Why are dentistry and oral health care practices seemingly easy to question?

The topic of evidence in dentistry and oral health care has been in the news a lot recently, with articles like this column in the New York Times by a professor of pediatrics.

In his column, Aaron Carroll discusses the differences he sees between his own and his wife’s dental journeys, as well as what little rigorous research has been done to support certain generally recommended dental practices.

What is interesting is that articles like this one and the popular flossing article from the Associated Press, among others, imply that recommendations made by dentists are based solely on limited or weak evidence – or worse, based simply on what the dentist will get paid for by an insurance company.

They also leave readers feeling that plaque removal and cavity prevention/treatment are the only elements necessary to address for good oral health.

Ultimately, Carroll suggests in his column that while lack of evidence doesn’t mean oral health prevention efforts don’t work, we should invest in research to ensure that those things we do are evidence-based.

For those of us in the business of improving oral health, we couldn’t agree more with that conclusion. But let’s take a closer look at some of the points that may have gone overlooked by recent press coverage.

We know that evidence something works for populations doesn’t directly translate into solutions for a specific individual – that is in fact why Carroll and his wife have such dramatically different dental journeys.

Carroll notes he has had just one filling in his life and doesn’t religiously care for his mouth, while his wife has “more fillings than [he] can count” but is fastidious in her oral care routines.

This underscores two important points:

1. Every person is different. Individualizing care is critical to improved oral health.

While evidence-based research informs standards of care, it is the dental team that must develop the best care plan for any given person’s situation. That is why DentaQuest invests in the development and adoption of evidence-based care protocols that focus on prevention, early intervention and disease management.

Our investments in disease management and risk assessment help provide dental teams with the knowledge and tools they need to best serve their patients.

For instance, across a five-year period, the DentaQuest Oral HealthCenter demonstrated that risk assessment and intense preventive efforts (including sealants and fluoride varnish) directly resulted in a reduction in the need for invasive surgical procedures.

Sealants are one of the most cost-effective strategies for protecting teeth, as noted in another recent New York Times column. This is because they provide a physical barrier against cavities. They can even be applied to teeth that are just starting to show signs of new cavities, and stop them from getting bigger.

The best time to seal a tooth is immediately after it erupts in the mouth, and so the DentaQuest Oral Health Center strives to set aside extra time at visits for children ages 6 and 11 since the permanent molars are usually erupting at that time. It is also why the DentaQuest Foundation collaborates so closely with school-based health alliances working to improve access to oral health care – and sealants – among children in grade school.

Additionally, with a patient population of over 10,000, the DentaQuest Oral Health Center works in collaboration with the DentaQuest Institute to refine strategies that make patients healthier. And when these best practices are implemented, they actively improve peoples’ health.

2. Prevention and oral health improvement do not take place solely in the dental chair.

Preventive dental visits provide an important opportunity for people to check in on their oral health habits and get evaluations for early signs of not just dental disease, but also chronic diseases like diabetes and hypertension.

Most of us spend two hours a year in a dental office. And, if we are to reconsider the benefit of two annual preventive visits as Carroll suggests, some of us might end up spending even less time with a clinician. So what about the other 8,758 hours?

The differences in the oral health of Carroll and his wife are not because he brushes with an electric toothbrush every day or because she is doing something “wrong” in her routine. Oral health care is more than just brushing and flossing. In fact, it is about more than your teeth and gums.

To make an impact, we have to take a look at how we pay for oral health care, how our public policies enable it, and how our communities prioritize it, in addition to how we provide it.

Addressing just one of those will not improve oral health care on the larger scale or reduce health care costs, as Carroll aims to do with his recommendations. We know oral health care is indeed critical for overall health. This is why we at DentaQuest look far beyond the dental chair.

For example, as part of Oral Health 2020, the DentaQuest Foundation is investing in efforts to incorporate oral health into the primary education system. Oral health education, screenings, assisted referral, and delivery of preventive care through our schools provide equitable, reliable entry into long-term oral health care.

DentaQuest also champions efforts to include innovative financing models for dental in person-centered approaches to care enabled by the Affordable Care Act (ACA).

Over the last decade, we’ve seen significant movement to transform our health care system into one that improves quality, lowers costs, and makes people healthier. In fact, on the medical side the Triple Aim is starting to be supported by alternative payment and care delivery models that are person-centered and focus on prevention.

Why did that happen? Because experts and advocates knew there had to be a better way forward for a healthier America.

The same is true for oral health. We are beginning to see that it is possible to live in a world where optimal oral health is the expectation, not the exception. We must continue to invest the same transformative energy into improving the oral health of all because you cannot have optimal overall health without optimal oral health.

 

To Fill or Not to Fill: That is the Question

By Dr. Doyle Williams, Chief Dental Officer, DentaQuest

Recently, the New York Times published an article, “A Closer Look at Teeth May Mean More Fillings for Dentists,” which discussed microcavities and the different ways dental care providers treat them. A 22 year old college student who had grown up without ever having a cavity visited a dentist while at college and found out she had a cavity – in fact, multiple cavities. Somehow, in just 12 months, she went from perfect oral health to having many cavities. How can that be?

Ever new technologies make it possible for dentists to find very early stage cavities (microcavities) that can’t be seen with X-rays or the naked eye. These technologies are an effective tool in identifying early decay and allowing dentists to address it before it progresses to become a bigger and more painful problem.

The microcavities they detect are abnormalities which can be an indication of the beginnings of tooth decay. For patients who previously had perfect oral health, hearing they may have a number of cavities that need to be filled is a shock. If you are concerned that a diagnosis doesn’t match up with your prior dental history (and there has been no change in your home care or health), it is never a bad idea to get a second opinion.

Today, when dental teams catch disease in an early stage, there are more options for patients than the traditional filling. For example, dentists can watch and wait to see what happens as suggested in the article by Dr. James Bader, a research professor at the University of North Carolina School of Dentistry.

Another approach is to take preventive steps. The diagnosis of a microcavity may lead a dentist to recommend the application of sealants, a thin plastic coating applied to the teeth to protect them from the bacteria that causes dental disease and the potential for further decay.

Or, a dental health professional may attempt to help “heal” the tooth. At the DentaQuest Oral Health Center, the dental team would take steps to reduce the level of the decay-causing bacteria in the patient’s mouth, and enhance the body’s natural ability to replace minerals. So instead of placing fillings that will need to be replaced in the future, they use other measures to stop early decay, help the tooth heal, and then make it more resistant to future decay. It’s a prevention-focused approach to oral health care.

My colleague, Peter Blanchard, DDS, MBA; Director, Evidence-based Practice, DentaQuest Oral Health Center, wrote an op ed in response to the New York Times article entitled “To fill or not to fill: That is the question” which was published on DrBicuspid.com.

Finding cavities early is never a bad idea. It gives us more options to help our patients stay disease free.

Penny Wise, Pound Foolish?

This week, two news stories caught my eye. One, in the Washington Post, was about a vote taken in the U.S. House of Representatives to repeal mandatory funding for school-based health center construction. The other, in the Worcester, MA Telegram & Gazette, recalled the days when children in Worcester received their dental care within the public school system. That ended in the late 1970s when most school dental clinics were closed. And since then, the rate of dental disease in the city’s children has been on the rise. It also doesn’t help that the city of Worcester does not fluoridate its water supply.

Across the United States, school-based health centers are becoming an important vehicle for health care delivery for all children, but especially for poor, uninsured or underinsured children. Providing health services where children spend the greatest part of their day makes sense. It eliminates the biggest impediments to getting care – such as the parent/caregiver getting time off from work, finding a provider who accepts the family’s insurance plan, and securing appropriate transportation. School-based health centers help families too, especially when the providers introduce children, siblings and the extended family to community health resources that all can use.

School-based clinics are a first line of disease prevention and eradication. When children and their caregivers know what to do to take care of teeth, and when they are able to see a dentist when something is wrong, cavities are nearly completely preventable. And when neither of the above takes place, children can end up with serious decay and infections that require emergency room care and extreme interventions. (Read about Early Childhood Caries in this blog here and here.)

Today Worcester, MA is working to establish a pathway for young at-risk children and their families to a lifetime of good oral health. Through a pilot program, 730 Head Start children and their families are learning about oral health as part of classroom activities and parent meetings. They are introduced to the dentist as a friendly, supportive adult. Parents/caregivers get a colorful “Baby Tooth Timeline” -- a growth chart which tracks age, height and weight and provides useful dental health information for the child’s first five years. The chart explains when to expect first teeth, what to do to prevent decay, and when to schedule dentist visits.

The next step is to be sure the children have connections in the community to get care when they need it. Statistically, low-income children suffer from dental disease at much greater rates than the general population. Many Head Start children are covered by Medicaid; but not all dentists accept Medicaid patients.

And, not all school-based health centers provide dental services. We think they should. As the Worcester example shows, prevention works. It would be nice if the U.S .House of Representatives would reconsider their recent vote, and instead, approve the wise investment in school-based health centers.

Dr. Mark Doherty is Executive Director of the DentaQuest institute, a not-for-profit organization focused on improving efficiency, effectiveness and quality in dental care.

Some Good News at Massachusetts’ Medicaid Dental Program

This February, U.S. District Court Justice Rya W. Zobel ended 5-years of court oversight of the MassHealth (Medicaid) dental care program for low-income children.

This is a milestone to celebrate.

In 2005, as the conclusion to a class action lawsuit against the Commonwealth of Massachusetts, Judge Zobel ruled that Massachusetts children covered by the MassHealth dental program encountered “extraordinary difficulty” in obtaining timely dental care, and that the program violated federal Medicaid law. At the time, barely a third of eligible children Massachusetts were being treated by a dentist.

The judge ordered Massachusetts to bring the MassHealth children’s dental program into compliance with federal law and appointed a neutral Monitor, Dr. Catherine Hayes, to make sure the necessary changes were made.

Since then, Massachusetts has made significant improvements to its Medicaid dental program.

1. The state established a full time Medicaid Dental Director. Previously, there was a part-time leader/advocate for oral health.

2. The state hired a 3rd party dental management administrator (DentaQuest) to efficiently manage the processing of claims and to provide provider relations.

3. The Massachusetts legislature increased the fees paid to dentists treating Medicaid patients to a point far more comparable with the cost of providing care. Previously, dentists were reluctant to treat Medicaid patients. In 2009, the Massachusetts Dental Society set a goal to have 65 percent of its membership, including specialists, participate in the MassHealth program by the year 2013. New dentists are joining MassHealth every day.

These changes are making a difference. In 2010, 50% of the children in the program saw a dentist compared to 33% before 2005. So after reviewing the current data, Judge Zobel declared the MassHealth dental program free to function without a guardian.

In Massachusetts, there are other good news events for children’s oral health. School-based programs are now in place across the state, some state-funded and some funded by private philanthropy-- they provide dental examinations including placing dental sealants (thin plastic coatings on molars) and fluoride treatments on children’s teeth to protect against cavities. And, MassHealth is now paying pediatricians and nurse practitioners when they apply fluoride treatments and advise parents and caregivers on how they can help prevent cavities in children.

That’s not to say that there still aren’t oral health challenges in Massachusetts. Benefits are closely tied to the economy and the state’s budget. In 2010, dental benefits for adults in the MassHealth program were cut back. Adult benefits are vulnerable because states are not required to provide them, even though doing so makes good sense. Parents’ dental coverage is a good predictor of whether or not their children will obtain dental services.

Despite economic challenges, more Massachusetts children are getting good preventive dental care, and that’s great news.