A Quality Improvement Director Goes to the Forum...

This week, staff from DentaQuest’s Institute attended the 2017 Institute for Healthcare Improvement (IHI) Forum. During this multi-day conference, healthcare professionals from around the globe meet in Orlando to talk healthcare improvement. While oral healthcare is not a prominent discussion topic, DentaQuest has been attending since 2011. 

At Monday's pre-conference Scientific Symposium, Dr. Natalia Chalmers and Quality Improvement Project Manager Carrie Peltier presented a poster on our Dental Caries Management (DCM) Collaborative results (pictured left). Over 200 posters were submitted for consideration; the Institute’s poster was one of 70 - and the only one on oral health - chosen. Dr. Chalmers commented that the buzz about the importance of good oral health being vital to overall health was inspiring. Many wanted to learn more about the DentaQuest approach.

The general session featured a series of keynotes and 200+ workshops topics covering improvement science, joy in work, leadership, population health, person-centered care, safety, moving from volume to value to name a few. 

This year’s Forum opened from the lens of patient experience. The keynotes challenged care teams to create a bidirectional transfer of knowledge between patient and care team; this is, in fact, an act of caring. Care teams must work to create this space. It truly matters. Keynote Tiffany Christensen commented: we must ask generous questions to know and learn what matters to our patients. Our job is to make sure there is equity. These sentiments very much resonate with the Institute.

Later in the afternoon, we heard from Bryan Stevenson, a social justice advocate. Mr. Stevenson powerfully reminded us that it is our duty to create healthier communities. We must get closer to the poor and to communities that have been marginalized, neglected, and isolated. There is power in proximity. We also need to change the narrative that defines the difference of race. We must stay hopeful, as our hope has to fuel our practice. And lastly, we need to do the things that are uncomfortable. We have to make the choice to do the difficult thing.

General Stanley McChrystal shared his Team of Teams vision. He spoke about organizational change; being at an inflexion point and ready. He talked about ‘shared consciousness,’ meaning to connect on something with purpose and time and focus. “Together we need to project 'this place' where we want to go and make it to fruition.” This requires leadership that composes self-awareness, discipline, decision making, effective communication, connection, constant learning and functional excellence.

Lastly, as is IHI tradition, we heard from Dr. Don Berwick, president emeritus and senior fellow at IHI. Dr. Berwick’s spot-on remarks and reflections on the American healthcare system ring true year after year, and this year was no different. He shared a moving personal story of needing - and using - the healthcare system for his own family. He charged organizations to “snuggle,” meaning outline a clear and common purpose, be all together, or none at all and provide a safe vessel – failures are instructive; it’s OK to try, there can be shared honor, and we must have affection and mutuality. As this culture is what saved his brother.

Healthcare is complex; like the organizations who provide care and coverage. Inter-organizational competition is not the answer; coordination is. And DentaQuest is no different. Leaving this year’s Forum, I couldn’t help but board my plane back to Boston with some puffed feathers … DentaQuest has these pieces. We are prime to be the ‘Leading Voice.’ Improvement work is a social thing. It asks us to reflect, to adjust, to learn from, and to collaborate. It demands that we ask is what we are doing better or more of the same? We want better; we want to improve the oral health for all. That means understanding the system, at the macro, meso and micro levels. All together, or none at all. We must always ask “what do we want to learn over time?” and chart that course.

Cheers to another amazing Forum. Kaiser Permanente sent over 400 staff this year. Won’t you consider joining us next December in Orlando? This stuff matters!

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Cindy Hannon, MSW

Quality Improvement Director 

DentaQuest Institute  

"When you believe in this stuff, it is easy to write!"

‘Action for Dental Health’ in Congress

While we all paid close attention to health care in the Senate last week, the House Energy and Commerce Committee made a critical, yet mostly overlooked step to advance oral health for at-risk populations.

On July 27^th, the Committee unanimously passed HR 2422, or the Action for Dental Health Act of 2017. This bill calls for Congress to authorize additional oral health promotion and disease prevention programs to help at-risk populations struggling to obtain appropriate oral health care.

The bill points out that more than 181 million Americans will not see a dentist, but almost half of people ages 30 and older have some form of gum disease and nearly a quarter of children under age 5 already have cavities. 

As we at DentaQuest well know, caries is the most prevalent chronicdisease among children and can be prevented. What’s more, we see time and again that Americans of all ages are in desperate need of access to oral health care - Missions of Mercy like the one in Wise County, Va., is a great example. Both the Washington Post and The New York Times covered the July event, for which thousands of people come from miles away and lineup for hours and even days just to get access to dental and other services.

If this new legislation passes through Congress, the Centers for Disease Control and Prevention will award grants and collaborate with states, counties, public officials, or other stakeholders to implement a variety of initiatives.

These activities could include oral health programs that:

·         more broadly use portable/mobile dental equipment;

·         facilitate the establishment of dental homes;

·         eliminate geographic, language, cultural, or other barriers to care;

·         reduce the use of emergency departments for dental conditions; and

·         provide dental care to nursing home residents.

It is exciting to see bipartisan support for dental care initiatives that have tremendous impacts on the oral and overall health of patients. This type of work will drastically improve the health of Americans. And it has the ability to address the estimated $2.6 billion in free care that dentists currently deliver, as well as the nearly $2.1 billion spent on dental cases in hospital emergency departments – 80 percent of which could be treated in a dental office for roughly $4 million total, according to the bill.

Bipartisanship like this must continue and we urge legislators to make oral health a critical component of any health reform legislation that passes through this Congress. 

Congress: Protect Access to Dental Health Care

As the Senate debates health care bill proposals to transform our care delivery and financing systems, we must ensure they protect access to dental coverage for all Americans.

Over the past few years, more and more Americans have been able to access affordable dental coverage. In fact, since 2000, the percentage of children without dental coverage has been cut in half.

Medicaid has played a critical role in this progress. Dental services are considered an essential part of the Early Periodic Screening, Diagnostic and Treatment (EPSDT) program, which ensures that children receive regular dental care. Adults have also benefited in recent years, with 5.4 million adults gaining coverage through Medicaid expansion.

Other public programs have also helped. Because pediatric dental benefits are considered an essential health benefit on the exchanges, more kids have coverage. Further, many adults have selected dental coverage through the marketplaces.

As more of us gain access to coverage, we see the rate of untreated decay declining among low-income children, and research shows that costly emergency department visits for dental-related issues have declined. These improvements are in large part attributable to the fact that more people have access to dental coverage.

Over the past several months – continuing this week and for likely the near future – Congress has explored various avenues for health care reform. The value of oral health care and dental coverage cannot be overlooked in these conversations.

Let’s not overlook that tooth decay remains the most chronic condition among children, which can affect school performance and attendance.

Additionally, optimal oral health is not simply a goal in itself, but is vital to creating healthier communities. Research has shown that tooth decay can result in an elevated risk for diabetes, heart disease, and stroke. What’s more, recent studies demonstrate that treatment of gum disease can lead to better overall health management—as evidenced by lower health care costs and fewer hospitalizations—among people with common health conditions like those mentioned above or even pregnancy.

Any health care reforms must ensure dental remains a priority.

By improving access to dental coverage for low-income families in the past few years, we as a nation have made tremendous strides to

• ensure children are well-positioned for a lifetime of optimal health;  

• decrease poor quality, high-cost emergency department visits for dental-associated issues; and

• improve the oral and overall health of vulnerable populations.

We hope Congress pursues solutions that protect these improvements.

Let's Talk Water Fluoridation this Children's Dental Health Month

In addition to Valentine’s and Presidents’ Days, February also marks National Children’s Dental Health Month, with a theme this year connected to fluoridation.

Dating back to February 1941, the month-long celebration brings together dental professionals, health care providers, educators, policymakers and more stakeholders to promote the benefits of good oral health for children through various activities and events.

This year’s campaign slogan is “Choose Tap Water for a Sparkling Smile,” focusing on the value of fluoridation.

Fluoride combines with enamel on the tooth’s surface to make it stronger, better able to resist decay, and prevent dental caries —the most common chronic disease for children.  

Over the years, research has supported the value of fluoridation:

• In 2013, the U.S. Task Force on Community Preventive Services found that on average fluoridated water increased the number of people in a community without dental caries by 25 percent. 

• A 2010 American Journal of Public Health article indicated that a child who consumes fluoridated water is less likely to have lost teeth from decay 40 to 50 years later in adulthood. 

Water fluoridation, since it requires passive action to show effect, offers a simple solution to contain total oral health expenditures, improve population health, and set children up to have better oral health as adults.

Water fluoridation benefits the entire community, regardless of status or background, which is critical to addressing ethnic, geographic, and socioeconomic barriers to effective oral healthcare—a widespread problem in the United States.

National Institutes of Health data indicates that 20 percent of White, non-Hispanic Americans have untreated tooth decay compared to 40 percent for Black, non-Hispanic Americans and 38 percent for Mexican Americans.

This data also showed that individuals below the federal poverty line (FPL) are almost three times more likely to have untreated decay compared to those making twice the FPL or above.

This makes dental disease a disease of disparities, which can be prevented, in part, by easy and free access to fluoride.

Fluoridated water is an evidence-based, cost-effective path to promote health equity and, as an oral health organization committed to improving the oral health of all, it is just another reason DentaQuest celebrates National Children’s Dental Health Month.

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.

 

Make This a Fall for Smiles!

By Steve Pollock, President, DentaQuest

Good dental health starts at home, and parents and caregivers are THE most important role models for their children. Oral Health America has a nice booklet, Fall for Smiles, on their website that can help families talk about good oral health. Also, from September 19-25, Trident gum is donating 5 cents to Smiles Across America® for every pack of Trident gum sold. Smiles Across America helps children who do not get regular dental visits because their families lack resources, insurance, transportation, or because of language barriers.

Make this a fall for Smiles! Brush and floss your teeth daily. Be careful about the sugars in your diet. Avoid tobacco products. And schedule a visit with your dentist.

Tooth protection: Sealants for better oral health

We in the oral health community often take it for granted that everyone understands the importance of preventive treatments when it comes to good oral health. But the reality is that everyone isn’t aware of simple, cost effective things they can do—like brushing and flossing every day and seeing your dental care provider every year. And sometimes we don’t fully appreciate how difficult it may be for some to get dental services -- and that limits their use of preventive treatments.

Prevention is important for everyone, but especially so for children. If we can keep children free from dental disease, we are giving them a strong start to a healthy life. As I’ve said here before, it is hard to do well in school or in life, when you have constant tooth pain.

Dental sealants are a very good way to prevent tooth decay in children.

For those who may not be familiar with them, dental sealants are thin plastic coatings applied to permanent molars. The sealant is applied as a liquid that is brushed onto the deep grooves of teeth by your oral healthcare professional. Sealants dry into the plastic film that provides a physical barrier to bacteria and sugar and effectively protects the pits and grooves on the biting surfaces of teeth from dental decay.

Sealants are considered a cost-effective intervention to prevent tooth decay. Consider this: the cost of applying one dental sealant is significantly less than the average cost of filling that same tooth. And when you think that a single sealant may prevent that tooth from being re-filled many times over a lifetime, it is just pennies spent for every dollar saved.

In support of sealants as a proven preventive treatment, the U.S. Department of Health and Human Services’ Healthy People 2020 set a goal of increasing the number of children who have received dental sealants on their molar teeth to 50 percent. But, despite numerous studies confirming that sealants are a cost-effective intervention, only a handful of states have reached this goal.

To help reach this national goal, the DentaQuest Institute is working with five community health center dental programs to find effective ways to increase the use of sealants for children aged 6 to 8 and adolescents 12 to 14. Those are the ages when the permanent molars erupt into the mouth. We hope the results of this Dental Sealants Initiative will help other oral health care providers make sure sealants are a standard tool in their offices for preventing cavities in children and adolescents.

We are optimistic the results of this DentaQuest Institute quality improvement initiative will increase the number of children who receive dental sealants. And that means less dental disease.

Related Posts:
· Some Good News at Massachusetts’ Medicaid Dental Program
· Healthy Smiles in Miami Dade Schools
· Washington’s Unseen Oral Health Debate
· Let’s Talk About the Oral Health of America’s Children
· Is Anyone Listening?

Sip Safely

Spring and summer are a time of sports and hot, humid weather which leads to very thirsty kids. That often translates into an increase in the consumption of sugary and acidic sports drinks. These seemingly harmless liquids can actually wreak havoc on children’s teeth.

The combination of acidic components, sugars, and additives in sports drinks combine to erode the tooth’s surface, weakening the enamel that protects teeth from bacteria. The enamel erosion ultimately makes teeth more susceptible to bacteria and leads to hypersensitivity, staining, and tooth decay.

Frequent consumption of sports drinks lowers the pH in the mouth promoting the demineralization of tooth enamel. (The lower the pH, the more acidic the item.) Demineralization is caused primarily by stable acids found in acidic foods and drinks or which form as by product from bacteria feeding on starches and sugars in the mouth, especially refined sugars.

Demineralization begins at a pH level of 5.5 although under certain conditions, may even start at a higher pH. Popular sports drinks can have a pH of 2.4 and contain 5.5 tsp of sugar in a 12 oz can. So, not only does the drink have a pH that promotes demineralization, it also contains 5.5 tsp of sugar, which can independently contribute to demineralization and tooth decay.

To put the sports drink pH of 2.4 in perspective, compare it to battery acid, which has a pH of 0 and water, which has a pH of 5-7 (neutral). Shocking that a sports drink is closer on the pH scale to battery acid, than water.

Given all this, water is always the best option for everyone but the highest performing athletes who need to replenish minerals from intensive workouts.

If these facts haven’t convinced you to avoid the casual consumption of sports drinks, here are a few tips to keep in mind:

Don’t sip the drink throughout the day. - Drinking them for short periods of time means less time for the sugars and acids to erode enamel. Rinse your mouth with water when you’re done to clear away remaining acids and sugars.

Don’t swish the drink around your mouth. - That only increases the risk of erosion. Instead, use a straw so teeth aren’t immersed in or in direct contact with the sugars and acids in the beverage.

Resist the urge to brush your teeth immediately after finishing a sports drink. - Tooth enamel softens after consumption of acidic drinks, making teeth susceptible to more wear from the abrasives in toothpaste. Wait 45 minutes to an hour before brushing to give your saliva time to re-mineralize the tooth structure and neutralize the damage.

Seek regular dental care. - Tooth decay is the most common chronic childhood disease, five times more common than asthma. It’s also preventable with proper care. Your dentist can identify early signs of erosion, pinpoint the causes, and advise you on how to prevent further damage and more serious problems from occurring.

Eradicating Early Childhood Caries

This year, the Centers for Medicare & Medicaid Services and other experts estimate that more than 300,000 children under the age of six, many from lower-income households, will suffer from Early Childhood Caries (ECC) and require hospitalization. These young children often have a mouthful of cavities and a potentially life-threatening bacterial infection that may cause them to seek hospitalization. Another 1.5 million children are considered at risk for ECC. Hospital resources are so limited that children requiring operating room care at one of the few hospital-based dental clinics commonly wait up to six months before receiving treatment. In the meantime, parents rely on powerful antibiotics to keep the infection in check. (Not much can be done about the pain).

Early Childhood Caries can be prevented. But to do this, young parents need the right information about the oral health of their babies and toddlers in time to prevent infection. Without access to preventive education and care, children may find themselves facing rampant cavities, a hospital stay, and residual lifelong disadvantages—such as malnutrition, school absences, and missed work.

We at the DentaQuest Institute are tackling this preventable, chronic childhood disease head on. Working in partnership with researchers at Children’s Hospital Boston, we have developed a clinical protocol for treating Early Childhood Caries that works with primary care providers and parents to improve treatment in the hospital and, most importantly, at home. This program is using education and case-management to help change behavior at home and the dental office. Where this treatment plan has been used, we have been able to reduce the percentage of young children (under 60 months) with new cavities by 69 percent; reduced those who needed treatment by 55 percent; and reduced reports of children with mouth pain by 50 percent. The DentaQuest Institute is now working to expand the ECC program to 10 dental clinics across 8 states—including MA, RI, OH, NY, FL, CA, WA and NY. In many ways, Early Childhood Caries is a parable for what plagues healthcare: small problems that turn into big problems because the right information and resources weren’t available in the first place to stop the progression. Preventive health care is part of the solution, but it means nothing unless you know how to use it.

Dr. Mark Doherty, Executive Director, DentaQuest Institute and Dr. Jay Anderson, Director of Quality Improvement, DentaQuest Institute