CDA Journal - September 2021: Addressing the Needs of Patients with Chronic Conditions

Journa C A L I F O R N I A

D E N TA L

September 2021 Oral Health and Dementia Human Papillomavirus Vaccinations Hypertension Screening Oral Health Literacy Toolkit

A S S O C I AT I O N

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S E P T E M B E R 2021

Jayanth Kumar, DDS, MPH

Vol 49 Nº 9

Addressing the Needs of Patients With Chronic Conditions in Dental Settings: A Look Into the Future

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Sept. 2021

C D A J O U R N A L , V O L 4 9 , Nº 9

d e pa r t m e n t s

545 Guest Editorial/How Lucky We Are …

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Impressions

551 Winners of the 2021 Dennis Shinbori, DDS, Table Clinic Competition 595 RM Matters/Saving Time and Staying Safe With Paperless Documentation 597 Regulatory Compliance/Disability Access and Nondiscrimination Laws 601 Tech Trends f e at u r e s

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555 Addressing the Needs of Patients With Chronic Conditions in Dental Settings: A Look Into the Future An introduction to the issue.

Jayanth Kumar, DDS, MPH

559 Oral Health and Dementia C.E. Credit This article discusses conditions that lead to cognitive decline in older individuals as well as strategies for providing oral health care services for these individuals.

Paul Glassman, DDS, MA, MBA

569 Dental Professionals and Human Papillomavirus Vaccinations This article explains how dental professionals are well positioned to be at the forefront of educating patients about human papillomavirus, discussing the HPV vaccine and promoting vaccination with their patients.

Alessandro Villa, DDS, PhD, MPH, and Dalton Pham, DMD

575 Hypertension Screening in the Dental Setting: A Pilot Program to Enhance Chronic Disease Management Through Medical-Dental Integration This paper addresses the importance of hypertension screening within the dental setting and outlines the development, implementation, results and lessons learned from the Maryland Hypertension Screening in the Dental Setting pilot program funded by the CDC. John Welby, MS; Debony Hughes, DDS; and Kristi Pier, MHS, MCHES

toolkit

587 California Oral Health Literacy Toolkit This toolkit includes five components to help providers learn or review basic oral health literary principles, including communicating clearly and with cultural humility and creating a welcoming environment for all patients.

California Department of Public Health, Office of Oral Health and the Health Research for Action Center at the University of California, Berkeley, School of Public Health

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C D A J O U R N A L , V O L 4 9 , Nº 9

Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

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D E N TA L

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Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor

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Jayanth Kumar, DDS, MPH Guest Editor

Volume 49 Number 9 September 2021

Letters to the Editor www.editorialmanager. com/jcaldentassoc

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Copyright 2021 by the California Dental Association. All rights reserved.

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Guest Editorial

C D A J O U R N A L , V O L 4 9 , Nº 9

How Lucky We Are …

Natasha Lee, DDS

P

eering out from behind my PPE and trying to say hello over the white noise of the air purifier, I sat down to do Lisa’s recall exam just like I had every six months for the many years I’ve been her dentist.

I asked her if she and her family were doing okay and she became quiet for a moment. She then explained that even though her family was totally healthy, she and her husband both had stable jobs and could work from home, and their kids were not suffering academically, she still found herself collapsed down on the floor in a sobbing mess recently.

A week later, I asked another patient how she was doing, knowing that she was an ICU nurse. Her eyes welled up with tears and she didn’t even have to say a thing for me to know that she was not OK. Yet another patient told me with all sincerity that he needed to get back to work for the sake of his marriage and his sobriety.

And on numerous occasions over the past many months, we’ve all had patients tell us how their visit to the dental office was really their first outing during the pandemic and how amazing it was for them to get to have a conversation with someone outside of their household, in person rather than on Zoom.

So lately I’ve been reflecting a lot on how very lucky we are to be dentists.

In the middle of a pandemic, we’ve been the ones who have figured out a way to safely interact with people up close and personally. We get to leave the house each day and interact with co-workers and patients.

We’ve been able to maintain human connectivity like very few have, and we should not take that for granted.

In the middle of a pandemic, we’ve been the ones who have figured out a way to safely interact with people up close and personally.

I also think about how much our patients have confirmed for us how much they really trust us. They have not only demonstrated trust in our infection control standards during a pandemic, but have shown us how much they trust us enough to tell us what ails them other than just tooth #19.

There have been numerous reports of patients seeking dental care for broken teeth and restorations, TMJ and muscle pain, many physical and outward signs of the stress and anxiety within. While the pandemic has taught us how resilient we really are, we will probably continue to see both the physical and emotional aftermath of what has been an incredibly challenging period of our lives.

As dentists we are uniquely positioned to be able to not only identify dental disease, but as compassionate human beings and empathetic listeners, we are truly capable of bringing so much more to our patients. And of course, we must also make sure we are being compassionate and empathetic with ourselves. As we are getting vaccinated and feeling a sense of hope on the horizon for a return to normal, I hope that we don’t lose sight of what we have learned from these extraordinary times about the importance of human connection, and how lucky we are to be dentists.

Natasha Lee, DDS, is the president of the San Francisco Dental Society and a former CDA president. She has a private practice in San Francisco.

Reprinted with permission from the San Francisco Dental Society.

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

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Impressions

C D A J O U R N A L , V O L 4 9 , Nº 9

Study Reveals New Aspects of Body’s Response to Plaque

3D rendering of a neutrophil.

(Blausen.com staff (2014).

“Medical gallery of Blausen Medical 2014” WikiJournal of Medicine.)

A team led by University of Washington researchers has, for the first time, identified and classified how different people respond to the accumulation of dental plaque. The study, recently published in the journal Proceedings of the National Academy of Sciences (PNAS), sheds important new light on why some people may be more prone to serious conditions like gingivitis that lead to tooth loss and other problems.

The researchers also found a previously unidentified range of inflammatory responses to bacterial accumulation in the mouth.

Bacteria buildup on tooth surfaces generates inflammation, a tool the body uses to tamp down the buildup. Previously, there were two known major oral inflammation phenotypes: a high or strong clinical response and a low clinical response. The team identified a third phenotype, which they called “slow:” a delayed strong inflammatory response in the wake of the bacterial buildup.

The study revealed for the first time that subjects with low clinical response also demonstrated a low inflammatory response for a wide variety of inflammation signals. Richard Darveau, MS, PhD, of the UW School of Dentistry, one of the study’s authors, wrote that understanding the variations in gum inflammation could help better identify people at elevated risk of periodontitis. It is also possible that this variation in the inflammatory response among the human population may be related to susceptibility to other chronic bacterial-associated inflammatory conditions such as inflammatory bowel disease.

In addition, the researchers found a novel protective response by the body, triggered by plaque accumulation, that can save tissue and bone during inflammation. This mechanism, which was apparent among all three phenotypes, utilizes white blood cells known as neutrophils. In the mouth, they act something like cops on the beat, patrolling and regulating the bacterial population to maintain a stable condition known as healthy homeostasis.

In this instance, plaque is not a villain. To the contrary, the researchers said that the proper amount and makeup of plaque supports normal tissue function. Studies in mice have also shown that plaque also provides a pathway for neutrophils to migrate from the bloodstream through the gum tissue and into crevices between the teeth and gums.

When healthy homeostasis exists and everything is working right, the neutrophils promote colonization resistance, a low-level protective inflammatory response that helps the mouth fend off an excess of unhealthy bacteria and resist infection. At the same time, the neutrophils help ensure the proper microbial composition for normal periodontal bone and tissue function.

The researchers’ findings underscore why dentists preach the virtues of regular brushing and flossing.

Read more of this study in PNAS (2021); doi.org/10.1073/ pnas.2012578118. n

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IMPRESSIONS C D A J O U R N A L , V O L 4 9 , Nº 9

Mucus and Mucins: Medicine of the Future Tooth Loss Associated With Dementia Tooth loss is a risk factor for cognitive impairment and dementia — and with each tooth lost, the risk of cognitive decline grows, according to a new analysis led by researchers at the NYU Rory Meyers College of Nursing and published in JAMDA: The Journal of Post-Acute and Long-Term Care Medicine. However, this risk was not significant among older adults with dentures, suggesting that timely treatment with dentures may protect against cognitive decline.

About 1 in 6 adults aged 65 or older have lost all of their teeth, according to the Centers for Disease Control and Prevention. Prior studies show a connection between tooth loss and diminished cognitive function, with researchers offering a range of possible explanations for this link. For one, missing teeth can lead to difficulty chewing, which may contribute to nutritional deficiencies or promote changes in the brain. A growing body of research also points to a connection between gingivitis and cognitive decline. In addition, tooth loss may reflect lifelong socioeconomic disadvantages that are also risk factors for cognitive decline.

For the study, researchers conducted a meta-analysis using longitudinal studies of tooth loss and cognitive impairment. The 14 studies included in their analysis involved a total of 34,074 adults and 4,689 cases of people with diminished cognitive function.

The team found that adults with more tooth loss had a 1.48 times higher risk of developing cognitive 548 SEP TEMBER

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Researchers from the DNRF Centre of Excellence, Copenhagen Center for Glycomics, have discovered how to artificially produce the healthy mucus that helps protect the human body from infectious diseases. The study was published in Nature Communications in July.

“We have developed a method for producing the important information found in human mucus, also called mucins, with their important sugars. Now, we show that it is possible to artificially produce it in the same way as we produce other therapeutic biologics today, such as antibodies and other biological medicine,” said Henrik Clausen, PhD, lead author of the study and director of the Copenhagen Center for Glycomics.

The mucus, or mucins, consist mostly of sugars. In the study, the researchers show that it is actually special patterns of sugars on the mucins that the bacteria recognize.

The researchers are particularly interested in the mucus in the gastrointestinal (GI) tract. Like a giant fishing net, the mucus keeps track of all the bacteria, the microbiome, in the GI tract. So, if the ability of bacteria to attach to the intestinal mucus could be imitated, oral medications that stick to the mucus could be designed, making the medications more effective.

Researchers have found a small molecule from bacteria — which they call X409 — that binds to the intestine.

“An incredible number of diseases have a connection to the intestinal flora, but we still know very little about how we can control the intestinal flora in the treatment of diseases. This is where synthetic mucins could open up new treatment options,” said Associate Professor Yoshiki Narimatsu, PhD, one of the lead authors of the study.

“Ultimately, one can imagine using mucins as a prebiotic material, that is, as molecules that help the good bacteria in the body.”

Read more of this study in Nature Communications (2021); dx.doi.org/ 10.1038/s41467-021-24366-4.

impairment and 1.28 times higher risk of being diagnosed with dementia, even after controlling for other factors.

However, adults missing teeth were more likely to have cognitive impairment if they did not have dentures (23.8%) compared to those with dentures (16.9%); a further analysis revealed that

the association between tooth loss and cognitive impairment was not significant when participants had dentures.

Learn more about this study in JAMDA (2021); doi.org/10.1016/ j.jamda.2021.05.009.

C D A J O U R N A L , V O L 4 9 , Nº 9

Third Molar Extraction May Improve Long-Term Taste Function Patients who had their third molars extracted had improved tasting abilities decades after having the surgery, according to a new Penn Medicine study published in the journal Chemical Senses. The findings challenge the notion that removal of the third molars only has the potential for negative effects on taste and represent

one of the first studies to analyze the longterm effects of extraction on taste. “This new study shows us that taste function can actually slightly improve between the time patients have surgery and up to 20 years later,” said senior author Richard L. Doty, PhD, director of the Smell and Taste Center at the University of Pennsylvania.

Machine-Learning Algorithms May Help Predict Tooth Loss New research led by investigators at the Harvard School of Dental Medicine (HSDM) suggests that machine-learning tools can help identify those at greatest risk for tooth loss and refer them for further dental assessment in an effort to ensure early interventions to avert or delay the condition.

The study, published in PLOS ONE in June, compared five algorithms using a different combination of variables to screen for risk. The results showed those that factored medical characteristics and socioeconomic variables, such as race, education, arthritis and diabetes, outperformed algorithms that relied on dental clinical indicators alone.

For the study, researchers used data comprising nearly 12,000 adults from the National Health and Nutrition Examination Survey to design and test five machinelearning algorithms and assess how well they predicted both complete and incremental tooth loss among adults based on socioeconomic, health and medical characteristics.

Notably, the algorithms were designed to assess risk without a dental exam.

Anyone deemed at high risk for tooth loss, however, would still have to undergo an actual exam.

“Our analysis showed that while all machine-learning models can be useful predictors of risk, those that incorporate socioeconomic variables can be especially powerful screening tools to identify those at heightened risk for tooth loss,” said study lead investigator Hawazin Elani, PhD, assistant professor of oral health policy and epidemiology at HSDM. The approach could be used to screen people globally and in a variety of health care settings even by nondental professionals, she added.

Learn more about this study in PLOS ONE (2021); dx.doi.org/10.1371/ journal.pone.0252873.

Dr. Doty and co-author Dane Kim, a third-year student at the University of Pennsylvania School of Dental Medicine, evaluated data from 1,255 patients who had undergone a chemosensory evaluation at Penn’s Smell and Taste Center over the course of 20 years. Among that group, 891 patients had received third molar extractions and 364 had not.

The “whole-mouth identification” test incorporated five different concentrations of sucrose, sodium chloride, citric acid and caffeine. Each solution was sipped, swished in the mouth and then spit out.

Subjects then indicated whether the solution tasted sweet, salty, sour or bitter.

The extraction group outperformed the control group for each of the four tastes, and in all cases, women outperformed men. The study suggests, for the first time, that people who have received extractions in the distant past experience, on average, an enhancement (typically a 3% to 10% improvement) in their ability to taste.

Two possibilities could explain the enhancement, according to the authors.

First, extraction damage to the nerves that innervate the taste buds on the front of the mouth can release inhibition on nerves that supply the taste buds at the rear of the mouth, increasing whole-mouth sensitivity. Second, hypersensitivity after peripheral nerve injury from a surgery like an extraction has been well documented in other contexts.

Learn more about this study in Chemical Senses (2021); dx.doi.org/ 10.1093/chemse/bjab032.

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table clinics 2021 C D A J O U R N A L , V O L 4 9 , Nº 9

Winners of the 2021 Dennis Shinbori, DDS, Table Clinic Competition Dental students, dental assistant students and military/residents from across the state competed virtually in the California Dental Association’s annual Table Clinic Competition, now named in honor of the late Dennis Shinbori, DDS, at CDA Presents in May. Judges conducted Q&A sessions via Zoom with the top 17 applicants for the second round and winners were announced during a live awards presentation May 16. The Journal is pleased to publish abstracts from the first-place winners in each category.

dental student winners Dental students Eugenie Choi, Christopher Chaffin and Joraldine Feliciano received first place in the dental student category.

Their research evaluated intraoral scanners.

Ability of Intraoral Scanners To Capture Crown Finish Line at Various Depths Eugenie Choi, Christopher Chaffin and Joraldine Feliciano, Loma Linda University School of Dentistry

Intraoral scanners (IOSs) have increased in use in dentistry, but there is a notable absence of literature analyzing their ability to capture a distinct and accurate crown finish line. This study measured the distinctness of the finish line of an all-ceramic crown typodont tooth at 1 mm supragingival to 3 mm

ABSTRACT:

subgingival depths, decreasing in 1 mm increments. The tooth was inserted into five 3D printed dentoform models with a removable gingiva and scanned. Each scan was superimposed over a control scan of the tooth, sectioned at 12 points, and the distinctness of the finish line was measured by finding the radius of each sectioned exit angle. Statistical analysis found that finish line distinctness decreased as subgingival depths increased and were statistically significant below the 1 mm subgingival depth. The results of this study appear to show that IOSs cannot capture a distinct and accurate finish line below 1 mm subgingival depths.

T HE CORRE S P ON DIN G AU T HOR , Eugenie Choi, can be reached at euchoi@students.llu.edu.

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table clinics 2021 C D A J O U R N A L , V O L 4 9 , Nº 9

military/resident winner

dental assisting student winner

Is Botox Beneficial in Dentistry?

Capt. Heather Baughman, DDS, DC, USAF, was the winner in the military/resident category. She researched the impact of breastfeeding on occlusion.

Taya Vongphachanh, Antelope Valley High School

Thank you to the following judges for the annual Dennis Shinbori Table Clinic Competition: Dental Assisting Students Judges Patricia Acosta, RDA Maleah Brooks, RDA Dental Students Judges Monica Bruce, DDS Pradip Patel, DDS Peter Young, DDS

Impact of Breastfeeding on Occlusion Capt. Heather Baughman, DDS, DC, United States Air Force

Functional stimuli, such as breathing, swallowing, chewing and sucking, have a major effect on craniofacial growth and development.

Breastfeeding in particular involves intense muscular activity that favors proper lip closure and tongue posture and stimulates mandibular function as well as decreases the deleterious effects of sucking habits. The protective factor of breastfeeding therefore contributes to proper development of the oral cavity leading to prevention of posterior crossbite and decreased incidence of detrimental nonnutritive sucking habits.

ABSTRACT:

THE AU THOR , Capt. Heather Baughman, DDS, DC, can be reached at baughmanmh@gmail.com. She acknowledges Dr. Jacob A. Powell, Lt. Col., USAF, DC, and Dr. Matthew Stratmeyer, Lt. Col., USAF, DC.

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Military Judges Tony Daher, DDS, MSEd Stafford Duhn, DDS Hemant Joshi, DDS Chi Leung, DDS Kenneth Yaros, DDS

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IT’S A VERB.

introduction C D A J O U R N A L , V O L 4 9 , Nº 9

Addressing the Needs of Dental Patients With Chronic Conditions: A Look Into the Future Jayanth Kumar, DDS, MPH

GUEST EDITOR Jayanth Kumar, DDS, MPH, is the state dental director for the California Department of Public Health.

Conflict of Interest Disclosure: None reported.

T

he coronavirus disease 2019 (COVID-19) pandemic has caused more harm to patients with preexisting, chronic conditions such as diabetes and obesity than healthy patients. As of June 30, 2021, the 65 and older age group accounted for 73.3% of 63,023 confirmed COVID-19-related deaths in California, suggesting an increased susceptibility in part due to higher rates of chronic diseases.1 As a result, this pandemic has brought increased attention to the needs of older adults and those suffering from chronic conditions.

Moving forward, the needs of older adults will require greater attention from U.S. policymakers and health care providers. In the recently released “Master Plan for Aging,” Gov. Gavin Newsom wrote, “Ten years from now, California will be home to 10.8 million people age 60 and over — nearly twice as many as in 2010. One out of every four Californians will be older adults, a seismic demographic shift that will change every aspect of our lives, from the structures of our families and communities to the drivers of our state’s economy.”2 According to this report, nearly half of all Californians will

develop one or more chronic illnesses.

Nearly 9 in 10 older adults take at least one prescription drug, with 1 in 4 finding their costs unaffordable, even with insurance coverage. Older adults are also at particular risk for mental health issues like depression.3 Another challenge Californians face is that approximately 20% of all people 65 and older live in poverty. One-quarter of people over 65 rely almost entirely on their Social Security benefits, which average about $1,500 per month for retired workers and $1,250 per month for disabled workers.

This issue of the Journal spotlights the burden of chronic diseases and its implications for dentistry. The California Department of Public Health 2020 report titled “The Burden of Chronic Disease, Injury and Environmental Exposures, California” provides a snapshot of chronic conditions, injuries and environmental exposures in the state.4 Approximately 40% of California adults reported having at least one chronic condition: serious psychological distress, high blood pressure, heart disease, diabetes or asthma. One in every six children in California and 1 in 3 teens are already overweight or obese, which is a risk factor for cardiovascular SEP TEMBER 2 0 2 1

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introduction C D A J O U R N A L , V O L 4 9 , Nº 9

disease, cancer and other chronic diseases. In 2016, an estimated $141 billion in direct costs was spent treating six chronic conditions in California: cardiovascular diseases, arthritis, cancer, diabetes, depression and asthma.5 In a previous issue of the Journal, we discussed6 the prevalence of tooth loss among Californians. In the combined years of 2014 and 2016, the prevalence of severe tooth loss among California adults (aged 25 years and older) was 41.4%.

The prevalence of tooth loss was higher among people with diabetes compared to those without diabetes (63.6% versus 38.7%). It was also associated with smoking, a common risk factor for many chronic diseases. Furthermore, there was disparity with respect to race/ ethnicity, income and education. Severe tooth loss (six or more teeth) was more common among older adults (25.9%).

The findings have enormous implications for dentistry. Future generations of older adults will have higher expectations to eat well, socialize more and enjoy a better quality of life. Therefore, older adults will likely opt for dental implants to replace missing teeth instead of unsupported dentures. While Medicare covers many types of implants, including cochlear, dental implants are not a covered benefit. This coverage gap is one of many challenges dentistry will have to face.

About 690,000 Californians aged 65 and older are living with Alzheimer’s disease.7 In this issue of the Journal, Paul Glassman, DDS, MA, MBA, discusses the management of dental patients with dementia. He has offered a thoughtful approach, which consists of planning treatment, supporting behavior during dental treatment and encouraging daily mouth care. In addition, dental practitioners may explore the concept of “community-engaged oral health systems” to help people 556 SEP TEMBER

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with Alzheimer’s disease and dementia obtain and maintain good oral health.

Annually, an average of nearly 35,000 HPV-related cancers occur in the U.S., and more than 90% percent of HPV-related cancers are preventable through HPV vaccination. Yet, only about 54.2% of teens were fully vaccinated against HPV in 2019, a slight improvement compared to 51.1% in 2018.8 In this issue, Alessandro Villa, DDS, PhD, MPH, and Dalton Pham, BS, discuss the role of dental professionals in preventing HPV-related

Dental professionals can play a significant role in addressing hypertension and heart disease by screening their patients.

cancers. Much like dental professionals’ role in addressing COVID-19 vaccine hesitancy, dental practitioners are well-positioned to promote HPV vaccination by providing counseling.

In California, approximately 63,000 people die each year from heart disease.

Stroke and hypertension cause more than 21,000 deaths.9 Dental professionals can play a significant role in addressing hypertension and heart disease by screening their patients. John Welby, MS, and colleagues discuss the Maryland Hypertension Screening in the Dental Setting pilot program to address a major risk factor for heart disease. Forty-seven dental practices were recruited and trained and conducted blood pressure screenings over 15 months. About 2,689 patients (7.2%) exceeded the blood

pressure threshold and were referred to primary care practices for follow-up evaluation. This pilot program offered many lessons and identified opportunities for medical-dental integration.

At the national level, there are several initiatives to integrate medical and dental systems. The Centers for Disease Control and Prevention Division of Oral Health awarded funding to the National Association of Chronic Disease Directors to develop a national framework for medical-dental integration. The Health Resources Services Administration developed the Integrating Oral Health and Primary Care Practice (IOHPCP) initiative to improve the knowledge and skills of primary care clinicians and promote interprofessional collaboration across health professions. The “Oral Health Delivery Framework” developed by a partnership of experts offers a practical model for partnership between primary care and dentistry.10 The National Interprofessional Initiative on Oral Health sponsored the “Oral Health Integration in Primary Care Project” to implement the framework.11 As part of a paper commissioned for the Roundtable on Health Literacy of the National Academies of Sciences, Engineering and Medicine, Atchison and colleagues12 discussed the importance of incorporating oral health literacy principles into all levels of a health care organization, establishing formal collaboration and referral networks, conducting research and demonstration programs on the integration of oral health into primary care and developing effective linkages between primary care teams and dentists in private practices.

As the population ages and develops multiple chronic conditions, dental practitioners will need to communicate more frequently with primary care providers. In the medical setting, this

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happens primarily through the electronic platform. However, dentistry is not well connected with such platforms. As noted by the Health Policy Institute of the American Dental Association, physicians are dissatisfied with current referral systems to dentists.12 Resolving this will require the development of an integrated electronic referral management system. In addition, dental practitioners should also be prepared to collaborate with other health care teams to address the problems of patients with multiple chronic conditions. n

RE FE RE N C E S 1. Tracking COVID-19 in California. Infections by group.

Accessed July 1,2021. covid19.ca.gov/state-dashboard.

2. California Department of Aging. Master Plan for Aging. A Message from Governor Gavin Newsom, p. 2. 2021.

3. California Department of Aging. Master Plan for Aging.

Goal Two. Health Reimagined, p. 10. 2021.

4. California Department of Public Health, Center for Healthy Communities. The Burden of Chronic Disease, Injury and Environmental Exposure, California, 2nd ed. 2020.

5. Yoo BK, Xing G, Hoch JS, Taylor C, Núñez de Ybarra J. Economic Burden of Chronic Disease in California in 2018.

6. Cigarette smoking and tooth loss in California: The role of dental professionals in promoting tobacco cessation. J Calif Dent Assoc 2019;47(2):97–102.

7. Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. www.alz.org/alzheimers-dementia/facts-figures.

8. Elam-Evans LD, Yankey D, Singleton JA, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2019. MMWR Morb Mortal Wkly Rep 2020 Aug 21;69(33):1109–1116. doi: 10.15585/mmwr.mm6933a1.

9. Centers for Disease Control and Prevention. Stats of the State of California. www.cdc.gov/nchs/pressroom/states/california/ california.htm.

10. Qualis Health. Oral Health: An Essential Component of Primary Care. White paper. June 2015.

11. National Interprofessional Initiative on Oral Health. Oral Health Integration Implementation Project. www.niioh.org/ Implementation-Guide.

12. Atchison KA, Rozier RG, Weintraub JA. 2018. Integration of oral health and primary care: Communication, coordination and referral. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, D.C. doi.org/10.31478/201810e.

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dementia C D A J O U R N A L , V O L 4 9 , Nº 9

C.E. Credit

Oral Health and Dementia Paul Glassman, DDS, MA, MBA

abstract There is a significant increase in the number of people over age 60 who are living with dementia. It is important that oral health practitioners understand conditions that lead to cognitive decline in older individuals as well as strategies for providing oral health care services for these individuals. These strategies include conducting office-based care as well as creating community-engaged oral health systems that can help people with Alzheimer’s disease and dementia obtain and maintain good oral health.

Keywords: Oral health, dental treatment, Alzheimer’s disease, dementia, cognitive decline, communityengaged oral health systems

AUTHOR Paul Glassman, DDS, MA, MBA, is a professor and associate dean for research and community engagement at California Northstate University College of Dental Medicine in Elk Grove, Calif.

Conflict of Interest Disclosure: None reported.

I

mproved living conditions, increasing lifespans and better health care have resulted in shifting disease patterns across the world.1 One result has been a 113% increase between 1990 and 2010 in the worldwide number of people over age 60 living with dementia.2 This is a far larger increase than the increase in those living with cardiovascular disease (22%), diabetes (80%) and vision and hearing impairment (49% and 42%). In 2020, the World Health Organization (WHO) reported that there were 50 million people living with dementia and over 10 million new cases each year.3 The WHO also reported that the total number of people with dementia is projected to reach 82 million in 2030 and 152 million in 2050. These trends have major implications for health and the provision of health care, including oral health care.

A recent systematic review indicated the relationship between learning and memory, complex attention and executive function with poor oral

health in old age.4 Mechanisms for this association include reduced ability to perform daily mouth care procedures, difficulty accessing and receiving dental care and reduced salivary flow.5–9 Given the increasing number of people with some form of dementia, it is important that oral health practitioners understand conditions that lead to cognitive impairment in older individuals as well as strategies for providing oral health care services for these individuals.10,11

Dementia and Other Causes of Cognition Impairment

There are a number of conditions that can lead to cognitive impairment in older adults. These conditions are often categorized as the “3 Ds” — delirium, depression and dementia.12 They can all produce presenting signs that include memory loss, lack of responsiveness, confusion and difficulty completing tasks of daily life.

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Delirium is sometimes characterized as a disturbance of awareness. It is usually a sudden and temporary change resulting in a state of confusion.

It typically results from a specific underlying cause such as serious medical conditions, an infection with systemic manifestations, recovery from general anesthesia or a side effect of medication.13 The individual may exhibit changes in alertness, sleep patterns, short-term memory, disorganized thinking and emotional or personality changes.

Although the manifestations of delirium often recede if the underlying cause is addressed, delirium can become chronic and permanent.

Depression is sometimes characterized as a disturbance of mood. Major depression is one of the most common mental disorders in the United States.14,15 It is characterized by a period of at least two weeks when a person experiences a depressed mood or loss of interest or pleasure in daily activities along with a majority of specified symptoms, such as problems with sleep, eating, energy, concentration or self-worth.14 Symptoms of depression can also include tearful or sad feelings, weight change (usually decreased), trouble sleeping, psychomotor agitation, fatigue or loss of energy, feelings of worthlessness or guilt, loss of ability to concentrate and indecisiveness.

In contrast to delirium and depression, dementia is often characterized as a disturbance of cognitive function including problems with thinking, memory and reasoning.16 It can include: ■ Aphasia or language impairment affecting the production or comprehension of speech.

■ Apraxia or loss of ability to carry out movements such as writing, gait and complex tasks.

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Agnosia or loss of ability to recognize objects or persons.

■ “Executive function loss” or loss of ability to plan ahead and foresee consequences.

There are a number of causes of dementia. Most are progressive and not amenable to treatment. However, in some cases the manifestations of dementia, as is the case with delirium, can be brought on by an underlying medical condition or infection or tumors that can be treated. For this reason, it is critical that an oral health practitioner who ■

Major depression is one of the most common mental disorders in the United States.

recognizes altered mental functioning in one of their patients, including any of the manifestations listed previously, ensure that the patient has had a thorough medical work-up and diagnosis.

Causes of Dementia

As indicated, there are a number of causes of dementia.17 The most common is Alzheimer’s disease, but causes also include frontotemporal disorders, Lewy body dementia and other neurodegenerative disorders and vascular conditions.

Frontotemporal disorders are the result of damage to the neurons (nerve cells) in parts of the brain called the frontal and temporal lobes.18 They are caused by a family of brain diseases known as frontotemporal lobar degeneration (FTLD), which results in the severe loss

of thinking abilities. These disorders are progressive and result in increasingly severe symptoms over time. People can live with these disorders for a decade, and no treatment is currently available.

Lewy body dementia (LBD) is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain.19 These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior and mood. LBD is one of the most common causes of dementia.

The disease starts with mild symptoms and progresses over time. It typically takes five to eight years from diagnosis to death, but some people can live up to 20 years after the diagnosis.

Other neurodegenerative diseases such as Parkinson’s and Huntington’s primarily cause progressive difficulty with movement.20,21 However, the diseases can, as they advance, produce mental and behavioral changes, sleep problems, depression and memory difficulties.

Dementia may also be related to vascular disease that causes brain damage by restricting blood flow to certain areas of the brain.22 One type, vascular dementia, is caused by a series of small strokes. This can result in what is known as “stairstep decline” with periods of stable symptoms and then occasional sudden progression of symptoms following a small stroke. This is in contrast to other forms of dementia, which tend to exhibit a relatively steady decline.

Finally, the most common form of dementia is Alzheimer’s disease, which affects an estimated 5.5 million Americans.23,24 Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory, thinking skills and, eventually, the ability to carry out basic activities of living. Most people with Alzheimer’s disease find

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that the first symptoms appear in their mid-60s and slowly progress over five to 10 years. However, about 200,000 Americans under age 65 have youngeronset Alzheimer’s disease.25 Dr. Alois Alzheimer first described the progressive changes in 1906. On autopsy, the brains of people with Alzheimer’s are found to contain many abnormal clumps known as amyloid plaques and tangled bundles of fibers called neurofibrillary tangles. Changes in brain structure can now be detected by brain imaging even before symptoms start as neurons die and parts of the brain begin to shrink.

to go on with their daily lives. There are a number of studies underway to try to detect biomarkers or other early signs of this disease. Some common early signs include:25 ■ Memory loss that disrupts daily life.

■ Challenges in planning or solving problems.

■ Difficulty completing familiar tasks.

■ Confusion with time and place.

■ Trouble understanding visual images or spatial relationships.

■ New problems with words in speaking or writing.

Stages of Alzheimer’s Disease

Before describing the stages of dementia, it is important to distinguish between normal age-related memory loss and symptoms of Alzheimer’s or dementia.26 Many older adults experience some form of memory loss but are unlikely to have dementia. What is sometimes described as “age-related memory impairment” does not impact the ability to carry out activities of daily living and is unlikely to progress to interfere with those activities.

Age-related memory impairment is described as an individual having some difficulties with memory, but these difficulties are not noticeably disrupting daily life and are not affecting the ability to complete tasks as they are normally done. Individuals with this condition have no difficulty learning and remembering new things and have no underlying medical condition that is causing the memory problems.

Alzheimer’s disease and dementia in general are described as progressing through stages.27,28 In the early stages of Alzheimer’s disease, people can experience mild cognitive impairment (MCI). They may have increasing memory problems but are still able

Alzheimer’s disease and dementia in general are described as progressing through stages.

Misplacing things and losing the ability to retrace steps.

■ Decreased or poor judgement.

■ Withdrawal from work or social activities.

■ Changes in mood or personality.

As the brain damage causing dementia continues, symptoms can progress. The term moderate Alzheimer’s disease describes people with greater memory loss who may have symptoms that include wandering and getting lost, trouble handling money and paying bills, repeating questions, taking longer to complete normal daily tasks and personality and behavior changes.

In the later stages of severe Alzheimer’s disease, people will lose the ability to communicate and will become completely dependent on others for care.

■

Diagnosis and Treatment of Alzheimer’s Disease

Although there is no single gene that directly causes Alzheimer’s disease, there is a genetic component to the disease.29 Those people who have a parent or sibling with Alzheimer’s are more likely to develop the disease than those who do not have a firstdegree relative with Alzheimer’s. Those who have more than one first-degree relative with Alzheimer’s are at an even higher risk.

A diagnosis of Alzheimer’s disease is made using a variety of tests and indicators.30 These involve a health history, mental status exam and blood tests for heart, lung, liver, kidney or thyroid problems to rule out other underlying causes of symptoms. In addition, brain, imaging tests such as a computerized tomography (CT) scan or a magnetic resonance imaging (MRI) scan can reveal brain structure shrinkage. A single proton emission computed tomography (SPECT) scan can reveal blood flow through the brain, and a positive electron tomography (PET) scan can reveal how different areas of the brain respond during certain activities such as reading and talking.

There are currently no cures for Alzheimer’s disease. However, there are some medications that treat some symptoms for a limited time.31 The U.S. Food and Drug Administration (FDA) has approved two types of medications: cholinesterase inhibitors (Aricept, Exelon, Razadyne) and memantine (Namenda) to treat the cognitive symptoms (memory loss, confusion and problems with thinking and reasoning) of Alzheimer’s disease.

While they can slow down or delay the worsening of symptoms, they do not prevent the ultimate progression of the disease.

Dental Treatment and Dementia

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primary categories: planning treatment, supporting behavior during dental treatment and supporting daily mouth care.

Planning Treatment

Planning oral health care treatment for people with dementia includes all the same steps in data gathering, diagnosis and treatment planning that are used with people without dementia.

However, as is the case when planning treatment for people with a wide variety of complicated conditions, there are additional components of this process that oral health providers must include in order to produce a plan that is appropriate for that individual (FIGURE).9,32,33 The first step in planning treatment is gathering data. In gathering data about a patient with dementia, it is important to expand the typical data gathered in a medical and dental history to investigate and understand the following: The ability of the individual to function on a daily basis. These abilities are characterized as limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL).34 ADLs are the most basic activities of daily living including feeding, dressing, bathing and walking. IADLs are activities needed to be able to live independently in a community. These include cooking, cleaning, transportation, laundry and managing finances. Although there are formal assessment tools for these limitations, valuable information can be obtained by including questions about these abilities in a health history. It may be necessary to ask both the patient and someone who lives with them or helps to care for them to obtain a full picture.

Limitations in ADLs and even IADLs can predict problems completing “daily mouth care” routines or being able to receive dental care in an office environment.

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Health conditions that can impact oral health and oral health care. Many health conditions can impact oral health or the ability to receive oral health care. One that is of special concern is the high incidence of xerostomia in people with dementia. In a study of individuals in health care centers with mild cognitive impairment or dementia, over 70% of those with cognitive impairment had xerostomia compared with only 37% of those without cognitive impairment.35

Limitations in ADLs and even IADLs can predict problems completing “daily mouth care” routines or being able to receive dental care in an office environment.

Oral health-related abilities of the individual. This includes an understanding of what the individual is able to do. Some people, in spite of a specific limitation in ADLs or IADLs, can still do some things that are important for oral health. This might include performing independently or allowing, with support, completion of “daily mouth care” procedures. It might also include the ability to sit in the dental chair and allow some types of procedures to be performed.

Social situation of the individual. This includes a full understanding of the individual’s living arrangements, who they live with, whether someone else has responsibility for helping them with ADLs or IADLs and whether they are connected with social service or other support-

systems organizations. It also includes their ability to have transportation to office appointments, as well as their financial situation. It is critical that the oral health professional understand the level of support available for the individual both to know who to work with in planning treatment, who will be responsible for carrying out various aspects of the treatment plan and what kind of care could be realistic for this individual.

History or ability of an individual to receive treatment in a dental office. It may be possible to predict the individual’s ability to go into a dental office, sit in the dental chair and allow simple or complex dental procedures to be performed based on their history with similar circumstances.

Of course, when dealing with a neurodegenerative disorder, a more recent history is more valuable than a history of events that took place in the distant past.

Who can provide consent. This includes understanding whether the individual is able to provide their own consent for dental procedures or whether someone else is designated and allowed to do so.

In general, people retain the ability to provide or deny consent for health care procedures unless they have used legal instruments or processes to assign or have that ability assigned to another legal guardian or decision-maker. The legal term for this ability is “capacity.”36 Some individuals, at a stage when they still have this capacity, prepare a formal power of attorney designating someone else to be able to make health care decisions for them once they no longer have that capacity. However, all individuals experiencing cognitive impairment may not have done that and also may not be able to provide an informed consent, which requires that they make health care decisions after understanding the

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PLANNING DENTAL CARE FOR OLDER ADULTS CONSIDER: Ability to function in daily life Ability to perform basic life functions like independently eating, dressing, bathing, walking

Oral health abilities Ability to perform “daily mouth care” procedures

Ability to function in daily life Ability to sit in a dental chair and allow simple or complex procedures to be performed What methods can be used to assist with dental treatment in an office?

To complete their dental treatment, will they need behavior support, physical support, sedation?

Impact of current oral health conditions What will the impact be of current oral health problems? Do they need treatment?

Health conditions that impact oral health and oral health care Medical, physical and mental conditions, especially those leading to “dry mouth” Social situation Living arrangements, social support system, caregiving arrangements

Determine who can provide consent Does the individual have “capacity” to make health care decisions? If not, who can make that decision?

Will their conditions get worse?

Will their health, physical or mental conditions get worse? How quickly?

USE THESE FACTORS TO DEVELOP A PLAN: Limited versus complex treatment Can complicated procedures be performed and maintained or is limited treatment needed?

Behavior support strategies Can behavior support strategies be used to help the person have treatment in an office?

Community-based care Should the emphasis be on providing some care preventive procedures in community sites?

Use telehealth-connected teams such as the virtual dental home system Should a full-services, telehealth-supported community-care system like the virtual dental home be used?

FIGURE . Oral health providers need to consider additional components when planning treatment for those with complicated conditions.

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risks, benefits and alternatives to any proposed procedures.37 In some cases, it is not clear to the oral health practitioner whether the individual has the capacity to make an informed consent. It might be possible for the oral health practitioner to ask the patient to repeat back to them what they were told about the risks, benefits and alternatives to the proposed procedure. If they can do that, the oral health practitioner can conclude that they have capacity to make that decision.

If they cannot and no one is designated to provide a legal consent, the oral health practitioner may need to contact the patient’s next of kin, social service systems or organizations the individual is involved with or other resources to make that determination. Some social service systems or organizations have the ability to act as a “public guardian” and provide consent for health care procedures.38–40 The prognosis for progression of the individual’s limitations. It is critical that the oral health practitioner understand the prognosis for progression of the individual’s cognitive limitations as well as other associated medical and social conditions.

Individuals with similar sounding diagnoses may have a significantly different prognosis for how quickly their limitations will progress. For example, someone with mild cognitive impairment due to a developmental intellectual disability may have the same level of cognitive ability for many years, whereas someone with a similar current level of cognitive ability due to mild cognitive impairment from Alzheimer’s disease may have significantly less ability in a few years. While both individuals may be able to have the same kind of dental treatment performed now, they may differ in their ability to maintain their oral health in a few years. These predictable future differences are important to consider when planning treatment.

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The ability to use various treatment modalities. There are many ways that dental treatment can be delivered. These range from normal dental office routines to the use of behavioral, physical or social supports to the use of pharmacological agents in the office or operating room environment. A consensus development consent process conducted by the Special Care Dentistry Association resulted in a set of guidelines about the use of sedation, anesthesia and alternative techniques for people with special needs.41,42 The resulting guidelines

Some social service systems or organizations have the ability to act as a “public guardian“ and provide consent for health care procedures. emphasize the use of nonpharmacological interventions that can reduce the need for pharmacological intervention. This is particularly important in people with dementia who are at increased risk for developing complications following sedation or anesthesia.43 The impact of current oral health conditions. Some oral health conditions, although not “ideal” or even “optimum,” may cause relatively few problems for the individual. In contrast, addressing those problems may be extremely difficult for individuals and their caregivers or support systems. It is important for oral health practitioners to remember that there are situations where “the cure may be worse than the problem.”

Once the oral health practitioner has obtained the information described above, it is important to weigh the various factors and present a plan to the patient or appropriate decision-makers that properly weighs these factors. An example decision-making guide for weighing these factors is presented in the TA BLE . The left column lists various factors that would lead to the conclusion that very limited treatment should be provided, maybe only treatment of pain and infection and any other palliative treatment. The right column lists factors that would lead to the conclusion that extensive or complicated treatment could be provided. These factors do not have precise definitions and require the practitioner to assess and weigh judgement. In addition, most individuals will have a mixture of these factors and therefore require careful consideration and presentation of the alternatives and of the risks, benefits and alternatives for that individual before a treatment plan is completed.

Behavior Support During Dental Treatment

If a decision is made to provide dental treatment in an office setting, there are a number of nonpharmacological approaches that can increase the likelihood of having a successful appointment.44–47 These are, of course, more likely to be successful with people with mild impairment and less likely as the condition progresses.

Some things to try are: ■ Obtain a good history about the individual’s behavior in other settings. Find out what things are likely to make an encounter with this individual go well and what might produce the opposite or unintended results.

■ Understand and discuss the value of having someone who knows

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TABLE

Analysis of Alternative Treatment Plan Approaches Based on History Factors Limited treatment

the individual accompany them into the dental treatment area. In some situations, and with some individuals, this may be helpful and for others it may not.

■ Schedule appointments early in the day rather than later, as people with progressing dementia tend to have better cognitive functioning in the morning compared to the afternoon.

■ Approach the individual slowly from the front and position yourself so you are at the individual’s eye level.

■ Use a calm demeanor and voice when speaking to the individual. Be patient, flexible and understanding. Smile.

■ Allow enough time for the person to respond (counting to five between phrases is helpful).

■ Focus on the person’s feelings, not the facts.

■ Introduce yourself and remind them why they are there and what you’re going to do in simple terms. Depending on the level of impairment, you may need to do this multiple times during the appointment.

■ Increase the use of gestures and other nonverbal communication techniques.

■ Watch for signs that the individual is becoming agitated and be prepared to stop, provide a break or stop the appointment for that day.

■ As dementia progresses, people may have good and bad days. If an appointment does not go well on a specific day, it is possible that rescheduling for a different day could produce better results.

It is important to match the strategy used to the individual’s cognitive and communication abilities. Not understanding their abilities could

• • • • • • • • • •

Poor medical prognosis Poor cognitive prognosis Little functional reserve High degree of dependence Limited communication Difficulty with office treatment Little caregiver participation No social support Limited finances Poor dental prognosis

result in being perceived as “talking down” to them or treating an adult as a child when there is no need to do so.

Community-Engaged Oral Health Systems

As individuals experience increased cognitive impairment, the likelihood that they will access dental care in a dental office declines.48 Therefore, providing oral health services for people with dementia may require reaching them in community caregiving settings. In addition, while a dental office may be needed for procedures that require surgical interventions, it may not be the best environment for many other activities critical to obtaining and maintaining oral health. These include the adoption of daily mouth care routines and the use of minimally invasive medical and early intervention procedures that can be accomplished in community settings outside of a dental office.49 There is growing recognition that delivery systems that “bring care to where people are” have significant potential to create important “community-clinical linkages.” This phrase refers to systems that involve and deliver health services in community settings and link those community delivery systems to office- or clinic-based care to create seamless, fullservice systems of care. These systems have important ingredients in prevention and control of chronic diseases including

Complex treatment • • • • • • • • • •

Good medical prognosis Good cognitive prognosis High functional reserve High degree of independence Good communication Able to have office treatment Good caregiver participation Good social support No financial limitations Good dental prognosis

oral diseases.50 They also allow the reach of dental practices to be extended beyond the walls of dental offices.

According to the American Dental Hygienists’ Association (ADHA), in 2021, 42 states had some form of “direct access” rule that allows dental hygienists the ability to initiate treatment based on their assessment of a patient’s need for dental hygiene services without the specific authorization of a dentist, treat the patient without the presence of a dentist and maintain a providerpatient relationship.”51 In California, the license category that permits these duties is registered dental hygienist in alternative practice (RDHAP)52 and there is a 150-hour training requirement to obtain this license. The training program this author started and directed for 16 years at the University of the Pacific, Arthur A. Dugoni School of Dentistry and the program this author started at California Northstate University have an emphasis on background and principles for providing dental hygiene services in community settings for traditionally underserved groups including people with dementia.53 Graduates of these programs are able to bring oral health services to community locations. Further, in California, dental hygienists working in the virtual dental home (VDH) model of care, which links patients to a dentist and source of comprehensive care, can also place silver diamine fluoride (SDF) to stop the progression of dental caries SEP TEMBER 2 0 2 1

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lesions and, with additional training and certification, place interim therapeutic restorations at the direction of the dentist.

These services are critical components of oral health systems needed to maintain oral health for people with dementia in community caregiving settings.

The VDH system of care is a system that uses allied oral health personnel including dental hygienists and assistants to bring care to community sites, involve dentists in the care through a telehealth system and keep as many people healthy through interventions performed in the community.54 It has demonstrated the ability to keep most people healthy in community sites, refer people to dental offices when they need advanced surgical services that require that environment and increase patient and caregiver adoption of daily mouth care routines that are critical for maintaining oral health. This system is an example of a “community-engaged oral health system” that can reach people with dementia who are not accessing regular dental care in office environments.

Summary

Improved living conditions, increasing lifespans and better health care have resulted in a significant increase in the number of people over age 60 living with dementia.1,2 It is important that oral health practitioners understand conditions that lead to cognitive decline in older individuals as well as strategies for providing oral health care services for these individuals.

Strategies for helping individuals with Alzheimer’s disease and dementia obtain and maintain good oral health include gathering data beyond what is typically included in a health history and understanding the medical, legal and behavioral considerations critical to providing oral health services. In addition, fully effective systems of care 566 SEP TEMBER

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for people with Alzheimer’s disease and dementia, referred to here as community-engaged oral health systems, are evolving and demonstrating the value of “community-clinical linkages” for developing full-service systems for care that can help people with Alzheimer’s disease and dementia obtain and maintain good oral health. n RE FE RE N CE S 1. World Health Organization. Global Health and Aging.

2011. www.nia.nih.gov/sites/default/files/2017-06/global_ health_aging.pdf. Accessed Dec. 6, 2020.

2. He W, Goodkind D, Kowal P. U.S. Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015. U.S. Government Publishing Office: Washington, D.C.; 2016.

3. World Health Organization. Dementia. www.who.int/newsroom/fact-sheets/detail/dementia. Accessed March 4, 2021.

4. Nangle M, Riches J, Grainger S, et al. Oral health and cognitive function in older adults: A systematic review. Gerontology 2019; 65(6):659–672. doi. org/10.1159/000496730.

5. Ship JA, Pillemer SR, Baum BJ. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002 Mar;50(3):535–43. doi: 10.1046/j.1532-5415.2002.50123.x.

6. Gil-Montoya JA, Sanchez-Lara I, Carnero-Pardo C, et al. Oral hygiene in the elderly with different degrees of cognitive impairment and dementia. J Am Geriatr Soc 2017 Mar;65(3):642–647. doi: 10.1111/jgs.14697. Epub 2016 Dec 26.

7. Delwei S, Binnekade TT, Perez RS. Oral health and orofacial pain in older people with dementia: A systematic review with focus on dental hard tissues. Clin Oral Investig 2017 Jan;21(1):17–32. doi: 10.1007/s00784-016-1934-9. Epub 2016 Sep 8.

8. Delwei S. Binnekade TT, Perez RS. Oral hygiene and oral health in older people with dementia: A comprehensive review with focus on oral soft tissues. Clin Oral Investig 2018 Jan;22(1):93–108. doi: 10.1007/s00784-017-2264-2. Epub 2017 Nov 15.

9. Brennan LJ, Strauss J. Cognitive impairment in older adults and oral health considerations: treatment and management.

Dent Clin North Am 2014 Oct;58(4):815–28. doi: 10.1016/j.cden.2014.07.001. Epub 2014 Aug 3.

10. Hyde S. Dentistry for the Ages: Part I. J Calif Dent Assoc 2015 Jul;43(7)360–362.

11. Lauritano D, Morea G, Della Vella F, et al. Oral health status and need for oral care in an aging population: A systematic review. Int J Environ Res Public Health 2019 Nov 18;16(22):4558. doi: 10.3390/ijerph16224558.

12. Sorting out the 3 D’s: delirium, dementia, depression: Learn how to sift through overlapping signs and symptoms so you can help improve an older patient’s quality of life. Holist Nurs Pract May–Jun 2005;19(3):99–104; quiz 104–5. doi: 10.1097/00004650-200505000-00004.

13. Fong TG, Tulebaev, SR, Inouye SK. Delirium in elderly adults: Diagnosis, prevention and treatment. Nat Rev Neurol

2009 Apr;5(4):210–20. doi: 10.1038/nrneurol.2009.24.

14. National Institute of Mental Health. Depression basics. www.nimh.nih.gov/health/publications/depression. Accessed Dec. 6, 2020.

15. National Institute of Mental Health. Major depression. www.nimh.nih.gov/health/statistics/major-depression.

Accessed Dec. 6, 2020.

16. National Institute on Aging. Alzheimer’s disease and related dementias. www.nia.nih.gov/health/alzheimers.

Accessed Dec. 6, 2020.

17. National Institute on Aging. Related dementias. www.nia. nih.gov/health/topics/related-dementias. Accessed Dec. 6, 2020.

18. National Institute on Aging. What are frontotemporal disorders? www.nia.nih.gov/health/what-are-frontotemporaldisorders. Accessed Dec. 6, 2020.

19. National Institute on Aging. What is Lewy body dementia? www.nia.nih.gov/health/what-lewy-body-dementia. Accessed Dec. 6, 2020.

20. National Institute on Aging. Parkinson’s Disease. www.nia. nih.gov/health/parkinsons-disease. Accessed Dec. 6, 2020.

21. Huntington’s Disease Society of America. Overview of Huntington’s disease. hdsa.org/what-is-hd/overview-ofhuntingtons-disease. Accessed Dec. 6, 2020.

22. National Institute on Aging. Vascular contributions to cognitive impairment and dementia. www.nia.nih.gov/health/ vascular-contributions-cognitive-impairment-and-dementia.

Accessed Dec. 6, 2020.

23. National Institute on Aging. Basics of Alzheimer’s Disease and Dementia. www.nia.nih.gov/health/alzheimers/basics.

Accessed Dec. 6, 2020.

24. National Institute on Aging. Alzheimer’s Disease Fact Sheet. www.nia.nih.gov/health/alzheimers-disease-fact-sheet.

Accessed Dec. 6, 2020.

25. Alzheimer’s Association. What is Alzheimer’s disease. www.alz.org/alzheimers-dementia/what-is-alzheimers.

Accessed Dec. 6, 2020.

26. Alzheimer’s Society of Canada. The differences between normal aging and dementia. alzheimer.ca/en/aboutdementia/do-i-have-dementia/differences-between-normalaging-dementia. Accessed Dec. 6, 2020.

27. Alzheimer’s Disease International. World Alzheimer Report 2013: Journey of caring: An analysis of long-term care for dementia. www.alzint.org/resource/world-alzheimerreport-2013. Accessed Dec. 13, 2020.

28. Alzheimer’s Disease International. World Alzheimer Report 2015: The global impact of dementia: An analysis of prevalence, incidence, cost and trends. www.alzint.org/ resource/world-alzheimer-report-2015. Accessed Dec. 13, 2020.

29. Alzheimer’s Association. Is Alzheimer’s genetic? www.alz. org/alzheimers-dementia/what-is-alzheimers/causes-and-riskfactors/genetics. Accessed Dec. 6, 2020.

30. Alzheimer’s Society of Canada. What to expect while getting your diagnosis. alzheimer.ca/en/about-dementia/doi-have-dementia/how-get-tested-dementia/what-expect-whilegetting-your-diagnosis. Accessed Dec. 6, 2020.

31. Alzheimer’s Association. Medications for memory. www. alz.org/alzheimers-dementia/treatments/medications-formemory. Accessed Dec. 6, 2020.

32. Glassman P, Subar P. Planning dental treatment for people with special needs. Dent Clin N Am 2009 Apr;53(2):195–

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205, vii-viii. doi: 10.1016/j.cden.2008.12.010.

33. Gao SS, Chu CH, Young FKF. Oral health and care for elderly people with Alzheimer’s disease. Int J Environ Res Public Health 2020 Aug; 17(16):5713. doi: 10.3390/ ijerph17165713.

34. Guo HJ, Sapra A. Instrumental activity of daily living.

NCBI. Updated March 18, 2020. www.ncbi.nlm.nih.gov/ books/NBK553126. Accessed Dec. 13, 2020.

35. Gil-Montoya J, Barrioss R, Sanchez-Lara I, et al. Prevalence of drug-induced xerostomia in older adults with cognitive impairment or dementia: An observational study. Drugs Aging 2016 Aug;33(8):611–8. doi: 10.1007/s40266-016-0386-x.

36. Geddis-Regan A, Kerr K, Curl C. The impact of dementia on oral health and dental care, part 2: Approaching and planning treatment. Prim Dent J 2020 Jun;9(2):31–37. doi: 10.1177/2050168420923862.

37. American Dental Association Center for Practice Success.

Informed Consent/Refusal. success.ada.org/en/practicemanagement/guidelines-for-practice-success/managingpatients/informed-consent-refusal. Accessed Dec. 13, 2020.

38. California Association of Counties. Public Guardian. www. counties.org/county-office/public-guardian. Accessed March 1, 2021.

39. California Courts. Conservatorship FAQs. www.courts. ca.gov/1303.htm?rdeLocaleAttr=en. Accessed March 1, 2021.

40. California Legislative Information. Regional Center Responsibilities. Welfare and Institutions Code Division 4.5, Chapter 5, Article 2, Section 4655. leginfo.legislature.ca.gov/ faces/codes_displaySection.xhtml?lawCode=WIC&sectionN um=4655. Accessed March 1, 2021.

41. Glassman P, Smith B. Oral health of vulnerable older adults and persons with disabilities: A national coalition consensus conference. Spec Care Dentist Jul–Aug 2013;33(4):155. doi: 10.1111/scd.12032.

42. Glassman P, Caputo A, Dougherty N, et. al. Special

Care Dentistry Association consensus statement on sedation, anesthesia and alternative techniques for people with special needs. Spec Care Dentist Jan–Feb 2009;29(1):2–8; quiz 67–8. doi: 10.1111/j.1754-4505.2008.00055.x.

43.Nishizaki H, Morimoto Y, Hayashi M, et.al. Analysis of intravenous sedation for dental treatment in elderly patients with severe dementia — a retrospective cohort study of a Japanese population. J Dent Sci 2021 Jan;16(1):101–107. doi: 10.1016/j.jds.2020.06.027. Epub 2020 Jul 18.

44. Lyons R. Understanding basic behavioral support techniques as an alternative to sedation and anesthesia.

Spec Care Dentist Jan–Feb 2009;29(1):39–50. doi: 10.1111/j.1754-4505.2008.00061.x.

45. Chalmers J. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec Care Dentist Jul–Aug 2000;20(4):147–54. doi: 10.1111/j.1754-4505.2000.tb01152.x.

46. Dentistry IQ. Treating Alzheimer’s patients: Tips for dental hygienists. www.dentistryiq.com/dental-hygiene/clinicalhygiene/article/16352607/treating-alzheimers-patients-tipsfor-dental-hygienists. Accessed Dec. 13, 2020.

47. Alzheimer’s Association. Campaign for Quality Care.

Dementia Care Practice Recommendations for Professionals Working in a Home Setting. Phase 4. www.alz.org/national/ documents/phase_4_home_care_recs.pdf. Accessed Dec. 13, 2020.

48. Fereshtehnejad SM, Garcia-Ptacek, Religa D, et.al. Dental care utilization in patients with different types of dementia: A longitudinal nationwide study of 58,037 individuals.

Alzheimers Dement 2018 Jan;14(1):10–19. doi: 10.1016/j. jalz.2017.05.004. Epub 2017 Jul 8.

49. Glassman P, Harrington, M, Namakian M. Promoting Oral Health Through Community Engagement. J Calif Dent Assoc 2014 Jul;42(7):465–70.

50. Centers for Disease Control and Prevention. Communityclinical linkages for the prevention and control of chronic

diseases: A practitioner’s guide. www.cdc.gov/dhdsp/pubs/ docs/ccl-practitioners-guide.pdf. Accessed Dec. 13, 2020.

51. American Dental Hygienists’ Association. Direct Access 2021. www.adha.org/resources-docs/ADHA_Direct_ Access_Map_6-2021.pdf. Accessed Aug 10, 2021.

52. Dental Hygiene Board of California. Registered Dental Hygienist in Alternative Practice (RDHAP). www.dhbc.ca.gov/ consumers/duties_rdhap.shtml. Accessed Dec. 13, 2020.

53. California Northstate University. College of Dental Medicine. RDHAP Education Program. dentalmedicine.cnsu. edu/registered-dental-hygienist-in-alternative-practice-rdhap.

Accessed Dec. 13, 2020.

54. Glassman P, Harrington M, Namakian, M, Subar P. The virtual dental home: Bringing oral health to vulnerable and underserved populations. J Calif Dent Assoc 2012 Jul;40(7):569–77.

T HE AU T HOR , Paul Glassman, DDS, MA, MBA, can be reached at Paul.Glassman@cnsu.edu.

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C .E. CREDIT QUESTIONS

September 2021 Continuing Education Worksheet This worksheet provides readers an opportunity to review C.E. questions for the article “Oral Health and Dementia” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as 1.0 of Core C.E. 1. Dental practitioners can expect to see relatively more patients with chronic diseases in their practice. In the next decade, the greatest increase in the number of people over age 60 living with a condition is among people with: a. Dementia b. Cardiovascular disease c. Diabetes d. Vision and hearing impairment e. None of the above 2. Recent studies have indicated a relationship between learning and memory, complex attention and executive function with poor oral health in old age. The proposed mechanisms for this association include: a. Reduced ability to perform daily mouth care procedures b. Difficulty accessing and receiving dental care c. Reduced salivary flow d. All of the above 3. Dementia is often characterized as a disturbance of cognitive function including problems with thinking, memory and reasoning. It can include: a. Aphasia or language impairment affecting the production or comprehension of speech b. Apraxia or loss of ability to carry out movements such as writing, gait and complex tasks c. Agnosia or loss of ability to recognize objects or people d. “Executive function loss” or loss of ability to plan ahead and foresee consequences e. All of the above 4. Which one of the following is a true statement about Alzheimer’s disease: a. The most common form of dementia is Alzheimer’s disease b. The most common form of Alzheimer’s disease is dementia c. Alzheimer’s disease is a reversible condition d. Changes in brain structure cannot be detected 5. Some common early signs of Alzheimer’s disease include the following except: a. Memory loss that disrupts daily life b. Challenges in planning or solving problems c. Difficulty completing familiar tasks d. Confusion with time and place e. Delirium and depression 568 SEP TEMBER

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6. The first step in planning treatment of a patient with a history of Alzheimer’s disease in the family is gathering the following data except: a. The ability of the individual to function daily b. Health conditions that can impact oral health and oral health care c. The individual’s history or ability to receive treatment in a dental office d. Who can provide consent e. Dental and medical insurance coverage 7. Selection criteria for limited treatment for people with dementia include: a. Poor medical and cognitive prognosis b. Limited communication c. Difficulty with providing treatment in a dental office d. Limited finances e. All of the above 8. A number of nonpharmacological approaches can increase the likelihood of having a successful dental appointment. These include all of the items below except: a. Scheduling appointments early in the day rather than later b. Approaching the individual slowly from the front and positioning yourself so you are at the individual’s eye level c. Using a calm demeanor and voice when speaking to the individual d. Introducing yourself and reminding them why they are there and what you’re going to do in simple terms e. If an appointment does not go well on a specific day, referring the patient to another dentist 9. The virtual dental home (VDH) system of care uses allied oral health personnel including dental hygienists and assistants to bring care to community sites. The VDH system: a. Involves dentists in the care through a telehealth system b. Keeps as many people healthy as possible through interventions performed in the community c. Helps people with dementia who are not accessing regular dental care in office environments d. Refers people to dental offices when they need advanced surgical services e. All of the above 10. True or False: In more than two-thirds of U.S. states, “direct access” rules permit dental hygienists to assess patients’ needs for dental hygiene services and initiate treatment without the authorization or presence of a dentist.

hpv vaccines C D A J O U R N A L , V O L 4 9 , Nº 9

Dental Professionals and Human Papillomavirus Vaccinations Alessandro Villa, DDS, PhD, MPH, and Dalton Pham, DMD

abstract Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Highrisk type HPV infections can cause many types of cancers, including oropharyngeal cancer. The HPV vaccine is the most effective method for the prevention of HPV-related cancers. However, HPV vaccination rates remain low in the United States. Dental professionals are well positioned to be at the forefront of educating patients about HPV, discussing the HPV vaccine and promoting vaccination with their patients.

Keywords: Human papillomavirus, HPV, vaccinations

AUTHORS Alessandro Villa, DDS, PhD, MPH, is the chief of the Sol Silverman Oral Medicine Clinic and the program director for the oral medicine residency program at the University of California, San Francisco.

He is a fellow of the Royal College of Surgeons of Edinburgh.

Conflict of Interest Disclosure: None reported.

Dalton Pham, DMD, is a graduate of the Harvard School of Dental Medicine and is a resident in New York City. He has worked on HPV prevention with Dr. Villa for two years.

Conflict of Interest Disclosure: None reported.

H

uman papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with approximately 80 million people, most in their late teens and early 20s, infected. HPV is transmitted through skin-to-skin contact.1 Almost every person who is sexually active who does not get the HPV vaccine will be infected with HPV in their lifetime, usually with no signs or symptoms. Most HPV infections clear spontaneously in one year, and only persistent high-risk HPV infections lead to multiple types of cancers, including oropharyngeal, cervical, anal, vaginal, vulvar and penile cancers.

Recent data from the Centers for Disease Control and Prevention (CDC) report an annual average of nearly 45,300 HPV-related cancers in the U.S., with oropharyngeal cancer being

the most prevalent (19,775), followed by cervical (12,143) and anal (7,083) cancers.2 The incidence of HPV-related oropharyngeal cancer has been increasing significantly over the past 30 years, especially among males. Men are almost three times more likely to have an oral HPV infection compared to women.3 The goal of this review is to provide a general overview of the current preventive strategies available for HPVassociated oropharyngeal cancer and discuss the role of dental professionals.

HPV Vaccination and Cancer Prevention

Most HPV-associated cancers are caused by persistent infection with HPV types 16, 18, 31, 33, 45, 52 and 58. Over 90% of HPV-related cancers are preventable through HPV vaccination, including oropharyngeal SEP TEMBER 2 0 2 1

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cancers (Gardasil 9 HPV 9 valentvaccine, recombinant, Merck & Co. Inc., West Point, Penn.).2 In addition, HPV vaccination protects from HPV types 6 and 11 that can cause warts (e.g., papilloma, verruca vulgaris and condyloma) in the oral cavity, the genital area, anus and oropharynx. Gardasil 9 is a recombinant vaccine that contains virus-like proteins (VLP) that resemble the HPV virus. Following administration, the HPV vaccine induces the humoral immune response to target HPV-16, -18, -31, -33, -45, -52, -58, -6 and -11.

The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination at ages 11 or 12. However, vaccination can start at age 9 and the series should finish by age 13. The ACIP also recommends HPV vaccinations for everyone aged 13 to 26 who were not adequately vaccinated previously. Depending on the age of initial vaccination, the series may be either two doses (for individuals starting the series before their 15th birthday) or three doses (for individuals who start the series at ages 15 through 26 years and for immunocompromised individuals). Shared clinical decisionmaking regarding HPV vaccination is recommended for some adults aged 27 to 45 who are not adequately vaccinated.4 The American Dental Association (ADA) adopted a policy on HPV vaccination that “urges dentists to support the use and administration of the HPV vaccine” and encourages research efforts to improve the understanding of the natural history of oral HPV infection, transmission risks, prevention, screening and testing.5 The HPV vaccine has a reassuring safety record backed by 10 years of monitoring and research, and the 9-valent HPV vaccine currently available protects against nine HPV types, including seven types that can cause 570 SEP TEMBER

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cancer. Despite the recommendations endorsed by the ACIP, HPV vaccine uptake in the U.S. remains lower than the goal of 80% proposed by the Healthy People 2020 initiative.6 In 2019, only 54% of adolescents in the U.S. were reported to be up to date with HPV vaccination.7 Compared to the 80% vaccination goal, only 56% of adolescents in California are up to date with HPV vaccination.8 In California, the rate of HPV vaccination varies by geographic location, with the lowest vaccination rates tending to be in counties in the

HPV vaccination stands to be the most effective preventive measure against HPV-related cancers.

northern third of the state as well as more rural counties. The rates of initiation and completion of the HPV vaccine series were reported to be as low as 16% and 8%, respectively, among 13-yearolds in some California counties.9 With the exception of cervical cancer, recommended screening tests for HPVrelated oropharyngeal cancers do not yet exist.10 These cancers may go undetected for years until they cause significant health problems, deteriorate quality of life and even decrease life expectancy.

In addition to the negative impact of HPV-related cancers on patients, significant health care costs are incurred for the treatment of these cancers.11 An estimated 10% of HPV-related cancers in the U.S. occur in California.2 It has been projected that if 99.5% of 20-year-

old individuals in California were to be vaccinated against HPV, the state could avoid spending a total of $52.2 million that would be needed to treat the cancer cases, with $21.3 million of the cost attributed to treating male oropharyngeal cancer and $16.1 million to treating cervical cancer.11 Therefore, in order to curtail the substantial cost of treatment and until more reliable recommended screening tests are developed for detecting HPV-related cancers, greater emphasis should be placed on preventive practices, namely vaccination.

HPV vaccination stands to be the most effective preventive measure against HPV-related cancers. While multiple factors influence HPV vaccination uptake, vaccine recommendation by a health care provider is one of the most important and consistent predictors of vaccination.12–15 Dental providers have a unique opportunity as health care professionals to build relationships with patients and facilitate conversations to promote education and practices for improving their health. Recent reports from the CDC show that while 54.5% of people in the U.S. made a visit to their primary physician, 65% of adults aged 18 and older visited the dentist in the past year.16,17 For children aged 2 to 17, that number was even higher at 85%.18 This large proportion of pediatric dental visits presents a great opportunity to start the conversation with parents regarding HPV, prevention and vaccination. Furthermore, considering the recommended six-month recall schedule for dental check-ups and cleanings, it is likely that patients see their dentists more frequently than physicians.

According to the ADA, almost 10% of the U.S. population visits a dentist, but not a physician, annually.19,20 These routine visits allow dental providers to build rapport with their patients and would help patients feel more comfortable discussing HPV and vaccination.

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Addressing HPV With Patients

Dental providers have demonstrated success in interventional and preventive measures with their patients, as seen by the effectiveness of oral cancer screenings as well as smoking-cessation efforts in the dental office.21–23 Resources such as guidelines for how to conduct systematic oral cancer screening exams have enhanced early detection rates.24 Additionally, recommendations for how to discuss smoking cessation through methods such as motivational interviewing have been instrumental in the success of interventions that begin in the dental office.25 Along these same lines, studies show that the majority of dentists feel comfortable speaking to patients about HPV and even feel comfortable providing HPV vaccinations as well.26 However, of the dental providers who do not discuss the HPV vaccine with patients, the most common reasons include believing it is a topic better suited for other health care professionals, not knowing how to address it and feeling uncomfortable discussing HPV as a sexually transmitted infection.26 Studies have shown that dental providers who underwent training programs designed to increase HPV knowledge reported feeling more comfortable and prepared to discuss HPV and prevention with patients.27–29 In order to better facilitate the discussion of HPV and vaccination with patients, especially adolescent patients and their parents, providers should frame the vaccine by incorporating it within the set of age-appropriate routine vaccinations for the child. Doing so has demonstrated greater parental acceptance of the vaccine for their children.30–32 Parental concern about HPV, the vaccine and its implications regarding their child’s sexual activity can be effectively addressed by informing parents that the administration of the vaccine is not about sex, but rather

cancer prevention, and that the HPV vaccine has a stronger immune response when administered at younger ages.31,33 Moreover, the quality of the provider’s recommendation plays a role in the patient’s acceptance of the vaccine.

Stronger provider recommendations for HPV vaccination are associated with greater uptake by parents and patients.34 Additionally, in the decision-making process, parents of adolescents reported wanting more detailed communication regarding logistics of the vaccine, namely the schedule of dosing, number

Research has demonstrated that if dentists recommend the HPV vaccine, there is a significant increase in vaccination uptake by patients.

recommend the HPV vaccine, there is a significant increase in vaccination uptake by patients.40 Interestingly, in Oregon, dentists are approved to administer any vaccine, and in Minnesota and Illinois, dentists can administer the flu vaccine to adults.41–43 Further, due to the COVID-19 pandemic, dentists in all states have been approved to administer COVID-19 vaccines.44–46 In the context of HPV, dental providers who participated in educational programs to increase HPV knowledge reported feeling more comfortable not only discussing prevention with patients, but also with administering the HPV vaccine as well.29 Studies have shown that a majority of parents are receptive to speaking about HPV and vaccination with dental providers, and even expect dental providers to communicate and recommend HPV vaccination.47,48 Moreover, a majority of parents have also reported feeling comfortable with their children receiving the HPV vaccine from dental providers.47,48

of doses, recommended age and cost of the vaccination series.32,35 Patientcentered materials such as pamphlets in the waiting room may serve to not only educate patients about HPV prevention but also prompt patients to initiate the conversation with specific questions for their dental providers.36 Organizations such as Team Maureen, the ADA and the National HPV Roundtable offer a dental toolkit of HPV resources, including patient brochures and office posters that can be distributed and displayed in a dental office.37

Conclusion

Dental Professionals and Vaccines

RE F E RE N C E S 1. Centers for Disease Control and Prevention. Genital HPV Infection — Fact Sheet. Centers for Disease Control and Prevention; 2019. www.cdc.gov/std/hpv/HPV-FS-print.pdf.

Accessed Dec. 13, 2020.

2. Senkomago V, Henley SJ, Thomas CC, Mix JM, Markowitz

Dental providers acknowledge and are in favor of their role and responsibility in HPV prevention efforts.38,39 Research has demonstrated that if dentists

Dental professionals’ knowledge, training and demonstrated success in prevention make them well positioned to be at the forefront of increasing patient knowledge and prevention of HPV. Patients and parents are receptive to speaking with their dental providers about HPV and to receiving vaccination in a dental setting. As such, emphasizing the role of dental professionals in HPV education and prevention stands to be an effective preventive measure against HPV and HPV-related cancers. n

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LE, Saraiya M. Human papillomavirus — attributable cancers — United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2019 2019 Aug 23;68(33):724–728. doi: 10.15585/ mmwr.mm6833a3.

3. Centers for Disease Control and Prevention. Cancers Associated with Human Papillomavirus, United States—2013-2017. USCS Data Brief, no 18. 2020.

4. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human papillomavirus vaccination for adults: Updated recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2019 Aug 16;68(32):698–702. doi: 10.15585/mmwr. mm6832a3.

5. Manchir M. ADA adopts policy supporting HPV vaccine.

American Dental Association, ADA News; 2018. www.ada. org/en/publications/ada-news/2018-archive/october/ ada-adopts-policy-supporting-hpv-vaccine. Accessed Dec. 19, 2020.

6. Office of Disease Prevention and Health Promotion.

Immunization and infectious diseases and global health progress review. Healthy People 2020 topics and objectives.

2020. www.healthypeople.gov/2020/topics-objectives/topic/ immunization-and-infectious-diseases/objectives. Accessed Dec. 13, 2020.

7. Centers for Disease Control and Prevention. Human papillomavirus (HPV) vaccination coverage among adolescents 13–17 years by state, HHS region and the United States, National Immunization Survey-Teen (NIS-Teen), 2019. www. cdc.gov/vaccines/imz-managers/coverage/teenvaxview/datareports/hpv/dashboard/2019.html. Accessed Dec. 14, 2020.

8. Centers for Disease Control and Prevention. 2008 through 2019 adolescent human papillomavirus (HPV) vaccination coverage trend report. 2020. www.cdc.gov/vaccines/imzmanagers/coverage/teenvaxview/data-reports/hpv/trend/ index.html. Accessed Dec. 14, 2020.

9. California HPV Vaccination Roundtable. Assessment of human papillomavirus (HPV) attributable cancers and vaccination rates in California: Report of findings of the California HPV vaccination roundtable. May 2020. 90s.8f6. myftpupload.com/wp-content/uploads/2020/05/CA-HPVRoundtable-Vaccination-and-Attributable-Cancers-Report-ofFindings-1.pdf. Accessed Dec. 15, 2020.

10. Kreimer AR, Shiels MS, Fakhry C, Johansson M, Pawlita M, Brennan P, Hildesheim A, Waterboer T. Screening for human papillomavirus-driven oropharyngeal cancer: Considerations for feasibility and strategies for research. Cancer 2018 May 1;124(9):1859–1866. doi: 10.1002/cncr.31256. Epub 2018 Mar 2.

11. Baughan EB, Keizur EM, Damico CA, Arnold EM, Ko JS, Klausner JD. Excess cancer cases and medical costs due to suboptimal human papillomavirus vaccination coverage in California. Sex Trans Dis 2019 Aug;46(8):527–531. doi: 10.1097/OLQ.0000000000001016.

12. Rosen BL, Shepard A, Kahn JA. U.S. health care clinicians’ knowledge, attitudes and practices regarding human papillomavirus vaccination: A qualitative systematic review.

Acad Pediatr 2018 Mar;18(2S):S53–S65. doi: 10.1016/j. acap.2017.10.007.

13. McRee AL, Gilkey MB, Dempsey AF. HPV vaccine hesitancy: Findings from a statewide survey of health care providers. J Pediatr Health Care Nov–Dec 2014;28(6):541– 9. doi: 10.1016/j.pedhc.2014.05.003. Epub 2014 Jul 10.

14. Berenson AB, Rahman M, Hirth JM, Rupp RE,

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Sarpong KO. A brief educational intervention increases providers’ human papillomavirus vaccine knowledge.

Hum Vaccin Immunother 2015;11(6):1331–6. doi: 10.1080/21645515.2015.1022691.

15. White L, Waldrop J, Waldrop C. Human papillomavirus and vaccination of males: Knowledge and attitudes of registered nurses. Pediatr Nurs Jan–Feb 2016;42(1):21–30, 35.

16. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey, 2016. National Center for Health Statistics. www.cdc.gov/nchs/data/ahcd/namcs_ summary/2016_namcs_web_tables.pdf. Accessed Dec. 15, 2020.

17. Clarke TC, Schiller JS, Boersma P. Early release of selected estimates based on data from the 2019 National Health Interview Survey. National Center for Health Statistics, National Health Interview Survey Early Release Program; 2020. www.cdc.gov/nchs/data/nhis/earlyrelease/ EarlyRelease202009-508.pdf. Accessed Dec. 16, 2020.

18. Dental visits in the past year, by selected characteristics: United States, selected years 1997–2017. Centers for Disease Control and Prevention. Health, United States, 2018; Table 037. National Center for Health Statistics. www.cdc.gov/nchs/ data/hus/2018/037.pdf. Accessed Dec. 14, 2020.

19. Vujicic M. Health care reform brings new opportunities. J Am Dent Assoc 2014 Apr;145(4):381–2. doi: 10.14219/ jada.2014.16.

20. Leader D, Vujicic M, Harrison B. Could Dentists Relieve Physician Shortages, Manage Chronic Disease? American Dental Association, Health Policy Institute, Research Brief; 2018. www.ada.org/~/media/ADA/Science%20and%20 Research/HPI/Files/HPIBrief_1218_1.pdf. Accessed Dec. 18, 2020.

21. Abadeh A, Ali AA, Bradley G, Magalhaes MA. Increase in detection of oral cancer and precursor lesions by dentists: Evidence from an oral and maxillofacial pathology service. J Am Dent Assoc 2019 Jun;150(6):531-539. doi: 10.1016/j. adaj.2019.01.026. Epub 2019 Apr 25.

22. Psoter WJ, Morse DE, Kerr AR, Tomar SL, Aguilar ML, Harris DR, Stone LH, Makhija SK, Kaste LM, Strumwasser B, Pihlstrom DJ, Masterson EE, Meyerowitz C, National Dental PBRN Collaborative Group. Oral cancer examinations and lesion discovery as reported by U.S. general dentists: Findings from the National Dental Practice-Based Research Network. Prev Med 2019 Jul;124:117–123. doi: 10.1016/j. ypmed.2019.03.034.

23. Hanioka T, Ojima M, Tanaka H, Naito M, Hamajima N, Matsuse R. Intensive smoking-cessation intervention in the dental setting. J Dent Res 2010 Jan;89(1):66–70. doi: 10.1177/0022034509350867.

24. Maybury C, Horowitz AM, Goodman HS. Outcomes of oral cancer early detection and prevention statewide model in Maryland. J Public Health Dent Winter 2012;72 Suppl 1:S34–8. doi: 10.1111/j.1752-7325.2012.00320.x.

25. Omana-Cepeda C, Jane-Salas E, Estrugo-Devesa A, Chimenos-Kustner E, Lopez-Lopez J. Effectiveness of dentist’s intervention in smoking cessation: A review. J Clin Exp Dent 2016 Feb 1;8(1):e78–83. doi: 10.4317/jced.52693. eCollection 2016 Feb. 26. Patton LL, Villa A, Bedran-Russo AK, Frazier K, Khajotia S, Lawson NC, Park J, Lipman RD, Urquhart O, Council on Scientific Affairs. An American Dental Association Clinical Evaluators Panel survey. J Am Dent Assoc 2020

Apr;151(4):303–304.e2. doi: 10.1016/j.adaj.2020.01.027.

27. Shukla A, Nyambose J, Vanucci R, Johnson LB, Welch K, Lind E, Villa A. Evaluating the effectiveness of human papillomavirus educational intervention among oral health professionals. J Cancer Educ 2019 Oct;34(5):890–896. doi: 10.1007/s13187-018-1391-z.

28. Pampena E, Vanucci R, Johnson LB, Bind MA, Tamayo I, Welch K, Lind E, Wagner R, Villa A. Educational interventions on human papillomavirus for oral health providers. J Canc Educ 2020 Mar;35:689–695. doi.org/10.1007/s13187-01901512-7.

29. Salous MH, Bind MA, Granger L, Johnson LB, Welch K, Villa A. An educational intervention on HPV knowledge and comfortability discussing vaccination among oral health care professionals of the American Indian and Alaskan Native population. Hum Vaccin Immunother 2020 Dec 1;16(12):3131–3137. doi: 10.1080/21645515.2020.1752595. Epub 2020 May 13.

30. Gilkey MB, McRee AL. Provider communication about HPV vaccination: A systematic review. Hum Vaccin Immunother 2016 Jun 2;12(6):1454–68. doi: 10.1080/21645515.2015.1129090. Epub 2016 Feb 2.

31. Brewer NT, Hall ME, Malo TL, et al. Announcements versus conversations to improve HPV vaccination coverage: A randomized trial. Pediatrics 2017 Jan;139(1):e20161764. doi: 10.1542/peds.2016-1764. Epub 2016 Dec 5.

32. Perkins RB, Clark JA, Apte G, et al. Missed opportunities for HPV vaccination in adolescent girls: A qualitative study.

Pediatrics 2014 Sep;134(3):e666–74. doi: 10.1542/ peds.2014-0442.

33. Giuliano AR, Lazcano-Ponce E, Villa L, et al. Impact of baseline covariates on the immunogenicity of a quadrivalent (types 6, 11, 16 and 18) human papillomavirus virus-likeparticle vaccine. J Infect Dis 2007 Oct 15;196(8):1153–62. doi: 10.1086/521679. Epub 2007 Sep 17.

34. Gilkey MB, Calo WA, Moss JL, et al. Provider communication and HPV vaccination: The impact of recommendation quality. Vaccine 2016 Feb 24;34(9):1187– 92. doi: 10.1016/j.vaccine.2016.01.023. Epub 2016 Jan 24.

35. Alexander AB, Stupiansky NW, Ott MA, Herbenick D, Reece M, Zimet GD. What parents and their adolescent sons suggest for male HPV vaccine messaging. Health Psychol 2014 May;33(5):448–56. doi: 10.1037/a0033863. Epub 2014 Mar 3.

36. Griner SB, Thompson EL, Vamos CA, Chaturvedi AK, Vazquez-Otero C, Merrell LK, Kline NS, Daley EM. Dental opinion leaders’ perspectives on barriers and facilitators to HPV-related prevention. Hum Vaccin Immunother 2019;15(78):1856–1862. doi: 10.1080/21645515.2019.1565261.

Epub 2019 Feb 20.

37. Team Maureen. Dental Toolkit; 2020. teammaureen.org/ about/materials/c/680. Accessed Dec. 21, 2020.

38. Kline N, Vamos C, Thompson E, et al. Are dental providers the next line of HPV-related prevention? Providers’ perceived role and needs. Papillomavirus Res 2018 Jun;5:104–108. doi: 10.1016/j.pvr.2018.03.002. Epub 2018 Mar 7.

39. Kepka D, Rutkoski H, Pappas L, et al. U.S. oral health students’ willingness to train and administer the HPV vaccine in dental practices. Prev Med Rep 2019 Jul 17;15:100957. doi. org/10.1016/j.pmedr.2019.100957.

40. Wakim S, Ramirez R. Dental interventions improve youth HPV vaccination rates to help prevent oral cancer. Oral Health Dent Sci 2020;4(3):1–6.

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41. Solana K. Oregon passes bill allowing dentists to administer vaccines. American Dental Association, ADA News; 2019. www.ada.org/en/publications/ada-news/2019archive/april/oregon-passes-bill-allowing-dentists-to-administervaccines20190426t142836. Accessed Dec. 19, 2020.

42. IMCare Provider Manual. Chapter 9A, Immunizations and Vaccinations. Revised April 12, 2018. www.co.itasca.mn.us/ DocumentCenter/View/725/Chapter-9A-Immunizations-andVaccinations-PDF. Accessed Dec. 19, 2020.

43. Illinois General Assembly, Joint Committee on Administrative Rules. Administrative Code: Title 68: Professions and Occupations. Chapter VII: Department of Financial and Professional Regulation Subchapter b: Professions and Occupations Part 1220 Illinois Dental Practice Act Session 1220.403 Dentists Administering Flu Vaccines; 2016. www.ilga.gov/commission/jcar/ admincode/068/068012200D04030R.html. Accessed Dec. 19, 2020.

44. COVID-19 Vaccination Plan, State of Arkansas. Arkansas Department of Health; 2020. www.healthy.arkansas.gov/ images/uploads/pdf/ADH_COVID-19_Vaccination_Plan.pdf.

Accessed Dec. 19, 2020.

45. COVID Vaccine. Connecticut State Dental Association; 2020. www.csda.com/coronavirus/covid-vaccine. Accessed Dec. 21, 2020.

46. North Carolina Interim COVID-19 Vaccination Plan Executive Summary. North Carolina COVID-19 Vaccination Planning Team; 2020. files.nc.gov/covid/documents/NCCOVID-19-Vaccine-Plan-with-Executive-Summary.pdf. Accessed Dec. 19, 2020.

47. Dean TC, Gilliland AE, Cameron JE. Parents’ receptiveness to oral health clinic-based vaccinations.

Vaccine 2020;38(27):4226–4229. doi.org/10.1016/j. vaccine.2020.03a.062.

48. Stull C, Freese R, Sarvas E. Parent perceptions of dental care providers’ role in human papillomavirus prevention and vaccine advocacy. J Am Dent Assoc 2020 Aug;151(8):560– 567. doi: 10.1016/j.adaj.2020.05.004.

TH E CO RRE S P O NDIN G AU T H O R , Alessandro Villa, DDS, PhD, MPH, can be reached at Alessandro.Villa@ucsf.edu.

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hypertension screening C D A J O U R N A L , V O L 4 9 , Nº 9

A

Hypertension Screening in the Dental Setting: A Pilot Program to Enhance Chronic Disease Management Through Medical-Dental Integration John Welby, MS; Debony Hughes, DDS; and Kristi Pier, MHS, MCHES

abstract As health care providers and public health professionals peel back the barriers preventing medical/dental collaboration, the benefits of these partnerships have become clear. Even so, the potential for dental and medical professionals working together to prevent and treat disease has yet to be fully realized. Put simply, there is more work to do and much more to learn. The Maryland Hypertension Screening in the Dental Setting pilot offers a glimpse into the benefits that can be achieved when dental professionals explore new models of care. Because of the impact of programs like the Maryland pilot and others that work to foster medical/dental collaboration, patients are beginning to see life-changing and sometimes even life-saving results.

Keywords: Collaboration, hypertension, high blood pressure, dental care, chronic disease, medical/ dental collaboration, oral and overall health, dentist, primary care provider, communication

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AUTHORS John Welby, MS, is the director of health literacy and social marketing for the Maryland Office of Oral Health at the Maryland Department of Health.

He obtained his master’s in communication from Clarion University and has developed and produced social and behavior change campaigns for some of the nation’s most respected health care organizations.

Conflict of Interest Disclosure: None reported.

Debony Hughes, DDS, is the director of the Office of Oral Health at the Maryland Department of Health. She received her DDS degree and certificate in advanced general dentistry from the Howard University College of Dentistry and is a fellow in the American College of Dentists and the International College of Dentists. Dr. Hughes serves on several boards and has provided testimony for oral health legislation to the Maryland Legislature and the United States Senate.

Conflict of Interest Disclosure: None reported.

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Kristi Pier, MHS, MCHES, is the director of the Center for Chronic Disease Prevention and Control at the Maryland Department of Health. She holds a Master of Health Science degree from the Johns Hopkins University Bloomberg School of Public Health and is a Master Certified Health Education Specialist. Ms. Pier is a member of the National Association of Chronic Disease Directors Board.

Conflict of Interest Disclosure: None reported.

S

ince the publication of “Oral Health in America: A Report of the Surgeon General” in 2000, there has been a steady increase in investigating and promoting the connection between oral health and overall health.1 Public health organizations throughout the nation have recognized and increasingly called for the integration of oral and overall health. Medical and dental practices have begun to collaborate, often in federally qualified health center

Number one on the list is to integrate oral health and primary health care.

(FQHC) settings or in partnership with public health organizations to investigate the benefits of integrating preventive oral health services in medical settings and preventive health services in dental settings. In 2016, the publication of “The Oral Health Strategic Framework” by the U.S. Department of Health and Human Services elevated the importance of medical-dental integration even more by listing five overarching goals to be considered when strategically working to improve oral health.

Number one on the list is to integrate oral health and primary health care.2 Recognizing this movement within public health, the Centers for Disease Control and Prevention (CDC) issued a request for proposals in 2016 entitled

Models of Collaboration for State Chronic Disease and Oral Health Programs. This funding opportunity was designed to integrate medical and dental care by fostering collaboration between state oral health and chronic disease programs and to test innovative approaches of incorporating oral health into chronic disease management systems, such as those developed to manage diabetes, hypertension, obesity and tobacco usage. The Maryland Department of Health (MDH) Office of Oral Health (OOH) received this funding to develop, implement and evaluate a pilot program that integrated hypertension screening and referrals into the daily workflow of select dental settings.

This paper addresses the importance of hypertension screening within the dental setting and outlines the development, implementation, results and lessons learned from the Maryland Hypertension Screening in the Dental Setting pilot program funded by the CDC. This program recognizes that dentists are trained in dental school to take a patient’s blood pressure and views the dental setting as a place where hypertension screening should readily occur. It also acknowledges that screening for common chronic diseases such as hypertension, diabetes, obesity and tobacco usage can be instituted within the dental setting to identify and refer patients to appropriate diagnostic and treatment services.

Moreover, it calls on state oral health and chronic disease programs to seek partnerships that will identify and build programs that can screen for chronic disease in the dental setting and refer dental patients to medical providers for appropriate follow-up services. By doing so, state oral health and chronic disease programs can play

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a key role in operationalizing medical/ dental integration throughout the nation and can significantly contribute to the management of chronic disease, thereby not only improving oral health but also overall health.

Hypertension Screening and the Dental Provider

Heart disease is the leading cause of death worldwide. In the United States, more than 650,000 people die of heart disease every year: 1 in every 4 deaths.3 Heart disease is the leading cause of death for both men and women and people of most racial and ethnic groups.3 Coronary artery disease, the most common type of heart disease, occurs when a build-up of plaque accumulating within the arteries restricts blood flow to the heart.3 Coronary artery disease is a major cause of heart attacks.3 Every year more than 800,000 Americans have a heart attack: approximately one every 40 seconds. One of every five heart attacks occur without the individual being aware of the conditions that led to the attack.3 When the heart beats, it creates pressure that pushes blood through a network of blood vessels, which include arteries, veins and capillaries.4 High blood pressure (HBP or hypertension) is when the force of your blood pushing against the walls of your blood vessels is consistently too high.4 High blood pressure or hypertension is a major risk factor for heart disease and can lead to heart attack, stroke, heart failure and premature death.5 Known as a silent killer, hypertension can commonly present itself without symptoms; consequently, many people with hypertension do not know they have the disease.5 It

is therefore important that blood pressure is monitored regularly.5 The primary way that high blood pressure causes harm is by increasing the workload of the heart and blood vessels — making them work harder and less efficiently.4 Over time, the force and friction of high blood pressure damages the delicate tissues inside the arteries. In turn, LDL (bad) cholesterol forms plaque along tiny tears in the artery walls, signifying the start of atherosclerosis.4 The more the plaque and damage increase,

As the prevalence of hypertension continues to increase, it is estimated that more than 1.5 billion people will be diagnosed with hypertension by 2025. the narrower (smaller) the insides of the arteries become — raising blood pressure and starting a vicious circle that further harms arteries, the heart and the rest of the body.4 Hypertension affects more than 1 billion people worldwide.6 Nearly half of U.S. adults have hypertension and only about 1 in 4 of those individuals have their blood pressure under control.7 As the prevalence of hypertension continues to increase, it is estimated that more than 1.5 billion people will be diagnosed with hypertension by 2025.8 This estimate becomes even more alarming when we consider that millions of people with hypertension remain undiagnosed.

The potential benefits of spreading the word about the prevalence and

impact of hypertension and educating the public about the importance of working with their health care provider to detect hypertension are significant and may save countless lives.9 A blood pressure reading is given in millimeters of mercury (mm Hg) and has two numbers. The first, or upper, number measures the pressure in the arteries when the heart beats (systolic pressure).10 The second, or lower, number measures the pressure in the arteries between beats (diastolic pressure).10 According to the hypertension guidelines published by the American Heart Association, the ranges of blood pressure measurement include normal, elevated, hypertension stage 1, hypertension stage 2 and hypertensive crisis. Normal blood pressure reading ranges include readings less than 120/80 mm Hg.11 Elevated blood pressure readings range from 120–129 systolic and less than 80 mm Hg diastolic.11 It is important to start regular monitoring of blood pressure at this level. Hypertension stage 1 ranges from 130–139 systolic or 80–89 mm Hg diastolic. Lifestyle changes such as a strict diet regimen and regular exercise are recommended at this stage. Some patients might also be prescribed medications to regulate their blood pressure. The hypertension stage 2 range is at 140/90 mm Hg or greater. Providers will most likely advise blood pressure medications and lifestyle changes for this category. The hypertensive crisis range is anything greater than 180/120 mm Hg which requires immediate medical attention.11 The significance of regular blood pressure measurement in the dental office as a component of comprehensive health care is within the professional responsibility of dentists and cannot be minimized.

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Dental professionals not only have the responsibility to take every patient’s blood pressure, they must also make sure to follow up with appropriate education and/or referrals to medical care when appropriate.

Measurement of blood pressure in the dental setting is also important, as many clinical decisions occur within the dental setting, such as the choice of an appropriate anesthetic and whether to perform certain invasive procedures that require knowledge of a patient’s blood pressure measurement.

Also, taking a patient’s blood pressure is an opportunity to make patients aware of the connection between oral and overall health.

Once an elevated blood pressure has been detected, the patient should be educated about its negative impact on the body as well as counseled on the health habits that can help control hypertension, such as maintaining a healthy weight, regular exercise and choosing a healthy diet, so that these habits can be incorporated into their lifestyle to help manage the condition. The dental professional has the responsibility to make the appropriate referral to the patient’s primary care physician for follow-up when hypertension is suspected due to elevated blood pressure readings. This referral to the primary care provider is not only essential, it will also demonstrate to the patient that the dentist is concerned with more than the patient’s oral health and will help the patient understand the important relationship between oral and overall health. One strategy in “The Surgeon General’s Call to Action to Control Hypertension” is to optimize patient care by promoting team-based care.7 Although including dental providers as part of multidisciplinary team578 SEP TEMBER

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based care is often overlooked, it holds great promise for enhancing the collaboration needed to ensure that appropriate referrals to primary care physicians for hypertension or other chronic diseases are made.

As important as this process is, it can be difficult to ensure appropriate follow-up due to the lack of communication infrastructure between dental and medical facilities, entrenched systemwide practice patterns within these settings and the challenges of working with high-risk

Taking a patient’s blood pressure is an opportunity to make patients aware of the connection between oral and overall health.

populations. In fact, communication within the medical system itself is not without its own challenges. One study found in caring for 100 Medicare patients, the average primary care provider will need to coordinate care with 99 other providers working across 53 practices.12 Additionally, a national survey of communication between primary care providers and specialists found 69% of primary care providers reported sending basic patient information to specialists either “always” or “most of the time.”13 Nonetheless, according to a research brief published by the Health Policy Institute of the American Dental Association, physicians report being dissatisfied with current referral systems to dentists.14 Physicians

reported that an inadequate dental referral system exists and the creation of an electronic medical record or method that enhanced communication and referrals between doctors and dentists was necessary. They also called for an increase in promoting dental education among physicians.

They felt that these changes would benefit both providers and patients by improving care as well as increasing referrals, collaboration and satisfaction among physicians and dentists.14 Referrals to a primary care physician are a necessary expectation when hypertension is suspected due to elevated blood pressure readings; therefore, it is important to be aware of and address the communication challenges that surround the dental-to-medical referral process.

Communication between medical and dental providers is difficult. Shared electronic health records between medical and dental providers do not always provide the needed information that either medical- or dental-specific systems offer. When systems are not in place to facilitate communication and complete the referral process, it is the responsibility of individual providers to investigate alternatives, build professional relationships and develop and implement demonstration projects that will create effective linkages between primary care teams and dentists in private practices so the accurate health status of the patient is maintained throughout the referral process and course of treatment.13

The Maryland Pilot

In 2016, the MDH was awarded the CDC “Models of Collaboration for State Chronic Disease and Oral Health Programs” grant funding to create a two-year pilot program to provide

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hypertension and tobacco screening within select dental settings in Maryland.

Partner offices within MDH for this project were the OOH, the Center for Chronic Disease Prevention and Control (CCDPC) and the Center for Tobacco Prevention and Control. The goal of the pilot was to enhance and expand the integration of oral health and chronic disease public health programs to involve dental providers in chronic disease prevention activities and to identify and understand challenges and opportunities for future medical and dental integration.

The program sought to engage dentists in Maryland to provide hypertension and tobacco screenings during routine dental visits and to refer patients with undiagnosed or uncontrolled hypertension to primary care providers for follow-up evaluation when necessary. Tobacco users who expressed a willingness to participate in tobacco cessation counseling were referred to the Maryland Tobacco Quitline.

To accomplish program objectives, the MDH formed an advisory committee of dental and medical professionals as well as representatives from academia and health-related industries. Together, they developed the framework and standards for the implementation of hypertension and tobacco screening protocols as well as identified the appropriate equipment used for hypertension screening during routine dental visits. The advisory committee also determined thresholds for dental professionals to follow when referring hypertensive patients to primary care providers for follow-up medical care.

Initially, patients were referred to primary care providers when a blood pressure measurement of 140/90 mm Hg or greater was obtained. In 2017, as the pilot was being implemented, the American Heart Association and the American College of Cardiology issued new blood pressure

guidelines based on updated medical research and accumulated evidence. The Maryland hypertension screening in the dental setting pilot program adopted the new guidelines. The new referral measurement at which dental providers referred their patients was updated to 120 mm Hg to 129 mm Hg systolic and less than 80 mm Hg diastolic.

Implementation

The MDH collaborated with 14 local health departments (LHDs) throughout the state to implement pilot program

The dental practices recruited were intentionally diverse and included private practices, clinic settings and FQHCs located near the LHD sites.

activities that took place from Sept. 1, 2016, to Aug. 31, 2018. The LHD model had been previously utilized in MDH chronic disease management programs to establish referral systems with provider practices for evidence-based programs to prevent and manage diabetes and hypertension. The 14 LHDs engaged 47 dental practices to participate in the pilot program and introduce hypertension and tobacco screenings into their clinical practice. The dental practices recruited were intentionally diverse and included private practices, clinic settings and FQHCs located near the LHD sites. The MDH provided digital blood pressure cuffs, clinical protocols, skills training, data collection advisement, customized education materials and follow-up procedures for dental providers to use

when screening and referring patients to the appropriate primary care provider. For quality assurance, a “train-the-trainer” approach was utilized to implement the pilot at the dental practice sites.

Training components included: ■ Workflow process mapping, which allowed for visualization of the workflow within the dental practice that facilitates improvements and ensures an efficient and sustainable implementation of screenings for hypertension within dental practices.

■ Learning about the hypertension screening process, which entailed a review of the hypertension screening guidelines adopted by the advisory panel as well as standards and the procedures for taking accurate blood pressure measurements using the selected blood pressure monitoring equipment.

■ Data collection methods, which included discussions regarding the proper methods of collecting and recording data, specific instructions on how to collect data from the participating dental practices so LHDs could accurately complete the reporting template that would be submitted to the OOH on a quarterly basis.

■ Dental referrals to primary care providers, which was comprised of a review of best practices when making referrals from dental providers to primary care providers by using a standardized medical-dental referral form created for this initiative.

To ensure both dental patients and providers were informed and motivated to take part in the initiative, a health literacy/social marketing campaign was created entitled “2 Minutes With Your SEP TEMBER 2 0 2 1

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hypertension screening C D A J O U R N A L , V O L 4 9 , Nº 9

2M I

ST TI

TH YOUR S WI E DE UT N N

2

CA

N

HEART DISEASE is the leading cause of death in Maryland.

High blood pressure, a major risk factor for heart disease, affects more than one-third of Maryland adults.1

11,000

It is known as a “silent killer” because there are often no signs to alert you.

That’s why it is important to get your blood pressure checked often.

deaths per year

HIGH BLOOD PRESSURE PREVENTION

Your dentist STARTS WITH

LIF SA V R U E YO

E

Ask your dentist TO SCREEN YOU FOR HIGH BLOOD PRESSURE TODAY

SYS DIA

<120 < 80

GET YOUR BLOOD PRESSURE CHECKED Ask your dentist or dental hygienist to screen you for high blood pressure.

Know your numbers!

A healthy blood pressure number is less than 120 and less than 80.

PRACTICE HEALTHY HABITS

QUIT TOBACCO

Brush twice a day

If you use tobacco and want to quit, free resources are available through the Maryland Tobacco Quitline.

Visit your dentist regularly Choose fresh foods low in salt and sugar Exercise regularly

1-800-QUIT-NOW (1-800-784-8669)

1. Maryland Behavioral Risk Factor Surveillance System, 2013. www.marylandbrfss.org.

Brought to you by Maryland Department of Health’s Office of Oral Health and the Center for Chronic Disease Prevention and Control.

www.Health.Maryland.gov/oral-health

FIGURE 1. Patient postcard (front and back). A health literacy/social marketing campaign was created entitled “2 Minutes With Your Dentist Can Save Your Life.” The goal of the campaign was to help patients understand the connection between oral and overall health and recognize the importance of hypertension screenings in the dental setting.

Dentist Can Save Your Life.” The goal of the campaign was to help patients understand the connection between oral and overall health and recognize the importance of hypertension screenings in the dental setting and its relationship to helping prevent heart disease.

Implementation of the campaign included dental office posters, patient postcards, prescription pads, a website, television, Facebook and internet advertising and a media and community relations strategy (FIGURE 1 ). The advertising launch included a 30-second television ad that also ran in movie theaters and on gas station pump TV screens located in areas approximate to participating LHD 580 SEP TEMBER

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communities and dental practices as well as on targeted cable TV stations.

Data Collection

During the train-the-trainer sessions, LHDs were instructed on how to train participating dental practices, FQHCs and dental clinics in data collection using an Excel spreadsheet created by the OOH and CCDPH for data collection purposes. The LHDs then trained participating dental practices using the Excel spreadsheet.

As participating dental practices initiated hypertension screenings, data from patient encounters were collected using the data tracking

Excel document and reported to LHDs. LHDs then compiled the data from the participating dental practices and reported them to OOH and CCDPH on a quarterly basis.

Data included the number of patients seen, clinical visits, patients offered screening for hypertension, patients who received screening, patients referred to their PCP for high blood pressure (> = 140/90) and confirmed referral visits to primary care. Data were also collected on patients who identified as a “current smoker” and the number of “current smokers” who were referred to the Maryland Tobacco Quitline. Demographic data

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Referral Consultation Request Form SECTION A: DENTAL PRACTICE TO COMPLETE Patient Information:

Practice Information:

Name:

Referring Practice:

DOB: mm

/

dd

/

Consulting Practice: yyyy

Referral Consultation Reason:* (Please include any relevant diagnostic information available to assist with the consultation) Patient presented for dental appointment with BP of:

/

.

Current diagnosis of hypertension.

Patient is referred for follow-up with primary care.

Yes: 

No: 

Yes: 

No: 

Patient was educated on tobacco cessation.

Yes:  No: 

Current tobacco user.

Yes:  No: 

Additional Comments:

Referring Provider Name:

Signature:

(Please Print)

Date:

Contact #: (

)

-

*Please document relevant information regarding consultation referral in patient’s chart.

SECTION B: MEDICAL PRACTICE TO COMPLETE

Practice Information: Consulting Practice: Referring Practice:

Referral Consultation Response: Was unable to make contact with patient (If applicable, list additional information below).

Patient seen in practice/clinic and evaluated. Current BP is

/

.

Current recommendations and treatment:

Consulting Provider Name:

Signature: (Please Print)

Date:

Contact #: (

)

-

FIGURE 2 . Medical/dental referral form created by the Office of Oral Health and the Center for Chronic Disease Prevention and Control. The form is completed by the dental practice and faxed to a medical practice where the patient would undergo further evaluation and receive follow-up care if necessary.

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hypertension screening C D A J O U R N A L , V O L 4 9 , Nº 9

14,000

47 45

•

39

•

40

•

10,000

Number of patients

45

13,224

35 9,334

27

8,000

30

•

25 7,083

6,000

20 5,534 15

4,000 8

10

•

2,000

1,821 94

0

FY17, Quarter 4

756

486

680

673

Number of participating practices

12,000

50

5 0

FY18, Quarter 1

FY18, Quarter 2

FY18, Quarter 3

FY18, Quarter 4

Number of patients who received screenings for hypertension Number of patients referred to a primary care provider for follow-up Total participating dental practices

FIGURE 3. Patients screened in dental offices for hypertension.

were also collected, including age, gender, race and county of residence.

Dental patients were referred to primary care providers if the patients’ blood pressure reading was (> = 140/90). A medical/dental referral form was created by OOH and the Center for Chronic Disease Prevention and Control for this purpose (FIGURE 2 ).

This form was completed by the dental practice and faxed to a medical practice where the patient would undergo further evaluation and receive follow-up care if necessary. After follow-up, the medical practice would complete the appropriate portion of the medical/dental referral form and fax it back to the dental practice, thus closing the referral feedback loop. In addition, patients who were identified as tobacco users interested 582 SEP TEMBER

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in quitting were referred to the Maryland Tobacco Quitline using the quitline’s fax-to-assist referral form.

Results

Hypertension screening activities were monitored from April 1, 2017, to June 30, 2018. During this time, 47 dental practices were recruited, trained and conducted blood pressure screenings with 36,996 patients; of those patients, 2,689 (7.2%) were referred to primary care providers for follow-up evaluation because their blood pressure reading met or exceeded the predetermined threshold criteria (FIGURE 3 ). Of the total patients screened for hypertension, 2,855 identified themselves as tobacco users; of those identified as tobacco users, 1,302 were referred to

the Maryland Tobacco Quitline for tobacco cessation support. The social marketing campaign “2 Minutes With Your Dentist Can Save Your Life” was conducted through this time period and created significant program awareness, generating more than 3.1 million viewer impressions in the target audience.

Challenges

Multiple challenges emerged at the outset of the program while recruiting dental practices. Dental providers expressed a concern that the implementation of regular hypertension screening would be challenging and time-consuming.

This feeling was common despite the recognition by the American Dental Association (ADA) that hypertension is one of the most common and deadly cardiovascular conditions in the U.S. and that blood pressure management is considered an important screening vital sign at dental visits.15 Dentists and dental hygienists are trained to take a patient’s blood pressure as part of the patient’s medical history, which is considered standard practice.

Nonetheless, dentists felt that adding hypertension screening to the practice workflow would take time away from staff who were needed to complete the scheduled dental procedures for patients. This is consistent with findings from another study conducted with 100 dental hygienists where the majority indicated they were not conducting blood pressure screenings during appointments, even though their training emphasized doing so, because of insufficient time and the minimal value given to the procedure by their employers.16 Additionally, the lack of insurance reimbursements for hypertension screenings caused

C D A J O U R N A L , V O L 4 9 , Nº 9

concern for some providers. Dental providers stated the time needed to screen each patient would add up to a considerable amount of time that could be used to address oral health concerns. In a study conducted in Georgia to understand whether dental providers were monitoring blood pressure, the study revealed the majority of the dentists or dental hygienists were not monitoring blood pressure despite inclusion of it in their dental curriculum.16 The main reason stated was their perception that doing so would increase the amount of time it would take for them to finish the appointment.

The study recommended that dental curricula in colleges and universities prioritize the importance of blood pressure screening for all patients.

Another challenge was a low rate of referrals from dental practices to medical practices. Dental practices were asked to create partnerships with medical practices in their community to establish a feedback mechanism for patient referrals and follow-up. Only 43% of dental practices were able to establish this feedback loop. Some cited lack of medical practices in the dental practice area as others indicated that potential referral sites were unable to take on new patients. FQHCs were generally more successful in this endeavor than private dental practices, as medical and dental services were often provided within the same facility.

A method that proved useful in creating feedback loops within private practices was to have a dedicated member of the dental team follow up with the medical practice on a regular basis after the referral was made.

This hurdle persisted throughout the pilot even though a review of best practices for referrals from dental

providers to primary care providers and a standardized dental-medical referral form was created for and provided to participating dental practices in the initial training sessions. Furthermore, dental providers were often unable to complete follow-up on referrals they made to primary care providers, and primary care providers were unwilling, unable or simple too busy to connect with dental providers to confirm their patients had been seen for medical follow-up. The feedback from dental providers as to why this referral

Only 43% of dentists were able to generate a bidirectional referral process with primary care providers.

process was not seamless indicated that inadequate communication channels between dental and medical practices were common and that the lack of a shared electronic health record was considered to be the main obstacle contributing to this lack of communication.

Lessons Learned

Dental practices that received guidance and support from the MDH and LHDs incorporated hypertension screenings into their workflow with little disruption. This observation highlights the importance of proper guidance and support for maximum program integration. Moreover, once dental providers were able to detect patients with undiagnosed or elevated blood

pressures in their patient population and were able to refer them to primary care physicians for follow-up care, they began to view hypertension screenings as a vital service for their patients. This new perspective eased dental providers’ concerns regarding the lack of time and financial reimbursement as well as the potential workflow disruptions they initially felt hypertension screening would cause.

Even so, only 43% of dentists were able to generate a bidirectional referral process with primary care providers.

Clearly, the most important lesson learned from the Models of Collaboration for State Chronic Disease and Oral Health Programs initiative was that improved communication between medical and dental providers is necessary and holds tremendous promise for improved health outcomes in the identification and management of hypertension. This pilot showed that a strong bidirectional referral system that is integrated into existing health records and medical-dental referral systems is needed to help facilitate the communication and collaboration necessary to screen for and help manage chronic disease within the dental setting.

Recommendations

In developing medical-dental collaboration programs, a greater focus should be on creating and building a strong referral network among medical and dental providers prior to program implementation. In addition, increasing communication between dental and medical providers and emphasizing the importance of shared program goals before program implementation can lead to an increase in bidirectional referrals between medical and dental providers.

It is also recommended that both medical and dental practices explore SEP TEMBER 2 0 2 1

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opportunities to integrate existing health records into electronic referral systems.

Such systems will ensure patients receive the proper follow-up, diagnosis and treatment when presenting with hypertension during routine dental visits. A case management system should be considered to help with communication between medical and dental professionals, which can also help patients understand and navigate their treatment. In addition to improving and integrating existing electronic health referral systems, the creation of a standalone electronic application, designed to help facilitate referrals between medical and dental providers, should be researched and potentially developed to improve communication between medical and dental providers and increase the rate of successful referrals that occur between them.

The experience of collaboration between staff at the state’s OOH and CCDPH throughout this pilot was an invigorating, organic process that systematically grew into the development and implementation of the pilot. Each team member brought their own excitement and expertise to the project, and as a result, the project and team members benefited greatly. The level of engagement, trust and teamwork that occurred cannot be overstated.

Therefore, it is strongly recommended that oral health programs consider building collaborative relationships with state chronic disease programs.

These collaborative relationships centered on addressing shared oral health and chronic disease interests can not only help to potentially reduce common chronic diseases, but can also stimulate the workplace, inspire staff and provide a clear window into fostering and operationalizing medical/dental integration.

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Lifesaving Outcomes

In several cases, patients in the pilot who were found to have hypertension reported lifesaving and life-changing results after leaving the dental office. This occurred in a few patients who chose to visit hospital emergency departments after their screening. In one instance, a 41-year-old male whose blood pressure reading was 140/101 mm Hg reported that upon leaving the dental office he immediately visited the closest emergency department. There he was diagnosed with an untreated heart condition and was briefly hospitalized, treated and released. In another case, an individual with hypertension who presented to an emergency department after screening in the dental setting was diagnosed with a heart condition requiring surgery.

This patient recounted how he was immediately transferred to a second hospital where the successful surgery took place. In both cases, the patients are now doing well and credit the dental professionals who took the time to take their blood pressure during their dental visit for saving their lives.

Conclusion

Integration between oral health care and primary health care is a key factor to improving overall health as well as reducing mortality. The CDC Models of Collaboration for State Chronic Disease and Oral Health Programs grant program has clearly demonstrated how dental providers can play a significant role in the overall health of their patients. Another CDC grantee, the Minnesota Department of Health, conducted a pilot medicaldental integration bidirectional referral system for both blood pressure and periodontal disease. Their project results

showed that approximately one-third of people screened for hypertension had high blood pressure. Without collaboration between state oral health and chronic disease programs and the subsequent medical-dental integration that occurred, these cases simply would have been missed opportunities to curb disease and potentially save lives.17 In a recent podcast, Drs. Riedy and Jiang of the Center for Integrating Primary Care and Oral Health funded by the Health Resources and Services Administration (HRSA) at the Harvard School of Dental Medicine highlight the dental practice as playing a key role in helping to identify and treat chronic comorbid conditions, citing the bidirectional link between diabetes and periodontal disease and its impact on glycemic control.18 The CDC and HRSA through grant opportunities have signaled their recognition and support of the integration of oral health and chronic disease programs as a pathway to improve overall health and reduce illness. These grant programs, if continued, will hopefully allow state health departments across the country to create models of integrated care.

In a 2014 study published by the ADA Health Policy Research Center, screening for high blood pressure, diabetes and high cholesterol in the dental office could save the health care system up to $102.6 million each year.19 These recent developments and findings, along with the many health care, public health, professional and advocacy groups calling for increased integration of medicine and dentistry, have created a ground swell of momentum that can increase collaboration as a way to ensure access to quality health care, decreased costs and improved health outcomes throughout the nation.

C D A J O U R N A L , V O L 4 9 , Nº 9

The Maryland Hypertension Screening in the Dental Setting pilot program is only one example of the many programs demonstrating the significant impact dental professionals can have on the reduction of hypertension and other chronic diseases.

In the Maryland pilot, 47 dental practices screened 36,996 patients for hypertension and referred 2,689 to primary care physicians for further evaluation and/or treatment in just more than one year. These numbers indicate the positive impact of chronic disease screening in the dental setting and the potential for nationwide incorporation of hypertension screening in dental practices to help the fight to reduce heart disease. n

Readings. www.heart.org/en/health-topics/high-bloodpressure/understanding-blood-pressure-readings.

12. Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: The scope of care coordination.

Ann Intern Med 2009 Feb 17;150(4):236–42. doi: 10.7326/0003-4819-150-4-200902170-00004.

13. Atchison KA, Rozier RG, Weintraub JA. Integration of Oral Health and Primary Care: Communication, Coordination and Referral. nam.edu/integration-of-oral-health-and-primary-carecommunication-coordination-and-referral.

14. Miloro MB, Vujicic M. Physicians dissatisfied with current referral process to dentists. Health Policy Institute Research Brief. American Dental Association. www.ada.org/~/media/ ada/science%20and%20research/hpi/files/hpibrief_0316_5. pdf.

15. American Dental Association. Hypertension (High Blood Pressure). www.ada.org/en/member-center/oral-health-topics/ hypertension.

16. Hughes CT, Thompson AL, Browning WD. Blood pressure screening practices of a group of dental hygienists: A pilot study. J Dent Hyg Fall 2004;78(4):11. Epub 2004 Oct 1.

17. Hughes D. Hypertension Screening in Dental Settings. decisionsindentistry.com/article/hypertension-screening-dentalsettings.

18. Center for the Integration of Primary Care and Oral Health, audio blog interview. www.listennotes.com/podcasts/rosreview-of/ros-drs-christine-riedy-tien-Sw3UoeA0G1P. 19. Burger D. New Guideline on Hypertension Lowers Threshold. American Dental Association. New guideline on hypertension lowers threshold. www.ada.org/en/publications/ ada-news/2017-archive/november/new-guideline-onhypertension-lowers-threshold.

N OTE : To find more information on Maryland’s Hypertension Screening in the Dental Setting pilot program, visit: Maryland Department of Health. Models of Collaboration for State Chronic Disease and Oral Health Programs in Maryland. phpa.health.maryland.gov/oralhealth/Documents/ HypertensionFinalReport.pdf.

T HE CORRE S P ON DIN G AU T HOR , John Welby, MS, can be reached at john.welby@maryland.gov.

RE FEREN CE S 1. U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health (2000). Oral Health in America: A Report of the Surgeon General. www.nidcr.nih.gov/sites/default/ files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf.

2. U.S. Department of Health and Human Services Oral Health Coordinating Committee (2016). U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014–2017. Public Health Rep 2016 Mar–Apr; 131(2): 242–257.

3. Centers for Disease Control and Prevention. Heart Disease Facts. www.cdc.gov/heartdisease/facts.htm.

4. American Heart Association. What is High Blood Pressure? www.heart.org/en/health-topics/high-blood-pressure/the-factsabout-high-blood-pressure/what-is-high-blood-pressure.

5. World Health Organization. Hypertension. www.who.int/ news-room/fact-sheets/detail/hypertension.

6. American Heart Association. Blood pressure toolkit. www. heart.org/en/health-topics/high-blood-pressure/high-bloodpressure-toolkit-resources.

7. Centers for Disease Control and Prevention. The Surgeon General’s Call to Action to Control Hypertension. www.cdc. gov/bloodPressure/CTA.htm.

8. Chockalingam A, Campbell NR, Fodor G. Worldwide epidemic of hypertension. Can J Cardiol 2006 May 15;22(7):553–5. doi: 10.1016/s0828-282x(06)70275-6.

9. CDC National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Million Hearts Undiagnosed Hypertension. millionhearts.hhs.gov/tools-protocols/undiagnosedhypertension.html.

10. Mayo Clinic. High blood pressure (hypertension). www. mayoclinic.org/diseases-conditions/high-blood-pressure/ diagnosis-treatment/drc-20373417.

11. American Heart Association. Understanding Blood Pressure SEP TEMBER 2 0 2 1 LDM_CDA_Journal_1.3_Square_LindaBrown_05_23_17.indd 1

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Making your transition a reality.

Dr. Thomas Wagner

Dr. Russell Okihara

LIC #01418359

LIC #01886221

Jim Engel LIC #01898522

(916) 812-3255 (619) 694-7077 (925) 330-2207 46 Years in Business 39 Years in Business 47 Years in Business

Jay Harter LIC #01008086

Kerri McCullough LIC #01382259

Gina Miller LIC #02015193

Steve Caudill LIC #00411157

Jaci Hardison LIC #01927713

Christy Conway LIC #: Coming soon!

Kim Ta LIC #02085576

Thinh Tran LIC #01863784

(916) 812-0500 (949) 300-0312 (707) 391-7048 (714) 318-4911 (951) 314-5542 (408) 687-5001 (619) 889-6492 (949) 675-5578 38 Years in Business 36 Years in Business 31 Years in Business 31 Years in Business 27 Years in Business 18 Years in Business 17 Years in Business 12 Years in Business

PRACTICE SALES • VALUATIONS/APPRAISALS • TRANSITION PLANNING • PARTNERSHIPS • MERGERS • ASSOCIATESHIPS NORTHERN CALIFORNIA ALAMEDA: 4 Ops in busy shopping center. 29 yrs Goodwill. 2019 GR $246K on 27 hrs/wk. Room to grow!#CA1268 ALAMEDA COUNTY SOUTH-ORTHO: New Listing! 3 Chairs, below-market rent with over 50% Net profit and 2020 GR of $505K. Orthowave and Digital Pan/Ceph. Great satellite office or for first-time buyer. #CA2785 EAST BAY AREA PEDO: Well-established with 8 Ops, Digital, plumbed for Nitrous, and high NP count. Associate-driven with Delta PPO. 2019 GR $832K on 3-4 days/wk., 2020 Production $523K. #CA2523 FAIR OAKS/CITRUS HEIGHTS AREA: Successful practice w/ 38 yrs. Goodwill. Nice décor, Digital, 6 hyg days/wk. Growth potential with Ortho/Implants. 4 Ops in 1,100 sf. 2019 GR $970K+ on 32 hrs/wk. #CA656 FREMONT ORAL SURGERY: New Listing!

34 yr history, diverse high-tech community. 4 Ops Digital, 7-10 y/o equipment, Pano. 2019 GR $548K on 3.5 days/wk. #CA2754 GREATER SACRAMENTO: Paperless, hiend retail area, 5 Ops, 30 yrs Goodwill. Most Specialties referred. 2020 GR$781K on 32 hrs/ wk. Seller can work back post-sale. #CA2465 GREATER SONORA AREA: Rural lifestyle GP/Real Estate, 5 Ops, Dentrix, Strong hyg prog in stable community. 2019 GR $698K. #CA1713 HAYWARD: New Listing! Great neighborhood practice +RE opportunity. 4 Ops, digital, updated. 2019 GR $730K. #CA2771 LAKE TAHOE AREA: 4 Ops, 37+ yrs Goodwill. Rural lifestyle GP in growing resort community. 2019 GR $760K. #CA1715 LAKE TAHOE AREA: GP practice with 5 Ops w/ 6th Open, Operatory views of Lake Tahoe, only 34 Delta Premier patients, 2,100 sf.

2019 GR $579K on 22 avg. Dr. hrs/wk. #CA608 MILLBRAE: Role Reversal, 5 Ops. 2019 GR $1M+ on 4 days/wk. and 6 hyg days. Seller offering 6 mo. employment and work back 6 mo. after sale. Digital, Pano, Waterlase & Periolase. #CA1139 NORTHERN CA PERIO: 4 Ops, Consult Rm, Upgraded Tech with Digital, LANAP, Paperless. 2019 GR $900K+. Draws from lg area with little competition. #CA1553 NORTHERN SACRAMENTO: Busy location, Paperless, 3 Ops+4th shared, CEREC, Digital Pano. 2019 GR $671K on 24-32 hrs/wk. #CA1745 NORTHERN SACRAMENTO: 5 Ops, busy retail shopping center. Digital, strong hygiene, and high NP count. Room for growth with specialties. 2020 GR $900K. #CA2464 OAKLAND: 3 Ops, Room to expand, Digi Xrays, Paperless, 40+ yrs Goodwill. 2019 GR $675K w/ room to grow Specialties. Prime location, retiring doctor will help with a smooth transition. Seller-owned RE to purchase or lease. #CA1380 REDDING AREA: Price reduced by $100K under valuation price! Modern office with 5 Ops, 4 Eq., Digital, Newer CEREC, 23 NP/mo with no marketing. Strong Hygiene, specialties referred. 2019 GR $558K. #CA1742 ROSEVILLE/CITRUS HTS: New Listing! 6 Ops, high traffic area, 13 yrs goodwill, Digital, lasers, 26 NP/mo, 5 days Hygiene, specialties referred. Seller will work back. #CA2749

SACRAMENTO: New Listing! 5 Ops+RE in a busy medical/dental/retail area. Digital, 50 yrs Goodwill, 6 hyds/wk. and 3.5 Dr. days/wk. 2019 GR of $697K with specialties referred. #CA2620 SAN JOSE: Practice+RE, 3 Ops, Modern design in open concept in desirable location. 2019 GR $374K. #CA2613 SAN MATEO: New Listing! 5 Ops, Digital, iTero Scan, CEREC, Laser, Paperless, Microscope. Seller-owned stand-alone building to lease. $1.4M GR on 4 days/wk. #CA2596 SONOMA COUNTY: New Listing! 4 Ops with room to expand into suite next door. GR over $1M for last 3 yrs. Est. 30+ years. Strong hygiene, digital, space available to lease or buy. #CA2790 SONOMA COUNTY: New Listing! 4 Ops in spacious layout in heart of the area off main highway. Est 22 yrs with 5 star Google reviews, Paperless with CEREC, Scope, Laser, Strong Hyg. Retiring seller. 2019 GR $782K with good post-COVID recovery. #CA2594 SONOMA COUNTY: Stand-alone 3,000 sf, 72 NP/mo. & 10 hyg days. 6 Ops, Pano, Dexis, Cameras, Laser, Dentrix. Business & RE for sale or Lease. Doctor Retiring. 2019 GR $2.3M+. #CA544 VACAVILLE AREA: Price Reduced! Seller will work back for up to 6 mo. Centrally-located & hi-traffic location with 25+ yrs goodwill. 5 Ops in 1,700 sf. 2019 GR $556K on 32 hrs/wk. #CA645 VACAVILLE AREA: New Listing! 4 Ops, 3 equipped, 45 years goodwill, Digital, paperless, most specialties referred. 2019 GR $723K on 30 hour week. #CA2748

CENTRAL CALIFORNIA CENTRAL COAST: 5 Ops, digital, 25+ yrs Goodwill. Newly renovated, practice sees 30 NP/mo. Strong hyg prog. 2019 GR $1.1M+. #CA1218 CENTRAL VALLEY/MODESTO: New Listing! 8 Ops, high visibility retail, Open 20+ yr, Digital, soft/hard tissue lasers, 3,300+ active pts., 24+ NP/mo., 4 hyg days/wk., 18.5 hour Dr. work week. 2019 GR $852K, 2020 84% of 2019. #CA2721 MODESTO AREA: Est. area with 60+ yrs. goodwill. 5 Ops, 2019 GR $1.1M+ on 3 days/ wk. Dental Condo also available for purchase or lease, Seller may consider financing. #CA635 MONTEREY: New Listing! 4 Ops, Paperless, Digital, Pano. 2019 GR $1.1M with Adj. Net over $450K. Post-COVID revenue has grown even more! RE for sale, non-Delta Premier office, FFS and some PPOs. #CA2614 SANTA CRUZ/APTOS PERIO: New Listing!

4 Ops+RE, Paperless, Digital, CBCT, 27 years goodwill. Seller will help with smooth transition of strong referral base. #CA2725 STOCKTON: Practice+RE available, 5 Ops, 5 Hyg. Days/wk. 2019 GR $812K on 32 hr. week.

High level of Ortho, seller can work back. #CA2006

SOUTHERN CALIFORNIA ANTELOPE VALLEY: New Listing! 7 Ops in fast-growing community. Paperless with Dentrix, digital x-rays, 8 days of hyg./week and dedicated staff. Room to grow with specialties! #CA2612 BAKERSFIELD: 7 Ops w/high-end equipmentCEREC, Digital X-rays, Cone Beam, Implant motor. 7 days of hygiene with room to grow. GR $1M+ with low overhead. The building is for sale at $650K. #CA1120

Northern California Office

800.519.3458

Henry Schein Corporate Broker #01230466

BAKERSFIELD: 6 Ops, 40 yrs Goodwill, great reputation in the area. 6 hyg ds/wk and most specialty work referred. Digital pano, digital X-rays. 2019 GR $600K. RE also for sale. #CA1274 BAKERSFIELD: New Listing! 6 Ops, 5 Equipped, Digital, 2020 Collections $1M+ with 6 days hygiene and 2 P/T associates. #CA2587 BURBANK: New Listing! Big opportunity for large practice merger, 6 Ops, Digital, seller retiring. 6 days of hygiene, specialties referred.

Seller will transition, open to financing options.

2019 GR $918K. #CA2632 COASTAL ORANGE COUNTY: New Listing! 5 Ops, 4 Equipped, Digital Pano and Xrays, well-established neighborhood, very desired area. 2019 GR over $1M. #CA2787 CORONA: 4 Ops, Digital, excellent growth opportunity. Main street location in small strip center. 2019 GR $280K. #CA2002 HUNTINGTON BEACH: PRICE REDUCED FOR QUICK SALE! 5 Ops, desirable loc, Digital, Strong hyg prog. 2019 GR $604K. #CA685 HUNTINGTON BEACH: 4 Ops, located in a busy retail center with great visibility. Practice utilizes Digital X-rays and Easy Dental PMS. 2019 GR $466K. #CA673 INDIO: New Listing! 4 Ops, single-story medical/retail center. Digital, CEREC w/milling unit and oven. GR $764K in 2019 and $535K in 2020. 7 Hyg days/wk. Great Opportunity. #CA2619 LONG BEACH: RE Ownership an option!

Upper middle-class residential practice est. in 1950. Existing 4 Ops, 3 Equip, Digital, Easy expansion next door to add 3 Ops, 2 are equip.

Most Specialty referred. Strong post-COVID production. 2019 GR $696K. #CA671 LOS ANGELES: Cash/PPO office in great DTLA Location. 3 Ops with low rent. Digital with scanner and lasers. 2020 GR $299K on 2 days/wk. #CA2493 ORANGE COUNTY: Price Reduced! 5 Ops, Digital, Retiring seller. Excellent reputation, affluent area, high quality care. Modern, welcoming office with strong hyg prog. Room to grow specialties. 2019 GR $642K. #CA1676 ORANGE COUNTY: Strip center location at a major intersection. 2019 GR $329K with low overhead and great take-home Net. 5 Ops, 3 equipped, seller works average 25 hrs./wk.

Great potential, low asking price of $175K. A must-see! #CA1728 ORANGE COUNTY: New Listing! 4 Ops in sought-after area. 34 yrs Goodwill, many hi-end procedures done in-house but room to grow other specialties. Digital. FFS/Cash. #CA2704 OXNARD: 7 Ops, nice office, paperless, digital, 11 days of hygiene/wk. 2019 GR $1.55M. #CA1829 OXNARD: 4 Ops, Digital X-rays, Est. 35+ yrs ago. Seller owned it for 3 yrs and has a primary office in LA. 2019 GR $662K. #CA1164 PALM DESERT: 4 Ops 27 yrs Goodwill.

Strong hyg prog w/ hi-end patient base of locals/snowbirds. 2019 GR $809K on only 16 days/mo. with low overhead. Call today! #CA691 SAN GABRIEL VALLEY: 4 Ops, Digital Xrays, 65 yrs Goodwill. Most specialty work referred out, most PPO plans are accepted. Busy road with great visibility, open 4 days/wk.

Nicely appointed; excellent opportunity. #CA596

www.henryscheinppt.com

SOUTH BAY LOS ANGELES: New Listing!

3 Ops, retiring seller with 34 yrs goodwill. Ready to take to the next level with technology of your choosing. Amazing location in desired area. 2019 GR of $300K with low expenses, a wonderful opportunity to grow. #CA2807 SOUTH BAY LOS ANGELES: Ready to retire!

7 Ops, real estate for sale also. 50% Denti-Cal, some HMO and PPO. 2019 GR $568K. #CA1050 SOUTH ORANGE COUNTY PERIO: 4 Ops, 3 Equip, Coastal Community, Modern, Busy strip center location near hi-end residential. 2019 GR $845K. #CA643 SANTA BARBARA: New Listing! 4 Ops in beautiful setting. Digital, FFS, strong hygiene, and room to grow with specialties. Consistently collects $1M+/yr. with manageable overhead. #CA2531 SANTA BARBARA: New Listing! 4 Ops with Digital x-rays, 5 hygiene days/wk. Most specialties referred, beautiful area. 2019 GR $790K with attractive net. #CA2722 VALENCIA: New Listing! 4 Ops, digital X-Ray, Pano, 5 y/o equipment, 2019 GR $605K and 2020 $507K, 30+ years of goodwill.Retiring seller, priced to sell! #CA2691

SAN DIEGO DEL MAR: New Listing! 4 Ops, Digital, Open Dental, Conservative Practitioner who refers out specialties. 4 days of hygiene per week.

Seller is eager for a quick sale. Excellent opportunity in a very desirable location. #CA2724 NATIONAL CITY: 6 Ops, 14 yrs Goodwill, strip mall with high visibility, Digital, loyal staff and patients. 2019 GR $754K. #CA1465 SANTEE: Practice+RE – 7 Ops, Digital, Pan, in excellent location with parking. Growing area with many years of goodwill. #CA2549

OUT OF CALIFORNIA BIG ISLAND, HAWAII: 3 Ops, non-digital, excellent location plus rare option to purchase office space. Room to grow! #HI1929 PORTLAND, OR: New Listing! Great location. 5 Ops, 4 equipped, Digital, Pano, 50% Medicaid. Turn-key practice on main road. 2019 GR $646K. #OR2757 SOUTHERN OREGON: New Listing! 5 Ops, Paperless, CEREC, Laser, and much more.

Doctor is available to stay on for transition, if desired. Turn-key office. 2020 GR $1.5M. #OR2688 SOUTHERN OREGON: Quaint GP in ideal location in desirable town. 4 Ops with room to grow adding days and specialties. Open 31 yrs.

Digital with EagleSoft. $276K GR in 2020. #OR2574 TRI-CITIES, WASHINGTON: New Listing!

Small modified start up, fully equipped! Access to 1500 patient records, Open Dental software, laser, x-ray sensors. Desirable location, affordable rent. #WA2629

Southern California Office

888.685.8100

toolkit C D A J O U R N A L , V O L 4 9 , Nº 9

Development of the California Oral Health Literacy Toolkit Linda Neuhauser, DrPH, MPH; Anthony Eleftherion; Rebecca Freed; Karen Sokal-Gutierrez, MD, MPH; Rosanna Jackson; Jessica Liu, MPH; Susan L. Ivey, MD, MHSA; Kristin Hoeft, PhD, MPH; Alice M. Horowitz, RDH, MA, PhD; and Jayanth Kumar, DDS, MPH

AUTHORS Linda Neuhauser, DrPH, MPH, is a clinical professor of community health sciences at the University of California, Berkeley, School of Public Health and co-principal investigator of Health Research for Action.

Anthony Eleftherion, is the director of communications at Health Research for Action.

Rebecca Freed is the associate director, health literacy communications at Health Research for Action.

Rosanna Jackson is an oral health program manager at the Office of Oral Health in the California Department of Public Health.

Karen Sokal-Gutierrez, MD, MPH, is a clinical professor at the University of California, Berkeley, School of Public Health.

Jessica Liu, MPH, is the research project coordinator at Health Research for Action.

Susan L. Ivey, MD, MHSA, is a professor adjunct at the University of California, Berkeley, School of Public Health and the director of research at Health Research for Action.

Kristin Hoeft, PhD, MPH, is an assistant professor in the department of preventive and restorative dental sciences at the University of California, San Francisco, School of Dentistry.

Alice M. Horowitz, RDH, MA, PhD, is an associate research professor in the department of behavioral health and community health at the University of Maryland School of Public Health.

Jayanth Kumar, DDS, MPH, is the state dental director for the California Department of Public Health.

Conflict of Interest Disclosure for all authors: None reported.

A

lthough many factors contribute to the high prevalence of oral health problems and widening disparities in the U.S., limited oral health literacy has emerged as a major contributor.1–3 Oral health literacy (OHL) refers to people’s abilities to access, understand and use oral health information to inform decisions and actions for themselves and others.2,4 It also refers to providers’ abilities to communicate clearly, equitably and persuasively with patients and caregivers and to the “patient friendliness” of oral health practice sites. Studies over the past two decades show a strong association between low individual, provider and organizational OHL and the prevalence of oral health problems and inequities.2,5,6 Many federal health agencies and national and state dental and public health associations have defined policy goals to improve OHL. For example, the American Dental Association established its National Advisory Committee on Health Literacy in Dentistry. This committee has provided sessions on oral health literacy at the ADA annual sessions and sponsors national oral health literacy surveys about knowledge, opinions and practices among dental practitioners and students.2 Additionally, the California Dental Association recommends promoting evidence-based approaches to increase oral health literacy.7

Because the public receives most of its oral health information at dental practices, dental providers play a central role in advancing OHL. Research studies now provide important best-practice guidance about ways that dental providers can improve their own OHL and that of their patients. These approaches include assessing the practice setting for “patient friendliness” (easy-to-navigate, shame-free and understandable intake and consent forms and educational materials) and for good provider–patient communication (culturally competent, easy to understand and using “teach-back” check-ins with patients).2,5 However, few dental providers have received OHL training in professional settings or through continuing education.2,5,8 In addition, although health literacy toolkits and other resources have been developed,9 none has been adapted to support dental provider education in a way that works within practice constraints.7 Beginning in 2018, the California Department of Public Health, Office of Oral Health engaged with the Health Research for Action Center at the University of California, Berkeley, School of Public Health to create the California Oral Health Literacy Toolkit Project — intended to advance its statewide goal of improving OHL among dental providers.7,10,11 In the project’s first phase, the project team conducted a review SEP TEMBER 2 0 2 1

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of the literature about studies related to OHL for dental providers, conducted 50 in-depth interviews with national OHL experts and diverse California dental providers, and performed an environmental scan of available OHL materials and training resources for dental providers.

Results showed low rates of dental provider knowledge and adoption of recommended OHL practices and very limited availability of OHL resources for providers.7 The interviews with California dental providers similarly showed low rates of OHL knowledge and use of recommended communication practices and demonstrated that providers were very interested in having OHL training and supportive resources. Providers recommended having statewide and local training and a concise, digital, skills-based provider toolkit that explains OHL fundamentals and offers strategies for implementing OHL techniques in dental practices.

Developing the Toolkit

In the project’s second phase, the team drew on the initial study findings and available resources to develop an OHL toolkit, using an iterative, participatory process that involved OHL experts, diverse California dental providers and community members. The California Oral Health Literacy Toolkit includes five components to help providers learn or review basic OHL principles, including communicating clearly and with cultural humility and creating a welcoming environment for all patients: ■ Oral Health Literacy in Practice, a 24-page guidebook that reviews essential principles of OHL and suggests ways to implement OHL at every touchpoint of patient visits.

■ Practice Assessment Checklist, an easy-to-use first step to assess a dental practice’s OHL preparedness.

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What Is Teach-Back, an example-based quick reference for learning and practicing how to use teach-back with patients.

■ Health Literacy Action Plan, a worksheet that dental teams can use to write down health literacy goals as well as identify steps to reach them.

■ Going to the Dentist, a six-panel brochure that guides patients through the “before, during and after” of dental visits using clear communication principles.

The toolkit is available to download free of charge from the California Oral Health Technical Assistance Center.

As of May 2021, trainings for providers on the toolkit and oral health literacy are being offered through the California Dental Association (offering continuing education credits) and at local dental societies. The project team encourages dental professionals to enroll in a training, download the toolkit components and consider how each might help their dental practice begin or continue adopting OHL principles and approaches. n ■

AC KN OW LE DGM E N T S This project was funded by the California Department of Public Health (CDPH) under Contract Number 18-10565.

We appreciate expert guidance from our colleagues at the CDPH Office of Oral Health, especially Joanna Alboe, Karen Jacoby and Steven Starr; from our colleagues at the American Dental Association National Advisory Committee on Health Literacy in Dentistry, especially Lindsey Robinson, Dushanka V. Kleinman and Cynthia E. Baur. We thank Gayle Mathe at the California Dental Association and dentists Francisco RamosGomez, Lesley Latham, Jean Creasey and David Trent for help with reviewing the toolkit and developing training. We also appreciate the participation of the many dental providers and community members involved in this study and research support from a number of UC Berkeley students.

RE F E RE N C E S 1. Centers for Disease Control and Prevention. Division of Oral Health at a Glance. 2019. www.cdc.gov/chronicdisease/ resources/publications/aag/oral-health.htm. Cited Aug. 8, 2019.

2. Horowitz AM, Kleinman DV, Atchison KR, Weintraub JA, Rozier RG. The evolving role of health literacy improving oral health. In: Logan RA, Siegel ER eds. Health literacy in clinical practice and public health: New initiatives and lessons learned at the intersection with other disciplines. Amsterdam: IOS Press; 2020. doi: 10.3233/SHTI200025.

3. Ramos-Gomez F, Kinsler J, Askaryar H. Understanding oral health disparities in children as a global public health issue: How dental health professionals can make a difference.

J Public Health Policy 2020 Jun;41(2):114–124. doi: 10.1057/s41271-020-00222-5.

4. U.S. Department of Health and Human Services. Healthy People 2030: Understanding and Improving Health. 2020.

5. Rozier RG, Horowitz AM, Podschun G. Dentistpatient communication techniques used in the United States: The results of a national survey. J Am Dent Assoc 2011 May;142(5):518–30. doi: 10.14219/jada. archive.2011.0222.

6. Firmino RT, et al. Oral health literacy and associated oral conditions: A systematic review. J Am Dent Assoc 2017 Aug;148(8):604–613. doi: 10.1016/j.adaj.2017.04.012.

Epub 2017 May 3.

7. California Dental Association Access Report. Phased Strategies for Reducing the Barriers to Dental Care in California. November 2011, edited May 2012.

8. Tseng W, Pleasants E, Ivey SL, Sokal-Gutierrez K, Kumar J, Hoeft KS, Horowitz AM, Ramos-Gomez F, Sodhi M, Liu J, Neuhauser L. Barriers and facilitators to promoting oral health literacy and patient communication among dental providers in California. Int J Environ Res Public Health 2020 Dec 30;18(1):216. doi: 10.3390/ijerph18010216.

9. DeWalt DA, et al. Health literacy universal precautions toolkit. Rockville, Md.: Agency for Healthcare Research and Quality; 2010:1–227.

10. Kumar J. Improving oral health literacy in California: A perspective. J Calif Dent Assoc 2020 Aug 8(48):397–399.

11. California Department of Public Health. California Oral Health Plan 2018–2028. 2018. California Department of Public Health.

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The Oral Health Literacy Toolkit The components of The Oral Health Literacy Toolkit have been designed to help you implement oral health literacy in your practice in a way that fits your needs. Peruse these pages and see which of the components work best for you and your practice.

Oral Health Literacy in Practice This 24-page guidebook to oral health literacy provides a simple road map for assessing your practice and implementing change at your own pace.

• Suggests strategies for communicating clearly and empowering patients.

Oral Health Literacy in Practice CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

• Contains example scripts and templates.

Download and view digitally.

The guidebook contains several tools for implementing health literacy, such as example scripts.

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Practice Assessment Checklist This checklist will help you assess your practice for health literacy. Whether your practice is new to health literacy or looking to improve upon previous work, the results can help you and your team develop a health literacy plan that works for your practice. To make a plan, review the OHL Guidebook and use the HL Action Plan template.

Preparing for change

Doesn’t meet expectations

Meets expectations

Exceeds expectations

Doesn’t meet expectations

Meets expectations

Exceeds expectations

1. Oral health literacy team or leader has been selected.

2. Practice has an oral health literacy action plan.

3. Staff understands the impact of oral health literacy.

4. Each staff member understands their role in oral health literacy.

5. Each staff member understands their role in the action plan.

6. Staff has received health literacy training.

Creating a health-literate environment 1. Patients can speak to a person when they call.

2. Signs are in plain language and are easy to understand.

3. Signs are in the languages spoken by the patient population or used commonly in the community.

4. Patient waiting room is friendly and inviting.

Ideas for improvement

The checklist helps you assess your practice’s health literacy preparedness.

Practice Assessment Checklist This two-page checklist helps you to identify oral health literacy strengths and opportunities for improvement and helps your dental team to quickly learn what they can do to improve patient communication.

Download and print.

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Practice teach-back by yourself or with a partner.

What Is Teach-Back?

This two-page tip sheet has brief instructions on how to use the teach-back method.

• Helps you learn some easy ways to use teach-back.

• Provides a few scenarios to use in practicing your skills.

Download and print.

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Oral Health Literacy Action Plan This two-page printable worksheet helps you choose health literacy goals for your practice, then decide how to put those goals into action.

Download and print.

The action plan template helps you organize the steps for improving OHL at your practice.

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The brochure helps patients understand what to expect before, during and after their visit.

Going to the Dentist patient brochure This six-panel patient brochure explains what to expect during a dental visit and how to prepare.

• Written for people who are new to oral health care.

• Print on legal-size paper and fold for patients or bring the file to a professional printer.

Download and print.

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RM Matters

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Saving Time and Staying Safe With Paperless Documentation TDIC Risk Management Staff

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f you’ve ever lost a receipt, arrived at the grocery store without your list or misplaced a lucky lottery ticket, you’ve experienced the perils of paper.

When navigating your dental practice’s many documentation requirements for patients, benefit plans and employees, those perils are exponentially multiplied.

Analysts who answer The Dentists Insurance Company (TDIC) Risk Management Advice Line field thousands of calls about practice challenges — many of which are related to navigating paper and digital documents.

Saying yes to paperless in four steps ■

The downside of paper docs

As reported during a recent Advice Line call, a dentist who shared a storage area with another tenant experienced an issue when the space was being remodeled. When returning to work after the weekend, she realized that some charts were misplaced and was unsure whether information was missing and possibly even compromised. The analyst advised the dentist to conduct a HIPAA breach assessment. Without any certainty of the scope of the issue, the practice might have needed to send a blanket notification to all patients whose charts were contained in the storage area.

The inability to monitor, track and access paper documents during practice interruptions — no matter how brief — introduces risk. Whether you’re working through converting existing records into digital formats or looking for more paper-free opportunities, be thoughtful and strategic in your approach.

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■

■

Understand retention guidelines.

The amount of time you keep dental records after a patient’s last visit is determined by each state’s laws and the provisions of any contracted benefit plans — ranging from several years to “indefinitely.” Employment documents, tax returns, business contracts and insurance policies all have unique retention guidelines.

Digital solutions allow you to more easily find and access documents on the cloud without the clutter. Check with your state dental association or dental board for region-specific requirements.

Secure records against risks.

One of the biggest benefits of going paperless is the ability to protect important and confidential information from loss, theft or damage. Your role is to ensure that the right individuals on the practice team have access, that passwords are strong, that protocols are consistent and that your practice is insured for potential liabilities. Comprehensive protection to respond to and recover from cyber-related incidents is essential for dental offices of any size.

Get on a backup cycle.

Another paperless upside is anytime, anywhere access. During an emergency or unforeseen event, you can have confidence that you’ll connect to the data you need. Your

backup cycle is determined by your risk tolerance. How much data can you afford to compromise in a day, a week or a year? Secure, HIPAAcompliant, cloud-based solutions can back up data dependably but still need to be checked that they are functioning as expected.

■

Facilitate team buy-in.

While digital documents can streamline processes, the entire team still needs to be aligned. Use consistent naming conventions for files so that information can be crossreferenced or searched with ease.

Provide training and opportunities for staff to weigh in on how the practice can be most successful at going green. Those who do the most paperwork can be the best champions for reducing repetitive tasks.

Saving paper beyond the chart

Of course, patient records aren’t the only place to go paperless. Discover new ways to go green, streamline and save time.

For example, here are three ways to manage insurance documents: ■

Policy documents.

Through TDIC’s enhanced website, policyholders can access accounts 24/7 to download insurance policy documents, update profile information and preferences and make or request policy changes.

C D A J O U R N A L , V O L 4 9 , Nº 9

■

■

Bill payment.

TDIC’s site also offers online bill payment and the option to set up recurring autopay debits. “Set it and forget it” billing ensures that payments are trackable and on time for many of your practice’s services and vendors and online statements can facilitate budget reconciliation.

Claims reporting.

When experiencing an accident or emergency, you’ll want to file a claim quickly and return your focus to patient care. Whether you report your claim online or by phone, logging in to track your claim through the process can provide more transparency and relief.

Engage the whole team in your efforts toward a paperless practice. Start with quick wins, like online access for insurance and business services. And commit to consistent safety and security protocols that allow you to enjoy the flexibility of digital documents. n The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 800.733.0633.

Here are more ways to streamline tracking equipment and supplies: ■

■

Inventory and asset tracking.

In the event of an emergency, you’ll want records of your practice’s contents to be accessible too. With a little time invested on the front end, you can create a full view of the value of your assets in software or apps designed just for the task. Update and sync as you introduce new equipment and capture warranties, receipts, manuals and serial numbers.

Supply shopping.

From dental equipment to break room essentials, creating digital checklists of frequently ordered items can help you cut down on shopping time, better organize and review invoices and avoid gaps and duplications.

Bundling orders is another way to go green. Cut down on packaging and reduce your carbon footprint with fewer, well-planned deliveries.

answers

From one-on-one risk management advice by phone to informed consent forms to expert-led seminars, we’re here to help you practice with confidence.

We are The Dentists Insurance Company.

Learn more at tdicinsurance.com/rm

Protecting dentists. It’s all we do.

®

800.733.0633 | tdicinsurance.com | Insurance Lic. #0652783

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Regulatory Compliance

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Disability Access and Nondiscrimination Laws CDA Practice Support

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ederal and state disability access and nondiscrimination laws have a broad impact on dental practices.

A practice owner needs to ensure that the office:

■ ■

■

■

■

Meets physical access standards.

Provides sign language interpreters to individuals who are deaf or hard of hearing if they request them.

Ensures website content is accessible to individuals with sight impairment.

Permits a service dog or service dogin-training to accompany their owner.

Does not deny services based on an individual’s disability.

Recently, the U.S. Department of Justice settled with a North Carolina dental practice over a complaint that an individual was denied routine dental services because they have HIV.1 In California, CDA and TDIC have heard from many dental offices in the last few years who have sued over the accessibility of their respective websites.2 CDA Practice Support regularly receives calls from dental offices seeking to verify that they are indeed required to provide a sign language interpreter for patients who are deaf or hard of hearing.

Clearly, dentists and their staff need to better understand their obligations under disability access and nondiscrimination laws. This article does not intend to be a comprehensive look at these obligations and will instead point to resources for compliance assistance.

Physical Accessibility Standards

Physical accessibility standards are part of the California Building Standards Code 596 SEP TEMBER

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with the Division of the State Architect in collaboration with stakeholders, experts and public entities to develop regulations and to interpret code. The building code is available on the state Building Standards Commission website.

A local building department may have additional requirements and is permitted to interpret and enforce the state building codes to best fit community needs.

Building owners may seek assistance from a state-certified access specialist (CASp) to ensure compliance. An owner can obtain compliance information from a CASp working at the local building office or hire a CASp to walk through a site or review building plans. A list of these specialists is available on the website of the Division of the State Architect. The website also has an FAQ for business owners and information on financing for small businesses that want to make accessibility improvements.

Communicating With the Deaf or Hard of Hearing

A dentist is required to ensure a patient understands the risks and benefits of proposed dental treatment. When working with a patient who is deaf or hard of hearing, the dental practice should ask the patient which communication method they prefer. The options include using: ■ Printed or written instructions, questions, responses via paper and pen, computer or other device.

■ Lip reading.

■ Sign language, either in person or live-remote.

Not all patients who are deaf or hard of hearing ask a dental practice to provide

a sign language interpreter. Be prepared, however, to provide an interpreter if requested. A dental practice may not charge the patient for the cost of providing the interpreter or for any other cost associated with ensuring you and your patient are able to communicate. If the patient has dental benefit coverage, contact the plan and inquire about the availability of an interpreter. Medi-Cal Dental also will provide interpreters for its beneficiaries with advance notice.

Website Accessibility

Litigation over the accessibility of business websites is growing. If a dental practice is uncertain its website content is fully accessible to individuals with visual impairments, it should take the website down as soon as possible. To ensure it has an accessible website, a dental practice should work with a website designer who is familiar with the Americans with Disabilities Act standards for website design known as WCAG 2.0 levels A and AA. If a website has videos or links to videos on another site, it should have closed captions or another option so that an individual knows what the video content is without watching it. Another way to improve the website’s readability for an individual with sight impairment is to ensure high contrast between the text, graphics and background. The best practice, however, is to have the entire website reviewed regularly, dependent on how frequently the website is changed.

If a dental practice is served with a notice of a lawsuit, it should contact the liability carrier.

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Service Dogs

A service dog is one that is trained to do work or perform tasks for the benefit of an individual with a disability. Places of public accommodation, such as a dental practice, may not prohibit or limit an individual with a service dog or a service dog in training or the dog itself from entering solely due to the animal’s presence.

A business may not require documentation that the service dog is certified or licensed as a service dog. If the need for a service dog is not obvious, dental practice staff may ask two questions of the individual with the service dog: (1) Is the dog required because of a disability and (2) what work or task is the dog trained to perform? A comfort animal is not the same as a service dog, and the dental practice is not required to accommodate a comfort animal.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

Nondiscrimination

Under state and federal law, a business may not: Refuse service to an individual because of their disability.

■ Require additional steps or fees in providing service to a person with a disability.

■ Discriminate against an employee or potential employee because of an individual’s disability.

Additional information on how to comply with state and federal laws on disability access and nondiscrimination is available in a CDA Practice Support resource titled “Best Defense Against Disability Lawsuits” on cda.org. n ■

RE FEREN CE S 1. Settlement Agreement Between the United States of America and Night and Day Dental Inc. Under the Americans With Disabilities Act, DJ #202-54-195, www.ada.gov/night_and_ day_sa.html. Accessed June 24, 2021.

2. Website accessibility a legal issue for dental practices, cda. org; Practice Website Accessibility: A New Wave of AwDA Litigation. J Calif Dent Assoc 49 Mar(3):185–186.

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Tech Trends

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A look into the latest dental and general technology on the market

Combo Touch Backlit Keyboard

Microsoft To Do (Free, Microsoft)

(starts at $199, Logitech)

The humble to-do list has been a staple for mobile computing since the very first “palmtop” device, the Atario Portfolio, was introduced in 1989. Whether tapped out on a text file or synchronized across multiple mobile devices, electronic to-do lists must be easy to use, readily available and faultlessly reliable. The to-do list space is well-tread and filled with competition from the largest technology players. Microsoft To Do is one of many such products, and while it doesn’t break new ground, it offers a streamlined and useful experience, especially when paired with other Microsoft services.

Apple markets the latest iPad Pro and iPad Air as powerful productivity tools and offers Pro accessories to pair with them such as the Magic Keyboard. While these accessories compliment the amazing performance of these devices, other manufacturers seek to provide customers with better alternatives. Logitech has created the Combo Touch keyboard case with trackpad that brings remarkable versatility to the iPad Pro and iPad Air. The Combo Touch is a rubberized plastic molded case that protects the corners of the device and magnetically attaches to a keyboard cover with backlit keys and a multitouch trackpad. The case is surrounded by a durable woven fabric and contains an adjustable kickstand with up to 50 degrees of tilt to provide a wide viewing angle range. It is powered by the Smart Connector built into the iPad Pro and iPad Air so it does not require Bluetooth pairing, charging or additional software to use. One edge of the case is uncovered to accommodate the magnetic attachment of an Apple Pencil for charging. The attached keyboard can be used upright in typing mode with the kickstand extended or detached and flipped and reattached with the keys facing inward for reading mode. The kickstand can also be extended with the keyboard detached for viewing mode or fully extended in sketch mode for writing notes or drawing. The full-sized keyboard has plenty of room and tactile feedback for a comfortable typing experience. A full row of function keys is also a welcome feature that allows for useful shortcuts and adjustment of screen brightness, keyboard brightness, volume and media controls. The multitouch trackpad has an impressive surface area that has a physical click mechanism and is responsive to gestures.

These amazing features, however, come at a sacrifice. The case combined with the attached keyboard adds over an additional pound of weight and over half an inch of thickness to the device. Overall, the case provides excellent additional protection and functionality when compared to the Apple Magic Keyboard.

As mobile tablets today become more powerful and useful, available accessories will also continue to optimize their potential. The Logitech Combo Touch brings a wide array of features in a keyboard case to the iPad Pro and iPad Air to increase their versatility and productivity but at a significant decrease to portability.

— Hubert Chan, DDS 598 SEP TEMBER

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To Do came out of Wunderlist, one of the most popular mobile apps in the early 2010s. After acquiring the start-up company in 2015, Microsoft pledged to develop Wunderlist into an uncomplicated, multiplatform task management hub. Six years later, Microsoft has finally made good on its promise with To Do. On start-up, To Do asks for users to log into their Microsoft account. It takes a few moments to scour a user’s account for any task lists that have been created in Outlook, Teams or Planner, then it goes to a pleasantly uncluttered home screen. Existing tasks are in the middle of the screen and buttons at the four corners: account management, search, new list and new group. Individual tasks can be customized with items like due dates, subtasks and notes, with a single tap.

These tasks can then be grouped into lists. At every level, items can be shared with others either to view or edit. The experience is similar across both desktop and mobile environments and synchronization happens quickly (though occasionally unreliably) through Microsoft servers. Overall, To Do is an easy-to-use task list for the user who is heavily entrenched in the Microsoft ecosystem. Unfortunately, To Do is not enough of an upgrade for anyone who is happy with their current electronic task list to consider switching.

— Alexander Lee, DMD

Time is running out The Mandate for Electronic Prescriptions Starts on January 1, 2022

Soon, California will require all dental practices to issue prescriptions electronically. Act fast to avoid penalties — and choose a solution that offers more than compliance: ePrescribe.

• Gain seamless workflows by integrating with practice management systems.

• Get access to the California Prescription Drug Monitoring Program.

• Clarify communication by eliminating handwritten notes and transmitting instantly to pharmacies.

• Improve safe practices by automatically checking for drug allergies and interactions, dosage errors and duplicate therapies.

• Help save patients’ money by using insurance and pharmacy information to estimate drug costs.

Don’t Get Caught Unprepared — Get ePrescribe Today Call 833.907.1747 for more info or visit: HenryScheinOne.com/ePrescribe/CA

©2021 Henry Schein One. Henry Schein One makes no representations or warranties with respect to the contents or use of this documentation, and specifically disclaims any express or implied warranties of title, merchantability, or fitness for any particular use. All contents are subject to change. Third-party products are trademarks or registered trademarks of their respective owners.

®

STRENGTH + TRUST.

More membership value through Endorsed Services.

At the California Dental Association, we leverage the strength of our large membership to deliver more value to practices of every size. Through Endorsed Services, find support to control expenses, generate revenue, streamline operations and achieve compliance. Every one of our Endorsed Services has been vetted by CDA. Discover member-exclusive offers on products, services and expertise for the business side of practice at cda.org/endorsedservices.

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