CDA Journal - December 2021: More Than Words. Reframing Our Approach to Oral Health Literacy by California Dental Association

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December 2021 Organizational Health Literacy Language Access in Dentistry UCLA-Sesame Street Collaboration

A S S O C I AT I O N

More Than Words Reframing Our Approach to Oral Health Literacy

D E C E M B E R 2021

Vol 49 Nº 12

Lindsey A. Robinson, DDS, and Nicole Holland, DDS, MS

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d e pa r t m e n t s

727 Guest Editorial/Corona Creative 731 Impressions 785 RM Matters/Romance, Risks and Regret: The Drama of Interoffice Dating

789 Regulatory Compliance/Electrical Safety, Fire Extinguishers, Eyewash, Exit Signs and Other Cal/OSHA Regulations

791 Tech Trends

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735 More Than Words: Reframing Our Approach to Oral Health Literacy An introduction to the issue. Lindsey A. Robinson, DDS, and Nicole Holland, DDS, MS

739 Organizational Health Literacy in Oral Health: A Multilevel Perspective This commentary highlights on-the-ground organizational health literacy best practices in oral health. Lindsay Rosenfeld, ScD, ScM; Kathryn Atchison DDS, MPH; Nicole Holland, DDS, MS; Kelly Cantor, MPH, CHES; and Lindsey A. Robinson, DDS C.E. Credit

749 A Historical Overview of Language Access in Dentistry: The Impact of Language Access Protections on Oral Health Care This article provides a brief history of language access policy in this country, discusses the impact of language access protections on the dental profession and recommends actionable steps for dental providers to facilitate equitable, quality care for their patients and communities. Nicole Holland, DDS, MS

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Oral Health Literacy Framework: The Pathway to Improved Oral Health This article provides a proposed conceptual framework that discusses the potential mechanism of upstream and intermediate factors impacting oral health literacy and how OHL affects oral health outcomes. Francisco Ramos-Gomez, DDS, MS, MPH, and Tamanna Tiwari, MPH, MDS, BDS

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UCLA-Sesame Street Collaboration To Improve Children’s Oral Health This paper describes a series of activities through which UCLA and Sesame Street collaborated to develop and use oral health resources as part of a children’s oral health awareness campaign. James J. Crall, DDS, ScD; David Cohen, Sofia Polo, MPH; and Sylvia Rusnak, PhD

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Innovative Health Literacy Strategy Advances Health Equity: Perspectives of the Cambridge Health Alliance Past and Present Department Chiefs This commentary discusses the mission and the focus of the Cambridge Health Alliance and how it aligns with the Healthy People 2030 initiative. Ryan S. Lee, DDS, MPH, MHA, and Brian J. Swann, DDS, MPH D ECEMBER 2 0 2 1

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published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

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Lindsey A. Robinson, DDS, and Nicole Holland, DDS, MS Guest Editors

Volume 49 Number 12 December 2021

Letters to the Editor www.editorialmanager. com/jcaldentassoc

Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif. Bradley Henson, DDS, PhD , associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif. Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif. Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

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Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Richard W. Valachovic, DMD, MPH, president emeritus, American Dental Education Association, Washington, D.C.

Guest Editorial

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Corona Creative Eric K. Curtis, DDS, MA

fter what seemed like a lifetime, we crept back to the office and cracked the door open, checking supplies, flushing lines and tentatively inviting our patients back into an environment more fully than ever wrapped, masked, wiped, suctioned and distanced. My employees were nervous about the prospect of facing the public, terrified of a menace that, the avalanche of media reportage notwithstanding, was next to impossible to assess. As novelist Arundhati Roy wrote, “Who can look at anything anymore — a door handle, a cardboard carton, a bag of vegetables — without imagining it swarming with those unseeable, undead, unliving blobs dotted with suction pads waiting to fasten themselves on to our lungs?”1 The virus made me uneasy too, but I still found myself craving the rhythms and clarity of work. Being sidelined for seven weeks might have been a rehearsal for retirement, but only if retiring consisted of retreating to a cave. I woke at odd hours. I lost track of days. From inside my little grotto, the Arizona governor’s executive order to resume “nonessential” surgeries beckoned like sunshine, and I was ready to stagger out into its warmth, even if fresh air would have to be muzzled by filtration-efficient masks and the light refracted through a face shield. (Sunburn and heat stroke and skin cancer? Life demands that we weigh risks.) My staff was brave: The employees voted to reopen the office, and they made light of their fears by taking “socially distancing” photos wearing inflatable body balls. My colleagues were resourceful, helping me find masks and offering me tips on managing patient flow. My patients

Reading pandemic fiction during a pandemic feels even more edgy and piquant than I would have imagined — and much more empowering.

were supportive — one, a nurse, supplied us with scarce hand sanitizer that she found at a feed store. My mother even sewed a stack of cloth gowns that we could change for laundering between patients. Yet of all the preparations for engaging with the realities of my new world, none gave me better psychological cover than reading fiction. I’ve always been a reader. I developed the habit early in life, pulling books out of my parents’ bookshelves — inevitably with a sense of mystery, as if unsheathing broadswords of mythical promise — and riding my bike down to the local library on Saturdays, intrigued that linear marks on a page could readily open my brain to other people’s consciousness, their realities, ideas and lively conversations. Reading invited an introverted kid to live boldly, imagine the world’s vastness and fly to its far corners, even to blast off the planet, G-forces tearing at my mind, to touch the stars. So, of course, when I found myself pressed under the thumb of the COVID-19 pandemic, I naturally fell back on that well-worn impulse to read my way out. If you like books about mass calamity, you’ll need more than seven weeks. Disaster threats, both real and imagined, are as old as history, and their symbolic trappings often loom as important as the event. The “Epic of Gilgamesh” describes

a civilization-ending flood so dramatically pegged to notions of religious obedience and sacrifice that the story was retold in the Bible, the Quran and the Hindu Dharmasastra, from which it rippled into Buddhist and Jainist texts. Moses’s Egyptian plagues, what with all those frogs and the pharaoh’s disdain and the lamb’s blood daubed on Israelite doors, famously celebrated in Cecil B. DeMille’s Hollywood, are more circumspectly remembered each year at Passover. Latter-day cataclysms sparked by the struggle of good versus evil, as promised in the book of Revelation, continue to resonate in Terry Pratchett and Neil Gaiman’s novel “Good Omens” (1990). The earliest tales of apocalypse invariably warn against human hubris. “You are the plague,” a blind man tells Oedipus in that classical Greek tragedy, as Jill Lepore reports in “Don’t Come Any Closer: What’s at stake in our fables of contagion?”2 Ancient lessons are rebirthed in modern yarns of technology-triggered disaster, including H.G. Wells’s “The Time Machine” (1895), Ray Bradbury’s “The Martian Chronicles” (1950), Walter M. Miller’s “A Canticle for Leibowitz” (1959) and Kurt Vonnegut’s “Cat’s Cradle” (1998). But the most expansive, the most profound and perhaps the most gripping annihilation stories arise from the unpredictability of disease. D ECEMBER 2 0 2 1

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Susan Sontag describes the universality of physical entropy in “Illness as Metaphor” (1978): “Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.” Sontag also outlines the social mayhem of everyone getting sick at the same time. Pandemic, she writes, offers “evidence of a world in which nothing important is regional, local, limited; in which everything that can circulate does, and every problem is, or is destined to become, worldwide.” Contagion stories, from Boccaccio’s “The Decameron” (1353) — in which some rich folks repair to a villa above Florence to self-isolate during an epidemic of bubonic plague — to Daniel Defoe’s “A Journal of the Plague Year” (1722), quickly went global far ahead of any germ theory. The early pandemic narratives feel, even now — especially now — eerily prescient. Consider, for instance, “Frankenstein” author Mary Shelley’s 1826 tale “The Last Man,” in which an unnamed pestilence brought on by climate change wipes out the world’s population in the 21st century. “There has always been literature of pandemic because there have always been pandemics,” Ed Simons writes, noting that narrative is an attempt to make meaning out of the randomness of disease, to confirm “that sense still exists somewhere.”3 Stories about illness, Simons concludes, are “a reclamation against that which illness represents — that the world is not our own.” Parables of pestilence generally embody, as Sontag implies, a kind of analysis of society in reverse, a way of examining our values by looking at their shadows. “The great dream of the Enlightenment was progress; the great dread of epidemic is regress,” Lepore writes. “But in American literature such destruction often comes with a democratic twist: Contagion is the last leveler.” 728 D ECEMBER

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Some such tales are patterned on real events. “Pale Horse, Pale Rider” (1939) by Katherine Anne Porter covers the 1918 Spanish flu pandemic. “Love in the Time of Cholera” (1988) by Gabriel García Márquez revolves around a 19th century cholera epidemic. “Outbreak” (1987) by Robin Cook and “The Hot Zone” (1999) by Richard Preston reflect on the Ebola virus. Norman Spinrad’s “Journal of the Plague Years” (1988) and Tony Kushner’s “Angels in America” (1991) chronicle AIDS. Many, including Stephen King’s “The Stand” (1978), “The Dog Stars” (2012) by

Parables of pestilence generally embody, as Sontag implies, a kind of analysis of society in reverse.

Peter Heller and Emily St. John Mandel’s “Station Eleven” (2014), focus on the flu. “I keep having people say, ‘Gee, it’s like we’re living in a Stephen King story,’” King told National Public Radio. “And my only response to that is, ‘I’m sorry.’”4 But many more come steeped in pure fantasy. In “The Andromeda Strain” (1969) by Michael Crichton, an Arizona town is the first to go when extraterrestrial microbes fall to earth and wreak havoc. “The Book of M” (2018) by Peng Shepherd describes a perplexing medical condition in which whole populations lose their memory — and their shadow. Some tales turn victims into monsters. Vampire tropes are popular, including Richard Matheson’s “I Am Legend” (1954), in which a virus engineered to cure cancer transforms humans into

blood-sucking mutants, and Justin Cronin’s “The Passage” (2010), where a botched government experiment to prolong human life unleashes a bat-vectored virus that converts most of humanity into the undead. Viral pandemics that change people into zombies also loom large, from Max Brooks’s “World War Z” (2006) to “Zone One” (2011) by Colson Whitehead. In Cormac McCarthy’s “The Road” (2006), an unnamed apocalyptic event simply turns humans into their worst selves. The most influential pandemic narrative, and the one that has become a touch point for this pandemic, is arguably Albert Camus’s “The Plague” (1947). Just as W.H. Auden’s poem “September 1, 1939,” which, although referencing Germany’s invasion of Poland, evoked the image of a lonely, frightened person in New York and so became an anthem of 9/11, “The Plague” speaks powerfully to the current coronavirus moment. I studied “The Plague” with a virtual reading group led by a novelist on faculty at Columbia University’s Narrative Medicine program. The story follows the work of a physician in a French colonial city in North Africa as it suffers an outbreak of bubonic plague. The townspeople, suddenly ordered to shelter in place, feel exiled and imprisoned, like pawns pushed around someone else’s board game. Through the eyes of the doctor, who witnesses denial, outrage, suffering, terror, resignation and death on scales both enormous and intimate — most of his closest friends succumb — Camus’s narrative explores themes of isolation and separation and individual morality and community responsibility in the face of public disruption. What was Camus’s point? And what should a reader take away from the experience of living through a pandemic while reading about one?

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For one thing, Camus thought that extremity should force us to rise to the occasion, rejecting greed and selfishness, and gathering to our hearts and minds renewed courage, patience, cooperation and love. “[Camus] was a public man of action who insisted that all truly important questions came down to individual acts of kindness and goodness,” Tony Judt writes.5 For another, Camus may have hoped that people learn humility. A pandemic, he judged, shows that success is never fully self-determined, nor advancement wholly predicated on skill, talent and a committed work ethic. Some circumstances are random, and nature always wins. As philosopher Alain de Botton puts it, “Being alive always was and will always remain an emergency”6 “The Plague” also warns against complacency and apathy. “The plague bacillus never dies or vanishes entirely,” Camus writes. Instead, it lurks, biding its time, ready to return without warning “for the instruction or misfortune of mankind.” Yet even if plagues never expire, our resolve to fight them often does, and the danger of laxity rises with time. As David Quammen writes, “Mundane but crucial infectioncontrol measures — the assiduous hand washing and wiping of doorknobs with alcohol — can lapse after a crisis.”7 Finally, Camus seems to believe that pandemonium should reacquaint us with sensitivity and subtlety. We live in a world of sharp dichotomies — us versus them, red versus blue, urban versus rural—that limit our imagination, our compassion and our ability to navigate setbacks. As Colum McCann writes: “We refuse to embrace contradiction. We eschew the notion of nuance … but what if this virus, which makes us tiny and epic both, can teach us a little about holding contradictory ideas again?”8

And this, I think, is Camus’s greatest lesson in “The Plague”: Negotiating an emergency demands that we embrace contradictions. Camus’s doctor is able to work through the catastrophe that engulfs him by learning to hold inconsistent or conflicting thoughts at the same time— urgency and composure, helplessness and control, solitude and companionship, despair and hope. (In the latter, I am reminded of the introspective pastor, played by Ethan Hawke, in the 2017 film “First Reformed,” which my wife Tonka and I watched one night last month as our normal lives lay frozen. The pastor tells one of his parishioners, “Wisdom is holding two contradictory truths in our mind simultaneously, hope and despair.”) Life is not binary — choices are never just right or left, this or that, up or down, good or bad. The chips simply don’t fall one way or the other. We live with ambiguity, and many events and circumstances arrive as a mixed bag. Acknowledging both life’s uncertainties and its possibilities, Camus concludes that the sort of mental balancing act that accepts — together, one informing the other — such opposing elements as worry and confidence, or anxiety and determination, or confusion and decisiveness, is one likely to handle the dislocations of crisis. “The Plague,” then, helped me understand that bewilderment can yet propel sound decisions, tempering audacity with a grounded calculation — like the emotional version of a cost-benefit analysis. The recognition gave me a needed shot of optimism. The governor wielded his executive order, but Albert Camus sent me back to work. n

RE F E RE N C E S 1. Roy A. The Pandemic Is a Portal. Financial Times April 3, 2020. 2. Lepore J. What Our Contagion Fables Are Really About. The New Yorker March 30, 2020. 3. Simon E. On Pandemic and Literature. themillions.com March 12, 2020. 4. Gross T. Stephen King Is Sorry You Feel Like You’re Stuck in a Stephen King Novel. NPR April 8, 2020. 5. Just T. On “The Plague.” The New York Review Nov. 29, 2001. 6. de Botton A. Camus on the Coronavirus. The New York Times March 19, 2020. 7. Quammen D. Why Weren’t We Ready for the Coronavirus. The New Yorker May 11, 2020. 8. McCann C. Til’ Human Voices Wake Us: What If This Virus Can Teach Us To Change Ourselves? Time May 1, 2020.

Eric K. Curtis, DDS, MA, is the editor for the Arizona Dental Association. He teaches creative writing in the Arizona state educational system and practices family dentistry in Safford, Arizona. Reprinted with permission from Inscriptions, the Journal of the Arizona Dental Association, June 2020 issue.

The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA. D ECEMBER 2 0 2 1

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Reviewers

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Thank You to the 2021 Reviewers The Journal of the California Dental Association is grateful for the many professionals who formally reviewed manuscripts in 2021 and offered their recommendations. We extend our thanks to those who are instrumental in helping us produce this award-winning scientific publication. Kenneth Abramovitch, DDS, MS Loreto Abusleme, DDS, PhD Marco M. Allard, PhD Tamer Alpagot, DDS, PhD Pamela Alston, DDS, MA Baharak Amanzadeh, DDS, MPH Homa Amini, DDS, MS, MPH Elizabeth Andrews, DDS, MS Phimon Atsawasuwan, DDS, MSc, MSc, MS, PhD David M. Avenetti, DDS, MPH, MSD Leif K. Bakland, DDS Wade M. Banner, DMD Nicole Barkhordar, DDS, MEd Moshe Benarroch, DMD Joel Berg, DDS, MS Jonas Bianchi, DDS, MS, PhD Patrick Blahut, DDS, MPH John L. Blake, DDS Robert L. Boyd, DDS Carolyn Brown, DDS Michael E. Cadra, DMD, MD Jean Marie Calvo, DDS, MPH Benjamin Chaffee, DDS, MPH, PhD David Chambers, EdM, MBA, PhD Evan Chang, DDS Jennifer Chang, DDS, MSD Kai Chiao Joe Chang, DDS, MS Daniel Chavarria, DDS, PhD Elisa M. Chávez, DDS Yo-wei Chen, DDS, MSc Katharine Ciarrocca, DMD, MSEd Donald Clem, DDS Scott Conley, DDS Shannon M. Conroy, PhD, MPH Santos Cortez, DDS Darren P. Cox, DDS. MBA Michael John Danford, DDS Gerald E. Davis, DDS, MA, MS Raymond Dionne, DDS, PhD Evelyn Donate-Bartfield, PhD Gary L. Dougan, DDS, MPH Gerald I. Drury, DDS Gregory Dussor, PhD Robert M. Eber, DDS, MS Chad Edwards, DDS Alec Eidelman, DMD, MPH 730 D ECEMBER

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Joel P. Epstein, DMD, MSD Margaret Fehrenbach, RDH, MS Alan L. Felsenfeld, DDS Leticia Ferreira, DDS, MS Debra S. Finney, MS, DDS Julie Frantsve-Hawley, PhD, CAE Simon Gamer, DDS Jack D. Gerrow, DDS, MS, MEd, Cert Pros Donald B. Giddon, DMD, PhD Alan H. Gluskin, DDS Rhoda Gonzales, RDH, RDHAP Harry S. Goodman, DMD, MPH Carmen V. Graves, DDS, MSc, MS Colleen C. Greene, DMD, MPH Rishi Jay Gupta, DDS, MD, MBA Mina Habibian, DMD, MS, PhD Bradley Henson, DDS, PhD Reza Heshmati, DDS, MPH, MS Alice Horowitz, PhD Robert A. Horowitz, DDS Robert Isman, DDS, MPH Lisa Itaya, DDS Parvati Iyer, DDS Poonam Jain, BDS, MS, MPH Daniel Jenkins, DDS Peter Fink Johnson, DMD Robert Julian, DDS, MD Richard T. Kao, DDS, PhD Mathew Thomas Kattadiyil, BDS, MDS, MS Junad Khan, BDS, MSD, MPH, PhD Gary D. Klasser, DMD Navid N. Knight, DDS Richie Kohli, BDS, MS Paul H. Korne, DDS, MCID Satish Kumar, DMD, MDSc, MS Brian Laurence, DDS, PhD Huong Le, DDS Irving Lebovics, DDS Brian LeSage, DDS P. Lundergan, DDS William P. Lundergan, DDS, MS Cindy Lyon, RDH, DDS, EdD Mark D. Macek, DDS, DrPH Monty MacNeil, DDS, MDentSc Peter Mah, DMD, MS

Fatima Mashkoor, DDS Malay Mathur, DDS Melanie E. Mayberry, DDS, MS Keith A. Mays, DDS, MS, PhD Carol J. McCutcheon, DDS Diana Messadi, DDS, MMSc, DMSc Peter G. Meyerhof, DDS, PhD Peter Milgrom, DDS Somsak Mitrirattanakul, DDS, PhD Shelley Miyasaki, DDS, PhD Sherry Mostofi, JD Peter Moy, DMD Roseann Mulligan, DDS, MS Richard P. Mungo, DDS, MSD, MeD Theodore A. Murray Jr., DDS Richard J. Nagy, DDS M. Sedegh Namazikhah, DMD, MSEd Mahvash Navazesh, DMD Man Wai Ng, DDS, MPH Warden H. Noble, DDS, MS Nooshin Noghreian, DDS Gregory Olson, DDS, MS Temitope Omolehinwa, BDS, DScD Udochukwu Oyoyo, MPH Kimberlie Payne, RDH, BA Leslie Plack, DMD Howard F. Pollick, BDS, MPH Ryan Quock, DDS Lori Rainchuso, DHSc, MS, RDH Daniel Ramos, DDS, PhD Rajesh Raveendranathan, BDS, MICCMO, PhD David Reznik, DDS Dwight D. Rice, DDS Lindsey Robinson, DDS Giampiero Rossi-Fedele, BDS, MDS, PhD Ilan Rotstein, DDS Shaiba Sandhu, BDS, DDS Vidya Sankar, DMD, MHS Elise Sarvas, DDS, MSD, MPH Karen Schulze, DDS, PhD Kumar C. Shah, BDS, MS Gina Sharps, MPH, RDH, CTTS Muhammad Ali Shazib, DMD

Ya Shen, DDS, PhD Charles Shuler, BSc, DMD, PhD Steven Silverstein, DMD, MPH Harel Simon, DMD Piedad Suárez Durall, DDS Montry Suprono, DDS, MSD Jaydeep S. Talim, BDS, MSC. George Taylor, DMD, MPH, DrPH Marisol Tellez-Merchan, BDS, MPH, PhD Bobby Thikkurissy, DDS, MS Thanh Tam Ton, DDS, MS, MPH Richard D. Trushkowsky, DDS Robert Utsman, DDS, MPM William Van Dyk, DDS Timothy F. Walker, BS, MS, DDS Lynn Walton-Haynes, DDS, MPH Marisa K. Watanabe, DDS, MS Bruce L. Whitcher, DDS Jill White, MSc, DDS Andrew Young, DDS, MSD Anna Yuan, DMD, PhD Zhe Zhong, DDS, PhD Zheng Zhou, DDS, PhD Anthony J. Ziebert, DDS, MS Every effort was made to ensure the accuracy of the list of contributors. If you discover an error or omission, please accept our apologies.

Impressions

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Nanozymes Prevent Dental Plaque Build-Up

FerIONP can detect pathogenic biofilms on natural teeth via a facile colorimetric reaction. Findings provide clinical evidence and the theranostic potential of catalytic nanoparticles as a targeted anti-infective nanomedicine. (Reprinted with permission from Nano Lett. 2021 Oct 25. doi: 10.1021/acs.nanolett.1c02702. Online ahead of print. Copyright 2021 American Chemical Society.)

Research from the University of Pennsylvania, in collaboration with Indiana University, suggests that an FDA-approved therapy for irondeficiency anemia also holds promise for treating, preventing and even diagnosing dental decay. The therapeutic — a combination of an ironoxide nanoparticle-containing solution called ferumoxytol and hydrogen peroxide — was applied to real tooth enamel placed in a denture-like appliance and worn by the study subjects. The study, published in the journal Nano Letters, found that a twice daily application of ferumoxytol, which activated hydrogen peroxide contained in a follow-up rinse, significantly reduced the buildup of harmful dental plaque and had a targeted effect on the bacteria largely responsible for tooth decay. These types of nanoparticles with enzyme-like properties are sometimes known as “nanozymes” and are increasingly being explored for their potential in biomedical and environmental applications. “We found that this approach is both precise and effective,” said Hyun (Michel) Koo, DDS, MS, PhD, a professor at the University of Pennsylvania School of Dental Medicine. “It disrupts biofilms, particularly those formed by Streptococcus mutans, which cause caries, and it also reduced the extent of enamel decay. This is the first study we know of done in a clinical setting that demonstrates the therapeutic value of nanozymes against an infectious disease.” The work is an extension of a 2018 paper published in Nature Communications in which Dr. Koo and colleagues showed that the iron oxide nanoparticle-hydrogen peroxide treatment could prevent biofilm accumulation and tooth decay in an experimental model and an animal model. In the current work, the scientists wanted to take the next logical step: working in humans. In a randomized study, 15 participants used a removable, denture-like device with real tooth enamel attached. The participants applied a sugar-containing solution to the appliance four times a day, mimicking high-sugar meals and snacks consumed in the course of daily life. Participants were asked not to brush the enamel specimens but instead to rinse the appliance twice a day. Participants were divided into three groups. One group used the ferumoxytol then the hydrogen peroxide rinse, another group rinsed with a solution that provides the inactive ingredients in ferumoxytol, and the third group rinsed with water alone. After 14 days, the researchers analyzed the biofilms that accumulated on the enamel specimens. They found the experimental treatment potently reduced the growth of biofilms containing S. mutans and could kill this bacterium with high specificity. Other commensal bacteria normally found in the mouth were not affected by the ferumoxytolhydrogen peroxide therapy. Read more of this study in Nano Letters (2021); doi:10.1021/ acs.nanolett.1c02702. n D ECEMBER 2 0 2 1

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Best, Worst and Unproven Tools for Dental Care

Study Reveals How Acid Damages Teeth The University of Surrey and the School of Dentistry at the University of Birmingham have developed a new technique to improve understanding of how acid damages teeth at the microstructural level. The researchers performed a technique called “in situ synchrotron X-ray microtomography” at Diamond Light Source, a special particle accelerator facility. There, electrons were accelerated to near light speed to generate bright X-rays that were used to scan dentine samples while they were being treated with acid. This enabled the team to build clear 3D images of dentine’s internal structure with submicrometer resolution (a micrometer being onethousandth of a millimeter). By analyzing these images over the six hours of the experiment, the researchers conducted the first-ever time-resolved 3D study (often referred to as 4D studies) of the dentine microstructural changes caused by acid. The study, published in Dental Materials, highlights that acid dissolves the minerals in different structures of dentine at different rates, which can affect the integrity of the dental structure. This research aims to develop knowledge that leads to new treatments that can restore the structure and function of dentine. Before this study, relatively little was known about how exactly acid damages the dentin inside of teeth at a microstructural level, 732 D ECEMBER

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New research led by the University at Buffalo aims to determine which oral hygiene tools actually prevent gum disease. The paper, published in the Journal of the International Academy of Periodontology, examines the effectiveness of various oral hygiene devices. The result: Only a handful of self-administered interventions provide additional protection against gingivitis and periodontitis beyond brushing one’s teeth with a basic toothbrush. At the moment, all other oral hygiene interventions are only supported by insufficient evidence, said Frank Scannapieco, DMD, PhD, principal investigator and chair and professor of oral biology in the UB School of Dental Medicine. According to the research, interdental brushes and water picks performed better than other interdental oral hygiene devices at reducing gingivitis, and both should be used in combination with daily toothbrushing to prevent gum disease. Among the numerous mouth rinses examined, those based on CHX, CPC and essential oils (such as Listerine) were proven to be effective at significantly reducing plaque and gingivitis. While not effective at fighting gingivitis, toothpicks were useful for monitoring gum health. The study found that Triclosan toothpastes and mouth rinses significantly reduced plaque and gingivitis, however, the compound is linked to the development of various types of cancers and reproductive defects. Triclosan has been removed from most popular toothpastes in the U.S. Electric-powered toothbrushes are no more effective at reducing plaque and gingivitis than a basic toothbrush, according to the study. And while little evidence has been published in support of dental floss to reduce plaque and gingivitis, the authors say that floss is useful to remove interdental plaque for people with tight space between their teeth and reduces the risk for caries. The investigators found insufficient evidence that mouthwashes based on tea tree oil, green tea, anti-inflammatory agents, hydrogen peroxide, sodium benzoate, stannous fluoride, hexetidine or delmopinol reduced gingivitis. They also found little evidence that supports the claim that dietary supplements improve gum health and insufficient evidence that scaling prevents gum disease. Learn more about this study in the Journal of the International Academy of Periodontology (2021); International Academy of Periodontology (perioiap.org).

said Dr. Tan Sui, PhD, senior lecturer in materials engineering at the University of Surrey, who led the research group.“ This new research technique changes that and opens the possibility of helping

identify new ways to protect dental tissues and develop new treatments,” he said. Learn more about this study in Dental Materials (2021); doi:10.1016/ j.dental.2021.09.002.

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Heartburn Drugs May Have Oral Health Benefits The use of heartburn medication is associated with decreased severity of gum disease, according to a recent University at Buffalo study. The research found that patients who used

proton pump inhibitors (PPIs) — a class of drugs commonly prescribed to treat heartburn, acid reflux and ulcers — were more likely to have smaller probing depths in the gums.

Study Finds Skull Growth Determines Tooth Emergence Most people get their three adult molars at ages 6, 12 and 18 — much later than our closest living relative, the chimpanzee, who gets those same adult molars at around ages 3, 6 and 12. Paleoanthropologists have wondered why humans evolved molars that emerge into the mouth at these specific ages and why those ages are so delayed compared to living apes. A study, published in the journal Science Advances, may have answered those questions. Scientists at the University of Arizona and Arizona State University discovered that the combination of how fast jaws grow with how long or protruding jaws will ultimately become in adults determines the timing of when molars will emerge. This delicate dance results in molars coming in only when enough of a “mechanically safe” space is created. Molars that emerge “ahead of schedule” would do so in a space that, when chewed on, would disrupt the fine-tuned function of the entire chewing apparatus by causing damage to the jaw joint. The research team created 3D biomechanical models of skulls, including the attachment positions of each major chewing muscle, throughout the growth period in nearly two dozen different species of primates ranging from small lemurs to gorillas. When combined with details about the rates of jaw growth in these species, their integrative models revealed the precise spatial relationship and temporal synchrony of each emerging molar within the context of the growing and shifting masticatory system. The authors noted that this research establishes two things: It convincingly demonstrates that it is the precise biomechanical relationship between growing faces and growing chewing muscles that results in the tight and predictive relationship between dental development and life history, and it reveals that our species’ delayed molar emergence schedules are a result of the evolution of overall slow growth coupled with short jaws and retracted faces — faces situated directly beneath our braincase. Read more of this study in Science Advances (2021); doi:10.1126/ sciadv.abj0335. Lateral view of skulls (A) and the position and orientation of muscle lines (B). (Credit: H. Glowacka, University of Arizona.)

The findings, published in the journal Clinical and Experimental Dental Research, may be linked to the side effects of PPIs, which include changes in bone metabolism and in the gut microbiome, says lead investigator Lisa M. Yerke, DDS, clinical assistant professor in the department of periodontics and endodontics at the UB School of Dental Medicine. “PPIs could potentially be used in combination with other periodontal treatments; however, additional studies are first needed to understand the underlying mechanisms behind the role PPIs play in reducing the severity of periodontitis,” Dr. Yerke said. For the study, researchers analyzed clinical data from more than 1,000 periodontitis patients either using or not using PPIs. Probing depths were used as an indicator of periodontitis severity. Only 14% of teeth from patients who used PPIs had probing depths of 6 millimeters or more compared to 24% of teeth from patients who did not use the medication. And 27% of teeth from patients using PPIs had probing depths of 5 millimeters or more, compared to 40% of teeth from nonPPI users, according to the study. The researchers theorized that PPIs’ ability to alter bone metabolism or the gut microbiome, as well as potentially impact periodontal microorganisms, may help lessen the severity of gum disease. Learn more about this study in Clinical and Experimental Dental Research (2021); doi:10.1002/cre2.495.

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More Than Words: Reframing Our Approach to Oral Health Literacy Lindsey A. Robinson, DDS, and Nicole Holland, DDS, MS

GUEST EDITORS Lindsey A. Robinson, DDS, is a board-certified pediatric dentist and has maintained a dental practice in Grass Valley, Calif., since 1996. She has served on the National Academies of Sciences, Engineering and Medicine Roundtable on Health Literacy as an oral health representative since 2013. Conflict of Interest Disclosure: None reported.

Nicole Holland, DDS, MS, is an assistant professor and the director of health communication, education and promotion in the Tufts University School of Dental Medicine’s Department of Public Health and Community Service. Her research interests include the intersection of health literacy, language access and oral health as well as the impact of oral health messaging in the media. Conflict of Interest Disclosure: None reported.

he intersection of health literacy, health equity and oral health is bursting with opportunities to enact change for a better future for our patients, communities and nation. As stated in both the foundational principles and overarching goals of the most recent release of the national health promotion and disease prevention initiative Healthy People 2030: Achieving health and well-being requires eliminating health disparities, achieving health equity and attaining health literacy.1 Of note, 15 oral healthrelated objectives have been identified to facilitate achieving those goals.2 Building from the definitions of personal and organizational health literacy referenced from Healthy People 2030,3 this issue of the Journal of the California Dental Association takes a unique look at how oral health organizations can play a critical role at the intersection of health literacy and health equity. The authors offer rich perspectives with key takeaways, including concrete action

steps and useful resources. It is our hope that readers will finish this issue catalyzed and ready to affect change in their respective practices and organizations. The issue kicks off with the article “Organizational Health Literacy in Oral Health: A Multilevel Perspective” by the team led by Dr. Lindsay Rosenfeld. The authors make a compelling argument for how organizational health literacy can be used to reach oral health and health equity goals. By presenting best practice examples across national, state and community levels, the authors elucidate the crucial role of oral health organizations in driving system-level changes and challenge readers to consider how an organizational health literacy approach can help improve the oral health of our patients and communities. A system-level approach would be remiss without considering the significance of linguistic diversity in our communities and the ways in which language barriers impact the provision of equitable oral health care services, D ECEMBER 2 0 2 1

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which is often overshadowed in larger discussions of oral health literacy. Dr. Holland’s article outlines a brief historical overview of language access policy and its impact on the dental profession, providing actionable recommendations for dental providers to facilitate equitable, quality care for their patients and communities. Adequately stating, “Oral health cannot be positioned as a matter of social justice, health equity and human rights if patients are unable to gain, process and understand oral health, available oral health services and healthy oral health behaviors,” the article “Oral Health Literacy Framework: The Pathway to Improved Oral Health” by Drs. Francisco Ramos-Gomez and Tamanna Tiwari details myriad ways in which health literacy influences oral health. The authors propose a conceptual framework addressing language, culture and other factors impacting oral health literacy and the effects on oral health outcomes. The issue culminates in two distinct examples of applied organizational approaches to oral health literacy. The article “UCLA-Sesame Street Collaboration To Improve Children’s Oral Health” by Dr. James Crall and his team sheds light on a collaborative partnership between UCLA and Sesame Street resulting in an evidence-based, children’s oral health awareness campaign to inform families and caregivers about the importance of early childhood oral health and finding a dental home by age 1. With a goal of improving the oral health of children in Los Angeles County, this article acknowledges the limitations of narrowly focusing on biological risk factors of early childhood caries and highlights the need for a broadened scope focused on social, behavioral and family factors and oral health literacy. The article “Innovative Health Literacy Strategy Advances Health Equity: 736 D ECEMBER

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Perspective of Cambridge Health Alliance Past and Present Department Chiefs” by Drs. Ryan Lee and Brian Swann details the transformative experience of an expanding dental department in a nonprofit, community hospital by exploring how fundamental health literacy principles, particularly the role of provider literacy, impact the ways in which equitable oral health care and services are communicated and practiced throughout their safety-net organization. We thank our many health literacy colleagues for generously sharing their knowledge and experience as authors for this Journal issue. Collectively, the articles articulate the understanding that health literacy is multidimensional and influenced by environmental conditions, system complexities, communication context and social and cultural factors. With the exacerbation of health disparities and inequities in a post-pandemic world, now is the time for practices and organizations to focus intentional efforts on health literacy improvements to optimize oral and overall health for all. n RE SO U RCE S 1. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030 Framework. 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Health Literacy in Healthy People 2030.

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commentary C D A J O U R N A L , V O L 4 9 , Nº 12

Organizational Health Literacy in Oral Health: A Multilevel Perspective Lindsay Rosenfeld, ScD, ScM; Kathryn Atchison DDS, MPH; Nicole Holland, DDS, MS; Kelly Cantor, MPH, CHES; and Lindsey A. Robinson, DDS

abstract Healthy People 2030 has been released and includes new health literacy definitions that more fully reflect it as a multidimensional concept connected to the social and structural determinants of health. Keywords: Oral health literacy, Healthy People 2030, general health, organizational health literacy, oral health, health equity

AUTHORS Lindsay Rosenfeld, ScD, ScM, is a social epidemiologist with research, practice and policy interests focused on the social and structural determinants of health and child equity. She is an instructor at the Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences and a scientist and lecturer with the Institute for Child, Youth and Family Policy at the Brandeis University, Heller School for Social Policy & Management. Conflict of Interest Disclosure: None reported.

Kathryn A. Atchison, DDS, MPH, is a professor in the division of public health and community dentistry at the University of California, Los Angeles, School of Dentistry and is jointly appointed in the UCLA Jonathan and Karin Fielding School of Public Health, department of health policy management. Conflict of Interest Disclosure: None reported.

Lindsey A. Robinson, DDS, is a board-certified pediatric dentist and has maintained a dental practice in Grass Valley, Calif., since 1996. She has served on the National Academies of Sciences, Engineering and Medicine Roundtable on Health Literacy as an oral health representative since 2013. Conflict of Interest Disclosure: None reported.

he importance of health literacy in oral and general health is wellestablished.1 Two previous issues of the Journal of the California Dental Association (April 2012, August 2020) were dedicated to the idea that health literacy is vital to positive oral health outcomes.2 The recent release of Healthy People 2030 includes new health literacy definitions that more fully reflect the connection to the social and structural determinants of health.3 Personal health literacy is defined as: “The degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others.” Organizational health literacy is defined as: “The degree to which organizations equitably enable individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others.” A 2021 article by Brach and D ECEMBER 2 0 2 1

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Harris describes how Healthy People 2030 features health literacy as part of its framework, emphasizing the responsibility of organizations at any level to focus on the systems, processes, operations and interactions that make information and services easy to find, understand and use.4 This commentary was invited to highlight on-the-ground organizational health literacy best practice in oral health in order to galvanize the field toward more robust adoption of such practices in efforts to meet the 15 oral health objectives in Healthy People 2030. For example, OH-02: Reduce the proportion of children and adolescents with active and currently untreated tooth decay in their primary or permanent teeth, and OH-11: Increase the proportion of persons served by community systems with optimally fluoridated water systems. As such, the newest Healthy People health literacy definitions are vital primers for the focus of this commentary and the featured examples, which highlight systems change to drive optimal, equitable oral health opportunities and outcomes through a health literacy lens. To choose the examples described, the authors discussed the best practices they had seen themselves or heard about from colleagues or via conferences, presentations, articles, listservs and beyond. This is the first known attempt to convey such organizational health literacy practice across levels in oral health, with the aim of galvanizing next research and action steps.

Health Literacy and Oral Health

Briefly, health literacy is an interaction, comprised of literacy skills (e.g., skills of people and professionals related to reading, writing, talking, listening and numeracy), texts (e.g., informational brochures, patient-provider discussions, signage, websites), tasks (e.g., from completing a health history form 740 D ECEMBER

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to registering for an appointment) and context (e.g., emotive and physical issues, practice norms, structural facilitators and barriers), involving patients, professionals, organizations and systems.5 Descriptions of the relationship between health literacy and individual or population skills are most common thus far, suggesting that more-developed personal literacy skills are related to more positive general health and oral health outcomes.1,6–8 An increasing evidence base also demonstrates the importance of organizational health literacy, the role of an organization

The authors discussed the best practices they had seen themselves or heard about from colleagues or via conferences, presentations, articles, listservs and beyond. in equitably enabling people to find, understand and use health information and services. This encompasses organizational policies, institutional practices, navigation, provider/patient communication and interaction, culture and language, communication (print materials, forms, websites, patient portals) and the patient/ family population, staff and others who may participate in the environment.9 For example, a 2014 American Journal of Public Health article focused on dental organizational health literacy found that implementation of a health literacy environmental scan was acceptable to dental directors and provided clinic directors information on how to enhance care and outreach to make dental environments more user-friendly and health literate.10

An organizational health literacy approach allows for organizations and oral health practices to assess, adapt and design an environment that can improve general and oral health.9–12 Though organizational health literacy assessments originally focused on patientfacing entities (e.g., dental clinics, dental practices),9,11,13–16 organizational-level assessments are also used by oral health organizations to improve their own organizational health literacy, which extends to their staff and constituents. We present examples of organizations that have used an organizational health literacy lens to improve health at various levels (e.g., individual/ family, community, state, regional/ multistate and national) (FIGURE ).

The National Academies’ Role in the Evolution of Organizational Health Literacy Across Levels

The National Academies of Sciences, Engineering and Medicine (NASEM) is an independent, nonprofit organization that was established to provide evidencebased information to decision-makers in the public and private health sectors.17 Under the NASEM umbrella, the Roundtable on Health Literacy (Roundtable) has led efforts to explore the discipline since 2004, shortly after the release of the seminal publication “Health Literacy: A Prescription to End Confusion.”7 In the ensuing years, health literacy has become a priority for national action. It was initially fueled by evidence reporting that people with limited literacy skills had worse health outcomes, in general.6 And even those with average literacy skills had difficulty understanding basic printed health information, according to the 2003 National Assessment of Adult Literacy.18 Simultaneously, the concept of health literacy evolved. Initially the emphasis

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National

American Dental Association

NIDCR/ NIH1

Atrium Health

Regional/ Multistate

California Dental Association UC3 Dental School Partnerships

Insurance-payer groups

CDC2 HealthPartners

State Depts of Public Health

State

Community Dental schools

Schoolbased clinics

Dental practices

Local dental associations/ societies

Individual /Family

Kaiser

Minnesota Health Literacy Partnership

State dental licensure

FQHC4 dental clinics

FIGURE . This figure displays oral health organizations and the levels on which they operate. The bolded ovals are discussed directly in the text. Nonbolded ovals are examples of organizations at that same level: 1. National Institute of Dental and Craniofacial Research, National Institutes of Health; 2. Centers for Disease Control and Prevention; 3. University of California; 4. Federally Qualified Health Centers.

was on the measurement of individual literacy skills and interventions focused on patients with underdeveloped literacy skills. Later, a shared responsibility model was highlighted, acknowledging the demand placed on patients by the complexities of the health care system (e.g., complicated informational materials, confusing health history forms, technical jargon in discussions, myriad dental benefits programs, insurance limitations, policy restrictions). Consistent with other researchers in the field, Roundtable members recognized that systems level changes were necessary to reduce the mismatch between systems demands and population skills — that is, an organizational health literacy focus.19,20 In 2012, the Roundtable convened a workshop aimed to catalyze discussion to develop a set of national objectives for health literacy. These were aimed at health systems to support the

incorporation of health literacy principles and practices into organizational strategic goals, infrastructure, priority initiatives, workforce development, policies and communication strategies. The workshop resulted in a 2012 paper by Roundtable members and associated colleagues: Ten Attributes of Health Literate Health Care Organizations11 (TA BLE 1 ). The attributes consolidated current science and practice to propose ways that health care entities could implement strategies using the attributes within an organization, including dental practices, federally qualified health centers (FQHCs), dental schools, oral health payers or accrediting bodies. Since the release of the 10 attributes, an increasing number of health systems have used them and other organizational health literacy assessments to guide organizational health literacy goals.9,13,16,21 In 2017, the transformational experiences

of three pioneering organizations were chronicled by Dr. Cindy Brach, senior health policy researcher at the Agency for Healthcare Research and Quality and a former Roundtable member.22 Although the three health care systems took different approaches, common characteristics catalyzed change within their organizations. Importantly, they all had dedicated internal champions or outside consultants with expertise, leadership buy-in, alignment with organizational mission and vision, readiness to change and belief in sufficient return on investment.

Oral Health: Organizational Health Literacy Across Levels Oral health organizations have a critical role in driving health literacy systems change. National, state and community oral health organizations have a unique role to play in leading

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TABLE 1

The 10 Attributes: Original Attributes and CDC Attributes Attribute

Original 10 Attributes11

CDC-Adapted 10 Attributes29

Has leadership that makes health literacy integral to its mission, structure and operations.

Integrates health literacy into planning, evaluation measures, patient safety and quality improvement.

Integrates health literacy into strategic and operational planning, quality improvement, goals and measures.

Prepares the workforce to be health literate and monitors progress.

Prepares the workforce to address health literacy issues and monitors progress.

Includes populations served in the design, implementation and evaluation of health information and services.

Includes members of groups served in the design, implementation and evaluation of health information and services.

Meets the needs of populations with a range of health literacy skills while avoiding stigmatization.

Meets the needs of audiences with a range of health literacy skills while avoiding stigmatization.

Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.

Uses health literacy strategies in oral communication.

Provides easy access to health information and services and navigation assistance.

Provides easy access to health information and services and help finding the way in facilities.

Designs and distributes print, audiovisual and social media content that is easy to understand and act on.

Addresses health literacy in high-risk situations, including care transitions and communications about medicines.

Addresses health literacy in highrisk situations, such as emergency preparedness, crisis and emergency response and clinical emergencies or transitions.

10.

Communicates clearly what health plans cover and what individuals will have to pay for services.

Communicates clearly available health services and costs.

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the way to fully incorporate health literacy across levels for optimal oral health outcomes. Countless researchers, health professionals and national and international organizations use this multilevel perspective (the social ecological model) to explore how various levels influence health outcomes, beyond individual or family behavior alone.23–25 The FIGURE shows many organizations across multiple levels of influence that impact individual, family and population oral health outcomes. Creating equitable access to optimal oral health opportunities and outcomes requires a health equity perspective. Taking on such a viewpoint requires attention to various issues including the social and structural determinants of health, structural racism, impacts across the life course, disability, family engagement, health literacy and more. Here, we focus on the role of health literacy and specifically organizational health literacy in reaching oral health and health equity goals.26,27 Organizations across national (e.g., American Dental Association, NIDCR/NIH and Centers for Disease Control and Prevention), regional/multistate (e.g., Atrium Health, HealthPartners and Kaiser), state (e.g., California Dental Association and other state associations and state departments of public health, state dental accreditation and state dental schools) and community levels (e.g., dental practices, FQHCs, local dental associations/societies, dental schools and school-based clinics) have a crucial role to play in creating health literate organizations. Oral health organizations across levels must incorporate health literacy principles routinely and systematically to equitably meet Healthy People 2030 oral health objectives. We present best practice work across national, state and community levels to describe

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TABLE 2

Top 5 Areas To Consider First: Health Literate Oral Health Organizations 1. Clear communication 2. Safety

best practice and highlight areas that organizations (e.g., dental practices, payors, FQHCs) might focus on in pursuit of organizational health literacy. We recommend focusing on one of five areas as you get started in considering the examples highlighted for applying an organizational health literacy perspective to organizational change. They include clear communication, safety, plain language and access in multiple languages, quality improvement and systems (TA BLE 2 ).

National Level American Dental Association

In 2006, the leadership of the American Dental Association (ADA) established the National Advisory Committee on Health Literacy in Dentistry (NACHLD) in recognition of the important role of health literacy in achieving or maintaining good oral health. In the same year, the ADA adopted a health literacy definition for its institutional operations and practices and developed two additional health literacy-related policy statements soon after. To date, the NACHLD has developed three health literacy organizational action plans (2010-2015, 2016-2020 and 2020-2024) outlining strategic health literacy focus areas in its role in providing guidance to the ADA.28 Over the years, the NACHLD has served as an important resource to identify and advise on opportunities in oral health and health literacy for the ADA. As a health care professional organization, the ADA’s mission focuses on helping dentists succeed in advancing the public’s oral health. To serve this purpose, the ADA is working toward shaping the 10 attributes and the objectives to fit its unique context. They followed the example of the Centers for Disease Control and Prevention’s (CDC) modification to the original

10 attributes to adapt to organizations supporting a population, such as a dental practice. They divided the attributes into two main categories: attributes about leadership, priorities, training, access and special situations and attributes about audience and group participation and feedback in health communication and information activities.29 A NACHLD workgroup met with ADA staff to map its unique organizational structure, including departmental relationships and responsibilities as well as past and current health literacy-related initiatives. Next, they reviewed each attribute to explore whether the attribute applies to the ADA organizational structure, previous and/or current health literacy-related efforts and potential future application strategies. This process of adapting the attributes is in progress and critical to appropriately align the process of becoming a health literate organization. In an effort to have “leadership that makes health literacy integral to its mission, structure and operations” (attribute 1), the workgroup highlighted the ADA’s unique organizational leadership and workforce model, comprised of both paid staff members and volunteer dentists. To achieve greater continuity, staff liaisons from various ADA departments have been appointed to the NACHLD to enhance cross-departmental collaboration. Additionally, the need for health literacy training for paid ADA staff as well as new and existing ADA board and trustee members (i.e., rotating, volunteer dentists) has been established. To further enhance the design and distribution of print, audiovisual and social media content that is easy to understand and act on (attribute 10), ADA departments also collaborate with NACHLD members so they may more fully incorporate health literacy into

3. Plain language and multiple languages 4. Quality improvement 5. Systems

their practices (e.g., NACHLD review of COVID-19 health information materials prior to public release). In tandem with the ADA’s health literacy work, a need was identified for the dental profession to take the lead in oral health quality improvement efforts and development of clinical performance measures. As such, the ADA established the Dental Quality Alliance (DQA) in 2010.30 The group is composed of key stakeholders in oral health care delivery whose mission is “to advance performance measurement as a means to improve oral health, patient care and safety through a consensus building process.”31 Over the years, the DQA has implemented a comprehensive strategy to develop and validate cariesrelated measures that are used to evaluate utilization, quality and cost of programs and plans. This aligns with attribute 2 to integrate health literacy into strategic and operational planning, quality improvement, goals and measures. The ADA also sponsors a variety of outward-facing health literacy training opportunities for dentists, the oral health community and the greater public (e.g., national conference presentations, webinars aimed at oral health professionals and the nationwide Health Literacy in Dentistry Essay Contest for dental students). Additionally, NACHLD’s work on initial recommendations for the teaching and application of health literacy in dental education was adopted by the Commission on Dental Accreditation (CODA). These initiatives are a result of cross-organization and cross-level, collaborative efforts prompted by an organizational health literacy perspective. D ECEMBER 2 0 2 1

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Regional/Multistate Level Atrium Health (formerly Carolinas Healthcare System)

Atrium Health is a large nonprofit based in Charlotte, North Carolina, with over 1,500 care delivery locations and nearly 70,000 employees across academic medical centers, hospitals, urgent care clinics and medical practices. Spanning three states (North Carolina, South Carolina and Georgia), Atrium Health has become a dynamic innovator in the delivery of quality, compassionate care at the individual, community and population levels. While Atrium Health has not incorporated an oral health component, their experience highlights the realities of a health system applying an organizational health literacy perspective in that the path is not typically linear and often initially quite fragile. The first milestone for Atrium was the creation of the Health Literacy Learning Collaborative, which created and enacted an action plan to extend a health literacy initiative across the system. Nine measures were generated and then evaluated at the end of one year. The plan’s goals were to improve health outcomes, patient satisfaction and value. A chief nurse executive (CNE) was hired to catalyze progress by focusing on two key, systemwide health literacy approaches (Teach Back and Ask Me 3) across levels: provider, staff and patients. Shortly thereafter, the new position of senior vice president of patient experience helped to solidify these organizational changes. The 10 attributes are now assessed on an annual basis to inform progress, new goals and board decision-making.22

State Level Minnesota Health Literacy Partnership Organizational health literacy initiatives are a focal point of statewide 744 D ECEMBER

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coalition work dedicated to improving population health outcomes by promoting health literacy practices. The Minnesota Health Literacy Partnership is one such coalition comprised of 43 members who represent health systems, payers, nonprofits and the Minnesota Department of Health. Formed in 2006, a coalition action plan was developed to prioritize six activities for members and other health organizations:35 ■ Adopt and use health literacy best practices. ■ Make information about health useful and accessible.

The first milestone for Atrium was the creation of the Health Literacy Learning Collaborative.

Increase and improve patientcentered resources. ■ Provide opportunities for education about health literacy at all levels. ■ Streamline processes to make it easier for patients to navigate the health care system. ■ Invest in resources to ensure that health information is culturally appropriate and in a patient’s preferred language. By leveraging the expertise and resources of members, the partnership has made great strides toward achieving health care equity and affordability, improving health system safety and quality and addressing community needs particularly around language and culture. Their stewardship has created a state focus on organizational health literacy with the ■

goal of making it easier for Minnesotans to understand, navigate and use information and services to take care of their health. For example, HealthPartners, an accountable care organization offering medical and dental care, is using an organizational health literacy perspective to achieve organizational goals as one of the 43 members of the Minnesota Health Literacy Partnership. This perspective has generated health literacy action in concrete ways. One is the creation of a formal patient council, which is charged with bringing the patient perspective so leadership can incorporate this lens in discussions and decisions. Another is focused on continual assessment of the patient experience through questions such as whether the patient receives information from their doctor in a way that they can understand and whether the patient is encouraged to be part of the decision-making regarding their care.36 Statewide learning, strategizing and collaboration have characterized the Minnesota Health Literacy Partnership’s pursuit of applying health literacy at organization and state levels.

California Dental Association

Similar to the ADA, the California Dental Association (CDA) has a history of supporting health literacyrelated policies that have informed activities across the organization. An important example is the development of the 2012 Access Plan approved by CDA’s governing body. It guides the organization in efforts to improve the oral health of Californians. The first recommendation was to “establish oral health leadership and build an oral health infrastructure” by hiring a state dental director and staff to prioritize six objectives, including to promote “evidence-based approaches to increase oral health literacy.”32 This objective was

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recently accomplished with development of the California Oral Health Literacy Toolkit in collaboration with the California Office of Oral Health and the Health Research for Action Center at the University of California, Berkeley, School of Public Health.32,33 The toolkit has a set of six resources to guide dental providers in incorporating oral health literacy best practices and strategies into their clinical environments. Resources include a practice assessment checklist, a printable poster on how to use Teach Back and plain language patient education materials focused on “going to the dentist.” Finally, CDA continues to fund a seat on the National Academies’ Health Literacy Roundtable to ensure advancements in health literacy research and policy benefit from oral health expertise.34 CDA initiatives are a direct consequence of incorporating an organizational health literacy perspective across the organization.

University of California-Based Dental School Partnerships

The California Oral Health Technical Assistance Center (COHTAC) was created by a group of oral health experts and researchers from the University of California, San Francisco, to work in partnership with the state Office of Oral Health with the goal of improving the overall health of Californians. Funded by Proposition 56, the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, the programmatic focus has centered on school oral health programs, tobacco cessation and water fluoridation. Additionally, the group provides technical assistance for local, community-based oral health programs under the direction of the state dental director. The COHTAC website also maintains a collection of evidence-based communication resources that are accessible to all.

In addition, Sesame Street in Communities began a partnership in 2018 with More LA Smiles, a dental pilot program led by the University of California, Los Angeles (UCLA). The goal was to improve the oral health of children in Los Angeles County who are enrolled in the Medi-Cal Dental Program. With funding from the California Department of Health Care Services, More LA Smiles was created through a collaboration of multisector stakeholders that included state-funded health plans, early childhood education experts, quality improvement organizations,

An organizational health literacy perspective in dental practice is essential to achieve oral health equity.

professional organizations and family support programs. The partnership uses performance measures in the delivery of high value care and to improve oral health access through a number of strategies, such as the development of professional education programs, practice and systemslevel improvements and information technology innovations. Sesame Street has long been a pioneer in the development of family-informed and evidence-based early childhood programming. As part of the partnership, a children’s oral health awareness campaign was created to inform families and caregivers about the importance of early childhood oral health and finding a dental home by age 1. All new videos and downloadable graphics feature beloved Sesame Street characters and are available free at morelasmiles.org.

Community Level Dental Practices

An organizational health literacy perspective in dental practice is essential to achieve oral health equity. While there are many areas of important focus as outlined previously (TA BLE 2 ), we will highlight safety here, in particular, preventable adverse oral health outcomes as described by the NASEM 2000 report “To Err is Human: Building a Safer Health System.”37 Health literacy issues related to safety across levels include medical/dental errors; lack of team member communication (e.g., safe practice discussions among team members, patients and families); and lack of care coordination within the health care system.38–40 Preventable adverse events in dental practice include wrong tooth extractions, sedation complications and foreign body aspiration, among others. Related environmental safety issues in dentistry include dental unit waterlines and infectious disease transmission.41 Subsequently, calls for a stronger dental safety culture have been raised within the ADA.42,43 However, thus far, many of the considerations regarding safety have focused on the physical provision of care.44 An organizational health literacy perspective can help broaden the focus so that dental practices can respond to all three critical aspects of the NASEM safety culture: patient-centered care, equitable care and effective care. There are many ways to tackle these safety pillars from an organizational health literacy perspective. For example, patientcentered care considers the patients’ health needs and preferred outcomes.45 Part of accomplishing this requires that dental practices incorporate a plain language focus for clear communication and collaboration between the health system, the dental practitioner and the patient. Plain language also helps to counter misinformation, which creates safety problems in both dental and D ECEMBER 2 0 2 1

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TABLE 3

Getting Started: Ways To Incorporate an Organizational Health Literacy Perspective Into Your Dental Practice or Organization This table suggests how to get started addressing organizational health literacy in an oral health organization, starting tomorrow and over the next year. Tomorrow

Talk to someone in your organization or dental practice about health literacy, oral health and health equity.54 Raise a new question to a colleague or at a staff meeting.

Next week

Invite colleagues to an informal “brown-bag” discussion about your oral health organization and organizational health literacy; you could use this article as recommended prereading.

Next month

Bring an interactive speaker/trainer to your organization (e.g., webinar, journal club) who can talk about — and help the organization consider how to create — a health literate organization. Find some colleagues who want to complete a training or attend a conference and talk about it.55

Within six months

Convene a health literacy taskforce or appoint a health literacy practice manager. Explore the California Oral Health Literacy Toolkit and choose an area of focus to start.33 Complete a preliminary organizational health literacy assessment (e.g., the walking interview) with staff and the primary audience (e.g., members, patients) and/or consider the relationship between racial and health equity and health literacy.56,57

Over the next six months

Plan measurable next steps. Use learnings to create a quality improvement goal and accompanying process aligned with Healthy People 2030 oral health objectives.

medical care. Patient-centered care is also linked to rebuilding pervasive feelings of distrust and disregard for public health and oral health care safety recommendations, such as community water fluoridation and vaccine uptake. Likewise, delivering equitable care means attending to “digital divide” issues, whereby lower income and rural patients and dental practices might be disproportionately impacted in their ability to engage in optimal dental care because of inconsistent, or completely absent, internet infrastructure. Equitable care also involves providing plain language information in multiple languages. Recently, many safety initiatives have blossomed to provide information that meet the above considerations, particularly related to COVID-19 and the vaccine. For example, UCLA launched a COVID-19 vaccination website with information in 17 different languages.46 Similarly, the Health Literacy Solutions Center COVID-19 Plain Language Resources site became a clearinghouse for health professionals seeking materials following health literacy principles.47 Effective care is also central to safety and 746 D ECEMBER

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can be optimized by coordination of health literacy at a practice level, making “it easier for people to navigate, understand and use information and services to take care of their health.”40 For example, informed consent and after-visit summaries that meet health literacy principles (e.g., plain language, multiple languages, accessible, actionable) are crucial to safe, effective care.48 Some dental practices prioritize being a health literate environment by designating one staff member as the “health literacy manager.” This professional works with staff to build a health literate organizational culture step by step, including bringing in resources and practices such as those mentioned in this article. Creating a health literate dental practice is key to delivering excellent care, and it requires resolving organizational barriers to safety, among other factors. The Oral Health Literacy Toolkit is a great place to get started.

Next Steps for the Health Literate Oral Health Organization

Organizations that use an organizational health literacy perspective to meet safety, communication and other

health literacy goals are well-equipped to face challenges to the provision of equitable, quality oral health care.49,50 Likewise, working toward becoming a health literate organization aligns directly with safety goals put forward by the Joint Commission’s 2007 report “What Did the Doctor Say?” The report propelled the health literacy field forward to conceptualize a health literate approach as “universal precautions.”51 Clear, usable and actionable information and processes are preferable, whether by patients, oral health professionals or the public. In a health literate oral health organization (TA BLE 2), plain language guidelines for clear communication are applied to elevate all patient or publicfacing materials: forms, websites, postoperative instructions, educational materials and provider/patient interactions, including clinical treatment decision-making. For safety and other goals, communication and other organizational processes are discussed, practiced and revisited; this can include techniques like Teach Back and Ask Me 3. Information and conversation are also available in multiple languages, preferably the top three to five languages of the intended audience. Processes should be in place if information or conversation is needed in languages not routinely offered. A health literate organization also consistently uses quality improvement methods to rigorously plan, explore, try out and revise best practices that are attuned with the organization’s audience and the field’s evidence base.31 A health literate oral health organization is also one that regularly incorporates a systems perspective to understand and design interactions that account for multiple levels and actors engaging daily in oral health care. Finally, it identifies actions across levels and invites staff and the intended audience to the table to discuss

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what these issues are and how to address them. Whether you’re considering oral health outcomes, insurance complexities or structural racism, consider the many levels on which these concerns operate and the role of multisector systems, collaboration and policy in solving them.52,53 A health literacy and equity focus are part of the process, across levels, not just a desired outcome. Consistent with the Healthy People 2030 health literacy framework, the health literate oral health organization (FIGURE ) rigorously and continuously considers clear communication, safety, plain language/ multiple languages, continuous quality improvement and cross-organizational, collaborative systems (TA BLE 2 ) to achieve equitable oral health outcomes. Use TA BLE 3 to plan your next action steps, for tomorrow and over the next year. n RE FEREN CE S 1. The National Academies of Sciences, Engineering and Medicine. Integrating oral and general health through health literacy practices: Proceedings of a workshop. Washington, D.C.: The National Academies Press; 2019. doi: 10.17226/25468. 2. Robinson LA. Oral Health Literacy: August 2020 issue. J Calif Dent Assoc Aug;48(8):371–402. 3. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Health Literacy in Healthy People 2030. 2020. Accessed April 28, 2021. 4. Brach C, Harris LM. Healthy People 2030 Health Literacy Definition Tells Organizations: Make Information and Services Easy to Find, Understand and Use. J Gen Intern Med 2021 Apr;36(4):1084–1085. doi: 10.1007/s11606-020-06384-y. Epub 2021 Jan 22. 5. Rudd RE. Health Literacy: Insights and Issues. Stud Health Technol Inform 2017;240:60–78. 6. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: An updated systematic review. Ann Intern Med 2011 Jul 19;155(2):97– 107. doi: 10.7326/0003-4819-155-2-201107190-00005. 7. Institute of Medicine Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. Washington (DC): National Academies Press; 2004. doi: 10.17226/10883. 8. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, D.C.; 2010. 9. Rudd RE, Oelschlegel S, Grabeel KL, Tester E, Heidel E. HLE2: The Health Literacy Environment of Hospitals and Health Centers. Boston: Harvard T.H. Chan School of Public Health; 2019.

10. Horowitz AM, Maybury C, Kleinman DV, et al. Health literacy environmental scans of community-based dental clinics in Maryland. Am J Public Health 2014 Aug;104(8):e85–93. doi: 10.2105/AJPH.2014.302036. Epub 2014 Jun 12. PMCID: PMC4103217. 11. Brach C, Keller D, Hernandez LM, et al. Ten Attributes of Health Literate Health Care Organizations. Washington, D.C.: National Academy of Medicine; 2012. 12. Groene RO, Rudd RE. Results of a feasibility study to assess the health literacy environment: Navigation, written and oral communication in 10 hospitals in Catalonia, Spain. J Commun Healthc 2011;4(4):227–37. doi.org/10.1179/175380761 1Y.0000000005. 13. Thomacos N, Zazryn T. Enliven Organisational Health Literacy Self-Assessment Resource. Melbourne: Enliven & School of Primary Health Care, Monash University; 2013. 14. Trezona A, Dodson S, Osborne RH. Development of the Organisational Health Literacy Responsiveness (Org-HLR) selfassessment tool and process. BMC Health Serv Res 2018 Sep 6;18(1):694. doi: 10.1186/s12913-018-3499-6. PMCID: PMC6128002. 15. Trezona A, Dodson S, Fitzsimon E, LaMontagne AD, Osborne RH. Field-Testing and Refinement of the Organisational Health Literacy Responsiveness Self-Assessment (Org-HLR) Tool and Process. Int J Environ Res Public Health 2020 Feb 5;17(3):1000. doi: 10.3390/ijerph17031000. PMCID: PMC7037726. 16. Agency for Healthcare Research and Quality. CAHPS Health Literacy Item Sets. Rockville, Md: 2018. Accessed April 28, 2021. 17. The National Academies of Sciences, Engineering and Medicine. The National Academies of Sciences, Engineering, and Medicine. 2021. Accessed April 28, 2021. 18. Kutner M, Greenberg E, Jin Y, Paulsen S. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy U.S. Department of Education; 2006. 19. Parker R. Measuring Health Literacy: What? So What? Now What? Paper presented at Measures of Health Literacy Workshop, 2009; Washington, D.C. 20. Rudd RE. Health literacy skills of U.S. adults. Am J Health Behav Sep–Oct 2007;31 Suppl 1:S8–18. doi: 10.5555/ ajhb.2007.31.supp.S8. 21. Agency for Healthcare Research and Quality. AHRQ Health Literacy Universal Precautions Toolkit. Accessed April 28, 2021. 22. Brach C. The Journey To Become a Health Literate Organization: A Snapshot of Health System Improvement. Stud Health Technol Inform 2017;240:203–37. PMCID: PMC5666686. 23. Bronfenbrenner U. Ecology of Human Development: Experiments by Nature and Design. Cambridge: Harvard University Press; 2009. 24. UNICEF. Communication for Development. Accessed April 28, 2021. 25. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. The Social-Ecological Model: A Framework for Prevention. Accessed April 28, 2021. 26. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Healthy People 2030: Oral Conditions. Accessed April 28, 2021.

27. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Healthy People 2030 Framework. Accessed April 28, 2021. 28. American Dental Association Council on Access, Prevention and Interprofessional Relations. Health Literacy in Dentistry Action Plan 2010–2015; 2009. 29. Centers for Disease Control and Prevention. Attributes of a Health Literate Organization. Accessed April 28, 2021. 30. Vidone L, Hunt RJ, Ojha D. An Emerging Era in Dentistry — Quality Measurement. J Mass Dent Soc 2016 Autumn;65(3):18–21. 31. American Dental Association Dental Quality Alliance. About Dental Quality Alliance 2021. Accessed April 28, 2021. 32. California Dental Association. Phased Strategies for Reducing the Barriers to Dental Care in California. California Dental Association Access Report; 2011. 33. California Office of Oral Health. California Oral Health Literacy Toolkit. 34. Robinson LA. National Academies of Science, Engineering and Medicine: Dentistry’s Valuable Investment in the Health Literacy Roundtable. J Calif Dent Assoc 2020 Aug;48(8):400–02. 35. Minnesota Health Literacy Partnership. Partnering for the health of all Minnesotans. Accessed April 28, 2021. 36. Atchison KA, Weintraub JA, Rozier RG. Bridging the dental-medical divide: Case studies integrating oral health care and primary health care. J Am Dent Assoc 2018 Oct;149(10):850–858. doi: 10.1016/j.adaj.2018.05.030. Epub 2018 Jul 26. 37. Institute of Medicine Committee on Quality of Health Care in America. To err is human: Building a safer health system. Washington, D.C.: National Academies Press 2000. doi: 10.17226/9728. 38. Hakanen JJ, Schaufeli WB. Do burnout and work engagement predict depressive symptoms and life satisfaction? A three-wave seven-year prospective study. J Affect Disord 2012 Dec 10;141(2-3):415–24. doi: 10.1016/j. jad.2012.02.043. Epub 2012 Mar 24. 39. Erikson CE, Pittman P, LaFrance A, Chapman SA. Alternative payment models lead to strategic care coordination workforce investments. Nurs Outlook Nov–Dec 2017;65(6):737–745. doi: 10.1016/j.outlook.2017.04.001. Epub 2017 Apr 13. 40. Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. How Can Health Care Organizations Become More Health Literate: Workshop Summary. Washington, D.C.: National Academies Press; 2012. doi: 10.17226/13402. 41. Walji MF, Yansane A, Hebballi NB, et al. Finding Dental Harm to Patients Through Electronic Health Record-Based Triggers. JDR Clin Trans Res 2020 Jul;5(3):271–277. doi: 10.1177/2380084419892550. Epub 2019 Dec 10. 42. Casamassimo PS. Safety in dental care: Where is our surveillance imperative? J Am Dent Assoc 2020 Jun;151(6):381–383. doi: 10.1016/j.adaj.2020.02.019. 43. Ramoni RB, Walji MF, White J, et al. From good to better: Toward a patient safety initiative in dentistry. J Am Dent Assoc 2012 Sep;143(9):956–60. doi: 10.14219/jada. archive.2012.0303. 44. Burger D. ADA council tasked with fostering prioritization of safety in dentistry: House of Delegates passes resolution D ECEMBER 2 0 2 1

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advocating more attention to protecting dentists, staff, patients. ADANews. Chicago: American Dental Association; 2019. 45. NEJM Catalyst. What Is Patient-Centered Care? NEJM Catalyst 2017;2017(Jan. 1). 46. Wolf J. UCLA multilingual COVID-19 website offers vaccine information in more than a dozen languages. Newsroom. Los Angeles; 2021. 47. Health Literacy Solutions Center. Coronavirus (COVID-19) Resources 2021. Accessed April 28, 2021. 48. Institute of Medicine. Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. Washington, D.C.: The National Academies Press; 2014. doi: 10.17226/18834. 49. Bastos JL, Constante HM, Celeste RK, Haag DG, Jamieson LM. Advancing racial equity in oral health (research): More of the same is not enough. Eur J Oral Sci 2020;128(6):459–66. doi.org/10.1111/eos.12737. 50. Bastos JL, Constante HM, Jamieson LM. Making science and doing justice: The need to reframe research on racial inequities in oral health. Community Dent Health 2021 May 28;38(2):132–137. doi: 10.1922/CDH_IADRBastos06. 51. Commission TJ. “What Did the Doctor Say?” Improving Health Literacy to Protect Patient Safety. Health Care at the Crossroads: The Joint Commission; 2007.

52. Adkins-Jackson PB, Legha RK, Jones KA. How To Measure Racism in Academic Health Centers. AMA J Ethics 2021;23(2):E140–145. doi: 10.1001/amajethics.2021.140. 53. Bailey ZD, Feldman JM, Bassett MT. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities. N Engl J Med 2021;384(8):768–73. doi: 10.1056/NEJMms2025396. 54. U.S. National Oral Health Alliance. Summary of the Third Leadership Colloquium: Oral Health Literacy as a Pathway to Health Equity. June 6-7, 2012; San Francisco. 55. Centers for Disease Control and Prevention. Health Literacy: Find Training. Accessed April 28, 2021. 56. Rudd RE. The Health Literacy Environment Activity Packet: First Impressions & Walking Interview. Health Literacy Studies, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health; 2010. 57. Annie E. Casey Foundation. Race Matters: Organizational Self-Assessment. Baltimore; 2006. TH E CO RRE S P ON DIN G AU T HOR , Lindsay Rosenfeld, ScD, ScM, can be reached at ler@brandeis.edu.

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C.E. Credit

A Historical Overview of Language Access in Dentistry: The Impact of Language Access Protections on Oral Health Care Nicole Holland, DDS, MS

abstract Background: More than 67 million Americans (22%) speak a language other than English at home, with more than 25 million (8.4%) speaking English “less than very well.” Language, culture and literacy are intimately related. However, the significance of language is often overshadowed in the larger conversation of oral health and health literacy. Methods: Studies have shown language-related barriers to be associated with medical errors, decreased patient satisfaction, poorer self-management and worsened clinical outcomes. Alternatively, use of professional interpreters and other quality language assistance services enhance language access, resulting in improved patient engagement and satisfaction, increased care quality and better clinical outcomes. Conclusions: Ensuring language access for our patients is a critical component in achieving oral health equity. This article provides a brief history of language access policy in this country, discusses the impact of language access protections on the dental profession and recommends actionable steps for dental providers to facilitate equitable, quality care for their patients and communities. Practical implications: Maintaining and prioritizing language access protections alongside other nondiscrimination practices mitigates significant barriers to care and helps to ensure all patients are able to receive the quality oral health care they need. Keywords: Language access, limited English proficiency (LEP), health equity, health literacy, interpreter services, oral health

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AUTHOR Nicole Holland, DDS, MS, is an assistant professor and the director of health communication, education and promotion in the Tufts University School of Dental Medicine’s Department of Public Health and Community Service. Her research interests include the intersection of health literacy, language access and oral health as well as the impact of oral health messaging in the media. She is co-chair of the American Dental Association’s National Advisory Committee on Health Literacy in Dentistry and serves on the National Academies of Science, Engineering and Medicine’s Roundtable on Health Literacy. Dr. Holland is a diplomate of the American Board of Orofacial Pain. Conflict of Interest Disclosure: None reported.

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hen will language, a basic form of human communication and connection, no longer be a stumbling block preventing one from obtaining quality health care? Language, culture and literacy are intimately related. However, the significance of language is often overshadowed in the larger conversation of oral health and health literacy. More than 67 million Americans (22%) speak a language other than English at home, with more than 25 million (8.4%) speaking English “less than very well” (with these numbers likely to increase upon release of the 2020 Census data).1 Because access to oral health care is already a challenge for many in the U.S.,2 language barriers can further complicate many aspects of care. English proficiency is not a requirement for receiving health care in this country, and all patients ought to have the opportunity to receive health care they can understand. However, individuals with limited English proficiency (LEP) (defined as “individuals who do not speak English as their primary language and who have a limited ability to read, speak, write or understand English”3) are subject to greater communication challenges and obstacles when navigating the health care system, putting them at greater risk of suboptimal care. Many individuals with LEP may not comprehend critical information, express concerns or ask relevant questions in a clinical encounter, despite their ability to communicate in English fairly well. Others may feel uncomfortable revealing they have trouble communicating in English. Studies have shown language-related barriers to be associated with medical errors, decreased patient satisfaction, poorer self-management and worsened clinical outcomes.4–9 Alternatively, use of professional interpreters and other quality

language assistance services enhance language access (defined as “providing LEP people with reasonable access to the same services as English-speaking individuals”10) and facilitate effective communication across languages. This results in improved patient engagement and satisfaction, increased care quality and better clinical outcomes, thereby reducing disparities; despite these benefits, however, language assistance services remain underutilized.6,11–16 Providing equitable, quality-driven and patient-centered oral health care requires dental offices to not only be aware of but also be prepared to address the cultural and linguistic needs and preferences of patients, including language. Ensuring language access for our patients is a critical component in attaining health literacy and achieving oral health equity. The goal of this article is to provide a brief history of language access policy in this country, discuss the impact of language access protections on the dental profession and recommend actionable steps for dental providers to facilitate equitable, quality care for their patients and communities.

Language Access Policy in U.S. Health Care: History in Brief ( FIGURE ) 1964

Title VI of the 1964 Civil Rights Act (which states “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of or be subjected to discrimination under any program or activity receiving federal financial assistance”17) initially laid the legal foundation for language access across many societal sectors in this country, including health care.18 While a robust discussion of the history, interpretation and implementation of this act in its entirety is beyond the scope of this paper, two items of note are of

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Language Access in U.S. Health Care: History in Brief significance as they relate to language access: 1) historically, the interpretation of this act has generally been that failure to provide language access has a discriminatory impact on the basis of national origin and 2) the federal origin of this act applies to institutions and programs (including dental) receiving federal funds (such as Medicaid and Medicare payments, federal grants, etc.).

1964 Title VI of the Civil Rights Act is signed into law by Lyndon B. Johnson, laying the legal foundation for legal access protections in the U.S.

2000 Bill Clinton signs Executive Order 13166, “Improving Access to Services for Persons With Limited English Proficiency”.

2000

In 2000, Executive Order 13166 “Improving Access to Services for Persons with Limited English Proficiency” signed by President Bill Clinton legally bolstered language access-related components of the 1964 Civil Rights Act,19 requiring federal fund recipients to reasonably provide language services (such as remote interpreter services [telephone or video], translators, bilingual staff or professional on-site interpreters) for all using their programs, activities or services. Subsequently, the Office of Civil Rights (OCR) issued policy guidance20 (which was then revised in 2003 under the Bush administration21) “to clarify the responsibilities of providers of health and social services who receive federal financial assistance … and assist them in fulfilling their responsibilities to LEP persons, pursuant to Title VI of the Civil Rights Act of 1964.”20 Essentially, recipients are required to take “reasonable steps to ensure meaningful access” to their programs and activities for individuals with LEP. The OCR acknowledged the potential for disparate impact and burden on smaller organizational recipients (e.g., small businesses) regarding size, available resources and budget constraints when considering language assistance services provisions, writing “Smaller recipients with more limited budgets are not expected to provide the same level of language services as

2010 The Affordable Care Act (ACA) is signed into law by Barak Obama, further strengthening language access protections for LEP individuals under Section 1557.

2020 The Department of Health and Human Services finalizes revised regulations implementing Section 1557 of the ACA, scaling back language access protections issued in the 2016 rule.

2016 The Office of Civil Rights of the Department of Health and Human Services issues the final rule implementing Section 1557 of the ACA.

FIGURE . Language access in U.S. health care: history in brief.

larger recipients with larger budgets. In addition, reasonable steps may cease to be ‘reasonable’ where the costs imposed substantially exceed the benefits.”21 The guidance specifically identified four factors (referred to as the “four-factor analysis”) for all recipients to consider when determining the extent and types of language assistance to offer: 1) number (or proportion) of LEP individuals served or eligible to be served; 2) frequency of contact; 3) nature and importance of service provided; and 4) resources and costs. There was no question that large health care entities such as hospitals or health systems ought to provide language assistance services. However, even with the guidance, the terms “reasonable steps” and “meaningful access” were considered broad, and vague and specific application to the dental profession, where private practice is the primary business model, has never been clearly outlined.

2010

Building on the aforementioned civil rights pillars (1964 Civil Rights Act and

Executive Order 13166), the Affordable Care Act of 2010 (ACA) reinforced longstanding nondiscrimination protections (including language access protections for individuals with LEP) under Section 1557, broadening its scope to include not only federal fund recipients but also health programs or activities administered by federal agencies and entities created under Title I of the ACA, which includes health insurance marketplaces.22

2016

While Section 1557’s protections took effect in 2010 with the enactment of the ACA, regulations issued by the Department of Health and Human Services (HHS) were not implemented until July 2016.23 The 2016 rule prohibited discrimination in health care on the basis of race, color, national origin, sex, age or disability. Key language access-related regulations in the 2016 rule included: definitions and related requirements regarding the use of “qualified” interpreters and bilingual D ECEMBER 2 0 2 1

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TABLE

Comparison of Language Access Protections in 2016 vs. 2020 Section 1557 Final Rule Key regulation revisions

2016

2020

Focus of language access protection (individual vs. entity)

Individual-level protections: Covered entities must take reasonable steps to provide meaningful access to each individual with LEP eligible to be served or likely to be encountered.

Entity-level protections: Removes reference to each individual and focuses on the LEP population in relation to the entity.

Definition of “qualified”

Requires use of “qualified” interpreters for oral communication and “qualified” translators for written communication (“qualified” defined in the regulation).

Use of qualified interpreters and translators still necessary when deemed reasonable by the entity; however, definition of “qualified” is removed.

Remote interpreting services

Includes standards for video remote interpreting services.

Requires only audio remote interpreting (video remote interpreting only when necessary).

Notices and taglines

Requires nondiscrimination notices in English and taglines (indicating availability of language assistance services) in the top 15 languages spoken by individuals with LEP in the state.

Notices and taglines no longer required.

Assessment of compliance

Considers whether the entity has a language access plan. Considers the nature and importance of the health program or activity as well as communication involving the individual with LEP.

Reference to language access plan is removed. Four-factor analysis: 1) Number or proportion of individuals with LEP eligible to be served or likely to be encountered; 2) frequency that individuals with LEP are in contact with the health care entity; 3) importance and nature of the health care entity; and 4) resources available to the health care entity and costs.

Grievance procedures

Requires covered entities with 15 or more employees to implement a grievance procedure and designate an employee to be responsible for grievances.

Grievance-related procedural and employee requirements no longer required.

providers/staff; prohibiting reliance on low-quality video remote interpretation services; requiring providers to provide free and timely interpreting services (i.e., eliminating burden from patients to provide their own interpreter); and requiring covered institutions to post a notice of nondiscrimination and taglines in the 15 most prevalent languages spoken in their respective states informing individuals of their rights to free language assistance services. Additionally, practices with 15 or more employees were required to adopt a grievance procedure and designate an employee to be responsible for grievances. Of note, the regulations directly acknowledged that general language fluency does not always equate to proficiency in interpreting complex health information (e.g., “I speak Spanish” versus “I have the necessary skills to adequately and professionally interpret complex health care information in a given setting”); as such, Section 1557 specifies the need to ensure adequate interpreter skills of providers as well. Another distinguishing 752 D ECEMBER

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factor of Section 1557 is that it allows an individual or entity to file a civil rights complaint with the HHS OCR.

2020

In June 2020, anti-discrimination protections in health care, including those involving language access, were significantly eliminated and/or reduced under the revised Section 1557 final rule (2020 rule) issued by the Trump administration. According to the amended 2020 rule, revisions are intended to clarify the scope of 1557 and reduce confusion, better comply with congressional mandates and relieve financial and administrative burden.24 Language access-specific revisions include a shift in reference from individuals with LEP to entities; elimination of taglines and notice requirements; removal of the language access plan recommendation; removal of the definition of “qualified interpreter;” and removal of video remote interpreting standards, now requiring only audio remote interpreting. Key regulations remaining in the revised 2020 rule

include: Interpretation must be accurate, timely and free of charge and individuals with LEP cannot be required to bring their own interpreter or rely on a minor child or accompanying adult to interpret.

2021

To date, the majority of the 2020 rule remains in effect, including the reduction of many language access protections (as shown previously). Another political administration is currently in place, and some major Section 1557 policy reversals (unrelated to language access) have already occurred,25 others are anticipated and pending lawsuits remain.26 Because Section 1557 will likely evolve (including language access-related components), dentists need to remain vigilant. Of note, the history in brief as written above consists of only federal laws and regulations. State laws do exist and provide additional specificity and protections; however, they vary by state. California has historically had and continues to have the highest number of language access-related provisions. The

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National Health Law Program created a comprehensive summary of language access-related state laws as of 2019.27

Impact of Language Access Protections on the Dental Profession

As mentioned, the impact of language access protection laws and regulations has been confusing for many, often leaving dentists across a variety of practice settings to question which regulations apply to them. In short, the laws have always applied and still remain applicable to all federal fund recipients, including dental providers. Since 2016, however, the enhanced specificity and additional requirements of the 1557 regulations have acutely heightened awareness within the dental community, further leading to confusion and much disdain. As noted, the 1557 regulations apply to dentists and other health care providers receiving federal funds through HHS, including Medicaid, the Children’s Health Insurance Program and providers reimbursed by Medicare Part C (Medicare Advantage, independent of whether the plan reimburses the provider or patient). Under the 2016 rule, covered entities (e.g., dental offices, dental schools, community health centers and other entities that receive federal financial assistance) were required to “provide meaningful access to individuals with limited English proficiency” by posting two types of notices (i.e., notice of nondiscrimination and taglines in the top 15 non-English languages spoken in the state indicating that free language assistance services are available) in the dental office, on the website and in any “significant” publications and communications and adopting a grievance procedure and designating an employee to be responsible for grievances (applicable to practices with 15 or more employees). These new requirements were found to be

burdensome for multiple reasons, as follows: Use of vague terminology (e.g., wording such as “significant” publications and communications as well as “reasonable steps” to provide “meaningful access”) left implementation open to interpretation (i.e., which publications are significant? What steps are considered reasonable? What is meaningful access?); enhanced rules regarding interpreter and translation services (i.e., definitions regarding who is “qualified,” among others) were considered by some to be “overly prescriptive” for small-business practice settings; and

As noted, the 1557 regulations apply to dentists and other health care providers receiving federal funds through HHS, including Medicaid. requiring provision of language assistance services free of charge while not simultaneously considering reimbursement strategies for providers placed additional financial burden on small-business practice owners.

Burden on Dentists: Response From the Dental Profession

The ADA, the largest dental association in the nation representing over 160,000 member dentists,28 has conspicuously stated that while it “strongly supports nondiscrimination in health care and equal access to health care for all patients,” it did not support the 2016 rule, deeming it to be “confusing, duplicative and burdensome as well as unnecessary.”29 Similarly, in an effort to delay the rule’s enforcement date, the Organized Dentistry

Coalition also reflected disapproval in a 2016 letter to the OCR.30 Opposite the original intent to expand language access as a means of enhancing the health of the nation, the 2016 regulations, according to the ADA, actually adversely affected oral health access due to the increased costs and resulting financial burden placed on dentists, ultimately making it more difficult for dentists to deliver quality, affordable care. Given that small-business practice owners comprise the majority of dentists, the ADA also strongly advocated for the inclusion of a small-business exception (25 employees or fewer), which was denied.31 Despite its staunch opposition to the Section 1557 regulations, the ADA worked to support its members by developing dental-specific resources on 1557 as well as endorsing CyraCom as an interpreter services provider, offering a member discount when utilizing their services. Following a change in political administration, HHS proposed to revise the 2016 rule32 and then-ADA President Jeffrey M. Cole and Executive Director Kathleen T. O’Loughlin conveyed strong support, writing the following in a 2019 letter to the OCR: “The time and cost associated with interpreting these regulations, printing these documents or altering existing publications and modifying websites to comply with these requirements has been significant for dental offices. We conservatively estimate the dental profession has spent $240,450,000 on compliance to date.”33 Since the finalization of the amended 2020 rule, notices and taglines in all significant communications are no longer routinely required of covered dental practices (only “when necessary”), and use of acceptable, audio-based interpretation services has also been expanded. (See the TA BLE for comparison of key changes.) When use of interpreters is needed, D ECEMBER 2 0 2 1

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interpretation must still be accurate, timely and free of charge, and individuals with LEP cannot be required to bring their own interpreter or rely on a minor child or accompanying adult to interpret. The 2020 rule is supported by the ADA and the Organized Dentistry Coalition in hopes that it will largely reduce costs and overall burden on many dental practices.33,34 But where does this leave language access protections for dental patients with LEP? As noted previously, Section 1557 regulations will likely continue to evolve. However, matters of health equity, such as language access, supersede the ebb and flow of political administrations of the time. Ultimately, language should not be a barrier to oral health care. It is worth noting that, as outlined above, the legal foundation for language access protection was established in 1964 with Title VI of the Civil Rights Act and has applied to the dental profession since its inception. In a 2016 correspondence with then-ADA President Carol Gomez Summerhays and Executive Director Kathleen T. O’Loughlin, OCR Director Jocelyn Samuels wrote “…many of the obligations imposed by the regulations have for many years applied to dental practices of all sizes, as well as other covered entities, under other federal civil rights laws. For example, the obligation to take reasonable steps to provide meaningful access to individuals with limited English proficiency has applied, under Title VI of the Civil Rights Act of 1964, to all dental practices that receive Federal financial assistance.” They also pointed out similar obligations, such as providing “auxiliary aids and services and reasonable modifications of policies, practices, and procedures, to individuals with disabilities … under Section 504 of the Rehabilitation Act of 1973 and 754 D ECEMBER

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to dental practices that own, lease or operate a place of public accommodation under the Americans with Disabilities Act.”31 While certain laws and regulations will continue to evolve, the spirit of Section 1557 lies in the statutes that come before it, with the ultimate goal of establishing protection from discrimination for individuals with LEP. Language directly impacts patient care. The question is not whether language access should exist, but rather how can we as a profession balance the needs and responsibilities of running a

Some patients may not feel comfortable revealing they have trouble communicating in English.

dental practice with the cultural and linguistic needs of our patients and communities. How can dentists ensure language is not a barrier to quality oral health care, and what can dentists do to support language access protections for individuals with LEP?

Recommendations for Dental Practice Know the Community You Serve Research demographic information of your local community beyond patients of record in your practice. (Resources may include U.S. Census, public health departments [state and local], department of education [state-level], local hospitalization utilization data and/or municipal boards of health). Understand your dental practice in the context of the larger community.

Assess the Language Assistance Needs of Your Patient Population

Determine whether your current language assistance options meet the needs of patients speaking languages other than English. Some patients may not feel comfortable revealing they have trouble communicating in English. Identify any unmet needs by systematically asking and verifying the preferred language in which your patients would like to receive their oral health care. Consider including preferred language as a question on your intake form and/or creating fields in your electronic health record to capture language preference and interpreter use.35

Research Language Assistance Options and Identify Which Are Most Reasonable To Offer in Your Practice

While notices and taglines may no longer be required of covered practices as of the revised 2020 rule, language assistance may very well still be needed. (Interpretation must still be accurate, timely and free of charge, and individuals with LEP cannot be required to bring their own interpreter or rely on a minor child or accompanying adult to interpret.) Initial efforts might include hiring staff who reflect the linguistic and cultural diversity of your community and contracting with an interpreter services company to provide remote (telephone or video) interpreter services as needed. (Consider taking advantage of the discounted interpreter services fee agreement for ADA member dentists.36) Verify language proficiency of all practice staff (including providers) who communicate with patients in non-English languages and support and encourage health care interpreter training, when applicable.

Establish Practice Policies for Working With LEP Individuals

Develop written policies37 regarding how patient language needs are assessed and

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documented, when and how interpreters should be used, how proficiency of multilingual staff is verified and where and how language assistance is documented.

Train All Dental Team Members

Offering culturally and linguistically appropriate services transcends the efforts of one person.38 Train all members of your dental team on team communication, cultural competency, respectful assessment and documentation of preferred language and interpreter needs and effectively working with interpreters (in person and remote). Explain why use of friends or family members for interpretation is not recommended and use of minors is prohibited.

Advocate for Adequate Reimbursement for Dentists

Language assistance services are required to be of no cost to the patient, which leaves the financial burden to the entity/provider as an operating expense. Practical implementation in the dental profession is challenging, particularly for those in small business/private practice models. If a new patient visit involving comprehensive oral evaluation and fullmouth radiographs generates $200-$300 in production for an average dental practice, how much can that practice routinely justify paying for interpreter services for that visit? Because balancing necessary nondiscrimination practices with fiscally responsible health care services can be difficult, advocating for adequate reimbursement from insurance companies as well as state and federal agencies is essential. Datadriven evidence regarding the financial implications of providing language assistance services, the need for adequate reimbursement for dental visits requiring such services and possible alternative payment models is needed.

Conclusion

Health information is complex and difficult to understand and navigating the U.S. health care system is challenging — independent of the language one may speak. Language is integral to health literacy, communication, patient care and, ultimately, health equity. Further research is needed on the state of language access in the dental profession as well as its impact on patients, providers and the larger oral health and health care system. Maintaining and prioritizing language access protections alongside other nondiscrimination practices mitigates significant barriers to care and helps to ensure all patients are able to receive the oral health care they need. n RE FE RE N C E S 1. U.S. Census Bureau. American Community Survey, 2019 American Community Survey 1-Year Estimates, Table DP02. Accessed March 12, 2021. 2. Gupta N, Vujicic M. Barriers to dental care are financial among adults of all income levels. Health Policy Institute Research Brief. American Dental Association. April 2019. Accessed May 13, 2021. 3. Limited English Proficiency. Commonly Asked Questions. Washington, D.C.: U.S. Department of Justice, Civil Rights Division; 2002. Accessed March 12, 2021. 4. Flores G, Abreu M, Barone CP, Bachur R, Lin H. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Ann Emerg Med 2012 Nov;60(5):545–53. doi: 10.1016/j.annemergmed.2012.01.025. Epub 2012 Mar 15. 5. Wisnivesky JP, Krauskopf K, Wolf MS, et al. The association between language proficiency and outcomes of elderly patients with asthma. Ann Allergy Asthma Immunol 2012 Sep;109(3):179–84. doi: 10.1016/j.anai.2012.06.016. Epub 2012 Jul 18. 6. Gany F, Leng J, Shapiro E, et al. Patient satisfaction with different interpreting methods: A randomized controlled trial. J Gen Intern Med 2007 Nov;22 Suppl 2(Suppl 2):312–8. doi: 10.1007/s11606-007-0360-8. 7. Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215. Epub 2020 Dec 7. 8. Wasserman M, Renfrew MR, Green AR, Lopez L, TanMcGrory A, Brach C, Betancourt JR. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual May–Jun 2014;36(3):5–16. doi: 10.1111/jhq.12065. Epub 2014 Mar 16. 9. Tseng W, Pleasants E, Ivey S, et al. Barriers and Facilitators to Promoting Oral Health Literacy and Patient Communication Among Dental Providers in California. Int J Environ Res

Public Health 2020 Dec 30;18(1):216. doi: 10.3390/ ijerph18010216. 10. Migration Policy Institute. Frequently asked questions on legal requirements to provide language access services. Accessed March 12, 2021. 11. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007 Apr;42(2):727–754. doi: 10.1111/j.14756773.2006.00629.x. PMID: 17362215. 12. Karliner AS, Kruger JF, Quan J, Fernandez A. From admission to discharge: Patterns of interpreter use among resident physicians caring for hospitalized patients with limited English proficiency. J Health Care Poor Underserved 2014 Nov;25(4):1784–98. doi: 10.1353/hpu.2014.0160. 13. Schenker Y, Pérez-Stable EJ, Nickleach D, Karliner LS. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med 2011 Jul;26(7):712–7. doi: 10.1007/s11606-010-1619-z. Epub 2011 Feb 19. PMCID: PMC3138590. 14. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S, Zavotsky K, Eisenstein R. Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: Results of a randomized controlled trial. Ann Emerg Med 2011 Mar;57(3):248–256.e1–4. doi: 10.1016/j. annemergmed.2010.05.032. Epub 2010 Aug 3. 15. Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient access to professional interpreters in the hospital decreases readmission rates and estimated hospital expenditures for patients with limited English proficiency. Med Care 2017 Mar;55(3):199–206. doi: 10.1097/ MLR.0000000000000643. PMCID: PMC5309198. 16. Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: The importance of language concordance and interpreter use. J Gen Intern Med 2007 Nov;22 Suppl 2(Suppl 2):324–30. doi: 10.1007/s11606-007-0340-z. PMCID: PMC2078537. 17. 42 U.S.C. §2000d. Prohibition against exclusion from participation in, denial of benefits of and discrimination under federally assisted programs on ground of race, color or national origin. 18. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med 2007 Nov;22 Suppl 2(Suppl 2):362–7. doi: 10.1007/s11606-007-0366-2. PMCID: PMC2150609. 19. 65 FR 50121. Improving Access to Services for Persons With Limited English Proficiency. 20. 65 FR 52762. Title VI of the Civil Rights Act of 1964; Policy Guidance on the Prohibition Against National Origin Discrimination as It Affects Persons With Limited English Proficiency. 21. 68 FR 47311. Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. 22. Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111–148, 124 Stat. 119 (2010), Codified as Amended 42 U.S.C. § 18001. 23. 81 FR 31375. Nondiscrimination in Health Programs and Activities. 24. 85 FR 37160. Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority. D ECEMBER 2 0 2 1

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25. 86 FR 27984. Notification of Interpretation and Enforcement of Section 1557 of the Affordable Care Act and Title IX of the Education Amendments of 1972. 26. Musumeci M, Dawson L, Sobel L, et al. Recent and Anticipated Actions to Reverse Trump Administration Section 1557 Non-Discrimination Rules. KFF; June 9, 2021. Accessed June 28, 2021. 27. Youdelman, M. Summary of State Law Requirements Addressing Language Needs in Health Care. National Health Law Program. April 2019. Accessed May 1, 2021. 28. American Dental Association. About the ADA. Accessed April 15, 2021. 29. Summerhays CG, O’Loughlin K. American Dental Association: Letter to Samuels J. Office for Civil Rights, Department of Health and Human Services. Washington, D.C. 30. American Dental Association, ADA News. ADA urges members to contact members of Congress regarding final rule on Sec. 1557; 2016. Accessed April 15, 2021. 31. Samuels J. Office for Civil Rights, Department of Health and Human Services. Washington, D.C. Letter to Summerhays CG, O’Loughlin K, American Dental Association; 2016 August 15. 32. 84 FR 27846. Nondiscrimination in Health and Health Education Programs or Activities.

33. American Dental Association, ADA News. ADA supports Office for Civil Rights proposal to amend parts of Sec. 1557; 2019. Accessed April 15, 2021. 34. American Dental Association, ADA News. Organized dentistry supports Office for Civil Rights proposal to amend Sec. 1557; 2019. Accessed April 15, 2021. 35. Hasnain-Wynia R, Pierce D, Haque A, Hedges Greising C, Prince V, Reiter J. ifdhe.aha.org/hretdisparities/toolkit. Accessed Oct. 9, 2021. 36. American Dental Association. ADA Member Advantage — Endorsed Programs. Accessed April 15, 2021. 37. U.S. Department of Health and Human Services. Example of a Policy and Procedure for Providing Meaningful Communication with Persons with Limited English Proficiency. Washington, D.C.: U.S. Department of Health and Human Services, Office of Civil Rights; 2013. Accessed Oct. 9, 2021. 38. Think Cultural Health. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. U.S. Department of Health and Human Services, Office of Minority Health. Accessed Oct. 9, 2021. T H E AU T H O R , Nicole Holland, DDS, MS, can be reached at Nicole.Holland@tufts.edu.

C .E. CREDIT QUESTIONS

December 2021 Continuing Education Worksheet This worksheet provides readers an opportunity to review C.E. questions for the article “A Historical Overview of Language Access in Dentistry: The Impact of Language Access Protections on Oral Health Care” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as .5 of Core C.E. 1. According to the 2019 U.S. Census Bureau American Community Survey, approximately what percentage of Americans speak a language other than English at home? a. 18% b. 22% c. 30% d. 37% 2. Studies have shown language-related barriers to be associated with all but which of the following? a. b. c. d.

Poorer self-management Decreased health care provider satisfaction Medical errors Worsened clinical outcomes

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3. Which of the following statements apply to this clause of the 1964 Civil Rights Act, “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of or be subjected to discrimination under any program or activity receiving federal financial assistance”? (mark all that apply) a. It laid the legal foundation for language access across many societal sectors in the U.S., including health care. b. Failure to provide language access has a discriminatory impact. c. It applies to all institutions and programs receiving federal funds, such as Medicaid, CHIP and Medicare payments and federal grants. d. It has been clarified and strengthened over the years by executive order and policy guidance.

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C .E. CREDIT QUESTIONS

December 2021 Continuing Education Worksheet, continued 4. Guidance on the language access-related components of the 1964 Civil Rights Act, first issued by the Office of Civil Rights (OCR) in 2000 under President Clinton and later clarified in 2003 under President Bush, acknowledged the difference in resources between large and small health care entities and identified four factors for consideration when determining the extent and types of language assistance to offer. These include all but which of the following? a. Number (or proportion) of LEP individuals served or eligible to be served b. Nature and importance of service provided c. Extent of each person’s inability to understand English d. Resources and costs 5. In 2010, Section 1557 of the Affordable Care Act (ACA) brought changes to requirements for health care providers who receive federal funds, including dentists, but they were not implemented until 2016 with the release of “The 2016 Rule.” This rule included which of the following? a. Definitions and related requirements regarding the use of “qualified” interpreters and bilingual providers/staff. b. Prohibition of low-quality video remote interpretation services. c. Requirements that providers offer free and timely interpreting services. d. Taglines in the 15 most prevalent languages spoken in their respective states informing individuals of their rights to free language assistance services. e. All of the above. 6. Significant changes to language assistance requirements came again in June 2020, with the Trump administration’s release of an amended “Section 1557 Final Rule.” Which of the following are included in the 2020 rule? (mark all that apply)

7. True or False: To ensure uniformity, the amended 2020 Final Rule prohibits states from enacting their own laws or regulations regarding language access. 8. The author makes several recommendations for dental practices to ensure language is not a barrier to quality oral health care and to support language access protections for individuals with LEP. Which of the following does she recommend dental practices consider for meeting language-assistance needs in their practice? (mark all that apply) a. Establish practice policies for working with individuals with LEP. b. Train all members of the dental team on communication, cultural competency, respectful assessment and documentation of preferred language and interpreter needs. c. Hire staff who reflect the linguistic and cultural diversity of the community. d. Contract with an interpreter services company to provide remote (telephone or video) interpreter services as needed. e. All of the above. 9. True or False: The ADA offers a discounted interpreter services fee agreement for ADA member dentists. 10. True or False: Though the language-access provisions of Section 1557 of the ACA, which reinforced longstanding nondiscrimination protections, were amended as recently as 2020, dentists should pay close attention to this as further revisions are anticipated.

a. Requires notices and taglines in communications of covered dental practices only “when necessary.” b. Expands the use of acceptable, audio-based interpretation services. c. Requires that interpretation must still be accurate, timely and free of charge. d. Permits individuals with LEP to bring their own interpreter or rely on a minor child or accompanying adult to interpret. e. All of the above.

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oral health literacy C D A J O U R N A L , V O L 4 9 , Nº 12

Oral Health Literacy Framework: The Pathway to Improved Oral Health Francisco Ramos-Gomez, DDS, MS, MPH, and Tamanna Tiwari, MPH, MDS, BD

abstract Background: Oral health literacy (OHL) is the degree to which a patient receives, gains, processes and understands basic oral health knowledge, the services available to them and the behaviors required of them to make healthy decisions. Types of studies reviewed: Studies reviewed focused on oral health disparities, barriers to OHL and patient-provider communication, parental engagement and factors contributing to the improvement of OHL for vulnerable communities. Results: The consequences of low OHL are far reaching and compounded by disparities that already exist for patients and communities on multiple levels. This article discusses barriers to OHL, the impact of OHL on oral health and oral health disparities and recommendations for improving patient OHL. Practical implications: The article provides a proposed conceptual framework that discusses the potential mechanism of upstream and intermediate factors impacting OHL and how OHL affects oral health outcomes. Keywords: Oral health literacy, oral health equity, oral health education, parental engagement, oral health disparities

AUTHORS Francisco RamosGomez, DDS, MS, MPH, is a professor of pediatric dentistry at the University of California, Los Angeles, chair of the division of growth and development at the UCLA School of Dentistry and director of the UCLA Center Children’s Oral Health (UCCOH). Conflict of Interest Disclosure: None reported.

Tamanna Tiwari, MPH, MDS, BDS, is an assistant professor in the department of community dentistry and population health, associate director of the Center for Oral Disease Prevention and Population Health Research and program director DDS/ MPH at the School of Dental Medicine at the University of Colorado. (ORCID ID: orcid.org/0000-00019334-4440). Conflict of Interest Disclosure: None reported.

isparities in children’s oral health continue to persist across the United States and are influenced by factors including race, ethnicity and socioeconomic status. According to the American Dental Association, the prevalence of untreated dental caries in children ages 5 to 9 from 2011–2014 was 23.9% in Mexican American children and 22.9% in non-Hispanic Black children, significantly higher than the prevalence of 16.2% in non-Hispanic white children.1 Disparities also exist in dental care

utilization for children according to race; in 2017–2018, the percentages of children who had visited the dentist in the past year was 42.6% for Black children, 45.4% for Asian children, 46.9% for Hispanic children and 55.5% for white children.2 In Los Angeles County alone, tooth decay continues to be more prevalent among children from socioeconomically disadvantaged and Spanish-speaking households as well as among children from Asian, Black/African American and Latinx backgrounds.3 According to the Smile Survey 2020, roughly 2 out D ECEMBER 2 0 2 1

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of 3 disadvantaged children in Los Angeles experience dental decay with more than 1 out of 5 experiencing untreated decay, significantly higher than the 1 in 3 nondisadvantaged children who experience decay and 1 in 7 who experience untreated decay. Language also played a role in oral health disparities; in households where Spanish was the primary language, the likelihood of tooth decay was 70% compared to 47% in primarily English-speaking households. This disparity implies that children from Spanish-speaking homes have more limited access to preventive services and behaviors than their English-speaking peers.3 These disparities underline the need for oral health to be framed as a matter of social justice, human rights and health equity. Recent research has found correlations between oral health disparities and oral health literacy levels, highlighting the necessity for oral health care providers to educate patients and families at an appropriate literacy level.4 The consequences of low oral health literacy (OHL) are far reaching and compounded by disparities that already exist and affect patients on multiple levels.5–9 Over the past 20 years, research has shown that low OHL contributes to poor oral health, such as periodontal disease, tooth decay and missing teeth,10,11 as well as missed preventive dental appointments and minimally invasive treatment options.12 In order to ensure that all patients, regardless of race, background or socioeconomic status, have access to quality oral health care and education, oral health literacy strategies must be improved and implemented nationwide.

OHL

The World Health Organization (WHO) defines health literacy as “the motivation and ability of individuals 760 D ECEMBER

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to gain access to, understand and use information in ways which promote and maintain good health.”13 Based on this definition, OHL can be defined as the extent to which a patient is motivated and able to gain, understand and use basic oral health knowledge, the services available to them and the behaviors required of them to make healthy decisions. Because the patient is the best manager of their own health, OHL must be patient-focused. Additionally, information must be presented to the patient at a level and in a format and

The consequences of low OHL are far reaching and compounded by disparities that already exist.

language they can understand. If a patient cannot understand the information that is being shared with them, it is impossible for that individual to benefit from it. In the realm of pediatric dentistry, parents’ OHL takes on a crucial role. Because the patient is a child, their oral health is entirely dependent on the parent’s or caregiver’s level of OHL. Because pediatric patients depend on parents and caregivers for good oral health and behaviors, family oral health education is a key piece of OHL. Family oral health education (FOHE) is oral health education that focuses not only on the child, but the entire family. Family education on topics like the importance of pediatric oral health, behaviors necessary to protect oral health and prevent oral disease and the role of pediatric oral

health in overall health throughout the life course, can increase OHL by improving families’ understanding of oral health. The potential impacts are far reaching, resulting in healthier habits at home, prevention of the chronic disease early childhood caries (ECC) and cavityfree futures for children regardless of socioeconomic status, race or background. In its 2020 publication “Healthy People 2030,” the U.S. Department of Health and Human Services Office of Disease Control and Prevention identified two levels of health literacy.14 Personal health literacy looks at the understanding of individuals and their knowledge of oral health as it enables them to make healthy decisions for both themselves and others. Organizational health literacy is “the degree to which organizations equitably enable individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others.”1 When it comes to advocating for pediatric oral health, both levels of OHL are critical. In order for oral health education to be effective, it is necessary that the education materials be culturally and linguistically appropriate and accessible.15 By prioritizing OHL, health care professionals can pave the way to oral health equity as a matter of social justice and human rights.2 As such, pediatric dental and medical providers have a responsibility to ensure that oral health education remains accessible to patients from all backgrounds and populations. This includes ensuring their practices and office environments are culturally competent, advocating for policies that advance social justice and health equity and engaging community leaders to join the fight against oral health disparities.16 The Centers for Disease Control and Prevention (CDC) defines cultural competence as “a set

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TABLE 1

Summary of Key Factors Impacting Oral Health Literacy (OHL) Types of Factors

Definition

Upstream factors

Factors that influence at the broadest level

• Maternal education, personal education, participation in education and training • Social context of communities, economic hardships, racial bias

Intermediate factors

Factors that influence individuals and communities closely

• Cultural: cultural values, help-seeking beliefs, community engagement • Linguistic: language spoken at home, understanding of health care services and available health information • Acculturation: community values, community engagement, social support

of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations,” adding that organizations that promote cultural competence value diversity, self-evaluate their environment, learn and apply cultural knowledge and adapt to diversity in their communities.17

Barriers to OHL

Patient-provider communication is a key barrier to OHL. Patient-provider communication is impacted on both sides; patients with low OHL skills may struggle to describe dental problems or concerns to their dental providers, while providers’ efforts to describe or explain dental conditions may not be fully understood. In a study of dental providers in California that examined communication techniques, participants referenced multiple barriers to patientprovider communication. When asked what barriers existed, providers cited patients’ inability to follow recommended oral health practices, patients’ lack of understanding of oral health information, language and cultural barriers between patients and providers, patients’ lack of interest/ prioritization in their own oral health, limitations in provider training/ clinical practice and a lack of OHL communication training and proficiency requirements in professional schools/ continuing education.4 These answers indicated that providers are in need of further training on OHL principles and techniques in order to best serve and reach their patients. However, the answers also conveyed a tendency

Examples

for providers to shift responsibility for communication onto patients rather than examining ways they can take responsibility themselves and adapt their practices and communication styles to be more appropriate and accessible, both culturally and linguistically. In the same study, dental providers reported needing help communicating with the following specific disadvantaged patient populations:4 ■ Patients with limited English proficiency (LEP) (65%). ■ People with cognitive disabilities (54%). ■ Older adults (42%). ■ People with limited education (35%). ■ The deaf or hard of hearing (31%). ■ Early childhood age groups (31%). Patients with LEP experience the greatest oral health communication barriers for a multitude of reasons.4 They face frequent challenges due to cultural differences and language barriers, and these challenges impact information input and output when it comes to patient-provider communication. These obstacles to effective communication are often compounded by the cultural differences that tend to accompany language barriers as well as the failure of many dental practices to adequately use translation or interpretation services. This highlights a need for oral health materials and dental environments that are culturally and linguistically appropriate for all patients, regardless of language, culture or background.4 According to the National Hispanic Council on Aging, nonnative English speakers are more likely to have low

health literacy than native English speakers, and immigrants are more likely to have difficulty navigating the U.S. health care and insurance systems. These disparities are further exacerbated by the linguistic and cultural barriers that face immigrant and nonnative English-speaking populations.14 This is demonstrated by the fact that 41% of Latino adults lack basic health literacy, and only 4% have the necessary level of health literacy proficiency to make informed health decisions.18

The OHL Framework

The conceptual framework illustrated in FIGURE 1 and summarized in TA BLE 1 provides a potential mechanism of upstream and intermediate factors impacting OHL and how OHL affects oral health outcomes.

Upstream Factors (Factors that influence at the broadest level)

OHL is strongly associated with upstream factors such as race/ethnicity, educational attainment, social-economic factors, geographic location and immigrant status of the population. Complex factors such as maternal education, personal education and participation in education and training were found to contribute to health literacy. OHL represents an interaction between personal capacity and social and environmental factors that impact the health-related actions and behaviors of individuals.19 Thus, the social context of the communities, economic hardships and racial bias plays a role in how individuals and communities gain OHL and increase their capacity to use it D ECEMBER 2 0 2 1

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Intermediate factors Upstream factors

Language spoken at home

Intermediate effects

Acculturation

Access to oral health care

Oral health literacy

Patient-provider engagement/ relationship of trust

Race/ethnicity Education Age Income

Oral health outcomes and oral health equity

Employment status Immigration status

Community values and engagement

Oral health behaviors

Geographic location Social support

FIGURE . Pathways between oral health literacy and oral health outcomes (modified from Ju et al.).68

to improve access to care, patient-provider communication and oral health behaviors.

Intermediate Factors (Factors that influence the individuals and communities closely)

Culture and language spoken at home are important factors impacting immigrant populations and OHL. Cultural factors should go beyond the language barriers and include a broader appreciation of cultural values, help-seeking beliefs and community engagement — all these factors play a role in enhancing OHL. Linguistic barriers can impact OHL through less understanding of health care services, including health information that is available to them.20 Studies show that children of Latino parents who do not speak English at home and face linguistic challenges while attending dental visits have poorer oral health outcomes, 762 D ECEMBER

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including higher dental caries, fewer preventive visits and fewer dental sealants than the general U.S. population.21–23 Recent literature shows links between acculturation, OHL and oral health outcomes.24 Acculturation is a process by which individuals adopt the values and behaviors from another culture, affecting their lifestyle and beliefs.25,26 Acculturation impacts the ability of an individual to navigate the dental health care system. Lower acculturation can increase language barriers that can lead to poor OHL.27 For example, language proficiency within immigrant communities was one of the most influential factors impacting visits to the dentist and adhering to recommended behaviors.28 It has also been reported that higher language proficiency was associated with higher OHL, improved oral health knowledge, enhanced oral hygiene practices and increased utilization of preventive dental services.28,29

Acculturation influences Latino children’s oral health through parental oral health knowledge and OHL. It has been shown that more acculturated Latino parents had better OHL, perceived fewer barriers in seeking care and promoted better oral health behaviors — such as brushing teeth twice daily — for their children compared to Latino parents who were less acculturated. Additionally, it has been shown that more acculturated Latino parents had higher socioeconomic status, reported better overall health and were more likely to have dental insurance compared to less acculturated Latino parents.30 These studies demonstrate the interconnectedness of upstream and intermediate variables and their impact on OHL and Latino communities.30 Community values and engagement are essential components to be recognized in terms of OHL, especially in minority and immigrant communities. For

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example, Latino communities value interdependence and have perceived norms related to oral health prevention that can impact OHL and dental care utilization.31 Social and cultural factors such as collective attitudes and behaviors related to oral health with a Latino community can act as enabling factors or barriers to gaining OHL.32 In addition, Latino communities have close relationships with family and community — these values of familism and generational living with multiple caregivers are common practices in Latino families and immigrant communities and are important factors to take into consideration in terms of OHL and associated oral health outcomes for children.33 Social support is another important factor associated with OHL, especially for immigrant groups. Social support from close groups, family, extended kin and friends contributes to individuals obtaining relevant health-related information and making informed medical decisions. In the Latino community, which is often family centered with strong social support networks, higher social support is associated with higher OHL and better oral health outcomes.31,34

Intermediate Effects Access to Oral Health Care

Individuals with limited OHL may avoid or delay seeking care because they may not fully understand the value of preventive treatments or may not understand the signs and symptoms of diseases. Additionally, individuals may fear their limited OHL will be exposed in a clinical setting, causing them to feel shame or embarrassment.35 As a result, individuals may avoid seeking care.35,36 Language proficiency and OHL play a part in navigating the health system. Individuals with poor OHL may face

additional challenges navigating the complex U.S. health and insurance systems. Many individuals are eligible but not enrolled in programs such as Medicaid, and not all states include an oral health benefit in Medicaid. The complexity and lack of understanding of benefits may be a heightened barrier for individuals with limited health literacy. Additionally, people with limited language proficiency and OHL have reported difficulty locating health facilities and following instructions. These factors heighten challenges for individuals

Implementing medical and dental integrated models can provide streamlined care for people with poor OHL.

with poor language proficiency and OHL in accessing oral health services. Implementing medical and dental integrated models can provide streamlined care for people with poor OHL. Integrated models of care have been shown to close care gaps for some of the most vulnerable populations in our country by bringing multiple silos of care together in one place.37

Patient-Provider Engagement/ Relationship of Trust

OHL plays an integral part in building trust between the patient and the provider. Limited OHL has been associated with greater distrust of providers, pessimism about treatment and lower care satisfaction.38 Trust is critical in any patient-provider relationship because it is

known to affect health outcomes, improve health status and increase patients’ satisfaction,39–41 thereby improving patients’ usage of available health services and the extent to which they follow care guidelines.38 While many factors impact patients’ levels of trust in their provider, the provider’s communication skills, mutual understanding and caring attitude appear to be closely connected to patient trust.41,42 This indicates that the ability of dental professionals to communicate with their patients’ health literacy is directly linked to improved health outcomes, guiding and informing patients’ ability to implement appropriate oral health care and make decisions that benefit their health overall.43 In fact, as Horowitz and Kleinman note in comparisons of health literacy definitions, what all definitions have in common is an expression of the idea that by improving people’s access to health information and their ability to appropriately use it, overall health outcomes would improve.43 It is critical for patients, especially those with low OHL, to clearly understand instructions, follow recommendations and feel comfortable asking questions. When these key aspects are lacking, it can contribute to poor patient-provider engagements and lead to miscommunication. Additionally, poor OHL can make it challenging for providers to educate on the importance of prevention or adhering to good oral health behaviors. Often, patients receive an abundance of oral health information but are rarely evaluated for comprehension.44–46 Therefore, it is crucial for oral health providers to recognize literacy challenges for their patients. One way to address this challenge is to ensure dental professionals are trained to provide culturally competent care and communicate with their patients in a linguistically appropriate way to assess D ECEMBER 2 0 2 1

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TABLE 2

Summary of Intermediate Effects of Oral Health Literacy (OHL) Intermediate Effect

Summary

Access to oral health care

Individuals with low OHL may: • Avoid or delay seeking care. • Fear exposure of limited OHL resulting in shame or embarrassment.35 • Face additional challenges navigating the U.S. health and insurance systems. • Have difficulty locating health facilities and following instructions.

Patient-provider engagement/ relationship of trust

Low OHL is associated with: • Greater distrust of providers. • Pessimism about treatment. • Lower care satisfaction.38 • Poor patient-provider engagements. • Increased miscommunication. • Challenges in oral health education.

Oral health behaviors

Low OHL is associated with: • Low knowledge of good oral health behaviors.50 • Low confidence of parents to care for their child’s oral health. • More perceived barriers to accessing care. • Fewer perceived benefits of preventive dental visits.50–53

Role in oral health inequities

OHL levels influence: • Oral health care delivery. • Individual’s knowledge, behaviors and capacity for health-related decisions. • Access to meaningful information about oral health for vulnerable populations. • Access to preventive services to vulnerable populations.

their comprehension of the information they are receiving. Providing culturally competent care can improve patientprovider trust and communication. Because patients with limited health literacy receive less primary prevention, it is vital for providers to invest in building a strong relationship with their patients while in the office.47 Cultural competency training is provided as a part of predoctoral training within most dental schools and continuing professional development.48 However, more training opportunities for the dental workforce are needed in regard to providing care to a diverse population.49

Oral Health Behaviors

OHL and oral health behaviors are closely associated. Lower OHL is associated with lower knowledge regarding recommended oral hygiene and dietrelated behaviors.50 Parents who have low OHL exhibit lower confidence that they can take care of their children’s 764 D ECEMBER

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teeth. In addition, they perceive more barriers to accessing care and fewer benefits of preventive dental visits.50–53

Role of Oral Health Literacy in Oral Health Inequities

Improving OHL will indirectly have a beneficial effect on reducing oral health inequities.19 OHL influences several aspects of oral health, including oral health care delivery, and the individual’s knowledge, behaviors and capacity for health-related decisions. For example, improved OHL could improve patient access to preventive services, increase patients’ trust in the provider and help motivate patients to adhere to recommended oral health behaviors, which may ultimately reduce oral health inequities. For vulnerable groups, such as the Latino population and other immigrant groups, low OHL impacts access to meaningful information about oral health issues and access to preventive services, which may contribute

to the deterioration in health status and lead to oral health inequities. The intermediate effects of OHL are summarized in TA BLE 2 .

Next Steps

Research has shown that patients’ oral health is impacted by their OHL levels and, where the pediatric population is concerned, the OHL level of parents and caregivers.4 Consequently, steps must be taken to address low OHL levels in patients and families in order to improve patient-provider communication and increase oral health overall. The following steps are recommended moving forward as strategies to increase the OHL of families and improve children’s oral health and are summarized in TA BLE 3 .

Promoting Oral Health Education and Counseling

Studies have shown that improved patient-dentist communication is a critical step in improving the population’s oral health.54,55 With this in mind, promoting oral health education that is culturally and linguistically appropriate is a key step in improving OHL. Furthermore, improved OHL through oral health education has the potential to impact bigpicture issues including policy, education and public health-related reform and solutions.16 Essential aspects of oral health education include the following:

Caries Risk Assessments

A caries risk assessment is an essential component in the decision-making process of dental providers for the appropriate prevention and management of dental caries.56 Multiple caries risk assessment forms and algorithm-based programs based on a combination of scientific evidence and expert opinion are available to providers to help guide practitioners in assigning risk status based on a variety

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TABLE 3

Summary of Next Steps for Improving Oral Health Literacy (OHL) Next Step

Summary

Promoting oral health education and counseling

Patients’ oral health is impacted by their OHL levels and, for children, the OHL levels of their parents or caregivers.4 Steps must be taken to address low OHL levels in patients and families in order to improve patient-provider communication and increase oral health overall.

• • • • •

Training for providers

Ensuring that dental providers and their teams are effectively trained in OHL communication techniques is a priority when it comes to research and effective OHL practices.

• Culturally and linguistically appropriate resources. • Effective communication. • Patient-friendly health care environments.

Community oral health workers (COHWs) or promotoras

COHWs or promotoras are layperson health educators who can serve as a bridge between families and providers and help facilitate culturally and linguistically appropriate care.

• Provide connections to dental homes and referrals to providers.67 • Assist in scheduling appointments.67 • Follow up with families.67 • Help families navigate the health care system. • Provide oral health education in the family’s preferred language and with cultural sensitivity.

Interprofessional collaboration

Oral health education can be provided by both medical and dental providers.15

• Remind parents of the importance of parental engagement in their child’s oral health. • Remind expecting parents that a child’s oral health starts prenatally and from infancy. • Stress the importance of preventive dental care. • Promote healthy habits and behavior change.

Prioritization of the age 1 visit

All children should receive an oral health exam upon the eruption of their first tooth or by age 1.

• Assessment of child’s risk level and proactive preventive care. • Opportunity to offer appropriate education to parents using OHL strategies.

of clinical and social factors.57 Once risk status is identified, providers can direct more intensive preventive care to those patients who are at high risk for caries.

Self-Management Goals

Self-management goals are used to guide parents or caregivers to commit to manageable goals related to their child’s oral health habits and behaviors in the home. Self-management goals contribute to behavior change that has the potential to improve both the child’s oral health and their caries risk level.

Anticipatory Guidance

Through anticipatory guidance, health providers counsel parents about the development of their child’s health. Anticipatory guidance is perhaps one of

Includes Caries risk assessments. Self-management goals. Anticipatory guidance. Motivational interviewing. Open-ended questions, Affirmations, Reflective listening, Summaries (OARS). • The six-step infant oral care visit. • TeleOral health education and health promotion.

the most effective methods of ECC prevention in that it proactively educates parents about their child’s oral development and behaviors to implement at home in order to keep their teeth healthy and caries free. Providers are encouraged to use the teach-back method to ensure the parent/caregiver comprehends what is being suggested.

Motivational Interviewing

Providers can use motivational interviewing as a means of connecting with families and providing oral health education. Motivational interviewing should be incorporated into conversations surrounding caries risk assessment and selfmanagement goals. A variety of toolkits and resources exist to assist providers in providing effective motivational

interviewing, including the Association of State and Territorial Dental Directors early childhood committee’s list of motivational interviewing resources58 and the updated Your Ultimate Motivational Interviewing Toolkit, available at PositivePsychology.com.59

OARS

Throughout the entire oral health education process, providers are encouraged to remember the acronym OARS, which stands for open-ended questions, affirmations, reflective listening and summaries. By employing the OARS technique, providers ensure that parents are given an opportunity to share their concerns and perspectives, that they feel affirmed and supported, that they feel listened to and understood D ECEMBER 2 0 2 1

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and that they leave the conversation having understood the information and instructions that were conveyed to them. When implemented correctly, OARS supports and promotes effective OHL practices and culturally appropriate care.

The Six-Step Infant Oral Care Visit

An infant oral care visit is made up of six steps: caries risk assessment, knee-toknee exam, toothbrushing prophylaxis, clinical exam, fluoride varnish treatment and anticipatory guidance, counseling and self-management goals. In the context of the six-step infant oral care visit, patient and caregiver education should take place both during the caries risk assessment and at the end of the visit.

Teleoral Health Education and Health Promotion

Teledentistry or teleoral health will be an essential tool in delivering oral health education and health promotion. One of the benefits of teledentistry is it can provide health care providers with insight into the lives of their patients by bringing the dental practice into patients’ homes and is increasingly being used to promote patient-provider relationships that build trust, cultural competency and continuity of care across the patient’s lifetime.60 However, the development of protocols and cultural competency training is needed for providers to deliver oral health promotion in a telehealth setting. Telehealth as a format of health care is well suited to many encouraged communication practices including agenda-setting, plain language usage, avoiding overloading patients with information and using the teach-back method.61,62 Telehealth also has the potential to improve communication between patients and providers by reducing anxieties often connected to visiting health care facilities, which may 766 D ECEMBER

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otherwise interfere with attention to and retention of information.62 The increased use of telehealth may improve access to care specifically for individuals from lower-income communities who tend to face obstacles to health care such as transportation to health care facilities, conflicts with work schedules or the demands of caregiving responsibilities.62 It is important to note that providers can still implement strategies for clear communication when providing services over a telehealth platform. According to Coleman, these strategies include using

Providers can still implement strategies for clear communication when providing services over a telehealth platform.

health literacy universal precautions (precautions that minimize risk for all patients through how health care is structured),63 utilizing professional medical interpreters for patients with LEP, establishing an agenda at the beginning of the encounter, using plain language, avoiding unnecessary medical jargon, being careful not to overload patients with information, repeating and/ or summarizing key information, utilizing visual aids and written summaries in order to accommodate multiple learning styles, asking open-ended questions and using teach-back.61,62

Training for Providers

Ensuring that dental providers and their teams are effectively trained in OHL communication techniques is now

considered a priority when it comes to research and developing effective OHL practices.18 Among current strategies, the following health literacy intervention strategies have shown positive results in medical settings64,65 and should be incorporated into provider OHL training: ■ Resources — Train providers to provide resources that are in the patient’s or caregiver’s preferred language and at their designated literacy level, making it easy for patients to learn from and implement the information. Providing patients with resources that are culturally and linguistically appropriate is necessary when disseminating oral health information. Providers are encouraged to have oral health pamphlets and other materials available in multiple languages according to the demographics of the community.66 Pamphlets should include information on accessing dental care and should provide resources and information on finding affordable dental insurance.66 Additionally, dentists can partner with schools and communitybased organizations outside of their dental practice as a means of increasing OHL on dietary behaviors and oral hygiene.15,66 ■ Communication — Ensure that health providers and staff receive the necessary training on how to communicate effectively with all patients, regardless of their language, culture, background or health literacy level. ■ Environment — Equip providers to foster health care environments that are “patient friendly” and “shame-free,” ensuring that patients feel comfortable,

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welcome and free to ask questions without fear of judgment.65

Community Oral Health Workers or Promotoras

Community oral health workers (COHWs) or promotoras (lay-person health educators in the Hispanic/ Latino community) can serve as a bridge between families and providers and help to facilitate culturally and linguistically appropriate care. Research of a promotoras-led oral health promotion workshop in an underserved primarily Hispanic/Latino community showed notable improvements in the oral health-related knowledge and beliefs of caregivers participating in the workshop.67 Thus, including COHWs as part of the dental team has many potential benefits. Through in-person interaction with families, COHWs can provide connections to dental homes and referrals to providers.67 They can assist in scheduling appointments and follow up with families to ensure that children are receiving the care they need at home.67 By helping families navigate the health care system and providing oral health education in the family’s preferred language and with cultural sensitivity, COHWs are in a prime position to improve OHL within their community.

Interprofessional Collaboration

In order to maximize oral health education for parents and caregivers, it is important to remember that education can be provided by both medical and dental providers.15 Dentists and primary care providers should remind parents and caregivers of the importance of parental engagement when it comes to their child’s oral health. They can remind expecting parents that a child’s oral health starts prenatally and from

infancy throughout childhood and can stress the importance of preventive dental care. Additionally, they can promote healthy habits and behavior change that will benefit the child’s oral health from a young age.

Prioritization of the Age 1 Visit

The importance of oral health education and OHL emphasizes just how critical the age 1 visit is for every child’s oral health. All children should receive an oral health exam upon the eruption of their first tooth or by

To progress toward “oral health equity,” OHL, patient engagement and oral health education must play a central role.

age 1. In addition to allowing dental providers to assess the child’s risk level and take proactive steps to stop caries before they begin, the age 1 visit also allows providers to offer appropriate education to parents using OHL strategies, equipping both caregiver and child to keep the infant’s healthy teeth caries free throughout the life course.

Conclusion

If we are aiming to progress toward “oral health equity” on a cavity-free future for patients from all backgrounds and races, OHL, patient engagement and oral health education must play a central role. Oral health cannot be positioned as a matter of social justice, health equity and human rights if patients are unable to gain, process and

understand oral health, available oral health services and healthy oral health behaviors. Providers and patients can work together to overcome barriers to OHL by understanding the patientprovider relationship of trust and engagement. Furthermore, dental and medical providers are well-positioned to support patients and their families in the context of the upstream and intermediate factors affecting them, thanks in part to the increased utilization of teleoral health, which has the potential to help decrease barriers in access to oral health care while enabling oral health care providers to continue to utilize strategies for clear communication with their patients. Through more sensitivity, understanding, improved provider training skills and effective dissemination of resources, interprofessional providers can work together to increase oral health education, patient engagement and OHL interaction to advocate and promote transformative policies such as the age 1 visit and establishing a dental home for the child and the families. As such, health professionals can pave the way for improved access to care, the patientprovider relationship and addressing oral health behaviors on diet, nutrition and appropriate individual “patient-centered” guided home care as a way to improve oral health and well-being as we move into the future. n AC KN OW L E DG M E N T S The authors acknowledge the contributions of Dr. Jayanth Kumar, Dr. Linda Neuhauser and Dr. Lindsey Robinson and thank Janni Kinsler and Stephanie Parkinson for collaborating on the content of the article. RE F E RE N C E S 1. ADA Health Policy Institute. ADA Racial Disparities in Untreated Caries Narrowing for Children. 2. ADA Health Policy Institute. ADA Dental Care Utilization Among the U.S. Population, by Race and Ethnicity. 3. Los Angeles County Department of Public Health. Smile Survey 2020. 4. Tseng W, Pleasants E, Ivey SL, Sokal-Gutierrez K, Kumar D ECEMBER 2 0 2 1

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J, Hoeft KS, Horowitz AM, Ramos-Gomez F, Sodhi M, Liu J, Neuhauser L. Barriers and Facilitators to Promoting Oral Health Literacy and Patient Communication among Dental Providers in California. Int J Environ Res Public Health 2020 Dec 30;18(1):216. doi: 10.3390/ijerph18010216. PMID: 33396682; PMCID: PMC7795206. 5. Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007 Sep;138(9):1199–208; quiz 1266–7. doi: 10.14219/jada. archive.2007.0344. 6. White S, Chen J, Atchison R. Relationship of preventive health practices and health literacy: A national study. Am J Health Behav May–Jun 2008;32(3):227–42. doi: 10.5555/ ajhb.2008.32.3.227. 7. Sabbahi DA, Lawrence HP, Limeback H, Rootman I. Development and evaluation of an oral health literacy instrument for adults. Community Dent Oral Epidemiol 2009 Oct;37(5):451–62. doi: 10.1111/j.16000528.2009.00490.x. 8. Firmino RT, Ferreira FM, Paiva SM, Granville-Garcia AF, Fraiz FC, Martins CC. Oral health literacy and associated oral conditions: A systematic review. J Am Dent Assoc 2017 Aug;148(8):604–613. doi: 10.1016/j.adaj.2017.04.012. Epub 2017 May 3. 9. Horowitz AM, Kleinman DV, Atchison KR, Weintraub JA, Rozier RG. The evolving role of health literacy improving oral health. In Logan RA, Siegel ER, eds. Health literacy in clinical practice and public health: New initiatives and lessons learned at the intersection with other disciplines. In press. Amsterdam: IOS Press; 2020:95–114. 10. Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health 2018 Oct 24;18(1):172. doi: 10.1186/s12903-018-0640-1. PMID: 30355347; PMCID: PMC6201552. 11. Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY. The impact of oral health literacy on periodontal health status. J Public Health Dent 2014 Winter;74(1):80–7. doi: 10.1111/j.1752-7325.2012.00375.x. Epub 2012 Nov 2. PMID: 23121152; PMCID: PMC3800213. 12. Baskaradoss JK. The association between oral health literacy and missed dental appointments. J Am Dent Assoc 2016;147(11):867–874. doi: 10.1016/j.adaj.2016.05.011. Epub 2016 Aug 3. 13. World Health Organization. Health Promotion Glossary. Health Promot Int 1998; 13(4):349–364. 14. U.S. Department of Health & Human Services Office of Disease Prevention and Health Promotion. Healthy people 2030. www.healthypeople.gov/2020/About-Healthy-People/ Development-Healthy-People-2030/Framework. 15. FDI policy statement on perinatal and infant oral health: Adopted by the FDI General Assembly: 13 September 2014, New Delhi, India. Int Dent J 2014 Dec;64(6):287–8. doi: 10.1111/idj.12147. 16. Ramos-Gomez F, Kinsler J, Askaryar H. Understanding oral health disparities in children as a global public health issue: How dental health professionals can make a difference. J Public Health Policy 2020 Jun;41(2):114–124. doi: 10.1057/s41271-020-00222-5. PMID: 32054981. 17. Centers for Disease Control and Prevention. Cultural Competence in Health and Human Services. 18. The National Hispanic Council on Aging. Health Literacy. 19. Simich L. Health Literacy and Immigrant Populations

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(2009). 20. Zanchetta MS, Poureslami IM. Health literacy within the reality of immigrants’ culture and language. Can J Public Health May–Jun 2006;97 Suppl 2:S26–30. 21. Finlayson TL, Gansky SA, Shain SG, et al. Dental utilization by children in Hispanic agricultural worker families in California. J Dent Oral Craniofac Epidemiol 2014;2(1–2):15–24. 22. Kim YO. Reducing disparities in dental care for low-income Hispanic children. J Health Care Poor Underserved 2005 Aug;16(3):431–43. doi: 10.1353/hpu.2005.0052. 23. Mejia GC, Weintraub JA, Cheng NF, et al. Language and literacy relate to lack of children’s dental sealant use. Community Dent Oral Epidemiol 2011 Aug;39(4):318–24. doi: 10.1111/j.1600-0528.2010.00599.x. Epub 2010 Dec 29. 24. Geltman PL, Adams JH, Penrose KL, Cochran J, Rybin D, Doros G, Henshaw M, Paasche-Orlow M. Health literacy, acculturation and the use of preventive oral health care by Somali refugees living in Massachusetts. J Immigr Minor Health 2014 Aug;16(4):622–30. doi: 10.1007/s10903-013-98460. 25. Redfield R, Linton R, Herskovits MJ. Memorandum for the Study of Acculturation. Am Anthro 1936, 38, 149–152. 26. Luo H, Hybels CF, Wu B. Acculturation, depression and oral health of immigrants in the USA. Int Dent J 2018 Aug;68(4):245–252. doi: 10.1111/idj.12364. Epub 2017 Dec 21. 27. Tiwari T, Albino J. Acculturation and pediatric minority oral health interventions. Dent Clin North Am 2017 Jul;61(3):549– 563. doi: 10.1016/j.cden.2017.02.006. Epub 2017 May 4. 28. Dahlan R, Badri P, Saltaji H, Amin M (2019) Impact of acculturation on oral health among immigrants and ethnic minorities: A systematic review. PLoS One 2019 14(2): e0212891. doi.org/10.1371/journal.pone.0212891. 29. Gao XL, McGrath C. A review on the oral health impacts of acculturation. J Immigr Minor Health 2011 Apr;13(2):202– 13. doi: 10.1007/s10903-010-9414-9. 30. Tiwari T, Poravanthattil A, Rai N, Wilson A. Association of acculturation and Latino parents’ oral health beliefs and knowledge. Children (Basel) 2021 Mar;8(3):243. doi. org/10.3390/children8030243. 31. Tiwari T, Rai N, Wilson A, Gansky S, Albino J. What can we learn from parents of caries-free and caries-active Hispanic children? JDR Clin Trans Res 2021 Jan;6(1):47–58. doi: 10.1177/2380084420904043. Epub 2020 Feb 10. 32. Mejia GC, Kaufman JS, Corbie-Smith G, Rozier RG, Caplan DJ, Suchindran CM. 2008. A conceptual framework for Hispanic oral health care. J Public Health Dent Winter 2008;68(1):1–6. doi: 10.1111/j.1752-7325.2007.00073.x. 33. Updegraff KA, Kuo SI, McHale SM, Umaña-Taylor AJ, Wheeler LA. Parents’ traditional cultural values and Mexican origin young adults’ routine health and dental care. J Adolesc Health 2017 May;60(5):513–519. doi: 10.1016/j. jadohealth.2016.10.012. Epub 2016 Dec 14. 34. Laniado N, Sanders AE, Fazzari MJ, Badner VM, Singer RH, Finlayson TL, Hua S, Isasi CR. Social support and dental caries experience: Findings from the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study. Community Dent Oral Epidemiol 2021 Oct;49(5):494–502. doi: 10.1111/cdoe.12626. Epub 2021 Feb 27. 35. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med 1996

Jun;5(6):329–34. doi: 10.1001/archfami.5.6.329. 36. Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr 2000 Dec 1;25(4):337–44. doi: 10.1097/00042560200012010-00007. 37. McKernan SC, Kuthy R, Tuggle L, García DT. MedicalDental Integration in Public Health Settings: An Environmental Scan. Iowa City, Iowa: University of Iowa Public Policy Center: 2018. 38. Yamalik N. Dentist-patient relationship and quality care 2. Trust. Int Dent J 2005 Jun;55(3):168–70. doi: 10.1111/j.1875-595x.2005.tb00315.x. 39. Rogers WA. Is there a moral duty for doctors to trust patients? J Med Ethics 2002 Apr;28(2):77–80. doi: 10.1136/jme.28.2.77. 40. Goold SD, Lipkin M. The doctor-patient relationship: Challenges, opportunities and strategies. J Gen Intern Med 1999 Jan;14 Suppl 1(Suppl 1):S26–33. doi: 10.1046/j.1525-1497.1999.00267.x. 41. Thorn DH, Campbell B. Patient-physician trust: An explanatory study. J Family Prac 1997 44: 169–176. 42. Lahti S, Tuutti H, Hausen H, KIaarianinen R. Patients’ expectations of an ideal dentist and their views concerning the dentist they visited: Do the views confirm the expectations and what determines how well they conform? Community Dent Oral Epidemiol 1996 Aug;24(4):240–4. doi: 10.1111/j.16000528.1996.tb00852.x. 43. Horowitz AM, Kleinman DV. Oral health literacy: The new imperative to better oral health. Dent Clin North Am 2008 Apr;52(2):333–44, vi. doi: 10.1016/j.cden.2007.12.001. PMID: 18329447. 44. Formicola AJ, Stavisky J, Lewy R. Cultural competency: Dentistry and medicine learning from one another. J Dent Educ 2003;67:869–875. PMID: 12959160. 45. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington D.C.: National Academy Press; 2001: 360. 46. Makoul G. Essential elements of communication in medical encounters: The Kalamazoo Consensus Statement. Acad Med 2001 Apr;76(4):390-3. doi: 10.1097/00001888200104000-00021. 47. Garcia RI, Cadoret CA, Henshaw M. Multicultural issues in oral health. Dent Clin North Am 2008 Apr;52(2):319–32, vi. doi: 10.1016/j.cden.2007.12.006. 48. Tiwari T, Palatta AM. An adapted framework for incorporating the social determinants of health into predoctoral dental curricula. J Dent Educ 2019 Feb;83(2):127–136. doi: 10.21815/JDE.019.015. 49. Tiwari T, Palatta A, Stewart J. What is the Value of Social Determinants of Health in Dental Education? NAM Perspectives 2020 Apr 6. 50. Brega AG, Jiang L, Johnson RL, et al. Health literacy and parental oral health knowledge, beliefs, behavior and status among parents of American Indian newborns. J Racial Ethn Health Disparities 2020 Aug;7(4):598–608. doi: 10.1007/ s40615-019-00688-4. Epub 2020 May 8. 51. Vann WF, Jr., Lee JY, Baker D, Divaris K. Oral health literacy among female caregivers: Impact on oral health outcomes in early childhood. J Dent Res 2010 Dec;89(12):1395–400. doi: 10.1177/0022034510379601. Epub 2010 Oct 5.

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52. Brega AG, Thomas JF, Henderson WG, et al. Association of parental health literacy with oral health of Navajo Nation preschoolers. Health Educ Res 2016 Feb;31(1):70–81. doi: 10.1093/her/cyv055. Epub 2015 Nov 26. 53. Vilella KD, Alves SG, de Souza JF, Fraiz FC, Assuncao LR. The association of oral health literacy and oral health knowledge with social determinants in pregnant Brazilian women. J Community Health 2016 Oct;41(5):1027–32. doi: 10.1007/s10900-016-0186-6. 54. Guo Y, Logan HL, Dodd VJ, et al. Health literacy: A pathway to better oral health. Am J Public Health 2014;104:e85–e91. doi:10.2105/AJPH. 2014.301930. Epub 2014 May 15. 55. Horowitz AM, Kleinman DV. Oral health literacy: A pathway to reducing oral health disparities in Maryland. J Public Health Dent Winter 2012;72 Suppl 1:S26–30. doi: 10.1111/j.1752-7325.2012.00316.x. 56. Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci 2009;21:91–101. doi: 10.1159/000224214. Epub 2009 Jun 3. Epub 2009 Jun 3. 57. Chaffee BW, Featherstone JDB, Gansky SA, Cheng J and Zhan L. Caries risk assessment item importance: Risk designation and caries status in children under age 6. JDR Clin Trans Res 2016 Jul; 1(2):131–142. doi: 10.1177/2380084416648932. Epub 2016 May 5. 58. The Association of State and Territorial Dental Directors Early Childhood Committee (2016). What’s in Your Toolkit? Changing the Oral Health Conversation With Families. 59. Vowell C. Your Ultimate Motivational Interviewing Toolkit (2020 update). positivepsychology.com. 60. Ramos-Gomez F. Understanding oral health disparities in the context of social justice, health equity and children’s human rights. J Am Dent Assoc 2019 Nov;150(11):898–900. doi: 10.1016/j.adaj.2019.09.004. PMID: 31668165. 61. Coleman C, Hudson S, Pederson B. Prioritized health literacy and clear communication practices for health care professionals. Health Lit Res Pract 2017 Jul;1(3):e91– e99. doi. org/10.3928/24748307-20170503-01. PMID:31294254. 62. Coleman C. Health literacy and clear communication best practices for telemedicine. Health Lit Res Pract 2020 Nov 6;4(4):e224–e229. doi: 10.3928/24748307-2020092401. PMID: 33170288. 63. DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health literacy universal precautions toolkit. 64. Berkman ND, Sheridan SL, Donahue KE, et al. Health literacy interventions and outcomes: An updated systematic review. Evid Rep Technol Assess (Full Rep) 2011 Mar;(199):1– 941. PMCID: PMC4781058. 65. Taggart JA, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract 2012 Jun 1;13:49. doi: 10.1186/1471-2296-13-49. PMCID: PMC3444864. 66. Jackson A. The state of Medi-Cal Dental and children’s oral health issues. Presentation at the UCLA Oral Health Innovation. October 2018. 67. Villalta J, Askaryar H, Verzemnieks I, Kinsler J, Kropenske V, Ramos-Gomez F. Developing an effective community oral health workers – “promotoras” model for early Head Start. Front Public Health 2019 Jul 3;7:175. doi: 10.3389/fpubh.2019.00175. PMID: 31334211; PMCID:

PMC6621922. 68. Ju X, Brennan D, Parker E, Mills H, Kapellas K, Jamieson L. Efficacy of an oral health literacy intervention among Indigenous Australian adults. Community Dent Oral Epidemiol 2017 Oct;45(5):413–426. doi: 10.1111/cdoe.12305. Epub 2017 May 19. TH E CO RRE S P ON DIN G AU T HOR , Francisco RamosGomez, DDS, MS, MPH, can be reached at frg@dentistry. ucla.edu.

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UCLA-Sesame Street Collaboration To Improve Children’s Oral Health James J. Crall, DDS, ScD; David Cohen; Sofia Polo, MPH; and Sylvia Rusnak, PhD

abstract Background: This paper describes a series of activities through which UCLA and Sesame Street collaborated to develop and use oral health resources as part of a children’s oral health awareness campaign. Methods: Activities included producing five new Sesame Street oral health videos featuring Muppets, supporting a children’s oral health awareness campaign through social media, distributing child and parent educational resources and conducting focus groups of parents, caregivers and oral health professionals to assess their perspectives about children’s oral health, messages and strategies. Results: The awareness campaign exceeded each of six preestablished goals, with the social media campaign generating impressive metrics within a month of the release of the fifth video. The five new videos generated over 687,000 views across UCLA’s More LA Smiles and Sesame Street websites. Conclusions: Resources developed through the UCLA-Sesame Street collaboration for the children’s oral health awareness campaign were accessed by targeted populations at rates that exceeded expectations both during and after the campaign. Practical implications: These new resources are available at no cost via the internet and can contribute to additional efforts aimed at increasing oral health literacy for young children, their parents and caregivers. Keywords: Children; oral health; health literacy; Sesame Street; dental health education

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AUTHORS James J. Crall, DDS, ScD, is a professor and chair of the division of public health and community dentistry at the University of California, Los Angeles, School of Dentistry. Conflict of Interest Disclosure: None reported. David Cohen is the director of education, research and outreach at Sesame Workshop in New York. Conflict of Interest Disclosure: None reported.

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Sofia Polo, MPH, is a research strategist at Fluent Research in New York. Conflict of Interest Disclosure: None reported. Sylvia Rusnak, PhD, is a senior research analyst at Sesame Workshop in New York. Conflict of Interest Disclosure: None reported.

ental caries is the most common chronic disease of childhood and affects high-risk children beginning in infancy and early childhood.1 Chronic diseases are highly dependent on lifestyle and behaviors that increase or reduce disease risk, social determinants of health and health literacy. Chronic diseases also often share many common risk factors.2 Evidence indicates that disadvantaged children who participate in early childhood education programs with an emphasis on health and nutrition have significantly lower prevalence of risk factors for diet-related chronic diseases in their mid-30s.3 The evidence is especially strong for males. Evidence also shows that tooth decay in early childhood is a risk factor for caries development in permanent teeth.4 Accordingly, efforts to find effective methods to improve health literacy and establish healthy behaviors related to young children’s oral health are warranted from a life-course perspective.5 Sesame Street has been recognized as a trusted educational source for young children for over 50 years. In 2005, Sesame Workshop launched Healthy Habits for Life, a multi-year, contentdriven initiative to help young children and their caregivers establish an early foundation of healthy habits.6 The vision of this initiative is to harness the power and reach of Sesame Street to make overall health and well-being as crucial to the healthy development of young children as learning to read and write — helping to establish habits that will last a lifetime. Collaboration between UCLA and Sesame Street regarding oral health began in 2005 as part of planning for a UCLA-directed Health Resources and Services Administration (HRSA) National Maternal and Child Oral Health Policy Center national symposium on

oral health and school readiness, which was convened in Washington, D.C. in November 2006. The collaboration served to heighten Sesame Street’s awareness of the extent and impact of early childhood caries and oral health disparities among U.S. children. Sesame Street subsequently convened the Children’s Oral Health Expert Meeting in May 2008 to gather input for a new oral health initiative, “Healthy Teeth, Healthy Me.”7 The initiative and necessary resources ultimately were developed with funding provided by the MetLife Foundation and Sam’s Club and was launched nationally in 2012 in New York City.8 Included in the initial set of resources created for “Healthy Teeth, Healthy Me” is the “Elmo Brushy Brush” video, which has garnered over 1.6 billion views on YouTube, making it the mostviewed Sesame Street video of all time. The UCLA-Sesame Street partnership reengaged formally in 2018 as part of the UCLA-led Medi-Cal 2020 Local Dental Pilot Project known as More LA Smiles (MLAS). MLAS partnered with Sesame Street in Communities (SSIC) to create a children’s oral health awareness campaign, including local events, installation of Sesame Street Comfy Cozy Spaces, production of new video resources, convening of focus groups comprised of providers and caregivers and updating and distributing 100,000 “Healthy Teeth, Healthy Me” education kits. This paper highlights key resources developed through this partnership, describes how the resources were used as part of a recent children’s oral health campaign and provides perspectives regarding the value of these resources in efforts to improve oral health literacy.

Materials and Methods

As noted above, UCLA partnered with Sesame Street and its Sesame

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Street in Communities program as part of the UCLA-led Medi-Cal 2020 Dental Transformation Initiative Local Dental Pilot Project, known as More LA Smiles (MLAS).9 Major activities included: production of five new Sesame Street oral health videos featuring various Muppet characters, supporting a MLAS Children’s Oral Health Awareness Campaign, printing 100,000 co-branded “Healthy Teeth, Healthy Me” child and parent education booklets. Sesame Street in Communities also organized focus groups comprised of diverse Los Angeles caregivers and oral health care providers to assess their perspectives about young children’s oral health and to gather feedback on messages and strategies.

Production of New Sesame Street Oral Health Videos

Key messages emphasized in the new Sesame Street oral health videos included: ■ Daily toothbrushing with fluoride toothpaste. ■ Recommended amounts of toothpaste for young children. ■ Making toothbrushing a part of regular nighttime routines (brush, read, sleep). ■ Eating healthy snacks and drinking water. ■ Taking children for their first dental visit by age 1 and having regular check-ups thereafter. A list of the titles and links to internet locations for English and Spanish versions of the five new videos and additional Sesame Street oral health resources is provided in TA BLE .

Production and Distribution of ‘Healthy Teeth, Healthy Me’ Resources

“Healthy Teeth, Healthy Me” is a bilingual (English and Spanish), multimedia outreach initiative motivating children ages 2 to 5, their parents and

caregivers to care for children’s oral health. Original versions of “Healthy Teeth, Health Me” were formatted as printed multimedia resource kits that included a Sesame Street DVD and a family guide. In response to changes in information technology, an online toolkit was created. The online kit includes the Provider’s Guide (supporting health practitioners as they create partnerships with families), the Family Guide (with tips for parents/caregivers and children’s activities), an interactive “Brush Those Teeth” game for kids, printable oral health educational activities for children and families and a YouTube playlist of “Healthy Teeth, Healthy Me” initiative video clips. Resources available through More LA Smiles were used to update content using the five new Sesame Street videos and to produce 100,000 print copies of “Healthy Teeth, Healthy Me” booklets for distribution locally at various events in Los Angeles County.

Maple Primary Elementary School • Transformed the nurse’s office into a Comfy Cozy Space. • Rotated all children through oral health activity stations. • Received a special visit from Grover.

Freemont High School • Joined the annual holiday event and distributed Sesame Oral Health Toolkits to all children.

More LA Smiles Children’s Oral Health Awareness Campaign Sesame Street involvement in the MLAS Awareness Campaign also included helping develop and implement an overall educational campaign and marketing strategy, organizing and participating in local MLAS events in Los Angeles, producing cobranded educational materials and designing and supporting a social media campaign.

Local Events

Local MLAS Children’s Oral Health Awareness Campaign events in Los Angeles were conducted during December 2019 at three sites: Maple Primary Elementary School, Freemont High School and T.H.E. Clinic, a local community health center. The events were designed to be engaging educational activities tailored to the unique

T.H.E. Clinic • Transformed the dental clinic into a Comfy Cozy Space. • Rotated all children through oral health activity stations. • Received a special visit from Grover and Elmo. FIGURE 1. In December 2019, the Sesame Street in Communities team traveled to Los Angeles to support More LA Smiles in a series of “Sesametized” community events, reaching more than 1,000 LA children and providing them with free oral health resources. D ECEMBER 2 0 2 1

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Reach and engagement across all released videos on all platforms Goal

Metric definitions Reach is the total number of people who see your content.

Total

Impressions are the number of times your content is displayed, whether it was clicked or not.

12,500

Engagement (25% of reach)

160,107

Engagement is the total number of actions that people take involving your post.

50,000

Reach 291,232

Views are the number of times a video has been watched.

FIGURE 2 . Social media metrics for More LA Smiles children’s oral health awareness campaign.

characteristics of different settings. At Maple Primary School, activities included participatory educational activities for students focused on tooth-friendly foods and drinks, toothbrushing technique (using interactive e-tablets) and creating their own customized toothbrushes. Additional elements of these local events involved “Sesametizing” sites by creating Sesame Street “Comfy Cozy Spaces” in school and clinic settings, having life-size Muppet characters interact with children and program staff, and distributing toothbrushes, toothpaste and oral health education materials (FIGURE 1 ). Local events also served as opportunities to engage local media in highlighting the importance of children’s oral health. A number of additional local events were planned for 2020 but had to be canceled due to the COVID-19 pandemic.

Social Media Campaign

From Aug. 25 through Sept. 22, 2020, MLAS conducted a children’s oral health awareness campaign in partnership with Sesame Street in Communities (SSIC) 774 D ECEMBER

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using UCLA social media channels and websites. The aim was to inform parents, caregivers and children about the importance of oral health using engaging Sesame Street educational videos produced with support from MLAS and featuring Muppet characters Grover and Elmo. For this campaign, MLAS communications and SSIC staff developed a partner toolkit that outlined the goal of the campaign, how partners and interested organizations could participate and some general messages (English and Spanish) that could be shared on social media. A campaign webpage was also created that provided premade social media graphics, easy access to UCLA social media channels, a social media calendar of the important dates on which each video would be released and other assorted SSIC resources. In support of MLAS marketing endeavors, SSIC posted the oral health videos and boosted them in two phases: Phase one posted three of the videos and targeted just the Los Angeles region; this phase was completed in Sept., 2020, and featured posts linked to the MLAS website. Phase two posted each of the

five videos and targeted a more general audience and also featured links to the SSIC website; this phase ran from midOctober through mid-December 2020.

Focus Groups

Sesame Street organized a qualitative study using focus groups to examine dentists’, child care providers’ and parents’ current practices and perceptions of the barriers Chinese-speaking, Spanishspeaking, Korean-speaking, Black and Filipino families encounter with regard to the oral health of their young children. The focus groups also sought to solicit feedback on SSIC’s oral health resources. Research objectives included identifying stakeholders’ top priorities and concerns around the oral health of young children; exploring stakeholders’ current practices for promoting the oral health of young children and pinpointing where they learned about these practices; describing the challenges and barriers parents encounter in promoting the oral health of young children, including those unique to specific language/ethnic groups; and

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gathering feedback and recommendations on the SSIC resources and soliciting ideas for effective dissemination strategies to reach the specific language/ethnic groups. The focus groups consisted of 16 in-depth 45- to 60-minute individual interviews with dentists via Zoom and 13 90-minute virtual focus groups with mothers and child care providers conducted via Zoom.

■

Results More LA Smiles Children’s Oral Health Awareness Campaign

During the lifetime of the campaign, the aim was to achieve the following goals across all platforms on social media: ■ Reach 10,000 users per video at minimum. ■ Achieve 25% engagement across all posts per video views. ■ Receive 20,000 views per Dentist Grover video. ■ Receive 50,000 views for Elmo’s Toothy Dance. ■ Increase followership by 50% across all platforms. ■ Recruit at least five local and/ or national partners. Results of the awareness campaign exceeded each of the preestablished goals, with the social media campaign generating impressive metrics within a month of the release of the fifth video (FIGURE 2 )10 and a grand total of over 687,000 views of the five featured new videos across MLAS and SSIC websites by the conclusion of the project in December 2020. Followers increased across all social media platforms, with Facebook followers showing the highest percentage increase (112%) and Instagram having the greatest number of followers (204).

Focus Groups

High-level/executive summary findings from the focus groups organized by Sesame Street include the following:

Dentists’ top priorities: Helping families form habits and routines around brushing two times per day, visiting the dentist two times per year, eating healthy foods and taking care of primary (baby) teeth. Mothers’ top priorities: Mothers’ primary concerns centered on their children having a good-looking smile so that they reflect well on them and their family. Mothers also see an attractive smile and good oral health as providing more opportunities to be successful in life.

Mothers also see an attractive smile and good oral health as providing more opportunities to be successful in life.

Child care providers’ top priorities: Promoting good oral health by educating children and families and using videos and books to teach children about the importance of brushing to encourage good habits at home. Participants in the focus groups identified several common barriers that are experienced by families, including financial constraints, time constraints, misconceptions about diet and the belief that dental visits are only for acute issues (when dental problems have been identified), rather than for prevention or a part of wellness. Parents reported that knowledge about oral health comes primarily from personal experiences, pediatricians’ advice and dentists’ advice. Participants felt that the most effective ■

way to share information about children’s oral health is through child care providers and educators who share them with parents and having resources available in dentists’ and doctors’ offices. Chineseand Korean-speaking participants emphasized the need for all resources to be translated in order for them to be useful to members of their communities.10

Distribution of Oral Health Supplies and Multimedia Resources

More LA Smiles distributed oral health educational content and oral health supplies through a variety of channels. As noted, the three local events held at local partner sites during December 2019 provided opportunities to distribute “Healthy Teeth, Healthy Me” educational booklets and oral health supplies (toothbrush, toothpaste, timer, oral health handout) to over 1,000 children in underserved areas. MLAS and SSIC also partnered with and participated in a large day-long community event at Dodger Stadium organized by The L.A. Trust for Children’s Health, a nonprofit organization that works to promote health for children enrolled in Los Angeles Unified School District (LAUSD) schools. The onset of the COVID-19 pandemic resulted in the cancellation of many community outreach events during the final nine months of 2020. However, MLAS was able to distribute “Healthy Teeth, Healthy Me” booklets and oral health supplies to community partners to use during various community outreach activities (e.g., grab-and-go food distribution, local clinics and health fairs). MLAS also partnered with The LA Trust to facilitate incorporation of the MLASSesame Street videos into educational programming for LAUSD students (280 televised spots with an estimated 2.1–2.8 million total views), which was broadcast by local television station D ECEMBER 2 0 2 1

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TABLE

Overview of More LA Smiles: Sesame Street Videos and Website Links • Elmo’s Toothy Dance shows kids (and parents) how to brush and make it fun! • Starting Early is a reminder that kids should visit the dentist early and get regular check-ups. • How Much Toothpaste? explains how much toothpaste to use when brushing kids’ teeth. • Tooth-Friendly Foods emphasizes eating healthy foods and drinking water. • Brushy, Booky, Nighty Night reviews the importance of health routines, including brushing before bed, reading to children and plenty of sleep.

Links to the Spanish versions: • morelasmiles.org/elbailediente • morelasmiles.org/empezartemprano • morelasmiles.org/pastadedientes • morelasmiles.org/alimentos • morelasmiles.org/cepillodebuenasnoches • Elmo’s Brushy Brush video is a Sesame Street video showing Elmo, kids and parents (including many celebrities) brushing and having fun, with lots of good oral health messages for parents and youngsters. • Sesame Street oral health resources

KLCS during the prolonged period when school facilities were closed and schools were operating with remote instruction.

Conclusions and Discussion

This paper highlights collaborations between UCLA and Sesame Street to develop and utilize educational and motivational resources to improve the oral health of young children. The goal of these efforts was to increase awareness of behaviors that are recommended for reducing the prevalence, severity and impact of early childhood caries (ECC), including establishing a dental home by age 1 and having regular dental checkups, toothbrushing daily with fluoride toothpaste and reducing caries risk by substituting healthy foods and water for sugar-containing foods and beverages.11 Progress toward reducing the prevalence and impact of ECC and oral health disparities among young children has proved challenging. Despite significant research, ECC remains a significant public health problem. Recent systematic reviews have failed to establish evidence for the best way to prevent and manage the disease, but frequently suggest that, in addition to the traditional narrow focus on biological risk factors, greater attention be given to approaches that focus on social, behavioral and family factors and oral health literacy.12 There also is growing recognition that the chronic disease management concept, focusing on self-care through identifying 776 D ECEMBER

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facilitators and barriers for healthy behaviors, is a promising approach. Interest in behavioral interventions stems from the understanding that most preventive strategies require action on the part of the individuals who would benefit — action that may not occur naturally and therefore must be actively motivated in some way.13 Emerging evidence suggests that web-based educational programs for increasing oral health and caries-related knowledge, attitudes and planned behaviors in young mothers can be an effective and low-cost strategy for promoting maternal and infant oral health.14 Clinical approaches used heretofore to educate mothers and young children about oral health have limitations stemming from oral health care not being initiated at an early age, especially in high-risk populations such as those covered by Medicaid. Despite recommendations for children to have their first dental visit by age 1, visits to dentists by children under age 3 — especially children from low-income households — remain relatively low.15 Recent efforts have recognized the important potential contributions of primary care providers in improving the oral health of young children. However, despite growing interest and various initiatives to increase integration of oral health into primary care services, evidence from Medicaid program data shows that the impact remains relatively modest in most states.16

These limitations underscore the need for additional approaches to educate parents and young children about oral health and help promote the development of healthy habits. Sesame Street is a trusted source of information for young children, with demonstrated positive effects of programming on cognitive outcomes (including literacy) and health and safety knowledge by children in the U.S. and other countries.17–18 Resource and time constraints did not allow for assessment of these types of outcomes as part of the MLAS project. Results from this pilot project did however demonstrate that resources developed as part of the UCLA-Sesame Street collaboration for the MLAS children’s oral health awareness campaign were accessed by targeted segments of the population at rates that exceeded expectations both during and after the campaign. By virtue of being accessible at no cost via the MLAS and Sesame Street internet sites, these resources have the potential to contribute to additional efforts aimed at increasing oral health literacy for young children, their parents and caregivers. n AC KN OW L E DG M E N T S The UCLA-led local dental pilot project (More LA Smiles) was supported by the California Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services through the Medi-Cal 2020 Dental Transformation Initiative. The authors express appreciation to the DHCS program staff for their support throughout the project and to the following More LA Smiles project staff members who contributed to the collaboration with Sesame Workshop: Landon Celano, Mary Esser and Tanvir Kaur. We also acknowledge the support provided by Jasmin Williams,

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Rochelle Haynes and Jeanette Betancourt of Sesame Workshop to the More LA Smiles project. RE FEREN CE S 1. Sheiham, A. Dental caries affects body weight, growth and quality of life in preschool children. Br Dent J 2006 Nov 25;201:625–626. doi: 10.1038/sj.bdj.4814259. 2. Egger G, Dixon J. Beyond obesity and lifestyle: A review of 21st century chronic disease determinants. Biomed Res Int 2014;2014:731685. doi: 10.1155/2014/731685. Epub 2014 Apr 7. PMCID: PMC3997940. 3. Campbell F, Conti G, Heckman JJ, Moon SH, Pinto R, Pungello E, Pan Y. Early childhood investments substantially boost adult health. Science 2014 Mar 28;343(6178):1478– 85. doi: 10.1126/science.1248429. PMID: 24675955; PMCID: PMC4028126. 4. Crall JJ, Quinonez R, Zandona A. Caries risk assessment: Rationale, uses, tools and state of development. In: Berg JH, Slayton RL, eds. Early Childhood Oral Health. 2nd ed. Hoboken, N.J.: Wiley-Blackwell; 2015:193–220. 5. Crall JJ, Forrest CB. A life course health development perspective on oral health. In: Halfon N, Forrest C, Lerner R, Faustman E, eds. Handbook of Life Course Health Development. Cham, Switzerland: Springer; 2018:299–320. PMID: 31314282. Erratum: doi.org/10.1007/978-3-31947143-3_27. 6. U.S. Department of Health & Human Services/NIH/NIEHS. Sesame Workshop Healthy Habits for Life — A great start to a lifetime of good health. Accessed Aug. 27, 2021. 7. Sesame Street. Healthy Teeth, Healthy Me. Accessed Aug. 27, 2021. 8. Sesame Street. Sesame Street: Healthy Teeth, Healthy Me Launch! Accessed Aug. 27, 2021. 9. UCLA Dental Transformation Initiative. More LA Smiles. Accessed Aug. 27, 2021. 10. Sesame Street in Communities (SSIC). More LA Smiles &

SSIC Project Recap: 2019–2020. Project report prepared by Sesame Street for More LA Smiles, 2020. 11. World Health Organization. WHO Expert Consultation on Public Health Intervention against Early Childhood Caries: Report of a meeting. Accessed Aug. 27, 2021. 12. Twetman S. Preventing early childhood caries: Motivating families. Ann Royal Australasian Coll Dent Surg 2016;23:40– 42. 13. Albino J, Tiwari T. Preventing childhood caries: A review of recent behavioral research. J Dent Res 2016 Jan;95(1):35–42. doi: 10.1177/0022034515609034. Epub 2015 Oct 5. 14. Albert D, Barracks SZ, Bruzelius E, Ward A. Impact of a web-based intervention on maternal caries transmission and prevention knowledge and oral health attitudes. Matern Child Health J 2014 Sep;18(7):1765–71. doi: 10.1007/s10995013-1421-8. 15. Griffin SO, Barker LK, Wei L, Li CH, Albuquerque MS, Gooch BF; Centers for Disease Control and Prevention (CDC). Use of dental care and effective preventive services in preventing tooth decay among U.S. children and adolescents — Medical Expenditure Panel survey, United States, 2003–2009 and National Health and Nutrition Examination survey, United States, 2005–2010. MMWR Suppl 2014 Sep 12;63(2):54– 60. PMID: 25208259. 16. Centers for Medicaid and Medicare Services. Annual EPSDT Participation Report: Form CMS-416, Fiscal Year 2019. www.medicaid.gov/medicaid/benefits/early-and-periodicscreening-diagnostic-and-treatment/index.html. Accessed Aug. 25, 2021. 17. Mares ML, Pan Z. Effects of Sesame Street: A metaanalysis of children’s learning in 15 countries. J Appl Dev Psychol 2013 May–Jun;34:140–151. doi.org/10.1016/j. appdev.2013.01.001. 18. Kearney MS, Levine PB. Early childhood education by MOOC: Lessons from Sesame Street. National Bureau of Economic Research. Working paper no. 21229, June 2015;

Cambridge, Mass. www.nber.org/papers/w21229. Accessed Aug. 25, 2021. T HE CORRE S P ON DIN G AU T HOR , James J. Crall, DDS, ScD, can be reached at jcrall@dentistry.ucla.edu.

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Innovative Health Literacy Strategy Advances Health Equity: Perspectives of the Cambridge Health Alliance Past and Present Department Chiefs Ryan S. Lee, DDS, MPH, MHA, and Brian J. Swann, DDS, MPH

AUTHORS Ryan S. Lee, DDS, MPH, MHA, is the chief of dental services at the Cambridge Health Alliance, a community health system serving Cambridge, Somerville and Boston’s metro-north communities. Conflict of Interest Disclosure: None reported.

Brian J. Swann, DDS, MPH, is the former chief of dental services at the Cambridge Health Alliance. Conflict of Interest Disclosure: None reported.

n 2008, the Cambridge Health Alliance (CHA) began a transformative journey. This journey not only ensured the survival of community health services in danger of being diminished or completely lost, but also improved health literacy for its peers and patients as well as utilizing core health literacy concepts to advance health equity. As the organization experienced a complete paradigm shift that involved new leadership, in-depth internal evaluation and assessments, personnel and policy changes and consistent emphasis on operational fitness, the CHA incorporated a steady focus on better educating its patients and peers as well as maintaining standards of excellence in its fair and equitable delivery of community health services. The CHA was faced with myriad challenges resulting from the 2008 economic downturn, including the loss of state funding due to reallocations, an inefficient dental billing system and a major decrease in its revenue stream

leading to reductions in staff and programs as well as decreased access to dental services and oral health education for patients. Committed to creating a healthliterate community and fair and equitable treatment for all, the CHA recognized the need for cultural sensitivity and input from the community regarding needed services. The CHA also recognized that health equity across all segments of the population required patient and provider health literacy. Despite the challenges, the CHA conducted its operations based on guidelines described in the Healthy People Initiative. The alliance managed to survive, created innovative and inclusive programs and continued to expand community services. The mission and focus of the CHA remain constant and directly align with the central goals of the Healthy People 2030 initiative,1 which is to eliminate health disparities, achieve health equity and attain health literacy to improve the health and welfare for all. The CHA has D ECEMBER 2 0 2 1

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continued to maintain its standards of excellence and to focus on improving the overall health care of its community. The values of the organization are integrity, respect, compassion, learning, inclusion and excellence. Although these values may seem idealistic to some, they are exactly what are required to establish and maintain patient-provider trust, create health literacy and consistently deliver fair and equal care to all members of the community. The 2030 initiative provides the following new definitions of personal and organizational health literacy:2 Personal health literacy is the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others. Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand and use information and services to inform health-related decisions and actions for themselves and others. In a change from the health literacy definitions used in Healthy People 2010 and 2020, the new Healthy People 2030 initiative definitions emphasize people’s ability to use health information rather than just understand it; focus on the ability to make “well-informed” decisions rather than “appropriate” ones; incorporate a public health perspective; and acknowledge that organizations have a responsibility to address health literacy.3 Simply put, health literacy on the part of the patient and the community of providers makes it possible for individuals and families to seek proper care, locate appropriate care, make good decisions and follow instructions for comprehensive treatment. Health literacy warrants 780 D ECEMBER

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that all members of the health care community clearly understand the need to embrace an integrative model of comprehensive health care that includes oral health services. Health equity is achieved when each person has the chance to reach their full health potential without facing obstacles based on social position or other socially determined circumstances.4 Health equity can only be achieved when obstacles within each community are neutralized, including language barriers. Equity requires an emphasis on the contextual

Health equity can only be achieved when obstacles within each community are neutralized, including language barriers.

circumstances and social determinants of health such as education, income, employment, race, age, gender, housing, environment, food, transportation, safety and more. It also requires an integrative health care model that includes medical and oral health care providers working collaboratively toward a common goal.

Background

Cambridge Hospital was founded in 1917 with the goal of being a primary care, safety-net, community hospital. The facility merged with Somerville Hospital in 1996, with Everett Hospital 2001 and eventually became the CHA, a nonprofit, academic, community hospital and safety-net organization. According to the National Academies of Science, Engineering and Medicine, a

safety-net organization delivers a significant level of health care and other needed services to the uninsured, underinsured and other vulnerable populations.5 These populations include, but are not limited to, adults, children, the elderly, people with physical and psychiatric disabilities, medically compromised populations, people recently and long-term unemployed, immigrants, undocumented individuals, people without housing, survivors of abuse, members of the armed services and their spouses, veterans, those with addictions and the poor. In the early 2000s, in collaboration with the dean of the Harvard School of Dental Medicine (HSDM) and the department chair of oral health policy and epidemiology, the chiefs of pediatrics and internal medicine recommended that an oral health department be included at the CHA. Based on a needs assessment of the city and input from Cambridge citizens, it was unanimously decided that the CHA needed to include a department that would provide oral health services. Since then, the number of dental sites has fluctuated based on a common theme of budget cuts and the rising cost of oral health care.

The Integrative Model Involving the Oral Physician

To survive its many challenges, the CHA needed to create a multidisciplinary environment of health care providers and administrators who could appreciate the value of integrating oral health as a component of comprehensive health care. The CHA team created a strategy to improve health literacy and ultimately help to achieve health equity that included improved access to care, cultural sensitivity, interdisciplinary bias minimization, enhanced and transparent communication and learning and role modeling. The team shared

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with colleagues across health disciplines that the inclusion of oral health care could play a pivotal role in providing primary preventive care and secondary care in the form of early detection. A general practice residency (GPR) program that operated through an affiliation between the CHA and the HSDM was enhanced to provide awareness and recognition of the value that oral health brings to primary care. Every meeting with peers and executives became an opportunity to share the potential for oral health to build capacity within the patient-centered and comprehensive care system. An emeritus Harvard professor suggested that the CHA team incorporate the oral physician model into our GPR residency program.6 This concept basically called for oral health providers to work more comprehensively and at their level of training. This model would serve as an asset for the perennial and widespread shortages in primary care. Compounding the shortage of primary care providers, the fact that oral disease is a risk factor for systemic diseases necessitates awareness of the oral-systemic connection by all health care providers. The team worked to ensure that patient visits occurred before their health conditions progressed or benefits expired and before children had to return to school. Our solution involved “group visits,” a concept that involves observations and treatment of multiple patients simultaneously in one locale. The modalities included group denture visits, whereby multiple patients received treatment for partial or full dentures grouped by appointment sequence (i.e., the border molding procedure was provided simultaneously for several patients at once, thereby increasing efficiency in communication and turnaround time);7 pediatric group

visits; periodontal disease prevention for diabetic groups and for suboxone groups in primary care; and pregnancy visits with patients and their partners to discuss prevention and best practices for mothers and newborns. Most of these visits involved dental, medical and other allied health providers. The incorporation of the medical interview as a valuable and essential tool increased the opportunity for early detection, developed rapport and established patient-provider trust. Combined with the fact that a significant

The oral physician model has shown early signs of directly impacting integrative care.

number of patients visit the dental office more often than their primary care office,8 this creates an opportunity for the oral health provider to screen and refer potentially undiagnosed health conditions. As such, health literacy across disciplines is an important element in the earliest stages of training for the oral physician model of care. As the oral health department adopted the oral physician model, the perception for the oral health provider changed and justified creating a more robust experience for the residents. Their curriculum included rotations in oral medicine, oral pathology, orthodontics and oral surgery. Residents participated in presentations that included public health, peer communication, health IT system improvements and practical applications of oral anesthesia and other medications.

Interdepartmental shadowing experiences were arranged for medical residents and undergraduate students, including dental assisting, hygiene and pharmacy students. GPR residents also supervised a monthly student-run pediatric clinic. Looking beyond the head and neck, oral physicians are also cognizant of behavioral health relative to signs of abuse, attention deficit syndrome, depression and PTSD issues. At nearby elementary schools and local homeless shelters, residents screened patients and provided follow-up referrals to the CHA clinic site. They treated domestic abuse survivors and immigrants in various shelters, participated in outreach programs for Native Americans and taught prevention to Spanish- and Haitian Creole-speaking diabetic groups. These experiences coupled with research projects, recognized, emphasized and improved on a tripartite partnership between providers, patients and parent organizations to enhance health literacy resulting in increased capacity across disciplines. In this fashion, the oral physician model has shown early signs of directly impacting integrative care.9,10 Eventually, the chief of oral health and the GPR director were invited to become members of the CHA academic council. They participated in discussions regarding research and integrated learning opportunities to build capacity across disciplines and to ensure a more comprehensive and collaborative educational experience for the next generation of providers. Such discussions enabled dialogue regarding health communication and literacy across multiple health disciplines. Upon graduation from the GPR program, each resident received two certificates: one for the general practice residency program and one for the oral physician certificate from both the D ECEMBER 2 0 2 1

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CHA and the HSDM. Postgraduates have incorporated the oral physician concept in several ways. A recent graduate became the first oral physician to be accepted as a fellow to receive a master’s in health education through a partnership with the University of Dundee in Scotland. Other graduates of the program have pursued dual degrees in medicine and dentistry, while many others have reimagined and redesigned their clinics, both public and private, to reflect the integration of medicine and oral health.

services and the Wampanoag Native American communities. Financial and educational support from industry partners with orthodontic, dental implant and technology sectors contributes to our ability to lower fees for those in need. Beyond price innovation, however, clinical innovation remains a core mission for the CHADIP, which has continued its implementation of digital dentistry involving CBCT, intraoral scanning, 3D printing and open-source milling to deliver same-day printed dentures, provide guided implant surgery and ensure

The CHA Dental Implant Program

One new example of this innovation has been the CHA Dental Implant Program (CHADIP), which was implemented in January 2021. Considerations of dental implants in the past have posed a challenge for many underserved patients due to finances, time or logistics-related constraints. The program at the CHA now offers dental implant care for all patients, regardless of socioeconomic status or demographics. Any patient with missing dentition may receive an implant consultation and a cone beam CT scan. A patient in need can receive the entire package of services including: ■ Surgical placement of a dental implant fixture. ■ Prefabricated or customized abutment. ■ The final prosthodontic crown. ■ Associated procedures (e.g., bone grafting, sinus augmentation, soft tissue regeneration). The cost is less than one-third of the average fees in comparison to practices in the region.11 The CHADIP has expanded and developed implant services for patients in partner organizations such as Boston Healthcare for the Homeless, the Salvation Army, PACE elder care 782 D ECEMBER

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COVID-19 has demonstrated that all segments of our community need and must receive equal care and attention.

optimal pre-, peri- and postoperative care. To reflect the health literacy needs involving said new procedures and care modalities, the CHADIP has updated all relevant patient information, consent forms and interhospital documents. Because information regarding dental implants can be difficult to understand for patients,12,13 plain-language concepts have been incorporated in all such documents. Trainees at all levels, including dental students, undergraduate externs and GPR residents, have undertaken research projects supported by the implant program, some of which fall into health communication and health literacy arenas. Provider literacy, even at the attending oral physician level, must follow suit to provide excellent care, especially as these services seek to integrate oral

health with other arenas of medicine. At the intersection of price innovation and clinical innovation, health literacy must play a pivotal role to ensure health equity for our underserved patients. The CHADIP is not simply about offering excellent treatment for all patients at an affordable cost; every consultation, treatment visit and postoperative appointment must be delivered in plain language that involves health literacy and communication as core concepts, which serve as a foundation for all clinical care. Health care is multifactorial. All patients, regardless of background and culture, must be understood, must feel respected and must know that they are receiving the best treatment available. COVID-19 has demonstrated that all segments of our community need and must receive equal care and attention, lest we run the risk of devastating consequences.

The Future of Oral Health at the CHA Today, primary care, specialty care, mental health and substance abuse programs exist across two hospitals and 12 associated community clinics, totaling more than 20 affiliated programs across five cities located north and west of Boston. Teaching affiliations include the Harvard Medical School, the HSDM, the Tufts School of Medicine and the Massachusetts College of Pharmacy and Health Sciences. Of note, the CHA recently won awards for its delivery of care and services in the areas of maternal health and psychiatry.14 Specific to oral health, the CHA’s department of dental medicine and oral health was awarded a $4.5 million expansion grant in 2020, during the height of the COVID-19 pandemic no less, serving as a testament to the organization’s commitment to oral health and its integration with primary care. The expansion will create a

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new hub site, triple the operational capacity, double the number of residents and share the same location with the primary care’s home office. Another aim is to create a translational “innovation laboratory” based on best clinical and administrative practices to create, test and deliver novel models of care. This will explore access, enhance communication and integrate electronic health records, thereby improving health outcomes and reducing health costs. This expansion aims to improve and reinforce health literacy and equity by offering our patients a user-friendly and culturally sensitive environment in which the patient will be heard and will feel welcomed to receive quality care. With the creation of an integrated and diverse advisory committee, we will keep taking concrete steps to remain a health-literate organization. As our regional, national and global communities emerge from the COVID-19 pandemic, safety-net organizations like the CHA must continue innovations to continue equitable care delivery for underserved patient populations. To that end, we have provided point-of-care COVID-19 testing in our dental facility to determine risk assessment for all patients needing care. For certain patients, telehealth visits are available to minimize any health risks. Every consent form for every new procedure we implement must meet the literacy, numeracy and overall language needs of each patient. Undoubtedly, health communication and literacy have in the past and will continue to play a critical role in our mission to deliver innovative, customized, culturally sensitive and friendly care for all patients and families. The CHA offers translations in 60 languages online or in person throughout the entire system. As Healthy People 2030 now emphasizes the importance of health literacy at

organizational levels, the CHA and its department of dental medicine and oral health seek to lead by example in the intersection of health literacy, health equity and oral health integration. n RE FE RE N C E S 1. U.S. Department of Health and Human Services. 2021. Health Literacy in Healthy People 2030. Accessed Oct. 9, 2021. 2. U.S. Department of Health and Human Services. 2021. History of Health Literacy Definitions. Accessed Oct. 9, 2021. 3. Ibid. 4. Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2008. 5. Institute of Medicine. America’s Health Care Safety Net: Intact but Endangered. Washington, D.C.: The National Academies of Press; 2020. doi.org/10.17226/9612. 6. Giddon DB. Should dentists become ‘oral physicians’? Yes, dentists should become ‘oral physicians.’ J Am Dent Assoc 2004 Apr;135(4):438, 440, 442 passim. doi: 10.14219/ jada.archive.2004.0208. 7. Chandrupatla SG, Thompson LA, Kuna S, Swann BJ. Denture group visits: A model to improve access to care and reduce treatment period for dentures. J Calif Dent Assoc 2018 Nov;26(9):707–713. 8. Vujicic M, Israelson H, Antoon J, Kiesling R, Paumier T, Zust M. A profession in transition. J Am Dent Assoc 2014 Feb;145(2):118–21. doi: 10.14219/jada.2013.40. 9. Giddon DB. Oral physicians. Br Dent J 2012;213(10):497–498. doi.org/10.1038/ sj.bdj.2012.1038. 10. Giddon DB, Swann BJ, Hertzman-Miller R. Oral physicians: An opportunity for dentists? Am J Public Health 2012 Jul;102(7):e8; author reply e8–9. doi: 10.2105/ AJPH.2012.300667. Epub 2012 May 17. 11. FAIR Health Consumer. Total cost related to surgical placement of a dental implant into the jaw bone D6010. Accessed Oct. 9, 2021. 12. Jayaratne YS, Anderson NK, Zwahlen RA. Readability of websites containing information on dental implants. Clin Oral Implants Res 2014 Dec;25(12):1319–24. doi: 10.1111/ clr.12285. Epub 2013 Oct 22. 13. Leira-Feijoo Y, Ledesma-Ludi Y, Seoane-Romero J, BlancoCarrion J, Seoane J, Varela-Centelles P. Available web-based dental implants information for patients. How good is it? Clin Oral Implants Res 2015 Nov;26(11):1276–80. doi: 10.1111/clr.12451. Epub 2014 Jul 21. 14. Cambridge Health Alliance. 2021. Academic Scholarship and Research. Accessed Oct. 9, 2021. T H E CO RRE S P ON DIN G AU T HOR , Ryan Lee, DDS, MPH, MHA, can be reached at ryalee@challiance.org.

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RM Matters

C D A J O U R N A L , V O L 4 9 , Nº 12

Romance, Risks and Regret: The Drama of Interoffice Dating TDIC Risk Management Staff

ove and romance can blossom just about anywhere, including in the dental setting. While most relationships don’t begin with the end in mind, the failure to forecast possible repercussions of a breakup can result in big problems for your business. In a dental office, staff get to know each other well by working in

close quarters and often sharing common interests. It is inevitable that there will be some sparks. But occasionally flirtation can develop into a mutual attraction or an uncomfortable misunderstanding.

Here are just a few scenarios: ■

A relationship develops between a dental team member and the practice

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owner whose wife is the office manager. Once the affair is revealed, the owner could feel pressured to terminate the employee and the whole practice could be embroiled in office drama. ■ An interoffice relationship ends and one of the parties, feeling hurt and angry, lashes out by leveraging inside knowledge or making accusations. This could mean exposing the practice to scrutiny through emotion-fueled allegations of questionable billing practices, OSHA violations or breaches of confidential patient and staff information. ■ There is a misunderstanding, and the perception of the relationship isn’t mutual. A touch, gesture or comment, like a hug at a holiday party, is perceived as having romantic intent — or worse, sexual harassment. Couldn’t these issues occur at any small business? Yes, there is the potential for relationship risks in any office. However, the demographics of dental offices tend to make these issues statistically more likely. While dentistry is becoming increasingly more diverse, and women are outpacing men as new dental school graduates, just 34.5% of practicing dentists in the U.S. today are female, according to the Health Policy Institute. It won’t be long before there is gender parity in the profession. However, the rest of the dental team isn’t pacing the same. Delta Dental recently reported that 98% registered dental hygienists are female along with 97% of dental

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assistants and 97% of office managers. This means that there is still a high number of practices with a male supervisor and an all- or almost-all female staff. So, it can be statistically more likely for a dentist to have a relationship — one with an imbalance of power — with a staff member. And spousal working arrangements aren’t uncommon in dentistry, with the wife more likely to be in the position of office manager. Interoffice dating fuels drama and opens the practice up to friction, fraught working relationships and significant liability risks. In addition, sensitive personal, business, health and financial information can all become weaponized.

What are the risks to your practice? ■

■

The development of perceptions of unfair treatment and favoritism if a supervisory relationship exists. Personal discomfort that other employees may have over public displays of affection. The potential that if the relationship deteriorates, claims of sexual harassment will later develop. Allegations of conflicts of interest, impaired business judgement and confidentiality breaches on the part of a supervisor involved in such a relationship. The negative impact on employee morale.

Where can you turn for guidance?

As a benefit to CDA members and TDIC policyholders, the Risk Management Advice Line provides confidential, no-cost guidance on how to handle challenging practice situations. In 2020 alone, the Advice Line received more than 18,000 calls. Year after year, a consistent source of caller concern has been the chaos

created by personal relationships within the dental office. While dental professionals know that interoffice dating is unwise, often when emotions take over, judgement can be clouded.

Case study: A relationship ends

In a recent Advice Line call, the dentist stated that he did something he was “told not to do” and dated a registered dental hygienist on his staff. As what often happens in workplace relationships, it didn’t work out and they mutually decided to end the relationship. The dentist shared that the hygienist was a good employee and there were no performance concerns; however, he was anxious there could be awkward encounters and conversations in the future. It wasn’t until the relationship ended that he began to consider how uncomfortable the situation could be. He asked the analyst what his recourse was if she spoke about him negatively to other employees or her behavior became toxic and how to proceed if he decided to terminate her. The dentist expressed that he wanted to speak to the hygienist proactively and let her know he hoped there wouldn’t be friction at work and that she didn’t plan on creating workplace drama with the other employees. The analyst advised the dentist not to project potential problems and to only address issues as he would with any of the other employees, if and when they actually arose. As an employer, he should remain objective, take it day by day and address performance or behavior issues with her using a fair and reasonable approach.

Case study: A secret revealed

In another call, an associate dentist was concerned that the actions of the practice owner may have ramifications for her and the rest of the practice. It had recently come to light that the

owner had been carrying on a longstanding affair with one of the staff. The relationship was exposed when the office manager fired a long-term employee. The employee, who felt her termination was unfair, then had an angry outburst in the office and expressed regrets for participating in the coverup and secrets. The associate dentist only learned of the issue at the time of the outburst, and she was concerned that the former employee was looking to attack anyone associated with the practice. Could she or others be dragged into this office drama that could reflect negatively upon her and the practice? The analyst advised that while the former employee could potentially pursue an employment claim against the owner-dentist and the practice, the associate dentist was not responsible for supervising the employee, conducting performance reviews or paying her wages, so it was unlikely that she influenced the termination decision. It’s important to note that associate dentists, in their roles as licensed practitioners, can be seen as supervisors. Liability would extend beyond the owner if facts around sexual harassment are general knowledge in the office, or there is awareness of an issue, but no action is taken.

What can you do to protect yourself and your practice? ■

Keep interoffice relationships professional. As always, dentists must model the behavior they want to see in the practice. Set clear boundaries, as you do with patient relationships, neither initiating nor encouraging romantic interest. The best relationships can become strained and hard to maintain; the worst end in retaliation and harassment claims. D ECEMBER 2 0 2 1

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■

Know that termination may be off the table. What’s the most dangerous part of dating an employee? You’ve possibly lost your ability to monitor, discipline or sanction them. Regardless of the trajectory of the relationship, your employee can become impregnable against termination. Take sexual harassment prevention training. As of 2019, the California Legislature required sexual harassment prevention training for businesses of at least five employees, with separate training for managers and

nonmanagers. Practices of every size can benefit from specific guidance on complying with anti-harassment laws and learning how to detect and report inappropriate behaviors. ■

Add a layer of protection as an employer. Consider adding employment practices liability (EPLI) coverage. As an endorsement to your professional liability policy, EPLI provides protection if you or one of your employees is sued for harassment, discrimination, wrongful termination or failure to promote employment-related issues.

Outside the workplace, romance may know no bounds. But, before pursuing any personal relationship within the practice, take a moment to imagine the worst-case scenario. If a romance ends badly, the collateral damage could be much more than you or your practice’s reputation can afford. n The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected by TDIC. To schedule a consultation, visit tdicinsurance. com/RMconsult or call 800.733.0633.

Search and post on DentalPost, the nation’s #1 dental job board & community with more than 900,000 dental professionals.

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Regulatory Compliance

C D A J O U R N A L , V O L 4 9 , Nº 12

Electrical Safety, Fire Extinguishers, Eyewash, Exit Signs and Other Cal/OSHA Regulations CDA Practice Support

entists should be aware of certain occupational safety regulations for which dental facilities have been cited for violating. These regulations are found in the California Code of Regulations Title 8 Chapter 4 Subchapter 1 Unfired Pressure Vessel Safety Orders, Subchapter 3 Compressed Air Safety Orders, Subchapter 5 Electrical Safety Orders and Subchapter 7 General Industry Safety Orders and can be viewed on the Department of Industrial Relations website, dir.ca.gov. This article reviews Cal/OSHA regulations on: ■ ■ ■ ■ ■

Electrical safety. Portable fire extinguishers. Eyewash stations. Exit signs. Maintenance and access to exits.

§2340.16 Work space about electric equipment

Sufficient access and working space are required to be maintained around all electric equipment in order to ensure their safe operation and maintenance. Three feet is the minimum required distance under most conditions, although the table in the regulation should be referenced for more details on voltage and conditions. Proper illumination must be available and provided as necessary to work on equipment.

§2340.17 Guarding of energized parts

Energized parts of electric equipment operating at 50 volts or more must be

guarded against accidental contact through use of approved cabinets or other forms of approved enclosures. Also acceptable are one of these four methods: located in enclosed space accessible only to qualified persons;

and a fire prevention plan that meet Cal/OSHA requirements, the employer need only meet the following inspection, maintenance and testing requirements: ■ ■

Dentists should be aware of certain occupational safety regulations for which dental facilities have been cited for violating.

■

use of suitable partitions that only a qualified person can use to access the space; located at an elevated location to prevent access by an unqualified person; or located 8 feet or more above the working area. Other electrical safety regulations govern equipment identification, receptacles and cord connectors and prohibit specific uses and locations of flexible cords and cables.

§6151 Portable fire extinguishers

The regulation applies to the placement, use, maintenance and testing of portable fire extinguishers provided for the use of employees. In offices where extinguishers are provided but are not intended for employee use and the employer has an emergency action plan

Monthly visual inspection. Annual maintenance check. Record date of maintenance check and retain record for one year after last entry. Alternate protection must be provided when portable extinguisher is removed from service for maintenance and recharging. Empty and recharge every six years a stored pressure dry chemical extinguisher that requires a 12-year hydrostatic test, except if it has a nonrefillable disposable container. Hydrostatic testing performed by a trained individual with suitable testing equipment and facilities.

If employees are intended to use the fire extinguishers, an employer must provide training to employees to familiarize them with the general principles of fire extinguisher use and hazards of their use. Training must be done upon employment and at least annually thereafter. Extinguishers should be mounted on the wall and identified and maintained in a fully charged and operable condition. They should be kept in their designated locations at all times except during use. Selection and distribution of fire extinguishers within the dental facility must be based on the types of fires anticipated in the workplace. D ECEMBER 2 0 2 1

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TABLE

Fire Classification Class A fires include wood, paper and textiles: Place extinguisher every 75 feet or less. Class B fires include flammable liquids: Place extinguisher every 50 feet or less. Class C fires include electrical equipment: Extinguisher placement dependent on placement of other extinguishers. Class D fires include metal powders and shavings: Place extinguisher every 75 feet or less.

Extinguisher type Water and foam: Class A fires only. Carbon dioxide: Class B and Class C fires; ineffective on Class A fires. Dry chemical, multipurpose: Class A, B and C fires. Dry chemical, ordinary: Class B and C fires. Wet chemical: Kitchen fires (deep-fat fryers). Clean agent: Class A, B and C fires. Dry powder: Class D fires only; ineffective on all other fires. Water mist: Class A and C fires. Cartridge operated dry chemical: Class A, B and C fires. Source: Fire Equipment Manufacturers Association. femalifesafety.org/fire-equipment/portable-fire-extinguishers. Accessed Oct. 4, 2021.

§5162 Emergency Eyewash and Shower Equipment

A dental facility must have a plumbed or self-contained eyewash or eye/facewash equipment that meets at a minimum the standards set in section 5, 7 or 9 of ANSI Z358.1-1981, “Emergency Eyewash and Equipment.” Personal eyewash units or drench hoses may be used in support of the required equipment but not in lieu of them. The equipment must be in an accessible location that requires no more than 10 seconds for an injured person to reach. Keep the area around the equipment free of obstructions. The required equipment must be able to supply potable water at 1.5 liters per minute for 15 minutes, which is the flow rate and time duration specified in the ANSI standard. The control valve must allow the water flow to remain on without requiring the use of an operator’s hands, and the valve must remain activated until intentionally shut off. Activate plumbed eyewash equipment monthly to flush the line and verify proper operation. Logging this activity is highly recommended. Maintain a selfcontained unit in accordance with the 790 D ECEMBER

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manufacturer’s instructions. Improperly maintained eyewash stations may cause damage to employees’ eyes.1

§3216 Exit Signs

Exit signs are required for any room or building that has an occupant load of more than 50. The words on the exit sign must be in block letters at least 6 inches in height with a stroke of not less than three-quarters of an inch. The color or design of the letters must be in strong contrast to the sign background. The luminance on the face of the sign may not be less than 50 lux. An exit sign must be at every exit door, at the intersection of corridors, at exit stairways or ramps and at other locations and intervals deemed necessary to inform individuals. Exit signs that are required to be electrically illuminated should be lighted with two bulbs, either one of which shall be sufficient to provide the required luminance on the face of the sign.

§3225 Maintenance and Access to Exits

Every required exit must be kept free of obstructions or impediments

at all times. Do not hang draperies, mirrors or other hangings that can conceal or obscure an exit door. No mirror may be placed adjacent to an exit door. The path to an exit should be kept clear and should not require an individual to pass through a restroom, closet or high-hazard area. n RE F E RE N C E Health effects from contaminated water in eyewash stations, OSHA InfoSheet. www.osha.gov/sites/default/files/ publications/OSHA3818.pdf. Accessed Oct. 4, 2021.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit  cda.org/ practicesupport  for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

Tech Trends

C D A J O U R N A L , V O L 4 9 , Nº 12

A look into the latest dental and general technology on the market

Pixel Liber RGB Video Light ($66.99, PIXEL)

YubiKey 5 Series (starts at $45, Yubico)

Portable, versatile and modular equipment has become incredibly appealing to dentists in recent years. It is now common for a single handpiece to be used in multiple dental disciplines or for all the intraoral X-ray units in a practice to be handheld. For equipment that is less often used (like lights for clinical photos), these qualities become paramount. The Pixel Liber is a newly released camera light that boasts qualities of professional equipment, but in a form that fits in the palm of one’s hand at an incredibly competitive price. This product was tested with a Nikon z50 camera with a Sigma 105mm f2.8 macro lens (intraoral images) and a Nikkor 85mm f1.8 lens (extraoral images).

The YubiKey 5 Series consists of physical security keys that support modern online account authentication protocols. The series contains different versions to accommodate computer, tablet and phone connections such as USB-A, USB-C, Lightning and NFC. Depending on the protocol supported by the account, these keys can function as a 2FA, MFA or single-factor password-less login. Yubico maintains an extensive online catalog of applications that work with YubiKey along with setup instructions for each account.

Pixel is a Hong Kong-based company that specializes in camera accessories. It has distilled its experience in this space to produce the Liber, which boasts a softbox diffuser, mobile app control, adjustable color temperatures between 2500k-8500k, 10 flash effects, magnetic mounting and a rechargeable battery with a 90-minute continuous use life. The Liber weighs less than 3 ounces and is no larger than a modern cell phone. The Pixel Link mobile app allows one mobile device to wirelessly control up to eight Liber lights simultaneously. Drawbacks of the device include poor stability with the magnetic mounts, overheating with continuous use of more than 40 minutes, a fragile softbox and an overly focused beam of light despite the softbox. Intraoral images taken with just the Liber are acceptable, though the reflectivity of teeth is accented because of the light’s tightly focused beam. Extraoral images are easier to acquire well than intraoral images. Overall, the Liber is a good choice for practitioners who want to use affordable, portable devices for camera lighting, but it does not serve those seeking all-in-one, plug-and-play options. — Alexander Lee, DMD

For accounts that support password-less authentication, such as Microsoft, users can register one or more keys along with a unique PIN. Whenever users reach an account login prompt or screen, they simply insert their key, tap its touch area and enter their PIN to authenticate. No passwords are required and multiple registered keys can serve as backup in case one is lost or stolen. Users can easily deregister a key that’s no longer in their possession to maintain account security. For other supported accounts that do not accept password-less logins, these keys can serve as the 2FA or MFA after users enter their credentials, where a prompt appears for them to insert and tap the key followed by entering their PIN to authenticate. For accounts that only support the time-based onetime password (TOTP) security protocol, users can store their TOTPs using the Yubico Authenticator app, which requires a physical security key to open. All of these authentication options require users to have a registered physical security key on hand to access supported accounts, which greatly enhances security and decreases the likelihood of malicious account takeovers. The setup, however, is tedious and requires some knowledge and experience in the management of online accounts. Numerous cybersecurity and identity theft incidents occur daily to average users. It is a constant battle for organizations to educate and protect their users from online attacks. Users can do their part by reviewing their online accounts to ensure all security recommendations are in place. While no single measure is completely effective against malicious threats, a combination of security protocols significantly reduces the chances of account theft. The YubiKey 5 Series is an additional physical tool that further adds to the security of supported online accounts for advanced users. — Hubert Chan, DDS

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CDA Journal - December 2021: More Than Words. Reframing Our Approach to Oral Health Literacy

Articles inside

Tech Trends: A look into the latest dental and general technology on the market

Regulatory Compliance: Electrical Safety, Fire Extinguishers, Eyewash, Exit Signs and Other Cal/OSHA Regulations

RM Matters: Romance, Risks and Regret: The Drama of Interoffice Dating

Innovative Health Literacy Strategy Advances Health Equity: Perspectives of the Cambridge Health Alliance Past and Present Department Chiefs

UCLA-Sesame Street Collaboration To Improve Children's Oral Health

Oral Health Literacy Framework: The Pathway to Improved Oral Health

C.E. Credit: A Historical Overview of Language Access in Dentistry

Organizational Health Literacy in Oral Health: A Multilevel Perspective

Introduction: More Than Words: Reframing Our Approach to Oral Health Literacy

Guest Editorial: Corona Creative