IHPI Seminar: "Diabetes and Oral Health - Lessons Learned and Implications for the Future / HealthChoice

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good afternoon pleasure freedom to use today's speaker our masterson spreaded longtime colleague he was Dean at Columbia when I was in that University mission we had a lot of long stories to talk to us the idea is that mental training at the State University of New York estate and continuous training with investor medical taxes to our University impression between the Periodontology be

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served on faculty the Harvard School of Medicine Fairleigh Dickinson College of evidence and community colleges and very also serve as dean from 2009 to 2012 the beginning firm he served as a senior vice president medical center from 2006 to 2012 apparently professor department whole policy of Management at Columbia milk school can tell now this research has

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focused on diagnostic testing and risk assessment for embassies in delicious foreign all disease and systemic disease or health care needs of older adults future dental education and practice is it a savage Health Sciences Research peer through this highly partisan accomplished mentor scald moderator and seasoned administrator with lost intimidation identification or criminal dysfunction in scientific rigor but this is had one mission walking bottom

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accidents in front row diabetes accountant words implications for the future [Applause] so thank you I certainly want to thank Peter for the invitation to come back to the University of Michigan it's always good to start with a little bit of a story so the last time I was here I had an hour off at some point and I went to the university mission books bookstore and I was looking at it was very

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football oriented and I thought that was great so I was looking through this book I guess is a book of all the games played by the University of Michigan football team and lo and behold I find a game between Michigan diversity of Michigan Columbia University I think was actually the Rose Bowl in the 30s and Columbia lost but something like 21 14 if they play today I don't think the score would be quite dead today close so let me just tell you one other a club university football story or

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antidote I was at a meeting once with one of the former presidents of Columbia University and this was during the time that Columbia's football team had lost 44 games in a row there was a lot of heat even the New York Times was picking up on 44 losses you know with the Ivy League and I remember him saying as long as the number of Nobel laureates associated with Columbia exceeds the number of losses I was fine with that I think oh my god how how Ivy tower that was so those are my only two Columbia

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football stories so again I want to thank Peter for the invitation to speak today what I'm going to do given that this is a policy institute or healthcare policy and innovation is kind of go through a historical perspective on how I came to be where I was or at where I am I began like most of us as an assistant professor at the Medical Center I wanted to achieve Kenya I wanted to do my research how did I end up thinking

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about the future of the of the dental profession I think you'll see given the sort of path I've drawn on how that occurred like this there we go so I've titled it diabetes and oral health lessons learned in implications for the future of the demo profession so this is a I don't know how many of you here are dentists but this is a an intraoral view of a patient who

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on the palatal surface of a patient who has periodontal disease and you can see here this this is the normal appearing tissue and you can see this sort of demarcation between the sort of normal appearing paddled tissue and the sort of granulomatous tissue here and you also can see evidence of absolute so how many of us who are clinician clinically will look back and say who was the patient or what was the event that sort of brought you down a path and for me it was actually this patient I was in practice part time practice and this patient

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shows up in my office and I didn't quite know what this was the patient had periodontal disease obviously and I'm a periodontist but but I didn't really know what was going on here and I looked at the medical history as because we would and there was no indication but what I came to learn as a patient was evaluated is this is really that the classical signs of diabetes mellitus in the oral cavity and it was described in the French literature probably 175 years ago that you had this granulomatous

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replacement and abscess formation but at the time I didn't know it I was fascinated by this patient in in many ways as sort of led to research that has gone on for the last twenty five years so my understanding is their number of people in this audience who know a lot about diabetes mellitus let me just go over some some facts as they come from the Center for Disease Control and Prevention 9.3 percent of the population have diabetes mellitus this is across

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all age groups and about interesting enough about 28% of them what 28% of them excuse me 28% of them are are not are undiagnosed and then the question of how many of you diagnosed a well-managed is another issue so it's obviously a very major healthcare concern in the United States and really across the globe and if you break this down on the basis of age in fact things get worse as people get older and here at 45 to 64 year olds you can see it's it's the

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percent who have diabetes about 16 percent and by the time you're an older adult or the older adult population it's about one in form and have diabetes mellitus and you can see the differences bye-bye by sex so what are the medical complications again I'm just going to spend just a minute on this early complications include retinopathy nephropathy and end-stage renal disease the primary reason for kidney transplants in the United States macro vascular disease heart attacks strokes

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peripheral and autonomic neuropathy impaired wound healing and in 1993 Harold Lowe who was the director of the nidcr at that time had proposed periodontal disease as actually the sixth complication the dental profession accepted that unfortunately our colleagues in medicine have yet to accept it but they are beginning to acknowledge that it can become a real problem in a patient who's poorly managed but what about the oral manifestations I'm trying to build a case here for why diabetes mellitus is particularly

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important for for for people in the oral healthcare field but also should be considered by people who were in healthcare in general what are the oil complications of diabetes notice and actually there are many so the first thing that perhaps the most important is periodontal disease and diabetes mellitus is the only recognized systemic risk factor for periodontal disease so the only cigarette smoking we also know as an important risk factor for for periodontal disease but that's more environmental well we also see an increase in dental caries and people who

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have periodontal disease specifically excuse me who have diabetes knows specifically caries or decay it on the roof surfaces then we also see this tetrad of findings that tend to come together salivary dysfunctions xerostomia so they get dry mouth and this is not related to medication related to the disease taste the neuro sensory disorders can been infection which may be as a result of celebrators function or low salary flow and then burning mouth syndrome which also could

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be a result of Candida infection there's also altered tooth eruption in children with diabetes mellitus there are teeth tend to erupt a little bit sooner than a child who does not have diabetes mellitus and lastly and there are others on this list but all this limit is here in a person who has diabetes mellitus for extended period of time some people begin to show this is parotid swelling bilateral swelling which is is a benign process but can be quite disfiguring in some individuals so

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so who is the dental profession never say dental session to know a great deal about diabetes mellitus and what to look for in the oral cavity but also there's a concern in the patient who is well managed perhaps too well managed that hypoglycemia could result while we're providing dental services and this can be quite upsetting both to the patient and to the provider if there's a hypoglycemic episode so again it speaks to the issue a need for for oral healthcare providers to be very familiar with diabetes mellitus and this is

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typically the patient who is is very well controlled taking their medication may not have eaten before they come to then office and then quietly the glucose level Falls to great you know but 15 milligrams percent of their about so what are the lessons that I've learned let me go through all this that was kind of background the first question and this really again came from that patient who who I showed you in the very first slide what are the mechanistic links to other complications that I was

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interested in inflammation I'm a paradise my area of research was in inflammation I was working in inflammatory mediators in different biological fluids different oral fluids we said you know maybe there's something here maybe there's something that needs to be to be looked at so if you look at the literature back in 1990s why do people who have diabetes mellitus get more periodontal disease it was attributed to poor wound healing it was very very vague and not descriptive so I was able to identify at Colombia's Medical Center a

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colleague anne-marie Schmidt who some of you may know her name she actually had done a great deal of work working with David Stern on the advanced glycation end-products and she characterized the receptor for advanced vocation and product and and what you see here is kind of what occurs you have a reducing sugars such as glucose will combine with proteins non-enzymatic alee so it's not limited by the enzyme it's limited really by the amount of reducing sugar that's present they form a series of chemical change of shift basement

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imadori products and ultimately disease advanced glycation end-products which really are pro-inflammatory and you find receptor receptors for advanced vacation end products on macrophages and endothelial cells and other cells but in the oral cavity and in the periodontium the macrophages and endothelial cells are probably particularly important so they tend to stimulate an inflammatory response and here's just a mechanism you have rage on the surface of the cell and age then binds with that and through an NF kappab NF kappa-b mechanism you begin

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to generate these inflammatory mediators TNF alpha il-6 etc all of the all of these the cytokines and Flemington media's are familiar with so in thinking about this and thinking about anne-marie's work we said well we really need to learn more about the role of advanced location end products and periodontal disease so we developed a mouse model of accelerated periodontal disease in diabetes mellitus so what we did is we took a standard strain of

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animal mouse and we made them diabetic by giving them shipped to us at Ocean I miss created a relative insulin deficiency as the beta cells were were eliminated we then gave in certain groups and I'll show you the four combinations they're pretty straightforward they give them an oral infection with poor families ginger valves which is an organism that has been linked to human periodontal disease and periodontal disease and other types of mammals as well and then we would sacrifice them over a period of time one two and three months

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and we looked at both the bone level that the periodontal bone the alveolar bone and we also looked at the tissue to see what what we could find so the mandibles were dissected the slides were scanned and images were analyzed and this is the kind of thing we would see so here would be a control animal and this would be the lingual surface of the lower jaw these would be the teeth and this would be the crown portion this would be the root portion and we actually measured the area within

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each of these of these without doing the crest of the bone and the cementoenamel junction here you can see a control animal and just for representation you can see a test animal in which there was been more of almost it was really quite a quite a precise and an elegant model and this was the data and I don't want to spend too much time with this because again I'm trying to bring you down this this path so we had we had three four combinations we had animals that were not diabetic and did not receive infection with animals that had been made diabetic that did not receive

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infection animals that were not diabetic and had infection at animals that had boat as you can see here the greatest amount of bone loss and this was this is depicted through that that we use that program to identify those odd of shapes or actually the area within the odd shape you can see that when there was double hit off the infection as well as diabetes mellitus present the amount of bone loss was significantly above any of the other combinations and it had a very nice stepwise kind of progression we

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looked at the tissue for levels of inflammatory mediators associate with periodontal disease and the the MMPs that makes Excel proteinaceous levels were off tuna alpha levels were high all six seven levels were so clearly the inflammation was closely linked to the progression of bone loss and this was related to levels of age and rage so we developed this model or conceptualized this model based on our data and other people's data that you had a bacterial infection in there

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mouth is always infected you had this enhanced tissue inflammation as a result of this rage mediated phenomenon you'll get to see tissue destruction but then others had shown there was a reduced number in fibroblasts and other cells that were involved in repair likely related to enhanced apoptosis and this this model is the one I think that's currently accepted as as positive those it explains the enhanced periodontal disease and patients with

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diabetes mountain so that was really the first step we had an animal model we think we had advanced the field but at some point you have to move into the human and we did that and it was a general understanding in the literature that that adults who had diabetes mellitus had more periodontal disease so we proposed to look at early complications of diabetes mellitus and specifically we looked at children and adolescence in in our in our diabetes center and look at the changes in the mouse that occurred in patients with diabetes modest compared to some control

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so we had children adolescence to routine six and 18 years of age we've looked at them both cross-sectionally and longitudinally for for patients and then we had a group of age matched controls and we explored mechanisms that accounted for periodontal disease the complication of diabetes mellitus I'll just show you summarizing this quickly there were quite a number of publications that came out of this the diabetes mellitus promotes periodontal destruction and children and here's a let me just sort of lay this out here are all subjects there were a total of 700 individuals in

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this sorry this thing is very very sensitive there we go there were 700 subjects and they were broken down 6 to 11 years old and 12 to 18 years old and the end here includes both the cases in control so the 350 cases 350 controlled and here was the odds ratio of having this amount of periodontal disease which is not an excessive amount but certainly more than you'd expect for all subjects for those

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that were younger comparing cases and controls and those that were older and you can see the odds ratios indicated that those with periodontal disease I'm sorry those with diabetes mellitus had more periodontal disease than those that did not have diabetes mellitus and this was statistically significant for all subjects combined for just the younger individuals and then it was approached significance for the for the 12 to 18 year old now these children we also given that we were working through the Diabetes Center we were able to have

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fundus photography we look the retina of these individuals we also looked at the kidney function and they did not manifest those early clinical signs of diabetes mellitus so the periodontal changes which were subtle but able to be visualized in the mouth were occurring very early in the disease certainly earlier than or maybe even the same time as one can argue as the early other complications and then we looked at what were the parameters that actually identify these children in fact here you can see we looked at me

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naitch' B a1c this is over two year period if they or as long as we had data for them the duration of diabetes mellitus or the BMI for age and in all cases whether you look at the entire cohort you look just the younger individuals or the older individuals it was the mean hba1c which was in keeping with other complications that what had been seen in some of the major trials such as the DC CT DC CT trial that HB I wouldn't see at least elevations about hba1c were were linked

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to complications so that was the second lesson and let me summarize all the work we had done it it was evidence of increased period on destruction in children adolescents with diabetes mellitus perdón complications occurred before other clinical complications may be out look that back and say certainly at the same time of it perhaps earlier than other complications because we didn't do kidney biopsies or anything like that we did do written photography however the elevated mean hba1c is a significant risk factor for periodontitis news

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children so we link to that and again that was in keeping with what others had found for complications in the relationship to hba1c so that was the second lesson we had gone from an animal model to a cross-sectional and short-term longitudinal trial with children adolescents and at some point we said that we've got to take this one step further and we've got to see what role can oral health care providers have an undying the in diagnosing unidentified or undiagnosed diabetes

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mellitus and this was kind of this is where the policy part really came in there were many complications that could occur in the mouth it was a variety of other reasons which I'll outline why oral health care providers dentists hygienists and others need to be aware could we really make something of this that we really be able to show that we could have an effect so we created a trial that was a cross-sectional trial with the exception of one part which I'll show you and this was a name was developed and evaluated targeted

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screening protocol for undiagnosed dysplasia via both diabetes mellitus and and pre-diabetes and patients presenting it at a dental clinic here's here's the rationale for the study so firstly the increasing prevalence of DM was acknowledged 28% of those were unidentified on diagnosed we know that the complications of DM if allowed to occur if the disease allowed to occur associated with increased morbidity and mortality in addition to enormous cost to the healthcare system we know that

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early diagnosis of BM or pre-diabetes with treatment or with some sort of intervention would reduce the complications both in intensity and frequency patients with DM have oral complications I showed you that in one of the earlier slides there were eight there they're also indication that there are changes to implants or populated aid then we'll therapy implants or at risk and patients with diabetes mellitus that oil complications of BM occur early we showed you that we showed that in the

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child in the children studied children adolescent step and successful dental care for patients at DM requires good metabolic control to avoid hypoglycemia but also we recognize that if you treat the superiority on a patient HEIs periodontitis but also at diabetes mellitus the diabetes mellitus is not well controlled the patient does not respond well the therapy so here's just an example of a kind of patient that we were interested in this was not a patient in the study so you can see here

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that it obviously been a fair amount of tooth loss also see here that the tissue inflammation is is marked and here's the palatal surface the inside surface of that same patient and you can look at the unusual again for those that are not dead assume you may not see it but the this is a lot of inflammation with unusual architecture to the tissue this is obviously been a very fulminant and rapidly progressive type of periodontal disease and this happened to be a

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patient with diabetes no is just not not in your study again here's another appearance of the mandibular anterior on the lingual surface so we created we performed a study that was was actually a really a labor of love and combined the cost so I was the Dean at the time so I could tell the clinic okay it was was okay to do this because obviously it took it interrupted the flow of clinic activities in the dental school it

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became really a challenge to finish this study when I when I left the deanship nobody wants nobody thought we should disrupt the clinic as we were but they agree to do it so let me go through this study and I think you'll see why it's important so in this first phase of the study there was 600 new patients who had come to the dental school for dental services they didn't know anything about diabetes knowledge didn't come to come there with this home sort and the entry criteria included you had to be over 40 years old if why for over 30 years old if you were

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Hispanic or non-white and this reflects obviously what occurs in in the in the population and they never had to been told that they had a history that they personally had a history of diabetes knowledge obviously they had to agree to participate in the study of the 601 that originally were screened about 90 percent 89 percent of those also answered yes to at least one of four questions and these questions where you had to have a family history of diabetes

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mellitus and and here we were talking about any family history of them didn't have to be a parent or said it could be a first cousin do you personally have hypertension do you personally ever been told you had high cholesterol and were you ever told you're overweight and obese and they had obviously agreed to participate and complete the protocol which was also going to include a complete periodontal examination and a point-of-care hba1c tested chairside hba1c test and here was the analyzer

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that we use there are a number of them there now today they're much smaller much less expensive but just to give you an idea of what we were using at the time and here's the first interesting finding from from the study of those 535 that were offered the opportunity to be in the study 96% of them agreed to participate in it because a lot of that happened at that very first visit but they also had to come back the next morning for a blood draw for a fasting

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plasma glucose so but maybe six percent of people who come for dental visit in free dental visit in our community where north of Manhattan primarily Hispanic a low SES population agreed to come back which I think this really is is really pretty remarkable see let me go back and they had to come in for a blood draw refugees they had to come back the next day so what do we find for these for these 506 individuals we found that 4.2

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percent were in the diabetes range and this is by the fpg test not by the HPA see the chairside hba1c and 32% were identified with pre in a pre-diabetes range so we thought about this and I said well maybe we can refine the algorithm because we're testing all of these people we get a lot of negatives we would actually get 64% who who are not in the range so what we're saying is that you know given this these criteria

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of age and health history we saw a yield of 36% but we wanted to improve the algorithm and the way we the first thing we looked at is what happens if we looked at the oral examination data remember they had a complete prairie dog exam which include periodontal disease as well as tooth loss and if we consider the number of the percentage teeth with a set of teeth with at least one side of five millimeters this is a an indication of the existence of some periodontal disease or they had at least four missing teeth if we added that to the

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algorithm we could improve beyond sorry about this be very sensitive we can improve the algorithm to between 73 and 92 percent yield which which made a lot of sense of here we're combining the oral data and the health history data to increase the yield and if you look at this this is the criteria to your left would be what we're used and it was specifically focused on sensitivity how many of those who had disease were identified as having disease if we

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looked at the teeth that had periodontal disease but measured by beef pockets or missing teeth we owe the sensitivity 0.73 if we combine that point-of-care hba1c we are up to 92% and we looked at just the point-of-care hba1c 75% so you can see how these numbers are fairly comparable so there did seem to be a linkage so here I am just trying to go along try to to move this forward and

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this path was was continuing we then we then expanded the study because right about this time hba1c laboratory HPLC hba1c became a for identifying pre-diabetes and diabetes mellitus so we we then added a second component to the study with the same entry criteria but the outcome was or the definitive diagnosis was provided by H V laboratory hba1c so we ended up with twelve hundred and forty

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individuals originally about 1100 of them met the criteria again the same criteria which I talked about and if you look at so the definitive diagnosis with either an X a FPGA fasting plasma glucose or the same day HPLC HPLC hba1c test that made it so much easier for the patients to come in we found and this is identified down here five point six would have been in the diabetes range

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and 35% would have been in the pre-diabetes range these are people who were just coming to a dental clinic for for dental services without any indication of a history of diabetes I'm sorry with an indication that they had diabetes mellitus so that was the third lesson I'm continuing to develop this we were running out of money at this point we had support from nidcr and then we had support from industry but we were running out of it out of funding but we

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wanted to see whether the fact that we can identify a patient who was at risk we're not diagnosing anything a person who was at risk for diabetes mellitus or pre-diabetes would take our advice and come and follow through with a medical provider to begin some sort of treatment of some sort of intervention and we had enough to do a small randomised control enough funds to do a small randomised control trial to this look at what the how the referral was was accepted by these individuals because obviously

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identifying the risk for disease or even disease and they're not getting treatment you've accomplished absolutely nothing so we refer to this as a referral pilot and medical follow-up study what we did is we took a hundred patients or one hundred impatience and we created two groups and most of these were in at least our analysis had been in the pre-diabetes range seven were in the diabetes range we divided in two groups randomly half of them received an intensive intervention we would talk to them about

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what the findings were we would give them a letter we would call their physician or their health care provider we would follow up within a week we follow up within two months to see what they have done and the other was giving a regular what we call the regular intervention and where they were told they were given a letter but we didn't follow up we did say we're going to call you in six months to come back to the dental clinic but we we didn't follow up in intensively and let me say that the results were essentially the same there's no statistical difference between the two so I'm going to lump all

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of this together and and what we stayed here is at the of this 101 patients 73 of them for about 73% returned to the dental clinic six months later we call them and said we want to see you would you come back 70% better than 70% came back and this is being they were being seen not for dental care at this return visit they were being seen for a follow-up to discuss what they had done where they had they seen a medical provider what was what was done

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and looking at this 73 percent 60 of them nearly 60 percent had seen a medical provider and a certain percent were tested etc we have all sorts of data as to what kind of intervention there was so this was pretty good we feel like this is pretty good patients especially where we were they don't always follow through on on health care advice or suggestions they it's not like we could just take them to the next room so here as a physician here's a medical provider see they actually actively had

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a seek someone out for the intensive group we tried to assist with that but we were very happy with this return of 60% return and I'm going to show you these are these are hard to assess but let me show you how the hba1c the chair side HPA one see change between the initial view and the secondary and the second view with six months and this was the these are the patients who had pre-diabetes and this is the basic group this is the intensive intense intervention group and

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you can sort of see a trend here and I'll just show you one other slide then I'll tell you about the summary statistics these were the people who were in the diabetes range and you can see that here all above 6.5 we felt that this might have been an outlier so just looking at all of these individuals might or excuse me all these as opposed to seven of them the six of the individuals taking this outlier how you can see they all went from the diabetes range above 6.5 to the pre-diabetes range so if you look at the the total

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population about sixty per about 30% of them 32% I believe improved in terms of this chair site hba1c or at least improved from let's say a pre-diabetes - to normal glycemic range or diabetes the pre-diabetes about about 32% of those improves 60% stayed in the same category and 8% actually got worse and those are people who were in normal range who then went up with it who then increased so so that was the lesson at least the the

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fourth lesson that we had learned that you could have screening for diabetes mellitus in patients who are being seen for routine dental care and that you could make a difference in terms of their accessing healthcare and beginning to address their their disclose female so the next part of the study that we picked up on was something that obviously is a great concern today in something that's concerned here in the Institute what is the economic impact of

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early diagnosis of diabetes mellitus for oral healthcare provider so you figure with early diagnosis there's going to be a saving of some sort and we were reacting to two things like this this is an infographic that had been produced by the American demo Association and they talked about screening for chronic disease within the dental office such as Peter knows and when she knows there's a determiner american dental association is a big believer in this has been moving this forward in the 88 but there's a box as

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part of this infographic and this the outline is mine we outline this it said screening for chronic diseases and dental offices could reduce US healthcare costs by up to 100 million dollars and frankly we thought this was naive because if you if you obviously if you have a person who has who identified earlier as dis glycemia they're going to go into some sort of treatment or require some sort of intervention and that's going to cost money and that doesn't seem to be considered in this

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particular particular calculation so we gauged one of the health economists at columbia idelle and we looked at the cost-effectiveness of diabetes screening initiated through a dental visit and we use the the archimedes simulation model to to identify the cost associated with treating pre-diabetes or diabetes mellitus and here you can see the cost-effectiveness of weight watchers intervention for pre diabetic population there's a whole bunch of different combinations the archimedes simulation and it is a simulation obviously that's

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a drawback because you're not actually following the patient to see what their costs would be but it's it's a well recognized and accepted algorithm we looked at the cost-effectiveness of weight watchers intubation pre-diabetic and again many many different combinations in the paper but just to show you one so that looked at quality of life years which is that what the outcome is here at a quality of life year that less than about $50,000 is considered to be cost cost-effective and obviously here we can we were getting

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below this $50,000 range and depending upon the decay in other words if the patient returned to the original weight or was able to maintain the reduced weight again this is all in the model it was amazingly cost effective but it wasn't it was with cost it was with cost you're not going to just save 100 nomes so the conclusions were the identification of persons with dyslexia in the dental office for initiating pre-diabetic care is a cost-effective means of identifying and treating effective individuals costs were noticeably higher for people with

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diabetes nas as you expect when medication starts to become involved and not just performative but some of the newer generation medications the the cost went out so so we need to be realistic you can't just say that screening in the dental office is going to save money there's going to be a cost associated with preventing the complications that will occur down the room so I and beautiful vorenii and a variety of others have begun to think about ways in which the dental profession and the practice of Dentistry

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in the United States can evolve to include other things that typically are not done and we put together a monograph engaging some people who've been thinking about this to look at a variety of different types of activities that occur in the dental office and look at the literature to suggest what could happen and if you look at this this area the whole idea of primary health care the dental office there's some people who are proposing a very broad range of

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activities from lipid screening to variety of other things this monograph attempted to look at things that were really much more relevant to the dental profession and to dental practice on the day to day basis so certainly they've talked about assessing hypertension in the dental office has been talked about for 50 years maybe maybe longer than that certainly don't want to give the epinephrine to a patient's hypertensive etc but just to go through a few of these smoking cessation oral cancer traditional oral cancer or oral cancer

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that's not HPV associated as well as periodontal disease are directly linked to smoking and you can't treat these diseases unless you get the patients stopped smoking but this is traditionally not performed not done in the dental office the idea is screening we just we just talked about obesity management dentist and oral healthcare providers know a fair amount about carbohydrate intake and the importance of diet as it relates to oral disease could therefore haps be identification of the of the

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overweight or the obese patient and whether it if the oral healthcare provider says I don't want to manage us myself may be awkward to take some of the measurements that are required they could then be a source of referral to someone who can measure measure or we could manage the obesity manager identification of osteoporosis from dental radiographs you don't use a dental radiographs to identify osteoporosis but the data already exists is already available x-rays in the devil' office and there's some interesting algorithms an

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interesting programs that have been created that show that you can with reasonable accuracy identify osteoporosis from this already existing database and lastly and there are others I mean this is an obvious one identification of suspicious dermatological Lisa we always tell our dental students don't look immediately at the piece and look at the patient look look at the ear look at the forehead look at the facial skin look at the exposed skin surfaces to see if there are our lesions that need to be of good that are of concern so I think it's

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pretty obvious that result of this shift will be improved health not just oral health and the key here for many of us is when we talk about the future of the profession is the dental profession going to continue to be siloed the way it has been for for decades and decades certainly since 1965 when it was excluded from Medicare but even before that or will we become a more important part of health care in general so it's very easy to say these things it's much

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more difficult to operationalize these things so we began to talk a little bit now and I'll just go through this very quickly exam leave some time for questions and back and forth is to think about how the dynamics of dental practice will have to change if you if you would adopt this so here's what we do currently we spend a fair amount of time not a great amount of time on diagnosis and treatment planning our interdisciplinary activities our interaction with physicians and pharmacists and nurses and social workers is pretty limited basically what

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we do is we provide dental services and and we do spend some time supervising auxiliaries most dentists have a dental hygienist in their office and there's a relationship between the two of them but in the future if this concept that we're proposing is adopted it will have to change you'll spend more time on diagnosis because it won't be just diagnoses a broad term it won't just be evaluating your oral cavity for disease and treatment planning but looking at the patient who may be at risk for four

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NCDs will spend obviously more time in interdisciplinary activities you can have to communicate with physicians and pharmacists pharmacists and diabetes educators and others will spend less time perhaps on actually providing services and here I'm talking about the dentist who spend less time providing dental services because this time has to come from somewhere and perhaps we should be giving oops perhaps we should be giving greater responsibility to auxilary so they can work to their level

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of education as well but here trying but we've learned the hard way that again you can't be naive I can get up and talk about this but how do you operationalize this well first thing you have to look at is estate practice X what are dentists or all health care providers allowed to do so I asked a student that's what students are good for they're good for many things I said them I want you to go and look at every practice act of all 50 states and what are they say the and the American Dental

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Association has defined dentistry very broadly and it is to sort of paraphrase it says diseases of the oral cavity and the mouth and contiguous structures and there's a phrase and their effect on the body from their effect on the entire and that language actually is in about half of the state practice X which gives much more leeway and about happy the other half of the states the definition is much more narrow it defines you know

42:39

repair of tooth diseases of the teeth the periodontium that said a removal third most much more prescriptive so about half the states have a very broad very broad definition and when we were thinking about I was thinking about as in my life in public health school about how do we actually bring this into practice in New York State I was thinking about a legislative approach where we get someone a legislator in the assembly or Senate to sponsor a bill and then move this forward to let's say

43:10

diabetes testing and primary health care activities and screening can be conducted in dental office I like to talk to the New York State Dental Association says that you don't need to do that because we can do it right now will defend anyone who is sued for that reason so and I had some funding from the State Health Foundation to look at this we created a brief and apparently they're they're very willing to consider this oops that are you okay so the second issue and maybe even the first issue is reimbursement no matter how much good

43:40

work how many good how much good would come out of this unless you provide reimbursement even modest reimbursement you're not going to get buy-in from the profession and the question of how do you do this is is is it is a challenge i sat on a redesign team for our Medicaid program in New York State I think it could come to a Medicaid program we have a very robust dental benefit result that they will benefit from New York and they've already approved a smoking

44:11

cessation as a compensated service in the dental office reimbursement through that mechanism as possible but a number of the insurance companies have actually started to think now innovatively about how they can provide additional dental benefits for patients with NCDs cardiovascular is diabetes mellitus obviously we're going to have to revise our dental school curriculum to prepare students to do this I think some schools it will be rather easy to do the schools that have an emphasis on basic sciences for some schools it's not going to be as easy we

44:42

feel that for those of you who do not know in many places in the United States when you graduate dental school you can go into practice if you practice a licensing exam a number of states have started to pass mandatory pgy one and this would be an ideal place to further emphasize the importance of this to bring this into the practice mentality of new dentists this is not certainly across the entire United States what about the acceptance by oral healthcare providers

45:13

survey suggests they'd be willing to do it these have been I think somewhat superficial surveys when we've looked at this in greater detail it was a lot of hesitancy really around knowledge how much knowledge the providers have in order to be able to talk intelligently and comfortably with patients about what the findings would be so this has to be addressed the acceptance by patients has been generally quite positive and again some some studies suggest the patients are are willing to go through the testing but they don't follow up in the

45:44

cases they do follow up but this has to be addressed and lastly is the acceptance by other healthcare providers how will physicians and nurse practitioners and pas and others feel about dentists doing this and at the Medical Center at least and that's probably not the best gauge something out the gauge of the community there was very good acceptance of what we're doing so I'm going to stop there I'm going to leave left about 10 minutes for questions as I said in the beginning it's really important for people like me

46:16

to hear from people like you about the concerns and the issues because we spend a lot of time talking to one another and patting each other on the back and telling each other how good an idea this is but I'd rather hear from others about about their concerns and about any questions that might arise so please question absolutely perfect argument there's no question that this should be adapted tomorrow doctor tomorrow wake up really like the be a progression for basic signs that

46:52

when you go around this is that someone who was just concerned about getting tenure originally and had moved from that into a into a school public health yes are under attack whether you thought much about that callosum all in other social physical physical environment risk factors that may be contributing the very novel to be people to be especially in the mechanical media medical centers but but well by

47:22

ecological model you're referring to access to care and to yeah there's no question that that it comes into play but in the study of 1,100 people they would they were the same people coming from the community they didn't differ in terms of their ethnicity in terms of sex the apparent all diseases complicated the complex needs but there's no question that I think mellitus is a risk factor the only systemic diseases are respected or for carried on busy smoking exist to

47:52

but the hoops did not differ in terms of their smoking history so so I think yes I think there are unanswered questions in the model but the reality is we identify 40 percent of the people who are dyslexic and any whether it's pre-diabetes is really something that many people in beacon so it was we encountered some of that actually seventy Somali came back you know what is your position or closing position some cases it was a spectacle think about this and in some cases they sell

48:23

don't worry about that you know you're not six point five we tell you how to scale those you really don't have to worry about it now we'll worry however these are people with an economically distressed areas and a lot of things that we really concern with but III don't think I think this important issue basically is a religious question and you know that there are a position for

48:52

example care imagine that there are very high rates of diabetes in creating networks not able to process it was experience of the release of the environment about a principle don't necessarily have dental coverage but may have medical coverage whether there's a way to them in Korea to dissident love it I got there we used to get their care cover Norfolk covers but they're kind of caught either so I'm not quite sure I understand the question but let me try

49:25

to answer right I think we're asking is not good you correctly checked I think that one of the things we know is a patient with diabetes if you can look at pace with diabetes mellitus and how often he was with the ophthalmologist the podiatrist and the dentist they visit the dentist release all of those other providers and below the national average and I think that's the cost their medical providers are not sending the message about ahead your eyes ship you got ahead you also need to have great opportunity

49:55

so we started a dialogue racing with the American Association of daiyousei teams figuring it may be that the endocrinologist for primary care physician the family physician to busy the diabetes education know about this and make it by spreading spreading the word so part of it is is the whole issue of access to care and if you're asking if the people who don't see a physician or not are also not going to see a Deadhead I think there's sort of some some truth to that we just completed a study with the New York City Department

50:25

of Health and Mental Hygiene to look at primary care visits medical visits and dental visits it is part of a New York City survey and a surprisingly high number I don't have the data so I want to quote specifics I don't have to forget that it was probably behind under people have dental visits in New York City but it did not have many ways that's not 90% it could be 10 or 15% so even if you catch some of those numbers some of those would be not going to catch everyone where you can catch a

50:56

nuts where it could could impact and obviously with follow-up you're going to convince I don't actually give you a little bit in addition to cares about about dental insurance Inagaki there are more weeks agenda coverage of our medical investment of these barriers and status people accidentally certainly true but in our area Medicaid is a major provider insurer and what's interesting and maybe sacred in your question is we looked at

51:28

the utilization of medical services and dental services in our catchment area for people with Medicaid and about 85% of them on an annual basis access medical care and about 45% increase at utilizing or access dental even though they had insurance but across the country there's no question that what people have medical coverage and the dental coverage these are going to get care to be getting worse and not better but even if we catch the 45% or have

51:59

access to 45% and I'm not even talking here about the people who who have a core where the diagnosis sort of poorly managed this so that are not were not diagnosed they have been identified I think this bequeath the model flying different ways that we actually talk to you if they have foundation about a an approach that can be in dental offices where you have just a simple little stand up about asking dentists about diet use in the mouth so I think they're

52:30

all with different ways it needs to be a more defined side perhaps not a not a question but a comment and certainly appreciate your presentation I thought it was really quite good from basic signs to the clinic as a piece I'm concerned about the dramatic increase of diabetes in our country and it's related to lifestyle dietary issues and so forth so from a public health perspective it's all

53:06

running good that we're trying to identify people with diabetes but probably as a country as a whole we need to be focusing to a great extent on preventing people from getting diabetes in the first place so I think this is a great step forward but we need to kind of grants also look at a bigger picture so if I didn't know better I would get a typing question because one of the things that we've been looking at now is

53:37

how do you improve oral hygiene because we know that patients don't listen to us when we tell them and what are the approaches that we're considering now is providing a lifestyle message in their dental illness because if you go back to this slide whether it's whether it's personal hygiene or diet or exercise they all fit in pretty nicely with a number of these smoking cessation they

54:08

all fit in pretty nicely with this model right not exactly and here you can say we're toasting my oral hygiene but the fertilizer clear up is your lifestyle and any smoking cessation and weight and diet so there's a message that can be delivered by oral health care providers I fit into this new model in dental practice that is in perfect agreement fallacious so the one slide read that one right here if you go back to that slide where you showed a different distribution of

54:42

time in future so one possibility maybe the community educating different types of dentists notices that they actually invest much more time of diagnosis the patient education and let that services the vegetative expanding group of for-profit health schools and hold that do not invest in research and discovery which we kind of be important to giving to educate the students be able to function and that's group in that sort of domain of primary care is it

55:13

possibility that we're actually dealing with the Terek level of dental practitioner you know i mean i can i I realize it that's heresy but frankly have to reduce my site anonymity you know dr. pol reading history is outlawed in eight state to mandate a intent of putting a state requesting of course I but I think you're exactly right I mean it's any heresy to say that we educate Nathan two types of is more of

55:43

the mechanical menace and more of the somme ecologist I think that's a hard sell but it's what's happening organically right the schools like Columbia and Michigan and Harvard and Penn why they're educating students to a broader the broader mindset then you have these other schools the schools are not affiliated with allopathic medical school and medical centers that are doing a bunch of providing much more than technical mechanical type of way

56:15

education and why know is that we've got to change if we keep doing what we've done for the last 100 years of me as a profession we're going to be relegated to the to the allied health world and not where I think we should be in many of us feel we can make a difference and that simply has to be a reality I think how we doing then I have some very preliminary discussion I think it's got to be more of a soft sell at least initially what the message is the right can't people will need a certain

56:46

training which is education in order to be able to adopt we remodel a you know one of the things that I always hear when I present this is well we don't generate any ink on board with people to production income from a case study one when I was in practice I know I've had some diabetes not only practicing it a day a week but I would see a fair number people with diabetes mellitus referred by physicians the pointed it's an opportunity to have a new patient so we

57:18

know that 40% only 40% of adults take 42 percent of adults today see it ends in a year's time I mean even if we increase that seven or eight percent because of this flow between medical providers respected physicians etc and in dental offices there alone will will make up in volume what we might be able but we're maybe losing because obviously this is where the income generally the larger procedures there's reconstructive procedures to the implants this is where the money comes

57:49

in and the reality is this could be used to fund the other thing too and Plus this whole issue of what are what are what other members of the dental team are actually doing in it is really really very very important and it's a too much time doing things that the Train much more quite right there the sort of procedures that we do not need someone all that education well thank

58:20

you good questions and again I appreciate the opportunity to present this in a in this day you would turn a distinguished University and again I thank to you for [Applause]

IHPI Seminar: "Diabetes and Oral Health - Lessons Learned and Implications for the Future

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