident of history that has been compounded by education, policy and economics. So how, what are some of the, to the detriment of the patient, what are some of these consequences of separating dentistry from medicine? What are some of these historical origins? And then how can people as dental professionals think about advocacy for expanded coverage and how to think about dental insurance? So can you just shed us a little bit of insight on that? Sure. So I'm a history nerd, so I have to go back. Many people already know much of this, probably better than I do. In 1842, we have the founding of the first dental school in the United States founded by physicians in the 1860s. We have the founding of the First University Ability Dental School, also founded by physicians. And these positions are good guys, right? Like they're thinking, wow, teeth are pretty important. It looks like we're not graduating people with the skills to take care of them. Maybe we should have a training program where people can learn that. Like that is a fundamentally good thing. It's the initiation of our profession. But once you start a school and it's not the medical school anymore, it's a different thing. They've built the base of the silo and it just continued from there. That's an accident. Like I think that if you took Nathaniel Cooley-Keap in 1860 and like brought him in a time machine to today, I don't think he would be elated at what happened. But I think their intentions of this system are good. And then going forward, this educational separation, which I would argue is sort of the earliest separation of venison and dentistry, developing into dentistry being its own self-regulated profession. But then that has been compounded by the ways in which dental care and medical care are delivered. Part of that, I think, is dentistry has been small enough to evade a lot of national attention on the way care is delivered, which the overall healthcare system has not succeeded in. And I would argue that's two of the way health insurance developed versus dental insurance, which as everyone in this room knows, is not insurance. You are not insured against anything. It is a discount plan. But then also in the ways that federal policy has forced change onto the health system for the benefit of the nation and which dentistry has successfully evaded. In 1965, the American Medical Association, the American Dental Association joined forces to oppose Medicare and Medicaid. It's not like the American Medical Association is higher and mightier from an ethical perspective than we are. It's that they lost in room one. But those outcomes continue to be compounded. I'm sure all of us have cared for older adult patients who may even have had dental insurance in the past and lost their coverage at a time when their risk of oral health need in this heavy metal generation with lots and lots of restorations is being expected to pay out of pocket for substantial need that doesn't happen in medicine. And on the Medicaid scale, adults are uncovered who are eligible for Medicaid in almost 50% of states which is astonishing. And then even in the states where they are provided coverage, dental acceptance of Medicaid is astonishingly low. These are structural historical things that have very tangible concrete measurable outcomes. And that's not even getting into some of the more intangible but equally essential changes in oral health versus health that make it much harder for people to see any of us and to get the care we all provide. More broadly, I just think about it as the more doors you have to walk through to get something, the harder it is to get that thing. Especially if you are vulnerable in any manner of ways that makes competing priorities very challenging for you. In dentistry, we're a separate door. That's harder. If we were just part of the one big door, that would be a lot better for probably the patients at least for me that I remember the most that keep me up at night, that I feel like I have failed, that I feel like this are better. Thank you for your question. Can I just address a little bit of this question? I mean, I avoid now these dental days like band-aids like helicopters and very much against them. What we're changing now, and I really hope that all the ACD members here endorse this concept of adopt a community. Adopt a partner. It's not one day, one hour, one week. It's not a month. It's a whole investment of your professional lifetime. So I really encourage my students to work with an early head start with a week, whatever is close in their community, with their church, whatever is there, to bring the issue of all health awareness. So I'm not sure if that answers a bit about having a day or a mission or what we're doing, but and also we need to take care of our very, very much the patches of third, fourth, and third world country we have in urban cities in the US. Like in LA, I don't send my students to go to Mexico, but the matter, when we have South Central LA or when we have out in our front yard, all these humongous disparities, so that's where we have to really make a difference, right? Think globally, but act locally in your place and adopt your community where you're gonna be working for the year, three years, five years, not just one day. Great. Thank you for your question. Scott, do you have anything to add? Yeah, so, well, you know what I mean, an idea that I'm careful about bringing up because I work for a public university and I think my dean is in the audience here and my former dean from my last institution is here, also a public supported school. So particularly in a public supported dental school, roughly half the tuition is paid for by the taxpayers of that state. And yet, we as a profession have no expectation or obligation of our graduates to pay back in some way. Other countries do, other countries where... Yeah, a fifth year of social service. Exactly, and so I know it may not be a popular idea, but we've got, we keep creating more and more dentists. We have five new dental schools that will be opening in the next year or so. Appalling. So we're just gonna keep creating more dentists, but without changing the system. The curriculum. We're still gonna have the same issues. I mean, it may not be politically popular, but that's one potential strategy. I work a lot with a number of federally qualified health centers in the Chicago area. And I can tell you, they struggle to find dentists in an area where we've got two dental schools and actually the third one in the southern part of the state, their graduates also come up to Chicago. And so we've got plenty of dentists, very few that wanna work in FQHCs or other... So you're proposing five years of dental school and then extra year of really community engagement and service because we applaud that, ACD, can you imagine if you guys come up with a policy? Yeah, I think people should obviously be paid for that, but I think that's part of the, we talked about social contract, as part of... Yes, you wanna be a dentist. I would extend it to pediatric dentistry. So we've used HRSA funds for a number of years to support expanding pediatric dental residencies, again, with no expectation that they either accept Medicaid, that they work in an underserved community. And I think we as a society should... To be part of a social contract. Lisa, go ahead. Sorry, I'll be quick in problematizing this because principle I agree with everything. And I think having like a mandatory rural in the United States would be like so awesome. But I will also point out that one of the reasons that we feel so impossible is because of the burden of debt that most dentists are graduating. That's the elephant in the room, yeah. And even compared, and again, all kind of compared to medicine, which also graduates people with a crippling amount of medical debt, of educational debt, it's still about $100,000 per person less for a graduating physician than a graduating dentist in the US. And those are just numbers that are... Stagger. You'll make your eyes pop out. No, it is, half a million, the average now is half a million dollars on student debt when they're in their residency program. And I get it. So how are they gonna do the right thing in life? I mean, how are they gonna really engage with them? The walk the walk when they're staring down debt. That's the elephant in the room, yeah. Great. And so they have to, we have to have a before solution and then get them into the FQHC. I think, Terry, you had a comment. Let's take another question. Can I just... Oh, go ahead, Carl. Terry, you can come over. A part of the gentleman's question was, and I don't know if everyone heard him, he was talking about the notion that perhaps a part of, we should require in some way for people to get like their continued education credits and things like that to participate in some of these volunteer type of things. And so I think in theory, I can understand the intention. And I think a robust benefit of these kinds of meetings is to have some exchange around these kinds of ideas and not just do what we've always done because that's how we've always done it. But I would say with that particular suggestion, I have challenged with it because of all the implicit bias that each of us bring to certain situations. So specifically, if we're gonna require, until dental education is really gonna fix or in somehow perfect the idea of who our providers are, similar to what Lisa was saying about why they want to become dentists, I have pause about unleashing on particularly already traumatized and underserved communities, folks that may not have the right emotional intelligence and cultural sensitivity, cultural humility to engage with certain populations without re-traumatizing them. Does that make sense? And also not to mention that we don't wanna discredit the people who are already doing this volunteer work. The burden tends to be put on dentists from already marginalized populations. And then you use them as sort of the phase to go and fix these issues in these communities or fix issues in the profession. So we can also ignore that there's already people doing the work, but they tend to- And I wanna make sure everyone really heard, Francisco's point, because I have, I'm interdisciplinary by nature, so I have this whole other life of theology and everything. And when I went to seminary at Duke in Durham, they had this diversity, inclusive program exchange thing with Sudan, and it was great. It was awesome. And they won awards and they won grants, but they didn't do a thing in the public housing right in the city of Griswam. Across the street from there. And colloquially, I would say, they're comfortable going to Sudan, but nobody wants to deal with Pookie and them. Exactly. Just right around the corner. All right? And so that is something we would have to face where we're not just doing this sort of tourism, missionary dentistry, let's take photos. Let me feel good. These little brown kids and post them on Facebook, but we're actually gonna go in and do real work that you could do right in your community. And I understand levels of poverty are different all across the globe. I'm not in any way arguing that, but I think we have a lot of disparity right here that we tend to turn a blind eye to because I think one of our overall challenges, dentistry is individualistic. You floss and you'll be better, right? Floss, brush. You do these things. And so we kind of don't think globally or holistically or about a system because we're kind of just individually focused. So I think that sometimes is something that's a hurdle in our way. Right. Do you have a short follow up? Go ahead. Just a quick comment. I've been in academics for more than 50 years and I have some time problem with the armchair academics, particularly for theology and so it's a doubt should do everything for everybody. You are saying they would be traumatized for unwilling people, for community who have zero facility available, they would love to have an unwilling dentist or a physician come and take care. Instead of worrying about we are traumatizing it because the practitioner is not that interested. I think we have a difference of opinion there. I do not think it's appropriate if we unleash on communities that are already historically disenfranchised, systemically locked out, if you unleash on them providers who have no racial or cultural sensitivity or will potentially just blame them for the situation they stand in, I understand they want their tooth out, they want the abscess fixed. But there is this notion of generational trauma that happens and so what we don't wanna do is re-injure and that leads me, I'll just throw in here too. I'm a little bit obsessed with this, there's some indigenous scholarship right now that talks about cultural geography, right? And so, and what that means is that, for example, our hospital systems, for some folks when they see a hospital, that is a place of restoration, that is a place of healing, that is a place where I go to get my needs met. For the other people of different cultural backgrounds, that same site is horrible. Yes, a horror story. And so, I just think that's a balance that we have to understand and I understand there is need across the board, but I just think that has to be a part of the conversation. Let's get another question in the back, I've been waiting for a while, go ahead. This is a comment I think in response to one of the gentlemen, I was surprised to hear that your state subsidizes about 50% of the dental education. I practiced here in Houston and went to dental school here, graduated 49 years ago and it was almost fully subsidized by the state at that point. For the last year, I know about, for the dental school here in Houston, the state share of my dental school's budget was 16%. You know, a certain amount of that gets made up by philanthropy, of course. A good bit of it gets made up by fee income that the school takes in, but in my opinion, an inordinate burden of that is in tuition cost to our students. And so, I don't know whether this reflects the will of the citizens of the state of Texas, but I'm pretty sure it does reflect the will of our elected officials. And that seems to me to be a, and it may not be that way any place else in this country, but it's a systemic problem here and it makes it difficult to bottom line work for Medicaid fees, for example, and it just ripples on up from there. I think it varies from state to state. I'm in Virginia and so I would say our state only contributes about five to 10% of our dental school budget. So it definitely varies, but I think that is where groups like this can put pressure in terms of advocacy on our legislatures to say, you know, if we have this responsibility, particularly the state dental schools, you know, we have this responsibility to care, but where is your fiduciary assistance in helping us meet those needs? So especially it will have a huge impact in the debt of the students in the future. I'm Carol Aiken, I'm from Boston. I have two comments. One is that we currently have a crisis in auxiliaries in the dental profession really escalated by COVID that in my area up to 40% of offices have an open position. 30,000 hygienists have left the profession and it profoundly affects the delivery of care. Additionally, in underserved areas, can you address the issue of mid-level providers and what they will add to the delivery of care in a more equitable way? Great. Scott, you wanna take that one? Sure. So unfortunately what you've described in terms of difficulty in hiring, particularly dental assistants and dental hygienists, yeah, unfortunately this is everywhere. So in fact even in our neck of the woods we have one FQHC that developed its own in-house dental assisting program because it's the only way they could get dental assistants. Our college, actually I think it's the first time but we're actually starting our own dental assistant program in a doctoral degree granting institution because we have this same problem. So I don't know the short-term answer to that. In terms of mid-level provider, I think it absolutely has a place in many parts of society. I had the opportunity a couple of years ago to go to Minnesota to observe their dental therapist working in a number of different settings, including in a private practice and spoke with both the practice owner and the dental therapist in that practice and it really wound up as a win-win. So the dentist said, well because I think they had a lot of their pediatric dentistry and a lot of their pediatric restorative care was provided by their dental therapist and frankly she was really, really good at it. He felt that he was freed up to be able to do the things that he otherwise wouldn't have had time to do. So actually substantially increased the amount of crown and bridge and implants and things. At the same time they dramatically increased the number of Medicaid insured patients that they could see. So in that practice actually wound up as a win-win-win because they increased access to care, they increased their bottom line and the dental therapist actually was making a very nice living. And so I think that it absolutely has a place and particularly in parts of the country where we talked about the difficulty in getting dentists to practice in some areas, I think in some areas if we can hire people from those communities, that has a grounding in that community, it's been shown over and over that it could be a very successful model of providing at least within the scope of care that they could provide. Excellent, sir. Yes, so I mean I love Carlos, he always gives the other side of the coin so I'm gonna give the other side of the coin and again I am really a pro dental therapist and I think that they have an incredible place in some areas in our nation and our country. But I'm gonna say do we need more drill fillers and billers so I'm gonna tell you because I studied a little bit about some of the dental therapist models and this is an exciting and amazing success story but in the other hand I also saw a model where some DSOs have hired these dental therapists for much lower income like fourth of what they will pay a dentist. They put them there to see 40, 50 patients in one day, cashing, cashing, cashing, especially in FQHCs where they make a bundle and where they can really make a huge amount of dollars. So they are now the slaves of dental practice, right? So that's also the other side of the equation that you have to be aware of. I go back to community health workers, some states like our state in California has chosen not to go for a dental therapist model but have chosen to go for a community health worker which again I wanna make a plea for the ACD to really look and see how we can add these community health workers as part of our team. They are the ones that are from the community, they speak their language, they have a cultural sensitivity, that cultural community to really engage with families on behavioral changes which is what we need the most and they can really focus in the social determinants of health but also are you flossing or are you brushing or you're not brushing or do you have food insecurities? For example, we are doing now two measures of food insecurities that we're asking families not to address some of the social determinants, language barriers, immigration issues. Are you fearful of accessing dental care because some of your immigration status have nothing to do with that? So we demystify some of these fears that families have especially in our Latino community in Los Angeles. So we're really trying to address some of this just through these community health workers. We find them incredible, incredible amazing resources as part of the team because they really provide what the dentists don't have the time to really engage with families at their level and meet them where they are at. Lisa? Sure. Well, first of all, I had the pleasure of meeting Dr. Anken on the plane on the way down here and I assure you she's, even though we had a great conversation, she's not a plant, but I agree with everything you said, Dr. Anken, thank you for bringing it up. And I think that there's a role for both of those and it comes down to what you described, Francisco, which is that we need to be thinking about dental care delivery as a team-based professional. Yes. This is something that has started to take shape in medicine where it's seen as much more de rigueur that I'm a physician but I have a team that includes the nurse case managers, it includes social workers, it includes community health workers, it includes MPs and PAs. And it's not about the different levels of capacity we have for certain complexity but more about our specific roles on the team. We know that on teams that have dental therapists, patients have better outcomes, but that's not to say that a dental therapist is doing better work than a dentist. It's that together on a team, everyone can do their best work. And we can improve the oral health of the family, yes, at home. It's more pleasurable, too. Absolutely. It gives you a sense of being in the weeds with someone and you get to more effectively meet families' needs. Like this is absolutely true in medicine, it is a more satisfying game when you play on a team. Brown. I think we have, oh, I'm sorry. No, no, no, please. I think we have to also be honest about how hierarchical we are. Yes. As a profession, right? And so if 20 years ago, we were lambasting and arguing against remote supervision of hygiene, now we're arguing against, and no one up here, but it's arguing against dental therapy. And I'm not saying there are pros and cons that are worthwhile to be explored, but I think the ethical question is what are we afraid of? Are we afraid, as dentists, that we're gonna lose our position at the top of the so-called pyramid? I think sometimes that is part of these scenarios, whether that is about dental therapy, whether that is about Medicare covers that will have a dental benefit. I think we have to ask some real ethical questions of ourselves as to why we either oppose an issue or we're in favor of it. Right. So I think this is a good place to sort of talk about population-specific issues. Oh, you have a question? Sorry, go ahead. Yes, I'm Russell Cove from Wichita, Kansas. Based on the gray hairs on my chin, I've been at this 36 years. And my question is, if we have the money and if we have all of the practitioners we have, we need, okay? How do we get people to want the dentistry that we have to provide, even if it's provided free, because I've been in situations where people can get free dentistry at a list of people, okay? Less than half of them ever came to see me. So how do, you know, people want the cell phone that they want the electric toothbrush was provided. The electric toothbrush broke down. Did they go buy another toothbrush? Okay, I mean, I've seen us wanting things, society wanting telephones more than we're willing to spend two bucks to buy a toothbrush. How do we get the population to change the mindset instead of just trying to make more of us available to take care of what people don't want to get? Carlos, you wanna frame this question for us? Sure, thank you so much for your comment there. So by nature, I am probably a both and person versus an either or. And so that's my preface to my answer to this question or talking about a response to this question. I think that's why social determinants of health is so important because this is a complex ordeal we're talking about, right? In terms of if you have, because that's why there's data that shows even when we eliminate costs, similar to what our colleague has offered, even when we eliminate costs, barriers remain. And so that's what we have to really dig into and figure out is what are these barriers that remain, why do they still remain even if we've accounted for the cost of the dentistry, right? We did a, we have a couple of advocacy groups in the Richmond, Virginia area that pre-COVID they did an assessment. And I talked a little bit about this this morning but where they did some qualitative interviews with providers, staff, those folks on this side and then with patients, right? And they said, what is in the way of you getting care? And for the providers, what is in the way of patients receiving care? Two diametrically opposed viewpoints came out. The providers and the staff said oral health literacy. They don't know enough about why this is important, right? Which I'd argue that could be applicable in certain circumstances, right? But what was profound is that the patients said cost was number one. And so if we eliminate that and then they said appointment times. They could never, it didn't work for their working schedule in terms of taking time off or when the offices were open or childcare, you know, all types of factors, right? So I think that's a, it's a very good question. How do we get patients to show up if the cost is mitigated or eliminated or not a factor? And that's where these social determinants have held in all these different barriers, some of which we discussed. A lot of them we haven't even touched come into play I think in a very profound sense. Good, I think this is a good, go ahead, one more. Like it's 26, I'm just gonna, I will take this moment to be very vulnerable and tell you that I've not been to a dentist in five years. Partly that's because I think like many of our patients maybe I don't have problems stop bothering me. So it's probably fine. Well, during medical school, so you have an excuse. Residency, I'm working 80 hours a week and I just had a baby. These are all things. And like I have so many privileges. Like the finances of dentistry are not gonna be a problem for me. Not only because I could afford to treat a problem if I had it, but also because I grew up in a four dated community where my parents were able to afford dentistry when I was a child, where I didn't have traumatic experiences with a dentist when I was younger. All of these things that make it very easy for me to access dental care, better than probably 90, and I'm a dentist, probably 99.9% of people in the population. And even I have barriers to getting to dental care that are both psychological and about my lived experience and they're partly structural. But I think it's important to be holistic about those things because everyone's living with those sets of feelings. Even people who have a lot of very good reasons to visit the dentist. Right. And it's a structural barrier, right? Do people have childcare? What's the location of the place? Their transportation, do they have paid time off, right? Is going to the dentist mean that their check is gonna be less and then they can't afford to things like food that they are putting brightly so as more important than seeing a dentist. So. I have an example of that recently that someone really came very upset because the office they went, it took them three months to get to their appointment, to get an appointment done. And they were 20 minutes late and the dentist would not see them because they were turning. So going back to the revolving door. So I think empathy and awareness and putting yourselves where these, that our patients are such an essential. I think it goes back to Carl's point about hierarchy, right? It's the, when we put these time limits and things, are we afraid of losing that procedure, that position of I'm at the top and this is how I run my office? So I think this is a good segue to talk about a little bit with you, Francisco, about population issues, right? So at the beginning we talked a lot about specific populations who are affected by social determinants of oral health. We talked about immigrants. We talked about racial and ethnic minorities. We talked about elderly. And then we talked a little bit about children and poverty. I know that there are a lot of pediatric dentists here to know Francisco, that's something that you know a lot about as well. So let's go ahead and talk about that. And so one thing that we know and then I'm learning from you is that children, particularly children from low income homes are greatly impacted, right? They're one of these groups that are greatly impacted by oral health. But they're also vulnerable to lots of social determinants of health. Children are the most affected by things like environmental issues, poverty, other social issues. So how do we acknowledge the enormity of their risk for poor oral health? But also that there are significant cultural, commercial and political determinants that influence their health. And then how do we position pediatric oral health as an issue of social justice, as an issue of ethics, right? I know this is a big question, but how do we put it at the forefront of social justice issues and look at it from an ethical lens? Just how much social determinants of health influence pediatric oral health? Yes, I mean, this is like the million dollar question, right? I know it's a big question, but you are the person to answer it. I mean, again, for me, it's really the parts of my multidisciplinary collaborative approach. Medical dental integration is essential. If you think about it, in the first year of life of these babies by 12 months of age, there have been seen by a pediatrician in average of six times or maybe seven, eight, I assume. How can they just don't give us one of those visits for a baby wellness dental visit, right? Where we can do risk assessment. This is the bonding experience for the parents. It's really eager to learn about babies' health in general. How can we really bring the issue of just brushing their child's teeth by the first tooth in the mouth, first birthday, with Florida toothpaste. If you can help us with this notion of really, really being advocates for the use of fluoride toothpaste at all ages, from the first tooth in the mouth to 110 years of age, there's a consensus there, and you'll be appalled to see how many pediatricians and even dentists recommend non-fluoride toothpaste for God's sakes. What are they thinking? My God, right? So when these parents come in like, with the child filled of holes in their teeth, like, oh, but the pediatrician might then tell me to use this training toothpaste. I say, I'm sorry, but this is garbage, and I throw it to the garbage can, right? I mean, this is that kind of voice we need. And also for fluoride in the water, right? There's a huge risk that we're gonna lose a water fluoridation if we don't get our act together and speak out and be all in unity to talk about this. Fluoride is in huge danger. We need to really address the issues of water fluoridation and the universal use of fluoride toothpaste will be an issue of equity, social justice, and human rights to start with. And I mean, again, to sound like a broken record, the age one visit is essential for us to start with pregnant women getting to them to show that toothbrushing, like washing the baby's hands or changing the diapers should be part of a bonding experience. The AAP has a great book brush, sing that they can sing a song, read a little book, and then brush your teeth, make it a nice, nice experience for the child. And I'm like, go brush your teeth at the end of the day. I'm happy to give you the, you know, this is the kind of change we need to do. And it has to come from us as providers to give us all the literacy and tools for parents' motivational interviewing and engagement to see how by doing very simple little things in their household can make a huge sense of difference, right? I might be with your child, Lisa, maybe two hours in a year as a pediatric dentist that you chose me if you ever choose one of them. And, but you are with your child almost 10,000 hours in that year, you do the math, right? If I can not you, if I can engage you to say, oh, have you noticed your child's teeth or look for white solutions or just wipe your child's teeth or don't leave the child with the breast or the ball at night or the milk in there. I mean, just those simple things can make such a world of difference for the child's health outcomes in general. Not just health but health outcomes in general. And here I want to take that chance because we have not touched and it's another afternoon or day for special needs children. I've never seen in my 35 years as a pediatric dentist the number, the huge number of increasing, unfortunately, children under the spectrum. So this is something that we're very, very also concerned. We don't have the training necessary. We are trying to now provide training for pediatric dentists to really deal with a very broad rainbow of children under spectrum and special needs. Great. Carlos, anything to add? How do we frame pediatric health in terms of social terms of health and ethical lens? Yeah, so I'm not a pediatric dentist. I'm a general dentist. But I think we have to really think about what we used to call soft skills. They call them executive functioning skills now at least in my little second graders school. That's what they're learning, which I think is fascinating. I'm like, oh, your second grade teacher needs to come and give a talk at the dental school. But, you know, and being aware, early in my career, I worked in a federally qualified health center in Rocky Mountain, North Carolina, and I was single. I didn't have any other obligations. So I did locum tenoms on Saturday. It was very popular in North Carolina to do locum tenoms dentistry. And so I moonlighted in this pediatric dental office. And most of the population was completely Spanish speaking. I'll never forget this little boy. He was obese, I mean, without question, right? And he showed up. He was a little apprehensive. But I'm like, oh, you know, I'm Dr. Carlos. I'm ready to sing my songs, do all this stuff to get him engaged. And he's great. And he had some cavities, but nothing crazy. We were just treatment planning. We were going to do nitrous and all this stuff. So I asked if he had mom and dad there. Now, he was the oldest of several siblings. They had like four kids with them, right? And he's eight. So you can imagine what's happening at home in terms of he's maybe left to fend for himself just a little bit as the oldest. And so when I was going through the medical history and I asked something about the last time he vomited or something like that because we're doing nitrous. And she said, oh, he vomits every day. And I thought, wait a minute, am I translating this wrong? What did she certainly didn't say he throws up every day? And so I asked again. And she said, no, he throws up every day. And I thought, he throws up every day. And so I said, have you taken him to the pediatrician? Have they talked about this? Have you guys talked about it's not my thing, but does he have GI issues, stomachs? Like, what's going on? And she said, oh, no, he just throws up every day. So we never thought about it. And so I thought, OK. So I encouraged him, go to the pediatrician. So he comes back for our next visit. I mean, he's Stone Cold Steve Austin. He won't look at me. He doesn't want to talk to me. I thought we were friends. I'm like, hey, I'm Dr. Carlson. I thought we were buddies. No, I don't like you anymore. And so I said, well, what happened, bud? He said, well, because of you, I can't eat as much as I want to anymore. And so what was happening, I got him to tell me a little bit more. And then I talked to Mom. They were so busy with the other kids, and just not in any neglectful way, but just the modus operandi of the day, right? You're getting dinner ready. You're doing that. He's eight. Let him figure something out, right? He was just eating and eating, eating until he vomited. And so I think a lot of what we can do is be aware and say something. Like, when something feels off, don't just keep going and say, let me get my production for the day, right? And I think some of that connects to our role. I think Dick Jones this morning was talking about this notion of dentist as community pillar, right? I think some of that is because we have to see ourselves in this way that I can make a difference beyond just this 5DO that I need to do, right? So I think some of it is awareness and really seeing it and then translating that individual type of thing to a systemic level, and so that policy and systems can work together with individual interventions. Great question. Thank you for that, Carlos. This is probably more statement and maybe getting a reaction from you all. It's a little depressing, but I'm getting through it. I'm old, and these stories have been around for a long time. I also have a bias that we as dentists are very good about talking about things, but we can't flip the action. So my challenge is I bet there's so many people in this room that have success stories that we can learn from and not have to repeat frustrations. I'll give you two examples in my own life. And I know Oregon and Missouri have been a pilot for us. We learned from it in Ohio. We're going to work with a program where actually that initial dental visit is going to be in the pediatrician's office. We're working with collaboration. And some of the silver-diamond fluoride treatments can be done. We're trying to embed in the pediatrician's office the community health worker that has the dental education also for our CDHCs and get that. And then pairing them with a dental office that unfortunately, there's still an awful lot of unmet need with dental care that needs to actually physically be done. So we're trying to create that thing and get the pathway back and forth. So there's one program that you can learn from. If you look at an Oregon hazard, I know Missouri has it. Ohio, this is our first go at it. We're ready to launch probably in January. We'll share everything with you. The other one that I learned and I learned a lot, and in fact, the American College is going to give an award to Dr. Irvin Silverstein, who I learned so much from in the school-based health care systems. And I've watched in Cincinnati, Ohio, and I'll take this program. I'll share it with you. I'll bring you to watch it. But we have had so much success and a very at-risk population in a place where we turned the entire life surround with data to prove it now of these young children who their whole lives were a mess. They had less than 80% of the kids ever went on to the ninth grade out of this community. And now 60% of kids that go to this K to 12 school graduate from high school now, and they go on to extra education, whatever it be. And it was all centered out of health care. The community, the school became the community center. And the families, it became the place they met. And from birth, you had young children who might have children. They had a nursery in there where these kids from birth were taken care of. So it was a beginning of life to get them there. And it was all based on education. It was on total health care. There was nursing. There was psychiatry. There was eye care. And it was private public participation. So we needed the private industry helps, too. But the school since the night of public school was very open. We now have 11 of these centers operating where it's total care. And we're trying to still build on it. Unfortunately, money is tough to come by. The evil word is always there. But my point is we should stop and learn. The success stories you all have, we should share them so that we can learn more. And maybe we can actually get a little action to start showing some effect. And then collecting the data. And in our more care project, we're going to collect data so that we can show results. We're using incentive money. We're paying more money to these practices that are in than they could typically get from the reimbursements so that there's an incentive for them to collect the data so that we can learn from it. Because unfortunately, data is king. So my only suggestion, and you might react to this stuff, is let's learn from what a success everybody's having and start driving some of this stuff and actually doing it so that we can get some results. Absolutely. Thank you for your comment. I really appreciate it. Yeah, there's some amazing, successful stories. And we really, really commend you. And we hope that we learn from each other about successful programs, which I'm sure there are so many out there. And all the efforts that this group is doing. Great. I think let's keep continuing talking about these groups that are disproportionately affected by poor oral health, as well as the NIH report. Let's go back to that a little bit. So let's talk about access to care. So access to care is in the report. However, I think some people might argue that access to care from a systems view, I know that's a term that we keep using for good reason. But I think that that is a lens that some people would argue is missing, like a grander scale lens. For instance, people might, I think, could argue things like classism, racism, ableism, discrimination against LGBTQ people, and how those groups, how those views can somehow make it less accessible for these particular groups who access oral health care. So I wonder, why do you think a larger ethical lens, a larger systems view for particular groups is missing from the report? And how do we, or you all as practicing dentists, how do you stay conscious of those populations who have less access or those systems of oppression for people who are disabled or are from low income backgrounds or are from LGBTQ communities? How do we keep these people at the forefront of the way that you all practice dentistry and why it's a little not as much in the report as some of you may like? Let's start with Lisa. What do you think? Well, again, I think that, again, and I will be grateful to Scott for pointing out that it's not absent in the report, that these words are used. But again, in an attempt to include as much as possible to include everyone, to represent everything, it's very difficult to maintain that ethical lens and to use that as the primary viewpoint through which we maybe shine a light on specific communities or identity groups. And I really like what Francisco mentioned about this idea of sustained community partnership because I think the most important thing for any group but especially those who are at highest risk of poor oral health is to listen and to center community voices. That can be an individual thing that you do with individual patients. I know that when I meet patients for the first time through like in medical education, I was lucky enough to get a fair amount of exposure to trauma informed care which is all about listening. It's asking, is there anything important about your experience with healthcare or with dental care in the past that you want me to know? It can be as simple as that. It can take one minute of your time and you will see the change in people. But then on a structural level, it's thinking about the ways communities can tell us what they need and listen and actually believe them. And that goes back to Carlos's point about when we talk to providers and we talk to patients, there's very different perspectives on what makes it hard to get dental care. And so those are I think sort of fundamental ways to listen to the communities we purport to serve. And then to be servants of those communities ourselves. Great. Scott, you want to go next? Sure. So obviously increasing access to care, it's a complex problem. One of the issues that we talked about this little bit earlier is that the more the providers look like and understand the communities that they serve, the more I think the better traction we'll get. And so part of it, and thank the previous questioner about the comment about school-based health centers. So a big part of our curriculum is actually having our dental students working in a variety of community populations, community settings. So if one thing that they learn to experience is that for communities that develop, and again, not everybody feels comfortable in every setting, but over time we find that there are people that say, oh, I like working in this kind of community. And so ultimately we create a cadre of providers that develop some degree of cultural competence in working in those communities. And then a big part of it is in what we try to, one of the side effects we have in having our students work, for example, in schools, and for many years ran a school-based sealant program, not only delivering preventive care, but they're providing incredibly great role modeling for the kids that they're serving. In many cases, this was the first dentist that these kids ever saw. And so again, I think we try to attack these from a multitude of directions. First, to try to get our dental workforce to look a little bit more like the communities that we serve. And at least in our institution, we've had some success stories in that. We've had a program through our urban health program working with kids as young as fourth and fifth grade. And actually we've dramatically increased the proportion of our classes that are now African American from about 5% to now it's about 20% in our current class. And again, I'm not saying that we've arrived, we still have a way to go. But I think, again, that these are long-term things because the school has made a conscious effort to try to engage particularly kids much earlier. Get them interested in dentistry and provide some role modeling. And again, also trying to provide the experiences for our students so that when they make a practice decision, they will have had some of these experiences. Great, yes. Okay, so the panel may not be surprised that I wanna ask a question about technology, but I'll be sure to bring it back to community and population health. First, I'm Terry Dolan, vice president of the ACD. And I wanna thank our panelists and moderator for really tackling some really challenging topics in such an open and honest way. And it's probably one of the more honest conversations that I've experienced that's been organized by the ACD. So I wanted to say thank you for that. As I read the latest Oral Health in America report, of course, I was very excited to see section six, which focused on promising technologies. And there wasn't a section like that in the original 2020 report, in the 2000 report. So I was really excited about that, but I do have mixed feelings about technology and sometimes, Carlos, you made your comments earlier about AI and potential bias and some negative impacts. But then I was thinking about, I live in Florida and we had our hurricane experience two weeks ago and how the technology was so effective in getting public health information to me when it was time to evacuate, when my water was safe to drink. And I'm thinking, why aren't we using these technologies to impact behavior at the individual or community level to really improve health and health outcomes? And then Scott, I was also thinking about your work in oral cancer prevention, where you have to remind me of the details of your work, but where you worked with communications and marketing experts to really use innovative ways to get the message out about the importance of an oral self-exam, for example. So your thoughts and feedback about, you know, is technology, you know, what are the opportunities to use technology to really advance the public's health? And access to care. So I think that goes great with our last question. Scott, you wanna start? Sure, I agree, Terry, that it's a tremendously untapped resource in general in oral health is the use. And we saw a little bit of actually takeoff during the pandemic, you know, the expansion and use of things like telehealth, teledentistry, you know, I don't, you know, some of it that expanded I think has, you know, maybe contracted a little bit, but I think it's still a largely inadequately used technology. The one thing I do fear with technology, and again, not that I'm afraid of technology, but to some extent I have a fear that it will actually increase the gulf between the haves and the have nots. I've yet to see a technology that's, correct me if I'm wrong, but I have not yet seen a technology that's reduced the cost to the individual for that healthcare service. It may create more efficiency for the system. I'm not sure that we've seen the cost of care go down. And so the extent to which new technologies might actually be more expensive for people to access, is that gonna create a greater goal? I think that we have, you know, the whole area of communications, frankly, we in oral health have done an abysmal job. Francisco, I think you mentioned about the fluoridation. We've had, you and I have gone through fluoridation battles, the complete lack of knowledge in the public of something that's been around for now more than 75 years, people don't know what fluoride is, they don't know what it does, they don't know if it's in the water. If it is in the water, they don't know why. Especially the legislators, making decision makers, supporting the lack of knowledge of fluoride. We've just done just a terrible job. And so all you need is a little bit of misinformation out there, and we're already behind the curve. Fluoridation right now is really under the gun. There's been some highly publicized studies that have come out, a lot of it refuted. But again, I don't know that the public really understands the nuance on study design and things. But I think it's really a role where we as dentists need to be talking to our patients as well as the legislators about these things. But yeah, I think in almost every area, we've just not done a great job with communications. Great, thank you for that question. Go ahead, Carl. I think it's also how you use the technology, right? So I'm at VCU, which is in Richmond, Virginia. We have a new dean, Lyndon Cooper, who, if you're a process artist, you may know that name. And so he has this idea, which I think is brilliant, we haven't implemented it yet. But he wants, when every patient comes in, like say just for a general screening or their first comprehensive exam, that there's a full mouse scan done. Because we use a lot of digital and scanning technology in our institution. And what he wants to connect it to, he wants to greatly reduce the number of appointments for a full denture. And so his concept is if we have this scan from a mediacy, can the denture actually, instead of it taking seven appointments, could it be three? And then does that connect to them taking less time off work, less money spent on public transportation, less emissions, sustainability-wise, however they get there? So we could connect the dots, and we could battle around some issues or mitigate some issues around access and equity. But I think it depends on how you have a vision for the technology and how you wanna use the technology and what you're gonna do with it in terms of implementation. So that's one. I think the other thing that you brought up that I think is really fascinating, you talked about how in the hurricane you were getting these messages around when it's safe to drink your water again and all this kind of stuff. And so in my mind, what I heard about is you trust the public health messaging. But think about in this kind of quasi-end of no longer pandemic, maybe in the pandemic and the CDC said this one week and I'm not discharging anyone who works at the CDC or used to, but just how confusing the messaging is and in a lot of public health circles, we've got some work to do to restore public trust in what health professionals say. And so I think that's a really big issue that I think we're not really thinking about which connects to what Scott said around misinformation. And so misinformation about everything, across the oral health gambit or across fluoride or when you're supposed to bring your, people still don't know when they're supposed to bring their child to the dentist. And we've been talking about that for eons in terms of a first visit and you still have journal practitioners who say, oh, bring them when they're for. And it's like, that is not what we're supposed to do. I'm gonna stop you there, Garland. We're actually almost at the end. So we need to wrap up. So I'm just, I want to end this. We have like just a few minutes, we're already changing batteries. I am, I see, we're changing batteries. I think that means it's time to go. So if you have a very quick question, we only have a few minutes, so go ahead. Okay, do I have 60 seconds? Oh, absolutely. Okay, good. I'll give you 90. All right, because a whole lot had happened since the last time I stood up here. And so I wanted to say that, one, when you mentioned the technology, and so you're right, it just kind of depends on where you are because we heard it for a long, long time about the quality of water in Flint, Michigan, and how our population had to deal with that, and how it took so long for that. I wanted to mention that. And then one of our colleagues mentioned, you know, about the, well he didn't mention reimbursement about Medicaid, but it's not very encouraging or inviting for our younger dentists to even participate. But we took a dental oath, and I've been in practice also for, you know, coming on for decades, I think, I don't know, but I think so. And it was important for us to provide quality healthcare for the underserved communities. And my focus in my practice has been to treat patients with severe mental and physical challenges. And most of them are awards of the state. So reimbursement is through Medicaid, but it's been quite rewarding. But we get back to these social and political determinants of health. Our reimbursement rates are different just based on our zip codes. And so it just really brings this thing back home. And so what you did during this conversation make me aware that we have children's hospitals who treat patients with disabilities, then they outage the program, and they don't even inform patients where they can even go. And I did challenge our children's hospital about that, but it doesn't happen. And we're one and a half miles apart. So we do have a lot to do in these arenas. And I know we're not gonna get to all of this. So we do have success stories, but we really have to focus on these problems that we have. And I too think we need to talk more about that fluoride. So I'm sitting down, but we have to deal with it. And because these are all real, and when we deal with this every day, you see it and you see the problems that we are faced with. And so I don't know how you're gonna keep this going, but we need to keep this. Yeah, no, I think that is a great way to end this. And I wanna end this with giving you all just, we 30, 60 seconds to address just very quickly. How, what's the parting message? How do we keep ethics at the forefront when you're going from patient to patient, you're busy, you still have your families to do, all right, you have so many obligations on your time, but you have such an important role in communities and such an important role in helping underserved communities have proper oral health. How do you keep these ethical obligations, these social justice obligations at the forefront of your career when there's lots of demands on time? So again, quickly we'll start Carlos and just work our way down. Sure, so I would say self-awareness and emotional intelligence, really asking yourself the hard questions and then taking those questions to larger venues and larger audiences and your society meetings and your component meetings. I do wanna just quickly say, we touched very briefly on workforce. I do wanna just bring up and ask an ethical question. I'm not saying this is the answer, but an ethical question around workforce. Take for example, we want a workforce that more mirrors the population is what Scott said and what the original Satchel report said over 20 years ago, but we still have barriers, for example, like the DAT. And so if you look at any actual literature, there is no literature that connects DAT success to clinical success as a third or fourth year professional student or even success in preclinical lab in terms of hand skills. There's some correlation to basic science knowledge, but I think we have to ask the question, who benefits from the DAT continually to be administered? It's a financial game for some entity. It's also another way to just weed out and say this is a differential. So I think asking hard questions like that of any topic is really how we move the needle, and that's just one that I know is controversial, but I think it's worth us thinking about. And you say you're gonna move. Okay, great. And we have a little bit more time, so after our panelists finish, then we can take some more questions, but same question to you at least. Sure, well I'm gonna try and take the spirit of the commenter who mentioned thinking about success stories, and I feel like having this conversation today, and when I gaze at everyone here to me that's a success story. And so when I think about carrying an ethical frame through our profession, I think the answer is community, and that includes our community here, and having people who will challenge you with the hard questions, who will help you to grow, who will tell you things you didn't know before, or learn from you, those exchanges I think are so important and so sustaining, especially when the work of dentistry can often be very isolating. And then beyond our dental community or our professional community, there's also the communities in which we live and we care for patients, and we are ourselves a part of, and the joy that is present in being a part of those communities and reminding ourselves that we are not just someone who does a five M.O., we're someone who takes care of our community members, who serves in that community, who can be a leader in that community, and who can listen to that community. And I think that done right, there's nothing better. And I think that's something all of us are capable of, especially because we're dentists and especially because we have this professional community to grow from as well. For me, I think the long-hanging fruit, and first and foremost, I really wanna thank the organizers, Terry and Annette and Susan, and who am I missing, someone else, but I really wanna thank you guys for putting these on the ACV for having us here. It's such an important issues for all of us. You guys are the core, you're the conscious of dentistry. And I really commend you for doing that. We wanna be part of this with you. We wanna follow the All Health America report. There's some very specific umbrella themes that are low-hanging fruits that are very actionable items. I'm not sure if your leaders or the board is thinking about strategic plan for ACV, but I really strongly recommend to start thinking or rethinking your plan of action. We cannot take it all in, but there's some very specific opportunities right now that I really encourage you, and I invite you to really think strategically how we can really make a huge difference and make implementable some of the things that we need and we think that they have to be done, right? So this is something that I really wanna leave you with, and I hope more of these forums. I am part of many, many speak engagements, and I've not recall having an amazing panel like my panelists peers here, and also the provoking things we have to really address for us to make change. And please go back to really rethink curriculum reform. I think that's really something that we need to address ASAP as soon as possible and should be part of these themes. Thanks again for this great thing. Kisha, you've been amazing while you're here. Got same question. Again, yeah, first of all, yeah, thank you all for being here, for sticking it out. Again, I would urge the organization to try to think big picture. So again, I understand the realities of day-to-day practice, running a business, dealing with employees and insurance companies and all that, but I think this organization of all dental organizations I think really has that ethical obligation to think big picture. What can we do to improve the health of the entire community, not just our patients? An example, we didn't talk about the other end of the age spectrum, but we've had a lot of discussion about Medicare coverage. Well, if we truly believe that oral health is an essential part of overall health, well, then we should be advocating for coverage of dental care in Medicaid Part B. We shouldn't have conditions on that. That's right. I think we have to see what barriers we can remove that we, as a profession, have imposed on the ability of, for example, dental hygienists to work to their full scope of services in many states. Their hands are tied, as we've shown in many places, preventive services that can be done safely and effectively, but yet in many states, they still, dental hygienists still face tremendous barriers in bringing preventive services to the most vulnerable communities. And so again, I think we have to take a step back and say, what is an organization, can we, can we champion that we'll try to reach, we want to do the best for our own patients, but we want to do the best for those who for whatever reason can't or don't get into our office. Great. Well, I hold this up. Are there any questions for our panelists? Pam has a question, I think, or comment. Oh, please. You've really been a wonderful session. I've really appreciated it. I have a question for you educators. So Dr. Cheryl Lee, she pointed out the problem with reimbursement for Medicaid, but there's a problem with reimbursement in general, fee for service. It's not based on patient outcomes. So are students being taught to focus on patient outcomes? Sometimes it is at the expense of fees for service. I mean, the whole area of value-based care is essential. So we are actually giving them some scenarios. I mean, we're really showing them different models, at least in our program. We're trying to really engage with them about what this future, whatever model is going to be like, what it would look like. So value-based is really in the forefront, as you know. But we've been talking about value-based for at least the last 20 years that I recall. It doesn't seem that we've been able to pan out specifically, especially because, first and foremost, I think that huge dilemma in the elephant in the room is that the lack of diagnostic codes, Pam. You tell me, when are we going to have diagnostic codes that will match your billing codes, right? Nowhere. I mean, you tell this to a physician, they are appalled. They can't believe it. They cannot believe it, right? So my question to you, when it's organized, then, is you're going to allow us to use the diagnostic codes we have there so we can move into health outcomes or health outcomes and really match the diagnostic code with your treatment code and not get away with murder, which we've been having for so long. So yeah, thank you for that question. So I can tell you, actually, at our store, we're opening a new clinic specifically focused on teaching our students to work in a value-based patient outcome-centered approach. So like many schools, we teach them a bit about prevention, a bit about health promotion, but then they get in the clinic, and it's all about producing X number of widgets. So we're really, again, we're in the early stages. We're currently renovating the space, even as we speak. But that's exactly our gestalt, and that is to give the students experience in what it would look like. And we're also doing that in an interprofessional model. So we're actually collaborating with folks from the Department of Nutrition, Nursing, and Pharmacy, who will also be part of this. And just what they're learning a lot through this amazing new trend of externships. So we are all in the fourth year, most of the dental schools, as you know, they're sending the dental students outside to community health centers, FJHCs, where they say, at least, what is the approach of that one stop shop, multidisciplinary approach, and also really the patient payment per visit, not for fee for service, which is a huge open device. So I think these community externships are so essential. But again, going back, I wish we have those for year four and your fifth of dental schools where we can really send them where they are needed the most and learn about this experience. Doesn't that deserve some applause? I don't want to problematize that. But you are. But you are. I promise, by personality, I am an optimist. But I think these are unique circumstances and situations, at least of what I am familiar with across the dental education landscape. Now, I think we're trying to move in that direction. But I think, and my day's not here, so maybe I won't get in trouble. But I think, in general, dental education is still in 1968. Archaic. In terms of models of care delivery. Yes. And so I think even those of you who are educators in the room will totally understand why I say competency education. So several decades ago or two decades ago, we moved from where you needed to do 10 crowns. You needed to do this many DOs. You need this many gold foils, or this many whatever, to this notion of competence. And you did enough to, and then you could test for competence or proficiency. Now, certainly all of us who are clinicians in the room know you don't get better at something unless you do more of it. So you have to do more. But then I do think students get to third year or whatever year they're more robustly in the clinic. And a lot of this goes out the window because they need butts in the seats to produce this revenue and to get these skills. And so I think in many ways, we teach one thing and say one thing, but the application, there's a tension between what's actually being applied and how it's played out in the clinics. I think external rotations are great. I know at our school our students spend almost 30 days in external rotations. They love it. But I still think that's a little bit separate. And maybe some different models like ECU or Cal North State that have these models where they're almost totally immersed in satellite clinics, you might have a different result. But I think unfortunately, we're still procedurally based. Yes. And so until we can move away from that, I don't know how we set students up to see it differently. But it takes really maybe small incremental steps. And I will follow exactly what you just said because in my years, we were sort of qualified of how many stainless steel cranes and properties I was doing. So one of the huge, and it took us maybe, I would say, six years, five, six years, and we're still getting there, to now addressing not how many stainless steel cranes our residents are doing, but how many of their patients go from dimming to rimming. And that's why I'm putting a magnifying glass. And we have a competition of how many of our residents comply with the risk assessments to all of their patients, how many of them are in satellite clinics, and how many can they show me that when a child comes in with generalized widespread lesions, D, F, and G, and lower molars, how many of them can actually change from dimming to rimming. And that's been really an eye-opener for all of us. So we now grade them, and they show me the cases when they graduate of how many they do that. So it takes small incremental steps. I don't think we can go through a whole change in the world. But I think it's going to take to that point to really value what preventative efforts and also that you can really keep healthy, enamel, healthy air into the future, right? No matter what restoration you're going to have, whatever treatment you're going to get, there's nothing better than your sound, enamel, healthy. And that's kind of the concept we want to change. Question. Go ahead. Sure. I'm Kayon Parcie. I'm the current president of the American Society for Biathletics and Humanities. I just wanted to say this was a fantastic, I've gone to a lot of conferences in my career. This is really one of the best, fantastic panel. I've been hearing a lot about silos and kind of this historical division between medicine and dentistry. And I was wondering if you all could speak just a little bit about the value of interprofessional education and interprofessional research. It seems like this has been a movement that's been going on for some years at my school, Loyola-Hingford-Chicagox Church School of Medicine. We have an Institute on Interprofessionalism. But it's one of these things where we're always trying to reform medical education. But we don't seem to really take it to the next level. And I'm just curious what your thoughts are about really pushing interprofessional education and research to the next level. Thanks. Lisa, start us off, please. Sure. Thank you so much for your work and for your question. I sort of grew in my both dental and medical training and in my role as an educator, I feel like I live and breathe IPE. But I feel like the thing that we're missing is the interprofessional practice. I participated in a lot of interprofessional initiatives. And as an educator, I think we think about how can we run simulations that are more like real life? How can we create these scenarios that will prepare trainees for working in a team, for working with others, for understanding the job that other health care providers have? And I have seen success in all of those things. In fact, it's a quota requirement, but also it's a requirement for medical education, for nursing education, for social work education. So in some ways, it's easier to accomplish an education. Because then you get into practice and you live in your little tiny bubble where you don't actually interact with other professionals. So in some ways, I think it's less about IPE and more about what you do with the next step. The former dean of the dental school, Bruce Donoff, used to say that we are preparing students for professions that do not yet exist. Which I think is like a really radical optimism that I love and that I embrace because I went to medical school, which my job is not one that exists yet. But I also think it's challenging because if you train students for the perfect world that we want them to live in, for a world where there's value-based reimbursement systems and there's true interprofessional practice and there's a Medicare dental benefit and universal Medicaid dental benefit for adults and all the things I think we want. And dental therapists do practice alongside them. These are really aspirational things. If we then fail them as soon as they walk out our front door, I think in some ways that engenders more frustration than if we never made these promises in the first place. And I will take a page of Carlos's book and problematize it without posing the answer. But I think the challenge is I don't want to stop doing the IPE. I want to do more. I think we need to continue to have those dialogues. And in fact, there's even a movement for pre-IPE, which is basically to have students be talking about this before they're differentiated at all when they're still in college or in high school. But I think we also need to start building a system that puts these trainees in positions where they can use those skills. So it doesn't just feel like fluff. And I don't know how we get to that in step, but it's the one I think we need to see now. Absolutely. I think we have some of the... So, I think we're... Come on now. Yes, I just want to say a quick thank you to the panelists. They did such an awesome job. Please give them a round of applause. Good job for you. We appreciate them so much. And Annette, thank you, Annette. You helped us out to close our chair leader. Thanks, Annette, so much. I'll turn it over to you. Thank you, Kiesha. Wow, I feel like I had the opportunity to sit in the living room with five brilliant people. So thank you, Kiesha, Carlos, Lisa, Francisco, and Scott. And thank you to our brilliant editor, Annette Elster. Yes. Actually, we did it together. Thank you, Annette, thank you, thank you, thank you. And I, the college would like to present the speakers, token of our appreciation to them. Thank you so much. Thank you. Appreciate that. And then I have another exciting thing for all of you. The Regency Breakout Sessions, which I think is one of the greatest parts of our meeting because it's an opportunity for you all to attend your Regency. You do not have to be an officer. In fact, I encourage any fellow to attend their Regency. It's an opportunity to exchange ideas, to ask questions, find out what works, what could work better. And so I want to announce those rooms. Regency one is room 335A. Regency two, 337AB. Regency three, 335B. Regency four, 335C. Regency five, 336AB. Regency six, 338. Regency seven, 340B. And Regency eight is 340A. And the continuing education code is fellows with a capital F 2022, fellows 2022. And with that, thank you for being here. Thank you for staying here. And let's give them another round.