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Summer 2025 vol. 91 | no. 4

JACD The Official Journal of the American College of Dentists

2024 ACD ETHICS SUMMIT PROCEEDINGS

Dentistry’s Ethical Responsibility as a Partner in Healthcare acd.org

A publication advancing ethics, professionalism, leadership, and excellence in dentistry. The Journal of the American College of Dentists (ISSN 0002-7979) is published by the American College of Dentists, Inc. 103 North Adams Street Rockville, Maryland 20850. Copyright 2025 by the American College of Dentists.

Send address changes to: Publication Manager Journal of the American College of Dentists 103 North Adams Street Rockville, Maryland 20850 While every effort is made by the publishers and the Editorial Board to see that no inaccurate or misleading opinions or statements appear in the Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, etc., herein are the responsibility of the contributor. Accordingly, the publishers and the Editorial Board and their respective employees and officers accept no liability whatsoever for the consequences of any such inaccurate or misleading opinions or statements. For bibliographic references, the Journal is abbreviated J Am Col Dent and should be followed by the year, volume, number, and page. The reference for this issue is J Am Col Dent 2025; 91 (4): 1-64.

Communication Policy

It is the communication policy of the American College of Dentists to identify and place before the Fellows, the profession, and other parties of interest those issues that affect dentistry and oral health. The goal is to stimulate this community to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promote specific views at the expense of others. The positions and opinions expressed in College publications do not necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists THE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in healthcare, advance the standards and efficiency of dentistry, develop good human relations and understanding, and extend the benefits of dental health to the greatest number, declares and adopts the following principles and ideals as ways and means for the attainment of these goals, A. To urge the extension and improvement of measures for the control and prevention of oral disorders; B.

To encourage qualified persons to consider a career in dentistry so that dental health services will be available to all and to urge broad preparation for such a career at all educational levels;

C. To encourage graduate studies and continuing educational efforts by dentists and auxiliaries; D. To encourage, stimulate, and promote research; E.

To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

To encourage the free exchange of ideas and experiences in the interest of better service to the patient;

G. To cooperate with other groups for the advancement of interprofessional relationships in the interest of the public; H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge the acceptance of them; I.

To encourage individuals to further these objectives and to recognize meritorious achievements and the potential for contributions to dental science, art, education, literature, human relations, or other areas which contribute to human welfare—by conferring Fellowship in the College on those persons properly selected for such honor.

Executive Director Michael A. Graham Editor Toni M. Roucka, RN, DDS, MA, FACD Program Director Suzan Pitman Publication Manager, JACD Communications Director Matthew Sheriff, BA, MS Editorial Board Albert Abena, DDS, JD, FACD Odette Aguirre, DDS, MS, MPH, FACD Joshua Bussard, DDS, FACD Michael Maihofer, DDS, FACD Ethan Pansick, DDS, MS, FACD Vishruti Patel, DDS, FACD Catherine Frankl Sarkis, JD, MBA Earl Sewell, MFA Carlos Smith, DDS, MDiv, FACD Kristi Soileau, DDS, MEd, MSHCE, FACD Pamela Zarkowski, JD, MPH, FACD Officers Robert A. Faiella, President Terry L. Norris, President Elect Peter H. Guevara Vice President Joseph P. Crowley, Treasurer Teresa A. Dolan, ACD Foundation President Regents Julie A. Connolly, Regency 1 Robert G. Plage, Regency 3 Brenda Thompson, Regency 4 Nancy Y. Larson, Regency 5 Kristi M. Soileau, Regency 6 Ned L. Nix, Regency 7 Robin Henderson, Regency 8 Krista Jones, At Large Regent Toni Roucka, At Large Regent Pamela Alston, At Large Regent William Calnon, At Large Regent Pamela Zarkowski, ASDE Liaison Daniel Carney, SPEA Liaison Joshua Bussard, Regent Intern Correspondence Address correspondence relating to the Journal to: Managing Editor Journal of the American College of Dentists 103 North Adams Street Rockville, Maryland 20850 Business Office Journal of the American College of Dentists Tel. (301) 977-3223 Letters from Readers The Journal of the American College of Dentists (JACD) welcomes letters to the editor. The opinions and views expressed in letters to the editor submitted to the JACD are those of the individual authors and do not necessarily reflect the opinions, positions, or policies of the JACD, its editorial board, or the American College of Dentists. The JACD reserves the right to edit submitted letters for clarity, length, and adherence to our editorial guidelines. The publication of a letter does not imply endorsement by the JACD or its affiliates. Readers are encouraged to critically evaluate the content of each letter and to consider it within the broader context of scientific and professional literature. Submit letters to editor@acd.org.

Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, RN, DDS, MA, FACD; Scott L. Tomar, DMD, DrPH

14 Medical-Dental Integration: Dispatches From “Both Sides of the Aisle” Lisa Simon, MD, DMD

20 How Can We Go Far Together in Healthcare Education and Training? Nader A. Nadershahi, DDS, MBA, EdD

25 Interprofessional Models of Care: A Strategic Framework for Advancing Integrated Healthcare Daniel J. Pihlstrom, DDS

30 Breaking Down the Silo of Dental Reimbursement Ron Inge, DDS

35 The Role of Research in Fostering Dentistry’s Partnership in Healthcare Scott L. Tomar, DMD, DrPH

41 Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America Mary Otto

47 A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

55 Leading the Way in Dentistry’s New Era: Integration, Wellness, and Respect Brett Kessler, DDS

60 Guest Editorial: Unifying Health and Oral Health—An Ethical Imperative Sheila Brear, BDS

Summer 2025 Volume 91, Number 4

B REA KIN G D O W N T H E SILOS :

Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, DDS, MA, FACD; Scott Tomar, DMD, DrPH, FACD

LISTEN TO THIS ARTICLE

he Ethics Summit, Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare, was held on September 12-13, 2024, in Rockville, Maryland. Sponsored by the American College of Dentists Foundation (ACDF) and the Santa Fe Group (SFG), this issue of the JACD is dedicated to the proceedings of that important event.

Journal of the American College of Dentists

INTRODUCTION

As oral healthcare providers, dentists share responsibility for overall wellness with their medical and allied health colleagues. With growing awareness of the connection between oral health and general health, it’s clear that greater collaboration across disciplines is needed. By working together more effectively, we can close gaps in care and communication and create a healthcare system that better serves all patients. Traditionally, we’ve often heard the phrase “doctors and dentists” to describe healthcare professionals. While many in the dental field may view this distinction as a sign of professional recognition, it may be more accurate—and equitable—to use the term “physicians and dentists” when referring to the broad spectrum of healthcare providers. The idea for the Ethics Summit took root in 2021 during Dr. Richard Jones’s term as ACD president. Though the ACDF frequently sponsors ethics-focused content and events, it had never sponsored a summit on this topic. Dr. Jones, driven by a deep commitment to patient-centered care, proposed the idea, which led to the formation of a planning task force. Guided by ethical principles, this group shaped the summit’s goals and structure. The mission of the ACD is to advance excellence, ethics, professionalism, and leadership in dentistry. Among its core objectives are the promotion of the highest ethical standards, the stimulation of interprofessional relationships, and the encouragement of dentists to engage with the broader responsibilities of citizenship and social accountability.1 The Ethics Summit aligned perfectly with this mission. Planning the event occurred over three years, with regular monthly to biweekly meetings. The COVID-19 pandemic caused delays, ultimately pushing the summit back by a year. A major priority was assembling a team of nationally recog5

nized leaders who could energize the profession and inspire action—experts who could offer real insights into integrating dentistry into the larger healthcare system while preserving its essential values and autonomy. To create a more integrated and patientcentered system, we must establish a clear path forward. As the 2021 Santa Fe Group report Advance Health Equity—An Alignment and Action Summit emphasized:

To achieve improved patient health at lower costs, the health system must incentivize health. Value-based models offering team care in patient-centered health homes are at the forefront of this transformation. Yet oral health is typically left out of these initiatives and calculations, owing to the long separation of medicine and dentistry. Continuing disparities, a rapidly transforming health system, and the pursuit of health equity mandate the integration of oral health into overall health. This is our defining moment.2 It’s a big challenge—but one that must be met. The ACD Ethics Summit built on this call to action with dentistry as its central focus. By bringing together invited oral healthcare professionals, including practitioners, educators, policy experts, researchers, and other industry leaders, the summit provided a unique space for meaningful dialogue and the sharing of ideas. Summer 2025 Volume 91, Number 4

Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, DDS, MA, FACD; Scott Tomar, DMD, DrPH, FACD

Through keynote speeches, targeted sessions, and interactive forums, participants explored the ethical and practical dimensions of integration, aiming to develop actionable strategies to improve patient care and system efficiency.

The key learning objectives of the summit included: 1. Understand dentistry’s ethical responsibility to be a partner in overall healthcare. 2. Review progress and acknowledge the 2021 Santa Fe Group Continuum, Advance Health Equity—An Alignment and Action Summit.2 3. Examine the challenges faced by the dental profession in breaking down silos between healthcare professions. 4. Formulate and prioritize strategies to overcome barriers. 5. Develop an agenda for ongoing collaboration among dental leaders. Pre- and post-summit surveys were conducted to gauge participants’ understanding of medicaldental integration. These results are discussed in the article in this issue by Mr. John Kerns3— now Dr. Kerns (Marquette University School of Dentistry, Class of 2025)—whose leadership with the Student Professionalism and Ethics Association (SPEA) played a valuable role in shaping the summit’s direction. Dr. Lisa Simon opened the summit with a powerful keynote that underscored the ethical imperative of bridging dental and medical care, as outlined in her article in this issue.4 Her presenJournal of the American College of Dentists

tation set the tone for the event, encouraging participants to envision a system without silos. Additional presentations by pillar leaders followed, focusing on education and training (Dr. Nader Nadershahi), interprofessional practice models (Dr. Dan Pihlstrom), research (Dr. Jennifer Webster-Cyriaque), and reimbursement strategies (Dr. Ron Inge). These sessions spotlighted current challenges and highlighted proven models of collaboration with the goal of motivating attendees to move the profession forward to a more integrated healthcare system. Day 2 featured an inspiring keynote from Dr. Natalia Chalmers, Chief Dental Officer at CMS, who emphasized the critical role of federal policy and outlined CMS’s ongoing efforts. Author and journalist Mary Otto shared a sobering patient perspective, reminding us why this work is so vital through the tragic story of Deamonte Driver.5 The preface to Mary’s book, Teeth, is published here in this issue. Each afternoon, breakout sessions led by the four pillar leaders provided attendees with an opportunity to delve deeper, identify specific goals, and develop strategies to enhance interprofessional collaboration. Their work is captured in their contributions that follow in this issue.6-9 The integration of dentistry into healthcare will not happen by chance. It requires deliberate, coordinated efforts across education, policy, practice, and technology. Interoperable health systems, standardized care protocols, and supportive reimbursement models are essential. Dental education must also evolve to prepare students for team-based care, systems thinking, and collaborative problem-solving. Yet, we face uncertainty. The US Department of Health and Human Services is currently undergoing a period of transition, which may impact the momentum of these integration efforts. Federal instability can delay policy alignment and hin6

Summer 2025 Volume 91, Number 4

Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, DDS, MA, FACD; Scott Tomar, DMD, DrPH, FACD

der systems-level progress. Still, this uncertainty opens the door for professional organizations like the ACD to lead by building consensus, championing change, and driving ethical progress.

To move forward, dentistry must embrace its role not as an adjunct to medicine but as a full partner in health. With commitment, vision, and collaboration, we can break down the silos and build a system that truly serves the whole person.

ETHICS SUMMIT AGENDA Day 1 Thursday, September 12, 2024

Day 2 Friday, September 13, 2024

7-8:30 am Breakfast

7-8:30 am

Breakfast

8:30 am

Keynote Presentation

8:30-10:00 am Keynote Presentation Lisa Simon, MD, DMD. Dispatches from Both Sides of the Aisle 10:00 am Break 10:15 am Pillar Leader Presentations Education and Training Dr. Nader Nadershahi Interprofessional Practice Models of Care Dr. Dan Pihlstrom Research Dr. Jennifer Webster-Cyriaque Third-Party Payers/ Reimbursement Models Dr. Ron Inge 12:30 pm Lunch Special Presentation 1:30 pm Mary Otto, Author. Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America 2:00 pm

Pillar Groups

3:00 pm

Break

3:15 pm

Reconvene Whole Group

5:30 pm

Reception at the ACD Office

Journal of the American College of Dentists

Natalia Chalmers, DDS, MHSc, PhD. Oral Health Advancements: Updates from the Centers for Medicare & Medicaid Services 10:00 am

Break

10:15 am

Review Objectives for the Day

10:45 am

Pillar Groups

12:30 pm

Lunch

1:30 pm

Resume Pillar Groups

2:45 pm

Break

3:00 pm

Reconvene Whole Group

4:30 pm

Wrap-Up and Next Steps

4:45 pm

Adjourn

SPEAKER BIOS Natalia Chalmers, DDS, MHSc, PhD Keynote Presenter Organization Representing: Centers for Medicare & Medicaid Services. Dr. Natalia Chalmers is a board-certified pediatric dentist, oral health policy expert, and public health advocate who brings more than 20 years of clinical, research, industry, and regulatory experience to CMS in her role as chief dental officer in the Office of the Administrator. Previously, Dr. Chalmers served as a dental officer at the US Food and Drug Administration. Her research has translated into action, improving oral care and advocating for the role health policy can play across the lifespan—particularly when it embraces dental well-being as a facet of care for the whole person. Ronald Inge, DDS Pillar Leader Organization Representing: Dental Benefits Industry. Dr. Ron Inge is the chief strategy officer for 32Health, an AI-powered healthcare administration platform, where he leverages his years of experience in the dental benefits industry to assist in the development of artificial intelligence models that perform routine administrative tasks. Dr. Inge started his dental care in a private dental practice for 15 years. He has served in executive roles at various organizations, including Aetna, Delta Dental of Washington, Delta Dental of California, the American Dental Association, DentiCare of California, and AVP Vision Plans. In 2016, Dr. Inge moved to Missouri, where he served as the chief dental officer, chief operating officer, and vice president of professional services at Delta Dental of Missouri. In these roles, Dr. Inge was responsible for all aspects of the dental networks and directing the organization’s operations, including the claims and customer service teams. Dr. Inge serves his community as a volunteer on numerous boards and is the recipient of numerous awards for his professional contributions. He received his Bachelor of Arts degree in human biology from Stanford University and his Doctor of Dental Surgery degree from the University of California, Los Angeles. Dr. Inge also had a very successful athletic career as a running back for Stanford University, where he holds the record for the most kickoff returns in Stanford Football Team history. More importantly, he was the hero of the 1976 Big Game (between Stanford and Cal Berkeley) when he scored the winning touchdown against Cal in the last minute of the game.

Summer 2025 Volume 91, Number 4

Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, DDS, MA, FACD; Scott Tomar, DMD, DrPH, FACD

Nader Nadershahi, DDS, MBA, EdD Pillar Leader Organization Representing: University of the Pacific Arthur A. Dugoni School of Dentistry. Dr. Nader A. Nadershahi serves as the ninth dean of the University of the Pacific’s Arthur A. Dugoni School of Dentistry and vice provost of the San Francisco campus, bringing to the role nearly 30 years of leadership experience in dental education, organized dentistry, and clinical practice. He has earned his DDS, completed GPR training, and also earned an MBA and an EdD. He is a fellow of the American College of Dentists, the Academy of Dentistry International, the International College of Dentists, and the Pierre Fauchard Academy. He also completed a fellowship at the ADEA Leadership Institute and served as an advisor. Dr. Nadershahi has led milestone projects, including strategic planning and implementation, the design and implementation of the school’s integrated curriculum and competencies, and raising $69.3 million in a comprehensive fundraising campaign. He helped develop the university’s San Francisco campus facilities and the new collaborative teaching, clinical, and education facilities in Sacramento. He supported the launch of new health science programs, such as the MPAS, and the eventual creation of the School of Health Sciences. He serves as a Board member for the Bay Area Council and the San Francisco Chamber of Commerce and was appointed by the governor to serve as vice chair of the California Health Workforce Education and Training Council. He has delivered more than 140 presentations, authored 30 publications, contributed five book chapters, and published numerous abstracts and other works. Dr. Nadershahi has been actively involved in organized dentistry and dental education. He served as chair of the Board of Directors for the American Dental Education Association, serves as a delegate to the ADEA and American Dental Association houses, and is currently vice chair of the ADA Foundation. He also serves as a member of the California Dental Association Board of Directors. Dr. Nadershahi is a member of the Santa Fe Group and has been actively involved in leadership development, accreditation, national licensure, and the evolution of oral health education and collaborative care. Mary Otto Guest Speaker Mary Otto is the oral health topic leader for the Association of Healthcare Journalists. She began writing about oral health at The Washington Post, where she worked for eight years covering social issues, including healthcare and poverty. The author of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America (The New Press), she lives in Washington, DC.

Journal of the American College of Dentists

Daniel Pihlstrom, DDS DDS Daniel Pihlstrom, Pillar Leader Chief Dental Officer

Permanente Dental Associates, P.C.

Organization Representing: Permanente Dental Associates. Daniel Pihlstrom, DDS, is the chief dental officer of Permanente Dental Associates In this role, oversees the agenda of the Daniel(PDA). Pihlstrom, DDS,Dr.isPihlstrom chief dental officer ofquality Permanente Kaiser Permanente Dental program, helping to ensure the organization’s Dental Associates (PDA). In this role, Dr. Pihlstrom 290,000 members receive patient-centered, integrated, value-based care. oversees the quality agenda of the Kaiser Permanente Dr. Pihlstrom has practiced general dentistry for over 20 years and has held Dental program, helping to ensure the organization’s various leadership roles within PDA. During his career at PDA, Dr. Pihlstrom 290,000 members receive patient-centered, integrated, developed the Kaiser Permanente Medical-Dental Integration (MDI) program, which incorporated livalue-based care. censed practical nurses, dentist-administered flu vaccinations, and medical care coordination into daily clinical practice. Dr. Pihlstrom Dr. is anPihlstrom affiliate investigator at thegeneral Kaiser Permanente for Health has practiced dentistry forCenter over 20 Research and has contributed to numerous scientific publications on evidence-based dentistry and years and has served in various leadership roles for PDA. medical-dental integration, including the 2021 Surgeon General’s Report on Oral Health in America. During his career at PDA, Dr. Pihlstrom developed the Kaiser Permanente Medical-Dental Dr. Pihlstrom graduated from the University of Minnesota with a Bachelor of Science in Biochemistry Integration (MDI) program - incorporating licensed practical nurses, dentist-administered flu and received his dental degree from the University of Minnesota School of Dentistry in 2000. He comvaccinations, medical care coordination into daily clinical practice. Dr. Pihlstrom is Affiliate pletedand a general practice residency at Oregon Health & Sciences University and joined PDA in 2001. Investigator at the Kaiser Permanente Center for Health Research and has contributed In 2019, he completed the Harvard Business School Executive Leadership Program. Dr.to Pihlstrom lives numerous scientific publications on evidence-based dentistry and medical-dental integration, with his wife, three children, and beloved golden doodle in Lake Oswego, Oregon.

including the 2021 Surgeon Generals' Report on Oral Health in America.

Dr. Pihlstrom graduated from theToni University of Minnesota with a Bachelor of Sciences in Roucka, DDS, MA Biochemistry and received his dental degree from the University of Minnesota School of Summit Cochair Dentistry in 2000. He completed a General Practice Residency at the Oregon Health & Organization ACD. Sciences University and joined PDA in 2001. Representing: In 2019 he completed the Harvard Business School Executive Leadership Program. Dr. Toni Roucka is a professor of developmental sciences and director of graduate studiesand at Marquette University She received Dr. Pihlstrom lives with his wife, three children, the beloved goldenSchool doodleofinDentistry. Lake Oswego, her undergraduate degree in nursing from the College of DuPage. She Oregon.

received her DDS from the University of Illinois, Chicago, and an MA in bioethics from the Medical College of Wisconsin. Dr. Roucka is a nationally recognized speaker on dental ethics and has numerous publications in peer-reviewed journals on ethics topics such as social media and dentistry, sustainability in healthcare, and narrative ethics. She also authors a regular ethics column for the Academy of General Dentistry’s journal, General Dentistry. Dr. Roucka is a past president of the American Society for Dental Ethics, a Fellow of the American College of Dentists and the Pierre Fauchard Academy, and regent at large on the Board of the American College of Dentists, serving a four-year term.

Summer 2025 Volume 91, Number 4

Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare Toni M. Roucka, DDS, MA, FACD; Scott Tomar, DMD, DrPH, FACD

Lisa Simon, MD, DMD Planning Committee and Keynote Presenter Dr. Lisa Simon is a physician, dentist, and health services researcher. She has been involved in the implementation of medical-dental integration projects in both primary care, dental, and inpatient settings and has published more than 70 peer-reviewed articles on oral health policy and the separation of medicine and dentistry. She is a faculty member in the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital, Harvard Medical School, and the Harvard School of Dental Medicine. Scott L. Tomar, DMD, DrPH Summit Cochair Dr. Scott Tomar is a professor and the associate dean for prevention and public health sciences at the University of Illinois, Chicago College of Dentistry, and is the immediate past president of the American Board of Dental Public Health. Dr. Tomar has published about 180 journal articles and book chapters and contributed to seven reports of the US Surgeon General. He is a former editor of the Journal of Public Health Dentistry and the Journal of Evidence-Based Dental Practice and has received numerous awards, including IADR’s H. Trendley Dean Distinguished Scientist Award. Jennifer Webster-Cyriaque, DDS, PhD Pillar Leader Organization Representing: NIDCR/NIH. Dr. Jennifer Webster-Cyriaque is the deputy director of the National Institute of Dental and Craniofacial Research, National Institutes of Health. An accomplished clinician, researcher, and leader, Dr. Webster-Cyriaque previously served as a faculty member at the University of North Carolina (UNC) schools of dentistry and medicine for more than two decades. As a tenured full professor at UNC, Dr. Webster-Cyriaque also served as the attending on clinical service at the UNC Hospital’s dental clinic. While there, she led research into a potential etiologic agent for salivary gland disease in patients living with HIV, assessed the oral microbiome and its implications for cancer-causing viruses, and studied the impact of the oral microbiome and oral health on HIV outcomes. In addition to her research, Dr. Webster-Cyriaque has held leadership roles as the chair/vice chair of the Oral HIV/AIDS Research Alliance, as research director at the National Dental Association Foundation, and as director of postdoctoral CTSA training, along with multiple roles within the American Association for Dental, Oral, and Craniofacial Research and the International Association for Dental Research. Since 2004, she has led the UNC Malawi project and provided assistance in founding Malawi’s first dental school in 2019. Dr. Webster-Cyriaque earned her PhD in microbiology/immunology from the University of North Carolina-Chapel Hill in 1998, her DDS from SUNY Buffalo in 1992, and her BA in biology and interdisciplinary social science from SUNY Buffalo in 1988. Journal of the American College of Dentists

Summit Attendees Deesha Bhaumik, PhD Sheila Brear, BDS Bruce Donoff, DMD, MD Ashland Doomes, DMD Thomas Elliott, JD Carole Hanes, DMD Irene Hilton, DDS, MPH Robert Iovino, DDS Richard Jones, DDS, MSD Krista Jones, DDS Dushanka Kleinman, DDS, MS Jandra Korb, DDS Robert Lamb, DDS

Tim Leeth, CPA Jennifer McGuire Haveman, DMD An Nguyen, DDS, MPH Kayhan Parsi, JD, PhD, HEC-C Donald Patthoff, DDS Gary Pickard Lance Rucker, DDS Michele Schultz-Robins, DMD Carlos Smith, DDS, MDiv Kristi Soileau, DDS Dawne Stefanik, DDS Gina Thornton-Evans, DDS, MPH Pamela Zarkowski, JD, MPH

The ACDF would like to acknowledge the ACD Summit Planning Committee and Contributors Jane Barrow, MS Jackson Bickford (SPEA) Michael E. Cadra, DMD, MD Teresa Dolan, DDS. MPH Benjamin Hung (SPEA) Mike Graham Richard Jones, DDS, MSD John Kerns (SPEA) Robert Lamb, DDS

Jessica Martin (SPEA) Keith A. Mays, DDS, PhD Emily Nguyen (SPEA) Stephen M. Pachuta, DDS, MSHS Suzan Pitman Thomas E. Raimann DDS Toni M. Roucka, DDS, MA Lisa Simon, MD, DMD Scott L. Tomar DMD, DrPH

The Ethics Summit was sponsored by the Santa Fe Group and the ACD Foundation. REFERENCES 1. American College of Dentists. American College of Dentists Mission Statement. Accessed June 6, 2025. https://www.acd.org/about-us/. 2. The Santa Fe Group. Advance health equity—an alignment and action summit summary report. 2022. Accessed June 6, 2025. https://santafegroup.org/wp-content/uploads/2023/03/sfg-report-final.pdf. 3. Kerns, J. A student’s perspective on breaking down the silos in healthcare. J Am Coll Dent. 2025;91(4): p. 47-54. 4. Simon, L. Medical-dental integration: Dispatches from “both sides of the aisle.” J Am Coll Dent. 2025;91(4): p. 14-19. 5. Otto, M. Teeth. The New Press;2017. ISBN 978-1-62097-482-7 (pbk). 41-46. 6. Nadershahi, N. How can we go far together in healthcare education and training? J Am Coll Dent. 2025;91(4): p. 20-24. 7. Pihlstrom, D. Interprofessional models of care: A strategic framework for advancing integrated healthcare. J Am Coll Dent. 2025;91(4): p. 25-29. 8. Inge, R. Breaking down the silo of dental reimbursement. J Am Coll Dent. 2025;91(4): p. 30-34. 9. Tomar, S. The role of research in fostering dentistry’s partnership in healthcare, J Am Coll Dent. 2025;91(4): p. 35-40. 13

Summer 2025 Volume 91, Number 4

PERSPECTIVE

Medical-Dental Integration: Dispatches From “Both Sides of the Aisle” Lisa Simon, MD, DMD Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA

n 1840, when Chapin Harris and three other physicians founded the first dental school in the United States, they could not have known that their intention to elevate the practice of dentistry and improve dental care would have such a dramatic unintended consequence: to wholly sever the educational connection between medicine and dentistry.1 Since then, differences in policy, funding, and self-regulation of medicine and dentistry have only forced the fields further apart. As an example, in 1958, the Joint Council to Improve the Healthcare of the Aged was founded by both the American Medical Association and the American Dental Association in opposition to Medicare; after Medicare was signed into law, covering medical services but excluding dental care, dentistry evolved further away from the rest of the healthcare system.2

Journal of the American College of Dentists

An Ethical Approach to Medical-Dental Integration In recent years, many advocates within and outside of dentistry have made impassioned attempts to reintegrate medicine and dentistry. The basis of much of this advocacy has been the prospect of improving systemic health outcomes and reducing healthcare costs. Yet the data backed by these claims has not been definitive. One study found that patients on hemodialysis with periodontal disease actually lived longer than those without.3 A rigorous meta-analysis of the effect of periodontal treatment on cardiovascular outcomes found no benefit.4 A randomized controlled trial of scaling and root planing for pregnant women with periodontitis did not find reductions in preterm birth or increased birth weight.5 And the randomized controlled trial of scaling and root planing for patients with diabetes and periodontitis published in the Journal of the American Medical Association was stopped early due to lack of efficacy.6 Even the strongest supporting evidence for medical-dental integration due to the oral-systemic health link is weak: A 2022 meta-analysis found that treatment of periodontal disease could improve hemoglobin A1c by 0.5 percentage points, yet the generic diabetes medication metformin decreases it by 1.2 percentage points, on average, and blockbuster glucagon-like peptide 1 (GLP1) agonists by an additional 1-2 percentage points.7 15

Though well-intentioned, attempts to improve access to dental care and integration with the medical system based on these questionable health benefits ignore the ethical imperative to ensure access to dental care for all because of the intrinsic dignity and right to healthcare of every human being. If expanded coverage of dental treatment is justified by the potential for cost savings or because of its impact on specific disease states, our field risks being interpreted as advocating for dental care for some, but not all—or that if access to dental care became cost-ineffective or cost-neutral, it would no longer be worthwhile. Dentistry is not alone in working to strike a balance between the pragmatic and evidence-based and the ethical. The Camden Coalition of Healthcare Providers, a health system in Camden, New Jersey, implemented a rigorous randomized controlled trial to evaluate the effect of its hot-spotting program. As reported in The New Yorker, “hot-spotting” identified patients with high rates of health system utilization due to serious illness and multiple social challenges. The program provided a robust set of social and medical services to patients, such as on-call nursing and social work staff.8 However, the results of the trial, intended to reduce hospital admissions and frequent emergency department use and published in the New England Journal of Medicine, were null.9 From an ethical perspective, however, one may ask if reducing hospital admissions was the outcome that truly mattered for these extraordiSummer 2025 Volume 91, Number 4

Medical-Dental Integration: Dispatches From “Both Sides of the Aisle” Lisa Simon, MD, DMD

narily vulnerable patients, or whether there may in fact be other value derived from furthering connection and care coordination for those with the greatest health and social challenges. Tragically, such inequities persist in dentistry. Those who stand to benefit most from more comprehensive integration of medicine and dentistry are those who struggle to access dental care: people who are low-income, have disabilities, or live in rural areas, and people of color.10 For many of these Americans, dental care is already “integrated”—in that their primary source of care for dental problems is a hospital emergency department or even an inpatient ward. And though 1.5% of all emergency department visits are for dental problems,11 fewer than half of patients with an emergency department dental visit ultimately see a dentist within six months.12

Defining Integration Rather than being a single concept, medical-dental integration can be thought of as a spectrum, with increasing levels of collaboration, colocation, and information transfer to improve patient care in both the medical and dental settings. The SAMHSA-HRSA Center for Integrated Health Solutions previously generated a similar framework for behavioral health and primary care.13 Importantly, even smaller-scale efforts can be accommodated on the spectrum, such as a private dental and medical office in the same building developing a mutual referral system. Integration can be bidirectional; application of fluoride varnish in the primary care setting and tobacco cessation counseling in the dental office are both important opportunities to improve health and collaborate in ways that center patients and their needs. However, large-scale integration requires structural and systematic reform. Without corresponding

Journal of the American College of Dentists

billing codes within the Council on Procedural Terminology (CPT)14 and Code on Dental Procedures and Nomenclature (procedural coding systems in medicine and dentistry, respectively),15 provider uptake of even evidence-based services will be low. For example, although the application of fluoride varnish in pediatric medical offices is evidence-based and effective for caries prevention, it was not until widespread insurance coverage for the procedure that it became more widespread.16 The recent approval of a CPT code for silver diamine fluoride in 2022 has resulted in educational programming for medical providers to learn how to apply it,17 a measure to track procedure uptake, and a way to ensure providers can bill for providing it.18 But medical-dental integration also contains cautionary tales. Incorporating a screening test without having the infrastructure to manage positive screening results and effectively navigate patients to care can result in patient harm and moral distress to providers. For example, screening for hypertension receives an “A” evidence grade from the United States Preventive Services Task Force, the primary arbiter of what preventive care is covered in the US.19 The dental setting is a perfect opportunity for office-based screening, particularly for the 9% of American adults who see a dentist but not a physician every year.20 However, the American Dental Association’s guidelines also advise that patients with a systolic blood pressure greater than 180 do not receive dental treatment and that those with a systolic blood pressure greater than 160 do not receive elective dental treatment, even if they are asymptomatic.21 If patients found to have high blood pressure in the dental clinic do not have access to primary care and their dentist cannot refer them, chairside blood pressure screening effectively becomes a barrier to dental care, rather than an opportunity for hypertension treatment—a finding that has been borne out in the literature.22,23

As our profession and its allies move forward, I invite us to consider that, rather than focusing on whether dental care is cost-saving, able to prevent other chronic diseases, or even an important part of overall health, we instead acknowledge that dental care is healthcare, and healthcare is a human right.

Medicare: An Example of Policy in Action As noted above, medical-dental integration represents a spectrum of interventions and policies that support better oral and overall health for all. An example of the progress to be made is that Medicare, which provides health insurance for more than 65 million older adults and people with disabilities, has a “statutory exclusion” that restricts coverage for dental treatment.24 Repeated attempts to introduce a Medicare dental benefit, most recently under the Biden administration, have been unsuccessful.25 However, starting in 2023, the Centers for Medicare & Medicaid Services began expanding coverage of services it deemed “inextricably linked” to covered medical services. As of 2025, dental care meeting this requirement is covered for patients undergoing organ transplant, cardiac valve surgery; those with cancer being treated with chemotherapy, chimeric antigen receptor therapy, or high-dose antiresorptive therapy; any patient with head and neck cancer; and patients receiving dialysis.26 On its face, this appears to be a fundamental integration of medical and dental care, yet the policy’s success requires a multifaceted approach. Dentists must be encouraged to enroll in Medicare, such as through a toolkit produced by the American

Dental Association.27 Specialist physicians who care for these patients, and patients themselves, must be made aware of the new benefit.28 Coding infrastructure must exist to allow for dentist billing, including guidance on what procedures are covered. Lastly, reimbursement rates must not be so low as to disincentivize participation, as has contributed to low Medicaid participation among many dentists.29 Nonetheless, many Americans previously lacking dental coverage are now eligible to receive it.

Conclusion While the last decade has been one of exciting evolution in expanded access to dental care, there is much more work to be done. Retaining an ethical core to our shared mission is key to reducing the pain and suffering caused by dental disease that disproportionately burdens vulnerable Americans. As our profession and its allies move forward, I invite us to consider that, rather than focusing on whether dental care is cost-saving, able to prevent other chronic diseases, or even an important part of overall health, we instead acknowledge that dental care is healthcare, and healthcare is a human right. No one should suffer pain, stigma, and shame from a preventable disease. With an ethical approach at the forefront of our work, we can truly improve the lives of millions and change our field for the better.

Summer 2025 Volume 91, Number 4

Medical-Dental Integration: Dispatches From “Both Sides of the Aisle” Lisa Simon, MD, DMD

REFERENCES 1. McGough E, Simon L. Is oral health essential? AMA J Ethics. 2022;24(1):80-88. doi:10.1001/AMAJETHICS.2022.80. 2. Simon L. Overcoming historical separation between oral and general healthcare: Interprofessional collaboration for promoting health equity. AMA J Ethics. 2016;18(9):941-949. doi:10.1001/journalofethics.2016.18.9.pfor1-1609. 3. Ruospo M, Palmer SC, Wong G, et al. Periodontitis and early mortality among adults treated with hemodialysis: A multinational propensity-matched cohort study. BMC Nephrol. 2017;18(1):1-10. doi:10.1186/S12882-017-0574-X. 4. Ye Z, Cao Y, Miao C, et al. Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis. Cochrane Database of Systematic Reviews. 2022;10:CD009197. doi:10.1002/14651858.CD009197.PUB5/INFORMATION/EN. 5. Michalowicz BS, Hodges JS, DiAngelis AJ, et al. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med. 2006;355(18):1885-1894. doi:10.1056/NEJMoa062249. 6. Engebretson SP, Hyman LG, Michalowicz BS, et al. The effect of nonsurgical periodontal therapy on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: A randomized clinical trial. JAMA. 2013;310(23):2523-2532. doi:10.1001/jama.2013.282431. 7. Trujillo JM, Nuffer W, Smith BA. GLP-1 receptor agonists: An updated review of head-to-head clinical studies. Ther Adv Endocrinol Metab. 2021;12:2042018821997320. doi:10.1177/2042018821997320/ ASSET/IMAGES/LARGE/10.1177_2042018821997320-FIG2.JPEG. 8. Finkelstein A, Cantor JC, Gubb J, et al. The Camden Coalition Care Management Program improved intermediate care coordination: A randomized controlled trial. Health Aff. 2024;43(1):131-139. doi:10.1377/HLTHAFF.2023.01151/ASSET/IMAGES/LARGE/FIGUREEX3.JPEG. 9. Finkelstein A, Zhou A, Taubman S, Doyle J. Healthcare hotspotting — a randomized, controlled trial. N Engl J Med. 2020;382(2):152-162. doi:10.1056/NEJMSA1906848. 10. Fleming E, Frantsve-Hawley J, Minter-Jordan M. Health equity needs teeth. AMA J Ethics. 2022;24(1):E48-E56. doi:10.1001/AMAJETHICS.2022.48. 11. CareQuest Institute for Oral Health. Recent Trends in Hospital Emergency Department Visits for Non-Traumatic Dental Conditions; 2022. Accessed January 20, 2025. https://www.carequest.org/system/files/CareQuest_Institute_Recent-Trends-in-Hospital-ED-Visits_6.7.22_FINAL.pdf. 12. Singhal A, Momany ET, Jones MP, et al. Dental care after an emergency department visit for dental problems among adults enrolled in Medicaid. J Am Dent Assoc. 2016;147(2):111-119. doi:10.1016/j. adaj.2015.08.012. 13. SAMHSA-HRSA Center for Integrated Health Solutions. Behavioral Health in Primary Care / SAMHSA-HRSA. Accessed May 14, 2017. http://www.integration.samhsa.gov/integrated-care-models/ behavioral-health-in-primary-care#additional resources. 14. American Medical Association. About CPT. AMA Physician Resources. Published 2016. Accessed August 4, 2016. https://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt.page?. 15. The American Dental Association. Code on Dental Procedures and Nomenclature. Accessed January 4, 2024. https://www.ada.org/publications/cdt.

Journal of the American College of Dentists

16. Isong IA, Silk H, Rao SR, Perrin JM, Savageau JA, Donelan K. Provision of fluoride varnish to Medicaid-enrolled children by physicians: The Massachusetts experience. Health Serv Res. 2011;46(6pt1):1843-1862. doi:10.1111/j.1475-6773.2011.01289.x. 17. Keeper J, Bernstein R, Siever K. Silver diamine fluoride. Smiles for Life Oral Health. December 2024. Accessed January 20, 2025. https://www.smilesforlifeoralhealth.org/courses/silver-diamine-fluoride/. 18. CareQuest Institute for Oral Health. The CPT code for the application of silver diamine fluoride, explained. October 28, 2022. Accessed June 19, 2023. https://www.carequest.org/about/blog-post/ cpt-code-application-silver-diamine-fluoride-explained. 19. A and B Recommendations. United States Preventive Services Task Force. Accessed June 19, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations. 20. Manski R, Rohde F, Ricks T, Chalmers N. STATISTICAL BRIEF #544: Number and Percentage of the Population with Any Dental or Medical Visits by Insurance Coverage and Geographic Area, 2019; 2022. Accessed January 20, 2025. https://www.meps.ahrq.gov/data_files/publications/st544/stat544. shtml. 21. Miller CS, Glick M, Rhodus NL. 2017 Hypertension guidelines: New opportunities and challenges. J Am Dent Assoc. 2018;149(4):229-231. doi:10.1016/j.adaj.2018.01.047. 22. Nath S, Jiang T, Barrow J, Simon L. Treatment deferral for elevated blood pressure at a dental school clinic. J Dent Educ. 2024;88(1):51-55. doi:10.1002/JDD.13369. 23. Yarows SA, Vornovitsky O, Eber RM, Bisognano JD, Basile J. Canceling dental procedures due to elevated blood pressure: Is it appropriate? J Am Dent Assoc. 2020;151(4):239-244. doi:10.1016/J. ADAJ.2019.12.010. 24. Social Security Act of 1965 Title XVIII Health Insurance for the Aged and Disabled, Section 1862(12) Exclusions from Coverage; 1965. 25. Simon L, Giannobile W V. Is it finally time for a Medicare dental benefit? New England J Med. 2021;385:e80. doi:10.1056/NEJMP2115048. 26. Simon L, Song Z, Barnett ML. The new Medicare dental benefit—small but mighty. JAMA Intern Med. 2024;184(12):1407-1408. doi:10.1001/JAMAINTERNMED.2024.4802. 27. Anderson O. Updated Medicare toolkit available on ADA website. ADA News. Published March 18, 2024. Accessed April 4, 2024. https://adanews.ada.org/ada-news/2024/march/updated-medicare-toolkit-available-on-ada-website/. 28. Simon L, Paly J, Park E, Samuels-Kalow M. Medicare dental coverage for patients with head and neck cancer: An opportunity in need of advocates. Oral Oncol. 2024;153:106754. doi:10.1016/J. ORALONCOLOGY.2024.106754. 29. Nasseh K, Fosse C, Vujicic M. Dentists who participate in Medicaid: Who they are, where they locate, how they practice. Med Care Res Rev. 2023;80(2):245-252. doi:10.1177/10775587221108751.

Summer 2025 Volume 91, Number 4

PERSPECTIVE

How Can We Go Far Together in Healthcare Education and Training? Nader A. Nadershahi, DDS, MBA, EdD

“If you want to go fast, go alone. If you want to go far, go together.”

his African proverb highlights the importance of collaboration and cooperation to achieve long-term success and impact. This sentiment applies to many aspects of life, and it certainly applies to our reflection on the importance of breaking down the silos that have developed in healthcare. Our healthcare system has been siloed in all aspects, including delivery models, payment systems, education, and training.

Journal of the American College of Dentists

More recently, there has been a growing movement and understanding of the importance of bringing together our professions to improve outcomes for individuals seeking care and for the entire healthcare delivery ecosystem. The Interprofessional Education Collaborative (IPEC) was formed in 2009 with the support of six national education association members.

To understand where we are going, it is critical to reflect on where we have been and where we are currently. Our reflection goes back to the origins of any practice of medicine, dating back to prehistoric times, with the use of medicinal plants and other healing practices.1 The earliest known instance of dentistry dates back to around 7000 BCE in the Indus Valley with evidence of the drilling of human teeth.2 The focus of this brief manuscript will be on the dental and medical education systems. The educational systems in the United States also evolved separately, with the first medical school in the US being founded in 1765 at the College of Philadelphia, now the University of Pennsylvania Perelman School of Medicine, by Dr. John Morgan and Dr. William Shippen Jr.3 The education of students to practice dentistry was first formalized in 1840 with the creation of the Baltimore College of Dental Surgery by Dr. Chapin A. Harris and Dr. Horace H. Hayden.4 Later, the Carnegie Foundation for the Advancement of Teaching was established in 1905 by American industrialist Andrew Carnegie. The work of the foundation helped standardize higher education, create a pension plan for college teachers, develop educational standards such as credit hours, and classify schools and colleges in higher education.5 Between 1907 and 1952, the foundation published a series of 52 bulletins, including ones specific to medicine and dentistry. In 1910, Abraham Flexner completed Bulletin Number Four, outlining the reform of medical education,6 and in 1926, William J. Gies complet21

ed Bulletin Number Nineteen, establishing the importance of dentistry as a healing science and an essential component of higher education in the health professions.7 These reports provided the foundation for our modern siloed educational systems in healthcare, with a continued separation of educational delivery, accreditation, and organizational structures behind medicine, dentistry, pharmacy, nursing, physician assistant, and other specialties. More recently, there has been a growing movement and understanding of the importance of bringing together our professions to improve outcomes for individuals seeking care and for the entire healthcare delivery ecosystem. The Interprofessional Education Collaborative (IPEC) was formed in 2009 with the support of six national education association members. The World Health Organization framed the importance of interprofessional education and collaborative practice in 2010.8 IPEC released its first set of interprofessional education core competencies in 2011. The National Institutes of Health furthered the conversation around the importance of interprofessional learning in 2015, sharing a conceptual model for an interprofessional learning continuum that encompasses foundational, graduate, and continuing professional development.9 This framework established the importance of bringing the professions together from education to practice. Then, IPEC released version 2 of the IPEC core competencies in 2016 and version 3 in November 2023, endorsed by 22 member organizations across healthcare education.10 Summer 2025 Volume 91, Number 4

How Can We Go Far Together in Healthcare Education and Training? Nader A. Nadershahi, DDS, MBA, EdD

With this evolution over the years, the higher education community appears to have developed a shared understanding and set of values. This responsibility for interprofessional training and education is reflected in current accreditation standards across most disciplines, which include language to support and encourage interprofessional training for students. These collaborative opportunities currently exist in didactic, simulation, clinical, and community service-learning settings. In September 2024, the American College of Dentists convened a summit of thought leaders from across oral healthcare to discuss the theme of “Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare.” During this program, one of the key pillars of discussion was education and training. Participants in this group reflected on where we have been and where we are currently to create a vision of where we may be going. The discussion began with a definition of the core focus of shared work for oral health and broader health education: fostering a holistic approach to healthcare education by integrating medical and dental training across all levels, including predoctoral and postdoctoral programs and continuing education. This framework encourages both intra- and interprofessional collaboration to enable effective community outreach. Then the focus shifted to a statement of purpose for this education and training pillar in breaking down silos. The purpose of this pillar is to integrate health professions’ training and encourage collaboration between healthcare professionals to improve patient care, community engagement, health outcomes, and provider satisfaction. This approach addresses social determinants that affect health, increases communication and respect among professionals, and builds trust with society while making health professions training more affordable. By overcoming chalJournal of the American College of Dentists

lenges such as financial barriers and clarifying practice roles, dental professionals will be better equipped to deliver effective, team-based, person-centered care. Next, the group shifted focus to why this work is important and impactful. The following list outlines the summary of the “why”: •

Enhances patient health and care efficiency, boosting health outcomes and satisfaction

•

Helps mitigate social determinants of health like transportation barriers, improving access to care

•

Increases patient trust in healthcare systems and reduces costs for patients and providers

•

Promotes interprofessional collaboration, enhancing mutual respect, communication, and understanding across professions

•

Supports provider satisfaction, knowing patients receive person-centered care

•

Advances professional development and enhances learning opportunities

Finally, the summit participants focused on a series of recommendations and next steps for our broader healthcare and healthcare education community. The hope is that this work will serve as a catalyst for partners from across our healthcare disciplines to define and champion these opportunities, aligning with their vision and understanding. 1. Increase postdoctoral education standards within residencies, fellowships, and continued education. 2. Explore solutions notwithstanding financial barriers. 3. Define the scope of practice, eg, clarifying if dentists can administer vaccines.

This conversation and discussion represent small steps in a long journey to improve equity, access, and outcomes in the US healthcare system. Although the summit participants were primarily from the oral healthcare profession, it was clear that this work needs to be completed with partners and collaborators from across all healthcare disciplines. 4. Expand screening and preventive care protocols, such as HPV vaccination. 5. Facilitate medical and dental student interprofessional, hands-on/in-person experiences. 6. Advocate for supportive policies with licensing bodies and legislators.

The group discussed the importance of communication, beginning with this white paper, focusing on engaging relevant partners in years 2 and 3, then beginning advocacy efforts in year three.

7. Increase the confidence of all allied provider types to collaborate.

The parties responsible for working together to achieve these recommendations may include:

The pillar group focused their work on suggested next steps, a timeline, and responsible parties to engage in the work.

•

Interprofessional Education Collaborative (IPEC)

•

Federation of Associations of Schools of the Health Professions (FASHP)

Research: Gather existing interprofessional education (IPE) resources, metrics, and standards across all health professions that have already been developed.

•

Organized professional groups

•

Government and nongovernment healthcare services

•

Patients and community partners

YEAR 2

•

Funders

YEAR 1

Evaluate: Evaluate existing accreditation standards for all health professions and recommend revisions to standards to facilitate interprofessional experiences.

YEAR 3 Educate: Educate to share the value of IPE and develop communication strategies to engage communities of interest, including patients. Implement: Recommend new collaboration opportunities within the existing healthcare curricula and continuing education, such as developing a pilot program that models IPE.

Advocate: Encourage state licensing boards to require the inclusion of IPE-related content in multi-professional healthcare continuing education.

This conversation and discussion represent small steps in a long journey to improve equity, access, and outcomes in the US healthcare system. Although the summit participants were primarily from the oral healthcare profession, it was clear that this work needs to be completed with partners and collaborators from across all healthcare disciplines. We have spent a great deal of time moving fast and have made some good progress in healthcare, but if we want to truly go far with the impact and outcomes that are shared by our colleagues and community, we must do it together.

Summer 2025 Volume 91, Number 4

How Can We Go Far Together in Healthcare Education and Training? Nader A. Nadershahi, DDS, MBA, EdD

REFERENCES 1. History of medicine. Wikipedia. Accessed April 30, 2025. https://en.wikipedia.org/wiki/History_of_ medicine. 2. Coppa A, Bondioli L, Cucina A, et al. Early Neolithic tradition of dentistry. Nature. 2006;440(7085):755-756. doi:10.1038/440755a. 3. Royal College of Physicians. John Morgan and the first medical school in America. Published 2020. Accessed April 30, 2025. https://history.rcp.ac.uk/blog/john-morgan-and-first-medical-school-america. 4. University of Maryland School of Dentistry. History. Accessed April 30, 2025. https://www.dental. umaryland.edu/about/history/. 5. Carnegie Foundation for the Advancement of Teaching. Foundation history. Accessed April 30, 2025. https://www.carnegiefoundation.org/about-us/foundation-history/. 6. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. Carnegie Foundation for the Advancement of Teaching; 1910. 7. Gies WJ. Dental Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 19. Carnegie Foundation for the Advancement of Teaching; 1926. 8. World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. WHO/HRH/HPN/10.3. World Health Organization; 2010. 9. Institute of Medicine. Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. National Academies Press; 2015. doi:10.17226/21726. 10. Interprofessional Education Collaborative. IPEC Core Competencies for Interprofessional Collaborative Practice: Version 3. Interprofessional Education Collaborative; 2023.

Journal of the American College of Dentists

PERSPECTIVE

Daniel Pihlstrom, DDS Chief Dental Officer Permanente Dental Associates, P.C.

Daniel Pihlstrom, DDS, is chief dental officer of Permanente Dental Associates (PDA). In this role, Dr. Pihlstrom oversees the quality agenda of the Kaiser Permanente Dental program, helping to ensure the organization’s 290,000 members receive patient-centered, integrated, value-based care.

Interprofessional Models of Care: A Strategic Framework for Advancing Integrated Healthcare

Dr. Pihlstrom has practiced general dentistry for over 20 years and has served in various leadership roles for PDA. During his career at PDA, Dr. Pihlstrom developed the Kaiser Permanente Medical-Dental Integration (MDI) program - incorporating licensed practical nurses, dentist-administered flu vaccinations, and medical care coordination into daily clinical practice. Dr. Pihlstrom is Affiliate Investigator at the Kaiser Permanente Center for Health Research and has contributed to numerous scientific publications on evidence-based dentistry and medical-dental integration, including the 2021 Surgeon Generals' Report on Oral Health in America. Dr. Pihlstrom graduated from the University of Minnesota with a Bachelor of Sciences in Biochemistry and received his dental degree from the University of Minnesota School of Dentistry in 2000. He completed a General Practice Residency at the Oregon Health & Sciences University and joined PDA in 2001. In 2019 he completed the Harvard Business School Executive Leadership Program.

Dr. Pihlstrom lives with his wife, three children, and the beloved golden doodle in Lake Oswego, Oregon.Daniel J. Pihlstrom, DDS

Summer 2025 Volume 91, Number 4

Interprofessional Models of Care: A Strategic Daniel J. Pihlstrom, DDS

Introduction

nterprofessional models of care (IPMC) provide a vital framework for improving the delivery of health services through the alignment of medical and dental protocols, integration of shared health data, and collaborative, team-based care. Drawing on both empirical data and theoretical models, this analysis explores how integrated care can become the norm rather than the exception.

Data from Kaiser Permanente Dental has shown that integrated care models are not only clinically effective but also cost-efficient. These models have demonstrated success in closing thousands of care gaps, particularly among older adults.1 To structure this discussion, the conceptual framework articulated by Valentijn et al is applied.2 This framework emphasizes the integration of care at the clinical (micro), organizational (meso), and system (macro) levels, supporting the delivery of person-centered care across the health continuum. The working group examined the barriers and opportunities for integration, drawing on both research and real-world examples. These include bidirectional models such as dental clearance for surgeries, fluoride varnish application during pediatric medical visits, immunizations administered in dental settings, and screenings for social determinants of health. These examples underscore the shared responsibility of dental and medical professionals in comprehensive patient care. Insight from the summit pillar presentation, small group discussions, and plenary sessions led to a statement of purpose, strategic approach, goals, and milestones focused on how the American College of Dentists (ACD) could promote IPMC. Journal of the American College of Dentists

Statement of Purpose: Build upon existing practice models to establish integrated, person-centered care that enhances awareness of, and cooperation with, diverse healthcare roles, including introducing students to interprofessional models of care to cultivate a sustainable interprofessional approach to patient care.

Why It Matters Integrated care represents a moral and systemic imperative. Fragmented care perpetuates inefficiencies, health disparities, and poor patient outcomes. By contrast, IPMC offers several advantages: •

Broadened Reach: Better addresses the diverse and complex health needs of various populations.

•

Elevated Role of Dentists: Increases public and provider recognition of dental practitioners as essential members of the healthcare team.

•

Improved Continuity of Care: Supports coordinated treatment and referrals between disciplines.

•

Stronger Patient Support Networks: Delivers more comprehensive and reliable care.

Strategic Framework for Advancing Interprofessional Models of Care Recognizing the multifaceted nature of integrating interprofessional care, the working group developed a strategic framework to advance sustainable models. The framework aims to address gaps in infrastructure, education, and policy while fostering collaboration across medical and dental disciplines. With a focus on long-term transformation, the strategies outlined below aim to move interprofessional models of care from isolated innovations to standardized practice across healthcare systems.

Through structural reform, educational alignment, and shared leadership, dentistry can serve as a vital force in transforming the delivery of care.

Summer 2025 Volume 91, Number 4

Interprofessional Models of Care: A Strategic Daniel J. Pihlstrom, DDS

Recognizing the multifaceted nature of integrating interprofessional care, the working group developed a strategic framework to advance sustainable models. The framework aims to address gaps in infrastructure, education, and policy while fostering collaboration across medical and dental disciplines. 1. American College of Dentists (ACD) as a Neutral Ground for Shared Learning The ACD serves as a convening space to promote dialogue, shared learning, and system-wide improvement. Through the Ethics Summit and similar initiatives, the ACD provides an unbiased platform for cross-disciplinary engagement.

2. Toolkit Creation to Support Adoption A practical toolkit should be developed to assist dental and medical professionals in transitioning to integrated care models. This toolkit would include sample protocols, referral templates, communication guidelines, and case studies that illustrate best practices in IPMC.

3. Promotion of Interprofessional Externships Clinical education should prioritize early exposure to interprofessional care. Development of externship opportunities in academic, nonprofit, and private settings—where dental and medical professionals collaborate in real time— would support this goal.

4. Shared Health Information Systems Access to integrated Electronic Health Records (EHRs) is essential. Seamless data exchange enables the real-time coordination of care.

5. Policy and Licensing Incentives Licensure and reimbursement policies should align with the goals of interprofessional care. Policy advocacy at the state and federal levels is necessary to incentivize the implementation of IPMC. Journal of the American College of Dentists

6. Supportive Infrastructure Development Billing, scheduling, education, and IT systems must be restructured to facilitate integration. The development of infrastructure that reduces administrative burden and promotes seamless interprofessional workflows is essential. The strategic framework outlined above offers a foundational pathway for achieving sustainable IPMC. To translate this vision into practice, it is essential to establish concrete, measurable goals that will drive implementation across educational, clinical, and policy domains. These actionable goals were developed through consensus during the Ethics Summit working group discussions and are designed to address the structural, educational, and systemic changes necessary to establish interprofessional models of care as a functional and enduring standard. The following strategies reflect a commitment to transforming healthcare delivery by embedding collaboration at every level of the patient care experience.

Actionable Goals for Implementation Goal 1: Promote IPMC as the Standard for Whole-Person Care •

Establish shared, outcome-focused care protocols that are easy to implement and evaluate.

•

Mobilize professional organizations to engage in interprofessional advocacy and education.

•

Engage the public through strategic marketing initiatives—using commercials, community surveys, and celebrity endorsements to build support.

Goal 2: Establish Learning Communities to Sustain and Expand IPMC

•

Utilize existing federal and state-level resources (eg, CMS) to increase access to IPMC services.

•

Promote continuing education (CE) for providers on how to access and use these systems.

•

Form a national advisory group to define the parameters and phases of IPMC implementation, tasked with: •

Defining IPMC with an emphasis on medical-dental integration.

• •

Timeline and Milestones •

Creating a framework for levels/phases of IPMC development.

Year 1: Convene a national advisory group and define the phases of IPMC development.

•

Designing and conducting a national survey to document and describe existing models

Year 2: Conduct a nationwide survey of existing IPMC models.

•

Year 3: Analyze survey data and launch a national IPMC learning community.

Design and execute a national survey to identify current interprofessional models in public, nonprofit, military, academic, and healthcare systems. Use survey insights to propose a formal, sustainable learning community committed to advancing IPMC.

Goal 3: Develop and Strengthen Supportive Systems •

Advance health information integration by developing a toolkit utilizing CDT/CPT codes to support integrated billing and data sharing.

•

Enhance care navigation by publishing resources to help providers and patients better coordinate across medical and dental systems.

In conclusion, as health systems grow more complex and patient needs evolve, the argument for integrated care becomes ever more compelling. Dentistry must transcend its siloed history and assume its rightful place within the broader healthcare continuum. Through shared infrastructure, coordinated protocols, and educational reform, interprofessionalism can be embedded at every level of practice. This session reinforced that interprofessional practice is no longer optional but necessary for meeting the healthcare demands of today’s populations. Through structural reform, educational alignment, and shared leadership, dentistry can serve as a vital force in transforming the delivery of care. The outlined goals and roadmap provide a strategic path toward full integration and lasting impact.

REFERENCES 1. Mosen DM, Banegas MP, Dickerson JF, et al. Examining the association of medical-dental integration with closure of medical care gaps among the elderly population. J Am Dent Assoc. 2021;152(4):302308. doi:10.1016/j.adaj.2020.12.010. 2. Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated care: A comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care. 2013;13:e010. doi:10.5334/ijic.886.

Summer 2025 Volume 91, Number 4

PERSPECTIVE

Breaking Down the Silo of Dental Reimbursement Ron Inge, DDS

Journal of the American College of Dentists

The result is a fractured system that limits the integration of care and perpetuates health disparities. Patients with diabetes, cardiovascular disease, and other systemic conditions benefit from coordinated dental and medical care. Yet, in practice, they encounter two isolated systems that rarely communicate, share data, or coordinate treatment.

ike it or not, reimbursement is at the heart of all actions and changes in our healthcare system. Several factors have contributed to the isolation of dentistry from the rest of the healthcare ecosystem, not the least of which is dentistry’s reliance on its own coding system. The American Dental Association (ADA) successfully established the Current Dental Terminology (CDT) codes as the official code set for submitting electronic claims. This action further solidified the separation of dentistry from the broader healthcare system. In recent years, the ADA has added CDT codes to reflect procedures previously limited to physicians, such as vaccines and immunizations. The irony of this action is that CDT codes, which are primarily used to describe the procedures provided, are only processed by dental insurance companies for reimbursement purposes. Yes, dental insurance companies are required to accept medical codes, such as ICD-10 codes, on a dental claim form. Unfortunately, there was no requirement for these codes to be used in the adjudication or payment of a dental claim.

Some insurance companies have integrated the submission of medical codes to identify patients for enhanced dental benefits. This type of integration is limited by dentists’ disuse of and/or knowledge to submit these codes. As the CDT code set expands to cover procedures normally covered under a medical plan, the expectation is that dental insurance companies should reimburse these codes. Herein lies the disconnectedness and the arrogance of dentistry. Dental insurance companies cover dental procedures. Dental insurance companies do not receive payment from employers to cover non-dental procedures. Yes, dental insurance companies do cover specific dental procedures that have been shown to benefit a patient’s overall health, but dental insurance coverage does not extend to services that are not specifically related to the teeth and the gums. The CDT codes used to report medical procedures performed by a dentist are not generally reimbursable under a dental plan. The result is a fractured system that limits the integration of care and perpetuates health disparities. Patients with diabetes, cardiovascular disease, and other systemic conditions benefit from coordinated dental and medical care. Yet, in practice, they encounter two isolated systems that rarely communicate, share data, or coordinate treatment. This fragmentation is ethically troubling and clinically inefficient. Summer 2025 Volume 91, Number 4

Breaking Down the Silo of Dental Reimbursement Ron Inge, DDS

Organized dentistry must mount a campaign to promote collaboration between dental insurance companies and medical insurance companies. Organized dentistry must engage with dental insurance companies for the patient’s benefit. Reimbursement cannot be the leading demand by organized dentistry.

The greatest barriers to integration are not scientific or clinical; they are economic and structural. Reimbursement systems that fail to reflect the interconnected nature of health send the wrong message: that dental care is less important, optional, or not worthy of inclusion in comprehensive care planning. This not only undermines the credibility of dentistry as a healthcare profession but also harms patients. During the Summit, the reimbursement work group reached a consensus on a purpose statement, which enabled them to develop actionable strategies to guide the future of medical-dental integration in this realm. The purpose of this pillar is to understand that patient-centered healthcare is primary to best promoting whole-person wellness, to developing ways and means for dentists to explore new avenues in which coordinated care can be delivered.

How can this be accomplished? Organized dentistry must mount a campaign to promote collaboration between dental insurance companies and medical insurance companies. Organized dentistry must engage with dental insurance companies for the patient’s benefit. Reimbursement cannot be the leading demand by organized dentistry. If the true mission of organized dentistry is to improve the health of the patients it serves, then organized dentistry must

Journal of the American College of Dentists

recognize that dental insurance is only a vehicle by which it receives payment for dental services. For change to occur, there must be a “win-win” outcome for both parties. “Win-win” is not measured by one side winning more than the other. “Win-win” should be measured by the benefits to the patient. Organized dentistry can support dental insurance companies to educate employers on the benefits to their employees (and to their bottom line) of integrating dental and medical care. If the employer does not see value in offering an integrated healthcare solution to their employees, it will not happen. Employers have the power to influence medical and dental plans to work together. The existing system of coding and reimbursement represents the most significant challenge. But not an insurmountable challenge. Crosswalks have been created to translate CDT codes into medical codes. Dentists must learn to bill medical plans for those medical services that are not reimbursed by dental plans. Organized dentistry should lobby medical carriers to recognize dentists as qualified healthcare providers, whether they are accepted as in-network or out-of-network providers. Using crosswalks for coding, dentists will be able to bill medical carriers directly. The importance of integrating dental care with medical care is not yet universally accepted. Many dentists are unaware of the benefits or are less interested in them due to a lack of reim-

bursement for medical services. Dental boards vary in their acceptance of dentists performing procedures that were previously reserved for physicians. The same is true for physicians. Campaigns must be targeted at the providers of care to facilitate the integration of care, ultimately benefiting the patient. Technology represents the greatest challenge and the greatest opportunity for integration. Currently, dental and medical systems at all levels are separate. Yes, some dental software has been developed to facilitate interprofessional practice. Most of these programs are used in Federally Qualified Health Centers (FQHCs). There are medical software systems that have incorporated a dental component into their platforms. Unfortunately, these solutions are proprietary and costly. With advances in technology, the ability to communicate across different systems and platforms is now a capability. The challenge is to effect change management across the user community. Resistance to change is the greatest barrier to moving forward. The specific action plan of this group included the following:

1. Communicate with Medical Carriers •

Initiate targeted discussions with major medical insurers to explore pathways for dentists to participate in disease management protocols.

•

Compile a prioritized list of CDT codes representing systemic health-related procedures provided by dentists, such as immunizations and sleep apnea appliances.

•

Advocate for these CDT codes to be recognized and reimbursed by medical carriers when performed within dentists’ scope of practice.

2. Communicate with Dental Boards •

Engage state dental boards to evaluate systemic-focused CDT codes and determine whether these procedures fall within the legal scope of dental practice.

•

Once defined, engage with state legislatures to draft supportive legislation promoting medical-dental integration.

•

Recommend the development of model guidelines and a toolkit for states to adopt consistent policies.

3. Communicate with CMS •

Collaborate with the Centers for Medicare & Medicaid Services (CMS) to develop methods of reimbursing integrated services (eg, blood glucose testing in dental settings).

•

Pilot demonstration projects that integrate dental services into CMS disease management protocols, with reimbursement frameworks to match.

•

Advocate for the inclusion of dental providers as reimbursable practitioners under broader CMS policies.

4. Communicate with Dentists •

Educate dentists on ACD’s vision for integration through professional journals (eg, American Association of Dental Editors and Journalists (AADEJ), webinars, CE courses, and social media campaigns.

•

Emphasize the clinical, ethical, and financial benefits of integration.

•

Provide training on medical coding and billing, as well as guidance on submitting claims to medical insurers.

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Breaking Down the Silo of Dental Reimbursement Ron Inge, DDS

5. Communicate with Physicians •

•

Partner with medical associations to educate physicians on dentists’ role in diagnosing and managing systemic disease. Develop collaborative protocols for comanaging patients, especially those with chronic diseases. Promote integrated care models where dentists and physicians share diagnostic responsibility and contribute equally to patient health outcomes.

Timeline for Implementation Year 1: Focus on Strategies 1 and 2 (Medical Carriers and Dental Boards). •

Begin dialogue with insurance carriers.

•

Engage dental boards across states to assess and expand the scope.

•

Run these strategies in tandem with outreach to CMS (Strategy 3).

Years 2-3: Launch Strategies 4 and 5 (Outreach to Dentists and Physicians). •

Expand educational initiatives.

•

Formalize communication toolkits.

•

Initiate joint projects with physician groups.

Journal of the American College of Dentists

Responsible Parties Strategy 1: Chief Medical Officer, Council on Dental Benefits, Professional Relations Officers. Strategy 2: American Association of Dental Boards (AADB), Council on Dental Education and Licensure (CDEL). Strategy 3: CMS, Chief Dental Officer. Strategy 4: ACD, ADEA, AADEJ, Dental Schools, CE Providers. Strategy 5: Chief Medical Officer, American Society of Medical Ethics, Interprofessional Education Leaders. In summary, change happens incrementally. First, as healthcare professionals, we must speak with one voice on the benefits of integrating dental and medical care for the benefit of our patients. We must educate healthcare professionals at every level on the benefits of collaboration and establish communication channels that enable patients to understand they are at the center of their own healthcare. As more and more healthcare professionals push the limits of collaboration, change will occur across all segments of healthcare delivery. By reimagining reimbursement as a vehicle for collaboration rather than division, we can begin to close the gaps that undermine health outcomes. This will require courage, creativity, and a steadfast commitment to the principle that the mouth is part of the body, and that oral health is essential to overall health and well-being.

PERSPECTIVE

The Role of Research in Fostering Dentistry’s Partnership in Healthcare Scott L. Tomar, DMD, DrPH

n 2000, the landmark report Oral Health in America: A Report of the Surgeon General highlighted the magnitude of oral health disparities in the country and emphasized the importance of oral health for overall well-being, calling for a health infrastructure that effectively integrates oral health into overall health.1 More than two decades later, dental and oral diseases remain prevalent among parts of the American population,2 key strategies for disease prevention are under attack, and dentistry remains largely isolated from the rest of the US healthcare system. While many factors need to be addressed to change that status, it is widely recognized that research plays an integral role in reducing the burden of disease, eliminating oral health inequities, and supporting the transition to a more integrated healthcare system. Indeed, “Integrate Oral and General Health” was the first strategic priority in the 2021-2026 Strategic Plan of the National Institute for Dental and Craniofacial Research.3

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The Role of Research in Fostering Dentistry’s Partnership in Healthcare Scott L. Tomar, DMD, DrPH

In Part I of its meeting during the summit, participants in the Research pillar reflected on the core focus of the group, articulated the key reasons they felt that research is critical for medical-dental integration, developed a purpose statement, and created an outline of an approach to achieve its purpose.

There is widespread recognition that additional research is needed to support the development of evidence-based clinical guidelines that can be incorporated into medical and dental practice, as well as to examine the impact of medical-dental integration on health and economic outcomes. Of course, such investigations require an appropriately trained and competent research workforce. Research was one of the key pillars at the September 2024 Ethics Summit of the American College of Dentists, Breaking Down the Silos: Dentistry’s Ethical Responsibility as a Partner in Healthcare. In Part I of its meeting during the summit, participants in the Research pillar reflected on the core focus of the group, articulated the key reasons they felt that research is critical for medical-dental integration, developed a purpose statement, and created an outline of an approach to achieve its purpose. The group defined its core focus as determining the current gaps in understanding the benefits of medical and dental integration. The Research Group then articulated the main reasons it felt research was important in this context: (1) to streamline research information to improve access to research data, increase awareness, and empower patients in a community-driven partnership; and (2) to educate citizens of the research community and public servants on change expectations around oral health. The Purpose Statement of the Research pillar was:

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(I) To generate evidence through qualitative and quantitative methods that support policy and translation/implementation through transdisciplinary, collaborative approaches; and to create systems and data that are equitably available, intraoperative, standardized, and structured. (II) To promote interventional research efforts that benefit from the expansion of methodological expertise, including social science, health policy research, economics, and data science. (III) To have whole-person, culturally competent research that captures upstream factors with data that can be disaggregated to capture disparate populations. The outline of the approach that was articulated in Part I was: •

Recruit experts to train dentists from outside fields, including health/policy experts, computer scientists to centralize data, social scientists, and engineers.

•

Democratize data and standardize data collection by, for example, having a validated question bank.

•

Include qualitative and quantitative data representing all populations across all studies.

•

Build a transdisciplinary team with representation of different professions and identities.

In Part II, the Research pillar developed measurable and achievable goals and described strategies to achieve them. For each goal, the participants identified the responsible parties, developed a timeline, and outlined a communication plan.

•

Build campaigns around public health to engage with underserved communities.

•

Use multiple systems for data, including large language learning models.

•

Compare medical outcomes for people in research studies with integrated systems (medical/dental) and non-integrated systems.

Goal 1. Create a framework on how to approach interprofessional whole person-centered care and to identify/prioritize research gaps. •

•

Convene all healthcare stakeholders to build partnerships that will support an evidence base for better health and overall wellness to enable policy change to have better educational, healthcare, and financial systems. Bring in data informatics, health policy, public health, education, and big national campaigns for oral health awareness.

Responsible Parties •

Federal agencies: National Institutes of Health (NIH), Centers for Disease Prevention and Control (CDC), Centers for Medicare & Medicaid Services (CMS)

•

Dental and interprofessional societies such as American College of Dentists (ACD); Santa Fe Group; National Academies of Science, Engineering, and Medicine (NASEM); American Academy of Pediatrics; American Dental Association (ADA); American Medical Association (AMA)

•

Stakeholders for feedback (health systems, payors, patient advocates, community members)

Timeline Year 1: ACD Summit and convene NASEM. Year 2: Work on cross-cutting federal initiatives, intra-institutional collaboration at NIH, stakeholder feedback and response, and a conference on research gaps using this framework as a guide. Year 3: Notices of special Interest or funding opportunity announcements focusing on addressing research gaps.

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The Role of Research in Fostering Dentistry’s Partnership in Healthcare Scott L. Tomar, DMD, DrPH

Communication Plan •

Work to amplify conference proceedings, including publishing in peer-reviewed literature.

•

Make the framework widely available and include it as part of a research data hub.

•

Disseminate funding opportunities for broad engagement.

Goal 2. Increase availability of data: create a standardized question bank for various dental social determinants of health to have outcomes display data. •

Include data on mortality/morbidity of dental-originated issues across national records.

•

Include oral health outcomes in national survey instruments and use of centralized data repositories with common data elements.

Responsible Parties •

Federal agencies: CDC, NIH/National Institute of Dental and Craniofacial Research (NIDCR), Agency for Healthcare Research and Quality (AHRQ)

•

State policymakers

•

Hospital/hospice system representatives

•

Researchers

Timeline Year 1: • Create a Question Bank Task Force (QBTF) with cross-sectional areas of expertise and broad perspectives. •

•

Raise awareness of the necessity of including dental-related morbidity and mortality data (begin conversations with stakeholders). Complete the QBTF-suggested question bank.

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Year 2: • Approach CDC (National Health and Nutrition Examination Survey) and AHRQ (Medical Expenditure Panel Survey) to include the suggested QBTF question bank for utilization in the next survey cycle. Year 3: • December 2027: One state system per region accurately incorporating dental-originated morbidity and mortality data across state records. •

Communication Plan

•

QBTF to publish a commentary on the creation of the suggested question bank.

•

Outreach to CDC and AHRQ to include suggested questions for inclusion in national surveys.

Goal 3. Prioritize interoperable data: Build a language learning model (LLM) to develop tools and algorithms that would standardize data elements from disparate sources and implement diagnostic codes. Responsible Parties NIH, CDC, CMS, and other potential collaborators that can handle large data sets.

Timeline •

Year 1: Gather available data that includes partnerships with NIH institutes and other organizations that could have both medical and dental data.

•

Clinically, push for integrated claims data.

•

Identify partnerships for conducting LLMs to standardize the data and create a data dictionary across all sources.

Year 2: • Create a repository for all types of data, which includes claims, clinical, and pharmaceutical data. •

Work to de-identify the data and have a safe storage space.

Year 3: • Start implementing LLMs with partnerships.

Year 3: • Dissemination strategies and identify research gaps.

•

Communication Plan

Year 4: • Synthesize research findings, obtain feedback.

•

NIH to identify potential collaborators across its institutes and dental organizations.

Communication Plan

•

Outreach to various health informatics specialists to understand data feasibility and resources needed.

•

ADA will invite researchers to participate in the development of clinical guidelines.

•

Goal 4. Identify and support clinical guidelines.

NIDCR will recruit researchers and other critical partners such as CMS, NIH institutes, AAP, AMA, and NASEM to ask good questions.

•

Identify dissemination strategies to reach the medical and dental communities.

•

Develop translational research strategies.

•

Collect large data sets—including public, private, and out-of-pocket—to use for effectiveness studies based on existing data. Conduct interventional trials to identify and support evidence-based clinical guidelines for dentistry and medicine.

Responsible Parties •

Federal agencies: NIH, CDC, CMS

•

Professional organizations: American Dental Association, American Medical Association, others

•

Patients and community representatives

Timeline Year 1: • Prioritize needs based on an environmental scan of available evidence and guidelines, including US Preventive Services Task Force, Cochrane Reviews, Guide to Community Preventive Services, NIH/NIDCRfunded grants, ADA guidelines, and CMS implementation and payment. 39

Year 2: • Develop guidelines based on available research.

Goal 5. Target research workforce: Grow the dental research profession and promote career opportunities to broaden perspectives in middleschool/high-school students to support and sustain current DDS/ PhD students and school faculty. Responsible Parties •

NIH/NIDCR, Oral Health Pathway Taskforce, American Association for Dental, Oral, and Craniofacial Research (AADOCR), Science Educators Association

Timeline Year 1: • Partner with responsible parties to define materials to be used to promote research as a career option. Summer 2025 Volume 91, Number 4

The Role of Research in Fostering Dentistry’s Partnership in Healthcare Scott L. Tomar, DMD, DrPH

Communication Plan •

Dissemination of existing training grants to increase awareness of their existence.

The work of the Research pillar represents an initial step of one key component in the move toward greater integration of oral health into the US healthcare system. As described in ACD’s 2022 white paper, Healthcare Integration through an Ethical Lens,4 the dental profession has an ethical obligation to close the medical-dental divide, which would lead to better patient outcomes and a healthier population. Recognizing that the dental profession itself may be a major barrier to that integration, the summit intentionally focused on the internal discussion within various segments of the oral health

community. Operationalizing this initial research agenda will help to build the evidence base on how to move forward with that initiative. Clearly, advancing the research agenda will require leadership, partnership with key allies, and funding, but perhaps most of all, it requires a commitment by the dental profession to embrace change.

Acknowledgments The summit organizers would like to acknowledge the tremendous contributions and leadership of Jennifer Webster-Cyriaque, DDS, PhD, Acting Director of the National Institute of Dental and Craniofacial Research. Dr. Webster-Cyriaque delivered a keynote address at the summit and served as leader of the Research pillar.

REFERENCES 1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2000. Accessed June 11, 2025. https://www. nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf. 2. National Institutes of Health. Oral Health in America: Advances and Challenges. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021. Accessed June 11, 2025. https://www.nidcr.nih.gov/research/oralhealthinamerica. 3. National Institute of Dental and Craniofacial Research. NIDCR Strategic Plan | 2021-2026. Bethesda, MD: National Institutes of Health, National Institute of Dental and Craniofacial Research; 2021 (updated 2025). Accessed June 11, 2025. https://www.nidcr.nih.gov/sites/default/files/2022-01/NIDCR-Strategic-Plan-2021-2026.pdf. 4. Cadra ME, Mays KE, Pachuta SM, Raimann TE, Roucka TM, Tomar SL. Healthcare integration through an ethical lens: A white paper prepared by a subcommittee of the Board of the American College of Dentists. American College of Dentists; 2022. Accessed June 11, 2025. www.dentalethics.org/ wp-content/uploads/2023/11/final-paper-healthcare-integration-2022_08_08-1.pdf.

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Copyright © 2017 by Mary Otto. This excerpt originally appeared in Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, published by The New Press. Reprinted here with permission.

Summer 2025 Volume 91, Number 4

Preface

Aida Basnight stood on a wintry street corner in downtown Washington, D.C. She was dressed in a bright, hand-knit hat and scarf and a heavy coat. She was working to sell a newspaper produced by the city’s homeless. There was solemn beauty in her dark eyes, in her high cheekbones, in her smooth skin, but she was careful to smile with her mouth closed. Her missing teeth bore testimony to her life’s hardships. Her molars had been the first to go. She lost them to infection in her thirties when she was working as a secretary in Chicago. She woke up in terrible pain with a swollen face, and the molars were extracted. Amid other difficulties, other teeth went bad. When she was in her mid-fifties she lost a steady job working with computers. Then she fell behind on her rent and lost her home. She slept in a park for a while. “It’s really scary being out there in the street and being homeless,” she said. She eventually found help through a women’s supportive housing program. But Basnight, who always prided herself on her

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work ethic and skills, had been unable to find a lasting job, in spite of dozens of applications. “Nobody’s gonna hire you with that bunch of gaps in your teeth,” her elderly mother warned her. Basnight feared her mother was right. “I always feel self- conscious about them in the interviews. I can’t smile because I’ve got no teeth.” She said she kept hoping for something better. But in the meantime she stood in the cold with her newspapers, facing the welldressed commuters. They hurried past her, toward the rush-hour trains. Shame is common among the millions of Americans who lack dental care. More than one out of three low-income adults avoids smiling, according to a Harris poll conducted on behalf of the American Dental Association in 2015.1 America’s social welfare programs continually emphasize the importance of self-advancement, but, lacking dental care, the poor and working poor find it especially difficult to improve their lives. In the competition for service jobs, working at restaurants or retail counters or reception desks, they are often passed over. “Unless they look good, you don’t want to hire them,” observed dentist Judith Allen, who spends her days working with poor and uninsured patients in a city health department clinic in Cincinnati, Ohio. When patients get to Allen they are often in pain. Their lips and even eyes may be swollen by oral infections. Their teeth are diseased and ruined. Many have gone for so long without dental care, extraction is the only option. “We remove what we can’t save. And then we go in and we restore what we have left.” Without her help their teeth will continue to mark them as broken people. And across the country, millions go without help. There is a shortage of places like the Cincinnati clinic where Allen works. Stigma is an ancient word: a brand or mark of subjection or disgrace. In the way that they disfigure the face, bad teeth depersonalize the sufferer. They confer the stigma of economic and even moral failure. People are held personally accountable for the state

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vii

of their teeth in ways that they are not held accountable for many other health conditions. There has been a scarcity of sociological research on this subject, but a team of British researchers looked at the phenomenon. “Although tooth decay and gum disease involve diseased tissue, those experiencing these physical states are not generally regarded as being ill,” observed the author of their study. “In part, this may be because oral health problems are seen as a failure of individual responsibility rather than misfortune.” In the study, participants, who lost their teeth through disease and trauma, discussed their feelings. “It’s almost as if I feel as if I’ve failed because I’ve got dentures,” said one woman. “I don’t think people feel the same way about knee replacements, do they?” responded the researcher. “No, that’s right,” the woman said.2 For reasons including poverty, isolation, and the lack of private insurance and providers available to treat the poor, roughly onethird of the people living in America face significant barriers to obtaining dental care. Medicaid, the federal-state health program that now covers more than 72 million poor Americans, treats adult dental benefits as optional. It is up to states to decide whether to offer them. In hard times, coverage of even the most basic dental procedures often ends up on state chopping blocks. The young and the old also suffer. More than 35 million poor children are entitled by federal law to dental benefits under Medicaid, but about half go without care. Fewer than half the nation’s roughly one hundred fifty thousand working dentists participate in the program. Only a tiny fraction work in federally funded safety net clinics. Approximately 49 million Americans live in communities that are federally designated as dental professional shortage areas. Medicare, the federal health care program that currently provides benefits to more than 55 million aged and disabled people, has never included coverage for routine dental care. In the seventeenth century, French philosopher René Descartes introduced a theory that changed the world. He uncoupled the indivisible spiritual human mind from the divisible working

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machinery of the human anatomy, thus liberating scientific inquiry from religious dogma. He also, it could be said, removed the head from the body. In the wake of Descartes, increasingly specialized healers began laying claim to parts of the body for study and treatment. For centuries, along with shaving and tonsuring, leeching and cupping, barber surgeons had counted tooth extractions among the deeply personal services they performed. But the teeth were worthy of science too, Pierre Fauchard, the eminent eighteenth-century surgeon-dentist, insisted. He advanced the idea that dentistry was a unique and important branch of surgery. Cartesian dualism served its purpose, opening new possibilities for physiological exploration. Yet at the same time, medical research became more reductive and mechanistic, less personal and less holistic. Some have suggested that the formative influence of Descartes stubbornly persists in the ways the modern health care system fails to integrate care.3 Perhaps, too, it lingers in the gulf between the head and the body, the understanding of oral health and overall health. It has been said that this gulf must be bridged to bring a more complete kind of health to America. “Just as we now understand that nature and nurture are inextricably linked, and mind and body are both expressions of our human biology, so, too, we must recognize that oral health and general health are inseparable,” declared the then U.S. surgeon general David Satcher in his landmark report, Oral Health in America, published in 2000.4 In the ways they connect us to the world, in the ways they allow us to survive and to express ourselves, the teeth and other tissues of the mouth and face “represent the very essence of our humanity,” noted Satcher. Systemic health and disease are mirrored in the components of our saliva. Our first permanent molars bear the time stamp of our births. Pain, loss of function, serious illness, and even death result from untreated oral conditions and offer harrowing reminders that the mouth is part of the body and that oral health is essential to overall health. Yet the separate, carefully guarded, largely private

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system that provides dental care in America can be enormously difficult to reach for those without mobility or money or adequate dental benefits. In his report, Satcher warned of a “silent epidemic” of oral disease. This book began in 2007, at the heart of that epidemic, at the bedside of a Maryland schoolboy who was dying of complications from an untreated dental infection. The story of the death of twelve-year-old Deamonte Driver, which appeared in the Washington Post, helped inspire reforms in Maryland and in Medicaid dental systems nationwide. But America’s silent epidemic of oral disease persists. This book provides a look into the insular world of dental care in America. It examines the enduring tension between the need of all Americans for dental services and the lack of services available to millions of us under the current system. Beginning with the world’s first dental college that opened in Baltimore in 1840, not far from where Deamonte died, this book explores dentistry’s evolution in isolation from the rest of the nation’s health care system. Its narrative seeks to explain why obtaining dental services may require a journey that some patients never manage to make. My reporting took me from Florida to Alaska, and in my travels, patients, providers, policy makers, researchers, and public health leaders spoke of their own experiences, their own journeys. Their stories were by turns agonizing, challenging, confounding, and hopeful. They described the raw physical suffering of disease and exquisite moments of understanding. They explained the intricacies of enormous government programs, the hidden worlds of microbiology, the vagaries of diagnostic coding. Some proudly defended the current system of providing dental care in America. Some described a vision for a transformed oral health care system— one that incentivizes disease prevention over drilling, that uses new kinds of teams to reach the millions currently not receiving oral x PrEfACE health care, a system where dentists spend less time extracting and more time healing and where patients break the cycle of disease and pain and loss. Some spoke of bridging the gap between oral health and overall health. Some spoke of ending the silent epidemic. Journal of the American College of Dentists

STUDENT PERSPECTIVE

A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

Summer 2025 Volume 91, Number 4

A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

n my preparations to attend the ACD Ethics Summit in Rockville, Maryland, this past September, I discussed my brief absence from the clinic with a group practice leader. “I’ll be helping make sure the event on medical-dental integration runs smoothly,” I told him. “On what?” “Medical-dental integration,” I replied, confused, expecting the topic to be ubiquitous among dental professionals, especially those in academia and organized dentistry.

“I have no idea what that is,” the doctor told me bluntly, as was his modus operandi. He expressed support for my involvement in the event (he generously supports student involvement in organized dentistry), though he was unsure about the scope of the summit. Unfortunately, the many facets of medical-dental integration have been discussed in a piecemeal fashion, with researchers and advocates highlighting one aspect after another, creating a mosaic that focuses on one specific problem or solution. What comes to mind are sights of faculty lectures about making well-written medical consults; public health initiatives to improve access to in-hospital dental care, especially for pediatric cases under general anesthesia;1 articles about dentists administering vaccines in light of efforts during the COVID-19 pandemic;2 near-daily Facebook arguments about inadequate insurance reimbursement and whether this should mimic medical reimbursement or every dentist should simply be fee-for-service; dentists/dental specialists on social media offering purely correlative research articles as evidence for the oral ecosystem’s effect on other organ systems; and conversations amongst classmates and peer medical students making light of deep concerns about our student loan balances. Here is what made the summit exciting: Some of

Journal of the American College of Dentists

the brightest minds from diverse organizations across the nation were to further conversations on medical-dental integration, culminating in actionable strategies. These strategies would be overarching and grounded in discussions of ethics. My clinic absence would be worth it. In the months leading up to the summit, I made an effort to prepare myself as thoroughly as possible. I would read research articles, blogs, legislative reports, and other relevant materials to avoid embarrassment in conversations with the leading thinkers with whom I would be interacting. In an attempt to settle my anxieties, one younger doctor who is heavily involved in organized dentistry told me that these sorts of summits involve lots of ideas being shared yet rarely result in meaningful progress—and that afterwards, despite this, the attendees would pat each other’s backs for a job well done. Regardless, I could still learn from the discussions. At a minimum, I was eager to meet my fellow SPEA students from the University of Maryland, Benjamin Hung, Jessica Martin, and Emily Nguyen, as well as my Marquette University peer, Jackson Bickford. During the planning stages, we were eager for the summit. We would at least engage with leading thinkers and, at most, contribute to society by helping to streamline the creation of actionable strategies.

Planning for the summit included many Zoom meetings with both the ACD Planning Committee and the SPEA team. We had the idea of creating a survey for attendees simply as an attempt to understand their perspectives beforehand. The following statements were asked on a casual, non-rigorously tested Likert scale. Parenthetically is what the average attendee responded. 1. Accreditation standards promote an integrated healthcare system. (Average is split.) 2. Non-dental health workers are trained to identify oral health-related conditions. (Average disagrees.) 3. Oral healthcare providers are trained to identify chronic medical conditions and work collaboratively with their medical colleagues. (Average is split.) 4. Current education and continuing education systems adequately incorporate inter- and intra-professional training to prepare students for an integrated and collaborative healthcare system. (Average disagrees.) 5. Current medical-dental integration (MDI) healthcare delivery models improve overall patient outcomes. (Average agrees.) 6. Current MDI healthcare delivery models adequately promote teamwork between dental and medical professionals while fostering the team dentist’s professional growth. (Average disagrees.) 7. I see and understand how a dental practice could evolve from its current model into a more interprofessional practice model. (Average agrees.) 8. I am aware of efforts to integrate medical and dental interoperable electronic health record data. (Average agrees.)

9. Current national efforts for data acquisition, the promotion of observational data studies, and community engagement with organized and managed data will elicit an ideal integrated healthcare system. (Average is split.) 10. Sufficient evidence exists that supports how preventive and diagnostic treatments for highrisk populations can be cost-effective. (Average agrees.) 11. A dental benefit should be added to Medicare, and it should be included in Part B. (Average agrees.) 12. Under the status quo of dental delivery and policies, rules, and regulations, the following goals can plausibly be aligned: unified metrics of treatment quality, new provider types (eg, dental therapists/hygienists), and dental code utilization. (Average disagrees.) 13. Current reimbursement models elicit an ideal integrated healthcare system that aligns with patient needs and private practice viability. (Average disagrees.) 14. Medical plans should cover services provided in a dentist’s office. (Average agrees.) (Split averages occurred within a 10% margin; agreements had more than a 30% margin.) In open-ended questions, attendees identified key barriers for dentists to submit claims to medical carriers as coding and billing complexities, a lack of integration between dental and medical systems, and administrative challenges. They mentioned limited coverage and dentists’ unfamiliarity with medical claim processes as barriers. Respondents also saw value in medical services such as taking blood pressure, HbA1c testing, etc. for patient-centered care and risk assessment. Some believed dentists are qualified to provide these services, while others pointed to the time and resources needed as prohibitive.

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A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

“ Placing oral health’s importance within the context of other organ systems is flatly unnecessary. It is not that “oral health is vital to overall health,” “a healthy mouth is the gateway to a healthy body,” or “your mouth is a mirror of your overall health”; it is that oral health’s importance is intrinsic.” –paraphrased from Dr. Lisa Simon

Admittedly, this survey accentuates the mosaic-like idea of medical-dental integration. We instead wanted to focus on an overarching exploration of dentistry’s ethical responsibility as an integral partner in the larger healthcare ecosystem. Even so, the survey does point to some general themes amongst summit participants. These themes presented themselves during lively discussions that later ensued. When I arrived at the summit, I felt a mix of nervousness and awe. Every attendee was kind and fully present, eager to participate in learning and discussion. Dr. Lisa Simon’s opening keynote was particularly impressive. I had been exposed to her work surrounding the complexities of the medical-dental divide when I entered dental school,3 and I was eager to meet her. She did not disappoint. After weaving key points of the history of oral healthcare in America, she presented a jarring notion: Placing oral health’s importance within the context of other organ systems is flatly unnecessary. It is not that “oral health is vital to overall health,” “a healthy mouth is the gateway to a healthy body,” or “your mouth is a mirror of your overall health”; it is that oral health’s importance is intrinsic. As an incoming periodontics resident, I felt particularly exposed. Dr. Simon presented snippets of research suggesting that evidence regarding the impact of periodontitis or its treatment on mortality risk in kidney disease patients, the prevention of cardiovascular disease, and rates of preterm birth, low birth weight, or fetal growth restriction Journal of the American College of Dentists

can be characterized as “not reliable,” “inconclusive,” and “of low certainty.”4-6 Further, evidence from studies on glycemic control and periodontitis treatment—often purported as key for patients with diabetes mellitus to receive periodontal treatment—was, at most, “moderate.”7-8 I am not yet a periodontist resident, and I do not claim to be an expert on correlative research between periodontal disease and systemic diseases. Nor do I yet make any claim about knowing what evidence doctors would describe as clinically relevant. However, I am aware that such claims are often made to the general public, either on social media or in person. Based on Dr. Simon’s address, it may not be the best approach to convincing our patients that oral health matters. When I was going through school, the mental health advocacy community urged legislators and lay alike that “mental health matters.” Dr. Simon pointed out this fact and urged the summit attendees to ground discussions in ethics. Those discussions and their strategies were held and devised within the four “pillars” of the summit: Education, Interprofessional Models of Care, Research, and Reimbursement. The discussions in most ways resembled concerns shared by me, the SPEA team, and other dental students with whom I interact. She closed with the statement (which may go viral on social media at some point, judging by the number of attendees taking photos of her lecture slide), “Dental care is healthcare, and healthcare is a human right.” 50

Education When entering discussions, attendees expressed concern about inadequate training for both dental and non-dental providers in identifying and collaborating on systemic conditions. They also expressed skepticism about whether current education systems and accreditation standards are preparing the workforce for integrated care. Dr. Nader Nadershahi of the University of the Pacific led the Education pillar. It primarily focused on interprofessional education (IPE) as a means to empower patients through a community-driven partnership between oral healthcare and other healthcare systems. The University of the Pacific is already empowering its community through a new academic and clinical collaborative facility that combines dental, mental, and behavioral healthcare. This idea was particularly exciting for SPEA student Benjamin Hung, who observed and synthesized this group’s discussions over the two-day summit. The idea of a physical IPE facility may be new to students, even if dental schools are required to incorporate some level of IPE. A possible benefit of such a facility might be to fill the void of something I believe is often overlooked in current IPE models: peer socialization. At Marquette University, we have the Medical College of Wisconsin and the University of Wisconsin, Madison, as our closest medical school neighbors. While we do interact with other Marquette University nursing, physician assistant, and behavioral health students, we have very minor academic events with medical students. I know that my experience may not be universal for other schools that perhaps share classes with our medical colleagues during early dental school. Nevertheless, peer socialization fosters cooperation and respect in future patient-centered interactions and should be a common practice in all IPE programs. Peer socialization can occur in various ways. The University of Minnesota, for example, has a large yearly social event between its medical and law schools.

Might this event be an immediately deployable opportunity (low-hanging fruit) for dental schools to mirror and, in effect, increase peer socialization beyond academic settings? Whether through physical facilities or other events, educators should not disregard the social benefits of IPE.

Interprofessional Models Dr. Dan Pihlstrom of Permanente Dental Associates led the discussions on the Interprofessional Models of Care pillar. SPEA representative Emily Nguyen synthesized them. Summit attendees generally agreed that integrated models can improve patient outcomes. When I talked with her about the group’s discussions, I was struck by the number of systems involved that were important for change. Even IT systems such as electronic health records, payment, and referral management were principal factors in eliciting more interprofessional models. Urging dental organizations to front support, leadership, policy, and advocacy, including the idea that 100% of dental practice leaders and policymakers should participate in IPE care workshops, seemed optimistic yet appropriate. IPE was again discussed at the school level, with the aim of improving it through new facilities or externships at existing facilities, such as rural clinics or federally qualified health centers. The group saw IPE as a means to introduce incoming health professionals to interprofessional models of care. While I am not yet sufficiently informed about IT systems and relevant intra-organizational politics in current dental professional organizations, regarding the principle of improving collaborative care, I absolutely acknowledge its importance. I am a fervent advocate for significantly improving IPE with the intention of at least making interprofessional models of care more prevalent. I (and many other students who shadow) have seen firsthand the invaluable work that integrated clinics like Health Partners in Minnesota, for example, do for their communities. More students should reach Summer 2025 Volume 91, Number 4

A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

out to such clinics to shadow or work with them after graduation. Yet, I am hesitant about hastily bolstering IPE at the dental school level. A common complaint among dental school students and dentists is the perceived lack of clinical preparedness among students upon graduation. At Marquette, this view is not the norm—I believe that current Marquette graduates generally have great clinical readiness. Although adding more educational quotas within the same four-year period is inevitable, it also restricts the time available to achieve technical mastery. And while the goal of a DDS program is not technical mastery but, more broadly, oral healthcare delivery,9 adequate incorporation of additional externships or IPE opportunities absolutely must not diminish the quality or time of current clinical education. Students want to learn the best techniques and receive the best value for their incredible tuition rates so they may be optimally prepared to help our communities. The evolution of predoctoral education to drastically improve exposure to different interprofessional models is imperative, but it should be done with great regard for current or more rigorous clinical standards. Ever the optimist, I refuse to believe that they are mutually exclusive. Change here must therefore be cautious, well deliberated, and not so hasty as to disregard the desires of students (and their patients on the receiving end of care) to achieve technical mastery as deemed by their clinical instructors. It must carefully replace the already siloed general health curriculum within dental schools with meaningful, sustained engagement alongside other health professionals in integrated clinical environments.

Research SPEA representative Jessica Martin was exceptional in recording the involved, thorough discussions of the Research pillar group led by Dr. Jennifer Webster-Cyriaque of NIDCR. In many ways, all oth-

Journal of the American College of Dentists

er pillars are connected to Research. Their discussions led to clear, actionable goals that included creating a framework for how to approach interprofessional person-centered care, prioritizing dental and medical outcomes data, especially beyond correlative associations and delineating when oral interventions provide systemic benefit, and growing the research workforce. As a predoctoral student involved in research, I was particularly excited about the idea of promoting opportunities to students at the undergraduate, high school, and middle school levels. I notice an eagerness among predental student organizations, such as those at my alma mater, the University of Wisconsin, Madison, to learn more about and contribute to research. Even local programs, such as UW Health’s Health Occupations and Professions Exploration (HOPE) Program, which encourages underrepresented high school students to explore careers in various healthcare fields,10 may serve as conduits for enticing younger students to become involved in oral health research.

Reimbursement Jackson Bickford was the SPEA student who kept track of the animated discussions in the Reimbursement pillar, led by Dr. Ron Inge of 32Health, and who has many years of experience in the dental benefits industry. Attendees disagreed that current reimbursement structures support meaningful progress, citing policy and financial misalignments that instead lead to health disparities. Administrative and billing complexities hindering patient health progress were simplified by the group’s notion: “Dental procedures are medical procedures and should be reimbursed in the same way.” According to Dr. Inge, making changes in this pillar will be cumbersome yet essential to meaningful integration and the nurturing of the doctor-patient relationship.

The SPEA students noticed how student loan debt was so pervasive in side conversations that we almost wished it had its own pillar. The educational debt crisis is affecting all healthcare students, but especially dental and medical students.

Student Loan Debt The SPEA students noticed how student loan debt was so pervasive in side conversations that we almost wished it had its own pillar. The educational debt crisis is affecting all healthcare students, but especially dental and medical students. As a May 2025 dental graduate who deliberately selected in-state educational pathways and, for both predoctoral and residency training, the least expensive dental schools available, I am witnessing how educational debt suffocates young professionals’ abilities to maintain work-life balance, wellness, and career fulfillment, as Dr. Joshua Bussard describes in a recent JACD article.11 Dentistry, once celebrated as a profession combining service and financial stability, now feels increasingly compromised. A peer burdened by undergraduate and dental school loans recently stated they expect to repay student debt for the remainder of their life. Yet, among predental students, the lay public, and many senior practitioners, a persistent narrative suggests that high incomes will easily offset debt. This normalization of extreme indebtedness reflects another ethical concern: Students across dentistry and medicine are assuming liabilities exceeding $1 million without fully informed consent. Rarely is educational debt contextualized in accessible terms, such as monthly obligations surpassing standard repayments of $8,000 (this number is not made up) alongside taxes, rent, and basic living expenses. What does this mean for affording groceries, a doctor’s visit, or even child care? Consultants

suggest that new graduates must earn between $300,000 and $400,000 annually to meet rising economic demands.12 Dentistry and medicine are not siloed in this crisis. To address these challenges, current professionals must mentor pre-health students, engage with pre-health and high school student organizations, and advocate publicly for financial transparency and reform. These conversations must especially reach the public, whose understanding of healthcare’s realities will shape the future of healthcare systems.

Overall Perspective As a student, I find my perspective most closely aligned with discussions in the Educational and Interprofessional Models pillars of the summit, rather than in the Research and Reimbursement pillars. I wish this were not so. These pillars are intertwined, and a complete understanding of the profession demands engagement across all of them. The research articles, blogs, and legislative reports I initially read to become conversant sparked curiosities about this intertwinement that deepened after the summit. With an eagerness to learn, especially amid ongoing national politics, I am grateful to ACD for including SPEA students in these discussions and hope more dental organizations will create similar opportunities. Early exposure to the broader complexities of the dental profession shapes clinicians who are prepared not only to navigate clinical demands but also to uphold the profession’s ethical responsibilities.

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A Student’s Perspective on Breaking Down the Silos in Healthcare John Kerns, BS

REFERENCES 1. Children’s Health Alliance of Wisconsin. Wisconsin’s Roadmap to Improving Oral Health 2020-2025. Published January 28, 2019. Accessed April 28, 2025. https://www.chawisconsin.org/download/oralhealth-roadmap/. 2. France K, Faist M, Kost D, et al. Perceptions of the role of dentists in human papillomavirus and COVID-19 vaccinations: Results of a cross-sectional validated survey of adults. J Am Dent Assoc. 2024;155(10):871-880. doi:10.1016/j.adaj.2024.07.016. 3. Simon L. From exceptionalism to essentialism in dentistry. J Law Med Ethics. 2021;49(1):89-91. doi:10.1017/jme.2021.14. 4. Ruospo M, Palmer SC, Wong G, et al. Periodontitis and early mortality among adults treated with hemodialysis: A multinational propensity-matched cohort study. BMC Nephrol. 2017;18:213. doi:10.1186/s12882-017-0574-x. 5. Ye Z, Cao Y, Miao C, et al. Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis. Cochrane Database Syst Rev. 2022;10(10):CD009197. doi:10.1002/14651858.CD009197.pub5. 6. Michalowicz BS, Hodges JS, DiAngelis AJ, et al. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med. 2006;355(18):1885-1894. doi:10.1056/NEJMoa062249. 7. Engebretson SP, Hyman LG, Michalowicz BS, et al. The effect of nonsurgical periodontal therapy on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: A randomized clinical trial. JAMA. 2013;310(23):2523-2532. doi:10.1001/jama.2013.282431. 8. Simpson TC, Clarkson JE, Worthington HV, et al. Treatment of periodontitis for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2022;4(4):CD004714. doi:10.1002/14651858.CD004714.pub4. 9. Donoff RB, Simon L. To achieve oral health in America, dental education needs to evolve [published correction appears in J Am Dent Assoc. 2022 Nov;153(11):A8. doi:10.1016/j.adaj.2022.09.002.]. J Am Dent Assoc. 2022;153(8):731-733. doi:10.1016/j.adaj.2022.05.002. 10. Health Occupations and Professions Exploration (HOPE) Program. UW Healthcareers website. Accessed April 28, 2025. https://careers.uwhealth.org/health-occupations-and-professions-exploration-hope-program/. 11. Bussard J. Young dentist leadership: The future of oral healthcare. J Am Coll Dent. 2025;91(2):30-32. 12. Haskell BS, Keefe T. Changing private practice ownership guidelines: A response to increasing dental school debt. American College of Dentists. Published January 2023. Accessed April 28, 2025. https://www.dentalethics.org/wp-content/uploads/2023/01/changing-private-practice-ownershipguidelines-a-response-to-increasing-dental-school-debt.pdf.

Journal of the American College of Dentists

PERSPECTIVE

Leading the Way in Dentistry’s New Era: Integration, Wellness, and Respect Brett Kessler, DDS

s President of the American Dental Association (ADA), I’m reminded every day of how much this profession has given me, and how dentists have the power to give back.

Dentistry changed my life. It’s given me purpose, helped me rebuild from personal struggle, and inspired me to show up every day as a catalyst for positive change. That same spirit of renewal fuels my vision for where our profession can go next. That’s why I’ve focused my presidential year around three pillars: Promoting wellness, fostering a culture of respect, and reconnecting the mouth to the body. Each pillar is vital to the future of our profession—and to the well-being of everyone we serve.

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Leading the Way in Dentistry’s New Era: Integration, Wellness, and Respect Brett Kessler, DDS

Every day, we see where dentistry is too often left out—in the operatory, in our insurance denials, in the health policy debates. Our health systems have treated the mouth as separate from the rest of the body, marginalizing oral health as cosmetic or non-essential. Elevating Oral Health in Primary Care As greater integration between primary care and oral health takes center stage, dentistry has a renewed opportunity to lead. And we are. Throughout my presidency, I’ve made it a priority to bridge the divide between dentistry and medicine. Every day, we see where dentistry is too often left out—in the operatory, in our insurance denials, in the health policy debates. Our health systems have treated the mouth as separate from the rest of the body, marginalizing oral health as cosmetic or non-essential. Consider this: In medicine, a patient with degenerative joint disease in the hip can receive a titanium replacement through their medical benefits. Yet, in dentistry, a patient cannot access the finest treatments the field has to offer, such as dental implants, to replace a missing tooth. If we applied the dental benefit model to medicine, patients needing hip replacements would only receive crutches, the equivalent of offering a flipper instead of a hip replacement. Why do we accept this? Why is walking more important than chewing? A healthy, functional, and aesthetically pleasing dentition is essential to overall health. We know this. Science backs it. Research1 from the ADA Forsyth Institute and the National Institute of Dental and Craniofacial Research has mapped out links between dental disease and systemic conditions like Alzheimer’s, diabetes, and cardiovascular disease.

Journal of the American College of Dentists

And yet, oral health remains largely absent from healthcare conversations on state and national policy, payment models, and primary care. This must change.

Reinventing the Care Model Most patients visit dentists for preventive care, whereas they see physicians when symptoms arise. That puts dentistry in a unique position to detect systemic conditions early, counsel patients on chronic disease risks, and help them lead healthier lives—practices already gaining traction in various settings. As a profession, we’re already screening for early-stage diabetes, airway disorders, and oral cancers. The science is clear: Periodontal treatment, for example, improves glycemic control.2 Oral cancer screenings save lives. Dentists are already on the frontlines of whole-person care. But we need a system that recognizes and supports this broader role. That means rethinking the care model that has long separated dentistry from medicine. It means payment reform that reimburses dentists not only when the drill is spinning, but also when it is not. It means embedding dental care in national prevention strategies. And it means treating the mouth as what it is: a gateway to the body. To support this shift, I’m excited to share that the ADA and the University of Pennsylvania School of Dental Medicine have collaborated to establish the ADA Living Guideline Program3—the first and only known living clinical practice guideline program

dedicated to oral health. This program equips dental professionals and patients with up-to-date, evidence-based recommendations as soon as new research emerges. It keeps care grounded in science and empowers providers, policymakers, and patients to make faster, more informed decisions. By translating research into real-time guidance, we’re not only supporting better care; we’re also providing policymakers with the tools they need to shape smarter health policy.

Leading With Purpose and Advocacy Advocacy is a core part of the ADA’s mission and why we’re working hard to ensure oral health is a national priority. With a new US presidential administration shaping its healthcare agenda, this is a pivotal moment for our profession to lead. In April, I had the honor of joining fellow ADA leaders at the White House to advocate for evidence-based oral health strategies to be included in the national healthcare agenda, focusing on prevention, nutrition, and chronic disease management. We emphasized key issues, including community water fluoridation, workforce development, and the need for funding to expand access to care. Our discussions also included perspectives from the ADA Forsyth Institute, the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services (CMS). Earlier this year, I also published an editorial in The Washington Post4 calling on federal leaders to prioritize dental insurance reform, disease prevention, workforce support, and oral health literacy. And we’re backing those priorities with action. The ADA is actively working on solutions to improve recruitment and retention across the dental team, especially in rural and underserved areas. This means addressing workforce shortages,5 expanding training opportunities, and ensuring that dentists, hygienists, and assistants have the neces57

sary tools and support to succeed. We’re also pushing for third-party payors, Medicaid agencies, and employer groups to cover preventive services that support lifelong health, such as fluoride treatments, dental sealants, and regular periodontal care.6 Equally important is an expansion of coverage to behavior modification consultations, such as tobacco and drug cessation, diet consultations, and oral hygiene instructions. Thus reducing the burden of disease, improving quality of life, and supporting medical-dental integration goals. At the same time, we’re defending community water fluoridation as a proven public health measure.7 As misinformation spreads, the ADA is working closely with state and local dental societies to protect access to fluoridated water as a safe and effective way to help prevent tooth decay, backed by over 80 years of proven research. On the innovation front, the ADA Forsyth Institute is driving breakthrough research, from stem cell mapping8 and tissue regeneration9 to precision diagnostics, and helping to bring evidence-based insights into national policy discussions in new and powerful ways. I’ve seen what this kind of advocacy can achieve. In Colorado, when I learned that more than one-third of residents lacked access to dental care, our state dental association took that data to the legislature and helped create an adult Medicaid dental benefit, which provided a dental home for 300,000 people who had never had one before. That’s what leading with purpose looks like. The ADA is at the forefront of dental benefits reform,10 ensuring that both public and private programs enable patients to access quality oral healthcare as part of essential healthcare. The ADA’s Council on Government Affairs is actively lobbying for adult dental Medicaid benefits federally and improved access for pregnant women, young children, and people with disabilities at the state level. Summer 2025 Volume 91, Number 4

Leading the Way in Dentistry’s New Era: Integration, Wellness, and Respect Brett Kessler, DDS

Our support extends to vital legislation like the Action for Dental Health Act of 2023, which aims to reduce disparities by providing dental homes to underserved populations and reducing emergency department visits through increased access to preventive oral healthcare. We’re also leading efforts to improve the private insurance landscape. Through dental loss ratio legislation, we’re pushing for greater transparency and accountability in dental plan premiums, aligning more closely with medical insurance standards. And we continue to advocate with states for a multitude of dental insurance reforms to improve the marketplace. We’re building bridges, too—forging partnerships across healthcare and government. We continue to meet with members of Congress, CMS, and the Department of Health and Human Services (HHS) to advocate for policy changes. And through events like our Dentistry’s Role in Complete Health symposium,11 we are bringing together dentists, physicians, public health experts, and educators to explore how dentistry can lead in this new era of integrated care.

Wellness and Respect: Foundations of Care Integration isn’t just about science or policy. It’s also about how we care for the people doing the work. Dentists are struggling. According to ADA’s 2024 trend report,12 more than 80% of dentists are experiencing major career stress. Many feel burned out, isolated, and overwhelmed by challenges like insurance reimbursement and workforce issues. I’ve been there myself, and I know how hard it can be to speak up.

ness,13 launched a peer-driven Wellness Ambassador Program, and connected members to state well-being programs. We’re also pushing to eliminate stigmatizing licensure questions that keep our colleagues from seeking help.14 At the same time, we’re working to create a more inclusive, respectful profession—one where every voice matters. That’s what my third pillar is all about: fostering a culture where everyone feels seen, heard, and valued, regardless of how they practice or where they come from. Through programs like the ADA Leadership Institutes15 and governance reforms that invite more voices to the table, we’re making progress. But we have more work to do.

Conclusion The ADA is well positioned to keep creating meaningful change, not just for dentistry, but for all the communities we serve and the broader healthcare landscape. When we treat oral health as essential, we save lives. When we integrate care, we improve patient outcomes. And when we lead with purpose, grounded in science, compassion, and respect, we unlock the full potential of what this profession can be. We have the power to shape the future we want to see for our profession, where every dentist lives their best life and every patient receives the care they deserve. This is our moment. Let’s seize it and shape the future of health together.

That’s why wellness is one of my top priorities. We’ve expanded ADA resources at ADA.org/well-

Journal of the American College of Dentists

REFERENCES 1. American Dental Association. Forsyth Friday: New antibodies may aid diagnosis of gum-linked systemic diseases. ADA News. Published April 5, 2025. Accessed May 31, 2025. https://adanews.ada. org/ada-news/2025/april/forsyth-friday-new-antibodies-may-aid-diagnosis-of-gum-linked-systemic-diseases/. 2. Offenbacher S, Barros SP, Beck JD. Rethinking periodontal inflammation. J Periodontol. 2008;79(8 Suppl):1577-1584. doi:10.1902/jop.2008.080048. 3. American Dental Association. ADA announces living guideline program to advance evidence-based care. ADA News. Published May 3, 2025. Accessed May 31, 2025. https://adanews.ada.org/adanews/2025/may/ada-living-guideline-program-announced/. 4. American Dental Association. America’s well-being depends on oral health. Washington Post (sponsored content). Published May 2024. Accessed May 31, 2025. https://www.washingtonpost.com/ creativegroup/american-dental-association/americas-well-being-depends-on-oral-health/. 5. American Dental Association. Workforce. Accessed May 31, 2025. https://www.ada.org/advocacy/ advocacy-issues/workforce. 6. American Dental Association. ADA leaders continue advocating for preventive services and fluoride. ADA News. Published May 10, 2025. Accessed May 31, 2025. https://adanews.ada.org/adanews/2025/may/ada-leaders-continue-covering-preventive-services-fluoride/. 7. American Dental Association. Fluoride in water. Accessed May 31, 2025. https://www.ada.org/resources/community-initiatives/fluoride-in-water. 8. Forsyth Institute. Oral stem cells genome mapping. Accessed May 31, 2025. https://forsyth.org/oralstem-cells-genome-mapping/. 9. Forsyth Institute. ADA Forsyth scientists work to bring tissue regeneration to replace root canal treatment. Accessed May 31, 2025. https://forsyth.org/ada-forsyth-scientists-work-to-bring-tissue-regeneration-to-replace-root-canal-treatment/. 10. American Dental Association. 2024 Lobbying Accomplishments. Published 2024. Accessed June 3, 2025. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/advocacy/2024_lobby_accomplishments.pdf. 11. American Dental Association. Dentistry’s role in complete health 2025: We make people healthy! Published 2025. Accessed June 3, 2025. https://www.ada.org/education/continuing-education/adace-live-workshops/dentistrys-role-in-complete-health. 12. American Dental Association. 2024 ADA trend report. Published October 2024. Accessed May 31, 2025. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/press-releases/2024_trend_report.pdf. 13. American Dental Association. Wellness resources. Accessed May 31, 2025. https://www.ada.org/resources/practice/wellness. 14. American Dental Association. States remove stigmatizing mental health questions from dental licensure applications. ADA News. Published October 17, 2024. Accessed May 31, 2025. https://adanews.ada.org/ada-news/2024/october/states-remove-stigmatizing-mental-health-questions-from-dental-licensure-applications/. 15. American Dental Association. ADA Leadership Institutes. Accessed May 31, 2025. https://www.ada. org/resources/careers/ada-leadership-institutes.

Summer 2025 Volume 91, Number 4

EDITORIAL

Unifying Health and Oral Health—An Ethical Imperative REFLECTIONS FROM THE 2024 ACD ETHICS SUMMIT Sheila Brear, BDS

Journal of the American College of Dentists

In the face of growing complexity and persistent inequities, the American College of Dentists reaffirms its commitment to advancing the integration of oral health into the larger health ecosystem.

he 2024 Ethics Summit, Breaking Down the Silos, convened by the American College of Dentists, marked a pivotal moment in the ongoing discourse on the ethical responsibilities of oral healthcare professionals. This distinguished gathering of interprofessional experts offered an insightful and urgent exploration into one of healthcare’s most pressing yet underexamined ethical imperatives: the moral obligation to fully integrate oral health into the broader healthcare system. The summit’s focus aligns powerfully with the mission of the American College of Dentists to advance excellence, ethics, professionalism, and leadership in oral healthcare.

A Call to Ethical Integration Opening keynote speaker Lisa Simon, MD, DMD, in her address, Dispatches From Both Sides of the Aisle, delivered a compelling case for medical-dental integration. She framed oral healthcare as a fundamental human right and identified entrenched systemic barriers, most notably the reimbursement structure, as key impediments to progress. Dr. Simon emphasized that the Current Dental Terminology (CDT) system, while evolving, still reinforces the artificial divide between dentistry and the larger healthcare ecosystem. Despite advances, dental insurers remain under no obligation to reimburse procedures traditionally classified as “non-dental,” even when performed by oral health professionals. She further highlighted challenges posed by inconsistent state regulations, fragmented coding systems, and the technological hurdles that inhibit the integration of medical and dental health records.

Vision and Policy Natalia Chalmers, DDS, MHSc, PhD, Chief Dental Officer at the Centers for Medicare and Medicaid Services (CMS), expanded the dialogue with a comprehensive overview of federal initiatives aimed at increasing access to oral health services for more than 150 million Americans. She outlined CMS’s growing commitment to oral-systemic integration and provided a critical review of the administrative and structural barriers that disproportionately affect marginalized populations. Dr. Chalmers’ insights underscored the urgent need to dismantle artificial divisions and align incentives, policies, and infrastructures to facilitate a unified approach to healthcare. Mary Otto, acclaimed journalist and author of Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America, reminded participants that the roots of oral health disparities are deeply social and structural. Her commentary on the social determinants of health added an essential ethical lens to the summit’s technical and policy-oriented discussions.

The Four Pillars of the Summit The summit’s working groups coalesced around four strategic focus areas: Education, Interprofessional Models of Care, Research, and Reimbursement. •

Education and Training: Dr. Nader Nadershahi, Dean of the University of the Pacific Arthur A. Dugoni School of Dentistry, challenged the profession to confront the legacy of siloed educational structures. He emphasized the need for early, sustained interprofessional learning Summer 2025 Volume 91, Number 4

Unifying Health and Oral Health—An Ethical Imperative Sheila Brear, BDS

grounded in core competencies developed by the Interprofessional Education Collaborative (IPEC) and the World Health Organization’s collaborative practice frameworks. His call to action included seven strategic recommendations for embedding interprofessionalism into curricula across the health professions. •

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Interprofessional Models of Care: Dr. Dan Pihlstrom, Chief Dental Officer of Kaiser Permanente Dental Associates, presented evidence from successful medical-dental integration (MDI) models. These models, characterized by shared electronic health records, collocated services, and integrated care programs, exemplify how bidirectional communication and aligned incentives can yield improved health outcomes and more efficient care. Research: Dr. Jennifer Webster-Cyriaque illuminated the critical role of the National Institute of Dental and Craniofacial Research (NIDCR) in promoting oral-systemic integration. She highlighted several federal initiatives, including the NIH Common Fund Program, which supports clinical research in primary care settings. Research presented showed that risk-based oral health interventions for high-risk pediatric populations offer cost-effectiveness comparable to other primary prevention strategies. She also introduced the forthcoming Data-Driven Science (DDS) hub—a new platform to facilitate cross-disciplinary data sharing, a crucial step toward breaking down research silos. Reimbursement: Dr. Ron Inge tackled one of the thorniest obstacles to integration: the misalignment of insurance systems. Dental and medical insurers operate on distinct philosophies, often reinforcing disjointed care. He referenced integration pioneers, including Aetna’s Dental-Medical Integration Program (2003) and Delta Dental of Washington’s Oral Health Integration Resource, as early models of reform. Yet even these remain exceptions in a

Journal of the American College of Dentists

system that structurally disincentivizes integrated practice.

From Dialogue to Action Throughout the summit, participants affirmed a central ethical truth: oral health and overall health are not separate domains. Dr. Simon rightly stated that there is no ethical justification for addressing one without the other. Yet, structural fragmentation—in insurance, education, workforce incentives, and clinical practice—continues to impair efforts toward meaningful integration. Examples such as dental clearances for medical procedures and medical screenings in dental settings show that integration is not only possible but effective. These approaches have demonstrated reduced healthcare costs, improved patient outcomes, and more comprehensive care delivery.

The Path Forward The integration of oral and systemic healthcare is no longer an abstract ideal; it is a moral imperative. As health disparities widen and vulnerable populations continue to fall through the cracks of a bifurcated system, the need for unified, person-centered care becomes more acute. The summit underscored that while technical, financial, and regulatory challenges persist, they are surmountable through strategic collaboration and ethical leadership. In the face of growing complexity and persistent inequities, the American College of Dentists reaffirms its commitment to advancing the integration of oral health into the larger health ecosystem. The models presented at the summit demonstrate that such integration is not only feasible but also necessary. It is cost-effective. And it is just. Let us heed the summit’s call and move from conversation to action, from vision to implementation—guided always by our shared ethical obligation to serve the whole patient. 62

Submitting Manuscripts for Potential Publication in JACD The communication policy of the College is to “identify and place before the Fellows, the profession, and other parties of interest those issues that affect the dental profession and oral health. The goal is to stimulate this community to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College.

3. Sufficiently de-identify any descriptions of patients and/or clinical encounters;

Manuscripts for potential publication in the Journal of the American College of Dentists should be sent as attachments via e-mail to editor@acd.org. In the submission cover letter, please confirm that the manuscript or substantial portions of it or prior analyses of the data upon which it is based have not been previously published and that the manuscript is not currently under review by any other journal.

7. Ensure all published references are cited in the text and numbered consecutively. No references should be cited in the abstract. Each reference should be cited only once; the original number should be used in subsequent citations.

Submissions must include: 1. The full name of each author; 2. E-mail address, mailing address, fax number, and phone number for each author; 3. Degrees and institutional affiliation (if appropriate) of each author; and 4. Statement of responsibility from each author indicating what they have contributed to the document. Submissions should: 1. Be between 1500 and 3000 words in length. 2. Use inclusive language, including genderneutral pronouns, unless referring to specific persons; 63

4. Include disclosure of any conflicts of interest; 5. Designate a corresponding author; 6. Follow the most recent edition of the American Medical Association Manual of Style; and

Review Process: Unless a solicited article, review by the editor (or, in some instances, a “guest editor”) will occur within 21 days of receiving a manuscript to determine whether it suits the general content and quality criteria for publication in the JACD. All manuscripts that are suitable for publication will undergo single-blinded peer review. Usually there are two anonymous reviewers comprised of subject matter experts and board members of the College and/or the JACD editorial board. Because all peer reviewers are volunteers, review may take between 4 and 6 weeks. Once reviewer comments are received by the editor, a decision will be made to accept, accept with minor revisions, accept with major revisions, or reject. JACD reserves the right to edit manuscripts to ensure conciseness, clarity, and stylistic consistency.

Summer 2025 Volume 91, Number 4