CDA Journal - April 2022: Improving the Oral Health of Pregnant People

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Journa C A L I F O R N I A

D E N TA L

April 2022 Dental Care During Pregnancy Adults and Infants Oral Health Preconception Intervention

A S S O C I AT I O N

Improving the Oral Health of Pregnant People The Need for a Health Care-Public Health Partnership

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Nº 4

A P R I L 2022

Vol 50

Jayanth V. Kumar, DDS, MPH and Renee Samelson, MD, MPH


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April 2022

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d e pa r t m e n t s

195 Guest Editorial/Who We Are and Where We Are Going 199 Impressions 225 RM Matters/Best Practices for Hiring the Right Employee 229 Regulatory Compliance/ What To Expect During a Cal/OSHA Inspection

231 Tech Trends

199 f e at u r e s

203 Improving the Oral Health of Pregnant People: The Need for a Health Care-Public Health Partnership An introduction to the issue. Jayanth V. Kumar, DDS, MPH, and Renee Samelson, MD, MPH

207 Dental Care in California During Pregnancy This paper highlights the Maternal and Infant Health Assessment data on dental visits by pregnant people and discusses steps that public health and dental health professionals can take to improve access to and utilization of oral health services during pregnancy. Lynn Walton-Haynes, DDS, MPH; Joanna Aalboe, RDH, MPH; and Jayanth V. Kumar, DDS, MPH

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Improving Oral Health and Overall Health for Pregnant People and Infants This article describes the Perinatal and Infant Oral Health Quality Improvement initiative, launched to improve integration of preventive oral health care into primary care for pregnant people and infants. Katrina Holt, MPH, MS, RD, and Ruth Barzel, MA

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Oral Health Intervention Before Pregnancy: A Preconception Approach This manuscript discusses how oral health interventions in the preconception phase, the lifecycle during which a person is not but could become pregnant, represent an untapped opportunity to improve oral and systemic health outcomes for people of childbearing age and their offspring. Rachel Anderson, BS, and Hugh Silk, MD, MPH C.E. Credit

223 C.E. Credit Worksheet This worksheet provides readers an opportunity to review C.E. questions for the three articles in this issue before taking the C.E. test online. This test counts as 1.5 of Core C.E.

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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

CDA Officers Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

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

Carliza Marcos, DDS Vice President vicepresident@cda.org

Marisa K. Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

Volume 50 Number 4 April 2022

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus Robert E. Horseman, DDS Humorist Emeritus

Production Shelly Peppel Senior Visual Designer

Upcoming Topics May/General Topics June/Special Needs Dentistry July/Dental Benefits Policy

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Jayanth V. Kumar, DDS, MPH, and Renee Samelson, MD, MPH Guest Editors 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.

Journal of the California Dental Association Editorial Board Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York 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.

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Copyright 2022 by the California Dental Association. All rights reserved.

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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 5 0 , Nº 4

Who We Are and Where We Are Going Ariane Terlet, DDS Editor’s Note: Dr. Ariane Terlet was installed as the 2022 CDA president at the 2021 virtual CDA House of Delegates meeting. Her inaugural address is presented here in an adapted form.

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y practice consists of two worlds: private and public health. All of us work in the service of the public even though our practice settings, payers and patient demographics may be different. Public health is the reason that I joined CDA. My decision to join CDA after five years of practice was in reaction to the threat of geographic managed care to both private practice and our public health clinics. I learned to appreciate the advocacy arm of our organization. Our dues do not come close to what it would cost us as individuals to hire attorneys to represent our practices in insurance and regulatory arenas. After 30 years, it is gratifying to see the working relationship that CDA has with public health and our state legislature. Our profession is founded on responsibility and integrity. We are all members of a healing profession and have a covenant with the public to improve the oral health of our patients as well as the advancement of the profession of dentistry. As individual members, we are the heart and soul of our association. Our CDA leaders and staff team members perform the magic behind the scenes. We work in collaboration to support and promote our successful practice in our service to our patients and the public. As delegates and members of the CDA House of Delegates, we are the leadership

We are all members of a healing profession and have a covenant with the public to improve the oral health of our patients as well as the advancement of the profession of dentistry. of CDA. We are charged with making the best decisions for all of our collective and diverse members. The 2021 CDA House of Delegates gave direction for a new governance structure. So, where do we go from here? Max De Pree’s quote on leadership has guided me throughout this pandemic: “The first responsibility of a leader is to define reality. The last is to say thank you. In between the two, the leader must become a servant.” In order to be successful, we must have good communication. In order to have communication, we must share the same reality. Our reality is COVID-19. It has imposed itself on practically every aspect of our lives. It has imposed itself on our plans. It has caused us to change course, adapt and in some cases delay our plans. Though COVID-19 is still impacting our lives and the practice of dentistry, it is now time to move away from the emergency mode and get back to business in this, our new normal. Our strategic plan needs to be reviewed and updated. COVID-19 impacted several of our revenue streams. We need to continue to be fiscally responsible as we plan for the future. We need to prepare for challenges to existing insurance reform legislation, the Medical Injury Compensation Reform

Act (MICRA). This is a major threat to our practices and could lead to increased costs for our patients. We need to explore the increased overhead costs that we are experiencing due to COVID-19. We need to be more involved in grassroots actions. The ADA has reported that only 65% of dentists are registered voters and fewer actually vote. Please register and vote. Our collective futures depend on it. We have increased costs that are not going away anytime soon. Our pre-COVID-19 concerns about thirdparty reimbursements continue. Sometimes the tax category “nonprofit” is mistaken for a business model that achieves no profit margin. In public health, our common saying is “no margin, no mission.” This is true for all of our practices. No margin, no mission. We will explore ways that our governance structure might work more effectively to meet the changing needs of our members while continuing to be fiscally responsible. We will continue to address dental practice staffing shortages by developing partnerships in recruitment and training. The pool of dental assistants must be grown to fill the critical need felt locally, statewide and nationally. APRIL 2 0 2 2

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EDITORIAL C D A J O U R N A L , V O L 5 0 , Nº 4

Our policy on diversity, equity, inclusion and belonging will be implemented and become an integral part of the fabric of our organization. Our CDA leaders have had a long history of facing facts and making difficult decisions. Challenges to our profession have become opportunities for growth. A few examples are: ■ The formation of TDIC, in the face of skyrocketing insurance rates. ■ Addressing the access-to-care issue head on. Where would we all be without a state dental director during COVID-19 to advocate that while we are one of the professions with the highest risk for exposure, we are also the safest. ■ The formation of TDSC as a disrupter to the dental supply system. We learned a great lesson about the profit margins that leave us paying a premium for our supplies. TDSC resulted in more than $21 million in savings to members up to this point. While we no longer operate the company, we still hold an interest in it. This interest can provide us with a future source of nondues revenue as the company continues to provide value for members. Scope-of-practice issues are ever present. As dentists we are perfectionists, but we might serve our patients and the public better if we as team leaders train our teams so their hands can be an extension of our hands. We should all be practicing at our highest level of licensure while maintaining the highest quality of care. Moving forward, we have more challenges and opportunities. One in eight U.S. residents lives in California. In 2030, 30% of California’s population will be age 60 and over. Who will be providing their dental care?

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This is a difficult and complicated question, but we will work to be on the right side of history. In the end, it is important to remember that we cannot become what we need to be for tomorrow by remaining what we are today. I am truly humbled and grateful to have been elected president of the most innovative and progressive organization in our country. It is my pledge to you as the incoming president to carry out the directives of our house and work to ensure that the proper checks and balances are in place for the continued growth and strength of our association. We have our work cut out for us. I look forward to serving with you and for you in 2022. n

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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IT’S A VERB.


Impressions

C D A J O U R N A L , V O L 5 0 , Nº 4

Synthetic Enamel Could Make Teeth Stronger and Smarter Enamel is the hardest substance in the human body. It is also notoriously difficult to replicate artificially. Throughout history, dentists have repaired damaged and decayed teeth with everything from beeswax to mercury composites to modern ceramic- or resin-based materials. But they might soon have a synthetic option that is much closer to the real thing. A team of chemical and structural engineers has invented a new material that mimics enamel’s fundamental properties: strength and elasticity. This versatile material could potentially be used to reinforce fractured bones, craft better pacemakers and, beyond serving as a replacement for dental enamel, take fillings to the next level by creating “smart teeth.” A study on this work was published recently in the journal Science. Natural enamel has the difficult job of protecting teeth, which are constantly being strained by oral bacteria, acidic foods, chewing and speaking. Over time, the wear and tear take a toll on the enamel. “You carry the same set of teeth for 60 years, or maybe even more,” said Nicholas Kotov, PhD, a chemical engineer at the University of Michigan and coauthor of the study. “So it’s an enormous chemical and mechanical stress.” And unlike bone, enamel cannot be regenerated by the human body. Enamel’s crucial combination of toughness and flexibility is tricky to reproduce. The secret to its uniquely balanced properties lies in its structure, which is composed of millions of closely packed rods of calcium phosphate visible only through an electron microscope. This arrangement allows the rods to compress slightly under pressure, rather than shattering, while also keeping the overall structure extremely strong. The artificial enamel mimics this configuration, bundling calcium phosphate rods together with flexible polymer chains. The researchers fashioned their new material into a tooth shape, then tested whether it would crack under intense heat and pressure. Ultimately, the team found the artificial enamel could withstand more force than natural enamel. Outside of its obvious potential in dentistry, researchers envision the material being used to build better and longer-lasting pacemakers for people with heart conditions or to reinforce crumbling bone in those with severe osteoporosis. The material could even be modified to create a “smart tooth,” a prosthetic containing sensors that could sync to a smartphone. Such a device could monitor a person’s breath and mouth bacteria for anomalies, which would allow doctors to catch conditions such as diabetes before a patient experiences symptoms. The research team used strictly biocompatible compounds in the fabrication process, which means the artificial enamel should theoretically be safe for humans. The team hopes to see it used in the next few years. Read more about this study in Science (2022); doi.org/10.1126/ science.abj3343. n APRIL 2 0 2 2

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Study Uncovers Insights of Bacterial Type VI Secretion System Social Isolation Associated With Tooth Loss Among Elderly Older adults who are socially isolated are more likely to have missing teeth — and to lose their teeth more quickly over time — than those with more social interaction, according to a new study of Chinese older adults led by researchers at NYU Rory Meyers College of Nursing. The findings were published in the journal Community Dentistry and Oral Epidemiology. Social isolation and loneliness in older adults are major public health concerns around the world and are risk factors for heart disease, mental health disorders, cognitive decline and premature death. In some countries, including the United States and China, up to 1 in 3 older adults are lonely, according to the World Health Organization. The COVID-19 pandemic has exacerbated these issues among older adults. Social isolation and loneliness are related but different. Social isolation is an objective measure defined as having few social relationships or infrequent social contact with others, while loneliness is the feeling created by a lack of social connection. To understand the relationship between social isolation, loneliness and tooth loss in older adults in China, the researchers used the Chinese Longitudinal Healthy Longevity Survey to analyze data from 4,268 adults aged 65 and up. The participants completed surveys at three different timepoints (2011-12, 2014 and 2018), which captured measures 200

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The microbiome is home to an estimated 100 trillion bacteria, existing as a dense colony of many different strains and species. Similar to all organisms, bacteria must also compete with one another for space and resources, engaging in “warfare” by releasing toxins to kill competitors. One of the many weapons bacteria use in this inevitable fight is the type VI secretion system (T6SS), which delivers toxic effectors into its enemies. Researchers from the Max Planck Institute of Molecular Physiology and McMaster University in Canada have uncovered the high-resolution 3D structure of such an effector from Pseudomonas protegens by cryo-electron microscopy. The effector protein, called RhsA, has a toxic component that sits unlocked and ready to be fired within a molecular cocoon sealed by a cork-like structure. The findings will not only help in understanding how the T6SS machinery works but will also promote the future development of antibacterial treatments and plant protection strategies. The study was published in the journal PLOS Pathogens. In a series of earlier collaborative projects, the scientists gained a lot of knowledge about how the T6SS injection system works. They were able to reveal how effectors are transported inside the cell, how they are loaded on the poison dart and how the dart is then delivered into the host cell. “I am quite optimistic that our continued collaboration will uncover even more details of the T6SS machinery. This could one day allow for the engineering of bacteria with improved pathogen suppression capabilities useful for antibacterial and antifungal applications,” said Stefan Raunser, PhD, of the Max Planck Institute of Molecular Physiology. Learn more about this study in PLOS Pathogens (2022); doi.org/10.1371/ journal.ppat.1010182. Cryo-EM density of RhsAΔTMD displayed perpendicular to the central symmetry axis of the barrel and rotated 90 degrees clockwise (map postprocessed with DeepEMhancer). (Credit: Günther P, et al. Licensed under Creative Commons CC BY-NC 4.0.)

of social isolation and loneliness, how many teeth they had and lost over the seven-year study and other factors. More than a quarter (27.5%) of the study participants were socially isolated and 26.5% reported feeling lonely. The researchers found that higher levels of social isolation were associated with having fewer teeth and losing teeth more quickly over time, even when controlling for other factors such as oral hygiene, health status, smoking,

drinking and loneliness. Older adults who were socially isolated had, on average, 2.1 fewer natural teeth and 1.4 times the rate of losing their teeth than those with stronger social ties. Surprisingly, loneliness was not associated with the number of remaining teeth nor with the rate of tooth loss. Learn more about this study in Community Dentistry and Oral Epidemiology (2022); doi.org/10.1111/ cdoe.12727.


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Photodynamic Therapy With Chlorin e-6 Effective for Treating Caries A study by Brazilian researchers found that photodynamic therapy (PDT) using chlorin e-6, a photosensitizer marketed in several countries, is an effective auxiliary treatment for dental caries that can be used in the consulting room. The study was published in the journal Pharmaceutics. For the study, the researchers collected samples of carious dentin

from three patients and formed biofilms in the laboratory. The microbial composition of the biofilms varied among the patients, comprising streptococci, lactobacilli and yeasts. The biofilms were treated with PDT associated with LED irradiation mediated by a photosensitizer derived from chlorin e-6 (Fotoenticine) and

Vitamin D Levels May Contribute to Bruxism The severity of tooth clenching and grinding that patients experience may be associated with their vitamin D levels, according to a study by researchers at the Department of Oral Medicine, Faculty of Dentistry, University of Damascus in Syria. The study was published in Clinical and Experimental Dental Research. Blood tests revealed that individuals with low levels of 25-hydroxyvitamin D (25[OH]), the metabolized form of vitamin D that is used to assess deficiency, reported having moderate and severe bruxism, the authors wrote. To study the correlation between bruxism and vitamin D levels, researchers tested the blood of 100 participants. Of those participants, 76 reported experiencing bruxism and 24 did not. For vitamin D levels, concentrations of less than 20 ng/ml were considered deficient, levels between 21 ng/ml and 29 ng/ml were considered insufficient and concentrations between 30 ng/ml and 150 ng/ml were considered as sufficient. Of the participants, 43% had vitamin D deficiencies. After analyzing the data, the authors found an association between deficient levels of vitamin D and the severity of bruxism. More individuals reporting moderate and severe bruxism were deficient in vitamin D concentrations than those experiencing no symptoms or other levels of tooth clenching or grinding. The study had limitations, including that the diagnosis was based on clinical exams and self-reports from participants. A definitive diagnosis of bruxism should be supported by instrumental approaches, clinical features and exams and self-reports. However, instrumental approaches were not available. Learn more about this study in Clinical and Experimental Dental Research; doi.org/10.1002/cre2.530.

A

B

Cariogenic microcosm biofilm not treated (A ) and treated (B ) with photodynamic therapy. (Credit: Juliana Campos Junqueira.)

then analyzed by counting the colonyforming units (CFU) in selective and nonselective culture media. Overall, PDT eliminated S. mutans and decreased total microorganisms by up to 3.7 units (log10 CFU). In the case of streptococci, the reduction was 2.8. For lactobacilli and yeasts, the reduction was 3.2 each. The reductions indicated approximately 99% efficacy of antimicrobial activity. The treatment was also shown to disaggregate the biofilms and reduce acid concentration (which contributes to caries formation) by 1.1 to 1.9 mmol lactate/L. Biofilm structure and acid production by microorganisms were analyzed using microscopic and spectrophotometric analysis respectively. PDT is a chemical process resulting from the interaction of light, oxygen and a drug sensitive to light — a photosensitizer — that is administered in the form of an ointment or injected. After a certain interval, the tissue is irradiated with light at a specific wavelength depending on the drug. The light activates the drug, which reacts with the oxygen in the infected cells, resulting in their death. The authors said PDT can be used as an auxiliary treatment for children — as a quick and painless alternative to drilling. PDT is already used by dentists, but the most widely used photosensitizer is methylene blue, which is a dye and must be used sparingly to avoid staining the teeth. Learn more about this study in Pharmaceutics (2021); doi.org/10.3390/ pharmaceutics13111907. APRIL 2 0 2 2

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Improving the Oral Health of Pregnant People: The Need for a Health CarePublic Health Partnership Jayanth V. Kumar, DDS, MPH, and Renee Samelson, MD, MPH

GUEST EDITORS Jayanth V. Kumar, DDS, MPH, is the state dental director at the California Department of Public Health. Conflict of Interest Disclosure: None reported. Renee Samelson, MD, MPH, is a professor of obstetrics and gynecology at Albany Medical College in Albany, New York. Conflict of Interest Disclosure: None reported.

Publication Policy Disclaimer The findings and conclusions in this article are those of the authors and do not necessarily represent the views or opinions of the California Department of Public Health or the California Health and Human Services Agency.

G

ood oral health habits and timely dental care protect a person’s health before and during pregnancy and can reduce the transmission of caries causing bacteria from mothers to their children.1 The recently published report, “Oral Health in America: Advances and Challenges” further emphasizes the importance of early prevention and regular health care, including activities that promote oral health during preconception, pregnancy and the first three years of life because lifelong health determinants are established from the moment of conception.2 The mother’s oral health status profoundly influences oral health outcomes in children.3 In addition, providing timely educational information and dental care to pregnant people has been shown to reduce the risk for dental caries in their children.4 To promote oral health during pregnancy, the California Dental Association Foundation and the American College of Obstetricians and

Gynecologists, District IX, developed the Perinatal Oral Health Practice Guidelines in 2010.5 Since creating these guidelines, several initiatives have been undertaken at the national and state levels to ensure that health professionals and pregnant people know the importance and safety of receiving oral health care during pregnancy.6,7 These initiatives include programs, policies, resources and training. For example, the federal Maternal and Child Health (MCH) Services Block Grant (Title V of the Social Security Act), a foundation for ensuring the health of our nation’s mothers, children and adolescents, including those with special health care needs, has established performance measures regarding preventive dental visits.8 Also, the American Dental Association’s (ADA) Council on Advocacy for Access and Prevention has fostered efforts to make the profession aware of the importance and safety of providing oral health care throughout pregnancy. The American College of Obstetrics and Gynecology (ACOG) has also recommended oral APRIL 2 0 2 2

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health care during pregnancy and throughout the lifespan. Furthermore, an ACOG committee opinion has been revised to reinforce the importance of the “fourth trimester” and proposes a new paradigm for postpartum care, including chronic disease management.9 In addition, the Association of State and Territorial Dental Directors has compiled a Best Practice Approach report to help achieve successful outcomes. Lastly, the MediCal Dental Program’s Smile campaign has developed educational materials for pregnant people in California. Therefore, this issue of the Journal provides an opportunity to assess the progress made over the last decade and renew the state’s commitment to improving the oral health of pregnant people and children. In their manuscript, Lynn WaltonHaynes, DDS, MPH, and colleagues reviewed the California Maternal and Infant Health Assessment (MIHA) data. Overall, they found that 43.9% of California people with a live birth had a dental visit during their pregnancy in 2017 and 2018. Before the publication of the California Perinatal Oral Health Practice Guidelines in 2010, the dental visit rate was 37.9%. Thus, the increase in the dental visit rate has only been modest during the last decade. Nationally, Lee et al. found that only about half of the people (51.7%) reported having at least one dental visit for a cleaning during their most recent pregnancy.10 Consistent with the national data, the MIHA survey data also showed that disparities in the utilization of dental services during pregnancy exist by age, race/ethnicity, geographic region, income level, insurance status and educational levels. For example, the dental visit rates in 2017-2018 varied from a low of 31.1% in the southeastern California region to a high of 54.9% in the San Francisco Bay Area. Additionally, the dental visit rate 204

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among Medi-Cal beneficiaries varied from a low of 22.7% in San Bernardino County to a high of 73.3% in Sonoma County. In an analysis by the state, Lee et al. also noted that the proportion of Medicaidenrolled people who had a dental visit for a cleaning during pregnancy ranged from 19.6% in Maine to 51.1% in Washington. We must understand the reasons for such variation and address them to improve dental visit rates. In their article, Katrina Holt, MPH, MS, RD, and Ruth Barzel, MA, describe the Health Resources and Services

Dentistry can learn from California’s success in reversing the troubling trends in multiple measures of maternal health.

Administration’s Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative, launched nationally to improve the integration of preventive oral health care into primary care for pregnant people and infants, respectively. From 2013 through 2019, HRSA funded 16 demonstration projects as part of the PIOHQI initiative. The authors discuss many lessons learned from these projects, including making training modules available online to meet staff training needs, identifying educational messages and resources for professionals to use during visits and having oral health champions with relevant data to make a case for the importance of perinatal and infant oral health. In their article, Rachel Anderson, BS, and Hugh Silk, MD, MPH,

propose a more upstream approach by addressing oral health needs in the preconception phase. They cite studies to show that people with periodontal disease take longer to conceive. Further, treating periodontal disease during pregnancy may be too late to affect the disease-related inflammatory cascade that has already set in. Therefore, they recommend a multidisciplinary approach involving dental and medical professionals providing consistent messaging and synergistic care during the preconception period. This approach would require medical-dental integration, training and incentives to foster clinical practice changes. Dentistry can learn from California’s success in reversing the troubling trends in multiple measures of maternal health. In an article in the journal Health Affairs, Main, Markow and Gold described how the California Maternal Quality Care Collaborative was formed as a public-private partnership to address maternal mortality and morbidity in California.11 According to the authors, while the U.S. maternal mortality rate has worsened in the 2010s, California cut its rate nearly in half, from 13.1 per 100,000 live births, on average, in the baseline period of 2005-09 to a threeyear average of 7.0 during 2011-13. The state’s rate had become comparable to the average rate in Western Europe (7.2 per 100,000). They identified several key steps, including linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives and implementing a series of datadriven, large-scale quality improvement projects. Similar health care and public health partnerships can increase dental visit rates during pregnancy and help


C D A J O U R N A L , V O L 5 0 , Nº 4

eliminate disparities in dental care utilization among pregnant people. California is committed to providing health insurance coverage for all pregnant people. The Medi-Cal Dental Program covers dental services during pregnancy and 60 days postpartum, and effective April 1, the postpartum period extends to 12 months. In 2019, there were 446,479 live births in California, about oneeighth of the national births. Medicaid pays for slightly less than half of all births nationally, thus playing a pivotal role in delivering maternity-related services for pregnant people. As part of the national PIOHQI demonstration project, the California Department of Public Health, Office of Oral Health partnered with the Sonoma County Department of Health Services’ Dental Health Program and six community health centers integrated oral health and primary care. The strategies included taking an inventory of Local Health Jurisdiction assets to enlist various programs, hosting educational seminars to foster collaboration, sharing

best practices and forming a Community of Practice (CoP) to implement quality improvement initiatives. As a result, the MIHA data showed that the dental visit rate in the 2017-18 cycle was 73.3% and 61.6% among Medicaid beneficiaries and privately insured pregnant people, respectively. With an estimated number of 50,000 active dentists and dental hygienists in California, there is an adequate dental workforce to address the need of every pregnant person. Therefore, initiatives like the Sonoma project demonstrate that remarkable improvements can be achieved through the concerted efforts of partner organizations. n RE FE RE N C E S 1. Oral Health Care During Pregnancy Expert Workgroup. 2012. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center. 2. U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research. Oral Health in America: Advances and Challenges. Bethesda, Md. 3. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s oral health: A conceptual model. Pediatrics 2007

Sep;120(3):e510–20. doi: 10.1542/peds.2006-3084. 4. Meyer K, Geurtsen W, Gunay H. An early oral health care program starting during pregnancy: Results of a prospective clinical long-term study. Clin Oral Investig 2010 Jun;14(3):257–64. doi: 10.1007/s00784-009-0297-x. Epub 2009 Jun 17. 5. CDA Foundation. Oral Health During Pregnancy and Early Childhood: Evidence‑Based Guidelines for Health Professionals. 2010. 6. Barzel R, Holt K. Promoting Oral Health During Pregnancy: Update on Activities — October 2021. National Maternal and Child Oral Health Resource Center. Washington, D.C. 7. National Maternal and Child Oral Health Resource Center. Promoting Oral Health During Pregnancy: Update on Activities — May 2020. Washington, D.C. 8. MCH Evidence. Preventive Dental Visit (Oral Health). Evidence Tools. 9. Optimizing Postpartum Care. ACOG Committee Opinion 736. American College of Obstetrics and Gynecologists. Obstet Gynecol 2018 May;131(5):e140–e150. doi: 10.1097/AOG.0000000000002633. 10. Lee H, Tranby E, Shi L. Dental visits during pregnancy: Pregnancy risk assessment monitoring system analysis 2012–2015. JDR Clin Trans Res 2021 Jul 29;23800844211028541. doi: 10.1177/23800844211028541. Online ahead of print. 11. Main EK, Markow C, Gould J. Addressing Maternal Mortality and Morbidity in California Through Public-Private Partnerships. Health Aff (Millwood) 2018 Sep;37(9):1484– 1493. doi: 10.1377/hlthaff.2018.0463. T HE CORRE S P ON DIN G AU T HOR , Jayanth V. Kumar, DDS, MPH, can be reached at jayanth.kumar@cdph.ca.gov.

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dental visits C D A J O U R N A L , V O L 5 0 , Nº 4

C.E. Credit: Part 1 of 3

Dental Care in California During Pregnancy Lynn Walton-Haynes, DDS, MPH; Joanna Aalboe, RDH, MPH; and Jayanth V. Kumar, DDS, MPH

abstract Background: Dental visits during pregnancy can discover and address problems early, helping to prevent complications that can lead to adverse pregnancy outcomes. Dental care during pregnancy is safe and effective in improving and maintaining the oral health of mothers and children and should be accessible and equitable for all pregnant people. Methods: To explore the prevalence of dental visits in California during pregnancy, we used recent data from the Maternal and Infant Health Assessment (MIHA) survey. MIHA is an annual, population-based survey of California-resident people with a live birth. Results: Less than half (43%) of people in California with a live birth received a dental visit during their pregnancy. In California, disparities exist by age, race/ethnicity, geographic region, family income and education level. Conclusion and practical implications: MIHA survey data show that disparities in utilization of dental services during pregnancy exist by age, race/ethnicity, geographic region, family income and educational levels. Dental professionals can work collectively with others to eliminate these disparities and advance oral health equity. Keywords: Pregnancy, dental visit, prevention, oral health equity, oral health disparity, equity

AUTHORS Lynn Walton-Haynes, DDS, MPH, is the dental program consultant, Office of Oral Health, California Department of Public Health. Conflict of Interest Disclosure: None reported.

Joanna Aalboe, RDH, MPH, is the health program manager and local programs statewide interventions unit chief, Office of Oral Health, California Department of Public Health. Conflict of Interest Disclosure: None reported. Jayanth V. Kumar, DDS, MPH, is the state dental director, California Department of Public Health. Conflict of Interest Disclosure: None reported.

D

ental care (preventive, diagnostic and restorative) during pregnancy is safe and effective in improving and maintaining the oral health of mothers and children. Practice guidelines on oral health care during pregnancy underscore this fact.1–5 Addressing manageable problems early helps increase the safety of care by preventing dental disease complications that can lead to adverse pregnancy outcomes, such as preterm and lowweight birth, preeclampsia and gestational

diabetes.6,7 In addition, the mother’s oral health is one of the best predictors of their child’s oral health.8 And yet less than half (43.9%) of California people with a live birth received a dental visit during their pregnancy.9 National and state efforts, such as the Maternal and Child Health Bureau-funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Initiative, have produced strategies to reduce oral disease in pregnant people and infants at high risk for oral disease by increasing access to and utilization of oral health care.10 California’s APRIL 2 0 2 2

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TABLE 1

Receipt of Dental Visit During Pregnancy Among California People With a Recent Live Birth by Region, Maternal and Infant Health Assessment (MIHA) Survey, 2017 and 2018 Prevalence (%)

95% confidence interval

Annual population estimate

43.9

(42.7–45.1)

198,600

Los Angeles County

39.3

(36.4–42.3)

43,700

Lower than rest of CA

San Francisco Bay Area

54.9

(52.4–57.3)

44,500

Higher than rest of CA

San Diego County

52.3

(47.5–57.1)

20,800

Higher than rest of CA

Orange County

48.7

(43.4–54.0)

17,300

No statistical difference

San Joaquin Valley

36.8

(34.5–39.1)

21,700

Lower than rest of CA

Greater Sacramento Region

48.8

(44.5–53.2)

13,800

No statistical difference

Southeastern California

31.1

(27.8–34.5)

18,700

Lower than rest of CA

Central Coast Region

50.5

(47.6–53.5)

13,000

Higher than rest of CA

North/Mountain Region

42.4

(37.4–47.4)

5,200

No statistical difference

California total

Compared to rest of California (CA)

Region*

*San Francisco Bay Area: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, Sonoma; San Joaquin Valley: Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus, Tulare; Greater Sacramento Region: El Dorado, Placer, Sacramento, Sutter, Yolo, Yuba; Southeastern California: Imperial, Riverside, San Bernardino; Central Coast Region: Monterey, San Benito, San Luis Obispo, Santa Barbara, Santa Cruz, Ventura; North/Mountain Region: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Tehama, Trinity, Tuolumne.

PIOHQI pilot project in Sonoma County, which we discuss later in this paper, successfully improved utilization of oral health care. This paper highlights the MIHA data on dental visits by pregnant people and discusses steps that public health and dental health professionals can take to improve access to and utilization of oral health services during pregnancy.

Methods

We used data from the MIHA survey to explore the prevalence of dental visits during pregnancy in California. MIHA is an annual, population-based survey of California-resident people with a live birth. The survey is a collaborative effort of the Maternal, Child and Adolescent Health Division and the Women, Infants and Children Division in the California Department of Public Health (CDPH) and the Center for Health Equity at the University of California, San Francisco. For dental visit data, there was a statewide sample size of 6,430 in 2017 and 6,131 in 2018. MIHA survey participants were sampled from the California Automated Vital Statistics System. Prevalence (%), 95% confidence interval (95% CI) and population estimates 208

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(rounded to the nearest hundred) are weighted to represent all people with a live birth. Population estimates are a two-year average (2017 and 2018). Regional comparisons show whether the health indicator in the region was statistically different from the rest of the state (p-value < 0.05, chi-square test). Tables in this report were created by the Office of Oral Health using data prepared by the UCSF Center for Health Equity for the CDPH Maternal, Child and Adolescent Health Division. MIHA survey participants were asked, “During your most recent pregnancy, did you visit a dentist, dental clinic or get dental care at any other health clinic?” People could report “Yes” or “No.”

Results

Forty-four percent (43.9%) of California people with a live birth received a dental visit during their pregnancy.9 TA BLE 1 shows the variation in dental visits received during pregnancy for nine California geographical regions. People in Los Angeles County, the San Joaquin Valley and southeastern California had a lower prevalence (39.3%, 36.8% and 31.1%, respectively) of receiving

a dental visit during pregnancy than people in the rest of California. TA BLE 2 shows disparities in receipt of dental visits during pregnancy by insurance type, age, race/ethnicity, family income and educational level. ■ Only 35% of people with Medi-Cal prenatal health insurance received a dental visit during pregnancy. ■ Similarly, just 35% of people younger than 25 years of age received a dental visit during pregnancy. ■ Black people and Latina people had a lower prevalence (33% and 37%, respectively) of receiving a dental visit during pregnancy than people overall. People with lower incomes and those with less than a college degree had significantly lower prevalence of receiving a dental visit during pregnancy than people overall.

Discussion

The data presented above underscore that much work is needed to improve access to and utilization of oral health care during pregnancy. The CDPH California Oral Health Plan 2018–2028 (plan) provides a roadmap for oral


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TABLE 2

Receipt of Dental Visit During Pregnancy Among California People With a Recent Live Birth by Insurance, Maternal Age, Race/Ethnicity, Family Income and Educational Level Maternal and Infant Health Assessment (MIHA) Survey, 2017 and 2018 Prevalence (%)

95% confidence interval

Annual population estimate

43.9

(42.7-45.1)

198,600

Medi-Cal

34.7

(33.1-36.3)

76,400

Lower than rest of CA

Private

53.6

(51.7-55.5)

111,800

Higher than rest of CA

15-24 years

35.4

(32.8-38.0)

31,700

Lower than rest of CA

25-34 years

44.0

(42.4-45.7)

113,400

No statistical difference

35+ years

50.7

(48.0-53.3)

53,500

Higher than rest of CA

Asian/Pacific Islander

45.4

(41.6-49.1)

32,500

No statistical difference

Black

33.0

(30.0-36.0)

8,200

Lower than rest of CA

Latina

36.8

(35.1-38.4)

78,100

Lower than rest of CA

White

55.4

(53.2-57.7)

70,500

Higher than rest of CA

<= 100% FPG

34.4

(32.3-36.5)

48,000

Lower than rest of CA

101-200% FPG

35.2

(32.7-37.7)

31,200

Lower than rest of CA

> 200% FPG

56.4

(54.4-58.4)

105,600

Higher than rest of CA

High school/GED or less

34.5

(32.4-36.5)

49,100

Lower than rest of CA

Some college

37.2

(35.1-39.3)

52,800

Lower than rest of CA

College graduate

58.2

(56.1-60.3)

95,400

Higher than rest of CA

California total

Compared to rest of California (CA)

Prenatal insurance

Maternal age

Maternal race/ethnicity

Family income

Maternal education level

health improvements and equity for all Californians over the course of a 10-year period. The plan offers a structure for collective action to assess and monitor oral health status and disparities, prevent oral diseases, increase access to dental services, promote best practices and advance evidence-based policies. Working with the California Oral Health Plan Advisory Committee, the Office of Oral Health created the California Partnership for Oral Health Plan (partnership). With a vision of “oral health equity and well-being for all Californians,” the partnership promotes a public health approach to California’s oral health needs and enables partners to work together to achieve the goal of the plan. The partnership includes a diverse group of stakeholders from state and local government, academic institutions,

foundations, professional organizations and community health champions. One key strategy to increase oral health care during pregnancy is to enhance the integration of oral health and primary medical care. This was successfully demonstrated in the Sonoma County PIOHQI pilot project, which used a multipronged approach: Oral health education for the medical team, a coordinated scheduling system between the medical and dental electronic health record systems, standard protocols to identify infants eligible for dental visits and incentives to medical assistants for increasing the number of infant dental appointments. All of these strategies led to an increase of infant visits from 10.7% to 45.5% over a 21-month period.11 Leveraging funding from the California Healthcare, Research and Prevention Tobacco Act of

2016, the CDPH Office of Oral Health and the local oral health programs are planning or already implementing medical-dental integration approaches to increase dental visits during pregnancy. Dental health professionals are trusted members of their communities and as champions of oral health can serve a vital role to increase understanding of the importance of receiving oral health care during pregnancy. Utilizing available resources such as the Oral Health Literacy Toolkit, the oral health care team can maximize the opportunity to communicate effectively with their patients and communities. Dental health professionals also can partner with prenatal providers, hospitals and First 5 organizations to inform and educate the public. The First 5 parenting guide stresses the importance of oral health during pregnancy. APRIL 2 0 2 2

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As we work to achieve oral health equity, we must ensure that everyone has access to oral health care. Health equity is defined as “the absence of systemic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages.”12 In California, data show disparities exist by age, race/ethnicity, geographic region, family income and educational level. California has made significant improvements to the Medi-Cal Dental Program. To increase dental visit rates, the Smile, California campaign has created brochures and flyers.13 Recently, Medicaid extended postpartum coverage from 60 days to one year. This, along with increasing the number of health professionals who accept Medi-Cal beneficiaries in their practice, could increase the opportunity for people to receive oral health care during pregnancy. Through participation with state and local oral health program initiatives, dental organizations, community groups and others, dental health professionals can play a significant role toward achieving oral health equity.

Conclusion

MIHA survey data show that disparities in utilization of dental services during pregnancy exist by age, race/ ethnicity, geographic region, family income and educational level. Dental professionals can work collectively with others to eliminate these disparities and advance oral health equity. n

AC KN OW LE DGM E N T The authors thank the Maternal and Infant Health Assessment Project Team at the California Department of Public Health, Maternal, Child and Adolescent Health Division and University of California San Francisco, Center for Health Equity (cdph.ca.gov/ miha) for preparing the data used in this article. The authors also thank Karen Jacoby, health program specialist, Office of Oral Health, California Department of Public Health, for the editorial assistance. RE FE RE N CE S 1. Barzel R, Holt K, eds. 2020. Oral Health During Pregnancy: A Resource Guide (3rd ed.). Washington, D.C.: National Maternal and Child Oral Health Resource Center. 2. New York State Department of Health (August 2006). Oral Health Care During Pregnancy and Early Childhood Practice Guidelines. 3. National Maternal and Child Oral Health Resource Center, Georgetown University (2008). Oral Health Care During Pregnancy: A Summary of Practice Guidelines. 4. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, D.C.: National Maternal and Child Oral Health Resource Center, 2012. 5. California Dental Association Foundation (February 2010). Oral Health During Pregnancy and Early Childhood: Evidence Based Guidelines for Health Professionals. 6. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996 Oct;67(10 Suppl):1103–13. doi: 10.1902/jop.1996.67.10s.1103. 7. Walia M, Saini N. Relationship between periodontal diseases and preterm birth: Recent epidemiological and biological data. Int J App Basic Med Res 2015 Jan-Apr; 5(1):2–6. doi: 10.4103/2229-516X.149217. PMID: 25664259. 8. Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the Relationship Between Children’s Oral Health Status and That of Their Mothers. J Am Dent Assoc 2011 Feb;142(2):173–83. doi: 10.14219/jada. archive.2011.0061. 9. California Department of Public Health. Maternal and Infant Health Assessment (MIHA) survey data, 2017and 2018. 10. Lorenzo S, Goodman H, Stemmler P, Holt K, Barzel R, eds. 2019. The Maternal and Child Health Bureau-Funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Initiative 2013–2019: Final Report. Washington, D.C.: National Maternal and Child Oral Health Resource Center. 11. Association of State and Territorial Dental Directors. California Infant Dental Visit Quality Improvement Projects, ASTDD Best Practice Report. December 2019. 12. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003 Apr;57(4):254–8. doi: 10.1136/jech.57.4.254. 13. Smile, California. Partners and Providers. Accessed Jan. 31, 2022. T H E CO RRE S P ON DIN G AU T HOR , Lynn WaltonHaynes, can be reached at Lynn.Walton-Haynes@cdph.ca.gov.

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pregnancy and oral health C D A J O U R N A L , V O L 5 0 , Nº 4

C.E. Credit: Part 2 of 3

Improving Oral Health and Overall Health for Pregnant People and Infants Katrina Holt, MPH, MS, RD, and Ruth Barzel, MA

abstract Background: This article describes the Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative, launched to improve integration of preventive oral health care into primary care for pregnant people and infants. Case description: Pregnancy is characterized by physiological changes that may adversely affect oral health and increase the risk for oral diseases. Hormonal and immunologic changes make pregnant people susceptible to oral health problems, which can have implications for infant oral health. The PIOHQI initiative worked to improve integration of preventive oral health care into primary care for pregnant people and infants. Practical implications: Project findings provide promising evidence for efficacy of PIOHQI interventions. Keywords: Pregnant people, infants, oral health

AUTHORS Katrina Holt, MPH, MS, RD, is the project director for the National Maternal and Child Oral Health Resource Center at Georgetown University. She is a fellow of the Academy of Nutrition and Dietetics. Conflict of Interest Disclosure: None reported.

Ruth Barzel, MA, is a senior editor/writer for the National Maternal and Child Oral Health Resource Center at Georgetown University. Conflict of Interest Disclosure: None reported.

P

regnancy is a unique time of life characterized by complex physiological changes that may adversely affect oral health and increase risk for oral diseases.1 Pregnancy can lead to oral health problems in people, including increased risk for tooth decay and gum disease. Several factors play a part in a pregnant person’s oral health: financing oral health care; people’s ability to access and utilize care; people’s knowledge, attitudes and behaviors; and workforce preparedness and willingness to provide oral health care to pregnant people. Behavioral (e.g., vomiting, increased frequency of eating), hormonal and immunologic changes make pregnant people susceptible to oral health problems

that can have implications for infant oral health. Local, systemic, genetic and environmental conditions can affect the formation of teeth throughout life. During pregnancy, maternal risk factors for tooth anomalies and developmental defects of the teeth include pregnancy problems, smoking and malnutrition.2,3 After pregnancy, a mother’s oral health is closely associated with their infant’s oral health. Mothers with high levels of the bacteria that cause tooth decay can transmit the bacteria to their infants.4 The American College of Obstetricians and Gynecologists (ACOG) suggests that providing counseling on good oral health behaviors, promoting optimal oral hygiene and providing treatment during the perinatal period (i.e., pregnancy and APRIL 2 0 2 2

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the first year after birth) may reduce mother-to-child transmission, thereby preventing or delaying the onset of disease in the child while improving the mother’s oral health.1 Despite this potential benefit, fewer than half of pregnant people received recommended preventive oral health services between 2012 and 2015.5 Because pregnant people may be receptive to changing health behaviors to improve their own health and the health of their unborn child, pregnancy is an opportune time to intervene. It is essential for pregnant people to receive appropriate and timely oral health care, including preventive, diagnostic and restorative treatment as well as education about how to maintain their own and their infant’s oral health.6 The lack of knowledge and understanding about perinatal oral health appears to cross demographic boundaries and is not limited to a single socioeconomic group. All people need to receive education about oral health changes during pregnancy, the importance and safety of oral health care while pregnant, how their oral health impacts their child’s oral health and the oral health care programs and coverage available in their state. They can also benefit from learning how eating healthy foods, practicing good oral hygiene and practicing other healthy behaviors will help keep them and their infant healthy.6 People may also need help with overcoming their fears about receiving oral health care in general as well as their concerns about the safety of receiving oral health care during pregnancy. Medical professionals play a critical role in connecting oral health care and primary care, because they are often first to assess pregnant person’s and infants’ health and can promote oral health care. Incorporating oral health care (e.g., risk assessment, screening, education, 212

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anticipatory guidance and referral) into primary care is a promising strategy for reducing oral health disparities.7 A majority of dentists believe that perinatal oral health is important and are willing to provide oral health education and counseling during pregnancy.8–10 However, their beliefs and treatment practices when caring for pregnant people vary significantly. Despite the benefits of receiving oral health care during pregnancy, oral health professionals often postpone providing care to pregnant people until after their delivery.5

Although adult dental services are available in all 50 states, some provide only emergency services.

In addition to a knowledgeable workforce, adequate reimbursement for oral health care is key to ensuring that pregnant people have access to care. Dental coverage in Medicaid is mandatory for children and adolescents ages 0 to 21 who are enrolled through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, which helps increase access to care. Pregnant adolescents up to age 21 can receive dental coverage through their state’s EPSDT program. However, states are not required to provide any dental coverage for adults. Although adult dental services are available in all 50 states, some provide only emergency services. In addition, there is considerable variation among states in eligibility policies and scope of dental coverage for people during the

perinatal period. In several states, pregnant people with low incomes are eligible for Medicaid dental coverage and thus have access to care that they don’t have during other periods of their lives.11 In 2011, the Health Resources and Services Administration (HRSA) in collaboration with ACOG, the American Dental Association and the National Maternal and Child Oral Health Resource Center (OHRC) convened an expert workgroup meeting that resulted in the landmark publication “Oral Health Care During Pregnancy: A National Consensus Statement.” Ultimately, the implementation of the guidance in the consensus statement should bring about changes in the health care delivery system and improve the standard of oral health care.6 From 2013 through 2019, HRSA funded the Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative to define and implement evidencedbased models of care that would integrate preventive oral health care into primary care for pregnant people and infants.

Methods

The PIOHQI initiative funded 16 demonstration projects, which were intended to be unique and impactful and to meet local and community oral health needs. Three pilot projects — Connecticut, New York and West Virginia — were funded through 2018, and 13 expansion projects — Arizona, California, Colorado, Maine, Maryland, Massachusetts, Minnesota, New Mexico, Rhode Island, South Carolina, Texas, Virginia and Wisconsin — were funded through 2019.12 PIOHQI projects were able to accelerate progress by participating in a learning collaborative that provided peer-to-peer learning opportunities to share information about successes and challenges in common strategy areas.


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The learning collaborative was initially coordinated by the National Learning Network consortium, led by the Children’s Dental Health Project, which worked with the Association of Maternal and Child Health Programs, the Association of State and Territorial Dental Directors (ASTDD) and the FrameShift Group (2014 to 2017). Subsequently, support for the learning collaborative was transferred to the National Maternal and Child Center for Oral Health Systems Integration and Improvement consortium led by OHRC working in partnership with ASTDD (2017 to 2019). During this period, the learning collaborative also received support from the FrameShift Group. Technical assistance (TA) provided to the PIOHQI projects included monthly webinars, biannual meetings, a discussion list, a web portal and individualized technical assistance.

Outcomes

Throughout the initiative, PIOHQI projects engaged in numerous wide-ranging activities to reduce the prevalence of oral disease in pregnant people and infants at high risk for oral disease through improved access to and utilization of oral health care. While robust evidence for PIOHQI effectiveness is not available, project findings provide promising evidence for the efficacy of PIOHQI interventions. “Ten Essential Public Health Services” and “Essential Public Health Services To Promote Oral Health in the United States” provide a strategic framework for many national programs, including the PIOHQI project.13,14 Within the strategic framework, the PIOHQI project addressed the following essential services: ■ Assessing oral health status and implementing an oral health surveillance system. ■ Mobilizing community partners to leverage resources and advocate for/act on oral health issues.

Developing and implementing policies and systematic plans that support state and community oral health efforts. Ensuring an adequate and competent public and private oral health workforce.

Assessing Oral Health Status Massachusetts Department of Public Health

The Massachusetts project worked with early intervention sites in two communities to develop an oral health

Throughout the initiative, PIOHQI projects engaged in numerous wide-ranging activities to reduce the prevalence of oral disease.

screening form for use during intake sessions and an oral health training module for staff. At the intake sessions, children who needed oral health care were referred to a dentist, and at the six-month follow-up visit, staff determined whether the child had a dental visit. Beginning in August 2018, 930 completed screening and referral forms were collected. Of the children screened, 81% had teeth, and of those, 85% were encouraged to make an appointment for a dental visit. Over a four-month period, the percentage of children who were seen by a dentist increased from 41% to 53%. The project successfully made the case, upon sharing findings with the state early intervention program, for incorporating oral health questions into its existing intake form,

referring children to a dentist as needed and incorporating an oral health training module for staff onboarding.

Mobilizing Community Partners Children’s Hospital of Wisconsin

The Wisconsin project integrated oral health education, preventive care and referral to a dentist into a prenatal care coordination (PNCC) program and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Process-level data collected from six implementation sites were analyzed to identify strategies to increase utilization of oral health care and key educational messages that resonated with the target population. Two of the six sites had a dental clinic as a partner for referrals. At one of the two sites, 25% of pregnant people enrolled in the PNCC program needed to see a dentist, and 66% of those who received a referral to a dentist at the clinic completed the appointment. At the other site, 40% of pregnant people enrolled in WIC needed to see a dentist, and 50% of those who received a referral to see a dentist at the dental clinic completed the appointment. Two models emerged: 1) closed-loop referral (i.e., following a referral from a primary care practice to a dental clinic, the dental clinic communicates with the primary care practice about the pregnant people) for an appointment for a dental visit and 2) integrated preventive oral health services.

West Virginia Department of Health and Human Resources

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offered ($25 per visit for up to two visits through 60 days postpartum).

Developing and Implementing Policies and Systematic Plans California Department of Public Health

The California project worked with a consortium of health centers to increase the dental visit rate for infants. Petaluma Health Center used a multipronged approach, including oral health education for the medical team, building a coordinated scheduling system between the medical and dental electronic health record systems, creating standard protocols to identify infants eligible for dental visits and providing incentives to medical assistants for increasing the number of dental appointments for infants. Over a 21-month period, the number of infants with a well-child visit who visited the dentist by age 12 months rose from 68 to nearly 200 per month, and the number of surgery center referrals for dental procedures and the rate of tooth decay for children who received care fell.

Colorado Department of Public Health and Environment Oral Health Program: Cavity Free at Three The Colorado project tested promising practices to integrate prenatal oral health screening, education and referral to oral health professionals into health care delivery systems that serve populations at high risk for oral disease, launching the pilot in two health centers and later expanding to private clinics. Project components consisted of clinical training for staff, a quality improvement approach to test strategies to increase access to oral health care and development of referral systems between oral health professionals and medical professionals. Preliminary results indicated that integrating prenatal screening, education and referral into health care delivery 214

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systems resulted in approximately four times as many patients receiving oral health care during pregnancy.

MaineHealth

The Maine project worked on a statewide pilot to integrate oral health screenings, risk assessments and referrals into prenatal medical visits. The project trained over 324 staff from 15 OB-GYN and family medicine sites to increase their awareness about the importance of prenatal oral health. Eighty-seven percent of pregnant people (1,093) at the sites

The California project worked with a consortium of health centers to increase the dental visit rate for infants.

received an assessment. Ten of the 15 sites exceeded the assessment goal of 80%.

Maryland Department of Health and Mental Hygiene, Office of Oral Health

The Maryland project, with assistance from an interprofessional steering committee, produced “Oral Health Care During Pregnancy: Practice Guidance for Maryland’s Prenatal and Dental Providers.” Selected content was adapted from “Oral Health Care During Pregnancy: A National Consensus Statement.” The document provides recommendations and resources for prenatal care and oral health professionals to increase utilization of oral health care and improve the oral health of pregnant people and infants throughout the state. The document was mailed to

about 7,600 dentists, dental hygienists, OB-GYNs and nurse midwives and sent electronically to numerous academic institutions, provider organizations and public health programs in Maryland.

Rhode Island Department of Health

The Rhode Island project worked with two health centers to test and track ways to increase referrals for pregnant people between medical practices and oral health practices. Strategies tested included conducting oral health training with medical and front office staff, regularly identifying and sharing lists of pregnant people with oral health staff and incorporating oral health into organizational strategic and incentive plans. At one health center, the percentage of pregnant people receiving oral health care increased from 14% to 31% during the project period. A dental hygienist worked with private medical practices to integrate oral health risk assessment, fluoride-varnish application and referral into practice workflow. Fluoride-varnish application rates in these medical practices increased from 4% to 10% during the project period for children ages 2 and under who were enrolled in Medicaid.

Ensuring Adequate and Competent Workforce Children’s Dental Services (Minnesota)

The Minnesota project used workforce innovations, such as collaborative practice dental hygienists, advanced dental therapists and teledentistry, to expand oral health care access for pregnant people and infants, particularly in WIC clinics and early childhood programs located in rural and remote areas. The workforce innovations enabled more cost-efficient use of staff to provide care to more pregnant people and infants while decreasing per-patient costs.


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Northern Arizona University

The Arizona project analyzed the state’s 2016 and 2017 Medicaid dental claims data to understand Arizona’s oral health workforce capacity and its impact on access to and utilization of oral health care. After completing the analysis, project staff developed infographics to help partners advocate for legislative change, including the addition of an adult emergency dental benefit passed in 2018 and a pregnant person’s benefit passed in 2019.

South Carolina Department of Health and Environmental Control

The South Carolina project collaborated with the South Carolina Department of Health and Human Services to establish a dental periodicity schedule and fluoride-varnish reimbursement policy to allow nonoral health professionals in primary care settings to receive reimbursement for fluoride-varnish applications up to four times a year, doubling allowed applications for children at risk for tooth decay who benefit from increased application frequency (every three to four months). The change resulted in a statewide increase in fluoride-varnish applications among infants and children from birth through age 4 from 15,207 applications in 2016 to 18,439 in 2018.

Participating in a learning collaborative contributed to the project’s success.

Developing practice guidance can be very time-consuming. It may be more efficient to adapt existing guidance rather than starting from scratch. ■ Data are necessary for monitoring the impact of project activities. Evidence can be used to advocate for increased funding. ■ Participating in a learning collaborative contributed to the project’s success. ■ Securing funding and technical assistance, such as that provided by HRSA, is necessary to conduct any work in this area. Success stories from the PIOHQI initiative mark the beginning of a roadmap that key federal, state and local stakeholders can follow, but the journey has only begun. More work is needed if further progress in improving perinatal and infant oral health is to be made. n ■

F U N DIN G The authors received financial support for the development of this article from the Health Resources and Services Administration, grant no. U44MC30806.

Lessons Learned

The PIOHQI projects revealed important lessons about how to increase access to and utilization of oral health care for pregnant people and infants at high risk for oral disease. Many of these lessons are applicable to organizations providing oral health care as well as to those striving to increase access to and utilization of overall health care. Specific lessons learned through the projects included the following:15

Securing a commitment from leadership is important to achieving project goals and cultivating and sustaining leadership’s interest and engagement. Making training modules available online (versus offering trainings in person only) is necessary to meet staff training needs. In addition, identifying educational messages and resources for professionals to use during visits is essential in light of workload challenges for both primary care professionals

and social services professionals. Focusing community outreach with a direct connection to health professionals enables measurement of outcomes by determining the number of patients who received oral health care. Processes and procedures must be adapted locally to enable functionality at individual sites — a one-size-fits-all approach does not work. Policy change comes about slowly, and it is important to be ready when an opportunity for change presents itself. Having oral health champions with relevant data to make the case for the importance of perinatal and infant oral health is essential to effect change.

AC KN OW L E DG M E N T S The authors acknowledge Pamella Vodicka, MS, RD, captain, U.S. Public Health Service, Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, and Maria Teresa Canto, DDS, MS, MPH, dental officer, Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, for their helpful comments on drafts of this article. RE F E RE N C E S 1. American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. Oral health care during pregnancy and through the lifespan. Washington, D.C.: American College of Obstetricians and Gynecologists. 2017. 2. Salantri S, Seow WK. Developmental enamel defects in the primary dentition: Aetiology and clinical management. Aust Dent J 2013 Jun;58(2):133–40; quiz 266. doi: 10.1111/ adj.12039. Epub 2013 May 5. 3. Wagner Y. 2016. Developmental defects of enamel in primary teeth — findings of a regional German birth cohort study. BMC Oral Health 2016 Jul 7;17(1):10. doi: 10.1186/ s12903-016-0235-7. PMCID: PMC4948106. 4. Finlayson TL, Gupta A, Ramos-Gomez FJ. Prenatal maternal APRIL 2 0 2 2

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factors, intergenerational transmission of disease and child oral health outcomes. Dent Clin N Am 2017 Jul;61(3):483–518. doi: 10.1016/j.cden.2017.02.001. 5. Centers for Disease Control and Prevention, Pregnancy Risk Assessment Monitoring System. Prevalence of selected maternal and child indicators for all PRAMS sites, Pregnancy Risk Assessment Monitoring Systems (PRAMS), 2012-2015. Atlanta: Centers for Disease Control and Prevention. Accessed Aug. 23, 2021. 6. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, D.C.: National Maternal and Child Oral Health Resource Center. 7. Azofeifa A, Yeung LF, Alverson CJ, Beltrán-Aguilar E. Oral health conditions and dental visits among pregnant and nonpregnant people of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004. Prev Chronic Dis 2014 Sep 18;11:E163. doi: 10.5888/pcd11.140212. PMCID: PMC4170723. 8. Da Costa EP, Lee JY, Rozier RG, Zeldin L. Dental care for pregnant women: An assessment of North Carolina general dentists. J Am Dent Assoc 2010 Aug;141(8):986–94. doi: 10.14219/jada.archive.2010.0312. 9. Huebner CE, Milgrom P, Conrad D, Lee RS. 2009. Providing dental care to pregnant patients: A survey of Oregon general dentists. J Am Dent Assoc 2009 Feb;140(2):211–22. doi: 10.14219/jada.archive.2009.0135. 10. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008 Jan;21(1):63–71. doi: 10.1080/14767050701796681. 11. Kloetzel MK, Huebner CE, Milgrom PM. Referrals for dental care during pregnancy. J Midwifery Womens Health Mar–Apr 2011;56(2):110–7. doi: 10.1111/j.15422011.2010.00022.x. Epub 2011 Feb 28. 12. National Maternal and Child Oral Health Resource Center. MCHB funded projects: Perinatal and Infant Oral Health Quality Improvement initiative. Accessed Aug. 19, 2021. 13. Centers for Disease Control and Prevention. 10 essential public health services. Accessed Aug. 19, 2021. 14. Association of State and Territorial Dental Directors. Essential public health services to promote oral health in the United States. 2021. 15. Lorenzo S, Goodman H, Stemmler P, Holt K, Barzel R, eds. The Maternal and Child Health Bureau-funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative 2013-2019: Final Report. T HE CORRE S P ON DIN G AU T HOR , Katrina Holt, MPH, MS, RD, can be reached at kholt@georgetown.edu.

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C.E. Credit: Part 3 of 3

Oral Health Intervention Before Pregnancy: A Preconception Approach Rachel Anderson, BS, and Hugh Silk, MD, MPH

AUTHORS Rachel Anderson, BS, is a medical student at the University of Massachusetts Chan Medical School. Conflict of Interest Disclosure: None reported.

Hugh Silk, MD, MPH, FAAFP, is a professor in the department of family medicine and community health at the University of Massachusetts Chan Medical School. He also teaches at the Harvard School of Dental Medicine. Conflict of Interest Disclosure: None reported.

O

ral disease is prevalent and has wide-ranging ramifications that have an important impact on overall health across the lifespan.1 Almost 100% of adults will suffer from caries, which can be complicated by abscesses, hospitalization and death,2 and 50% of adults will suffer from periodontitis, which has been linked to numerous poor health outcomes.3 The devastating effects of poor oral health are experienced disproportionately by communities of color and those who are impoverished. These disparities are provoked by limited access to care, systemic racism and competing priorities of health and social needs.4 Efforts have been made at nearly every stage of the lifecycle to reduce the burden of oral disease including prenatal, pediatric and geriatric care. However, interventions in the preconception phase, which encompasses the entire lifecycle during which a person is not but could become pregnant, beginning at menarche and concluding with menopause, have been limited, and this could represent an untapped opportunity to improve oral and systemic health outcomes for people of childbearing age and their offspring.5

Importance of Oral Health in the Preconception Phase

The preconception phase, prior to a pregnancy, may be particularly important for caries prevention in children born to mothers with significant oral disease (FIGURE ). Oral disease begins early in life as soon as teeth begin to erupt, and early caries affect a child’s growth, selfesteem and long-term dental outcomes in adulthood.6–8 Studies have shown that caries-causing bacteria are passed from caregivers to offspring around the time of tooth eruption in infants.9 If people received oral health care prior to pregnancy and their bacterial load was decreased at this time, caries rates in children would likely be reduced.10 In addition to increasing caries risk in offspring, oral disease during pregnancy can be harmful for the pregnant individual’s health. Periodontal disease has been linked to adverse pregnancy outcomes including preeclampsia, gestational diabetes, preterm delivery and low birth weight.11–13 As such, treatment of oral disease prior to pregnancy could be conducive to nurturing healthy mothers, healthy pregnancies and healthy infants. There are numerous barriers to dental care during pregnancy, and pregnant individuals are less inclined to be seen by APRIL 2 0 2 2

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Better for babies Children born to people with oral disease are more likely to develop early childhood caries.

A preconception approach to oral health Better for mothers

Better for pregnancies

Periodontal disease has been associated with poor systemic health outcomes including worsening of diabetes and infections.

Periodontal disease is associated with preeclampsia, gestational diabetes, preterm delivery and low birth weight.

FIGURE . A three-pronged benefit of a preconception approach to oral health.

dentists during pregnancy and in the 12 months after pregnancy.14 In fact, only 46% of pregnant people receive any dental care.9 However, even for those who do receive treatment for periodontal disease during pregnancy, the treatment has failed to decrease adverse outcomes such as preterm birth, fetal growth restriction and preeclampsia.15 It has been hypothesized that treating periodontal disease during pregnancy is too late, as the disease-related inflammatory cascade has already begun.16 As such, it may be favorable to take a more upstream approach, addressing oral health needs in the preconception phase. The importance of oral health education in the preconception phase may have added benefits for people trying to get pregnant. Emerging research suggests that oral disease negatively impacts fertility. Studies have shown that people with periodontal disease take longer to conceive, even when controlled for factors known to affect fertility such as age, BMI and smoking status.17 Further, people with infertility have higher numbers of advanced caries and higher indicators of dental disease such as the 218

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percentage of bleeding on probing, gingival index and probing depth.18

Addressing Oral Health in Preconception

An effective approach to preconception oral health requires a multidisciplinary approach that involves both dentists and medical providers including family physicians, internists, obstetricians and gynecologists (OBGYNs), midwives and their nurse practitioner (NP) and physician assistant (PA) counterparts providing consistent messaging and synergistic care. The SAMHSA-HRSA Center for Integrated Health Solutions proposes a six-tier approach to oral health integration.19 Level one begins with medical providers addressing oral health needs in their own settings. Level two adds an aspect of communication between medical and dental providers in individual patient care. Level three requires increased communication and level four incorporates sharing of records and faceto-face interactions. In level five, medical and dental providers often share an

electronic health record (EHR) and seek ways to work together through regular meetings. Finally, in level six, medical and dental providers work seamlessly together to provide continuous multidisciplinary care. Integrated medical-dental care, at any level, includes providing education, mitigating risk factors, delivering preventive care and treating active disease. To better understand the challenges of achieving such a high level of integrated care, one must acknowledge that the U.S. health care system is complex, consisting of a wide variety of medical and geographical settings. Level six medical-dental integration will be achievable only in ideal settings. As such, providers must have a broad range of options for oral health care delivery so that they can provide such care in a way that works best within the confines of their practice and their community. Historically, oral health education has been well-integrated into pediatric well-child visits, and the American Academy of Pediatrics’ Bright Futures practice guidelines provide topics for relevant anticipatory guidance for each age group, including adolescents who are in the beginning of the preconception phase.20 Anticipatory guidance for adolescents includes making regular dental appointments, brushing teeth twice daily with fluoridated toothpaste, flossing daily, limiting sugary snacks and drinks, drinking fluoridated water, using protective gear such as mouthguards to prevent traumatic dental injuries and avoiding smoking.20 Similar education and anticipatory guidance should continue to be addressed at well/annual visits into adulthood. Well visits also provide an opportunity to address risk factors for oral disease. Some risk factors such as poverty, racial discrimination and access to dental care can be extremely


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challenging to effectively address. Other risk factors such as poor personal dental hygiene and high-sugar diets can be more easily addressed with education and consistent messaging. Preventive oral health care should be offered during primary care office visits as indicated by age and risk. This may include applying fluoride varnish, prescribing oral fluoride supplements or offering xylitol gum and chlorhexidine rinses when appropriate. Annual physical exams are an ideal time to perform an oral exam to look for active disease. Those with active periodontal disease and/or demineralization and caries should be referred for treatments such as scaling, root planing, restorations, root canals and extractions respectively. Primary care providers must approach oral health in the preconception period much like cervical cancer or heart disease by proactively educating, screening, preventing and treating early disease. Oral health is a component of systemic health and must be taken seriously and addressed routinely. To ensure healthy mothers, healthy pregnancies and healthy infants, this preventive approach to oral health must be used to address and treat oral disease in preconception.

Next Steps

While medical-dental integration in the preconception phase is theoretically simple, the reality of incorporating oral health into preconception care can be quite challenging. Lasting changes in medical education and practice typically occur through a combination of incentives and mandates. Incentives can include readily available curricula, efficient workflow designs and financial reimbursement, while mandates often include national education accreditation requirements, quality improvement standards and public reports of clinician outcomes.

Involving Trusted Medical Organizations If providers who care for people during the preconception phase are serious about changing their practices, they must expand upon their current collaborations with trusted organizations to evolve and promote clinical guidelines and recommendations, such as the American Academy of Family Physicians (AAFP), American College of Obstetrics and Gynecology (ACOG) and American Academy of Pediatrics (AAP) as well as their NP, PA and midwifery counterparts.

Annual physical exams are an ideal time to perform an oral exam to look for active disease.

This should occur concurrently with dental organizations such as the American Dental Education Association (ADEA) and the Commission in Dental Accreditation (CODA). Providers must encourage these organizations to continue to emphasize the importance of oral health, publish preconception oral health guidelines for clinical practice and set standards for the inclusion of preconception oral health in medical and dental education as part of an emphasis on oral-systemic health. Further, they must utilize the guidelines to their fullest extent in clinical practice and encourage their peers to do the same. Many trusted medical organizations have already taken tremendous steps in promoting preconception oral health. The AAFP is editing its original preconception

care position paper to include advice for oral health promotion.21 The ACOG’s committee opinion “Oral Health in Pregnancy and Through the Lifespan,” which was created in 2013 and reaffirmed in 2017, includes the importance of oral health for a person’s general health throughout their life and the importance of reducing the transmission of cariesproducing oral bacteria from mothers to their infants.22 A consortium of oral health advocates have recently submitted oral health as a topic for The Women’s Prevention Services Initiative to consider including as one of their recommended health topics for people.23 The Center for Integration of Primary Care and Oral Health (CIPCOH) is carrying out a project called the 100 Million Mouths campaign to recruit and train educational oral health champions in each state to engage health schools, programs and residencies to teach oral health promotion and disease prevention.24 The American Academy of Pediatrics already has oral health champions to engage pediatric clinicians around oral health.25 The Primary Care Collaborative has created a report entitled “Innovations in Oral Health and Primary Care Integration” promoting mechanisms and scope of integration efforts.26 Sharing these efforts, endorsed by these organizations that providers already trust for clinical guidelines, will be fundamental in the integration of oral health into preconception care.

Providing Easily Accessible Curricula

Easy access to oral health curricula for providers is essential to incorporating oral health into medical education and clinical practice. Smiles for Life is an existing national resource that consists of a comprehensive oral health curriculum targeted at primary care providers and includes a module focused specifically on APRIL 2 0 2 2

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pregnancy and people’s oral health, which promotes addressing oral health at all people’s well visits.27 In addition to Smiles for Life, there are other proven curricula including the American Academy of Pediatrics Tiny Teeth and the Association of American Medical Colleges’ (AAMC) Oral Health Collection of MedEdPortal touching on a range of oral health topics for people.24,28,29 Of course this curricula should be edited as new evidence becomes available and efforts should be made to promote these curricula that many schools and programs are unfamiliar with.30 Most health care providers have continuing education requirements to maintain their licensure. Incorporation of oral health education into continuing education requirements for physicians and their PA/NP counterparts would increase awareness of the importance of oral health, especially in preconception.

courses and rotations to normalize oral health as part of overall health and wellness. For preconception oral health, topics to teach would include oral anatomy, risk history, oral exam, dental hygiene promotion and awareness of referral resources. Curricular evaluation could be performed by multiple choice and short-answer questions, oral reports and observed feedback in clinical encounters. The importance of oral health should be further emphasized in residency programs that train physicians who care for preconception-age people — family

Midwifery is an excellent example of successful integration of oral health.

Engaging Upstream Learners

While incorporating oral health into continuing education is a step toward educating clinicians on this important topic, it would be best to take a more upstream approach and highlight the importance of oral health during preconception to medical learners beginning in medical, PA, NP and midwifery school. Midwifery is an excellent example of successful integration of oral health. Midwifery education has core requirements for oral health teaching, and 100% of programs currently teach oral health to students.31 Schools can use CIPCOH’s Entrustable Professional Activities (EPAs) for oral health to calibrate their offerings.32 Other resources for ensuring a comprehensive curriculum would be the AAMC’s Oral Health Core Competencies or Smiles for Life’s comprehensive list of objectives.27,33 Schools and programs should be encouraged to have a spiral curriculum with small amounts of oral health offered in many 220

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medicine, internal medicine, OB-GYN and pediatrics. Existing curricula must be promoted widely to program directors at national academic conferences and relevant academic journals. For true universal integration, accreditation standards must be developed. OB-GYNs are often the primary point of contact with health care for people in the preconception phase, but less than half of OB-GYN physicians receive oral health training during residency.30 Because oral health is so neglected in their training, less than 12% of OB-GYN physicians have referred preconception people for dental care.34 While 81% of family medicine residencies include oral health education, only 31% include four hours or more of oral health education,35 leaving significant room for improvement. Pediatric residencies tend

to include more appropriate amounts of oral health education, which can be largely attributed to the importance placed on oral health by the AAP, but specific coverage of preconception oral health is unknown.36 Lastly, over 100,000 internists in the U.S. provide primary care, yet oral health education in an internal medicine residency is essentially nonexistent.37,38

Facilitating Incorporation Into Clinical Practice

One of the largest challenges to incorporating oral health care into preconception well visits is the significant time constraints that primary care providers face. As such, it is crucial to provide tools to ease the integration of oral health care with a minimal time burden. Electronic health records (EHRs) have been found to improve the quality of preventive care by reminding providers when preventive care is due and generating feedback to determine if preventive care targets are being met.39 Oral health screening is preventive care and can be incorporated into the EHR in this way with simple prompts. Other measures to ease clinical incorporation of oral health include dividing tasks from the front staff to the clinician, having handouts available and setting up billing codes as needed (e.g., fluoride varnish). This requires an office champion, some basic in-service training and periodic reports on quality. It is not difficult but does require an initial investment of time and energy. Qualis Health and others have created very clear documents with examples and case studies.40

Educating Preconception People Directly

In addition to training medical providers, public outreach campaigns directly targeting people of preconception age can empower them to self-advocate


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for their oral health. Addressing the oral health of other caregivers, including fathers and adoptive parents, during this same time period prior to the introduction of a newborn could further decrease the risk of passing caries-causing bacteria to infants. Social media campaigns have shown promising results in the public health realm, particularly in motivating users to take small, concrete actions.41 Social media campaigns have been utilized in this manner by large medical organizations, including the World Health Organization (WHO) and Center for Disease Control (CDC). The AAFP, AAP, American College of Physicians (ACP) and the American Dental Association (ADA) together have over 150 million Instagram followers, representing a significant opportunity for a wide-reaching oral health education campaign. In an age of rampant misinformation, it is important to create easily accessible resources for those looking for accurate information. Oral health fact sheets written at a variety of different health literacy levels and directed at the general population should be published in a central online location. Information should include the effects of oral disease on overall health, pregnancy and newborn health. The AAP and ADA have such resources; however, they need to be more widely promoted on popular medical consumer sites.42,43

Conclusion

Oral health is an important yet frequently neglected component of overall health and as such should be a focus of primary care providers. Oral disease can cause or is associated with systemic illness such as infection, heart disease and diabetes. During pregnancy, oral disease has been linked to poor outcomes. Infants born to mothers with oral disease are more likely to have early childhood

caries, putting them at greater risk of oral disease later in life. Because oral disease is detrimental to mothers, newborns and pregnancy itself, interventions during pregnancy have been attempted to decrease the adverse outcomes but have been ineffective, as pregnancy appears too late to stop the complications. As such, experts have suggested a more upstream approach to identifying, preventing and treating oral disease prior to conception. Such an approach requires coordinated care between dentists and medical providers who treat preconception people. To foster clinical practice changes, we must gather support from trusted medical and dental organizations, provide easily accessible mandated curricula for providers, integrate oral health into medical education at all levels and create workflows and EHR shortcuts to ease clinical practice incorporation. We must also educate people and other caregivers directly about the importance of oral health to promote healthier mothers, pregnancies and infants. n RE FE RE N C E S 1. Kane SF. The effects of oral health on systemic health. Gen Dent Nov-Dec 2017 65(6):30–34. 2. National Institute of Dental and Craniofacial Research. Dental Caries in Adults. July 2018. 3. Eke PI, Borgnakke WS, Genco RJ. Recent epidemiologic trends in periodontitis in the USA. Periodontol 2000 2020 Feb;82(1):257–267. doi: 10.1111/prd.12323. PMID: 31850640. 4. Koppelman J, Cohen RS. Dental health is worse in communities of color. Pew Trusts; May 2016. Accessed Oct. 4, 2021. 5. Boggess KA, Edelstein BL. Oral health in women during preconception and pregnancy: Implications for birth outcomes and infant oral health. Matern Child Health J 2006 Sep;10(5 Suppl):S169–S174. doi:10.1007/s10995-006-0095-x. 6. Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. Br Dent J 2006 Nov 25;201(10):625–6. doi: 10.1038/sj.bdj.4814259. 7. Singh N, Dubey N, Rathore M, Pandey P. Impact of early childhood caries on quality of life: Child and parent perspectives. J Oral Biol Craniofac Res 2020 Apr– Jun;10(2):83–86. doi: 10.1016/j.jobcr.2020.02.006. Epub 2020 Feb 17. PMID: 32181125; PMCID: PMC7062923. 8. Songur F, Simsek Derelioglu S, Yilmaz S, Koşan Z. Assessing the impact of early childhood caries on the development of first permanent molar decays. Front Public Health 2019

Jul 9;7:186. doi: 10.3389/fpubh.2019.00186. PMID: 31338357; PMCID: PMC6629786. 9. Damle SG, Yadav R, Garg S, Dhindsa A, Beniwal V, Loomba A, Chatterjee S. Transmission of mutans streptococci in motherchild pairs. Indian J Med Res 2016 Aug;144(2):264–270. doi: 10.4103/0971-5916.195042. PMCID: PMC5206879. 10 Nakai Y, Shinga-Ishihara C, Kaji M, Moriya K, MurakamiYamanaka K, Takimura M. Xylitol gum and maternal transmission of mutans streptococci. J Dent Res 2010 Jan;89(1):56–60. doi: 10.1177/0022034509352958. 11. Contreras A, Herrera JA, Soto JE, et al. Periodontitis is associated with preeclampsia in pregnant women. J Periodontal 2006 Feb;77(2):182–8. doi: 10.1902/ jop.2006.050020. 12. Vivares-Bulles, AM, Rangel-Rincón, LJ, et al. Gaps in knowledge about the association between maternal periodontitis and adverse obstetric outcomes: An umbrella review. J Evid Base Dent Pract 2018 Mar;18(1):1–27. doi: 10.1016/j.jebdp.2017.07.006. Epub 2017 Jul 15. 13. Abariga, SA, Whitcomb, BW. Periodontitis and gestational diabetes mellitus: A systematic review and meta-analysis of observational studies. BMC Pregnancy and Childbirth 2016 Nov 8;16(1):344. doi: 10.1186/s12884-016-1145-z. PMCID: PMC5101727. 14. American Public Health Association. Improving Access to Dental Care for Pregnant Women through Education, Integration of Health Services, Insurance Coverage, an Appropriate Dental Workforce, and Research (Policy Statement). 2020. Accessed Oct. 4, 2021. 15. Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. Am J Public Health 2004 May;94(5):765–71. doi: 10.2105/ajph.94.5.765. PMCID: PMC1448335. 16. Xiong X, Buekens P, Goldenberg RL, et al. Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: Before or during pregnancy? Am J Obstet Gynecol 2011 Aug;205(2):111.e1–6. doi: 10.1016/j.ajog.2011.03.017. Epub 2011 Mar 16. 17. Hart R. Periodontal disease: Could this be a further factor leading to subfertility and is there a case for a prepregnancy dental check-up? Womens Health (Lond) 2012 May;8(3):229–30. doi: 10.2217/whe.12.15. PMID: 22554169. 18. Yildiz Telatar G, Gürlek B, Telatar BC. Periodontal and caries status in unexplained female infertility: A casecontrol study. J Periodontol 2021 Mar;92(3):446–454. doi: 10.1002/JPER.20-0394. Epub 2021 Jan 6. PMID: 33331005. 19. Heath B, Wise Romero P, Reynolds K. A Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013. 20. Casamassimo P, Holt K, eds. 2016. Bright Futures: Oral Health Pocket Guide (3rd ed). Washington, D.C.: National Maternal and Child Oral Health Resource Center. 21. Wilkes J. AAFP release position paper on preconception health. Am Fam Physician 2016 Sep 15;94(6):508–510. 22. Committee Opinion No. 569: Oral Health Care During Pregnancy and Through the Lifespan Obstet Gynecol 2013 Aug;122(2 Pt 1):417–422. doi: 10.1097/01. AOG.0000433007.16843.10. 23. Women’s Prevention Services Initiative. New Topic Nomination. Accessed Oct. 4, 2021. APRIL 2 0 2 2

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24. Center for Integration of Primary Care and Oral Health. 100 million mouths project. Accessed Oct. 4, 2021. 25. American Academy of Pediatrics. Oral Health. Accessed Oct. 4, 2021. 26. Primary Care Collaborative. Innovations in Oral Health and Primary Care Integration – Alignment with the Shared Principles of Primary Care. Accessed Oct. 4, 2021. 27. Sievers K, Clark MB, Douglass AB, Maier R, Gonsalves W, Wrightson AS, Quinonez R, Dolce M, Dalal M, Rizzolo D, Simon L, Deutchman M, Silk H. Smiles for Life: A National Oral Health Curriculum. 4th ed. Society of Teachers of Family Medicine. 2020. Accessed Oct. 4, 2021. 28. American Academy of Pediatrics. Tiny Teeth – Oral Health Campaign Toolkit. Accessed Oct. 4, 2021. 29. Association of American Medical Colleges. MedEdPortal Dental Collection. Accessed Oct. 4, 2021. 30. Curtis M, Silk H, Savageau J. Prenatal Oral Health Education in U.S. Dental Schools and Obstetrics and Gynecology Residencies. J Dent Educ 2013 Nov;77(11):1461–1468. 31. Haber J, Dolce M, Hartnett E, Savageau JA, Altman S, Kessler J, Silk H. Integrating Oral Health Curricula in Midwifery Graduate Programs: Results of a United States Survey. J Midwifery Womens Health 2019 Jul;64(4):462–471. doi: 10.1111/jmwh.12974. Epub 2019 Apr 29. 32. Goodell KH, Ticku S, Fazio SB, Riedy CA. Entrustable

Professional Activities in Oral Health for Primary Care Providers Based on a Scoping Review. J Dent Educ 2019 Dec;83(12):1370–1381. doi: 10.21815/JDE.019.152. Epub 2019 Sep 9. 33. Crandall S, Fletcher S. Oral Health in Medicine Collection – Curriculum Toolkit Instructor’s Guide. Association of American Medical College’s Building Oral Health Capacity (BOHC) Toolkit 2014:32. Accessed Oct. 4, 2021. 34. Ganganna A, Devishree G. Opinion of dentists and gynecologists on the link between oral health and preterm low birth weight: “Preconception care — treat beyond the box.” J Indian Soc Pedod Prev Dent 2017 Jan–Mar 2017;35(1):47– 50. doi: 10.4103/0970-4388.199231. PMID: 28139482. 35. Silk H, Savageau JA, Sullivan K, Sawosik G, Wang M. An Update of Oral Health Curricula in US Family Medicine Residency Programs. Fam Med 2018 Jun;50(6):437–443. doi: 10.22454/FamMed.2018.372427. 36. Dalal M, Isong I, Savageau JA, Silk H. Oral Health Training in Pediatric Residency Programs: Pediatric Program Director Perspectives. J Dent Educ 2019 Jun;83(6):630–637. doi: 10.21815/JDE.019.058. Epub 2019 Feb 25. 37. Dalen JE, Ryan KJ, Alpert JS. Where have all the generalists gone? They became specialists, then subspecialists. Am J Med 2017 Jul;130(7):766–768. doi: 10.1016/j. amjmed.2017.01.026. Epub 2017 Feb 20. 38. Ticku S, Savageau JA, Harvan RA, Silk H, Isong IA,

Glicken AD, Dolce MC, Riedy CA. Primary Care and Oral Health Integration: Comparing Training Across Disciplines. J Health Care Poor Underserved 2020;31(4) Suppl:344–59. 39. Manca DP. Do electronic medical records improve quality of care? Yes. Can Fam Physician 2015 Oct;61(10):846–851. PMCID: PMC4607324. 40. Hummel J, Phillips KE, Holt B, Virden M. Organized evidenced-based care: Oral health integration. Implementation guide supplement. Seattle, Qualis Health 2016. Accessed Oct. 4, 2021. 41. Freeman B, Potente S, Rock V, McIver J. Social media campaigns that make a difference: What can public health learn from the corporate sector and other social change marketers? Public Health Res Pract 2015 Mar 30;25(2):e2521517. doi: 10.17061/phrp2521517. 42. American Academy of Pediatrics. Brushing for Two: How Your Oral Health Affects Baby. Accessed Oct. 4, 2021. 43. American Dental Association. Oral Health Topics: Pregnancy. Accessed Oct. 4, 2021. T HE CORRE S P ON DIN G AU T HOR , Rachel Anderson, BS, can be reached at rachel.anderson@umassmed.edu.

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C .E. CREDIT QUESTIONS

April 2022 Continuing Education Worksheet This month’s journal provides 1.5 CORE C.E. credits, covering the material provided in all three of the pregnancy-related articles. This worksheet provides readers an opportunity to review the C.E. questions before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here.

1. True or False: Though a mother’s oral health is one of the best predictors of her child’s oral health, the 2017-18 Maternal and Infant Health Assessment (MIHA) survey showed that less than half of California women with a live birth received a dental visit during pregnancy. 2. MIHA analysis showed dental visit rates for pregnant women varied throughout California. Which of the following regional visit rate data is incorrect? a. San Joaquin Valley: 36.8% b. Los Angeles County: 39.3% c. North/Mountain Region: 42.4% d. Central Coast Region: 50.5 % e. Orange County: 67.1 % 3. MIHA visit data revealed all but which one of the following: a. 35% of women with Medi-Cal prenatal health insurance received a dental visit during pregnancy b. 33% of Black women received a dental visit during pregnancy c. 37% of Latina women received a dental visit during pregnancy d. 39% of women younger than age 25 received a dental visit during pregnancy 4. True or False: According to Holt and Barzel, a majority of dentists believe that perinatal oral health is important and readily provide dental care to pregnant women throughout their pregnancy a. Both phrases are true b. Both phrases are false c. Only the first phrase is true d. Only the second phrase is true 5. Which of the following statements applies to the national 2013-2019 Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative (mark all that apply)? a. California was one of the 16 funded PIOQHI demonstration projects b. PIOHQI project progress was accelerated through participation in a peer-to-peer learning collaborative c. PIOHQI projects tested a standardized set of activities to improve access to oral health care d. Robust evidence verified that these standard approaches are effective e. All of the above

6. PIOHQI lessons learned included (mark all that apply): a. Making training modules available online (versus offering trainings in person only) is necessary to meet staff training needs b. Identifying educational messages and resources for professionals to use during visits is essential c. Processes and procedures must be adapted locally to enable functionality at individual sites d. Data are necessary for monitoring the impact of project activities and can be used to advocate for increased funding e. All of the above 7. According to Anderson and Silk, the primary reason to treat periodontal disease prior to pregnancy is based on a hypothesis that dental treatment during pregnancy: a. May endanger the fetus b. May inadvertently stimulate premature delivery c. Occurs too late to effectively reverse disease-related inflammation d. May interfere with optimal healing of the periodontal tissues 8. The professional oral health education and curricular resources that have been developed by a variety of entities include all but which of the following? a. Smiles for Life (Society of Teachers of Family Medicine Group on Oral Health) b. Oral Health and You (American Academy of Family Physicians) c. Tiny Teeth (American Academy of Pediatrics) d. Oral Health Core Competencies (Association of American Medical Colleges) 9. To effect clinical practice changes, Anderson and Silk propose that which of the following are necessary (mark all that apply)? a. Support from trusted medical and dental organizations b. Easily accessible and mandated provider curricula integrated into all education levels c. Workflow and EHR shortcuts to ease clinical practice incorporation d. Dental and medical provider care coordination for women of all ages e. All of the above 10. The Sonoma County PIOHQI pilot project used all but which one of the following strategies to successfully improve dental visit rates for pregnant women? a. Oral health education for the medical team b. Coordinated scheduling between medical and dental electronic health record systems c. Standard protocols to identify infants eligible for dental visits d. Incentives to medical assistants to increase the number of infant dental appointments e. Incentives to dental providers to participate in the program APRIL 2 0 2 2

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Keep up with regulatory compliance. Get expert guidance from CDA Practice Support analysts on the latest regulations affecting your practice, plus new resources to make it easier to keep pace. Benefit from dentistry-centered forms, required docs, checklists, a compliance calendar and more. Explore your CDA member resources at cda.org/RegulatoryCompliance.

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RM Matters

C D A J O U R N A L , V O L 5 0 , Nº 4

Best Practices for Hiring the Right Employee TDIC Risk Management Staff

M

oviegoers love a case of mistaken identity, especially when the mix-up has characters taking on jobs for which they are wholly unsuited. While it may be entertaining to watch a rock star try to teach elementary school or a precocious teen evade the FBI as an airline pilot, the reality of dealing with an employee who has misrepresented their competencies is not nearly as fun. The average cost to hire an employee is about $4,400, and it takes around 42 days to fill a position, according to a recent study by the Society for Human Resource Management. What’s even more expensive is a bad hire. Per the U.S. Department of Labor, the cost of a bad hire is at least 30% of the employee’s first-year earnings. And that’s just the monetary cost — other considerations are the loss of dental practice production and the labor loss of current employees being distracted and slowed by training. There’s also a potential negative impact on employee morale when a new team member isn’t a good fit. While bad hires come in several forms, candidates who misrepresent their competencies are the most frequent topic of calls to The Dentists Insurance Company’s Risk Management Advice Line.

When good candidates become bad hires

A sampling of phone calls received by the Advice Line reveals some unfortunate similarities. ■ One dental office called for guidance on a newly hired financial coordinator. The employee had been on a performance improvement

plan for a month due to not being able to perform tasks as indicated on her resume. In addition, it was discovered that she had been arrested for criminal offenses. Among other problems, the shift of this employee’s responsibilities to other staff caused resentment from those team members. Another caller had learned that a recently hired hygienist was practicing with an inactive license. The issue only became known when

a patient complained about an interaction with the hygienist and demanded her license information. The discovery that an unlicensed employee was providing patient care caused reputational damage to the practice and a concern by patients about a perceived lack of controls implemented within the practice. There’s a simple adage that applies to these situations: An ounce of prevention is worth a pound of cure. Both bad hires could have been detected as unqualified

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

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candidates before they were hired had a few essential steps been taken to vet their qualifications and capabilities during the screening and interview process. Many dentists urgently need to fill open positions in their practices, which can lead to justifying shortcuts, but investing the time upfront to create a robust screening and interviewing process is invaluable. When these filters are in place, you essentially refine your pool of candidates to avoid costly and time-consuming hiring mistakes.

Filter One: Good Job Descriptions

A carefully composed job description allows an employer to define their expectations, qualifications, necessary experience and education involved to set a future employee up for success in their role. Michelle Coker, employment analyst at the California Dental Association, explains, “The job description will guide you when reviewing resumes and applications and in crafting your interview questions. Narrow down your pool of candidates through the job description.” ■ The job title should be clear and concise. “Fluffy” job titles may only make sense to your practice. Keep it simple. ■ Outline the responsibilities and use bullet points. The shorter and easier to understand, the better. Plus, it’s better for online viewing. ■ Focus on the key job functions. Summarize the essential functions to answer the question “Why does this job exist?” ■ Avoid unrealistic requirements but make a point of stating the requirements that are nonnegotiable (such as maintaining an active license). ■ Define the work hours (full or part time) and attendance expectations (remote or on-site). 226

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Beyond the hiring process, a welldefined job description functions as a tool to guide initial training of the new employee and is essential in setting performance expectations. When an employee knows what’s expected, they can better gauge their own performance and meet the expectations of the role. Additionally, the description will assist the employer as a reference when providing performance feedback and, if needed, the development of a performance improvement plan. Your documentation of their job description is

Not requiring the candidate to fill out a job application is a missed opportunity for filtering out potential bad hires.

essential should any employee not meet the expectations of the role and you find it necessary to end the relationship.

Filter Two: An Employment Application

Too often, employers decide that a resume and cover letter will provide all the information they need to know about a candidate. Not requiring the candidate to fill out a job application is a missed opportunity for filtering out potential bad hires. There are several advantages to having job seekers fill out a job application along with submitting their resume: ■ An application provides a consistent format for employers, and consistency can reduce liability. When the same data is gathered in the same format from each candidate, employers

gain standardization of information, making comparisons of candidates’ credentials easier. It also establishes a consistency of process to avoid potential allegations of unlawful preferential treatment of applicants. ■ Discrepancies between application and resume information are a red flag indicating a potential misrepresentation of competencies and should signal employers to proceed with caution. ■ An application gives the potential employer the ability to obtain the applicant’s signature certifying that all statements on the application for employment are true and authorizing an investigation of all information submitted. This allows the employer to check the accuracy of all data provided on the employment application including employment history, education history, degrees earned and so forth. Fraudulent claims and information on application materials, including fake degrees, exaggerated job descriptions, fake dates of employment and other falsehoods, are increasing. ■ The application is also an opportunity to obtain the applicant’s signature to certify that they have read and understood certain policies and procedures of the employer that are spelled out on the employment application. When creating an application, it’s important to be mindful of the employment laws that exist to protect potential employees from discrimination. Use a state-specific application that includes, at minimum, a basic waiver that allows the employer to check past employment, personal references and education.

Filter Three: Interviews

Once you have identified candidates who can fulfill the duties of the job


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description and who have accurately portrayed their qualifications, an interview is the next step in the filtration process. Maintain consistency in the questions you ask other candidates applying for the same job as a basis for equitable comparison. Make sure to keep copies of the application questions and answers in case they need to be referred to later. TDIC’s Risk Management analysts provide additional tips for vetting the knowledge, skills and expertise of clinical staff. ■ Ask for a copy of the candidate’s license (RDA, RDH, DDS) and verify that the license is in good standing with the state dental board. This is often assumed, but not confirmed, during the hiring process. ■ Ask the candidate how they prepare for the workday and for each patient’s treatment. What is the candidate’s process for organizing trays? What is their process to keep different procedures straight? This will demonstrate the candidate’s ability to follow directions and follow a system. ■ Ask the candidate to describe a procedure from beginning to end. This will show the candidate’s knowledge of the procedure and attention to detail as well as indicate holes in that knowledge that will need to be addressed through training. ■ Ask the candidate to walk you through a typical schedule of the practice they have worked in most recently. How many chairs did they support? What was the procedure mix? How many patients were seen per day? Were treatment notes dictated by the dentist and entered by the RDA or did the doctor do all the treatment entries? How was treatment presented and by whom? When your staffing needs are immediate, you may be tempted to

expedite available candidates and minimize their shortcomings. Frequent staff changes can reflect negatively on patients’ perceptions of your business practices, impact morale of existing staff and create an emotional and financial drain for practice owners. Protect your practice by implementing effective processes to find and hire solid employees. Your patients, your employees and your practice will all be the grateful beneficiaries of your careful screening procedures. 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.

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CDA PRESENTS

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IT’S EASY TO GET STARTED! Already a CDA member? Set up your Online Learning account with the same email you use to access your cda.org account to access a members-only catalog and special pricing. Then, sign in at any time to explore all your options. Not yet a member? Set up your account and sign in to access select courses, or join CDA to benefit from discounts and expanded learning options. Learn more at cda.org/online-learning.


Regulatory Compliance

C D A J O U R N A L , V O L 5 0 , Nº 4

What To Expect During a Cal/OSHA Inspection CDA Practice Support The following Q&A is excerpted from Chapter 7 of the CDA Legal Reference Guide for California Dentists.

What happens during a Cal/OSHA inspection?

Complaint-based inspections are unannounced. Cal/OSHA will request the presence of the employer or a representative for the inspection. You can accompany the inspector during the walkthrough of the facility, but you may not be present during the inspector’s interviews with staff. An employee or employee representative may also accompany the inspector during the walk-through. The inspection starts with an opening conference in which the inspector provides information on the purpose and scope of the inspection and how it will be conducted. The inspector reviews required written plans and then walks through the facility taking photographs and speaking with staff as needed. At the end of the walk-through, the inspector meets with the employer for an exit conference. If violations were observed, the inspector may issue citations during the exit conference or provide the employer with a preliminary report, with citations to be issued at a closing conference that will be scheduled later. During the closing conference, Cal/ OSHA staff review their findings with the employer, including the nature of the violations and how they can be abated. Penalties are proposed and the employer is informed of the requirement to post a citation and other notices so employees may view them. Cal/OSHA informs the employer of the opportunity to hold an informal conference with the district

manager to discuss the citation and penalties and of the separate opportunity to appeal. Cal/OSHA’s inspection procedures are detailed in its policies and procedures manual available at dir.ca.gov/samples/search/querypnp.htm.

Do I have to provide the Cal/OSHA inspector access to my staff and office?

Always verify the identity of individuals to whom you allow access to

your office. Cal/OSHA prefers to have your permission to conduct the inspection. An inspector may be willing to wait while you finish treating a patient but will not wait beyond a reasonable time. If you are not present at the office when the inspector arrives, Cal/OSHA staff will attempt to contact you by telephone to gain permission. If the inspector cannot contact you, they will document the attempts to gain your permission and then will commence the inspection. If you

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refuse permission, the inspector will report back to the district manager who will initiate the process for obtaining a warrant or taking other appropriate action. If a warrant is served for an inspection, that warrant is a court order mandating the inspection, and refusal to comply is likely to result in fines or possible incarceration.

I received a letter from the Division of Occupational Safety and Health regarding a complaint — what should I do?

Respond to Cal/OSHA’s request for information to the extent possible. Provide photographs if they are useful. Once you have provided the information, do not expect Cal/OSHA to send you a notice that you have satisfactorily answered its inquiries. If Cal/OSHA finds your response unsatisfactory, an unannounced on-site inspection will occur. Cal/OSHA may choose to investigate some nonformal serious complaints by telephone or fax. It contacts employers first by telephone, then by faxed letter. The employer has five working days to respond; employers who do not respond are scheduled for an on-site inspection. Follow-up inspections may occur for some of the complaints handled through this process.

What triggers a Cal/OSHA inspection?

Cal/OSHA reviews all complaints and classifies each as to whether it presents an imminent hazard, is a serious complaint or is a nonserious complaint. Complaints from self-identified employees, employee representatives and government representatives are classified as formal complaints. All formal complaints trigger an on-site inspection. Nonformal complaints are those made by nonemployees and employees who do not identify themselves. Nonformal serious complaints are investigated by telephone 230

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first and may be followed by a letter or an on-site inspection. Nonformal, nonserious complaints are investigated by a letter to the employer in lieu of an on-site inspection. However, Cal/OSHA district managers have some discretion to conduct on-site investigations of these complaints. A complaint is invalid if the district manager determines it involves willful harassment of an employer. Cal/OSHA is not obliged to provide the employer with the identity of the complainant. Cal/OSHA also conducts “programmed inspections” when it is targeting an industry. For example, agriculture and the garment industry have been targets of programmed inspections. There is also a possibility that your practice will be inspected if a neighboring dental office has had frequent complaints and inspections.

I was cited by Cal/OSHA — what should I do? Do I need an attorney?

At the closing conference, Cal/OSHA staff will have reviewed their findings with you or your representative. You may choose to take one of these actions: ■ Correct the violations and pay the proposed penalties. In this scenario, you effectively agree that there were violations and you will not appeal the citations. ■ Appeal the citations and proposed penalties. File an appeal with the Occupational Safety and Health Appeals Board within 15 working days of receiving citations. You can also request an informal conference with the district manager while you await your appeal hearing. An informal conference allows you to present evidence, offer explanations and clarify issues. After an informal conference, a district manager will determine if it is appropriate to withdraw or amend citations and revise penalties. An informal conference does not negate your right

to a hearing before the appeals board, nor is it the same as the prehearing conference scheduled by the appeals board although the scope is the same. You may request an informal conference any time before the day of the appeal hearing. Additional information on the appeals and hearing process and on informal conferences can be found in the Cal/ OSHA policies and procedures manual. Whether you need or want an attorney depends on the nature and scope of the citations. A few nonserious violations may not warrant it, but seeking legal counsel is advisable for serious violations such as an injury to an employee or an allegedly unsafe work environment. n 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.


Tech Trends

C D A J O U R N A L , V O L 5 0 , Nº 4

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

Chrome OS Flex (free, Google) Many homes and businesses have a collection of outdated computers. These machines, once powerful sources for gaming and productivity, have relatively little use or purpose once software and support have reached the end of life. Google is breathing new life into these desktops and laptops with Chrome OS Flex, a cloudbased operating system that brings modern and secure features to obsolete hardware. Chrome OS Flex can be installed on Mac and PC computers. Google maintains a certified list of hardware models that this operating system is expected to work on. To get started, users install and launch the Chromebook Recovery Utility extension on the Chrome browser of a current device, which will prompt the creation of a USB installer. The USB installer is then inserted into the legacy device and powered on. Chrome OS Flex will boot from the USB drive and give users the experience of temporarily running the operating system on the legacy device. As with all other Chrome OS devices, Chrome OS Flex requires a Google account to sign in and use the device. Once signed in, users are presented with the standard Chrome OS desktop that is familiar to all Chromebook users. Because the operating system is web based, everything is accessed through the Chrome web browser, which includes productivity app suites such as Microsoft 365, Google Workspace and more. When there are security updates to the browser or operating system, they are automatically downloaded and installed during the next restart. When users are comfortable with Chrome OS Flex, they can have it permanently installed on their machine by selecting the install option at the sign-in screen, which will erase all data on the legacy device. There are limitations with Chrome OS Flex. For example, users cannot install Google Play or Android apps. There is also limited support for peripherals and devicespecific hardware including biometric scanners, pen inputs, disk drives and proprietary connectors and docks.

Bebird C3 Wireless Otoscope ($39.99, Bebird)

Most practitioners are familiar with grainy, unfocused pictures and videos sent from concerned family and friends about something going on in their mouths. While demand for teledentistry has grown by leaps and bounds during the pandemic, picture quality has not improved much, as cellphones and webcams are still our patients’ primary ways of visually conveying their issues. Otoscopes are not ideal devices either, but their ability to focus on small objects over very short distances is a desired property for teledentistry applications. In recent years, consumer-grade otoscopes have flooded the market, often priced under $30. For patients who have hardships getting to their providers, such as the elderly in care facilities, the severely immunocompromised or those with limited access to providers, would having an affordable wireless otoscope like the Bebird C3 help them better convey their needs? The Bebird C3 is not the most intuitive device to use. It requires downloading an app, connecting a mobile device to the Bebird’s Wi-Fi, then going back to the main menu to see what the camera is displaying. The Bebird can focus on objects from about 3 inches away to as close as 1 centimeter away. There are occasional latency issues where the display on the paired mobile device requires two to three seconds to catch up to where the Bebird is pointed. Though the camera boasts a 3-megapixel resolution, the images are grainy and teeth are washed out, but great detail on the tooth surfaces can be seen. Pictures and videos are saved to the app, which can then be exported to a mobile device’s gallery for sharing. Bebird does make a product dedicated for the mouth (Bebird W3), but its model lines are unclear and difficult to discern. For the price, the Bebird C3 is an improvement over cellphone pictures of the oral cavity and can be a tool for practitioners to more closely evaluate their patients in teledentistry situations. — Alexander Lee, DMD

— Hubert Chan, DDS

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SIMPLY BRI L LIANT. Dentistry’s favorite convention is back! Reconnect with your community this spring at CDA Presents The Art and Science of Dentistry. Be inspired by leading speakers, earn C.E. at new workshops, explore innovative exhibitors and join the after-hours fun in Anaheim.

Learn more and register now at cda.org/ANA.

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MAY 12–14, 2022 ANAHEIM CONVENTION CENTER