April 2019 Comprehensive Older-Adult Care Interprofessional Oral Health Education Spectrum of Prevention JournaCALIFORNIA DENTAL ASSOCIATION Strategies Applications

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DEPARTMENTS

205 The Editor/So Chocolate Is Not a Remedy?

207 Impressions

273 RM Matters/Balance Honesty With Objectivity When Addressing Prior Treatment

277 Regulatory Compliance/Are You Cybersecurity Aware? 282 Tech Trends 207

FEATURES

213 Older Adults: The Long and Winding Road To Address Their Needs An introduction to the issue. Elisa M. Chávez, DDS

217 On Lok PACE Integrates Oral Health Care as Part of Comprehensive Health Care for Seniors This article demonstrates how PACE integrates with an interdisciplinary adult day health center to provide medically necessary dental coverage for skilled-nursing eligible older adults. Diana Teng, MSN, RN, AGNP; Bonnie Lederman, DDS; and Charlotte Carlson, MD, MPH

225 The Gary and Mary West Senior Dental Center: Whole-Person Care by Community-Based Service Integration This article summarizes the new whole-person community-based integrated care model, results from the first year of operations, lessons learned and considerations for how dental providers can better care for seniors. Karen Becerra, DDS, MPH; Tracy L. Finlayson, PhD; Ayrielle Franco, MPH; Padideh Asgari, MPH; Ian Pierce, MS; Melinda Forstey, MBA; Paul Downey, BA; Joseph Gavin, MS; and Eliah Aronoff-Spencer, MD, PhD

235 Strategies for Oral Health Care Practitioners To Manage Older Adults Through Care-Setting Transitions The goal of this paper is to describe strategies for oral health care professionals to manage care for older adults over a lifetime using dependency, living environments and care settings as a framework. Elisa M. Ghezzi, DDS, PhD, and Mary M. Fisher, DDS

247 Developing an Interprofessional Oral Health Education System That Meets the Needs of Older Adults This article discusses how education can bridge the silos between dental and medical care to better serve older adults who suffer from complex dental and medical conditions. Kathryn A. Atchison, DDS, MPH; Anita Duhl Glicken, MSW; and Judith Haber, PhD, APRN, BC

257 A Conceptual Framework for Improving Oral Health Among Older Adults: Application of the Spectrum of Prevention Strategies This paper examines the oral health of older adults and discusses the application of the Spectrum of Prevention strategies to address the complex needs of older adults. Jayanth Kumar, DDS, MPH, and Ravi Dasu, PhD

265 A Dental Benefit in Medicare: Examining the Need in California This paper reviews the current oral health status of older Californians, the bidirectional relationship with systemic health and the barriers to access affordable dental services, including the limitations of the Medi-Cal Dental Program. Sahiti Bhaskara, MPH, BDS; Amber C. Christ, JD; Conrado E. Barzaga, MD; Kevin Prindiville, JD; and Elisa M. Chávez, DDS

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Volume 47, Number 4 JournaCALIFORNIA DENTAL ASSOCIATION April 2019 CDA Classifieds.

Free postings. published by the Editorial Production Manuscript California Kerry K. Carney, DDS, CDE Randi Taylor Submissions SENIOR GRAPHIC DESIGNER Priceless results. Dental Association EDITOR-IN-CHIEF www.editorialmanager. 1201 K St., 14th Floor [email protected] com/jcaldentassoc Sacramento, CA 95814 Upcoming Topics Ruchi K. Sahota, DDS, CDE 800.232.7645 May/Biomaterials ASSOCIATE EDITOR Letters to the Editor cda.org June/Sleep-Disordered

Breathing www.editorialmanager. Brian K. Shue, DDS, CDE July/Safety and Risk com/jcaldentassoc ASSOCIATE EDITOR CDA Offi cers Management I R. Del Brunner, DDS Subscriptions PRESIDENT Gayle Mathe, RDH Advertising Annual subscriptions are [email protected] SENIOR EDITOR Sue Gardner available to association ADVERTISING SALES members at a rate of $36. Richard J. Nagy, DDS Elisa M. Chávez, DDS To manage your printed PRESIDENT-ELECT GUEST EDITOR [email protected] Journal subscription online, [email protected] 916.554.4952 Andrea LaMattina, CDE log in to your cda.org account or email Judee Tippett-Whyte, DDS PUBLICATIONS MANAGER Permission and [email protected] for VICE PRESIDENT Reprints Kristi Parker Johnson assistance. View the [email protected] Andrea LaMattina, CDE EDITORIAL AND publication online at PUBLICATIONS MANAGER COMMUNICATIONS SPECIALIST cda.org/journal. Ariane R. Terlet, DDS [email protected] SECRETARY 916.554.5950 [email protected] Blake Ellington TECH TRENDS EDITOR Steven J. Kend, DDS TREASURER Jack F. Conley, DDS [email protected] EDITOR EMERITUS CDA classifiedsclassifieds wworkork harder to Debra S. Finney, MS, DDS, Robert E. Horseman, DDS bbringring you resuresults.lts. SeSellinglling a practice SPEAKER OF THE HOUSE HUMORIST EMERITUS or a piece ooff equipment? Now you [email protected] Connect to the CDA community by can include photos to help buyers Natasha A. Lee, DDS IMMEDIATE PAST PRESIDENT following and sharing on social channels see the potential. [email protected]

And if you’re hiring, candidates Management @cdadentists anywhere can apply right from Peter A. DuBois EXECUTIVE DIRECTOR the site. Looking for a job? You can Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. post that, too. And the best part— Carrie E. Gordon CHIEF STRATEGY OFFICER Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. it’s free to all CDA members. Kristine Allington The California Dental Association holds the copyright for all articles and artwork published CHIEF MARKETING OFFICER All of these features are designed to herein. The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for help you get the results you need, Alicia Malaby any expression of opinion or statement of fact, all of which are published solely on the authority COMMUNICATIONS of the author whose name is indicated. The association reserves the right to illustrate, reduce, faster than ever. Check it out for DIRECTOR revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal. yourself at cda.org/classifieds. Cris Weber CREATIVE AND UX DIRECTOR Copyright 2019 by the California Dental Association. All rights reserved.

204 APRIL 2019 Editor CDA JOURNAL, VOL 47, Nº4

So Chocolate Is Not a Remedy? Kerry K. Carney, DDS, CDE

othing seems as true on the face of it as data that support a previously held With just a little digging, and just a little belief. That is confi rmation scientifi c skepticism, these benefi ts start to look bias in a nutshell. We Ntend to attribute greater importance more like unfounded, poorly tested claims. to and have more faith in facts that support our opinion. Conversely, facts that call into question or contradict our beliefs may be deemed inconsequential His early research dealt with how norm: One week coffee, cheese and or simply untrue (read: fake). people make decisions about what and red wine are found to be protective That is why I like to read about how much they eat. He found that against heart disease and cancer, and the health benefi ts of dark chocolate. the size of the plate infl uenced the the next week a new crop of studies It is so reassuring to read that my daily amount of food that was consumed. pronounce that they cause it.”2 1- to 2-ounce dose of dark chocolate is He published more and more and Rigorous, random controlled trials helping me live a healthier, happier life. at some point his articles began to are diffi cult to perform even in a It is easy to Google sources that attract highly critical attention. His laboratory. Nutrition epidemiology is presume to assure the public that the data detractors pointed out the defi ciencies usually based on notoriously unreliable supporting chocolate’s nutritional benefi ts in the academic rigor of his research. subject recall and recording. In are reliable and trustworthy. But with just They argued “that an alarming addition, there are many other factors, a little digging, and just a little scientifi c number of food studies are misleading, like “exercise, socioeconomic status, skepticism, these benefi ts start to look unscientifi c or manipulated to draw sleep, genetics and environment,”2 that more like unfounded, poorly tested claims. dubious conclusions.”2 Specifi cally, may infl uence health and obscure the The retail food industry in the U.S. Dr. Wansink and his co-authors cause and effect associations of diet. totaled $5.75 trillion in 2017.1 Weight- were accused of data dredging. “You can analyze observational loss programs were responsible for a little Data dredging is the opposite of the studies in very different ways and more than $68 billion in the same year. scientifi c method. Where the scientifi c depending on what your belief is — With that kind of money at stake, it is no method is based on the principles of and there are very strong nutrition wonder that nutrition, diet and marketing observation, hypothesis construction, beliefs out there — you can get can become inextricably confl ated. experimental testing of a null hypothesis some very dramatic patterns.”2 The New York Times recently and conclusion, data dredging involves In order to reduce the practice chronicled the decline and disgrace of a casting a wide net over a fi eld of of data dredging, some authorities former rising star of nutrition studies, Brian observations and speculating causal have suggested the following Wansink, PhD, of Cornell University. relationships based on associations that guidelines for nutrition studies: His story typifi es the ongoing problems may be the result of random chance. ■ Register study protocols with food and nutrition research today. For example, Dr. Wansink would beforehand. Dr. Wansink became a media ask his associates to mine existing data ■ Share raw data to increase darling, writing best-selling books, for associations that might produce transparency. publishing numerous studies and being controversial or interesting articles ■ Focus on large randomized the go-to interview for health and that would get a lot of attention. controlled trials to produce diet. He served in “a top nutrition This technique is not uncommon in stronger statistical evidence. policy role at the Department of food studies. According to the Times, ■ Refrain from reworking large Agriculture under George W. Bush, “nutrition epidemiology is notorious observational data sets into where he helped shape the government’s for this … it is one reason contradictory multiple research papers to avoid infl uential dietary guidelines.”2 nutrition headlines seem to be the magnifying weak results.2

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The Journal welcomes letters Though Dr. Wansink has had to the right side of that divide. We are retract at least seven papers, his critics grateful for the time they volunteer We reserve the right to edit all are quick to point out that the research to keep their colleagues up to date. communications. Letters should discuss an problems that he epitomizes are not So, chocolate is probably not much item published in the Journal within the last unique to nutrition studies. Retraction of a remedy for anything, but surely the two months or matters of general interest to our Watch, a website that keeps track of such walk to the kitchen to retrieve another readership. Letters must be no more than 500 things, contrasted Dr. Wansink with an piece of chocolate at least increases words and cite no more than fi ve references. No anesthesiologist on their list who had physical activity by some small amount. illustrations will be accepted. Letters should be 183 retracted papers to his discredit. Can that be anything but good? There submitted at editorialmanager.com/jcaldentassoc. It is easy to get people to write about must be some data to support that. ■ By sending the letter, the author certifi es that nutrition and diet but it is very diffi cult to neither the letter nor one with substantially similar get the articles through peer review. Good REFERENCES content under the writer’s authorship has been peer review is what divides a scientifi c 1. U.S. Food Retail Industry — Statistics and Facts. www.statista. published or is being considered for publication journal from a magazine. We depend com/topics/1660/food-retail. 2. O’Connor A. No, Chocolate Probably Isn’t a elsewhere, and the author acknowledges and on the expertise and professionalism Superfood. www.wral.com/no-chocolate-probably-isn-t-a- agrees that the letter and all rights with regard to of our reviewers to keep the Journal on superfood/17882364. the letter become the property of CDA.

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206 APRIL 2019 Impressions CDA JOURNAL, VOL 47, Nº4

Getting Rights Right David W. Chambers, EdM, MBA, PhD

Somebody told me years ago that just because somebody has a right to do something does not mean it is right for him or her to do it. We are free to do many stupid things. A who believes his or her colleague is practicing below the standard of care has a right to notify some party within organized dentistry to say so. (The ADA code of professional conduct says a dentist in such a position MUST do so. As far as I know, no dentist has ever been removed from organizational membership for failing to do so. The California Dental Association Code of Ethics does not contain this provision.) The difference between having a right and doing what is right comes down to the ground on which one makes a stand. Licensure: practice on a license to provide commercial services to the public in a safe and nondiscriminatory fashion. State attorneys general manage licenses consistent with statutes and regulations voted by legislatures and enforce these through investigatory mechanisms and state dental boards (or state comprehensive health professional boards). Professional membership: Two-thirds of dentists belong to organized dentistry. This is a voluntary membership that The nub: includes a promise to abide by a code of professional conduct. Typically, the code contains behavior concerning relationships 1. Lay state representatives among professionals who are not part of licensure and a clause grant licenses; organized saying that all members must also abide by civil laws and dentistry grants membership. licensure requirements in the appropriate jurisdictions. There are separate standards, investigation and informants 2. Legal and moral rights and penalties for licensure and for voluntary membership. In are diff erent and cannot be some states, judicial councils, or some such body, will function in parallel with state licensure enforcement but each has a substituted for each other. separate standing. One can remove a practitioner’s license; the other can remove a practitioner’s membership in the 3. The moral can infl uence voluntary organization. The recent U.S. Supreme Court the legal but not substitute for decision regarding the role of the state dental board in North it (and vice versa). Carolina explicitly recognized the ADA code. It praised the association for calling for high standards and specifi cally stated that the code had no legal status with respect to licensure. There is a moral side to the issue as well. There, one stands on David W. Chambers, EdM, MBA, PhD, is a professor of dental education at the University of the Pacifi c, Arthur what is right (ethically appropriate). Sometimes, the best thing A. Dugoni School of Dentistry in San Francisco and the to do is sit down with a colleague whose behavior is damaging editor of the American College of Dentists. patients and the profession. The ultimate authority in this case is the ethical convictions of two moral agents. (It is unfair and unwise to go into these matters assuming one is ethical and the other is not.) The collective wisdom of the profession on how to practice is a powerful resource, even though it lacks legal standing. But there is a danger there. Trial in the court of public opinion or rumor discipline is immoral and may even be legally actionable. ■

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Drug Combining Rises to Dangerous Level The number of Americans taking a dangerous combination of opioids and benzodiazepines increased by 250 percent over a 15-year period and the number of patients taking both benzodiazepines and so-called Z-drugs, which act similarly to benzodiazepines, increased by 850 percent, according to a new study published in the journal Sleep. Survey: Parents Still Believe The research by Nicholas Vozoris, MHSc, MD, an associate scientist at the Li Opioids Are Best Pain Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto and a sleep medicine specialist, relies on data from eight National Health and Nutrition Reliever for Kids Examination Survey cycles between 1999 and 2014. It found the prevalence of A nationwide survey commissioned benzodiazepine and opioid co-usage in the U.S. in 2014 was 1.36 percent, by the American Society of while the prevalence of benzodiazepine and Z-drug co-usage was 0.47 percent. Anesthesiologists (ASA) found that These drug-use patterns are associated with increased risks for serious parents remain confl icted about opioids adverse outcomes including breathing problems and death. despite recent reports that 90 percent “While the proportions may seem small, these percentages at a of addictions start in the teen years. A population-level correspond to millions of people and the growth of these report on the survey was published on numbers is alarming,” said Dr. Vozoris. “The FDA has gone as far as to issue its the ASA website in January 2019. strongest form of safety warning about this suboptimal prescribing practice and “While most parents said they were mixing of opioids and benzodiazepines.” concerned about side effects and risks such The 1.36 percent prevalence of benzodiazepine and opioid co-usage as addiction, improper or recreational use translated to about 4.3 million people, while the 0.47 percent prevalence of and overdose, they still thought opioids benzodiazepine and Z-drug co-usage amounted to about 1.5 million people. work best to manage pain,” said ASA Commonly prescribed benzodiazepines include alprazolam, clonazepam President Linda J. Mason, MD, FASA. and lorazepam while Z-drugs include zaleplon, zolpidem and zopiclone. Dr. The 17-question survey was conducted Vozoris has seen a lot of confusion about benzodiazepines and Z-drugs among online between Nov. 25 and Dec. 2, both patients and other medical professionals. 2018, among 1,007 parents of children “There are doctors and members of the public aged 13 to 24. If their children were ever often not realizing that Z-drugs are very similar in prescribed opioids, parents were asked action to benzodiazepine drugs,” he said. to think of their child with the most Read more of this study in Sleep (2019); recent prescription when answering the questions. If their children were doi.org/10.1093/sleep/zsy264. never prescribed opioids, parents were asked to answer for their oldest child. Of the parents surveyed, one-third of whose children had been prescribed opioids, more than half expressed And while 83 percent of parents suggesting there is a need for improved concern that their child may be at risk surveyed said they were prepared to awareness on opioid alternatives, safe for opioid addiction. However, nearly safely manage their child’s opioid use if storage and proper disposal, talking to two-thirds of the parents expressed the prescribed, the facts don’t quite bear out, children about risks, and the benefi ts of belief that opioids were more effective at according to the survey. Opioid-related naloxone, an emergency medication that managing their child’s pain after surgery deaths among children and adolescents reverses the effects of an opioid overdose. or a broken bone than nonprescription nearly tripled between 1999 and 2016, Find more survey results in medication or other alternatives. driven mostly by prescription opioids, the newsroom at asahq.org.

208 APRIL 2019 CDA JOURNAL, VOL 47, Nº4

Researchers Regenerate Dental Tissue From Stem Cells Collaborative research between in the journal Tissue Engineering. the Maurice H. Kornberg School of Seeking a better treatment than Dentistry and the College of Engineering the inert substance typically used in at Temple University uses stem cells root canals, Maobin Yang, DDS, MS, to regrow the pulp-dentin complex associate professor of endodontology researched the use of stem cells that makes up the center of a tooth. and director of the regenerative health to simultaneously regenerate the The research was recently published research laboratory at Kornberg, pulp tissue (including blood vessels and nerves) and dentin tissue that comprise the inside of a tooth. But in generating the tissue using stem cells, he found that the Study Unveils New Evidence on the Cause of components had no spatial control when they were put into the canal; Alzheimer’s Disease therefore, the components didn’t know A prominent bacteria found in has been identified in where to grow the pulp and dentin. the brains of patients with Alzheimer’s disease, providing strong evidence Dr. Yang, with the help of Peter connecting P. gingivalis to the development of Alzheimer’s, according to a Lelkes, PhD, professor and department study published in the journal Science Advances. chair of bioengineering at Temple, In a model done on mice, oral P. gingivalis led to increased production of developed a bioengineered two-sided amyloid beta, a component of amyloid plaques commonly associated with scaffolding to guide the tissue growth. Alzheimer’s disease. The team also found the organism’s toxic enzymes, or “The beauty of the system is that we gingipains, in the neurons of patients with the disease. Gingipains are secreted have shown in vitro that we can engineer and transported to outer bacterial membrane surfaces and have been shown a two-sided scaffold and can guide the stem to mediate the toxicity of P. gingivalis in a variety of cells. cells to differentiate into both pulp cells and In attempts to block the neurotoxicity, researchers designed and dentin, producing odontoblasts that will synthesized small-molecule inhibitors targeting gingipains. In preclinical eventually repair the root canal,” Dr. Lelkes experiments, researchers demonstrated that gingipain inhibition reduced the said. “We — our smart scaffold — can do bacterial load of an established P. gingivalis brain infection, blocked amyloid this differentially with great effi cacy.” beta production, reduced neuroinflammation and rescued neurons in the The next step for the researchers hippocampus — the part of the brain that mediates memory and frequently is to test the tissue growth technique in animal models. deteriorates in the early stages of Alzheimer’s disease. “I believe in the next 10 years, or Jan Potempa, PhD, a researcher in the University of Louisville School of even sooner, when patients come to the Dentistry’s department of oral immunology and infectious diseases, was part of endodontist for a , the team of international scientists led by Cortexyme Inc., a privately held, we will be able to provide an alternative, clinical-stage pharmaceutical company. equivalent or even better treatment “An even more notable aspect of this study is demonstration of the potential for modality, which is to regrow the nerves a class of molecule therapies targeting major virulence factors to change the and the blood vessels and to grow new trajectory of Alzheimer’s disease, which seems to be pulp back into your tooth, instead of epidemiologically and clinically associated with using inert material,” Dr. Yang said. “With periodontitis,” Dr. Potempa said. investments and with lots of research, I Learn more about this study in Science Advances believe that we will get there soon.” (2019); doi:10.1126/sciadv.aau3333. Read more of this study in Tissue Engineering (2019); doi. org/ 10.1089/ten.tea.2018.0041.

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I1

Research Develops New Extra-Strong I1 C' Translucent Glass Ceramic Researchers at Ångström Laboratory at Uppsala University in Sweden have developed glass ceramics that are three times stronger than the C’ ceramics currently in use. The study was published in the journal Nano Letters in late 2018. The new ceramic is translucent while other ceramics are white, and the combination of color and durability has proven to be particularly successful Dental remains of the Xujiayao juvenile, original for dentists to use to repair teeth. Xujiayao fossil. I1 and C’ were removed from their “The dilemma in dentistry today is that existing strong materials are white in sockets and appear as isolated teeth. Photographed color (a white that does not look natural) and materials that are translucent are by S.X. from Institute of Vertebrate Paleontology and not as strong,” said Wei Xia, PhD, an associate professor at Uppsala who heads Paleoanthropology, Chinese Academy of Sciences. the research team. “Our ceramics are three times stronger and also translucent. This means that you can customize the color of the tooth to match the patient’s other teeth, resulting in a natural appearance. The material is intended for use in Dental Growth of Ancient dental repairs, for broken teeth and for bridges and crowns.” Ancestors Similar to The research team hopes that the new material will provide patients Modern Humans with better oral health and make dental care less expensive in the long run because patients will not need to visit their dentist as often. The plan is to A recent study on the dental remains use the glass ceramics in areas that need strong and translucent material, of an ancient fossil has revealed similarities such as various types of implants. to those of modern humans. Published in “This study deepens our fundamental understanding of the microstructure- Science Advances, the study was the fi rst mechanical strength relationship, which could guide the systematic assessment of dental growth in design and manufacture of other high-strength, an East Asian archaic hominin. Researchers translucent glass ceramics,” the authors stated. found the study results surprising because Learn more about this study in Nano Letters many of the other features of the fossil, (2018); doi:10.1021/acs.nanolett.8b03220. known as the Xujiayao juvenile, a child 6 ½ years old who lived at least 104,000 years ago in northern China, are not modern, such as the shape and thickness of the skull and the large size of the teeth. “The researchers were surprised to a slow life history like modern humans, lines in teeth retain a record of dental fi nd that in most ways, this child’s dental with a prolonged period of childhood development, teeth provide some of the best development was very similar to what you dependency, according to the study. data anthropologists have about the growth would fi nd in a child today,” said Debbie Another aspect similar to modern and development of our ancient ancestors.” Guatelli-Steinberg, PhD, co-author of humans was the perikymata — the Researchers were able to fi nd at least the study and a professor of anthropology incremental growth lines that appear one differentiation between the fossil and at The Ohio State University. on the surface of the tooth. modern humans — the rate of growth Compared to our primate cousins, “We found that the way these in the roots of the teeth. The juvenile modern humans and their teeth take perikymata were distributed on the Xujiayao showed relatively fast growth, compared a long time to form and develop. The juvenile teeth was close to what we see in to a slower growth in modern humans. dental remains of the Xujiayao juvenile modern humans and not to Neanderthals,” Read more about this study in Science suggest that these archaic humans had said Dr. Guatelli-Steinberg. “Because growth Daily (2019); doi:10.1126/sciadv.aau0930.

210 APRIL 2019 CDA JOURNAL, VOL 47, Nº4

Opioid Overdose Crisis Predicted To Worsen by 2025 A study from investigators at In their report published in JAMA the Massachusetts General Hospital Network Open, the research team noted (MGH) Institute for Technology that the changing nature of the epidemic, Assessment projects that the opioid which is now driven by the use of illicit overdose epidemic in the U.S. is likely opioids like heroin and fentanyl, has to increase in the coming years and that reduced the potential impact of programs Health and the Centers for Disease measures based on restricting access to targeting prescription opioids. Control and Prevention to develop prescription opioids will have a minimal The team used data from sources such the Opioid Policy Model to refl ect the impact in reducing overdose deaths. as the National Survey on Drug Use and trajectory of the opioid epidemic in the U.S. from 2002 to 2015. They then used that model to make projections for probable outcomes from 2016 to 2025. Under a status quo scenario in which Not Proven To Prevent Oral Decay no further reduction in the misuse of A recent study is challenging the belief that orthodontic treatment can prescription opioids occurs in coming prevent future . The study, conducted by Esma J. Doğramaci, BDS, years, the model projects that the annual MSc, and co-author David Brennan, PhD, both from the University of Adelaide number of opioid overdose deaths will in Australia, was published in the journal Community Dentistry and Oral increase from 33,100 in 2015 to 81,700 Epidemiology in January 2019. in 2025, a 147 percent increase. The For the study, researchers assessed the long-term dental health of 448 model also predicts that during those 30-year-olds from South Australia. The subjects had previously taken part in an years, approximately 700,000 people will oral epidemiology study when they were 13 years old and were subsequently die from an opioid overdose, with 80 traced through the Australian electoral roll and invited to participate in a percent of those deaths from illicit drugs cross-sectional study investigating long-term dental health outcomes. like heroin and fentanyl. The researchers Participants who accepted the invitation completed a questionnaire that also estimate that by 2025 half of all collected information on sociodemographic characteristics, dental health new opioid users will begin with illicit behaviors and receipt of orthodontic treatment. Following completion of the rather than prescription drugs. In all questionnaire, researchers performed clinical examinations of the participants scenarios tested, interventions directed and recorded their number of decayed, missing or filled teeth. toward reducing misuse of prescription More than a third of the participants had received orthodontic treatment by opioids were projected to decrease overdose deaths by only 3–5 percent. age 30, and on examination, researchers found that those participants did not “This study demonstrates that have better dental health than those who had not received orthodontic initiatives focused on the prescription treatment, according to the study. opioid supply are insuffi cient to bend “There is a misconception among patients that orthodontic treatment the curve of opioid overdose deaths prevents tooth decay, but this is not the case,” said Dr. Doğramaci, a lecturer in in the short and medium term,” said orthodontics at the University of Adelaide. “Evidence co-author Marc Larochelle, MD, from the research clearly shows that people cannot MPH, of the Grayken Center for avoid regularly brushing their teeth, good Addiction at Boston Medical Center. and regular dental check-ups to prevent decay later in life.” “We need policy, public health and Learn more about this study in Community health care delivery efforts to amplify Dentistry and Oral Epidemiology (2019); harm reduction efforts and access doi.org/10.1111/cdoe.12446. to evidence-based treatment.” Read more of this study in Jama Network Open (2019); doi:10.1001/ jamanetworkopen.2018.7621.

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introduction

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Older Adults: The Long and Winding Road To Address Their Needs

Elisa M. Chávez, DDS

GUEST EDITOR GUEST EDITOR’S NOTE

Elisa M. Chávez, DDS, This issue of the Journal ur colleagues in geriatric The baby boomers, the fi rst is an associate professor contains several references dentistry and public health generation to benefi t from water in the department of to resources developed have been telling us for fl uoridation, who have so far diagnostic sciences at the by Oral Health America University of the Pacifi c, (OHA), a national at least the last 30 years maintained more of their dentition Arthur A. Dugoni School of organization that has that a crisis in oral health than any generation before them, Dentistry in San Francisco. contributed signifi cantly Ocare for seniors was imminent in the face now face signifi cant oral diseases and She graduated from the over the last several of inaction and that the repercussions challenges to maintaining their oral University of California, decades to improving the would be great. Much of what you are health. While rates of edentulism San Francisco, School oral health of people of of Dentistry and earned all ages. In early 2019, about to read, about the importance of have decreased over generations, the her certifi cate in geriatric OHA ceased active addressing issues in oral health care for risks to oral health and resultant oral dentistry from the University operation and stated that seniors, is not new, but the causes of health needs have increased for seniors of Michigan, Ann Arbor. it was seeking to transition disparities and the current and projected overall and disparities in access to Dr. Chávez has practiced in programs and projects to needs are compounded by time that has care have widened considerably in private, community health, other organizations. We are long-term care and hospital hopeful that the resources been lost to apathy on a broad scale some populations and socioeconomic settings. She developed cited in this issue will not be This is an urgent moment in health groups. People are living longer with and directs an extramural lost to readers, but rather care and dentistry because our population chronic diseases that directly and student rotation at On Lok will be available again has been aging without reliable resources indirectly impact their oral health Lifeways, a Program for under the leadership of to receive the oral health care needed and ability to receive dental care. All-Inclusive Care for Elders other oral health advocacy (PACE). As a recent fellow organizations. to maintain oral health over a lifetime. At the same time, aging adults have and current scholar with There are greater expectations for oral both diminishing fi nancial resources The Santa Fe Group, she health as people age and yet knowledge and access to dental insurance after is an advocate for the oral is still limited about how deeply oral retirement. Now that the so-called health needs of seniors and systemic health are intertwined and “silver tsunami” has reached the shore, nationwide. Confl ict of Interest the implications for successful aging. we must consider and implement Disclosure: None reported. Without appropriate intervention, future broad-reaching and innovative ways to populations are in line to lose all the approach the challenges older adults gains we have made in prevention on face in maintaining their oral health their behalf as younger individuals. and accessing adequate oral health care.

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A scene in a movie got me thinking procedures; maintaining our private requires a team about not just the future of oral health practices that, while meticulously approach to ensure appropriate and care for older adults, but our future as a and successfully self-managed, are comprehensive care for patients with profession. The lead female character physically, financially, ideologically complex medical and dental needs. in the movie, a professor of economics, and technologically isolated from the Routinely caring for these populations schooled a student on game theory. rest of health care? Or will we play as a part of the team presents a rich She explained that he lost a game of to win and, if so, what could that opportunity in dentistry to explore poker to her because he played not mean: full engagement as an integral best practices, gain valuable knowledge to lose and she had played to win. So part of interdisciplinary health care and remove the barriers that have long I wondered, how will our profession teams; focus on risk assessment and separated medicine and dentistry. But play our hand? Will we play not to prevention; ongoing assessment patients and providers need appropriate lose and, if so, what would that and subsequent action to improve information and resources if we are mean: accepting an elective health outcomes in dentistry and medicine as to bring down the barriers that have care status; continuing to accept the legacy of our participation in the prevented this integration. Ahead in reimbursement based solely on changing paradigms in health care? this issue, you will fi nd three models of direct patient care that have sought to overcome some of those barriers; a conceptual framework for a broad public health approach to improve oral health among older adults; recommendations for what we will need to do in dental education to prepare current and future practitioners to practice as part of a larger health care team to care for older adults with a broad spectrum of independence and dependence; and a discussion of the need for a dental benefi t in Medicare to remove disparities in oral health care for older adults and create opportunities for our profession to more fully engage with our partners in medicine — in California and across the country. Many thanks to my colleagues who have shared their time, vision, enthusiasm, lessons learned and a few road maps to bring this edition of the Journal to fruition and to help our profession catch up and keep pace with the needs of a complex and diverse population of older adults. ■

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On Lok PACE Integrates Oral Health Care as Part of Comprehensive Health Care for Seniors

Diana Teng, MSN, RN, AGNP; Bonnie Lederman, DDS; and Charlotte Carlson, MD, MPH

ABSTRACT This article demonstrates how the Program of All-Inclusive Care for the Elderly (PACE) model, as exemplifi ed by On Lok PACE, integrates dentistry with an interdisciplinary adult day health center to provide medically necessary dental coverage for skilled-nursing eligible older adults living in the community. This comprehensive, federally funded, cost-effective model targets multiple barriers to oral health care, ensuring participants have access to regular preventive dental services, which reduces oral and other health complications.

AUTHORS

Diana Teng, MSN, RN, department of diagnostic eet your patient, Mrs. The dentist was not in at the time, AGNP, is a board-certifi ed sciences at the University Y, an 89-year-old but the on-call registered nurse (RN) adult geriatric nurse of Pacifi c, Arthur A. Dugoni practitioner who graduated School of Dentistry. Dr. partially edentulous was able to triage the situation and from the University of Lederman is also a Veterans monolingual Cantonese- speak with the on-call medical doctor California, San Francisco, Aff airs geriatric dentist in a speaking woman (MD). The on-call MD reviewed Mrs. in 2016. She is part of the community long-term care interdisciplinary team at facility in San Francisco. Mwith . She lives with her Y’s medical records, which included her the Institute on Aging, one Confl ict of Interest daughter in San Francisco and dental notes, to determine the next steps of On Lok’s PACE centers, Disclosure: Dr. Lederman lacks decision-making capacity. of action. Mrs. Y was then recommended and is a volunteer clinical is employed by On Lok’s preceptor for UCSF’s nurse PACE center. On a Friday afternoon, her distressed not to use her for the time being, practitioner students. daughter calls Mrs. Y’s primary care to use salt-water rinses and to apply Confl ict of Interest Charlotte Carlson, MD, medical facility after clinic hours to pressure to the bleed site; she was also Disclosure: Ms. Teng is MPH, is an associate employed by On Lok’s medical director at On Lok report profuse bleeding inside of her downgraded to a soft diet until she could PACE center. Lifeways in San Francisco. mother’s mouth. Her medications be seen by her regular dentist. With the Confl ict of Interest include Coumadin and Prolia and she application of these recommendations Bonnie Lederman, DDS, is Disclosure: Dr. Carlson a clinical staff dentist at On is employed by On Lok’s has a medical history of coronary artery and the reassurance that her mother Lok Lifeways, senior health PACE center. disease, , and a would be seen by clinic staff within 24 services (PACE). She is prosthetic valve replacement. Mrs. Y’s hours, the daughter was able to control adjunct faculty for preventive and restorative dental terrifi ed daughter reports that she has no Mrs. Y’s bleed and their anxieties were sciences at the University of idea how this bleed started and is asking relieved. They also had the option of California, San Francisco, if her distressed and confused mother having a home-visiting RN further assess School of Dentistry and adjunct faculty in the should go to the emergency room (ER). for the development of an abscess or

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Day health program Home care Primary Cognitive impairment 75.5 medical care Home- Chronic kidney disease 58 delivered ersonal r p fam Medication Dementia 55.5 meals u il Yo y Diabetes 41 Acute Participant and Transportation hospice care Depression family 40.3 h e m X-ray, al a Congestive heart failure 19 Nursing th care te ambulance, home care lab Atrial fi brillation 14.7 Medical Rehabilitative specialists therapies Dental, 0 10 20 30 40 50 60 70 80 optometry, Percentage audiology, podiatry

FIGURE 1. The PACE health care team model (On Lok, 2018). FIGURE 2. On Lok’s top chronic conditions 2017 and On Lok quality assessment data (On Lok, peer reviews and quality reports data Q2 2016–Q2 2018). infection. However, because the bleed On Lok, Cantonese for “peaceful, Medicare and gave states the ability to was stopped by instructions given over happy home,” is based in the San include PACE as a Medicaid benefi t.3 the phone, Mrs. Y was coordinated for a Francisco Bay Area and is the Today, there are 255 PACE programs visit to the Saturday medical clinic by the original PACE program. Established across 31 states in the U.S., all of facility’s transportation services and was in 1971 by a public health dentist, which are securely funded by a waiver assessed directly by the medical team the William Gee, DDS, and a social program with the Centers for Medicare following morning. By the time Mrs. Y’s worker, Marie-Louise Ansak, On and Medicaid Services (CMS).4 regular dentist saw her on the following Lok’s program model was designed as As illustrated in Mrs. Y’s case, which Monday, the bleeding had stopped and an alternative to nursing home care will be further explored in this paper, she was spared an unnecessary ER visit. that would provide a comprehensive, the PACE model operates through an interdisciplinary, community-based extensive interdisciplinary team (IDT) On Lok Program of All-Inclusive Care care system for older adults, which to provide optimal comprehensive health for the Elderly included oral health.1 By 1983, care to participants. This team includes Many older adults have been in a On Lok secured pooled capitated primary care providers (MDs/nurse scenario similar to the one above, but funding through Medicare and practitioners), dentists, RNs, pharmacists, with very different outcomes because Medicaid waivers.1 To determine the social workers (SW), registered of limitations in physical resources or feasibility and sustainability of the dietitians (RD), physical therapists (PT), medical data available to the health On Lok PACE model, the Robert occupational therapists (OT), activities care or dental team at the time. The Wood Johnson Foundation along therapists (AT), home-care workers availability of on-call triaging staff, readily with the Health Care Financing (HCW), day health center workers, accessible dental and medical records, Administration funded the expansion transportation staff as well as off-site home-visiting RNs, weekend clinics and and replication of six new PACE contracted specialists such as endodontists, transportation are often nonexistent or programs based on the On Lok PACE oral surgeons, etc. (FIGURE 1).The services inaccessible to many seniors. However, model in 1986.2 These six PACE provided through PACE’s IDT model of these resources are readily available for programs were also funded by pooled care are aimed at limiting functional loss, patients like Mrs. Y and her providers capitation dollars from Medicare and promoting physical and mental health because she is enrolled with On Lok Medicaid.2 Due to the success of these as well as engagement and socialization. PACE, the original model program early programs, the Balanced Budget Helping the participants establish and for what is now the Program of All- Act of 1997 gave PACE programs maintain oral health is an important Inclusive Care for the Elderly (PACE). permanent provider status under element in achieving these broader goals.

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Who Qualifi es for PACE Services? is still an integral part of overall utilization for dental problems and To be eligible for PACE services, a health.9,10 Dental disease worsens improving the options for nursing home participant must be aged 55 or older, with increased medical complexities, and other institutionalized adults to certifi ed by the state to need a nursing home cognitive decline and functional receive dental services.18 ERs may seem level of care, yet be able to live safely in decline, all of which are commonly to be a convenient way to access dental the community and reside within a PACE seen in the aging population.6 Risk care and address dental pain, however, service area. Nearly half of California PACE factors of diabetes and cardiovascular many individuals, including low-income participants have dementia and nearly all diseases have been linked with older adults, are unaware that ERs are need assistance with some activities of daily worsened oral health, while poor oral not appropriate places to seek care living (ADL), such as toileting, grooming, health is linked to dental pain, poor for preventable dental conditions.19,20 feeding and moving. PACE programs serve nutritional status, dehydration and Preventable dental conditions are defi ned a diverse and vulnerable population of older increased chronic and acute infection as nontraumatic dental conditions adults in the community, many of whom rates.11,12 Poor oral health can also (NTDC), such as issues from tooth decay also have low incomes. In 2017, more than be socially isolating, impeding one’s and , which can be 70 percent of PACE participants throughout addressed with routine preventive dental California were eligible for both Medicaid care.21 On the national level, in 2012 the and Medicare.3 At On Lok PACE in 2017, treatment of preventable dental conditions more than 60 percent of participants were Dental disease worsens in ERs throughout the U.S. cost the health Asian, followed by Hispanic at 15 percent, with increased medical care system $1.6 billion dollars with an 22 Caucasian at 11 percent and African- complexities, cognitive average cost of $749 per visit. It should American at 3 percent. The average age be noted that those aged 65 and older of participants was 84, and 97 percent of decline and functional decline, accounted for about 4.5 percent of costs of participants had an income of less than all of which are commonly seen NTDCs. It is also important to note that $1,200 per month while 58 percent had in the aging population. this 65-year- category is anticipated an income of less than $400 per month. to grow in the next several decades. The top chronic conditions seen ER utilization for NTDCs is especially in On Lok PACE participants include important to note for Medicaid users, as chronic kidney disease, dementia, diabetes ability to speak and communicate, seen from 2009–2014 when Medi-Cal, and congestive heart failure (FIGURE 2). which can impact one’s self-esteem California’s Medicaid program, along with Additionally, 75 percent of On Lok and quality of life.13,14 Through several other states cut comprehensive PACE participants also have cognitive many studies, it has been established adult dental coverage resulting in an impairment. Due to these high rates of that good overall health requires increase of approximately 1,800 additional chronic conditions and impaired cognition, good oral health and vice versa.15 dental-related ER visits in California PACE participants have both high risk for per year. This increased ER utilization oral health complications and an equally Overcoming Barriers to Oral Health for NTDCs was seen across all adult age high need for consistent oral health in Older Adults and Reducing groups and cost the health care system services.5–7 In 2015, an estimated one-third Emergency Room (ER) Utilization an additional 68 percent in dental ER of the participants were edentulous and for Dental Care visits ($1.25 million) per year.23 many had limited or no dental care for For older adults, cost, physical access According to the CDC, 70.9 percent many years prior to joining the program.8 to routine oral health care and challenges of California residents aged 65 or older in navigating the health care and dental visited a dentist in the past year, but the The Impact of Oral Health on Overall systems are some of the biggest barriers percentage proportionally decreased with Health in Older Adults to routine and nonemergent medical lower-income status.24 In 2015, 79 percent For older adults, complex medical and dental care.16,17 The California of those earning more than $75,000 per conditions are often the primary Department of Public Health Oral year visited the dentist within the past year, focus of care and overshadow oral Health Program’s (COHP) 2028 goals as compared with only 50 percent of older health needs. Nonetheless, oral health are focused on decreasing repeat ER adults with annual salaries up to $50,000.25

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Acute referrals 7% Extractions 10%

Root canals 3% Root planing 16% Initial/Annual Procedures 48% Fillings 16% exams 25% (All services aside from assessments. Prophylaxis Breakdown detailed 34% in Figure 4.) Follow-up Fluoride 21% visits 20%

FIGURE 3. 2015 overall dental visit types at On Lok PACE. (Ten percent sample FIGURE 4. Sample of 2015 dental procedures. (Data from 10 percent sample of all visits.) of visit types, excluding examinations, X-rays and .)

Additionally, data from the National (Denti-Cal) in California have been requests to resume dental care. These Hospital Ambulatory Medical Care Survey, recently expanded, there are still many data illustrate that with a high emphasis a branch of the Centers for Disease Control limitations to the benefi ts provided. And, on preventive and restorative care and and Prevention’s National Hospital Care importantly, because they come through the means to have frequent follow up, Survey, confi rm that minority populations, Medicaid and not Medicare, the benefi ts dental visits at On Lok have high rates such as African-Americans, Hispanics and are not guaranteed.28 Not all states provide of preventive and planned interventions Native Americans, and those with lower an adult dental benefi t through Medicaid with a relatively low percentage of dental socioeconomic status have the highest rates and the level of benefi ts are variable visits for true acute or emergent issues. of ER utilization for NTDCs.26 These data from state to state.29 With fl uctuations highlight the racial and socioeconomic in the economy leading to cuts to dental Cost of On Lok PACE Dental Care disparities in oral health care among older coverage, maintaining consistent dental On Lok PACE’s dentists are not paid adults. PACE is able to address these care on Medicaid funding alone is on a fee-for-service basis, but instead disparities in access to oral health care unpredictable for many patients. However, function as salaried members of the IDT or and deliver comprehensive dental care even if a patient is in a state without are hired as contract providers at an hourly to a diverse population of underserved, comprehensive dental coverage through rate. There are no production-based frail, older adults. Unfortunately, these Medicaid, they would still be guaranteed incentives that encourage overutilization. data also highlight that many seniors comprehensive dental services if they Preauthorization is not required for dental who enroll in PACE have likely already are enrolled in a PACE program.27 services, giving providers the freedom experienced years of dental neglect and fl exibility to provide the most because of barriers to resources. On Lok PACE’s Dental Service appropriate services without the usual Utilization constraints of Medicare and Medicaid Dental Care Utilization and Delivery In 2015, an analysis of visit types reimbursements.28 On Lok PACE also at On Lok PACE over one year at On Lok demonstrates contracts with off-site private dentists and that a large portion of procedures dental specialists such as endodontists, Scope of Dental Services Covered by were for nonurgent preventive dental oral surgeons and periodontists. On Lok PACE care such as prophylaxis and fl uoride Although On Lok PACE generally pays Dental services provided at On Lok (FIGURES 3 and 4). As this is a small at Medicare and Medicaid rates when PACE include all dental procedures and sample size, this is a rough estimate for applicable, On Lok PACE is not limited outside referrals to dental specialties the rest of On Lok PACE’s visits.8 to those rates. This may provide an deemed medically necessary by dental In 2017, data from our combined incentive for some private providers to providers in collaboration with IDT dental and medical visits showed that participate who would not otherwise members. The broad scope of services 89 percent of all visits were routine, 8 contract at the usual Medicaid rates. provided by On Lok PACE is all part of percent were urgent and only 3 percent Participants with Medicare and monthly capitated payments by CMS.27 were emergent. To note, urgent dental Medicaid have coverage of all PACE/ In contrast, while adult dental benefi ts visits can also entail a broad spectrum On Lok PACE-related costs, including through the Medi-Cal Dental Program of visits that includes dental sores or dental care with no premium or

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copayments.28 However, those who dental needs. As seen in many cases Ease of Provider Communication and have Medicare only are charged a similar to Mrs. Y’s, nondental providers Collaboration Through Co-Location fl at monthly fee for all services in the can often be the fi rst to discover a As part of the on-site health care program based on their income bracket patient’s dental issues. This ensures team, On Lok PACE dentists have unique and the county where the PACE that the participant’s care needs are resources available to them that further program is located.30 As all services are assessed and addressed frequently, optimize On Lok PACE’s ability to provide covered either through Medicare and which allows for early identifi cation, effi cient and comprehensive dental Medicaid or a monthly fee, there are management and frequent follow-up care. Although all PACE programs are no complicated dental benefi t rules for of both dental and medical problems. structured to encourage interdisciplinary participants to decipher. As for out- Physical access to dental care is team collaboration based on the On Lok of-pocket costs, participants are only facilitated by the availability of such PACE model, not all PACE programs required to pay for the completion of team members as home-care workers, have on-site dentists and many contract treatments begun at other dental offi ces van drivers, van escorts and clinic with private dentists and send patients prior to the time of enrollment or aids, all of whom are instrumental in off-site for care. Co-Location of On Lok those not deemed medically necessary PACE dentists with the rest of the IDT by the IDT. In 2015, the average cost makes communication convenient as for direct dental care (including the well as fl exible. Dentists are more aware cost of the provider, the supplies, the As seen in many cases of health care issues that may alter dental services and staff directly involved in management and are able to quickly providing care) per On Lok participant similar to Mrs. Y’s, adapt to changes in a participant’s medical per month was $26.16, a much lower nondental providers can status. Dental providers can easily consult cost than the out-of-pocket costs for often be the fi rst to discover with the IDT and make decisions on-site insured Americans at approximately regarding a participant’s ability and capacity $700 annually without extensive a patient’s dental issues. to tolerate and benefi t from various work (or about $58 per month).8,31 treatment and procedures. Furthermore, patients are saved from lengthy delays while How Does the On Lok PACE Model providers wait for pre-authorizations from Overcome Other Barriers to Dental Care? getting patients to the dentist/PACE remote sources to initiate more complex center. For appointments outside of the procedures such as root canals, complicated Protocols, Standards and Physical PACE center, the schedulers and social extractions or fabrication of new dentures. Access to Dental Care workers coordinate the appointments Co-Location of On Lok PACE Upon enrollment to a PACE and arrange the physical assistance and dentists with IDT members also creates program, participants receive initial transportation so participants need familiarity. On Lok PACE dentists and medical, nursing, social work, physical not worry about navigating complex medical providers can easily walk over therapy, home safety and dietary health care paperwork and appointment to each other’s offi ces and discuss patient assessments. After having medical systems. In the mornings, home-care care needs face to face. This cuts down on conditions addressed and support systems workers help participants get ready the lag time waiting on emails or missed to assure access to care established, for their day, including assistance phone calls. Face-to-face communication such as home care and transportation, with oral care if needed. Van drivers between providers also decreases participants then undergo initial dental pick participants up from their homes the chances of miscommunication. assessments within three months and, if necessary, PACE van escorts Urgent questions about care can be of joining the program followed by and clinic aids help participants with immediately answered or clarifi ed and annual dental evaluations and all other walking or otherwise navigating their documented. This ease and clarity in IDT disciplines. As an extra safety physical surroundings. On- and off-site communication also leads to faster net, during their respective routine interpreters are available to remove responses to requests for consultation quarterly and biannual evaluations, language barriers that may exist and better communication about and the IDT may identify outstanding between participants and providers. compliance related to follow-up needs.

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Home care Outside specialist Participant and family Home-visiting RN appointment

Complex dental Oral hygiene procedures

Transportation Services at On Lok PACE Center

Clinic/PCP/RN/ Rehab Dietitian Social worker Dentist Pharm PT/OT

Medical condition Swallow Diet texture Navigate health Preventive, management evaluations adjustments care system restorative, palliative, emergent services

Learning Unifi ed EMR opportunities

FIGURE 5. On Lok services delivering dental care.

Unifi ed Electronic Health Record Short Wait Times/Quick Access to Interprofessional Education Across Disciplines Oral Health Care Opportunities On Lok PACE provides cross- Per California’s Timely Access Working on an interdisciplinary discipline access to an integrated Regulation, § 1300.67.2.2., current health care team results in reciprocal electronic health records (EHR) system. wait times for urgent health care learning across disciplines. An On NextGen is the EHR system used by On issues must be within 48–96 Lok dentist learns about the medical Lok PACE, and it has been customized hours and 10–15 business days for management of the patient, while to be known as “PaceLink,” which allows nonurgent issues.33,34 Across On Lok’s the medical team learns about the all IDT members, including medical, PACE centers, only one urgent and patient’s dental health and oral care dental, rehab, home-care teams, etc., to one emergent referral were ordered management (FIGURE 5). Because chart within one system. Most important, during the second quarter of 2018; nurses and primary care providers a unifi ed EHR allows for ease of access to in both cases, participants were are often the front line in assessing pertinent data giving a complete picture seen by the appropriate providers and managing oral health concerns of a patient’s health status and care needs. within one day of the referral orders. prior to referring to dentistry, it is On Lok’s dentists are easily able to review Participants are able to be seen at especially important for medical participants’ past and present medical/ On Lok PACE the same or next staff to have a strong basis of dental rehab/social work/etc. notes, medications day because of effi cient triage and knowledge. Conversely, dentists can list, ADLs, diet restrictions, in-home referral protocols combined with the also be the fi rst to identify such chronic nursing support and surrogate decision- staff and physical support as noted conditions as bleeding disorders and maker contact information — all of above. And, because participants oral cancers. Shared knowledge within which are crucial when developing dental are required to have a scheduled the medical team is crucial for ongoing care plans for older adults with complex day health center attendance, management of a patient’s overall medical and dental needs.6,32 Conversely, the on-site On Lok PACE dental health and a source of continuous other On Lok providers can easily access team can provide routine dental learning for the providers.35 Many prior dental notes and diagnoses as services well within the required providers from On Lok PACE have needed for their respective care plans. timely access law requirements. training in geriatrics and

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4. CMS. Seniors and Medicare and Medicaid enrollees; 2017. hold faculty appointments at local may potentially benefi t from the PACE Medicaid.gov/Medicaid/eligibility/medicaide-enrollees/index. 4,36 universities, allowing them to teach model of care. Recently, the National html. Accessed Nov. 15, 2018. dental, medical and nursing students PACE Association launched the PACE 5. Sutherland S. Seniors oral health unites the profession. J Can Dent Assoc 2008;74(8):677. on-site. The On Lok centers are a 2.0 initiative that aims to expand PACE 6. Pretty IA, Ellwood RP, Lo EC, et al. The Seattle Care Pathway unique and critical interdisciplinary services to more dual-eligible seniors, for Securing Oral Health in Older Patients. Gerodontology 2014 environment for training future ambitiously aiming to enroll 100,000 Feb;31 Suppl 1:77–87. doi:10.1111/ger.12098. 36 7. Chávez EM, Hendre A. Caring for older adults with complex providers in team-based patient care. seniors by 2021. And there are many needs: Drafting an interdisciplinary team. J Calif Dent Assoc more older adults who do not qualify 2015;43(10):597–604. How On Lok PACE Impacted Mrs. Y’s for Medicaid but do not have adequate 8. Chávez EM, Hendre A, Lederman B, Luxenberg J. Dental service utilization at On Lok Lifeways. Poster presented at The Dental and Overall Health Care resources to meet their health and oral National PACE Association Conference; Oct. 23–26, 2016, 16,17,23 Mrs. Y, whom we met at the health care needs. On Lok PACE and San Francisco. beginning of this article, joined On other PACE programs embody a uniquely 9. Center for Oral Health. A Healthy Smile Never Gets Old: A California report on the oral health of older adults; 2018. Lok PACE in 2016 and attends an On cost-effective and effi cient model of centerfororalhealth.org/wp-content/uploads/2018/03/Oral- Lok PACE day health center three comprehensive health care that integrates Health-ofOlder-Adults.pdf. Accessed July 15, 2018. days a week. On attendance days, she oral health care with the rest of medical 10. Slavkin HC. A national imperative: Oral health services in Medicare. J Am Dent Assoc 2017 May;148(5): 281–283. receives comprehensive dental care care. Many of On Lok’s participants have doi:doi.org/10.1016/j.adaj.2017.03.004. along with socialization, meal services, come from underserved populations and 11. Taylor GW, Borgnakke W. Periodontal disease: Associations physical rehabilitation, medical care, have had limited preventive health care with diabetes, glycemic control and complications. Oral Dis 2008 Apr;14(3):191–203. doi:10.1111/j.1601- transportation services and home- and dental care prior to enrollment. As 0825.2008.01442.x. care services. Since joining, she has seen in ER utilization data referenced 12. Gil-Montoya JA, Subira C, Ramon JM, Gonzalez-Moles MA. had more than 20 dental visits in earlier, an episodic approach to dental Oral health-related quality of life and nutritional status. J Public Health Dent 2008 Spring;68(2):88–93. doi:10.1111/j.1752- two years, including biannual dental care is often the default mindset. The 7325.2007.00082.x. cleanings, fl uoride treatments, nonurgent interdisciplinary health care team works 13. Gil-Montoya JA, de Mello AL, Barrios R, Gonzalez-Moles preventive dental procedures and other through a coordinated and comprehensive MA, Bravo M. Oral health in the elderly patient and its impact on general well-being: A nonsystemic review. Clin Interv Aging 2015 treatments such as extractions, fi llings approach to not only treat active disease in Feb 11;10:461–467. doi:10.2147/CIA.S54630. and adjustments of her partial dentures. the mouth, but also to seamlessly reinstate 14. Karasneh J, Al-Omiri MK, Al-Hamad KQ, Al Quran FA. Now that her oral health is stabilized, regular preventive oral health care to Relationship between patients’ oral health-related quality of life, satisfaction with dentition and personality profi les. J Contemp Dent she continues to receive preventive care, optimize overall health and function. On Pract 2009 Nov 1;10(6)E049–E056. such as regular cleanings and fl uoride, Lok PACE’s comprehensive model of care 15. U.S. Department of Health and Human Services. Oral Health with the frequency based on her risk of targets multiple barriers to dental care in America: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of oral disease such as caries. All of these to ensure its participants have access to Dental and Craniofacial Research, National Institutes of Health, dental services have been provided at necessary restorative and preventive dental 2000. www.nidcr.nih.gov/research/data-statistics/surgeon- no out-of-pocket costs to her. As Mrs. Y services that can meet the needs of a diverse general. Accessed July 15, 2018. 16. Montini T, Tseng TY, Patel H, Shelley D. Barriers to ■ lacks decision-making capacity, On Lok and complex population of older adults. dental services for older adults. Am J Health Behav 2014 PACE dentists have been able to work Sep;38(5):781–788. doi:doi.org/10.5993/AJHB.38.5.15. closely with her surrogate decision-maker ACKNOWLEDGMENT 17. Raphael C. Oral health and aging. Am J Public Health 2017 The authors thank Jay Luxenberg, MD, On Lok’s chief medical June;107(Suppl 1):S44–S45. doi:10.2105/AJPH.2017.303835. and the IDT to provide these dental offi cer, for his signifi cant contributions to the continuous 18. California Department of Public Health Oral Health Program services along with regular updates and improvement of the dental program by sharing his expertise in (COHP).2018–2028 California oral health plan; 2018. www. oral care education for her caregivers. geriatrics, PACE and On Lok Lifeways. cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20 Document%20Library/Oral%20Health%20Program/COHP%20 REFERENCES At%20a%20Glance%20Final%20OPA.pdf. Accessed July 15, 2018. Looking Ahead 1. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of 19. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Patient Currently, the 255 PACE centers All-Inclusive Care for the Elderly (PACE): An innovative model of characteristics and trends in nontraumatic dental condition visits to integrated geriatric care and fi nancing. J Am Geriatr Soc 1997 emergency departments in the United States. Clin Cosmet Investig throughout the U.S. service a little Feb;45(2):223–32. Dent 2012 Jan 16;4:1–7 doi:10.2147/CCIDEN.S28168. more than 45,000 participants; however, 2. Kunz E, Shannon K. PACE: Managed care for the elderly. Am J 20. Pajewski NM, Okunseri C. Patterns of dental service according to CMS data, there are 8.3 Manag Care 1996; 2: 301–4. utilization following nontraumatic dental condition visits to the 3. CalPACE. Program of all-inclusive care for the elderly; 2018. emergency department in Wisconsin Medicaid. J Public Health million people who are “dually eligible” calpace.org/wp-content/uploads/2018/04/CalPACE_General_ Dent 2014 Winter;74(1):34–41. doi.org/10.1111/j.1752- for both Medicaid and Medicare and Fact_Sheet_02.21.2018.pdf. Accessed July15, 2018. 7325.2012.00364.x.

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21. Association of State and Territorial Dental Directors (ASTDD) you-retire. Accessed July 15, 2018. 32. Shay K. Identifying the needs of the elderly dental Best Practices Committee. Best practice approach: Emergency 26. Okunseri C, Pajewski N, Brousseau D, Tomany-Korman S, patient. The geriatric dental assessment. Dent Clin North Am department referral programs for nontraumatic dental condition; Snyder A, Flores G. Racial and ethnic disparities in nontraumatic 1994;38(3):499–523. November 2015. www.astdd.org/bestpractices/bpa-emergency- dental-condition visits to emergency departments and physician 33. Department of Managed Health Care (DMHC). California department-referral-programs-for-non-traumatic-dental-conditions. offi ces. A study of the Wisconsin Medicaid program. J Am Dent Knox-Keene Health Care Service Plan. 2018. www.dmhc.ca.gov/ pdf. Accessed July 15, 2018. Assoc 2008 Dec;139(12):1657–1666. Portals/0/Docs/OLS/2018%20KKA%20and%20Title%2028. 22. Wall T, Vujicic M. Emergency department use for dental 27. Centers for Medicare and Medicaid Services (CMS). Program pdf. Accessed July 15, 2018. conditions continues to increase. Health Policy Institute Research of All-Inclusive Care for the Elderly (PACE); 2016. www.medicaid. 34. Act and Regulations. 2017 Edition. Timely Access to Non– Brief. American Dental Association April 2015 www.ada. gov/medicaid/ltss/pace/index.html. Accessed June 27, 2018. Emergency Health Care Services. §1300.67.2.2. 2017. www. org/~/media/ADA/Science%20and%20Research/HPI/Files/ 28. Department of Health Care Services Denti-Cal California. dmhc.ca.gov/LicensingReporting/SubmitHealthPlanFilings/ HPIBrief_0415_2.ashx. Accessed July 15, 2018. Medi-Cal Dental Services 2018 Benefi ciary Handbook. TimelyAccessReport.aspx#2016. Accessed July 15, 2018. 23. Singhal A, Caplan D, Jones M, et al. Increased dental 2018. www.denti-cal.ca.gov/DC_documents/benefi ciaries/ 35. Atchison KA, Weintraub JA. Integrating oral health and emergency visits and associated costs. Health Aff (Millwood) DC_benefi ciary_handbook.pdf. primary care in the changing health care landscape. N C Med J 2015;34(5). doi.org/10.1377/hlthaff .2014.1358. 29. Doan L, Tiwari T, Brunson D, Carey CM. Medicaid Adult 2017;78(6):406–409. doi:10.18043/ncm.78.6.406. 24. Centers for Disease Control and Prevention (CDC). Status Dental Benefi t Impact on Dental Utilization: A University Clinic 36. National PACE Association (NPA). National PACE 2.0: of oral health in California: Oral disease burden and prevention Setting. Front Public Health 2017;5:147. Published online 2017 Charting a course for exponential PACE growth. 2018. www. 2017; 2017. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/ Jul 4. doi:10.3389/fpubh.2017.00147. npaonline.org/member-resources/strategic-initiatives/pace2-0. CDCB/CDPH%20Document%20Library/Oral%20Health%20 30. Bodeneimer T. Long-term care for frail elderly people — the On Accessed Nov. 16, 2018. Program/Status%20of%20Oral%20Health%20in%20California_ Lok model. N Engl J Med 1999 Oct 21;341(17)1324–1328. FINAL_04.20.2017_ADA.pdf. Accessed July 15, 2018. 31. Manski RJ, Moeller J, Chen H, St. Clair PA, Schimmel J, Pepper THE CORRESPONDING AUTHOR, Diana Teng, MSN, RN, AGNP, 25. Blanton K. Get dental work before you retire. Squared Away JV. Dental care expenditures and retirement. J Public Health can be reached at [email protected]. blog. Center for Retirement Research at Boston College; 2017. Dent 2010 Spring;70(2):148–155. doi: 10.1111/j.1752- squaredawayblog.bc.edu/squared-away/get-dental-work-before- 7325.2009.00156.x.

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The Gary and Mary West Senior Dental Center: Whole-Person Care by Community-Based Service Integration

Karen Becerra, DDS, MPH; Tracy L. Finlayson, PhD; Ayrielle Franco, MPH; Padideh Asgari, MPH; Ian Pierce, MS; Melinda Forstey, MBA; Paul Downey, BA; Joseph Gavin, MS; and Eliah Aronoff -Spencer, MD, PhD

ABSTRACT The Gary and Mary West Senior Dental Center (SDC) launched in 2016 pioneering a new model of accessible and affordable dental care for vulnerable seniors. The unique SDC is co-located within a thriving senior wellness center in downtown San Diego. This article summarizes the SDC origin, new whole-person community- based integrated care model, results from the fi rst year of operations, lessons learned and considerations for how other dental providers can better care for seniors.

AUTHORS

Karen Becerra, DDS, Padideh Asgari, MPH, operating offi cer for Serving and a Master of Science espite signifi cant advances MPH, is the CEO and holds a Master of Public Seniors in San Diego. in gerontology from San in oral health care, dental dental director for the Gary Health in health promotion Confl ict of Interest Diego State University. He disease remains one of the most and epidemiology and is a is the chief program and and Mary West Senior Disclosure: None reported. prevalent and neglected chronic Dental Center in San Diego. senior research analyst with community engagement Confl ict of Interest West Health Institute in La Paul Downey, BA, is the offi cer for the San Diego health conditions in America. Disclosure: None reported. Jolla, Calif. CEO of Serving Seniors in Seniors Community DThe problem is even more severe among Confl ict of Interest San Diego and serves on Foundation and was low-income or impoverished seniors Tracy L. Finlayson, PhD, Disclosure: None reported. the Public Policy Committee previously the director of who often lack access to care. Among integrated services for is a professor of health for the American Society on those who are living independently in management and policy Ian Pierce, MS, received Aging. He recently completed Serving Seniors in San at the San Diego State a Master of Science in his term as commissioner of Diego. the community, access to dental care and University School of Public medical informatics and the California Commission Confl ict of Interest optimal oral health is often less essential Health and a consultant bioinformatics from San on Aging and is the past Disclosure: None reported. than access to other necessities like food, with West Health Institute in Diego State University in president and a board a roof over their head or, in many cases, 2017. Since then, he has Eliah Aronoff -Spencer, La Jolla, Calif. member of the National access to a cellphone. When fi xed incomes Confl ict of Interest worked as a research Association of Nutrition and MD, PhD, is a consultant Disclosure: None reported. analyst with the West Health Aging Services Programs and principal investigator force 41 percent of American seniors to Institute in La Jolla, Calif. based in Washington, D.C. for West Health Institute and choose between rent and nutrition each Ayrielle Franco, MPH, is Confl ict of Interest Confl ict of Interest a physician and researcher day, it is little wonder that our nation’s food the program manager for Disclosure: None reported. Disclosure: None reported. dedicated to developing pantries and meal programs are inundated informatics and diagnostic the Gary and Mary West with individuals whose “golden years” fi nd Senior Dental Center in Melinda Forstey, MBA, Joseph Gavin, MS, holds solutions for medical care in 1 San Diego. has 15 years of experience a Bachelor of Science in resource-limited settings. them desperate to meet basic needs. For Confl ict of Interest in the nonprofi t sector psychology from Governors Confl ict of Interest the seven in 10 seniors without dental Disclosure: None reported. and serves as the chief State University in Chicago Disclosure: None reported. insurance, oral health care gets short shrift

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Quality of life as they struggle with needs that seem Nutrition Context more immediate.2 Unfortunately, ignoring or postponing dental care has negative health and psychosocial consequences for seniors and strains the health system as a whole.3 With 10,000 Americans Function Social turning 65 every day, this problem is big, growing and touches all of us.4 The urgent need for dental care was identifi ed at Serving Seniors’ Gary and Mental Dental Mary West Senior Wellness Center (SWC) where it was noted that many FIGURES 1. Workfl ow: A patient-centered clients were unable to eat the meals Medical model of care based on provided due to missing teeth and/or oral whole-person assessment discomfort and pain. While oral health is and service integration often and mistakenly compartmentalized by metrics-based triage from the rest of the body, it is inextricably and referral. linked to overall health and quality of FIGURE 1A. Whole-person assessment. life.5 In a 2014 survey conducted among a convenience sample of 314 seniors at the SWC (unpublished SWC report), 43 scale, seniors can access affordable oral serve vulnerable older adults. The SWC percent of participants reported having health care services in a dental home that provides a range of services including pain in at least one tooth, 35 percent is co-located in a familiar, accessible and meals, physical activity and social, legal, reported diffi culty chewing, 22 percent trusted setting, creating an innovative, mental health and care-coordination reported issues with bad breath and dry coordinated, community-based system services to low-income older adults. mouth and 21 percent reported bleeding of care for older adults. Through clinical gums. Over half (58 percent) stated they treatment and teaching, broad assessment Workfl ow had not seen a dentist in more than with metrics-based referral and integration The SDC’s and SWC’s approach to a year and, in many cases, more than across multiple organizations, the SDC whole-person care is refl ected throughout fi ve or 10 years. Seniors identifi ed the has been able to “reconnect” the mouth both centers’ practices and protocols. top three barriers to care as high cost, with the rest of the body and raise the Defi nitions of “whole-person care” transportation and lack of providers status of this vital barometer of health. may vary.7 Whole-person care can be accepting the Medicaid dental benefi t This paper summarizes program defi ned as the “coordination of health, (commonly called Denti-Cal in California). development and results from the behavioral health and social services Additionally, Medicare does not provide SDC’s fi rst year of operations, lessons in a patient-centered manner with the dental benefi ts for routine care and the learned and considerations for how other goals of improved health outcomes majority of Medicare Advantage plans dental practitioners and allied health and more effi cient and effective use cover less than 5 percent of dental costs.6 providers can better care for seniors. of resources” (dhcs.ca.gov). Complex The Gary and Mary West Senior needs and priorities are integrated into a Dental Center (SDC) was launched in Methods person-centered workfl ow that connects June 2016 to address these barriers to care, oral health care and education, wellness bringing oral health care to the second fl oor Setting and social services and external medical of the bustling wellness center that serves The SDC is co-located with and dental care (FIGURE 1A). External meals and provides supportive services Serving Seniors at the SWC in an services include primary or acute medical to more than 500 low-income seniors on urban setting in downtown San Diego. care and pro-bono specialty dental any given day. By accepting the Medicaid Both are nonprofi t, community-based care (dentallifeline. org) for patients dental benefi t and using a sliding-fee organizations with aligned missions to whose needs are too complex for the

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Not acute Start Acute 911

(SDC and SWC). Trained SDC and SWC Acute staff collected patient information from Pre-CGA Doctor screen intake through treatment completion and referral for adjunct services. We extracted Lifeline and merged patient data after Institutional Review Board (IRB) approval as a continuous quality improvement (CQI) study (exemption granted by Western Oral health IRB, reference number 1-969904-1). CGA education BSS exam Data Analysis Descriptive characteristics for the cohort of seniors seen in 2016 for dental services and for a subset of the fi rst 97 Social work Mental Care Dental care health coordination patients who completed dental treatment were tabulated. This 2016 cohort includes seniors (n = 504) with completed CGAs FIGURE 1B. Metrics-based triage. from calendar year 2016 (Jan. 1–Nov. 23, 2016). Descriptive statistics about the care provided to the treatment-complete SDC (FIGURE 1B). These modalities are older adults are still available at www. group were summarized. Seniors in the coordinated and the patient referred using toothwisdom.org). The education module treatment-complete group completed a new, real-time, digital comprehensive provides information on the importance of assessments before and after treatment geriatric assessment (CGA) that allows oral health and its link to chronic diseases, and rated their overall general health metrics-based triage of dental, medical, hygiene instructions and nutritional status and oral health status (on a scale mental health and social services counseling and is offered concomitantly of poor, fair, good, very good, excellent), (APPENDIX, see online at cda.org/SDC). with a dental hygienist administering a general pain and dental pain, diffi culty Patients seeking care are fi rst assessed Basic Screening Survey (BSS).8 The BSS chewing (none versus any), frequency for acute dental, medical or mental health is an oral health surveillance tool available of limiting food due to problems with needs (e.g., severe dental infection, active for purchase from the Association of teeth (seldom/never versus sometimes/ medical conditions such as hypertensive State and Territorial Dental Directors often/always). Pre-post comparisons were emergency, myocardial infarction, (ASTDD, www.astdd.org/basic-screening- made with the McNemar test for all hyperglycemia or acute psychiatric illness). survey-order-form) that the SDC uses categorical variables to examine if there Non-acute patients are given preparatory to triage the patients’ dental needs and were statistically signifi cant differences materials (pre-CGA) then screened using urgency before the fi rst dental visit. At before and after dental treatment. the CGA. Based on the results, a care each dental visit, the patient’s vitals, coordination team refers to dental and/or weight, blood glucose levels and HbA1C Results other services including social work and (when appropriate) are measured. mental health. Non-acute medical needs Cohort Demographics are coordinated with off-site primary care Data Collection Patients (n = 504) were aged 60 to providers via care-coordination referral, as We collected data using traditional 101 with an average age of 71. About medical care is not provided at the SWC. electronic records, integrated by a half (49 percent) of the patients were All non-acute patients undergo a one- patient-centered shared health record male and 71 percent had at least some hour, group oral health education module that captured CGA data, computed college or a more advanced degree. The developed by Oral Health America clinical heuristics and metrics and allowed cohort was economically vulnerable, (OHA, which has recently ceased communication and referral between with more than half (59 percent) living operations, but oral health resources for patients and the providing organizations at or below the federal poverty level.

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Preventive: 97

Restorative: 63

The average monthly income was Treatment complete: 97 Total referrals: 121 : 13 $1,036. Patients came from a diverse set Dental services: 461 of racial and ethnic backgrounds, with Periodontics: 86 57 percent white, 14 percent black/ African-American, 25 percent Asian Prosth., removable: 55 and 2 percent other. Of the 57 percent Prosth., fixed: 4 reporting white as their race, 16 percent Oral surgery: 43 reported Hispanic as their ethnicity. English, Mandarin and Spanish were Adjunctive: 34 the most common primary languages. Serving Seniors: 30 One hundred (20 percent) reported the Other: 66 need for translation. TABLE 1 includes Social support groups: 9 sociodemographic characteristics of the Nursing/care coordination: 5 Housing services: 5 cohort of seniors seen in 2016 (N = 504), Lifelong learning: 4 along with the subset of 97 seniors who Mental health: 4 completed dental treatment. TABLE 2 Legal aid: 3 includes various dental, medical and psychosocial characteristics of the cohort. FIGURE 2. SDC and SWC referral outcomes for the treatment-complete group (n = 97).

Baseline Health Status Of the 504 patients assessed, 41 Psychosocial and Functional Status services were provided. All 97 patients percent had full or partial dentures, 39 One-quarter (25 percent) of patients who completed their treatment plans percent reported toothache or other reported a signifi cant mental health received preventive care, 63 received dental pain, 50 percent had diffi culty diagnosis and 41 percent reported they restorative, 86 received periodontics, chewing and 73 percent reported food were not in treatment. The average Patient 13 received endodontics, 55 received limitation due to oral health problems. Health Questionaire-9 (PHQ-9)9 was 3.0 prosthodontics (removable) and four Slightly over half (57 percent) had (range 0–27; lower is better) and quality of received fi xed, 34 received adjunctive not seen a dentist within the last year life assessed by the Older People’s Quality care, 43 had oral surgery and 66 had and 41 percent had urgent dental care of Life Questionnaire (OPQoL-brief)10 other services (TABLE 3). The SWC needs based on the BSS administered was 50.3 (range 13–65; higher is better). had 30 referrals that included mental during triage. Analysis of medical Average functional status as measured by health services (four), nursing/care status showed an average of 1.6 chronic the Vulnerable Elders Survey (VES-13)11 coordination (fi ve), support groups medical conditions and 2.5 active was 2.1 (range 0–10; lower is better). (nine), legal aid (three), lifelong medical symptoms with general pain learning (four) and housing support affecting 77 percent of respondents. Referral Outcomes (fi ve). The most common medical conditions Of 504 patients seen, 97 completed included (45 percent), their dental treatment plans during the Treatment Outcomes arthritis (23 percent) and diabetes (22 fi rst year. Twelve were referred from the Pre- and post-dental intervention percent). About half the cohort reported CGA due to acute complaints: eight for (through treatment completion) problems with vision (56 percent), urgent dental care and four for oral and general health statuses were memory (52 percent) and hearing emergency (911) medical services or followed by comparing the initial (41 percent). One-third (32 percent) immediate primary care for medical CGA with a posttreatment assessment reported a fall within the last year and attention. For non-acute patients given within 30 days of treatment (13 percent) reported a hospitalization referred to dental, 30 were referred for completion. For this cohort, there within the last six months. Only 7 additional services provided by the SWC was a signifi cant 20 percent absolute percent reported the lack of a primary for a total of 121 referrals for 97 patients reduction in dental pain, a 60 percent care physician (PCP) or medical home. (FIGURE 2). A total of 461 dental improvement in self-rated oral health,

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TABLE 1 Cohort Demographics for Seniors Seen in 2016 (n = 504) and First Treatment-Complete Group (n = 97)

Cohort characteristics N = 504 N = 97 Demographics N(%) N(%) Age* 71 (7.3)* 72 (6.1)* Male 261 (49) 45 (46) ≤ High school education 154 (31) 24 (25) Single/widowed/separated/divorced 391 (78) 83 (86) Average monthly income* $1,036 (481.5)* $1,102 (406.4) ≤ 99% federal poverty level 282 (59) 53 (56) Race White/Caucasian 281 (57) 64 (68) Black/African-American 71 (14) 14 (15) Asian 124 (25) 12 (13) Other 15 (2) 4 (4) Ethnicity Hispanic 79 (16) 17 (18)

*Mean (SD)

an 18 percent improvement in chewing and health services. Using the clinic’s services to locations where older adults and a 27 percent improvement in food whole-person approach in conjunction already receive services and support in limitation (all p-values < 0.05). There with an expanded CGA, dental the community is an effective strategy was a signifi cant 20 percent overall professionals looked beyond traditional for reaching this population. In the case improvement in general pain and a 7 dental, medical, mental health and of the SWC-SDC collaboration, co- percent overall improvement (trending functional measures to identify barriers location made it easy for seniors to access toward statistical signifi cance, p = 0.07) to care, nutrition, social needs and other dental services. Bringing health care to in perception of general health (fair/ quality-of-life issues in a multidisciplinary a convenient place in the community poor: 26 percent pretreatment versus and timely manner. Many patients who is evidenced by the SDC’s low no-show 19 percent posttreatment) (TABLE 4). were seen in the fi rst year were frail, rate of 4.9 percent. Other community medically complex or had mental health, health centers have reported no-show Discussion behavioral or developmental conditions rates of 20–25 percent12 ranging up to 40 The SDC team’s refl ections and disabilities. Oral health is too often percent13 or 50 percent.14 Future analyses on lessons learned in the fi rst year a low priority for these lower-income will examine the periodic maintenance are summarized in TABLE 5. These older adults and many simply were used utilization patterns and extent of observations from the fi eld relate to to poor function. Triage was important to clinical improvement among the fi rst seven broad areas: triage, scheduling, screen for the most acute health issue and patients who completed treatment. staffi ng, communication, management address that need fi rst before referring to The philosophy and expectation at of medically complex patients, special dental services. Unmet dental needs were the SDC is that seniors are partners in needs/considerations for treating prevalent among seniors at the SDC. their oral health, and all treatment plans seniors and resources needed to provide One of the key aspects of the initial included preventive services and patient whole-person dental care for seniors. success of the SDC has been its ability to engagement through supplemental The SDC’s unique collaboration engage patients where they already are and teaching and education modules outside with the SWC provided an opportunity get them to return to complete treatment. the clinic chair in the SWC. Importantly, to design and evaluate the effi cacy of The seniors frequenting the SWC value the seniors in the treatment-complete group a human-centered model of care that meals and social support services provided self-reported signifi cant improvements integrated community-based dental, social there. Bringing comprehensive oral health in function posttreatment. In the future,

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TABLE 2 Cohort Psychosocial Needs and Health Characteristics for Seniors Seen in 2016 (n = 504) and First Treatment-Complete Group (n = 97)

N = 504 N = 97 Oral health N(%) N(%) Full or partial dentures 206 (41) 27 (30) No dental visit in last year 286 (57) 45 (46) Dental pain (toothache) 196 (39) 35 (36) Diffi culty chewing 252 (50) 42 (43) Limiting food 364 (73) 63 (65) Need urgent dental care 137 (41) 33 (36) Average number of dental symptoms* 3.1 (1.9) 2.8 (1.9)

Medical Average number of medical conditions* 1.6 (1.4) 1.9 (1.5) Average number of medical symptoms* 2.5 (2.4) 2.3 (2.3) Hypertension 227 (45) 39 (40) Arthritis (rheumatoid and osteoarthritis) 117 (23) 25 (26) Hyperlipidemia 131 (26) 34 (35) Diabetes 109 (22) 24 (25) Vision problems 282 (56) 52 (54) Hearing problems 206 (41) 31 (32) Memory problems 261 (52) 43 (44) Lack of primary care provider (PCP) 37 (7) 2 (2) Fell in the last year 159 (32) 24 (25) Hospitalized within last six months 67 (13) 12 (12) Average pain score (0–10)* 3.2 (3.0) 4.1 (2.9) General pain** 388 (77) 80 (82) Psychosocial Mental diagnosis 125 (25) 23 (24) Mental diagnosis and in treatment 74 (59) 12 (52) Average PHQ-9 score (range 0–27)* 3.0 (4.0) 2.6 (3.4) Average OPQoL-B score (range 13–65)* 50.3 (6.2) 51.3 (5.9) Average VES-13 score (range 0–10) 2.1 (2.0) 4.0 (1.4)

*Mean (SD) **Any pain when more patients complete their be analyzed in depth in the future. The and new smiles with other seniors. treatment plans, subgroup analyses will SDC will continue to directly involve In order to effectively engage characterize low versus high utilizers, seniors in their care maintenance and and work with diverse patients, the compare and contrast group differences solicit their feedback about next steps. SDC assembled a culturally and and further examine the impact of dental In 2018, the SDC established an Oral linguistically diverse care team with care within these groups posttreatment. Health Peer Ambassador Program to training in geriatrics, special needs and While some dental chair time and further engage patients who completed advanced prosthodontics and worked education program data have been their treatment plans in promoting oral collaboratively with the SWC staff to collected, these data were incomplete and health among their peers and community integrate care processes. The model not yet available for this analysis and will by sharing their experiences, stories presented here demonstrates the oral

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TABLE 3 TABLE 4 Service Utilization by Category Pre-Post Dental Treatment Results for Treatment-Complete Group (N = 97) Among the Treatment-Complete Group (n = 97), Unduplicated Patients Variables Pre Post Absolute diff erence p-value Self-rated general health .07* N Fair/poor 26% 19% –7% Diagnostic and preventive1 97 General pain < .0001* Restorative 63 No pain at all 18% 38% +20% Endodontic 13 Dental pain <.01** Periodontic 86 No pain at all 64% 84% +20% Prosthetic, removable 55 Self-rated oral health status < .0001* Prosthetic, fi xed 4 Fair/poor 74% 14% –60% Oral surgery 49 Diffi culty chewing < .01** Adjunctive2 34 No diffi culty at all 57% 75% +18% Other3 66 Limiting food < .0001** 1Preventive category also included diagnostic services. 2Adjunctive category included standard CDT codes as well as Seldom/never 48% 75% +27% “missed appointment,” “offi ce visit for observation,” “translation” or “palliative emergency treatment for pain.” *p-values reported from Fisher Exact test for cell size < 5 3Other category most commonly included services like **p-values reported from McNemar’s χ2 test “postoperative check” as well as documenting “attempt.”

TABLE 5 Lessons Learned From the First Year of Operation of the SDC

Triage ■ Prescreening for acute medical, mental health or dental emergencies is needed before dental referral. ■ Interdisciplinary referrals to care or social services strengthen the value of dental care provided. Scheduling ■ Co-location led to a low no-show rate of 4.9 percent at the SDC. ■ Extra time is needed to explain treatment options and determine patient’s needs for treatment that will enable functionality and improve quality of life. ■ Appointment times need to be extended for certain patients, e.g., when extra time is needed for set up and/or transfers for seniors with mobility issues. ■ Seniors are less able to sit for long periods for treatment and more appointments may be needed to provide care safely. ■ High-risk seniors require more frequent preventive and maintenance visits. Staffi ng ■ Bilingual teams (specifi cally Mandarin and Spanish) are needed to be linguistically and culturally competent. ■ Interprofessional care teams are needed to provide true whole-person care. Communication ■ Communication with other medical providers and primary care providers (PCPs) can be challenging. There is a need to consult PCPs often due to early memory issues and the number of medications and medical conditions that typically tend to increase over time. ■ Patient overall health, motivation and ability to maintain treatment are key parts of the discussion for treatment planning. ■ Patients need clear documentation of the treatment plan and all postoperative instructions so it is easy for them to remember. Managing ■ Extra time is necessary to review patient’s medications at every visit and make sure the expectations and understanding for their medically treatment needs are realistic. complex patients ■ Patients with multiple medical and mental health needs require more time overall as their ability to comprehend, tolerate and maintain treatment is a constant challenge. ■ Need to screen for active medical problems (e.g., hypertensive urgency, bleeding problems or poorly managed diabetes) at each dental visit. Special needs/ ■ Availability of restorative materials with anticariogenic and self-adhesive properties seems to be of importance in this population as considerations for the minimum preparation, fl uoride release, reasonable aesthetics, biocompatibility and less technique sensitivity off er an advantage as treating seniors compared to composites.21 ■ Constant communication with the patients is key to validate patient preferences and input for their needs and wants during treatment planning. This is critical to select the treatment that will be best to fulfi ll patient needs and improve quality of life to prevent or delay further disability. Resources ■ Financing is a challenge and in many cases is not easy for the patient to admit to due to competing fi nancial priorities. Off ering sliding-scale fees and treatment options that are not complex or too expensive improves access to care. ■ Many seniors are single or widowed and require the support of the care coordination team to facilitate their treatment.

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health and other benefi ts of a whole- dentistry and teledentistry options and to open a senior-focused dental center person team-based approach and the the virtual dental home has been piloted inside every wellness center or other importance of being able to provide successfully with older adults.16,17 The community-based organization, there referrals to many services in addition future of dentistry will require new are a number of lessons learned that to providing comprehensive dental workforce models that include dental dental providers can use to prepare care. In several cases, it was critical providers as part of multidisciplinary care and create partnerships in their own to address other care coordination teams in order to move toward a whole- communities to support new and needs before a patient could be safely person approach to care.18 Team-based improved interprofessional models of seen at the SDC, for example, when care models allow dentistry to establish care for underserved, vulnerable older dealing with homelessness or acute relationships with other care and service adults in California and nationwide. ■ psychiatric or medical conditions. providers and increase awareness of ACKNOWLEDGMENTS New tools and technology are needed the role social determinants of health The authors thank all patients, volunteers, staff and clinical to support this kind of whole-person play in the treatment of patients,19,20 directors who consented to participate in this program, integrated care model, such as integrated particularly vulnerable adults. especially Paul Downey, CEO of Serving Seniors, which runs the Serving Senior’s Gary and Mary West Senior Wellness electronic health records (EHR) that Center where the Gary and Mary West Senior Dental medical, dental and behavioral health Center is located; Vyan Nguyen, program offi cer; and providers can all access to document John Little, CFO at the Gary and Mary West Foundation (GMWF). The authors also thank Shelley Lyford, CEO and needs and coordinate care. In late 2016, president of the GMWF and the Gary and Mary West additional data points were added to the Cost is the most commonly Health Institute. CGA to capture more information about cited barrier among seniors seniors’ social context and perceived FUNDING nationwide to accessing This work was supported by the Gary and Mary West isolation and loneliness. Future analyses Foundation and the Gary and Mary West Health Institute. will be able to report on these important needed dental care. aspects of quality of life for seniors. REFERENCES 1. Padilla-Frausto ID, Wallace SP. The Hidden Poor: Over Cost is the most commonly cited Three-Quarters of a Million Older Californians Overlooked by barrier among seniors nationwide to Offi cial Poverty Line. Policy Brief UCLA Cent Health Policy Res accessing needed dental care.15 The 2015;(PB2015-3):1–8. 2. Manski R, Brown E. MEPS Chartbook No.17 [Internet]. SDC sought to remove fi nancial Conclusion Agency for Healthcare Research and Quality; 2007. meps.ahrq. barriers to dental care for seniors and The Gary and Mary West Senior gov/data_fi les/publications/cb17/cb17.pdf. in its fi rst year served many patients Dental Center promotes the importance 3. Griffi n SO, Jones JA, Brunson D, Griffi n PM, Bailey WD. Burden of Oral Disease Among Older Adults and Implications for Public who were uninsured. However, a major of senior oral health care and combined Health Priorities. Am J Public Health 2012;102(3):411–8. challenge at the SDC is securing their efforts with the Senior Wellness 4. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The sustainable funding to offset the Center to create a new model of care Older Population in the United States, Current Population Reports, P25-1140. U.S. Census Bureau, Washington, D.C. 2014. cost of providing affordable care and for older adults. Public health dentistry 5. Mertz EA. The Dental-Medical Divide. Health Aff (Millwood) running the operation. Donations and community wellness workfl ows 2016 Dec 1;35(12):2168–75. alone are not enough and therefore are integrated via whole-person 6. Medicare Current Benefi ciary Survey Data Highlight. Dental Services Among Medicare Benefi ciaries: Source of Payment other innovative sources of revenue care. During the fi rst year, the SDC and Out-of-Pocket Spending. March 2016. www.cms.gov/ generation are being investigated to served more than 500 seniors, with 97 research-statistics-data-and-systems/research/mcbs/downloads/ ensure sustainability of the model. completing their initial treatment plan dentaldatahighlightmarch2016.pdf. 7. Thomas H, Mitchell G, Rich J, Best M. Defi nition of Whole Future directions of the SDC and reporting substantial improvements Person Care in General Practice in the English Language include plans to start testing mobile in oral health status posttreatment in Literature: A Systematic Review. BMJ 2018 Dec 14;8(12) dentistry on a small scale. Teledentistry the fi rst year. Although the program doi:10.1136/bmjopen-2018-023758. 8. Lueth J, Jacobi D, Kelly G. A Valuable Assessment Tool: The is a promising option to explore is new and the data are only from the ASTDD’s BSS. Northwest Dent 2009;88(3):37–40. further and may be a way for the SDC fi rst year of operations, there are a 9. Kroenke K, Spitzer RL, Williams, JB. The PHQ-9: Validity to expand services to seniors with number of SDC elements that could of a Brief Depression Severity Measure. J Gen Intern Med 2001;16(9),606–613. more limited mobility. California’s be replicated in other community 10. Bowling A. The Psychometric Properties of the Older People’s laws and workforce support mobile settings. While it may not be possible Quality of Life Questionnaire, Compared with the CASP-19

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and the WHOQOL-OLD. Curr Gerontol Geriatr Res 2009. doi:10.1155/2009/298950. 11. Saliba D, Elliott M, Rubenstein LZ, Solomon DH, Young RT, PEMPHIGUS / PEMPHIGOID AWARENESS Kamberg CJ, Roth C, MacLean CH, Shekelle PG, Sloss EM, Wenger NS. The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community. J Am Geriatr Soc Pemphigus and pemphigoid are rare, autoimmune, skin and (2001);49(12),1691–1699. 12. Soares C. No Show Rates at East Hartford Community Health mucosal blistering diseases. Patients often experience delayed Center. University of Connecticut Dental Search 2011. www. GLDJQRVLV DQG WKH\ FRPPRQO\ SUHVHQW ZLWK RUDO V\PSWRPV ȴUVW chcact.org/resource-fi les/Soares_PPT.pdf. These include blisters, lesions, pain when brushing or eating, and 13. Jones J, Mofi di M, Bednarsh H, Gambrell A, Tobias CR. Increasing access to oral health care for people living with HIV/ the peeling of oral tissue with simple pressure. AIDS in rural Oregon. Public Health Rep 2012;127 Suppl 2(Suppl 2):65–72. You can accelerate diagnosis times! 14. Storrs M J, Ramov, H M Lalloo R. An Investigation Into Patient Non-Attendance and Use of a Short-Message Reminder System at a University Dental Clinic. J Dent Educ 2016; 80(1):30–39. 15. Vujicic M, Buchmueller T, Klein R. Dental Care Presents the Highest Level of Financial Barriers, Compared to Other Types of ASK YOUR PATIENTS: Health Care Services. Health Aff 2016;35(12):2176–82. 16. Glassman P. Geriatric Dentistry in the 21st Century: Environment and Opportunity. J Calif Dent Assoc Do you have more than one blister 2015;43(7):389–93. 1 17. Glassman P, Harrington M, Namakian M. Promoting oral or lesion in your mouth? health through community engagement. J Calif Dent Assoc 2014;42(7):465–70. 18. Edelstein BL. A Public Health Perspective on Paying for Have your blisters or lesions lasted Dentistry, the Aff ordable Care Act and Looking to the Future. Dent 2 for more than a week? Clin North Am 2018;62(2):327–40. 19. Sabato E, Owens J, Mauro AM, Findley P, Lamba S, Fenesy K. Integrating Social Determinants of Health into Dental Curricula: An Have you continually had blisters Interprofessional Approach. J Dent Educ 2018;82(3):237–45. 20. Tiwari T, Palatta AM. An Adapted Framework for 3 or lesions that don’t heal? Incorporating the Social Determinants of Health into Predoctoral Dental Curricula. J Dent Educ 2019 Feb;83(2):127–136. doi:10.21815/JDE.019.015. Do you have blisters or lesions in 21. Burgess JO, Gallo JR. Treating root surface caries. Dent Clin 4 N Am 2002;25:385–404. any locations outside the mouth?

THE CORRESPONDING AUTHOR, Karen Becerra, DDS, MPH, can be reached at [email protected]. If your patient answers YES to 3 or MORE of these questions, a biopsy should be considered. Both conventional H&E histology (in formalin) and DIF (in Michel’s/Zeus) are needed for a diagnosis. Specimens must contain intact epithelium over the underlying connective tissue. More info and photos at https://pemphig.us/cal

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CDA JOURNAL, VOL 47, Nº4

Strategies for Oral Health Care Practitioners To Manage Older Adults Through Care-Setting Transitions

Elisa M. Ghezzi, DDS, PhD, and Mary M. Fisher, DDS

ABSTRACT As patients age, there are changes in dependency, medical conditions and mobility that directly affect treatment needs and recommendations. Some of these patients can be treated in a private practice setting while others require treatment in long-term care facilities or places of residency. As older adults transition through stages of dependency and housing environments, oral health care providers simultaneously must transition how care is managed in the areas of assessment, prevention, treatment and communication.

AUTHORS

Elisa M. Ghezzi, DDS, Mary M. Fisher, DDS, ost patients who are people transition through stages of PhD, provides dental care established a mobile older adults are not dependency and housing environments for residents of nursing and practice, Michigan Geriatric TABLE 2 assisted living facilities in Dental Care, in 1982 and signifi cantly different ( ), their oral health care needs the metropolitan Detroit partnered with Premier than their younger simultaneously transition. The goal of area. In addition, she is an Healthcare Management counterparts. So, what this paper is to describe strategies for adjunct clinical assistant in 1987 in providing dental Mmakes an older adult different? When oral health care professionals to manage professor in the department care to William Beaumont of cariology, restorative Hospital affi liates’ extended- does the care of an older adult change care for older adults over a lifetime sciences and endodontics at care facilities. She has been substantially from what would be the care using dependency, living environments the University of Michigan, practicing dentistry in the for a younger patient? The latter question and care settings as a framework. School of Dentistry. Dr. West Bloomfi eld, Mich., Ghezzi serves as the past area since 1981and is a was addressed by Iain Pretty, BDS, MSC, 1 chair of the Coalition for member of the Oakland MPH, PhD, et al. in the development Private Practice Oral Health for the Aging County Dental Society, of the Seattle Care Pathways. This Oral health care providers in private and is a member of the the Michigan Dental framework structured the care of older practice will see a range of patients Healthy Aging Committee Association and its Forensic of the Association of State Dental Identifi cation adults (assessment, prevention, treatment, who transition from no dependency to and Territorial Dental Team, the American communication) based on their level of predependency to low dependency. The Directors and the Oral Dental Association, the frailty or dependency (TABLE 1). Many clinical care objective for this group Health Workgroup of the International Congress Gerontological Society of Oral Implantologists older adults pass through some of the is to assist in maintaining oral health of America. and the Coalition for Oral early stages of dependency (none/pre/ for a lifetime while cognizant of future Confl ict of Interest Health for the Aging. low) while still in a private practice challenges that will present as dependency Disclosure: None reported. Confl ict of Interest setting though they may start to need increases. Having a dentist and good Disclosure: None reported. more intervention. Those with medium oral hygiene habits are associated with a or high dependency often reside in decreased risk of caries development in long-term care settings or at home home-dwelling people with moderate or with substantial assistance. As older substantial supportive care for daily living.2

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TABLE 1 The Seattle Care Pathway: Actions Required To Maintain Oral Health at Different Levels of Dependency

Actions Level of Dependency None Pre Low Medium High Communication Explain Explain to patients and Expand to all members Maintain communication Monitor established implications health care providers the of the health care team; with members of the communication and include of increased signifi cance of conditions emphasize preventive interprofessional health family and friends to allow dependency. likely to complicate the strategies to manage the care team; increase for continuous adjustments management of oral health risk of oral disease and vigilance regarding daily to by as dependency increases. maintain oral function. oral care plan. everyone involved. Prevention Home-care plan Consider prescribing Base preventive plans on Monitor and help Focus on the increasing for better oral for oral disease; risk identifi ed aggravating contributions to oral health challenges of preventing health. modifi cation for oral cancer, factors; adjust methods of regimens; reassess the need and managing oral infection tooth surface loss and delivering predependency to increase prescriptions for and disorders; emphasize mucositis; develop daily oral prescriptions; assess risks oral disease; reassess risks the management of pain care plan. and manage adverse eff ects and manage the adverse and infection; maintain the of ; monitor eff ects of polypharmacy; use of prescribed agents daily oral care plan. reassess the eff ectiveness of for oral disease; manage daily oral care plan. severe mucositis. Assessment Appropriate Systemic conditions; Risk of oral disease; Participate in social and Identify barriers to dental recall. appropriate dental recall; increase dental recall; other medical services; emergency palliative and strategic health care plan strategic health care plan reassess long-term viability elective oral care; monitor delivery; recognize risk delivery; growing risk of of oral health-related burden of oral care on the is elevated by increased oral disease; long-term preventive strategies. patient and others; monitor dependency; long-term viability of oral health and the oral health care plan; viability of oral health; management strategies. increase vigilance for assess for elder abuse. elder abuse. Treatment Routine. Long-term viability of Treatment to maintain Conservative treatment; Off er palliative treatment on existing treatment plans; function; maintain function use prosthetics to simplify demand from the patient to plan treatment outcomes for and oral health. hygiene and maintenance. control pain and infection easy maintenance. and maintain social contacts and activities.

From: Al-Sulaiman A, Jones J. Geriatric oral health care delivery in the United States of America. Curr Oral Health Rep Published online 18 June 2016. Pretty IA, Ellwood RP, Lo ECM, MacEntee MI, Müller F, Rooney E, Thomson WM, Van der Putten GJ, Ghezzi EM, Walls A, Wolff MS. The Seattle Care Pathway for securing oral health in older patients. Gerodontology 31(Suppl. 1):77–87; 2014.

There are critical components is recommended but it may not be a stable oral status, then a change needs of care that will be used throughout attainable for patients with limited to be implemented. As an example, the dependency transitions that should be dexterity or those who require full use of a power toothbrush instead of a established while patients have minimal assistance with oral hygiene daily. This manual one is often necessary for those to no dependency. Every patient in document can be provided to care staff patients with dexterity limitations (e.g., private practice should have a daily oral when people are admitted to hospitals or , ). Implement care plan (TABLE 3, available as a form short-stay rehabilitation environments strategies to maintain autonomy as at cda.org/CT1). This is a document so oral hygiene is not neglected and the long as possible until the risk for decay that is relatively straightforward for presence of prostheses is made known. or becomes too great. people who are independent, but can At each dental cleaning appointment, Treatment planning for the become more complex as dependency the daily oral care plan should be reviewed aging patient must be based on the increases. Keeping instuctions simple and updated.3 See TABLE 4 for guidelines needs of the individual and enhance and not creating elaborate, multistep in the assessment process, which should their quality of life; therefore, it is oral hygiene regimens is benefi cial include current oral status, current individual based.4 Several treatment if the plan is to be implemented regimen, current level of intervention, planning paradigms have been and maintained. Idealistic regimens risk assessment and determination of developed for the aging population. can be overwhelming. For example, modifi cation required. If the current level The rational treatment plan includes interproximal cleaning such as fl ossing of intervention is not adequate to promote evaluation of the following factors:

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TABLE 2 Housing Environment Timeline Home Independent Assisted living Nursing home: Nursing home: Nursing home: living (community Subacute Rehabilitation Long-term care/ apartment living) cognitive impairment Independent home: Typically private Typically start as private Typically short stay Typically short stay Short- or long-term stay, Typically private practice patients; practice patients. following hospitalization following hospitalization often until the end of life. practice* patients some have cars. Often transition to need prior to returning to prior to returning to Focus on preventive and Home with in-home May transition into for mobile or virtual home or assisted living home or assisted living palliative care. (aspiration pneumonia/ requiring PT/OT (hip assistance: Typically assisted living following dentistry and aggressive May need some private practice patients an acute hospital stay preventive strategies as COPD and CHF or knee replacement/ exacerbation). stroke). rehabilitation; no Homebound: Patients that may have required dependency increases. urgency. rehabilitation. Often are no longer Often are no longer require mobile dental care Can transition from Address acute needs needing assistance able to access regular able to access regular Bedbound: Patients dental care in private dental care in private and observe chronic require mobile dental care to full dependence issues; plan long-term and mortality without practice and have practice and have signifi cant needs; often signifi cant needs; often strategy to address entering the nursing dental needs. home environment. need signifi cant dental need signifi cant dental rehabilitation and rehabilitation and Typically have multiple aggressive preventive aggressive preventive hospitalizations over the strategies. strategies. course of time. Educate patient’s Educate patient’s May spend time in decision-maker of need decision-maker of need rehabilitation prior to continue regular care to continue regular care to returning from a following discharge. following discharge. hospitalization.

*“Private practice” is used to include any practice setting where the patient would travel independently to receive care including community health clinics.

■ The patient’s desires recall frequency with adjunctive therapies bathroom” or “Sometimes I forget my and expectations. such as fl uoride rinses, varnishes, gels appointments” can indicate a change in ■ The type and severity of the and pastes. As cervical plaque and food dependency. Further discussion is needed patient’s dental needs. impaction are the most common causes with the patient to determine appropriate ■ How the patient’s dental problems of tooth decay in older adults, crowns interventions to not only improve oral affect their quality of life. fabricated with subgingival margins can care, but also logistical arrangements to ■ The patient’s ability to tolerate increase longevity.6 Occlusal guards are keep appointments. Increased assistance the stress of treatment. recommended to protect the restorations by family or friends can help a patient ■ The patient’s ability to maintain following restorative treatment in people continue to be seen in the private practice oral health independently. with bruxism.7 Treatment planning for environment, which is often the ideal ■ The probability of positive 50- to 70-year-old edentulous patients for location for care until no longer feasible. treatment outcomes. implant-retained lower dentures will allow Transitioning through the stages ■ The availability of reasonable and for adequate nutrition and an improved of dependency requires the addition of less-extensive treatment alternatives. alternative to ill-fi tting lower dentures reliance on assisted devices. Oftentimes, ■ The patient’s fi nancial status. and resultant ulcerations that accompany older, dependent patients arrive at a ■ The dentist’s ability to deliver a severely resorbed mandibular ridge.6 private practice with assisted devices (e.g., the care needed (e.g., resources, Oral health care providers are active walkers, canes) as well as wheelchairs and, skills, equipment). participants in identifying changes in some instances, motorized scooters. ■ Other issues (e.g., the patient’s in a patient’s dependency. At routine A private practice should formulate an life span, family infl uences and cleanings, an increase in the presence of offi ce policy regarding the level of staff expectations and bioethical issues).5 cervical plaque, calculus and food debris involvement with patient transfers. A Clinical treatment planning for with increased gingival infl ammation written directive provided to patients older adults must incorporate strategies may be the fi rst indication of a functional regarding transfer responsibilities is helpful. to maintain teeth when oral hygiene is decline.8 Statements made by the patient They should be informed in advance that no longer ideal. This includes increased such as “I have a hard time getting to the transfer responsibilities of the patient to

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TABLE 3 Daily Oral Care Plan Recommendations No changes in oral hygiene regimen recommended at this time. Recommend changes in current oral hygiene regimen to prevent tooth decay and gingival infl ammation. A professional cleaning recall interval of 1 2 3 4 6 months is recommended to maintain oral health. Care of Patient’s Teeth The patient has been instructed/needs assistance to brush their teeth daily with a toothbrush and fl uoride toothpaste two (2) times per day, after breakfast and before bedtime. An order was written for fl uoride gel application: Using a toothbrush, apply fl uoride gel to all tooth surfaces before bedtime following toothbrushing. Patient must not eat, drink or rinse for two (2) hours following application. If uncooperative, apply a thin layer to the cheekside of teeth using a toothette. An order was written for 0.12% chlorhexidine gluconate: Swish and spit 1 tablespoon or apply with toothette following morning and/or evening toothbrushing. Other Care of Patient’s Dentures The patient has been instructed/needs assistance to remove their upper and/or lower dentures at night. Dentures should be cleaned with toothbrush and toothpaste and placed in a denture cup with water and tablet of eff ervescent denture cleanser (Polident, Eff erdent or other generic denture cleanser) overnight. The denture should be thoroughly rinsed and placed back in the mouth in the morning before breakfast. The patient has been instructed/needs assistance to place a very thin and even layer of denture adhesive in their upper and/or lower denture each morning. The patient has been instructed/needs assistance to remove their upper and/or lower dentures following each meal, rinse with water and place back in mouth. Other

(Full version available as a form at cda.org/CT1) and from the dental chair is a duty of the needs to determine how involved the staff Transitioning Out of Private Practice caregiver who brings the patient to the will become in the facilitation of care. As private practitioners, we are dental appointment. It is not prudent to Many patients can continue to be treated busy treating the patients “in front of have dental staff members involved with in a private practice setting if family or us.” Schedules are routinely fi lled with transferring a patient from a wheelchair friends can be contacted to assist with the patients who actively seek treatment. or motorized scooter to a dental chair logistics of transportation, scheduling, Therefore, older adults in private practice unless the staff members are trained. transferring into the dental chair and who are transitioning through the stages Letting patients know that dental offi ce understanding and following posttreatment of dependency can unintentionally get staff members will assist with moving instructions and recommendations. lost. One day, we think about Mr. and wheelchairs once the patient has transferred Setting a guideline requiring a person Mrs. Smith and realize we haven’t seen to the dental chair and will open and close other than the patient to be designated them in a while. We may learn that Mr. offi ce and car doors for the patient and responsible for coordination of care can Smith has entered an assisted living their escort is reasonable. When patients help achieve successful outcomes. Often facility. Because clinicians stay busy are no longer able to transfer to a dental with cognitive changes come behavioral running their practices, there is little time chair, the practitioner needs to decide if changes. These can be displayed as to follow up with this group of elderly the patient can comfortably and safely increased anxiety or belligerence toward patients who no longer make their recall continue to be treated in a dental offi ce oral care. Use of oral sedation such appointments because of medical issues, setting. Reasons to consider transitioning as lorazepam or alprazolam (TABLE 5) cognitive decline, transportation and out of a dental practice include patient in a private practice setting could be other problems. What are our options and practitioner challenges with treatment considered, but may require additional at this point in time? Do nothing and provided in a wheelchair and unavailability training and licensure in certain states. let the patient drop out of your practice of transfer devices such as Hoyer lifts. Dentists, staff and patients should also be and disappear, or be proactive and Besides patient transfer, cognitive aware of an increased fall risk, in the offi ce start the conversation at the time the concerns create challenges to providing and after dismissal as long as the patient debility is fi rst noticed or encountered? care in a private practice setting. When is sedated, and plan accordingly. This When noticing decline in a patient, patients start to forget appointments, forget could require an escort to and from the start the discussion and “set the stage” oral hygiene instructions or lack the ability dental appointment or use of a wheelchair for them to move out of your practice. to implement instructions, a practice until the patient is no longer sedated. “Decline” can run the gamut from

238 APRIL 2019 CDA JOURNAL, VOL 47, Nº4

TABLE 4 Daily Oral Care Assessment and Intervention

■ What is the current oral status (generalized cervical plaque//food hoarding/open contacts with food impaction/fi xed prostheses with food impaction at abutments)?

■ What is the current daily oral care regimen (toothbrushing/tongue brushing/fl ossing/oral rinse/fl uoride application/prosthetic care)?

■ Defi ne the current level or stage of daily oral care intervention: ◆ Person brushes teeth 2x/day without reminder. ◆ Person brushes teeth 2x/day needing reminder: •Verbal reminder. •Take to bathroom. •Hand person toothbrush with toothpaste in bathroom. ◆ Person brushes teeth 2x/day with reminder and with caregiver involvement: •Hand person toothbrush with toothpaste in bathroom. • After person independently brushes teeth, caregiver brushes maxillary and mandibular teeth along gum line. ◆ Person unable to brush teeth independently; needs complete caregiver assistance.

■ What is the risk of losing teeth due to caries or periodontal disease with subsequent decline in oral function?

■ Concepts: • Maintain autonomy as long as possible, but not at the risk of increased decay or tooth loss. • Determine current level of intervention; if not adequate to promote a stable oral status, move to the subsequent level.

mobility issues noticed when seating brushing station bedside so the patient and have little time to devote to oral and dismissing the patient from the can continue to provide their own oral health.9 Staff attitudes toward oral chair (counter holding) to memory care or provide specifi c instruction if a care, lack of time and staff to complete impairment issues evidenced during dental caregiver will be required to supervise oral care and behavioral and physical conversation as well as loss of a driver’s oral hygiene. Let the family know that diffi culties with residents have been license and/or recent change in living ensuring twice-daily brushing is vital to found to adversely impact oral health arrangement. Be proactive and discuss preserving the investment the patient care delivery in LTC facilities.10 mobility issues such as challenges related has made in their dentition during their When approaching an LTC or to being wheelchair or bedbound. Obtain lifetime as well as their quality of life. assisted living facility in which a previous permission to reach out to other family private practice patient now resides, it members and discuss the situation. If it Facility Relationship is important to understand relationship is feasible for the practice, let the family A decision to provide oral health building. Rushing in and overwhelming know the patient is welcome to continue care to residents of a long-term care the facility with an increased workload is care at the offi ce with their support. (LTC) facility should be made with asking for disaster. To be successful, the More often than not, care deliberation. The closest LTC facility oral health care provider must develop management is in upheaval when a to an offi ce may not be the best place relationships with the facility staff, from patient transitions to a facility and leaves to develop a working relationship if administration to patient aides. This their home and the routine of life that the LTC staff do not make oral health takes time. Start small and grow slowly. accompanied it. Often, routine dental a priority. When a patient transitions Although private practitioners are used care is missed because of the pressing to an assisted living facility, an LTC to being in charge of their offi ce and staff, medical issue(s) that brought on the facility or simply remains at home with recognize that LTC facilities have their facility admission. Families appreciate increasingly challenging mobility issues, own rules and regulations. Oral health being informed of a missed three-, four- or it is important to understand that oral care professionals may take on more of six-month prophylaxis interval and now health may not be a priority for the a role as consultant to assist the facility may add this appointment to the list of facility or patient and oral hygiene in improving and maintaining the oral appointments that they need to schedule may become more diffi cult for the health of their residents. Education is and attend. Letting the family know homebound patient. Facilities routinely always a key piece in success. Starting a that oral hygiene may now be more of a deal with their own management issues relationship with a LTC facility through challenge due to the patient’s increased (e.g., adequate staffi ng, instituting and a patient who has just transitioned to dependence is important. Provide following policies, providing adequate their care is often the best introduction. suggestions such as setting up a dental patient care and addressing regulations) When the patient is no longer able to

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TABLE 5 Commonly Used Prescriptions

■ Indication: Caries risk Fluorides Rx: 1.1% sodium fl uoride gel Dispense: 1 (one) tube routinely seek care outside the facility, a Instructions: Using a toothbrush, apply fl uoride gel to all tooth surfaces before bedtime following mobile practice model must be considered toothbrushing. Patient must not eat, drink or rinse for two hours following application. If uncooperative, to take services to the patient. apply a thin layer to the cheek side of teeth using a toothette. The role of an LTC facility is to ■ Indication: Severe gingival infl ammation/halitosis secondary to periodontal disease facilitate residents obtaining the care they Rx: 0.12% chlorhexidine gluconate desire and to ensure the patient’s decision- Dispense: 1 (one) 64-ounce bottle maker is addressing all care needs. The Instructions: Swish 1 tablespoon for 30 seconds then spit out or apply to gums with toothette following LTC facility needs to document where morning and/or evening toothbrushing. residents will obtain oral health care ■ Indication: Tooth extraction* or oral pain services at time of admission as well as Rx: Extra-strength acetaminophen (500 mg or 625 mg)** Dispense: 16 (sixteen) tablets address this at yearly care-plan meetings Instructions: Patient to be given one tablet four times a day for oral pain for four days following tooth extraction. with the patient’s decision-maker. An authorization for dental examination form ■ Indication: Acute swelling and infection Antibiotics (TABLE 6, available as a form at cda.org/ Rx: Amoxicillin 500 mg CT2) can be adapted to be included in Dispense: 40 (forty) tablets admission packets given to the patient’s Instructions: Take two tablets immediately, then one tablet four times a day until gone. decision-maker to notify them of services ■ Indication: Candidiasis available on-site or to document where Rx: Nystatin suspension (100,000 units/cc) oral health care will be sought off-site. Dispense: 160 ml This will be documented at the time of Instructions: With denture out, swish and spit 1 tablespoon four times a day for two weeks. admission and reviewed with the daily oral ■ Indication: Behavioral management/unable to cooperate for oral care care plan and oral health care/dental plan Sedation at annual care-plan meetings with the •Training and licensure as required by state law. patient’s decision-maker and the nursing •Obtain medication administration record (MAR). staff. Due to challenges in transportation •Consult with primary care physician (PCP). •Discuss risk versus benefi t with patient/patient’s decision-maker including postadministration of highly dependent patients, some precautions until sedation wears off . facilities will choose to enlist a mobile Rx: Lorazepam 0.5 mg practice to meet oral health needs on-site. Dispense: 2 (two) tablets Determining how to approach Instructions: Patient to be given 0.5 mg lorazepam one hour prior to treatment with an additional providing consultations and direct care in 0.5 mg lorazepam given if needed. a facility can be challenging. Attempting Rx: Alprazolam 0.25mg to screen all patients at a facility for Dispense: 2 (two) tablets oral health needs can be ineffi cient Instructions: Patient to be given 0.25 mg alprazolam one hour prior to treatment with an additional and expensive if there is little interest 0.25 mg alprazolam given if needed. in follow-up care. It can be costly to * PCP consultation may also be indicated prior to extractions for persons on blood thinners such as warfarin, clopidogrel, follow up with the patients’ decision- rivaroxaban and apixaban. makers on oral fi ndings and treatment ** Always check the MAR for other sources of acetaminophen to avoid liver toxicity. Acetaminophen may not be indicated and duplicative if the patient is regularly taking stronger pain medications (e.g., hydrocodone with acetaminophen), as those will be adequate recommendations as well as obtaining for pain control. If greater pain relief is needed than what is provided by acetaminophen, it is recommended that the PCP be consulted. permission and fi nancing for further care. If you fi nd you are creating treatment plans, but few patients are moving practice dentist and intruding on that dental need. A mobile practice dentist forward to obtain treatment, it may be relationship may not be welcomed. is often contacted when an acute dental necessary to modify to a consultant model The consult-based model is practical, problem arises. The nature of consults to identify those residents who would effi cient and helpful. The consult-based can run the gamut from acute infections benefi t and follow up with treatment model works toward maintaining the oral to a simple denture problem or a broken recommendations. Many patients have health of an individual resident desiring tooth or to request routine care that has an existing relationship with a private dental care and is specifi c to an emergent been missed. It is very common to be

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TABLE 6 Sample Authorization for Dental Examination Form Introduction With XX years of experience in treating the elderly in assisted living facilities, nursing homes, hospitals and the dental offi ce, Dr. XX is pleased to announce the expansion of his/her dental practice to your residence. Services living or long-term care setting. If there In his/her fee-for-service practice, Dr. XX is able to provide comprehensive dental care through portable dentistry and offi ce care. The services provided through the mobile dental practice include oral is no access, it is imperative to continue examinations, regular professional cleanings, restorations, crowns and bridges, extractions and complete preventive care outside the facility setting and partial denture construction and rebasing. to reduce the need for restorative or Further services can be provided at his/her dental offi ce in XX. Referrals are also available to dentists closer specialty care (such as oral surgery). A to your residence. To ensure regular oral care, we maintain a schedule for regular oral examinations and well-transitioned patient would be one dental cleanings at an agreed upon interval that is appropriate to maintain oral health. who obtains oral hygiene twice daily as Payment ordered by a dental provider and receives The practice is fee for service. As a service to you, we submit all bills to the dental insurance company preventive care by a dental professional at provided to us. The insurance reimbursement will be paid directly to the insured and a bill will be sent to intervals determined by their individual the patient’s decision-maker for payment in full. risk factors for oral diseases14 (TABLE 7). Appointment information When meeting patients for the fi rst If you have any questions about our services or would like to schedule an appointment or consultation, time in a long-term care setting, the fi rst please contact us at phone number or email address. visit should include an initial assessment We look forward to helping you maintain a healthy smile for a lifetime. of the patient’s oral hygiene, an oral ❏ I am currently seeing my private dentist regularly for oral health care and do not desire to receive examination, appropriate radiographs and, in-house dental services at this time. if possible, a prophylaxis or full-mouth debridement after a thorough review of ❏ I would like an oral examination to be performed by the in-house dental service, which will cost $. No further treatment will be provided without the approval of the patient’s decision-maker. past dental and medical histories. After fi ndings have been gathered, urgent (Full version available as a form at cda.org/CT2) treatment needs should be completed fi rst. There is no need to rush the completion consulted for an acute dental problem and services to those residents who desire of necessary restorative treatment given then learn when gathering past dental preventive care as well as hands-on the patient will likely need to be seen history that the resident has not been education to the nursing staff on daily oral on a three-month interval. It is prudent seen by a dental professional for several care is ideal.11 The four-pronged role of to treat the worst areas of decay fi rst and years. Family members and the patients’ this on-site oral health champion would reassess the next pressing treatment needs decision-makers who realize there is a include performing clinical procedures, at each three-month prophylaxis interval dental need or that the patient has missed developing and maintaining oral hygiene until all needs are addressed. Having a their routine cleaning appointment often care plans for residents, providing in- 12- to 18-month plan is not uncommon request that their family member continue service training and continuous support if treatment is not urgent, and this time to receive comprehensive dental care. for nursing home staff and assisting staff can be extended if at each assessment with incorporating oral hygiene care into there is minimal decline in oral status. Mobile Dentistry in Long-Term Care the residents’ daily hygiene schedules.12,13 Surgical and restorative procedures should The delivery of mobile dentistry This provider can also serve to screen be completed strategically and according to the geriatric population is uniquely new patients with problems and gather to the patient’s ability to tolerate and challenging and requires the delivery information needed for the dentist to benefi t from such treatment. For example, of dental care in a physically rigorous, plan necessary future treatment. consideration to extract a second molar emotionally charged and mentally Ideally, all patients who transition in a case where there is an open contact challenging environment. Obstacles can from a private practice setting to an with interproximal decay and food arise from facility regulations, family and assisted living or LTC setting would be impaction may be necessary to retain patient expectations, equipment repair seen by an oral health care provider at the the fi rst molar. Placement of restorations and maintenance issues and sometimes recommended preventive care interval when the patient’s oral hygiene is unable even from the dental profession. at which they had been maintained (i.e., to support them may not be prudent. The presence of a registered dental three, four or six months) in the recent Small areas of decay and root caries decay hygienist or an appropriately trained past. However, that usually requires under crowns can be observed and treated provider on a routine basis to provide access to oral health care in the assisted with silver diamine fl uoride (SDF) at

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TABLE 7 Oral Prevention in Long-Term Care Settings

■ Daily oral care ◆ Every resident should have a daily oral care plan. ◆ Supervised toothbrushing should occur twice daily — after breakfast and before bedtime — with a regular toothbrush and fl uoride toothpaste, not a toothette or sponge. recommended intervals.15,16 SDF is also a ◆ An accountability system with regular evaluation should be established. good option for the uncooperative patient ◆ Yearly oral health education of staff should be provided via in-servicing. who is not a candidate for restorative ■ Daily fl uoride application20 treatment. Preventive prescription ◆ First, a decay risk assessment21 should be performed to determine fl uoride need. fl uoride products should be used daily ◆ An assessment of resident pharmacy formularies should be performed to determine fl uoride prescrip- according to caries risk as well as patient tion coverage and availability. and caregiver ability to comply with the ◆ Appropriate fl uoride application should be administered depending on the level of decay risk: fl uoride proposed regimen1 (TABLES 5 and 7). toothpaste, fl uoride rinse, fl uoride gel (Jenson et al. 2007).14 The discussion with a patient and/or ◆ Staff training should occur annually for proper administration of fl uoride toothpaste, fl uoride rinse and their decision-maker in a mobile practice fl uoride gel. setting should begin with a recap of the ■ Regular professional cleanings screening/preventive/emergent-need ◆ The last cleaning and due date for the next cleaning should be documented in the resident’s medical appointment. These decision-makers are record upon admission. ◆ quite accustomed to speaking to medical Assessment and identifi cation of barriers to obtaining regular professional cleanings should be performed (i.e., funds, transportation, behavior challenges). and other health care professionals about ◆ Confi rmation and documentation that the facility dental provider off ers regular professional cleanings their loved ones. Address the primary (i.e., every three to six months) for the residents should be secured. reason for the dental consult, list other From: Fisher MM and Ghezzi EM. Preparing Patients for Future Oral Healthcare Decline; Compendium 34(2): 150-151; 2013. pertinent fi ndings, such as an obvious See Spolsky et al., 2007 for comprehensive list of Caries Management by Risk Assessment (CAMBRA) products. decline in oral hygiene, broken teeth or presence of caries, and focus on which teeth can be saved. Recommending understanding that there is still a need and a background check. In some states, strategies that are tried and true with for continuing oral care as long as the a mobile dental license or permit is positive outcomes is an important way patient desires, requires and can tolerate required if dental care is to be provided to build the provider/patient/patient’s the treatment planned. Whether or not outside a private practice setting. decision-maker relationship. Focus on the the patient continues to take food by When fi rst contacted to provide dental challenges at hand, acknowledge mouth, the need to clean the oral cavity care for a person in an LTC facility, it the challenges inherent for highly daily exists. A need for education arises is important to obtain the document dependent patients in a mobile practice when patients’ decision-makers or hospice that includes the patient’s demographic, and discuss how best to overcome and providers deem that because the patient insurance and patient’s decision- work through them in a timely manner. has been transferred to hospice, there is maker information (commonly called Educating families of patients no future need for preventive care, only a facepage) as well as the medication experiencing cognitive, behavioral comfort care. Comfort measures can administration record (MAR) that and functional decline is one of the include a broad range of interventions, not only lists current medications and biggest challenges a dental provider from chemotherapeutics to adjustment dosages, but often includes the patient’s faces. Helping families understand that of prostheses and other procedures to medical diagnoses and allergies. It would patients with increasing dependency meet preventive or surgical needs.17 be important to note medications such issues are a unique population with ever- as anticoagulants, bisphosphonates, changing needs and unique challenges Practical Implementation of immunosuppressants, pain or sedative is a necessary but extremely diffi cult Mobile Dentistry medications and medications causing task. Many times families want their Prior to seeing a patient in an xerostomia. Also note that patients loved one to receive dental care similar LTC facility, permission must be with medications for behavioral to what they receive (e.g., a six-month obtained from the patient’s decision- management (e.g., quetiapine, recare interval) and acceptance of the maker and the facility. Most facilities lorazepam, haloperidol) may have limitations imposed by declining physical require credentialing that can include diffi culty cooperating for oral health and cognitive conditions can be diffi cult. submission of a state dental license, a care. Consultation with the primary The transition from a long-term care Drug Enforcement Agency license, proof care physician (PCP) may be required setting into hospice care requires the of malpractice insurance, fi ngerprinting to determine the risk of complications

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TABLE 8 A Morning in the Life of a Mobile Dental Practice

Two weeks prior: ■ Determine facility and patients to be visited. ■ Contact the facility: Determine who is still a resident and who has passed away. ■ Send sympathy cards to families of deceased patients. ■ Determine who will need sedation; PCP consults for patients with new sedation orders. ■ Contact patients’ decision-makers, notify of date and intended treatment. ■ Determine if patients’ decision-makers plan to be present; provide with two-hour window when patient will be seen.

One week prior: ■ Send orders for medications required for day of treatment.

One day prior: ■ Fax list of patients to be seen with arrival time and times of medication administration; do not include specifi c appointment times or sequence of patients as it is not predictable. ■ Pack car with equipment; note that in cold weather, electrical equipment can blow a fuse after being left outside for prolonged periods. Visit day: 7 a.m.: ■ Phone call from daughter of patient No. 1 states that the daughter is sick and unable to be at the appointment, so she would like to cancel treatment.*

8:30–8:45 a.m.: ■ Call the facility prior to arrival to let them know who you want to see fi rst. ■ Dentist and assistant arrive at location to be ready to begin seeing patients at 9 a.m.** ■ Visit all patients’ rooms to notify them and their direct care staff that they will be seen for dental care. ■ Confi rm with med techs that required premedication has been administered. ■ Determine facility staff who will be assisting in bringing patients for care. ■ Set up equipment.

9 a.m.: ■ Patient No. 1: Canceled. ■ Patient No. 2: New consult for treatment. Patient just returned from rehabilitation. Brief exam reveals upper denture coated with plaque; erythematous upper ridge; anterior teeth Nos. 21–27 with crowns; no acute needs; cooperative; needs denture cup. Discuss need for daily denture hygiene with care staff . Next visit: Comprehensive examination/prophylaxis/full-mouth radiographs/clean upper denture/maxillary complete denture rebase once erythema resolves/oral care plan/Rx: fl uoride gel/treatment plan/three-month recall. ■ Patient No. 3: Follow-up examination to evaluate need for immediate treatment. Met patient at last facility visit for consultation for upper and lower dentures. Patient presented with multiple decayed and broken teeth; uncooperative due to cognitive decline; not a candidate for dentures; recommend full-mouth extractions of remaining seven teeth and four retained roots; family unable to aff ord treatment and desires only urgent care; no swelling, pain or abscesses noted; recommend reevaluate in three to six months. ■ Patient No. 4: Staff states patient doesn’t want to be seen. ■ Patient No. 5: Periodic examination and prophylaxis (sonic scaling/polish/fl oss) for patient on three-month recall; Medicaid only covers cleanings every six months; family has agreed to pay for additional cleanings; patient lives on memory care unit and with 0.5 mg lorazepam is able to cooperate for cleanings; adequate but not ideal oral hygiene: generalized plaque and calculus but no decline in oral status; patient with severe cognitive impairment has been in practice for almost four years and maintained dentition with only routine cleanings. ■ Patient No. 6: Patient arrives with son; wearing upper denture coated with plaque and root remnant of tooth No. 24; erythematous upper ridge; patient refused to get out of bed for examination at the previous visit; goal of today’s treatment is to evaluate existing prostheses to determine which are usable, but unable to accomplish goal because facility is no longer able to locate the prostheses; radiograph taken of root remnant; topical and local anesthetic applied; root remnant removed; no pain medication prescribed; needs denture cup; discuss need for daily denture hygiene with care staff ; consider maxillary complete denture rebase once erythema resolves and add patient’s name to denture; consider Rx: nystatin if erythema not resolved by daily oral care. ■ Patient No. 4: In courtyard smoking; approach to discuss need for care; patient agreeable to treatment and will come after fi nishes smoking. ■ Patient No. 7: In bathroom; will come to appointment when done. ■ Patient No. 8: Younger, 79-year-old patient in practice for almost three years at four- to six-month intervals (due to fi nancial constraints); two teeth have been extracted, one tooth restored and three crowns completed; silver diamine fl uoride placed on eight teeth today in areas of decay at cervical margins of crowns; patient is on a three-month recall with a stable dentition as treatment needs were present at initial examination. ■ Patient No. 7: Needs help in the bathroom; decides to brush hair; seen for six-month evaluation and cleaning of upper and lower complete dentures; severe mandibular bone loss and maxillary anterior bone resorption; uses denture adhesive in previously rebased maxillary denture. ■ Patient No. 4: Periodic examination and prophylaxis (sonic scaling/polish/fl oss) for patient on three-month recall; seen during the lunch hour as he will be able to eat independently following treatment; presents with maxillary complete denture and mandibular removable partial denture coated with plaque; clean prostheses and three remaining lower teeth; ulceration in area of posterior right mandibular fl ange; mandibular RPD adjusted.

Noon: ■ Wrap up. ■ Follow-up phone calls to patients’ decision-makers discussing oral fi ndings, treatment provided and further recommendations.

* Patient was uncooperative at the initial visit, but able to have treatment subsequently with 0.5 mg lorazepam and daughter present to calm and redirect the patient; the patient will be rescheduled for another visit when the daughter can be present. ** If attempt is made to start treatment prior to 9 a.m., many residents are still eating breakfast or not dressed and ready to be seen.

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TABLE 9 Required Equipment for Treatment Models

■ Screenings (may be referred to private practice for care) from dental procedures related to the care coordinator, but could be a social ◆ Light/coat/gloves/masks/explorer/mirror use of some medications, such as those worker as facility staff structure can ◆ Documentation/forms listed previously, or their indication vary greatly among facilities. Knowing ■ Denture adjustment for use. Also consider the potential the key players in each facility helps ◆ Light/coat/gloves/masks for adverse drug interactions with to establish accountability. Prior to a ◆ Documentation/forms medications administered or prescribed facility visit, send the LTC facility a ◆ Portable adjustment tool with burs to the patient for dental needs. schedule indicating the arrival time of ◆ Applicable denture adjustment supplies The oral care of people in long- the provider, the patients to be seen (articulating paper, PIP) term care settings does not require a and all medication names, dosages and ■ Radiographs (may be referred to private complicated list of prescriptions in times to be administered (TABLE 8). practice for care) one’s arsenal. Indications for commonly Ordering prescription medication ◆ Light/coat/gloves/masks/X-ray holders used prescriptions include caries needed for routine care may be ◆ Documentation/forms risk, severe gingival infl ammation, required up to a week in advance. ◆ Portable X-ray machine (Nomad); extra halitosis, oral pain, candida, acute Assessing the oral status, diagnosing batteries and recharger swelling and infection and behavior disease and recommending interventions ◆ Film/developer (if not transported to off -site management (TABLE 5). The role of and treatment are accomplished at the dental offi ce for processing) or sensors/ the PCP is to manage the medical care clinical visit. As fi ndings are documented, laptop/software and medications for their patients. If oral care plans (TABLE 3) and treatment ◆ Patient and provider lead aprons a patient is unable to cooperate for plans are developed and distributed to ■ Prophy dental care and a sedative medication multiple parties (LTC facility, patient, ◆ Light/coat/gloves/masks/explorer/mirror is indicated, submitting a consultation patient’s decision-maker). It is helpful ◆ Documentation/forms to the PCP can be both a courtesy and to develop forms that can be duplicated, ◆ Ultrasonic scaler (recommended) confi rmation that the PCP is aware of the disseminated and placed in the patient’s ◆ Portable suction with compressor new medication with potential adverse facility chart. The patient and/or (recommended) side effects. The patient’s decision-maker patient’s decision-maker determine ◆ Polishing handpiece with prophy angles will often be much more agreeable to desires for daily and professional care. ◆ Disposables (fl oss/bridge threaders/ and comfortable with the use of sedation Oral health care professionals assess daily fl uoride varnish) for oral health care if the PCP is aware oral care and oral hygiene, providing ■ Restorative or surgical treatment and has approved its use. Although most feedback and education and creating dentists are licensed to write sedation accountability through care plans and ◆ Light/coat/gloves/masks/explorer/mirror orders, it is helpful if the consultation orders made within the LTC facility. ◆ Documentation/forms provides the specifi c order requested to be There are many treatment models ◆ Portable suction with compressor (required) written by the PCP. Many patients have that can be implemented for the provision ◆ High- and low-speed handpieces PRN orders for pain medications that of mobile oral health care depending ◆ Restorative or surgical materials and supplies could be used following an extraction. on the level of care to be provided. It is ■ Denture treatment However, given the challenges of people recommended that any provider interested ◆ Light/coat/gloves/masks with cognitive impairment to verbalize in considering mobile dental care start ◆ Documentation/forms pain, it is best to write an order for with minimal investment of time and ◆ Portable adjustment tool with burs TABLE 5 scheduled pain medication ( ). equipment to develop relationships with ◆ Torch and fuel (restricted use around people Communication and relationship facilities and patients before expanding using oxygen) building with an LTC facility are to an extensive treatment model. ◆ Applicable denture treatment supplies critical for success. On both sides of the Valuable practical information can be (impression materials) relationship, there should be designated obtained by contacting mobile dental ◆ Water bath (consider logistical challenges) contact people with whom schedules, care providers and organizations such ■ Sterilization prescriptions and treatment can be as Apple Tree Dental in Minnesota ◆ Portable autoclave versus transportation of relayed. Oftentimes in a facility, this (appletreedental.org), which has used instruments (per state law) person is the director of nursing or the developed a sophisticated means of

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delivering care to older adults in long-term Conclusion 11. Seleskog B, Lindqvist L, Wardh I, Engstrom A, von Bultzingslowen I. Theoretical and hands-on guidance care. Equipment costs and requirements Patients will age and experience from dental hygienists promotes good oral health in elderly vary based on the type of treatment to be changes in dependency, medical people living in nursing homes, a pilot study. Int J Dent Hyg provided (TABLE 9). Much can be done conditions and mobility. Dental providers 2018 Nov;16(4):476–483. doi:10.1111/idh.12343. Epub 2018 Apr 12. with little investment and expansion is must be sensitive to these changes and 12. Chalmers JM, Ettinger RL. Public health issues in typically dictated by patient demand. proactive in modifying preventive and geriatric dentistry in the United States. Dent Clin North One innovation to improve access to restorative treatment recommendations. Am 2008 Apr;52(2):423–46, vii–viii. doi:10.1016/j. cden.2007.12.004. care for patients with limited mobility Observing our patients for subtle 13. Amerine C, Boyd L, Bowen DM, Neill K, Johnson T, and access to care is the virtual dental changes in cognition and behavior, Peterson T. Oral health champions in long-term care facilities: A home.18 The virtual dental home is anticipating their needs and initiating pilot study. Spec Care Dentist 2014 Jul–Aug;34(4):164–70. doi: 10.1111/scd.12048. Epub 2013 Aug 19. “based on the principles of bringing the discussion of these changing needs 14. Jenson L, Budenz AW, Featherstone JDB, Ramos- care to places where underserved with the patient and family members as Gomez FJ, Spolsky WV, Young DA. Clinical protocols for populations live, work or receive appropriate through stages of dependency caries management by risk assessment. J Calif Dent Assoc 35(10):714–723; 2007. social, educational or general health is essential. As oral health care providers, 15. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. services, integrating oral health with we too need to transition our established Controlling caries in exposed root surfaces with silver diamine general health, social and educational model of care to suit the increasingly fl uoride: A systematic review with meta-analysis. J Am Dent Assoc 2018 Aug;149(8):671–679.e1. doi:10.1016/j. delivery systems, and using telehealth complex needs and environments adaj.2018.03.028. Epub 2018 May 24. technologies to connect a geographically frail older adults must navigate. ■ 16. Hendre AD, Taylor GW, Chavez EM, Hyde S. A systematic distributed, collaborative dental team review of silver diamine fl uoride: Eff ectiveness and application REFERENCES in older adults. Gerodontology 2017 Dec;34(4):411–419. with the dentist at the head of team- 1. Pretty IA, Ellwood RP, Lo ECM, MacEntee MI, Muller F, doi:10.1111/ger.12294. 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Treatment planning concepts for the ageing upon pertinent fi ndings. This type of patient. Australian Dent J 60 Suppl 1: 71–85; 2015. THE CORRESPONDING AUTHOR, Elisa M. Ghezzi, DDS, PhD, can care model allows a provider a bonanza 5. Lindquist TJ, Ettinger RL. The complexities involved with be reached at [email protected]. of information and more time to managing the care of an elderly patient. J Am Dent Assoc 134(5):593–600; 2003. focus on necessary restorative and/or 6. Fisher MM, Ghezzi EM. Preparing patients for future oral prosthetic treatment when they are on- health care decline: What dentists can do today. Compend site as a mobile provider or to limit the Contin Educ Dent 2013 Feb;34(2):150–1. 7. Johansson A, Omar R, Carlsson GE. Bruxism and prosthetic necessity of in-offi ce visits, scheduling treatment. J Prosthodont Res 2011 Jul;55(3):127–36. doi: only when treatment needs exceed 10.1016/j.jpor.2011.02.004. Epub 2011 May 18. what can safely be done on-site with 8. van der Putten GJ, de Baat C, De Visschere L, Schols J. Poor oral health: A potential new geriatric syndrome. Gerontology the resources available to the provider. 2014 Feb;31 Suppl 1:17–24. doi:10.1111/ger.12086. This model of care allows streamlined 9. Lindquist L, Seleskog B, Wardh I, von Bultzingslowen I. communication and information sharing Oral care perspectives of professionals in nursing homes for the elderly. Int J Dent Hyg 2013 Nov;11(4):298–305. with other specialists (oral surgeons), doi:10.1111/idh.12016. Epub 2013 Feb 25. facilities and family members and 10. Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, allows a provider the necessary time Kambhu PP. Factors infl uencing nurses’ aides’ provision of oral care for nursing facility residents. Spec Care Dentist 1996 to complete administrative duties. Mar–Apr;16(2):71–79.

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CDA JOURNAL, VOL 47, Nº4

Developing an Interprofessional Oral Health Education System That Meets the Needs of Older Adults

Kathryn A. Atchison, DDS, MPH; Anita Duhl Glicken, MSW; and Judith Haber, PhD, APRN, BC

ABSTRACT This article discusses how education can bridge the silos between dental and medical care to better serve older adults who suffer from complex dental and medical conditions. A strong interprofessional team-based, patient-centric care model is essential to reach older adults who attend primary care visits but do not have regular dental care or vice versa. Interprofessional didactic and clinical education opportunities are needed to train a broad mix of health professional students and practitioners to work together to integrate oral health care, particularly directed at the complex medical, social and fi nancial needs of older adults.

AUTHORS

Kathryn A. Atchison, recommendations for collaboration and of a national nursing oral he number of individuals in DDS, MPH, is a professor improving the integration of health equity. health initiative, the Oral the U.S. aged 65 and older in the division of public oral health and primary care. Confl ict of Interest Health Nursing Education health and community Confl ict of Interest Disclosure: None reported. Practice Program, funded is expected to double from dentistry at the University Disclosure: None reported. by the DentaQuest and 2012 to 2050, increasing from of California, Los Angeles, Judith Haber, PhD, Arcora Foundations, and 43.1 million to 83.7 million.1 School of Dentistry and is Anita Duhl Glicken, APRN, BC, is the Ursula the principal investigator on jointly appointed in the UCLA MSW, associate dean Springer Leadership the HRSA-funded program, TThe population will also be more Jonathan and Karin Fielding and professor emerita at Professor in Nursing at Teaching Oral-Systemic diverse racially; by 2055 it is projected School of Public Health, the University of Colorado the NYU Rory Meyers Health. that there will no longer be a white department of health policy Anschutz Medical Center, College of Nursing. Dr. Confl ict of Interest management. She served now serves as the executive Haber is the NYU leader of Disclosure: None reported. majority, refl ecting strong Asian and UCLA as the vice provost, director of the National interprofessional education Hispanic growth.2 These changes are new collaborative initiatives Interprofessional Initiative and practice, with a special clearly demonstrated in California, from 2011 to 2016 where on Oral Health (NIIOH) focus on oral-systemic she assisted faculty in providing backbone support health, collaborating the most populous state in the union. launching novel academic to a national movement with interprofessional Among the 37 million California and research programs. She to integrate oral health partners at the NYU residents, 57 percent are white, 37 recently led a team of public into primary care. Her College of Dentistry and health experts to create a career has focused on School of Medicine where percent are Hispanic or Latino, 13 report, commissioned by health care transformation, she co-chairs the NYU percent are Asian, 6 percent are black the National Academies of creating innovative Interprofessional Research, or African-American, 16 percent Sciences, Engineering and education and care Education and Practice Medicine’s Roundtable on delivery models grounded Steering Committee. She identify as “other” race and 2 percent Health Literacy, to outline in interprofessional is the executive director report being two or more races.3

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Within the U.S., there is a wide demonstrates disparities in health. For that ACOs that include dental services variation in the population who identify example, the proportion of older adults were more likely to include federally as “older adults.” Many are well-educated, who have lost all natural teeth is currently qualifi ed health centers (FQHCs) and fi nancially well-off and have good health 13 percent of adults aged 65 to 74, but community health centers that have insurance. They seek regular primary the percentage increases to 26 percent a Medicaid contract to provide care. care visits and their lives continue among adults 75 and older.6 The rate Building oral health into health insurance much as they did in the years prior to of edentulous adults also documents programs increases recognition of the retirement. However, many other older income and race disparities. However, as oral-systemic connection and helps to adults suffer from multiple chronic a measure, edentulousness alone does not support dental care for older adults who diseases that impact activities of daily clearly indicate a need for dental care or otherwise fi nd that dental treatment living, have no retirement income, active disease. Active dental caries and remains an expensive out-of-pocket cost. lack dental insurance, lack English periodontal diseases continue into older age Finally, Vujicic stressed the need to profi ciency, have limited health literacy and measuring untreated caries or active bridge the silos of traditional dental and and/or have little social support. The periodontal disease signifi es a need for medical care. This is especially true for rapid growth of this segment of the aging care of older adult populations that often population presents many challenges suffer from complex medical conditions to our health care system, particularly such as diabetes and , an evolving health care workforce. Older adults ... have which are now considered to be related numerous oral and physical to periodontal disease. Older adults, more Mapping Our Health Care System to health problems that call for than any other age group, have numerous the Needs of Older Adults oral and physical health problems that In a recent editorial, Vujicic4 an interprofessional approach call for an interprofessional approach to proposed reforms to the dental care to primary, acute and primary, acute and long-term care. For a system that are essential to expand the long-term care. number of diseases common among older use of dental care by all older adults and adults, oral systemic associations have been to create meaningful improvements in reported and management of these diseases overall health, including oral health. are reasonable places for oral health to be First, Vujicic observed that dental care dental treatment. This would be a useful integrated as part of the standard of care use among seniors is driven by affl uent measure for older adults as it emphasizes the by primary and acute care providers and seniors, thus we should improve dental oral-systemic connection and may relate to dentists. For example, the infl ammatory coverage in order to increase access to care measures of improvement in overall health. process in diabetes is a common and decrease disparities in oral health. Vujicic further suggested that pathophysiological process that increases The high cost of dental care is reported reimbursement models for health care the risk for periodontal disease with related as the key reason that older adults do recognize treatment that improves infection and tooth loss.9,10 Microorganisms not receive dental care.4 Medicaid, a health outcomes. Accountable care and infl ammation also play a role in the state-federal assistance program, covers organizations (ACOs) are groups of health association between periodontitis, poor adult dental benefi ts in only about half care providers who are contractually oral hygiene and respiratory diseases. of the states, and benefi ts vary, with 19 responsible for both the cost and quality For example, plaque accumulation and states providing emergency-only adult of care provided.7 Now serving more biofi lm in the upper respiratory tract can benefi ts for nonpregnant adults, leaving than 18 million Americans, ACOs are serve as a haven for respiratory pathogens many older adults with no coverage.5 testing the need to build dental services that can travel to the lungs in frail and/ Second, Vujicic advised that the into their list of covered health services. or critically ill older adults at home and dental system needs to measure things Demonstration programs have shown that in long-term care or hospital settings. that are important to both patients and increased use of emergency rooms and Aspiration pneumonia is a leading providers. A commonly used outcome failure to have regular preventive dental contributor to morbidity and mortality in measure is the proportion of the population care such as cleanings drove up the total older adults. Oral hygiene is recognized that is edentulous; this measure often cost of care. Fraze and colleagues8 found as an evidence-based intervention

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for reduction of risk for ventilator- have been associated with depression.16 to dental providers.19 There are almost acquired pneumonia and nonventilator For older adults who have longstanding 200,000 working dentists20 and more hospital-acquired pneumonia.11 serious and persistent mental health than 170,000 dental hygienists21 in the Chronic conditions common to disorders like schizophrenia, bipolar U.S. Few dentists offer dental services older adults, such as hypertension, disorder or substance abuse, years of in peoples’ homes, nursing homes or dyslipidemia, depression, refl ux and chronic neglect to physical health and oral long-term care facilities. It will be critical obstructive pulmonary disease (COPD), health, coupled with the use of mood to develop a strong interprofessional, often require multiple medications stabilizers and antipsychotic medications, team-based, patient-centric care model that result in xerostomia and decreased are associated with gingival hyperplasia, to reach older adults who see a primary salivary production. The resulting dry increased risk for periodontal disease, tooth care provider but do not have regular mouth provides a climate conducive to decay, tooth loss and poor nutrition.17,18 dental care. The nondental health accumulation of plaque, bacteria and It is also important to note that a care workforce, comprised of more infl ammation. Chronic conditions that signifi cant proportion of older adults than 4 million nurses, 250,000 nurse affect mobility and the completion of reside in the community and, eventually, practitioners, 1 million physicians activities of daily living (ADL), such as and 131,000 physician assistants, has Parkinson’s disease, arthritis, stroke and signifi cant capacity to assess risk for oral dementia, can make oral self-care and health problems, provide preventive the ability to obtain adequate nutrition Producing this services such as oral cancer screening, diffi cult and, with increasing motor and/or tobacco-cessation counseling and cognitive dysfunction, require special aids interprofessional oral health fl uoride treatment, identify oral health for handling utensils and performing oral workforce, however, requires problems, provide referral to dental hygiene.12,13 These conditions exacerbate a signifi cant shift in professionals as needed and ultimately the likelihood of dental decay.14 help extend the reach of the dental Older adults with cancer commonly health-profession education. workforce to improve the oral health experience acute and chronic oral and overall health of older adults.22,23 sequelae of their chemotherapy and/or Primary care professions are in radiation treatments including xerostomia, the midst of transforming health mucositis, oral ulcers, candidiasis and some will enter long-term facilities and profession education and practice in osteonecrosis. These side effects make oral may require assistance from caregivers ways that will be benefi cial for treating hygiene diffi cult but critical to accomplish as they lose the ability to brush and fl oss older individuals. These initiatives because the xerostomia and open lesions daily and complete their own denture are increasingly focused on bridging provide an increased risk for infection in care. Caregivers are often unprepared professional silos through team-based, already immunocompromised patients. to assume this ADL and may need collaborative care models. Three Moreover, eating and obtaining adequate coaching to learn strategies to overcome complementary initiatives describe nutrition are challenges related to the pain residents’ resistance to oral hygiene while the development and implementation of having food in an ulcerated mouth as maximizing residual self-care capacity. of competencies, models and guides well as painful chewing and swallowing.15 that can be used to improve the way Oral health has also been found to Importance of Interprofessional Care multiple professions can and should have a bidirectional association with for Older Adults work together to improve oral health. mental and psychosocial health problems. The U.S. dental workforce will not be Producing this interprofessional oral Mental health problems, like depression suffi cient to handle all of the preventive health workforce, however, requires a and anxiety, can make people indifferent and therapeutic oral health needs of a signifi cant shift in health-profession to their oral hygiene and to seeking regular growing older population. There are more education, beginning with educator dental treatment. Likewise, older adults than 5,866 dental Health Professional commitment to develop and train health with signifi cant dental problems who Shortage Areas, including rural and urban profession students and clinicians to work have attendant symptoms such as pain areas across the U.S. representing almost across traditional professional lines to when chewing or drinking cold drinks 63 million Americans with poor access integrate oral health in their curriculum.

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TABLE Interprofessional Education Collaborative (IPEC)*

Competency 1. Work with other professionals to maintain a climate of mutual respect and shared values. (values/ethics for interprofessional practice) Competency 2. Use the knowledge of one’s own role and those of other professions to appropriately The Institute of Medicine assess and address the health care needs of patients and to promote and advance the health of released competencies focused on populations. (roles/responsibilities) providing patient-centered care, Competency 3. Communicate with patients, families, communities and professionals in health and other identifying technologies for teamwork fi elds in a responsive and responsible manner that supports a team approach to the promotion and communication and coordination and maintenance of health and the prevention and treatment of disease. (interprofessional communication) the importance of using evidence and Competency 4. Apply relationship-building values and the principles of team dynamics to perform continuous quality improvement to eff ectively in diff erent team roles to plan, deliver and evaluate patient/population-centered care and population health programs and policies that are safe, timely, effi cient, eff ective and equitable. (teams lay out the process and skills needed and teamwork) to inform collaborative practice models for geriatric oral health.24 The *Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, D.C.: Interprofessional Education Collaborative. Interprofessional Education Collaborative (IPEC) builds on these competencies by proposing a set of interprofessional Progress has been made in care educators and clinicians to support collaborative competencies for health- interprofessional education. All dental workforce training. Smiles for Life, a profession education.25 Competency schools are now instructed to “provid(e) national oral health curriculum created domains fall into four categories: values/ opportunities early in their educational by the Society of Teachers of Family ethics for interprofessional practice, experiences to engage allied colleagues Medicine, offers eight modules that cover roles/responsibilities, interprofessional and other health care professionals.” oral health issues across the lifespan, communication and teams and teamwork Nonetheless, the Commission on including geriatric oral health.29 Smiles (TABLE). In 2014, the Health Resources Dental Accreditation recognizes there for Life has been endorsed by the ADA and Services Administration (HRSA) are signifi cant challenges to providing along with more than 18 other professional used these foundational guidelines to opportunities for dental students to partner academies and organizations. The training create a report specifi c to interprofessional with other “health care professionals is used in private practice as well as oral health. The Integration of Oral educated to deliver patient-centered community health settings to create a Health and Primary Care Practice care as members of an interdisciplinary common knowledge base for integrating includes a set of oral health core clinical team.”27 Although the accreditation cycle team-based care. Providers and students competencies for nondental primary means that change is not immediate, the can complete the curriculum online or care providers.26 The competencies American Dental Education Association educators/trainers can download slides include risk assessment, oral health noted that by 2014, 90 percent of and speaker notes for in-person training. evaluation, preventive interventions, dental schools offered interprofessional The NIIOH and its funders also communication and education and education (IPE) experiences for their commissioned the Qualis Health interprofessional collaborative practice. It students, although only 69 percent of Oral Health Delivery Framework and was recommended that the competencies those activities were mandatory and Implementation Guide.30 Offered from be integrated into existing accreditation some involved volunteer or service the perspective of how primary care and certifi cation standards associated with projects only. Experiences, however, can providers communicate with dental education and training at the predoctoral be quite limited, ranging from a one- professionals after providing an oral and continuing education levels. The hour seminar to an extended learning health screening, the framework provides report further describes a systems experience over several months or years.28 a pathway to integrate oral health into approach defi ning the interdependent In 2009, The National Interprofessional the practicing clinician’s primary care elements needed to implement and Initiative on Oral Health (NIIOH) was workfl ow. The framework also aligns adopt the competencies into primary created to advance oral health integration with transitioning the traditional head, care practice and an implementation across health-profession education and eyes, ear, nose and throat (HEENT) strategy for translating these into primary practice. In addition to cultivating components of a physical examination to care practice within safety-net settings. leadership and facilitating interprofessional include oral health (HEENOT),31 thus Taken together, these three initiatives learning and agreement, two national intentionally including oral health in provide valuable signposts that are guiding resources supported by NIIOH are free all aspects of patient history taking and transformation across our workforce. online and now widely used by primary physical exam by asking clinicians to:

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■ ASK questions about oral professional training by defi ning what ■ The Oral Health Nursing health when completing each profession can contribute and how Education and Practice (OHNEP) the health history. they will work together in a team- program at the New York ■ LOOK in the mouth and complete based, collaborative-care environment. University College of Nursing the intraoral exam including Nonetheless, this is not suffi cient. A and College of Dentistry offers an oral cancer screening. position statement by the Partnership an innovative, educational ■ DECIDE on the patient’s risk for Health in Aging Workgroup on experience for dental and nurse factors and formulate your Interdisciplinary Team Training in practitioner (NP) students to focus management plan including those Geriatrics noted that most health on oral-systemic health and team- related to the patient’s oral health. care professionals lack “suffi cient based care as they rotate through ■ ACT to engage the patient in opportunities to learn with, from and a nursing faculty practice, conduct preventive interventions that about other health care professionals.”32 an oral health assessment and a include oral health (e.g., smoking Survey results show that many primary physical exam and then, if needed, cessation, management of glycemic care professionals do not feel competent refer patients for dental care.34 control, motivational interviewing ■ The Western University of for lifestyle change, oral hygiene Health Sciences implemented coaching, dental referrals). a three-phase interprofessional ■ DOCUMENT oral health fi ndings Dental schools and education and practice (IPE- for the history, physical exam, dental professional IPP) program including a case- risk factors and interventions, organizations need to fi nd based curriculum with small- including referrals. group discussions, followed by The implementation guide offers ways to work with other collaborative, team-based oral a practical approach to enhance health professions to educate health care in the Western partnerships between primary care our colleagues on oral health. U Diabetes Institute.35,36 and dental providers and includes ■ The University of Colorado tools and strategies that were deemed Denver medical and dental useful by the participants who fi eld- schools offer an oral health tested the framework in FQHCs and to perform an oral exam without clinical program for medical and private practices. The tools include training and clinical experiences. physician assistant (PA) the key components of a dental referral Dental schools and dental professional students where third-year as well as a dental-consultation note organizations need to fi nd ways to work dental students and faculty back to the primary care team. The with other health professions to educate provide hands-on instruction framework, endorsed by 18 professional our colleagues on oral health. To help in oral health prevention and academies and organizations including inform this work, the National Center diagnosis including physical- the ADA, could be a ready initiation for Integration of Primary Care and Oral exam skills and techniques of point for discussing collaboration Heal (CIPCOH) created a partnership fl uoride varnish application.37 with other health providers about of several academic institutions in the ■ A community-based program elders’ overall health or in a Boston area to conduct systems-level developed by the University of continuing education program. research on educational resources used Alabama’s School of Dentistry and barriers to successful oral health and the Fairhaven Retirement Educational Opportunities Are integration into primary care training.33 Community created the Fairhaven Needed for Interprofessional The following initiatives, Oral Health Center, a combined Oral Health Training offered by dental and other health dental clinic and learning The accomplishments discussed professions schools, are examples of center that trains medical previously in this article help to innovative programs that provide and dental professionals to defi ne and frame the competencies interprofessional training within the understand the interconnection and curriculum needed for health- university and in the community. of oral and overall health.38

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■ The University of Iowa Colleges such as securing transportation to dental treatment.41 Medicaid coverage of Dentistry, Nursing and Social dental and primary care visits, access varies from state to state and is not Work offer an innovative to free or low-cost medication and guaranteed year to year.42 ACOs may community-based program access to fi nancial resources for dental provide oral health services in order serving frail older adults in nursing coverage. Transportation barriers are to improve the overall health of the homes using a mobile dental particularly important for elders with patient, although they may require billing clinic staffed by a joint team of lower incomes, mobility problems and periodontal services or extractions under their students. The approach the underinsured/uninsured.40 Patient the medical insurance, using medical ICD immerses students in patient cases navigators, such as those described in codes, and to facilitate measurement of with multiple chronic conditions the University of Iowa program, and the patient’s overall health improvement, that need to be considered in community health workers can be rather than only outcomes in oral health. improving the patient’s total particularly helpful in bridging access to The IPEC competencies emphasize the health, including oral health.39 care. Social workers can often address importance of communication training for These examples demonstrate viable a wide array of social, behavioral and students and existing health professionals ways to provide clinical and didactic to develop a verbal, electronic and written training across professions that can engage common language in order to collaborate clinicians and students to work together across professions. Communication to address the oral-systemic connection. Transportation barriers are training and utilization of information technology often receives little emphasis Discussion particularly important for in health-profession education, but is a Dental, medical and other health elders with lower incomes, critical element to be assured that the educators and practitioners will mobility problems and the provider can adequately communicate increasingly be called upon to provide with the patient, caregivers (if needed) leadership, expertise and collaboration underinsured/uninsured. and other health care providers so all in shaping effective new policies and will have a common understanding of standards to address Vujicic’s reforms4 the patient’s problems, the proposed care and to ultimately integrate oral health path and how each provider contributes and overall health care. These leaders payment system factors that contribute to improving the health of the patient. will also need to develop strategies to to better health outcomes, including One dental school study showed that strengthen the current workforce through education and behavior management as poor health literacy was the strongest professional development and increased well as resources to support medication predictor of patients failing to show up for opportunities for multidisciplinary training and payment for services. They can a dental appointment.43 Clearly explaining for faculty, residents and students. assist providers with referrals and the patient’s problems, medications or Health professional students, coordinate patient management for potential secondary preventive behaviors especially dental professionals, can complex and co-morbid conditions. needed to manage their problems and benefi t from training that prepares Older adults benefi t from collaborative treatment options is the challenging them to collaborate with social service practice where communication communication responsibility of the agencies that can facilitate patient and shared management of support provider. Health literacy is described access to dental care. Older patients services and health care are brought as “the degree to which individuals have multiple needs, such as physical, together on behalf of the patient. can obtain, process, understand and mental and fi nancial challenges that Dental, medical, nurse practitioner communicate about health-related the older adult and/or their caregivers and PA students also need to learn about information necessary to make informed must address to secure appropriate the nuances of the health care payment decisions.”44 Older adults with poor health oral health care. Health professionals system to best serve their patients. Many literacy often feel overwhelmed trying are confronted with responding to are surprised to learn that Medicare does to resolve the multiple challenges of the multiplicity of health-related not cover most dental care except under fi nding appropriate primary and specialty and nonhealth-related challenges, narrowly defi ned medically necessary health care providers while managing

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other physical and fi nancial problems of population. Accessed Sept. 18, 2018. care. Clin J Oncol Nurs 2015 Oct;19(5):615–9. doi: transportation and medication renewals 3. Suburban Stats. Current population demographics and 10.1188/15.CJON.615-619. statistics for California by age, gender and race. Population 16. Kressin NR, Spiro A, Atchison KA, Kazis L, Jones JA. associated with multiple chronic diseases Demographics for California 2017, 2018. Suburban Stats Is depressive symptomatology associated with worse oral and dental providers must also be prepared Inc.; 2018. suburbanstats.org/population/how-many- functioning and well-being among older adults? J Public to help them navigate these systems. people-live-in-california. Accessed Sept. 28, 2018. Health Dent 2002;62(1):5–12. 4. Vujicic M. Our dental care system is stuck and 17. Haber J, Hartnett E, Allen K, et al. The impact of oral- here is what to do about it. J Am Dent Assoc 2018 systemic health on advancing interprofessional education Conclusion Mar;149(3):167–169. doi: 10.1016/j.adaj.2018.01.006. outcomes. J Dent Educ 2017;81(2):140–148. Ultimately, we must educate dental 5. Medicaid Coverage of Dental Benefi ts for Adults. In: 18. Fereshtehnejad SM, Garcia-Ptacek S, Religa D, et Report to Congress on Medicaid and CHIP; chapter 2. al. Dental care utilization in patients with diff erent types students and existing practitioners to Washington, D.C.: Medicaid CHIP Payment and Access of dementia: A longitudinal nationwide study of 58,037 successfully function as part of a health Commission (MACPAC); 2015. www.macpac.gov/wp- individuals. Alzheimers Dement 2018 Jan;14(1):10–19. doi: care team. This means understanding content/uploads/2015/06/Medicaid-Coverage-of-Dental- 10.1016/j.jalz.2017.05.004. Epub 2017 Jul 8. Benefi ts-for-Adults.pdf. Accessed Sept. 18, 2018. 19. The Kaiser Family Foundation State Health Facts. Dental their role on the team and communicating 6. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries care health professional shortage areas (HPSAs). Data that to patients and the others on the and tooth loss in adults in the United States, 2011–2012. source: Bureau of Health Workforce, Health Resources team. They must also understand the Hyattsville, Md.: National Center for Health Statistics; 2015. and Services Administration (HRSA), U.S. Department of Data Brief No. 197. www.cdc.gov/nchs/data/databriefs/ Health and Human Services, Designated Health Professional responsibilities and functions of the other db197.pdf. Accessed Sept. 18, 2018. Shortage Areas Statistics: Designated HPSA Quarterly professions to make appropriate and 7. Leavitt Partners. Dental care in accountable care Summary, as of Dec. 31, 2016. www.kff .org/other/state- effective referrals and develop meaningful organizations: Insights from fi ve case studies. Publication indicator/dental-care-health-professional-shortage-areas-hps in collaboration with American Dental Association and as/?currentTimeframe=0&sortModel=%7B%22colId%22:% collaborations. The ongoing trend toward American Academy of . 2015. www.ada. 22Location%22,%22sort%22:%22asc%22%7D. Accessed a patient-centered medical-dental home org/~/media/ADA/Science%20and%20Research/HPI/ Aug. 17, 2018. model describes the type of patient care Files/HPIBrief_0615_1.pdf?la=en. Accessed June 22, 2017. 20. Health Policy Institute. American Dental Association. 8. Fraze T, Colla C, Harris B, Vujicic M. Early insights on Workforce. www.ada.org/en/science-research/health- experience that accommodates the oral dental services in accountable care organizations. Health policy-institute/dental-statistics/workforce. Accessed Dec. and systemic needs of the older adult Policy Institute Research Brief. American Dental Association. 10, 2018. and focuses on clear communication April 2015. www.ada.org/~/media/ADA/Science%20 21. Data USA. Dental Hygienists. datausa.io/profi le/ and%20Research/HPI/Files/HPIBrief_0415_1.ashx. soc/292021. Accessed Dec. 10, 2018. between the health professional and the Accessed Sept. 18, 2018. 22. Haber J. Building a culture of collaboration. patient. Models such as this integrate 9. Madianos PN, Koromantzos PA. An update of Interprofessional education and practice. Journal of the many health professionals within one the evidence on the potential impact of periodontal Academy of Distinguished Educators 2014;2(1):12–14. therapy on diabetes outcomes. J Clin Periodontol 2018 dental.nyu.edu/content/dam/nyudental/documents/jade/ “home” and emphasize good access to Feb;45(2):188–195. doi: 10.1111/jcpe.12836. Epub vol2/jade_v2_haber.pdf Accessed Sept. 27, 2018. primary care, shared decision-making and 2017 Dec 26. 23. Catalanotto F, Koppelman J, Haber J. Emerging models education and navigation that support 10. Southerland JH, Taylor GW, Off enbacher S. Diabetes of dental practice aim at addressing needs of the aged. and periodontal infection: Making the connection. Clin Compend Contin Educ Dent 2017 Oct;38(9):606–610; 45–47 personal health management. More Diabetes 2005;23(4):171–178. doi.org/10.2337/ quiz 613. interprofessional didactic and clinical diaclin.23.4.171. 24. Institute of Medicine and National Research Council. educational opportunities are needed 11. Li L, Ai Z, Li L, Zheng X, Jie L. Can routine oral care with Improving access to oral health care for vulnerable and antiseptics prevent ventilator-acquired pneumonia in patients underserved populations. Washington, D.C.: The National to prepare dental professionals for the receiving mechanical ventilation? An update meta-analysis Academies Press; 2011. www.hrsa.gov/sites/default/ integration of oral health care with from 17 randomized controlled trials. Int J Clin Exp Med fi les/publichealth/clinical/oralhealth/improvingaccess.pdf. medical care, particularly directed at the 2015 Feb 15;8(2):1645–1657. eCollection 2015. Accessed Sept. 27, 2018. 12. Rozas NS, Sadowsky JM, Jones DJ, Jeter CB. 25. Interprofessional Education Collaborative. Core complex medical, social and fi nancial Incorporating oral health into interprofessional care competencies for interprofessional collaborative practice: needs of older adults to improve their teams for patients with Parkinson’s disease. Parkinsonism 2016 update. Washington, D.C.: Interprofessional Education health and experience while maintaining Relat Disord 2017 Oct;43:9–14. doi: 10.1016/j. Collaborative; 2016. nebula.wsimg.com/2f68a39520b03336 parkreldis.2017.07.012. Epub 2017 Jul 17. b41038c370497473?AccessKeyId=DC06780E69ED19E2B3 or decreasing the cost of health care. ■ 13. Plemons JM, Al-Hashimi I, Marek CL, American Dental A5&disposition=0&alloworigin=1. Accessed Sept. 27, 2018. Association Council on Scientifi c Aff airs. Managing 26. Integration of oral health and primary care practice. U.S. REFERENCES xerostomia and salivary gland hypofunction. February Department of Health and Human Services, Health Resources 1. Ortman JM, Velkoff VA, Hogan H. An aging nation: The 2015. www.ada.org/~/media/ADA/Science%20and%20 and Services Administration; 2014. www.hrsa.gov/sites/ older population in the United States. Population estimates Research/Files/CSA_Managing_Xerostomia.pdf?la=en. default/fi les/hrsa/oralhealth/integrationoforalhealth.pdf. and projections. Washington, D.C.: U.S. Census Bureau; Accessed Dec. 21, 2018. Accessed Feb. 23, 2018. 2014. Current Population Reports, P25–1140. www.census. 14. Taking care of your teeth and mouth. Bethesda, Md.: 27. Commission on Dental Accreditation. Accreditation gov/content/dam/Census/library/publications/2014/ U.S. Department of Health and Human Services, National standards for dental education programs. Education demo/p25-1140.pdf. Accessed Sept. 18, 2018. Institute on Aging. www.nia.nih.gov/health/taking-care-your- Environment, page 15. Chicago: Commission on Dental 2. United States Population 2018. World Population teeth-and-mouth. Accessed Sept. 27, 2018. Accreditation; 2018. www.ada.org/~/media/CODA/Files/ Review. worldpopulationreview.com/countries/united-states- 15. Hartnett E. Integrating oral health throughout cancer pde.pdf?la=en. Accessed Aug. 16, 2018.

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28. Atchison KA, Rozier RG, Weintraub JA. Integrating oral Accessed Sept. 18, 2018. 2012;2012:149673. doi: 10.1155/2012/149673. Epub health, primary care and health literacy: Considerations 31. Haber J, Hartnett E, Allen K, et al. Putting the mouth 2012 May 17. for health professional practice, education and policy. back in the head: HEENT to HEENOT. Amer J Public Health 35. Aston SJ, Rheault W, Arenson C, et al. Interprofessional Commissioned by the Roundtable on Health Literacy, Health 2015;105(3):437–441. education: A review and analysis of programs from three and Medicine Division, the National Academies of Sciences, 32. Oral health an essential element of aging. academic health centers. Acad Med 2012;87(7):949–955. Engineering and Medicine; 2017. nationalacademies. Interprofessional solutions for improving oral health 36. Andrews EA. The future of interprofessional education org/hmd/~/media/Files/Activity%20Files/PublicHealth/ in older adults: Addressing access barriers, creating and practice for dentists and dental education. J Dent HealthLiteracy/Commissioned%20Papers%20-Updated%20 oral health champions. The Gerontological Society of Educ 2017 Aug;81(8):eS186–eS192. doi: 10.21815/ JDE.017.026. 2017/Atchison%20K%20et%20al%202017%20 America; 2017. www.geron.org/images/gsa/documents/ gsa2017oralhealthwhitepaper.pdf. Accessed Sept. 18, 37. Bowser J, Sivahop J, Glicken A. Advancing oral health Integrating%20oral%20health%20primary%20care%20 2018. in physician assistant education: Evaluation of an innovative and%20health%20literacy.pdf. Accessed Feb. 23, 2018. 33. Health Resources and Services Administration Data interprofessional oral health curriculum. J Physician Assist 29. Clark M, ed. Smiles for life: A national oral health curriculum. Warehouse. Active Grants for HRSA Program(s): Academic Educ 2013;24(3): 27–30. 3rd ed. Society of Teachers of Family Medicine; 2010. www. Units for Primary Care Training and Enhancement 38. Fournier R. Wisdom of the Ages: Geriatric patients teach smilesforlifeoralhealth.com. Accessed Sept. 27, 2018. (UH1). Data current as of Aug. 1, 2018. ersrs.hrsa.gov/ dental students about the future. UAB Magazine, Spring 30. Hummel J, Phillips KE, Holt B, Virden M. Safety Net ReportServer/Pages/ReportViewer.aspx?/HGDW_Reports/ 2018. www.uab.edu/uabmagazine/features/wisdom-of-the- Medical Home Initiative. Implementation guide supplement. FindGrants/GRANT_FIND&ACTIVITY=UH1&rs:Format=HTM ages. Accessed Sept. 27, 2018. Organized, evidence-based care: Oral health integration. L4.0 Accessed Sept. 18, 1028. 39. Anderson L. UI College of Dentistry promotes geriatric Seattle: Qualis Health; 2016. www.safetynetmedicalhome. 34. Dolce MC, Haber J, Shelley D. Oral health nursing dental care in the classroom and community. University org/sites/default/fi les/Guide-Oral-Health-Integration.pdf. education and practice program. Nurs Res Pract of Iowa; 2017, March 24. now.uiowa.edu/2017/03/ ui-college-dentistry-promotes-geriatric-dental-care-classroom- and-community. Accessed Sept. 27, 2018. 40. Syed ST, Gerber BS, Sharp SK. Traveling towards disease: Transportation barriers to health care access. J Community Health 2013 Oct;38(5):976–93. doi: 10.1007/s10900-013-9681-1. 41. Billing medical plans for dental treatment. Sacramento, Calif.: California Dental Association; 2016. www.cda. org/news-events/billing-medical-plans-for-dental-treatment. Help is one Accessed Aug. 17, 2018. 42. Incurred medical expenses. Paying for dental care: A how-to guide. American Dental Association, National Elder call away. Care Advisory Committee, Council on Access, Prevention and Interprofessional Relations; 2017. www.ada.org/~/media/ ADA/Member%20Center/FIles/ime_documents.ashx%20 The CDA Accessed%20August%2017. Accessed Sept. 18, 2018. Well-Being Program 43. Holtzman JS, Atchison KA, Gironda MW, Radbod R, Gorbein J. The association between oral health literacy and If someone you know or love may have failed appointments in adults attending university-based general dental clinic. Community Dent Oral Epidemiol 2014 an alcohol or chemical dependency Jun;42(3):263-70. doi: 10.1111/cdoe.12089. Epub 2013 problem, contact a support person near Dec 24. you for 24-hour confidential assistance. 44. Institute of Medicine. Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription To End Northern California Confusion. Washington, D.C.: The National Academies Press; 2004. doi.org/10.17226/10883. 530.898.0821 (cell) 45. Ridpath JR, Larson EB, Greene SM. Can integrating San Francisco Bay Area health literacy into the patient-centered medical home help us weather the perfect storm? J Gen Intern Med 209.601.4410 (cell) 2012;27(5):588–594. 46. Mills I, Frost J, Cooper C, Moles DR, Kay E. Patient- Central California centered care in general dental practice — a systematic 916.947.5676 (cell) review of the literature. BMC Oral Health 2014;14:64. doi: 10.1186/1472-6831-14-64. Southern California 47. Damiano P, Reynolds JC, McKernan SC, Mani S, Kuthy R. 310.487.5040 (cell) The need for defi ning a patient-centered dental home model in the era of the Aff ordable Care Act. The University of Iowa San Diego Public Policy Center; 2015. ppc.uiowa.edu/sites/default/ 562.832.2489 (cell) fi les/pchdjul2015.pdf. Accessed Sept. 18, 2018.

THE CORRESPONDING AUTHOR, Kathryn A. Atchison, DDS, MPH, can be reached at [email protected].

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CDA JOURNAL, VOL 47, Nº4

A Conceptual Framework for Improving Oral Health Among Older Adults: Application of the Spectrum of Prevention Strategies

Jayanth Kumar, DDS, MPH, and Ravi Dasu, PhD

ABSTRACT: In California, the older adult population is growing rapidly. Both national and state data show a considerable need for oral health care. Despite the unique challenges with access to care that older adults face, very little attention has been paid to the development of a comprehensive public health approach that addresses their needs at a national level. This paper examines the oral health of older adults and discusses the application of the Spectrum of Prevention strategies to address the complex needs of older adults.

AUTHORS

Jayanth Kumar, DDS, Ravi Dasu, PhD, is a ral health is integral population has important implications MPH, is the state dental research scientist III, Offi ce to overall health and for California because this population director, Offi ce of Oral of Oral Health, in the Health, in the California California Department of affects quality of life, yet is growing so rapidly that by 2030 there Department of Public Health. Public Health. oral health is often not will be an estimated 10.9 million older Confl ict of Interest Confl ict of Interest considered in integrated Californians.2 While dental insurance Disclosure: None reported. Disclosure: None reported. Oapproaches to overall health promotion.1 coverage for children has improved Poor oral health not only leads to pain signifi cantly in recent years because of and discomfort, but also affects food the Affordable Care Act, dental care choices and the ability to chew. In for adults is not covered by Medicare addition, deteriorating oral health can and is an optional benefi t in Medicaid be detrimental to speech and social with no minimum standards.3 interaction. Healthy teeth are needed for Nationally, Griffi n et al.4 reported chewing food that supports a healthful signifi cant racial/ethnic and income diet, such as fruits and vegetables. disparities in untreated dental disease This paper examines the oral health and oral health-related quality of life of older adults and discusses a broad among older adults. Older people public health framework for addressing with chronic conditions, such as their needs in California. The problem arthritis, cardiovascular disease, of poor oral health among the older adult chronic obstructive pulmonary disease,

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TABLE 60% New Spectrum of Prevention 50% Framework for Public Health Practice 49.8 40% ■ Infl uencing policy and legislation ■ Mobilizing community activities 30% 35.3 29.4 ■ Fostering coalitions and networks

Percentage 20% ■ Changing organizational practices 17.2 10% 14.5 ■ Educating providers

■ Promoting community education 0% <15K 15K–35K 35K–50K 50K–75K 75K+ ■ Strengthening individual knowledge and skills Income (K = thousand dollars) ■ Assuring access to quality health care

Data source: California Behavioral Risk Factor Surveillance System (BRFSS) survey data 2016. More details about CA-BRFSS can be found at www.csus.edu/research/phsrp/brfss.html. Source: Contra Costa Health Services. The Spectrum Data represent mean ± SE of weighted frequencies. of Prevention. cchealth.org/prevention/spectrum.

FIGURE 1. Tooth loss (six or more teeth) among older adults (aged 65 and older) by income, 2016.

diabetes and low vision/blindness, skilled nursing facilities has lost all strategy to address the oral health needs had higher rates of complete and their teeth and nearly 40 percent of of homebound and long-term care partial tooth loss when compared skilled nursing home residents cannot (LTC) residents; and an assessment with people without these conditions. chew. Furthermore, more than 1 in 3 of the feasibility of ensuring a safety About 22 percent of adults aged 65 community-dwelling older adults has net that covers preventive and basic to 74 reporting poor general health untreated tooth decay and 18 percent restorative services to eliminate oral also reported avoiding particular of those screened had lost all of their pain and infection. Tilly8 has outlined foods because of problems with their natural teeth.6 Moreover, disparities in several options for expanding access teeth, dentures or mouth. Based on oral health are persistent. For example, to oral health, including encouraging the analysis of the 2011–12 National the California 2016 Behavioral Risk the coordination of aging and public Health and Nutrition Examination Factor Surveillance System (BRFSS) health networks to expand oral health Survey (NHANES) data, Dye et al.5 showed that lower-income older promotion. Albert et al.9 demonstrated found that nearly all U.S. adults aged adults reported approximately two that prevention behaviors with respect 65 and older (96 percent) with any to three times more severe tooth loss to chronic diseases can be activated in permanent teeth had experienced dental (loss of six or more teeth) than those aging-services settings and incorporated caries and approximately 19 percent with higher incomes (FIGURE 1).7 into daily routines. In spite of the unique had untreated caries. The prevalence Griffi n et al.4 reported that not only challenges with access to care, mobility of edentulism was 13 percent and is the burden of oral disease particularly and chronic morbid conditions that 26 percent among adults aged 65 to high among those with poor general older adults face and the opportunities 74 and 75 and older, respectively. health and in lower-income groups available, very little attention has A recent report by the Center for but also a signifi cant number of older been paid to the development of a Oral Health found that a signifi cant adults lack access to interventions comprehensive public health approach number of older adults in California that are effective in preventing and to address their needs at a national level. are burdened by oral health problems controlling oral disease. Based on To implement these suggestions despite the fact that dental disease these fi ndings, Griffi n et al. suggested at a community level, we propose the is largely preventable.6 The report that public health priorities include: adoption of the Spectrum of Prevention indicated that, among several other better integration of oral health into developed by Larry Cohen.10 This was oral health issues, half of the older medical care; community programs initially developed as a systems approach adults residing in skilled nursing to promote healthy behaviors and to address injury prevention in Contra facilities have untreated tooth decay, improve access to preventive services; Costa County and included six strategies 1 in 3 older adults in California’s the development of a comprehensive that shifted the emphasis from education

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Use these resources to engage these activities to obtain these results and benefi ts Resources/Inputs Strategies Outcomes Leadership 1. Infl uence policy and programs Infrastructure Behavioral •Decrease in intake of sugar- Strategic planning 2. Mobilize neighborhoods and •Policies sweetened beverages and communities •Transportation Commitment increase in fl uoridated water 3. Fostering coalitions and Partners •Standard of care consumption networks •Staffi ng Funding •Healthy oral hygiene habits 4. Changing organizational Environment Capacity development practices Health •Community water •Increase in dental visit rates Sectors 5. Educating providers fl uoridation (short term) Long-term care (LTC) facilities 6. Promoting community education •Availability of oral •Decrease in dental diseases health care products Homebound older individuals 7. Strengthening individual and conditions (long term) knowledge and skills •Availability of fruits Older community dwellers •Improved quality of life and 8. Assuring access to quality oral and vegetables general health Skilled nursing homes (SNH), health care Cognitive assisted living •Awareness, knowledge, Community senior apartment living beliefs, attitudes Data collection and evaluation Nursing home rehabilitation •Social norm

FIGURE 2. Logic model for a public health program for improving oral health among older adults. only to a set of comprehensive strategies. undertaken simultaneously to address Proposed Framework Elements While health education is important, it the multiple determinants of oral health To produce positive outcomes, the is, on its own, not suffi cient to address as well as untreated oral disease. The Spectrum of Prevention strategies12 complex health needs. The Prevention Spectrum of Prevention framework10,12 and corresponding activities should Institute has compiled examples of the gives local health departments (LHDs) use the resources and inputs for oral adoption of the Spectrum of Prevention and community-based organizations disease prevention effectively, together tool in the prevention of injury, violence, a structure within which to organize with leadership, political commitment, smoking and obesity.11 Rattray et al.12 their efforts to deal with complex public funding and capacity development described how Contra Costa Health health problems. According to Rattray (FIGURE 2). These strategies comprise Services has used this framework et al.,12 these actions, when considered concerted plans for action that, when for improving community health. as parts of a single approach, become implemented, can project the extent of Veschusio et al.13 used this framework an effective tool for planning public progress in oral health care among older to implement the Community Water health interventions and coordinating adults. Based on the results of earlier Fluoridation Advocacy Training Project. the activities of multiple programs prevention efforts using the Spectrum This was designed to develop networks and agencies. This framework allows of Prevention strategies, we propose of community water fl uoridation fl exibility to adapt the model based on the utilization of these strategies in a advocates in rural communities in their needs, assets and resources.10,12 framework to improve older adults’ oral South Carolina. More recently, Contra While one of the objectives of the health. According to the Contra Costa Costa Health Services expanded this California Oral Health Plan 2018–2028 is Department of Health Care Services, the approach, called the “New Spectrum of to increase dental visit rates among older Spectrum of Prevention strategies10,12 have Prevention,” to include eight strategies adults, it recognizes that achieving optimal been used to give planners a structure for addressing a wide range of public oral health requires a commitment to self- within which to consider a range of efforts health issues, including chronic disease care and preventive behaviors as well as to address complex health issues. In prevention (TABLE).12 While most ongoing professional care.14 Tobacco use, addition, they have helped to coordinate suggestions regarding prevention are excessive alcohol consumption, poor dietary the efforts of different groups working on in the realm of primary prevention, choices, oral hygiene habits and dry mouth health issues by providing a framework secondary prevention efforts, such caused by medication play a signifi cant and common language for people from as screening, early detection and role in oral health. Research shows that diverse backgrounds to come together, treatment, are also needed to address conditions in community environments share information, highlight gaps in the oral health needs of older adults. have a far greater effect on health outcomes service and develop joint plans to achieve Therefore, several activities should be than access to health care alone.15 positive health outcomes. Attention to

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these strategies can provide support to including oral health in integrated California Pan-Ethnic Health Network local-level oral health program activities. care models, as well as exploring (CPEHN) has received funding to We therefore propose that the following alternative models for the delivery of serve as the backbone organization for examples of activities be considered for oral health care like the virtual dental the California Oral Health Network.18 implementation to improve oral health home.17 The virtual dental home model The network seeks to include engaged, among older adults in California. employs telehealth technology to link diverse stakeholders from multiple sectors allied dental professionals working in and populations who are committed Infl uencing Policy and Legislation the community with dentists located to advancing oral health equity for all. The Older Americans Act in dental offi ces or clinics. The CPEHN is working to strengthen existing Reauthorization Act16 includes a community-based providers collect relationships and create new connections, provision allowing area aging agencies patient information, including medical provide timely information and share to use the funds they receive to histories and X-ray images, which is best practices, align state and local oral conduct oral health screenings as then sent to the collaborating dentist health efforts, provide opportunities for part of their disease prevention and to develop an appropriate treatment engagement in advocacy and advance health promotion activities. Enacting equitable oral health policies to best these policies requires community meet community needs.18 Activities that mobilization, the fostering of coalitions promote coalitions and networks comprise and the promotion of community The virtual dental home establishing community and aging- education. In California, LHDs and model employs telehealth services partnerships for oral health care, community organizations can explore technology to link allied dental expanding community-clinical linkages the possibility of an oral health safety- to provide oral health care for older adults net coverage policy for low-income professionals working in the and the integration of dental services with and racial/ethnic elderly minorities. community with dentists located educational, social and medical services. Policies can also be developed to in dental offi ces or clinics. support regulations that enforce Changing Organizational Practices daily mouth care in institutional According to the Spectrum of settings, regular dental visits and Prevention,12 changing organizational transportation. Moreover, the local plan. Community-based providers practices involves modifying the coalitions can work with national render preventive services, and patients internal policies and practices of organizations to include oral health requiring more complex services are agencies and institutions. Advocating coverage in the Medicare program. referred to a collaborating dentist. Local for organizational change at agencies dental societies can help to coordinate such as the Area Agencies on Aging, Mobilizing Community Activities these efforts by connecting community- LTC facilities and senior nursing Making the oral health of older based organizations to providers. homes can result in a broad impact on adults an important issue requires community health. Activities to support community engagement. In California, Fostering Coalitions and Networks this strategy may include encouraging LHDs receiving Proposition 56 tobacco Many communities in California have primary care physicians, caregivers, tax grants for improving oral health developed coalitions and networks to dietitians and geriatricians to learn are required to identify their needs, promote oral health policies, programs and about the burden of poor oral health resources and assets and to develop a organizational change. These coalitions among the elderly and to explore ways plan to address these needs. Dental and networks have been successful in to provide on-site oral health care and professionals can provide valuable re-establishing the State Oral Health education, which could include the guidance in this process. Some of the Program, restoring the adult Medicaid use of teledentistry for sites challenged activities that facilitate community program and including oral health in with access to care. In addition, dental mobilization include building the the 2016 tobacco tax initiative. The education programs can change the capacity of local providers to integrate California Dental Association has been predoctoral dental curriculum to oral health into community programs, a strong leader in these efforts. The promote interprofessional education.

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Educating Providers programs may approach the media to such as through patient support groups. This strategy involves both dental and disseminate important messages on oral Training programs in such areas as nondental providers who have regular health. Oral health care organizations communication, advocacy and policy contact with large numbers of people and advocacy groups could work with development could lead to an increase in at high risk for oral disease as they can media to disseminate important messages media advocacy, community mobilization become powerful advocates and champions about the oral health needs of adults and and work with policymakers. of oral health care. Educating providers raise awareness about local resources. will help to not only enhance their Assuring Access to Quality Oral capacity to manage oral health problems Strengthening Individual Knowledge Health Care of individuals, but also to help motivate and Skills Regular dental care provides an them to take broader actions that affect Dental hygienists and other staff opportunity for people to maintain good the oral health at the community level. members work with patients in their oral health, prevent dental complications In addition to rendering care, health care homes, community settings, private and improve oral health. For low-income, providers can encourage the adoption of practices and clinics to provide uninsured and underinsured Californians, healthy behaviors, screen for oral disease assuring access to quality oral health care risks, contribute to community oral health requires the availability of a suffi cient education and advocate for oral health care number of providers in the Medi-Cal policies and legislation. Similarly, dental Educating providers will help Dental Program, access to dental clinics, providers can screen for chronic disease to not only enhance their and oral health care at LTC facilities, indicators and promote timely receipt capacity to manage oral nursing homes and senior living facilities. of vaccines and preventive regimens. In California, adult dental benefi ts have Additional activities may include training health problems of individuals, been restored in the Medi-Cal Dental primary care providers, LTC staff and but also to help motivate them Program and signifi cant improvements pharmacists about oral health issues among to take broader actions. have been made, such as in the enrollment older adults. Smiles for Life19 is a national process, billing, prior authorization of oral health curriculum developed for services and reimbursement. Therefore, medical professionals and includes geriatric activities such as recruiting providers oral health. Such educational efforts may information that promotes oral health. to participate in the Medi-Cal Dental be useful in establishing training programs. Individual-based learning, such as Program, expanding the capacity of motivational interviewing and teach- health centers to provide dental care Promoting Community Education back methods, has been employed in and exploring innovative models of Communitywide health education has other areas of health care to change oral health care access and delivery like the potential to reach a large number of behaviors, encourage compliance the virtual dental home17 or the Gary individuals. The national media campaign, and improve outcomes with daily and Mary West Senior Dental Center Tips From Former Smokers, featured regimens.21–23 The opportunities for approach24 can have a signifi cant impact. former smokers coping with devastating integration of oral health education oral diseases caused by their tobacco use.20 into group-based learning on self- Opportunities for Applying the It is possible to engage the media to create management practices with respect Spectrum of Prevention Framework awareness about oral health and to earn to nutrition and chronic diseases California has a unique opportunity coverage if there are interesting stories or such as diabetes could be explored. to make progress toward achieving reports to share. Activities to accomplish According to the Spectrum of national and state oral health objectives. this strategy may consist of providing Prevention,12 another component of Oral Health America, a national community education on the impact of strengthening individual knowledge advocacy group, ranks each of the 50 oral health on quality of life, including the and skills involves building the states on the overall health status of common risk factors for poor oral health and capacity of community members to use older adults measured by an overall chronic conditions commonly associated new approaches and to educate other state score in their State of Decay with aging. Oral health staff in a variety of individuals in their communities, report.25 The state score is based on

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six indicators (percentage of adults 65 program. Such a program is best described population and individual mediators of and older missing six or more teeth using a logic model (FIGURE 2). A logic behavior (e.g., awareness, knowledge, because of disease or decay, percentage model provides a picture of how a attitudes, beliefs, values, preferences of adults 65 and older with a dental visit program is intended to work. If adequate and skills) and the actual behavioral within the past 12 months, the extent resources are used to implement the and social changes that affect older to which a state Medicaid program strategies and activities, the program adults’ oral health. The health outcomes covers 13 commonly used Medicaid should yield the anticipated outcomes. are important both at an individual dental services, the percentage of the The anticipated outcomes shown level and a population level for those population covered by community water in the logic model include short-, implementing large-scale programs fl uoridation, the existence and extent to intermediate- and long-term outcomes. targeting communities. The long-term which a state plan contains immediate The outcomes achieved in the program outcomes relate to the improved oral or recent strategies to improve the oral (FIGURE 2) will depend on the nature health and overall health of older health of its older adults and the status and length of the interventions and adults and their improved quality of of a state’s Basic Screening Survey).25 the resources available to implement life. It should be acknowledged that California jumped from No. 30 in the the achievement of these outcomes state rankings in 2016 to No. 9 in will require signifi cant planning 2018 because a state oral health plan and may require years of effort. was created and the Medi-Cal Dental Structural, institutional Program restored the full set of 13 Evaluation Medicaid dental services for older adults. and environmental factors It is essential to develop the metrics The application of the Spectrum of can signifi cantly infl uence and design a data collection system in Prevention strategies has the potential to access to and the availability the beginning that allow assessments make progress toward achieving one of to be undertaken and interpreted so the Healthy People (HP) 2020 leading of oral health care. as to generate information that can national health indicators, a subset of be used to determine the success of national health objectives that includes the strategies. The data collected may the proportion of children, adolescents be used to evaluate the effectiveness and adults who visited a dentist in the the interventions. The timeline of the of the interventions implemented, past year.26 The California Oral Health interventions often determines whether monitor changes in dental visit rates Plan 2018–202814 supports the HP 2020 the program can progress toward a and oral health conditions, assess objective of annual visits to a dentist, short-term outcome (e.g., increasing improvement in the quality of life, local oral health infrastructure and the number of transportation services determine the cost of interventions and capacity, reducing disease risk factors, to provide access to oral health care support planning and the allocation of promoting healthy habits and improving among older adults), an intermediate- appropriate resources within the public oral health. Indeed, screening, counseling term outcome (e.g., increased dental health and health care systems.29 and preventive services are strongly visits among older adults) or a long- Both process and outcome recommended in community settings. term outcome (e.g., a decrease in evaluations can be used to assess the Another strategy is the promotion of untreated oral disease). Outcomes may strategies and activities implemented. training programs such as the American be categorized based on the nature of the The process evaluations can provide Dental Association’s Dentistry in change (FIGURE 2): structural outcomes, information regarding the strength Long-Term Care: Creating Pathways to environmental outcomes, cognitive and of the underlying program rationale Success and Care,27 the University of social outcomes, behavioral outcomes to address oral health among older the Pacifi c’sOvercoming Obstacles to and health outcomes. Structural, adults, the ways in which the program Oral Health28 and Smiles for Life.19 institutional and environmental factors is suited to specifi c settings and the The implementation of the Spectrum can signifi cantly infl uence access to ways and extent to which the program of Prevention framework could be tested and the availability of oral health implementation matches the program in a community as a pilot demonstration care. Behavioral outcomes include the plan. The results obtained through

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the process evaluation will provide 3. Vujicic M, Buchmueller T, Klein R. Dental Care Presents Oral Health Network. Advancing Oral Health Equity in the Highest Level of Financial Barriers, Compared to Other California. cpehn.org/page/california-oral-health-network. information to the program planners Types of Health Care Services. Health Aff (Millwood) 2016 Accessed Nov. 10, 2018. on the need to make adjustments to Dec 1;35(12): 2176–2182. 19. Wrightson AS, Stein PS. Smiles for Life: An Oral the program during its formative stages 4. Griffi n, SO, Jones JA, Brunson D, Griffi n PM, Bailey Health Education Resource. J Am Med Dir Assoc 2012 WD. Burden of Oral Disease Among Older Adults and Oct;13(8):679–81. doi: 10.1016/j.jamda.2012.07.012. and will offer critical insights into the Implications for Public Health Priorities. Am J Public Health Epub 2012 Aug 29. intervention after the outcome data 2012;102(3):411–418. 20. Centers for Disease Control and Prevention. Tips from are available. Determining the increase 5. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries former smokers. www.cdc.gov/tobacco/campaign/tips/ and tooth loss in adults in the United States, 2011–2012. index.html. in dental visit rates and subsequent NCHS data brief, no. 197. Hyattsville, Md: National Center 21. Droppa M, Lee H. Motivational interviewing: A journey improvements in oral health, general for Health Statistics. 2015. to improve health. Nursing 2014 Mar;44(3):40–5; quiz health and quality of life requires the 6. Center for Oral Health. A Healthy Smile Never Gets 45-6. doi:10.1097/01.NURSE.0000443312.58360.82. Old: A California Report on the Oral Health of Older 22. Speros CI. More than Words: Promoting Health establishment of a data-gathering Adults. www.centerfororalhealth.org/wp-content/ Literacy in Older Adults. Online J Issues Nurs 2009; 14(3), system. To assess these intermediate and uploads/2018/11/Oral-Health-of-Older-Adults.pdf. manuscript 5. long-term outcomes, periodic surveys 7. California Department of Public Health. California 23. AHRQ. Use the Teach-Back Method: Tool No. Behavioral Risk Factor Surveillance System 2016. www. 5. Content last reviewed February 2015. Agency for of a panel of community members csus.edu/research/phsrp/brfss.html. Healthcare Research and Quality, Rockville, Md. www.ahrq. may also have to be undertaken in 8. Tilly J. Oral health’s relationship to disease and options gov/professionals/quality-patient-safety/quality-resources/ addition to gathering other health for expanding services for older adults and adults who tools/literacy-toolkit/healthlittoolkit2-tool5.html. have disabilities. www.acl.gov/sites/default/fi les/news%20 24. The Gary and Mary West Senior Dental Center — Oral information and perspectives. 2017-04/OralHealthPaper101316.pdf. Accessed Sept. Healthcare and Care Coordination. www.westhealth.org/ 6, 2018. our-focus/chronic-care/oral-healthcare-care-coordination. Conclusion 9. Albert SM, King J, Jones JR, Danielson ME, Park Y, Accessed Dec. 14, 2018. Newman AB. Using the Infrastructure of State Aging 25. Oral Health America. A State Of Decay. Are Older The oral health needs of the Services to Promote Prevention Behavior. Prev Chronic Americans Coming Of Age Without Oral Healthcare? Vol. older adult population will require Dis 2018;15:170567. doi:dx.doi.org/10.5888/ IV, 2018. considerable attention because of the pcd15.170567. 26. U.S. Department of Health and Human Services. Offi ce 10. Cohen L, Swift S. The spectrum of prevention: of Disease Prevention and Health Promotion. Healthy People growth in this population demographic Developing a comprehensive approach to injury prevention. 2020. Leading Health Indicators. www.healthypeople. and its unmet needs. As suggested Inj Prev 1999 Sep;5(3):203–207. gov/2020/Leading-Health-Indicators. Accessed Sept. 6, by Griffi n et al.,4 there is a need for a 11. Prevention Institute. The Spectrum of Prevention: Case 2018. Examples. www.preventioninstitute.org/profi les/spectrum- 27. ADA Dentistry in Long Term Care: Creating Pathways to comprehensive public health approach. prevention-case-examples. Accessed Nov. 10, 2018. Success. www.dental.pacifi c.edu/departments-and-groups/ The framework presented here will 12. Rattray T, Brunner W, Freestone J. The New Spectrum pacifi c-center-for-special-care/education/ada-dentistry-in- assist in identifying the relevant sectors, of Prevention: A Model for Public Health Practice. Contra long-term-care-course. Accessed Sept. 6, 2018. Costa Health Services. cchealth.org/prevention/spectrum. 28. University of the Pacifi c. Overcoming Obstacles: the necessary resources and inputs, Accessed Sept. 6, 2018. A Course for Caregivers. www.dental.pacifi c.edu/ effective strategies and activities and 13. Veschusio C, Jones MK, Mercer J, Martin AB. departments-and-groups/pacifi c-center-for-special-care/ the explicit structural, environmental, Readying community water fl uoridation advocates through education/overcoming-obstacles. Accessed Sept. 6, 2018. training, surveillance and empowerment. Community 29. Teutsch SM, Churchill RE. Principles and Practice of behavioral and health outcomes that Dent Health 2018 May 30;35(2):67-70. doi:10.1922/ Public Health Surveillance. 2nd ed. New York: Oxford could signify meaningful changes in CDH_4021Veschusio04. University Press Inc.; 2000:1–16. the oral health and overall health of 14. California Department of Health. California Oral Health Plan 2018-2028. Oral Health Program. www.cdph. THE CORRESPONDING AUTHOR, Jayanth Kumar, DDS, MPH, can older adults. The proposed framework ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20 be reached at [email protected]. will contribute to building a strong Document%20Library/Oral%20Health%20Program/ evidence base on which promising and FINAL%20REDESIGNED%20COHP-Oral-Health-Plan-ADA. pdf. Accessed Sept. 6, 2018. best practices can be identifi ed and 15. Braverman P, Gottlieb L. The Social Determinants of scaled up statewide and nationally. ■ Health: It’s Time To Consider the Causes of the Causes. Public Health Rep 2014; 129 Suppl 2:19–31. REFERENCES 16. Public Law 114–144 114th Congress. An Act to 1. World Health Organization. Oral Health in Ageing reauthorize the Older Americans Act of 1965, and for other Societies, Integration of Oral Health and General Health. purposes. www.congress.gov/bill/114th-congress/senate- Geneva: World Health Organization; 2006, NLM bill/192. Accessed Nov. 13, 2018. classifi cation: WU 490. 17. University of Pacifi c. Virtual Dental Home System of 2. California Department of Aging. California State Plan on Care. www.dental.pacifi c.edu/departments-and-groups/ Aging, 2017–2021. www.aging.ca.gov/docs/Highlights/ pacifi c-center-for-special-care/innovations-center/virtual- CSP_Plan_Aging/California%20State%20Plan%20on%20 dental-home-system-of-care. Accessed Sept. 6, 2018. Aging%202017-2021.pdf. Accessed Sept. 6, 2018. 18. California Pan Ethnic Health Network. California

APRIL 2019 263 QUESTIONS MOST OFTEN ASKED BY SELLERS:

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A Dental Benefi t in Medicare: Examining the Need in California

Sahiti Bhaskara, MPH, BDS; Amber C. Christ, JD; Conrado E. Barzaga, MD; Kevin Prindiville, JD; and Elisa M. Chávez, DDS

ABSTRACT Many older adults in California lack access to oral health care due to the absence of affordable, comprehensive dental coverage. As a result, older Californians have a high prevalence of oral diseases. Forty-six percent of community-dwelling older adults and 65 percent of older adults living in skilled nursing facilities have untreated oral diseases. A comprehensive dental benefi t added to Medicare Part B could help all older Californians maintain health and dignity over their lifetime.

AUTHORS

Sahiti Bhaskara, BDS, health care and long-term Education at Sacred Heart Arthur A. Dugoni School of ourteen percent of California’s MPH, is the director of services and supports for University. Dentistry in San Francisco. population, more than 5 million public policy research at low-income older adults Confl ict of Interest She graduated from the people, are currently aged 65 or older nationwide. Ms. Christ is a Disclosure: None reported. University of California, the Center for Oral Health and this fi gure is expected to almost and directs and managed lecturer at the UCLA School San Francisco, School the organization’s policy, of Law. Kevin Prindiville, JD, of Dentistry and earned double by 2030, when the youngest 1 research and evaluation Confl ict of Interest is the executive director her certifi cate in geriatric Fbaby boomers will reach retirement age. work. She is working with Disclosure: None reported. of Justice in Aging. He is dentistry from the University Upon reaching retirement, many people several counties to develop a nationally recognized of Michigan, Ann Arbor. lose access to dental insurance when Conrado Bárzaga, expert on Medicare and Dr. Chávez has practiced in their oral health strategic their employer-based dental coverage plans and designing the MD, is an internationally Medicaid policy and private, community health, Oral Health Action for recognized public health has served as counsel in long-term care and hospital ends. Original Medicare, the federal Older Adults project, a leader with more than several class-action lawsuits settings. She developed insurance program that is the primary multipronged policy and 20 years of progressively protecting low-income and directs an extramural form of medical coverage for older adults, awareness initiative aimed important positions with seniors’ access to public student rotation at On Lok does not include an oral health benefi t organizations addressing benefi ts. He has a long Lifeways, a Program for at improving the oral health and dental benefi ts through private of older adults. public health issues. He history of developing All-Inclusive Care for Elders Confl ict of Interest serves as president and partnerships and directing (PACE). As a recent fellow Medicare Advantage plans or other Disclosure: None reported. chief executive director at strategic advocacy eff orts. and current scholar with standalone plans are often costly and the Center for Oral Health. Confl ict of Interest The Santa Fe Group, she limited in scope. Without access to dental Amber C. Christ, JD, Prior to this appointment, Disclosure: None reported. is an advocate for the oral insurance, dental utilization diminishes he served in top leadership health needs of seniors is directing attorney with and oral and systemic health can suffer.2 Justice in Aging based in positions for the Los Angeles Elisa M. Chávez, DDS, nationwide. its Los Angeles offi ce. She County Commission on is an associate professor Confl ict of Interest While California’s poorest older adults develops and implements Children and Families (First in the department of Disclosure: None reported. have oral health coverage through the projects and initiatives that 5 LA), Planned Parenthood diagnostic sciences at the Medi-Cal Dental Program (Denti-Cal), improve access to oral and the Area Health University of the Pacifi c, California’s Medicaid dental benefi t for

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80%

60% the state’s lowest-income benefi ciaries, 50% 40% 48% 46% 48% low provider participation and many administrative barriers make the benefi t 20% diffi cult to access. Californians have experienced the effects of a labile system 0% of dental coverage through the Denti- 65 and older 65–74 75–84 85 and older Cal system, including the loss of adult Age in years dental benefi ts in 2009 that were only fully restored last year. There are also Data source: A Healthy Smile Never Gets Old — A California Report on the Oral Health of Older Adults, 2018. Note: Data represent a probabilistic representative sample of older adults aged 65 and older residing in California’s many older adults who do not qualify for skilled nursing homes. Data were collected between March 2016 and September 2017. Denti-Cal but don’t have the means for regular dental care. A comprehensive FIGURE 1. California skilled nursing home residents (aged 65 and older) with untreated tooth decay, by age. Medicare Part B dental benefi t could address disparities in access to oral health care by providing a guaranteed paradigm shift at both the individual periodontal infections may have poorer benefi t to all older adults in California and population level. This includes a glycemic control than their counterparts and the nation, across all income levels.3 strong emphasis on early detection and who don’t have a periodontal infection.11 Additionally, a comprehensive benefi t risk assessment, minimally invasive The association between oral infections would help to integrate oral health care dentistry, interprofessional collaboration and acute exacerbations of aspiration with medical care aimed at improving across the health care delivery sector pneumonia is another example among health outcomes overall. Good oral and development of models that frail older adults and nursing home health can have signifi cant physical, demonstrate integration of oral health residents.12 One study by Hirotomi et psychological and social benefi ts that care with medical care.7 In the absence al. showed that older adults with 20 or ultimately contribute to successful aging.4 of broadly accessible oral health more natural teeth have a signifi cantly This paper reviews the current oral coverage and a coordinated system for lower adjusted mortality rate than their health status of older Californians, the care, older adults will not have the counterparts with 19 or fewer teeth.13 bidirectional relationship with systemic opportunity to benefi t from such efforts. Additionally, medications used to health and barriers to the access of manage chronic diseases and conditions affordable dental services, including the The Unique Oral Health Needs of can increase the risk for oral diseases. limitations of Denti-Cal. This review also Older Adults Hypertension treated with calcium lays out the rationale for a comprehensive Older adults have unique needs that channel blockers can result in gingival oral health benefi t within Part B of make access to oral health care vital to enlargement, and COPD treated with Medicare and discusses potential costs maintaining their overall health. Older steroid inhalers can increase the risk for and savings. Finally, it discusses efforts adults have on average at least one .14 Several medications to build consensus around the need and chronic health condition and about 20 commonly used by older adults, like scope of a benefi t and additional steps percent have more than one.8 Chronic antihypertensives and , needed to move the effort forward. diseases and conditions can impact oral inhibit salivary fl ow, increasing the risk of health, and poor oral health has been dry mouth and, resultantly, oral disease.15 Changing Paradigms in Oral shown to have numerous associations Older adults face additional Health Care with chronic infl ammation and systemic challenges. Nationally, approximately Oral health is integral to systemic disease.9 Tooth decay, oral pain/infection, 50 percent of nursing home residents health, well-being and quality of life tooth loss and the inability to chew due are unable to perform three or more of throughout the lifespan.5 Social, political to lack of functional, occlusal contact can the “activities of daily living,” one of and economic infl uences can prevent result in poor nutrition and weight loss which is personal hygiene that includes individuals and certain populations and exacerbate conditions like diabetes oral care.16 Normal age-related changes from achieving and maintaining good and heart disease.10 Research indicates such as those that occur in hearing and oral health.6 Dentistry is undergoing a that diabetic individuals who have vision can complicate access to and

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Both periodontal and early/urgent No obvious 80% care needed problem 74.8% 13.7% 60% 37.8% 21.3% 40% Only periodontal 27.2% 20% care needed 18.4% 6.8% 0% No natural teeth 1 to 6 More than 6 Only periodontal natural teeth natural teeth care needed

Data source: A Healthy Smile Never Gets Old — A California Report on the Oral Data source: A Healthy Smile Never Gets Old — A California Report on the Oral Health Health of Older Adults, 2018. Note: Data represent a probabilistic representative of Older Adults, 2018. Note: Data represent a convenience sample of 1,179 community- sample of older adults aged 65 and older residing in California’s skilled nursing dwelling older adults (aged 65 and older). Data were collected between March 2016 and homes. Data were collected between March 2016 and September 2017. September 2017.

FIGURE 2. California skilled nursing home residents (aged 65 and older) who FIGURE 3. Tooth loss as measured by the number of remaining natural teeth in need early or immediate dental treatment and periodontal care. California community-dwelling adults aged 65 and older. receipt of care.17 Other examples include Oral Health Status of Older Adults adults (with at least one remaining natural changes in dexterity and cognition, due in California tooth) showed signs of substantial oral in part to aging but often compounded A recent California study presents debris or deposits covering two-thirds of by comorbidities like degenerative a grim picture of the oral health of their natural tooth surfaces. In summary, arthritis and other neurodegenerative older Californians.22 This study, using 65 percent of older adults residing in disorders that challenge many older the Association of State and Territorial California’s SNFs have unmet treatment adults’ ability to maintain good oral Dental Directors’ Basic Screening Survey needs for tooth decay and/or gingival/ health and to access and receive methodology for dental disease surveillance, periodontal disease (FIGURE 2). Disparities services in a timely and favorable measured the oral health status of a by rurality of residence were also apparent. manner. Furthermore, these age-related probabilistic sample of older adults residing Older Californians residing in SNFs in conditions and age-prevalent diseases in skilled nursing facilities (SNFs). The rural counties were 9 percent more likely complicate prevention, restoration study also documented the oral health to have untreated tooth decay than and maintenance efforts to achieve status of a convenience sample of 1,179 their counterparts in urban counties.22 optimal oral health for older adults.10 community-dwelling older adults. Findings Of the 1,179 community-dwelling Nationally, about 1 in 5 older adults showed that 48 percent of the older adults older adults in the survey, 32 percent have (aged 65 and older) has lost all of residing in SNFs have untreated tooth untreated tooth decay, 18 percent are their natural teeth18 and 70 percent of decay (FIGURE 1) and nearly 17 percent edentulous (FIGURE 3) and 46 percent have older adults have periodontal disease.19 of all residents have untreated tooth unmet treatment needs for tooth decay Although largely preventable, many decay in four or more teeth. One in 3 and/or gingival/ periodontal disease.22 Americans reach adulthood and older residents has one or more decayed root adulthood with untreated dental fragments and, overall, institutionalized Barriers to Oral Health Care for Older diseases. Oral diseases are chronic older Californians have a signifi cantly Adults in California conditions and tend to be progressive higher burden of untreated tooth decay As noted, traditional Medicare does if left untreated, but are amenable than the national average of 30 percent.22 not include an oral health benefi t. Some to timely preventive interventions.20 Thirty-fi ve percent of older adults in private Medicare Advantage plans Owing to its chronic nature coupled California’s SNFs are edentulous and 4 in do offer dental benefi ts, but coverage with natural physiological changes 10 older adults do not have a functional varies widely from plan to plan. Benefi ts that accompany aging and those that posterior occlusal contact on either side of are typically limited in scope, often come with diseases most commonly their mouth, either due to missing teeth with signifi cant co-insurance and associated with aging, addressing and/or missing or ill-fi tting dentures. The low annual maximum benefi t limits. oral health needs of older adults rate of periodontal disease was also found Standalone dental plans also require is vital yet uniquely complex.21 to be high. Forty percent of dentate older enrollees to pay a premium with high

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cost-sharing amounts and a limited Enrollment is limited to individuals who Cal benefi ts. While California’s Denti-Cal menu of benefi ts with low annual have income below $15,000 and less than benefi t is fairly comprehensive compared maximum benefi t limits. Consequently, $2,000 in resources.29 Medi-Cal includes a to other states, there are numerous many older adults forgo oral health dental benefi t delivered through its dental restrictions to Denti-Cal services, such as coverage because it is too costly. For program (Denti-Cal). However, benefi ts limited preventive care and restorative example, just over one-third of low- through Denti-Cal have been unstable. care that is not based on individual income Medicare benefi ciaries had a They were eliminated for adults in 2009 need or medical necessity, as well as low dental visit in the last year compared in response to the recession. During the annual caps on coverage and low provider to nearly three-quarters of higher- time benefi ts were eliminated, emergency reimbursement. Low reimbursement rates income Medicare benefi ciaries23 with room visits for dental-related emergencies have deterred providers from participating a signifi cant number of low-income increased.30 Adult benefi ts were partially in the program. As of 2017, there were Medicare recipients specifi cally citing restored in 2014, but major services fewer than 10 participating providers cost as the reason for either delaying or including root canals on posterior teeth, in 22 of California’s 58 counties with entirely forgoing dental treatment.24 partial dentures, periodontal treatment and no providers available in seven rural Many of the 5.3 million older adults counties.33 Consequently, for the 1.4 living in California today cannot afford million older adults relying on Denti-Cal, oral health coverage. Of this number, 49.3 access to oral health treatment remains a percent are living below the supplemental While the average white challenge, which is evidenced by the fact poverty level.25 Due to economic, health that only 1 in 4 older adults on Denti- and social inequities compounded over Medicare recipient has Cal had a dental visit in the last year.34 time, certain groups have even fewer $108,250 in savings, resources. For example, black and the average black recipient Adding Oral Health Coverage to Hispanic Medicare recipients have average Medicare Part B: Benefi t Structure annual incomes of $17,350 and $13,650 has only $16,000. and Financing respectively compared to $30,050 for white With a growing need and gap in Medicare recipients. Furthermore, while coverage, adding oral health coverage to the average white Medicare recipient Medicare is essential to ensure that older has $108,250 in savings, the average many other services remained uncovered. adults age in good health and with dignity. black recipient has only $16,000.26 The Little Hoover Commission in its Medicare provides medical coverage to The issue of affordability is particularly 2016 report on the state of the Denti- individuals aged 65 and older and to acute for the 750,000 older Californians Cal program declared: “… Denti-Cal, people with disabilities. Medicare benefi ts who have income and resources that California’s Medicaid dental program, is are delivered through different parts: Part exceed the eligibility limits for public widely viewed, historically, and currently, A covers inpatient hospital services, Part programs, but not enough income to pay as broken, bureaucratically rigid and B provides outpatient services, Part C for their basic needs of food, clothing unable to deliver the quality of dental allows Medicare benefi ciaries to select and housing.27 The need is projected to care most other Californians enjoy.”31 a private Medicare Advantage plan to grow. Over the next 20 years, California’s Adult Denti-Cal benefi ts were entirely administer their benefi ts and Part D population older than 65 will almost restored as of January 2018. Nevertheless, provides prescription drug coverage.35 double, with the biggest growth occurring the permanence of dental benefi ts through The way to include oral health in the age group older than 75 and Medicaid (Denti-Cal) is uncertain as coverage under Medicare seamlessly would within nonwhite racial groups.28 coverage is labile and benefi ts are neither be to lift the current exclusion of coverage California has the second highest mandatory nor guaranteed.31 Accordingly, for dental services in Medicare and senior poverty rate in the country with many other states, in addition to California, provide coverage through Part B, which approximately 1.4 million of California’s reduce or eliminate dental benefi ts already covers outpatient and preventive poorest older adults and people with and other optional Medicaid benefi ts services. This approach would ensure the disabilities eligible for both Medicare and when faced with budget constraints.32 integration of oral health coverage with Medi-Cal, California’s Medicaid program. Other barriers affect access to Denti- overall health coverage and would mirror

268 APRIL 2019 CDA JOURNAL, VOL 47, Nº4

the medically necessary criteria currently dollar value caps would cost the federal periodontal disease and found that good used to administer other Part B benefi ts. government $32.3 billion in 2018. The periodontal maintenance resulted in an Inclusion under Part B would also ensure estimated base premium increase for a Part annual reduction of health care costs that individuals enrolled in traditional B benefi t would be $14.50 per benefi ciary of $2,840 (40.2 percent) for patients Medicare and in Medicare Advantage per month. This estimate assumes a general with Type 2 diabetes, $5,681 (40.9 plans (Part C) would have access to the fund contribution of 75 percent of all percent) for patients with cerebral same benefi t because Medicare Advantage costs and takes into account low-income vascular disease, $1,090 (10.7 percent) plans are responsible for delivering all benefi ciary subsidies applied to premiums for patients with cardiovascular disease Part A and Part B covered benefi ts. and cost-sharing as well as surcharges paid and $581 (6.3 percent) for patients with The Medicare oral health benefi t by high-income benefi ciaries, like the rheumatoid arthritis.42 The study also would be subject to the same cost sharing current Medicare Part B funding structure. found a reduction in hospital admissions as other Part B benefi ts and further The study assumes a reimbursement among patients with Type 2 diabetes fi nanced through premiums just as Part rate pegged to fees charged by at least (39.4 percent reduction), cerebral B benefi ts are funded today. Low-income 50 percent of dentists in the U.S.36 vascular disease (21.2 percent) and Medicare benefi ciaries would receive cardiovascular disease (28.6 percent).42 the same fi nancial assistance through Several retrospective studies from Medicare Savings Programs as they do insurance companies have demonstrated today for Part B benefi ts including help Several retrospective studies cost savings when their consumers with premiums and cost sharing.36 utilized their dental benefi ts.3,39 A study A dental benefi t through Medicare from insurance companies conducted for Pacifi c Dental Services Part B would also improve access to have demonstrated cost by Avalere Health LLC estimated that coverage for California’s low-income older savings when their consumers over 10 years the potential medical cost adults who currently rely on Denti-Cal. A savings to Medicare from providing Medicare benefi t could allow benefi ciaries utilized their dental benefi ts. periodontal treatment alone was $63.5 to access services based on medical billion.43 This does not suggest that these necessity like other health benefi ts without savings should or would pay for dental many of the restrictions set by Denti-Cal. services if they were included in Medicare, Additionally, the Medicare Part B payment Research is also available to help but including the services would help systems and rules are well-established assess potential offsetting savings in offset costs through those savings and and Medicare reimbursement rates are overall health costs. There is evidence by improving outcomes in other areas of historically higher than those in Medicaid, that the receipt of oral health care can medical care. Importantly, without better likely increasing provider participation. potentially reduce overall health care costs integration of medical and dental services In fact, in a survey conducted by the for individuals.39 In a Cigna study, a year and broader access to dental care, more American Dental Association (ADA), of dental coverage provided to its clients deliberate, prospective study of these more than 70 percent of dental providers was associated with medical cost savings interactions will be diffi cult to achieve. agree that Medicare should include of approximately $1,418 per patient.40 comprehensive oral health coverage.37 In the absence of a usual source of oral Building Consensus health care, individuals often end up in Several groups including The Santa Fe Potential Savings and Cost Analysis the emergency room for nontraumatic Group, Oral Health America and others While the ADA has not taken a dental conditions as a last resort, which have convened meetings of stakeholders position on including a dental benefi t is an expensive source of dental care, to discuss the need for the Medicare dental in Medicare,38 the organization recently does not result in defi nitive treatment benefi t and ideas about benefi t structure. conducted a study that analyzed various of the issue and is often followed by In 2015, Oral Health America held its cost structures for dental benefi t designs repeated visits to the emergency room.41 fi rst Dental in Medicare symposium.44 within Medicare based on 2016 self- A landmark study conducted by the Seeing that more broad awareness and insured market rates.36 The study estimated University of Pennsylvania examined input was needed to advance the effort, that a comprehensive benefi t without more than 200,000 patients with groups engaged in the Oral Health

APRIL 2019 269 medicare part b

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Equity and Progress Network (OPEN), National and state surveys are rich commitment to maintaining oral health including The Santa Fe Group, Oral sources of self-reported data, owing to care as a part of Medicaid despite Health America and The DentaQuest the unique and hidden nature of oral its many challenges and limitations, Foundation, convened and sponsored a diseases. However, objective data on the state is well-positioned to help group to examine and work on developing the prevalence and burden of dental lead efforts to remove the exclusion a dental benefi t in Medicare.45,46 OPEN disease is critical to help make informed from Medicare while working toward also included adding a dental benefi t to programmatic and policy decisions aimed the development of a meaningful Medicare in its 2020 goals.46 To move at improving older adult oral health at and sustainable benefi t for all. All this effort forward, representatives of the population level. Inclusion of dental older Californians would stand to diverse organizations and institutions benefi ts to Medicare will not only address benefi t from the inclusion of dental were invited to attend The Santa Fe a key barrier faced by older adults in services in Medicare Part B. ■ Group Salon in 2016 and weigh in on achieving optimal oral health fi nances, 47 REFERENCES the proposal and draft benefi t proposals. but will also provide a signifi cant source 1. Beck L, Johnson H. Planning for California’s Growing From those initial meetings, experts of data to examine critically the unmet Senior Population. 2015. www.ppic.org/content/pubs/ in dentistry and medicine, academics, need, burden of disease and correlation/ report/R_815LBR.pdf. Accessed Jan. 11, 2019. 2. Manski RJ, Moeller J, Chen H, et al. Dental policy, organized dentistry, insurance, association/causal relationship between Care Coverage and Retirement. J Public Health government, senior consumer groups, law oral disease and systemic disease. Dent 2010;70(1):1–12. doi:10.1111/j.1752- and others have continued discussion, 7325.2009.00137.x. 3. Chávez EM, Calvo JM, Jones JA. Dental Homes for and more consensus around developing Legislative Changes Needed Older Americans: The Santa Fe Group Call for Removal a benefi t that would more closely mirror and Strategies of the Dental Exclusion in Medicare. Am J Public the way the structure of the Medicare Today, Medicare does not provide Health. 2017;107 (Suppl 1):S41–S43. doi:10.2105/ 3,36,44,46 AJPH.2017.303864 medical benefi t has evolved. dental benefi ts due to statutory language 4. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey This broad interest demonstrates that that specifi cally excludes dental WD. Burden of Oral Disease Among Older Adults all interested stakeholders are seriously coverage under the Medicare program.48 and Implications for Public Health Priorities. Am J Public Health 2012;102(3):411–418. doi:10.2105/ considering the importance of creating Accordingly, the fi rst step to offering AJPH.2011.300362. such a benefi t and the importance of a dental services under Medicare requires 5. U.S. Department of Health and Human Services. Oral structure that adds value beyond fee- passing federal legislation to remove Health in America: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human for-service structures, supports provider this statutory exclusion and specifi cally Services, National Institute of Dental and Craniofacial participation and avoids artifi cial caps add oral health coverage and payment Research, National Institutes of Health. 2000. and restrictions on necessary services. for services under Part B.3,36 Legislation 6. Marmot M, Friel S, Bell R, Houweling TAJ, Taylor S. Commission on Social Determinants of Health. To secure comprehensive oral would also need to grant the Centers Closing the gap in a generation: Health equity through health coverage in Medicare, the dental for Medicare and Medicaid Services action on the social determinants of health. Lancet profession must educate policymakers the authority to issue regulations to 2008;372(9650):1661–9. doi: doi.org/10.1016/S0140- 6736(08)61690-6. about the oral health needs of older implement and administer the benefi t. 7. Benzian H, Greenspan JS, Barrow J, Hutter JW, Loomer adults, the potential negative health PM, Stauf N, Perry DA. A competency matrix for global outcomes of poor oral health as well as Conclusion oral health. J Dent Educ 2015;79(4):353–61. 8. Ward BW, Schiller JS. Prevalence of Multiple Chronic the monetary and nonmonetary costs Access to a dental benefi t through Conditions Among U.S. Adults: Estimates From the that ensue in the absence of access Medicare would help people continue National Health Interview Survey, 2010. Prev Chronic Dis to regular oral health care. Patients to receive dental care over their 2013;10:E65. doi:10.5888/pcd10.120203. 9. Slavkin HC, Abel S, et al. A National Imperative: must also be educated. Many Medicare lifetime and help those who have not Oral Health Services in Medicare. J Am Dent Assoc benefi ciaries do not realize that Medicare had regular access to care as adults, or 2017;148(5):281–283. doi.org/10.1016/j. does not include oral health coverage, maybe even since childhood, access adaj.2017.03.004. 10. Association of State and Territorial Dental Directors. so it is equally important to arm current treatment that can benefi t their total Best Practice Approach Report: Oral Health in the Older and future Medicare benefi ciaries with health and well-being. It is never too Adult Population (Age 65 and older). 2017. www.astdd. tools to educate their communities and late to seek the quality of life and org/bestpractices/bpar-oral-health-in-the-older-adult- population-age-65-and-older.pdf. Accessed Jan. 11, 2019. empower them to advocate for these dignity that good oral health can 11. Taylor GW, Borgnakke WS. Periodontal disease: benefi ts with federal policymakers.36,44 provide. Given California’s proven Associations with diabetes, glycemic control and

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complications. Oral Dis 2008; 14(3):191–203. Policy Res 2015;(PB2015-3):1–8. Department Visits for Preventable Dental Conditions doi:10.1111/j.1601-0825.2008.01442.x. 26. Beck L, Johnson H. Planning for California’s Growing in California. 2009. www.chcf.org/wp-content/ 12. Sjögren P, Nilsson E, Forsell M, Johansson O, Senior Population. 2015 www.ppic.org/content/pubs/ uploads/2017/12/PDF-EDUseDentalConditions.pdf. Hoogstraate J. A Systematic Review of the Preventive report/R_815LBR.pdf. Accessed Jan. 11, 2019. Accessed Jan. 11, 2019. Effect of Oral Hygiene on Pneumonia and Respiratory 27. Schoen C, Davis K, Willink A. Medicare Beneficiaries’ 42. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Tract Infection in Elderly People in Hospitals and High Out-of-Pocket Costs: Cost Burdens by Income Blum JJ. Impact of periodontal therapy on general health: Nursing Homes: Effect Estimates and Methodological and Health Status. 2017. www.commonwealthfund. Evidence from insurance data for five systemic conditions. Quality of Randomized Controlled Trials. J Am Geriatr org/publications/issue-briefs/2017/may/medicare- Am J Prev Med 2014;47(2):166–174. doi: 10.1016/j. Soc 2008; 56(11):2124–30. doi:10.1111/j.1532- beneficiaries-high-out-pocket-costs-cost-burdens-income. amepre.2014.04.001. Epub 2014 Jun 18. 5415.2008.01926.x. Epub 2008 Sep 15. 28. The Henry J. Kaiser Family Foundation. Oral 43. Avalere Health. Evaluation of Cost Savings Associated 13. Hirotomi T, Yoshihara A, Ogawa H, Miyazaki H. Health and Medicare Beneficiaries: Coverage, Out-of- With Periodontal Disease Treatment Benefit. Memo to Number of teeth and five-year mortality in an elderly Pocket Spending, and Unmet Need. 2012. www.kff. Pacific Dental Services Foundation. 2016. oralhealth. population. Community Dent Oral Epidemiol 2015; org/medicare/issue-brief/oral-health-and-medicare- hsdm.harvard.edu/files/oralhealth/files/avalere_health_ 43(3):226–31. doi:10.1111/cdoe.12146. Epub 2015 beneficiaries-coverage-out. estimated_impact_of_medicare_periodontal_coverage.pdf. Jan 19. 29. The Henry J. Kaiser Family Foundation. Number of 44. Oral Health America. Adding a Dental Benefit in 14. Cox DP, Ferreira L. The Oral Effects of Inhalation Dual Eligible Beneficiaries. www.kff.org/medicaid/state- Medicare. oralhealthamerica.org/our-work/advocacy/ Corticosteroid Therapy: An Update. J Calif Dent Assoc indicator/dual-eligible-beneficiaries/?currentTimeframe=0& medicare-dental. Accessed Jan. 11, 2019. 2017;45(5):227–33. sortModel=%7B%22colId%22:%22Location%22,%22sort% 45. Jones JA, Monopoli M. Designing a New Payment 15. Fardal Ø, Lygre H. Management of periodontal 22:%22asc%22%7D. Model for Oral Care in Seniors. Compend Contin Educ disease in patients using calcium channel blockers — 30. Singhal A, Caplan DJ, Jones MP, Momany ET, Dent 2017 Oct;38(9):616–624. gingival overgrowth, prescribed medications, treatment Kuthy RA, Buresh CT, Isman R, Damiano PC. Eliminating 46. Chazin S, Bond M. Report on Progress Towards responses and added treatment costs. J Clini Periodontol Medicaid Adult Dental Coverage in California Led To the 2018 Milestones. Oral Health Progress and Equity 2015;42(7):640–6. doi:10.1111/jcpe.12426. Epub Increased Dental Emergency Visits and Associated Costs. Network (OPEN), November 2018. www.oralhealth. 2015 Jul 14. Health Affairs 2015;34(5):749-56. doi: 10.1377/ network/d/do/1092. Accessed Jan. 11, 2019. 16. Interagency Forum on Aging-Related Statistics. Older hlthaff.2014.1358. 47. Santa Fe Group. santafegroup.org. Accessed Jan. 11, Americans 2016: Key Indicators of Well-Being. 2016. 31. Little Hoover Commission. Fixing Denti-Cal. Report 2019. agingstats.gov/docs/latestreport/older-americans-2016- #230. 2016. lhc.ca.gov/sites/lhc.ca.gov/files/ 48. 42 U.S. Code § 1395y — Exclusions from coverage key-indicators-of-wellbeing.pdf. Accessed Jan. 11, 2019. Reports/230/Report230.pdf. and Medicare as secondary payer. United States 17. Ship JA, Chavez EM. Management of systemic diseases 32. Center for Health Care Strategies. Medicaid Adult Code, 2006 Edition, Supplement 4, Title 42 — the and chronic impairments in older adults: Oral health Dental Benefits: An Overview. 2018. www.chcs.org/ Public Health and Welfare. 2010. www.gpo.gov/ considerations. Gen Dent 2000;48(5):555–65. resource/medicaid-adult-dental-benefits-overview. fdsys/search/pagedetails.action?packageId=USCODE- 18. QuickStats: Prevalence of Edentulism in Adults Aged 33. Department of Health Care Services. Little Hoover 2010-title42&granuleId=USCODE-2010-title42-chap7- ≥ 65 Years, by Age Group and Race/Hispanic Origin — Comission Hearing: Medi-Cal Dental Services. Jennifer Kent subchapXVIII-partE-sec1395y. National Health and Nutrition Examination Survey, 2011– Written Testimony. 2018. lhc.ca.gov/sites/lhc.ca.gov/files/ 2014. MMWR Morb Mortality Wkly Rep 2017;66(3):94. Reports/243/WrittenTestimony/KentMar2018.pdf. THE CORRESPONDING AUTHOR, Elisa M. Chávez, DDS, can be doi:10.15585/mmwr.mm6603a12. 34. California Department of Health Care Services. reached at echavez@pacifi c.edu. 19. Eke PI, Dye BA, Wei L, et al. Update on Prevalence Medi-Cal Dental: Annual Dental Visits Statewide — Fee-for- of Periodontitis in Adults in the United States: NHANES Service and Dental Managed Care. www.dhcs.ca.gov/ 2009 to 2012. J Periodontol 2015;86(5):611–622. services/Pages/DentalReports.aspx. doi:10.1902/jop.2015.140520. 35. Centers for Medicare and Medicaid Services. www. 20. Murray Thomson W. Epidemiology of oral health cms.gov/Medicare/Medicare-General-Information/ conditions in older people. Gerodontology 2014; 31 MedicareGenInfo/index.html. Accessed Jan. 11, 2018. Suppl 1:9–16. doi:10.1111/ger.12085. 36. Oral Health America. An Oral Health Benefit in 21. Hyde S, Dupuis V, Mariri BP, Dartevelle S. Prevention of Medicare Part B: It’s Time to Include Oral Health in Health tooth loss and dental pain for reducing the global burden Care. 2018. oralhealthamerica.org/wp-content/uploads/ of oral diseases. Int Dent J 2017; 67 Suppl 2:19–25. White-Paper-Final.pdf. doi:10.1111/idj.12328. 37. American Dental Association Health Policy Institute. 22. Bhaskara S, Barzaga CE. A Healthy Smile Never Gets www.ada.org/en/science-research/health-policy-institute. Old. 2018. www.centerfororalhealth.org/wp-content/ 38. American Dental Association. (3000–3999) uploads/2018/11/Oral-Health-of-Older-Adults.pdf. Committee B — Dental Benefits, Practice and Related Accessed Jan. 11, 2019. Matters, All Inclusive.pdf. www.ada.org/en/member- 23. The Henry J. Kaiser Family Foundation. How Many center/leadership-governance/house-of-delegates/board- Seniors Live in Poverty? 2018. www.kff.org/medicare/ reports-resolutions. (Posted Oct. 10, 2018). Accessed Jan. issue-brief/how-many-seniors-live-in-poverty. Accessed Jan. 11, 2018. 11, 2019. 39. Elani HW, Simon L, Ticku S, Bain PA, Barrow J, Riedy 24. Jacobson G, Griffin S, Neuman T, Smith K. Income CA. Does providing dental services reduce overall health and Assets of Medicare Beneficiaries, 2016-2035. 2017. care costs? J Am Dent Assoc 2018;149(8):696-703.e2. www.kff.org/medicare/issue-brief/income-and-assets-of- doi:10.1016/j.adaj.2018.03.023. Epub 2018 Jun 14. medicare-beneficiaries-2016-2035. Accessed Jan. 11, 40. Cigna. Improved Health and Lower Medical Costs: 2019. Why Good Oral Health Is Important. 2010. www.cigna. 25. Padilla-Frausto ID, Wallace SP. The Hidden Poor: Over com/static/www-cigna-com/docs/employers-brokers/ Three-Quarters of a Million Older Californians Overlooked dental-white-paper.pdf. by Official Poverty Line. Policy Brief UCLA Cent Health 41. California Health Care Foundation. Emergency

APRIL 2019 271 Specializing in selling and appraising dental practices for over 40 years!

LOS ANGELES COUNTY ORANGE COUNTY CANOGA PARK— 25+ years of goodwill GP w/ ANAHEIM— GP located in 2 story building w/ OCEANSIDE— Established in 1990 with 4 eq 4 eq ops and 1 plmbd not eq op. Located in a heavy traffic flow. Has 8 eq ops. Grossed ap- ops in a one story busy shopping center. PPO single story bldg. Proj. approx. $366K for prox. $754K in 2018. Property ID #5255. and Cash Only. Grossed approx. $560K in 2018. Property ID #5241. 2018. Property ID #5267. IRVINE - Well established Cash Only GP w/ 5 CENTURY CITY—GP in 11 story prof med bldg. eq ops in a1,915 sq office . Grossed approx. SAN DIEGO— Price Reduced!! GP in med/ Has 5 eq in a 1,955 sq . Grossed approx. $482K in 2017. PropertySOLD ID #5193. dent bldg. w/ 3 eq ops. Fee for service. Estab. $715K. Buyer’s net of $200K. Property ID circa 1950. Grossed $306K in 2018. Net LADERA RANCH— Beauful GP in premier 4509. $151K. Property ID # 5212. shopping center. Has 11 eq ops. Grossed ENCINO— GP with 40 years of goodwill in $1.9M in 2018. Property ID 5262. SAN DIEGO—Spacious GP located in a 3 story professional building. Has 5 eq ops in a 2,157 presgious 12 story med/prof. building. Has 4 ORANGE— Turn-Key GP in small shopping sq suite. Grossed approx. $652K in 2018. eq ops and 1 plumbed not eq. Grossed ap- center on a major heavy traffic street. Has 3 eq Property ID #5233. prox. $309K in 2018. Property ID #5263. ops in a 1,800 sq suite. Proj. approx. $164K for 2018. Property ID # 5253. SAN DIEGO— Beauful GP in a 2 story profes- LANCASTER—GP + Real Estate! Long estab- sional bldg w / 6 eq ops and 2 plmd not eq in a lished pracce w/ 4 eq ops in a single standing SANTA ANA— GP W/ 3 eq ops and 1 plmb not 2,250 sq suite. Grossed approximately eq in 4 story med bldg. Property ID 5113. $1.2M in 2018. Property ID #5251. bldg. On a major downtown street. Net $239K. Property ID #5222. STANTON— Turn-Key GP in a single story RIVERSIDE & corner strip mall. PPO and Cash only! Has 2 LA PUENTE - Established in 1961 in single free eq ops in 797 sq suite. Grossed approx. SAN BERNARDINO COUNTIES standing building with 4 eq ops and 1 plumbd $237K in 2018. Property # 5267. PALM DESERT— Beauful GP located in a not eq. Grossed approx. $300K in 2018. Prop- TUSTIN— LH & EQUIP ONLY! Beauful remod- single story corner building. Heavy traffic flow. erty ID # 5269. eled office with 3 eq op and 1 plmbd not eq. Consists of 4 eq opsSOLD in a 1,800 sq office. Located in a singleSOLD story professional building. Reasonable rent. Monthly revenues of $132K. LOS ANGELES— Beauful office with a great Has two price points. Property ID #5244. built out. Has 5 eq ops and 1 plmbd not eq . Grossed $1.4M in 2017. NET $477K. Property YORBA LINDA— GP established in 1987 con- Has Easy 2000 soware. Grossed approx. ID #5217. sists of 4 eq ops in a 1,150 sq suite. PPO & $420K in 2018. Property ID # 4489. Cash Only. Grossed approx. $658K in 2018. TEMECULA - Pedo and Ortho PracƟce + Real Property # 5258 LYNWOOD— GP in single story busy shopping Estate!! It’s located in a duplex single story center. Absentee owner. Grossed approx. building. ProjecƟngSOLD approximately $1.8M $610K in 2018. Property ID #5264. with a Buyer’ net of $1M. PPO/Cash/Den-cal. Has 8 eq ops in a 3,500 sq office. Property ID WOODLAND HILLS - Well established GP in a 5 # 5243. story med/dent bldg with 4 eq ops and 1 plmbd not eq. ProjecSOLDƟng $1M for 2018. Prop- SAN DIEGO COUNTY TEMECULA—Absentee owner GP with 2 GP erty ID #5246. CARLSBAD— This beauful pracce has over 22 Associates. Has 4 eq ops in busy shopping KINGS & VENTURA COUNTIES yrs of goodwill. Has 4 eq ops in a 1,800 sq center. Grossed approx. $327K in 2018. Prop- suite. Fee for service office. ProjecƟng approx. erty ID 5259. LEMOORE— GP + Real Estate. 33 years of $440K for 2018. Property ID # 5256. goodwill with 5 eq ops in a 1,655 sq office. COMING SOON EL CAJON - GP + Real State. Consists of 5 eq Averaging 35-40 new paents/mo. Grossed ops and equipped with 3D Sirona CBCT Digital X Chula Vista, Escondido, La Jolla, Orange, $1.4M in 2017. Net $377K. Property ID # -ray. Grossing over $1M in the past 10 years. 5232. Property ID # 5265. San Diego, Sorrento Valley, & Stanton

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CONTACT US FOR A FREE CONSULTATION WWW.CALPRACTICESALES.COM Phone: (800) 697-5656 CA BRE #00283209 RM Matters CDA JOURNAL, VOL 47, Nº4

Balance Honesty With Objectivity When Addressing Prior Treatment TDIC Risk Management Staff

entists are naturally proud The patient returned two weeks of their profession. After all, later to have the permanent restoration they’ve built a life around delivered. The following day, the helping patients improve and A dental practice that offi ce received a call from the patient maintain their oral health. So, has not received a written reporting discomfort with his new Dit’s understandable to be a bit disconcerted crown and feeling that the crown was when they come across questionable request to log injuries and high. He was seen the same day for work performed by a colleague. illness is not required to an occlusal adjustment. The patient Dentists often fi nd themselves complete these two forms. returned for subsequent occlusal in an awkward predicament when a adjustments. After each visit, he left the patient presents with what appears offi ce happy and free from discomfort. to be substandard work by another Approximately two weeks after that, provider. On one hand, patients the patient returned, frustrated, stating have a right to be informed about be restored. The dentist did not have a he had been in so much pain that he the state of their oral health. On the previous working relationship with the had to go back to the endodontist. other, dentists should avoid openly other endodontist, but had heard from The endodontist told him that the criticizing another dentist’s work, colleagues in the community that this pain was coming from the ill-fi tting even if that criticism may be justifi ed. endodontist was known for questionable crown and advised him to go back Finding the right balance between work and an unwillingness to work to the dentist to have it redone. The candidness and restraint can be tricky. collaboratively with other providers. dentist was surprised by the criticism In a case reported to The Dentists The patient was adamant about getting of her treatment from the endodontist Insurance Company, a dentist saw the crown done without any further given the fact that the root canal he a patient who had mild discomfort delay. The dentist took a radiograph had performed was of poor quality. on a lower molar. He stated that to assess the status of the root canal The dentist tried to adjust the crown he had been to three other dentists treatment. To her surprise, the radiograph once more, but ended up adjusting off and they had not been able to help revealed a slight overfi ll. The patient an excessive amount of the porcelain him. The patient insisted on a crown expressed his relief at fi nally being pain- layer. She informed the patient and and was convinced that it would free and shared that he believed the offered to remake the crown at no make his symptoms disappear. The endodontist he chose did a great job. additional charge. The patient was dentist performed an exam and took The dentist chose not to discuss annoyed but hesitantly agreed. The radiographs of the tooth in question. her fi ndings with the patient, nor dentist removed the crown to take a new Based on her fi ndings, the dentist did she attempt to reach out to the impression for a replacement crown. recommended a root canal. Due to endodontist to discuss her concerns, as The patient continued having calcifi cation and curvature at the she assumed he would not be willing symptoms for the next few weeks. apex, she referred the patient to an to speak with her. Because the patient He canceled his appointment to endodontist. The patient took the was not experiencing any symptoms have the permanent restoration referral slip and left the offi ce. and the specialist’s report indicated that delivered and demanded a refund. A few months later, the patient the tooth was ready to be restored, she He stated that he had gone back to returned to the offi ce with a report from proceeded with preparing the tooth for the endodontist, who then referred a different endodontist. The report a crown, although she had concerns him to another dentist to remake the indicated that the tooth was ready to about the presence of the overfi ll. crown. Regretting her decision to allow

APRIL 2019 273 APRIL 2019 RM MATTERS

CDA JOURNAL, VOL 47, Nº4

the patient to dictate treatment in sure to remain objective. They of his or her oral health, the dentist the fi rst place, the dentist agreed to should avoid fi nger-pointing and should exercise care that the comments provide the patient with a refund. disparaging comments when referring made are truthful, informed and Senior TDIC Risk Management to another dentist’s work. justifi able …. A difference of opinion as Analyst Taiba Solaiman says this “While these comments may to preferred treatment should not be case demonstrates the necessity for seem innocent, they can aggravate communicated to the patient in a dentists to inform patients of their a patient who may already be manner which would unjustly imply fi ndings, regardless of how awkward or emotionally charged,” Solaiman said. mistreatment. There will necessarily be uncomfortable it may be. Dentists have The ADA’s “Principles of Ethics cases where it will be diffi cult to an ethical responsibility to be upfront and Code of Professional Conduct” determine whether the comments made about their patient’s oral health and states: “Patients are dependent on are justifi able. Therefore, this section is should feel empowered to provide their the expertise of dentists to know phrased to address the discretion of professional opinions in an honest their oral health status. Therefore, dentists and advises against unknowing manner. That said, dentists must be when informing a patient of the status or unjustifi able disparaging statements against another dentist.” Before making a determination, it is advised to contact the previous treating dentist, with the patient’s permission, to determine under what circumstances and conditions the treatment was performed. When you discuss another dentist’s treatment with your patient, be sure the comments are justifi able and based answers on objective facts and not merely a difference of opinion. Presenting your fi ndings without bias or undue criticism maintains the integrity of your profession and ensures you’re taking the right steps in protecting your patients’ oral health. ■

TDIC’s Risk Management Advice From one-on-one risk management advice by phone Line is a benefi t of CDA membership. to informed consent forms to expert-led seminars, If you need to schedule a confi dential we’re here to help you practice with confidence. consultation with an experienced risk management analyst, visit tdicinsurance. We are The Dentists Insurance Company. com/RMconsult or call 800.733.0633.

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274 APRIL 2019 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY

4338 PENINSULA PROSTHODONTIC PRACTICE Preeminent 45 4344 SF GP Prime & convenient location in Laurel Heights year Prosthodontic practice located in mid peninsula neighborhood. neighborhood. 9 year practice averageing $500K+ with approx. 50% State-of-the-art 1,242 square foot facility with 5 operatories. Seller overhead in fully-equipped 2 op. modern faciltiy. Motivated seller willing to help in the transition. Outstanding referral sources. Average relocating out-of area. Asking $110K. Gross Receipts $1.3M with 4 doctor-days per week. Asking $884K. 4336 SAN BRUNO GP Legacy practice centrally located in a 4256 SANTA CRUZ COUNTY GP Seller moving out-of-state and combined commercial & residential neighborhood, convenient to offering 33 years of goodwill. Wonderful location on major thoroughfare highways 101, 280, and 380LD and close to the BART station. Elegant, in a charming beach community close to wineries and the water. remodeled 1,463 sq.S ft.O office with 5 fully-equipped ops. & digital Tranquil and modern, beautifully appointed, 5 op facility. Approx. 1,300 radiography. 5 year average Gross Receipts $922K+. 1,000 active active patients (all fee-for-service). Seller will help for smooth transition. patients with an average of 10 new patients per month. Asking $661K. Asking $180K. 4316 SARATOGA GP Vibrant and active practice located in beautiful 4343 CAPITOLA GP Ample 3,000 sq.ft. faciltiy w/5 fully-equipped 4 op, fully-equipped, facility at upscale residential, professional, and LD operatories,. Terrific opportunity to own the facility and well-established commercial neighborhood.SO 10 new pts./month. 4 doctor days & 4 community practice with quality and seasoned staff. Average Gross hygiene days per week. $464 avg. Gross Receipts. Asking $357K. Receipts $870K+. Asking $643K. 4216 SIERRA NEVADA FOOTHILLS 23 year practice located in the 4261 CAPITOLA GP Retiring doctor offering an established practice in heart of the Sierra Nevada foothills in modern building close to LD professional office complexSO built around a garden setting. Beautiful and downtown area. 1,024 square foot office with 4 fully- equipped ops., modern 1,465 square foot facility with 4 fully-equipped operatories. upgraded major equipment and digital radiography. Average Gross Average gross $743K+ with 3 doctor days and 6 hygiene days per Receipts $890K+ with 56% average overhead. Asking price for practice week. Approximately 1,800 active patients. Asking $562K. $604K. Seller is offering real estate for sale to the buyer of his practice.

4349 CONTRA COSTA COUNTY PEDIATRIC Practice in a bright 4262 MOUNTAIN VIEW GP Desirable 1,700 square foot Mountain and relaxing atmosphere in anN ampleG 1,600 sq. ft. 3 op facility with View location. 5 fully equipped operatories. Average Gross Receipts large private office that canD beI upgraded to include a fourth op. $886K+ with 4 doctor days and 6 hygiene days. Practice with an EN Surrounded by referralP sources in a class A medical center. 3 doctor emphasis on Restorative andIN PreventativeG care. Seller retiring. Great ND days per week. Scan X with Visix software fully-integrated with Open opportunity for a skilledPE dentist to take over a 35 year practice with Dental. Seller retiring. Great upside potential. Asking $141K. seasoned staff and loyal patient base. Asking $619K.

4172 NAPA GP Amazing opportunity to own the practice of your 4340 WEST SONOMA COUNTY GP Charming and growing dreams in one of the world’s premier wine destinations! Situated in a community practice with over 40 years goodwill in seller owned D prime neighborhood closeO toL many amenities. 1,200 square foot office building. Busy corner location adjacent to several retailers. Well with 4 fully-equipped andS updated operatories. Over 1,000 active appointed, 4 op office with several Recent leasehold improvements and D patients. Average annual gross receipts over $700K. Asking price for upgrades. ApproximatelyO 1,000L active patients. Average Gross practice $484K. Building available for purchase. Receipts $788K with consistentS growth. 2018 on schedule for $822K with 65% overhead and 3.5 doctor days per week. Asking $538K. 4233 SF GP Seller offering 26+ year general practice in SF Financial district. Ground floor office with high volume foot traffic. Approx. 1,200 COMING SOON: sq. ft. facility with 4 fully-equippedLD ops. $930K+ avg. annual GR. Seller SF GP, Sonoma County GP, Napa County GP & Monterey willing to help for a smoothSO transition. Asking $640K. County GP

4331 SF GP Downtown SF practice in gorgeous, remodeled 1,300 office with panoramic views. Suite includes 4 fully equipped ops, reception area, business office, private office, staff lounge, lab area, Carroll & Company and sterilization area. Beautiful, modern cabinetry and equipment. 2055 Woodside Road, Suite 160 Redwood City, CA 94061 1,600 active patients with 15-20 new patients/mo. Owner/doctor BRE #00777682 works 3 days/wk with 5 hygiene days/wk. Average gross receipts $738K with average adj. net of $305K. Asking $495K. Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll

carroll.company [email protected] (650) 362-7004 (650) 362-7007 Making your transition a reality. 7*4*564"5$%"#005)

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Are You Cybersecurity Aware? CDA Practice Support

ental practices rely on TABLE electronic information Five Prevailing Cybersecurity Threats to Health Care Organizations systems to perform critical Threat Potential impact of attack. operations, such as scheduling patients, fi ling claims, tracking Email phishing attack Malware delivery of credential attacks. Both attacks further compromise the organization. Dpatient accounts and analyzing practice performance. Technology has eased the Ransomware attack Assets locked and held for monetary ransom (extortion). practice of dentistry in many respects, May result in permanent loss of patient records. but it has also presented new concerns Loss or theft of equipment or data Breach of sensitive information. May lead to patient and challenges. A practice owner’s identity theft. unawareness of an information system’s Accidental or intentional data loss Removal of data from the organization (intentionally vulnerabilities and the owner’s failure or unintentionally). May lead to a breach of sensitive information. to consider natural, environmental and man-made threats to the system Attack against connected medical Undermined patient safety, treatment and well-being. place the practice’s reputation and devices that may aff ect patient safety fi nances at risk. A prudent practice Source: Technical Volume 1: Cybersecurity Practices for Small Health Care Organizations, phe.gov/Preparedness/ owner should maintain a certain level planning/405d/ Documents/tech-vol1-508.pdf. of awareness of information security risks and take recommended steps (TABLE) and discusses the cybersecurity can prevent unauthorized users to reduce their potential impact. A practices that can be implemented. from viewing electronic data and practice owner should be cybersecurity One volume of the publication can substantially reduce the risk of aware, which means to be aware of is focused on small health care compromising patient information. A criminal or unauthorized efforts to access organizations. Another volume includes dental practice may utilize encryption the practice’s servers, workstations, resources for an organization’s IT staff software or one of many email service networks, programs, mobile devices, and advisers. It would be well worth providers that encrypt messages. A electronic devices and stored data. a practice owner’s time to review the HIPAA-covered entity must assess The federal government takes guidelines with his or her IT adviser whether encryption is a reasonable cybersecurity very seriously. The and discuss whether recommended and appropriate safeguard as a means Cybersecurity Act of 2015 mandated, steps can or should be implemented. of protecting electronic protected among many things, the development In October 2018, the Offi ce for Civil health information at rest (stored) of practical cybersecurity guidelines Rights (OCR), the HHS division that and in motion (transmitted). to reduce risks in the health care enforces HIPAA, highlighted a handful Social engineering: Untrained industry. The guidelines were published of basic cybersecurity safeguards that can and unaware staff can be victims in December 2018 by the U.S. reduce the impact of malicious/malevolent in one of the most common and Department of Health and Human actors or system failures. October is effective social engineering tactics Services (HHS), which collaborated National Cybersecurity Awareness for stealing user credentials and other with the industry in its development. Month and 2018 was the 15th year of the sensitive information. Phishing is the “Health Industry Cybersecurity awareness program. The following are act of sending deceptive emails to Practices (HICP): Managing Threats the safeguards highlighted by the OCR: users, enticing them to disclose login and Protecting Patients” is a four- Encryption: Encryption is the credentials or click links that may volume publication that delivers process of converting electronic data install malware, such as ransomware. actionable and practical advice.1 The into a coded form that is unreadable Phishing exploits human vulnerabilities, publication explores fi ve current threats without a decryption key.2 Encryption such as inattention to details, fear

APRIL 2019 277 APRIL 2019 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 47, Nº4

and being rushed or threatened. A logs. The owner or IT adviser may require appropriate settings in order to practice owner should ensure that be able to detect suspicious activities function as intended. For example, an staff is trained to recognize phishing or reconstruct events by reviewing older version of encryption software attempts. A suggestion is to fi nd a the logs. The audit log can be an may not be as effective. Maintaining short video on YouTube; many IT important security tool as long as the and updating malware defi nitions within and security companies have posted log is reviewed on a regular basis. the anti-malware program is necessary useful videos that can be used for Audit logs are one of the required for maximum protection. Audit logs training. The HIPAA Security Rule HIPAA Security Rule safeguards. must be properly confi gured in order does require security awareness Secure confi gurations: Proper to collect and retain the correct data training for all workforce members. confi guration of information system and to protect against unauthorized Audit logs: A practice owner devices, network and software will manipulation or deletion of data. The can record network and system improve a dental practice’s cybersecurity confi guration of fi rewalls, workstations, activity and monitor the activity by defenses. Safeguards, including routers, servers and other components reviewing, or auditing, the activity encryption, anti-malware and audit logs, all play an important role in minimizing the chance of security incidents.3 ■

REFERENCES 1. U.S. Department of Health and Human Services. Health Industry Cybersecurity Practices: Managing Threats and Protecting Patients. www.phe.gov/Preparedness/ planning/405d/Pages/hic-practices.aspx. 2. National Institute of Standards and Technology (NIST). Encryption Basics. www.nist.gov/publications/encryption-basics. 3. Johnson L, Dempsey K, Ross R, Gupta S, Bailey D. NIST Special Publication (SP) 800–128: Guide for Security-Focused Confi guration Management of Information Systems. August 2011. csrc.nist.gov/publications/detail/sp/800-128/fi nal.

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

CORRECTION In the March 2019 Regulatory Compliance article, the following should have been a bullet under the Prescribing section: “Starting Jan. 1, 2019, a uniquely serialized number in a manner prescribed by the Department of Justice.” We apologize for the omission.

278 APRIL 2019 Specialists in the Sale and Appraisal of Dental Practices Serving California Dentists since 1966 Practices How much is your practice worth?? Wanted Visit PPS at CDA Anaheim Booth 1157

NORTHERNNORT RN CALIFORNIA SOUTHERN CALIFORNIA CALIF (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6162 REDDINGDING 2018 collected $700,000 $700 000 on Owner’s Owner’s 3.5 3 5 day week. week 4-days ALTA LOMA Great exposure. Grossing $700,000. 5-ops, 3-equipped. of hygiene. 5-ops. River views. BAKERSFIELD AREA Grossing $1.2. Owner works 16-hours. Nets 6161 SAN FRANCISCO BAY AREA PROS PRACTICE - “OUT-OF- $300,000. NETWORK” 2018 produced $1.18 Million and collected $1.18 Million. BAKERSFIELD AREA Grossing $40,000/month on 2-days. 5-ops. 4-days of Hygiene. Owner available for long transition. Condo optional BAKERSFIELD Practice & building. Has done $500,000. Full Price for purchase. both $350,000. 6160 SAN FRANCISCO’S 450 SUTTER 12th floor with unencumbered CAPISTRANO BEACH Senior DDS Grosses $200,000. Full Price views of Downtown. Upgraded office, technology and delivery systems. PPO $150,000. practice collected $270,000 part-time due to Owner’s East Bay practice. DEL MAR -- ENCINITAS HMO grossing near $400,000. 4-ops. 6159 WOODLAND 3-day practice perfect for first practice, or acquisition by DENTURE PRACTICE Needs Western Boards. Grossing $750,000. Did nearby DDS as can be relocated. Collections in 2018 totaled $518,000. 3-days $1.2 with OS. Prosthodontist / Implant Specialist will do extremely well. of Hygiene. 4-ops in well-designed office. Quality patients. Full Price $250,000. DIAMOND BAR High identity Asian center. Will do $1 Million. Hundreds of people walk by each day. 6158 FORTUNA Relaxed lifestyle in Humboldt County’s Banana Belt. Adjacent to Ferndale. Perfect for Dentist seeking small town living. Collects EMERGENCY SALE SoCal Paradise. Seller moving out-of-state. 9-ops. $390,000. 6-weeks off. Lots of work referred. Full Price $75,000. Skilled and rive Successor can net $400,000 first year one and it will only get better. 6157 SACRAMENTO’S ELK GROVE AREA 2018 collected $909,000 on Owner’s 3-day week. Successor can immediately increase to 4-days as ENDODONTIST Join Periodontist in Santa Clarita, Only $35,000 or GP practice is rich in patients. 25+ new patients per month. 5-ops, digital Pan, who wants a good reliable job. strong Recall, great staff. Want to be busy and make a “no-risk” acquisition? GLENDALE / BURBANK Grosses $840,000. Includes apartment. Then investigate this opportunity. INLAND EMPIRE Adec, cone beam. Gross $1.3 Million. Includes RE. 6156 SANTA ROSA Sited on Sonoma Highway near Oakmont. Strong INLAND EMPIRE DentiCal grossing near $300,000. Full Price $150,000. foundation evidenced by 4-days of Hygiene. Well-designed 5-op office. 2018 INLAND EMPIRE Union Practice can do $1+ Million. 5-ops. collected $730,000. Over $200,000 invested in equipment and technology. INLAND EMPIRE HMO $8-to-10K/month. Grossing $500,000. All Full Price $325,000. Hispanic. FP $450,000 6155 LAKEPORT - “SOLD” 5-days of Hygiene. 2018 collected IRVINE Female Grossing $1.2 Million. 5-ops. $825,000. Lakeside location and nicely equipped. Seller happily looks LA HABRA Shopping mall. Female Grossing $330,000. 6-ops, 5 equipped. forward to retirement. Full Price $225,000. Million Dollar location. Full Price $270,000. 6152 SAN RAFAEL - “SOLD” Across the street from Marin Academy. LA MIRADA Like new 5-ops, 3-equipped. Grossing $450,000. 2018 collected $520,000. Stand-alone building optional purchase. Nearby NORTH PASADENA Million Dollar practice. 5-op free-standing building DDS who desires their own building should vertically integrate their practice across from Starbucks. here and have an instant $1+ Million practice in a superior location. OC BEACH 6-ops, Dentrix, digital, computerized. Full Price $150,000. 6151 MODESTO Located on north end of Coffee Road where new OC BEACH Absentee owned, grossing $550,000. 4-ops. New Doc does $1 development is occurring. Attractive 3-op office. 2018 collected $408,000 on Million. 2-day week. Did $700,000+ in 2016 when Owner was full time with $240,000 in Profits. Full Price $200,000. OC BEACH Grossed $100,000 last month. Full Price $900,000. 6150 HAYWARD - “SOLD” Strong Dental DNA. Well-designed 5-op OC’S FASHION ISLAND Grossing $650,000. Rare opportunity. office. Digital radiography and computers. 2018 trending $850,000+. 5-days ORANGE COUNTY- INLAND-EMPIRE 2-practices grossing $1.8 of hygiene. Full Price $200,000. Million. Right Buyer does $3 Million. 6149 NOVATO - PERFECT START-UP OPPORTUNITY – BUILDING PEDO Chinese & Latino. Grosses $450,000. Full Price $285,000. + 3-YEAR OLD OFFICE Stand-alone building at busy stop light RIVERSIDE Female grossing $250,000. 30-new patients/mth. FP $165,000. intersection off Highway 101. 4-ops, paperless at cost of $180,000. Doorway SANTA CLARITA Hi identity center. DDS wants to share office and remain to Hamilton with 100s of homes. No competition. Perfect for Dentist seeking 1 day in 2 ops. 8 ops avail. 70,000 autos pass/day. This location did almost $2 perfect location. Scott McDonald from Doctor Demographics states: “Well, I Million in past. have to say that you were right, Ray. This is an interesting and viable TUSTIN - SANTA ANA Just opened. $450,000 invested. Cone Beam. location.” TORRANCE Entrance to Palos Verdes. Grossing $300,000+. Full Price 6147 SAN FRANCISCO BAY AREA - “OUT-OF-NETWORK” - $290,000. “SOLD” 2018 collected $2.2 Million. Hygiene produced $1+ Million. UPLAND Grossing $135,000 part-time. 3-ops. Full price $65,000. $700,000+ in profits. Unique in so many ways! Seller available for long VAN NUYS 2 Ops, room for more. Hi identity medical building. On first transition. floor. Full Price $150,000 6143 BERKELEY’S ALTA BATES VILLAGE - “SOLD” 3-day week VENTURA 3 practices HMO grossing $2.6 million. collected $540,000 in 2018. 4-days of Hygiene. Housed in its own building on Webster Street. WEST COVINA Grossing $650,000. 2 days hygiene. Refers lots of work!

Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-886 SAN FRANCISCO (Facility): Unsurpassed CG-859 SONOMA: Priced below market value at only EN-836 CITRUS HEIGHTS: IG-881 TURLOCK: Broker in visibility & locaon! Potenal here is limitless! 850 sf $395k! 2000 sf w/ 4 ops highly esteemed FFS Prac- $188k $360k w/ 3 ops $85k tice $395k EN-885 ROSEVILLE Facility: IN-764 STOCKTON: AG-871 SAN FRANCISCO: Seller Movated! 600 sf CN-911 SANTA ROSA: “Quality Care & Paent well- $65k RE: $450k Only: $120k! Northern w/ 2 ops Price Reduced $65k being FIRST”. 2250 sf w/4 ops + 1add’l. $545k EN-899 DIXON: IN-917 MERCED AREA: AG-944 SAN FRANCISCO: An opportunity like this CN-951 VALLEJO Facility: Move In Ready! 2000 sf Only $95k! Reduced! $295k does not come along very oen! 980 sf w/ 3 ops w/ 4 fully equipped ops. Negoate your new lease! EN-935 SACRAMENTO: JC-811 FRESNO COUNTY: California $595k Only $50K $400k $350k

AG-945 SOUTH SAN FRANCISCO: Be a part of this DC-930 FREMONT (Facility): 1846 sf w/5 ops! In- EN-977 MIDTOWN SACRAMENTO: Grossed over $1.4M in 2018! JC-823 LOS BANOS: vibrant, diverse populaon. 1800 sf w/ 4 ops $495k cludes some dental equipment! FREE – JUST TAKE $950k $80k AN-939 REDWOOD CITY: Tradion of restoring OVER LEASE! FC-650 FORT BRAGG: $350k Over $34.5M smiles & improving dental health! 1165sf w/ 4 op + DC-946 REDWOOD CITY: Long established. Seller for the Pracce & $400k for the Real Estate SOUTHERN CALIFORNIA 2 add’l. $295k unable to work full-me due to health issues. 1577 FC-962 HEALDSBURG: AN-947 DALY CITY: Great staff, stellar reputaon are sf w/ 2 ops & plumbed for 2 add’l $120k $180k KL-909 SAN DIEGO: in 2017 sales just some of this opportunies aributes! 1500sf DG-862 MID-PENINSULA: Rare gem with up to 7 FG-841 ARCATA: Reduced NOW ONLY $910k w/ 4 ops. $375k operatories in the Bay Area!! 2274 sf w/ 6ops + 1 Price: $250k/ Real Estate Also Available KG-921 SANTA MARIA:

BC-741 DANVILLE (FACILITY): Move in Ready! ~ add’l. $475k FN-961 EUREKA: Seller Movated $315k 1600 sf w/ 3 ops. PRICED TO SELL! $10k DG-936 SUNNYVALE: Hesitate and you may lose out $395k/ Real Estate Available $395k! KL-955 SAN DIEGO: Extensive Buyer BC-926 ANTIOCH: Long established, well respected on this opportunity of a lifeme! ~1000 sf w/ 3 ops. FN-855 NO. HUMBOLDT: office. 1866 sf w/ 5 ops $495k Call For Details! $275k $225k Database & BC-949 ALBANY: Desirable commercial/residenal DG-978 PALO ALTO: Imagine the possibilies with GN-799 PARADISE: area. Medical Prof Bldg w/ good frontage. 3200sf the newly opened Amazon corporate office near- Pracce $375k, Real Estate $325k SPECIALTY PRACTICES Unsurpassed w/ 4 ops $695k Real Estate: $1.8 by! $455k GN-953 CHICO: BG-925 HAYWARD: Profits close to $900K per DN-898 SAN JOSE: Built-out 2015 w/ locaon, visi- $315k BC-784 CENTRAL CONTRA COSTA CO Perio: Exposure allows year! ~ 1930 sf w/ 6 ops $1.15M bility, convenience in mind! 2,204 sf w/4ops + 2 HG-815 TRUCKEE AREA: $395k BG-981 BERKELEY: Long established, family- add’l. $500k $165k/ Real Estate $437k BG-843 WALNUT CREEK Perio us to offer you oriented practice. 1100 sf w/ 3 Ops $345k/ Real DN-914 SANTA CLARA: This beauful and compact HG-827 SO. LAKE TAHOE: Reduced Price: $595k Estate Available $499k office produces a lot of denstry! 950sf w/ 3 ops. $310k DC-835 TRI-VALLEY Perio:

BN-891 PINOLE: This seller is ready to rere, & $210k HG-851 SO LAKE TAHOE:

looking for someone to connue the legacy! 1300 DN-937 SAN JOSE: This opportunity is waing for $425k $800k sf w/3 ops. $350k your talent & skills! 2210 sf w/ 4 Ops + 2 add’l. HG-983 GRASS VALLEY: DG-912 SUNNYVALE Ortho: BN-906 OAKLAND: Located in Oakland’s thriving $500k Call For Details! $925k Better and bustling China Town! 1,000sf w/2 ops. $195k DN-938 SUNNYVALE: The ideal opportunity to prac- HN-618 SIERRA FOOTHILLS: DN-908 SAN JOSE Pedo: BN-943 MARTINEZ: Opportunies like this only ce in this community! 2000 sf w/ 4 Ops + 2 add’l. $65k $175k comes along every great once in a while. 1520sf w/ $500k HN-740 SHASTA CO: DN-959 APTOS Perio: Candidate 4 ops +1 add’l. . $450k NORTHERN CALIFORNIA $475k/ $750k / Real Estate Available $650k BN-952 BERKELEY: Step into this quality pracce and Real Estate $350k EG-903 CARMICHAEL Oral Surgery: you’ll know you belong here! ~ 835 sf w/ 3 Ops. EN-664 SACRAMENTO Facility: Great corner loca- HN-773 SUTTER CREEK: $450k on, excellent visibility & easy access! 2300 sf w/ 4 Only $95k! Amazingly Priced: $450k CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 ops. $30k HN-879 SONORA: GG-940 NORTHERN CALIFORNIA Pedo: Better ops 640 sf Collections $433k in 2017 $275k EG-910 MIDTOWN SACRAMENTO: Unlimited Po- Reduced Price: $265k $695k CC-927 SAN RAFAEL: Build the practice of your tenal. ~ 1107 sf w/ 2 ops + 1 add’l. $248k HG-934 GRASS VALLEY: JG-757 VISALIA Perio: dreams by increasing this 2-day work week! 800 sf EG-965 SOUTH AUBURN VICINITY: The ideal op- $225k/Real Estate $190k Steal at $335k w/ 3 ops $225k portunity to pracce in this community! ~1100 sf HN-941 GOLD COUNTRY/CALAVERAS CO: Fit CC-960 SONOMA: Great location in one-of-a-kind w/ 4 Ops.. $350k $175k setting! 950 sf w/ 3 ops. $385k/ Real Estate Availa- EG-968 SACRAMENTO: Desirable, mid-town neigh- ble $350k borhood, w/ ample parking in garage! ~1527 sf w/ CENTRAL VALLEY CC-963 SANTA ROSA: Dream Pracce in Free 5 Ops. $550k Standing Building on major thoroughfare. 1765 sf EG-972 ELK GROVE: Prime locaon & spacious IG-832 OAKHURST: $235k/ Better w/ 5 ops $550k office! ~3500 sf w/8 ops +add’l. $599k Real Estate 375k

Price 800.641.4179 [email protected] “ASK THE BROKER” WWW.WESTERNPRACTICESALES.COM

Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA CONTINUED CENTRAL VALLEY CONTINUED

AC-886 SAN FRANCISCO (Facility): CG-859 SONOMA: EN-836 CITRUS HEIGHTS: Well-established, quality pracce. 30+ years of IG-881 TURLOCK: Consistently growing pracce ~3500 sf w/ 10 Ops Broker in goodwill. 1300 sf w/3 ops + 2 add’l. $188k (shared). $360k $85k $395k EN-885 ROSEVILLE Facility: Ideal locaon w/ visibility & close to about any- IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- AG-871 SAN FRANCISCO: CN-911 SANTA ROSA: thing! 1000 sf w/3 ops. $65k RE: $450k ized. 5,000 sf w/10 ops. Only: $120k! Northern Price Reduced $65k $545k EN-899 DIXON: State-of–the-art office, with all the “bells & whistles”! This IN-917 MERCED AREA: Well established pracce with a stable, loyal pa- AG-944 SAN FRANCISCO: CN-951 VALLEJO Facility: fantasc pracce w/ 3 ops. Only $95k! ent base! 1300 sf w/ 3 Ops. Reduced! $295k EN-935 SACRAMENTO: Word to the wise: Act fast on this, it will not be avail- JC-811 FRESNO COUNTY: Amazing Opportunity! Considerable Goodwill in California $595k Only $50K able for long! 1800sf w/ 4 ops. $400k Community! 3,000 sf w/ 6 ops $350k

AG-945 SOUTH SAN FRANCISCO: DC-930 FREMONT (Facility): EN-977 MIDTOWN SACRAMENTO: Grossed over $1.4M in 2018! State-of- JC-823 LOS BANOS: Heavy emphasis on hygiene. Growth potenal by increas- $495k FREE – JUST TAKE the-art equipped, 1800sf w/5 ops. $950k ing DDS days. 1000 sf w/ 3 ops $80k AN-939 REDWOOD CITY: OVER LEASE! FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000 sf $350k Over $34.5M DC-946 REDWOOD CITY: for the Pracce & $400k for the Real Estate SOUTHERN CALIFORNIA $295k FC-962 HEALDSBURG: Known as 1 of top 10 small cities in the US! Amazing AN-947 DALY CITY: $120k practice w/ 1200 sf & 3 ops. Beautifully landscaped professional plaza $180k KL-909 SAN DIEGO: Remarkable Opportunity. Long established in vi- in 2017 sales DG-862 MID-PENINSULA: FG-841 ARCATA: Own a little slice of heaven! 1114 sf w/3 ops Reduced brant North Park. 2400 sf w/ 5 ops & 2 Pedo chairs NOW ONLY $910k $375k Price: $250k/ Real Estate Also Available KG-921 SANTA MARIA: Live and pracce in this desirable collegiate coastal

BC-741 DANVILLE (FACILITY): $475k FN-961 EUREKA: Where the quality of life can’t be beat! 1400sf w. 4 ops. community! 930 sf w/ 3 ops Seller Movated $315k PRICED TO SELL! $10k DG-936 SUNNYVALE: $395k/ Real Estate Available $395k! KL-955 SAN DIEGO: Just Listed! Well established & centrally located in 1st Extensive Buyer BC-926 ANTIOCH: FN-855 NO. HUMBOLDT: Seller relocang! Long-established, 100% FFS floor suite w/easy freeway access. Adjacent vacant suite available for $495k Call For Details! pracce! 1600 sf w/ 3ops + 1 add’l. $275k expansion. $225k Database & BC-949 ALBANY: DG-978 PALO ALTO: GN-799 PARADISE: Remarkable opportunity – Call for Details! 1800 sf w/ 4 ops. Pracce $375k, Real Estate $325k SPECIALTY PRACTICES Unsurpassed $695k Real Estate: $1.8 $455k GN-953 CHICO: Established for 55 years and the seller is passing their good- BG-925 HAYWARD: DN-898 SAN JOSE: will on to you! 1067sf w/ 3ops. $315k BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like Exposure allows $1.15M HG-815 TRUCKEE AREA: Busy, productive practice with 3 days of hygiene! well-oiled machine! 3 ops $395k BG-981 BERKELEY: $500k 1000 sf w/ 3 ops $165k/ Real Estate $437k BG-843 WALNUT CREEK Perio: Collecons over $1M! Great gross and profit us to offer you $345k/ Real DN-914 SANTA CLARA: HG-827 SO. LAKE TAHOE: Ski, live, play and pracce here where your for only 2 ½ days per week! 1085 sf w/ 4 ops Reduced Price: $595k Estate Available $499k lifestyle can’t be beat! 1200 sf w/4 ops. $310k DC-835 TRI-VALLEY Perio: Professional office bldg in highly desirable loca-

BN-891 PINOLE: $210k HG-851 SO LAKE TAHOE: Projected Revenue on track to do $700k this year! tion. Owner available to work back to assist w/ transition. Collections

DN-937 SAN JOSE: 2100 sf w/ 5 ops $425k over $1.2M. 2,100 sf $800k $350k HG-983 GRASS VALLEY: Newly remodeled office in highly desirable neighbor- DG-912 SUNNYVALE Ortho: Premier ORTHO practice opportunity in the BN-906 OAKLAND: $500k hood! ~1250 sf w/ 3 ops. Call For Details! Silicon Valley today! ~2030 sf w/ 5 chairs in open bay $925k Better $195k DN-938 SUNNYVALE: HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by DN-908 SAN JOSE Pedo: Amazing Location! Providing affordable pediatric BN-943 MARTINEZ: increasing office hours! 750 sf w/ 2 ops $65k denstry to families! 3600 sf w/ 4ops + 3 add’l. $175k $500k HN-740 SHASTA CO: Beauful mountain community, well-established DN-959 APTOS Perio: Highly successful at this proven locaon! 1350sf w/ Candidate . $450k NORTHERN CALIFORNIA pracce, exceponal long-term staff. 2400 sf w/5 ops + 1 add’l. $475k/ 4op. $750k / Real Estate Available $650k BN-952 BERKELEY: Real Estate $350k EG-903 CARMICHAEL Oral Surgery: Gross receipts were over $1.1 million in EN-664 SACRAMENTO Facility: HN-773 SUTTER CREEK: Qualified & credenaled Seller willing to show you 2017! Stable paent base won’t be affected by transion! 2282 sf w/ 5 ops $450k how! 1536 sf w/4 ops + 1 add’l Only $95k! Amazingly Priced: $450k CC-846 SAN RAFAEL: $30k HN-879 SONORA: Great Cash-Flow for Only 3 Days a Week! 2950 sf w/ 3 GG-940 NORTHERN CALIFORNIA Pedo: Pracce is on track to collect more Better $275k EG-910 MIDTOWN SACRAMENTO: ops Reduced Price: $265k than $1 million in revenues this year! 4300 sf w/ 5 ops. $695k CC-927 SAN RAFAEL: $248k HG-934 GRASS VALLEY: Just imagine living and praccing here! ~1200 sf w/ JG-757 VISALIA Perio: 9 Hygiene days per week, this practice is a rare EG-965 SOUTH AUBURN VICINITY: 3 Ops $225k/Real Estate $190k gem! ~ 2,000 sf w/ 5 ops Steal at $335k $225k HN-941 GOLD COUNTRY/CALAVERAS CO: This is the right pracce for you! Fit CC-960 SONOMA: . $350k 2,300sf w/2 ops + 3 add’l. $175k We are a proud member of: * Western Practice Sales is a member of American Dental Sales (ADS Transitions), $385k/ Real Estate Availa- EG-968 SACRAMENTO: a nationally recognized organization of dental practice brokers throughout the ble $350k CENTRAL VALLEY United States. ADS members have a CC-963 SANTA ROSA: $550k strategic alliance & combined marketing efforts with other practice brokerage EG-972 ELK GROVE: IG-832 OAKHURST: Rare Opportunity. 2048 sf w/3 ops + 1 add’l. $235k/ firms, financial companies & lending Better $550k $599k Real Estate 375k organizations. All ADS companies are independently owned and operated.

Price 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 47, Nº4

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

Blink XT ($129 to $499, Blink) ranges, motion-detection optimization and fi eld-of-view coverage to Security is at the forefront of every practice owner’s mind. Many consider. The Blink XT is not a perfect system, but for the money and practitioners have sophisticated, monitored security systems complete ease of use, it is an attractive option for the practitioner who would with burglar alarms, glass-break sensors and motion-sensing like to try their hand at a DIY security camera system. cameras. These systems can cost thousands of dollars to set up, carry —Alexander Lee, DMD monthly charges in the hundreds of dollars and require professionals to install. Because of these factors, a new cottage industry has appeared on the market: the do-it-yourself security system. These Citymapper Transit Navigation systems leverage technologies like mobile devices and Wi-Fi to (Free, Citymapper Limited) provide consumers with simple-to-set-up, no-monthly-cost solutions. Citymapper for iOS and Android is an app that combines various The Blink XT is an entry in the wireless, indoor and outdoor, motion- modes of transportation and fi gures out the best route to get from sensing HD camera system market, and it manages to introduce points A to B in 39 major cities around the world. Depending on the some eye-catching features that warrant it serious consideration. city selected, the service collects information for the most popular Blink was founded in 2009 as a home automation company, and modes of transit in the area including, but not limited to, walking, bus, thanks to its successes, was acquired by Amazon in 2017. The rail, ferry, cab, Uber, Lyft, shared bicycles and trains. Users simply Blink XT is the company’s only outdoor-capable camera, boasting enter a starting point, a destination and when they would like to a 1080p HD resolution, motion detection, microphone and an depart or arrive. The app will display suggested transit options and operating temperature range of minus 4 to 113 degrees F. The Blink their costs along with estimated times. For those interested in fi tness XT is smaller than a modern cellphone and is powered by 2 AA and wellness, the suggested options also take into consideration batte ries for up to two years, but it can also be powered with a USB the number of estimated calories burned with the various modes cable. By connecting to its sync module (which can support up to of transportation. Once an option is selected, the app will provide 10 cameras) wirelessly, the Blink XT can record, store and stream detailed directions and notifi cations on how to get to a destination. video to users’ cellphones via a mobile app. The app can also be installed on Apple Watch and Android Wear devices to provide the same directions and notifi cations in real The app itself is minimalistic to a fault. Features like the scheduler, time. If a transit option involves a paid service such as Uber or Lyft, snapshot updating and device management can be challenging Citymapper will link to its corresponding installed app and provide to fi nd. Despite those challenges, setting up and using the Blink a seamless experience to book a ride. This app is only useful for XT system requires only a basic set of tools if a user desires their travelers who are not tied to a static mode of transportation aside from cameras to be mounted. Finding the appropriate range to cover a personal bicycle. For example, those who own their own vehicle will a property can be tricky as the Blink XT requires it to be both in not be able to incorporate the app into a commute because personal range of its sync module and a strong Wi-Fi signal. In day-to-day vehicles are not included as a mode of transportation. practical use, the Blink XT functions as advertised, sending alerts when triggered, always recording high-quality video and remaining —Hubert Chan, DDS operational in extreme temperatures. The motion detection is a letdown: If an object moves even briskly, it is possible to trigger the Blink XT but leaves it unable to capture the object, person or event Would you like to write about technology? that triggered it. Camera placement aff ects all aspects of the camera Dentists interested in contributing to this section should contact greatly, as there are ideal operating temperatures, data transmission Andrea LaMattina, CDE, at [email protected].

282 APRIL 2019 ®

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