Cultural Awareness and Technology: The Core of Dental Care Transformation with Dr. Scott Howell, Director of Public Health Dentistry and Teledentistry for Arizona School of Dentistry & Oral Health

[00:00:04] Welcome to Think Oral, where we connect the unconnected between oral and physical health.

[00:00:10] I'm your host, Dr. Jonathan Levine, and I'm your host, Maria Filipova.

[00:00:15] Let's get at it!

[00:00:21] Hello everyone and welcome to another exciting episode of the Think Oral Health podcast

[00:00:27] where myself and Dr. Jonathan Levine spotlight leaders in healthcare policy technology

[00:00:35] in oral health that bridge the gaps and build bridges across silos.

[00:00:41] We're very pleased today to welcome our next conversation partner for this exciting topic

[00:00:48] today, Dr. Scott Howell. Scott, welcome to the podcast.

[00:00:52] Thank you so much. I'm so excited to be here.

[00:00:55] I will start by doing a brief introduction to you, Scott. We're very grateful to have you.

[00:01:02] You're not only an associate professor and director of public health dentistry and teledentistry at

[00:01:07] Arizona School of Dental and Oral Health. You also serve as a clinical advisor for

[00:01:12] mouthwatch and teledentistry platform and a senior Atlantic Fellow for Health Equity.

[00:01:18] We're very pleased to have you because of your notable academic career,

[00:01:23] but also because of the fact that your work in overseeing dental programs

[00:01:28] provide care for individuals experiencing homelessness, teenagers in county detention,

[00:01:34] and men coming out of prison going through substance use treatment and counseling.

[00:01:38] Your stellar career is very impressive, but your role in the community and offering access,

[00:01:46] bridging bringing access to dental care to some of the underserved communities is even

[00:01:51] more impressive than that. So thank you for all you do and thank you for joining us on

[00:01:55] the podcast today. Yeah, I'm thrilled to get to talk about some of the work I'm doing and also

[00:02:00] get to talk with you both. Thank you. Thank you. Those of our listeners who are frequent listeners

[00:02:07] to this podcast have heard me and Jonathan describe ourselves as troublemakers for good.

[00:02:14] You squarely fall in that category. In fact, I know we know that you have gotten yourself

[00:02:20] in trouble. Fun fact with the military not in any other country, but in North Korea.

[00:02:28] So sounds like you are a troublemaker, both in your professional life, but also as a tourist.

[00:02:34] So do tell us a little bit about how you got in trouble with the authorities in North Korea.

[00:02:40] So I had the amazing opportunity to actually teach and live in South Korea for about a year

[00:02:46] and a few months. And it was absolutely amazing opportunity just I always tell people if I'm going

[00:02:52] to get a tattoo one day, it's going to say I found happiness in Korea and it'll be in Korean and we'll

[00:02:57] say, 한국에서 행복을 찾았어 because it was just an amazing opportunity for me to explore

[00:03:03] the world. Well, I had an opportunity then to go to North Korea. This was back in 2007,

[00:03:09] I want to say, and the relations between the two countries were very different at that time.

[00:03:14] But you still had to be very careful where you took pictures and it was in the Gungang Mountain

[00:03:19] region, very famous mountain area of North Korea. And our tour guide from South Korea said, hey,

[00:03:25] let's take a picture here. And it was in front of this sign in Korean that said,

[00:03:30] we'll do it our own way more or less. And all of a sudden from the woods,

[00:03:35] you could hear whistles being blown at us because there were soldiers watching us every

[00:03:39] step of the way and we had no clue they were there. And our guide was like, okay, go. And what's

[00:03:43] terrifying is like those can turn into really bad situations. So I'm very grateful it didn't,

[00:03:49] but it was such a unique experience to go to North Korea and to see things through a very

[00:03:54] different lens. But I'm very glad I got back from the South. Yes, I was I had a chance

[00:04:01] to go to the United Horizon, the border between the North and the South Korea where there's

[00:04:06] a lot of activity and economic activity back in 2011. And I can imagine, and even in the tourist

[00:04:14] areas where it was all very well polished and scrubbed up of any military was still tense.

[00:04:23] So I can only imagine what that looked like. No, and I couldn't communicate like there's no

[00:04:28] communication with North Koreans. Anytime I tried to talk to someone it just it nothing

[00:04:32] could occur. It was a fascinating cultural experience. Cultural differences and cultural shocks.

[00:04:37] Maybe we'll start there, John. So what do you think we like talking about leadership and culture

[00:04:42] and change? And so Scott in your current role as a public health trained public health dentist

[00:04:49] an educator and somebody who's deeply involved in caregiver in the community overseeing that

[00:04:56] what is the role in culture building and leadership that you see for us to be able to

[00:05:03] assure this new era of dentistry, if you will. One of our previous guests mentioned that dentistry

[00:05:10] is on the cusp of its golden age. And so tell us a little bit about from your perspective,

[00:05:14] what is the role culture plays in that transitioning from traditional models of care

[00:05:20] to that next generation of dentistry, if you will. Yeah, that's like so fascinating to me as it

[00:05:26] relates to culture is culture presents itself in I think in numerous capacities. It could be

[00:05:32] you know, their identities cultures are forms of identities, I believe. And so all of us carries

[00:05:37] with us different types of identities, race, gender, ability, disability. The list goes on language,

[00:05:44] religion, and over the past. So I had the opportunity to come back to AT Still University,

[00:05:50] where I teach now at the Arizona School of Dentistry and Oral Health. And the classes

[00:05:55] look so different now than it did when I was a student, I graduated in 2014. The face of

[00:06:01] the future dentist looks so different and then the historical face of the dentist and the dental

[00:06:08] community. And one thing that is really important to me is to understand who are the faces, what makes

[00:06:15] them, what do they thrive off of, what's important to them. One big very obvious shift is the gender

[00:06:21] difference in dentistry. Those who dentistry has been as we know historically male, but I want to

[00:06:28] say in our current dental school, it's majority female. And that is people come with their

[00:06:34] different lived experiences. Women come with different lived experiences than men, and that

[00:06:39] shapes the kind of healthcare providers we're going to see. I've interviewed applicants who

[00:06:45] may or may not end up coming to the dental school, but during the interview process,

[00:06:49] they tell me stories of driving hours and hours to get to a dentist that speaks their

[00:06:55] family's language because they've come from Vietnam or China or somewhere in other part

[00:06:59] of the world. But the opportunity to see a healthcare provider who understands where they're

[00:07:05] coming from a cultural language perspective is a very powerful aspect of healthcare. And so that

[00:07:11] part of culture and seeing the changing face of the future dental profession is really fascinating

[00:07:17] because they're bringing different asks and different wants to us too, and we have to pivot

[00:07:22] and it's academia doesn't pivot quickly, but the face is changing quickly. And so it's an

[00:07:28] interesting journey to be on. Well, Maria, a good follow up to that as I'm listening here is to ask

[00:07:36] the question, what is the positive when you think about this dramatic shift in gender

[00:07:45] as relates to the quality of care, the ability to listen to the patient? What is that shift in

[00:07:53] gender and more of a female percentage of the overall? What's the positive optimism there that

[00:08:01] we could look into the future for? If it's okay, I'll broaden it a little bit just

[00:08:06] a positive of just the general change. But to start with- Just answer their own questions,

[00:08:11] Scott. This is entirely friendly. Because I love it because it is like change is difficult.

[00:08:18] And I think we all have to acknowledge that like anything that we have to change try

[00:08:22] putting on your pants, the other leg first. And like your brain is like, wait, what are we trying

[00:08:27] to do here? So anytime there's change, I think it's important to have the conversation around

[00:08:33] what are the challenges we're going to face and what are the opportunities, what are the positives?

[00:08:37] When I was studying global health as part of my public health curriculum, we often talked about

[00:08:42] the role of mothers and the role of female caregivers in communities. And in many communities,

[00:08:50] the women in the community, whether it was their own children or they were other just caregivers

[00:08:54] within the community. In many cultures and communities, women are the primary health decision

[00:09:01] makers. They are the people who support the health and well-being of the community.

[00:09:05] And that could be like we go back to long, long time ago with looking at like

[00:09:10] societies where men were the primary red winners, if you will, and so forth,

[00:09:15] or even going further back where the male part of the community was out there hunting and gathering,

[00:09:20] in some capacity. It's really fascinating to see just the different levels of compassion

[00:09:27] and empathy. And I think even the less or the more conservative approach that sometimes

[00:09:34] our female students will take as compared to our male students. So like when I read evaluations

[00:09:39] of the students and the experiences they're having, they do fourth year externships at

[00:09:43] health centers around the country. And I'll often read that our female students might be a

[00:09:48] little bit more conservative as compared to the male students. And so why is that positive?

[00:09:54] I think that's positive, a more conservative approach because that is the way dentistry is

[00:09:58] going. We're not, I was listening to your podcast with Dr. Norris talking about the

[00:10:03] unethical aspect of patient-based board exams because we've got this tiny little cavity

[00:10:08] that we used to do a filling on to prove we could do a filling, but now there'd be

[00:10:12] absolutely no reason to fill that tooth. And because we have the medications,

[00:10:17] we have a more holistic approach. And so the positive that I think any change we see in

[00:10:23] the face of dentistry is bringing those lived experiences, bringing those different ways of

[00:10:28] approaching healthcare. Because we talk about what are some of the biggest barriers that

[00:10:32] communities face? It's not having a dentist who understands the challenges that they may

[00:10:38] be facing. And when you bring in those different lived experiences, we then can bring in the

[00:10:43] solutions to those lived experiences to break down the barriers. And that to me is one of

[00:10:49] the best positives. Just the things that students bring to me that I would never

[00:10:52] consider are going to change the way we can deliver healthcare. I believe, but I'm very

[00:10:59] hopeful. Yeah, I couldn't agree with you more. And as a clinician and also as an academic,

[00:11:04] the shift, I couldn't agree more that from predominantly male to now you're really going

[00:11:11] more towards this direction of predominantly women. I look at it as a very big positive.

[00:11:17] My clinic that has always been my center of universe and 27 people, I would say there's

[00:11:22] about 21 that are women. And the quality of care and the empathy and the listening

[00:11:28] and the listening for understanding and then developing treatment plans that are

[00:11:34] more minimally invasive and conservative. And how do I get to this solution in a way that is

[00:11:42] least obtrusive and have a high level of quality of care? So I completely agree with you.

[00:11:48] And it's an interesting direction. So, Scott, you live in these different worlds. Tell us

[00:11:53] a little bit about that Arizona State at the university. What are you seeing from a standpoint

[00:12:00] of innovation and newness for the education of these young dentists as we think about

[00:12:08] meeting the needs of the future? What's the opportunity? Where are the areas that are

[00:12:13] the challenges? And because we all know how important is for this experience in education

[00:12:19] for these young dentists? So I just met our first year students that just started last week.

[00:12:25] And I did this little activity. I had like a half an hour with them and I wanted to get to

[00:12:29] know them a little better. So I would say, okay, stand up if you blah, blah, blah. And one of

[00:12:35] the first questions I asked was stand up if your prom was canceled because of COVID.

[00:12:40] And about 10 to 15% of the students stood up. So that means those are the students that

[00:12:45] went right from high school to undergrad to dental school. It was much lower than I expected.

[00:12:50] It seems like we're having more students take maybe time off or explore life like I did. I was out of

[00:12:55] school for four years before I'm going back to dental school. And what I think is really

[00:13:00] interesting is they do not want to be read to. I mean, I don't think anyone does when

[00:13:05] that you know, you've got a PowerPoint in front of you and I have professors who would just

[00:13:08] read the PowerPoint to us. And the fact is, and I say this with a lot of love and compassion,

[00:13:15] you can learn most of the techniques of dentistry by going to YouTube. It's a technical skill that

[00:13:23] even when I was training in my hospital residency, the anesthesiologist said, hey,

[00:13:27] do you want to intubate tomorrow? Would you like to intubate the patient? I said,

[00:13:30] oh absolutely, that would be an amazing learning experience. And she said, okay,

[00:13:34] go watch some YouTube videos and then we'll come in tomorrow and I'll let you do it.

[00:13:37] And I was like, wait, what? They just go train myself. Of course she was there and

[00:13:42] she gave me like 10 seconds to do it. And then at that point she took over.

[00:13:46] But the simple fact is the technical skills of our profession can be learned

[00:13:51] almost anywhere in our students lives because of the way the world is so connected now.

[00:13:56] What I think is important in dental education is to make sure that we recognize that people,

[00:14:03] the way we learn as humans is somewhat changing. But as we change the face of dentistry,

[00:14:10] as we talked about before, the way we teach is different too and the way people learn is

[00:14:15] different. So like for me, I don't do traditional exams because I get one day in my classes.

[00:14:21] I have a one four hour block. So I'm thinking how can I really get the most out of this?

[00:14:26] I incorporate cahoot. I love cahoot because it makes it more interactive,

[00:14:29] it gamifies it. And then I throw in some gift cards as like a reward to the first,

[00:14:33] second, third place. I make sure that if I'm going to teach a class for four hours,

[00:14:39] at least 50% of it, if not more, I'm not talking. In some way though, there's an

[00:14:46] interaction. There's a group activity. There's an opportunity to do cahoot. There's

[00:14:50] some sort of hands-on experience. We have a great department of special care dentistry

[00:14:56] at the Arizona School of Dentistry. And so much of the curriculum they learn is

[00:15:01] the lived experience of someone with a disability. So we have tremor gloves. So they can put on these

[00:15:06] gloves and then when they try to write their name, the tremor kicks in and they lose control.

[00:15:11] Or we have different goggles that simulate different visual conditions. The more we can

[00:15:18] make it a interactive, the more we can make it a hands-on experience. I think our students are

[00:15:27] going to be better prepared, especially as it relates to how to interact with humans because

[00:15:32] that here's the craziest thing. When I look at some of these social media accounts, it's someone

[00:15:36] talking to themselves but acting as different people. And that's something that just,

[00:15:41] I don't think that's the best way to teach our students is to have them interact with

[00:15:45] themselves. They've got to interact with others. And so that's one of the things I think we have

[00:15:50] to continue to look at is how can we engage with them to be the best communicators? Because I will

[00:15:55] admit, that is probably one of the bigger challenges I'm seeing. And so being preparing

[00:15:59] them that way is going to be really crucial. Right. Much to unpack there. Yeah. Yeah. Yeah.

[00:16:06] Developing those soft skills and we know in all the healthcare that goes across the board,

[00:16:10] medicine and dentistry. And unfortunately on the medicine medical side, managed care

[00:16:17] just pushes down the time that a doctor might have for diagnostics and really listening

[00:16:23] to the issue and technology is helping. And of course, the same thing goes in dentistry

[00:16:28] and the ability to really ask these effective questions and understand our patients.

[00:16:34] And those communication skills are so important. And thus I think it's very

[00:16:38] interesting the trending that is going on. Amazing. So Maria, I know you're thinking about

[00:16:45] something. I do. I have I really want to get Scott's thoughts on two aspects here. One,

[00:16:53] John, the new and I talk about the adoption curve of technology in healthcare versus dentistry.

[00:16:57] And so Scott as a innovative educator, right, who was pushing the boundaries of what is the

[00:17:04] traditional model of education in the classroom versus the experiential model of education.

[00:17:10] Where do you see the role of AI and technology in bringing in graduating more empathetic

[00:17:22] technology, literate clinicians who are who is skilled clinicians as well. Do you see

[00:17:29] a trade off between AI assisting in reading radiology or images versus the human eye?

[00:17:38] How what's the role and the technology in your practice?

[00:17:42] We have given that a lot of what I do is teledentistry based. So I'm working on telehealth

[00:17:47] connected teams where a hygienist is going out into a community setting, sending data back to

[00:17:52] me and my colleagues we evaluate it and come up with a plan in terms of other ways that

[00:17:57] students are using it. Our school has always been trying to be on the forefront of technology

[00:18:02] even since we're a newer school. We never had paper charts. We started with digital

[00:18:07] radiographs digital EHR digital EHRs. But even now, like I have a disclaimer at the end of my emails

[00:18:14] that say I use AI assisted technology to help with my emails because sometimes I can't find the

[00:18:21] right words. And so I'll type up something put it into Gemini the Google like chatbot

[00:18:27] and have it spit back out like make my email more empathetic or make my email more succinct

[00:18:31] because I can talk and write a lot. What I want the students to recognize is that the technologies

[00:18:37] are not the decision makers, but I absolutely believe that the technologies can help us even

[00:18:44] understand ourselves better understand like I might want to be more empathetic in my email,

[00:18:50] but I might not know the right language that makes it more empathetic. Our students

[00:18:54] have to do reflective essays because there are soft skills that you can't evaluate with a multiple

[00:19:00] choice test. And could they be writing those essays using AI assisted technology? Yeah,

[00:19:08] and that makes me a little nervous because I don't want them to write the entire essay just

[00:19:11] saying give me a 3000 word essay on patient communication. But what I want them if they

[00:19:17] if maybe they are a student who English is their second language absolutely why not use that

[00:19:22] technology to help them be successful. Same thing with radiology and radiographs why not use the

[00:19:29] technology in a way that will help us identify problems that we might not otherwise catch.

[00:19:36] But with the big caveat that in the end, you if you're going to hand in a paper, you need to

[00:19:41] read it you need to go through it you can't just hand it in is it the language is it you

[00:19:45] even though it might not be your exact words? I probably have a lot of people that are

[00:19:49] mad at me for saying that but I would be okay with that because I just need you to communicate the

[00:19:55] ideas. I need you to be able to understand what's on the radiograph. So if the technology is saying

[00:20:01] hey there might be carries here, you should know if that is actually carries and then decide how

[00:20:07] am I going to treat it? What am I going to do next? And I'm all for decision making trees

[00:20:12] things that help us make better decisions based on the statistics and based on the reality

[00:20:18] or based on the big picture but we're still a human in front of us and that human is not

[00:20:24] plugged into the internet and so we still have to be careful to not let the technology

[00:20:29] lead us but really make sure it's simply assisting. So I'm all for it but caveats.

[00:20:36] There's a big difference between AI assisted and AI authored. Yes, exactly.

[00:20:44] The best expression I ever heard on this which was really early on

[00:20:49] is that AI is a co-pilot for us and as a co-pilot we're leading but it makes us more effective

[00:20:58] and efficient and I love what you said about AI helping us understand ourselves better and as

[00:21:05] machine learning and computational science gets faster and faster as Moore's law and the ability

[00:21:11] literally for computers, computer knowledge to really understand and go beyond the parroting

[00:21:19] of what a human would say but to go so deeper in our own understanding. I think if it's position

[00:21:27] properly it just makes everything everyone does in every industry that much better not to be

[00:21:35] scared of it but to embrace. I couldn't agree with you more on what you said. Yeah, I think a lot

[00:21:40] about that notion of AI helping us or technology helping us understand ourselves better. I think of

[00:21:48] it as allowing us to personalize care to a much greater extent and personalizing care means

[00:21:58] you could decide to offer a less invasive, minimally invasive treatment versus a restorative

[00:22:04] more invasive treatment or you could also decide that this patient has special needs or they're

[00:22:10] differently abled and you need to personalize your care and approach to them. The same way

[00:22:17] you personalize your care to somebody who is a busy executive who needs to go see a dentist after

[00:22:22] hours or a single mom who has two kids and a day job that she can't take a break from. Personalization

[00:22:31] of care is where technology could play a big role in my view across all different patient

[00:22:38] populations. What do you guys think about that? Yeah, yeah, well they're companies right now and so

[00:22:44] next generation of their product pipeline is not only reading x-rays and reading panorexes

[00:22:51] and reading cbcts but the ability to write diagnostics of what exactly it's seeing

[00:22:59] to both the professional and also to a consumer side of the patient side which is not the

[00:23:06] dental language but a language that the patient would understand both with a visual language

[00:23:12] and a written language and that's right around the corner. In addition, both in all the healthcare

[00:23:18] both dentistry and medicine is the same issues. The mouth is connected to the rest of the body.

[00:23:23] Treatment plans and treatment plan options based on machine learning when hundreds of thousands

[00:23:28] of treatment plans and diagnostics how we get to those treatment plans are right around the

[00:23:33] corner also. It's quite exciting what technology is going to do but to Scott's point we still

[00:23:39] have to lead. It's not going to replace the healthcare professional both in medicine and

[00:23:44] dentistry but it's going to make us that much better and the dentist need to have as you think

[00:23:50] about the future what Scott was talking about the dentist need to have these soft skills in a

[00:23:55] very big way more now than ever. Yeah, let's talk a little bit about that Scott please jam in here.

[00:24:00] Let's talk a little bit about how technology allows us to take care of patients with different

[00:24:04] needs. What's your experience on that and how are you incorporating technology to serve those

[00:24:09] communities? So a lot of my background a little bit while I don't think one's pedigree is their full

[00:24:16] story as we were talking about before we got started here. I had the opportunity to train at

[00:24:20] Swedish Medical Center and Seattle Special Care Dentistry a really fascinating hospital residency

[00:24:25] that I spent a year at and struggled at because it was harder than anything I've ever done

[00:24:30] in my life working in a hospital and just working with such complex needs but with

[00:24:36] that said one thing that I think technology one of your podcasts you guys were talking about

[00:24:41] Epic and dental school were actually looking at exploring a new electronic health record

[00:24:45] and bringing we brought Epic or the folks that that company brought them to campus I guess and

[00:24:52] when I was talking to the person leading this effort to change the EHR I said we would our

[00:24:57] medical consults would be lightning faster not 100% better but because Epic allow I use

[00:25:03] in the hospital system it allows us to pull records from other healthcare systems.

[00:25:08] I don't have to wait I don't have to send out 30 different medical consults for our patients

[00:25:13] with complex medical conditions. I can go to one resource and get their records and see yeah

[00:25:19] here's their last A1C here was their last cardiology visit and what the cardiologist said

[00:25:24] we would their hypertension. I had the opportunity to partner with a clinic here in Arizona

[00:25:29] that they had something like 30 some specialties they had never had dentistry but we incorporated

[00:25:35] a hygiene clinic with telehealth capabilities so the hygienists could connect with me and I had

[00:25:41] a patient there with 45 medical conditions taking 26 medications a day and because their care was

[00:25:50] centralized at this facility I had all the information I needed in order to make the

[00:25:55] best decision for this patient in order to know because that's the thing with when I'm working

[00:25:59] with a patient with complex medical needs or disabilities it's all about the accommodation

[00:26:04] that might be needed do I need to keep my visits short do I need to do SDF versus

[00:26:10] versus maybe a traditional filling because the only way we're going to do a traditional

[00:26:13] filling is if we do general anesthesia or sedation which has its own risks so oftentimes

[00:26:19] with my patients with complex medical needs it's not I wouldn't say necessarily the dental

[00:26:24] technology although I give a lot of credit to like CADCAM and you put the patient under once

[00:26:28] you get the crown made and you seat the crown and you don't have to put the patient under again

[00:26:33] under general anesthesia or sedation to do the filling or to do the to place the crown

[00:26:37] lots of opportunities there but honestly it's the ability to know because one of my

[00:26:43] faculty who he sadly died of Lou Gehrig's disease a few years ago but he worked up until a

[00:26:47] week before he died he did not let that condition slow him down he was limited but

[00:26:53] he always said never treat a stranger know who this person is and if I can use technology to

[00:27:00] have a better sense of who that person is then I'll be a better healthcare provider and Jonathan

[00:27:04] like you said we're oral health physicians we really need to move away from dentist I think

[00:27:10] then the way I was trained to think because it's more than just about the teeth

[00:27:14] we are physicians of the oral complex and that is the whole body it's just focused here

[00:27:21] and if we don't understand the person sitting in our chair we're going to cause a lot of harm

[00:27:25] and I've seen that I've seen dentists who don't know how to manage a patient who's had head

[00:27:30] neck cancer treatment radiation to the jaw I've seen dentists who don't understand

[00:27:33] like how medications interact and what they might do and it's concerning it's very concerning

[00:27:38] because people are living longer they're living longer with more chronic conditions and we are

[00:27:43] more medicated than we've been in a very long time because that is how we treat so many

[00:27:47] medical conditions so knowing our patients never treating a stranger and using technology to make

[00:27:53] sure we're as informed as possible also just go into google if you don't know what the answer is

[00:27:57] I don't know if this med is I can go to google and find the appropriate resource and that's

[00:28:02] another thing and then I'll shut up because I guess I can go on for a while like please go

[00:28:05] I tell the students you can't know everything but you need to know your resources and the

[00:28:11] internet is a phenomenal resource it's also a deadly resource if you don't know if you

[00:28:16] don't know how to evaluate the quality of the information that's evidence-based dentistry

[00:28:21] that's evidence-based medicine is being able to evaluate the quality but a lot of healthcare

[00:28:25] providers don't have that skill because they were trained to use their hands more tend to use

[00:28:32] their critical thinking I think it's something we've got to work at but the technology is

[00:28:37] there to help us do that too yeah that's exactly right stay right there with evidence-based

[00:28:42] dentistry dentistry has always been fragmented I like to refer to it as a solo climber sport

[00:28:49] when I got into it which was in the 80s I just I literally couldn't believe how they didn't

[00:28:56] really have this working together mindset it was really very solo one Dennis one hygienist

[00:29:03] one assistant that was the business model and look how it's really changed over the last 40 years

[00:29:09] where the collaboration is in teams are in dental schools are working as groups multi-specialty

[00:29:18] practices is the future how do we collaborate how do we have like grand rounds in hospitals

[00:29:25] how do we have grand rounds in the dental office which we do in in our practice because we have

[00:29:30] all the specialists and we put all the data up and even if it's a fairly simple case we all

[00:29:35] learn together but the trend is very positive and technology is just an amazing co-pilot to

[00:29:43] really help us do that to both of you how does that improve access because I think a lot about

[00:29:49] the dental deserts and if we think that the the access to dental care for a single mom of two

[00:29:55] healthy kids is difficult think about two kids with special needs that not every general dentist

[00:30:02] takes those patients I I saw an article recently that stuck in my head where there were kids in

[00:30:10] California with special needs that had to wait years to see a dentist who would take their insurance

[00:30:16] and who would take them as patients and so there's this disconnect at least for me where we're

[00:30:22] graduating dentists from programs like what scott is running where we're expanding their mindset

[00:30:28] and teaching them how to know their patients and not to treat strangers but at the same time when

[00:30:34] they go in the real world maybe under the pressure of school debt and the pressure of reimbursement

[00:30:40] things change so where is that disconnect is it we're not graduating enough dentists are we not

[00:30:46] incentivizing them appropriately is technology not fully deployed yet what is there to be done

[00:30:53] for that access issue a lot of the way dental schools run is based on the

[00:30:59] council on dental accreditation I think I've got that acronym right coda and coda sets the

[00:31:05] standards they tell us what we have to teach to they don't tell us how to teach it but they tell

[00:31:10] us what we have to teach to for example in the world of special care dentistry as defined by

[00:31:14] coda is patients with physical disabilities like physical intellectual disabilities which I think

[00:31:19] in general what most people think of if they think special care they think someone with

[00:31:23] down syndrome intellectual disabilities someone with learning disabilities whatever it may be

[00:31:29] uses a wheelchair for example another example of physical but then actually the other components

[00:31:34] of special care dentistry are geriatric more focused on the frail elderly individual who is

[00:31:41] how a lot of medications oftentimes living in some kind of assisted care long-term care maybe

[00:31:46] and the hospital dental patient which most dental students that third one in particular

[00:31:51] most of them are not going to encounter that patient because that's seen in more general practice

[00:31:56] residencies or in programs that have a connection to a hospital our dental school for example we

[00:32:02] don't have a hospital connected to our university so we don't have an easy way to work to see

[00:32:06] that patient population so with those three patients the medically complex hospital patient

[00:32:11] disabilities and elderly frail elderly the challenge we have is

[00:32:17] are our patients are our students ready but more importantly are the schools ready to

[00:32:23] teach it because coda tells us going back to coda they say we have to I forget the

[00:32:28] exact standard but it's something like we the students have to be able to assess

[00:32:32] and manage the patient well assess and manage simply means going through the medical

[00:32:38] history and determining if the patient can be safely seen in the dental office or if they have

[00:32:42] to be referred somewhere else there is no treatment requirement from coda now keep in mind just

[00:32:48] getting to manage and assess took years because initially it was you have to be able to assess

[00:32:52] the patient but if there aren't enough faculty to teach these skills because historically we

[00:33:00] haven't taught these skills then who's teaching the dental students say the standard of care

[00:33:06] for specialty care in dentistry is lower is only assess and manage versus the standard of care for

[00:33:14] other dentistry is goes to treatment basically it's the way you're saying it I'm like oh yeah it is

[00:33:21] it's that bad in a sense but like when you talk about I had training from some of the top special

[00:33:28] care dentist in my opinion in the country but you start learning like I think NYU actually

[00:33:34] Jonathan you might be familiar I think NYU opened up a special needs clinic recently

[00:33:38] university of Pennsylvania Pennsylvania yep thank you I think under Mark Wolf they open

[00:33:42] an amazing clinic we've had a special needs clinic since our dental school started but it takes

[00:33:47] infrastructure changes and for these established dental schools that's millions of dollars

[00:33:52] you're looking at so where are the resources and you know what you don't get when you treat

[00:33:56] patients with special needs more money because it takes more time like you still do the same

[00:34:02] procedure that's right yeah and there are some codes on Medicaid sometimes pays out on the

[00:34:06] behavior management code but 10 bucks doesn't cover the bills for widening your doors and having a

[00:34:13] bariatric dental chair for patients who would not be able to sit in a traditional dental chair

[00:34:18] for wheelchair accessible rooms there's and then on top of that I'll share my own story of a patient

[00:34:25] a young patient had a very pretty complex heart condition and by the time he got to me

[00:34:31] he got to the hygienist who we did a virtual consultation with him he had been to five dentists

[00:34:38] and he had the pulp was extruding itself from the tooth they were such bad inflammation

[00:34:44] he had in fact you could see he hadn't even been chewing on the right side of his mouth because

[00:34:47] of all the calculus and tartar that had built up on one side of his mouth this not even

[00:34:52] teenage your kid had been rejected by five dentists because of his medical history

[00:34:57] so the technology where does this come in it's called a telephone and you pick it up and you call

[00:35:03] someone to say what do I do who you call honestly is the physician and say this kid has a complex

[00:35:10] heart condition is it safe enough does he have any limitations to his care that you are aware of

[00:35:16] and the simple fact is this kid had no limitations because he was well managed

[00:35:20] even though he had a complex medical condition but even picking up that phone

[00:35:24] is just not something I think that we're training people to do because it's time consuming itself

[00:35:28] I'm a dentist I treat teeth I don't necessarily have to talk to the mental health physician or the

[00:35:33] cardiovascular physician or the primary care doctor they write off a med consult that says

[00:35:39] can I and one thing we teach our students you never ask for permission you never ask

[00:35:45] an a physician for permission to do a filling a cleaning whatever it might be you

[00:35:49] ask the physician to tell me more about this patient that I might not already know so that I

[00:35:54] as the other doctor in this scenario can determine if it's safe to move forward with treatment

[00:35:59] and that's honestly what we spend most of the time talking to our students about is how do you

[00:36:03] have those conversations and I have seen some abysmal communication from clinics that I've

[00:36:08] worked with or in terms of how they communicate with medical colleagues it's frustrating to

[00:36:13] say the least so the technology is pretty basic but you know what I mean like it comes

[00:36:18] down to you got to use it technology is only as powerful as our ability to adapt business models

[00:36:25] and workflows and mindsets to it technology is never the barrier or bottleneck to changing

[00:36:32] care or bringing silos together I'm yet to find an oral health physician who said I wish

[00:36:38] the only thing that's preventing me from being an oral health physician is more technology

[00:36:42] it's an enabler it's a tool and then it's up to the mindset and how we use it

[00:36:47] so Scott you painted the very sobering picture of where dentistry is today for special care

[00:36:55] dentists dentistry based what advice and where do you see that changing how do you see that

[00:37:00] changing there's a lot of influential decision makers patients clinicians administrators

[00:37:08] of benefits or education who are want to do something about this or want to be part of the

[00:37:15] change and so where do you see the change coming from and is there a call to action or advice from

[00:37:22] you to those individuals who want to do something about it you know so I think one of the most

[00:37:29] important parts is education but the simple fact is we're not there are a lot of people who

[00:37:34] aren't going to go back to dental school to get that education so I think it is a matter of

[00:37:39] understanding one's resources I think I would love for there to be some kind of either reimbursement

[00:37:46] mechanism for dentists that spend additional time training in those areas that are needed for CE

[00:37:51] maybe making scholarships available in fact University of Washington I will throw a plug

[00:37:55] into my colleague Dr. Kim Espinosa up there at the decode clinic and I apologize I can't

[00:38:00] avoid decode stands for but it's their special needs clinic at UW there are she has a fellowship

[00:38:06] program a short like a one week or I think you can come by over three weeks over a period of time

[00:38:11] but if folks want to look it up at DECOD that their decode clinic they offer hands-on training

[00:38:17] they also offer for those living in Washington working in rural areas they've had some

[00:38:22] scholarships in the past to cover the cost of the training too so there are some folks out

[00:38:26] there doing that I think there's opportunities for us to look at maybe dental practice acts

[00:38:32] and to look at what CE is required we require CPR you've got to be re-registered every two years

[00:38:39] but CPR only gets you so far you want to avoid the emergency that's the whole part of special

[00:38:45] care training is making sure you don't get to the emergency you're prepared for it when it

[00:38:49] happens with CPR but you know how to avoid it with special care training I think also

[00:38:55] awareness as we were talking about my background is the disability pride month flag and I didn't

[00:39:00] even know this was a thing until last night actually I was going through some emails and I got an

[00:39:04] email from the American Association of Public Health Dentistry about disability pride month

[00:39:09] and I think understanding taking time to understand disabilities and understanding what

[00:39:15] the challenges that people face it just it's a step it's not the end step but it is a

[00:39:20] step in the process and understanding like the men I work with coming out of prison

[00:39:26] who are dealing with substance use issues all of them are telling me about the coping skills that

[00:39:32] they are learning as a process as part of this rehabilitation they're going through I've had kids

[00:39:39] in detention tell me that they start using drugs because of loss death heartache in their

[00:39:45] own personal lives because they don't know what other resources are available they don't have

[00:39:49] access to other resources and then I look at my own experience as a kid as someone dealing with

[00:39:54] some invisible disabilities and even learning being diagnosed very recently in the last year

[00:39:59] learning more about how my brain works I never had to go to rehab to learn coping skills I never

[00:40:05] had to go to prison or go into jail to learn that that substances aren't the only path forward

[00:40:12] and it breaks my heart that we live in a system that is so lush with cash but that

[00:40:22] you honestly have to be lucky you honestly have to be lucky where you're born the family you're

[00:40:27] born into the life you're born into to have access to those resources and I was just one

[00:40:32] of the lucky ones because I very much could have been on the streets due to my own

[00:40:38] disabilities that I face that honestly I wouldn't call disabilities they're just who I am

[00:40:42] but because they fall under the category of disabilities I'm like okay that's what it is

[00:40:46] I don't feel unable to do anything I just have to learn how to work with it and that's what this

[00:40:52] is all about is understanding what our patients have to work with so if I've got a patient

[00:40:56] with ADHD sitting in my chair in front of me I'm not going to tell them well you just need

[00:41:00] to do a job better job brushing no because a kid's not going to get a dopamine hit which

[00:41:05] is the primary issue with ADHD not having enough dopamine ready to go in the brain

[00:41:10] I need to find how can we incentivize it how can we make a reward out of this how can we make it

[00:41:15] novel so that it doesn't get boring we have to move away from being the kind of the patriarchal

[00:41:22] system where we just tell people what to do but rather work with them and that's to me

[00:41:27] that's a crucial aspect of where healthcare dentistry needs to move to and so for those

[00:41:32] living with disabilities for those who want to help them begin on begin to understand the condition

[00:41:38] better and then I think we can have better conversations with our patients and then change

[00:41:43] the insurance system to reimburse us to have those conversations with the patient because

[00:41:48] no one's going to do it if they can't get paid for it honestly why would they

[00:41:52] because there's so much else to do and it's not a niche thing right it's 25 to 30% of Americans

[00:42:00] live with some sort of a disability so this is the notion this is just a small subset of the

[00:42:06] population is truly a myth and thank you for sharing that Scott yeah no that's it is so poignant

[00:42:14] and so important with the dental schools have to really Scott I'm sure you would agree every

[00:42:20] dental school has to have a division or a subset of teaching for special needs

[00:42:28] because it isn't such a small little piece it's bigger than everybody realizes and what you said

[00:42:34] was I think we have to underline it the people who were not lucky to be born under the opportunity

[00:42:40] to take care of these needs and to have the healthcare professionals around you

[00:42:45] we can't forget about them and that's where the empathy needs to come in and thank you for

[00:42:50] shining a light on that and working on that and hopefully the dental schools will and the

[00:42:54] educators will help bring in this new generation of dentists with a much greater awareness well Maria

[00:43:02] this was amazing this was amazing and really Scott thank you so much for bringing this conversation

[00:43:07] to us I appreciate the opportunity to share a little bit of what we're working on the exciting

[00:43:12] part is what do they say change the only thing constant has changed and so I fully believe that

[00:43:19] as we have more of these conversations that like you said as we build these clinics it's

[00:43:23] slow but that's also my role the public health you even mentioned it in one of your podcasts

[00:43:27] the 17 years before clinicians actually adopt change right and but that's the thing when we do

[00:43:34] the work that we do we're the eternal optimist because we know it's not going to happen tomorrow

[00:43:38] but we know that it can happen if we keep working towards it patients with special

[00:43:42] healthcare needs are going to be better off in the future patients who are living in rural

[00:43:48] communities will be better off in the future but it's going to take time and it's going to take a

[00:43:53] lot of work so I think if we keep having the conversations and keep up the positivity don't

[00:43:58] let the setbacks knock us out knock us on knock our feet out from under us there's only skies

[00:44:06] the limit and I'm just honored and thrilled to be able to have this conversation thank you

[00:44:10] for your time and thank you for having these conversations that not everyone's having

[00:44:14] it's fascinating to hear what you all are talking about in yours realm too just getting started this

[00:44:19] is it this is we're just getting started and we would love to follow your success your good work

[00:44:25] we'll make sure that our listeners have a way to get in touch with you in the comments and the

[00:44:30] notes of this episode and have Scott back we absolutely want to have you back celebrate

[00:44:36] some of the amazing work that you're doing thank you guys be great all right guys thank

[00:44:42] you and I'll see you next time yeah thank you Scott thanks for listening to the think oral podcast

[00:44:53] for the show notes and resources from today's podcast visit us at www.outcomesrocket.health

[00:45:02] slash think oral or start a conversation with us on social media until then keep smiling

[00:45:09] and connecting care