In the Dental Clinic, a New Approach to a Complex Problem

Bringing good oral health within reach for patients with disabilities or extensive medical issues

“Across the country there are few dental providers able and willing to treat individuals with disabilities and complex medical issues,” says Athanasios Zavras, chair of Public Health and Community Service at Tufts University School of Dental Medicine.

When the first Surgeon General’s Report on Dental Health came out in 2000, it noted that “great progress” had been made on reducing oral diseases in the United States. Yet the 332-page document also cautioned that various inequities kept good oral health at bay for many Americans, and that poor oral health had profound, far-reaching consequences.

Nearly 23 years later, those inequities and barriers are still at play, especially for people with complex medical conditions, social issues, or behavioral health care needs. A new program for predoctoral students at Tufts University School of Dental Medicine (TUSDM) seeks to improve oral health care for these vulnerable populations. 

“Across the country there are few dental providers able and willing to treat individuals with disabilities and complex medical issues,” says Athanasios Zavras, DG93, Delta Dental of Massachusetts Professor and chair of Public Health and Community Service at TUSDM.

The TUSDM program aims to improve patient experiences at the school’s Medically Complex Patient (MCP) Clinic in Boston, and to identify best practices for future use at Tufts Dental Facilities, a network of seven clinics throughout Massachusetts for people with intellectual and developmental disabilities. Along the way, the program will teach students skills essential to holistic oral health care.

“To establish dental students’ confidence and competence early in their careers, one of our goals is to increase the frequency and intensity of supervised training with vulnerable populations,” Zavras says. For already-vulnerable patients with disabilities, having TUSDM as their dental home is crucial to maintaining good oral health, in part because there are not many comparable specialized dental centers that accept patients with medical complexities, and in part because dental procedures are often not covered by Medicare and many state Medicaid programs.

The project is funded by a five-year, $1.5 million grant from the Health Resources and Services Administration (HRSA). As the program team brainstorms on a more succinct title, the initiative is known as Integrated Care to Address Complexities of Oral Health for Vulnerable and Underserved Populations: Interprofessional Teamwork, Cultural Competence, Health Literacy, and Social Determinants of Health.

The project team is led by  Maria Dolce, professor and Director of Interprofessional Education and Practice, and includes, along with Zavras, TUSDM faculty Cynthia Yered, D90; Karin Arsenault, D94; Samantha Parad, D21;  Andrea Zandona, professor and chair of the Department of Comprehensive Care and Aruna Ramesh, associate dean for academic affairs; Robin Harvan,  professor at the Massachusetts College of Pharmacy and Health Sciences; and Wayne Altman, professor and Jaharis Family Chair of Family Medicine at Tufts University School of Medicine.

Dolce knew from past projects at other schools that connecting care providers and professionals with different specialties improves outcomes for vulnerable patients. At Harvard School of Dental Medicine, Dolce was the architect of the nurse practitioner-dentist model for primary care, an innovative collaborative practice mode designed to improve health outcomes of older adults with chronic health conditions. This HRSA-funded project demonstrated improved health outcomes related to self-management of diabetes and hypertension.

The non-medical aspects of people’s lives–housing, food security, transportation, income, and a myriad of other factors–are known as the social determinants of health. Addressing those is key to providing quality, holistic oral health care, Dolce says. And for people with disabilities, “social determinants of health are much more complicated, so we believe that the social worker should be a bigger part of the treatment equation,” Zavras says. 

Dolce expects collaboration with social workers to improve patient care and experiences at Tufts’ MCP, and for the project as a whole to have a similar effect at the seven TDF clinics throughout Massachusetts. Along the way, the initiative will help teach students how to work collaboratively across specialties and professions. 

To that end, project leaders are developing several new virtual reality (VR) educational modules. The idea is to use VR to enhance “interprofessional communication, teamwork, and social determinants–while teaching cultural competence and health literacy,” Dolce says. The modules will use the same headsets associated with video games to simulate clinical experiences based on real-world patient cases at the MCP Clinic.

The program’s third prong, the Advanced Response for Complex Treatment and Integrated Care (ARCTIC) Team, which Zavras and Arsenault will lead, is intended to enhance collaboration across dental specialties. The ARCTIC team will include a dentist from each of the dental school’s seven clinical departments and will meet regularly. “We will work with the MCP dentists to look at the most demanding and complex cases, think collectively, create treatment plans that engage the family as partners in the care of their loved ones, try to anticipate problems, and find solutions before we engage the patients in treatment,” Zavras says. 

 “It’s also about collaborating with our partners at Simmons University and Massachusetts College of Pharmacy and Health Sciences to plan out Tufts dental school being a clinical placement for their students to rotate into the MCP clinic,” Dolce says. 

“We have the medical health system and the dental health system, and neither of them are really talking together or to each other. It’s very disjointed and essentially sparked a movement of integrating oral health and primary care,” Dolce says. “So a lot of my work has been to educate primary care providers, whether they’re physicians, physicians’ assistants, or advanced practice nurses, about oral health so that we improve access to care.”

Ultimately, all Tufts predoctoral dental students will learn from the project during their third-year rotation at MCP. Dolce will be updating her interprofessional education workshop to reflect the project’s new integrated care model. Additionally, the ARCTIC team’s live-streamed meetings will be available so that all Tufts dental students can observe an array of dental professionals make patient care plans together.

“Tufts is the second-largest dental school [in the United States], so by having the whole student body participate, we hope to make a significant health impact at the population level,” Zavras says.

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