​You
What contributed to making your switch from clinical dentistry to more so the research and advocacy side of it?

Participant
So I don't think I was ever truly invested in clinical dentistry per se so I didn't really move away from it. I just sort of wanted to combine dentistry with what I already knew anyway. And I always was probably much more of a social science person than a hardcore biological science person.

You
So over the span of your career as you worked both clinically and now and focused on more social care, have you seen the field of dental public health evolve over time?

Participant
I mean, I think that dental public health has a large role to play in clinical dentistry in certain settings, especially because I think people trained in public health have a much stronger sense of, you know, what individuals—especially those who are more marginalized or who need more help—dental public health people, you know, have a better handle on what the resources can be for them or, you know, are better trained in how to help them manage those resources, how to help find funding in situations that help enough organizations that help people like that. I don't think there's been a big change in public health that way, but I do think that it can't be seen just as people doing policy and research. There's a wide spectrum that covers clinical dentistry as well. 

You
Yeah, I agree with that. So have you personally worked with Medicaid patients before?

Participant
Oh yes, yes.

You
OK, so that's a large topic of discussion within the dental side of things, as a lot of insurance plans and Medicaid don't fully cover the care needed for dentistry. Still, in your experience, what are the biggest barriers to equitable dental care access in underserved communities both in the US—mainly focusing on Medicaid—and global as well? 

Participant
Well, I mean, it's nearly always cost and access. So Medicaid depends on where you live. I'm in Massachusetts, so Medicaid coverage right now is quite good. It's not comprehensive, it's not perfect for adults, but it's very good for children and it's pretty good for adults compared to many other states. The problem is that not everything is available and not all providers take Medicaid, so even in a state with a good plan, you have rate-limiting factors such as who will provide the care and finding a provider to give you care.

You
Right.

Participant
Sometimes people are on waitlists for a long time, can't find anyone who—you know, they'll find providers that take Medicaid but then don’t have any openings. And providers are also allowed, at least in Massachusetts, to limit how many Medicaid patients they take at any given time or they’re enrolled. So they can reach that limit and perhaps deny new patients and have no room for new patients. And yes, some procedures are not covered—that is true—and for those procedures that are not covered, that could be a problem for some patients. But even with regular insurance, there is a maximum per year, and that maximum can be low and people can reach that point and not be able to get the coverage they want. The dental insurance—it's not really insurance; it's a prepaid plan—and for some people, if they max out in a year, they are not able to get everything they need. They might have to wait till the following year. But also, some procedures are only 50% covered. For some individuals, paying for the other 50% might be more than they can afford. So I would say that, you know, the payment of medical care could be an issue for a lot of people, not just those on Medicaid.

You
Right, makes sense. So what would be the most—well this is kind of similar to the first question—but just the most pressing challenges for Medicaid-enrolled families in accessing comprehensive dental care?

Participant
Well, I think finding a provider and having the access could be problematic, depending on where they live. And, you know, there could be long wait times. Sometimes there are issues with knowing whether they're covered or floating in and out of coverage depending on their income. But I would say the number one is access—finding a provider. And rural sites are more difficult. They're more difficult in general, but more difficult when it comes to this.

You
Exactly. So because Medicaid has such low reimbursement rates for providers, do you think that plays a major role in a lot of providers not accepting Medicaid?

Participant
No, not always, because Medicaid is not always such a low reimbursement. And again, in Massachusetts, that's not necessarily true. It could be true in other places. But I think there are many factors why providers enroll. One of them could be that their particular state has lower reimbursement. Another one is fear of extra bureaucratic paperwork, even though it's not really that bad anymore. And then, you know, there's literature that some people don't want Medicaid people in their office. I don't know if that's—I'm sure that's not something anybody would admit to. But yeah, I think the reimbursement is always going to be a little bit lower, but I have to say that here in this state, that hasn’t been the case in many instances. And we've actually—with increasing reimbursement—had a lot more enrollment in Medicaid.

You
OK, that sounds good. And then, so how would you see social determinants such as education, income, and location influencing oral health outcomes in children, and besides the most obvious fact of just not having access to these providers?

Participant
No, not having the access is very big. But also, you know, perhaps not having as much access to healthy foods, having parents who have to work many hours and not supervise them—their eating habits or their hygiene or keeping up with appointments. For some families, just getting to the dentist is a lot of work. They have to take off from work. That's why school-based programs work really well with communities like that. They can bring prevention to the school and try to examine kids—look for problems before they become worse.

You
What role do you believe schools and just overall training programs should play in preparing these trained dental students to serve Medicaid populations or work in a more community-based setting?

Participant
I think most schools already have outreach programs where students spend some time in community health centers. But if they don't, they should have that, of course. But I think the biggest message—and this would work for all populations—is to work harder on using all the available techniques that are out there now to emphasize more prevention and prevention-based procedures, to fight for that reimbursement for those procedures. Because if you have better prevention, then the care at the level that is reimbursed well is no longer needed. And we have tools for doing that now, but in general, they're reimbursed at a very low rate. So I think dental schools can advocate that. Also, you know, try to create a group of graduates who will be better advocates for the kind of system that rewards you for keeping your patients healthy rather than always being stuck in the surgical drill-and-fill model. And that, I think, is a big role of dental public health.

You
Exactly. So one of your large projects that you took on is the healthy weight intervention program, and it's a really good example of integrating systemic health into dental health. So what were some of the challenges and successes you experienced while implementing this program?

Participant
The biggest challenge is that most community health centers in places where the kids could use this extra help couldn’t or wouldn’t take the extra time to do it once there was no longer grant funding. Still, taking the weight, taking time to talk to the kids was something that they loved doing, but they couldn’t. It took an extra five minutes or so, and at the end of the day, that’s an extra 15 minutes that wasn’t reimbursed. And so that was the one biggest challenge. It wasn’t parental—you know, it wasn’t that the parents disliked it. It wasn’t the people doing it—they delighted. It was the lack of reimbursement for it and the fact that, you know—and this is why we have to get out of this model that we’re in right now—we’re in a model of... sorry, I don’t know why, but Alexa is talking to me. Anyway, we’re in a model of, you know, procedure—everything’s a fee-for-service procedure—so if you do something that doesn’t have a fee associated with it, you don’t get paid for it. And if that’s how you have to earn a living—by procedure-based items that have a price tag associated with them—in general, people will avoid the ones that don’t have a price tag associated with them.

You
Yeah.

Participant
And that’s why this model, this child obesity model intervention, cannot work in the current fee-for-service system.

You
Do you believe programs like the healthy weight intervention could be scaled nationally, especially in Medicaid-serving practices?

Participant
I think so. I don't see why not. I mean, it’s hard to mandate that somebody do something, but I can tell you that if it were associated with a fee, it probably would be done. Again, that sort of reinforces the fee-for-service model, which I think we should get rid of. So I think it would be better to say that, you know, you saw a change—that you could report seeing a change in weight or a change in eating habits over time through the efforts of the dental staff, measuring outcomes that way.

You
Right.

Participant
Yes, something like that—something very similar—could be done almost anywhere.

You
So what role can policy play in reducing disparities within oral healthcare, especially for underserved populations and minority groups who don't have the same access?

Participant
Say, you know, possibly a policy of making sure that all children could be seen, you know, and, you know, improving school-based programs in certain communities that are underserved by providers. Finding, you know, new more innovative ways to provide a dental home. If we can increase how many kids could be seen and use preventive methods—you know, SDF, for instance, to arrest caries—you not having to do restoration—then you can use more individuals in a dental setting. Hygienists, assistants—everyone could work to the top of their license, and you could see more people, particularly kids, in the same site. So therefore, people could be seen in a more timely way. I mean, I do think a lot of this is linked to our mode of delivering care. I think it's antiquated, and it needs to be changed. And I think if it is changed, more people will benefit.

You
Right. In your opinion, what specific state-level policies could most significantly improve oral health outcomes for Medicaid-insured children?

Participant
The only way Medicaid coverage can be equal across all states is for the federal government to mandate it. And I don't think that's going to happen anytime soon. So, the reason children are covered across all states is because there is a federal mandate—Early Periodic Screening. So EPSDT—Early Periodic Screening, Diagnosis, and Treatment. That federal mandate requires all states provide basic levels of treatment and services for children under age 21. And because of that, no matter which state you live in, you’ll have those services covered. They may not all be reimbursed as well as others—that could vary from state to state—but we know that reimbursement is linked to access, because if it’s not reimbursed well enough, they won’t deliver the services. However, it does level the playing field. The EPSDT does level the playing field across the states. We have nothing similar for adult coverage, so it would be nice to have that—to say that all Medicaid adult programs must have the following. But right now, I'm not even sure there's a mandate to have adult Medicaid. So certainly there isn’t a mandate for what should be covered. So yes, that could go a long way. Individual states—well, it'd be nice if they could decide to cover costs at a level closer to what, you know, is covered by private insurance so that more participate willingly. And even if they don’t broaden the services, at least offer services that can restore health—meaning strong preventive services.

You
Yeah, that makes a lot of sense. So with the growing understanding of the oral-systemic health link, as I’m sure you know through your healthy weight intervention program, are there any more practical steps that general dentists or hygienists can take to be more involved in holistic care? And maybe that could include just more education, especially for younger children who are still developing, or any other tools that can be this preventative care before they even have to see a dental professional?

Participant
Many states are allowing dentists to vaccinate. So dentists could take that upon themselves to be vaccine providers, especially with HPV vaccine, which is something that is very much in the realm of oral health—but certainly other vaccines as well. We do have a couple of private dentists in the Boston area who’ve become “super VAX” that way. So that is one way to help with general health—at least, you know, providing information about it as well. Taking blood pressure—like something we’re all taught in school and then immediately stop doing when we leave—taking blood pressure, monitoring. This is mostly the case with adults, but if someone’s blood pressure is high, you know, taking it again, making sure—asking them to check in with their physicians. You know? And then from beyond that, there's now diabetes monitoring and testing that can be done. A simple weight, BMI assessment. I think there’s a lot of dentists who don’t want to deal with that. They don’t feel it’s in their realm, but it certainly could be—maybe should be. You know, asking when your patient last saw their physician. And we did a sort of mini study. It wasn’t really a study; we were trying to gather data for a grant submission. And our fear was that people hadn’t seen their physicians as much as we think they do—and we were right. And in fact, the older people were, the less likely it had been that they had seen their physician within the past year. And it was more true with men than women. So some of the chronic diseases that men are more at risk for as they age—it seemed crazy that they are the ones who seemed to have gone two or three years without a check-up.

You
Yeah.

Participant
So I think even simply taking a medical history about that at every—you know—periodically, at least once a year, and suggesting that they get their physical. And if they haven’t, then maybe taking, you know, their blood pressure, checking for—checking for that—sorry—checking for, you know, HbA1c, if they're feeling OK about doing a finger stick. Having those tools available in the office. And then of course the things that we can do—oral cancer screening and making it an annual procedure for all your patients.

You
Yeah. Yeah, that makes a lot of sense. And I think what’s interesting is that kind of more so recently, people are understanding the interconnectedness of dental care and overall systemic body care. As a lot of people in past decades haven’t really—although they’ve probably acknowledged that they’re connected—they haven’t really done anything to educate future practitioners. And just now there’s researchers coming out and speaking upon this, which I think is extremely important because it can prevent a lot of the reasons why people even go to the dentist in the first place—because they don’t understand their mouth is connected to the rest of their body.

Participant
Yes.

You
And so, kind of like reflecting on your own research projects and public health initiatives, which one do you think made the biggest difference?

Participant
My own initiatives? I mean, I think the healthyweight made a big difference for some kids, definitely.

You
Yeah.

Participant
Not all, but for some. I think some parents seriously thought about changing habits with food—at least they reported it. So I think it could’ve made a difference in how they had their meals and how they regarded their, you know, their kids and the intake of—especially around things like soda. Some parents were just in denial that their kids were obese or overweight. So I could see where that made a difference. But I think in terms of my clinical world, the use of SDF—I think it made a huge difference in treating kids and even adults. So, you know, I think we’re just still under-using it and that it could be a big game-changer if we were to use it more.

You
Right. So kind of just wrapping up and everything—what advice would you give to young researchers and advocates like myself, who are students and obviously can’t get involved in the specific dental clinical care, but people who are interested in creating systemic change in oral healthcare access?

Participant
I think, you know, any chance you can have to advocate is a good one. Learning as much as you can about your political environment—where you live, where you go to school—how some changes can be made or what needs to be done. Joining organized dentistry, because organized dentistry now—especially now—is becoming more and more focused on these problems with access. So be there to work alongside them, especially as someone who feels that it’s important policy to promote. And then finding your own ways—as you, and I assume you say students should be dental students—finding your own— ways as you develop your own theories about practice. Learning everything you can about how do I keep my patient healthy—not just how do I fix their teeth. And how do I keep their teeth healthy—not just how I fix them after they’re broken. And just keep pushing, pushing, pushing for the kind of value-based care model that will allow you to keep your patients healthy and not just reward you for fixing things after they're broken.

You
Exactly, that makes sense. Well, that was kind of all the questions that I had for you. Is there anything else that you'd like to share?

Participant
No, thank you. You're very comprehensive.

You
Thank you.