Linda C. Niessen, DMD, MPH
How a public health and public policy focus have driven a dental career.
Inside Dentistry (ID): What was it about a career in dentistry that attracted you to the profession, and how did you broaden your focus to public health?
Linda C. Niessen (LCN): Dentistry provided an opportunity to serve the public as a healthcare professional,.combining artistic skills and scientific knowledge to develop medical and surgical therapies that help patients improve their health. During dental school, the questions I found most intriguing were those that examined population issues. Why were some patients more susceptible to periodontal disease than others? How could we prevent caries in a group of children? I liked thinking about how to improve the oral health of the public on a population basis. It was one of my professors and mentors during dental school, Walter Guralnick, DMD, chairman of the oral surgery department, who recognized this in me and identified me as the “public health dentist” in my class. I wasn’t sure what that was or what it meant, but I was willing to learn. During my senior year in dental school, I pursued a Masters of Public Health degree, graduating with both the DMD and MPH from dental school—something my son also did when he graduated from Arizona School of Dentistry and Oral Health in 2010.
After 3 years in the U.S. Public Health Service, I returned to Boston to enroll in a dental public health residency, and concurrently enrolled in the Masters of Public Policy degree at Harvard’s Kennedy School of Government. While dentistry represented 4% to 5% of healthcare costs, the public policy training provided a perspective on how healthcare fits into the overall public agenda, how it competes with education, transportation, defense, economic development, social services, and corrections. The mentorship of Chester Douglass, DDS, my residency program director, provided practical insights on policy development and how organizations can change to improve the oral health of the public. The combination of the MPH degree, residency, MPP degree, and the mentorship of Dr. Douglass all provided me with valuable insights that broadened my focus toward the specialty of dental public health. This perspective enabled me to navigate a career that has spanned clinical care in the Department of Veterans Affairs, an academic career as a professor and chair in a dental school, and now as chief clinical officer for DENTSPLY International, a large global dental manufacturer.
ID: What is dentistry like in the Department of Veterans Affairs system? What career opportunities exist in serving our nation’s veterans?
LCN: The VA, like the military, provides an excellent environment in which to practice dentistry and serve our nation’s veterans. These systems provide an interdisciplinary clinical environment where the dental team is recognized as part of the healthcare team that cares for current or former servicemen and women.
What I liked about practicing dentistry at the VA was the same thing I liked about practicing dentistry in the U.S. Public Health Service Division of Indian Health in Talihina, Oklahoma. Both enabled me to provide clinical care to individual patients as part of the hospital healthcare team, while at the same time considering the preventive or educational programs that could be implemented on a population basis to improve the oral health of the broader population.
Practicing dentistry within a hospital setting provides considerable intellectual nourishment. Hospital-based patients are usually medically.complex patients whose problems often require interactions with physicians, nurses, pharmacists, occupational therapists, social workers, and of course, other dental specialists. I enjoyed the complex decision-making required to care for these patients, and it regularly demonstrated the important role dentistry plays in improving a patient’s overall health, not to mention the clear relationship between systemic and oral health.
The VA continues to train a number of dentists in dental residency programs. I highly recommend the VA as a career option for those who enjoy practicing clinical dentistry on complex patients and working as part of a dental and medical group practice, so to speak. It is, indeed, an honorable career to practice dentistry in service to our nation’s veterans.
ID: The place of research and providing research experiences for students in pre-doctoral programs is frequently a contentious topic—especially among educators. How would you define this issue, and where do you stand on it?
LCN: The greatest contribution dental professionals make to dentistry is the thinking they do on behalf of their patients. Dentists are men and women of science. Our 4-year college degree, which is designed to meet dental school science pre-requisites, is the first step in the development of the scientific method and critical thinking. Dental education takes this basic knowledge and focuses it on the oral-health sciences. However, it is often the research experience during college or dental school that enables students to actually apply the scientific method; until you apply it, you don’t realize how complex it is.
Research is about asking the right questions and being willing to re-evaluate old questions. If you don’t ask, you won’t learn. Why do we perform a procedure a certain way? Is there a better approach that may be faster or easier and provide better ou.comes for the patient? I understand that the dental school curriculum has too much material to cover in too short a time, but I think a research experience at some point during dental education enables students to refine, reinforce, and practice their critical-thinking skills.
I applaud the American Dental Association for setting up an Evidence-Based Dentistry (EDB) Center, conducting CE courses on EBD, and educating dentists as EDB champions. The best clinicians are evaluating their clinical techniques and practice outcomes all the time. The EBD Center can help dentists who didn’t have a research experience during dental school gain those additional insights.
ID: In your current position, you are closely involved with a longstanding and much-acclaimed ADA/Dentsply Student Clinician Research awards program (SCADA) —both here in the United States and internationally. How has this organization developed over the years, and what have been some of the benefits for the students?
LCN: The ADA/DENTSPLY Student Clinician Research Program (nicknamed SCADA-Student Clinicians of the ADA) was launched in 1959, as a joint venture between the American Dental Association and DENTSPLY International. It was created by Harold Hillenbrand, DDS, then the executive director of the American Dental Association, and Henry Thornton, then the CEO of DENTSPLY International. Together, they wanted to develop a program that would celebrate the 100th anniversary of the American Dental Association. Its purpose was two-fold: 1) to recognize dental students for their research contributions; and 2) demonstrate to students the value of membership in organized dentistry. Fifty-two years later, this program continues and is stronger than ever; it has expanded to include dental students from 36 countries competing in 17 Student Clinician Programs around the world.
Reflecting on its 52-year history, SCADA has proven to be a leadership development program. Many who have participated as student clinicians have gone on to become leaders in dentistry as faculty, clinicians, and research scientists. Among them are Gordon Christensen, DDS, who participated in the first SCADA program in 1959; Rick Valachovic, DMD, the current executive director of the American Dental Education Association; Leo Rouse, DDS, the dean of Howard University School of Dentistry and current president of ADEA; Chuck Shuler, DMD, the dean of University of British Columbia; and scientists such as David Wong, DMD, at University of California at Los Angeles and Bill Giannobile, DDS, at the University of Michigan.
The SCADA programs around the world continue to expand. Those in South Africa, Australia, and China have all recently invited new schools to participate in the program. We would like every dental school to have its students participate.
Recognizing the leadership potential of these students, we are now linking with ADEA and other organizations to help recruit these students to careers in dental education and research. We believe that student research strengthens dental education and our dental schools. Without a strong research base, we don’t have a strong dental profession. The SCADA program helps ensure the future of this research base.
ID: Generally, are dentists adequately prepared during their education to accept innovation and new technologies? What might be some of the barriers to acceptance and adoption?
LCN: Dentists will see an array of innovations and new technologies in the span of their 30 to 40-year dental careers. Critical-thinking skills and lifelong learning are critical to helping dentists evaluate these new technologies and innovations. Our dental students today clearly have the intellectual bandwidth to be critical thinkers, and I think our dental schools are working diligently to instill these skills in their students. Whether an individual dentist adopts that technology will come down to decisions based on what is best for his/her practice and patients.
Technology transfer, or how an innovation diffuses through a population, is the subject of considerable research. For health professionals, the barriers are greater than in the general population, because patient outcomes are at stake. To ove.come barriers to adoption, a new technology/technique must be reliable, dependable, and consistently produce good patient outcomes.
Like the general population, some dentists will be early adopters, while others may lag behind. Dentists’ critical-thinking skills—the ability to evaluate the science underlying the innovation, its effect on patient outcomes, and obviously the cost of the innovation in both time and money—will contribute to the dentist’s decision about adopting a new technology. To the extent our dental schools continue to emphasize critical thinking in the curriculum and our students are.committed to lifelong learning, they will be able to evaluate innovations and make decisions based on what is right for them and their patients. Ultimately, if an innovation enables dental care provision that is faster, easier, and better, with the same or improved patient ou.comes, and also has a reasonable cost and is covered by the reimbursement system, it has a very good chance of being adopted.
ID: What do you see as the great challenges facing dentistry in terms of access to services in a changing healthcare environment, and how can the profession prepare for that?
LCN: I see the profession facing serious access issues on both ends of the age spectrum. First, many of our children are having difficulty receiving needed dental services at the same time we are seeing increases in oral diseases in children. The Patient Protection and Affordable Care Act (PPACA) will help improve access to care for children because it includes a children’s dental benefit (as yet undefined). It is estimated that 10 to 20 million children may have access to dental care through this new dental benefit, either through private insurance or expansion of Medicaid. At the other end of the age spectrum are the baby boomers who will continue to need dental care as they age. These baby boomers—10,000 of whom turn 65 every day—are the first generation to benefit from widespread fluoride use, either through.community water fluoridation or fluoride toothpaste. As a result, they are reaching age 65 with virtually all their teeth. As they develop chronic medical conditions, take more medications, and perhaps even require a nursing home admission, their oral health needs will become more complex.
The baby boomers are also the first generation to have had workplace dental insurance benefits. Now as they retire, and their health insurance switches to Medicare, in effect, they will lose their dental insurance (only a few Medicare Advantage programs include dental benefits) at a time when their dental needs may increase.
The other significant unmet oral health need concerns the 1.6 million people who currently reside in nursing homes. The current state of oral healthcare for nursing home residents is dismal, bordering on neglect. We have to figure out how to reach all these vulnerable populations with basic prevention and primary oral healthcare.
The profession—already challenged by technology and the movement toward consolidation—will need to prepare to meet these patient needs. It is not clear whether new providers and the economic investment these developing infrastructures require will solve this access issue. I am convinced that we do need to look at the roles of each of us in dental practice—dentist, hygienist, assistant, and laboratory technician—and determine how we can all practice at the top of our licenses and interact with our health professional colleagues in ways that benefit our patients.
As I see it, this approach offers another very exciting opportunity for both dentist and patient—the chance to prevent disasters. Among the worst experiences of clinicians is seeing patients who are very diligent about their oral hygiene regimen and regular in-office maintenance care, yet continue to deteriorate despite our best efforts. With early intervention in such patients, this progression can be averted, something that is very rewarding for the dentist, the staff, and, of course, the patient.
ID: What are your hopes and expectations for the future of dentistry?
LCN: I think the future of dentistry is incredibly exciting. Our students graduating in 2012 can look forward to a challenging and ever-changing career as they dedicate their lives to improving the oral health of their patients. Because we can’t predict the future, and we know the rate of change will only increase, a dentist’s commitment to lifelong learning and critical thinking are essential to ensuring a successful and intellectually nourishing career in dentistry.
New dentists face a wide array of opportunities in which to practice—in a solo private practice, a hospital setting like the VA, group practices, and everything in between. I tell students that dentistry is a mansion, not a one-room house. There are many rooms in this profession, with room for all to practice in a meaningful way and serve their patients.
As for my hopes, I would love to see the day when I do an extraction, put in a tooth bud, and a new tooth grows; perform an endodontic treatment, and place stem cells in the pulp to grow new dentin; and dissolve caries and add a material that stimulates dentin and enamel repair. The future holds an exciting biological approach based on harvesting the fruits of our molecular biology research and stimulating what the tooth—as the sophisticated and specialized organ that it is—does naturally.
What Lies Ahead?
Inside Dentistry asked Dr. Niessen what she thought the dental office as we know it today might look like 20 years from now.
“Envisioning the future is always risky business,” says Dr. Niessen, “but here goes. Picture this small-town, Midwestern dental office in the year 2032…”
- It is a group practice with five to eight dentists, including one to two specialists and a dental laboratory technician, who functions as the “digital specialist.”
- A nurse practitioner conducts a kind of “mini-physical” prior to the dental examination that includes taking the blood pressure; drawing blood to assess hemoglobin A1C, cholesterol, and C-reactive protein; as well as other new diagnostic tests.
- A preventive professional conducts salivary diagnostic tests—which are reimbursed—for oral diseases and other systemic diseases, as well as a risk assessment, such as CAMBRA, for oral diseases.
- This all-digital office includes electronic medical records, digital radiography, an intraoral scanner, and CAD/CAM.
- Dental diagnostic codes are universally accepted and used.
- Clinical guidelines—developed and agreed upon by the ADA and other dental organizations—outline a non-surgical (medical) approach prior to any surgical intervention.
- Surgical intervention subscribes to minimal invasive criteria.
- New dental materials include stem cells and tooth buds to grow new tissues and new teeth; and new adhesive and restorative materials no longer require removal of tooth structure, plus they work in the presence of blood and saliva.
- The practice is linked to other dental specialists and primary medical professionals to ensure that patients receive the referrals needed to improve their health.
- Each dentist provides a certain amount of community service, not because it is mandated but because it has become an accepted part of a dentist’s professional life.
- Most of all, dentists are still among the most highly respected health professionals because they have continued their com>mitment to access, prevention, and education of their patients.
About Dr. Niessen
Linda C. Niessen, DMD, MPH serves as vice president, chief clinical officer of DENTSPLY International and clinical professor in the department of restorative sciences at Texas A&M Health Science Center, Baylor College of Dentistry in Dallas. She is a Diplomate of the American Board of Dental Public Health and the American Board of Special Care Dentistry.
Dr. Niessen has served as president of the American Association of Public Health Dentistry, the American Association of Women Dentists, Dallas County Dental Society, Friends of the National Institute of Dental and Craniofacial Research, and the American Board of Dental Public Health. Currently she is vice president of the American Academy of Esthetic Dentistry, and serves on the Board of Regents of the American College of Dentists and the Board of Directors for Oral Health America.