Dental Therapists in the United States: Health Equity, Advancing.

BACKGROUND: Dental therapists (DTs) are primary care dental providers, used globally, and were introduced in the United States (US) in 2005. DTs have now been adopted in 13 states and several Tribal nations. OBJECTIVES: The objective of this study is to qualitatively examine the drivers and outcomes of the US dental therapy movement through a health equity lens, including community engagement, implementation and dissemination, and access to oral health care. METHODS: The study compiled a comprehensive document library on the dental therapy movement including literature, grant documents, media and press, and gray literature. Key stakeholder interviews were conducted across the spectrum of engagement in the movement. Dedoose software was used for qualitative coding. Themes were assessed within a holistic model of oral health equity. FINDINGS: Health equity is a driving force for dental therapy adoption. Community engagement has been evident in diverse statewide coalitions. National accreditation standards for education programs that can be deployed in 3 years without an advanced degree reduces educational barriers for improving workforce diversity. Safe, high-quality care, improvements in access, and patient acceptability have been well documented for DTs in practice. CONCLUSION: Having firmly taken root politically, the impact of the dental therapy movement in the US, and the long-term health impacts, will depend on the path of implementation and a sustained commitment to the health equity principle.

Implementing care coordination in a large dental care organization in the United States by upskilling front office personnel.

BACKGROUND: Care coordination is a key strategy used to improve health outcomes and efficiency, yet there are limited examples in dentistry. A large dental accountable care organization piloted care coordination by retraining existing administrative staff to coordinate the care of high-risk patients. Following the pilot's success, a formal "dental care advocate" (DCA) role was integrated system-wide. The goal of this new role is to improve care, patient engagement, and health outcomes while integrating staff into the clinical care team. We aim to describe the process of DCA role implementation and assess staff and clinician perceptions about the role pre- and post-implementation. METHODS: Guided by the Consolidated Framework for Implementation Research, semi-structured interviews with clinical and operational administrative staff and observation at the company-wide training session were combined with pre- and post-implementation electronic surveys. Descriptive statistics and mean scores were tested for significance between each survey sample (t-tests), and qualitative data were thematically analyzed. RESULTS: With preliminary evidence from the pilot and strong executive support, a dedicated leadership team executed a stepwise rollout of the DCA role over 6 months. Success was facilitated by an organizational culture of frequent interventions deployed rapidly through a centralized system, along with supportive buy-in from managerial teams and high staff acceptance and enthusiasm for the DCA role before implementation. Following implementation, significant changes in attitudes and beliefs about the role were measured, though managers held stronger positive impressions than DCAs. DCAs reported high confidence in new skills and dental knowledge post-implementation, including motivational interviewing and the ability to confidently answer patients' questions about their oral health. Overall, the fast-paced implementation of this new role was well received, although consistent and significant differences in mean attitudes between managers and DCAs indicate more work to fine-tune the role is needed. CONCLUSIONS: Successful implementation of the new DCA role was facilitated by a strong organizational commitment to team-based dentistry and positive impressions of care coordination among staff and managers. Upskilling existing administrative staff with the necessary training to manage some high-risk patient needs is one method that can be used to implement care coordination efforts in dentistry.

Developing and Testing Electronic Health Record-Derived Caries Indices.

Caries indices, the basis of epidemiologic caries measures, are not easily obtained in clinical settings. This study's objective was to design, test, and validate an automated program (Valid Electronic Health Record Dental Caries Indices Calculator Tool [VERDICT]) to calculate caries indices from an electronic health record (EHR). Synthetic use case scenarios and actual patient cases of primary, mixed, and permanent dentition, including decayed, missing, and filled teeth (DMFT/dmft) and tooth surfaces (DMFS/dmfs) were entered into the EHR. VERDICT measures were compared to a previously validated clinical electronic data capture (EDC) system and statistical program to calculate caries indices. Four university clinician-researchers abstracted EHR caries exam data for 45 synthetic use cases into the EDC and post-processed with SAS software creating a gold standard to compare the -VERDICT-derived caries indices. Then, 2 senior researchers abstracted EHR caries exam data and calculated caries indices for 24 patients, allowing further comparisons to VERDICT indices. Agreement statistics were computed among abstractors, and discrepancies were resolved by consensus. Agreement statistics between the 2 final-phase abstractors and the VERDICT measures showed extremely high concordance: Lin's concordance coefficients (LCCs) >0.99 for dmfs, dmft, DS, ds, DT, dt, ms, mt, FS, fs, FT, and ft; LCCs >0.95 for DMFS and DMFT; and LCCs of 0.92-0.93 for MS and MT. Caries indices, essential to developing primary health outcome measures for research, can be reliably derived from an EHR using VERDICT. Using these indices will enable population oral health management approaches and inform quality improvement efforts.

Systematically assessing the quality of dental electronic health record data for an investigation into oral health care disparities.

OBJECTIVES: This work describes the process by which the quality of electronic health care data for a public health study was determined. The objectives were to adapt, develop, and implement data quality assessments (DQAs) based on the National Institutes of Health Pragmatic Trials Collaboratory (NIHPTC) data quality framework within the three domains of completeness, accuracy, and consistency, for an investigation into oral health care disparities of a preventive care program. METHODS: Electronic health record data for eligible children in a dental accountable care organization of 30 offices, in Oregon, were extracted iteratively from January 1, 2014, through March 31, 2022. Baseline eligibility criteria included: children ages 0-18 with a baseline examination, Oregon home address, and either Medicaid or commercial dental benefits at least once between 2014 and 2108. Using the NIHPTC framework as a guide, DQAs were conducted throughout data element identification, extraction, staging, profiling, review, and documentation. RESULTS: The data set included 91,487 subjects, 11 data tables comprising 75 data variables (columns), with a total of 6,861,525 data elements. Data completeness was 97.2%, the accuracy of EHR data elements in extracts was 100%, and consistency between offices was strong; 29 of 30 offices within 2 standard deviations of the mean (s = 94%). CONCLUSIONS: The NIHPTC framework proved to be a useful approach, to identify, document, and characterize the dataset. The concepts of completeness, accuracy, and consistency were adapted by the multidisciplinary research team and the overall quality of the data are demonstrated to be of high quality.

American Indian/Alaska Native, Black, and Hispanic dentists' experiences of discrimination.

OBJECTIVE: Little is known about the scope and role of discriminatory experiences in dentistry. The purpose of this study is to document the experiences that American Indian/Alaska Native (AI/AN), Black, and Hispanic dentists have had with discrimination. METHODS: This study reports data from a 2012 nationally representative study of dentists documenting experiences with discrimination during their dental careers or during dental school by the setting of the discrimination, the providers' education, and geographic location. This study does not differentiate between levels of discrimination and focuses holisticly on the experience of any discrimination. RESULTS: Seventy-two percent of surveyed dentists reported any experience with discrimination in a dental setting. The experiences varied by race/ethnicity, with 49% of AI/AN, 86% Black, and 59% of Hispanic dentists reporting any discriminatory experiences. Racial/ethnic discrimination was reported two times greater than any other type. CONCLUSIONS: Experiences with racial/ethnic discrimination are prevalent among AI/AN, Black, and Hispanic dentists, suggesting that as a profession work is needed to end discrimination and foster belonging.

Practice patterns of postgraduate trained dentists in the United States.

OBJECTIVE: Postgraduate dental (PGD) primary care training has grown significantly. This study examines the individual, educational, community, and policy factors that predict practice patterns of PGD-trained dentists. STUDY DESIGN: Individual dentist records from the 2017 American Dental Association Masterfile, with indicators of Medicaid participation and practice in a Federally Qualified Health Center (FQHC), were linked to postdoctoral training, community/practice location, and state policy factors. Generalized logistic models, adjusted for these factors, were used to predict PGD-trained dentists: (1a) serving Medicaid children, (1b) accepting new Medicaid patients, and (2) working in an FQHC. RESULTS: Individual attributes that predicted serving Medicaid children included all race/gender combinations (vs. White females), and foreign-trained dentists and contractors/employees/associates (vs. practice owners). Black women are most likely to work in an FQHC. Residency attributes that predicted serving Medicaid children and working in an FQHC were Health Resources and Services Administration postdoctoral funding and being community based. Dentists practicing in rural or high-poverty communities were more likely to serve Medicaid children and work at FQHCs. States with higher levels of graduate medical education investment, higher Medicaid rates, and more generous adult dental Medicaid benefits increased the likelihood of serving Medicaid children, while states with more expansive adult dental Medicaid benefits increased the likelihood of working in an FQHC. CONCLUSION: Federal training investment in PGD education combined with Medicaid payment and coverage policies can strongly impact access to dental care for vulnerable populations. Yet, oral health equity cannot be achieved without increasing dentist workforce diversity.

Trends in postgraduate dental training in the United States.

OBJECTIVE: This study examines the individual, educational, and policy factors that predict dentists pursuing postgraduate dental (PGD) training. METHODS: Individual dentist records from the 2017 American Dental Association Masterfile were linked with pre-doctoral training attributes and state-level dental policy factors. Generalized logistic models, adjusted for individual, educational, and policy factors, were used to predict: (1) attending any PGD program, and (2) primary (i.e., advanced general practice, pediatrics, or dental public health, per the Health Resources and Services Administration [HRSA]) versus specialty care. RESULTS: The majority of new PGD residency slots (77%) were in primary care. Women held 56% of primary care slots; men held 62% of specialty slots. Individual characteristics that predicted PGD primary care training included being Black, Hispanic, Asian, or other race; being male or older age reduced the odds. Pre-doctoral school characteristics that predicted PGD primary care training included having a pre-doctoral HRSA grant, affiliation with an academic medical center, and being a historically Black college/university; being a private school or in a small metro area lowered the odds. At the policy level, the strongest predictors of attending PGD primary care training are a residency requirement in the state you currently practice in and federal graduate medical education (GME) investment per residency slot. CONCLUSION: Pursuing PGD training is variable based on the race/ethnicity/gender of the dentist. Federal investments in pre-doctoral dental education and GME can drive equity, as they significantly increase the odds that dentists will go on to PGD training, as do state licensure requirements.

Tracking oral health in a standardized, evidence-based, prevention-focused dental care system.

OBJECTIVES: Learning health-care systems are foundational for measuring and achieving value in oral health care. This article describes the components of a preventive dental care program and the quality of care in a large dental accountable care organization. METHODS: A retrospective study design describes and evaluates the cross-sectional measures of process of care (PoC), appropriateness of care (AoC), and outcomes of care (OoC) extracted from the electronic health record (EHR), between 2014 and 2019. Annual and composite measures are derived from EHR-based clinical decision support for risk determination, diagnostic and treatment terminology, and decayed-missing-filled-teeth (DMFT) measures. RESULTS: Annually, 253,515 ± 27,850 patients were cared for with 618,084 ± 80,559 visits, 209,366 ± 22,300 exams, and 2,072,844 ± 300,363 clinical procedures. PoC metrics included provider adherence (98.3 percent) in completing caries risk assessments and patient receipt (96.9 percent) of a proactive dental care plan. AoC metrics included patients receiving prevention according to the risk-based protocol. The percent of patients at risk for caries receiving fluoride varnish was 95.4 ± 0.4 percent. OoC metrics included untreated decay and new decay. The 6-year average prevalence of untreated decay was 11.3 ± 0.3 percent, and average incidence of new decay was 13.6 ± 0.5 percent, increasing with risk level: low = 7.5 percent, medium = 18.8 percent, high = 29.4 percent, and extreme = 28.1 percent. CONCLUSIONS: The preventive dental care system demonstrates excellent provider adherence to the evidence-based prevention protocol, with measurably better dental outcomes by patient risk compared to national estimates. These achievements are enabled by a value-centric, accountable model of care and incentivized by a compensation model aligned with performance measures.

The Impact of Federal and State Policy on Oral Health Care Delivery in Long-Term Care Settings.

Residents of long-term care (LTC) facilities have a significantly higher risk of poor oral health status compared with those living independently; moreover, the provision of oral health services to LTC residents is often limited. This study identifies and classifies state-level policies and funding sources for dental services that are available to LTC residents. The research details variability in coverage levels, payment sources, workforce capacity, and care delivery configuration, finding little coherence between policy and the needs of patients or providers. Reforms to address the oral health care needs of vulnerable populations in LTC settings should start with defining a clearer standard of oral care required for this population. This will allow best practices in policy, practice, and accountability to be structured around care that improves patients' oral health.

Underrepresented Minority Dentists: Quantifying Their Numbers And Characterizing The Communities They Serve.

The underrepresentation of Blacks, Hispanics or Latinos, and American Indians or Alaska Natives among dentists raises concerns about the diversity of the dental workforce, disparities in access to dental care and in oral health status, and social justice. We quantified the shortage of underrepresented minority dentists and examined these dentists' practice patterns in relation to the characteristics of the communities they serve. The underrepresented minority dentist workforce is disproportionately smaller than, and unevenly distributed in relation to, minority populations in the United States. Members of minority groups represent larger shares of these dentists' patient panels than of the populations in the communities where the dentists are located. Compared to counties with no underrepresented minority dentists, counties with one or more such dentists are more racially diverse and affluent but also have greater economic and social inequality. Current policy approaches to improve the diversity of the dental workforce are a critical first step, but more must be done to improve equity in dental health.

A fully automated microfluidic femtosecond laser axotomy platform for nerve regeneration studies in C. elegans.

Femtosecond laser nanosurgery has been widely accepted as an axonal injury model, enabling nerve regeneration studies in the small model organism, Caenorhabditis elegans. To overcome the time limitations of manual worm handling techniques, automation and new immobilization technologies must be adopted to improve throughput in these studies. While new microfluidic immobilization techniques have been developed that promise to reduce the time required for axotomies, there is a need for automated procedures to minimize the required amount of human intervention and accelerate the axotomy processes crucial for high-throughput. Here, we report a fully automated microfluidic platform for performing laser axotomies of fluorescently tagged neurons in living Caenorhabditis elegans. The presented automation process reduces the time required to perform axotomies within individual worms to ∼17 s/worm, at least one order of magnitude faster than manual approaches. The full automation is achieved with a unique chip design and an operation sequence that is fully computer controlled and synchronized with efficient and accurate image processing algorithms. The microfluidic device includes a T-shaped architecture and three-dimensional microfluidic interconnects to serially transport, position, and immobilize worms. The image processing algorithms can identify and precisely position axons targeted for ablation. There were no statistically significant differences observed in reconnection probabilities between axotomies carried out with the automated system and those performed manually with anesthetics. The overall success rate of automated axotomies was 67.4±3.2% of the cases (236/350) at an average processing rate of 17.0±2.4 s. This fully automated platform establishes a promising methodology for prospective genome-wide screening of nerve regeneration in C. elegans in a truly high-throughput manner.

The role of TGF-ß and myofibroblasts in the arteritis of Kawasaki disease.

Inflammation of medium-sized, muscular arteries and coronary artery aneurysms are hallmarks of Kawasaki disease (KD), an acute, self-limited vasculitis of children. We previously reported that genetic variation in transforming growth factor (TGF)-ß pathway genes influences both susceptibility to KD and coronary artery aneurysm (CAA) formation. TGF-ß signaling has been implicated in the generation of myofibroblasts that influence collagen lattice contraction, antigen presentation, and recruitment of inflammatory cells as well as the generation of regulatory T-cells (Tregs). These processes could be involved in aneurysm formation and recovery in KD. Coronary artery tissues from 8 KD patient autopsies were stained to detect proteins in the TGF-ß pathway, to characterize myofibroblasts, and to detect Tregs. Expression of proteins in the TGF-ß pathway was noted in infiltrating mononuclear cells and spindle-shaped cells in the thickened intima and adventitia. Coronary arteries from an infant who died on Illness Day 12 showed α-smooth muscle actin (SMA)-positive, smoothelin-negative myofibroblasts in the thickened intima that co-expressed IL-17 and IL-6. CD8+ T-cells expressing HLA-DR+ (marker of activation and proliferation) were detected in the aneurysmal arterial wall. Forkhead box P3 (FOXP3), whose expression is essential for Tregs, was also detected in the nucleus of infiltrating mononuclear cells, suggesting a role for Tregs in recovery from KD arteritis.TGF-ß may contribute to aneurysm formation by promoting the generation of myofibroblasts that mediate damage to the arterial wall through recruitment of pro-inflammatory cells. This multi-functional growth factor may also be involved in the induction of Tregs in KD.

Kawasaki disease in monozygotic twins.

Multiple lines of evidence suggest that susceptibility to Kawasaki disease (KD) is influenced by host genetics. Subclinical coronary artery vasculitis may be present in monozygotic twins who are discordant for clinical signs of KD. Health care providers should consider laboratory testing and echocardiography in both monozygotic twins when only one twin presents with clinical KD.