Dentistry in 2040: Through the Looking Glass
Republished from the May 2017 Issue of WSDA News, "Dentistry in 2040: Through the looking glass."
If the Jetsons, the cartoon series from the 60s, is at all predictive, in 45 years we’ll be flying our cars, have robot maids, and live and work in buildings suspended in space. That being said, we already have Roomba, a robotic vacuum; self driving cars are quickly moving from theoretical to actual; and CNN recently ran a piece about a building designed to be suspended from an asteroid circling the earth. Nothing, it seems, is impossible any longer. We wondered then, what lies ahead for dentists in the year 2040? Not quite the time of the Jetsons, but far enough out that we could expect to see real change.
We wondered specifically about critical issues facing dentistry, including debt and financing, licensure, technology and innovation, integration of medicine and dentistry, and insurance.
We figured that dentists, being the curious, analytical types that they are, would also wonder what was in store, so for this issue we reached out to Dr. Dave Preble, Vice President of the ADA’s Practice Institute, Marko Vujicic, Chief Economist and Vice President of the ADA Health Policy Institute, Dr. Mark Koday, Chief Dental Officer for the Yakima Valley Farm Workers Clinic (YVFWC), and Dr. Jeremy Horst, postdoctoral fellow in the DeRisi Lab at the University of California San Francisco Department of Biochemistry and Biophysics, to elicit their predictions for the future. (In the next issue, we’ll continue to look into the future with additional interviews.)
Dr. Jeremy Horst, postdoctoral fellow in the DeRisi Lab at the UCSF Department of Biochemistry and Biophysics
Silver diamine fluoride research
Dr. Jeremy Horst, a UWSoD graduate, has spent the last three years as a postdoc at UCSF, creating guidelines and doing research on the use of silver diamine fluoride (SDF). You’ve probably heard about it, and may even be using it. It’s a clear liquid that you brush onto cavities to inhibit the cavity’s growth, while strengthening the tooth. It’s truly Jetsonian, if you will, and currently in use by about 10 percent of dentists in the country. Its most obvious drawback is that it turns the decay jet black, but it raises questions, too, such as, why do some cavities appear continue to grow despite treatment, and why do people who are treated get less new cavities? Lately, much of Horst’s research has been focused on figuring out why silver diamine fluoride doesn’t work all the time. “I don’t have the answer yet,” he says. “Everything that we assumed is wrong, and we’re still scratching our heads and testing hypotheses. Still, it stops 80 to 90 percent of all caries.”
Using the compound is relatively simple. The affected area is dried with air or cotton, and the practitioner applies microliters of the product to the affected area. The cavity turns black, but the healthy part of the tooth stays white. Of course, dentists have all sorts of tricks to cover up the black part, if that is desired. “What’s been shocking to all of us, including myself, is how little patients and parents don’t really care about whether there is a black spot on a baby tooth that is going to fall out, when faced with general anesthetic and a visit to the hospital to get a filling done on a 3-year old,” says Horst.
One of the things the compound does best is harden the cavity dramatically. Says Horst, “In our research we discovered that the silver casts wires within the dentin porosities, which end up working like rebar. Imagine cement without rebar, and being able to paint something on that casts the rebar in situ, without drilling. That’s exactly what’s happening, and it’s really cool. At the very least SDF hardens cavities, and for most it stops all the activity, but sometimes it doesn’t. So it seems like the best approach with permanent teeth is to seal when there is an actual cavitation. When there is not actually a hole, then it appears that brushing on SDF is satisfactory. The basic rules don’t change, however. The cavity should not touch the pulp; if it does, we have root canals and extractions. If the cavity is in the pulp or knocking on the door of the pulp, then we still need our advanced techniques.”
Short of that, Horst says, the medicine is amazing. He has used silver diamine fluoride on more than 400 patients. He seals up bigger cavities with a glass ionomer cement. “I don’t like the word synergy, but I can’t figure out any other way to describe what’s going on,” he says. “We have 2-year-olds that I treated with silver fluoride twice and then shoved the filling material in with my finger; three years later the filling looks perfect. Normally, the filling material would have fallen out, and the cavity would have started growing again. So there’s some kind of magic there. So if there’s a hole, we fill it. If there’s not a hole, we do topical treatment only.”
Currently, Horst says, 7 to 8 percent of dentists nationwide have a bottle of the medicine in their practice, and that number is approaching 50 percent in Oregon. Based upon sales figures alone, he explains, silver diamine fluoride has been adopted even faster than the high-speed handpiece. There is plenty of high-quality clinical trial evidence showing that it works for treatment and prevention. The problem, he says, is that researchers are not entirely sure how it works, or how well it works. “Dentists are mechanistic people. We want to understand how something works to figure out how to optimize it,” he says. “Both the ADA and the Academy of Pediatric Dentistry have written policy statements about the use of silver diamine fluoride that will be voted on at the upcoming annual meetings, and the Indian Health Services has adopted a policy that I helped develop to promote use in their patients across the many Native nations.”
Still, questions about the material abound. Horst says, “We don’t really know how it works. We understand the basics, but how does that translate into optimizing a protocol? This is intense stuff. It’s high-concentration silver, ammonia, and fluoride, so we don’t just slather it over people’s teeth as many dentists do with fluoride varnish. We want to focus this on high-risk surfaces in high-risk patients. Dental providers want to know: once a patient is in front of me, how exactly do I place SDF? What should I look out for? How frequently should we apply the medicine, a bunch of times at the beginning, and then decrease with time? There are many parameters that haven’t been worked out. We know that it kills all the bacteria, and seems to soak up differentially in the most weakened parts of the tooth. But, additionally, we’ve observed in two clinical trials that by treating cavities only, patients get less new cavities on untreated surfaces without changing anything about the patient’s lifestyle. So far, I’ve been shocked that the mechanisms we expected don’t appear to be the explanation. The studies have been pretty short term, but we still don’t know how that is happening. If we did, it would help form other approaches to managing caries, and we would be able to move forward a little better.”
Uncovering the mystery
One of the confusing pieces is that when you look at the clinical trial data at six months, 45 percent of cavities look like they have stopped. At a year it’s about 60 percent, and at two years it’s 80 to 90 percent. So the question Horst wants answered is, “What about that other 10 to 20 percent? If 55 percent of cavities don’t look like they’ve stopped at six months, but they will stop later, and yet others won’t stop, what should the dentists do, when, and how can we differentiate those? That’s the hard part. When do you make the switch back to a normal filling? It’s the big hairy question. At the six month follow-up, how do we make the decision to treat using more traditional operative methods or keep doing the medical treatment for the one tooth?” Again, one option is to combine the technique with glass ionomer fillings, for which much of the cavity can be left in place.
The good news is that nearly everyone can apply silver diamine fluoride. It’s that easy. “It’s hard to place sealants, and slow. This can be done more easily, and fast. It doesn’t appear to be quite as good at preventing cavities as sealants, but it’s close, and it is a lot more cost effective,” says Horst. “There have been a couple clinical trials showing that you can just rub a little of this on the molars when they first come in, and those molars get less cavities. Similarly, for older adults, there are a few trials showing simply wiping SDF on healthy root surfaces prevents the formation of cavities. The bottom line is that SDF is a cost-effective procedure that you don’t need a dentist to do. A dental assistant can do this, a hygienist can do this, and a nurse can do this. We can see this going out to nursing homes and schools, bringing dentistry to the populations that need it, where they are.”
Incentivizing invasive procedures
The other issue, of course, is will this relatively inexpensive treatment translate into cost savings for either providers or patients, and how will it be billed? That’s where things get a little wonky. How much does a filling cost? That depends on the practice, the insurance, and the plan. Horst says, “The insurance companies are setting the prices for silver diamine now. It’s cheaper and a lot simpler than a filling, so the cost should be lower. But we’ll have to apply it over time, which changes things. For instance, for a kid with really bad cavities, I’ll apply it during the first appointment, then two weeks later, then at one month, then three months, then six months, and then every six months thereafter. We’re basically increasing time between treatments, but how do I bill for that? Do I bill every time I see the patient, or do I bill per tooth?”
Obviously, it’s a huge question that has yet to be worked out, and it shifts our discussion away from silver diamine fluoride to insurance models. “Our incentives are all backwards,” Horst explains. “We are incentivized to do more procedures for our patients, though there have been groups who are actively working to change that. There is a group in Oregon that has had capitation going for 25 years, and the biggest Medicaid provider in the country just bought them. If we got paid to keep people healthy, how would that change what we do? I can think of five different ways to slow down cavities in someone’s mouth that don’t involve expensive procedures. And if dentists actually get paid more to help people manage their disease and keep their tooth structure, then we’re going to see them do cost-effectiveness analysis so they get paid more, and we’ll have a shift in what procedures are done. The economic model will guide what people will do. There are other incentives besides money. I hope that by 2040 we’ll change things around in terms of how things are done to the point where we will be incentivized to get and keep people healthy, and to provide treatment that doesn’t hurt patients to get them out of pain. We need to figure out how to decrease the amount of pain that we cause to get patents out of pain, and silver diamine fluoride enables this.”
Affecting change today
While researchers like Horst are trying to unlock the mysteries of silver diamine fluoride, the one thing they do know is how it is affecting change already. Horst explains, “In my practice the amount of times that I take kids to general anesthesia or even use local anesthetic has dropped dramatically. This is the central piece about silver diamine fluoride. It is the medicine that has enabled a medical approach to managing caries. There are other aspects of care, like working with people to change their sugar intake, for example, but this is the thing that has made that approach work. Before this we were all kind of scratching our heads, and not making much progress. SDF has enabled us to tip the scales back in our favor, instead of the disease’s.”
Horst says that social media is the driving force behind the changes he expects to see in the next couple of years. “Patient demand will change dentists’ behaviors. Because of social media like Facebook and Twitter, parents are informed about new procedures like this one, and they’re demanding it more often,” he says. “They see the posts of other parents who were able to avoid taking their child to the hospital, and the pain associated with traditional methods. The ADA has established guidelines and those are helpful, but it’s probably going to be the patients who are guiding the expectations of what dentists provide.”
A look to the future · medical advances and more
What else does Horst think will change in the future? The delivery model. “In 2040, I would guess that there are going to be way more practitioners going to the patients. We see this currently in elementary schools and nursing facilities, but that’s expanding,” he says. “The biggest change is with big internet factories in cities like San Francisco, where every day dental vans go to Facebook, Apple, and Twitter, decreasing the time that someone has to be out of the office. Since these people are app friendly, they can get a text letting them know when their appointment is running early or late. They optimize their time, the company saves money, and people actually get to the dentist. In fact, at one of the companies, the workers were too wrapped up in their work to go out of the building, so they figured out a way to get the dentist into their office for routine screenings.”
Much more is happening medically, as well. Horst says, “About 20 years ago, the cavity experts from around the world started getting together and saying that fluoride was not enough. We need antimicrobials that we can paint on somebody’s mouth or tooth. Adding silver to fluoride is just one example that seems to work. But this overall philosophy of adding materials that can control the bacteria in our mouth to supplement the effects of fluoride seems to be working. For instance, we found that chlorhexidine doesn’t seem to be effective, but there is great promise with iodine, which is the most readily available antiseptic in the world. It turns out that using iodine before a fluoride varnish decreases new cavities in little kids dramatically, and so they’re starting more studies on that now. There has been a lot of work on trying to engineer biologically inspired treatments for cavities, and there has been failure. But we’ve finally seen the first clinical trial of a new peptide that self-assembles and aggregates within carious dentin into structured forms, and then promotes remineralization from within. It’s not perfect, but there is no drilling. I think we’re going to see some of these new approaches sorted out in the very near future. Overall, I think there’s going to be a lot less drilling in the future, and it’s going to challenge us to figure out where the balance is between the side of the physician and the side of the surgeon in our training and our practices.”
Marko Vujicic, Chief Economist and Vice President,
ADA Health Policy Institute
Debt and funding
With dental tuition soaring and leaving new grads in debt for years, we reached out to Marko Vujicic for his insight on the future of debt and funding, and we got a little tough love right off the bat. “The one thing that it is important for the dental community to realize is that this is not unique to dentistry. It’s happening in medicine, law, veterinary medicine, and pharmacy,” he says. “A lot of fields are seeing this, it’s just a higher education trend. This first question I would ask is, ‘What is the problem?’”
Obviously, says Vujicic, more student debt is a bad thing, but when you look at the rate of return for dental education compared to other fields, it’s still pretty competitive. The most important thing pre-dent students can do is educate themselves. He says, “People applying to dental school should go into this thing with their eyes wide open. There should be much more financial literacy and knowledge of the typical debt load, and a clear understanding of the typical earnings when you graduate. When I talk with dental students across the country, they’re not even aware of this. Not fourth-years, they know, but people just applying to dental school. To avoid surprises, it’s important to put out more information. I don’t see anything major on the horizon to change the trajectory of rising tuition and student debt.”
What he is seeing, he says, is that the percent of loans that get paid down every year hasn’t changed much. Because students are starting with a higher debt load, it takes longer to pay down debt. Earnings have an important implication on that, so debt loads could take even longer to pay down if new grads opt for lower-paying jobs. Regardless, Vujicic doesn’t predict any major uptick in dentists’ earnings, noting that income has remained flat for several years after declining.
Debt loads and influence
We wondered, are high-debt loads influencing the decision to enter dental school or a postgrad career track? Not as much as you might think, says Vujicic, explaining, “The research we’ve done shows that debt has an impact on some career decisions, like whether you specialize. It does not have an impact on the likelihood to own a practice, which surprised us. And it doesn’t affect your probability of accepting Medicaid.” Gender, age, ethnicity, and whether your parent was a dentist were far more influential than debt load. The good news, says Vujicic, is that the ADA has responded to the debt issue in a positive way, by partnering with a company that allows students to refinance their student debt, and even saves ADA members a portion of a percent, bringing costs down even further. It’s a step in the right direction, according to Vujicic, because it’s saving dentists money. (WSDA members should check out our endorsed company, SoFi, at https://tinyurl.com/WSDASOFI.) Beyond that, when he talks with policymakers in Washington, D.C., he promotes the idea of creative loan repayment programs that incentivize service in shortage areas. “The problem,” he says, “is that a lot of students with a high debt load feel the need to make a lot of money, which they equate to being in a high-end practice in an urban area. You have a disincentive to take a lower-paying job, so I think there is a role for policymakers to step in and tie these loan repayment options to areas with true shortages of providers for a finite period, perhaps three to five years.”
Do other innovations exist?
“I wish I knew of some, but dental education is not really my expertise” says Vujicic. “I’m OK saying that I’m somewhat underwhelmed by innovations in dental education. I feel that we’re not aggressively pursuing disruptive innovation. Do we need four years of investment to train a dentist, or can we use some type of different model? It is something we urgently need to explore. How can we bring tuition down? Again, I am not an expert in this area, but the evidence supports that having fewer, and much larger, schools reduces costs. Because of economies of scale, the bigger schools are more efficient. But that gets into political economy and the mission of the school, and facility costs come into play. There are no easy solutions. We should explore other, more innovative options, like shorter education and more residency, which would get students out in the field faster.”
Dr. Mark Koday, Chief Dental Officer for the Yakima Valley Farm Workers Clinic (YVFWC)
Integration of medical and dental services
Integration of medical and dental services is on a lot of minds these days, with Drs. Joel Berg, Mark Koday, and Jeremy Horst including similar principals in their conversations with the WSDA News. For Koday and the YVFWC, it’s further along in their Oregon clinics, where hygienists are allowed to perform more procedures. “We’re doing it for two reasons,” Koday explains. “The biggest reason is to improve oral health. When I look at current oral health delivery for high-risk populations, it’s a failed system. We failed because we’re not accessing the population very well, and we’ve failed to have a significant impact on reducing caries rates. In Yakima County there are a lot of private dentists and health centers working on the Medicaid population. We’ve increased access for Medicaid children to 68 percent, which is the highest in the state, and one of the highest in the country. When you look at the data, the unfilled caries rates are lower and the filled rates are higher, but the rampant decay data hasn’t changed in years.”
In 2016, the cost to deliver care to Yakima County was $26 million, an amount Koday says is not sustainable if costs keep rising. “We’re working hard,” he says, “but we’ve failed to deliver what we wanted to.” So what exactly does integration of medical and dental look like in Koday’s vision? He’s starting by putting a hygienist on the medical side to work with pediatricians during their patients’ yearly checkups. “We’re looking to address the kids who aren’t getting into dental,” he explains. “In Yakima County if 68 percent are getting dental, then 32 percent aren’t. You could easily argue that the 32 percent are the highest-risk most at-need kids. However, they’re more likely to visit a physician than they are a dentist because of immunization programs and the WIC program, and because medical departments are typically three to four times the size of the dental department.”
Koday is a big proponent of the Community Dental Health Coordinator (CDHC) model, and hopes to one day have a cadre of CDHC dental assistants out in the community doing some primary prevention, and hygienists trained as CDHCs in medical clinics as part of the primary team. “Because we can’t access the population we need to right now to any full degree,” Koday explains, “we hope to put them in medical. In Oregon, hygienists are employed by the dental team, but work in medical. They do assessments, place temporary fillings and glass ionomers, and can use silver diamine fluoride, keeping patients at low risk. Obviously, some patients won’t be appropriate candidates for the low-risk treatments, so those will be sent to dental. This isn’t just my idea. We’re looking at what Dr. Paul Glassman is doing down in California, and there’s a pediatrician named Dr. Dee Robertson who is working with the IHS on a national health level. Again, if you look at the current system, we’re trying to drill and fill our way out with a population we can’t access to a full degree. I’m a big proponent of access, but it’s not the only answer because the decay rate is out of control. There are so many factors involved.”
Referring to Maslow’s “Hierarchy of Needs,” Koday says, “Most of our patients are still at Maslow’s first or second level, trying to get their most basic needs met. Sometimes we’ll see two or three families living in the same house, and the kids who live in these situations are so overwhelmed that the message to brush and floss isn’t getting through. I’ve only met a handful of what I would call bad parents. Most of the parents I’ve met are really good people, they’re just struggling.” Integrating dental with medical would help to assure that the most difficult-to-reach patients get at least a fighting chance at access, but there’s a way to go before any of this becomes a reality.
Like everyone, Koday has to show that the programming is sustainable and financially viable, and that embedded hygienists can generate enough work to pay for their salaries. “We have to develop metrics, which aren’t cheap. They can cost $12,000 to $15,000 every time you develop an automatic metric report, but I need to develop all the necessary reports to prove the program’s viability,” he says. “On paper, it all works, but reality is a different story. If it works in Oregon, then we’ll bring it to Washington to try. In Washington, there would need to be some regulatory changes, but they’re not huge, and other states have successfully made the changes needed. But until then we can still have hygienists in medical, but doing primary and not secondary prevention services.” If everything pans out, Koday hopes to have the program in Washington clinics by sometime next year, which he admits is ambitious. “It will require a paradigm shift, and I have a hierarchy to prove things to first,” he says. “I don’t know if that’s being too optimistic, but there’s more and more talk in our clinic about the need to do something.”
The referral process
One way Koday promotes the integration process is through the referral process. “All pregnant women are offered dental, and they’re highly encouraged to have dental appointments. The same is true of our WIC department. We run metrics of how many kids we refer to dental, and how many actually get into a dental chair, and try to figure out why there is a difference in the numbers,” he says. “We also try to do what we call warm hand-offs as often as we can. If there is a dentist available that day, we can walk them down to dental and have them seen immediately.”
Some obstacles to iron out
As Koday notes, YVFWC has 20 medical facilities, but only half have dental, which makes integration difficult. “You can still carry out the health education aspect,” he explains, “but the process that I would really like to see is an integral link of medical and dental. To really make this work, you need medical and dental clinics that share the same facility, otherwise it’s much harder.”
Additionally, he notes, there’s some resistance to integration on the part of both dentists and physicians because it is new, untested, and unfamiliar, so Koday is working to get the concept taught in medical and dental schools, with some success. He says, “This coming year we’re hoping that our dental residents and our local medical students will work together on some joint projects. The dental residents will teach them about oral health, and the medical students will teach them about how to refer better to physicians. We need to start at that level to be successful.”
Dr. David Preble, Vice President of the ADA’s Practice Institute
“The first thing you need to understand,” Dr. David Preble told us, “is that dental insurance is not insurance. Insurance is when somebody purchases an assignment of risk. Someone else is taking the risk for something happening. Dental insurance is a defined benefit. They pay certain amounts for certain things up to a typical yearly max of $1,500. So that’s not really accepting the full risk of dental treatment, which can range from just a couple of hundred dollars for a cleaning and an exam, to tens of thousands for a full-mouth reconstruction. Dental insurance doesn’t cover that, so it’s not really insurance.”
In 2040, Preble tells us, what is at least possible is that we will have true dental insurance that will cover everything. “We would anticipate that as it starts to align closer to what medical coverage is, certain things would be incentivized by higher payments,” he explains. “For instance, it’s now being shown that preventions in the dental side of things can affect the medical side, which could translate into better dental insurance.” Preble goes on to say that if dental were to become real insurance, you would imagine there could be higher incentives for certain procedures at that point. “Dentistry has been very good at prevention,” he says. “I would say much better than medicine. It’s part of what they do every day, whereas it seems to me that medicine is so busy trying to treat disease that they tend to forget about prevention. Still, the prevention that dentistry does so well is not compensated for. If we want to flip the paradigm from prevention of disease instead of treatment of disease, we’re going to have to realign our financial incentives, and I think that will happen by 2040.”
Preble’s insights apply only to insurers carrying both medical and dental books of business, not standalone dental insurers. “Dental insurance companies without a medical side may have to look at their business model differently. There are some who have said that standalone dental without both lines of business are not going to exist by 2040. I’m not sure about that because the benefit companies have shown themselves to be nimble when faced with going out of business,” he says. “The only way I can conceive that you can go to a model without any annual maximums like real insurance is if it was merged with medical, and you had a larger group of money amassed over a larger population. While there’s a lot of money spent by people on dental in this country, it’s still a miniscule fraction of what is spent on medicine. There is plenty of room to put more money into oral health and not break the bank, but there has to be an appetite for it.”
Most dental plans sold in the country are purchased by employers, and they’re very sensitive about what they have to spend. They want to give employees benefits, but they don’t want to pay more than they have to. “We can’t just say we’re overhauling the dental insurance business, and now your dental plans are going to cost you twice as much per person,” he says. “They would say no thanks. There are still a lot of things to be worked out.”
The truth is that nobody knows how real dental insurance might work. As Preble said, if they find out that by spending more dollars in dental they save money in medical, a multi-line carrier could implement and save money. But, if a standalone carrier incentivizes prevention, they may have to change the benefits for the actual treatment. The reality is that not all dental disease is going to be prevented. Patients aren’t always going to do what the doctor says, so we’re still going to need treatments, meaning you can’t put all of the money in prevention. “We don’t have the answers about how this kind of shift in insurance will work,” Preble says. “These are the basic themes that I see moving forward. Possibly moving toward a prevention model, possibly finding ways to incentivize prevention even more than we do now, while at the same time not destroying the ability to get actual care when it is needed.”
Preble says that some companies are looking at merging and buying dental practices, serving as both the provider and the insurer. He explains, “They see it as having the best of both worlds. They deliver the right treatment for the right reasons, but can massage the financial incentives so that it works for both sides of the equation. That’s how standalone dental insurers could stay in business.” Would that work in a state like Washington, where a dentist has to own the practice? “Sure,” says Preble. “They would align with a dentist, so they wouldn’t necessarily have to buy a practice. They could be paid to provide a suite of management services, while not controlling what the doctor does. Alternatively, they could work with a consortium, for instance. I’m sure that people will be able to figure out ways to do that. There are wholly doctor-owned groups that do both now. It’s not the only way to skin it, but it’s a different way of doing things.”
Before any real insurance benefits can be paid, the industry is going to expect real data that can only be delivered through the use of diagnostic coding in dentistry. The code set exists, but it’s not in common use for data collection at this point. Once it is in place, insurance companies will be able to track outcomes of procedures. You can’t track outcomes unless you know where you started, and diagnostic coding provides a clear benchmark. And that’s one of the things Preble says will absolutely change by 2040. “If your goal is to get and keep patients healthy, you’ll be able to track what procedures resulted in less dental disease. It’s already being done in some dental schools very successfully,” he explains.“For instance, we already know that dental sealants work because we’ve been able to track their success over a population. If the percentage of kids that get dental sealants goes up, then the incidence of dental decay usually goes down. If we’re able to use diagnostic coding, we’ll be able to track many other, more complex treatments.”
More next issue
Next issue we’ll continue the conversation with the rest of our experts and get their take on changes in the licensure process, plaque biofilm research, curriculum and funding issues for dental schools, and more.