Diversifying the Way You Practice
The impact of developments in health equity, medical-dental integration, and more
Over the past decade or so, general dentists have been diversifying their clinical skill sets, adding procedures ranging from root canal treatments to oral surgery to their armamentariums. The so-called "Super GP" can certainly offer an extensive set of services to patients. However, beyond clinical disciplines, how diverse are today's dentists in how they practice? Most primarily serve patients with private dental insurance or the means to pay significant out-of-pocket costs, and very few treat patients from among the more than 7 million Americans with intellectual and developmental disabilities (IDDs).1,2 And despite research indicating the relationship between oral and systemic health, most dentists are still unable to easily integrate patients' medical records or treatments into the care that they provide. Change appears to be on the horizon, however. The health equity and medical-dental integration movements are gaining traction, dental schools are updating their curricula to include treatment of patients with IDDs, and more. Regarding electronic health records (EHRs), options are expanding, and even insurance reimbursement models are evolving in some respects. Although for many dentists the focus of the past decade may have been on diversifying what they can accomplish inside the mouth, the future may be more about understanding a broader scope of needs for a wider range of patients.
Whom Are You Treating?
Hundreds of dentists travel to underdeveloped nations each year on mission trips. For a child who lives in a remote village of Trinidad who has to undertake a 2-hour trek through the jungle to get to the nearest dentist, even a basic extraction can be a life-changing procedure. An unfortunate reality, however, is that access to care is not much better in certain parts of the United States. For many, dentistry has remained a privilege limited to certain socioeconomic classes.
As of 2019, only 39% of US dentists accepted Medicaid. In 2012, then-Senator Barbara Ann Mikulski cited "skimpy to spartan" reimbursement rates and social service needs among the reasons for the low numbers.3 Meanwhile, there are no minimum federal requirements for states to provide dental services to their adult Medicaid-eligible populations.4 The Center for Health Care Strategies, Inc. classifies only 19 states as ones that offer "extensive" dental benefits for adults in Medicaid programs.5 Although meaningful change does not appear immediately imminent, leading voices in the profession are advocating for it by noting the potential for overall cost savings due to the oral-systemic health connection, among other benefits. The Oral Health Response Workgroup, a collection of leaders and organizations from across the dental industry, released a community statement in December 2022 calling on the US Congress to improve oral health equity and access by including extensive adult dental benefits in all state Medicaid programs.6 In addition, in 2021, New York State Medicaid data were used to examine the relationship between the receipt of dental services and all-cause emergency department visits, inpatient admissions, pharmacy costs, and total healthcare costs within the adult Medicaid population, and the analysis demonstrated that significantly lower costs were realized with the provision of dental care services.7 "Many in the academic and policy fields are really questioning the decades-long separation between dentistry and medicine in Medicare and Medicaid," says one of the authors of that study, Ira B. Lamster, MMSc, DDS, dean emeritus of the Columbia University College of Dental Medicine and professor in the Department of Health Policy and Management at Columbia's Mailman School of Public Health.
Until recently, Medicare has paid only for "dental services that are an integral part either of a covered procedure … or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw," as well as "oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances."8 In September 2021, the US House of Representatives initially included a proposal to expand dental benefits under Medicare in 2028 as part of a $3.5 trillion budget reconciliation package, but the American Dental Association (ADA) opposed the provision, and ultimately, it was removed. Coverage for treatments such as dentures and preventive services would have been included.9 "The ADA is opposed to the Medicare dental provision as proposed in the committee-passed bill, but does support an alternative proposal expanding access to oral healthcare for low-income seniors," the ADA said at the time, arguing that Medicare would not reimburse enough money to cover the costs under the House's proposal.9 Approximately a year later, however, the US Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) announced that it would "pay for dental examinations and treatments in more circumstances" and also establish an annual review process to consider further expansion.10 The final Medicare Physician Fee Schedule for 2023 specifically codifies Medicare coverage for dental services that are inextricably linked and substantially related and integral to organ transplant surgery, cardiac valve replacement, valvuloplasty procedures, and head and neck cancers, as well as the wiring of teeth related to covered medical services, the reduction of jaw fractures, the extraction of teeth in preparation for radiation treatment of neoplastic disease, dental splints for covered treatment of certain medical conditions, and oral or dental examinations relating to renal transplant surgery.11 Regarding implementation, challenges are likely to remain. "We are unsure of how the individual dentist will adapt to this change, but we suspect that DSOs will be very supportive because they have and can develop the infrastructure to allow Medicare to be billed for patient care," Lamster says. "DSOs are looking for ways to expand the population that receives dental care."
Access to care issues go beyond Medicaid and Medicare, of course; location is another limiting factor because many rural areas are classified as health professional shortage areas (HPSAs). However, various organizations are working to amend that as well. For example, at least one DSO is specifically dedicated to serving rural populations.12 Mobile services also bring dental care to schools, nursing homes, and other locations in these areas. In addition, dental therapy is authorized in at least some settings in 13 states, with more exploring authorizing it,13 and several states also permit expanded functions for dental hygienists and assistants. "Geographically, HPSAs make up almost the entire country," says Crystal Spring, RDH, president of Smiles Across Montana, a mobile dentistry service. "We work hard to not only reach patients in those areas but also connect them with the nearest dentists because continuity of care is so important."
Even in areas with plenty of dentists, access to care is often a problem for the IDD population, but that is changing as well. The Commission on Dental Accreditation (CODA) mandated that all US predoctoral education programs provide education to students regarding the management of patients with IDDs starting in 2020.14 Organizations such as the American Academy of Developmental Medicine & Dentistry (AADMD) and programs such as the National Inclusive Curricula for Health Education (NICHE), along with the American Dental Education Association (ADEA) itself, are working to ensure that as many dentists as possible are capable of treating patients with IDDs. "Dental schools have often said that they do not have the necessary personnel to teach these skills, but I believe that they do; we just need to provide the tools," says Allen Wong, DDS, EdD, a professor and director of the advanced education in general dentistry program at the University of the Pacific Arthur A. Dugoni School of Dentistry and past president of the AADMD. "The NICHE program will be a collection of tools that any junior faculty member can utilize anywhere." Wong adds that today's dental students are eager to learn these skills and serve a broader population. "The AADMD's student chapters are the driving forces leading institutions to make these changes," he says. "It is amazing when this population understands injustice. They are ready to make an impact, and their energy propels those of us who have been fighting this fight for a long time."
Treating a more diverse patient population can be a different experience for many dentists. "Be prepared for emotional situations when you see patients who have not previously had access to care," Spring says. "We go into schools and see holes in children's teeth. Many of them do not have their own toothbrushes." Spring emphasizes the importance, however, of maintaining the standard of care. "Many people think that public health work is substandard," she says, "but it is so important to do everything that you would do in a regular office—maybe even more. Education is particularly critical for these patients because so many of them have never learned about proper oral hygiene or how it can impact their overall health."
Although patients who have not received dental treatment regularly may have increased anxiety, dentists can utilize the same skills that they use on any patient with anxiety. "Regardless of the patient, it is all about the culture of the practice and the way that you embrace the individual," says Tommy Dorsey, DDS, owner of Colonial Drive Family Dentistry, a Heartland Dental supported practice in Ocoee, Florida. "Healthcare is a service, and empathy and understanding are the first keys to being able to relate to anyone who comes into a practice."
Lulu Tang, DMD, the owner of Sahara Modern Dentistry in Las Vegas, Nevada, emphasizes that her office has been successful with underserved patients because they prioritize the emotional factor more than some others might. "People often avoid the dentist out of fear of being judged, so when they do come to our office, we do everything possible to ensure that they feel warm and welcome," she says. "We apply that standard to every patient though."
Similarly, treating patients with IDDs often does not require any special skills or training. "IDDs encompass a huge variety of patients, but a person with Down syndrome, for example, is often easier to treat than a 50-year-old neurotypical patient," says David Ferguson, DDS, owner of Special Need Dental in San Antonio, Austin, and Houston, Texas. "Teeth are teeth. You may need to learn some skills with behavior management, but that primarily just involves taking an extra 5 minutes to talk to the patient to make him or her feel comfortable." Ferguson's practice exclusively treats patients with special needs, but he did not always practice that way. He started at a regular general practice and was merely willing to treat patients with special needs; however, that population organically became 60% of his patient base because so few other dentists would treat them. Ferguson later purchased his current practice so that he could focus exclusively on those patients. "There will be patients with unique needs, and there are specialists like us for that," he says. "However, many dentists would be surprised by how few patients with IDDs require them to modify anything. They just need a dentist with an open mind and an open heart. The most important advice I would offer is to just try it; if things do not go well, you can refer them. This population's caregivers are typically very forgiving because they understand the challenges." As treating patients with IDDs becomes more of a standard across general dentistry, Ferguson says it should be seen less as an expectation and more as an opportunity. "An expectation can come with guilt and anxiety," he says. "I hope we can reframe it as a blessing and an opportunity for which we never knew we were already equipped."
Ultimately, the most significant challenge in treating a more diverse patient base could be billing more services to Medicare and Medicaid. "The individual dentist or small group practice may have a difficult time adapting," says Solomon G. Brotman, DDS, a clinical instructor in the Department of Neural and Pain Sciences at the University of Maryland and chief clinical officer of USAble Life, a Blue Cross dental affiliate in seven states. "DSOs continue to develop the necessary infrastructure, which will expedite their growth as a major force in the delivery of dental care in the United States."
What Are You Treating and How?
The patient population is not the only element of dentistry that is diversifying. The aforementioned oral-systemic health connection has led to a push for fundamental changes in the way that dentistry is practiced, particularly regarding greater collaboration with physicians. "Multiple trends and interests are presently aligning to create an exciting moment where fundamental transformation is possible in how we approach and implement care delivery," says Steven William Kess, MBA, vice president of global relations for the Office of the Chairman & CEO at Henry Schein, Inc. "Dentistry is positioned to be a centerpiece to drive this shift toward holistic patient-centered practice."
Dental professionals are incorporating systemic considerations into their examinations and treatments and pursuing collaboration with their medical counterparts. "The correlation is just so two-sided," Spring says. "We are not only looking for oral manifestations of overall health but also at how oral health is affecting overall health—especially for diabetes." A study published in Compendium of Continuing Education in Dentistry in 2022 indicated that "adherence with preventive dental care is strongly associated with significantly lower healthcare costs. Average healthcare cost savings were progressively higher for patients with diabetes, coronary artery disease, and diabetes plus coronary artery disease."15
According to Dorsey, some Heartland Dental supported practices have been researching correlations between Alzheimer's disease and both periodontal disease and malocclusion. "We already know about correlations between oral disease and atherosclerosis,16 low birth weight,17 stroke,18 hypertension,19 and more," he says. "Periodontal disease and malocclusion have a high propensity to show us when our everyday patients have other systemic illnesses, and as we correct those oral health issues, the patient's overall health often improves."
Brotman, one of the Compendium study's authors, notes that the ideal impact of this and other similar research would be increased insurance reimbursement rates for preventive and diagnostic services. "A dentist's time is quite valuable, and we would like to see reimbursement models pay more for dentists' time than for procedures," he says. "Procedure codes for medicine are based on time. If dentistry can make that shift, it will be in the patient's best interest."
As the evidence supporting the oral-systemic connection mounts, medical insurance providers may even begin to cover preventive dental treatments. "We can now show that if we pay for relatively inexpensive prophylactic services under the medical benefit for members who are predisposed to inpatient care because of heart disease, diabetes, or both, then we might be able to save the medical plan quite a bit of money by decreasing hospitalization," says Mark T. Jansen, MD, vice president and chief medical officer for Arkansas Blue Cross and Blue Shield and another co-author of the Compendium study. "That makes a lot of sense to me, and it could become a differentiator for us with customers. Science is very interesting, but if you can prove to someone that they are being affected financially, then they usually start paying attention."
As important as insurance reimbursements are, another key to medical-dental integration may be the evolution of EHRs. Although integration with dental practice management software remains challenging, some dental practices have implemented EHRs from Epic, which holds more than 250 million patient records, to varying degrees.20 Jansen asserts that the medical side is willing but that there are remaining hurdles to overcome. "When EHRs first were developed, everyone believed we would all be able to see each other's records within a year," he says. "Now, the systems of interface are getting better. The biggest problems that remain with those exchanges involve data use agreements, internet security, and legal liability for data breaches. However, interoperability is coming, and I believe that it is coming quickly."
Some providers are taking medical-dental collaboration to the next level by co-locating practices. This strategy can improve the accessibility of dental care via convenience for patients, easier referrals for higher-risk patients from medical providers to dental providers or vice versa, and an enhanced ability to jointly manage complex patients.21 Two leaders in this movement have been Pacific Dental Services, which recently announced that it will open at least 25 more fully integrated practices within MemorialCare Medical Group health centers over the next 5 years,22 and The Aspen Group, which acquired WellNow Urgent Care in 2016.23 Tang, whose practice is supported by Pacific Dental Services, says the co-location is most helpful when patients present with elevated blood pressure. "We are able to bring the nurse practitioner into the room to evaluate whether a patient can safely undergo a procedure at that time," she says. "We either get instant approval, or we are told that it would be best to reschedule after further evaluation on the medical side. If that further evaluation is necessary, the medical provider can be the one breaking that news to the patient instead of the dentist or hygienist."
Although some education regarding medical conditions may be helpful for dentists, nothing extensive should be necessary to collaborate. "Dentists have the skills; they just do not realize it," says Carolina Salaberrios, MSN, FNP-C, of Sahara Health Group, which is co-located with Tang's practice. "They are doing thorough assessments, but they have had a different scope of practice. Perhaps a little bit of education on diabetes, for example, may help, but they do not need to be experts. They just need to know what a normal A1C level is and how to refer a patient with abnormal levels to a physician."
Tang's office also utilizes integrated Epic EHR software, which she notes is perhaps even more helpful than the co-location. She can see what procedures a patient has undergone or what conditions have been noted, along with their dental history, all in sequence. "On a busy day," she says, "we do not have time to sit down and discuss every patient. Having the ability to see each other's notes allows us to be so efficient." For example, one patient complained of bleeding gums, and Tang was able to quickly identify that he had skipped laboratory work that his medical provider had ordered to check for Type 1 diabetes. "He was very physically fit, so he was likely in denial, but I was able to reinforce the necessity of the laboratory work by telling him that I could not treat his bleeding gums permanently if his systemic health was not treated," she says. For the most part, dentists should not need to do anything very differently on their part after implementing EHRs. "You still do dentistry the same way, and you still chart the same way, but you know that your colleagues on the medical side will be following your notes, so there may be more intentionality in your language," Tang says.
Beyond collaboration, dental providers could supplement their medical providers in the delivery of certain medical services. The Public Readiness and Emergency Preparedness Act was already amended in 2021 and 2022 to allow dentists and dental students to administer COVID-19 and orthopoxvirus vaccines, respectively, and former Assistant Surgeon General Timothy L. Ricks, DMD, MPH, has spearheaded a Santa Fe Group effort over the past year to explore bringing more primary care services into dental offices. "Twenty-nine million Americans see a dentist each year but not a physician," Brotman says. "Performing certain screening activities in dental offices would be in patients' best interests."
Blood pressure screenings are perhaps the most impactful and realistic such service. Tang's office has made hemoglobin A1C testing a standard of care for every one of its dental patients, and the results have been alarming. "We are seeing so many patients who have undiagnosed elevated A1C levels," she says. "It has been eye-opening to see how many people just do not know what is going on in their bodies. Some dentists may be reluctant to do these screenings because a negative number can delay a treatment, but an ‘ignorance is bliss' approach is not what is best for the patient."
Brotman also mentions pulse oximetry, tobacco cessation programs, and maternal health screenings. "The maternal mortality rate in this country is higher than it should be, so we are considering a pilot project in areas with poor access to medical facilities and OBGYN services, whereby dental offices would perform urine tests on pregnant women to screen for protein that could signify preeclampsia or glucose that could signify gestational diabetes," he says. "Dental assistants would do most of the work, but we, as dental carriers, would need to pay for these services in order for the utilization to be significant, so the Santa Fe Group is investigating how to actually implement payment in a way that will be cost-effective for dentists and how to ensure that dental schools are teaching students how to perform these services properly."
Why Are You Treating?
Whether providing primary care services, collaborating with medical providers, or simply applying the latest research to a comprehensive dental examination, the dentist of the future will need to understand considerations beyond the mouth more than ever before. "The research is now there," Dorsey says. "As dentists in the modern era of dentistry, we need to be first in all aspects of oral-systemic health. We need to be able to thoroughly understand patients' laboratory results and medical histories, and we need to be able to tie that into the decisions that we make from an oral health standpoint."
According to Spring, treating the patient as comprehensively as possible is a responsibility for all dental professionals. She believes that dentists should not be reluctant to perform tests such as blood pressure screenings. "It is our job," she says. "It is within our scope of practice. We are part of the healthcare team. We are not just dental professionals; we are healthcare professionals."
There will be challenges. What is in the best interest of a patient's overall health-delaying a dental procedure, for example—may not always be in the best interest of the dental practice's efficiency or bottom line. In addition, evolution is gradual, so dramatically changing the way that dentistry is practiced will not be like flipping a switch. Tang is aware that patients who do not appreciate her attention to their medical histories and conditions sometimes simply find another dentist with a different approach; she is convinced, however, that her progressive approach is the proper way to provide care, and that is enough for her. "Our decisions should be based on what is right for the patient," she says. "I absolutely love helping patients understand what is going on with their bodies and doing what is best for their long-term health." Tang recommends that all dentists take steps toward preparing for a future that includes more diversity in the way that they practice. "One call to action is starting to prepare your partnerships with the local medical community," she says. "Start the referral process. Just as dental providers need to be educated on medical issues, medical providers need to be taught to look out for dental issues. It becomes a collaborative effort that does not require co-located practices. You never know if you are the last healthcare provider that your patient is seeing, so maximizing that appointment is so important. We want to work to not only get patients out of pain in the short term but also keep them healthy in the long term."
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