 The Fellows Forum is our traditional time to gather together, to discuss big issues facing the profession, and to consider the role of the college in the context of that issue. Our topic today is the opening session of what will be at least a year long active participatory exploration of medical dental integration. And how the college might foster better health outcomes for all through the integration. The ACP will host an ethnic summit of medical dental integration in August of 2024, bringing together interested organizations and doctors across the profession. Drs. Tony Moonga and Scott Tomar fellows are today's moderators and have put together panel of experts to begin the conversation among us fellows. Tony Moonga is currently the Associate Dean for Academic Affairs at Marquette University. And Scott Tomar is Associate Dean for Prevention and Public Health Sciences and a professor in the Department of Pediatric Dentistry at the University of Illinois. Both Drs. Ruka and Tomar are fellows of the college. Dr. Ruka and Dr. Tomar please introduce our topic and our panel. Thank you so much. Sorry for the rough start this morning. Welcome to the 2023 Fellows Forum. We're really excited to present this topic this morning. The ethics of medical and dental integration, starting the conversation within the dental profession. So Scott and I will be asking our panelists questions, but first we'll start with a 20 minute presentation from each panelist. But at this time I'd like to introduce our panelists. Dr. Marco Vuchovic is the current Chief Economist and Vice President of Health Policy and the Institute at American Dental Association. He is recognized, he's a recognized thought leader in healthcare policy as it relates to dental care. He has published extensively in peer reviewed journals such as Health Affairs, The New England Journal of Medicine, and his team's work is regularly cited by CNN, The New York Times, Wall Street Journal, Fox News, and other media outlets. Previously he was Senior Economist with the World Bank in Washington, D.C., focusing on health systems reform in developing countries. Scott, are you mic'd up now? No, okay. I would be LAMSTER, Dr. Ira LAMSTER, served as Dean of Columbia University College of Dental Medicine from 2001 to 2012, and Senior Vice President of Columbia University Medical Center 2006-2012. Dr. LAMSTER is the current Dean of Medicine at Columbia University College of Dental Medicine and a local professor studying at University School of Dental Medicine. He is also a member of the San Jose Group and is leading the development of the Coalition for World Health Policy. Dr. LAMSTER's research efforts have focused on diagnostic testing, risk assessment for periodal disease, interrelationship of periodal disease and systemic disease, funeral health needs of older adults and the future of dental education practice. This research is supported by the support of NIH, corporations, and foundations. And finally, Dr. R. Rastana, the Walter C. Brilette Dispinning Distinguished Professor of Royal Medicine at Max Salvation Surgery at Harvard University Distinguished Service Professor, served as Dean of Harvard School of Dental Medicine from 1994 to 2019. In addition to leading the school as a student, Dr. Dada, as Dean of Dr. Dada, made major contributions in research to the specialty of oral and exorbitant surgery. He was interested in the bone marrow survival, sensory nerve repair, and oral cancer. He has published a quarter of papers, often text books, and lectured for a while. Recently, Dr. Walsh, the trustee of our initiative, integrated oral health and medicine, a project of great importance. Please help me in welcoming Dr. C. Brilette. We have presentations by our speakers first in our community session. So with that, we'll get started with our presentation. Hi, good morning, everyone. It's a great discussion. But first, I really want to just thank the college for inviting me to this, for giving me the honor of being in Dr. Dada's fellows. It's insightful. I'm not a dentist. I don't sit well with dentists. It's nice to be recognized. At least for making us think and sometimes be uncomfortable. But honestly, it's a real pleasure to be honored. I'm going to kick off with some very 30,000-foot things. I have no clinical experience. What my team does at the ADA is research. We do a lot of analysis of data, nothing critical, but trends and chemistry. So it's very data-driven and scientific. That's different than being interesting and relevant. But thankfully, a lot of our work is increasingly incorporated into debates, into popular press, into forums like this. So it's important that you know who I am and where I'm coming from. So I am a dispassionate analyst. I have an economics background. But I am part of what my team does is look at trends outside of chemistry. It was happening in healthcare policy overall. It was happening in household trends and consumers. And really try to bring some important insights to leadership and chemistry outside the ADA groups like you. That's really what my team is about. And so this morning, I really wanted to start because and I should be allowed to, again, congratulations to her. But one of the things she put up was that, oh, the volume can't be healthy without a healthy mouth. Well, that's the focus of our whole discussion today is about integration and reconnecting out the mind. But when we look at it, and two years ago, we had a very large NIDCR led, a 20-year retrospective, looking at what way to live. It kind of made a bold statement. The search in general did in 2000. Where are we in 2020 in terms of the nation's oral health? And one of the huge conclusions was, for children, we've made a lot of progress in 20 years. More kids in dental homes, untreated caries rates declining. And the biggest increases were among the most vulnerable kids. So kind of the children's trends were the good stories, so to speak, looking at that 20-year retrospective. For adults and seniors, completely different story. And if you haven't looked at the report, just go look at the oral health in America. Just look at the tag lines. We've done zero improvements for working age adults. You look at untreated disease rates, or you look at how many are going to the dentist. We've stalled. And the data are crystal clear on that. For older Americans, most metrics have stalled some non-preventive improvements, for example, in dental dentition, routine dentition and stuff. But unlike for kids, among the senior population, the improvements in oral health have been focused among high-income groups. So those disparities are widening by race, by income, unlike children. So the point here is we have to face out to the reality that whatever we're saying, and however important we all think oral health is as a nation, other than children, we're not moving an eel. And so a few years ago, I wrote a piece. I think you guys are not blinded. So I wrote a piece a few years ago, provocatively calling it more stuff, and from a policy lens when I said what would we actually need to do to significantly advance oral health and to basically get a ton more Americans accessing dental care. And one of the things is really to change this delivery model. So in a nutshell, and this is what our panel is going to talk about, I don't think we will significantly get more Americans accessing dental care with that least in part, breaking down the silo between the dental care system and let's call it primary care overall. So there are a lot of other things we need to do to kind of fix the protocol of the system. Like our insurance fraud is broken. We need to reform how dental insurance works. That's one of the things I highlighted. But this siloing of the delivery model is something very important to discuss. And I'm not saying do it or don't do it, but as an analyst I'm saying, the reason why we're not seeing as much improvement in oral health in the population is because we are having a separate dental care system and the rest of the health care system. Now many people love that, right? A lot of dentists go into the profession because of that. That's all fair. But we cannot be reaching oral health as an equitable body health but to put the mouth back into the body and get every diabetic into a dental home in today's delivery model. And this is the controversy. And the point is this is why I think we're at a very crucial moment for this profession, for oral health in America is because kind of the system has delivered as much as it's going to deliver the way it's been designed. It works pretty well for middle-to-upper income adults and seniors and most children. The rest fall through the cracks. The system works pretty well for dentists and dental care providers. Good income, lots of interest in the profession, et cetera. But if we want to go to that next level, for example, what would it take for every newly diagnosed person with diabetes to be referred automatically for an oral health screening? What would that take? That's the kind of questions, if we're serious, that takes a lot. It takes getting that script on the primary care physician or nurse practitioner's worksheet, right? That's not happening right now. What do you do then to refer somebody? The systems don't talk to each other, right? You go to first screening to your internist or something, they're like, okay, go get this exam, go see the cardiologist, here's the cardiologist script, go book the appointment on your way out. Boom. Doesn't happen like that in dental because it's a separate system, separate payment model, separate delivery model, separate IT systems, et cetera. So that's the uncomfortable debate or that's where I feel we need to talk about as a profession, like what is the vision? If the vision is that, it comes with a lot of change and it comes with a lot of uncomfortable change. Again, and please, I'm not saying do X or do Y, I'm posing the question because we're at a point where these questions need to be answered. So Bruce and Ira are going to talk a bit more about the nuts and bolts of that. What I think is very interesting and I want to, because I'm talking to providers, I wanted to show you why I think on the provider side, a lot of things are changing to potentially make dentists more open to these different types of delivery models. And here it is. We have a big generational turnover happening among dentists. With baby boomer cohort dentists slowly exiting the market and a lot more millennial and soon Gen Z dentists coming into the market. So not to go back to our high school statistics, but this is a bell curve of the age distribution of dentists 20 years ago. I promise you this statistics will give us insights. What do you see? It's pretty smooth, right? We had a lot of dentists 20 years ago who were in their 40s and we didn't have many in their 30s and we didn't have many in their 60s at all. So there was like an average dentist. It was a he, it was white solo practice in their 40s. What's changed dramatically is how this looks five years ago. Look at this. By 2017 we no longer see that smooth bell curve shape that we got used to in high school statistics. We see like a bimodal distribution if you're wonky or bat ears if you're into biology or two groups of dentists emerging. All of a sudden we have a lot of dentists in their 30s five years ago, a lot. And we have a lot in their 60s, right? Well those a lot in their 60s were those that were 40s 20 years ago, right? That's that big surge of training that happened in the 80s and they're moving in the system, right? Why do we have so many dentists now in their 30s? Why? Turn to you, shout out. Where did all the... Okay, so there's 70 dental schools today, right? Dental school enrollment is really increased significantly. So we don't train providers in this country with a slow drip of the faucet, right? It comes in surges. So there were surges in the 80s then dental schools closed. Surges in the 2000s and more surges. So why am I showing you this? I'm showing you this because like many things in America the average today is not that important, right? They have kind of two groups here of providers moving through the system. We have a large group of that baby boomer cohort. And again, trained differently, wanting to be solo practice, many in solo practice. Again, the race and gender data are very stark. 56% of the income in class last fall was women in dental school. It's not even 50-50. It's 56-44. So that's a significant change, right? You heard earlier, practice models are changing. The group on the left is much more in groups, less ownership, more in DSOs. So there's a whole practice model evolution. So what I'm interested in is as this advances to today, so just look at this five-year change. Baby boomer dentist numbers fall and we continue to see increases in the millennial generation of dentists. So what's happening now? This is what I mean by this generational turnover, right? In the next five years, most of that group on the right will have retired, right? And we're going to be in a situation where the workforce is much younger, predominantly female, predominantly in models that are different than today. And so my question becomes, is this one of the things that may spur on more of this medical dental integration? I don't know. I don't sit in dental schools. I research young dentists a lot. But the question I want to ask the panel is, do you think a 27-year-old dentist today or somebody just going into dental school today is open to working in a large organization that collaborates with primary care or Walgreens or the Walmarts or the Kaiser Permanentes of the world? Or are we still bringing people into this profession who don't want that? They want to be separate quote-unquote from medicine because we cannot have this both ways. So I'm going to end just with these three questions because I really think that the trends to me suggest were at an important, whatever you want to call it, inflection point or a fork in the road to borrow Robert Frost's analogy. I think these are questions, not that are just interesting anymore, but somebody needs to answer them because the profession right now I feel does not have a clear vision for the next 30 years. Are we okay with the way delivery and financing is working today? And if you say yes to that, then don't say, I also want to get millions of more people into dental homes and I want every diabetic referred into a dentist. You cannot have it both ways. Or do we want to say, it's time for the profession to have a different vision. Maybe we want to be more collaborative with the primary care system. Do I want CVS to automatically, when they fill medications for heart disease, diabetes, pregnancy care, boom, something pops up and says, have you had a dental screening? And if the answer is no, here's a tool that helps you actually find that. And then what do you do with the payment model? For example, it's great that we talk about mouth-body connection, but the vast majority of seniors don't have any coverage for dental. So to ask them to just pay out a pocket for a dental screening because they got newly diagnosed with diabetes or something, I don't think that's feasible in today's world anymore. But anyway, I'll leave you with this. So question one, I think is honestly, do you want to get millions of more Americans into dental home? The 20-year trend suggests for adults and seniors, we're not doing much, right? Do we really think dentistry is essential health care? Or do we use that essential when it's kind of convenient, like in a pandemic to get PPE? Make sure we're essential so we're on the list. But when it comes to Medicare and dental, maybe we have a different view of what essential care is. Or Obamacare. Obamacare was a codification of essential services in the law. And adult and dental, a dental for adults and seniors was not put in that, right? So those are the kinds of things I talk about. I mean when I say essential. I don't mean, Marco, do you think dentistry is essential? Of course I do. I can't be healthy without a healthy mouth. But health policy does not say dentistry is essential other than for kids. It's very clear, right? There's optional benefits in Medicaid. Medicare Advantage is a crazy Wild West in terms of plans having one cleaning versus four cleanings versus covering nothing. You get where I'm going. So do we really think this is an essential service or is it something more discretionary? I prefer you pay out of pocket. I don't want to deal with insurance. That's a different vision. Again, both are valid and both can, I mean, I'm not judging anything here. Again, I'm just laying out the questions. And then the third is really about this walking the talk, so to speak, right? Again, mouth connected to body is a great tagline. But to truly, truly move the system so that medical providers live this. Pay or community lives this. Diabetes, oh, boom, automatically a dental screening is paid for in your medical insurance plan. That's something I'm talking about, right? So I don't have those answers. It's not for me to answer those. But again, I just thought given where the trends are going, I feel leaders in dentistry, you're part of that group. ADA, we talk about this a lot. I know there's a couple of former presidents here too can chime in. They're not easy questions to answer. But the reason why I put those distributions up is, I don't know, it's a reflection. Is it maybe a moment in time where there's so much change among the clinician community and the generational shift among dentists themselves that maybe the viewpoints to these questions may not be the same for like a 27-year-old dentist versus a 67-year-old dentist? I don't know. But hopefully we get a chance to talk more about these. And while the next person comes up, just because I want to take advantage, you can get in touch with me here if you want to follow up. So thank you. That's all. Great. Well, good morning. Before my slides come up, let me also thank the American College for inviting me in to be a panel participant with my colleagues, Marco Bujasek and Bruce Donoff. And I think that the topic today represents, I think, one of the most important questions we must ask ourselves as we look to the future. This is a topic that I thought a great deal about, but I've looked at it always from the financial perspective. How do we reimburse? I've looked at it from the health or oral health perspective. But when the college asked the question, is this an ethical question? To me, I think that was a different way of looking at it. So I'm going to answer that question with my second slide and then provide you with what I refer to as a quantitative rationale for why we should be thinking this way. So this is not see every coop. This is Irel Amster's statement about the question. I said a fully engaged healthcare professional or fully engaged healthcare professionals are concerned with the health and well-being of patients. Dental professionals are in an ideal position to contribute to improving the general health and oral health of their patients. So we have a healthcare-seeking population in a healthcare environment. This is an opportunity that should not be dismissed and should not be missed. When you talk about medical integration and Marco touched on a number of these points, there's a number of ways you have to look at this. And I've listed just a couple of them here. There's changes to the dental education paradigm. We can't expect a new practice paradigm unless we begin to educate our students now as to what this means. Is it just talking about the co-location of medical and dental care? The FQHCs, I think, have done this effectively. But there's questions as to how real is the actual integration. And something that I'm going to really be talking about in greater detail today, and that's primary care activities in the dental office. So let me just give you some population data. This is data from 2019 from the medical expenditure analysis that the federal government does periodically. And this is the number of persons who have a medical or dental visit. And as you can see, 29.5 million individuals, almost 30 million people in 2019 had a dental visit but did not have a medical visit. In addition to that, 120, a little more than 120 million people had both a dental and medical visit, meaning that essentially about half the population see a dentist. These are adults who see a dentist. Then, of course, there are individuals who see none or who just see a medical provider. So again, the opportunity to reach 50% of the adult population, again, the data as current is available, again, is imposing. Here again, from a general perspective, what are the potential screening opportunities that can move forward in the dental office? Well, there's the low-hanging fruit, hypertension screening. We've been talking about that as a profession for probably 75 years now, HPV vaccination education, tobacco screening, certainly diabetes assessment, et cetera. And then there are other, many other, many other types of procedures that have been proposed. Some of them will directly impact the delivery of dental care. Some will not. But still, a value to the patients. So what I decided to do today is provide you what I refer to as quantitative rationale. What does the data say in terms of the potential value of integrating medicine and dentistry in the truest sense? So I'm going to talk to you about three parts of this question, all of which, all of this data I've been involved in for the last 25 years, maybe even longer than that. My focus is going to be on diabetes Melanus and Marco alluded to that in his presentation. The first is, can we identify undiagnosed dysglycemia in the dental office? Now, there have been a number of studies that have looked at this. We've participated in one. And I'm going to show you just some of the data from that study that was performed at Columbia University in Northern Manhattan, a primarily Hispanic community. So our aim was really quite simple. It stated here to develop and evaluate a targeted screening protocol for undiagnosed dysglycemia. And this includes both diabetes and pre-diabetes in patients preventing to a dental clinic who were there for dental services. They did not come to be screened or to be evaluated for medical condition or diabetes medical. So here's the rationale. And there are six points. There's an increasing prevalence of diabetes in the U.S. and currently 23% of the adult population would classify as having diabetes. A significantly larger percentage of the population would actually be diagnosed with pre-diabetes in this interim between normal blood sugar levels in blood and true diabetes. And the importance of pre-diabetes is that oftentimes it is reversible for the appropriate treatment and sometimes treatment could be as simple as lifestyle changes. The complications of diabetes are very significant in terms of both morbidity and mortality. You're familiar with these. Retinopathy, nephropathy, cardiovascular disease, nephropathy and poor wound healing. And the cost to the U.S. healthcare system in terms of treating these patients is well over $200 billion a year. Third point, we do know that early diagnosis of diabetes mellitus with treatment will lead to reduction in complications. So the quality of life issues in addition to all the other advantages how patients will benefit I think is enormous. We know that patients with diabetes mellitus have oral complications and many of them I think a total of 11 different complications have been identified. Some of them you're quite familiar with, of course they're common these include an increase in periodontal disease dry mouth, burning mouth syndrome candida infection complications of implants et cetera. Oral complications of DM occur early. We did a study looking at young individuals in our community children and adolescents who had type 2 diabetes we found that changes in the gingiva inflammatory changes, loss of attachment actually preceded nephropathy and lastly we know that successful care for patients with DM requires good metabolic control. If you treat, a patient presents who has diabetes mellitus and has periodontal disease, you treat the periodontal disease you don't really address the metabolic control your care will not be successful. So we did a study ultimately the study involved 1200 people and I'm going to delve into data but bear with me. I'm just going to show you the first part of the study, it was very basic these were patients who presented to the dental clinic at Columbia for dental services and the criteria for asking them if they wanted to be in the study, was that if you had to be at least 40 years old if you were non-Hispanic white or over 30 years old if you were Hispanic or non-white because the risk factors for diabetes in Hispanics and non-whites is higher at an earlier age and they had to have never been told never were told that they had diabetes and they agreed to participate they had to answer one of these questions in the affirmative do you have a family history of diabetes do you personally have hypertension high cholesterol or overweight and obesity and they had to agree to continue in the study and let me just go back one second the study included a periodontal examination but it also included a point of care HBA1C like KD Hemoglobin test at the same time that they had their dental examination but the gold standard for diabetes at this time was fasting plasma glucose they had to come back the next day the next morning for fasting plasma glucose now the first bit of data from this study that really surprised us was that 95% of those people who qualified 95% came back the next day for the fasting plasma glucose which is a blood drug which is much higher than we expected and to summarize the findings that 4.2% of this group of 506 individuals were in the diabetes range by fasting plasma glucose and 31.8% were in the pre-diabetes range so we asked the question the return on investment here the cost-benefit ratio was not that favorable but the percentage of the individuals who were in this category of these two categories we wanted to identify so then we started looking at the dental data and we said what are the criteria in an oral examination which might improve our yield so we settled on the percent of teeth with sites greater than or equal to 5mm probing depth that is and the number of missing teeth would here happen to be 4 and we were able to adjust the cutoff value with appropriate cutoffs we were able to adjust the yield to between 73 and 92% in terms of identification of people who are in one of these two categories I'm not going to go into this in any great detail but let's just take a look at the first column sensitivity which is a statistical measure of the true positives in the population and you can see all the way to the left the certain criteria whether it was dental criteria plus this point of care HBA1C measure or just the point of care HBA1C you can see the sensitivities range between 73 and 92% so using relatively simple screening tools a finger stick test in the dental office dental examinations which we're doing anyway we were able to pick up between 73 and 92% of those that were in the dysglycemic range we then said to ourselves we're not making a diagnosis here let's make that very clear what we're identifying people who are at risk again the gold standard here being this fasting plasma glucose the next morning so we had enough funds to conduct a small referral pilot we wanted to see if we could deliver a message to patients telling them what we found and telling them they needed to go see a medical provider so we looked at just about 100 patients and there were two groups one just had what we called the regular follow up which means we gave them a letter saying this is what we found please go see a physician or a medical provider the other group which we called the intensive group we did the same thing but then we followed it up with phone calls over the next couple of weeks if you look at the percentage of the number that returned 6 months later because we called them back 6 months later 73 of the 101 actually returned that's a very high yield in this population it's a much larger number than we expected to come back we asked what percentage of these individuals saw a physician or a medical provider and it was 60% so 73% came back or 73% of 101 came back 60% of 101 or 59% 60% actually had followed up and taken our advice to see a medical provider between the intensive and regular follow up groups and the percentage that went tested that was I think pretty impressive to have 60% of the individuals who we told you had some sort of of a concern some sort of a medical issue you had a follow up listen to us and then follow it up with a provider and then came back to see us so what were the key clinical outcomes from this study again 73 of 101 subjects returned at 6 months almost 60% reported having seen a physician almost 50% reported at least one positive lifestyle change so again for pre-diabetes the idea of exercise, weight loss, etc really is the first line of therapy and for those participants with DM there were relatively few only 7 so this is certainly not definitive we found that the reduction between what we determined initially and what we saw at 6 months the average reduction in HBAC was 1.46% now remember HBAC is measured on a scale that goes from about 4 or 5 to maybe 12 or 13 so a reduction of 1.5 units 1.5% is very very significant second point conservative periodontal treatment is associated with reduced glycated hemoglobin let me point out and I think most of you know glycated hemoglobin represents perhaps the most valuable monitoring tool monitoring assessment in terms of the management of the person with diabetes over their life course this is looked at by what's referred to as the Cochrane Library or Cochrane Collaborative and what this is is an organization that tries to in a very rigorous way look at the data that asks a particular question here's the treatment and here's the outcome what are the results and the studies are conducted differently so they have certain criteria for admitting one of the published studies into their analysis and then they try to make a hole out of these disparate parts this was the most recent review and it was published in 2022 let me point out this is the third review that the group has done on this question the third review here were the findings they used 35 studies again this has been done this analysis has been done across the globe mostly type 2 patients and a little over 3,000 patients were included they looked at only randomized controlled trials did you have cases, did you have controls were they treated the same way etc and the follow up was 3 to 12 months and what they found was that the reduction following conservative periodontal therapy in patients who had relatively high levels of HPA1C was a 0.43 to 0.5 reduction in HPA1C clinically significant and statistically significant and here is a direct quote from that paper again this third cockpit review we now have moderate certainty that periodontal treatment using sub-digital instrumentation improves glycemic control in patients with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual treatment that's a pretty powerful statement second further trials and this is really the key evaluating periodontal treatment versus no treatment are unlikely to change the overall conclusion of this review the third time they did this and they were able to make that statement the first two times they did the review in earlier years simply they felt was not enough data to draw a valid conclusion now they felt there was so that's the second point and here's the third and this is perhaps the most controversial of all conservative periodontal treatment is associated with improved health outcomes reduced utilization and lower costs and again they're probably now about 9 or 10 studies that have looked at this the majority from the United States but also from Germany, the Netherlands etc so this is a study that we published in 2001 and it just prompts me to tell you a little bit about the study itself what was beautiful about the Medicaid program in New York State is number one it had dental data and it also had medical data and the dental coverage in Medicaid in New York State is probably the most robust for adults of any state in the country and we had all of this data together now we were particularly interested in the people over 65 but this population was only between 42 and 64 because the medical and dental data were together we looked at people over 65 the medical data really was in the Medicare database which we did not have direct access to it was a three year evaluation and we looked at people who were continuously enrolled for three years and the first two years what kind of dental treatment did they have or how much dental care did they have and the third year we looked at their medical outcomes and I guess the most important point from this is the total number of cases or lives that we had in this study was 550,000 over close to half a million individuals were included in this study it's an amazing, amazing database so we published that first study was in the entire cohort and then we looked at a sub-cohort and these were only the people who had diabetes maladies because again those are the individuals who are that's the situation that we feel best represents the importance of medical dental integration so I'm going to show you this data it's a little bit hard to read and I'm just here going to show you some cost data and I'll ask you to focus on the second set of information so we grouped the individuals into did you have any dental care did you see a dentist for any reason emergency cleaning exam did you have any preventive care which is either maintenance or scaling and root planing did you have preventive care but did not have an endodontic endodontic therapy or oral surgery, tooth removal because that was our surrogate for a person who had a significant oral infection preventative care with extraction or endodontics and the last group had an extraction or endodontic therapy but no preventive care and if you could look at the numbers just to the right of that you can see that the savings for all groups except the last one were significant and in parentheses is the 95% confidence interval and as long as it doesn't cross one it's statistically significant so what we saw that it was there were significant savings in terms of medical costs if a patient had access to preventive dental care what I did not show you is data we have on in terms of the dose response effect the New York State Medicaid program allows two of these cleaning visits per year so we looked at over the course of two years did you have one did you have two did you have three and we saw this stepwise progression the more visits you had the better the outcomes were the more the cost savings were and that was also true for utilization it was also further down most of the savings were in inpatient admissions which as we know in the treatment of people who have chronic diseases it's the inpatient costs that drive about 70% of the total expenditure so let me conclude by summarizing these three parts of the case I'm trying to make using simple screening tools patients with undiagnosed dysglycemia can be identified in the dental office again we're not making a diagnosis we're identifying risk we're then referring to a medical one of our medical colleagues to make the diagnosis point number two preventive dental care treatment is associated with clinically significant reductions an important risk factor for complications of diabetes melodies and we've had cases and there aren't enough really to report formally in which patients who are not seeing a physician were being managed medically but were not seeing the results that they would have expected who then had this conservative therapy in fact did then see better control as indicated by HBONC and lastly and this is again these are controversial studies but I think particularly important preventive dental care conservative panel treatment is associated with improved health outcomes this is not a simple topic I recognize that I think we all do the data is I think convincing and what I've hoped to do this morning is really provide you with a quantitative rationale there are ethical rationales there are moral rationales but this data and I think we have to identify ultimately on data says this is an opportunity that we're missing so thank you good morning I'm Bruce Donoff I've been a member of the American College of Dentists for far too many years and the last time I was at a national meeting was in San Francisco with Mike Alfano and Marjorie Jeff Coat to induce a friend from NYU but I'm very pleased to be here because medical dental integration whether it be the ethics side or the education side is one of my passions so in 1982 I had just become a professor at Harvard I had just become head of the department I had just become chief of the service of master general hospital but I always saw patients and I went down to see a patient who I had seen before he needed a tooth out and I had no trouble taking the tooth out before but he put his hand up and he said doc put on gloves I said what do you mean he said I just came back from Seattle where I had a bone marrow transplant and developed graft versus house disease and I have something called AIDS I put on gloves and so did all of you in 1982 and we still wear them an event like that can change things and it doesn't always have to be a disease implicated event but it can be an educational event so we should remember that my talk is entitled redesigning and improving health care integrating oral and medical research and practice and the reason I have research on this is I've been serving on an NIDCR working group that's looking at issues in terms of applicants for research grants and applicants for PhD programs there's a wonderful book called innovation and its enemies and the question is with everything that's going on in the profession in terms of maintaining the status quo can we create medical dental champions for change I think last year this group heard from one of my colleagues Dr. Lisa Simon who was on this program through the dental school and the medical school and is now joining the internal medicine and primary care staff at the Brigham and Women's Hospital these are the kind of people who can become champions and I'll explain why so let me discuss some of the history of this as soon as I figure this out so there's been huge changes in the scope of dental practice I often think where would we be if implants didn't come around interestingly I did my first dental implant in 1982 but in those days I had to go take a weeks course with a whole group from Sweden and we marked down every implant that we did to keep a log of all of that and that's gone by the wayside not to say that implantology isn't important but I think what I'd like to emphasize is oral health and primary care change versus continuity innovation versus incumbency a little disruptive innovation is a theory of a good friend of mine who's passed away at the business school, Clay Christensen who believes that lots of innovations start low and have a small cadre of participants and I think that's the way that oral health and primary care is going to start but on occasion we have a catalytic mechanism and I like catalytic mechanisms too because they really change things fast a brief history just so we remember where we are what if the Baltimore College of Dentistry had been accepted by the University of Maryland we wouldn't be here the Harvard dental school started in 1867 I was in the centennial class in the 80's five dental schools closed why? Well I knew a couple a very good one, Wash U in St. Louis and the main reason it closed is because the medical faculty wanted the space believe it or not and they had their way but then Arizona and Jack Duhlenberg entered the fray and public health became an important part of our profession but most of the new schools have been predominantly osteopathic associated schools and there have been few true university based dental schools there have been attempts in medical dental education integration the Geyser report said that dentistry should always be aligned but separate from medicine what if Alfred Ory had his way and not William Geys in the 1930's at Dean Wintelitz Yale Medical School started an MD program for dentists at Yale and just a few of the people who went through that Burkitt Cressover and Weisberger did some amazing things lest the Burkitt started the whole field of oral medicine Sy Cressover was head of the NIH for a number of years in 1940 Harvard undertook an experiment giving dual degrees it was interrupted by the war and so never came to fruition and in 1971 a program that I'm a product of the Harvard MGH oral and maxillofacial surgery program came about because it was felt by leadership at that time Walter Garelnik and Jerry Austin that an MD would allow general surgery to be taken at the correct level of responsibility there have been a number of reports of importance lots of reports lots of words we need action, the Geys report inflects the report dental education, the crossroads in 1995 a wonderful study from the Institute of Medicine read by 8% of dentists the 21st century Geys report by Edea in 2017 and most recently follow up to the Sachs Oral Health report Oral Health in America 2021 hundreds of words hundreds of words and not a lot of action items sitting on this NIH working group there are a number of priorities at the NIDCR to integrate oral and general health more precise and individualized treatment translate and implement science diverse research pipeline and partner and collaborate but fewer and fewer people in our profession are going into science and it's worrisome why don't we have a medical treatment for periodontal disease after all these years no one is one, only one person surgical personality is one a Nobel Prize Joe Murray for kidney transplants everything else relates to medicine and intricacies of the body's systems changes hard a tool Gawande and noted author and also a physician talks about slow ideas ether anesthesia when it was introduced in the early 1800s was adopted very quickly why although it was mainly used for amputations that was the main operation at the time because it helped the doctor asepsis list as contribution took many many years to catch on because it was hard work for people to implement aseptic technique real change as mentioned by linsky adaptive versus technical change adaptive change changes the culture it really causes change it's not just a technical change and it always involves a loss for someone that's the problem so two stories from 1973 just because I like to tell stories in 1973 there was a great race named secretariat he won the Kentucky derby then he won the pretenace steaks and then he stopped training well he used to consume 23 bales of hay he went down to one and no one knew why until the vet came to see him he had an abscess tooth the tooth was drained and he won the Belmont steaks by 23 and a half furlongs so oral health counts the unfortunate patient was when I was back in medical school at a particular hospital they used to call on me for oral consults even though I was a medical student because physicians don't look in the mouth and they still don't a patient with a fever of 106 almost comatose no source of infection abscess third molar crazy it was the first malpractice case in Massachusetts and I remember the Lubin and Maya were the attorneys they became very famous as malpractice attorneys and after the case they said doc you were great what can we do for you can we get you a bottle of wine I think things have changed the Jupiter trial the statins that I bet you a lot of people take statins here ok involved 173,000 patients and there was not one dentist in the study sad and he has a student conference on learning science and patient care very but I know Marco has presented some data on an ADA survey but I'm not sure that still holds I wrote a long time ago it's time for a new guys report in 2008 and I think that's true and in 2016 along with several people Dr. McDonough and others in the New England Journal we talked about integrating oral and general health with payment systems and education this was a Alan Formacola and Howard Baylitz attempt the 21st century guys report but we have implicated an oral health project where primary care and dental services are integrated at the present time it involves a nurse practitioner but it involves students and dental patients who don't have primary care physicians are welcome to join this practice so lots of things are possible the paper on the right oral health care in the 21st century the paper I wrote with George Daley who's still the dean of the medical school talking about the potential to add an MD program to people going into primary care not oral surgery and some schools are trying it you mass is trying it and Harvard is still trying to do it and someday we will oral health care for all was a summary report of the recent NIDCR report on oral health that some of you have seen I bet you didn't read it it's multiple pages but the more important piece on this is behind health robbing elements inflammation periodontal disease is not mentioned once in this New York Times article and that's one of the problems we face so what are the options for change well the NIH has already transformed the PBRN to prime end we can change the practice acts not easy we can add into professional education and practice when there's practitioners we can change dental education not easy we can do give dual degrees in residency in family medicine or primary care possible we can give a DMDMD dental school to medical school or DMDMD medical school to dental school something with we're experimenting with UMass medical school so there are a number of options you just have to be willing to try listening to ira talk about diabetes I'll never forget being in a meeting in Washington DC and it was a meeting like this but the American Diabetes Association was meeting down the hall and I spent one day at the American Diabetes Association they did not mention oral health once so it's where you stand we need to the practice of the future needs to be teams we have the cleft palate teams we've shown that it works with integrated care integrated financing and true into professional practice most of what we're doing does not work we need to be like Walmart not like Best Buy and other specialty stores very much like he used to always go to a gas station for gas and a convenience store for food or drink you now can get them both in one place and that's what we need to do in oral health and primary care lots of reports lots of words I'm not going to spend a lot of time on them but in fact the pandemic may have given us a chance to do something like the glove story that I started this talk with the alliance between medicine and dentistry is more important now than ever it signals a commitment to science I do not think that the status quo is inevitable and I promise not to die before I do something about it thank you La Cascada declaration from South America talks about dual education if you haven't seen it it's an excellent document we formed the Harvard initiative integration and the center for primary integration of primary care and our job is to produce champions for this and everybody can contribute we started a leadership series for this and the initiative for integration of medicine and oral health has a yearly conference it's now run by Jane Barrow at our institution and this is our world you see up in the left the IOM report dental education at the crossroads the academic colors of medicine and dentistry together in fact one of the options was a dual degree for advancing our profession the guys report in the middle the innovators dilemma which was Clay Christensen's first attempt to talk about disruptive innovation blue ocean strategy is wrinkling brothers and Barnum and Bailey circus doesn't exist anymore the circus away does and my favorite the Oreo package that you just pull and it opens with one full swipe so you can get to the cookies quick so here is the Harvard the initiative for integrating oral health and medicine and SIPCO which was grant funded and this is a quote from one of my favorite people Lewis Menand the marketplace of ideas the key to reform of almost any kind in higher education lies not in the way that knowledge is produced it lies in the way that the producers of knowledge are produced and the little insert is a paper that Lisa Simon and I wrote as an editorial in our journal last spring and it's worth reading I think thank you very much thank you Dr. Donoff what wonderful presentations from all three of our speakers thank you so much so we have a few questions for you all Dr. Tomar hasn't had a chance to say anything with his mic turn it on there you are thank you all for wonderful presentations I wonder if I could kick it off with some questions actually I'll start with with you Marco so we know that getting the medical community interested in oral health is just so hard I certainly hear from colleagues that are physicians, nurses PAs, nurse practitioners that they already have so much on their checklist that they have to cover during a patient visit what needs to change to get the medical community truly committed to incorporating oral health into primary care look fundamentally you need to get oral health on these checklists on these care protocols so you think of a medical system this is not Bruce practices this way, Ira practices this way there's much more of that standardization of care so the question is how would I get referral to an oral screening on the checklist for I just diagnosed you with diabetes so that and chime in guys but that requires US preventive services task force different agencies that regulate to have that kind of mandate come down so fundamentally a lot of this requires advocacy from the oral health community right to do this and bluntly I don't know where this stands in all the priorities there's lots of priorities for lobbying right there's fixed dental insurance and XYZ and all that so I'm fundamentally convinced there is an opening here to do this we just need to get on the same page and make this a priority and if we don't have the evidence to convince those authorities then let's generate that evidence I don't agree I think we do have the evidence but it's fundamentally just a sea change in vision for the profession like that's the big thing and then the tactics we can work on but I don't know how many dentists are like yes that's priority number one honestly given all the things that are happening of course I would add that I think more than a quarter of the general health practice in our country is administered by non physicians yes that just came out and nurse practitioners and yet dental therapists remain a great source of contention despite the fact that orthodontists thrive by having multiple assistants in their office who could help we need to talk about that so there's been attempts to do what you are suggesting they've been targeted specific and limited so maybe if the college is going to do this as a year-long study they could then begin to plan for how do we bring all of the entities together in a single voice or single front to approach those that need to hear this we've tried it individually at Columbia we found we first wanted to get some dental lectures into the medical school curriculum and we did we got 6 hours or 8 hours I mean it means nothing in terms of the long term training so what we decided to do is to focus on students for example as we started to focus on those programs, medical training programs such as the endocrinology such as OBGYN where these issues really are very much that are for, we're not successful with cardiology but we did have on again on a limited basis we did have some success in terms of showing the data and I think that's why I focused on this I think you have to have the quantitative data you have to have the data in order to develop the rationale for the opportunity over the next year as you begin to do this to begin to marshal the resources and bring people together so we are not individuals with a light and the darkness but really something much more substantial next week the American College of Surgeons is meeting in Boston and I'm going to stop by, I'm a member but when the dual degree oral surgery program started the American College of Surgeons accepted only dual degree oral surgeons but that changed they formed the section and now single degree oral and max facial surgeons eligible so those kinds of possibilities exist for Ira if we did adopt a new paradigm in dental education how would that be addressed do you think? how do we move that forward? well that's a tremendous challenge as you know so I'm going to say something that probably many people in this room won't agree with it's impossible to educate a fully formed dental provider in four years there simply is too much information both didactic information and clinical experiences that are necessary as you know in New York State I think we had some partial success on that one but I think the it's going to unfortunately probably have to start with the council on dental accreditation because if it's in the requirements for accreditation it'll be done and I think there has to be specifically written as to what we're intending or what we think should be done in order to prepare our young dentists for the future we have to have to start that way because other than that 70 dental schools are all going to teach what encodes as basic sciences differently and with lesser and greater focus so Bruce you had talked about the center for integration of medical and dental care established at Harvard if we were to do that on a national scale who would be the lead for that NIDCR who would potentially spearhead that well you know when Hal Slavkin became director of the NIDR at that time National Institutes of Dental Research he lobbied and changed the name to National Institutes of Dental and Craniofacial Research so it's possible to change the name of that institute to include the notion and the ideas of integration so that's one place I think the other thing is to create a freestanding center for integration and invite people to join the ADA, the AMA the A-D-E-A double AMC these are the groups that should get together so physicians and dentists are talking to each other but possible why not I was at the inauguration of the New Harvard president last week and she kept saying why no why not for Marco what do you think it will take for the medical dental integration to move faster and do you anticipate any accelerating factors in the near future that might push you forward? I thought about this a lot definitely I have your question again the reason why I showed this generational turnover concepts among the provider community among dentists is I do fundamentally believe and the data support this when you look at surveys of fourth year dental students there is a change in terms of openness to collaboration outside of dental street getting outside the silo part of that is because we've been training them for a long time we've been taking care of dental services and physicians so I definitely think that's one of the tailwinds that's happening I think younger dentists this will come across the wrong way but there is less baggage there isn't a status quo they are looking at and dying to preserve I am trained I am going in and I will see what my options are but I do want to come back and for us as a profession I say us even though I am not a clinician but I don't see a true north here I don't see a 30 year strategy on what we want to become it's kind of like react to change as it comes up and I look at behavioral health as a complete counter example right 20 years ago that community said no more backwater mental health is core health it's all those statements that were on the screen can't be healthy without mental health but look where they've come in 20 years like think about where you or your children or your grandchildren are screened for mental health and anxiety like it's on every form I roll my kids in sports camps it's like have you felt down have you felt anxiety it's a completely different paradigm it's codified in the affordable characters think about who covers now therapy sessions and anxiety prescription medication that wasn't like that 20 years ago because that community said that's our true north we want to expand access to these services it's a challenge for us and I'd like to hear questions what is our true north like what do we want different tomorrow and is this integration part of that as a profession or is it like no we want everything to stay as it is and we'll kind of react to change as it comes very very different and those are not easy discussions I don't mean to be flipping about it but they're very hard and it's about the core identity of who you are as a profession and that's not easy let me go back to this year-long program that you're going to be beginning the most important thing is it should not result in another thick report that sits on a desk or sits in a bookshelf and it gets no daylight after that there must be a roadmap created as to how to move forward who are the potential partners who is going to be contacting those partners can they be part of the process let's say after maybe the second half of the year to actually engage them in this because what's worked what's happened in the past simply has not worked and it's got to be really action oriented as a follow up who do you see as the primary stakeholders that need to be at the table well we we've had limited success in talking to the endocrinologist we had great success talking to the diabetes educators you know they're not the top of the pyramid not the top of the food chain but they still are the ones who manage patients on a day-to-day and week-to-week basis so again it has to be selective and it has to be identified based on who sees contact we found when we dealt with individual residency programs or fellowship programs at Columbia we got great buy-in great buy-in but it was one-to-one and the credibility had been established before we we went in so again it's a question of maybe a document sort of laying the case out and then the action items I would recommend family medicine we've had great success dealing with family medicine departments particularly at UMass and at Brown and now at Dartmouth-Hitchcock all very good medical schools that don't have medical dental schools which is another consideration so shifting a little bit to creating the next generation of rural health care professionals we saw some of the data on the demographic trends but you know for those of us that have spent much of our careers in dental academia and certainly I know there's many dental educators in the audience dental school curricula are just notoriously crowded it's really really difficult to change what advice can you offer to long-established dental schools what how they can foster greater medical dental integration into their pre-doctoral dental programs is that a constraint though I mean I don't you've all sat in dental schools do you feel that's the constraint though that some awareness is missing or some I don't know how to do an A1C test or I don't know because to me it's like when I look at let's say this referral model right it's like the constraints are in what's covered in terms of dentistry has a lot of things that's not covered like Medicare and even insurance plans for dental don't cover everything so there's that as a constraint and then there's the literally the nuts and bolts of how do you do a referral system that's closed like I don't maybe I'm wrong but I don't see the education method to be a constraint for dentists to participate more closely with with medicine but is it I don't know you guys all sit in schools with dental education or at least in some form exists now in every most dental schools I'm sure it'll eventually be all dental schools but the question is there's a busyness factor supposedly there's a busyness factor dentists are complaining they're not as busy as they could be if we teach how to talk to our colleagues in medicine, in nursing in PAs what have you the idea that you establish a collaboration with another provider a group of providers in your town I think there's an incentive there in terms of just generating patients and maybe that's how we have to begin one of the things that happened to me when I was in limited practice is I ended up in conversation with local endocrinologists because I was seeing their patients that led to a further discussion and then patients started to flow not in great numbers but started to flow from their offices to mine and then of course from my offices to there so it's a grassroots effort but that sort of thing can be encouraged in dental schools and I think we'll begin to convince both sides that this is worthwhile and in professional education is one of the COTA standards so that is one of the things that we are needing to do yeah but so is research you know if you want a COTA standard you say COTA say it dental schools should force the research boom there it is it's a it's not the greatest system in my opinion what are their teeth are their teeth in that standard and I don't think there are I think when I first became dean I'm a storyteller so I'll tell another one I assembled all the executive directors and presidents of dental societies in New England and asked them their thoughts about a mandatory internship here for dental graduates which doesn't exist it's immediately put off as a fifth year of dental school which it's not okay and I'll never forget meeting at the school with these people great people who I knew well and you don't need that I spent two years in the army after dental school it was the greatest two years of my life I spent three years in the air for so they did it the first dental internship in Vermont is being established this year there is none can you along kind of those same lines can you share examples of healthcare systems or organizations that have successfully incorporated medical dental care models well Harvard was always based on it the dental students are in medical school the first year and a half and they still turned out being pretty good dentists although I do hold the world record for the fewest number of blue wax carved teeth in Harvard history one because I didn't see any reason for carving blue wax when you could take care of patients but UCLA UConn I just saw a graduate who is now in UConn I don't know if she's here today Stony Brook Howard Oaks was the founding dean all followed that system and it seemed to work I'm not sure it's working as well now but that's a system that can work and on this in practice this is what's exciting I would call it meaningful experimentation and solutions at small scale so there's lots of clinics that collaborate there's lots of practices in my town I have relationships with the pediatricians there's lots of this what the challenge is is I have not seen anything at scale until what recently happened in Oregon so Oregon the Medicaid population is managed in ACOs we call them CCOs but accountable care organization so think of it as you manage a population and it's not like capitation in the 80s a lot of those problems have been solved but as far as I know they're the only large scale health system where part of their 20 scorecard measures is the percent of newly diagnosed diabetics who had a dental screening within 12 months so that to me is that's meaningful that is statewide it's the whole Medicaid adult population and it's an actual quality metric that the organization is evaluated on so that to me is something where like that's been a big development to go from something that's experimentation at small scale to very systems wide I don't know how they did it that'd be a good case study how did it get there it's interesting I sit on a board of a federally qualified health center on Cape Cod and getting ACOs accepted in Massachusetts is not easy although it has a very unique thing that I would recommend to all states the medical society has an oral health committee some of you may have heard Hugh Silk who started this early practitioner great advocate for oral health those are the kind of people that you need at your side so let me is New York going to do this I don't know you add dental benefits to the Medicare program that'll generate it very controversial I understand that but it's something that is long overdue and I think that more than anything else will generate the collaboration that's required but I understand it's not a simple it's not a simple from the CMS side it's not a simple from the organized industry side but it has to be taken up and I think that will be a major push towards this becoming a reality are there any international models we talked about are there other countries where they're much further along medical, dental integration less than you think a lot of the OECD has models that mimic ours here I'm from Canada the national health care system dentistry is just like it is in the US employer provided very small social program but it was interesting I did some work in Malaysia and there when you go for prenatal visits in Malaysia you go, you get barcode scanned on what's getting done for your visit today it's this test, it's this sonogram et cetera and oral health screening is part of that so there's another example where I found, wow, in their whole national health system they're saying pregnant women part of your regular care is a dental screening joint visits are very important some of the federally qualified health centers have been doing joint visits for behavioral health for years and Cambridge Health Alliance one of the hospitals that in the Harvard realm Brian Swan who some of you may know was the first dental director and they had joint medical dental visits and we always called it the oral physician program and it's still going you know I don't know if there are any clinical examples in terms of clinical care but I know what is different in Europe as opposed to the United States is the collaboration between the professional organizations I think is much stronger in Europe than it is here the European Federation of Periodontology for example has terrific relationships with the cardiology group the diabetes group in Europe much stronger than we have here how they've done it is something I don't know the details but it's a way at least of communicating on that level the advantages of collaboration Innsbruck has a joint program for medical and dental students same program except most of them will get their MDs go off into all the maxillations separate again right did you want to open up yes we'd like to open up questions from the audience at this point there's a microphone in the center feel free to to jump in you know Colgate years ago had that statement a moral systemic connection remember that and somehow know they got away from that but that was originally supposed to be exactly what you're saying in terms of recognizing the periodontal problems associated with the medical problems sidebar the American Academy of Pediatric Dentistry and the American Academy of Pediatrics collaborated and said we do not need to have children waiting until years of age to see a pediatric dentist and that's the collaboration that they made as a member of the Medical Academy of Pediatrics and that's the kind of collaboration that could be done with not forget your name in the middle Marco you should be the leader of the collaboration of getting these people together this is an excellent point but I didn't catch your name Lauren Albus Lauren Albus but the important thing there is for the children that became easier because all Medicaid programs must cover children's care at least even pre-ACA but post-ACA pediatric dental was a mandated benefit we have 9% of US kids only that lack dental coverage that's gone down dramatically from 20 years ago where it was 25 right so absolutely 100% agree with children I think though we've had a different approach we've somehow said we're okay with mandatory coverage in all programs for dental care but for adults and kids we haven't as a profession kind of gone there so great point though I think we can learn a lot from the pediatric experience I want to reinforce that well thank you Marco for saying that because I'm a pediatric dentist as well I was the access to chair for Wisconsin back from 8184 I was access to care chairman for the American Dental Association and prevention chair for the American Dental Association when there was a caper council that's a council on access prevention and interprofessional relations that got killed and we were supposed to have our last meeting the day after September 11th and obviously that meeting didn't happen Homeland Security took over and we lost the interprofessional relations part of that council that council had Jaco on it it had the American Hospital Association in it it had the American Medical Association in it and you can name on one after another all the dental facilities etc and we lost that and I think that when I was the access chair I co-wrote the definition of early childhood dental carriers with Admiral Dr. Moss Bill Moss and that was finally adopted by the American Medical Association the House of Delegates right after the year after 9-11 and I just happened to be at the meeting it was no longer in charge of anything and it just so happened I got drafted into the House because a lot of members did not want to come and fly to that meeting and the things that happened with the Surgeon General's Conference didn't happen by accident as he mentioned it took a number of different individuals within the American Academy of Pediatric Dentistry and the American Academy of Pediatrics because in 1988 our current hospital in Green Bay, Wisconsin denied having any ADA brochures in their hospital because the pediatricians felt that children should not have to be seen until age 5 and our brochure at that time said 18 months well I have some Irish and I got the Irish up in me so I ended up becoming very politically active after that so I was able to attend the Surgeon General's Conference and one of the main concerns we had at that conference is there was someone in the CDC that didn't like fluoridation because they had a little burr under their saddle and so we went in and thought we were going to be ambushed as the American Dental Association and I kind of represented Caper at that meeting and as it turned out the American Academy of Pediatrics said 25% of the health care dollar for children should be going to oral health care and on with study after study and they talked about not only children that have good health otherwise but they also talked about children and its effect upon their schools as far as absence from schools children had mental and physical disabilities that's what they called it at the time that was affected too as well so it wasn't a happenstance thing because the council and access and interprofessional relations was heavily involved with that Surgeon General's Conference and so was the American Dental Association and other specialty groups but you know he's right stuff like that doesn't happen by chance sometimes what happens and I would suggest that we get that interprofessional relations council back on board and have people like Marco and you guys up there as part of it as well as the original group like Jaco in other words for you to get hospital accreditation you have to follow these steps boom boom boom boom and the idea same thing accreditation of the dental schools and whatever they do at the medical school level too as well the biggest hurdle that we have has always been government because at the time where the American Academy of Pediatrics said 25% of the health care dollar it was 1% and you know nothing happens when that happens and we were lucky in our community that we ended up getting a Croc Center Ray Croc and his wife was founded McDonald's and we competed with a whole bunch of cities and we ended up getting it and then the Rotary Club got involved and through collaboration between that organization and our local dental society now we have a free clinic in our area that is heavily a lot of the millennials and generations these are heavily involved even though they're under this massive debt because it gave them the opportunity to serve and if you can give the opportunity to serve by doing some collaboration I think you will have, you will see change and I suggest that if we're really concerned about this diabetes problem that we make it mandatory at the medical education level that they look at the periodontal aspect of the patients AC and Dennis we look at the H1AC and that's part of our education and just becomes just like they take the blood pressure every time they see an adult patient they do the H1AC on a periodic basis Marko asked what is our true north my name is Dr. Moab Raskala many of you know me as the author and filer of question 2 in Massachusetts which established 83% medical loss ratio for the first time in this country what is our true north I'd like to answer that question and dovetail it into the topic of dental medical integration we do need dental and medical integration on so many levels but the only way we're going to get dental and medical integration which was already answered by Marko is to have coverage coverage coverage for it the question is how do we establish coverage for dental and medical integration there have been conversations already up at the front here saying we need to get dental coverage into medical coverage in Medicare that also would apply to Medicaid but ultimately there's a problem there's a barrier we're talking about this this is where I work all the time the problem with getting coverage for dental in medical is that procedures for dental are not that big now you go get your medical insurance whether you have private insurance or if you have public insurance if you're in the private world you have to pay deductibles okay but those deductibles will stop you from getting dental care because your dental care is not that expensive so they would have to reformulate insurance medical insurance so that there is a dental subsection in your medical insurance so that your deductibles did not prohibit you from getting dental care see the problem? that's the problem because for the reality is that medical care is not for minor preventive work what we are paying for in our medical care is actually for catastrophic care but dentistry is not catastrophic care that's the problem we've really got to understand that and that's why I started with Marco's fantastic question what is true north? true north is no way, that's our barrier and our ability to get past that barrier may be a long term solution but in the short term how do we get coverage the answer is a federal medical loss ratio that doesn't just apply to Massachusetts it applies across the country and in my strong opinion that is point one of true north that's what we need point two and this should be the focus of ACD, ADA every single dental organization should be focused on these two things, number one federal medical loss ratio the number two is there are five existing Medicaid laws, I wrote question two I made that law but you don't need to make a law in five Medicaid laws which is my point two there are five Medicaid laws that are federal laws they are not options they are requirements they must be followed and no state in this country follows those if they were followed and if as the ADA the ACD all the different leadership in this country if we made a federal medical loss ratio and those five laws covered you would have the coverage you need to be able to pay for all of the medical integration we're talking about, thank you I'm another pediatric dentist I'm Martha and Kiehl's from North Carolina so Mark I wanted to throw out an innovative idea that I am a passionate private practitioner that our practice does have running eagle soft and epic side by side because we have elected to maintain privileges that Duke and UNC and because of that every day on epic I'm able to enter in as a diagnosis dental caries and then maybe say I have a severe concern about this child's diet I can enter in delayed eruption I'm concerned about this child's growth home early loss of teeth I'm concerned and to get to your point about talking doctors don't have time to talk to us and we don't have time to talk to them it's electronic communication and my wish for ACD and ADA and the AGD is to talk to the number one electronic healthcare providers in medicine one being epic and get every practitioner the way to have that parallel in their office so they can run dentrics and epic eagle soft and epic you don't have to run that's epic's version and I choose not to because it's not as good as eagle soft but when you start talking like that electronically then the nurse practitioner the dietitian people behind the scenes like you communicate behind the scenes electronically and I'm in that second bump because I'm almost 70 but I'm communicating with that first bump and that first bump is on their phones all the time you know reading my note that I put in epic and I mean I actually just did it twice already communicating about a child that's got a severe immune complex I've communicated in a matter of seconds with a team of 10 doctors so we're on the same page but I think that's my wish when you're innovating is to give my gift that I would give every private dentist whether you choose to practice corporate wherever you're practicing you're paralleling electronic healthcare record until we can figure out what he just mentioned about how we're going to pay for all this but we could start today letting them know what we see so that they could move on it and they're very very appreciative of that we just don't have time to talk to each other and that's my wish for us thank you Hi my name is Donna Clouser I'm section chair for Southern California and I wanted to thank you all for today I started a non-profit a while back regarding dispensing free Narcan to our youth 96% of our Gen Z population aged 15 to 23 are dying from fentanyl overdose accidental poisoning and I've distributed about 250 Narcan intranasal spray to children in my community you've spoken to me in my heart I want to make sure that I'd like to ask you for guidance with collaborating with our legislature also now with medicine pediatricians not just pediatric dentistry that Dr. Brett Kessler said Donna you have to be with pediatric dentists and I said oh my gosh what about pediatricians this is why these meetings are so important because you get to meet with really brilliant people that could continue to help save lives so thank you good morning thank you for this opportunity for our movement in this direction and I want to echo the comments that were made by previous speaker with regards to communicating with physicians and I'm going to throw in the basic science element here and in terms of when you have a developing system or a system that we want to develop form follows function and my question is in the dental school setting is how can we help our students better communicate with the physicians and other health care providers that our patients see and so our students will submit a medical consult it gets faxed to the practitioner's office we may or may not hear a response or the students will pose questions that are specific to this patient's care and what we can and cannot do for this patient within the context of everything else they're going through we'll just say give us a yes or no and really not answer the questions so you're right the physicians do not have time to communicate with us but some do take the time so before we have an electronic health record that we all have access to what can we do when we get back to school next week to help our students better communicate with the physicians so they do get a response and I think the more that clinicians be it in dental schools or in private practice community health centers communicate with physicians and truly collaborate on a patient by patient basis I think that can start to at least demonstrate a need for an improvement in the infrastructure that we have thank you you know I think that you know IPE has to be part of the curriculum in the first second third and fourth years it often occurs early on in the curriculum and then by the time the students are in their clinical years and thinking about such things including determining more about the medical status of a patient that IPE experiences is just in the background so I think IPE certainly has to be considered as part of all four years or three years depending on the length of the dental school curriculum and it has to be reinforced good morning I'm Dr. Felicia and I want to speak to you briefly because we talked about has this happened in our country well I'm a former dental director at an Indian Health Service clinic and if I don't know how many of you know but Indian Health Service is the government mandated care for members of federally recognized tribes and that's the closest I've had to medical dental integration working one on one with physicians to care for my patients however Native Americans have the expertise in this country so is this model working there's so much work that needs to be done and we need to look at all those things the coverage like that's huge you know if there's a mandate for coverage that's great but with Indian Health Service there is a mandate for coverage and yet we still have poor oral health so there's so many things that we need to address in that arena and speaking from my personal experience I feel I've made changes in my community but it's very grassroots and it's you know there's only so much I can do as one person and I feel the biggest challenges with collaboration so it's just great to see all of us here together and figuring out how we can work within our major organizations to collaborate and improve the the oral and medical health of our nation so thank you Hi my name is Fernando Flores I'm a tenured associate professor at the College of Dentistry in Oklahoma City so the University of Oklahoma and first I would like to thank you for the amazing presentations and the discussion and the question I have is is it truly possible to have true integration without having a footprint of dental clinics in hospitals across the country because life is getting more and more busy our patients doesn't really have the time to go to a medical appointment and then go to several dental appointments so is it true is it possible rather to have us working on the same physical space that's one part of the question the second part is is it possible to have true integration without having the alignment of the missions across the board of organized medicine and organized dentistry thanks great questions I don't really think you know a lot of hospital dental services were eliminated because they didn't generate enough money every Boston Harvard hospital had a dental service now there's only one left in Mass General but the interesting thing is students rotate where the physicians rotate is a different story I used to teach physical diagnosis to medical students in a course called patient doctor one where they learned to take a history and do a physical exam this was so long ago that the drug companies used to give out free black bags now they spend that money on late night advertising of drugs that are useless but in any case um I'm sorry there is an opportunity to teach medical students to look at the mouth and to learn something about that it's happening a little bit in Maine we're just doing it in Rwanda to school at Paul Farmer helped us start but physicians there's just no time in a medical school curriculum medical students get two days of dermatology that kind of business everybody is worried about being a radiologist now because of artificial intelligence um so there's going to be some massive changes going on and we need to be part of them on your point A I mean I agree with Bruce I don't think co-location is needed what I think the evidence suggests is much more important is that there's a closed referral made not here's a paper go find a dentist but literally if when you're checking out let us book that appointment for you now that's complicated how do you get all those people connected the previous speaker just talked how does the medical record talk to the dental viopic etc but to your first point no I don't think you need co-location your second one is a very insightful question I am not sure I'd be happy with alignment on this within the dental community I don't even think there's alignment on this within dentistry I don't see as a vision but I don't feel all these professional organizations in dentistry are moving to like in a decade I want everybody referred to dental that has chronic conditions I don't see that so yes it'd be great if the broader medical and healthcare community signed on to something like that but I frankly think we need to start and maybe that's something in the next year ACD can do like start with that and really push us push us to be like it's easy to say this is important but are you lobbying for it is it top three issues, is it not that's the real thing and I'm not sure we're there I think we also have to understand more about how physicians are educated there's a trend now and you may be familiar with this to shorten medical school from four to three years the reason being that most physicians learn to be physicians when they finish medical school and the point is so who are we reaching out to should we reaching out to the medical student or should we reaching out to the resident or to the fellow and it will have to be on that basis but if we get an entire discipline or subdiscipline in agreement of these kinds of actions and I'm talking about from the medical side are potentially very worthwhile institution organization to organization you can do it on the grassroots level you can reach out to an endocrinologist in your community that's not going to change the culture across the country but let me ask this in medical school I don't know if this is happening but let's ask the question for this to happen what needs to change you want when you learn about diabetes in medical school there's a paragraph in the book or whatever they say oh by the way gum inflammation a person screened for oral health what would it take for that to happen in med school like is it science advocacy that needs to change more than that we gave the medical students one day on oral health can you imagine that but it's not the oral health part it's the diabetes part when they're learning about diabetes they get portion of it is by having a dental person come in and talk about it so that part's taken care of it's just in practice then they get busy and it's not a let me make sure I ask you about whether you have a dentist or not thank you my name is Hailey Harvey I am a dentist a public health dentist that works in the hospital I am section chief in director of dental education in the hospital I can affirm that having a dental clinic 22 laboratories embedded inside of a hospital does not ensure medical dental integration I know that from my lived experience I know that from a patient that I recently referred to ENT and oncology because I suspected squamous cell carcinoma and how challenging that referral was it was complicated because the patient was also on state insurance is not covered under dental no oral surgeon would see them to be clear I'm not an oral surgeon and so my question is how do we also address and how do we establish our North Star when we don't address the elephant in the room in that our country our organizations have stratifications which means for me my experience has been that physicians are higher in the hierarchy than are the dentists in fact there was a joke because at one point a podiatrist was chief medical officer and the joke was well who's lower the podiatrist or the dentist in the hierarchy did you understand my question how are we going to address this integration until we address hierarchy I'm sorry what state are you in Iowa the great state of Iowa I've been to Iowa and I talked at the center for what's it called I forget there's an osteopathic medical school the moin right is it DMU the moin university one of the things that's been suggested and hasn't come up here yet in terms of this is Richard Manskey at the University of Maryland who heads their public health department suggested in a paper some time ago on how to change the scope of practice the scope of practice in dentistry has changed in a couple of ways sleep medicine cause you can get paid for making a thing and a lot of fornectomies I've never seen so many fornectomies done in my life in all my years of practice I said I think I did three but in any case because they're chronic remunerative conditions in any case I think there can be an experiment in states where the state dental board and the state medical board permits medical schools and dental schools to do some things that might be prevented by the state practice act as an experiment and see what that leads to no one's ever tried that so your comment about the state practice act I think is very important we actually look at the definition of what is a dentist and what is a dentist allowed to do in the 50 states and you know the ADA has a very broad definition of what dentistry is even says oral conditions and its effect on the body so about half the states that have adopted the same definition and that about half the states are much more restrictive actually talking about partial dentures and complete dentures and the like and we found that for example in New York which has a very broad definition they were willing and interested in let's say defending a dentist who might have taken an HBA1C in the office because the definition was broad so I think starting with the state dental associations I'm not sure this is exactly your question but it's a point I think I can take anyway that might be a way of moving this forward the other thing, again not your question but something that came to mind is that we I don't know if there's ever been a legitimate high level discussion among the American Dental Association that ADA and the American Diabetes Association that ADA to really talk about collaborate. We've talked a lot about the fact that there's principles or standards of care that doesn't really mention periodontal disease or doesn't really mention the oral cavity the approach needs to be different I mean it really has to happen at all levels grassroots to organizational let me interrupt for just one minute we're going to wrap up at around 11.15 so we can take one quick question and we'll wrap up I'm Dr. April Linder Pacheco I'm from Maryland and I just wanted to pose to everybody a different lens that hasn't really been addressed is the general sorry I'm short let's see is that better yeah I'm Dr. April Linder Pacheco I practice in Maryland and I just wanted to pose a different lens for everybody to think about is how do we educate the general public to care about dentistry a lot of people only go to the dentist when they have pain and so access to care and paying for that and everything else especially for the public that doesn't have access that's the only reason that they go and so us saying we have the systemic condition diabetes whatever and so you should care about it from a periodontal standpoint they may say okay sure but to pay for that or to go to the dentist or do this all business it's not inherently there so I don't know if that has to start in the public's you know general education in schools elementary schools general just populist education on social media somewhere that that value of dental care and how it's important for your overall health needs to come from somewhere beyond just this intermingling and interprofessionalism because that is when the person knows they have a problem and they've already gone to their medical professional what about all those people who aren't even getting to that stage or aren't being asked those questions of you know should we have this desire or not to care about it even just when to go to the dentist for the first time I think a lot of you know new moms they don't even think about it it's just they have so many other things on their mind that you know kids first birthday or first tooth just that general idea I recently bought a practice and they had not been doing medical histories let's say for a very long time so I said okay every patient who comes in needs to do a medical history who hasn't done one and I had so much pushback you're just the dentist why do you need to know about these things you know taking their blood pressure I had so many patients that said I see my doctor on a regular basis why are you even doing this the education that I've had to drive this uphill battle for these patients is incredible they don't see me as their medical healthcare team and so it's a different story to try to get the medical profession to understand that but if our patients are driving that force as well and asking their doctors those questions or just generally having more value and dentistry in the way that that affects the rest of their body I think that would help with a lot of these policy changes you know maybe the government will start listening the general populace thinks it's a problem they'll go to their policy makers they'll start to ask those questions and us as a profession we're only so many people but that's just something I've been thinking about as everyone's been talking thanks talk to her later well that's good what state are you from I didn't hear that Maryland I mean my only reaction there is the first of all it's valuable to do I would just temper expectations around this and we've done a lot of research on this like when you pull the public and you ask them about do you know mouth is connected to body do you value oral health the results are very very strong that they do and when you look at the barriers to care knowledge or interest in oral health is not number one like lack of it it's things like I can't afford it my insurance doesn't cover it there's a lot on this that's the reality I know providers are like I don't I don't agree with that that's okay but I think the reality is the profession has built itself a paradigm where this is not covered or or some of the comments earlier you're telling me I need this but I'm out of my thousand dollar annual limit so now what do you mean this is necessary and then you have gaps in adult medicaid medicare doesn't cover dental you have all these signals in society and like it or not folks like this is moving to a publicly funded system slowly as much as the rhetoric is in politics right we have 8% of Americans uninsured today that is dramatically lower than pre-Obama care right we have government spending on health care expanding we are moving to not covered it's not important we are moving away from I value your services I'll pay out of pocket that's gone the next generation if it's not covered it's not important so this is where again I'm not answering questions but this is part of that identity crisis of the profession now like if you want to still remain outside of poor mainstream health care don't expect to be treated equal like mainstream health care and both choices are valid but you just got to pick one and so I really love this question because I feel the public's knowledge is not the issue I feel it's like we have an opportunity to kind of elevate dentistry to really be core health care in the eyes of not just the public which I think it already is but in the whole health care community like that's the opportunity but it's not easy change and that's where we need direction that's where organized dentistry has to listen to you in terms of the trends that you're seeing that I think are very accurate and they have to be reactive or I really say proactive as opposed to reactive down the road but that's true north but it's not easy I understand why again it's on me to maybe hear the trends and hear what you should think about but somebody has the leaders and organizers you have to answer these questions and pick a path that's not easy because we have this generational turn over and people go in for this vision of the profession yet the world is putting trends that are really kind of challenging that vision right so it's not easy it's exciting but this is where we have a chance to really recast what dentistry is and the new kind of so we're going to allow the American college to stop yeah you have a so I would just like to thank our panelists here for a very insightful that was exceptional did you listen I asked because the college has a century long history of insightful intelligent impatient change and changes slow we've been working on this for two years I anticipate it'll take another two years to begin pushing a boulder up the hill the fellows in this room are the agents of change value-based ethical change so next summer in August Tony Ruka Scott Tomar will be leading our fifth ethics summit on the topic of medical integration and then we'll work on an action plan importantly more timely course evaluations and verifications will be sent to registered participants who also complete the evaluation I thought we were going to have the code displayed do we have a staff person in back working on that if you did not register please email the office please email office at acd.org and for those of you who registered for the convocation luncheon at 1130 that's what 10 minutes it's being held in Regency Ballroom UV for those involved in the convocation ceremony please be in the lineup room no later than 2pm for our guest attending the convocation please be in your seats no later than 2.20 thank you enjoy the rest of the day