Dental Health Care Needs Quality Improvement Now

The message couldn’t be clearer: The time for the dental profession to jump on the health care quality improvement (QI) bandwagon is now.

In the past quarter-century, the United States has seen medical care improve and per capita health care costs go down thanks to QI standards adapted from other industries like manufacturing. But why has the dental profession been so slow to join the game? Our recent DentaQuest Institute editorial in the July/August 2016 issue of Pediatric Dentistry provides some clues.

In our editorial, we argue that, because of QI’s effectiveness—in medicine and other fields—it is 

“...imperative that dental professionals create the culture and systems necessary to apply QI principles and activities for the benefit for our patients, the public at large, and our profession.” 

That may be easier said than done, but our own Dr. Natalia Chalmers, who heads DentaQuest Institute’s Analytics and Publication team, and her colleagues lay out a number of programs that place a heavy emphasis on QI - from DentaQuest Institute’s EarlyChildhood Caries (ECC) program and the UCLA-First 5 LA Oral Health Program to new initiatives from the American Dental Association’s Dental Quality Alliance. 

The common thread with these programs: they all work.

• Through ECC Collaborative, an effort to reduce dental caries in young children, 32 federally-qualified health centers (FQHCs) significantly improved patient outcomes after implementing a disease-management approach to QI.
• The UCLA program helped 22 local FQHCs redesign workflows based on QI models, improving diagnostic, preventive and treatment services in participating dental clinics. With the “triple aim” of improving patient experiences, improving health status, and lowering costs, the ADA’s Dental Quality Alliance seeks to help dental practices establish processes “to reliably deliver evidence-based care to every patient.”

The authors note small steps may be all that’s needed to push the profession toward QI. For example, the Plan-Do-Study-Act cycle results in a trial-and-error approach until performance improvements are realized. This practice has helped improve quality performance in industries from high-tech to higher education. There’s no reason dentistry can’t do the same.

They also understand that integrating QI into a dental practice requires considerable planning, coordination and commitment. And it takes a team for QI to take root. Dental practitioners, office staff and even patients must be invested in the process for it to work.

That said, dentists need to begin thinking now about QI at the practice level. These efforts will have an enormous impact on the way dental care is delivered. And, as the DentaQuest editorial illustrates, that’s a win-win for everyone.     

           

What AP Didn’t Mention about Flossing

The recent flurry of news regarding the benefits of dental floss has left out an important point of view: while the evidence of flossing’s medical benefits may be weak, the evidence that it is pointless or harmful is even weaker. What’s more, flossing is an inexpensive oral hygiene practice accessible for people most in need of improved oral health.

But let’s break this down.

The Associated Press reported:

The evidence for flossing is "weak, very unreliable," of "very low" quality, and carries "a moderate to large potential for bias." … One study review in 2011 did credit floss with a slight reduction in gum inflammation — which can sometimes develop over time into full-fledged gum disease. However, the reviewers ranked the evidence as "very unreliable."

But the study review authors actually noted:

There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months.

What is important to note here is:

1. The "weak, unreliable" language actually references the evidence that flossing specifically reduces plaque, not gum disease. But more importantly, the language used comes from a different lexicon than we use every day. “Weak, unreliable, low quality” all sound like common terminology, but in the research world, this type of language doesn’t indicate the science shouldn’t be believed. The terms actually may reflect that study authors left out some details (such as the exact method of randomizing people) that the study reviewers could not confirm, not that the research is bad. 
2. The fact the review of studies could not prove plaque reduction at 1 and 3 months is very likely because tooth decay and gum disease are slow progressing issues that would require multi-year studies. It may also be because the standard for measuring plaque reduction only scores visible surfaces, so plaque may be reduced on non-visible surfaces such as directly between teeth.
3. In March 2015, the same study review linked above also determined: the very low evidence for the efficacy [of flossing], however, does not preclude the use of floss. For instance, in inter-dental situations that only allow for the penetration of a string of dental floss, floss is the best available tool.

When the U.S. government removed flossing from its 2015-2020 Dietary Guidelines, it did so because the strength of published studies regarding the effectiveness of flossing were admittedly weak, as the AP reports. The studies were generally short-term with a small number of participants due to the cost of running what constitutes high-quality clinical trials. 

Aside from cost, a clinical study comparing patients who did and did not floss would also mean exposing and even encouraging control group patients to worsen their oral health – and watch as it happens without intervention. In the research world, this is considered unethical. We don’t allow people to develop diseases as part of research, and that helps protect every patient in the United States.

According to dental experts including the DentaQuest Institute’s Dr. Brian Nový, Director of Practice Improvement, the lack of long-term clinical trials is also because there is already significant scientific evidence indicating how cavities form and how to prevent them.

Clinical trials don’t investigate how teeth decay, they examine new types of interventions. Oral health experts thus have relied on evidence extrapolated from shorter term studies as well as years of clinical experience and practice standards.

We know the easiest way to prevent cavities is to keep your mouth clean and minimize plaque, and that premise is incorporated into many clinical trials because it is accepted as standard oral hygiene practice. 

In one small study out of the University of North Carolina Chapel Hill, researchers randomized 119 adults who already had gum inflammation. After two weeks, they found the group that only brushed achieved a 35 percent reduction in bleeding sites between teeth, while the other groups who brushed and used floss achieved “dramatic reductions of about 67 percent” – almost double the improvement.

While small, this particular study correlates with the evidence dentists see every day among their patients – flossing creates a healthier mouth and less disease.

“The real problem is that the modern American diet is full of refined carbohydrates, which has changed the type of plaque that forms on our teeth,” Dr. Nový notes. “It is much stickier and more dangerous and everyone should want to keep it off their teeth if they want to avoid dental problems.” 

Tooth decay and gum disease can occur anywhere that food debris and plaque accumulate. The ideal spot is between teeth since it is difficult for the toothbrush bristles to remove or even attempt to remove any of the debris. That is why flossing or use of an inter-dental brush is recommended - to best remove the food debris that would remain between the gums and the teeth where a toothbrush cannot fit.

In response to the AP article, Dr. Robert Compton, Chief Dental Officer, DentaQuest and President, DentaQuest Institute, recalled an observation frequently used by health experts: the evidence to support the effectiveness of parachutes is weak because there has never been a double-blind randomized controlled trial to demonstrate effectiveness. That does not mean that parachutes are not effective. It just means no one has conducted expensive research that compared the effectiveness of somebody jumping with a parachute to a control group jumping without one.

“There's not enough money to conduct research for cancer cures and treatment for heart disease,” said Dr. Compton, adding, “if there isn’t funding for life-saving interventions, there will likely never be funding for the kind of research the AP reports would be required to sanction flossing as a recommended oral health habit.”

While flossing may be a habit that is difficult for people to connect with, it definitely helps remove food debris from hard-to-reach places. It is a low-cost, easy-to-use intervention that has the potential to improve the oral health of many, in particular those already suffering from dental disease.

This, among other reasons, is why oral health clinicians Tim Iafolla of the National Institutes of Health and Wayne Aldredge of the American Academy of Periodontology both told the AP they maintain flossing is important.

And Dr. Nový adds, “It comes down to personal hygiene. Do you want to have bad breath, and puffy bleeding gums, or do you want people to notice your smile because it’s healthy and attractive?  Flossing will improve many aspects of your life and no one has mentioned the research that shows male patients who don’t floss are more likely to experience erectile dysfunction...”  

Advocacy Efforts Encourage U.S. Treasury to Address Pediatric Dental

Earlier this month, the U.S. Department of Treasury released a proposed rule clarifying that pediatric dental benefits should be part of the calculation for marketplace tax credits. If implemented, this rule will be a major victory for low-income families in need of access to affordable dental coverage for their children.

Pediatric dental coverage is one of the 10 essential health benefits for marketplace plans that are subsidized based on income level under the Affordable Care Act (ACA).

Unfortunately, the cost of pediatric dental coverage is often not included in the total subsidy amount that roughly 85 percent of those purchasing coverage through the marketplace receive to help pay for the total cost of coverage for their family.

Without the full subsidy to cover all 10 essential health benefits promised under the ACA, many families struggle to get access to dental coverage for their children.

And Congress noticed.

A few months ago, Sen. Debbie Stabenow (D-Mich.) took the lead with a group of Senators who co-signed a letter urging the Treasury to make sure that the advanced premium tax credits under the ACA accounts for the cost of pediatric dental benefits.

The National Association of Dental Plans (NADP) and Delta Dental Plans Association (DDPA) led a coalition of organizations, including DentaQuest, to garner support for Sen. Stabenow’s efforts on this issue.

So, what’s changed for pediatric dental benefits?

The latest proposed rule ensures pediatric dental is included in the subsidy calculation for all families. 

Once finalized, this rule will mean that more families have the financial support they need to get the coverage they need to #ExpectOralHealth.

Industry advocates resoundingly supported the announcement. The American Dental Association (ADA), the Children’s Dental Health Project (CDHP), DDPA, and NADP released a joint press release applauding it.

And Sen. Stabenow said:

“For young children, early dental care is especially important, and this decision will help make dental coverage more affordable for families in Michigan and across the country.”

As policies aimed at improving access and affordability continue to evolve, it is equally critical that they are implemented effectively. We are pleased to see the Treasury Department taking steps to ensure that low-income children get access to the dental coverage they need to lead productive, healthy lives. 

As health care continues to undergo significant changes, oral health is too important to be forgotten. 

Oral Health Disparities between Men and Women

Did you know men are more likely to get oral cancer than women? Men are also more likely to skip dentist and doctor visits. For Men’s Health Month happening now, let’s raise awareness about these and other disparities.

Overall, more than 10 adults out of every 100,000 will develop oral cancer.

Oral cancer incidence among men is more than twice as high as among women in the United States. The same holds true when broken out by race for those who identified as white, American Indian/Alaska Native, and Asian or Pacific Islander.

However, prevalence among black men is more than three times as high as among black women. The disparity is similar among Hispanic men and women, too.

What’s more, oral cancer rates increase with age among both women and men. The increase becomes more rapid after age 50 and peaks between ages 60 and 70.

But diagnosing oral cancer at an early stage significantly increases five-year survival rates. Today, we are more aware of the importance of oral health and how to prevent disease thanks in large part to better education, greater access and advances in technology.

These factors have helped oral cancer survival rates steadily improve since 1975, though the disparity among white and black men has remained largely unchanged.

So what more can be done to reduce oral health disparities?

To start, efforts like those funded by the DentaQuest Foundation are designed to target prevention and collaboration in hyper-local ways.

One investment supports the Chicago Community Oral Health Forum to develop and expand school-based oral health education to students in the Chicago Public School system and the development of dental homes for students with urgent needs.

Another investment is supporting the University of Alabama as it implements a framework for interprofessional training that will produce health care practitioners in Alabama with a greater understanding of oral health and the ability to work in health teams to provide optimal care to their patients – from geriatrics to pediatrics.

These types of programs happening across the country target long-term improvements and sustainable changes for a variety of communities – from predominantly black public schools in Chicago to the elderly in Alabama.

The DentaQuest Institute, meanwhile, is expanding oral health care to rural parts of the country. Experts are working closely with local teams, helping providers develop evidence-based and financially-sound practices that ensure a continuum of care for regions that largely have been without regular access to dental care.

With dedication and support, these projects can ultimately change the trajectory of oral health disparities in America.

 

Engaging Grassroots with Grassmiddles to Facilitate Changes in Oral Health Equity

Why should grassroots and grassmiddles engage for oral health care? “If you want to go fast, go alone. If you want to go far, go together.” – African proverb

It’s been a busy spring for our team as we just wrapped up six meetings in six states (in just three weeks!). During the months of April and May, DentaQuest Foundation convened partners in the six states of our Grassroots Engagement Initiative, which launched last year in Arizona, California, Florida, Michigan, Pennsylvania, and Virginia.

The grassroots strategy aims to amplify the voice of those most impacted by oral health disparities –people who are living with tooth and mouth pain, limited access to dental services or affordable coverage, and other barriers to obtaining good oral health.

These meetings brought together those working at the state level (like oral health coalitions) – also known as the “grassmiddles” – with local-level community advocacy organizations – the “grassroots” groups.

DentaQuest Foundation’s grassmiddle partners have been working in oral health for many years and have a deep understanding of the policy environment in their states, often in addition to clinical knowledge or experience. Grassroots organizations, meanwhile, understand the needs of their communities and are experts at organizing and mobilizing community members to create change around issues like the environment, racial justice, jobs and more.

Why the Grassroots Engagement Initiative? Within it, these stakeholders learn from each other’s respective expertise. Together, they can take aligned action to improve oral health while also respecting and including the voices of those most impacted by oral health disparities.

These kinds of partnerships only serve to strengthen the effort of a larger national movement by getting everyone to agree on the priorities and join together where action is needed to improve oral health.

Illustrating the power of partnership

One of the Grassroots Engagement Initiative grantees in California is SCOPE (Strategic Concepts in Organizing and Policy Education) helped bring grassroots and grassmiddle partners to agreement on oral health change efforts.

SCOPE is a group that first emerged in the early ‘90s in the midst of the Los Angeles uprising following the Rodney King verdict. Staff from SCOPE facilitated what’s called “power mapping” at each of the six state meetings.

 “Power mapping” asks:

•  what are the major issues in a state (for example, in Arizona: lack of adult dental coverage in Medicaid, lack of access to quality oral health care in Native American and other poor communities, and a weak social safety net);
• who are the decision makers that could potentially influence those issues (for example, Governor Ducey and the Arizona legislature); and finally,
• who else might be potential allies or challengers.

Participants then map out where all of these factors and people stand on the issue. Finally, they strategize on what’s needed to shift these dynamics in a way that positively impacts oral health in the state. Ultimately, the resulting power map should be used to track progress by revisiting it periodically to see how opinions have shifted.

At each state meeting, SCOPE helped participants reach consensus on a draft power map to begin using and measuring against. The agreement resulted from peer-to-peer learning, as well as collaboration across grassmiddles and grassroots experience.

Why does this matter? How will oral health equity improve?

Power mapping can be an excellent complement to the state’s oral health plan, which is goal-oriented and shows where the state wants to go. In fact, the power map and community level actors can help inform how to get there – an element that is improved with grassroots and grassmiddles on the same page.

Ultimately, it’s crucial that efforts to create change are in line with one another when facing a problem as significant as poor oral health. These state meetings seek to encourage all of us to see ways in which we can work together, and bring our respective strengths to the table, as we work for a healthier America. 

Oral Health, Meet Eye Health

During Healthy Vision Month each May, the National Eye Institute encourages Americans to make their eye health a priority and informs them about steps they can take to protect their vision. But why are we talking about eye health on an oral health blog? 

Oral health is a critical piece to the oral health puzzle, but so is vision. Just as the mouth can be the first place to spot signs of chronic disease, so can the eyes. 

An eye exam, for example, can uncover broken or leaking blood vessels in the retina, which are an indicator of diabetes. Specifically, the capillaries that deliver blood to the retina can be broken down by a buildup of sugar in the bloodstream, and elevated blood sugar is a warning sign for diabetes that a vision provider would spot perhaps before anything else triggers a diabetes test from a primary care provider. 

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Some even suggest that identifying chronic diseases such as diabetes and hypertension at the eye doctor or dentist is more cost effective and can mean better outcomes for people who otherwise might not be diagnosed until a chronic disease has progressed or other complications develop.
Moreover, a healthy set of eyeballs means productivity and independence are within reach for much longer.

So what does the National Eye Institute encourage for healthy vision?

• Get a comprehensive dilated eye exam.
• Live a healthy lifestyle, including eating healthy foods, maintaining a healthy weight, managing chronic conditions, and not smoking.
• Know your family history.
• Use protective eye wear.
• Wear sunglasses.

Taking these steps can help prevent vision loss or blindness, which can result from many diseases and conditions. In addition, comprehensive dilated eye exams can detect problems early, when they’re easier to treat.

DentaQuest believes in eye care as much as oral health because you cannot have improved overall health without healthy eyes and mouths. This is in part why we created eyeQuest back in 2009.

At the start of 2009, we began administering a Medicaid vision program for 40,000 people in Nevada with Amerigroup coverage. As of April 1, 2016, we now administer vision programs across 9 states for 1.6 million people!

Still need convincing that vision is important to care for the same way you care for the rest of your body? Commemorate Healthy Vision Month by pondering and sharing these fun facts:

• 80 percent of what we learn is through our eyes.
• Eyes are the second most complex organ after the brain.
• An eye is composed of more than 2 million working parts.

Beyond Your Mouth: The Social Determinants of Oral Health

April is minority health month, and there’s no better time to focus on dental health—which so profoundly affects the overall health of minorities. As the commemorative month comes to a close, consider the importance of improving the oral health of all (our mission lived each day).

“Oral health implies much more than healthy teeth. The mouth is both a cause and a reflection of individual and population health and well-being,” states a study published in BMC Oral Health. This notion reflects the fact that many of the determinants of dental health go way beyond medical factors—they are behavioral, cultural, social, and economic as well.

For example, tooth decay is a major dental health issue for the United States. And the food we eat plays an important role in this. Foods rich in sugar and carbohydrates help to form plaque acid that attacks tooth enamel. But those who live in food deserts with no access to healthy, nutrient rich food, may be forced to rely heavily on these foods in their diet.

Education also plays an important role in tooth decay. 

According to the Centers for Disease Control and Prevention (CDC):

• Adults aged 35–44 years with less than a high school education experience untreated tooth decay nearly three times that of adults with at least some college education.

• In addition, adults aged 35–44 years with less than a high school education experience destructive periodontal (gum) disease nearly three times that of adults with at least some college education.

Access to fluoride is also key. 

Prior to World War II, Americans were plagued by toothache and tooth loss.  But in 1948 the National Institute of Dental and Craniofacial Research was formed and researchers began demonstrating the effectiveness of fluoride in preventing tooth decay. 

According to a Surgeon General’s report, “Community water fluoridation remains one of the great achievements of public health in the twentieth century—an inexpensive means of improving oral health that benefits all residents of a community, young and old, rich and poor alike.”

While community water fluoridation is highly recommended by nearly all public health, medical and dental organizations, some may still lack this important program. (Check your community’s status in this CDC fluoride finder.)

Dental insurance inequalities also contribute to health disparities, as preventive oral care including check-ups and regular dental cleanings are crucial. That is one reason we created the unique PreventistrySM approach, which not only fully covers most preventive services, but also helps highlight for network dentists those members at higher-risk of tooth decay.

This year’s minority health month theme is Accelerating Health Equity for the Nation. Long past just recognizing health inequalities, this theme calls us to improve our work toward health equity, in part by focusing specifically on the social determinants. 

As you continue to think about this theme—hopefully long past April—don’t forget about the intertwined importance of oral health.