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INTERPROFESSIONALEDUCATIONAND PRACTICE MOVING TOWARDCOLLABORATIVE,PATIENT-CENTERED CARE

Lindsey A. Robinson, DDS, andDavid M. Krol, MD, MPH, FAAP

Health Care Legislation

Integration of Oral andOverall Health Care

Anatomy of the DentalBenefit Marketplace

January 2014

Vol42

No1

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You are not amarket segment.

Professional Liability

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January 2014

D EPARTMENTS

The Editor/Numeracy and Innumeracy

JournalReviewers

Impressions

Practice Support/Changing to a Different Practice Model

RM Matters/Compromised Health Warrants

Medical Clearance

Regulatory Compliance/Prescribing and Dispensing

Periscope

Tech Trends

Dr. Bob/A Very Good Year

5

7

9

53

55

60

65

67

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Interprofessional Education and Practice Moving Toward Collaborative, Patient-centered Care

An introduction to the issue, the first of three this year on the topic.

Lindsey A. Robinson, DDS, and David M. Krol, MD, MPH, FAAP

The Roles of Federal Legislation and Evolving Health Care Systems in Promoting Medical-Dental Collaboration

Dentistry will likely lag behind medicine toward value-based and accountable care organizations, but dentists will be

affected by changing consumer expectations.

Burton L. Edelstein, DDS, MPH

Integrating Oral and Overall Health Care On the Road to Interprofessional Education and Practice:Building a Foundation for Interprofessional Education and Practice

These remarks were presented as the keynote address at the Symposium on Interprofessional Education and Practice

hosted by the Columbia University College of Dental Medicine on June 14-15, 2012.

Richard W. Valachovic, DMD, MPH

Interdisciplinary Collaboration: What Private Practice Can Learn From the Health Center Experience

Health Centers have embarked on several initiatives that incorporated the development of infrastructure for

medical-dental integration. This paper reviews these efforts and highlights successes, challenges and best practices

that can bolster efforts in all dental practice settings.

Irene V. Hilton, DDS, MPH

Overview of the Anatomy of the Dental Benefit Marketplace and Emerging Concepts

Changing dental trends, increase in the number of stakeholders involved with dental benefits, health care reforms and

the oral-systemic connection will all have a significant impact on dental practice.

Paul Manos, DDS

Interprofessional Education Between Dentistry and Nursing: The NYU Experience

This article recounts the unique interprofessional model created between the New York University College

of Dentistry and College of Nursing and describes examples of success and past and current challenges.

Judith Haber, APRN, PhD; Andrew I. Spielman, DMD, MS, PhD; Mark Wolff, DDS, PhD; and Donna Shelley, MD, MPH

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F E A T U R E S

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CDA Offi cersJames D. Stephens, DDSPRESIDENT

[email protected]

Walter G. Weber, [email protected]

Kenneth G. Wallis, [email protected]

Clelan G. Ehrler, DDSSECRETARY

[email protected]

Kevin M. Keating, DDS, MSTREASURER

[email protected]

Alan L. Felsenfeld, [email protected]

Lindsey A. Robinson, [email protected]

ManagementPeter A. DuBoisEXECUTIVEDIRECTOR

Jennifer GeorgeCHIEFMARKETINGOFFICER

Cathy MudgeVICEPRESIDENT,COMMUNITYAFFAIRS

Alicia MalabyCOMMUNICATIONS DIRECTOR

EditorialKerry K. Carney, DDS, [email protected]

Ruchi K. Sahota, DDS, CDEASSOCIATEEDITORBrian K. Shue, DDS, CDEASSOCIATEEDITOR

Robert E. Horseman, DDSCONTRIBUTINGEDITOR

Lindsey A. Robinson, DDSGUESTEDITOR

David M. Krol, MD, MPH,FAAPGUESTEDITOR

Andrea LaMattinaPUBLICATIONSSPECIALIST

Blake EllingtonTECHTRENDSEDITOR

Courtney GrantCOMMUNICATIONS SPECIALIST

Jack F. Conley, DDSEDITOREMERITUS

ProductionVal B. MinaSENIORGRAPHICDESIGNER

Randi TaylorSENIORGRAPHICDESIGNER

Upcoming TopicsFebruary/Controversiesin Dentistry

March/General Topics

April/State of the OralHealth Infrastructure

AdvertisingCorey [email protected]

Letters to the Editorwww.editorialmanager.

com/jcaldentassoc

Permission andReprintsAndrea LaMattinaPUBLICATIONSSPECIALISTAndrea.LaMattina@cda.org916.554.5950

ManuscriptSubmissionswww.editorialmanager.com/jcaldentassoc

SubscriptionsSubscriptions are availableonly to active members ofthe Association. Thesubscription rate is $18 andis included in membershipdues. Nonmembers canview the publication onlineat cda.org/journal.

Manage your subscription

online: go to cda.org, log inand update any changes toyour mailing information.Email questions or otherchanges to [email protected].

Volume 42, Number 1

January 2014

In fact, from letters to the

editor to reviews, the new

site is now the only way

to submit anything to the

Journal of the CaliforniaDental Association.

Upload your content,

receive automatic status

updates, even track

progress anytime day or

night. See for yourself at

editorialmanager.com/jcaldentassoc

Submitting

a manuscriptto the Journal?Theres a sitefor that.

Journal of the California Dental Association( ISSN1043-2256) is published monthlyby the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814,916.554.5950. Periodicals postage paid at Sacramento, Calif. Postmaster: Send addresschanges toJournal of the California Dental Association, P.O. Box 13749, Sacramento,CA 95853.

TheJournal of the California Dental Association is published under the supervision of CDAseditorial staff. Neither the editorial staff, the editor, nor the association are responsible for any

expression of opinion or statement of fact, all of which are published solely on the authority ofthe author whose name is indicated. The association reserves the right to illustrate, reduce, reviseor reject any manuscript submitted. Articles are considered for publication on condition that theyare contributed solely to theJournal.

Copyright 2014 by the California Dental Association.

published by theCalifornia

Dental Association

1201 K St., 14th Floor

Sacramento, CA 95814

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Editor

Numeracy and InnumeracyKerry K. Carney, DDS, CDE

The post ofce is a lonely placenow that it is known as the snailmail ofce. Last week I took alarge envelop to the post ofcebecause I was not certain I had

sufcient postage. I had placed eight66-cent stamps on it, but it was pretty

heavy. When it was my turn, I slid theenvelope across the counter to the postalworker. She slid it back to me and toldme I would have to add it up rst beforeshe could tell me if I needed to add morestamps. I must have looked dumbstruck,because she proceeded to explain, thoughshe had a scale to weigh the envelope, shehad no calculator. She would not be ablecalculate what amount was already appliednor any difference I might need to add.

Bam. I ran smack into anexample of innumeracy.

The term innumeracy describes thelack of understanding of fundamentalmathematical principles and logicalanalysis. We encounter it every day. It maybe the miscommunication of a discountpercentage in a retail transaction, theirrelevant statistics of a sports commentator,the incorrect risk assessment of rain bythe weather forecaster or the confusionof coincidence with cause and effect thatunderlies paranormal investigations.

Innumeracy reinforces ones reliance

on emotional appeals even when theycontradict data-based risk assessments.For example, when a politicianpronounces he or she will spend whateveris necessary to achieve a zero risk ofa national disaster/terrorist attack/insert-some-horrible-event-here. There isa fundamental misunderstanding of riskand prevention in such a statement.

We desire a zero risk of a bad thinghappening, but if that is not achievableand we consent to unconstrained spending

in the pursuit of the zero risk, we havechosen the emotionally appealing butrealistically impossible and scallyimprudent option. Policy decisions basedon innumeracy and emotion can lead tounfounded and crippling anxieties or toimpossible and economically paralyzingdemands for risk-free guarantees.1

State lotteries would likely be unsus-tainable if our collective understanding ofchance or probability were higher. Thoseof us who rely on the state lottery as ourretirement plan have traded the math-ematical improbability of our winning forthe seductive wish that it could be me.

During informed consent discussionswith our patients, we have to evaluatethe numeracy level of the patient inorder to communicate the risks andbenets of alternative treatments in anunderstandable manner. The dark sideof conversations between individualswith uneven levels of numeracy is the

unethical manipulation of the informationto draw out the more lucrativeprocedure decision from the patient.

The most obvious and widespreadcurrent example of a numeracy challengemay be realized in the navigation throughand understanding of the Affordable CareAct marketplace and its many insurancecoverage choices. Being able to compareand understand the advantages and risksassociated with coverage alternatives isa daunting test of everyones numeracy.

Innumeracy also plays a large rolein how we interpret or misinterpretscientic ndings. We accept percentageswithout knowing actual numbers (the

N value). We embrace trends withoutdescriptions of how these trends weredetermined. We accept small, nonrandomsamples as having strong, predictivepower. We accept an arithmeticalaverage, or mean, when a range, modeor median might be more relevant.

Some professionals exhibit a slavishdevotion to that ubiquitous indicatorof statistical signicance, the Pvalue.Many of us tend to go directly to the Pvalue to evaluate whether experimentaldata is worth further consideration.

Glick and Greenberg discuss how areliance solely on the Pvalue can leadus to falsely infer far more about theimportance and clinical relevance of astudys outcome than it actually implies.They argue that a studys methodology and

other statistical measures can tell us muchmore about the magnitude and variabilityof the experimental effect being measured.2

For example, if a study produces astatistically signicant difference betweenthe effects of two drugs, but the magnitudeof that variation is small, then thedifference in the treatments may have littleclinical relevance. This kind of statisticallysignicant outcome might be used tosupport heavy marketing of an expensivedrug over an inexpensive one. In the end,

Being able to compare and understand

the advantages and risks associated

with coverage alternatives is a daunting

test of everyones numeracy.

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the consumer could be inuenced to paymore for the heavily marketed drug andnever realize he is paying for statisticalsignicance over clinical signicance.

As health professionals, we havean obligation to improve our ownlevel of numeracy so we can identifyand correct examples of innumeracythat inuence oral health care.

Paulos points out in his 1988 book,

Innumeracy, that many of us take a perversepride in mathematical ignorance. Thesame people who cringe when words suchas imply and infer are confused reactwithout a trace of embarrassment to eventhe most egregious of numerical solecisms.When questions about the methodologi-

cal details of a study are posed, they aresometimes viewed as impolite or distracting.

Innumeracy is pervasive andinsidious. Innumerate pronouncementsare encountered daily, rarely recognizedas such and even less frequentlycorrected. Innumeracy is the basisfor misunderstanding the meaning ofinformation in many forms. It can keep usfrom a true understanding of risk, statistical

signicance and clinical relevance. Ina real sense, it can be the basis for afundamental misunderstanding of theworld and how it operates on a daily basis.

Paulos summed up nicely howinnumeracy can interfere with ourunderstanding of very simple interactions.

He tells the story of a tourist in Vermontwho takes several items to the cash registerin a small country store. The store ownertells the tourist the bill total is $17.37.The tourist places the exact change on thecounter. The store owner counts it onceand looks up at the tourist. He counts itagain and looks at the tourist again. Afterhe counts it the third time, the tourist says,Doesnt it add up to $17.37? And the

store owner looks with great suspicion atthe tourist and says, Yes, but just barely.

REFERENCES

1. Innumeracy: Mathematical Illiteracy and Its Consequences,

John Allen Paulos 1988.

2. The Hermeneutic Pitfalls of P. Michael Glick, DMD, and

Barbara L. Greenberg, MSc, PhD. December 2010 vol.141 no.

12 1404-1407.

UCSF Dental Center

Compliance Officer

Te University of California, San Francisco Dental Center seeks applicants for a full time ComplianceOfficer. Te UCSF Dental Center is comprised of seventeen individual clinics with over 120,000 visitsreported annually.

Te UCSF Dental Center Compliance Officer is responsible for a comprehensive approach that promotesethical, safe and proper behavior in the School. Tis Compliance Officer implements and enforcesUniversity and School policy with the goal of minimizing risk associated with laboratory and clinicaloperations in the Dental Center. Te Compliance Officer reports to the Associate Dean for Clinical Affairsand works with the Associate Dean, Clinic Directors and Clinic Manager to establish standards andprocedures to be followed by Dental Center employees and trainees. Tis is a non-tenure-track position

in the School of Dentistry.

Candidates must possess good clinical skills, dental knowledge, and ability to effectively communicateverbally and in writing. Demonstrated ability to work collaboratively with others and proven ability toinuence others and affect change without direct supervisory authority. Must have experience with QualityAssurance or Continuous Quality Assurance programs. Dental experience (private or academicinstitution), experience teaching dental students preferred. DDS, MA, MS or RN required. Interestedapplicants should submit a cover letter and curriculum vitae to: [email protected] (Attn: MariaGuerra, Manager)

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Reviewers

Thank You to theJournalReviewers

Authors have bylines on their articles. Guest editors and staff get their names in the masthead. But

theJournal requires many more people whose names you never see in print. These busy professionals

review all manuscripts and offer their expert recommendations and opinions before any article appear

TheJournalrelies on these reviewers to maintain a quality publication and extends its thanks to all

who made this invaluable contribution in 2013.

Kathryn Atchison, DDS, MPHLeif K. Bakland, DDS

Rahmat Barkhordar, DDS

Ivan Berger, DDS

Paul Binon, DDS

John S. Bond, DMD

Ana Carolina Botta, DDS, MS, PhD

Robert L. Boyd, DDS

James Bramson, DDS

Ronald Brown, DDS, MS

William M. Carpenter, DDS, MS

David W. Chambers, PhD

Russell Christensen, DDSStephen Cohen, DDS

Darren Cox, DDS, MBA

Arthur W. Curley, JD

Michael John Danford, DDS

Gary L. Dougan, DDS, MPH

Nejat Duzgunes, PhD

W. Stephan Eakle, DDS

Joel Epstein, DMD, MSD, FRCD(C), FDS RCS

Allen L. Felsenfeld, DDS

Jared Ira Fine, DDS, MPH

Clayton Fuller, DDS

Sushama Galgali, MDSRobert E. Gillis, DMD, MSD

Alan Gluskin, DDS

Lionel Gold, DDS

Jay Golinveaux, DDS, MS

Charles J. Goodacre, DDS, MSD

William A. Grippo, DDS

Mina Habibian, DMD, MS, PhD

Janice Handlers, DDS

Thomas Tim Henderson, MSPH

Jeffrey M. Henkin, DDS

Gary N. Herman, DDSEdmond Hewlett, DDS

Kelly Hicklin, DDS

Stefan Highsmith, PhD

Thomas Indresano, DMD

Robert Isman, DDS, MPH

Lisa Itaya, DDS

Peter Jacobsen, DDS, PhD

Larry E. Jenson, DDS, MA

Barbara Kabes, DDS, MS

Kian Kar, DDS, MS

David Keinan, DMD, MSc, PhD, MHA

Robert D. Kiger, DDSOphir Klein, MD, PhD

Alton M. Lacy, DDS

Jonathon E. Lee, DDS

Tom Lenhart, DMD

Yiming Li, DDS, MSD, PhD

Michael Marshall, DDS, HDS

Kevin McNeil, DDS

Charles McNeill, DDS

Raymond Melrose, DDS

Diana Messadi, DDS, MMSc, DMSc

David Milder, DDS, MD

J. Todd Milledge, DDSEdward J. Miller, DMD

Theodore A. Murrary Jr., DDS

Rizan Nashef, DMD

Mahvash Navazesh, DMD

David Nelson, DDS, MS

Ichiro Nishimura, DDS, DMD

W. Craig Noblett, DDS, MS

Melanie Parker, DDS, MS

David Warren Peters, JD

Howard F. Pollick, BDS, MPH

Steve Ralls, DDS, EdD, MSDMichele Ravenel, DMD

Donald Rollofson, DMD

Alvin Rosenblum, DDS

David Lawrence Rothman, DDS

Mark Ryder, DMD

Ruchi K. Sahota, DDS

Donald C. Schmitt, DDS

Charlotte L. Senseny, DMD

Frederic J. Sherman, DDS

Brian K. Shue, DDS

Sol Silverman Jr., DDS

Andrew Soderstrom, DDSAndrew Sonis, DMD

Duane Spencer, DDS

James D. Stephens, DDS

Ilanit Stern, DMD

Charles Stewart, DMD

Charles Streckfus, DDS, MA

Piedad Surez Durall, DDS

Stanley R Surabian, DDS, JD

Samuel C. Thacher, DDS

Mahmud Torabinejad, DMD

Richard D. Udin, DDS

Rodney Vergotine, DDSShane White, PhD, MS, MA

Larry Wolinsky, PhD, DMD

Alfred Jeff Wood, DDS

Juan Fernando Yepes, DDS, MD, MPH, MS,

DrPh

Douglas A. Young, DDS, EdD, MBA, MS

Guang-Yan Yu, DDS, MD

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Renew today.cda.org/renew

You are the protector of the smile. You enable people to

laugh without shame, eat their favorite foods and experience

the dignity of aging with grace. And because you are the

champion of the smile, CDA is yours. Its why we tirelessly

advocate for the profession and stand up for those in need of

care. Because the world is a better place when people are

smiling, and thats thanks to you.

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Smoking Guns and Targets

Impressions

David W. Chambers, PhD

Imagine that you are on trial, having been accused ofbeing ethical. This is a bit surrealistic, but the questionarises: is there enough evidence to get a conviction? Youexplain to your attorney that you have passed the stateboards ethics test. She shakes her head. We need to nd asmoking gun, or perhaps a pattern of consistent behavior.

A smoking gun would be a single dramatic act. Tomake it bulletproof, it should have no mixed motivesand look 100 percent volitional. Was that pro bono workfor the patients sake or bad debt repackaged as good

public relations? In your heart, your intentions werepure. But the world is so likely to misunderstand.

Perhaps it would be better to go for a pattern of outcomes.Open your charts, gather testimonials, point to your cleanrecord. There is power in trends, but not so much whenthey come after the fact. A few targets with bullet holeswhere they should be might be impressive. But any lawyerworth his or her fee would show that (a) a pattern ofoutcomes does not prove that a particular act caused it,(b) chance could produce almost any pattern if we lookedhard enough and (c) selective evidence is suspect.

This way of looking at matters is annoying. If we begin with theassumption that the profession is perfectly ethical, this all seemslike mean-spirited troublemaking. But perhaps others do not startfrom that position. Can we really use profession of an intendedoutcome to demonstrate that we have behaved as intended?

Now lets change the situation in just one small way. Imagineyou are on trial, but this time accused of being unethical. Thereis the smoking gun. An undisclosed broken le in the sinus, aninsurance claim for extracting a tooth that is still in the arch. Itwas an atypical accident, a reporting error, a misunderstanding,you say. You can explain it away. Some dentists believe theADA Code of Ethics says do not criticize other dentists workbecause you do not know the circumstances under which it wasperformed. Not quite true. It says you should take steps to nd out

what those circumstances were.But perhaps there is an ugly pattern. Insurance companiestell me they can name the dozen most unethical practitionersbased on distinctive claims patterns. Usually these problems aremade to go away privately because there is no smoking gun andstate enforcement agencies are underfunded out of mistrust ofeffective government. The best defense against pattern detectionof immoral behavior is to break the chain of evidence. Until wecurb policies of nondisclosure and settlements that self-dissolve toprevent discovery of past wrongdoing, smoking guns and patternswill be weak stuff.

The nub:

All evidence is only partially valid.

Whether we use evidenceof ethical conduct cannot bedetermined by which outcomewe want to appear.

Confronting immoral behavior isan act of courage that involvesmorality.

David W. Chambers, PhD, is professor of dental

education, Arthur A. Dugoni School of Dentistry, San

Francisco, and editor of theJournal of the American

College of Dentists.

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FDA to ProposeHydrocodone Reclassification

The U.S. Food and DrugAdministration recently said that, in

recent years, it has become increasinglyconcerned about the abuse and misuseof opioid products, which have sadlyreached epidemic proportions incertain parts of the United States.

As a result, the agency announcedit would recommend a more restrictiveclassication of certain pain medicationsprescribed by physicians and dentists to

increase the controls on these products.Due to the unique history of this

issue and the tremendous amount ofpublic interest, we are announcing

the agencys intent to recommend toHHS (U.S. Department of Health andHuman Services) that hydrocodonecombination products should bereclassied to a different and morerestrictive schedule, the FDA saidin a statement on its website.

According to a news story fromthe American Dental Association,the ADA and American Associationof Oral and Maxillofacial Surgeons

previously told federal regulators thatthe proposed reclassication couldcause inconvenience, unnecessarysuffering and higher out-of-pocketcosts for patients with a legitimateneed for the medications.

Going forward, the agency willcontinue working with professionalorganizations, consumer and patientgroups and industry to ensure that

prescriber and patient education toolsare readily available so that theseproducts are properly prescribed andappropriately used by the patientswho need them most, the FDA said.

For more information, see thestatement from the FDA at www.fda.gov/Drugs/DrugSafety/ucm372089.htm or read the ADA news storyat ada.org/news/9390.aspx.

ADA Approves Topical PrescriptionFluoride for Home

With evidence-based clinical recommendations

published in the NovemberJournal of the American

Dental Association, the ADA recently approved the use

of topical prescription fluoride for home use.

A panel of experts convened by the ADA Council on

Scientific Affairs authored the recommendations, which are

an update of the 2006 ADA recommendations and cover

professionally applied and prescription-strength, home-use topical fluorideagents for caries prevention.

The authors reviewed 71 clinical trials from 82 articles and assessed the

effi cacy of various topical fluoride caries-preventive agents, including mouth rinses,

varnishes, gels, foams and pastes.

The panel recommends the following for people at risk of developing dental

caries: 2.26 percent fluoride varnish or 1.23 percent fluoride (APF) gel, or a

prescription-strength, home-use 0.5 percent fluoride gel or paste or 0.09 percent

fluoride mouth rinse for patients 6 years or older. Only 2.26 percent fluoride

varnish is recommended for children younger than 6 years, the authors wrote.

According to the publication, the panel judged that the benefits outweighed

the potential for harm for all professionally applied and prescription-strength,

home-use topical fluoride agents and age groups except for children younger

than 6 years. In these children, the authors wrote, the risk of experiencing

adverse events (particularly nausea and vomiting) associated with swallowing

professionally applied topical fluoride agents outweighed the potential benefits of

using all of the topical fluoride agents except for 2.26 percent fluoride varnish.

Finally, the authors conclude that as part of the evidence-based approach to

care, these clinical recommendations should be integrated with the practitioners

professional judgment and the patients needs and preferences.

For more, see the clinical recommendations in theThe Journal of the American

Dental Association, vol. 144, no. 11, pp. 1279-1291.

on

n

are

ver

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Uncontrolled Diabetes Could Lead to Inflamed Gums

According to the American Diabetes Association, an estimated 7 million of the26 million people who have diabetes have no idea that they have the disease. Whats

more, a recent study in The Journal of the American Dental Associationreported that

one in five cases of total tooth loss in the United States can be linked to diabetes.

Oral health and overall health are related, so part of my role as a dentist is

to flag signs of poor oral health that might also signal other serious health conditions, said

Alice G. Boghosian, DDS, a consumer advisor for the ADA, in a news release. Severely

inflamed gums, coupled with a patients medical history, can be cause for concern.

In the news release on its website, the ADA said patients with diabetes have

a lower resistance to infection, and that, combined with a longer healing process,

makes them more susceptible to developing gum disease. It is especially important

to remember that a dentist can be a valuable member of a patients diabetes health

care team to help check for the signsof gum disease and provide tips on

how to keep patients mouths healthy.

For more information, visit ada.

org/9341.aspx or see the study,

Diabetes and tooth loss, in The Journal of

the American Dental Association, May 1,

2013, vol. 144, no. 5, pp. 478-485.

In a new study, authors investigatedthe use of ceramic primers combined withself-adhesive resin composite cementson the shear bond strength (SBS) tozirconia and compared them with oneconventional resin composite cement.

According to the study, published

in TheJournal of the American DentalAssociation, application of a ceramicprimer did not result in a negativeimpact on SBS.

The authors examined the self-adhesive resin composite cements withand without the use of a ceramic primerand measured SBS initially (37 C for

three hours), after water storage(37 C for one, four, nine, 16 or 25days) and after thermal cycling. Theyconcluded that ceramic primer incombination with self-adhesive resincomposite cement demonstrated apositive effect on SBS to zirconia,

and added that because no negativeimpact was observed with the ceramicprimers overall, they recommendclinicians apply a ceramic primer beforecementing zirconia restorations.

For more, see the study in TheJournalof the American Dental Association,vol. 144, no. 11, pp. 1261-1271.

Study: Ceramic Primer and Bond Strength

Limit Sugar to Less than FiveTeaspoons Daily

As part of a global initiative to reduce

tooth decay, Newcastle University researchers

recommend reducing sugar intake after

recently studying the effects of sugars on our

oral health. The researchers show that when

less than 10 percent of total calories in the

diet is made up of free sugars there are much

lower levels of tooth decay. In this study, they

go one step further and suggest that limiting

sugars to less than 5 percent of calories

(about five teaspoons a day) would bring

even further benefits minimizing the risk of

dental cavities throughout life. For more, see the

study, Effect on Caries of Restricting Sugars

Intake, published online before print Dec. 9,

2013, in theJournal of Dental Research.

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Practice Support

Cutting Costs

I cant afford a

practice management

consultant,but Icould sure use a

little help. Where do

I even begin ?Start your search on CDAs Compass. Its packed with

insightful articles and valuable resources to help you with

every angle of practice management. Whats more, CDA

members have access to Practice Support Analysts who

are experts in dental benefits, practice management,

regulatory compliance and employment practices. So ifyou have an urgent question, theyre at the ready to help.

CDA Practice Support, its how smart dentists get smarter.

866.232.6362or cda.org/compass

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Treating Traumatic DentalInjuries: Updated Guidelinesfrom the AAE

The American Association ofEndodontists recently publishednewly revised guidelines to helpdental professionals quicklydetermine the best course of actionto treat traumatic dental injuries.

According to a news release from theassociation, the Recommended Guidelinesof the American Association of Endodontists

for the Treatment of Traumatic DentalInjuriesfeatures treatment protocols fora variety of traumatic dental injuriesincluding fracture, luxation, subluxation,

concussion and avulsion. The Guidelinesinclude diagnosis, treatment, patientinstruction and follow-up procedures.

Initially developed by the AAEin 2004, the revised Guidelinesaim toensure consistency in addressing acutephase treatment while focusing onpost-traumatic endodontic care. Notablechanges in the revised Guidelinesinclude: Recommendations for utilizationof 3-D imaging for the detection

and monitoring of dental injuries; Revised timelines for the treatment ormonitoring of various injuries; and

The utilization of the latest materials forvital pulp therapy in the trauma patient.The AAE and IADT [International

Association of Dental Trauma] sharea commitment to providing the mostcurrent and evidence-based informationpertaining to the treatment of dental

trauma to both professionals and thepublic, said Linda G. Levin, DDS, PhD,chair of the AAE special committeeto revise the trauma guidelines, in thenews release. It is one more way wework to save the natural dentition.

The Guidelines, and other dentaltrauma resources, are available free fromthe AAE website at aae.org/clinical-resources/trauma-resources.aspx.

Drug May Guard Against PeriodontitisAuthors of a new study, published in Antimicrobial Agents and Chemotherapy,

report that a drug currently used to treat intestinal worms could protect people from

periodontitis.

According to a news release from the American Society for Microbiology, the

investigators showed in an animal model of periodontitis that the drug Oxantel inhibits

the growth of polymicrobial biofilm by interfering with an enzyme that bacteria requirefor biofilm formation.

The researchers, who initially began their search for a therapy for periodontitis

by studying the symbioses of the periodontal pathogens, found that the growth of

periodontal biofilm was dependent on the availability of iron and heme (an iron-

containing molecule related to hemoglobin), and that restricting these reduced levels of

the enzyme fumarate reductase. Since Oxantel was known to inhibit fumarate reductase

in some bacteria, the researchers tested its ability to inhibit fumarate reductase activity in

P. gingivalis, according to the news release.

Authors of the new study also found that Oxantel disrupted the growth of

polymicrobial biofilms containing P. gingivalis, Tannerella forsythiaand Treponema

denticola, a typical composition of periodontal biofilms, despite the fact that the latter

alone is unaffected by Oxantel.The researchers found that treatment with Oxantel downregulated six P. gingivalisgene

products, and upregulated 22 gene products,

all of which are part of a regulon (a genetic

unit) that controls availability of heme.

For more information, see the study

published ahead of print in the journal

Antimicrobial Agents and Chemotherapy,

Oct. 28, 2013.

J A N . 2 0 1 4 I M P R E S S I O N S

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A team of researchers at the Universityof Pittsburgh recently conducted a newanimal study and found that the red,swollen and painful gums and bonedestruction of periodontal disease couldbe effectively treated with the right kindof immune system cells.

The current strategies of mechanicaltartar removal above and below the gumline and antimicrobial delivery aim toreduce the amount of oral bacteria onthe tooth surface, explained co-authorand co-investigator Charles Sfeir, DDS,PhD, of Pitts School of Dental Medicine,

in a news release from the school.Currently, we try to control the

buildup of bacteria so it doesnt triggersevere inammation, which couldeventually damage the bone and tissuethat hold the teeth in place, Sfeir said inthe news release. But that strategy doesnt

address the real cause of the problem,which is an overreaction of the immunesystem that causes a needlessly aggressiveresponse to the presence of oral bacteria.There is a real need to design newapproaches to treat periodontal disease.

In the new study, the research

Treating Gum Disease With Specific Immune Cells

team developed a system of polymermicrospheres to slowly release achemokine, or signaling protein, calledCCL22 that attracts regulatory T-cells,and placed tiny amounts of the paste-likeagent between the gums and teeth ofanimals with periodontal disease. Theyfound that bringing specic immunecells to the inamed tissues led to

improvements of standard measures ofperiodontal disease, including decreasedpocket depth and gum bleeding,reecting a reduction in inammationas a result of increased numbers ofregulatory T-cells. Additionally, theresearchers report that microCT-scanningshowed lower rates of bone loss.

The tools are better and people arebetter trained now, but weve been doingmuch the same thing for hundreds ofyears, said senior author Steven Little,

PhD, in the news release. Now, thishoming beacon for Treg cells, combinedwith professional cleaning, could giveus a new way of preventing the seriousconsequences of periodontal diseaseby correcting the immune imbalancethat underlies the condition.

For more information, see the studypublished in Proceedings of the National

Academy of Sciences, Nov. 12, 2013,vol. 110, no. 46, pp. 18525-18530.

Visual Illusion Can Influence TreatmentIn a new study, authors focused on the way that endodontists perform root canals

and how illusions can influence treatment.

To evaluate this, researchers supplied eight practicing endodontic specialists

with at least 21 isolated teeth each, randomly sampled from a much larger

sample of teeth they were likely to encounter. The teeth contained holes, and

the endodontists were asked to cut cavities in preparation for filling. Each tooth

presented varying degree of visual illusion, the Delboeuf illusion, that made the

holes appear smaller than they were.

The Delboeuf illusion is one example of visual illusions in which the context of

an object affects its perceived size. When the context is large, the object appears

smaller than it is, authors explained. In this study, the endodontists and the persons

measuring the cavities were blind to the parameters of the illusion.

The authors found that the size of cavity endodontists made was linearly related to

the potency of the Delboeuf illusion (p

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i n t r o d u c t i o n

issues, the California Dental Associationand American Dental EducationAssociation (ADEA) are co-sponsoringa conference on IPE to be convened inSan Francisco Feb. 34 to understandthe evolving role of dentists as part ofa multidisciplinary health care team.

Traditionally, health professionaleducation has been delivered in isolatedsilos to the detriment of safety and qualitycare delivery making it more difcult tomeet the needs of patients who presentwith complex conditions more conducive

to a multidisciplinary treatment approach.In the last dozen years, much has beenwritten on the subject of interprofessionalteam building, including the reportpublished by the Institute of Medicinein 2003, HealthProfessions Education: ABridge to Quality,which urged educatorsin the health professions and accreditingagencies to ensure that students graduatedwith prociency in ve domains, includingworking as part of an interdisciplinaryteam.2In 2008, six national education

This is the rst of three

Journalissues dedicated tointerprofessional education(IPE) and practice. The WorldHealth Organization denes IPE

as occurring when students from twoor more professions learn about, fromand with each other to enable effectivecollaboration and improve healthoutcomes. It denes interprofessionalor collaborative practice as occurringwhen multiple health workers fromdifferent professional backgrounds provide

comprehensive services by workingwith patients, their families, careersand communities to deliver the highestquality of care across settings.1To befaithful to the theme, a pediatricianand a pediatric dentist have teamedup to bring together a group of authorswho are national leaders in the eldwho have a deep understanding ofthe challenges and opportunities thissubject represents for the professionof dentistry. In addition to theJournal

Interprofessional Educationand Practice Moving

Toward Collaborative,Patient-centered CareLindsey A. Robinson, DDS, and David M. Krol, MD, MPH, FAAP

GUEST EDITORS

Lindsey A. Robinson,

DDS, is the immediate past-president of the California

Dental Association, past

chair of the CDA Foundation

and represents CDA on

the Institute of Medicine

Health Literacy Roundtable.

She received her dental

degree from the Herman

Ostrow School of Dentistry

of the University of Southern

California and a certificate

in pediatric dentistry from

the University of Florida. Dr.

Robinson was a member

of the ADA Council onAccess, Prevention and

Interprofessional Relations

for six years and served as

vice chair for a year and

chair for two years. She is

a founding board member

of the U.S. National

Oral Health Alliance. Dr.

Robinson practices in

Grass Valley, Calif.

Conflict of Interest

Disclosure: None reported.

David M. Krol,

MD, MPH, FAAP, a

pediatrician, is a senior

program offi cer of the

Robert Wood Johnson

Foundation. He serves on

the executive committee of

the American Academy of

Pediatrics (AAP) Section on

Oral Health and is on the

steering committee of the

AAP Oral Health Initiative.

Dr. Krol received his master

of public health degree

from the Mailman School of

Public Health at Columbia

University, and his medicaldegree from the Yale School

of Medicine. Dr. Krol played

professional baseball with

the Minnesota Twins.

Conflict of Interest

Disclosure: None reported.

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associations representing the healthprofessions3established a uniquepartnership called the InterprofessionalEducation Collaborative (IPEC), andconvened an expert panel to developcore competencies needed to train futurehealth professionals to provide team-based, quality care within an evolvingnational health care system.4Building onthis work in 2011, a conference sponsored

by the Health Resources and ServicesAdministration (HRSA) and three privatefoundations was held to develop strategiesbased on IPECs core competencies totransform health professional educationand health care delivery in the UnitedStates.5More recently, HRSA andfour private foundations funded the

National Center for InterprofessionalPractice and Education at the Universityof Minnesota to serve as a nationalcoordinating center for interprofessionaleducation and collaborative practice.

Kicking off this issue is an article byBurton Edelstein, DDS, MPH, foundingpresident of the Childrens Dental HealthProject and professor of Health Policyand Management at Columbia UniversitySchool of Dental Medicine. Dr. Edelsteinexplains how recent federal legislationcontains drivers that promote medical-dental collaboration and sets the stagefor increased integration of nancing anddelivery systems. He goes on to describeadditional trends that will inuence dental

care practice aggregation, consumerism,a population-based focus and movementtoward value-based purchasing andaccountable care organizations.

Following in the issue is the keynoteaddress given by the president andCEO of ADEA, Richard Valachovic,DMD, MPH, for the Symposium onInterprofessional Education and Practicehosted by Columbia University Collegeof Dental Medicine in June of 2012. Hedescribes how the collaborative model

will completely shift the way healthprofessionals are educated and howhealth care is delivered. This movementrepresents a profound systemic changetoward an interdisciplinary team-basedapproach to care that has the potential toincrease quality while providing greatervalue for health care dollars spent.

In the area of public health practice,community Health Centers have

pioneered the integrated deliverysystem approach made easier throughco-location of multiple disciplines,including primary care, dentistry andmental health, at the same site. IreneHilton, DDS, MPH, describes the 15-yearinitiative to develop infrastructure fordelivery system integration, highlightingsuccesses and challenges that willhelp inform other practice settings.

Paul Manos, DDS, dental directorfor United Concordia Dental (UCD),contributes a payers perspective from acompany that offers both medical anddental insurance to large group purchasers.He lays out trends within the dentalbenets industry to incorporate evidencein benet structure and the developmentof metrics to measure improvementsin health outcomes. Given the knownoral-systemic connection related to thechronic disease of diabetes, Dr. Manostells the story of how UCD researchedclaims data to determine if there was ameasurable relationship between dental

treatment and diabetic outcomes.Finally, the article by interprofessionalcolleagues at New York University, JudithHaber, APRN, PhD, Andrew I. Spielman,DMD, MS, PhD, Mark Wolff, DDS, PhD,and Donna Shelley, MD, MPH, describesthe rst eight years of experience witha pioneering model of interprofessionaleducation and collaborative practicethat began in 2005 with the merger ofthe Colleges of Dentistry and Nursing,whose goal was establishing an integrated

oral-systemic approach toward clinicaleducation, research and practiceexperience that improves health outcomesfor patients. They thoughtfully sharesuccesses, lessons learned and challengesthat will inform other institutions movingforward with this unique model.

Our great appreciation and thanks goto our authors for generously sharing theirknowledge and experience of IPE and a

multidisciplinary approach to practice.Collectively, these articles provide muchfood-for-thought on why and how dentistswill need to adapt to take on new rolesin the evolving health care system.

REFERENCES

1. World Health Organization (WHO) (2010). Framework

for action on interprofessional education and collaborative

practice. Geneva: World Health Organization. whqlibdoc.who.

int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf.

2. Institute of Medicine (IOM). Health Professions Education:

A Bridge to Quality. www.iom.edu/Reports/2003/Health-

Professions-Education-A-Bridge-to-Quality.aspx.

3. The American Association of Colleges of Nursing, the

American Association of Colleges of Osteopathic Medicine, theAmerican Association of Colleges of Pharmacy, the American

Dental Education Association, the Association of American

Medical Colleges and the Association of Schools of Public

Health.

4. Core Competencies for Interprofessional Collaborative

Practice. Sponsored by the Interprofessional Education

Collaborative. www.aacp.org/resources/education/

Documents/10-242IPECFullReportfinal.pdf.

5. Team-based Competencies. Building a Shared Foundation

for Education and Clinical Practice. www.AAMC.org/

download/186752/data/team-based_competencies.pdf.

i n t r o d u c t i o n

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h e a l t h c a r e l a w s

health benets. These benets, to beoffered by insurance plans sold in state-based insurance exchanges beginningthis year, require pediatric services,including oral and vision care. Thisphrasing, for the rst time in federal

legislation, characterizes dental servicesas an essential component of pediatrichealth care. Congress clearly deemedthat oral health care for children isto be regarded as a key component ofwell-child care, not as a separate serviceor independent benet. As such, thelaw anticipates a role for primary caremedical providers pediatricians,pediatric nurse practitioners and familyphysicians in collaboration withdental professionals, in assuring oral

Recent major federal health carelaws the Affordable CareAct (ACA) and the ChildrensHealth Insurance ProgramReauthorization Act (CHIPRA)

contain drivers for interprofessional

collaboration that promise to bridgethe medical-dental divide. Some ofthese laws provisions are explicit intheir promotion of interprofessionalcollaboration while others are implicit.Taken together, they set the stage fora future in which distinctions betweenmedical and dental delivery and nancingsystems may become increasingly muted.

Paramount among explicit driversis the very denition of dental carewithin the ACAs listing of essential

AUTHOR

Burton L. Edelstein,

DDS, MPH, is a professor

of Dentistry and Health

Policy and Management

at Columbia University in

New York City. He is also a

senior fellow in public policy

and founding president ofthe Childrens Dental Health

Project in Washington, D.C.

Conflict of Interest

Disclosure: None reported.

The Roles of FederalLegislation and Evolving HealthCare Systems in PromotingMedical-Dental CollaborationBurton L. Edelstein, DDS, MPH

A B S T R A C T Recent federal health care legislation contains explicit and implicit

drivers for medical-dental collaboration. These laws implicitly promote health

care evolution through value-based nancing, big data and health information

technology, increased number of care providers and a more holistic approach.

Additional changes practice aggregation, consumerism and population health

perspectives may also inuence dental care. While dentistry will likely lag behind

medicine toward value-based and accountable care organizations, dentists will be

affected by changing consumer expectations.

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health supervision from early in a childslife. Congresss action reects increasingoral health activity by pediatric healthcare experts. According to the AmericanAcademy of Pediatrics, roles for medicalproviders in an integrated approachto oral health supervision includescreening, counseling, uoridating(typically with uoride varnish) andreferring for ongoing comprehensive

dental care.1Additional evidence oforal health engagement by primary caremedical providers include the AmericanAcademy of Family Physicians Smiles forLife online curriculum,2the AmericanAcademy of Pediatrics Bright Futureswell-child guidance3and ChildrensOral Health activities,4increasingnumbers of state Medicaid programsthat reimburse primary care medicalproviders to apply uoride varnish5andfederal Medicaids requirement that statesreport on the number of children [inMedicaid and CHIP] receiving [dental]services from a nondentist provider.6

Unfortunately, recent federalregulatory efforts addressing theparticipation of stand-alone dentalinsurers in the exchanges haveperpetuated the longstanding segregationof dental from medical coverage,nancing and care. Integration of dentalservices with pediatric health care willnow depend signicantly on actionstaken by states as they tailor their

exchange policies and procedures inways that can either promote or countermeaningful medical-dental integration.

ACA also anticipates the need tobetter train both dental and medicalpediatric providers in the best care ofchildren with regard to their oral health.Embedded in the authorization for primarycare dental programs is an authorizationfor grants to provide technical assistanceto pediatric training programs in developingand implementing instruction regarding the

oral health status, dental care needs and

risk-based clinical disease management ofall pediatric populations with an emphasis

on underserved children. Congressionalintent was to ensure that both dentaland medical providers of pediatricservices would enhance their learningand skills in ways that address inequitiesin oral health and best practices forprevention and disease management.

Also explicit in promoting medical-dental collaboration around oral healthis the requirement in CHIPRA thatstates, The Secretary shall develop and

to implement this provision that isprogressive in its neonatal attention tooral health and its assumption of sharedresponsibility by medical insurers.

Less obvious, but perhaps more far-reaching, are other elements of ACAand CHIPRA that aggressively stimulatesystemic change in U.S. health care.While these will impact medical providersinitially, they are likely to impact dental

providers over time as they play outin health care marketplaces across thecountry. These may either facilitate orhamper integration depending upon localor state action by governments, healthcare systems, insurers and provider groups.Yet each of these elements of health careenvisioned by ACA can be consideredpotential drivers of change that maystimulate creative and dynamic advancesin U.S. health care, including medical,dental and interdisciplinary endeavors.

Value-based PurchasingPaying for value (that is, incentivizing

best health outcomes per unit cost),rather than our current practice of payingfor volume (that is, rewarding numbersof services regardless of outcomes), is arevolutionary approach to health carenancing that requires outcome metricsthat are meaningful, measurable andmanageable. Envisioned by ACA areglobal payments to vertically integratehealth care systems called accountable

care organizations (ACOs) thatincentivize aggregate health outcomesfor the covered population. In such asystem, for example, medical providerswould be paid based on the proportionof patients diagnosed with hypertensionwho are normotensive, of diabeticswho have a stable hemoglobin A1C,of smokers who quit smoking and/orthe proportion of births that are notpremature or underweight. As oral healthis increasingly recognized to impact

implement, through entities that fund orprovide perinatal care services to targeted

low-income children, a program todeliver oral health educational materials that

inform new parents about risks for, andprevention of, early childhood caries and theneed for a dental visit within their newborns

rst year of life.This requirement

engages health plans and obstetrical andpediatric medical providers in assuringthat new parents are informed aboutoral health and dental care appropriatefor their newborns. By structuring therequirement in this way, Congresshas paved the way for medical-dentalintegration and has shared responsibilityfor oral health promotion with medicalproviders. Again, regulations have notkept up with congressional intent asno nal rules have yet been established

h e a l t h c a r e l a w s

This phrasing, for thefirst time in federal legislation,characterizes dental servicesas an essential component

of pediatric health care.

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many medical conditions, one strategythat ACOs might pursue in maximizingtheir value proposition is the inclusionof dental services within their medical-management programs for patients whohave such chronic conditions or arepregnant. In such cases, the potentialpositive return on investment in dentalcare may overwhelm any reticence toinclude dental care in chronic disease

management protocols or prenatal care.Such creative and dynamic rethinkingof the medical-dental interface maybe a natural outgrowth of value-basedpurchasing, vertical integration andACOs. Additionally, value-basedpurchasing will likely reach dentistryat some time in the future. Suchnancing approaches will require thatdentistry demonstrate value in terms ofhealth outcomes rather than assume,as is inherent in nancing today, thatmore procedures yield better oralhealth outcomes. As dentistry exploresoptions to implement such an approach,it may look to and further engagewith medicine to learn of potentialcollaborations, pitfalls and best practices.

A secondary impact of this value-based purchasing and recognition ofthe importance of dental care withingeneral health care is a potential shiftin perception about dentistry itself.Today, many patients and potentialpatients perceive dentistry as an elective,

esthetics-oriented service that is focusedon whitened, straightened teeth ratherthan as an essential health service. Aspatients increasingly nd dental providersembedded within medical systems ofcare, this awareness is likely to growconsiderably. As they become accustomedto medical care that is oriented to theiroverall health status, rather than to onlythe alleviation of their current medicalproblem, they may similarly look todentists for oral health outcomes.

Big Data and Health InformationTechnology (HIT)

Although authorized through aseparate law, the health informationtechnology for economic and clinicalhealth (HITECH) provisions of the 2009American Recovery and ReinvestmentAct (ARRA) are intimately linked toACA provisions in support of healthcare information technology that

seamlessly informs a patients multipleproviders, is interoperable across variousIT platforms and promotes efciencythrough the elimination of redundancy.

processing vendor, each purchase madeonline and each web-based activityengaged by dentists creates a datatrail that can be aggregated by bigdata vendors. Using algorithms, thesevendors can both target the individualdentist and characterize each dentistscontribution to the overall dentaldelivery system. Algorithms that linkmedical and dental care, particularly

around individual practices or patients,may in the future drive enhancedinterprofessional collaboration. As healthsystems continue to aggregate smallproviders (individual and small grouppractices), it is easy to envision a daywhen a patients record on a computerscreen reminds the dentist to monitor thepatients blood pressure or hemoglobinA1C and to remind the patient ofan upcoming medical visit or dietaryrecommendation. Such medical-dentalintegrated records systems are already inplace in many health care systems andhealth centers, notably the VeteransAdministration and the Family HealthCenter of Marsheld in Marsheld, Wis.

The National Institutes of Health isalready engaged in promoting the best useof big data and HIT to advance boththe content and structure of U.S. healthcare. It has recently initiated a big datato knowledge (BD2K) initiative to fundlong- and short-term training at allprofessional levels, in areas essential

for accessing, organizing, analyzing andintegrating biomedical big data.8

More Primary Care Providers andNew Provider Types

The ACA foresees the ongoing needfor expanded availability of primary caremedical and dental services and takes anumber of steps to promote expansionsincluding increased training grants andgraduate medical education support forprimary care training in medicine and

The interoperability requirement coupledwith the meaningful use requirement7for certied electronic health records willfacilitate medical-dental collaborationthrough HIT. Already in place aresignicant multiyear nancial incentivesto medical and dental providers whoparticipate in federal insurance programs

to purchase hardware and software.Also driving the likely impact of HITin dentistry is the growing adoptionof electronic health records and ofcemanagement programs by dentists,even without federal incentives. Whileindividual dentists, practicing in solo orsmall group environments, may regardthemselves as independent, electronicrecords systems create virtual networksof dental practices. Each dental claimsubmitted through an electronic claims

The potential positive returnon investment in dental caremay overwhelm any reticenceto include dental care in

chronic disease managementprotocols or prenatal care.

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dentistry, expanded funding to trainprimary care faculty and assistance withfaculty loan repayment, authorizationto fund demonstrations of alternativedental providers, including those whowould work with medical providers, andsupport of a multidisciplinary publichealth workforce program. The lawalso authorizes a National Health CareWorkforce Commission to support

national, state and local policymaking,coordinate workforce issues acrossagencies, evaluate the education andtraining of health professionals withregard to demand for services, facilitatecoordination across levels of governmentand encourage workforce innovations.Because dentistry is cited as a priorityissue for the commission, it is likelythat interprofessional collaborationsand mainstreaming of dentistrywithin primary health care are likelytopics for the commission to explore.

In their search for efciency andvalue, ACOs will also drive expandedroles for nontraditional health careproviders, especially for the helpingprofessions and ancillary health workers,including health educators, nutritionists,social workers, technicians, psychologists,pharmacists and community healthworkers, among others. These healthcare counselors will promote wellness,advance health literacy, encouragepositive health habits and facilitate

individualized care plans. Many arelikely to be generalists in the sensethat they will engage patients inholistic health promotion that is assalutary for oral as general health.

Federal legislation has a secondaryeffect of promoting other changescurrently underway in the health carenancing and delivery environments.These too may devolve onto dentistryas they continue to play out in thelarger health care environment.

Practice AggregationAs health care providers are called upon

to become increasingly cost-conscious,as consumers of health care services gainaccess to comparative cost informationon the web and as the public has becomeincreasingly savvy about their healthcare needs, there is growing pressure tocapitalize on economies of scale and newbusiness models. The solo physician is

becoming scarcer. Medical group practicesare increasing in numbers and size.Practice management organizations areevolving. Health systems are purchasing

only to the health of individuals, isa concept of increasing interest tohealth care purchasers. Governmentand business alike seek to determinehow a covered populations healthimpacts other issues of importance tothem, issues as disparate as workforceproductivity and disability payments.

Considering all of these explicit andimplicit legislative drivers for health care

change that may promote interprofessionalengagement, it appears that dentistryis likely to be at the tail end of thisnext health care evolution. Dentistsare likely to become engaged in thesetransformations rst through the back doorwherever ACOs determine that dentalservices can truly improve managementof medical conditions. With time, ifthese changes come to be and if patientsroles and views evolve as these forcesanticipate, our patients too may expect adifferent kind of care one that is moreabout oral health than about dental repair.

While medical care system evolutionmay or may not move the majority ofdentists into tighter collaboration withmedical care providers, it will likelycreate many opportunities for someto engage in interdisciplinary value-based medical systems. Others mayemulate the best of what they see onthe medical side while remainingindependent of ACOs, and still othersmay elect to watch from the sidelines.

Regardless of which path a dentist maychoose, it is the health of our patientsthat can benet most from ever-strongermedical-dental collaboration.

REFERENCES

1. Section on Pediatric Dentistr y and Oral Health, American

Academy of Pediatrics. Policy Statement: Preventive Oral

Health Intervention for Pediatricians. Pediatrics

2008;122:1387-1394. Doi. 10.1542/peds.2008-2577.

pediatrics.aappublications.org/content/122/6/1387.full.

2. Society of Teachers of Family Medicine Group on Oral

Health. Smiles for Life: A National Oral Health Curriculum

(3rded.). Continuing education credits by the American Academy

of Family Physicians. AAFP certification begins March 11, 2013.

and aggregating small practices into theirsystems in preparation for transformationinto ACOs. Medical care is moving closerto the public via urgent care centers, docsin the box, expanding roles for pharmacistsand placement of nurse practitioners inpharmacies and other consumer sites.

ConsumerismInformation technology, socialnetworking and a growing sense ofconsumer empowerment in healthcare are changing the patient-doctordyad in ways that may both promoteand endanger health outcomes.

Population HealthPopulation health, the notion

that health care providers contributeto the health of groups rather than

Regardless of which patha dentist may choose, it isthe health of our patientsthat can benefit most from

ever-stronger medical-dentalcollaboration.

h e a l t h c a r e l a w s

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www.smilesforlifeoralhealth.org. Accessed on May 22, 2013.

3. Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures:

Guidelines for Health Supervision of Infants , Children,

and Adolescents, 3rd ed. Elk Grove Village, IL: American

Academy of Pediatrics (AAP). Funded by the Health Resources

and Services Administrations (HRSA) Maternal and Child

Health Bureau (MCHB) . brightfutures.aap.org/3rd_Edition_

Guidelines_and_Pocket_Guide.html. brightfutures.aap.org.

Accessed on May 22, 2013.

4. Section on Oral Health and Chapter Oral Health Advocates.

American Academy of Pediatrics. Childrens Oral Health

website funding provided by the Health Resources and Ser vices

Administrations Maternal and Child Health Bureau and the

American Dental Association Foundation. www2.aap.org/oralhealth. Accessed on May 22, 2013.

5. Deinard, A. More State Medicaid Programs Pay for

Childrens Oral Health Prevention Ser vices in Doctors Offi ces.

Celebrating Our Wins. January 2013. American Academy of

Pediatrics. Division of State Government Affairs. www2.aap.

org/oralhealth/docs/CelebratingOurWins.pdf. Accessed on

May 22, 2013.

6. 2700.4 Early and Periodic Screening, Diagnostic, and

Treatment (EPSDT) Report (Form CMS-416). CMS 416

Instruction (June 2011 version) . Medicaid.gov, Keeping

America Healthy. Centers for Medicare & Medicaid Services.

www.medicaid.gov/Medicaid-CHIP-Program-Information/

By-Topics/Benefits/Early-Periodic-Screening-Diagnosis-and-

Treatment.html. Accessed on May 22, 2013.

7. Meaningful Use Definition & Objectives. Electronic Health

Record (EHR) Incentives & Certification. HealthIT.gov. www.

healthit.gov/providers-professionals/meaningful-use-definition-objectives. Accessed on May 22, 2013.

8. NIH Offi ce of the Director. NIH News. National Institutes of

Health. U.S. Department of Health and Human Services. Press

release: December 7, 2012. NIH proposes critical i nitiatives to

sustain future of U.S. biomedical research. Actions would aim

to strengthen the biomedical research workforce and manage

deluge of data. www.nih.gov/news/health/dec2012/od-07.

htm. Accessed on May 22, 2013.

THEAUTHOR, Burton L. Edelstein, DDS, MPH, can be reached [email protected].

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k e y n o t e a d d r e s s

I was asked to speak on buildinga foundation for interprofessionaleducation and practice. In order forme to do that, I need to provide a bitof a historical perspective as well aslet you know about my work at theAmerican Dental Education Associationrelated to interprofessional educationand collaborative practice. Just threeyears ago, the term IPE, as we now callinterprofessional education, was a bit ofan ethereal concept to which I devotedvery little time in my role as executive

director of the ADEA. Today, the workthat I do that is related to IPE consumesabout a third of my time. Three yearsago, there were not even architecturaldrawings for a foundation of IPE inhealth professions education. Today, thefoundation has been built just as surelyas if it were concrete and plans are beingnalized for the rest of the structure.

What happened in these three years tomake such a tectonic shift occur? We allrecognize that the cost of health care in

The following remarks were made byDr. Valachovic as the keynote address

at the Symposium on InterprofessionalEducation and Practice hosted by theColumbia University College of Dental

Medicine on June 14-15, 2012.

Interprofessional education andpractice are game changers. They willcompletely change the way that healthprofessionals are educated and theway that health care is delivered. The

transition from our current silo-based

approach to team-based education andpractice is underway, and there is nothingthat we can do to stop it from happening.I say that these are game changers. Theyare. The changes that are underway arenot just minor revisions of the rules thathave been in place for the last century.The changes represent a systemic changein the culture of health professionseducation and practice. And for thoseof us in the dental profession, I rmlybelieve that it is a game changer as well.

AUTHOR

Richard W. Valachovic,

DMD, MPH, is the

president and CEO of

the American Dental

Education Association

(ADEA). Dr. Valachovic

has led the organizations

work in integrating dentistry

with interprofessional

education and practice,

and represents ADEA on the

Interprofessional Education

Collaborative (IPEC).

IPECs focus is to more

thoroughly coordinate and

integrate the education of

dentists, physicians, nurses,pharmacists, public health

professionals and other

members of the health

care team to provide more

collaborative and patient-

centered care. This address

is reprinted with permission

from Dr. Valachovic.

Conflict of Interest

Disclosure: None reported.

Integrating Oral and OverallHealth Care On the Roadto Interprofessional Educationand Practice: Building a

Foundation for InterprofessionalEducation and PracticeRichard W. Valachovic, DMD, MPH

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the United States consumes way too muchof our gross domestic product. The U.S.spends more on health care as a percentageof GDP than any other country in theworld. And of the money that we spend onhealth care in this country, nearly two-thirds of it comes from the government interms of Medicare, Medicaid, TRICAREfor military personnel, CHIP and theVeterans Administration. In the private

sector, more and more individuals arebeing insured by major managed healthcare systems like Kaiser Permanente,UnitedHealthcare, Geisinger, MayoClinic and others. UnitedHealthcarealone insures 70 million Americans.And at the same time, we also recognizethat the quality of care remains a criticalissue to be addressed. Are there ways tobend the health care cost curve and toraise the level of quality of the care thatis being provided? Team-based care isnow being recognized as one of the mostpromising answers to this question. Andto have team-based practice, one has tobegin with interprofessional education.Which comes rst, IPE or team-basedcare? A question like this should have aneasy answer. But it is much more like thequestion, Which came rst, the chickenor the egg? The answer is not so easy.

So what has happened in the past fewyears to drive the IPE and team-basedcare train? First there are market forces.The large managed health care systems

like UnitedHealthcare and others haverecognized that there are signicant costsavings and improved patient outcomesthrough team-based care. Add to thisthe experience of the VA and othergovernmental health care systems thatuse team-based care approaches, andone can start to see the impact. The year2012 is the rst year that more than 51percent of all physicians are employeesand not independent practitioners. Wehave to acknowledge that Dr. Marcus

Welby has nally closed his practice. Weknow that many of these systems willinclude dental care as part of their marketapproaches to differentiate themselvesfrom their competitors. Second, therewill be regulatory issues, and these willbe in place no matter what the decisionis of the Supreme Court this month orthe presidential election in November.The Patient Protection and Affordable

Care Act is focused on team-basedcare. Throughout the law, there aremultiple references to team-based andcollaborative care. Included in the law is

regulatory and delivery portal issues will beon the value of prevention. The Centersfor Medicare and Medicaid ServicesInnovation Fund and the CDC are nowsponsoring a prevention effort called theMillion Hearts Campaign, working toprevent a million heart attacks and strokesin the next ve years. The campaignaddresses the ABCS aspirin, bloodpressure, cholesterol and smoking. Less

than half of Americans meet the targetsfor these factors. In my conversationswith leaders at CMS and at CDC, theyalways point to dentistry as the exampleof successful prevention. Sure, we allknow that community water uoridationis recognized as one of the 10 publichealth successes of the 20th century. Butthey also always talk about their dentalhygienist, and how the hygienist is themost effective prevention provider outthere, making each of them feel guiltyabout ossing and their oral health. Thereis a general feeling that dentistry has muchto offer the rest of the health care worldas they develop prevention strategies.

So, what does the foundationfor interprofessional education andcollaborative practice look like? As I havebeen saying, the speed of change in IPE isunbelievably fast. We are in whitewaterright now. So much has happened in justthe last three years. If I were to identifywhere it all started and the foundationwas being laid, it would be the decision

by six associations of schools of the healthprofessions that came together in 2008, theAssociation of American Medical Colleges(AAMC), the American Associationof Colleges of Osteopathic Medicine(AACOM), the American Associationof Critical-Care Nurses (AACN), theAmerican Association of Colleges ofPharmacy (AACP), the Association ofSchools of Public Health (ASPH) and us,to form the Interprofessional EducationCollaborative, what we refer to as the

There is a general feelingthat dentistry has much tooffer the rest of the healthcare world as they develop

prevention strategies.

the implementation of accountable careorganizations, or ACOs, for which team-based care will be one of the primary waysthat systems can nancially succeed andcompete under this new structure. Thereare many, many references to dental carein the ACA, especially for children. Third,there will be issues related to the way in

which health care is delivered. The focusof health care delivery in the future willbe in ambulatory medical and surgicalsettings. Hospitals will become much morefocused on intensive care. Chronic diseasemanagement is much more likely to beprovided in community settings. Thesedelivery portals are much more efcientwhen care is delivered by a team. In lightof this, dental care is much more likelyto be delivered integrated with these newsettings. Fourth, a focus of these market,

k e y n o t e a d d r e s s

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IPEC. We decided to come together todevelop a common set of competenciesfor interprofessional education andpractice. The report, Core Competencies forInterprofessional Collaborative Practice, wasproduced by an expert panel convened bythe IPEC, and each of us appointed tworepresentatives to serve on the panel. Ourrepresentatives were Sandra Andrieu, PhD,from LSU School of Dentistry and Leo

Rouse, DDS, from the Howard UniversityCollege of Dentistry. The report, releasedlast May, identies four broad domains ofinterprofessional competency valuesand ethics, roles and responsibilities,interprofessional communicationand team-based care as well as 38subcompetencies that specically describeessential behaviors. The six of us whoare the chief appointed ofcers of ourorganizations have met every Mondaymorning for the past three years and oncea month for a full day meeting. Two keyreports were also released during this time,one in Lanceton IPE and collaborativepractice and the other by the Institute ofMedicine on the future of nursing. Bothof these reports highlight the value of IPEand team-based care, and the importanceof allowing health care professions to workat the full scope of their licenses. ADEAis a founding member of a new Instituteof Medicine Global Forum on Innovationin Health Professional Education. Thesix of us in the IPEC created an IPEC

Faculty Development Institute. Thirtyacademic health centers (AHC) sentteams from multiple schools withintheir AHC to a program that we held inWashington, D.C., last month, of which11 had a dental school representative.Sixty additional AHCs are on a waitinglist for an additional program that willbe held in October. On behalf of theIPEC, AAMC has established a newportal within MedEdPORTAL to houseresources for IPE for all of the health

professions. Throughout all of this, GeorgeThibault, MD, and the Macy Foundation,along with many others, have beenstrong supporters of the work developingthese documents and resources. Finally,there has been signicant movementwithin the accrediting bodies of thehealth professions, including theCommission on Dental Accreditation(CODA), to promote the integration

of IPE into the curriculum.There is no doubt that the challenges

to implementing IPE on campuses canbe enormous. There are logistical issues

So, lets come back to dentistry andthe reasons that dentistry needs to be partof IPE now and collaborative practicein the future. Whatever the relationshipbetween oral health and overall well-beingturns out to be, the mouth will remain asignicant source of inammation. Wenow practice in a primary care model inambulatory settings in the vast majorityof cases. There are more than 300 million

dental encounters each year, and for themost part, they are well-patient visits, asopposed to medical visits, which tend tobe motivated by some sign or symptom of adisease or medical condition. Dentistry hasan historical focus on primary prevention.The mouth is a mirror of many underlyingconditions in the human body. Ourpatients are living longer, are retainingmore of their teeth through the end oftheir lives and have more complicatedmedical conditions, often requiring morecollaboration between the dentist and thepatients health care provider. One of thekey results from the reports that we aregetting from the eld is that the personalrelationships that develop when dentalstudents and residents are part of healthcare teams result in a much more effectiveunderstanding of the role that dentists playin the well-being of patients and enhancedreferrals for dental care are the result.

I believe that the opportunities for usas educators to introduce interprofessionaleducation are immense at this time,

that improved patient outcomes willresult, that dentistry will nally beintegrated into an overall approach tohealth for our patients and that all ofsociety will be better off as a result.

Thank you for your attention.

THEAUTHOR, Richard W. Valachovic, DMD, MPH, can bereached at [email protected].

There are more than 300million dental encounterseach year, and for the mostpart, they are well-patient visits,

as opposed to medical visits.

related to the timing of semesters, of classtime scheduling and of externship androtation lengths. The individual schoolswithin many academic health centersare geographically distributed, and someactually have their health professionsschools in different cities. For dentalschools, not all of our campuses are

within universities that have a medicalschool. There are cultural issues thatneed to be overcome. The pipeline fornew health professions students includemany who assume that independentsiloed practice is what they have dreamedof and are led to believe would beavailable to them. But, we in the IPECbelieve that with the right leadershipand the appropriate commitment,these mostly logistical challengeswill be addressed and eliminated.

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h e a l t h c e n t e r s

podiatry, optometry, laboratory, imagingand alternative medicine. Dental careis one of the most frequently providedservices. In 2011, of 1,128 granteeorganizations, 862 Health Centers (77percent) had at least one dental site, andcollectively provided dental care to 4million individuals.5It should be noted,however, that these numbers show that

Health Center dental programs currentlyonly have the capacity to meet the needsof 23 percent of the medical users.

Because the majority of HealthCenters have at least one location whereprimary care is located at the same siteas dental and other health services,intuitively, Health Centers would appearto be ideal locations for the developmentof programs and initiatives that explorecloser collaboration between disciplinesand afford the opportunity to study

Health Centers are community-based and patient-directedorganizations that servepopulations with limitedaccess to health care.1Health

Centers were rst developed and fundedin the mid-60s as part of PresidentLyndon Johnsons war on poverty.2,3Section 330 of the Public Health Service

Act consolidated and dened thecharacteristics of Health Centers.4Froman initial group of two demonstrationsites, the number of Health Centershas grown to 1,128 organizations acrossthe United States and its territories,many with multiple clinic locations,providing primary care medical servicesto 20.2 million individuals in 2011.5

Most Health Centers provide multiplehealth care services that can includedental, behavioral health, pharmacy,

AUTHOR

Irene V. Hilton, DDS,

MPH, is a clinical dentist

with the San Francisco

Department of Public

Health, a dental consultant

for the National Network

for Oral Health Access

and a California Dental

Association trustee.

Conflict of Interest

Disclosure: None reported.

Interdisciplinary Collaboration:What Private PracticeCan Learn From the HealthCenter ExperienceIrene V. Hilton, DDS, MPH

A B S T R A C T Ideas on what medical-dental integration can look like on a practical

level can be gained from studying efforts made in Federally Qualied Health Centers

(Health Centers). Over the last 15 years, Health Centers have embarked on several

initiatives that incorporated the development of infrastructure for medical-dental

integration. This paper reviews these efforts and highlights successes, challenges and

best practices that can bolster efforts in all dental practice settings.

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the implementation of such programsand understand the facilitators andbarriers to successful implementation.

Early ExperiencesThe initial experiences in medical-

dental integration in Health Centersoccurred in 1998, when the HealthResources and Services Administration(HRSA) Bureau of Primary Health Care

(BPHC), in partnership with the Institutefor Healthcare Improvement, embarked ona nationwide initiative to improve care forpeople with chronic conditions by fundingHealth Disparities Collaboratives.6The rstCollaborative focused on diabetes, one ofthe most common chronic diseases foundin Health C